Non-resolving neuroinflammation regulates axon regeneration in chronic spinal cord injury.

Chronic spinal cord injury (SCI) lesions retain increased densities of microglia and macrophages. In acute SCI, macrophages induce growth cone collapse, facilitate axon retraction away from lesion boundaries, as well as play a key role in orchestrating the growth-inhibitory glial scar. Little is known about the role of sustained inflammation in chronic SCI, or whether chronic inflammation affects repair and regeneration. We performed transcriptional analysis using the Nanostring Neuropathology panel to characterize the resolution of inflammation into chronic SCI, to characterize the chronic SCI microenvironment, as well as to identify spinal cord responses to macrophage depletion and repopulation using the CSF1R inhibitor, PLX-5622. We determined the ability for macrophage depletion and repopulation to augment axon growth into chronic lesions both with and without regenerative stimulation using neuronal-specific PTEN knockout (PTEN-KO). PTEN-KO was delivered with spinal injections of retrogradely transported adeno associated viruses (AAVrg's). Both transcriptional analyses and immunohistochemistry revealed the ability for PLX-5622 to significantly deplete inflammation around and within chronic SCI lesions, with a return to pre-depleted inflammatory densities after treatment removal. Neuronal-specific transcripts were significantly elevated in mice after inflammatory repopulation, but no significant effects were observed with macrophage depletion alone. Axon densities significantly increased within the lesion after PLX-5622 treatment with a more consistent effect observed in mice with inflammatory repopulation. PTEN-KO did not further increase axon densities within the lesion beyond effects induced by PLX-5622. We identified that PLX-5622 increased axon densities within the lesion that are histologically identified as 5-HT+and CGRP+, both of which are not robustly transduced by AAVrg's. Our work identified that increased macrophage/microglia densities in the chronic SCI environment may be actively retained by homeostatic mechanisms likely affiliated with a sustained elevated expression of CSF1 and other chemokines. Finally, we identify a novel role of sustained inflammation as a prospective barrier to axon regeneration in chronic SCI.

Association between proactive esophageal cooling and increased lab throughput.

INTRODUCTION: Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. METHODS: EP lab throughput data were obtained from three EP groups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling. RESULTS: Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre-adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < .0001), despite the loss of two operators during the post-adoption time frame. CONCLUSION: Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.

Extra-gastrointestinal stromal tumour of the lesser omentum presenting as a massive intra-abdominal swelling: A case report and literature review.

Extra gastrointestinal stromal tumour(EGIST) is rare and is regarded as gastrointestinal stromal tumour(GIST) that originates outside of the gastrointestinal tract. They originate from other intraabdominal tissues such as the omentum, mesentery and peritoneum. The cell of origin is the interstitial cell of Cajal(ICC), a pacemaker cell that controls gastrointestinal peristalsis and the tumor is characterized by the expression of KIT(CD117) a transmembrane tyrosine kinase receptor. Here, a 49-year-old female who presented with a 6 month history of abdominal pain, progressive abdominal swelling and the presence of an upper abdominal mass. She had surgical resection and adjuvant imatinib for the intraabdominal mass diagnosed on histology and immunohistochemistry as EGIST of the lesser omentum. Serial CT 14 months after surgery revealed no evidence of recurrence or metastasis. Clinicians should consider EGIST in the differential diagnosis of abdominal masses.

Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms.

OBJECTIVE: Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs. METHODS: This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed. RESULTS: Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges. CONCLUSION: Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.

Recurrent Lateral Abdominal Wall Hernias: Options for Reconstruction.

Management of lateral abdominal wall hernias presents a surgical challenge, and best management is controversial. Flank hernias as a surgical sequela occur more commonly, whereas flank hernias resulting from trauma are a rare occurrence. In this article, we present a review of the literature and a case of flank hernia presenting after trauma and recurring after repair. An anchored suture repair was performed and reinforced by the addition of a polyester underlay mesh.

