Lifestyle management and brain MRI metrics in female Australian adults living with multiple sclerosis: a feasibility and acceptability study.

BACKGROUND: Limited studies of multiple sclerosis (MS) exist whereby magnetic resonance imaging (MRI) of the brain with consistent imaging protocols occurs at the same time points as collection of healthy lifestyle measures. The aim of this study was to test the feasibility, acceptability and preliminary efficacy of acquiring MRI data as an objective, diagnostic and prognostic marker of MS, at the same time point as brain-healthy lifestyle measures including diet. METHODS: Participants living with relapsing remitting MS partook in one structural MRI scanning session of the brain, completed two online 24-hour dietary recalls and demographic and self-reported lifestyle questionnaires (e.g. self-reported disability, comorbidities, physical activity, smoking status, body mass index (BMI), stress). Measures of central tenancy and level of dispersion were calculated for feasibility and acceptability of the research protocols. Lesion count was determined by one radiologist and volumetric analyses by a data analysis pipeline based on FreeSurfer software suite. Correlations between white matter lesion count, whole brain volume analyses and lifestyle measures were assessed using Spearman's rank-order correlation coefficient. RESULTS: Thirteen female participants were included in the study: eligibility rate 90.6% (29/32), recruitment rate 46.9% (15/32) and compliance rate 87% (13/15). The mean time to complete all required tasks, including MRI acquisition was 115.86 minutes ( ± 23.04), over 4 days. Conversion to usual dietary intake was limited by the small sample. There was one strong, negative correlation between BMI and brain volume (rs = -0.643, p = 0.018) and one strong, positive correlation between physical activity and brain volume (rs = 0.670, p = 0.012) that were both statistically significant. CONCLUSIONS: Acquiring MRI brain scans at the same time point as lifestyle profiles in adults with MS is both feasible and accepted among adult females living with MS. Quantification of volumetric MRI data support further investigations using semi-automated pipelines among people living with MS, with pre-processing steps identified to increase automated feasibility. This protocol may be used to determine relationships between elements of a brain-healthy lifestyle, including dietary intake, and measures of disease burden and brain health, as assessed by T1-weighted and T2-weighted lesion count and whole brain volume, in an adequately powered sample. TRIAL REGISTRATION: The study protocol was retrospectively registered in the Australia New Zealand Clinical Trials Registry (ACTRN12624000296538).

Acquired Bronchobiliary Fistula in a Young Adult Patient With Sepsis: A Case Report.

Bronchobiliary fistula (BBF) is a rare, highly morbid condition that results from an abnormal connection between biliary channels and the bronchial tree. In the past, this condition has been known to be caused by untreated hydatid cysts or hepatic abscesses that can erode through the diaphragm into the pleural cavity and bronchial tree, creating fistulation. However, the condition's spectrum has changed in recent years, and BBFs have also become associated with neoplasm, iatrogenic causes, and trauma. Cases of BBF are treated differently, either with simple conservative management or invasive surgery. We present a case of a 46-year-old male initially presenting with sepsis, who was found to have a BBF. The diagnosis was made after a hepatobiliary iminodiacetic acid scan showed the flow of a tracer in the lung fields. The condition was likely due to acute cholecystitis and prior biliary instrumentation. The patient was treated successfully with percutaneous cholecystostomy tube insertion followed by elective laparoscopic cholecystectomy several weeks after hospital discharge.

Leptomeningeal Carcinomatosis: A Rare Presentation of Perforated Gastric Cancer.

Leptomeningeal carcinomatosis (LMC) or leptomeningeal metastasis is defined as metastasis to the pia mater, arachnoid, and subarachnoid space. Only very few patients with cancer have LMC. In the practice of general surgeons, this diagnosis is rarely, if ever, encountered. We present a rare case of a patient presenting to ED with worsening headaches over several months that developed acute-onset abdominal pain while being evaluated. Further workup showed free air, and the patient was taken emergently to the OR, where a perforated gastric ulcer was identified and biopsied. Pathology revealed gastric adenocarcinoma and subsequent MRI pointed to suspected LMC. Unfortunately, till today there is no effective treatment for advanced-stage gastric cancer, and aggressive intrathecal chemotherapy is only available to mitigate leptomeningeal involvement.

