Mercy General Hospital

Ultrasound-guided compression repair (UGCR) of catheterization-related femoral artery injuries was evaluated as a possible new imaging-guided interventional procedure. Thirty-nine femoral artery injuries (35 pseudoaneurysms, four arteriovenous fistulas) were detected with color Doppler flow imaging in patients with enlarging groin hematomas and/or groin bruits 6 hours to 14 days after catheterization procedures. UGCR was not performed in 10 patients due to spontaneous thrombosis (n = 4), infection (n = 1) or skin ischemia (n = 1), unsuitable anatomy (n = 3), or excessive discomfort (n = 1). The remaining 29 patients underwent a full trial of compression therapy, and the lesion was eliminated in 27. Follow-up color flow scans were obtained after 24-72 hours in all 27 successful cases and at 1-15 months in 19; no recurrences or complications occurred. UGCR for acute injuries is safe and technically simple and is promising as a cost-effective, first-line treatment for uncomplicated catheterization-related femoral artery injuries. UGCR is probably not appropriate for long-standing injuries.

BACKGROUND AND PURPOSE: A previous trial (the Clomethiazole Acute Stroke Study) generated the hypothesis that clomethiazole is effective in patients with a major ischemic stroke (total anterior circulation syndrome), and this was tested in the present study. METHODS: A total of 1198 patients with major ischemic stroke and a combination of limb weakness, higher cortical dysfunction, and visual field deficits were randomly assigned to clomethiazole (68 mg/kg IV over 24 hours) or placebo. The study drug was initiated within 12 hours of symptom onset. Functional outcome and neurological recovery were assessed at days 7, 30, and 90, with the proportion of patients with a Barthel Index > or =60 at last follow-up as the primary outcome measure. RESULTS: The patients were randomly assigned equally, and the two treatment groups were well matched for baseline characteristics, including stroke severity (mean National Institutes of Health Stroke Scale score 16.9+/-5.2). Ninety-six percent were classified as total anterior circulation syndrome. The proportion of patients reaching a Barthel Index score of > or =60 was 42% in the clomethiazole-treated group and 46% in the placebo-treated group (odds ratio, 0.81; 95% CI, 0.62 to 1.05; P=0.11). There was no evidence of efficacy on any secondary outcome variables (modified Rankin Score, National Institutes of Health Stroke Scale, Scandinavian Stroke Scale, and 30-day CT infarct volumes) compared with placebo. Subgroup analysis showed a similar lack of treatment effect in patients treated early (<6 hours) and in those treated later (6 to 12 hours). Somnolence was an expected pharmacological effect of clomethiazole, and this occurred during treatment as an adverse event in half of the patients randomly assigned to study drug. CONCLUSIONS: The target population was selected, and sufficient drug was given to produce the expected pharmacological effect in the brain. Clomethiazole does not improve outcome in patients with major ischemic stroke.

PURPOSE: To compare the enhancement patterns of focal liver lesions at dynamic breath-hold gadolinium-enhanced multiplanar spoiled gradient-recalled (SPGR) magnetic resonance (MR) imaging with T2 relaxation times in the differentiation of liver hemangiomas from malignancies. MATERIALS AND METHODS: Forty-seven patients with focal liver lesions underwent MR imaging with spin-echo and gadolinium-enhanced multiplanar SPGR techniques. T2 relaxation times and enhancement patterns were compared for accuracy in liver lesion characterization. RESULTS: Enhancement patterns allowed better characterization of liver lesions than did T2 relaxation times. Only specific patterns of contrast enhancement indicated a hemangioma. Although 18 of the 33 malignancies and 10 of the 12 hemangiomas showed progressive centripetal hyperintense enhancement, only hemangiomas filled in with hyperintense peripheral nodules. Malignancies often filled in with hyperintense thick rinds. CONCLUSION: Gadolinium-enhanced multiplanar SPGR imaging allows more accurate characterization of liver lesions than does T2 relaxation time.

