Significant Clinical Improvement Research Articles

FLOT compared to FOLFOX/XELOX as a neoadjuvant chemotherapy in locally advanced gastric cancer: Experience of two clinics.

361 Background: The optimal regimen of neoadjuvant chemotherapy (NCT) in locally advanced gastric cancer (GC) remains controversial, especially whether triplet (FLOT) or duplet (FOLFOX/XELOX) regimen is superior since escalation does not always lead to significant clinical improvement. The aim of this study is to assess efficacy of triplet and duplet chemotherapy regimens as a neoadjuvant approach in locally advanced GC via retrospective data. Methods: We queried the data for 334 patients with locally advanced GC (cT2-4 or cN+) diagnosed in 2016–2023 yy administered with multi-agent NCT: FLOT or XELOX/FOLFOX. The primary endpoints were the ratio of patients with disease progression on NCT, rates of ypN0, and rates of pathological complete response (pCR). Secondary endpoints included progression free survival (PFS) and overall survival (OS). Results: 156 patients (out of total 334 included in the study) received doublet NCT (FOLFOX/XELOX, 8/6 cycles respectively), 61.5% were males, median age was 67.4 (range 21.3-85.4) years, 88.2% had cT3-4. and 22.4% had locally advanced gastroesophageal junction (GEJ) adenocarcinoma. 177 patients were treated with triple NCT (FLOT, 8 cycles), 62.1% were males, median age was 59.9 years, 89.2% had cT3-4, and locally advanced GEJ adenocarcinoma was diagnosed in 21.0%. At a median follow up of 34.7 months (mth) using FLOT regimen as NCT was associated with better clinical outcomes. The ratio of patients who have progressed on NCT was 21.5% and 31% in triplet and doublet arms, respectively (p=0.098). Rates of ypN0 were 50.5% in FLOT arm and 43.7% in XELOX/FOLFOX arm (p=0.36). pCR was achieved in 8.2% and 6.3% in FLOT and XELOX/FOLFOX arms, respectively (p=0.59). Median PFS was 20.3 mth in FLOT arm in comparison to 15.7 mth in FOLFOX/XELOX arm (p=0.012). Median OS was not reached (NR) for triplet arm and was 25.1 mth for doublet arm (p= 0.003). Patients who conversed resectable disease had median PFS of 34.5 and 23.1 months for FLOT and FOLFOX/XELOX arms, respectively (p=0.024). Median OS in these subgroups was NR and 37.0 mth (p=0.003). Conclusions: We report that triplet regimen (FLOT) in comparison with doublet (FOLFOX/XELOX) regimen is the more favorable option as a neoadjuvant setting in locally advanced gastric cancer. FLOT NCT is associated with increased ypN0, pCR and shows statistically significant difference in PFS and OS.

Combining low-dose regorafenib with pembrolizumab for patients with MSI-H colorectal cancer: REGPEM-CRC-01.

TPS238 Background: Treatment for microsatellite instability-high (MSI-H)/mismatch repair deficient (MMR-D) colorectal cancer (CRC) has rapidly evolved in the last decade. The KEYNOTE 177 trial recently established pembrolizumab as a frontline therapy for patients with MSI-H CRC. However, in this study, approximately 40% of patients were noted to have disease progression within 6 months of treatment. Furthermore, an additional 10% of patients experienced acquired resistance to therapy. Therefore, there is an unmet need to improve outcomes for patients with MSI-H CRC. Preclinical studies have shown vascular endothelial growth factor (VEGF) signaling to be overactive in MSI-H compared to MSS CRC (Hansen et al. Colorectal Dis. 2011). Moreover, exploratory analysis of CALBG-80405 and PARADIGM trials showed that patients with MSI-H CRC were more likely to benefit from anti-VEGF therapy than those with MSS disease. Regorafenib, an FDA-approved agent for patients with mCRC, is a potent VEGF inhibitor with immune modulatory effects on the tumor microenvironment. We hypothesize that adding low-dose regorafenib to pembrolizumab as frontline therapy may create synergistic activity in addition to the known clinical activity of each agent in MSI-H CRC. Methods: In the lead-in arm of this prospective study, 22 patients will be enrolled. Patients will receive regorafenib 60 mg daily on days 1–14 (2 weeks on) followed by 7 days off (1 week off) in combination with pembrolizumab 200 mg in the cycle 1. In the following cycles, patients will receive regorafenib 90 mg daily for 2 weeks on 1 week off in combination with pembrolizumab 200 mg every 3 weeks. The primary outcome for the lead-in arm is overall response rate (ORR) within 12 months of treatment by RECIST 1.1. criteria. A formal one-sided hypothesis test will be conducted for futility, assuming that we will reject the null hypothesis of a target ORR only if we have strong evidence. In this study, we assume a null hypothesis that ORR is 0.60, which would reflect significant clinical improvement over the current standard of ORR = 0.43 from KEYNOTE 177. The alternative hypothesis is that ORR is less than 0.60. For the lead-in phase of the study, the emphasis is on controlling Type I error to be small, approximately 0.05. In the randomized phase of the study, patients will receive pembrolizumab monotherapy or pembrolizumab in combination with regorafenib 90 mg. The sample size for the randomized phase of trial was determined based on an assumed median of PFS of 28 months with pembrolizumab and regorafenib combination (investigational arm). The standard of care pembrolizumab monotherapy results in a median PFS of 16 months when given as a first-line therapy. We hypothesize the proposed treatment will increase median PFS to 28 months from 16 months (N=132; H0: 16 months vs., H1: 28 months; Type I error: 0.05, power 80%). Clinical trial information: NCT06006923 .

