Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder primarily affecting motor neurons; however, non-motor symptoms, including sensory and autonomic disturbances, are increasingly recognized. This retrospective cross-sectional study evaluated the frequency of sensory and entrapment neuropathies in 114 patients with ALS using electrodiagnostic (EDX) studies. Demographic characteristics, comorbidities, and sensory and autonomic symptoms were documented. Electrophysiological evidence of sensory neuropathy was identified in 20 patients overall (20/114, 17.5%), including 10 patients without diabetes mellitus (DM), whereas entrapment neuropathy was detected in 28 patients overall (28/114, 24.6%), including 16 of those without DM or hypothyroidism. Sensory neuropathy was significantly associated with both DM and a history of chronic disease. In contrast, these comorbid conditions were not significantly associated with entrapment neuropathy. Furthermore, patient-reported symptoms showed no correlation with electrophysiological evidence of sensory involvement on EDX. Sensory neuropathy was more frequent in patients with spinal-onset than bulbar-onset disease, although the difference was not statistically significant. This study confirms that sensory involvement is not uncommon in ALS. Although clinical symptoms are poor predictors, electrophysiological abnormalities consistent with sensory and entrapment neuropathies are common. A significant proportion of these abnormalities are idiopathic and may directly reflect the disease process itself, particularly in spinal-onset cases.
This study highlights the vital role of personalized treatment strategies in managing multiple myeloma (MM) among older patients, a population greatly affected by this disease. We conducted a retrospective analysis using data from the National Cancer Database (NCDB) collected between 2004 and 2021. Multiple myeloma patients ≥70 years were included in the analysis, as this age threshold aligns with NCDB categorization and reflects a group with higher clinical complexity. Utilizing a data analysis software, patients were categorized into three age groups: 70-74 years, 75-79 years, and 80 years and above. Patients were excluded if treatment regimen exposure could not be definitively confirmed in the database. Additionally, those lacking follow-up beyond diagnosis or with an unknown vital status were not included in the study. Analysis shows that while survival outcomes typically decline with age, tailored regimens can provide substantial benefits. The combination of chemotherapy, bisphosphonate therapy, and immunotherapy, where all treatments were given within 30 days of each other (C + H + I), yielded the highest median overall survival (64.2 months) and the lowest adjusted hazard ratio for mortality (HR = 0.575), yet this regimen remains underutilized in older patients. Findings emphasize that with proper patient selection and supportive care, intensive regimens like C + H + I can be both effective and safe. Furthermore, extended treatment duration-particularly beyond 180 days-was linked to improved survival, supporting maintenance and continuous therapy approaches. This study underscores the necessity of moving away from uniform treatment models and toward individualized care plans that account for functional status and comorbidities in older adults with MM.
Administering intrathecal nusinersen to patients with spinal muscular atrophy (SMA) is commonly done under fluoroscopic guidance, and the use of the transforaminal intrathecal route has also been reported to be successful without major complications. However, this case report presents a patient who developed radicular neuritis following a transforaminal administration of nusinersen. A 28-year-old patient with SMA type 2 and severe scoliosis experienced persistent back and leg pain after a transforaminal intrathecal injection. Lumbar magnetic resonance imaging revealed contrast enhancement of the left L4 nerve root, suggesting neuritis. Despite medical treatment, the patient's symptoms did not improve significantly. As an alternative, a transforaminal epidural steroid injection, a method used commonly for radicular pain, was administered. After the procedure, the patient's pain was markedly alleviated. This case highlights the diagnosis and management of a rare iatrogenic complication associated with transforaminal access and emphasizes transforaminal epidural steroid injection as a potential treatment option in similar clinical scenarios.