BACKGROUND AND PURPOSE: A large community hospital implemented an acute stroke program to respond to stroke patients in a consistent, systematic, and efficient manner. The primary objectives were to monitor the care delivered, improve the quality of care, and move the patients through their initial hospital stay in a timely manner. METHODS: Acute stroke standing orders were developed, with a critical path developed on the basis of these orders and an expected length of stay. A multidisciplinary team began the rehabilitation process early in the hospital stay, monitored patient progress and length of stay, and provided appropriate discharge placement. Retrospective chart reviews were performed over a 4-year period, and the data were collated on a yearly basis. RESULTS: Over a 4-year period, 414 Medicare patients demonstrated a steady decline of initial hospital length of stay from 7.0 to 4.6 days. During this same period of time, there was a decline in total hospital charges from $14,076 to $10,740 per patient. This represented a total dollar savings in charges of $1,621,296 (approximately $453,000 per year). The mortality rate for 1994 was 4.6%, with 46.5% of survivors discharged to home, 16.9% to acute rehabilitation, and 32.6% to nursing homes. CONCLUSIONS: The implementation of a multidisciplinary acute stroke program decreased length of stay and hospitalization costs of Medicare patients.

<h2>Abstract</h2><h3>Background</h3> The TRANSFORM (Multicen<b>t</b>er Experience With <b>R</b>apid Deployment Edw<b>a</b>rds I<b>N</b>TUITY Valve <b>S</b>ystem <b>for</b> Aortic Valve Replace<b>m</b>ent) trial (NCT01700439) evaluated the performance of the INTUITY rapid deployment aortic valve replacement (RDAVR) system in patients with severe aortic stenosis. <h3>Methods</h3> TRANSFORM was a prospective, nonrandomized, multicenter (n = 29), single-arm trial. INTUITY is comprised of a cloth-covered balloon-expandable frame attached to a Carpentier-Edwards PERIMOUNT Magna Ease aortic valve. Primary and effectiveness endpoints were evaluated at 1 year. <h3>Results</h3> Between 2012 and 2015, 839 patients underwent RDAVR. Mean age was 73.5 ± 8.3 years. Full sternotomy (FS) was used in 59% and minimally invasive surgical incisions in 41%. Technical success rate was 95%. For isolated RDAVR, mean crossclamp and cardiopulmonary bypass times for FS were 49.3 ± 26.9 minutes and 69.2 ± 34.7 minutes, respectively, and for minimally invasive surgical 63.1 ± 25.4 minutes and 84.6 ± 33.5 minutes, respectively. These times were favorable compared with Society of Thoracic Surgeons database comparators for FS: 76.3 minutes and 104.2 minutes, respectively, and for minimally invasive surgical, 82.9 minutes and 111.4 minutes, respectively (<i>P</i> < .001). At 30 days, all-cause mortality was 0.8%; valve explant, 0.1%; thromboembolism, 3.5%; and major bleeding, 1.3%. In patients with isolated aortic valve replacement, the rate of permanent pacemaker implantation was 11.9%. At 1 year, mean effective orifice area was 1.7 cm²; mean gradient, 10.3 mm Hg; and moderate and severe paravalvular leak, 1.2% and 0.4%, respectively. <h3>Conclusions</h3> INTUITY RDAVR performed effectively in this North American trial. It may lead to a relative reduction in aortic crossclamp time and cardiopulmonary bypass time and has excellent hemodynamic performance. Pacemaker implantation rate observed was somewhat greater than European trials and requires further investigation.

Injury to the frontal or other facial nerve branches can result in an asymmetry that can be very distressful to both patient and surgeon. This is especially true following cosmetic procedures such as rhytidectomy. We propose a means to create temporary symmetry while awaiting the possible return of nerve function. Botulinum neurotoxin causes a muscle paralysis lasting for approximately 3 months, and it is well established as the preferred treatment for blepharospasm. A case is presented in which botulinum toxin type A was injected into the opposite functioning frontalis muscle of a patient with unilateral frontal nerve paralysis. The patient experienced satisfactory relief of the asymmetry caused by onesided forehead wrinkling and brow elevation. Botulinum toxin therapy should be considered for both temporary and permanent facial asymmetries due to facial nerve paralysis as well as spasm.

