Sumair Ahmad

Serum vitamin D levels correlate to coronary artery disease severity: a retrospective chart analysis

ABSTRACT Background: The pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. We further emphasized and evaluated the severity of coronary artery disease (CAD) with varying levels of vitamin D in relation to age, gender, ethnicity and baseline confounders. Methods: A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed levels of 25(OH)D and extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Results: Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis of the extent of coronary disease, we identified 20% of patients having normal coronaries, 55% having obstructive CAD and 25% having non-obstructive CAD. Baseline clinical risk factors and co-morbidities did not differ between the groups. Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2 – 9.5, p < 0.0001). Comparing patients with normal 25(OH)D levels, patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 62% were found to have obstructive CAD (n = 624, OR: 2.9, 95% CI: 2.3-3.7, p < 0.0001) and 25% had non-obstructive CAD (n = 249, OR: 1.5, 95% CI: 1.1-2, p = 0.02). Conclusion: Normal coronaries and CAD were shown to correlate with normal and low levels of 25(OH)D, respectively. There is an inverse relationship between the percentage of coronary artery occlusion and serum 25(OH)D concentrations. Vitamin D may provide benefits in risk stratification of patients with CAD and serve as a possible risk factor.

Risk factors for coronary artery disease and acute coronary syndrome in patients ≤40 years old

OBJECTIVE In this study, we assessed the risk factor profile in premature coronary artery disease (CAD) and acute coronary syndrome for adults ≤40 years old. METHODS A retrospective chart analysis of 397 patients ≤40 years old admitted from 2005 to 2014 for chest pain and who underwent coronary arteriography. RESULTS Of 397 patients that had undergone coronary arteriography, 54% had CAD while 46% had normal coronary arteries. When compared with patients with normal coronary arteries, patients with CAD were more likely to smoke tobacco, have dyslipidemia, be diabetic, have BMI >30 kg/m(2), have a family history of premature CAD and be male in gender. CONCLUSION Healthcare intervention in the general population through screening, counseling and education regarding the risk factors is warranted to reduce premature CAD.

Morbidity and Mortality of Congestive Heart Failure in Trauma Patients

Background: Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay (LOS) are considered. With increasing average life expectancy, HF prevalence continues to rise. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggest that HF is the most common cause for hospital admission in patients older than 65 years. Objective: In this study, we sought out to compare the 30‐day readmission rate in trauma patients who have a preexisting history of HF to those who do not have a history of HF. Additionally, we emphasized the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] versus HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic versus nonischemic). Methods: A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005 and 2013 secondary to trauma with an Injury Severity Score <30. Data were extracted using International Classification of Diseases, Ninth Revision codes. Neurotrauma patients were excluded. Results: Of 8,137 trauma patients, 334 had preexisting HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology versus 44 nonischemic. Of 334 HF patients, 81 patients (24%) were readmitted within 30 days versus 1,068 (14%) of the non‐HF patients (95% CI: 1.52‐2.25, relative risk: 1.85, P < 0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus HFrEF groups. Mortality, 30‐day readmission and LOS were all significantly higher in the ischemic versus nonischemic HFrEF group. Conclusions: In our trauma population, HF patients had a significantly higher 30‐day readmission rate when compared to non‐HF patients. The pathophysiology of HF (HFpEF versus HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and LOS were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with preexisting HF.

Primary squamous cell carcinoma of the rectum: a case report and literature review.

Squamous cell carcinoma (SCC) of the rectum is a rare occurrence with an incidence rate of 0.1–0.25% per 1,000 cases. Herein, we report a case of a 52-year-old female who presented with a 2-month history of diffuse lower abdominal pain and hematochezia. Abdominal CT scan revealed a 7-cm irregular rectal mass, and the biopsy showed SCC.

