Recurrence Of Symptoms In Patients Research Articles

Complex regional pain syndrome I (reflex sympathetic dystrophy).

Complex regional pain syndrome I (reflex sympathetic dystrophy).

Redone endoscopic perforator surgery: Feasibility and failure analysis

Purpose: In many hospitals and medical practices, subfascial endoscopic perforator surgery (SEPS) has become the treatment of choice in patients with incompetent perforator veins and active venous ulcers. A substantial number of surgeons consider SEPS to be an operation that can be performed only once because extensive scarring and narrowing of the subfascial space make a second endoscopic operation impossible. It is the purpose of this report to prove the feasibility, efficacy, and safety of a second SEPS procedure. Methods: Within a period of 30 months, 105 primary SEPS procedures were performed in patients with healed or still active ulcers. In addition to these cases, within a period of 30 months, a consecutive number of 19 patients were examined and scheduled for a second SEPS procedure. All patients were in class 5 with healed ulcers or in class 6 with still active ulcers. The CEAP classification of the American Venous Forum was used to evaluate the results and to calculate the clinical, disability, and outcome scores. The redone operation was performed by using CO 2 insufflation, a dual-port technique, and subfascial balloon dissection. Results: In two patients conversion to a conventional procedure was necessary. There were no major complications, but there was a 21% incidence of minor problems, such as hematoma or cellulitis. The mean total clinical score improved after surgery from 7.91 to 3.23 ( P < .01), the disability score changed from 1.10 to 0.57 after surgery ( P < .02), and the clinical outcome score was 1.47 after surgery ( P < .001). Cumulative ulcer healing could be achieved in 85.8% of class 6 patients. Failure analysis revealed that an incomplete subfascial dissection had been performed during the first endoscopic operation. A septum intermusculare medialis or an intact deep posterior fascia with incompetent Cockett II perforators were major factors contributing to the initial treatment failures. In addition to incompetent perforators, postthrombotic deep venous reflux was seen in eight (42.1%) patients, and four (21%) patients had a combination of secondary reflux and obstruction. Conclusion: Subfascial endoscopic procedures can be redone safely. In addition to exploring the superficial posterior compartment, the deep posterior compartment must be opened to prevent recurrent symptoms in patients with incompetent perforator veins. (J Vasc Surg 1999;30:720-6.)

Multiphasic anaphylaxis: an uncommon event in the emergency department.

To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED. Retrospective chart review of out-of-hospital, ED, and hospital records over 4.5-year period (July 1991 to December 1995) at a university hospital ED with an annual patient volume of 60,000. Subjects were ED anaphylaxis patients with > or = 2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. The major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surrounding hospitals (radius of 75 miles from the primary institution) within a 7-day period from the initial visit. Review of the state death registry also was made to verify the absence of out-of-hospital deaths. The medical records of 1,261 allergic reaction patients were reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms and signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throat/chest tightness, 25 (37%); orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory shock, 32 (48%); upper airway angioedema, 7 (33%); stridor, 11 (16%); and bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resolution and remained asymptomatic for a mean time of 4.2 hours in the ED. Protracted reaction occurred in 5 cases (3 using beta-adrenergic blocking agents). For 19 (28%) patients admitted to hospital, the mean hospital length of stay was 63 hours. Only 2 (3%) recurrent cases were identified, both manifested solely by urticaria. Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient management of patients with severe anaphylactic reactions that promptly respond to therapy with complete, rapid resolution may be reasonable. Further study of this medical emergency is required to develop criteria to guide the choice of an outpatient disposition.

Antisecretory Therapy in 1017 Patients with Ulcerlike or Refluxlike Dyspepsia in General Practice

Objectives: The effect of omeprazole and H2-blockers in patients with ulcerlike and refluxlike dyspepsia is mainly studied in endoscoped patients. In general practice most patients are treated without endoscopy. We studied the effect of omeprazole versus H2-blockers and placebo in patients consulting the general practitioner because of dyspeptic complaints in which, based on symptom clusters, ulcerlike or refluxlike symptoms were predominant.Methods: Patients with ulcerlike or refluxlike dyspepsia according to a symptom-based classification were randomised to treatment with omeprazole 20 mg in the morning versus cimetidine 400 mg twice daily (n=469), if the patients had a verified medical history of peptic ulcer disease or reflux oesophagitis, or to a treatment with omeprazole 20 mg in the morning versus placebo (n=548), if no such history was present. The endpoint was a total relief of symptoms after two weeks of treatment.Results: In both groups treatment success was obtained in 50% of the patients treated with omeprazole versus 35% (p=0.002) of those treated with cimetidine, and 36% (p=0.009) of those treated with placebo, respectively.Conclusions: The response rates indicate that patient selection based on symptom clusters is insufficient for predicting the response to acid suppression, and that aspects other than acid-related factors contribute to symptom presentation. The lack of difference in the response to omeprazole treatment in the two groups indicates that recurrence of dyspeptic symptoms in patients with previous peptic ulcer disease or reflux oesophagitis does not necessarily reflect a relapse of the disease.