Practical Clinical Consensus Guidelines for the Management of Cancer Associated Anemia in Low- and Middle-Income Countries.

Purvish M. ParikhCancer-associated anemia (CAA) remains a major unmet need that compromises overall survival (OS) and quality of life (QoL). Currently, available guidelines do not take into consideration the unique challenges in low- and middle-income countries (LMIC). Our CAA patients have to battle preexisting impaired nutritional status, depleted body iron stores, financial limitations, and difficulty in having easily accessible affordable healthcare. Hence, we fulfilled the need of guidelines for LMIC. A group of subject experts were put together, given background literature, met in a face-to-face discussion, voted using Delphi process, and finally agreed on the contents of this guideline document. As many as 50% of cancer patients will have significant anemia (hemoglobin < 10 g/dL) at initial diagnosis. It is most commonly seen with gastrointestinal malignancies, head and neck cancers, and acute leukemias. The hemoglobin falls further after initiation of cancer directed therapy, due to chemotherapy itself or heightened nutritional deficiency. Its evaluation should include tests for complete blood count, red blood cell morphology, reticulocyte count, Coombs test, and levels of vitamin B12 and folic acid. Iron status should be monitored using test to measure serum iron, total iron binding capacity, transferring saturation, and serum ferritin levels. A minimum of 50% of cancer patients with anemia require iron supplements. The preferred mode of therapy is with intravenous (IV) iron using ferric carboxymaltose (FCM). Most patients respond satisfactorily to single dose of 1000 mg. It is also safe and does not require use of a test dose. Significant anemia is found in at least half of all cancer patients in India, South Asian Association for Regional Cooperation region, and other LMIC countries. Its awareness among healthcare professionals will prevent it from remaining undiagnosed (in up to 70% of all cancer patients) and adversely affecting OS and QoL. The benefits of treating them with IV iron therapy are quick replenishment of iron stores, hemoglobin returning to normal, better QoL, and avoiding risk of infections/reactions with blood transfusions. Many publications have proven the value of single-dose FCM in such clinical situations. CAA has been proven to be an independent prognostic factor that adversely affects both QoL and OS in cancer patients. Use of FCM as single IV dose of 1000 mg is safe and effective in the majority of patients with CAA.

Learning curve across 2000 thoracolumbar pedicle screw placements using O-arm navigation: technical difficulties and their solutions.

INTRODUCTION: Instrumentation using the intraoperative O-arm navigation technique appears safer than its predecessor techniques. However, only a handful of surgeons often used navigation during spinal surgeries. Too many operative glitches and unreliable navigation accuracy were the important reasons cited even by experienced surgeons for not using spinal navigation. We have studied the accuracy of pedicle screw placement during the learning curve and beyond it. We have also discussed in detail the intricacies of the technique and solutions to the difficulties encountered using spinal navigation. MATERIALS AND METHODS: A total of 2000 thoracolumbar pedicle screws have been placed in the 324 spine surgeries meeting the inclusion and exclusion criteria included in this retrospective study. We have divided 2000 pedicle screw placements into consecutive groups of 200 each. We have compared these groups for the accuracy of screw placement with the surgeon's experience. RESULTS: The accuracy of pedicle screw placement using the "in-versus-out" grading system in group 1 was 85.5% which significantly increased in group 2 to 93.5% (p-value: 0.0099), and thereafter, there was a nonsignificant increase in subsequent groups with the graph achieving the shape of a plateau. CONCLUSION: Surgeons should learn the correct principles of the technique of O-arm navigation to prevent the loss of accuracy and place pedicle screws with high accuracy. There is a learning curve of around 30-35 surgeries or 200 pedicle screw placements to acclimatize with the technique of O-arm navigation and learn its principles.

Use of chitosan wound dressing for the treatment of surgical site infection: a case report.