Early Celecoxib use in Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) can cause rapid brain inflammation. There is debate over the safety and efficacy of anti-inflammatory agents in its treatment. With a particular focus on cyclooxygenase 2 (COX2) selective inhibition, we sought to determine the impact of celecoxib versus no celecoxib treatment on outcomes in patients with TBI and compare these with outcomes associated with nonselective COX inhibition (ibuprofen) and corticosteroid (dexamethasone) treatment. METHODS: This retrospective cohort study used TriNetX, a large publicly available global health research network, to gather clinical data extracted from the electronic medical records. Using International Classification of Diseases, Tenth Revision and pharmacy codes, we identified patients with TBI who were and were not treated with celecoxib, ibuprofen, and dexamethasone. Analysis was performed on propensity-matched and unmatched cohorts, which were matched on demographics, comorbidities, and neurological injuries. Our primary end point was 1-year survival. Secondary end points were ventilator and tracheostomy dependence, gastrostomy tube placement, seizures, and craniotomy. RESULTS: After propensity score matching, a total of 1443 patients were identified in both the celecoxib and no celecoxib cohorts. Ninety-two (6.4%) patients in the celecoxib cohort died within 1 year following TBI versus 145 (10.0%) in the no celecoxib cohort (odds ratio 0.61; 95% confidence interval 0.46-0.80; p = 0.0003). The 1-year survival rate was 96.1% in the celecoxib cohort versus 93.1% in the no celecoxib cohort (p < 0.0001). At the end of the 1-year period, celecoxib was associated with significantly lower gastrostomy tube dependence (p = 0.017), seizure activity (p = 0.027), and myocardial infarction (p = 0.021) compared with the control cohort. Ibuprofen was also associated with higher 1-year survival probability and lower rates of post-TBI complications. Dexamethasone was broadly associated with higher morbidity but was associated with higher 1-year survival probability compared with the no dexamethasone cohort. CONCLUSIONS: Early celecoxib and ibuprofen use within 5 days post TBI was associated with higher 1-year survival probabilities and fewer complications. With emerging yet controversial preclinical evidence to suggest that COX inhibition improves TBI outcomes, this population-level study offers suggestive support for these drugs' clinical benefit, which should be pursued in prospective clinical studies.

Atrioesophageal Fistula Rates Before and After Adoption of Active Esophageal Cooling During Atrial Fibrillation Ablation.

BACKGROUND: Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. A formal analysis of the atrioesophageal fistula (AEF) rate with active esophageal cooling has not previously been performed. OBJECTIVES: The authors aimed to compare AEF rates before and after the adoption of active esophageal cooling. METHODS: This institutional review board (IRB)-approved study was a prospective analysis of retrospective data, designed before collecting and analyzing the real-world data. The number of AEFs occurring in equivalent time frames before and after adoption of cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were quantified across 25 prespecified hospital systems. AEF rates were then compared using generalized estimating equations robust to cluster correlation. RESULTS: A total of 14,224 patients received active esophageal cooling during RF ablation across the 25 hospital systems, which included a total of 30 separate hospitals. In the time frames before adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In the preadoption cohort, a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates for procedures using LET monitoring. In the postadoption cohort, no AEFs were found in the prespecified sites, yielding an AEF rate of 0% (P < 0.0001). CONCLUSIONS: Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.

PTEN knockout using retrogradely transported AAVs transiently restores locomotor abilities in both acute and chronic spinal cord injury.

Restoring function in chronic stages of spinal cord injury (SCI) has often been met with failure or reduced efficacy when regenerative strategies are delayed past the acute or sub-acute stages of injury. Restoring function in the chronically injured spinal cord remains a critical challenge. We found that a single injection of retrogradely transported adeno-associated viruses (AAVrg) to knockout the phosphatase and tensin homolog protein (PTEN) in chronic SCI can effectively target both damaged and spared axons and transiently restore locomotor functions in near-complete injury models. AAVrg's were injected to deliver cre recombinase and/or a red fluorescent protein (RFP) under the human Synapsin 1 promoter (hSyn1) into the spinal cords of C57BL/6 PTENFloxΔ/Δ mice to knockout PTEN (PTEN-KO) in a severe thoracic SCI crush model at both acute and chronic time points. PTEN-KO improved locomotor abilities in both acute and chronic SCI conditions over a 9-week period. Regardless of whether treatment was initiated at the time of injury (acute), or three months after SCI (chronic), mice with limited hindlimb joint movement gained hindlimb weight support after treatment. Interestingly, functional improvements were not sustained beyond 9 weeks coincident with a loss of RFP reporter-gene expression and a near-complete loss of treatment-associated functional recovery by 6 months post-treatment. Treatment effects were also specific to severely injured mice; animals with weight support at the time of treatment lost function over a 6-month period. Retrograde tracing with Fluorogold revealed viable neurons throughout the motor cortex despite a loss of RFP expression at 9 weeks post-PTEN-KO. However, few Fluorogold labeled neurons were detected within the motor cortex at 6 months post-treatment. BDA labeling from the motor cortex revealed a dense corticospinal tract (CST) bundle in all groups except chronically treated PTEN-KO mice, indicating a potential long-term toxic effect of PTEN-KO to neurons in the motor cortex which was corroborated by a loss of ß-tubulin III labeling above the lesion within spinal cords after PTEN-KO. PTEN-KO mice had significantly more ß-tubulin III labeled axons within the lesion when treatment was delivered acutely, but not chronically post-SCI. In conclusion, we have found that using AAVrg's to knockout PTEN is an effective manipulation capable of restoring motor functions in chronic SCI and can enhance axon growth of currently unidentified axon populations when delivered acutely after injury. However, the long-term consequences of PTEN-KO on neuronal health and viability should be further explored.

