Duration Of Medical Therapy Research Articles

Conservative Management of Bowel Endometriosis: Cross-Sectional Analysis for Assessing Clinical Outcomes and Quality-of-Life.

Background/Objectives: Bowel endometriosis (BE) is characterized by the presence of endometrial-like tissue within the muscular layer of the bowel wall. When BE does not result in the severe obstruction to fecal transit and in the absence of (sub)occlusive symptoms, the decision to perform surgery can be challenging, as intestinal procedures are associated with higher complication rates and long-term bowel dysfunction. This cross-sectional study aims to evaluate the quality of life (QoL) in patients with BE who avoided surgery, as well as to investigate the impact of the characteristics of BE nodules on the QoL and intestinal function. Methods: A retrospective cross-sectional analysis was conducted involving 580 patients with BE who did not undergo surgery but were treated conservatively with medical therapy or expectant management between January 2017 and August 2022. The diagnosis of BE was established through transvaginal ultrasound and confirmed via double contrast barium enema. After at least one year of follow-up, the QoL and intestinal function were assessed using the Endometriosis Health Profile-5 (EHP-5) questionnaire and the Bowel Endometriosis Symptom (BENS) score, while pain symptoms were quantified with the Visual Analog Scale (VAS 0-10). Statistical analyses were performed to explore potential associations between the QoL and the characteristics of BE nodules (size, location, and evidence of stenosis), as well as the type and duration of medical therapy. Results: Patients with BE reported a satisfactory overall QoL, with a mean EHP-5 score of 105.42 ± 99.98 points and a VAS score below three across all pain domains. They did not demonstrate significant impairment in bowel function, as indicated by a mean BENS score of 4.89 ± 5.28 points. Notably, patients receiving medical therapy exhibited a better QoL compared to those not receiving treatment (p < 0.05), with the exception of postmenopausal patients, who reported the highest QoL overall (p < 0.05). Among the characteristics of BE, nodule location significantly impacted the QoL and symptom intensity, with low (rectal or rectosigmoid) nodules less tolerated compared to sigmoid nodules, particularly regarding non-menstrual pelvic pain (NMPP), dyschezia, and psychological impact on daily life (p < 0.05). Conclusions: Women can effectively manage BE conservatively in the absence of (sub)occlusive symptoms, even when large nodules are present, causing significant radiological stenosis. The characteristics of BE nodules do not significantly affect the QoL or symptom intensity; however, the location of BE nodules is a crucial factor negatively influencing these outcomes. Medical therapy may confer a beneficial impact on patients of reproductive age with BE, but its use should be carefully considered for those approaching menopause, weighing the risks and benefits.

Investigation of possible predictive factors, clinical characteristics, and treatment in vascular Behçet's disease: real-life data from a single center

Objective: The aim of this study was to investigate the phenotypes, predictive factors, and treatment approach of Behçet's patients with vascular involvement. Material and Method: This retrospective study analyzed 123 patients with Behçet's disease, 28 of whom had vascular involvement, and were followed up in our center. The study presented the vascular involvement patterns of the patients along with their clinical characteristics and comorbid conditions. The drugs usage by the patients were analyzed based on the first line and current medications, duration of medical therapy, and drug retention rate. Results: In Behçet's patients with vascular involvement, the male sex ratio was statistically higher compared to those without vascular involvement (60.7% vs 37.9%; OR=2.82(1.17-6.77); p=0.018). The frequencies of Behçet's clinical manifestations, smoking, and comorbidities were similar in both groups. The most common subtype of vascular Behçet's is deep vein thrombosis (18; 64.2%), followed by superficial thrombophlebitis (5; 17.8%), neurovascular involvement (5; 17.8%), cardio-aortic (2; 7.1%) and pulmonary arterial (2; 7.1%). Azathioprine, glucocorticoid, and cyclophosphamide are the most preferred immunosuppressives in vasculo-Behçet's. Anticoagulant therapy was initiated in 67.8% (19; 28) of the patients at the first vascular event. Conclusion: The study presented that male gender predicts vascular involvement in Behçet's disease, with deep vein thrombosis being the most common vascular subtype. Although immunosuppressive drugs represent the cornerstone of treatment for vasculo-Behçet's disease, most patients had also received anticoagulant therapy following the initial attack.

