Follow-up Status Research Articles

Efficacy and safety with the use of Antibiotic-impregnated Poly-methyl methacrylate (AI-PMMA) for thoracolumbar spinal reconstruction in pyogenic Spondylodiscitis: Retrospective cohort study

BackgroundSurgical treatment of spinal osteomyelitis and discitis remains challenging due to the risk of implant colonization. We sought to demonstrate the safety and efficacy of using antibiotic-impregnated poly-methyl methacrylate (AI-PMMA) in spinal reconstruction for pyogenic spondylodiscitis. MethodWe retrospectively analyzed prospective data on consecutive patients who underwent AI-PMMA interbody fusion for thoracolumbar pyogenic spondylodiscitis from December 2011 to October 2016 at a single institution with multiple surgeons. We included consecutive patients who underwent AI-PMMA spinal reconstruction and fusion and were older than 18 years of age. All patients were included in the analysis regardless of their follow-up status who had previous spine surgery in the same area were excluded. Vancomycin powder was mixed with PMMA and tobramycin. The AIPMMA was introduced into the disc space as 5–10 mm beads, then contoured to fit. The primary outcome was fusion using CT or X-ray. Secondary outcomes were recurrent infection, PMMA-related complications, and VAS results. Descriptive statistics and univariate analyses were used. ResultsSixty-two patients were included in the study. The mean follow-up interval was 18.6 months (3–66 months). Sixty-six AI-PMMA levels demonstrated a fusion rate of 100% (95% CI: 94.9%–100%). There was no cement extravasation or embolism. One patient (1.6%) developed a recurrent infection at the same level requiring revision surgery. Five patients (8%) died on long-term follow-up due to non-PMMA/infection-related causes. VAS back showed significant improvement in pain (7.8 vs. 3.5; 95% CI 2.8–5.8; p = 0.00). ConclusionWe demonstrated that the application of AI-PMMA for spinal reconstruction in pyogenic spondylodiscitis is safe and efficacious. The study is limited by its retrospective design. Prospective studies are warranted.

A Comparison of In-flight and Ground-Based Emergency Medical Events on the Clinical Demand for Outreach Medical Services at Taoyuan International Airport, Taiwan.

Background: Limited information is available covering all medical events managed by the airport-based outreach medical service. This study explores the clinical demand for emergency medical outreach services at Taoyuan International Airport (TIA), Taiwan.Methods: Electronic medical records collected from TIA medical outreach services from 2017 to 2018, included passengers' profiles, flight information, events location, chief complaints, diagnosis (using ICD-9 -CM codes), and management outcomes. Medical events distribution was stratified by location and ages, and were compared statistically.Results: Among 1,501 eligible records, there were 81.8% ground-based emergency medical events (GBME), 16.9% in-flight medical events (IFME) managed after scheduled landing, and 1.3% IFME leading to unscheduled diversion or re-entry to TIA. The top three GBME diagnoses were associated with neurological (23.3%), gastrointestinal (21.2%), and trauma-related (19.3%) conditions. The top three IFME diagnosis that prompted unscheduled landings via flight diversion or re-entry were neurological (47.4%), psychological (15.8%), and cardiovascular (10.5%). The chief complaints that prompted unscheduled landings were mostly related to neurological (42.1%), cardiovascular (26.3%), and out-of-hospital cardiac arrest (OHCA) (10.5%) symptoms. A higher frequency of IFME events due to dermatologic causes in patients aged ≤ 18 years compared with adults and older adults (19 vs. 1.5% and 0, respectively); and a higher frequency of IFME due to cardiovascular causes in adults ≥ 65 years compared with patients aged ≤ 65 (15.1 vs. 9%). Among all IFME patients, six out-of-hospital deaths occurred among passengers from scheduled landings and two deaths occurred among 18 IFME passengers who were transferred to local hospitals from flight diversion or re-entry. A statistically significant difference in outcomes and short-term follow-up status was found between patients with IFME and those with GBME (p < 0.001).Conclusion: Ground-based emergency medical events exceeded in-flight medical events at TIA. The most frequent events were related to neurological, gastrointestinal symptoms, or trauma. Results of this study may provide useful information for training medical outreach staff and preparing medical supplies to meet the clinical demand for airport medical outreach services.

