Partial Resolution Of Symptoms Research Articles

BMET-24CRANIOTOMY FOR TUMOR RESECTION IN PATIENTS WITH MULTIPLE BRAIN METASTASES: CHARACTERISTIC OF THE DOMINANT METASTATIC LESION

In the surgical management of multiple brain metastases, resection of the lesion occurs in the setting of neurological compromise. There is a paucity of data characterizing the lesion. This study aims to quantitatively and qualitatively describe a dominant metastatic lesion and assess symptomatic improvement following resection. All adult patients with multiple brain metastases (2 or more) from 2007 to 2013 who underwent craniotomy for tumor resection for were identified. Outcomes of interest were perioperative complications and change/resolution of symptomology at discharge. Characteristics associated with symptom resolution were assessed via chi-squared test. A total of 38 patients were included in the study. 36.8% were male and mean age was 59.0 years. Of the 38 tumors resected, 94.7% enhanced, 50.0% were hemorrhagic, and 28.9% had cystic components. The mean largest diameter of the lesion was 39.5 mm and mean volume was 202873.2 mm3. The next largest lesion had a mean diameter of 13.2 mm (range 3 mm to 31 mm) and volume of 11496.9 mm3. The metastatic lesion proved to be at least 299.2% larger in mean largest linear dimension and 1764.6%% larger by volume compared to the next largest metastatic lesion. 65.9% of patients achieved gross total resection and 68.4% of patients had at least partial resolution of symptoms. Resection of the lesions with greater than 3 times the diameter or greater than 15 times the volume than the next largest lesion had significantly higher rates of symptom relief compared to smaller lesions (80.0% vs. 46.2%, p = 0.033). In patients with cerebellar lesions, symptom improvement occurred 100.0% of the time. Craniotomy for resection of metastatic tumors is effective for symptomatic relief, especially for lesions 3 times the diameter or 15 times the volume of the next largest lesion.

A Diagnostic Evolution: Surgical Experience with Popliteal Artery Entrapment Syndrome at a Military Tertiary Referral Center

Popliteal artery entrapment syndrome (PAES) is an increasingly encountered disorder that typically presents as claudication in young and active individuals. However, despite the increased recognition, accurate preoperative diagnosis can be difficult. The objective of this study was to describe the surgical assessment and outcomes of patients treated for PAES. Retrospective case series of all patients managed surgically for a diagnosis of PAES at the San Antonio Military Medical Center from 2005 to 2013. Over 8 years, PAES was surgically treated in 25 consecutive limbs of 15 patients (mean age, 35; range, 21-49) in a military tertiary medical center. Type III was the most common variant (n = 13, 52%), followed by type VI (n = 7, 28%). Most patients presented with class I or II ischemia (88%), with anterolateral symptoms (56%), and were referred by orthopedics (66%). Diagnostic work-up included stress ankle-brachial indices, magnetic resonance imaging (MRI) and provocative angiography. Sixty-three percent of limbs with negative MRI demonstrated findings consistent with either type III or V PAES. Tendon release was used in those with types III and V, whereas liberal myectomy was used in those with types I, II, or VI. Two patients required revascularization. At a median follow-up of 126 days (range, 25 days-7 years), 83% of patients with type III demonstrated partial resolution of symptoms. Only 27% of patients without an identifiable muscle slip had clinical improvement. Despite modern imaging, open surgical exploration remains the definitive diagnostic modality for PAES. Patients with a muscular or tendinous slip identified intraoperatively have the best clinical outcomes. Those with no identifiable muscle slip (functional entrapment) are less likely to demonstrate clinical improvement. Further evaluation on outcomes in the management in PAES is warranted.

Case-matched series of a non-cross-linked biologic versus non-absorbable mesh in laparoscopic ventral rectopexy

Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh. Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh. Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group. LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.

