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1.
Neuromodulation ; 2024 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-38752946

RESUMO

INTRODUCTION: The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation. MATERIALS AND METHODS: Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant. RESULTS: The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS: The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

2.
Telemed J E Health ; 2024 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-38669107

RESUMO

Background: Little is known about the implication of launching virtual-first primary care (VPC) in a health system. Our experience and survey can guide others to establish their virtual-first programs. This study examines implementation, patient perspectives, and satisfaction with VPC at University of Pittsburgh Medical Center (UPMC). Methods: We conducted a Web-based survey to examine factors associated with the likelihood of early adoption and continued use of VPC. We used bivariate comparisons and cluster analysis to evaluate the results. The survey was sent to 1,420 patients seen between August 2022 and January 2023. Responses related to demographics, doctor-patient relations, savings, experience, and future preferences of use were aggregated. To evaluate the relationship between demographics and survey responses, we conducted univariate analysis. Results: Females and patients between 40 and 50 years of age were the primary users and indicated the most interest in continued use. Health insurance status seems not to be a significant predictor in the selection and use of VPC. Most (78%) felt that the physician-patient relationship was unimpaired. The survey showed that 90% of patients saved time by using VPC, and 66% reported saving money on tolls, childcare, or gasoline. Only 13% reported not wanting to continue VPC. Discussion: A majority of surveyed patients felt the doctor-patient relationship was not negatively affected in VPC. VPC programs can be implemented with high patient satisfaction in an integrated health system. VPC is acceptable to most patients, and further expansion of the model is warranted.

3.
Cureus ; 16(3): e55550, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-38576678

RESUMO

Background This pilot study aims to examine the effectiveness of a spinal cord stimulator (SCS) simulator training system in improving the confidence of pain fellows in SCS placement. Methodology Five Ukrainian physicians (neurologists, neurosurgeons, and an anesthesiologist) completed a 10-item survey regarding their confidence in various aspects of SCS placement and their opinions on how effective SCS models were for educational purposes. After placing SCS leads using the SCS simulator, the physicians took the same survey again. The Mann-Whitney U test was used to determine if there was a significant difference in total scores pre and post-simulator training. The software PAST (PAleontological STatistics) was used for statistical analysis. Results Overall, five participants had a 38% statistically significant increase in survey scores before and after the intervention (mean: 4.2 vs. 6.2, p = 0.0055). With regards to each item of the survey, participants had a significantly increased confidence in driving leads (2.6 vs. 5.2, p = 0.008) and in overall technical skills for the SCS procedure after the training (2.8 vs. 5.2, p = 0.0188). Although the other eight survey items were not statistically significant (p > 0.05), participants had a 28% increase in confidence when inserting epidural needles, a 20% increase in interpreting simulated X-rays, a 32% increase in navigating challenging anatomical variations, a 12% increase in identifying key anatomical landmarks, a 20% increase in ensuring the correct placement of the lead, or a 53% increase in preparedness for performing an SCS procedure in a real clinical setting. The participant's perspective on how valuable the stimulator training was for enhancing procedural skills increased by 38% and how well the simulator replicated real-life SCS procedure increased by 52%, although both were statistically insignificant (p > 0.05). Conclusions This pilot study shows that the utilization of simulated neuromodulation training is a viable means of augmenting neuromodulation education by increasing physician's confidence in aspects of the SCS placement procedure. The extent to which simulator training improves procedural skills in a real-life SCS placement needs to be investigated further.

4.
Sultan Qaboos Univ Med J ; 24(1): 99-102, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38434472

RESUMO

Objectives: This study aimed to review the blood stream infections of major burn patients in a tertiary care burn unit to determine the most prevalent infecting organisms in order to have a better empirical therapy protocol. Methods: This retrospective study analysed the blood stream infection of 155 major burn (>20% Total Body Surface Area [TBSA]) patients in Khoula Hospital, Muscat, Oman between January 2014 to December 2019. Results: The median age was 33 years and 57.42% of patients were male. The median TBSA was 38%, mortality was 25.16% and 50.9% of patients had positive blood cultures. The expired patients had higher TBSAs, Abbreviated Burns Severity Index scores and earlier first positive blood cultures. Candida was commonly grown in all the blood cultures, but the most prevalent organisms were Acinetobacter, Staphylococci, Klebsiella, Enterococcus and Pseudomonas. All Acinetobacter species are multidrug resistant. Of the 17 patients who had Kelbsiella grown in the blood culture, 8 grew multidrug-resistant Klebsiella. Only 4 patients' blood cultures grew methicillin-resistant Staphylococcus aureus. The number of blood culture samples taken ranged between 1-28 (median = 6). The first positive blood culture showed that Staphylococcus epidermidis and Acinetobacter were the most common infecting organisms. Conclusions: Multidrug-resistant Acinetobacter was the most predominant microorganism grown from the blood cultures of major burn patients in a tertiary care burn unit. Empirical therapy should include antibiotics that are effective against this organism to reduce the mortality.


