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BACKGROUND: Positron emission tomography (PET) myocardial flow reserve (MFR) is a noninvasive method of detecting cardiac allograft vasculopathy in recipients of heart transplants (HTs). There are limited data on longitudinal change and predictors of MFR following HT. METHODS: We conducted a retrospective analysis of HT recipients undergoing PET myocardial perfusion imaging at an academic center. Multivariable linear and Cox regression models were constructed to identify longitudinal trends, predictors and the prognostic value of MFR after HT. RESULTS: Of HT recipients, 183 underwent 658 PET studies. The average MFR was 2.34 ± 0.70. MFR initially increased during the first 3 years following HT (+ 0.12 per year; Pâ¯=â¯0.01) before beginning to decline at an annual rate of -0.06 per year (P < 0.001). MFR declines preceding acute rejection and improves after treatment. Treatment with mammalian target of rapamycin (mTOR) inhibitors (37.2%) slowed the rate of annual MFR decline (Pâ¯=â¯0.03). Higher-intensity statin therapy was associated with improved MFR. Longer time post-transplant (P < 0.001), hypertension (P < 0.001), chronic kidney disease (P < 0.001), diabetes mellitus (Pâ¯=â¯0.038), antibody-mediated rejection (Pâ¯=â¯0.040), and cytomegalovirus infection (Pâ¯=â¯0.034) were associated with reduced MFR. Reduced MFR (HR: 7.6, 95% CI: 4.4-13.4; P < 0.001) and PET-defined ischemia (HR: 2.3, 95% CI: 1.4-3.9; P < 0.001) were associated with a higher risk of the composite outcome of mortality, retransplantation, heart failure hospitalization, acute coronary syndrome, or revascularization. CONCLUSION: MFR declines after the third post-transplant year and is prognostic for cardiovascular events. Cardiometabolic risk-factor modification and treatment with higher-intensity statin therapy and mechanistic target of rapamycin inhibitors are associated with a higher MFR.
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BACKGROUND: Gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) are useful in acute rejection (AR) surveillance in orthotopic heart transplant (OHT) patients. We report a single-center experience of combined GEP and dd-cfDNA testing for AR surveillance. METHODS: GEP and dd-cfDNA are tested together starting at 2 months post-OHT. After 6 months, combined testing was obtained before scheduled endomyocardial biopsy (EMB), and EMB was canceled with a negative dd-cfDNA. This approach was compared to using a GEP-only approach, where EMB was canceled with a negative GEP. We evaluated for frequency of EMB cancellation with dd-cfDNA usage. RESULTS: A total of 153 OHT patients over a 13-month period underwent 495 combined GEP/dd-cfDNA tests. 82.2% of dd-cfDNA tests were below threshold. Above threshold results identified high-risk patients who developed AR. 378 combined tests ≥6 months post-OHT resulted in cancellation of 83.9% EMBs as opposed to 71.2% with GEP surveillance alone. There were 2 acute cellular and 2 antibody-mediated rejection episodes, and no significant AR ≥6 months. CONCLUSION: Routine dd-cfDNA testing alongside GEP testing yielded a significant reduction in EMB volume by re-classifying GEP (+) patients into a lower risk group, without reduction in AR detection. The addition of dd-cfDNA identified patients at higher risk for AR.
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Ácidos Nucleicos Livres , Transplante de Coração , Transplante de Rim , Rejeição de Enxerto , Humanos , Doadores de TecidosRESUMO
PURPOSE: The goal of our study was to determine if patients with Parkinson's disease (PD) are more susceptible to hospitalization for traumatic brain injury (TBI). METHODS: The US Nationwide Inpatient Sample database was queried (2004-2011) to identify cohorts of patients with PD (N = 1â 047â 656) and without PD (N = 115â 95â 173). The age range of the study population was 60-89 years. The incidence of TBI among patients with PD was compared to the incidence of TBI in patients without PD. A multivariate logistic regression model, adjusted for all covariates that significantly differed in the bivariate analyses, was used to determine if PD was an independent predictor of TBI hospitalization. RESULTS: The incidence of TBI hospitalization was significantly higher (relative risk: 1.76, 95% CI: 1.73-1.80) in the PD cohort. The PD cohort with TBI had fewer comorbidities and risk factors for falls/TBI compared to the non-PD cohort with TBI. The multivariable analysis, adjusting for other TBI risk factors, revealed that PD status increased the likelihood of TBI hospitalization (odds ratio: 2.99, 95% CI: 2.93-3.05). CONCLUSION: Our study shows that patients with PD are more susceptible to hospitalization for TBI. A greater proportion of fall-related TBI occurs in patients with PD compared to patients without PD. Further research is needed to prevent falls in PD patients to avoid TBI.
