An Umbrella Review of Self-Management Interventions for Health Conditions With Symptom Overlap With Traumatic Brain Injury

OBJECTIVE

To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI.

DESIGN

An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI.

METHOD

A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2).

RESULTS

A total of 26 reviews met the inclusion criteria, covering a range of chronic conditions and a range of outcomes. Seven reviews were of moderate or high quality and focused on self-management in persons with stroke, chronic pain, and psychiatric disorders with psychotic features. Self-management interventions were found to have positive effects on quality of life, self-efficacy, hope, reduction of disability, pain, relapse and rehospitalization rates, psychiatric symptoms, and occupational and social functioning.

CONCLUSIONS

Findings are encouraging with regard to the effectiveness of self-management interventions in patients with symptoms similar to those of TBI. However, reviews did not address adaptation of self-management interventions for those with cognitive deficits or for populations with greater vulnerabilities, such as low education and older adults. Adaptations for TBI and its intersection with these special groups may be needed.

Autonomic Cardiovascular Control, Psychological Well-Being, and Cognitive Performance in People With Spinal Cord Injury

PURPOSE

To examine associations between parameters of psychological well-being, injury characteristics, cardiovascular autonomic nervous system (ANS) control, and cognitive performance in persons with spinal cord injury (SCI) compared with age-matched uninjured controls. This is an observational, cross-sectional study including a total of 94 participants (52 with SCI and 42 uninjured controls: UIC). Cardiovascular ANS responses were continuously monitored at rest and during administration of the Paced Auditory Serial Addition Test (PASAT). Self-report scores on the SCI-Quality of Life questionnaires are reported for depression, anxiety, fatigue, resilience, and positive affect. Participants with SCI performed significantly more poorly on the PASAT compared with the uninjured controls. Although not statistically significant, participants with SCI tended to report more psychological distress and less well-being than the uninjured controls. In addition, when compared with uninjured controls, the cardiovascular ANS responses to testing were significantly altered in participants with SCI; however, these responses to testing did not predict PASAT performance. Self-reported levels of anxiety were significantly related to PASAT score in the SCI group, but there was no significant relationship between PASAT and the other indices of SCI-Quality of Life. Future investigations should more closely examine the relationship among cardiovascular ANS impairments, psychological disorders, and cognitive dysfunction to better elucidate the underpinnings of these deficits and to guide interventions aimed at improving physiological, psychological, and cognitive health after SCI. Tetraplegia, paraplegia, blood pressure variability, cognitive, mood.

The effects of cognitive rehabilitation combined with aerobic exercise or stretching-and-toning on new learning and memory in persons with moderate-to-severe TBI: Protocol for a randomized controlled trial

This paper describes the protocol for a Phase I/II, parallel-group, blinded randomized controlled trial that compares the effects of 12-weeks of combined learning and memory rehabilitation with either aerobic cycling exercise or stretching on cognitive, neuroimaging, and everyday life outcomes in 60 persons with moderate-to-severe traumatic brain injury (TBI) who demonstrate impairments in new learning. Briefly, participants will undergo baseline testing consisting of neuropsychological testing, neuroimaging, daily life measures, and cardiorespiratory fitness. Following baseline testing, participants will be randomized to one of 2 conditions (30 participants per condition) using concealed allocation. Participants will be masked as to the intent of the conditions. The conditions will both involve supervised administration of an enhanced, 8-week version of the Kessler Foundation modified Story Memory Technique, embedded within either 12-weeks of supervised and progressive aerobic cycling exercise training (experimental condition) or 12-weeks of supervised stretching-and-toning (active control condition). Following the 12-week intervention period, participants will complete the same measures as at baseline that will be administered by treatment-blinded assessors. The primary study outcome is new learning and memory impairment based on California Verbal Learning Test (CVLT)-III slope, the secondary outcomes include neuroimaging measures of hippocampal volume, activation, and connectivity, and the tertiary outcomes involve measures of daily living along with other cognitive outcomes. We further will collect baseline sociodemographic data for examining predictors of response heterogeneity. If successful, this trial will provide the first Class I evidence supporting combined memory rehabilitation and aerobic cycling exercise training for treating TBI-related new learning and memory impairment.

A - 74 You've Got a Friend in me: the Importance of a Confidant and its Role on Health and Well-Being among Women with Multiple Sclerosis (MS)

OBJECTIVE

The role of social support or connectedness on health is profound. While this has been known for some time, recent reports of the role of social activity on mortality, general health, cognition, and well-being have suggested that it may play a larger role than the known culprits of poor outcomes (e.g., smoking, diet, exercise). The present study looked at the role of social support among women with multiple sclerosis (MS), specifically whether one felt that they had a friend to confide in.

METHODS

One hundred and sixty women with MS completed measures of general health, MS symptomatology, and well-being. Participants also completed the Community Integration Questionnaire in which they were asked if they had a close friend that they could confide in. Thirty (19%) reported that they did not (Confidant -). We compared these women to those that did (Confidant +).

RESULTS

There were no differences between the groups on age, education, relationship status, disease course or duration. The Confidant - group reported worse general, physical, and mental health and greater fatigue, pain, and sleep disturbance (p's < 0.05). They also reported greater depression and anxiety and worse satisfaction with life and psychological well-being (p's < 0.001). Consistent with this, they reported lower perceived social support and partner satisfaction (p's < 0.001).

CONCLUSION

The simple question of "Do you have a best friend" was a large determinant in individuals' health and well-being. Findings urge practitioners to inquire about one' social network and support and assist individuals in assuring greater social connectedness in hopes of maintaining or improving one's health.

Feasibility of remotely delivered and supported aerobic walking exercise training for cognitive processing speed impairment in fully-ambulatory persons with multiple sclerosis

PURPOSE

The current pilot, single-blind, randomized controlled trial (RCT) examined the feasibility of remotely-delivered and supported aerobic walking exercise training compared with an active control condition on cognitive processing speed (CPS) in 19 fully-ambulatory persons with multiple sclerosis (pwMS) who were pre-screened for impaired CPS.

METHODS

Feasibility was assessed in the domains of process (e.g., recruitment), resource (e.g., monetary costs), management (e.g., time requirements), and scientific outcomes (i.e., treatment effect). Fully-ambulatory, but CPS-impaired pwMS were randomly assigned into either 16-weeks of home-based aerobic walking exercise or home-based stretching and range-of-motion activities. Both conditions involved delivery of informational newsletters and one-on-one, online video chats with a behavior coach. Participants across both conditions tracked their activity using highly accurate wearable motion sensors. Treatment-blinded assessors administered the Symbol Digit Modalities Test (SDMT) remotely before and after the 16-week study period.