Surgical site infections (SSIs) are treated using topical antiseptics and systemic antibiotics, but some cases are unresponsive to such regimens. This case study reports the effective healing of an SSI by a chitosan wound dressing (MaxioCel; Axio Biosolutions Private Limited, India) in a 63-year-old female patient. The patient presented with an infected, hard-to-heal wound in the abdominal region, developed after a hernia surgery, and was initially treated with standard procedures. However, due to the continuous progression of infection, a highly absorbent, bioactive microfibre dressing was selected for the treatment and was continued for two months with alternate-day dressing changes. After 60 days of treatment, wound healing was observed, along with remission from the infection, as well as reduction in exudate level and pain. The use of chitosan wound dressing in management of hard-to-heal infected wounds provides efficient remission of SSI and a faster healing rate.

Quantifying the Prognostic Value of Preoperative Surgeon Intuition: Comparing Surgeon Intuition and Clinical Risk Prediction as Derived from the American College of Surgeons NSQIP Risk Calculator.

BACKGROUND: Surgical risk prediction models traditionally use patient attributes and measures of physiology to generate predictions about postoperative outcomes. However, the surgeon's assessment of the patient may be a valuable predictor, given the surgeon's ability to detect and incorporate factors that existing models cannot capture. We compare the predictive utility of surgeon intuition and a risk calculator derived from the American College of Surgeons (ACS) NSQIP. STUDY DESIGN: From January 10, 2021 to January 9, 2022, surgeons were surveyed immediately before performing surgery to assess their perception of a patient's risk of developing any postoperative complication. Clinical data were abstracted from ACS NSQIP. Both sources of data were independently used to build models to predict the likelihood of a patient experiencing any 30-day postoperative complication as defined by ACS NSQIP. RESULTS: Preoperative surgeon assessment was obtained for 216 patients. NSQIP data were available for 9,182 patients who underwent general surgery (January 1, 2017 to January 9, 2022). A binomial regression model trained on clinical data alone had an area under the receiver operating characteristic curve (AUC) of 0.83 (95% CI 0.80 to 0.85) in predicting any complication. A model trained on only preoperative surgeon intuition had an AUC of 0.70 (95% CI 0.63 to 0.78). A model trained on surgeon intuition and a subset of clinical predictors had an AUC of 0.83 (95% CI 0.77 to 0.89). CONCLUSIONS: Preoperative surgeon intuition alone is an independent predictor of patient outcomes; however, a risk calculator derived from ACS NSQIP is a more robust predictor of postoperative complication. Combining intuition and clinical data did not strengthen prediction.

Osteochondroma as an Unusual Cause of Popliteal Artery Pseudoaneurysm and Occlusion.

Osteochondromas are the most common benign bony tumour, usually occurring in the 2nd/3rd decade of life and generally asymptomatic. However, there have been reports of bony tumours causing arterial vascular injuries via erosion into vessel walls. We present a case of a 16-year-old M with no significant past medical history who presented with acute-on-chronic Right Lower Extremity (RLE) pain and numbness who was found to have a popliteal artery pseudoaneurysm and occlusion. We will discuss our initial work up, management, outcomes and follow up and compared our results with an English language literature search for comparable cases.

Perception, magnitude, and implications of cancer-related fatigue in breast cancer survivors: Study from a developing country.

