Long Periods In Patients Research Articles

A Retrospective Analysis of Venographic Images of a Central Venous Port without Blood Return and Its Usable Period.

Objective In routine practice, central venous ports without blood return (CVPWBRs) are common. However, very few studies have reported on the viable period of CVPWBR use. We therefore investigated this period by retrospectively analyzing the venographic images of CVPWBRs. Methods We examined patients' venography through the CVPs at the point when they became CVPWBRs for the first time and analyzed the reasons for becoming CVPWBRs. For patients with minor complications of CVPs or normal venographic findings, we used the Kaplan-Meier method to evaluate the period for which such CVPWBRs could be used. Patients or Materials Eighty-four patients with malignancy whose CVPs became CVPWBRs for the first time between July 31, 2015, and March 12, 2020, were included. Results Nine (10.7%) patients had major complications that made the CVPs unusable. Thirty-three (39.3%) patients had minor complications, and the remaining 42 (50.0%) had normal venographic findings. For the 75 patients with minor complications or normal venographic findings who continued to use their CVPWBRs, the Kaplan-Meier method estimated that 25% of complications that might make it unusable would occur within 1,273 days. Conclusion There are two learning points in our study. First, venography is needed when the CVP becomes a CVPWBR for the first time due to the high risk, and second, CVPWBRs can be used for a relatively long period in patients without major complications. It is necessary to develop an appropriate follow-up management method for CVPWBRs in prospective studies.

Identifying Recall Under Sedation by a Novel EEG Based Index of Attention-A Pilot Study.

OverviewRecall is an accepted consequence of sedation. But due to the very low prevalence of the more devastating awareness under anesthesia (AUA), it might be of value to assess first the efficacy of new markers for AUA by their efficacy in discovering the more prevalent recall under sedation (RUS). In this pilot study we assessed whether a novel index for attentional effort, the cognitive effort index (CEI), derived in real-time from one forehead EEG channel, could differentiate between patients with or without RUS.MethodsEEG was sampled from 2 groups: (1) Patients who underwent deep sedation (n = 25) (using drugs according to the anesthesiologist preference, but generally combining either Midazolam or Propofol together with either Fentanyl or Remifentanil). (2) Patients who underwent general anesthesia (GA, n = 13, a negative control for recall). In recovery, recall was assessed using the BRICE questionnaire.ResultsOf the 25 sedated patients, 11 experienced recall. The CEI marker was high during significantly longer periods in patients with recall, compared to sedated patients, or patients under GA, without recall. Moreover, the increase in CEI was evident mainly toward the end of the procedure.ConclusionRUS seems to associate with higher level of attention, which is identified in real-time by the easy-to-extract CEI marker.

Comparison Study of Anterior Capsule Contraction of Hydrophilic and Hydrophobic Intraocular Lenses Under the Same Size Capsulotomy.

PurposeTo compare anterior capsule contraction of two kinds of hydrophilic and hydrophobic acrylic intraocular lenses (IOLs) under the same size capsulotomy with femtosecond laser-assisted cataract surgery (FLACS).MethodsA total of 320 eyes in 320 patients who underwent FLACS were included. The patients were scheduled to have hydrophilic acrylic IOLs (MI60, 509M) and hydrophobic acrylic IOLs (iSert250, ZCB00) implanted. Visual acuity and anterior segment photography using a slit lamp microscope were performed at postoperative one week, one month, three months, and one year.ResultsThe contraction of the anterior capsule opening area (mm2) and circumference (mm) in the hydrophilic group were larger than that of the hydrophobic group from postoperative one week to one year (P < 0.001, P < 0.001, respectively). The postoperative contraction of the capsule opening area in MI60 was larger than in 509M (P < 0.001) and larger in 509M than in iSert250 and ZCB00 (P = 0.008, P = 0.019, respectively), but no difference was observed between iSert250 and ZCB00 (P = 0.867). During postoperative one to three months, all groups had the maximum capsule contraction (P < 0.001).ConclusionsUnder the same size capsulotomy with FLACS, the postoperative anterior capsule contraction induced by hydrophobic IOLs was less than that induced by hydrophilic IOLs. Among the four IOLs, the capsule contraction was largest in MI60, followed by 509M, and least in iSert250 and ZCB00, which was time-dependent.Translational RelevanceOur findings implied that patients with a high risk of ACC should choose hydrophobic IOLs, as well as nonsteroidal anti-inflammatory drugs may be used for a longer period in patients with high risk of capsule contraction syndrome.

