Acute Structural Failure of the Trifecta Aortic Valve Bioprosthesis.

Advancements in bioprosthetic valve technology have greatly enhanced the haemodynamic performance and long-term durability of tissue valves. These features, along with the key advantage of avoiding lifelong anticoagulation, have made bioprosthetic valves increasingly attractive for clinicians and patients alike. The St Jude Trifecta valve is a novel, bovine pericardial bioprosthesis with promising early data for performance and safety. However, no prosthetic valve is perfect and prosthesis failure can occur with even the most reliable and well-designed devices. We report a case of early and acute structural deterioration (stent-post leaflet rupture) of the Trifecta valve, explanted after 33 months, in a 76-year-old male.

Mild Traumatic Brain Injury Is Associated With Increased Dual-Task Cost During Ambulation: A Preliminary Study.

OBJECTIVE: The aim of the study was to determine the impact of dual-task conditions on mobility after mild traumatic brain injury. DESIGN: Eleven adults with mild traumatic brain injury within 1 wk of injury and 10 age- and sex-matched healthy controls completed gait trials with a single-task condition and three separate dual-task conditions: counting by 1 (low), serial subtraction by 3 (medium), and alternating letters and numbers (high). Dual-task cost was calculated as dual-task cost = ([dual-task performance] - [single-task performance]) / [single-task performance] × 100%. RESULTS: Participants with mild traumatic brain injury ambulated slower than control subjects (P < 0.001). Significant differences in dual-task cost were noted for both group (P < 0.001) and dual-task condition (P = 0.005). Dual-task cost was greater for those with mild traumatic brain injury compared with controls with significant group differences for the low and high cognitive loads (P < 0.05). Only 1 of the 11 individuals with mild traumatic brain injury and 1 of the 10 controls demonstrated gait speed less than 80 cm/sec, which is predictive of community mobility, during any dual-task condition. Dual-task cost exceeded 11.9%, previously determined to be the minimal detectable change in healthy adults, for 9 of the 11 individuals with mild traumatic brain injury compared with 3 of the 10 controls. CONCLUSIONS: Dual-task cost may be a more sensitive measure for impairment during dual-task conditions than gait speed after mild traumatic brain injury.

Remote ischemic preconditioning stimulus decreases the expression of kinin receptors in human neutrophils.

BACKGROUND: Remote ischemic preconditioning (RIPC) has been shown to reduce ischemic-reperfusion injury and is induced by brief forearm ischemia. Kinins are known to be involved in RIPC and act via the G protein coupled B1 and B2 receptors. Interaction of the kinins with their respective receptors causes receptor internalization, thereby reducing the potential for further activation. This may be critical for the protective effect of RIPC and if so, we hypothesized, would significantly decrease the expression of kinin receptors on the surface of neutrophils. METHODS: The study was performed on five healthy human volunteers. The left forearm was rendered ischemic for three 5-min periods, each separated by 5 min of reperfusion. Three venous blood samples were taken from the right arm, one before and two after RIPC. Neutrophil isolation, immunofluorescence labeling, and confocal microscopy were performed. Mean pixel intensity data were generated using a fixed circular area of interest (AOI, 40×40 µm). For every image, the AOI was placed over a cell and the mean pixel intensity was recorded. The mean intensity was expressed as pixel×10(2)/µm(2) and presented as mean±SEM. Immunofluorescence at the different time points was compared by one way analysis of variance with Bonferroni's post-hoc test. A P value<0.05 was considered significant. RESULTS: The mean pixel intensity for kinin B1 receptors was decreased at 24 h after RIPC compared with both baseline and 15 min after RIPC (P<0.001). Similarly, the intensity for B2 receptor labeling on neutrophils was significantly decreased 24 h after RIPC compared with the baseline value (P<0.001). CONCLUSIONS: RIPC decreases expression of kinin receptors on circulating human neutrophils. Reduction in kinin surface receptors suggests internalization of receptors and is consistent with the concepts of kinin receptor activation and their role in RIPC.

