Complete Resolution Research Articles

Salvage Endovascular Thrombectomy for Splenic Vein Thrombosis After Pancreas Transplantation: A Single-Center Experience and Systematic Literature Review.

Technical graft loss, usually thrombotic in nature, accounts for most of the pancreas grafts that are removed early after transplant. Although arterial and venous thrombosis can occur, the vein is predominantly affected, with estimated overall rate of thrombosis of 6% to 33%. In late diagnosis, the graft will need to be removed because thrombectomy will not restore its functionality. However, in early diagnosis, a salvage procedure should be attempted. We conducted a retrospective, descriptive analysis of a prospective database of patients who underwent pancreas transplant from April 2008 to June 2020 at a single center. We evaluated post-transplant clinical glucose levels, imaging, treatment, and outcomes. We also performed a systematic review of publications for endovascular treatment of vascular graft thrombosis in pancreas transplant. In 67 pancreas transplants analyzed, 13 (19%) were diagnosed with venous thrombus. In 7 of 13 patients (54%), systemic anticoagulation was prescribed because of a non-occlusive thromboses, resulting in complete resolution for all 7 patients. Six patients (46%) required endovascular thrombectomy because of the presence of complete occlusive thrombosis; 4 of these patients (67%) needed a second procedure because of recurrence of the thrombosis. One of the 6 patients (17%) required a surgical approach, resulting in successful removal of the recurrent clot. Twelve of the 13 grafts (92%) were rescued. Graft survival at 1 year was 84%; graft survival at 3, 5, and 10 years remained at 70%. Pancreas vein thrombosis represents a frequent surgical complication and remains as a challenging problem. In our experience, early diagnoses and an endovascular approach combined with aggressive medical treatment and follow-up can be used for successful treatment and reduce graft loss.

Single-center experience with the JETi Hydrodynamic Thrombectomy System for acute limb ischemia

ObjectiveAcute limb ischemia (ALI) remains a vascular emergency with high morbidity and mortality. While the JETi Hydrodynamic Thrombectomy System (Abbott) offers a percutaneous approach to fragment and aspirate the thrombus in patients with arterial occlusions, data on its efficacy and safety are limited. This study reports our early experience using the JETi device to treat ALI at our institution. MethodsThis is a single-center, retrospective review of patients with ALI treated with the JETi device between September 2020 and December 2022. Patients were included if the JETi device was used either as a primary intervention or as an adjunct procedure. The primary endpoint was technical success defined as <50% residual thrombus after intervention. Secondary endpoints included achieving complete resolution of the thrombus on angiogram, acute kidney injury (AKI), major bleeding, 30-day major amputation, and 30-day mortality. ResultsA total of 59 JETi procedures for ALI (median age 62 years [interquartile range: 56-71 years]) were performed on 39 male and 20 female patients. The median time from onset of symptoms to hospitalization was 24 hours (interquartile range: 4-168 hours). Rutherford classifications were I (10), IIa (27), IIb (14), and undocumented (8). Etiology of ALI was native vessel thrombosis (27), embolism (16), graft/stent thrombosis (14), and iatrogenic (2). A total of 124 vessels were treated, with an average of 2.1 vessels per procedure. The primary outcome was achieved in 86% (107/124) of the arteries, with 82% (102/124) successfully opened using the JETi device alone without the need for any adjunctive therapy. Complete resolution of the thrombus using JETi was achieved in 81% (101/124) arteries, with or without the use of adjunctive therapy. A total of 6.7% (4/59) patients required a major limb amputation within 30 days despite successful recanalization, and one 30-day mortality was recorded. Complications included distal embolization (5), access site hematoma (2), and AKI (4). No major bleeding, hemolysis-induced AKI, or vessel dissection or perforation was observed. ConclusionsThe JETi device appears to be a safe and effective percutaneous treatment option in the management of ALI. It provides definitive treatment with a high technical success rate of 86% and a good safety profile.

Atypical Presentation and Surgical Management of Ectopic Mandibular Third Molar in Subcondylar Region: A Rare Case Report

Abstract Ectopic teeth arise from developmental abnormalities and can be supernumerary, deciduous, or permanent teeth. They can cause orofacial pain, swelling, and infection. There is a major paucity in literature about ectopic mandibular third molar (EMTM) and its causes, symptoms, and treatment. We present an unusual case of EMTM in the mandibular subcondylar region and its surgical management. A 58-year-old female reported with complain of pain and swelling in the right preauricular region. On radiographic assessment, the right mandibular third molar was ectopically present in the subcondylar region and associated with a small dentigerous cyst. Complete removal of cystic lining and extraction of EMTM was done under general anesthesia using a retromandibular approach. After surgery, there was a complete resolution of symptoms within 1 month with uneventful healing and no postoperative complications.

