Partial Resolution Of Symptoms Research Articles

FRI0448 FOUR CASES OF SYPHILIS MIMICKING RHEUMATOLOGICAL CONDITIONS PRESENTING TO THE GENERAL RHEUMATOLOGY SERVICE AT ST GEORGES HOSPITAL, LONDON, UK IN 2018-2019

Background:Sir William Osler once wrote: “He, who knows syphilis, knows medicine”.Whilst the Tuskegee Syphilis trials live in infamy, the advent of succesful penicillin treatment and sexual health education resulted in the lowest recorded incidence ever in 20011.Unfortunately, cases of syphilis have nearly tripled in the past decade (from 2,847 in 2009 to 7,541 in 2018 in the UK)1. WHO now estimates the global median prevalence of Syphilis, among men who have sex with men, is 6%2The current cohort of clinicians will therefore have limited clinical experience of Syphilis, which can often mimic rheumatic conditions. We present the clinical experience of a tertiary teaching centre hospital.Objectives:To identify the scope of clinical cases, with a diagnosis of Syphilis, during 2018-2019 at St Georges University Hospital, London, UK.Methods:Clinical cases were identified by health professionals and a retrospective review of medical records was undertaken.Results:There were 4 cases identified during 2018-19.PatientAgeSexPast Medical HistorySymptomatologyRisk FactorsPresumed DiagnosisSerology169MaleHypertensionGCABilateral visual loss, rashMSMPrednisoloneTocilizumabGCA-related visual lossRPR 1:64TPPA 1: 10248246FemaleNilJoint pain and swelling, rashHepatitis B Core Antibody positiveUndifferentiatedInflammatory ArthritisRPR 1: 16340MaleNilJoint pain, alopecia, uveitis and rash, weight lossMSMPrimary SyphilisRPR 1: 16TPPA 1: 10248486FemalePulmonary Sarcoidosis, Squamous cell carcinoma of left maxillary sinusLower motor neuron facial nerve palsyPrednisoloneSarcoidosisRPR 1:4TPPA 1:80GCA: Giant cell arteritis, MSM: Men who have sex with men, RPR: rapid plasma regain, TPPA: Treponema pallidum particle agglutination assayCase 1:The patient was diagnosed with bilateral uveitis secondary to primary syphilis, and immunosuppression may have contributed to this.Case 2:The rash developed after the initial presentation and an extended infection screen was performed.Case 3:The patient had a 6 month duration of symptoms and had had a negative sexual health screen 1 year prior to presentation.Case 4:The patient had no features of extra pulmonary sarcoidosis and an infectious screen was undertaken.All 4 cases were referred to the Infectious Disease Unit for treatment. 3 patients received standard treatment with Penicillin, and 1 patient received an oral course of Doxycycline, due to a penicillin allergy.2 of the 4 cases had complete resolution of symptoms, and 2 of the cases had only partial resolution of symptoms at the time of publication.Conclusion:Syphilis can present with an inflammatory arthritis, PMR and GCA –type symptoms, ocular inflammation, neurological disturbance and rashes that can mimic autoimmune conditions.Our cases highlight the increasing incidence, as well as the risk of reactivation following immunosuppression. Current practice does not advise routine testing for syphilis prior to initiation of immunosuppressive therapy. However the rising incidence should prompt careful evaluation, and detailed sexual history, particularly in high risk groups. The diagnostic test interpretation and treatment requires close collaboration with Infectious Diseases Specialists.

Carotid-Cavernous Fistula Presenting With Bilateral Abducens Palsy.

Carotid-Cavernous Fistula Presenting With Bilateral Abducens Palsy.

Which procedure for stress urinary incontinence? Injectable.

Which procedure for stress urinary incontinence? Injectable.

