Cognitive changes in patients treated for Obstructive Sleep Apnea with upper airway stimulation, maxillomandibular advancement, or expansion sphincter pharyngoplasty

Introduction: Obstructive sleep apnea (OSA) is a prevalent diagnosis that has been shown to not only affect sleepiness, but daytime cognitive function — specifically attention, working memory, and executive function. CPAP treatment is troublesome for some patients and it is possible that superior treatment options, specifically novel surgical techniques, are available, though none have been evaluated for their long-term effects on neurocognition. We hypothesize that treating patients with upper airway stimulation surgery (UAS) UAS, maxillomandibular advancement surgery (MMA), and expansion sphincter pharyngoplasty surgery (ESP) for OSA produces a significant improvement in cognition from baseline. Methods: For inclusion in the study, two important criteria must be met: 1) a previous diagnosis of OSA 2) patients have failed CPAP. Exclusion criteria include pediatric population (\u3c18 years of age), and those without ability to complete the NIH Toolbox assessment on an iPad in English. Using the iPad-based NIH Toolbox assessment, the primary outcome of the study is to analyze the effect of UAS, MMA, and ESP treatment on three markers of cognition: the Processing Speed Test, the Inhibitory Control and Attention Test, and Sorting Working Memory Test (15 minutes total). Results: Data reported below is for one timepoint for nine patients receiving UAS: ▪ Age=53.8 ± 15.4 ▪ BMI=29.2 ± 4.2 ▪ Depression diagnosis:3/9 ▪ CCI \u3e 0: 5/9 ▪ Age-adjusted national percentiles: ▪ Processing speed: 61.4±43.7 ▪ Inhibitory Control and Attention Test: 59.1±32.3 ▪ Sorting Working Memory Test: 52.8±23.7 Discussion: The results of this study will give providers additional information in evaluating treatment options for patients with cognitive deficit related to OSA. The gold standard for assessing neurocognitive function is fMRI, as demonstrated by studies done showing improvement in CPAP patients. Success in this study may support further research using fMRI data to support the hypothesis of improvement in cognition

Same-day vs. next-day reconstruction following Mohs micrographic surgery: a comparative study

BACKGROUND: Skin cancer is the most common malignant neoplasm, with more than 5.4 million cases diagnosed annually in the United States. Treatment varies based on the type of neoplasm, its location, as well as primary vs. recurrent lesions. Nonetheless, surgical treatment remains the gold standard. Mohs micrographic surgery (MMS) is a commonly used surgical technique in the excision of such neoplasms. The technique of MMS allows for the precise removal of skin cancers while offering the highest cure rates with maximal preservation of surrounding tissue. Repairs of MMS defects are often done the same day if performed by the resecting Mohs surgeon. However, for more complicated reconstructive procedures, repairs are often performed by a separate reconstructive surgeon. When this occurs, MMS repairs may be delayed and performed on a different day due to a variety of factors such as surgical scheduling conflicts and patient tolerance. Researchers are urgently trying to explore the implications and postoperative complications of delayed MMS as compared to same day MMS. OBJECTIVE: This study compares same-day vs. next day eyelid reconstruction following MMS with attention to postoperative complications. Our aim is to investigate whether or not a delay in closure is associated with an increase in postoperative complications. METHODS: We performed a retrospective chart review of patients who underwent eyelid reconstruction following MMS from January 2008 to December 2018, by a single private practice oculoplastic surgeon. The timing of each patient’s reconstruction along with age, sex, comorbidities, such as diabetes, current smoking status, previous radiation therapy, anticoagulation treatment, and occurrence of postoperative complications were recorded. The specific location of the defect was recorded as well. The timing of reconstruction was classified as same-day or next-day reconstruction. No reconstructions took place more than 48 hours after tumor excision. The complications included in our analysis were: hematoma, wound infection, flap necrosis, dehiscence, and ectropion. Statistical significance was determined by Pearson’s chi-squared analysis. RESULTS: A total of 485 procedures were performed on 390 patients. 334 (69%) of those procedures were same-day reconstructions, while 151 (31%) of those procedures were next-day reconstructions. 19 (5.7%) of the 334 same-day reconstructions and 9 (5.9%) of the 151 next-day reconstructions were associated with complications (p=0.905). Therefore, a total of 28 (5.8%) procedures were associated with complications. More women (54%) than men (46%) underwent reconstruction. Multivariate logistic regression showed that males had a 1.274-fold higher risk of developing complication post reconstruction. Current smokers had a 1.054-fold higher risk of developing complications post reconstruction. CONCLUSIONS: There is no statistically significant difference in the postoperative complication rate when comparing same-day vs. next-day eyelid reconstruction following Mohs micrographic surgery