Nuclear Medicine Scintigraphy (NMS) Results Predict Symptom Resolution After Sphincterotomy in Patients With Sphincter of Oddi Dysfunction (SOD)

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry is the gold standard test for diagnosis of SOD, but is associated with high risk of complications. A nuclear medicine scintigraphy (NMS) test is a safe, non-invasive, alternative test for evaluation of biliary SOD. ERCP with biliary sphincterotomy is the standard treatment for SOD. Our study aim is to assess the utility of NMS results in predicting symptom resolution after sphincterotomy in patients with SOD type 2. Methods: In this retrospective cohort study, patients who underwent both NMS and sphincterotomy for SOD type 2 between 2007 and 2014 were included. Patient demographics, clinical symptoms, laboratory tests, imaging studies, endoscopic ultrasound, and ERCP findings were recorded. The NMS results were reported on a scoring system ranging from 0 to 12. The symptom resolution after sphincterotomy was stratified into “no response,” “partial response,” or “complete response.” We compared the sphincterotomy response with NMS score results using the analysis of variance (ANOVA) or the Kruskal-Wallis tests for continuous variables and Pearson’s chi-squared tests or Fisher’s exact tests for categorical factors (P<0.05 for significance). The results were adjusted for age, sex, gender, history of smoking, and alcohol use using logistic regression analysis. We used SAS version 9.2 soft ware for the analysis. Results: A total of 30 patients with SOD type 2 met the inclusion criteria. Average age was 47 years and 87% (n=26) were female. During a mean follow-up of 20.6 months, none of the patients achieved complete response, while 57% (n=17) patients had partial response after sphincterotomy. Subjects with partial response were more likely to have abnormal NMS results (p<0.001) as well as higher scores in NMS test (p<0.001). Significance for these findings was maintained even after adjusting for age, gender, and history of smoking or history of alcohol use. A total NMS score of 5 or more would provide sensitivity of 82%, and specificity of 92% (area under the curve=0.93) for prediction of partial symptom resolution after sphincterotomy. Among NMS components, bile duct emptying score (p<0.002), bowel visualization score (p<0.002), and bile duct prominence score (p<0.003) were better predictors compared to peak time score (p=0.073). Conclusion: NMS total score was found to provide accurate prediction of symptom resolution after sphincterotomy. These findings are helpful to stratify patients based on the safe, non-invasive NMS test results that would be benefit from biliary sphincterotomy.

Ultrasound-Guided Needle Localization during Open Parotid Sialolithotomy.

Our objective is to describe a novel operative technique for localization of parotid sialolithiasis, demonstrate the feasibility of the technique, and discuss its indications. Prospective study. Tertiary-level academic center. Patients with symptomatic parotid sialolithiasis who had failed prior sialendoscopic extraction underwent ultrasound needle localization and open sialolithotomy. Data were prospectively collected. Independent variables included size of and location of sialoliths. Eleven patients were treated using transcutaneous ultrasound-guided needle placement and injection of methylene blue prior to external sialolithotomy. Follow-up ranged from 6 to 12 months. Ten (91.9%) patients had stones within the proximal one-third of the ductal lumen, and 1 (9.1%) had stones present within both the proximal one-third and middle one-third of the ductal lumen. The average surgical time was 53 ± 10.8 minutes. The average sialolith length was 7.6 ± 2 mm. The average sialolith width was 6 ± 1.9 mm. All 11 (100%) cases were successful for stone retrieval. Ten (91%) patients had complete symptom resolution, and 1 (9.1%) patient had partial resolution of symptoms. No patients had major complications. Three (27.3%) patients had minor complications. After failing a purely endoscopic approach, sialoliths of the parotid gland pose a problem for precise localization and treatment. Ultrasound has been demonstrated to be reliable for identifying sialoliths. We propose a novel technique and assert that ultrasound-guided needle localization is a reliable aid to effective external parotid sialolithotomy, especially for larger stones >4 mm that are not amenable to sialendoscopic retrieval.

Can peptide receptor radionuclide therapy be safely applied in florid bone metastases? A pilot analysis of late stage osseous involvement.