Neurocognitive Assessments Are More Important Among Adolescents Than Adults for Predicting Psychosis in Clinical High Risk

BackgroundFew studies have examined the effects of age on neurocognition to predict conversion to psychosis in individuals at clinical high risk (CHR). This study aimed to compare the extent and predictive performance of cognitive deficits between adolescents and adults at CHR. MethodsA comprehensive neuropsychological battery was performed on 325 CHR individuals and 365 healthy control (HC) subjects. The subjects were first divided into 189 CHR adolescents (age 12−17 years), 136 CHR adults (age 18−45 years), 88 HC adolescents, and 277 HC adults. CHR subjects were then divided into converters (CHR-Cs) (adolescents, n = 43; adults, n = 34) and nonconverters (CHR-NCs) (adolescents, n = 146; adults, n = 102) based on their 2-year follow-up clinical status. ResultsThe adolescents and adults at CHR performed significantly worse than their control groups on all neurocognitive tests, except for performance on the continuous performance test in adolescents. In the comparison between adolescents and adults, patterns of neurocognitive deficits seemed to vary in HC subjects rather than in CHR subjects. In the comparison between CHR and HC subjects, the rank order of effect sizes across the neurocognitive tests was similar for the top two tests of symbol coding and verbal learning. Comparison between CHR-Cs and CHR-NCs revealed that adolescent CHR-Cs performed significantly worse than CHR-NCs on seven of eight neurocognitive tests; however, adult CHR-Cs performed significantly worse than CHR-NCs only in the visuospatial memory test. ConclusionsThe role of neurocognitive dysfunction may have different patterns and weights during the onset of psychosis in adolescents and adults at CHR, implicating the development of specific strategies that could monitor and improve cognitive function in CHR adolescents.

Pretreatment Neutrophil-to-Lymphocyte Ratio: A Prognostic Biomarker of Survival in Patients With Epithelial Ovarian Cancer.

BackgroundInflammation is pathognomonic of all stages of tumor formation, and therefore, there is renewed interest in systemic inflammatory response (SIR) markers including haematological inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR) as prognostic predictors in several cancers.AimThis study was aimed to investigate the effect of pretreatment peripheral blood NLR on the survival prognosis of patients with epithelial ovarian cancer (EOC).MethodsWe identified 93 patients with a complete clinical record from a cohort of 155 patients who received treatment for EOC between 2009 and 2018. Patients’ sociodemographic and clinicopathologic characteristics, and updated three-year follow-up status were extracted from medical records. Pretreatment peripheral blood NLR was calculated by dividing the neutrophil count by the lymphocyte count. We employed the receiver operating characteristic (ROC) curve to identify the optimal cut-off value of the NLR in estimating progression-free survival (PFS) and overall survival (OS). The PFS and OS were assessed using the Kaplan-Meier method, and survival differences were compared using the Log Rank (Mantel-Cox) test. Independent prognostic predictors were determined using Cox regression analysis.ResultsAccording to the ROC curves, the optimal cut-off values for the NLR were 2.23 and 1.93 for PFS and OS, respectively. A high NLR was associated with poor PFS (P = 0.033) and OS (P = 0.013) in the univariate analyses. In the multivariate analyses, a high NLR was still an independent predictor of OS (hazard ratio [HR] = 2.23; 95% CI, 1.08 to 4.61) but not PFS (hazard ratio [HR] = 2.43; 95% CI, 0.95 to 6.27).ConclusionThe NLR at an optimum cut-off value of 1.93 is an independent prognostic predictor of OS in patients with EOC.

Error characteristic analysis of fiber optic current transformer with sine modulation

The optoelectronic circuit and modulation circuit of the fiber optic current transformer (FOCT) are easily affected by the complex environment in the converter station during operation, leading to abnormal operation and fault warning. In order to analyze the error characteristic on the output signal and harmonics of FOCT, the output signal models of FOCT with sine modulation in steady-state and error-state are established respectively in this paper. Combined with the output signal, the key parameters are solved, and it is pointed out that the change of photoelectric circuit may cause the ratio error. The Faraday phase shift and the change of the modulation circuit may cause the drift error. The error characteristics of the FOCT under different influencing factors are simulated and analyzed. The results show that output signal of FOCT is influenced by photoelectric circuit, Faraday phase shift circuit and modulation circuit. Changes in the photoelectric circuit will cause a proportional change in the FOCT output signal and harmonics. Both the Faraday phase-shifting and the increasing of modulation amplitude will reduce the minimum value of output signal. Changes in Faraday phase shift will cause an approximately proportional change in first harmonic. Changes in modulation signal amplitude will cause the harmonics to appear attenuate and oscillate. The modulation frequency is inversely proportional to the period of the output signal and harmonics. Both the first and second harmonics can be used as the monitoring state parameters of fault determination. Designed experiment verified the correctness of the conjecture. This article provides a theoretical basis for the follow-up status monitoring and fault diagnosis of FOCT.

