A modified Delphi survey on the signs and symptoms of low back pain: indicators for an interventional management approach.

BACKGROUND: Low back pain (LBP) symptoms and signs are nonspecific. If required, diagnostic blocks may find the source of pain, but indicators of suspect diagnosis must be defined to identify anatomical targets. OBJECTIVE: To reach a consensus from an expert panel on the indicators for the most common causes of LBP. MATERIAL AND METHODS: A 3-round (2 telematic and 1 face-to-face) modified Delphi survey with a questionnaire on 78 evidence-based indicators of 7 LBP etiologies was completed by 23 experts. RESULTS: 98.7% of the questionnaire was consensuated. The most accepted indicators were for zygapophysial joint pain, painful ipsilateral paravertebral palpation, worsening with trunk extension, paravertebral musculature spasm on the affected articulation, and referred pain above the knee, without radicular pattern. For sacroiliac joint pain, unilateral pain when seating, with at least 3 described provoking tests: Approximation; gapping; Patrick's; Gaenslen's; thigh thrust; Fortin finger; and Gillet's tests. For discogenic pain, midline pain that may be provoked by pressure on the spinal processes at the affected level; for quadratus lumborum muscle, painful palpation on both the L1 level paravertebral region, referred to iliac crest, and the iliac crest, referred to greater trochanter. For iliopsoas muscle, pain elicited by thigh flexion, referred to buttock, inguinal region, and anterior thigh. For pyramidal muscle, pain while sitting on the affected side and positive Freiberg's test. For radicular pain, paresthesias and positive Lassègue's test at 60°. CONCLUSION: Seventy-seven diagnostic suspect indicators of LBP conditions were consensuated. These may facilitate conservative or interventional pain management decision-making.

The effect of reactor scale on biochars and pyrolysis liquids from slow pyrolysis of coffee silverskin, grape pomace and olive mill waste, in auger reactors.

Several studies have addressed the potential biorefinery, through small-scale pyrolysis, of coffee silverskin (CSS), grape pomace (GP) and olive mill waste (OMW), which are respectively the main solid residues from coffee roasting, wine making and olive oil production processes. However, increasing the scale of reactor to bring these studies to an industrial level may affect the properties, and hence applications, of the resulting products. The aim of this study is therefore to perform pilot scale experiments to compare and verify the results of analytical study (TGA) and bench scale reactor runs, in order to understand the fundamental differences and create correlations between pyrolysis runs at different scales. To this end, pyrolysis liquids and biochars from the slow pyrolysis of CSS, GP and OMW, performed using different scale auger reactors (15 kg/h and 0.3 kg/h), have been analysed (TGA, pH, density, proximate and ultimate analyses, HHV, FTIR, GCMS) and compared. The results showed no major differences in biochars when the temperature and the solid residence time were fixed. However, regarding pyrolysis liquids, compounds from the lab reactor were more degraded than pilot plant ones, due to, in this case, the vapour residence time was longer. Regarding the properties of the pyrolysis products, GP 400 °C biochars showed the best properties for combustion; CSS biochars were especially rich in nitrogen, and 400 °C GP and OMW pyrolysis liquids showed the highest number of phenolics. Hence, this study is considered a first step towards industrial scale CSS, GP and OMW pyrolysis-based biorefinery.

A facility and community-based assessment of scabies in rural Malawi.

BACKGROUND: Scabies is a neglected tropical disease of the skin, causing severe itching, stigmatizing skin lesions and systemic complications. Since 2015, the DerMalawi project provide an integrated skin diseases clinics and Tele-dermatology care in Malawi. Clinic based data suggested a progressive increase in scabies cases observed. To better identify and treat individuals with scabies in the region, we shifted from a clinic-based model to a community based outreach programme. METHODOLOGY/PRINCIPAL FINDINGS: From May 2015, DerMalawi project provide integrated skin diseases and Tele-dermatological care in the Nkhotakota and Salima health districts in Malawi. Demographic and clinical data of all patients personally attended are recorded. Due to a progressive increase in the number of cases of scabies the project shifted to a community-based outreach programme. For the community outreach activities, we conducted three visits between 2018 to 2019 and undertook screening in schools and villages of Alinafe Hospital catchment area. Treatment was offered for all the cases and school or household contacts. Scabies increased from 2.9% to 39.2% of all cases seen by the DerMalawi project at clinics between 2015 to 2018. During the community-based activities approximately 50% of the population was assessed in each of three visits. The prevalence of scabies was similar in the first two rounds, 15.4% (2392) at the first visit and 17.2% at the second visit. The prevalence of scabies appeared to be lower (2.4%) at the third visit. The prevalence of impetigo appeared unchanged and was 6.7% at the first visit and 5.2% at the final visit. CONCLUSIONS/SIGNIFICANCE: Prevalence of scabies in our setting was very high suggesting that scabies is a major public health problem in parts of Malawi. Further work is required to more accurately assess the burden of disease and develop appropriate public health strategies for its control.

Production of antioxidants and other value-added compounds from coffee silverskin via pyrolysis under a biorefinery approach.

