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Abstract Context Dystonia is a movement disorder that causes involuntary muscle contractions leading to abnormal movements and postures, such as twisting. Dystonia is the third most common movement disorder in the United States, with as many as 250,000 people affected. Because of its complexity, dystonia presents a significant challenge in terms of management and treatment. Despite limited research, osteopathic manipulative treatment (OMT) has been considered as an adjunctive treatment due to its inexpensive and noninvasive nature, as opposed to other modalities such as botulinum toxin injections, deep brain stimulation (DBS), and transcranial magnetic stimulation, which are often expensive and inaccessible. OMT treatments performed in case studies and series such as balanced ligamentous tension/articular ligamentous strain (BLT/ALS), muscle energy (ME), high-velocity low-amplitude (HVLA), and myofascial release (MFR) have shown reduction of pain and muscle hypertonicity, including in patients with dystonia. Objectives The studies reviewed in this paper provide a snapshot of the literature regarding the current evidence of OMT’s role for dystonia. Methods A medical reference librarian conducted a thorough literature search across multiple databases including PubMed and Google Scholar to find articles relevant to the use of OMT for dystonia. The search employed a combination of Medical Subject Headings (MeSH) terms and keywords related to osteopathic medicine and dystonia to ensure precise retrieval of relevant articles within the last 20 years. Despite limited research on the topic, all four relevant reports found in the literature were selected for review. Results Of the four relevant reports, case series and studies highlighted the potential benefits of OMT in managing dystonia, particularly cervical dystonia and foot dystonia. OMT has shown promising results addressing pain, stiffness, and impaired motor function. In cases of foot dystonia in Parkinson’s disease, OMT has helped improve gait and reduce pain by targeting somatic dysfunctions (SDs) associated with dystonia, such as abnormalities in foot progression angle (FPA) and musculoskeletal imbalances. Also, OMT has been found to alleviate symptoms of cervical dystonia, including tremors, muscle spasms, and neck stiffness. These interventions performed in case studies and series led to improvements in gait biomechanics in foot dystonia and overall symptom severity in patients with cervical dystonia. Conclusions Currently, botulinum toxin, oral medications, physical therapy, and rehabilitation are commonly utilized in managing dystonia. The studies reviewed in this paper suggest that these treatments may lead to improvements in pain and muscle hypertonicity in patients with dystonia. It is important to investigate whether factors such as the type of dystonia (eg, focal vs. segmental) and its underlying cause (eg, idiopathic, trauma, infection, autoimmune, medication side effects) influence treatment outcomes. Further research is recommended to explore the role of OMT in managing dystonia.

AbstractIntroductionThe impact of mRNA‐based coronavirus disease‐2019 (COVID‐19) vaccines on atrial arrhythmias (AA) and ventricular arrhythmias incidence is unknown.MethodsBIOTRONIK Home Monitoring data and Medicare Claims data were utilized to identify individuals implanted with a cardiac implantable electronic device (CIED) between 2010 and 2020 who received one or more doses of COVID‐19 vaccine in 2021. The burden of AA (%) in the 3 months postvaccination was compared to those noted in the preceding 3 months using the Wilcoxon signed rank test. Sub‐analyses comparing the effects of the influenza vaccine against the COVID‐19 vaccine were also evaluated for individuals who received the influenza vaccine in 2020. A 1:1 propensity score match comparison between COVID‐19 vaccine and non‐vaccinated patients was also performed.ResultsFirst and second doses of the COVID‐19 vaccine were administered to 7757 and 6579 individuals with a CIED (age 76.2 ± 9.0 years, 49% males), respectively. While a small but statistically significant increase in the burden of AA was noted in the 3 months postvaccination compared to the preceding 3 months after the first dose of the COVID‐19 vaccine (0.43 ± 9.04%, p = .028) a similar rise in AA was found following the influenza vaccine and for matched patients who did not receive the COVID‐19 vaccine. No significant difference in device therapies was seen pre‐ and postvaccination.ConclusionsThough we report a small but significant increase in the number of CIED‐detected AAs following vaccination for COVID‐19 over a 3‐month window, we believe these results correlate more with time and the progressive nature of AF rather than the vaccine itself. While these data should not dissuade from the use of these vaccines, increased vigilance and prompt treatment of AF is required for high‐risk groups, specifically males over 70 years of age, following vaccination.