A renal biopsy was performed on a patient with syphilitic glomerulonephritis characterized clinically by the acute onset of nephrosis that responded dramatically to penicillin therapy. Histologic, electron microscopical and immunohistochemical studies revealed an early membranous glomerulonephritis characterized by the presence of subepithelial basement-membrane deposits containing IgG and C3. The glomerular lesion, however, differed from that in the usual case of membranous nephropathy in that distinctive segmental lesions were present at the tubular poles of the glomeruli, and all the glomeruli exhibited mild proliferation of mesangial cells in association with the presence of IgM within mesangial areas. Antibody elution studies performed on the renal-biopsy specimen demonstrated the presence of antitreponemal antibody within the glomerular immune-complex deposits. This finding indicates that the glomerular injury occasionally complicating secondary syphilis is due to the deposition of treponemal antigen-antitreponemal antibody complexes.

<h3>Background</h3> There are no recommendations on the optimal dosing for cryoablation of atrial fibrillation (Cryo-AF). <h3>Objective</h3> The purpose of this study was to develop and prospectively test a Cryo-AF dosing protocol guided exclusively by time-to-pulmonary vein (PV) isolation (TT-PVI) in patients undergoing a first-time Cryo-AF. <h3>Methods</h3> In this multicenter study, we examined the acute/long-term safety/efficacy of Cryo-AF using the proposed dosing algorithm (Cryo-AF_Dosing; n=355) against a conventional, nonstandardized approach (Cryo-AF_Conventional; n=400) in a nonrandomized fashion. <h3>Results</h3> Acute PV isolation was achieved in 98.9% of patients in Cryo-AF_Dosing (TT-PVI = 48 ± 16 seconds) vs 97.2% in Cryo-AF_Conventional (<i>P</i> = .18). Cryo-AF_Dosing was associated with shorter (149 ± 34 seconds vs 226 ± 46 seconds; <i>P</i> <.001) and fewer (1.7 ± 0.8 vs 2.9 ± 0.8; <i>P</i> <.001) cryoapplications, reduced overall ablation (16 ± 5 minutes vs 40 ± 14 minutes; <i>P</i> <.001), fluoroscopy time (13 ± 6 minutes vs 29 ± 13 minutes; <i>P</i> <.001), left atrial dwell time (51 ± 14 minutes vs 118 ± 25 minutes; <i>P</i> <.001), and total procedure time (84 ± 23 minutes vs 145 ± 49 minutes; <i>P</i> <.001) but similar nadir balloon temperature (–47°C ± 8°C vs –48°C ± 6°C; <i>P</i> = .41) and total thaw time (43 ± 27 seconds vs 45 ± 19 seconds; <i>P</i> = .09) as compared to Cryo-AF_Conventional. Adverse events (2.0% vs 2.7%; <i>P</i> = .48), including persistent phrenic nerve palsy (0.6% vs 1.2%; <i>P</i> = .33) and 12-month freedom from all atrial arrhythmias (82.5% vs 78.3%; <i>P</i> = .14), were similar between Cryo-AF_Dosing and Cryo-AF_Conventional. However, Cryo-AF_Dosing was specifically associated with fewer atypical atrial flutters/tachycardias during long-term follow-up (8.5% vs 13.5%; <i>P</i> = .02) as well as fewer late PV reconnections at redo procedures (5.0% vs 18.5%; <i>P</i> <.001). <h3>Conclusion</h3> A novel Cryo-AF dosing algorithm guided by TT-PVI can help individualize the ablation strategy and yield improved procedural endpoints and efficiency as compared to a conventional, nonstandardized approach.

