Initial Medical Treatment Research Articles

Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience

ObjectiveNon-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management. MethodsA retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020. ResultsSeventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1–6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2–411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis. Conclusion and RelevanceParotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.

Cardiogenic shock in patients presenting with acute left main coronary artery occlusion

Abstract Background and purpose Acute myocardial infarction (AMI) due to left main coronary artery (LMCA) occlusion is a rare event, often catastrophic. Limited data are available about management and outcomes of patients with acute LMCA occlusion, including those presenting with cardiogenic shock (CS) at hospital admission. This study sought to describe patients with AMI due unprotected LMCA occlusion presenting with CS and to evaluate their in-hospital outcomes and 1-year mortality. Methods In this retrospective 2-center study, we identified 7630 patients with ST-segment elevation myocardial infarction (STEMI) or hight risk non-ST segment elevation myocardial infarction who underwent to emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analysed 94 patients who presented with unprotected LMCA occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and divided them in 2 groups according to presence of signs of cardiogenic shock at admission: CS and no-CS. Results Of 94 patients with AMI due LMCA occlusion, 52 patients presented with CS (53.3%). Mean age was 62.8±11.5 years in CS and 62.0±15.9 years in no-CS patients, p=0.766. In both groups, most patients were male. STEMI presentation was more frequent in CS group (80.4% vs. 52.4%, p=0.004). Severe systolic dysfunction of left ventricle was more frequent in CS patients (81.1% vs. 33.3%, p&amp;lt;0.001). Compared to no-CS patients, CS group shown more often TIMI=0 (67.3% vs. 26.2%, p&amp;lt;0.001), collateral coronary circulation Rentrop 0–1 (95.3% vs. 75.0%, p=0.008), and slow-reflow/no-reflow phenomena (30.6% vs 3.8%, p=0.019) in emergent coronary angiography. The need of invasive mechanical ventilation (68.9% vs. 21.4%, p&amp;lt;0.001), and haemodialysis (20.5% vs. 2.4%, p=0.010) were more prevalent in CS patients. Likewise, mechanical circulatory support (MCS) was more frequently used in patients presented with CS (52.9% vs. 26.2%, p=0.009). In subgroup analysis, MCS implantation was not a survival predictor in CS patients (Odds ratio: 3.9 [95% confidence interval: 0.4 to 36.3], p=0.229). Ultimately, in-hospital mortality (78.8% vs. 16.7%, p&amp;lt;0.001) was higher in CS patients. On the other hand, in hospital survivors, there was no significant differences in 1-year mortality (11.1% vs. 23.5%, p=0.42) between both groups. Conclusions Nearly half of patients with AMI due LMCA occlusion presented with CS signs at first medical evaluation. This subgroup of patients had higher in-hospital mortality compared to those without CS, despite MCS implantation. Whether the use of a specific MCS device or whether early use of MCS can change the outcome remains to be elucidated. CS patients who survive to index-hospitalization, had similar long-term outcomes compared to no-CS patients. Further studies are imperative in this population to refine initial medical treatment in order to improve their prognosis. Funding Acknowledgement Type of funding sources: None.

A case report on loss of vision secondary to odontogenic orbital cellulitis

We report a rare case of complete loss of vision secondary to odontogenic orbital cellulitis. A 54 years old female presented with 3 days history of left sided periorbital swelling and nasal discharge complaining of increasing facial pain. She was diagnosed with orbital cellulitis and treated empirically with intravenous antibiotic. Despite initial medical treatment, symptoms worsened leading to loss of vision. Indirect fundoscopy confirmed a left central retinal artery occlusion. An urgent CT revealed left maxillary sinus opacification with diffuse periorbital oedema, proptosis and no drainable orbital collection. She underwent Lynch Howarth procedure to reduce the orbital pressure. Ischaemic optic neuropathy and central retinal artery occlusion secondary to tension orbit odontogenic orbital cellulitis with no orbital collection are rare. We propose by serial intraocular measurements and maintaining the pressure below 21 mmHg with topical and systemic treatments, the risk of visual loss in patients presenting with similar pathology can be reduced.

