Delayed sternal closure does not reduce complications associated with coagulopathy and right ventricular failure after left ventricular assist device implantation

Delayed sternal closure (DSC) is occasionally adopted after implantation of left ventricular assist device (LVAD). Recent studies suggest that DSC be used for high risk group of patients with coagulopathy, hemodynamic instability or right ventricular failure. However, whether DSC is efficacious for bleeding complication or right ventricular failure is not known. This study is single center analysis of 52 patients, who underwent LVAD implantation. Of those 52 patients, 40 consecutive patients underwent DSC routinely. The sternum was left open with vacuum assist device after implantation of LVAD. Perioperative outcome of the patients who underwent routine DSC were compared with 12 patients who had immediate sternal closure (IC). Mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level of IC group and DSC group were 2.7 and 2.6, respectively. Postoperative bleeding (643 vs. 1469 ml, p?<?0.001), duration of inotropic support (109 vs. 172 h, p?=?0.034), and time to extubation (26 vs. 52 h, p?=?0.005) were significantly increased in DSC group. Length of ICU stay (14 vs. 15 days, p?=?0.234) and hospital stay (28 vs. 20 days, p?=?0.145) were similar. Incidence of right ventricular failure and tamponade were similar in the two groups. Routine DSC after implantation of an LVAD did not prove to be beneficial in reducing complications associated with coagulopathy and hemodynamic instability including cardiac tamponade or right ventricular failure. We suggest that DSC be selectively applied for patients undergoing LVAD implant.     

Active Relearning for Robust Supervised Training of Emphysema Patterns

Radiologists are adept at recognizing the character and extent of lung parenchymal abnormalities in computed tomography (CT) scans. However, the inconsistent differential diagnosis due to subjective aggregation necessitates the exploration of automated classification based on supervised or unsupervised learning. The robustness of supervised learning depends on the training samples. Towards optimizing emphysema classification, we introduce a physician-in-the-loop feedback approach to minimize ambiguity in the selected training samples. An experienced thoracic radiologist selected 412 regions of interest (ROIs) across 15 datasets to represent 124, 129, 139 and 20 training samples of mild, moderate, severe emphysema and normal appearance, respectively. Using multi-view (multiple metrics to capture complementary features) inductive learning, an ensemble of seven un-optimized support vector models (SVM) each based on a specific metric was constructed in less than 6 s. The training samples were classified using seven SVM models and consensus labels were created using majority voting. In the active relearning phase, the ensemble-expert label conflicts were resolved by the expert. The efficacy and generality of active relearning feedback was assessed in the optimized parameter space of six general purpose classifiers across the seven dissimilarity metrics. The proposed just-in-time active relearning feedback with un-optimized SVMs yielded 15 % increase in classification accuracy and 25 % reduction in the number of support vectors. The average improvement in accuracy of six classifiers in their optimized parameter space was 21 %. The proposed cooperative feedback method enhances the quality of training samples used to construct automated classification of emphysematous CT scans. Such an approach could lead to substantial improvement in quantification of emphysema.     

Stretch reflexes and joint dynamics in rheumatoid arthritis

In clinically diagnosed rheumatoid arthritis (RA), studies were conducted to investigate the reflex and passive tissue contribution to measured increases in joint stiffness in the resting upper limb and during constant contractions of an attached muscle. The tonic stretch reflex was induced by a servo-controlled sinusoidal stretch perturbation of the metacarpophalangeal joint of RA patients, and age- and sex-matched controls. The resulting reflexes and mechanical changes in the RA affected joint were explored. Surface electromyographic (EMG) measurements were obtained from first dorsal interosseus muscle. Reflex gain (EMG/joint angle amplitude ratio), phase difference (reflex delay after stretch), coherence square (proportion of EMG variance accounted for by joint angle changes), joint mechanical gain (torque–joint angle amplitude ratio) and mechanical phase difference (torque response delay after stretch) were determined. RA patients showed decreased reflex gain that was partly due to coexistent severe muscle weakness, as determined from maximum voluntary contraction and grip pressure estimates. The decreased reflex gain was most evident at high stretch frequency suggesting a disproportionate loss of the large diameter afferent response and also increased reflex delay in the patients. These changes ensemble suggest significant loss of neural drive to the motor unit population. Patients also showed increased joint stiffness (measured as torque gain) in the contracting muscle, but there was no evidence of reflex activity or increased stiffness at rest. This suggests that the increased joint stiffness in RA was due to changes in the mechanical properties of the active muscle–joint system rather than changes in reflex properties.     

