Clinical and Safety Outcomes of Endovascular Therapy 6 to 24 Hours After Large Vessel Occlusion Ischemic Stroke With Tandem Lesions / 대한뇌졸중학회지

Background@#and Purpose Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6–24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6–24 hours. @*Methods@#This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6–24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0–2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality. @*Results@#Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0–2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49–1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44–1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20–1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0–2 (aOR 0.99, 95% CI 0.96–1.01, for each hour delay) among patients presenting <24 hours. @*Conclusion@#EVT for acute TL-LVO treated within 6–24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.

Biomechanics of implant-supported restorations / Biomecânica das restaurações implantossuportadas

The rehabilitation of patients with dental implant-supported restorations is an ideal treatment option in contemporary dentistry. The aim of this review was to compile and to demonstrate the mechanical response during loading condition, on the stress distributions of implant-supported prostheses. The findings show that the majority of stresses were concentrated in the cervical region of the implant/abutment interface and that they can be affected by several clinical parameters and loading conditions. Finally, the final prosthetic design should combine superior mechanical response, long-term survival rate and allow patient satisfaction. (AU)

A reabilitação de pacientes com restaurações implanto-suportadas é uma opção de tratamento ideal na odontologia contemporânea. O objetivo desta revisão foi compilar e demonstrar a resposta mecânica durante a aplicação de carga, na distribuição de tensão de próteses implanto-suportadas. Os achados mostram que a maioria das tensões se concentram na região cervical da interface implante/pilar e pode ser afetada por diversos parâmetros clínicos e condições de carregamento. Por fim, o desenho protético final deve combinar uma melhor resposta mecânica, taxa de sobrevida a longo prazo e permitir a satisfação do paciente. (AU)

A narrative review on invasive brain stimulation for treatment-resistant depression

While most patients with depression respond to pharmacotherapy and psychotherapy, about one-third will present treatment resistance to these interventions. For patients with treatment-resistant depression (TRD), invasive neurostimulation therapies such as vagus nerve stimulation, deep brain stimulation, and epidural cortical stimulation may be considered. We performed a narrative review of the published literature to identify papers discussing clinical studies with invasive neurostimulation therapies for TRD. After a database search and title and abstract screening, relevant English-language articles were analyzed. Vagus nerve stimulation, approved by the U.S. Food and Drug Administration as a TRD treatment, may take several months to show therapeutic benefits, and the average response rate varies from 15.2-83%. Deep brain stimulation studies have shown encouraging results, including rapid response rates (> 30%), despite conflicting findings from randomized controlled trials. Several brain regions, such as the subcallosal-cingulate gyrus, nucleus accumbens, ventral capsule/ventral striatum, anterior limb of the internal capsule, medial-forebrain bundle, lateral habenula, inferior-thalamic peduncle, and the bed-nucleus of the stria terminalis have been identified as key targets for TRD management. Epidural cortical stimulation, an invasive intervention with few reported cases, showed positive results (40-60% response), although more extensive trials are needed to confirm its potential in patients with TRD.

General Well-being and Coping Strategies in Adult Eosinophilic Esophagitis Patients