Rare presentation of drug-induced oral erythema multiforme and its management: a case report

Aim. This case report discusses a rare variant of drug-induced erythema multiforme, focusing on its clinical features, diagnosis, and management. Background. Drug-induced erythema multiforme (DI-EM) is a hypersensitivity reaction occurring due to exposure to certain medications. DI-EM typically presents as erythematous and painful lesions on the oral mucosa, including the lips, tongue, and buccal mucosa. Case description. A 42-year-old male was referred to the Oral Medicine clinic with a chief complaint of painful lip ulceration and eruptions on the body after consuming medications. A detailed history was taken, and after a thorough examination, a perilesional biopsy for histopathological and immunopathological tests was performed. Following the exclusion of all other conditions with a similar presentation, a diagnosis of drug-induced erythema multiforme (DI-EM) was established. Conclusion. DI-EM can pose a diagnostic challenge due to its presentation. However, a diagnosis can be established by excluding other conditions associated with chronic inflammation or the formation of vesicles or bullae. Clinical Significance. DI-EM is a rare variant of EM with a very low prevalence in the general population, making it a challenging condition to diagnose due to its similarity in presentation with other mucocutaneous disorders. A thorough medical history, along with histopathology and immunology tests, coupled with ruling out other diseases and noting a positive history of recent drug consumption, aids in recognizing this condition, given the absence of any confirmatory diagnostic test. Early diagnosis and cessation of causative drugs, along with supportive medications, contribute to the complete resolution of the condition.

Postpartum Bilateral Nerve Palsy: A Harbinger for Preeclampsia?

Objective: To report a case of postpartum bilateral facial weakness that preceded the diagnosis of preeclampsia. Introduction: Bell’s palsy is a neuromuscular disorder that can cause paralysis or weakness of the face. It is the most common cause of unilateral facial weakness; however, bilateral weakness is rare. Bell’s palsy is one of the most common neuromuscular disorders observed in pregnancy, though the link between the two is not entirely clear. Proposed etiologies include reactivation of human herpes viruses, immune mediated inflammatory demyelination of the facial nerve, and microangiopathy as a result of systemic hypertension. There have been several case reports and studies suggesting a correlation between preeclampsia and Bell’s palsy. We present a rare case of postpartum bilateral Bell’s palsy in the setting of preeclampsia. Design: Case report. Results: Our patient is a 24 year-old G6P4116 Caucasian woman with no significant past medical history who presented with bilateral facial weakness and headache. She was postpartum day four from a spontaneous vaginal delivery of dichorionic diamniotic twins at 35 weeks at an outside hospital. She denied any elevated blood pressures during her pregnancy. Initially, on postpartum day two she had reported a severe headache that initially affected her occipital region bilaterally before migrating to her ears and forehead. At this time the patient was normotensive and was discharged home on analgesics. On postpartum day three, she returned to another emergency department with a worsening, severe headache. She was sent home with a diagnosis of anxiety. On postpartum day four, her symptoms persisted and she came to the emergency department at our facility. During our initial evaluation, her blood pressure was 170/98. She was admitted for severe preeclampsia and given IV magnesium and nifedipine. However, her headache persisted and she developed bilateral facial weakness, neck pain, and swelling. She reported that she was unable to move her face and had difficulty smiling. Her face was expressionless. She denied nausea, vomiting, dysphagia, double vision, gait disturbances, hearing loss, fever, shortness of breath, numbness, or tingling. She denied recent travel, sick contacts, or animal or tick bites. She was evaluated by neurology and her initial physical exam revealed intact cranial nerves, though the patient appeared to have difficulty squeezing her eyes shut and smiling. Periorbital edema was noted. Facial symmetry and sensation were intact bilaterally. She had difficulty saying the letter “P.” Her MRIs of both brain and cervical spine, chest x-ray, and lumbar puncture were all normal. Our working diagnoses included bilateral Bell’s palsy, Guillain-Barré and Miller-Fischer syndromes. The antibody panel drawn for Miller-Fischer syndrome subsequently resulted as negative. Our patient received three days of IVIG and was discharged on a week supply of prednisone 60mg with a taper thereafter. At discharge, she had severe bilateral facial droop. She was unable to puff out her cheeks or raise her eyebrows. Neurology recommended outpatient follow up. One month after discharge she had residual right sided facial droop, but the deficits of the left side of her face had mostly resolved. Discussion: Current literature suggests a correlation between preeclampsia and Bell’s palsy. There is some thought that elevated blood pressure leads to facial nerve compression secondary to edema or microemboli. One report suggested that the onset of Bell’s palsy antepartum or postpartum may be a predictor of preeclampsia. An English language PUBMED search revealed six case reports on bilateral Bell’s palsy in either the pregnant or postpartum state. Cases reported occurred in either the third trimester or within the first week postpartum. This was consistent with the onset of our patient’s symptoms during her first week postpartum. In one case, neurological symptoms preceded preeclampsia. Our patient complained of headaches and neck pain prior to having elevated blood pressures. Three of these cases included twin gestations, as did our case. Outcomes varied, with some patients seeing complete resolution of symptoms within weeks to others having recurring symptoms over a year. Providers should consider the relationship between preeclampsia and Bell’s palsy when treating pregnant or postpartum patients with new onset neurological symptoms. Pregnant and postpartum patients are at greater than three times increased risk for Bell’s palsy and have more severe symptoms and longer recovery times compared to the average population. It is important that obstetricians and gynecologists assess for signs of preeclampsia in pregnant or postpartum patients with concerns for Bell’s palsy, as well as refer patients for a complete neurological workup. Ultimately, more research is needed to further understand the relationship between preeclampsia and Bell’s palsy.