Cardioprotective Strategies from Cardiotoxicity in Cancer Patients: A Comprehensive Review.

Cardiotoxicity is a significant complication of chemotherapeutic agents in cancer patients. Cardiovascular incidents including LV dysfunction, heart failure (HF), severe arrhythmias, arterial hypertension, and death are associated with high morbidity and mortality. Risk stratification of cancer patients prior to initiation of chemotherapy is crucial, especially in high-risk patients for cardiotoxicity. The early identification and management of potential risk factors for cardiovascular side effects seems to contribute to the prevention or minimization of cardiotoxicity. Screening of cancer patients includes biomarkers such as cTnI and natriuretic peptide and imaging measurements such as LV function, global longitudinal strain, and cardiac MRI. Cardioprotective strategies have been investigated over the last two decades. These strategies for either primary or secondary prevention include medical therapy such as ACE inhibitors, ARBs, b-blockers, aldosterone antagonists, statins and dexrazoxane, physical therapy, and reduction of chemotherapeutic dosages. However, data regarding dosages, duration of medical therapy, and potential interactions with chemotherapeutic agents are still limited. Collaboration among oncologists, cardiologists, and cardio-oncologists could establish management cardioprotective strategies and approved follow-up protocols in patients with cancer receiving chemotherapy.

Proportion and predictors of Hypogonadism Recovery in Men with Macroprolactinomas treated with dopamine agonists.

Hypogonadism is the most common form of hypopituitarism in men with macroprolactinoma. However, evidence on factors related to hypogonadism recovery is limited. We estimated the proportion of hypogonadism in men with macroprolactinoma exclusively treated with dopamine agonists, and we assessed the factors predicting hypogonadism recovery. This was a multicenter retrospective study of men with macroprolactinoma identified using ICD 9 and 10 codes and treated between 2009 and 2019 in five centers in the United Arab Emirates and Saudi Arabia. We evaluated hypogonadism, defined as low total testosterone (TT) level with normal or low gonadotropins on presentation and during the last clinic visit. A total of 79 patients (median age 32 years) were included in the study. The most common symptoms at presentation were headache (73.7%), erectile dysfunction (55.4%), and low libido (54.3%). The median tumor size was 2.9cm (1.0-9.7) at diagnosis. Sixty-three patients (79.7%) had hypogonadism at baseline. Growth hormone deficiency (GHD) and hypothyroidism were present in 34.4% and 32.9% of patients, respectively. The median serum prolactin (PRL) level was 20,175 (min-max 2254 - 500,000) mIU/l with a median serum TT of 4.5 (min-max 0.4-28.2) nmol/l. Most patients were treated with cabergoline (n = 77, 97.5%) with a median of 6 (min-max 0.6-22) years. At follow-up, 65% of patients recovered their pituitary-testicular axis. Patients with recovered hypogonadism had smaller median tumor size (2.4 [1-5.4] vs. 4.3 [1.6-9.7], p = 0.003), lower PRL level (18, 277 [2254 - 274, 250] vs. 63,703 [ 3,365-500,000], p = 0.008 ), higher TT level (4.6 [0.6-9.2] vs. 2.3 [0.5-7.3], p = 0.008), lower PRL normalization time on medical therapy (8 months (0.7-72) vs. 24 (3-120), p = 0.009) as well as lower frequency of GHD (17.1% vs. 60%, p = 0.006) and secondary hypothyroidism (17.9% vs. 57.1%, p = 0.003) compared with those with persistent hypogonadism respectively. Age at diagnosis, presenting symptoms and duration of medical therapy did not predict hypogonadism recovery. About two-thirds of men with macroprolactinoma recover from hypogonadism, mostly with 24 months of therapy. Smaller adenoma size, lower prolactin level, earlier prolactin normalization, and higher testosterone patients were related to testosterone normalization.

