Distinct Clinical Improvement Research Articles

Is it worth the risk? Clinical and radiographic outcomes 24 months after reverse shoulder arthroplasty in an advanced geriatric population

BackgroundThe application of reverse shoulder arthroplasty (RSA) has risen in the past decades especially due to its excellent long-term outcomes. With this positive trend, the indications for RSA have gradually extended to a broader age spectrum. The objective of this study was to identify the benefits of primary RSA in an advanced geriatric population with considerable comorbidity burden and higher perioperative risk.MethodsFor this observational study using data collected from our local RSA register, we identified 73 patients (77% female) with a minimum age of 85 years (range: 85-93 years) at the time of surgery and a complete 24-month postoperative follow-up. Clinical evaluations of pain, Subjective Shoulder Value, Constant score, Shoulder Pain and Disability Index, quality of life (European Quality-of-Life 5-Dimension 5-Level utility), and patient satisfaction were made. Radiographic evaluation followed an international consensus core set. Adverse events were documented according to a core event set.ResultsPreexisting medical conditions categorized following the American Society of Anesthesiologists physical status classification system indicated only 22% of patients with mild comorbidities (American Society of Anesthesiologists I-II), whereas severe (American Society of Anesthesiologists III-IV) comorbidities were common (78%). Indications for surgery were rotator cuff deficiency (72%), post-traumatic conditions (18%), and primary arthrosis (10%). There was significant improvement in all clinical evaluations up to 24 months post RSA: mean pain levels decreased from 6.2 to 1.6 points, where 0 indicates no pain (P < .001) and Subjective Shoulder Value, Constant score, Shoulder Pain and Disability Index, and European Quality of Life 5 Dimensions 5 Level increased from 36% to 76%, 26 to 61 points, 29 to 74 points, and 0.58 to 0.79, respectively (P < .001). Most patients (88%) opted in favor of undergoing the same surgery again based on their personal outcome. There were no signs of early loosening, migration or dislocation at 24 months postsurgery. However, 6 periprosthetic fractures were identified, 5 of which were treated conservatively. Adverse events were reported for 39% of patients, yet rarely led to the need for revision surgery (1.8%) or hospital readmission (3.6%).ConclusionDespite an advanced age over 85 years and numerous associated comorbidities, our geriatric population showed a distinct clinical improvement in their daily activities with high rates of patient satisfaction. Radiographic analysis at 24 months after surgery identified adequate implant stability. RSA is a safe procedure, even in these elderly patients, with an acceptable risk of unfavorable medical and surgical events.

Double-blind controlled randomised study of lactulose and lignin hydrolysed combination in complex therapy of atopic dermatitis

BackgroundAtopic dermatitis (AD) is an immune mediated disease with complex pathogenesis characterised by persistency, frequent exacerbations, and inefficacy of existing therapies. Damaged or weakened intestinal microbiocenosis is considered as an important aetiological factor of AD. The aim of this study was to evaluate the efficacy and safety of medical preparation Lactofiltrum (lactulose and sorbent (lignin hydrolysed)) in comparison with placebo in complex with standard therapy of AD.MethodsDouble-blind, placebo controlled, randomised comparative study of effectiveness and safety of 400 mg lactulose and 120 mg lignin hydrolysed combination as a part of standard combined AD treatment, conducted in parallel groups of patients aged 18–60.ResultsComparison of clinical efficacy of Lactofiltrum in combination with the standard treatment has been demonstrated by measuring the following parameters: administration of Lactofiltrum results in 1) distinct clinical improvement in 56.75% of patients, 2) decrease of the mean values of scoring atopic dermatitis (SCORAD) index in 71.94% of patients, 3) elimination of itching in 50% of patients, and 4) life quality improvement for 76.41%. In the placebo group, 1) distinct clinical improvement was observed in 20% of patients, 2) decrease in SCORAD index values observed by 56.98%, 3) itching relief in 15.56%, and 4) life quality improvement by 36.38%.ConclusionsClinical improvement and persistent termination of clinical symptoms provide evidence of effectiveness in use of Lactofiltrum combined with the standard treatment of AD.