Background Shock‐reduction implantable cardioverter‐defibrillator programming (SRP) was associated with fewer therapies and improved survival in randomized controlled trials, but real‐world studies investigating SRP and associated outcomes are limited. Methods and Results The BIOTRONIK CERTITUDE registry was linked with the Medicare database. We included all patients with an implantable cardioverter‐defibrillator implanted between August 22, 2012 and September 30, 2021 in the United States. SRP was defined as programming to either a therapy rate cutoff ≥188 beats per minute or number of intervals to detection ≥30/40 for treatment. Among 6781 patients (mean 74±9 years; 27% women), 3393 (50%) had SRP. Older age, secondary prevention indication, and device implantation in the southern or western United States were associated with lower use of SRP. The cumulative incidence rate of implantable cardioverter‐defibrillator shocks was lower in the SRP group (5.1% shocks/patient year) compared with the non‐SRP group (7.2% shocks/patient year) (adjusted hazard ratio [HR], 0.83 [95% CI, 0.73–0.96]; P =0.005). Over a median follow‐up of 2.9 years, 739 deaths occurred in the SRP group and 822 deaths occurred in the non‐SRP group (adjusted HR, 0.97 [95% CI, 0.88–1.07]; P =0.569). SRP was associated with a lower all‐cause mortality among patients without ischemic heart disease compared with patients with ischemic heart disease (adjusted HR, 0.64 [95% CI, 0.48–0.87] versus adjusted HR, 1.02 [95% CI, 0.92–1.14]; P interaction =0.004). Conclusions Adoption of SRP is low in real‐world clinical practice. Age, clinical variables, and geographic factors are associated with use of SRP. In this study, SRP‐associated decrease in mortality was limited to patients without ischemic heart disease.

Introduction: Atrial Fibrillation (AF) is an important contributor to insufficient left ventricular pacing and mortality in patients undergoing cardiac resynchronization therapy (CRT). The incidence and prevalence of AF post-CRT implant, in patients with and without previous history of AF, has not previously been described. Hypothesis: AF prevalence in CRT patients, despite history of AF, is higher than previously understood. Methods: Subjects implanted with a CRT-Defibrillator (CRT-D) enrolled in the PainFree SST study and with device data collection were analyzed. Subjects who exited within 30 days of implant, had < 27 days of available daily AT/AF burden data, or had ≥ 10% of daily AT/AF data missing were excluded. We defined incidence and prevalence of clinically meaningful device documented AF using previously published criteria (≥1 day with AF > 6 hours). History of AF at enrollment was documented based on clinical history. Results: The analysis included 944 patients (68±11 years; 78% male, EF 28±9%, QRS 152±29 ms; 59% NYHA III/IV). The duration from implant to study exit or death was 2.0 ± 0.8 years (IQR 1.5-2.5). History of AT/AF was documented in 37% of patients at baseline. Overall, any AT/AF was found in 85.2 % of subjects during follow-up. Clinically meaningful AT/AF was found in 30.3% of subjects. Of the 345 subjects with history of AF at baseline, 51.9% had clinically meaningful AT/AF during follow-up vs.17.9% for subjects without known AF (p<0.0001). 24.8% of subjects experienced at least one day of ≥ 23h of AT/AF. 6.9% of subjects had ≥ 23h of AT/AF for > 95% of days with data. Conclusions: AF occurs in a substantial proportion of CRT-D patients and clinically documented history of AF prior to CRT-D implant corresponds poorly with device documented AT/AF during follow-up. Device documented AF should be evaluated in CRT-D patients with and without previous history of AF to individualize strategies to maximize left ventricular pacing and minimize disruption due to AF.