Treatment of Persistent Air Leaks using Endobronchial Valves

Introduction: Persistent air leaks (PAL) are from bronchopleural fistula resulting from communication between the bronchial tree and pleural space. Endobronchial valves (EBVs) are unidirectional valves placed bronchoscopically preventing airflow to the diseased lung lobe. For non-operable patients with PALs, EBVs offer a potential non-invasive treatment approach to stop air leak and allow lung healing. The purpose of this study is to retrospectively analyze EBV placement to treat non-operable adult patients with PALs. Methods: We retrospectively analyzed all adult patients that underwent EBV placement for PAL treatment at our institution from January 2016 to June 2019. All patients failed conservative therapy with chest tubes before EBV placement. Descriptive statistics were used to analyze leak etiology, number of valves placed, duration of placement, and PAL resolution. Results: A total of 20 EBV procedures occurred in patients with a median age of 63 (range = 38–79). Air leaks were spontaneous in 13 patients and either due to post-surgical or iatrogenic causes in 7 patients. By last follow-up, 60% of patients still retained all valves. Among patients that had valves removed, EBVs were in place for a median of 6 months (range = 2–21). 19 patients PALs resolved after EBV placement. Discussion: Our data supports previous reports of the feasibility of successfully treating PALs using EBVs. Although this report requires validation in a larger cohort, our data suggests that compassionate exemption EBV placement can be a possible treatment alternative to current standard of care for patients with PALs that are non-operable

Assessing the environmental triggers for C. botulinum type E growth and toxin production in Lake Michigan's Cladophora algae mats

Library Student Mini Grant Award Year 2017-2018Mainly during the fall season, waterfowl in the Great Lakes ingest a neurotoxin produced by the bacterium Clostridium botulinum, which emerges from its resting state to proliferate and produce this deadly toxin. This toxin is thought to be produced within decaying algal mats, called Cladophora, that ravage the lakes. By implementing various combinations of suspected environmental stressors in Cladophora enrichment cultures in the lab, we expect to experimentally uncover the conditions that promote the toxin production in the algal mats. Our results will be incorporated into an avian botulism outbreak model, which would allow better prediction of outbreaks and inform management practices for the preservation and conservation of the lakeshore ecosystem.https://deepblue.lib.umich.edu/bitstream/2027.42/142998/1/Zingas, Cole_MiniGrant2018.pptxDescription of Zingas, Cole_MiniGrant2018.pptx : Presentatio

InternalBrace for Anatomic AITFL Augmentation and Syndesmotic Stabilization: Results at Long-term Follow Up

