Saint Luke's Research Day 2025

Background

Pyogenic vertebral osteomyelitis is a serious infection of the spine with increasing incidence. While many cases can be managed conservatively, surgical intervention is often required for patients with neurological deficits, spinal instability, or failure of medical management. However, the optimal surgical approach remains controversial. This study aimed to synthesize the available evidence comparing outcomes between different management strategies and surgical techniques.

Objective

To compare clinical outcomes between anterior, posterior, and combined surgical approaches for the treatment of pyogenic vertebral osteomyelitis.

Methods

A systematic review and meta-analysis was conducted of studies comparing surgical and medical management of vertebral osteomyelitis. Primary outcomes included clinical deterioration, reoperation rates, length of hospital stay, and mortality. Secondary analysis compared outcomes between anterior, posterior, and combined surgical approaches.

Results

Thirty-eight studies with 1,885 patients were included. There were no significant differences between surgical and medical management in clinical deterioration (mean difference -0.0674, 95% CI: -0.172 to 0.038, p=0.208), reoperation rates (mean difference 0.0626, 95% CI: -0.032 to 0.157, p=0.195), length of stay (mean difference -0.045, 95% CI: -1.30 to 1.21, p=0.944), or mortality (mean difference 0.037, 95% CI: -0.0541 to 0.128, p=0.426). Anterior approaches were associated with the highest rates of improved clinical outcomes (71.2%) compared to posterior (63.8%) and combined approaches (5.45%), though differences were not statistically significant (p=0.347).

Conclusion

This meta-analysis found no significant differences in outcomes between surgical and medical management of vertebral osteomyelitis. Among surgical approaches, anterior techniques may be associated with better clinical outcomes, though high-quality comparative studies are needed to confirm these findings.

Lay Summary

Spine infections (vertebral osteomyelitis) are increasingly common and can cause severe pain, disability, and even death if not properly treated. While antibiotics work for many patients, some need surgery due to nerve damage, spine instability, or when medications fail. This study reviewed evidence from 38 studies involving 1,885 patients to determine whether surgery or antibiotics alone work better, and which surgical technique is most effective. Results showed no significant differences between surgical and non-surgical treatments in terms of recovery, complications, hospital stay length, or survival rates. Among surgical techniques, approaching the infection from the front of the spine appeared to produce slightly better outcomes than approaches from the back or combined techniques, though more research is needed. These findings help doctors make better treatment decisions for patients with spine infections, potentially improving care while avoiding unnecessary surgeries. Future studies should focus on identifying which specific patients benefit most from each approach.

Almekkawi, Ahmad Kareem

Saint Luke's Hospital

Background

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have cardioprotective effects without acting directly on the myocardium.

Objective

To evaluate the impact of SGLT2i on myocardial glucose utilization.

Methods

This retrospective propensity-matched cohort study examined subjects who underwent whole body 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) for oncologic purposes between 2016-2024. A 1:1 propensity match compared SGLT2i-treated vs untreated patients regarding PET-derived myocardial FDG uptake, maximum myocardial standardized uptake value (SUV), and total cardiac glycolysis.

Results

Among 6747 subjects, 187 were actively prescribed SGLT2i and matched with 187 who were not. Mean age was 68.4 ± 9.7 years, 57.5% were males, 81.8% had diabetes, and 41.4% had heart failure. Myocardial FDG uptake (to quantify glucose utilization) was absent in 64.7% of patients on SGLT2i and 37.4% not on SGLT2i (p<0.001), despite higher pre-scan glucose in those receiving SGLT2i (124 vs 110 mg/dL). Quantitatively, SUVmax (5.4 vs 5.8, p=0.004), volume of myocardial FDG uptake (0.8 cm3 vs 4.6 cm3, p=0.001), and total cardiac glycolysis (1.6 g vs 20.6 g, p<0.001) were also significantly lower in patients treated with SGLT2i vs those untreated. There was no difference in background FDG uptake using SUVmax and SUVmean in the blood pool and liver.

Conclusions

SGLT2i use was associated with a greater suppression of myocardial glucose utilization without affecting background tissue glycolysis despite higher pre-scan glucose levels. These findings add to the understanding of the effect of SGLT2i on the myocardium and may have implications with respect to cardiac imaging protocols that require glucose manipulation.

Lay Summary

Medications called SGLT2 inhibitors, originally used to lower blood sugar in people with diabetes, have also been shown to protect the heart—but it’s unclear how. This study looked at whether these medications change how the heart uses sugar for energy. Researchers reviewed PET scan images from people who had them done for cancer screening and compared those taking SGLT2 inhibitors to those who weren’t. They found that people on these medications had much lower sugar use in their heart muscle—even though their blood sugar was higher before the scan. This suggests the heart may be using other fuels like fat instead, which might be part of how these medications protect the heart. These findings could help doctors better understand how these drugs work and may also influence how heart scans are done in the future. More research is needed to see how this change in energy use affects long-term heart health.