Efficacy of Mirabegron as Medical Expulsive Therapy for Distal Ureteral Stones: A Prospective, Randomized, Double-Blinded, Controlled Study

Background: Today, medical expulsive therapy (MET) is more effective and commonly used in distal ureteral stones when compared with conservative treatments. Many treatments, namely, alpha-adrenergic blockers and calcium channel blockers, prostaglandin synthesis inhibitors, glyceryl trinitrate, and steroids, have been, therefore, utilized to mitigate such complications and accelerate stone expulsion. Several animal and human studies revealed the presence of β3-receptors in the ureter and bladder, where stimulating these receptors could relax the distal ureteral segment. Objectives: The aim of the study was to evaluate the efficacy of use of mirabegron as MET for distal ureteral stones (intramural and extramural). Methods: This is a prospective randomized controlled study including 90 patients who had distal ureteral stones less than 10 mm and were evaluated between January and June 2020. The patients were classified into 3 groups: group (A) 30 patients: mirabegron 50 mg d−1 + diclofenac Na 100 mg tab (to be taken only during colic episodes), group (B) 30 patients: tamsulosin HCL 0.4 mg cap + diclofenac Na 100 mg tab (to be taken only during colic episodes), and group (C) 30 patients: diclofenac Na 100 mg tab only (to be taken only during colic episodes). Age, sex, stone size, laterality, and grade of ureterohydronephrosis were recorded. Patients were observed for 30 days, and ureteroscopy was completed for those with nonexpulsed stones. Follow-up parameters included number of renal colic episodes, duration of medical therapy, stone expulsion time, and stone expulsion rate (SER). Results: In the group (A), 2 (6.6%) patients were excluded due to nasal congestion, and 1 (3.3%) patient was excluded due to a 20-mm Hg systolic blood pressure increase. Four (13.3%) patients in group (B) were noncompliant on medical treatment. In addition, 2 (6.6%) patients in group (A), 1 (3.3%) patient in group (B), and 5 (16.6%) patients in group (C) who did not attend follow-up examinations were excluded from the study. The SER increased significantly in group (A) and (B) when compared with group (C). The mean time of stone expulsion was about 15, 25, and 12 days for groups A, B, and C, respectively, and there was a significant statistical difference (p value = 0.006) among the 3 groups. The mean number of renal colic episodes of group (A) of patients was 1.8 times, while that of group (B) was 2.6 times and that of group (C) was 2.16 times with no significant statistical difference after comparing the 3 groups (p value = 0.660). Conclusions: Treatment with mirabegron appears to be a safe and effective medical expulsion therapy for distal ureteric stones and is better than tamsulosin.

Patterns of Weight Loss Medication Utilization and Outcomes Following Bariatric Surgery

BackgroundBariatric surgery is the most effective treatment for obesity; however, some patients experience significant weight regain. Weight loss medications (WLM) are being increasingly used in surgery patients with limited evidence. We examine weight loss outcomes in patients using WLM after bariatric surgery. MethodsIn a retrospective study, 197 bariatric surgery patients who started WLM between 2016 and 2019 at a single center were analyzed. Patients were categorized into 3 groups based on outcomes of the initial surgery: (1) Weight regainers (WR) = achieved goal weight loss after surgery (15% total body weight loss (TBWL) for sleeve gastrectomy (SG) and 25% TBWL for Roux-en-Y gastric bypass (RYGB)) with subsequent regain of > 20% of weight lost; (2) Adequate weight loss (AWL) = achieved goal weight loss without > 20% weight regain; (3) Non-responders (NR) = never achieved goal weight loss. Weight loss and medication use patterns were analyzed. ResultsAmong the three categories, there was no significant difference in duration of medical therapy or %TBWL with medications. RYGB patients lost more weight than SG patients using WLM (p = 0.03). Of the medications used, patients treated with phentermine + topiramate had the highest likelihood of achieving 5%, 10%, and 15% weight loss. Compared to other 2 groups, AWL group initiated WLM earlier and experienced more weight loss when compared to their pre-operative weight or post-operative nadir. ConclusionsRYGB patients respond better to WLM than SG patients. Those who had started WLM before regaining weight (AWL) experienced greater overall weight loss, suggesting that proactive medical therapy at the time of weight plateau can help with greater total weight loss. Phentermine + topiramate is the most effective WLM in post-bariatric surgery patients.

