Concurrent Pathology Research Articles

Subglottic cysts: The Great Ormond Street experience in 105 patients.

The aim of the study was to assess the contemporary presentation and management of subglottic cysts and make recommendations on the treatment of these patients. Retrospective case series of 105 patients between October 1999 and November 2017 from a paediatric teaching hospital. Ninety-one percentage (n = 96) had a history of prematurity, with a mean gestation of 27.2weeks (SD ± 4.1). A history of intubation was found in 99% (n = 104) of cases [median 18days (range = 1-176)]. Presenting symptoms were: Stridor 57.1%, (n = 60), difficult intubation 14% (n = 15), recurrent croup 11.4% (n = 12), failed extubation 7.6%, (n = 8), hoarseness/weak cry 10.5% (n = 10). Ninety percentage (n = 94) underwent intervention for management of SGCs with 86% (n = 81) treated with cold steel marsupialisation and 14% (n = 13) with CO2laser. Recurrent cysts occurred in 56% (n = 53) of cases. Treatment modality did not affect recurrence (p = 0.594Δ). Sixty-six percentage (n = 69/105) of patients had one or more concurrent airway pathology at MLB. Most frequent was subglottic stenosis 47% (n = 49), with 16% (n = 8) subsequently requiring open reconstructive airway surgery. Mean duration of follow-up was 47.6months (SD ± 38.3). SGC are an uncommon, reversible cause of upper airway obstruction and should be considered in the list of differential diagnoses in patients with a history of prematurity and perinatal intubation, presenting with stridor. While concurrent SGS is common, adequate symptom improvement in such cases may be achieved with SGC removal alone. Management is by surgical marsupialisation. Recurrence and additional airway pathologies are common and may necessitate longer-term treatment in centres with paediatric airway expertise.

Atypical ductal hyperplasia bordering on DCIS on core biopsy is associated with higher risk of upgrade than conventional atypical ductal hyperplasia.

Upgrade rates of conventional ADH are reported at 10-30%; however, rates for ADH bordering on DCIS (ADH-BD) are largely unknown. We examined the upgrade rate of ADH-BD and core needle biopsy (CNB) features associated with upgrade. Surgical management in patients with concurrent ipsilateral breast cancer (BC) was also examined. From 2000 to 2018, women with CNB diagnosis of ADH-BD were prospectively identified. Women with pure ADH-BD and concurrent ipsilateral ADH-BD/BC were analyzed separately, and upgrade rates were calculated. CNB features associated with upgrade and type of surgery were examined in women with pure ADH-BD; CNB features and concurrent pathology associated with upgrade were examined in women with ipsilateral BC. 108/236 (46%) patients with pure ADH-BD on CNB had DCIS (40%) or invasive carcinoma (6%) on surgical excision. DCIS or invasive carcinoma was more frequently found on excision of a mass that yielded ADH-BD on biopsy than excision of calcifications (65% vs 38%; p < 0.001). The breast conservation success rate was high (80%) in patients who upgraded, despite a high re-excision rate of 46%. The upgrade rate of ADH-BD in women with concurrent ipsilateral BC was 41%. Most women (94%) with ADH-BD in the same quadrant as the BC were candidates for breast conserving surgery, with a success rate of 89%. The upgrade rate for pure ADH-BD is significantly higher than that reported for women with conventional ADH, especially in women with a mass on imaging. The upgrade rate of concurrent ipsilateral ADH-BD and BC is similarly high. Excision with a margin of normal tissue and specimen inking should be routine to minimize the need for re-excision.

Renal Contributions in the Pathophysiology and Neuropathological Substrates Shared by Chronic Kidney Disease and Alzheimer's Disease.