Almohtasib, Yazan

University of Missouri-Kansas City. Saint Luke's Mid-America Heart Institute

Purpose/Background

Primary ciliary dyskinesia is a condition that results from impaired movement of cilia, leading to recurrent respiratory infections, chronic sinusitis, and infertility, particularly in males. Approximately 50% of individuals with primary ciliary dyskinesia present with Kartagener’s syndrome, a rare autosomal recessive disorder characterized by a triad of situs inversus (mirror-image reversal of internal organs), bronchiectasis (abnormal dilatation of the airways), and sinusitis. Patients may experience chronic cough, sputum production, and progressive respiratory impairment. Radiology plays a crucial role in both the diagnosis and management of Kartagener’s syndrome. Typical imaging features on computed tomography (CT) include bronchiectasis with a predilection for the middle and lower lobes, consolidation, mucocele, and impacted mucus in the bronchioles. Tree-in-bud pattern or centrilobular nodules may indicate mucus impaction and endobronchial spread of infection. Given the multifaceted nature of the disease, early recognition and multidisciplinary management are critical in improving outcomes and preventing complications.

Methods

A review of the patient’s medical records, including clinical history, laboratory results, imaging studies, and treatment interventions, was conducted.

Results A 37-year-old male with a history of recurrent pneumonia presented to the emergency department with shortness of breath. Laboratory results revealed an elevated white blood cell count of 15,000/µL. Initial chest radiograph showed bronchiectasis and situs inversus, along with bilateral lower lobe predominant heterogeneous opacities. To rule out pulmonary embolism, a CT angiography of the chest was performed, revealing mosaic attenuation of the lungs, with severe varicose, cystic, and cylindrical bronchiectasis. These findings were consistent with the patient's history of Kartagener’s syndrome. Additionally, multifocal nodular opacities, diffuse centrilobular nodules, and tree-in-bud opacities were noted, suggestive of an infectious bronchiolitis. Bronchoscopy confirmed a Pseudomonas aeruginosa infection. The patient was treated with targeted antibiotics, resulting in clinical improvement.

Conclusions

The management for Kartagener’s syndrome is multidisciplinary, with imaging playing a crucial role in directing treatment. Disease severity can vary significantly. Some studies suggest that aggressive airway clearance and early antibiotics may help slow disease progression. Chronic infection and recurrent inflammation may eventually lead to scarring, sometimes necessitating pulmonary resection surgery. Early identification of these radiologic signs allows for timely intervention and improved outcomes.

Lay Summary

Kartagener’s syndrome is a rare genetic disorder that affects the movement of tiny structures called cilia, which are responsible for clearing mucus from the airways. This leads to repeated lung infections, breathing problems, and sinus issues. Affected individuals also have a condition called situs inversus, where the internal organs are reversed. In this case, a 37-year-old male with Kartagener’s syndrome developed a lung infection, and imaging tests helped the providers make the diagnosis. This case highlights the importance of recognizing the signs of Kartagener’s syndrome on imaging, which can guide treatment decisions. Typical imaging features include damaged airways that may have mucus build up as well as unusual lung patterns suggestive of an infectious process. The goal of this case report is to emphasize how early diagnosis through imaging can help manage the disease and prevent complications, ultimately improving patient outcomes and quality of life.

Ayoub, Joseph

University of Missouri-Kansas City

Background

Vasoplegic shock is a distributive form of shock characterized by low systemic vascular resistance and normal or elevated cardiac output despite high-dose vasopressors. It presents a significant therapeutic challenge, especially in non-surgical, drug-induced etiologies. Benzodiazepines can contribute to vasodilation via central autonomic inhibition and nitric oxide-mediated pathways. While methylene blue has shown efficacy in treating vasoplegia, its use is limited in patients on serotonergic agents due to the risk of serotonin syndrome. Hydroxocobalamin, an alternative agent, has demonstrated promise through inhibition of gaseotransmitters such as nitric oxide and hydrogen sulfide.

Case Presentation

We describe the case of a 33-year-old male with a history of depression, anxiety, alcohol abuse, and suspected clonazepam overdose. The patient developed distributive shock unresponsive to fluid resuscitation and escalating doses of norepinephrine, vasopressin, and angiotensin II. Due to concurrent use of SSRIs and trazodone, methylene blue was avoided.

