Responder analysis confirms results of a stroke transitional care trial but provides more interpretable results

OBJECTIVES

Interpreting between-group differences in patient-reported outcome measures can be challenging. Responder analyses, which compare the proportions of patients who achieve a meaningful clinical change, represent a more interpretable approach. We conducted a secondary responder analysis of the Michigan Stroke Transitions Trial (MISTT).

STUDY DESIGN AND SETTING

The MISTT randomized 265 patients with stroke to three treatment groups: usual care [UC], social work case management [SWCM], or social work case management plus access to a patient-oriented website [SWCM + website]. Two Patient-Reported Outcomes Measurement and Information System (PROMIS) Global-10 subscales (representing physical and mental health) and 5 additional patient-reported outcomes were collected at baseline and 90-days. Responder analyses were conducted using modified Poisson and linear regression using published minimal important differences. Multiple imputation was used to address missing data.

RESULTS

For the PROMIS-10 global physical health subscale, responders were 80% more common in the SWCM + website group compared to the UC group (relative risk = 1.8, 95% confidence interval [CI]: 1.0, 3.1), with a number needed to treat of 7 (95% CI: 3, 112). No significant treatment effects were observed for the PROMIS-10 global mental health subscale.

CONCLUSION

Results of this responder analysis were largely consistent with the original trial analysis but have the advantage of presenting treatment effects using more clinically interpretable number needed to treat metrics.

Effect of transitional care stroke case management interventions on caregiver outcomes: the MISTT randomized trial

This study reports on outcomes for 169 caregivers enrolled in the Michigan Stroke Transitions Trial (MISTT), an RCT of social work case management for stroke patients returning home. A mixed-model approach examined the mean change from 7- to 90-days post-discharge with group-by-time interactions for differences between treatment groups. Caregivers reported few life changes or depressive symptoms from caregiving. There was no significant change over time or treatment effects. Negative aspects of stroke caregiving may take longer to develop. Focused caregiver assessment at discharge and a better understanding of how caregiving develops over time may improve the type and timing of support.

Changes in PHQ-9 depression scores in acute stroke patients shortly after returning home

Introduction

Post-stroke depression is a disabling condition that occurs in approximately one-third of stroke survivors. There is limited information on changes in depressive symptoms shortly after stroke survivors return home. To identify factors associated with changes in post-stroke depressive symptoms during the early recovery period, we conducted a secondary analysis of patients enrolled in a clinical trial conducted during the transition period shortly after patients returned home (MISTT).

Methods

The Michigan Stroke Transitions Trial (MISTT) tested the efficacy of social worker case management and access to online information to improve patient-reported outcomes following an acute stroke. Patient Health Questionnaire-9 (PHQ-9) scores were collected via telephone interviews conducted at 7 and 90 days post-discharge; higher scores indicate more depressive symptoms. Generalized estimating equations were used to identify independent predictors of baseline PHQ-9 score at 7 days and of changes over time to 90 days.

Results

Of 265 patients, 193 and 185 completed the PHQ-9 survey at 7 and 90 days, respectively. The mean PHQ-9 score was 5.9 at 7 days and 5.1 at 90 days. Older age, being unmarried, and having moderate stroke severity (versus mild) were significantly associated with lower 7-day PHQ-9 scores (indicating fewer depressive symptoms). However, at 90 days, both unmarried patients and those with moderate or high stroke severity had significant increases in depressive symptoms over time.

Conclusions

In stroke patients who recently returned home, both marital status and stroke severity were associated with depressive symptom scores; however, the relationships were complex. Being unmarried and having higher stroke severity was associated with fewer depressive symptoms at baseline, but both factors were associated with worsening depressive symptoms over time. Identifying risk factors for changes in depressive symptoms may help guide effective management strategies during the early recovery period.

Opening Pandora's Box: From Readmissions to Transitional Care Patient-Centered Outcome Measures

BACKGROUND

Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice.

METHODS AND RESULTS

This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition.

CONCLUSION

Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Presumed neuroprotective therapies prescribed by veterinary ophthalmologists for canine degenerative retinal and optic nerve diseases

OBJECTIVE

To investigate veterinary ophthalmologists' use of presumed neuroprotective therapies for degenerative retinal and optic nerve diseases in dogs.

