Evaluation of spinal cord stimulation on the symptoms of anxiety and depression and pain intensity in patients with failed back surgery syndrome.

BACKGROUND: Spinal cord stimulation (SCS) is now established as the primary treatment for failed back surgery syndrome (FBSS). Commonly, patients with chronic pain and FBSS often report symptoms of anxiety and depression resulting from this condition. These factors can modulate and amplify the pain experience, therefore, further challenging treatment success. AIMS: This study examined the efficacy of SCS on alleviating the symptoms of anxiety and depression associated with chronic pain as well as pain intensity in a group of patients with FBSS. METHODS: A convenience sample (n = 26) was selected for participation. Questionnaires [Hospital Anxiety and Depression Scale (HADS) and Brief Pain Inventory Short Form (BPI-SF)] were completed and examined pre and post spinal cord implant. RESULTS: Analysis of the data 1 year following SCS indicates that there was a statistical significant improvement in the symptoms of depression and anxiety reported as well as pain intensity in all participants (p < 0.001). Both anxiety and depression scores on the HADS were significantly lower compared to baseline (p < 0.001). Pain intensity scores decreased by ≥50% from baseline in all participants. Opioid analgesia was discontinued by 90% (n = 8) of participants. CONCLUSION: Whilst it is already recognised that SCS reduces pain in FBSS, this study demonstrated that it also reduced the symptoms of anxiety and depression with an associated reduction in opioid consumption.

Polymer coordination promotes selective CO2 reduction by cobalt phthalocyanine.

Cobalt phthalocyanine (CoPc) is a known electrocatalyst for the carbon dioxide reduction reaction (CO2RR) that, when adsorbed onto edge-plane graphite (EPG) electrodes, shows modest activity and selectivity for CO production along with co-generation of H2. In contrast, electrodes modified with CoPc immobilized in a poly-4-vinylpridine (P4VP) film show dramatically enhanced activity and selectivity compared to those modified with CoPc alone. CoPc-P4VP films display a faradaic efficiency of ∼90% for CO, with a turnover frequency of 4.8 s-1 at just -0.75 V vs. RHE. Two properties of P4VP contribute to enhancing the activity of CoPc: (1) the ability of individual pyridine residues to coordinate to CoPc and (2) the high concentration of uncoordinated pyridine residues throughout the film which may enhance the catalytic activity of CoPc through secondary and other outer coordination sphere effects. Electrodes modified with polymer-free, five-coordinate CoPc(py) films (py = pyridine) and with CoPc catalysts immobilized in non-coordinating poly-2-vinylpyridine films were prepared to independently investigate the role that each property plays in enhancing CO2RR performance of CoPc-P4VP. These studies show that a synergistic relationship between the primary and outer coordination sphere effects is responsible for the enhanced catalytic activity of CoPc when embedded in the P4VP membrane.

Cerebrospinal fluid levels of glial cell-derived neurotrophic factor correlate with spinal cord stimulation frequency in patients with neuropathic pain: a preliminary report.

STUDY DESIGN: Case series. OBJECTIVES: To evaluate relationships between spinal cord stimulation (SCS) parameters and levels of glial cell-derived neurotrophic factor (GDNF). SETTING: Ambulatory pain clinic of St James's Hospital, Dublin, Ireland. METHODS: Nine patients with an implanted SCS and Failed Back Surgery Syndrome (FBSS) were administered the Brief Pain Inventory and Short Form (36) Health Survey. Following a lumbar puncture, levels of GDNF in cerebrospinal fluid (CSF) were assayed and correlated with stimulation parameters. Controls were patients with arthritic back pain who were matched for age, gender and SF-36 score. RESULTS: Concentrations of GDNF in CSF are higher in patients with FBSS than controls (P=0.002) and correlate with SCS frequency (P=0.029). CONCLUSION: Concentrations of GDNF in CSF are higher in neuropathic pain and appear to be related to stimulation frequency. Further work is needed to evaluate this potential relationship, both in neuropathic pain and in other contexts such as locomotor dysfunction.

Spinal cord stimulation in pregnancy with failed back surgery syndrome.

Women of child-bearing age who are candidates for trial and possible implantation of a spinal cord stimulator (SCS) may express concerns regarding its effect on their ability to become pregnant, to maintain a pregnancy and to breastfeed. Despite the large number of SCS implanted worldwide there is a paucity of data regarding its effect on fertility and the course of the pregnancy. We describe a case of 32 year old lady in our centre who became pregnant after SCS implantation and had an uneventful pregnancy with delivery of a healthy baby which was breastfed.

Social class variation in the predictors of rapid growth in infancy and obesity at age 3 years.

