Retrospective Clinical Cohort Study Research Articles

Does the Addition of a Dynamic Pedicle Screw to a Fusion Segment Prevent Adjacent Segment Pathology in the Lumbar Spine?

Study DesignRetrospective clinical cohort study.Purpose To investigate whether the combined use of dynamic pedicle screws and polyaxial pedicle screws was effective on adjacent segment pathology (ASP).Overview of LiteratureVarious screw and rod models have been recently developed for preventing adjacent segment disease, and hybrid systems have been described along with posterior instrumentation in the fusion segment. In the literature, although the success of dynamic systems has been demonstrated in non-fusion posterior instrumentation, it remains unclear whether the addition of a screw-based dynamic system to a fusion segment would successfully prevent ASP in the long term.MethodsThe study included 101 patients who underwent surgery for degenerative spine diseases between 2007 and 2014 with lumbar stabilization that used either polyaxial pedicle screws alone or polyaxial pedicle screws plus dynamic stabilization screws (with hinged screw heads). These two patient groups were compared using retrospectively obtained postoperative new clinical findings, Oswestry disability index (ODI) scores, visual analog scale (VAS) scores, and radiological data.ResultsThe proportion of patients with ASP who were radiologically assessed was low (p <0.01) in the group that underwent lumbar stabilization along with dynamic screws. Treatment outcomes were clinically successful in both groups according to ODI and VAS scores, and no significant difference was determined between the groups in terms of clinical ASP (p >0.05).ConclusionsAlthough the combined use of dynamic screws and the static system was radiologically found to be effective for preventing ASP in patients who underwent lumbar fusion with posterior instrumentation, it did not completely eliminate ASP or result in a significant improvement in clinical ASP.

Traitement des luxations acromioclaviculaires type III selon Rockwood : TightRope® versus brochage. Une étude comparée

Background and hypothesisThe aim of this study was to address the inconsistency regarding the operative treatment of Rockwood type III acromioclavicular joint separation. We compared results after single and double TightRope® reduction with results after acromioclavicular transfixation via K-wires only and additional ligament augmentation in acute acromioclavicular (AC) joint separations graded Rockwood type III, and hypothesized that the TightRope® technique leads to better clinical and radiological results. Patients & methodsWe conducted a retrospective clinical cohort study and included 42 consecutive patients (mean age 43 years [24–66]) diagnosed and operatively treated between 2004 and 2012 (mean follow up was 54.6 months [15–118]). Specific shoulder scores as well as scores reflecting the patients’ overall mental and physical health status were used. Radiological evaluation was also performed. ResultsThe SF12 test revealed comparability between all subgroups. Specific shoulder tests and a visual analogue scale demonstrated comparable results. Radiographic measurements showed a significant reduction in the AC distance and CC distance after surgery in all subgroups. The early complication rate was 9.5 % for all patients while late complications occurred in 14.3 % of all cases. ConclusionsCompared to the established methods, the operative TightRope® procedures represent a safe alternative in Rockwood III injuries. All investigated techniques predominantly led to good and excellent clinical results in acute Rockwood type III AC joint instabilities. Avoidance of material removal and shorter hospital stays appear to speak in favour for the TightRope® technique. Level of evidenceIV.

Costs of Diagnosing Breast-Related Conditions at a Large, Public Hospital in a Middle-Income Country Without Population-Level Screening