Subscribers' Perspectives and Satisfaction with the MoreGoodDays Supportive Text Messaging Program and the Impact of the Program on Self-Rated Clinical Measures.

Background: Young adults (18 to 30 years of age) are confronted with numerous challenges, such as academic stressors and peer pressure. The MoreGoodDays program was co-designed with young adults to alleviate psychological issues, improve their mental well-being and provide support for young adults in Alberta during the COVID-19 pandemic and beyond. Objective: The current study aimed to explore subscribers' perspectives and satisfaction with the MoreGoodDays supportive text messaging program and the impact of the program on self-rated clinical measures. Methods: Subscribers of the MoreGoodDays program were invited via a link delivered in a text message to complete online evaluation surveys at six weeks, three months and six months. Program perception and satisfaction questions were adapted from those used to evaluate related programs. Anxiety, depression and PTSD symptoms were respectively assessed using the Generalized Anxiety Disorder-7 scale, the Patient Health Questionnaire-9 scale and the PTSD Civilian Checklist 5, and resilience levels were assessed using the Brief Resilience Scale (BRS). Data were analyzed with SPSS version 26 for Windows utilizing descriptive and inferential statistics. Results: There was a total of 168 respondents across the three follow-up time points (six weeks, three months and six months). The overall mean satisfaction with the MoreGoodDays program was 8.74 (SD = 1.4). A total of 116 (69.1%) respondents agreed or strongly agreed that MoreGoodDays messages helped them cope with stress, and 118 (70.3) agreed the messages helped them cope with loneliness. Similarly, 130 (77.3%) respondents agreed that MoreGoodDays messages made them feel connected to a support system, and 135 (80.4) indicated the program helped to improve their overall mental well-being. In relation to clinical outcomes, the ANOVA test showed no significant differences in mean scores for the PHQ-9, GAD-7 and PCL-C scales and the BRS from baseline to the three follow-up time points. In addition, there was no statistically significant difference in the prevalence of likely GAD, likely MDD, likely PTSD and low resilience at baseline and at six weeks. Conclusions: Notwithstanding the lack of statistically significant clinical improvement in subscribers of the MoreGoodDays program, the high program satisfaction suggests that subscribers accepted the technology-based intervention co-created with young adults, and this offers a vital tool to complement existing programs.

Endovascular treatment of chronic ilio-femoral vein obstruction with extension below the inguinal ligament in patients with post-thrombotic syndrome

