A Tubular-Mounted Digital Camera Versus Optical Surgical Microscope for Minimally Invasive Lumbar Decompression Surgery: The Impact on Operative Times, Ergonomics, and Workflow

OBJECTIVE

Understanding ergonomic impact is foundational to critically evaluating value and safety of enabling technologies in minimally invasive spine surgeries. This study assessed the impact of a tubular-mounted digital camera (TMDC) versus an optical surgical microscope (OSM) in single-level minimally invasive spine surgeries on operative times, durotomy rate, surgeon ergonomics, safety, and operating room workflow.

METHODS

This retrospective study compared consecutive single-level minimally invasive lumbar decompression surgeries in a TMDC cohort (September 2021-June 2022) with an historical OSM cohort (January 2020-July 2021). Data included patient demographics, operative times, durotomy incidence, surgeon ergonomics (Rapid Entire Body Assessment scores), and equipment impact via staff surveys. Operative times were assessed by t test, while Pearson χ2 test compared sex. Age, body mass index, and Charlson Comorbidity Index comparisons were made by Wilcoxon rank sum tests, and survey results were analyzed with Wilcoxon signed rank tests.

RESULTS

TMDC and OSM groups included 74 and 82 patients, respectively. Age, sex, and Charlson Comorbidity Index did not significantly differ between groups. The TMDC group had a higher body mass index (29.6 ± 5.1) than the OSM group (29.0 ± 7.5) (P = 0.04). The TMDC group had significantly shorter operative times (57.3 ± 16.6 minutes) than the OSM group) (66.7 ± 22.5 minutes) (P = 0.004), with no difference in durotomy rates (P = 0.42). TMDC use yielded lower Rapid Entire Body Assessment scores compared with OSM (4.1 ± 0.77) (P < 0.001). Surveys indicated improved safety, setup time, and workflow with TMDC (P < 0.001).

CONCLUSIONS

TMDC in single-level minimally invasive lumbar decompression surgery improved surgeon ergonomics, reduced operative times, and maintained durotomy rates, enhancing operating room efficiency. Evaluating ergonomic impact of technology is vital for safety and value assessment.

Effects of a comprehensive brain computed tomography deep learning model on radiologist detection accuracy

OBJECTIVES

Non-contrast computed tomography of the brain (NCCTB) is commonly used to detect intracranial pathology but is subject to interpretation errors. Machine learning can augment clinical decision-making and improve NCCTB scan interpretation. This retrospective detection accuracy study assessed the performance of radiologists assisted by a deep learning model and compared the standalone performance of the model with that of unassisted radiologists.

METHODS

A deep learning model was trained on 212,484 NCCTB scans drawn from a private radiology group in Australia. Scans from inpatient, outpatient, and emergency settings were included. Scan inclusion criteria were age ≥ 18 years and series slice thickness ≤ 1.5 mm. Thirty-two radiologists reviewed 2848 scans with and without the assistance of the deep learning system and rated their confidence in the presence of each finding using a 7-point scale. Differences in AUC and Matthews correlation coefficient (MCC) were calculated using a ground-truth gold standard.

RESULTS

The model demonstrated an average area under the receiver operating characteristic curve (AUC) of 0.93 across 144 NCCTB findings and significantly improved radiologist interpretation performance. Assisted and unassisted radiologists demonstrated an average AUC of 0.79 and 0.73 across 22 grouped parent findings and 0.72 and 0.68 across 189 child findings, respectively. When assisted by the model, radiologist AUC was significantly improved for 91 findings (158 findings were non-inferior), and reading time was significantly reduced.

CONCLUSIONS

The assistance of a comprehensive deep learning model significantly improved radiologist detection accuracy across a wide range of clinical findings and demonstrated the potential to improve NCCTB interpretation.

CLINICAL RELEVANCE STATEMENT

This study evaluated a comprehensive CT brain deep learning model, which performed strongly, improved the performance of radiologists, and reduced interpretation time. The model may reduce errors, improve efficiency, facilitate triage, and better enable the delivery of timely patient care.

KEY POINTS

• This study demonstrated that the use of a comprehensive deep learning system assisted radiologists in the detection of a wide range of abnormalities on non-contrast brain computed tomography scans. • The deep learning model demonstrated an average area under the receiver operating characteristic curve of 0.93 across 144 findings and significantly improved radiologist interpretation performance. • The assistance of the comprehensive deep learning model significantly reduced the time required for radiologists to interpret computed tomography scans of the brain.

Global research trends in central nervous system tuberculosis - A bibliometric analysis

Background

Central Nervous System Tuberculosis (CNS-TB) is a serious public health concern causing significant morbidity and mortality, especially in high TB burden countries. Despite the expanding research landscape of CNS-TB, there is no comprehensive map of this field. This work aims to (1) obtain a current and comprehensive overview of the CNS-TB research landscape, (2) investigate the intellectual and social structure of CNS-TB publications, and (3) detect geographical discrepancies in scientific production, highlighting regions requiring increased research focus.

Methods

We conducted a bibliometric analysis on CNS-TB literature indexed in Web of Science from 2000 to 2022, evaluating 2130 articles. The dataset was analyzed in R for descriptive statistics. We used R-bibliometrix and VOSViewer for data visualization.

