Dorsal Root Ganglion Stimulation for the Management of Phantom Bladder Pain: A Case Report.

Phantom bladder pain, a rare condition following cystectomy, can pose a challenge to pain management providers. We present the case of a 43-year-old male who developed severe phantom bladder pain post-cystectomy. Despite multiple treatments, his symptoms persisted, significantly affecting his quality of life. Dorsal root ganglion stimulation (DRGS) was attempted after conventional therapies failed. The DRGS trial provided significant relief, leading to permanent implantation and a 90% reduction in pain. This case highlights DRGS as a potential treatment for phantom bladder pain, expanding its applications beyond traditional uses. Further research is needed to elucidate its mechanisms and broader applicability.

Wireless High-Frequency Peripheral Nerve Stimulation for Chronic Refractory Knee Pain Post-total Knee Replacement.

The number of joint replacement surgeries, especially knee replacement surgeries, is rising with the rising geriatric population. Chronic unremitting knee pain post-total knee replacement surgery is a common phenomenon. Usually, the pain responds to conservative measures, including physical therapy and medical management. In some patients, the pain post-knee replacement surgery can be refractory and unremitting. In such scenarios, peripheral nerve stimulation, or neuromodulation, can be an effective option.

Dorsal Root Ganglion Stimulation Therapy for Refractory Idiopathic Pudendal Neuralgia.

Dorsal root ganglion stimulation is a relatively new treatment option for chronic pain conditions such as pudendal neuralgia, which is a chronic pain condition affecting the pudendal nerve in the pelvic region. Pudendal neuralgia is a debilitating condition that can significantly affect the patient's quality of life. In dorsal root ganglion stimulation, a small device is implanted that delivers electrical impulses to the dorsal root ganglion to modulate pain signals coming from the pudendal nerve. The procedure is considered investigational and has been investigated in case series and case reports with promising results. However, more research is needed to fully understand its safety and effectiveness. This case report highlights the potential of dorsal root ganglion stimulation as a treatment option for pudendal neuralgia and the need for further research to establish it as a standard treatment option.

Ultrasound-Guided Erector Spinae Block for Refractory Abdominal Pain Due to Acute on Chronic Pancreatitis.

Erector spinae blocks (ESBs) are a type of fascial pain block that has been safely used for various applications, including post-operative and post-trauma pain in several thoracic and abdominal surgeries. Pain related to an acute flare-up of chronic pancreatitis is usually challenging to control and impacts patient comfort and discharge planning. This case report describes an application of ESBs for the effective treatment of refractory abdominal pain associated with acute exacerbation of chronic pancreatitis. Application of ESB in the emergency room setting can potentially decrease hospital admission for this common condition and increase patient satisfaction.

A Microbiological Assay of Common Operating Room (OR) Tapes: Developing a Culture for Patient Safety.

BACKGROUND: There are no existing practices or methods to ensure cleanliness, sterility, or prevent cross-contamination when it comes to common operating room (OR) tape. The authors hypothesized that adhesive tapes used by anesthesia providers in ORs and off-site surgical areas might be colonized by microorganisms and that culturing these tape rolls would reveal significant monomicrobial and polymicrobial contamination.  Material and Methods: The primary objective of this observational cohort study was to report and compare contamination rate including polymicrobial contamination rate between tape specimens collected from storage site and specimen from the ORs, off-sites, and after use on a patient. The outcome measures were the culture reports of the adhesive tapes. The authors then designed an intervention that integrated anesthesia providers' hand hygiene and maintenance of a barrier between the OR tapes and OR surfaces. RESULTS: The authors reported gross contamination and cross-contamination among the OR off-site tapes. The contamination rates reported for tapes from OR, off-site specimens, and patient specimens were 68.2%,63.2%, and 100%, respectively. The authors again cultured adhesive tapes after the intervention and reported improved outcomes. CONCLUSIONS: The current quality improvement (QI) project identified the potential for OR tapes to serve as microbial vectors. The authors advocate environmental decontamination and anesthesia providers' hand hygiene in parallel as a part of routine anesthesia care in their practice and agree that the endotracheal tubes (ETTs) and orogastric or nasogastric tubes should be pre-packaged with single-use tape, which can be used for securing devices.

An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis.

BACKGROUND: Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. METHODS: In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. RESULTS: Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). CONCLUSIONS: This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.

Current Concepts in the Management of Shoulder Instability.