Incidence of outflow tract ventricular tachycardia long after surgical aortic valve replacement.

BackgroundThe peri‐outflow tract region could be the origin of ventricular tachycardia (VT) after aortic valve replacement (AVR). However, the clinical characteristics of outflow tract ventricular tachycardias (OTVTs) after AVR are yet to be clarified. This study investigated the incidence, risk factors, and clinical characteristics of patients with OTVTs after AVR.MethodsWe retrospectively analyzed the clinical course of 120 patients who had undergone surgical AVR (SAVR) between April 1980 and October 2018. The patients had no ischemic or diagnosed cardiomyopathies other than primary aortic valve diseases.ResultsSix patients (5.0%) developed OTVTs after SAVR. The average onset was at 10.8 ± 5.7 years after SAVR. All cases of VT arose from the inferior axis and included left and right bundle branch block configuration. Two patients who underwent cardiac magnetic resonance imaging (MRI) had late gadolinium enhancement (LGE) in the midlayer of the left ventricle basal anteroseptal wall. Patients with periaortic VTs had significantly larger left ventricular (LV) diameter at systole, lower LV ejection fraction, higher positive rates of signal‐averaged electrocardiogram (SAECG), and nonsustained VTs on Holter monitoring. On ablation, local fragmented potentials with low voltage zones were observed in accordance with the LGE distribution. Multiple VTs originating from the periaortic region were provoked in the sessions.ConclusionsAcute OTVT was found in 5% of patients after SAVR. Arrhythmia risk stratification by SAECG, Holter ECG, and cardiac MRI should be considered for a long period in patients after SAVR.

The delayed appearance of occult cervical lymph node metastasis after long periods in patients with tongue squamous cell carcinoma: A report of three cases

The delayed appearance of occult cervical lymph node metastasis after long periods in patients with tongue squamous cell carcinoma: A report of three cases

Telemetric Monitoring of Intracranial Pressure

Background: We present the application of a modern telemetric method that records and monitors Intracranial Pressure (ICP) over long periods in patients with possible intracranial hypertension. Methods: A telemetric devise (Raumedic, Neurovent P-tel) was surgically implanted in six (6) patients. Three (3) patients with inconclusive diagnosis of idiopathic intracranial hypertension, two (2) patients with possible diagnosis of aqueduct stenosis and one (1) patient with Normal Pressure Hydrocephalus. All patients underwent a 3-day ICP recording within the nursing unit. Two more recordings were obtained over a period of 2-6 months at outpatient base. Results: All patients had an uncomplicated post-operative course. Analysis of the data excluded the diagnosis of idiopathic intracranial hypertension in two patients. Contrary in four patients data confirmed elevated ICP values and subsequently three of them underwent shunts implantation, while one patient refused further neurosurgical treatment. Conclusions: The telemetric device could be safely implanted in selected patients. It could provide long-term ICP recordings, which are necessary to confirm diagnosis and guide to the appropriate treatment.

Outcomes of Perianal Fistulising Crohn's Disease Following Anti-TNFα Treatment Discontinuation.

Discontinuation of antitumour necrosis factor (TNF)α therapy with perianal fistulising Crohn's disease remains controversial due to the risk of severe relapse without any clear evidence. The aim of this study was to assess the rate and type of perianal and luminal relapses following anti-TNFα discontinuation. All patients treated with anti-TNFα for perianal fistulising Crohn's disease with subsequent discontinuation of therapy were retrospectively reviewed from a prospective database (1998-2016). Cumulative probabilities of relapse-free survival were estimated by actuarial analysis. After a median follow-up of 62 months, 24 of the 45 patients experienced perianal relapse. A new surgical drainage was needed in 19 (79%) patients. The cumulative probabilities of perianal relapse at 1 and 5 years were 24% and 55%, respectively. Ileal localization (L1) at diagnosis, persistence of an external fistula opening, second line anti-TNFα use, or prior dose optimization was associated with perianal relapse, whereas continuation of immunosuppressive agents decreased this risk (HR = 0.3). Luminal relapse occurred in 42% of patients at 5 years. The cumulative probability of global relapse at 5 years was 67%. Retreatment with anti-TNFα allowed further remission in 23 of 24 (96%) patients. Half of patients with perianal fistulising Crohn's disease relapse within 5 years after anti-TNFα discontinuation. Immunosuppressant continuation may decrease this risk. The high risk of relapse (perianal and luminal) may suggest a benefit in pursuing biologics over a longer period in patients with perianal fistulas.