Assuntos
Staphylococcus aureus Resistente à Meticilina , Sepse , Humanos , Masculino , Adulto , Feminino , Omã/epidemiologia , Hemocultura , Unidades de Queimados , Estudos Retrospectivos , Atenção Terciária à Saúde
5.
Neuromodulation ; 27(1): 1-12, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37952135

RESUMO

OBJECTIVES: Neuromodulation therapies use a variety of treatment modalities (eg, electrical stimulation) to treat chronic pain. These therapies have experienced rapid growth that has coincided with escalating confusion regarding the nomenclature surrounding these neuromodulation technologies. Furthermore, studies are often published without a complete description of the effective stimulation dose, making it impossible to replicate the findings. To improve clinical care and facilitate dissemination among the public, payors, research groups, and regulatory bodies, there is a clear need for a standardization of terms. APPROACH: We formed an international group of authors comprising basic scientists, anesthesiologists, neurosurgeons, and engineers with expertise in neuromodulation. Because the field of neuromodulation is extensive, we chose to focus on creating a taxonomy and standardized definitions for implantable electrical modulation of chronic pain. RESULTS: We first present a consensus definition of neuromodulation. We then describe a classification scheme based on the 1) intended use (the site of modulation and its indications) and 2) physical properties (waveforms and dose) of a neuromodulation therapy. CONCLUSIONS: This framework will help guide future high-quality studies of implantable neuromodulatory treatments and improve reporting of their findings. Standardization with this classification scheme and clear definitions will help physicians, researchers, payors, and patients better understand the applications of implantable electrical modulation for pain and guide informed treatment decisions.


Assuntos
Dor Crônica , Terapia por Estimulação Elétrica , Humanos , Dor Crônica/terapia , Manejo da Dor , Próteses e Implantes
6.
Braz. j. biol ; 842024.
Artigo em Inglês | LILACS-Express | LILACS, VETINDEX | ID: biblio-1469402

RESUMO

Abstract This study explores the antioxidant activity, phytochemical screening, total phenolic and flavonoids contents in the extracts of four locally available weeds plants namely Convolvulus arvensis, Chenopodium murale, Avena fatua and Phalaris minor with different solvents. The antioxidant activities of these extracts were determined via various in-vitro methods such as total antioxidant activity (TAA), reducing power (RP), DPPH (2,2-Diphenyl-1-Picrylhydrazyl) free radical scavenging and hydrogen peroxide scavenging assays. Phytochemical screening was performed both qualitatively as well as quantitatively. Total phenolic content (TPC) and total flavonoid content (TFC) were determined through Folin- Ciocalteu reagent and aluminium chloride methods respectively. Methanol-chloroform solvent showed the presence of a high amount of TPC in milligram of gallic acid equivalent per gram of dry weight (mg of GAE/g of DW) in the extracts of all weeds. Their descending sequence was Avena fatua (74.09) Phalaris minor (65.66) Chenopodium murale (64.04) Convolvulus arvensis (61.905), while, chloroform solvent found to be best solvent for the extraction of TFC. Methanol-chloroform solvent was also found to be best solvent for TAA (Total antioxidant activity assay) which showed values in milligram of ascorbic acid equivalent per gram of dry weight (mg of AAE /g of DW), for DPPH scavenging activity, reducing power (antioxidant activity) and hydrogen peroxide scavenging activity. Phytochemical screening indicated the presence of polyphenols, flavonoids, tannins, saponins, alkaloids and glycosides in these weeds.


