Prediction of 2-year major adverse cardiac events from myocardial perfusion scintigraphy and clinical risk factors.

BACKGROUND: We developed CRAX2MACE, a new tool derived from clinical and SPECT myocardial perfusion imaging (MPI) variables, to predict 2-year probability of major adverse cardiac event (MACE) comprising death, hospitalized acute myocardial infarction or coronary revascularization. METHODS: Consecutive individuals with SPECT MPI 2001-2008 had two-year MACE determined from population-based health services data. CRAX2MACE included age, sex, diabetes, recent cardiac hospitalization, pharmacologic stress, stress total perfusion deficit (TPD), ischemic (stress-rest) TPD, left ventricular ejection fraction and transient ischemic dilation ratio. Two-year event rates were classified as low (< 5%), moderate (5.0-9.9%), high (10-19.9%) and very high (20% or greater). RESULTS: The study population comprised 3896 individuals for the development and 1946 for the validation subgroups with subsequent MACE in 589 (15.1%) and 272 (14.0%), respectively. CRAX2MACE, derived from the development subgroups, accurately stratified MACE risk in the validation subgroup (area under the receiver operating characteristics curve 0.79) with stepwise increase in the observed event rate with increasing predicted risk category (low, 2.3%; moderate, 5.5%; high, 18.8%; very high 33.2%; P-trend < 0.001). CONCLUSIONS: A simple tool based upon clinical risk factors and MPI variables predicts 2-year cardiac events. Risk stratification between the low and very high groups was greater than tenfold.

Reassessment Intervals for Transition From Low to High Fracture Risk Among Adults Older Than 50 Years.

Importance: Fracture risk scores are used to identify individuals at high risk of major osteoporotic fracture or hip fracture for antiosteoporosis treatment. For those not meeting treatment thresholds at baseline, the optimal interval for reassessing fracture risk is uncertain. Objective: To examine reassessment intervals for transition from low to high fracture risk under guidelines-defined treatment thresholds. Design, Setting, and Participants: This retrospective cohort study included persons aged 50 years or older with fracture risk below treatment thresholds at baseline who had fracture risk reassessed at least 1 year later. Data were obtained from a population-based bone mineral density registry (baseline assessment during 1996-2015; reassessment to 2016) in the Province of Manitoba, Canada. Primary analysis was performed from May to June 2019. Analysis for the revision was performed in October 2019. Main Outcomes and Measures: The primary outcome was time to transition from low (below the treatment threshold) to high fracture risk (treatment-qualifying risk score using osteoporosis clinical practice guidelines strategies for Canada, the United States, and the United Kingdom). Results: The study population consisted of 10 564 individuals (94.1% women; mean [SD] age at baseline, 63.2 [8.2] years). At the time of reassessment (a mean [SD] interval of 5.2 [2.9] years between initial and subsequent fracture risk assessment), 690 (6.6%) had reached the fixed major osteoporotic fracture treatment threshold of 20%, 1546 (16.2%) had reached the fixed hip treatment threshold of 3%, and 932 (9.4%) had reached the age-dependent major osteoporotic fracture treatment threshold. Among those below 25% of the treatment threshold at baseline for each guideline, few (0%-3.0%) reached guidelines-defined high fracture risk at follow-up. In contrast, among those at the upper end of the scale for each guideline (75%-99% of the treatment threshold at baseline), 30.6% to 74.4% reached guidelines-defined high fracture risk. An increased number of clinical risk factors was associated with increased likelihood of reaching guidelines-defined high fracture risk (range for 3 guidelines, 17.1%-28.2%) compared with unchanged or decreased clinical risk factors (range for 3 guidelines, 3.3%-12.8%) (P < .001). Estimated time for 10% of the population to reach treatment-qualifying high fracture risk ranged from fewer than 3 years to more than 15 years. Conclusions and Relevance: The findings suggest that baseline fracture risk (as a fraction of the treatment threshold) and change in clinical risk factors can identify individuals with low and high probability of guidelines-defined high fracture risk during follow-up, thereby potentially helping to inform the reassessment interval.

Factors Associated With Bone Density Monitoring While on Antiosteoporosis Treatment in Routine Clinical Practice: A Registry-Based Cohort Study.

The role for bone mineral density (BMD) monitoring while on antiosteoporosis therapy remains controversial. The current study used population-based registries to identify factors associated with BMD monitoring in women within 5 yr of receiving antiosteoporosis treatment vs treatment without monitoring in routine clinical practice. The analytical dataset consisted of women age 40 yr and older at baseline receiving antiosteoporosis therapy: 6877 with BMD monitoring (mean interval 3.2 yr) and 6747 without BMD monitoring. There was a significant negative secular trend in BMD monitoring during the study period (p < 0.001). Multivariable logistic regression demonstrated that parental hip fracture, glucocorticoid and aromatase inhibitor use, and lower baseline BMD were independently and positively associated with BMD monitoring. Individuals with increasing age, greater body mass index, smoking, rheumatoid arthritis, later calendar year, diabetes, rural residency, lower income, and greater comorbidity score were less likely to undergo monitoring. A shorter monitoring interval (<23 mo) was strongly associated with glucocorticoid and aromatase inhibitor use. In conclusion, our study identifies factors associated with BMD monitoring over 5 yr in patients receiving antiosteoporosis therapy.