Results

Despite the use of triple vasopressors and corticosteroids, the patient’s mean arterial pressure (MAP) remained critically low. Following a multidisciplinary discussion, 5 grams of hydroxocobalamin (Cyanokit®) were administered, leading to a marked and sustained improvement in MAP into the 70–80 mmHg range. Vasopressors were subsequently tapered and discontinued. Although initial lactate levels remained elevated, renal function improved with continuous renal replacement therapy (CRRT). The patient was extubated on hospital day 5 and transferred to inpatient psychiatry in stable condition.

Conclusions

This case illustrates the potential role of hydroxocobalamin in treating vasoplegic shock secondary to benzodiazepine overdose, particularly when methylene blue is contraindicated. The rapid hemodynamic response highlights the agent’s efficacy in restoring vascular tone. Clinicians should consider hydroxocobalamin as a viable therapeutic option in refractory vasoplegia, especially in patients on serotonergic medications. Further research is warranted to define its role within standardized treatment algorithms for vasoplegic shock.

Lay Summary

This case report highlights a rare and serious condition called vasoplegic shock, where blood vessels become dangerously relaxed and blood pressure drops to life-threatening levels. It can happen after certain surgeries, infections, or drug overdoses. We describe a young man who overdosed on anxiety medication and alcohol and developed this type of shock. Usual medications to raise his blood pressure didn’t work. One option, methylene blue, was too risky because of his psychiatric medications. Instead, doctors used a medication called hydroxocobalamin, normally used for cyanide poisoning. Remarkably, it helped restore his blood pressure quickly and safely. This case shows that hydroxocobalamin can be a life-saving alternative for patients where other treatments are unsafe. Our findings suggest the need for more research into this treatment so that doctors can have more options to save lives in similar situations.

Baniowda, Muath

University of Missouri-Kansas City (UMKC) School of Medicine

Background

Atrio-esophageal fistula (AEF) is a rare but life-threatening complication of atrial fibrillation ablation, with an incidence of 0.03-0.08%. Prompt diagnosis and management are critical, but the optimal approach remains controversial. We present a case of suspected AEF where endoscopic evaluation resulted in a catastrophic outcome, emphasizing the need for extreme caution with invasive procedures.

Case Presentation

A 65-year-old male with recent atrial fibrillation ablation presented with altered mental status and syncope 4 weeks post-procedure. Initial CT angiography of the chest revealed pericardial fluid and air, concerning for AEF. CT chest also demonstrated mediastinitis and pericardial empyema. MRI brain showed multifocal acute infarcts but no air emboli. Repeat CT chest with oral contrast confirmed a moderate pericardial effusion with a gas-containing fluid collection in the superior mediastinum.

The patient underwent emergent sternotomy which revealed a left atrial perforation that was repaired. Purulent pericardial fluid was noted but no obvious esophageal perforation was seen. Post-operatively, GI was consulted for EGD to directly visualize the esophagus prior to performing a TEE. During the EGD, the patient suffered a PEA arrest. Post-resuscitation CT brain showed multiple air emboli, edema and hydrocephalus. The patient progressed to brain death the following day.

Discussion

This case illustrates catastrophic complications from EGD in suspected AEF. The abnormal connection between left atrium and esophagus allows air and bacteria to enter circulation. Insufflation during EGD likely exacerbated a residual fistula, causing massive air embolism. Diagnosing AEF requires high suspicion in patients with chest pain, neurologic deficits, or GI bleeding post-ablation. Classic CT findings should prompt expedited workup. However, EGD should be strictly avoided, as multiple reports document immediate deterioration due to air embolism. Diagnosis should focus on less invasive modalities like CT angiography or direct surgical exploration.

Our case adds evidence that EGD is contraindicated in suspected AEF due to high risk of air embolism. Clinicians must maintain high suspicion and proceed with a multidisciplinary approach prioritizing non-invasive diagnostics and prompt surgical intervention.

Lay Summary

When doctors treat an irregular heartbeat called atrial fibrillation, they sometimes use a procedure that heats heart tissue. Rarely, this can create a dangerous connection between the heart and food pipe (esophagus). This connection, while uncommon, can be deadly. Our research highlights a critical safety warning: using a camera scope to look inside the esophagus when this connection is suspected can lead to catastrophic outcomes. In our case study, this procedure caused air to enter the bloodstream and resulted in brain death. We want doctors to recognize that non-invasive imaging, like CT scans, should be used instead of camera scopes in these rare but high-risk situations. Our findings emphasize the importance of collaborative care teams making careful decisions based on the safest approach. This knowledge can help save lives by preventing dangerous complications when treating this rare but serious condition.

