The approach to intrathecal (IT) drug delivery malfunction is complicated, particularly for iodine-allergic patients. In these situations, the current literature has not addressed the use of IT ...gadolinium. Case reports exist showing severe neurotoxic manifestations with IT gadolinium use. We sought to provide a resource for chronic pain physicians treating an iodine-allergic patient and considering the use of IT gadolinium.
A thorough literature search identified 11 published cases of gadolinium-induced neurotoxicity due to IT injection and those cases are described in detail. The literature was also reviewed for safe dosages of IT gadolinium.
After thorough review, a safe IT gadolinium dose is provided. Additionally, an algorithm was developed for the workup of an IT pump malfunction in iodine allergic patients.
Herein, we provide guidance on IT gadolinium usage and a framework for IT pump malfunction in iodine allergic patients.
Abstract Study objective To determine the demographic characteristics of patients undergoing primary total knee arthroplasty during the years 1989, 1999, and 2009 at our institution and determine ...whether their characteristics mirror the changing US demographic characteristics. Design Retrospective chart review of patients and prospective survey of experienced anesthesia providers in total knee arthroplasty. Setting Tertiary care academic medical center. Patients All patients 18 years and older who underwent unilateral primary total knee arthroplasty in 1989, 1999, and 2009 were identified through the Mayo Clinic Total Joint Registry. For each year, 200 patients were randomly selected. Measurements The demographic characteristics, comorbidities, perioperative care, and postoperative outcomes of patients, as well as survey responses from experienced anesthesia providers. Main results During the 3 study years, a total of 591 patients were included for analysis. A statistically significant increase in body mass index (BMI) was observed over time in patients undergoing primary total knee arthroplasty (average BMI, 29.01 in 1989, 31.32 in 1999, and 32.32 in 2009 P < .001). Despite the increase in patient comorbidities, the percentage of patients who had postoperative complications decreased over time ( P = .003), and postoperative disposition (general medicine ward vs intensive care unit) did not change. Our provider survey received a 76% response rate. In total, 82% of anesthesia providers who responded to the survey perceived that both BMI and the number of comorbidities had increased. Of survey respondents, 67% state that they have modified their perioperative anesthesia care because of changes in body habitus and patient comorbidities. Conclusions The number of obese patients with comorbidities who present for total knee arthroplasty at our institution has increased over the past 20 years. Despite this fact, a reduction was detected in postoperative complications.
Abstract
Objectives. Our purpose was to determine the incidence of surgical site infection (SSI) in cancer patients receiving an intrathecal drug delivery system (IDDS) and compare that rate with the ...incidence of SSI in the general population receiving an IDDS or spinal cord stimulator. We attempted to describe risk factors for SSIs in cancer patients treated with IDDS in terms of exposure to cancer treatments.
Design. Retrospective review.
Setting. Large tertiary care center.
Patients. Cancer patients receiving an IDDS in 2006–2013.
Methods. The incidence of SSI was determined according to the US Centers for Disease Control and Prevention definition. Medication regimens and current cancer treatment were investigated to identify immunocompromised patients during IDDS placement. Microbacteriology, treatment, and overall outcomes were investigated.
Results. Sixty-four patients had an IDDS implanted in 2006–2013. SSI developed in four patients (6.2%). All four patients had received chemotherapy or radiotherapy within three months before implantation. Three of the three were receiving dexamethasone, and three of the four required explantation of the IDDS.
Conclusion. The incidence of SSI was at the upper end of the published infection rates for IDDS. The risk of SSI may be increased in this population because of factors that alter the patient’s immune status, including concomitant corticosteroid use, radiotherapy near the SSI, and presence of immunomodulators. The identification and mitigation of certain risk factors for this population may prevent infection in future patients.
To assess demographic characteristics and perceptions of female physicians in attendance at a medical conference for women with content focused on growth, resilience, inspiration, and tenacity to ...better understand major barriers women in medicine face and to find solutions to these barriers.
A Likert survey was administered to female physicians attending the conference (September 20 to 22, 2018). The survey consisted of demographic data and 4 dimensions that are conducive to women’s success in academic medicine: equal access, work-life balance, freedom from gender biases, and supportive leadership.
All of the 228 female physicians surveyed during the conference completed the surveys. There were 70 participants (31.5%) who were in practice for less than 10 years (early career), 111 (50%) who were in practice for 11 to 20 years (midcareer), and 41 (18.5%) who had more than 20 years of practice (late career). Whereas participants reported positive support from their supervisors (mean, 0.4 SD 0.9; P<.001), they did not report support in the dimensions of work-life balance (mean, −0.2 SD 0.8; P<.001) and freedom from gender bias (mean, −0.3 SD 0.9; P<.001).
Female physicians were less likely to feel support for work-life balance and did not report freedom from gender bias in comparison to other dimensions of support. Whereas there was no statistically significant difference between career stage, trends noting that late-career physicians felt less support in all dimensions were observed. Future research should explore a more diverse sample population of women physicians.
Surgical site infection is a potential complication of spinal cord stimulator (SCS) implantation. Current understanding of the epidemiology, diagnosis, and treatment of these infections is based ...largely on small clinical studies, many of which are outdated. Evidence-based guidelines for management of SCS-related infections thus rely instead on expert opinion, case reports, and case series. In this study, we aim to provide a large scale retrospective study of infection management techniques specifically for SCS implantation.
A multicenter retrospective study of SCS implants performed over a seven-year period at 11 unique academic and non-academic institutions in the United States. All infections and related complications in this cohort were analyzed.