Low dose, targeted alpha blockers for refractory bladder dysfunction in children – a single centre experience

In children with refractory bladder dysfunction, the use of alpha blockers is being explored; although it remains off-label in Australia. We report subjective and objective outcomes of low dose targeted alpha blocker therapy in refractory bladder dysfunction. A retrospective chart review at John Hunter Children’s Hospital between March 2015 and March 2019 was performed. Children with high post-void residuals (PVR) or frequency-urgency symptoms, who had failed or were intolerant to standard treatments, and were given additional alpha blocker therapy were included in this study. Data collected included; patient characteristics, medication used with its dose and duration, side effects, subjective outcomes in the form of symptomatic response and objective outcomes measured by PVR and uroflowmetry. Fifteen patients (male=13, median age=8 years) were trialled on alpha blockers, with a median follow-up of 12 months. Alpha blockers were commenced due to ongoing high PVR (n=11) or overactive bladder syndromes (n=4) (Table 1). Alpha blockers used included: Tamsulosin (n=6), Terazosin (n=7) and Prazosin (n=2). Partial resolution of symptoms was achieved in 60% (9/15), and complete resolution in 33% (5/15) of patients. In the high PVR cohort, mean PVR decreased from 100mls to 23.1mls post-alpha blocker use. Severe nausea was noted in one patient on Terazosin, necessitating discontinuation.Table 1Symptomatic response to alpha blockers for different bladder syndromes based on ICCS definitionsIndication for Alpha blockersComplete responsePartial responseNo responseValve-bladder syndrome (high PVR)21Dysfunctional voiding (high PVR)13Bladder neck dysfunction (high PVR)1Underactive detrusor (high PVR)2Voiding postponement (high PVR)1Overactive bladder syndrome121Total:591 Open table in a new tab Low dose alpha blocker therapy may provide symptomatic improvement in children with refractory bladder symptoms. The results appear less encouraging in children with overactive bladder syndrome.

Follow-up of patients subject to the mild traumatic brain injury

Background: In the past decade, accidents have been one of the top 10 causes of death in Taiwan. Head trauma caused by accidents has been an issue of concern in Taiwan. Although serious long-term effects have been documented, research on mild traumatic brain injury (mTBI) remains scarce. Thus, the main purpose of this study was to analyze post-concussion symptome (PCS) and the relevant impact on physical, emotional, and cognitive functions. Materials and Methods: During 2012–2013, 105 patients with mTBI in a single hospital were surveyed based on the Rivermead postconcussion symptoms questionnaire in 1 week, and their postinjury status was followed 1 month later. The collected data were analyzed using the paired t-test and descriptive statistics. Results: The collected data were included patient demographics and pretrauma risk factors. A total of 101 patients were subject to mTBI. The rate increased among males and the population aged from 21 to 44 years old. The most common cause of injury was the motorcycle accident, where half of the patients had an initial loss of consciousness and posttraumatic amnesia. Partial resolution of symptoms was noted within 1 month for all participants, but some symptoms persisted (P Conclusion: This study presents patients' PCS symptoms in different periods. Those symptoms improved gradually in 1 month, but some symptoms persisted, especially those affecting emotional and cognitive functions. Most patients in this study were young, and the illness had impact on the patients' daily life. As shown by the results, the risk factors were associated with prolonged PCS among females. Aside from physical symptoms, special attention should be paid to mental care as well. More predictors for mTBI may improve medical care quality and reduce losses of medical resources.

Long Term – Twenty Nine Years – Results of the Conventional Surgical Treatment of the Subclavian Steal Syndrome – A Single Center Experience

