Intolerable Pain Research Articles

Effects of Single Low-Frequency Repetitive Transcranial Magnetic Stimulation on Motor Cortical-Subcortical-Cerebellar Circuit

The primal instinct of neurosurgeons has been to maintain spinal stability and motion since the beginning of spinal procedures. Conventional anterior approaches without fusion eliminate motion in time as fusion invariably sets in and hampers the vertebral column's normal dynamic physiology.We reported a 60 years old male patient who presented with signs of myelopathy, but his primary complaint was brachialgia. He had myelopathic features for eight years, for which he offered fusion surgery at multiple levels years ago, and he denied it. He was static since then, and the disease did not progress further. For intolerable pain, he agreed to minimally invasive surgery. Therefore, we operated for a right C6 transcorporeal microforaminotomy and removed the inciting disc material.Clinical implication for anterior cervical microforaminotomy for this patient was successful where there was acute disc prolapse in cervical spondylotic myelopathy.Finally, functional preservation of the cervical spine in multilevel spondylosis can optimize the fusion. In this case, the report authors have explored the comparison between the PROMIS score and the Nurick score, reporting for the first time.

Pain Relief Salvage with a Novel Minimally Invasive Posterior Sacroiliac Joint Fusion Device in Patients with Previously Implanted Pain Devices and Therapies.

BackgroundSacroiliac joint (SIJ) pain is a common cause of low back pain, a problem experienced by two-thirds of adults in the United States population. Traditionally, the management of persistent SIJ-related pain has involved conservative therapies (physical therapy, topical medications, oral anti-inflammatory medications), interventional therapies (SIJ steroid injections or ablation), and surgery (SIJ fusion; open and lateral approach). Recent advancements in technology have paved the way for SIJ fusion via a posterior approach, which aims to minimize complications and enhance recovery.ObjectiveThe purpose of this study is to introduce the concept of the posterior approach to SIJ fusion as a feasible adjunct and salvage technique for patients with inadequate pain relief from other minimally invasive surgical procedures, and to validate its efficacy through a retrospective multicenter data analysis.DesignMulticenter retrospective observational study.MethodsPatients with refractory SIJ pain were treated by interventional pain physicians at one of the eight different pain management centers. All patients underwent posterior SIJ fusion via the LinQTM sacroiliac fusion procedure. Demographical data were collected, in addition to patient-reported pain relief.ResultsA total of 111 patients were included in the study and underwent posterior SIJ fusion for refractory SIJ-related pain following the use of spinal cord stimulation (SCS), interspinous spacer (ISS), intrathecal drug delivery (IDDS), and/or minimally invasive lumbar decompression (MILD). Overall, the mean patient reported pain relief following posterior SIJ fusion was 67.6%. In patients with a history of failed back surgery syndrome, the mean patient reported pain relief was 76.5%.ConclusionIn this retrospective case series of patients with continued intolerable pain following SCS, ISS, IDDS, or MILD, a novel posterior SIJ fusion device provided significant pain relief in a salvage manner. These early results suggest that this intervention may be a therapeutic option to consider in these patients.

Advanced Cardiac Rhythm Management by Applying Optogenetic Multi-Site Photostimulation in Murine Hearts.

Ventricular tachyarrhythmias are a major cause of mortality and morbidity worldwide. Electrical defibrillation using high-energy electric shocks is currently the only treatment for life-threatening ventricular fibrillation. However, defibrillation may have side-effects, including intolerable pain, tissue damage, and worsening of prognosis, indicating a significant medical need for the development of more gentle cardiac rhythm management strategies. Besides energy-reducing electrical approaches, cardiac optogenetics was introduced as a powerful tool to influence cardiac activity using light-sensitive membrane ion channels and light pulses. In the present study, a robust and valid method for successful photostimulation of Langendorff perfused intact murine hearts will be described based on multi-site pacing applying a 3 x 3 array of micro light-emitting diodes (micro-LED). Simultaneous optical mapping of epicardial membrane voltage waves allows the investigation of the effects of region-specific stimulation and evaluates the newly induced cardiac activity directly on-site. The obtained results show that the efficacy of defibrillation is strongly dependent on the parameters chosen for photostimulation during a cardiac arrhythmia. It will be demonstrated that the illuminated area of the heart plays a crucial role for termination success as well as how the targeted control of cardiac activity during illumination for modifying arrhythmia patterns can be achieved. In summary, this technique provides a possibility to optimize the on-site mechanism manipulation on the way to real-time feedback control of cardiac rhythm and, regarding the region specificity, new approaches in reducing the potential harm to the cardiac system compared to the usage of non-specific electrical shock applications.