Improved 1-year outcomes after active cooling during left atrial radiofrequency ablation.

BACKGROUND: Active esophageal cooling during pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF) is increasingly being utilized to reduce esophageal injury and atrioesophageal fistula formation. Randomized controlled data also show trends towards increased freedom from AF when using active cooling. This study aimed to compare 1-year arrhythmia recurrence rates between patients treated with luminal esophageal temperature (LET) monitoring versus active esophageal cooling during left atrial ablation. METHOD: Data from two healthcare systems (including 3 hospitals and 4 electrophysiologists) were reviewed for patient rhythm status at 1-year follow-up after receiving PVI for the treatment of AF. Results were compared between patients receiving active esophageal cooling (ensoETM, Attune Medical, Chicago, IL) and those treated with traditional LET monitoring using Kaplan-Meier estimates. RESULTS: A total of 513 patients were reviewed; 253 received LET monitoring using either single or multi-sensor temperature probes; and 260 received active cooling. The mean age was 66.8 (SD ± 10) years, and 36.8% were female. Arrhythmias were 60.1% paroxysmal AF, 34.3% persistent AF, and 5.6% long-standing persistent AF, with no significant difference between groups. At 1-year follow-up, KM estimates for freedom from AF were 58.2% for LET-monitored patients and 72.2% for actively cooled patients, for an absolute increase in freedom from AF of 14% with active esophageal cooling (p = .03). Adjustment for the confounders of patient age, gender, type of AF, and operator with an inverse probability of treatment weighted Cox proportional hazards model yielded a hazard ratio of 0.6 for the effect of cooling on AF recurrence (p = 0.045). CONCLUSIONS: In this first study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, a clinically and statistically significant improvement in freedom from atrial arrhythmia at 1 year was found in patients treated with active esophageal cooling when compared to patients who received LET monitoring. More rigorous prospective studies or randomized studies are required to validate the findings of the current study.

Improved hospital discharge and cost savings with esophageal cooling during left atrial ablation.

BACKGROUND: Left atrial ablation to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is a technologically intensive procedure utilizing innovative and continually improving technology. Changes in the technology utilized for PVI can in turn lead to changes in procedure costs. Because of the proximity of the esophagus to the posterior wall of the left atrium, various technologies have been utilized to protect against thermal injury during ablation. The impact on hospital costs during PVI ablation from utilization of different technologies for esophageal protection during ablation has not previously been evaluated. OBJECTIVE: To compare the costs of active esophageal cooling to luminal esophageal temperature (LET) monitoring during left atrial ablation. METHODS: We performed a time-driven activity-based costing (TDABC) analysis to determine costs for PVI procedures. Published data and literature review were utilized to determine differences in procedure time and same-day discharge rates using different esophageal protection technologies and to determine the cost impacts of same-day discharge versus overnight hospitalization after PVI procedures. The total costs were then compared between cases using active esophageal cooling to those using LET monitoring. RESULTS: The effect of implementing active esophageal cooling was associated with up to a 24.7% reduction in mean total procedure time, and an 18% increase in same-day discharge rate. TDABC analysis identified a $681 reduction in procedure costs associated with the use of active esophageal cooling after including the cost of the esophageal cooling device. Factoring in the 18% increase in same-day discharge resulted in an increased cost savings of $2,135 per procedure. CONCLUSIONS: The use of active esophageal cooling is associated with significant cost-savings when compared to traditional LET monitoring, even after accounting for the additional cost of the cooling device. These savings originate from a per-patient procedural time savings and a per-population improvement in same-day discharge rate.

An Esophageal Cooling Device During Radiofrequency Ablation for Atrial Fibrillation-A Comparison Between Reactive and Proactive Esophageal Cooling.

