Impact of pretransplant mitral annular calcification on the incidence of cardiac events after renal transplantation.

BACKGROUND: Mitral annular calcification (MAC) is associated with increased risk of major adverse cardiac events. We hypothesized that MAC, identified on a pretransplant transthoracic echocardiography (TTE), is predictive of cardiac events following renal transplantation (RT). METHODS: In a retrospective cohort of consecutive RT recipients, pretransplant MAC presence and severity were determined on TTE performed within 1 year prior to transplant. MAC severity was quantified based on the circumferential MAC extension relative to the mitral valve annulus. Post-transplant cardiac risk was assessed using the sum of risk factors (range: 0-8) set forth by the American Heart Association/American College of Cardiology Foundation consensus statement on the assessment of RT candidates. Subjects underwent pretransplant stress single-photon emission computed tomography myocardial perfusion imaging and followed for post-transplant composite outcome of cardiac death or myocardial infarction (CD/MI). RESULTS: Among 336 subjects (60.5% men; mean age 52 ± 12 years), MAC was present in 78 (23%) patients. During a mean follow-up of 3.1 ± 1.9 years, a total of 70 events were observed. Patients with MAC had a higher event rate compared with those without MAC (34.6% versus 17.8%, log-rank P = 0.001). There was a stepwise increase in CD/MI risk with increasing MAC severity (P for trend = 0.002). MAC-associated risk remained significant after adjusting for sex, duration of dialysis, sum of risk factors, ejection fraction and perfusion abnormality burden, providing an incremental prognostic value to these parameters (Δχ2 =4.63; P = 0.031). CONCLUSION: Among RT recipients, the burden of pretransplant MAC is an independent predictor of post-transplant risk of CD/MI. MAC should be considered in the preoperative assessment of RT candidates.

The prognostic value of heart rate response during vasodilator stress myocardial perfusion imaging in patients with end-stage renal disease undergoing renal transplantation.

BACKGROUND: In asymptomatic end-stage renal disease (ESRD) patients undergoing vasodilator stress myocardial perfusion imaging (MPI) prior to renal transplantation (RT), the impact of pre-transplant heart rate response (HRR) to vasodilator stress on post-RT outcomes is unknown. METHODS: We analyzed a retrospective cohort of asymptomatic patients with ESRD who underwent a vasodilator stress SPECT-MPI and subsequently received RT. Blunted HRR was defined as HRR <28% for regadenoson stress and <20% for adenosine stress. The primary endpoint was major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. Clinical risk was assessed using the sum of risk factors set forth by the AHA/ACCF consensus statement on the assessment of RT candidates. RESULTS: Among 352 subjects, 140 had an abnormal pre-transplant HRR. During a mean follow-up of 3.2 ± 2.0 years, 85 (24%) MACEs were observed. Blunted HRR was associated with increased MACE risk (hazard ratio 1.72; 95% confidence interval 1.12-2.63, P = 0.013), and remained significant after adjustment for gender, sum of AHA/ACCF risk factors, summed stress score, baseline heart rate, and ß-blocker use. HRR was predictive of MACE in patients with normal MPI and irrespective of clinical risk. Blunted HRR was associated with a significant increase in post-operative (30-day) MACE risk (17.9% vs 8.5%; P = 0.009). CONCLUSION: In asymptomatic ESRD patients being evaluated for RT, a blunted pre-transplant HRR was predictive of post-RT MACE. HRR may be a valuable tool in the risk assessment of RT candidates.

Validation of a clinical pathway to assess asymptomatic renal transplant candidates using myocardial perfusion imaging.

