The Effect of Local Anesthetics and Contrast Agents on Radiofrequency Ablation Lesion Size.

BACKGROUND: Radiofrequency ablation (RFA) is a validated treatment option for the treatment of chronic pain in patients with lumbar spondylosis. Lesion size has been suggested to correlate with good clinical outcomes. This has created an abundance of scientific interest in the development of products with larger lesion characteristics. Needle characteristics, energy transfer, and heat rate are known to modify lesion size. Here, we demonstrate that common intraoperative solutions, such as lidocaine, iodine, and gadolinium-based products, can also affect lesion shape. OBJECTIVES: To determine whether lidocaine and contrast agents modify lesion characteristics during the performance of monopolar RFA. STUDY DESIGN: Controlled, ex vivo study using clinically relevant conditions and pre-injections. SETTING: Academic institution in a procedural setting. METHODS: RFA lesion size was compared among six cohorts: 1) lidocaine 1%, 2) lidocaine 2%, 3) iohexol 180, 4) iohexol 240, 5) gadodiamide, and 6) control (no fluid control). Radiofrequency (RF) current was applied for 90 seconds at 80°C via 20-gauge 100-mm standard RFA needles with 10-mm active tips in orgranic chicken breasts without preservative at room temperature (21°C). Twelve lesions were performed for each medication cohort. The length, width, and depth of each lesion were measured. The statistical significance between each medication group and the control group was evaluated by t test. RESULTS: The mean lesion surface area of monopolar RFA without any pre-injection used was 80.8 mm2. The mean surface area of the monopolar RF lesion with a pre-injection of 0.2 mL of 2% lidocaine was 114 mm2, and the mean surface area of the monopolar RF lesion with a pre-injection of 0.2 mL of iohexol 240 was 130.6 mm2. The statistical analysis demonstrated that the control group had significantly smaller lesion sizes than did the groups in which lidocaine 2% and iohexol 240 were used (P<0.01). There were no statistically significant differences among the groups in which lidocaine 1%, iohexol 180, and gadodiamide were used. A notable difference was a 20% longer lesion with iohexol 240 compared with the control group and a 20% wider lesion with lidocaine 2% compared with the control group. LIMITATIONS: In vivo anatomy within a human was not used in this study, nor were the chicken breasts heated to physiological temperature. Randomization of pieces of chicken breast did not occur, and thus intrinsic differences among the chicken breast pieces could play a confounding role. CONCLUSIONS: Lidocaine 2% and iohexol 240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol 180, or gadodiamide were not found to produce a statistically significant difference in lesion size compared with monopolar RFA without the use of injectate.

Diaphragm depth in normal subjects.

INTRODUCTION: Needle electromyography (EMG) of the diaphragm carries the potential risk of pneumothorax. Knowing the approximate depth of the diaphragm should increase the test's safety and accuracy. METHODS: Distances from the skin to the diaphragm and from the outer surface of the rib to the diaphragm were measured using B mode ultrasound in 150 normal subjects. RESULTS: When measured at the lower intercostal spaces, diaphragm depth varied between 0.78 and 4.91 cm beneath the skin surface and between 0.25 and 1.48 cm below the outer surface of the rib. Using linear regression modeling, body mass index (BMI) could be used to predict diaphragm depth from the skin to within an average of 1.15 mm. CONCLUSIONS: Diaphragm depth from the skin can vary by more than 4 cm. When image guidance is not available to enhance accuracy and safety of diaphragm EMG, it is possible to reliably predict the depth of the diaphragm based on BMI.

Seizures and epilepsy in elderly patients of an urban area of Iran: clinical manifestation, differential diagnosis, etiology, and epilepsy subtypes.