Combined Pressure and Flow Measurements to Guide Treatment of Coronary Stenoses

The aim of this study was to assess clinical outcomes after combined pressure and flow assessment of coronary lesions. Although fractional flow reserve (FFR) remains the invasive reference standard for revascularization, approximately 40% of stenoses have discordant coronary flow reserve (CFR). Optimal treatment for these disagreements remains unclear. A total of 455 subjects with 668 lesions were enrolled from 12 sites in 6 countries. Only lesions with reduced FFR and CFR underwent revascularization; all other combinations received initial medical therapy. Fourteen percent of lesions had FFR≤0.8 but CFR≥2.0 while 23% of lesions had FFR >0.8 but CFR<2.0. During 2-year follow-up, the primary endpoint of composite all-cause death, myocardial infarction, and revascularization in lesions with FFR≤0.8 but CFR≥2.0 (10.8% event rate) compared with lesions with FFR >0.8 and CFR≥2.0 (6.2% event rate) exceeded the prespecified+10% noninferiority margin (P=0.090). Target vessel failure models using both continuous FFR and continuous CFR found that only higher FFR was associated with reduced target vessel failure (Cox P=0.007) after initial medical treatment. Central core laboratory review accepted 69.8% of all tracings with mean differences of<0.01 for FFR and<0.02 for CFR, indicating no material impact on clinical measurements or outcomes. All-cause death, myocardial infarction, and revascularization after 2 years was not noninferior between lesions with FFR≤0.8 but CFR≥2.0 and lesions with FFR >0.8 and CFR≥2.0. These results do not support using invasive CFR≥2.0 to defer revascularization for lesions with reduced FFR if the patient would otherwise be a candidate on the basis of the entire clinical scenario and treatment preference.

A2As or stimulants: which is better for treatment of ADHD in young children?

The use of α2-adrenergic agonists (A2As), like guanfacine and clonidine, in preschool-aged children with ADHD has been on the rise, even though little data support safety and effectiveness for these medications in this patient population. A May 2021 study conducted by Harstad and colleagues and published in JAMA compared the use of A2As with stimulants in childhood ADHD. Similar to other studies, the research team found that both A2As and stimulants were associated with improvement in ADHD symptoms for most children between approximately 4 and 6 years in whom they were initiated, with clinical improvement in 66% and 78% of young children, respectively. The study highlights the potential role that A2As could play in treating young children with ADHD, said Elizabeth Harstad, MD, MPH, a physician at Boston Children's Hospital and an assistant professor of pediatrics at Harvard Medical School. According to the American Academy of Pediatrics (AAP) and the Society for Developmental and Behavioral Pediatrics (SDBP), firstline therapy for ADHD is behavioral intervention, followed by stimulant treatment with methylphenidate (Ritalin) at the lowest effective dose if behavioral interventions are not sufficient. In general, AAP recommends behavioral therapy first then medication treatment, if necessary. Amphetamine salts (Adderall) are FDA-approved for children as young as 3 years because they were grandfathered in, not because there is stronger evidence for their use compared with methylphenidate, said Michael Ellis, DO, a child and adolescent psychologist and clinical associate professor at Mercer College of Medicine in Georgia. He said methylphenidate has more efficacy and safety data to promote its use, even though it is approved for individuals 6 years and older. “In general, I find less irritability with methylphenidate and prefer the use of that medication first, especially for those with ADHD and autism spectrum disorder,” Ellis said. The NIH's Preschool ADHD Treatment study, a randomized, placebo-controlled study, found that children between the ages of 3 and 5.5 years who were treated with methylphenidate had a significant reduction in ADHD symptoms, but often experienced adverse effects like irritability and depressive symptoms, like crying and sadness. The retrospective, medical records study in JAMA examined 497 preschool-age children younger than 6 years with ADHD. They came from seven academic developmental behavioral pediatric programs located in diverse geographical locations across the United States. “We found that developmental behavioral pediatricians use A2As when initiating medication treatment and use stimulant medication about two-thirds of the time,” said Harstad. “Children who were younger, or had a coexisting autism or sleep disorder, were more likely to be initiated on A2As.” Since stimulants are associated with more adverse effects than A2As—like moodiness/irritability (50% vs. 29%, respectively), appetite suppression (38% vs. 7%, respectively), and sleep difficulties (21% vs. 11%, respectively)—some providers prefer to prescribe A2As for their patients. “But these are not as effective for focus [compared with stimulants], and there can be a good deal of somnolence or hypotension,” said Ellis. Daytime sleepiness was the only adverse effect that was more common when young children with ADHD took A2As versus stimulants (38% vs. 3%, respectively), according to the study. A limitation of the study is its retrospective nature, which resulted in the collection of non-randomized and non-controlled data regarding the level of improvement over time, severity of baseline ADHD symptoms, and severity of adverse effects, said Harstad. “Medication may have been influenced by confounding factors [such as coexisting conditions]. Therefore, it is clinically imperative to conduct a prospective clinical study to assess effectiveness,” said Harstad. Preschool-aged children are being diagnosed with ADHD at higher rates than ever before. According to a 2018 article published in the Journal of Clinical Child & Adolescent Psychology, preschool ADHD rates have risen from 1.0% in 2007 to 2.4% in 2016. Since delay in early detection can lead to expulsion from preschool, future underachievement in school, and undue family stress, it is important for parents to have their child evaluated early on. “Preschoolers especially with severe ADHD likely need treatment right away,” said Ellis. While there are benefits and risks to treatments with both A2As and stimulants, options should be assessed with a patient-centered approach to optimize individual needs. Future randomized, controlled studies are also needed to assess efficacy and safety with both medication classes to determine more conclusive results.