ObjectiveThis study aimed to evaluate postoperative outcomes of patients with chronic iliofemoral venous outflow obstruction and post-thrombotic syndrome (PTS) who underwent endovascular recanalization and stenting across the inguinal ligament. MethodsAll consecutive patients with chronic iliofemoral venous outflow obstruction and PTS were included in the analysis, from January 2018 and February 2022. Preoperative, intraoperative, and postoperative outcomes were assessed. Primary endpoints analyzed were major adverse events (MAEs) at 30 days and primary patency rate at 2 years of follow-up. Secondary endpoints assessed were secondary patency rate, target vessel revascularization, and clinical improvement evaluated with the Venous Clinical Severity Score (VCSS) classification, Villalta scale, and visual analog scale (VAS), respectively. ResultsA total of 63 patients (mean age, 48.1 ± 15.5 years; female, 61.9%) were evaluated. No intraoperative and 30-day postoperative complications were documented. The technical success rate was achieved at 100%. Overall, one in-stent occlusion and five in-stent restenosis were detected during follow-up. The primary patency rate was 93.7% (95% confidence interval [CI], 87.8%-99.9%) and 92.1% (95% CI, 85.6%-99%), at 1- and 2-year follow-up, respectively (Kaplan-Meier analysis). Target vessel revascularization was conducted in two cases, resulting in a secondary patency of 98.4% (95% CI, 95.4%-100%) at 2 years of follow-up. Stent fracture and/or migration were not observed during follow-up. A significant clinical improvement in the patient’s quality of life was documented. The median improvement of VCSS and Villalta scores were 4 (interquartile range, 2-7; P = .001), and 3 (interquartile range, 1.5-5; P = .001) vs baseline at the last follow-up. Overall, pain reduction of 17 mm on the VAS scale was documented at 2 years of follow-up. At multivariate analysis, presence of trabeculation into the femoral vein and deep femoral vein (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043), and Villalta scale >15 points at admission (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043) were predictive for in-stent occlusion during the follow-up. ConclusionsThe use of a dedicated venous stent across the inguinal ligament was safe and effective for the treatment of symptomatic iliofemoral venous disease with acceptable primary and secondary patency rates at 2 years of follow-up.

Utility of Intraprocedural Luminal Diameter and Distensibility Measurements During the Esophageal Peroral Endoscopic Myotomy Procedure.

Through evaluation of the lower esophageal sphincter immediately before and after myotomy using an endoluminal functional lumen imaging probe (EFLIP), our study aimed to determine the clinical response to peroral endoscopic myotomy (POEM) and the incidence of postprocedure reflux. Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and diminished peristalsis. POEM is a therapeutic option for durable management of achalasia. However, symptomatic acid reflux and esophagitis are well-known adverse effects of the procedure. Electronic medical records of 168 patients who underwent POEM for achalasia at 2 tertiary care referral centers from May 2014 to May 2021 were reviewed. EFLIP was used at a range of catheter fill volumes to assess LES dynamics. Preprocedure and postprocedure Eckardt Symptom Scores were recorded. Significant clinical improvement from POEM was sustained in over 94% of patients after 1 year. EFLIP changed intraprocedural management 5% of the time by means of myotomy extension. In patients with reflux>1 year following POEM, there was no significant difference in post-POEM LES diameter or change in LES diameter compared with those without reflux. However, post-POEM LES distensibility index (DI) was significantly higher in patients with reflux after 1 year compared with those without reflux. POEM is a safe and increasingly effective therapy for patients with symptomatic achalasia. Intraprocedural EFLIP measurements suggest that post-POEM reflux may be correlated more with DI than LES diameter. Yet, more data is needed to substantiate these outcomes.

A Very Rare Case of Primary Mural Endocarditis of the Right Atrium due to Candida Albicans

Right-sided infective endocarditis accounts for 5-10% of all infective endocarditis cases. Fungal endocarditis represents 1-3% of all of infective endocarditis cases, with Candida spp. being the most common microbiological cause. Primary mural endocarditis is defined by the absence of valvular vegetations together with the presence of vegetations on the endocardial free wall that are not associated with myocardial abscesses, cardiac structural abnormalities, devices, prosthetic material, thrombi or tumors. It constitutes a very rare entity and only 63 cases have been published the literature. C. albicans is the microbiological cause in only nine of these cases, none of which involves the right atrium. We report the case of a frail 84-year-old female patient with a pacemaker presenting with fever. In the transthoracic and three-dimensional transesophageal echocardiograms, a mobile mass was found attached on the free wall of the right atrial base. Blood cultures were positive for C. albicans and the modified Duke criteria were fulfilled for a definite diagnosis of infective endocarditis. After evaluation from a heart team the patient was managed with transvenous lead extraction and intravenous high-dose caspofungin, according to the 2023 Guidelines of the European Society of Cardiology for the management of endocarditis. Pacemaker lead cultures were negative leading to the diagnosis of primary mural endocarditis. The patient responded well to treatment with significant clinical and laboratory improvement. Long-term oral fluconazole was initiated after hospital discharge with a close follow-up plan. To our knowledge this is the first case of primary mural endocarditis of the right atrium due to C. albicans.

