Reoperation Rates of Percutaneous and Paddle Leads in Spinal Cord Stimulator Systems: A Single-Center Retrospective Analysis.

OBJECTIVE: We hypothesize that reoperation rates of spinal cord stimulation (SCS) systems utilizing percutaneous leads are comparable to those utilizing paddle leads. We attempt here to characterize causes for those reoperations and identify any related patient characteristics. DESIGN AND SUBJECTS: This study is a single-center retrospective chart review of 291 subjects (410 operations) who underwent at least one permanent SCS implantation utilizing percutaneous or paddle leads over a 10-year period at the Medical University of South Carolina. METHODS: Charts were reviewed for height, weight, body mass index, gender, race, age, stimulator type, type of reoperation, diabetes status, history and type of prior back surgery, top lead location, and number of leads placed. Comparisons of patient and procedural characteristics were conducted using a two-sample t test (continuous variables), chi-square, or Fisher exact approach (categorical variables). Univariate and multivariate Cox regression models were developed, identifying associations between patient characteristics, SCS characteristics, reoperation rates, and time to reoperation. RESULTS: Thirty point five eight percent of subjects (89/291), required at least one reoperation. The reoperation rate was 27.84% for percutaneous systems (N = 54/194) and 27.78% for percutaneous systems (N = 60/216). Time to reoperation also did not differ between the two systems (hazard ratio [HR] = 1.06, 95% CI = 0.70-1.60). Of all factors examined, younger age at time of placement was the only factor associated with risk of reoperation (HR = 0.73, 95% CI = 0.62-0.87, P < 0.001). CONCLUSIONS: Our data suggest that reoperation rates and time to reoperation between percutaneous and paddle leads are clinically similar; therefore, rates of reoperation should have no bearing on which system to choose.

Detection of subclinical Harlequin syndrome in pediatric patients.

BACKGROUND: Harlequin syndrome presents as differences in facial coloring due to unilateral flushing. This is the result of the inability to flush on the affected side due to the disruption of vasomotor and sudomotor sympathetic activity. The neurologically intact side appears flushed. A 2°C temperature difference between the flushed and nonflushed sides of the face has been detected in patients presenting with Harlequin syndrome. This difference in temperature might be detectable even in the absence of unilateral flushing, and this subclinical manifestation of the syndrome may occur more often than realized. AIM: To measure and compare the difference in the change in temperature on both sides of the face in patients with a thoracic epidural. METHODS: Fifteen pediatric patients receiving thoracic epidurals for the correction of pectus excavatum via Nuss procedure were enrolled. Temperature measurements on each side of the face were collected at three time points: prior to epidural placement in the holding area, one hour after epidural analgesia had been instituted, and after the patient awakened in the recovery area. The primary outcome is whether or not a temperature difference occurred between the two sides of the face over time. RESULTS: Comparing the pre-op temperature change to post-op temperature change for each side of the face, patient 2 had a large increase in temperature on the left side of the face with a decrease in temperature on the right side of the face. The largest observed difference between the changes in temperature from pre-op to post-op between the right and left sides of the face was 1.85°C in patient 2. This was more than two standard deviations from the mean difference in the patient population. Patient 15 also had a large difference in change in temperature from pre-op to post-op between the right and left sides of the face with an observed difference of 1.14°C, although this was not more than two standard deviations from the mean. None of the patients had unilateral facial flushing. CONCLUSION: Asymmetric effects or distribution of local anesthetic used in thoracic epidurals may result in asymmetric blockade of efferent sympathetic nervous system activity. This may cause differences in temperature between the two sides of the face without unilateral flushing. This phenomenon has previously been termed subclinical Harlequin syndrome. Subclinical Harlequin syndrome may be more common than anticipated and may be detected by comparing temperature differences in patients.

Instillation of 5% Povidone-Iodine Ophthalmic Drops Decreases the Respiratory Rate in Children Undergoing Strabismus Surgery: A Randomized Controlled Trial.

