Saint Agnes Hospital

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis, becoming the gold standard for many patients. Despite its advantages over surgical aortic valve replacement, TAVR is associated with significant complications, including paravalvular leakage, conduction disorders, and cerebrovascular events. This review focuses on the pathophysiology, incidence, and management of cerebrovascular complications following TAVR. We explore the mechanisms leading to these events, including embolization of debris from the calcified valve and aortic arch, and the role of procedural factors. The review also discusses the timing of cerebrovascular events, diagnostic approaches, and potential preventive strategies, including embolic protection devices. Understanding these complications is crucial for improving patient outcomes and refining TAVR techniques.

Retrograde Intubation in Advanced Nasopharyngeal Carcinoma with Airway Obstruction: A Case Report and Literature ReviewLaxman Wagle MBBS1*, Dhiraj Raj Regmi MBBS2, Sangharsha Thapa MBBS3, Mustafa Abdulmahdi MD4Department of Internal Medicine, Ascensio

Stereotactic ablative body radiotherapy (SABR) is an emerging treatment for patients with primary renal cell carcinoma (RCC), however variation in treatment protocols can exist between institutions. The goals of this study were to measure the variation in contouring RCC tumors for patients being treated with SABR and to develop consensus recommendations. An international panel of 16 radiation oncologists was created from the IROCK meeting during ASTRO 2023. Four patient cases were: Case 1, a renal tumor greater than 10 cm in size with an IVC tumor thrombus; Case 2, a central renal tumor abutting the renal hilum; Case 3, a local recurrence of RCC post-nephrectomy; and Case 4, a residual tumor post-radiofrequency ablation (RFA). For each Case, panelists were asked for radiation planning details and to contour the target volumes on representative axial images using a computer-based training tool. Comparison of panelist contours with the were performed using the Dice-Similarity Coefficient (DSC), the Mean Distance to Agreement (MDA) and the Hausdorff Distance (HD). The DSC measures the overlap between two contours, so a higher DSC suggests greater agreement. The MDA and HD represent the mean and maximum distances between points on the two contours, so higher MDA and HD represent lower agreement. Consensus target volumes were derived using the STAPLE algorithm and discussed amongst the panel. Altogether, the panel included radiation oncologists from Canada, the USA, Australia, the Netherlands, and India. All panelists had previously treated at least 10 patients with SABR for primary RCC. Table 1 shows the DSC, MDA and HD for each case. Using an ANOVA analysis, for all Cases, the DSC, MDA and HD were not statistically different between participants (p = 0.32, p = 0.24, and p = 0.23, respectively). On qualitative inspection of participant contours, Case 4 showed the most agreement, followed by Case 3, Case 2, and then Case 1. There was good agreement from our international expert panel on contouring renal tumors in all four Cases, with Case 4 having the greatest agreement, and Case 1 having the least agreement. Consensus recommendations based on this study may help improve the quality of SABR for RCC moving forward.

4126 Background: The clinical implications and management of bone metastases in patients (pts) with gastrointestinal neuroendocrine tumors (GI-NETs) is poorly characterized. In this study we investigated the frequency of bone metastases and skeletal-related events (SRE) in pts with GI-NETs. Methods: Retrospective review of ptswith GI-NETs seen at our institution between 2010-2022. We collected clinicopathologic data including tumor primary site, tumor differentiation, grade using Ki-67 labeling index (G1, G2, or G3), time of diagnosis of metastatic GI-NET, and development of bone metastases (synchronous or metachronous). Diagnosis of metastatic bone disease was assessed by contrast imaging (CT, MRI) and/or functional imaging studies (FDG or DOTATATE PET). SRE were defined as bone pain, spinal cord compression, pathological fracture or tumor-related hypercalcemia. Bone directed therapy was defined as use of bisphosphonates, radiation therapy, and surgical intervention. Results: We identified a total of 865 pts with metastatic GI-NETs. Of these, 122 pts (14%) had evidence of bone metastases. In pts with bone metastases, median age was 60 y/o and 72 pts (59%) were male. Primary tumor sites included pancreas (n=52, 47%), small bowel (n=50, 45%), rectum (n=4, 4%), colon (n=3, 3%), and gallbladder (n=1, 1%). Tumors were G1 (n=31, 28%), G2 (n=51, 47%), G3 (n=27, 25%). The majority of pts had well-differentiated tumors (n=103, 84%). Imaging for initial diagnosis of bone metastasis included PET (n=65, 53%), MRI (n=29, 24%), and CT (n=28, 23%). Synchronous metastases occurred in 34 pts (28%). Metachronous bone metastasis occurred in 88 pts (72%) with a median time to developing bone metastasis of 38 months. SRE occurred in 46 pts (38%), with 36 pts (30%) experiencing bone pain, 5 pts (4%) experiencing pathological fracture, 5 pts (4%) experiencing spinal cord compression, and 2 pts (2%) experiencing hypercalcemia. Thirty-six pts (30%) received bone-directed therapy, including bisphosphonates (n=25, 20%), radiation (n=19, 16%), or surgical intervention (n=4, 3%). Median overall survival (OS) was 83.3 months. Factors associated with increased probability of SRE included younger age, non-white race, low tumor grade, synchronous presentation, and poorly differentiated tumor. Risk factors for decreased OS included male gender, intermediate or high-grade disease, and spinal cord involvement. Bisphosphonate therapy was the most frequently used bone-directed treatment (n=25, 20%). Conclusions: Bone metastases occurred in 14% of pts with GI-NETs and SRE occurred in 38% of these pts. SRE were more likely to occur in pts with synchronous metastatic bone disease, intermediate/high grade tumors or poorly differentiated tumors. Further studies evaluating interventions to decrease SRE and impact in quality of life in pts with GI-NETs are warranted.