Different origins of chronic heart failure in patients with chronic obstructive pulmonary disease

The aim of this study was to analyze prevalence, clinical course and pathogenesis of chronic heart failure (CHF) in patients with chronic obstructive pulmonary disease (COPD). Methods. The study involved 309 patients with COPD who underwent spirometry and Doppler echocardiography. Natriuretic peptide level was measured in blood. Results. One hundred and twelve (36.2%) patients had CHF. Patients with comorbidity were older, had higher body mass index, longer and more severe smoking history. Dyspnea as one of the main COPD symptoms existed for longer period in patients with COPD and CHF. CHF was related to severity of the airflow limitation. There was no difference between patients with different origin of CHF. The rate of hypertension was similar in COPD patients with and without CHF, but the duration of hypertension was almost twice as higher in patients with CHF. The left ventricular ejection fraction (LV EF) was significantly lower in COPD patients with CHF compared to those without CHF and was significantly lower in patients with ischaemic CHF compared to CHF of another origin. Also, COPD patients with CHF had significantly lower physical tolerance measured by 6-min walk test and more severe hypoxemia. Conclusion . Prevalence of CHF in COPD patients is quite high. CHF is caused both by concomitant cardiovascular disease (coronary heart disease, hypertension, etc.) and actually by progressive chronic cor pulmonale. Unaffected LV EF is seen more often in COPD patients; however, decreased LV EF is associated with coronary heart disease. Development of CHF in COPD patients is also associated with such risk factors as smoking, severe bronchial obstruction, hypoxemia, and tachycardia.

Eating Disorders in Adolescents With Chronic Pain

IntroductionGiven that youth with chronic pain frequently experience disruptions in eating patterns that may place them at risk for disordered eating, the purpose of this study was to examine the clinical characteristics and illness course of adolescents with chronic pain and comorbid eating disorders. MethodsUsing a retrospective chart review, 34 adolescents with chronic pain and concurrent eating disorders were identified. These adolescents were compared with 34 age-, gender-, and eating disorder symptom–matched adolescents who had an eating disorder without chronic pain. ResultsThe majority of adolescents with chronic pain and an eating disorder had a primary medical diagnosis of abdominal pain (n = 14), followed by autonomic dysfunction (n = 10) and headache (n = 6). Although in 41.2% of teens with chronic pain, eating disorder symptoms developed after the onset of their pain, 35.3% reported having eating disorder symptoms before they experienced chronic pain. Body mass index did not differ between the groups, but the duration of eating disorder symptoms was significantly longer for the chronic pain group (p < .001). DiscussionDespite comparable severity, eating disorders are undetected for longer periods in patients with chronic pain, which may contribute to a poorer prognosis. Implications for eating disorder conceptualization, detection, and treatment are discussed.

Peripheral venous pressure as a reliable predictor for monitoring central venous pressure in patients with burns.

Background:Optimizing cardiovascular function to ensure adequate tissue oxygen delivery is a key objective in the care of critically ill patients with burns. Hemodynamic monitoring may be necessary to optimize resuscitation in serious burn patients with reasonable safety. Invasive central venous pressure (CVP) monitoring has become the corner stone of hemodynamic monitoring in patients with burns but is associated with inherent risks and technical difficulties. Previous studies on perioperative patients have shown that measurement of peripheral venous pressure (PVP) is a less invasive and cost-effective procedure and can reliably predict CVP.Objective:The aim of the present prospective clinical study was to determine whether a reliable association exists between changes in CVP and PVP over a long period in patients admitted to the Burns Intensive Care Unit (BICU).Subjects and Methods:The CVP and PVP were measured simultaneously hourly in 30 burns patients in the BICU up to 10 consecutive hours. The predictability of CVP by monitoring PVP was tested by applying the linear regression formula and also using the Bland–Altman plots of repeated measures to evaluate the agreement between CVP and PVP.Results:The regression formula revealed a reliable and significant association between CVP and PVP. The overall mean difference between CVP and PVP was 1.628 ± 0.84 mmHg (P < 0.001). The Bland–Altman diagram also showed a perfect agreement between the two pressures throughout the 10 h period.Conclusion:Peripheral venous pressure measured from a peripheral intravenous catheter in burns patients is a reliable estimation of CVP, and its changes have good concordance with CVP over a long period of time.