SOLID ENDOBRONCHIAL ASPERGILLOMA: A RARE ENTITY

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aspergillosis refers to disease caused by a fungus of the genus Aspergillus, with the most common species being A. fumigatus. The most commonly affected organs are the lungs. Aspergilloma is a mass more commonly known as a “fungus ball” consisting of fungal hyphae mixed with cellular debris and mucus. An aspergilloma usually forms within cavities in the lungs. It may occur in a person with normal immunity but with structurally abnormal lungs, with preexisting cavities that lead to airflow stasis [1]. Endobronchial aspergilloma (EBA) is a rare presentation of pulmonary aspergillosis with only a handful of reported cases in literature. Here we present a case of endobronchial aspergilloma with significant space occupying and obstructing mass. CASE PRESENTATION: A 57-year-old female with recent history of thrombotic thrombocytopenic purpura that was treated with plasmapheresis and a pertinent medical history of diabetes, COPD and is an active smoker. She was evaluated in the pulmonary office for a cavitary lung lesion and was admitted for further workup including bronchoscopy. CT chest was obtained which did reveal a cavitary lesion in the right upper lobe (Figure 1) and atelectasis of the right middle and lower lobe. She then underwent bronchoscopy, which revealed an obstructing mass in the right bronchus intermedius with abnormal changes in the mucosa distal to the mass (Figure 2). Closer examination revealed some bleeding from around the mass. Multiple biopsies were then obtained revealing abundant septate hyphae consistent with aspergillus. Patient was started intravenous voriconazole and subsequently switched to oral on discharge with plans for repeat follow up bronchoscopy in 6 months. DISCUSSION: EBA is a very rare entity and is typically encountered as an incidental finding on bronchoscopy. It is usually defined as a noninvasive type of aspergillosis. An endobronchial mass the aspergilloma can be mistaken for lung cancer and can also sometimes hide an underlying cancer [2,3]. It can be very easily diagnosed with histopathologic examination of endobronchial mass revealing the fungal elements. Review of literature revealed only a handful of published cases and 1 case series reporting EBA. There are no established treatment guidelines or recommendations for EBA [2]. Pulmonary aspergillosis with cavitary lesions in the parenchyma is treated surgically with limited role of systemic antifungal therapy. However EBA the current consensus seems to be bronchoscopic intervention followed by systemic antifungal therapy [2,3]. Short-term follow up bronchoscopy is recommended to evaluate for response to therapy [2]. CONCLUSIONS: EBA is a rare presentation and usually diagnosed incidentally during bronchoscopy. It can occur in immune competent patients with underlying structural lung disease. Much remains to be learned as the optimal treatment and duration of medical therapy is not yet established. Reference #1: Huang, D., Li B., Chu, H., Et al. Endobronchial Aspergilloma: A Case Report and Literature Review. Experimental and Therapeutic Medicine. 2017;14:547-554 Reference #2: Ma, J., Yun, E., Kim, Y., Et al. Endobronchial Aspergilloma: Report of 10 cases and Literature Review. Yonsei Medical Journal. 2011;52(5):787-792 Reference #3: Araujo, D., Figueiredo, M., Monteiro, P. Endobronchial Aspergilloma: An Unusual Presentation of Pulmonary Aspergillosis. Pulmonology. 2016;22(1):61-62 DISCLOSURES: No relevant relationships by Mohammed Ali, source=Web Response No relevant relationships by Humayun Anjum, source=Web Response No relevant relationships by Aisha Mujahid, source=Web Response No relevant relationships by Salim Surani, source=Web Response No relevant relationships by Abhay Vakil, source=Web Response

Impact of Safe Distance on Long-Term Outcome After Surgical Therapy of Alveolar Echinococcosis.

