Mild Persistent Symptoms Research Articles

COVID-19-Associated Cerebellitis: A Case Report and Rehabilitation Outcome

Introduction. The COVID-19 pandemic has brought attention to neurological complications, including cerebellitis, characterized by inflammation of the cerebellum. Despite its rare occurrence, cerebellitis has been associated with COVID-19 infection, albeit the pathogenic mechanisms remain unclear. Case report. We present the case of a 22-year-old male with acute onset ataxia and dysarthria during a SARS-CoV-2 infection. Diagnostic evaluations ruled out other causes, confirming cerebellitis. Treatment included steroid therapy, vitamin supplementation, physiotherapy, and intravenous immunoglobulins. Rehabilitation focused on enhancing balance, coordination, and daily activities. The patient showed significant improvement in functional abilities, with increased autonomy in daily activities and improved ambulation. Despite persistent mild symptoms, the multidisciplinary rehabilitation approach led to remarkable progress. Conclusions. This case underscores the importance of recognizing and managing neurological complications, such as cerebellitis, in COVID-19 patients. A comprehensive approach combining medical treatment and rehabilitation is essential for optimizing outcomes. Further research is needed to elucidate the pathogenesis and optimal management strategies for such complications.

A Newborn with Congenital Stridor.

A Newborn with Congenital Stridor.

Trajectories of physical symptom burden and psychological distress during the last year of life in patients with a solid metastatic cancer.

To delineate the trajectories of physical symptoms and psychological distress among patients with a solid metastatic cancer during the last year of life. We used data of 345 decedents from a prospective cohort of 600 patients with a Stage IV solid cancer. Using group-based trajectory modelling, we assessed (a) demographic (age, gender, education, cancer site) predictors of trajectory membership, (b) shift in trajectories associated with planned and unplanned hospitalizations, emergency room visits and chemotherapy, and (c) the association between trajectory membership and place of death. We identified three trajectories of physical symptoms-"persistent mild" (56%), "progressive moderate" (36%), and "progressive severe" (8%), and two for psychological distress-"persistent mild" (72%) and "progressive distress" (28%). Females (β=1.40 [SE=0.55], p-value=0.01) and highly educated patients (β=1.46 [SE=0.62], p-value=0.02) were more likely to experience progressive severe symptoms compared to persistent mild symptoms. Older patients were less likely (β=-1.01 [SE=0.33], p-value=0.003), while those with gynecological cancers (β=1.51 [SE=0.65], p-value=0.02) were more likely to experience progressive distress compared to persistent mild distress. Planned and unplanned hospitalizations, emergency room visits, and chemotherapy were associated with a worsening in trajectories. Patients with higher distress were more likely to die in a hospice compared to a hospital. Interventions to improve physical symptoms and distress can focus on patients at risk of being in worse trajectories and at critical time points in the last year of life-hospitalizations, emergency room visits, and chemotherapy.

Minimal channel GreenLight photovaporization before permanent implant prostate brachytherapy for patients with obstructive symptoms: Technically feasible and safe

PurposeBrachytherapy (BrT) is a standard treatment for low-risk to favorable-intermediate-risk prostate cancer but is a relative contraindication for patients with obstructive symptoms. We aimed to assess the feasibility and urinary toxicity of a minimal photovaporization (mPVP) before implantation. Materials and MethodsBetween 04/2009 and 08/2016, 50 patients candidates for BrT but with International Prostate Symptom Score (IPSS)>15, uroflowmetry <15 mL/s, obstructive prostate or large median lobe underwent a mPVP (GreenLight Laser) at least 6 weeks (median 8.5) before permanent seed implantation (loose seeds, 125I, 160 Gy). ResultsTwo patients (4%) did not have sufficient improvement and did not undergo BrT, although it would have been possible at 3 months. For the 48 (96%) other patients, at the baseline, mean IPSS was 15.5 (±5.3), vs. 8.6 (±4.4) after mPVP (p = 1 × 10−6), and uroflowmetry 11.7 mL/s (±4), vs. 17.4 (±5.4) (p = 1.4 × 10−5). We did not experience any difficulty for BrT. Mean IPSS did not significantly increase 1, 3, or 6 months after BrT. With a median followup of 60 months [30–120], (92% assessed at last followup), only 4 patients (4/48 = 8.3%) experienced urinary retention and 5 (10.4%) needed surgery for urinary toxicity. In addition, only 2 patients (4%) needed medical treatment at last followup. Considering the 8 patients with de novo incontinence at 1 year, only 2 (4%) had persistent mild symptoms at last followup (36 months) (ICS1-2). ConclusionsThese results suggest that a two-step approach with an mPVP at least 6 weeks before BrT is feasible, with no excessive urinary toxicity, and may be a good strategy for obstructive patients seeking BrT.