Highly advanced metastatic bone disease with extensive osseous infiltration of neuroendocrine tumours (NET) may preclude patients from treatment with peptide receptor radionuclide therapy (PRRT) in concern about haematotoxicity. This study aims to assess the safety and efficacy of PRRT with 177Lu-octreotate in a patient cohort with this condition. 41 PRRT courses were performed in 11 patients with gastroenteropancreatic neuroendocrine tumours (GEP-NET) and florid bone metastases (severely advanced widespread metastatic bone disease). A mean activity of 6.95 GBq 177Lu-octreotate was administered per treatment cycle, aimed at four courses with standard intervals of 3 months. Haematological parameters were determined prior to each treatment course, in 2-4 weeks intervals between the courses, 8-12 weeks after the last course of PRRT and in 3 monthly intervals thereafter. Toxicity was recorded using Common Terminology Criteria for Adverse Events v3.0. Restaging was performed 3 months after termination of PRRT with CT/MRI and functional imaging (modified MDA criteria). Significant (grade III-IV), reversible haematotoxicity occurred in 4 (35%) patients and after 10 (24%) administrations. It either resolved spontaneously (1 patient) or was controlled by supportive measures (3 patients), such as blood transfusions (3 patients) or deferral of the subsequent therapy cycle (1 patient). Patients returned to baseline blood values within up to 23 months after termination of PRRT. The observed treatment response of bone metastases consisted of a partial response in 2, a minor response in 1, stable disease in 7, and progressive disease in 1 patient. Of the 4 patients with metastatic bone pain, 1 experienced complete and 3 partial resolution of symptoms within 3-10 weeks after commencement of PRRT. These preliminary data indicate that PRRT with 177Lu-octreotate can be safely applied even in florid bone metastases with extensive, severely advanced osseous replacement. The higher myelosuppression rate was not associated with serious complications and should not preclude patients from being treated and potentially experiencing remarkable treatment efficacy despite the very advanced stage.

Erratum to “Addition of Metanx in Pregabalin Partial Responders for Painful Diabetic Neuropathy”

Objective: To study the effect of addition of Metanx on burning parasthesias in patients with symptomatic diabetic neuropathy who had obtained only partial symptom resolution with pregabalin. Research design and methods: This was an open-label pilot study. There were 16 patients (7 males, 9 females) in the study group and 8 patients (3 males, 5 females) in the control group. A patient numeric rating scale (0 - 10) of neuropathy associated pain was obtained at baseline and at 20 weeks. The control group continued on a fixed dosage of pregabalin without additional medication, while the study group was supplemented with Metanx (a proprietary blend of bioactive B-vitamins), in addition to being continued on a fixed dosage of pregabalin. Results: After 20 weeks, significantly more patients in the study group experienced pain relief compared to the control group (87.5% vs. 12.5%, respectively, p =0.005). The average pain score reduction after 20 weeks in the study group was 3 compared to0.25 inthe control group (p may be used for the relief of pain in patients that have obtained only partial resolution of symptomatology from pregabalin.

Ulnar Hammer Syndrome

Ulnar hammer syndrome is an uncommon form of arterial insufficiency. Many treatments have been described, and debate continues about the best option. The goal of this systematic review was to determine whether ulnar hammer syndrome has an occupational association, to identify the most reliable diagnostic test, and to determine the best treatment modality. A comprehensive literature search was conducted using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE. Data from articles meeting inclusion criteria were collected in duplicate. Methodological quality of studies was assessed using the Methodological Index for Nonrandomized Studies scale. Thirty studies were included in the systematic review. No randomized controlled trials were identified. There is low-quality evidence suggestive of an association between exposure to repetitive hand trauma and vibration and ulnar hammer syndrome. Various diagnostic investigations were used, but few were compared, making it difficult to determine the most reliable diagnostic test. Numerous nonoperative and operative treatments were reported. With nonoperative treatment, 12 percent had complete resolution and 70 percent had partial resolution of their symptoms. Of patients treated operatively, 42.5 percent had complete resolution and 42.5 percent had partial resolution of their symptoms. The heterogeneity in study design and outcome measures limits definitive conclusions about occupational association, best diagnostic test, and treatment for ulnar hammer syndrome. However, there is low-quality evidence that suggests that most patients with ulnar hammer syndrome will have partial relief of symptoms with nonoperative treatment, and operative treatment results in complete or partial resolution of symptoms in the majority of cases. Therapeutic, IV.