THE effect of increased intra-abdominal pressure due to ascites upon portal and systemic hemodynamics has not been directly documented although the hemodynamics of ascitic cirrhotic patients have been the subject of multiple studies.1 2 3 4 5 6 7 8 9 This investigation was designed to monitor the effect of measured gradual withdrawal of ascitic fluid upon hepatic-vein wedge pressure, inferior-vena-cava pressure, intraperitoneal pressure and cardiac output.Materials and MethodsTen patients with cirrhosis and tense ascites were studied. There were 5 men and 5 women, ranging in age from thirty-six to sixty-seven, with an average age of fifty-two years. All 10 patients gave a history of excessive . . .

BACKGROUND: Cryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce. METHODS: The YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible. RESULTS: A total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 10 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was -49±8°C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months. CONCLUSIONS: The incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03645577. Graphic Abstract: A graphic abstract is available for this article.

BACKGROUND AND PURPOSE: Licostinel (ACEA 1021; 5-nitro-6, 7-dichloro-2,3-quinoxalinedione), a competitive antagonist of glycine at the N-methyl-D-aspartate (NMDA) receptor, is an effective neuroprotective agent in animal models of cerebral ischemia. The purpose of this study was to assess the safety, tolerability, and pharmacokinetics of licostinel in patients with acute stroke. METHODS: In this 5-center dose escalation trial, patients were enrolled within 48 hours of an ischemic stroke and treated with ascending doses of a short infusion of licostinel or a placebo. Adverse effects were assessed with clinical and laboratory measurements, and patient outcome was determined with the National Institutes of Health Stroke Scale. RESULTS: Sixty-four patients (44 treated with escalating doses of licostinel and 20 who received placebo) were treated. Lower doses of licostinel (0.03 to 0.60 mg/kg) were not associated with any significant adverse effects. Higher doses of licostinel (1.2 to 3.0 mg/kg) were associated with a variety of mild-to-moderate adverse effects including neurological and gastrointestinal complaints. No major psychotomimetic effects or significant safety concerns occurred. At the higher dose levels, peak plasma concentrations of licostinel were substantially higher than those required for neuroprotection in animal stroke models. A similar improvement in National Institutes of Health Stroke Scale scores over time was seen in both the placebo group and the licostinel-treated patients. CONCLUSIONS: A short infusion of licostinel in doses up to 3.0 mg/kg is safe and tolerable in acute stroke patients. Licostinel may be a safer and better tolerated neuroprotective agent than many of the previously evaluated NMDA antagonists.

The frequency and clinical significance of platelet/fibrin microemboli in the microcirculation were investigated in 24 patients whose deaths (before and during hospital admission) were associated with acute myocardial infarction. An acute coronary thrombus was present in all the hearts. In nine hearts an acute thrombus was found in more than one major epicardial coronary artery. A total of 35 acute thrombi were found in the 24 hearts. Platelet/fibrin microemboli were found in 19 (79%) hearts. Eighteen patients died in hospital. The hearts of 16 of these cases showed microemboli; 16 had important arrhythmias or various forms of heart block; 13 showed acute pathological changes in the conduction system. Fourteen of the deaths in hospital were primarily the result of cardiogenic shock and four were primarily caused by arrhythmia. Six of the deaths that occurred before admission to hospital were regarded as being arrhythmic in origin. Three of these showed microemboli and the other three had acute pathological changes in the conduction system. Microemboli were found in two (24%) of 12 control hearts. Coronary thrombosis was found in most deaths caused by acute myocardial infarction and platelet/fibrin microemboli were present in the majority of such hearts. These may arise from the coronary thrombus in the larger upstream vessel supplying the microcirculation.