Esophageal thermal injury is one of the most feared risks of ablation of the posterior left atrium despite the various devices used to monitor esophageal temperature or deviate the esophagus. Reactive cooling, in which cold water is manually instilled into the esophagus via an orogastric tube in response to rises in luminal esophageal temperature (LET), has been used by operators, but the availability of a dedicated esophageal cooling device offers the ability to provide proactive esophageal cooling without having to react to individual temperature rises in the esophagus. The objective of this study was to evaluate the feasibility of using a commercially available esophageal cooling device to provide esophageal protection during left atrial catheter ablation, then to compare this approach to standard LET monitoring with reactive cooling via manual cold-water instillation. In this study, we randomized 6 patients undergoing catheter ablation for atrial fibrillation. Three patients received the standard of care for our site (use of a single-sensor temperature probe, with adjunct ice-water instillation for any temperature increases of >1°C). Three patients underwent standard ablation after placement of the esophageal cooling device at a circulating water temperature of 4°C, without the use of any esophageal temperature monitoring. All patients underwent transesophageal echocardiography and esophagogastroduodenoscopy on the day prior to the ablation, followed by a second esophagogastroduodenoscopy the day after. The 6 patients in this study were enrolled between March and August 2018. In the 3 control patients, 1 had no evidence of esophageal mucosal damage, 1 had diffuse sloughing of the esophageal mucosa and multiple ulcerations, and 1 had a superficial ulcer with a large clot. Both patients with lesions were classified as 2a cases using the Zargar grading scheme for caustic injury. In the 3 patients treated with the cooling device, 1 had no evidence of esophageal mucosal damage, 1 had esophageal erythema (Zargar grade 1), and 1 had a solitary Zargar grade 2a lesion. At 3 months of follow-up, 1 patient in each group had recurrence of atrial fibrillation. Although a number of subsequent studies have confirmed the reduction of esophageal injury with the use of proactive esophageal cooling, this study is the only one to date to compare reactive cooling (via manual cold-water instillation) and proactive cooling (via a dedicated esophageal cooling device). Moreover, this is the first study to support the feasibility of using a dedicated cooling device for this purpose and provides the basis for further investigation.

Does Distraction Lower Risk of VPI Compared to Conventional Maxillary Advancement? A Retrospective Cohort Study of Adolescents with Cleft Palate.

OBJECTIVE: To determine whether method of maxillary advancement in adolescents with cleft palate with or without cleft lip (CP ± L) influences post-operative velopharyngeal function. DESIGN: Retrospective cohort. SETTING: Pediatric Tertiary Care Hospital. PARTICIPANTS: One hundred and ninety-nine patients with CP ± L after LeFort I osteotomy for maxillary advancement at our institution between January 2007 and June 2019. INTERVENTIONS: LeFort I osteotomy via distraction osteogenesis (DO) or conventional osteotomy (CO). MAIN OUTCOME MEASURES: Patients who underwent DO or CO were compared for the presence of new velopharyngeal insufficiency (VPI), as measured by perceptual rating by a craniofacial speech-language pathologist.Of the 199 patients who underwent maxillary advancement, 126 were available for analysis. The DO group was younger, male, and had more severe maxillary hypoplasia. Following surgery, 17/41 (41.5%) of the DO group had new VPI, compared to just 23/85 (27.1%) of the CO group. After adjusting for cleft type and predicted maxillary advancement, however, there was not sufficient evidence to reject the null hypothesis of no difference in risk of post-operative VPI between the two surgical groups (prevalence ratio [PR] 1.40, 95% CI 0.68-2.90). Increased prevalence of VPI after DO versus CO was primarily observed among patients with a pre-operative velopharyngeal need ratio < 0.8 (PR = 2.01, 95% CI 0.79-5.10) and patients with normal velopharyngeal function pre-operatively (PR = 2.86, 95% CI 0.96-8.50).Our results suggest an increased rather than decreased risk of VPI following DO relative to CO. This association is primarily seen among those with a smaller velopharyngeal ratio or perceptually normal velopharyngeal function pre-operatively.

Active esophageal cooling during radiofrequency ablation of the left atrium: data review and update.

INTRODUCTION: Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the esophagus can occur during this procedure, potentially creating an atrioesophageal fistula (AEF) which is 80% fatal. The ensoETM (Attune Medical, Chicago, IL), is an esophageal cooling device that has been shown to reduce thermal injury to the esophagus during RF ablation. AREAS COVERED: This review summarizes growing evidence related to active esophageal cooling during RF ablation for the treatment of AF. The review presents data demonstrating improved outcomes related to patient safety and procedural efficiency and suggests directions for future research. EXPERT OPINION: The use of active esophageal cooling during RF ablation reduces esophageal injury, reduces or eliminates fluoroscopy requirements, reduces procedure duration and post-operative pain, and increases long-term freedom from arrhythmia. These effects in turn increase patient same-day discharge rates, decrease operator cognitive load, and reduce cost. These findings are likely to further accelerate the adoption of active esophageal cooling.