A Study Demographic, Histopathological Patterns and Clinical Profile of Oral Squamous Cell Carcinoma in East Java, Indonesia: A Hospital-Based Study

Background. Cancer remains a health problem in the world. Estimated 12,7 million new case and 7,6 deaths cause of cancer each year. Oral carcinoma is one of head and neck carcinoma. Oral carcinoma is 6th the most cancer in the world and 90% of the cases are squamous cell carcinoma. The purpose of this research is to study the clinic-epidemiological profile among Indonesian patients associated with oral cancer cases managed in Head and Neck Surgery Unit of Dr Soetomo General Hospital between January 2013- December 2016.Methods. Records of 116 cases were reviewed for clinical details, histopathological data, and follow-up status. Study variables included demographic factor, modifiable risk factors such as tobacco usage and alcohol consumption, site involved, staging, histopathological result, and treatment modalities. Data was presented in form of percentages and proportions.Results. Out of the total 116 cases, majority of the subjects were above 40 years old. Twenty-two (22%) of subjects were young adult (below 40 years old). Seventy-seven subjects (77 %) were male. It was observed that 16 cases (21%) of male subjects was a smoker before they had disease. No female subject consumed tobacco in all form or drinking alcohol. The most common site involved was tongue, followed by lower ginggivo-buccal complex. Histopathologically, 110 cases (95%) was well-differentiated squamous cell carcinoma. Most of the cases (88.8 %) were in advanced stage (stage III or IV) and were treated with surgery followed by adjuvant therapy.Conclusions. The most common site for oral cancer was tongue and majority of the cases were well-differentiated squamous cancer presented in advanced stage of disease. We observed that alcohol consumption and smoking did not have any role in causing oral cancer in women, therefore further study needed to evaluate other possible factors such as diet pattern and oral hygiene. Cigarette smoking might be the cause of oral cancer in male patients.

Combined Clinical and Gene Expression Score Identifies Follicular Lymphoma Patients with High Risk of Transformation in the Rituximab Era

Background: Follicular lymphoma (FL) is usually an indolent malignant B-cell lymphoma with median survival now approaching 20 years in the rituximab treatment era. However, at an annual rate of 2-3%, FL patients experience transformation to Diffuse Large B-cell Lymphoma (DLBCL) with inferior survival. Early identification of patients with high risk of transformation would open the possibility of tailored treatment. We recently developed a statistical method inspired by the Copy Number and Expression in Cancer (CONEXIC) algorithm (Akavia et al, Cell 2010) to identify putative drivers in cancer by integration of DNA copy number, mRNA gene expression and prior knowledge of protein network interactions in FL (Brodtkorb et al, Blood 2014). This method identified six copy number driven genes that are upstream regulators of NF-κB, and their corresponding gene signature scores were predictive of transformation in the pre-rituximab treatment era. Here, we further developed this analysis to rituximab treated FL patients.Material and Methods: We performed a network-based integrative analysis of 168 FL biopsies from 127 patients with long clinical follow-up and transformation status from two cohorts. Cohort I included 44 patients diagnosed with FL and who were mainly treated prior to the introduction of rituximab. Cohort I was selected for transformation cases in particular, and 61% of these patients transformed during a median follow-up of 88 months (range 10-294) (Eide et al, Blood, 2010; Brodtkorb et al, Blood, 2014). Cohort II consisted of 83 patients diagnosed with FL and included in two prospective clinical trials with rituximab with or without interferon α in first line (Kimby et al., Leukemia Lymphoma, 2008 and 2015). During follow-up with median observation time of 129 months (range 6-312), 22 of the patients in Cohort II (27%) experienced transformation to more aggressive disease. Both cohorts had available DNA copy number profiles (array CGH, Affymetrix SNP6.0) and gene expression profiles (Affymetrix Gene Chip HGU 133 Plus 2.0) from FL biopsies: 75 in Cohort I, and 93 in Cohort II. In Cohort II, 85 biopsies were sampled before start of rituximab treatment, and eight were sampled at relapse, before new treatment was administered. Gene signatures were first analyzed by calculating the gene signature scores as described in Brodtkorb et al. (Blood, 2014) and testing for association to transformation. We subsequently extended the analysis by calculating the principal components of the gene signatures. All biopsies were included in the analyzes, also when the same patient had several biopsies. Survival analysis (Kaplan-Meier plots) was performed in Cohort II, keeping the earliest high-score biopsy for cases with serial biopsies, and using a Log-rank test to assess the significance.Results: Integrative analysis of copy number and gene expression data from the 168 biopsies revealed a consistent pattern of copy number driven gene expression alterations in the two independent treatment cohorts. A set of NF-κB related gene expression scores previously found to predict transformation in Cohort I also predicted transformation in patients treated with rituximab (Cohort II). We found a shift in expression towards DLBCL for FL biopsies from patients with subsequent transformation, and this shift could be detected years before transformation. Combining a gene expression score with clinical parameters, we were able to identify a subgroup of patients (16%) with short time to transformation (P=0.000003), as well as short time to new treatment for relapse after rituximab without chemotherapy in first line (P=0.00434). The median time to new treatment was 22.7 months (95% CI: 14.3-42.6) in the high-risk group versus 70.9 months (95% CI: 41.5-95.0) for the rest of the patients.Conclusion: Integrative analysis identified molecular markers for transformation risk and a gene expression score predicted transformation in FL-patients treated with rituximab in first line.Combination of an expression marker with clinical features improved the early identification of FL patients with high risk of transformation and risk of relapse. DisclosuresKimby:Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Research Funding; Pfizer: Research Funding. Holte:Oslo University Hospital: Employment; Nordic Nanovector: Consultancy; Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees.