Within our study of 2737 SCS implant procedures, we identified all procedures complicated by infection (2.45%). Localized incisional pain and wound erythema were the most common presenting signs. Laboratory studies were performed in the majority of patients, but an imaging study was performed in less than half of these patients. The most common causative organism was Staphylococcus aureus and the IPG pocket was the most common site of an SCS-related infection. Explantation was ultimately performed in 52 of the 67 patients (77.6%). Non-explantation salvage therapy was attempted in 24 patients and was successful in resolving the infection in 15 patients without removal of SCS hardware components.
This study provides current data regarding SCS related infections, including incidence, diagnosis, and treatment.
INTRODUCTION:Chronic abdominal and flank pain can be multifactorial and difficult to treat. Loin pain hematuria syndrome (LPHS) is a rare clinical cause of chronic abdominal and flank pain and is a ...diagnosis of exclusion with limited treatment options, ranging from medications to renal autotransplantation or even nephrectomy in resistant cases.
CASE DESCRIPTION:A 50-year-old man with a history of recurrent nephrolithiasis secondary to hypercalcemia presented to the pain clinic with bilateral flank pain. After failed conservative medical management, the decision was made to proceed to interventional modalities. He responded for a short duration to a splanchnic nerve block and subsequently had a longer analgesic response to pulsed radiofrequency (PRF) ablation to the splanchnic nerves.
DISCUSSION:LPHS is a difficult clinical scenario to diagnose and treat. Conservative options are often unsuccessful, but the more extreme interventions such as renal autotransplantation and nephrectomies are invasive and not always effective. In this case report, we describe the novel use of PRF to the splanchnic nerves as an alternative treatment modality for patients with LPHS.Although the exact mechanism of action of PRF on nerve tissue is unclear, its indication in pain management requires further research and discussion. Our patient experienced substantial and sustained relief of his flank pain. PRF may be a viable option for patients with LPHS.
Introduction. Spinal cord stimulators (SCS) are indicated for the management of multiple pain states with strong evidence. Recent guidelines recommend discontinuing aspirin or non-steroidal ...anti-inflammatory drugs (NSAIDs) for the described procedures. The goal of this investigation is to assess the rate of bleeding and neurologic sequelae in patients undergoing SCS trials and implantation.
Methods. This is a retrospective review from 2005 through 2014 of all patients 18 years or older undergoing the following procedures: Percutaneous SCS implantations, SCS revisions, and SCS trials. Baseline characteristics, antiplatelet and anticoagulation medications, coagulation parameters, and procedural details were extracted. The primary outcome was the presence of a bleeding complication within 31 days of the procedure requiring emergency medicine, neurology, or neurosurgical evaluation. The neurological complication was independently categorized for its potential relationship to procedural bleeding, and periprocedural red blood cell transfusion requirements were analyzed as a secondary outcome.
Results. A total of 642 percutaneous SCS procedures were performed on 421 unique patients, including 346 SCS trials, 255 SCS implantations, and 41 revision surgeries. Patients had received aspirin or NSAIDs within 7 days of needle placement for 101 procedures (15.7%). There were no bleeding or neurological complications identified in this cohort.
Conclusion. Although the incidence of epidural hematoma is low, the development of bleeding complications following SCS lead placement can be devastating. In the present investigation, we identified no cases of epidural hematoma following percutaneous SCS lead placement, including more than 100 patients receiving aspirin or NSAIDs. Future investigations with larger numbers are needed to better define the relationships between periprocedural aspirin and NSAID utilization and bleeding complications.
Although the majority of opioids in the US are prescribed by nonpain specialists, these providers often report inadequate training in chronic pain management and opioid prescribing. The extent of ...health care providers' knowledge of opioid prescribing for chronic pain has not been well established. The purpose of this study was to assess knowledge about the use of opioids for chronic pain among health care providers seeking pain-focused continuing medical education.
The study participants (n=131) were recruited at a pain-focused continuing medical education conference for nonpain specialists. Upon commencement of the conference, the KnowPain-50 survey was completed. The survey comprised 50 questions, and 18 questions were related to opioid management. The focus of each opioid question was further categorized as either medicolegal (n=7) or clinical (n=11).
The majority of study participants were male physicians with a mean age of 51.8 years. The proportion of correct responses to the 50-item survey was 72%. The proportion of correct responses to the 32 nonopioid questions was 74%, and the proportion of correct responses to the 18 opioid questions was 69% (P<0.001). Similarly, the proportion of correct responses to the seven medicolegal opioid questions was 74%, and the proportion of correct responses to the eleven clinical opioid questions was 67% (P<0.001).
Health care providers demonstrated gaps in knowledge about the use of opioids for chronic pain. Lower scores on clinically based opioid questions may indicate an opportunity to provide focused educational content about this area of practice. This information could be helpful in designing future educational modules for nonpain providers.
To examine the incidence of percutaneous spinal cord stimulator lead migration, given current hardware and surgical technique.
We retrospectively reviewed records of patients who underwent spinal ...cord stimulator implantation with percutaneous leads at our institution from 2008 through 2011. We determined the number of patients who required surgical revision for clinically significant lead migration.
Clinically significant lead migration requiring surgical revision occurred in three of 143 patients (2.1%) with primary SCS system implants utilizing percutaneous-type leads.
The rate of lead migration observed in our practice was considerably lower than previously published estimates of clinically significant lead migration or revision for lead migration (13%-22%). However, our study did not determine the reason for the decreased rate, which may be influenced by current hardware and implant techniques.
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