Findings

Publication output grew annually at an average rate of 6·88%, driven primarily by India and China. International collaborations comprised 16·44% of total publications but contributed to 11 of the 15 top-cited papers. Additionally, we identified discrepancies of CNS-TB research in many low- and middleincome countries relative to their TB incidence.

Interpretation

Our findings reveal a growing interest in CNS-TB research from China and India, countries with rapidly developing economies, high TB burdens, and a recent increase in research funding. Furthermore, we found that international collaborations are correlated with high impact and accessibility of CNS-TB research. Finally, we identified disparities in CNS-TB research in specific countries, particularly in many low- and middle-income countries, emphasizing the need for increased research focus in these regions.

Predicting Acoustic Hearing Preservation Following Cochlear Implant Surgery Using Machine Learning

OBJECTIVES

The aim of the study was to train and test supervised machine-learning classifiers to predict acoustic hearing preservation after CI using preoperative clinical data.

STUDY DESIGN

Retrospective predictive modeling study of prospectively collected single-institution CI dataset.

METHODS

One hundred and seventy-five patients from a REDCap database including 761 patients >18 years who underwent CI and had audiometric testing preoperatively and one month after surgery were included. The primary outcome variable was the lowest quartile change in acoustic hearing at one month after CI using various formulae (standard pure tone average, SPTA; low-frequency PTA, LFPTA). Analysis involved applying multivariate logistic regression to detect statistical associations and training and testing supervised learning classifiers. Classifier performance was assessed with numerous metrics including area under the receiver operating characteristic curve (AUC) and Matthews correlation coefficient (MCC).

RESULTS

Lowest quartile change (indicating hearing preservation) in SPTA was positively associated with a history of meningitis, preoperative LFPTA, and preoperative SPTA. Lowest quartile change in SPTA was negatively associated with sudden hearing loss, noise exposure, aural fullness, and abnormal anatomy. Lowest quartile change in LFPTA was positively associated with preoperative LFPTA. Lowest quartile change in LFPTA was negatively associated with tobacco use. Random forest demonstrated the highest mean classification performance on the validation dataset when predicting each of the outcome variables.

CONCLUSIONS

Machine learning demonstrated utility for predicting preservation of residual acoustic hearing in patients undergoing CI surgery, and the detected associations facilitated the interpretation of our machine-learning models. The models and statistical associations together may be used to facilitate improvements in shared clinical decision-making and patient outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:926-936, 2024.

Clinical Guidelines for the Evaluation and Treatment of Lumbar Disc Herniations: How Accurate is the Internet?

OBJECTIVE

To compare information online regarding lumbar disc herniation (LDH) on commonly searched websites and compare those findings with the evidence-based recommendations listed in the North American Spine Society (NASS) clinical practice guidelines.

METHODS

NASS Clinical Practice Guidelines, Internet searches were performed utilizing three common search engines (Google, Bing, Yahoo) and keywords associated with LDH. The top 20 websites from each search were selected. The content regarding diagnosis and treatment of LDH was compared to the NASS clinical practice guidelines.

RESULTS

On average, websites mentioned only 59% of recommendations supported by Level I evidence. Websites included an average of 3 recommendations not discussed in the NASS guidelines out of an average of 12 total recommendations. Muscle and sensory testing and physical therapy were the most frequent recommendations, appearing on over 80% of websites. Websites were equally likely to contain recommendations backed by high-quality evidence as recommendations not included in NASS guidelines.

CONCLUSIONS

This study demonstrates that websites regarding LDH contain a mix of information, with only a fraction of recommendations aligning with NASS clinical guidelines. Patients who use these websites are presented with unsubstantiated information, conceivably impacting their understanding, expectations and decision-making in physician offices.

Ten-Year Durability of Hypothalamic Deep Brain Stimulation in Treatment of Chronic Cluster Headaches: A Case Report and Literature Review

Chronic cluster headache (CCH) is a debilitating primary headache that causes excruciating pain without remission. Various medical and surgical treatments have been implemented over the years, yet many provide only short-term relief. Deep brain stimulation (DBS) is an emerging treatment alternative that has been shown to dramatically reduce the intensity and frequency of headache attacks. However, reports of greater than 10-year outcomes after DBS for CCH are scant. Here, we report the durability of DBS in the posterior inferior hypothalamus after 10 years on a patient with CCH. Our patient experienced an 82% decrease in the frequency of headaches after DBS, which was maintained for over 10 years. The side effects observed included depression, irritability, anxiety, and dizziness, which were alleviated by changing programming settings. In the context of current literature, DBS shows promise for long-term relief of cluster headaches when other treatments fail.

Early experience with percutaneous balloon kyphoplasty for treatment of osteoporotic vertebral compression fracture in Nepal: A case report

Key Clinical Message

Balloon kyphoplasty is a promising treatment option for osteoporotic vertebral compression fractures with posterior cortical defect, offering pain relief, vertebral height restoration, and low risk of cement leakage.

