Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians.
To develop evidence-based ...clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain.
Systematic assessment of the literature.
Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.
Short-term pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term.
The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2.
The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations.
The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. Further, these guidelines also do not represent "standard of care."
Ionospheric irregularities affect the propagation of Global Navigation Satellite System (GNSS) signals, causing radio scintillation. Particle precipitation from the magnetosphere into the ionosphere, ...following solar activity, is an important production mechanism for ionospheric irregularities. Particle precipitation also causes the aurorae. However, the correlation of aurorae and GNSS scintillation events is not well established in literature. This study examines optical auroral events during 2010–2011 and reports spatial and temporal correlations with Global Positioning System (GPS) L1 phase fluctuations using instrumentation located at South Pole Station. An all‐sky imager provides a measure of optical emission intensities (OI 557.7 nm and 630.0 nm) at auroral latitudes during the winter months. A collocated GPS antenna and scintillation receiver facilitates superimposition of auroral images and GPS signal measurements. Correlation statistics are produced by tracking emission intensities and GPS L1 σφ indices at E and F‐region heights. This is the first time that multi‐wavelength auroral images have been compared with scintillation measurements in this way. Correlation levels of up to 74% are observed during 2–3 hour periods of discrete arc structuring. Analysis revealed that higher values of emission intensity corresponded with elevated levels of σφ. The study has yielded the first statistical evidence supporting the previously assumed relationship between the aurorae and GPS signal propagation. The probability of scintillation‐induced GPS outages is of interest for commercial and safety‐critical operations at high latitudes. Results in this paper indicate that image databases of optical auroral emissions could be used to assess the likelihood of multiple satellite scintillation activity.
Key PointsCollocated GPS scintillation receiver and all‐sky imager at the South PoleFirst statistics from simultaneous tracking of GPS signals and optical auroraeGPS phase scintillation correlates closely at times with discrete auroral arcs
The article examines the relatively neglected Discourse 4 of The Enlightener, Iosif Volotskii's famous treatise written to defend Orthodoxy against religious dissidents known to history as the ..."Judaizing" heretics. In Discourse 4, Iosif deals with the divine economy, the possibility of repentance, and with God's deviousness in achieving his purposes. In contrast to the other discourses of The Enlightener, here in Discourse 4 Iosif argues his case in a relatively non-polemical manner. The text has some significance for evaluating his work as a father confessor, and for his well-known severity towards heretics and apostates.
This article examines the famous conflict beween Iosif of Volokolamsk and Archbishop Serapion of Novgorod that in 1509 saw Iosif excommunicated and then Serapion deposed. The immediate cause of the ...conflict was the transfer of Iosif's monastery from the control of the local prince, Fedor Borisovich, to the protection of the grand prince of Moscow, Vasilii III Ivanovich, without the prior knowledge or consent of the ecclesiastical superior, the archbishop of Novgorod. While the episode has attracted previous scholarly attention, this article examines the handling of the canonical issues underlying the positions of the two protagonists.
Interventional pain management is a specialty that utilizes invasive procedures to diagnose and treat chronic pain. Patients undergoing these treatments may be receiving exogenous anticoagulants and ...antithrombotics. Even though the risk of major bleeding is very small, the consequences can be catastrophic. However, the role of antithrombotic therapy for primary and secondary prevention of cardiovascular disease to decrease the incidence of acute cerebral and cardiovascular events is also crucial. Overall, there is a paucity of literature on the subject of bleeding risk in interventional pain management along with practice patterns and perioperative management of anticoagulant and anti-thrombotic therapy.
Best evidence synthesis.
To critically appraise and synthesize the literature with assessment of the bleeding risk of interventional techniques including practice patterns and perioperative management of anticoagulant and antithrombotic therapy.
The available literature on the bleeding risk of interventional techniques and practice patterns and perioperative management of anticoagulant and antithrombotic therapy was reviewed. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 through December 2012 and manual searches of the bibliographies of known primary and review articles.
