Fantastic Four: Age, Spinal Cord Stimulator Waveform, Pain Localization and History of Spine Surgery Influence the Odds of Successful Spinal Cord Stimulator Trial.

BACKGROUND: There is a dearth in our understanding of the factors that are predictive of successful spinal cord stimulator (SCS) trials and eventual conversion to permanent implants. Knowledge of these factors is important for appropriate patient selection and treatment optimization. OBJECTIVES: Although previous studies have explored factors predictive of trial success, few have examined the role of waveform in trial outcomes. This study sought to establish the relationship of neuraxial waveform and related measures to trial outcomes. STUDY DESIGN: This study used a retrospective chart review design. METHODS: Data were retrospectively collected on 174 patients undergoing SCS trials upon institutional review board approval of the study protocol. Indications for SCS were: complex regional pain syndrome, failed back surgery syndrome with radicular symptoms, peripheral neuropathy, and axial low back pain. Descriptive statistics and logistic regression analyses were used to assess the association of demographic and clinical variables with SCS trial outcomes. RESULTS: The study population comprised 56% women, had a median age of 55 (interquartile range [IQR], 44-64), and 32 of 174 (18%) patients failed SCS trials. Individuals with successful trials (>= 50% pain relief) were significantly younger and had a median age of 54 years (IQR, 42-60) compared to those who failed SCS trials (median age 66 years; IQR, 50-76; P = .005). Adjusting for age, gender, number of leads, pain category, and diagnoses: surgical history (odds ratio [OR] = 4.4; 95% confidence interval [CI], 1.3-15.8) and paresthesia-based tonic-stimulation (OR = 10.3; 95% CI, 1.7-62.0), but not burst or high frequency, were significantly associated with successful trials. Of note, the number of leads (whether dual or single), pain duration, characteristics, and category (nociceptive vs neuropathic) were not significant factors. An interaction between surgical spine history and lower extremity pain was significantly associated with a positive trial (P = .005). LIMITATIONS: This study was limited by its retrospective nature and focus on a patient population at a single major academic medical center. CONCLUSIONS: Paresthesia-based tonic stimulation, age, and surgical history have significant effects on SCS trials. Prospective and randomized controlled studies may provide deeper insights regarding impact on costs and overall outcomes.IRB Approval #: 2018P002216. KEY WORDS: Pain duration, pain location, spinal cord stimulator trial, stimulator waveform, surgical history.

Let's move salad bars to schools: a public-private partnership to increase student fruit and vegetable consumption.

Few school-age youth consume the recommended amounts of fruits and vegetables, and increasing fruit and vegetable intake in children and adolescents is an important public health goal to maintain long-term good health and to decrease risk of chronic disease and obesity. School salad bars are an important tool to promote fruit and vegetable consumption among schoolchildren. Studies show that introduction of school salad bars increases the amount and variety of fruits and vegetables consumed by children in schools. However, many schools cannot afford the capital investment in the salad bar equipment. In 2010, the National Fruit & Vegetable Alliance (NFVA), United Fresh Produce Association Foundation, the Food Family Farming Foundation, and Whole Foods Market launched Let's Move Salad Bars to Schools (LMSB2S) in support of First Lady Michelle Obama's Let's Move! initiative. The goal of LMSB2S is to place 6000 salad bars in schools over 3 years. As of June, 2012, over 1400 new salad bar units have been delivered to schools across the United States, increasing access to fruits and vegetables for over 700,000 students. Any K through 12 school district participating in the National School Lunch Program is eligible to submit an application at www.saladbars2schools. org/. Requests for salad bar units ($2625 each unit) are fulfilled through grassroots fund raising in the school community and through funds raised by the LMSB2S partners from corporate and foundation sources. LMSB2S is a model for coalition-building across many government, nonprofit, and industry partners to address a major public health challenge.

Can schools save kids' palates? Cooking from scratch in schools--the greatest food service challenge of our time.

