Musculoskeletal and Neuropathic Pain in COVID-19.

Chronic pain constitutes a significant disease burden globally and accounts for a substantial portion of healthcare spending. The COVID-19 pandemic contributed to an increase in this burden as patients presented with musculoskeletal or neuropathic pain after contracting COVID-19 or had their chronic pain symptoms exacerbated by the virus. This extensive literature review analyzes the epidemiology of pain pre-pandemic, the costs associated with the COVID-19 pandemic, the impact of the virus on the body, mechanisms of pain, management of chronic pain post-pandemic, and potential treatment options available for people living with chronic pain who have had or are currently infected with COVID-19.

Advances in Spinal Cord Stimulation.

Neuromodulation, specifically spinal cord stimulation (SCS), has become a staple of chronic pain management for various conditions including failed back syndrome, chronic regional pain syndrome, refractory radiculopathy, and chronic post operative pain. Since its conceptualization, it has undergone several advances to increase safety and convenience for patients and implanting physicians. Current research and efforts are aimed towards novel programming modalities and modifications of existing hardware. Here we review the recent advances and future directions in spinal cord stimulation including a brief review of the history of SCS, SCS waveforms, new materials for SCS electrodes (including artificial skins, new materials, and injectable electrodes), closed loop systems, and neurorestorative devices.

De-Prescribing Proton Pump Inhibitors in Patients With End Stage Kidney Disease: A Quality Improvement Project.

Background: Proton pump inhibitors (PPIs) are widely prescribed and may be associated with harm; hypomagnesemia and reduced effectiveness of calcium carbonate phosphate binders may be important in end-stage kidney disease (ESKD). Objectives: Our objectives included (1) discontinuing PPIs and H2 blockers and (2) assessing the impact on serum magnesium and markers of mineral metabolism. Design: Prospective cohort. Setting: Satellite hemodialysis unit of a tertiary care hospital. Patients: Incident and prevalent patients with ESKD treated with hemodialysis. Measurements: We assessed the impact of stopping PPI/H2 blockers in patients who did not have an absolute indication as per guidelines in the general population; serum magnesium, calcium, and phosphate were measured before and approximately 8 weeks later. Analysis of variance (ANOVA) test and Kruskal-Wallis was used to describe the population. Wilcoxon signed rank test for the paired change scores (from pre to post). Methods: The electronic medical record (EMR) was extensively searched for absolute indications for a PPI. Results were reviewed with the primary nephrology team before approaching patients about stopping the PPI. Basic demographic information and select medications were also collected. Results: Electronic medical records were reviewed for 179 patients, 74 had a PPI or H2 antagonist or both on their medication list (43%); 23 (31%) were assessed as appropriate. After primary team and patient review, 29 patients agreed to a trial of PPI withdrawal. Fourteen patients restarted their PPI, most for gastroesophageal reflux disease. Three patients had a GI bleed, 1 fatally. Serum calcium (P = .17) and the dose of phosphate binders (P = .075) did not change but serum phosphate increased (1.55 [0.29] to 1.85 [0.34] mmol/L; P = .0005). Serum magnesium also increased (1.01 [0.16] to 1.06 [0.14] mmol/L; P = .01). Limitations: Small patient numbers and observational nature of the study does not establish causation in this population at high risk to experience a gastrointestinal bleed. Conclusions: Our results suggest that PPI deprescribing as recommended in the general population may be associated with harm in patients with ESKD and requires further study. Trial Registration: Not registered.

Contexte: Les inhibiteurs de la pompe à protons (IPP) sont largement prescrits et peuvent être associés à une atteinte rénale; l'hypomagnésémie et la réduction de l'efficacité des chélateurs de phosphate à base de carbonate de calcium peuvent devenir significatifs chez les patients avec insuffisance rénale terminale (IRT). Objectifs: Nos objectifs comprenaient 1) l'arrêt des IPP et des antagonistes H2 et 2) l'évaluation des conséquences sur le taux de magnésium sérique et les marqueurs du métabolisme minéral. Conception: Étude de cohorte prospective. Cadre: L'unité d'hémodialyse satellite d'un hôpital de soins tertiaires. Sujets: Patients incidents et prévalents atteints d'IRT et traités par hémodialyse. Mesures: Nous avons évalué les conséquences de l'arrêt des IPP et antagonistes H2 chez les patients qui n'avaient pas d'indication absolue pour ces médicaments, conformément aux directives pour la population générale. Les taux sériques de magnésium, de calcium et de phosphate ont été mesurés avant l'arrêt et environ huit semaines plus tard. Les tests ANOVA et Kruskal-Wallis ont été utilisés pour décrire la population, et le test de rang de Wilcoxon pour les scores de changement appariés (de pré à post-intervention). Méthodologie: Les dossiers médicaux électroniques (DMÉ) ont été consultés rigoureusement à la recherche d'une indication absolue pour un IPP. Les résultats ont été revus avec l'équipe de néphrologie primaire avant d'approcher les patients quant à un arrêt des IPP. Les données démographiques initiales et les prescriptions pour certains médicaments ont également été recueillies. Résultats: Les DMÉ de 179 patients ont été consultés, révélant que 74 (43 %) d'entre eux prenaient soit un IPP, soit un antagoniste H2, soit les deux; chez 23 patients (31 %) la prescription était appropriée. Après évaluation par l'équipe médicale et discussion avec les patients, 29 patients ont accepté de cesser l'IPP. Quatorze patients ont recommencé les IPP, la plupart pour un reflux gastro-œsophagien. Trois patients ont souffert d'une hémorragie gastro-intestinale, dont une s'est avérée fatale. Le taux de calcium sérique (p=0,17) et la dose de chélateurs du phosphate (p=0,075) n'ont pas changé, mais le taux de phosphate sérique a augmenté (1,55 [0,29] à 1,85 [0,34] mmol/L; p=0,0005), tout comme le taux de magnésium sérique (1,01 [0,16] à 1,06 [0,14] mmol/L; p=0,01). Limites: Le faible échantillon de patients et la nature observationnelle de l'étude ne permettent pas d'établir un lien de causalité dans cette population présentant un risque élevé d'hémorragie gastro-intestinale. Conclusion: Nos résultats suggèrent que la déprescription des IPP recommandée dans la population générale pourrait être associée à un préjudice chez les patients atteints d'IRT. Des études plus approfondies sont nécessaires. Enregistrement de l'essai: Non enregistré.

