Maximal Medical Therapy Research Articles

Maximal medical therapy in extensive subdural empyema of the brain and spinal cord

Maximal medical therapy in extensive subdural empyema of the brain and spinal cord

Suprachoroidal hemorrhage postintracameral bevacizumab injection: An unusual case report and review of literature

Suprachoroidal hemorrhage (SCH) is a dreaded complication of intraocular surgery. We report a case of a 65-year-old male with left eye primary angle-closure glaucoma and idiopathic elevated episcleral venous pressure with neovascularization of the iris. Due to uncontrolled intraocular pressure even after maximum medical therapy, trabeculectomy with mitomycin C was planned. Preoperative intracameral bevacizumab was given to avoid intraoperative bleeding. Postinjection, localized SCH was noted, which settled spontaneously on conservative management. A combination of ocular and systemic risk factors, such as arteriosclerosis and idiopathic elevated episcleral venous pressure accentuated by intraoperative hypotony during intracameral injection, led to SCH. There are no previous reports of a localized SCH following intracameral bevacizumab.

Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease.

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for the treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were reported. Since the 2011 guidelines, several studies and a few systematic reviews comparing CEA and CAS have been reported, and the role of medical management has been reemphasized. In the present publication, we have updated and expanded on the 2011 guidelines with specific emphasis on five areas: (1) is CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (grades of recommendation assessment, development, and evaluation) approach, as was used for other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low-risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be<3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin scale score, 0-2), carotid revascularization is considered appropriate for symptomatic patients with >50% stenosis and should be performed as soon as the patient is neurologically stable after 48hours but definitely<14days after symptom onset. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients with an increased risk of carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. For patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and coronary artery bypass grafting, we suggest CEA before, or concomitant with, coronary artery bypass grafting to potentially reduce the risk of stroke andstroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience.

Correlation between choroidal thickness and intraocular pressure control in primary angle-closure glaucoma

Purpose:To study the correlation between choroidal thickness (CT) and IOP control in primary angle-closure glaucoma (PACG).Methods:In total, 61 patients (102 eyes) with PACG underwent subfoveal CT (SFCT) scanning using enhanced depth imaging–optical coherence tomography. The subjects with PACG were further grouped as controlled IOP (≤21 mm Hg on maximal medical therapy) and uncontrolled IOP (>21 mm Hg on maximal medical therapy). The average CT of the PACG eyes was calculated and compared between both groups. A correlation analysis was done between CT and intereye difference in CT with the disease parameters.Results:The mean CT was 274.38 ± 42.10 μm in 102 PACG eyes. SFCT was significantly increased in the uncontrolled IOP group as compared with the controlled IOP group. The mean SFCT was 245.57 ± 62.10 μm in the controlled group and 294.46 ± 51.05 μm in the uncontrolled group (P < 0.01). Factors associated with a thicker choroid were younger age, high IOP, and higher optic nerve head cupping (P < 0.001). Neither the visual field-mean deviation (VF-MD) nor pattern standard deviation (PSD) was found to be associated with overall CT. The intereye asymmetry between CT was significantly associated with poor VF-MD and PSD.Conclusion:PACG eyes with thicker choroid may be a risk factor for poor IOP control on medical anti-glaucoma therapy. Thicker choroid as compared to the fellow eye is a poor prognostic sign and these eyes should be monitored closely.

Primary laryngeal lymphoma: a diagnostic challenge

&lt;p class="abstract"&gt;Lymphomas of head and neck constitute 5-15% of malignancies in this region. However, its primary occurrence at the larynx is exceedingly rare due to the paucity of lymphoid tissue. Here, we reported a case of a 41 year old male who presented with a 1 month history of hoarseness and odynophagia. The examination revealed right vocal cord palsy and an ipsilateral subglottic exudate, that was misdiagnosed as infectious disease. The lesion quickly progressed to airway obstruction, requiring a tracheotomy. Multiple biopsies under general anesthesia were needed before reaching the final diagnosis of diffuse large B-cell lymphoma, Epstein-Barr positive. Selected treatment modality included 3 cycles of chemotherapy followed by radiotherapy in moderate dose with complete remission after 2 years of follow up. The tracheotomy was removed, however, the patient did not recover vocal quality. This case highlighted the heterogeneous presentation of extra-nodal head and neck lymphomas and emphasized the need for suspicion of neoplasm when an infection doesn’t respond to maximal medical therapy.&lt;/p&gt;

The patient's perspective: a qualitative study of individual experience with decision-making, treatment, and recovery for resectable pancreatic cancer.