Chronic kidney disease and Alzheimer’s disease are chronic conditions highly prevalent in elderly communities and societies, and a diagnosis of them is devastating and life changing. Demanding therapies and changes, such as non-compliance, cognitive impairment, and non-cognitive anomalies, may lead to supplementary symptoms and subsequent worsening of well-being and quality of life, impacting the socio-economic status of both patient and family. In recent decades, additional hypotheses have attempted to clarify the connection between these two diseases, multifactorial in their nature, but even so, the mechanisms behind this link are still elusive. In this paper, we sought to highlight the current understanding of the mechanisms for cognitive decline in patients with these concurrent pathologies and provide insight into the relationship between markers related to these disease entities and whether the potential biomarkers for renal function may be used for the diagnosis of Alzheimer’s disease. Exploring detailed knowledge of etiologies, heterogeneity of risk factors, and neuropathological processes associated with these conditions opens opportunities for the development of new therapies and biomarkers to delay or slow their progression and validation of whether the setting of chronic kidney disease could be a potential determinant for cognitive damage in Alzheimer’s disease.

Novel clinicopathological characteristics differentiate dementia with Lewy bodies from Parkinson's disease dementia.

This study investigated clinical and neuropathological differences between DLB and PDD. 52 PDD and 16 DLB cases from the Queen Square Brain Bank (QSBB) for Neurological disorders were included. Comprehensive clinical data of motor and cognitive features were obtained from medical records. Neuropathological assessment included examination of CAA, Lewy body and AD pathology. CAA was more common in DLB than in PDD (P=0.003). The severity of CAA was greater in DLB than in PDD (P=0.009), with significantly higher CAA scores in the parietal lobe (P=0.043), and the occipital lobe (P=0.008), in DLB than in PDD. The highest CAA scores were observed in cases with APOE ε4/4 and ε2/4. Survival analysis showed worse prognosis in DLB, as DLB reached each clinical milestone sooner than PDD. Absence of dyskinesia in DLB is linked to the significantly lower lifetime cumulative dose of levodopa in comparison with PDD. This is the first study which identified prominent concurrent CAA pathology as a pathological substrate of DLB. More prominent CAA and rapid disease progression as measured by clinical milestones distinguish DLB from PDD.

Pre-operative preparation to anesthesia in children

The objective: the article is devoted to specific parameters of pre-operative preparation for anesthesia in children above 1 month old which is significantly different from adult practice. Special attention is paid to ensuring the psychological comfort of the child, collecting history and physical examination, which allows to assess the physical status of the patient, concomitant diseases and risk factors of airway obstruction during anesthesia. The article presents basic principles of anesthesia risk assessment in children and modern scales used for this purpose. It describes possible complications of anesthesia due to concurrent hereditary pathology in the child. Special parts of the article are devoted to pre-operative starvation, the problem of choice of premedication, specific pre-operative management in case of acute respiratory infections and acute surgical diseases of the abdomen.

Advantages and faults of laparoscopic operations in treatment of ventral hernias

Objective. To conduct a comparison analysis of modern open, classic laparoscopic and separation laparoscopic hernioplastic procedures in treatment of ventral and postoperative ventral hernias.&#x0D; Materials and methods. During 2009 - 2019 yrs on the base of Odessa Regional Clinical Hospital 193 patients, suffering ventral and postoperative ventral hernias were operated. Depending on the hernioplasty method applied all the patients were divided on two groups. In the first one 100 patients were exposed to laparoscopic hernioplasty, including 91 patients - the standard laparoscopic operations. In the second group in 93 patients open hernioplasty was performed.&#x0D; Results. In the first group while using a standard laparoscopic procedures of hernioplasty the average duration of operation have constituted (114.0 ± 7.4) min, recurrence was revealed in 7 patients with large hernias (W3). In the second group the operation duration have constituted (130.0 ± 6.1) min, and recurrence was revealed in 8 patients.&#x0D; Conclusion. The operation method choice ought to be individually adjusted, taking into account the patient general status and age, presence of concurrent pathology, as well as the hernia defect dimensions and localization, in particular.

