Utility of [11C]PBR28 PET in the imaging of inflammatory arthritis

Background

PET is a cellular imaging modality that uses radionuclides targeted to a molecule of interest. Since macrophages have a crucial role in synovitis, PET targeted to translocator protein (TSPO), a mitochondrial protein upregulated in macrophages, is postulated to be a sensitive and specific means of imaging synovitis. We aimed to ascertain whether the TSPO tracer [¹¹C]PBR28 can detect and quantify synovitis in a proof-of-principle study.

Predictors and Clinical Impact of Prosthesis-Patient Mismatch After Self-Expandable TAVR in Small Annuli

ObjectivesThe aim of this study was to define predictors of prosthesis-patient mismatch (PPM) and its impact on mortality after transcatheter aortic valve replacement (TAVR) with self-expandable valves (SEVs) in patients with small annuli.BackgroundTAVR seems to reduce the risk for PPM compared with surgical aortic valve replacement, especially in patients with small aortic annuli. Nevertheless, predictors and impact of PPM in this population have not been clarified yet.MethodsPredictors of PPM and all-cause mortality were investigated using multivariable logistic regression analysis from the cohort of the TAVI-SMALL (International Multicenter Registry to Evaluate the Performance of Self-Expandable Valves in Small Aortic Annuli) registry, which included patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm² on computed tomography) treated with transcatheter SEVs: 445 patients with (n = 129) and without (n = 316) PPM were enrolled.ResultsIntra-annular valves conferred increased risk for PPM (odds ratio [OR]: 2.36; 95% confidence interval [CI]: 1.16 to 4.81), while post-dilation (OR: 0.46; 95% CI: 0.25–0.84) and valve oversizing (OR: 0.53; 95% CI: 0.28–1.00) seemed to protect against PPM occurrence. At a median follow-up of 354 days, patients with severe PPM, but not those with moderate PPM, had a higher all-cause mortality rate compared with those without PPM (log-rank p = 0.008). Multivariable Cox regression confirmed severe PPM as an independent predictor of all-cause mortality (hazard ratio: 4.27; 95% CI: 1.34 to 13.6).ConclusionsAmong patients with aortic stenosis and small aortic annuli undergoing transcatheter SEV implantation, use of intra-annular valves yielded higher risk for PPM; conversely, post-dilation and valve oversizing protected against PPM occurrence. Severe PPM was independently associated with all-cause mortality.     

Patient and health-care factors associated with potentially missed acute deterioration in primary care: a retrospective observational study of linked primary and secondary care data

BackgroundIn the UK, the majority of patient contact with health services occurs in primary care. Most of these contacts are uncomplicated; however, patient safety incidents (eg, failure to recognise patient deterioration) can occur. We aimed to explore patient and health-care factors associated with a self-referred admission, in patients with deteriorating health who consulted a general practitioner (GP).MethodsIn this observational study, we identified patients who had consulted a GP in the 3 days before an unplanned admission (indication of deterioration) between April 1, 2014, and Dec 31, 2017, in England, using the Clinical Practice Research Datalink with linkage to inpatient hospital admissions and emergency department data. We applied a multivariable, multilevel logistic regression model (generalised estimating equations) to investigate factors associated with self-referral (ie, patient age and existing health conditions, GP consultation, deteriorating health condition, and previous health service use) compared with other-referred unplanned admissions (eg, GP-referrals). Self-referred admission, as a composite measure, was defined as an unplanned admission via the emergency department (inpatient data) recorded as a self-referral in the corresponding emergency department record. We investigated all diagnoses and a subset of commonly reported missed conditions: sepsis, pulmonary embolism, urinary tract infections, and ectopic pregnancies in women.FindingsOf 405 878 unplanned admissions, 116 094 (28%) patients had contact with a GP 3 days before admission. The proportion of self-referred admissions varied by region (4189 [31%] of 13 639 inpatient admissions in London vs 1721 [12%] of 14 641 inpatient admissions in south west England), age, deteriorating health, and existing health conditions. Patients with sepsis or a urinary tract infection were more likely to self-refer than patients with other conditions (adjusted odds ratio [OR] 1·10, 95% CI 1·02–1·19 for sepsis; 1·09, 1·04–1·14, for urinary tract infection). GP appointment length was associated with a self-referred admission: a 5 min increase in consultation duration decreased the risk of self-referral by 6% (OR 0·94, 0·91–0·97). Telephone consultations, comorbidity, and previous health service use were also associated with self-referred admission.InterpretationDifferentiating deterioration from self-limiting conditions is difficult for GPs, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The negative association between GP consultation duration and self-referral supports demand for longer GP consultations. However, more research is needed to investigate the underlying mechanism between GP consultation time and referral.FundingNational Institutes for Health Research.     

Long-Term Outcomes in Patients With New Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Replacement

Objectives

This study sought to evaluate the long-term clinical impact of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR).