Efficacy of Continuous Intrathecal Infusion Trialing with a Mixture of Fentanyl and Bupivacaine in Chronic Low Back Pain Patients.

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.

Mitochondrial DNA analysis of the putative skeletal remains of Sieur de Marle: Genetic support for anthropological assessment of biogeographic ancestry.

In 1932, seven burials were discovered on a Texas plantation that was originally the site of a 17th-century Caddo Indian village. Of the seven excavated graves, one set of remains (an adult male) was notably buried in a manner inconsistent with traditional Caddoan burial practices and has long been purported to be the remains of Sieur de Marle (a member of the French explorer La Salle's last expedition). Diary accounts of La Salle's expedition scribe report that Sieur de Marle died along a river near an Indian village during a trek to Canada to find help for colonists left behind at the ill-fated Fort St. Louis. Additionally, two lead projectiles recovered from the grave were ballistically analyzed and determined to be consistent with ammunition used in 17th-century weaponry. In the 1980s, anthropologists requested access to the remains for study, but the skull was missing. Cranial measurements recorded in 1940 and 1962 (by two independent anthropologists) were used to investigate the ancestry of this individual; and the Giles-Elliot (G-E) discriminant function was calculated to be 18.1, within the Anglo-European range. Dietary isotope testing on non-cranial skeletal elements determined that this unknown male's diet was rich in animal/marine protein sources, which differs appreciably from Caddo Indian populations of that time period. In order to genetically assess this individual's biogeographic ancestry and to provide further support that this individual is of European descent, mitochondrial DNA (mtDNA) sequencing was performed using the Applied Biosystems™ Precision ID mtDNA Whole Genome Panel. mtDNA sequencing of multiple sections from two different long bones yielded compiled results consistent with either Haplogroup H or R, both predominantly European mtDNA haplogroups. Further anthropological calculations were conducted using cranial measurements, FORDISC™ software, and discriminant function analysis. Two-way, four-way, and multigroup discriminant function analyses further classify this set of unidentified remains as being White (European) in origin, with posterior probabilities of 0.999, 0.881 and 0.986, respectively. Combined with historical records of Sieur de Marle's death, as well as overlays of historical and contemporary maps which demonstrate that the plantation site aligns with Joutel's diary accounts of de Marle's burial, these collective results support that these remains are of a European male and may possibly belong to this prominent member of La Salle's expedition team.

Forensic genetic investigation of human skeletal remains recovered from the La Belle shipwreck.

In 1995, the historical shipwreck of La Belle was discovered off the coast of Texas. One partial human skeleton was recovered from alongside cargo in the rear portion of the ship; a second (complete) skeleton was found atop coiled anchor rope in the bow. In late 2015, comprehensive forensic genetic testing began on multiple samplings from each set of remains. For the partial skeleton recovered from the ship's rear cargo area, results were obtained for 26/27 Y-STRs using traditional CE; with MPS technology, results were obtained for 18/24 Y-STRs, 56/56 ancestry-informative SNPs (aiSNPs), 22/22 phenotype-informative SNPs (piSNPs), 22/27 autosomal STRs, 4/7 X-STRs, and 94/94 identity-informative SNPs (iiSNPs). For the complete skeleton of the second individual, results were obtained for 7/17 Y-STRs using traditional CE; with MPS technology, results were obtained for 5/24 Y-STRs, 49/56 aiSNPs, 18/22 piSNPs, 15/27 autosomal STRs, 1/7 X-STRs, and 66/94 iiSNPs. Biogeographic ancestry for each set of skeletal remains was predicted using the ancestry feature and metapopulation tool of the Y-STR Haplotype Reference Database (YHRD), Haplogroup Predictor, and the Forensic Research/Reference on Genetics knowledge base (FROG-kb). Phenotype prediction was performed using piSNP data and the HIrisplex eye color and hair color DNA phenotyping webtool. mtDNA whole genome sequencing also was performed successfully. This study highlights the sensitivity of current forensic laboratory methods in recovering DNA from historical and archaeological human remains. Using advanced sequencing technology provided by MiSeq™ FGx (Verogen) and Ion S5™ (Thermo Fisher Scientific) instrumentation, degraded skeletal remains can be characterized using a panel of diverse and highly informative markers, producing data which can be useful in both forensic and genealogical investigations.

Factors contributing to patient nonattendance at open-access endoscopy.

Patients who miss endoscopy appointments cause inefficient utilization of medical resources. Because national nonattendance rates are as high as 27% and reasons for nonattendance have not been well studied, we sought to quantitate nonattendance at our tertiary care institution. We conducted a retrospective records review of the institutional database to identify patients who did not attend a scheduled endoscopy appointment between January 2000 and December 2003. Nonattendance was defined as either not showing up for an appointment or canceling it on the day it was scheduled. At our institution, patient care assistants contact such patients to document their reasons in the database. Of 36,480 patients scheduled for outpatient endoscopy, 1,490 (4.1%) did not show up because of either facility-related (44.3%; e.g., scheduling errors) or patient-related (55.7%; e.g., noncancellation, illness, or hospitalization) reasons. Our 4.1% nonattendance rate over 4 years is considerably lower than that reported by other endoscopy centers.

Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding.

PURPOSE: Capsule endoscopy (CE) has been shown to have a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB). It is not known if repeating CE improves diagnostic yield or changes patient management when the initial CE is negative or nondiagnostic. The aims of this study are (1) to understand the reasons for repeat CE, (2) to determine the diagnostic yield of repeat CE, and (3) to establish if findings on repeat CE resulted in a change in patient management. METHODS: Between August 2001 and October 2003, we performed 391 capsule studies. Of these, 24 were repeat studies in patients with OGIB. We retrospectively reviewed the charts of these 24 patients. RESULTS: The reasons for repeat CE were: recurrent gastrointestinal bleeding (13), limited visualization on first exam due to poor prep or blood (10), complication (1) (capsule impaction at cricopharyngeus). Eighteen of 24 (75%) repeat capsule studies revealed additional findings (7 arteriovenous malformations, 2 gastropathy, 2 erosions, 2 masses, 1 ulcer, 2 red spots, 1 linear streak, 1 erythema). These findings led to changes in patient management in 15 of the 24 (62.5%) cases. CONCLUSIONS: Indications for repeat CE most commonly include recurrent gastrointestinal bleeding and limited visualization on initial study. Repeat CE results in a high yield of new findings that lead to changes in patient management. Repeat CE should be considered in patients with persistent OGIB when the initial study is negative or inconclusive.