Management of Sternal Wounds, Infections, and Sternal Non-Union with Plate Fixation: Result from a Single Site Experience.

Background: Patients with sternal wounds, infection, or non-union after cardiac surgery continue to have increased morbidity and mortality rates compared with those without sternal complications. Reconstructive methods have largely centered on soft tissue approaches, including muscle or omental flaps, which result in functional loss. Some data show early positive advantages using sternal rigid plate fixation (SRPF), however, it is debated in the setting of active infection. The goal of this study is to examine the outcomes of SRPF in patients with and without infections. Patients and Methods: This is a retrospective study of consecutive patients who underwent SRPF by a single plastic surgeon from April 2013 to August 2021. Patients treated without SRPF, lacking at least six months of follow-up, or those plated more than once were excluded. Ninety-seven patients were included. Demographic and peri-operative factors associated with sternal infection after SRPF were evaluated. Results: Sixty-eight patients were clinically infected/culture positive or open (INFECTED), and 29 were clean/primary plating (CLEAN). Sixteen percent of the INFECTED cases (11/68) returned with infection. Fourteen percent of the CLEAN cases (4/29) had subsequent infections. Additionally, we did note a decrease in rates of infections overall (p < 0.0001) as experience and frequency of plate fixation increased (p < 0.0001). Regardless of infection status, all but one patient had a healed and stable sternum at the end of data collection. Conclusions: There is no statistically significant difference between wound class prior to SRPF and development of infection after SRPF. Even in infected settings, patients can be treated successfully with SRPF. Further study is needed.

Genetic selection for reduced health treatment costs in Holstein cows: implications from a long-term study.

The objective of this study was to estimate genetic parameters of health treatment cost of Holstein cows from producer-recorded health treatments in 8 herds over an 8-yr period of time. Genetic parameters of health treatment cost were estimated in first (n = 2,214), second (n = 1,487) and third (n = 800) parities of US Holstein cows. The health treatments were uniformly defined and consistently recorded by 8 high-performance dairy herds in Minnesota from 2008 to 2015. A fixed treatment cost was assigned to 14 types of health treatments, and the cost included the mean veterinary expense obtained from the veterinary clinics that serviced the 8 herds, pharmaceuticals, and labor cost. The labor cost was $18/h, and the time incurred for each type of health treatment was determined from interviews with the herd owners. The 14 types of health treatment costs were partitioned into 5 categories: mastitis (including mastitis diagnostic test), reproduction (cystic ovary, retained placenta, and metritis), lameness (hoof treatments), metabolic (milk fever, displaced abomasum, ketosis, and digestive), and miscellaneous (respiratory, injury, and other). Health treatment cost for each cow was summed by category within lactation and also across categories within lactation. The estimates of heritability for health treatment cost were 0.13, 0.04, 0.10, 0.12, and 0.04 for the mastitis, reproduction, lameness, metabolic, and miscellaneous categories, respectively, in first parity. Genetic correlations between categories of health treatment cost in first parity were greatest for mastitis and reproduction (r = 0.85); however, phenotypic correlations between all categories were small (r < 0.16). Total health treatment cost had a large genetic correlation with somatic cell score (0.93) and 305-d milk production (0.44) in first parity; however, the genetic correlation (-0.60) between total health treatment cost and udder depth in first parity indicated a genetic relationship exists between shallow udders and less total health treatment cost. Total health treatment cost across categories had a heritability estimate of 0.25 in first parity, 0.16 in second parity, and 0.17 in third parity. Consequently, genetic selection for reduced health treatment cost should be possible by using producer-recorded health treatment records supplemented with treatment costs.

Health Treatment Cost of Holsteins in Eight High-Performance Herds.

