Showing papers by "Bethesda Hospital published in 2009"
TL;DR: Evidence is found at level III leading to recommendations at grade B, that sestamibi scintigraphy is a recommended first test, but that US by an experienced investigator may be an alternative.
Abstract: Imaging in patients with primary hyperparathyroidism has been proven difficult. During the last decade, sestamibi scintigraphy and ultrasound (US) have been used with various success. The importance of these procedures has risen since minimal invasive parathyroid (MIP) surgery also has developed, and it is claimed that preoperative localization usually is needed before embarking on such a procedure. We have scanned the most recent literature in this matter in order to identify evidence, using commonly accepted grading, and also concluded a number of recommendations. We found evidence at level III leading to recommendations at grade B, that sestamibi scintigraphy is a recommended first test, but that US by an experienced investigator may be an alternative. MIP may be performed when both tests are concordant, and in case of only one test being positive, unilateral exploration and use of intraoperative PTH measurements are recommended. Bilateral neck exploration is used when both tests are negative. For reoperative procedures, repeat investigations are recommended, but also to use US-guided fine needle aspiration and PTH measurements as well as venous sampling. However, for reoperative procedures, the level of evidence is weaker—level IV, but recommendations still at grade B.
132 citations
TL;DR: In women, depressive symptoms are associated with several variables of the metabolic syndrome, and Elevated afternoon and evening cortisol appear to partially mediate this association.
85 citations
TL;DR: The results suggest that an opening-wedge high tibial osteotomy with locked plate fixation allows a correct valgus angle to be achieved with good short-term results.
Abstract: BACKGROUND: High tibial osteotomy has been recognized as a beneficial treatment for osteoarthritis of the medial compartment of the knee. The purpose of this prospective study was to assess the short-term results of opening-wedge high tibial osteotomies with locked plate fixation.
METHODS: From September 2002 to November 2005, fifty-one consecutive medial opening-wedge high tibial osteotomies were performed. The mean age of the patients at the time of the index operation was forty-nine years. The preoperative and postoperative factors analyzed included the grade of arthritis of the tibiofemoral compartment (the Ahlback radiographic grade), the anatomic tibiofemoral angle, patellar height, the Hospital for Special Surgery rating system score, and the Lysholm and Gillquist knee score.
RESULTS: Postoperatively, one superficial wound infection occurred. Fifty of the fifty-one osteotomies healed after an average period of 12.9 weeks (range, eight to sixteen weeks) without bone grafts. A nonunion developed in a sixty-two-year-old patient who was a cigarette smoker. The average postoperative tibiofemoral angle was 9° of valgus. Forty-nine patients were followed for a mean of fifty-two months. The average score on the Hospital for Special Surgery rating system was 86 points at the time of the most recent follow-up. The rating was excellent in twenty-eight patients (57%), good in twelve (24%), fair in four (8%), and poor in five (10%). The average score on the Lysholm and Gillquist knee-scoring scale was 83 points. According to these scores, the outcome was excellent in nine patients (18%), good in thirty-one (63%), fair in three (6%), and poor in six (12%). Four knees failed after an average of thirty-six months.
CONCLUSIONS: Our results suggest that an opening-wedge high tibial osteotomy with locked plate fixation allows a correct valgus angle to be achieved with good short-term results.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
ORIGINAL ABSTRACT CITATION: “Opening-Wedge High Tibial Osteotomy with a Locked Low-Profile Plate” (2009;91:2581-8).
75 citations
TL;DR: The new SGS diabetes education programme, focusing on the learning capabilities and the particular needs of older persons, is effective in improving metabolic control and in maintaining auto-sufficiency in geriatric patients with diabetes mellitus.
Abstract: Objectives: evaluation of the effectiveness of a new structured diabetes teaching and treatment programme (DTTP) with specific didactical approaches and topics for geriatric patients with diabetes mellitus.
Design: a prospective randomised controlled multi-centre trial.
Setting and participants: a total of 155 geriatric patients were randomly admitted to either the new DTTP SGS (n = 83) or the standard DTTP (n = 72) for insulin-treated patients with type 2 diabetes mellitus (HbA1c 8.0 ± 1.4%, age 76.2 ± 6.3 years).
Measurements: biometrical data, metabolic control, acute complications, diabetes knowledge, self-management.
Results: SGS participants showed improved levels of HbA1c 6 months after the DTTP, and less acute complications than the standard group (P<0.009). Both groups demonstrated a good capacity for diabetes self-management and improvement in diabetes knowledge after the DTTP (P<0.01).
Conclusion: the new SGS diabetes education programme, focusing on the learning capabilities and the particular needs of older persons, is effective in improving metabolic control and in maintaining auto-sufficiency in geriatric patients with diabetes mellitus.
