Follow-up Of Asymptomatic Patients Research Articles

The Role of Global Longitudinal Strain in the Follow-Up of Asymptomatic Patients with Chronic Primary Mitral Regurgitation.

Background/Objectives: In patients with chronic primary mitral regurgitation (MR), postoperative persistent left ventricular (LV) dysfunction underlines the lack of a sensitive parameter that can identify subclinical LV dysfunction and optimize the timing of intervention. Left ventricular global longitudinal strain (LV-GLS) is a measure of the longitudinal left ventricular systolic function, with prognostic significance. Its role in the follow-up of asymptomatic patients with MR is, however, poorly defined. The aim of this study was to assess the relative changes in LV-GLS in a cohort of MR patients and to correlate these changes with the need for intervention during a follow-up period. Methods: We conducted a prospective study on a cohort of 218 patients, divided into three subgroups according to MR severity (mild, moderate, severe). LV-GLS was measured at baseline and every six months during a median follow-up period of 30 months. The composite endpoint was the occurrence of heart failure symptoms, hospitalization for heart failure, LVEF < 60%, LVEDD > 45 mm, new onset atrial fibrillation, or cardiovascular death. Results: Patients with moderate and severe MR had a significantly lower GLS at baseline than those with mild MR (19.5% and 19.1% versus 22.3%, p < 0.01) despite a normal LVEF in all subgroups. The relative decrease in LV-GLS occurred earlier (at 12 months vs. 24 months) and was more evident in patients with moderate and severe MR (13.6% and 14.5%, respectively) versus patients with mild MR (6.72%). The baseline LV-GLS being under 18% and a relative decrease of over 10% in GLS were independent predictors of a composite outcome (HR = 1.59, CI 95% 1.17-2.86; HR = 1.74, CI 95% 1.2-2.91, p < 0.01). Conclusions: LV-GLS is a valuable monitoring tool for asymptomatic MR patients, a relative decrease > 10% in GLS may be predictive for the need for valve intervention.

Serum Sodium Alterations in Children with Primary Monosymptomatic Nocturnal Enuresis Using Desmopressin

Background: Hyponatremia/water intoxication has been considered a rare but serious complication of desmopressin (DDAVP) for the treatment of primary monosymptomatic nocturnal enuresis (PMNE). Objectives: This study aimed to identify the incidence and risk factors of serum sodium (Na) alterations in children with PMNE treated with oral or intranasal DDAVP. Methods: A total of 201 patients with PMNE were evaluated in 2 groups using intranasal (n = 127) or oral DDAVP (n = 74) for approximately 6 months. Treatment efficacy was defined as a more than 50% decrease in wet nights after 1 month of treatment. Serum Na was measured before, during, and after treatment in all patients. Predisposing factors of serum Na disturbance were evaluated concomitantly. Results: The mean age of patients was 8.8 ± 2.6 (5 - 17.5) years, and males outnumbered females (M/F = 1.68). Treatment efficacy was 100% in 93 (46.2%), and &gt; 90% in 157 (78.1%) cases. Oral DDAVP had significantly more therapeutic effects than intranasal treatment (P = 0.024). However, serum Na had no significant difference between the 2 groups (P = 0.52). Hyponatremia occurred in 7 (3.5%) patients (3 in oral treatment and 4 in intranasal treatment; P = 0.73) with no significant correlation to age, gender, body weight, frequency of enuresis, and initial serum Na. However, decreased serum Na &gt; 5 mEq/L was a significant risk factor for the prediction of hyponatremia in our patients (P &lt; 0.001). Conclusions: Oral DDAVP had more therapeutic effects than intranasal treatment for the treatment of PMNE. Serum Na had no significant alteration in both oral and intranasal treatments, and hyponatremia was a rare complication of DDAVP, which occurred significantly in children with a &gt; 5-mEq/L decrease of initial serum Na concentration. As a suggestion, monitoring serum Na is not an essential follow-up in asymptomatic patients in DDAVP treatment.

