Initial Period Of Improvement Research Articles

Risk factors for postoperative late deterioration in patients with spinal dural arteriovenous fistulas

BackgroundApproximately 86% of patients with spinal dural arteriovenous fistulas (SDVAFs) exhibit clinical improvement after surgery. However, 12%-55.8% of these patients experience late deterioration (LD) after an initial period of improvement. The risk factors for LD remain unclear. The aim of this study was to explore the risk factors for LD in SDVAF patients.MethodsThe clinical data of patients who were admitted to two tertiary hospitals between June 2014 and May 2022 were reviewed. Patients were divided into two groups: the LD group and the no LD group. The severity of neurological dysfunction (NDF) was evaluated using the Modified Aminoff and Logue Scale. Univariable and multivariable Cox regression analyses were performed.ResultsA total of 105 eligible patients were enrolled, with a mean age of 57.55 ± 9.42 years. The LD group comprised 37 individuals, while the no LD group consisted of 68 individuals. According to the univariable analysis, preoperative NDF severity and treatment strategy were associated with the risk of LD. According to the multivariable analysis, patients who underwent microsurgery (MS) had a lower risk of LD than did those who underwent endovascular treatment (EVT; HR 0.197, 95% CI 0.085-0.457), and patients with severe NDF had a higher risk of LD than did those with mild NDF (HR 3.604, 95% CI 1.226-10.588), whereas the risk of LD in patients with moderate NDF was similar to that of patients with mild NDF (HR 1.352, 95% CI 0.519-3.524).ConclusionEVT and severe preoperative NDF are independent risk factors for LD.

Disseminated Rasamsonia argillacea infection in a dog

ABSTRACT Case history A 4-year-old, male neutered Borzoi presented for unlocalised pain and frequent episodes of vocalisation. Clinical findings Pain was localised to the lumbar spine and radiographs revealed a L3–L4 lesion consistent with discospondylitis. The dog was treated for presumptive bacterial discospondylitis with surgical debridement, spinal stabilisation, and cephalexin. Samples collected from the affected intervertebral disc at the time of surgery revealed lymphoplasmacytic inflammation with no causative agent identified on histopathology or bacterial culture. After an initial period of improvement, signs recurred despite an 8-week antibiotic course, with the development of inappetence, weight loss, polydipsia, and polyuria. Repeat radiographs revealed a new cervical intervertebral lesion, and concurrent pyelonephritis was diagnosed based on blood and urine results. Fungal culture of urine resulted in growth of Rasamsonia argillacea species complex and disseminated fungal disease was clinically diagnosed. Antifungal treatment was commenced, however the dog deteriorated, and euthanasia was performed. Pathological findings Multifocal white plaques were grossly visualised in the spleen, mesenteric lymph nodes, cervical vertebrae, and kidneys. Periodic acid-Schiff-positive, fine, parallel-walled, occasionally branching, septate hyphae 5–10 μm in diameter, and conidia 5–7 μm in diameter were found on sectioning all organs. R. argillacea species complex was identified by fungal culture of urine and was considered the species of fungal organism seen histologically. The isolate was subsequently confirmed as R. argillacea by DNA sequencing. Diagnosis Disseminated Rasamsonia argillacea infection. Clinical relevance Rasamsonia argillacea species complex is a recognised invasive mycosis in veterinary medicine, with disseminated disease causing significant clinical complications and death. This is believed to be the first report of infection caused by R. argillacea in a dog in Australasia and highlights the importance of awareness of a potential fungal aetiology in dogs with discospondylitis. Abbreviations: CLSI: Clinical and Laboratory Standards Institute; CRI: Constant rate infusion; MEC: Minimum effective concentration; MIC: Minimum inhibitory concentration; PAS: Periodic acid-Schiff

Endoscopic Approach at Two Non-Sequential Levels in Lumbar Discitis

We report a case of spondylodiscitis in two non-sequential segments of the lumbar spine that was unresponsive to antibiotic treatment instituted and guided by results of blood and urine cultures.A 70-year-old female was admitted to our hospital with complaints of adynamia, low fever, and severe lower back pain that caused difficulty in mobilizing the lower limbs. Spinal tomography and magnetic resonance imaging (MRI) of the lumbar spine suggested L2L3 and L5S1 spondylodiscitis. After an initial period of improvement, the patient’s condition began to deteriorate again four weeks after initiating the antibiotic therapy. We then opted for surgical treatment through a full-endoscopic transforaminal route, with the aim of collecting intervertebral discs material and performing debridement. After the procedure, the patient experienced immediate relief from the pain and was able to stand and walk without assistance. Cultures from disc fragments showed different bacterial species than that found in the first examination.The endoscopic approach allowed less tissue damage, debridement of the disc, collection of multiple fragments, thereby facilitating the best antibiotic therapy, and shortening the duration of hospital stay.