Pancreatic ductal adenocarcinoma cancer (PDAC) remains a challenging diagnosis. The likelihood of long-term survival is limited even for patients who undergo maximal medical therapy with systemic chemotherapy and surgical resection. Within this intensive process, there remains limited understanding of patients' pretreatment expectations of PDAC treatment experience and their decision-making process. PDAC patients who underwent chemotherapy and surgical resection were retrospectively identified. Semi-structured phone interviews were completed regarding patient experience with therapy. Qualitative descriptive analysis was performed, and categories, subcategories, and themes were determined. Fifteen patients were interviewed regarding their experience with PDAC treatment. An overall personal disease trajectory experience was identified with two phases. The first phase encompassed the patients' treatment. In this phase, patients expressed a choice, non-choice regarding therapy decisions, viewing therapy as the only option. Misconceptions about the roles of therapies and expected experience of treatment were observed. The second phase focused on life after therapy. Patients reported persistent physical changes secondary to therapy. An overall realistic understanding of the patient's limited prognosis was observed, with patients expressing appreciation of the life time gained as a benefit of treatment. There remains critical areas for improvement in communication and care of patients with PDAC. Physicians should continue to ensure that patient's goals and wishes are respected when making treatment decisions and confirm that patients understand the roles and limitations of prescribed therapies. Additionally, patients continue to have significant physical changes post treatment which should be assessed for and managed as appropriate to maintain quality of life.

Intracranial Atherosclerotic Disease: Current Concepts in Medical and Surgical Management.

This article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery. Data from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT. ICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.

EP.TU.688The fate of the rectal stump following subtotal colectomy for acute colitis

Abstract Aims Acute severe colitis requires surgery in approximately thirty percent of cases. Subtotal colectomy with end ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Controversy surrounds the optimal short and long-term management of the distal rectal stump. This study reviews the clinical outcomes and the fate of the rectal stump in this patient cohort. Methods Analysis of prospective data of patients who underwent emergency subtotal colectomy for severe acute colitis between 2010 and 2020 in a tertiary referral centre. Results Sixty-six patients underwent subtotal colectomy (median age, 40years; M:F, 1.3:1). Subtotal colectomy was performed for failure of medical therapy during an acute episode of severe colitis (56%), for fulminant colitis (40%), or for colonic strictures (4%). In 98% percent of patients the rectal stump was closed at the level of the recto-sigmoid junction and in 2% a mucous fistula was formed. 73% of patients opted for no further surgery, but 27% underwent a completion proctectomy, most commonly performed because of rectal stump bleeding. The median follow-up was 6.25years, during which 17% of those with a completion proctectomy underwent an ileo-pouch anal anastomosis (IPAA). Conclusions Subtotal colectomy with closed rectal intra-peritoneal stump and end ileostomy is the procedure of choice in severe acute colitis refractory to maximal medical therapy or fulminant colitis. Given the patient dissatisfaction and morbidity associated with mucous fistula, this procedure should be abandoned. Pelvic dissection should not be performed at the time of the emergency subtotal colectomy given the risk of morbidity.