The coffee roasting industry produces about 0.4 Mt of coffee silverskin (CSS) per year, the only residue generated from the roasting process that is mostly disposed as industrial waste. The aim of this study is to convert CSS into value-added products by intermediate pyrolysis, transforming the waste into a resource within an integrated biorefinery perspective. To this end, bio-oils and biochars from the intermediate pyrolysis of CSS at 280 °C, 400 °C and 500 °C have been studied. GC-MS analysis showed that bio-oils were composed of value-added products such as caffeine, acetic acid, pyridine and phenolics, the latter being the most interesting due to their antioxidant properties. Total phenolic content and antioxidant capacity of the samples were determined through Folin-Ciocalteu (FC) and DPPH methods, revealing an increase in phenolics in bio-oils compared to CSS extract directly from the feedstock. The bio-oil with the highest phenolic content and antioxidant properties was produced at 280 °C and contained 6.09 and 3.02 mg of gallic acid equivalents /g of bio-oil determined by FC and DPPH methods, respectively. This represents a global potential of up to 487 and 242 tones of gallic acid equivalents per year, considering the FC results and DPPH respectively. The resulting 280 °C biochar presented significant calorific values (22 MJ/kg), indicating its potential use as an energy source. Hence, CSS pyrolysis converts a waste into a by-product and a resource, increasing the environmental benefits and contributing to the circular economy and bioeconomy.

Trans-facet-joint approach to pulsed radiofrequency ablation of the L5 dorsal root ganglion in a patient with degenerative spondylosis and scoliosis.

Mechanical low back pain secondary to degenerative facet joint changes is a common reason for referral to pain clinics. When these changes cause encroachment into the intervertebral foramen, radicular pain may result. While pulsed radiofrequency of the dorsal root ganglion can be used in this setting, the anatomic deformity may make the transforaminal approach difficult. We report a case where a trans-facet approach was used successfully and describe the technique.

Thermocoagulation of the ganglion impar or ganglion of Walther: description of a modified approach. Preliminary results in chronic, nononcological pain.

The ganglion impar, a single structure usually found at the anterior aspect of the sacrococcygeal joint, is the lowest ganglion of the paravertebral sympathetic chain. Its blockade is indicated in visceral pain syndromes and/or sympathetic pain syndromes of the perineal region. Several approaches to this block have been described, mainly through the anococcygeal or sacrococcygeal ligaments. We propose a modified approach to thermocoagulation of the ganglion impar, using a two-needle technique, the first one, placed through the sacrococcygeal ligament, the transsacrococcygeal needle, and the second one through a coccygeal disc, the transdiscal needle. The thermocoagulation technique that we employ uses a conventional radiofrequency application of 80 degrees C for 80 seconds through each needle. In this prospective study, 13 patients with chronic perineal, noncancer-related pain were followed for a maximum of 6 months. All of these patients underwent diagnostic ganglion impar block with local anesthetic prior to inducing neurodestruction with conventional radiofrequency application, as a positive result to the diagnostic local anesthetic block was a requisite for radiofrequency neurodestruction. We measured pain using a visual analog scale (VAS) before and after treatment. Statistical significance was assessed using the Mann-Whitney U-test and Wilcoxon range summation test. Initially the VAS was equal to or greater than 7. After therapy the VAS decreased by an average of 50% in the whole group. There were no adverse events. Our result show that this proposed modified approach to the block and use of radiofrequency for the ganglion impar is useful for the treatment of perineal noncancer-related pain.

Unnecessary surgical treatment in a case of olfactory reference syndrome.

We present a case of olfactory reference syndrome (ORS) with complaints of bromhidrosis. This patient underwent a lumbar sympathectomy to correct the imagined body odor problem. The patient reported experiencing an improvement after surgery, but later, the olfactory symptoms returned. The main objective with ORS patients should be to begin psychiatric treatment early. Other treatments usually appear to be ineffective and cause great dissatisfaction.

Uveal melanoma in a 19-month-old child.

Uveal melanoma is extremely rare in children. Its clinical and histopathological features have been reported to be similar to those observed in adults. The tumor usually presents as a sessile or dome-shaped mass with secondary nonrhegmatogenous retinal detachment. We report a 19-month-old boy with a choroidal melanoma presenting as hemorrhagic retinal detachment and buphthalmos. The eye was enucleated, but the child subsequently died from systemic metastases.

Dual spinal cord stimulation for complex pain: preliminary study.

Objectives To retrospectively analyze by indices of success, patients with chronic complex pain, including, axial low back pain, receiving dual spinal cord stimulation (SCS) systems. Methods Eighteen patients with dual spinal cord stimulators have been retrospectively and nonrandomly analyzed. The preponderance of patients in our study group had failed back surgery syndrome (FBSS). Parameters of success of our therapy included reduction of medication, if any, complications, if any, and satisfaction with therapy and improvement in the quality of life, measured by a visual analogical scale (VAS) from 0 to 10. Patients were asked to rate their overall experience with their SCS systems and were divided into four separate groupings according to their overall rating of their therapy. These four groupings included therapy ratings of excellent (70-100%), good (> 50%), fair (< 50%), and poor (< 30%). Satisfaction with therapy and improvement in quality of life were evaluated on a five-point scale. Patients were asked to rate changes in their quality of life after therapy using the following normative scale: much better, better, no change, worse, and much worse. All the patients in our study were asked if they would repeat their therapy with dual spinal cord stimulation. Results Paresthesia coverage, overlapping the reported painful region, was obtained in 80% of the patients in our study. The VAS decreased an average of 5.6 (range 2-10) after 6 months and 4.9 (range 2-8) at the end of the study. Six patients (37.5%) reported excellent results; four patients (25%) reported good; three (18.7%), fair and poor. Seventy percent of the patients were satisfied with the treatment and reported an increase in their quality of life. Medications were reduced in 75% of the patients. Thirteen (81%) patients with dual lead SCS therapy were willing to repeat the SCS implant procedure. Complications occurred in 43.7%. Conclusions Dual spinal cord stimulation is appropriate and efficacious for treating complex pathology and complex pain that including pain of the low, axial back.