Serum Phosphate: A Neglected Test in the Clinical Management of Primary Hyperparathyroidism

Background Although the inverse correlation between serum PTH and phosphate (P) levels in patients with primary hyperparathyroidism (PHPT) is well known, the relationship between P levels and the clinical picture of the disease has not been well investigated. This was thus the aim of this paper. Patients A total of 472 consecutive patients with PHPT attending our center were retrospectively evaluated at diagnosis. Results P levels lower than 2.5 mg/dL (HypoP) were found in 198/472 patients (41.9%). HypoP was mild (2-2.5 mg/dL), moderate (1-1.9 mg/dL), and severe (<1 mg/dL) in 168 (84.9%), 30 (15.1%), and 0 cases, respectively. P levels were lower in males than females. Patients with more severe bone density impairment at the radial (but not the vertebral or femoral) site had P levels significantly lower than other patients. PHPT severity was worse in HypoP patients, both clinically (higher prevalence of renal stones, but not of osteoporosis) and biochemically (higher serum calcium and PTH levels). All patients in the moderate HypoP group were either symptomatic or asymptomatic reaching surgical indication according to the latest guidelines. Conclusions We observed a relationship between P levels and biochemical and clinical features of PHPT severity. In asymptomatic PHPT patients, even moderate HypoP is predictive of surgical indication, regardless of age and hypercalcemia severity.

AB0497 IMPACT OF COXITIS ON THE BONE MINERAL DENSITY OF THE HIP IN ANKYLOSING SPONDYLITIS

Background:Ankylosing spondylitis (AS) is an inflammatory disease, with new bone formation and ossification of the ligamentous apparatus as the primary pathological changes. The osteoporosis is coexisting with new bone formation. It is well known a common complication of this chronic disease. Hip involvement is common in AS [1].Objectives:The objective of this work is to assess the impact of chronic inflammation of the hip (coxitis) on the bone density at this site.Methods:This is a cross-sectional study of patients who fulfil the modified New York criteria for AS. These patients had not medical history of osteoporosis or other condition that may affect bone metabolism. Hip involvement was appreciated by physical examination and pelvic x-ray. The functional hip gene was assessed by Lequesne Algofunctional Index (LFI). Bone mineral density at the femoral site was measured using Lunar Prodigy dual-energy X-ray absorptiometry. Osteoporosis is defined when T score is ≤ -2.5 DS (standards deviations). Osteopenia is defined when T score is ≤ -1 DS but more than -2.5 DS. A p value <0.05 was considered significant.Results:Forty-seven AS patients were collected, 12 women and 35 men with a mean age of 43.8 ± 13.4 years. Smoking was noted in 25% of cases. AS clinical form was axial in 33 cases (70.2%) and mixed (axial and peripheral) in 14 cases (29.8%). The mean duration of AS was 15 ± 10.9 years. Nineteen patients (40.4%) were on DMARD at the time of the study. Coxitis was present in 31 patients (66%). It was bilateral in 13 cases (42.5%). The mean of the LFI was 7.1 ± 6.5 with extremes of 0 to 18. Coxitis form was early in 18 cases (40.9%), synostosis in 15 cases (34.1%) and destructive in 11 cases (25%). Twenty-nine patients (61.7%) had normal femoral bone densitometry, 13 patients (27.7%) had osteopenia and 4 patients (8.5%) had osteoporosis. The mean T-score value at femoral neck site was -0.5 SD ± 1.303 [-3– -2]. Patients with coxitis had a significantly lower T score at the femoral site compared to those without coxitis (-0.77 ± 1.31 DS versus 0.07 ± 1.11 DS respectively with p = 0.036).Conclusion:Our study confirms the role of chronic inflammation in the genesis of bone loss in AS. Given the risks of developing secondary complications as a result of low bone density, early management of AS should be recommended in order to control the inflammatory process and prevent the onset of osteoporosis.References:[1]Toussirot E, Wendling D. Bone mass in ankylosing spondylitis. Clin Exp Rheumatol 2000:16–20.Disclosure of Interests:None declared.

Radiofrequency Multi Echographic Spectrometry (REMS) Technology in Patients With Bone Artifacts

