Recurrent Pain Research Articles

Neurovascular Compression in Patients With Trigeminal Neuralgia May Be Associated With Worse Outcomes After Primary Percutaneous Rhizotomy

BACKGROUND AND OBJECTIVES: Percutaneous rhizotomy may be an effective primary intervention in patients with trigeminal neuralgia who are poor candidates for microvascular decompression or those who desire a less invasive approach. However, the influence of neurovascular compression on pain-free survival after primary percutaneous rhizotomy is not well understood. METHODS: We retrospectively reviewed all patients undergoing percutaneous rhizotomy at our institution from 1995 to 2022. Patients were included if they had no history of surgical intervention, available preoperative MRI imaging, and postoperative follow-up data. Barrow Neurological Institute pain scores were assigned at various time points. We collected baseline patient information, pain characteristics, and perioperative complications for each patient. In addition, we recorded evidence of pain recurrence. Patients were dichotomized into those with evidence of neurovascular compression on preoperative MRI vs those without. The effect of neurovascular compression on pain-free survival was assessed using Kaplan-Meier Cox proportional hazards analyses. RESULTS: Of the 2726 patients reviewed, 298 met our inclusion criteria. Our study comprised 261 patients with no evidence of neurovascular compression on preoperative MRI vs 37 patients with evidence of neurovascular compression on preoperative MRI. Patients in the compression group had a shorter median duration to recurrence compared with those in the no compression group, P = .01. Kaplan-Meier survival analysis revealed that patients with preoperative evidence of neurovascular compression on MRI imaging demonstrated shorter pain-free survival compared with those without such evidence [hazard ratio = 1.57 (1.03-2.4), P = .037]. Cox proportional hazards analysis demonstrated that evidence of neurovascular compression was associated with poor pain-free survival [hazard ratio = 1.64 (1.06-2.53), P = .03]. CONCLUSION: Patients with neurovascular compression on preoperative MRI may experience reduced time to recurrence compared with those without after percutaneous rhizotomy. These patients should be counseled on potential reduced efficacy of percutaneous rhizotomy as a primary intervention for their pain.

Percutaneous ballon compression for recurrent TN -a retrospective study of 33 cases.

To investigate the clinical efficacy of percutaneous microballoon compression in the treatment of recurrent TN. This retrospective study included 33 patients who underwent percutaneous microballoon compression for the treatment of recurrent TN from March 2019 to May 2022. Postoperative pain recurrence and facial numbness were assessed according to the Barrow Neurological Institute (BNI) pain score. Patients' anxiety and sleep status during follow-up were assessed according to the Self-rating Anxiety Scale (SAS) and Pittsburgh Sleep Quality Index (PSQI). All patients (33 cases) were followed up for 12-38 months, with an average follow-up time of 23 months. On postoperative day 1, 31 patients (93.9%) reported no pain, and 2 patients were given drug treatment for pain relief, The total efficacy was 93.9%. Moreover, 2 patients (6.1%) reported significant pain relief 2 weeks postoperatively. There are many complications during and after PBC. The incidence of the trigeminocardiac reflex (TCR) during surgery was 100%, and the incidence of facial numbness, masseter muscle weakness, labial herpes and headache was 97, 60.6, 12.1 and 3%. No patient experienced severe facial numbness, hearing impairment, diplopia, injury to cranial nerves, Meningitis, intracranial haemorrhage or keratitis. 1 patient had recurrence of pain at 6 months post-op, which was relieved by oral medication. 81.8% suffered from anxiety and 54.5% had poor sleep quality before surgery. After the period of PBC, SAS and PSQI scores decreased continuously. There were significant improvements in anxiety and sleep status postoperatively compared with preoperatively. PBC is a safe and effective option for the treatment of recurrent TN. The arduous and demanding nature of the clinical course subjects the patient to severe pain, mental, and physical stress. Thankfully, it significantly improves the symptoms of anxiety, depression, and sleep quality.

