Treatment Of Symptoms In Patients Research Articles

Surgical approaches to intramedullary spinal cord astrocytomas in the age of genomics.

Intramedullary astrocytomas represent approximately 30%–40% of all intramedullary tumors and are the most common intramedullary tumor in children. Surgical resection is considered the mainstay of treatment in symptomatic patients with neurological deficits. Gross total resection (GTR) can be difficult to achieve as astrocytomas frequently present as diffuse lesions that infiltrate the cord. Therefore, GTR carries a substantial risk of new post-operative deficits. Consequently, subtotal resection and biopsy are often the only surgical options attempted. A midline or paramedian sulcal myelotomy is frequently used for surgical resection, although a dorsal root entry zone myelotomy can be used for lateral tumors. Intra-operative neuromonitoring using D-wave integrity, somatosensory, and motor evoked potentials is critical to facilitating a safe resection. Adjuvant radiation and chemotherapy, such as temozolomide, are often administered for high-grade recurrent or progressive lesions; however, consensus is lacking on their efficacy. Biopsied tumors can be analyzed for molecular markers that inform clinicians about the tumor’s prognosis and response to conventional as well as targeted therapeutic treatments. Stratification of intramedullary tumors is increasingly based on molecular features and mutational status. The landscape of genetic and epigenetic mutations in intramedullary astrocytomas is not equivalent to their intracranial counterparts, with important difference in frequency and type of mutations. Therefore, dedicated attention is needed to cohorts of patients with intramedullary tumors. Targeted therapeutic agents can be designed and administered to patients based on their mutational status, which may be used in coordination with traditional surgical resection to improve overall survival and functional status.

The Efficacy and Cost-Effectiveness of Umeclidinium/Vilanterol versus Tiotropium in Symptomatic Patients with Chronic Obstructive Pulmonary Disease.

Both long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) are widely used in the treatment of chronic obstructive pulmonary disease (COPD). A novel LAMA/LABA combination of umeclidinium/vilanterol (UMEC/VI; 62.5 μg/25 μg) is approved for chronic obstructive pulmonary disease (COPD) treatment. This study aimed to assess the efficacy and cost-effectiveness of UMEC/VI versus tiotropium (TIO) 18 μg in symptomatic patients with COPD from the perspective of the Chinese National Healthcare System. A simple analysis included three studies in the meta-analysis that compared UMEC/VI with TIO. A Markov model was developed to estimate the cost-effectiveness of UMEC/VI compared with TIO treatment in symptomatic patients with COPD. First, utilities, clinical efficacy, and adverse events obtained from the literature were utilized as model inputs. Costs were from Chinese average data, including local data. Costs were expressed in dollars based on 2020 prices. Then, the model outputs including drug costs, other medical costs, and total costs, and quality-adjusted life years (QALYs) were estimated. Costs and outcomes were discounted at a 5% annual rate. Furthermore, incremental cost-effective ratios (ICERs) were analyzed. Finally, the influences of changing parameters on the uncertainty of the results were assessed by means of one-way and probabilistic sensitivity analyses. This study revealed that UMEC/VI treatment had a higher rate of clinical efficacy in comparison with TIO, and the differences in the rate of adverse events between the two treatments were not significant. The results indicated that UMEC/VI was superior to TIO, which provided an increase in QALYs (0.002) and a total cost savings of $765.67 per patient over 3 years. In the base case, the ICER of UMEC/VI is -$397468.04/QALY compared with TIO, suggesting that UMEC/VI may be considered a dominant option over TIO. According to the Chinese medical system, the probability of UMEC/VI being cost-effective was 61.6% at a willingness-to-pay (WTP) of $31554/QALY. Sensitivity analyses confirmed that the results were robust. UMEC/VI could be considered a cost-effective treatment compared with TIO in symptomatic COPD patients from the Chinese National Healthcare System perspective. These results may help decision-makers in China when making judgements on which treatments to administer.