Postpartum Bilateral Nerve Palsy: A Harbinger for Preeclampsia?

Objective: To report a case of postpartum bilateral facial weakness that preceded the diagnosis of preeclampsia. Introduction: Bell’s palsy is a neuromuscular disorder that can cause paralysis or weakness of the face. It is the most common cause of unilateral facial weakness; however, bilateral weakness is rare. Bell’s palsy is one of the most common neuromuscular disorders observed in pregnancy, though the link between the two is not entirely clear. Proposed etiologies include reactivation of human herpes viruses, immune mediated inflammatory demyelination of the facial nerve, and microangiopathy as a result of systemic hypertension. There have been several case reports and studies suggesting a correlation between preeclampsia and Bell’s palsy. We present a rare case of postpartum bilateral Bell’s palsy in the setting of preeclampsia. Design: Case report. Results: Our patient is a 24 year-old G6P4116 Caucasian woman with no significant past medical history who presented with bilateral facial weakness and headache. She was postpartum day four from a spontaneous vaginal delivery of dichorionic diamniotic twins at 35 weeks at an outside hospital. She denied any elevated blood pressures during her pregnancy. Initially, on postpartum day two she had reported a severe headache that initially affected her occipital region bilaterally before migrating to her ears and forehead. At this time the patient was normotensive and was discharged home on analgesics. On postpartum day three, she returned to another emergency department with a worsening, severe headache. She was sent home with a diagnosis of anxiety. On postpartum day four, her symptoms persisted and she came to the emergency department at our facility. During our initial evaluation, her blood pressure was 170/98. She was admitted for severe preeclampsia and given IV magnesium and nifedipine. However, her headache persisted and she developed bilateral facial weakness, neck pain, and swelling. She reported that she was unable to move her face and had difficulty smiling. Her face was expressionless. She denied nausea, vomiting, dysphagia, double vision, gait disturbances, hearing loss, fever, shortness of breath, numbness, or tingling. She denied recent travel, sick contacts, or animal or tick bites. She was evaluated by neurology and her initial physical exam revealed intact cranial nerves, though the patient appeared to have difficulty squeezing her eyes shut and smiling. Periorbital edema was noted. Facial symmetry and sensation were intact bilaterally. She had difficulty saying the letter “P.” Her MRIs of both brain and cervical spine, chest x-ray, and lumbar puncture were all normal. Our working diagnoses included bilateral Bell’s palsy, Guillain-Barré and Miller-Fischer syndromes. The antibody panel drawn for Miller-Fischer syndrome subsequently resulted as negative. Our patient received three days of IVIG and was discharged on a week supply of prednisone 60mg with a taper thereafter. At discharge, she had severe bilateral facial droop. She was unable to puff out her cheeks or raise her eyebrows. Neurology recommended outpatient follow up. One month after discharge she had residual right sided facial droop, but the deficits of the left side of her face had mostly resolved. Discussion: Current literature suggests a correlation between preeclampsia and Bell’s palsy. There is some thought that elevated blood pressure leads to facial nerve compression secondary to edema or microemboli. One report suggested that the onset of Bell’s palsy antepartum or postpartum may be a predictor of preeclampsia. An English language PUBMED search revealed six case reports on bilateral Bell’s palsy in either the pregnant or postpartum state. Cases reported occurred in either the third trimester or within the first week postpartum. This was consistent with the onset of our patient’s symptoms during her first week postpartum. In one case, neurological symptoms preceded preeclampsia. Our patient complained of headaches and neck pain prior to having elevated blood pressures. Three of these cases included twin gestations, as did our case. Outcomes varied, with some patients seeing complete resolution of symptoms within weeks to others having recurring symptoms over a year. Providers should consider the relationship between preeclampsia and Bell’s palsy when treating pregnant or postpartum patients with new onset neurological symptoms. Pregnant and postpartum patients are at greater than three times increased risk for Bell’s palsy and have more severe symptoms and longer recovery times compared to the average population. It is important that obstetricians and gynecologists assess for signs of preeclampsia in pregnant or postpartum patients with concerns for Bell’s palsy, as well as refer patients for a complete neurological workup. Ultimately, more research is needed to further understand the relationship between preeclampsia and Bell’s palsy.