PURPOSE: To investigate the effects of topical application of ophthalmic 5% povidone-iodine eye drops, which has been reported to cause apnea in spontaneously breathing children during general anesthesia. METHODS: The authors conducted a randomized, controlled, single-blinded study comparing the effect of balanced salt solution eye drops and povidone-iodine eye drops on respiration in spontaneously breathing children during general anesthesia with sevoflurane via a laryngeal mask airway. Fifty patients received balanced salt solution eye drops and 50 patients received 5% povidone-iodine eye drops. RESULTS: None of the control patients had a significant change in respiration. Thirty of the 50 (60%) povidone-iodine patients had a slowing of respiration within the first 6 breaths after eye drop instillation (P < .001). The median time of respiratory pause in those 30 patients was 18.5 seconds (range: 4.36 to 96.2 seconds). Among the povidone-iodine patients, children with a history of a prior tonsillectomy and adenoidectomy and/or bilateral myringotomy had a 7.2 times greater chance of experiencing a change in respiration after instillation of the povidone-iodine eye drops. CONCLUSIONS: Topical application of 5% povidone-iodine eye drops causes a slowing and pause in spontaneous ventilation in a majority of children prior to strabismus surgery. This may represent activation of the diving reflex. [J Pediatr Ophthalmol Strabismus. 2019;56(6):378-382.].

Association of age-related macular degeneration with complement activation products, smoking, and single nucleotide polymorphisms in South Carolinians of European and African descent.

Purpose: Smoking and the incidence of age-related macular degeneration (AMD) have been linked to an overactive complement system. Here, we examined in a retrospective cohort study whether AMD-associated single nucleotide polymorphisms (SNPs), smoking, ethnicity, and disease status are correlated with blood complement levels. Methods: Population: The study involved 91 AMD patients and 133 controls, which included 73% Americans of European descent (EUR) and 27% Americans of African descent (AFR) in South Carolina. Readouts: Participants were genotyped for 10 SNPs and systemic levels of complement factor H (CFH) activity, and the complement activation products C3a, C5a, and Bb were assessed. Main Outcome Measures: Univariate and multivariable logistic regression models were used to examine associations between AMD status and distinct readouts. Results: AMD affects EUR individuals more than AFRs. EUR but not AFR AMD subjects revealed higher levels of Factors C3a and Bb. In all subjects, a 10-unit increase in C3a levels was associated with an approximately 10% increase in the odds of being AMD-positive, and C3a and Bb were associated with smoking. While CFH activity levels were not correlated with AMD, a significant interaction was evident between patient age and CFH activity. Finally, EURs had lower odds of AMD with enhanced copies of rs1536304 (VEGFA) and higher odds with more copy numbers of rs3766404 (CFH). Conclusions: Our results support previous studies of systemic complement components being potential biomarkers for AMD, but they suggest that smoking and disease do not synergistically affect complement levels. We also suggest a novel susceptibility and protective haplotypes in the South Carolinian AMD population. Our studies indicate that augmented complement activation associated with advanced AMD could be attributed to a decrease in CFH activity in younger patients.

Environmental perfluorooctane sulfonate exposure drives T cell activation in bottlenose dolphins.

Perfluoroalkyl acids (PFAAs) are highly stable compounds that have been associated with immunotoxicity in epidemiologic studies and experimental rodent models. Lengthy half-lives and resistance to environmental degradation result in bioaccumulation of PFAAs in humans and wildlife. Perfluorooctane sulfonate (PFOS), the most prevalent PFAA detected within the environment, is found at high levels in occupationally exposed humans. We have monitored the environmental exposure of dolphins in the Charleston, SC region for over 10 years and levels of PFAAs, and PFOS in particular, were significantly elevated. As dolphins may serve as large mammal sentinels to identify the impact of environmental chemical exposure on human disease, we sought to assess the effect of environmental PFAAs on the cellular immune system in highly exposed dolphins. Herein, we utilized a novel flow cytometry-based assay to examine T cell-specific responses to environmental PFAA exposure ex vivo and to exogenous PFOS exposure in vitro. Baseline PFOS concentrations were associated with significantly increased CD4+ and CD8+ T cell proliferation from a heterogeneous resident dolphin population. Further analysis demonstrated that in vitro exposure to environmentally relevant levels of PFOS promoted proinflammatory cytokine production and proliferation in a dose-dependent manner. Collectively, these findings indicate that PFOS is capable of inducing proinflammatory interferon-gamma, but not immunoregulatory interleukin-4 production in T cells, which may establish a state of chronic immune activation known to be associated with susceptibility to disease. These findings suggest that PFOS directly dysregulates the dolphin cellular immune system and has implications for health hazards. Copyright © 2017 John Wiley & Sons, Ltd.