The Incidence of Pleural Effusion on Dasatinib Treatment Is Associated with CD56 Positive Cell Values One Month after Commencing Dasatinib and Achievement of an Early Molecular Response in Newly Diagnosed Chronic Myeloid Leukemia Patients: Results of a D-First Study

▪Background: The introduction of the tyrosine kinase inhibitor (TKI) imatinib has dramatically improved the outcomes for patients diagnosed with chronic myeloid leukemia (CML). Furthermore, second-generation TKIs nilotinib and dasatinib, approved as initial treatment agents for patients with chronic myeloid leukemia-chronic phase (CML-CP), are now available clinically. Although the DASISION study demonstrated that in comparison to imatinib treatment dasatinib significantly improves both the major molecular response (MMR) and complete molecular response (CMR) rates; there remains serious concern about the adverse effects associated with it such as pleural effusion (PE). Further, the clinical significance of the mechanism underlying the development of PE is still elusive, especially in the upfront setting. Thus, we analyzed the clinical significance of PE incidence and the association of immunoprofiles based on records derived from the prospective D-First study (ClinicalTrials.gov NCT01464411). The present study sought to investigate the efficacy and safety profile of dasatinib treatment (100 mg QD) among newly diagnosed CML-CP patients in Japan.Patients and Methods: Fifty-two patients with newly diagnosed CML-CP were enrolled in the study. All patients in the present study were followed for at least 18 months. Chest radiographs, and molecular assessments for detecting and quantifying BCR-ABL transcript levels, were performed routinely (at 1, 3, 6, 9, 12, 15, and 18 months) after initiation of dasatinib treatment. An MMR was defined as <731 copies/μg RNA of real-time quantitative polymerase chain reaction (RQ-PCR) value (equivalent to BCR-ABLIS <0.1%). A CMR was defined by an undetectable value of RQ-PCR (<50 copies/μg RNA, equivalent to BCR-ABLIS <0.0069%). A single case with an undetectable BCR-ABL transcript level was excluded from the molecular assessment results. Pearson’s chi-squared test and Student’s t-test were used to compare differences between the two groups. Receiver operating characteristic (ROC) curves were generated to investigate the correlation of factors and to determine optimal threshold values. Statistical analyses were performed using JMP software, version 11 (SAS Institute Inc., Cary, NC, USA).Results: Of the patients enrolled into the study, 17 (33%) developed PE but all were moderate (Grade 1, 10 and Grade 2, 7). In examining patients at diagnosis with or without PE (PE+ or PE-), a significant difference was observed by patient age (median 63 and 41 years, P = 0.00075); however other characteristics including sex, Sokal risk, BCR-ABL transcript value, body weight, or performance status, did not differ. The MMR rate by 3 months in the PE+ group was significantly higher than that in the PE- group (59% vs 24%, P = 0.013); however, the MMR rates by 12 months and CMR rates by 18 months did not differ by group (MMR rates 82% vs 74%, P = 0.48; CMR rates 71% vs 53%, P = 0.23). Because the incidence of PE was associated with an early response to dasatinib, we investigated the immunoprofiles of patients at 1, 2, and 3 months after treatment with dasatinib according to the presence or absence of PE by 18 months. We found that the lymphocyte value at 1 month significantly affected the incidence of PE by 18 months (area-under-the-curve [AUC] 0.64, 48% vs 21% in lymphocytes ≥1,550/μL and <1,550/μL groups, P = 0.038, odds ratio 3.51, 95% confidence interval [CI] 1.04–11.8). According to immunoprofile, the value of CD56-positive cells at 1 month was more significantly associated with the incidence of PE (AUC 0.65, 50% vs 25% in CD56+ cells ≥427/μL and <427/μL groups, P = 0.026, odds ratio 4.00, 95% CI 1.14–14.0) than that of CD3+/CD8+ cells (AUC 0.56, 45% vs 23% in CD3+/CD8+ cells ≥360/μL and <360/μL groups, P = 0.108, odds ratio 2.69, 95% CI 0.79–9.12).Conclusion: The incidence of PE on dasatinib treatment is associated with advanced patient age, lymphocyte value at 1 month (especially in the CD56-positive fraction), and achievement of an early molecular response. These results suggest that the incidence of PE until 18 months may be due to an immune-mediated mechanism involving NK-cells, with the underlying mechanism contributing to a transient tumor decline that is probably not retained over a long period in patients newly diagnosed with CML-CP. DisclosuresIriyama:Bristol: Honoraria. Yoshida:Bristol: Honoraria. Chiba:Bristol: Honoraria. Ohyashiki:Bristol: Honoraria. Morita:Bristol: Honoraria. Sakamaki:Bristol: Honoraria, Research Funding.