In humans, alveolar echinococcosis (AE) is a serious helminthic disease. Additionally to a long-term medical treatment, in all suitable cases a complete surgical resection with a 20-mm safe distance (minimal distance of larval tissue to resection margin) is recommended. We analyzed the influence of the safe distance and the effect of the postoperative anthelmintic prophylaxis on the long-term outcome of patients who underwent surgery with curative intent. Ninety-two operated patients were evaluated regarding the safe distance, the duration of medical therapy with benzimidazole derivates, and the further course of AE. Median follow-up after surgical procedure was 8.3years. Twelve patients had a safe distance of 20mm or more, 16 patients between 10 and 19mm, 21 patients between 1 and 10mm, and 10 patients 1mm. In a further 33 patients, the affected liver was resected without any safe distance. Recurrence of AE was seen in 15 patients between 4months and 24years after initial operation. Safe distances of patients with recurrent disease were: 13× no safe distance, one patient with 1-mm and one patient with 13-mm safe distance. In all patients except one with recurrent AE, postoperative therapy with benzimidazole derivates was stopped. A safe distance of at least 1mm in combination with medical anthelmintic treatment continuing for two years might offer a good chance of being disease-free long term, but the exact period of medical treatment needed is not defined. The therapy regime should be determined through an interdisciplinary approach in specialized centers.

Response: "Commentary: Peripartum Cardiomyopathy in Intensive Care Unit: An Update".

We are very glad that our work got the attention of Dr. Biteker, and we wish to thank him for mentioning PPCM definition by ESC. According to workshop recommendations of National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) “peripartum cardiomyopathy is defined on the basis of 4 criteria, adopted from work by Demakis et al. (1, 2) which include the development of the disease in the last month of pregnancy or within 5 months of delivery; absence of an identifiable cause of heart failure; absence of recognizable heart disease prior to the last month of pregnancy and LV systolic dysfunction demonstrated by classical echocardiographic criteria” (3). Time period from 1 month before delivery and 5 months after delivery was emphasized as an exclusion factor for other, previously undiagnosed or preexisting types of cardiomyopathies, which can be unmasked by hemodynamic changes during pregnancy. U.S. National Library of Medicine still supports this definition of PPCM (4). Unfortunately, at this moment, there is no consensus about the definition of PPCM in scientific community, and we think that both definitions of PPCM are equally acceptable. Considering echocardiography, we think that echocardiographic cutoff should not always lead to underdiagnosis, especially not in cases of latent forms of PPCM without clinical symptoms. Currently, there is no consensus on the appropriate duration of medical therapy in PPCM. No recommendations can be made because only limited prospective long-term data are available. We appreciate data provided by Biteker et al. Regarding levosimendan, there are case reports (5, 6) about its successful use in PPCM. The study by Biteker et al. definitely provides additional data on the value of levosimendan in the treatment of PPCM. Contrary to the case reports that we cited (5, 6) this study did not show any benefit from levosimendan. This study was though labeled as “small sample size, single center experience, open label design” by Desplantie et al. (7). We believe that one study cannot prove or disapprove the value of levosimendan in PPCM and that more research is necessary.

Impact of treatment satisfaction on quality of life of patients with acromegaly

To evaluate satisfaction of acromegalic subjects with their medical treatment and its contribution to their quality of life. This cross-sectional study included a total of 159 medications used in 133 subjects with acromegaly (controlled n = 84 and uncontrolled n = 49, female/male: 81/52). Subjects were asked to complete questionnaires on symptoms of depression (BDI) and satisfaction with the medical therapy they received for acromegaly (TSQM). Acromegaly cases also completed Acromegaly Quality of Life Questionnaire (AcroQoL). Subjects on pegvisomant therapy scored lower on convenience (p = 0.007). Cases on combination therapy had lower domain scores for effectiveness, convenience and global satisfaction in comparison to the cases on monotherapy (p = 0.01, p = 0.01 and p = 0.01, respectively). The time elapsed since diagnosis and the duration of medical therapy were positively correlated with effectiveness score (r = 0.2, p = 0.007 and r = 0.2, p = 0.04, respectively). The AcroQoL score was positively correlated with all domains of TSQM (for effectiveness r = 0.2, p = 0.01; for side effects r = 0.3, p = 0.001; for convenience r = 0.3, p = 0.004 and for global satisfaction r = 0.2, p = 0.01). In contrast, the BDI score was inversely correlated with all domains of TSQM (for effectiveness r = -0.3, p = 0.001; for side effects r = -0.2, p = 0.006; for convenience r = -0.3, p < 0.001 and for global satisfaction r = -0.3, p = 0.001). In acromegaly, quality of life, status of depression and satisfaction of the subjects with their treatment are intercorrelated.

