In-hospital thromboembolic complications after frozen elephant trunk aortic arch repair

OBJECTIVE

This study evaluated the frequency and clinical impact of thromboembolic complications after frozen elephant trunk aortic arch repair using the Thoraflex device (Terumo Aortic).

METHODS

A total of 128 consecutive patients (mean age 67.9 ± 13.7 years, 31.0% female) underwent frozen elephant trunk aortic arch repair using the Thoraflex device between September 2014 and May 2021 in 4 Canadian centers. Patient baseline characteristics, intraoperative details, and frozen elephant trunk thromboembolic complications were collected retrospectively and analyzed.

RESULTS

Fifteen patients (11.7%) had thrombus visualized within the frozen elephant trunk stent graft on imaging (n = 8; 53.3%) or had a thromboembolic event (n = 9; 60.0%) before hospital discharge. Sites of embolism were mesenteric (n = 8; 88.9%), renal (n = 4; 44.4%), and iliofemoral (n = 1; 11.1%). Patients who experienced thromboembolic complications were more likely to have a history of autoimmune disease (n = 3; 20.0% vs n = 2; 1.8%; P = .01) and implantation of a longer frozen elephant trunk stent graft (150 mm vs 100 mm) (n = 13; 86.7% vs n = 45; 39.8%; P < .001). All patients with thromboembolic complications received therapeutic anticoagulation, and a smaller proportion required an open surgical (n = 5; 33.3%) or an endovascular (n = 2; 13.3%) intervention. Radiographic resolution of thromboembolic complications was observed in 86.7% of patients (n = 13). In-hospital mortality occurred in 1 patient, stroke occurred in 1 patient, and transient spinal cord injury occurred in 1 patient.

CONCLUSIONS

Thromboembolic complications occur more often than previously recognized after frozen elephant trunk aortic arch repair using the Thoraflex device and are associated with increased rates of surgical and endovascular reintervention. Prevention and management of these complications require further study.

Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data

BACKGROUND

Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD).

METHODS

The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral.

RESULTS

The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia.

CONCLUSIONS

Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry

OBJECTIVE

We compared perioperative outcomes of patients with acute type A aortic dissection undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention.

METHODS

Nine hundred twenty-nine patients underwent acute type A aortic dissection repair (2002-2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included elephant trunk, antegrade thoracic endovascular aortic replacement, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, computed tomography malperfusion resolution, and a composite. Multivariable logistic regression was also performed.

RESULTS

Mean age was 66 ± 18 years, 30% (278 out of 929) were women, and HA was performed more frequently (75% [n = 695]) than EA (25% [n = 234]). EAD techniques included: dissection stent (39 out of 234 [17%]), thoracic endovascular aortic replacement (18 out of 234 [7.7%]), and elephant trunk (87 out of 234 [37%]). In-hospital mortality (EA: n = 49 [21%] and HA: n = 129 [19%]; P = .42), and neurological deficit (EA: n = 43 [18%] and HA: n = 121 [17%]; P = .74) were similar. EA was not independently associated with death (EA vs HA odds ratio, 1.09; 95% CI, 0.77-1.54; P = .63) or neurologic deficit (EA vs HA odds ratio, 0.85; 95% CI, 0.47-1.55; P = .59). Composite adverse events differed significantly (EA vs HA odds ratio, 1.47; 95% CI, 1.16-1.87; P = .001). Malperfusion resolved more frequently after EAD (EAD: n = 32 [80%], EAND: n = 18 [56%], HA: n = 71 [50%]; P = .004), although multivariable analysis was not significant (EAD vs HA odds ratio, 2.17; 95% CI, 0.83-5.66; P = .10).

CONCLUSIONS

Extended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.

Association of Cerebral Oximetry With Brain Ischemic Lesions and Functional Outcomes in Arch Repair

BACKGROUND

This exploratory analysis of the randomized controlled Aortic Surgery Cerebral Protection Evaluation CardioLink-3 trial sought to determine if cerebral oximetry desaturation during elective proximal arch repair is associated with detrimental postoperative neuroradiologic and neurofunctional outcomes.

METHODS

Cerebral oximetry and pre- and postoperative brain magnetic resonance imaging data from 101 participants were analyzed. Oximetry data from the trial allocation groups were compared; the relationships between cerebral oximetry indices and new ischemic cerebral lesions on magnetic resonance imaging and neurologic outcomes were also evaluated.

RESULTS

Total cerebral desaturation events (>20% decrease from baseline) on the left (median [interquartile range], 1 [1-3] vs 1.5 [0.5-3] with innominate and axillary cannulation; P = .80) were comparable to those on the right (1 [1-3] vs 1 [0-3]; P = .75) as were the total area under the curve of desaturation (left, P = .61; right, P = .84). Seventy patients had new ischemic lesions, among whom 36 had new severe lesions. Total desaturation events and area under the curve of desaturation were similar in patients with and without new ischemic lesions or severe lesions. The nadir regional cerebral saturation was lower on the left (49% [41-56]) than the right (53% [44-59]); left desaturation episodes were associated with lower postoperative cognitive test scores (P = .004).

CONCLUSIONS

The innominate and axillary cannulation techniques for elective proximal arch repair with unilateral antegrade cerebral perfusion were associated with similar occurrences of cerebral oximetry desaturation and neither were associated with new ischemic lesions.

Clinical Characteristics and Outcomes of Patients Screened for Transcatheter Tricuspid Valve Replacement: The TriACT Registry

BACKGROUND

Transcatheter tricuspid valve replacement (TTVR) abolishes tricuspid regurgitation (TR) and has emerged as a definitive treatment for TR.

OBJECTIVES

The purpose of this multicenter, observational study was to determine the clinical characteristics and short-term outcomes of patients with TR screened for TTVR.

METHODS

Patients underwent TTVR screening at 7 centers on a compassionate-use basis. The primary endpoints were NYHA functional class and TR grade at 30-day follow-up. Secondary endpoints included all-cause mortality, heart failure hospitalization, technical success, and reasons for TTVR screening failure.

RESULTS

A total of 149 patients (median age 79 years [Q1-Q3: 72-84 years], 54% women) underwent TTVR screening. The TTVR screening failure rate was 74%, mainly related to large tricuspid annular diameter. Patients undergoing TTVR (n = 38) had significant functional improvements (NYHA functional class I or II from 21% to 68%; P < 0.001), with TR ≤1+ in 97% at 30-day follow-up (P < 0.001 from baseline). Technical success was achieved in 91%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 8%, heart failure hospitalization 5%, major bleeding 18%, and reintervention 9%. Patients who failed screening for TTVR and subsequently underwent "bailout" transcatheter edge-to-edge repair (n = 26) had favorable outcomes (NYHA functional class I or II from 27% to 58%; P < 0.001), with TR ≤1+ in 43% at 30-day follow-up (P < 0.001 from baseline).

CONCLUSIONS

This first real-world report of TTVR screening demonstrated a high screening failure rate, mainly related to large tricuspid annular diameter. Patients undergoing TTVR had superior TR reduction and symptom alleviation compared with bailout tricuspid transcatheter edge-to-edge repair, at the cost of greater procedural complications.

Cusp overlap method for self-expanding transcatheter aortic valve replacement

BACKGROUND

Conduction disturbances and the need for permanent pacemaker (PPM) implantation remains a common complication for transcatheter aortic valve replacement (TAVR), particularly when self-expanding (SE) valves are used.

AIMS

We compared in-hospital and 30-day rates of new PPM implantation between patients undergoing TAVR with SE valves using the conventional three-cusp coplanar implantation technique and the cusp-overlap technique.

METHODS

We retrospectively compared patients without a pre-existing PPM who underwent a TAVR procedure with SE Evolut R or PRO valves using the cusp-overlap technique from July 2018 to September 2020 (n = 519) to patients who underwent TAVR using standard three-cusp technique from April 2016 to March 2017 (n = 128) in two high volume Canadian centers.