Differentiated approach to treatment of arterial hypertension in patients, suffering ischemic cerebral stroke

Objective. To raise the efficacy of treatment of arterial hypertension in patients, suffering ischemic cerebral stroke of the middle grade of severity on background of determination of hemodynamic variant of arterial hypertension.&#x0D; Materials and methods. Prospective nonrandomized investigation concerning 42 patients, suffering ischemic cerebral stroke of middle severity in accordance to the insult severity scale of National Institute of Health (National Institutes of Health Stroke Scale - NIHSS), was conducted. The patients’ middle age have constituted (69.4 ± 1.4) yrs. There were the central hemodynamic indices measured, the arterial hypertension hemodynamic variant determined, the oxygen and hemodynamic status estimated, and in accordance to the results obtained - the differentiated antihypertensive therapy was administered. All the patients were divided into three groups, depending on hemodynamical variant of arterial hypertension: the first group – patients with eukinetic variant, the second group – patients with hypokinetic variant, the third group – patients with hyperkinetic variant. Hemodynamical variant of arterial hypertension was determined in accordance to the referent level of cardiac index. The groups were representative in accordance to age, height, the body mass, the main and concurrent pathology and the cerebral affection degree.&#x0D; Results. In the patients, suffering initial eukinetic hemodynamical variant of arterial hypertension, the cardiac index have fluctuated from 2.88 to 4.67 l × min-1 × m-2, general peripheral vascular resistance have rested in the norm borders, the oxygen saturation level of arterial blood did not demand the oxygen therapy, index of the oxygen delivery have exceeded the appropriate values and fluctuated in borders from 541 to 903 l × min-1 × m-2. In complex of differentiated antihypertensive therapy there was applied a constant intravenous injection of magnesium sulfate in a daily dose 2500 - 5000 mg. For patients with initial hypokinetic hemodynamic variant of arterial hypertension following signs are characteristic: low cardiac index - from 1.65 to 2.08 l × min-1 × m-2, the enhanced general peripheral vascular resistance - 2813 (from 2393 to 3403) dyne × s-1 × cm-5 and the lowered index of the oxygen delivery - from 306 to 412 l × min-1 × m-2. Differentiated antihypertensive therapy was conducted, using urapidyl: intravenous boluses 1.25 – 2.5 mg with further infusion 5 - 40 mg × h-1. For hyperkinetic hemodynamic variant of arterial hypertension the raised cardiac index is characteristic – 3.75 l × min-1 × m-2 (fluctuated in borders from 3.62 to 4.10 l × min-1 × m-2), as well as normal general peripheral vascular resistance - 1189 (from 1055 to 1449) dyne × s-1 × cm-5 and raised index of the oxygen delivery - 762 (from 725 to 828) l × min-1 × m-2. Differentiated antihypertensive therapy was conducted, using labetalol: intravenous infusion with velocity 2 - 8 mg × min-1.&#x0D; Conclusion. In the patients with ischemic cerebral stroke of the middle grade of severity the conduction of differentiated antihypertensive therapy, taking into account hemodynamic type of arterial hypertension and the oxygen-hemodynamic stabilization of the blood circulation system, improved the results of treatment and accelerated the rehabilitation duration.

Concomitant Laparoscopic Splenectomy and Cholecystectomy: A Systematic Review of the Literature.

Background: Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) is performed for concurrent pathologies of the spleen and gallbladder. This systematic review aimed to evaluate the available evidence on its indications, operative technique, and outcomes. Materials and Methods: The PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: December 6, 2019) for studies reporting on CLSC. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was utilized for the evaluation of eligible articles. Results: Eight studies met inclusion criteria and concerned collectively 108 patients (53 males and 55 females) with a mean age of 27.02 ± 20.48 years (mean, SD). The most common surgery indications were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Laparoscopic cholecystectomy preceded splenectomy in the majority of cases (75%). A five-trocar approach was most frequently (89.8%) utilized. The mean operation duration was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weight was 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). The conversion rate was 2.7%, while 20.4% of included cases experienced postoperative complications. Most frequent ones included pulmonary infection (6.5%) and portal/splenic vein thrombosis (4.6%). No postoperative death was recorded. Mean hospitalization period was 5.43 ± 3.18 days (mean, SD). Conclusions: CLSC is a safe and feasible operation for simultaneous diseases of the spleen and gallbladder that require elective procedures. High-quality clinical trials are essential to further elucidate clinical evidence and standardize operative technique.

Concurrent thoracic pathology identified with radiology in hyperthyroid cats referred for radioiodine therapy.