Montelukast use over the past 20 years: monitoring of its effects and safety issues.

Montelukast, a leukotriene receptor antagonist, was launched 20 years ago in Korea. It is recommended as an alternative treatment for asthma in children with mild persistent symptoms or as an add-on treatment to existing low-dose inhaled corticosteroids (ICSs) in children who require additional treatment. However, in the real-world setting, many doctors and patients prefer montelukast over ICSs despite their lower efficacy. Although montelukast is considered to be a safe drug, there are concerns regarding adverse drug reactions, including the rare occurrence of Churg-Strauss syndrome and, despite insufficient data, the possibility of neuropsychiatric events such as anxiety, depression, sleep disturbance, and suicidality. This review identified that montelukast has significantly contributed to asthma control over the past 20 years in Korea and has been critical for reducing asthma severity, especially early wheezing and disease control. Our findings suggest that the effects of montelukast treatment can be monitored by measuring serum eosinophilderived neurotoxin levels.

TRAJECTORIES AND CORRELATES OF POST-LOSS DEPRESSIVE SYMPTOMS IN FORMER DEMENTIA CAREGIVERS

Approximately 30-40% of family caregivers of relatives living with dementia report depression, compared to 9.5% of the general adult population. Studies suggest that depressive symptoms persist for many years following the care recipient’s death, despite resolution of caregiving responsibilities. However, long-term patterns of post-loss depressive symptoms remain poorly understood. The aim of this integrative review was to examine longitudinal trajectories and correlates of depressive symptoms in dementia caregivers following the care recipient’s death. A literature search was conducted using CINAHL, MEDLINE, and PsycINFO databases. Studies met the eligibility criteria if they were peer-reviewed, primary sources and reported research exploring correlates and/or longitudinal patterns of post-loss depressive symptoms in dementia caregivers. Data quality was evaluated using the widely-used quality appraisal tool developed by Hawker and colleagues (2002). Data were extracted, displayed in matrix format, and synthesized into themes. Fourteen studies met the eligibility criteria and were rated as high quality. Overall, depressive symptom severity trended down during the first year post-loss but did not reduce to levels reported by non-caregiving controls. Symptom trajectories varied among unique caregiver subgroups and included persistent-distressing symptoms, persistent-mild symptoms, and asymptomatic. Greater severity of post-loss depressive symptoms was associated with female gender, lower income, less social support, pre-loss depression, neurotic and optimistic personality traits, and avoidant coping style. The findings indicate that many caregivers could benefit from mental health screening and psychosocial support during the first year post-loss and underscore the need for longitudinal studies that explore depressive symptom trajectories beyond the first 1-2 years post-loss.

MODERATE PERSISTENT ASTHMA IN CHILDREN;

