Citations

Abstract Optimal management of anticoagulation for patients with aortic mechanical heart valves (MHVs) receiving vitamin K antagonists (VKAs) undergoing gastrointestinal endoscopic procedures is clinically challenging. Risk of bleeding from an unanticipated polypectomy or biopsy further complicates this issue. Current guidelines on use of bridging with low-molecular-weight heparin (LMWH) for these procedures are based on low-quality evidence. We conducted a subanalysis of a retrospective, multicenter observational study of adult patients with aortic MHVs receiving VKAs who underwent elective gastrointestinal endoscopies (colonoscopy or upper endoscopy). We included patients who underwent the procedure between July 1, 2020, and July 1, 2023, at five centers in Canada and the United States Patients with procedures performed on separate days within a 30-day period were excluded. Efficacy and safety outcomes included thromboembolic events, major bleeding (MB), and clinically relevant non-major bleeding (CRNMB) in the 30 days post procedure. A total of 192 endoscopic procedures were analyzed. Median (interquartile range [IQR]) patient age was 66 years (58.2–72.8) and 22% were female. Warfarin was interrupted for 185 procedures (96%). Among these, 119 (64%) received LMWH bridging: 33 (17%) pre-procedure only, 10 (5%) post-procedure only, and 76 (40%) both pre- and post-procedure. Post-procedure LMWH was initiated a median (IQR) of 1 day (1–1) and discontinued 5 days post-procedure (3–8). MB occurred in two patients (1%), CRNMB in two patients (1%), and one death (0.5%) was identified; no thromboembolic events occurred. Prior to propensity score matching (PSM), post-procedure LMWH with or without pre procedure LMWH was associated with the composite outcome of MB and CRNMB (P = 0.034), although not with MB or CRNMB individually. After stepwise regression and PSM analyses, no significant differences in bleeding outcomes were observed between patients who received LMWH bridging and those who did not. Our findings indicate that although adverse thrombotic events were rare and use of post-procedure LMWH bridging was significantly associated with a small absolute increased risk of bleeding, it was not significant after PSM. Larger prospective studies are needed to better inform antithrombotic management guidelines for patients with aortic MHVs undergoing gastrointestinal endoscopy.

Abstract We aim to compare the benefits, harms, and costs of multiple plastic stents (MPS) versus covered self-expandable metallic stents (CSEMS) in the treatment of benign biliary strictures (BBS). A comprehensive database search through June 6, 2024 identified randomized controlled trials (RCT) involving adult patients with BBS comparing MPS to CSEMS in terms of stricture resolution, recurrence, technical success, number of required procedures and stents, treatment duration, all-cause mortality, adverse events, and stent migration. We utilized the Cochrane Risk of Bias (RoB) tool2 for study quality assessment. Meta-analysis following the random effects model was performed. After screening 365 references, we included 7 RCTs (high RoB) involving 594 patients. Most reported stricture etiology is chronic pancreatitis (52.4%), followed by orthotopic liver transplant (40.5%). Compared with MPS, CSEMS achieved similar efficacy and safety. However, CSEMS required fewer procedures (mean difference [MD]: −1.84 [−2.56 to −1.11]; I2 = 76%) and stents (MD: −6.04 [−9.55 to −2.52]; I2 = 93%), amounting for shorter duration of treatment (MD: −119.02 days [−137.41 to −100.62]; I2 = 96%) and savings in costs between 41 and 57% with absolute savings of 4,019$ to 9,192$ favoring CSEMS. All outcomes had a low to very low certainty of evidence (CoE), except for technical success and stricture resolution (moderate CoE). Our analysis suggests that CSEMSs are comparable to MPSs in terms of efficacy and safety. However, it shows that CSEMSs are more cost-effective. Sample size calculations from our analyses can guide the design of future studies to validate the safety profiles and determine the feasibility of the two modalities.

Abstract Coronary artery bypass graft (CABG) surgery is one of the most commonly performed surgeries in the United States. It remains the gold standard of coronary artery revascularization despite the introduction of percutaneous coronary interventions and advancements in medical therapy. First conceptualized in the 1900s, CABG underwent decades of trials, experimentation, innovations, and even failures. Despite the challenges, CABG continued to innovate, overcoming the complexities of coronary artery disease and improving patient outcomes. This manuscript aims to discuss the beginnings, evolution, and future of CABG.