Transarterial Embolization of Symptomatic Focal Nodular Hyperplasia

PurposeTo evaluate the effectiveness of small size trisacryl gelatin microsphere embolization as a minimally invasive treatment option for patients with symptomatic focal nodular hyperplasia (FNH). Materials and MethodsA retrospective review was performed of experience with transarterial bland embolization of FNH during the period 2006–2011 in 12 patients (10 women and 2 men; age range, 18–61 y) with a total of 17 lesions presenting with symptoms of pain. FNH was pathologically proven in 11 lesions from 10 patients; the remaining lesions exhibited the classic imaging appearance for FNH. All patients underwent superselective embolization with 100–300 μm trisacryl gelatin microspheres. Lesion size and contrast enhancement before and after treatment were compared to determine success of the procedure. Clinical response was determined by review of the electronic medical record. ResultsAfter embolization, seven patients showed complete resolution and five patients showed partial resolution of symptoms. Compared with imaging performed before the procedure, mean decrease in lesion size after embolization was 61% (range, 26%–90%) on cross-sectional imaging obtained 4–10 weeks after embolization and 87% (range, 54%–98%) on subsequent imaging. Diminished contrast enhancement was universally noted, with 5 of 17 lesions showing complete lack of residual enhancement. ConclusionsTransarterial bland embolization of FNH with trisacryl gelatin microspheres in symptomatic patients is a suitable treatment alternative to surgical resection.

Surgery for Reflux‐Induced Airway Disease: A Systematic Review

Objectives: 1) Evaluate the current evidence regarding the efficacy and safety of anti-reflux surgery for the treatment of severe gastroesophageal reflux related airway disease in children. 2) Provide evidence based recommendations regarding indications and outcomes of anti-reflux surgery for airway disease in children. Methods: An a priori protocol was defined to identify all articles addressing anti-reflux surgery for the treatment of reflux related airway disease in children where details regarding the diagnosis, treatment, and outcomes were clearly presented. The search was inclusive of all references available through January 2013 and included electronic databases to identify candidate articles as well as a comprehensive series of crosschecks. The two authors independently determined which references met inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled using a random effects model due to significant study heterogeneity. Results: Thirteen articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I2 = 77%; P &lt; .001). However, each article uniformly presented cases suggesting that anti-reflux surgery is efficacious and safe in treating children with severe reflux related respiratory disease. The pooled success rate for complete or partial resolution of symptoms after anti-reflux surgery was 0.899 (95% confidence interval [CI]: 0.866, 0.932). The pooled success rate for complete symptom resolution after surgery was 0.697 (95%CI: 0.591, 0.803). Conclusions: The current literature suggests that anti-reflux surgery is an effective and safe treatment for severe reflux related airway disease. However, the level of evidence lacks strength, and further investigation is warranted.

A randomised controlled trial of alcohol delamination and phototherapeutic keratectomy for the treatment of recurrent corneal erosion syndrome

AimTo compare the efficacy of alcohol delamination (ALD) and phototherapeutic keratectomy (PTK) for the treatment of recurrent corneal erosion syndrome (RCES) in a prospective, randomised, controlled trial.MethodsPatients with RCES not...

Tranexamic Acid–Induced Toxic Epidermal Necrolysis

To report a case of toxic epidermal necrolysis (TEN) induced by orally administered tranexamic acid in a patient with liver cirrhosis and acute rectal bleeding. A 67-year-old male with a history of liver cirrhosis due to alcohol consumption with ascitic decompensation, esophageal varices, and multifactorial renal insufficiency presented with rectal bleeding. The patient was prescribed oral tranexamic acid (1000 mg every 8 hours), with partial resolution of symptoms. Ten days after treatment with tranexamic acid began, a purplish macular rash appeared over the patient's trunk. The dose of tranexamic acid was reduced to 1000 mg every 12 hours, adjusting for renal function. In the following days the lesions extended and became confluent with blisters and epidermal necrosis. Multiple mucosal surfaces were also affected. He denied allergies to any medications and had no history of tranexamic acid exposure. Treatment with tranexamic acid was suspended and fluid replacement therapy, oral prednisone therapy (0.4 mg/kg per day), and N-acetylcysteine 2 g every 6 hours was started, with the empiric diagnosis of TEN. Results of a skin biopsy were compatible with TEN. Resolution of the skin lesions was favorable, but after 2 weeks the patient died secondary to acute renal failure, respiratory infection, and multiorgan failure. TEN is a rare, severe mucocutaneous adverse reaction. Although infrequent, TEN has a significant impact on public health because of its high mortality. Its pathogenesis is unclear, but it seems to be a form of delayed hypersensitivity. To our knowledge, a well-documented case of TEN following tranexamic acid use has not been reported (MEDLINE search to June 2012). There have been recent reports of skin hypersensitivity reactions through different mechanisms (immunologic and nonimmunologic). The Naranjo probability scale indicates a probable relationship between the development of TEN and tranexamic acid use in our patient. This appears to be the first report of a case of TEN that occurred in a patient being treated with oral tranexamic acid. Clinicians should be made aware of this potential severe cutaneous adverse reaction that may be caused by tranexamic acid administration.

