Youth fatal drug overdose and suicide: Trends in Connecticut, 2019-2021

BACKGROUND AND OBJECTIVES

Increasing rates of fatal drug overdose (FDO) among youth since 2016 have been driven by fentanyl and polysubstance use. Suicide by youth also increased steadily since 2007. The manner of FDO may be accidental (i.e., unintentional) or suicidal (i.e., intentional). This report examines the rate of youth intentional and unintentional FDO as well as specific drug toxicology in Connecticut, between the years 2019 and 2021, compared to a 2016-2018 report.

METHODS

We reviewed N = 286 consecutive FDO files of youth, <26 years of age dated for 2019-2021 from the Connecticut Medical Examiner's office.

RESULTS

FDO attributed to fentanyl increased significantly from 2016 to 2018 to 2019 to 2021. Xylazine FDO emerged in 2019 and reached 16% in 2021. Intentional FDO rates doubled between these periods from 3.8% to 7.7%. Most FDOs involved individuals aged 20-25 years, whereas 10% were among those aged 15-19. For the first time since 2018, FDO among 10-14 years old was detected. Analysis of gender found no differences. Within each gender, however, FDO attributed to fentanyl increased significantly between these periods. The FDO rate for Hispanics increased significantly, while the rate for Whites decreased significantly.

DISCUSSION AND CONCLUSIONS

The availability of high lethality potential drugs leading to youth FDO including an increasing rate of intentional FDO, is a public health concern. It is prudent to identify modifiable acute high-risk circumstances for intentional FDO and prevention-intervention evidence-based approach to reduce FDO.

SCIENTIFIC SIGNIFICANCE

This is the first study of FDO among youth examining the manner of death by suicide.

Impact of allogeneic stem cell transplantation on thyroid function

PURPOSE

Primary hypothyroidism is a main endocrine complication after allogeneic stem cells transplantation (allo-SCT) in children, but in adults data on post-SCT hypothyroidism are limited. The aims of this observational, cross-sectional study were to assess the prevalence of hypothyroidism in adult allo-SCT recipients according to time from transplantation, and to identify risk factors.

METHODS

One hundred and eighty-six patients (M 104; F 82; median age 53.4 years) who underwent allo-SCT between January 2010 and December 2017 were enrolled and divided into three groups, according to time from allo-SCT (1-3 years; 3-5 years; > 5 years). Pre-transplant TSH and fT4 levels were available for all patients. After transplantation, TSH, fT4 and anti-thyroperoxidase antibodies (TPO-Ab) were evaluated.

RESULTS

After a follow-up of 3.7 years, 34 (18.3%) patients developed hypothyroidism, with higher prevalence in females (p < 0.001) and in patients who received matched unrelated donor grafts (p < 0.05). No difference in prevalence was found at different time points. Patients who developed hypothyroidism showed higher rate of TPO-Ab positivity (p < 0.05) and higher pre-transplant TSH levels (median 2.34 µU/ml) compared to those with preserved thyroid function (median 1.53 µU/ml; p < 0.001). Multivariable analysis identified higher pre-transplant TSH levels as a positive predictor of hypothyroidism (p < 0.005). The ROC curve analysis identified a pre-SCT TSH cutoff of 1.84 µU/ml, which can predict hypothyroidism with sensitivity 74.1% and specificity 67.2%.

CONCLUSIONS

About one out of four patients developed hypothyroidism after allo-SCT, with a greater incidence in females. Pre-transplant TSH levels seem to predict the onset of post-SCT hypothyroidism.

Disparities in Deceased Donor Kidney Offer Acceptance: A Survey of Canadian Transplant Nephrologists, General Surgeons and Urologists

Background

Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking.

Objective

To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals.

Design

A survey study of theoretical deceased donor kidney cases of increasing complexity.

Setting

Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022.

Participants

Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call.

Measurements

Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance.

Methods

Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined.

Results

In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P-value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities.

Limitations

As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient.

Conclusion

In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist.

The utilization and mortality benefits of pulmonary artery catheterization in patients with cardiogenic shock

Introduction

Pulmonary artery catheterization (PAC) can provide essential hemodynamic data to assist in managing critical patients with cardiogenic shock. The use of PAC has been controversial as clinical studies have shown a lack of benefit. However, with the recent widespread availability of mechanical circulatory assists devices, the application and benefits of PAC are expected to rise.