Abstract

Millions of people worldwide suffer from osteoporotic vertebral compression fractures (OVCFs) annually, which cause pain and functional limitations, particularly in the elderly. Conservative treatments such as pain management, rest, and medication are frequently used, while surgical options such as vertebroplasty and kyphoplasty are considered. We present a case of 68-year-old female with vertebral compression fracture of L1 vertebra with posterior cortical defect and posterior wall retropulsion. She was treated successfully with balloon kyphoplasty. Kyphoplasty appears to be a better option than vertebroplasty in cases with posterior cortical defect due to lower chance of cement leakage.

Academic neurosurgery in Nepal: Present status and future directions

Introduction

The establishment of local neurosurgery training programs in Nepal has proven critical for the expansion of the discipline across the country. This paper aims to describe the evolution, current status, challenges, and future directions of academic neurosurgery in Nepal.

Research question

What is the current status and international standing of academic neurosurgery in Nepal?

Material and methods

Information related to growth and development in Nepal was obtained from universities and regulatory bodies in Nepal. Variables described are the current number of neurosurgeons, the number of neurosurgical centers and centers with accreditation for training, the description of existing training models, the number of graduates, and the contribution of Nepalese neurosurgeons to world literature.

Results

Formal neurosurgical training started in Nepal in 1999. Of 67 hospitals with neurosurgical facilities, 10 (14.9%) are accredited. Three training models (MCh, NBMS, and FCPS) currently exist. Of 116 neurosurgeons currently practicing in the country, 47 (40.5%) are homegrown. The contribution of the Nepalese neurosurgical community to the world includes the training of the first two Maldivian neurosurgeons and an increasing presence in world neurosurgical literature.

Conclusions

Although comparable to other countries with similar economies, Nepal still faces some challenges to the sustainability and further developments of Neurosurgery. Continued concerted efforts will help Nepalese neurosurgeons achieve the goal of securing self-reliance in neurosurgical education.

The Surgeon Ergonomic Impact of a Tubular-Based Digital Camera to Perform a Seated Posterior Cervical Foraminotomy

BACKGROUND

Posterior cervical decompression is a common spine procedure that can be performed with the patient in prone or sitting position. The sitting position provides the potential benefits of more facile retraction of surrounding soft tissues, increased operative field and fluoroscopic visualization, and decreased epidural bleeding. However, the surgeon's ergonomics of this positioning can be quite challenging when using the standard operative microscope to perform the procedure and may cause musculoskeletal harm to the surgeon.

METHODS

A sterile digital camera was brought into the field to perform a sitting foraminotomy completed through the tube retractor at both C6-7 and C7-T1 levels. For half of the procedure, a typical neurosurgical operative microscope was brought into the field to evaluate surgeon ergonomics using baseline Rapid Entire Body Assessment (REBA) scores for 2 surgeons of differing stature. The digital camera was inserted onto the tubular retractor, and REBA scores were calculated.

RESULTS

With a microscope, the surgeon with taller stature scored a 5 on the initial REBA scale, and the surgeon with shorter stature scored a 6, placing both in the medium-risk category. Once the tubular-based camera was placed, repeated REBA score of both surgeons was 3, placing them in the low-risk category.

CONCLUSIONS

Using a tubular-based digital camera system, the ergonomics of the surgery are substantially improved. The surgeon can stand closer to the operative field and look directly at a front-facing screen, allowing increased relaxation of the upper extremity and cervical musculature; improving overall ergonomic function.

Establishing a Reference Procedure Length for Anterior Cervical Fusions: The Role for Standards in Surgical Process Improvement

Surgical process improvement strategies are increasingly being applied to specific procedures to improve value. A critical step in any process improvement strategy is the identification of performance benchmarks. Procedure length is a performance benchmark for anterior cervical discectomy and fusion (ACDF) procedures; therefore, we sought to establish reference procedure lengths for 1-level, 2-level, and 3-level ACDFs at both teaching and non-teaching institutions and to describe methods for using this information to advance surgical process improvement initiatives. We performed a retrospective analysis of consecutive ACDFs performed at a resident teaching institution (RT) and a non-teaching institution (NT) for all 1-level, 2-level, and 3-level ACDFs. Mean case lengths and patient outcomes were calculated for individual surgeons and institutions. After limiting cases to 1-level, 2-level, and 3-level ACDFs and applying all exclusion criteria, 991 cases at the RT institution and 131 cases at the NT institution (a total of 1122 cases) were available for analysis. The mean (SD) procedure length for 1-level, 2-level, and 3-level ACDFs at the RT versus NT institutions were 121.9 min (36.3 min) and 73.6 min (29.7 min) (p<0.001), 172.7 min (44.8 min) and 112.0 min (43.0 min) (p<0.001), and 218.3 min (54.9 min) and 167.6 min (54.2 min) (p<0.001), respectively. Thirty-day outcomes were the same between institutions, except that the RT institution had a shorter mean hospital length of stay for 2-level ACDFs (1.6 days versus 2.9 days, p=0.001). This study is the first to attempt to establish a standard reference procedure length for 1-level, 2-level, and 3-level ACDFs. These data can guide efforts in surgical process improvement.