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Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/terapia , Hospitalização/estatística & dados numéricos , Doença de Parkinson/epidemiologia , Acidentes por Quedas/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/etiologia , Estudos de Coortes , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Cardiac allograft vasculopathy (CAV) limits long-term survival after heart transplantation (HT). This study evaluates the relationship between clinically significant cytomegalovirus infection (CS-CMVi) and CAV using cardiac positron emission tomography (PET). METHODS: We retrospectively evaluated HT patients from 2005 to 2019 who underwent cardiac PET for CAV evaluation. Multivariable linear and logistic regression models were used to evaluate the association between CS-CMVi and myocardial flow reserve (MFR). Kaplan-Meier and Cox regression analyses were used to assess the relationship between CS-CMV, MFR, and clinical outcomes. RESULTS: Thirty-two (31.1%) of 103 HT patients developed CS-CMVi at a median 9 months after HT. Patients with CS-CMVi had a significantly lower MFR at year 1 and 3, driven by reduction in stress myocardial blood flow. Patients with CS-CMVi had a faster rate of decline in MFR compared to those without infection (-0.10 vs -0.06 per year, p < 0.001). CS-CMVi was an independent predictor of abnormal MFR (<2.0) (odds ratio: 3.8, 95% confidence intervals (CI): 1.4-10.7, p = 0.001) and a lower MFR (ß = -0.39, 95% CI: -0.63 to -0.16, p = 0.001) at year 3. In adjusted survival analyses, both abnormal MFR (log-rank p < 0.001; hazard ratio [HR]: 5.7, 95% CI: 4.2-7.2) and CS-CMVi (log-rank p = 0.028; HR: 3.3, 95% CI: 1.8-4.8) were significant predictors of the primary outcome of all-cause mortality, retransplantation, heart failure hospitalization, and acute coronary syndrome. CONCLUSIONS: CS-CMVi is an independent predictor of reduced MFR following HT. These findings suggest that CMV infection is an important risk factor in the development and progression of CAV.
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Doença da Artéria Coronariana , Infecções por Citomegalovirus , Transplante de Coração , Humanos , Estudos Retrospectivos , Transplante de Coração/efeitos adversos , Miocárdio , Coração , Infecções por Citomegalovirus/complicações , Tomografia por Emissão de Pósitrons , Doença da Artéria Coronariana/etiologiaRESUMO
Background: Aortic regurgitation (AR) is common and detrimental in patients with left ventricular assist devices (LVADs). Off-label use of transcatheter aortic valve replacement (TAVR) has emerged as a potential treatment option. Further data are required regarding the feasibility and outcomes of TAVR to treat AR in LVAD recipients. Methods: A retrospective review of all patients with LVADs who underwent TAVR for the treatment of AR at a single center was performed. All echocardiograms were independently reviewed to ensure accuracy. Results: Eleven patients with continuous-flow LVADs underwent TAVR for AR. All patients had moderate or severe AR with New York Heart Association (NYHA) class III and IV symptoms. Implantation of more than 1 valve was required in 4 (36.3%) patients; 1 patient died during the procedure because of valve migration into the left ventricle and 1 patient died in-hospital after TAVR. Of 9 (81.8%) patients discharged alive, 8 (72.7%) were alive at 12 months and all survivors had improvement in AR severity, natriuretic peptide levels, left ventricle end-diastolic diameter, and NYHA class. Five (62.5%) survivors had a large improvement (>20 points) in the Kansas City Cardiomyopathy Questionnaire score at 1 year. One survivor experienced heart failure, requiring hospitalization, within 1 year. Conclusions: In this single-center series, TAVR for the treatment of AR in patients with LVADs is technically challenging but feasible in select patients and may produce durable improvements in AR severity, functional status, and quality of life.