RESULTS

There was no significant difference in baseline RBBB between the groups (10.4% vs. 13.2; p = 0.35). The rate of in-hospital new complete heart block (9.4% vs. 23.4%; p ≤ 0.001) and PPM implantation (8% vs. 21%; p ≤ 0.001) were significantly reduced when using the cusp-overlap technique. The incidence of new LBBB (30.4% vs. 29%; p = 0.73) was similar. At 30 days, the rates of new complete heart block (11% vs. 23%; p ≤ 0.001) and PPM implantation (10% vs. 21%, p ≤ 0.001) remained significantly lower in the cusp-overlap group, while the rate of new LBBB (35% vs. 30%; p = 0.73) was similar.

CONCLUSION

Cusp-overlap approach offers several potential technical advantages compared to standard three-cusp view, and may result in lower PPM rates in TAVR with SE Evolut valve.

Measuring grip strength in adolescents and adults with cerebral palsy in a clinic setting: Feasibility, reliability, and clinical associations

AIM

To determine the feasibility and reliability of measuring grip strength and its association with anthropometrics and diseases among adolescents and adults (≥16 years old) with cerebral palsy (CP).

METHOD

In this cross-sectional study, individuals with CP, classified in Gross Motor Function Classification System (GMFCS)/Manual Ability Classification System (MACS) levels I to V, were recruited to measure grip strength, anthropometrics, and self-reported current/history of disease during a routine clinical visit. Feasibility was determined as the proportion recruited/consented/completed testing. Test-retest reliability of three maximal effort trials per side was assessed. Linear regression determined associations of grip strength with anthropometrics after adjusting for age, sex, and GMFCS. The predictive ability of GMFCS alone, grip strength alone, GMFCS + grip strength, and GMFCS × grip strength for diseases was compared.

RESULTS

Of 114 individuals approached, 112 participated and 111 successfully completed all tasks. There was good to excellent reliability of test-retest grip strength between trials for dominant and non-dominant sides for the entire cohort and when stratified by each GMFCS and MACS level (intraclass correlation coefficient range 0.83-0.97). Sex, GMFCS, MACS, body mass, and waist circumference were associated with grip strength (p < 0.05), but not hip circumference, waist:hip ratio, or triceps skinfold thickness. Modeling grip strength with GMFCS had a higher predictive value for relevant diseases than GMFCS alone.

INTERPRETATION

Grip strength is a feasible and reliable measurement for CP, and is associated with some demographics and anthropometric measures. Grip strength, in addition to the GMFCS, enhanced prediction of disease outcomes.

WHAT THIS PAPER ADDS

Measurement of hand grip strength is clinically feasible for adolescents/adults with cerebral palsy. Grip strength has good to excellent test-retest reliability across Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) levels. Grip strength is associated with sex, weight, waist circumference, GMFCS, and especially MACS. Grip strength, in addition to GMFCS, shows promise for enhancing disease prediction in this cohort.

Type 2 Diabetes Increases the Risk of Serious and Life-Threatening Conditions Among Adults With Traumatic Spinal Cord Injury

Objective

To compare the incidence of and adjusted hazards for serious and life-threatening morbidities among adults with traumatic spinal cord injury (TSCI) with and without type 2 diabetes (T2D).

Participants and Methods

A retrospective longitudinal cohort study was conducted from September 1, 2022 to February 2, 2023, among privately insured beneficiaries if they had an International Classification of Diseases, 9th Revision or 10th Revision, Clinical Modification diagnostic code for TSCI (n=9081). Incidence estimates of serious and life-threatening morbidities, and more common secondary and long-term health conditions, were compared at 5 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for serious and life-threatening morbidities.

Results

Adults living with TSCI and T2D had a higher incidence of all of the morbidities assessed as compared with nondiabetic adults with TSCI. Fully adjusted survival models reported that adults with TSCI and T2D had a greater hazard for most of the serious and life-threatening conditions assessed, including sepsis (hazard ratio [HR]: 1.65), myocardial infarction (HR: 1.63), osteomyelitis (HR: 1.9), and stroke or transient ischemic attack (HR: 1.59). Rates for comorbid and secondary conditions were higher for individuals with TSCI and T2D, such as pressure sores, urinary tract infections, and depression, even after controlling for sociodemographic and comorbid conditions.

Conclusion

Adults living with TSCI and T2D have a significantly higher incidence of and risk of developing serious and life-threatening morbidities as compared with nondiabetic adults with TSCI.

Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy I: Key Ingredients for Bone and Muscle Health

Physical activity of a sufficient amount and intensity is essential to health and the prevention of a sedentary lifestyle in all children as they transition into adolescence and adulthood. While fostering a fit lifestyle in all children can be challenging, it may be even more so for those with cerebral palsy (CP). Evidence suggests that bone and muscle health can improve with targeted exercise programs for children with CP. Yet, it is not clear how musculoskeletal improvements are sustained into adulthood. In this perspective, we introduce key ingredients and guidelines to promote bone and muscle health in ambulatory children with CP (GMFCS I-III), which could lay the foundation for sustained fitness and musculoskeletal health as they transition from childhood to adolescence and adulthood. First, one must consider crucial characteristics of the skeletal and muscular systems as well as key factors to augment bone and muscle integrity. Second, to build a better foundation, we must consider critical time periods and essential ingredients for programming. Finally, to foster the sustainability of a fit lifestyle, we must encourage commitment and self-initiated action while ensuring the attainment of skill acquisition and function. Thus, the overall objective of this perspective paper is to guide exercise programming and community implementation to truly alter lifelong fitness in persons with CP.

Changes to physical activity behavior during the COVID-19 pandemic and their associated factors: a cross sectional survey of Mexican women

BACKGROUND

On March 24, 2020, the Mexican Government established social distancing measures to address the outbreak of the COVID-19 pandemic. The resulting home confinement affected daily lifestyle habits such as eating, sleeping, and physical activity (PA). The objectives of this study were to determine changes in PA behaviors among Mexican women due to the COVID-19 pandemic and to assess potential factors associated with these changes.

METHODS

This was a cross-sectional study based on an anonymous online questionnaire developed by the Task Force on Physical Activity for Persons with Disabilities (PAPD) within the International Society of Physical and Rehabilitation Medicine (ISPRM). Descriptive, quantitative statistics were used for data analysis. A Chi-squared (χ²) test was used to explore associations between dependent and independent variables.

RESULTS

A total of 1882 surveys were completed. Among the respondents, 53.3% declared that their PA was reduced during the pandemic, 26.6% reported similar PA behavior, and 20.1% declared that their PA had increased during the pandemic. Lower PA behavior during the pandemic was associated with lower education levels, stricter pandemic constraints, obesity, and lower self-perceived functioning levels. A statistically significant association between poorer self-perceived mental health and decreased PA behaviors was also found. Respondents who were younger, self-perceived as unimpaired, not overweight, and whose income was not impacted by COVID-19 were associated with higher levels of reported physical and mental health.

CONCLUSIONS

The study results identify disparities experienced in PA behavior during the COVID-19 pandemic among Mexican women and highlights the need for social support for PA participation.

Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

BACKGROUND

Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details.

METHODS

Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI.

RESULTS

A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001).

CONCLUSIONS

AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

ACTIVE STRIDES-CP: protocol for a randomised trial of intensive rehabilitation (combined intensive gait and cycling training) for children with moderate-to-severe bilateral cerebral palsy

INTRODUCTION

For children with cerebral palsy (CP), who are marginally ambulant, gross motor capacity peaks between 6 and 7 years of age with a subsequent clinical decline, impacting their ability to engage in physical activity. Active Strides-CP is a novel package of physiotherapy targeting body functions, activity and participation outcomes for children with bilateral CP. This study will compare Active Strides-CP to usual care in a multisite randomised waitlist-controlled trial.