P.172 Work-up and management of asymptomatic extracranial traumatic vertebral artery injury

Background: Extracranial traumatic vertebral artery injury (eTVAI) is common following non-penetrating head and neck trauma. Most cases are initially asymptomatic with an increased risk for stroke. Consensus is lacking regarding screening, treatment, and follow-up of asymptomatic patients with eTVAI. Our objective was to investigate national practice patterns reflecting these domains. Methods: An electronic survey was distributed via the Canadian Neurological Sciences Federation and Canadian Spine Society. Two case-based scenarios featured asymptomatic patients with eTVAI. Case 1: non-displaced cervical lateral mass fracture; angiography stratified by luminal diameter reduction. Case 2: complex C2 fracture; angiography featuring pseudoaneurysm dissection. Analysis: descriptive statistics. Results: Response Rate: 108 of 182 participants (59%), representing 20 academic institutions.Case 1: 78% of respondents would screen using CTA (97%), immediately (88%). Most respondents (97%) would initiate treatment, using aspirin (89%) for 3-6 months (46%).Case 2: 73% of respondents would screen using CTA (96%), immediately (88%). The majority of respondents (94%) would initiate treatment, using aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy.In both cases, the majority of respondents would follow-up clinically or radiographically every 1-3 months, respectively. Conclusions: This study highlights consensus in Canadian practice patterns for the workup and management of asymptomatic eTVAI.

Prognostički doprinos dvodimenzionalnog opterećenja leve pretkomore kod pacijenata sa asimptomatskom mitralnom stenozom u tuniskoj populaciji

Objective. The two-dimensional strain is an objective echocardiographic technique allowing the quantification of myocardial deformation. The aim of this study was to specify prognostic contribution of left atrial strain in patients with asymptomatic mitral stenosis. Methods. We included consecutive patients followed for severe or moderately severe rheumatic Mitral Stenosis (MS), asymptomatic, during the period from January 2015 to June 2020 in the Military Hospital of Tunis. The patients followed were divided into two groups according to one criterion of judgment composed of: Cardiac mortality, The occurrence of hospitalization for cardiac reasons, The occurrence of atrial fibrillation (AF), The occurrence of a thromboembolic event, and the need for cardiac surgery or mitral valvuloplasty. Results. Initially eighty patients were selected, but only 53 were followed and then divided into two groups: 30 patients had at least one event and 23 patients had no events according to the occurrence of the major endpoint of the study. In a univariate study and for conventional echocardiographic parameters, we determined that if Left Atrium Area (LAA) is larger than 30 cm 2 and left atrium volume (LAV) more than 100ml/m 2, the risk of occurrence of an event increased significantly respectively (LAA: 69% vs 10%; p = 0.01; OR = 6.6; 95% CI [1.5-28]) and (LAV: 71.4% vs 39%; p = 0.002; OR = 4; 95% CI [1.1-13]). The same was true for left atrium deformation parameters, both Peak Atrial Longitudinal Strain (PALS) &lt;25% and Peak Atrial Contraction Strain (PACS) &lt;10 % were predictive of events in univariate study with the following respective odds ratios (ORs) (PALS: 83% vs 30.4%; p = 0.0001; OR = 11.4; 95% CI [3-42]), and (PACS: 90% vs 47%; p = 0.001; OR = 9.8; 95% CI [2.3-41]). In a multivariate study, the only independent parameter of the occurrence of an event was PACS &lt;10% (p = 0.013; OR = 44; 95% CI [2.19-80]). Conclusion. PACS have prognostic value in asymptomatic MS as it predicts the occurrence of pathologic events in the followup of asymptomatic patients.

Median Nerve and Carpal Tunnel Morphology Before and After Endoscopic Carpal Tunnel Release: A 6-Year Follow-up Study.

Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR). In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point. All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years. We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

Dental implant imaging: What do South African dentists and dental specialists prefer?

To document the types of imaging modalities that are commonly prescribed during dental implant therapy in South Africa. The radiographic preferences were obtained from practitioners via an electronic survey that was disseminated during local dental conferences, electronic channels (e.g., email lists) of multiple dental schools and local dental scientific societies, and personal interviews. The survey consisted of multiple-choice questions which were designed to investigate the most common radiographic prescriptions during various treatment phases of implant therapy. The responses of one hundred and forty-two participants (General practitioners and dental specialists) practising in different South African provinces were collected and assessed. Principally, panoramic radiographs combined with cone beam computed tomography (PAN + CBCT) followed by CBCT, as a single examination (ASE), were the most preferable modalities during the implant planning phase (39% and 29%, respectively). During and directly after the surgery, periapical radiographs (ASE) were the most preferred (87% and 65%, respectively). The most widely preferred radiographic examination during the planning of implants was panoramic radiographs combined with CBCT. Periapical radiographs (ASE) were favoured during, directly after the treatment, and during the follow-up of asymptomatic patients by the majority of participants. However, CBCT (ASE) was preferred in the follow up of symptomatic patients. Factors related to extra anatomical information and superior dimensional accuracy provided by three-dimensional volumes (e.g., CBCT volumes), were the most indicated influencing factors on the radiographic prescriptions during implant planning.

