Cardiac magnetic resonance imaging in heart transplant recipients with biopsy-negative graft dysfunction

AIMS

Graft dysfunction (GD) after heart transplantation (HTx) can develop without evidence of cell- or antibody-mediated rejection. Cardiac magnetic resonance imaging (CMR) has an evolving role in detecting rejection; however, its role in biopsy-negative GD has not been described. This study examines CMR findings, evaluates outcomes based on CMR results, and seeks to identify the possibility of rejection missed through endomyocardial biopsy by using CMR in HTx recipients with biopsy-negative GD.

METHODS AND RESULTS

HTx recipients with GD [defined as a decrease in left ventricular ejection fraction (LVEF) by >5% and LVEF < 50%] in the absence of rejection by biopsy or allograft vasculopathy and who underwent CMR were included in the study. The primary outcome was a composite of all-cause mortality, re-transplantation, or persistent LVEF < 50%. Overall, 34 HTx recipients developed biopsy-negative GD and underwent CMR. Left ventricular late gadolinium enhancement (LGE) on CMR was observed in 16 patients with two distinct patterns: diffuse epicardial (n = 13) and patchy (n = 3) patterns. Patients with LGE developed GD later after HTx [4 (1.4-6.8) vs. 0.8 (0.3-1.2) years, P < 0.001], were more often symptomatic (88% vs. 56%, P = 0.06), and had greater haemodynamic derangement (pulmonary capillary wedge pressure: 19 ± 7 vs. 13 ± 3 mmHg, P = 0.002) as compared with those without LGE. No significant difference was observed in the primary composite outcome between patients with LGE and those without LGE (50% vs. 38% of patients with events, P = 0.515). During a median follow-up of 3.8 years, mean LVEF improved similarly in the LGE-negative (37-55%) and LGE-positive groups (32-55%) (P = 0.16).

CONCLUSIONS

Biopsy-negative GD occurs with and without LGE when assessed by CMR, indicative of possible rejection/inflammation occurring only in a subset of patients. Irrespective of LGE, LVEF improvement occurs in most GD patients, suggesting that other neurohormonal or immunomodulatory mechanisms may also contribute to GD development.

Clinical Response to Tumor Necrosis Factor-α Inhibitor Therapy in the Management of Cardiac Sarcoidosis

Evidence that tumor necrosis factor-α (TNF-α) inhibitors may benefit patients with cardiac sarcoidosis (CS) is limited to small case series and both imaging and clinical outcomes in this population are not well known. This study aimed to evaluate the disease course of patients with CS treated with either infliximab or adalimumab therapy based on serial 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging and clinical outcomes. An institutional CS research database was queried for patients treated with TNF-α inhibitors between 2016 and 2021. Outcomes included (1) change in mean prednisone dose, (2) FDG-PET improvement, and (3) unplanned hospitalizations, advanced heart failure therapies, or death. Our query yielded 31 patients with CS. A total of 13 patients were on infliximab, 15 patients were on adalimumab, and 3 patients were on adalimumab before transitioning to infliximab. Mean prednisone dose decreased between FDG-PET immediately preceding TNF-α and second after TNF-α FDG-PET (18.6 ± 15.7 mg to 7.7 ± 12.4 mg, p = 0.018). A significant decrease was seen in the mean number of segments demonstrating FDG uptake between most recent pre-TNF-α and first after TNF-α inhibitor FDG-PET (mean segments = 4.2 vs 3.1, p = 0.048). Between earliest pre-TNF-α and first after TNF-α FDG-PET there was a numerical decrease in average myocardial maximum standard uptake values (SUVmax) (4.4 vs 3.1, p = 0.18), and the ratio of SUVmax myocardium:SUVmax blood pool (1.9 vs 1.5, p = 0.26). Within 36 months of initiating TNF-α inhibitor, 4 patients (13%) experienced unplanned cardiovascular hospitalization (median time to hospitalization = 12.1 months). In conclusion, in patients with CS, TNF-α inhibitor therapy is associated with decreased glucocorticoid use, numerical decrease in cardiac FDG uptake, and minimal cardiac morbidity.