Ventricular Septal Defect Post-Myocardial Infarction: About 5 Cases.

Post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but potentially catastrophic mechanical complication that occurs in less than 1% of patients following a myocardial infarction and it is associated with a high morbidity and mortality despite improvements in medical and surgical therapies of revascularization. Our article is based on the study of the occurrence of the VSD after a myocardial infarction in 5 patients. With an average age of 60 years, the prognosis was good if the rupture was small and the patient was hemodynamically stable. VSD tends to occur within the first week after acute myocardial infarction. In most cases, there is an immediate decline in hemodynamics which can lead to cardiogenic shock. VSD is a surgical emergency needing immediate treatment in symptomatic patients. The procedure requires the closure of the VSD and coronary artery bypass grafting.

Why Is There an Increased Risk for Sudden Cardiac Death in Patients With Early Repolarization Syndrome?

The last two decades have changed the viewpoint on early repolarization syndrome (ERS). The prevalence of the early repolarization pattern is variable and ranges between 3-24% depending upon age, gender, and criteria used for J-point upliftment from baseline (0.05mV vs. 1 mV). While this pattern was previously linked with a benign result, multiple recent investigations have found a link between early repolarization and Sudden Cardiac Death (SCD) by causing life-threatening arrhythmias like Ventricular tachycardia/Ventricular fibrillation, a condition known as early repolarization syndrome. The syndrome falls under a broader bracket of J wave syndromes, which can be caused by early repolarization or depolarization abnormalities. The characteristics of early repolarization that are considered high risk for Sudden Cardiac Death include the amplitude of J-point upliftment from baseline ( > 0.2 mV), Inferior-lateral location of Early Repolarization pattern, and horizontal and downsloping ST-segment. Patients with symptomatic early repolarisation patterns on ECG are more likely to have repeated cardiac episodes. Implantable Cardioverter-Defibrillator (ICD) implantation and isoproterenol are the recommended treatments in symptomatic patients. On the other hand, asymptomatic patients with early repolarization patterns are prevalent and have a better outcome. Risk categorization is still obscure in asymptomatic early repolarization patterns. This traditional review outlines the known knowledge of pathophysiology behind the increased risk of sudden cardiac death, risk stratification of patients with ERS, and the treatment guidelines for patients with ERS. Further prospective studies are recommended to elucidate the exact mechanism for ventricular arrhythmogenesis in ERS patients and to risk stratifying asymptomatic patients with ERS.

Submucosal Clustered Brownish Microvessels Based on NBI Endoscopy: A Characteristic of LPR.

This study aimed to analyze the characteristics of laryngopharyngeal reflux (LPR) by using narrow band imaging (NBI) endoscopy. A prospective study. A large-volume practice with tertiary care providers. A total of 67 patients with suspected LPR who underwent 24-hour multichannel intraluminal impedance-pH monitoring were included from June 2020 to March 2022. Manifestations of NBI endoscopy included submucosal clustered brownish microvessels (CBMs), spotted brownish microvessels, and no special microvessels; the latter 2 formed the non-CBM group. The manifestations of all patients and their changes were observed after 8 weeks of proton pump inhibitor and symptomatic treatment for patients with LPR, and symptomatic treatment for patients without LPR. According to the results of 24-hour multichannel intraluminal impedance-pH monitoring, the incidence of submucosal CBMs was significantly higher in patients with LPR (30 cases) than in those without LPR (37 cases, P < .001), particularly in the posterior cricoid area (P < .001). Besides Reflux Finding Score, the incidence of signs such as subglottic edema and vocal fold edema was significantly higher in the CBM group than the non-CBM group (P < .05). Finally, 22 patients with LPR (91.7%) and only 2 patients without LPR (28.6%) underwent a transformation from CBMs to spotted brownish microvessels after continuous medication for 8 weeks in the CBM group (χ2 = 15.916, P < .001), while no significant change was observed in patients with or without LPR in the non-CBM group (P > .05). Submucosal CBMs in the posterior cricoid area under NBI endoscopy may be a characteristic of LPR.