Long-Term Cognitive Decline After Stroke: An Individual Participant Data Meta-Analysis.

Poststroke cognitive impairment is common, but the trajectory and magnitude of cognitive decline after stroke is unclear. We examined the course and determinants of cognitive change after stroke using individual participant data from the Stroke and Cognition Consortium. Nine longitudinal hospital-based cohorts from 7 countries were included. Neuropsychological test scores and normative data were used to calculate standardized scores for global cognition and 5 cognitive domains. One-step individual participant data meta-analysis was used to examine the rate of change in cognitive function and risk factors for cognitive decline after stroke. Stroke-free controls were included to examine rate differences. Based on the literature and our own data that showed short-term improvement in cognitive function after stroke, key analyses were restricted to the period beginning 1-year poststroke to focus on its long-term effects. A total of 1488 patients (mean age, 66.3 years; SD, 11.1; 98% ischemic stroke) were followed for a median of 2.68 years (25th-75th percentile: 1.21-4.14 years). After an initial period of improvement through up to 1-year poststroke, decline was seen in global cognition and all domains except executive function after adjusting for age, sex, education, vascular risk factors, and stroke characteristics (-0.053 SD/year [95% CI, -0.073 to -0.033]; P<0.001 for global cognition). Recurrent stroke and older age were associated with faster decline. Decline was significantly faster in patients with stroke compared with controls (difference=-0.078 SD/year [95% CI, -0.11 to -0.045]; P<0.001 for global cognition in a subgroup analysis). Patients with stroke experience cognitive decline that is faster than that of stroke-free controls from 1 to 3 years after onset. An increased rate of decline is associated with older age and recurrent stroke.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis.

0802 To Examine the Effect of Gabapentin Enacarbil in Primary Restless Legs Syndrome Patients Who are on Dopaminergic Agents and Exhibiting Augmentation

Abstract Introduction Augmentation is defined as worsening of the symptoms of Restless Legs Syndrome after a brief period of initial improvement with dopaminergic agents resulting in either an earlier onset, increase in severity, quicker onset, spread to other body parts. The exact prevalence of this phenomenon is not known and in patients experiencing augmentation, it can pose a difficult diagnostic and therapeutic challenge to the clinician. In our study, we found extended-release gabapentin to be an effective intervention in patients experiencing dopaminergic augmentation Methods This is an open-label single-arm study done in patients exhibiting augmentation while on dopaminergic agents. Patients who were enrolled in the study were initiated on oral extended-release gabapentin(Horizont) 600 mg at 5 pm at the beginning of the study. At day 90, attempts were made to reduce or discontinue dopaminergic agents. International Restless Legs Syndrome-Rating Scale (IRLS) and Augmentation Severity Rating Scale(ASRS) were recorded at each visit. Results A total of 10 patients were enrolled in the study while only 8 patients completed it. Compared to the baseline (visit 2), there is a significant improvement in both the augmentation severity(p= 0.0131) and the IRLS (p=0.0497). Wilcoxon matched-pairs signed rank test was used for statistical analysis. Conclusion Extended-release Gabapentin is an effective treatment option in primary RLS patients experiencing augmentation secondary to dopaminergic medication usage. Support The study is funded and medication is provided by Arbor Pharmaceuticals.

Total Hip Arthroplasty Performed for Coxarthrosis Preserves Long-Term Physical Function: A 40-Year Experience