Survivors of Congenital Diaphragmatic Hernia Repair Face Barriers to Long-Term Follow-Up Care

Congenital diaphragmatic hernia (CDH) carries high morbidity and mortality, and survivors commonly have neurodevelopmental, gastrointestinal, and pulmonary sequela requiring multidisciplinary care well beyond repair. We predict that following hospitalization for repair, CDH survivors face many barriers to receiving future medical care. A retrospective review was conducted of all living CDH patients between ages 0 to 12 years who underwent repair at Riley Hospital for Children (RHC) from 2010 through 2019. Follow-up status with specialty providers was reviewed, and all eligible families were contacted to complete a survey regarding various aspects of their child's care, including functional status, quality of life, and barriers to care. Bivariate analysis was applied to patient data (P < 0.05 was significant) and survey responses were analyzed qualitatively. After exclusions, 70 survivors were contacted. Thirty-three (47%) were deemed lost to follow up to specialist providers, and were similar to those who maintained follow-up with respect to defect severity type (A-D, P=0.57), ECMO use (P=0.35), number of affected organ systems (P=0.36), and number of providers following after discharge (P=0.33). Seventeen (24%) families completed the survey, of whom eight (47%) were deemed lost to follow up to specialist providers. Families reported distance and time constraints, access to CDH-specific information and care, access to CDH-specific resources, and access to healthcare as significant barriers to care. All respondents were interested in a multidisciplinary CDH clinic. CDH survivors require multidisciplinary care beyond initial repair, but attrition to follow-up after discharge is high. A multidisciplinary CDH clinic may address caregivers' perceived barriers.

Plasmacytoma and plasma cell myeloma affecting the jaws: A multi-institutional collaborative study.

Plasma cell neoplasms are characterized by the proliferation of a single clone of plasma cells with production of a monoclonal immunoglobulin. They can manifest as a single lesion (plasmacytoma) or as multiple lesions (multiple myeloma). Paraffin-embedded tissue blocks of patients microscopically diagnosed with plasma cell neoplasms in the jaws were retrieved from five pathology files. Data including clinical, radiographic, microscopic and immunohistochemical findings, treatment employed and follow-up status were retrieved from the pathology reports. Fifty-two cases were retrieved (mean age: 59.4years) without sex predilection. The mandible was the most affected site (67.3%), usually associated with pain and/or paresthesia (53.8%). Lesions in other bones besides the jaws were reported for 24 patients (46.2%). Radiographically, tumours usually presented as poorly defined osteolytic lesions with unilocular or multilocular images, while microscopy revealed diffuse proliferation of neoplastic plasma cells with nuclear displacement and abundant eosinophilic cytoplasm. Two cases were classified as anaplastic, and amyloid deposits were found in two other cases. Immunohistochemistry was positive for plasma cell markers and negative for CD20 and CD3, and monoclonality for kappa light chain predominated. The overall survival rate after 5years of follow-up was 26.6%. Plasma cell neoplasms are aggressive tumours with a poor prognosis and involvement of the jaws may be the first complaint of the patient. Thus, oral pathologists, head and neck surgeons and dentists should be aware of their clinical, radiographic and microscopic manifestations.

