Intracochlear schwannoma presenting as diffuse cochlear enhancement: diagnostic challenges of a rare cause of deafness

Intracochlear schwannoma is a rare, treatable, cause of unilateral hearing loss. Due to the small size, position, and variable clinical and imaging features, diagnosis presents a significant challenge and is often delayed. We present a case of a patient with an intracochlear schwannoma presenting as a diffuse enhancement of the cochlea, mimicking an infectious or inflammatory process. The absence of focal nodularity in this lesion on multiple high-resolution MRI examinations led to a delay of over 3 years from the patient’s initial presentation to surgical diagnosis. Clinical history and examination, imaging features, pathologic findings, and surgical management options are described

Human amnion epithelial cells rescue cell death via immunomodulation of microglia in a mouse model of perinatal brain injury

BACKGROUND: Human amnion epithelial cells (hAECs) are clonogenic and have been proposed to reduce inflammatory-induced tissue injury. Perturbation of the immune response is implicated in the pathogenesis of perinatal brain injury; modulating this response could thus be a novel therapy for treating or preventing such injury. The immunomodulatory properties of hAECs have been shown in other animal models, but a detailed investigation of the effects on brain immune cells following injury has not been undertaken. Here, we investigate the effects of hAECs on microglia, the first immune responders to injury within the brain. METHODS: We generated a mouse model combining neonatal inflammation and perinatal hyperoxia, both of which are risk factors associated with perinatal brain injury. On embryonic day 16 we administered lipopolysaccharide (LPS), or saline (control), intra-amniotically to C57Bl/6 J mouse pups. On postnatal day (P)0, LPS pups were placed in hyperoxia (65% oxygen) and control pups in normoxia for 14 days. Pups were given either hAECs or saline intravenously on P4. RESULTS: At P14, relative to controls, LPS and hyperoxia pups had reduced body weight, increased density of apoptotic cells (TUNEL) in the cortex, striatum and white matter, astrocytes (GFAP) in the white matter and activated microglia (CD68) in the cortex and striatum, but no change in total microglia density (Iba1). hAEC administration rescued the decreased body weight and reduced apoptosis and astrocyte areal coverage in the white matter, but increased the density of total and activated microglia. We then stimulated primary microglia (CD45(low)CD11b(+)) with LPS for 24 h, followed by co-culture with hAEC conditioned medium for 48 h. hAEC conditioned medium increased microglial phagocytic activity, decreased microglia apoptosis and decreased M1 activation markers (CD86). Stimulating hAECs for 24 h with LPS did not alter release of cytokines known to modulate microglia activity. CONCLUSIONS: These data demonstrate that hAECs can directly immunomodulate brain microglia, probably via release of trophic factors. This observation offers promise that hAECs may afford therapeutic utility in the management of perinatal brain injury

ACUTE PHYSIOLOGICAL RESPONSES TO ELECTRICAL MUSCULAR STIMULATION WITH BLOOD FLOW RESTRICTION IN DAILY WHEELCHAIR USERS

Lauren Hopps, Abby R. Fleming, Tiffany Adams, Jordan Saliba, Lee J. Winchester. University of Alabama, Tuscaloosa, AL. BACKGROUND: The application of blood flow restriction (BFR) during low intensity resistance training has been found to increase muscular strength to a similar extent as high-intensity resistance training. Electrical muscular stimulation in everyday wheelchair users has been found to reverse vascular damage and improve muscle strength resulting from injury or inactivity. Utilizing EMS during BFR in the lower extremities may increase muscle hypertrophy and strength, improve vascular health, and contribute to improved function. The purpose of this study was to compare acute physiological responses to EMS with and without BFR among individuals that primarily use wheelchairs for activities of daily life. METHODS: 10 participants who require daily wheelchair use are being recruited for this study. Individuals meeting the inclusion criteria are participating in 3 randomized experimental sessions: EMS, BFR, and EMS+BFR. Upon arrival, participant anthropometrics are collected and then the participants are seated on a standard hospital bed in an upright position. After 5 minutes of rest, fingerprick lactate and posterior tibial artery ultrasound analysis are assessed. One of 3 treatment conditions are applied for 20 minutes and upon treatment cessation, lactate and arterial analyses are repeated. Repeated measures ANOVA will be used to assess differences between means, with an alpha level of 0.05 set for statistical significance. RESULTS: Preliminary data (n=4) for blood lactate show higher blood lactate post treatment in EMS compared with other groups (EMS pre = 1.05 + 0.22 mmol, post = 4.0 + 1.78 mmol; BFR pre = 0.93 + 0.29 mmol, post = 1.23 + 0.29 mmol; EMS+BFR pre = 1.02 + 0.09 mmol, post = 1.36 + 0.14 mmol). Posterior tibial artery diameter via ultrasonography seems to be similar among all conditions (EMS pre = 0.24 + 0.40 cm, post = 0.25 + 0.05 cm; BFR pre= 0.22 + 0.009 cm, post= 0.21 + 0.007 cm; EMS and BFR pre= 0.21 + 0.003 cm, post= 0.21 + 0.01 cm). Tibial artery volume flow follows a general trend for reduced volume flow after treatment, with BFR and EMS+BFR having the greatest change (EMS pre= 26.58 + 9.28 cc/min, post= 23.80 + 12.15 cc/min; BFR pre= 18.24 + 5.05, post= 14.26 + 5.06 cc/min; EMS and BFR pre= 18.29 + 10.88 cc/min, post = 10.74 + 2.96 cc/min). However, these results are preliminary and have not been statistically analyzed due to a very small sample number

Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study

Abstract Background Veterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions. Methods A qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs. Results There was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs. Conclusions Since program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings