Eldaly, Abdullah S.

Background: The use of bone morphogenic protein and mesenchymal stem cells has shown promise in promoting bone regeneration in calvarial defects. However, a systematic review of the available literature is needed to evaluate the efficacy of this approach. Methods: We comprehensively searched electronic databases using MeSH terms related to skull defects, bone marrow mesenchymal stem cells, and bone morphogenic proteins. Eligible studies included animal studies that used BMP therapy and mesenchymal stem cells to promote bone regeneration in calvarial defects. Reviews, conference articles, book chapters, and non-English language studies were excluded. Two independent investigators conducted the search and data extraction. Results: Twenty-three studies published between 2010 and 2022 met our inclusion criteria after a full-text review of the forty-five records found in the search. Eight of the 23 studies used mice as models, while 15 used rats. The most common mesenchymal stem cell was bone marrow-derived, followed by adipose-derived. BMP-2 was the most popular. Stem cells were embedded in Scaffold (13), Transduction (7), and Transfection (3), and they were delivered BMP to cells. Each treatment used 2 × 104–1 × 107 mesenchymal stem cells, averaging 2.26 × 106. Most BMP-transduced MSC studies used lentivirus. Conclusions: This systematic review examined BMP and MSC synergy in biomaterial scaffolds or alone. BMP therapy and mesenchymal stem cells in calvarial defects, alone, or with a scaffold regenerated bone. This method treats skull defects in clinical trials. The best scaffold material, therapeutic dosage, administration method, and long-term side effects need further study.

Introduction: The COVID-19 pandemic has had major impacts on all healthcare services, including cardiac imaging. In this study, we investigate annual changes in cardiac imaging procedural volume and reimbursement among Medicare Beneficiaries (MB) from 2018 to 2020. Methods: We used the Center of Medicare and Medicaid Services database to identify a 100% sample of MB who underwent cardiac imaging procedures from 2018 to 2020. Using the Current Procedural Terminology (CPT) codes, we identified transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), stress echocardiogram, and nuclear stress test procedures. We examined each procedure’s total, inpatient (facility), and outpatient (non-facility) annual volumes per 1,000 MB. We also examined the total annual Medicare reimbursement per imaging type during that period. We compared annual changes in volumes and total reimbursement between two-time intervals: 2018-2019 and 2019-2020. Results: All annual cardiac imaging procedural volumes decreased significantly in 2020 compared to 2019 ( P<0.001 ). The biggest change was observed in TEE, which decreased by 29.20%, followed by stress echocardiography (26.01%), nuclear stress test (22.96%), and TTE (10.68%). The decrease was more evident in the inpatient setting. Inpatient stress echocardiography decreased by 27.04% (vs 23.82% in the outpatient setting), nuclear stress test decreased by 24.82% (vs 20.66%), and TTE decreased by 11.03% (vs 9.58%). There was also a significant reduction in total annual reimbursement for all procedures in 2020 compared to 2019 ( P=0.0015 ). Stress echocardiogram, nuclear stress test, TEE, and TTE reimbursement decreased by 28.08%, 24.00%, 21.11%, and 15.79%, respectively. Conclusions: The COVID-19 pandemic was associated with a significant and abrupt reduction in annual cardiac imaging procedural volumes and total reimbursement among MB in both inpatient and outpatient settings.

AbstractBackgroundAortic stenosis (AS) is associated with myocardial ischemia through different mechanisms and may impair coronary arterial flow. However, data on the impact of moderate AS in patients with acute myocardial infarction (MI) is limited.AimsThis study aimed to investigate the impact of moderate AS in patients presenting with acute myocardial infarction (MI).MethodsWe conducted a retrospective analysis of all patients who presented with acute MI to all Mayo Clinic hospitals, using the Enterprise Mayo PCI Database from 2005 to 2016. Patients were stratified into two groups: moderate AS and mild/no AS. The primary outcome was all cause mortality.ResultsThe moderate AS group included 183 (13.3%) patients, and the mild/no AS group included 1190 (86.7%) patients. During hospitalization, there was no difference between both groups in mortality. Patients with moderate AS had higher in‐hospital congestive heart failure (CHF) (8.2% vs. 4.4%, p = 0.025) compared with mild/no AS patients. At 1‐year follow‐up, patients with moderate AS had higher mortality (23.9% vs. 8.1%, p < 0.001) and higher CHF hospitalization (8.3% vs. 3.7%, p = 0.028). In multivariate analysis, moderate AS was associated with higher mortality at 1‐year (odds ratio 2.4, 95% confidence interval [1.4–4.1], p = 0.002). In subgroup analyses, moderate AS increased all‐cause mortality in STEMI and NSTEMI patients.ConclusionThe presence of moderate AS in acute MI patients was associated with worse clinical outcomes during hospitalization and at 1‐year follow‐up. These unfavorable outcomes highlight the need for a close follow‐up of these patients and for timely therapeutic strategies to best manage these coexisting conditions.

