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BACKGROUND: The dorsal root ganglion (DRG) has been identified as an important neural structure in the development and maintenance of chronic pain. We present a retrospective case series of patients with refractory painful diabetic peripheral neuropathy (PDPN) that underwent electrical stimulation of the DRG and report on changes in their overall perceived pain and complication rates. METHODS: Ten diabetic males (mean age 65.2 [SD 8.8] years) with painful symptoms of the lower limbs were enrolled and trialed with up to four quadripolar percutaneous DRG stimulation leads between L2 and L5 spinal levels. Patients received a fully implantable neurostimulation system (Abbott Laboratories, Sunnyvale, CA, USA) immediately or after a successful trial period (>50% reduction in pain). Overall perceived pain was measured by visual analogue scale (VAS) at baseline, one-week postimplantation and one-, three-, six-, and twelve-month follow-up (n = 5). RESULTS: Ten patients were included in this retrospective study. Seven of these subjects received permanent stimulator implants after successful externalized or intraoperative trials. Two of those patients subsequently required explantation, due to failure to capture primary pain area (n = 1) and personal reasons (n = 1). For the five subjects that proceeded to clinical follow-ups, baseline VAS was reduced by an average of 63.90% (SD 21.39; p < 0.001) postimplantation. For four patients with available 12-month follow-up data, mean relative reduction in overall perceived pain averaged 64.16% (SD 35.8; p< 0.001). CONCLUSION: Early findings from this small retrospective case series, suggest DRG is a safe and effective neuromodulation modality to improve painful symptoms in PDPN patients. Future prospective trials are required to further investigate the use of DRG stimulation for this clinical indication.
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Neuropatías Diabéticas/terapia , Terapia por Estimulación Eléctrica/métodos , Ganglios Espinales/fisiopatología , Anciano , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVES: Conventional spinal cord stimulation (SCS) delivers a tonic waveform with consistent stream of pulses; burst delivers groups of pulses separated by short pulse-free periods. The current study compared the short-term safety and efficacy of burst with tonic stimulation in subjects already receiving SCS. MATERIALS AND METHODS: At 4 IRB-approved sites, 22 subjects previously implanted with an SCS device for intractable, chronic pain gave informed consent and received burst stimulation for 14 days. Subjects reported average daily Visual Analog Scale (VAS) for overall, trunk, and limb pain using tonic stimulation and after 7 and 14 days of burst stimulation. Thoughts about pain were assessed using the Pain Catastrophizing Scale. Areas of paresthesia were assessed during tonic and burst stimulation using body maps. Assessment of patient satisfaction and preferred stimulation occurred after 14 days of burst. RESULTS: Average daily overall VAS reduced 46% from a mean of 53.5 (±20.2) mm during tonic SCS to 28.5 (±18.1) mm during burst (p < 0.001); trunk and limb VAS scores were also reduced by 33% and 51%, respectively. During burst, 16 subjects (73%) reported no paresthesia, 5 (23%) reported a reduction, and 1 (4%) reported increased paresthesia. After 14 days, 21 subjects (95%) reported being very satisfied or satisfied with burst. Burst was preferred by 20 subjects (91%), tonic by 1 (5%), and 1 (5%) reported no preference. Better pain relief was the most common reason cited for preference. CONCLUSIONS: A majority of subjects reported improved pain relief using burst compared with tonic stimulation. Most subjects experienced less paresthesia during burst and preferred burst citing better pain relief.
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Manejo del Dolor , Dolor/fisiopatología , Estimulación de la Médula Espinal/métodos , Adulto , Anciano , Biofisica , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Factores de TiempoRESUMEN
INTRODUCTION: Scientific evidence supports spinal cord stimulation (SCS) as a cost-effective treatment option that, for many disease states, should be employed earlier in the treatment continuum. Reimbursement for SCS in the cervical spine has recently been challenged based on supposed lack of clinical literature. To refute this assumption, we analyzed data from an international registry to support the use of cervical SCS. MATERIALS AND METHODS: The following outcomes were collected as part of an institutional review board-approved, prospective, multicenter, international registry: pain relief, Pain Disability Index (PDI) score, quality of life (QoL), and satisfaction at 3, 6, and 12 months post-implantation. Descriptive statistics are provided for all measures. Changes from baseline in PDI scores were analyzed using Tukey's pairwise comparisons. RESULTS: Thirty-eight patients underwent implantation of SCS leads in the cervical spine at 16 study sites in the United States and 3 international study sites. Direct patient report of percentage of pain relief was 54.2%, 60.2%, and 66.8% at 3, 6, and 12 months post-implantation, respectively. Pain relief was categorized as excellent/good by 61.6% of patients at 3 months, with similar results observed at 6 and 12 months. PDI scores were significantly reduced at all time points. At 3 months post-implantation, 92.4% of patients indicated they were very satisfied/satisfied with the SCS device. No patients indicated that they were dissatisfied. Overall QoL was reported as improved/greatly improved by 73.1% of patients at 3 months. Similar results for QoL and satisfaction were reported at 6 and 12 months. CONCLUSION: The results suggest that the use of SCS in the cervical spine is a medically effective method of pain management that satisfies and improves the QoL of most patients. The use of SCS can reduce the high cost of direct medical treatment of pain, as well as increasing the productivity of patients, and therefore should be reimbursed in appropriately selected patients.
