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Association of Atrial Fibrillation and Cognitive Dysfunction: A Comprehensive Narrative Review of Current Understanding and Recent Updates
No full textAtrial fibrillation (AF) is the most common sustained arrhythmia in adults. The prevalence of both AF and dementia is steadily rising and is expected to rise further in the coming decades. There is increasing evidence to suggest an association between AF and various degrees of cognitive dysfunction, from mild cognitive impairment to severe dementia. In this review, we aimed to discuss the epidemiological aspects, pathophysiological mechanisms, role of neuroimaging, impact of treatment modalities, and clinical and socioeconomic impact of this association. Numerous observational studies and meta-analyses have revealed this association to exist in AF patients with and without a history of stroke, and the association also persists after adjusting for shared risk factors such as hypertension and diabetes mellitus. Various pathophysiological mechanisms have been proposed for this association, including silent cerebral infarcts, cerebral microbleeds, cerebral hypoperfusion, inflammation, and atherosclerosis. While neuroimaging findings have been utilized to suggest some of these pathophysiological mechanisms, more studies are needed to further elucidate this and to determine the potential role of neuroimaging in altering anticoagulation and other treatment decisions. Anticoagulants have shown effectiveness in reducing the rate of cognitive decline in AF patients; however, their role in low-risk AF patients remains under investigation. Even though AF patients receiving catheter ablation may have post-operative cognitive dysfunction in the short term, long-term follow-up studies have shown an improvement in cognitive function following ablation. Cognitive decline in AF patients often occurs with greater functional decline and other psychosocial impairments such as depression and anxiety and future research on this association must incorporate aspects of social determinants of health and associated outcomes
Reply: Light as a Drug: Prospective Randomized Evaluation and Comparison of the Effect of Decreased Illumination on Visual Recovery Following Cataract Surgery
No full textEscalation From Intra-Aortic Balloon Pump to Axillary Impella 5.5 Support: Staged Removal of the Femoral Access
No full textBackground: With the growing population of advanced heart failure, the use of Impella 5.5 has been increasing. Here, we report an effective strategy of removing the intra-aortic balloon pump (IABP) in the setting of escalation of support to Impella 5.5. Results: From January 1, 2022 to June 30, 2022, a total of 6 patients have undergone IABP removal during Impella 5.5 insertion. The IABP was subsequently removed over the long wire with manual compression on the femoral artery to control bleeding. An 8 or 9 Fr short sheath is inserted over the wire. Staged hemostasis was successfully performed in 4 patients, and the remaining two patients required escalation of support to veno-arterial membrane oxygenation as EC-PELLA utilizing the femoral arterial sheath. Conclusion: This does not only achieve secured hemostasis but also enables a smooth transition to further escalate support such as extracorporeal membrane oxygenation support, if necessary
Repair of Radiation-Induced Rectovaginal Fistula With Rectal Stricture by a Combined Tuttle, Turnbull-Cutait and Singapore Flap Approach
No full textRadiation-induced rectovaginal fistula (RI-RVF) with associated rectal stricture represents a challenging problem in management. The aim of the present technical note is to describe a surgical technique aimed at minimizing disease recurrence by avoiding radiated tissue in the reconstruction: 1. Tuttle longitudinal incision of posterior vaginal wall with sharp excision of proximally located fistula; 2. Resection of strictured rectum via a combined transvaginal/laparotomy access, reconstruction with Turnbull-Cutait colon pull-through, and delayed handsewn coloanal anastomosis with loop ileostomy; 3. Bridge closure of the posterior vaginal wall by the interposition of a Singapore flap. This approach resulted in a favorable outcome at the 1-year follow-up in one patient with a medical history of gynecological carcinoma status after hystero-salpingo-oophorectomy followed by adjuvant radiation
Practical Approach to Confirm Femoral Artery Patency After Percutaneous Closure for Veno-Arterial Extracorporeal Membrane Oxygenation Decannulation