Shoulder instability ranges from subtle instability to frank dislocation. Our understanding on the subject is getting better. Patient lifestyle, increased awareness/expectations, better availability of information, improved imaging modalities, and increased awareness about the previously less known concepts in instability all add to the challenges of managing the problem. History and clinical examination without over reliance on imaging remain essential. We used Embase, PubMed, Medline, CINAHL, Cochrane Library, Scottish Intercollegiate Guidelines Network and Google Scholar search for published literature in English. We used various combinations of the keywords, namely, human shoulder instability, sports injuries, dislocation, surgery, latarjet, glenohumeral, glenoid, and arthroscopy from 1980 to March 2017. The systematic search captured 310 publications. After applying initial exclusion criteria, 41 abstracts were assessed for eligibility. Of these, we selected 20 full-text articles with the majority of focus primarily on surgical management of traumatic shoulder instability. A tailor-made approach for the management of the individual patient is essential and should involve shared decision making. In this article, we have tried to simplify and present the current evidence in the management of traumatic shoulder instability, particularly in sportsperson.

Fibular insufficiency fracture: an under-reported complication of advanced tibialis posterior dysfunction.

We present a case of fibular insufficiency (stress) fracture in a patient with pre-existing asymptomatic advanced tibialis posterior dysfunction. The patient had severe planovalgus (flat foot) deformity but no pain before the injury; hence had never sought any treatment. She was first treated conservatively for the fracture which failed to control the deformity and had ongoing symptoms. She eventually required tibio-talo-calcaneal fusion. To the best of our knowledge, this is the first case report of this condition in the English literature. In patients with severe tibialis posterior dysfunction, weight-bearing axis passes directly from calcaneum to fibula making it vulnerable to fracture. Patients should be made aware of this risk even if they are asymptomatic and encouraged to use orthotic support for protection against insufficiency fractures.

Upper Antero-Medial Thigh as an Alternative Site for Implantation of Intrathecal Pumps: A Case Series.

INTRODUCTION: Neuraxial drug delivery via intrathecal drug delivery systems (IDDS) is becoming an increasingly common mode of treating intractable cancer-related pain, chronic pain, or severe spasticity. An implanted infusion pump delivers medication into the intrathecal (subarachnoid) space via a thin catheter. These pumps are commonly placed in the anterior abdominal wall. Certain conditions may render it difficult or unsafe for an IDDS to be implanted at the traditional site; thus, alternative sites have been explored. We report on the use of the upper antero-medial thigh as a safe alternative site for this purpose. METHODS AND MATERIALS: Nine patients between 22 and 69 years of age underwent placement of an IDDS infusion pump in the upper antero-medial aspect of one thigh. In each patient, the anterior abdominal wall was precluded for implantation due to various reasons, such as extensive abdominal scar tissue from previous surgeries, placement of feeding tubes and ostomies, large ventral hernia or metastatic masses protruding from the abdomen. RESULTS: Nine patients, with ages ranging from 22 to 69 years old, had IDDS implantation in the upper thigh. The first patient experienced wound dehiscence (antero-lateral location) and after explantation, another pump was placed successfully in the opposite thigh (antero-medial location). One patient has had pump replacement due to end-of-battery life. She also needed an unrelated catheter revision. Seven patients have expired from their disease progression after living for an average of 142.7 days (range 50 days to 354 days) while two patients continue to experience relief from pain and spasticity years later (see Table 1). No neurovascular damage, infections, or other complications occurred in our series. CONCLUSION: The upper antero-medial thigh is a safe alternative to the anterior abdominal wall for implantation of an IDDS.

Brachial Plexus Block for Cancer-Related Pain: A Case Series.