Introduction: Dual-energy X-ray Absorptiometry (DXA) is considered the gold standard examination for the evaluation of bone mineral density (BMD). However, it is known that some conditions, such as arthrosis, vertebral collapse, or vertebroplasty, result in an overestimation of the BMD measured by DXA. Conversely, Radiofrequency Echographic Multi-Spectrometry (REMS) technology is able to automatically discard signals related to bone artifacts, such as calcifications or osteophytes, thanks to the identification of unexpected spectral features (Diez-Perez et al. 2019). The aim of this work is to assess the performance of REMS technology in patients with bone alterations that could alter the densitometric examination. Materials: The bone densitometry exams, both REMS and DXA, of patients with evidences of bone alterations at lumbar vertebrae or femoral neck were analysed. Written patient informed consent was obtained before the scans. Results: Eighty-seven patients with spinal artifacts, including 22 patients with vertebroplasty, 26 patients with bone fracture and 38 patients with osteo-arthrosis were considered. At lumbar spine, the mean BMD and T-score values assessed by REMS was lower than the ones measured by DXA. Moreover, the results obtained by the two technologies were not correlated. On the contrary, the BMD and T-score values measured by REMS and DXA at the femoral site were highly correlated (p&lt;0.01), as well as BMD and the T-score values measured by DXA at the femoral neck and by REMS at the lumbar spine (p&lt;0.01). As concerning artifacts involving femoral site, a patient with an intramedullary gamma nail positioned following a displaced pertrochanteric fracture of the left femur underwent a DXA scan of the right femur and a REMS scan of both femurs. A diagnosis of osteoporosis at the right femur was posed by both technologies. At the left femur with intramedullary gamma nail, REMS only made a diagnosis of osteoporosis highly corresponding with the one performed at right femur. Conclusions: The results from the patient series with spinal artifacts and the clinical case with femoral intramedullary gamma nail show the ability of REMS to evaluate anatomical sites that would not be assessable by DXA, such as in case of implanted nails, or that would give unreliable higher BMD values, such as in case of vertebroplasty, osteo-arthrosis and bone fracture. References: Diez-Perez et al. Aging Clin Exp Res 2019;31(10):1375–89

Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial

Background Vascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury. Patients and methods We performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. Results Among the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34–4.07), p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98–1.00), p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64—1.25), p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred. Conclusion Femoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.

Comparison of mechanical complications of central venous catheter according to the insertion site in an intensive care unit of Bangladesh

Background: Central venous catheter (CVC) insertion is very common in intensive care unit (ICU). CVC is usually inserted in subclavian, internal jugular and femoral veins. However, CVC insertion may lead to significant mechanical complications. Our aim was to detect the occurrence of CVC related mechanical complications according to different insertion site. Methods: This prospective observational study was carried out during the period of May 2016 to July 2019 in Department of Critical Care Medicine, BIRDEM General Hospital, Dhaka, enrolling 349 adult patients requiring new CVC insertion in ICU. Results: Among 349 study subjects, 167 CVC were inserted through subclavian vein, 88 through internal jugular and 94 through femoral vein. There was no significant difference among three groups (subclavian / internal jugular / femoral) in terms of age, gender distribution, presence of co-morbid illness.Total mechanical complicationsin study population was 43 (12.3 %) including pneumothorax (14, 4.0%), arterial puncture (10, 2.9%), hemorrhage (11, 3.2%), catheter tip malposition (6, 1.7%), hemothorax (1, 0.3%) and lost guidewire (1, 0.3%). Pneumothorax was more with internal jugular (9.1%) than subclavian (3.6 %) route, which was statistically significant (p=0.007). Although hemorrhage and arterial puncture events were higher with femoral site than subclavian or internal jugular, which were not significant. Catheter tip malposition occurred in 4 (2.4%) patients with subclavian insertion and 2 (2.3%) patients with internal jugular site, no such event in femoral site. Hemothorax and lost guidewire occurred in only 1 patient with subclavian and internal jugular site respectively. Site-wise total mechanical complications were higher in internal jugular (17.0%) followed bysubclavian (10.8%) site and femoral site (10.6%). Conclusion: In this study, though not statistically significant, CVC related mechanical complications occurred more in subclavian site than in internal jugular or femoral insertion site. Birdem Med J 2020; 10(2): 115-119