There is good evidence for the risk of thromboembolic phenomenon in patients who discontinue antithrombotic therapy, spontaneous epidural hematomas occur with or without traumatic injury in patients with or without anticoagulant therapy associated with stressors such as chiropractic manipulation, diving, and anatomic abnormalities such as ankylosing spondylitis, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. There is fair evidence that excessive bleeding, including epidural hematoma formation may occur with interventional techniques when antithrombotic therapy is continued, the risk of thromboembolic phenomenon is higher than the risk of epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques, to continue phosphodiesterase inhibitors (dipyridamole Persantine, cilostazol Pletal, and Aggrenox aspirin and dipyridamole), and that anatomic conditions such as spondylosis, ankylosing spondylitis and spinal stenosis, and procedures involving the cervical spine; multiple attempts; and large bore needles increase the risk of epidural hematoma; and rapid assessment and surgical or nonsurgical intervention to manage patients with epidural hematoma can avoid permanent neurological complications. There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy clopidogrel (Plavix), ticlopidine (Ticlid), or prasugrel (Effient) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxaban (Xarelto) to discontinue to avoid bleeding and epidural hematomas during interventional techniques and to continue to avoid cerebrovascular and cardiovascular thromboembolic events.
The recommendations derived from the comprehensive assessment of the literature and guidelines are to continue NSAIDs and low dose aspirin, and phosphodiesterase inhibitors (dipyridamole, cilostazol, Aggrenox) during interventional techniques. However, the recommendations for discontinuation of antiplatelet therapy with platelet aggregation inhibitors (clopidogrel, ticlopidine, prasugrel) is variable with clinical judgment to continue or discontinue based on the patient's condition, the planned procedure, risk factors, and desires, and the cardiologist's opinion. Low molecular weight heparin (LMWH) or unfractionated heparin may be discontinued 12 hours prior to performing interventional techniques. Warfarin should be discontinued or international normalized ratio (INR) be normalized to 1.4 or less for high risk procedures and 2 or less for low risk procedures based on risk factors. It is also recommended to discontinue Pradaxa for 24 hours for paravertebral interventional techniques in 2 to 4 days for epidural interventions in patients with normal renal function and for longer periods of time in patients with renal impairment, and to discontinue rivaroxaban for 24 hours prior to performing interventional techniques.
The paucity of the literature.
Based on the available literature including guidelines, the recommendations in patients with antithrombotic therapy for therapy prior to interventional techniques are provided.
The study on which this paper reports examined how the widespread changes in the NHS workforce and in higher education which have transformed nurse education in recent decades have impacted on ...responsibility for the leadership of student nurse learning in clinical practice. Findings from this mixed methods case study carried out at four English higher education institutions between 2006 and 2007 suggest that link lecturers’ presence in clinical areas is diminishing, and that practice nurses’ involvement with pre-registration students’ learning may be limited. Ward managers lead learning at ward level but changes to their role limit their presence on the wards, so that mentors lead student learning on a day to day basis, which they must balance with caring for patients. Changes to the nurse’s role mean that modelling bedside care often falls to health care assistants. This deficit of leadership for learning may be understood as a manifestation of the ‘uncoupling’ of education and practice following the move of nurse education into higher education and subsequent changes to nursing roles. Strengthening leadership for learning is likely to be associated with recoupling practice and education and indicators to assess the quality of leadership for learning in clinical practice are suggested.
In a classic paper,
Menzies (1960) argued that nurses distanced themselves from patients in order to avoid direct engagement with them and as a means of managing their anxiety. Reflecting on the work ...40
years later Fabricius argued that in the move from hospital-based nurse education to universities, nurse educators had further entrenched this defence. It is from both these perspectives that we locate this paper to explore the position of nurse teachers today drawing on empirical data from a study set up to investigate who currently leads student nurse learning in the clinical areas and as a follow up to original research on the emotional labour of nursing (
Smith, 1992). This paper presents findings from interviews with nurse teachers which are complemented by student nurse responses to a ward learning environment questionnaire, interviews with ward based nurses and documentary analysis.
A major theme to emerge from the study was that there has been an uncoupling of education and practice as a consequence of the changes taking place in nurse education over the last two decades. This paper describes the range of emotions expressed as a consequence of this uncoupling such as increasing feelings of uncertainty over the nurse teacher’s role in clinical practice and anxiety generated from working in a university system which appeared to devalue caring. The apparent impact of these feelings on nurse teachers was to reinforce the education/practice split and the projection of their anxiety onto students and practitioners. We suggest that nurse teachers and in particular the system in which they work need to recognise both split and projection so that they are able to bear their anxiety and manage it in their teaching.