BACKGROUND: An AHA/ACCF scientific statement proposed 8 risk factors to assess the need for noninvasive coronary artery disease (CAD) surveillance in asymptomatic patients undergoing evaluation for kidney transplantation. The clinical application of these risk factors and the role of noninvasive testing in this context have not been defined. METHODS AND RESULTS: We retrospectively followed a cohort of 581 consecutive kidney transplant recipients of whom 401 had pre-transplant radionuclide myocardial perfusion imaging (MPI) and 90 had pre-transplant coronary angiography. The sum of pre-transplant AHA/ACCF risk factors (age >60 years, hypertension, diabetes, cardiovascular disease, dyslipidemia, smoking, dialysis >1 year, left ventricular hypertrophy) was calculated. MPI scans were analyzed by a "blinded" reader. Patients were followed for a mean of 3.7 ± 2.3 years post-transplant for major adverse cardiac events (MACE), defined as cardiac death or non-fatal myocardial infarction. The sum of risk factors was associated with modest discriminatory capacity for obstructive angiographic CAD (area under the curve [AUC], 0.70; P = 0.004), 30-day post-operative MACE (AUC, 0.60; P = 0.036), and long-term MACE (AUC, 0.63; P < 0.001). A threshold of ≥3 risk factors was optimal for identifying patients at risk. MPI provided incremental predictive value for obstructive CAD (P = 0.02) and long-term MACE (P = 0.04) but not post-operative MACE (P = 0.56). MPI was best predictive of long-term MACE in intermediate risk (3-4 risk factors) patients. CONCLUSIONS: Asymptomatic kidney transplant candidates with ≥3 AHA/ACCF risk factors are at increased cardiac risk, and should be considered for noninvasive CAD surveillance. Intermediate risk patients (3-4 factors) benefit the most from pre-transplant MPI to define long-term MACE risk.

The prognostic value of regadenoson SPECT myocardial perfusion imaging in patients with end-stage renal disease.

BACKGROUND: The prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) has not been specifically studied in patients with end-stage renal disease (ESRD). METHODS AND RESULTS: We prospectively followed ESRD patients enrolled in the ASSUAGE and ASSUAGE-CKD trials in which they received regadenoson-stress 99mTc-tetrofosmin SPECT-MPI. Images were semiquantitatively analyzed by an investigator blinded to clinical and outcome data. Patients were followed for cardiac death, myocardial infarction (MI), and coronary revascularization (CR). Revascularizations occurring >90 days post-MPI were considered "late" events. Survival analysis was performed using Cox regression models, adjusting for age, gender, diabetes, dyslipidemia, smoking, and known coronary artery disease. We analyzed 303 patients (mean age 54 years; 64% men), who were followed for 35 ± 10 months. Adjusting for clinical covariates, abnormal regadenoson-stress MPI (SSS ≥ 4) was associated with increased risk of the composite of cardiac death or MI (23.9% vs 14.4%; HR 1.88; CI 1.04-3.41; P = .037) and the composite of cardiac death, MI, or late CR (27.3% vs 16.7%; HR 1.80; CI 1.03-3.14; P = .039). Adjusting for clinical covariates, regadenoson-induced myocardial ischemia (SDS ≥ 2) was associated with increased rate of the composite endpoint of cardiac death, MI, or CR (33.3% vs 16.9%; HR 1.97; CI 1.19-3.27; P = .008). CONCLUSION: Regadenoson-stress SPECT-MPI provides a significant prognostic value in patients with ESRD. ESRD patients with normal SPECT-MPI have relatively high adverse event rates.

Impact of a regimented aminophylline administration protocol on the burden of regadenoson-induced ischemia detected by SPECT myocardial perfusion imaging.

BACKGROUND: In patients undergoing regadenoson SPECT myocardial perfusion imaging (MPI), it is unknown how soon and at which dose intravenous aminophylline can be administered to reverse regadenoson-related adverse effects without blunting stress-induced myocardial ischemia. METHODS AND RESULTS: We analyzed the pooled database of the ASSUAGE and ASSUAGE-CKD trials (n = 548). These were double-blinded, placebo-controlled, randomized clinical trials in which 75 mg of aminophylline or placebo was administered intravenously 90 seconds following 99mTc-tetrofosmin injection. There were no statistically significant differences in summed difference score (SDS) burden (P = .87) and in the rates of myocardial ischemia (SDS ≥ 2) (P = .93) between the aminophylline (n = 274) and placebo (n = 274) groups. There was no interaction between aminophylline use and SDS as a determinant of the composite endpoint of cardiac death or MI (P = .32) or the composite endpoint of cardiac death, MI, or coronary revascularization (P = .92). CONCLUSION: In patients undergoing regadenoson-stress SPECT-MPI, the intravenous administration of 75 mg of aminophylline as early as 90 seconds after radioisotope injection does not seem to attenuate the burden of myocardial ischemia.

