Short-term Symptomatic Improvement Research Articles

Specific back pain - effective diagnosis and treatment from the radiologist's point of view.

The diagnosis and treatment of specific back pain is important in radiology. Due to the high number of patients suffering from back pain, it is important to provide excellent diagnostic and therapeutic support.Based on a recent literature search and considering the relevant guidelines as well as expert opinions, the aspects of specific back pain important for radiologists in terms of pathogenesis, diagnosis, and treatment are presented.Clinical examination in combination with the medical history provides a valid suspected diagnosis. This should subsequently be verified radiologically. MRI is the most effective cross-sectional diagnostic method for investigating specific back pain. A conventional X-ray on two planes in a standing position can be a useful addition if postural causes are suspected. If the clinical symptoms match the morphological findings, radiological treatment can be carried out for nerve root involvement as well as for inflammatory changes of the facet joints. The improvement in symptoms after radiological therapy is considered good overall; at least a short-term improvement in symptoms can generally be achieved, but no reliable data is available regarding the long-term outcome. Using preparations containing triamcinolone, low dosages should be selected in accordance with the guidelines. Embedding in a multimodal pain therapy treatment concept should be considered.Radiology provides essential diagnostic findings regarding specific back pain. Interventional pain therapy is an effective and safe method of treating proven specific back pain. · First examine clinically, then confirm the suspected diagnosis radiologically.. · MRI is usually the method of choice.. · Interventional pain therapy should show success after a maximum of 2 interventions.. · The anti-inflammatory drug dose should be kept as low as possible.. · The individual course determines the number of interventions.. · Stueckle CA, Haage P. Specific back pain - effective diagnosis and treatment from the radiologist's point of view. Fortschr Röntgenstr 2024; DOI 10.1055/a-2371-1752.

Comparative Study between Ultrasound Guided Intraarticular Injection of Corticosteroids and Ultrasound Guided Genicular Nerve Block in Patients with Chronic Knee Pain