CT-guided transforaminal epidural steroid injection for discogenic lumbar radiculopathy: influence of contrast dispersion and radiologist\u2019s experience on clinical outcome

ObjectiveTo investigate the impact of contrast dispersion pattern/location during lumbar CT-guided transforaminal epidural steroid injection (TFESI) and experience of the performing radiologist on therapeutic outcome.Materials and methodsIn this single-center retrospective cohort study, two observers analyzed contrast dispersion during CT-guided TFESI of 204 patients (age 61.1 ± 14 years) with discogenic unilateral single-level L4 or L5 radiculopathy. The contrast dispersion pattern was classified as “focal,” “linear,” or “tram-track”; the location was divided into “extraforaminal,” “foraminal,” or “recessal.” Pain was assessed before and 4 weeks after treatment using a numerical rating scale (0, no pain; 10, intolerable pain). Additionally, the patient global impression of change (PGIC) was assessed. The TFESI was performed by musculoskeletal radiologists (experience range: first year of musculoskeletal fellowship training to 19 years). Contrast pattern/location and radiologist’s experience were compared between “good responder” (≥ 50% pain reduction) and “poor responder” (< 50%). A p-value < 0.05 was considered to be statistically significant.ResultsOverall, CT-guided TFESI resulted in a substantial pain reduction in 46.6% of patients with discogenic radiculopathy. The contrast dispersion pattern and location had no effect on pain relief (p = 0.75 and p = 0.09) and PGIC (p = 0.70 and p = 0.21) 4 weeks after TFESI. Additionally, the experience of the radiologist had no influence on pain reduction (p = 0.92) or PGIC (p = 0.75). Regarding pre-interventional imaging findings, both the location and grading of nerve compression had no effect on pain relief (p = 0.91 and p = 0.85) and PGIC (p = 0.18 and p = 0.31).ConclusionOur results indicate that neither contrast agent dispersion/location nor the experience of the radiologist allows predicting the therapeutic outcome 4 weeks after the procedure.

Incidence and risk factors of lateral cage migration occurred after the first-stage lateral lumbar interbody fusion surgery

BackgroundLateral lumbar interbody fusion (LLIF) is a novel, minimally invasive technique for the surgical treatment of lumbar diseases. The aim of this study was to identify the incidence and risk factors of lateral cage migration (LCM) occurred after the first-stage LLIF. HypothesisThe hypothesis was that LCM occurred after the first-stage LLIF was associated with some demographic characteristics, surgical variables and radiographic parameters. Patients and methodsBetween June 2016 and August 2020, 335 patients (901 levels) underwent staged LLIF were retrospectively reviewed. Patients were classified into LCM and non-LCM group based on the experience of LCM before the second-stage posterior instrumentation. 100 patients in non-LCM were randomly sampled as a control group. Incidence of LCM was determined; demographic characteristics, surgical variables and radiographic parameters associated with LCM were compared between the LCM and control group. Univariate analyses and multivariable logistic regression analysis were used to identify the risk factors. ResultsLCM occurred after the first-stage LLIF was found in 19 (5.7%) patients. Bony endplate injury (OR, 106.255; 95% CI, 1.265–8924.765; p=0.039) and greater preoperative range of motion (ROM) (OR, 2.083, 95% CI, 1.068–4.066, p=0.031) were high risk factors for LCM. LCM occurred mainly 3 days later after the first-stage LLIF, while 4 cases experienced severe neural symptoms, intolerable low back pain and finally underwent reoperation. DiscussionLCM occurred after the first-stage LLIF was significantly associated with bony endplate injury and greater preoperative ROM. Second-stage posterior fixation should be performed as soon as possible or a supplement lateral fixation/self-locking cage should be used in high-risk patients. Level of evidenceIV.

