Long-term efficacy of spinal cord stimulation for chronic primary neuropathic pain in the contemporary era: a systematic review and meta-analysis.

INTRODUCTION: Spinal cord stimulation (SCS) is a modern neuromodulation technique extensively proven to be an effective modality for treatment of chronic neuropathic pain. It has been mainly studied for complex regional pain syndrome (CRPS) and failed back surgery syndrome (FBSS) and recent data almost uniformly establishes its statistically significant positive therapeutic results. It has also been compared with other available treatment modalities across various studies. However, long term data on maintenance of its efficacious potential remains less explored. Few studies have reported data on long follow-up times (>= 12 months) and have compared its efficacy with other treatment options for chronic pain, respectively. Our study pools and analyzes the available data and compares SCS with other treatment options. It also analyzes the efficacy of SCS in long term management of patients with chronic pain. EVIDENCE ACQUISITION: We reviewed all the data available on MEDLINE, Embase and Cochrane CENTRAL using a search strategy designed to fit our pre-set inclusion and exclusion criteria. Both single-arm and double-arm studies were included. The primary outcome was defined as decrease of visual analogue scale (VAS) by >50% at 6, 12 and/or 24 months after SCS. EVIDENCE SYNTHESIS: According to the pooled data of double-arm studies, SCS has unanimously proven its superiority over other treatment options at 6 months follow-up; however it fails to prove statistically significant difference in results at longer treatment intervals. Dorsal root ganglion stimulation, a relatively recent technique with the same underlying physiologic mechanisms as SCS, showed far more promising results than SCS. Single-arm studies show around 70% patients experiencing greater than 50% reduction in their VAS scores at 6 and 12 months. CONCLUSIONS: SCS is a viable option for management of chronic neuropathic pain secondary to FBSS and CRPS. However, data available for its long term efficacy remains scarce and show no further statistically significant results.

Knowledge and practice of ethics among postgraduates in a public sector tertiary care hospital.

OBJECTIVE: To explore the present state of competency in clinical ethics among postgraduate trainees in a tertiary care hospital. METHODS: The interview-based cross-sectional study was conducted at the Civil Hospital, Karachi, from September 2018 to March 2019, and comprised postgraduate trainees of either gender in any year of the training programme across all specialties. Data was collected using self-reported questionnaire seeking opinion about present working conditions regarding clinical ethical issues on the hospital ground and problems they face from day to day. Data was analysed using SPSS 23. RESULTS: Of the 153 subjects, 96(62.7%) were females, 73(47.7%) were from Medicine and allied disciplines, and 80(52.3%) were from Surgery and allied disciplines. The primary source of their clinical ethics' understanding was derived from their workplace [116(75.82%)]. While only 104 (68%) of the subjects knew about the Hippocratic Oath's contents, less than 10% knew about Nuremberg Code and Helsinki declaration. They mainly relied on their seniors at work for guidance on ethical issues [108 (70.59%)]. Overall, the subjects lacked basic knowledge of medical ethics and failed to practise ethical conduct during their training. CONCLUSIONS: The knowledge of medical ethics was found to be unsatisfactory among doctors, and timely intervention was needed to improve the situation.