Remote ischemic conditioning: evolution of the concept, mechanisms, and clinical application.

Remote ischemic conditioning is a novel concept of protection against ischemia-reperfusion injury. Brief controlled episodes of intermittent ischemia of the arm or leg may confer a powerful systemic protection against prolonged ischemia in a distant organ. This conditioning phenomenon is clinically applicable and can be performed before--preconditioning, during--perconditioning, or after--postconditioning prolonged distant organ ischemia. The remote ischemic conditioning may have an immense impact on clinical practice in the near future.

High-Intensity Interval Cycle Ergometer Training in Parkinson's Disease: Protocol for Identifying Individual Response Patterns Using a Single-Subject Research Design.

Background: People with Parkinson's disease (PD) experience not only motor problems but also non-motor problems that seriously impede their daily functioning and quality of life. The current pharmacologic treatment of PD is symptomatic, and alternative rehabilitation treatments, which preferably also have a disease-modifying effect and promote neuroplasticity, are needed. Recent studies suggest that high-intensity interval training (HIIT) is promising for promoting neuroplasticity in human PD, with short training time and reduced burden. Biomarkers for neuroplasticity such as brain-derived neurotrophic factor (BDNF) and neurodegeneration (including neurofilament NfL and α-synuclein) may play a role, but their response to HIIT is not well-investigated. Objectives: The aims of this study were (1) to study the effects of 4 weeks of HIIT compared with 4 weeks of continuous aerobic exercise on motor and non-motor outcomes of PD and (2) to investigate the association between HIIT, motor/non-motor performances changes, and blood biomarker levels for neuroplasticity and neurodegeneration. Study Design: Single-subject research design with alternating treatment setup (ABACA) and frequent repeated measurements was used. Each participant received different intervention conditions (B/C) interspersed with baseline periods (A, i.e., ABACA or ACABA), and frequent repeated assessment of outcome measures is done to quantify within-subject, individual response patterns with sufficient power for data analysis. Blood samples were collected once a week in the baseline and training phases (A1 and B/C) and once every 2 weeks in the washout phases (A2 and A3). Intervention: Four subjects with PD on stable dopaminergic medication, two in Hoehn-Yahr stage 1-2, and two in Hoehn-Yahr stage 2.5-3 followed an ABACA or ACABA schedule, consisting of blocks with 30-min sessions of "B" (HIIT) or 50-min sessions of "C" [continuous aerobic exercise (CAE)] 3×/week for 4 weeks, separated by baseline "A" periods of 8 weeks for a total duration of 28 weeks. Outcome Measures: Outcome measures include disease status [Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS)], blood biomarkers (BDNF, Nfl, and α-synuclein), measures for functional mobility (including an activity tracker), and activities of daily living, as well as cognition, mood, biorhythm (sleeping problems), and quality of life. Data Analysis: Visual analysis of trends in level, slope, and variability in response patterns was carried out, confirmed by longitudinal regression analysis with phase (ABACA) as the independent variable.

Use of an instrumented dual-task timed up and go test in children with traumatic brain injury.