Empty Sella Syndrome as a Window Into the Neuroprotective Effects of Prolactin.

Background: The goal of this study was to relate diffusion MR measures of white matter integrity of the retinofugal visual pathway with prolactin levels in a patient with downward herniation of the optic chiasm secondary to medical treatment of a prolactinoma.Methods: A 36-year-old woman with a prolactinoma presented with progressive bilateral visual field defects 9 years after initial diagnosis and medical treatment. She was diagnosed with empty-sella syndrome and instructed to stop cabergoline. Hormone testing was conducted in tandem with routine clinical evaluations over 1 year and the patient was followed with diffusion magnetic resonance imaging (dMRI), optical coherence tomography (OCT), and automated perimetry at three time points. Five healthy controls underwent a complementary battery of clinical and neuroimaging tests at a single time point.Results: Shortly after discontinuing cabergoline, diffusion metrics in the optic tracts were within the range of values observed in healthy controls. However, following a brief period where the patient resumed cabergoline (of her own volition), there was a decrease in serum prolactin with a corresponding decrease in visual ability and increase in radial diffusivity (p < 0.001). Those measures again returned to their baseline ranges after discontinuing cabergoline a second time.Conclusions: These results demonstrate the sensitivity of dMRI to detect rapid and functionally significant microstructural changes in white matter tracts secondary to alterations in serum prolactin levels. The inverse relations between prolactin and measures of white matter integrity and visual function are consistent with the hypothesis that prolactin can play a neuroprotective role in the injured nervous system.

Videourodynamic Precision Diagnosis and Treatment of Lower Urinary Tract Symptoms in Women

Lower urinary tract symptoms (LUTSs) in women are common in urological practice but are usually uninformative for diagnosing the underlying lower urinary tract dysfunction. To obtain a precise diagnosis and devise a precise treatment strategy, a videourodynamic study (VUDS) is an essential tool for investigating the bladder and bladder outlet dysfunction, especially when LUTS cannot be relieved after initial medical treatment. An accurate VUDS diagnosis can guide effective treatment and prevent unnecessary or incorrect surgical intervention. This article reviews updated applications of VUDS in the diagnosis and treatment of LUTS in women.