Globally, heart failure (HF) readmission presents a significant challenge. Although anemia (reflected by hemoglobin [Hb]) and renal dysfunction (reflected by creatinine [Cr]) are established independent risk factors for poor HF outcomes, the value of their combined ratio called hemoglobin-creatinine ratio (HBCR), specifically for six-month all-cause readmission risk in patients with HF, requires further exploration. This study aimed to investigate the association between admission HBCR and six-month all-cause readmission after HF hospitalization. We conducted a retrospective cohort study of 1,833 adults who survived an initial HF admission. HBCR was calculated by dividing the admission Hb (g/L) by the admission Cr (µmol/L). The primary outcome was six-month all-cause readmission. Multivariable analysis adjusted for demographics, comorbidities, and key labs assessed the independent association. Within six months, 689 patients (37.6%) were readmitted. Lower admission HBCR significantly correlated with a higher readmission hazard. After full adjustment, each one standard deviation (SD) increase in HBCR was independently associated with a 20% lower readmission hazard (adjusted hazard ratio [aHR] = 0.80, 95% confidence interval [CI]: 0.71-0.90, p <0.001). This association showed a graded inverse relationship across tertiles: versus the lowest, the highest tertile had a 41% reduced risk (aHR = 0.59, 95% CI: 0.48-0.73, p <0.001). Admission HBCR is independently associated with six‑month all‑cause readmission in Chinese patients hospitalized for HF and may help identify patients at higher risk before discharge. Prospective interventional studies and external validation are required to determine whether HBCR‑guided management reduces HF readmissions.
Although human epidermal growth factor receptor 2 (HER2)-targeted therapies have been approved for HER2-mutant NSCLC, real-world outcome data especially in the second-line setting remains limited. This non-interventional study utilized the Center for Cancer Genomics and Advanced Therapeutics national database to identify patients with HER2-mutant NSCLC who received second-line treatment in Japan. The primary objective was to characterize this population. Secondary objectives included describing second-line treatments and clinical outcomes (overall response rate [ORR], disease control rate [DCR], time on treatment [ToT] and reasons for second-line treatment termination). Among 3012 NSCLC patients identified, 168 (5.6%) had a HER2 mutation. In all NSCLC and HER2-mutant patients, median age was 66.0 years; 38.1% and 53.6% were female; 68.2% and 42.3% had a history of smoking; and 25.8% and 31.0% had brain metastases. In HER2-mutant patients, use of molecular targeted therapy (MTT, 44.6%) and chemotherapy (36.9%) as second-line treatment were comparable, followed by immunotherapy (15.5%), and immunochemotherapy (3.0%). Overall, median ToT with second-line treatment was 4.8 months (95% CI: 4.1-6.2). The longest median ToT was observed with MTT (8.1 months, 95% CI: 4.8-9.7), followed by chemotherapy (3.9 months, 95% CI: 2.5-5.2), immunochemotherapy (3.2 months, 95% CI: 0.4-not reached) and immunotherapy (5.5 months, 95% CI: 3.8-8.5). The ORR was 33.1% (95% CI: 25.4-41.6) and DCR was 78.4% (95% CI: 70.6-84.9). MTT was the most common second-line treatment, however, outcomes were generally poor, emphasizing the unmet need for effective second-line treatments for HER2-mutant NSCLC.
Vertebral compression fractures (VCFs) are a common and debilitating consequence of multiple myeloma (MM). Acute VCFs often benefit from percutaneous vertebral augmentation (PVA), indicated by bone marrow edema (BME) on MRI. We present a rare case of a MM patient with several acute VCFs lacking BME on imaging who was successfully treated with PVA. A 49-year-old woman with a history of MM presented with acute mid-back pain. MRI revealed multiple compression fractures without BME, interpreted as chronic. Suspicion was increased based on the presentation and a review of prior imaging confirmed recent fractures. The patient then underwent PVA successfully with significant improvement. MRI is the gold standard method of determining the morphology of VCFs. However, this report demonstrates that MRI may not be accurate in detecting BME in MM patients. Clinicians should make a careful evaluation in determining the candidacy of these patients for PVA in case of contradictory MRI findings.