Resumo Este estudo investiga a atividade antioxidante, a triagem fitoquímica, os teores de fenólicos totais e de flavonoides nos extratos de quatro plantas daninhas disponíveis localmente, quais sejam, Convolvulus arvensis, Chenopodium murale, Avena fatua e Phalaris minor com diferentes solventes. As atividades antioxidantes desses extratos foram determinadas por meio de vários métodos in vitro, tais como atividade antioxidante total (TAA), poder redutor (RP), sequestro de radicais livres DPPH (2,2-Difenil-1-Picril-hidrazil) e ensaios de sequestro de peróxido de hidrogênio. A triagem fitoquímica foi realizada tanto qualitativamente quanto quantitativamente. O teor de fenólicos totais (TPC) e o teor de flavonoides totais (TFC) foram determinados pelos métodos do reagente de Folin-Ciocalteu e do cloreto de alumínio, respectivamente. O solvente metanol-clorofórmio mostrou a presença de elevada quantidade de TPC em miligramas de ácido gálico equivalente por grama de peso seco (mg de GAE/g de DW) nos extratos de todas as plantas daninhas. Sua sequência descendente foi Avena fatua (74,09) Phalaris minor (65,66) Chenopodium murale (64,04) Convolvulus arvensis (61,905), enquanto o solvente clorofórmio foi o melhor solvente para a extração de TFC. O solvente metanol-clorofórmio também foi considerado o melhor solvente para AAT (ensaio de atividade antioxidante total), que apresentou valores em miligramas de equivalente de ácido ascórbico por grama de peso seco (mg de AAE/g de DW), para atividade sequestrante de DPPH, RP (atividade antioxidante) e atividade de sequestro de peróxido de hidrogênio. A triagem fitoquímica indicou a presença de polifenóis, flavonoides, taninos, saponinas, alcaloides e glicosídeos nessas plantas daninhas.

7.
Neurosurgery ; 93(3): 493-495, 2023 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-37458729

RESUMO

BACKGROUND: The Guidelines Task Force conducted a systematic review of the relevant literature on occipital nerve stimulation (ONS) for occipital neuralgia (ON) to update the original 2015 guidelines to ensure timeliness and accuracy for clinical practice. OBJECTIVE: To conduct a systematic review of the literature and update the evidence-based guidelines on ONS for ON. METHODS: The Guidelines Task Force conducted another systematic review of the relevant literature, using the same search terms and strategies used to search PubMed and Embase for relevant literature. The updated search included studies published between 1966 and January 2023. The same inclusion/exclusion criteria as the original guideline were also applied. Abstracts were reviewed, and relevant full text articles were retrieved and graded. Of 307 articles, 18 were retrieved for full-text review and analysis. Recommendations were updated according to new evidence yielded by this update . RESULTS: Nine studies were included in the original guideline, reporting the use of ONS as an effective treatment option for patients with medically refractory ON. An additional 6 studies were included in this update. All studies in the original guideline and this current update provide Class III evidence. CONCLUSION: Based on the availability of new literature, the current article is a minor update only that does not result in modification of the prior recommendations: Clinicians may use ONS as a treatment option for patients with medically refractory ON.


Assuntos
Neuralgia , Neurocirurgiões , Humanos , Cefaleia/terapia , Neuralgia/terapia , Cervicalgia
8.
Mymensingh Med J ; 32(3): 802-806, 2023 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-37391977

RESUMO

Now-a-days Laparoscopic cholecystectomy is regarded as the gold standard treatment for benign gallbladder disease but in certain situations conversion to open cholecystectomy is extremely important for the safety of the patient. The objective of this study was to evaluate the reason for conversion of this operation to open surgery. This prospective study was carried out on 392 patients in a single unit of Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh and in a private hospital from July 2013 to December 2018. Maximum (28.3%) patients were 31-40 years age group. Majority (75.3%) was female and 24.7% were male. It was observed that only 2.1% were converted due to dense adhesion (n=3), severe inflammation (n=2), difficult to define anatomy of Calot's triangle (n=2) and Mirizzi syndrome (n=1). Meticulous dissection and proper case selection can reduce the rate of conversion to open surgery.


Assuntos
Colecistectomia Laparoscópica , Laparoscopia , Humanos , Feminino , Masculino , Estudos Prospectivos , Centros de Atenção Terciária , Bangladesh , Colecistectomia
10.
J Appl Clin Med Phys ; 24(6): e13919, 2023 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-37278646

