No survival benefit associated with waiting for non-lung donor heart transplants for adult recipients with congenital heart disease.

BACKGROUND: Adults with congenital heart disease (CHD) awaiting heart transplant (HT) have higher mortality and waitlist removal due to clinical deterioration than those without CHD. The selective use of non-lung donors (NLD) to recover donor pulmonary vasculature to assist in graft implantation may be a contributing factor and is supported by consensus statements despite the recent use of pericardium or graft material as an alternative in pulmonary vascular reconstruction. The impact of selecting NLD for CHD recipients on wait time and mortality has not been evaluated. METHODS/RESULTS: In the United Network for Organ Sharing (UNOS) Registry, 1271 HT recipients age ≥ 18 with CHD were identified between 1987 and 2016, 68% of which had NLDs. Prior to HT, NLD recipients were significantly less likely to be listed UNOS Status 1A, require mechanical ventilation, or intra-aortic balloon pump support. There was no difference in mean waitlist time (254 vs. 278 days, p = .31), 1-year mortality (82% vs. 80%, p = .81; adjusted odds ratio 1.32, 95% confidence interval [CI] 0.96-1.83, p = .08), or overall mortality (adjusted hazard ratio 1.08, 95% CI 0.86-1.36, p = .48) between recipients from NLD and concomitant lung donors. CONCLUSIONS: Adult CHD patients who are less critically ill or listed at a lower status are more likely to receive HT from NLD. There is no overall mortality benefit associated with this practice. While specific cases may necessitate waiting for NLD, programs need to re-evaluate whether this should remain a more widespread practice among CHD patients.

Heart transplantation and in-hospital outcomes in adult congenital heart disease patients with Fontan: A decade nationwide analysis from 2004 to 2014.

INTRODUCTION: Treatment of adult congenital heart disease patients who require advanced therapies remains challenging due to high perioperative and wait-list mortality and limited donors. Patients palliated with Fontan are at the highest risk of early mortality due to multiorgan involvement and few centers able to safely transplant them. We sought to evaluate the early outcomes of heart transplants in these adult Fontan patients. METHODS: Using the Nationwide Inpatient Sample database, we identified all adults aged at least 18 years old who underwent heart transplantation across U.S. hospitals from 2004 to 2014. We then identified those with specific ICD-9 codes to include tricuspid atresia, hypoplastic left heart syndrome and common ventricle. Multivariate regression models were created to adjust for potential confounders. RESULTS: A total of 93 Fontan patients underwent heart transplant during the study time (0.5% of all heart transplants). Compared to non-Fontan heart transplantations, Fontan patients were younger, with a higher incidence of liver disease and coagulopathy. Fontan patients receiving heart transplant had higher mortality during transplant hospitalization compared to non-Fontan patients (26.3% vs 5.3% OR, 18.10, CI, 5.06-65.0 P < .001). Extracorporeal membrane oxygenator (ECMO) usage and bleeding were also higher in the Fontan cohort with an OR of 5.30 (P = .016) and 5.32 (P = .015) for ECMO and bleeding, respectively. The remaining outcomes were similar for both cohorts. CONCLUSION: Adults with Fontan palliation undergoing heart transplantation have exceptionally high inpatient mortality, which is nearly five times that of non-Fontan heart transplant recipients, perhaps related to a delayed referral, surgical complexity, and coexistent, underrecognized liver failure.

The Arctic in the Twenty-First Century: Changing Biogeochemical Linkages across a Paraglacial Landscape of Greenland.

The Kangerlussuaq area of southwest Greenland encompasses diverse ecological, geomorphic, and climate gradients that function over a range of spatial and temporal scales. Ecosystems range from the microbial communities on the ice sheet and moisture-stressed terrestrial vegetation (and their associated herbivores) to freshwater and oligosaline lakes. These ecosystems are linked by a dynamic glacio-fluvial-aeolian geomorphic system that transports water, geological material, organic carbon and nutrients from the glacier surface to adjacent terrestrial and aquatic systems. This paraglacial system is now subject to substantial change because of rapid regional warming since 2000. Here, we describe changes in the eco- and geomorphic systems at a range of timescales and explore rapid future change in the links that integrate these systems. We highlight the importance of cross-system subsidies at the landscape scale and, importantly, how these might change in the near future as the Arctic is expected to continue to warm.