BACKGROUND: Wearable sensors have allowed researchers to instrument tests of gait-related mobility, including the widely used timed 'up-and-go' test (TUG). Currently, there is a lack of instrumented test data on whether children with moderate to severe traumatic brain injury (TBI) perform differently on the TUG compared to typically developed (TD) controls during a cognitive-motor task. RESEARCH QUESTION: The aim was to explore the effects of a cognitive-motor task on TUG subcomponents among children with TBI compared to TD children. METHODS: This observational cross-sectional study included 12 children with moderate to severe TBI (6 males and 6 females, age 10.5 ±â€¯1.5 years of age) and 10 age and sex-matched TD controls (5 males and 5 females, 10.4 ±â€¯1.3 years of age). Each participant completed 6 trials of the TUG wearing a single inertial measurement unit sensor at a self-selected walking pace while listening to an array of 10 randomly presented single digits during each TUG trial. RESULTS: Total time to complete the TUG was not significantly different between groups. The cognitive-motor task led to significantly lower mean turn and peak turn angular velocity values during the turn-around-the-cone and turn-before-sitting TUG subcomponents in children with TBI compared to the TD controls (p ≤ 0.05). Additionally, the cognitive-motor task led to significantly lower values for maximum torso flexion to extension angle, peak flexion and extension angular velocity and peak vertical acceleration for the sit-to-stand subcomponent (p < 0.05). Peak flexion angular velocity during the stand-to-sit subcomponent was lower for the TBI group compared to the children with TD (p < 0.05). SIGNIFICANCE: The study provides new insights into the performance of complex gait-related mobility tasks in the context of an instrumented TUG among children with moderate to severe TBI. Our results highlight the potential benefits of outfitting pediatric inpatients with an IMU while completing the TUG.

Outcomes of video-assisted thoracoscopic surgery lobectomy in septuagenarians.

BACKGROUND: Spread of technology and increased surveillance have led to more patients with lung cancers being identified than ever before. Increasingly, patients from the elderly population are referred for surgery; however, many studies do not focus on this patient group. We reviewed the outcomes of septuagenarians who underwent lobectomy via an open thoracotomy (OT) or video-assisted thoracoscopic surgery (VATS) approach to determine whether the VATS approach would result in superior post-operative outcomes. METHODS: Between January 2010 and June 2016, a total of 96 patients aged 70 years or older underwent a lobectomy for non-small cell lung carcinoma. Patients who underwent resection for metastatic disease, small cell lung cancer or neuroendocrine tumour were excluded. Demographic details, early and late post-operative outcomes including post-operative arrhythmia, myocardial infarction, respiratory failure, cerebrovascular events, infection, prolonged air leak, delirium, readmission and 30-day mortality were studied. Mean follow-up duration was 23 ± 19.1 months. RESULTS: Seventy-five patients underwent lobectomy via a VATS approach and 21 patients underwent lobectomy via an OT approach. There was no 30-day mortality and no difference in overall survival between the two techniques (P = 0.25). There was no significant difference between the two techniques with regard to post-operative stroke, myocardial infarction, atrial fibrillation, pneumonia, delirium or bronchopleural fistula. VATS patients had a significantly shorter mean hospital length of stay (VATS 4.7 days, OT 9.3 days, P = 0.005). CONCLUSION: Septuagenarians with non-small cell lung carcinoma can successfully undergo curative lung resection with a low incidence of post-operative complications.

Moderate exposure to allogeneic blood products is not associated with reduced long-term survival after surgery for coronary artery disease.

BACKGROUND: It has been suggested that blood transfusion has an adverse effect on long-term health, mainly through immune modulation and tumor promotion. To further assess this concern, the authors have performed a prospective observational study with the hypothesis that after taking perioperative risk factors relevant to long-term survival into account, patients undergoing coronary artery surgery who receive a perioperative allogeneic blood transfusion have worse long-term survival than those who do not. METHODS: The health outcomes of 1,841 consecutive subjects who had isolated nonemergency first-time coronary artery surgery and who survived more than 60 days after surgery were determined by record linkage. The association between length of survival, blood products transfused, and risk factors for long-term survival at entry to the study were determined by Cox proportional hazards regression. RESULTS: A total of 1,062 subjects were transfused. Of these, 266 subjects died during a mean follow-up of 8.1 yr. Of subjects who were transfused, 27% had a new malignant condition recorded on the death certificate, compared with 43% who were not transfused. Older age, cerebrovascular disease, use of a mammary graft, chronic pulmonary disease, renal dysfunction, reduced left ventricular function, and preoperative anemia were predictive of reduced long-term survival. There was no association between transfusion of blood products and long-term survival. CONCLUSIONS: Patients who have undergone coronary artery surgery and who have received moderate amounts of blood as part of responsible and conservative management should be reassured that they are unlikely to experience a reduction in long-term survival.