RESUMO

To evaluate the image quality, dosimetric properties, setup reproducibility, and planar cine motion detection of a high-resolution brain coil and integrated stereotactic brain immobilization system that constitute a new brain treatment package (BTP) on a low-field magnetic resonance imaging (MRI) linear accelerator (MR-linac). Image quality of the high-resolution brain coil was evaluated with the 17 cm diameter spherical phantom and the American College of Radiology (ACR) Large MRI Phantom. Patient imaging studies approved by the institutional review board (IRB) assisted in selecting image acquisition parameters. Radiographic and dosimetric evaluation of the high-resolution brain coil and the associated immobilization devices was performed using dose calculations and ion chamber measurements. End-to-end testing was performed simulating a cranial lesion in a phantom. Inter-fraction setup variability and motion detection tests were evaluated on four healthy volunteers. Inter-fraction variability was assessed based on three repeat setups for each volunteer. Motion detection was evaluated using three-plane (axial, coronal, and sagittal) MR-cine imaging sessions, where volunteers were asked to perform a set of specific motions. The images were post-processed and evaluated using an in-house program. Contrast resolution of the high-resolution brain coil is superior to the head/neck and torso coils. The BTP receiver coils have an average HU value of 525 HU. The most significant radiation attenuation (3.14%) of the BTP, occurs through the lateral portion of the overlay board where the high-precision lateral-profile mask clips attach to the overlay. The greatest inter-fraction setup variability occurred in the pitch (average 1.08 degree) and translationally in the superior/inferior direction (average 4.88 mm). Three plane cine imaging with the BTP was able to detect large and small motions. Small voluntary motions, sub-millimeter in magnitude (maximum 0.9 mm), from motion of external limbs were detected. Imaging tests, inter-fraction setup variability, attenuation, and end-to-end measurements were quantified and performed for the BTP. Results demonstrate better contrast resolution and low contrast detectability that allows for better visualization of soft tissue anatomical changes relative to head/neck and torso coil systems.


Assuntos
Neoplasias Encefálicas , Humanos , Reprodutibilidade dos Testes , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/radioterapia , Encéfalo , Imageamento Tridimensional , Imageamento por Ressonância Magnética/métodos , Imagens de Fantasmas
11.
Heliyon ; 9(4): e15427, 2023 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-37151680

RESUMO

We explore how asset returns could be a good proxy to detect interlinkages in the financial system. This paper employs a US dataset for the 2002-2021 period. Pairwise returns correlation indicate the interconnectedness at the preliminary stage. The Principal Component Analysis captures a significant portion of variance and detects the co-movement and highly connected state of the financial market during crises. Granger centrality tested with pairwise directional variance decomposition indicates the importance of banks and insurance companies in the US financial system. This paper recommends policymakers use multiple network models to validate and calibrate the SIFIs list.

13.
Trop Med Infect Dis ; 8(3)2023 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-36977150

RESUMO

INTRODUCTION: Malaria and soil-transmitted helminth (STH) co-infection is an important parasitic infection affecting populations in co-endemic countries including Equatorial Guinea. To date, the health impact of STH and malaria co-infection is inconclusive. The current study aimed to report the malaria and STH infection epidemiology in the continental region of Equatorial Guinea. METHODS: We performed a cross-sectional study between October 2020 and January 2021 in the Bata district of Equatorial Guinea. Participants aged 1-9 years, 10-17 years and above 18 were recruited. Fresh venous blood was collected for malaria testing via mRDTs and light microscopy. Stool specimens were collected, and the Kato-Katz technique was used to detect the presence of Ascaris lumbricoides, Trichuris trichiura, hookworm spp. and intestinal Schistosoma eggs. RESULTS: A total of 402 participants were included in this study. An amount of 44.3% of them lived in urban areas, and only 51.9% of them reported having bed nets. Malaria infections were detected in 34.8% of the participants, while 50% of malaria infections were reported in children aged 10-17 years. Females had a lower prevalence of malaria (28.8%) compared with males (41.7%). Children of 1-9 years carried more gametocytes compared with other age groups. An amount of 49.3% of the participants infected with T. trichiura had malaria parasites compared with those infected with A. lumbricoides (39.6%) or both (46.8%). CONCLUSIONS: The overlapping problem of STH and malaria is neglected in Bata. The current study forces the government and other stakeholders involved in the fight against malaria and STH to consider a combined control program strategy for both parasitic infections in Equatorial Guinea.