BackgroundLimited data exist on cryoablation of atrial fibrillation (Cryo-AF) using the newly available third-generation (Arctic Front Advance-Short Tip [AFA-ST]) cryoballoon.ObjectiveIn this multicenter study, we evaluated the safety and efficacy of Cryo-AF using the AFA-ST vs the second-generation (Arctic Front Advance [AFA]) cryoballoon.MethodsWe examined the procedural safety and efficacy and the short- and long-term clinical outcomes associated with a first-time Cryo-AF performed in 355 consecutive patients (254/355 [72%] with paroxysmal AF), using either the AFA-ST (n = 102) or the AFA (n = 253) cryoballoon catheters.ResultsAcute isolation was achieved in 99.6% of all pulmonary veins (PVs) (AFA-ST: 100% vs AFA: 99.4%; P = .920). Time to pulmonary vein isolation was recorded in 89.2% of PVs using AFA-ST vs 60.2% using AFA (P < .001). PVs targeted using AFA-ST required fewer applications (1.6 ± 0.8 vs 1.7 ± 0.8; P = .023), whereas there were no differences in the balloon nadir temperature (AFA-ST: −47.0°C ± 7.3°C vs AFA: −47.5°C ± 7.8°C; P = .120) or thaw time (AFA-ST: 41 ± 24 seconds vs AFA: 44 ± 28 seconds; P = .056). However, AFA-ST was associated with shorter left atrial dwell time (43 ± 5 minutes vs 53 ± 16 minutes; P < .001) and procedure time (71 ± 11 minutes vs 89 ± 25 minutes; P < .001). Furthermore, Cryo-AF using AFA-ST was completed more frequently by “single-shot” PV ablation (27.4% vs 20.2%; P = .031). Persistent phrenic nerve palsy (AFA-ST: 0% vs AFA: 0.8%; P = .507) and procedure-related adverse events (AFA-ST: 1.0% vs AFA: 1.6%; P = .554) were similar, as was the freedom from recurrent atrial arrhythmias at 10 months of follow-up (AFA-ST: 81.8% vs AFA: 79.9%; P = .658).ConclusionCryo-AF using the AFA-ST cryoballoon offers an enhanced ability to assess time to pulmonary vein isolation, allowing for fewer cryoapplications and shorter left atrial dwell time and procedure time. Consequently, this allowed for procedural completion more frequently using a “single-shot” PV ablation with equivalent safety and efficacy. Limited data exist on cryoablation of atrial fibrillation (Cryo-AF) using the newly available third-generation (Arctic Front Advance-Short Tip [AFA-ST]) cryoballoon. In this multicenter study, we evaluated the safety and efficacy of Cryo-AF using the AFA-ST vs the second-generation (Arctic Front Advance [AFA]) cryoballoon. We examined the procedural safety and efficacy and the short- and long-term clinical outcomes associated with a first-time Cryo-AF performed in 355 consecutive patients (254/355 [72%] with paroxysmal AF), using either the AFA-ST (n = 102) or the AFA (n = 253) cryoballoon catheters. Acute isolation was achieved in 99.6% of all pulmonary veins (PVs) (AFA-ST: 100% vs AFA: 99.4%; P = .920). Time to pulmonary vein isolation was recorded in 89.2% of PVs using AFA-ST vs 60.2% using AFA (P < .001). PVs targeted using AFA-ST required fewer applications (1.6 ± 0.8 vs 1.7 ± 0.8; P = .023), whereas there were no differences in the balloon nadir temperature (AFA-ST: −47.0°C ± 7.3°C vs AFA: −47.5°C ± 7.8°C; P = .120) or thaw time (AFA-ST: 41 ± 24 seconds vs AFA: 44 ± 28 seconds; P = .056). However, AFA-ST was associated with shorter left atrial dwell time (43 ± 5 minutes vs 53 ± 16 minutes; P < .001) and procedure time (71 ± 11 minutes vs 89 ± 25 minutes; P < .001). Furthermore, Cryo-AF using AFA-ST was completed more frequently by “single-shot” PV ablation (27.4% vs 20.2%; P = .031). Persistent phrenic nerve palsy (AFA-ST: 0% vs AFA: 0.8%; P = .507) and procedure-related adverse events (AFA-ST: 1.0% vs AFA: 1.6%; P = .554) were similar, as was the freedom from recurrent atrial arrhythmias at 10 months of follow-up (AFA-ST: 81.8% vs AFA: 79.9%; P = .658). Cryo-AF using the AFA-ST cryoballoon offers an enhanced ability to assess time to pulmonary vein isolation, allowing for fewer cryoapplications and shorter left atrial dwell time and procedure time. Consequently, this allowed for procedural completion more frequently using a “single-shot” PV ablation with equivalent safety and efficacy.