PROCEDURES

An online survey was sent to 663 board-certified veterinary ophthalmologists who were Diplomates of the American College of Veterinary Ophthalmologists (ACVO), Asian College of Veterinary Ophthalmologists (AiCVO), Latin American College of Veterinary Ophthalmologists (Colegio Latinoamericano de Oftalmólogos Veterinarios, CLOVE), or European College of Veterinary Ophthalmologists (ECVO). The survey was created using Qualtrics® software and focused on the prescription of presumed neuroprotective treatments for canine glaucoma, sudden acquired retinal degeneration syndrome (SARDS), progressive retinal atrophy (PRA), and retinal detachment (RD).

RESULTS

A total of 165 completed surveys were received, representing an overall response rate of 25%, which was comparable across the four specialty colleges. Of all respondents, 140/165 (85%) prescribed some form of presumed neuroprotective therapies at least once in the last five years: 114/165 (69%) for glaucoma, 51/165 (31%) for SARDS, 116/165 (70%) for PRA, and 50/165 (30%) for RD. The three most recommended neuroprotective reagents were the commercial Ocu-GLO™ Vision Supplement for animals, amlodipine, and human eye supplements.

CONCLUSIONS

Despite lack of published clinical efficacy data, the majority of surveyed board-certified veterinary ophthalmologists previously prescribed a presumed neuroprotective therapy at least once in the last five years in dogs with degenerative retinal and optic nerve diseases.

Unmet Needs of US Acute Stroke Survivors Enrolled in a Transitional Care Intervention Trial

BACKGROUND

Needs of patients that go unmet after a stroke can compromise the speed and extent of recovery. While unmet needs in long-term survivors has been studied, less is known about the unmet needs of acute stroke survivors. We examine unmet needs in the immediate postdischarge period among 160 participants in the (blinded for review) a transitional care intervention conducted in (blinded for review [1 US state]) during 2016 and 2017.

METHODS

Bivariate and multivariate analyses using Poisson models were used to examine the relationship between total number of unmet needs and demographics, stroke type and severity, stroke effects, and stroke risk factors.

RESULTS

The mean number of unmet needs was 4.55; number of unmet needs ranged from 2 to9; all participants had some unmet need. The most common unmet needs were stroke education (73.8%), financial (33.8%), and health-related (29.4%). In the final multivariate model income and education were inversely associated with number of unmet needs. As total number of stroke effects increased, so did number of unmet needs. Demographic variables (age, gender, and race), stroke risk factors, stroke type, and stroke severity were not statistically significantly associated with the number of unmet needs.

CONCLUSIONS

These results identify that in the acute post discharge period stroke survivors have many unmet needs that range from physical to psychosocial. Targeting interventions to those with the potential for greater numbers of unmet needs might be a salient clinical approach to improving stroke recovery and rehabilitation.

Michigan Stroke Transitions Trial

BACKGROUND

To test whether access to home-based social worker-led case management (SWCM) program or SWCM program combined with a website providing stroke-related information improves patient-reported outcomes in patients with stroke, relative to usual care.

METHODS AND RESULTS

The MISTT (Michigan Stroke Transitions Trial), an open (unblinded) 3-group parallel-design clinical trial, randomized 265 acute patients with stroke to 3 treatment groups: Usual Care (group-1), SWCM (group-2), and SWCM+MISTT website (group-3). Patients were discharged directly home or returned home within 4 weeks of discharge to a rehabilitation facility. The SWCM program provided in-home and phone-based case management services. The website provided patient-orientated information covering stroke education, prevention, recovery, and community resources. Both interventions were provided for up to 90 days. Outcomes data were collected by telephone at 7 and 90 days. Primary patient-reported outcomes included Patient-Reported Outcomes Measurement Information System Global-10 Quality-of-Life (Physical and Mental Health subscales) and the Patient Activation Measure. Treatment efficacy was determined by comparing the change in mean response (90 days minus 7 days) between the 3 treatment groups using a group-by-time interaction. Subjects were aged 66 years on average, 49% were female, 21% nonwhite, and 86% had ischemic stroke. There were statistically significant changes in Patient-Reported Outcomes Measurement Information System Physical Health ( P=0.003) and Patient Activation Measure ( P=0.042), but not Patient-Reported Outcomes Measurement Information System Mental Health ( P=0.56). The mean change in Patient-Reported Outcomes Measurement Information System Physical Health scores for group-3 (SWCM+MISTT Website) was significantly higher than both group-2 (SWCM; difference, +2.4; 95% CI, 0.46-4.34; P=0.02) and group-1 (usual care; difference, +3.4; 95% CI, 1.41-5.33; P<0.001). The mean change in Patient Activation Measure scores for group-3 was significantly higher than group-2 (+6.7; 95% CI, 1.26-12.08; P=0.02) and marginally higher than group-1 (+5.0; 95% CI, -0.47 to 10.52; P=0.07).