Posterior capsular rupture causing posterior shoulder instability: a case report.

We report the case of a 20-year-old male competitive football player who was treated for a midsubstance posterior capsule rupture after a posterior dislocation from falling onto his shoulder. Conservative management for 5 months after the injury failed to improve his subjective symptoms, with the primary symptom being activity-related posterior shoulder pain. Advanced imaging findings and physical examination were consistent with posterior instability, thought to be due to a posterior labral tear. At the time of a diagnostic arthroscopy, the patient was found to have an oval-shaped rupture of the capsule that was neither a reverse humeral avulsion of the glenohumeral ligament lesion nor a posterior labral tear. The capsular tear was repaired through an all-arthroscopic technique with nonabsorbable sutures. The patient returned to his previous competitive function, had no pain, and had full motion at final follow-up without recurrence of instability or pain symptoms.

Postoperative rupture of the anterolateral deltoid muscle following reverse total shoulder arthroplasty in patients who have undergone open rotator cuff repair.

BACKGROUND: Postoperative ruptures of the antero-lateral deltoid in patients with reverse total shoulder arthroplasty utilizing the delto-pectoral approach following failed mini-open or open rotator cuff repairs have not been reported in the English literature. The incidence of this complication is unknown. MATERIALS AND METHODS: A retrospective review of 199 patients who underwent reverse total shoulder arthroplasty utilizing a deltopectoral approach was performed. These procedures were performed by 2 surgeons in 2 hospitals. There were 3 patients who had postoperative rupture of the deltoid. These ruptures occurred without any history of trauma to the patient. In all 3 patients, past surgical history was significant for a rotator cuff repair utilizing a mini-open or mini-open modified to open approach. Successful repair of the deltoid was achieved using a transosseous suture repair in all 3 patients. RESULTS: At most current follow-up (all >12 months), average forward elevation was 120°. A small residual anterior deltoid defect was present in all 3 patients, but pain was quantified as 0-4 out of 10 and radiographs demonstrated satisfactory position of the reverse arthroplasty implants. CONCLUSION: Postoperative ruptures of the antero-lateral deltoid can occur in patients who have undergone reverse total shoulder arthroplasty, utilizing the delto-pectoral approach following failed mini-open or open rotator cuff repairs. A supero-lateral approach during reverse total shoulder arthroplasty could be useful in assessing and possibly reinforcing a deltoid origin previously damaged or repaired during mini-open or open rotator cuff repair.

How trauma related to sex trafficking challenges parenting: Insights from Mexican and Central American survivors in the US.

Sex trafficking, a form of human trafficking for the purpose of commercial sexual exploitation, with a global prevalence of 4.5 million, has pervasive effects in the mental and physical health of survivors. However, little is known about the experiences and needs of Latinx migrants (the majority of sex trafficking victims in the US) after trafficking, particularly regarding parenting. This QUAL-quant study examines how 14 survivors of sex trafficking (mean age = 30) from Mexico and Central America encounter and respond to parenting experiences after escaping sexual exploitation. Combining a bio-ecological model of parenting with Zimmerman's framework on human trafficking we identified how trauma related to sex trafficking can challenge parenting and how relational and contextual pre and post trafficking factors (dis)enable women to respond to such challenges. Psychological consequences of daily victimization primarily manifested in three ways: overprotective parenting in a world perceived to be unsafe, emotional withdraw when struggling with stress and mental health symptoms, and challenges building confidence as mothers. These experiences were accentuated by pre-trafficking experiences of neglect and abuse, forced separation from their older children, poverty post-trafficking, and migration-related stressors. Yet, finding meaning in the birth of their child, having social support, and faith, also enable mothers to cope with such challenges. We conclude that motherhood after surviving sex trafficking presents new challenges and opportunities in the path to recovery from trauma. Interventions at the policy, community and individual level are needed to support survivors of sex trafficking as they enter motherhood.

Greater admissions, mortality and cost of heart failure in adults with congenital heart disease.