METHODS AND ANALYSIS

150 children with bilateral CP (5-15 years), classified in Gross Motor Function Classification System (GMFCS) levels III and IV will be stratified (GMFCS III vs IV, age 5-10 years; 11-15 years and trial site) and randomised to receive either (1) 8 weeks of Active Strides-CP two times/week for 1.5 hours in clinic and one time/week for 1 hour alternating home visits and telehealth (total dose=32 hours) or (2) usual care. Active Strides-CP comprises functional electrical stimulation cycling, partial body weight support treadmill training, overground walking, adapted community cycling and goal-directed training. Outcomes will be measured at baseline, immediately post-intervention at 9 weeks primary endpoint and at 26 weeks post-baseline for retention. The primary outcome is the Gross Motor Function Measure-66. Secondary outcomes include habitual physical activity, cardiorespiratory fitness, walking speed and distance, frequency/involvement of community participation, mobility, goal attainment and quality of life. Analyses will follow standard principles for randomised controlled trials using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models. A within-trial cost utility analysis will be performed.

ETHICS AND DISSEMINATION

The Children's Health Queensland Hospital and Health Service, The University of Queensland, The University of Melbourne and Curtin University Human Research Ethics Committees have approved this study. Results will be disseminated as conference abstracts and presentations, peer-reviewed articles in scientific journals, and institution newsletters and media releases.

TRIAL REGISTRATION NUMBER

ACTRN12621001133820.

Grip strength is inversely associated with DNA methylation age acceleration

BACKGROUND

There is a large body of evidence linking muscular weakness, as determined by low grip strength, to a host of negative ageing-related health outcomes. Given these links, grip strength has been labelled a 'biomarker of aging'; and yet, the pathways connecting grip strength to negative health consequences are unclear. The objective of this study was to determine whether grip strength was associated with measures of DNA methylation (DNAm) age acceleration.

METHODS

Middle age and older adults from the 2006 to 2008 waves of the Health and Retirement Study with 8-10 years of follow-up were included. Cross-sectional and longitudinal regression modelling was performed to examine the association between normalized grip strength (NGS) and three measures of DNAm age acceleration, adjusting for cell composition, sociodemographic variables and smoking. Longitudinal modelling was also completed to examine the association between change in absolute grip strength and DNAm age acceleration. The three DNAm clocks used for estimating age acceleration include the established DunedinPoAm, PhenoAge and GrimAge clocks.

RESULTS

There was a robust and independent cross-sectional association between NGS and DNAm age acceleration for men using the DunedinPoAm (β: -0.36; P < 0.001), PhenoAge (β: -8.27; P = 0.01) and GrimAge (β: -4.56; P = 0.01) clocks and for women using the DunedinPoAm (β: -0.36; P < 0.001) and GrimAge (β: -4.46; P = 0.01) clocks. There was also an independent longitudinal association between baseline NGS and DNAm age acceleration for men (β: -0.26; P < 0.001) and women (β: -0.36; P < 0.001) using the DunedinPoAm clock and for women only using the PhenoAge (β: -8.20; P < 0.001) and GrimAge (β: -5.91; P < 0.001) clocks. Longitudinal modelling revealed a robust association between change in grip strength from wave 1 to wave 3 was independently associated with PhenoAgeAA (β: -0.13; 95% CI: -0.23, -0.03) and GrimAgeAA (β: -0.07; 95% CI: -0.14, -0.01) in men only (both P < 0.05).

CONCLUSIONS

Our findings provide some initial evidence of age acceleration among men and women with lower NGS and loss of strength over time. Future research is needed to understand the extent to which DNAm age mediates the association between grip strength and chronic disease, disability and mortality.

Risk of type 2 diabetes mellitus among adults aging with vision impairment: The role of the neighborhood environment

BACKGROUND

Vision impairment (VI) affects approximately 1 in 28 Americans over the age of 40 and the prevalence increases sharply with age. However, experiencing vision loss with aging can be very different from aging with VI acquired earlier in life. People aging with VI may be at increased risk for diabetes due to environmental barriers in accessing health care, healthy food, and recreational resources that can facilitate positive health behaviors.

OBJECTIVE

This study examined the relationship between neighborhood characteristics and incident type 2 diabetes mellitus (T2DM) among a cohort of 22,719 adults aging with VI.

METHODS

Data are from Optum® Clinformatics® DataMart, a private administrative claims database (2008-2017). Individuals 18 years of age and older at the time of their initial VI diagnosis were eligible for analysis. VI was determined using vision impairment, low vision, and blindness codes (ICD-9-CM, ICD-10-CM). Covariates included age, sex, and comorbidities. Cox models estimated adjusted hazard ratios (HRs) for incident T2DM. Stratified models examined differences in those aging with (age 18-64) and aging into (age 65+) vision impairment.

RESULTS

Residence in neighborhoods with greater intersection density (HR = 1.26) and high-speed roads (HR = 1.22) were associated with increased risk of T2DM among older adults with VI. Living in neighborhoods with broadband internet access (HR = 0.67), optical stores (HR = 0.62), supermarkets (HR = 0.78), and gyms/fitness centers (HR = 0.63) was associated with reduced risk of T2DM for both younger and older adults with VI.

CONCLUSIONS

Findings emphasize the importance of neighborhood context for mitigating the adverse consequences of vision loss for health.

Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial

BACKGROUND

to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery.

METHODS

This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging.

RESULTS

Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres (P=0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10-2.95]; P=0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00-1.32]; P=0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00-1.04]; P=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00-1.14]; P=0.06) were associated with greater number of lesions.

CONCLUSIONS

In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02554032.

Potentially Preventable Hospitalizations Among Adults With Pediatric-Onset Disabilities

OBJECTIVE

To examine the risk of any and specific potentially preventable hospitalizations (PPHs) for adults with cerebral palsy (CP) or spina bifida (SB). We hypothesize that PPH risk is greater among adults with CP/SB compared with the general population.

PATIENTS AND METHODS

Using January 1, 2007, to December 31, 2017, national private administrative claims data (OptumInsight) in the United States, we identified adults with CP/SB (n=10,617). Adults without CP/SB were included as controls (n=1,443,716). To ensure a similar proportion in basic demographics, we propensity-matched our controls with cases in age and sex (n=10,617). Generalized estimating equation models were applied to examine the risk of CP/SB on PPHs. All models were adjusted for age, sex, race/ethnicity, health indicators, US Census Division data, and socioeconomic variables. Adjusted odds ratios were compared within a 4-year follow-up.

RESULTS

Adults with CP/SB had higher risk for any PPH (odds ratio [OR], 4.10; 95% CI, 2.31 to 7.31), and PPHs due to chronic obstructive pulmonary disease/asthma (OR, 1.85; CI, 1.23 to 2.76), pneumonia (OR, 3.01; 95% CI, 2.06 to 4.39), and urinary tract infection (OR, 6.48; 95% CI, 3.91 to 10.75). Cases and controls who had an annual wellness visit had lower PPH risk (OR, 0.52; 95% CI, 0.41 to 0.67); similarly, adults with CP/SB who had an annual wellness visit compared with adults with CP/SB who did not had lower odds of PPH (OR, 0.75; 95% CI, 0.60 to 0.94).

CONCLUSION

Adults with pediatric-onset disabilities are at a greater risk for PPHs. Providing better access to preventive care and health-promoting services, especially for respiratory and urinary outcomes, may reduce PPH risk among this patient population.