Clinical presentation of celiac disease in adult patients: current real-life experience.

The clinical presentation of celiac disease (CD) has changed over time with more patients presenting with non-classical symptoms, extra-intestinal manifestations (EIM) or no symptoms. We aimed to investigate the main symptoms/signs leading to the diagnosis of CD in adult patients. As secondary end-point, we evaluated the outcome of gastrointestinal (GI) symptoms following gluten-free diet (GFD). All consecutive CD adult patients referring to our University Hospital from September 2022 to February 2024 were included. Clinical data were retrospectively evaluated. 134 patients, 104 females/30 males, median age at diagnosis 35years, were included. 79 patients reported GI symptoms (i.e., diarrhea, abdominal bloating, dyspepsia) as the main symptom leading to CD diagnosis. In 40 patients, the leading symptom/sign was an EIM (i.e., iron deficiency anemia, infertility/miscarriages, dermatitis, osteoporosis, elevated transaminase levels). Fifteen patients were asymptomatic, being diagnosed because of a positive family history or concomitant autoimmune hypothyroidism. Of the 79 patients reporting GI symptoms, 20 did not experience complete resolution with the GFD. Among the 17 patients who reported a strict adherence to GFD (vs 1 patient with low-adherence, 2 non-compliant), lactose intolerance and irritable bowel syndrome overlap were diagnosed in 2 and 15 patients, respectively. GI manifestations remain the main symptoms at presentation of CD, however clinicians should be aware of the EIM of CD and the association with other autoimmune disorders. In non-responsive CD patients, an overlap with functional disorders might be considered.

Treatment of telangiectasias with a 595-nm pulsed dye laser following hemangioma involution: a retrospective analysis.

Telangiectasias are the most frequent type of sequelae of infantile hemangiomas after involution. Few studies have reported the treatment of telangiectasias with 595-nm pulsed dye lasers. Therefore, the objective of this study was to assess the efficacy and safety of a 595-nm pulsed dye laser for treating residual telangiectasias following hemangioma involution. This is a retrospective case series that analyzes the medical records and reviews the charts of 22 patients who had undergone 595-nm pulsed dye laser treatment for residual telangiectasias. Pre- and post-treatment digital images were independently assessed, and the changes were scored to ascertain the efficacy of the treatment (0 = no change, 4 = complete improvement). Of the 22 patients, 59.1% experienced complete resolution of telangiectasias following treatment. No serious complications or side effects were reported. The observations indicate that the 595-nm pulsed dye laser is effective and safe for treating residual telangiectasias following hemangioma involution.

Neurological phenotypes and treatment outcomes in Eagle syndrome: systematic review and meta-analysis.

Eagle syndrome is caused by an elongated styloid process affecting carotid arteries and cranial nerves. Pain, dysphagia, tinnitus, paresthesia (classic subtype), and neurovascular events (vascular subtype) may be triggered by head movements or arise spontaneously. However, Eagle syndrome remains underappreciated in the neurological community. We aimed to determine the most common neurological and non-neurological clinical presentations in patients with Eagle syndrome and to assess the clinical outcome post-surgical resection in comparison to non-surgical therapies. We conducted a systematic review of patient-level data on adults with Eagle syndrome, following PRISMA guidelines. We extracted data on demographics, presenting symptoms, neurological deficits, radiological findings, and treatments, including outcomes and complications, from studies in multiple indexing databases published between 2000 and 2023. The study protocol is registered with PROSPERO. In total, 285 studies met inclusion criteria, including 497 patients with Eagle syndrome (mean age 47.3 years; 49.8% female). Classical Eagle (370 patients, 74.5%) was more frequent than vascular Eagle syndrome (117 patients, 23.5%, p < 0.0001). Six patients (1.2%) presented with both variants and the subvariant for four patients (0.8%) was unknown. There was a male preponderance (70.1% male) in the vascular subtype. A history of tonsillectomy was more frequent in classic (48/153 cases) than in vascular (2/33 cases) Eagle syndrome (Odds Ratio 5.2, 95% CI [1.2-22.4]; p = 0.028). By contrast, cervical movements as trigger factors were more prevalent in vascular (12/33 cases) than in classic (7/153 cases) Eagle syndrome (Odds Ratio 7.95, 95% CI [2.9-21.7]; p = 0.0001). Headache and Horner syndrome were more frequent in vascular Eagle syndrome and dysphagia and neck pain more prominent in classic Eagle syndrome (all p < 0.01). Surgically treated patients achieved overall better outcomes than medically treated ones: Eighty-one (65.9%) of 123 medically treated patients experienced improvement or complete resolution, while the same applied to 313 (97.8%) of 320 surgical patients (Odds Ratio 1.49, 95% CI [1.1-2.0]; p = 0.016). Eagle syndrome is underdiagnosed with potentially serious neurovascular complications, including ischemic stroke. Surgical treatment achieves better outcomes than conservative management. Although traditionally the domain of otorhinolaryngologist, neurologist should include this syndrome in differential diagnostic considerations because of the varied neurological presentations that are amenable to effective treatment.