RESULTS

The study was cost-effective, accessible, and acceptable. The intervention further was safe. Adherence and compliance rates across both conditions exceeded 80%. There was an overall moderate effect for change in SDMT score between the conditions (d = 0.42). The intervention was associated with a 4.8-point improvement in SDMT scores (d = 0.70; 10% increase) compared with a 1-point improvement for the control condition (d = 0.09; 2% increase).

CONCLUSIONS

This remotely-delivered and supported aerobic walking exercise training intervention was safe and feasible for fully-ambulatory, CPS-impaired pwMS. The pattern of results, including the promising effects on CPS, support the design and implementation of an appropriately-powered RCT on this approach for managing CPS impairment in a large MS sample.

Associations between smartphone keystroke dynamics and cognition in MS

Objective

Examine the associations between smartphone keystroke dynamics and cognitive functioning among persons with multiple sclerosis (MS).

Methods

Sixteen persons with MS with no self-reported upper extremity or typing difficulties and 10 healthy controls (HCs) completed six weeks of remote monitoring of their keystroke dynamics (i.e., how they typed on their smartphone keyboards). They also completed a comprehensive neuropsychological assessment and symptom ratings about fatigue, depression, and anxiety at baseline.

Results

A total of 1,335,787 keystrokes were collected, which were part of 30,968 typing sessions. The MS group typed slower (P < .001) and more variably (P = .032) than the HC group. Faster typing speed was associated with better performance on measures of processing speed (P = .016), attention (P = .022), and executive functioning (cognitive flexibility: P = .029; behavioral inhibition: P = .002; verbal fluency: P = .039), as well as less severe impact from fatigue (P < .001) and less severe anxiety symptoms (P = .007). Those with better cognitive functioning and less severe symptoms showed a stronger correlation between the use of backspace and autocorrection events (P < .001).

Conclusion

Typing speed may be sensitive to cognitive functions subserved by the frontal-subcortical brain circuits. Individuals with better cognitive functioning and less severe symptoms may be better at monitoring their typing errors. Keystroke dynamics have the potential to be used as an unobtrusive remote monitoring method for real-life cognitive functioning among persons with MS, which may improve the detection of relapses, evaluate treatment efficacy, and track disability progression.

Kessler Foundation Strategy-Based Training to Enhance Memory (KF-STEM™): Study protocol for a single site double-blind randomized, clinical trial in Multiple Sclerosis

New learning and memory impairments are common in Multiple Sclerosis (MS) and negatively impact everyday life, including occupational and social functioning. Despite the demand for learning and memory treatments, few cognitive rehabilitation protocols are supported by Class I research evidence, limiting the degree to which effective treatments may be utilized with persons with MS. The present double-blind, placebo controlled randomized clinical trial (RCT) examines the efficacy of an 8-session cognitive rehabilitation protocol encompassing training in the application of three strategies with the strongest empirical evidence (self-generation, spaced learning and retrieval practice) to treat impaired learning and memory in persons with MS, Kessler Foundation Strategy-based Training to Enhance Memory (KF-STEM™). A sample of 120 participants with clinically definite MS who have impairments in new learning and memory will be enrolled. Outcomes will be assessed via three mechanisms, an Assessment of Global Functioning, which examines everyday functioning and quality of life, a Neuropsychological Evaluation to examine objective cognitive performance, and functional Magnetic Resonance Imaging to examine the impact of treatment on patterns of cerebral activation. We will additionally evaluate the longer-term efficacy of KF-STEM™ on everyday functioning and neuropsychological assessment through a 6-month follow-up evaluation and evaluate the impact of booster sessions in maintaining the treatment effect over time. The methodologically rigorous design of the current study will provide Class I evidence for the KF-STEM™ treatment protocol for persons with MS.

An epidemiologic retrospective study of maxillofacial traumatology in the elderly

INTRODUCTION

The elderly population, which is more active than before, is increasingly suffering from trauma (loss of reflexes and systemic pathologic conditions). Surgical management may be more controversial due to the potential consequences of general anesthesia and the sometimes negligible consequences of functional management. The main objective of this study was to analyze the causes and location of facial fractures in subjects older than 65 years. The secondary objective was to evaluate the management of these fractures (surgical or functional) according to comorbidities.

MATERIAL & METHODS

In this retrospective study (over a five-year period), we analyzed the causes and management of facial fractures in patients aged over 65 years, and the medical history of each patient was investigated.

RESULTS

One hundred and nineteen patients with 198 facial fractures were included. The main cause of fractures was a fall (50%). The zygomatic region (39.9%) and mandible (27.8%) were the sites of the most frequent fractures. Comorbidities were found in 84.9% of patients, the majority of which were cardiovascular diseases (82.3%). 75.8% of fractures were treated surgically and 4.8% of patients had complications.

DISCUSSION

This work is a help to understanding the causes and consequences of facial trauma in the elderly population. The management of these facial fractures requires a multidisciplinary assessment, taking into account the patient's medical history and evaluating the risks and benefits of a surgical procedure with general anesthesia.

Bendamustine is safe and effective for lymphodepletion before tisagenlecleucel in patients with refractory or relapsed large B-cell lymphomas

BACKGROUND

Anti-CD19 chimeric antigen receptor T-cell immunotherapy (CAR-T) is now a standard treatment of relapsed or refractory B-cell non-Hodgkin lymphomas; however, a significant portion of patients do not respond to CAR-T and/or experience toxicities. Lymphodepleting chemotherapy is a critical component of CAR-T that enhances CAR-T-cell engraftment, expansion, cytotoxicity, and persistence. We hypothesized that the lymphodepletion regimen might affect the safety and efficacy of CAR-T.

PATIENTS AND METHODS

We compared the safety and efficacy of lymphodepletion using either fludarabine/cyclophosphamide (n = 42) or bendamustine (n = 90) before tisagenlecleucel in two cohorts of patients with relapsed or refractory large B-cell lymphomas treated consecutively at three academic institutions in the United States (University of Pennsylvania, n = 90; Oregon Health & Science University, n = 35) and Europe (University of Vienna, n = 7). Response was assessed using the Lugano 2014 criteria and toxicities were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and, when possible, the American Society for Transplantation and Cellular Therapy (ASTCT) consensus grading.

RESULTS

Fludarabine/cyclophosphamide led to more profound lymphocytopenia after tisagenlecleucel infusion compared with bendamustine, although the efficacy of tisagenlecleucel was similar between the two groups. We observed significant differences, however, in the frequency and severity of adverse events. In particular, patients treated with bendamustine had lower rates of cytokine release syndrome and neurotoxicity. In addition, higher rates of hematological toxicities were observed in patients receiving fludarabine/cyclophosphamide. Bendamustine-treated patients had higher nadir neutrophil counts, hemoglobin levels, and platelet counts, as well as a shorter time to blood count recovery, and received fewer platelet and red cell transfusions. Fewer episodes of infection, neutropenic fever, and post-infusion hospitalization were observed in the bendamustine cohort compared with patients receiving fludarabine/cyclophosphamide.