IntroductionWhile cardiac neoplasms can disrupt conduction pathways, events of arrhythmias among patients with benign neoplasm of the heart (BNH) and malignant neoplasm of the heart (MNH) are not well reported. We aim to assess patient characteristics and odds of cardiac arrhythmias between BNH and MNH.MethodsRecords of adults with BNH or MNH were extracted from the 2016–2020 National Inpatient Sample using relevant ICD-10 codes. Differences in various characteristics, presence of cardiac arrhythmias and outcomes were explored.Results23,450 patients diagnosed with a cardiac neoplasm were included. 21,200 (90.4%) had a recorded diagnosis of BNH, while 2,250 (9.6%) had a diagnosis for MNH. BNH cases were older (65.07 vs 52.15, p<0.01), consisted mostly of patients of female sex (63.5% BNH vs 48.2% MNH, p<0.01) and were more comorbid, with significantly higher proportion of patients with cirrhosis, diabetes, hypertension, peripheral vascular disease, smoking, obesity, chronic kidney disease, alcohol abuse, drug abuse, and lipid disorder compared to those with MNH (all p=<0.001). While the majority of BNH cases were covered by Medicare, Private insurance forms were mostly used by MNH patients. Despite BNH having higher proportions of comorbidities, a higher mean Charlson Comorbidity Index (CCI) score was noted among the MNH cohort. (2.71 BNH vs 5.23 MNH, p<0.01) After adjusting for confounding factors, BNH patients had higher odds of reporting ventricular tachycardia (aOR 1.58 95% CI 1.17–2.14, p=0.003), while showing reduced odds of events for atrial flutter (aOR 0.51 95% CI 0.44–0.61, p<0.001). The BNH cohort also had reduced odds of adverse outcomes of cardiogenic shock (aOR 0.377, 95% CI 0.306–0.466, p<0.001), acute kidney injury (AKI) (aOR 0.629, 95% CI 0.553–0.716, p<0.001), and death (aOR 0.200, 95% CI 0.166–0.241, p<0.001) than those with MNH (table 1).ConclusionWhile patients with BNH were older and had higher a proportion of comorbidities, they reported reduced odds of atrial flutter and better overall outcomes, but higher odds of ventricular tachycardia. 128 Table 1aPatient Characteristics and differences between cases of benign heart neoplasm versus malignant heart neoplasm among adults Benign Heart Neoplasm (n=21200) (%) Malignant Heart Neoplasm (n=2250) (%) p-value Mean Age (Years) 65.07 52.15 <0.01 Female 63.5 48.2 <0.01 Comorbidities Cirrhosis 2.0 1.1 <0.01 Diabetes 29.4 18.0 <0.01 Hypertension 42.1 26.4 <0.01 Chronic Kidney Disease 19.7 8.2 <0.01 Lipid Disorder 48.9 28.4 <0.01 Mean Charlson Comorbidity Index (CCI) score 2.71 5.23 <0.01 Outcomes Cardiogenic Shock 2.2 6.9 <0.01 Acute Kidney Injury 17.3 18.0 0.412 Death 2.6 10.3 <0.01 128 Table 1bAdjusted odds ratio for presence of various cardiac arrhythmias and outcomes with Benign neoplasm of the heart as compared to those with Malignant neoplasm of the heart (reference) p-value aOR Lower 95% CI Upper 95% CI Atrial Fibrillation 0.315 1.057 0.948 1.179 Supraventricular Tachycardia 0.078 0.821 0.659 1.022 Ventricular Tachycardia 0.003 1.582 1.170 2.137 Ventricular Fibrillation 0.416 0.864 0.607 1.229 Atrial Flutter <0.001 0.513 0.435 0.605 Complete AV Block 0.615 0.919 0.662 1.276 Cardiogenic Shock <0.001 0.377 0.306 0.466 Acute Kidney Injury <0.001 0.629 0.553 0.716 Death <0.001 0.200 0.166 0.241 128 Figure 1Adjusted odds ratio for presence of various cardiac arrhythmias and complications in patients with Benign neoplasm of heart as compared to those with Malignant neoplasm of the heart(reference)Conflict of InterestNone