Favourable results in treatment-resistant schizophrenic patients under combination of aripiprazole with clozapine

Clozapine is still the gold standard in treatment-resistant schizophrenia. However, a substantial amount of patients do not fully recover on clozapine monotherapy. Though there is still a lack of randomised controlled studies of combination strategies in treatment-resistant schizophrenia, they are widely used. Aripiprazole is a relatively new therapeutic option due to its partial D2 agonism. Both clozapine and aripiprazole, though having a generally favourable side-effect profile, may lead to insufficient response and might provoke side effects in monotherapy. We report the case of four patients in whom we observed a distinct clinical improvement with respect to positive and negative symptoms without major side effects under a combination of clozapine and aripiprazole. The combination of clozapine action and aripiprazole-mediated D2 receptor regulation could be responsible for the described favourable effects and for the increase of D2 receptor blockade after adding aripiprazole to clozapine observed in one patient. A combination of clozapine and aripiprazole may be an effective therapeutic strategy for some schizophrenic patients, leading to a good response with respect to positive and negative symptoms without the occurrence of major side effects.

What is the appropriate duration of a therapeutic trial in cutaneous tuberculosis? Further observations

Laboratory tests for the diagnosis of cutaneous tuberculosis lack adequate sensitivity and specificity and a trial of therapy is often used as a diagnostic test in difficult cases. However, the duration for which the trial should be undertaken is not clearly defined. Our previous study indicated that one month of therapy was adequate to detect a clinical response to treatment. However, about half the patients first reported after one month of treatment, some much later. We therefore analysed the treatment records of 107 patients who received four-drug, short course, antitubercular therapy for a diagnosis of cutaneous tuberculosis in our hospital and who were asked to return for follow-up at biweekly intervals in the first month of treatment. Twenty-one patients did not return for any follow-up visit, nine patients did not respond to treatment and treatment was stopped in one patient. Of the remaining 76 patients, 72 patients were recorded to have distinct clinical improvement within five weeks of starting treatment while only four patients showed improvement after 60-123 (8-17 weeks) days of therapy. These findings indicate that five weeks appears to be an adequate duration of a therapeutic trial in patients suspected to have cutaneous tuberculosis, with the exception of tuberculids and patients showing minimal clinical activity before treatment. Patients who have not responded by this time are unlikely to do so with further treatment and should have their diagnosis reviewed.

Chronische Radikulopathie

Treatment of chronic low back pain exhibiting radicular symptoms poses a clinical problem that has not yet been solved. The technique of percutaneous minimally invasive neurolysis described by Racz is being performed increasingly to treat chronic radiculopathy. A total of 61 patients with corresponding symptomatology after screening for inclusion and exclusion criteria in the region of the lumbar spinal nerve were treated with the Racz catheter technique. Distinct clinical improvement was observed at the 3- and 6-month follow-ups after percutaneous minimally invasive epidural neurolysis. Subjective pain perception, quantified by the McNab score, clearly improved after 3 as well as 6 months. With the exception of partial catheter shearing in two cases and one occurrence of infection, no relevant side effects were noted. The Racz catheter technique for treatment of chronic radiculopathy following disk surgery is suitable with minimal side effects.

Treatment of an infant with X‐linked severe combined immunodeficiency (SCID‐X1) by gene therapy in Australia