CONCLUSIONS

Bendamustine for lymphodepletion before tisagenlecleucel has efficacy similar to fludarabine/cyclophosphamide with reduced toxicities, including cytokine release syndrome, neurotoxicity, infectious and hematological toxicities, as well as reduced hospital utilization.

Surviving a global pandemic: The experience of depression, anxiety, and loneliness among individuals with multiple sclerosis

Background

The world has been experiencing one of the most significant worldwide health pandemics in modern history. The result has been increased depression, anxiety, and loneliness in the general population. However, populations who demonstrated pre-pandemic emotional disturbance and social isolation, such as individuals with multiple sclerosis (MS), are likely uniquely vulnerable to such symptoms.

Objective

The purpose of the present investigation was to examine the emotional outcomes, including reports of loneliness, in individuals with MS during the COVID-19 pandemic. We additionally sought to examine how individuals’ experiences during the pandemic may contribute to a specific COVID-19-related depression or anxiety.

Methods

142 individuals with MS who previously participated in a national, online, survey-based study were asked to complete an online survey assessing their current level of depression, anxiety, loneliness, and perceived impact of the COVID-19 pandemic.

Results

Increases in the rates of depression and anxiety were noted, with approximately 54% and 33% reporting “new” depression or anxiety, respectively. Given this increase, we examined how individuals with “new” depression or anxiety differed from those without depression and anxiety and those with pre-pandemic depression and/or anxiety. Significant differences in person-specific factors (e.g., personality, self-efficacy) were noted between the groups. Increased loneliness was also found among both those with depression or anxiety regardless of whether “new” or pre-pandemic. Finally, all those depressed or anxious reported greater disruption and distress related to the COVID-19 pandemic with a trend for increased anxiety specifically related to the pandemic (e.g., fear or dying due to COVID-19) among those with new depression or anxiety when compared to those with existing depression or anxiety, suggesting an influence of the pandemic that is specific to reports of new depression or anxiety.

Conclusion

Findings suggest increased depression, anxiety, and loneliness among individuals with MS following the COVID-19 pandemic, with reports of “new” depression or anxiety, which appears to be related to the pandemic, specifically. Moreover, factors commonly associated with depression or anxiety in MS (e.g., personality, self-efficacy) were more common among those with existing depression or anxiety but not among those experiencing new depression or anxiety. These differences should be considered when attempting to ameliorate the impact of the COVID-19 among those experiencing emotional distress.

A-17 Self-Generation Improves Prospective Memory Performance in Individuals with Moderate–Severe Traumatic Brain Injury

Objective

Self-generation has long been studied in healthy adults as a method to improve encoding of new information. The present study applied this strategy to prospective memory (PM; the ability to remember future intentions) in individuals with traumatic brain injury (TBI).

Method

Participants included 17 healthy adults and 34 individuals with moderate–severe TBI, who were at least one year post-injury and impaired encoding on a test of verbal learning. Participants completed a 15-minute computer-based lexical decision task in which PM trials were embedded. Following a baseline block of 100 lexical decision trials, participants completed 2 blocks with 5 p.m. targets each. PM targets were learned in a didactic or self-generated fashion using semantically-related word pairs, counterbalanced for order effects.

Results

MANOVAs were conducted for PM accuracy and recognition, with performance in the didactic and self-generation conditions as within-subjects variables and diagnostic group as the between-subjects variable. Only the within-subjects variables were significant [PM accuracy: F(1,49) = 5.228, p = 0.027; PM recognition: F(1,49) = 7.226, p = 0.010]. Within the TBI sample, paired t-tests demonstrated significantly improved PM accuracy [t(33) = −2.069, p = 0.046, Hedge’s g = 0.38] and PM target recognition [t(33) = −2.458, p = 0.019, Hedge’s g = 0.52] under self-generated compared to didactic conditions.

Conclusion

Results indicate that self-generation is an efficacious strategy to improve PM in individuals with moderate–severe TBI and encoding deficits. The lack of interaction suggests that the generation effect is robust enough to provide comparable benefit to both individuals with significant neurocognitive deficits as well as healthy adults. Future efforts should explore the incorporation of self-generation in cognitive rehabilitation protocols for PM in neurologic populations.

A-119 PPVT Impacted by Neuropathology in Moderate to Severe TBI

Objective

Estimating premorbid intellectual functioning after brain injury is a critical element of determining cognitive decline. However, little research has been conducted on how Peabody Picture Vocabulary Test (PPVT-IV) performs in adults after traumatic brain injury (TBI). Given that PPVT measures receptive vocabulary, it has potential to serve as a hold measure test. The objective was to explore characteristics of PPVT in TBI relative to a commonly used proxy of premorbid function (Wechsler Test of Adult Reading, WTAR).

Method

Sixty-one adults with moderate to severe TBI underwent a comprehensive neuropsychological evaluation and structural neuroimaging. Principal components analyses were used to create cognitive composite scores. Pearson’s correlations were conducted to explore the relationships between PPVT/WTAR standard scores (SS) and neuropathology (white matter integrity as whole brain functional anisotropy [FA]). The relationships between PPVT/WTAR SSs and cognitive constructs were similarly examined.

Results

PPVT was significantly related to FA (r = 0.34, p = 0.014). However, there was no relationship between WTAR and neuropathology. PPVT was significantly related to age (r = 0.38, p = 0.006), so this variable was controlled for in associated analyses (NB. WTAR was not related to age). PPVT was found to be significantly related to contextualized and noncontextualized memory, attention, executive function, and processing speed (all ps &lt; 0.05). In contrast, WTAR was only significantly related to contextualized memory, attention, and executive function.

Conclusions

PPVT appears to be impacted by neuropathology, indicating that it may not be appropriate as a hold measure after TBI. This may be explained by PPVT’s significant relationship with fluid intelligence domains known to be impacted after neurologic insult.

POS0020 EFFICACY AND SAFETY OF SECUKINUMAB IN PATIENTS WITH ROTATOR CUFF TENDINOPATHY: A 24-WEEK, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, PHASE II PROOF-OF-CONCEPT TRIAL

Background:

Rotator cuff tendinopathy (RC TP) is a multifactorial condition and one of the most common causes of musculoskeletal burden. Current standard of care (SoC) is limited to pain relief with NSAIDs and physiotherapy. Recent evidence indicates that IL-17A-expressing tendon-resident immune cells are present in human overuse tendinopathy, and IL-17A levels are increased in early human tendinopathic tissue samples [1, 2]. Secukinumab (SEC) is a fully human, monoclonal antibody that binds to and neutralises IL-17A.

Objectives:

To evaluate the efficacy and safety of SEC in patients with active overuse RC TP refractory to oral NSAIDs/acetaminophen, physiotherapy or corticosteroid injections.

