Aims: To improve the experience of Transition for children and Young People (CYP) with Intestinal Failure (IF) Background: All health care professionals have access to documents describing transition and what it should look like in theory. Putting this theory into actual practice is challenging, heightened by the complexities of the CYPs medical, nursing and psycho/social needs. Advances in management techniques and science have resulted in many more children and young people receiving HPN surviving into adulthood and therefore requiring a transition pathway. A UK review of transition practices for CYP and IF in 2014 highlighted that this cohort were complex in nature and that transition service standards for young people on HPN were lacking and required practical elements of transition such as independence and training. Methodology: Working with a PINNT we developed documents for the main stakeholders of Transition (the young person, parent/carer and health care professional) providing support, assessment and readiness tools for transition. Incorporated into this is an instrumental annual transition clinic for all children in secondary education, including independence training which is planned and secured in a partnership with the tertiary centre, home care company and young person. Results: Eight young adults are currently enrolled in the annual transition clinic; four have completed the independence programme designed for them according to physical and emotional maturity and readiness. 100% of CYP and parents attending the transition clinic report positive experiences and conclude rounded involvement and participation positively prepares all parties for transition. The health care professionals in attendance (consultants, clinical nurse specialists, dietitians and pharmacists) all reported a feel good factor and increased job satisfaction that can only enhance the fresh new forming relationships as the young person transitions and bids slowly good bye to these long extensive relationships in paediatrics. Conclusion: All CYP with IF require a robust transition pathway. The complex nature of IF including the psycho-social and educational influences, requires tools to assess need and readiness in order to construct individually tailored plans that can be incorporated into the transition pathway.

Aim: To use a web based management platform to prevent occlusions and preserve the lifespan of a central venous access devices (CVAD) for Home Parenteral Nutrition (HPN). Background: Despite many techniques, adjuncts and pharmaceutical agents there are some CVADs that remain troublesome with frequent partial and full occlusions that require CVAD exchanges. The CVAD for a child or young person that requires HPN can be described as a “lifeline” and all options to maintain long term patency should be utilised. MicrelCare have a web based care management platform that monitors real time infusion pressures relaying information from the home to the hospital Methodology: Using one teenage male on HPN (who had experienced 3 CVAD exchanges in 2 years) as a candidate for MicrelCare, we virtually monitored his CVAD pressure’s and infusion alarms via a real time platform. This virtual platform alongside clinical correlation (patient consultations and physical assessment) allowed for the determination of pressure range monitoring and the early detection of line stiffness and pre cursors to occlusion. Results: We were able to determine that for this patient when the CVAD pressure levels reached 0.2 bar it was imperative that we physically assessed the CVAD and followed the in house protocol of Urokinase/Alteplase instilment followed by an Ethanol treatment if required (including hub inspection and POP technique) to prevent irreversible occlusion. Interestingly the pressure bar for this young man is lower than MicrelCare would expect and that of our patient cohort. Conclusion: MicrelCare can be a useful tool to virtually monitor and predict precursors to CVAD stiffness and occlusion when used with clinical correlation.This allows the development of a robust tailored care plan, which prolongs the life of a CVAD and in turn preserves venous access.

When patients with implantable cardioverter defibrillators (ICD) develop symptomatic atrial fibrillation (AF), external direct current cardioversion (EDCCV), as well as internal cardioversion using their ICD, are the options available. It is currently unknown which of these two methods are more effective. We compared the effectiveness of EDCCV versus internal cardioversion to terminate AF in patients with a single-coil ICD. This randomized controlled trial (clinicaltrial.gov NCT03164395) enrolled consecutive patients with a single-coil ICD that presented with symptomatic AF of less than 1-year duration. They received either the maximum energy internal shock through the ICD or an EDCCV using transcutaneous pads of 200 J. The primary endpoint was a successful conversion to sinus rhythm after one shock. Crossover was permitted if the first shock was unsuccessful. Thirty-one patients were enrolled in the study, including 16 in the internal ICD cardioversion group. The study included patients with a mean age of 59.5 ± 16.0 years, 41.9% females, median AF duration 1 month (interquartile range 1–3), 45.2% non-ischemic cardiomyopathies, mean EF 28.6 ± 16.0%, and 45.2% biventricular ICD. There were no significant differences in baseline clinical characteristics between the two groups. In the internal cardioversion group, 5/16 patients (31.3%) met the primary endpoint versus 14/15 (93.3%) in the EDCCV group, p < 0.001. All patients that failed the first shock were subsequently cardioverted externally. Among patients with a single-coil ICD and symptomatic AF of less than 1 year, external direct current cardioversion is much more effective than internal shock through the ICD.