Pituitary tumors in childhood

This review focuses on recently published literature on pituitary tumors in children with special focus on craniopharyngioma and prolactinoma. Although most pituitary masses are benign neoplasms, they are associated with high morbidity and mortality related to their proximity to vital neurologic structures including the optic chiasm, hypophysis and hypothalamus, resulting in disruption of pituitary hormone secretion. The role of Wingless/β-beta catenin signaling and aryl hydrocarbon receptor-interacting protein mutations in pituitary tumor formation has been recognized. There is general agreement on optimal treatment of prolactinomas, although duration of medical therapy in children deserves more specific attention. Advances in imaging, medical, surgical and radiotherapy techniques have greatly increased survival rates for all pituitary tumors, but high recurrence rates after attempted complete resection and high progression rates after incomplete resection of craniopharyngioma remain troublesome. Long-term morbidity and late mortality of all pituitary tumors have become better appreciated with recent focus placed on severe obesity. A trend toward a more multidisciplinary approach for craniopharyngioma, including radiotherapy and chemotherapy, particularly when tumor burden involves the hypothalamus, continues. A vast amount of literature has been recently published, focusing on the management and long-term sequelae of all pituitary tumors in children. Craniopharyngioma remains the most challenging mass arising within sellar and parasellar areas, and optimal treatment continues to be hotly debated. Recognizing the rarity of pediatric pituitary tumors, the field would greatly benefit from more prospective multicenter trials, as well as from standardization of the assessment of preoperative function and post-treatment outcomes.

Aftercare in patients with Cushing’s disease and acromegaly: is there room for improvement?

Evaluation of aftercare, medical therapy and remission rate for Cushing's disease (CD) and acromegaly (AC). Fifty-eight CD and 83 AC patients operated on over 10 years were carefully evaluated. The patients received a disease-related questionnaire and were invited for a follow-up at the outpatient clinic of the Department of Neurosurgery. Thirty-three CD and 52 AC patients returned the questionnaire; 25 CD and 37 AC patients participated personally. CD patients underwent a dexamethasone suppression test, and IGF-1 levels were assessed in AC patients. Data on postoperative therapy were assessed. 84.8% of those with CD and 75.0% of those with AC had been followed by endocrinologists; 9.1% of CD and 1.9% of AC patients had been under no aftercare; 96% of CD patients were in remission. A recurrence occurred in four patients, two were newly detected by our study. IGF-1 was postoperatively normalized in 25 of 37 AC patients (67.6%). Twenty patients remained in remission, five relapsed. One patient received medical therapy upon recurrence and presented normal IGF-1; four patients with relapse had not been treated yet. Ten of 12 patients with elevated early postoperative IGF-1 received medical therapy that was commenced within 6 months in nine cases. The mean duration of medical therapy was 36 months (range 2-92). IGF-1 was still elevated at the last follow-up in eight of these ten patients, all of them receiving monotherapy. In four patients, the dose had been increased once. The postoperative transfer back to the endocrinologist after operative treatment is achieved well in both groups. In uncured AC, medical therapy is initiated early, but options of therapy offer room for improvement. Therapy of recurrence is delayed in both pathologies.

Pharmacotherapy in pediatric obesity: Current agents and future directions

Childhood obesity is emerging as a major public health threat, with adverse implications on the health of individuals and long-term costs to society. Family-based lifestyle interventions with behavioral modification, diet and exercise form the mainstay of treatment. Pharmacologic treatment may be considered in selected subjects, especially in the presence of significant and severe comorbidities, when lifestyle intervention has failed to achieve weight reduction. Orlistat and sibutramine are FDA-approved for treatment of pediatric obesity; metformin may be considered in the presence of clinically significant insulin resistance. Evidence is lacking on the appropriate duration of medical therapy and optimal combination with lifestyle intervention. Lack of coverage of medications by insurance and high out-of-pocket costs may be limiting factors to some families. Adverse effects necessitate careful monitoring and may lead to discontinuation of medication. Pharmacologic agents with novel mechanisms of action offer hope of improved efficacy, tolerability and safety.