Device infection is associated with increased mortality in cardiovascular implantable electronic device (CIED) recipients. However, published data regarding clinical predictors of mortality in patients with CIED infection are limited. In current investigation, we sought to identify patient and device-related factors associated with mortality in CIED infection cases. We performed a retrospective review of all cases of CIED infection admitted to Mayo Clinic Rochester from 1991 to 2008. Survival data were obtained from hospital medical records and United Sates Social Security Index. Key data regarding patient demographics, device features, comorbid conditions, clinical presentation, echocardiographic findings and management strategies were abstracted. Potential risk factors for short (30-day) and long-term mortality were analyzed using univariate and multivariable logistic and Cox proportional hazards regression models, respectively. 415 cases of CIED infection were identified from the institutional database. The mean duration of follow-up for the 243 patients who were alive at last follow-up was 6.9 years. In multivariable model, congestive heart failure (CHF, Odds ratio 9.31, 95% CI 2.08-41.67), chronic corticosteroid use (OR 4.04, 1.40-11.60) and presentation with CIED-related infective endocarditis (CIED-IE), (OR 5.6, 2.25-13.92) were associated with increased odds of short-term mortality. Independent predictors of long-term mortality on multivariable model included patients' age (hazard ratio for 10-year increase 1.2, 95% CI 1.06-1.36), CHF (HR 2.01, 1.42-2.86), metastatic malignancy (HR 5.99, 1.67-21.53), corticosteroid use (HR 1.97, 1.22-3.18), renal failure (HR 1.94, 1.37-2.74) and CIED-IE (HR 1.68, 1.17-2.41). Our investigation provides some novel insights into predictors of short- and long-term mortality in CIED infection cases. While comorbid conditions and immunocompromised host status were primary determinants of both short- and long-term mortality, complicated device infection (CIED-IE) is the only predictor that presents an opportunity for intervention where mortality may be reduced by early diagnosis and expedited device removal.

Objective Endoscopic sleeve gastroplasty (ESG) has gained global adoption but our understanding of its mechanism(s) of action and durability of efficacy is limited. We sought to determine changes in gastric emptying (GE), gastric motility (GM), hormones and eating behaviours after ESG. Design A priori-designed single-centre substudy of a large US randomised clinical trial, adults with obesity were randomised to ESG or lifestyle interventions (LS) alone. We measured GE, hormones and weight loss and assessed eating behaviours. In a subset of ESG patients, we assessed GM. The primary outcome was the change in T1/2 (min) at 3 months, and secondary outcomes were changes in weight, GE, GM, hormones and eating behaviours. We used t-test analyses and regression to determine the association between GE and weight loss. Results 36 (ESG=18; LS=18) participated in this substudy. Baseline characteristics were similar between the two groups. At 3 months, T1/2 was delayed in the ESG group (n=17) compared with the LS group (n=17) (152.3±47.3 vs 89.1±27.9; p<0.001). At 12 months, T1/2 remained delayed in the ESG group (n=16) vs control group (n=14) (137±37.4 vs 90.1±23.4; p<0.001). Greater delays in GE at 3 months were associated with greater weight loss. GM was preserved and fasting ghrelin, glucagon-like peptide 1 and polypeptide YY significantly increased 18 months after ESG. Conclusion ESG promotes weight loss through several key mechanistic pathways involving GE and hormones while preserving GM. These findings further support clinical adoption of this technique for the management of obesity. Trial registration number NCT03406975.

Background: Isovolumic contraction time (ICT) and pre-ejection period (PEP) are altered by electrical conduction delay as well as impaired contractility. An abnormal PEP has been used to select patients for cardiac resynchronization therapy (CRT), however, the predictive value of PEP for reverse remodeling (RR) has not been reported. The purpose of this study is to determine the predictive value of ICT and PEP for the RR in a prospective, single center CRT registry. Methods: Prospective registry of all heart failure patients undergoing CRT with echo pre-implant and at 3 and 6 months after implant. PEP was measured from the ECG Q wave onset to the aortic valve opening from the left ventricular outflow tract pulsed-wave Doppler tracing. The timing interval from the QRS onset to mitral valve closure was measured (mitral valve closure time). ICT was calculated as PEP-mitral valve closure time. RR was defined as >15% reduction in end-systolic volume (ESV) measured by biplane Simpson’s method. Death due to cardiac cause and heart transplantation during the 6 month period were considered as a non-response in the receiver-operating characteristics (ROC)analysis. Results: Echocardiography data was available in 83 patients at 3 and 59 patients at 6 month after CRT. RR occurred in 42 patients (51%) at 3 months and in 32 (54%) patients at 6 months By ROC analysis, the area under the curve (AUC) for predicting RR was 0.74 for ICT (p<0.001) and 0.73 for PEP (p=0.001) (See table ). ICT>123 ms yielded a very high specificity of 90–93% to predict responders at 6 month after CRT either in entire population or after excluding the patients with atrial fibrillation. Conclusion: A prolonged ICT is highly specific for predicting reverse remodeling after CRT although it is found in a limited number of patients. A strategy employing a screening ICT measurement may identify patients highly likely to achieve reverse remodeling after CRT, but can not be used to exclude patients for CRT. ROC analysis

