Fantastic Four: Age, Spinal Cord Stimulator Waveform, Pain Localization and History of Spine Surgery Influence the Odds of Successful Spinal Cord Stimulator Trial.

BACKGROUND: There is a dearth in our understanding of the factors that are predictive of successful spinal cord stimulator (SCS) trials and eventual conversion to permanent implants. Knowledge of these factors is important for appropriate patient selection and treatment optimization. OBJECTIVES: Although previous studies have explored factors predictive of trial success, few have examined the role of waveform in trial outcomes. This study sought to establish the relationship of neuraxial waveform and related measures to trial outcomes. STUDY DESIGN: This study used a retrospective chart review design. METHODS: Data were retrospectively collected on 174 patients undergoing SCS trials upon institutional review board approval of the study protocol. Indications for SCS were: complex regional pain syndrome, failed back surgery syndrome with radicular symptoms, peripheral neuropathy, and axial low back pain. Descriptive statistics and logistic regression analyses were used to assess the association of demographic and clinical variables with SCS trial outcomes. RESULTS: The study population comprised 56% women, had a median age of 55 (interquartile range [IQR], 44-64), and 32 of 174 (18%) patients failed SCS trials. Individuals with successful trials (>= 50% pain relief) were significantly younger and had a median age of 54 years (IQR, 42-60) compared to those who failed SCS trials (median age 66 years; IQR, 50-76; P = .005). Adjusting for age, gender, number of leads, pain category, and diagnoses: surgical history (odds ratio [OR] = 4.4; 95% confidence interval [CI], 1.3-15.8) and paresthesia-based tonic-stimulation (OR = 10.3; 95% CI, 1.7-62.0), but not burst or high frequency, were significantly associated with successful trials. Of note, the number of leads (whether dual or single), pain duration, characteristics, and category (nociceptive vs neuropathic) were not significant factors. An interaction between surgical spine history and lower extremity pain was significantly associated with a positive trial (P = .005). LIMITATIONS: This study was limited by its retrospective nature and focus on a patient population at a single major academic medical center. CONCLUSIONS: Paresthesia-based tonic stimulation, age, and surgical history have significant effects on SCS trials. Prospective and randomized controlled studies may provide deeper insights regarding impact on costs and overall outcomes.IRB Approval #: 2018P002216. KEY WORDS: Pain duration, pain location, spinal cord stimulator trial, stimulator waveform, surgical history.

Motivation in computer-assisted instruction.

OBJECTIVES/HYPOTHESIS: Computer-aided instruction (CAI) is defined as instruction in which computers play a central role as the means of information delivery and direct interaction with learners. Computer-aided instruction has become mainstream in medical school curricula. For example, a three-dimensional (3D) computer module of the larynx has been created to teach laryngeal anatomy. Although the novelty and educational potential of CAI has garnered much attention, these new technologies have been plagued with low utilization rates. Several experts attribute this problem to lack of motivation in students. Motivation is defined as the desire and action toward goal-oriented behavior. Psychologist Dr. John Keller developed the ARCS theory of motivational learning, which proposed four components: attention (A), relevance (R), concentration (C), and satisfaction (S). Keller believed that motivation is not only an innate characteristic of the pupil; it can also be influenced by external factors, such as the instructional design of the curriculum. Thus, understanding motivation is an important step to designing CAI appropriately. Keller also developed a 36-item validated instrument called the Instructional Materials Motivation Survey (IMMS) to measure motivation. The objective of this study was to study motivation in CAI. Medical students learning anatomy with the 3D computer module will have higher laryngeal anatomy test scores and higher IMMS motivation scores. Higher anatomy test scores will be positively associated with higher IMMS scores. STUDY DESIGN: Prospective, randomized, controlled trial. METHODS: After obtaining institutional review board approval, 100 medical students (mean age 25.5 ± 2.5, 49% male) were randomized to either the 3D computer module (n = 49) or written text (n = 51). Information content was identical in both arms. Students were given 30 minutes to study laryngeal anatomy and then completed the laryngeal anatomy test and IMMS. Students were categorized as either junior (year 1 and 2) or senior (year 3 and 4). RESULTS: There were no significant differences in anatomy scores based on educational modality. There was significant interaction of educational modality by year [F(1,96) = 4.12, P = 0.045, ω(2) = 0.031]. For the total score, there was a significant effect of year [F(1,96) = 22.28, P < 0.001, ω(2) = 0.178], with seniors (15.4 ± 2.6) scoring significantly higher than juniors (12.8 ± 3.1). For the motivational score, the total IMMS score had two significant effects. With educational modality [F(1,96) = 5.18, P = 0.025, ω(2) = 0.041], the 3D group (12.4 ± 2.8) scored significantly higher than the written text group (11.7 ± 3.2). With year [F(1,96) = 25.31, P < 0.001, ω(2) = 0.198], seniors (13.4 ± 3.0) scored significantly higher than juniors (10.8 ± 2.5). Pearson's correlation showed positive associations (r = 0.22-0.91) between anatomy scores and IMMS motivation scores (P < 0.05). CONCLUSION: Computer-aided instruction conferred no measurable educational benefit over traditional written text in medical students; however, CAI was associated with higher motivational levels. Computer-aided instruction was found to have a greater positive impact on senior medical students with higher anatomy and motivational scores. Higher anatomy scores were positively associated with higher motivational scores. Computer-aided instruction may be better targeted toward senior students. LEVEL OF EVIDENCE: N/A. Laryngoscope, 126:S5-S13, 2016.

Evaluating the quality and readability of thyroplasty information on the Internet.

OBJECTIVES/HYPOTHESIS: To assess the quality and readability of thyroplasty information available on the Internet. STUDY DESIGN: Cross-sectional study. METHODS: We conducted a Google search for "thyroplasty treatment" and analyzed the first 50 Web sites using the DISCERN instrument, the Flesch Reading Ease Score (FRES), and the Flesch-Kincaid Grade Level (FKGL) score. DISCERN is a 16-item validated questionnaire used to assess the quality of written health information for patients. FRES and FKGL are commonly used instruments to assess readability of written information. We also further analyzed major versus minor and patient-targeted versus professional Web sites. RESULTS: Overall DISCERN score was 2.20 ± 0.60. Overall FRES score was 29.68 ± 16.64. Overall FKGL score was 13.07 ± 3.95. We found significant differences between patient-targeted and professional Web sites on FRES (43.80 ± 2.78 and 18.58 ± 9.04, respectively) and FKGL (11.46 ± 3.36 and 14.33 ± 4.30, respectively) (P < 0.00 and P = 0.01, respectively). We also found significant differences between major and minor Web sites on DISCERN (2.35 ± 2.35 and 1.95 ± 0.61, respectively), FRES (24.75 ± 14.61 and 37.71 ± 16.97, respectively), and FKGL (14.19 ± 3.68 and 11.24 ± 3.77, respectively) (P = 0.03, 0.01, and 0.01, respectively). CONCLUSIONS: Thyroplasty information available online is of suboptimal quality and written at a level too difficult for the average American adult to read comfortably. Major Web sites have higher quality information but are more difficult to read. Professional Web sites are also more difficult to read than patient-targeted Web sites.