Biodegradable Antimicrobial Agent/Analgesic/Bone Morphogenetic Protein-Loaded Nanofibrous Fixators for Bone Fracture Repair

PurposePostoperative infection and pain management are of great concern to orthopedic surgeons. Although there are several protocols available to deal with these aspects, they are fraught with complications, such as cartilage damage, cardiovascular and neurological intoxication, and systemic adverse responses. Therefore, it is necessary to develop safe and effective perioperative protocols. In the current study, antimicrobial agents/analgesics/growth factor-embedded biodegradable hybrid fixators (polycaprolactone fixator + poly[lactide-co-glycolide] sheath-core structured nanofibers) for bone fracture repair were designed.MethodsThe biodegradable hybrid fixators were fabricated using solution-extrusion three-dimensional printing and electrospinning. In vitro, the characteristics of the hybrid fixators were examined. Additionally, the release of the incorporated vancomycin, ceftazidime, lidocaine, and bone morphogenetic protein-2 (BMP-2) was evaluated. The in vivo efficacy including drug-eluting properties, fracture repair, and pain management of the biomolecule-loaded nanofibrous fixators was investigated in rabbit rib-fracture models.ResultsThe nanofibrous fixators released vancomycin, ceftazidime, and lidocaine in a sustained manner under both in vitro and in vivo conditions and protected BMP-2 from burst release. The implantation of these hybrid fixators around the fractured rib significantly improved animal activities and bone union, indicating that the inclusion of analgesic in the fixator effectively reduced postsurgical pain and thereby helped in recovery.ConclusionThe novel biomolecule-loaded nanofibrous hybrid fixators resulted in excellent therapeutic outcomes. These fixators may be effective in the repair of rib fractures in clinical settings and may help mitigate surgical complications, such as infection, nonunion, and intolerable postoperative pain.

Systolic finger pressures during an Allen test before hemodialysis access construction predict severe postoperative hand ischemia

ObjectiveThe Allen test is a simple bedside method for determining hand perfusion. Earlier studies in patients on hemodialysis (HD) found that an Allen test before access construction did not predict hand ischemia later on. The study aimed to assess whether an Allen test combined with finger plethysmography before access surgery has a potential to predict the onset of severe HD access induced distal ischemia (HAIDI). MethodsBefore the first access construction in patients with chronic kidney disease, systolic finger pressures (Pdig, in millimeters of mercury) were obtained using plethysmography at rest and after serial compression of the radial and ulnar artery. A decrease in Pdig (∂Pdig) was calculated as the difference between Pdig-rest and Pdig-compression. The severity of postoperative HAIDI was graded as suggested by a 2016 consensus meeting. Patients with a severe type of HAIDI (grade 2b-4, intolerable pain, invasive treatment required) were compared with controls not having HAIDI. ResultsA total of 105 patients with chronic kidney disease (mean age 70 ± 13 years; 65% males) receiving their first access between January 2009 and December 2018 in one center fulfilled study criteria. Ten patients (10%) developed severe HAIDI at 14 ± 5 months after access construction. Before access creation, all patients with HAIDI demonstrated a radial or ulnar dominant hand perfusion pattern compared with just 57% in controls (P = .010). Compression resulted in an almost two-fold greater ∂Pdig in patients with severe HAIDI (51 ± 8 mm Hg vs 27 ± 3 mm Hg; P = .005). A 40-mm Hg ∂Pdig cut-off value demonstrated optimal tests characteristics (sensitivity of 80%, specificity of 77%, positive predictive value of 27%, negative predictive value of 97%) indicating a 10 times greater risk of developing severe HAIDI. ConclusionsFinger plethysmography quantifying ∂Pdig during an Allen test before access creation may identify patients who have a substantially increased risk of developing severe hand ischemia after HD access surgery.

