Maximal Medical Therapy Research Articles

In-hospital and 90-day outcomes after total pancreatectomy with islet autotransplantation for pediatric chronic and acute recurrent pancreatitis.

Total pancreatectomy with islet autotransplantation (TPIAT) is used to treat debilitating chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) that has failed medical and endoscopic therapy. We performed a retrospective review of TPIAT patients at a free-standing children's hospital to evaluate perioperative outcomes. Twenty patients (median age 13, 65% female) underwent TPIAT (2015 through 2017). Of the 20 patients, 95% had CP and 1 patient (5%) had ARP alone. Seventy-five percent of the patients had a pancreatitis-associated genetic mutation; 40% had pancreas divisum. The median surgical time was 757 (IQR 657 to 835) minutes. Median islet equivalents per kg of body weight (IEQ/kg) were 6404 (IQR 5018 to 7554). At 90days postoperatively vs preoperatively, significantly fewer patients were receiving parenteral nutrition (0% vs 25%, P=.006) and opioids (45% vs 75%, P=.01). Short Form 36-Item Health Survey (SF-36) physical health module scores and total scores improved (34.0 preoperatively vs 54.6 at 90days, P=.008, and 47.1 vs 65.3, P=.007, respectively); SF-10 physical health scores also improved (13.4 vs 33.1, P=.02). Insulin requirement decreased from 0.5 unit/kg/day to 0.4 unit/kg/day between discharge and 90days (P=.02). TPIAT is an effective option when debilitating disease persists despite maximal medical and endoscopic therapy. Opioid, parenteral nutrition, and exogenous insulin use can successfully be weaned within 90days after TPIAT, with gains in health-related quality of life.

Is acupuncture effective in reducing overall symptomatology in chronic rhinosinusitis?

Is acupuncture effective in reducing overall symptomatology in chronic rhinosinusitis?

Indwelling Pleural Catheter Placement for Nonmalignant Pleural Effusions.

Pleural effusions account for significant symptoms and morbidity. Recent studies demonstrate a high mortality in patients with "benign" pleural effusions, now better characterized as nonmalignant pleural effusions (NMPEs) based on their prognosis. The most common nonmalignant clinical conditions with recurrent pleural effusions are congestive heart failure and hepatic hydrothorax, although many other diseases exist in isolation or as comorbid conditions. When conventional therapy fails, thoracentesis is often performed for relief of dyspnea. Many times, however, the effusions recur despite maximal medical therapy. Placement of tunneled or indwelling pleural catheters provides an effective therapeutic strategy for recurrent NMPEs when other medical therapy fails.

ASPIRIN DESENSITIZATION AND MAINTENANCE THERAPY IN A NURSING AERD PATIENT

Introduction Aspirin exacerbated respiratory disease (AERD) is characterized by upper and lower respiratory symptoms upon ingestion of aspirin and other cyclooxygenase 1 inhibitors. Aspirin is generally not used in pediatric patients due to potential risks, such as the development of Reye's syndrome. There is little data on the safety of aspirin desensitization and aspirin therapy in patients who are nursing. Case Description A nursing 30-year old woman with AERD and a long-standing history of chronic rhinosinusitis, nasal polyps, and asthma was referred by her otolaryngologist for aspirin desensitization. Maximal medical therapy, including leukotriene inhibitors, topical nasal steroids, topical antihistamines, as well as allergen immunotherapy and nasal polyp surgery, were ineffective in controlling the rhinosinusitis and nasal polyps. Total nasal symptom score (TNSSs) involving nasal congestion, sneezing, nasal itch, and nasal drainage at baseline was 12. To minimize infant exposure to aspirin during desensitization, patient had utilized pumped breast milk and infant formula. Patient underwent a two-day protocol of aspirin desensitization, starting with 40.5 mg aspirin through 325 mg. Through consultation with pediatrics, it was decided that patient would be maintained at 81 mg aspirin daily while nursing. Patient responded well with this therapy with TNSSs of 4 at one month, three months, and twelve months after desensitization with no adverse events in child or patient. Discussion Aspirin desensitization and maintenance therapy can be considered in nursing AERD patients after careful assessment of risks and benefits along with pediatric consultation. It can potentially alleviate symptoms of rhinosinusitis, asthma, and nasal polyps.