Abstract 42 Background: Literature regarding the costs and cost-effectiveness of diagnosing breast disease globally, including cancer, has focused on mammographic screening in high-income settings. South Africa, a middle-income country, is currently crafting its first national breast cancer policy, and information on costs and best practices for national imaging services in low- and middle-income settings is required. We undertook this work to estimate the average cost per procedure and per patient for diagnosis of breast conditions by using a large, public outpatient clinic in Johannesburg as well as to explore potential cost savings through rationing mammography for diagnosis. Methods: Results of a retrospective clinical cohort study conducted at an outpatient clinic in 2013 and 2014 were used to establish a 12-month population of clinic patients and diagnostic service statistics. We used microcosting to estimate the average cost for each diagnostic procedure from the health service perspective. An Excel-based model and scenario analysis were used to explore changes in total and per patient costs when mammography use was incrementally reduced by shifting patients to ultrasound-based services. Results: We estimated that 3,867 individuals attended the clinic over 12 months. The average cost per patient for initial consultation and/or exam was $10.14 (2015 USD). Mammography was more costly than ultrasound at $59.96 and $21.11, respectively. Procedures for pathology were the most costly diagnostic (stereotactic core needle biopsy, $330.05; ultrasound-guided core needle biopsy, $279.42; fine needle aspiration, $101.00) because of substantial laboratory charges. The average cost per patient seen was $115.96. Hypothetically, replacing mammography with ultrasound resulted in minimal decreases in the average cost per patient as a result of the high cost of the mammogram machine. Cost savings at the facility level may be achieved when mammography use is eliminated entirely. Conclusion: Per patient mammography costs are largely dependent on economies of scale. Because ultrasound can be considered as an alternative for many women without compromising imaging in nonoccult disease, diagnostic mammography should be offered in centralized locations for maximum efficiency gains. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Naomi Lince-Deroche No relationship to disclose Craig Van Rensburg No relationship to disclose Cindy Firnhaber Research Funding: Merck (Inst) Carol Benn No relationship to disclose Grace Rubin No relationship to disclose Pam Michelow No relationship to disclose Sarah Rayne Travel, Accommodations, Expenses: Novartis

Outcomes of Left Heart Bypass Versus Circulatory Arrest in Elective Open Surgical Descending and Thoraco-abdominal Aortic Repair

To compare early (30 day mortality and major complications) and midterm (survival) outcomes in elective open surgical descending and thoraco-abdominal aortic repair using left heart bypass (LHB) versus hypothermic circulatory arrest (HCA) for organ protection, hypothesising non-inferiority of HCA management. This was a retrospective clinical cohort study with cross sectional follow-up. All elective (n=90) descending or thoraco-abdominal aortic repairs performed between 2004 and 2015 using either LHB (n=57) or HCA (n=33) were included. Pre- and intra-operative variables were evaluated by univariate statistical analysis. Thirty day and follow-up mortality were primary endpoints; major complications were secondary endpoints. Propensity score matching was employed to adjust for selection bias. Kaplan-Meier methods were used to estimate midterm survival. Overall 30 day mortality was 8/90 (8.9%): 6/57 (10.5%) using LHB vs. 2/33 (6.1%) using HCA, p=.47. Five patients (5.6%) suffered paraplegia: 3/57 (5.3%) using LHB vs. 2/33 (6.1%) using HCA, p=.87. Stroke occurred in 6/57 (11%) vs. 2/33 (6.1%), p=.76; renal failure in 27/57 (47%) vs. 19/33 (58%), p=.90; and respiratory failure in 17/57 (30%) vs. 11/33 (33%), p=.68. In 26 propensity score matched pairs, findings remained unaltered. Total follow-up was 443 patient years (median 4.9 years). Estimated survival was 78% at 1year and 77% at 5 years in LHB vs. 72% and 67%, respectively, with HCA; there were no significant inter-group differences, before or after propensity score matching. In elective descending or thoraco-abdominal aortic repair, no statistically significant differences in 30 day mortality, major complications, or follow-up survival were found when LHB and HCA were compared. These findings remained after propensity score matching.

Comparative study on the treatment of Rockwood type III acute acromioclavicular dislocation: Clinical results from the TightRope® technique vs. K-wire fixation

Background and hypothesisThe aim of this study was to address the inconsistency regarding the operative treatment of Rockwood type III acromioclavicular joint separation. We compared results after single- and double TightRope® reduction with results after acromioclavicular transfixation via K-wires only and additional ligament augmentation in acute acromioclavicular (AC) joint separations graded Rockwood type III, and hypothesized that the TightRope® technique leads to better clinical and radiological results. Materials and methodsWe conducted a retrospective clinical cohort study and included 42 consecutive patients (mean age 43 years [24–66]) diagnosed and operatively treated between 2004 and 2012 (mean follow-up was 54.6 months [15–118]). Specific shoulder scores as well as scores reflecting the patients’ overall mental and physical health status were used. Radiological evaluation was also performed. ResultsThe SF12 test revealed comparability between all subgroups. Specific shoulder tests and a visual analogue scale demonstrated comparable results. Radiographic measurements showed a significant reduction in the AC distance and CC distance after surgery in all subgroups. The early complication rate was 9.5% for all patients, while late complications occurred in 14.3% of all cases. ConclusionsCompared to the established methods, the operative TightRope® procedures represent a safe alternative in Rockwood III injuries. All investigated techniques predominantly led to good and excellent clinical results in acute Rockwood type III AC joint instabilities. Avoidance of material removal and shorter hospital stays appear to speak in favour for the TightRope® technique. Level of evidenceIV.

