Transcatheter heart valve failure: a systematic review.

AIMS: A comprehensive description of transcatheter heart valve (THV) failure has not been performed. We undertook a systematic review to investigate the aetiology, diagnosis, management, and outcomes of THV failure. METHODS AND RESULTS: The systematic review was performed in accordance with the PRISMA guidelines using EMBASE, MEDLINE, and Scopus. Between December 2002 and March 2014, 70 publications reported 87 individual cases of transcatheter aortic valve implantation (TAVI) failure. Similar to surgical bioprosthetic heart valve failure, we observed cases of prosthetic valve endocarditis (PVE) (n = 34), structural valve failure (n = 13), and THV thrombosis (n = 15). The microbiological profile of THV PVE was similar to surgical PVE, though one-quarter had satellite mitral valve endocarditis, and surgical intervention was required in 40% (75% survival). Structural valve failure occurred most frequently due to leaflet calcification and was predominantly treated by redo-THV (60%). Transcatheter heart valve thrombosis occurred at a mean 9 ± 7 months post-implantation and was successfully treated by prolonged anticoagulation in three-quarters of cases. Two novel causes of THV failure were identified: late THV embolization (n = 18); and THV compression (n = 7) following cardiopulmonary resuscitation (CPR). These failure modes have not been reported in the surgical literature. Potential risk factors for late THV embolization include low prosthesis implantation, THV undersizing/underexpansion, bicuspid, and non-calcified anatomy. Transcatheter heart valve embolization mandated surgery in 80% of patients. Transcatheter heart valve compression was noted at post-mortem in most cases. CONCLUSION: Transcatheter heart valves are susceptible to failure modes typical to those of surgical bioprostheses and unique to their specific design. Transcatheter heart valve compression and late embolization represent complications previously unreported in the surgical literature.

The Utility of Magnetic Resonance Imaging-based Vertebral Bone Quality Scores as a Predictor of Cage Subsidence Following Transforaminal and Posterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVES: The objectives were to determine whether vertebral bone quality (VBQ) scores are associated with interbody cage subsidence following transforaminal (TLIF) and posterior (PLIF) lumbar interbody fusions and whether there is a clinically sensitive threshold for subsidence. BACKGROUND: Interbody cage subsidence following lumbar fusion is a complication that can generate poor surgical outcomes. Prior research has correlated cage subsidence with bone mineral density. VBQ scores derived from magnetic resonance imaging (MRI) have been proposed as a tool for measuring bone mineral density, offering a potential new and convenient preoperative risk assessment tool for subsidence. METHODS: The study involved patients undergoing single-level PLIF or TLIF between 2007 and 2022. Exclusions were for nondegenerative diagnoses, multilevel/revision surgeries, inadequate radiographs, missing immediate postoperative radiographs, and preoperative MRI studies older than 1 year. VBQ was calculated at L1-L4 from preoperative T1-weighted MRI images. Subsidence was assessed by changes in disc height (DH; >2 mm difference) and segmental lordosis (SL; >5 degrees difference) between immediate weight-bearing postoperative and latest postoperative lateral radiographs. Statistical analysis included descriptive and inferential statistics. RESULTS: Subsidence was observed in 27% (SL parameter) and 47% (DH parameter) of 51 total patients. VBQ scores were significantly associated with cage subsidence based on both SL (odds ratio = 7.750, P = 0.012; correlation coefficient = 0.382, P = 0.006) and DH (odds ratio = 4.074, P = 0.026; correlation coefficient = 0.258, P = 0.057) in the combined TLIF/PLIF cohorts. In the cohort of 36 patients undergoing TLIF, a VBQ of 2.70 yielded 100.0% sensitivity and 46.2% specificity in detecting subsidence with SL measurement (area under the curve = 0.812, P < 0.001) and 86.7% sensitivity and 47.6% specificity with the DH measurement (area under the curve = 0.692, P = 0.033). CONCLUSIONS: We found that MRI-based VBQ scores are effective predictors of cage subsidence following TLIF surgery. A VBQ score of 2.70 demonstrated a reliable model and high sensitivity for doing so, identifying a potential clinical threshold for preoperative subsidence risk assessment. LEVEL OF EVIDENCE: Level III.

Gender and Racial Bias in Letters of Recommendation for Orthopedic Surgery Residency Positions.

OBJECTIVE: The primary purpose of this study was to retrospectively analyze letters of recommendation written for medical students applying to orthopedic residency for implicit race and gender bias. The secondary purpose was to determine if the presence of bias was influenced by the gender of the letter writer. DESIGN: This was a retrospective institutional review board (IRB) approved study. All letters of recommendation received in the years 2016 to 2018 were deidentified and analyzed using the Linguistics Inquiry and Word Count (LIWC) 2015 software. Independent variables in our analysis were applicant gender and applicant race. Dependent study variables included the summary and characteristic variables of a letter of recommendation, which are word count, analytic, clout, authenticity, tone, and positive and negative emotion word categories. Separate analyses were completed by gender of the letter writer as well. SETTING: Institution: Temple University Hospital, Philadelphia, Pennsylvania. PARTICIPANTS: Medical students applying to Temple University Hospital Orthopaedic Surgery Program from 2016 to 2018. A total of 2113 applicants were included in the study. RESULTS: Female, Asian and underrepresented minority applicants' letters were more likely to have a higher word count. In our subset analysis by gender of letter writer, when the letter writer was male, Asian applicants' letters were more likely to convey analytical thinking and authenticity. When the letter writer was male, male applicants scored higher for authenticity. Letters written by female attendings demonstrated no significant difference for male or female applicants in terms of composite variables or word categories. CONCLUSIONS: Our study shows that letters of recommendation for orthopedic surgery residency positions are likely to contain some degree of bias. Further studies are required to fully characterize the degree and magnitude of bias in letters of recommendation and whether the findings of our study are significant enough to contribute to the difference in socioeconomic demographics between orthopedic residents and society at large.