Purpose

To determine the impact of PAC on inpatient outcomes and the utilization of advanced heart failure devices in these patients.

Methods

The National Inpatient Sample from 2016 to 2018 was queried to identify patients with cardiogenic shock. Of these patients, we compared those who received invasive hemodynamic monitoring (IHM) with PAC to those who did not receive PAC. Patients under age 18 and those undergoing surgical or transcatheter cardiac procedures during the same admission were excluded. Multivariate logistic regression was used to select matched samples between groups accounting for patient/hospital demographics and medical comorbidities. The primary endpoint was a comparison of in-hospital mortality, length of hospitalization, and medical costs. The secondary endpoints compared the utilization of mechanical circulatory assists devices: percutaneous ventricular assist devices (pVAD), extracorporeal membrane oxygenation (ECMO), and left ventricular assist device (LVAD), and the incidence of post-PAC complications: pneumothorax, sepsis, and hemorrhage/hematoma.

Results

We identified a total of 279,619 patients admitted with cardiogenic shock, of these patients 25,166 (9%) received IHM with PAC. Patients who had PAC had decreased in-hospital mortality (22.3% vs 29.7%; p&lt;0.001), increased length of hospitalization (12 days vs 9 days; p&lt;0.001), and increased medical costs ($65,884 vs $47,983; p&lt;0.001). Furthermore, in patients with PAC there was increased utilization of pVAD (4.5% vs 1.9%; p&lt;0.001), ECMO (0.07% vs 0.01%; p&lt;0.001), and LVAD (2.2% vs 0.3%; p&lt;0.001). There was no difference in the prevalence of post-PAC complications between both groups.

Conclusions

The use of IHM with PAC was associated with improved mortality and utilization of mechanical circulatory assist devices in patients with cardiogenic shock without increasing risk for post-procedural complications. Therefore, the increased average duration and medical costs of hospitalization with PAC patients likely resulted from improved patient survival. Therefore, the present study indicated that IHM with PAC is safe and beneficial for patients with cardiogenic shock.

Funding Acknowledgement

Type of funding sources: None.

Diffusely abnormal white matter in clinically isolated syndrome is associated with parenchymal loss and elevated neurofilament levels

We characterized the frequency of diffusely abnormal white matter (DAWM) across a broad spectrum of multiple sclerosis (MS) participants. 35% of clinically isolated syndrome (CIS), 57% of relapsing remitting and 64% of secondary progressive MS participants demonstrated DAWM. CIS with DAWM had decreased cortical thickness, higher lesion load and a higher concentration of serum neurofilament light chain compared to CIS without DAWM. DAWM may be useful in identifying CIS patients with greater injury to their brains. Larger and longitudinal studies are warranted.

Comparing outcomes of transcatheter versus surgical aortic valve replacement in patients with atrial arrythmias

Introduction

In patients with severe aortic valve stenosis, clinical trials have demonstrated a similar mortality risk with transcatheter aortic valve replacement (TAVR) compared to surgical aortic valve replacement (SAVR) in low to intermediate-risk patients. However, data comparing these procedures in patients with atrial arrhythmias is lacking.

Purpose

This study aimed to evaluate and compare the in-hospital mortality and outcomes of TAVR and SAVR for severe aortic stenosis in patients with atrial fibrillation or atrial flutter.

Methods

We performed a retrospective cross-sectional analysis using the 2018 National Inpatient Sample. Patients aged 50 years and older with TAVR or SAVR related hospitalizations were identified. Patients with endocarditis and those undergoing coronary artery bypass grafting or other valvular procedures were excluded. Propensity score matching was utilized to mitigate selection bias. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, hospital region, hospital teaching status, median household income, and medical comorbidities. Using 8-to-1-digit match, we paired each admission in TAVR group with one admission in SAVR group.