El Mais, Huda

University of Missouri-Kansas City, Kansas City, Department of Medicine; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA

Background

While paradoxical embolism through a patent foramen ovale (PFO) is a recognized phenomenon, its real-time visualization is extraordinarily rare. Most cases are only diagnosed after cerebrovascular events have already occurred. Additionally, evolving evidence supports early catheter-directed intervention for submassive pulmonary embolism (PE) with significant clot burden when hypoxia persists, even with normal blood pressure.

Case Presentation

A 36-year-old female long-haul truck driver presented with progressive dyspnea, pleuritic chest pain, and right lower extremity swelling. Despite normal blood pressure, she exhibited persistent hypoxia requiring supplemental oxygen. CT pulmonary angiography demonstrated extensive bilateral pulmonary emboli with right heart strain and thrombus traversing inter-atrial septum. Lower extremity ultrasound confirmed right popliteal deep vein thrombosis. Notably, transthoracic echocardiography captured a large, mobile thrombus traversing a PFO and prolapsing into the left ventricle. Given the significant clot burden and worsening hypoxia despite adequate anticoagulation, the patient underwent catheter-directed pulmonary artery thrombectomy. When follow-up imaging showed persistent left-sided intracardiac thrombus, she proceeded to successful surgical thrombectomy with PFO closure. Subsequent antiphospholipid antibody testing was positive, and the patient was discharged on long-term anticoagulation.

Discussion

This case is remarkable for capturing a paradoxical embolism in transit before cerebral embolization - a phenomenon rarely documented in real-time imaging. While current guidelines and technological advances have expanded options for PE intervention, the management of concurrent intracardiac thrombi requires careful consideration of risks and benefits. This case highlights several critical learning points: 1) The importance of early echocardiographic evaluation in acute pulmonary embolism; 2) The role of surgical intervention as the definitive treatment for left-sided intracardiac thrombi, particularly when thrombolysis and catheter-based interventions may increase fragmentation risk; and 3) The necessity of thorough hypercoagulability workup in young patients with extensive thrombosis.

Conclusion

Our patient’s successful outcome demonstrates how aggressive, staged management combining both catheter-based and surgical approaches can prevent catastrophic neurologic complications in complex PE cases.

Lay Summary

Blood clots typically form in leg veins and can travel to the lungs, causing breathing difficulties. In some people, a small hole exists between the heart's upper chambers. This hole can allow clots to cross from the right to left side of the heart and potentially travel to the brain, causing strokes. We report an extremely rare case where we captured images of a blood clot crossing through this hole in real-time, before it could cause a stroke. This is significant because doctors rarely see this happening—usually, they only diagnose it after a stroke has occurred. Our patient was successfully treated with a two-step approach: first removing clots from her lungs using a catheter, then surgically removing the clot from her heart and closing the hole. This case highlights the importance of comprehensive imaging in patients with blood clots and demonstrates how timely, coordinated care can prevent life-threatening complications.

El Mais, Huda

University of Missouri-Kansas City, Department of Medicine; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA

Background

False positive human chorionic gonadotropin and high-sensitivity troponin (hsTn) due to circulating heterophile antibodies is well documented. However, false positive hsTn is rarely described in pregnancy. We present a diagnostic conundrum of persistently elevated hsTn in one patient across multiple trimesters.

Case Presentation

A 24-year-old G2P1 with prior preeclampsia presented at 5 weeks gestation with presyncope and chest tightness following parainfluenza infection. HsTn was 3,681 pg/dL (>100x normal) raising concern for SCAD. ECG showed nonspecific changes and echocardiogram was normal. HsTn persisted through discharge with nadir of 3,115 pg/dL. She was treated with aspirin and metoprolol, with planned postpartum coronary CT angiography and fibromuscular dysplasia screening. She re-presented at 33 and 34 weeks with dyspnea and palpitations. HsTn was 4,200-4,900 pg/dL during each hospitalization. Differential diagnosis broadened to viral versus pregnancy-associated myocarditis. Postpartum cardiac MRI was planned, with close monitoring until delivery. Delivery at 37 weeks was offered. Following shared decision-making, the patient favored 39-week delivery. On presentation for scheduled caesarean section, hsTn was unchanged despite resolution of symptoms, raising suspicion for false positive. CK-MB was normal. Two hsTn assays performed by external reference lab were negative confirming false positive status, consistent with presence of interfering heterophile antibodies.

Conclusion

Increased awareness of false positive hsTn and appropriate confirmational methods is key to avoiding an unnecessary diagnostic and treatment cascade in pregnant patients with persistently elevated hsTn despite clinical improvement. In this case, judicious noninvasive diagnostic testing and clinically driven treatment resulted in the recognition of a false positive hsTn.