Free-floating thrombus of the aorta: 3 case reports

BackgroundIdiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences. The initial symptoms are typically cerebral or peripheral embolisms. Surgical thrombectomy and thrombolysis are two primary treatments for FFT. Here, we report three cases of patients with idiopathic FFT in the absence of coagulopathy who were treated successfully by surgery with no recurrent thrombi or relapse of symptoms.Case presentationCase 1 involved a 72-year-old male patient with a pedunculated thrombus in the distal aortic arch. Case 2 involved a 62-year-old female patient with a cylinder thrombus in the aortic arch and left common carotid artery. Case 3 involved a 65-year-old male patient with three pedunculated thrombi in the ascending aorta, aortic arch, and left subclavian artery. None of the patients had clinical signs of coagulopathy. Pedunculated or cylinder thrombi have a greater risk of breaking off, which can produce severe peripheral embolism in contrast with intramural thrombi (73% vs. 12%). Due to the high embolism risk for each patient, conservative medical treatment by heparinization was deemed inappropriate, so each patient underwent emergency surgical thrombus removal. After surgery, each of the three patients was treated with warfarin for secondary prevention of thromboembolism. At 7-month follow-up in outpatient practice, a computed tomography (CT) scan indicated that Patient 1 had no recurrent thrombus, and the patient has been symptom-free for 11 months. At 1-month follow-up in outpatient practice, a CT scan indicated that Patient 2 had no recurrent thrombus, and the patient has been symptom-free for 8 years. At 3-week follow-up in hospital, a CT scan indicated that Patient 3 had no recurrent thrombus, but he failed to follow-up after discharge, so his follow-up status is unknown.ConclusionsFor a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed. And, in surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus. After surgery, anticoagulant is important to prevent recurrent idiopathic thrombi.

Association between thromboembolic and bleeding risk with adverse outcomes in contemporary European atrial fibrillation patients: final analysis from the ESC-EHRA EORP AF general long-term registry

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The ESC-EHRA EORP AF General Long-Term Registry provides a contemporary snapshot of European atrial fibrillation (AF) patients’ characteristics and management. Aims: We present data about the final 2-years follow-up observation of AF patients enrolled in the ESC-EHRA EORP AF General Long-Term Registry. Methods A contemporary evaluation of residual risk of adverse outcomes in a cohort of largely anticoagulated AF patients according to the baseline thromboembolic and bleeding risk, defined according to CHA2DS2-VASc and HAS-BLED scores. We determined cardiovascular (CV) events, CV death and all-cause death as outcomes. Results Among the original 11069 patients enrolled, 8409 (76.0%) patients had available follow-up status at the end of the 2-years follow-up. Patients age, female sex and most comorbidities were progressively more prevalent across the spectrum of thromboembolic and bleeding risk. Data on adverse outcomes were available for 10087 (91.1%), over the 2-year observation period. Outcome rates were progressively higher across CHA2DS2-VASc and HAS-BLED scores (all p &amp;lt; 0.0001). A fully adjusted Cox multivariable regression analysis, adjusted for clinical covariates selected by a univariate procedure and not included in the scores, showed that increasing baseline CHA2DS2-VASc score was associated with an higher risk for CV events (hazard ratio [HR]: 1.25, 95% confidence interval [CI]: 1.21-1.30), CV death (HR: 1.31, 95%CI: 1.25-1.38) and all-cause death (HR: 1.30, 95%CI: 1.25-1.36). Similarly, increasing baseline HAS-BLED score was associated with an increased risk for all 3 outcomes (HR: 1.21, 95%CI: 1.13-1.28; HR: 1.24, 95%CI: 1.14-1.34; HR: 1.22, 95%CI: 1.14-1.31, respectively). An association with a progressively higher risk was found for all outcomes across the spectrum of thromboembolic and bleeding risk [Figure]. Both CHA2DS2-VASc and HAS-BLED scores showed a modest to good predictive ability for cardiovascular (CV) events, CV death and all-cause death, in terms of c-index and 95% CI[0.66 (0.64-0.68) and 0.62 (0.61-0.64), 0.70 (0.68-0.72) and 0.65 (0.63-0.67), 0.69 (0.68-0.71) and 0.64 (0.63-0.66) for CHA2DS2-VASc and HAS-BLED for each outcome respectively. Conclusions In this large contemporary European-wide cohort of AF patients, both baseline thromboembolic and bleeding risks were associated to an increased risk of major clinical outcomes. Both scores are reflective of high risk clinical states, and are predictive of major adverse outcomes even in a large cohort of largely anticoagulated patients with a lower residual risk of adverse outcomes. Abstract Figure.