Objective: The objective of this study is to compare the effects of inhaledbeclomethasone with oral montelukast in long term management of moderate persistent asthmain children. Design: Quasi experimental study. Period: 6 months, from July 20,2007 to January20, 2008. Settings: Out patient paediatric department at Fauji Foundation hospital, Rawalpindi.Material and Methods: 8o children between 5-12yrs of age presenting with moderate persistentasthma, divided in two groups of 40 each. Group A treated with beclomethasone inhaler whileGroup B was started on oral montelukast. Drugs effect was recorded on a 2 wkly proforma for 8weeks. Results: There were 54(67.5%) male and 26(33%) female. Most common triggeringfactor seen in 54(67.5%) patients was recent history of respiratory tract infection, exposure tocarpet dust in 43(53.75%), cigarette smoke in 42(52.5%),recent psychological stress in 28(35%) ,pollen allergy in 26 (32.5%) , pets exposure in 8 (10%) and to mite was noticed in 5(6.25%)children. Marked improvement was observed in day time cough in group A with 10(25%) patientsbeing free of cough with inhaler, while 20(50%) showed mild intermittent symptoms. 1(2.5%)showed mild persistent symptoms. In Group B 3(7.5%) patients were symptom free,23(57.5%)with mild intermittent and 4(10%) with mild persistant symptoms while 6(15%)continued to have moderate persistent symptoms. P value was 0.01. Regarding day timebreathlessness, P value was significant of 0.258. Similarly marked improvement was observed innight symptoms of breathlessness, cough and sleeplessness in both groups. P value was lessthan 0.05 in majority of the variables showing statistically significant improvement with inhaledbeclomethasone than with oral montelukast. Conclusions: Inhaled beclom

Middle Mesial and Middle Distal Canals in Mandibular First Molar.

Root canal anatomy is a complex entity. The main objective of root canal treatment is to get rid of the infection and have a good apical and coronal seal with an appropriate filling. Inability to achieve thorough cleaning and shaping followed by three-dimensional obturation of the root canal system usually causes root canal treatment failure. For this reason, clinicians should be aware of these anatomical variations to achieve successful treatment. The aim of this article is to report on the successful treatment and follow-up of mandibular first molar with additional middle mesial (MM) and middle distal (MD) canals. A 29-year-old white male patient reported with a complaint of pain in relation with tooth #19. On clinical examination, diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis and condensing osteitis was made and nonsurgical root canal treatment was planned. Initially, two mesial and two distal canals were located, and the patient was planned for the obturation in the second visit. The complaint of mild persistent symptoms gave a possibility of additional canals. Under the dental operating microscope and selective troughing on the floor of the pulp chamber with ultrasonic tips, additional canals were located as MM and MD canals. Leaving some area of the root canal system untreated is found to be one of the main reasons for root canal treatment failure. Dentists should take advantage of new tools, such as dental operating microscope and ultrasonic tips to be able to locate and treat the hidden and unusual anatomy. Mandibular first molar with six canals is very rare to encounter. Clinician should have a thorough knowledge of these unusual anatomy to avoid treatment failure due to incomplete disinfection of the root canal system.

Allergen-specific immunoglobulin E and allergic rhinitis severity.

Background:Allergic rhinitis (AR) is a common disorder. The diagnosis is based on the concordance between allergy sensitization and history. Serum allergen specific immunoglobulin E (sIgE) assessment allows characterization of the relevant sensitizing allergens. Presently, Allergic Rhinitis and its Impact on Asthma (ARIA) classification subdivides AR based on symptoms severity and duration. However, the relationship between sIgE levels and symptom severity is still a matter of debate.Objective:Therefore, this study aimed at relating sIgE levels with symptom severity assessed by ARIA classification in a group of patients with AR.Methods:We enrolled 217 patients with AR (123 women; median age, 39.5 years). The sIgE levels (expressed in kUA/L) to house-dust mite were detected by the fluorescence enzyme immunoassay in peripheral blood samples. The IgE calibrators were traceable to the second international reference preparation 75/502 of human serum IgE from the World Health Organization. Symptom severity was assessed by ARIA classification.Results:We found a significant difference in sIgE levels in patients with mild intermittent versus mild persistent symptoms (p < 0.05), mild intermittent versus moderate-to-severe persistent symptoms (p < 0.001), moderate-to-severe intermittent versus moderate-to-severe persistent symptoms (p < 0.01), and mild persistent versus moderate-to-severe persistent symptoms (p < 0.05).Conclusion:Analysis of these findings indicated that the sIgE level to house-dust mite might be a reliable biomarker for symptom severity in patients with AR. This outcome might be clinically relevant, particularly in candidates for immunotherapy.

It’s the adherence, stupid (that determines asthma control in preschool children)!