The incidences of seizures and epilepsy in the population show a peak after 60 years of age. Due to the lack of reported clinical aspects of seizure and epilepsy in the older patients in our region in Iran, this study was conducted to describe the clinical manifestation, etiology, differential diagnosis, and epilepsy subtypes of epilepsy and seizure. A cross-sectional retrospective study was performed on all consecutively elderly seizure and epilepsy patients, referred to the Epilepsy Association in the city of Qom, Iran over a 10-year period. A total of 466 patients aged >60 years were admitted. 31 % of the patients had epilepsy or seizure and 69 % of them had non-epileptic events. The most prevalent differential diagnoses in the beginning were syncope and cardiovascular disorders. The most frequent clinical symptom of epilepsy was generalized tonic-clonic seizures (75 %). The most common cause of seizure was systemic metabolic disorder (27 %). In epileptic elderly patients, no cause was ascertained for 38 % and the most frequently observed pathological factors were cerebrovascular diseases, which accounted for 24 %. The most common type of epileptic seizure was generalized epileptic seizures (75 %). 10 % of elderly epileptic patients suffered from status epilepticus, which was primarily caused by anoxia. Despite the rising rate and potentially profound physical and psychosocial effects of seizures and epilepsy, these disorders have received surprisingly little research focus and attention in Iran. Referring older patients to a specialist or a specialist epilepsy center allows speedy assessment, appropriate investigation and treatment, and less likely to miss the diagnosis.

Adipose Tissue Impacts Radiofrequency Ablation Lesion Size: Results of an Ex Vivo Poultry Model.

BACKGROUND: Radiofrequency ablation (RFA) is a common treatment in which radiofrequency (RF) is used to heat neural tissue and reduce pain. The impact of adipose content in tissue on the lesion size may impact efficacy, and to date, there is little, if any, data comparing its influence on RFA. OBJECTIVES: We evaluated the influence of adipose tissue on RF lesion size. STUDY DESIGN: Controlled, ex vivo study. SETTING: Academic institution in a procedural setting. METHODS: RF lesions were created using 20-G 10-mm protruding electrode (PE) needles inserted into unbrined chicken breasts and thighs at 21°C. RF current was applied for 90 seconds at 80°C. Chicken breasts were used as the control group and chicken thighs were used as the high adipose variant. Four different groups were examined: 1- Standard 20 g RFA needle, 2- 20 g RFA PE needle, 3- Standard RFA needle with lidocaine 2% injectate, and 4- Standard RFA needle with iohexol 240 mg injectate. There were 12 lesions performed in each group; length, width, and depth were measured. RESULTS: The control group had significantly deeper lesions in all 4 cohorts. Lesions' lengths were smaller in the fat-rich group. The control and PE cohorts showed a significant difference in width between the 2 fat-rich and nonfatty groups. LIMITATIONS: Radiofrequency ablation was performed at room temperature and not heated to physiological temperature. This was an ex vivo study, thus factors of human anatomy and physiology could not be evaluated. CONCLUSIONS: Adipose tissue content was inversely related to lesion size in all samples. This factor should be considered when assessing methods of enhancing lesion size in human models.

Square Biphasic Pulse Deep Brain Stimulation for Parkinson's Disease: The BiP-PD Study.

BACKGROUND: Conventional Parkinson's disease (PD) deep brain stimulation (DBS) utilizes a pulse with an active phase and a passive charge-balancing phase. A pulse-shaping strategy that eliminates the passive phase may be a promising approach to addressing movement disorders. OBJECTIVES: The current study assessed the safety and tolerability of square biphasic pulse shaping (sqBIP) DBS for use in PD. METHODS: This small pilot safety and tolerability study compared sqBiP versus conventional DBS. Nine were enrolled. The safety and tolerability were assessed over a 3-h period on sqBiP. Friedman's test compared blinded assessments at baseline, washout, and 30 min, 1 h, 2 h, and 3 h post sqBIP. RESULTS: Biphasic pulses were safe and well tolerated by all participants. SqBiP performed as well as conventional DBS without significant differences in motor scores nor accelerometer or gait measures. CONCLUSION: Biphasic pulses were well-tolerated and provided similar benefit to conventional DBS. Further studies should address effectiveness of sqBIP in select PD patients.

Square biphasic pulse deep brain stimulation for essential tremor: The BiP tremor study.