Neoplastic brachial plexopathy (NBP) is caused by a cancerous infiltration into the brachial plexus, presenting often as severe pain in the affected upper extremity. Such pain can be resistant to medical treatment. Invasive interventions such as brachial plexus neurolysis with phenol or cordotomy may result in severe complications including permanent neurological damage and death. Continuous brachial plexus and paravertebral block with local anesthetic have been reported to successfully control pain from NBP, but these techniques are logistically challenging and frequently have catheter-related complications. We report a series of patients who received single-shot brachial plexus blocks with a mixture of local anesthetic and corticosteroid (bupivacaine 0.25% with methyl-prednisolone 20-120 mg) for the treatment of refractory cancer-related pain in the brachial plexus territory, mostly from NBP. Theoretically, such blocks could provide immediate analgesia from the local anesthetic and a longer-lasting analgesia from the slow-release steroids. Responders reported a sustained decrease in their pain (lasting from 2 weeks to 10 months), a significant decrease in their opioid and non-opioid (ketamine, gabapentin) consumption, overall satisfaction with the block, and unchanged or improved function of their limb. The ideal candidate for this procedure is a patient who has pain that is predominantly neuropathic from a lesion within the brachial plexus and with anatomy amenable to ultrasound-guided nerve block. Our case series suggests that, in the appropriately selected patient, this technique can safely and effectively alleviate pain from NBP. The procedure is simple, spares limb function, and can be diagnostic, predicting response to more complex procedures. To the best of our knowledge, this is the first report using this technique for NBP.

Harlequin Syndrome Following Implantation of Intrathecal Pumps: A Case Series.

OBJECTIVE: Harlequin syndrome (HS) is a condition that has been associated with one-sided sympathetic denervation of the face, characterized by contralateral hemifacial flushing and relative hyperhidrosis. Case series associate HS with conditions and procedures, including neuraxial anesthesia, that disrupt unilateral facial sympathetic innervation. However, to the best of our knowledge, this is the first series of HS following implantation of an intrathecal drug delivery system. CASE SERIES: A 37-year-old and 58-year-old female patients with intractable pain from metastatic cancer were scheduled for placement of an intrathecal pump drug delivery system. Thirty minutes after a mixture of hydromorphone, bupivacaine, and clonidine was initiated through the intrathecal pump, both patients developed well-demarcated skin flushing, confined to one side of their face. Patients were not in distress, and physical examination revealed neither focal neurological deficits nor ocular involvement. Postprocedure thoracolumbar spine magnetic resonance imaging (MRI) was done in the first patient and showed no evidence of neuraxial bleeding or spinal cord compression. The flushing gradually faded and eventually disappeared without any untoward effects. CONCLUSION: HS is a condition associated with one-sided sympathetic denervation of the face that can occur after intrathecal pump implantation. An understanding of the pathophysiology of this condition and reassurance are vital factors for successful management of this condition.

Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review.

Ankle osteoarthritis is less common than hip or knee osteoarthritis; however, it is a relatively common presentation and is predominantly related to previous trauma. Treatments have traditionally consisted of temporizing measures such as analgesia, physiotherapy, and injections until operative treatment in the form of arthrodesis is required. More recently, interest has been increasing in both nonoperative and alternative operative options, including joint-sparing surgery, minimal access arthrodesis, and new arthroplasty designs. The present systematic instructional review has summarized the current evidence for the treatment options available for ankle osteoarthritis.

The UMLS-CORE project: a study of the problem list terminologies used in large healthcare institutions.

OBJECTIVE: To study existing problem list terminologies (PLTs), and to identify a subset of concepts based on standard terminologies that occur frequently in problem list data. DESIGN: Problem list terms and their usage frequencies were collected from large healthcare institutions. MEASUREMENT: The pattern of usage of the terms was analyzed. The local terms were mapped to the Unified Medical Language System (UMLS). Based on the mapped UMLS concepts, the degree of overlap between the PLTs was analyzed. RESULTS: Six institutions submitted 76,237 terms and their usage frequencies in 14 million patients. The distribution of usage was highly skewed. On average, 21% of unique terms already covered 95% of usage. The most frequently used 14,395 terms, representing the union of terms that covered 95% of usage in each institution, were exhaustively mapped to the UMLS. 13,261 terms were successfully mapped to 6776 UMLS concepts. Less frequently used terms were generally less 'mappable' to the UMLS. The mean pairwise overlap of the PLTs was only 21% (median 19%). Concepts that were shared among institutions were used eight times more often than concepts unique to one institution. A SNOMED Problem List Subset of frequently used problem list concepts was identified. CONCLUSIONS: Most of the frequently used problem list terms could be found in standard terminologies. The overlap between existing PLTs was low. The use of the SNOMED Problem List Subset will save developmental effort, reduce variability of PLTs, and enhance interoperability of problem list data.

Combining lexical and semantic methods of inter-terminology mapping using the UMLS.