REFRACTORY NASAL POLYPOSIS TREATED WITH OMALIZUMAB IN A CHILD

Introduction Current treatment of inflammatory nasal polyposis consists of nasal/oral glucocorticoid therapy and surgical management if unresponsive to pharmacotherapy. The etiology is often multifactorial and requires combination management with both pharmacotherapy and surgery. We present a case of refractory nasal polyposis in a child treated with omalizumab, preventing the need for repeat surgical intervention. Case Description A 12-year old male with history of severe asthma, allergic rhinitis and allergic fungal sinusitis requiring functional endoscopic sinus surgery, developed worsening nasal polyposis despite maximal medical therapy. Physical and endoscopic exam revealed left sided nasal polyps, bilateral inferior turbinate hypertrophy, vocal cord nodules and hoarse voice. FeNO was uptrending, ranging from 98-175 ppb over the past year. Management included allergen immunotherapy, oral leukotriene-receptor antagonist, high-dose inhaled corticosteroid/long-acting beta agonist, oral antihistamine, intranasal antihistamines, high-dose intranasal steroid rinses, and oral steroids. His asthma was well controlled. Repeat surgical intervention was anticipated. Given his rising FeNO levels despite oral steroids, omalizumab was initiated in an attempt to decrease his nasal inflammatory process. Significant symptomatic improvement was noted after two omalizumab injections and his FeNO decreased to 65 ppb, the lowest value in the previous 3 years. Six months later, his FeNO has declined further to 29 ppb. Endoscopic exam showed polyp regression. This has prevented need for nasal surgery with continued use. Discussion Off-label use of omalizumab for atopic nasal polyposis should be considered in patients nonresponsive to traditional pharmacotherapies.

The Prevalence of Gastroesophageal Reflux in Patients With Excessive Central Airway Collapse

Gastroesophageal reflux (GER) is increasingly recognized as an exacerbating or causal factor in several respiratory diseases. There is a high prevalence of GER in infants with airway malacia. However, such data are lacking in adults. This retrospective study was conducted to determine the relationship between GER and excessive central airway collapse (ECAC). The study included consecutive patients with ECAC referred to the Complex Airway Center at Beth Israel Deaconess Medical Center who underwent esophageal pH testing for GER between July 2014 and June2018. Sixty-three of 139 patients with ECAC (45.3%) had documented GER as shown by an abnormal esophageal pH test result. The mean DeMeester score was 32.2, with a symptom association probability of 39.7%of GER-positive patients. Twenty-nine of 63 patients (46%) with GER reported improvement in respiratory symptoms following maximal medical therapy or antireflux surgery without requiring further treatment forECAC. GER is prevalent among patients with ECAC, and aggressive reflux treatment should be considered in these patients prior to considering invasive airway procedures or surgery.

Benchmarking of a Simple Scintigraphic Test for Gastro-oesophageal Reflux Disease That Assesses Oesophageal Disease and Its Pulmonary Complications

