Microsurgical treatment of cranial and spinal dural arteriovenous fistulas for acute occlusion: a single institution's experience.

OBJECTIVES: To determine the success rate of primary microsurgical treatment of both cranial and spinal dural arteriovenous fistulas (cdAVFs and sdAVFs). METHODS: Data of 40 consecutive patients (mean age, 64.5 years; range, 35-88 years) who underwent microsurgical treatment for a diagnosed cdAVF/sdAVF at a single academic institution were retrospectively obtained. General patient information, such as age on the day of surgery and sex, patient charts, admission protocols, operating reports, and discharge protocols were reviewed. Outcomes, including modified Rankin Scale (mRS) scores and the rate of complete occlusion confirmed by a postoperative angiography were analyzed. RESULTS: The overall post-treatment occlusion rate was 100% in sdAVFs and 92% in cdAVFs. The most common presentation of cdAVFs was intracerebral hemorrhage (67%), followed by headache (53%) and vertigo (33%). The main symptoms of sdAVFs were sensory deficits, paresis, gait abnormalities, and incontinence. Additional endovascular treatment after primary surgery was needed in seven (47%) patients with cdAVF and one patient (4%) with sdAVF. All sdAVFs were classified as Cognard grade V, while six (40%) cdAVFs were Cognard grade III, eight (54%) were grade IV and one (6%) was grade V. Complications included cerebrospinal fluid (CSF) fistulas, CSF circulation disorders, meningitis, and epidural and intracerebral hemorrhages. Furthermore, sdAVF showed higher rates of clinical improvement than cdAVF (56% vs. 47%). DISCUSSION: Microsurgery resulted in complete occlusion in most cases of sdAVFs. However, additional endovascular treatment was necessary in nearly 50% of patients with cdAVF. Therefore, combined treatment in cranial cdAVF seems to be the desired strategy.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients.

INTRODUCTION: The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients. METHODS: A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05. RESULTS: 449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05). CONCLUSION: In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial.

PURPOSE: Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. METHODS: We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%). RESULTS: Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up. CONCLUSIONS: This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Enhanced photoinduced chi((2)) in gamma-ray-irradiated bulk glass.

Gamma-ray-irradiated light-flint silicate bulk glass (Schott Glass LF5), which contains a large amount of lead oxide, displays enhanced photoinduced quasi-phase-matched second-harmonic generation (PSHG), whereas nonirradiated glass under the same experimental conditions does not generate this nonlinear effect. The dependence of the efficiency of PSHG on the amount of gamma radiation (up to 530 krad) is experimentally studied, as is the role of thermal recovery (bleaching) of the color centers as a result of seeding with the second harmonic. The effect of long-term fading is studied with a sample that was irradiated 8 years ago. Gamma irradiation of boron-crown silicate glass (BK7) does not show this enhancement.

The face of AIDS: Effects of physical attractiveness and target gender on inferred mode of HIV infection.

We examined the effects of physical attractiveness on the assumed mode of HIV acquisition. 176 students read a description of an HIV-positive target whose photograph was placed above the description. A 2 (target gender) by 2 (attractive or unattractive target) factorial design was used. Unattractive targets were perceived as more likely to have acquired HIV through homosexual relationships. Further, men were perceived as more likely than women to have acquired HIV homosexually. Attractiveness did not bias health-care allocations regarding the infected target.

Detection of adenovirus in patient specimens by indirect immune electron microscopy.

Immune electron microscopic procedures for the detection of adenovirus type 7 directly in throat swab specimens from patients are described. Nineteen of 25 throat swab samples, known to be positive for adenovirus type 7 by isolation of virus from tissue culture, were shown to contain aggregates of adenovirions coated with antibody. Sensitivity tests of the immune electron microscopic method showed that as few as 16 to 32 tissue culture infective doses of virus could be detected by the direct immune electron microscopic technique. It was also demonstrated that aggregation of virus-antibody complexes could be further enhanced by use of anti-immunoglobulin G sera (indirect immune electron microscopic procedures). These results demonstrate that examination of patient specimen by immune electron microscopic procedures is a feasible and rapid method for adenovirus detection and suggest that it could be applied as a routine laboratory procedure for the diagnosis of other virus infections.

Visualization by immune electron microscopy of viruses associated with acute respiratory disease.

A sensitive and rapid method for detecting adenovirus and influenza viruses has been demonstrated by using both the direct and indirect immune electron microscopy technique. The indirect method was from 4 to over 32 times more sensitive than the direct method. The technique appears to have the sensitivity approaching tissue culture methods, but is much more rapid, requires less laboratory support personnel and space, and should lend itself to detection of noncytologic agents. These data suggest a new role for the electron microscope in diagnostic virology.