Primary breast lymphoma (PBL) in men — a systematic review

Primary breast lymphoma (PBL) is a rare type of lymphoma, especially in men. Details of the clinical course are not well recognized, and a consensus on the treatment of PBL in male is not available. The objective of presenting this study was to find the most common presentation and the best treatment options for male PBL by collecting and analysing data of all reported cases published between 1985 and 2019. A comprehensive search in Google Scholar, Ovid Medline, PubMed, and Scopus databases for any case of PBL presenting in men between 1985 and 2019 was performed. Patient information such as age, diagnosis, type of treatment(s), time to follow-up and patient status were recorded. A total of 28 studies containing data of 34 male patients with PBL were included in this review. The mean age of patients was about 61 (range: 26–85) years. The mean tumour size was 46.05 ± 20.37 mm. The majority of cases were presented with a palpable breast mass (unilateral or bilateral). Nine patients (26.5%) had previous comorbidities. Diffuse large B cell lymphoma was the most common histologic diagnosis (85.3%). Treatment consisting of systematic therapy combined with radiotherapy showed benefit outcome. The results of the analysis showed that the response to different therapies was better in younger patients with PBL. It seems that systemic therapy combined with at least a 30 Gy dose of radiation has the best outcome in male patients with PBL. Considering limited data in each group of treatment modality, further follow-up studies in these patients are necessary.

Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms.

Wide-necked bifurcation aneurysms remain a challenge for endovascular surgeons. Dual-stent-assisted coiling techniques have been defined to treat bifurcation aneurysms with a complex neck morphology. However, there are still concerns about the safety of dual-stenting procedures. Stent plus balloon-assisted coiling is a recently described endovascular technique that enables the coiling of wide-necked complex bifurcation aneurysms by implanting only a single stent. To investigate the feasibility, efficacy, safety, and durability of this technique for the treatment of wide-necked bifurcation aneurysms. A retrospective review was performed of patients with wide-necked intracranial bifurcation aneurysms treated with stent plus balloon-assisted coiling. The initial and follow-up clinical and angiographic outcomes were assessed. Preprocedural and follow-up clinical statuses were assessed using modified Rankin scale. A total of 61 patients (mean age: 54.6± 10.4 yr) were included in the study. The immediate postprocedural digital subtraction angiography revealed complete aneurysm occlusion in 86.9% of the cases. A periprocedural complication developed in 11.5% of the cases. We observed a delayed ischemic complication in 4.9%. There was no mortality in this study. The permanent morbidity rate was 3.3%. The follow-up angiography was performed in 55 of 61 patients (90.1%) (the mean follow-up period was 25.5± 27.3 mo). The rate of complete aneurysm occlusion at the final angiographic follow-up was 89.1%. The retreatment rate was 1.8%. The results of this study showed that stent plus balloon-assisted coiling is a feasible, effective, and relatively safe endovascular technique for the treatment of wide-necked bifurcation aneurysms located in the posterior and anterior circulation.

Robotic transoral approach for salvage retropharyngeal node dissection: an analysis of functional and oncological outcomes.

Presence of metastatic tumour in the retropharyngeal node has a negative impact on the prognosis. We present here our 5-year experience and the outcomes of transoral robotic retropharyngeal node dissection (RPND) in salvage settings. Hospital database was accessed to extract details of patients with head and neck cancer who developed retropharyngeal (RP) node metastasis. Patients who underwent transoral robotic surgery (TORS) for RPND in salvage settings were included for the study. Patients were first followed-up after 10days of discharge and then on a monthly basis after completion of treatment. At each follow-up, swallow functions and disease status were recorded. A total of 10 patients met the inclusion criteria and underwent salvage transoral robotic RPND. The total number of lymph nodes removed from these patients were 11, with all having malignant tumour deposits. The median follow-up was 20months. Four patients developed distant metastasis. There were no major procedure-related complications. Our experience suggests that TORS as treatment modality is oncologically sound and feasible for salvage RP node dissection.Level of evidence Retrospective Study (3).

