Raleigh Neurology Associates

Spontaneous uterine perforation due to pyometra, the accumulation of fluid within the uterus, is an uncommon cause of acute abdomen. Malignancy should be ruled out in these cases, as pyometra is often associated with gynecological cancers. Symptoms of perforated pyometra are often vague and mistaken for gastrointestinal perforation. A 74-year-old postmenopausal woman presented with severe abdominal pain and nausea. Due to the nonspecific symptoms and pneumoperitoneum on CT imaging, preoperative assessment was consistent with perforated bowel; however, upon diagnostic laparoscopy and peritoneal lavage, perforated pyometra was found. A total hysterectomy with bilateral salpingo-oophorectomy was subsequently performed. Though rare, perforated pyometra should be considered in postmenopausal females with symptoms of acute abdomen due to its high morbidity and mortality. Diagnostic laparoscopy is effective for diagnosing unclear etiologies of acute abdomen and has many benefits compared to exploratory laparotomy.

To determine the clinical characteristics of patients with multiple sclerosis (MS) who switch from B-cell depleting therapies (anti-CD20s) to natalizumab (NTZ; TYSABRI®); to estimate the annualized relapse rate (ARR), time to first relapse, and MS healthcare resource utilization (HRU) and healthcare costs (HCC).

Summary:The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET—The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.

Aim: The availability of long-term (>2years) safety outcomes of spinal cord stimulation (SCS) remains limited. We evaluated safety in a global SCS registry for chronic pain. Methods: Participants were prospectively enrolled globally at 79 implanting centers and followed out to 3yearsafter device implantation. Results: Of 1881 participants enrolled, 1289 received a permanent SCS implant(1776completed trial). The annualized rate of device explant was 3.5% (all causes), and 1.1% due to inadequate pain relief. Total incidence of device explantation >3years was 7.6% (n=98). Of these, 32subjects (2.5%) indicated inadequate pain relief as cause for removal. Implantsite infection (11 events) was the most common device-related serious adverse event(<1%). Conclusion: This prospective, global, real-world study demonstrates a high-level of safety for SCS with low rate of explant/serious adverse events. Clinical Trial Registration: NCT01719055 (ClinicalTrials.gov).

Polyvinylidene fluoride (PVDF) has been considered as an alternative suture material to replace polypropylene (PP) due to its superior biocompatibility and mechanical properties, but it has never been examined for use in barbed sutures, particularly for tendon repair. This study fabricated size 2–0 PVDF and PP bidirectional barbed sutures and compared their mechanical properties and anchoring performance in patellar tendons. The mechanical properties were evaluated via tensile testing, and the anchoring performance of the barbed sutures was assessed by a tendon suture pullout test. Sixty porcine patellar tendons were harvested, transected to mimic a full‐thickness injury, and repaired using a cross‐locked cruciate suturing technique. The ultimate tensile force was 60% higher for the PVDF barbed sutures (22.4 ± 2.1 N) than for the PP barbed sutures (14.0 ± 1.7 N). The maximum pullout force was 35% higher for PVDF barbed sutures (70.8 ± 7.8 N) than for PP barbed sutures (52.4 ± 5.8 N). The force needed to form a 2‐mm gap, indicative of repair failure, was similar between the PVDF (29.2 ± 5.0 N) and PP (25.6 ± 3.1 N) barbed sutures, but both were greater than the 2‐mm‐gap forces for non‐barbed sutures of the same size. In this study, PVDF barbed sutures provided better mechanical properties and improved tissue anchoring performance compared to the barbed PP sutures for porcine patellar tendon repair, demonstrating that PVDF monofilament sutures can be barbed and used effectively for tendon repair.

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a self-limited idiopathic inflammatory ophthalmologic condition with characteristic funduscopic and fluorescein angiography findings. It is typically characterized by a flu-like prodrome followed by monocular or binocular vision loss. Often, prognosis is excellent with complete or near-complete recovery of vision. Rarely, however, APMPPE is associated with neurologic complications, including meningitis, cerebral vasculitis, and stroke. Treatment in patients with central nervous system (CNS) involvement involves steroids and ultimately other immunosuppressive therapy, as there can be significant resulting morbidity and mortality otherwise. Evidence or guidelines regarding duration of treatment are lacking. We present 4 patients diagnosed with APMPPE who demonstrate the spectrum of neurologic sequelae associated with APMPPE. The first 2 cases highlight cerebrospinal fluid lymphocytic pleocytosis as an indicator of active CNS inflammation and the potential utility of serial lumbar punctures (LPs) to guide treatment duration. Cases 3 and 4 demonstrate the neurovascular complications seen in CNS vasculitis. Case 4 also highlights the potential use of magnetic resonance vessel wall imaging (VWI) as a noninvasive means for disease surveillance and treatment guidance. This case series emphasizes the importance of recognition by neurologists of APMPPE as an entity associated with strokes and cerebral vasculitis in order to provide appropriate and timely treatment. Active CNS inflammation warrants continued aggressive immunosuppressant treatment, and we propose that serial LPs and/or magnetic resonance VWIs may be effective tools to guide disease surveillance and subsequent treatment duration.

Noninvasive anatomic imaging is critical to management of pediatric congenital heart disease. With the introduction of high-pitch dual-source computed tomography (CT), comprehensive, high-temporal resolution cardiovascular imaging can now be performed without the need for breath-holding or patient sedation with very low radiation dose. In this article, we review the unique advantages of dual-source cardiac CT relative to other imaging modalities and illustrate its utility for patient management with multiple case examples.