ID: 38: PRIMARY SQUAMOS CELL CARCINOMA OF THE RECTUM

Introduction Squamous cell carcinoma (SCC) of the gastrointestinal (GI) tract is an uncommon occurrence, as it usually involves the esophagus or anal canal. Approximately 90% of cases of rectal malignancy are adenocarcinoma and other rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%). We are presenting a rare and unique case of patient with SCC of the rectum presenting with lower abdominal pain and significant weight loss. Case A 52 year old female was admitted with a two month history of diffuse lower abdominal pain and hematochezia. The pain was constant and pressure like. The patient was a nonsmoker and nondrinker. Review of systems was pertinent for an unintentional weight loss of 10lbs. Physical examination revealed diffuse lower abdominal tenderness and a firm, irregular anterior rectal mass. She had no lymphadenopathy and her skin exam was normal. Laboratory results a normocytic anemia with a hemoglobin of 8.8 g/dl and a CEA of 1.35 ng/ml. Abdominal CT scan revealed a 7 cm irregular rectal mass with extra luminal compression to the rectosigmoid area, (figure 1). The mass did not extend from uterus and confirmed with transvaginal ultrasound. Patient underwent a flex sigmoidoscopy which revealed a lesion 5 cm from anal verge extending distally. There is a semi-circumferential narrowing occupying 7% of lumen and a dense layer of mass tissue with superficial friability of mucosa. Biopsy was taken from the mass, histology shows invasive moderately differentiated squamous cell carcinoma (figure 1). Discussion SCC of the rectum has a very similar presentation to colon adenocarcinoma. Diagnoses can be established by proctoscopy/colonoscopy and more specifically, a biopsy to get a definitive histological analysis. The latter is a used to differentiate from SCC of the anus, which presents similarly. Immunohistochemistry has proved useful in characterizing lesions, especially when using cytokeratin stains. Pathogenesis is unclear due to its rarity; however one of the proposed mechanisms suggests that inflammation or infection results in squamous metaplasia from which carcinoma develops. Thus there is an association with HPV and various squamous cancers. In conclusion, SCC of rectum is a distinct entity and it is important to shed some light on this rare condition because it has different epidemiology, etiology, pathogenies and requires a different treatment approach than other colorectal carcinomas. Surgery is the primary treatment which consists of local excision versus radical resection and the need for adjuvant therapy. Abstract ID: 38 Figure 1

ID: 28: ACQUIRED IMMUNODEFICIENCY SYNDROME RELATED KAPOSI SARCOMA A RARE INTRUDER AFFECTING THE STOMACH

Introduction Kaposi sarcoma (KS) is a vascular tumor that is commonly associated with human herpesvirus 8 (HHV-8). The epidemic type of KS is associated with the most common tumor arising in HIV infected people, which is considered by CDC guidelines an AIDS defining illness. Lesions on the skin are the most common initial presentation in patients unlike the involvement of visceral sites. We present a unique case of KS affecting the stomach, initially presenting as abdominal pain and diarrhea. Case Patient is a 34 year old female with past medical history of AIDS/HIV with a CD4 count of 143 cells/μL, VL 46 copies/mL on HAART therapy diagnosed with visceral and cutaneous manifestations presents to the ED with nausea, vomiting, diarrhea and diffuse abdominal pain for three days. The symptoms have progressively gotten worse. Patient denies any history of fevers, recent travel, sick contacts or recent antibiotic use. On examination, the patient had stable vitals and evidence of dark brown, papular skin lesions of various sizes over face, torso and upper extremity. Abdominal examination revealed tenderness in the epigastric area. Laboratory studies and initial abdominal cat-scan with contrast were unremarkable. All infectious workup was negative. However, EGD revealed esophageal nodule in the mid-distal esophagus (figure 1A), non-obstructive lower esophageal (LE) stricture (figure 1B), and a gastric ulcer raised with heaped margins (figure C). Biopsy of the gastric ulcer reveals KS with necrosis. Throughout hospital course, patient received 12 rounds of Doxirubicin for treatment, continued with HAART therapy. Patient is tolerating chemotherapy well, cutaneous lesions are improving and signs and symptoms of diarrhea and abdominal pain have alleviated. Discussion Cutaneous manifestation is usually the initial presentation of KS and visceral involvement is typically a later manifestation of disease. What is interesting in this case is the involvement of both cutaneous and visceral sites. It can be observed in the gastrointestinal (GI) tract, but rarely seen in the stomach. GI lesions may be asymptomatic or may cause weight loss, abdominal pain, nausea, vomiting and obstruction, which is seen in our case. EGD revealed distal LE stricture and gastric ulcer biopsy showing KS with necrosis. For AIDS patients who have KS, HAART therapy should be initiated to induce regression. For systemic treatment chemotherapy with Doxirubicin should be considered when there is symptomatic visceral or mucosal involvement and extensive cutaneous KS. We suggest the KS be included in the differential in AIDS patients with diarrhea and non-specific GI symptoms. Moreover, EGD should be considered for symptomatic patients because untreated GI KS includes hemorrhage and perforation. Abstract ID: 28 Figure 1