Identifying Symptom Clusters in Cancer Patients Receiving Chemotherapy using Symptom Occurrence and Distress Dimensions.

The current study explored symptom clusters in a heterogenous sample that includes all age groups, and all types of cancer being treated with chemotherapy. A cross-sectional survey design was used. The sample comprise 393 cancer patients with a mean age of 52.1 years (SD 13.9). The most prevalent symptoms were tiredness (78.9%), lack of energy (71.8%), and irritability (66.9%) and the most distressing symptom was lack of appetite. Four clusters of the symptom experience: chemotherapy-related, psychological, fatigue and pain, and gastrointestinal symptoms, regardless of the dimension used, were identified. The content and number of symptoms within each cluster using the distress dimension were slightly different from the occurrence dimension. The findings call for an early comprehensive assessment and treatment of symptoms for patients undergoing chemotherapy. Also, healthcare providers especially nurses need to thoroughly assess and manage these symptoms to ease patients' experience, enhance their compliance and improve their quality of life.

Transoral awake state neuromuscular electrical stimulation therapy for mild obstructive sleep apnea

IntroductionObstructive sleep apnea (OSA) is a common disorder with major neurocognitive and cardiovascular sequelae. The treatment of symptomatic patients with mild OSA remains controversial given that adherence to positive airway pressure (PAP) has historically been suboptimal. With this notion in mind, we assessed a daily transoral neuromuscular electrical stimulation (NMES) device for individuals with mild OSA.MethodsThe sample represents a subset of participants with a baseline AHI 5–14.9 events/hour, drawn from a parent study which also included participants with primary snoring. Outcome measures for the current study included changes in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and snoring levels before and after use of the NMES. ResultsAmong 65 participants (68% men) with median age of 49 years (range 24 to 79) and median BMI of 27.7 kg/m2 (range 20 to 34), the NMES device was used daily for 6 weeks. We observed a significant improvement in the AHI from 10.2 to 6.8 events/hour among all participants and from 10.4 to 5.0 events/h among responders. Statistically significant improvements in the ESS, PSQI, objectively measured snoring, and bed partner-reported snoring were observed. Adherence among all participants was 85%.DiscussionThis NMES device has the benefit of being a treatment modality of daytime therapy which confers a high level of tolerability and patient acceptance. It alleviates the need for an in situ device during sleep and leads to improvements in OSA severity, snoring, and subjective sleep metrics, potentially crucial in mild OSA. Further studies are needed to define which individuals may benefit most from the device across the wider spectrum of OSA severity and assess long-term therapeutic outcomes.Trial registrationClinicalTrials.gov Identifier: NCT03829956.

Holmium laser enucleation of the prostate in patients with preexisting inflatable penile prostheses

This retrospective study evaluated the safety and efficacy of holmium laser enucleation of the prostate (HoLEP) in patients with an inflatable penile prosthesis (IPP). Five men with a preexisting IPP underwent HoLEP for obstructive lower urinary tract symptoms at Baylor Scott and White Medical Center between January 2016 and September 2020. None of the patients had preexisting prostate malignancy or urethral strictures. Minimal blood loss was seen during HoLEP, with an average length of hospital stay of 1.4 days and an average time of catheterization of 1.4 days. None of the patients had any known postoperative complications, including need for transfusions, return to the operating room for postoperative bleeding, or clot evacuation. In conclusion, there was no increased risk of perioperative or postoperative complications for HoLEP in this group compared with the general population. HoLEP appears to be a safe and efficacious method for the treatment of lower urinary tract symptoms in patients with a preexisting IPP.

Colorectal cancer outcomes are significantly influenced by the mode of presentation: Results of an England-wide population study assessing the impact of referral pathways on oncological outcomes.

