The Impact of Upper Airway Stimulation on Swallowing Function

OBJECTIVE

To evaluate the impact of upper airway stimulation therapy (UAS) on swallowing function in patients with obstructive sleep apnea.

STUDY DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PARTICIPANTS AND OUTCOME MEASURES

We recorded demographic, preoperative polysomnogram (PSG), operative, and postoperative PSG data. We assessed the patients swallowing function using the Eating Assessment Tool (EAT-10) dysphagia questionnaire. This was administered both pre- and postoperatively. The postoperative EAT-10 survey was administered at least 3 months after UAS implantation.

RESULTS

During the study period, 27 patients underwent UAS implantation, completed the pre- and postoperative EAT-10 questionnaire, met inclusion/exclusion criteria, and were included in the study. The cohort consisted of 16 men and 11 women with a mean age of 63.63 years. The mean preoperative BMI, Epworth Sleepiness Scale (ESS), and Apnea Hypopnea Index (AHI) were 29.37, 10.33, and 34.90, respectively. The mean postoperative ESS and AHI were 5.25 and 7.59, respectively. These were both significantly lower than the preoperative values (P = .026 and P < .001). The mean pre- and postoperative EAT-10 scores were 0.37 and 0.22, respectively (P = .461).

CONCLUSION

Our data suggest that UAS likely does not lead to postoperative dysphagia.

TAVI for Pure Native Aortic Regurgitation: Are We There Yet?

Treatment of degenerative aortic stenosis has been transformed by transcatheter aortic valve implantation (TAVI) over the past 10-15 years. The success of various technologies has led operators to attempt to broaden the indications, and many patients with native valve aortic regurgitation have been treated 'off label' with similar techniques. However, the alterations in the structure of the valve complex in pure native aortic regurgitation are distinct to those in degenerative aortic stenosis, and there are unique challenges to be overcome by percutaneous valves. Nevertheless some promise has been shown with both non-dedicated and dedicated devices. In this article, the authors explore some of these challenges and review the current evidence base for TAVI for aortic regurgitation.

Hybrid transcatheter tricuspid valve-in-valve placement of an Edwards Sapien XT valve in palliated hypoplastic left heart syndrome

Tricuspid regurgitation in the context of hypoplastic left heart syndrome (HLHS) carries a significant burden of both mortality and morbidity. We report successful hybrid trans-atrial implantation of an Edwards Sapien XT valve into a dysfunctional bioprosthetic valve in the tricuspid position of a 9-year-old patient with HLHS. There was an immediate fall in the Fontan pressures combined with significant clinical improvement and the valve continues to function well nearly 3 years post implant. To the best of our knowledge, this is the first described implantation of a transcatheter valve in this specific position and anatomy.

S100A8 & S100A9: Alarmin mediated inflammation in tendinopathy

Alarmins S100A8 and S100A9 are endogenous molecules released in response to environmental triggers and cellular damage. They are constitutively expressed in immune cells such as monocytes and neutrophils and their expression is upregulated under inflammatory conditions. The molecular mechanisms that regulate inflammatory pathways in tendinopathy are largely unknown therefore identifying early immune effectors is essential to understanding the pathology. Based on our previous investigations highlighting tendinopathy as an alarmin mediated pathology we sought evidence of S100A8 & A9 expression in a human model of tendinopathy and thereafter, to explore mechanisms whereby S100 proteins may regulate release of inflammatory mediators and matrix synthesis in human tenocytes. Immunohistochemistry and quantitative RT-PCR showed S100A8 & A9 expression was significantly upregulated in tendinopathic tissue compared with control. Furthermore, treating primary human tenocytes with exogenous S100A8 & A9 significantly increased protein release of IL-6, IL-8, CCL2, CCL20 and CXCL10; however, no alterations in genes associated with matrix remodelling were observed at a transcript level. We propose S100A8 & A9 participate in early pathology by modulating the stromal microenvironment and influencing the inflammatory profile observed in tendinopathy. S100A8 and S100A9 may participate in a positive feedback mechanism involving enhanced leukocyte recruitment and release of pro-inflammatory cytokines from tenocytes that perpetuates the inflammatory response within the tendon in the early stages of disease.

Tranexamic acid toxicity in human periarticular tissues

Objectives

Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce perioperative bleeding. Increasingly, topical administration as an intra-articular injection or perioperative wash is being administered during surgery. Adult soft tissues have a poor regenerative capacity and therefore damage to these tissues can be harmful to the patient. This study investigated the effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations.

Methods

Tendon, synovium, and cartilage obtained from routine orthopaedic surgeries were used for ex vivo and in vitro studies using various concentrations of TXA. The in vitro effect of TXA on primary cultured tenocytes, fibroblast-like synoviocytes, and chondrocytes was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays, fluorescent microscopy, and multi-protein apoptotic arrays for cell death.