Calcaneal Fractures in Non-Racing Dogs and Cats: Complications, Outcome, and Associated Risk Factors.

To estimate the prevalence of complications and describe the outcome associated with calcaneal fractures in non-racing dogs and in cats. Retrospective multicenter clinical cohort study. Medical records of client-owned dogs and cats (2004-2013). Medical records were searched and 50 animals with calcaneal fractures were included for analysis. Complications were recorded and an outcome score applied to each fracture. Associations between putative risk factors and both major complications, and final outcome scores were explored. Complications occurred in 27/50 fractures (61%) including 23 major and 4 minor complications. At final follow-up, 4 animals (10%) were sound, 27 (64%) had either intermittent or consistent mild weight-bearing lameness, 7 (17%) had moderate weight-bearing lameness, and 1 (2%) had severe weight-bearing lameness. Fractures managed using plates and screws had a lower risk of complications than fractures managed using pin and tension band wire, lag or positional screws or a combination of these techniques (Relative risk 0.16, 95% CI 0.02-1.02, P=.052). Non-sighthounds had reduced odds of a poorer outcome score than sighthounds (Odds ratio 0.11, 95% CI 0.02-0.50, P=.005) and fractures with major complications had 13 times the odds of a poorer outcome score (Odds ratio 13.4, 95% CI 3.6-59.5, P<.001). This study reports a high occurrence of complications associated with calcaneal fracture stabilization in non-racing dogs and in cats, and a poorer outcome score was more likely in animals with complications. A more guarded prognosis should be given to owners of non-racing dogs or cats with calcaneal fractures than previously applied to racing Greyhounds with calcaneal fractures.

Feasibility of Dental Implant Replacement in Failed Sites: A Systematic Review.

To assess the clinical outcomes of replaced implants after removal of failed ones. In addition, associated risk factors that might affect the final outcome of these procedures were also explored. An electronic literature search was conducted by two reviewers in several databases for articles written in English up to November 2014. Human clinical trials with a minimum of 10 subjects enrolled that reported clinical outcomes with a mean follow-up period of at least 12 months after implant replacement were included. Implant survival and nonmodifiable/modifiable factors at second and third implant placement attempts were studied. Hence, the PICO question that was aimed to be addressed was: Do patients undergoing implant replacement (second and third attempts) in previous failed sites have comparable clinical outcomes by means of implant survival/failure rate to implants placed at the first attempt? Five retrospective clinical cohort studies and two case series satisfied the selection criteria and thus were included in this review. In total, 396 patients were studied due to implant replacement in previous failed sites. The survival rate for implant replacement at the second attempt was 88.84% (390/439; range, 71% to 94.6%) with a mean follow-up of 41.59 ± 16.77 months. Thirty-one implants were replaced for a third attempt with a mean survival rate of 74.19% (23/31) at the follow-up of 29.66 ± 14.71 months. Major risk indicators were generally divided into patient-related factors (health status, smoking habits, and oral hygiene maintenance), implant characteristics (dimensions, coating, and loading), and site characteristics (bone quality and density, vertical and horizontal dimensions, soft tissue around the implant). Implant replacement is a reasonably feasible option for scenarios of early and late implant failure. However, modifiable risk factors must be controlled before proceeding for implant replacement.

Validation of ABCD2 scores ascertained by referring clinicians: a retrospective transient ischaemic attack clinic cohort study

IntroductionTransient ischaemic attack (TIA) services routinely use ABCD2 scores ascertained by referring clinicians to triage patients. Most ABCD2 validation studies have used ABCD2 scores calculated by stroke-specialist investigators and not...

Orthogeriatric Service Reduces Mortality in Patients With Hip Fracture.