Impact of integrating heart rate response with perfusion imaging on the prognostic value of regadenoson SPECT myocardial perfusion imaging in patients with end-stage renal disease.

BACKGROUND: We investigated whether integrating heart rate response (HRR) to regadenoson with myocardial perfusion imaging (MPI) analysis can enhance risk prediction in end-stage renal disease (ESRD) patients. METHODS AND RESULTS: We prospectively followed 303 ESRD patients after regadenoson stress MPI for a mean of 35 months. Normal HRR to regadenoson was defined as ≥28% increase from baseline. Normal MPI was defined as a summed stress score ≤3 and left ventricular ejection fraction ≥50%. The study cohort was divided in four groups based on various combinations of normal/abnormal HRR and MPI. There was a step-wise increase in the risk of primary endpoint of all-cause death and the composite secondary endpoint of cardiac death or myocardial infarction; patients with Normal MPI/Normal HRR had the lowest event rates and those with Abnormal MPI/Abnormal HRR had the highest, whereas subjects with Abnormal MPI/Normal HRR and Normal MPI/Abnormal HRR had intermediate event rates. This pattern was maintained after adjusting for important clinical covariates. CONCLUSION: In ESRD patients, integrating HRR to vasodilator stress with MPI interpretation improves risk stratification. Normal HRR/Normal MPI identify truly low-risk group, whereas abnormal MPI or abnormal HRR portrays elevated risk.

Prognostic value of heart rate response during regadenoson stress myocardial perfusion imaging in patients with end stage renal disease.

BACKGROUND: Blunted heart rate response (HRR) to vasodilator stress agents is associated with worse outcomes. There are limited data assessing the effect of impaired HRR to regadenoson among patients with end-stage renal disease (ESRD) undergoing stress myocardial perfusion imaging (MPI). METHODS: We prospectively followed patients with ESRD enrolled in the ASSUAGE and ASSUAGE-CKD trials. HRR was defined as 100*(peak stress heart rate-resting heart rate)/resting heart rate. Study cohort was dichotomized to blunted and normal HRR groups according to an established median HRR value <28% or ≥28%, which were propensity-score matched based on 22 clinical and imaging covariates. The Primary endpoint was all-cause death. The secondary cardiac-specific endpoints included: (1) the composite endpoint of cardiac death or myocardial infarction; (2) the composite endpoint of cardiac death, myocardial infarction, or late (>90 days) coronary revascularization. RESULTS: There were 303 patients followed for 35 ± 10 months. In the entire cohort, there was a stepwise increase in the rates of death and all secondary endpoints with worsening HRR (P values ≤.001). Blunted HRR (<28%) was associated with increased risk of death (unadjusted hazard ratio 4.10 [1.98-8.46], P < .001) and all secondary endpoints (P ≤ .001). After multivariate adjustment, HRR remained an independent predictor of mortality and secondary endpoints whether used as continuous or dichotomous variable, and added incremental prognostic value for all-cause death (P = .046). Blunted HRR was associated with increased event rate among patients with normal myocardial perfusion (P = .001) and abnormal perfusion (P = .053). In the propensity-matched cohort of 132 patients (66 in each group), blunted HRR was associated with significant increase in all-cause death (21% vs. 5%, HR 5.09 [1.46-17.7], P=.011), and similarly for the secondary endpoints. CONCLUSION: Blunted HRR (<28%) to regadenoson is a strong and independent predictor of death and cardiovascular events in patients with ESRD and adds incremental prognostic value.

Missed Opportunity: The Unseen Driver for Low Coronavirus Disease 2019 Vaccination Rates in Underserved Patients.