Hybrid arch frozen elephant trunk repair for acute type A aortic dissection: Extra-anatomic subclavian reconstruction

Acute type A aortic dissection is a life-threatening condition that confers significant early perioperative risk but is also associated with late aortic disease progression and the need for reintervention. Recent efforts to improve patient outcomes have focused on improving quality of care and extending treatment in the aortic root and arch to reduce late aortic events. The hybrid arch frozen elephant trunk technique facilitates a more aggressive distal aortic repair that may help mitigate the early and late deleterious effects of persistent false lumen perfusion. However, in the acute and emergency settings, management of the left subclavian artery remains a challenge. We present a step-by-step instructional guide on performing an emergency hybrid arch frozen elephant trunk procedure with emphasis on management of the difficult left subclavian artery. Our case report demonstrates a transthoracic aortoaxillary extra-anatomic bypass of the left axillary artery. We discuss the most important considerations when managing the left subclavian artery in an acute type A aortic dissection. Finally, we detail the benefits and limitations of the transthoracic aortoaxillary extra-anatomic technique and discuss other approaches to left subclavian artery reconstruction.

Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection

Importance

Early data revealed a mortality rate of 1% to 2% per hour for type A acute aortic dissection (TAAAD) during the initial 48 hours. Despite advances in diagnostic testing and treatment, this mortality rate continues to be cited because of a lack of contemporary data characterizing early mortality and the effect of timely surgery.

Objective

To examine early mortality rates for patients with TAAAD in the contemporary era.

Design, Setting, and Participants

This cohort study examined data for patients with TAAAD in the International Registry of Acute Aortic Dissection between 1996 and 2018. Patients were grouped according to the mode of their intended treatment, surgical or medical.

Exposure

Surgical treatment.

Main Outcomes and Measures

Mortality was assessed in the initial 48 hours after hospital arrival using Kaplan-Meier curves. In-hospital complications were also evaluated.

Results

A total of 5611 patients with TAAAD were identified based on intended treatment: 5131 (91.4%) in the surgical group (3442 [67.1%] male; mean [SD] age, 60.4 [14.1] years) and 480 (8.6%) in the medical group (480 [52.5%] male; mean [SD] age, 70.9 [14.7] years). Reasons for medical management included advanced age (n = 141), comorbidities (n = 281), and patient preference (n = 81). Over the first 48 hours, the mortality for all patients in the study was 5.8%. Among patients who were medically managed, mortality was 0.5% per hour (23.7% at 48 hours). For those whose intended treatment was surgical, 48-hour mortality was 4.4%. In the surgical group, 51 patients (1%) died before the operation.

Conclusions and Relevance

In this study, the overall mortality rate for TAAAD was 5.8% at 48 hours. For patients in the medical group, TAAAD had a mortality rate of 0.5% per hour (23.7% at 48 hours). However, among those in the surgical group, 48-hour mortality decreased to 4.4%.

Racial and Ethnic Inequities in Use of Preventive Services Among Privately Insured Adults With a Pediatric-Onset Disability

PURPOSE

Cerebral palsy (CP) and spina bifida (SB) are pediatric-onset disabilities. Adults living with CP/SB are in a greater need of preventive care than the general population due to their increased risk for chronic diseases. Our objective was to compare White/Black and White/Hispanic inequities in the use of preventive services.

METHODS

Using 2007-2017 private claims data, we identified a total of 11,635 adults with CP/BS. Of these, 8,935 were White, 1,457 Black, and 1,243 Hispanic. We matched health-related variables (age, sex, comorbid conditions) between White adults and those in each minority subpopulation. Generalized estimating equations were used and all models were adjusted for age, sex, comorbidities, income, education, and US Census divisions. Outcomes of interest were: (1) any office visit; (2) any physical/occupational therapy; (3) wellness visit; (4) bone density screening; (5) cholesterol screening; and (6) diabetes screening.

RESULTS

The rate of recommended services for all subpopulations of adults with CP/SB was low. Compared with White adults, Hispanic adults had lower odds of wellness visits (odds ratio [OR] = 0.71, 95% CI, 0.53-0.96) but higher odds of diabetes screening (OR = 1.48, 95% CI, 1.13-1.93). Compared with White adults, Black adults had lower odds of wellness visits (OR = 0.50, 95% CI, 0.24-1.00) and bone density screening (OR = 0.54, 95% CI, 0.31-0.95).

CONCLUSIONS

Preventive service use among adults with CP/SB was low. Large White-minority disparities in wellness visits were observed. Interventions to address physical accessibility, adoption of telehealth, and increased clinician education may mitigate these disparities, particularly if initiatives target minority populations.

Musculoskeletal Morbidity Among Adults Living With Spina Bifida and Cerebral Palsy

Background

Individuals living with cerebral palsy (CP) or spina bifida (SB) are at heightened risk for chronic health conditions that may develop or be influenced by the impairment and/or the process of aging.

Objectives

The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal (MSK) morbidities among adults living with and without CP or SB.

Methods

A retrospective, longitudinal cohort study was conducted among adults living with (n = 15,302) CP or SB and without (n = 1,935,480) CP or SB. Incidence estimates of common MSK morbidities were compared at 4 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident MSK morbidities. The analyses were performed in 2019 to 2020.

Results

Adults living with CP or SB had a higher 4-year incidence of any MSK morbidity (55.3% vs. 39.0%) as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with CP or SB had a greater hazard for all MSK disorders; this ranged from hazard ratio (HR) 1.40 (95% CI, 1.33 to 1.48) for myalgia to HR 3.23 (95% CI, 3.09 to 3.38) for sarcopenia and weakness.

Conclusion

Adults with CP or SB have a significantly higher incidence of and risk for common MSK morbidities as compared to adults without CP or SB. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of MSK disease onset/progression in these higher risk populations.

Opioid prescription patterns among adults with cerebral palsy and spina bifida

Background

Pain is the most common symptom of cerebral palsy and spina bifida (CP/SB). The objective of this study was to compare the opioid prescription patterns for differing pain types and overlapping pain among adults living with and without CP/SB.

Methods

Privately-insured beneficiaries were included if they had CP/SB (n = 22,647). Adults without CP/SB were also included as controls (n = 931,528). Oral morphine equivalents (OMEs) were calculated. A multivariable logistic regression was used to analyze the association between CP/SB and OMEs, across the three pain categories: (1) no pain, (2) isolated pain, and (3) pain multimorbidity.

Results

Adults living with CP/SB had a higher OME prescription pattern per year than adults without CP or SB (8,981.0 ± 5,183.0 vs. 4,549.1 ± 2,988.0), and for no pain (4,010.8 ± 828.1 vs. 1,623.53 ± 47.5), isolated pain (7,179.9 ± 378.8 vs. 3,531.0 ± 131.0), and pain multimorbidity (15,752.4 ± 1,395.5 vs. 8,492.9 ± 398.0) (all p < 0.001), and differences were to a clinically meaningful extent. Adjusted odds ratios (OR) for prescribed OMEs were higher for adults with CP/SB vs. control and (1) no pain (OR: 1.51; 95%CI: 1.46, 1.56), (2) isolated pain (OR: 1.48; 95%CI: 1.44, 1.52), and (3) pain multimorbidity (OR: 1.79; 95%CI: 1.72, 1.86).

Conclusions

Adults with CP/SB obtain significantly higher prescription of OMEs than adults without CP/SB.

A core outcome set for multimorbidity risk in individuals with cerebral palsy

AIM

To: (1) investigate the importance of outcome measurement instruments (OMIs) within a core outcome set (COS) for multimorbidity (at least two chronic health conditions) risk in individuals with cerebral palsy (CP); (2) investigate the feasibility of OMIs within the COS in international clinical research settings in adolescents and adults with CP; and (3) describe the associations between the COS data and Gross Motor Function Classification System (GMFCS) levels.