Natural Language Processing Applications in the Clinical Neurosciences: A Machine Learning Augmented Systematic Review

Natural language processing (NLP), a domain of artificial intelligence (AI) that models human language, has been used in medicine to automate diagnostics, detect adverse events, support decision making and predict clinical outcomes. However, applications to the clinical neurosciences appear to be limited. NLP has matured with the implementation of deep transformer models (e.g., XLNet, BERT, T5, and RoBERTa) and transfer learning. The objectives of this study were to (1) systematically review NLP applications in the clinical neurosciences, and (2) explore NLP analysis to facilitate literature synthesis, providing clear examples to demonstrate the potential capabilities of these technologies for a clinical audience. Our NLP analysis consisted of keyword identification, text summarization and document classification. A total of 48 articles met inclusion criteria. NLP has been applied in the clinical neurosciences to facilitate literature synthesis, data extraction, patient identification, automated clinical reporting and outcome prediction. The number of publications applying NLP has increased rapidly over the past five years. Document classifiers trained to differentiate included and excluded articles demonstrated moderate performance (XLNet AUC = 0.66, BERT AUC = 0.59, RoBERTa AUC = 0.62). The T5 transformer model generated acceptable abstract summaries. The application of NLP has the potential to enhance research and practice in the clinical neurosciences.

Vascularized Bone Grafts for Spinal Fusion-Part 3: The Occiput

BACKGROUND

Obtaining successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. This challenge stems from the relatively hypermobile joints between the occipital condyles, the motion that occurs at C1 and C2, as well as the paucity of dorsal bony surfaces for posterior arthrodesis. While multiple different techniques for spinal fixation in this region have been well described, there has been little investigation into auxiliary methods to improve fusion rates.

OBJECTIVE

To describe the use of an occipital bone graft to augment bony arthrodesis in the supraaxial cervical spine using a multidisciplinary approach.

METHODS

We review the technique for harvesting and placing a vascularized occipital bone graft in 2 patients undergoing revision surgery at the craniocervical junction.

RESULTS

The differentiation from nonvascularized bone graft, either allograft or autograft, to a bone graft using vascularized tissue is a key principle of this technique. It has been well established that vascularized bone heals and fuses in the spine better than structural autogenous grafts. However, the morbidity and added operative time of harvesting a vascularized flap, such as from the fibula or rib, precludes its utility in most degenerative spine surgeries.

CONCLUSION

By adapting the standard neurosurgical procedure for a suboccipital craniectomy and utilizing the tenets of flap-based reconstructive surgery to maintain the periosteal and muscular blood supply, we describe the feasibility of using a vascularized and pedicled occipital bone graft to augment instrumented upper cervical spinal fusion. The use of this vascularized bone graft may increase fusion rates in complex spine surgeries.

Machine learning applications to neuroimaging for glioma detection and classification: An artificial intelligence augmented systematic review

Glioma is the most common primary intraparenchymal tumor of the brain and the 5-year survival rate of high-grade glioma is poor. Magnetic resonance imaging (MRI) is essential for detecting, characterizing and monitoring brain tumors but definitive diagnosis still relies on surgical pathology. Machine learning has been applied to the analysis of MRI data in glioma research and has the potential to change clinical practice and improve patient outcomes. This systematic review synthesizes and analyzes the current state of machine learning applications to glioma MRI data and explores the use of machine learning for systematic review automation. Various datapoints were extracted from the 153 studies that met inclusion criteria and analyzed. Natural language processing (NLP) analysis involved keyword extraction, topic modeling and document classification. Machine learning has been applied to tumor grading and diagnosis, tumor segmentation, non-invasive genomic biomarker identification, detection of progression and patient survival prediction. Model performance was generally strong (AUC = 0.87 ± 0.09; sensitivity = 0.87 ± 0.10; specificity = 0.0.86 ± 0.10; precision = 0.88 ± 0.11). Convolutional neural network, support vector machine and random forest algorithms were top performers. Deep learning document classifiers yielded acceptable performance (mean 5-fold cross-validation AUC = 0.71). Machine learning tools and data resources were synthesized and summarized to facilitate future research. Machine learning has been widely applied to the processing of MRI data in glioma research and has demonstrated substantial utility. NLP and transfer learning resources enabled the successful development of a replicable method for automating the systematic review article screening process, which has potential for shortening the time from discovery to clinical application in medicine.

Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives

Successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. Different techniques for spinal fixation in this region have been well described, along with auxiliary methods to improve fusion rates. The occipital vascularized bone graft is a novel technique that can be used to augment bony arthrodesis in the supra-axial cervical spine. It provides the benefits of a vascularized autologous graft, such as accelerated healing, earlier fusion, and increased strength. This technique can be learned with relative ease and may be particularly helpful in cases with high risk of nonunion or pseudoarthrosis in the upper cervical spine.

Bone density in transfusion dependent thalassemia patients in Urmia, Iran

BACKGROUND

Patients with thalassemia major and intermedia are susceptible to osteopenia and osteoporosis. The mechanism of osteoporosis in these patients is multifactorial. Transfusion related iron overload in endocrine organs leads to impaired growth hormone secretion, diabetes mellitus, hypothyroidism, hypoparathyroidism, lack of sex steroids and vitamin D deficiency that contribute to impairment in achieving an adequate bone mass .The aim of this study was assessment of frequency of bone loss in patients with thalassemia major and intermedia in Urmia City of West Azerbaijan, Iran.