Results

There was a significant (p < 0.01) increase in cell death within all tissue explants treated with 100 mg/ml TXA. MTT assays revealed a significant (p < 0.05) decrease in cell viability in all tissues following treatment with 50 mg/ml or 100 mg/ml of TXA within four hours. There was a significant (p < 0.05) increase in cell apoptosis after one hour of exposure to TXA (100 mg/ml) in all tissues.

Conclusion

The current study demonstrates that TXA caused significant periarticular tissue toxicity ex vivo and in vitro at commonly used clinical concentrations.

Cite this article: M. McLean, K. McCall, I. D. M. Smith, M. Blyth, S. M. Kitson, L. A. N. Crowe, W. J. Leach, B. P. Rooney, S. J. Spencer, M. Mullen, J. L. Campton, I. B. McInnes, M. Akbar, N. L. Millar. Tranexamic acid toxicity in human periarticular tissues. Bone Joint Res 2019;8:11–18. DOI: 10.1302/2046-3758.81.BJR-2018-0181.R1.

Two-dimensional frequency-swept pulse with resilience to both B1 and B0 inhomogeneity

Applications of multidimensional spatially-selective pulses are sometimes limited by their long pulse durations resulting from the need to execute a modulated gradient waveform in concert with RF transmission. Here, we introduce a method to design two-dimensional selective adiabatic pulses using a Cartesian k-space trajectory. The full pulse can be sampled using various undersampled segments to create a multidimensional pulse resilient to large off-resonances. Moreover, the pulse can be designed to be resilient to B1+ inhomogeneity. Experimental demonstrations of fully segmented and single-shot k-space sampling patterns are presented.

Initial experience of a large, self-expanding, and fully recapturable transcatheter aortic valve: The UK & Ireland Implanters' registry

OBJECTIVES

The UK & Ireland Implanters' registry is a multicenter registry which reports on real-world experience with novel transcatheter heart valves.

BACKGROUND

The 34 mm Evolut R transcatheter aortic valve is a self-expanding and fully recapturable transcatheter aortic valve, designed to treat patients with a large aortic annulus.

METHODS

Between January 2017 and April 2018, clinical, procedural and 30-day outcome data were prospectively collected from all patients receiving the 34 mm Evolut R valve across 17 participating centers in the United Kingdom and Ireland. The primary efficacy outcome was the Valve Academic Research Consortium-2(VARC-2)-defined endpoint of device success. The primary safety outcome was the VARC-2-defined composite endpoint of early safety at 30 days.

RESULTS

A total of 217 patients underwent attempted implant. Mean age was 79.5 ± 8.8 years and Society of Thoracic Surgeons Predicted Risk of Mortality Score 5.2% ± 3.4%. Iliofemoral access was used in 91.2% of patients. Device success was 79.7%. Mean gradient was 7.0 ± 4.6 mmHg and effective orifice area 2.0 ± 0.6 cm² . Paravalvular regurgitation was more than mild in 7.2%. A new permanent pacemaker was implanted in 15.7%. Early safety was demonstrated in 91.2%. At 30 days, all-cause mortality was 3.2%, stroke 3.7%, and major vascular complication 2.3%.

CONCLUSIONS

Real-world experience of the 34 mm Evolut R transcatheter aortic valve demonstrated acceptable procedural success, safety, valve function, and incidence of new permanent pacemaker implantation.

Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality

OBJECTIVE

To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults.

METHODS

We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate.

RESULTS

Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93).

CONCLUSION

The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

Percutaneous extraction of an embolized progesterone contraceptive implant from the pulmonary artery

The Nexplanon^® implant is a commonly used radiopaque contraceptive device that contains progestogen associated with an ethylene vinyl-acetate copolymer resulting in a slow release of the active hormonal ingredient. It is inserted into the subdermal connective tissue and provides contraceptive efficacy for up to 3 years. Device removal for clinical, personal or device “end-of-life span” reasons is straightforward. In rare cases, implant migration can occur locally within centimeters of the insertion site. Distant device embolization is extremely rare and can result in complications including chest pain, dyspnoea, pneumothorax and thrombosis or prevent conception until the active ingredient is depleted. We present one such case, where a Nexplanon^® implant embolized into the pulmonary artery of a young female patient. We describe the initial “missed” diagnosis of embolized device on a chest radiograph and subsequent successful percutaneous removal once distant embolization was diagnosed.