METHOD

Eighty-three individuals with CP completed a survey on health outcomes: physical behaviour, nutrition, sleep, endurance, body composition, blood pressure, blood lipids, and glucose. A cross-sectional study assessed the feasibility of the COS in 67 adolescents and adults with CP (mean age 30y, SD 15y 1mo, min-max: 14-68y, 52.2% male) at four centres. Prevalence of multimorbidity risk and associations with GMFCS levels are described.

RESULTS

Most participants rated physical behaviour, nutrition, sleep, and endurance as very important. Body composition, blood pressure, nutrition, and sleep were highly feasible since data were collected in 88% or more participants who consented to having the assessments. Physical behaviour, cardiorespiratory endurance, and blood draws were collected in less than 60% of participants. Total time sedentary (ρ=0.53, p<0.01) and endurance (ρ=-0.46, p<0.01) were significantly associated with GMFCS level.

INTERPRETATION

The COS identified that most participants had poor sleep quality and endurance, did not have healthy diets, and showed increased sedentary behaviour. Individuals with CP valued these outcomes as most important, suggesting a need to assess these modifiable behaviours in this population. Objective measures of physical behaviour and cardiorespiratory endurance in the COS required additional personnel, time, and participant burden. We recommend that healthcare providers should perform a simpler first screen using questionnaire-based assessments and then focus the use of the remainder of the COS if required for the patient.

Disparities in Morbidity After Spinal Cord Injury Across Insurance Types in the United States

OBJECTIVE

To compare the prevalence and incidence of, and adjusted hazards for comorbidities among adults with traumatic spinal cord injuries (TSCIs) across insurance types (private vs governmental insurance) in the United States.

PATIENTS AND METHODS

Privately insured (N=9081) and Medicare (N=7645) beneficiaries with a diagnosis of TSCI were included. Prevalence and incidence estimates of common psychological, cardiometabolic, and musculoskeletal morbidities were compared at baseline and at 4-years after index diagnosis, respectively. Survival models were used to quantify hazard ratios (HRs) for outcomes, controlling for insurance type, sociodemographic characteristics, and other comorbidities. Sensitivity analyses were conducted to determine the effects of insurance and race/ethnicity.

RESULTS

Adults with TSCIs on Medicare had a higher prevalence of any psychological (54.7% vs 35.4%), cardiometabolic (74.7% vs 70.1%), and musculoskeletal (72.8% vs 66.3%) morbidity than privately insured adults with TSCIs. Similarly, the 4-year incidences of most psychological (eg, depression: 37.6% [Medicare] vs 24.2% [private]), cardiometabolic (eg, type 2 diabetes: 22.5% [Medicare] vs 12.9% [private], and musculoskeletal (eg, osteoarthritis: 42.1% [Medicare] vs 34.6% [private]) morbidities were considerably higher among adults with TSCIs on Medicare. Adjusted survival models found that adults with TSCIs on Medicare had a greater hazard for developing psychological (HR, 1.40; 95% CI, 1.31-1.50) and cardiometabolic (HR, 1.21; 95% CI, 1.10-1.33) morbidities compared with privately insured adults with TSCI. There was evidence of both insurance and racial disparities.

CONCLUSION

Adults with TSCIs on Medicare had significantly higher prevalence and risk for developing common physical and mental health comorbidities, compared with privately insured adults with TSCIs.

Location of Aortic Enlargement and Risk of Type A Dissection at Smaller Diameters

BACKGROUND

Previous work has demonstrated that more than one-half of acute type A aortic dissections (ATADs) occur at a maximal aortic diameter (MAD) of <5.5 cm. However, no analysis has investigated whether ATAD risk at smaller MADs is more common with modest dilation of the aortic root (AR) or supracoronary ascending aorta (AA) in patients without genetically triggered aortopathy.

OBJECTIVES

This study sought to determine if the segment of modest aortic dilation affects risk of ATAD.

METHODS

Using the International Registry of Acute Aortic Dissection (IRAD) database from May 1996 to October 2016, we identified 667 ATAD patients with MAD <5.5 cm. Patients were stratified by location of the largest proximal aortic segment (AR or AA). Patients with known genetically triggered aortopathy were excluded. MADs at time of dissection were compared between AR and AA groups. Secondary outcomes included operation, postoperative outcomes, and long-term survival.

RESULTS

Of patients with ATAD at an MAD <5.5 cm, 79.5% (n = 530) were in the AA group and 20.5% (n = 137) in the AR group. Modestly dilated ARs (median MAD 4.6 cm [IQR: 4.1-5.0 cm]) dissected at a significantly smaller diameter than modestly dilated AAs (median MAD 4.8 cm [IQR: 4.4-5.1 cm]) (P < 0.01). AR patients were significantly younger than AA patients (58.5 ± 13.0 years vs 63.2 ± 13.3 years; P < 0.01) and more commonly male (78% vs 65%; P < 0.01). Postoperative and long-term outcomes did not differ between groups.

CONCLUSIONS

ATAD appears to occur at smaller diameters in patients with modest dilation in the AR vs the AA (4.6 vs 4.8 cm). These findings may have implications for future consensus guidelines regarding the management of patients with aortic disease.

Transcatheter Tricuspid Valve Replacement With the EVOQUE System: 1-Year Outcomes of a Multicenter, First-in-Human Experience

OBJECTIVES

The aim of this study was to report the midterm outcomes at 1 year in the expanded first-in-human experience with the transfemoral EVOQUE system (Edwards Lifesciences) for tricuspid regurgitation (TR).

BACKGROUND

Untreated TR is associated with excess mortality and morbidity. The first-in-human experience with the EVOQUE tricuspid valve replacement system reported favorable 30-day outcomes with no mortality in a compassionate use population.

METHODS

Twenty-seven patients with severe TR were treated with the EVOQUE system in a compassionate use experience at 7 centers between May 2019 and July 2020. All patients had clinical right-sided heart failure (HF) and were deemed inoperable and unsuitable for transcatheter edge-to-edge repair by the institutional heart teams. The clinical outcomes collected included all-cause mortality, symptom status, TR severity, HF hospitalization, and major adverse cardiovascular events.

RESULTS

At baseline, all patients (age: 77 ± 8 years, 89% female) were at high surgical risk (mean Society of Thoracic Surgeons score: 8.6% ± 5.5%), with 89% New York Heart Association functional class III/IV. TR was predominantly functional in etiology (19/27, 70%). At 1 year, mortality was 7% (2/27), 70% of patients were New York Heart Association functional class I/II, and 96% and 87% of patients had a TR grade ≤2+ and ≤1+, respectively. Between 30 days and 1 year, 2 patients experienced HF hospitalizations, and 1 patient required a new pacemaker implantation.

CONCLUSIONS

In this early, compassionate use experience, the transfemoral transcatheter EVOQUE tricuspid valve replacement system demonstrated durable efficacy, persistent improvement in symptom status, and low rates of mortality and HF hospitalizations at a 1-year follow-up. Further studies are underway to validate its efficacy.

Preventative Services Use and Risk Reduction for Potentially Preventative Hospitalizations among People with Traumatic Spinal Cord Injury

OBJECTIVE

To examine the risk of potentially preventable hospitalizations (PPHs) for adults (18 years or older) with traumatic spinal cord injury (TSCI) to identify the most common types of preventable hospitalizations and their associative risk factors.

DESIGN

Cohort study.

SETTING

Using 2007-2017 U.S. claims data from the Optum Clinformatics Data Mart, we identified adults (18 years or older) with diagnosis of TSCI (n=5380). Adults without TSCI diagnosis were included as controls (n=1,074,729). Using age and sex, we matched individuals with and without TSCI (n=5173) with propensity scores to address potential selection bias. Generalized linear regression was applied to examine the risk of TSCI on PPHs. Models were adjusted for age; sex; race and ethnicity; Elixhauser comorbidity count; any cardiometabolic, psychological, and musculoskeletal chronic conditions; U.S. Census Division; socioeconomic variables; and use of certain preventative care services. Adjusted odds ratios were compared within a 4-year follow-up period.