School District Food Service Departments are faced with the enormous task of feeding children in the United States up to two thirds of the meals that they consume during the week at school. The shift in food production since the 1970s produced a trend away from scratch-cooked foods and resulted in more meals created from processed foods. The United States has reached a tipping point where the health of the current generation is compromised by increasing health risks of diet-related disease. Schools have been identified as a critical environment in which there is an opportunity to effect change in what children eat. As a result, in the last 10 years, there has been a resurgence of interest in freshly prepared meals in schools. This article explores one chef's transition from the private sector to the public sector and the experiences of working with school districts to successfully transform their school food service operations into a scratch cooking model.

Dual-plane prosthetic reconstruction using the modified wise pattern mastectomy and fasciocutaneous flap in women with macromastia.

BACKGROUND: Skin-sparing mastectomy and immediate breast reconstruction in women with macromastia is often difficult. The Wise pattern skin-reducing mastectomy often provides the best options for shape and symmetry, but is not without morbidity. The authors reviewed their experience with a modified Wise pattern mastectomy and tissue expander reconstruction to improve safety. METHODS: All patients with breast cancer who underwent a skin-sparing mastectomy and modified Wise pattern skin-reducing reconstruction with a tissue expander were included. A dual-plane technique was used by covering the expander with the pectoralis muscle and a vascularized lower pole fasciocutaneous flap. Patient demographics were queried and outcomes were assessed. RESULTS: Twenty-seven patients (34 breasts) underwent tissue expander reconstruction using the dual-plane vascularized coverage technique. The average body mass index was 34 (range, 24 to 42). The average contralateral reduction weight was 502 g on all 20 unilateral reconstructions. Postoperative complications occurred in 37 percent of the patients (10 of 27), with seroma being the most common [six of 34 reconstructions (18 percent)]. The unplanned reoperation rate was 15 percent. The average follow-up was 16 months (range, 2 months to 4.5 years). CONCLUSIONS: The authors have demonstrated that modifications to the Wise pattern mastectomy with a tissue expander using a dual plane of vascularized tissue coverage can optimize results in patients with breast cancer and macromastia. Complications still occur, but they can usually be treated conservatively.

Terminating migraine with allodynia and ongoing central sensitization using parenteral administration of COX1/COX2 inhibitors.

OBJECTIVE: To determine whether delayed infusion of COX1/COX2 inhibitors (ketorolac, indomethacin) will stop migraine in allodynic patients, and suppress ongoing sensitization in central trigeminovascular neurons in the rat. BACKGROUND: The majority of migraineurs seeking secondary or tertiary medical care develop cutaneous allodynia during the course of migraine, a sensory abnormality mediated by sensitization of central trigeminovascular neurons in the spinal trigeminal nucleus. Triptan therapy can render allodynic migraineurs pain free within a narrow window of time (20 to 120 minutes) that opens with the onset of pain and closes with the establishment of central sensitization. Can drugs that tackle ongoing central sensitization render allodynic migraineurs pain free after the window for triptan therapy has expired? METHODS: Patients exhibiting migraine with allodynia were divided in two groups (n=14, each): group 1 received delayed sumatriptan injection (6 mg) 4 hours after onset of attack--which failed to render them pain free-and ketorolac infusion (two 15-mg boluses) 2 hours later; group 2 received delayed ketorolac monotherapy 4 hours after onset of attack. Pain intensity (visual analog scale) and skin sensitivity (quantitative sensory testing) were measured when the patients were migraine free (baseline); 4 hours after onset of migraine (just before treatment); 2 hours after sumatriptan; 1 hour after ketorolac. In the rat, we tested whether infusion of ketorolac (0.4 mg/kg) or indomethacin (1 mg/kg) will block ongoing sensitization in peripheral and central trigeminovascular neurons. The induction of sensitization (using topical application of inflammatory soup on the dura) and its suppression by COX1/COX2 inhibitors were assessed by monitoring changes in spontaneous activity and responses to mechanical and thermal stimuli. RESULTS: Patients had normal skin sensitivity in the absence of migraine, and presented cutaneous allodynia 4 hours after onset of migraine. In group 1, all patients continued to exhibit allodynia 2 hours after sumatriptan treatment, and none of them became pain free. However, 71% and 64% of the patients in groups 1 and 2, respectively, were rendered free of pain and allodynia within 60 minutes of ketorolac infusion. Nonresponders from both groups, in contrast to the responders, had had a history of opioid treatment. In the rat, infusion of COX1/COX2 inhibitors blocked sensitization in meningeal nociceptors and suppressed ongoing sensitization in spinal trigeminovascular neurons. This inhibitory action was reflected by normalization of neuronal firing rate and attenuation of neuronal responsiveness to mechanical stimulation of the dura, as well as mechanical and thermal stimulation of the skin. CONCLUSIONS: The termination of migraine with ongoing allodynia using COX1/COX2 inhibitors is achieved through the suppression of central sensitization. Although parenteral administration of COX1/COX2 inhibitors is impractical as routine migraine therapy, it should be the rescue therapy of choice for patients seeking emergency care for migraine. These patients should never be treated with opioids, particularly if they had no prior opioid exposure.