α2-Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.4% of preschool-age children. Stimulants are recommended as first-line medication treatment. However, up to 25% of preschool-age children with ADHD are treated with α2-adrenergic agonist medications, despite minimal evidence about their efficacy or adverse effects in this age range. To determine the frequency of reported improvement in ADHD symptoms and adverse effects associated with α2-adrenergic agonists and stimulant medication for initial ADHD medication treatment in preschool-age children. Retrospective electronic health record review. Data were obtained from health records of children seen at 7 outpatient developmental-behavioral pediatric practices in the Developmental Behavioral Pediatrics Research Network in the US. Data were abstracted for 497 consecutive children who were younger than 72 months when treatment with an α2-adrenergic agonist or stimulant medication was initiated by a developmental-behavioral pediatrician for ADHD and were treated between January 1, 2013, and July 1, 2017. Follow-up was complete on February 27, 2019. α2-Adrenergic agonist vs stimulant medication as initial ADHD medication treatment. Reported improvement in ADHD symptoms and adverse effects. Data were abstracted from electronic health records of 497 preschool-age children with ADHD receiving α2-adrenergic agonists or stimulants. Median child age was 62 months at ADHD medication initiation, and 409 children (82%) were males. For initial ADHD medication treatment, α2-adrenergic agonists were prescribed to 175 children (35%; median length of α2-adrenergic agonist use, 136 days) and stimulants were prescribed to 322 children (65%; median length of stimulant use, 133 days). Improvement was reported in 66% (95% CI, 57.5%-73.9%) of children who initiated α2-adrenergic agonists and 78% (95% CI, 72.4%-83.4%) of children who initiated stimulants. Only daytime sleepiness was more common for those receiving α2-adrenergic agonists vs stimulants (38% vs 3%); several adverse effects were reported more commonly for those receiving stimulants vs α2-adrenergic agonists, including moodiness/irritability (50% vs 29%), appetite suppression (38% vs 7%), and difficulty sleeping (21% vs 11%). In this retrospective review of health records of preschool-age children with ADHD treated in developmental-behavioral pediatric practices, improvement was noted in the majority of children who received α2-adrenergic agonists or stimulants, with differing adverse effect profiles between medication classes. Further research, including from randomized clinical trials, is needed to assess comparative effectiveness of α2-adrenergic agonists vs stimulants.

Long-term seizure and psychosocial outcome in childhood epilepsy of unknown cause.

The purpose was to investigate long-term prognosis of epilepsy of unknown cause with onset between ages 2 and 16 in children without any major disability, by evaluation of a previously described prognostic model and long-term follow-up of a study on the impact of duration of initial antiseizure medication (ASM) treatment. Patients included in a randomized controlled trial (RCT) of either one or three years of ASM therapy prior to withdrawal (if seizure-free for at least 6months) were contacted after 29-35years and asked to complete a survey. Potential prognostic factors were evaluated: duration of initial ASM treatment, seizure type, seizure frequency, and score in a prognostic model developed in the initial publication. One hundred and forty-nine subjects answered the questionnaire (response rate 65%). Seizure freedom without treatment was found in 110 responders (77%, 95%CI: 73-81). There was no significant difference in score in the prognostic model between responders with and without epilepsy at follow-up. Those with active epilepsy were unemployed significantly more often and perceived their mental health significantly more affected than those seizure-free without treatment. Duration of initial ASM treatment was not associated with any difference in subsequent epilepsy risk. This indicates that the timing of withdrawal attempts is unlikely to alter the long-term prognosis of uncomplicated childhood epilepsy. The failure of the prognostic model from the initial study to predict long-term outcome argues that although prediction of relapse risk in the shorter term may be possible, the bearing of such models on long-term epilepsy risk is more questionable.