Abstract Reactive arthritis is an immune-mediated arthropathy caused by a preceding remote infection. Typically, reactive arthritis affects the joints of the lower extremities but can occur in the upper extremity. There are a few case reports of reactive arthritis primarily involving the joints of the hand and wrist, necessitating surgical intervention. We describe the case of a 37-year-old, right-hand dominant female who presented with severe left wrist pain. After obtaining radiographs, she was diagnosed with severe erosive changes in the radiolunate joint and distal radioulnar joint (DRUJ) and secondary reactive gonococcal arthritis of the DRUJ. The patient failed conservative measures and ultimately underwent radioscapholunate (RSL) arthrodesis, distal ulna resection, and wrist denervation. Postoperatively, she had resolution of her pain and an excellent functional outcome. Refractory reactive arthritis of the DRUJ can cause concomitant adjacent joint erosive changes. Performing RSL arthrodesis and distal ulna resection can provide an excellent functional outcome and still allow motion to be preserved through the midcarpal joint. IV: Case report level IV or higher evidence.

Abstract Left atrial enlargement is a well-recognized marker of adverse cardiovascular outcomes, but its impact on early morbidity and mortality after valve replacement remains uncertain. We retrospectively reviewed 422 patients who underwent aortic and/or mitral valve replacement (MVR) for rheumatic heart disease at X between 2004 and 2022. Preoperative left atrial diameter index (LADI) was measured, and patients were classified as normal (<2.3 cm/m2) or abnormal (≥2.3 cm/m2). Clinical, operative, and postoperative outcomes were compared. The primary endpoint was 30-day all-cause mortality; secondary endpoints included postoperative atrial fibrillation (POAF), neurological events, renal impairment, re-exploration for bleeding, and intraoperative pacing wire requirement. Nearly half of patients (48.8%) had abnormal LADI. Patients with enlarged atria were more often female, had smaller body size, and were significantly more likely to undergo MVR (42.7% versus 18.1%, p < 0.001). Abnormal LADI was strongly associated with POAF (16.0% versus 7.4%, p = 0.006) and intraoperative pacing wire insertion (38.3% versus 23.5%, p = 0.001). Multivariate analysis confirmed severe LADI as an independent predictor of POAF (OR 3.91, p = 0.001) and pacing requirements (OR 2.31, p = 0.004). No significant differences were observed in 30-day mortality, stroke/transient ischemic attack, renal dysfunction, or bleeding complications. Preoperative LADI is an independent predictor of postoperative arrhythmic complications and pacing needs after valve replacement, but not early mortality. Incorporating LADI into preoperative risk assessment may improve rhythm surveillance and perioperative planning. Future prospective studies should evaluate its long-term prognostic value and role in reverse remodeling after surgery.

Abstract The purpose of the current study was to identify the influence of individual characteristics on differences in body fat percentage between air displacement plethysmography and dual-energy X-ray absorptiometry (change in body fat percentage) in 360 collegiate student-athletes. Body fat percentage was obtained from air displacement plethysmography and dual-energy X-ray absorptiometry. A 2 (sex)×3 (Brozek body fat percentage, Siri body fat percentage, and dual-energy x-ray absorptiometry body fat percentage) analysis of variance was used to evaluate the difference between the body fat percentages obtained from air displacement plethysmography and dual-energy x-ray absorptiometry in men and women. The agreement between air displacement plethysmography and dual-energy X-ray absorptiometry was evaluated via Bland–Altman plot and linear regression. Multiple linear regression was used to identify the influence of sex, race, height, and body mass on the change in body fat percentages. Dual-energy X-ray absorptiometry yielded greater body fat percentages in both men (4.8±2.8; p < 0.001) and women (2.2±2.9; p < 0.001) compared to air displacement plethysmography measurements. Proportional and systematic biases were observed between air displacement plethysmography and dual-energy X-ray absorptiometry. Race, height, and mass were significant predictors of the body fat percentage difference between air displacement plethysmography and dual-energy X-ray absorptiometry (R 2=0.445, p<0.001, and standard error of the estimate=2.527). The present study suggests that air displacement plethysmography underestimates body fat percentages when compared to dual-energy X-ray absorptiometry and this underestimation may not be the same for every athlete due to their individual characteristics.