OBJECTIVE: Limited contemporary data exist regarding outcomes and resource use among adults with congenital heart disease and heart failure (ACHD-HF). This study compared outcomes, emergency department (ED) and hospital resource use, and advanced heart failure (HF) therapies in ACHD-HF versus non-ACHD with HF (HF-non-ACHD). METHODS: The Nationwide Emergency Department Sample and Nationwide Inpatient Sample were used to analyse outcomes and resource use among ACHD-HF ED visits and hospitalisations from 2006 to 2016. ACHD-HF was stratified by single-ventricle (SV) and two-ventricle (2V) disease. RESULTS: A total of 76 557 ACHD-HF visits (3.6% SV physiology) and 31 137 414 HF-non-ACHD visits were analysed. ACHD-HFs were younger (SV 33 years (IQR 25-44), 2V 62 years (IQR 45-76); HF-non-ACHD 74 years (IQR 63-83); p<0.001). ACHD-HFs had higher ED admissions (78% vs 70%, p<0.001), longer hospital length of stay (5 days (IQR 2-8) vs 4 days (IQR 2-7), p<0.001) and greater hospital costs ($49K (IQR 2K-121K) vs $32K (17K-66K), p<0.001). Mortality was significantly higher among ACHD-HFs with SV physiology (6.6%; OR 1.6, 95% CI 1.1 to 2.3) or 2V physiology (6.3%; OR 1.4, 95% CI 1.3 to 1.5) versus HF-non-ACHD (5.5%). ACHF-HF hospitalisations increased more (46% vs 6% HF-non-ACHD) over a 10-year period, but the proportion receiving ventricular assist device (VAD) (ACHD-HF -2% vs HF-non-ACHD 294%) or transplant (ACHD-HF -37% vs HF-non-ACHD 73%) decreased. CONCLUSION: ACHD-HFs have significant ED and hospital resource use that has increased over the past 10 years. However, advanced HF therapies (VAD and transplantation) are less commonly used compared with those without adult congenital heart disease.

Investigation of complementary reactions of a dipyrromethane with a dipyrromethanemonocarbinol leading to a 5-isocorrole.

Two complementary dipyrromethane + dipyrromethanemonocarbinol routes to a meso-substituted 5-isocorrole were investigated. While both routes could afford the identical 5-isocorrole, self-condensation of the different dipyrromethanemonocarbinol precursors could potentially lead to a second porphyrinoid of different structure (a porphyrin or a porphodimethene). The two reaction routes were examined to compare the distribution of porphyrinoid products, probe the effect of key reaction parameters on the product distribution, and identify conditions for the efficient preparation of the 5-isocorrole so that its spectral properties and stability toward light and air could be assessed. For each route, a systematic survey of reaction parameters was performed via analytical-scale reactions monitored for the yields of the 5-isocorrole and self-condensation product by HPLC. The two reaction routes were found to afford very different product distributions in accordance with the anticipated nucleophilicity of the dipyrromethane and dipyrromethanemonocarbinol precursors. The most promising reaction condition (InCl(3), 0.32 mM) was performed on a preparative-scale providing the 5-isocorrole in an isolated yield of 31% (102 mg). Spectroscopic analysis was consistent with the 5-isocorrole structure. The stability of the 5-isocorrole in dilute solution upon exposure to light and air was assessed by UV-vis spectroscopy and HPLC and was found to be excellent.

The effects of eszopiclone on sleep spindles and memory consolidation in schizophrenia: a randomized clinical trial.

Sleep spindles, defining oscillations of stage 2 non-rapid eye movement sleep (N2), mediate memory consolidation. Schizophrenia is characterized by reduced spindle activity that correlates with impaired sleep-dependent memory consolidation. In a small, randomized, placebo-controlled pilot study of schizophrenia, eszopiclone (Lunesta®), a nonbenzodiazepine sedative hypnotic, increased N2 spindle density (number/minute) but did not significantly improve memory. This larger double-blind crossover study that included healthy controls investigated whether eszopiclone could both increase N2 spindle density and improve memory. Twenty-six medicated schizophrenia outpatients and 29 healthy controls were randomly assigned to have a placebo or eszopiclone (3 mg) sleep visit first. Each visit involved two consecutive nights of high density polysomnography with training on the Motor Sequence Task (MST) on the second night and testing the following morning. Patients showed a widespread reduction of spindle density and, in both groups, eszopiclone increased spindle density but failed to enhance sleep-dependent procedural memory consolidation. Follow-up analyses revealed that eszopiclone also affected cortical slow oscillations: it decreased their amplitude, increased their duration, and rendered their phase locking with spindles more variable. Regardless of group or visit, the density of coupled spindle-slow oscillation events predicted memory consolidation significantly better than spindle density alone, suggesting that they are a better biomarker of memory consolidation. In conclusion, sleep oscillations are promising targets for improving memory consolidation in schizophrenia, but enhancing spindles is not enough. Effective therapies also need to preserve or enhance cortical slow oscillations and their coordination with thalamic spindles, an interregional dialog that is necessary for sleep-dependent memory consolidation.