Measures of long-term success of total hip arthroplasty (THA) over the past 50years have focused primarily on implant survival, with less evidence on long-term functional outcomes. We aimed to study 20-to-40-year functional outcomes after primary THA. We investigated the extent to which (1) functional outcomes after THA are maintained long term; (2) patient characteristics such as age, hip disease diagnosis, and comorbidities affect recovery of function and survivorship after THA; and (3) patients' overall function after THA is affected by the need for revision, the aging process, and associated comorbidities. We retrospectively reviewed outcomes of the senior author's patients between 1968 and 1993. Of 1207 patients, we identified 167 patients (99 female, 68 male; 276 primary THAs) who were at least 65years old at follow-up and had at least 20years of follow-up. Mean age at surgery was 55years; mean follow-up time was 27years. Bilateral THAs were performed in 109 patients (65%), and revisions in 81 patients (48.5%). Clinical outcomes including pain level, walking ability, range of motion, and overall function were determined by the Hospital for Special Surgery (HSS) hip scoring system. Contralateral and revision surgery, as well as patient age, sex, and body mass index, were included as covariates. To account for unequally spaced follow-up time points and competing causes of functional decline (e.g., age, contralateral hip disease, and need for revision THA), a latent class mixed model approach was used to identify unobserved classes of patients who had similar outcomes. Linear, quadratic, and piecewise-polynomial growth models were considered for class identification. The best fitting model was determined based on Bayesian information criterion. A four-class model of this patient population was identified: (1) the Elderly Class, who had a mean age of 62years at the time of primary THA; (2) the Bilateral Class, who underwent simultaneous or staged bilateral THA; (3) the Revision Class, who required at least one revision; and (4) the Youngest Class, who had a mean age of 49years. After an initial period of improvement in all groups, the functional trajectory diverged according to classifications. Age was the strongest determinant of long-term outcome, with HSS hip scores in the Elderly Class declining after about 20years. The Youngest Class maintained good-to-excellent hip function for over 30years. Revision THA and contralateral THA accounted for a temporary decline in function, after which overall good function was regained for the long term. All classes in the study population enjoyed good-to-excellent outcomes after THA for about 20years. Thereafter, functional decline was attributed more to aging than to the need for revision. One or more revision THA did not negatively influence long-term clinical outcomes, suggesting that, even for younger patients, symptoms, rather than the avoidance of possible revision, should be the primary determining factor when indicating THA.

Delayed spinal cord infarction following anterior cervical surgical decompression

Anterior cervical discectomy and fusion (ACDF) for cord compression is a safe and effective procedure with good outcomes. However, worsening of myelopathy is the most feared adverse event of the...

Transcatheter Aortic Valve Replacement as a Treatment for Late Apicoaortic Conduit Obstruction in a Patient With Severe Aortic Stenosis

A 62-year–old man presented with progressive exertional dyspnea and angina. His past medical history is notable for coronary artery disease, for which he underwent a coronary artery bypass graft surgery 8 years earlier. A few years afterward, he underwent aortic valve (AV) bypass (AVB) surgery for severe aortic stenosis (AS) using an apicoaortic conduit to the descending aorta consisting of a 16-mm connector and an 18-mm valved conduit (Hancock valve; Medtronic, Minneapolis, MN; Figures 1 and 2; online-only Data Supplement Movie I). After a period of initial improvement in symptoms, the patient developed progressive dyspnea and angina and was referred for additional cardiac workup. Figure 1. An ECG-gated thin-slice contrast-enhanced cardiac computed tomography scan showing a heavily calcified native aortic valve (AV), hypertrophied left ventricle (LV), and the apical LV insertion site of the apicoaortic valved conduit. Figure 2. A 3-dimensional cardiac computed tomography reconstruction image showing the apicoaortic valved conduit, extending from its apical insertion site into the left ventricle (LV) to its insertion site into the descending aorta. Arrow , Conduit valve. The patient underwent a bicycle ergometer test, which showed a diminished functional capacity and was stopped because of fatigue and a hypotensive response. He underwent a 2-dimensional transthoracic echocardiogram with gradual dobutamine infusion. He was found to have a heavily calcified AV (online-only Data Supplement Movie II) with a rest mean transvalvular gradient of 34 mm Hg and velocity of 3.5 m/s, which increased to 50 mm Hg and 4.8 m/s, respectively, at peak dobutamine dose (Figure 3). This corresponded with a …

Treatment of End-Stage “Trash Feet” With the End-Diastolic Pneumatic Boot

This study reassessed the clinical effect of Circulator Boot (CB) therapy in patients with cholesterol embolization syndrome (CES) of the lower extremities. The medical records were reviewed of 27 patients consecutively referred to the Bryn Mawr Wound Care and Vascular Center with CES who had not responded to previous therapies. All patients with CES referred from January 1, 1997, to September 19, 2005, were followed up and included in the study. The alternate therapy offered for most patients at the time of referral was limb amputation. The median age of the patients was 65 years (age range, 46-84 years) at the time of diagnosis. Healing of CES was observed after a median interval of 11 months (range, 3-32 months) following the initiation of CB therapy. The total number of legs treated was 41. Of 41 legs, 33 (81%) were totally healed, 6 (15%) improved, and 2 (5%) were amputated. After an initial period of improvement, one patient died a month later of causes unrelated to CES or CB therapy. Another patient improved and discontinued treatment before he was totally healed. Cholesterol embolization syndrome is seen predominantly in patients following cardiac or vascular procedures but may occur spontaneously. The CB seems to be the only effective noninvasive therapy for CES. Early initiation of therapy is essential to minimize tissue loss and patient discomfort.