Endoscopic radial incision and cutting method for adult congenital duodenal webs: A case report

BACKGROUND Congenital duodenal webs are rare in adults and can lead to various symptoms such as nausea, vomiting, and postprandial fullness. The treatment for this disease is mostly surgical. Endoscopic treatment techniques have been developed and attempted for this disease. Endoscopic radial incision and cutting (RIC) techniques are reportedly very effective in benign anastomotic stricture. This case report highlights the effectiveness and safety of endoscopic RIC as a minimally invasive treatment for adult congenital duodenal webs. CASE SUMMARY A 23-year-old female patient with indigestion was referred to a tertiary hospital. The patient complained of postprandial fullness in the epigastric region. Previous physical examinations or blood tests indicated no abnormalities. Computed tomography revealed an eccentric broad-based delayed-enhancing mass-like lesion in the second portion of the duodenum. Endoscopy showed an enlarged gastric cavity and a significantly dilated duodenal bulb; a very small hole was observed in the distal part of the second portion, and scope passage was not possible. Gastrografin upper gastrointestinal series was performed, revealing an intraduodenal barium contrast-filled sac with a curvilinear narrow radiolucent rim, a typical "windsock" sign. Endoscopic RIC was performed on the duodenal web. The patient recovered uneventfully. Follow-up endoscopy showed a patent duodenal lumen without any residual stenosis. The patient reported complete resolution of symptoms at the 18-month follow-up. CONCLUSION Endoscopic RIC may be an effective treatment for congenital duodenal webs in adults.

Comparison of efficacy and safety between oral propranolol combined with and without intralesional injection of lauromacrogol for infantile hemangioma.

The purpose of this study was to compare efficacy and side effects between oral propranolol combined with and without intralesional injection of lauromacrogol for infantile hemangioma (IH). This was a single center randomized controlled prospective study, all participants were firstly diagnosed with IH between August 2022 and January 2023 in our hospital and without any treatment before. Patients were randomized into two groups. PRO group: oral propranolol (2 mg/kg/day) continued for 6 months; PRO + LAU group: oral propranolol (2 mg/kg/day) for 6 months and intralesional injection of lauromacrogol for 2-4 times within 6 months. The dimensions, color, consistency, photographic documentation were well recorded based on Visual Analogue Scale (VAS) before and after starting treatment. According to the treatment response after 6 months, the results were classified into four levels: Grade 1, complete resolution achieved; Grade 2, with ≥50% reduction in size of IH; Grade 3, with <50% reduction in size of IH; Grade 4, no response or worsening of IH. A total of 67 patients were involved in the study (17 boys, 50 girls; mean age, 3.6 months, range, 1.1-7.2 months) and randomized to receive oral propranolol combined with or without intralesional injection of lauromacrogol (29 in PRO group, 38 in PRO + LAU group). All patients completed treatment. Eleven patients (37.9%) in PRO group were in Grade 1, 14 patients (48.3%) in Grade 2, 4 patients (13.8%) in Grade 3, compared with these in PRO + LAU group, 11 patients (28.9%) in Grade 1, 24 patients (63.2%) in Grade 2, and 3 patients (7.9%) in Grade 3. No patient was in Grade 4, and no severe side effects were observed in both group. In PRO group, it takes an average of 17.1 ± 5.4 weeks from the start of treatment to cure, and in PRO + LAU group, the average time is 13.7 ± 4.9 weeks. Oral propranolol with intralesional injection of lauromacrogol was a safety treatment strategy for IH. But it was not superior to oral propranolol in final cure rates (P = 0.45), moreover, it cannot certainly offer the benefits of shortening the duration of oral drug treatment (P = 0.24).