Radioiodine (RAI) treatment for hyperthyroidism is becoming increasingly available in the UK. Pretreatment assessment is commonly performed, as patient handling is limited once RAI has been administered. The aims of this study were to determine the prevalence of thoracic pathology using thoracic radiography in hyperthyroid cats referred for RAI treatment and to determine the value of this technique pretreatment. The hospital databases were searched for hyperthyroid cats referred for RAI treatment at the Feline Centre, Langford Vets, between January 2012 and July 2016. Radiographs were reviewed by Diplomates of the European College of Veterinary Diagnostic Imaging at the time of treatment and each set of radiographs was subsequently reviewed by one radiologist for the study. Cardiorespiratory signs were recorded, if present, and any change in treatment plan or suitability for RAI treatment was documented. Two hundred and fifty-two cats were included in the study. Thoracic pathology was identified in 77% (n = 194/252) of the cats, of which 59% (n = 115/194) had pulmonary abnormalities with bronchial and bronchointerstitial patterns most frequently; 57% (n = 111/194) had skeletal abnormalities and 43% (n = 84/194) had cardiac abnormalities, with mild-to-moderate cardiomegaly most prevalent. Other abnormalities included sternal lymphadenomegaly (7%; n = 13/194), mediastinal pathology (3%; n = 5/194), oesophageal pathology (2%; n = 4/194) and pleural space disease (0.5%; n = 1/194).Twelve cases (6%) had a change in their treatment plan as a result of thoracic radiographic abnormalities, of which five subsequently underwent RAI treatment. A low prevalence of significant thoracic pathology was identified on radiographs in hyperthyroid cats referred for RAI treatment. Incidental thoracic abnormalities were found much more commonly; hence, results of thoracic radiology need to be combined with the clinical picture, to decide whether further investigations or alterations to the treatment plan are required pre-RAI.

Brachycephalic airway syndrome: management of post‐operative respiratory complications in 248 dogs

As ownership of brachycephalic dog breeds rises, the surgical correction of components of brachycephalic airway syndrome (BAS) is increasingly recommended by veterinarians. This study's objective was to describe the incidence of, and strategies for the management of post-operative respiratory complications in brachycephalic dogs undergoing surgical correction of one or more components of BAS. Medical records of 248 brachycephalic dogs treated surgically for BAS were retrospectively reviewed for demographic information, procedures performed, post-operative complications and treatment implemented, hospitalisation time, and necessity for further surgery. Pugs, Cavalier King Charles Spaniels and British Bulldogs were the most commonly encountered breeds. Dogs which experienced a complication were significantly older (mean was 5.5 years, compared with 4.1 years [P < 0.01]). Fifty-eight dogs (23.4%) had complications which included: dyspnoea managed with supplemental oxygen alone (7.3%, n = 18), dyspnoea requiring anaesthesia and re-intubation (8.9%, n = 22), dyspnoea necessitating treatment with a temporary tracheostomy (8.9%, n = 22), aspiration pneumonia (4%, n = 10), and respiratory or cardiac arrest (2.4%, n = 6). Five of the 22 dogs requiring anaesthesia and re-intubation deteriorated 12 or more hours after post-surgical anaesthetic recovery. The overall mortality rate in this study was 2.4% (n = 6). Age, concurrent airway pathology, and emergency presentation significantly predicted post-operative complications. Our data show the importance of close monitoring for a minimum of 24 h following surgery by an experienced veterinarian or veterinary technician. Surgical intervention for BAS symptomatic dogs should be considered at an earlier age as an elective procedure, to reduce the risk of post-operative complications.

Is debridement beneficial for focal cartilage defects of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU)