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Dolor Crónico/terapia , Manejo del Dolor/métodos , Estimulación de la Médula Espinal , Vértebras Cervicales , Síndromes de Dolor Regional Complejo/terapia , Análisis Costo-Beneficio , Evaluación de la Discapacidad , Electrodos Implantados , Síndrome de Fracaso de la Cirugía Espinal Lumbar/terapia , Humanos , Manejo del Dolor/economía , Dimensión del Dolor , Satisfacción del Paciente , Selección de Paciente , Calidad de Vida , Radiculopatía/terapia , Sistema de Registros , Estimulación de la Médula Espinal/efectos adversos , Estimulación de la Médula Espinal/economía , Estimulación de la Médula Espinal/métodos , Resultado del TratamientoRESUMEN
Background: Previous open-label studies showed that chronic post-stroke pain could be abated by treatment with perispinal etanercept, although these benefits were questioned. A randomized double-blind placebo controlled clinical trial was conducted to test perispinal etanercept for chronic post-stroke pain.Research design and methods: Participants received two treatments, either perispinal etanercept (active) or saline (control). Primary outcomes were the differences in daily pain levels between groups analyzed by SPSS.Results: On the 0-100 points visual analog scale, perispinal etanercept reduced mean levels for worst and average daily pain from baseline after two treatments by 19.5 - 24 points (p < 0.05), and pain alleviation was maintained in the etanercept group, with no significant change in the control group. Thirty percent of etanercept participants had near complete pain abatement after first treatment. Goniometry of the paretic arm showed improved mean shoulder rotation by 55 degrees in active forward flexion for the etanercept group (p = 0.003) only.Conclusions: Perispinal etanercept can provide significant and ongoing benefits for the chronic post-stroke management of pain and greater shoulder flexion by the paretic arm. Effects are rapid and highly significant, supporting direct action on brain function.Trial registration: ACTRN12615001377527 and Universal Trial Number U1111-1174-3242.
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Antiinflamatorios no Esteroideos/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Etanercept/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Anciano , Dolor Crónico/etiología , Método Doble Ciego , Femenino , Humanos , Inyecciones Espinales , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Accidente Cerebrovascular/complicaciones , Resultado del TratamientoRESUMEN
It is almost ten years since the Banerjee 2009 report established that inappropriate prescribing of antipsychotics in the elderly was occurring in the UK and such patients had an 85% increased risk of adverse events and greater mortality. This report was a critical analysis addressing the outcomes of treatment practices for dementia in UK patients and globally, aimed at reducing prescribing of antipsychotic drugs for dementia. Since 2009, many significant studies worldwide (including several more recent large retrospective studies) provide more extensive longitudinal data for the adverse impacts of antipsychotic drugs in dementia. We have used the data in these studies including from over 380,000 dementia patients, with 85,069 prescribed antipsychotic agents as well as from 359,235 non-dementia antipsychotic drug users to provide an up-dated meta-analysis. This is the first meta-analysis to include evidence from general mental health studies showing that antipsychotic drugs precipitate excessive mortality across the spectrum. Prescribing of antipsychotic drugs for dementia or for other mental health care should be avoided and alternative means sought for handling behavioral disorders of such patients.
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Intralipid has been proposed as a treatment option for local anesthetic (LA) toxicity, which does not respond to traditional resuscitation methods. This paper presents a case report of a patient who developed signs of local anesthetic toxicity and was subsequently treated with 20% Intralipid with a positive response. Some background and practical applications regarding this treatment are discussed.
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Anestésicos Locales/efectos adversos , Enfermedades del Sistema Nervioso Central/inducido químicamente , Enfermedades del Sistema Nervioso Central/tratamiento farmacológico , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/inducido químicamente , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/tratamiento farmacológico , Emulsiones Grasas Intravenosas/uso terapéutico , Adulto , Enfermedades del Sistema Nervioso Central/complicaciones , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/complicaciones , Humanos , MasculinoRESUMEN
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether ultrasound probe central line placement reduced complications and time to placement in patients undergoing coronary artery bypass grafting surgery. Altogether, 193 papers were found from Medline using the reported search of which 6 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses and comments were tabulated. We conclude that in patients with a potentially difficult central line insertion, the ultrasound technique reduces complications and time to insertion. However, in those patients where no difficulty is predicted, there is no evidence that the ultrasound technique confers any advantage.