Background: Vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus have been available since December 2020. Vaccination rates among hospitalized patients at our institution remained low at approximately 40%, thus we sought to understand the drivers of vaccine hesitancy in our patient population. Methods: All unvaccinated adult patients admitted to our hospital were asked to participate in a survey to assess coronavirus disease 2019 (COVID-19) vaccine hesitancy. Updated vaccination status was collected at the end of the study. Results: Ninety-seven patients agreed to participate, 34% of which were SARS-CoV-2 positive based on results from polymerase chain reaction tests. Of the 64 participants eligible to receive the vaccine, 57.8% were agreeable but only 27% received the vaccine before discharge. Conclusion: Many patients are willing to receive the vaccine, and hospitalization provides a unique opportunity to interact with patients who have been otherwise unaware, unable, or unwilling to pursue vaccination outside of the hospital.

Topographical Evaluation of Penile Lichen Sclerosus Reveals a Lymphocytic Depleted Variant, Preferentially Associated With Neoplasia: A Report of 200 Cases.

Since the seminal study of Hart and Helwig in 1975, there are few detailed pathological studies of lichen sclerosus (LS). The aims of this study were to provide a detailed histopathological description of penile LS, as well as to explore its relationship with penile intraepithelial neoplasia (PeIN) or invasive carcinoma. We evaluated 200 patients and designed a topographical approach for the histological evaluation focusing in alterations of the following anatomical layers: squamous epithelium, lamina propria, dartos, and corpus spongiosum. We documented the quantity and topographical location of stromal lymphocytes. The prevalent lesions found were epithelial hyperplasia, atrophy, PeIN, basal cell vacuolization, lamina propria sclerosis, and variable patterns of lymphocytic infiltration. Various unique patterns of stromal sclerosis were described: perivascular, globular, linear, and solid fibrosis/hyalinization; any of them were found to be diagnostic for LS. The variation in the topography and density of lymphocytes was determinant for the identification of LS morphological variants: lichenoid, band-like, lymphocytic depleted, and mixed. A major finding was the identification of the variant designated as lymphocytic depleted LS, which we considered as the morphological prototype of LS associated with penile neoplasia. The detailed description of this complex lesion presented in this study may help pathologists in practice to identify and better define LS. The identification of the special variants suggests a role of the stromal lymphocytes in the process of carcinogenesis. Confirmation of the observations with more studies is necessary to determine the significance of these findings.

Effect of intensive and standard blood pressure control on cardiovascular outcomes based on body mass index: sub-analysis of the sprint trial.

The present study is a sub-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) that aimed to evaluate the role of intensive vs. standard hypertensive treatment on cardiovascular outcomes according to the body mass indices of trial participants. SPRINT participants were categorized according to their baseline BMI values into normal (BMI ≥ 18.5 to <25), overweight (BMI ≥ 25 to <30), and obese (BMI ≥ 30) groups. The primary cardiovascular outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular cause. Cox regression analysis was used to calculate hazard ratios for the study outcome in intensive and standard BP treatment among those with varying BMI. Among 9237 participants with, 1682, 3599, and 3956 were normal, overweight and obese, respectively. After a median follow-up of 3.26 years, the hazard ratios for the primary endpoint were 0.82 (95% CI 0.58, 1.16), 0.71 (95% CI 0.54, 0.94), and 0.76 (95% CI 0.59, 0.98) for the normal, overweight, and obese participants, respectively (P value for interaction 0.79). The effect of intensive versus standard SBP treatment for the other secondary endpoints and serious adverse events were all similar in participants of different BMI (all P-interaction > 0.05). In this sub-analysis of the SPRINT trial, intensive blood pressure control had a beneficial effect in reducing the primary endpoint and all-cause mortality irrespective of the participants' BMI.

Revisiting the evolution of tuberculosis therapy: historical reflections in the modern era.

Management of tuberculosis (TB) has witnessed several changes over the past decades. While medical management is now the mainstay of therapy, surgical intervention was once the only treatment option physicians had to offer. We discuss some historical surgical procedures and take a quick glance at the evolution of TB therapy. We note the importance of adequate history-taking and the implications of what seemingly obsolete techniques may have in contemporary practice. We also highlight the re-emergence of surgical options in the modern era with the rise of multidrug-resistance.

Salt intake and blood pressure in the University of Asuncion-Paraguay youths: a preliminary study.