Background: Despite the knowledge that the stage of colorectal cancer (CRC) at the time of diagnosis has a dramatic effect on survival, England has one of the lowest early detection and survival rates from CRC compared to other high-income countries. To improve early detection in asymptomatic individuals and initiate prompt referral and treatment in symptomatic patients, the UK has a national bowel cancer screening programme (BCSP) and an urgent suspected cancer referral system called the two-week wait outpatient clinic.

Effect of glucocorticoids combined with disease modifying anti-rheumatic drugs on the improvement of symptoms in patients with rheumatoid arthritis.

Objectives:To explore the effect of glucocorticoids combined with disease modifying anti-rheumatic drugs in the treatment of symptoms in patients with rheumatoid arthritis.Methods:Medical records of patients with rheumatoid arthritis treated in the Rheumatology and Immunology Department of Yiwu Central Hospital from March 2020 to March 2021 were selected. A total of 38 patients were treated with disease modifying anti-rheumatic drugs Group-I and 44 patients were treated with disease modifying anti-rheumatic drugs and glucocorticoids Group-II. The symptom improvement of the two groups were compared and analyzed Serological indexes and adverse reactions.Results:Swollen joint counts (SJC), tender joint counts (TJC), rheumatoid arthritis disease activity evaluation form (DAS28) score, erythrocyte sedimentation rate, levels of ESR, C-reaction protein (CRP) and rheumatoid factor (RF) of Group-II patients were lower than those in Group-I (P<0.05). The adverse reaction rate in Group-II patients was 12.20%, which was similar to that of Group-I patients. There was no significant difference in 9.76% of the patients (P>0.05).Conclusion:The combination of glucocorticoids and disease modifying anti-rheumatic drugs in the treatment of patients with rheumatoid arthritis is safe can further improve their symptoms and serological indexes, and will not lead to increased adverse reactions.

Professionals’ views on shared decision-making in severe aortic stenosis

ObjectiveTo provide insight into professionals’ perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS).MethodsA semistructured interview study was performed in...

Diagnosis and Treatment of Acquired Hemophilia: One Single-Center Experience from PR. China

Objective: To deepen the understanding of the clinical manifestations of acquired hemophilia A for timely and correctly treatment.Methods: The clinical data of the acquired hemophilia A patients diagnosed in the hospital from Jan 2006 to Mar 2021 were retrospectively analyzed, and the relevant literature was reviewed.Results: 17 patients with acquired hemophilia A, male: female =10: 7, median age 61 years (19 to 78 years), were diagnosed and treated in the hospital with the median time from the onset to diagnosis 21 days (2 days to 6 months). Six patients had comorbidity, including hepatitis B carrying, chronic myelomonocytic leukemia, diabetes, hypertension and positive autoantibodies, pemphigoid and gastric cancer, respectively. Other 11 patients were healthy before the onset. All patients had large large ecchymosis of skin, and one case was combined with hematuria, and one case with retroperitoneal hematoma. All patients had APTT extension (45s-144.7s) and the prolonged APTT could not be corrected with normal mixed plasma with and without incubation at 37℃ for 2 hours. FVIII activity was 1% - 8.9% and inhibitor titer 2 - 128 Bu/ml. All patients with bleeding were with prothrombin complex/recombinant activated coagulation factor VII, some of them with pd-coagulation factor FVIII preparations. Inhibitors were removed with prednisone acetate (1 case) + chemotherapy (1 case), prednisone acetate / + CTX (11 cases) + chemotherapy (1 case), prednisone acetate/prednisolone + mabthera (2 cases) + CTX (1 case), respectively. The removal time of inhibitor was from 8 days to 4 years. During the treatment process, two patients developed lower extremity venous thrombosis, and one patient was complicated with lung infection.Conclusion: Patients with unexplained bleeding and prolonged APTT should be conducted normal mixed plasma correction test, coagulation factor activity and inhibitor titer examination. After correctly diagnosis, bypass agents /coagulation factor VIII preparations should be given timely for hemostasis, protocol based on glucocorticoid + CTX/mabthera to remove the inhibitor and symptomatic treatment for patients with primary comorbidity disease at the same time. DisclosuresNo relevant conflicts of interest to declare.

