Use of Radiofrequency Ablation for the Management of Headache: A Systematic Review.

BACKGROUND: Headache is a very common condition that affects 5-9% of men and 12-25% of women in North America and Europe. Globally, the prevalence of active headaches among adults is 47%. The most common type of headache is tension headaches (38% of adults), followed by migraines (10%), and chronic headaches (3%). While the majority of headaches are benign, the disorder can severely negatively influence a patients' quality of life, which is directly reflected in societal costs. OBJECTIVE: The objective of this review was to summarize available evidence behind radiofrequency ablation (RFA) for headache, including pain outcome measures, secondary outcomes, and complications. STUDY DESIGN: Systematic review. SETTING: This systematic review examined studies that applied the use of RFA for management of headache. METHODS: This systematic review was reported following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Two reviewers independently scored the methodological quality of the selected studies. Due to heterogeneity of studies, a best-evidence synthesis of the available prognostic factors was provided. RESULTS: In the present investigation, we evaluated 18 studies composed of 6 randomized controlled trials (RCTs), 6 prospective studies, and 6 retrospective studies. All the studies assessed pain improvement with RFA in patients with headache. Most studies targeted the occipital nerve for treatment. Complications were mostly mild and self-limiting, including eyelid swelling, rash, superficial infection of the procedural site, and worsening of headache. LIMITATIONS: A large variability in definitions of trigeminal neuralgia, radiofrequency technique, and patient selection bias was observed in our selected cohort of studies. In addition, there is a paucity of strong longitudinal RCTs and prospective studies. CONCLUSION: Our review discusses several studies that suggest the efficacy of RFA in the treatment of headaches. Outcomes varied based on the difference in approaches regarding continuous radiofrequency versus pulsed radiofrequency, temperature, and duration of administration. The majority of the studies discussed in this review indicate a therapeutic benefit of RFA for headaches over a short-term period. Pain outcomes beyond one year are understudied and further studies are needed to determine the long-term effects of RFA for headaches.

Glycemic variability of acute stroke patients and clinical outcomes: a continuous glucose monitoring study.

INTRODUCTION: Glycemic variability (GV) has been associated with worse prognosis in critically ill patients. We sought to evaluate the potential association between GV indices and clinical outcomes in acute stroke patients. METHODS: Consecutive diabetic and nondiabetic, acute ischemic or hemorrhagic stroke patients underwent regular, standard-of-care finger-prick measurements and continuous glucose monitoring (CGM) for up to 96 h. Thirteen GV indices were obtained from CGM data. Clinical outcomes during hospitalization and follow-up period (90 days) were recorded. Hypoglycemic episodes disclosed by CGM but missed by finger-prick measurements were also documented. RESULTS: A total of 62 acute stroke patients [48 ischemic and 14 hemorrhagic, median NIHSS score: 9 (IQR: 3-16) points, mean age: 65 ± 10 years, women: 47%, nondiabetic: 79%] were enrolled. GV expressed by higher mean absolute glucose (MAG) values was associated with a lower likelihood of neurological improvement during hospitalization before and after adjusting for potential confounders (OR: 0.135, 95% CI: 0.024-0.751, p = 0.022). There was no association of GV indices with 3-month clinical outcomes. During CGM recording, 32 hypoglycemic episodes were detected in 17 nondiabetic patients. None of these episodes were identified by the periodic blood glucose measurements and therefore they were not treated. CONCLUSIONS: Greater GV of acute stroke patients may be related to lower odds of neurological improvement during hospitalization. No association was disclosed between GV indices and 3-month clinical outcomes.

Auxiliary Tests of Autonomic Functions.

SUMMARY: The autonomic nervous system is a complex neural network that controls several organ systems. Its assessment includes a detailed history of autonomic functions, clinical examination, and autonomic tests. Most widely used is a battery of tests that assess cardiovascular reflex autonomic and sudomotor tests, which include deep breathing (assesses parasympathetic function), Valsalva maneuver, tilt test (both assess parasympathetic and adrenergic functions), and sudomotor testing for the evaluation of postganglionic sudomotor fibers. These basic tests represent a foundation of autonomic testing. Nevertheless, the autonomic nervous system also controls organ systems not directly assessed by basic tests. This review describes a number of auxiliary autonomic tests that can be used in addition to basic autonomic tests or can be used independently to explore particular autonomic functions or to answer a specific clinical question. The auxiliary tests described in this review evaluate cardiovascular, thermoregulatory, gastrointestinal, genitourinary, eye, and exocrine functions. These tests are cold pressor test, sustained handgrip maneuver, reverse tilt test, venoarteriolar reflex, laser Doppler flare imaging, microneurography, neck suction, lower body negative pressure, venous occlusion plethysmography, pharmacologic assessment of postganglionic sympathetic outflow, plasma norepinephrine, sympathetic skin response, video cinefluoroscopic swallowing test, esophageal manometry test, small bowel manometry test, wireless motility capsule test, urodynamic studies, penile plethysmography, intracavernosal papaverine injection, infrared video pupillography, corneal confocal microscopy, pupillary response to dilute pilocarpine and hydroxyamphetamine, Schirmer test, tear osmolarity test, and salivary secretion test. The protocol of each test is described in detail. This review can be used as a quick reference for the auxiliary autonomic tests.

