Comparative Effectiveness of Initial Treatment for Infantile Spasms in a Contemporary US Cohort

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012511
Author(s):  
Zachary M Grinspan ◽  
Kelly G Knupp ◽  
Anup D Patel ◽  
Elissa G Yozawitz ◽  
Courtney J Wusthoff ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Initial Treatment ◽  
Standard Therapy ◽  
Treatment Initiation ◽  
Infantile Spasms ◽  
Class Iii ◽  
Statistical Confidence ◽  
Oral Steroids ◽  
New Onset

Objective.Compare the effectiveness of initial treatment for infantile spasms.Methods.The National Infantile Spasms Consortium prospectively followed children with new onset infantile spasms that began at age 2-24 months at 23 US centers (2012-2018). Freedom from treatment failure at 60 days required no second treatment for infantile spasms and no clinical spasms after 30 days of treatment initiation. We managed treatment selection bias with propensity score weighting and within-center correlation with generalized estimating equations.Results.Freedom from treatment failure rates were: ACTH 88/190 (46%), oral steroids 42/95 (44%), vigabatrin 32/87 (37%), and non-standard therapy 4/51 (8%). Changing from oral steroids to ACTH was not estimated to affect response (observed 44% estimated to change to 44% [95% CI 34–54]). Changing from non-standard therapy to ACTH would improve response from 8% to 39 [17–67]%, and to oral steroids from 8% to 38 [15–68]%. There were large but not statistically significant estimated effects of changing from vigabatrin to ACTH (29% to 42 [15–75]%), vigabatrin to oral steroids (29% to 42 [28–57]%), and non-standard therapy to vigabatrin (8% to 20 [6-50]%). Among children treated with vigabatrin, those with tuberous sclerosis complex (TSC) responded more often than others (62% vs 29%; p<0.05)Conclusion.Compared to non-standard therapy, ACTH and oral steroids are superior for initial treatment of infantile spasms. The estimated effectiveness of vigabatrin is between ACTH / oral steroids and non-standard therapy, though the sample was underpowered for statistical confidence. When used, vigabatrin worked best for TSC.Classification of Evidence:This study provides Class III evidence that for children with new onset infantile spasms, ACTH or oral steroids were superior to non-standard therapies.

Severe pemphigoid gestationis responsive to intravenous immunoglobulins after initial treatment failure of combined oral steroids and cyclosporin

2021 ◽  
Vol 31 (2) ◽  
pp. 245-246
Author(s):  
Lisa Killion ◽  
Paula Beatty ◽  
Emma Tierney ◽  
Caitriona Hackett ◽  
Anne Marie Tobin ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Initial Treatment ◽  
Intravenous Immunoglobulins ◽  
Pemphigoid Gestationis ◽  
Oral Steroids

scholarly journals Optimized Treatment for Infantile Spasms: Vigabatrin versus Prednisolone versus Combination Therapy

2019 ◽  
Vol 8 (10) ◽  
pp. 1591
Author(s):  
Hahn ◽  
Park ◽  
Kang ◽  
Lee ◽  
Kim ◽  
...  
Keyword(s):  
Combination Therapy ◽  
Initial Treatment ◽  
Dose Group ◽  
Treatment Initiation ◽  
Infantile Spasms ◽  
Second Line ◽  
Long Term Outcomes ◽  
First Line ◽  
Optimized Treatment

Hormone therapies and vigabatrin are first-line agents in infantile spasms, but more than one-third of patients fail to respond to these treatments. This was a retrospective study of patients with infantile spasms who were treated between January 2005 and December 2017. We analyzed the response rates of initial treatment and second-line treatment. Responders were defined as those in whom cessation of spasms was observed for a period of at least one month, within 2 weeks of treatment initiation. Regarding the response rate to initial treatment, combination therapy of vigabatrin with prednisolone showed a significantly better response than that of vigabatrin monotherapy (55.3% vs. 39.1%, p = 0.037). Many drugs, such as clobazam, topiramate, and levetiracetam, were used as second-line agents after the failure of vigabatrin. Among these, no antiepileptic drug showed as good a response as prednisolone. For patients who used prednisolone, the proportion of responders was significantly higher in the higher-dose group (≥40 mg/day) than in the lower-dose group (66.7% vs. 12.5%, p = 0.028). Further studies of combination therapy to assess dosage protocols and long-term outcomes are needed.

scholarly journals Endoscopic Insufflation–Induced Gastric Barotrauma during Percutaneous Endoscopic Gastrostomy: A Report of Three Patients and Review of Literature