Although guideline-based asthma care and adherence to inhaled corticosteroids are predictors of asthma control, the role of adherence in maintaining long-term asthma control is largely unknown. This study was designed to explore the relationship between adherence to inhaled corticosteroids and long-term asthma control in young children with asthma. In this observational study, 81 2-6-year-old asthmatic children, using inhaled corticosteroids, closely followed-up in a programme with extensive self-management training, were enrolled. Adherence was measured daily for 12 months using Smartinhaler (Nexus6 Ltd, Auckland, New Zealand) devices. Long-term asthma control was assessed by parents and physicians and included clinical assessment, an asthma control questionnaire and lung function measurement. We examined the association of adherence to asthma control, adjusting for seasonal influences and clinical characteristics. Median (interquartile range) adherence was 87% (70-94%), and 64 (79%) children had well-controlled asthma throughout follow-up. Adherence >80% was associated with better asthma control, and we found no important confounders of this association. Children with persistent mild symptoms had lower adherence rates (p=0.028). Guideline-based asthma care was associated with good asthma control in most children. Adherence to inhaled corticosteroids was an independent strong predictor of long-term asthma control, with highest levels of asthma control found in children with adherence >80% of doses prescribed.

Preventive Asthma Care Delivery in the Primary Care Office: Missed Opportunities for Children With Persistent Asthma Symptoms

ObjectiveTo describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity. MethodsWe approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit. ResultsWe identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14–0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19–0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19–0.87), and receipt of action plan (OR 0.37, 95% CI 0.16–0.86). ConclusionsMany children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.

Natural History and Response to Treatments of Sclerosing Mesenteritis: Case Series and a Systematic Review

Purpose: To report natural history and response to treatments of sclerosing mesenteritis. Introduction: Sclerosing mesenteritis is an extremely rare nonneoplastic disease, characterized by fat necrosis, fibrosis, and chronic inflammation. It is in a spectrum of IgG4 sclerosing disease that usually involves pancreas, mesentery, biliary tract, and retroperitoneum. Previous studies revealed inconsistent data of natural history and response to treatment. We report case series diagnosed in our institutions and a systemic review of the disease. Methods: Two reviewers independently conducted a detailed literature search using MeSH terms: sclerosing mesenteritis, mesenteric lipodystrophy, mesenteric panniculitis, and retractile mesenteritis on major electronic databases including PubMed, Ovid Medline, Cochrane Library, and Embase. The reference list of each article was then hand searched. Exclusion criteria are incomplete clinical data, follow up duration of less than 1 month, and lack of histology. We also identified 6 cases from our institutions shown in a Table.Table: [274] Patients with sclerosing mesenteritis at University of Minnesota and VA Minneapolis Medical CenterResults: A total of 248 abstracts were scanned. We identified 25 studies(264 patients, 69% were male, with median age of 63 years) published during 1980 and 2012 to characterize natural history of the disease and 21 studies(138 patients) to evaluate responses to treatments. Presenting symptoms included abdominal pain in 60%, palpable mass in 29%, weight loss in 24%, obstruction in 19%, diarrhea in 16%, and chylous ascites in 6%. Treatment included medical therapy alone in 30%, surgery alone in 31%, surgery followed by medical therapy in 8%, and 31% received no treatment. Among 138 patients, 60% responded to medical therapy alone, 48% responded to surgery therapy alone, and 64% responded to additional medical treatment after surgery. Among patients treated with medical therapy alone, 67% responded to tamoxifen-based regimen(44%) while 48% responded to non-tamoxifen-based regimen(56%). Bowel obstruction was the major indication for surgery. Among patients who received no treatment, 27% resolved spontaneously while 70% had mild persistent symptoms. In our own institutions, 4 cases had mesenteric mass on initial CT abdomen, one had mesenteric mass found on exploratory laparotomy, and the other one presented with chylous pleural effusion. Response to treatment correlated with prior studies. Conclusion: Symptomatic patients may benefit from tamoxifen-based regimen therapy. Additional medical therapy after surgery might improve prognosis.