Vertebral Fracture Assessment Increases Use of Pharmacologic Therapy for Fracture Prevention in Clinical Practice.

The impact of vertebral fracture assessment (VFA) on lateral spine images in clinical practice on subsequent patient use of fracture prevention medication is unknown. Our objective was to determine the association of prevalent vertebral fracture identified on bone density lateral spine images (positive VFA) with subsequent use of fracture prevention therapy in usual clinical practice, using the Manitoba Bone Density Program database prospective observational cohort. Since 2010, targeted VFA imaging has been done at the time of bone densitometry in Manitoba for 21% of women and men meeting criteria based on age, bone mineral density (BMD), height loss, and glucocorticoid use. Among 6652 treatment-naive individuals with at least 90 days follow-up who had VFA imaging, 923 (13.9%) had one or more definite vertebral fractures identified using a modified algorithm-based qualitative (ABQ) method. For those with a positive VFA, their bone density reports stated the patient was at high risk of subsequent fracture and qualified for fracture prevention therapy. Subsequent osteoporosis treatment initiated within the next 12 months was identified using population-based pharmacy data. Logistic regression models were used to estimate the association of positive VFA with subsequent prescription (Rx), compared to negative VFA. Fracture prevention medication was started by 2127 (32%) individuals, 52.3% with positive versus 28.4% with negative VFA (p value <0.001). This association was substantially stronger in those designated (before VFA results were known) to have low or moderate fracture risk compared to high fracture risk (interaction p value <0.001), and in those with osteopenia (OR 4.51; 95% CI, 3.48 to 5.85) compared to those with osteoporosis by BMD criteria (OR 1.72; 95% CI, 1.43 to 2.08, interaction p value <0.001). Targeted VFA imaging at the time of bone densitometry substantially improves identification of those at high fracture risk and fracture prevention medication use among those with prevalent vertebral fracture. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.

Association of Bone Density Monitoring in Routine Clinical Practice With Anti-Osteoporosis Medication Use and Incident Fractures: A Matched Cohort Study.

Routine bone mineral density (BMD) monitoring of individuals during the initial 5 years of anti-osteoporosis treatment is controversial. Using a registry-based cohort from the Province of Manitoba, Canada, we compared anti-osteoporosis medication use and fracture outcomes in women with versus without BMD monitoring receiving anti-osteoporosis medication. We identified 4559 women aged 40 years and older receiving anti-osteoporosis therapy with serial BMD testing (monitoring) within 5 years (mean interval 3.2 years) and 4559 propensity score-matched women without BMD monitoring. We assessed anti-osteoporosis medication use over 5 years from a population-based retail pharmacy database. Incident fractures to 10 years from health services data. During median 10 years observation, 1225 (13.4%) women developed major osteoporotic fracture, including 382 (4.2%) with hip fractures. Monitored women had significantly better fracture-free survival for major osteoporotic fracture (p = 0.040; 10-year cumulative risk 1.9% lower, 95% confidence interval [CI] 0.3-3.6%) and hip fracture ( p = 0.001; 10-year cumulative risk 1.8% lower, 95% CI 0.7-2.8%) compared with women who were not monitored. Hazard ratios (HRs) were significantly lower in monitored versus not monitored women for major osteoporotic fracture (HR = 0.89, 95% CI 0.80-0.98) and hip fracture (HR = 0.74, 95% CI 0.63-0.87). Days of medication use, medication persistence ratio, and treatment switching over 5 years were greater in monitored versus not monitored women. At the end of 5 years, more women in the monitored group persisted on treatment and more switched treatment, with switching behavior associated with an observed interval reduction in BMD. In conclusion, our findings suggest a possible role for BMD monitoring after initiating anti-osteoporosis therapy in the routine clinical practice setting. © 2019 American Society for Bone and Mineral Research.

Prevalent vertebral fracture on bone density lateral spine (VFA) images in routine clinical practice predict incident fractures.