The emerging plasma biomarker Dickkopf-3 (DKK3) and its association with renal and cardiovascular disease in the general population

Dickkopf-3 (DKK3) is an emerging biomarker for cardiovascular disease (CVD) and chronic kidney disease (CKD). Herein, baseline DKK3 plasma levels were measured in 8420 subjects from the Prevention of Renal and Vascular ENd-stage Disease (PREVEND) cohort, a large general population cohort, using enzyme-linked immunosorbent assays. Associations with clinical variables and outcomes were analysed. Median DKK3 level was 32.8 ng/ml (28.0–39.0). In multivariable linear regression analysis, the strongest correlates for plasma DKK3 were age, body mass index and estimated glomerular filtration rate (eGFR). At baseline, 564 (6.7%) subjects had CVD (defined as a myocardial infarction and/or cerebrovascular accident) and 1361 (16.2%) subjects had CKD (defined as eGFR < 60 ml/min/1.73m2 and/or urinary albumin excretion (UAE) > 30 mg/24 h). Of subjects with known CVD and CKD follow-up status (respectively 7828 and 5548), 669 (8.5%) developed CVD and 951 (17.1%) developed CKD (median follow-up respectively 12.5 and 10.2 years). Crude logistic regression analysis revealed that DKK3 levels were associated with prevalent CVD (Odds ratio: 2.14 [1.76–2.61] per DKK3 doubling, P < 0.001) and CKD (Odds ratio: 1.84 [1.59–2.13] per DKK3 doubling, P < 0.001). In crude Cox proportional hazard regression analysis, higher DKK3 levels were associated with higher risk for new-onset CVD (Hazard ratio: 1.47 [1.13–1.91] per DKK3 doubling, P = 0.004) and CKD (Hazard ratio: 1.45, [1.25–1.69] per DKK3 doubling, P < 0.001). However, these associations remained no longer significant after correction for common clinical variables and risk factors, though independently predicted for new-onset CKD in a subgroup of subjects with the lowest UAE values. Together, DKK3 plasma levels are associated with cardiovascular risk factors, but are generally not independently associated with prevalent and new-onset CVD and CKD and only predicted for new-onset CKD in those subjects with the lowest UAE values.

Adults referred to a national ADHD clinic in Iceland: clinical characteristics and follow-up status

Objective Evaluate adults referred to a national ADHD clinic, by comparing those diagnosed with those who were not, and those who screened negative and to evaluate changes among those diagnosed at follow-up. Method Data obtained from 531 patients’ medical records (49.7% males). One hundred thirty-six screened negative, 395 positive and 305 met diagnostic criteria for ADHD. Eighty-three of them were contacted by phone at follow-up. Results ADHD diagnosis was associated with lower educational status and more concerns expressed by parents and teachers during childhood. Participants not diagnosed with ADHD more often met diagnostic criteria for dysthymia, agoraphobia and generalized anxiety, and were more likely to be diagnosed with two or more comorbid disorders. At follow-up, all reported a significant reduction of ADHD symptoms, irrespective of medication, but the medicated participants reported fewer symptoms of inattention and better functioning in daily life. Conclusion Adults referred to ADHD clinics may have multiple mental health problems, regardless of whether they receive ADHD diagnosis or not. This could have implications for differential diagnoses of ADHD in adults and emphasises the need to have appropriate treatment available for both groups. Psychoeducation about ADHD may be very helpful in decreasing anxiety and ADHD symptoms.

Association of Refractory Pain in the Acute Phase After Subarachnoid Hemorrhage With Continued Outpatient Opioid Use.

Little is known about the prevalence of continued opioid use following aneurysmal subarachnoid hemorrhage (aSAH) despite guidelines recommending their use during the acute phase of disease. We sought to determine prevalence of opioid use following aSAH and test the hypothesis that acute pain and higher inpatient opioid dose increased outpatient opioid use. We reviewed consecutively admitted patients with aSAH from November 2015 through September 2019. We retrospectively collected pain scores and daily doses of analgesics. Pain burden was calculated as area under the pain-time curve. Univariate and multivariable regression models determined risk factors for continued opioid use at discharge and outpatient follow-up. We identified 234 patients with aSAH with outpatient follow-up. Continued opioid use was common at discharge (55% of patients) and follow-up (47% of patients, median 63 [interquartile range 49-96] days from admission). Pain burden, craniotomy, and racial or ethnic minority status were associated with discharge opioid prescription in multivariable analysis. At outpatient follow-up, pain burden (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.5-2.4), depression (OR 3.1, 95% CI 1.1-8.8), and racial or ethnic minority status (OR 2.1, 95% CI 1.1-4.0) were independently associated with continued opioid use; inpatient opioid dose was not. Continued opioid use following aSAH is prevalent and related to refractory pain during acute illness, but not inpatient opioid dose. More efficacious analgesic strategies are needed to reduce continued opioid use in patients following aSAH. This study provides Class II evidence that continued opioid use following aSAH is associated with refractory pain during acute illness but not hospital opioid exposure.