Pulmonary and Cardiac Sarcoidosis - Diagnosis and Therapy

Sarcoidosis occurs predominantly in younger adults and may involve multiple organ systems. Although classical features such as bihilar lymphadenopathy, low grade fever, fatigue, pulmonary opacities, ocular lesions and arthritis occur frequently it must be kept in mind that sarcoidosis is able to mimic virtually any other disease. A thorough and systematic diagnostic strategy is warranted since even the histological hallmark of non-caseating granulomas occurs in a variety of other granulomatous diseases and even malignancies. A firm diagnosis is based on a match of clinical features, imaging results and histopathological findings. The Scadding classification describes four different types, not stages, of thoracic sarcoidosis based on mediastinal lymph node and lung parenchyma involvement. Medical treatment of pulmonary sarcoidosis is indicated only in patients exhibiting progressive disease and/or organ function impairment. Cardiac sarcoidosis manifests itself by clinical signs of heart failure, impaired cardiac function and arrhythmias including ventricular tachycardia, ventricular fibrillation and AV-conduction abnormalities. Patients with symptomatic or suspected cardiac sarcoidosis require rapid and elaborate diagnostic testing including cardiac MRI and PET imaging. Referral to a specialized center should be considered to establish a firm diagnosis and to initiate medical treatment and eventual device implantation. Oral corticosteroids, as the initial medical treatment of choice, carry side effects that must be weighed carefully against clinical benefits. Immunosuppressive therapy with methotrexate, azathioprine or TNF-blockers is usually reserved for patients that are either not responsive or intolerant to systemic steroids or that require steroid maintenance therapy above the cushing threshold. Diagnosed early and treated correctly, pulmonary and cardiac sarcoidosis mostly carry a favorable prognosis.

ENDOSCOPIC SINUS SURGERY DECISION AND TIMING FOR ENDODONTIC ORIGIN SINUSITIS AFTER FAILURE OF PRIMARY MEDICAL TREATMENT

Background: Odontogenic sinus disease require optimal management that involves definitive treatment of the underlying dental pathology. Further endodontic management with root canal, dental extraction, or apicoectomy. So, endoscopic sinus surgery (ESS) is recommended for patients who fail initial medical and/or dental treatment. However, the optimal timing for ESS is still unclear in literatures. Objective: The aim of this study is to find the optimal time for ESS in odontogenic sinusitis (ODS) patients after the failure of the primary medical treatment. Patients and Methods: This study was conducted on 25 patients with ODS: 14 males and 11 females. After the failure of primary medical treatment, these patients had preferred and undergone ESS. Another 21 patients who had dental intervention were used for comparison (12 females and 9 males). Assessment of the outcome was performed by SNOT-22 questionnaire to all patients. Results: The patients improved as there is a decrease in SNOT-22 score from 38.75 ± 9.56 to 15.7 ± 18.12 in ESS group (p =0.000), more than dental group that decreased from 37.93 ± 11.3 to 28.42 ± 21.7 (p= 0.039). It was observed that the SNOT-22 score increased as the time of intervention increased, so it is advised to start ESS as early as possible to have a successful surgery. Conclusion: An early ESS of ODS is a clue for a fast and successful treatment outcome. So, it is recommended that primary ESS is first to be performed, particularly in patients sufferings severe unresolved sinusitis, followed by dental treatment.

Design and implementation of a prospective cohort study of persons living with and without HIV infection who are initiating medication treatment for opioid use disorder

BackgroundOpioid use disorder (OUD) negatively impacts the HIV continuum of care for persons living with HIV. Medication treatment for OUD (MOUD) may have differential biological effects in individuals with HIV and OUD. To address the question of modulation of immune responses by MOUDs, we describe state of the art systems biology approaches to carry out the first prospective, longitudinal study of persons with and without HIV infection with OUD initiating MOUD. MethodsA prospective cohort study of persons with DSM-5 diagnosed OUD who are living with and without HIV infection and initiating treatment with methadone or buprenorphine is underway to assess biological effects of these medications on immunobiological outcomes. ResultsWe describe the recruitment, laboratory, and statistical methods of this study as well as the protocol details. Of those screened for enrollment into the study, 468 (36%) were eligible and 135 were enrolled thus far. Retention through month 6 has been high at 80%. ConclusionsThis study will use state of the art systems biology approaches to carry out the first prospective, longitudinal studies of persons living with and without HIV with DSM-5 OUD initiating treatment with MOUD.