Introduction:Orthogeriatric service has been shown to improve outcomes in patients with hip fracture. The purpose of this study is to evaluate the effect of orthogeriatrics at Bispebjerg University Hospital, Denmark. The primary outcome is mortality inhospital and after 1, 3, and 12 months for patients with hip fracture. The secondary outcome is mortality for home dwellers and nursing home inhabitants.Materials and Methods:This is a retrospective clinical cohort study with an historic control group including all patients with hip fracture admitted from 2007 to 2011. Patients with hip fracture are registered in a local database, and data are retrieved retrospectively using the Danish Civil Registration Number.Results:We included 993 patients in the intervention group and 989 patients in the control group. A univariate analysis showed only significantly decreased mortality inhospital 6.3% vs 3.1% (P = .009) after orthogeriatrics. However, when adjusting for age, gender, and American Society of Anaesthesiologists (ASA) score in a multivariate analysis, including all patients with hip fracture, we find significantly reduced mortality inhospital (odds ratio [OR] 0.35), after 30 [OR 0.66] and 90 days [OR 0.72] and 1 year [OR 0.79]). When using a univariate analysis for home-dwelling patients, we found significantly reduced mortality inhospital (8.3-2.0%, P < .0001), after 30 days (12.2-6.8%, P = .004) and 90 days (20.5-13.0%, P = .002). One-year mortality was not significant. Patients from nursing homes had no significant decreasing mortality at any point of time in the univariate analysis.Conclusion:We have shown significant decreases for inhospital, 30 day, 90 day, and 1-year mortality after implementation of orthogeriatric service at Bispebjerg Hospital when adjusting for age, gender, and ASA score. Future trials should include frail patients with other fracture types who can benefit from orthogeriatrics.

Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection.

Anastomotic leakage presents the most feared complication after low anterior resection (LAR). A proximal diversion of the gastrointestinal tract is recommended to avoid septic complications of anastomotic leakage. The aim of the present study was to evaluate the benefits and risks of diverting ileostomy (DI) created during laparoscopic LAR because of low rectal cancer. This was a retrospective clinical cohort study conducted to assess outcomes of laparoscopic LAR with/without DI in a single institution within a 6-year period. In total, 151 patients were enrolled in the study (73 patients without DI, 78 patients with DI). There were no significant differences between both groups regarding demographic and clinical features. Overall 30-day morbidity rates were significantly lower in patients without DI (23.3 vs. 42.3%, P=0.013). Symptomatic anastomotic leakage occurred more frequently in patients without DI (9.6 vs. 2.5%, P=0.090); surgical intervention was needed in 6.8% of patients without DI. Post-operative hospital stay was significantly longer in the group of patients with DI (11.3±8.5 vs. 8.1±6.9days, P=0.013). Stoma-related complications occurred in 42 of 78 (53.8%) patients with DI; some patients had more than one complication. Acute surgery was needed in 9 patients (11.5%) because of DI-related complications. Small bowel obstruction due to DI semi-rotation around its longitudinal axis was seen in 3 patients (3.8%) and presents a distinct complication of DI laparoscopic construction. The mean interval between LAR and DI reversal was more than 8months; only 19.2% of patients were reversed without delay (≤4months). Morbidity after DI reversal was 16.6%; re-laparotomy was necessary in 2.5% of patients. The present study indicates that DI protects low rectal anastomosis from septic complications at a cost of many stoma-related complications, substantial risk of acute surgery necessity and long stoma periods coupled with decreased quality of life.

Assessment of tuberculosis situation in Cairo governorate from 2006 to 2012 after application of directly observed therapy short-course strategy

Directly observed therapy short course (DOTS) is a strategy in which a trained healthcare worker or a designated individual provides the prescribed antituberculous drugs and watches the patient to ensure the patient is taking each dose. The objective of this work was to study tuberculosis situation in Cairo governorate from 2006 to 2012 after application of DOTS. This was a retrospective clinical cohort study carried out at the Cairo governorate. Percentages of cure and complete treatment were 61.6 and 20.4%, respectively. The incidence of failure, death, default, and transfer out decreased after DOTS (2.2, 4.5, 8.6, and 2.7, respectively). The introduction of DOTS in the Cairo governorate has led to a treatment success rate of 82% (nearly similar to the WHO target of ‘85%’).