PARTICIPANTS

Adults with and without TSCI (N=5,173).

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

Any PPH and specific PPHs RESULTS: Adults with TSCI had higher risk for any PPH (odds ratio [OR], 1.67; 95% CI,1.20-2.32), as well as PPHs because of urinary tract infection (UTI) (OR, 3.78; 95% CI, 2.47-5.79), hypertension (OR, 3.77; 95% CI, 1.54-9.21), diabetes long-term complications (OR, 2.54; 95% CI, 1.34-4.80), and pneumonia (OR, 1.71; 95% CI. 1.21-2.41). Annual wellness visit was associated with reduced PPH risk compared with cases and controls without annual wellness visit (OR, 0.57; 95% CI, 0.46-0.71) and among people with TSCI (OR, 0.69; 95% CI, 0.55-0.86) compared with cases without annual wellness visit.

CONCLUSIONS

Adults with TSCI are at a heightened risk for PPH. They are also more susceptible to certain PPHs such as UTIs, pneumonia, and heart failure. Encouraging the use of preventative or health-promoting services, especially for respiratory and urinary outcomes, may reduce PPHs among adults with TSCI.

Valve-sparing aortic root replacement: a primer for cardiologists

PURPOSE OF REVIEW

The purpose of this article is to review the contemporary evidence supporting valve-sparing aortic root replacement as the best option for patients with aortic root aneurysms and preservable aortic valves as well as to review the technical variations and modern adjuncts of these operations that impact both short and long-term durability.

RECENT FINDINGS

In patients with an aortic root aneurysm, with or without aortic valve regurgitation, valve-sparing aortic root replacement provide excellent clinical outcomes and stable valve function over several decades. Successful execution of this operation depends on careful patient selection and a thorough understanding of the anatomical and physiological relationships between the various components of the aortic root. Echocardiography remains the mainstay of imaging to determine the feasibility of valve-sparing root replacement.

SUMMARY

Valve-sparing aortic root replacement is an excellent alternative to composite valve graft replacement in nonelderly patients with aortic root aneurysms. Dedicated aortic root surgeons perform several technical variations of valve-sparing procedures aimed at matching the specific aortic root disorder with the optimal operation.

Longitudinal Associations Between Vision Impairment and the Incidence of Neuropsychiatric, Musculoskeletal, and Cardiometabolic Chronic Diseases

PURPOSE

To compare the incidence and hazard of neuropsychiatric, musculoskeletal, and cardiometabolic conditions among adults with and without vision impairment (VI).

DESIGN

Retrospective cohort study.

METHODS

The sample comprised enrollees in a large private health insurance provider in the United States, including 24 657 adults aged ≥18 years with VI and age- and sex-matched controls. The exposure variable, VI, was based on low vision and blindness International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM), diagnosis codes. Physician-diagnosed incident neuropsychiatric, musculoskeletal, and cardiometabolic diseases were identified using ICD codes. Separate Cox proportional hazards regression models were used to assess the association of VI with incidence of 30 chronic conditions, adjusting for Elixhauser Comorbidity Index. Analyses were stratified by age 18-64 years and ≥65 years.

RESULTS

In individuals with VI aged 18-64 years (n=7478), the adjusted hazard of neuropsychiatric (HR 2.1, 95% CI 1.9, 2.4), musculoskeletal (HR 1.8, 95% CI 1.7, 2.0), and cardiometabolic (HR 1.8, 95% CI 1.7, 2.0) diseases was significantly greater than in matched controls (mean 5.5 years follow-up). Similar associations were seen between patients with VI aged ≥65 years (n=17 179) for neuropsychiatric (HR 2.4, 95% CI 2.1, 2.7), musculoskeletal (HR 1.8, 95% CI 1.6, 1.9), and cardiometabolic (HR 1.7, 95% CI 1.4, 2.0) diseases. VI was associated with a higher hazard of each of the 30 conditions we assessed, with similar results in both age cohorts.

CONCLUSION

Across the life span, adults with VI had an approximately 2-fold greater adjusted hazard for common neuropsychiatric, musculoskeletal, and cardiometabolic disorders compared with matched controls without VI.

Risk of early- and late-onset Alzheimer disease and related dementia in adults with cerebral palsy

AIM

To examine the risk of Alzheimer disease and related dementia (ADRD) among adults with cerebral palsy (CP).

METHOD

Using administrative insurance claims data for 2007 to 2017 in the USA, we identified adults (45y or older) with a diagnosis of CP (n=5176). Adults without a diagnosis of CP were included as a typically developing comparison group (n=1 119 131). Using age, sex, ethnicity, other demographic variables, and a set of chronic morbidities, we propensity-matched individuals with and without CP (n=5038). Cox survival models were used to estimate ADRD risk within a 3-year follow up.

RESULTS

The unadjusted incidence of ADRD was 9 and 2.4 times higher among cohorts of adults 45 to 64 years (1.8%) and 65 years and older (4.8%) with CP than the respective unmatched individuals without CP (0.2% and 2.0% among 45-64y and 65y or older respectively). Fully adjusted survival models indicated that adults with CP had a greater hazard for ADRD (among 45-64y: unmatched hazard ratio 7.48 [95% confidence interval {CI} 6.05-9.25], matched hazard ratio 4.73 [95% CI 2.72-8.29]; among 65y or older: unmatched hazard ratio 2.21 [95% CI 1.95-2.51], matched hazard ratio 1.73 [1.39-2.15]).

INTERPRETATION

Clinical guidelines for early screening of cognitive function among individuals with CP need updating, and preventative and/or therapeutic services should be used to reduce the risk of ADRD.

Diagnosis of Alzheimer's disease and related dementia among people with multiple sclerosis: Large cohort study, USA

BACKGROUND

Alzheimer's disease and related dementia (ADRD) and multiple sclerosis (MS) are two neurodegenerative diseases with some shared pathophysiological characteristics. While the salient attribute of ADRD is a progressive decline in cognitive function, MS is mainly known for causing physical weakness, vision loss, and muscle stiffness. Progressive cognitive decline, however, is not uncommon among MS patients, and many case reports of MS were indicative of ADRD coexistence. Due to a lack of large epidemiological studies on this topic, we aimed to examine time to diagnosis of and adjusted hazard for ADRD using administrative claims data, comparing adults with and without MS.

METHODS

Using 2007-2017 private claims data from Optum Clinformatics Data Mart in the U.S., we identified adults (45+) with a MS diagnosis (n = 6151) as well as adults without MS for comparison (n = 916,143). We propensity score matched people with MS with those without (n = 6025) using age, sex, race/ethnicity, chronic conditions including cardiometabolic, psychologic, and musculoskeletal, U.S. Census Division, and socioeconomic variables. In addition to incidence estimates of ADRD diagnosis compared at 4-years, survival models were utilized to quantify unadjusted, fully adjusted, and adjusted propensity-matched hazard ratios.

RESULTS

Unmatched data revealed that incidence of early-onset ADRD diagnosis was 7 times higher among adults 45-64 years old with MS (1.4%) compared to those without (0.2%); among older adults (65+) with MS, incident ADRD was 4.0% compared to 3.3% among those without MS. Adjusted survival models indicated that adults with MS had a substantially high risk for early-onset ADRD diagnosis (among 45-64 years old: unmatched hazard ratio (HR): 4.25 (95% CI: 3.40 -5.32), matched HR: 4.49 (95% CI:2.62-7.69); among 65+ years old: unmatched HR: 1.39 (95% CI: 1.22, 1.58), matched HR: 1.26 (1.04, 1.54)).

CONCLUSIONS

Individuals with MS had a greater incidence of and risk for early- and late-onset ADRD diagnosis compared to those without MS. It is not clear whether this greater risk is due to an accelerated dementia risk or at least partially due to clinical misdiagnosis. Advancements in the development of clinical and imaging biomarkers should be more commonly used in clinical settings to facilitate future research on this topic.