Brown bowel syndrome: A rare and often overlooked complication of intestinal atresia

Dear Editor, I read with great interest the recent article by Akkoyun et al.[1] Interestingly, one rare complication of intestinal atresia that is often overlooked is “Brown bowel syndrome” (BBS). The pathogenesis of BBS involves the deposition of lipofuscin in the intestinal tunica mucularis in paranuclear vacuoles.[2] It usually affects the large intestinal wall, but can affect the small intestine also especially the jejunum. The appendix may also be affected. Lipofuscin deposition may also be seen in the arteries in the muscularis propria. The brownish discoloration is secondary to the release of lipofuscin from the degenerated mitochondria.[3] The liopofuscin deposits usually spare the actual mucosal lining. BBS may affect any age. Cases as young as 11 years of age have been reported. Vitamin E deficiency is typically seen in BBS. A consequent mitochondrial myopathy develops. Intestinal malabsorption is further accentuated as a result of atony and decreased peristalsis in the intestinal wall. Simultaneous deficiency of vitamin D is usually seen. Thiamine deficiency as well as vitamin A deficiency is also fairly common. Patients with a long history of ethanol abuse are more likely to develop BBS. BBS has also been reported recently by Connolly et al., in patients with Cohn's disease.[4] Rarely, BBS may occur secondary to an intestinal malignancy. For instance, it has been reported in conjunction with jejunal carcinomas. Intestinal atresia especially “jejunal atresia” may also lead to the development of BBS.[3] Progressive accentuation of jejunal dilatation is seen in these cases. BBS has also been reported to develop secondary to chronic esophagitis.[2] Associated esophageal strictures may also contribute to the evolution and progression of BBS. BBS has also been reported recently as a late complication of “jejunoileal bypass” surgery.[5] Patients usually present with severe malnutrition and muscle wasting. Severe cachexia may be present in chronic cases. Chronic diarrhea especially steatorrhea is usually present.[6] Abdominal pain and distension may be present simultaneously. Severe vomiting may accompany the above features. This may be marked in patients with significant colonic dilatation. Signs suggestive of toxic megacolon may be present rarely.[2] Dehydration is usually elicited on physical examination. Altered neurologic function may be present in some patients. For instance, signs and symptoms consistent with peripheral neuropathies may be present. Signs and symptoms consistent with myopathy may develop in severe cases.[7] Rarely patients may present with an acute abdomen that on further evaluation leads to a diagnosis of BBS.[5] The acute abdomen may be secondary to the development of an acute intussusception. Rarely, patients may develop decreased tone of the internal sphincter also. This was recently reported by Waldron et al.[7] Rarely, severe lower gastrointestinal bleeding may occur secondary to BBS. This was recently reported by Hurley et al.[8] Cardiac deposition of lipofuscin may also occur resulting in cardiac symptoms. Simultaneous osteomalacia and secondary hyperparathyroidism may also be present.[4] Barium follow through studies are usually recommended initially. These studies typically demonstrate delayed transit through the affected intestinal portion. Proximal intestinal dilatation is seen simultaneously. Transmural intestinal biopsies stain with the “Fontana-Masson” stain indicating the presence of lipofuscin.[4] The deposits also stain with periodic acid-Schiff. Deposits are seen both in the longitudinal as well as the circular intestinal musculature. Vitamin E levels may be undetectable in severe cases.[5] Concurrent selenium deficiency is seen in most patients. Liver function tests (LFTs) may be altered and prothrombin time (PT) may be elevated. Peripheral blood examination reveals highly fragile red blood cells (RBCs).[7] Muscle biopsies in severe cases reveal fatty replacement with concurrent myopathic changes. Stool cultures are typically negative. Rarely, mesenteric lymphadenopathy may develop in association with BBS. In these cases, the lymphatic reticuloendothelial cells typically exhibit lipofuscin deposits.[2] Lipofuscin deposits have also been reported in the eye and thyroid tissue at the same time as the BBS. The urinary bladder and the prostate gland are also prone to develop simultaneous lipofuscin deposition. This was recently reported by Braunstein et al. Vitamin E therapy should be initiated as soon as the diagnosis is made. Parenteral vitamin E supplementation may be necessary in some cases.[6] Surgical intervention such as “subtotal colectomy” may be necessary in certain patients. Limited intestinal resection with “end-to-end anastomosis” is necessary in patients with a history of intestinal atresia.[9,10] Complete or partial resolution of symptoms is seen in patients who develop myopathy. Intestinal transplantation may be needed in severe cases of BBS. BBS may rarely be fatal. As is obvious from the above discussion BBS is a rare complication of intestinal atresia and should be watched out for in these patients.