Objectives:Gastro-oesophageal reflux disease (GORD) is both common and troubling with a prevalence of 20-40%. We assessed the utility of a scintigraphic reflux study to evaluate the oesophageal and extra-oesophageal manifestation of disease compared to the standard tests such as pH monitoring and manometry.Methods:Patients were recruited into a prospective database of referrals to a tertiary referral center for either resistance to maximal medical therapy or extra-oesophageal symptoms of GORD. Data included 2 channel 24-hour pH monitoring and manometry results, as well as scintigraphic reflux data with late images assessing pulmonary aspiration of refluxate.Results:Study population included 250 patients (155 F, 95 M) with an average age of 60 years. Patients were clinically classified as either GORD (n=72) or laryngopharyngeal reflux (LPR) (n=178). Pulmonary aspiration of the refluxate was detected significantly more commonly in LPR patients (58/178 compared with GORD 10/72). Strong correlations were found between the scintigraphic time-activity curves in the upper oesophagus and pharynx, and ineffective oesophageal motility and pulmonary aspiration. pH studies correlated with the scintigraphic studies but did not predict aspiration similar to other modalities when evaluated by ROC analysis.Conclusion:Scintigraphic reflux studies offer a viable alternative test for GORD and extra-oesophageal manifestations of reflux disease. Strong correlations were found between measurable scintigraphic parameters and oesophageal motility and lung aspiration of refluxate. This may provide a more confident decision analysis in patients being considered for fundoplication for troubling extra-oesophageal symptoms.

Adenoidectomy With Balloon Catheter Sinuplasty: A Randomized Trial for Pediatric Rhinosinusitis

To compare treatment outcomes in pediatric patients with chronic rhinosinusitis (CRS) using adenoidectomy and maxillary sinus irrigation with or without balloon catheter sinuplasty (BCS). Prospective, randomized, and blinded. Patients between 2 and 12 years who met clinical and computed tomography criteria for CRS unresponsive to maximal medical therapy and no prior sinus- or adenoid-related procedures were eligible. Twenty-five patients were randomized, had surgery, and completed the follow-up. The control group underwent adenoidectomy with maxillary sinus irrigation alone; the treatment group underwent the same, with the addition of maxillary BCS for the maxillary sinus irrigation. Patients and parents were blinded to group assignment throughout the follow-up time frame. A validated questionnaire, the Sinus and Nasal Quality of Life Survey (SN-5), was used to measure health status changes and quality of life (QOL) at baseline, 6 months, and 12 months postintervention. Data was analyzed using t tests and multivariate linear regression. There were 12 patients in the BCS group and 13 in the control group. Other than a higher atopic history in the control group (P = 0.047), there were no significant differences (P = 0.07) in the two groups (demographics and baseline SN-5 scores). Following surgery, both groups demonstrated similar improvement in QOL scores and median SN-5 scores in all domains (number of sinus infections, nasal obstruction, allergy symptoms, emotional distress, and activity limitations). The addition of BCS to adenoidectomy/maxillary sinus irrigation did not provide additional QOL and sinonasal symptom improvement in the surgical treatment of pediatric CRS. 1b Laryngoscope, 128:2893-2897, 2018.

P.097 Subarachnoid hemorrhage associated with a thromboembolic ischemic stroke- an unexpected observation

Atherosclerosis is a significant risk factor for ischemic stroke, and is a frequent cause for extra- and intra-cranial vessels stenosis. Here, we present an unusual case of ischemic stroke associated with intra-cranial vessel stenosis and subarachnoid hemorrhage (SAH) secondary to carotid artery atheroma. A 64-year old female known for hypertension and dyslipidemia presented with a three-day history of three transient episodes (< 30 minutes) of dysarthria and right hand weakness. An initial brain CT scan revealed left frontal SAH. She was admitted to our Stroke Unit for observation and management. CT-angiogram revealed 90% ICAs stenosis bilaterally with several short focal stenotic lesions, involving several left MCA branches. Brain MRI revealed acute infarcts in the left insula, external capsule and inferior frontal gyrus. The clinical picture was attributed to a thromboembolic left MCA ischemic stroke. She was managed with maximum medical therapy, and later underwent successful left carotid endarterectomy. The presence of SAH on our patient’s presenting CT scan lead to an initial radiological diagnosis of RCVS. However, subsequent imaging studies indicated that SAH had occurred in association with a thromboembolic ischemic stroke. Despite its rarity, this clinical association is important to recognize to avoid diagnostic confusion and guide appropriate management.

