Objective Generator site pain is a relatively common phenomenon in patients undergoing spinal cord stimulation (SCS) that complicates management and effective pain relief. This pain may be managed conservatively, with repositioning of the battery and in some cases with explant. Here we explore our experience with management of generator site pain (‘pocket pain’) in a large single-center study. Methods All SCS permanent implants and implantable pulse generator (IPG) placements over 9 years were reviewed. Of 785 cases, we identified 43 patients with pocket pain (5.5%). Demographics and treatments of the pocket pain cohort were analyzed. Results The mean age (± SEM) of the pocket pain cohort was 46.86 ± 1.06 and there were 10/33 males/females. Females were overrepresented in pocket pain cohort (76.7%) when compared to the total SCS cohort (59.0%) (X2 = 5.93, p = 0.015). Diagnosis included failed back surgery syndrome (51.2%), complex regional pain syndrome (23.3%), and chronic neuropathic pain (25.5%). No patients improved with conservative therapy. All patients either went on to revision (n = 23) or explant (n = 20). Time from initial surgery to development of pocket pain was 7.5 months (range: 0.3-88) and from pocket pain to revision surgery was 4.5 months (range: 0.4-26). In addition, significantly more pocket pain patients (65.1%) had workers’ compensation (WC) insurance compared to patients without pocket pain (24.9%) (X2 = 33.3, p < 0.001). Conclusion In our institutional experience, pocket pain was inadequately managed with conservative treatments. Being female and having SCS filed under WC increased risk of pocket pain. Future work will explore the nuances in device placement based on body shape and manual activity responsibilities.
Purpose Many patients with COVID-19 who develop acute respiratory distress syndrome (ARDS) require prolonged periods of mechanical ventilation. Mechanical ventilation may amplify ventilator-associated complications and extend resource utilization. A better understanding of prognostic indicators could help in the planning and distribution of resources, particularly in resource-limited areas. We analyzed laboratory studies of intubated COVID-19 patients with the goal of identifying biomarkers that may predict extubation success and survival to discharge. Methods A retrospective chart review was performed on all COVID-19 patients requiring mechanical ventilation between January 3, 2020, and January 7, 2020, in a single academic tertiary care center in Northeastern New York State. The electronic medical record was used to collect 14 laboratory variables at three time points: admission, intubation, and extubation (including terminal extubation) for all intubated intensive care unit (ICU) patients treated for COVID-19. Mean laboratory values were analyzed with the Mann-Whitney U test. Categorical variables were analyzed with the two-sample Wilcoxon rank-sum test. Results Seventy-two patients met the inclusion criteria. Forty-three patients were male. The mean age was 61 years. The overall mortality was 50%. On admission, intubated patients who survived had significantly higher platelet counts (p=0.024), and absolute lymphocyte counts (ALC; p=0.047). Notably, ferritin (p=0.018) and aspartate transaminase (AST; p=0.0045) levels were lower in survivors. At the time of intubation, survivors again had a higher platelet count (p=0.024) and ALC (p=0.037) levels. They had a lower D-dimer (p=0.0014), ferritin (p=0.0015), lactate dehydrogenase (LDH; p=0.0145), and AST (p=0.018) compared to intubated patients who died. At extubation, survivors had higher platelet count (p=0.0002), ALC (p=0.0013), and neutrophil/lymphocyte ratio (NLR; p=0.0024). Survivors had lower d-dimer (p=0.035), ferritin (p=0.0012), CRP (p=0.045), LDH (p=0.002), AST (p<0.001), and ALK (p=0.0048). Conclusions Biomarkers associated with increased risk of mortality include platelet count, ALC, lymphocyte percentage, NLR, D-dimer, ferritin, C-reactive protein (CRP), AST, alanine transaminase (ALT), and alkaline phosphatase (ALK). This study provides additional evidence that these biomarkers have prognostic value in patients with severe COVID-19. The goal is to find objective surrogate markers of disease improvement or success of extubation. When considered within the larger body of data, it is our hope that a mortality risk calculator can be generated for intubated COVID-19 patients.