ID: 2: VITAMIN D AND ITS ASSOCIATION IN OBSTRUCTIVE, NON-OBSTRUCTIVE CORONARY ARTERY DISEASE, AND NORMAL CORONARIES ASSESSED ON CORONARY ANGIOGRAPHY

Background Pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. To further demonstrate this phenomenon, we evaluated the degree of coronary artery disease (CAD) with varying levels of vitamin D. Method A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed the degree of 25(OH)D and the extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Results Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis for the extent of coronary disease we identified 259 patients (20%) having normal coronaries, 720 patients (55%) with obstructive CAD and 291 patients (25%) with non-obstructive CAD. Baseline clinical risk factors, and co-morbidities did not differ in either groups. Patients with 25(OH)D deficiency and insufficiency (n=1003) developed symptomatic CAD at a mean age of 63-years-old versus 67 with normal 25(OH)D (n=308, p<0.0001). Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2–9.5, p<0.0001). Comparing patients with normal 25(OH)D levels, in patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 65% were found to have obstructive CAD (n=612, OR: 2.9, 95% CI: 2.3–3.7, p<0.0001) and 24% had non-obstructive CAD (n=237, OR: 1.5, 95% CI: 1.1–2, p=0.02). In a head-to-head, sub-grouped comparison, patients with 25(OH)D deficiency and insufficiency were found to have obstructive CAD (n=394, OR: 2.7, 95% CI: 2–3.4, p<0.0001) and non-obstructive CAD (n=169, OR: 2.6, 95% CI: 2–3.4, p<0.0001), respectively. Conclusion Vitamin D deficiency and insufficiency correlate with obstructive and non-obstructive CAD, respectively. Normal coronaries were shown to be related with normal levels of vitamin D. Vitamin D levels may provide benefit in improving risk stratification for patients with CAD as a possible modifiable risk factor. Further studies may be needed to enhance our findings.

ID: 3: MORBIDITY AND MORTALITY OF CONGESTIVE HEART FAILURE IN TRAUMA PATIENTS: A RETROSPECTIVE CHART ANALTSIS

Background Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay are considered. With increasing life expectancy, HF prevalence continues to increase. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggests that HF is the most common cause for hospital admission in patients older than 65 years. Objective In this study, we sought out to compare the morbidity, mortality, 30-day readmission rate and length of stay in trauma patients who have a pre-existing history of HF to those who do not have a history of HF. Additionally, we emphasize the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] vs. HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic vs. nonischemic). Methods A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005–2013 secondary to trauma with an Injury Severity Score<30. Data was extracted using ICD-9 codes. Neurotrauma patients were excluded. Results Of 8,137 trauma patients, 334 had pre-existing HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology vs. 44 nonischemic. Of 334 patients, 81 patients (24%) were readmitted within 30 days vs. 1,068 (14%) of the non-HF patients (95% CI 1.52–2.25, RR: 1.85, p<0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus. HFrEF groups (figure 1 and table 1). Mortality, 30-day readmission and length of stay were all significantly higher in the ischemic vs. non-ischemic HFrEF group (figure 1 and table 2). Conclusions In our trauma population, HF patients had a significantly higher morbidity, mortality and 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF vs. HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and length of stay were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with pre-existing HF. Abstract ID: 3 Figure 1