Risk stratification on admission for predicting death or need for surgery in patients with acute type A intramural hematoma receiving medical therapy – validation cohort

Abstract Background There has been continuing discussion regarding the treatment strategy for acute type A intramural hematoma (IMH). We previously examined the risk factors of death or need for surgery for acute type A IMH in patients receiving medical treatment using clinical findings on hospital arrival and developed a simple risk score using the factors. Purpose We examined the accuracy of the risk score in the validation cohort. Methods From 2009 to 2014, 57 consecutive patients diagnosed with acute type A IMH who were receiving initial medical treatment were retrospectively included for derivation cohort. Primary endpoint was a composite of cardiovascular death and operation within 1 year after onset. On admission, the primary endpoint could be predicted with 89.7% sensitivity and 75% specificity if the patient had ulcer-like projection (ULP) and/or ≥2 of the following factors: systolic blood pressure (SBP) &amp;lt;120 mmHg, ascending aorta diameter&amp;gt;45 mm, and pericardial effusion (PE). In the current study, validation cohort study was performed from 2015 to 2020 in 73 consecutive patients who met the same inclusion criteria for derivation cohort to evaluate the risk factors and the accuracy of the risk score. Result Mean age of onset was 74 years old. Mean SBP on arrival was 134 mmHg. Computed tomography (CT) on arrival showed a mean ascending aorta diameter of 46 mm. ULP and PE were seen in 27% and 41% of cases, respectively. Thirty-three patients (45.2%) reached the primary endpoint (cardiovascular death, 8 cases [11%]; operation, 25 cases [34.2%]). In univariate analysis of admission values, the primary endpoint group had significantly lower SBP (116±29 vs 147±35 mmHg), higher ascending aorta diameter (49±8 vs 45±9 mm), and higher frequency of ULP (50% vs 10%) and PE (56% vs 29%) than did the event-free group. Multivariate analysis showed that ULP and SBP were significant predictors of the primary endpoint. The total risk score ≥2 could predict the primary endpoint with 87.5% sensitivity and 71.7% specificity (area under the receiver operating characteristic curve, 0.791). Conclusion The risk score was useful to predict cardiovascular death and the need for surgery in patients with acute type A IMH receiving medical therapy in the validation cohort study. ROC curve for the risk score Funding Acknowledgement Type of funding source: None

Guidelines for the Management of Unilateral Vocal Fold Paralysis From the Korean Society of Laryngology, Phoniatrics and Logopedics.

The Korean Society of Laryngology, Phoniatrics and Logopedics appointed a task force to establish clinical practice guidelines for the management of unilateral vocal fold paralysis (UVFP). These guidelines cover a comprehensive range of management-related factors, including the diagnosis and treatment of UVFP, and provide in-depth information based on current, up-to-date knowledge. Detailed evidence profiles are provided for each recommendation. The CORE databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers, using a predefined search strategy. When insufficient evidence existed, expert opinions and Delphi questionnaires were used to fill the evidence gap. The committee developed 16 evidence-based recommendations in six categories: initial evaluation (R1–4), spontaneous recovery (R5), medical treatment (R6), surgical treatment (R7–14), voice therapy (R15), and aspiration prevention (R16). The goal of these guidelines is to assist general otolaryngologists and speech-language pathologists who are primarily responsible for treating patients with UVFP. These guidelines are also intended to facilitate understanding of the condition among other health-care providers, including primary care physicians, nurses, and policy-makers.

Clinical features and surgical outcomes of type A intramural hematoma.