Abstract P5-08-06: Comparison of risk prediction with the 21-gene recurrence score (oncotype DX) and the 70-gene signature (MammaPrint) in patients with estrogen receptor-positive early stage breast cancer

Abstract Background: Gene expression profiling assays estimate prognosis &amp; predict benefit from adjuvant chemotherapy in patients (pts) with estrogen receptor positive (ER+) early stage breast cancer (ESBC). The 21-gene recurrence score (RS) and 70-gene signature (MP) are widely used assays. Pts may have both tests performed to adjudicate discordant results. We compared RS and MP in pts with both tests and evaluated their impact on adjuvant treatment decisions. Methods: This was a retrospective clinical cohort study from 5 centers from 2007-2014. Eligibility included ER+ ESBC with RS and MP results from the same tissue sample; exclusions included carcinoma in situ, primary metastatic disease, &amp; bilateral breast cancer. Two definitions of RS risk were evaluated (Genomic Health [GH] or TAILORx [TRx]): low risk (GH:0-17) or (TRx:0-10); intermediate risk (GH:18-30) or (TRx:11-25); and high risk (GH:&amp;gt;31) or (TRx:&amp;gt;26). Demographic, clinicopathologic (CP) data, and treatment decisions were extracted from medical records. Agreement was assessed between RS and MP using weighted kappa scores. CP factors were assessed with the t-test and chi-square test. Results: 123 pts were identified from UCSF or 4 US Oncology Network practices. 60 pts had low risk RS (GH); 27 were low risk by MP (45% agreement). 15 cases had a low risk RS (TRx); 9 were low risk by MP (60%). 10 pts had high risk RS (GH); 8 were high risk by MP (80.0%). Similarly, 18 cases had high risk (TRx) RS;16 were high risk by MP (88%). Using the RS GH risk definition, there was poor agreement for low risk RS/MP and high risk RS/MP (kappa=0.169). However, using the TRx RS risk definition, there was good agreement for low risk RS/ MP and high risk RS/MP (kappa=0.509). 53 pts had intermediate risk RS by (GH); by MP 16 were low risk (30%), and 37 were high risk (70%). 90 pts had an intermediate risk RS by TRx; by MP 34 were low risk (37.8%), and 56 were high risk by MP (62.2%). Using TRx RS increased the number of pts classified as intermediate risk compared to GH RS (73.2 vs 43.1%). Complete adjuvant treatment data were available for 90 patients. Of 40 pts with low risk RS (GH), 25% received chemotherapy associated with node status but not tumor size, grade, or MP. Of 10 pts with high risk RS (GH), 70% received chemotherapy without association with CP features or MP. For the 45 pts with intermediate risk RS (GH), 53% received chemotherapy, without correlation with CP features. Receipt of chemotherapy was positively associated with MP high risk, but this was not significant (odds ratio 2.08, 95% CI 0.54-8.01); p-0.29. Conclusion: Concordance in risk prediction between RS and MP was greater using RS defined by TRx compared to GH, and RS using TRx increases those categorized as intermediate risk. There appeared to be no correlation between CP features and decisions to use chemotherapy across risk groups. Interestingly, in those with intermediate risk RS (GH or TRx), there was a non-significant trend toward use of chemotherapy in those with high risk by MP. Although gene expression tests are used frequently to aid in treatment decisions in ESBC, considerable variation exists in their application in clinical practice. Citation Format: Jiang H, Denduluri N, Majure M, Favret A, Rugo HS. Comparison of risk prediction with the 21-gene recurrence score (oncotype DX) and the 70-gene signature (MammaPrint) in patients with estrogen receptor-positive early stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-06.

Extension deficit after ACL reconstruction: Is open posterior release a safe and efficient procedure?

BackgroundExtension loss is a potentially devastating consequence of anterior cruciate ligament reconstruction (ACLR). It can often be treated by anterior arthroscopic release. In rare cases, a chronic flexion contracture requires an additional posterior open release. To our knowledge, no study analysing the results of both posteromedial and posterolateral approaches has been performed so far.The purposes of this study were (1) to analyse the midterm outcome and complications of a combined procedure, anterior arthroscopic debridement and posterior open capsulotomy — for the treatment of chronic extension deficits after ACLR and (2) to describe the surgical technique of posterior open release with both posteromedial and posterolateral approaches. Material and methodsThis is a retrospective clinical cohort study. Twelve patients presenting a chronic flexion contracture of 10° or more after ACLR treated by open posterior arthrolysis with an average follow-up time of 38months (range six to 90) were included. At last follow-up, they underwent both a clinical examination with range of motion analysis, International Knee Documentation Committee (IKDC) and KOOS scores. ResultsAt follow-up, all patients except one (93%) achieved complete extension. Only one patient (7%) had a residual post-operative flexion deformity of five degrees. The range of motion (ROM) improved significantly after arthrolysis from 96°±14.3° (SD) to 14.3°±7°(SD)(p<0.001).No post-operative complications were recorded. No patients required further open debridement.The post-operative objective IKDC score was grade A for five patients, B for seven versus C for five patients and D for seven preoperatively. The mean post-operative subjective IKDC score was 86.4±9.7. The post-operative Knee injury and Osteoarthritis Outcome Score (KOOS) distribution was as follows: pain 93.8±5 (SD); symptoms 88±8.6 (SD); ADL 96.8±3.7 (SD); sports activities 83.6±12.3 (SD); and quality of life 82.9±8.8 (SD). Mean patients' satisfaction was 9.25±0.6 (SD) out of 10 after arthrolysis. ConclusionsOpen posterior release with both posteromedial and posterolateral approaches is a safe and efficient additional procedure in case of persistent flexion contracture after ACLR with good ROM gain, functional scores and patients' satisfaction. Level of evidenceTherapeutic study — Level IV