Results

In 2018, a total of 3487 TAVRs and 1466 SAVRs were performed in patients who had atrial fibrillation or atrial flutter. TAVR and SAVR had no statistically significant difference in inpatient mortality (0.9% vs 0.8%, p=0.79). However, SAVR was associated with higher odds of cardiogenic shock (OR 1.82; 95% CI 1.41–2.35, p&lt;0.0001), acute kidney injury (OR 2.29; 95% CI 1.77–2.97, p&lt;0.0001), mechanical ventilation (OR 2.06; 95% CI 1.75–2.43, p&lt;0.0001), pneumonia (OR 1.76; 95% CI 1.37–2.28, p&lt;0.0001), pneumothorax (OR 6.38; 95% CI 4.17–9.76, p&lt;0.0001) and postoperative hemorrhage (OR 3.21; 95% CI 2.13–4.85, p&lt;0.0001). On the contrary, SAVR was associated with decreased likelihood of subsequent cardiac conduction disorders (OR 0.63; 95% CI 0.51–0.79, p&lt;0.0001) and pacemaker implantation (OR 0.69; 95% CI 0.49–0.98, p=0.037). SAVR was associated with an increased length of hospitalization (3.9 vs. 8.4 days, p&lt;0.0001), with no difference in medical costs.

Conclusion

Inpatient mortality for TAVR and SAVR was similar in patients with atrial fibrillation and atrial flutter. TAVR was associated with a lower risk of inpatient complications, indicating greater suitability for high-risk patients. However, clinicians should be cognizant of the increased risk for cardiac conduction disorders after TAVR, necessitating pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None. Characteristics of the matched cohortForest plot comparing outcomes

Comparing the adverse outcomes of left atrial appendage occlusion in patients with diabetes

Introduction

In patients with atrial fibrillation, it is estimated that greater than 90 percent of left atrial thrombi are located in the left atrial appendage. Multiple percutaneously implanted devices have been approved worldwide for left atrial appendage occlusion (LAAO) to reduce stroke risk in patients not suitable for long-term oral anticoagulation. Device implantation has been associated with a high success rate and low risk for peri-procedural complications. However, as the prevalence of diabetes continues to rise, there is a considerable need to establish peri-procedural risk in these patients.

Purpose

This study aimed to evaluate and compare the in-hospital outcomes of LAAO in patients with and without diabetes.

Methods

We performed a retrospective cross-sectional analysis using the 2018 National Inpatient Sample. All patients aged 18 years and older with atrial fibrillation and LAAO-related hospitalizations were included in this study. To mitigate selection bias and control for patient and institutional imbalances, propensity scoring method was used to select matched sample between patients with diabetes and patients without diabetes. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, hospital region, hospital teaching status, median household income, and medical comorbidities. Using an 8-to-1-digit match, we paired each admission in the diabetes group with one admission without diabetes.

Results

We identified a total of 3572 patients admitted for LAAO; 1298 of these patients had comorbid diabetes. Diabetics did not have a higher risk of in-hospital mortality with LAAO (0.2% vs 0.3%, p=0.620). The risk for 17 out of the 18 identified peri-procedural complications was similar in patients with and without diabetes. However, diabetes was associated with an increased risk of acute kidney injury (Adjusted OR 1.75; 95% CI 1.05–2.93, p=0.03). Interestingly, 0 endocarditis events were captured in both groups, indicating that this complication is only seen in long-term follow-up and had a peri-procedural risk of 0%.

Conclusion

As the use of implantable LAAO devices increases worldwide, clinicians should be cognizant of the increased risk for peri-procedural acute kidney injury in diabetics. Patients with diabetes often have diabetes-induced chronic kidney disease with susceptibility to acute injury. Therefore, volume status should be closely monitored in the peri-procedural period to mitigate further damage to the kidneys in these patients.

Funding Acknowledgement

Type of funding sources: None. Characteristics of the matched cohortOutcomes in the matched cohort

1543 Response to Neoadjuvant Chemotherapy as An Indication for Breast-Conserving Surgery

Aim

Pathological response to neoadjuvant chemotherapy (NAC) seeks to induce tumour regression pre-operatively. The present study aimed to assess tumour response to NAC and to evaluate the appropriateness of subsequent breast-conserving surgery (BCS) to avoid disfiguration of healthy breast tissue.

Method

Analysis of all patients undergoing NAC and wide local excision (WLE) surgery for primary breast cancer between April 2012 and December 2020 at a tertiary breast unit was conducted. Statistical analysis was performed using IBM® SPSS Statistics Software v27.0.