Case Report: Acquired hemophilia A following COVID-19 vaccine

Background: In December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified and has subsequently been responsible for immense morbidity and mortality. This resulted in the development of vaccines in record time, potentially posing safety issues. Several cases of acquired hemophilia A (AHA) following coronavirus disease 2019 (COVID-19) vaccines have been described in the literature. AHA is a rare autoimmune disease due to the production of IgG autoantibodies to coagulation FVIII that burdens high morbidity and mortality. It is presumed mainly on identifying an increased activated partial thromboplastin time (aPTT), even without bleeding and is confirmed by determining a FVIII inhibitor. To the best of our knowledge, this is the first report of AHA after inactivated virus COVID-19 treated with low dose rituximab (RTX). Lower RTX doses may lead to shorter infusion duration, lower risk of adverse events and lower costs. Case presentation: We report a case of AHA occurring in a 69-year-old man 60 days after an inactivated Sinovac-coronavac COVID-19 vaccine. Diagnosis of AHA was based on clinical presentation and confirmed with prolonged activated partial thromboplastin time, Factor VIII deficiency and the presence of an FVIII inhibitor. Follow-up showed a significant clinical and biological improvement, aPTT was normalized as of 18 days of treatment with corticosteroids along with low dose rituximab. Conclusions: In the literature, the reported cases of AHA following COVID-19 vaccination occurred after Adenoviral Vector DNA- and SARS-CoV-2 mRNA-based COVID-19 vaccines. Here, AHA was presented following inactivated virus COVID-19 vaccine. AHA treated with low dose rituximab can limit occurrence of side effects and the cost of treatment.

Changes in cerebral cortex activity during a simple motor task after MRgFUS treatment in patients affected by essential tremor and Parkinson's disease: a pilot study using functional NIRS

Objective. Magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) is a non-invasive thermal ablation method that involves high-intensity focused ultrasound surgery (FUS) and Magnetic Resonance Imaging for anatomical imaging and real-time thermal mapping. This technique is widely employed for the treatment of patients affected by essential tremor (ET) and Parkinson’s disease (PD). In the current study, functional near-infrared spectroscopy (fNIRS) was used to highlight hemodynamics changes in cerebral cortex activity, during a simple hand motor task, i.e. unimanual left and right finger-tapping, in ET and PD patients. Approach. All patients were evaluated before, one week and one month after MRgFUS treatment. Main results. fNIRS revealed cerebral hemodynamic changes one week and one month after MRgFUS treatment, especially in the ET group, that showed a significant clinical improvement in tremor clinical scores. Significance. To our knowledge, our study is the first that showed the use of fNIRS system to measure the cortical activity changes following unilateral ventral intermediate nucleus thalamotomy after MRgFUS treatment. Our findings showed that therapeutic MRgFUS promoted the remodeling of neuronal networks and changes in cortical activity in association with symptomatic improvements.

A Novel 3D Tunneling Surgical Technique (3DT) for the Treatment of Gingival Recessions with Reconstruction of the Deficient Interdental Papilla and Interproximal Attachment Regeneration: Case Series.

Current concepts in periodontology emphasize an important distinguishing aspect of the interproximal attachment, assigning its major influential significance as a key diagnostic and prognostic factor. A complete regeneration of the interproximal clinical attachment has become a primary determinant of the periodontal success. Since mid - 20th century have been published numerous articles on root coverage procedures but mostly for non-proximal gingival recessions. When it comes to the interdental area, literature does not inspire the same level of confidence. This study is aimed to introduce an innovative 3D - Tunneling Surgical Technique for the gingival papilla reconstruction and supra-alveolar interproximal attachment regeneration. The technique is described step by step and shown on three selected clinical cases of multiple bilateral adjacent gingival recessions type 2 and 3 in the lower anterior area with follow - up results of up to 6.5 years. A total of 18 proximal, mid-buccal and mid-lingual recessions were treated simultaneously. Mean root coverage up to 88.9% has been achieved in the proximal area. Within its limits, this study demonstrates a possibility of treating gingival recessions with deficient papilla in the mandibular anterior region, achieving a significant clinical improvement with the long-term stability.

Evaluating the clinical efficacy of pulsed dye laser with sirolimus for treatment of capillary malformations: A systematic review.