Heat stroke and multi-organ failure with liver involvement in an asylum-seeking refugee

Heat stroke is the result of exposure to high environmental temperature and strenuous exercise representing a medical emergency characterized by an elevated core body temperature and central nervous system disorders. Slightly elevated liver enzymes, lacking clinical significance, seem to be frequent in heat stroke, whereas severe, clinically relevant, hepatocellular injury has been observed in only a minority of cases. In the present report we describe the case of an otherwise healthy young asylum-seeking refugee from East Timor, who developed severe heat stroke during his transportation to Greece in a closed container on a ship under unusually high temperatures. He was admitted to the hospital with severe multi-organ failure. After a short period of initial improvement, he developed severe hepatocellular injury and hepatic encephalopathy. Other causes of liver damage were excluded. The patient completely recovered.

Severe Acute Pancreatitis: Nutritional Management in the ICU

Patients with acute pancreatitis have elevated nutritional needs due to increased energy expenditure and catabolism. It is a clinical challenge to provide adequate nutrition to these patients while maintaining gut function, preventing pancreatic stimulation, and minimizing the risk of septic and metabolic complications associated with nutritional support. We present the case of a patient who had severe acute pancreatitis and was initially given total parenteral nutrition. After a period of initial improvement, he developed hyperglycemia, bacteremia, and sepsis. Parenteral nutrition was discontinued and infection was treated with antibiotics. Subsequent nutritional support consisted of enteral feeding with an elemental diet infused via a nasojejunal feeding tube. His condition improved gradually and he made a full recovery. This case illustrates the difficulties encountered while managing a case of severe acute pancreatitis and provides an evidence based approach to the nutritional management of severe acute pancreatitis in the intensive care unit setting.

Management of acute bacterial rhinosinusitis.

Acute bacterial rhinosinusitis is an infection of the nasal epithelium and paranasal sinus mucosa, usually caused in children by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and, less frequently, group A Streptococcus species. The clinical diagnosis is based on daytime cough that may be worse at night or purulent rhinorrhea, or both, lasting at least 10 days, often worsening after a period of initial improvement after initial symptoms of the common cold, and often associated with facial or dental pain, facial fullness, or swelling, headache, and fever. Sinusitis is diagnosed clinically; radiographic evaluation is not indicated for diagnosis. When the disease persists despite treatment, or is complicated by potential intracranial or orbital extension, CT is the preferred imaging modality. Initial therapy should be amoxicillin in a high dosage (80-90 mg/kg/day). Treatment is generally for 10 to 14 days and for at least 7 days beyond the time of substantial improvement in symptoms. Complications of acute bacterial rhinosinusitis in children are rare.

The significance of recurrent lung opacities in neonates on surfactant treatment for respiratory distress syndrome.

To determine the significance of recurrent opacities in chest radiographs of neonates on surfactant therapy for respiratory distress syndrome (RDS) after an initial period of improvement. Serial pre-and post-surfactant chest radiographs on 94 preterm infants with RDS were analyzed and the pattern of chest radiographic response was classified as (a) clear, (b) recurrent opacities, and (c) no response. Their clinical characteristics were also recorded. In 34 infants the RDS changes cleared within 3 days. 31 infants developed lung opacities within 10 days after an initial period of improvement. Twenty-nine infants failed to respond to the surfactant. The corresponding mean birth weights for the three groups were 1.74, 1.19, and 0.76 kg and the mean gestation ages 32.6, 27.7, and 25.4 weeks. The incidence of bronchopulmonary dysplasia (BPD) was highest among the slumping infants (72% vs. 50% in no responders, P<0.001) The pattern of chest radiographic response is primarily affected by gestation age and birth weight. Recurrent lung opacity after an initial positive response to surfactant therapy may be caused by such factors as edema from barotrauma and patent ductus arteriosus. Infants with intraventricular hemorrhage may demonstrate neurogenic edema. Other contributory factors include pneumonia and abnormal consumption of surfactant. Recurrent lung opacities after surfactant may be a predictor of chronic lung disease in the preterm infant.