Lay Summary

Cardiovascular problems in pregnancy are high stakes for both mother and baby. Several diagnostic imaging tests that are used in non-pregnant women are rarely used during pregnancy due to concerns for fetal safety. We rely heavily on bloodwork for diagnosis of heart attacks and other life-threatening conditions during pregnancy. This is a case of a rare false-positive lab value which was ultimately identified as a false positive at the end of the patient’s pregnancy and after multiple hospitalizations. Our hope in sharing this experience is to raise awareness of false positive lab tests in pregnant women that can impact care. Additionally, we describe how the false positive was confirmed by external lab validation.

Granstaff, Kaitlyn

UMKC Cardiology Fellowship

Background

Heparin-induced thrombocytopenia (HIT) is an immune-mediated response to heparin therapy, characterized by the formation of antibodies against the heparin-platelet factor 4 complex and a paradoxical increase in thrombotic risk. ​HIT is life-threatening and management includes immediate cessation of heparin and initiation of alternate anticoagulants. ​However, heparin remains the anticoagulant of choice for cardiopulmonary bypass due to its rapid onset, reversibility, and familiarity in cardiac surgery.​ We describe a complex case of severe mitral stenosis (MS) who underwent cardiopulmonary bypass surgery using heparin for urgent valve replacement in the setting of acute HIT.​

Case Presentation

A 46-year-old woman with severe MS was admitted to the ICU for acute limb ischemia. Work-up revealed atrial fibrillation & Left Atrial Appendage (LAA) thrombus. She underwent appropriate vascular intervention and was started on a heparin drip. On hospital day 9, she developed acute thrombocytopenia with 4T-Score of 6/8. Heparin was discontinued for argatroban. HIT was confirmed with a positive HIT-antibody and serotonin release assay.​​

Unfortunately, she developed bleeding complications, including an intracerebral punctate hemorrhage, leading to cessation of argatroban. Subsequently, she had worsening renal function requiring continuous renal replacement therapy (CRRT). She developed pulmonary edema refractory to fluid removal with CRRT necessitating non-invasive ventilation. In the absence of any anticoagulant, she experienced another cardioembolic event. Given her worsening clinical status & inability to provide therapeutic anticoagulation, urgent mitral valve replacement surgery was pursued.​

Intraoperative use of direct thrombin inhibitors or antiplatelet agents was initially considered. However, due to recent intracranial bleeding, ongoing renal dysfunction, and concerns regarding reversibility, these options posed significant risks. Therefore, we opted to initiate plasmapheresis and clear circulating HIT antibodies to enable safe intraoperative use of heparin. Seroreversion of the HIT-antibody was achieved after just two cycles of plasmapheresis. Cardiopulmonary bypass surgery was then successfully performed using heparin.​

The patient underwent mitral valve replacement, maze procedure, and removal and closure of the LAA thrombus without any intraoperative complications. Post-operatively, bivalirudin was resumed. She experienced no further thrombotic or bleeding events. The patient gradually stabilized, with improvement in her renal function and respiratory status, and was eventually discharged to follow-up care.​

Discussion

This case highlights the challenges of managing anticoagulation during urgent or emergent cardiopulmonary bypass surgeries in patients with acute HIT. Multiple strategies have been studied to enable anticoagulation during cardiopulmonary bypass surgeries. Some of these enable intra-operative heparin use by pre-operative treatment with plasmapheresis or IVIG, or with concomitant intra-operative use of antiplatelet agents, such as epoprostenol. Another approach is to avoid heparin altogether and use intra-operative direct thrombin inhibitors, such as bivalirudin or tirofiban.​ Though the options are laid out, there is lack of prospective data and clear guidelines on which strategy is most suitable in different clinical scenarios.​ In this case, the decision to use plasmapheresis until HIT-antibody seroreversion, resulting in a successful outcome, is emphasized.​

Lay Summary

A 46-year-old woman in the ICU faced a critical situation after developing heparin-induced‬ ‭ thrombocytopenia (HIT), a rare but dangerous reaction to the blood thinner heparin. HIT occurs‬ ‭ when the immune system mistakenly produces autoantibodies that attack platelets, leading to‬ ‭ excessive clotting instead of preventing it. While awaiting urgent heart valve replacement, she‬ ‭ suffered strokes, kidney failure, severe bleeding, and respiratory distress, making standard‬ ‭ treatments risky. With her condition worsening, doctors turned to plasmapheresis—a procedure‬ ‭ that removes harmful antibodies from the blood—allowing them to reintroduce heparin for‬ ‭ surgery safely. This innovative approach enabled a successful heart valve replacement without‬ ‭ major complications. The patient recovered in the ICU without further clotting or bleeding‬ ‭ problems. This case highlights a life-saving strategy for managing HIT in critically ill patients‬ ‭ undergoing emergency heart surgery, offering hope for others facing this complex condition.‬

Hansraj, Sagar <sagar.hansraj@umkc.edu>

University of Missouri – Kansas City

Background

Colosplenic fistula (CsF) is a rare and underreported condition, with the largest known institutional series comprising only 13 cases. Its diagnosis and management remain poorly characterized due to limited clinical experience and literature. We present a case of CsF secondary to a locally aggressive adenocarcinoma of the splenic flexure.