The relative contribution of cognition and symptomatic remission to functional outcome following treatment of a first episode of psychosis.

Functional recovery remains the primary goal following treatment of a psychotic disorder, especially after a first episode. Evidence regarding relative contributions of predictors of functional outcome, including symptoms and cognition, remains equivocal. The objective of the study was to determine the relative contribution of cognition, in particular verbal memory, and symptomatic remission to social and occupational functioning while controlling for established predictors of functioning in a large sample of patients presenting with a first episode of a schizophrenia spectrum or affective psychosis. Patients (aged 14-35 years) met DSM-IV criteria for a first episode of a schizophrenia spectrum or affective psychosis and had been admitted to the Prevention and Early Intervention Program for Psychoses, Montreal, Quebec, Canada, between 2003 and 2009 for treatment and follow-up for 2 years. Established predictors (duration of untreated psychosis, medication adherence, age at onset, substance use, premorbid adjustment), verbal memory, and length of positive and negative symptom remission were regressed on functioning (using the Strauss Carpenter Scale) at 1 (n = 208) and 2 (n = 159) years. Regressions were conducted with established predictors in the first step, followed by verbal memory and consecutive months of combined positive and negative symptom remission in the third step. Regressions were then repeated with length of positive and negative symptom remission, respectively. Length of combined positive and negative symptom remission explained the most variance in functioning at 1 (R² adjusted = 0.35, F₉,₁₂₉ = 9.33, P < .001) and 2 (R² adjusted = 0.38, F₉,₉₇ = 8.21, P < .001) years, and verbal memory contributed only slightly to such outcome. While length of remission of negative symptoms was a stronger predictor of functioning than remission of positive symptoms at 1 year, length of positive symptom remission also made a large contribution at 2 years. These results highlight the importance of achieving and maintaining remission of both negative and positive symptoms for longer periods in patients with a first episode of a psychotic disorder and the need for effective interventions to do so.

Neuronal differences between chronic low back pain and depression regarding long‐term habituation to pain

Longitudinal studies of experimental pain are rare and little is known about the differences regarding sensitization and habituation over longer periods in patients with chronic pain or depression compared with controls. We used a standardized longitudinal painful heat paradigm that was designed to induce long-term habituation in 19 patients with chronic low back pain (CLBP), 21 patients with depression (DEP) and 21 healthy participants (controls) over a time course of eight consecutive days. We applied functional magnetic resonance imaging on the first and last day of this period and after 3 months. Although the pain paradigm was standardized, patients with DEP exhibited significantly higher pain thresholds and a trend to higher pain ratings and, in functional imaging, showed less activation of the operculum and the secondary somatosensory cortex (S2) as compared to patients with CLBP and controls. Conversely, patients with CLBP showed increased activation in the anterior insula and parietal operculum as compared to patients with DEP and controls. Within session, all participants sensitized to pain, which was associated with higher activation levels in the thalamus, amygdala, midcingulate cortex, and sensory and motor areas. However, patients with depression showed significantly less activation in midbrain and brainstem areas. Given that pain and depression potentiate each other clinically, our data suggest that this may involve different cortical pain areas.

Effect of Pulsed Radiofrequency Neuromodulation on Clinical Improvements in the Patients of Chronic Intractable Shoulder Pain