Abstract Background Chronic knee pain represents a major cause of disability and a burden on healthcare systems worldwide, being more prevalent in middle-aged and elderly patients. It can take a toll on patients’ daily life, keeps them from their favorite activities, saps of productivity, and diminishes overall quality of life. It can be caused by degenerative conditions, such as osteoarthritis (the most common cause), rheumatoid arthritis, crystalline arthritis and gout. lifestyle modification, pharmacologic management, and injections are the mainstay of therapy for elderly patients having chronic symptomatic knee pain with multiple medical comorbidities who do not wish/fit for surgical options. Intra-articular corticosteroid injection (IACSI) was commonly adopted to alleviate chronic knee pain and was traditionally performed blindly depending only on anatomical land marks. Recently, Genicular nerve block (GNB) has recently emerged as a novel alternative treatment for chronic knee pain. Both Intra-articular corticosteroid injection (IACSI) and Genicular nerve block (GNB) can be carried out under Ultrasound guidance as a safer, cheaper and more feasible imaging modality for guidance as it provides real-time imaging for the knee structures in a dynamic manner giving the ability to do interventional procedures and providing more effective clinical results when compared to blind injections. Aim of the Work Illustrate the technical aspects, the indications and the methodology of local therapies for chronic knee pain performed by interventional radiologists and provide current evidence. Assess the efficacy of Ultrasound (US) guided intraarticular corticosteroids injection and Genicular nerve block to control moderate and advanced chronic knee pain. Compare the immediate and short-term symptomatic and functional improvement obtained after both techniques. Patients and Methods The study was carried out on 30 patients of symptomatic chronic knee pain with radiologically proven knee joint arthritis (26 of them had osteoarthritis, 3 had gout arthritis and one patient had rheumatoid arthritis), all of them were not responding to medical treatment. They were divided into two groups (intraarticular corticosteroids injection group and Genicular nerve block one) both procedures were performed under ultrasound guidance to identify target points for injection. GNB target points for injection where close to the superior lateral, superior medial and inferior medial genicular arteries while target point for the IACSI group was the suprapatellar bursa. All procedures were performed with a spinal needle (22 G) introduced under ultrasound guidance till reaching the desired target points at both groups. Then injection of a mixture of Lidocaine, Bupivacaine hydrochloride and Triamcinolone Acetonide was done. Results In our study, in IACSI group the mean of initial VAS was 80.7±10.3 compared to 81.3±7.7 in GNB group. The mean VAS significantly dropped to be 20.7±5.3 in IACSI group compared to 18.3±5.9 in GNB group. After 2 weeks, it was 34.3±8.4 and 27.7±8.2 respectively. After 4 weeks, it increased to 40±8.7 and 33.7±9.3 respectively. At 8 weeks, it was obviously increased to 75.3±10.3 and 66.7±11.4 respectively and the effect returned gradually till nearly the baseline at 8 weeks. In our study, in IACSI group the mean of initial OKS was 48.6±7.4 compared to 50.1±7.6 in GNB group. After 2 weeks, it was markedly decreased to 25.5±3.9 and 22.7±6.8 respectively. After 4 weeks, it increased to 31.1±3.5 and 27.±6.9 respectively. At 8 weeks, it was obviously increased to 44.1±7.1 and 39.3±6.1 respectively and the effect returned gradually till nearly the baseline at 8 weeks. Conclusion Ultrasound guided genicular nerve block with a mixture of corticosteroid and local anesthetic is an effective, radiation free method to alleviate chronic knee pain and improve knee joint function. US guided intra-articular corticosteroid injection through suprapatellar approach is also an effective method to relive chronic knee pain and inflammation and to improve knee joint functional capacity. Both procedures are effective in alleviation of chronic knee pain for up to 4 weeks with marked decrease in VAS score after 2 weeks and slight increasing trend towards 4 weeks. The favorable effect returned gradually till nearly the baseline at 8 weeks. Genicular nerve block is more effective than intra-articular corticosteroid injection in both pain alleviation and improving knee joint function. The earlier the Kellgren- Lawrence score is, the more reduction in chronic knee pain and the more improvement of joint function is achieved after both procedures.

A Review of Lateral Epicondylitis Injection: Drugs Used, Injection Techniques and Guidance Method

Abstract This article aimed to study the most suitable drug for injection, injection techniques and guidance method for treating tennis elbow. The words ‘injection technique’, ‘lateral epicondylitis’ and ‘tennis elbow’ were keyed into PubMed search base, and 145 full-text English language articles were obtained, from which 22 articles were deemed suitable for review based on content and relevance. One article was added from the author’s collection. The eligibility was (a) patients with tennis elbow or lateral epicondylitis, (b) patients who had undergone injection therapy and (c) studies that had done a comparison between two or more agents or two techniques or used comparison between using or not using imaging guidance for injection. It was found that corticosteroid injections in tennis elbow produce a short-term improvement in symptoms, while prolotherapy, autologous blood and platelet-rich plasma (PRP) injections may show more efficacy in the long term. In terms of technique, peppering seems to be a better alternative to tender point injections. The use of ultrasound guidance does not seem to have any effect on the overall efficacy of the injection treatment. The evidence in this study shows that it is better to use corticosteroids for short-term improvement, whereas bioactive agents like PRP injections may work better in the long term.

Effectiveness and safety of botulinum neurotoxin for treating dyssynergic defecation: A systematic review and meta-analysis

