Paediatric researchers have devised an innovative, safe and minimally invasive procedure that helps relieve rare but potentially life-threatening airway blockages occurring in children who had surgery for congenital heart defects.
The physician-researchers developed new imaging tools and used minimally invasive catheterization techniques to treat plastic bronchitis, a condition in which abnormal circulation causes lymphatic fluid to dry into solid casts that clog a child’s airways.
The study, which describes the pathophysiological mechanism of plastic bronchitis and a treatment approach, arose from collaboration between Maxim Itkin, MD, an associate professor of Radiology in the Perelman School of Medicine at the University of Pennsylvania, and Yoav Dori, MD, a pediatric cardiologist in the Cardiac Center at The Children’s Hospital of Philadelphia (CHOP). They co-lead a specialized team dedicated to the care of lymphatic disorders as part of the Center for Lymphatic Imaging and Interventions at The Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania.
‘This is a new treatment option for children with plastic bronchitis and has the potential to offer long-term improvement of this condition,’ said Dori. ‘This procedure may even provide cure and avoid the need for a heart transplant.’
The current study builds on the team’s 2014 article in Pediatrics, the first case report of the successful use of their technique in a patient with plastic bronchitis. ‘We have expanded on that study to report short-term outcomes in a larger group and to share insights into the development of plastic bronchitis, which has been poorly understood,’ said Itkin. In addition to heart patients, children and adults with idiopathic plastic bronchitis, in which the cause is unknown, have also been treated successfully using these techniques.
Itkin and Dori discovered that the primary cause of plastic bronchitis is a lymphatic flow disorder, due to abnormal lymphatic flow into lung tissue. Because physical examinations and conventional imaging may not provide specific findings, lymphatic flow disorders often go undiagnosed.
Over the past several years, Itkin and Dori developed a customized form of magnetic resonance imaging (MRI), called dynamic contrast enhanced MR lymphangiogram, to visualize the anatomy and flow pattern of a patient’s lymphatic system. This technique allows clinicians to locate the site at which lymph leaks into the airways.
Plastic bronchitis may occur in children as a rare complication of early-childhood heart surgeries used for single-ventricle disease, in which one of the heart’s pumping chambers is severely underdeveloped. Approximately 5 percent of children surviving this surgery experience plastic bronchitis because the surgery alters venous and lymphatic pressure. The authors argue that this altered pressure may interact with pre-existing anatomical differences in the patients’ lymphatic vessels.
The abnormal circulation causes lymph to ooze backward into a child’s airways, drying into a caulk-like cast formation that takes the shape of the airways. The first sign of plastic bronchitis may be when a child coughs out the cast. However, if unable to cough it up, a child may suffer fatal asphyxiation.
After identifying the leakage site in a lymphatic vessel, the lymphatic team intervenes, using a technique called lymphatic embolization. Through small catheters, the team blocks the abnormal flow with a variety of tools: coils, iodized oil, and covered stents, based on an individual patient’s needs.
In the current report, the team was able to perform lymphatic embolization in 17 of their 18 patients, ranging from age 2 to age 15 (median age 8.6 years). Fifteen of those 17 patients had significant improvements in cast formation, in some cases being cast-free longer than two years. Patients had transient side effects of abdominal pain and hypotension (low blood pressure), but the authors reported the procedure appeared safe in their patient group.

The Children’s Hospital of Philadelphia http://tinyurl.com/hjr4jps

Computational modelling makes it possible to predict the onset and progression of knee osteoarthritis in overweight people, shows a new study from the University of Eastern Finland. A computational model based on the degradation of the collagen fibril network in the articular cartilage was able to predict the onset and progression of osteoarthritis in overweight people during a four-year follow-up. In normal-weight people, osteoarthritis did not develop within this time span.

The study also developed a model of the knee joint which makes it possible to evaluate the mechanical responses experienced by cartilage cells in healthy and osteoarthritic cartilage during daily activities such as walking. The model demonstrated that both menisectomy and osteoarthritic changes to the cartilage cause significant alterations in cartilage cell responses.