Amantadine: an old drug reborn

In my opinion, amantadine is the most under-appreciated, under-utilised, and under prescribed oral medication in the treatment of patients with Parkinson's disease. I applaud Olivier Rascol and colleagues 1 Rascol O Fabbri M Poewe W Amantadine in the treatment of Parkinson disease and other movement disorders. Lancet Neurol. 2021; (published online Oct 19)https://doi.org/10.1016/S1474-4422(21)00249-0 Google Scholar for providing a timely update on the uses of amantadine in the treatment of Parkinson's disease and other movement disorders. Their Personal View also provides insight into the reasons why amantadine is not so widely used and emphasises the fact that, even though this drug has been available for 50 years, its complex pharmacology is still not fully understood nor are the mechanisms behind its beneficial effects. Amantadine in the treatment of Parkinson's disease and other movement disordersThe efficacy of amantadine in the symptomatic treatment of patients with Parkinson's disease, discovered serendipitously more than 50 years ago, has stood the test of time and the drug is still commonly used by neurologists today. Its pharmacological actions are unique in combining dopaminergic and glutamatergic properties, which account for its dual effect on parkinsonian signs and symptoms and levodopa-induced dyskinesias. Furthermore, amantadine has additional and less well-defined pharmacological effects, including on anticholinergic and serotonergic activity. Full-Text PDF

Outcomes of radiofrequency catheter ablation for persistent and long-standing persistent atrial fibrillation

Abstract Introduction Catheter ablation has become the first-line treatment for symptomatic patients with atrial fibrillation (AF). Several approaches of substrate ablation have been used for persistent and long-standing persistent AF and the best protocol procedure is yet to be established. The purpose of this study was to evaluate the outcomes of patients submitted to catheter ablation of persistent and long-standing persistent AF adding extra-pulmonary substrate approaches to pulmonary vein isolation. Methods We retrospectively studied 67 consecutive patients referred for the first procedure of catheter ablation of persistent or long-standing persistent AF from May 2016 to October 2018. The first 27 patients were subjected to pulmonary vein isolation and complex fractionated atrial electrograms (CFAE) ablation (group 1) and the last 40 patients were subjected to a tailored approach guided by voltage map areas and CFAE (group 2). Patient characteristics, procedure details and follow-up were assessed, and predictors of recurrence were determined. Results Mean age was 59±11 years with 58% being male. During a mean follow-up of 16±6 months 27% of the patients showed AF recurrence. There were no differences in baseline characteristics of group 1 and 2. A higher recurrence rate was found in group 1 by comparison with group 2 (40.7% vs 17.5%, Log Rank X2 = 5.076, P=0.024) (Figure 1). Also, recurrence was associated with a longer AF duration, an increased baseline Brain Natriuretic Peptide (BNP), an increased left atrium (LA) volume, the presence of hyperthyroidism, the absence of sinus rhythm after procedure, the inducibility of AF post-ablation and the absence of an antiarrhythmic drug at hospital discharge. After adjustment for other confounders, the patient group (HR 5.16 [1.23–21.71] P=0.025), a long-standing AF (HR 9.09 [1.41–58.82] P=0.020), the BNP value at admission (HR 1.03 [1.01–1.05] P=0.033) and the LA volume index (HR 1.13 [1.02–1.25] P=0.017) were the only independent predictors of recurrence. Conclusion Ablation of persistent and long-standing persistent AF is feasible with good results when a substrate approach is added to pulmonary vein isolation. A tailored approach seems to be more efficient, showing best outcomes in mid-term follow-up. A long-standing AF, higher BNP value and the LA enlargement are important predictors of recurrence and should be used to better select patients and to manage follow-up. Funding Acknowledgement Type of funding sources: None.