BACKGROUND: We have analyzed perceptions, magnitude, interventions adopted, and overall implications of cancer-related fatigue (CRF) in breast cancer survivors (BCSs). METHODOLOGY: BCSs who attended follow-up clinic at our institute between January and June 2018 were asked to fill a questionnaire focused on assessing an individual's perception, severity, potential causes, implications on quality of life, and measures taken to deal with CRF. RESULTS: Sixty-five patients were included. Fifty-four (83%) had undergone surgery, 59 (91%) chemotherapy, 43 (66%) radiation therapy, and 36 (55%) hormonal/targeted therapy. Sixty-two (95%) patients experienced any grade CRF. Fifty-five (85%) patients experienced moderate to severe CRF affecting work (58%) and activities of daily living (27%). CRF was perceived as generalized weakness by 54 (83%) patients, diminished concentration/attention span by 24 (37%) patients, decreased motivation and interest in usual activities by 29 (45%) patients, and emotional labiality by 16 (25%) patients. Fifty-six patients (86%) believed that fatigue was due to the effect of cancer treatment on the body, while only 8 (12%) attributed it to underlying cancer. CRF had negative impact on mood, daily activities, interpersonal relationships, and professional work in 40 (62%), 39 (60%), 13 (20%), and 10 (15%) patients, respectively. Measures taken to overcome CRF were increased physical exercise, psychosocial interventions, mind-body interventions, and pharmacological interventions in 32 (49%), 8 (12%), 28 (43), and 17 (26%) patients, respectively. Thirty-nine (60%) patients reported persistence of CRF after completion of treatment while it took up to 6 months, 6-12 months, and more than 12 months for resolution of CRF in 13, 10, and 3 patients, respectively. CONCLUSION: Development and persistence of CRF remains a major health concern, and current interventions are not able to mitigate this problem. Further research in this field is warranted.

Addition of docetaxel or abiraterone to androgen deprivation therapy in metastatic hormone-sensitive prostate cancer in Indian population.

BACKGROUND: The addition of docetaxel or abiraterone to androgen deprivation therapy (ADT) achieves superior survival outcomes in metastatic hormone-sensitive prostate cancer (mHSPC) in predominantly Western population. We sought to evaluate the treatment outcomes of adding docetaxel or abiraterone to ADT in Indian population. METHODS: We reviewed the medical records of ninety patients with newly diagnosed mHSPC who received treatment between January 2015 and June 2018. Patients received ADT alone or ADT + docetaxel or ADT + abiraterone as initial treatment. Monthly clinical evaluation and prostate-specific antigen (PSA) measurement were done. Outcome measures analyzed included PSA decline <90%, serological complete response (sCR) (PSA < 0.2 ng/ml), and progression to CRPC. Outcome variable was compared using Fisher's exact test. RESULTS: Patients received ADT alone (n = 37) or ADT + docetaxel (n = 31) or ADT + abiraterone (n = 22). The median age was 67.5 years (range, 41-87 years) and the median PSA was 88.5 ng/ml (range, 1.12-4000). PSA decline <90% was seen in 22 (73%), 24 (86%), and 17 (94%) patients in the ADT alone, ADT + docetaxel, and ADT + abiraterone groups. sCR was achieved in 5 (17%), 10 (36%), and 9 (50%) patients in the ADT alone, ADT + docetaxel, and ADT + abiraterone groups. Progression to CRPC was observed in 18 (60%), 11 (39%), and 2 (11%) patients in the ADT alone, ADT + docetaxel, and ADT + abiraterone groups. CONCLUSION: The addition of docetaxel or abiraterone to ADT achieves a deeper serological response and reduces progression to CRPC compared to ADT alone in mHSPC patients of Indian origin. Longer follow-up is required to comment on overall survival and also to determine which combination (ADT + docetaxel or ADT + abiraterone) is superior to others, if at all.

High-power solid-state amplifier for superconducting radio frequency cavity test facility.

A horizontal test facility is set up at the Raja Ramanna Centre for Advanced Technology to test the superconducting radio frequency dressed cavities. Along with the cryomodule, control instrumentation, and the power coupler, this facility incorporates a high-power solid-state amplifier for establishing the desired cavity voltage gradient during the testing. This article describes the design, construction, rigorous testing, and measured results of this high-power solid-state radio frequency amplifier and its constituent components. Its maximum output power is 36 kW (average) at the operating frequency of 650 MHz. Its main features are its modular and scalable design with in-house developed constituent components. These components include 500 W, 20 dB gain modules, novel two-tier radial dividers, combiners, power sensors, and aperture-coupled directional couplers. Their excellent reprise performance for the multiple quantities confirms the design methodology presented here. The measured wall plug efficiency of this 36 kW amplifier is 43.6%, and its power gain is 86 dB. The designed radial combiner is highly efficient (power-combining efficiency of 98.4%), and the directional coupler exhibits a very low loss (insertion loss of 0.05 dB).