Introduction: The aim of the study was to assess the patency rates, symptoms resolution rates and the safety of the surgical procedures performed in the conventional surgical treatment of the subclavian steal syndrome, which is caused by severe atherosclerotic lesions of the proximal part of the subclavian or innominate artery and may result in cerebral or upper extremity ischemia. Vast majority of those lesions may be treated with endovascular methods. However, in particular cases conventional surgical procedure remains the best option. Methods: A retrospective review of 75 patients with subclavian steal syndrome, who underwent conventional surgical treatment in our Department between 1988 and 2019, was performed. The vertebrobasilar insufficiency symptoms that covered: dizziness, vertigo, headache, tinnitus, drop attacks, perioral numbness, visual disturbances and arm claudication were most commonly presented among our study group. The indications for surgical treatment included: 44 subclavian artery occlusions, 18 failed angioplasty procedures, 7 innominate artery stenosis, 3 innominate artery occlusions, one carotid subclavian graft thrombosis and 2 restenoses after multiple transluminal angioplasties with stent implantation. The following vascular procedures were performed: 38 subclavian-carotid transpositions, 16 carotid-subclavian PTFE bypasses, 16 endarterectomies of the subclavian or innominate artery, 4 aorto-subclavian or aorto-innominate artery bypasses and one carotid-subclavian side-to-side anastomosis. During long-term follow-up period each patient underwent clinical examination, blood pressure ratio measurement between upper extremities, ultrasound examination and spiral Computed Tomography angiography at regular intervals. The life table method was used to calculate patency rate, overall survival rate, and symptom-free survival. Results: 30 day primary patency and symptom-free survival were observed in 69 patients (92%). Early thrombosis of subclavian artery with concomitant stroke complicated 3 operations (4%), temporary left phrenic nerve disfunction was observed in 5 cases (6,7%) and lymph leak occurred in 6 patients (8%). In one patient with Marfan syndrome a post-operative dissection of the transposed subclavian artery with the vessel obstruction was observed - despite this partial resolution of symptoms was achieved (1,3%). One patient died due to stroke after transposition complication treatment (1,3%). 49 out of the 75 patients (65,3%) of study group remained under direct supervision during the follow-up period ranging from 1 to over 19 years (12-228 months). 7 stenoses of the subclavian artery (14,3%), one subclavian artery occlusion (2%), one false aneurysm of innominate artery (2%), 6 vertebral artery occlusions (12,2%) and one subclavian dissection were stated (2%). Despite those findings 41 patients (83,6%) remained asymptomatic during the whole follow-up period. Conclusion: 1. Surgical treatment of the subclavian steal syndrome is featured with low mortality rate and relatively small number of complications. 2. Long term patency rate exceeding 80 % combined with good symptom-free survival confirms the efficacy of conventional surgical treatment. 3. Open surgery should be the treatment of choice in case of severe in-stent restenosis or occlusion after endovascular procedures. Disclosure: Nothing to disclose

Inferior Vena Cava Atresia: Characterisation of Risk Factors, Treatment, and Outcomes.

To characterise (1) the risk factors associated with inferior vena cava (IVC) atresia, (2) the radiographic and clinical presentations of deep vein thrombosis (DVT) in patients with IVC atresia, and (3) the treatment and outcome of DVT in patients with IVC atresia. The electronic medical record was systematically reviewed for thrombotic risk factors in patients who presented with lower-extremity DVT (n = 409) at a single centre between 1996 and 2017. Patients with IVC atresia were identified based on imaging and chart review. Differences in demographics and thrombotic risk factors between patients with and without IVC atresia were statistically assessed. Extent and chronicity of DVT on imaging, clinical presentation, treatment, and outcomes were evaluated for all patients with IVC atresia. 4.2% of DVT patients (17/409) were found to have IVC atresia; mean age at diagnosis was 25.5 ± 9.4years. The rate of heritable thrombophiliawas significantly higher in patients with IVC atresia compared to patients without IVC atresia (52.9% vs. 17.9%, p < 0.0001). There were bilateral DVT in 70.6% of IVC atresia patients; DVT was chronic in 41.2% and acute on chronic in 58.8%. Pre-intervention Villalta scores were 13.9 ± 9.8 in the left limb and 8.5 ± 7.0 in the right limb. DVT in IVC atresia patients was typically treated with catheter-directed thrombolysis followed by stent placement, achieving complete or partial symptom resolution in 78.6% of cases. Thrombotic risk factors such as heritable thrombophilia are associated with IVC atresia. IVC atresia patients can experience high burdens of lower-extremity thrombotic disease at a young age which benefit from endovascular treatment. Level 4.

Effect of L1-79 on Core Symptoms of Autism Spectrum Disorder: A Case Series

PurposeThis study examines the effects of the tyrosine hydroxylase inhibitor L1-79, a racemic formulation of α-methylparatyrosine, in patients with autism spectrum disorder (ASD) in a prospective case series. The l-isomer formulation of α-methylparatyrosine, metyrosine, is approved for the management of patients with pheochromocytoma. MethodsSix male and 2 female patients aged 2.75 to 24 years with ASD were treated for 8 weeks at L1-79 doses ranging from 90 to 400 mg thrice daily. Assessments at weekly intervals included the Aberrant Behavior Checklist–Community (ABC-C), Connor's Parent Rating Scale (CPRS), and Clinical Global Impressions (CGI) scale. The Autism Diagnostic Observation Schedule (ADOS) was administered at baseline and week 10. FindingsThe ABC-C and CPRS scores improved between baseline and end of study for 7 of 8 participants; most participants' assessment scores decreased. At week 8, the CGI efficacy index was 05 for 6 of 8 participants, indicating modest improvement with at least partial resolution of symptoms and no medication adverse effects, and 09 for 2 participants, indicating minimal improvement and no change in status or care needs, without adverse effects. The mean ADOS scores improved by ≥31% for 4 of the 6 participants tested, with 1 patient experiencing a 47% improvement. Seven of the 8 participants previously taking psychotropic medications were stable without their legacy medications while receiving L1-79, and 1 patient resumed a single legacy medication at a lower dose. Three adverse events were reported; symptoms were mild and resolved without change in therapy. ImplicationsThese results suggest L1-79 may be a tolerable and effective treatment for the core symptoms of ASD, which must be confirmed with double-blind studies.