Is performing joint arthroplasty surgery during the COVID-19 pandemic safe?: A retrospective, cohort analysis from a tertiary centre in NCR, Delhi, India

PurposeResuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients. MethodsA retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection. ResultThe most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission. ConclusionJoint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a ‘ring-fenced’ peri-operative pathway.

Debridement and corpectomy via single posterior approach to treat pyogenic spondylitis after vertebral augmentation

BackgroundInfection after vertebral augmentation (VA) often limits the daily activities of patients and even threatens their life. The operation may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of the treatment of pyogenic spondylitis after vertebral augmentation (PSVA) with Single posterior debridement, vertebral body resection, and intervertebral bone graft fusion and internal fixation (sPVRIF).MethodsThe study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA.ResultsA total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture(OVF) in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities. The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment. The surgical time was 175.0±16.8 min, and the intraoperative blood loss was 465.6±166.0 mL. Pathogenic microorganisms were cultured in 12 patients.ConclusionPSVA is a severe complication that can even threaten the life of the patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.

Non – Clinical Pain Assessment System – A Pilot Study

The term ‘Pain’ refers to the sensory response of the body when the reflex tolerance level of the person exceeds the threshold value. Though most of the pain senses are tolerable, it still disturbs the normal anatomical actions of the body, classifying it as tolerable and intolerable pain. Various techniques have evolved in the past few years to quantify pain; however, they are successful only in subjective determination thus leading to inaccuracy in prediction. The proposed paper discusses a few objective methods to quantify non – clinical pain. FLIR spectroscopic images can recognize inflammation and high-temperature points in a given region. Upon using various mechanical algorithms, accurate pain values can be determined. Similarly, by solving the pain-causing equation, we can derive the pain peak values. These methods can replace the conventional scales and help in subsidiary pain assessment.

O luto perinatal e neonatal e a atuação da psicologia nesse contexto

Atualmente, a morte na infância é pouco comum, considerando-se todos os recursos de modernidade que se disponibilizam hoje, quais sejam, cuidado pré-natal, UTI neonatal, dentre outros. Por isso mesmo, quando acometida por essa fatalidade, a família sente estranheza e forte impacto. A perda de um bebê pode produzir uma dor intolerável, uma vez que significa frustração de desejos, fantasias, devaneios e não menos importante, a impotência ante a possibilidade de aplicar sua capacidade de ser mãe/pai. Neste sentido, salienta-se a necessidade de profissionais como o psicólogo, a fim de que possa auxiliar a família a enfrentar o luto parental e a elaboração da perda de um filho. Desta forma, este estudo visou dissertar sobre a importância da intervenção psicológica em situações de luto: perinatal e neonatal. A partir de uma pesquisa qualitativa, de revisão bibliográfica, foi possível identificar que esse tipo de luto contraria o que culturalmente em nossa sociedade se espera sobre o andamento do ciclo de vida. Isso posto, diante do que essas perdas podem provocar nas famílias e até mesmo nas equipes de saúde, faz-se necessária a presença do psicólogo nesse contexto. Consubstancialmente, salienta-se a importância de estudos futuros que possam investir em novas reflexões acerca do luto perinatal, uma vez que as considerações trazidas por eles podem ter implicações na prática do psicólogo no âmbito hospitalar.

Palliation of malignant esophageal obstruction using an anti-migration self-expandable metal stent: Results of a prospective multicenter study