Isolated Anterior Talofibular Ligament (ATFL) vs Combined ATFL and Calcaneofibular Ligament Suture Tape Augmentation for the Treatment of Lateral Ankle Instability: Are Outcomes Equivalent?

Background

The Broström procedure with suture tape augmentation has become commonplace for surgical treatment of chronic lateral ankle instability. However, there is no consensus among surgeons whether internal bracing of the ATFL alone or a combined ATFL and calcaneofibular ligament (CFL) internal brace produces superior clinical outcomes. This retrospective study aims to investigate whether isolated internal bracing of the ATFL has comparable outcomes to combined ATFL and CFL brace.

Methods

There were 85 patients from a single tertiary medical center's electronic medical record identified who underwent an ATFL or ATFL and CFL reconstruction between January 2017 and December 2020. Postoperative outcomes including patient satisfaction, ankle instability, ankle pain, and the need for revision surgery at 1-year follow-up were evaluated.

Results

Forty-eight patients underwent isolated ATFL reconstruction, and 37 underwent combined ATFL and CFL reconstruction. The choice was made between the 2 options based on surgeon preference. At 1-year follow-up, postoperative outcomes were statistically indistinguishable between the 2 treatment groups.

Conclusion

The modified Broström reconstruction with ATFL and CFL reconstruction with an internal brace did not produce superior functional outcomes measured at 1 year compared to isolated ATFL reconstruction. Further investigation of long-term functional outcomes is needed to evaluate the long-term efficacy of combined or single-ligament reconstruction.Level of Evidence: Level III, retrospective study.

Radiographic Outcomes of Titanium Augment vs Bone Graft in Lateral Column Lengthening for Adult-Acquired Flatfoot Deformity

Background

Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction and, in theory, also increases the longitudinal arch by plantarflexion of the first ray through tensioning the peroneus longus for patients with stage IIB adult acquired flatfoot deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus, which is then filled with autograft, allograft, or a porous metal wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes following LCL for stage IIB AAFD.

Methods

We conducted a retrospective review of all patients who underwent LCL from October 2008 until October 2018. Preoperative weightbearing radiographs, initial postoperative radiographs, and 1-year weightbearing radiographs were reviewed. The following radiographic measurements were recorded: incongruency angle, talonavicular coverage angle (TNCA), talar-first metatarsal angle (T-1MT), and calcaneal pitch.

Results

A total of 44 patients were included in our study. The mean age of the cohort was 54 (range, 18-74). The study cohort was divided into 2 groups. There were 17 (38.7%) patients who received a titanium metal wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (59 vs 47 years old, P = .006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (32 vs 27 degrees, P = .013). There were no significant differences in postoperative TNCA, incongruency angle, or calcaneal pitch at 6 months or 1 year.

Conclusion

At 6 months and 1 year, no radiographic differences were found between autograft/allograft bone substitutes vs titanium wedge in LCL.

Level of Evidence

Level III, retrospective cohort study.

Team Approach: Perioperative Management of Pilon Fractures

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Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.

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A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes.

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The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.

Opioid usage after left ventricular assist device implantation: A single center retrospective analysis

BACKGROUND

Opioid use disorder is a known national concern and extends across multiple populations; however, opioid use in the left ventricular assist device (LVAD) population and subsequent outcomes is not well described.

OBJECTIVES

We sought to understand opioid use and patient characteristics among the LVAD population at a single center and associated outcomes after index LVAD hospitalization in relation to opioid use.

METHODS

A single center retrospective review of pre-operative and post-operative opioid use was characterized during the index admission for LVAD implantation. Additionally, we reviewed medical records from patients with opioid prescription at hospital discharge stratified by oral morphine equivalents (OME) and refills of opioid prescriptions with analysis of the outcomes of readmission and death after hospital discharge from the index admission for LVAD implantation.

RESULTS

Opioid exposed patients in this cohort increased in frequency from 0% of patients in 2007 to a peak of 25.9% of patients in 2013, and gradually declined thereafter to 12.5% in 2017.

CONCLUSIONS

Despite the rate of high dose opioid therapy in this cohort, neither opioid use, opioid history, oral morphine equivalents (OME), or opioid refills portended worse survival after LVAD implantation.