Clinical and functional recovery in a patient with pulmonary hypertension after bariatric surgery

Severe pulmonary hypertension (PH) in obese patients pose a challenge to treat despite advances in medical therapeutics. Current treatment options are limited for patients who are not responding to maximal medical therapy. Here, we present a case of multifactorial PH, not responsive to ambrisentan, tadalafil, and treprostinil, even after optimization of cardiac and pulmonary function and had a poor prognosis. She demonstrated weight loss after bariatric surgery, improving her restrictive lung disease, obstructive sleep apnea and PH, and overall functionality. Bariatric surgery may offer a potential therapeutic option, in patients with morbid obesity and PH resistant to maximal medical therapy.

Outcomes and lessons learned from two decades’ experience with glaucoma drainage device implantation for refractory Sturge Weber–associated childhood glaucoma

To evaluate glaucoma drainage device (GDD) implantation for refractory pediatric glaucoma associated with Sturge-Weber syndrome (SWS). The medical records of consecutive children with SWS-associated glaucoma at a single center who were treated by a single surgeon using GDDs over 20years were reviewed retrospectively. The main outcome measure was GDD treatment success, defined as absence of any of the following indications of treatment failure: (1) intraocular pressure (IOP) of >21mm Hg on two consecutive visits despite maximal medical therapy, (2) additional IOP-lowering surgery, and (3) sight-threatening complications. A total of 22 eyes of 22 children were included. The median age at glaucoma diagnosis was 0.73years (range, 0.06-13.2), and the median age at GDD surgery was 4.8years (range, 0.6-13.3). Most eyes (14 [68%]) had prior glaucoma surgery. Mean follow-up was 2.8±1.5years. Success (95% confidence interval) by Kaplan-Meier analysis for GDD surgery at 1, 3, and 5years was 91% (68-98), 75% (50-89), and 52% (24-73), respectively. Failure occurred in 8 eyes (36%). Complications were common, occurring in 50% of eyes, with 23% of eyes having more than one complication. Severe vision-threatening complications (n=3) included one case each of possible infection requiring GDD removal, persistent hypotony, and cilioretinal artery occlusion. GDDs are an effective treatment for SWS-associated glaucoma but have a high rate of complications. We report several severe complications that prompted surgical modifications for increased safety when implanting GDDs in eyes with SWS-associated glaucoma.

The surgical management of heart failure: heart transplantation in the era of SARS-CoV-2 pandemic

Abstract Purpose End-stage heart failure (HF) is a major global clinical problem with a growing number of patients worldwide. Heart transplantation (HTx) and mechanical circulatory support (MCS) represent the two most effective procedural options for the treatment of end-stage HF. HTx remains the treatment of choice in patients who reach maximal medical therapy, but, remain incapacitated by their symptoms. The COVID-19 pandemic caused by SARS-CoV-2 has significantly affected the delivery of medical care across all specialties, therefore, it is not a surprise that the number of HTx has drastically diminished worldwide during the pandemic. We developed in our Center of Heart Diseases effective safety measures and team approach in order to perform HTx with excellent outcomes. Methods All patients with reduced ejection fraction, heart failure at presentation and had been adequately investigated had been evaluated by a multidisciplinary team and when appropriate entered into a waiting list for HTx. Results From March2020 to March 2021, 96 patients underwent orthotopic HTx. The age range was 33 - 66 yrs and a median of 54 yr. Both donor and recipient were tested for SARS-CoV-2 within 48 hrs of the procedure, and none tested positive. All recipients were regularly tested following the procedure, too, and none were positive. 53 patients with INTERMACS 4 class have been treated, 31 with INTERMACS 3 class and 11 patients with INTERMACS 2. Only one patient with INTERMACS 1 underwent HTx. 6 (10%) patients died within the first 30 days following HTx. All staff caring for those patients were screened for SARS-CoV-2 at regular intervals. There was liberal use of PPE at all stages of the care of the patients, with strict hand hygiene. All surviving patients were subjected to the normal protocol of post-operative management in terms of immunosuppression and other medications. Conclusion Heart transplantation remains the treatment of choice for advanced heart failure. About 85% of heart transplant patients survive one year following the procedure thus giving them a better quality of life. We have shown that successful heart transplantation may be performed during the SARS-CoV-2 pandemic. Funding Acknowledgement Type of funding sources: None.