Clinical utility and economic impact of routine delayed follow-up radiographs in children with uncomplicated distal radius Salter-Harris 2 fractures.

Salter-Harris 2 fractures of the distal radius are common in pediatrics. Children with these fractures have a theoretical risk of developing a physeal bridge with subsequent growth disturbance. The purpose of this study was to investigate the clinical utility and economic impact of obtaining routine delayed radiographs in asymptomatic patients with uncomplicated Salter-Harris 2 fractures of the distal radius. Radiology records were searched retrospectively between Jan. 1, 2016, and Jan. 1, 2018, to identify patients with an acute Salter-Harris type 2 fracture of the distal radius and delayed wrist radiography 3 to 8months after the injury. Exclusion criteria included distal radius surgery, clinical symptoms, secondary wrist trauma or a history of infection. The financial cost associated with follow-up imaging was determined based on standard charges associated with wrist/forearm radiography, wrist magnetic resonance imaging (MRI) and orthopedic clinical care. A total of 381 children with Salter-Harris 2 fractures of the distal radius and delayed radiographs were identified, 56% male (ages 1-18years, mean: 9.8years). Four children were excluded because of surgical intervention or clinical symptoms to the same wrist resulting in 377 subjects. There were five confirmed positive cases (1.3%) of distal radius physeal bridge formation, with four cases confirmed on MRI and one case confirmed clinically and radiographically. Based on routine institutional charges for the wrist/forearm radiographs and orthopedic clinic visits, the total billed charges for the 377 patients would equal $245,804, or $49,161 in billed charges per identified physeal bridge. Only three of the five positive cases of confirmed physeal bridge went on to surgical treatment. The billed charges per identified physeal bridge requiring surgery were $81,935. In asymptomatic children with uncomplicated Salter-Harris 2 fractures of the distal radius, detection of a physeal bridge on delayed radiographs is rare. The financial burden of routine delayed follow-up in asymptomatic patients, a common clinical practice, is an important consideration.

How much does a Medical and Healthcare Products Regulatory Agency medical device alert for metal-on-metal hip arthroplasty patients really cost?

Background:Many worldwide regulatory authorities recommend regular surveillance of metal-on-metal hip arthroplasty patients given high failure rates. However, concerns have been raised about whether such regular surveillance, which includes asymptomatic patients, is evidence-based and cost-effective. We determined: (1) the cost of implementing the 2015 MHRA surveillance in “at-risk” Birmingham Hip Resurfacing (BHR) patients; and (2) how many asymptomatic hips with adverse reactions to metal debris (ARMD) would have been missed without patient recall.Methods:All BHR patients eligible for the 2015 MHRA recall (all females, and males with head sizes ⩽46 mm, regardless of symptoms) at one centre were invited for review (hips = 707; patients = 593). All patients were investigated (Oxford Hip Score, radiographs, blood metal ions, and targeted cross-sectional imaging) and managed accordingly. Surveillance costs were calculated using finance department data.Results:The surveillance cost £105,921.79 (range £147.76–£257.50/patient). Radiographs (£39,598) and nurse practitioner time/assistance (£23,618) accounted for 60% of overall costs. 31 hips had ARMD on imaging (12 revised; 19 under surveillance). All revisions were symptomatic. 7 hips with ARMD under surveillance were asymptomatic and remain under regular review. The number needed to treat to avoid missing one asymptomatic ARMD case was 101 patients, representing a cost of £18,041 to avoid one asymptomatic case.Conclusions:Implementing MHRA surveillance for “at-risk” BHR patients was extremely costly. The risk of asymptomatic ARMD was low with the BHR (1%), suggesting recommended follow-up in asymptomatic patients is not cost efficient. This raises concerns about the increasingly intensive surveillance recommended in the 2017 MHRA guidance for metal-on-metal hip patients.