Laser Trabeculoplasty in Modern Glaucoma Therapy - a Review

Laser trabeculoplasty (LTP) is a well established treatment modality in the management of chronic open angle glaucoma. Nonetheless there is much variation in practice. A literature search in the PubMed database was conducted and the most important evidence-based results were summarised. Argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT) are safe and effective treatment modalities, achieving an IOP reduction of 20 - 30%. Similar success rates have been reported for both procedures. A 50% rate of failure occurs after 2 - 5 years. Repeat-ALT is associated with a lower IOP decrease and a shorter duration of treatment effect. Repetition of SLT after initial SLT seems to be associated with loss of efficiency as well. SLT has been shown to be successful after initial ALT, whereas there are no data on ALT after initial SLT. For advanced glaucoma on maximum medical therapy, low success rates have been reported with regard to additional interventions. LTP is a good option for initial and adjunctive treatment. In advanced glaucoma on maximum medical therapy, low target pressures are needed, and filtering surgery has to be considered.

Double Lungtransplantation In Patients with End-Stage Pulmonary Arterial Hypertension or End-Stage Inoperable Chronic Thromboembolic Pulmonary Hypertension

In the last two decades survival is improved in patients with pulmonary arterial hypertension (PAH) due to targeted therapy but the long-term outcomes remain uncertain. Favorable results are obtained in patients with chronic thromboembolic pulmonary hypertension (CTEPH) due to surgical and percutaneous treatments except for inoperable patients. Lung transplantation (lung-tx) is an important option for patients with inadequate clinical response despite maximal medical or interventional therapy. The aim of the study is to compare survival of PAH and CTEPH patients listed for double lung-tx who underwent transplantation and patients listed who didn't.

Endoscopic Management of Recalcitrant Marginal Ulcers by Covering the Ulcer Bed.

Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence. To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS). Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8weeks despite maximal medical therapy (open capsule PPI, 40mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication. Eleven patients (age range 31-60; all females) with mean BMI of 27.72± 5.93kg/m2 underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50months (range 3-120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported. Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU.

Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic obstructive cardiomyopathy.

Despite excellent long-term results reported for a trans-aortic septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM), surgery for patients with diffuse hypertrophy is very challenging. In addition, a left ventricular outflow obstruction is often aggravated by an abnormal mitral valve and subvalvular apparatus. We performed video-assisted minimally invasive trans-mitral septal myectomy procedures in 3 patients with diffuse-type HOCM, who were highly symptomatic despite maximal medical therapy. Each had at least moderate mitral regurgitation (MR) due to systolic anterior motion (SAM). Using a right mini-thoracotomy, the anterior mitral leaflet was detached, through which an extended septal myectomy could easily be performed. Abnormal bridging chordae between the septum and papillary muscle (PM) were divided, then anterior mitral leaflet continuity was restored with direct closure or augmentation using a glutaraldehyde-treated autologous pericardium. A PM reorientation procedure was performed in 1 case in which both PMs were approximated and sutured onto the posterior ventricular wall. The postoperative course was uneventful in all patients, with marked improvement of symptoms in each. The peak ventricular outflow gradient decreased from 134 ± 40 to 23 ± 5mmHg with significantly diminished SAM, especially in the patient who underwent the PM reorientation procedure. During a mean follow-up period of 42 ± 14 months, no MR has been detected in any case. We believe that a minimally invasive trans-mitral septal myectomy is preferable for HOCM-patients with diffuse hypertrophy and mitral valve abnormality. Aggressive PM reorientation may also be useful for those with an abnormal PM orientation.