CONCLUSIONS

An intervention that combined SWCM with access to online stroke-related information produced greater gains in patient-reported physical health and activation compared with usual care or case management alone. There was no intervention effect on mental health.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02653170.

Abstract TP337: Predictors of the Patient Activation Measure (PAM) Among Acute Stroke Survivors: An Analysis of the Michigan Stroke Transitions Trial (MISTT) Data

Introduction: Stroke transitions-of-care are complex and effective self-management is required for success. Patient activation, measured by the Patient Activation Measure (PAM), is a self-management construct that measures knowledge, skill, and confidence to manage one’s own health. Scores from this 13-item instrument range from 0-100 with mean scores of 62 (SD=13). PAM has been validated among ill and healthy populations, however, little is known about what factors are associated with PAM among stroke survivors.

Methods: This cross-sectional analysis of the Michigan Stroke Transitions Trial (MISTT) utilized interview data collected 7 days after stroke survivors returned home. Multivariable linear regression was used to identify independent associations between PAM scores and a range of patient factors including sociodemographic, perceived support, general health, and stroke-related characteristics. Age and education were forced into the model.

Results: Of 265 participants, 180 (70%) completed the 7-day interview. Mean age was 66 years (range 27-90), 49% were female, 18% were non-white, 88% had ischemic stroke, and 53% were discharged to acute or sub-acute rehab. 64% also had a caregiver enrolled in the MISTT trial. The mean PAM score was 64.5 (SD=16). Perceived emotional support was positively associated with PAM score, while having a consented caregiver and higher self-reported post-stroke disability were negatively associated with PAM (Table).

Conclusions: Perceived emotional support, caregiver involvement, and post-stroke disability were associated with patent activation. These may represent intervention targets for enhancing post-stroke transitions.

Abstract TP353: Accuracy of Self-reported 90-day Home Time in Stroke Survivors: Data from the Michigan Stroke Transitions Trial (MISTT)

Introduction: Home time, defined as the number of days spent away from home following hospital discharge, is used as a proxy measure of functional recovery in stroke studies. Data on home time may be obtained from clinical or administrative data, or by direct patient interview. There is little information on the accuracy of self-reported home time.

Methods: We measured the accuracy of self-reported home time using data from the Michigan Stroke Transitions Trial (MISTT) - a randomized trial of case management to improve outcomes in acute stroke patients who returned home after hospitalization. We calculated 90-day home time using information on readmissions to hospitals or rehab facilities obtained from the eMRs of the original admitting hospital and other external reports. Patients or their proxies who completed a 90-day telephone interview reported the number of nights they spent away from home due to medical reasons since first returning home. We compared the agreement between calculated and self-reported home time using kappa statistics.

Results: Of 265 enrolled subjects, 214 (81%) completed a 90-day interview and of these, self-reported home time data was available on 195 (91%). Based on calculated home time, 21.5% (42/195) of patients spent at least one night away from home during the 90-day period. The mean and median calculated home time was 88 and 90 days, respectively. When compared to self-reported home time, the kappa statistic for the binary outcome of 90-day home time versus <90days was 0.64 (95%CI = 0.51-0.77). When home time was classified into 3 categories (Table), the observed agreement was 85% and the weighted kappa 0.59 (95%CI = 0.45-0.72) indicating good agreement beyond chance. Women and patients first discharged to a rehab facility were more likely to report discrepancies of >= 1 week in home time.

Conclusions: Self-reported home time data has acceptable reliability for use as an outcome measure in stroke studies.