Prevalence estimates of genital Chlamydia trachomatis infection in Belgium: results from two cross-sectional studies

BackgroundChlamydia trachomatis (chlamydia) is the most diagnosed sexually transmitted infection in Belgium. Screening programs focus on young women, due to the implications of chronic asymptomatic infections for reproductive health. Thereby, the frequency of infections in men and older adults is underestimated. This study aimed to estimate the point-prevalence of chlamydia in the broader Belgian population, to inform evidence-based prevention and control strategies.MethodsWe conducted two cross-sectional prevalence studies of chlamydia infection in the population of Belgium aged 16–59 years, 2018–2020. In the CT1 study 12,000 representative individuals were randomly selected from the national register and invited by letter to collect a urine sample at home. The CT2 study used urine samples collected through the Belgian Health Examination Survey. Molecular detection of chlamydia DNA was performed using Xpert® or Abbott Real-Time CT/NG assays. Weighted estimated prevalence and 95% confidence interval (CI) was calculated per gender and age groups of 16/18–29, 30–44 and 45–59 years, relative to the general Belgian population. Data collected on sociodemographic variables and sexual behavior were used to identify potential risk factors for chlamydia infection through calculation of the odds ratio (OR).ResultsThe population-wide weighted estimated prevalence was 1.54% (95% CI 0.78–3) in CT1 and 1.76% (95% CI 0.63–4) in CT2. We observed no statistically significant difference between men and women or age groups. Civil relationship status (OR = 14.1 (95% CI 1.78–112), p < 0.01), sexual intercourse with a casual partner (OR = 6.31 (95% CI 1.66–24.1), p < 0.01) and > 3 sexual partners in the last 12 months (OR = 4.53 (95% CI 1.10–18.6), p = 0.02) were associated with higher relative risk for chlamydia infection.ConclusionNationwide prevalence studies are relevant to assess the distribution of chlamydia and inform public health actions. The overall low prevalence and heterogeneous distribution of chlamydia in the general Belgian population needs to be considered for future strategies and potential harm of testing and treating asymptomatic individuals need to be taken into account. Effective case management should include appropriate treatment of symptomatic patients and partner notification, and prevention strategies should encourage behaviors such as condom use.

Allergen immunotherapy against house dust mites in patients with local allergic rhinitis and asthma

Local allergic rhinitis (LAR) is a clinical rhinitis phenotype characterized by the presence of nasal symptoms of AR in nonatopic patients with a negative skin prick test and undetectable specific IgE (sIgE) in serum against inhalant allergens but with a positive nasal allergen provocation test. This study evaluated the effectiveness of a 12-month course of sublingual immunotherapy (SLIT) for house dust mite (HDM) allergies in adult patients with confirmed LAR and concomitant asthma. Methods The study was a prospective, double-blind, placebo-controlled trial with patients diagnosed with LAR to HDMs and with concomitant asthma who underwent a 12-month treatment course of SLIT for HDM allergies. Seventeen patients were randomized to SLIT with the use of allergen extracts of D. pteronyssinus and D. farinae (50/50%) in SQ-HDM SLIT tablets and 15 patients were randomized to the placebo group. The total rhinitis score (TRSS), total asthma symptom score (TASS), combined total symptom score (TSS), total medication score (TMS), and FEV1 were analyzed. Results: In the final analysis, 16 patients who received SLIT and 14 who received placebo who completed the study protocol were included. Significant reductions in TRSS, TASS, TSS, and TMS after 12 months of treatment were observed in patients after SLIT (p < 0.05). A significant increase in the mean FEV1 between baseline and after 12 months of therapy was observed in the study, with p = 0.03 in the study group. Conclusion: SLIT can improve nasal and bronchial symptoms and reduce symptomatic treatment in patients with LAR and asthma and with hyperresponsiveness to HDMs.