2021 ◽  
Vol 12 (02) ◽  
pp. 103-106
Author(s):  
Avnish Kumar Seth ◽  
Rinkesh Kumar Bansal
Keyword(s):  
Percutaneous Endoscopic Gastrostomy ◽  
Gastrointestinal Endoscopy ◽  
Gastroesophageal Junction ◽  
Upper Gastrointestinal Endoscopy ◽  
Proximal Stomach ◽  
Endoscopic Gastrostomy ◽  
Lesser Curvature ◽  
Upper Gastrointestinal ◽  
New Onset

Abstract Background We report three patients with endoscopic insufflation–induced gastric barotrauma (EIGB) during upper gastrointestinal endoscopy (UGIE) for percutaneous endoscopic gastrostomy (PEG). A definition and classification of EIGB is proposed. Materials and Methods Records of patients undergoing UGIE over 7 years (April 2013–March 2020) were reviewed. Patients who developed new onset of bleeding or petechial spots in proximal stomach, in an area previously documented to be normal during the same endoscopic procedure, were studied. Results New onset of bleeding or petechial spots in proximal stomach occurred in 3/286 (0.1%) patients undergoing PEG and in none of the 19,323 other UGIE procedures during the study period. All patients were men with median age 76 years (range 68–80 years), with no coagulopathy. Aspirin and apixaban were discontinued 1 week and 3 days prior to the procedure. Fresh blood was noted in the stomach at a median of 275 seconds (range 130–340) seconds after commencement of endoscopy. At retroflexion, multiple linear mucosal breaks of up to 3 cm, with oozing of blood, were noted in the proximal stomach along the lesser curvature, close to the gastroesophageal junction in two patients. In the third patient, multiple petechial spots were noticed in the fundus. The plan for PEG was abandoned and the stomach deflated by endoscopic suction. There was no subsequent hematemesis, melena, or drop in hemoglobin. One week later, repeat UGIE in the first two patients revealed multiple healing linear ulcers of 1 to 3 cm in the lesser curvature and PEG was performed. Conclusion Overinsufflation over a short duration during UGIE may lead to EIGB. Early detection is key and in the absence gastric perforation, patients can be managed conservatively.

Paediatric empyema: worsening disease severity and challenges identifying patients at increased risk of repeat intervention

2020 ◽  
Vol 105 (9) ◽  
pp. 886-890 ◽  
Author(s):  
Stuart Haggie ◽  
Hasantha Gunasekera ◽  
Chetan Pandit ◽  
Hiran Selvadurai ◽  
Paul Robinson ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Initial Treatment ◽  
Group A Streptococcus ◽  
Thoracoscopic Surgery ◽  
Tertiary Hospital ◽  
Fibrinolytic Therapy ◽  
Younger Age ◽  
Increased Risk ◽  
Group A ◽  
Single Intervention

ObjectiveEmpyema is the most common complication of pneumonia. Primary interventions include chest drainage and fibrinolytic therapy (CDF) or video-assisted thoracoscopic surgery (VATS). We describe disease trends, clinical outcomes and factors associated with reintervention.Design/setting/patientsRetrospective cohort of paediatric empyema cases requiring drainage or surgical intervention, 2011–2018, admitted to a large Australian tertiary children’s hospital.ResultsDuring the study, the incidence of empyema increased from 1.7/1000 to 7.1/1000 admissions (p<0.001). We describe 192 cases (174 CDF and 18 VATS), median age 3.0 years (IQR 1–5), mean fever duration prior to intervention 6.2 days (SD ±3.3 days) and 50 (26%) cases admitted to PICU. PICU admission increased during the study from 18% to 34% (p<0.001). Bacteraemia occurred in 23/192 (12%) cases. A pathogen was detected in 131/192 (68%); Streptococcus pneumoniae 75/192 (39%), S. aureus 25/192 (13%) and group A streptococcus 13/192 (7%). Reintervention occurred in 49/174 (28%) and 1/18 (6%) following primary CDF and VATS. Comparing repeat intervention with single intervention cases, a continued fever postintervention increased the likelihood for a repeat intervention (OR 1.3 per day febrile; 95% CI 1.2 to 1.4, p<0.0001). Younger age, prolonged fever preintervention and previous antibiotic treatment were not associated with initial treatment failure (all p>0.05).ConclusionWe report increasing incidence and severity of empyema in a large tertiary hospital. One in four patients required a repeat intervention after CDF. Neither clinical variables at presentation nor early investigations were able to predict initial treatment failure.