The Sistrunk procedure for thyroglossal duct cyst (TGDC) resection leaves a visible neck scar. Transoral endoscopic approaches offer potential cosmetic advantages, but pediatric data remain limited. This study evaluated the feasibility, safety, and outcomes of a modified transoral endoscopic vestibular approach for pediatric TGDC. We retrospectively review 20 pediatric patients undergoing TGDC resection between November 2023 and October 2024. Seven underwent transoral endoscopic vestibular resection (gasless technique with unilateral oral distractor and mental nerve preservation), and 13 underwent transcervical Sistrunk procedure. Outcomes including operative details and cosmetic satisfaction were compared. All transoral procedures were completed without conversion. Operative time (230.7 ± 32.3 vs. 80.0 min, p < 0.05) and hospital stay (3.9 ± 0.4 vs. 2.0 days) were significantly longer in the transoral group. One patient (14.3%) experienced transient mental nerve paresis resolving by 6 months; one transcervical patient (7.7%) developed seroma. Cosmetic satisfaction was significantly higher in the transoral group (VAS 9.9 ± 0.4 vs. 6.0 at 12 months, p < 0.01). Transoral endoscopic vestibular resection of pediatric TGDC is technically feasible with superior cosmetic satisfaction compared to transcervical excision, despite longer operative time and hospitalization. Strict adherence to the 'safety zone between the mandibular canines' minimizes mental nerve injury. These preliminary findings require validation in larger cohorts.
The exercise is medicine (EIM) initiative, promoted as routine care for cancer populations, is inadequately integrated into oncology practice. While barriers to and facilitators of physical activity (PA) promotion are well documented, oncology nurses' perspectives on EIM remain underexplored. This mixed-methods study examined oncology nurses' current PA promotion practice and perspectives on implementing the EIM initiative in China. A total of 155 oncology nurses across Hong Kong and Shenzhen in China participated in an online survey (including a 3-min EIM introductory video) assessing current PA promotion practices, personal PA habits, and attitudes toward PA and EIM, among which 14 were subsequently interviewed. The results revealed infrequent PA discussions with patients and relatively low confidence in PA promotion. After watching an EIM introductory video, participants' attitudes toward PA promotion improved slightly, with most expressing average interest and preparedness to integrate EIM in practice. Qualitative analysis revealed 5 key themes influencing EIM implementation: confidence in PA promotion, perceived priority of promoting PA in practice, perceived appropriateness of promoting PA for patients, organizational infrastructure (trainings, guidelines, collaborations, resources), and societal support. Oncology EIM implementation requires systematic organizational support, necessitating a multifaceted approach encompassing competency development, standardized procedural guidelines, cross-sector collaborations, and strategic resource allocation. Integrating EIM in oncology care requires enhanced organizational support, including training, guidelines, collaboration and resources. Implementation assessment and research are essential to ensure successful and sustainable integration and to evaluate applicability, effectiveness, and sustainability of EIM in real-world oncology settings.
Tarsal coalition is an abnormal union between 2 or more tarsal bones that can potentially cause pain, stiffness, and altered foot biomechanics. A 49-year-old man presented to the clinic with chronic dorsal pain in the left foot. Magnetic resonance imaging (MRI) revealed multiple unilateral nonosseous calcaneonavicular and talocalcaneal coalitions, with associated bone marrow edema. Conservative treatment of the condition, including range-of-motion and strengthening exercises, resulted in gradual improvement. This case underscores the importance of MRI in detecting nonosseous coalitions and associated edema. Notably, the presence of multiple coalitions in a nonsyndromic patient is rare, as such findings are typically associated with syndromic conditions. Awareness of this possibility aids accurate diagnosis and management.
Parkinson's disease (PD) is a progressive neurological condition that primarily affects the central nervous system. It causes neurons to eventually degrade, leading to muscle tremors, rigidity, bradykinesia, impaired balance, and mask-like facies, among other symptoms. A combination of levodopa and carbidopa is the most common treatment for PD, though they are also given separately. These treatments have significant side effects, including headache, dizziness, nausea, somnolence, loss of appetite, diarrhea, constipation, and dyskinesia, which further exacerbate the already present PD symptoms. No disease-modifying treatment exists. Mesenchymal stem cell (MSC) secretome refers to the molecules secreted by stem cells during expansion in culture, which can include growth factors, cytokines, and exosomes. They have shown efficacy in models of PD in numerous preclinical studies and could provide an alternative, minimally invasive, and potentially disease-modifying treatment for PD. We hypothesized that secretome treatment via intranasal instillation would decrease PD symptoms and possibly be disease modifying. Patients diagnosed with PD were enrolled in the trial and received umbilical cord-derived MSC secretome (AlloEx Exosomes®) intranasal installations over a 2-day period. All patients were treated in our treatment facility located in Antigua. Treatment was repeated if desired by the patients at a minimum of 2-month intervals. Efficacy was measured using the Parkinson's Disease Questionnaire (PDQ-39) rating, electroencephalogram (EEG) tests, and patient reports. Nineteen patients were enrolled in the trial and received a total of 40 doses throughout the treatment. There were no adverse events from treatment. Two patients reported no improvement, 2 patients had transient improvement, while the remaining patients saw a significantly maintained decrease in symptoms with follow-up of up to one year. Average combined PDQ-39 scores decreased with each treatment, indicating an increase in the patient cohort's quality of life. Improvements were seen in the patient's EEG results, tremors, sensory impairments, bladder/bowel dysfunction, and sleep quality. Limitations of the study included a short follow-up length that limited the ability to determine if the treatment was disease modifying. Intranasal MSC secretome installation is a safe method that is consistently effective in reducing Parkinson's symptoms and may represent the first-identified PD disease-modifying treatment.