Horner Syndrome After Anterior Cervical Discectomy and Fusion: Case Series and Systematic Review

Horner syndrome is an infrequently seen complication of anterior cervical discectomy and fusion (ACDF). Multicenter studies have reported a very low incidence, less than 0.1%. To identify the incidence in, characteristics of, and postoperative course in patients in whom postoperative Horner syndrome developed after ACDF. We performed a retrospective review of all patients who experienced Horner syndrome after ACDF for cervical degenerative disease at a single tertiary care institution between 2017 and 2018. A systematic review was then performed to identify studies investigating prevalence, diagnosis, and treatment of postoperative Horner syndrome after ACDF. Of 1116 patients at our institution who underwent ACDF, the incidence of Horner syndrome was 0.45%. C4/5 and C5/6 were the 2 most common surgical levels. The complication was noted to occur immediately after surgery, and at least partial improvement was identified in all patients an average 3.5 months after surgery (range, 10 days to 6 months). These findings were consistent with our systematic review of 21 studies that showed an incidence of 0.6% (range, 0.02% to 4.0%), the most common surgical level C5/6 (64%), and 82% of patients experiencing at least partial resolution of symptoms within 1 year (60.7% complete, 21.4% partial resolution). Horner syndrome occurs in 0.6% of patients undergoing ACDF. Careful postoperative examination should reveal this complication, which may be underdiagnosed or underreported in larger multicenter case series. The majority of patients experience complete resolution of symptoms within 6 months to 1 year and can be treated conservatively and expectantly.

Candy cane revision after Roux-en-Y gastric bypass

BackgroundAn excessively long-blind end of the alimentary limb following a Roux-en-Y gastric bypass (RYGB), known as a ‘candy cane’ (CC), may cause symptoms including abdominal pain, regurgitation and vomiting. Very few studies have examined the efficacy of surgical resection of the CC.ObjectivesThe aim of this study was to assess sensitivity of preoperative diagnostic tools for CC, as well as perioperative outcomes and symptom resolution after CC revision surgery.SettingHigh volume bariatric centre of excellence, United Kingdom.MethodsObservational study of CC revisions from 2010 to 2017.ResultsTwenty-eight CC revision cases were identified (mean age 45 ± 9 years, female preponderance 9:1). Presenting symptoms were abdominal pain (86%), regurgitation/vomiting (43%), suboptimal weight loss (36%) and acid reflux (21%). Preoperative tests provided correct diagnosis in 63% of barium contrast swallows, 50% of upper gastrointestinal endoscopies and 29% computed tomographies. Patients presenting with pain had significantly higher CC size as compared with pain-free group (4.2 vs. 2 cm, p = 0.001). Perioperative complications occurred in 25% of cases. Complete or partial symptom resolution was documented in 73% of patients undergoing CC revision. Highest success rates were recorded in the regurgitation/vomiting group (67%).ConclusionSurgical revision of CC is associated with good symptom resolution in the majority of patients, especially those presenting with regurgitation/vomiting. However, it carries certain risk of complications. CC diagnosis may frequently be missed; hence more than one diagnostic tool should be considered when investigating symptomatic patients after RYGB.

A novel computed tomography guided, transcutaneous approach to treat refractory autophony in patients with a patulous Eustachian tube - a case series.

Patulous Eustachian tube is a benign but notoriously difficult condition to treat successfully. Symptoms include autophony of voice and breathing, and aural fullness. This paper presents a series of 8 patients (12 ears) for whom a novel computed tomography guided injection of silicone elastomer suspension implant (Vox) was used to treat patulous Eustachian tube. This is the largest and only series in the current literature using this technique. The combined complete and partial symptom resolution rate was 91 per cent. Complications related to the procedure are described. The pros and cons of this novel approach are also discussed in relation to traditional endoscopic transnasal techniques. Computed tomography guided injection of Vox for the treatment of patulous Eustachian tube is suggested to be a feasible alternative to endoscopic transnasal approaches, particularly for refractory cases.