Cost of scheduled and unscheduled asthma management in seven European Union countries

Frequent need for emergency healthcare indicates poor asthma control and consumes resources that might be better spent on improved management. This study estimated the cost of scheduled and unscheduled healthcare for asthma in seven European Union (EU) countries.The occurrence of asthma-related healthcare resource use and asthma symptom severity were identified from a telephone sample of people with asthma in France, Germany, Italy, the Netherlands, Spain, Sweden and the UK. Healthcare resource use was multiplied by country-specific unit costs to estimate per patient annual expenditure. Patients were divided into four groups according to asthma symptom severity: mild intermittent symptoms, mild persistent symptoms, moderate persistent symptoms and severe persistent symptoms. Cost was divided between scheduled and unscheduled care. Drug cost was not evaluable.The study included 2,803 patients, of whom 1,695 (60%) reported mild symptoms and 2,050 (73%) were aged ≥16 yrs. The average annual per patient cost was €789 for patients aged 0–4 yrs, €463 for patients aged 5–15 yrs and €566 for adults. Unscheduled care accounted for 47% of total cost in infants, 45% in children and 56% in adults.Around half of expenditure on asthma management was found to be due to unscheduled care regardless of the severity of patient symptoms.

Congenital lung malformations?antenatal and postnatal evaluation and management

We reviewed our institutional experience with pulmonary resection for congenital bronchopulmonary malformations and analysed the management and outcome of pregnancies with a prenatal diagnosis of congenital lung malformations. Between January 1993 and December 2003, 31 patients underwent evaluation and pulmonary resection for bronchopulmonary malformations. Common clinical presentations were respiratory distress (9), respiratory infections/pneumonias (22), and dyspnoea (9). Diagnostic modalities included chest radiography, CT scan (22), MRI scan (7), arteriography (1), and bronchoscopy (5). There were 13 congenital cystic adenomatoid malformations (CCAM), six pulmonary sequestrations, three bronchogenic cysts, and nine congenital lobar emphysemas (CLE). Fifteen patients who underwent resection were diagnosed by antenatal ultrasound. No foetus had hydrops or associated malformations. No pregnancy was terminated. There was no foetal demise. Regression of the sonographic appearance was observed in six cases. Amniotic puncture was required for hydramnios in three cases. Eight emergency resections were performed (CCAM 4; CLE 3; Bronchogenic cyst 1). Surgical procedures included 24 lobectomies, one right middle lobectomy with a wedge resection of the right lower lobe, one completion right lower lobectomy, four sequestrectomies, one mediastinal mass excision and one wedge resection for a bronchogenic cyst. There were no deaths. Postoperative complications included: persistent air leak (n=2; one requiring completion lobectomy) and pneumothorax (1). Persistent mild symptoms were present in five patients, at long-term follow-up. Congenital cystic adenomatoid malformation and congenital lobar emphysema were the commonest congenital anomalies. Congenital lung malformations are increasingly diagnosed antenatally, sometimes necessitating emergent surgical resection. The natural history is variable. All infants with a prenatal diagnosis require postnatal evaluation. Patients should be evaluated for associated disorders. The presence of mass effects is an indication for therapeutic decompression. The risk of pulmonary compression, infection and malignant degeneration makes resection imperative, even in asymptomatic patients. Lobectomy is the procedure of choice, is well tolerated, and leads to excellent outcomes.

The development of psychological changes following whiplash injury

Psychological distress is a feature of chronic whiplash-associated disorders, but little is known of psychological changes from soon after injury to either recovery or symptom persistence. This study prospectively measured psychological distress (General Health Questionnaire 28, GHQ-28), fear of movement/re-injury (TAMPA Scale of Kinesphobia, TSK), acute post-traumatic stress (Impact of Events Scale, IES) and general health and well being (Short Form 36, SF-36) in 76 whiplash subjects within 1 month of injury and then 2, 3 and 6 months post-injury. Subjects were classified at 6 months post-injury using scores on the Neck Disability Index: recovered (<8), mild pain and disability (10–28) or moderate/severe pain and disability (>30). All whiplash groups demonstrated psychological distress (GHQ-28, SF-36) to some extent at 1 month post-injury. Scores of the recovered group and those with persistent mild symptoms returned to levels regarded as normal by 2 months post-injury, parallelling a decrease in reported pain and disability. Scores on both these tests remained above threshold levels in those with ongoing moderate/severe symptoms. The moderate/severe and mild groups showed elevated TSK scores at 1 month post-injury. TSK scores decreased by 2 months in the group with residual mild symptoms and by 6 months in those with persistent moderate/severe symptoms. Elevated IES scores, indicative of a moderate post-traumatic stress reaction, were unique to the group with moderate/severe symptoms. The results of this study demonstrated that all those experiencing whiplash injury display initial psychological distress that decreased in those whose symptoms subside. Whiplash participants who reported persistent moderate/severe symptoms at 6 months continue to be psychologically distressed and are also characterised by a moderate post-traumatic stress reaction.

Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery

Hypersensitivity to a variety of sensory stimuli is a feature of persistent whiplash associated disorders (WAD). However, little is known about sensory disturbances from the time of injury until transition to either recovery or symptom persistence. Quantitative sensory testing (pressure and thermal pain thresholds, the brachial plexus provocation test), the sympathetic vasoconstrictor reflex and psychological distress (GHQ-28) were prospectively measured in 76 whiplash subjects within 1 month of injury and then 2, 3 and 6 months post-injury. Subjects were classified at 6 months post-injury using scores on the Neck Disability Index: recovered (<8), mild pain and disability (10–28) or moderate/severe pain and disability (>30). Sensory and sympathetic nervous system tests were also measured in 20 control subjects. All whiplash groups demonstrated local mechanical hyperalgesia in the cervical spine at 1 month post-injury. This hyperalgesia persisted in those with moderate/severe symptoms at 6 months but resolved by 2 months in those who had recovered or reported persistent mild symptoms. Only those with persistent moderate/severe symptoms at 6 months demonstrated generalised hypersensitivity to all sensory tests. These changes occurred within 1 month of injury and remained unchanged throughout the study period. Whilst no significant group differences were evident for the sympathetic vasoconstrictor response, the moderate/severe group showed a tendency for diminished sympathetic reactivity. GHQ-28 scores of the moderate/severe group were higher than those of the other two groups. The differences in GHQ-28 did not impact on any of the sensory measures. These findings suggest that those with persistent moderate/severe symptoms at 6 months display, soon after injury, generalised hypersensitivity suggestive of changes in central pain processing mechanisms. This phenomenon did not occur in those who recover or those with persistent mild symptoms.

Improvement of inflammatory bowel disease after allogeneic stem-cell transplantation.

Because causes of inflammatory bowel disease (IBD) remain obscure and a curative therapy is still lacking, the influence of stem-cell transplantation (SCT) on IBD is of major interest. We retrospectively analyzed the course of seven patients with Crohn's disease and four patients with idiopathic ulcerative colitis who underwent allogeneic SCT between July 1994 and August 2002 for acute and chronic myeloid leukemia and myelodysplastic syndrome. After a median follow-up of 34 months posttransplantation, 10 patients are alive. None of the patients showed IBD activity after SCT, except one patient with mild persistent symptoms of Crohn's disease early after transplant. Colonoscopy after complete discontinuation of prophylactic posttransplant immunosuppression revealed no pathologic findings. These observations imply that host immune dysregulation plays a central role in the perpetuation of IBD. It may be influenced by the implementation of a new allogeneic immune system resulting from the transplantation of hematopoietic stem cells.