Mitral valve leaflet abscess complicating infective endocarditis.

Infective endocarditis is a life threatening condition with high morbidity and mortality. We present a case report of a young female who had a rare complication of infective endocarditis in the form of mitral valve leaflet abscess. Patient underwent successful surgical treatment with valve replacement.

Value of multislice CT scan in redo cardiac surgery with previous Lita graft.

Redo cardiac surgery is commonly performed in the current era. We describe a clinical scenario in a patient with a patent left internal thoracic artery to left anterior descending artery graft, requiring replacement of ascending aortic aneurysm with previous coronary artery bypass operation complicated by mediastinitis. A pre-operative 64 slice computed tomographic scan helped us plan and perform replacement of ascending aorta safely.

"Gumnut" device for off-pump proximal aortocoronary anastomosis.

Use of side-biting clamps in patients with coronary artery disease and atheromatous disease of ascending aorta, undergoing coronary artery surgery can lead to major postoperative neurological events. We describe the use of a simple device to avoid use of side-biting clamp on aorta for proximal aortocoronary anastomosis.

Palliative surgical management of iatrogenic oesophageal perforation in the setting of malignant disease.

Iatrogenic oesophageal injury is a common cause of oesophageal perforation. This complication carries a poor prognosis in the setting of malignancy of oesophagus. We discuss the role of stents in the management of a case in this clinical scenario.

Spontaneous subscapular abscess: a rare surgical condition.

Subscapular abscess is a rare clinical problem. Herein we describe a young male patient who presented with a subscapular abscess and was managed successfully with surgical drainage and debridement of the cavity.

Papillary fibroelastoma of aortic valve: diagnosis and surgical management.

Papillary fibroelastoma (PFE) is a rare and benign cardiac tumour that mainly affects the valves. This tumour has the potential to cause serious life threatening thromboembolic complications. Herein, we describe successful excision of an aortic valve papillary fibroelastoma. The importance of valve sparing tumour resection is emphasised.

Large bronchogenic cyst: diagnosis and surgical management.

Herein we describe a patient with an unusually large bronchogenic cyst. The removal of the cyst was performed through a mini-thoracotomy and facilitated by video-assisted thoracic surgery (VATS).

Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age.

Physical activity and exercise are important adjuncts to medical treatment for overall health in individuals with traumatic brain injury (TBI); however, many individuals do not partake in the recommended weekly exercise. The objective of this study was to investigate the barriers to exercise after TBI and determine whether these barriers varied by age. The sample was 172 adults with moderate to severe TBI who completed Barriers to Physical Exercise and Disability (B-PED) survey. Lack of interest, motivation, and energy as well as cost, lack of counseling on exercise by a physician, not having home equipment, and being too lazy were reported as barriers to exercise by all age groups. Those aged 35 to 54-years-old were more likely to report that cost, lack of transportation, having health concerns, not knowing where to exercise, and fear of leaving the home as barriers to exercise than those aged 18 to 34-years-old or 55-years-old and older. Overall, adults with TBI report multiple barriers to exercise, and these barriers vary by age.

Exercise-induced increase in brain-derived neurotrophic factor in human Parkinson's disease: a systematic review and meta-analysis.