Diagnostic Performance and Advanced Imaging Reduction With Digital Tomosynthesis in Scaphoid Fracture Management

BACKGROUND

Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS.

METHODS

From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question.

RESULTS

A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information.

CONCLUSIONS

Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.

Cadaveric Gait Simulation of the Effect of Subtalar Arthrodesis on Total Ankle Replacement Kinematics

BACKGROUND

Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR.

METHODS

Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-ST_fuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-ST_fuse.

RESULTS

There were significant differences in kinematics and range of motion between TAR and TAR-ST_fuse groups. At the ankle joint, TAR-ST_fuse had less internal rotation in early-mid stance (P < .05), with decreased range of motion in the sagittal (-2.7 degrees, P = .008) and axial (-1.8 degrees, P = .002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P < .001) and late (+2.5 degrees, P = .012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P < .05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P < .003).

CONCLUSION

In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint.

CLINICAL RELEVANCE

These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure.

De Ritis-adjusted AST provides comparable efficacy to lactate dehydrogenase as a biomarker for detection of LVAD hemolysis or thrombosis

BACKGROUND

Lactate hydrogenase (LDH) is a common biomarker utilized in the detection and monitoring of left ventricular assist device (LVAD) hemolysis and thrombosis. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are common laboratory tests that can be used to calculate the De Ritis ratio and the De Ritis adjusted AST.

METHODS

A retrospective review of LVAD patients was performed to identify three cohorts of patients: those with confirmed pump thrombosis after device exchange, those with LVAD-related hemolysis who were medically managed without pump exchange, and those who did not meet these criteria and served as the control cohort. Evaluation of AST, AST/ALT ratio (referred to as the De Ritis ratio) as well as AST x (AST/ALT) or the De Ritis-adjusted AST (DRA) was performed.

RESULTS

There were 29 patients who underwent device exchange for thrombosis, 25 patients who were diagnosed with hemolysis and treated medically (clopidogrel (N = 6), heparin (N = 13), tirofiban (N = 8), eptifibatide (N = 2), and some received more than one of these treatments), and 425 control patients. A qualitatively comparable relative and absolute rise in DRA and LDH were found in both surgically managed pump thrombosis and suspected device-related hemolysis.

CONCLUSIONS

Both AST and LDH as well DRA are significantly associated with pump thrombosis (p < 0.0001 for each). DRA is a potential screening biomarker for hemolysis and device thrombosis in stable left ventricular assist device patients.

Intrinsic Tendon Regeneration After Application of Purified Exosome Product: An In Vivo Study

Background:

Tendons are primarily acellular, limiting their intrinsic regenerative capabilities. This limited regenerative potential contributes to delayed healing, rupture, and adhesion formation after tendon injury.

Purpose:

To determine if a tendon’s intrinsic regenerative potential could be improved after the application of a purified exosome product (PEP) when loaded onto a collagen scaffold.

Study Design:

Controlled laboratory study.

Methods:

An in vivo rabbit Achilles tendon model was used and consisted of 3 groups: (1) Achilles tenotomy with suture repair, (2) Achilles tenotomy with suture repair and collagen scaffold, and (3) Achilles tenotomy with suture repair and collagen scaffold loaded with PEP at 1 × 10¹² exosomes/mL. Each group consisted of 15 rabbits for a total of 45 specimens. Mechanical and histologic analyses were performed at both 3 and 6 weeks.

Results:

The load to failure and ultimate tensile stress were found to be similar across all groups (P ≥ .15). The tendon cross-sectional area was significantly smaller for tendons treated with PEP compared with the control groups at 6 weeks, which was primarily related to an absence of external adhesions (P = .04). Histologic analysis confirmed these findings, demonstrating significantly lower adhesion grade both macroscopically (P = .0006) and microscopically (P = .0062) when tendons were treated with PEP. Immunohistochemical staining showed a greater intensity for type 1 collagen for PEP-treated tendons compared with collagen-only or control tendons.

Conclusion:

Mechanical and histologic results suggested that healing in the PEP-treated group favored intrinsic healing (absence of adhesions) while control animals and animals treated with collagen only healed primarily via extrinsic scar formation. Despite a smaller cross-sectional area, treated tendons had the same ultimate tensile stress. This pilot investigation shows promise for PEP as a means of effectively treating tendon injuries and enhancing intrinsic healing.