Trends in Renal Function Among Heart Transplant Recipients of Donor-Derived Hepatitis C Virus.

Donor-derived hepatitis C (dd-HCV) infection may increase the risk of renal impairment (RI) among heart transplantation (HT) recipients. Sofosbuvir, an integral component of HCV direct-acting antivirals (DAAs) has also been linked to RI. To date, no study has examined the trends in renal function for HT recipients of dd-HCV infection and assessed safety and efficacy of Sofosbuvir-based DAAs. Between September 2016 and June 2018, 46 HCV-naive patients and one patient with a history of HCV treated pretransplant, underwent HT from HCV-positive donors (follow-up available through October 10, 2018). Patients were treated with Ledipasvir-Sofosbuvir (genotype 1) or Sofosbuvir-Velpatasvir (genotype 3) for 12 or 24 weeks; no dose adjustments were made for renal function. Data on renal function were available for 23 patients who achieved a sustained virologic response at 12 weeks after the treatment (SVR12; cohort A) and 18 patients who completed 1 year of follow-up (cohort B). Treatment of dd-HCV infection was initiated at a median of 6 weeks post-HT. In both cohorts, a nonsignificant reduction in median estimated glomerular filtration rate (eGFR; ml/min/1.73 m) was noted (cohort A: pretransplant eGFR: 62 [interquartile range {IQR}: 1-84] to SVR12 eGFR: 49 [IQR: 37-82]; p = 0.43; cohort B: pretransplant eGFR: 65 [IQR: 54-84] to 1 year post-HT eGFR: 56 [IQR: 39-75]; p = 0.29). Pretreatment renal function had no significant impact on changes in renal function during treatment. All patients tolerated DAAs well with 100% completion rate to the assigned therapy and duration and 100% success at achieving SVR12. In this first and largest reported case series to date of HT recipients with dd-HCV infection, we observed that neither the dd-HCV infection nor its treatment with Sofosbuvir-based DAAs increased the risk of RI. Sofosbuvir-based DAAs appear safe, tolerable, and effective for HCV treatment even in presence of severe RI.

Association between plural legal systems and sexual and reproductive health outcomes for women and girls in Nigeria: A state-level ecological study.

Nigeria has a plural legal system in which various sources of law govern simultaneously. Inconsistent and conflicting legal frameworks can reinforce pre-existing health disparities in sexual and reproductive health (SRH). While previous studies indicate poor SRH outcomes for Nigerian women and girls, particularly in Northern states, the relationship between customary and religious law (CRL) and SRH has not been explored. We conducted a state-level ecological study to examine the relationship between CRL and SRH outcomes among women in 36 Nigerian states and the Federal Capital Territory of Abuja (n = 37), using publicly available Demographic and Health Survey data from 2013. Indicators were guided by published research and included contraception use among married women, total fertility rate, median age at first birth, receipt of antenatal care, delivery location, and comprehensive knowledge of HIV. To account for economic differences between states, crude linear regression models were compared to a multivariable model, adjusting for per capita GDP. All SRH outcomes, except comprehensive knowledge of HIV, were statistically significantly more negative in CRL states compared to non-CRL states, even after accounting for state-level GDP. In CRL states in 2013, compared to non-CRL states, the proportion of married women who used any method of contraception was 22.7 percentage points lower ([95% CI: -15.78 --29.64], p<0.001), a difference that persisted in a model adjusting for per capita GDP (b[adj] = -16.15, 95% CI: [-8.64 --23.66], p<0.001.). While this analysis of retrospective state-level data found robust associations between CRL and poor SRH outcomes, future research should incorporate prospective individual-level data to further elucidate these findings.

CardioMEMS Implantation in Patient With a Systemic Right Ventricle.

