Impact of diabetes on the severity of COVID-19 infection in pregnant women - A single-center descriptive study.

BACKGROUND AND AIMS: Pregnant women have significant morbidity and mortality due to COVID-19 infection. Pregnancy and diabetes are known risk factors for severe COVID 19 infection. Understanding the interactions between COVID-19 and diabetes in pregnancy is crucial in developing appropriate therapeutic approaches. India, like many other countries, has a very high prevalence of diabetes and COVID-19 infected cases. Such studies are minimal worldwide and none from India to the best of our knowledge. MATERIALS AND METHODS: We did a retrospective cross-sectional study. 856 COVID-19 infected pregnant women were included in the study. We estimated the impact of diabetes on the severity of COVID-19 infected pregnant women and compared the outcomes with the non-diabetic group. RESULTS: Prevalence of diabetes in pregnancy in the present study was 15.43%(n = 132/856). Prevalence of diabetes in non-severe infection was 14%(n = 115/818), severe infection was 44.73%(n = 17/38), and in maternal deaths was 75% (n = 6/8). The age-adjusted odds ratio for diabetes for severe infection was 4.492 (95% CI = 2.277-8.865, p < 0.001). COVID-19 infected pregnant women with diabetes were at higher risk for Cesarean section (78.3%) and ICU admission for newborns (14.81%) CONCLUSION: Diabetes in pregnant women is strongly associated with the severity of COVID-19 infection. The prevalence of diabetes in pregnancy increases as the severity of COVID-19 infection increases. Diabetes is associated with more adverse outcomes in mothers and newborns. It is necessary to identify pregnant women with diabetes and prioritize them in public health interventions like vaccination.

Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy.

Increased prescribing of opioids for chronic noncancer pain is associated with significant social costs, including overdose and addiction. In this context, there is interest in interdisciplinary chronic pain rehabilitation programs focusing on self-management and minimizing opioid use. This study examined outcomes of patients weaned from opioids in an ICPRP from 2007 to 2012. Participants included 413 patients on high dose chronic opioid therapy (COT; >100 mg), 528 on low dose COT, and 516 not on opioids (NO). Outcomes were assessed at discharge, 6, and 12 months posttreatment through self-report and chart review. One thousand one hundred ninety-four participants completed treatment (81.95%); 86.74% of those on opioids were weaned. High doses were less likely to complete (78.45%) than NO participants (85.27%; P < 0.05). Results showed immediate (P < 0.01) and sustained improvements (P < 0.05) in pain severity, depression, anxiety, and functional impairment with no group differences. Effect sizes ranged from medium to large (Cohen d values 0.57-1.96). Longitudinal medication use data were available for 319 no dose and 417 weaned participants; opioid resumption rates were 10.51% and 30.70% respectively. There were no differences in resumption between the high dose and low dose groups. Logistic regression analyses determined that opioid dose predicted neither treatment completion nor opioid resumption. Anxiety predicted completion, and functional impairment predicted opioid resumption within 1 year of discharge. Results suggest that patients on COT can be successfully weaned with long-term benefits in pain, mood, and function. Targeting anxiety and functional restoration may increase success rates.

The Impact of Preoperative Depression and Health State on Quality-of-Life Outcomes after Anterior Cervical Diskectomy and Fusion.

Study Design Retrospective cohort study. Objective We sought to assess the predictive value of preoperative depression and health state on 1-year quality-of-life outcomes after anterior cervical diskectomy and fusion (ACDF). Methods We analyzed 106 patients who underwent ACDF. All patients had either bilateral or unilateral cervical radiculopathy. Preoperative and 1-year postoperative health outcomes were assessed based on the visual analog scale, Pain Disability Questionnaire (PDQ), Patient Health Questionnaire (PHQ-9), and EuroQol-5 Dimensions (EQ-5D) questionnaire. Univariable and multivariate regression analyses were performed to assess for preoperative predictors of 1-year change in health status according to the EQ-5D. Results Compared with preoperative health states, the ACDF cohort showed statistically significant improved PDQ (78.5 versus 57.9), PHQ-9 (9.7 versus 5.3), and EQ-5D (0.55 versus 0.68) scores at 1 year postoperatively and surpassed the minimum clinically important difference for the EQ-5D of 0.1 units (all p ≤ 0.01). Multivariate linear regression indicated that anxiolytic use and higher EQ-5D preoperative scores were associated with less 1-year postoperative improvement in health status. Although not statistically significant, clinically important effects of preoperative depression, as measured by the PHQ-9, were observed on postoperative QOL outcome (-0.006, 95% confidence interval -0.014 to 0.001). Conclusions Of patients who undergo ACDF with similar preoperative QOL health states, those with a greater degree of depression may have lower improvements in postoperative QOL compared with those with less depression. Patients with anxiety and better preoperative health states also attain less 1-year QOL improvements.

The impact of preoperative depression on quality of life outcomes after posterior cervical fusion.

BACKGROUND CONTEXT: Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery. PURPOSE: To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF. STUDY DESIGN: A retrospective cohort analysis. PATIENT SAMPLE: Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed. OUTCOME MEASURES: Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire. METHODS: Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status. RESULTS: Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index). CONCLUSIONS: Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements.