Degenerative disc disease is a leading cause of low back pain. Conservative treatments like pain medication and exercise therapy have shown mixed results, while procedures like fusion surgery carry risks such as adjacent segment disorder and surgical morbidity. Therefore, there is a critical need for treatments that bridge the gap between conservative care and surgery. To assess the efficacy of intradiscal hydrogel implantation compared with sham treatment of intradiscal injection of saline in patients with chronic discogenic low back pain. Prospective, double-blind, randomized, controlled, multicenter trial. Two tertiary interventional pain care centers in Switzerland and in the Netherlands. Forty-nine patients with chronic discogenic low back pain unresponsive to conservative treatment were randomized to receive either intradiscal hydrogel implantation or a sham treatment. Control Group patients could cross over to hydrogel treatment after 6 months. The primary outcome was pain improvement at 6 months. Secondary outcomes included disability, quality of life, employment status, Patient Global Impression of Change score, analgesic use, disc space height, and disc degeneration. Adverse events were continually assessed. At 6 months postprocedure, the Hydrogel Group patients had improved pain scores compared to Control Group patients, though not statistically significant (P = 0.070). Six out of 24 patients in the Hydrogel Group reported much improvement on their Patient Global Impression of Change scores, compared to 0 out of 25 in the Control Group (P = 0.008). Within-group disability improvements were statistically significant in the Hydrogel Group but not in the Control Group. No significant differences were found between groups in disability, quality of life, or employment status. Only one serious adverse event was reported-a patient from the Hydrogel Group was hospitalized due to a possible exacerbation of low back pain 6 days postprocedure. This trial's limitations include strict eligibility criteria and questions about the validity of intradiscal saline as a placebo. This trial suggests that percutaneous intradiscal hydrogel implantation may reduce chronic discogenic pain and disability, with significant Patient Global Impression of Change improvements, though larger trials are needed to confirm efficacy.
Chemotherapy-induced peripheral neuropathy (CIPN) affects approximately 50% of patients who receive chemotherapy. CIPN often results in dose reductions, therapy discontinuation, and long-term neurological impairment. Despite existing studies, identifying high-risk populations remains challenging, particularly in patients with diabetes, diabetic neuropathy, and those undergoing corticosteroid therapy. We sought to evaluate the key risk factors associated with CIPN by analyzing patient demographics, comorbidities, and chemotherapy regimens, with a specific focus on diabetes-related variables in order to inform early identification and prevention strategies. Retrospective, single-center, observational cohort study. Academic tertiary care cancer center. Adult patients who received chemotherapy between January 2016 and December 2023 were identified through electronic medical records. Patients with CIPN were defined by the International Classification of Disease, Tenth Revision G62.0 diagnosis code (drug-induced polyneuropathy) and an associated diagnosis of "painful peripheral neuropathy." Extracted data included demographics (age, body mass index [kg/m2], race/ethnicity), clinical variables (alcohol use, corticosteroid use, diabetes-related factors), and chemotherapy regimen details. Descriptive statistics, Wilcoxon rank sum, c2/Fisher's exact tests, and multivariable logistic regression were performed. Institutional review board (IRB) approval was obtained (IRB exemption #2024-0139). Among 36,949 patients, significant CIPN risk factors included older age (40-80 years, P < 0.0001), women (odds ratio [OR] 1.89; P < 0.0001), non-Hispanic/non-Latino ethnicity (OR 1.29; P < 0.0001), and corticosteroid use (OR 2.01; P < 0.0001). African American patients had lower odds of CIPN than White patients (OR 0.78; P < 0.0001). Diabetic neuropathy was strongly associated with increased CIPN risk (OR 5.35; P < 0.0001). Alcohol use was inversely associated with CIPN (OR 0.75; P < 0.0001). Several chemotherapy agents also showed significant associations. Our study is limited by its retrospective design, potential misclassification bias in CIPN diagnosis, and reliance on electronic medical records. Alcohol use data were frequently missing or unspecified, limiting interpretation. Key CIPN risk factors include age, race/ethnicity, corticosteroid use, and diabetic neuropathy. Alcohol use appeared inversely associated with CIPN, though causality remains unclear. Individualized patient assessments and proactive management strategies may help reduce CIPN incidence and improve outcomes in patients with cancer who are receiving chemotherapy.