Evaluation of Mobile Health Applications to Track Patient-Reported Outcomes for Oncology Patients: A Systematic Review.

PURPOSE: In response to the COVID-19 pandemic, there has been a rapid growth in the use of telehealth/telemedicine that will likely be sustained in the postpandemic setting. Mobile health applications (apps) can be used as part of the telehealth encounter to monitor patient-reported outcomes (PROs) and enhance patient-provider communication. METHODS AND MATERIALS: A systematic review was performed of mobile health apps with symptom trackers. We searched the iOS App Store and Android Google Play using the words cancer, oncology, and symptom tracker. Apps were included if they incorporated a symptom tracking function that could allow patients with cancer to record symptoms and PROs. Apps were evaluated using the mobile apps rating scale, which includes engagement, functionality, aesthetics, information, and app subjective quality. RESULTS: The initial search yielded 1189 apps, with 101 apps eligible after title and description screening. A total of 41 apps met eligibility criteria and were included in this study. The majority of apps (73%, n = 30) were general health/pain symptom trackers, and 27% (n = 11) were cancer-specific. The app quality mean scores assessed using the mobile apps rating scale ranged from 2.43 to 4.23 (out of 5.00). Only 1 app has been trialed for usability among patients with cancer. CONCLUSIONS: Although various symptom tracking apps are available, cancer-specific apps remain limited. Future collaboration between oncologists, app developers, and patients to optimize PRO assessment and integration with telehealth/telemedicine encounters to increase symptom recognition and enhance patient-provider communication is urgently needed.

Takotsubo in Acute and Chronic Coronary Artery Disease.

Cardiomyopathy of Takotsubo syndrome (TS) is typically triggered by an emotional stress in postmenopausal women. Coexistent coronary artery disease presents diagnostic dilemmas in patients with TS, as seen in the 2 cases presented. In the first case, acute coronary syndrome acts as a physical trigger for TS when a middle-aged man presents with an inferior myocardial infarct, and in the second case, coronary artery disease is a bystander when an elderly woman develops TS after a fall and facial trauma. The novel teaching point is that acute non-left anterior descending acute coronary syndrome could trigger TS.

La cardiomyopathie du syndrome de Takotsubo (ST) est généralement déclenchée par un stress émotionnel chez les femmes en postménopause. Comme nous l'avons observé dans les 2 cas présentés, la coronaropathie coexistante pose des dilemmes en matière de diagnostic chez les patients atteints du ST. Dans le premier cas, le syndrome coronarien aigu agit comme un déclencheur physique du ST lorsqu'un homme d'un certain âge subit un infarctus de la région inférieure du myocarde, et dans le second cas, la coronaropathie constitue un « spectateur ¼ lorsqu'une femme âgée subit un ST après une chute et un traumatisme facial. La nouvelle leçon à retenir est que le syndrome coronarien aigu qui ne provient pas de l'artère interventriculaire antérieure pourrait déclencher le ST.

Revisiting the mechanisms of copper toxicity to rainbow trout: Time course, influence of calcium, unidirectional Na(+) fluxes, and branchial Na(+), K(+) ATPase and V-type H(+) ATPase activities.

In order to resolve uncertainties as to the mechanisms of toxic action of Cu and the protective effects of water [Ca], juvenile rainbow trout were acclimated to baseline soft water (SW, [Na(+)]=0.07, [Ca(2+)]=0.15, [Mg(2+)]=0.05mmolL(-1)) and then exposed to Cu with or without elevated [Ca] but at constant titratable alkalinity (0.27mmolL(-1)). The 96-h LC50 was 7-fold higher (63.8 versus 9.2µgCuL(-1); 1.00 versus 0.14µmolCuL(-1)) at [Ca]=3.0 versus 0.15mmolL(-1). Gill Cu burden increased with exposure concentration, and higher [Ca] attenuated this accumulation. At 24h, the gill Cu load (LA50≈0.58µgCug(-1); 9.13nmolCug(-1)) predictive of 50% mortality by 96h was independent of [Ca], in accord with Biotic Ligand Model (BLM) theory. Cu exposure induced net Na(+) losses (J(Na)net) by increasing unidirectional Na(+) efflux rates (J(Na)out) and inhibiting unidirectional Na(+) uptake rates (J(Na)in). The effect on J(Na)out was virtually immediate, whereas the effect on J(Na)in developed progressively over 24h and was associated with an inhibition of branchial Na(+), K(+) ATPase activity. The J(Na)in inhibition was eventually significant at a lower Cu threshold concentration (15µgCuL(-1)) than the J(Na)out stimulation (100µg Cu L(-1)). Elevated Ca protected against both effects, as well as against the inhibition of Na(+), K(+) ATPase activity. Branchial V-type H(+) ATPase activity was also inhibited by Cu exposure (100µgCuL(-1)), but only after 24h at high [Ca] (3.0mmolL(-1)). These novel results therefore reinforce the applicability of BLM theory to Cu, clarify that whether Na(+) influx or efflux is more sensitive depends on the duration of Cu exposure, show that elevated water [Ca], independent of alkalinity, is protective against both mechanisms of Cu toxicity, and identify V-type H(+)ATPase as a new Cu target for future investigation.