Category: Ankle; Trauma Introduction/Purpose: In the light of recent randomized control trials, both suture-button and syndesmotic screw fixation are considered standard-of-care for syndesmotic fixation, but no gold standard currently exists. An alternative technique that has been described to stabilize the syndesmosis is with use of suture-tape (InternalBrace, Arthrex) to augment a torn AITFL. This method has been the subject of several biomechanical studies that show it better restores anatomic relationships and can provide a preinjury level of syndesmotic stability. Additionally, it is thought to allow for protected healing of native ligaments, which may be of benefit to patients in the long-term. With this study we sought to explore the long-term outcomes of anatomic augmentation of the AITFL with the InternalBrace for the treatment of syndesmotic injury. Methods: We identified 31 patients who had suffered an acute or subacute syndesmotic injury and were treated with the InternalBrace technique (with or without adjunctive syndesmotic fixation) over a 12-month period from 2019-2020 by a single surgeon. The primary outcome variable was the Olerud-Molander Ankle Score (OMAS) at long-term follow up (12-36 months). Other outcomes collected were FAOS scores, range of motion data, and complications. Additionally, radiographs at five timepoints were reviewed to determine maintenance of syndesmotic reduction. Results: At final follow-up, 15 patients completed the primary outcome with a mean OMAS of 78 (SD, 18). All 31 patients were determined to have a successful syndesmotic reduction at the time of the index procedure. No patients were noted to have a radiographic loss of reduction with a tibiofibular clear space > 6mm at time of final radiographic follow up (mean follow-up 439 days). For those patients with ROM data collected at final follow up, 12/15 patients were limited in dorsiflexion (average deficit 6 degrees), and 7/15 in plantarflexion (average deficit 14 degrees). In total, 10/31 patients developed symptoms of anterolateral impingement, for which six underwent secondary arthroscopic debridement. Conclusion: We report the first mid-to-long term clinical results of a newer alternative method of syndesmotic stabilization. Functional results are comparable to current standards-of-care. AITFL augmentation provides consistent anatomic reduction of the syndesmosis with enough biomechanical strength to resist rotation and diastasis. However, in some patients the development of irregular thickening/scarring of the AITFL contributed to symptoms of anterolateral impingement and stiffness. To avoid this complication, alterations in technique, such as a more proximal application of the suture-tape or avoidance of overtightening, are possible and emphasize the importance of future research

Posterior Malleolus Fixation Using a Suture Button

Category: Trauma Introduction/Purpose: Despite the increasing awareness and literature addressing fractures of the posterior malleolus (PM), no biomechanical nor clinical studies have been able to establish consensus surgical indications or treatment methods for these common orthopedic injuries. A posterolateral or posteromedial approach allows fixation to be placed in a compressive mode as opposed to the more traditional anterior to poster placed screws which relies upon static screw placement. We designed a technique that utilizes a suture button device for fixation. This technique allows for compression across the fracture site while avoiding cumbersome patient positioning and extensive posterior dissection. Methods: Our technique utilizes a standard lateral approach to the fibula which is fixed routinely. Finger dissection is then carried out between the posterior fibula and perennial tendons to grant access to the PM which typically reduces via ligamentotaxis. A PCL drill guide is then placed on the substance of the PM and a cannulated drill is advanced through the distal tibia from anterior to posterior after careful dissection through a small incision on the anterior tibia. A suture lasso then brings the suture button through the drill tunnel and it is compressed over a knotless endobutton which rests on the anterior tibia. The medial malleolus is then addressed routinely. Following placement of all hardware an external rotation stress test is performed to assess syndesmotic stability. After IRB approval the clinical and radiographic data of patients who underwent this technique was retrospectively reviewed. Results: Seven patients underwent treatment of a PM fracture using our technique. All cases achieved an anatomic reduction of the PM based on available imaging. One patient was found to have a loss of reduction of her medial malleolus at the first post- operative visit and underwent revision surgery with a good result. Final follow up averaged 9.5 months. Four of the seven patients underwent additional surgical procedures. Final ROM was available for 5 patients. Of the five, 4 achieved dorsiflexion greater than 5 degrees and had an arc of motion greater than 35 degrees. The final patient had a final ROM arc of 10-30 degrees of plantar flexion despite progressive dorsiflexion casting and lysis of adhesions. AOFAS score of available patients averaged 81.5. Conclusion: Our technique of using a suture button as fixation for PM fractures has several advantages. First, patient position improves surgical ease. Second, this approach avoids extensive posterior dissection and bulky hardware which we believe may lead to posterior scar formation and resultant ankle stiffness. Finally, the posterior button allows for compression of the PM which may contribute to the improved results seen with a posterior approach. We were able to achieve a radiographically anatomic reduction, satisfactory ROM and good outcome scores. We believe that our technique is a viable option in those injuries that benefit from surgical treatment of the PM component