Retrospective study on endoscopic findings of gastritis in children attending the gastrointestinal tract endoscopic unit of Assiut University Children Hospital over a 15-year-period

Background: Children with gastritis typically exhibit recurrent stomach pain and dyspepsia or vomiting.Objectives: To assess the frequency, clinical manifestations, endoscopic pictures, aetiology and outcome of gastritis in children who visited the gastrointestinal tract (GIT) endoscopic unit of Assiut University Children Hospital.Method: This was a retrospective, crosssectional study conducted at Assiut University Children Hospital GIT Endoscopic Unit from 1st January 2005 to 31st December 2019.Results: Upper GI endoscopy, done in all cases, showed that 66 (8.1%) had erythematous gastric mucosa, 106 (13%) had nodular gastric mucosa, 212 (25.9%) had erythematous gastric mucosa and hyperaemia, 147 (18%) had erythematous gastric mucosa and nodularity, 156 (19.1%) had hyperaemic mucosa and petechiae, 77 (9.5%) had hyperaemic mucosa and erosion, and 53 (6.5%) had multiple erosions and ulcers.Conclusions: Gastritis represented 9.4% of children who underwent upper GI endoscopy. Helicobacter pylori was the commonest cause with high recurrence. Patients presented with recurrent GI bleeding, and those with erythematous hyperaemic mucosa on endoscopy showed recurrence compared to their counterparts.

Impact of Multiple Sclerosis Subtypes on Pain Management in Patients With Trigeminal Neuralgia After Stereotactic Radiosurgery: An International Multicenter Analysis.

Trigeminal neuralgia affects approximately 2% of patients with multiple sclerosis (MS) and often shows higher rates of pain recurrence after treatment. Previous studies on the effectiveness of stereotactic radiosurgery (SRS) for trigeminal neuralgia did not consider the different MS subtypes, including remitting relapsing (RRMS), primary progressive (PPMS), and secondary progressive (SPMS). Our objective was to investigate how MS subtypes are related to pain control (PC) rates after SRS. We conducted a retrospective multicenter analysis of prospectively collected databases. Pain status was assessed using the Barrow National Institute Pain Intensity Scales. Time to recurrence was estimated through the Kaplan-Meier method and compared groups using log-rank tests. Logistic regression was used to calculate the odds ratio (OR). Two hundred and fifty-eight patients, 135 (52.4%) RRMS, 30 (11.6%) PPMS, and 93 (36%) SPMS, were included from 14 institutions. In total, 84.6% of patients achieved initial pain relief, with a median time of 1 month; 78.7% had some degree of pain recurrence with a median time of 10.2 months for RRMS, 8 months for PPMS, 8.1 months for SPMS ( P = .424). Achieving Barrow National Institute-I after SRS was a predictor for longer periods without recurrence ( P = .028). Analyzing PC at the last available follow-up and comparing with RRMS, PPMS was less likely to have PC (OR = 0.389; 95% CI 0.153-0.986; P = .047) and SPMS was more likely (OR = 2.0; 95% CI 0.967-4.136; P = .062). A subgroup of 149 patients did not have other procedures apart from SRS. The median times to recurrence in this group were 11.1, 9.8, and 19.6 months for RRMS, PPMS, and SPMS, respectively (log-rank, P = .045). This study is the first to investigate the relationship between MS subtypes and PC after SRS, and our results provide preliminary evidence that subtypes may influence pain outcomes, with PPMS posing the greatest challenge to pain management.

A refined percutaneous rhizotomy with DSA-guided ethanol for the second-line treatment of trigeminal neuralgia

BackgroundPercutaneous rhizotomy is a group of techniques used to treat trigeminal neuralgia. Radiofrequency thermocoagulation (RF) and Chemical Rhizotomy (CR) using glycerol are among the most frequently used methods. We have recently refined Ethanol Rhizotomy (ER) under Digital Subtraction Angiography (DSA) guidance. ObjectiveA descriptive, retrospective study was conducted to compare our refined ER and RF ablation in patients with trigeminal neuralgia in terms of long-term pain relief and side effects. MethodBetween 2012 and 2014, 33 patients with typical trigeminal neuralgia were enrolled, 10 of whom received RF and 23 received ER under (DSA) guidance with ethanol injected while in the supine position. The pain relief, duration of pain-free period, need for repeat injection, and recurrence of pain were recorded together with procedure-related complications within 7 years after the procedures. ResultsAfter a single intervention or, in some cases, a maximum of two repeated interventions, all 33 patients experienced complete pain relief. Nevertheless, following a single procedure, the success rate was 95.6% (22/23) in the ER group and 60% (6/10) in the RF group. Notably, complete numbness was the most significant side effect, with a higher incidence in the ER group (30.4%) compared to the RF group (0%) (p = 0.02). The recurrence rate was statistically different (p = 0.01) between the two groups, with 4.4% and 40% recorded in the ER and RF groups, respectively. ConclusionWe demonstrated the usefulness of our refined ER procedure as a safe, cost-effective, and efficient second-line treatment for TN.