IntroductionFocal cartilage defects of the knee are often treated with arthroscopic debridement. Existing literature discussing the benefit of debridement for small articular cartilage lesions is scarce, especially if the debridement was not part of a combined operative cartilage procedure including meniscal and ligament repair. The purpose of this study was to examine the patients´ benefit after arthroscopic debridement for the treatment of isolated focal chondral defects with or without partial meniscus resection.Materials and methodsBaseline (preoperative data) and 12-month follow-up of the five Knee Osteoarthritis Outcome Score (KOOS) subscores and the Numeric Rating Scale (NRS) for pain were analyzed in 126 patients undergoing debridement for focal chondral defects of the knee from the German Cartilage Registry. Sub-analysis for patients receiving isolated debridement and debridement with concomitant partial resection of meniscal pathologies was performed. Thus, four subgroups were created according to the treated defect size and presence of meniscal pathologies: “debridement-only < 2 cm2”, “debridement-only > 2 cm2”, “debridement and partial meniscus resection < 2 cm2” and “debridement and partial meniscus resection > 2 cm2”.ResultsKOOS-subscores showed a significant increase from baseline to follow-up evaluation (p = 0.017–0.037) within the 126 patients. Sub-analysis showed significant improvement of all five KOOS-subscores in all three subgroups, except for the “debridement and partial meniscus resection > 2 cm2”—group: in this group the KOOS subscores symptoms and sports showed no significant improvement. The NRS scores revealed no significant changes from baseline to 12-month follow-up within the four subgroups.ConclusionAn overall benefit of arthroscopic debridement for focal cartilage lesions of the knee could be conducted. Isolated cartilage defects seem to benefit from debridement irrespectively of size. In patients with large cartilage defects (> 2 cm2) and concurrent meniscal pathology expectation to improvement should be humbled. Effective reduction of pain by arthroscopic debridement remains unclear.

COVID-19 Patients Encountered by a General Surgeon: Seven Unique Scenarios

With rising demand of surgical interventions post-lockdown due to Coronavirus Infectious Disease (COVID)-19, surgeons all over the country have restarted their surgical practice. To increase caution and safety, seven scenarios in which surgeons in a Tertiary Care Centre in North India encountered COVID-19 patients during lockdown are being highlighted in the present case series. The main aim was to encourage prompt recognition and isolation of positive patients along with establishment of a clear institutional protocol for surgical practice to keep our system resilient and useful for the population we serve. Clinical and radiological records of eleven patients admitted from 22.3.2020 to 31.5.2020 (period of lockdown) in a Tertiary Care Hospital in India were studied separately and concluded consensually by two surgeons and seven unique scenarios in which a surgeon may encounter a COVID-19 patient were identified. First was the COVID-19 positive patient with concurrent symptomatic surgical pathology, second was COVID-19 positive patient incidentally diagnosed with additional surgical pathology and third was a solely surgical patient mimicking COVID-19 positive symptomatology. Fourth was a COVID-19 negative surgical patient acquiring nosocomial COVID-19 infection, fifth was COVID-19 positive surgical patient with false negative COVID-19 test report, sixth was COVID-19 suspected by intraoperative unusual intestinal findings and then, getting postoperative COVID-19 test positive for the patient and last was COVID-19 patients requiring elective surgical procedures.

Diagnosis and Management of Apical Fenestrations Associated with Endodontic Diseases: A Literature Review.

Apical fenestration describes a window-like opening of the alveolar bone that involves the root apex of the associated tooth. Mucosal fenestration is a similar defect of the overlying mucosa and, when presented with a concomitant apical fenestration, may expose the root apex to the oral environment. A fenestration may arise from physiological and pathological processes. Although its presence does not necessitate treatment per se, these lesions have significant clinical implications when associated with endodontic diseases. Apical fenestrations associated with endodontic infections are relatively uncommon and can easily be overlooked or misdiagnosed. A thorough understanding of these lesions is key for timely diagnosis and successful management. The aim of this study was to review the epidemiology, aetiological factors, characteristics, management methods and potential outcomes of apical fenestrations associated with endodontic diseases. A search of online databases for relevant studies was conducted. With the inclusion of hand searched articles, 20 articles, consisting of case reports and series, were identified, and the key characteristics of each case were summarised. Apical fenestrations were found to be most commonly associated with maxillary teeth and almost always occur on the buccal aspect of the alveolar bone. Clinicians may consider the possibility of an apical fenestration with concurrent endodontic pathology when patients present with non-healing sinus tracts, exposed tooth apices and/or persistent pain after endodontic treatment, particularly on palpation and mastication. Clinical signs and symptoms can vary, hence cone-beam computed tomography is an important tool for diagnosis. The management involves surgically restoring a favourable anatomical configuration of the root apex in relation to the alveolar bony housing and may be combined with guided tissue regeneration and/or grafting procedures. Sloughing, reopening and infection are potential complications. The literature on apical fenestrations associated with endodontic diseases is limited, thus further research is needed to develop evidence-based guidelines for the diagnosis and management of these lesions.