No full textBackground: We describe a technique to assess blood flow distal to the decannulation site after deployment of Perclose ProGlide (Abbott Vascular, Abbott Park, Ill) in patients on femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. Technique: An antegrade distal perfusion catheter was placed in all patients, and decannulation was primarily performed at bedside (N = 11/12). With the VA-ECMO circuit switched off, a needle was inserted into the arterial tubing, passed through the femoral arterial cannula into the artery. The arterial cannula was removed over a wire and the previously placed Proglide Perclose sutures were secured. Back bleeding from the antegrade distal perfusion catheter, confirmed using a three-way connector, indicated blood flow to the superficial femoral artery. This was followed by confirmation of blood flow to the lower leg using a Doppler ultrasound. Hemostasis of the antegrade perfusion catheter was achieved through manual compression. Results: We implemented this technique in 12 patients with a technical success rate of 100%. There were no ipsilateral leg ischemia, bleeding, pseudoaneurysm, or infection after decannulation. Conclusions: This technique allows prompt assessment of blood flow to the distal leg immediately following arterial decannulation
Glucose Control and Risk of Symptomatic Intracerebral Hemorrhage Following Thrombolysis for Acute Ischemic Stroke: A SHINE Trial Analysis
No full textBackground and ObjectivesBaseline hyperglycemia is associated with worse outcomes in acute ischemic stroke (AIS), including higher risk of symptomatic intracerebral hemorrhage (sICH) following treatment with thrombolysis. Prospective data are lacking to inform management of post-thrombolysis hyperglycemia. In a prespecified analysis from the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial of hyperglycemic stroke management, we hypothesized that post-thrombolysis hyperglycemia is associated with a higher risk of sICH.MethodsHyperglycemic AIS patients \u3c12 hours onset were randomized to intensive insulin (target range 80-130 mg/dL) vs standard sliding scale (80-179 mg/dL) over a 72-hour period, stratified by treatment with thrombolysis. Three board-certified vascular neurologists independently reviewed all sICH events occurring within 7 days, defined by neurologic deterioration of ≥4 points on the NIH Stroke Scale (NIHSS). Associations between blood glucose control and sICH were analyzed using logistic regression accounting for NIHSS, age, systolic blood pressure, onset to thrombolysis time, and endovascular therapy (odds ratios [OR], 95% CI). Additional analysis compared patients in a high-risk group (age older than 60 years and NIHSS ≥8) vs all others. Categorical variables and outcomes were compared using the χ2 test (p \u3c 0.05).ResultsOf 1151 SHINE participants, 725 (63%) received thrombolysis (median age 65 years, 46% women, 29% Black, 18% Hispanic). The median NIHSS was 7, baseline blood glucose was 187 (interquartile range 153-247) mg/dL, and 80% were diabetic. Onset to thrombolysis time was 2.2 hours (1.6-2.9). Post-thrombolysis sICH occurred in 3.6% (3.0% intensive vs 4.3% standard glucose control, OR 1.10, 0.60-2.01, p = 0.697). In the first 12 hours, every 10 mg/dL higher glucose increased the odds of sICH (OR 1.08, 1.03-1.14, p = 0.004), and a greater proportion of glucose measures in the normal range (80-130 mg/dL) decreased the odds of sICH (0.89, 0.80-0.99, p = 0.030). These associations were strongest in the high-risk group (age older than 60 years and NIHSS ≥8).DiscussionIn this prespecified analysis from the SHINE trial, intensive insulin therapy was not associated with a reduced risk of post-thrombolysis sICH compared with standard sliding scale. However, early post-thrombolysis hyperglycemia was associated with a higher risk of sICH overall, particularly in older patients with more severe strokes. Further prospective research is warranted to address the risk of sICH in hyperglycemic stroke patients undergoing endovascular therapy.Trial Registration InformationNCT01369069
Botulinum Toxin Therapy in Parkinson Disease-Related Lower Limb Dystonia. an 8 Year Retrospective Review
No full textBackground: Lower extremity dystonia (LED) is a frequent complication of Parkinson disease (PD). Treatment with botulinum neurotoxinA (BoNTA) over 8 years was retrospectively reviewed. Cases 14 patients with LED received an average of 3.86 injections (1–8). Mean interval was 40 weeks (median of 25). Average dose was 182 units. Injections were well-tolerated. Using a 6 point scale, there was an average of 3.37 point improvement in disability after each session, with average duration of 28.56 weeks (median 11 weeks). After mean follow-up of 101 weeks, disabling dystonia was not present in 11 of 14 patients. Conclusions: Botulinum toxin is safe and effective in PD related LED. Good response to the first two injection sessions was significantly associated with greater likelihood of long-term response. Assertive BoNTA dosing may lead to sustained remission of symptoms. As natural history of LED in PD has not been reported, prospective placebo-controlled studies are needed
The Intra-Articular Tendinous Graft Diameter of 10-Mm Bone–Patellar Tendon–Bone Autografts in Adolescent Patients: An MRI Analysis of 100 Patients
