Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes. METHODS: In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models. RESULTS: The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome. CONCLUSIONS: Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

Morning Surge and Peak Morning Ambulatory Blood Pressure Versus Automated Office Blood Pressure in Predicting Cardiovascular Disease.

INTRODUCTION: Automated office blood pressure (AOBP) has been recently shown to predict equally well to ambulatory blood pressure (ABP), conventional office blood pressure (OBP) and home blood pressure (HBP), cardiovascular (CV) events among hypertensives. AIM: To compare AOBP recording and ABP monitoring in order to evaluate morning blood pressure (BP) peak in predicting CV events and deaths in hypertensives. METHODS: We assessed 236 initially untreated hypertensives, examined between 2009 and 2013. The end points were CV and non-CV death and any CV event including myocardial infarction, evidence of coronary heart disease, heart failure hospitalization, severe arrhythmia, stroke, and symptomatic peripheral artery disease. We fitted proportional hazards models using the different modalities as predictors and evaluated their predictive performance using two metrics: the Akaike's Information Criterion, and Harrell's C-index. RESULTS: After a mean follow-up of 7 years, 23 subjects (39% women) had at least one CV event. In Cox regression models, systolic conventional OBP, AOBP and peak morning BP were predictive of CV events (p < 0.05). The Akaike Information Criterion showed smaller values for AOBP than peak morning BP, indicating a better performance in predicting CV events (227.2736 and 238.7413, respectively). The C-index was 0.6563 for systolic AOBP and 0.6243 for peak morning BP indicating a better predicting ability for AOBP. CONCLUSION: In initially untreated hypertensives, AOBP appears to be at least equally reliable to 24-h monitoring in the evaluation of morning BP peak in order to detect CV disease whereas the sleep-trough and preawakening morning BP surge did not indicate such an effect.

The optimal night-time home blood pressure monitoring schedule: agreement with ambulatory blood pressure and association with organ damage.

OBJECTIVE: Night-time home blood pressure (HBP) monitoring has emerged as a feasible, reliable and low-cost alternative to ambulatory blood pressure (ABP) monitoring. This study evaluated the optimal schedule of night-time HBP monitoring in terms of agreement with night-time ABP and association with preclinical target-organ damage. METHODS: Untreated hypertensive adults were evaluated with ABP (24-h) and HBP monitoring (daytime: six days, duplicate morning and evening measurements; night-time: three nights, three-hourly automated measurements/night), and determination of left ventricular mass index, common carotid intima-media thickness and urinary albumin excretion. RESULTS: A total of 94 patients with all nine night-time HBP measurements were analysed [mean age 51.8 ±â€Š11.1 (SD) years, men 57%). By averaging an increasing number of night-time systolic HBP readings, there was a consistent trend towards stronger association of night-time HBP with night-time ABP (correlation coefficients r increased from 0.69 to 0.81), and with target-organ damage indices (for left ventricular mass index r increased from 0.13 to 0.22, carotid intima-media thickness 0.12-0.25, urinary albumin excretion 0.33-0.41). However, no further improvement in the association was observed by averaging more than four to six night-time readings. The diagnostic agreement between HBP and ABP in detecting nondippers was improved by averaging more readings, with a plateau at four readings (single reading: agreement 81%, kappa 0.37; four readings: 88%, 0.49; nine readings: 84%, 0.40). CONCLUSION: A two-night HBP schedule (six readings) appears to be the minimum requirement for a reliable assessment of night-time HBP, which gives reasonable agreement with ABP and association with preclinical organ damage.

Home, automated office, and conventional office blood pressure as predictors of cardiovascular risk.

Automated office blood pressure (AOBP) has recently been shown to closely predict cardiovascular (CV) events in the elderly. Home blood pressure (HBP) has also been accepted as a valuable method in the prediction of CV disease. This study aimed to compare conventional office BP (OBP), HBP, and AOBP in order to evaluate their value in predicting CV events and deaths in hypertensives. We assessed 236 initially treatment naïve hypertensives, examined between 2009 and 2013. The end points were any CV and non-CV event including mortality, myocardial infarction, coronary heart disease, hospitalization for heart failure, severe arrhythmia, stroke, and intermittent claudication. We fitted proportional hazards models using the different modalities as predictors and evaluated their predictive performance using three metrics: time-dependent receiver operating characteristics curves, the Akaike's Information Criterion, and Harrell's C-index. After a mean follow-up of 7 years, 23 participants (39% women) had experienced ≥1 CV event. Conventional office systolic (hazard ratio [HR] per 1 mm Hg increase in BP, 1.028; 95% confidence interval [CI], 1.009-1.048), automated office systolic (HR per 1 mm Hg increase in BP, 1.031; 95% CI, 1.008-1.054), and home systolic (HR, 1.025; 95% CI, 1.003-1.047) were predictive of CV events. All systolic BP measurements were predictive after adjustment for other CV risk factors (P < .05). The predictive performance of the different modalities was similar. Conventional OBP was significantly higher than AOBP and average HBP. AOBP predicts equally well to OBP and HBP CV events. It appears to be comparable to HBP in the assessment of CV risk, and therefore, its introduction into guidelines and clinical practice as the reference method for assessing BP in the office seems reasonable after verification of these findings by randomized trials.

Night-time home versus ambulatory blood pressure in determining target organ damage.