Methods:

96 patients with symptomatic RC TP with no or <50% rupture were randomly assigned to receive seven subcutaneous injections of SEC 300 mg or placebo (PBO) at baseline and Weeks 1, 2 and 3, followed by every 4 weeks starting at Week 4. The primary endpoint was change from baseline in the Western Ontario Rotator Cuff (WORC) index score at Week 14 for SEC vs PBO (two-sided p<0.1). Secondary endpoints included, visual analogue scale (VAS) pain score, Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) score, American Shoulder and Elbow Surgeons Shoulder Evaluation Form (ASES), EQ-5D-5L score and patient global assessment (PGA) score. All endpoints were assessed through 24 weeks.

Results:

Clinically relevant improvement in both SEC and PBO groups on top of SoC treatment was observed, with no statistically significant difference demonstrated in the full study population on physical symptoms and function (Table 1). Similar results were observed in the secondary endpoints with marked improvement in both groups over time. Exploratory post-hoc analyses in a subpopulation of 39% of the study subjects with non-acute, moderate to severe disease, SEC provided significant and clinically relevant improvements vs PBO through Week 24 in total WORC score (overall treatment difference: 19.2, p <0.01) and pain (VAS, overall treatment difference: 15, p = 0.02) with early effect observed after two weeks (Figure 1). A favourable treatment effect in the more severe subgroup was demonstrated in other patient-reported outcomes. No serious adverse events were reported.

Conclusion:

Although SEC did not demonstrate a significant benefit vs PBO in the overall patient population with active overuse RC TP, SEC did provide benefit in the subpopulation with non-acute, moderate to severe disease. Larger clinical trials of SEC in this area are warranted.

References:

[1]Millar NL, et al. Sci Rep. 2016;6:27149.

[2]Millar NL, et al. Nat Rev Rheumatol.2017;13:110-122.

Table 1.

Change from baseline in the SEC versus PBO groups in WORC index and pain (VAS)

VisitSEC 300 mgPBOp-valueTotal treated population N=96WORC Index percentage score (0 worst -100 best)aDay 2922.3519.490.45Day 9937.0037.770.87Day 16943.4140.970.64Pain (VAS, 0 best - 100 worst)bDay 29−26.04−23.130.57Day 99−46.11−40.560.28Day 169−52.23−50.740.78Post-hoc population* N=37WORC Index percentage score (0 worst - 100 best)cDay 2930.0910.840.002Day 9948.2631.830.048Day 16955.9835.240.028Pain (VAS, 0 best - 100 worst)dDay 29−29.20−14.850.125Day 99−51.48−35.370.045Day 169−57.01−46.640.217

aDay 1: SEC 42.47, PBO 40.47; bSEC 67.04, PBO 64.85; cSEC 35.93, PBO 32.90, dSEC 71.72, PBO 67.58. Day 1 values are given as absolute values to describe baseline WORC/Pain status

*Post-hoc subpopulation: Baseline: (Disease duration 2-6 months) AND (WORC ≤40 OR Tear Thickness (Bauer) ≥1 OR Sein ≥2)

PBO, placebo; SEC, secukinumab; SoC, standard of care; WORC, Western Ontario Rotator Cuff Index; VAS, visual analogue scale

Figure 1.

Post-hoc analysis of function (WORC) in the treatment groups in non-acute, moderate to severe subpopulation

SEC

SE, standard error; SEC, secukinumab; WORC, Western Ontario Rotator Cuff Index

Disclosure of Interests:

Neal L Millar Grant/research support from: Honoraria or research funding from Novartis and Stryker, Iain McInnes Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB, Linda Mindeholm Employee of: Employee of Novartis, Abdelkader Seroutou Employee of: Employee of Novartis, Jens Praestgaard Employee of: Employee of Novartis, Ursula Schramm Employee of: Employee of Novartis, Rafael Levitch Employee of: Employee of Novartis, Eckhard Weber Employee of: Employee of Novartis, Didier Laurent Employee of: Employee of Novartis, Jeffrey Rosen Consultant of: Research advisor for Novartis, Georg Schett Speakers bureau: Received speakers honoraria from Abbvie, Amgen, BMS, Eli Lilly, Gilead, Janssen, Novartis, UCB, Ronenn Roubenoff Employee of: Employee of Novartis, Matthias Schieker Employee of: Employee of Novartis.

The Neural Mechanisms Underlying Processing Speed Deficits in Individuals Who Have Sustained a Spinal Cord Injury: A Pilot Study

Our objective was to determine differences in brain activation during a processing-speed task in individuals with SCI compared to a group of age-matched healthy controls and to a group of older healthy controls. Ten individuals with cervical SCI (C3-C5), 10 age-matched healthy controls and 10 older healthy controls participated in a cross-sectional study in which performance on neuropsychological tests of processing speed and brain activation were the main outcome measures. The brain areas used by the individuals with SCI during the processing-speed task differed significantly from the age-matched healthy controls, but were similar to the older control cohort, and included activation in frontal, parietal and hippocampal areas. This suggests that individuals with SCI may compensate for processing-speed deficits by relying on brain regions that classically support control cognitive processes such as executive control and memory.

Diagnostic performance of mobile cone beam computed tomography versus conventional multi-detector computed tomography in orbital floor fractures: a study on human specimens

The aim of this study was to evaluate the diagnostic accuracy of mobile cone beam computed tomography (MCBCT) versus multi-detector computed tomography (MDCT) in orbital floor fractures. Twenty-four fresh cadaver heads were used, and one orbital floor was fractured for each head by transconjunctival approach. MDCT and MCBCT were performed on each of the heads. The images obtained were then analysed independently by eight evaluators. The radiological characteristics of the orbital floor fractures were visualized with good interpretation agreement between the two images. The location of the fracture and enophthalmos were identified in a comparable manner with strong agreement (κ=0.93 and κ=0.85, respectively). Measurements of fatty hernias and bone defects showed a strong correlation between the two imaging modalities (Pearson coefficient between 0.64 and 0.71 and between 0.67 and 0.71, respectively). The fracture limits and the presence of bone fragments, an intrasinus fatty hernia, and a fracture of the associated medial orbital wall were visualized in both examinations with good agreement (κ=0.68, κ=0.51, κ=0.57, and κ=0.46, respectively). The soft tissue study showed superiority for MDCT, with a κ<0.0009. MCBCT showed good diagnostic performance in the study of orbital floor fracture characteristics.