Dyssynergic defecation (DD) is a common cause of chronic constipation. Owing to the lack of a comprehensive synthesis of available data on the effectiveness of botulinum neurotoxin (BoNT) for treating DD, we performed a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane databases from inception to May 9, 2023. The outcomes comprise short-term and long-term symptom improvement, various anorectal function measurements, complications of fecal incontinence, and symptom improvement after repeated BoNT injections. A meta-analysis comparing BoNT injection with either surgery or biofeedback (BFB) therapy in treating DD was also conducted. Subgroup analysis and meta-regression were performed to identify possible moderator effects. We included five randomized controlled trials, seven prospective studies, and two retrospective observational studies. Short-term potential improvement in symptoms (event rate [ER], 66.4%; 95% CI, 0.513 to 0.783) was identified, but in the long-term (>12 months), this effect was decreased (ER, 38.2%; 95% CI, 0.267 to 0.511). Short-term improvements in objective anorectal physiologic parameters were also observed. Repeated BoNT injection was effective for patients with symptom recurrence. Subgroup analysis revealed enhanced long-term symptom improvement with high-dose BoNT, but this treatment also increased the risk of complications and recurrence compared with low doses. The effectiveness, complications, and recurrence of symptoms associated with BoNT injection and surgery did not differ significantly. BoNT injection significantly provided short-term symptom improvement but also heightened the risk of incontinence compared with BFB therapy. Our systematic review and meta-analysis indicated that BoNT could be beneficial for short-term symptom improvement in patients with DD, but this effect tended to decline 12 months after injection. Standardized BoNT intervention protocols remain warranted. Among the several treatments for DD, we concluded that BoNT injection is not inferior to other options considering its effectiveness in relieving symptoms, the associated complication development, and the risk of symptom recurrence.

SAT059 Metastatic Insulinoma Diagnosed Postpartum

Abstract Disclosure: A. Faber: None. H. Lam: None. R. Simon: None. Introduction: Insulinomas are rare neuroendocrine tumors derived from the beta cells of the pancreas. These tumors generally occur at a rate of four cases per million per year, and they are seen across all demographics. Affected patients present with symptoms of hypoglycemia, including confusion, diaphoresis, and palpitations. Insulinomas occur as single or multiple tumors, and can be benign or malignant. Insulinomas with metastases are defined as malignant. The primary treatment is surgical resection. However, in the case of metastatic insulinomas prognosis can be quite poor with limited treatment options. Case Presentation: A 24-year-old female employed as a nurse with otherwise negative medical history originally presented around 3 months postpartum with epigastric pain which was attributed to gas. Symptoms progressed to include lightheadedness, palpitations, and sweating. She checked her blood glucose during these events and noted it to be consistently in the 30s-40s. She would treat these episodes with food and had short-term improvement in symptoms. She presented to an outside hospital where imaging revealed: hepatomegaly with innumerable hypodense liver lesions, hypo-enhancing pancreatic head lesion, sclerotic focus in T4 vertebral body, as well as multiple enlarged upper abdominal lymph nodes including peripancreatic, porta hepatis, and gastrohepatic. Liver biopsy revealed well-differentiated neuroendocrine tumor, WHO grade 3 likely from a pancreatic primary and chemotherapy was initiated with carboplatin and paclitaxel with some response. However, hypoglycemia became refractory to management with 5% dextrose drip, so she was transferred to our facility for escalation of care. TPN was initiated and dextrose drip was escalated eventually to 40% dextrose. She was also given octreotide, hydrocortisone, and eventually diazoxide. Given degree of tumor burden as well as abdominal ascites and clinical condition, surgery was deemed high risk and not recommended. Tumor board meeting was held and her chemotherapy regimen was changed to Carboplatin/Etoposide/Atezolizumab. She subsequently underwent hepatic artery embolization twice with improvement of hypoglycemia. Despite decreasing dextrose drip requirements by over 50%, patient was unable to be liberated from dextrose infusion and had multiple discussions about management options and prognosis. The patient eventually elected to go home with home hospice. Discussion: Insulinoma diagnosed in pregnancy or shortly after pregnancy is extremely rare. There are only three case reports of malignant insulinoma diagnosed in or after pregnancy. Given the degree of extensive metastases at time of presentation, we expect our patient’s insulinoma was present prior to delivery. Hypoglycemia may have only manifested in the postpartum period when there was decreased levels of placenta-derived counterregulatory hormones. Presentation: Saturday, June 17, 2023

Positional shunt assist for slit ventricle syndrome.