The Column Procedure

Thirty-eight elbows (thirty-seven patients) with an extrinsic contracture were treated operatively with a limited lateral approach to the anterior and posterior aspects of the capsule. Because the procedure elevates muscles from the anterior and posterior aspects of the lateral supracondylar osseous ridge, we called it the column procedure. The mean preoperative arc of flexion was 49 degrees (from 52 to 101 degrees). At a mean of forty-three months (range, twenty-four to seventy-four months) postoperatively, the mean arc of flexion was 94 degrees (from 27 to 121 degrees). The mean total gain in the arc of flexion-extension was 45 degrees; thirty-four elbows (89 percent) had an improved range of motion at the latest follow-up examination. Overall, thirty-one elbows (82 percent) had a satisfactory result. Greater improvement was obtained in elbows that had had severe stiffness (a total arc of 31 to 60 degrees) or very severe stiffness (a total arc of 30 degrees or less) or that had had a combined flexion and extension contracture. A complication occurred in four elbows (11 percent). A hematoma developed in two elbows and impaired the final outcome in one of them. Two elbows had transient ulnar paresthesia, which resolved spontaneously. The arc of flexion obtained at the time of the operation was lost in ten elbows (26 percent) after an initial period of improvement; at the latest follow-up evaluation, four of these elbows had a mean decrease in the arc of flexion of 24 degrees compared with preoperatively. The column procedure is associated with a low rate of complications and is safe and effective for the treatment of a limitation in flexion or extension resulting from an extrinsic contracture of the elbow.

Patient Outcomes after Reoperation on the Lumbar Spine*

A consecutive series of thirty-nine patients who had had a reoperation of the lumbar spine was followed up for an average of forty-eight months (range, twenty-four to eighty-six months). The patients were evaluated with regard to pain, functional status, and work status. Twenty-eight patients (72 percent) had a successful outcome, as determined by their ability to return to work, their lack of a need for narcotic analgesics, and their satisfaction with the operative results. Factors that were significantly associated with a successful outcome included a younger age (p < 0.02), working outside the home (p < 0.05), an initial period of improvement after the previous (index) operation (p < 0.01), fewer spinal levels operated on previously (p < 0.05), and a revision procedure incorporating anterior interbody arthrodesis (p < 0.02).

Long-term outcome of iontophoresis treatment for torticollis.

In 1969, a patient with torticollis was successfully treated by a procedure called iontophoresis. Between 1958 and 1972 223 patients with torticollis were treated with this procedure. 88 of these patients (39%) were located and 56 (25% of the total, 64% of those located) returned a survey regarding their condition. 28 (13% of the total, 32% of those located, 50% of those responding) enjoyed an initial period of improvement. Of these, 16 patients (7% of the total, 18% of those located, 29% of those responding, 51% of those with initial improvement) reported sustained improvement through the time of the survey. However, 5 of these patients had additional treatment with botulinum toxin or selective denervation. We conclude that the long term effectiveness of iontophoresis treatment in the course of torticollis is minimal.

Late Recovery of Function After Oculomotor Nerve Palsy

We studied three patients who developed oculomotor nerve paresis from different causes. Each patient improved somewhat over several months, after which there was no further improvement for at least six months. Although the pareses were thought to be stable after the period of no improvement, each patient subsequently had further improvement in both motility and alignment with resolution of diplopia in primary position and in more than one of the cardinal positions of gaze. Patients with oculomotor nerve paresis may improve further after an initial period of improvement followed by several months of stability.

Syndrome de détresse respiratoire aiguë d'origine tuberculeuse

The adult respiratory distress syndrome (ARDS) is rarely due to tuberculosis. Two new cases are reported here. Both were female patients, aged 33 and 41 years. The first, of North African origin, was admitted for epigastralgia, hyperpyrexia and intestinal problems. She underwent an exploratory laparotomy, which only showed oedematous mesenteries. Hepatic and lymph node biopsies revealed an ongoing tuberculosis. On the 4th postoperative day, she developed ARDS. Despite an initial period of improvement after proper treatment (antituberculous drugs, steroids, positive pressure ventilation) had been started, she died 27 days later. In the other patient, smoker and alcoholic, the diagnosis of tuberculosis relied only on bacterial culture of various excretions. She also died after 8 days of treatment. In both patients, the symptoms were atypical. The febrile non cardiogenic pulmonary oedema of sudden onset masked the typical miliary mottling pattern on chest X-rays. The life-threatening character of this condition requires that rapid histological studies are carried out to obtain an early diagnosis. Indeed, the precociousness of appropriate treatment seems to be the essential element of the prognosis.

Renal artery angioplasty. Technical considerations and results.

Renal angioplasty was attempted on 38 renal arteries in 34 patients and was technically successful in 84.2%. Twenty-four patients were followed for 1 to 36 months (mean 15.3 months). The hypertension was cured or improved in 18 (75%), unchanged in 2 and recurrent after an initial period of improvement in four. Six patients were not available for further evaluation as five had additional renovascular surgery and one was lost to followup. Four patients had major complications; loss of the kidney occurred in one patient (2.9%). Respiratory renal mobility, predilatation with tapered teflon catheters and the contralateral femoral approach were found to be important technical aids for successful renal artery angioplasty.