BACKGROUND: Conventional deep brain stimulation (DBS) utilizes regular, high frequency pulses to treat medication-refractory symptoms in essential tremor (ET). Modifications of DBS pulse shape to achieve improved effectiveness is a promising approach. OBJECTIVES: The current study assessed the safety, tolerability and effectiveness of square biphasic pulse shaping as an alternative to conventional ET DBS. METHODS: This pilot study compared biphasic pulses (BiP) versus conventional DBS pulses (ClinDBS). Eleven ET subjects with clinically optimized ventralis intermedius nucleus DBS were enrolled. Objective measures were obtained over 3 h while ON BiP stimulation. RESULTS: There was observed benefit in the Fahn-Tolosa Tremor Rating Scale (TRS) for BiP conditions when compared to the DBS off condition and to ClinDBS setting. Total TRS scores during the DBS OFF condition (28.5 IQR = 24.5-35.25) were significantly higher than the other time points. Following active DBS, TRS improved to (20 IQR = 13.8-24.3) at ClinDBS setting and to (16.5 IQR = 12-20.75) at the 3 h period ON BiP stimulation (p = 0.001). Accelerometer recordings revealed improvement in tremor at rest (χ2 = 16.1, p = 0.006), posture (χ2 = 15.9, p = 0.007) and with action (χ2 = 32.1, p=<0.001) when comparing median total scores at ClinDBS and OFF DBS conditions to 3 h ON BiP stimulation. There were no adverse effects and gait was not impacted. CONCLUSION: BiP was safe, tolerable and effective on the tremor symptoms when tested up to 3 h. This study demonstrated the feasibility of applying a novel DBS waveform in the clinic setting. Larger prospective studies with longer clinical follow-up will be required.

Hospitalization and rehospitalization in Parkinson disease patients: Data from the National Parkinson Foundation Centers of Excellence.

BACKGROUND: Patients with Parkinson disease (PD) are at high risk of hospital encounters with increasing morbidity and mortality. This study aimed to determine the rate of hospital encounters in a cohort followed over 5 years and to identify associated factors. METHODS: We queried the data from the International Multicenter National Parkinson Foundation Quality Improvement study. Multivariate logistic regression with backward selection was performed to identify factors associated with hospital encounter prior to baseline visit. Kaplan-Meier estimates were obtained and Cox regression performed on time to hospital encounter after the baseline visit. RESULTS: Of the 7,507 PD patients (mean age 66.5±9.9 years and disease duration 8.9±6.4 years at baseline visit), 1919 (25.6%) had a history of a hospital encounter prior to their baseline visit. Significant factors associated with a history of a hospital encounter prior to baseline included race (white race: OR 0.49), utilization of physical therapy (OR 1.47), history of deep brain stimulation (OR 1.87), number of comorbidities (OR 1.30), caregiver strain (OR 1.17 per standard deviation), and the standardized Timed Up and Go Test (OR 1.21). Patients with a history of hospitalization prior to the baseline were more likely to have a re-hospitalization (HR1.67, P<0.0001) compared to those without a prior hospitalization. In addition, the time to hospital encounter from baseline was significantly associated with age and number of medications. In patients with a history of hospitalization prior to the baseline visit, time to a second hospital encounter was significantly associated with caregiver strain and number of comorbidities. CONCLUSION: Hospitalization and re-hospitalization were common in this cohort of people with PD. Our results suggest addressing caregiver burden, simplifying medications, and emphasizing primary and multidisciplinary care for comorbidities are potential avenues to explore for reducing hospitalization rates.

B-mode ultrasound assessment of diaphragm structure and function in patients with COPD.

BACKGROUND: Electromyographic evaluation of diaphragmatic neuromuscular disease in patients with COPD is technically difficult and potentially high risk. Defining standard values for diaphragm thickness and thickening ratio using B-mode ultrasound may provide a simpler, safer means of evaluating these patients. METHODS: Fifty patients with a diagnosis of COPD and FEV1 < 70% underwent B-mode ultrasound. Three images were captured both at end expiration (Tmin) and at maximal inspiration (Tmax). The thickening ratio was calculated as (Tmax/Tmin), and each set of values was averaged. Findings were compared with a database of 150 healthy control subjects. RESULTS: There was no significant difference in diaphragm thickness or thickening ratio between sides within groups (control subjects or patients with COPD) or between groups, with the exception of the subgroup with severe air trapping (residual volume > 200%), in which the only difference was that the thickening ratio was higher on the left (P = .0045). CONCLUSIONS: In patients with COPD presenting for evaluation of coexisting neuromuscular respiratory weakness, the same values established for healthy control subjects serve as the baseline for comparison. This knowledge expands the role of ultrasound in evaluating neuromuscular disease in patients with COPD.

