Deep Brain Stimulation Management of Essential Tremor with Dystonic Features

Clinical Vignette: A 64-year-old female with essential tremor (ET) presents for evaluation of deep brain stimulation (DBS) candidacy. Examination revealed subtle dystonic features as well as a disabling postural-action tremor. Clinical Dilemma: Can dystonia occur in the setting of the diagnosis of ET and can its presence alter DBS target selection? Clinical Solution: Unilateral DBS implantation of the ventralis intermedius (Vim) led to improvement in both tremor and dystonic posturing. Gap in Knowledge: Case reports of DBS in dystonic tremor suggest Vim, globus pallidus internus (GPi), and subthalamic targets may all be effective, to varying degrees, in improving both tremor and dystonia. More rigorous studies are needed to identify the optimal target(s). Expert Commentary: This case underscores the limited evidence available to guide a clinician’s choice of DBS targets in patients with ET and dystonia. The severity of the dystonia and the presence of more generalized dystonia may alter the thinking about optimal targeting. Vim, GPi, and subthalamic targets appear potentially acceptable options, though Vim is usually the first target attempted when postural-action tremor is the chief complaint. Occasionally, a second rescue DBS lead may be necessary

Forms of ministry that can offer good news, and inspire commitment and moral leadership in post-apartheid South Africa among students at the University of Natal (Pietermaritzburg).

Thesis (M.Th.)-University of Natal, Pietermaritzburg, 2000.This study in Practical Theology has been motivated by a concern that, in post-apartheid South Africa, it has become more difficult for yoling people in general, and university students in particular to have a vision for, and hope in the future, and hence to demonstrate commitment to working for a new world. It therefore seeks to identify ways in which such commitment and leadership can be nurtured, by engaging in a critical reflection on ministry to university students. This is done through the use of the critical hermeneutical method of correlation between the Christian tradition and human life experience as employed by Don S. Browning, lames and Evelyn Whitehead, and Stuart Bate. This involves beginning with concrete practice, going to theory, and then concluding with practice, in an ongoing hermeneutical circle. A case study is presented of the Association of Catholic Tertiary Students (ACTS) at the University of Natal in Pietermaritzburg (UNP), and an analysis of their situation is undertaken, using two mediations. A psychological mediation identifies the psychological structures to which university students are capable of evolving at their stage of development, which is characterised by relativism and probing commitment. A socio-cultural mediation explores the roots of the loss of a sense of commmunity, and the growth in a spirit of individualism that epitomise the central issues within the UNP ACTS group. These roots are identified in the globalisation that is taking place at an economic, social and cultural level, resulting in relativisation, rationalisation, and personalisation in all dimensions of life. This gives rise to increasing competition, individualism and cultural dislocation, which are particularly evident since the demise of apartheid and the international integration of South Africa, coupled with the collapse of many of the hopes generated in the struggle against apartheid. A theological judgement of the ministry being employed within ACTS is then made, which points to the forms of ministry which could offer good news, evoke deeper commitment, and build stronger moral leadership amongst the students. The priority emerging is to foster selfesteem amongst them, primarily through building a joyful, accepting community with a small group pedagogy so that they can discover liberating message of the gospel in their quest for God, for survival in a hostile world, and for personal intimacy and acceptance. Such empowerment, it is suggested, makes deeper commitment possible

Living Donor Liver Transplantation for Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is in most transplant regions a contraindication for liver transplantation, even ruling out an active waiting list registration. However, recent studies showed that well-selected patients after a neo-adjuvant treatment benefit from liver transplantation with good long-term outcomes. The role of living donor liver transplantation is unclear for this indication. The current study focuses on LDLT for intrahepatic cholangiocarcinoma

Impact of a specialty trained billing team on an academic otolaryngology practice

PURPOSE: To determine how the incorporation of specialty specific training for coders within a focused billing team affected revenue, efficiency, time to reimbursement, and physician satisfaction in an academic otolaryngology practice. MATERIALS AND METHODS: Our academic otolaryngology department recently implemented a new billing system, which incorporated additional training in otolaryngology surgical procedures for medical coders. A mixed model analysis of variance was used to compare billing outcomes for the 6 months before and 6 months after this new approach was initiated. The following metrics were analyzed: Current Procedural Terminology codes, total charges, time between services rendered and billing submission, and time to reimbursement. A survey of department physicians assessing satisfaction with the system was reviewed. RESULTS: There were 4087 Current Procedural Terminology codes included in the analysis. In comparing the periods before and after implementation of the new system, statistically significant decreases were found in the mean number of days to coding completion (19.3 to 12.0, respectively, p \u3c 0.001), days to posting of charges (27.0 to 15.2, p \u3c 0.001), days to final reimbursement (54.5 to 27.2, p \u3c 0.001), and days to closure of form (179.2 to 76.6, p \u3c 0.001). Physician satisfaction with communication and coder feedback increased from 36% to 64% after initiation of the new program. CONCLUSIONS: The implementation of additional specialty training for medical coders in the otolaryngology department of a large medical system was associated with improved revenue cycle efficiency. Additionally, this model appears to improve physician satisfaction and confidence with the coding system