66 citations
TL;DR: The results suggest that ‘pain exposure physical therapy’ is effective and safe for patients who are unresponsive to accepted standard therapies.
Abstract: Objective: To determine if treatment of longstanding complex regional pain syndrome type 1, focusing on functional improvement only while neglecting pain, results in clinical improvement of this syndrome.Design: Prospective description of a case series of 106 patients.Setting: Outpatient clinic for rehabilitation.Interventions: Physical therapy of the affected limb directed at a functional improvement only while neglecting the pain, was performed following an extensive explanation. Normal use of the limb between the treatments was encouraged despite pain. A maximum of five of these sessions were performed in three months.Measures: Radboud Skills Test was used to monitor functional improvement of the arms. Speed and walking distance was used as the measure of outcome for the legs.Results: The function of the affected arm or leg improved in 95 patients. Full functional recovery was experienced in 49 (46%) of them. A reduction in pain presented in 75 patients. In 23 patients functional recovery was reached d...
66 citations
TL;DR: Evidence is provided for a double dissociation between feeling emotions and autonomic responses to emotions, in response to music stimuli.
58 citations
TL;DR: The data confirm that patients with ischemic attack and stroke enrolled in randomized clinical trials are only partially representative of patients in clinical practice, and use of less strict enrollment criteria could enhance “generalizability” and result in more efficient selection of patients for randomized clinical Trials.
Abstract: Background and Purpose—Many randomized clinical trials have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of new vascular events in patients with a recent transient ischemic attack or ischemic stroke. Evidence from these trials forms the basis for national and international guidelines for the management of nearly all such patients in clinical practice. However, abundant and strict enrollment criteria may limit the validity and the applicability of results of randomized clinical trials to clinical practice. We estimated the eligibility for participation in landmark trials of antiplatelet drugs of an unselected group of patients with stroke or transient ischemic attack from a national stroke survey. Methods—Nine hundred seventy-two patients with transient ischemic attack or ischemic stroke were prospectively and consecutively enrolled in the Netherlands Stroke Survey. We applied 7 large antiplatelet trials’ enrollment criteria. Results—In total, 886 patients were discharg...
48 citations
TL;DR: Even if TAPP after radical prostatectomy is a difficult operation it can be performed efficiently and safely, however, for a definite decision regarding recurrence rate long-term results have to be waited for.
Abstract: Feasibility of laparoscopic transperitoneal inguinal hernia repair (TAPP) in primary hernias has been well established, but can the TAPP also be recommended after radical prostatectomy? Our prospectively collected patient database was reviewed from March 1996 until December 2006 in order to compare operative data and postoperative outcomes in 264 TAPPs after prostatectomy with 10,962 TAPPs because of primary hernias. Patients operated after prostatectomy were divided into two subgroups (year of surgery March 1996–July 2002 and August 2002–December 2006, with 132 TAPPs per group) to check for a possible learning curve. In the group operated after prostatectomy patients were older (70 vs. 59 years), duration of operation was longer (59 vs. 40 min) and morbidity was higher (5.7 vs. 2.8%), but recurrence rate was similar (0.8 vs. 0.7%) as was body mass index (BMI) (25 kg/m2). Subgroup analysis showed a clear learning curve with a decrease of morbidity (9.8–1.5%) and recurrence rate (1.5–0%) but similar results in operation time (60 and 58 min). Even if TAPP after radical prostatectomy is a difficult operation it can be performed efficiently and safely. However, for a definite decision regarding recurrence rate long-term results have to be waited for.
45 citations
TL;DR: The BiClamp® procedure proved superior or similar to conventional ligation, particularly with regard to intraoperative blood loss, operating time and postoperative pain, although statistical significance was not attained for postoperativePain.
Abstract: Purpose
To compare bipolar vessel sealing (BVS; BiClamp®) versus conventional suture ligation in vaginal hysterectomy.
34 citations
TL;DR: Two validated MRI methods for the non-invasive determination of the liver iron concentration are compared and it is concluded that the Kreeftenberg method shows a better inter- and intra-observer correlation and is more accurate because of the automated preselection of one of five sequences most sensitive in the estimated liverIron concentration range.
24 citations
TL;DR: A case of an 81-year-old immunocompetent man, who underwent a mastoidectomy because of unexplained, progressive otalgia in spite of a noninflamed and air-containing middle-ear space, and Histopathology yielded Aspergillus fumigatus.
Abstract: Aspergillus mastoidits and skull-base osteomyelitis are extremely rare, even in immunocompromised patients. We report a case of an 81-year-old immunocompetent man, who underwent a mastoidectomy because of unexplained, progressive otalgia in spite of a noninflamed and air-containing middle-ear space. Histopathology yielded Aspergillus fumigatus. When confronted with otitis with an unexpected clinical course a high index of suspicion is required to facilitate early diagnosis and appropriate therapy of a potential lethal Aspergillus infection, even in immunocompetent patients. This seems to be more so in older patients with an open middle-ear cavity and/or when there is facial nerve involvement.