Socioeconomic Disparities and Metabolic Risk in Veterans with Serious Mental Illness

Socioeconomic disparities were assessed in predicting metabolic risk among veterans with serious mental illness. Veterans with schizophrenia, schizoaffective, or bipolar disorders were identified in VISN 4 facilities from 10/1/2010 to 9/30/2012. Differences between patients with and without metabolic syndrome were compared using t-tests, Chi square tests and multivariate logistic regressions. Among 10,132 veterans with mental illness, 48.8% had metabolic syndrome. Multivariate logistic regression analysis confirmed that patients with metabolic syndrome were significantly more likely to be older, male, African-American, married, and receiving disability pensions but less likely to be homeless. They were more likely to receive antipsychotics, antidepressants, or anticonvulsants. Bivariate cross-sectional analysis revealed that patients with metabolic syndrome had higher rates of coronary artery disease, cerebrovascular disease, and mortality, and that metabolic syndrome was more often associated with emergency visits and psychiatric or medical hospitalizations. Demographics, socioeconomic status and medications are independent predictors of metabolic syndrome and should be considered in broader screening of risk factors in order to provide preventive interventions for metabolic syndrome.     

3D Morphometric Analysis of Human Fetal Cerebellar Development

To date, growth of the human fetal cerebellum has been estimated primarily from linear measurements from ultrasound and 2D magnetic resonance imaging (MRI). In this study, we use 3D analytical methods to develop normative growth trajectories for the cerebellum in utero. We measured cerebellar volume, linear dimensions, and local surface curvature from 3D reconstructed MRI of the human fetal brain (N?=?46). We found that cerebellar volume increased approximately 7-fold from 20 to 31 gestational weeks. The better fit of the exponential curve (R (2)?=?0.96) compared to the linear curve (R (2)?=?0.92) indicated acceleration in growth. Within-subject cerebellar and cerebral volumes were highly correlated (R (2)?=?0.94), though the cerebellar percentage of total brain volume increased from approximately 2.4% to 3.7% (R (2)?=?0.63). Right and left hemispheric volumes did not significantly differ. Transcerebellar diameter, vermal height, and vermal anterior to posterior diameter increased significantly at constant rates. From the local curvature analysis, we found that expansion along the inferior and superior aspects of the hemispheres resulted in decreased convexity, which is likely due to the physical constraints of the dura surrounding the cerebellum and the adjacent brainstem. The paired decrease in convexity along the inferior vermis and increased convexity of the medial hemisphere represents development of the paravermian fissure, which becomes more visible during this period. In this 3D morphometric analysis of the human fetal cerebellum, we have shown that cerebellar growth is accelerating at a greater pace than the cerebrum and described how cerebellar growth impacts the shape of the structure.     

The psychometric validation of the Sheehan Disability Scale (SDS) in patients with bipolar disorder

Bipolar disorder (BD) adversely affects daily activities/functioning. The Sheehan Disability Scale (SDS) assesses disability in work/school activities, family relationships, and social functioning, and it evaluates the functional impact of psychiatric disorders. BD outpatients from 21 U.S. sites completed a battery of validated instruments (including the SDS) three times over 8–12 weeks. Instrument reliability (internal consistency, test–retest), validity (construct, convergent validity, known groups) and responsiveness were measured. There were missing data for the SDS in 2% of the 225 subjects with BD. One factor explained 82% of the variance. All SDS items had rotated factor loadings on the first factor > 0.90, confirming the appropriateness of the SDS total score. Item-scale correlations surpassed 0.40. There was excellent internal consistency reliability for the SDS total score (Cronbach's alpha = 0.89). Test–retest reliability was acceptable for the SDS total score (intraclass correlation coefficient = 0.73). Correlations with other instruments demonstrate convergent and divergent validity. The SDS total and item scores significantly discriminated between (self-rated) overall health status, clinician-rated functional status, and clinician-rated depression, evidencing known group validity. The SDS demonstrated ability to detect change over time. The SDS is a valid, reliable measure of disability and is responsive to change over time when used in subjects with BD.     