Port-wine stains (PWS) are capillary vascular anomalies that are often treated with pulsed-dye laser (PDL). Revascularization limits persistent clearance; however, the anti-angiogenic effects of sirolimus (SIRO) may inhibit revascularization. This review aims to determine differences in PWS outcomes when treated with PDL monotherapy or in combination with SIRO. A systematic review was conducted using PubMed, Cochrane, and Embase databases. The following search terms were used: 'port wine stain PDL SIRO', 'port wine stain PDL', and 'port wine stain PDL and topical treatment' with (MeSH) and (Title/Abstract) limits. The search was limited to the English language and human-subject studies conducted between 1 January 2000 and 1 June 2023. Inclusion criteria included studies evaluating SIRO as an adjunct to PDL in patients with PWS. Data extraction and quality assessment were performed by two independent reviewers. A total of nine studies met the inclusion criteria, which included randomized controlled trials (3), case series (2), case reports (3), and a prospective intrapatient study (1), which represented a total of 58 patients. Five studies showed improvement of a measured post-treatment PDL parameter including shortening treatment time and less frequent dosing. A subset of studies (4/9) which did not demonstrate significant clinical improvements exhibited significant photographic evidence of improvement. Heterogeneity among the studies highlights the need for further research and standardization. While adjunctive SIRO shows promise, larger studies and comprehensive evaluation methods are required to establish conclusive safety and efficacy guidelines to shape clinical decision-making.

Is Ultrasound-Guided Percutaneous Nephrostomy Efficacious and Safe in Pregnant Patients?: A Single Center Experience

Aim: To evaluate the safety and efficacy of ultrasound-guided percutaneous nephrostomy (PCN) placement in pregnancy. Method: Medical records of 26 pregnant patients who were inserted with a total of 27 PCN catheters between June 2020 to June 2023 were retrospectively analyzed to assess imaging findings, procedural parameters, technical success, delivery outcomes, and procedural complications. Results: At the time of placement of the PCN, the mean gestational age was 29.04±7.01 weeks (range 7 - 36 weeks). The indications for insertion of the PCN catheter included: 1) obstructing calculi (46.2%), 2) pyelonephritis (34.6%), and 3) symptomatic hydronephrosis without calculi (19.2%). Successful catheter placement was achieved in 25/27 procedures, yielding a success rate of 92.59%, and no major complications. Minor instances of transient hematuria were encountered in three cases. The mean duration of catheter retention was 72.58 days. All patients exhibited significant clinical and symptomatic improvement. Among these patients, 22 patients (84.6%) delivered their babies at full-term, 3 patients (11.5%) delivered prematurely, and 1 patient (3.8%) experienced a miscarriage. Conclusion: Ultrasound-guided PCN placement is a reliable method with high success and efficacy that can be applied during pregnancy. This procedure avoids the use of ionizing radiation, ensuring safety for both the fetus and the mother.

Pelvic AVM Embolization: A Tricky Affair-Multicenter Retrospective Experience.

Pelvic arteriovenous malformations (pAVMs) are congenital or acquired vascular anomalies, presenting with hematuria, menometrorrhagia, pelvic pain, and varices; they can be life-threatening in case of rupture. Surgical therapies have been proposed but endovascular embolization has been recognized as the primary modality. The aim of this article was to report a retrospective multicenter experience concerning embolization of pelvic AVMs and provide literature overview. We describe 18 patients (14 female and 4 male) diagnosed with pAVM and treated with minimally invasive methods. The pre-procedural imaging evaluation was based on transpelvic and/or transvaginal color Doppler ultrasound, contrast-enhanced computed tomography, and/or magnetic resonance. In 3 cases, the malformation was congenital and in other 15, acquired. Most common symptoms were menometrorrhagia, hematuria, pelvic pain and pressure, and heaviness in the lower abdominal region. In 10 cases (56%), only 1 procedure was required. Eight patients underwent multistage treatment. Complete occlusion of the lesion in post-procedural angiography was observed in 12 patients (67%). No major periprocedural complications were observed. In 14 cases (78%), both satisfactory embolization and significant clinical improvement was achieved in long-term follow-up. Sixteen patients (88%) were at least satisfied with the clinical outcome. One patient reported subsequent successful pregnancy 5 years after the treatment. Hemodynamics of pAVM are variable and thorough understanding of the vessel anatomy is crucial in planning and choosing proper treatment. Both transarterial and percutaneous direct puncture embolization strategies appear safe, technically feasible, and clinically effective. In this manuscript, we discuss the role of interventional radiology methods in the treatment of pelvic arteriovenous malformations along with its advantages, limitations and possible complications. In addition to this, we review the current literature and confront our findings with those made by other authors. We believe that modern endovascular methods offer safe and reliable alternative for traditional surgical therapy and should be therefore considered during multidisciplinary treatment of these patients.