BACKGROUND: Spinal cord stimulation (SCS) is a safe neuromodulatory treatment used to treat failed back surgery syndrome, chronic neuropathic pain, and complex regional pain syndrome. Despite its efficacy, some patients fail to achieve pain relief and elect to undergo removal of SCS paddle leads. The safety and best practices of these procedures have not been defined. OBJECTIVE: In this article, we describe our technique and complication rate in a series of SCS paddle removals. METHODS: All patients who underwent SCS paddle removal at the Albany Medical Center between 2011 and 2020 were identified. Medical charts were reviewed for demographic data, operative technique, and incidence of complications within 30 days of the procedure. RESULTS: Thirty-two (91%) patients underwent a thoracic paddle removal, whereas 3 (9%) underwent a cervical paddle removal. All cases underwent preoperative imaging with computed tomography or MRI, and all cases were performed with neuromonitoring and fluoroscopy. The technique required for paddle removal depended on the extent of local scar formation and ranged from soft tissue dissection to additional laminectomy at an adjacent level. Cases took on average 2 ± 0.09 hours with 23.21 ± 4.29 cc blood loss. Two patients had superficial infections, which were cleared with 1 week of oral antibiotics. There were no other adverse events. CONCLUSION: Thirty-five patients successfully underwent paddle removal with the minor complications reported. In this article, we show that by using neuromonitoring, fluoroscopy, and the techniques described, SCS paddle removal can be performed with minimal risk.
Introduction As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. Methods Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. Results 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019–2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. Discussion Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. Conclusion We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.
Von klinischer Seite werden heute verschiedene Typen von Hörprothesen eingesetzt, um sensorisch ertaubten Patienten mit Hilfe der Elektrostimulation (ES) der Innenohrschnecke (Cochlea) Höremp-findungen zu verschaffen. Voraussetzung ist, daß noch genügend nicht degenerierte Hörnervenfasern vorhanden sind. Durch ES mit Elektroden, die entweder extracochleär am Runden Fenster (RF) oder intracochleär in die Scala Tympani (ST) der Cochlea angebracht sind, kann den Hörnerven ein bestimmtes Impulsmuster aufgezwungen werden. Die Leistungsfähigkeit der verschiedenen Hörprothesenformen (Cochlea Implantate) wird durch ihre Fähigkeit, Sprachsignale in geeigneter Weise in Nervenimpulsmuster umzusetzen, bestimmt (s. Beitrag KLINKE). Zur Untersuchung der Impulsmuster wurden Einzelfaserableitungen vom Hörnerven normalhörender und ertaubter Katzen während ES registriert. I. Extracochleäre Stimulation Mit einer optisch isolierten Konstantstromquelle wurden die Cochleae über eine 0,8 mm 0 differente Kugelelektrode am RF und eine gleichgroße indifferente Elektrode im Mittelohr sinus-oder pulsförmig stimuliert. Aus den Einzelfaserableitungen wurden die Spontanaktivität, die Reizintensitäts-abhängigkeit, die Frequenzabhängigkeit und die Synchronisation der Nervenimpulse mit dem Stimulus über Perioden-und Intervallhistogramme gemessen und der Synchronisätionsindex (SI; Wertebereich 0 bis 1) berechnet. Aus früheren Untersuchungen /l/ zeigte sich bei normalhörenden Katzen mit extracochleärer sinusförmiger Stimulation niedrigste Impulsraten * schwellen im Bereich 50 bis 300 Hz (Schwelle 20 Imp/s > Spontanrate) bei 40 uArms und die Synchronisationsschwelle (SI> 0,1) bei 26 . Eine eindeutige Korrelation zwischen den akustisch bestimmten Charakteristischen Frequenzen (CF) der Fasern und den Spontanraten mit den elektrisch gemessenen Schwellen ließ sich nicht nachweisen. Bei Katzen, die durch lokale Infusion von NeomycinSulfat in die ST ertaubt waren, zeigte sich ein Verlust der Spontanaktivität und der akustischen Erregbarkeit. Die Schwellen bei ES blieben jedoch in der gleichen Größenordnung. Die niedrigsten Impulsratenschwellen lagen ebenfalls im Bereich um 100 Hz und stiegen zu hohen Frequenzen im Bereich > 10 kHz mit 6 dB/oct. Die Phasensynchronisation bei ES überstreicht einen Bereich bis 12 kHz und übertrifft den bei akustischer Stimulation um ca. eine Oktave. II. Intrachcochleäre Stimulation Um die Wirksamkeit von Mehrkanal-Implantaten zu untersuchen, wurden normalhörenden Katzen verschiedene Typen von Vielfachelektroden durch das eröffnete RF in die ST der ersten Cochleawindung implantiert. Es kamen speziell für Katzen adaptierte 4-kanalige oder für Menschen entwickelte 8-kanalige (HOOWAIR) mit Platin-Knopf-Elektroden oder 22-kanalige (NUCLEUS) mit Platin-Ring-Elektroden zur Anwendung. Die Elektroden wurden über optisch isolierte Stromquellen monopolar gegen die indifferente Elektrode (s.o.) oder paarweise bipolar angesteuert. Bei sinusförmiger Parallelreizung von 2 Paaren mit 100 Hz wurde der Phasen*inkel einer Stromquelle zwischen ...
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