scholarly journals MRI evaluation of thalamic volume differentiates MS from common mimics

2017 ◽  
Vol 4 (5) ◽  
pp. e387 ◽  
Author(s):  
Andrew J. Solomon ◽  
Richard Watts ◽  
Blake E. Dewey ◽  
Daniel S. Reich
Keyword(s):  
White Matter ◽  
Three Dimensional ◽  
Assessment Tools ◽  
Class Iii ◽  
Mri Segmentation ◽  
White Matter Abnormalities ◽  
Volumetric Assessment ◽  
Study Participants ◽  
Mri Evaluation

Objective:To determine whether MRI evaluation of thalamic volume differentiates MS from other disorders that cause MRI white matter abnormalities.Methods:There were 40 study participants: 10 participants with MS without additional comorbidities for white matter abnormalities (MS − c); 10 participants with MS with additional comorbidities for white matter abnormalities (MS + c); 10 participants with migraine, MRI white matter abnormalities, and no additional comorbidities for white matter abnormalities (Mig − c); and 10 participants previously incorrectly diagnosed with MS (Misdx). T1-magnetization-prepared rapid gradient-echo and T2-weighted three-dimensional fluid attenuation inversion recovery sequences were acquired on a Phillips Achieva d-Stream 3T MRI, and scans were randomly ordered and de-identified for a blinded reviewer who performed MRI segmentation using LesionTOADS.Results:Mean normalized thalamic volume differed among the 4 cohorts (analysis of variance, p = 0.005) and was smaller in the 20 MS participants compared with the 20 non-MS participants (p < 0.001), smaller in MS − c compared with Mig − c (p = 0.03), and smaller in MS + c compared with Misdx (p = 0.006). The sensitivity and specificity were both 0.75 for diagnosis of MS with a thalamic volume <0.0077.Conclusions:MRI volumetric evaluation of the thalamus, but not other deep gray-matter structures, differentiated MS from other diseases that cause white matter abnormalities and are often mistaken for MS. Evaluation for thalamic atrophy may improve accuracy for diagnosis of MS as an adjunct to additional radiologic criteria. Thalamic volumetric assessment by MRI in larger cohorts of patients undergoing evaluation for MS is needed, along with the development of automated and easily applied volumetric assessment tools for future clinical application.Classification of evidence:This study provides Class III evidence that MRI evaluation of thalamic volume differentiates MS from other diseases that cause white matter abnormalities.

scholarly journals ANALYSIS ON THE PATTERN OF USING THE SERVICE OF REMOVABLE PARTIAL DENTURE MAKING IN A DENTAL LABORATORY IN SURABAYA

2017 ◽  
Vol 52 (4) ◽  
pp. 270
Author(s):  
Okti Setyowati ◽  
Endang Kusdarjanti
Keyword(s):  
Dental Health ◽  
Class Ii ◽  
Class I ◽  
Class Iii ◽  
Removable Partial Denture ◽  
Partial Denture ◽  
Metal Framework ◽  
Removable Denture ◽  
Class Iv

The making of removable denture is performed by a dental laboratory. To facilitate the identification, according to Kennedy classification, classes are divided onto groups, the Kennedy class I, II, III and IV. To suit with the needs of the dental laboratory tasks commonly done, priority are necessary for common cases and should to be taught to students of Dental Health Technology Diploma. In Surabaya, research of various cases of removable partial denture with the various Kennedy classifications has never been done before. This study was to analyze the pattern of service for the removable partial denture manufacture in dental laboratory at Surabaya (2011 – 2013). The research is an observatory analytic. The population is all dental laboratories located around the campus of the Faculty of Dentistry Airlangga University Surabaya. The sample was the whole population is willing to become respondents. Sampling by total sampling. The method of collecting data using secondary data from a dental laboratory in Surabaya from 2011 until 2013. The note is cases removable denture according to the classification of Kennedy that Kennedy Class I, II, III and IV. Also of note kinds of materials used to make the denture base that is heat cured acrylic resins, thermoplastic resins and metals coherent. The data is a compilation table charting the frequency until needed, then analyzed using cross tabulation. Mostly denture type is flexible type and the least is metal framework. Most cases by classification Kennedy is followed by class II class III and class II and more recently is the fourth. In conclusion, in 2011 and 2013 the manufacture of removable partial dentures according to the classification of Kennedy Class III is the most common in both the upper arch and lower jaw, followed by Class II, Class I and Class IV. In 2012 which is the highest grade III followed by class II, class IV and class I. The denture type most used is a flexible denture, followed acrylic denture and the last is the metal framework.

