Georgia Panagopoulos

A Multicenter Study of the Outcomes of the Surgical Treatment Of Adolescent Idiopathic Scoliosis Using the Scoliosis Research Society (SRS) Outcome Instrument

Study Design. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society Questionnaire (SRS 24). Objective. To evaluate the patient based outcome of the surgical treatment of adolescent idiopathic scoliosis. Summary of Background Data. A paucity of information exists with respect to patient measures of outcome regarding the surgical treatment of adolescent idiopathic scoliosis. To our knowledge, no prospective outcome study on this topic thus far exists. Methods. Using the SRS 24 questionnaire, seven scoliosis centers agreed to prospectively assess outcome for surgically treated patients with adolescent idiopathic scoliosis. Data were collected before surgery and at 24 months after surgery. Data were analyzed using paired and independent samples t test for all seven SRS 24 questionnaire domains (Pain, General Self-Image, Postoperative Self-Image, Postoperative Function, Function From Back Condition, General Level of Activity, and Satisfaction) using Statistical Package for Social Science. The domains were analyzed with respect to the total cohort, gender, curve magnitude, and type of surgery using independent-samples t tests. Results. A total of 242 patients were included in our analysis. A baseline preoperative pain level of 3.68 of 5 was found. This improved to 4.63 after surgery, representing an improvement of 0.95 points. Surgical intervention was associated with improving outcome when compared with preoperative status. Pain, General Self-Image, Function From Back Condition, and Level of Activity all demonstrated statistically significant improvement as compared with preoperative status (P < 0. 001). Overall, patients were highly satisfied with the results of surgery. Conclusion. Preoperative pain exists in our adolescent scoliosis population. Pain scores were improved in our study population at the 2-year postsurgical follow-up. Statistically significant improvements were likewise seen in the General Self-Image, Function From Back Condition, and Level of Activity domains. The present study demonstrates the ability of surgery to improve the outcome of patients afflicted with adolescent idiopathic scoliosis.

Periurethral masses: etiology and diagnosis in a large series of women.

OBJECTIVE: To describe the differential diagnosis of periurethral masses in a consecutive series extracted from a single tertiary urogynecologic practice database. METHODS: A patient database of a private urology and urogynecology practice with 1,950 women was searched for patients who were found to have a periurethral mass during the accrual dates of 1994 to 2002, and these records were reviewed for diagnostic testing and results. All women provided a history, completed a questionnaire, and underwent physical examination, voiding diary, cystoscopy, and videourodynamic testing; selected patients then underwent additional imaging. RESULTS: Seventy-nine (4%) patients aged 41.2 ± 14 years were identified. Of these, 72 (91%) had been referred for evaluation of persistent irritative lower urinary tract symptoms or incontinence. Seven patients (9%) had been referred specifically because of a periurethral mass. Sixty-six patients (84%; 95% confidence interval [CI] 73%, 91%) had urethral diverticula, of which 4 (6%; 95% CI 2%, 14.8%) contained malignancies. Six patients (7%; 95% CI 3%, 15%) had vaginal cysts histologically identified as fibromuscular tissue, 4 (5%; 95% CI 1%, 12%) had leiomyomata, and 2 (2.5%; 95% CI 0.03%, 8.8%) had ectopic ureteroceles. Two patients had vaginal squamous cell carcinomas (2.5%; 95% CI 0.03%, 8.8%), and 1 had an infected granuloma. Masses were palpable in 42 patients (53.8%; 95% CI 42%, 64%) and in 37 patients either were encountered at surgery (n = 5) or were urethral diverticula diagnosed by voiding cystourethrogram (n = 32). CONCLUSION: Periurethral masses were encountered in less than 4% of our patient sample. Most masses were urethral diverticula; however, the differential diagnosis included leiomyoma, vaginal cysts, and malignancy. Masses were generally either palpable or seen at imaging studies performed during evaluation of lower urinary tract symptoms. LEVEL OF EVIDENCE: iii