Chronic pain rehabilitation.

The article discusses chronic pain rehabilitation and describes its components and some of the core operating principles. Outcomes in chronic pain are best when multiple treatment strategies with a focus on functional restoration are employed, and this is often best done in an interdisciplinary pain rehabilitation program.

Multimodal treatment of pain.

Chronic pain is a complex disorder with extensive overlap in sensory and limbic pathways. It needs systemic therapy in addition to focused local treatment. This article discusses treatment modalities other than surgical and interventional approaches and also discusses the literature regarding these treatment modalities, including pharmacotherapy, physical and occupational therapy, psychological approaches including cognitive behavior therapy, and other adjunctive treatments like yoga and tai chi.

Retrospective outcome analyses for headaches in a pain rehabilitation interdisciplinary program.

BACKGROUND: Incapacitating chronic migraine and other severe headaches can have significant impact on peoples' lives, including family and occupational functioning. Although a number of reports have investigated the prevalence and medical treatment of chronic headache, few have reported on the efficacy of treating these disorders within a comprehensive, intensive chronic pain rehabilitation program (CPRP), instead of a headache-specific program. CPRPs provide treatment of headache by focusing not only on physical pain, but also its association with impaired mood and function. METHODS: We examined the efficacy of CPRP in patients with chronic headache via a retrospective analysis of 123 patients (76.4% female), ages 21 to 85, who completed the CPRP at the Cleveland Clinic between January 2007 and December 2011, and were diagnosed using International Classification of Headache Disorders, 2nd edition and International Classification of Headache Disorders, 2nd edition revision, with migraine or headache as a major complaint. Outcome measures included: pain intensity scores present at the moment of questioning where 10 is the maximal (0-10/10), Depression Anxiety Stress Scale (DASS) scores, (measuring mood), and Pain Disability Index scores (measuring function). Repeated measures t-tests were used. RESULTS: Average pain score on admission was 6.4, and 3.4 upon discharge. Average function on admission was moderately impaired, and normalized on discharge. The average depression score was in the moderate range, and had normalized on discharge. The average anxiety score on admission was in the severe range and was in the mild range on discharge. CONCLUSIONS: Results indicate that individuals had statistically and clinically meaningful improvement in pain, mood, and function. Data suggest that an interdisciplinary CPRP approach for patients diagnosed with headache can be effective in helping to decrease pain, as well as normalize mood and function. Thus, CPRPs serve as an alternative treatment to multidisciplinary headache programs, interventional pain techniques, and primary care standard headache care.

Retrospective review of 707 cases of spinal cord stimulation: indications and complications.

Appropriate patient selection and minimizing complications are critical for successful spinal cord stimulation (SCS) therapy in managing intractable pain. We thus reviewed electronic medical records of 707 consecutive cases of patients who received SCS therapy in the Cleveland Clinic from 2000 to 2005 with an emphasis on indications and complications. SCS was used to treat complex regional pain syndrome (CRPS) (345 cases), failed back surgery syndrome (235 cases), peripheral vascular disease (20 cases), visceral pain in the chest, abdomen, and pelvis (37 cases), and peripheral neuropathy (70 cases). CRPS and failed back surgery syndrome accounted for 82% of the cases. The implant-to-trial ratio was 75% on average, with the highest for CRPS type 2 (83%) and the lowest for peripheral vascular diseases (65%). The only documented complication associated with SCS trials was lead migration in 5 of 707 patients (0.7%). There were no permanent neurological deficits or deaths as a result of SCS implant or its complications. Hardware-related complications were common (38%) and included lead migration (22.6%), lead connection failure (9.5%), and lead breakage (6%). Revisions or replacements were required in these cases. Biologically related complications included pain at the generator site (12%) and clinical infection (4.5%; 2.5% with positive culture). The rates of infection varied among the different diagnoses with the highest in failed back surgery syndrome (6.3%). Patients with diabetes had an infection rate of 9%, over the 4% in non-diabetics. Infections were managed successfully with explantation and antibiotic therapy without permanent sequela.

Atypical antipsychotics: new drugs, new challenges.

Compared with the first-generation, or "typical" antipsychotic drugs, second-generation or atypical antipsychotics cause fewer extrapyramidal (motor) problems, but they pose new challenges, as they often contribute to metabolic disturbances such as weight gain, hyperlipidemia, insulin resistance, and type 2 diabetes mellitus. Patients taking atypical antipsychotics should be monitored for glycemic and cardiovascular risk factors and should receive treatment for such problems as they arise.

Use of antipsychotics in the treatment of post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is a severe and disabling psychiatric syndrome. With the advent of selective serotonin reuptake inhibitors (SSRIs), major strides have been made in the realms of pharmacotherapy. The multiplicity of symptom complex includes specific target symptoms, such as intrusiveness, aggression, sleep disturbances, and co-existing psychotic symptoms. Consequently, atypical antipsychotics gradually have been gaining ground in terms of adjunctive utilization. The purpose of this review is to look into the available evidence for their adjunctive use in this chronic disorder.