Are familial colloid cysts of the third ventricle associated with a worse clinical course than sporadic forms?

The incidence of asymptomatic colloid cysts is increasing due to the widespread use of neuroimaging tools. According to previous works, familial forms (within first-degree relatives) represent 5-25% of the cases, and it is not clear whether they display specific features influencing the clinical behavior of the disease. We reviewed the literature to extract data from papers dealing with familial colloid cysts. For comparison, previous series dealing with the natural history of sporadic cases were identified. Also, we present two more cases of familiar colloid cysts from our experience. Fifty-one patients (23 reports, plus our cases) were analyzed from the literature. Familial cases showed a younger age at diagnosis (P=0.02) and fewer asymptomatic cases (P<0.001) compared to non-familial colloid cysts. The odds ratio and relative risk of needing surgery with a positive family history for surgical cyst removal were respectively 17.5 (CI: 1.6-197.4) and 1.9 (CI: 0.71 - 5.1). Screening of other family members identified further colloid cysts in 4% of families. Familial colloid cysts show a higher percentage of younger and symptomatic patients compared to non-familiar forms. A positive family history for surgical evacuation is a predictor for a similar outcome. This could indicate a predisposition to an earlier formation and faster growth, and the need for a stricter follow-up in asymptomatic patients. If confirmed in the future, this could suggest a review of the criteria for cyst treatment and extend the surgical indication to asymptomatic familial cases.

Exercise echocardiography in aortic stenosis with preserved ejection fraction.

The appropriate timing of intervention and follow-up in asymptomatic patients with aortic stenosis remains controversial. Risk stratification is a key, especially with the use of a multimodality imaging approach, including exercise stress echocardiography. This review focuses on the use of exercise echocardiography in asymptomatic patients with moderate and severe aortic stenosis with preserved left ventricular ejection fraction. It describes the exercise echocardiography protocol, parameters to be evaluated, and its role in guiding the timing of intervention and follow-up in these patients.

P71-S Transthyretin familial amyloid polyneuropathy (TTR-FAP). Neurophysiological assessment in asymptomatic carriers

Background Transthyretin familial amyloid polyneuropathy (TTR-FAP) is a rare hereditary disorder caused by mutations in the TTR gene. Unless treated, its course is very severe and death occurs after 7–10 years of symptoms onset. Genetic counseling is crucial in the detection of asymptomatic carriers, and scientific societies recommend a thorough examination and follow-up to detect the onset of the disease and indication of treatment. The aim of the study is to evaluate the usefulness of neurophysiological tests to detect the onset of polyneuropathy in asymptomatic carriers of the TTR mutation. Material and methods Asymptomatic carriers of the TTR mutation were selected. Clinical and neurophysiological evaluation were performed every 12 months. Motor and sensory nerve conduction studies (NCS) were used to evaluate thick nerve fiber in upper and lower limbs. The study of fine nerve fiber included the variation of the RR interval, cutaneous sympathetic response (SSR) by electrical stimulation, Sudoscan, and the study of thermal and algic thresholds by quantitative sensory test (QST) in the hands and feet. Results Nineteen asymptomatic carriers of the TTR mutation have been included (13 men and 6 women) and followed for an average of 5 years. Four of them developed some abnormality in the QST, 4 developed carpal tunnel syndrome, and 5 showed some abnormality of SSR and QST of uncertain significance. The sudoscan test provided greater sensitivity than the SSR. Conclusion The neurophysiological study of fine nerve fiber is a useful method in the follow-up of asymptomatic patients carrying TTR mutation.

What is the Relevance of the Systematic Use of Gadolinium During the MRI Follow-Up of Multiple Sclerosis Patients Under Natalizumab?

Multiple sclerosis (MS) patients represent apopulation potentially affected by the intracerebral accumulation of gadolinium-based contrast agents (GBCA) due to repeated magnetic resonance imaging (MRI) performed during their lifetime; however, MRI is still the best tool to monitor MS inflammatory activity. This study aimed to evaluate the relevance of GBCA injections during the MRI follow-up of MS patients under natalizumab (Tysabri) treatment. The MRI data results were retrospectively reviewed in amonocentric study (University Hospital of Toulouse, France) from all consecutive patients treated with natalizumab from January 2014 to January 2017. For each examination during the whole MRI follow-up, new lesions (enhancing and non-enhancing) were analyzed. Atotal of 129 patients were included in this study (65% female, mean age = 41years, mean treatment duration 6.5years, 50% positive for John Cunningham virus) and benefited from 735 MRIs with GBCA. Only 3MRIs showed anew enhancing lesion, systematically encountered after treatment discontinuation. According to this study based on the clinical and radiological practice, the systematic use of GBCA seems of limited relevance in the MRI follow-up of asymptomatic patients treated continuously with natalizumab.