Osteoarthritis is a joint disease estimated to affect around 5% of the total world population. Osteoarthritis is the most common in the knee or hip joint and it often develops as a result of ageing, but it can also develop due to excessive loading or joint injury. In Europe, over 100 million people have arthritis, and in America, direct costs of arthritis were $51.1 billion in 2004. In addition, it has been predicted that the number of patients with knee osteoarthritis increases by 40% by the end of 2050.

Osteoarthritis proceeds gradually, weakening the articular cartilage and ultimately wearing it off completely from the ends of articulating bones. In these cases, the patient suffers from heavy joint pain and the joint becomes stiff, often leading to incapacity for work. Joint replacement surgery is the only effective treatment for osteoarthritis, which is why the prevention of osteoarthritis would be a cost-effective alternative both for the patient and society at large.

The study utilised a computational modelling method integrating the tissue and cellular levels of the articular cartilage in order to analyse the function of the articular cartilage during the onset and progression of osteoarthritis. The method simulated the effect of articular cartilage composition, structure and various loadings on the volume, shape and mechanical responses of cartilage cells.

Compared to healthy cartilage, the cell volume of osteoarthritic cartilage increased as a result of mechanical loading. The modelling indicated that the most important explanatory factors for the cell volume increase were the pericellular fixed charge density, i.e. the number of proteoglycan molecules, and the stiffness of the collagen fibril network.

The study also analysed the effect of menisectomy, a commonly used method in knee surgery, and simulated overweight on cell responses. Both menisectomy and simulated overweight substantially increased fluid pressures in the cell and cartilage tissue during walking, but they did not have an effect on the cell shape or volume in healthy cartilage. In osteoarthritic cartilage, however, cells were compressed and elongated more, probably due to altered cartilage integrity.

During standing, the strains were amplified more in the cell than in pericellullar tissue in healthy joint cartilages, but the opposite was observed in osteoarthritic joint cartilage. It is possible that the pericellular tissue’s function is to protect cartilage cells from sudden changes and to promote cartilage health.

The study also developed computational algorithms for the degradation of the collagen fibril network in the articular cartilage and its reorganisation in order to predict the development and progression of osteoarthritis caused by overweight and cartilage damage. The estimate obtained from the degradation algorithm was well in line with the clinically observed progression of osteoarthritis during a four-year follow-up. Furthermore, the collagen fibril network structure in the mechanically injured cartilage was observed to be disorganised in the vicinity of the injury, suggesting that a cartilage injury exposes cartilage to further damage.

In-depth understanding of the effects of abnormal loading, early osteoarthritis and mechanical injuries on cellular and tissue responses in cartilage makes it possible to develop new strategies for the recognition, prevention and slowing down the progression of the disease. The methods developed in the study may become widespread in specialised health care in the future. However, rigorous clinical validation will be necessary before they can be introduced to clinical use.

University of Eastern Finlandwww.uef.fi/-/computational-modelling-can-predict-onset-and-progression-of-knee-osteoarthritis-in-overweight-people