An isolated third nerve palsy presenting as the primary manifestation of a lymphoma is rare, with only few cases having been described. The present study reports an unusual case of a healthy 67-year old male diagnosed with isolated right oculomotor nerve palsy (ONP), who was found to have an underlying B cell lymphoma. The patient's medical records were accessed upon consent. A thorough physical examination, including stroke and infections work-ups were performed. A chest computerized tomography (CT), brain magnetic resonance imaging and positron emission tomography (PET) scans and a mediastinal tissue biopsy, were performed as part of systematic diagnostic evaluations. The current report suggests that a PET fluorodeoxyglucose study or a CT scan of the chest, abdomen and pelvis (with contrast) may help in the early diagnosis of a cancer responsible for ONP, particularly if brain vessel imaging does not show a posterior cerebral artery aneurysm as a cause for the defect.

Atrial fibrillation is the leading cause of cardioembolic stroke, with emboli most commonly originating from the left atrial appendage. We report the case of a 71-year-old male with left atrial appendage closure via implantation of the WATCHMAN device, due to possible anticoagulation therapy failure and increased bleeding risk, following a stroke. Following a new stroke over a year later, a 1.8-mm peri-device leak was observed. Surgical records noted a minimal (<5 mm jet flow) peri-device leak after the installation, which was considered successful WATCHMAN implantation per protocol. This case highlights the persistent risk of cardioembolic stroke in patients with nonvalvular atrial fibrillation despite device implantation and questions the significance of peri-device leak and further management with anticoagulation for recurrent stroke.

BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice. However, the outcomes associated with AF in hospitalized patients with liver cirrhosis are unknown. AIM To determine the outcomes of hospitalized patients with liver cirrhosis and AF. METHODS In this study, we examined morbidity and mortality of patients with concomitant AF and liver cirrhosis from the National Inpatient Sample database, the largest publicly available inpatient healthcare database in the United States. RESULTS A total of 696937 patients with liver cirrhosis were included, 45745 of whom had concomitant AF (6.6%). Liver cirrhosis patients with AF had higher rates of in-hospital mortality (12.6% vs 10.3%, P < 0.001), clinical stroke (1.6% vs 1.1%, P < 0.001), and acute kidney injury (28.2% vs 25.1%, P < 0.001), and less gastrointestinal bleeding (4.4% vs 5.1%, P < 0.001) and blood transfusion (22.5% vs 23.8%, P < 0.001) compared with those who did not have the arrhythmia. In addition, they had a longer length of stay (8 ± 10 d vs 7 ± 8 d, P < 0.001) and higher hospitalization costs (20720 ± 33210 $ vs 16272 ± 24166 $, P < 0.001). CONCLUSION In subjects with liver cirrhosis, AF is associated with higher rates of inpatient mortality, stroke, and acute kidney injury compared to those who do not have the cardiac arrhythmia.

Tuesday, April 28April 14, 2020Free AccessMechanical Thrombectomy Could Still be Beneficial in Acute Large Vessel Occlusion with Large Core Infarction (2623)Riwaj Bhagat, Marwa Elnazeir, Gopika Kutty, Shivani Naik, Tina Walsh, Lisa Smith, Tracy Ander, Jignesh Shah, Kerri Remmel, and Wei LiuAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.2623 Letters to the Editor

May 5, 2019April 9, 2019Free AccessLess benefits of Mechanical Thrombectomy on Acute Large Vessel Occlusion Stroke Patients Who were Transferred to a Comprehensive Stroke Center (P1.3-032)Marwa Elnazeir, Michael Haboubi, Ruolan Liu, Elizabeth Wise, Tracy Ander, Shah Jignesh, Ozan Akca, Kerri Remmel, and Wei LiuAuthors Info & AffiliationsApril 9, 2019 issue92 (15_supplement)https://doi.org/10.1212/WNL.92.15_supplement.P1.3-032 Letters to the Editor

BACKGROUND Frequent premature ventricular contractions (PVCs) can cause disabling symptoms and decrease left ventricular ejection fraction. PVC burden, typically quantified by a 24-hour monitor, is one of the factors that determines the clinical management of PVCs. OBJECTIVE The purpose of this study was to evaluate the extent of variability in 24-hour PVC burden during 14-day ambulatory cardiac monitoring in patients with significant PVC burden. METHODS All patients referred for PVC evaluation received a 14-day ambulatory cardiac monitor. Parameters of interest included mean 14-day PVC burden, minimum and maximum 24-hour PVC burden, and absolute change in 24-hour PVC burden (maximum minus minimum). We included only patients with a mean 14-day PVC burden of more than 5%. RESULTS Fifty-nine patients were included in the study. The median of mean 14-day PVC burden, maximum 24-hour PVC burden, and minimum 24-hour PVC burden were 9.0% (IQR 6.4%-17.9%), 16.2% (IQR 11.7%-26.2%), and 4.5% (IQR 2.6%-11.2%) respectively (P < .001). The median of the absolute 24-hour PVC burden change was 9.9% (IQR 5.4%-14.5%). There was a 2.45-fold (IQR 1.68- to 5.55-fold) median difference between maximum 24-hour PVC burden and minimum 24-hour burden in the same patient. When categorized by low (<10%), intermediate (10%-20%), and high (>20%) 24-hour PVC burden, 72.9% patients fell into at least 2 categories depending on the 24-hour period considered. CONCLUSION There is a significant variation in 24-hour PVC burden when measured over a 14-day period in patients with of PVC burden of more than 5%. This variation might impact critical clinical decisions in a significant proportion of such patients.