S2776 A Rare Case of Pseudomonas Aeruginosa Colitis and Subsequent Bacteremia in the Setting of Alcohol-Induced Cirrhosis

Introduction: Pseudomonas aeruginosa is an opportunistic bacterium that commonly causes pneumonia and urinary tract infections. While cases of P. aeruginosa colitis have been infrequently reported, we identify a unique case of P. aeruginosa bacteremia occurring after antibiotic-treated P. aeruginosa colitis in a patient with alcohol-induced cirrhosis. Case Description/Methods: A 38-year-old male with class III obesity and alcohol use disorder presented with cramping abdominal pain, vomiting and dark stool. There was no recent hospitalization and no antibiotic or intravenous drug use. Last alcoholic drink was reported to be several days prior to presentation. Physical exam identified scleral icterus, abdominal distension without tenderness, and hepatomegaly. Laboratory test results are outlined in Table 1. Serum acetaminophen and alcohol levels were not detected. Urinalysis and chest x-ray were unremarkable. Ultrasound demonstrated cirrhotic liver morphology and ascites, but no cholelithiasis. Ceftriaxone was started due to concerns for an upper gastrointestinal bleed. On day 2, he developed watery diarrhea. Stool cultures were positive for P. aeruginosa, prompting antibiotic transition to cefepime. Clostridioides difficile testing was negative. He completed a five-day course of cefepime with resolution of diarrhea and leukocytosis. Subsequently, he was started on methylprednisolone for treatment of alcoholic hepatitis, and later discharged on a tapering dose. Eleven days later, he returned with vomiting and generalized weakness, and was admitted to the intensive care unit with pansusceptible P. aeruginosa bacteremia and septic shock. Unfortunately, clinical condition continued to deteriorate despite maximal medical therapy, and he ultimately expired. Discussion: P. aeruginosa has rarely been described in association with colitis. To our knowledge, this is the first reported case of P. aeruginosa colitis in a patient with alcohol-induced cirrhosis, and the first case of P. aeruginosa bacteremia after previously treated colitis. While the optimal duration of treatment for P. aeruginosa colitis is not well defined, this case supports extended antibiotic courses for the treatment of P. aeruginosa infections in decompensated cirrhosis and cautious post-treatment steroid utilization.Table 1.: This table depicts initial admission laboratory testing results for the patient’s two separate admissions.

S2886 Exertional Heat Stroke-Induced Acute Liver Failure and Liver Transplantation: A Case Report

Introduction: Exertional heat stroke (EHS) is characterized by excessive heat production and inadequate heat dissipation usually following heavy exertion in hot and humid climates. This is a medical emergency associated with hyperthermia and multiorgan dysfunction, including acute liver failure (ALF). Currently, there are no clear guidelines regarding the timing of liver transplantation (LT) in this patient population. Case Description/Methods: A 44-year old marathon runner with no past medical history presented to an outside hospital after being found unconscious following a 5-mile run in summer weather. Vitals were 39.4°C, HR 103, and MAP 50s. He was intubated, fluid resuscitated, started on vasopressors and broad-spectrum antibiotics, and admitted to a local intensive care unit where he underwent external cooling. Labs were notable for acute liver and kidney injury and rhabdomyolysis (peak ALT 10,850 IU/L, AST 870 IU/L, Cr 5.6 mg/dL and CK 16K U/L), and he required renal replacement therapy (Figure 1). He then developed disseminated intravascular coagulopathy (peak INR 7.9), which persisted despite multiple transfusions. Hepatitis panel was negative. He received N-acetylcysteine. On day 3, he was transferred to our hospital for consideration of LT. He was alert and interactive even while intubated. He was extubated, but after 48 hours became progressively encephalopathic. Therefore, he was listed for transplant as Status 1 and underwent successful cadaveric LT on day 7. Liver explant showed massive hepatocyte necrosis (>80%) in zones 2 and 3 and portions of zone 1. The patient was discharged on day 32 with recovery of renal function and at baseline mental status. His hospitalization was complicated by the development of an intra-abdominal hematoma and deep venous thrombosis. Two years post-LT, he continues to exhibit good graft function. Discussion: The overall mortality in EHS-related liver injury or failure has been shown to be 4-5%, and the liver transplantation rate ranges from 12.5-33.3%, with median time to liver transplantation of 3 days. A high index of suspicion and careful monitoring of mental status and coagulopathy are warranted given the high mortality rate in this patient population. In this patient, the decision to perform liver transplant was made after the development of hepatic encephalopathy and continued coagulopathy despite maximal medical therapy. This case illustrates the importance of early liver transplantation referral in patients with EHS-induced ALF.Figure 1.: Trend of patient's AST, ALT and total bilirubin during hospitalization.