Clinical Relevance:

The production of a cell-free, off-the-shelf product that can promote tendon regeneration would provide a viable solution for physicians and patients to enhance tendon healing and decrease adhesions as well as shorten the time required to return to work or sports.

Low-cost simulation training program for endoscopic sinus surgery: optimizing the basic skills level

Background: The purpose of this study is to develop and validate a low-cost simulation model and training program for the acquisition of basic skills in endoscopic sinus surgery. Methodology: Experimental study. An eight-task low-cost simulation model was developed based on feeding bottles. Junior residents, general otolaryngologists, and fellowship-trained rhinologists (experts) were recorded performing each task. Operative time and number of errors were measured. Videos were evaluated by two blinded experts using a validated global rating scale (GRS) and a specific rating scale (SRS). A group of residents completed a six-session training program and then were recorded and evaluated using the same methodology. Results: Twenty-five participants were recruited. Statistically significant higher scores in the GRS and SRS and lower operative time and errors at higher levels of expertise were found. A significant correlation between SRS and GRS was found. Seven residents completed the training program. A significant improvement of SRS and GRS scores and reduction of operative time and errors were observed after training. Moreover, compared to experts, statistically significant fewer errors were made by residents after training, and no significant differences were found in terms of performance quality and operative time among these groups. Conclusions: Our low-cost simulation model can be accurately used as a validated objective assessment and training tool for basic endoscopic skills necessary for FESS, and can be potentially used in any otolaryngology surgical training program for residents.

Electrogram-guided endomyocardial biopsy yield in patients with suspected cardiac sarcoidosis and relation to outcomes

OBJECTIVE

Endomyocardial biopsy (EMB) is a useful diagnostic tool though the yield may be limited in many myocardial diseases. Data on the diagnostic yield and prognostic significance of EMB guided by abnormal electrograms (EGM-Bx) in suspected cardiac sarcoidosis (CS) are scarce.

METHODS

Seventy-nine patients (mean age: 56 ± 12 years; 61% men) with suspected CS based on clinical and imaging features underwent right or left ventricular EGM-Bx guided by electroanatomic mapping. Tissue samples were obtained from sites with abnormal EGMs and/or abnormal cardiac imaging. The diagnostic yield of EGM-Bx was evaluated in reference to histopathologic analysis. Left ventricular assist device (LVAD) and transplantation-free survival were compared between patients with positive and negative EGM-Bx for CS.

RESULTS

A total of 254 samples were obtained from abnormal EGM sites, and 126 samples from normal EGM sites guided by pre-procedure imaging findings. Abnormal histopathology was noted in 65 (26%) and 10 (8%) samples from abnormal and normal EGM sites, respectively. Histopathology confirmed CS in 16 (20%) patients, while an alternative tissue diagnosis emerged in 10 (13%) patients. Abnormal EGMs at the biopsy site had sensitivity 89% and specificity 33% for a histopathologic diagnosis of CS. LVAD and transplantation-free survival were not significantly associated with the EGM-Bx result (log-rank p = .91).

CONCLUSION

In patients with suspected CS, abnormal EGM-Bx has high sensitivity and low specificity for establishing a definite CS diagnosis. Consideration of substrate abnormalities apparent on preprocedural imaging as an adjunct for selection of biopsy sites may further improve EGM-Bx yield.

Glucocorticoid therapy rather than the inflammatory state is associated with pulmonary embolism and deep vein thrombosis in cardiac sarcoid

Background

Sarcoidosis is an infiltrative inflammatory condition affecting multiple organs, with cardiac involvement designated as cardiac sarcoidosis (CS). It has been proposed that inflammatory conditions like sarcoid increase the risk of venous thromboembolism (VTE), defined as pulmonary embolism (PE) and deep vein thrombosis (DVT) due to the hypercoagulable environment created by inflammation.

Purpose

Although previous studies have demonstrated an association with sarcoidosis and VTE, these studies failed to account for steroid use (crucial for sarcoid treatment) as an important confounder. Also, no major studies have been done previously assessing the risk of VTE in CS specifically. The objective of this investigation is to determine the association between CS, steroid treatment for CS, and VTE.