Hydrocephalus is one of the most common pathologies in pediatric neurosurgery. One of the causes of recurring events of headaches among shunted children is "slit ventricle syndrome" (SVS). Several potential treatments have been proposed, yet SVS often represents a treatment challenge. The goal of the current series is to present our experience with adding a positional shunt-assist (SA) (Miethke, Aesculap) for the treatment of SVS. Clinical data was retrospectively collected from all consecutive children with SVS that were treated with SA (Miethke, Aesculap) at our center. Surgical and clinical outcomes as expressed by hospital visits, or need for additional surgery, were evaluated. Nine cases were included. Hydrocephalus etiology included IVH (6), postinfectious (1), and congenital syndromes (2). Average age at first shunt was 4months. Primary shunt type was differential-pressure-valve in all. Average age at SVS onset was 4years. Average age at SA placement was 5.5years. There were no perioperative complications besides a single stich abscess. A 6-month follow-up period after SA was compared to a 6-month period prior to the SA: average hospital visits decreased from 2.4 to 0.6 per patient (p < 0.0002). 4/9 patients needed an LP or shunt revision before the SA surgery, while no procedure was indicated during the immediate 6-month follow-up. At the last follow-up, there was a significant reduction in the rate of ER visits compared to prior to surgery; however, the number of neurosurgical procedures did not significantly differ. Using a SA for SVS was associated with a short-term improvement of symptoms in the majority of cases, reduction in hospital visits, and reduced need for SVS-related procedures.

Comparative Study of the Effect of Liraglutide and Donepezil on Learning and Memory in Diazepam-Induced Amnesic Albino Rats.

Background Dementia is an age-related gradual loss of memory that is progressive in nature. Presently, the most common cause of dementia is Alzheimer's disease (AD), which is treated with donepezil, an anticholinesterase. But it only provides short-term symptomatic improvement. Liraglutide, which is an anti-diabetic drug, stimulates the anti-apoptotic pathway of nerve damage, which helps in regenerating nerve cells; so, it may help in dementia cases. Therefore, this study aimed to explore the effect of liraglutide on learning and memory and to compare its effect with donepezil in diazepam-induced amnesic albino rats. Methodology Twentyhealthy male Albino rats weighing 150-200 grams were taken and divided into four groups: A, B, C, and D. Group A rats were normal rats, whereas the rats in groups B, C, and D were made amnesic by the intraperitoneal (i.p.) administration of 0.1 mg per kg of diazepam. Immediately after producing amnesia, group B rats received normal saline, group C received liraglutide, and group D received donepezil through the intraperitoneal route as test drugs. Group A rats received only normal saline. The amnesic effect was measured by the escape latency period, which was measured by using a Morris Water Maize (MWM) instrument. Escape latency is the time (in seconds) to locate the platform from the starting point. The amnesic effect is shown by an increase in escape latency and the anti-amnesic effect by a decrease in escape latency. Escape latency was recorded at 0 hr, 1 hr, 2 hr, 3 hr, and 4 hr after test drug administration. Results Group B rats showed an increase in escape latency, which shows the amnesic effect of diazepam. When group C and group D amnesic rats were treated with liraglutide and donepezil, respectively, a one-hour after-treatment increase in escape latency was seen but after two hours, both groups showed a decrease in escape latency, which indicates the anti-amnesic effect of both drugs. When groups C and D were compared, and the post-hoc highly significant difference (HSD) test was used, there was no significant difference between the two drugs, although the liraglutide-treated group(C) showed a lower anti-amnesic effect. However, group C showed a significant effect as compared to group B rats (p-value <0.05), which indicates the anti-amnesic property of liraglutide as compared to normal saline. Conclusion Liraglutide shows an anti-amnesic property. Since it works by a mechanism different from donepezil, it can be used as add-on therapy with donepezil in dementia patients.

Short-term symptom improvement in infants with suspected cow's milk protein allergy using amino acid formula: a prospective cohort analysis.