Neurogenic bowel dysfunction is a frequent but often underrecognized problem in patients with multiple sclerosis (MS) and may contribute to disability and reduced quality of life. The aim of this study was to determine the prevalence and severity of bowel dysfunction in patients with MS using the validated Neurogenic Bowel Dysfunction (NBD) score and to evaluate its associations with urinary dysfunction, anxiety, depression, fatigue, cognitive function, sleep quality, and quality of life. Patients aged ≥18 years with MS who fulfilled the 2017 revised McDonald criteria were included. This cross-sectional study prospectively collected questionnaire and clinical assessment data, while CSF findings were retrospectively obtained from patient records. Neurogenic bowel dysfunction was assessed using the NBD score. Clinical and psychosocial parameters were evaluated using validated questionnaires. Neurological disability was assessed with the EDSS. A total of 107 patients with MS were included. The mean NBD score was 4.56 ± 5.68, and most patients had very minor bowel dysfunction. Higher NBD scores were significantly associated with older age, higher disability level, urinary symptoms, fatigue severity, and lower physical quality-of-life scores. No significant associations were found with disease duration, anxiety, depression, cognitive function, sleep quality, or the mental health component of quality of life. Patients with progressive MS had significantly higher NBD scores than the relapsing-remitting MS group. Neurogenic bowel dysfunction is common in patients with MS, even at mild levels, and is associated with disability, urinary symptoms, fatigue, and reduced physical quality of life. These findings suggest that bowel dysfunction reflects multisystem involvement and should be routinely assessed in the clinical evaluation of patients with MS.
Lumbosacral radicular pain (LRP) results from the ectopic activation of nociceptive afferent fibers in a spinal nerve or its roots. Lumbar disc prolapse is the most prevalent cause of LRP. This condition significantly impacts patients' quality of life and is deemed a burden on communities and health care facilities alike. The utilization of pulsed radiofrequency (PRF) in dorsal root ganglion stimulation (DRG-S) has demonstrated efficacy with a wide applicability across various conditions. However, whether elevating the voltage of PRF to between 55-75 volts could augment its clinical efficacy remains uncertain. The primary measure of outcome was the Numeric Rating Scale (NRS) score between the 2 groups . The secondary outcomes included functional outcomes as evaluated on the Oswestry Low Back Disability Questionnaire and intra- or post-intervention complications. A prospective, double-blinded, randomized controlled study. The study was carried out at the Medical Research Institute of Alexandria University. The study included 96 patients with lumbosacral radicular pain caused by disc prolapse. They were randomly divided into 2 equal groups to receive high-voltage pulsed radiofrequency (HV-PRF) (Group I) or standard-voltage PRF (Group II) adjacent to the DRG corresponding to the affected dermatome. Scores on the NRS and Oswestry Low Back Disability Questionnaire were evaluated at one week and one, 2, 3, and 6 months after the intervention. The complications of the intervention were recorded. In both groups, NRS scores decreased significantly from the pre-intervention ratings at all post-intervention studied times (P ≤ 0.001). However, this decline was significantly more observable in Group I than in Group II (P ≤ 0.001). The percentage of patients reporting NRS reductions ≥ 50.0% was significantly higher in Group I than Group II at one, 2, 3, and 6 months after the intervention (P ≤ 0.001). Similarly, when compared to the pre-intervention ratings, Oswestry Low Back Disability scores decreased significantly in both groups at all studied post-intervention times (P ≤ 0.001), but this reduction was significantly greater in Group I than in Group II (P ≤ 0.001). The percentage of patients who reported Oswestry Low Back Disability score reductions ≥ 50.0% was also significantly higher in Group I (37.5%, 66.7%, 75% and 81.3% of patients at one, 2, 3, and 6 months, respectively, post-intervention) than in Group II (no patients at one and 2 months, 8.3% and 14.6% at 3 and 6 months, respectively, post-intervention) (P ≤ 0.001). No major complications were recorded for either of the studied groups. Short study period, single-centre study. High- and standard-voltage PRF administered in an area adjacent to the dorsal root ganglion provides significant improvements in radicular pain, as measured by the NRS, and function capacity, as measured by the Oswestry Disability Index, in patients with LRP associated with disc prolapse. However, of the 2 types of PRF procedures, HV-PRF yields superior pain relief and augments patients' functional status to a greater degree.