BackgroundData on the clinical features and surgical outcomes of type A intramural hematoma (IMH) in Chinese patients are very limited. We aimed to present the surgical experiences on type A IMH in our center, and report early and late outcomes.MethodsFrom February 2012 to April 2018, 106 consecutive patients underwent open surgery for type A IMH at our hospital. We adopted emergent operation for patients with cardiac tamponade or other severe complications, and recommended initial medical treatment followed by elective surgery for stable patients. The composite endpoints included operative mortality, permanent nerve damage (stroke, paraplegia), and new-onset renal failure necessitating hemodialysis. Risk factors for operative mortality and the composite endpoints were identified using univariable and multivariable logistic regression model analysis. The survival and freedom from aortic events were analyzed using a Kaplan-Meier surviving curve and a log-rank test.ResultsExcept 1 patient receiving emergent surgery (within 24 hours from onset) because of cardiac tamponade and cerebral malperfusion, all patients received initial medical treatment and delayed surgery. Two patient developed pericardial tamponade while waiting for surgery, and then received emergent surgery. Preoperative conversion to aortic dissection (AD) was noted in no patient. The operative techniques included ascending aorta replacement in 9 patients, hemiarch replacement in 18 patients, total arch replacement (TAR) with frozen elephant trunk (FET) in 45 patient and hybrid aortic arch repair in 34 patients. The mean cardiopulmonary bypass (CPB) time and cross-clamp time were 138.7±41.6 and 79.3±27.8 min, respectively. The operative mortality was 1.9% (2/106). And the composite endpoints occurred in 7 patients. Multivariable logistic regression analysis showed CPB time ≥200 min and chronic kidney disease were risk factors for the composite endpoints. The follow-up data were available in 97 survivors, with the mean follow-up time of 30.8±16.2 months. Three patients died and 5 patients developed aortic events during the follow-up. The overall survival at 1-, 3- and 5-year were 97.0%, 95.3%, and 79.4%, respectively. And freedom from aortic events at 1-, 3- and 5-year were 97.7%, 95.3% and 89.4%, respectively.ConclusionsOur strategy had got low mortality and excellent mid-term survival in patients with type A IMH. Therefore, our strategy was suitable for the surgical repair of type A IMH in Chinese population.

Prediction of outcome of treatment of acute severe ulcerative colitis using principal component analysis and artificial intelligence.

Background and AimAbout 15% patients with acute severe ulcerative colitis (UC) fail to respond to medical treatment and may require colectomy. An early prediction of response may help the treating team and the patients and their family to prepare for alternative treatment options.MethodsData of 263 patients (mean age 37.0 ± 14.0‐years, 176, 77% male) with acute severe UC admitted during a 12‐year period were used to study predictors of response using univariate analysis, multivariate linear principal component analysis (PCA), and nonlinear artificial neural network (ANN).ResultsOf 263 patients, 231 (87.8%) responded to the initial medical treatment that included oral prednisolone (n = 14, 5.3%), intravenous (IV) hydrocortisone (n = 238, 90.5%), IV cyclosporine (n = 9, 3.4%), and inflixmab (n = 2, 0.7%), and 28 (10.6%) did not respond and the remaining 4 (1.5%) died, all of whom did were also nonresponders. Nonresponding patients had to stay longer in the hospital and died more often. On univariate analysis, the presence of complications, the need for use of cyclosporin, lower Hb, platelets, albumin, serum potassium, and higher C‐reactive protein were predictors of nonresponse. Hb and albumin were strong predictive factors on both PCA and ANN. Though the nonlinear modeling using ANN had a good predictive accuracy for the response, its accuracy for predicting nonresponse was lower.ConclusionIt is possible to predict the response to medical treatment in patients with UC using linear and nonlinear modeling technique. Serum albumin and Hb are strong predictive factors.