Background/Aims@#Growing evidence suggests a negative effect of eosinophilic esophagitis (EoE) on patients’ general health-related quality of life (HRQOL). However, the relevance and use of coping strategies and its relation to (disease specific) HRQOL as well as its determinants have not been studied well. @*Methods@#Adult EoE patients were invited to complete standardized measures on general HRQOL (Short Form-36 Health Survey [SF-36]) and coping strategies (Utrechtse Coping Lijst [UCL]). Scores were compared to general population norms. The disease specific Adult Eosinophilic Esophagitis Quality of Life (EoE-QOL-A) measure was used to assess EoE-HRQOL. Socio-demographic-and clinical factors were also evaluated. @*Results@#In total, 147 adult EoE patients (61% males), age 43 (interquartile range, 29-52) years were analyzed. Mental health-scores (SF-36) were significantly lower in EoE patients, whereas physical health-scores (SF-36) were similar in EoE patients (vs the general population;P = 0.010 and P = 0.240), respectively. The subdomain “disease anxiety” (EoE-QOL-A) was mostly affected, determinants were; female gender, younger age, severe clinical disease activity, higher number of food bolus extraction, and more recent EoE-diagnosis. Less effective coping styles (ie, passive/palliative reaction) were associated with a significant impact on each individual EoE-HRQOLsubdomain as well as lower scores of the Mental Health Component Scale in male EoE patients. Passive reaction in female EoEpatients correlated with impairment of the EoE-HRQOL-domains “emotional impact” and “disease anxiety.” Active problem solving was significantly related to better perception of mental HRQOL (SF-36) in both males and females. @*Conclusions@#EoE has a significant negative impact on mental HRQOL, with less effective coping strategies––specifically in males, being a relevant determinant. Thus, a pro-active approach towards coping mechanisms is needed in order to enhance HRQOL and manage patients’ burden of EoE.

Thrombectomy in Acute Ischemic Stroke: Challenges to Procedural Success / 대한뇌졸중학회지

The overwhelming clinical benefit of intra-arterial stroke therapy owes to the major advance in revascularization brought on by the current generation of thrombectomy devices. Nevertheless, there remains a sizeable proportion of patients for whom substantial reperfusion cannot be achieved or is achieved too late. This article addresses the persistent challenges that face neurointerventionists and reviews technical refinements that may help to mitigate these obstacles to procedural success. Insights from in vitro modeling and clinical research are organized around a conceptual framework that examines the interaction between the device, the thrombus and the vessel wall.

Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders

Esophageal high-resolution manometry (HRM) is replacing conventional manometry in the clinical evaluation of patients with esophageal symptoms, especially dysphagia. The introduction of HRM gave rise to new objective metrics and recognizable patterns of esophageal motor function, requiring a new classification scheme: the Chicago classification. HRM measurements are more detailed and more easily performed compared to conventional manometry. The visual presentation of acquired data improved the analysis and interpretation of esophageal motor function. This led to a more sensitive, accurate, and objective analysis of esophageal motility. In this review we discuss how HRM changed the way we define and categorize esophageal motility disorders. Moreover, we discuss the clinical applications of HRM for each esophageal motility disorder separately.

Diagnosis and Management of Autoimmune Hepatitis: Current Status and Future Directions

Autoimmune hepatitis is characterized by autoantibodies, hypergammaglobulinemia, and interface hepatitis on histological examination. The features lack diagnostic specificity, and other diseases that may resemble autoimmune hepatitis must be excluded. The clinical presentation may be acute, acute severe (fulminant), or asymptomatic; conventional autoantibodies may be absent; centrilobular necrosis and bile duct changes may be present; and the disease may occur after liver transplantation or with features that suggest overlapping disorders. The diagnostic criteria have been codified, and diagnostic scoring systems can support clinical judgment. Nonstandard autoantibodies, including antibodies to actin, α-actinin, soluble liver antigen, perinuclear antineutrophil antigen, asialoglycoprotein receptor, and liver cytosol type 1, are tools that can support the diagnosis, especially in patients with atypical features. Prednisone or prednisolone in combination with azathioprine is the preferred treatment, and strategies using these medications in various doses can ameliorate treatment failure, incomplete response, drug intolerance, and relapse after drug withdrawal. Budesonide, mycophenolate mofetil, and calcineurin inhibitors can be considered in selected patients as frontline or salvage therapies. Molecular (recombinant proteins and monoclonal antibodies), cellular (adoptive transfer and antigenic manipulation), and pharmacological (antioxidants, antifibrotics, and antiapoptotic agents) interventions constitute future directions in management. The evolving knowledge of the pathogenic pathways and the advances in technology promise new management algorithms.