Thrombosed dialysis access grafts: randomized comparison of the Amplatz thrombectomy device and surgical thromboembolectomy

We report the final results of the trial comparing the Amplatz thrombectomy device (ATD) with surgical thromboembolectomy (ST) to declot thrombosed dialysis access grafts (DAG). The study population consisted of 174 DAG, 109 of which were randomized to mechanical thrombectomy using the ATD and 65 of which were randomized to conventional surgical thromboembolectomy. Forty grafts were re-enrolled in the trial when they failed beyond the 90 days follow-up after the initial treatment. Thirty-one were re-enrolled for mechanical thrombectomy and nine were re-enrolled for surgical thrombectomy, resulting in a total of 140 ATD procedures and 74 surgical thromboembolectomy. Immediate thrombectomy success was defined as greater than 90% thrombus removal followed by the ability to dialyze after treatment, and analysis of long term success based on graft patency at 30 and 90 days, with successful dialysis. Immediate thrombectomy success with the ATD procedure was achieved in 79.2% and with ST in 73.4%. Patency of the graft, with successful dialysis, at 30 days with the ATD procedure was 79.2% and with ST was 73.4%. Patency of the graft, with successful dialysis, at 90 days with the ATD procedure was 75.2% and with ST was 67.8%. The data collected in this study provided a prospective comparison of mechanical thrombectomy with the ATD and ST performance in thrombosed DAG. The results of the performance of both methods were comparable. No statistically significant differences were seen.List of Investigators: Carol C. Steenson (Department of Radiology, VA Medical Center, Minneapolis, MN), Renan Uflacker (Interventional Radiology, Medical University of South Carolina, Charleston, SC), Richard J. Gray (Interventional Radiology, Washington Hospital Center, Washington, DC), George A. Fueredi (St Marys Hospital, Milwaukee, WI), Michael P. Hickman (Vascular and Interventional Radiology, St Josephs Regional Health Center, Hot Springs, AR), Robert Smith (Interventional Radiology, Tulane University Medical Center, New Orleans, LA), Paul Kamin (Department of Radiology, Los Alamitos Medical Center, Los Alamitos, CA), Mac Dryjski (Department of Surgery, Millard Filmore Hospital, Buffalo, NY), Michael Bettman (Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH).     

A retrospective analysis of complex proximal humerus fractures managed with reverse shoulder arthroplasty in a level 1 trauma center

BackgroundThe treatment of complex 3- and 4-part proximal humerus fractures (PHFs) in the elderly poses significant challenges because of osteoporosis and fracture comminution. The wide range of surgical options available is evidence of the complex nature of the injury. At present, reverse shoulder replacement is gaining popularity among shoulder surgeons for treating these difficult fractures, and the literature has shown equivalent or superior outcomes with reverse shoulder arthroplasty (RSA). We aimed to analyze the long-term results of these complex PHF treated with reverse shoulder replacement.MethodsFor this study, fractures from 39 patients with a mean age of 63.18 years who were treated with RSA for acute complex fractures of the proximal humerus in our institution between 2013 and 2019 were analyzed (n = 31, acute 4-part fractures; n = 4, acute fracture–dislocation; n = 3, fracture with irreparable cuff tear; n = 1, osteoporotic 2-part fracture). All patients had a standard reverse shoulder replacement (cemented humeral stem n = 37 and uncemented stem n = 2) surgery in a level 1 trauma center. The mean follow-up duration was 60 months (24-111 months). The clinical outcomes (Oxford Shoulder Score and Constant Shoulder Score) and the complications at 6 months, 12 months, and 24 months were analyzed.ResultsOur study found a relatively younger population, with 21 patients (53.84%) aged <66 years. Spearman's correlation showed that younger patients had better signs of improvement in Oxford Shoulder Scores at 2 years (P = .008). The average Oxford Shoulder Score was 39.12 ± 4.327, and the average Constant Shoulder Score was 67.67 on the operated side. The mean active forward elevation was 142.56 ± 22.29º, abduction was 136.538 ± 24.31º, external rotation was 27 ± 9.011º, and internal rotation was 33 ± 20.41º. The overall complication rate of 17.94% (periprosthetic infection n = 2, periprosthetic humerus fracture n = 1, and hematoma evacuation n = 4) in our study was similar to those of recent studies in the literature.ConclusionRSA provides a reliable option for PHFs and offers good results in the form of pain relief and good functional outcomes at 2 years even in a younger age group. Thus, it is fast becoming an important option in treating complex PHF, but we must be wary of the steep learning curve and the complications pertinent to this procedure.     

Plesiomonas shigelloides sepsis and splenic abscess in an adolescent with sickle-cell disease.

Plesiomonas shigelloides is a rare cause of self-limiting gastroenteritis. We report a case of extraintestinal P. shigelloides infection in an adolescent with sickle-cell disease who presented with bacteremia complicated by a splenic abscess. Despite the high mortality rate reported in extraintestinal P. shigelloides infection, the patient survived after drainage of the abscess and treatment with antibiotics.