The impact of level of injury on patterns of cognitive dysfunction in individuals with spinal cord injury

Context: While it is well recognized that physical and physiological changes are more prominent in individuals with higher neurologic levels of spinal cord injury (SCI), the impact of level of lesion on cognition is less clear. Design: Cross-sectional, 3-group. Setting: Non-profit rehabilitation research foundation. Participants: 59 individuals with SCI (30 with tetraplegia, 29 with paraplegia) and 30 age-matched healthy controls (HC). Interventions: None. Outcome Measures: Neuropsychological tests in the domains of attention, working memory, processing speed, executive control, and learning and memory. Results: Results indicated significantly lower test performance in individuals with paraplegia on new learning and memory testing compared to HC. In contrast, compared to HC the group with tetraplegia, showed a significantly impaired performance on a processing speed task, and both the tetraplegia and the paraplegia groups were similarly impaired on a verbal fluency measure. SCI groups did not differ on any cognitive measure. Conclusion: Individuals with SCI may display different patterns of cognitive performance based on their level of injury.

How useful is intraoperative cone beam computed tomography in maxillofacial surgery? An overview of the current literature

Intraoperative imaging is increasingly used by surgeons and has become an integral part of many surgical procedures. This study was performed to provide an overview of the current literature on the intraoperative use of cone beam computed tomography (CBCT) imaging in maxillofacial surgery. A bibliographic search of PubMed was conducted in March 2020, without time limitation, using "intraoperative imaging" AND "maxillofacial surgery" AND "cone beam computed tomography" as key words. Ninety-one articles were found; after complete reading, 16 articles met the eligibility criteria and were analysed. The results showed that the majority of the indications were related to maxillofacial trauma, particularly zygomaticomaxillary complex fractures. Final verification with intraoperative CBCT before wound closure was the most common use of this device. However, innovative uses of intraoperative CBCT are expanding, such as CBCT coupling with mirror computational planning, and even the combined use of initial intraoperative CBCT acquisition with navigation. Immediate, fast, and easy evaluation of bone repositioning to avoid the need for further surgical revision is the main advantage of this technique. Imaging quality is comparable to that of multi-slice computed tomography, but with lower radiation exposure. Nevertheless, CBCT is still not widely available in maxillofacial centres, probably because of its cost, and perhaps because not everyone is aware of its advantages and versatility, which are reported in this review.

Beyond cognitive dysfunction: Relevance of ecological validity of neuropsychological tests in multiple sclerosis

In neurological diseases such as multiple sclerosis (MS), a neuropsychological assessment is often requested to assist clinicians in evaluating the role of cognition in a patient's level of everyday functioning. To be effective in this charge, it is assumed that performance on neuropsychological tests is related to how a person may function in everyday life, and the question is often asked: "Are neuropsychological tests ecologically valid?" In this review, we synthesize the literature that examines the use of neuropsychological tests to assess functioning across a variety of everyday functioning domains in MS (i.e. driving, employment, instrumental activities of daily living (IADLs)). However, we critically examine the usefulness of asking this broad question regarding ecological validity, given the psychometric and conceptual pitfalls it may yield. While many neuropsychological tests may be generally considered "ecologically valid" in MS, it is much more helpful to specify for whom, under what circumstances, and to what degree.

Vesicoamniotic shunting for fetal megacystis in the first trimester with a Somatex® intrauterine shunt

Purpose

The objective was to evaluate the feasibility of vesicoamniotic shunting (VAS) in the first trimester with the Somatex^® intrauterine shunt and report on complications and neonatal outcome.

Methods

Retrospective cohort study of all VAS before 14 weeks at two tertiary fetal medicine centres from 2015 to 2018 using a Somatex^® intrauterine shunt. All patients with a first trimester diagnosis of megacystis in male fetuses with a longitudinal bladder diameter of at least 15 mm were offered VAS. All patients that opted for VAS after counselling by prenatal medicine specialists, neonatologists and pediatric nephrologists were included in the study. Charts were reviewed for complications, obstetric and neonatal outcomes.

Results

Ten VAS were performed during the study period in male fetuses at a median GA of 13.3 (12.6–13.9) weeks. There were two terminations of pregnancy (TOP) due to additional malformations and one IUFD. Overall there were four shunt dislocations (40%); three of those between 25–30 weeks GA.

Seven neonates were born alive at a median GA of 35.1 weeks (31.0–38.9). There was one neonatal death due to pulmonary hypoplasia. Neonatal kidney function was normal in the six neonates surviving the neonatal period. After exclusion of TOP, perinatal survival was 75%, and 85.7% if only live-born children were considered.

Conclusion

VAS in the first trimester is feasible with the Somatex^® Intrauterine shunt with low fetal and maternal complication rates. Neonatal survival rates are high due to a reduction in pulmonary hypoplasia and the rate of renal failure at birth is very low. VAS can be safely offered from the late first trimester using the Somatex^® intrauterine shunt.

The high sub-mandibular approach: Our experience about 496 procedures

INTRODUCTION

The potential drawbacks of surgical approaches to neck and base fractures of the mandibular condyle (visible scare, facial nerve injury) are still considered by many surgeons as a brake for open reduction and internal fixation. The aim of our study was to analyze the results in terms of access, scare quality and complications that could be noticed in a 12 years period of time with the use of the high sub-mandibular approach (HSMA) we first described in 2006 for the surgical treatment of neck and base fractures.

MATERIAL AND METHOD

All the files of patients operated on for condylar neck and base fractures approached by mean of a HSMA between January 2006 and December 2018 in our department and containing information concerning age, sex, type of fracture, kind of osteosynthesis material, operating time, name of the surgeon, postoperative complication linked to the approach, scare quality at 6 months follow-up at least were included. The skin incision and the dissection planes followed the original publication of Meyer et al. in 2006.

RESULTS

434 patients (sex ratio: 2.06, mean age: 32, 496 approaches) met the inclusion criteria. Following the AO classification, 21.2% of the fractures were classified as neck fractures and 78.8% as base fractures. 97.6% of all fractures were stabilized by mean of a 3D plate (TCP® plate, Medartis, Basel-CH), the remaining ones by mean of a combination of 1.2, 1.5 and 2.0 straight plates. Mean operating time was 40minutes per side. Patients were operated on by senior surgeons in 71.7% of the cases and by trainees under supervision for the others. Concerning the complications linked to the approach, we noticed 11 (2.2%) temporary (0 definitive) paresis of the facial nerve, 1 (0.2%) hematoma and 1 (0.2%) abscess that both needed revision. Scare was hypertrophic or considered as unaesthetic by the patient in 5 cases (1%).

DISCUSSION

The HSMA, if performed as initially described, is a safe and quick procedure compared to other cutaneous approaches. It gives access to all base fractures and to most of neck fractures. The very low rate of facial nerve complications is mainly explained by the plane by plane dissection making it very easy to avoid the facial nerve branches or to check them when encountered. The HSMA is particularly suited to the use of TCP plates as the upper holes of these plates, placed horizontally, are easy to reach from below. The HSMA is therefore still our preferred cutaneous approach to the condylar process.