Variability in diaphragm motion during normal breathing, assessed with B-mode ultrasound.

STUDY DESIGN: Clinical measurement, cross-sectional. OBJECTIVES: To establish a set of normal values for diaphragm thickening with tidal breathing in healthy subjects. BACKGROUND: Normal values for diaphragm contractility, as imaged sonographically, have not been described, despite the known role of the diaphragm in contributing to spinal stability. If the normal range of diaphragm contractility can be defined in a reliable manner, ultrasound has the potential to be used clinically and in research as a biofeedback tool to enhance diaphragm activation/contractility. METHODS: B-mode ultrasound was performed on 150 healthy subjects to visualize and measure hemi-diaphragm thickness on each side at resting inspiration and expiration. Primary outcome measures were hemi-diaphragm thickness and thickening ratio, stratified for age, gender, and body mass index. Interrater and intrarater reliability were also measured. RESULTS: Normal thickness of the diaphragm at rest ranged from 0.12 to 1.18 cm, with slightly greater thickness in men but no effect of age. Average ± SD change in thickness from resting expiration to resting inspiration was 20.0% ± 15.5% on the right and 23.5% ± 24.4% on the left; however, almost one third of healthy subjects had no to minimal diaphragm thickening with tidal breathing. CONCLUSION: There is wide variability in the degree of diaphragm contractility during quiet breathing. B-mode ultrasound appears to be a reliable means of determining the contractility of the diaphragm, an important muscle in spinal stability. Further studies are needed to validate this imaging modality as a clinical tool in the neuromuscular re-education of the diaphragm to improve spinal stability in both healthy subjects and in patients with low back pain.

Impact of self-citation on the H index in the field of academic radiology.

RATIONALE AND OBJECTIVES: The Hirsch Index (H index) is widely applied as a metric of scientific productivity. The purpose of this study was to evaluate the role of self-citation on the H index in academic radiology. MATERIALS AND METHODS: Through the National Resident Matching Program's Web site, one third (47/139) of radiology residency programs were selected randomly. All chairpersons and full professors were included. Using the Scopus database, we calculated the H index as well as the number of cumulative citations with and without inclusion of self-citations. We determined the proportion of academic staff in which H index increased by one, two, or greater than two integers. We also correlated the proportional increase in H index before and after inclusion of self citations with the number of publications. RESULTS: A total of 487 academic staff (47 chair and 440 professors) was identified. Because of self-citation, mean ± SD of the H index increased from 13.7 ± 9.9 to 14.0 ± 10.2; mean ± SD of cumulative citations increased from 1804 ± 1889 to 1870 ± 1971. H index numbers did not change in 376/487 (77%) authors as a result of self-citation. There was no correlation between number of publications and proportional change of H index. CONCLUSION: The effect of self-citation is minimal in academic radiology, as evidenced by the fact that cumulative citations increase by only 2% and the large majority of H index values do not change by even a single integer after inclusion of self-citation.

A comparison of manual and quantitative elbow strength testing.

OBJECTIVE: The aim of this study was to compare the clinical ratings of elbow strength obtained by skilled clinicians with objective strength measurement obtained through quantitative testing. DESIGN: A retrospective comparison of subject clinical records with quantitative strength testing results in a motion analysis laboratory was conducted. A total of 110 individuals between the ages of 8 and 65 yrs with traumatic brachial plexus injuries were identified. Patients underwent manual muscle strength testing as assessed on the 5-point British Medical Research Council Scale (5/5, normal; 0/5, absent) and quantitative elbow flexion and extension strength measurements. RESULTS: A total of 92 subjects had elbow flexion testing. Half of the subjects clinically assessed as having normal (5/5) elbow flexion strength on manual muscle testing exhibited less than 42% of their age-expected strength on quantitative testing. Eighty-four subjects had elbow extension strength testing. Similarly, half of those displaying normal elbow extension strength on manual muscle testing were found to have less than 62% of their age-expected values on quantitative testing. Significant differences between manual muscle testing and quantitative findings were not detected for the lesser (0-4) strength grades. CONCLUSIONS: Manual muscle testing, even when performed by experienced clinicians, may be more misleading than expected for subjects graded as having normal (5/5) strength. Manual muscle testing estimates for the lesser strength grades (1-4/5) seem reasonably accurate.