MATERIALS AND METHODS

In this cross sectional descriptive study,10 patients (lower than 18 y/o)with transfusion dependent thalassemia attending to Motahari and Emam Khomeini hospitals in Urmia city of Iran were enrolled and scanned for Bone Mineral Density (BMD) starting at around 10 years old.

RESULTS

Tenatients (6 male and 4 female) with transfusion dependent thalassemia (β-thalassemia major and intermedia) aged 13to 17 years in Urmia city of Iran were enrolled. Mean age of patients was 15.1±.37year old. Among them, 8 patients (80%)had low BMD and2 of them (20%) had normal BMD in lumbar spine. Only 30% of patients had low BMD in the neck of femur.

CONCLUSION

We should perform annual BMD in patients with thalassemia major and intermedia and hemoglobin H disease in age of higher than 8 year old and treat low BMD with administration of bisphosphonate, calcium and vitamin D supplements. Medical consultation with a rheumatologist and /or an endocrinologist should be performed in these patients. Changing lifestyle with mild daily exercise, adequate calcium containing foods, avoiding heavy activities, stop smoking, iron chelation therapy in adequate dosage, early diagnosis and treatment of endocrine insufficiency and regular blood transfusions can help to achieve an optimal bone density in these patients.

Extra-esophageal manifestations of gastroesophageal reflux

Gastroesophageal reflux disease (GERD) is a common medical condition affecting approximately 35-40% of the adult population in the western world. The role of GERD in causing extra-esophageal symptoms including laryngitis, asthma, cough, chest pain, and dental erosions is increasingly recognized with renewed interest among gastroenterologists and other specialists. Direct injury by mucosal contact, and vagally mediated reflex from distal esophageal acid exposure are the two possible mechanisms by which reflux-related extra-esophageal tissue injuries may occur. Several investigational techniques may be used to diagnose gastroesophageal reflux; however, because of the poor sensitivity of endoscopy and pH monitoring, and the poor specificity of laryngoscopy, empiric therapy with proton-pump inhibitors (PPI) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. In those who improve with such therapy, it is likely that GERD may be the cause of the extra-esophageal presentation. In those who are unresponsive to such therapy, other diagnostic testing such as impedance/pH monitoring may be reasonable in order to exclude continued acid or weakly acid reflux. However, PPI-unresponsive patients usually have causes other than GERD for the extra-esophageal symptoms and signs.

Laryngeal disorders in patients with gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common medical condition affecting approximately 35-40% of the adult population in the western world. Chronic laryngeal signs and symptoms associated with GERD are often referred to as reflux laryngitis or laryngopharyngeal reflux (LPR). It is estimated that up to 15% of all visits to the otolaryngology offices are because of manifestations of LPR. Injury may occur as a result of one or chronic reflux of gastroduodenal contents directly injuring the laryngeal mucosa. Since less amount of acid is required to make the injury to the larynx as compared to injury to esophagus; it is believed that intermittent exposure to small amount of gastric content can result in laryngitis. The most common presenting symptoms of LPR include hoarseness, sore throat, throat clearing, and chronic cough. The diagnosis of LPR is usually made on the basis of presenting symptoms and associated laryngeal signs including laryngeal edema and erythema. Current recommendation for management of this group of patients is empiric therapy with twice daily proton-pump inhibitors for 2 to 4 months. In majority of those who are unresponsive to such therapy other causes of laryngeal irritation is considered. Surgical fundoplication is most effective in those who are responsive to acid suppressive therapy.

Injection of botulinum toxin before pneumatic dilatation in achalasia treatment: a randomized-controlled trial

BACKGROUND

Pneumatic dilatation is the first line therapy in achalasia, but half of patients relapse within 5 years of therapy and require further dilatations.

AIM

To assess whether botulinum toxin injection before pneumatic dilatation is superior to pneumatic dilatation alone in achalasia patients.

METHODS

Newly diagnosed achalasia patients were randomly assigned to receive botulinum toxin 1 month before pneumatic dilatation (botulinum toxin-pneumatic dilatation group: 27 patients with median age of 38) or to undergo pneumatic dilatation alone (pneumatic dilatation group: 27 patients with median age of 30). Response to therapy was assessed by clinical and objective methods at various intervals.

RESULTS

One-year remission rate of patients in botulinum toxin-pneumatic dilatation group was 77% compared with 62% in pneumatic dilatation group (P = 0.1). In pneumatic dilatation group, the oesophageal barium volume significantly (P < 0.001) decreased at 1 month, but this reduction did not persist over 1-year follow-up. Botulinum toxin-pneumatic dilatation group showed a significant (P < 0.001) reduction in barium volume at the various times intervals post-treatment. In the botulinum toxin-pneumatic dilatation group, 10/11 (91%) patients over 40 were in remission at 1 year, comparing with only five of nine (55%) cases in pneumatic dilatation group (P = 0.07).