Language barrier leads to the unnecessary intubation of trauma patients.

Airway evaluation in trauma patients is performed immediately upon patient contact, with communication being a vital component to this exam. Language and communication barriers may lead to the unnecessary placement of an artificial airway with resultant patient risk and elevation of health care costs. The objective of our study was to evaluate potentially preventable intubations in Spanish-speaking patients. A 9-year retrospective review was performed using the National Trauma Registry for The American College of Surgeons (NTRACS) database. We evaluated patients intubated on arrival to the trauma center and remaining intubated for less than 48 hours. Deaths were excluded. Patients who typically speak English were compared with patients who typically speak Spanish. Mechanism of injury (MOI), hypotension during resuscitation (HDR), illicit substance use, alcohol use, mean Glasgow Coma Score (GCS), mean Injury Severity Score (ISS), payer source, and hospital cost were compared. Forty-nine per cent and 38 per cent of Spanish and English speaking individuals, respectively, were intubated for less than 48 hours (P = 0.072). MOI, HDR, ISS, illicit substance use, alcohol use, and payer source were similar. GCS was statistically higher in the Spanish-speaking group (14 vs 12; P = 0.004). Language and communication barriers lead to potentially preventable intubations in trauma patients.

Defeating migraine pain with triptans: a race against the development of cutaneous allodynia.

For many migraine patients, triptan therapy provides complete pain relief in some attacks but not in others. Here, we tested whether the success of triptan therapy is hindered in the presence of cutaneous allodynia (pain resulting from a nonnoxious stimulus to normal skin), a phenomenon we previously described develop gradually during the course of the migraine attack in more than 70% of patients. We studied migraine patients repeatedly on three visits to the clinic: in the absence of migraine (baseline), within the first hour of one attack, or at 4 hours from onset of another attack. Presence or absence of allodynia was determined based on differences between migraine and baseline pain thresholds to mechanical and thermal stimulation of periorbital skin. In 31 patients, we studied 34 migraine attacks that were associated with allodynia at the time of triptan treatment and 27 attacks that were not. Within 2 hours of triptan treatment, patients were rendered pain-free in 5 of 34 (15%) of allodynic attacks versus 25 of 27 (93%) of nonallodynic attacks. Treating migraine attacks 1 hour (early) or 4 hours (late) after the onset of pain was equally ineffective in inducing a pain-free state in the presence of allodynia, and equally effective in the absence of allodynia. For patients susceptible to allodynia during the attack, triptan therapy was by far more likely to provide complete pain relief if administered before rather than after the establishment of cutaneous allodynia. Patients who never developed allodynia were highly likely to be rendered pain-free by triptan therapy anytime after the onset of pain. We conclude that the probability of consistent pain-free outcome increases drastically if triptan therapy is vigilantly timed to precede any signs of cutaneous allodynia.

Response of intractable post herpetic neuralgia to intrathecal baclofen.

An intractable case of Post-herpetic Neuralgia (PHN) in which all other treatment options were exhausted was successfully treated with intrathecal baclofen infusion with a complex continuous delivery mode. A 72-year old man presented to the pain clinic with a 4-year history of left lower extremity PHN. He had seen multiple experts in the field, failed numerous pharmacological therapies, and interventional techniques. After multiple neuraxial medications were tried, baclofen was chosen and an intrathecal drug delivery system was implanted. Eight months after the procedure he continues to have 80 % pain relief. PHN is a devastating complication of shingles. Fortunately, most cases respond to conventional therapies. For intractable cases intrathecal baclofen appears to be a safe and effective therapeutic modality.