PDGF-BB serum levels are decreased in adult onset Pompe patients

Adult onset Pompe disease is a genetic disorder characterized by slowly progressive skeletal and respiratory muscle weakness. Symptomatic patients are treated with enzymatic replacement therapy with human recombinant alfa glucosidase. Motor functional tests and spirometry are commonly used to follow patients up. However, a serological biomarker that correlates with the progression of the disease could improve follow-up. We studied serum concentrations of TGFβ, PDGF-BB, PDGF-AA and CTGF growth factors in 37 adult onset Pompe patients and 45 controls. Moreover, all patients performed several muscle function tests, conventional spirometry, and quantitative muscle MRI using 3-point Dixon. We observed a statistically significant change in the serum concentration of each growth factor in patients compared to controls. However, only PDGF-BB levels were able to differentiate between asymptomatic and symptomatic patients, suggesting its potential role in the follow-up of asymptomatic patients. Moreover, our results point to a dysregulation of muscle regeneration as an additional pathomechanism of Pompe disease.

313. Outpatient Treatment and Recurrence of Prosthetic Joint Infection (PJI) in Infectious Disease (ID) Physician Office Infusion Centers (POICs): A 2-Year Retrospective Multicenter Analysis

BackgroundA significant complication of prosthetic joint replacement is the development of a PJI. Therapy includes prolonged IV antibiotics (IVAB), usually delivered in the outpatient setting. Follow-up (FU) in this population can be difficult, particularly for the treating ID physician. We report our experience treating PJI in an ID POIC.MethodsRetrospective chart review was conducted of patients (patients) with initial knee or hip PJI, who received ≥3 days of IVAB in 14 ID POICs from July 2015 to July 2017. Initial clinical success (ICS) was defined as no evidence of infection at the completion of outpatient parenteral antimicrobial therapy (OPAT), although continued oral antibiotics were allowed. Available FU patients were assessed at 6 months for recurrence and associated factors analyzed using χ2 and Fisher’s exact test.ResultsWe evaluated 171 patients (122 knees, 49 hips) with a median age of 65 years (range 31–91) and 64% male. Infection occurred within 90 days of the implant in 40% (25% within 30 days). Prostheses were retained in 109 patients (64%). 91% were hospitalized prior to OPAT for 4.7 median days, with the remainder treated from the community. The median length of OPAT was 37 days (range: 8–77). Cultures were positive in 154 patients with 122 Staphylococcus spp. pathogens (43% MSSA, 43% CoNS, 13% MRSA) in 112 patients. Most commonly prescribed IVABs were vancomycin (41%) and cefazolin (37%). ICS was achieved in 163 patients (95%), independent of prosthesis removal, with 119 (73%) continuing oral antibiotics post OPAT. Eight patients did not complete OPAT. Six-month FU to the ID physician was available for 97/163 patients completing therapy (60%). Of these, recurrence occurred in 22 patients (23%) at a median of 2.1 months (range 0.2–6). Risk factors for recurrence are noted below. Oral rifampin use with IVAB was associated with a significantly lower rate of recurrence in patients with staphylococcal PJI (P = 0.004).ConclusionThis real-world evaluation underscores the challenges of successful treatment of PJI. ICS was readily achieved (95%). High recurrence (23%) may be exaggerated by lower likelihood of FU in asymptomatic patients. Lack of improvement in 6-month cure with prosthesis removal merits additional inquiry. Although the group was small, adjunctive rifampin suggests improved outcomes in staphylococcal PJI. Disclosures B. S. Metzger, Allergan: Speaker’s Bureau, Speaker honorarium. L. J. Van Anglen, Merck & Co.: Investigator, Research grant.