Utility of Prosthetic Replacement of the Ocular Surface Ecosystem Treatment in the Management of Patients with Refractory Intrinsic Evaporative Dry Eye Disease

Background: Dry eye disease is a multifactorial disease whose pathogenic mechanisms have not been investigated rigorously. The objective of this study was to evaluate the utility of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in the management of patients with intrinsic evaporative dry eye refractory to conventional therapies. Design: A retrospective clinical cohort study of patients with intrinsic evaporative dry eye disease refractory to conventional therapies seen between July 1, 2009 and May 31, 2012 at USC Eye Institute, a tertiary referral center. Participants: 36 eyes of 21 patients with intrinsic evaporative dry eye that completed PROSE fitting were included. Main outcomes measures: Outcomes based on pre and post PROSE visual acuity and visual function. Bestcorrected visual acuities were measured using a Snellen chart under standardized conditions. Visual function was assessed using the Ocular Surface Disease Index survey, a 12-item questionnaire that quantifies the severity of ocular discomfort and level of vision-related function. Results: Mean visual acuity improved from 0.33 ± 0.40 logMAR pre-PROSE to 0.10 ± 0.16 logMAR post-PROSE (Z=-4.3, p<0.0001, n=36). Thirteen of 21 patients completed pre-PROSE and post-PROSE surveys. Survey scores improved from 63.61 ± 15.76 pre-PROSE to 24.84 ± 29.58 post-PROSE (Z=-2.9, p=0.004, n=13). Conclusion: The results of our study strongly suggest PROSE treatment improves visual acuity and function in patients with refractory intrinsic evaporative dry eye disease and could serve as a viable alternative to more invasive procedures.

Tuberculosis situation in Ismailia governorate (2002–2012) before and after Direct Observed Therapy Short Course Strategy (DOTS)

BackgroundTuberculosis (TB) is a major cause of illness and death worldwide, especially in Asia and Africa. In the early 1990s tuberculosis control in Egypt faced many problems. Major progress in global tuberculosis control followed the widespread implementation of the DOTS strategy. AimThe objective of this work was to study the tuberculosis situation in the Ismailia governorate from 2002 to 2012 before and after Direct Observed Therapy Short Course Strategy (DOTS). MethodsThis was a retrospective clinical cohort study carried out at the Ismailia governorate. The registered data about all TB cases over a period of 10years (2002–2012) before and after the application of DOTS were collected from the chest hospital and TB registration units.Percentages of cure treatment significantly increased after DOTS (55.3%) than before (40.5%) (P<0.01). On the other hand, complete, failure, death, default and transfer out decreased after DOTS (32.5%, 1.3%, 6.3%, 2.5% and 2.0% respectively) than before it (38.7%, 3.1%, 6.9%, 7.2% and 4.0% respectively), the results were not significant (P>0.05) for all of them. The mean values of incidence rates (new and relapse cases, all cases and new smear positive pulmonary TB cases) of TB highly significantly (P<0.01) decreased after the application of DOTS for all of them except new smear positive pulmonary TB cases (P>0.05). Also, the cure rate and treatment success rate significantly increased (P<0.05), while retreatment TB cases rate, default rate, transfer out rate and retreatment failure rate did not significantly decreased (P>0.05) for all of them except retreatment failure rate (chronic TB rate) (P<0.05). Finally new pulmonary TB cases with no smear result significantly (P<0.05) decreased after DOTS. ConclusionThe introduction of DOTS in the Ismailia governorate has led to a significant increase in the treatment success (88.07%) which is higher than the WHO target (85%), and a decrease in the default and failure rates.