Use of Radiofrequency Ablation for the Management of Facial Pain: A Systematic Review.

BACKGROUND: Neuropathic facial pain occurs due to pathologic dysfunctions of a nerve responsible for mediating sensory fibers to the head. Surgical interventions, in cases of failed medical therapy, include microvascular decompression, radiofrequency (RF) ablation, percutaneous balloon decompression, and stereotactic radiosurgery. In this review, we focused on RF ablation as a treatment for chronic facial pain. OBJECTIVES: The objective of this review was to summarize available evidence behind RF ablation for facial pain, including pain outcome measures, secondary outcomes, and complications. STUDY DESIGN: Systematic review. SETTING: This systematic review examined studies that applied the use of RF ablation for management of facial pain. METHODS: This systematic review was reported following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two reviewers independently scored the methodological quality of the selected studies. Due to heterogeneity of studies, a best-evidence synthesis of the available prognostic factors was provided. RESULTS: We reviewed 44 studies and assessed their short- and long-term pain relief measurements, as well as secondary outcomes including patient satisfaction, quality of life improvements, decrease in oral medication use, and recurrence rates. Maximal pain relief was achieved in treatment groups using combined continuous radiofrequency (CRF) and pulsed radiofrequency (PRF) therapies, followed by CRF therapy alone and finally PRF therapy alone. All treatment regimens improved secondary outcomes. Common complications of treatment included facial numbness, masseter weakness, cheek hematomas, diminished corneal reflex, and dry eyes. LIMITATIONS: A large variability in definitions of trigeminal neuralgia, RF technique, and patient selection bias was observed in our selected cohort of studies. In addition, there was a paucity of strong longitudinal randomized controlled trials and prospective studies. CONCLUSIONS: This systematic review found evidence that RF ablation is efficient in treating patients with facial pain, as well as in improving quality of life and reducing oral medication use. Maximal pain control is achieved using combined CRF and PRF therapy. Complications are uncommon and include facial numbness, masseter weakness, cheek hematomas, diminished corneal reflex, and dry eyes.

[Perception of medical communication skills during the clinical interview in a Peruvian teaching hospital: validation and application of an assessment tool]. / Percepción de la competencia comunicativa médica durante la entrevista clínica en un hospital docente peruano: validación y aplicación de un instrumento evaluativo.

OBJECTIVE: To determine the perception of patients regarding physicians communication skills at the outpatient clinic of a teaching hospital in Lima-Peru, using the Communication Assessment Tool (CAT). METHODS: The study population was the group of patients treated in the outpatient clinics of the Cayetano Heredia Hospital. The CAT questionnaire contains 15 questions, and a version validated for Spanish was used. The perception of communication skills was defined as the sum of the scores of all the items, over the number of items, defined as: poor (1), fair (2), good (3), very good, (4), and excellent (5). RESULTS: The percentage of patients who rated communication skills as "poor" (average CAT Score) was 6.8%, "fair" 27.2%, "good" 23.9%, "very good" 30.1 and "excellent" 12.1%. Statistically significant differences were found when comparing the age ranges and among the different levels of education. The group of patients between 18 and 29 years old gave higher scores in the instrument (range 2.2 to 4.87, p = 0.001). Furthermore, when the educational level of the respondent was high, the participants tended to rate physicians with higher scores (range 3.67 to 4.73, p = 0.001). CONCLUSION: We found that 66.2% of patients had a positive perception of the physicians communication skills; only 12.1% rated it as "excellent," a value well below what is reported in the literature. Those who gave the best rating were younger patients with the highest level of education.

OBJETIVO: Determinar la percepción de los pacientes sobre la destreza en la comunicación de los médicos que atienden en consultorio externo de un hospital docente de Lima, Perú, según el instrumento Communication Assessment Tool. MÉTODOS: La población de estudio fue el colectivo de pacientes atendidos en los consultorios externos del Hospital Cayetano Heredia. El cuestionario Communication Assessment Tool consta de 15 preguntas, se utilizó una versión validada al castellano. La percepción de la destreza en comunicación se determinó como la sumatoria de los puntajes del total de las premisas, entre la cantidad de las premisas. Se definió como mala (1), justa (2), buena (3), muy buena (4) y excelente (5). RESULTADOS: El porcentaje de pacientes que calificaron la competencia comunicativa como “mala” (puntaje Communication Assessment Tool promedio) fue de 6,8%, “justa” 27,2%, “buena” 23,9%, “muy buena” 30,1% y “excelente” 12,1%. Se hallaron diferencias estadísticamente significativas respecto a los rangos de edad y entre los distintos grados de instrucción. El grupo de pacientes entre 18 y 29 años otorgó puntajes más altos en el Communication Assessment Tool (rango = 2,2 a 4,87; p = 0,001). Además, cuando el nivel educativo del encuestado fue superior tendió a colocar puntajes más altos (rango = 3,67 a 4,73; p = 0,001). CONCLUSIONES: Se determinó que 66,2% de los pacientes tuvo una percepción positiva, sólo 12,11% lo calificó como “excelente”, un valor muy por debajo a lo reportado en la literatura. Los que brindaron mejor calificación fueron los pacientes jóvenes y con mayor grado de instrucción.