Acute Upper Gastrointestinal Bleeding in Hexagenerians or Older (≥60 Years) Versus Younger (<60 Years) Patients: Clinico-Endoscopic Profile and Outcome.

Background and aims Acute upper gastrointestinal (UGI) bleeding is one of the serious and potentially life-threatening medical emergencies, causing significant mortality and morbidity. This study aimed to evaluate the clinico-endoscopic profile and outcome among patients aged <60 years who presented for UGI bleeding compared to those aged ≥60 years. Methods This prospective observational study was conducted among 194 patients who presented with symptoms or signs of UGI bleed. All patients were divided into two groups, group A (age <60 years), and group B (age ≥60 years). UGI endoscopy was performed using Olympus N19 Endoscope. Rockall scoring (RS) system and Glasgow Blatchford score (GBS) were used to predict the prognosis and re-bleeding. Results Of the total, group A included 150 (77.31%) patients and group B 44 (22.69%) patients. The most common presentation was hematemesis and melena in both groups, whilst isolated hematochezia was more common in group A (6.67%, vs. 2.27%, p>0.05). The main cause of bleeding was a variceal bleed in both groups, but it was significantly higher in group A patients (p<0.05). Elderly patients had a significantly higher number of peptic ulcer and malignancy-related bleed (p<0.05). Group A patients had a significantly higher proportion of patients with tachycardia (45.33%, vs. 27.27%, p<0.05), shock (43.33% vs. 13.63%, p<0.05), pallor (76.66% vs. 56.81%, p<0.05), and blood transfusion requirement (64% vs. 45.45%, p<0.05) as compared to group B. Thirty days re-bleeding and mortality rate were similar in both the groups. RS in both groups was 5.02±2.12 vs. 5.98±1.91, p>0.05. GBS was 11.65±4.61 vs. 10.68±4.65, p>0.05. Mortality was significantly higher in patients with RS ≥6 and GBS ≥10. Conclusion This study concluded variceal bleeding as a predominant cause of UGI bleed in both age groups, and it was significantly higher in younger. Interestingly, younger patients were more hemodynamically unstable, probably due to the presence of more severe anemia, shock, and hematochezia. The presence of multiple co-morbidities in both the group kept the 30 days mortality and re-bleed rates similar.

Overall survival in stage IV EGFR mutation­positive NSCLC: Comparing first­, second­ and third­generation EGFR­TKIs (Review).

A substantial (40­60%) proportion of patients with non­small cell lung carcinoma (NSCLC) have epidermal growth factor receptor (EGFR) mutations, a crucial therapeutic target in NSCLC. Treatment strategies for patients with advanced­stage NSCLC have markedly changed, from the empirical use of cytotoxic agents to targeted regimens. EGFR tyrosine kinase inhibitors (TKIs), the first­line therapy for advanced NSCLC, are reported to be the most effective. Although progression­free survival (PFS) and objective response rates have long been used as endpoints, meeting these endpoints may not necessarily coincide with an increase in overall survival (OS) among patients with advanced lung cancer. Recently, the FLAURA study with the third­generation, irreversible, oral EGFR­TKI, osimertinib, demonstrated an extended median OS by 6.8 months compared with standard EGFR­TKIs, with a 20% reduction in the risk of mortality [osimertinib, 38.6; EGFR­TKIs, 31.8; hazard ratio (HR), 0.80; 95% confidence interval (CI), 0.641­0.997; P=0.046]; this was in addition to meeting the primary endpoint of clinically and statistically significant PFS. Osimertinib was also shown to lead to a statistically significant reduction in the risk of central nervous system disease progression (HR, 0.48; 95% CI, 0.26­0.86; P=0.014). Notably, 28% of patients remained on osimertinib treatment for 3 years, considerably longer than those in the comparator group (9%). The duration of first subsequent treatment with osimertinib was 25.5 months compared with 13.7 months with standard EGFR­TKIs (HR, 0.478; 95% CI, 0.393­0.581; P<0.0001). Thus, the long­term OS benefit with first­line osimertinib highlights a promising option in the management of stage IV NSCLC. The present narrative review compares the OS benefit of first­, second­ and third­generation EGFR­TKIs for patients with stage IV EGFR mutation­positive NSCLC and discusses their role in disease management.