Abstract 119: Final Patient-Level Results From the Michigan Stroke Transitions Trial (MISTT): A Randomized Clinical Trial to Improve Stroke Transitions

Background: Navigating the transition after returning home following a stroke can be associated with substantial psychosocial and health-related challenges. The Michigan Stroke Transitions Trial (MISTT) tested the efficacy of a social work case management (SWCM) program and access to an online information and support resource (MISTT Website) to improve outcomes in acute stroke patients who returned home.

Methods: MISTT was a randomized, pragmatic, open, 3-group parallel designed trial conducted in 3 Michigan hospitals. Eligible subjects were acute stroke patients who returned home either directly or within 4 weeks of being discharged to a rehab facility. A total of 265 patients were randomized to one of 3 groups: 1) usual care, 2) SWCM program only, or 3) SWCM plus MISTT Website access. Interventions concluded after 90-days. Primary outcomes including Quality-of-Life (PROMIS Global-10 physical- and mental-health subscales) and the Patient Activation Measure (PAM) were collected by telephone at 7- and 90-days. The change in outcomes (90-day minus 7-day) between the three treatment groups was assessed using a differences-in-differences (D-in-D) analysis.

Results: The mean age of the 265 randomized subjects was 66 years, 49% were female, 21% non-white, 14% had hemorrhagic stroke, 56% were discharged to a rehab facility. Following the intervention there were statistically significant treatment group differences in PROMIS physical-health (p=0.003) and PAM (p=0.042), but not PROMIS mental-health (p=0.56). Mean change in physical-health scores for group-3 (SWCM+Website) was significantly higher than both group-1 (Usual Care) (difference= 3.4; 95%CI=1.41, 5.33; p<0.001) and group-2 (SWCM) (difference= 2.4; 95%CI=0.46, 4.34; p=0.02). The mean change in PAM scores for group-3 was significantly higher than group-2 (6.7; 95%CI=1.26, 12.08; p=0.02) and marginally higher than group-1 (5.0; 95%CI=-0.47, 10.52; p=0.07).

Conclusion: An intervention that combined social worker-led case management with access to online stroke-related information produced greater gains in patient-reported physical health and activation compared to usual care or case management alone. [ClinicalTrials.gov: NCT02653170].

ATR-101, a selective ACAT1 inhibitor, decreases ACTH-stimulated cortisol concentrations in dogs with naturally occurring Cushing's syndrome

BACKGROUND

Cushing's syndrome in humans shares many similarities with its counterpart in dogs in terms of etiology (pituitary versus adrenal causes), clinical signs, and pathophysiologic sequelae. In both species, treatment of pituitary- and adrenal-dependent disease is met with limitations. ATR-101, a selective inhibitor of ACAT1 (acyl coenzyme A:cholesterol acyltransferase 1), is a novel small molecule therapeutic currently in clinical development for the treatment of adrenocortical carcinoma, congenital adrenal hyperplasia, and Cushing's syndrome in humans. Previous studies in healthy dogs have shown that ATR-101 treatment led to rapid, dose-dependent decreases in adrenocorticotropic hormone (ACTH) stimulated cortisol levels. The purpose of this clinical study was to investigate the effects of ATR-101 in dogs with Cushing's syndrome.

METHODS

ATR-101 pharmacokinetics and activity were assessed in 10 dogs with naturally-occurring Cushing's syndrome, including 7 dogs with pituitary-dependent disease and 3 dogs with adrenal-dependent disease. ATR-101 was administered at 3 mg/kg PO once daily for one week, followed by 30 mg/kg PO once daily for one (n = 4) or three (n = 6) weeks. Clinical, biochemical, adrenal hormonal, and pharmacokinetic data were obtained weekly for study duration.

RESULTS

ATR-101 exposure increased with increasing dose. ACTH-stimulated cortisol concentrations, the primary endpoint for the study, were significantly decreased with responders (9 of 10 dogs) experiencing a mean ± standard deviation reduction in cortisol levels of 50 ± 17% at study completion. Decreases in pre-ACTH-stimulated cortisol concentrations were observed in some dogs although overall changes in pre-ACTH cortisol concentrations were not significant. The compound was well-tolerated and no serious drug-related adverse effects were reported.