Correlation of microglial activation with white matter changes in dementia with Lewy bodies.

Dementia with Lewy bodies (DLB) is characterized by alpha-synuclein protein deposition with variable degree of concurrent Alzheimer's pathology. Neuroinflammation is also increasingly recognized as a significant contributor to degeneration. We aimed to examine the relationship between microglial activation as measured with [11C]-PK11195 brain PET, MR diffusion tensor imaging (DTI) and grey matter atrophy in DLB. Nineteen clinically probable DLB and 20 similarly aged controls underwent 3T structural MRI (T1-weighted) and diffusion-weighted imaging. Eighteen DLB subjects also underwent [11C]-PK11195 PET imaging and 15 had [11C]-Pittsburgh compound B amyloid PET, resulting in 9/15 being amyloid-positive. We used Computational Anatomy Toolbox (CAT12) for volume-based morphometry (VBM) and Tract-Based Spatial Statistics (TBSS) for DTI to assess group comparisons between DLB and controls and to identify associations of [11C]-PK11195 binding with grey/white matter changes and cognitive score in DLB patients. VBM analyses showed that DLB had extensive reduction of grey matter volume in superior frontal, temporal, parietal and occipital cortices (family-wise error (FWE)-corrected p<0.05). TBSS showed widespread changes in DLB for all DTI parameters (reduced fractional anisotropy, increased diffusivity), involving the corpus callosum, corona radiata and superior longitudinal fasciculus (FWE-corrected p<0.05). Higher [11C]-PK11195 binding in parietal cortices correlated with widespread lower mean and radial diffusivity in DLB patients (FWE-corrected p<0.05). Furthermore, preserved cognition in DLB (higher Addenbrookes Cognitive Evaluation revised score) also correlated with higher [11C]-PK11195 binding in frontal, temporal, and occipital lobes. However, microglial activation was not significantly associated with grey matter changes. Our study suggests that increased microglial activation is associated with a relative preservation of white matter and cognition in DLB, positioning neuroinflammation as a potential early marker of DLB etio-pathogenesis.

Chronic Long Head Biceps Tendinitis Secondary to Anomalous Origins in Young Patients: A Case Series.

To describe a case series of young adult patients with isolated chronic proximal biceps tendinitis refractory to conservative care found to have anatomic long head biceps tendon (LHBT) origin variations who underwent arthroscopic-assisted subpectoral biceps tenodesis. Patients were included in this retrospective case series if they met all the following criteria: 1) had an anomalous origin of the LHBT without any pre-operative or concurrent pathologies at the time of surgery, 2) had non-traumatic anterior shoulder pain refractory to conservative care for >6 months, 3) pain relief with ultrasound guided steroid injections into the bicipital tendon sheath, and 4) routine radiographs and MRI-arthrogram demonstrating no pathology. All patients underwent arthroscopic assisted mini-open subpectoral biceps tenodesis. Pre- and post-operative active range of motion (ROM), strength, visual analog scale (VAS) for pain, and subjective shoulder values (SSV) were evaluated. Statistical analysis was done using repeated measure ANOVA. Seven patients mean age of 18.4 ± 3.5 years old were included in this study. Arthroscopic examination revealed anomalous origins of the LHBT in all patients with the following distribution: medial to superior labrum (x2), proximal insertion to the supraspinatus confluent with the superior labrum (x2), insertion into the superior capsular tissues at the rotator interval (x2), and bifid LHBT (x1). VAS score and SSV were significantly improved at 3 months (p <0.001 and = 0.024 respectively) and final follow-up. Anomalous origins of the LHBT may be a predisposing factor for chronic biceps tendinitis refractory to non-operative treatment in young adults. Biceps tenodesis seems to offer improvements in function and pain.

Evaluating empirically valid and clinically meaningful change in intensive residential treatment for severe eating disorders at discharge and at a 6-month follow-up.