Perioperative and Long-term Results of Zenith Fenestrated Aortic Repair in Women.

BACKGROUND: Inferior perioperative outcomes for women receiving major vascular surgery are well established in the literature in multiple arterial distributions. Therefore, this study was completed to determine the perioperative and durability results associated with women undergoing complex aortic reconstruction using the Zenith Fenestrated platform (ZFEN; Cook Medical, Bloomington, IN). METHODS: A retrospective review of a fenestrated endovascular aortic repair (FEVAR) database capturing all ZFENs performed at our institution between October 2012 and March 2019 was completed. Preoperative, intraoperative, perioperative, and follow-up outcomes were tabulated for females and compared with their male counterparts. RESULTS: Within our study period, 136 total ZFEN procedures were performed; of which, 20 devices (14.7%) were implanted in women. Intraoperatively, we observed a higher rate of estimated blood loss (660.0 mL vs. 311.6 mL, P < 0.01) and resultant need for transfusion (1.4 vs. 0.3 units, P < 0.01) in women despite a similar frequency of brachial (5.0% vs. 7.8%, P > 0.99) and femoral artery cutdowns (55.0% vs. 49.1%, P = 0.81). Operative (295.7 min vs. 215.7 mins, P < 0.01) and fluoroscopy (84.3 vs. 58.7 min, P < 0.01) times were also significantly higher in females than those in their male counterparts. In the perioperative (30-day) period, we observed significantly longer length of stay (5.6 days vs. 3.3 days, P = 0.03) and continued need for transfusion (50% vs. 9.5%, P < 0.01) in women. Statistical trends favoring men were also noted with respect to all-cause mortality, reintervention, visceral stent thrombosis, renal failure, acute kidney injury, and respiratory failure. After a mean follow-up of nearly 2 years, we found no differences in late all-cause or aneurysm-related mortality, major adverse cardiovascular events, or need for reinterventions. CONCLUSIONS: The implantation of ZFEN in females is significantly more difficult than that in their male counterparts and may result in increased perioperative, but not necessarily long-term, complications.

Endovascular Therapy for Spontaneous Ilio-Iliac Arteriovenous Fistula Due To Iliac Artery Aneurysm Rupture With Multi-Organ Dysfunction.

Iliac artery aneurysms can rarely present with rupture into adjacent iliac vein resulting in arteriovenous fistula leading to acute cardiac failure or multi-organ failure. End-organ damage can be reversed with timely diagnosis and intervention. Endovascular therapy is an attractive option to treat this pathology besides allowing for a quick recovery and mitigating the risk of mortality associated with open surgical treatment options. We report treatment of this pathology with Endovascular repair with preservation of ipsilateral hypogastric artery flow using an iliac branch graft device. The postoperative course was complicated by type 3 endoleak due to the separation of components between iliac branch graft and aortic stent graft with resultant recurrence of the fistula. Additional endovascular techniques, including placement of a venous stent and stent grafts to bridge the components, was used to treat the endoleak. We present this report due to the unique nature of the recurrent arteriovenous fistula, technical complexity, and resultant multi-organ dysfunction.

Perioperative and 1-year transcarotid revascularization outcomes in symptomatic patients.