Bartonella spp. Bloodstream Infection in a Canadian Family.

Historically, Bartonella spp. have been associated with febrile illness (Oroya fever, trench fever, and cat scratch disease), endocarditis (numerous Bartonella spp.), and vasoproliferative lesions (Bartonella bacilliformis, Bartonella quintana, Bartonella henselae, and Bartonella vinsonii subsp. berkhoffii), occurring most often but not exclusively in immunocompromised patients. Recently, bloodstream infections with various Bartonella spp. have been documented in nonimmunocompromised individuals in association with a spectrum of cardiovascular, neurologic, and rheumatologic symptoms. As documented in this family, symptoms for which the medical implications remain unclear can occur in multiple family members infected with one or more Bartonella spp. Serial serologic and molecular microbiological findings supported exposure to or infection with Bartonella spp. in all seven family members. Either antibiotics failed to eliminate bacteremic infection, resulted in partial resolution of symptoms, or potentially reinfection occurred during the 19-month study period. There is a substantial need for clinical research to clarify the extent to which Bartonella spp. bacteremia induces nonspecific cardiovascular, neurologic, or rheumatologic symptoms, for ongoing improvement in the sensitivity and specificity of diagnostic testing, and clarification as to if, when, and how to treat patients with documented Bartonella spp. bacteremia.

The efficacy of fluoroscopy-guided epidural blood patch in the treatment of spontaneous and iatrogenic cerebrospinal fluid leakage.

To evaluate patient outcomes following fluoroscopy-guided epidural blood patch (FGEBP), factors affecting the outcome, and to identify the rate of fluoroscopy-guided lumbar punctures (FGLP) requiring FGEBP. All FGLPs and FGEBPs between January 2014 and May 2017 were retrospectively evaluated. Information regarding patient characteristics, details of previous dural puncture (DP), details of the FGEBP, and FGEBP outcome were recorded. The outcome was classified into three categories as "complete response", "partial response", and "no response". Patients with "complete response" were compared to the combined group of "no response" and "partial response", classified as "incomplete response". Two-sample/Fisher's exact (continued/categorical variables) tests were used (p < 0.05). Sity-seven FGEBPs were performed in 63 patients (female/male, 36/27; mean age/BMI 38/28.2). Fifty-nine were referred following DP; 31 were performed by radiologists. The rate of FGLPs requiring FGEBP was 1.78% within 3.5years. The mean DP-FGEBP interval was 4.8days. "Complete response" was achieved in 56 (84.8%), "no response" was found following 4 (6%) procedures. Average applied blood volume was 16cc (5-30cc). No difference was found between "complete response" and "incomplete response" groups regarding age, sex, BMI, DP performer, DP level, DP fluoroscopy time, DP needle caliber/type, FGEBP level, FGEBP needle caliber/type, FGEBP fluoroscopy time, FGEBP performer, and applied blood volume (p > 0.05). Despite approaching significance, no statistically significant difference was found regarding the presence of previous DP (p = 0.06). The efficacy of FGEBP is high in a group of patients referred to radiology for treatment of CSF leakage with complete response in 84.8% of patients. • Fluoroscopy-guided epidural blood patch completely resolved symptoms in 85% of post-dural puncture headaches. • The success approaches 95% when including the patients with partial resolution of symptoms. • Epidural blood patch rate is found 1.8% following 1703 fluoroscopy-guided lumbar punctures.

Can Urethral Bulking Agents Salvage Failed Slings?

ObjectiveTo evaluate the efficacy of urethral bulking agents for stress urinary incontinence (SUI) in the setting of prior failed sling. MethodsThis is a retrospective review of patients who underwent urethral bulking agent injections for a primary complaint of SUI following prior failed sling surgery. The outcomes assessed were patient reported improvement, need for further interventions for incontinence and validated questionnaires. Values for questionnaires were obtained from the patient's preprocedure visit, at the first visit following their last injection and at their most recent visit within our system. ResultsOver the study period, 73 patients underwent urethral bulking agent injection following failed sling. Thirty-eight patients received Macroplastique injections and 35 had collagen injections. On average, patients underwent 2.6 injections. Seventy-one percent of patient reported at least partial symptom resolution at first postinjection follow-up. Validated questionnaire responses also improved at short-term follow-up (mean difference in American Urological Association Symptom Index-3.8, Michigan Incontinence Symptom Index-5.1, P <.01). Forty patients had long-term follow-up data available (mean 39.6 months postinjection). Statistically significant improvement persisted on the stress incontinence and quality of life domains of the validated questionnaires. ConclusionIn our cohort of patients with persistent or recurrent SUI following urethral sling procedure, 71% experienced short-term improvement or resolution of symptoms following urethral bulking agent injections, with SUI-specific improvement persisting at an average of 35 months in patients with available data.