S2172 Dysphagia Lusoria: A Rare Case of Aberrant Right Subclavian Artery Causing Esophageal Compression

Introduction: Dysphagia lusoria is a rare disorder found in only a small percentage of individuals with an anomalous right subclavian artery causing extrinsic compression of the esophagus. Diagnosis often requires a comprehensive evaluation of dysphagia and a high index of suspicion. We present a case of dysphagia lusoria followed by a review of the pathogenesis, clinical presentation, and management of this rare condition. Case Description/Methods: A 36-year-old female was admitted to our hospital with severe sepsis secondary to a UTI. During her hospitalization, she complained of progressive dysphagia to solids for approximately 6 months. She reported intermittent globus sensation and reflux for many years. An upper endoscopy was performed and revealed a pulsatile narrowing of the proximal esophagus. Gastric and esophageal biopsies were negative. CT angiogram identified possible extrinsic esophageal compression by an aberrant right subclavian artery (ARSA). High-resolution manometry demonstrated impression at the level of the upper esophagus with an increased pressure band likely due to the ARSA. Overall impedance to solids and liquids was normal and no underlying dysmotility was identified. A diagnosis of dysphagia lusoria was made based on these findings. Unfortunately, dietary modifications and maximal medical therapy proved ineffective. Due to the severity of her symptoms, surgical repair of the aberrant vessel was ultimately recommended. Discussion: Involution of the fourth vascular arch during embryogenesis leads to the formation of the ARSA from the persisting dorsal aortic arch distal to the left subclavian artery. Because the vessel most commonly crosses between the esophagus and vertebral column, retroesophageal compression can occur. However, dysphagia lusoria is an exceedingly rare cause of dysphagia in adults. A thorough evaluation of dysphagia with endoscopic, radiologic, and manometric testing is necessary to rule out other potential etiologies before the diagnosis can be made. Patients often complain of solid-food dysphagia (most common), regurgitation, postprandial bloating, chest pain, and coughing. Treatment strategies depend on the severity of symptoms, response to conservative therapies, and candidacy for surgical intervention. Mild symptoms can often be managed using a combination of dietary and lifestyle modifications and medical therapy. Surgical evaluation for repair of the aberrant vessel is indicated for severe or refractory symptoms.Figure 1.: Figure A. Upper endoscopy demonstrating extrinsic compression of the proximal esophagus. The narrowed segment was measured at 18 cm from the incisors and had a pulsatile appearance. Figures B & C. Computed tomography angiogram of the chest (axial and coronal cuts) demonstrating the aberrant right subclavian artery (yellow arrows) with its origin from the distal aortic arch. Figure D. High-resolution manometry study demonstrating impression with an increased pressure band in the upper to mid esophagus caused by the aberrant right subclavian artery. Overall impedance to solids and liquids was within normal limits (90% complete clearance of liquid bolus swallows) with normal esophageal motility (9/10 swallows had normal contraction pattern with a mean DCI of 3127 mmHg-s-cm).