The Learning Curve Associated With Thoracoscopic Spinal Instrumentation

Study Design. Consecutive case prospective radiographic and medical record review. Objective. To define the learning curve associated with thoracoscopic spinal instrumentation by evaluating operative data and early outcomes of 1 surgeon’s (B.L.) cases. Summary of Background Data. Thoracoscopic spinal instrumentation for the treatment of thoracic adolescent idiopathic scoliosis has emerged as an alternative to open anterior and posterior techniques. The technique is technically demanding and has been perceived as having a prohibitive learning curve. Methods. The operative reports, charts, and surgeon’s database were used to evaluate operating time, estimated blood loss, levels fused, complication rate, blood transfusions, and curve correction, among other variables. For purposes of analysis, the entire cohort was divided into 2 groups of 28 and 29 patients, respectively, and then 4 groups of 14 patients (the last group with 15) were used for comparison. Results. The records of 57 patients were evaluated. No significant difference in estimated blood loss or number of levels fused was noted for either comparison (P = 0.46 and P = 0.66, respectively). There was no significant difference in blood transfusion requirements, with 7% in group 1 and 18% in group 2 (P = 0.35). Operating time was significantly less after 28 patients were operated on 6.2 ± 1.3 hours versus 5.3 ± 1.2 hours (P = 0.011). Percent curve correction was significantly better after 28 cases were performed, 54.4 ± 17.9 in the former groups versus 65.7 ± 10.4 in the latter half of cases (P = 0.005). Complications were evenly distributed throughout the series. No significant differences were observed between the 2 groups in terms of rate of complication (P = 0.50). No major complications, such as neurologic deficit or significant hemorrhage, were observed. Conclusions. The learning curve associated with thoracoscopic spinal instrumentation appears to be acceptable. Significant differences were noted in operating time and percent curve correction after 28 cases. The complication rates remained stable throughout the surgeon’s experience.

One-Year Clinical Outcomes, Midterm Survival, and Predictors of Mortality After Carotid Stenting in Elderly Patients

Background— It has been demonstrated recently that carotid stenting can be performed safely in patients ≥80 years of age. However, it is uncertain whether these patients will derive benefit because longevity after revascularization is an important consideration. This study was conducted to determine survival and predictors of mortality of selected elderly patients after stenting. Methods and Results— One hundred forty-two consecutive elderly patients who were non–high risk for stenting underwent 153 procedures. Patients had either symptomatic stenosis ≥50% or asymptomatic stenosis ≥70%. Demographics and in-hospital outcomes were entered into a database; subsequent outcomes and mortality data were obtained retrospectively. Mean±SD age was 83.3±3.1 years. Symptomatic patients accounted for 28%. Overall survival at 3 years was 76% (85% at 2 years). At 1 year, 1 fatal stroke had occurred, with 97% of survivors (n=114) free of neurological events (neurological status was undetermined in the remaining 3%). Predictors of mortality were remote (≥6 months) transient ischemic attack or cerebrovascular accident, smoking history, and creatinine clearance (hemoglobin level showed a strong trend toward achieving significance); for the asymptomatic subgroup, predictors of mortality were smoking history, previous carotid endarterectomy, hemoglobin level, and increasing age. In particular, symptom status and sex were not independent predictors of mortality. Conclusions— This study demonstrates that in selected elderly patients, a high proportion (85%) survived 2 years and >75% survived 3 years after stenting. Carotid stenting may be considered a revascularization option in such patients. Better selection of patients using the predictors of mortality may help to reduce unwarranted procedures and to optimize survival likelihood.

Troponin I levels in asymptomatic patients on haemodialysis using a high-sensitivity assay.

BACKGROUND Troponin I (TnI) is an effective marker for detecting myocardial injury, but the interpretation of levels in the setting of end-stage renal disease (ESRD) is still unclear. TnI levels have been noted to be increased in 5-18% of asymptomatic haemodialysis (HD) patients with standard assays, but newer-generation, high-sensitivity assays have not been examined. In addition, there is limited data on the variability of TnI levels in patients over time as well as the effect of HD on TnI levels. The aim of this study was to prospectively explore the incidence of TnI with a high-sensitivity assay, the variability of TnI levels over time and the effect of HD on levels. METHODS We enrolled 51 asymptomatic HD patients and checked TnI levels using a high-sensitivity assay. Levels were drawn pre-HD monthly for three consecutive months. As per manufacturer guidelines, levels were considered normal up to 0.034 ng/mL, indeterminate elevation (IE) if between 0.035 and 0.120 ng/mL and consistent with myocardial infarction (MI) if >0.120 ng/mL. In the third month, post-HD TnI was also drawn to determine change with dialysis. RESULTS At baseline, median TnI level was 0.025 ng/mL (range, 0-0.461 ng/mL). Baseline TnI levels were normal in 63% and elevated (≥0.035 ng/mL) in 37%. Of those with elevations, 79% were in the IE range and 21% in the acute myocardial infarction range. Higher TnI levels at baseline were associated with a history of coronary artery disease, left ventricular hypertrophy, lower cardiac ejection fraction and higher serum phosphate levels. Average incidence of elevated TnI was 41% over the 3 months. Thirty-six patients had stable levels without a change in classification over 3 months. Twelve varied over time. Forty-five (94%) had no change in classification pre- and post-HD. CONCLUSION Using a new-generation, high-sensitivity assay, over a third of asymptomatic ESRD patients have an elevated TnI. The significance of these low-level elevations is unclear at this time. TnI levels remain stable over a 3-month period in most patients. HD treatment does not appear to affect the TnI level.

Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial).

OBJECTIVES This study sought to assess the utility of ultrasound (US) guidance for transradial arterial access. BACKGROUND US guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization. METHODS We conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access. RESULTS The number of attempts was reduced with US guidance [mean: 1.65 ± 1.2 vs. 3.05 ± 3.4, p < 0.0001; median: 1 (interquartile range [IQR]: 1 to 2) vs. 2 (1 to 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 ± 78 s vs. 108 ± 112 s, p = 0.006; median: 64 [IQR: 45 to 94] s vs. 74 [IQR: 49 to 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for ≥5 attempts, p < 0.001; 3.7% vs. 6.8% for ≥5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications. CONCLUSIONS Ultrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trial [RAUST]; NCT01605292).

The nature of inflammatory bowel disease in patients with coexistent colonic diverticulosis

Goals/Background Reports of segmental colitis with diverticula regard this entity as a local disease. Our goal was to reexamine the association of diverticula to colitis and question the relationship of colonic diverticulosis with generalized inflammatory bowel disease (IBD). Study A retrospective database review of more than 1600 patients matched 100 cases with IBD and colonic diverticulosis with a control group of 100 patients with IBD without diverticulosis. Patients were matched by gender, IBD diagnosis, and date of birth. Variables examined included disease distribution, strictures, fistulae, extraintestinal manifestations (EIMs), family history, and age at IBD diagnosis. Results For all IBD diagnoses, more sigmoid inflammation occurred in cases with diverticular disease: 82% versus 65% for controls (P=0.005), and in the rectum: 85% versus 69% for controls (P=0.005). In the Crohns disease with diverticulosis subset, sigmoid inflammation was more common: 70% versus 42% for controls (P=0.007), and in the rectum: 70% versus 46% for controls (P=0.02). Disease distribution was otherwise similar throughout the colon, ileum, and jejunum. The incidence of strictures (P=0.99) and fistulae (P=0.69) was similar. EIMs were more frequent in cases with diverticulosis: 28% versus 16% (P=0.05). Family history of IBD was similar: 26% for cases and 16% for controls (P=0.12). Age at IBD diagnosis was significantly greater in diverticulosis cases compared with controls: 51.5 years (±17.6) versus 42.8 years (±17.5) (P<0.001), respectively. Conclusions We observed an increased frequency of sigmoid and rectal inflammation, EIMs, and an older age of IBD onset in cases with diverticulosis. This suggests a role for diverticula in IBD beyond that of a mere coincidental finding.

Stent Gap by 64-Detector Computed Tomographic Angiography: Relationship to In-Stent Restenosis, Fracture, and Overlap Failure

OBJECTIVES The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), and overlap failure (OF). BACKGROUND SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR. METHODS A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents. RESULTS Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p < 0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p < 0.001). In univariate analysis, stent diameter > or =3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis. CONCLUSIONS Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated with > or =3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.

The Poppy Seed Test for Colovesical Fistula: Big Bang, Little Bucks!

PURPOSE Diagnosis of a colovesical fistula is often challenging, and usually involves numerous invasive and expensive tests and procedures. The poppy seed test stands out as an exception to this rule. We evaluated the accuracy and cost-effectiveness of various established diagnostic tests used to evaluate a suspected colovesical fistula. MATERIALS AND METHODS We identified 20 prospectively entered patients with surgically confirmed colovesical fistulas between 2000 and 2006. Each patient was evaluated preoperatively with a (51)chromium nuclear study, computerized tomography of the abdomen and pelvis with oral and intravenous contrast medium, and the poppy seed test. Costs were calculated using institutional charges, 2006 Medicare limiting approved charges and the market price, respectively. The z test was used to compare the proportion of patients who tested positive for a fistula with each of these modalities. RESULTS The chromium study was positive in 16 of 20 patients (80%) at a cost of

Outcome and Complications of Gastric Bypass in Super-Super Obesity versus Morbid Obesity

490.83 per study. Computerized tomography was positive in 14 of 20 patients (70%) at a cost of