Health treatments of Holstein cows (n = 2214) were recorded by the owners of eight high-performance dairy herds in Minnesota. Cows calved from March 2008 to October 2015, and 14 types of health treatments were uniformly defined across the herds. Specific types of health treatment were subsequently assigned a cost based on the mean veterinary cost obtained from the veterinary clinics that serviced the eight herds. A fixed labor cost for time (USD 18/h) associated with specific types of health treatment was determined based on interviews with the herd owners and was added to the veterinary cost. Health treatment cost was then partitioned into five health categories: mastitis (including mastitis diagnostic test), reproduction (cystic ovary, retained placenta, and metritis), lameness (hoof treatments), metabolic (milk fever, displaced abomasum, ketosis, and digestive), and miscellaneous (respiratory, injury, and other). Lactations of cows were divided into six intervals that corresponded with stage of lactation based on days in milk. The first interval of lactation was 30 days in length, followed by four intervals of 60 days each, and the final interval started on day 271 and had variable length because it continued to the end of lactation and included the dry period. Health treatment cost was summed within each interval of lactation and subsequently across lactations by parity. Statistical analysis by parity included the fixed effects of herd, interval, and the interaction of herd and interval, with interval regarded as a repeated measure of cows. Health treatment cost was highest during the first interval for all five parities of cows and ranged from USD 22.87 for first parity to USD 38.50 for fifth parity. Reproduction treatment cost was about one-half of the total health treatment cost during the first interval in all five parities. Metabolic treatment cost during the first interval ranged from USD 3.92 (in first parity) to USD 12.34 (in third parity). Compared to the other health categories, mastitis treatment cost was most evenly distributed across intervals of lactation in all parities. Lameness treatment cost was highest during mid- or late-lactation across parities and reflected the time when cows received routine hoof trimming. Additionally, treatment cost across health categories was summed across intervals of lactation for each cow, and the total health cost of cows varied substantially from herd to herd and ranged from USD 23.38 to USD 74.60 for first parity and usually increased with parity.

Stereotactic radiosurgery with and without checkpoint inhibition for patients with metastatic non-small cell lung cancer to the brain: a matched cohort study.

OBJECTIVE: Immune checkpoint inhibitors (ICIs) improve survival in patients with advanced non-small cell lung cancer (NSCLC). Clinical trials examining the efficacy of ICIs in patients with NSCLC excluded patients with untreated brain metastases (BMs). As stereotactic radiosurgery (SRS) is commonly employed for NSCLC-BMs, the authors sought to define the safety and radiological and clinical outcomes for patients with NSCLC-BMs treated with concurrent ICI and SRS. METHODS: A retrospective matched cohort study was performed on patients who had undergone SRS for one or more NSCLC-derived BMs. Two matched cohorts were identified: one that received ICI before or after SRS within a 3-month period (concurrent ICI) and one that did not (ICI naive). Locoregional tumor control, peritumoral edema, and central nervous system (CNS) adverse events were compared between the two cohorts. RESULTS: Seventeen patients (45 BMs) and 34 patients (92 BMs) composed the concurrent-ICI and ICI-naive cohorts, respectively. There was no statistically significant difference in overall survival (HR 0.99, 95% CI 0.39-2.52, p = 0.99) or CNS progression-free survival (HR 2.18, 95% CI 0.72-6.62, p = 0.11) between the two groups. Similarly, the 12-month local tumor control rate was 84.9% for tumors in the concurrent-ICI cohort versus 76.3% for tumors in the ICI-naive cohort (p = 0.94). Further analysis did reveal that patients receiving concurrent ICI had increased rates of CNS complete response for BMs treated with SRS (8/16 [50%] vs 5/32 [15.6%], p = 0.012) per the Response Assessment in Neuro-Oncology (RANO) criteria. There was also a shorter median time to BM regression in the concurrent-ICI cohort (2.5 vs 3.1 months, p < 0.0001). There was no increased rate of radiation necrosis or intratumoral hemorrhage in the patients receiving concurrent ICI (5.9% vs 2.9% in ICI-naive cohort, p = 0.99). There was no significant difference in the rate of peritumoral edema progression between the two groups (concurrent ICI: 11.1%, ICI naive: 21.7%, p = 0.162). CONCLUSIONS: The concurrent use of ICI and SRS to treat NSCLC-BM was well tolerated while providing more rapid BM regression. Concurrent ICI did not increase peritumoral edema or rates of radiation necrosis. Further studies are needed to evaluate whether combined ICI and SRS improves progression-free survival and overall survival for patients with metastatic NSCLC.

Predictors of 30-day mortality after endovascular mechanical thrombectomy for acute ischemic stroke.