Royal Philips and a consortium of leading European healthcare regions, companies, universities and hospitals* have announced the start of the first large scale care coordination and telehealth programme in the European Union to support tens of thousands of people living with chronic conditions. The three-year ACT@Scale programme will collect and analyse the health outcome and economic impact data for large populations of chronic patients and elderly people to develop, test and consolidate best practice’ care coordination and telehealth programmes that can be replicable and successfully rolled out across the European Union. The programme aims to reach more than 75,000 patients in the United Kingdom, the Netherlands, Spain and Denmark by 2019.
‘Today, 70 percent of Europe’s healthcare budget is spent on patients living with chronic conditions, largely a result of Europe’s aging population and rapidly changing care needs,’ said Jeroen Tas, CEO Connected Care and Health Informatics, Philips. ‘The ACT@Scale programme will provide the evidence needed to successfully deliver a seamless patient experience with better outcomes at lower cost.’
The five participating healthcare regions are all in the process of rolling out innovative care coordination and telehealth services. Within the ACT@Scale programme, they will share an agreed and standardized data set including programme outcomes such as the number of patients included, (re)hospitalizations, duration of hospitalizations and mortality rates. They will also assess economic impact factors such as cost per patient and the impact on hospitals income models. This data is to support the development of new and sustainable business models. Next to this, patient satisfaction scores are measured and the degree to which connected technology empowers people and affects health outcomes.
The regions involved comprise Catalonia (Spain), which has developed programmes to support nursing homes, reduce hospital re-admissions, manage complex cases and promote physical activity; Southern Denmark (Denmark), which is rolling out a telehealth programme to deliver psychiatric treatment; Northern Ireland (UK), which has remote telemonitoring programmes to support COPD and diabetes patients, and manage maternal obesity; Northern Netherlands (The Netherlands), with programmes to provide specialist support for COPD, asthma and heart failure patients, and connect healthcare and community services for chronic disease patients; and the Basque Country (Spain), which is rolling out programmes to support older people with complex health and social care needs, plus telehealth services for chronic heart failure patients.
‘Telehealth and coordinated care services may offer the elderly and otherwise frail individuals the ability to maintain their independence for longer and enjoy a significantly better quality of life, but they also involve significant changes to the healthcare system and the recipients’ ability to self-manage,’ said Professor Erik Buskens, Professor of Medical Technology Assessment at University Medical Center Groningen (UMCG). ‘ACT@Scale will allow us to determine the most cost-effective ways of implementing those changes while also maximizing the benefits for Europe’s ageing population.’
The ACT@Scale scientific consortium members comprise of University Medical Center Groningen (The Netherlands), Aristotle University of Thessaloniki (Greece), City University London (UK), Universitatsklinikum Wurzburg/Klinikum der Bayerischen Julius-Maximilians-Universitat (Germany), University of Hull (UK), Kronikgune-Centre for Research Excellence in Chronicity (Basque Country, Spain), Hospital Clinic of Barcelona (Spain) and Philips. It is anticipated that the first preliminary findings will be available from the end of Q4, 2016.
ACT@Scale builds on the successful ACT programme, a two-and-a-half year study (2013 – 2016) that looked into the results of European integrated care programmes. Thousands of interviews were conducted with participating patients and care providers. These learnings on success factors are applied to significantly grow the ACT@Scale healthcare regions’ coordination and telehealth programmes. The programme is part of the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA), an initiative from the European Commission under its Innovation Union strategy, and aims to increase the average healthy lifespan by two years by 2020.

www.philips.com

Wireless brain sensors developed by researchers at Washington University School of Medicine in St. Louis and the University of Illinois at Urbana-Champaign are smaller than a pencil tip and can monitor intracranial pressure and temperature before being absorbed by the body, negating the need for surgery to remove the devices.
Such implants potentially could be used to monitor patients with traumatic brain injuries, but the researchers believe they can build similar absorbable sensors to monitor activity in organ systems throughout the body.
‘Electronic devices and their biomedical applications are advancing rapidly,’ said co-first author Rory K. J. Murphy, MD, a neurosurgery resident at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis. ‘But a major hurdle has been that implants placed in the body often trigger an immune response, which can be problematic for patients. The benefit of these new devices is that they dissolve over time, so you don’t have something in the body for a long time period, increasing the risk of infection, chronic inflammation and even erosion through the skin or the organ in which it’s placed. Plus, using resorbable devices negates the need for surgery to retrieve them, which further lessens the risk of infection and further complications.’
Murphy is most interested in monitoring pressure and temperature in the brains of patients with traumatic brain injury.
About 50,000 people die of such injuries annually in the United States. When patients with such injuries arrive in the hospital, doctors must be able to accurately measure intracranial pressure in the brain and inside the skull because an increase in pressure can lead to further brain injury, and there is no way to reliably estimate pressure levels from brain scans or clinical features in patients.
‘However, the devices commonly used today are based on technology from the 1980s,’ Murphy explained. ‘They’re large, they’re unwieldy, and they have wires that connect to monitors in the intensive care unit. They give accurate readings, and they help, but there are ways to make them better.’
Murphy collaborated with engineers in the laboratory of John A. Rogers, PhD, a professor of materials science and engineering at the University of Illinois, to build new sensors. The devices are made mainly of polylactic-co-glycolic acid (PLGA) and silicone, and they can transmit accurate pressure and temperature readings, as well as other information.

Washington University School of Medicine at St Louis http://tinyurl.com/hoqcm6w