Single Center Experience with Isolated Spinal Cord Neurosarcoidosis

Isolated spinal cord neurosarcoidosis is extremely rare. The potential implications of long-term immunosuppressant therapy make correct diagnosis imperative. However, there are challenges inherent in isolated spinal cord involvement that require a multidisciplinary approach. Here we present the largest series of definite and possible isolated spinal neurosarcoidosis and discuss our institutional experience in managing this rare but morbid condition. A retrospective review was performed to identify all neurosarcoidosis cases starting from 2002 to 2020 at our institution. Patients were screened for cases of isolated spinal neurosarcoidosis. A descriptive analysis was performed for each case. A total of 64 cases of neurosarcoidosis were identified. The spine was involved in 26 (40.6%) patients. Only 4 (6.3%) cases had isolated spinal cord involvement. A full medical and imaging workup was performed in determining isolated spinal cord involvement. Three patients subsequently underwent surgical biopsy, and 1 did not undergo biopsy because of patient preference. One of the patients who underwent biopsy had an initial nondiagnostic biopsy and had a repeat biopsy. Corticosteroids were employed in all cases with additional immunosuppressive agents for maintenance therapy and refractory cases. All showed radiographic improvement and were clinically stable to improved. Isolated spinal cord involvement of neurosarcoidosis is rare and can present challenges in diagnosis. A biopsy can be performed when necessary. However, a biopsy of the spinal cord carries inherent risks and may not always be possible or result in a nondiagnostic sample. In the setting of high clinical suspicion, maximal medical therapy is still employed.

Long-term efficacy and safety of omalizumab for nasal polyposis in an open-label extension study

Chronic rhinosinusitis with nasal polyps (CRSwNP) frequently remains uncontrolled despite maximal medical therapy and sinonasal surgery, presenting several unmet needs and challenges. Omalizumab previously demonstrated efficacy in CRSwNP in duplicate phase 3, randomized, placebo-controlled trials (POLYP 1, POLYP 2). This open-label extension evaluated the continued efficacy, safety, and durability of response of omalizumab in adults with CRSwNP who completed POLYP 1 or 2. After 24 weeks of omalizumab or placebo in POLYP 1 and 2, patients (n= 249) received open-label omalizumab plus background nasal mometasone therapy for 28 weeks and were subsequently followed for 24 weeks after omalizumab discontinuation. Efficacy end points assessed change from baseline for the coprimary end points, Nasal Polyp Score and Nasal Congestion Score, and the secondary end points of Sino-Nasal Outcome Test 22, Total Nasal Symptom Score and its components, and University of Pennsylvania Smell Identification Test scores. Safety objectives included incidence of adverse events and adverse events leading to omalizumab discontinuation. Patients who continued omalizumab experienced further improvements across coprimary end points and secondary end points through 52 weeks. Patients who switched from placebo to omalizumab experienced favorable responses across end points through week 52 that were similar to POLYP 1 and 2 at week 24. After omalizumab discontinuation, scores gradually worsened over the 24-week follow-up, but remained improved from pretreatment levels for both groups. The safety profile was similar to previous reports. The efficacy and safety profile from this study supports extended omalizumab treatment up to 1 year for CRSwNP with inadequate response to nasal corticosteroids.

Inherited Arrhythmia Syndromes.

Inherited Arrhythmia Syndromes.

External carotid artery to internal carotid artery transposition to augment flow for a superficial temporal artery to middle cerebral artery bypass associated with severe external carotid artery stenosis.

Donor vessel quality can impact the outcome of extracranial-intracranial (EC-IC) bypass. External carotid artery (ECA) disease may produce embolism into the anastomosis and cerebral territory and possibly reduce flow in the superficial temporal artery (STA). Previously reported remedies to ECA stenosis include ECA endarterectomy, stenting, and angioplasty. Clinical presentation A middle-aged patient with chronic left MCA occlusion, progressive ischemic symptoms on maximal medical therapy, and imaging confirmation of compromised hemodynamic reserve was evaluated for EC-IC bypass. Angiography demonstrated severe ECA origin stenosis. An ECA-ICA transposition was performed, primarily to eliminate the risk of emboli and secondarily to possibly improve the STA flow. The patient sustained an excellent radiological and clinical outcome, and the STA donor cut-flow was increased modestly by 22% (45 to 55mL/min). This case is the first report of an ECA to internal carotid artery transposition as an option in the management of ECA stenosis in preparation for an STA-MCA bypass for the purpose of flow augmentation.