CONCLUSIONS

This study highlights the potential utility of naturally occurring canine Cushing's syndrome as a model for human disease and provides proof of concept for ATR-101 as a novel agent for the treatment of endocrine disorders like Cushing's syndrome in humans.

Improving stroke transitions: Development and implementation of a social work case management intervention

Strokes impact over 800,000 people every year. Stroke care typically begins with inpatient care and then continues across an array of healthcare settings. These transitions are difficult for patients and caregivers, with psychosocial needs going unmet. Our team developed a case management intervention for acute stroke patients and their caregivers aimed at improving stroke transitions. The intervention focusses on four aspects of a successful care transition: support, preparedness, identifying and addressing unmet needs, and stroke education. This paper describes the development and implementation of this program, and is an example of the synergy created between neuroscience and clinical practice.

Abstract WP313: Predictors of Early Depression in Stroke Patients Enrolled in the Michigan Stroke Transitions Trial (mistt)

Background: The period immediately after returning home from the acute care setting is a particularly stressful time for stroke patients. We report on depressive symptoms collected shortly after returning home in stroke patients enrolled in the Michigan Stroke Transitions Trial (MISTT) - a randomized trial designed to improve transition experience.

Methods: Acute stroke patients were recruited from 3 Michigan hospitals. Eligible subjects were those discharged home or expected to return home within 4 weeks of discharge to a rehab facility. Baseline data, which included demographics, socio-economic factors, stroke type, medical history, type and duration of rehab care, and recent hospital or ED visits, were abstracted from hospital charts or collected by phone interview conducted 7 days after returning home. Data on depressive symptoms at 7 days was collected using the PHQ-9 instrument (score range 0-27). A depressive disorder was defined as PHQ-9 score >=10 (equivalent to at least moderate depression). Risk factors for depression were identified using multivariable logistic regression. Race, sex and discharge destination were forced into the model regardless of significance.

Results: Of 199 subjects randomized in the first 12 months of the study, 156 (78%) had PHQ-9 data collected at 7 days, and 29 (18.6%) had a PHQ9 score of >= 10. Final multivariable model results (Table) indicate that only age and recent ED or hospital use were significantly associated with depression. Depression was much lower in older age groups, and a hospital or ED visit since returning home was associated with a 4-fold increase in the odds of depression. When history of past depression was added to the model the impact of recent hospital or ER visits attenuated.

Conclusion: Depressive symptoms are relatively common among stroke survivors within the first week of returning home. Young age, recent hospital visits, and a past diagnosis of depression were significant risk factors for early depression.

Abstract TP300: Where Did They Go? Recruitment and Retention in the Michigan Stroke Transitions Trial (MISTT)

Background: Poor transitions adversely affect stroke survivors and contribute to readmissions and poor quality of life. More randomized trials are needed to identify effective interventions to improve patient wellbeing during the transitional period. However, the post-discharge period is complex and presents many practical challenges for transition trials when patients move between different care settings. We report on recruitment and retention challenges in the Michigan Stroke Transitions Trial (MISTT) designed to improve the transition experience of stroke survivors.

Methods: MISTT, a 3 group pragmatic randomized trial, tested the efficacy of an in-home social work case management (SWCM) program and SWCM with an informational website against usual care. Eligible subjects were acute stroke patients discharged directly home or who had an expected rehab stay <4 weeks. Randomization occurred the day subjects were discharged home. Patient-centered outcomes were collected by phone 90-days later.

Results: Figure 1 shows recruitment and retention data during the first 15 months. Of 242 subjects enrolled, 40 (17%) were dropped pre-randomization largely due to extended rehab stays. Of 136 subjects randomized to SWCM or SWCM+website, the intervention was not started in 14 (10%) due to early withdrawals or unwillingness to participate. A total of 188 subjects were eligible for 90 day follow-up. Lost to follow-up (n=43) occurred in 20%, 24% and 21% of the usual care, SWCM, and SWCM+Website groups, respectively. Half of the LTFU was due to patient withdrawals (n=23); reasons included study demands (n=9), protocol deviations (n=6), and deteriorating health conditions (n=5).

Conclusion: The complexity of stroke transitions creates challenges for recruiting and retaining study participants in transition trials. These issues are important to consider in future study design and are relevant to understanding the validity of study results.

Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

Background

For some stroke patients and caregivers, navigating the transition between hospital discharge and returning home is associated with substantial psychosocial and health-related challenges. Currently, no evidence-based standard of care exists that addresses the concerns of stroke patients and caregivers during the transition period. Objectives of the Michigan Stroke Transitions Trial (MISTT) are to test the impact of a social worker home-based case management program, as well as an online information and support resource, on patient and caregiver outcomes after returning home.

Methods

The Michigan Stroke Transitions Trial is a randomized, pragmatic, open (un-blinded), 3-group parallel designed superiority trial conducted in 3 Michigan hospitals. Eligible participants are adult acute stroke patients discharged home directly or within 4 weeks of being discharged to a rehabilitation facility. The patient’s primary caregiver is also invited to participate. Patients are randomized on the day they return home using a randomized block design. Consented patients discharged to a rehabilitation facility who do not go home within 4 weeks are dropped from the study.

The 2 study interventions begin within a week of returning home and conclude 3 months later. The 3-group design compares usual care to either a home-based social worker stroke case management (SWSCM) program, or a combination of the SWSCM program plus access to an online information and support resource (MISTT website). Outcomes data are collected at 7-days and 90-days by trained telephone interviewers. Primary patient outcomes include the PROMIS global 10 score (a generic Quality of Life scale), and the Patient Activation Measure (PAM). Caregiver outcomes include the Bakas Caregiving Outcomes Scale. Final analysis will be based on 214 randomized acute stroke patients. To accommodate subjects excluded due to prolonged rehabilitation stays, as well as those lost-to-follow-up, up to 315 patients will be consented.

Discussion

The MISTT study will determine if a home-based case management program designed around the needs and preferences of stroke patients and caregivers, alone or in combination with a patient-centered online information and support resource can improve stroke survivor and caregiver outcomes 3 months after returning home.

Trial registration

ClinicalTrials.gov: NCT02653170 (Protocol ID: 135457). Registered April 9, 2015.

Effects of negative pressure wound therapy on healing of free full-thickness skin grafts in dogs

OBJECTIVE

To compare healing of free, full-thickness, meshed skin grafts under negative pressure wound therapy (NPWT) with bolster dressings in dogs.

STUDY DESIGN

Randomized, controlled experimental study, paired design.

ANIMALS

Dogs (n = 5) METHODS: Full-thickness skin wounds (4 cm × 1.5 cm) were created bilaterally on the antebrachia of 5 dogs (n = 10). Excised skin was grafted to the contralateral limb. Grafts were randomized to NPWT or bolster dressings (control; CON). NPWT was applied continuously for 7 days. Grafts were evaluated on Days 2, 4, 7, 10, 14, and 17, biopsied on days 0, 4, 7, and 14, and had microbial culture on Day 7. Outcome variables were: time to first appearance of granulation tissue, percent graft necrosis, and percent open mesh. Significance was set at P < .05. Histologic findings, culture results, and graft appearance were reported.

RESULTS

Granulation tissue appeared earlier in the NPWT grafts compared with CON grafts. Percent graft necrosis and remaining open mesh area were both greater in CON grafts compared with NPWT grafts at most time points. Histologic results showed no significant difference in all variables measured, and all cultures were negative.

CONCLUSIONS

Variables of graft acceptance were superior when NPWT was used in the first week post-grafting. Fibroplasia was enhanced, open meshes closed more rapidly and less graft necrosis occurred with NPWT application. More preclinical studies are required to evaluate histologic differences.

Effects of a cross-linked hyaluronic acid based gel on the healing of open wounds in dogs

OBJECTIVE

To compare effects of a cross-linked hyaluronic acid (HA) based gel (CMHA-S) to a standard wound management protocol on the healing of acute, full-thickness wounds in dogs.

STUDY DESIGN

A prospective, controlled, experimental study.

ANIMALS

Purpose-bred, adult, female beagles (n = 10).

METHODS

Two 2 × 2 cm wounds were surgically created bilaterally on the trunk of each dog and each side randomized to treatment (CMHA-S) or control (CON) groups. Total and open wound areas were measured with digital image planimetry at 15 time points. From these data, percent contraction and percent epithelialization were calculated. Tissue biopsies were obtained at 6 time points and histologic features were scored.