Two Cases of Endovascular Repair with the Stent Graft for Retrograde Type A Acute Aortic Dissection with Complications

Thoracic endovascular aortic repair (TEVAR) is used to treat retrograde type A acute aortic dissection (RTAAD). In case 1, a 52-year-old man, who was conservatively managed, reported worsening back pain. Emergency TEVAR was performed 7 days after onset. After deploying two GORE Conformable TAG (CTAG) in the descending aorta, his symptoms disappeared. In case 2, a 52-year-old man with progressive worsening resistant hypertension, renal dysfunction, and respiratory failure despite maximal medical therapy underwent TEVAR 8 days after onset. A CTAG was deployed from the left subclavian artery under rapid pacing, and two Zenith Dissection stents were placed, which resolved complications. In both cases, after 6 months, computed tomography (CT) scan showed complete resorption of the false lumen in the ascending aorta. TEVAR for RTAAD with complete thrombosis of false lumen in the ascending aorta can be an alternative to surgery when the primary tear is located in descending aorta.

Canaloplasty in Corticosteroid-Induced Glaucoma. Preliminary Results.

Purpose: to present the mid-term results of canaloplasty in a small cohort of corticosteroid glaucoma patients. Material and Methods: Nine eyes from seven patients with various types of corticosteroid glaucoma in maximum medical therapy underwent canaloplasty. Patients underwent complete ophthalmic examination every six months. Success was defined as: post-operative intraocular pressure (IOP) ≤ 21 mmHg and ≤ 16 mmHg without (“complete success”), and with/without medical treatment (“qualified success”). The IOP reduction had to be ≥ 20. The number of medications before and after surgery was considered. The follow-up mean period was 32.7 ± 20.8 months (range 14–72 months). Results: The pre-operative mean IOP was 30.7 ± 7.2 mmHg (range: 24–45). The mean IOP at 6 and 12-month follow-up was 13.1 ± 2.6 mmHg, and 13.7 ± 1.9 mmHg, respectively. Qualified and complete success at 6 and 12 months was 100% for both of the two definitions. The number of medications used preoperatively and at the 12-month follow-up was 4.3 ± 0.7, and 0.2 ± 1.0, respectively. No serious complication was observed. Conclusions: The mid-term results of canaloplasty in patients with corticosteroid-induced glaucoma appear to be very promising. Canaloplasty should be considered as a possible alternative to filtering surgery in this form of glaucoma, when medical therapy is not sufficient to maintain the IOP within reasonable limits.

Cardiac Rehabilitation Improves Cardiometabolic Health in Young Patients with Nonischemic Dilated Cardiomyopathy.

Nonischemic dilated cardiomyopathy is deadly and costly, and treatment options are limited. Cardiac rehabilitation has proved safe and beneficial for adults with various types of heart failure. Therefore, we retrospectively evaluated the hypothesis that rehabilitation is safe and improves cardiometabolic health in young patients with nonischemic dilated cardiomypathy. From 2011 through 2015, 8 patients (4 males) (mean age, 20.6 ± 6.6 yr; range, 10-31 yr) underwent rehabilitation at our institution. They were in American Heart Association class C or D heart failure and were on maximal medical therapy. Their mean left ventricular ejection fraction at baseline was 0.26 ± 0.15. Two patients had a left ventricular assist device, and 2 were inpatients. To evaluate safety, we documented adverse events during rehabilitation sessions. Clinical endpoints were measured at baseline, immediately after completing rehabilitation, and after one year. Patients attended 120 of 141 possible sessions (85%), with no adverse events. There were no marked changes in mean left ventricular ejection fraction or body mass index. The patients' mean waist circumference decreased by 1.37 ± 0.6 in (n=5; 95% CI, -2.1 to -0.63). Their 6-minute walk distance increased by a mean of 111 ± 75 m (n=5; 95% CI, 18-205). In our small sample of young patients with nonischemic dilated cardiomyopathy, cardiac rehabilitation was feasible and was associated with minimal risk. Our findings suggest that prospective studies in this population are warranted.