Physical and Mental Health Comorbidities Among Adults With Multiple Sclerosis

OBJECTIVE

To compare the incidence of and adjusted hazard ratios for common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities among adults with and without multiple sclerosis (MS).

PATIENTS AND METHODS

Beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for MS (n=9815) from a national private insurance claims database (Clinformatics Data Mart; OptumInsight). Adults without MS were also included (n=1,474,232) as a control group. Incidence estimates of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities were compared at 5 years of continuous enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident morbidities.

RESULTS

Adults with MS had a higher incidence of any common cardiometabolic disease (51.6% [2663 of 5164] vs 36.4% [328,690 of 904,227]), musculoskeletal disorder (68.8% [3411 of 4959] vs 47.5% [512,422 of 1,077,737]), and psychological morbidity (49.4% [3305 of 6691] vs 30.8% [380,893 of 1,235,388]) than adults without MS, and differences were clinically meaningful (all P<.001). Fully adjusted survival models revealed that adults with MS had a greater risk for any (hazard ratio [HR], 1.37; 95% CI, 1.32 to 1.43) and all (HR, 1.19 to 1.48) common cardiometabolic diseases, any (HR, 1.59; 95% CI, 1.53 to 1.64) and all (HR, 1.22 to 2.77) musculoskeletal disorders, and any (HR, 1.57; 95% CI, 1.51 to 1.62) and all (HR, 1.20 to 2.51) but one (impulse control disorders) psychological morbidity.

CONCLUSION

Adults with MS have a significantly higher risk for development of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities (all P<.001) than adults without MS. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of chronic physical and mental disease onset/progression in this higher risk population.

Pain Phenotypes in Adults Living With Cerebral Palsy

Background and Objectives

To identify pain phenotypes among adults living with cerebral palsy (CP) and compare phenotypes of pain intensity, anxiety and depressive symptoms, and self-reported perceived stress.

Methods

Seventy-one adults with CP presented to the University of Michigan (mean age = 39.3 ± 16.2; 43 women, 28 men). The median of 6 on the American College of Rheumatology fibromyalgia survey was used to classify patients for nociplastic pain centralization. The painDETECT Score was used to classify patients for neuropathic pain. These measures were then used to cross-classify each patient into 1 of 4 possible pain categories: neuropathic, nociplastic, mixed neuropathic/noclipastic, or nociceptive pain (-neuropathic/-nociplastic pain).

Results

Twenty-eight adults with CP (39.4%) were classified as nociceptive, 24 (33.8%) as nociplastic, 8 (11.3%) as neuropathic, and 11 (15.5%) as mixed neuropathic/nociplastic. Subgroups differed significantly on average scores on the Brief Pain Inventory pain intensity scale, the Perceived Stress Scale, and on the Patient-Reported Outcomes Measurement Information System measures of anxiety and depression; the nociceptive pain subgroup reported lower pain and emotional distress compared with the other groups.

Discussion

Findings suggest that type of pain is variable among adults with CP and may arise through multiple mechanisms.

Psychological, Cardiometabolic, and Musculoskeletal Morbidity and Multimorbidity Among Adults With Cerebral Palsy and Spina Bifida: A Retrospective Cross-sectional Study

BACKGROUND

Individuals living with cerebral palsy or spina bifida are at heightened risk for a number of chronic health conditions, such as secondary comorbidities, that may develop or be influenced by the disability, the presence of impairment, and/or the process of aging. However, very little is known about the prevalence and/or risk of developing secondary comorbidities among individuals living with cerebral palsy or spina bifida throughout adulthood. The objective of this study was to compare the prevalence of psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity among adults with and without cerebral palsy or spina bifida.

METHODS

Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for cerebral palsy or spina bifida (n = 29,841). Adults without cerebral palsy or spina bifida were also included (n = 5,384,849). Prevalence estimates of common psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity (≥2 conditions) were compared.

RESULTS

Adults living with cerebral palsy or spina bifida had a higher prevalence of all psychological disorders and psychological multimorbidity (14.6% vs. 5.4%), all cardiometabolic disorders and cardiometabolic multimorbidity (22.4% vs. 15.0%), and all musculoskeletal disorders and musculoskeletal multimorbidity (12.2% vs. 5.4%), as compared with adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent.

CONCLUSIONS

Adults with cerebral palsy or spina bifida have a significantly higher prevalence of common psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity, as compared with adults without cerebral palsy or spina bifida. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of disease onset/progression in these higher risk populations.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) List the main categories of morbidity that present with higher risk in adults with cerebral palsy and spina bifida; (2) Discuss the potential impact of multimorbidity on 'early aging' in adults living with cerebral palsy and spina bifida; and (3) Describe challenges that adults with cerebral palsy and spina bifida have in obtaining appropriate health care to address prevention and treatment of multimorbidity.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Pain phenotypes among adults living with cerebral palsy and spina bifida

ABSTRACT

Chronic pain is the most commonly reported physical symptomology of cerebral palsy (CP) and spina bifida (SB) throughout the lifespan, and yet, pain is perhaps the least understood comorbidity in these populations. The objective of this study was to compare the prevalence and types of pain diagnosed among adults living with and without CP or SB. In this retrospective cohort study, we analyzed data from a nationwide commercial insurance claims database. Beneficiaries were included if they had an International Classification of Diseases, Ninth revision, Clinical Modification diagnosis code for CP or SB (n = 22,648). Adults without CP or SB were also included as controls (n = 931,623). Pain phenotypes (nociceptive, nociplastic, and neuropathic pain) and pain multimorbidity (≥2 conditions) were compared. We found that adults living with CP or SB had a higher prevalence of any pain disorders (55.9% vs 35.2%), nociceptive pain (44.0% vs 26.7%), nociplastic pain (26.1% vs 11.9%), neuropathic pain (9.6% vs 5.6%), and pain multimorbidity (21.1% vs 8.4%), as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Adjusted odds ratios of nociceptive pain (odds ratio [OR]: 2.20; 95% confidence interval [CI]: 2.15-2.24), nociplastic pain (OR: 2.47; 95% CI: 2.41-2.53), neuropathic pain (OR: 2.71; 95% CI: 2.54-2.89), and other pain (OR: 3.92; 95% CI: 3.67-4.19) were significantly higher for adults living with CP or SB. In conclusion, adults with CP or SB have a significantly higher prevalence and odds of common peripheral, central, and neuropathic pain disorders and pain multimorbidity, as compared to adults without CP or SB.

Navigating the Pathway to Care in Adults With Cerebral Palsy

As individuals with cerebral palsy (CP) age, they face unique challenges which complicate their ability to access and receive appropriate health care. These problems exist at the level of the health care system, the clinician, and the individual. At the system level, there is an inadequate number of professionals who are informed of and interested in the care of adults with CP. Pediatric clinicians prefer treating children, and adult caregivers are not knowledgeable about and may feel less competent about CP. Pediatric care does not translate well to the adult population, and information about best practices for adults is just starting to develop. Differences in the physiologic development of individuals with CP render well-established clinical protocols for risk screening of chronic diseases less effective. Moreover, lack of supportive resources decreases a caregiver's sense of self-efficacy in treating this population. The patient's ability to navigate these barriers is complicated by the high prevalence of comorbid cognitive impairment and mental health issues including anxiety, depression, and other psychiatric disorders; a bidirectional relationship between challenges in navigating care/needs and comorbid mental health conditions appears likely. Many patients have additional barriers related to social determinants of health, such as access to transportation, accessible health care facilities, and other personal and environmental factors that may impede health maintenance and wellness. Increasing and disseminating knowledge, harnessing the power of new technologies such as telemedicine, and addressing mental health issues are some of the methods that are available to help adults with CP navigate this road.