Case Presentation

A 72-year-old woman presented with a one-week history of chills, profuse sweating, and left upper quadrant abdominal pain. Imaging demonstrated a mass at the splenic flexure with associated colonic perforation and a splenic abscess, raising suspicion of a CsF. Despite preserved bowel function and minimal gastrointestinal symptoms, the patient showed signs of sepsis and was taken urgently to the operating room. She underwent laparoscopic creation of a transverse loop colostomy for diversion, along with drainage of the splenic abscess following debridement of necrotic tissue at the inferior splenic pole. During operative manipulation, the colonic wall was avulsed; biopsy of the mass revealed invasive, moderately differentiated adenocarcinoma. The patient recovered well and was discharged on postoperative day nine. Three months later, she underwent definitive oncologic resection, which included left colectomy with en bloc resection of the left upper quadrant abdominal wall and diaphragm (with primary repair), distal pancreatectomy, splenectomy, left nephrectomy and adrenalectomy, omentectomy, cytoreduction with abdominal wall tumor resection (<5 cm), open appendectomy, and revision colostomy with re-siting. She tolerated the procedure well and was subsequently initiated on adjuvant chemotherapy with a FOLFOX regimen.

Conclusion

This case underscores the diagnostic and therapeutic complexity of CsF. While CT imaging is the diagnostic modality of choice, percutaneous drainage may offer temporary control of sepsis but is rarely definitive. Surgical management, typically involving splenectomy and resection of the affected colon, remains the cornerstone of treatment. Given the strong association with malignancy, particularly adenocarcinoma, early multidisciplinary coordination is essential for favorable outcomes.

Lay Summary

A rare condition called a colosplenic fistula, where the colon forms an abnormal connection to the spleen, developed in a 72-year-old woman due to colon cancer. She came to the hospital with fever, sweating, and pain in her upper left abdomen. Scans showed a tumor in her colon, a hole in the bowel, and a pus-filled area near the spleen. Though she had no major bowel issues, she was showing signs of serious infection. Surgeons first performed an emergency operation to divert her stool and drain the infection. Biopsies confirmed colon cancer. Three months later, she underwent a major surgery to remove the cancer, which included taking out parts of her colon, pancreas, spleen, kidney, adrenal gland, diaphragm, and abdominal wall. She recovered well and started chemotherapy. This case highlights how challenging it is to diagnose and treat colosplenic fistulas, which often require major surgery and close coordination among specialists.

Yin, Kanhua

Department of Surgery, Saint Luke's Health System, Kansas City, MO

Background

Hypertension during pregnancy poses significant health risks for both the expectant mother and the developing fetus. Risks for adverse outcomes related to hypertension do not cease after delivery of the child. In fact, more than half of pregnancy-related maternal deaths occur after the birth of the infant (Kassebaum, et al, 2014). Hypertensive Disorders of Pregnancy (HDP) can persist for weeks into the post-partum, or “4th trimester” of pregnancy. The American College of Obstetricians and Gynecologists recommend women with HDP have a postpartum follow-up visit for blood pressure evaluation no later than 7-10 days after birth, and women with severe hypertension within 72 hours.

Objective

The purpose of this project was to quantify total missed follow-up appointments among patients with HDP and identify common factors associated with missing the postpartum high blood pressure scheduled visit among patients seen in the maternal-fetal medicine (MFM) high risk pregnancy clinic at Saint Luke’s Hospital.

Methods A retrospective chart review was conducted on all patients seen in the MFM Clinic from January 1, 2023 to December 31, 2023 with any diagnosis of hypertension. Delivery date and discharge date were recorded, as well as the number of days elapsed from discharge to the first follow-up appointment. Patients were classified into those seen within 7 days of discharge and those not seen within 7 days of discharge. Demographics, including age, insurance status, obstetric history, severity of hypertensive diagnosis, presence of maternal congenital heart defect, and social determinants of health were collected and compared.

Results

This data is being analyzed and will be prepared for presentation for SLH Research Day in May.

Lay Summary

Stroke is severely disruptive for not only the person but family of the stroke survivor across the lifespan. Building a person’s ability to adapt or support personal resilience may allow for improved function, engage in recovery, and better quality of life. We can see that stroke survivors are more stressed and less resilient than non-stroke survivors. We currently do not understand the best way to support and promote resilience when stroke leaves its mark. By searching the evidence, trying out a strategy to build resilience and discussing a stroke survivor’s excellent resilience may aid development of model to support stroke survivors. Stroke care often neglects psychosocial factors, despite their significant impact. Stepping back to focusing on lifelong recovery broadens the view on the continuous impact of stroke. Nurses, the most ubiquitously dispersed and capable group of healthcare providers, are prepared to support a life worth living after stroke.

