Long-term outcome of children treated with rituximab for idiopathic nephrotic syndrome

Background

Rituximab (RTX) has recently showed promising results in the treatment of steroid-dependent idiopathic nephrotic syndrome (SDNS).

Methods

This was a retrospective multicenter study of 18 children treated with RTX for SDNS, with a mean follow-up of 3.2 years. RTX was introduced because of side effects or relapses during therapy with immunosuppressive agents. The children received one to four infusions of RTX during the first course of treatment, and subsequent infusions were given due to CD19-cell recovery (CD19?>1 %; 54 % of children) or relapse (41 %), as well as systematically (5 %).

Results

Treatment with RTX maintained sustained remission without relapse in 22 % of patients and increased the duration of remission in all other patients. The time between two successive relapses was 9 months in the absence of re-treatment and 24.5 months when infusions were performed at the time of CD19-cell recovery. At the last follow-up, 44.5 % of patients were free of oral drug therapy. Of those still receiving oral drugs, all doses had been decreased. No serious adverse events occurred.

Conclusion

The results of this retrospective study confirm the efficacy and very good safety of RTX in the treatment of SDNS. The optimal therapeutic protocol seems to be a repeated single infusion at the time of CD19-cell recovery.     

Early outcomes of antireflux surgery for United States lung transplant recipients

Background

This study aimed to evaluate early outcomes after antireflux surgery for lung transplant (LTx) recipients in the United States.

Methods

Adult patients undergoing elective antireflux surgery between 2003 and 2008 were identified in the Nationwide Inpatient Sample. A propensity-matched analysis compared early outcomes between prior LTx recipients and well-matched control subjects consisting of non-LTx patients undergoing elective antireflux surgery during the same era. The primary outcome was inpatient mortality, and the secondary outcomes were hospital length of stay (LOS), perioperative complications, and hospital costs.

Results

During the study period, 401 LTx recipients underwent elective antireflux surgery. These patients were well matched with 401 control patients in terms of age, sex, individual and overall comorbidity burden, hospital teaching status, hospital location, hospital antireflux volume, and open versus laparoscopic approach. The overall operative mortality rate was 1.4 %, with no difference between the groups. The overall and individual morbidity rates also were similar. The LOS and hospital costs were significantly greater in the LTx group. Multivariable logistic regression analysis confirmed that prior LTx did not confer an increased risk of inpatient mortality after antireflux surgery.

Conclusions

To date, this is the largest study to examine outcomes of antireflux surgery for LTx recipients. Operative mortality and morbidity appear to be comparable with those of the general population, although resource utilization is greater. Based on these data, trials to evaluate the role of antireflux surgery in preserving allograft function after LTx should not be hindered by a perceived notion of prohibitive operative risk in this patient population.     

Air in the insufflation tube may cause fatal embolizations in laparoscopic surgery: an animal study

Background

The aim of this study was to evaluate the risk of an air embolization with the volume of the insufflation tube during induction of laparoscopy. A further objective was to determine the LD₅₀ of air in young piglets.

Methods

End-tidal carbon dioxide pressure ( $ P_{{{\text{CO}}_{2} ,{\text{et}}}} $ ), pulmonary arterial pressure (P _pa), heart rate (f _c), and mean arterial pressure (P _{a carot}) were measured in 17 piglets divided into three groups: group 1 (n = 6), bolus application (CO₂ embolization, followed by air embolization, 2 mL/kg each), group 2 (n = 7), continuous air embolization (30 min, 0.2 mL/kg/min), and group 3 (n = 4), continuous CO₂ embolization (30 min, 0.4 mL/kg/min).

Results

All animals survived CO₂ embolism. Air embolization as a bolus (2 mL/kg) or with an accumulated volume of 3.1 mL/kg led to death. Decreases in $ P_{{{\text{CO}}_{2} ,{\text{et}}}} $ indicated air or massive CO₂ embolization only. There was a good correlation between $ P_{{{\text{CO}}_{2} ,{\text{et}}}} $ and P _pa in case of air embolization (r = ?0.80, p < 0.0001). In contrast, no dependency was recognized during CO₂ embolism (r = ?0.17, p = 0.2).

Conclusions

In order to minimize the lethal risk of gas embolization, the insufflation system has to be completely filled with CO₂ before connecting to the patient.     

Results of dynamic pedobarography following surgically treated intra-articular calcaneal fractures

Objective

To investigate the clinical outcome and gait analysis findings by dynamic pedobarography in patients following surgically treated single, closed, dislocated intra-articular calcaneal fractures.

Design

Retrospective single-center study with 26 patients. The average follow-up period was 34 months (range 18–61 months). We used the Zwipp score and a score based on a visual analog scale (VAS) to assess the subjective and objective clinical outcome. Dynamic pedobarography (EMED-M, 38 × 42 cm, four sensors per square centimeter, 50 Hz; Novel GmbH., Munich, Germany) was performed to retrieve gait patterns. Analysis was performed using the Emed-Software (Novel GmbH., Munich, Germany).