Use of a free proximal ulnar autograft for ipsilateral radial lengthening in a dog with a short radius and subsequent elbow incongruity

AbstractObjectiveTo report the technique and outcome of proximal ulnar autograft transplantation to achieve ipsilateral radial lengthening in a dog with premature closure of both proximal and distal radial physes.Study designCase report.AnimalsAn 8‐month‐old female spayed Border Collie.MethodsThe dog was presented for a grade III/IV left thoracic limb lameness localized to the elbow. Orthogonal radiographs of both forelimbs revealed a 7% length deficit of the left radius and elbow subluxation indices indicative of left elbow incongruity due to suspect premature closure of both radial physes. Radial lengthening consisted of a proximal ulnar ostectomy, a radial osteotomy, and transplantation of the ulnar autograft into the radial osteotomy site secured with an eight‐hole dynamic compression plate. Orthopedic examinations were conducted at 2 weeks, 4 weeks, and 3 years postoperatively. Radiographic examinations were completed preoperatively, immediately postoperatively, and at 4 weeks and 3 years postoperatively.ResultsLameness improved with a grade II/IV lameness at 4 weeks postoperatively and complete resolution at 3 years postoperatively. Radiographic examination at 4 weeks showed persistent radial lengthening of 1 cm, and a decreased humeroradial index (HRI), humeroulnar index (HUI), and radioulnar index (RUI) compared with preoperative values. At the 3 year examination, the HRI and HUI had increased indicating progression of elbow incongruity. The patient remained clinically unaffected.ConclusionIn dogs with radial shortening and elbow incongruity, use of an ipsilateral proximal ulnar autograft with rigid internal fixation can be an effective treatment for radial lengthening to improve elbow congruity and resolve lameness.

Comprehensive Treatment of Knee Osteoarthritis Pain through Cryoneurolysis: A Promising Approach for Deep and Superficial Genicular Nerve Modulation - Case Report

Background Knee osteoarthritis is a prevalent and debilitating condition characterized by joint pain, stiffness, and limited mobility. Conventional non-operative treatment approaches often do not provide adequate relief of the patient’s symptoms. Cryoneurolysis of the superficial genicular nerves is a growing and accepted technique used to treat knee pain, however, there is limited literature demonstrating the effectiveness of treating both the superficial and deep genicular nerves, as well as the use of subsequent repeat treatments. Case Report This case study reports on a 65 year-old male with Kellgren-Lawrence grade 2-3 tricompartmental bilateral knee osteoarthritis who underwent cryoneurolysis of the superficial and deep genicular nerves with the iovera° cryoneurolysis device followed by two subsequent repeat cryoneurolysis treatments. Conclusion The results demonstrated a complete resolution of the patient’s pain and enhanced quality of life following cryoneurolysis. Furthermore, subsequent repeat treatments sustained the pain reduction, offering the patient an extended period of improved mobility and reduced discomfort. This case study demonstrates that cryoneurolysis holds promise as a valuable addition to the armamentarium of interventions available for managing knee pain and improving the quality of life for patients suffering from osteoarthritis when they are unable or decide not to pursue surgical intervention.

Amitriptyline, Pregabalin and Duloxetine for Treatment of Painful Diabetic Peripheral Neuropathy.

Painful diabetic peripheral neuropathy is one of the frequent presenting complaints in diabetes and endocrine clinics. Our main objective was to compare effectiveness of three commonly prescribed drugs: amitriptyline, pregabalin and duloxetine for treatment of painful diabetic peripheral neuropathy. This was a comparative, prospective, observational study conducted among 99 diabetic patients with painful diabetic peripheral neuropathy having numeric rating pain scale ≥ 4. Thirty-three patients in each group were consecutively prescribed amitriptyline, pregabalin and duloxetine in lower dose (10mg/75mg/20mg) for first two weeks to gradually up titrate to higher dose (25mg/150mg/30mg) as per pain response for total duration of eight weeks. At the end of eight weeks, 84.9% in amitriptyline, 78.7% in pregabalin and 60.6% in duloxetine group had adequate pain reduction in form of mild or no pain. Among total patients, 42.5% patients had severe pain at baseline that decreased to 5% by the end of our study. Out of three drugs, 45.5% patients in amitriptyline group had complete resolution of pain as compared to 24.2% in pregabalin and 18.2% in duloxetine group (p value 0.05). Drowsiness (42.4%), dizziness (21.2%) and dry mouth (21.2%) were the commonest side effects among total participants in our study. Amitriptyline, pregabalin and duloxetine were all associated with adequate pain reduction among patients of painful diabetic peripheral neuropathy in our study, however, amitriptyline had more favorable findings with tolerable side effects.

Patients Engaged in Losing Weight Preoperatively Experience Improved Outcomes After Hiatal Hernia Repair.