Results

A database of 1490 female patients undergoing WLE was retrieved, of whom 88 received NAC. Average patient age was 56 (SD = 11). Tumours were either invasive ductal (n = 86, 97.7%) or lobular (n = 2, 2.27%) carcinomas and grade 2 (n = 31, 35.2%) or grade 3 (n = 57, 64.8%). Chemotherapy regimens included: 30 FEC-T (34.1%), 22 FEC (25%), 19 TC (21.6%) and 17 other (19.3%). On average, tumour diameter (mm) decreased by 45.9%(34.5) with NAC and a further 2.29%(57.7) from NAC cessation to excision. Tumour diameter varied significantly across time points χ2 (3) = 29.057, p &lt; 0.001. Post-hoc tests revealed a significant reduction in tumour diameter from pre- to post-NAC [Mean(SD):

Conclusions

Tumour diameter significantly reduced with the addition of NAC. There was no statistical difference between post-NAC and post-operative diameter, suggesting no growth between NAC cessation and surgery. Our findings support the use of NAC, where possible, to avoid the need for large resection margins.

Epidemiology of dancers fracture

BACKGROUND

Dancer's fracture is a spiral, oblique fracture of the diaphysis of the fifth metatarsal. Although it is a well-known fracture in high performance athletes, it is less studied in a general population. The article investigates the epidemiology within an adult population consulting a regional trauma and orthopedic center in the United Kingdom.

METHODS

Study population included all patients older than 16 years presenting with a dancer's fracture. Recorded data were age, sex, side and energy of trauma mechanism, applied treatment and time of healing.

RESULTS

Of all fifth metatarsal fractures, 25% was found to have a dancer's fracture. About 80% were women, and about 80% was older than 40 years. In the +40 y age group, all patients had a low energy trauma mechanism, where in the -40y age group this was only 27%. All patients were treated conservatively and no correlation was found between type of treatment (walker boot, stiff soled shoe) and time of healing. The time of healing was similar in both age groups and in general 1 out of 3 patients needed longer than 6 weeks to heal.

CONCLUSION

There is an increased incidence of dancer's fracture observed in the female general population +40y age. A strong correlation was found between the +40y age group and low-energy trauma mechanism. This shows the importance of treating dancer's fracture as a fragility fracture.

LEVEL OF EVIDENCE

Retrospective cohort study: level 3.

The Avocado Hand - the UK Experience of the Management of Avocado Hand Injuries

Background: Avocados are increasingly being consumed due to the nutritional benefits they provide. Avocado related hand injuries reflect their increasing popularity. Most injuries occur in attempting to de-stone the fruit. This is a prospective cohort study reviewing hand injuries sustained from preparing the fruit. Methods: Data was prospectively collected from three centres across United Kingdom (UK) over a 4-year period. The data was analysed for patient demographics, nature and zone of injury and management required. Results: A total of 35 patients and 42 injuries were included in the study. The median age of patients presenting with these injuries was 33 years, with majority of injuries occurring in the 21-30 age group. Most (88%, n = 31) of patients were male. Majority (85%, n = 36) of injuries happened during the de-stoning of the fruit. All injuries occurred in the non-dominant hand, with 70%, (n = 30) of wounds being sustained in zone 3. All injuries required surgical management and needed between 1 to 6 follow up outpatient visits. Vital structures such as tendons, digital nerves, pulleys and joint capsule were frequently implicated and required exploration or repair. Conclusions: Avocado related hand wounds are serious injuries with an associated morbidity. They frequently sustained by young patients. They usually require surgical management and may need numerous outpatient attendances. Caution and public education should be advocated on the preparation of avocados. This is the largest study to date that has reviewed the surgical management of avocado hand injuries.

221Evaluating the ability of different substrate mapping techniques to identify scar-related ventricular tachycardia circuits using computational modelling

Funding Acknowledgements

National Institute for Health Research; British Heart Foundation; and The Wellcome Trust and Engineering and Physical Sciences Research Council.

Background

Accurate identification of targets for catheter ablation therapy of ventricular tachycardias (VTs) in the postinfarction heart remains a significant challenge. Identification of such targets often requires VT-induction to delineate the entry/exit points of the reentrant circuit sustaining the VT. However, inducibility may not be possible due to hemodynamic instability. In this scenario, substrate ablation strategies can still be performed to uncover the arrhythmogenic substrate during sinus or paced rhythm. However, substrate mapping may fail to accurately delineate the reentrant circuit resulting in VT recurrence after the procedure.

Purpose

To use computer simulations to compare the ability of different electroanatomical maps constructed following typical substrate ablation strategies to identify the VT exit site.