OBJECTIVE: To examine the extent to which early child nutrition, maternal antenatal lifestyle behaviours and child diet and lifestyle explain social class inequalities in the risk of rapid weight gain between birth and 3 years and obesity at age 3 years. DESIGN: A longitudinal and prospective birth cohort study. SUBJECTS: Nationally representative sample of 11,134 children and their parents followed from 9 months of age until 3 years. Child weight and maternal height and weight were measured at 9 months and 3 years and child birth weight was extracted from hospital records. Other predictors of child growth and obesity were collected by maternal report at 9 months and 3 years. RESULTS: Although born lighter on average, children of unskilled manual parents were 274 g heavier than children of professional parents by 3 years of age. The fully adjusted model of rapid growth from birth to 3 years of age and obesity at 3 years of age accounted for all social class differentials. Breastfeeding and age at the introduction of solids were associated with the largest average reduction (41%) in the odds ratio (OR) of rapid growth in the first 9 months of life for each class relative to the professional class. In the period from 9 months to 3 years of age, the class differential in rapid growth was reduced most by measures of the child's diet and lifestyle. However, the impact of the groups of predictors varied by social class. For early life growth, among the non-manual classes the proportionate reductions are largest when adjusted for early infant nutrition, whereas maternal prenatal smoking is more important for the manual social classes. CONCLUSION: Preventative interventions to reduce levels of childhood obesity should be multi-dimensional but different dimensions should be given more or less significance depending on socio-economic group.

Ambulatory postoperative ward-based epidural analgesia: a retrospective review of 1,147 cases.

BACKGROUND: A retrospective review of 1,147 patients who received epidural analgesia (EA) in surgical wards from January 2008 to December 2009 to determine the prevalence of early ambulation and assess the efficacy and safety of EA for postoperative pain management. AIM: Outcome measures were the prevalence of ambulation, pain scores at rest/movement and adverse events. METHODS: Patients (N = 1,147) who received postoperative EA between January 2008 and December 2009 were included. Motor function was assessed using the Bromage scale. Ambulation was defined as: Day 1: mobilisation from bed to chair, walking on the spot, taking a few steps, thereafter walks of increasing duration and distance at least twice daily. Pain scores were measured using the verbal numerical rating scale (0-10), ≤4 signifying successful analgesia. Daily assessments and data recordings were performed by clinical nurse specialists (CNSs) using standardised charts. Data collected included patient demographics, surgical procedure, ambulation achieved, pain scores at rest/movement and adverse events. The data was analysed using Microsoft Excel(®). RESULTS: The prevalence of ambulation was 88% and this was maintained for the duration of EA. Ninety-eight percent of patients reported pain scores of ≤4 at rest and 88% reported pain scores of ≤4 on movement. Adverse events included motor block 12%, nausea 9%, hypotension 8%, catheter dislodgement 3.8%, leakage from insertion site 1.6%, decubitus ulcers 0.58% and infection 0.001%. Mean duration of EA was 4 days. CONCLUSIONS: Ward-based EA facilitates early ambulation, provides excellent postoperative pain relief and is associated with low prevalence of adverse events.

Polycythemia vera presenting as complex regional pain syndrome of the lower limbs.

CASE REPORT: A 73-year-old woman with bilateral severe pain in her legs and feet was admitted to the hospital. The pain had started spontaneously without any known trauma a year earlier and had progressively worsened to the point that she was unable to walk. The patient complained of pain, discoloration, and sweating of the lower extremities. Physical examination revealed swollen, cold, wet, and blue extremities, with both allodynia and hyperalgesia, fulfilling criteria for a diagnosis of complex regional pain syndrome (CRPS) type 1. Laboratory findings demonstrated a hemoglobin level of 180 g/L(-1) and a hematocrit of 47%, leading to a diagnosis of polycythemia vera (PCV). Her condition slowly improved after repeated venesection, mild analgesics, and amitriptyline. CONCLUSIONS: Polycythemia vera has not been described previously as a contributing factor in CRPS. In the present case, the diagnosis of PCV was important, because its treatment also improved the CRPS.

Gastroesophageal reflux during spontaneous respiration with the laryngeal mask airway.