To report the outcome of gene therapy in an infant with X-linked severe combined immunodeficiency (SCID-X1), which typically causes a lack of T and natural killer (NK) cells. Ex-vivo culture and gene transfer procedures were performed at The Children's Hospital at Westmead, Sydney, NSW, in March 2002. Follow-up to March 2005 (36 months) is available. A 9-month-old male infant with confirmed SCID-X1 (including complete absence of T cells) with an NK+ phenotype (a less common variant of SCID-X1), and no HLA-identical sibling donor available for conventional bone marrow transplantation. CD34+ haemopoietic progenitor cells were isolated from harvested bone marrow and cultured with cytokines to stimulate cellular replication. Cells were then genetically modified by exposure to a retrovirus vector encoding human gamma c (the common gamma chain of several interleukin receptors; mutations affecting the gamma c gene cause SCID-X1). Gene-modified cells (equivalent to 1.3 x 10(6) CD34+/gamma c+ cells/kg) were returned to the infant via a central line. T cells were observed in peripheral blood 75 days after treatment, and levels increased rapidly to 0.46 x 10(9) CD3+ cells/L at 5 months. Within 2 weeks of the appearance of T cells, there was a distinct clinical improvement, with early weight gain and clearance of rotavirus from the gut. However, T-cell levels did not reach the reference range, and immune reconstitution remained incomplete. The infant failed to thrive and developed weakness, hypertonia and hyperreflexia in the legs, possibly the result of immune dysregulation. He went on to receive a bone marrow transplant from a matched unrelated donor 26 months after gene therapy. This is the first occasion that gene therapy has been used to treat a genetic disease in Australia. Only partial immunological reconstitution was achieved, most likely because of the relatively low dose of gene-corrected CD34+ cells re-infused, although viral infection during the early phase of T-cell reconstitution and the infant's NK+ phenotype may also have exerted an effect.

Cytostatics for acromegaly

A 21-year-old woman suffering from acromegaly was treated with transsphenoidal subtotal hypophysectomy (microscopy: acidophilic adenoma), followed by x-ray and bromocriptine therapy. Seven years later she was re-operated because of a partial bitemporal loss of vision, intracranial hypertension, and regrowth of the pituitary tumour seen on CT-scan. A large part of the invasive suprasellar tumour was then removed by transcranial approach. The neurosurgery was followed by cobalt radiotherapy and bromocriptine administration. Two years later, symptoms and signs of tumour growth reappeared. Administration of cytostatics, such as doxorubicin (Adriamycin) and lomustine (Belustine), resulted in distinct clinical improvement associated with a seven-fold decrease in the serum growth hormone concentration. The visual field became normal and the intracranial mass on a CT scan decreased markedly. As a result the patient was able to resume work.

Clinical experience with intravenous Augmentin in the treatment of paediatric infections.

The clinical efficacy of intravenous Augmentin (a formulation containing amoxycillin plus clavulanic acid) was investigated in an open study in fifty-eight children with a mean age of 6 years (range 1-15 years). The normal dosage was in the range 100-200 mg/kg/day Augmentin, administered parenterally by short i.v. infusion in 3 or 4 divided doses. Most patients were hospitalised for lower respiratory tract infections. Complete clinical cure or distinct clinical improvement was achieved in all assessable cases. Bacteriological success was obtained in 92% of the assessable cases. In two patients, mild, transient exanthema was noted after i.v. Augmentin was replaced by oral Augmentin. No additional therapeutic measures were required.

1473 ABNORMAL CARDIORESPIROGRAPHIC (CRG) TRACINGS AND ELEVATED SERUM CREATINE PHOSPHOKINASE (CPK) IN INFANTS OF DRDG DEPENDENT MOTHERS. (IDDM)

Continuous respiratory & heart rate monitoring were done during the first 5 postnatal days in 12 IDDM & 19 normal infants (control). The results showed abnormal CRG patterns in the IDDM such as: (1) significantly (p<0.01) higher baseline heart rate. (BHR), beat to beat (BBV) & long term (LTV) variability, and resp. rate (RR) - See Table, (2) exaggerated response of HR to stimuli such as light, noise or pain, and (3) frequent & spontaneous occurences of large (Δ40 bpm), brief, rise and fall in HR giving a characteristic “wave-like” appearance to the tracings. The BBV & LTV changes were also more intense (p<0.02) in the IDDM with moderate to severe, as compared to mild withdrawal. Treatment of the withdrawal with drugs, did not abolish the CRG abnormalities despite distinct clinical improvement. Serum CPK (normal = 80 - 450 IU/L) was also analyzed in 16 IDDM during the first 2-7 days of life. Eleven infants (69%) had markedly elevated CPK levels (Mean = 1313 ± 401 IU/L; range = 459 - 5123), & predominantly of the MM fraction (89%). The elevated CPK did not correlate with the infant's birth weight, GA or Apgar score, but was usually found in the infants with significant tremors & hypertonicity. Conclusion: The chronic exposure of infants to drugs of abuse, in utero, induces striking changes in their CRG patterns postnatally & elevation of their serum CPK isoenzymes. These new findings may provide a probe which can be used to study this group of infants, ante-natally & postnatally.