CONCLUSION

Injection of botulinum toxin before pneumatic dilatation does not significantly enhance the efficacy of pneumatic dilatation.

Living unrelated versus living related kidney transplantation: 20 years' experience with 2155 cases

PURPOSE

To compare the long-term results of kidney transplantation from living unrelated donors (LURDs) with that from living related donors (LRDs).

MATERIALS AND METHODS

From 1984 to 2004, we performed 2155 kidney transplantations of which 374 were from LRDs and 1760 from LURDs. We reviewed and compared the long-term data from these cases.

RESULTS

The LURD group included 64.2% men with an overall mean age of 33.46 +/- 14.61 (range 3 to 76) years. Laparoscopic donor nephrectomy was performed in 329 cases (18.7%) with mean follow-up of 45.68 +/- 46.80 months. The LRD group included 66.5% of male recipients with overall mean age of 28.97 +/- 9.58 (range 9 to 65) years. Laparoscopic donor nephrectomy was performed in 12 cases (3.2%) of LRDs with mean follow-up of 81.15 +/- 67.03 months. One-, 3-, 5-, 10-, and 15-year graft survivals among LRDs were 91.6%, 81.7%, 76.4%, 64.4%, and 48.4%; and for LURDs, 91.5%, 86.7%, 81.4%, 68.2%, and 53.2%, respectively (P = .07). Patient survivals for 1, 3, 5, 10, and 15 years in LRDs were 94.6%, 91.9%, 83%, 79.5%, and 73.9%, and in LURDs were 93.6%, 91.7%, 89.3%, 84%, and 76.4%, respectively (P = .14).

CONCLUSION

The results of living unrelated kidney transplantation upon long-term follow-up with a large number of cases were as good as living related kidney transplantation. The organ shortage can be alleviated by using living unrelated kidney transplantation. To our knowledge this is the largest experience with long-term follow-up reported from one center to date.

Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial

OBJECTIVE

Persistent or recurrent radicular pain after lumbosacral spine surgery is often associated with nerve root compression and is treated by repeated operation or, as a last resort, by spinal cord stimulation (SCS). We conducted a prospective, randomized, controlled trial to test our hypothesis that SCS is more likely than reoperation to result in a successful outcome by standard measures of pain relief and treatment outcome, including subsequent use of health care resources.

METHODS

For an average of 3 years postoperatively, disinterested third-party interviewers followed 50 patients selected for reoperation by standard criteria and randomized to SCS or reoperation. If the results of the randomized treatment were unsatisfactory, patients could cross over to the alternative. Success was based on self-reported pain relief and patient satisfaction. Crossover to the alternative procedure was an outcome measure. Use of analgesics, activities of daily living, and work status were self-reported.

RESULTS

Among 45 patients (90%) available for follow-up, SCS was more successful than reoperation (9 of 19 patients versus 3 of 26 patients, P <0.01). Patients initially randomized to SCS were significantly less likely to cross over than were those randomized to reoperation (5 of 24 patients versus 14 of 26 patients, P=0.02). Patients randomized to reoperation required increased opiate analgesics significantly more often than those randomized to SCS (P <0.025). Other measures of activities of daily living and work status did not differ significantly.

CONCLUSION

SCS is more effective than reoperation as a treatment for persistent radicular pain after lumbosacral spine surgery, and in the great majority of patients, it obviates the need for reoperation.

Kidney retransplantation in comparison with first kidney transplantation

INTRODUCTION

The aim of this study was to depict the outcome of second and third kidney allografts in comparison with first kidney allografts.

METHODS

Among 2150 kidney transplantations are 103 second and 5 third transplantations. Demographic characteristics and survivals of retransplanted patients were compared with a randomly selected group of first kidney recipients, consisting of two cases matched with each retransplanted patient for age, gender, and date of transplantation.

RESULTS

Retransplanted patients consisted of 78 men and 30 women of mean age 32.63 +/- 11.92 years. They had received kidneys from 91 living-unrelated and 17 living-related donors. Median followup was 27 months. One-, 2-, 3-, and 5-year graft survivals were 81.4%, 78.9%, 78.9%, and 73.7% among retransplants, versus 92.9%, 91.5%, 89.8%, and 85.3% in the control group, respectively (P = .0037). Patient survival was 96%, 94.6%, 92.4%, and 87.8% in the retransplant group versus 93.1%, 92.4%, 90.9%, 87.4% in the control group, respectively (P = .63). Also, graft survivals were slightly lower in female compared to male retransplant patients (P = .09). No significant difference in survival rates was seen in different age groups.

CONCLUSION

It seems that kidney retransplantation can yield desirable outcomes, albeit relatively lower graft survivals.

Signs and symptoms of cytomegalovirus disease in kidney transplant recipients

PURPOSE

To investigate the range of clinical presentations of cytomegalovirus (CMV) disease in kidney transplant recipients.

MATERIALS AND METHODS

We retrospectively reviewed the records of hundred kidney recipients who developed CMV disease between 1984 and December 2002 for demographic characteristics, laboratory findings, and presenting signs and symptoms.