A 42-year-old woman with repaired, complex cyanotic congenital heart disease complicated by systemic right ventricular dysfunction presented for worsening heart failure. She successfully underwent CardioMEMS implantation and has since remained out of the hospital with improved functional class. (Level of Difficulty: Beginner.).

Wandering spleen in a geriatric patient - a rare presentation of gastric volvulus.

We report atypical gastric outlet obstruction in a geriatric patient caused by acute mesenteroaxial gastric volvulus precipitated by a wandering spleen.

Negative world views after trauma: Neurophysiological evidence for negative expectancies.

OBJECTIVE: Negative views of both the self and the world are commonly seen in individuals who have suffered psychological trauma. These negative cognitions are thought to be significant as they are likely to play a critical role in furthering, if not promoting, other symptoms and exacerbating the dysfunction sometimes seen after a traumatic event. This has led to the inclusion of "persistent negative beliefs and expectations about oneself or the world" in the DSM-5 (American Psychiatric Association, 2013). Although there is considerable self-report and behavioral evidence for negative biases after trauma, there is less concurrent neurophysiological data. This study used the N400, an event-related potential sensitive to semantic expectancies, to assess negative expectations in a trauma sample. METHOD: In this study, 39 participants completed an N400 task in which they read ambiguous sentence stems that ended either with a positive final word (Things will turn out . . . fine) or a negative final word (Things will turn out . . . badly). The authors predicted that those trauma survivors with negative cognitions (as measured by the Posttraumatic Cognitions Inventory [PTCI]: Foa et al., 1999) would show N400 amplitudes indicating expectancies for negative endings. Augmenting the previous self-report data, this would provide evidence for negative expectancies that are fairly early and relatively automatic. RESULTS: N400 amplitudes to negative sentence endings were significantly related to negative views of the world as measured by the PTCI. CONCLUSIONS: This suggests that negative world views in trauma survivors have demonstrable neurophysiological correlates and impact on expectations in ambiguous situations. (PsycINFO Database Record

Outcome analysis of agility total ankle replacement with prior adjunctive procedures: two to six year followup.

BACKGROUND: A retrospective case review of 65 agility total ankle replacements (64 patients) was done between April, 1998, and March, 2002. The purpose of this study was to more closely identify factors that may be predictive of a favorable outcome, including a comparison of outcome measures between patients who had preoperative corrective procedures and those patients who did not. METHODS: The outcomes of this series of patients were examined with post-operative Short Form (SF)-36 scores as well as chart and radiographic review. Endpoints for this study were amputation, arthrodesis, osteochondral allograft, total ankle revision, or revision of either or both components. The Kaplan-Meier survivorship curve also was estimated including the 95% confidence intervals. RESULTS: Patients with rheumatoid arthritis (RA) were found to have a statistically significant lower rate of failure. Use of a size 1 prosthesis was associated with subsidence and the highest rate of subsequent failure, but fell short of statistical significance (because of the limited power of the study). Smoking, diabetes, and methotrexate use were not associated with an adverse outcome either clinically or statistically, but the number of patients in each group was small. The age of the patient was not a factor in predicting failure of the prosthesis in the posttraumatic arthritis group; however it trended toward significance in the osteoarthritis group. The mean time to failure in patients with osteoarthritis was shorter than in the patients with post-traumatic arthritis but fell just short of statistical significance. CONCLUSIONS: From this series we concluded that rheumatoid arthritis and use of a prosthesis larger than size 1 are predictive factors for better outcome.

Accelerating access and scale-up of optimized ART in low-income and middle-income countries: a call for a coordinated end-to-end approach.

PURPOSE OF REVIEW: To discuss how aligning the collective power of scientists, regulators, drug companies, donors, implementers and advocates to achieve a single goal - accelerating access to simpler, safer, more robust and more affordable HIV treatment - can rapidly advance antiretroviral optimization efforts and enable scale-up. RECENT FINDINGS: Harmonization of traditionally sequential processes can address the delays commonly experienced in introducing new products to low-income and middle-income countries, by facilitating an 'end-to-end' approach that mitigates risk and encourages early planning for all aspects of product introduction. SUMMARY: Planning with the 'end-in-mind' can facilitate healthy markets, benefit the application of new technologies, and accelerate the development of improved products in parallel (versus traditionally sequential efforts).

Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis.

BACKGROUND: Insertional Achilles tendinosis is a clinical entity that commonly occurs with other posterior heel disorders such as retrocalcaneal bursitis, Haglund deformity, intratendinous ossification and pretendinous bursitis. Complete detachment and reconstruction of the Achilles tendon was evaluated as a method of treatment for this condition. METHODS: Seventy-five patients (81 heels) were treated over a 5-year period for chronic insertional Achilles tendinosis. These were divided in two groups: a nondetached group (26 patients, 31 heels, average age 55 years) included all patients with debridement of the Achilles tendon with no or partial detachment of the tendon, and a detached group (49 patients, 50 heels, average age 56.1 years) that included all patients with complete detachment, debridement, and reattachment with suture anchors of the Achilles tendon associated with proximal V-Y lengthening of the proximal aponeurosis. Sixty-one patients (65 heels) were contacted for an interview questionnaire, 22 patients from the nondetached group (26 heels) and 39 patients from the detached group (39 heels). The average followup for the nondetached group was 47 months and for the detached group 33 months. Items evaluated included pain, activity limitation, gait change, walking distance, return to sport or work, and level of satisfaction. RESULTS: No statistically significant differences were noted in relation to any of the items evaluated. In the nondetached group, the satisfaction rate was 92%, and 8% were dissatisfied. In the detached group, 74% were completely satisfied and 18% were satisfied with reservations. Eight percent were dissatisfied. Complications included minor wound dehiscence (one in the nondetached, five in the detached group), wound infection (one in the nondetached group, two in the detached group) and sural neuritis (two in the detached group). CONCLUSIONS: Complete detachment of the Achilles tendon and reattachment with suture anchors and a proximal V-Y lengthening was a reliable and effective method of treatment for severe chronic insertional Achilles tendinosis as was debridement of the tendon insertion without detachment for less severe involvement.

Intramedullary screw fixation of the fifth metatarsal: an anatomic study and improved technique.

Intramedullary screw fixation has been found to be a reliable treatment for certain fractures of the fifth metatarsal. Techniques for this treatment have been described relying largely on intraoperative fluoroscopy. Ten human cadaver specimens had their fifth metatarsals osteotomized and underwent retrograde intramedullary pin placement. Anatomic landmarks and the location of the sural nerve in relation to this starting point were measured. The trajectory of a pin reducing the osteotomy was analyzed. Using the resultant starting point and guide pin trajectory, intramedullary screw placement was performed reliably without the aid of fluoroscopy. This study demonstrates that intramedullary screw fixation of proximal fifth metatarsal fractures may be performed with the use of anatomic landmarks, which decreases the amount of intraoperative fluoroscopy needed.

Anchor enhanced capsulorraphy in bunionectomies using an L-shaped capsulotomy.

The objective of this study was to investigate potential benefit of a suture anchor-enhanced capsulorraphy in the early maintenance of correction in bunionectomies. We compared, retrospectively, in successive series, the loss of correction of the Hallux Valgus (HV) and intermetatarsal (IM) angle, in those repaired with an L-shaped capsulorraphy enhanced with anchors to those without. Intraoperative and second week postoperative simulated weightbearing anterior posterior (AP) X-rays were used to evaluate results. By using only intraoperative and early postoperative X-rays, we should have effectively eliminated extraneous factors that might have influenced our results. A Total of 106 cases were investigated, 65 of which were repaired using anchors, the remaining 41 without. In the anchor group, 38 underwent a proximal metatarsal concentric shelf osteotomy (CSO)/modified McBride procedure, while the remaining 27 had a distal Chevron correction. In the without-anchor group, 21 had a CSO/modified McBride procedure while 20 underwent the Chevron procedure. In the without-anchor group, the average HV and IM loss of correction was 4.60 degrees (range, -2 to 21 degrees) and 0.6 degrees (range, -1 to 9 degrees) respectively. In the anchor group, the corresponding loss was 2.8 degrees (range, -3 to 17 degrees) and 0.6 degrees (range, -2 to 14 degrees) respectively. These results, when statistically analyzed, demonstrated that while the IM angle change was not statistically significant, the HV angle change was statistically significant, implying that the anchor plays a significant role in maintaining the surgical correction in both the distal Chevron and CSO/ modified McBride bunionectomies.