14.
J Relig Health ; 62(3): 1897-1919, 2023 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-36810722

RESUMO

Cancer pain remains a significant problem worldwide. It is often undertreated and presents in about half of cancer patients. Although several guidelines and pharmacological interventions for cancer pain management (CPM) exist, inadequate assessment and undertreatment of cancer pain are well-documented globally, especially in developing countries, including Libya. Perceptions, cultural and religious beliefs of healthcare professionals (HCP), patients, and caregivers about cancer pain and opioids are reported as barriers to CPM globally. This qualitative descriptive study aimed to explore Libyan HCPs', patients', and caregivers' views and religious beliefs about CPM and involved semi-structured interviews with 36 participants: 18 Libyan cancer patients, 6 caregivers, and 12 Libyan HCPs. Thematic analysis was used to analyse the data. Patients, caregivers, and newly qualified HCPs were concerned about poor tolerance and drug addiction. HCPs perceived a lack of policies and guidelines, pain rating scales, and professional education and training as CPM barriers. Some patients were unable to pay for medicines if they faced financial difficulties. Instead, patients and caregivers emphasised religious and cultural beliefs for managing cancer pain, including the use of the Qur'an and cautery. Our results suggest that religious and cultural beliefs, lack of knowledge and training in CPM among HCPs, and economic and Libyan healthcare system-related factors negatively affect CPM in Libya.


Assuntos
Dor do Câncer , Neoplasias , Humanos , Cuidadores , Pessoal de Saúde , Pesquisa Qualitativa , Atitude do Pessoal de Saúde , Religião , Neoplasias/complicações
15.
Front Oncol ; 13: 1090582, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36761944

RESUMO

Objective: Magnetic resonance imaging (MRI) is a standard imaging modality in intracranial stereotactic radiosurgery (SRS) for defining target volumes. However, wide disparities in MRI resolution exist, which could directly impact accuracy of target delineation. Here, sequences with various MRI resolution were acquired on phantoms to evaluate the effect on volume definition and dosimetric consequence for cranial SRS. Materials/Methods: Four T1-weighted MR sequences with increasing 3D resolution were compared, including two Spin Echo (SE) 2D acquisitions with 5mm and 3mm slice thickness (SE5mm, SE3mm) and two gradient echo 3D acquisitions (TFE, BRAVO). The voxel sizes were 0.4×0.4×5.0, 0.5×0.5×3.0, 0.9×0.9×1.25, and 0.4×0.4×0.5 mm3, respectively. Four phantoms with simulated lesions of different shape and volume (range, 0.53-25.0 cm3) were imaged, resulting in 16 total sets of MRIs. Four radiation oncologists provided contours on individual MR image set. All observer contours were compared with ground truth, defined on CT image according to the absolute dimensions of the target structure, using Dice similarity coefficient (DSC), Hausdorff distance (HD), mean distance-to-agreement (MDA), and the ratio between reconstructed and true volume (Ratiovol ). For dosimetric consequence, SRS plans targeting observer volumes were created. The true Paddick conformity index ( C I p a d d i c k t r u e ), calculated with true target volume, was correlated with quality of observer volume. Results: All measures of observer contours improved as increasingly higher MRI resolution was provided from SE5mm to BRAVO. The improvement in DSC, HD and MDA was statistically significant (p<0.01). Dosimetrically, C I p a d d i c k t r u e   strongly correlated with DSC of the planning observer volume (Pearson's r=0.94, p<0.00001). Conclusions: Significant improvement in target definition and reduced inter-observer variation was observed as the MRI resolution improved, which also improved the quality of SRS plans. Results imply that high resolution 3D MR sequences should be used to minimize potential errors in target definition, and multi-slice 2D sequences should be avoided.

18.
J Cancer Educ ; 38(3): 789-797, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-35650378

RESUMO

Cancer pain presents in approximately 66% of patients in advanced stages. Although several guidelines and pharmacological options are available for cancer pain management (CPM), assessment and treatment of cancer pain remain inadequate globally, particularly in developing countries. Lack of knowledge and negative attitudes towards CPM among healthcare professionals (HCPs) are important barriers to CPM. This survey aimed to evaluate nurses' and physicians' knowledge, attitudes, and potential barriers regarding CPM in Libya. This cross-sectional survey involved a convenience sample of 152 oncology nurses and physicians working in six oncology settings in Libya. The response rate was 76%. The Barriers Questionnaire II (BQ-II) was used for data collection (higher scores signify greater attitudinal barriers and poorer knowledge). Data analysis was carried out using Statistical Package for Social Sciences (SPSS), version 26 software. An independent t-test (unadjusted estimate) indicated that Libyan nurses showed higher mean barrier scores (mean = 3.8, SD = 0.7) to CPM than physicians (mean = 2.9, SD = 0.8), p < 0.001. The six most common differences in attitudinal barriers between nurses and physicians were "opioid side effects," "poor tolerance," "strong patient endures pain," "distract the physician," "drug addiction," and "opioids impair immune function," p < 0.001. Multiple regression results (adjusted estimate) indicated that nurses had more barrier scores to CPM than physicians (B = - 0.530, p < 0.05), and participants with higher educational levels were associated with lower barrier scores to CPM (B = - 0.641, p < 0.05). Our results suggest that Libyan oncology HCPs hold perceived barriers, lack of knowledge, and negative attitudes towards CPM. Professional education and training in CPM, addressing phobia and myths on opioid usage, and the benefits and complications of using opioids are likely to result in reduced barriers to CPM in Libya.


