Effectiveness of combined plasma cell therapy and costimulation blockade based desensitization regimen in heart transplant candidates.

BACKGROUND: Desensitization is one of the strategies to reduce antibodies and facilitate heart transplantation in highly sensitized patients. We describe our center's desensitization experience with combination of plasma cell (PC) depletion therapy (with proteasome inhibitor or daratumumab) and costimulation blockade (with belatacept). METHODS: We reviewed five highly sensitized patients who underwent desensitization therapy with plasma cell depletion and costimulation blockade. We evaluated the response to therapy by measuring the changes in cPRA, average MFI, and number of positive beads > 5000MFI. RESULTS: Five patients, mean age of 56 (37-66) years with average cPRA of 98% at 5000 MFI underwent desensitization therapy. After desensitization, mean cPRA decreased from 98% to 70% (p = .09), average number of beads > 5000 MFI decreased from 59 to 37 (p = .15), and average MFI of beads > 5000 MFI decreased from 16713 to 13074 (p = .26). CONCLUSION: Combined PC depletion and CoB could be a reasonable strategy for sustained reduction in antibodies in highly sensitized patients being listed for heart transplantation.

Prevalence and associated factors of cerebral microbleeds in a rural population of the United States.

OBJECTIVE: Cerebral microbleeds (CMBs) can carry an advanced risk for the development and burden of cerebrovascular and cognitive disorders. Large-scale population-based studies are required to identify the at-risk population. METHOD: Ten percent (N = 3,056) of the Geisinger DiscovEHR Initiative Cohort participants who had brain magnetic resonance imaging (MRI) for any indication were randomly selected. Patients with CMBs were compared to an age-, gender-, body mass index-, and hypertension-matched cohort of patients without CMB. The prevalence of comorbidities and use of anticoagulation therapy was investigated in association with CMB presence (binary logistic regression), quantity (ordinal regression), and topography (multinomial regression). RESULTS: Among 3,056 selected participants, 477 (15.6 %) had CMBs in their MRI. Patients with CMBs were older and were more prevalently hypertensive, with ischemic stroke, arrhythmia, dyslipidemia, coronary artery disease, and the use of warfarin. After propensity-score matching, 477 patients with CMBs and 974 without were included for further analyses. Predictors of ≥5 CMBs were ischemic stroke (OR, 1.6; 95 % CI, 1.2 -2.0), peripheral vascular disease (OR, 1.6; 95 % CI, 1.1-2.3), and thrombocytopenia (OR, 1.9; 95 % CI, 1.2-2.9). Ischemic stroke was associated with strictly lobar CMBs more strongly than deep/infra-tentorial CMBs (OR, 2.1; 95 % CI, 1.5-3.1; vs. OR, 1.4; CI, 1.1-1.8). CONCLUSIONS: CMBs were prevalent in our white population. Old age, hypertension, anticoagulant treatment, thrombocytopenia, and a history of vascular diseases including stroke, were associated with CMBs.

Fast-Track Long Term Continuous Heart Monitoring in a Stroke Clinic: A Feasibility Study.

Background: Paroxysmal atrial fibrillation (PAF) or flutter is prevalent among patients with cryptogenic stroke. The goal of this study was to investigate the feasibility of incorporating a fast-track, long term continuous heart monitoring (LTCM) program within a stroke clinic. Method: We designed and implemented a fast-track LTCM program in our stroke clinics. The instrument that we used for the study was the ZioXT® device from IRhythm™ Technologies. To implement the program, all clinic support staff received training on the skin preparation and proper placement of the device. We prospectively followed every patient who had a request from one of our inpatient or outpatient stroke or neurology providers to receive LTCM. We recorded patients' demographics, the LTCM indication, as well as related quality measures including same-visit placement, wearing time, analyzable time, LTCM application to the preliminary finding time, as well as patients' out of pocket cost. Results: Out of 501 patients included in the study, 467 (93.2%) patients (mean age 65.9 ± 13; men: 48%) received LTCM; and 92.5% of the patients had the diagnosis of stroke or TIA. 93.7% of patients received their LTCM during the same outpatient visit in the stroke clinic. The mean wearing time for LTCM was 12.1 days (out of 14 days). The average analyzable time among our patients was 95.0%. Eighteen (3.9%, 95%CI: 2.4-6.0) patients had at least one episode of PAF that was sustained for more than 30 s. The rate of PAF was 5.9% (95% CI: 3.5-9.2) among patients with the diagnosis of stroke. Out of 467 patients, 392 (84%) had an out-of-pocket cost of < $100. Conclusion: It is feasible to implement a fast-track cardiac monitoring as part of a stroke clinic with proper training of stroke providers, clinic staff, and support from a cardiology team.