Emotional Support and its Medical and Healthcare Implications: A Mind and Body Approach

High complications and conversion rate associated with laparoscopic treatment for acute cholecystitis was a common sense by surgeons. The optimal time of laparoscopic cholecystectomy for acute cholecystitis remains controversial. Either early or interval elective to undergo laparoscopic cholecystectomy for acute cholecystitis could gain the best cost/beneficial ratio. A prospective randomized study was performed to make it clear. During a 29-month period, 97 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n= 48) or delayed interval surgery after initial medical treatment (delayed group, n=49). Thirteen patients (five in the early group and eight in the delayed group) were excluded because of refusal of operation (n=5), misdiagnosis (n=5), contraindication for laparoscopic surgery (ca. of gallbladder), or loss of follow-up (n=2). Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n=3) and persistent fever (n=5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs.11%; p=0.174) and complication rate (29% vs.13%; p=0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p=0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p＜0.001) and recuperation period (19 days vs.12 days; p＜0.001).We concluded that initial conservative treatment followed by interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early laparoscopic or traditional cholecystectomy within 72 hours may be safer and has definite socioeconomic benefits.

Pleural Infection—a Growing Problem in the Elderly

Pleural infection is a common cause of hospitalisation and associated with high morbidity and mortality. This review summarises our current knowledge and practice in cases of pleural infection, with a particular focus on the evidence relevant to the management of this condition in older adults. The incidence of pleural infection is rising in older adults, who often present with less specific symptoms and commonly suffer from one or more comorbidities that can both confound diagnosis and impact on longer-term outcomes. Aspiration of oropharyngeal contents plays an important role in the pathogenesis of pleural infection in older adults which needs to be taken into consideration when deciding on management strategies including antibiotic selection. Treatment focuses on improving the patient’s general condition, appropriate antibiotic therapy and adequate drainage of the infected pleural collection. In cases of failure of initial medical treatment, intrapleural fibrinolytics and surgical debridement of the pleural space are the two main options. Despite the fact that advanced age is a risk factor for poor outcome from pleural infection, older patients are less likely to be referred for definitive surgical treatment in these circumstances. However, the current evidence base does not necessarily show a significantly worse post-operative course in older patients undergoing surgical treatment for pleural infection in comparison to younger adults. Pleural infection is an increasingly common and frequently under-recognised pathology. Timely diagnosis and treatment can have a positive impact on morbidity and mortality, but further research is needed to allow a better understanding of how different or more aggressive treatment strategies might influence the outcome in an elderly and more vulnerable population.

Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma

PurposeTo evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH). Materials and MethodsFrom April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases. ResultsSuccessful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57. ConclusionsTEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.

Early Exposure to Cardiac Treatment and Distress Among Patients and Their Caregiving Partners.

Background: The experience of an acute coronary event (ACE), including early care and evaluation, can be a distressing and traumatic experience for patients and their romantic partners, who also act as caregivers. We hypothesized that, among partners who were present during the ACE, those who were also present during (1) transportation to the hospital and (2) initial medical treatment would experience greater (a) anxiety early post-event and (b) posttraumatic stress symptoms (PSS) related to the event 4 months later. The associations between partner presence with patient anxiety and PSS were also explored.Methods: Participants were ACE patients and their partners recruited between March 2015 and December 2016 from the Intensive Cardiac Care Unit (ICCU) of the Sheba Medical Center in Israel (N = 143; all patients were males and partners were females). Partners self-reported whether or not they were present during the cardiac event, the hospital drive, and initial care. Patients and partners self-reported anxiety in-hospital and PSS, keyed to the ACE, an average of 4 months later. Data were analyzed using General Estimating Equations (GEE) and Multilevel Modeling.Results: Neither patient anxiety nor PSS differed according to partner presence during the drive to the hospital. In contrast, partners had higher anxiety when they were not present at all (difference = 3.65, p = 0.019) and when present during the event and during the drive (difference = 2.93, p = 0.029) as compared to when they were present for the event but not for the drive. Partners who were present during the event, but not the drive, had lower PSS than those who were present for both the event and the drive (difference = −4.64, p = 0.026).Conclusions: Partners who accompany patients on the drive to the hospital may inadvertently put themselves at risk for greater distress following their loved one’s cardiac event. Future research should enroll couples in an acute care context to inform couple-targeted tailored interventions to reduce distress in patients and their caregiving partners.