Retropharyngeal Abscess in Children: 10-Year Study

Retrospective analysis of all patients treated for retropharyngeal infection in a tertiary care pediatric hospital. Charts were reviewed for demographic data, duration of symptoms, radiologic workup, antibiotic choice, microbiologic findings, surgical approach, complications, and duration of medical therapy. Surgical findings were correlated with computed tomographic (CT) scans. Sixty-eight patients were included in the study. Empirical intravenous clindamycin was started for a trial of conservative medical therapy. Fifty-one patients (75%) responded to medical treatment, and only 17 patients (25%) required surgical intervention. The CT scan showed a sensitivity of 43% and a specificity of 63% in this series. None of the patients with retropharyngeal infection died, had a major complication, or had a recurrence. Based on the current study, we propose that all patients should be given a trial of medical treatment with intravenous clindamycin. Surgery should be reserved for those who do not respond. An extensive review of the literature is presented.

Surgical management of retropharyngeal space infections in children.

To study the perioperative management strategies in a large group of pediatric patients undergoing surgical therapy for suppurative adenitis of the parapharyngeal and retropharyngeal spaces. Retrospective analysis of all patients treated surgically from January 1, 1989, to December 31, 1998, in a tertiary care pediatric hospital. Charts were reviewed for demographic data, duration and nature of symptoms, radiological workup, surgical approach, complications, duration of medical therapy and antibiotic choice, and bacteriological findings. Computed tomography (CT) results were correlated to surgical findings. A dramatic increase in the incidence of deep neck space infection was seen during the study period; this increase was congruent with the increase in culture-positive group A beta-hemolytic streptococcal abscesses. More than two-thirds of the patients were boys with the peak incidence being in the 3- to 5-year-old group. The duration of symptoms before presentation was less than might be expected, especially in the younger age groups. Seventy of 73 children were treated with a transoral approach. Sixty-eight of 73 were successfully treated with one operative intervention. Irregularity of the abscess wall was found to be a stronger predictor of the presence of pus than the presence of ring enhancement. The current study represents the largest series of pediatric retropharyngeal abscesses in the modern medical literature. Changes in the disease process and in management from the first half of the century to today are reviewed, and recommendations for optimal management presented. The data in this series support a transoral approach to these abscesses unless there is extension lateral to the great vessels.

Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy during a one-year follow-up: Relation to the clinical course of disease

In idiopathic dilated cardiomyopathy (IDC), an impaired left ventricular filling as assessed by the Doppler echocardiographic mitral flow pattem is closely related to the severity of congestive heart failure. This study examined the relation of left ventricular filling and the clinical course of the disease in patients with a recent diagnostic procedure and initiation of medical therapy (group 1, n = 15) as compared with patients in a chronic stage of the disease (group 2, n = 24) with the diagnosis established >1 year before. All patients had to be in sinus rhythm to facilitate the Doppler echocardiographic evaluation of left ventricular filling. The clinical status was assessed by the New York Heart Association classification and a heart failure score at baseline and after a period of 12 ± 7 months. At baseline the ratio of the peak early/atrial Doppler velocities ( V E V A ) was shifted toward the early diastole in group 1 as compared to group 2 (1.84 ± 1.02 vs 1.12 ± 0.55; p < 0.05). Symptoms of heart failure were more severe in group 1. During follow-up, V E V A tended to decrease in group 1 from 1.84 ± 1.02 to 1.35 ± 1.03 ( p = 0.07) and remained unchanged in group 2 (1.12 ± 0.55 and 1.34 ± 1.23; not significant). In a subgroup of 10 patients who underwent repeat right heart catheterization, the decrease of V E V A coincided with a decrease of the pulmonary capillary wedge pressure. The changes of the clinical symptoms and the left ventricular filling parameters during follow-up were concordant with a decrease of V E V A in case of a clinical improvement and an increase of V E V A when the clinical course deteriorated. medical therapy was comparable in both groups; however, duration of medical therapy was shorter in group 1. The serial evaluation of patients with IDC showed a close association between the distribution of left ventricular filling in early and late diastole and the clinical course of the disease. Doppler echocardiography may serve as a tool for the monitoring of the beneficial effects of long-term medical therapy on left ventricular diastolic function in these patients.