Belcher, Nikki

Saint Luke's Hospital of Kansas City

Background

Indications for tricuspid valve intervention (TVI) at the time of surgical pulmonary valve replacement (PVR) in repaired tetralogy of Fallot (rTOF) are not well established.

Objective

We sought to determine if right heart characteristics and TVI are associated with imaging and clinical outcomes after PVR.

Methods

A retrospective, single-center cohort study of subjects with rTOF who underwent an initial surgical PVR between 1998 and 2019. Selected imaging parameters on pre and post PVR imaging studies (echocardiogram, cardiac magnetic resonance) and clinical outcomes were analyzed.

Results

Among 258 subjects with rTOF undergoing index PVR, 34 underwent TVI. Right atrial (RA) volumes improved significantly in all subjects within one year of index PVR, most notably in the TVI group (-18ml/m² vs -8ml/m² p<0.001). Although RA volumes improved in subjects who had TVI, they were at greater risk of developing atrial arrhythmias (38% vs 13%, p<0.001).

Subjects who underwent TVI were more likely to have moderate or greater TR at a median of 7 years following PVR (38% vs 8% p <0.001), but when restricting the analysis to those with moderate TR preoperatively, there was no significant difference (56% vs 27% p=0.36, Table).

A larger preoperative right heart systolic volume index (RHSVi), defined as the combination of RA and RV indexed end-systolic volume, was associated with more TR at follow up (average RHSVi = 163 ml/m² vs. 129 ml/m² vs. 115 ml/m² for ≥moderate vs. mild vs. none/trivial TR respectively; p<0.001).

Conclusions

In subjects with rTOF, RA volumes improve significantly in those who have TVI at the time of index PVR, however, subjects are at greater risk of developing atrial arrhythmias and TR in the future. Larger RHSVi prior to PVR is associated with more TR at long term follow up.

Lay Summary

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart defect. As repairs in childhood have continued to improve, patients with congenital heart disease are living to older age. There are more adults with congenital heart disease than children. This study assessed how repairing one of the valves in the heart (tricuspid valve), at the time of replacing a commonly dysfunctional valve in ToF (pulmonary valve), could potentially have long term implications for the patient. We found that fixing both valves during an operation leads to short term improvement in the size of the atrium but is associated with more rhythm issues. So what? Are we creating sutures that act as arrythmia substrates? Is the intervention just a marker for sick patients? We will continue to reevaluate the type of repairs performed to find the techniques resulting in a sustainable improvement for patients with ToF.

DeZorzi, Christopher

Saint Luke's Mid America Heart Institute

Background

Myocardial perfusion imaging (MPI) using positron emission tomography (PET) is a diagnostic modality to diagnose coronary microvascular dysfunction (CMD). Coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) are increasingly being used as part of invasive coronary function testing (CFT) to diagnose CMD. There is paucity of data in the congruence of PET derived diagnosis of CMD and CFT derived diagnosis of CMD.

Methods

We analyzed data for 35 patients who underwent both PET MPI and CFT to assess for CMD. CFT included acetylcholine provocation, myocardial bridge evaluation and CMD evaluation using thermodilution method with adenosine. CFR and IMR were obtained. We defined CMD based on the CFT as CFR <2.5. It was further divided into structural and functional CMD based on IMR, where IMR >24 and CFR <2.5 was defined as structural CMD and IMR ¬<24 and CFR < 2.5 was functional CMD. We defined CMD on PET as global myocardial blood flow reserve less than 1.8 or peak myocardial global blood flow of <1.4mg/ml/min. We then compared the concordance between CFT and PET MPI in diagnosis of CMD.

Results

There were 5 patients with epicardial ischemia that were excluded from this study. The remaining 30 individuals included 20 women and 10 men with an average age of 66.7 years. The prevalence of coronary vasospasm and physiologically significant myocardial bridge was 67% and 7% respectively. The prevalence of CMD using CFT and PET was 33% and 43% respectively. There were 9 discordant cases in which CFT defined CMD in 3 cases and 6 cases of CMD based on PET. Of the concordant cases, 7 cases were CMD using on PET and CFT. The concordance rate between CFT and PET is 70%.

Conclusion

Both myocardial perfusion imaging with PET and invasive CFT can be used to diagnose CMD with a fair agreement between two diagnostic modalities.