Collinsella aerofaciens as a predictive marker of response to probiotic treatment in non-constipated irritable bowel syndrome

ABSTRACT Probiotics are exploited for adjuvant treatment in IBS, but reliable guidance for selecting the appropriate probiotic to adopt for different forms of IBS is lacking. We aimed to identify markers for recognizing non-constipated (NC) IBS patients that may show significant clinical improvements upon treatment with the probiotic strain Lacticaseibacillus paracasei DG (LDG). To this purpose, we performed a post-hoc analysis of samples collected during a multicenter, double-blind, parallel-group, placebo-controlled trial in which NC-IBS patients were randomized to receive at least 24 billion CFU LDG or placebo capsules b.i.d. for 12 weeks. The primary clinical endpoint was the composite response based on improved abdominal pain and fecal type. The fecal microbiome and serum markers of intestinal (PV1 and zonulin), liver, and kidney functions were investigated. We found that responders (R) in the probiotic arm (25%) differed from non-responders (NR) based on the abundance of 18 bacterial taxa, including the families Coriobacteriaceae, Dorea spp. and Collinsella aerofaciens, which were overrepresented in R patients. These taxa also distinguished R (but not NR) patients from healthy controls. Probiotic intervention significantly reduced the abundance of these bacteria in R, but not in NR. Analogous results emerged for C. aerofaciens from the analysis of data from a previous trial on IBS with the same probiotic. Finally, C. aerofaciens was positively correlated with the plasmalemmal vesicle associated protein-1 (PV-1) and the markers of liver function. In conclusion, LDG is effective on NC-IBS patients with NC-IBS with a greater abundance of potential pathobionts. Among these, C. aerofaciens has emerged as a potential predictor of probiotic efficacy.

Fusion with and without lever reduction in degenerative lumbar spondylolisthesis: a retrospective study.

The reduction of slipped vertebra is often performed during surgery for degenerative lumbar spondylolisthesis (DLS). This approach, while potentially improving clinical and radiological outcomes, also carries a risk of increased complications due to the reduction process. To address this, we introduced an innovative lever reduction technique for DLS treatment. This study aims to investigate the clinical efficacy, radiological outcomes, and complications of fusion with or without lever reduction. We conducted a retrospective review of prospectively collected data from a registry of patients who underwent lumbar fusion surgery for DLS, with a follow-up of at least 24months. Self-reported measures included visual analog scale (VAS) for back or leg pain, Oswestry Disability Index (ODI), and the achievement of minimal clinically important difference (MCID). Radiological assessments encompassed spondylolisthesis percentage (SP), focal lordosis (FL), and lumbar lordosis (LL). Complications were categorized using the modified Clavien-Dindo classification (MCDC) scheme. Patients were assigned to the reduction group (RG) and non-reduction group (NRG) based on the application of the lever reduction technique. Clinical and radiological outcomes at baseline, immediately after surgery, and at the last follow-up were compared. A total of 281 patients were analyzed (123 NRG, 158 RG). Baseline patient demographics, comorbidities, and surgical characteristics were similarly distributed between groups except for operating time (NRG 129.25min, RG 138.04min, P = .009). Both groups exhibited significant clinical improvement after surgery (all, P = .000), with no substantial difference between groups (VAS, ODI, or the ability to reach MCID). Patients in RG showed statistically lower SP and higher FL during follow-up (all, P = .000). LL was comparable at different time points within each group or at the same time point between the two groups (all, P > .050). The overall complication rate (NRG 38.2%, RG 27.2%, P = .050) or specific complication rates per MCDC were similar between groups (all, P > .050). Patients in RG were predisposed to a lower risk of adjacent segment degeneration (ASDeg) (NRG 9.8%, RG 6.3%, P = .035). There were no significant differences in postoperative measures such as VAS scores for back and leg pain, ODI, the ability to reach MCID, overall complication rate, or specific complication rates per MCDC between surgical approaches. However, fusion with lever reduction demonstrated a notable advantage in restoring segmental spinal sagittal alignment and reducing the occurrence of ASDeg compared to in situ fusion.