scholarly journals The efficacy of nonpharmacologic intervention for orthostatic hypotension associated with aging

Neurology ◽  
2018 ◽  
Vol 91 (7) ◽  
pp. e652-e656 ◽  
Author(s):  
Julia L. Newton ◽  
James Frith
Keyword(s):  
Older People ◽  
Orthostatic Hypotension ◽  
Response Rate ◽  
Cardiovascular Responses ◽  
Class Iii ◽  
Abdominal Compression ◽  
Compression Stockings ◽  
Water Drinking ◽  
Nonpharmacologic Intervention

ObjectiveTo determine the efficacy and safety of nonpharmacologic interventions for orthostatic hypotension (OH) secondary to aging.MethodsA total of 150 orthostatic challenges were performed in 25 older people (age 60–92 years) to determine cardiovascular responses to bolus water drinking, compression stockings, abdominal compression, and physical countermaneuvers. Primary outcome was response rate as assessed by proportion of participants whose systolic blood pressure (SBP) drop improved by ≥10 mm Hg.ResultsThe response rate to bolus water drinking was 56% (95% confidence interval [CI] 36.7–74.2), with standing SBP increasing by 12 mm Hg (95% CI 4–20). Physical countermaneuvers were efficacious in 44% (95% CI 25.8–63.3) but had little effect on standing SBP (+7.5 mm Hg [95% CI −1 to 16]). Abdominal compression was efficacious in 52% (95% CI 32.9–70.7) and improved standing SBP (+10 mm Hg [95% CI 2–18]). Compression stockings were the least efficacious therapy (32% [95% CI 16.1–51.4]) and had little effect on standing SBP (+6 mm Hg [95% CI −1, 13]). No intervention improved symptoms during standing. There were no adverse events.ConclusionsBolus water drinking should become the standard first-line nonpharmacologic intervention, whereas compression stockings should be disregarded in this population.Classification of evidenceThis study provides Class III evidence that for older people with OH, bolus water drinking is superior to other nonpharmacologic interventions in decreasing SBP drop.

Abstract T P47: Response to Thrombolysis in Ischemic Stroke Depends on the Presence of Initial Arterial Occlusion

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Freidrich Medlin ◽  
Michael Amiguet ◽  
Peter Vanacker ◽  
Patrik Michel
Keyword(s):  
Ischemic Stroke ◽  
Randomized Trials ◽  
Primary Outcome ◽  
Interaction Analysis ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Class Iii ◽  
Unfavourable Outcome ◽  
Stroke Registry

Objective: We aimed to assess effectiveness of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) depending on the presence or absence of cervical or intracranial arterial occlusion on acute CT angiography (CTA). Methods: Patients from the Acute STroke Registry and Analysis of Lausanne (ASTRAL) were included in the analysis if they had an onset-to-door-time ≤ 4hours, CTA within 24 hours of onset, premorbid modified Rankin scale (mRS) ≤ 2, and a National Institute of Health Stroke Scale score (NIHSS) >4. Patients having significant intracranial stenosis (50-99%) or receiving endovascular treatment were excluded. The primary outcome was a 3 month handicap of mRS >2. We used an interaction analysis of IVT and initial arterial occlusion after adjusting for potential confounders for the primary outcome. Results: Of 655 included patients, 382 patients (58%) showed arterial occlusion, of whom 263 (69%) received IVT. Of the 273 patients without arterial occlusion, 139 (51%) received IVT. In patients with initial arterial occlusion and after multiple adjustments, IVT was associated with lower likelihood of unfavourable outcome (adjusted OR 0.33, 95% CI 0.12-0.91, p=0.03) whereas it had no significant effect in non-occluded patients (OR 1.32, 95% CI 0.36-4.76, p=0.67). Similarly, the presence of arterial occlusion did not significantly worsen the outcome in thrombolysed patients (OR 1.99, 95% CI 0.68-5.81, p=0.21), whereas it did so in non-thrombolysed patients (OR 7.89, 95% CI 2.29-27.25, p<0.01). Conclusions: IVT for AIS is more effective in the setting of visible arterial occlusions on acute imaging. If confirmed in other studies, this information may influence thrombolysis decisions and planning of further randomized trials. Classification of evidence: This retrospective analysis provides class III evidence that IVT has less benefit in patients without visible occlusion on acute CTA.

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