On a recent surgical medical mission caring for Ukrainian pediatric burn and trauma patients in Poland, an assessment of the mental health and well-being of children and their caregivers was completed. Children living in war zones frequently experience significant distress and mental health problems, but little is known about the impact of coexisting related or unrelated burn injuries or physical disabilities. Nineteen Ukrainian children and their caregivers were interviewed utilizing validated questionnaires Child Behavioral Checklist (CBCL) and Youth Self-Report (YSR) to assess their risk for developing or for the presence of clinically significant mental health problems. We found a high percentage of children at risk for developing mental health disorders and an unexpectedly high number of children meeting the criteria for mental health disorders. As a result of interviewing the caregivers, agreement was seen between the self-assessment in children and the perception of parents about their children's well-being. Further study is needed to better understand the complex interactions between pre-existing burn and traumatic injuries and their impact on the psychosocial well-being of children living in war-torn environments.

Acute appendicitis, a typical abdominal emergency, presents in nonperforated and perforated forms. While nonperforated cases often respond well to antibiotics or appendectomy, perforated cases pose more significant challenges. We report a unique case of appendicitis in a 34-year-old female with an unusual anatomical adherence to the left ovary. The patient successfully underwent laparoscopic surgery, during which precise incisions were made to accommodate the unique location of the appendix. This tailored approach contributed to a positive surgical outcome.This case underscores the importance of tailored surgical approaches in managing complex appendiceal variations.

Introduction: Bronchobiliary fistula secondary to bile duct obstruction by gallstone can present with clinical and radiographic features of pneumonia. Bilioptysis is pathognomonic but may be mistaken for purulent sputum. Biliary drainage with treatment of underlying gallstone disease usually results in remission. Description: A 45 year-old male with past history of gallstone pancreatitis complicated by pseudocyst with common bile duct obstruction status post endoscopic cyst gastrostomy, and endoscopic retrograde cholangiopancreaticography (ERCP) with common bile duct (CBD) stenting presented with fever, cough with yellowish phlegm and dyspnea. Physical examination showed tachypnea and low oxygen saturation. He was placed on high flow nasal cannula (HFNC) but due to worsening hypoxia, he required intubation and mechanical ventilation. Leukocytosis was present. Bilirubin level was normal. CT scan of chest showed multilobar pneumonia with consolidation of right middle and lower lobes. Treatment for pneumonia was initiated with broad spectrum antibiotics. Endotracheal airway suctioning showed traces of bile. Sputum analysis confirmed bilioptysis. Bronchoscopy revealed copious bilious secretion in the right and left main bronchus. CT scan of the abdomen with contrast revealed dilated common bile duct, intrahepatic biliary dilatation and distended gallbladder with a 1.5 cm stone in the neck. Hepatobiliary iminodiacetic acid (HIDA) scan showed extravastion of tracer into the right chest. He subsequently underwent ERCP with sphincterotomy, stone removal and placement of biliary stent to relieve the fistula. Percutaneous cholecystostomy placement was done. This was followed by improvement of his clinical status and white cell count. He was discharged with cholecystostomy drain. He underwent elective interval laparoscopic cholecystectomy 12 weeks later. He had no recurrence of symptoms in the following 6 months. Discussion: The diagnosis of bronchobiliary fistula can be challenging. The clinical features, lab parameters and radiological picture may resemble pneumonia. A high degree of suspicion is required for patients who have had gallstone disease and previous hepatobiliary surgery. Identifying bile in the sputum is pathognomonic. Our experience can aid physicians in the diagnosis of bronchobiliary fistula.