Acute renal and splenic infarctions: a review

BACKGROUND

Renal and splenic infarctions are close entities, with few data concerning their clinical, biological and radiological features.

AIM

The aim of this study was to compare the clinical presentations, etiologies and outcomes of acute renal infarctions (RI) and splenic infarctions (SI).

DESIGN

A retrospective multicentric cohort study included patients of the 6 university hospitals in Lyon with RI, SI, or associated RI-SI infarctions was conducted.

METHODS

All consecutive cases diagnosed by CT imaging, between January 2013 and October 2016, were included. The exclusion criteria were causes of infarction that did not require additional investigations.

RESULTS

A total of 161 patients were selected for analysis: 34 patients with RI, 104 patients with SI and 23 patients with both RI-SI. Mean ± SD age of patients was 63.2 ± 16.6 years; 59.6% were male. Only 5/161 (3.1%) were healthy prior to the event. The main symptoms were diffuse abdominal pain (26.4%), followed by nausea/vomiting (18.3%) and fever (16.4%).The causes of RI or SI varied significantly within the three groups. Hypercoagulable state was associated with SI, and embolic disease and arterial injury were associated with RI. Extensive (i.e.>2/3 of organ volume) (OR 6.22, 95%CI 2.0119.22) and bilateral infarctions (OR 15.05, 95%CI 1.79-126.78) were significantly associated with hemodynamic shocks. The survival at 1 month follow-up did not significantly differ between the three groups.

CONCLUSION

Acute RI and SI are heterogenous entities in regards to their clinical presentation, etiology, associated venous or arterial thrombosis, but prognoses were not different at short term follow-up.

The application of Strategy-based Training to Enhance Memory (STEM) in multiple sclerosis: A pilot RCT

New learning and memory (NLM) impairments are common in multiple sclerosis (MS), negatively impacting daily life. Few studies seek to remediate these deficits to improve everyday functioning. Self-generation, spaced learning and retrieval practice have been shown to improve NLM in healthy persons and have been incorporated into an 8-session treatment protocol, Strategy-based Training to Enhance Memory (STEM). STEM teaches participants about each of the techniques, how to apply them in daily life and provides practice. Participants are taught to restructure a memory-demanding situation to optimize self-generation, spaced learning and retrieval practice. This pilot double-blind, placebo-controlled, randomized clinical trial (RCT) tested the efficacy of STEM in 20 learning-impaired participants with clinically definite MS (9 treatment, 11 control). Significant treatment effects were noted on self-report measures of daily functioning (primary outcome). Objective neuropsychological testing approached significance, showing a medium-large effect on verbal NLM. Results suggest that STEM may improve everyday functioning in individuals with MS. A full-scale RCT is warranted to validate findings in a larger sample so that findings may be generalized to the broader MS community.

Comparing learning performance on the open trial selective reminding test with the California verbal learning test II in traumatic brain injury

Introduction: Learning and memory deficits are prevalent following moderate to severe traumatic brain injury (TBI), affecting between 54% and 84% of impacted individuals.Objective: The current study examined learning performance on two tests of verbal memory: the OT-SRT and the CVLT-II.Methods: Sixty-eight participants with TBI performed the OT-SRT and the CVLT-II on two different days. Additionally, all participants completed cognitive tests assessing processing speed, working memory and executive functions. By definition, all participants with TBI were identified as having impaired learning on the OT-SRT, however only 38 were also identified as impaired on the CVLT-II. The sample was thus divided into two groups, those who failed both tests (Fail-2) and those who failed only the OT-SRT (Fail-1).Results: The Failed-1 group showed significantly better performance in processing speed, working memory and executive functions compared to the Fail-2 group. On the CVLT-II, the Fail-1 group performed significantly better on the number of words recalled on trials 1 and 5 compared to the Fail-2 group. Both groups performed similarly the OT-SRT.Discussion: The CVLT-II and the OT-SRT are not equivalent tests and should not be used interchangeably.

Factors associated with the remission of insomnia after traumatic brain injury: a traumatic brain injury model systems study

Objective: To examine the factors associated with the remission of insomnia by examining a sample of individuals who had insomnia within the first two years after traumatic brain injury (TBI) and assessing their status at a secondary time point.Design and Methods: Secondary data analysis from a multicenter longitudinal cohort study. A sample of 40 individuals meeting inclusion criteria completed a number of self-report scales measuring sleep/wake characteristics (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index, Sleep Hygiene Index), fatigue and depression (Multidimensional Assessment of Fatigue, Patient Health Questionnaire-9), and community participation (Participation Assessment with Recombined Tools-Objective). One cohort was followed at 1 and 2 years post-injury (n = 19) while a second cohort was followed at 2 and 5 years post-injury (n = 21).Results: Remission of insomnia was noted in 60% of the sample. Those with persistent insomnia had significantly higher levels of fatigue and depression at their final follow-up and poorer sleep hygiene across both follow-up time-points. A trend toward reduced community participation among those with persistent insomnia was also found.Conclusion: Individuals with persistent post-TBI insomnia had poorer psychosocial outcomes. The chronicity of post-TBI insomnia may be associated with sleep-related behaviors that serve as perpetuating factors.

Patterns of cognitive deficits in persons with spinal cord injury as compared with both age-matched and older individuals without spinal cord injury

Context/Objective: Cognitive deficits can impact as many as 60% of individuals with spinal cord injury (SCI). In an effort to identify the nature of cognitive deficits in SCI, we examined neuropsychological test performance in individuals with SCI, age matched healthy controls and older healthy controls.Design: Participants completed a motor-free neuropsychological test battery assessing attention, working memory, information processing speed, new learning /memory and executive control.Setting: Outpatient rehabilitation research facility.Participants: Participants included 60 individuals with chronic spinal cord injury [SCI; 32 with paraplegia (T2-T12) and 28 with tetraplegia (C3-T1)], 30 age-matched healthy controls (AMHC; 30-40 years old) and 20 older healthy controls (OHC; 50-60 years old).Outcome Measures: Wechsler Intelligence Scale - 3^rd edition (WAIS-III) Digit Span and Letter-Number Sequencing; Symbol Digit Modalities Test (SDMT) - oral version; California Verbal Learning Test-II; Paced Auditory Serial Addition Test (PASAT); Wechsler Abbreviated Scale of Intelligence (WASI); Delis-Kaplan Executive Function System; Verbal Fluency subtest.Results: Significant differences were noted between the SCI and AMHC groups on measures of information processing speed, new learning and memory, and verbal fluency. No significant differences were noted between the groups on tests of attention or working memory.Conclusion: The current study documented differences in specific realms of cognitive functioning between a chronic SCI sample and AMHC. Implications for cognitive rehabilitation and overall quality of life are discussed. Additional research is needed utilizing a more comprehensive battery of motor-free neuropsychological tests that avoid the confound of upper limb motor limitations on cognitive performance.