Therapeutic effects of extracorporeal shock wave therapy on patients with spastic cerebral palsy and Rett syndrome: clinical and ultrasonographic findings

BackgroundExtracorporeal shock wave therapy (ESWT) is reportedly effective for improving spasticity and motor function in children with cerebral palsy (CP). Because late-stage Rett syndrome has a similar presentation, this study aimed to investigate the effects of ESWT on these two diseases.Material and MethodsPatients diagnosed with spastic CP and Rett syndrome received 1500 impulses of ESWT at 4 Hz and 0.1 mJ/mm2, on their spastic legsonce weekly for a total of 12 weeks. Outcomes were assessed before and 4 and 12 weeks after ESWT. Clinical assessments included the Modified Ashworth Scale (MAS), passive range of motion (PROM), and Gross Motor Function Measure 88 (GMFM-88). Ultrasonographic assessments included muscle thickness, acoustic radiation force impulse (ARFI), and strain elastography.ResultsFifteen patients with CP and six with Rett syndrome were enrolled in this study. After ESWT, patients with CP showed significant clinical improvement in the MAS (P = 0.011), ankle PROM (P = 0.002), walking/running/jumping function (P = 0.003), and total function (P < 0.001) of the GMFM-88. The patients with Rett syndrome showed improved MAS scores (P = 0.061) and significantly improved total gross motor function (P = 0.030). Under ARFI, patients with CP demonstrated decreased shear wave speed in the gastrocnemius medial head (P = 0.038). Conversely, patients with Rett syndrome show increased shear-wave speeds after ESWT.ConclusionOur study provides evidence that a weekly course of low-dose ESWT for 12 weeks is beneficial for children with both CP and Rett syndrome, with the clinical effects of reducing spasticity and improving the gross motor function of the lower limbs. The ARFI sonoelastography reveals improvement of muscle stiffness in patients with CP after ESWT, but deteriorated in patients with Rett syndrome. The diverse therapeutic response to ESWT may be caused by the MECP2 mutation in Rett syndrome, having a continuous impact and driving the pathophysiology differently as compared to CP, which is secondary to a static insult.Trial registration IRB 201700462A3. Registered 22March 2017, https://cghhrpms.cgmh.org.tw/HRPMS/Default.aspx.

Doença da arranhadura do Gato - relato de caso

INTRODUCTION: Cat Scratch Disease (CSD) presents most commonly with fever and lymphadenopathy, but up to 25% of cases develop systemic manifestations. OBJECTIVE: to report a pediatric case of hepatosplenic form of CSD. METODOLOGY: this is a case report of a nine-year-old child hospitalized from October to November 2019. The report was written based on medical records and literature review, through Pubmed platform. Informed consent was given by the legal sponsor and the assent by the child. RESULT: a nine-year-old girl presents with swollen, tender and erythematous nodes in the right popliteal fossa and fever. Initial suspicion was of cellulitis, complicated with a popliteal abscess. Treatment was initiated with oxacillin for 3 days and later on with clindamycin and ceftriaxone for 11 days. On the eleventh day of hospital stay, the patient manifested hepatosplenic abscesses and antibiotic treatment was upscaled to vancomycin and piperacillin-tazobactam until she was diagnosed with a hepatosplenic form of CSD, which happened seventeen days after admission. Therefore, treatment was provided with Rifampicin and Clarithromycin for 14 days, with significant clinical improvement. CONCLUSION: this report aims to raise awareness regarding the wide clinical spectrum of this infection and how to better manage it.

TMR for Peripheral Sensory Nerve Neuroma around the Wrist Utilizing the Distal Anterior Interosseous Nerve.

Injury to the peripheral sensory nerves of the hand and wrist is common and can lead to debilitating neuromas and significantly impair patients' quality of life. Target-muscle reinnervation (TMR) is a novel method for treating neuromas that can result in significant clinical improvement. However, TMR for the peripheral sensory nerves in the hand and wrist is restricted by the limited options for motor branches. The adaptability of the anterior interosseous nerve (AIN) as a target for TMR treating peripheral sensory neuroma has not been thoroughly investigated or implemented therapeutically. This study aimed to evaluate the use of AIN as a viable recipient of TMR for treating peripheral sensory neuromas around the wrist. In this retrospective study, eight patients were included over 18 months from June 2021 to January 2023 at Hamad Medical Corporation. The average follow-up time after TMR was 13 months. The peripheral sensory nerves involved were the radial sensory nerve in five cases, the palmar cutaneous branch of the median nerve in one case, and the median nerve in one case. The preoperative average VAS pain score was 7 of 10 compared with the postoperative pain score of 2 of 10. In conclusion, the AIN can be used as a first-choice motor target for all peripheral sensory neuromas around the wrist for the following reasons: first, it can be reached by the peripheral sensory nerves around the wrist; second, the pronator quadratus muscle is expandable; and third, the AIN can be taken with a long proximal tail for flexible coaptation with the peripheral sensory nerves.