SAT0462 ASSESSMENT OF BONE MINERAL DENSITY IN INFLAMMATORY BOWEL DISEASE

Background:Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), is considered as a risk factor of low bone mineral density (BMD). In fact, the prevalence of osteoporosis ranges from 17% to 41% in IBD patients. The possible contributing factors may include malabsorption, glucocorticoid treatment and coexisting comorbiditiesObjectives:The purpose of our work was to determine the frequency and the determinants of osteoporosis in patients with IBD and to assess whether there is a difference in BMD status between UC and CD.Methods:This is a retrospective study, over a period of 5 years (from January 2014 to December 2018) and including patients followed for IBD who had a measurement of BMD by DEXA. Clinical, anthropometric and densitometric data (BMD at the femoral and vertebral site) were recorded. The WHO criteria for the definition of osteoporosis and osteopenia were applied.Results:One hundred and five patients were collected; among them 45 were men and 60 were women. The average age was 45.89 years old. The average body mass index (BMI) was 25.81 kg/m2 [16.44-44.15]. CD and UC were diagnosed in respectively 57.1% and 42.9%. A personal history of fragility fracture was noted in 4.8%. Hypothyroidism was associated in one case. Early menopause was recorded in 7.6%. 46.8% patients were treated with corticosteroids. The mean BMD at the vertebral site was 1.023 g/cm3 [0.569-1.489 g/cm3]. Mean BMD at the femoral site was 0.920g/cm3 [0.553-1.286g / cm3]. The mean T-score at the femoral site and the vertebral site were -1.04 SD and -1.27 SD, respectively. Osteoporosis was found in 25.7% and osteopenia in 37.1%. Osteoporosis among CD and UC patients was found in respectively 63% and 37%. The age of the osteoporotic patients was significantly higher compared to those who were not osteoporotic (52.23 vs 43.67 years, p = 0.01). We found a significantly higher percentage of osteoporosis among men compared to women (35.6% vs 18.3%, p=0.046). The BMI was significantly lower in the osteoporotic patients (23.87 vs 26.48 kg/m2, p=0.035) and we found a significant correlation between BMI and BMD at the femoral site (p=0.01). No increase in the frequency of osteoporosis was noted in patients treated with corticosteroids (27.9% vs 21.6%, p=0.479). Comparing the UC and CD patients, no difference was found in baseline characteristics, use of steroids or history of fracture. No statistically significant difference was found between UC and CD patients for osteoporosis(p=0.478), BMD at the femoral site (p=0.529) and at the vertebral site (p=0.568).Conclusion:Osteoporosis was found in 25.7% of IBD patients without any difference between CD and UC. This decline does not seem to be related to the treatment with corticosteroids but rather to the disease itself. Hence the interest of an early screening of this silent disease.Disclosure of Interests:None declared

Femoral placement of a totally implantable venous access port with spontaneous catheter fracture: case report

Background The incidence of catheter fracture after standard positioning of a totally implantable venous access port (TIVAP) is reported to be 1.1%–5.0%; however, the incidence of catheter fracture after TIVAP implantation at a femoral site remains unclear. Case presentation In a 30-year-old man with angiosarcoma of the right atrium, tumor embolism was observed from the left brachiocephalic vein to the superior vena cava. A TIVAP was implanted in the right femur. A catheter fracture was spontaneously observed after 7 months. Conclusions To the best of our knowledge, this is the first case of catheter fracture in a TIVAP implantation at a femoral site.

Mini-Invasive Extraarticular Stabilization of the Cranial Cruciate Deficient Stifle in Dogs

The purpose of this work was to describe three mini-invasive techniques for extraarticular stabilization of the deficient stifle based of bone anchores inserted in quasi-isometric sites.Suture stabilization of the stifle consisted of placing a monofilament nylon leader line or polyethylene suture between femoral site adjacent to the distal poles of the fabella, and tibial site immediately cranial to the long digital extensor tendon, using two anchor types. Each stifle was tested (cranial drawer test and tibial compression test) before and after arthroscopic transection of the cranial cruciate ligament and after performing the assigned procedure. Surgical approach, order of procedural steps, drill hole entrance and exit points, and techniques for anchors placement, tensioning, and securing were described.The results of the cranial drawer test and tibial compression test do not show statistically significant differences between the three applied techniques. All three techniques provide passive stability to the deficient stifle.

Use of a tracheal dilator for percutaneous insertion of 27F and 31F Avalon© dual-lumen cannulae for veno-venous extracorporeal membrane oxygenation in adults

Veno-venous extracorporeal membrane oxygenation can be performed either by two cannulae or by a single dual-lumen cannula. The dual-lumen cannulation configuration offers multiple advantages: it avoids the femoral site which may be at greater risk of infection, it improves patient mobility, eases prone positioning and greatly reduces recirculation. The Avalon was the first commercially available dual-lumen cannula for adults. It has gained much popularity, but, for more than a year now, the adult vascular access kit with the 30Fr dilator has been discontinued in the United Kingdom. In this article, we share our experience with an alternative insertion method, using a percutaneous dilatational tracheostomy kit. This off-label use of the tracheostomy dilator appears to be safe. It may allow the continuing use of Avalon dual-lumen cannulae while waiting for a more permanent solution to be provided by the manufacturer.

An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU

As part of the Keystone Intensive Care Unit project a bundle of evidence-based interventions was introduced in ICUs across the state of Michigan with the goal of decreasing catheter-related bloodstream infections (CRBI). The bundle included (1) hand washing, (2) full barrier precautions during placement of central venous catheters, (3) skin cleaning with chlorhexidine, (4) if possible, avoidance of femoral site, and (5) removing unnecessary central venous catheters. Post implementation rates of catheter-related bloodstream infections were compared to baseline data. The results showed a decrease from a baseline median rate of 2.7 infections per 1000 catheter-days to a median rate of 0 infections per 1000 catheter-days, which was sustained over 18 months of follow-up.