Treatment of cystinosis with a diet poor in cystine and methionine.

SUMMARYTwo siblings with cystinosis are presented.Case 1, a 16‐month‐old boy, presented with a severe renal tubular insufficiency. Case 2, a 7‐year‐old girl, was a dwarf with both glomerular and tubular renal insufficiency.Case 1 was initially treated with high doses of vitamin D2 and electrolyte supplements for more than 2 months without significant alteration of the condition. Thereafter he was treated for 23 days with 150 mg penicillamine per day again without any significant clinical or biochemical improvement. Both patients were then followed through 1 year on treatment with a diet poor in cystine and methionine supplemented with cholinechloride, an anabolic steroid, high doses of vitamin D2, electrolytes, oral iron and a combined vitamin preparation. After some time there was considerable difficulty in giving the patients sufficient amounts of the diet, consequently the diet had to be modified with supplement of cow's milk. On this treatment case 1 attained a distinct clinical improvement with healed rickets and normal growth. There was no evidence of mobilisation of the stored cystine.Case 2 obtained a healing of the rickets and some gain in height during the treatment, but otherwise the general condition was unaltered, and she continued to have increasing renal glomerular insufficiency.

Muscular dystrophy. VIII. Trials of protein hydrolysate, vitamin supplements, and physical therapy.

It has recently been reported that the ingestion of a protein hydrolysate together with a vitamin preparation produces distinct clinical improvement in muscular dystrophy.* A group of children believed to have this disease have therefore been placed on such a regimen. The results have been compared with those obtained with physical therapy alone as well as with the spontaneous changes which occur without hydrolysate and without physical therapy. MATERIAL AND METHODS Twenty-nine children afflicted with muscular dystrophy, 2 to 15 years of age, have been seen at intervals by a physical therapist, an orthopedist, and a physician. In all of these patients the diagnosis seems justified by virtue of the findings on physical examination and on biopsy of muscle sections. The details of these observations together with the results of certain biochemical studies of body fluids have been presented earlier.† Serial measurements of muscle strength have been made in the

The influence of thyroid substances on the absorption of pleural effusions.

A good many patients suffering with pneumonia develop during the course of their disease pleural effusions. Some of these effusions are small and assume no clinical importance since they are usually absorbed at or soon after the crisis. Others are large and manifest themselves by physical and röntgenological signs. They last for a number of weeks, are accompanied by moderate fever prolonged convalescence and sometimes undergo purulent metamorphosis. The gross appearance of the fluid is usually straw-colored, of varying transparency and usually bacteria-free on culture. The pathogenesis of these effusions is wholly unknown. It is possible that a certain type of pneumonia produces pleural exudation. This, if true, might explain the great frequency of this complication in the so-called influenza pneumonias. It can by no means, however, be said that the parapneumonic pleural effusions are confined to this type of pneumonia. It occurs frequently enough in conjunction with fibrinous lobar pneumonia. Perhaps certain individuals particularly predisposed develop effusions in the pleural space in the course of their pneumonias. This idea seemed not unlikely in the light of Eppinger's work on edema. Eppinger found that certain cases of cardiac or kidney disease were frequently typified by an enormous generalized subcutaneous edema, that treatment of the heart by digitalis, restriction of the fluid intake, a salt-free diet or the administration of diuretics had no effect. In such cases the feeding of thyroid gland produced a marked diuresis, the disappearance of edema and distinct clinical improvement sometimes for an extended period. He subjected these clinical observations to experimental investigation and found that there was a striking difference between the absorption of subcutaneous fluid from a normal and thyroidectonized animals. While normal animals absorbed considerable amounts of saline from the skin, thyroprivic animals could not absorb saline so injected.