OBJECTIVE: This study aimed to evaluate the association of night-time blood pressure (BP) assessed by home blood pressure (HBP) or ambulatory blood pressure (ABP) monitoring with preclinical target organ damage in untreated hypertension. METHODS: Untreated hypertensive study participants were evaluated with ABP monitoring (24-h) and HBP monitoring during daytime (6 days, duplicate morning and evening measurements) and night-time (automated asleep measurements, three nights, 3-hourly measurements/night). Target organ damage was assessed by echocardiographic left ventricular mass index (LVMI), common carotid intima-media thickness (cIMT), urine albumin excretion (UAE), and ankle-brachial index (ABI). RESULTS: A total of 131 study participants were analysed [mean age 52.1 ±â€Š11.9 (SD) years, BMI 29.9 ±â€Š5.3  kg/m2, men 58%, cardiovascular disease history 6.1%]. Daytime and night-time HBP were slightly higher than the respective ABP values (mean difference for systolic daytime/night-time 3.5 ±â€Š10.6/2.6 ±â€Š9.8  mmHg, P < 0.01 for both comparisons and diastolic -0.3 ±â€Š6.8/1.2 ±â€Š6.2  mmHg, P = NS/0.02, respectively). There was a strong correlation between daytime ABP and HBP (r = 0.71/0.72, systolic/diastolic), as well as between the respective night-time values (r = 0.80/0.79; all P < 0.01). Night-time ABP and HBP presented strong and comparable correlations with all the indices of preclinical target organ damage. In multivariate analyses, both LVMI (R2 = 0.26) and cIMT (R2 = 0.25) were determined by night-time systolic HBP, age and male sex; UAE (R2 = 0.28) by night-time systolic HBP and male sex; ABI (R2 = 0.20) by male sex and night-time home pulse pressure. CONCLUSION: In untreated hypertensives, night-time BP assessed by home monitoring appears to be as good as night-time ambulatory monitoring in determining preclinical target organ damage.

Automated office blood pressure is associated with urine albumin excretion in hypertensive subjects.

BACKGROUND: We aimed to investigate the association between automated office blood pressure (AOBP) readings and urine albumin excretion (UAE), and to assess if this association is as close as that between 24-h ambulatory blood pressure (ABP) and UAE. A strong association would suggest that AOBP may serve as an indicator of early renal impairment. METHODS: In a sample of 162 hypertensives, we compared AOBP with ABP measurements and their associations with UAE in two consecutive 24-h urine collections measured by an immunoturbidimetric assay. Microalbuminuria was defined as UAE of 30-300 mg/24 h. RESULTS: The age of the subjects was 53 ± 13 (mean ± s.d.) years. Twenty-two were microalbuminuric. In those, AOBP and 24-h ABP were higher than in the normoalbuminuric subjects: 152 ± 19 and 147 ± 20 vs. 138 ± 15 and 130 ± 11 mm Hg for systolic blood pressure (SBP), and 97 ± 15 and 92 ± 14 vs. 86 ± 10 and 82 ± 8 mm Hg for diastolic blood pressure (DBP) (P < 0.001). Correlations between AOBP and 24-h ABP with log-transformed urine albumin were 0.30 (P < 0.001) and 0.43 (P < 0.001) for SBP and 0.27 (P < 0.001) and 0.33 (P < 0.001) for DBP. Adjusting for age, sex, body mass index, and estimated glomerular filtration rate, both AOBP and 24-h ABP were independently associated with urine albumin (P < 0.001 for both associations). Receiver operating characteristics curve analysis showed a similar predictive ability for microalbuminuria for AOBP and for 24-h ABP (area under the curve: 0.819 (P < 0.001) for SBP, 0.836 (P < 0.001) for DBP vs. 0.830 (P < 0.001) for SBP and 0.845 (P < 0.001) for DBP). CONCLUSIONS: In this study, microalbuminuria correlated similarly with high-quality AOBP and ABP readings, further supporting the use of AOBP in the clinical setting.

Treatment of granulomatous amoebic encephalitis with voriconazole and miltefosine in an immunocompetent soldier.

A 38-year-old male immunocompetent soldier developed generalized seizures. He underwent surgical debulking and a progressive demyelinating pseudotumor was identified. Serology and molecular testing confirmed a diagnosis of granulomatous amoebic encephalitis caused by Acanthamoeba sp. in this immunocompetent male. The patient was treated with oral voriconazole and miltefosine with Acanthamoeba titers returning to control levels and serial imaging demonstrating resolution of the residual lesion.

Robotic long-distance telementoring in neurosurgery.

OBJECTIVE: To test the feasibility of long-distance telementoring in neurosurgery by providing subspecialized expertise in real time to another neurosurgeon performing a surgical procedure in a remote location. METHODS: A robotic telecollaboration system (Socrates; Computer Motion, Inc., Santa Barbara, CA) capable of controlling the movements of a robotic arm, of handling two-way video, and of audio communication as well as transmission of neuronavigational data from the remote operating room was used for the telementoring procedures. Four integrated services digital network lines with a total speed of transmission of 512 kilobytes per second provided telecommunications between a large academic center (Halifax, Nova Scotia) and a community-based center (Saint John, New Brunswick) located 400 km away. RESULTS: Long-distance telementoring was used in three craniotomies for brain tumors, a craniotomy for an arteriovenous malformation, a carotid endarterectomy, and a lumbar laminectomy. There were no surgical complications during the procedures, and all patients had uneventful outcomes. The neurosurgeons in the remote location believed that the input from the mentors was useful in all of the cases and was crucial in the removal of a mesial temporal lobe glioma and resection of an occipital arteriovenous malformation. CONCLUSION: Our initial experience with long-distance robotic-assisted telementoring in six cases indicates that telementoring is feasible, reliable, and safe. Although still in its infancy, telementoring has the potential to improve surgical care, to enhance neurosurgical training, and to have a major impact on the delivery of neurosurgical services throughout the world.