Methods

An image-based computational model of the porcine post-infarction left ventricle was constructed to simulate VT and paced rhythm. Electroanatomical maps were constructed based on the following features extracted from electrograms computed on the endocardial surface: activation time (AT), bipolar electrogram amplitude, signal fractionation and the reentry vulnerability index (RVI - a metric combining activation and repolarization timings to identify tissue susceptibility to reentry). Potential ablation targets during substrate mapping were compared for: highest 5% AT gradient; lowest 5% bipolar signal amplitudes; areas with fragmented signals (more than one peak); and lowest 5% RVI. The minimum distance, d, between the manually identified VT exit site and the targets was measured.

Results

The RVI performed better than the other metrics at detecting the VT exit site (see Figure). The minimum distance between sites of lowest RVI and the exit site was 3.2mm compared to 13.1mm and 15.9mm in traditional AT and voltage maps, respectively. As the scar was not transmural, parameters derived from all electrograms (including those located on dense scar regions) were used to construct the electroanatomical maps. This improved the performance of the RVI significantly, making it more specific than the other metrics as can be seen in the Figure.

Conclusions

Among all metrics investigated here, the RVI identified the vulnerable region closest to VT exit site. This finding suggests that activation-repolarization metrics may improve the detection of pro-arrhythmic regions without having to induce VT. Moreover, the RVI may be particularly well suited for detecting vulnerable regions within non-transmural scars.

Abstract Figure. VT and Substrate Mapping

0416 Poor Sleep Quality Predicts Serum Markers of Neurodegeneration and Cognitive Deficits in Warriors with Mild Traumatic Brain Injury

Introduction

Increasing evidence links neurodegeneration to traumatic brain injury (TBI), and a separate body of literature links neurodegeneration to sleep dysfunction, implicating increased toxin production and decreased glymphatic clearance. Sleep disorders affect 50% of TBI patients, yet the sleep-neurodegeneration connection in these patients remains unexplored. We hypothesized that warfighters with TBI and sleep dysfunction would have increased neuronal injury, revealing potential mechanistic underpinnings for TBI outcomes. We measured plasma biomarkers, cognitive function and sleep surveys for correlation analysis.

Methods

In a retrospective cross-sectional study of warfighters (n=113 chronic mild TBI patients), the Pittsburgh sleep quality index (PSQI) was compared with amyloid β42 (Aβ42), neurofilament light (NFL), tau, and phospho-tau (threonine 181) isolated from plasma and exosomes. Executive function was tested with the categorical fluency test. Exosomes were precipitated from plasma. Proteins were measured with the Single Molecule Array (Quanterix). Linear models were adjusted for age, ApoE, and number of TBIs.

Results

Poor sleepers with TBI (PSQI&gt;8) had elevated NFL compared to good sleepers in plasma (p=0.007) and exosomes (p=0.00017), and PSQI directly correlated with NFL (plasma: Beta=0.23, p=0.0079; exosomes: Beta=2.19, p=0.0013) stronger than any other marker of neurodegeneration. Poor sleepers also showed higher obstructive sleep apnea (OSA) risk compared to good sleepers by STOP-BANG scores (3.6, SD=1.6 vs 2.8, SD=1.74; p=0.0014) as well as decreased categorical fluency (20.7, SD=4.1) (18.3, SD=4.6, p=.0067). Plasma tau and Aβ42 also correlated with PSQI (Beta=0.64, p=0.028, and Beta=0.40, p=0.049 respectively).

Conclusion

This is the first reported data correlating markers of neuronal injury and cognitive deficits with sleep complaints and OSA risk in patients with TBI - possibly identifying treatable pathophysiological mediators of TBI neurodegeneration. Limitations include a small sample size, lack of objective sleep measures, and inability to establish directionality due to cross-sectional design. Prospective trials will be required to further explore our proposed hypothesis. If confirmed, these findings would call for targeting sleep disorders in the TBI population to mitigate risk of neurodegeneration.

Support

This work was supported by grant funding from: Department of Defense, Chronic Effects of Neurotrauma Consortium (CENC) Award W81XWH-13-2-0095 and Department of Veterans Affairs CENC Award I01 CX001135.

0021 RNA Sequencing Reveals Transcriptomic Changes in Individuals with Insomnia

Introduction

Insomnia affects 10–20% of the US population and is associated with negative health and psychosocial sequelae. Despite the public health impact of insomnia little is known about its underlying molecular mechanisms. The purpose of this study is to examine differentially expressed genes in 15 patients with chronic insomnia and age- and sex-matched good sleepers (n=15).