Methods

Patients referred to our institution with concern for sarcoid/CS were retrospectively assessed. Specific variables of interest including general baseline characteristics and those specific to CS were analyzed for their association with VTE development.

Results

Using Heart Rhythm Society guidelines, 649 patients were split into three categories: 235 with no sarcoid (NS), 91 with extra-cardiac sarcoid (ECS) only, and 323 with CS. In univariate analysis, 39 (12%) CS patients developed a PE vs 9 (4%) NS patients (OR 3.44, p=0.0003) and 44 (14%) CS patients developed DVT vs 18 (8%) NS patients (OR 1.90, p=0.02). In multivariate regression analysis however, neither CS nor ECS was an independent risk factor for VTE (p&gt;0.05) but steroid use was a strong predictor of VTE (HR 3.12, p=0.007 for PE, HR 6.17, p&lt;0.0001 for DVT). Also, steroid dose was found to be an independent predictor for both PE (p=0.001) and DVT (p=0.007) in a Cox proportionate hazards model (significance appeared at &gt;17.5 mg daily on a receiver operating characteristic curve).

Conclusion

Contrary to previous studies, the current study found that neither sarcoidosis nor CS is an independent risk factor for VTE. Rather, steroid therapy for CS treatment leads to an increased prevalence of VTE, specifically at a dose above 17.5 mg daily. More research is required to clarify this relationship and assess the importance of steroid-sparing immunosuppressive therapy and potentially VTE prophylaxis in CS management.

Steroid use and time to PE/DVT

Funding Acknowledgement

Type of funding source: None

Health Literacy and Recall of Postoperative Instructions in Patients Undergoing the Lapidus Procedure

Background:

Active participation in patients’ own care is essential for success after Lapidus procedure. Poor health literacy, comprehension, and retention of patient instructions may be correlated with patient participation. Currently, there is no objective measure of how well patients internalize and retain instructions before and after a Lapidus procedure. We performed this study to assess how much of the information given to patients preoperatively was able to be recalled at the first postoperative visit.

Methods:

All patients between ages 18 and 88 years undergoing a Lapidus procedure for hallux valgus by the senior author between June 2016 and July 2018 were considered eligible for inclusion. Patients were excluded if they had a history of previous bunion surgery or if the procedure was part of a flatfoot reconstruction. Patients were given written and verbal instructions at the preoperative visit. Demographic and comprehension surveys were administered at their first visit approximately 2 weeks postoperatively. A total of 50 patients, of which 42 (84%) were female and 43 (86%) had a bachelor’s degree or higher, were enrolled.

Results:

Mean overall score on the comprehension survey was 6.2/8 (±1.2), mean procedure subscore was 1.8/3 (±0.64), and mean postoperative protocol subscore was 4.4/5 (±0.8). The most frequently missed question asked patients to identify the joint fused in the procedure.

Conclusion:

Although comprehension and retention of instructions given preoperatively was quite high in our well-educated cohort, our findings highlight the importance of delivering clear instructions preoperatively and reinforcing these instructions often.

Level of Evidence:

Level II, prospective cohort study.

Desiderata for delivering NLP to accelerate healthcare AI advancement and a Mayo Clinic NLP-as-a-service implementation

Data is foundational to high-quality artificial intelligence (AI). Given that a substantial amount of clinically relevant information is embedded in unstructured data, natural language processing (NLP) plays an essential role in extracting valuable information that can benefit decision making, administration reporting, and research. Here, we share several desiderata pertaining to development and usage of NLP systems, derived from two decades of experience implementing clinical NLP at the Mayo Clinic, to inform the healthcare AI community. Using a framework, we developed as an example implementation, the desiderata emphasize the importance of a user-friendly platform, efficient collection of domain expert inputs, seamless integration with clinical data, and a highly scalable computing infrastructure.

P1805Troponin-T, NT-proBNP and creatinine at presentation predict outcomes in patients with cardiac sarcoidosis

Background

Cardiac sarcoidosis (CS) is an infiltrative inflammatory condition defined by infiltration of noncaseating granulomas into the heart. Based on the location of sarcoid lesion involvement, patients can present with symptoms of congestive heart failure, arrhythmias, and even sudden cardiac death.