Cerebrovascular accident (CVA) is one of the leading causes of death in the United States. Von Willebrand factor plays an important role in platelet activation and adhesion. It remains unclear whether Von Willebrand disease (vWD) is associated with a decreased risk of developing CVA. The study aimed to compare the relative risk (RR) of CVA in patients with and without vWD. We queried the National Inpatient Sample from 2009 to 2014 for discharge data and records for vWD and CVA using International Classification of Diseases, Ninth-Revision codes. The unadjusted and adjusted RR of CVA in patients with and without vWD were estimated using log-binomial model. Descriptive measures including means, medians, standard deviations, and range were presented based on normality test of continuous data. The prevalence of CVA was lower in patients with vWD than in those without vWD (1.31% vs 2.04%), with a RR of 0.64 (95% confidence interval (CI): 0.60–0.68). After adjusting for common CVA risk factors, the RR remained lower in vWD patients: 0.81 (95% CI: 0.76–0.86). vWD is associated with a lower RR of developing CVA. This suggests that deficiency of Von Willebrand factor is potentially protective against the development of CVA. To the best of our knowledge, this is the first study in humans to compare the RR of CVA in patients with and without vWD. Future studies are needed to explore causal relationships and therapeutic benefits.

In 2020, Mayo Clinic established an Advanced Care at Home (ACH) program. ACH is a virtual hybrid hospital-at-home (HaH) program that combines telemedicine with in-home care services by utilizing a state that is software-driven, vendor-mediate medical supply chain. The program initially focused on acute medical diagnosis but has expanded to oversee surgical and postsurgical patients with continued inpatient needs. Here, we report the first case of a small bowel obstruction (SBO) managed under a HaH program. A 52-year-old lady presented to the emergency department with symptoms suggestive of mechanical SBO. The diagnosis was confirmed with an abdominopelvic computed tomography (CT) scan, and the patient was admitted to the hospital. Based on the patient’s presentation and laboratory results, the care team proceeded with conservative treatment including nasogastric tube (NG) placement and suctioning, intravenous (IV) fluid replacement, and daily laboratory studies. She spent the first hospital day in the physical hospital ward so that the surgical team could ensure stability clinically and no urgent need for surgical intervention. On hospital day two, she was transferred home with ACH where the NG suctioning and IV replacement therapy could continue, while the medical team conducted daily virtual visits to ensure continued improvement. Additionally, a paramedic and a nurse performed an in-person, head-to-toe assessment and administered medications to the patient twice daily. She spent 5 days in ACH getting acute care and then was discharged into a postacute phase equivalent to outpatient monitoring called the restorative phase. She was monitored remotely for the duration of the restorative phase for 10 more days, and then she recovered fully. This case highlights that high-acuity patients with SBO can receive invasive treatments like NG tube suction as well as be appropriately monitored for clinical decompensation by a virtual hybrid home hospital program which combines virtual care providers with an in-home vendor-mediated supply chain.

Upper and lower limb amputations are frequently associated with phantom limb pain (PLP). Recently, virtual reality (VR) and augmented reality (AR) have been reported as a potential therapy of PLP. We have conducted a systematic review of literature to evaluate the efficacy of VR and AR in managing PLP. Four databases were searched: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for our organization. The initial search resulted in 164 results. After title, abstract, and full-text screening, 9 studies were included. One study was of good quality and 8 studies were of fair to poor quality. Seven studies utilized VR and 2 studies utilized AR. The number of treatment sessions ranged from 1 to 28 and the duration ranged from 10 minutes to 2 hours. Several pain scales were used to evaluate PLP pre- and postintervention including Numeric Rating Scale, Pain Rating Index, McGill Pain Questionnaire, and Visual Analog Scale. All the studies reported improvement of PLP on one or more of pain scales after one or more sessions of VR or AR. Despite the promising results reported by literature, we cannot recommend using VR or AR for PLP. Most of the studies are of poor design and have limited sample size with high bias levels. Therefore, no substantial evidence can be derived from them. However, we do believe further research with high-quality randomized controlled trials should take place to increase the knowledge of the potential advantages.

