Concept: Cleveland Clinic
BACKGROUND: It was the aim of this prospective study to analyze both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for complex fistulas in Crohn’s disease. METHODS: All patients with perianal Crohn’s disease suffering from complex fistulas who underwent definitive surgery using VAAFT combined with advancement flap repair were prospectively enrolled in the study. Only complex fistulas with concurrent stable disease and without any evidence of severe inflammatory activity or perianal sepsis were treated using the VAAFT technique. Patients with Crohn’s proctitis or prior proctectomy were not candidates for the procedure. VAAFT was performed by using the VAAFT equipment (Karl Storz, Tuttlingen, Germany). Key steps included visualization of the fistula tract and/or side tracts using the fistuloscope and correct localization of the internal fistula opening under direct vision with irrigation. Diagnostic fistuloscopy was followed by advancement flap repair. In addition to feasibility, primary end points included detection of side tracts, success and continence status (assessed by the Cleveland Clinic Incontinence Score). Success was defined as closure of both internal and external openings, absence of drainage without further intervention and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6 and 9 months postoperatively. RESULTS: Within a 3-month observation period (September to November 2011), VAAFT was attempted in 13 patients with Crohn’s associated complex fistulas. The completion rate was 85 % (11/13). In these 11 patients (median age 34 years, 64 % females), complex fistulas were transsphincteric (8), suprasphincteric (2) and recto-vaginal (1). Forty-six percent (5/11) had concomitant therapy with biologic drugs. In 36 % (4/11), VAAFT was performed with fecal diversion. Median duration of surgery was 22 (range 18-42) minutes. Using VAAFT, additional side tracts not detected preoperatively could be identified in 64 % (7/11). No morbidity occurred. After a mean follow-up of 9 months, the success rate was 82 % (9/11). No deterioration of continence was documented (Cleveland Clinic Incontinence Score 2.4 vs. 1.6, p > 0.05). CONCLUSION: Preliminary results of the addition of the VAAFT technique to advancement flap repair in Crohn’s fistulas demonstrate that this leads to a high identification rate of occult side tracts with encouraging short-term healing rates. Moreover, a completion rate of 85 % seems promising.
Using this case report we attempt to define the mechanism of endocardial lead-induced tricuspid regurgitation (TR) in particular the direct effect of endocardial pacing leads on the competence of the tricuspid valve. We recommend a high index of suspicion and an early diagnostic strategy in order to reduce long-term morbidity which is associated with this condition and the need for a potentially avoidable surgery.
Treatment of CMML remains a clinical challenge, with no drug demonstrating clear clinical benefit. Even if azacitidine is approved in the treatment of CMML, its role remains disputed. We report a cohort of 76 CMML patients (according to WHO classification) treated with azacitidine in 3 programs (French AZA compassionate program, Cleveland Clinic Foundation and H. Lee Moffitt Cancer Center). 45% had CMML2, and 55% had splenomegaly and/or WBC counts >13G/L, which are known to be poor prognostic factors in CMML. All patients received AZA for at least one cycle, and the median number of cycles administered was 6. Thirty-three patients (43%) achieved a response according to IWG 2006 criteria, including 13 complete remissions (%). Median survival was 29 months. Increased bone marrow blast percentage and proliferative features of the disease, including splenomegaly and high WBC counts, were significantly associated with shorter survival. By multivariate analysis, only marrow blasts >10% and palpable splenomegaly had prognostic impact on survival. Although promising, the efficacy of azacitidine in advanced CMML needs to be confirmed in a randomized prospective study.
We describe a minimally invasive heart surgery application of the EinsteinVision 2.0 3D high-definition endoscopic system (Aesculap AG, Tuttlingen, Germany) in an 81-year-old man with severe tricuspid valve insufficiency. Fourteen years ago, he underwent a Ross procedure followed by a DDD pacemaker implantation 4 years later for tachy-brady-syndrome. His biventricular function was normal. We recommended minimally invasive tricuspid valve repair. The application of the aformentioned endoscopic system was simple, and the impressive 3D depth view offered an easy and precise manipulation through a minimal thoracotomy incision, avoiding the need for a rib spreading retractor.
Statin therapy is a proven effective treatment of hyperlipidemia. However, a significant number of patients cannot tolerate statins. This study was conducted to review treatment strategies for patients intolerant to statin therapy with a focus on intermittent statin dosing.
- Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology
- Published almost 3 years ago
Aortic valve replacement for calcific aortic valve stenosis is one of the more common cardiac surgical procedures. However, the underlying pathophysiology of calcific aortic valve stenosis is poorly understood. We therefore investigated the histologic findings of aortic valves excised for calcific aortic valve stenosis and correlated these findings with their associated clinical features.
Pain and anxiety control is critical in dental practice. Moderate sedation is a useful adjunct in managing a variety of conditions that make it difficult or impossible for some people to undergo certain dental procedures. The purpose of this study was to analyze the sedation protocols used in 3 dental specialty programs at the Case Western Reserve University School of Dental Medicine, Cleveland, OH.
During the late 1950s and most of the 1960s, Dr John Ross and I led the busy clinical cardiology program then existing at the Clinical Center of the National Institutes of Health. During this period, the assessment and surgical treatment of severe aortic stenosis (AS) in adults, predominantly rheumatic in origin, were both undergoing rapid changes. In the 1950s, before open heart surgery and left-sided heart catheterization were available, after thoracotomy dilators were inserted through a ventriculotomy, and severely obstructed aortic valves were “blindly” opened.1 The selection of patients for this operation was difficult. Dr Paul Wood, Director of the National Heart Institute in London, who was considered by many to be the world’s leading clinical cardiologist of the era, wrote: “At the present time aortic valvotomy is too hazardous and too crude an operation to advise when it is most desirable (just before the onset of symptoms) and frequently too late when impending disaster makes it imperative."2.
Life-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear.
Safety and Efficacy of Occipital Nerves Stimulation for the Treatment of Chronic Migraines: Randomized, Double-blind, Controlled Single-center Experience
- Pain practice : the official journal of World Institute of Pain
- Published almost 2 years ago
A recent multicenter study presented 52-week safety and efficacy results from an open-label extension of a randomized, sham-controlled trial for patients with chronic migraine (CM) undergoing peripheral nerve stimulation of the occipital nerves. We present the data from a single center of 20 patients enrolled at the Cleveland Clinic’s Pain Management Department.