Methods

We performed total RNA-seq on 30 whole blood samples collected at 09:00 at 150 bp paired-ends on the Illumina NovaSeq-6000 platform. Alignment was performed using the STAR version 2.7.2a software on the human reference genome (GRCh38). Differential gene expression analysis was performed using DESeq2 version 1.24.0. Pathway analysis was performed using IPA, release 2019-08-30.

Results

An average of 86.7 million paired end reads per sample were sequenced. We found that 289 genes were differentially expressed in insomnia patients with a log fold change (LFC) ±0.50 and had a FDR p-value &lt; 0.05. Top dysregulated genes include CSMD1 (L2FC=-2.78; p=1.35E-06), DUX4L9 (L2FC=3.40; p=2.81E-06) and GRM4 (L2FC=2.45; p=4.50E-05). Among the functionally relevant genes, CSMD encodes a complement control protein that is known to participate in the complement activation and inflammation in the developing central nervous system. UTS2 (L2FC=1.778; p=8.94E-06) is involved in regulation of orexin A and B activity and rapid eye movement during sleep. Ingenuity Pathway Analysis revealed 3 associated networks: Hematological, Hereditary Disorder, Organismal Injury and Abnormalities (score: 46), Developmental, Hereditary Disorder, Metabolic Disease (score: 43), and Cell Cycle, Cell mediated Immune Response, Cellular Development (score: 43).

Conclusion

Overall, our study revealed dysregulated genes in individuals who suffer from insomnia. Notably, dysregulation of these functionally relevant genes could impair functional brain connectivity and synaptic function. Further investigation of these biological pathways will be useful to elucidate the pathogenesis of insomnia and identify novel biomarkers or drug targets for developing improved diagnostics and therapeutics.

Support

National Institutes of Nursing Research, Graduate Partnership Program

1118 Examining the Role of Serum and Exosomal Biomarkers in Symptoms of Fatigue and Daytime Sleepiness Following Traumatic Brain Injury

Introduction

Fatigue and daytime sleepiness are two of the most common chronic symptoms reported after traumatic brain injury (TBI). However, there is limited understanding of the pathophysiological mechanisms following TBI that result in these symptoms. Previous research has observed elevations in peripheral blood levels of proteins in TBI patients versus controls, including neurofilament light chain (NFL)—predominantly expressed in long myelinated subcortical axons—and glial fibrillary acidic protein (GFAP)—predominantly expressed in reactive astrocytes responding to central nervous system injuries. This study examines the relationship between serum and exosomal NFL and GFAP, and symptoms of fatigue and daytime sleepiness in TBI patients 1-year after injury.

Methods

Sixty-seven patients with TBIs ranging from mild to severe were included in this study. Blood samples were collected from all participants 1-year post TBI, with concentrations of GFAP and NFL measured in serum and exosomes using Single Molecule Array technology (Simoa), an ultrasensitive assay. Participants reported fatigue using the Fatigue Severity Scale (FSS), and daytime sleepiness using the Epworth Sleepiness Scale (ESS).

Results

A linear regression model of fatigue symptoms and exosomal NFL controlling for age revealed that fatigue was negatively associated with exosomal NFL concentrations (β = -.317, p = .041, ηp2 = -.343) and accounted for 20.2% of the change in NFL. Serum NFL concentrations were not associated with fatigue, nor were GFAP serum or exosomes. No significant associations were found between NFL, GFAP, and daytime sleepiness.

Conclusion

Our findings suggest that exosomal NFL may be related to mechanisms underlying TBI-related fatigue and the potential of NFL as a biomarker of fatigue. To our knowledge, this study is the first to examine the relationship between post-TBI NFL levels and fatigue symptoms. Further investigation into serum and exosome biomarkers of TBI-related fatigue and daytime sleepiness is warranted.

Support

National Institutes of Health and Center for Neuroscience and Regenerative Medicine

Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients

PURPOSE

to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment.

METHODS

We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization.

RESULTS

Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again.

CONCLUSIONS

The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment.

LEVEL OF EVIDENCE

Level IV case series.

Osteochondritis dissecans with associated secondary chondromatosis in an adolescent shoulder

Osteochondritis dissecans (OCD) of the humeral head is rare and usually occurs in adolescents. Secondary synovial chondromatosis occasionally occurs in the shoulder but has only been reported twice in an adolescent. We describe the case and management of an adolescent male who presented with features of OCD and secondary chondromatosis in his shoulder occurring simultaneously.