Results

For the Zwipp score (±200 points), the average was +54.4 points (±48.2); for the VAS score (0–100 points), the average was 58.3 points (±24.3). There was limited mobility in the upper and lower ankle joint. Pedobarography showed a clearly disturbed gait with increased pressure for the fractured side (157 vs. 119 kPa) in the midfoot region (71.8 vs. 68 kPa) and under fifth metatarsal bone (234 vs. 160 kPa). The gait line was lateralized. The force–time-integral (fractured vs. healthy side) showed significant differences for the medial (18 vs. 7 N s) and lateral (61 vs. 36 N s) midfoot region.

Conclusions

We found only an average clinical outcome and clear pathological gait patterns in our cohort with lateralization of the gait line.     

Neuropathic Pain Post Spinal Cord Injury Part 2: Systematic Review of Dorsal Root Entry Zone Procedure

Background:

Pharmacotherapy may not sufficiently reduce neuropathic pain in many individuals post spinal cord injury (SCI). The use of alternative therapies such as surgery may be effective in reducing neuropathic pain in these individuals. However, because of the invasive nature of surgery, it is important to examine the evidence for use of this treatment.

Objective:

The purpose of this study was to conduct a systematic review of published literature on the surgical treatment of neuropathic pain after SCI.

Methods:

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles in which surgical treatment of pain after SCI was examined. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a surgical intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention involving the dorsal root entry zone (DREZ) procedure was used to reduce pain. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale.

Results:

Eleven studies met the inclusion criteria. One study provided level 2 evidence, and the rest provided level 4 evidence. The DREZ procedure was shown to be more effective for segmental pain than for diffuse pain after SCI. Further, individuals with conus medullaris level injury were found to have a higher level of neuropathic pain relief than those with cervical, thoracic, or cauda equina injury.

Conclusions:

The studies demonstrated that the DREZ procedure may be effective in reducing segmental pain. Hence, DREZ may be important in treatment of neuropathic pain in individuals resistant to less invasive treatments. Because the studies lacked control conditions and examination of long-term effects, there is a need for larger trials with more stringent conditions.Key words: pain, spinal cord injury, surgical treatmentPain is a major cause of distress and disability in persons with spinal cord injury (SCI). It has been shown to lead to social isolation, unemployment, decreased function, decreased quality of life, depression, and even suicide.^1,2 More than 77% of individuals with an SCI indicated that pain interfered with one or more of their daily activities including sleep (40%), exercise (34.9%), and work (33.6%).² The International Association for the Study of Pain (IASP) defines neuropathic pain as “pain caused by a lesion or disease of the somatosensory nervous system.”³ After an SCI, individuals often report the onset of chronic neuropathic pain caudal to the level of the lesion or at the same level within the associated spinal cord segment.⁴ Dijkers et al⁵ reported no difference in the prevalence of pain based on level or completeness.The reported incidence of neuropathic pain after SCI varies greatly among studies, but between 10% and 30% of patients with SCI experience pain severe enough to interfere with their activities of daily living^6,7 and may require surgical intervention to relieve persistent and refractory pain.^4,8 Unmanageable neuropathic pain occurs more often in individuals with conus medullaris and cauda equina lesions where damage also involves the peripheral nerve roots.⁸When pharmacological and other noninvasive treatments fail to reduce pain, surgical spinal cord stimulation and dorsal root entry zone (DREZ) ablation treatments, such as DREZ lesioning and microsurgical DREZotomy (MDT), can be considered as options for the management of refractory pain.⁹ Neurosurgical procedures to reduce neuropathic pain should be reserved for cases in which medical therapies have failed to sufficiently reduce pain.⁴ The risks associated with ablative surgeries can be significant for individuals with incomplete neurological deficits; therefore, DREZ ablation is generally only considered a treatment option when neuropathic pain is present after a complete SCI.⁸ The MDT procedure targets for ablation the nociceptive fibers in the lateral bundle of the dorsal rootlet, the deafferented neurons of the dorsal horn, and the medial portion of the Lissauer tract.^4,6 This systematic review was conducted to assess the effectiveness of DREZ ablation therapies in reducing neuropathic pain in individuals following SCI.     

Physiologic Responses of Elite Paraplegic Road Racers to Prolonged Exercise

ABSTRACT

The purpose of this study was to determine cardiopulmonary and selected metabolic responses in spinal cord injured (SCI) paraplegics during prolonged arm crank exercise (ACE). Six male and one female elite SCI paraplegic (T4-12 lesions) road racers performed 40 continuous minutes of ACE at 60% of peak ACE oxygen uptake (VO₂). Blood samples (30 ml) were collected via antecubital venipuncture at rest and minutes 20 and 40 of ACE for determinations of hemoglobin, hematocrit, serum free fatty acid (FFA), and blood lactate (LA) concentrations. No significant differences were observed over time for V0₂ or pulmonary ventilation. Heart rate recorded at minutes 30 and 40 was significantly elevated’ above HR at minutes 10 and 20 of ACE indicating the presence of an upward drift in HR in paraplegics performing prolonged ACE. Compared to rest, LA concentration was significantly higher at minute 20 and remained relatively stable thereafter. A significant increase in FFA concentration at minute 40 combined with a significant decline in the respiratory exchange ratio suggested a preference for lipid substrate utilization by exercising muscle as ACE continued. The data indicate that the autonomic sympathetic nervous system impairment associated with paraplegia had no apparent adverse effects on cardiopulmonary or metabolic adjustments to prolonged ACE in these well-trained subjects.