Influence of shape and finishing on the corrosion of palladium-based dental alloys

PURPOSE: The purpose of this study was to evaluate the effects of the surface treatment and shape of the dental alloy on the composition of the prosthetic work and its metallic ion release in a corrosive medium after casting. MATERIALS AND METHODS: Orion Argos (Pd-Ag) and Orion Vesta (Pd-Cu) were used to cast two crowns and two disks. One of each was polished while the other was not. Two as-received alloys were also studied making a total of 5 specimens per alloy type. The specimens were submersed for 7 days in a lactic acid/sodium chloride solution (ISO standard 10271) and evaluated for surface structure characterization using SEM/EDAX. The solutions were quantitatively analysed for the presence of metal ions using ICP-MS and the results were statistically analysed with one-way ANOVA and a Tukey post-hoc test. RESULTS: Palladium is released from all specimens studied (range 0.06-7.08 microg.cm(-2).week(-1)), with the Pd-Cu alloy releasing the highest amounts. For both types of alloys, ion release of both disk and crown pairs were statistically different from the as-received alloy except for the Pd-Ag polished crown (P>.05). For both alloy type, disk-shaped pairs and unpolished specimens released the highest amounts of Pd ions (range 0.34-7.08 microg.cm(-2).week(-1)). Interestingly, in solutions submerged with cast alloys trace amounts of unexpected elements were measured. CONCLUSION: Shape and surface treatment influence ion release from dental alloys; polishing is a determinant factor. The release rate of cast and polished Pd alloys is between 0.06-0.69 microg.cm(-2).week(-1), which is close to or exceeding the EU Nickel Directive 94/27/EC compensated for the molecular mass of Pd (0.4 microg.cm(-2).week(-1)). The composition of the alloy does not represent the element release, therefore we recommend manufacturers to report element release after ISO standard corrosion tests beside the original composition.

Standardization of rehabilitation after limb salvage surgery for sarcomas improves patients' outcome

The purpose of this study is to establish a standardized postoperative rehabilitation protocol following limb salvage surgery [LSS] in patients with primary bone sarcoma in five major anatomical locations: distal femur, proximal tibia, proximal and total femur, humerus and shoulder girdle and pelvic resections. Retrospective study. All LSSs were performed by an orthopedic oncology surgeon, and rehabilitation of all patients was based on a devised standardized rehabilitation protocol. Patient outcomes were measured using the modified Musculoskeletal Tumor Society-International Symposium on the Limb Salvage [MSTS-ISOLS] scoring system. A total of 59 patients received LSS in the above mentioned locations; endoprostheses were used in 49, bone allograft in five, while no replacements were made in five patients. At a mean follow-up of 24 months, the mean modified MSTS-ISOLS score for all patients was 87% [95% CI; 0.85-0.89]. The highest scores were encountered for patients with distal femur replacement: 93% [95% CI; 0.91-0.95]. Seven patients had interruption of more than six weeks in their rehabilitation and had a mean score of 71% [95% CI; 0.64-0.82]. The proposed rehabilitation protocol is a comprehensive, organized and applicable guideline to be used after performing LSS at the above mentioned anatomical locations. The use of standardized rehabilitation protocol resulted in improved patient functional outcome

Indocyanine Green Videoangiography for Confirmation of Bypass Graft Patency

OBJECTIVE: The aim of the study is to determine the efficacy of indocyanine green (ICG) videoangiography for confirmation of vascular anastomosis patency in both extracranial-intracranial and intracranial-intracranial bypasses. METHODS: Intraoperative ICG videoangiography was used as a surgical adjunct for 56 bypasses in 47 patients to assay the patency of intracranial vascular anastomosis. These patients underwent a bypass for cerebral ischemia in 31 instances and as an adjunct to intracranial aneurysm surgery in 25. After completion of the bypass, ICG was administered to assess the patency of the graft. The findings on ICG videoangiography were then compared to intraoperative and/or postoperative imaging. RESULTS: ICG provided an excellent visualization of all cerebral arteries and grafts at the time of surgery. Four grafts were determined to be suboptimal and were revised at the time of surgery. Findings on ICG videoangiography correlated with intraoperative and/or postoperative imaging. CONCLUSION: ICG videoangiography is rapid, effective, and reliable in determining the intraoperative patency of bypass grafts. It provides intraoperative information allowing revision to reduce the incidence of technical errors that may lead to early graft thrombosis.