Restenosis After Delayed Coronary Angioplasty of the Culprit Vessel in Patients With a Recent Myocardial Infarction Treated by Thrombolysis

Clinical follow-up after percutaneous transluminal coronary angioplasty (PTCA) of an infarct-related lesion has demonstrated a low incidence of recurrent symptoms and repeated revascularization. In the absence of systematic angiographic follow-up, this low rate of clinical restenosis may reflect either a truly lower incidence of anatomic restenosis or the lack of recurrent symptoms in patients with extensive infarction in the territory of the restenotic vessel. We studied 300 consecutive patients who, after a thrombolysis for myocardial infarction, underwent delayed (10.5 +/- 6 days after the myocardial infarction) PTCA of the infarct-related lesion. Procedural success was obtained in 253 patients (84%), and angiographic follow-up was performed in 205 of this group (81%) at a mean of 7.3 +/- 1.9 months. Restenosis (defined as the recurrence of > 50% stenosis) was present in 105 patients (51%). Only 34 of the 105 patients (32%) with angiographic restenosis were symptomatic; the other 68% had clinically silent restenosis. Of these 105 patients, 27 (13% of the total population undergoing follow-up angiography) had reocclusion at the dilated site at follow-up. The severity of the stenosis at follow-up and the late loss in minimal lumen diameter followed a nearly Gaussian distribution if the lesions that were totally occluded at follow-up were excluded. By multivariate analysis, two independent predictors of reocclusion were identified: a small reference diameter (P < .0005) and the presence of collateral vessels before the procedure (P < .01). Only one factor was associated with restenosis in the 178 patients who did not have reocclusion at follow-up; a Thrombolysis in Myocardial Infarction grade < or = 2 before the procedure (P < .0001). At follow-up, there was a significantly (P < .01) higher ejection fraction in patients without restenosis (56.1 +/- 13.4%) and in patients with restenosis without total occlusion (56.0 +/- 13.8%) than in patients with reocclusion (46.4 +/- 13.0%). Despite a satisfactory clinical outcome, delayed PTCA of an infarct-related lesion is associated with a high rate of angiographic recurrence. Two distinct mechanisms account for recurrent stenosis: progressive luminal renarrowing as documented after angioplasty of stable lesions and reocclusion of the infarct-related lesion. Only reocclusion is associated with a deterioration in left ventricular function at follow-up.

The Role of Mesalazine in Crohn's Disease

Sulfasalazine continues to be a common treatment for active Crohn's disease. It has been shown to be more effective than placebo in patients with colonic disease and in patients without prior surgical resection. There is no clear clinical evidence for its use as maintenance therapy in quiescent Crohn's disease; nevertheless, it is widely used to prevent symptom recurrence in patients whose active disease responded to sulfasalazine. In a few preliminary controlled studies, mesalazine has been shown to be superior to placebo in the treatment of active Crohn's disease. Until recently, the results of trials of mesalazine as maintenance therapy in quiescent Crohn's disease were equivocal but promising.

Follow-up after successful transluminal angioplasty. Report of the initial Cleveland Clinic experience.

One hundred forty-nine patients underwent percutaneous transluminal coronary angioplasty (PTCA) over a 24-month period. PTC A was successful in 106 patients (71%) and 109 vessels (72%). Patients with primary success were followed for 9 ± 0.6 months (mean ± SEM). Follow-up, ranging from Ave to 28 months, was based primarily on the evaluation of functional status according to the New York Heart Association Classification. Forty-eight patients underwent repeat coronary angiography during the course of follow-up. Seventy-five patients (71%) experienced continued improvement in functional class at the end of the follow-up period. Sixty-nine patients (65%) were in functional class I at the conclusion of follow-up; 5 of these patients had documented angiographic recurrence, and 12 patients showed no recurrence at repeat angiography. Thirty-one patients (29%) had recurrence of anginal symptoms; 19, 5, and 7 patients were in functional class II, III, and IV, respectively. Of these 31, 14 patients were shown to have no angiographic recurrence, and 13 patients demonstrated recurrent stenosis at repeat angiography. Recurrent symptoms in patients with angiographically documented restenosis of the previously dilated site occurred on an average of 2.7 ± 2.1 months (mean ± SD) post-PTCA. The authors’ experience indicates that (a) long-term success is achievable in a substantial majority of PTCA candidates, (b) suspected recurrence must be documented angiographically, and (c) symptomatic recurrences are unusual beyond five months post-PTCA.

PITUITARY ADENOMAS AND DYSPITUITARISM

Recent studies of the structure and function of pituitary adenomas reveal that the majority are functional and that the commonest type is a prolactin secreting adenoma. Studies of hypothalamic-pituitary function provide evidence to suggest that the adenoma develops following prolonged hypothalamic stimulation of the pituitary gland, and that the clinical dyspituitarism is due to the hypothalamic-pituitary dysfunction and not to pituitary destruction by the adenoma. Pituitary adenomas may be classified into those due to a basic neuroendocrine dysfunction (prolactin secreting, acromegaly, Cushing's disease) and those arising secondary to end-organ failure (TSH and FSH secreting). The former group have APUD characteristics and may form part of a pluriglandular syndrome of apudomas. The persistence of a basic neuroendocrine dysfunction following the surgical removal of an adenoma explains the frequent recurrence of symptoms in patients and indicates a need for continued surveillance and long-term therapy.

False aneurysm after carotid endareterectomy.

To the Editor:— A case of false aneurysm of the carotid artery secondary to dehiscence of silk sutures holding a Dacron patch is presented. Symptoms of cerebral dysfunction secondary to probable embolization from the false aneurysm have focused our attention on this diagnosis as a possible cause of recurrent symptoms in patients who have previously had carotid artery surgery. False aneurysms have been reported after vascular reconstruction to the lower extremities. 1 To the best of our knowledge, false aneurysms after carotid artery reconstruction have not been previously described. This presentation reports a symptomatic false aneurysm of the carotid artery which occurred six years after carotid endarterectomy. Report of a Case:— A 56-year-old man was admitted to the San Francisco Veterans Administration Hospital on April 10, 1968, with acute hemiparesis on the right side and dysarthria. Several months prior to admission the patient had had an episode of transient right