Soft-tissue grafting for peri-implantitis-a treatment option in case of unsuitable skeletal basic morphology of the alveolar bone and lack of keratinized mucosa: a retrospective clinical cohort study.

BackgroundThis retrospective study evaluated soft-tissue grafting as a surgical treatment option for peri-implantitis in case of unsuitable basic skeletal morphology of the alveolar bone and lack of keratinized mucosa.MethodsTwenty-eight patients (21 females, 7 males, at a mean age 59.4 years) were included with a total of 54 implants. All implants showed peri-implantitis and attached keratinized buccal mucosa of ≤2 mm. A surgical procedure of soft-tissue grafting (STG) was made by inserting an inlay and inlay-onlay transplant. Clinical investigations were made prior to the STG (baseline) and after 9–180 months (Ø 43 months) including the following parameters: soft-tissue biotype, skeletal basic morphology of the alveolar bone, width of the peri-implant keratinized mucosa (KM), mobility of the KM, pocket probing depth (PPD), and bleeding on probing (BOP).ResultsNearly all patients showed a thin soft-tissue biotype. The analysis of the skeletal basic morphology of the alveolar bone revealed a narrow apical base in 18 patients, middle base in 7 patients, and broad base in 3 patients. Width of the KM increased significantly (p < 0.01) from 0.4 ± 0,5 mm to 4.3 ± 1.5 mm after STG and PPD was significantly (p < 0,01) reduced from 6.3 ± 2,3 mm to 4.1 ± 1.9 mm. A significant reduction (p < 0.01) in BOP was recorded. All patients reported a clinical improvement of the inflammatory symptoms at follow-up.ConclusionsThe results of this study showed that the STG can be applied successfully as a surgical treatment of peri-implantitis. It remains unclear whether soft-tissue biotype or the skeletal basic morphology of the alveolar bone affects the outcome of this surgical treatment.

Clinical features of Alzheimer disease with and without lewy bodies

Importance Lewy bodies are a frequent coexisting pathology in late-onset Alzheimer disease (AD). Previous studies have examined the contribution of Lewy bodies to the clinical phenotype of late-onset AD with variable findings. Objective To determine whether the presence of Lewy body pathology influences the clinical phenotype and progression of symptoms in longitudinally assessed participants with AD. Design, Setting, and Participants Retrospective clinical and pathological cohort study of 531 deceased participants who met the neuropathologic criteria for intermediate or high likelihood of AD according to the National Institute on Aging–Ronald Reagan Institute guidelines for the neuropathologic diagnosis of AD. All participants had a clinical assessment within 2 years of death. The data were obtained from 34 AD centers maintained by the National Alzheimer Coordinating Center and spanned from September 12, 2005, to April 30, 2013. Exposures Standardized neuropathologic assessment and then brain autopsy after death. Main Outcomes and Measures Clinical and neuropsychiatric test scores. Results The mean (SD) age at death was statistically significantly younger for participants who had AD with Lewy bodies (77.9 [9.5] years) than for participants who had AD without Lewy bodies (80.2 [11.1] years) ( P = .01). The mean (SD) age at onset of dementia symptoms was also younger for participants who had AD with Lewy bodies (70.0 [9.9] years) than for participants who had AD without Lewy bodies (72.2 [12.3] years) ( P = .03). More men than women had AD with Lewy bodies ( P = .01). The frequency of having at least 1 APOE e4 allele was higher for participants who had AD with Lewy bodies than for participants who had AD without Lewy bodies ( P = .03). After adjusting for age, sex, education, frequency of plaques (neuritic and diffuse), and tangle stage, we found that participants who had AD with Lewy bodies had a statistically significantly higher mean (SD) Neuropsychiatric Inventory Questionnaire score (6.59 [1.44] [95% CI, 3.75-9.42] vs 5.49 [1.39] [95% CI, 2.76-8.23]; P = .04) and a statistically significantly higher mean (SD) Unified Parkinson Disease Rating Scale motor score (0.81 [0.18] [95% CI, 0.45-1.17] vs 0.54 [0.18] [95% CI, 0.19-0.88]; P Conclusions and Relevance Participants with both AD and Lewy body pathology have a clinical phenotype that may be distinguished from AD alone. The frequency of Lewy bodies in AD and the association of Lewy bodies with the APOE e4 allele suggest potential common mechanisms for AD and Lewy body pathologies.

