Coronary artery calcium assessment on non-gated chest CT to optimize pre-operative cardiac screening in liver transplantation.

BACKGROUND: Guidelines recommend standard pre-operative cardiac screening in all liver transplantation (LT) recipients, despite the relatively low prevalence of obstructive coronary artery disease. Most LT recipients often have non-gated computed tomography (CT) performed of the chest and abdomen. This study evaluated the ability of coronary artery calcification (CAC) assessment on consecutively available scans, to identify a selection of low-risk patients, in whom further cardiac imaging can be safely withheld. METHODS: LT recipients with prior non-gated CT chest-abdomen were included. CAC was visually scored on a semi-quantitative ordinal scale. Stress myocardial perfusion, coronary CT angiography (CCTA) and invasive coronary angiography (ICA) were used as golden standard. The sensitivity and specificity of CAC to exclude and predict obstructive CAD were assessed. In addition, peri- and postoperative mortality and cardiac events were analyzed. RESULTS: 149 LT recipients (ranged 31-71 years) were included. In 75% of patients, no CAC and mild CAC could rule out obstructive CAD on CCTA and ICA with 100% certainty. The threshold of mild CAC had a sensitivity of 100% for both CCTA and ICA and a specificity of 91% and 68%, respectively. None of the patients with no or mild calcifications experienced peri- and post-operative cardiac events or died of cardiac causes. CONCLUSION: Visual evaluation of CAC on prior non-gated CT can accurately and safely exclude obstructive CAD in LT recipients. Incorporation of these already available data can optimize cardiac screening, by safely withholding or correctly allocating dedicated cardiac imaging in LT recipients. Thereby, reducing patients' test burden and save health care expenses.

Importance of complete response for outcomes of pregnancy in patients with autoimmune hepatitis.

BACKGROUND AND AIMS: While some articles describe outcome of pregnancy in autoimmune hepatitis (AIH), there are less data evaluating influence of AIH control on maternal and perinatal outcomes. This study analysed outcomes of pregnancy and related possible risk factors in AIH. METHOD: A retrospective multicentre cohort study on pregnancy in AIH was performed in 11 hospitals in the Netherlands. Maternal and neonatal outcomes were collected from records and completed by interview. Risk factors-including incomplete response, relapse and cirrhosis-for adverse outcomes were identified using logistic regression analysis. RESULTS: Ninety-seven pregnancies in 50 women resulted in 70 deliveries (72%) with a live birth rate of 98.5%. AIH relapse occurred in 6% during pregnancy, and in 27% of post-partum episodes. Absence of complete biochemical response at conception was identified as risk factor for the occurrence of gestational and post-partum relapses. Relapse of AIH in the year before conception was a risk factor for the occurrence of both gestational relapses and post-partum relapses. No complete biochemical response increased the risk for hypertensive disorders during pregnancy and intrahepatic cholestasis of pregnancy (ICP). Cirrhosis was found to be a risk factor for miscarriages, but not for other outcomes. CONCLUSION: Pregnancy in AIH is related to an increased incidence of maternal and fetal/neonatal complications; in most cases, outcome is good. Incomplete biochemical response at conception or relapse in the year before conception are risk factors for gestational and post-partum relapses, for hypertensive disorders and for ICP. Cirrhosis was a risk factor for miscarriages.

Quantifying effects of retinal illuminance on frequency doubling perimetry.

PURPOSE: To measure and quantify effects of variation in retinal illuminance on frequency doubling technology (FDT) perimetry. METHODS: A Zeiss-Humphrey/Welch Allyn FDT perimeter was used with the threshold N-30 strategy. Study 1, quantifying adaptation: 11 eyes of 11 subjects (24-46 years old) were tested with natural pupils, and then retested after stable pupillary dilation with neutral density filters of 0.0, 0.6, 1.2, and 1.6 log unit in front of the subject's eye. Study 2, predicting effect of reduced illuminance: 17 eyes of 17 subjects (26-61 years old) were tested with natural pupils, and then retested after stable pupillary miosis (assessed with an infrared camera). A quantitative adaptation model was fit to results of Study 1; the mean adaptation parameter was used to predict change in Study 2. RESULTS: Study 1: Mean defect (MD) decreased by 10 dB over a 1.6 log unit range of retinal illuminances; model fits for all subjects had r2> 95%. Study 2: Change in MD (DeltaMD) ranged from -7.3 dB to +0.8 dB. The mean adaptation parameter from Study 1 accounted for 69% of the variance in DeltaMD (P <0.0005), and accuracy of the model was independent of the magnitude of DeltaMD (r2< 1%, P >0.75). CONCLUSIONS: The results confirmed previous findings that FDT perimetry can be dramatically affected by variations in retinal illuminance. Application of a quantitative adaptation model provided guidelines for estimating effects of pupil diameter and lens density on FDT perimetry.