The need for inter-terminology mapping is constantly increasing with the growth in the volume of electronically captured biomedical data and the demand to re-use the same data for secondary purposes. Using the UMLS as a knowledge base, semantically-based and lexically-based mappings were generated from SNOMED CT to ICD9CM terms and compared to a gold standard. Semantic mapping performed better than lexical mapping in terms of coverage, recall and precision. As the two mapping methods are orthogonal, the two sets of mappings can be used to validate and enhance each other. A method of combining the mappings based on the precision level of sub-categories in each method was derived. The combined method outperformed both methods, achieving coverage of 91%, recall of 43% and precision of 27%. It is also possible to customize the method of combination to optimize performance according to the task at hand.

Who is using the UMLS and how - insights from the UMLS user annual reports.

The NLM's UMLS resources are available to users free of charge under a license that requires submission of an annual report on their usage. A new web-based template was used to collect users' annual reports for the calendar year 2004. Out of 2,677 li-censees, 1,427 (53%) submitted their annual reports through the web template. This represented a five-fold increase in the reports submitted compared to previous years. The information collected via the web template was more structured, more complete and easier to analyze. The main results from the 2004 annual reports are summarized and discussed. They are being used to guide UMLS developments.

Integrating SNOMED CT into the UMLS: an exploration of different views of synonymy and quality of editing.

OBJECTIVE: The integration of SNOMED CT into the Unified Medical Language System (UMLS) involved the alignment of two views of synonymy that were different because the two vocabulary systems have different intended purposes and editing principles. The UMLS is organized according to one view of synonymy, but its structure also represents all the individual views of synonymy present in its source vocabularies. Despite progress in knowledge-based automation of development and maintenance of vocabularies, manual curation is still the main method of determining synonymy. The aim of this study was to investigate the quality of human judgment of synonymy. DESIGN: Sixty pairs of potentially controversial SNOMED CT synonyms were reviewed by 11 domain vocabulary experts (six UMLS editors and five noneditors), and scores were assigned according to the degree of synonymy. MEASUREMENTS: The synonymy scores of each subject were compared to the gold standard (the overall mean synonymy score of all subjects) to assess accuracy. Agreement between UMLS editors and noneditors was measured by comparing the mean synonymy scores of editors to noneditors. RESULTS: Average accuracy was 71% for UMLS editors and 75% for noneditors (difference not statistically significant). Mean scores of editors and noneditors showed significant positive correlation (Spearman's rank correlation coefficient 0.654, two-tailed p < 0.01) with a concurrence rate of 75% and an interrater agreement kappa of 0.43. CONCLUSION: The accuracy in the judgment of synonymy was comparable for UMLS editors and nonediting domain experts. There was reasonable agreement between the two groups.

Achieving "source transparency" in the UMLS Metathesaurus.

The UMLS Metathesaurus is a syntactically uniform, concept-based, semantically enhanced representation of many of the world's authoritative biomedical vocabularies. Released several times a year, the Metathesaurus is becoming a common, longitudinally maintained source of the current versions of these vocabularies. As vocabularies become standards for reimbursement, reporting, interoperation, and use by applications, the vocabulary obtained from the Metathesaurus must be consistent with that obtainable from each vocabulary's authority. Effective with the first 2004 release, the Metathesaurus represents new and updated sources "transparently"--both users and applications are able to "see" each vocabulary in the Metathesaurus without any of the small losses of information introduced by abstractions used in previous versions. Thus, the Metathesaurus can continue to provide its many semantic and lexical value-added features while guaranteeing that original sources will be "visible" in intact form. Vocabulary users and application developers will benefit from the enhancements and economies of scale offered by the Metathesaurus, while preserving distinctions between content provided by external authorities and content added as part of the Metathesaurus development and maintenance process.

Constrained optimization for green engineering decision-making.

Green engineering requires the designer to consider a very extensive set of environmental impacts. To minimize these impacts, the designer must significantly expand his or her "toolset" of product design concepts, alternative materials, manufacturing systems, and analytic methods for addressing life cycle impacts. This can overwhelm a designer, who then resorts to overly simplistic rules or checklists out of necessity. The central issue is how to identify all "pollution prevention pays" opportunities and then how to deal with the unavoidable tradeoffs that arise after all these opportunities have been exhausted. This paper presents a framework for employing mathematical decision modeling toward this end. A domain-independent constrained optimization formulation is presented. A multiattribute utility function reflects the willingness to pay for environmental improvement and is the basis of the objective function. The feasibility constraints reflect the unavoidable tradeoffs. Several case studies are presented, including power systems, floor tile manufacturing, and computer systems.