Are there differences in lifestyle and environmental exposures, and clinical characteristics between patients with histologically confirmed endometriosis residing in regional and metropolitan locations in Australia, and their impact on phenotype and disease severity? A retrospective study of patients with histologically confirmed endometriosis and detailed phenotypic mapping willing to participate in a Lifestyle and Environmental Risk Factor questionnaire. Demographic, lifestyle, environmental and clinical factors were compared between patients residing in regional and metropolitan locations in Australia, and between patients presenting with different lesion types. Body mass index (BMI; mean ± SD 27.16 ± 5.39 and 25.22 ± 4.93, respectively) and exposure to animal and plant toxins (14.0% and 3.0%, respectively; P = 0.0020) and pesticides (20.0% and 6.0%, respectively; P = 0.0059) were higher in regional participants compared with metropolitan participants. Increasing age (mean ± SD 36.26 ± 8.09, 40.84 ± 7.81 and 33.88 ± 8.39, respectively; P < 0.0001), leiomyomata (16.4%, 19.5 and 6.8%, respectively; P = 0.03) and infertility (63.9%, 63.4% and 40.9%, respectively; P = 0.04) were associated with higher rates of deep infiltrating endometriosis (DIE) and ovarian endometrioma (OMA) compared with superficial disease (SUP). Mental and behavioural problems were reported more often in patients with SUP and DIE than OMA (52.4%, 59.2% and 38.1%, respectively; P = 0.01). This study suggests significant differences in environmental exposures and lifestyle factors between patients with endometriosis living in regional areas of Australia compared with patients with endometriosis living in metropolitan areas of Australia. These findings emphasize the importance of environmental and lifestyle considerations in understanding the clinical variability of endometriosis.
Part 2 of the guideline addresses the updates on treatment recommendations in immunocompetent as well as immunosuppressed patients with invasive cutaneous squamous cell carcinoma (CSCC), based on current literature and expert consensus. A multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS)-Dermatology Venereology and the European Organization of Research and Treatment of Cancer (EORTC), was formed to update the previous guideline on CSCC (version 2023). For common primary CSCC, first-line treatment is surgical excision with post-operative margin assessment or micrographically controlled surgery. Achieving clear histological margins is key for patients with CSCC amenable to surgery. Radiotherapy should be considered for non-surgical candidates/tumors. For patients with macroscopic regional lymph node metastases, individualized treatment should be discussed in the multidisciplinary tumor board. For patients with metastatic or locally advanced CSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the approved systemic agent for advanced CSCC by the EMA. Second-line systemic treatments for advanced CSCC, include clinical trials, EGFR inhibitors (cetuximab) combined with anti-PD-1 immunotherapy, or chemotherapy or radiotherapy. The decision for adjuvant cemiplimab for CSCC at high risk of recurrence after surgery and radiotherapy should be discussed in the multidisciplinary tumor board. In addition, multidisciplinary board decisions are mandatory for all patients with advanced CSCC, considering the risks of toxicity, the age and frailty of patients and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with best supportive care to improve symptom management and quality of life. Frequency of follow-up visits and investigations for subsequent new CSCC depend on underlying risk characteristics.