Efficacy of Low-Dose versus High-Dose Continuous Cyclic Azithromycin Therapy for Preventing Acute Exacerbations of COPD

Background: Long-term azithromycin therapy significantly reduces the frequency of COPD exacerbations (ECOPD). However, previous studies have used different dosing regimens, and the efficacy of these regimens has not been compared. Objective: Compare the efficacy of low-dose with high-dose continuous cyclic azithromycin (CC-A) in severe COPD. Methods: Patients with severe COPD and repeated exacerbations (ECOPD ≥4 or ≥3 with at least 1 hospital admission in the previous year) were prospectively recruited (January 2017 to December 2019) as a multicenter cohort (from 3 university hospitals in the Barcelona area) and treated with low-dose CC-A: 250 mg 3 times per week (250-CC-A group). This cohort was compared with a historical (January 2007 to December 2013) single-center cohort of severe COPD with frequent ECOPD treated with high-dose CC-A: 500 mg 3 times per week (500-CC-A group). To assess differences in ECOPD prevention according to the administration of low-dose or high-dose CC-A, moderate-to-severe ECOPD was evaluated during the 12-month period before and after starting CC-A therapy. Results: Fifty-eight patients with severe COPD were evaluated: 37 in the low-dose group and 21 in the high-dose group. The 250-CC-A therapy group achieved a mean reduction in moderate-to-severe ECOPD of 65.6% at 12 months after starting CC-A therapy (with a 61.5% reduction in hospitalizations), while the 500-CC-A group achieved a reduction of 60.5% (with a 44.8% reduction in hospitalizations). No significant differences between 250-CC-A and 500-CC-A dosages were observed in the mean annual reduction of moderate-to-severe ECOPD (p = 0.55) or hospitalizations (p = 0.07) with respect to the year prior to starting CC-A. Conclusions: Low-dose 250-CC-A therapy over a 1-year period is similar to high-dose 500-CC-A in reducing exacerbation frequency in severe COPD patients with frequent ECOPD despite maximal medical therapy.

Cell therapy for nonischemic dilated cardiomyopathy: A systematic review and meta-analysis of randomized controlled trials.

Cell therapy involves transplantation of human cells to promote repair of diseased or injured tissues and/or cells. Only a limited number of mostly small‐scale trials have studied cell therapy in nonischemic cardiomyopathy (NICM). We performed a meta‐analysis of randomized clinical trials (RCTs) to assess the safety and efficacy of cell therapy in NICM. Electronic databases were searched for relevant RCTs from inception until August 2020. Outcomes assessed were left ventricular ejection fraction (LVEF), left ventricular end‐diastolic diameter or volume (LVEDD), quality of life (QoL) indices, and major adverse cardiac events (MACEs). Weighted mean differences (MDs) and standardized mean differences (SMDs) were calculated using random‐effects methods. Eleven RCTs with 574 participants were included in the analysis. There was a significant increase in mean LVEF (MD, 4.17%; 95% confidence interval [CI] = 1.66‐6.69) and modest decrease in LVEDD (SMD, −0.50; 95% CI = −0.95 to −0.06) in patients treated with cell therapy compared with controls. Cell therapy was also associated with improvement in functional capacity, as assessed by the 6‐minute walking distance (MD, 72.49 m; 95% CI = 3.44‐141.53). No significant differences were seen in MACEs and QoL indices between treated and control groups. This meta‐analysis suggests that cell therapy may improve LV systolic function and may be associated with improvement in LVEDD and functional capacity compared with maximal medical therapy. Cell therapy was safe, with no significant difference in MACEs between treatment and control groups. However, given the limitations of current studies, larger well‐designed RCTs are needed to evaluate the efficacy of cell therapy in patients with NICM.