RESULTS

The most common presentations were elevated serum creatinine in 74 patients, fever in 71, thrombocytopenia in 43, nausea in 32, vomiting in 25, elevated alkaline phosphatase in 24, leukocytosis in 22, and leukopenia in 21. Tissue involvement was relatively rare, but six patients had pneumonia, two had conjunctivitis, and one had vascular dermatitis. Four percent of the patients had received intravenous ganciclovir prophylaxis, and 7% had received oral ganciclovir prophylaxis. Fever was associated with number of hospitalizations (P = .006), elevated creatinine (P = .006), nausea (P = .017), vomiting (P = .031), and previous posttransplantation infections (P < .001). All the patients with conjunctivitis, pneumonia, pulmonary symptoms, and abnormal heart sounds and most of those with arthralgia, nausea, and vomiting were febrile during their CMV disease course.

CONCLUSION

Our findings showed that leukocytosis should be considered as much as leukopenia when CMV disease is suspected. CMV-induced pneumonia is not common in renal transplant recipients compared to other organ transplant recipients. CMV invasion to other tissues is also rare. Finally, fever is a common symptom and important in assessing the severity and prognosis of the disease.

Pregnancy in Kidney Transplant Recipients

PURPOSE

Our aim was to investigate kidney allograft, obstetric, and maternal outcomes in pregnant women undergoing kidney transplantation in our center.

METHODS

Retrospective data on 74 pregnancies in 60 patients were reviewed and completed through phone interviews were compared with information on a control group of female kidney recipients.

RESULTS

Mean age of patients at transplantation was 26.55 +/- 4.72 years and the median interval between transplantation and pregnancy was 27.5 months. Gestational period was 8 months. Live birth was the outcome in 43.2% of pregnancies; 9.5% led to still birth, 24.3% were aborted, and obstetrical data of the remaining were unavailable. Among the 11 patients who became pregnant within 12 months after transplantation, we observed seven live births and four abortions. None of pregnancies that were accompanied by acute rejection episodes (ARE) were successful. Twenty-six patients experienced at least one ARE versus 23 patients of the control group (P = NS). However, the first ARE occurred later in the pregnant group (P = .028). Chronic rejection and graft loss were seen in 24 and 18 study group cases and 17 and 17 control cases, respectively (P = NS). One-, 3-, 5-, and 10-year graft survivals were 100%, 96.5%, 94.5%, and 77.1% in the pregnant group versus 93.2%, 85.7%, 81%, and 64.7% in the control group, respectively (P = .07).

CONCLUSION

Pregnancy in kidney recipients seems to be safe for kidney allograft recipients even within the first year posttransplant. Nonetheless, the outcomes of pregnancy in this group of patients is not always favorable, especially when rejection occurs simultaneously.

A Randomized Prospective Trial of Oral Versus Intravenous Ganciclovir for Prophylaxis of Cytomegalovirus Infection and Disease in High-Risk Kidney Recipients

PURPOSE

This study was designed to compare the efficacy and safety of oral versus intravenous ganciclovir in high-risk kidney recipients.

METHODS

Thirty-four, cytomegalovirus (CMV) seropositive recipients of kidneys from seropositive donors who had undergone antilymphocytic immunosuppressive therapy were assigned randomly to oral (1000 mg, three times a day, 12 weeks) versus intravenous (5 mg/kg, 2 weeks) ganciclovir prophylaxis. Follow-up was performed for 12 months. The patients were evaluated for clinical and laboratory outcomes regarding CMV serostatus, CMV disease, graft outcome, and ganciclovir side effects.

RESULTS

Sixteen patients in the oral group and 14 in the intravenous group completed the study. CMV infection occurred in 6 (37.5%) and 5 (35.7%) cases in the oral and intravenous groups, respectively (P = NS). The mean interval between prophylaxis initiation and the first positive CMV Ag result was 3 +/- 2.19 months, with no significant difference between the two groups. Only two patients in the intravenous group experienced CMV diseases, which were not tissue-invasive. Acute rejection episodes were observed in nine out of 30 recipients, but it did not show any association with the prophylaxis regimen or CMV serostatus. The patients tolerated oral ganciclovir well; the compliance percent was 81.6%. No complication was reported.

CONCLUSION

Oral and intravenous ganciclovir showed no significant difference to reduce the rate of CMV infection among high-risk kidney recipients. Oral ganciclovir was also effective and safe for the prevention of CMV disease. Moreover, it seems that CMV infection was not associated with acute rejection episodes.

Potential Risk Factors for Hypersensitization Reflected by Panel-Reactive Antibodies in Dialysis Patients

INTRODUCTION

The panel-reactive antibody (PRA) test has been considered to be a routine index of sensitization to human leukocyte antigens (HLA) in kidney transplant candidates. This study investigated the effect of potential risk factors and the time of blood sampling on PRA tests.

METHODS

A total of 98 patients at two dialysis centers in Tehran were tested for PRA levels before and after dialysis sessions. We evaluated their history of potential sensitizing events and patient interviews for their association with PRA levels. Also we compared PRA levels obtained before and after dialysis.