BackgroundSelf-expanding metal stents (SEMS) placement is primarily indicated to palliate dysphagia for patients with expected short-term survival. We aimed to assess the migration rate and other stent-related adverse events (AEs) of a fully covered SEMS with an anti-migration system (FCSEMS-AMS) for palliation of malignant dysphagia. MethodsThis is a prospective study including patients with inoperable esophageal cancer that received a FCSEMS-AMS (Taewoong, Niti-S Beta™), in five tertiary-care endoscopic centers from January 2014 to February 2016. ResultsFifty-three consecutive patients were enrolled. Tumor location was proximal, mid and distal esophagus±esophago-gastric junction (EGJ) in 6, 14, and 33 cases, respectively. Overall, non-severe AEs were reported in 18 patients (34.0%), 13 of them required an additional endoscopic procedure. Migration occurred in 7 patients (13.2%): 3 from the upper and 4 from the lower esophagus and EGJ. Stent retrieval was necessary in one patient due to intolerable pain. Food bolus impaction and tumor overgrowth occurred in 2 patients (3.8%) and 4 (7.5%) patients respectively. Four patients complained of gastroesophageal reflux as late AEs. Median follow-up was 19.3 months. Dysphagia significantly improved until 3 and 6 months from stent insertion (median score before FCSEMS-AMS: 3, vs median score: 1). Median dysphagia-free time was 10 months. ConclusionsPlacement of the Taewoong, Niti-S Beta™ stent appeared to be a safe and effective treatment of malignant dysphagia. The anti-migration system reduced the overall migration rate, although it remained high in strictures located in the upper esophagus and when the stent was placed across the EGJ.

Anterior Cervical Discectomy and Fusion Versus Conservative Treatment for Cervical Angina Conservative Treatment.

Study Design:This study employed a retrospective study design.Objective:This retrospective cohort study aimed to compare the outcomes of anterior cervical discectomy and fusion (ACDF), and those of conservative treatment for patients with cervical angina.Summary of Background Data:Cervical angina is typically characterized by intolerable and paroxysmal angina-like precordial pain, which is caused by cervical disk degeneration in patients without definitive cardiovascular abnormalities. Diagnosis is either delayed or neglected because of its various clinical manifestations. Whether conservative or surgical treatment is appropriate remains controversial because of the lack of comparative studies.Materials and Methods:From 2009 to 2016, 163 patients with cervical angina with advanced chest pain, tightness, or palpitation were retrospectively studied. Twenty-three patients underwent ACDF, and the other 140 patients were treated nonsurgically by medication, physical therapy, collar immobilization, or stellate ganglion block. Japanese Orthopedic Association (JOA) score and 20-point autonomic nervous system (ANS) score were assessed pretreatment and posttreatment. Patients’ satisfaction was assessed using the Odom criteria.Results:The average age of the patients was 50 years, and most of them were females. The average follow-up was 25.5 months. The pretreatment JOA and 20-point ANS scores in the conservative and ACDF groups were 13.3 versus 11.7 (P=0.110) and 13.0 versus 13.3 (P=0.928), respectively. Generalized estimating equation analysis showed that posttreatment JOA and ANS scores at each observation interval improved significantly in the ACDF group (P<0.001). Angina-like symptoms also improved significantly in the ACDF group (P<0.001). During an average 2-year follow-up, good or excellent results were obtained in 78.2% of surgical patients and 35% of nonsurgical patients.Conclusions:Compared with conservative therapy, surgical treatment with ACDF for cervical angina provided better and more consistent relief from angina-like symptoms and overall sympathetic symptoms.Level of Evidence:Level III.

A clinical study: Inguinal hernia repair under local block

This study was conducted to evaluate advantages of local anaesthesia in high risk patients and to assess patient’s satisfaction, speed of recovery and postoperative analgesia. In our study we gave combined Ilioinguinal and Iliohypogastric nerve block with field block in 30 patients. The patients were monitored for hemodynamic changes and total duration of analgesia and quality of analgesia. In this study 23% patients were of ASA I, 30% ASA II and 46.7% had ASA III grade. All patients were hemodynamically stable throughout procedure and surgery. Average duration of the analgesia was 188 min (about 3 hours). Quality of analgesia was excellent in 66.6% patients, good in 16.6% patients, poor in 6.6% patients and 10%patients had severe intolerable pain and converted to GA. We found that inguinal hernia repair under local anaesthesia was safe, simple, cost-effective and also provides good postoperative analgesia. It is more useful in high risk patients where we need to avoid effects of general, spinal or epidural anaesthesia for hernia surgeries.