Cold Case Homicides: DNA Testing of Retained Autopsy Sexual Assault Smears

Archival medical examiner specimens may contain perpetrator DNA evidence useful in unsolved ("cold case") homicides. The Office of the Chief Medical Examiner (OCME) histology slide archives were searched for sexual assault smears for all 376 female homicides from 1990 to 1999. Of these, the OCME had sexual assault smears on 84 of which 13 slides had sperm. Of these 13, six were still unsolved. DNA profiles were obtained on all six (5 from smears and one from swabs). Combined DNA Index System ( submission resulted in two matches ("hits") for new suspects. In addition, three suspects were eliminated in two cases. Our review of archival sexual assault smears resulted in DNA profiles that were able to assist in the investigation of four cold case homicide investigations. It may be worthwhile for medical examiner offices to search their archival histology slides for sexual assault smears on previously unsolved cases particularly those prior to the mid-1990s when DNA testing was less widely available.

Pediatric Nonalcoholic Fatty Liver Disease in New York City: An Autopsy Study

OBJECTIVE

To assess the prevalence and severity of nonalcoholic liver disease (NAFLD) in children in a diverse population sample in New York City.

STUDY DESIGN

Liver specimens were examined from children 2-19 years old who died of unexpected causes within 48 hours of medical presentation and underwent autopsy in New York City from 2005 to 2010. Records were reviewed for age, sex, weight, height, and race. Two hepatopathologists evaluated each liver specimen to determine pathologic diagnosis.

RESULTS

The final study cohort (n = 582) was 50% black, 33% Hispanic, 12% white, 3% Asian, and 2% other; 36% had a body mass index >85%. There were 26 cases of NAFLD (4.5%) of which 10 had nonalcoholic steatohepatitis (1.7%). There were no cases with severe fibrosis or cirrhosis. One percent (3/290) of black children had NAFLD and none had nonalcoholic steatohepatitis. White and Hispanic children had the highest percentages of NAFLD at 8.3% and 7.9%, respectively. In multiple logistic regression models, we observed that body mass index z-score (P < .001) was associated with NAFLD, and that white (P = .003) and Hispanic (P = .005) children had higher odds of having NAFLD compared with black children.

CONCLUSIONS

This review of liver tissue demonstrates a lower prevalence and severity of NAFLD in black children compared with the general obese pediatric population. Hispanic children did not have a significantly increased rate of NAFLD compared with white children, most likely related to the large proportion of Caribbean Hispanic children in New York City.

Heavy Drinkers and the Potential Impact of Minimum Unit Pricing-No Single or Simple Effect?

Aims

To explore the potential impact of a minimum unit price (MUP: 50 pence per UK unit) on the alcohol consumption of ill Scottish heavy drinkers.

Methods

Participants were 639 patients attending alcohol treatment services or admitted to hospital with an alcohol-related condition. From their reported expenditure on alcohol in their index week, and assuming this remained unchanged, we estimated the impact of a MUP (50 ppu) on future consumption. (Around 15% purchased from both the more expensive on-sale outlets (hotels, pubs, bars) and from off-sales (shops and supermarkets). For them we estimated the change in consumption that might follow MUP if (i) they continued this proportion of 'on-sales' purchasing or (ii) their reported expenditure was moved entirely to off-sale purchasing (to maintain consumption levels)).

Results

Around 69% of drinkers purchased exclusively off-sale alcohol at <50 ppu. Their drinking, post MUP, may reduce by a mean of 33%. For this group, from a population of very heavy, ill consumers, we were unable to show a differential effect across multiple deprivation quintiles. For other drinkers there might be no reduction, especially if after MUP there were many products priced close to 50 ppu. Moving away from on-sales purchases could support, for some, an increase in consumption.

Conclusions

While a proportion of our harmed, heavy drinkers might be able to mitigate the impact of MUP by changing purchasing habits, the majority are predicted to reduce purchasing. This analysis, focusing specifically on harmed drinkers, adds a unique dimension to the evidence base informing current pricing policy.

Short Summary

From drink purchasing data of heavy drinkers, we estimated the impact of legislating £0.50 minimum unit price. Over two thirds of drinkers, representing all multiple deprivation quintiles, were predicted to decrease alcohol purchasing; remainder, hypothetically, could maintain consumption. Our data address an important gap within the evidence base informing policy.