Purpose

Diagnosis of CS has been somewhat challenging, with the Heart Rhythm Society (HRS) and Japanese Ministry of Health and Welfare (JMHW) being the 2 widely accepted diagnostic guidelines. Endomyocardial biopsy is the gold standard to prove definite CS but has a low sensitivity. Imaging studies have been helpful as non-invasive methods to diagnose probable CS but these can be logistically difficult and expensive. Thus, investigating for laboratory biomarkers that can act as both diagnostic and prognostic can be crucial in how we diagnose and manage CS in the future.

Methods

Patients meeting HRS for CS were evaluated at a single institution (n=217). Biomarkers of interest included angiotensin-converting enzyme (ACE), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin-T, 1,25 dihydroxyvitamin D (1,25-OHVit-D), and creatinine. Biomarkers were stratified by clinical variables of interest and their association with prognosis was examined. The primary endpoint was LVAD implantation, transplantation, or death.

Results

Mean values on presentation were: ACE 32.9±28, ESR 12±13, CRP 7.4±19, NT-proBNP 1630±2923, Troponin-T 0.03±0.1, 1,25-OHVit-D 55.5±20, and creatinine 1.12±0.3. None of the biomarkers differed by sex, definite or probable CS, or a history of immunosuppression. ACE levels were associated with the presence of cardiac fibrosis on cardiac MRI (mean difference 14.7, p=0.032). Troponin-T (p=0.006; HR 1.06 per 0.01 ng/mL), NT-proBNP (p=0.0003; HR 1.31 per 1,000 pg/mL), and creatinine (p=0.01; HR 4.02 per mg/dL) were each associated with the primary endpoint (52/217 patients).

Biomarkers associated with long term outcomes in patients with cardiac sarcoidosis Biomarker Hazard ratio P value Troponin-T 1.06 (1.02–1.11)* 0.006 NT-pro BNP 1.31 (1.15–1.48)** 0.0003 Creatinine 4.02 (1.41–9.94)*** 0.01 *Per 0.01 ng/mL change; 99th percentile upper reference limit <0.01 ng/mL; **per 1,000 pg/mL change; ***per 1 mg/dL change.

Conclusion

Troponin-T, NT-proBNP, and creatinine at presentation predict outcomes in patients with CS. Further investigation on the utility of biomarkers for assessment of disease activity and treatment response is warranted.

Bilateral native knee septic arthritis due to Propionibacterium acnes; a case report and review of literature

Propionibacterium acnes should be considered in any case of indolent septic arthritis. Cultures should be followed for 2 weeks as our cultures were negative for 7 days before growing P. acnes. Irrigation and debridement followed by antibiotics is the standard of care.

Indolent Propionibacterium acnes infection associated with orthopedic hardware in the ankle: A case report and literature review

Propionibacterium acnes (P. acnes) infections of the foot and ankle are very rare and require a unique approach to prevention, diagnosis, and treatment. Clinicians should consider P. acnes as a cause for all late and indolent orthopedic infections, as appropriate surgical and medical management can result in a good outcome.

Isolated pediatric transolecranon fracture-dislocation of the elbow managed nonoperatively: A case report and review of literature

We report on the sixth case of an isolated pediatric transolecranon fracture-dislocation, and the first case utilizing nonoperative management in a cast following closed reduction resulting in an excellent outcome. Our case provides support for nonoperative management of these rare injuries, especially when surgery is not practical or desirable.

Online Patient Resources for Ankle Instability

Category:

Ankle

Introduction/Purpose:

The Internet has drastically changed how patients access health-related information. There are several ways the public can access online health-related information such as search engines, blogs, support groups and webinars. A recent study found that 45% of orthopedic patients searched for information online regarding their injury. Also, 78% believed they had better understanding of their condition after visiting these websites; furthermore, 41% felt the Internet supplied them with questions and concerns to discuss with their physicians. While most patients experience favorable outcomes after proper management of an isolated ankle sprain, inadequate treatment can lead to chronic ankle instability. The aim of our study is to evaluate the accuracy, quality and readability of online available information using the search terms “ankle sprain” and “ankle instability”.