Acute on Chronic Presentation of Trigeminal Neuralgia

Trigeminal neuralgia (TN) is characterized by sudden, severe, brief, stabbing, usually unilateral, and recurrent pain within one or more branches of the trigeminal nerve. It is divided into three types: (1) primary or classical TN, which requires demonstration of morphologic changes in the trigeminal nerve root from vascular compression, (2) secondary to other identifiable neurologic causes such as multiple sclerosis and intracranial space-occupying lesion, and (3) idiopathic, in which the etiology is unknown. Treatment and prognosis depend on the type. We present this case of an elderly woman with an unusual presentation of TN in a previously diagnosed case. The episodes were increasing in severity and duration, not responding to medical management, allodynia and constant pain was present, and they were accompanied by uncontrolled hypertension. These features strongly suggested other likely causes such as intracranial space-occupying lesions, multiple sclerosis, and central pain. Expert consultations from physicians and neurologists were sought for control of hypertension and reaching a diagnosis. Magnetic resonance angiogram of the brain was done and a diagnosis of classical TN with persistent background facial pain was established. The treatment was successfully done by radiofrequency ablation of the Gasserian ganglion. The pain and blood pressure responded to the treatment.

Percutaneous Sonoguided Pulsed Radiofrequency Ablation for Managing Pain associated with Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a sudden, unilateral, recurrent, and intense paroxysmal pain in the region of distribution of one or more branches of the trigeminal nerve. TN can be effectively treated by minimally invasive techniques such as microvascular decompression, balloon compression, and conventional radiofrequency thermocoagulation of the Gasserian ganglion. The three divisions of the trigeminal nerve can also be individually targeted for pain relief. Pulsed radiofrequency (PRF) is an alternate technique for treating pain along specific branches and has been proven to be a minimally invasive, safe, and effective interventional treatment choice for such patients. A 36-year-old female presented with pain on the left side of the cheek and upper lip part in the infraorbital nerve distribution (V2) and was diagnosed with TN. A neurological examination and magnetic resonance imaging were done. Medical treatment was prescribed initially but showed minimal improvement. Her pain was assessed using the Numeric Pain Rating Score. PRF ablation (PRFA) was done using short bursts of radiofrequency for 2 min each cycle with silent phases in between. Adequate pain relief was achieved with no complications postprocedure.

Syntropy - gastroesophageal reflux disease and ischemic heart disease - diagnostic methods and treatment tactics

Introduction. Studies describe chest pain as the common symptom for the association of gastroesophageal reflux disease (GERD) and coronary artery disease (ICD). Among the patients evaluated at the emergency department for chest pain >50% do not show signs of coronary ischemia and require further investigation. Materials and methods. The study was carried out by searching the articles that were published in the period 2016-2023, using the PubMed, NCIB, Medscape, Mendeley databases, using the keywords: „GERD”, „coronary artery disease”, „diagnosis” , „treatment”, as well as their association. Results. Both nosologies are clinically manifested by chest pain caused by gastrointestinal acid irritation, which activates the vagal reflex, and endothelial dysfunction, which causes ischemia and coronary vasoconstriction. Paraclinical findings are characterized by increased levels of IL1,6,8 and NO metabolites involved in disease pathogenesis. ECG and pH measurement for 24 h are sufficient at the first stage to determine the cause of attacks of recurrent chest pain. PPIs are the first line of treatment for chest pain relief in these patients. Conclusions. GERD and BCI represent diseases with a global impact, and the interdisciplinary therapeutic approach of these diseases, culminating in a targeted treatment program, determines the improvement of symptoms with an improvement of the patient’s quality of life.

Comparison of lumbar microdiscectomy and unilateral biportal endoscopic discectomy outcomes: a single-center experience.