Surgical outcomes and over one-year follow-up results of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: Single-center experiences

Laparoscopic antireflux surgery is a standard surgical treatment method for gastroesophageal reflux disease (GERD) in Western countries. However, the procedure has not been actively carried out in Korea because of concerns regarding surgical complications. Here, we conducted this study to evaluate short-term surgical outcomes of laparoscopic Nissen fundoplication (LNF) performed at a single institution. From January 2010 to August 2016, totally 29 patients underwent LNF for GERD performed by three surgeons at Asan Medical Center, Korea. All patients participated in a telephonic survey including the presence of symptoms and the status of quality of life (QOL). The median age at operation and BMI were 54 years and 23.8kg/m2, respectively. Preoperatively, 27 patients (93.1%) underwent PPI therapy. All patients had typical or atypical GERD symptoms. One patient (3.4%) required reoperation because of total gastroesophageal junction obstruction. 24 patients (82.8%) reported complete or partial resolution of symptoms, whereas 21 (72.4%) reported partial or complete improvement in quality of life. In patients with reflux esophagitis, GERD symptoms were significantly relieved after LNF (P=0.005). LNF responders tended to perceive an improvement in quality of life post operation (P<0.001). LNF is a feasible, safe, and effective treatment option for controlling GERD symptoms as well as improving the quality of life. Presence of reflux esophagitis was a predictor of successful outcomes.

A Comparison between Pulled and Pushed Monocanalicular Silicone Intubation in Management of Congenital Nasolacrimal Duct Obstruction

Background: Congenital nasolacrimal duct obstruction (CNLDO) is usually caused by a membranous block at the valve of Hasner. Symptoms of CNLOD include epiphora, mucous discharge, or mucopurulent discharge. Many CNLDOs can resolve spontaneously by the first year of life. Children who ultimately have unsuccessful responses to canalization will undergo invasive procedures for CNLDO, including probing, silicone intubation, balloon dacryocystoplasty and dacryocystorhinostomy. There are two types of lacrimal intubation, monocanalicular and bicanalicular. Pushed monocanalicular stent is characterized by the probe guide actually placed inside the silicone tube, rather than attached at the end as in conventional ‘‘pulled’’ intubations stents. Aim of the work: was to compare the success rate of pulled monocanalicular (MCI) versus pushed monocanalicular silicone intubation (PMCI) of the nasolacrimal duct for congenital nasolacrimal duct obstruction. Patients and methods: In a prospective randomized clinical trial 67 eyes of 67 patients with CNLDO underwent either pulled monocanalicular silicone intubation (MCI) (=32 eyes) or PMCI ( =35 eyes). Cases were considered successful if reached grade 0 or 1 in fluorescein dye disappearance test -complete or partial resolution of symptoms - after two months after tube removal. Results: This study included only patients with simple obstruction at the level of the Hasner valve and diagnosed intraoperative during the initial probing thus, the surgical outcome was assessed in 30 eyes of 30 patients in the MCI groups. 15 eyes received MCI in the upper punctum and 15 eyes received MCI in the lower punctum. The other 30 eyes 30 patients did PMCI with Masterka tube. 15 eyes received PMCI in the upper punctum and 15 eyes received PMCI in the lower punctum. 33 females (55%) & 27 males (45%) with age ranged from 12 to 46 months with mean of 26 ± 11 months. Follow-up of the patients was done at 1 week, 1 month, 2 and 3 months post-operative. Tube removal was done 3 months post operatively in both types of tube. The overall success rate in the MCI intubation groups was 86.7%, whereas in the PMCI intubation groups was 80%. However, the difference in the success rates between the two groups was statistically insignificant (P= 0.4884) using Chi-square test. Conclusion: Results indicate that MCI has higher success rate in CNLDO treatment compared with PMCI in this small series of patients.