Atrial fibrillation is a condition in which the heart beats irregularly, causing symptoms such as palpitations, dizziness, shortness of breath, and chest pain. Atrial fibrillation increases the risk of stroke, heart failure, dementia, and death. One treatment for atrial fibrillation is a procedure called a catheter ablation. This procedure is minimally invasive and is performed by a specialized cardiologist, called an electrophysiologist. The electrophysiologist, or operator, uses an energy source, such as radiofrequency energy (radio waves), to stop erratic electrical signals from traveling through the heart. One complication of the catheter ablation is an inadvertent injury to the esophagus, the organ that passes food from the mouth to the stomach. If the injury is severe, it may develop into an atrioesophageal fistula, which often results in death. In this review, a new technology is described that helps prevent this type of injury and can provide additional benefits for the patient, operator, and hospital.

Targeted Temperature Management Using Esophageal Cooling.

Although specific temperature targets are debated, targeted temperature management (TTM) is a common treatment for postcardiac arrest patients. However, consistently implementing a TTM protocol is challenging, especially in a community hospital. Often, the protocols described in the literature include labor- and cost-intensive methods that are not feasible or sustainable in many health care settings. Esophageal temperature management (ETM) is a TTM method that can be easily utilized alone or combined with surface methods. We sought to evaluate ETM in a cohort of patients treated with TTM after cardiac arrest. Chart reviews were conducted of all patients treated with ETM after cardiac arrest at our community medical center. Initial patient temperature, time to target, supplemental methods (water blankets, chest wraps, or head wraps), and patient survival were extracted for analysis. A total of 54 patients were treated from August 2016 to November 2018; 30 received ETM only, 22 received supplemental cooling, and 2 had treatment discontinued before reaching target due to recovery. Target temperatures ranged from 32°C to 36°C, depending on provider preference. The median time to target temperature for the entire cohort was 219 minutes (interquartile range [IQR] 81-415). For the cohorts without, and with, supplemental cooling modalities, the median time to attain target temperature was 128 minutes (IQR 71-334), and 285 minutes (IQR 204-660), respectively. Survival to intensive care unit discharge was 51.9% for the entire cohort. Survivors exhibited longer times to achieve goal temperature (median 180 minutes in nonsurvivors vs. 255 minutes in survivors). ETM attains target temperature at a rate consistent with current guidelines and with similar performance to alternative modalities. As in other studies, surviving patients required longer times to reach target temperature.

Novel and existing flexible survival methods for network meta-analyses.

Aim: Technical Support Document 21 discusses trial-based, flexible relative survival models. The authors generalized flexible relative survival models to the network meta-analysis (NMA) setting while accounting for different treatment-effect specifications. Methods: The authors compared the standard parametric model with mixture, mixture cure and nonmixture cure, piecewise, splines and fractional polynomial models. The optimal treatment-effect parametrization was defined in two steps. First, all models were run with treatment effects on all parameters and subsequently the optimal model was defined by removing uncertain treatment effects, for which the parameter was smaller than its standard deviation. The authors used a network in previously treated advanced non-small-cell lung cancer. Results: Flexible model-based NMAs impact fit and incremental mean survival and they increase corresponding uncertainty. Treatment-effect specification impacts incremental survival, reduces uncertainty and improves the fit statistic. Conclusion: Extrapolation techniques already available for individual trials can now be used for NMAs to ensure that the most plausible extrapolations are being used for health technology assessment submissions.

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation.

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the esophagus from inadvertent thermal injury. Active esophageal cooling is increasingly being used over traditional luminal esophageal temperature (LET) monitoring, and each approach may influence procedure times and the variability around those times. The objective of this study is to measure the effects on procedure time and variability in procedure time of two different esophageal protection strategies utilizing advanced informatics techniques to facilitate data extraction. Trained clinical informaticists first performed a contextual inquiry in the catheterization laboratory to determine laboratory workflows and observe the documentation of procedural data within the electronic health record (EHR). These EHR data structures were then identified in the electronic health record reporting database, facilitating data extraction from the EHR. A manual chart review using a REDCap database created for the study was then performed to identify additional data elements, including the type of esophageal protection used. Procedure duration was then compared using summary statistics and standard measures of dispersion. A total of 164 patients underwent radiofrequency PVI over the study timeframe; 63 patients (38%) were treated with LET monitoring, and 101 patients (62%) were treated with active esophageal cooling. The mean procedure time was 176 min (SD of 52 min) in the LET monitoring group compared to 156 min (SD of 40 min) in the esophageal cooling group (P = 0.012). Thus, active esophageal cooling during PVI is associated with reduced procedure time and reduced variation in procedure time when compared to traditional LET monitoring.