Hallazgos neuroendocrinos en el síndrome de ingesta nocturna / Neuroendocrine levels, circadian profiles, and sleep in night eating syndrome: integration of findings

El síndrome de ingesta nocturna (SIN) se caracteriza porhiperfagia vespertina y despertares acompañados deingesta nocturna de alimentos. Dilucidar el trastorno enla fisiología del sueño y la fisiología neuroendocrina subyacenteal síndrome clínico es fundamental y ayudará acentrar los tratamientos. Llevamos a cabo un estudio con15 mujeres internadas con sobrepeso y SIN y 14 participantescontroles similares para comparar las concentracionesen 25 horas y los patrones circadianos de los perfilesneuroendocrinos y de ingesta calórica y las característicaspolisomnográficas...

Night eating syndrome (NES) is characterized by eveninghyperphagia and awakenings with nocturnal foodingestions. Elucidation of the disturbance in sleep and neuroendocrine physiology that underlies the clinical syndrome is crucial and helps to target treatments. We conducted an inpatient study of 15 overweight women with NES and 14 similar control participants to compare the 25 h levels and circadian patterns of neuroendocrine and caloric intake profiles and polysomnographic features...

Metabolic and morphologic complication of Hiv infection

In the era of highly active antiretroviral therapy, long-term complications of HIV infection and antiretroviral therapy deserve heightened attention. Morphologic and metabolic complications seen during the course of HIV infections encompass a variety of entities that may share a common pathophysiologic pathway. This review article will discuss clinical syndromes such as wasting, lipoatrophy/ lipohypertrophy, polymetabolic syndrome as well as hyperlipidemia, cardiovascular disease, lactic acidosis, and metabolic bone disease in HIV-infected patients

Guías diagnósticas y terapéuticas para la hepatitis autoinmune / Diagnostic and therapeutic guidelines for autoimmune hepatitis

Autoimmune hepatitis can afflict all ages, races and genders, and it has diverse presentations (acute, fulminant, chronic, and indolent) before and after liver transplantation that can lead to misdiagnosis. The diagnostic criteria have been codified, and the preferred treatment is prednisone in combination with azathioprine. Two types have been proposed based on distinctive serological markers, but they are not established as valid clinical entities. Nonstandard autoantibodies, such as antibodies to actin, chromatin, and soluble liver antigen/liver pancreas, may have prognostic value by identifying individuals who relapse after corticosteroid withdrawal. The cytochrome mono-oxygenase, CYP2D6, is the target autoantigen of one form of the disease. Corticosteroids may decrease fibrosis and reduce the histological features of cirrhosis by suppressing inflammatory activity. Progressive fibrosis is associated with the HLA DR3/DR4 phenotype and an increase in the histological activity score during therapy. Potent immunosuppressive agents, such as cyclosporine and mycophenolate mofetil, have shown promise as salvage therapies, and site-specific interventions through molecular manipulations of pathogenic pathways are feasible. Variant syndromes have cholestatic features and variable responses to corticosteroids depending on the degree of cholestasis. Autoimmune hepatitis should be considered in the differential diagnosis of all patients with acute and chronic hepatitis of uncertain cause, including patients after liver transplantation.