PURPOSE: The predictive validity of vertebral fracture assessment (VFA) on bone density lateral spine images to identify prevalent vertebral fractures in routine clinical practice has not been established. Our objective was to estimate the associations of prevalent vertebral fracture identified on VFA images in routine practice with incident hip, all non-vertebral, major osteoporotic, and clinical vertebral fractures, using the Manitoba Bone Density database. METHODS: From 2010 onward, 9972 men and women (mean age [SD] 76 [6.9] years) had VFA images obtained at the time of bone densitometry that were interpreted for vertebral fracture by the clinicians reading the bone density tests. Definite and possible prevalent vertebral fractures, respectively, were identified in 1575 (15.8%) and 293 (2.9%) using a modified Algorithm Based Qualitative method. We ascertained incident fractures using Manitoba provincial health databases over a mean 2.8 (SD 1.7) years and used Cox proportional hazards models to estimate the associations of prevalent vertebral fractures with incident fractures. RESULTS: Compared to no prevalent vertebral fracture, those with definite prevalent vertebral fracture had higher hazard ratios for incident hip (HR 1.95, 95% C.I. 1.45 to 2.62), non-vertebral (HR 1.99, 95% C.I. 1.68 to 2.35), and clinical vertebral fracture (HR 2.68, 95% C.I. 1.69 to 4.23) adjusted for age, bone mineral density, body mass index, prior fracture, parental hip fracture, glucocorticoid use, alcohol use, smoking, and rheumatoid arthritis. These associations did not vary by FRAX fracture risk estimates or bone mineral density category. CONCLUSION: Prevalent vertebral fractures identified on densitometric VFA images in routine clinical practice are strongly associated with incident fractures, and this study is the first to show this using any lateral spine imaging modality outside of research settings. These findings are strong evidence supporting the targeted use of densitometric VFA imaging among post-menopausal women and older men referred for bone densitometry.

Neurolymphomatosis of the Brachial Plexus and its Branches: Case Series and Literature Review.

BACKGROUND: Neurolymphomatosis is a process of neoplastic endoneurial invasion, most strongly associated with non-Hodgkin's lymphoma. It must be distinguished from paraneoplastic, metabolic, nutritional and treatment-related causes of neuropathy that are common in this patient population. METHODS: This brief case series illustrates the protean manifestations of neurolymphomatosis of the brachial plexus, ranging from focal distal mononeuropathy to multifocal brachial plexopathy, either as the index manifestation of lymphoma or as a complication of relapsing disease. RESULTS: Prominent asymmetry, pain and nodular involvement on neuroimaging may help distinguish neurolymphomatosis from paraneoplastic immune demyelinating radiculoneuropathy. MR neurography criteria for the diagnosis of neurolymphomatosis include hyperintensity on T2 and STIR sequences, focal and diffuse nerve enlargement with fascicular disorganization and gadolinium enhancement. No specific anatomical distribution within the brachial plexus has, however, been found to be characteristic. Fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging is the imaging modality with the highest sensitivity for detection of nodal or extranodal spread in lymphoma. CONCLUSIONS: Brachial plexus neuropathy in neurolymphomatosis is highly protean in its distribution, semiology and relation to lymphoma staging. Dedicated MRI and PET-CT imaging are leading diagnostic modalities.

Cardiac metastases of neuroendocrine tumors treated with 177Lu DOTATATE peptide receptor radionuclide therapy or 131I-MIBG therapy.

Neuroendocrine tumors have a propensity to metastasize to the heart, although the reason for this remains unknown. A review of 251 neuroendocrine tumor patients treated with Lu DOTATATE peptide receptor radionuclide therapy or I-MIBG therapy at our institution since 2003 revealed 2 patients with cardiac metastases (incidence, 0.8%), one treated with Lu DOTATATE and one with I-MIBG. We present the imaging findings of these 2 patients, as well as their management and responses to therapy.

Acute obstruction of a chronic organoaxial gastric volvulus detected on blood pool imaging of a bone scan.

Acute obstruction of a chronic gastric volvulus was incidentally detected on blood pool imaging of a total body bone scan performed for an elevated prostate-specific antigen level. The patient had been diagnosed with an organoaxial gastric volvulus within a paraesophageal hernia 4.5 years previously, with no evidence for obstruction. The patient remained asymptomatic until becoming acutely obstructed on the day of his bone scan. This case gives further evidence for the additive utility of routine total body blood pool imaging for detecting and characterizing both osseous and nonosseous pathology.

Pseudomyogenic Hemangioendothelioma Mimicking Multiple Myeloma on 18F-FDG PET/CT, Followed by Spontaneous Regression.

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma is a rare, recently described vascular neoplasm that occurs predominantly in the distal extremities of young to middle aged adult males. In this report, we describe a patient who presented with numerous lytic bone lesions which were intensely ¹8F-FDG avid on PET/CT and presumed to be metastatic. Pathology revealed pseudomyogenic hemangioendothelioma. Follow-up CT showed enlargement and increasing sclerosis of several lesions, believed to represent progression; however, follow-up PET/CT confirmed a spontaneous regression of the disease.