Population-specific material properties of the implantation site for transcatheter aortic valve replacement finite element simulations

Patient-specific computational models are an established tool to support device development and test under clinically relevant boundary conditions. Potentially, such models could be used to aid the clinical decision-making process for percutaneous valve selection; however, their adoption in clinical practice is still limited to individual cases. To be fully informative, they should include patient-specific data on both anatomy and mechanics of the implantation site. In this work, fourteen patient-specific computational models for transcatheter aortic valve replacement (TAVR) with balloon-expandable Sapien XT devices were retrospectively developed to tune the material parameters of the implantation site mechanical model for the average TAVR population. Pre-procedural computed tomography (CT) images were post-processed to create the 3D patient-specific anatomy of the implantation site. Balloon valvuloplasty and device deployment were simulated with finite element (FE) analysis. Valve leaflets and aortic root were modelled as linear elastic materials, while calcification as elastoplastic. Material properties were initially selected from literature; then, a statistical analysis was designed to investigate the effect of each implantation site material parameter on the implanted stent diameter and thus identify the combination of material parameters for TAVR patients. These numerical models were validated against clinical data. The comparison between stent diameters measured from post-procedural fluoroscopy images and final computational results showed a mean difference of 2.5 ± 3.9%. Moreover, the numerical model detected the presence of paravalvular leakage (PVL) in 79% of cases, as assessed by post-TAVR echocardiographic examination. The final aim was to increase accuracy and reliability of such computational tools for prospective clinical applications.

Abstract WP294: Randomized Trial of an Attending Nurse Model of Care for Acute Stroke

Introduction: Poor medication adherence and insufficient stroke related knowledge may contribute to worse outcomes.

Hypothesis: A relationship-based attending nurse (AN) model of inpatient care for stroke patients will enhance medication adherence, stroke-related knowledge, and QOL after hospital discharge.

Methods: We performed a pseudo-randomized trial of AN + standard care vs. standard care at a single comprehensive stroke center (CSC). We enrolled patients with ischemic stroke, TIA, or ICH. The AN intervention consisted of a dedicated nurse focused on individual patient goals, expectations, and disease related knowledge deficits. After discharge, subjects were consented and assessed via structured telephone interviews using the Morisky Medication Adherence Scale (MMAS-4), Stroke Patient Education Retention tool (SPER), and Stroke Impact Scale (SIS).

Results: We randomly allocated 278 subjects to AN and 392 to standard models of care; 47% and 43% consented to participate, respectively. Patients in the AN group tended to have more severe strokes and lower baseline health literacy on a single Health Read question (Table). Overall, no significant differences were observed in the MMAS-4, SPER, or SIS. However, among those with low baseline health literacy, medication adherence was nearly doubled in the AN group, but no significant effect was observed on other outcomes.

Conclusion: Compared to standard nursing care alone, an attending nurse model did not improve medication adherence, stroke knowledge, or QOL in patients treated at a CSC. However, this intervention may hold promise and warrant further study in those with low baseline health literacy.

Linkage to HIV Outpatient Care Following an Inpatient Stay

Background

Immediate linkage to outpatient HIV follow-up care after hospitalization is a crucial opportunity to review treatment plan and coordinate necessary and additional services. The purpose of this review is to evaluate potential gaps in transition from inpatient to outpatient care services in persons with HIV. Data from multiple electronic medical records and billing systems were used to assess the rate of follow-up care at HIV outpatient facilities within the Mount Sinai Health System (MSHS), among patients hospitalized in four of the largest hospitals within MSHS.

Methods

ICD-10 codes were utilized to capture all hospitalized patients in 2016 with a primary or secondary diagnosis of HIV and their discharge date, across various electronic systems used by MSHS hospitals. Additional visit data was pulled from the EMR used by the five HIV outpatient facilities in order to determine the linkage to care rate. Linkage to HIV care was defined as the proportion of patients who attended an appointment at one of five HIV outpatient clinics within MSHS, within 90 days of discharge.

Results

A total of 3,992 inpatient discharges were associated with the diagnosis of HIV at the Mount Sinai Health System in 2016. Among these, 2,760 (69%) were male and 1,970 (49%) were African Americans while 56% were in the range of 50–69 years. The average length of stay was 6.6 days (SE±0.6). Out of these discharges, 1020 (25%) were scheduled to be seen at the system’s HIV outpatient care facilities within the 90 day interval. Subsequently, 275 patients (27%) have kept their appointments.

Conclusion

The data suggests that a smaller proportion of the inpatient discharges is linked to care within the system in addition to low appointment compliance rate. Further efforts to optimize early linkage to care and retention may help to affect patient outcomes. Interventions focusing on chronic disease management may assist to further improve these rates. At the systems level, enhanced and increased discharge planning and coordination is required between inpatient units and outpatient clinics in addition to greater outreach by outpatient clinics immediately upon discharge.

Disclosures

All authors: No reported disclosures.