Abstract Background Atrial fibrillation (AF) pulmonary vein isolation ablation has been utilized increasingly yet variably in the USA. Purpose To identify variations in AF ablation utilization and reimbursement among Medicare beneficiaries (MB). Methodology We used a 100% sample of MB who underwent AF ablation from 2013 to 2019. We stratified data geographically (Northeast, South, West, and Midwest), identified the mean AF prevalence and the number of AF ablations per 100,000 MB, and examined the correlation between AF prevalence and ablation. We also examined the number of cardiologists performing AF ablation per 100,000 MB and the average number of AF ablation per individual cardiologist (ablation/cardiologist), as well as average submitted charge (ASC) for AF ablation. Additionally, we stratified data per urban versus rural areas as well as the gender of performing cardiologists and examined ablation/cardiologist and the ASC. Results Geographic analysis: The mean AF prevalence, the rates AF ablation per 100,000 MB, the number of cardiologists per 100,000 MB, and ablation/cardiologist have shown a steady increase in all regions across years. In all years, the mean AF prevalence was significantly different among regions with the highest prevalence in the Northeast and the lowest in the West (all P&lt;0.001), however, there was no significant difference in the rates of AF ablation per 100,000 MB (all P≥0.056). There was significant correlation between AF prevalence and ablation only in the Midwest and the West, with 46.4% and 43.4% positive correlation respectively (P≤0.0001). The number of cardiologists performing AF ablation per 100,000 MB was not significantly different among regions in all years (All P≥0.48), however, ablation/cardiologist was significantly higher in the West and the South compared to the Northeast and the Midwest (All P&lt;0.0001). On the contrary, the ASC has shown steady decrease in all regions. The ASC was significantly different among regions in all year (all P≤0.003) with higher ASC in the Midwest and the Northeast compared to the south and the West. Urban vs rural analysis: Ablation/cardiologist was not significantly different between urban and rural areas in all years (all P≥0.068) except in 2013 when it was significantly higher in urban areas (P=0.004). The ASC was significantly higher in rural areas only in 2015 and 2019 (P=0.037 and P=0.029 respectively) however, there was no significant difference in the rest of the years (P≥0.07). Gender analysis: Ablation/cardiologist was not significantly different between male and female cardiologists in all years (P≥0.056) except in 2017 when the average was significantly higher per male cardiologists (P=0.007). The ASC was not significantly different in all years (P≥0.362). Conclusion There are variations in AF ablation utilization and reimbursement among MB in the USA according to geographic, urban and rural regions, and the gender of performing cardiologists. Funding Acknowledgement Type of funding sources: None.

Chronically ill patients with superimposed acute illness requiring hospitalization are more likely to develop an extended length of stay, hospital-acquired infections, and adverse events throughout their hospitalization. An excellent alternative to managing this population of patients in the traditional bricks-and-mortal (BAM) hospital is the hospital-at-home (HaH) model. The Advanced Care at Home (ACH) program is Mayo Clinic’s HaH model that provides acute and postacute care to high-acuity patients in their homes rather than in the traditional hospital and skilled nursing facility. We report a case of postoperative care through the ACH program of a patient suffering from short gut syndrome, high-output ileostomy, and severe protein-calorie malnutrition in the setting of previously diagnosed triple-negative invasive ductal carcinoma (IDC) of the right breast complicated by lung and brain metastasis. The patient had multiple complications that required repeated scare escalations directed by a multidisciplinary virtual care. Despite these complications, the ACH model of care was able to keep the patient in the home setting the majority of the time, limiting BAM hospital days, and eliminating the need to use the emergency department for acute escalation for 3 months. The patient was able to recover during this time period and proceed to successful take-down of the ileostomy. This case highlights the benefits of the ACH program by offering high-acuity hospital-level care to severely ill patients in the comfort of their homes. Highly qualified providers paired with curated technology in the home allowed for prompt identification of patient decompensation and timely initiation of treatment while avoiding institutionalization.