Background : Dyssynchrony indexes derived from time to peak systolic velocity and time to peak strain have been reported to predict left ventricular reverse remodeling (RR) after cardiac resynchronization therapy (CRT). The predictive characteristics of these indices have not been validated in a variety of clinical settings. Our objective was to determine the predictive value of strain and tissue velocity derived dyssynchrony indices for RR or clinical response to CRT in a prospective single-center CRT registry. Methods : Prospective registry of all heart failure patients (pts) undergoing CRT with echo before and 3 and 6 months after CRT. Color -coded tissue Doppler imaging in 12 segments was used to calculate the standard deviation of time to peak strain (Tϵ-SD) and time to peak systolic velocity (Tv-SD). RR was defined as a decrease in end systolic volume (ESV; biplane Simpson’s method) ≥15%. Indices were assessed with receiver-operating characteristics (ROC) analysis and the area under the curve (AUC) calculated in all pts and excluding those with atrial fibrillation at implant. Results : To date, of the first 87 patients, 4 died (classified as non-responder); 83 pts had 3 and 59 pts had 6 month echocardiography follow-up. Tϵ-SD (93%) and Tv-SD (98%) were feasible in most pts. RR occurred in 42 pts (51%) at 3 month and 32 patients (54%) at 6 month follow-up. See table . Tϵ-SD was superior to Tv-SD for prediction of RR in all pts and in those without atrial fibrillation. Findings were similar regardless of ischemic (68% of patients) or non-ischemic etiology. Neither baseline Tϵ-SD nor Tv-SD correlated with the improvement in clinical response measured by the change in six minute walk distance or peak VO 2 at 3 or 6 month after CRT (data not shown). Conclusions : In this single center experience, mechanical dyssynchrony measured by strain imaging but not tissue velocity imaging was predictive of RR. Neither index predicted clinical response.

Knowledge of major adverse clinical events (MACE) associated with ICD and pacemaker (PM) pulse generator (PG) and lead performance may be important for managing patients who have these devices. The aim of our study was to assess MACE in our Multicenter Registry. Participating centers prospectively reported ICD and PM PG and lead failures, and PG replaced for normal battery depletion (NBD). Data included dates of implant and removal, failure signs including the elective replacement indicator (ERI), clinical consequences, and reason for removal. MACE were death, inappropriate shocks (IAS), syncope, heart failure, ischemia, sustained tachyarrhythmias, and replacement of a normally functioning PG or lead due to a manufacturers recall. Since 1998, 6,291 ICD and PM PG and leads were removed from service. Of 5,212 ICD and PM PGs, 4,562 (88%) were removed for NBD, 346 (7%) for a recall, and 304 (5%) for component defects. MACE are shown in the Table . The deaths (n=2) were due to component defects causing an ICD PG to short-circuit and a PM PG to deliver high rate pacing. Thus, of the 304 component defects in our database, 2 resulted in death (0.7%). No deaths were associated with ICD or PM lead failure, but 2 deaths occurred following PM lead extraction. The ERI, signifying NBD, resulted in 48 MACE, primarily syncope (67%). Most MACE are due to replacement of normally functioning recalled devices. However, our experience suggests that death due to ICD and PM PG component or lead failure is rare; this finding may be important for managing patients who have recalled devices. Overall, MACE may be substantially reduced by improving high voltage lead reliability, and by providing physiologic ERIs.