Disparity in the management of Graves' disease observed at an urban county hospital: a decade-long experience

BackgroundThe objective of this study was to determine whether health care disparities exist in management of Graves' disease.MethodsPatients treated for Graves' disease from 1999 to 2009 were divided into medical and surgical treatment groups. A comparative analysis of age, sex, race, health insurance, and income was completed. Address and/or zip code were geocoded and median income was determined from census data.ResultsA total of 634 patients were treated for Graves' disease; 535 (84%) medically and 99 (16%) surgically. Mean age (40 ± 15 vs 43 ± 11 y), percentage of women (84% vs 91%), and racial distribution were similar in the 2 groups (P > .05). In the surgical group, median income was lower ($31,530 vs $34,404; P = .07) and 52% of patients were uninsured compared with 30% of patients treated medically (P < .0001).ConclusionsA disproportionate number of uninsured patients underwent thyroidectomy for Graves' disease. Social and economic factors may have a role in determining definitive therapy for Graves' disease.     

Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis

Aim  

We aimed to study the clinical profile, prognostic factors, and the 6-month outcome of patients with emphysematous pyelonephritis (EPN)     

Evolving Patterns of Spinal Cord Stimulation in Patients Implanted for Intractable Low Back and Leg Pain

The objective of this study was to examine the programming strategies used in patients with intractable low‐back pain treated with epidural spinal cord stimulation (SCS) utilizing paddle electrodes and a radio frequency (RF) stimulator. Programming strategies were examined in a group of patients implanted with a 16‐contact paddle electrode and a dual channel RF receiver to treat chronic low‐back pain. Baseline data included previous surgical history information, leg and low back pain severity and characteristics, and routine demographic information. Outcome measurements included the visual analog scale (VAS) 1 , patient pain relief rating scale, and programming parameters. Patients rated their pain relief on a 5‐point scale where 4 = excellent, 3 = good, 2 = fair, 1 = poor and 0 = none. Success was determined to be a pain relief score of “fair” or above. Data were collected during patient visits or by mail, at approximately 6, 12, and 24 months, postoperatively. Immediate postop data were available in 16 patients, 6‐month data in 21 patients, 1‐year data in 20 patients, and 2‐year data in 10 patients, and analyzed for the purposes of examining programming strategies. The most common location for the tip of the electrode (lead) was found to be in the middle of the 8th thoracic vertebrae (N = 26). At the immediate postop assessment, the majority of cathodes were activated in the upper half of T9. By the 6‐month follow‐up, the majority of cathodes had shifted to the bottom of T9 and top of T10. Overall 88% of cathode locations were changed at one or more study visits. At 2 years, 86% of the programs used four or more active contacts. At 6 months, 83% of the patients reported that the therapy was a success, at 1 year, success was 94%, and by 2 years, success was 75%. Both SCS and chronic pain are dynamic processes. Complex pain patterns, such as the ones of patients who have pain in the low back and in one or both lower extremities, require a high degree of flexibility in the implanted SCS system. The system must provide the capability to redirect the current electronically over at least two segments of the spinal canal, to electronically steer the current in a medio‐lateral direction, and to activate multiple electrical contacts simultaneously. The willingness and ability to provide extensive reprogramming in the long term follow‐up is also of the utmost importance. Pain and its treatment with SCS is a dynamic process.     

Rheumatoid arthritis is a risk factor for dry eye in the Indian population

PURPOSE: To compare the prevalence and severity of dry eye in patients with rheumatoid arthritis (RA) with that in age- and sex-matched controls in the Indian population. METHODS: A cross-sectional study was performed on 84 randomly selected eyes of 84 adult patients with well-documented rheumatoid arthritis and 84 eyes of 84 age- and sex-matched controls in the Department of Ophthalmology, Seth G.S. Medical College and K.E.M. Hospital. McMonnie's dry eye questionnaire was used to classify the patients on the basis of their symptoms. Dry eye was diagnosed if the wetting on Schirmer filter paper test was < or =5 mm at 5 minutes and the tear film breakup time was < 10 seconds on slit-lamp examination after fluorescein staining. RESULTS: Twenty three patients (27.3%) with rheumatoid arthritis had dry eyes based on the Schirmer test as compared to 10 (12%) age- and sex-matched controls; 19 (22.62%) patients with RA had a tear film breakup time of < 10 sec. on slit-lamp examination, compared to 8 (9.52%) patients without RA. The difference in the mean wetting (p = 0.003) and mean tear film breakup time (p < 0.001) between RA and non-RA patients was statistically significant. Ocular symptoms had a limited correlation with the results of these tests. CONCLUSIONS: Patients with RA in the Indian population have a significantly higher prevalence and severity of dry eye when compared to age- and sex-matched controls.     

Recurrent laryngeal nerve palsy after anterior cervical spine surgery: the impact of endotracheal tube cuff deflation, reinflation, and pressure adjustment

BACKGROUND: Vocal fold immobility (paresis or paralysis) from recurrent laryngeal nerve injury remains an important cause of morbidity after anterior cervical spine surgery. A maneuver involving endotracheal tube (ETT) cuff manipulation has been proposed to reduce its incidence. This study is a randomized, prospective, double-blind investigation to test the hypothesis that ETT cuff manipulation reduces the incidence of postoperative vocal fold immobility after anterior cervical spine surgery. METHODS: One hundred patients scheduled to undergo anterior cervical spine surgery were randomly assigned to one of two groups. After inducing general endotracheal anesthesia, patients in the intervention group had their ETT cuff pressures maintained at 20 mmHg or less. After placement of self-retaining retractors, the ETT cuff was deflated for 5 s and then reinflated. Patients in the control group had no further manipulation of their ETT once the cuff was inflated after intubation. Cuff pressures in both groups were recorded before skin incision (baseline) and after placement of self-retaining retractors (peak). Patients' vocal fold motion was evaluated by indirect laryngoscopy performed preoperatively and postoperatively. The examination was videotaped and reviewed by a blinded otolaryngologist. Postoperative vocal fold motion was graded as normal, paretic, or paralyzed. RESULTS: Complete data were available in 94 patients. The incidence of vocal fold paralysis was 3.2% (95% confidence interval, 0.7-9.4%). Cuff manipulation decreased ETT cuff pressure but did not reduce the incidence of vocal fold immobility (15.4% vs. 14.5%). CONCLUSION: Endotracheal tube cuff deflation/reinflation and pressure adjustment do not reduce the incidence of vocal fold immobility in anterior cervical spine surgery.     

Terlipressin in hepatorenal syndrome: a systematic review and meta-analysis

Background  

Hepatorenal syndrome (HRS) is a common complication in patients with cirrhosis or fulminant liver failure. We systematically reviewed the benefits and harms of using terlipressin, a novel vasoconstricting agent in patients with HRS.