PURPOSE: To determine the incidence of gastroesophageal reflux during general anesthesia with the Laryngeal Mask Airway (LMA). METHODS: Twenty unpremedicated patients with no risk factors for reflux having day case anesthesia were included. Type of surgery was Orthopedic (n=8), General (n=7) and Gynecological (n=5). The average duration of anesthesia was 38.1 min, range 12 - 71 min. Anesthesia was induced with 1-2 microg x kg(-1) fentanyl and 2-3 mg x kg(-1) propofol and maintained with oxygen 33%, nitrous oxide 66% and isoflurane 1% (end-tidal). Ventilation by hand was performed until spontaneous respiration resumed. To facilitate surgery, 13 patients were placed in the supine and seven in the lithotomy positions. Two pH-sensitive electrodes were used to identify reflux. One was placed in the oesophagus 20 cm from the anterior nares to detect esophageal reflux and the other was placed through the bars of the LMA to detect refluxing material around the LMA. RESULTS: Esophageal reflux occurred in 12 patients (60%), in five of the 13 in the supine position and in all patients in the lithotomy position. The LMA electrode detected a decrease in pH in four cases (20%), all in the lithotomy position. The incidence reflux in the lithotomy and supine positions was different (Exact Probability test; P = 0.01). CONCLUSION: This study suggests that the lithotomy position predisposes patients to a higher risk of aspiration than the supine position when using a LMA.

A prospective study comparing intravenous tenoxicam with rectal diclofenac for pain relief in day case surgery.

In a prospective, randomized, double-blind study, we compared intravenous tenoxicam with rectal diclofenac for post-operative pain relief after day case arthroscopy or laparoscopic sterilization. Intravenous tenoxicam (40 mg) was administered as a single bolus at induction, or rectal diclofenac (100 mg) was administered immediately after induction. Both groups were similar with respect to age, weight, sex of the patients, the operation performed and the operative time. There were no significant differences observed between the groups for pain scores at 30 min, 60 min and 24 h post-operatively. The time to first analgesic requirement, the dose of pethidine administered and total analgesic requirements in the first 24 h post-operatively were equivalent in both groups. In view of the similar efficacy of both of these drugs, patient preference and ease of administration, the use of tenoxicam is appropriate in many patients undergoing day case surgery.

Is repeat laparotomy of value in patients with suspected intra-abdominal sepsis in the intensive care unit?

The management of patients with suspected post laparotomy intra-abdominal sepsis poses a major therapeutic challenge to clinicians. The mortality is high and the optimal interventional modality remains ill-defined. We define the incidence, diagnostic methodology, pre- and postoperative findings and outcome of patients going from the intensive care unit for a repeat laparotomy in search of abdominal sepsis over a one year period. Fifteen patients were included with an overall mortality of 60 percent. In 6 cases more than one relaparotomy was performed with a mortality of 50 percent. Sepsis was found in 14 of the 15 cases with a mortality of 57 percent and the patient with a normal relaparotomy died. The primary surgery was elective in 26 percent of cases and the mortality was 50 percent. All the non-survivors required mechanical ventilation, inotropic support and continuous veno-veno haemodialysis while the survivors required less organ support. Radiological assessment (ultrasound scan and CT scan) were no better at predicting an abnormal relaparotomy than clinical assessment. Higher mortality rates were associated with increasing age and multi-system organ failure (p < 0.05).

Elective tracheal intubation in cervical spine injuries.

Patients presenting for surgical stabilisation of an unstable cervical spine are at risk of sustaining a further iatrogenic spinal cord injury during intubation of the trachea. Controversy exists regarding the optimal anaesthetic technique for securing the airway. We reviewed the techniques employed for intubating the trachea in our hospital over a five year period. Tracheal intubation was achieved using two different techniques: awake fibre-optic intubation with local anaesthesia, and general anaesthesia via the intravenous or inhalational route with neuromuscular blockade. Forty five patients were included. 16 patients demonstrated a pre-operative neurological deficit. Awake fibre-optic intubation was used in 27 cases, general anaesthesia was employed via the intravenous route in 17 cases and the inhalational route in 1 case. Weighted traction was employed in all cases to immobilize the cervical spine during intubation. There was no new neurological sequelae with any of these techniques. Our study suggests that there is no optimal anaesthetic technique for intubating the trachea in patients with cervical spine injuries and it is noteworthy that in line traction was used in every case.

Laryngeal mask airway positioning is related to Mallampati grading in adults.

The Mallampati classification is a commonly used means of preoperatively predicting a difficult endotracheal intubation. As the laryngeal portion of the laryngeal mask airway (LMA) must sit over the larynx, we wondered whether the Mallampati classification also predicts difficulty in achieving adequate seating of the LMA. LMA positioning was assessed prospectively in 100 adult patients by fiberoptic bronchoscopy to determine whether there was a relationship between the ease of seating of the LMA and the Mallampati classification. In 72 patients, optimal seating of the LMA was achieved on the first attempt at insertion, and all these patients were classified as Mallampati class 1 or 2. In all 28 cases of difficulty with LMA insertion, the patients were Mallampati class 2 or 3. In two cases the LMA was abandoned, and in these cases both patients were Mallampati class 3, (P = 0.0001 by chi 2 analysis). We conclude that the Mallampati classification indicates difficulty not only in tracheal intubation but also in achieving an adequate airway with the LMA.