BACKGROUND: There is no nonparenteral medication for the rapid termination of paroxysmal supraventricular tachycardia. OBJECTIVES: The purpose of this study was to assess the efficacy and safety of etripamil nasal spray, a short-acting calcium-channel blocker, for the rapid termination of paroxysmal supraventricular tachycardia (SVT). METHODS: This phase 2 study was performed during electrophysiological testing in patients with previously documented SVT who were induced into SVT prior to undergoing a catheter ablation. Patients in sustained SVT for 5 min received either placebo or 1 of 4 doses of active compound. The primary endpoint was the SVT conversion rate within 15 min of study drug administration. Secondary endpoints included time to conversion and adverse events. RESULTS: One hundred four patients were dosed. Conversion rates from SVT to sinus rhythm were between 65% and 95% in the etripamil nasal spray groups and 35% in the placebo group; the differences were statistically significant (Pearson chi-square test) in the 3 highest active compound dose groups versus placebo. In patients who converted, the median time to conversion with etripamil was <3 min. Adverse events were mostly related to the intranasal route of administration or local irritation. Reductions in blood pressure occurred predominantly in the highest etripamil dose. CONCLUSIONS: Etripamil nasal spray rapidly terminated induced SVT with a high conversion rate. The safety and efficacy results of this study provide guidance for etripamil dose selection for future studies involving self-administration of this new intranasal calcium-channel blocker in a real-world setting for the termination of SVT. (Efficacy and Safety of Intranasal MSP-2017 [Etripamil] for the Conversion of PSVT to Sinus Rhythm [NODE-1]; NCT02296190).

Important advances in immunosuppressive therapy and refinement in surgical techniques have allowed renal transplantation to become the treatment of choice for virtually all suitable candidates with end-stage renal disease. Compared to dialysis, kidney transplantation improves both patient survival and quality of life and, over time, can reduce the total cost of medical care. It must be noted, however, that although the risk of death in the first year after transplantation is <5%, not all patients qualify for the surgery because of their unacceptable risks for complications. The transplant evaluation process requires a comprehensive assessment of each patient's medical, surgical, and psychosocial histories. Selection of the suitable transplant candidate remains a challenge for transplant physicians owing, predominantly, to the presence of complex medical issues in the potential candidates and nonstandardized criteria for acceptance or rejection among transplant centers. Furthermore, with the ever-increasing disparity between donor organ supply and demand and resultant increased wait-list times, the transplant physicians must further consider the optimal management and re-evaluation of wait-list patients during the waiting period. This article describes a systematic approach for the evaluation of a potential renal transplant candidate. Various medical issues that arise during the evaluation process are discussed.

In malignant external otitis (MEO), determining the anatomic extent of disease and evaluating the physiologic response to therapy remain a problem. Magnetic resonance imaging (MRI) has recently become available in limited clinical settings. Four patients with MEO were evaluated using MRI, computerized tomography (CT), technetium-99 (Tc-99) bone scanning, and gallium-67 citrate (Ga-67 citrate) scanning. MRI is superior to CT, Tc-99 bone scanning, and Ga-67 citrate scanning in evaluating the anatomic extent of soft tissue changes in MEO. MRI alone cannot be relied upon to determine the physiologic response to therapy. MRI can, however, serve as a valuable guide to the interpretation of Tc-99 bone and Ga-67 citrate scans, and in this respect, MRI is extremely useful in the treatment of MEO.

