Spinal Cord Stimulation for Painful Diabetic Peripheral Neuropathy: A Systematic Review.

Painful diabetic neuropathy is a common disease that results in significant pain and disability. Treatment options have traditionally consisted of conservative measures including topical and oral medication management as well as transcutaneous electrical stimulation units. These treatments demonstrate various degrees of efficacy, and many times initial treatments are discontinued, indicating low levels of satisfaction or poor tolerability. Spinal cord stimulation has been proposed as an alternative therapy for treatment of painful diabetic neuropathy of the lower extremities. We performed a systematic literature review to evaluate the safety and effectiveness of this procedure. A literature search identified 14 prospective studies. Based on our analysis of the available evidence, there is moderate-quality evidence for the safety and efficacy of spinal cord stimulation for painful diabetic neuropathy. However, further high-quality research, including a large-scale randomized controlled trial is warranted.

Animal experimental research design in critical care.

BACKGROUND: Limited translational success in critical care medicine is thought to be in part due to inadequate methodology, study design, and reporting in preclinical studies. The purpose of this study was to compare reporting of core features of experimental rigor: blinding, randomization, and power calculations in critical care medicine animal experimental research. We hypothesized that these study design characteristics were more frequently reported in 2015 versus 2005. METHODS: We performed an observational bibliometric study to grade manuscripts on blinding, randomization, and power calculations. Chi-square tests and logistic regression were used for analysis. Inter-rater agreement was assessed using kappa and Gwet's AC1. RESULTS: A total of 825 articles from seven journals were included. In 2005, power estimations were reported in 2%, randomization in 35%, and blinding in 20% (n = 482). In 2015, these metrics were included in 9, 47, and 36% of articles (n = 343). The increase in proportion for the metrics tested was statistically significant (p < 0.001, p = 0.002, and p < 0.001). CONCLUSIONS: Only a minority of published manuscripts in critical care medicine journals reported on recommended study design steps to increase rigor. Routine justification for the presence or absence of blinding, randomization, and power calculations should be considered to better enable readers to assess potential sources of bias.

Intraoperative Acute Respiratory Failure in an Immunocompromised Patient with Human Metapneumovirus.

BACKGROUND Providing anesthesia to immunocompromised patients introduces unique challenges, including difficulty in detecting respiratory infections. Detailed preoperative evaluation and preparation for perioperative complications is crucial. Human metapneumovirus is a common but lesser known respiratory virus that can lead to pneumonia and respiratory compromise and is challenging to detect in the immunocompromised patient. CASE REPORT We present a case of an immunocompromised individual scheduled for umbilical hernia repair who developed severe bronchospasm and intraoperative respiratory failure after induction of general anesthesia. Preoperative evaluation of this patient revealed only minor respiratory symptoms and minimal rhonchi on lung auscultation. This patient did not meet extubation criteria in the operating room and was transferred to the medical intensive care unit. Human metapneumovirus was detected in his lower respiratory tract as the cause of the pneumonia and respiratory failure. CONCLUSIONS This case illustrates the difficulty in predicting pulmonary complications in immunocompromised patients and the potential severity of a respiratory infection with Human metapneumovirus. Detecting respiratory infections preoperatively in the immunocompromised patient is important for considering preoperative treatment or postponing elective surgery and potentially avoiding intraoperative respiratory failure.

SPECT/CT Improves Detection of Metastatic Sentinel Lymph Nodes in Patients with Head and Neck Melanoma.

BACKGROUND: A positive sentinel lymph node (SLN) is the most important prognostic factor for predicting survival in cutaneous melanoma. This study aimed to evaluate how the addition of single-photon emission computed tomography (SPECT) and computed tomography (CT) to planar lymphoscintigraphy (PL) alters SLN identification, yield, and localization of metastatic nodes in head and neck melanoma. METHODS: This retrospective review examined patients undergoing SLN biopsy for cutaneous melanoma of the head and neck between July 2003 and December 2015. Patient demographics and pathologic outcomes were compared for patients undergoing SPECT-CT versus PL. A multivariable logistic regression analysis was used to identify factors associated with the identification of a positive SLN. RESULTS: Among 176 patients undergoing SLN biopsy, 91 underwent PL and 85 underwent SPECT-CT and PL. The patients in the SPECT-CT group were older than the PL patients (p = 0.050) but the groups did not differ in gender (p = 0.447), Breslow thickness (p = 0.744), or total number of SLNs identified (p = 0.633). As shown by the multivariate regression analysis, only Breslow thickness [odds ratio (OR) 1.47; 95 % confidence interval (CI) 1.17-1.84] and SPECT-CT (OR 3.58; 95 % CI 1.24-10.4) were associated with a positive SLN. CONCLUSION: The use of SPECT-CT for patients with head and neck cutaneous melanoma significantly increases the likelihood of retrieving a positive SLN. Long-term follow-up evaluation is needed for further definition of the impact that SPECT-CT has on recurrence and survival.