La hepatitis autoinmune afecta a personas de todas las edades, razas y sexos y tiene presentaciones variadas (aguda, fulminante, crónica, indolente) antes y después del trasplante. Los criterios diagnósticos se estandarizaron y el tratamiento de elección es la prednisona en combinación con azatioprina. Se propusieron dos tipos de hepatitis autoinmune sobre la base de la presencia de marcadores serológicos distintivos. Los autoanticuerpos no estándar, tales como anticuerpos antiactina, anticromatina y antiantígeno soluble hepático del hígado/páncreas pueden tener valor pronóstico al identificar los individuos con recaídas luego del cese del tratamiento corticoideo. La citocromo monooxigenasa, CYP2D6, es el autoantígeno blanco de una de las formas de la enfermedad. Los corticoides pueden disminuir la fibrosis y reducir los hallazgos histológicos de cirrosis al suprimir la actividad inflamatoria del hígado. Los agentes inmunosupresores potentes como la ciclosporina y el mofetil micofenolato parecen ser promisorios como terapias de rescate y las intervenciones dirigidas hacia los mecanismos patogénicos específicos son factibles. Las variantes sindrómicas tienen hallazgos colestásicos y respuesta variable a los corticoides que dependen del grado de colestasis. La hepatitis autoinmune debe ser considerada en el diagnóstico diferencial de todos los pacientes con hepatitis aguda y crónica de causa desconocida, especialmente en aquellos que tienen indicación de trasplante hepático.

Leucemoid blood as a malignant sign in pertussis

1. The different non-leucemic blood pictures simulating leucemia are discussed2. Sixty-two cases of pertussis with bronchopneumonia that presented very high leucocyte counts are reported. In addition to the bronchopneumonia that was invariably present in all the cases, 9 were associated with other infections3. The white cell counts varied from 50,000 to 216,000 per cubic millimeter of blood, with preponderance of lymphocytes in 50 per cent of the cases, polymorphonuclears in 14.5 per cent of the cases, and equal neutrophiles and lymphocytes in the rest4. These leucemoid blood pictures although a bad omen in pertussis bronchopneumonias, are not necessarily the terminal stage of the disease5. Although the very high leucocyte counts simulated leucemias, they were proven not to be leucemias clinically, hematologically, and anatomically. The differences between leucemias and the leucemoid blood picture are also discussed6. The grave prognosis of bronchopneumonia cases secondary to pertussis, when attended by a leucemoid blood picture, especially if the blood picture persists in the subsequent counts, is also pointed out7. The necessity of making a leucocyte count in every pertussis case with bronchopneumonia, in order to be able to tell the serious cases from a group of clinically mild and moderate cases of infection, is emphasized8. The treatment of these cases with sulfapyridine and sulfathiazole is hopeful.(Summary and Conclusions)

Thoracotomy in the treatment of empyema thoracis in children

1. Forty-one cases of empyema thoracis treated with intercostal thoracotomy and open drainage are reported2. In more than 80 per cent of the bacteriologically examined cases the causative organism was pneumococcus3. The comparative study of the various reports on the therapy of empyema shows that pleurotomy gives a lower death rate, a shorter recovery period, and a higher percentage of cures, than closed drainage, ribresection, and repeated aspirations4. The average recovery period of the cases was 35.8 days. With properly timed operations and subsequent establishment and maintenance of adequate drainage, the period of convalescence was reduced to less than 24.88 days, the latter being the recovery period for uncomplicated empyema cases5. The optimum time for operation is in the fifth week after the onset of pneumonia. In the presence of infections other than empyema, better results were obtained when the operation was done within the optimum time for intervention, even if there were active but regressing complications, than when the operation was postponed to a later date when the coexisting infection had completely resolved6. Well-carried out lung gymnastics contributed to the early recovery from the temporary disabilities resulting from pleurotomy.(Summary)

Highlights of the weekly staff clinical conferences in 1940

We have tried, although in a brief way, to summarize the interesting and instructive features of the Weekly Staff Clinical Conferences in 1940A. The Department of Medicine presented a total of 41 cases for clinical study and discussion1. Eight cases were blood diseases. The etiology of the aplastic anemia in 3 cases is still obscure, hence they are considered idiopathic, but ankylostomiasis was found to have something to do with the production.(Summary)