Addition of Metanx in pregabalin partial responders for painful diabetic neuropathy

Objective: To study the effect of addition of Metanx on burning parasthesias in patients with symptomatic diabetic neuropathy who had obtained only partial symptom resolution with pregabalin. Research design and methods: This was an open-label pilot study. There were 16 patients (7 males, 9 females) in the study group and 8 patients (3 males, 5 females) in the control group. A patient numeric rating scale (0 - 10) of neuropathy associated pain was obtained at baseline and at 20 weeks. The control group continued on a fixed dosage of pregabalin (Lyrica) without additional medication, while the study group was supplemented with Metanx (L-methylfolate, methylcobalamin, and pyridoxal 5- phosphate), in addition to being continued on a fixed dosage of pregabalin. Results: After 20 weeks, patients in the study group experienced greater pain relief compared to the control group, (87.5% vs. 25% respectively, p = 0.005). The average pain score reduction after 20 weeks in the study group was 3 compared to0.25 inthe control group (p may be used for the relief of pain in patients that have obtained only partial resolution of symptomatology from pregabalin.

P63 Treatment of pelvic inflammatory disease using short-course azithromycin

BackgroundIn our centre, a novel 5-day regimen of azithromycin (1 g stat then 500 mg daily for 4 days with or without metronidazole and/or ceftriaxone) is used and has been...

Sensory neuropathy following suspension of the vaginal apex to the proximal uterosacral ligaments

Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients. A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected. Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management. Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.

Ultrasound-guided Injections for de Quervain’s Tenosynovitis

Nonsurgical management of de Quervain's tenosynovitis often includes corticosteroid injections. If the injection does not enter the compartment, or all subcompartments, response to the injection is variable. To ensure proper location of injections we evaluated the role of ultrasound. We determined (1) the incidence of two or more subcompartments, (2) the incidence of anatomic variations during surgical release after failed injections, and (3) the relief of pain after ultrasound-guided injections. A prospective series of 40 consecutive patients (42 wrists) diagnosed with de Quervain's tenosynovitis by clinical examination were referred to a radiologist for an ultrasound-guided injection. The radiologist injected the first dorsal compartment and noted any septations. Patients returned for followup where outcomes, DASH, and VAS scores were calculated. The treating surgeon was blinded to any anatomic variations. Followup was at 6 weeks and a minimum of 6 months (mean, 6 weeks, range, 3-17 months; mean, 11 months, range, 7-18 months). Four patients were lost to followup. Multiple subcompartments were noted in 22 of 42 (52%) wrists. At the 6-week followup, 36 of the 37 wrists examined in 36 patients (97%) had at least partial resolution of symptoms. Multiple subcompartments were identified in 52% of cases. At last followup, the mean DASH and VAS scores were 18.4 and 2.2, respectively. However 14% of wrists had recurrence of symptoms, all of which had subcompartments on ultrasound. No adverse effects from the injections were noted. We found ultrasound-guided injections to be useful for treatment of de Quervain's tenosynovitis. Our success with ultrasound-guided injections was slightly better than that reported in the literature and without adverse reactions.