Adherence to preoperative weight loss recommendations may serve as a surrogate for the level of engagement in hiatal hernia (HH) patients. This study aims to evaluate the relationship between achieving preoperative weight loss goals and outcomes after HH repair. A retrospective review of 235 patients undergoing laparoscopic HH repair at a single institution was performed. Patients were grouped based on the percentage of weight loss goal achieved. Low achievement was defined as the bottom quartile of goal achievement (≤75%); high achievement was defined as the top quartile (≥140%). Baseline characteristics, clinical outcomes, and patient reported outcomes (PROMs) were compared between groups. 131/235 (55.7%) achieved their weight loss goal. No differences in baseline characteristics or clinical outcomes were observed between the low and high achievement groups. While both groups experienced improvements in PROMs postoperatively, patients in the high achievement group demonstrated significantly lower symptom burden at one-month postoperatively. Further, high-achievement patients were more likely to experience complete resolution of common HH symptoms at one-month postoperatively, including no difficulty swallowing food, no breathing difficulties or choking episodes, no choking when eating food, no choking when drinking liquid, and no regurgitation of food or liquid. In patients undergoing laparoscopic HH repair, patients achieving their preoperative weight loss goals experienced less overall symptom burden and lower prevalence of common symptoms one-month postoperatively than those with low levels of goal achievement. These results demonstrate that patients can take an active role in improving their own surgical outcomes and health status.

Long-Term Outcomes of Respiratory Retraining Therapy for Exercise-Induced Laryngeal Obstruction

ObjectiveTo assess the long-term outcomes and efficacy of respiratory retraining therapy in patients with exercise-induced laryngeal obstruction (EILO). MethodsA retrospective chart review and prospective questionnaire-based survey was conducted on 88 patients who received respiratory retraining therapy for EILO at our institution over the past 5 years Results34 patients were included in the final analysis, with a mean age at symptom onset and age at initial evaluation of 13.67 ± 2.96 and 15.12 ± 3.48, respectively. We found a statistically significant difference in the pre-treatment and post-treatment Dyspnea Indices following respiratory retraining therapy, with a mean difference of 12.03 ± 7.18 (p < 0.001). When asked about the effectiveness of respiratory retraining therapy, the majority of patients (n = 28) reported improvement (13.3% “a little”, 13.3% “somewhat better”, 53.3% (“a lot better”, and 13.3% complete resolution of symptoms. Only 2 patients (6.7%) responded that their breathing “did not get better.” The most effective therapy techniques cited by patients were abdominal breathing (n = 10), ratio breathing (n = 5), and pursed lip or “straw” breathing (n = 5). ConclusionRespiratory retraining therapy represents an effective technique in both the short-term and long-term management of EILO. This therapy remains the first line in management of EILO due to its ease of administration, non-invasive nature, and durable effect on breathing function.

Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia

ObjectiveHemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the preferred treatment for HAIDI by many surgeons. Proximalization of arterial inflow (PAI) is a promising alternative technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients. MethodsThis is a single-center, retrospective cohort study of patients with both arteriovenous (AV) fistulas and grafts who underwent PAI for HAIDI from 2017 to 2023. A 4 × 7 tapered polytetrafluoroethylene (PTFE) graft was used to connect HD access inflow to the axillary artery in the majority of cases. The primary outcome of the study is resolution of HAIDI (complete, partial, or no resolution). Secondary outcomes include functional patency (primary and secondary) and 30-day complications following PAI. ResultsOf the 71 patients identified to have had PAI between May 2017 to August 2023, seven were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (standard deviation, 15 years), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions including 95.3% (61/64) hypertension; 50% (32/64) coronary artery disease; 79.7% (51/64) diabetes; and 43.8% (28/64) smoking history. Following PAI intervention for HAIDI, 55 of 64 patients (85.9%) experienced complete resolution of ischemic symptoms; five of 64 patients (7.8%) had partial resolution; two of 64 patients (3.1%) had no resolution, and two of 64 patients (3.1%) had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. The 30-day complication rate was 10.9% (7/64), with five of 64 (7.8%) thromboses, one of 64 (1.6%) thrombosis and infection, and one of 64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively. ConclusionsOur study, the largest case series of PAI to date, demonstrates that PAI is a reliable option for HAIDI intervention and has comparable safety and efficacy results to DRIL, despite the use of a synthetic graft. Furthermore, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for HAIDI management.