Assuntos
Dor do Câncer , Neoplasias , Humanos , Manejo da Dor/métodos , Dor do Câncer/etiologia , Analgésicos Opioides/uso terapêutico , Estudos Transversais , Líbia , Neoplasias/terapia , Conhecimentos, Atitudes e Prática em Saúde , Inquéritos e Questionários , Atitude do Pessoal de Saúde
19.
Pain Med ; 24(7): 796-808, 2023 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-36515491

RESUMO

Intrathecal trialing is used as a screening prognostic measure prior to intrathecal drug delivery system implant. The purpose of this study was to determine the efficacy of a continuous intrathecal infusion of an admixture of bupivacaine and fentanyl in patients with chronic low back pain. Patients with refractory chronic low back pain in the setting of previous lumbar spine surgery and/or chronic vertebral compression fracture(s) were enrolled in a randomized double blind cross-over study comparing saline infusion to infusion of a solution containing bupivacaine combined with low-dose fentanyl over a 14-18 hour period. The primary outcome measure was the change in pain intensity at the end of the screening trial. Patients who experienced significant pain reduction from either infusion relative to baseline pain were offered a permanent implant. In total, 36 patients were enrolled, with 31 patients trialed and 25 implanted. At the end of the screening trial, pain scores, at rest or with activity, decreased appreciably in both groups; however, significantly better improvements occurred in the fentanyl/bupivacaine group compared to saline both with activity and at rest (P = .016 and .006, respectively). Treatment order appeared to affect outcome with saline demonstrating a placebo response. At 12 months following implant, primary and secondary outcome measures continued to be significantly reduced from baseline. Continuous intrathecal delivery of a combination of zlow-dose fentanyl with bupivacaine is superior to saline in screening intrathecal trialing for back pain reduction. With longer term delivery, a sustained reduction of chronic low back pain was also observed.


Assuntos
Fraturas por Compressão , Dor Lombar , Fraturas da Coluna Vertebral , Humanos , Bupivacaína , Fentanila/uso terapêutico , Analgésicos Opioides/uso terapêutico , Dor Lombar/tratamento farmacológico , Estudos Cross-Over , Injeções Espinhais , Anestésicos Locais , Método Duplo-Cego
20.
J Craniovertebr Junction Spine ; 14(4): 393-398, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38268697

RESUMO

Context: Anterior craniocervical junction lesions have always been a challenge for neurosurgeons. Presenting with lower cranial nerve dysfunction and symptoms of brainstem compression, decompression is often required. While posterior approaches offer indirect ventral brainstem decompression, direct decompression via odontoidectomy is necessary when they fail. The transoral and endoscopic endonasal approaches have been explored but come with their own limitations and risks. A novel retropharyngeal approach to the cervical spine has shown promising results with reduced complications. Aims: This study aims to explore the feasibility and potential advantages of the anterior retropharyngeal approach for accessing the odontoid process. Methods and Surgical Technique: To investigate the anatomical aspects of the anterior retropharyngeal approach, a paramedian skin incision was performed below the submandibular gland on two cadaveric specimens. The subcutaneous tissue followed by the platysma is dissected, and the superficial fascial layer is opened. The plane between the vascular sheath laterally and the pharyngeal structures medially is entered below the branching point of the facial vein and internal jugular vein. After reaching the prevertebral plane, further dissection cranially is done in a blunt fashion below the superior pharyngeal nerve and artery. Various anatomical aspects were highlighted during this approach. Results: The anterior, submandibular retropharyngeal approach to the cervical spine was performed successfully on two cadavers highlighting relevant anatomical structures, including the carotid artery and the glossopharyngeal, hypoglossal, and vagus nerves. This approach offered wide exposure, avoidance of oropharyngeal contamination, and potential benefit in repairing cerebrospinal fluid fistulas. Conclusions: For accessing the craniocervical junction, the anterior retropharyngeal approach is a viable technique that offers many advantages. However, when employing this approach, surgeons must have adequate anatomical knowledge and technical proficiency to ensure better outcomes. Further studies are needed to enhance our anatomical variations understanding and reduce intraoperative risks.

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