Surgeon-Performed Ultrasound for Chronic Obstructive Sialadenitis Helps Predict Sialendoscopic Findings and Outcomes.

Objective To determine the accuracy of surgeon-performed ultrasound (SP-US) features for predicting intraoperative sialendoscopic findings and to correlate ultrasound features with short-term symptomatic outcomes following sialendoscopy-assisted salivary duct surgery (SASDS). Study Design Case series with chart review. Setting The practices of 2 academic sialendoscopy surgeons. Subjects and Methods Between February 2014 and September 2015, 82 patients with 105 symptomatic glands underwent SASDS, of whom 56 patients (75 glands) met inclusion criteria. SP-US and sialendoscopic findings were reviewed for patients with chronic obstructive sialadenitis who underwent SASDS and who had been prospectively evaluated with the University of California-San Francisco Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire (scored 0-100) administered preoperatively and 3 months postoperatively. Results The positive predictive value (PPV) and negative predictive value (NPV) of SP-US for identifying sialoliths intraoperatively were 94% (33/35) and 91% (39/43), respectively. Of glands with sialoliths on SP-US, 97% (34/35) had complete symptom resolution (COSS ≤10) after SASDS. The PPV and NPV of salivary duct dilation on SP-US for finding a corresponding stenosis on sialendoscopy were 93% (14/15) and 50% (14/28), respectively. Nonsialolith SP-US features with the highest PPV for complete or partial symptom resolution (COSS ≤25) following SASDS included distal duct dilation of all glands (86%; 6/7) and dilation of both distal and proximal parotid ducts (75%; 6/8). Conclusion SP-US has high accuracy for ruling in and ruling out sialoliths, as well as for ruling in but not for necessarily ruling out stenosis presence and location. Ultrasound is helpful in estimating degree of short-term symptom response following SASDS.

Cost-effectiveness of transfacial gland-preserving removal of parotid sialoliths.

Examine outcomes of transfacial gland-preserving removal of difficult parotid stones and compare the cost and operative time to traditional parotidectomy. Cost-effectiveness analysis and retrospective chart review. Patients who underwent transfacial removal of symptomatic parotid sialoliths at a tertiary medical center from June 2010 to July 2015 were evaluated. Outcomes included operative technique, stone size, stone location, complications, and symptom relief. In addition, patients who underwent traditional parotidectomy for chronic sialadenitis were identified. The charges and times for both procedures were reviewed and compared. Forty-four patients underwent transfacial resection for symptomatic parotid sialolithiasis. Stones were most often located in the main duct and hilum (53.3%), with fewer intraglandular stones (46.7%). No facial nerve weakness was observed. Of those with follow-up, 33 (87%) patients reported at least partial resolution of symptoms. Overall transfacial technique charges were significantly less expensive (U.S.$) than parotidectomy (mean difference -8,064.09; 95% confidence interval [CI] -13,472.78 to -2,655.40; P = 0.033). Anesthesia charges (mean difference -2,997.85; 95% CI, -5,748.81 to -246.89; P = 0.035) and operating room charges (mean difference -4,793.91; 95% CI, -8,958.09 to -629.72; P = 0.028) were also less expensive for the transfacial technique. Finally, mean procedure time for transfacial removal of parotid stones was shorter than for parotidectomy (120.2 ± 49.9 vs. 178.4 ± 41.3 minutes, respectively; P = 0.002). Transfacial gland-preserving removal of difficult parotid stones is a well tolerated and effective alternative to parotidectomy. Moreover, it is faster and less expensive than parotidectomy, maximizing both surgeon time and hospital resources. 4. Laryngoscope, 127:1080-1086, 2017.