Clinical Benefits for Older Alzheimer's Disease Patients: Okayama Late Dementia Study (OLDS).

There are few reports on the effects of anti-Alzheimer's disease (AD) drugs on older AD patients, and possible differences based on gender in a real world setting. "Okayama Late Dementia Study (OLDS)" is a retrospective clinical cohort study focusing on older AD patients (n = 373; age≥75 years) treated with monotherapy donepezil (n = 55), galantamine (n = 222), rivastigmine (n = 63), or memantine (n = 33). The patients were evaluated as an entire group and separated by gender, using seven batteries for dementia assessment at baseline and at 3, 6, and 12 months of drug therapy. All four drugs preserved cognitive and affective functions until 12 months, except for Frontal Assessment Battery (FAB) with memantine ( *p < 0.05 versus baseline). Donepezil monotherapy significantly improved Hasegawa Dementia Rating Scale-Revised (HDS-R) at 3 months ( *p < 0.05), and memantine (3 and 6 months, *p < 0.05) and rivastigmine (3 months, **p < 0.01) improved Abe's Behavior and Psychological Symptom of Dementia Score (ABS), respectively. Activities of daily living (ADL) became significantly worse with galantamine at 12 months ( *p < 0.05). Male Mini-Mental State Examination scores became worse at 12 months with donepezil ( *p < 0.05), as did female Geriatric Depression Scale scores at 6 months ( *p < 0.05). Male HDS-R and ABS scores were preserved in the galantamine group until 12 months. Female ABS scores with memantine improved at 6 months ( *p < 0.05), while male ADL scores became worse with rivastigmine at 12 months ( *p < 0.05). OLDS revealed that anti-AD drugs were effective even for older AD patients, and the clinical benefits of each drug showed a small difference with regard to gender.

Effect of pregnancy and the postpartum period on adherence to antiretroviral therapy among HIV-infected women established on treatment.

: Among women who become pregnant after initiating highly active antiretroviral therapy (HAART), few data describe the effect of pregnancy and postpartum on adherence. We conducted a retrospective clinical cohort study among therapy-naive women (age, 18-45 years) initiating HAART in Johannesburg, South Africa. Among 7510 women in our analysis, 896 experienced a pregnancy after starting HAART. Compared with nonpregnant periods of follow-up, there was an increased risk of nonadherence during the postpartum period (weighted risk ratio: 1.46, 95% confidence interval: 1.17 to 1.82) but not during pregnancy itself (weighted risk ratio: 0.95, 95% confidence interval: 0.78 to 1.17).

Tuberculosis situation in Port Said governorate (1995–2011) before and after Direct Observed Therapy Short Course Strategy (DOTS)

BackgroundTuberculosis (TB) is a major cause of illness and death worldwide, especially in Asia and Africa. In the early 1990s tuberculosis control in Egypt faced many problems. Major progress in global tuberculosis control followed the widespread implementation of the DOTS strategy. AimThe objective of this work was to study the tuberculosis situation in Port Said governorate from (1995–2011) before and after Direct Observed Therapy Short Course Strategy (DOTS). MethodsThis was a retrospective clinical cohort study carried out at the Port Said governorate. The registered data about all TB cases over a period of 16years (1995–2011) before and after the application of DOTS were collected from the chest hospital and TB registration units. ResultsPercentages of cure and complete treatment significantly increased after DOTS (48.7% and 29.3% respectively) than before (19.5% and 13.7% respectively) (P<0.001). On the other hand, failure, death, default and transfer out decreased after DOTS (5.9%, 3.2%, 7.5% and 5.4% respectively) than before it (6.5%, 6.1%, 34.7% and 19.5% respectively), the results were significant (P<0.05) for all of them except treatment failure. The mean values of incidence rates (new and relapse cases, all cases and new smear positive pulmonary TB cases) of TB significantly (P<0.05) decreased after the application of DOTS. Also, the cure rate and treatment success rate significantly increased (P=0.001), while retreatment TB cases rate, default rate, transfer out rate and retreatment failure rate significantly decreased (P<0.05). Finally new pulmonary TB cases with no smear result significantly (P<0.05) increased after DOTS. ConclusionThe introduction of DOTS in the Port Said governorate has led to a significant increase in the treatment success (82.7%) (Near the WHO target “85%”), and a decrease in the default and failure rates.