Cow's milk protein allergy (CMPA) occurs commonly in infants. While the long-term efficacy of amino acid formulas for managing CMPA is well-established, there is limited data on the short-term symptom improvement of using amino acid formula (AAF). This study aimed to determine the short-term effects of managing suspected CMPA in infants aged 6 months and under using a commercial AAF. Healthcare providers who treated infants with suspected CMPA aged 6 months or younger (n = 104) provided de-identified survey data in this prospective study. Healthcare providers scored symptoms for severity from 0 to 3 (none, low, moderate, severe) before using a commercial AAF at Visit 1 and at Visit 2 (3-6 weeks later). Gastrointestinal (94%), skin (87%), respiratory (86%), and uncategorized symptoms (89%) improved from AAF initiation, and these findings were consistent across different follow-up visit durations. This study is the most extensive prospective analysis conducted in the United States examining the short-term change in suspected CMPA symptoms using an AAF. These findings suggest that AAF may decrease the severity of suspected CMPA symptoms in infants 6 months or younger, often by the next follow-up visit. Further randomized controlled trials are required to confirm these initial findings.

Long-term outcomes of fornix reconstruction and cicatricial entropion repair in ocular mucous membrane pemphigoid and drug-related secondary pemphigoid

ObjectifExaminer les résultats à long terme de la reconstruction du fornix oculaire et de la réparation de l'entropion cicatriciel en présence d'une pemphigoïde de la muqueuse oculaire (MMP, pour mucous membrane pemphigoid) et d'une MMP secondaire. MéthodesOn a procédé à un examen rétrospectif des dossiers médicaux de patients qui présentaient une MMP et qui devaient subir une reconstruction du fornix oculaire (greffe de membrane amniotique ou greffe de muqueuse buccale) ou une réparation de l'entropion cicatriciel (intervention de Wies) entre le 1er janvier 2000 et le 1er septembre 2020. La biopsie de la muqueuse des patients était positive et/ou ces derniers présentaient des caractéristiques cliniques typiques d'une MMP ou d'une MMP secondaire. Le paramètre primaire consistait en une réussite globale de la reconstruction du fornix oculaire mesurée par le maintien de sa profondeur lors de la dernière visite de suivi. La disparition du trichiasis, l'acuité visuelle et le soulagement des symptômes subjectifs comptaient au nombre des paramètres secondaires. RésultatsAinsi, 8 patients (10 yeux) présentant un diagnostic de MMP (3 hommes et 5 femmes; âge médian : 71 ans) et 4 patients (4 yeux) présentant un diagnostic de MMP secondaire (2 femmes et 2 hommes; âge médian : 87 ans) ont été admis à l’étude. La durée moyenne du suivi était de 22,7 mois (fourchette : 0,3–87,5 mois) dans le cas des patients présentant une MMP et de 15,4 mois (fourchette : 3,0–43,9 mois) dans celui des patients présentant une MMP secondaire. Dans le groupe MMP, 30,0 % des yeux ont fait l'objet d'une reconstruction du fornix oculaire, 60,0 % des yeux ont fait l'objet d'une réparation de l'entropion et 10,0 % des yeux ont subi les 2 formes d'intervention. La récurrence d'un symblépharon et la perte de la profondeur du fornix oculaire sont apparues dans tous les yeux qui présentaient une MMP en moyenne 6,4 ± 7,0 mois après l'intervention; le trichiasis avait réapparu chez tous les patients lors de la dernière visite de suivi. Chez les patients qui présentaient une MMP secondaire, 75,0 % des yeux ont présenté une récurrence du symblépharon, et 66,7 %, une récurrence du trichiasis. On a noté un soulagement à court terme des symptômes tant dans la MMP que dans la MMP secondaire. ConclusionsLa reconstruction du fornix oculaire et la réparation de l'entropion cicatriciel au sein de notre cohorte de patients présentant une MMP ou une MMP secondaire ont donné lieu à un soulagement à court terme des symptômes, mais une récurrence s'est produite en moyenne 6 mois après l'intervention.