Antimigraine (Low‐Amine) Diet May Be Helpful in Children With Cyclic Vomiting Syndrome

To the Editor: Cyclic vomiting syndrome (CVS) is considered to be a functional gastrointestinal disorder characterised by stereotypical episodes of acute vomiting lasting <1 week with ≥3 discrete episodes in the previous year and absence of nausea and vomiting between the episodes. CVS has been managed with antiemetics and intravenous fluids with reasonable success (1,2). CVS is increasingly being recognised as a brain–gut disorder and has been associated with a high familial prevalence of migraine or considered to be a migraine variant in children (2,3). As with migraine, CVS has been associated with the ingestion of foods such as cheese, chocolate, citrus fruits, caffeine, yeast extract, and pork (2). A study in Italy showed improvement with the exclusion diet in CVS symptoms in 7 of 8 children. These children showed positive skin prick tests and specific immunoglobulin E to cow's-milk protein, egg whites, and soya; however, there was no history of specific food allergies (4). We describe a low-amine diet (LAD) as prophylactic therapy for CVS, which avoids all of the food groups previously implicated as migraine triggers (5). The food groups that need to be avoided include cheese, chocolate, citrus fruit and their juices, pork and pork products, peas, broad beans, game, shellfish, yeast extract, beef extract, gravies, drinks containing caffeine (tea, coffee, cola-based drinks), and alcohol (5). The single-centre cohort consisted of 21 children (9 girls [43%]) between 2 and 16 years who presented to the paediatric gastroenterology clinic with recurrent stereotypic episodes of frequent vomiting. A total of 17 children (81%) were reported as having abdominal pain and 6 children (29%) had nausea during the episodes. A total of 16 children (76%) came from families with a strong history of migraine. These children remained symptom free between the episodes. The rationale of LAD and expected benefits were discussed by a paediatric dietitian with the family before starting the therapy, which was continued for a minimum of 6 to 8 weeks. If adverse effects such as worsening of frequency or severity of vomiting or abdominal pain were noted, then the therapy was stopped earlier. A total of 18 children (86%) responded to the LAD therapy and the results are shown in Figure 1. In the group of children who had complete resolution of vomiting, 2 of 13 children continued to have abdominal pain and 1 child developed migraine symptoms later. In the 5 children who showed partial resolution of symptoms, the episodes of CVS were less frequent, less severe, and of shorter duration. Our preliminary findings suggest that LAD may be useful in some children with CVS.FIGURE 1: Response to low-amine diet on vomiting.

A Case of Acute Disseminated Encephalomyelitis Disguised as Mania in a Woman With Known Bipolar Disorder

Back to table of contents Previous article Next article LettersFull AccessA Case of Acute Disseminated Encephalomyelitis Disguised as Mania in a Woman With Known Bipolar DisorderDenise Cupina, and Brooke ShortDenise CupinaSearch for more papers by this author, and Brooke ShortSearch for more papers by this authorPublished Online:1 Apr 2012https://doi.org/10.1176/appi.neuropsych.11060118AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Acute disseminated encephalomyelitis (ADEM) is a rare acute widespread demyelinating condition affecting brain and spinal cord.1 It is characterized by multiple white matter lesions present on neuroimaging studies.1 The clinical manifestations vary widely and usually include a combination of neurological and psychiatric symptoms, however a predominantly psychiatric presentation is possible.2, 3Bipolar disorder is an affective disorder (BPAD) characterized by distinctive episodes of depression and mania with or without psychotic symptoms and full interepisode recovery.4We report a case of a woman with history of bipolar disorder who developed ADEM which presented clinically very similarly to a manic episode initially indistinguishable from her pre-existing psychiatric condition.A 31 year old woman with bipolar disorder was admitted with a relapse of manic symptoms. On admission, her physical examination, baseline blood tests and urine drug screen were unremarkable. She was recommenced on lithium and quetiapine but continued to present as elevated, highly labile and irritable despite restarting her usual treatment. After five weeks she achieved only partial resolution of symptoms, in contrast to her previous manic episodes that had resolved within a few weeks. Her medication was gradually changed to sodium valproate and risperidone, to which she developed severe extrapyramidal side effects. Risperidone was thus changed to olanzapine. Her mental state continued to fluctuate with evidence of disorientation, confusion and fluctuating attentiveness. A full neurological exam found no specific abnormalities other than parkinsonian signs. Neuroleptic malignant syndrome was considered but excluded due to normal serum creatine kinase, absence of pyrexia and autonomic instability. Her white cell count was mildly elevated with neutrophilia, but no infective focus was detected. Electroencephalogram was normal. Upon further questioning of family members history of an observed seizure prior to initial admission was obtained. An urgent magnetic resonance image (MRI) of her brain was arranged showing multiple areas of increased signal intensity on T2/FLAIR images in periventricular, subcortical, and brainstem regions bilaterally with no enhancement post-gadolinium.The patient was transferred urgently to the neurology ward. A lumbar puncture was conducted which found no abnormalities. Oligoclonal bands were positive in cerebrospinal fluid only. Serology testing and autoimmune markers were negative. A diagnosis of ADEM was made. The patient was commenced on IV Ceftriaxone and Methylprednisolone. Her delirium resolved but she continued to have residual mood and psychotic symptoms that took several weeks to improve. Her follow up brain MRI scan performed two months after the symptoms onset was unchanged. She was discharged home with a scheduled follow up appointment in the neurology outpatient clinic.Our patient developed ADEM that was initially diagnosed and treated as a relapse of bipolar disorder. ADEM can mimic various psychiatric disorders3 making its diagnosis in psychiatric patients extremely difficult. This case highlights the importance of taking a detailed neurological and medical history in every patient presenting with psychiatric symptoms. It additionally emphasizes the significance of recognizing atypical clinical features, such as poor response to usual treatment, increased sensitivity to medication side effects, changeable presentation and onset of delirium indicating organic rather than purely psychiatric aetiology.References1 Garg RK: Acute disseminated encephalomyelitis. Postgrad Med J 2003; 79:11–17Crossref, Medline, Google Scholar2 Patel SP, Friedman RS: Neuropsychiatric features of acute disseminated encephalomyelitis: a review. J Neuropsychiatry Clin Neurosci 1997; 9:534–540Link, Google Scholar3 Habek M, Brinar M, Brinar VV, et al.: Psychiatric manifestations of multiple sclerosis and acute disseminated encephalomyelitis. Clin Neurol Neurosurg 2006; 108:290–294Crossref, Medline, Google Scholar4. Kaplan HI, sadock BJ: Mood disorders. Kaplan and Sadock’s Synopsys of Psychiatry, 10th Edition, Sydney, Lippincott Williams & Wilkins 2077:527–578Google Scholar FiguresReferencesCited byDetailsCited ByAcute demyelinating encephalomyelitis presenting with psychiatric symptoms5 November 2013 | International Journal of Geriatric Psychiatry, Vol. 28, No. 12 Volume 24Issue 2 Spring 2012Pages E18-E18 Metrics PDF download History Published online 1 April 2012 Published in print 1 April 2012

Partial lumbosacral transitional vertebrae: 2 cases of unilateral sacralization

ObjectiveLumbosacral transitional vertebrae (LSTV) are relatively common skeletal anomalies with a debated role in low back pain. There are few documented cases of conservative care being used to address LSTV-associated symptomatology. The current report discusses chiropractic management of 2 patients with unilateral sacralization. Clinical FeaturesTwo patients with LSTV involving unilateral sacralization of L5, a Castellvi type IIIa variant, presented with back pain to a chiropractic clinic. Each case presented with symptomatology similar to piriformis syndrome. Intervention and OutcomeManual therapy, including spinal manipulation soft tissue therapies and exercise/stretching, was used to address the presenting symptoms. Approximately 2 weeks after initial treatment, the first patient subjectively reported a 70% improvement in symptoms, with lumbar extension increased to full in active range of motion at the lumbar spine but with continued tenderness and hypertonicity at the left piriformis and gluteus medius. After 4 weeks of treatment, the second patient reported improvement in pain and perceived mobility, although prolonged standing remained an aggravating factor. Although both showed improvement, neither case resulted in complete resolution of symptoms. ConclusionThe presenting cases demonstrated partial resolution of symptoms after chiropractic management. It is proposed that sacralization is a possible cause of back pain in these cases.