Abstract 1. 1. Eight cases of traumatic intrauterine adhesions are reported. 2. 2. The condition is revealed most often by hysterography in patients with a history of curettage of a recently pregnant uterus or a history of repeated abortion. 3. 3. The treatment of fundal adhesions is principally by dilatation while that of complete isthmic atresia is by abdominal hysterotomy or hysterectomy. 4. 4. The prognosis for relief of menstrual disability is excellent but the prognosis for delivery of a living child is more guarded, though not hopeless.

BACKGROUND: Although digital health tools are increasingly recognized as effective in improving clinical outcomes such as asthma control and medication adherence, few studies have assessed patient experiences and perception of value. OBJECTIVE: The aim of this study was to evaluate patient satisfaction, perception of usability and value, and desire to continue after 12 months of using a digital health intervention to support asthma management. METHODS: Participants were enrolled in a randomized controlled study evaluating the impact of a digital health platform for asthma management. Participants used electronic inhaler sensors to track medication use and accessed their information in a digital health platform. Electronic surveys were administered to intervention arm participants aged 12 years and older after 12 months of use. The survey assessed asthma control, patient satisfaction with the sensor device, and perception of the usability and value of the digital health platform through closed-ended and open-ended questions. Logistic regression models were used to assess the impact of participants' characteristics on survey completion, satisfaction, and perception of value. RESULTS: Of the 207 intervention arm participants aged 12 years and older, 89 submitted survey responses (42.9% response rate). Of these 89 participants, 70 reported being very satisfied (79%, 70/89) or somewhat satisfied (20%, 18/89) with the inhaler sensor device. Moreover, 93% (83/89) expressed satisfaction with the reports, and 90% (80/89) found the information from the reports useful for learning about their asthma. In addition, 72% (64/89) of the participants reported that they were interested in continuing to use the sensor and platform beyond the study. There were no significant differences in satisfaction with the device or the platform across participants' characteristics, including device type, age, sex, insurance type, asthma control, or syncing history; however, participants with smartphones and longer participation were more likely to take the survey. CONCLUSIONS: Electronic sensors and a digital health platform were well received by participants who reported satisfaction and perceived value. These results were consistent across multiple participants' characteristics. These findings can add to a limited literature to keep improving digital health interventions and ensure the meaningful and enduring impact on patient outcomes.

BACKGROUND: Lower body-mass index (BMI) in late life has been associated with an increased risk of dementia, and weight loss has been associated with more rapid decline in Alzheimer's disease (AD) dementia. OBJECTIVE: To explore the association between BMI and cortical amyloid burden in clinically normal (CN) elderly at risk for AD dementia. METHODS: Cross-sectional analyses were completed using baseline data from the Harvard Aging Brain Study, consisting of 280 community-dwelling CN older adults aged 62-90. Assessments included medical histories and physical exam, Pittsburgh compound B (PiB) positron emission tomography (PET) amyloid imaging, and apolipoprotein E ɛ4 (APOE4) genotyping. For the primary analysis, a general linear regression model was used to evaluate the association of BMI with PiB retention. Covariates included age, sex, years of education, and APOE4 carrier status. Secondary analyses were performed for BMI subdivisions (normal, overweight, obese), APOE4 carriers, and BMI×APOE4 interaction. RESULTS: In the primary analysis, greater PiB retention was associated with lower BMI (β = -0.14, p = 0.02). In the secondary analyses, APOE4 carrier status (β= -0.27, p = 0.02) and normal BMI (β= -0.25, p = 0.01), as opposed to overweight or obese BMI, were associated with greater PiB retention. The BMI×APOE4 interaction was also significant (β= -0.14, p = 0.04). CONCLUSIONS: This finding offers new insight into the role of BMI at the preclinical stage of AD, wherein lower BMI late in life is associated with greater cortical amyloid burden. Future studies are needed to elucidate the mechanism behind this association, especially in those with lower BMI who are APOE4 carriers.

BACKGROUND: Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm. OBJECTIVE: To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT). METHODS: HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up. RESULTS: A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms. CONCLUSION: Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms.