Pain relief and quality-of-life improvement after spinal cord stimulation in painful diabetic polyneuropathy: a pilot study.

BACKGROUND: Painful diabetic polyneuropathy (PDP) is associated with high pain scores and is difficult to treat. Therefore, spinal cord stimulation (SCS) has been suggested as second-line treatment. In this study, the feasibility and efficacy of SCS in PDP were investigated, as well as the predictive value of clinical sensory testing for the treatment outcome. METHODS: Fifteen patients with intractable PDP in the lower limbs were recruited. During lead implantation, the feasibility of achieving adequate paraesthesia coverage using one stimulation lead was investigated. If trial stimulation was successful, a definitive neurostimulator was implanted. Pain intensity was scored using an 11-point numeric rating scale and patients' global impression of change scale. Additionally, neuropathic pain characteristics, quality of life, sleep quality and mood were assessed. The predictive value of clinical sensory testing for the treatment outcome was analysed. RESULTS: Adequate paraesthesia coverage was achieved in 14 out of 15 patients. Clinically relevant pain relief was present in 11 patients after trial stimulation and 10 patients at 12 months. The quality of life was significantly increased at 2 weeks and 3 months in patients with successful SCS treatment. Several neuropathic pain characteristics and quality of sleep were improved at 2 weeks and 12 months. Preoperative clinical sensory testing did not differentiate between treatment responders from non-responders. CONCLUSIONS: SCS seems to be an efficacious and feasible treatment for intractable PDP. In this exploratory study, it was not possible to predict the treatment outcome using clinical sensory testing. These results justify performing a randomized clinical trial.

Toxinotype A Clostridium perfringens causing septicaemia with intravascular haemolysis: two cases and review of the literature.

BACKGROUND: Septicaemia with intravascular haemolysis is a rare, but often fatal, presentation of Clostridium perfringens infection. C. perfringens is a Gram-positive, anaerobic bacterium that can produce multiple toxins. Toxinotyping is not performed regularly. METHODS: This article describes two human cases of C. perfringens infections. Toxinotyping was performed using polymerase chain reaction (PCR). Additionally, a structured review of the literature was performed which searched specifically for cases of C. perfringens infection with haemolysis. RESULTS: Both cases were identified as toxinotype A strains and both cases were fatal. Also, both cases showed marked haemolysis during their clinical course, which is assumed to have played a significant role in their outcome. In total, 83 references were identified describing human C. perfringens infection with haemolysis. Mortality rates have been stable over the last 10 years at 80%. Toxinotyping has been performed in a total of six cases. Of the four cases analysed by PCR, all were identified as toxinotype A. CONCLUSIONS: Haemolytic C. perfringens infections are rare but are fatal in most cases. Toxinotyping is performed rarely. The authors advocate increased use of toxinotyping to gain insight into pathophysiology and more effective interventions.

Case report: direct revascularization in acute mesenteric ischemia by an endovascular approach.

BACKGROUND: Acute mesenteric ischemia is a relatively rare but life-threatening clinical condition. Outcome depends on early diagnosis and prompt intervention. CASE PRESENTATION: A 85-year-old man and a 75-year-old woman developed acute mesenteric ischemia due to cardiac embolism. The first patient received an insufficient dose of anticoagulants for atrial fibrillation and the second patient dicontinued her anticoagulantia to avoid bleeding during a routine colonoscopy. Both patients presented with severe abdominal pain and computed tomography showed thrombus in de superior mesenteric artery. Successfulrevascularization with good clinical outcome was achieved by means of an endovascular first approach. CONCLUSION: This case report shows that an endovascular approach - in contrast to open surgery - not only enables to revascularize main trunk lesions but can also facilitate revascularization of side branches. Endovascular treatment used to be limited to a selected group of patients without signs of bowel necrosis, but there is a tendency to initiate endovascular revascularization in all patients because it is associated with a reduced mortality, a reduced laparotomy rate and reduction in the resected length of bowel.