INTRODUCTION: High salt intake is a major risk factor related to many cardiovascular and renal diseases. World Action on Salt and Health is a newly formed coalition of heath professionals whose goal is to implement changes in salt consumption in their respective countries for the goal of reducing blood pressure. In the same vein, we have decided to study the amount of salt intake in Paraguay to determine if a relationship exists between salt intake and blood pressure. OBJECTIVE: A preliminary study was undertaken to determine salt intake in Paraguay and its relationship with blood pressure, in order to implement a national program to combat hypertension. METHODS: Cross-sectional, observational study of 72 students from various universities in Asuncion (age range 22-30 years). Sodium excretion in 24-hour urine samples and blood pressure were measured. Assuming a steady state, urinary sodium excretion was converted into grams of salt ingested per day. RESULTS: Only 7% of the 72 participants had a salt intake less than the recommended maximum of 5 g/day. Forty-six percent had a blood pressure between 120-139 mmHg and 3% had stage 1 hypertension. There was no significant relationship between sodium excretion and blood pressure. CONCLUSION: Salt intake and blood pressure were found to be significantly elevated in young adults in Paraguay and argues for the importance of instituting a national campaign to reduce salt intake in this society.

Salt intake and blood pressure in the University of Asuncion-Paraguay youths: a preliminary study / O consumo de sal e sua relacão com a pressão arterial em jovens da Universidade de Assunção-Paraguai: estudo preliminar

INTRODUCTION: High salt intake is a major risk factor related to many cardiovascular and renal diseases. World Action on Salt and Health is a newly formed coalition of heath professionals whose goal is to implement changes in salt consumption in their respective countries for the goal of reducing blood pressure. In the same vein, we have decided to study the amount of salt intake in Paraguay to determine if a relationship exists between salt intake and blood pressure. OBJECTIVE: A preliminary study was undertaken to determine salt intake in Paraguay and its relationship with blood pressure, in order to implement a national program to combat hypertension. METHODS: Cross-sectional, observational study of 72 students from various universities in Asuncion (age range 22-30 years). Sodium excretion in 24-hour urine samples and blood pressure were measured. Assuming a steady state, urinary sodium excretion was converted into grams of salt ingested per day. RESULTS: Only 7% of the 72 participants had a salt intake less than the recommended maximum of 5 g/day. Forty-six percent had a blood pressure between 120-139 mmHg and 3% had stage 1 hypertension. There was no significant relationship between sodium excretion and blood pressure. CONCLUSION: Salt intake and blood pressure were found to be significantly elevated in young adults in Paraguay and argues for the importance of instituting a national campaign to reduce salt intake in this society.

INTRODUÇÃO: O elevado consumo de sal é um importante fator de risco relacionado a muitas doenças cardiovasculares e renais. A Ação Mundial sobre Sal e Saúde (WASH) é uma coalizão recém-formada de profissionais de saúde, cujo objetivo é modificar o consumo de sal em seus respectivos países com a finalidade de reduzir os valores de pressão arterial. Neste contexto, decidimos estudar a quantidade de ingestão de sal no Paraguai para determinar se existe uma relação entre a ingestão de sal e valores de pressão arterial. OBJETIVO: Um estudo preliminar foi realizado para determinar o consumo de sal no Paraguai e sua relação com a pressão arterial, a fim de implementar um programa nacional para combater a hipertensão. MÉTODOS: Estudo transversal, observacional de 72 estudantes de várias universidades de Assunção (faixa etária 22-30 anos). Excreção de sódio em amostras de urina de 24 horas e valores de pressão arterial foram medidos. Assumindo um estado de equilíbrio, a excreção urinária de sódio foi convertida em gramas de sal ingeridos por dia. RESULTADOS: Apenas 7% dos 72 participantes tinham uma ingestão de sal menor ao máximo recomendado de 5g/dia. Quarenta e seis por cento tinham uma pressão arterial entre 120-139 mmHg e 3% tinham hipertensão estágio 1. Não houve relação significativa entre a excreção de sódio e pressão arterial. CONCLUSÃO: O consumo de sal e valores de pressão arterial encontrados foram significativamente elevados em adultos jovens do Paraguai, e defende-se a importância de se instituir uma campanha nacional para reduzir a ingestão de sal na sociedade.