RESULTS

Total wound area was significantly larger and percent contraction was significantly less in CMHA-S compared to CON wounds at all data points between days 9 and 18. At day 25, and for the remainder of the study, CMHA-S wounds were smaller and contracted more than CON wounds, reaching significance at day 32. Percent epithelialization was significantly less in CMHA-S compared to CON wounds at all data points after day 11. Histologically, fibroblastic cellular infiltration was significantly higher in CMHA-S wounds at day 21.

CONCLUSIONS

CMHA-S wounds healed more slowly than CON wounds. This HA-based gel is not indicated in acute, full-thickness skin wounds in dogs as administered in this study. However, treatment may be beneficial in the mid-to-late repair stage of healing, or if scar minimization is desired. Further studies to evaluate the effects of the CMHA-S gel on canine wounds are indicated.

Esophageal dysfunction in dogs with idiopathic laryngeal paralysis: a controlled cohort study

OBJECTIVES

To compare esophageal function in dogs with idiopathic laryngeal paralysis (ILP) to age and breed matched controls; to determine if dysfunction is associated with aspiration pneumonia over 1 year; and to compare clinical neurologic examination of dogs with ILP at enrollment and at 1 year.

STUDY DESIGN

Prospective controlled cohort study.

ANIMALS

Dogs with ILP (n=32) and 34 age and breed matched healthy dogs.

METHODS

Mean esophageal score was determined for each phase of 3 phase esophagrams, analyzed blindly. After unilateral cricoarytenoid laryngoplasty, dogs with ILP were reexamined (including thoracic radiography) at 1, 3, 6, and 12 months. Neurologic status was recorded at enrollment, 6 and 12 months.

RESULTS

Esophagram scores in dogs with ILP were significantly higher in each phase compared with controls, most notably with liquid (P<.0001). Dysfunction was more pronounced in the cervical and cranial thoracic esophagus. Five dogs that had aspiration pneumonia during the study had significantly higher esophagram scores than dogs that did not develop aspiration pneumonia (P<.02). Ten (31%) ILP dogs had generalized neurologic signs on enrollment and all ILP dogs developed neurologic signs by 1 year (P<.0001). Conclusions- Dogs with ILP also have esophageal dysfunction. Postoperative aspiration pneumonia is more likely in dogs with higher esophagram scores. Dogs with ILP will most likely develop generalized neuropathy over the course of 1 year.

CLINICAL RELEVANCE

Esophagrams and neurologic examinations should be performed on all dogs with ILP.

ESOPHAGEAL DYSFUNCTION IN DOGS WITH IDIOPATHIC LARYNGEAL PARALYSIS: A CONTROLLED COHORT STUDY

Objectives: To compare esophageal function in dogs with idiopathic laryngeal paralysis (ILP) to age- and breed-matched controls; to determine if dysfunction is associated with aspiration pneumonia over one year; and to compare clinical neurologic examination of dogs with ILP at enrollment and one year.

Study Design: Prospective controlled cohort study

Animals or Sample Population: 32 dogs with ILP, and 34 age- and breed-matched healthy dogs.

Methods: Three-phase esophagrams were performed on all dogs. Blinded analyses of the esophagrams were performed, and the mean esophageal score determined in each phase. Following unilateral crico-arytenoid laryngoplasty, dogs with ILP were re-examined including thoracic radiography at 1, 3, 6 and 12 months. Neurologic status was recorded at enrollment, 6 and 12 months.

Results: Esophagram scores in dogs with ILP were significantly higher in each phase compared to the controls, most notably with liquid (P&lt;.0001). Dysfunction was more pronounced in the cervical and cranial thoracic esophagus. The 5 dogs that experienced aspiration pneumonia during the study period had significantly higher esophagram scores than the dogs that did not develop aspiration pneumonia (P&lt;0.02). Ten of the 32 (31%) dogs with ILP had generalized neurologic signs upon enrollment and all (100%) dogs developed neurologic signs over one year (P&lt;.0001).

Conclusions: Dogs with ILP also have esophageal dysfunction. Post-operative aspiration pneumonia is more likely in dogs with higher esophagram scores. Dogs with ILP will most likely develop generalized neuropathy over the course of a year.

Clinical Relevance: Esophagrams and neurologic examinations should be performed on all dogs with ILP.