The present study evaluated the statistical and clinical significance of symptomatic change at discharge and after 6months of an intensive residential treatment for patients with eating disorders (ED), and explored the individual factors that may affect therapeutic outcomes. A sample of 118 female ED patients were assessed at intake and discharge on the following dimensions: BMI, ED-specific symptoms, depressive features, and overall symptomatic distress. A subsample of 59 patients filled out the same questionnaires at a 6-month follow-up after discharge. Findings evidenced statistically significant changes in all outcome measures at both discharge and follow-up. Between 30.1 and 38.6% of patients at discharge and 35.2-54.2% at the 6-month follow-up showed clinically significant symptomatic change; additionally, 19.8-29.1% of patients at discharge and 22.9-38.3% at follow-up improved reliably. However, 34.9-39.8% remained unchanged and 2-4.8% worsened. At the 6-month follow-up, 21.3-25.9% showed no symptomatic change and 0-3.7% had deteriorated. Unchanged and deteriorated patients had an earlier age of ED onset and were more likely to suffer a comorbid personality pathology and to be following concurrent pharmacological treatment. Results suggested that intensive and multimodal residential treatment may be effective for the majority of ED patients, and that therapeutic outcomes tend to improve over time. Prevention strategies should focus on early onset subjects and those with concurrent personality pathology. Level III, evidence obtained from a longitudinal cohort study.

Neurofilament Immunohistochemistry Followed by Luxol Fast Blue, for Staining Axons and Myelin in the Same Paraffin Section of Spinal Cord.

Many disorders of the central nervous system are characterized by both axonal pathology and demyelination. In assessing this concurrent pathology, techniques for staining axons or myelin are frequently used separately. Here we report the development of a combined immunohistochemical and tinctorial staining technique in which we have modified the Luxol fast blue myelin stain to be used in conjunction with a diaminobenzidine-based immunohistochemical stain for high molecular weight neurofilament (SMI-31). This modification of staining will have utility in experimental neuropathology laboratories investigating demyelination and axonal damage in human tissue and animal models.

Clinical Outcomes of Percutaneous Plantar Fasciotomy Using Microdebrider Coblation Wand.

Plantar fasciitis is the most common cause of heel pain in adults. Multiple conservative treatment plans exist; however, some cases do not obtain significant clinical improvement with conservative treatment and require further intervention. This retrospective case study evaluated the success rate of percutaneous plantar fasciotomy and confounding comorbidities that negatively affect outcomes. A series of 41 patients treated with percutaneous plantar fasciotomy using the Topaz EZ microdebrider coblation wand were invited to participate in this retrospective follow-up study, and 88% (N = 36) participated. A limited chart review was completed and the patients answered a survey with the visual analog scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire. Average outcomes were calculated and 45 variables were analyzed to determine if they were statistically significant confounders. Patients had symptoms for an average of 3 years before the procedure and were contacted for follow-up at an average of 14 months after the procedure. The average VAS for pain score was 1.3 ± 1.8 and the average FAAM score was 92 ± 15. Eighty-nine percent of patients had a successful outcome, defined as FAAM greater than 75. In addition, patients at 18 months postprocedure reported complete or near-complete resolution of symptoms with an FAAM score greater than 97. Concurrent foot pathologies (eg, tarsal tunnel syndrome), oral steroid treatment prior to the procedure, and immobilization with a boot prior to the procedure were statistically significant negative confounders (P < .05). Being an athlete was a positive confounder (P = .02). Percutaneous plantar fasciotomy using a microdebrider coblation was an effective treatment for plantar fasciitis, particularly without concurrent foot pathology, with a low risk of complications. Level IV, retrospective case series.