Lumbar microdiscectomy (LMD) is still the gold-standard treatment for lumbar disc herniations with progressive neurological deficits that are refractory to conservative treatment. With improvement of endoscopic systems in recent years, endoscopic discectomy techniques have been developed as an alternative to LMD. The unilateral biportal endoscopic discectomy (UBE) technique is one of these endoscopic techniques, and its popularity has increased in recent years because it does not require high-cost specialized endoscopes, many microsurgical instruments are compatible with this system, and it is similar to LMD in terms of anatomical orientation. This study compared results between LMD and UBE techniques in patients with lumbar disc herniations performed by the same spine surgeons at a single center. The data of patients with lumbar disc herniation who were operated on with LMD and UBE techniques were retrospectively reviewed. The data obtained were statistically evaluated. The operative video of one of the patients who underwent UBE was edited for demonstration. Between January 2021 and June 2022, 93 patients were operated on for lumbar disc herniation. LMD was performed in 39 patients, and UBE was performed in 54 patients. There were no significant differences in the complications, recurrence, postoperative back and leg pain, patient satisfaction rates, and quality of life index results of the patients in the two groups. The operation time was shorter in the LMD group. In the UBE group, estimated blood loss was lower and postoperative hospitalization was shorter. Although LMD is still the gold-standard treatment for lumbar disc herniation, the results of UBE are comparable to those of LMD, and it may be a good alternative for spine surgeons who prefer minimally invasive surgery.

МАГНИТНО-РЕЗОНАНСНАЯ ТОМОГРАФИЯ СЕРДЦА В ДИАГНОСТИКЕ МИКСОМЫ ЛЕВОГО ПРЕДСЕРДИЯ

Abstract. Introduction. Left atrial myxoma is one of the most common benign cardiac tumors. Myxomas occur most frequently in people aged 30-60 years. This tumor is one of the most difficult to diagnose due to the different density of its structure. Aim. To present our own clinical case report on choosing the strategy of managing a patient with left atrial myxoma. Materials and Methods. Female patient N., 66 years old, was admitted to the Department of Cardiology at City Clinical Hospital 7, Kazan on a referral from the polyclinic with complaints of recurrent burning chest pain radiating to the left arm and occurring during physical exertion (walking up to 50-100 m), accompanied by dyspnea; increase in blood pressure up to 180/100 mm Hg, heart performance disorders, heart palpitations, dizziness, and high-blood- pressure-associated headaches. When writing this article, the authors used the patient’s source documents (her case history). The article details the current disease history, clinical manifestations, examination findings, and the approaches to choosing the patient management considering her age and clinical manifestations. Results and Discussion. Clinical manifestations of the disease set on in January 2023 with dyspnea occurring during accelerated walking and burning chest pain. Before her admission to City Clinical Hospital 7, heart pain syndrome had recurred. In view of the clinical manifestations of acute coronary syndrome, the patient was prescribed coronary angiography that detected multivessel coronary artery disease. Echocardiography detected congenital heart disease: Secondary atrial septal defect. Thrombus? Myxoma? in the left atrium cavity. Magnetic resonance imaging of the heart was performed to verify the diagnosis. This technique allowed us to determine her accurate diagnosis: Left atrium myxoma; atrial septal defect. Conclusions. Practitioners will need these data to choose the strategy of managing patients with left atrial myxoma

Open and Laparoscopic Surgical Approache in Incisional Hernias: A Descriptive Analysis.

Background: Incisional hernias, occurring in 10-20% of patients post-abdominal surgery, significantly affect patient quality of life and healthcare systems. This study analyses two hernia repair methods: laparoscopic intraperitoneal onlay mesh (IPOM) and open on-lay hernioplasty. Key analysis factors include operative time, postoperative pain, complications, length of hospital stay, recovery speed, and recurrence rates, with the goal of identifying the most effective and beneficial approach for patients. Methods: We conducted a retrospective study on 70 patients with postoperative parietal defects at the Dr Carol Davila Clinical Nephrology Hospital, Bucharest, from January 2018 to December 2021. Patients underwent either laparoscopic IPOM (42 patients) or open hernioplasty (28 patients) for uncomplicated incisional hernia repair. We analyzed demographic data, comorbidities, defect size and location, previous surgeries, and surgical outcomes. Results: The laparoscopic group had a slightly shorter operative time and significantly lower postoperative pain levels, as assessed by the Visual Analog Scale. The laparoscopic approach also resulted in shorter hospital stays and quicker return to routine activities. Complications, such as seroma and hematoma, were more common in the open surgery group, but no wound infections or prosthesis rejections were observed in either group. Notably, the open surgery group showed a higher recurrence rate (11 %) compared to none in the laparoscopic group within a one-year follow-up. Conclusion: Laparoscopic IPOM for incisional hernia repair shows benefits over open hernioplasty, with less pain, shorter hospitalization, faster recovery, and lower recurrence. Its growing preference and potential for further research are highlighted.