OBJECTIVE: The aims of this single-center, retrospective cohort study are to assess the outcomes of endovascular mechanical thrombectomy (EMT) for acute ischemic stroke (AIS) and determine predictors of 30-day mortality at an academic comprehensive stroke center (CSC). METHODS: We retrospectively collected data from consecutive patients who underwent EMT for AIS at our institution between April 2016 and January 2018. Primary outcome was defined as mortality within 30 days from EMT. Successful revascularization was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b-3. Statistical analyses were performed to identify predictors of 30-day mortality. RESULTS: The study cohort was comprised 57 patients (51% male) with mean age of 72 years. Intravenous tissue plasminogen activator was administered in 51%. The median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) score were 8 and 20, respectively. The 30-day mortality rate was 39%. Univariate analyses found that older age (mean 77 vs. 68 years, p = 0.022), higher baseline NIHSS score (median 23 vs. 19, p = 0.032), NIHSS score at 24 h after EMT (median 14.5 vs. 7.5, p < 0.001), and lower rates of successful revascularization (59% vs. 89%, p = 0.021) were associated with 30-day mortality. CONCLUSION: We observed a moderate rate of 30-day mortality after EMT at an academic CSC. Older age, higher baseline NIHSS score, higher NIHSS score at 24 h after thrombectomy, and lower rates of successful revascularization were predictive of 30-day mortality in univariate analysis. Further efforts to identify modifiable risk factors of mortality are warranted.

Population and genetic outcomes 20 years after reintroducing bobcats (Lynx rufus) to Cumberland Island, Georgia USA.

In 1988-1989, 32 bobcats Lynx rufus were reintroduced to Cumberland Island (CUIS), Georgia, USA, from which they had previously been extirpated. They were monitored intensively for 3 years immediately post-reintroduction, but no estimation of the size or genetic diversity of the population had been conducted in over 20 years since reintroduction. We returned to CUIS in 2012 to estimate abundance and effective population size of the present-day population, as well as to quantify genetic diversity and inbreeding. We amplified 12 nuclear microsatellite loci from DNA isolated from scats to establish genetic profiles to identify individuals. We used spatially explicit capture-recapture population estimation to estimate abundance. From nine unique genetic profiles, we estimate a population size of 14.4 (SE = 3.052) bobcats, with an effective population size (N e) of 5-8 breeding individuals. This is consistent with predictions of a population viability analysis conducted at the time of reintroduction, which estimated the population would average 12-13 bobcats after 10 years. We identified several pairs of related bobcats (parent-offspring and full siblings), but ~75% of the pairwise comparisons were typical of unrelated individuals, and only one individual appeared inbred. Despite the small population size and other indications that it has likely experienced a genetic bottleneck, levels of genetic diversity in the CUIS bobcat population remain high compared to other mammalian carnivores. The reintroduction of bobcats to CUIS provides an opportunity to study changes in genetic diversity in an insular population without risk to this common species. Opportunities for natural immigration to the island are limited; therefore, continued monitoring and supplemental bobcat reintroductions could be used to evaluate the effect of different management strategies to maintain genetic diversity and population viability. The successful reintroduction and maintenance of a bobcat population on CUIS illustrates the suitability of translocation as a management tool for re-establishing felid populations.

Substantia nigra volume loss before basal forebrain degeneration in early Parkinson disease.

OBJECTIVE: To test the hypothesis that degeneration of the substantia nigra pars compacta (SNc) precedes that of the cholinergic basal forebrain (BF) in Parkinson disease (PD) using new multispectral structural magnetic resonance (MR) imaging tools to measure the volumes of the SNc and BF. DESIGN: Matched case-control study. SETTING: The Athinoula A. Martinos Imaging Center at the McGovern Institute for Brain Research, Massachusetts Institute of Technology (MIT), and the Massachusetts General Hospital/MIT Morris Udall Center of Excellence in Parkinson Disease Research. PATIENTS: Participants included 29 patients with PD (Hoehn and Yahr [H&Y] stages 1-3) and 27 matched healthy control subjects. MAIN OUTCOME MEASURES: We acquired multiecho T1-weighted, multiecho proton density, T2-weighted, and T2-weighted fluid-attenuated inversion recovery (FLAIR) sequences from each participant. For the SNc, we created a weighted mean of the multiple echoes, yielding a single volume with a high ratio of contrast to noise. We visualized the BF using T2-weighted FLAIR images. For each participant, we manually labeled the 2 structures and calculated their volumes. RESULTS: Relative to the controls, 13 patients with H&Y stage 1 PD had significantly decreased SNc volumes. Sixteen patients with H&Y stage 2 or 3 PD showed little additional volume loss. In contrast, the BF volume loss occurred later in the disease, with a significant decrease apparent in patients having H&Y stage 2 or 3 PD compared with the controls and the patients having H&Y stage 1 PD. The latter group did not differ significantly from the controls. CONCLUSION: Our results support the proposed neuropathological trajectory in PD and establish novel multispectral methods as MR imaging biomarkers for tracking the degeneration of the SNc and BF.