Pharmacological aspects of acute treatment glycoside intoxication

Despite the active introduction of surgical treatments for cardiac pathology and new synthetic cardiotonic drugs, cardiac glycosides (CG) remain an important component of the pharmacological treatment of heart diseases. Moreover, interest in this group of drugs is only increasing with the discovery of new pharmacological effects, such as antitumor and antiviral. However, despite many years of experience, the issue of managing patients with symptoms of both acute and chronic poisoning with cardiac glycosides remains one of the leading ones. The literature review provides a brief historical outline of cardiac glycoside poisoning and comprehensively describes the pharmacokinetics and pharmacodynamics of this group of drugs. The clinical picture of intoxication is described. We analyzed modern ideas and limitations of using antidote therapy such as digoxin immune Fab-antibody fragments, as well as the features of pathogenetic and symptomatic treatment of patients with acute glycoside poisoning.

Surgical management of pulmonary aspergilloma-12 years' experience from a tertiary care centre in India.

Pulmonary aspergilloma is the formation of saprophytic colonies of fungus in pre-existing pulmonary cavities. They may cause life-threatening haemoptysis. As medical treatment often fails, surgery is the mainstay of treatment in symptomatic patients. Earlier studies had reported high levels of mortality and morbidity with surgery while more recent studies have shown better results. Hence, being in a large tertiary care centre in India, we decided to analyse the details of our own experience in the surgical management of pulmonary aspergilloma. Details of all adult patients treated surgically for pulmonary aspergilloma, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analysed. There were 102 patients in the study. The average age was 40years. There was a male (M: F, 3:1) and right side preponderance. Pulmonary tuberculosis (TB) was the commonest cause for cavities in which aspergilloma developed as identified in 84 (82%) patients and diabetes mellitus, the commonest comorbidity present in 28 (27.5%) patients. Parenchyma-preserving lung resections (PPLRs) were feasible in 8 (44%) of the non-tubercular patients, but only in 14 (17%) of the TB patients. Post-operative complications (11.7%) were higher among the patients with TB. There were 2 (1.9%) post-operative mortalities. Though surgery is technically complex in the presence of pulmonary aspergilloma, it is yielding better results with improvements in treatment strategies. Surgery for aspergilloma in patients with prior or current pulmonary TB has more morbidity and mortality when compared to the non-TB patients.

Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

BackgroundTranspapillary biliary drainage in ERCP is an established method for symptomatic treatment of patients with unresectable malignant biliary obstruction. Percutaneous transhepatic biliary drainage frequently remains the treatment of choice when the transpapillary approach proves ineffective. Recently, EUS-guided extra-anatomical anastomoses of bile ducts to the gastrointestinal tract have been reported as an alternative to percutaneous biliary drainage. To assess the usefulness of extra-anatomical intrahepatic biliary duct anastomoses to the gastrointestinal tract as endotherapy for unresectable malignant biliary obstruction and to determine factors affecting the efficacy of treatment.MethodsA prospective analysis of the treatment results of all patients with unresectable biliary obstruction treated with EUS-guided hepaticogastrostomy at our institution in the years 2016–2019.ResultsTransmural intrahepatic biliary drainage (EUS-guided hepaticogastrostomy) was performed due to the ineffectiveness of ERCP in 53 patients (38 males, 15 females; mean age 74.66 [56–89] years) with unresectable biliary obstruction. Technical success of EUS-guided hepaticogastrostomy was achieved in 52/53 (98.11%) patients. Complications of endoscopic treatment were observed in 10/53 (18.87%) patients. Clinical success of EUS-guided hepaticogastrostomy was achieved in 46/53 (86.79%) patients. Bismuth type II–IV cholangiocarcinoma, hepatic metastases, ascites, suppurative cholangitis, and high blood bilirubin levels exceeding 30 mg/dL were independent factors for increased complications and inefficacy of EUS-guided hepaticogastrostomy.ConclusionsIn the event of transpapillary biliary drainage proving ineffective, extra-anatomical anastomoses of intrahepatic bile ducts to the gastrointestinal tract provide an effective method for the treatment of patients with malignant biliary obstruction.

Outcome Following Surgical Revascularization in Patients of Moyamoya Disease with Focus on Graft Patency and Angiographic Changes.

Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.