The Effect of Socioeconomic Disparity on Improvement in QuickDASH at 3 Months after Carpal Tunnel Release.

A single-institutional, prospective, longitudinal study was performed of 85 patients who underwent isolated, unilateral CTR for idiopathic carpal tunnel syndrome. Sixty-three patients (74%) who completed patient-reported outcome measures at 3 months after surgery comprised our study cohort. Socioeconomic disparity was assessed using the zip code level Distressed Communities Index (DCI) and the neighborhood level Area Deprivation Index. The outcome variables were the improvement in the QuickDASH score, 3 months postoperative QuickDASH score, and the preoperative QuickDASH score. Associations between continuous variables were assessed using simple linear regression. The mean DCI of the study cohort was in the 23rd national percentile, and the mean Area Deprivation Index was in the 15th national percentile. The mean preoperative QuickDASH of the study cohort was 49.3. The mean 3 months postoperative QuickDASH of the study cohort was 29.8. The mean improvement in QuickDASH at 3 months after surgery was 19.5, which was statistically significant and clinically meaningful. Area Deprivation Index and DCI were not associated with improvement in QuickDASH score or 3 months postoperative QuickDASH score. Higher DCI was associated with poorer baseline preoperative QuickDASH score. Patients of various socioeconomic backgrounds can expect similar short-term improvements in symptoms and function after CTR.

Effect comparison of neuroendoscopic vs. craniotomy in the treatment of adult intracranial arachnoid cyst.

Intracranial arachnoid cysts are common, accounting for about 1%-2% of intracranial space-occupying lesions. There is controversy over the method of surgical intervention, and in order to provide guidance for surgical decision making, this study compares the efficacy of craniotomy vs. neuroendoscopic surgery in treating arachnoid cysts. The adult patients with arachnoid cyst admitted to our department from October 2016 to August 2021 were retrospectively analyzed. Thirteen adult patients were recruited, and divided into two groups: neuroendoscopic group (group A) and craniotomy group (group B). We compared the gender, age, clinical symptoms, preoperative and postoperative cyst sizes, symptom improvement, complications, length of hospital stay, and hospital costs between two groups to analyze the therapeutic effects of these two surgical methods. The cost of hospitalization in group A was significantly lower than that in group B (47,292.8 vs. 65,151.8 yuan, P < 0.05), and there was no difference in the length of hospital stay between the two groups. The preoperative cysts in group A were significantly larger than those in group B (6.38 vs. 2.97 cm, P < 0.05). In groups A and B, the short-term symptom improvement rates were 100% and 75.0%, respectively. The long-term symptom improvement rates were 77.78% and 75.0% (P > 0.05), respectively. Both neuroendoscopic and craniotomy have good curative effects for the treatment of intracranial arachnoid cysts. There was no significant difference in the outcomes between the two surgical techniques. The cost of hospitalization can be reduced with neuroendoscopic surgery. Neuroendoscopic treatment is recommended for large intracranial arachnoid cysts, and craniotomy is suitable for small intracranial arachnoid cysts.

82. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review

82. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review

Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up.

The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty. We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board. A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P=.002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P<.001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P<.001) were apparent at a median follow-up of 13months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1second (preoperative median: 74% vs postoperative median: 82%, P=.001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P<.001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P=.02) measured at a median follow-up of 29months. Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.

Symptomatic versus disease-modifying effects of psychiatric drugs.

Drugs can be divided into two major categories, symptomatic and disease modifying. This review explores whether and how psychiatric drugs fall into one or the other of those categories, and the implications of those results for clinical practice and research in psychopharmacology. Narrative review. Most psychiatric drugs have only short-term effects of improving active symptoms. They do not show long-term benefits for the underlying disease, such as improving the course of illness and improving mortality. Evidence is provided for this claim in the treatment literature of antidepressants for depressive illness and antipsychotics for schizophrenia. Developing truly beneficial drugs for disease modification also is limited by the poor clinical and biological validity of Diagnostic and Statistical Manual diagnoses as well as the use of invalid falsely positive maintenance efficacy randomized discontinuation trial designs. Current psychopharmacology is limited mostly to symptomatic effects, not transformative treatments for the diseases underlying those symptoms. A change in approach is needed in psychopharmacology practice and research, focusing on long-term disease modification rather than short-term symptom improvement.

Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review

ObjectivesNeurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment...

Multi-Institutional US Experience of the Occlutech�AFR Device in Congenital and Acquired Heart Disease

Objectives: To detail the US multi-institutional experience with the Occlutech© (Occlutech International AB, Helsingborg, Sweden) atrial flow regulator (AFR) in children and adults with acquired or congenital heart disease. Background: The creation of a long-term atrial communication is desirable in several cardiovascular disease phenotypes, most notably pulmonary arterial hypertension, disorders of increased left ventricular filling and increased cavopulmonary pressures in patients with a Fontan type circulation. Methods: Patients were identified for inclusion from the AFR device manufacturer database. Data was collected using a RedCap database following IRB approval. 8 weeks of follow up data was sought for each patient based on available data. Data was analyzed and summarized using SPSS. Results: We report the experience of 6 US centers in the implantation of AFR devices in 15 patients, across a wide age range, with different disease phenotypes and a variety of indications. Implantation was technically successful in all patients and improvement was noted in both clinical and hemodynamic parameters. There were no immediate or intermediate term complications reported. 3 patients died remote from implantation. Their deaths were not felt to be related to the AFR device or related procedural complications. Conclusion: Compassionate use of the AFR device in children and adults with congenital & acquired heart disease is technically feasible and produces beneficial short term hemodynamic and symptomatic improvement. Widespread uptake of this technique and treatment at specialist centers has the potential to provide significant benefits to a variety of complex patients with currently limited treatment options and indeterminate prognosis.

Massage and touch-based therapy

BackgroundMassage and touch-based treatment are popular despite limited evidence from high quality clinical trials. This article reviews the rationale and evidence of treating older patients with psychiatric symptoms by touch-based therapy.MethodsNarrative literature review, based on Medline search with the following key words: massage, social touch, affective touch, clinical trial, meta-analysis. Citations of identified articles were searched for additional relevant studies.ResultsEvidence from clinical trials in adult patients with mainly chronic disorders of the musculoskeletal system suggests that massage therapy results in significant short-term improvement of symptoms; however, treatment effects appear not to be sustained. In addition, conclusions are difficult to draw owing to very heterogeneous study interventions, difficulties with definition of control conditions and treatment outcomes. There appears to be better evidence for improvement of psychological variables and subjective symptoms, such as pain and quality of life. A neuronal system of affective and social touch has been identified with specific afferents from C‑fibre coupled low threshold mechanoreceptors projecting into the insular cortex and the limbic system. This system may also mediate effects of massage in adult patients. Positive clinical trials for depressive symptoms of dementia and for behavioral symptoms of advanced dementia are available with encouraging results.ConclusionThe neuronal system of social and affective touch suggests a potential mechanism of action of touch-based interventions in geriatric psychiatry. In addition, it provides a rationale for applying and designing novel touch-based treatment strategies as adjunctive treatment for psychiatric disorders of old age.

Gastroparesis with concomitant gastrointestinal dysmotility is not a contraindication for per-oral pyloromyotomy (POP).