ObjectiveThe aim of this study was to evaluate effect of pulsed radiofrequency (PRF) neuromodulation of suprascpaular nerve (SSN) in patients with chronic shoulder pain due to adhesive capsulitis and/or rotator cuff tear.MethodsThe study included 11 patients suffering from chronic shoulder pain for at least 6 months who were diagnosed with adhesive capsulitis (n=4), rotator cuff tear (n=5), or adhesive capsulitis+rotator cuff tear (n=2) using shoulder magnetic resonance imaging or extremity ultrasonography. After a favorable response to a diagnostic suprascapular nerve block twice a week (pain improvement >50%), PRF neuromodulation was performed. Shoulder pain and quality of life were assessed using a Visual Analogue Scale (VAS) and the Oxford Shoulder Score (OSS) before the diagnostic block and every month after PRF neuromodulation over a 9-month period.ResultsThe mean VAS score of 11 patients before PRF was 6.4±1.49, and the scores at 6-month and 9 month follow-up were 1.0±0.73 and 1.5±1.23, respectively. A significant pain reduction (p<0.001) was observed. The mean OSS score of 11 patients before PRF was 22.7±8.1, and the scores at 6-month and 9 month follow-up were 41.5±6.65 and 41.0±6.67, respectively. A significant OSS improvement (p<0.001) was observed.ConclusionPRF neuromodulation of the suprascapular nerve is an effective treatment for chronic shoulder pain, and the effect was sustained over a relatively long period in patients with medically intractable shoulder pain.

Fluvastatin Improves Arterial Stiffness in Patients With Coronary Artery Disease and Hyperlipidemia A 5-Year Follow-up Study

The present study was designed to test the hypothesis that fluvastatin might improve arterial stiffness, as assessed with pulse wave velocity (PWV), in patients with coronary artery disease (CAD) and hyperlipidemia over the long term. Ninety-three patients were randomly assigned to either fluvastatin (group A, n=50) or bezafibrate (group B, n=43) and followed for 5 years. There was no difference in the clinical findings between the 2 groups. In group A, there was a progressive reduction in the brachial-ankle PWV along with a decrease in serum low-density lipoprotein-cholesterol (LDL-C) and C-reactive protein (CRP) by 12 months after fluvastatin, and the improvement was maintained until 5 years after treatment. In group B, despite identical lowering of the serum lipid, PWV was progressively increased. In group A, the percentage change in PWV correlated significantly with that of the serum CRP (r=0.49, p<0.001), but not with that of the serum LDL-C after treatment. The beneficial vascular effects of fluvastatin persisted for a long period in patients with CAD and hyperlipidemia. Its anti-inflammatory action might contribute to the favorable effects on arterial stiffness.

Long-term interleukin-10 presence induces the development of a novel, monocyte-derived cell type.

Interleukin (IL)-10 is one of the most crucial immunoregulatory cytokines. Its short-term effects have been analysed extensively, but little is known about its long-term effects. This is of considerable importance, as high systemic IL-10 levels are present for long periods in patients with persistent viral infections, certain cancers and in critical care patients. Our study investigated the effects of the long-term presence of IL-10 on human peripheral blood monocytes. In vitro, IL-10 treatment of these cells for 7 days induced the development of a novel cell type characterized by unique phenotypical and functional characteristics. These cells showed high HLA-DR expression and low expression of CD86 and other co-stimulatory molecules on their surface. The mRNA levels of both HLA-DR and CD86 were high, but no intracellular accumulation of CD86 protein was observed. With respect to its function, these cells showed strongly diminished tumour necrosis factor-alpha production following lipopolysaccharide stimulation, strongly diminished allogenic CD4(+) T cell stimulatory capacity, and even induced a hyporesponsive state in CD4(+) T cells. The phenotype remained stable despite the removal of IL-10. In vivo, we found monocytic cells from patients exhibiting this phenotype after long-term IL-10 exposure. These results complement our knowledge further about the biological effects of IL-10 and may provide an explanation for the sustained immunodeficiency in cases of the persistent presence of systemic IL-10.

Automatic adjustment of noninvasive pressure support with a bilevel home ventilator in patients with acute respiratory failure: a feasibility study

To test the feasibility of applying noninvasive ventilation (NIV) using a prototype algorithm implemented in a bilevel ventilation device designed to adjust pressure support (PS) to maintain a clinician-set alveolar ventilation in patients with acute respiratory failure after initial stabilization. Prospective crossover interventional study in an intensive care unit, university hospital. 19 patients receiving NIV for acute hypercapnic respiratory failure (13 men, 6 women; mean age 70+/-11 years). The same bilevel ventilator was used with manually adjusted PS and with the automated algorithm (autoPS), set to maintain the same alveolar ventilation as in PS. Sequence (measurements at end of each period): (a) prior to initiating NIV (baseline 1); (b) 45 min with manually set PS; (c) 60 min without NIV; (d) 45 min with autoPS; (e) 60 min without NIV; (f) 45 min with manually set PS. The magnitude of decrease in PaCO(2) and increase in pH with autoPS was comparable to that of conventional PS, with the same alveolar ventilation and level of PS. No technical problem occurred in autoPS mode, and no NIV trial had to be discontinued because of patient discomfort. These results suggest that the alveolar ventilation based automatic control of PS during NIV with a bilevel device is feasible and leads to beneficial effects in patients with acute respiratory failure comparable to those of manually set PS. Further studies should now explore the potential of this system over longer periods in patients with acute and chronic respiratory failure.