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BACKGROUND: Food environment factors contribute to cardiovascular disease, but their effect on population-level heart failure (HF) mortality is unclear. METHODS: We utilized the National Vital Statistics System and USDA Food Environment Atlas to collect HF mortality rates (MR) and 2 county food environment indices: (1) food insecurity percentage (FI%) and (2) food environment index (FEI), a scaled index (0-10, 10 best) incorporating FI% and access to healthy food. We used linear regression to estimate the association between food environment and HF MR Results: Mean county FI% and FEI were 13% and 7.8 in 2956 included counties. Counties with FI% above the national median had significantly higher HF MR (30.7 versus 26.7 per 100 000; P<0.001) compared with FI% below the national median. Counties with HF MR above the national median had higher FI%, lower FEI, lower density of grocery stores, poorer access to stores among older adults, and lower Supplemental Nutrition Assistance Program participation rate (P<0.001 for all). Lower county FI% (ß=-1.3% per 1% decrease) and higher county FEI (ß=-3.6% per 1-unit increase in FEI) were significantly associated with lower HF MR after adjustment for county demographic, socioeconomic, and health factors. This association was stronger for HF MR compared with non-HF cardiovascular disease MR and all-cause MR The relationship between food environment and HF MR was stronger in counties with the highest income inequity and poverty rate. CONCLUSIONS: Healthier food environment is significantly associated with lower HF mortality at the county level. This reinforces the role of food security on cardiovascular outcomes.
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Doenças Cardiovasculares , Insuficiência Cardíaca , Estados Unidos/epidemiologia , Humanos , Idoso , RendaRESUMO
Atypical antipsychotics are used in cardiac intensive care units (CICU) to treat delirium despite limited data on safety in patients with acute cardiovascular conditions. Patients treated with these agents may be at higher risk for adverse events such as QTc prolongation and arrhythmias. We performed a retrospective cohort study of 144 adult patients who were not receiving antipsychotics before admission and received olanzapine (n = 50) or quetiapine (n = 94) in the Michigan Medicine CICU. Data on baseline characteristics, antipsychotic dose and duration, length of stay, and adverse events were collected. Adverse events included ventricular tachycardia (sustained ventricular tachycardia attributed to the medication), hypotension (systolic blood pressure <90 mm Hg attributed to the medication), and QTc prolongation (QTc increase by ≥60 ms or to an interval ≥500 ms). Twenty-six patients (18%) experienced an adverse event. Of those adverse events, 20 patients (14%) experienced QTc prolongation, 3 patients (2%) had ventricular tachycardia, and 3 patients (2%) had hypotension. Patients who received quetiapine had a higher rate of adverse events (25% vs 6%, p = 0.01) including QTc prolongation (18% vs 6%, p = 0.046). Intensive care unit length of stay was shorter in patients who received olanzapine (6.5 vs 9.5 days, p = 0.047). Eighteen patients (13%) had their antipsychotic continued at discharge from the hospital. In conclusion, QTc prolongation was more common in patients treated with quetiapine versus olanzapine although the number of events was relatively low with both agents in a CICU cohort.