Change in obesity status and development of cardiometabolic disorders in school-age children

Objective: To analyze the influence of obesity status on the development of cardiometabolic disorders in school-age children. Methods: Information about children's body weight, body height and cardiovascular risk factors were collected in baseline survey in 2017 and follow-up survey in 2019. The school-age children were divided into four groups based on their baseline and follow-up obesity status, i.e. sustained non-obesity group, restored obesity group, newly classified obesity group, and persistent obesity group. Analysis of covariance was used to compare the difference of change in levels of cardiometabolic factors among the four groups. The multivariate logistic regression model was used to analyze the relationship between obesity status and the incidence risk of cardiometabolic disorders. Results: The present study included 11 379 school-age children (boys accounting for 49.6%). During the 2 years, the incidence of obesity was 3.2% (95%CI: 2.9%-3.5%) with the restoration ratio of obesity of 4.4% (95%CI: 4.0%-4.8%). Compared with the sustained non-obesity group, increases in SBP, DBP, TG, LDL-C and non-HDL-C were much higher in newly classified obesity group and persistent obesity group, but lower in restored obesity groups except for DBP (all P<0.05). In addition, the incidence risk of hypertension, high glucose, dyslipidemia and cardiometabolic disorders (≥2 risks) were much higher in newly classified and persistent obese children than in sustained non-obese children. No difference was found in incidence risks of most cardiovascular disorders between restored obese children and sustained non-obese children, except for hypertension and cardiometabolic risks. Conclusion: Both newly classified obesity and persistent obesity increased the incidence risks for multi cardiovascular disorders, while these risks could be reduced when non-obese status restore.

Epidemiological Profile of Diabetes Mellitus Patients in Diabetes Center in King Salman Specialist Hospital Hail Region Saudi Arabia

Objective: To investigate the degree of association between the specific epidemiologic factors of diabetes in the Hail Region of Saudi Arabia.&#x0D; Methodology: The research is considered a case study using information from the King Salman Specialist Hospital in Hail Saudi Arabia. 5000 Medical reports and records were used in the retrospective cross-sectional study. Data analysis was done using SPSS statistical software.&#x0D; Results: The Chi-square results indicated an insignificant association between gender and follow-up status (P &gt; 0.05). Both males and females sought treatment equally, whether follow-up or new treatments (P &gt; 0.05). There was a significant association between gender and diabetes type.&#x0D; The t-test results had varied results for the differences in age, BMI, and diabetes treatment. Age differences had no significant impact on the prevalence of diabetes among males and females (t (4998) = -0.63, P &gt; 0.05. Men had lower glycohemoglobin levels (8.11) differed significantly from that of women (8.58) t (4786) = -10.62, p &lt; 0.05. also, the creatine levels were higher in females than males. There were significant differences in low-density lipoprotein, hemoglobin, and BMI between men and women.&#x0D; Conclusions: The findings indicated differences in treatment such as unawareness of insulin injection, ignorance of health practices and unhealthy dietary habits, gender-related disparities, the inheritance of genes through which the disorder manifests, and exposure to environmental factors triggering and exacerbating the condition. Future studies should consider the genetic dimension Diabetes.

Evaluating participants' perceptions of a functional physical fitness assessment for those aged 60 years and over conducted in the community by student physiotherapists

Background/aims Physical fitness is crucial in preserving independence and quality of life for older adults. A functional physical fitness assessment has been designed specifically for those aged 60 years and over. This study explored older people's perceptions of this assessment, conducted by student physiotherapists, and the feasibility of a larger study to evaluate the long-term effects of its use. Methods A total of five scheduled drop-in sessions were arranged. Participants aged 60 years and over were recruited. Physiotherapy students conducted the assessment and participants completed follow-up physical activity status and quality of life questionnaires as well as an evaluation of the session. Focus groups were conducted to explore participant's perceptions and experiences. Data was analysed using descriptive statistics and thematic analysis. Results Overall, 91 adults (aged 60–93 years) participated, 75 (46 (61%) women and 10 (13%) men) completed questionnaires, and seven attended focus groups. In total, 100% of the 91 participants suggested that those aged 60 years and over would benefit from functional fitness assessment, and 79% perceived this would lead to increased physical activity. Focus group participants reported they enjoyed working with students and suggested that regular assessment would provide a yardstick for their level of fitness, that they would like to repeat their tests next year and that ‘they were mentally a positive thing’. Conclusions Functional fitness assessments were perceived as useful and encouraged older adults to increase their activity levels. Students successfully completed the tests in non-healthcare settings. This study suggests that a large trial designed to assess the benefit of regular functional fitness assessment for the over 60s in community settings is feasible.