This paper considers two questions: what pedagogies for teaching nursing are used in nurse education research? Are these pedagogies transferred to learning in the workplace? We argue that there are ...underpinning pedagogies identified in nurse education research in the area of workplace and work based learning which are broadly qualitative, action orientated and focused on knowledge generation. Such pedagogies are rooted in a philosophy of teaching and learning where learning is seen as active, reflective and socially constructed.
We consider possible answers to these questions through an exploration of empirical work by
Evans et al. (2009) which has focused on knowledge transfer in the workplace. Their work offers insights into how pedagogies can be applied to nurse education research which in turn may be transferred into the workplace. In particular, they argue that the concept of knowledge transfer is outdated and we should focus instead on how knowledge learnt in one context (the academy) is re-contextualised in another (the workplace). We also draw on
Aranda and Law’s (2007) paper on the debates concerning the use of sociology in nurse education to explore competing narratives.
We conclude that the pedagogies identified in educational research are not transferred to nurse education and practice yet offer an alternative view of knowledge transfer as illustrated by Evans et al.’s work which explores how learning in the workplace may be facilitated more effectively. We conclude that the lack of transfer of nurse education research pedagogies to practice learning undermines the position of nurse teachers within the academy as nurse education becomes a practice or professional discipline without a discrete disciplinary base.
Aims and objectives. This paper aims to increase our understanding about how student nurses’ experiences of supernumerary status are embedded in the hidden curriculum in clinical practice and ...contribute to the theory–practice gap in nursing.
Background. Current literature suggests that the hidden curriculum exists in many professional curricula and that it functions to socialise students into professional behaviours and practice. However, in nursing, there is a gap in our understanding of how these socialisation processes have been influenced by supernumerary status and what forms the hidden curriculum might take currently in clinical practice.
Design. An ethnographic case study design.
Method. Data were collected in four sites using fieldwork in clinical practice as well as interviews with students, mentors and key stakeholders, an online survey of student bodies and curriculum analysis in four universities. The findings in this paper are drawn from the qualitative fieldwork and interviews and were analysed thematically.
Results. The findings suggest that supernumerary status is an important aspect of the hidden curriculum in clinical learning for nursing students; that students are expected by trained staff to work while they learn and that on registration, they are expected to be competent to work immediately as registered nurses. These expectations are at odds with those of academic nurses and contribute to a theory–practice gap for student nurses. These expectations form part of the hidden curriculum that shapes the clinical context, and students have to learn to negotiate their status as supernumerary students in practice to meet these expectations.
Conclusion. Consequently, students have to learn in a disintegrated learning context where opposing values of learning exist.
Relevance to clinical practice. To reintegrate student nurses’ learning, educators in universities and clinical practice have to understand how the hidden curriculum and expectations around supernumerary status among trained staff affect learning for students.
Aim We present three case studies of discrimination to illustrate how racist bullying as discriminatory practices operates in the workplace.
Background Workplace bullying in the British health care ...sector is reported along with evidence of discrimination towards overseas‐trained nurses recruited to work in the United Kingdom (UK).
Methods The three interviews, which form the basis of the discussion in this paper, were selected purposively from a national study of overseas nurses because they present strong examples of the phenomenon of workplace bullying. The data on which this paper draws were collected through semi‐structured, audio‐recorded interviews and thematically re‐analysed using nvivo V2.
Results The national study showed how racism is entrenched in health workplaces. Our findings in this paper suggest that racism can be understood by the concept of racist bullying. There are four key findings which illustrate racist bullying in the workplace: abusive power relationships, communication difficulties, emotional reactions to racist bullying and responses to bullying.
Conclusions We argue that the literature on workplace bullying adds a layer of analysis of discrimination at the individual and organizational levels which enables us to further delineate racist bullying. We conclude that racist bullying can be specifically identified as a form of bullying.
Implications for nursing managers Our data may assist managers to challenge current workplace working practices and support bullied employees. The three interviews show different responses to racist bullying which allow us to explore some implications for management practice.
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