TL;DR: Despite moderate discriminative capacity and calibration of the scoring system, the screening strategy based on thescoring system appears clinically useful and there is need for better prediction models for GDM.
16 Apr 2009
Journal Article•
TL;DR: The authors call attention to the founder mutation of the Roma population in 7 patients suffering from congenital myasthenia from 3 Roma families, where ancient typical Roma founder mutations were found.
Abstract: The authors discuss the clinical and molecular genetic aspects of genetically determined neuromuscular disorders of some Roma families living in Hungary. Among the autosomal recessively inherited spinal muscular atrophic (SMA) group, 8 Caucasian children had the typical 7-8 exonal deletions of the SMA gene, but only 2 patients belonged to the Roma population. There was no difference in the molecular genetic findings among the Caucasian and the Roma SMA patients. All of them had 7-8 exonal deletions of the SMA gene. We wanted to call attention to the founder mutation of the Roma population in 7 patients suffering from congenital myasthenia (CMS) from 3 Roma families. The 1267G deletion for CMS was detected by molecular genetic method. Clinical onset was pubertal and relatively slow progression of specific and phenotypic features for this founder mutation of acetyl-cholin receptor epsylon gene. In 2 patients (sister and brother) the sarcoglycanopathy 2C type C283Q mutation was proven in one Roma family suffering from limb-girdle muscular dystrophy (LGMD). Two out of the three facioscapular-humeral dystrophy (FSHD) Roma families carried 21.8 kb and 18.5 kb alleles in FSHD A1 gene (D4S139). In one family together with prenatal diagnosis founder mutation in FSHD A1 gene was detected, according to the autosomal dominant (AD) inheritance. In (F2) prenatal diagnosis was carried out, 18.5 kb/18.5 kb homozygosity was proven in the fetus, so the pregnancy was interrupted. In the CMS, LGMD and FSHD Roma patients ancient typical Roma founder mutations were found.
DOI•
01 Jan 2009TL;DR: Stenosis was present in 38% of cases, with stenosis iof the anterior circulation being the more common, and the most frequent risk factors were hypertension, dyslipidemia, and diabetes.
Abstract: Intracranial large artery atherosclerosis is an important cause of stroke worldwide. Previous studies have shown that it is found more commonly in Asians. However, studies of intracranial stenosis in Indonesian stroke patients have been very few in number. The aim of this cross-sectional study was to determine the frequency and risk factors of intracranial stenosis in acute ischemic stroke. The data were obtained from 234 consecutive patients in the transcranial doppler (TCD) registry. Documentation of risk factors was performed systematically and for TCD sonography TD-DOP 9000 equipment with a 2-MHz probe was used for the examination of the intracranial circulation. The criteria of middle cerebral artery (MCA) stenosis used in this study were a peak systolic velocity (PSV) >140 cm/s or mean systolic velocity (MSV) >80 cm/s. For stenosis of the posterior circulation the criteria were PSV > 90 cm/s or MSV >60 cm/s. The data were obtained from 234 patients, and complete examinations were performed in 182 patients (77.7%). Ischemic stroke is the most common indication for performing TCD sonography. Stenosis was present in 38% of cases, with stenosis iof the anterior circulation being the more common. The most frequent risk factors were hypertension, dyslipidemia, and diabetes. Intracranial stenosis is common in stroke patients, in whom the risk factors are hypertension and diabetes.
TL;DR: Although IVF is often the first treatment of choice and has resulted in major advances in the management of infertility, tubal surgery has advantages, including the potential for prolonged restoration of fertility and, for some, overcoming the costs associated with IVF.
Abstract: Disease or damage of the fallopian tube accounts for 25– 35% of reported cases of infertility. A spectrum of severity of tubal disease exists from peritubal adhesions, through damaged fimbriae and distorted anatomy to tubal occlusion, hydrosalpinges and abnormal tubal mucosa. The factors responsible for tubal disease are diverse and varied and include previous surgery, endometriosis and pelvic infection. Tubal disease increases the rates of ectopic pregnancy and also miscarriage, especially in the case of hydrosalpinges. Accepted treatment for tubal infertility includes tubal surgery, expectant management (no treatment) or in vitro fertilisation (IVF). Although IVF is often the first treatment of choice and has resulted in major advances in the management of infertility, tubal surgery has advantages, including the potential for prolonged restoration of fertility and, for some, overcoming the costs associated with IVF. Furthermore, it offers an approach to patients who may have religious or cultural beliefs that prohibit IVF. It also avoids the adverse outcomes of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Importantly, avoiding IVF also means avoids other significant adverse outcomes, such as fetal anomaly and imprinting disorders.