Natural history and long-term outcomes of medically managed Type B intramural hematoma

ObjectiveType B intramural hematoma (IMH) is often managed medically, yet may progress to dissection, aneurysmal dilation, or rupture. The aim of this study was to report the natural history of medically managed Type B IMH, and factors associated with progression. MethodsWe reviewed patients with medically managed Type B IMH between January 1995 to December 2022 at a single center. Any patients with immediate surgical or endovascular intervention were excluded. Demographic profiles, comorbidities, imaging, and follow-up details were reviewed. Patients were divided into two groups: Group 1 had isolated IMH, and Group 2 had IMH along with aneurysm or dissection at the time of presentation. On follow-up, progression was defined as degeneration to aneurysm/dissection or increase in the thickness of IMH in Group 1. In Group 2, progression was an increase in the size of aneurysm or development of new dissection. ResultsOf 104 patients with Type B IMH during the study period, 92 were medically managed. The median age was 77 years, and 45 (48.9%) were females. Comorbidities included hypertension (83.7%), hypercholesterolemia (44.6%), and active smoking (47.8%). Mean Society for Vascular Surger comorbidity score was 6.3. Mean IMH thickness and aortic diameter at presentation were 8.9 mm and 38.3 mm, respectively. Median follow-up was 55 months. Overall survival at 1 year and 5 years was 85.8% and 61.9%, respectively. During follow-up, 19 patients (20.7%) required intervention, more common in Group 2 (Group 1, 8/66; 12.3% vs Group 2, 11/26; 42.3%; P = .001). This resulted in higher freedom from intervention in Group 1 at 1 year (93.5% vs 62.7%) and 5 years (87.5% vs 51.1%; P < .001). Indication for intervention was dissection (n = 4), aneurysm (n = 12), and progression of IMH (n = 3). In Group 1, progression was seen in 25 (37.9%), three (4.5%) remained stable, 29 (43.9%) had complete resolution of IMH, and nine patients were lost to follow-up. In Group 2, 11 patients (42.3%) had progression, seven (26.9%) remained stable, and eight were lost to follow-up. IMH thickness at presentation >7.2 mm is associated with both increased odds of progression (odds ratio, 3.3; 95% confidence interval, 1.2-11.1; P = .03) and intervention (odds ratio, 5.5; 95% confidence interval, 1.3-36.9; P = .03) during the follow-up. ConclusionsAlthough many patients with Type B IMH managed medically stabilize or regress, progression or need for intervention can occur in up to 40% of cases. This is associated with the presence of aneurysm, dissection, and IMH thickness. Long-term follow-up is mandatory as late interventions occur, particularly for higher risk patients.

Clinical Insights and Optimization of Surgical Approach for Lateral Femoral Cutaneous Nerve Injury/Entrapment: A Comprehensive Analysis of 184 Cases.

Entrapment or injury of the lateral femoral cutaneous nerve (LFCN) is being recognized with increasing frequency, often requiring a surgical approach to relieve symptoms. The presence of anatomic variations can lead to errors in diagnosis and intraoperative decision-making. This study presents the experience of a single surgeon (T.W.T.) in managing 184 patients referred with clinical issues related to the LFCN. A comprehensive review of these cases was conducted to develop a prospective surgical management algorithm. Data on the LFCN's anatomic course, pain relief outcomes, comorbidities, body mass index, and sex were extracted from patients' medical charts and operative notes. Pain relief was assessed subjectively, categorized into "excellent relief" for complete pain resolution, "good" for substantial pain reduction with some residual discomfort, and "failure" for cases with no pain relief necessitating reoperation. The decision tree is dichotomized based on the mechanism of LFCN pathology: compression (requiring neurolysis) versus history of trauma, surgery, and/or obesity (requiring resection). Forty-seven percent of the patients in this series had an anatomic variation. It was found that failure to relieve symptoms of compression often indicated the presence of anatomic variation of the LFCN or intraneural changes consistent with a neuroma, even if adequate decompression was achieved. With respect to pain relief as the outcome measure, recognition of LFCN anatomic variability and use of this algorithm resulted in 75% excellent results, 10% good results, and 15% failures. Twenty-seven of the 36 failures originally had neurolysis as the surgical approach. Twelve of those failures had a second surgery, an LFCN neurectomy, resulting in 10 excellent, 1 good, and 1 persistent failure. This article establishes an algorithm for the surgical treatment of MP, incorporating clinical experience and anatomical insights to guide treatment decisions. Criteria for considering neurectomy may include a history of trauma, prior local surgery, anatomical LFCN variations, and severe nerve damage due to chronic compression.

JAK inhibitors in refractory dermatomyositis: A case series.

This retrospective cohort study assessed the efficacy and safety of Janus kinase (JAK) inhibitors, tofacitinib and baricitinib, in 14 patients with refractory dermatomyositis (DM), a multisystemic autoimmune disorder with limited therapeutic options. Results demonstrated a significant median decrease of 21 points and a 76% reduction in the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) scores, along with a complete resolution of muscular symptoms in 64% of the patients. JAK inhibitors were effective in managing refractory DM across various subtypes with mild and manageable adverse events.