Neuromuscular electrical stimulation to augment lower limb exercise and mobility in individuals with spastic cerebral palsy: A scoping review.

Background: Neuromuscular Electrical Stimulation (NMES) is an emerging assistive technology applied through surface or implanted electrodes to augment skeletal muscle contraction. NMES has the potential to improve function while reducing the neuromuscular impairments of spastic cerebral palsy (CP). This scoping review examines the application of NMES to augment lower extremity exercises for individuals with spastic CP and reports the effects of NMES on neuromuscular impairments and function in spastic CP, to provide a foundation of knowledge to guide research and development of more effective treatment. Methods: A literature review of Scopus, Medline, Embase, and CINAHL databases were searched from 2001 to 2 November 2021 with identified inclusion and exclusion criteria. Results: Out of 168 publications identified, 33 articles were included. Articles on three NMES applications were identified, including NMES-assisted strengthening, NMES-assisted gait, and NMES for spasticity reduction. NMES-assisted strengthening included the use of therapeutic exercises and cycling. NMES-assisted gait included the use of NMES to improve gait patterns. NMES-spasticity reduction included the use of transcutaneous electrical stimulation or NMES to decrease tone. Thirteen studies investigated NMES-assisted strengthening, eleven investigated therapeutic exercise and demonstrated significant improvements in muscle structure, strength, gross motor skills, walking speed, and functional mobility; three studies investigated NMES-assisted cycling and demonstrated improved gross motor skills and walking distance or speed. Eleven studies investigated NMES-assisted gait and demonstrated improved muscle structure, strength, selective motor control, gross motor skills, and gait mechanics. Seven studies investigated NMES for spasticity reduction, and five of the seven studies demonstrated reduced spasticity. Conclusion: A growing body of evidence supports the use of NMES-assisted strengthening, NMES-assisted gait, and NMES for spasticity reduction to improve functional mobility for individuals with spastic CP. Evidence for NMES to augment exercise in individuals with spastic CP remains limited. NMES protocols and parameters require further clarity to translate knowledge to clinicians. Future research should be completed to provide richer evidence to transition to more robust clinical practice.

Procedural time reduction associated with active esophageal cooling during pulmonary vein isolation.

BACKGROUND: Active esophageal cooling is increasingly utilized as an alternative to luminal esophageal temperature (LET) monitoring for protection against thermal injury during pulmonary vein isolation (PVI) when treating atrial fibrillation (AF). Published data demonstrate the efficacy of active cooling in reducing thermal injury, but impacts on procedural efficiency are not as well characterized. LET monitoring compels pauses in ablation due to heat stacking and temperature overheating alarms that in turn delay progress of the PVI procedure, whereas active esophageal cooling allows avoidance of this phenomenon. Our objective was to measure the change in PVI procedure duration after implementation of active esophageal cooling as a protective measure against esophageal injury. METHODS: We performed a retrospective review under IRB approval of patients with AF undergoing PVI between January 2018 and February 2020. For each patient, we recorded age, gender, and total procedure time. We then compared procedure times before and after the implementation of active esophageal cooling as a replacement for LET monitoring. RESULTS: A total of 373 patients received PVI over the study period. LET monitoring using a multi-sensor probe was performed in 198 patients, and active esophageal cooling using a dedicated device was performed in 175 patients. Patient characteristics did not significantly differ between groups (mean age of 67 years, and gender 37.4% female). Mean procedure time was 146 ± 51 min in the LET-monitored patients, and 110 ± 39 min in the actively cooled patients, representing a reduction of 36 min, or 24.7% of total procedure time (p < .001). Median procedure time was 141 [IQR 104 to 174] min in the LET-monitored patients and 100 [IQR 84 to 122] min in the actively cooled patients, for a reduction of 41 min, or 29.1% of total procedure time (p < .001). CONCLUSIONS: Implementation of active esophageal cooling for protection against esophageal injury during PVI was associated with a significantly large reduction in procedure duration.