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Antipsicóticos/efeitos adversos , Unidades de Cuidados Coronarianos , Delírio/tratamento farmacológico , Hipotensão/induzido quimicamente , Síndrome do QT Longo/induzido quimicamente , Olanzapina/efeitos adversos , Fumarato de Quetiapina/efeitos adversos , Taquicardia Ventricular/induzido quimicamente , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/complicações , Arritmias Cardíacas/terapia , Delírio/complicações , Endocardite/complicações , Endocardite/terapia , Feminino , Parada Cardíaca/complicações , Parada Cardíaca/terapia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/complicações , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Choque Cardiogênico/complicações , Choque Cardiogênico/terapiaRESUMO
BACKGROUND: Idiopathic intracranial hypertension is a rare neurologic condition characterized by elevated intracranial pressure with normal cerebrospinal fluid analysis and neuroimaging. A subset of pediatric idiopathic intracranial hypertension patients are coincidentally found to have papilledema and elevated intracranial pressure without symptoms (eg, headache, visual blurring, tinnitus). This study aims to investigate the features of asymptomatic pediatric idiopathic intracranial hypertension. METHODS: Retrospective case-control study of patients aged 0 to 18 years who received idiopathic intracranial hypertension diagnosis from 2005 to 2016. Subjects were included if they met established diagnostic criteria for idiopathic intracranial hypertension diagnosis. Subjects were classified as symptomatic if they presented with 1 symptom related to elevated intracranial pressure, and asymptomatic if no symptoms were present. Statistical analysis was performed to compare the 2 groups. RESULTS: 12 (22.6%) of 53 pediatric idiopathic intracranial hypertension subjects were asymptomatic. Compared to symptomatic idiopathic intracranial hypertension, asymptomatic idiopathic intracranial hypertension had younger age of onset, lower initial opening pressure on lumbar puncture, lower optic nerve edema grades bilaterally, lower likelihood of globe flattening on magnetic resonance imaging (MRI), and smaller required dose of acetazolamide for resolution of papilledema (all P < .05). CONCLUSION: Asymptomatic idiopathic intracranial hypertension is common among pediatric patients with papilledema and is an important disease entity that requires special clinical management. It may exist as a milder version of idiopathic intracranial hypertension that occurs in younger children, or as a precursor state that later evolves into symptomatic disease.
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Encéfalo/diagnóstico por imagem , Pressão Intracraniana/fisiologia , Pseudotumor Cerebral/diagnóstico , Adolescente , Encéfalo/fisiopatologia , Estudos de Casos e Controles , Criança , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Neuroimagem , Pseudotumor Cerebral/diagnóstico por imagem , Pseudotumor Cerebral/fisiopatologia , Estudos Retrospectivos , Avaliação de SintomasRESUMO
INTRODUCTION: The ABR Core Examination tests the comprehensive radiology curriculum. On first attempt, 10% of radiology residents fail. This study investigates factors that predict success or failure on the examination. METHODS: An anonymous questionnaire was distributed to all accredited residency programs in diagnostic radiology. Residents who had recently taken the examination answered questions regarding demographics, program, preparation, learning methods, and examination results. Bivariate and multivariate analyses were performed. RESULTS: The study survey was completed by 273 residents. One-tenth of respondents failed or conditionally passed the examination. Residents were more likely to pass the examination if they had trained at an academic program, scored higher on the US Medical Licensing Examination Step 1 and Step 2, achieved higher in-training examination percentile score, completed more practice questions, practiced with both oral and multiple-choice practice questions, and slept longer per night (P < .05 for all). Success was not associated with utilization of specific study resources or protected study time. Lower total number of months spent studying and lower total number of call-containing weeks before the examination were protective factors on multivariate analysis. CONCLUSION: Prior performance on standardized examinations predicts success. Training at an academic institution confers an advantage in performance. The ACR In-Training Examination is an appropriate readiness preparation tool. No specific preparation material or resource can guarantee success. Short-duration, high-quality studying is the most effective method of preparation.
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Avaliação Educacional , Internato e Residência , Radiologia/educação , Currículo , Humanos , Inquéritos e Questionários , Estados UnidosRESUMO
Abdominal lymphangiectasia is a rare disease manifestation with a variety of anatomic locations and clinical presentations. The gastrointestinal tract may be affected, and lymphangiectasia originating in the wall of the intestine has rarely been described. We present a case of primary small bowel lymphangiectasia causing intussusception in a 30-year-old woman who presented with emesis and gastrointestinal bleeding. This case emphasizes the clinical presentation, diagnosis, and management in adults with abdominal lymphangiectasia. We highlight the importance of a high clinical suspicion for lymphangiectasia in an adult with acute abdomen to avoid catastrophic morbidity.