Role of 18F-FDG PET/CT in restaging and follow-up of patients with uterine sarcomas

PurposeUterine sarcomas are rare tumors with poor prognosis due to the high recurrence rates. The current role of 18F-FDG PET/CT in the post-therapy surveillance is not established yet. Materials and MethodsForty-one women with uterine sarcoma underwent 73 18F-FDG PET/CT for restaging in suspected recurrence or during follow-up in asymptomatic patients. Histopathology results and/or clinical/imaging follow-up for at least 12 months were considered the reference standard. The diagnostic accuracy and clinical impact of 18F-FDG PET/CT was calculated. ResultsThirty-three 18F-FDG PET/CT were positive, while the remaining 40 studies were negative. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 18F-FDG PET/CT were 88%, 98%, 97%, 91% and 93%, respectively. Considering patients with clinical or radiological suspicion of recurrence (n=47) and those during follow-up (n=26), sensitivity, specificity, PPV, NPV and accuracy of 18F-FDG PET/CT were 89%, 100%, 100%, 86% and 94%, and 80%, 95%, 80%, 95% and 92%, respectively. 18F-FDG PET/CT had a positive clinical impact in 9/73 (12%) studies and changed the clinical management in 8/41 (20%) patients. Conclusions18F-FDG PET/CT seems to be an accurate method for detection and localization of local and distant recurrence in patients with uterine sarcoma with good sensitivity and specificity and significant impact on clinical decision making.

The Prognostic Value and Clinical Use of Myocardial Perfusion Scintigraphy in Asymptomatic Patients after Percutaneous Coronary Intervention.

BackgroundThe role of myocardial perfusion scintigraphy (MPS) in the follow-up of asymptomatic patients after percutaneous coronary intervention (PCI) is not established.ObjectivesTo evaluate the prognostic value and clinical use of MPS in asymptomatic patients after PCI.MethodsPatients who underwent MPS consecutively between 2008 and 2012 after PCI were selected. The MPS were classified as normal and abnormal, the perfusion scores, summed stress score (SSS), and summed difference score (SDS) were calculated and converted into percentage of total perfusion defect and ischemic defect. The follow-up was undertaken through telephone interviews and consultation with the Mortality Information System. Primary endpoints were death, cardiovascular death, and nonfatal acute myocardial infarction (AMI), and secondary endpoint was revascularization. Logistic regression and COX method were used to identify the predictors of events, and the value of p < 0.05 was considered statistically significant.ResultsA total of 647 patients were followed for 5.2 ± 1.6 years. 47% of MPS were normal, 30% were abnormal with ischemia, and 23% were abnormal without ischemia. There were 61 deaths, 27 being cardiovascular, 19 non-fatal AMI, and 139 revascularizations. The annual death rate was higher in those with abnormal perfusion without ischemia compared to the groups with ischemia and normal perfusion (3.3% × 2% × 1.2%, p = 0.021). The annual revascularization rate was 10.3% in the ischemia group, 3.7% in those with normal MPS, and 3% in those with abnormal MPS without ischemia. The independent predictors of mortality and revascularization were, respectively, total perfusion defect greater than 6%, and ischemic defect greater than 3%. Forty-two percent of the patients underwent MPS less than 2 years after PCI, and no significant differences were observed in relation to those who underwent it after that period.ConclusionAlthough this information is not contemplated in guidelines, in this study MPS was able to predict events in asymptomatic after PCI patients, regardless of when they were performed.

The Management of the Paranasal Sinus Osteomas.

Osteoma is the most common benign tumor of the paranasal sinuses. The clinical characteristics and treatment of this disease remain controversial. The aim of this study is to determine the appropriate method of treatment approach according to the features of osteomas. Forty-one patients with paranasal sinus osteomas were included in the study. According to the location and the size of tumors, patients were followed up or operated. Surgical treatment was performed via external, endoscopic, or combined approaches for symptomatic patients. Routine physical and radiological evaluations were performed for follow-up in asymptomatic patients. Paranasal sinus osteomas were found most common in frontal sinus (n = 26, 63.4%) followed by ethmoid sinus (n = 10, 24.3%), maxillary sinus (n = 4, 9.7%), and sphenoid sinus (n = 1, 2.4%). Of the patients with frontal sinus osteomas, the endoscopic approach was performed in 11 patients, external approach (osteoplastic flap) in 9, and combined (external + endoscopic) approach in 5 patients. Endoscopic approach was preferred in all patients with ethmoid osteoma. The combination of Caldwell-Luc procedure and endoscopic approach was performed in 1 patient with maxillary sinus osteoma. In 3 patients, who underwent osteoplastic flap technique, mucocele developed in the postoperative period. Partial loss of vision developed postoperatively in 1 patient with a giant ethmoid osteoma. There were no other complications and recurrence in an average of 29 months follow-up. Paranasal sinus osteomas are rare, slow-growing benign lesions, with potentially serious complications. Main treatment option for sphenoid and ethmoid sinus and other symptomatic osteomas are surgical resection. Radiographic follow-up is necessary for asymptomatic lesions. Selection of surgical resection method depends on tumor location and size. Patients should be observed for recurrence with periodic examination and imaging techniques. Follow-up should be performed at least in 1-year intervals after the surgery. 1c.