Abstract WP127: Effects of EDAS Revascularization and Intensive Medical Management on the Cognitive Function of Patients With Intracranial Atherosclerosis

Introduction: Cognitive decline after transient ischemic attacks (TIA) or stroke is common. Evaluation with the Montreal Cognitive Assessment (MoCA) tool has shown a decrease in cognitive scores in more than 30% of patients at 1 year. We hypothesize that indirect revascularization with EDAS plus intensive medical management (IMM) would decrease the rate of decline. Methods: This is a prospective study of EDAS plus IMM in symptomatic patients with intracranial arterial stenosis of more than 70%. Patients had MoCA evaluations at baseline, 1 month, 6 months, and 12 months after EDAS. Differences in MoCA at baseline and follow-up were compared using mixed model repeated measures ANOVA. Results: Thirty-one patients with no aphasia or neglect were included. Mean age was 48.3 +/- 16.6 years. Twenty-one were females (70%). The mean MoCA scores at baseline and 12-months were 23.6 +/- 4.3 and 25.5 +/- 4.1, respectively. MoCA ≥ 1 improvement was seen in 78.9% at 12 months. However, differences in MoCA scores at these time points did not reach statistical significance (p= 0.49, Fig. 1). Only 9% of patients had a decline of ≥2 MoCA points at 12 months. These results are comparable to the twelve month MoCA data from the SAMMPRIS trial, which showed a mean MoCA for IMM of 25.4 +/- 3.73 and for percutaneous angioplasty and stenting (PTAS) of 25.6 +/- 3.89. The rate of decline of MoCA scores after EDAS plus IMM was significantly less than the reported natural history after TIA or strokes outside the SAMMPRIS trial (9% vs. 30%, p=0.03). Conclusion: Compared to historical data, the decline in MoCA scores after TIA and stroke was lower in patients treated with EDAS plus maximum medical therapy and has similar effects to those reported in the SAMMPRIS IMM and PTAS groups.

A simple management option for chronically impacted sharp tracheobronchial foreign bodies in children

Distally impacted chronic tracheobronchial sharp foreign bodies in children are a management challenge that presents with clinical subtlety and extreme variability. The use of image guided techniques, imaginative instrumentation, tracheotomy, thoracotomy, and even extracorporeal membrane oxygneation have been reported. Endoscopy is made difficult by the distal location, inflammatory reaction with granulation tissue formation, and bleeding obscuring the foreign body. Our aim is to describe our experience with two children who had removal of aspirated impacted sharp metallic foreign bodies from the distal airway using rigid bronchoscopy, preceded by maximal medical therapy.

The Effect of Intracoronary Infusion of Bone Marrow-derived Mononuclear Cells on Clinical Outcome and Cardiac Function in Chronic Heart Failure Patients: An Uncontrolled Study

Objective: To evaluate the effect of bone marrow-derived mononuclear cells (BM-MNCs) on clinical outcome and cardiac function in chronic heart failure (HF). Methods: An uncontrolled, open-label trial was performed on symptomatic patients (New York Heart Association [NYHA] Functional Classification II–IV) receiving maximal medical therapy for at least 2 months, with a left ventricular (LV) ejection fraction

Ambulatory Intra Aortic Balloon Pump in Advanced Heart Failure.

Cardiac transplantation is the gold standard treatment for patients with advanced congestive heart failure that is refractory to maximal medical therapy. However, donor heart availability remains the major limiting factor, resulting in a large number of patients waiting long periods of time before transplantation. As a result, mechanical circulatory support devices have been increasingly used as a 'bridge' in order to sustain organ function and stabilise haemodynamics while patients remain on the transplant waiting list or undergo left ventricular assist device surgery. Intra aortic balloon pumps (IABP) are commonly used for temporary circulatory support in patients with advanced heart failure. IABP is traditionally placed percutaneously through the transfemoral artery approach. The major limitation with this approach is ambulatory restriction that can promote deconditioning, particularly in situations of prolonged circulatory support. A subclavian/axillary artery approach IABP insertion allows patients to be ambulatory during the pre-transplant period. In this review, we aim to summarise the physiology of IABP, the evidence for its use in advanced CHF and the efficacy and safety of subclavian artery IABP insertion.