INTRODUCTION:Ventriculoatrial (VA) conduction is a critical component in many arrhythmias, has a diagnostic value in electrophysiology study (EPS), and is implicated in pacemaker-mediated arrhythmias. This study sought to characterize retrograde conduction during EPS and to utilize it as a diagnostic tool in patients without AV block.METHODS AND RESULTS:Patients with intact AV conduction undergoing EPS were included in this study to systematically evaluate baseline VA conduction. If absent, parahisian pacing was used to determine the level of block (nodal or infranodal). Recovery of VA conduction with increased sympathetic activity was assessed with isoproterenol infusion. Baseline characteristics and electrophysiological data were collected and analyzed. Among the 801 patients studied, VA conduction was present in 98% (81% at baseline and 17% after isoproterenol infusion). Parahisian pacing demonstrated that the block was at the AV node level among 150 patients with VA dissociation at baseline. Among patients presenting with supraventricular tachycardia (SVT), 98.7% with atrioventricular nodal reentrant tachycardia (AVNRT) had VA conduction at baseline versus 82.7% presenting with other SVT (atrial fibrillation excluded), P < 0.001. Thus, the absence of VA conduction at baseline during an EPS for SVT carries a negative predictive value (NPV) of 96.9% for AVNRT.CONCLUSIONS:VA conduction is present in most patients (98%) with intact AV conduction. The level of VA dissociation when present at baseline is always at the level of the AV node. Patients with SVT presenting for EPS that lacked VA conduction at baseline were unlikely to have AVNRT.

Catheter ablation (CA) is an effective treatment for ventricular arrhythmias (VA), with a potential for complications. The presence of structural heart disease (SHD) is associated with a higher complication rate although there is no data comparing CA of VA between patients with SHD and those without. We aimed to compare trends, morbidity, and mortality associated with real world practice of CA for VA (ventricular tachycardia and premature ventricular contraction) based on the presence of SHD. Using weighted sampling in the National Inpatient Sample database, we collected and compared characteristics and outcomes of patients with or without SHD that underwent CA of VA. Among 34,907 patients that underwent CA for VA (1999-2013), 18,014 (51.6%) had SHD. Major and all complications occurred among 1,135/18,014 (6.3%) and 2139/18,014 (11.9%) patients with SHD respectively compared with 355/16,893 (2.1%) and 739/16,893 (4.4%) for patients without SHD, p < 0.001 for both comparisons. Furthermore, 452/18,014 (2.51%) with SHD died versus 20/16,893 (0.12%) without SHD, p < 0.001. Heart failure was associated with an odds ratio (OR) of 3.09 for major complications (95%CI: 1.53-6.27, p = 0.002) for patients with SHD while coronary artery disease OR for major complications was 2.47 (95%CI: 1.44-4.23, p = 0.001) for patients without SHD. There was a significant increase in major complications over the 15-year study period in patients with SHD, p < 0.001. In conclusion, the presence of SHD during CA for VA increased the complication rate of major and any complications by approximately threefold for both and the hospital mortality by >20-fold compared with patients without SHD.

Catheter ablation (CA) is an effective treatment for atrial fibrillation (AF). The differences in complication rates and outcomes between women and men remain poorly studied. We aimed to study the sex differences in morbidity and mortality associated with CA in AF.

ABSTRACTBACKGROUND AND PURPOSEBlood–brain barrier (BBB) disruption detected on magnetic resonance imaging (MRI) in acute ischemic stroke as a hyperintense acute reperfusion marker (HARM) is associated with upregulation of matrix metalloproteinase‐9 (MMP‐9). Although activated leukocytes, including monocytes, are the main source of MMPs, limited data exist to support relationship between leukocyte activation and BBB disruption in patients with acute ischemic stroke. The goal of this study is to investigate the relationship between neutrophils, lymphocytes, and monocytes with BBB disruption detected as HARM (+) in patients with acute ischemic stroke.METHODSWe conducted a retrospective analysis of prospectively collected data in patients who did not receive any reperfusion therapy with acute (<12 hours) ischemic stroke. MRI scans were obtained at baseline, 24 hours, and 5 days. HARM was evaluated on the 24‐hour follow‐up scan.RESULTSThirty‐three patients were studied. HARM was detected in 27% of patients. Median volumes of baseline perfusion (mean transit time [MTT]) deficit (219.4 mL vs. 158.4 mL, P = .029) and DWI infarct growth at 24 hours (18.50 mL vs. .14 mL, P = .017), as well as the median absolute numbers (1 × 103/mm3) of monocytes, were significantly higher in HARM (+) versus HARM (−) patients (0.9 vs. 0.6, p = 0.011).CONCLUSIONIncreased monocyte count associated with HARM supports importance of systemic inflammation in BBB disruption in acute ischemic stroke.