Treatment of Insertional Achilles Tendinopathy with MRI Confirmed Small or No Tear Using a Gastrocnemius Recession

Category:AnkleIntroduction/Purpose:Insertional Achilles tendinopathy can be a distressing problem for an active patient. Treatment begins conservatively, and when this fails a patient’s next best option may involve operating on the affected tendon. Depending on the disease state of the tendon, the surgeon may decide to repair or augment the Achilles with a flexor hallucis longus (FHL) transfer. The current literature supports the gastrocnemius recession for non-insertional cases, but is inconsistent in its efficacy for insertional cases. Our study looks at how patients with insertional Achilles tendinopathy with a small tear involving 20% of the tendon or less responded to an isolated gastrocnemius recession. Our hypothesis was that patients could do well without the need for a large repair or FHL transfer procedure.Methods:We retrospectively reviewed patients who underwent an isolated gastrocnemius recession for recalcitrant insertional Achilles tendinopathy between January 2015 and July 2018. Patients were included based on the diagnosis of insertional Achilles tendinopathy, having an MRI confirming tendinopathy, a tear involving less than 20% of the tendon or no tear, and no other concurrent pathologies. These criteria yielded 14 patients. One of these 14 patients was removed from the data analysis due to non-surgical complaints after surgery stemming from new onset posterior ankle pain. The patient charts were reviewed for their subjective VAS pain scores during office visits pre and postoperatively. Immediate preoperative visit, initial postoperative visit and final visit VAS scores were recorded.Results:The average time of chart follow up for the 13 patients included in the study was 15.5±10.5 weeks postoperatively (range 4-38). 2 patients were found to have a tear <20% (15%), and the remaining 11 patients were found to have no tear on their MRI (85%). The average final preoperative VAS pain score for the patients was 5.4±1.8 (range 3-9). The average final postoperative VAS pain score for the patients was 0.9±1.3 (range 0-5). These values were found to be statistically different (p<0.001). Of note all patients saw a reduction in their pain score of at least 2 points.Conclusion:Previous literature is inconclusive on the efficacy of the gastrocnemius recession for insertional Achilles tendinopathy. No other study has identified the amount or type of tendon involvement by advanced imaging. Our study supports the notion that patients with MRI confirmed tendinopathy and a tear involving less than 20% of the tendon or no tear, often do quite well in reaching a reduction in their pain. Our study is limited in power due to our small sample size, but the results suggest that this procedure deserves more attention for the treatment of insertional Achilles tendinopathy when appropriate.

1833 Utilization of EndoFLIP to Diagnose Achalasia in a Patient With Chronic Dysphagia Previously Attributed to Dysphagia Lusoria

INTRODUCTION: Dysphagia lusoria is a rare cause of dysphagia resulting from compression of the esophagus due to an aberrant right subclavian artery. Less than 2% of the population have this anatomic variant and the majority are asymptomatic. An aberrant right subclavian artery may not be clinically significant in a patient with concurrent esophageal pathology. CASE DESCRIPTION/METHODS: An 87-year-old woman with a twenty year history of chronic dysphagia complicated by recurrent food impactions presented with poor oral intake and weakness. Previously attributed to paraesophageal hernia, the dysphagia persisted despite partial fundoplication surgery. Prior CTA abdomen was suggestive of dysphagia lusoria, identifying an aberrant origin of the right subclavian artery traversing behind a dilated esophagus with associated mass effect. Achalasia was previously suspected but never confirmed as the patient could not tolerate the manometry procedure. EGD with EndoFLIP revealed a distensibility index of 0.6, a diameter of 5 mm, and a balloon pressure of 29 mm Hg with no appreciable peristalsis, consistent with type I achalasia. EUS revealed an aberrant right subclavian artery without extrinsic esophageal compression. EGD with pneumatic dilatation was performed after which the distensibility index was 6 with a diameter of 12.5 mm. The patient was placed on clear liquids and successfully transitioned to a pureed diet with significant symptomatic improvement. Outpatient follow up is pending. DISCUSSION: The EndoFLIP and EUS results confirmed the diagnosis of achalasia while simultaneously showing that the aberrant right subclavian artery represented an incidental finding rather than the true etiology of dysphagia. Moreover, it was the esophageal dilatation caused by achalasia that likely led to the discovery of the previously undetected aberrant subclavian vessel. Given the rarity of clinically significant dysphagia lusoria, it is important to consider alternative diagnoses in the evaluation of dysphagia. Molz G, Burri B. Aberrant subclavian artery (arteria lusoria): Sex differences in the prevalence of various forms of the malformations. Evaluation of 1378 observations. Virch Arch A Pathol Anat Histol 1978;380:303–15.