Degradation and Removal Methods for Perfluoroalkyl and Polyfluoroalkyl Substances in Water

Several perfluoroalkyl and polyfluoroalkyl substances (PFASs) have been identified as chemicals of concern in the environment due to their persistence, global ubiquity, and classification as reproductive and developmental toxicants, endocrine disrupters, and possible carcinogens. Multiple PFASs are often found together in the environment due to product manufacturing methods and abiotic and biotic transformations. Treatment methods are needed to effectively sequester or destroy a variety of PFASs from groundwater, drinking water, and wastewater. This review presents a comprehensive summary of several categories of treatment approaches: (1) sorption using activated carbon, ion exchange, or other sorbents, (2) advanced oxidation processes, including electrochemical oxidation, photolysis, and photocatalysis, (3) advanced reduction processes using aqueous iodide or dithionite and sulfite, (4) thermal and nonthermal destruction, including incineration, sonochemical degradation, sub- or supercritical treatment, microwave-hydrothermal treatment, and high-voltage electric discharge, (5) microbial treatment, and (6) other treatment processes, including ozonation under alkaline conditions, permanganate oxidation, vitamin-B_(12) and Ti(III) citrate reductive defluorination, and ball milling. Discussion of each treatment technology, including background, mechanisms, advances, and effectiveness, will inform the development of cost-effective PFAS remediation strategies based on environmental parameters and applicable methodologies. Further optimization of current technologies to analyze and remove or destroy PFASs below regulatory guidelines is needed. Due to the stability of PFASs, a combination of multiple treatment technologies will likely be required to effectively address real-world complexities of PFAS mixtures and cocontaminants present in environmental matrices

Postoperative fluid collection after hybrid debranching and endovascular repair of thoracoabdominal aortic aneurysms

ObjectiveHybrid thoracic endovascular aneurysm repair (H-TEVAR) to include visceral and renal debranching has emerged as a potential therapeutic option for thoracoabdominal aneurysms (TAAA). This study was performed to characterize the frequently noted development of postoperative fluid collections surrounding the bypass grafts.MethodsAll patients undergoing H-TEVAR from 2000-2010 (n = 39, 43.6% male) were identified. One hundred thirty-two bypasses were constructed (median 4 per patient) using either polyester (30), thin-walled polytetrafluoroethylene (ePTFE, 100) or saphenous vein (2). Follow-up computed tomography (CT) imaging was routinely performed at 1 and 6 months, and annually thereafter.ResultsOf the 37 patients with one follow-up CT, 20 (54.1%) were found to have fluid collections. The natural history of the 17 patients with collections and further follow-up imaging was variable, with 2 resolving, 6 stable, and 9 enlarging. Two patients with collections developed evidence of graft infection requiring reoperation. Two patients with enlarging sterile collections required evacuation for symptoms. By multivariate analysis, both preoperative creatinine (P = .005) and number of bypasses constructed (P = .04) independently correlated with the development of a fluid collection.ConclusionsPostoperative fluid collections following hybrid debranching procedures identified in this series represent a unique complication not previously described. The subsequent clinical course of these fluid collections is variable and ranges from benign to frank graft infection and relate both to patient factors, as well as specific operative strategies. Longer-term studies with more robust numbers of patient numbers are warranted to determine whether this complication may limit the long-term durability of this procedure

Atrioventricular conduction in patients undergoing pacemaker implant following self‐expandable transcatheter aortic valve replacement

BackgroundHeart block requiring a pacemaker is common after self‐expandable transcatheter aortic valve replacement (SE‐TAVR); however, conduction abnormalities may improve over time. Optimal device management in these patients is unknown.ObjectiveTo evaluate the long‐term, natural history of conduction disturbances in patients undergoing pacemaker implantation following SE‐TAVR.MethodsAll patients who underwent new cardiac implantable electronic device (CIED) implantation at Michigan Medicine following SE‐TAVR placement between January 1, 2012 and September 25, 2017 were identified. Electrocardiogram and device interrogation data were examined during follow‐up to identify patients with recovery of conduction. Logistic regression analysis was used to compare clinical and procedural variables to predict conduction recovery.ResultsFollowing SE‐TAVR, 17.5% of patients underwent device placement for new atrioventricular (AV) block. Among 40 patients with an average follow‐up time of 17.1 ± 8.1 months, 20 (50%) patients had durable recovery of AV conduction. Among 20 patients without long‐term recovery, four (20%) had transient recovery. The time to transient conduction recovery was 2.2 ± 0.2 months with repeat loss of conduction at 8.2 ± 0.9 months. On multivariate analysis, larger aortic annular size (odds ratio: 0.53 [0.28–0.86]/mm, P = 0.02) predicted lack of conduction recovery.ConclusionsHalf of the patients undergoing CIED placement for heart block following SE‐TAVR recovered AV conduction within several months and maintained this over an extended follow‐up period. Some patients demonstrated transient recovery of conduction before recurrence of conduction loss. Larger aortic annulus diameter was negatively associated with conduction recovery.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150495/1/pace13694_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150495/2/pace13694.pd