Effects of Sulfated Polysaccharides on Inhibition of Thrombus Formation initiated by Different Stimuli

To test the possibility that different doses of heparin or other sulfated polysaccharides are required to inhibit thrombosis initiated by different stimuli, we compared the effects of heparin (HEP), pentosan polysulfate (SP54) and dermatan sulfate (DS) on the inhibition of thrombus formation induced by either I) tissue thromboplastin; II) thrombin; or III) factor Xa. Inhibition of thrombus formation induced by the stimuli was measured in a rabbit jugular vein hypercoagulation/stasis model. First, we determined the minimum dose of each sulfated polysaccharide which inhibited tissue thromboplastin-induced thrombus formation by ∼75%, and then compared the relative effectiveness of this dose to prevent thrombus formation initiated with the other two stimuli. HEP and SP54 were less effective when thrombin was the thrombogenic stimulus, while DS was more effective. HEP was the most effective agent when factor Xa was the stimulus. We conclude that the antithrombotic effectiveness of a given dose of a sulfated polysaccharide may vary depending on the stimulus which initiates thrombus formation.

Impact of frontal neurobehavioral symptoms on employment in individuals with TBI

OBJECTIVE

To explore the contribution of frontal systems behavioral dysfunction on employment outcomes in individuals with traumatic brain injury (TBI), in the context of relevant predictors of work status.

METHOD

Forty-two participants with history of moderate-to-severe TBI were classified as either "Employed" or "Unemployed." Groups did not differ on most demographic or injury variables, although the Unemployed sample reported greater symptoms of depression, pain, and fatigue (ps < 0.05). Participants completed a neuropsychological evaluation emphasizing frontal systems and Frontal Systems Behavior Scale (FrsBe; self- and informant-rated forms).

RESULTS

T tests using cognitive indicators of frontal dysfunction revealed no significant differences between groups (ps > 0.05). T tests using neurobehavioral indicators of frontal dysfunction (i.e., FrSBe) revealed differences between groups on both self- (Hedge's g = 0.71; p = .046) and informant-rated (g = 1.12; p = .001) FrSBe total T scores. Two logistic regressions for each FrSBe score were conducted, including relevant variables on which samples differed as covariates. Only the informant-rated FrSBe score remained a significant predictor of employment (FrSBe-informant: p = .038; R-squared change = 0.177). Self- and informant-rated FrSBe scores were significantly correlated in the Unemployed group (r = .403; p = .037) but not in the Employed sample (r = .102; p = .717).

CONCLUSIONS

These results suggest that behavioral indicators of frontal systems dysfunction are predictive of employment status in individuals with TBI. Future work should aim to test the efficacy of strategies to reduce dysfunctional frontal behaviors as a means to gain and maintain employment. (PsycINFO Database Record

Zur Enantioselektivität von Phenprocoumon beim Menschen*

Enantiomere sind Moleküle, die sich wie Bild zu Spiegelbild verhalten; sie weisen fast identische chemische oder physikalische Eigenschaften auf, unterscheiden sich aber in ihren physiologischen Wirkungen. Es wird über das unterschiedliche pharmakokinetische Verhalten und die differierenden pharmakodynamischen Eigenschaften der Enantiomeren der oralen Antikoagulanzien Phenoprocoumon (PH), Warfarin (WA) und Acenocoumarol (AC) beim Menschen und über die daraus resultierenden therapeutischen Konsequenzen berichtet.

Für eigene Untersuchungen zur enantioselektiven Elimination von PH bei einer großen Zahl von Patienten unter Langzeit-Antikoagulation wurden die Enantiomere aus Plasmaund Urinproben mit HPLC an chiralen Säulen getrennt und quantifiziert. Die Ergebnisse zeigten folgendes: 1. Bei 50% der Patienten wird das S-Enantiomer langsamer aus dem Plasma eliminiert als das R-Enantiomer, bei 25% mit gleicher Geschwindigkeit und bei weiteren 25% schneller. Dies weist auf eine große interindividuelle Variabilität hin. 2. Das S/R-Verhältnis im Plasma war über die Zeit konstant (intraindividuell konstantes S/R-Verhältnis). 3. Im Durchschnitt wird das S-Enantiomer jedoch nach Abbruch der PHTherapie schneller eliminiert als das R-Enantiomer. Die Eliminationshalbwertszeiten aus dem Plasma betragen 123,7 ± 43,6 h für das Sund 156,5 ± 72,4 h für das R-Enantiomer. 4. Die Plasmaproteinbindung für das Sund R-Enantiomer ist unterschiedlich (fu%: 0,198 für S; 0,322 für R). 5. Der enantioselektive Effekt der Elimination ist bei PH nicht so ausgeprägt wie bei WA und könnte das beobachtete unterschiedliche Spektrum an Interaktionen mit anderen Arzneimitteln erklären.

Veränderungen der freien Thrombozytennukleotide beim Sanarelli-Shwartzman-Phänomen

Beim Sanarelli-Shwartzman-Phänomen des Kaninchens findet man neben anderen Gerinnungsstörungen auch eine verminderte Retraktionsfähigkeit des Blutes. Ursache hierfür ist ein Verlust von energiereichem Phosphat (ATP) in den Thrombozyten, welches offenbar mit anderen Nukleotiden die geschädigten Plättchen verläßt. Es kann dabei eine quantitative Beziehung zwischen dem ATP-Gehalt der Plättchen und dem m-Wert des TEG nachgewiesen werden. Für die Thrombozytenschädigung wird intravasal auftretendes Thrombin verantwortlich gemacht, welches die viskose Metamorphose startet, die Permeabilität verändert und so die Blutplättchen zum Untergang vorbereitet. Quantitative und qualitative Plättchenveränderungen sind die Folge. Freiwerdende Plättchen- lipide gehen im Rahmen der Thrombokinasefunktion des Blutes in den ubiquitären intravasalen Gerinnungsprozeß ein. Die konsekutive Thrombozytopathie bzw. experimentelle “Thrombasthenie” bietet gewissermaßen im Modell weitere Ansatzpunkte für Thrombozytenstudien.