PHILOS Plate Plus Oblique Insertion of Autologous Fibula for 2-Part Proximal Humerus Fractures With Medial Column Disruption: A Retrospective Study.

Introduction:The aim of this retrospective study was to evaluate the outcomes of older patients with 2-part proximal humerus fractures (PHFs) with medial column disruption stabilized using a proximal humeral internal locking system (PHILOS) plate plus oblique insertion of autologous fibula as a primary procedure.Materials and Methods:Data involving 112 patients (112 shoulders) sustaining 2-part PHFs with medial column disruption treated with PHILOS plate plus oblique insertion of autologous fibula as a primary procedure during 2012-2019 were identified. The median follow-up was 36 months (range: 11.2-43.5 months). The primary endpoint was the Constant scores and American Shoulder and Elbow Surgeons (ASES) scores. The secondary endpoint was the main orthopedic complication rate.Results:The median Constant and ASES scores were 78 (range, 52-95) and 77 (range, 62-96) at the final follow-up, respectively. The main orthopedic complication rate was 10.7% (12/112). Twelve orthopedic complications in 8 patients were detected, and they involved loss of reduction, varus collapse, aseptic loosening, mal-union, revision, and intolerable shoulder pain. Of these complications, 3 (2.6%) involved loss of reduction, 2 (1.7%) involved varus collapse, 3 (2.6%) involved aseptic loosening, 1 (0.8%) involved mal-union, 2 (1.7%) required revision surgery, and 1 (0.8%) presented intolerable shoulder pain.Conclusion:PHILOS plate plus oblique insertion of autologous fibula as a primary procedure may yield good functional outcomes and a low rate of the main orthopedic complications.

Efficiency of Image Guided Percutaneous Celiac Plexus Neurolysis in Abdominal Malignancy: A Prospective Interventional Study

Introduction: Celiac Plexus Neurolysis (CPN) is an underutilised tool in oncology and interventional radiology set-up. Upper abdominal malignancy specifically carcinoma pancreas, carcinoma stomach which causes intolerable pain, for which patients require a high dose of pain killers. CPN being a day care procedure alleviates the pain in a short duration and its effectiveness may last for months. Aim: To assess the efficiency of image guided CPN in alleviating intractable pain in upper abdominal malignancy. Materials and Methods: A prospective interventional study was conducted on 25 patients with inoperable upper abdominal malignancy with intractable pain referred from the Palliative Care Department. These patients were subjected to Computed Tomography (CT)-guided or Ultrasonography (USG)-guided CPN using 97% absolute alcohol either via posterior or anterior approach under CT guidance or anterior approach in USG guidance. Pain intensity score was assessed before and after the procedure (one, three, and seven days after the procedure) using Visual Analogue Scale (VAS). Results: There was decrease of the pain intensity significantly in all the patients postprocedure. The VAS score at baseline was 6.48±1.56. One day after CPN, pain severity decreased to 4.16±2.17; three days later, it was 1.68±1.78; Seven days after CPN, pain severity still decreased significantly to 0.58±1.10. Percentage decrease in VAS from preprocedure to one, three, and seven days after procedure was found to be 39.07%, 76.29% and 90.06%, respectively and VAS score reduction was statistically significant at p-value &lt;0.001. Conclusion: CPN is an underutilised palliative procedure for upper abdominal malignancy which effectively controls pain, thus, reducing the need for analgesic medication. Both CT guidance and USG guidance can be used in performing the procedure.

Prognostic Factors of Mid- to Long-term Clinical Outcomes after Arthroscopic Partial Meniscectomy for Medial Meniscal Tears.