Relationship of number of seizures recorded on video-EEG to surgical outcome in refractory medial temporal lobe epilepsy.

INTRODUCTION: Surgical planning for refractory medial temporal lobe epilepsy (rMTLE) relies on seizure localization by ictal electroencephalography (EEG). Multiple factors impact the number of seizures recorded. We evaluated whether seizure freedom correlated to the number of seizures recorded, and the related factors. METHODS: We collected data for 32 patients with rMTLE who underwent anterior temporal lobectomy. Primary analysis evaluated number of seizures captured as a predictor of surgical outcome. Subsequent analyses explored factors that may seizure number. RESULTS: Number of seizures recorded did not predict seizure freedom. More seizures were recorded with more days of seizure occurrence (p<0.001), seizure clusters (p≤0.011) and poorly localized seizures (PLSz) (p=0.004). Regression modeling showed a trend for subjects with fewer recorded poorly localized seizures to have better surgical outcome (p=0.052). CONCLUSIONS: Total number of recorded seizures does not predict surgical outcome. Patients with more PLSz may have worse outcome.

Relationship of number of seizures recorded on video-EEG to surgical outcome in refractory medial temporal lobe epilepsy / Relação entre o número de crises epilépticas registradas em vídeo-EEG e o resultado cirúrgico na epilepsia refratária do lobo temporal

INTRODUCTION: Surgical planning for refractory medial temporal lobe epilepsy (rMTLE) relies on seizure localization by ictal electroencephalography (EEG). Multiple factors impact the number of seizures recorded. We evaluated whether seizure freedom correlated to the number of seizures recorded, and the related factors. METHODS: We collected data for 32 patients with rMTLE who underwent anterior temporal lobectomy. Primary analysis evaluated number of seizures captured as a predictor of surgical outcome. Subsequent analyses explored factors that may seizure number. RESULTS: Number of seizures recorded did not predict seizure freedom. More seizures were recorded with more days of seizure occurrence (p<0.001), seizure clusters (p<0.011) and poorly localized seizures (PLSz) (p=0.004). Regression modeling showed a trend for subjects with fewer recorded poorly localized seizures to have better surgical outcome (p=0.052). CONCLUSIONS: Total number of recorded seizures does not predict surgical outcome. Patients with more PLSz may have worse outcome.

INTRODUÇÃO: O planejamento cirúrgico para epilepsia refratária do lobo medial temporal (rMTLE) depende da localização da região de origem das convulsões por meio do eletroencefalografia (EEG) ictal. Múltiplos fatores podem influenciar o número de crises registradas. Neste artigo, avaliamos se a obtenção de liberdade de crises epilépticas no pós-operatório se relaciona com o número de crises epilépticas registradas durante a avaliação pré-operatória e os fatores que afetam tal resultado. MÉTODOS: Foram coletados dados de 32 pacientes com rMTLE que foram submetidos à lobectomia temporal anterior. A análise principal avaliou o número de convulsões captadas como fator preditivo do resultado cirúrgico, e as análises subsequentes exploraram outros fatores que podem ter afetado o resultado cirúrgico. RESULTADOS: O número de convulsões registradas não mostrou valor preditivo para resultados livres de crises. Foi registrado maior número de convulsões quando houve: maior número de dias em que ocorreram crises (p<0,001); salvas de convulsões (p<0,011); e localização subótima da origem das crises (PLSz) (p=0,004). O modelo de regressão mostrou tendência para os indivíduos com um menor número de crises pobremente localizadas terem um melhor desfecho cirúrgico (p=0,052). CONCLUSÕES: O número total de crises registrado não afeta o desfecho cirúrgico, que possivelmente é influenciado por múltiplos fatores. Pacientes com mais PLSz têm maior possibilidade de pior resultado cirúrgico.