Relationship between exercise pressure gradient and haemodynamic progression of aortic stenosis

We hypothesized that large exercise-induced increases in aortic mean pressure gradient can predict haemodynamic progression during follow-up in asymptomatic patients with aortic stenosis. We retrospectively identified patients with asymptomatic moderate or severe aortic stenosis (aortic valve area<1.5cm2 or<1cm2) and normal ejection fraction, who underwent an exercise stress echocardiography at baseline with a normal exercise test and a resting echocardiography during follow-up. The relationship between exercise-induced increase in aortic mean pressure gradient and annualised changes in resting mean pressure gradient during follow-up was investigated. Fifty-five patients (mean age 66±15 years; 45% severe aortic stenosis) were included. Aortic mean pressure gradient significantly increased from rest to peak exercise (P<0.001). During a median follow-up of 1.6 [1.1-3.2] years, resting mean pressure gradient increased from 35±13mmHg to 48±16mmHg, P<0.0001. Median annualised change in resting mean pressure gradient during follow-up was 5 [2-11] mmHg. Exercise-induced increase in aortic mean pressure gradient did correlate with annualised changes in mean pressure gradient during follow-up (r=0.35, P=0.01). Hemodynamic progression of aortic stenosis was faster in patients with large exercise-induced increase in aortic mean pressure gradient (≥20mmHg) as compared to those with exercise-induced increase in aortic mean pressure gradient<20mmHg (median annualised increase in mean pressure gradient 19 [6-28] vs. 4 [2-10] mmHg/y respectively, P=0.002). Similar results were found in the subgroup of 30 patients with moderate aortic stenosis. Large exercise-induced increases in aortic mean pressure gradient correlate with haemodynamic progression of stenosis during follow-up in patients with asymptomatic aortic stenosis. Further studies are needed to fully establish the role of ESE in the decision-making process in comparison to other prognostic markers in asymptomatic patients with aortic stenosis.

Imaging tests in staging and surveillance of non-metastatic breast cancer: changes in routine clinical practice and cost implications

Background:Although guidelines do not recommend computerised tomography (CT), positron emission tomography (PET) or magnetic resonance imaging (MRI) for the staging or follow-up of asymptomatic patients with non-metastatic breast cancer, they are often requested in routine clinical practice. The aim of this study was to determine the staging and follow-up patterns, and relative costs in a large population of breast cancer patients living and treated in a Southern Italian region.Methods:We analysed the clinical computerised information recorded by 567 primary-care physicians assisting about 650 000 inhabitants in the Campania region. Patients with non-metastatic breast cancer were identified and divided into calendar years from 2001 to 2010. The number of diagnostic tests prescribed per 100 patients (N/Pts) and the mean cost per patient was determined 3 months before diagnosis and up to 1 year after diagnosis. Costs are expressed in constant 2011 euros.Results:We identified 4680 newly diagnosed cases of asymptomatic non-metastatic breast cancer. N/Pts increased significantly (P<0.0001) from 2001 to 2010. The mean number of prescribed mammograms, bone scans, abdominal ultrasound and chest X-rays (‘routine tests’), and costs was unchanged. However, the number of CT, PET scans and MRI (‘new tests’)prescriptions almost quadrupled and the mean cost per patient related to these procedures significantly increased from €357 in 2001 to €830 in 2010 (P<0.0001).Conclusions:New test prescriptions and relative costs significantly and steadily increased throughout the study period. At present there is no evidence that the delivery of new tests to asymptomatic patients improves breast cancer outcome. Well-designed clinical trials are urgently needed to shed light on the impact of these tests on clinical outcome and overall survival.