BackgroudArthroscopic partial meniscectomy (APM) continues to be the popular treatment for meniscal tears, but recent randomized controlled trials have questioned its efficacy. To provide more evidence-based criteria for patient selection, we undertook this study to identify prognostic factors associated with clinical failure after APM for medial meniscus tears.MethodsMedical records of 160 patients followed up for at least 5 years after APM for medial meniscal tears were retrospectively reviewed. Demographic data (age, sex, and body mass index), radiographic variables (Kellgren-Lawrence [K-L] grade and hip-knee-ankle [HKA] angle), and clinical scores (International Knee Documentation Committee score, Tegner activity scale score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score) were recorded. Clinical failure was defined as the need for an additional surgical procedure (arthroscopy, osteotomy, or arthroplasty) or the presence of intolerable pain. Survivorship analysis with clinical failure as an end point was performed using Kaplan-Meier survival curves. Factors related to clinical failure were analyzed using a Cox proportional hazard model. Cutoff values were determined using areas under receiver operating characteristic (ROC) curves. Radiographic progression of osteoarthritis was analyzed using the chi-square test, and serial changes of clinical scores were analyzed using a linear mixed model.ResultsClinical success rates were 95.7% at 5 years, 75.6% at 10 years, and 46.3% at 15 years. Age, HKA angle, and K-L grade (p = 0.01, p = 0.02, and p = 0.04, respectively) were found to be significant risk factors of clinical failure. Cutoff values at 10 years postoperatively as determined by ROC analysis were 50 years for age (sensitivity = 0.778, 1−specificity = 0.589), grade 2 for K-L grade (sensitivity = 0.778, 1−specificity = 0.109), and 5.5° for HKA angle (sensitivity = 0.667, 1−specificity = 0.258). In patients who had clinical success until 10 years after APM, radiological osteoarthritis progressed gradually. However, the clinical scores of patients who achieved clinical success did not decrease significantly over the 10-year follow-up.ConclusionsThe poor prognostic factors found to be related to clinical failure after APM for a medial meniscal tear were patient age (≥ 50 years), preoperative K-L grade (≥ grade 2), and preoperative HKA angle (≥ varus 5.5°).

English

BACKGROUND Sleep disturbances usually accompany osteoarthritis (OA) because of chronic pain. Poor sleep quality is related to many factors like pain, fatiguability, restless leg syndrome, immobility of joints, anxiety and depression. But the quality of the sleep in patients with osteoarthritis has been rarely studied. We wanted to assess the prevalence of sleep disturbances in OA patients, determine the sleep quality in osteoarthritis patients and evaluate the relationship between pains and sleep quality. METHODS 150 patients with osteoarthritis were selected through convenience sampling as per the inclusion and exclusion criteria. Pittsburgh Sleep Quality Index (PSQI) and Numerical Pain Rating Scale (NPRS) were applied. Data was analysed using SPSS. One sample T test and Pearson Correlation were applied to find the correlation between the pains and sleep quality. RESULTS A total of 86 (57 %) patients with osteoarthritis were found to have sleep disturbances and were assessed for sleep quality and pain level. This group contains 18 (20 %) males and 68 (80 %) females. A total of 62 (72 %) osteoarthritis patients including 14 males and 48 females were having poor sleep quality; 67 (78 %) patients had intolerable pain (NPRS &gt; 7). Strong positive correlation (p-value &lt; 0.001) was found between GPSQI and NPRS. CONCLUSIONS Patients with osteoarthritis with high NPRS values have poor sleep quality. There is significant association between pain and poor sleep quality. It will be highly useful for the patients with osteoarthritis if osteoarthritis treatment protocol includes assessment and management of poor sleep quality. As poor quality is an early indicator of majority of mental illnesses, psychiatric liaison services will be highly beneficial for patients with osteoarthritis. KEYWORDS Osteoarthritis, Pain, Sleep Quality, Numerical Pain Rating Scale (NPRS), Pittsburgh Sleep Quality Index (PSQI)

Role of clip markers placed by endoscopic ultrasonography in contouring gross tumor volume for thoracic esophageal squamous cell carcinoma: one prospective study.