Total Hip Arthroplasty for Posttraumatic Osteoarthritis of the Hip Fares Worse Than THA for Primary Osteoarthritis.

We conducted a study to evaluate differences between patients who had total hip arthroplasty (THA) for posttraumatic osteoarthritis (OA) and patients who had THA for primary OA. Using a prospective database, we followed 3844 patients who had THA for OA. Those who had THA for secondary causes of hip OA, developmental hip dysplasia, or inflammatory processes were excluded. Of the remaining 1199 patients, 62 (63 fractures) had THA for posttraumatic OA after previous acetabular or proximal femur fracture fixation, and 1137 had THA for primary OA and served as the control group. In the posttraumatic OA group, mean time between fracture repair and conversion to THA was 74 months. Compared with the control patients, the posttrauma patients lost more blood, were transfused more units of blood, had longer operating room times, and had more complications (all Ps < .001). Posttrauma patients had a mean follow-up of 4.44 years and a mean postoperative modified Harris Hip Score of 81.3 at latest follow-up. Of these patients, 12.5% required revision a mean of 3.5 years after initial arthroplasty. THA in patients with posttraumatic hip OA after an acetabular or proximal femur fracture is a longer and more complicated procedure with a higher rate of early failure.

Smaller pelvic volume is associated with postoperative infection after pelvic salvage surgery for recurrent malignancy.

BACKGROUND: Patients with recurrent pelvic malignancy have few treatment options, and surgery is fraught with complications. We sought to characterize the relationship between radiographic pelvic volume and postoperative complications after pelvic salvage surgery. METHODS: A retrospective chart review of all patients undergoing pelvic exenteration or abdominoperineal resection for recurrent malignancy between 1998 and 2013 was performed. Preoperative computed tomography was used to determine pelvic volume. RESULTS: Forty-two patients underwent surgery for recurrent rectal (26, 62%), prostate (8, 19%), or anal squamous cell cancer (8, 19%). Thirty-eight patients (90%) suffered complications and there was one (2%) perioperative death. Decreasing pelvic volume was associated with deep or organ space infections (P = .01), sepsis (P = .03), and fistula (P = .05) on univariate analysis. Infections remained significant on multivariate analysis (odds ratio, 1.01; P = .02). CONCLUSIONS: Pelvic salvage surgery for recurrent malignancy is associated with a high complication rate yet low mortality. Decreasing pelvic volume is associated with increasing risk of deep or organ space infections.

Variation in lymph node examination after esophagectomy for cancer in the United States.

OBJECTIVES: To evaluate the quality of lymph node examination after esophagectomy for cancer in the United States based on current treatment guidelines (15 nodes) and to assess the association of patient, tumor, and hospital factors with the adequacy of lymph node examination. DESIGN: Retrospective observational study from 1998 to 2007. SETTING: National cancer database. PATIENTS: Patients with stage I through III esophageal cancer undergoing esophagectomy and not treated with neoadjuvant chemoradiotherapy. MAIN OUTCOME MEASURE: Rate of adequate lymph node examination (15 nodes). RESULTS: A total of 13 995 patients were identified from 639 hospitals. Overall, 4014 patients (28.7%) had at least 15 lymph nodes examined, which increased from 23.5% to 34.4% during the study period. At the hospital level, only 45 centers (7.0%) examined a median of at least 15 lymph nodes. In the most recent period (2005-2007), at least 15 nodes were examined in 38.9% of patients at academic centers vs 28.0% at community hospitals and in 44.1% at high-volume centers vs 29.3% at low-volume centers. On multivariable analysis, hospital type, surgical volume status, and geographic location remained significant predictors of having at least 15 lymph nodes examined. CONCLUSIONS: Fewer than one-third of patients and fewer than 1 in 10 hospitals met the benchmark of examining at least 15 lymph nodes. Hospitals should perform internal process improvement activities to improve guideline adherence.