OBJECTIVE: Previously published results of carotid revascularization with both transfemoral stenting and endarterectomy have demonstrated inferior perioperative stroke and death outcomes in neurologically symptomatic patients compared with those without symptoms. This study was completed to establish the real-world, symptom-based perioperative and follow-up outcomes for transcarotid artery revascularization (TCAR). METHODS: An institutional retrospective review of all TCARs performed outside of clinical trial regulations from 2016 to 2019 was completed. Eligible patients were classified as symptomatic or not based on a history of a unilateral neurologic deficit attributable to an extracranial carotid artery lesion within the previous 180 days. Univariate analysis consisting of Fisher's exact and Student t-tests, as appropriate, were performed between cohorts. Kaplan-Meier analysis was completed to estimate the stroke-free survival at 1 year postoperatively. RESULTS: Within the investigational period, 167 patients (85 symptomatic) qualified for study inclusion. Baseline demographics were roughly equivalent, although symptomatic patients were more likely to be female (28.0% vs 9.4%; P < .01). Procedures in symptomatic patients were associated with higher estimated blood loss (41 mL vs 58 mL; P = .04) and operative time (67 minutes vs 75 minutes; P = .06). We did not find an increased incidence of macroscopic debris in the filter of symptomatic patients after stent deployment. For symptomatic patients, we observed a perioperative (30-day) ipsilateral stroke risk of 1.2% (vs 2.4% in asymptomatic patients; P > .99), a myocardial infarction risk of 0% (vs 0%; P > .99), and a mortality risk of 4.9% (vs 0%; P = .06). Most deaths occurred after procedure-related discharge; as such, in-hospital (from index TCAR) mortality in symptomatic patients was 1.2%. The four perioperative deaths observed in our population were secondary to hemorrhagic stroke, acute on chronic congestive heart failure (n = 2), and unknown causes in the last patient. At 1 year after the procedure, 114 patients (54 symptomatic) had available data. In addition to the perioperative risks, in symptomatic patients we observed a rate of reintervention of 0% (vs 0%; P > .99), ipsilateral stroke of 3.7% (vs 0%; P = .22), >50% in-stent restenosis of 1.9% (vs 0%; P = .47), stent thrombosis of 3.7% (vs 0%; P = .22), and all-cause mortality of 13.0% (vs 10.0%; P = .77). Last, no difference was noted with respect to the 1-year stroke-free survival (P = .17) by Kaplan-Meier estimates. CONCLUSIONS: In this institutional series of patients undergoing TCAR, we found that symptomatic patients have a similar perioperative risk of stroke and myocardial infarction as asymptomatic patients. However, we did observe a strong statistical trend suggesting a higher mortality risk in symptomatic patients. There was no difference between cohorts with respect to 1-year stroke-free survival.

Subthalamic stimulation for cervical dystonia.

The globus pallidus internus (GPi) has been the primary target for deep brain stimulation (DBS) to treat severe medication-refractory dystonia. Some patients with primary cervical dystonia do not respond adequately to GPi stimulation. Subthalamic nucleus (STN) DBS may provide an alternative choice for treating this dystonia. In this study, we analysed the effect of bilateral STN DBS on two patients of medically refractory primary cervical dystonia. The severity of the dystonia was measured using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) preoperatively, and 1, 3, 6 and 12 months postoperatively and yearly follow-up was performed. Any change in mental status was recorded using the Mini-Mental State Examination (MMSE) score. Surgery was performed using the Leksell stereotactic system and by fusing CT scan and MR images with neuronavigation and microelectrode recording. Both patients were followed for more than 3 years. STN DBS was well-tolerated by both patients with no adverse effects. The benefit seems to be immediate. The first patient showed 74% improvement, and the second patient showed 84.3% improvement in the overall TWSTRS score. No mental deterioration was observed in either of the cases, as the MMSE score remained unchanged in both patients. A prior bilateral pallidal lesion in the first case did not adversely affect the outcome. This study showed that bilateral STN DBS results in a very significant improvement in cervical dystonia with no mental worsening and suggests that STN DBS may be an alternative to GPi DBS for treating primary cervical dystonia.

Wandering paravertebral catheter detected during thoracoscopy.

We report a case of intrapleural migration of paravertebral catheter inserted under ultrasound guidance, detected during video assisted thoracoscopic surgery.