Adolescent Varicocelectomy: Success at What Cost? Clinical Outcome and Cost Comparison of Surgical Ligation and Percutaneous Embolization.

Objectives: Evaluate clinical outcome, recurrence, morbidity, and cost associated with laparoscopic surgical ligation versus percutaneous embolization of adolescent varicocele. We hypothesize that both approaches are similar in outcomes, complications, and cost. Materials and Methods: A retrospective review of 56 consecutive adolescent males, ≤18 years from 2006 to 2016 with clinical varicocele who underwent laparoscopic surgical ligation or percutaneous embolization. Patient demographics, operative time, postoperative complications, success, varicocele grade, recurrence, and hospital charges were abstracted. Results: Mean age was 14.2 ± 2.1 years; 48 (86%) patients having undergone laparoscopic surgical ligation and 8 (14%) percutaneous embolization. Intervention in 45 (80%) patients was for testicular hypotrophy (mean 27.4% ± 15.6%) and 11 (20%) for pain symptomology. Median follow-up was 17.5 months (range 1-65 months). After ligation, 2 (4%) patients developed hydroceles (1 with subsequent hydrocelectomy) and 6 (12%) varicocele recurrence. There were no cases of hydrocele or varicocele recurrence after percutaneous embolization. Twenty ligation patients had postoperative scrotal ultrasound demonstrating an increase in testicular volume by a reduction in difference in testicular volume from 27.3% ± 14.7% preoperatively to 11.2% ± 13.6% postoperatively (P < .001). There was significant difference in mean operative time between the groups (surgical ligation 41.3 minutes versus percutaneous embolization 117.9 minutes, P < .001) and hospital charges for the procedure (surgical ligation $3983 versus percutaneous embolization $18.165, P < .001). Conclusions: Contrary to our hypothesis, percutaneous embolization has seemingly lower rates of postoperative hydrocele and varicocele recurrence in comparison to surgical ligation but with three times the exposure to general anesthesia and at four times the price.

Silver nitrate stain masquerading as a heterotopic ossification.

Silver nitrate is a commonly used substance in the cauterization of the traumatic soft tissue wounds to stop bleeding. As an inorganic compound with high density, silver nitrate is very radiodense. We present a case of topical silver nitrate application on a fingertip laceration of a 32-year-old diabetic woman, which was misinterpreted as heterotopic ossification. The appearance of silver nitrate on radiographic studies is not widely known, which can lead to misdiagnosis, further unnecessary imaging, and inappropriate surgery.

Diagnosis and follow-up of neonatal tetralogy of Fallot and hemitruncus with discontinuous pulmonary arteries noninvasively using awake ultra low-dose computed tomographic angiography.

We present a case of an ex-30 week premature male infant diagnosed postnatally with Tetralogy of Fallot, hemitruncus, and discontinuous pulmonary arteries (PAs) at 6 days of life. The patient was diagnosed by echocardiography, and the diagnosis was confirmed on subsequent dual-energy chest CT angiogram. In our patient, the left PA arose directly from the aorta, whereas the right PA originated normally from the right ventricular outflow tract. At 9 days of life, he underwent successful surgical palliation with placement of a modified Blalock-Taussig (aortopulmonary) shunt from the base of the left subclavian artery to the anomalously connected left PA along with anastomosis together of the right and left branch PAs to establish continuity with the main PA. Such cases have been described and are rare. The specific aim of this case report is to illustrate the added benefit of dual-energy electrocardiographically-triggered computed tomographic angiography (CTA) along with standard echocardiography. In addition, high quality images useful in preoperative planning were obtained noninvasively using an ultra low radiation dose without the need for sedation. The information obtained proved essential for confirmation of the diagnosis, preoperative planning, and post-surgical monitoring of branch PA development.

Unrelated hematopoietic stem cell transplantation in a patient with congenital dyserythropoietic anemia and iron overload.

CDA is a heterogeneous group of disorders that result in morphologically abnormal erythroid maturation and ineffective erythropoiesis. Curative therapy for CDA focuses on the use of HSCT using fully matched sibling donors. This is the first report of a Type II CDA patient with severe iron overload who was successfully treated with HSCT using a HLA-matched unrelated donor after aggressive chelation therapy. Given the challenges of HSCT in any patient with CDA and severe iron overload, the role of novel approaches to iron chelation and HSCT is discussed.