Abstract The diagnosis of predementia stages indicates an increased risk of progression to dementia. The Amyloid, Tau, and Neurodegeneration AT(N) classification considers measurements of altered proteins and the presence of neurodegeneration to classify the risk groups regarding the pathophysiology of Alzheimer's disease (AD). The cognitive and anatomical characteristics of the patients in the predementia stage according to the AT(N) classification are not fully understood. To investigate whether there are differences in the clinical and anatomical profiles among older adults in the predementia stage according to the ATN classification, and to investigate the associations involving cognition and cortical thickness and subcortical volume in the AT(N) groups. In total, 72 older adults with subjective cognitive decline and mild cognitive impairment were allocated to groups according to the AT(N) classification (AD continuum: n = 37; suspected non-AD pathophysiology: n = 8; normal biomarkers: n = 27). The participants were investigated through cognitive tests, magnetic resonance imaging scans, and cerebrospinal fluid analyses. We used multivariate and univariate analyses with post-hoc testing to verify differences among groups. In addition, linear regressions were performed to verify the interactions involving cognition and gray matter metrics. The suspected non-AD pathophysiology group showed worse performance in attention/executive function than the AD continuum and normal biomarkers groups (p = 0.04). However, the ATN classification groups did not differ in terms of cortical thickness (p > 0.05). In addition, in the AD continuum group, memory was associated with left fusiform gyrus thickness (p = 0.000 uncorrected; r = 0.238). Cognition, but not gray matter metrics, differs among AT(N) classification groups. Memory is associated with cortical thickness in patients with positive amyloid Beta (AD continuum).

Abstract Extra-axial chordoma (EAC) is a very rare, malignant tumor with metastatic potential that arises in the extra-axial skeleton and soft tissues. We report the case of a 51-year-old right-handed male with EAC of the left capitate. He underwent capitate resection and wrist arthrodesis utilizing scaphoid autograft with the treatment goal of minimizing risk of tumor recurrence and metastasis while maximizing hand and wrist function. His radiographic outcome demonstrated union of his arthrodesis site. However, 7 months postoperatively, he started experiencing increased hand and wrist pain and was found to have early tumor reoccurrence. Few cases of EAC have been reported in the literature. EAC is typically treated with resection alone, although there is a limited role for chemotherapy and radiation in the setting of locally reoccurring or metastatic disease. Functional outcomes of the affected extremity and survival outcomes vary widely. This is the first report in the literature of EAC of a single carpal bone and describes an innovative technique for definitive surgical treatment of this rare tumor. Utilization of scaphoid autograft for wrist arthrodesis in the setting of capitate resection allows the use of autograft in a wrist arthrodesis without the additional morbidity of iliac crest bone grafting. This case also demonstrates the importance of appropriate diagnosis and oncologic technique at the index surgery.

Abstract Patients with hypertensive disorders of pregnancy (HDPs) are recommended to attend an early postpartum follow-up visit for blood pressure monitoring. Follow-up frequency for patients with HDPs can vary widely, with some patients requiring multiple office visits. We sought to determine factors associated with multiple postpartum blood pressure visits among patients with HDPs. We retrospectively identified patients with HDPs who delivered at our maternity center in 2019 and compared factors between patients who attended a single blood pressure follow-up appointment without requiring further clinical evaluation for hypertension and patients who required multiple postpartum clinical evaluations for persistent hypertension. Univariate logistic regression models were used to identify factors associated with increased odds of having multiple clinically indicated postpartum visits for blood pressure monitoring. We identified 328 patients with HDPs, of whom 260 (79.3%) attended an initial postpartum blood pressure follow-up appointment and were included in further analyses. Of the 260 patients, 70 (26.9%) had multiple blood pressure visits. Factors associated with multiple blood pressure visits included delivery between 34 and less than 37 weeks of gestation (odds ratio [OR], 3.62; 95% CI, 1.07–12.30), systolic blood pressure before discharge of 140 mm Hg or higher (OR, 5.02; 95% CI, 2.57–9.82), and discharge with blood pressure medication (OR, 3.42; 95% CI, 1.82–6.41). Patients with HDPs who deliver preterm, have persistent hypertension before discharge, or are discharged with antihypertensive medication require continued close postpartum observation and continuity of care.