RESULTS

The mean age of the patients was 58.33 +/- 15.85 years. Only age and kidney transplantation history were correlated with PRA levels (r = .246, P = .014 and P = .0001, respectively). Logistic regression analysis revealed an association between age and PRA level (P = .037). Transplantation history was weakly correlated with PRA level (P = .076). History of pregnancy and transfusion, dialysis duration, gender, donor relation, and kidney allograft duration were not associated with PRA. PRA before dialysis sessions was significantly lower than that after dialysis (P = .0003). However, no difference was seen when divided into groups of negative/positive (PRA < 10% as negative) and high/low (PRA < 60% as low).

CONCLUSION

Many factors expose patients to HLA as sensitizing factors. However, it seems that PRA level is not always predictable by such conditions. Furthermore, dialysis as a confounding procedure impacts PRA results; thus, when to obtain a blood sample is a crucial question.

Spinal cord stimulation for axial low back pain: a prospective, controlled trial comparing dual with single percutaneous electrodes

STUDY DESIGN

A prospective, controlled, clinical trial comparing single and dual percutaneous electrodes in the treatment of axial low back pain from failed back surgery syndrome.

OBJECTIVES

To clarify technical requirements and test the hypothesis that placing two linear arrays in parallel, thereby doubling the number of contacts, improves outcome.

SUMMARY OF BACKGROUND DATA

Technical improvements have enhanced outcomes of spinal cord stimulation for chronic axial low back pain. Dual, parallel electrodes reportedly improve these outcomes.

METHODS

Acting as their own controls, 20 patients who passed screening with single, 4-contact electrodes received permanent dual, 4-contact electrodes with 7- or 10-mm intercontact distances at the same vertebral level(s). We quantified and compared the technical and clinical results of the single and dual electrodes, adjusting stimulation parameters to specific psychophysical thresholds.

RESULTS

Single electrodes provided significant (P < 0.01) advantages in patient- and computer-calculated ratings of pain coverage by paresthesias and in the scaled amplitude necessary to cover the low back, compared with dual 7-mm electrodes. Slight advantages without statistical significance were observed for the single over the dual 10-mm electrodes. Amplitude requirements were significantly lower for the single electrode than for either dual electrode. At long-term follow-up, 53% of patients met the criteria for clinical success.

CONCLUSIONS

While we observed disadvantages for dual electrodes in treating axial low back pain, we achieved technical success with single or dual electrodes in most patients and maintained this success clinically with dual electrodes in 53%.

Mandibular pyogranulomatous osteomyelitis in a Sannen goat

Mandibular pyogranulomatous osteomyelitis was diagnosed in a female Sannen goat. The doe presented for difficulty prehending and chewing food. The left mandible was swollen and firm on palpation. Radiographs revealed changes consistent with osteomyelitis of the affected mandible. Arcanobacterium pyogenes was isolated from aspirates of swollen mandible. Despite antimicrobial therapy, the goat died. Histopathological findings were consistent with pyogranulomatous disease of the affected mandible. The histopathological findings were similar to those reported for actinomycosis, caused by Actinomyces bovis. Mandibular osteomyelitis is a common condition in cattle and very rare in goat.

Reversal of attenuation of cerebrovascular reactivity to hypercapnia by a nitric oxide donor after controlled cortical impact in a rat model of traumatic brain injury

OBJECT

Traumatic brain injury (TBI) attenuates the cerebral vasodilation to hypercapnia. Cortical spreading depression (CSD) also transiently reduces hypercapnic vasodilation. The authors sought to determine whether the CSD elicited by a controlled cortical impact (CCI) injury masks the true effect of TBI on hypercapnic vasodilation, and whether a nitric oxide (NO) donor can reverse the attenuation of hypercapnic vasodilation following CCI.

METHODS

Anesthetized rats underwent moderate CCI. Cerebral blood flow was monitored with laser Doppler flowmetry and the response to hypercapnia was determined for injured and sham-injured animals. The effect of the NO donor, S-nitroso-N-acetylpenicillamine (SNAP), on this response was also assessed. At an uninjured cortical site ipsilateral to the CCI, a single wave of CSD was recorded and the CO2 response at this location was significantly attenuated for up to 30 minutes (seven rats, p < 0.05). At the injured cortex, hypercapnic vasodilation continued to be attenuated for 7 hours. The cerebral vasodilation to CO2 was 37 +/- 5% in injured rats (six) compared with 84 +/- 10% in the sham-injured group (five rats, p < 0.05). After 30 minutes of topical superfusion with SNAP, hypercapnic vasodilation was restored to 74 +/- 7% (nine rats, p > 0.1 compared with that in the sham-injured group). In contrast, papaverine, an NO-independent vasodilator, failed to reverse the attenuation of the CO2 response to CCI.

CONCLUSIONS

The authors conclude that CSD elicited by CCI can mask the true effect of TBI on hypercapnic vasodilation for at least 30 minutes. Exogenous NO, but not papaverine, can reverse the attenuation of cerebrovascular reactivity to CO2 caused by TBI. This result supports the hypothesis that NO production is reduced after TBI and that the NO donor has a potential beneficial role in the clinical management of head injury.