No full textBackground: Bone–patellar tendon–bone (BPTB) autograft size may be one modifiable predictor of anterior cruciate ligament (ACL) reconstruction postoperative success, as smaller graft diameter has been associated with higher rates of rupture requiring revision. However, measuring the true intra-articular tendinous graft diameter of the soft tissue portion of a BPTB graft with standard intraoperative methods is difficult while keeping the graft intact. Purpose/Hypothesis: The purpose of the study was to use 3-dimensional magnetic resonance imaging (MRI) measurements to determine the cross-sectional area of the soft tissue, tendinous portion of a standard BPTB autograft with 10-mm diameter bone plugs, and, by calculation, the collagen graft size (ie, graft diameter), as would typically be reported in ACL reconstruction studies that consider soft tissue graft size. It was hypothesized that the calculated collagen graft diameter of 10-mm BPTB autografts would be significantly smaller than 10 mm. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 patients (10 girls and 10 boys at each age from 13 to 17 years) who underwent a knee MRI at a single academic orthopaedic center without documented extensor mechanism pathology were identified. The central 10-mm width of the patellar tendon that would be harvested for BPTB autograft was measured. The region of interest area tool was then used to measure the cross-sectional area of a 10-mm BPTB graft with subsequent soft tissue autograft diameter calculation. Results: The mean calculated tendinous graft diameter of a 10 mm–wide BPTB graft was 6.3 ± 0.5 mm and was significantly smaller than a 10-mm reference (P≤.001). There was no significant association between age and cross-sectional area or graft diameter. Conclusion: Modern 3-dimensional imaging-based measurement techniques demonstrated that the true intra-articular tendinous soft tissue portion of 10-mm BPTB autografts shows substantial variation and is significantly smaller in diameter than the tunnels typically reamed to accommodate the bone plug portions of these grafts. Moreover, as graft size is a predictor of rupture rate, preoperative MRI-based evaluation may be an important tool when considering BPTB autograft for ACL reconstruction. Future comparative clinical research utilizing graft size as a study variable should consider quantifying and utilizing the diameter of the soft tissue component of BPTB autografts
The Role of Glutamate and Blood–Brain Barrier Disruption as a Mechanistic Link Between Epilepsy and Depression
No full textEpilepsy is associated with substantial neuropsychiatric impairments that persist long after the onset of the condition, significantly impacting quality of life. The goal of this review was to uncover how the pathological consequences of epilepsy, such as excessive glutamate release and a disrupted blood–brain barrier (BBB), contribute to the emergence of neuropsychiatric disorders. We hypothesize that epilepsy induces a dysfunctional BBB through hyperexcitation, which then further amplifies post-ictal glutamate levels and, thus, triggers neurodegenerative and neuropsychiatric processes. This review identifies the determinants of glutamate concentration levels in the brain and explores potential therapeutic interventions that restore BBB integrity. Our focus on therapeutic BBB restoration is guided by the premise that it may improve glutamate regulation, consequently mitigating the neurotoxicity that contributes to the onset of neuropsychiatric symptoms
The Risk Analysis Index Demonstrates Superior Discriminative Ability in Predicting Extended Length of Stay in Pituitary Adenoma Resection Patients When Compared to the 5-Point Modified Frailty Index
No full textObjective: To compare the predictive abilities of two frailty indices on post-operative morbidity and mortality in patients undergoing pituitary adenoma resection. Methods: The National Surgical Quality Improvement Program (NSQIP) database was used to retrospectively collect data for patients undergoing pituitary adenoma resection between 2015-2019. To compare the predictive abilities of two of the most common frailty indices, the 5-point modified frailty index (mFI-5) and the risk analysis index (RAI), receiver operating curve analysis (ROC) and area under the curve (AUC)/Cstatistic were used. Results: In our cohort of 1,454 patients, the RAI demonstrated superior discriminative ability to the mFI-5 in predicting extended length of stay (C-statistic 0.59, 95% CI 0.56-0.62 vs. C-statistic 0.51, 95% CI: 0.48-0.54, p = 0.0002). The RAI only descriptively appeared superior to mFI-5 in determining mortality (C-statistic 0.89, 95% CI 0.74-0.99 vs. Cstatistic 0.63, 95% CI 0.61-0.66, p=0.11), and NHD (C-statistic 0.68, 95% CI 0.60-0.76 vs. C-statistic 0.60, 95% CI: 0.57-0.62, p=0.15). Conclusions: Pituitary adenomas account for one of the most common brain tumors in the general population, with resection being the preferred treatment for patients with most hormone producing tumors or those causing compressive symptoms. Although pituitary adenoma resection is generally safe, patients who experience post-operative complications frequently share similar pre-operative characteristics and comorbidities. Therefore, appropriate pre-operative risk stratification is imperative for adequate patient counseling and informed consent in these patients. Here we present the first known report showing the superior discriminatory ability of the RAI in predicting eLOS when compared to the mFI-5