BackgroundWe aimed to analyze the value of metal clip markers guided and placed by endoscopic ultrasonography (EUS) in the delineation of gross tumor volume (GTV) for thoracic esophageal squamous cell carcinoma.MethodsFrom September 2016 to September 2018, patients with thoracic esophageal squamous cell carcinoma in Tianjin Medical University Cancer Institute and Hospital were recruited in the prospective trial, NCT02959385. They underwent titanium clips placement on tumor superior and inferior boundaries under EUS by a single expert endosonographer before radiotherapy computed tomography (CT) simulation. According to the clip markers, the reference GTVs were contoured by one experienced radiation oncologist. With the help of the Eclipse treatment planning system, clip markers on CT were concealed. Afterward, two other radiation oncologists with expertise in esophageal cancer delineated GTVs, defined as conventional GTVs, based on endoscopy and barium radiography findings. The two GTVs were compared and analyzed. Subgroup analysis was conducted in different T stage [early (T1 + T2) vs. advanced (T3 + T4)], focus location (upper vs. middle vs. lower segment), and tumor length (<5 vs. >5 cm) groups.ResultsThe trial recruited 55 patients with 60 thoracic esophageal cancer foci. A total of 111 titanium clips were guided and implanted by EUS. Before CT simulation, two titanium clips at two foci fell off. After the procedure, no case of intolerable esophageal pain, hemorrhage, or perforation occurred. Compared to reference GTVs’, discrepancies of conventional GTVs’ superior borders were 0.91±0.82 cm (P<0.001), while differences of inferior borders were 0.74±0.63 cm (P<0.001). On the contrary, conventional GTVs’ lengths were not significantly different from reference GTVs’ with discrepancies 0.08±1.30 cm (P=0.64). Regardless of T stage, tumor location, and tumor length, conventional GTVs’ superior and inferior borders were significantly different from reference GTVs’, while GTVs’ lengths differed insignificantly.ConclusionsThis study confirmed that EUS-placed titanium clips could correct contouring of GTVs in thoracic esophageal cancer in different T stages, tumor locations, and lengths.

Developing a Mobile App (iGAM) to Promote Gingival Health by Professional Monitoring of Dental Selfies: User-Centered Design Approach.

BackgroundDental visits are unpleasant; sometimes, patients only seek treatment when they are in intolerable pain. Recently, the novel coronavirus (COVID-19) pandemic has highlighted the need for remote communication when patients and dentists cannot meet in person. Gingivitis is very common and characterized by red, swollen, bleeding gums. Gingivitis heals within 10 days of professional care and with daily, thorough oral hygiene practices. If left untreated, however, its progress may lead to teeth becoming mobile or lost. Of the many medical apps currently available, none monitor gingivitis.ObjectiveThis study aimed to present a characterization and development model of a mobile health (mHealth) app called iGAM, which focuses on periodontal health and improves the information flow between dentists and patients.MethodsA focus group discussed the potential of an app to monitor gingivitis, and 3 semistructured in-depth interviews were conducted on the use of apps for monitoring gum infections. We used a qualitative design process based on the Agile approach, which incorporated the following 5 steps: (1) user story, (2) use cases, (3) functional requirements, (4) nonfunctional requirements, and (5) Agile software development cycles. In a pilot study with 18 participants aged 18-45 years and with different levels of health literacy, participants were given a toothbrush, toothpaste, mouthwash, toothpicks, and dental floss. After installing iGAM, they were asked to photograph their gums weekly for 4 weeks.ResultsAll participants in the focus group believed in the potential of a mobile app to monitor gingivitis and reduce its severity. Concerns about security and privacy issues were discussed. From the interviews, 2 themes were derived: (1) “what's in it for me?” and (2) the need for a take-home message. The 5 cycles of development highlighted the importance of communication between dentists, app developers, and the pilot group. Qualitative analysis of the data from the pilot study showed difficulty with: (1) the camera, which was alleviated with the provision of mouth openers, and (2) the operation of the phone, which was alleviated by changing the app to be fully automated, with a weekly reminder and an instructions document. Final interviews showed satisfaction.ConclusionsiGAM is the first mHealth app for monitoring gingivitis using self-photography. iGAM facilitates the information flow between dentists and patients between checkups and may be useful when face-to-face consultations are not possible (such as during the COVID-19 pandemic).