The Ross procedure and valve-sparing root replacement procedures in the adult patient: do guidelines follow the evidence?

Prosthetic aortic valve replacements have long been the mainstay of valvular surgery due to their favorable outcomes and low operative complexity. Yet, mechanical valves require lifelong anticoagulation, whereas bioprosthetic valves increase the risk for earlier and more frequent reoperation. Alternative reconstructive techniques have been proposed to address these challenges. These include valve-sparing root replacement procedures if the native aortic valve can be salvaged, and the Ross procedure, which nearly eliminates prosthetic valve-related thromboembolism, anticoagulation-related hemorrhage and endocarditis. Both procedures are technically more complex and thus subject to surgeons' volume and expertise compared to conventional aortic valve replacements. However, they are associated with more favorable outcomes compared to aortic valve replacements if performed by experienced surgeons, especially in younger patients. Nevertheless, despite the growing high-quality literature supporting both procedures, existing multi-society guidelines fail to acknowledge the strength of evidence in support of valve-sparing root replacement procedures and the Ross procedure. In this review, we summarize the existing long-term evidence for the use of each procedure, describe the current guidelines for the treatment of aortic valve pathology, and propose the reevaluation of guidelines based on the available clinical evidence.

Muscle weakness is a prognostic indicator of disability and chronic disease multimorbidity

BACKGROUND

The objective of this study was to use nationally-representative data on Americans greater than 50 years of age to determine the association between grip strength and inflammation as independent predictors of incident disability, chronic multimorbidity and dementia.

METHODS

Middle age and older adults (n = 12,618) from the 2006-2008 waves of the Health and Retirement Study with 8-years of follow-up were included. Longitudinal modeling was performed to examine the association between baseline grip strength (normalized to body mass: NGS) and high sensitivity C-reactive protein (hs-CRP) (≥3.0 mg/L) with incident physical disabilities (i.e., ≥2 limitations to activities of daily living), chronic multimorbidity (≥2 of chronic conditions), and dementia.

RESULTS

The odds of incident disability were 1.25 (95% CI: 1.20-1.30) and 1.31 (95% CI: 1.26-1.36) for men and women respectively, for each 0.05-unit lower NGS. The odds of incident chronic multimorbidity were 1.14 (95% CI: 1.08-1.20) and 1.14 (95% CI: 1.07-1.21) for men and women respectively for each 0.05-unit lower NGS. The odds of incident dementia were 1.10 for men (95% CI: 1.02-1.20) for each 0.05-unit lower NGS, but there was no significant association for women. Elevated hs-CRP was only associated with chronic multimorbidity among men (OR = 1.29; 95% CI: 1.00-1.73) and women (OR = 1.60; 95% CI: 1.26-2.02).

CONCLUSIONS

Our findings indicate a robust inverse association between NGS and disability and chronic, multimorbidity in older men and women, and dementia in men. Elevated hs-CRP was only associated with chronic multimorbidity in men and women. Healthcare providers should implement measures of grip strength in routine health assessments and discuss the potential dangers of weakness as well as interventions to improve strength with their patients.

Timecourse of Morbidity Onset Among Adults Living With Cerebral Palsy

INTRODUCTION

Despite the greater risk of an array of morbidities, little is known about when morbidities occur for adults with cerebral palsy. The objective of this study is to determine the timecourse of morbidity risk/development for adults with cerebral palsy and the effect by patient-level factors.

METHODS

Cross-sectional data from 2016 were used from a random 20% sample from the fee-for-service Medicare database. Diagnosis codes identified adults aged ≥18 years with cerebral palsy and 16 clinically relevant morbidities. Qualitative and quantitative approaches identified the age where each morbidity became exceedingly prevalent. The effect of the timecourse by sex, race, and co-occurring intellectual disabilities and epilepsy was examined. Data were sequestered and analyzed in 2020.

RESULTS

Among 16,818 adults with cerebral palsy, the prevalence of most morbidities was already high among those aged 18-30 years, and all morbidities increased with age except liver disease and anxiety. Hypertension and diabetes exhibited a positive linear trend with age. Of the morbidities that did not exhibit a linear trend, the qualitative and quantitative approaches were consistent considering that the cardiorespiratory diseases, osteoarthritis, renal disease, and dementia became exceedingly more prevalent at age >50 years, whereas the threshold was >60 years for depression, cancer, and metastatic cancer. There were interactions with sex, race, and co-occurring intellectual disabilities and epilepsy for some of the morbidities.

CONCLUSIONS

Morbidity prevalence is already elevated early in adulthood among individuals living with cerebral palsy, with an abrupt increase by age 50 years. Preventive efforts should be adopted early in the lifespan and not later than age 50 years for adults with cerebral palsy.

Development of Quality Indicators for the Management of Acute Type A Aortic Dissection

In an effort to further improve surgical outcomes in patients with acute type A aortic dissection (ATAD), the Canadian Thoracic Aortic Collaborative (CTAC), with the support of the Canadian Society of Cardiac Surgeons (CSCS), endeavored to develop quality indicators (QIs) for the management of patients with ATAD. After two successive consultations with the CTAC membership, 11 QIs were selected and separated into 5 broad categories: pre-operative (time from presentation to diagnosis, time from presentation to the operating room), intra-operative (use of hypothermic circulatory arrest and antegrade cerebral perfusion), 30-day outcomes (30-day rates of all-cause mortality, 30-day rates of new post-operative stroke), 1-year outcomes (1-year rates of follow-up imaging, 1-year rates of all-cause mortality, and 1-year rates of surgical re-intervention), and institutional (institutional surgical volumes, individual surgical volumes and presence of institutional aortic disease teams). The purpose of this manuscript was to describe the process by which QIs for the management of ATAD were developed and the feasibility by which they may be collected using existing clinical and administrative data sources. Furthermore, we demonstrate how they may be used to evaluate success following surgery for repair of ATAD and ultimately improve clinical outcomes.

Frozen Elephant Trunk for Aortic Arch Reconstruction is Associated with Reduced Mortality as Compared to Conventional Techniques

To examine the perioperative outcomes following aortic arch repair using frozen elephant trunk (FET) vs conventional elephant trunk (ET) techniques. Between 2002 and 2018, 390 patients underwent aortic repair with elephant trunk reconstruction at 9 centers: 172 patients received a FET (mean age: 65+/-13 years, 30% female, 37% aortic dissection) and 218 patients received an ET (mean age: 63+/-13 years, 37% female, 43% aortic dissection). Outcomes of interest included in-hospital mortality; stroke; and spinal cord injury (SCI). In-hospital mortality rate was 11% (n = 43) overall, 9% (n = 15) for FET and 13% (n = 28) for ET. Post-operative stroke occurred in 13% (n = 49) overall, 13% (n = 22) for FET and 12% (n = 27) for ET. The rate of post-operative SCI was 3% (n = 13) overall, 5.0% (n = 9) for FET and 2.0% (n = 4) for ET. When compared to ET, the propensity score analysis confirmed FET to be associated with lower mortality (adjusted risk difference -7.0% (95% CI -13.0 to -1.0), P = 0.02). There was no significant difference in the propensity score-adjusted risk difference for stroke between FET and ET (-0.7%, 95% CI -7.4% to 6.1%, P = 0.85), nor for SCI (3.3%, 95% CI -0.4% to 7.0%, P = 0.085) On multivariable analysis, FET was associated with lower odds of mortality (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and had similar odds of stroke (OR 0.83, 95% CI 0.41-1.70, P = 0.62) and SCI (OR 2.83, 95% CI 0.83-9.60, P = 0.1). FET repair is associated with lower in-hospital mortality as compared to conventional ET, and results in similar risk of stroke and spinal cord injury. Further investigation is warranted.