Trans-sacral canalplasty (TSCP) is a minimally invasive epidural adhesiolysis technique positioned between conventional block therapy and open surgery. However, the relationship among MRI-defined levels of stenosis, epidurographic block patterns, and clinical effectiveness remains unclear. To investigate the clinical significance of mismatch between MRI-defined levels of stenosis and epidurographic block as well as to evaluate the short-term outcomes and feasibility of adhesiolysis in patients undergoing TSCP. A retrospective observational study. A university hospital in Japan and an affiliated institution. We reviewed all patients who underwent TSCP between October 2024 and August 2025. Baseline characteristics, diagnosis, surgical history, and minimum dural sac area at L3/4, L4/5, and L5/S (measured on MRI using ImageJ2) were assessed. Epidurography was performed to identify block levels, and cases were categorized as concordant (MRI-defined level of stenosis = block level) or discordant (mismatch). Discordant cases were subclassified into a "tail-stop" type (in which contrast stopped in a position caudal to the MRI-defined level of stenosis) and a "pass-through" type (in which these levels differed). Clinical effectiveness was defined as an improvement in low back pain or leg pain at one week after the procedure. Feasibility of adhesiolysis was also evaluated. Twenty-eight patients underwent TSCP during the study period. Nine (32.1%) showed concordance between MRI-defined levels of stenosis and epidurographic block sites, and 19 patients (67.9%) showed discordance (tail-stop, n = 11; pass-through, n = 8). Overall, 23 patients (82.1%) experienced clinical improvement. The effectiveness rate was 66.7% (6/9) in the concordance group and 89.5% (17/19) in the discordance group; however, the difference was not statistically significant (P = 0.290). In the discordance group, there was a significant difference in gender distribution between subgroups, with men predominating in the tail-stop subtype and women in the pass-through subtype (P = 0.024), but not in age, diagnosis, surgical history, or minimum dural sac area. Epidural dissection was successful in 21 patients (75.0%), with no significant difference between the effective and noneffective groups (73.9% vs 80.0%, P > 0.999). A single-center retrospective design, small sample size, and short-term follow-up of only one week. TSCP demonstrated favorable short-term clinical effectiveness, even in cases with mismatches between MRI and epidurographic findings. The feasibility of adhesiolysis may contribute to the clinical success of TSCP. Epidurographic mismatch should not be considered a contraindication for TSCP, and our findings support its role as a minimally invasive option for patients with degenerative disorders of the lumbar spine who are unsuitable for open surgery.
A transversus abdominis plane block provides reliable abdominal wall analgesia, but which adjuvants best sustain its effect remains debated. By facilitating diffusion of local anesthetics, hyaluronidase may improve block quality. This study evaluated the safety and efficacy of 2 hyaluronidase doses added to bupivacaine for bilateral transversus abdominis plane blocks in patients having a cesarean delivery. A prospective, randomized, double-blind, controlled clinical trial. Benha University Hospital, Arab Republic of Egypt, from May 2023 through February 2024. A double-blind, controlled randomized trial was performed with 114 patients having elective cesarean delivery. The patients were allocated equally into 3 arms: Group I (bupivacaine alone), Group II (bupivacaine plus 750 IU hyaluronidase), and Group III (bupivacaine plus 1500 IU hyaluronidase). The time to first rescue analgesia served as the primary outcome. Secondary outcomes encompassed 24-hour morphine requirements, Visual Analog Scale pain score at rest and on coughing, patient satisfaction, hemodynamics, and adverse events. Analyses employed the appropriate statistical tests (parametric or nonparametric), with subsequent post hoc comparisons for significant findings. Both hyaluronidase groups had significant prolonged analgesia (median 8.1 hours and 9.6 hours) compared to the control group (5.8 hours) (P < 0.001). Morphine requirements over the first postprocedure 24 hours diminished significantly (P < 0.001); Groups II and III had lower pain scores at rest and on coughing between postprocedure hours 2 and 12 (all P < 0.05). Patient satisfaction increased with hyaluronidase (P = 0.0039). No group differences were observed for adverse events, including postoperative nausea and vomiting or local anesthetic toxicity. This single-center trial with 24-hour follow-up may restrict generalizability and long-term safety assessment; also only 2 hyaluronidase doses were examined. Adding hyaluronidase to bupivacaine for transversus abdominis plane block enhances analgesic duration and quality without compromising safety in patients having cesarean delivery. Both high and low doses appear equally effective, suggesting that even lower doses are sufficient for optimal effect.