Über die Wirkung von Lipidemulsionen auf Blutplättchen

In vorliegenden Untersuchungen konnte gezeigt werden, daß zahlreiche Lipid-Wasser-Emulsionen zu einer ausgeprägten und rasch einsetzenden Steigerung der Thrombozytenaggregation führen. Bei Abwesenheit von Kalziumionen in EDTA-Plasma ließ sich ein Lipideffekt an Thrombozyten nicht mehr nachweisen. Mehrfach gewaschene Plättchen zeigten jedoch auch ohne Kalziumionen eine deutliche Steigerung der Aggregation. Bei 4° C war der Ablauf der Aggregation deutlich verlangsamt. Die Zugabe von Albumin oder EPL verhinderte die aggregationssteigernde Wirkung einer Lipidemulsion. Adenosin führte lediglich zu einer teilweisen Hemmung der lipid -induzierten Klebrigkeitssteigerung. Aufgrund der Ergebnisse wird vermutet, daß der erste Schritt der Wirkung einer Lipidemulsion auf Thrombozyten mit der Oberflächenaktivität der Emulsionsteilchen in ursächlichem Zusammenhang steht. Im weiteren Verlauf kommt es zu einer Phagozytose von Lipidemulsionsteilchen durch Thrombozyten, was mit einer Zunahme einer Aggregationsneigung und erheblichen morphologischen und biochemischen Veränderungen verknüpft ist.

Über die Wirkung von Lipidemulsionen auf Blutplättchen

Der Einfluß emulgierter Lipide (Fettsäuren, Triglyzeride, Lipidgemische) und fettähnlicher Substanzen (Paraffin- und Silikonöl) auf die Struktur der Blutplättchen von Mensch und Schwein wurde licht- und elektronenmikroskopisch untersucht. Es zeigte sich, daß die Emulsionsteilchen aller geprüften Substanzen von den Plättchen durch Membraninvagination, wie das bei phagozytierenden Zellen bekannt ist, aufgenommen werden. Daneben beobachteten wir eine vermutlich ADP-induzierte Neigung der Plättchen zu aggregieren, die durch Adenosin gehemmt wurde. Emulsionen mit hohem Anteil unveresterter Fettsäuren oder reine Fettsäureemulsionen führten darüber hinaus zu starken Destruktionen der Plättchen, während nach Behandlung mit Triglyzeriden oder Lipidgemischen ohne freie Fettsäuren diese Erscheinungen erst nach langen Inkubationszeiten auftraten und sich vermindern ließen, wenn die intraplasmatische Lipolyse durch Protaminsulfat gehemmt wurde. Der Zusatz von Emulgatoren (Albumin, Phospholipide) setzte die Fettsäurewirkung und die Aggregationsneigung der Plättchen herab, EDTA verhinderte die Aggregatbildung völlig. Aus den Beobachtungen schließen wir, daß für die Aufnahme von Lipiden die Eigenschaften der Emulsionsteilchen bestimmend sind, während freie Fettsäuren aufgrund ihrer Moleküleigenschaften die Plättchenmembranen passieren und in hohen Konzentrationen zur Zellzerstörung führen.

Surgically assisted rapid palatal expansion in class III malocclusion: Our experience

INTRODUCTION

Maxillary transverse deficiency (MTD) is a common facial disharmony that may need surgical assisted rapid palatal expansion (SARPE). The aim of this study was to present our SARPE technique and to report about our experience.

MATERIEL AND METHOD

Medical records of all class III patients who underwent SARPE in our department from 2010 to 2015 and for whom a follow-up of at least 1year was available, were included in a retrospective study. The technique consisted, after short orthodontic preparation allowing for divergence of the upper central incisors, in a complete Le Fort I osteotomy without down fracture, and medial sagittal submucosal separation of the hard palate under general anesthesia in an inpatient procedure. Teeth-supported distracters were sealed preoperatively while bone-supported devices were inserted peroperatively. Activation of the distracter was allowed from day 2 at the rate of 2×0.25 per day during 4days and 2×0.5mm per day the following days. Distracters were left in place for about 4months. Orthodontic treatment resumption was allowed from the second month. The initial malocclusion, the amount and type (parallel or angular) of distraction that was needed, the type of distracter used, the amount of distraction obtained, the per- and postoperative complications and the clinical stability of the end result were analyzed.

RESULTS

The records of 23 patients (18 women, 5 men - average age: 25.4years, extremes: 16-55years) could be included. MTD was isolated in 6 cases, associated with a maxillary retrognathism in 5 cases, with a mandibular prognathism in 6 cases, and with both in 6 cases. The average amount of distraction needed was 7.2mm (range: 4-12), parallel in 20 cases and angular in 3 cases. The distracters were bone-supported (Rapid Palatal Expander^®, KLS Martin Group, Tuttlingen, Germany) in 3 patients and custom-made tooth-supported in 20 patients. The average amount of distraction obtained at the level of the distracter cylinder was 7.7mm (range: 5-13). We noted 2 cases of palatal fibromucosa perforations, 1 case of posterior excess of distraction, 1 case of nasal septum deviation, 1 case of iatrogenic necrosis of tooth No.°11, 1 case of naso-genial sulcus hematoma, 1 case of intraoperative mobility of tooth No.°21, 5 cases of asymmetric distraction. Seventeen patients needed a second orthognathic procedure and 22 had stable Class I occlusion after removal of appliances at 18 months follow-up on average.

DISCUSSION

SARPE is a quite safe procedure that allows for transverse coordination without dental extraction. Transverse discrepancies greater than 4mm are for us clear indications for SARPE. When a sagittal discrepancy is associated, we prefer performing SARPE first and correcting the sagittal plane in a second operation. The recent development of Le Fort I sliding osteosynthesis plates opens the way to one time correction and the development of double-action distracters fitted out with 2 cylinders will be helpful for performing angular distractions.

Pulmonary lymphatic vessel morphology: a review

Our understanding of lymphatic vessels has been advanced by the recent identification of relatively specific lymphatic endothelium markers, including Prox-1, VEGFR3, podoplanin and LYVE-1. The use of lymphatic markers has led to the observation that, contrary to previous assumptions, human lymphatic vessels extend deep inside the pulmonary lobule, either in association with bronchioles, intralobular arterioles or small pulmonary veins. Pulmonary lymphatic vessels may thus be classified into pleural, interlobular (in interlobular septa) and intralobular. Intralobular lymphatic vessels may be further subdivided in: bronchovascular (associated with a bronchovascular bundle), perivascular (associated with a blood vessel), peribronchiolar (associated with a bronchiole), and interalveolar (in interalveolar septa). Most of the intralobular lymphatic vessels are in close contact with a blood vessel, either alone or within a bronchovascular bundle. A minority is associated with a bronchiole, and small lymphatics are occasionally present even in interalveolar septa, seemingly independent of blood vessels or bronchioles. The lymphatics of the interlobular septa often contain valves, are usually associated with the pulmonary veins, and connect with the pleural lymphatics. The large lymphatics associated with bronchovascular bundles have similar characteristics to pleural and interlobular lymphatics and may be considered conducting vessels. The numerous small perivascular lymphatics and the few peribronchiolar ones that are found inside the lobule are probably the absorbing compartment of the lung responsible for maintaining the alveolar interstitium relatively dry in order to provide a minimal thickness of the air-blood barrier and thus optimize gas diffusion. These lymphatic populations could be differentially involved in the pathogenesis of diseases preferentially involving distinct lung compartments.