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OBJECTIVEFollowing traumatic brain injury (TBI), midline shift of the brain at the level of the septum pellucidum is often caused by unilateral space-occupying lesions and is associated with increased intracranial pressure and worsened morbidity and mortality. While outcome has been studied in this population, the recovery trajectory has not been reported in a large cohort of patients with TBI. The authors sought to utilize the Citicoline Brain Injury Treatment (COBRIT) trial to analyze patient recovery over time depending on degree of midline shift at presentation.METHODSPatient data from the COBRIT trial were stratified into 4 groups of midline shift, and outcome measures were analyzed at 30, 90, and 180 days postinjury. A recovery trajectory analysis was performed identifying patients with outcome measures at all 3 time points to analyze the degree of recovery based on midline shift at presentation.RESULTSThere were 892, 1169, and 895 patients with adequate outcome data at 30, 90, and 180 days, respectively. Rates of favorable outcome (Glasgow Outcome Scale–Extended [GOS-E] scores 4–8) at 6 months postinjury were 87% for patients with no midline shift, 79% for patients with 1–5 mm of shift, 64% for patients with 6–10 mm of shift, and 47% for patients with > 10 mm of shift. The mean improvement from unfavorable outcome (GOS-E scores 2 and 3) to favorable outcome (GOS-E scores 4–8) from 1 month to 6 months in all groups was 20% (range 4%–29%). The mean GOS-E score for patients in the 6- to 10-mm group crossed from unfavorable outcome (GOS-E scores 2 and 3) into favorable outcome (GOS-E scores 4–8) at 90 days, and the mean GOS-E of patients in the > 10-mm group nearly reached the threshold of favorable outcome by 180 days postinjury.CONCLUSIONSIn this secondary analysis of the Phase 3 COBRIT trial, TBI patients with less than 10 mm of midline shift on admission head CT had significantly improved functional outcomes through 180 days after injury compared with those with greater than 10 mm of midline shift. Of note, nearly 50% of patients with > 10 mm of midline shift achieved a favorable outcome (GOS-E score 4–8) by 6 months postinjury.

Background Navigable, large diameter aspiration catheters demonstrate markedly improved recanalization rates over smaller lumen devices in suction embolectomy. We evaluated the performance of a novel aspiration catheter system designed to maximize lumen size, and compare it to other commercially available aspiration catheters. Methods The 6F R4Q aspiration catheter system comprises a proximal pusher wire of 117 cm length connected to a distal catheter of 25 cm length. When placed through standard guide catheters and into the cerebral circulation, the proximal catheter makes a tight seal between its outer surface and the guide catheter’s inner surface. During aspiration, in vitro flow rates and tip suction force under gentle retraction were compared among 10 commercially available aspiration catheters and the R4Q system. Results The R4Q 6F, 5F, 4F, and 3F catheters achieved flow rates at least 21.9%, 24.7%, 61.9%, and 244.7% greater than the other catheters tested respectively and the R4Q 6F produced a 140.2% higher tip force than a catheter of similar size. Fluid flow rate in the R4Q 6F increased on retraction into the guide catheter, delivering a 58.2% increase from fully extended to fully retracted. Conclusion The R4Q design demonstrates a substantial increase in aspirated flow rate and suction force due to an increased effective diameter than standard tubular catheter designs tested. The prominent increase in the aspiration parameters measured in vitro supports the potential for improved clinical results during stroke thrombectomy procedures.

Objectives: Diagnosis of and treatment for posterior shoulder instability (PSI) has improved with advances in surgical technique and radiographic imaging. It is unknown if PSI, or surgical measures to correct PSI, affect the progression of osteoarthritis in the glenohumeral joint. The purpose of this study is to evaluate the effect of posterior capsulolabral reconstruction (PCLR) and demographic risk factors on the rate of radiographic progression of osteoarthritis in shoulders with PSI. Methods: The study population included 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with an average follow up of 12.5years (range 5-23). Medical records were reviewed to evaluate patient demographics, surgical intervention, and radiographic progression of osteoarthritis. Kaplan Meier survival was used to estimate survival and Cox models were used to examine associations with osteoarthritis progression. Results: Overall, 16/115 (14%) patients had radiographic progression of glenohumeral arthritis with 5-year survival at 88.3% (95% CI 79.7%-97.3%). Age ≥30 at the time of instability was associated with arthritis progression (p<0.05). The number of previous dislocations, sport, and gender each did not affect progression (p>0.05). PCLR with at least one anchor along the posterior glenoid rim was performed in 56/115 (48%) of patients. There was no difference in the rate of radiographic arthritic progression in those who underwent PCLR and those who did not (7/56, 13% vs 10/59, 17%, p>0.05). One male patient who underwent PCLR progressed to end-stage arthritis, necessitating a shoulder arthroplasty at age 53. Conclusion: Radiographic progression of glenohumeral arthritis occurred 14% of patients with PSI. Age ≥30 at the time of initial instability was associated with radiographic progression of glenohumeral arthritis.