The benefit of intravenous thrombolysis (IVT) in patients with acute mild, non-disabling ischemic stroke remains uncertain. We evaluated the real-world effectiveness and safety of IVT and explored heterogeneity of treatment effects in prespecified subgroups. We conducted a single-center retrospective observational cohort study of consecutive adults with acute mild, non-disabling ischemic stroke treated at the Stroke Center of the Fifth Affiliated Hospital of Sun Yat-sen University (March 2019-October 2023). Eligible patients presented within 6 h, had baseline NIHSS ≤ 5 with each item ≤ 1 (and 0 on consciousness items), and had no deficits perceived as potentially disabling. Patients receiving endovascular therapy after IVT or scheduled cerebrovascular intervention within 3 months were excluded. The primary outcome was excellent functional outcome (90-day mRS 0-1). Secondary outcomes were functional independence (90-day mRS 0-2) and early neurological deterioration (END; NIHSS increase>2 within 7 days). Safety outcomes included hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH). Group comparisons used standard univariable tests; prespecified subgroup analyses were performed. Among 228 patients (mean age 60.7 ± 12.5 years; 66.3% male), 185 received IVT and 43 did not. Baseline characteristics were similar, except for a slightly higher median admission NIHSS in the IVT group (2 [IQR 1-2] vs 1 [IQR 1-2]; P < 0.001). At 90 days, mRS 0-1 occurred in 84.9% with IVT versus 74.4% without IVT (P = 0.117); functional independence (mRS ≤ 2) was 94.1% vs 90.7% (P = 0.492). END occurred in 12.4% vs 25.6% (P = 0.054). Any HT occurred in 5.9% vs 4.7% (P = 0.542); sICH was rare (1.1% vs 0.0%; P = 0.658). Subgroup analyses suggested a potential benefit of IVT in patients aged ≥ 65 years for achieving mRS 0-1. In acute mild, non-disabling ischemic stroke, IVT was not associated with increased hemorrhagic complications and did not significantly improve overall 90-day excellent functional outcome. Patients aged ≥ 65 years may derive greater functional benefit from IVT, warranting confirmation in larger prospective studies.
Patients with acute myeloid leukemia (AML) experience severe, co-occurring, and fluctuating symptoms during treatment. Accurate identification is critical but often limited by under documentation and unstructured electronic health record notes. To develop and validate a natural language processing (NLP) system to extract symptoms from inpatient clinical notes, characterize prevalence and co-occurrence of documented symptoms, and examine whether documentation patterns vary by patient- and note-level factors. We analyzed 78,392 clinical notes from 812 AML patients admitted between 2006 and 2021. Ten symptom categories were defined (pain, gastrointestinal, myelosuppression, cardiopulmonary, skin, fatigue, anxiety/anger, central nervous system, depression, and sleep). The NLP system was validated against 240 manually annotated notes, with performance assessed by precision, recall, and F1 score. Exploratory analyses using generalized estimating equations estimated odds of documentation by sex, age, and author type. The NLP system achieved high performance across all symptom categories (average F1 = 0.90). Gastrointestinal (97.3%), pain (95.9%), and myelosuppression (95.7%) were most frequently documented, with extensive co-occurrence across encounters. Fatigue and depression were less common. Men had lower odds of depression documentation than women, and older patients had lower odds across multiple domains. Compared with physicians, advanced practice registered nurses more often documented cardiopulmonary symptoms, while other provider groups documented fewer symptoms overall. NLP enables accurate, scalable extraction of symptom data from unstructured notes, supporting large-scale surveillance and predictive modeling in AML. Findings highlight the need for standardized documentation and tailored interventions to address symptom risks across patient groups.