Timely Referral of Potential Organ Donors

Timely Referral of Potential Organ Donors

Seizure outcome in patients with a solitary cerebral cysticercus granuloma.

To study the long-term seizure outcome and determine factors that predict recurrence of seizures following early withdrawal of antiepileptic drugs (AEDs) in patients with a solitary cerebral cysticercus granuloma (SCCG). The authors prospectively studied 185 patients with SCCG and seizures in whom AEDs were withdrawn soon after (within 2 to 12 weeks) resolution of the SCCG was demonstrated on the CT scan. The follow-up of these patients ranged from 24 to 125 months (mean 65.8 months) or until seizure recurrence. Age, number of seizures, duration of AED therapy, occurrence of breakthrough seizures, administration of albendazole, and presence of a calcific residue of the SCCG on the CT scan were studied as prognostic factors to predict recurrence of seizures. One hundred fifty-seven patients (84.9%) were seizure-free, whereas 28 patients (15.1%) had recurrence of seizures after withdrawal of AEDs. The recurrences occurred at a mean duration of 18.8 months (range 0.5 to 78 months) after withdrawal of AEDs. Multivariate analysis showed that presence of calcific residue on the CT scan, occurrence of breakthrough seizures, and occurrence of more than two seizures were associated with a higher risk of recurrence of seizures. The other factors including administration of albendazole therapy did not affect seizure recurrence. Nearly 85% of patients with a solitary cerebral cysticercus granuloma have a good seizure outcome following resolution of the lesion and early withdrawal of AEDs. However, recurrence of seizures can be expected in about 15% of patients. Patients with more than two seizures, those with breakthrough seizures, and those whose follow-up CT scan shows a calcific residue of the granuloma have a higher risk of recurrence and therefore need to be appropriately cautioned after withdrawal of AEDs. AED therapy might also have to be continued for longer periods in patients with these risk factors.

Assessment of stricture formation with the ureteral access sheath

Objectives To analyze the long-term incidence of ureteral stricture formation in a series of patients in whom a new-generation ureteral access sheath was used. A new generation of ureteral access sheaths has been developed to facilitate ureteroscopic procedures. However, some have questioned their safety and whether the device might cause significant ureteral trauma. Methods Between September 1999 and July 2001, 150 consecutive ureteroscopic procedures with adjunctive use of an access sheath were performed. A retrospective chart review to April 2002 was done. Of the 150 patients, 130 underwent ureteroscopy for ureteral stones. Patients who underwent endoureterotomy or treatment of transitional cell carcinoma were excluded from this analysis. Sixty-two patients had follow-up greater than 3 months and were included in the analysis. Overall, 71 ureteroscopic procedures were performed, with 9 patients undergoing multiple procedures. Ninety-two percent of the patients had pathologic findings above the iliac vessels. The average patient age was 45.3 years (range 17 to 76), and 70% and 30% of the patients were male and female, respectively. The mean clinical follow-up was 332 days (range 95 to 821), and follow-up imaging was performed within 3 months after ureteroscopy in all patients. Results The 10/12F access sheath was used in 8 ureteroscopic procedures (11.2%), the 12/14F access sheath in 56 (78.9%), and the 14/16F access sheath in 7 (9.8%). One stricture was identified on follow-up imaging of 71 procedures performed, for an incidence of 1.4%. The patient developed the stricture at the ureteropelvic junction after multiple ureteroscopic procedures to manage recurrent struvite calculi. The access sheath did not appear to be a contributing factor. Conclusions The results of our series indicate that the ureteral access sheath is safe and beneficial for routine use to facilitate flexible ureteroscopy. However, awareness of the potential ischemic effects with the use of unnecessarily large sheaths for long periods in patients at risk of ischemic injury should be considered. We advocate the routine use of the device for most flexible ureteroscopic procedures proximal to the iliac vessels.