Neuroblastoma estágio 4S e hepatomegalia maciça: relato de caso

Objective: To report a case of stage 4S neuroblastoma and massive hepatomegaly that worsened the disease prognosis. Case Description: A 3-month-old male infant presented with 7 days of worsening abdominal distension, significant sweating, incessant crying, and irritability. His abdomen was globular and exhibited massive hepatomegaly. Imaging examinations detected multiple nodules in the liver parenchyma and a hypoechoic nodule in the right adrenal gland. The lesions were biopsied, with findings revealing infiltrative neuroblastoma in the liver tissue. The patient was diagnosed with International Neuroblastoma Staging System stage 4S, and treatment was started according to the International Society of Paediatric Oncology - Paediatric Oncology in Developing Countries protocol. During the first chemotherapy cycle, his condition required prolonged mechanical ventilation and hemodialysis. It was then decided to switch to the POG 9341-Modified regimen in an emergency mode. A significant clinical improvement response was observed after the third chemotherapy cycle. Subsequent cycles were administered based on the initial proposed protocol. Complete remission was achieved after the eighth cycle. Comment: Stage 4S neuroblastoma usually has a good prognosis; however, when associated with massive hepatomegaly, the prognosis becomes unfavorable. Complications during the first chemotherapy cycle required a change in management to the POG 9341-Modified regimen, which resulted in a reduction in the number and size of hepatic and adrenal nodules. Owing to significant clinical improvement, the remaining cycles were performed using the initial protocol. Despite the uncommon association and the lack of consensus for a specific treatment, complete remission was achieved by combining therapeutic regimens.

Bee Sting-induced Nephrotic Syndrome in a Child: A Case Report with Review of Literature

Abstract Background: Nephrotic syndrome (NS) is common in children, and it is usually idiopathic. Bee sting-induced NS in children is rarely reported. Clinical Description: A 9-year-old female child presented with a complaint of generalized edema for 2 days which started to develop 4 days after being stung on the dorsum of her right foot by a bee. She had pedal edema, facial puffiness, and abdominal distension. Management and Outcome: Laboratory investigations showed proteinuria, low serum protein, elevated serum cholesterol, serum triglycerides, and immunoglobulin E levels. A diagnosis of NS secondary to bee sting was made. The patient was treated with supportive measures for edema. There was a significant clinical and biochemical improvement by 10 days. Conclusion: This case reiterates the association between allergen exposure and NS, which is hardly reported in children. Such a phenomenon may be transient with requirement of only supportive therapy for symptom relief.

Modified triple pelvic osteotomy for residual acetabular dysplasia through double incisions: Technical note and review of short-term results.

To assess validity, safety, and efficacy of the modified triple pelvic osteotomy (TPO) approach for correction of residual acetabular dysplasia. This is a retrospective case series conducted on 15 hips in 15 patients from 2019 to 2023 with residual acetabular dysplasia treated by modified TPO as described by Tonnis with two modifications. The first modification is using a single medial incision for pubic and ischial cuts (the Vladimirov modification). The second modification is having the ischial cut closer to the acetabulum (Li modification) allowing free movement of the acetabular fragment for better femoral head coverage. The mean age at the time of surgery was 11.85years, (range 8-23). Cases presenting were 10 males (66.7%) and 5 females (33.3%). The mean follow-up period was 36.533 months (24-60 months). Our study revealed significant clinical and radiological improvement. The CE angle improved from a mean value of 10° (range 2-17) pre-operatively to 32.785° (range 18°-40°) post-operatively. The AI improved from a mean value of 32° pre-operatively to a mean value of 13.89° post-operatively. HHS increased from a preoperative mean value of 74.80° to a post-operative mean value of 90.67°. Also, there was a significant improvement in ROM (abduction and internal rotation). LLD improved from a mean value of 2.60cm preoperatively to a mean value of 0.37cm postoperatively. Delayed union was found in 3 cases. No cases of osteonecrosis or neurovascular complication were encountered in our study. The modified TPO technique using dual incisions can be considered safe and effective, providing adequate coverage of the femoral head in acetabular dysplasia with less surgical time, satisfactory functional outcomes, and minimal complications. IV.