Efficacy of Endoscopic Hydrostatic Balloon Dilation as Initial Intervention for Dysphagia/Emesis After Vertical Sleeve Gastrectomy

Introduction: Vertical sleeve gastrectomy (VSG) has gained popularity worldwide and is now the most commonly performed bariatric surgery in the USA. Dysphagia with emesis is commonly encountered after VSG, and a potential cause for these symptoms is partial obstruction of the gastric sleeve. Suggested treatment strategies to manage post-operative gastric stenosis include conservative medical therapy, endoscopic intervention, and surgical revision to gastric bypass surgery. The aim of this study is to determine the prevalence of partial obstruction of the sleeve gastrectomy in patients after VSG and to assess the efficacy of endoscopic hydrostatic balloon dilation as an intervention.Figure 1Figure 2Methods: This is a retrospective chart review of 400 consecutive patients above 18 years of age who underwent sleeve gastrectomy at a large, urban community hospital between 2013 and 2015. Patients with previous bariatric procedures were excluded. Patients with dysphagia and/or vomiting were offered upper endoscopy. Partial obstruction of gastric sleeve due to narrowing was defined by: 1. inability to pass a 9.6mm endoscope; 2. narrowing seen in upper GI x-ray series; or 3. sharp angulation of the gastric sleeve hindering passage of a 9.6 mm endoscope. Results: Out of 353 patients included in the final analysis, 33 (9.3%) had partial obstruction of gastric sleeve. Twenty-five patients (7.1%) had sharp angulation of the gastric sleeve and 8 (2.3%) had frank stenosis of the gastric sleeve. All 33 patients underwent endoscopic hydrostatic balloon dilation as the initial intervention. 13 (39%) had resolution of their symptoms with a single dilation, 5 (15%) required two sessions of dilation, 5 (15%) required three sessions of balloon dilation and 8 (24%) obtained only partial symptom resolution with multiple balloon dilations. Two (6%) patients showed no improvement with balloon dilation. Conclusion: Gastroenterologists will be more often asked to evaluate patients with dysphagia VSG. Dysphagia due to partial obstruction of the gastric sleeve is common in these patients and our present findings are consistent with prior small studies of gastric sleeve stenosis. There are no current guidelines on the management of symptomatic obstruction of the gastric sleeve after VSG. Our results suggest that an initial endoscopic balloon dilation of the gastric sleeve improve symptoms of dysphagia and vomiting in ˜70% of the patients. Up to 30% of the patients may require multiple dilation sessions before resolution of symptoms.

Intracranial MR-guided laser-induced thermal therapy: single-center experience with the Visualase thermal therapy system

OBJECTIVE MR-guided laser-induced thermal therapy (MRgLITT) can be used to treat intracranial tumors, epilepsy, and chronic pain syndromes. Here, the authors report their single-center experience with 102 patients, the largest series to date in which the Visualase thermal therapy system was used. METHODS A retrospective analysis of all patients who underwent MRgLITT between 2010 and 2014 was performed. Pathologies included glioma, recurrent metastasis, radiation necrosis, chronic pain, and epilepsy. Laser catheters were placed stereotactically, and ablation was performed in the MRI suite. Demographics, operative parameters, length of hospital stay, and complications were recorded. Thirty-day readmission rates were calculated by using the standard method according to America's Health Insurance Plans Center for Policy and Research guidelines. RESULTS A total of 133 lasers were placed in 102 patients who required intervention for intracranial tumors (87 patients), chronic pain syndrome (cingulotomy, 5 patients), or epilepsy (10 patients). The procedure was completed in 98% (100) of these patients. Ninety-two patients (90.2%) had undergone previous treatment for their intracranial tumors. The average (± SD) total procedural time was 170.5 ± 34.4 minutes, and the mean laser-on time was 8.7 ± 6.8 minutes. The average intensive care unit (ICU) and hospital stays were 1.8 and 3.6 days, respectively, and the median length of stay for both the ICU and the hospital was 1 day. By postoperative Day 1, 54% of the patients (n = 55) were neurologically stable for discharge. There were 27 cases of morbidity, including new-onset neurological deficits, and 2 perioperative deaths. Fourteen patients (13.7%) developed new deficits after the MRgLITT procedure, and of those 14 patients, 64.3% (n = 9) had complete resolution of deficits within 1 month, 7.1% (n = 1) had partial resolution of symptoms within 1 month, 14.3% (n = 2) had not had resolution of symptoms at the most recent follow-up, and 14.3% (n = 2) died without resolution of symptoms. The 30-day readmission rate was 5.6% CONCLUSIONS MRgLITT, although minimally invasive, must be used with caution. Thermal damage to critical and eloquent structures can occur despite MRI guidance. Once the learning curve is overcome, the overall procedural complication rate is low, and most patients can be discharged within 24 hours, with a relatively low readmission rate. In cases in which they occurred, most neurological deficits were temporary. The therapeutic role of MRgLITT in various intracranial diseases will require larger and more rigorous studies.