Methods:

Three websites [Google, Bing, and Yahoo] were searched for the terms “ankle sprain” and “ankle instability”. The first 25 websites from each search were collected. After removal of duplicates, 65 websites were left for evaluation. Nine websites were excluded: contained video links only (n=3), lacked information (n=3), presented unrelated information (n=2), or was not written in English (n=1). A total of 56 websites met the inclusion criteria. Each website was assessed for quality, accuracy, and readability by three orthopedic residents blinded to the search term utilized. The quality was evaluated using a previously developed grading rubric containing 25 points pertaining to relevant anatomy, diagnosis, treatment, and complications of ankle sprains. The accuracy of the websites was assessed using a scale from 1-4. The Flesch-Kincaid (F-K) scale was used to evaluate readability of the websites. Lastly, websites were evaluated for any commercial bias and whether written by physicians or not.

Results:

Table 1 displays the quality results of all websites. The mean quality of websites written >7th grade level was statistically significantly higher than those written at =7th grade (p=0.01). A summary of the accuracy results is depicted in Table 2. The mean accuracy of websites written >7th grade level was statistically higher than websites written at =7th grade level (p=0.01). Only six websites (10.7%) included in this study were written at a 7th grade level or below. Multivariable regression analysis revealed the accuracy of websites was significantly associated with the F-K score and absence of commercial bias. Furthermore, the quality of websites was positively correlated with the F-K score, use of the search term “ankle instability”, websites written by physicians, and absence of commercial bias.

Conclusion:

The current study highlights the poor quality and accuracy of online information related to ankle sprains, especially those with commercial bias. Furthermore, while websites written by or under supervision of physicians were found of superior quality, a majority of sites were found to have an unacceptably high reading level. As the importance of health literacy becomes more apparent, it is critical to remember the physician’s role in guiding patients to high quality and accurate resources written at an appropriate level.

Trends in Urgent Care Utilization Following Ankle Fracture Fixation

Category:

Ankle

Introduction/Purpose:

The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve post-discharge care and reduce unnecessary readmissions. Readmissions within 30-days are frequent and represent an economic burden on patients and the healthcare system alike. A recent study reported a 3.17% readmission rate after open reduction and internal fixation (ORIF) of ankle fractures. While readmission implies inpatient-discharge to inpatient-readmission, patients may present to urgent care facilities and receive medical treatment without being admitted. This too has socioeconomic implications. The incidence and reasons for urgent care visits following ankle fracture surgery has not been studied. The aim of this study is to evaluate the frequency and causes for urgent care visits within 30-days of discharge after ankle ORIF and determine factors correlated with such visits.

Methods:

This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between 7/1/2016 and 6/30/2017 were included. Patients were identified using CPT codes for ankle ORIF ((27814, 27822, 27823, 27792, 27766, and 27829). Patients less than 18 years of age, with open fractures or with other appendicular or axial skeleton injuries were excluded. Patients’ demographics including age, sex, race, BMI, occupation, insurance payer and comorbidities were documented. The primary outcome of our study was to determine the frequency of urgent care visits within 30-days of discharge after ankle ORIF. Our secondary goals were to evaluate the association between urgent care visits and demographics, and identify the reason for post-operative urgent care utilization.

Results:

A total of 333 patients met the inclusion criteria. Fifty four percent of our cohort were males. Thirty five patients (10.51%) had urgent care visits with 30-days of discharge. Patients presented at a mean of 11.83 days from the day of surgery. Sixteen patients (45.71%) had cast/splint related issues, seven (20%) presented with pain and seven (20%) with increased surgical site drainage (Fig 1). Univariable analysis demonstrated a statistically significant association between post-operative urgent care utilization and patients with diabetes (p=0.03) and underlying psychiatric disorders (p=0.03).

Conclusion:

In this population study of patients undergoing ankle fracture surgery who underwent ankle ORIF, we found that the rate of urgent care visits within 30-days of discharge exceeds the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders are significantly more likely to present to an urgent care facility post-operatively. This is an important finding, as there are large costs to the healthcare system associated with this. Future studies must identify additional risk factors and means of reducing such added costs to our already stressed healthcare system.