Jacob, Dany

Saint Luke’s Mid America Heart Institute and University of Missouri, Kansas City, Missouri, USA

Background

Drug coated balloons (DCB) is a promising therapeutic option for in-stent restenosis (ISR), however, there is limited data comparing the efficacy of DCB to conventional balloon angioplasty (BA) based on the angiographic restenosis pattern.

Methods

AGENT IDE is a multicenter, prospective, randomized trial that enrolled 600 patients with ISR who were randomly assigned 2:1 to either AGENT DCB or BA after successful lesion preparation. Patients were categorized into two subgroups based on Mehran ISR classification: 1) focal ISR and 2) diffuse ISR. A post-hoc analysis utilizing the Cox regression model was conducted to evaluate the safety and efficacy of AGENT DCB in focal and diffuse ISR lesions. The primary end point was 1-year target lesion failure (TLF), a composite of ischemia-driven target lesion revascularization, target vessel–related myocardial infarction, or cardiac death.

Results

There were 243 patients with focal ISR lesions vs 349 with diffuse ISR lesions with a lesion length of 7.0 mm vs 16.3 mm (P<0.001), respectively. DCB showed a 52% relative risk reduction in TLF vs BA in diffuse restenosis (HR 0.48, 95% CI [0.30-0.78]) and a 30% relative risk reduction in focal restenosis (HR 0.70, 95%CI [0.41-1.21]) (Table 1); no interaction for treatment effects was observed (P-interaction=0.29). There was no definite/probable stent thrombosis in the DCB cohort.

Conclusions

The safety and efficacy of AGENT DCB was consistent among both focal and diffuse ISR, with a greater therapeutic impact observed in the diffuse ISR subgroup.

Jacob, Dany

Saint Luke’s Mid America Heart Institute and University of Missouri, Kansas City, Missouri, USA

Background

Multiple lines of evidence suggest a role of inflammation in epilepsy. Seizure incidence in patients with multiple sclerosis (MS) is two-to-three folds higher than age-matched general population.

Objective

To explore the association of MS disease modifying therapies (DMTs) and FDA-approved Bruton tyrosine kinase inhibitors (for lymphocytic malignancies) with the occurrence of epilepsy using the FDA Adverse Event Reporting System (FAERS) database.

Methods

This study involved a secondary analysis of the FAERS database. We conducted a disproportionality analysis of FAERS between the fourth quarter of 2003 and the third quarter of 2023. MS DMTs and the Bruton tyrosine kinase inhibitor, ibrutinib, were included in the analysis. An inverse association was defined as the upper limit of the 95% confidence interval (CI) for the reporting odds ratio (ROR) being less than 1. A safety signal, per Evans criteria, was defined as ≥3 reports, proportional reporting ratio (PRR) ≥2, and chi-squared value ≥4.

Results

We found an inverse association between the following drugs and epilepsy: ibrutinib (ROR: 0.338; 95% CI: 0.218-0.524), ocrelizumab (ROR: 0.541; 95% CI: 0.341-0.859), ofatumumab (ROR: 0.536; 95% CI: 0.311-0.924), rituximab (ROR: 0.782; 95% CI: 0.639-0.957), and teriflunomide (ROR: 0.452; 95% CI: 0.285-0.718). The strongest inverse association was seen with ibrutinib. A safety signal for epilepsy was found for fingolimod based on the Evans criteria (PRR: 2.164; 95% CI: 1.863-2.513, χ2=106.06).

Conclusion

Our observations suggest that agents that reduce or modulate B lymphocytes (ibrutinib and the anti-CD20 agents) or reduce the proliferation of activated T and B lymphocytes (teriflunomide) may be inversely associated with epileptic seizures. The strongest inverse association was seen with ibrutinib, which has also been shown to modulate myeloid cell subsets, including CNS microglia. Our findings suggest the possibility of considering these medications for repurposing opportunities in epilepsy and support a potential pathogenic role of leukocyte subsets in seizure perpetuation.

Lay Summary

People with multiple sclerosis (MS), a condition where the immune system attacks the brain and spinal cord, are more likely to have seizures than the general population. Our research explored whether medications used to treat MS or certain cancer drugs that affect the immune system are linked to seizures. We used a large public safety database to look at reports of seizures in people taking these drugs. Interestingly, we found that some medications—particularly those that affect specific immune cells—were linked to fewer seizure reports. The strongest protective signal was seen with a cancer drug called ibrutinib. Our findings suggest that targeting certain immune cells may help reduce the risk of seizures, opening the door for these medications to be explored as new treatments for epilepsy. More research is needed, but this work highlights how medicines designed for one disease might benefit others.

Shirani, Afsaneh

Saint Luke’s Marion Bloch Neuroscience Institute, Kansas City, MO