Objectives: Among patients treated non-operatively for 1 year following a diagnosis of posterior shoulder instability (PSI), little is known about the the incidence of surgery between 1-13 years after injury. The purpose of this study is to define the frequency and evaluate the factors predictive for late surgical intervention of symptomatic PSI. Methods: This study included a population-based cohort of 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with a minimum 5-years follow-up (mean:13.9 years; range: 5-23 years). Landmark survival analysis was performed to evaluate incidence of surgery after 1 year. Survival was estimated using Kaplan Meier method and predictors of late surgical intervention were analyzed using Cox proportional hazards regression. Results: A total of 61/115 (53%) patients were treated non-operatively for 1 year following diagnosis of PSI. Of these, 24/61 (39%) converted to surgery for symptomatic PSI. The overall survival free of surgery at 1 and 5 years was 53.0% (95% CI 434.7-63.0) and 37.1% (95% CI 29.1-47.1), respectively. BMI >35 (p=0.04, HR 3.3) was predictive for late conversion to surgery. Age, gender, occupation, or history of glenohumeral dislocation were not significant. Assessing surgery as a time dependent covariate, a patient undergoing surgery was at an increased risk for radiographic progression of osteoarthritis (p=0.02, HR=4.0, 95% CI 1.2-13.2). Conclusion: Conservative management was performed for at least one year in over half of patients diagnosed with PSI. However, long-term follow-up demonstrates that nearly 40% of these patients eventually require surgery. Increased BMI was predictive for late failure of while age, gender, history of dislocation and occupation did not show an effect. Patients who underwent surgery were at an increased risk of radiographic progression of arthritis.

Objective To determine the accuracy of ultrasound guidance compared to palpation in performing carpometacarpal joint injections in cadavers. Design In all, 36 carpometacarpal joints were randomized to either ultrasound-guided or palpation-based injections, with 1 cc of blue latex solution injected into each joint. The specimens were then dissected and the distribution of the latex was assessed by two independent, blinded raters. Injection accuracy was evaluated on a four-point quartile rating scale of 1–4, corresponding to the amount of the latex solution within the joint (1 = 0–25%, 2 = 26–50%, 3 = 51–75%, 4 = 76–100%). Inter-rater reliability was a secondary measure. Results The mean rating of accuracy was 2.1 for both palpation-based and ultrasound-guided injections. There was no statistically significant difference in accuracy between the two injectors. Chi-square analysis testing differences in accuracy for the two conditions was not statistically significant. The Cronbach’s alpha for rater 2 was 0.74, which represents an acceptable level of reliability. A Friedman’s Chi-square for the two raters was 2.3 ( p = 0.13), indicating no significant difference between raters. Conclusion Ultrasound guidance did not improve the accuracy of carpometacarpal joint injections in cadavers. However, the high inter-rater reliability attests to the value of the novel assessment scale.

BackgroundGraft‐versus‐host disease (GVHD) following solid organ transplantation (SOT) is extremely rare and infrequently described in the dermatologic literature.MethodsWe performed a retrospective clinicopathologic review of our institution's experience with patients diagnosed with SOT‐associated GVHD (SOT GVHD) (May 1, 1996 to September 1, 2017).ResultsOf nine patients with SOT GVHD, seven had undergone liver transplantation, while two had undergone lung transplantation. All presented initially with a skin eruption, which developed an average of 63 days (range: 11‐162 days) post transplant. The average time to diagnosis following the onset of the skin eruption was 12 days (range: 0‐54 days). Diagnosis was often delayed because of a competing diagnosis of drug reaction. Frequent skin findings included pruritic erythematous to violaceous macules and papules with desquamation. Histopathology showed vacuolar interface dermatitis in 12 of 15 cases (80.0%). Of the 11 specimens in which a hair follicle was present for evaluation, vacuolar interface changes around the hair follicle were present in eight (72.7%) cases. Seven patients (77.8%) died from complications during the follow‐up period.ConclusionsSOT GVHD presents initially with skin involvement, is associated with vacuolar interface changes on skin biopsy, and is associated with a high mortality rate. Clinicopathologic correlation is required for accurate diagnosis.

Objectives Bipolar disorder (BD) with early disease onset is associated with an unfavorable clinical outcome and constitutes a clinically and biologically homogenous subgroup within the heterogeneous BD spectrum. Previous studies have found an accumulation of early age at onset (AAO) in BD families and have therefore hypothesized that there is a larger genetic contribution to the early‐onset cases than to late onset BD. To investigate the genetic background of this subphenotype, we evaluated whether an increased polygenic burden of BD‐ and schizophrenia (SCZ)‐associated risk variants is associated with an earlier AAO in BD patients. Methods A total of 1995 BD type 1 patients from the Consortium of Lithium Genetics (ConLiGen), PsyCourse and Bonn‐Mannheim samples were genotyped and their BD and SCZ polygenic risk scores (PRSs) were calculated using the summary statistics of the Psychiatric Genomics Consortium as a training data set. AAO was either separated into onset groups of clinical interest (childhood and adolescence [≤18 years] vs adulthood [>18 years]) or considered as a continuous measure. The associations between BD‐ and SCZ‐PRSs and AAO were evaluated with regression models. Results BD‐ and SCZ‐PRSs were not significantly associated with age at disease onset. Results remained the same when analyses were stratified by site of recruitment. Conclusions The current study is the largest conducted so far to investigate the association between the cumulative BD and SCZ polygenic risk and AAO in BD patients. The reported negative results suggest that such a polygenic influence, if there is any, is not large, and highlight the importance of conducting further, larger scale studies to obtain more information on the genetic architecture of this clinically relevant phenotype.

Objective: To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections. Design: Single-center, prospective, before-and-after feasibility trial. Setting: Emergency department of a sub-Saharan African district hospital. Patients: Patients > 28 days of life admitted to the study hospital for an acute infection. Interventions: The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases. Measurements and Main Results: Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed. Conclusions: Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).