CT or CT/PET Surveillance in Asymptomatic Adult and Pediatric Patients Following Curative Intent Therapy for Hodgkin Lymphoma and Aggressive Non-Hodgkin Lymphoma: A Systematic Review

Background:Hodgkin lymphoma (HL) and aggressive non-Hodgkin lymphoma (NHL) both have relatively high curative-potential with contemporary treatment strategies. Despite this, a substantial number of patients will relapse, and a principal objective of follow-up is to identify recurrent disease. The optimal method for detection of relapsed disease has been debated extensively in the literature. Previous guidelines recommended routine surveillance imaging (SI) as a means to detect relapsed disease; however, recent recommendations have de-emphasized routine SI. Nonetheless, controversy remains and approaches vary dramatically across different regions. Aim:We completed a comprehensive systematic review to evaluate whether routine surveillance with computed tomography (CT) and/or positron emission tomography (PET) for patients in complete remission following curative intent therapy for HL and/or aggressive NHL identifies more relapses than clinical vigilance strategies, and if it improves progression free (PFS) and/or overall survival (OS).Methods:We searched Medline, [1946 to Oct 18, 2015] andEMBASE [1980 to Oct 18, 2015] for English-language studies assessing one or more surveillance strategies in adult and/or pediatric patients in remission from HL and/or aggressive NHL. Reviews, conference abstracts, case reports, letters, comments, books, and editorials were excluded.Results:Our search identified 8719 potentially relevant titles for review. Two authors reviewed all titles and abstracts. A total of 120 papers were selected for full text review; of these, thirty-two papers (30 adult, 2 pediatric) were included and four were unavailable for full text review. Twenty-seven retrospective studies, four prospective cohort studies, and one randomized control trial were included. A majority of adult studies (29/30) reported on surveillance strategies in NHL/HL survivors (16/16 NHL, 11/12 HL, 2/2 evaluating both NHL and HL) as well as all pediatric studies (1/1 NHL, 1/1 HL). Almost all studies (15/16 adult NHL, 11/12 adult HL, 2/2 pediatric) reported patient-level data on the number of asymptomatic relapses identified through SI versus clinical signs or symptoms. There were a total of 797 documented relapses in the adult NHL studies and 523 relapses in the adult HL studies. Of the relapsed adult NHL patients, 78.2% (623/797) were diagnosed clinically and 19.6% (156/797) were diagnosed by SI. Among the adult HL patients, 63.1% (330/523) of relapses were diagnosed clinically and 36.5% (191/523) were diagnosed by SI. Of the two pediatric studies included, one NHL study showed that all 3 relapses were detected clinically, and one HL study showed 76.0% (19/25) of relapses were detected clinically or due to lab abnormalities, and 24.0% (6/25) were detected by SI.Fifteen adult studies reported comparative data on PFS and/or OS rates with SI versus clinical surveillance strategies (9 NHL studies, 4 HL studies, 2 NHL/HL studies). The majority of studies (12/15) documented no difference in PFS and/or OS with imaging versus clinical surveillance strategies (8/9 NHL, 3/4 HL, 1/2 NHL/HL). In the remaining three studies, the first demonstrated a significant reduction in risk of death (HR 0.47 for HL, 0.57 for DLBCL) with SI on univariate analysis, but this was not seen on multivariate analysis for DLBCL (data not analyzed for HL). A second study in NHL patients demonstrated a non-significant trend towards improved PFS (p = 0.12) and OS (p = 0.13) with SI, while the third suggested that asymptomatic individuals with HL do not benefit from SI, with the exception of those with a morphological residual mass (p < 0.00016, HR = 3.84) or advanced stage (p = 0.03644, HR 1.99).Conclusions:The preliminary analysis of this systematic review indicates that even when routine imaging surveillance is employed, a majority of NHL and HL relapses come to attention due to the development of clinical signs and/or symptoms. A small number of comparative studies have reported on PFS and/or OS, with the vast majority demonstrating no improvement in PFS or OS with routine imaging surveillance. Our study supports clinical vigilance as the predominant strategy for follow-up in asymptomatic patients following curative intent therapy for HL and aggressive NHL. DisclosuresNo relevant conflicts of interest to declare.