Per-oral pyloromyotomy (POP or G-POEM) provides significant short-term improvements in symptoms and objective emptying for patients with medically refractory gastroparesis, but it is unclear if patients with gastroparesis and co-existing dysmotility (small bowel or colonic delay) also benefit. In this study, we used wireless motility capsule (WMC) data to measure outcomes in patients with isolated gastroparesis (GP) and gastroparesis with co-existing dysmotility (GP + Dys) who underwent POP. We retrospectively analyzed patients who had POP and completed WMC data during their evaluation of intestinal dysmotility. WMC data were reviewed to identify patients who demonstrated isolated GP or GP + Dys. Each patient's pre-op and post-op Gastroparesis Cardinal Symptom Index (GCSI) and 4-h solid-phase scintigraphy gastric emptying studies (GES) scores were compared to evaluate improvement. Of the entire cohort (n = 73), 89% were female with a mean age of 47.0 ± 15.0years old. Gastroparesis etiologies were divided among idiopathic (54.8%), diabetic (26%), postsurgical (8.2%), autoimmune (5.5%), and multifactorial (5.5%).Forty-one patients (56%) had GP and 32 patients (44%) had GP + Dys. GCSI improved after POP whether the patient had isolated GP (- 12.31, p < 0.001) or GP + Dys (- 9.58, p < 0.001); however, there was no significant difference in total GCSI improvement between the two groups. A subset of patients had postoperative GES available (n = 47). In the isolated GP and GP + Dys cohorts, 15/28 (54%) and 12/19 (63%) patients had normal post-op 4-h GES, respectively, but no statistical difference between the two groups. Patients with medically refractory gastroparesis with and without concomitant gastrointestinal dysmotility show short-term subjective and objective improvement after POP. Concomitant small bowel or colonic dysmotility should not deter physicians from offering POP in carefully selected patients with gastroparesis.

Relation of the Number of Cardiovascular Conditions and Short-term Symptom Improvement After Percutaneous Coronary Intervention for Stable Angina Pectoris

With aging of the population, cardiovascular conditions (CC) are increasingly common in individuals undergoing PCI for stable angina pectoris (AP). It is unknown if the overall burden of CCs associates with diminished symptom improvement after PCI for stable AP. We prospectively administered validated surveys assessing AP, dyspnea, and depression to patients undergoing PCI for stable AP at our institution, 2016-2018. The association of CC burden and symptoms at 30-days post-PCI was assessed via linear mixed effects models. Included individuals (N=121; mean age 68 ± 10 years; response rate=42%) were similar to non-included individuals. At baseline, greater CC burden was associated with worse dyspnea, depression, and physical limitations due to AP, but not AP frequency or quality of life. PCI was associated with small improvements in AP and dyspnea (p ≤ 0.001 for both), but not depression (p=0.15). After multivariable adjustment, including for baseline symptoms, CC burden was associated with a greater improvement in AP physical limitations (p=0.01) and depression (p=0.002), albeit small, but not other symptom domains (all p ≥ 0.05). In patients undergoing PCI for stable AP, increasing CC burden was associated with worse dyspnea, depression, and AP physical limitations at baseline. An increasing number of CCs was associated with greater improvements, though small, in AP physical limitations and depression. In conclusion, the overall number of cardiovascular conditions should not be used to exclude patients from PCI for stable AP on the basis of an expectation of less symptom improvement.

Comparative Analysis of Aducanumab, Zagotenemab and Pioglitazone as Targeted Treatment Strategies for Alzheimer’s Disease

Alzheimer’s disease (AD) is the leading cause of dementia that has remained a major medical, sociocultural and economical challenge globally. Previously developed treatments like anticholinesterase inhibitors (AChEIs) and N-methyl-D-aspartate receptor (NMDAR) antagonists only provide short-term symptomatic improvement and do not prevent progression. Repeated setbacks and failures over the past 25 years in AD clinical trials have hindered efforts to develop effective AD treatments. Fortunately, Aducanumab, a specific anti-amyloid β antibody, has shown promising clinical results and was recently approved by the Food and Drug Administration (FDA) through an accelerated approval pathway. This has raised hopes for AD patients; however post-approval trials are necessary to estimate the true scope of its clinical benefits. We have reviewed several AD clinical studies and summarized the experience to date with Aducanumab and two other potential AD drugs including Zagotenemab (an anti-tau antibody) and Pioglitazone (nuclear Peroxisome-Proliferator Activated Receptor γ (PPARγ) agonist). These have shown mixed results so far and the next few years will be critical to elucidate and interpret their broad long-term protective effects. A concerted effort is required to understand and strengthen the translation of pre-clinical findings from these drugs to routine clinical practice.