Development of motor system dysfunction following whiplash injury

Dysfunction in the motor system is a feature of persistent whiplash associated disorders. Little is known about motor dysfunction in the early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms. This study measured prospectively, motor system function (cervical range of movement (ROM), joint position error (JPE) and activity of the superficial neck flexors (EMG) during a test of cranio-cervical flexion) as well as a measure of fear of re-injury (TAMPA) in 66 whiplash subjects within 1 month of injury and then 2 and 3 months post injury. Subjects were classified at 3 months post injury using scores on the neck disability index: recovered (<8), mild pain and disability (10–28) or moderate/severe pain and disability (>30). Motor system function was also measured in 20 control subjects. All whiplash groups demonstrated decreased ROM and increased EMG (compared to controls) at 1 month post injury. This deficit persisted in the group with moderate/severe symptoms but returned to within normal limits in those who had recovered or reported persistent mild pain at 3 months. Increased EMG persisted for 3 months in all whiplash groups. Only the moderate/severe group showed greater JPE, within 1 month of injury, which remained unchanged at 3 months. TAMPA scores of the moderate/severe group were higher than those of the other two groups. The differences in TAMPA did not impact on ROM, EMG or JPE. This study identifies, for the first time, deficits in the motor system, as early as 1 month post whiplash injury, that persisted not only in those reporting moderate/severe symptoms at 3 months but also in subjects who recovered and those with persistent mild symptoms.

Anti‐inflammatory treatment for recurrent wheezing in the first five years of life

Medications identified for the treatment of recurrent wheezing in preschool children by the Expert Panel Report of the NHLBI Guidelines for the Diagnosis and Management of Asthma include inhaled corticosteroids, chromones, theophylline, and leukotriene pathway modifiers. However, these various agents differ in their mechanism, extent of action on the airway inflammatory process, and degree of clinical efficacy. Inhaled corticosteroids can control symptoms in many young children with even severe persistent wheezing, but data on their long-term safety when administered in preschool-age children are scarce. There is some information on the uninterrupted use of inhaled corticosteroids in school-age children and the absence of an adverse effect on ultimate adult height. Despite laboratory evidence of adrenal suppression in some studies, few pediatric cases of clinical adrenal insufficiency have been reported. Low-dose inhaled corticosteroid (<400 mcg/day for beclomethasone), which is adequate for controlling mild persistent symptoms, is generally safe. Chromones have a remarkable safety profile, but they are most effective for symptoms of mild severity. Promising data have been published on the efficacy and safety of leukotriene pathway modifiers when used in young children with persistent symptoms. It is uncertain whether early introduction and long-term administration of inhaled corticosteroids prevent development of irreversible airway obstruction. Nevertheless, they may be especially useful for patients with moderate to severe disease in whom other agents (chromones or leukotriene pathway modifiers) will most likely fail to control symptoms. Pediatr Pulmonol. 2003; 35:241-252.

Endovascular Surgery: An Integral Component of Treatment for Infected Aortobifemoral Bypass Grafts

Endovascular reconstruction may be used alone or in combination with standard vascular techniques in dealing with infected grafts. This case report concerns a 53-year-old man who presented with sepsis 3 years after undergoing aortobifemoral bypass. The bypass was performed after two failed angioplasties. The proximal anastomosis was performed in an end-to-side fashion. One year prior to presenting with sepsis, the patient developed acute myelogenous leukemia and underwent chemotherapy with subsequent remission. Eight months later, the patient developed low-grade fever and chills and was treated for pulmonary infection. Persistent mild symptoms prompted a Gallium scan that raised the possibility of an infected aortic graft. Subsequent computed tomography (CT) scan, magnetic resonance imaging (MRI), and Indium scan were normal. Admission was prompted when he presented with biopsy-documented septic emboli to the right leg. Repeat CT scan suggested aortic graft infection localized to the proximal graft segment. Operative repair included a right common femoral endarterectomy, a right iliac balloon angioplasty, insertion of a right iliac Wallstent, and a right-to-left femoral-femoral polytetrafluoroethylene (PTFE) bypass. The well-incorporated femoral graft limbs were detached and the groins closed. Abdominal exploration identified a jejunal-aortic graft erosion with a localized abscess. The infected graft was removed and the aortotomy repaired with a patch fashioned from an endarterectomized portion of the occluded left external iliac artery. Small bowel resection with primary anastomosis and omental flap completed the operation. Four days postoperatively, the Wallstent required further expansion with an open balloon angioplasty to establish palpable pedal pulses. The patient recovered uneventfully and received a total of 6 weeks of broad-spectrum intravenous antibiotics. This case illustrates the use of adjunctive endovascular techniques in handling difficult vascular graft infections and stresses their importance as an integral component of the vascular surgeon's armamentarium.