TL;DR: The authors tested the combination of more than twofold elevated total bilirubin and alkaline phosphatase as a predictor for CBD stones, which works well in the experience.
Abstract: Dear Sir, We read with great interest the article by Yang et al. on biochemical predictors of common bile duct (CBD) stones [1], not least because we wrote a review article on the very same subject 15 years ago [2]. Obviously, the authors are to be congratulated on the enormous amount of data they have gathered on this interesting subject. Still, they have left us with some questions. First, since it is known that a combination of clinical and biochemical parameters increases the probability of CBD stones up to [90% [3], we wonder if it was specifically asked whether there were any signs of CBD obstruction (jaundice, light faeces, dark urine)? Second, since more than 7% of the patients did not undergo ultrasonography: was this not the first diagnostic imaging technique in the authors’ clinic in all cases, or were some patients asymptomatic? Third, for reasons of costs and radiation safety: why was the number of computed tomography (CT) scans so enormously high (almost one in every four patients)? This is especially interesting as the authors themselves state that this diagnostic tool is usually not recommended as the diagnostic modality of choice to predict absence or presence of CBD stones [1]. Finally, did the authors test the combination of more than twofold elevated total bilirubin and alkaline phosphatase as a predictor for CBD stones, which works well in our experience?
TL;DR: Emergency physicians should develop better methods to ensure adequate screening in the emergency department to target at risk groups and introduce interventions which are proven to be effective.
Abstract: Mild head injury is a common emergency presentation. Previously medical attention has focused on risk of injury requiring surgical intervention. The importance of long term sequelae in patients not requiring surgical intervention has now been recognised. It is not clear, however, how frequently this occurs, which patients are at risk and whether interventions improve outcome. The symptoms associated with mild traumatic brain injury have an organic basis. Some people will be helped by strategies to deal with these symptoms. Emergency physicians should develop better methods to ensure adequate screening in the emergency department to target at risk groups and introduce interventions which are proven to be effective.
TL;DR: It was shown that 3-year-old children who were exposed to valproate in utero had significantly lower IQ scores than those exposed to other antiepileptic drugs, and IQ scores were inversely correlated withValproate dose, which should not be considered as a first choice antiePileptic drug in women of childbearing potential.
Abstract: ED FROM Meador KJ, Baker GA, Browning N, et al. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Engl J Med 2009;360:1597–605. Correspondence to: Dr K J Meador, Emory University, Atlanta, GA, USA; kimford.meador@emory.edu Sources of funding: National Institute of Neurological Disorders and Stroke and United Kingdom Epilepsy Research Foundation. c Clinical impact ratings: GP/ FP/Primary care 6/7; GP/FP/Obstetrics 6/7; Paediatrics 6/7; Obstetrics 6/7; Psychiatry 6/7 Comparison of antiepileptic drugs used during pregnancy for IQ scores in children at 3 years of age* Outcome Valproate Carbamazepine Lamotrigine Phenytoin Mean difference (CI) Mean IQ (95% CI) 92 (88 to 97) 98 (95 to 102) — — 6 (0.6 to 12.0) 92 (88 to 97) — 101 (98 to 104) — 9 (3.1 to 14.6) 92 (88 to 97) — — 99 (94 to 104) 7 (0.2 to 14.0) *Data were imputed for 77 of 309 children, and analyses were adjusted for significant covariates: maternal IQ, age, and preconception use of folate; antiepileptic drug dose; and infant’s gestational age at birth. C O M M EN TA R Y B abies born to mothers with epilepsy have higher risks of congenital anomalies and developmental delay, and use of antiepileptic drugs increases risk of fetal malformations. 2 The NEAD study is following babies born to mothers with epilepsy who were taking 1 of 4 antiepileptic drugs during pregnancy. Strengths of the study include its prospective design, large sample size, and use of IQ score as a main outcome. A previous observational study found that fetal exposure to valproate was associated with increased risk of major congenital abnormality compared with exposure to other antiepileptic drugs, although that study did not evaluate cognitive effects. Meador et al showed that 3-year-old children who were exposed to valproate in utero had significantly lower IQ scores than those exposed to other antiepileptic drugs, and IQ scores were inversely correlated with valproate dose. Children’s IQ scores were significantly associated with maternal IQ scores for all drugs except valproate. The choice of which antiepileptic drugs to take during pregnancy should be based on individual factors, and physicians should discuss the risks and benefits of different antiepileptic drugs with patients. Based on the results of Meador et al, physicians should not consider valproate as a first choice antiepileptic drug in women of childbearing potential. Changing from valproate to other antiepileptic drugs should be done before conception since abrupt withdrawal or dose reduction of valproate will increase risks of harmful effects from loss of seizure control. Women with epilepsy should be told to plan their pregnancy, and discussion of risks associated with antiepileptic drugs should be part of pregnancy