BACKGROUND: Animal models of exercise and Parkinson's disease (PD) have found that the physiologic use of exercise may interact with the neurodegenerative disease process, likely mediated by brain derived neurotrophic factor (BDNF). No reviews so far have assessed the methodologic quality of available intervention studies or have bundled the effect sizes of individual studies on exercise-induced effects on BDNF blood levels in human PD. RESEARCH DESIGN AND METHODS: We searched MEDLINE, EMBASE, Cochrane Library, PsycINFO and PubMed from inception to June 2017. RESULTS: Data aggregated from two randomized controlled trials and four pre-experimental studies with a total of 100 ambulatory patients with idiopathic PD (Hoehn/Yahr ≤3) found improvements in BDNF blood concentration levels in all 6 studies (two RCTs and 4 pre-experimental studies). Pooled BDNF level change scores from the 2 RCTs resulted in a significant homogeneous summary effect size (Standardized Mean Difference 2.06, 95% CI 1.36 to 2.76), and a significant heterogeneous SES for the motor part of the UPDRS-III examination (MD -5.53, 95% CI -10.42 to -0.64). Clinical improvements were noted in all studies using a variety of outcome measures. LIMITATIONS: The evidence-base consists primarily of small studies with low to moderate methodological quality. CONCLUSIONS: This review provides preliminary evidence for the effectiveness of physical exercise treatments for persons with PD on BDNF blood levels. Further research is needed.

Reliability of the sub-components of the instrumented timed up and go test in ambulatory children with traumatic brain injury and typically developed controls.

BACKGROUND: Studies have evaluated the test-re-test reliability of subcomponents of the timed up and-go test in adults by using body-worn inertial sensors. However, studies in children have not been reported in the literature. RESEARCH QUESTION: To evaluate the within-session reliability of subcomponents of a newly developed electronically augmented timed 'upand-go' test (EATUG) in ambulatory children with traumatic brain injury (TBI) and children with typical development (TD). METHOD: The timed up and go test was administered to twelve consecutive ambulatory children with moderate to severe TBI (6 males and 6 females, age 10.5 ±â€¯1.5 years, range 8-13 years, during inpatient rehabilitation at 27.0 ±â€¯11.8 days following injury) and 10 TD age and sex-matched children (5 males and 5 females, 10.4 ±â€¯1.3 years, range 8-11 years). Participants wore a single chest-mounted inertial measurement sensor package with custom software that measured angular and acceleration velocity and torso flexion and extension angles, while they performed 6 trials of the EATUG test. Measures were derived from the overall time to complete the TUG test, angular velocity and angular displacement data for torso flexion and extension during sit-to-stand and stand-to-sit segments and both mean and peak angular velocities for two turning segments (i.e. turning around a cone and turning-before-sitting). RESULTS: Within-session reliability of the subcomponents of the TUG test for children with TBI assessed by the intra-class correlation coefficient was ICC (1,1) = 0.84, (range 0.82-0.96), and for TD children ICC (1,1) = 0.73, (range 0.53-0.89). Scores on Total Time, maximum torso flexion/extension angle and peak flexion angular velocity during sit-tostand, and peak turn angular velocity for both turns around the cone and turns before sitting were lower for children with TBI than for TD children (p ≤ 0.05). SIGNIFICANCE: The EATUG test is a reliable measure of physical function in children with TBI who are being discharged from inpatient rehabilitation.

Acute massive pulmonary embolism with cardiopulmonary resuscitation: management and results.

Patients who experience hemodynamic collapse after acute massive pulmonary embolism have a poor prognosis. Herein, we report our results with 8 patients and discuss a surgical strategy that can improve perioperative survival. From August 1994 through May 2005, 8 consecutive patients (6 women, 2 men; age range, 27-68 yr) were urgently referred to our unit after experiencing hemodynamic collapse. All required cardiopulmonary resuscitation. Seven patients underwent pulmonary embolectomy. One patient was successfully treated with thrombolytic therapy alone under continuous monitoring by the surgical team. There were 2 intraoperative deaths (30-day mortality rate, 28.5%). One survivor required a right ventricular assist device. Follow-up of the patients ranged from 8 months to 8 years. One patient died 8 months after the pulmonary embolectomy from long-term complications of cerebral damage that had occurred during preoperative resuscitation. We conclude that prompt surgical management improves the early survival rates of patients who require cardiopulmonary resuscitation subsequent to massive pulmonary embolism.