Rib pseudoarthrosis with thoracic outlet syndrome in pediatric gymnast: a case report

BackgroundThis case study evaluates the diagnosis and treatment of a 12 year old Caucasian male gymnast who had several diagnoses including an isolated first rib fracture, resultant pseudoarthrosis of the first rib, and the development of symptomatic thoracic outlet syndrome. We discuss the causes, prevalence, and suggestions for prompt diagnosis and treatment of these conditions in pediatric patients. Although all three conditions are rare in a child, this case highlights the importance of having a high clinical index of suspicion in recurrent pain in pre-pubertal athletes.Case presentationA 12 year old Caucasian male underwent several years of conservative treatment with physical therapy and rest without resolution of his left shoulder pain. He was subsequently diagnosed with pseudoarthrosis of the first rib and thoracic outlet syndrome, which was curative by surgical removal of the first rib, and allowed him to return to his baseline activity level.ConclusionsSince each of these diagnoses are rare, especially in the pediatric population, we aim to educate the medical community on the prompt diagnosis and treatment of these conditions.

Musculoskeletal physiotherapists' discharge practices for people treated with low back pain: A United Kingdom survey.

Persistent low back pain (LBP) is the leading cause of disability, and a major burden on the healthcare system globally. Many people with LBP experience recurrent pain flares and receive repeated appointments and re-referrals to services such as physiotherapy. However, it is not clear what the criteria are for discharging people with LBP from physiotherapy services. This study aims to describe the current practices for discharging people from physiotherapy for LBP in the United Kingdom (UK). A cross-sectional study using an anonymous online national (UK) survey was conducted among qualified physiotherapists who treat people with LBP in UK musculoskeletal out-patient services. A total of 104 surveys were completed. The majority of respondents reported using (i) a shared decision-making (77%) and (ii) person-physiotherapist goal attainment (74%) approach to discharging people with LBP. Sixty-three percent of respondents reported using a patient-initiated follow-up (PIFU) approach. Only 8% of respondents reported using a graded discharge approach with 'booster' appointments. A PIFU or graded discharge approach was considered most pertinent for people at higher risk of a pain flare (97%; 86%) and with low self-efficacy to self-manage their LBP. This UK survey established that discharge practices for people with LBP after physiotherapy vary. Whilst the majority of people are currently discharged with a PIFU appointment, a graded discharge approach may be more beneficial for people who are less likely to initiate a PIFU appointment. Further consideration on the development of such a pathway is now required.

Comparison of Open Lichtenstein Repair and Laparoscopic Transabdominal Preperitoneal of Inguinal Hernia: A Pragmatic RCT in Bangladesh

Background: Laparoscopic inguinal hernia repair has emerged as an effective alternative to open Lichtenstein mesh repair for inguinal hernias. Objective: The purpose of the present study was to compare the surgical outcomes of laparoscopic trans-abdominal pre-peritoneal (TAPP) and open Lichtenstein mesh repair for the treatment of inguinal hernia. Methodology: This single centered, pragmatic randomized controlled trial was conducted in the Department of Surgery at 300 bed hospital, Narayanganj, Bangladesh from January 2018 to June 2020 for a period of two and half year. Patients who were presented with reducible, primary/recurrent, complete/incomplete inguinal hernias among male and female in more than or equal to 18 years of age were selected as study population. Lichtenstein mesh repair was performed which was compared with the laparoscopy group. Open Lichtenstein repair was done under spinal anesthesia with lightweight poly propylene mesh. Laparoscopy was performed by trans-abdominal pre-peritoneal (TAPP) technique under general anesthesia and heavy weight mesh was used. The hospital stay, operating time, post-operative complications like superficial wound infection, seroma formation, scrotal swelling as well as early recurrence and chronic groin pain were compared among these group. Results: A total number of 90 patients presented with inguinal hernia were recruited for this study of which TAPP was performed in 25 cases and 65 cases were undergone Lichtenstein repair. The mean age of laparoscopy and open group of patients were 49.28±9.9 years and 55.05±14.4 years respectively (p-0.03). The mean operation time was 85±10.31 minutes and 52.1±15.36 minutes in laparoscopy and open group respectively (p-0.000). The mean post-operative hospital stay was 2.9±0.78 days and 2.9±0.71 days in laparoscopy and open group respectively (p-0.94). In this study 21 (23.3%) patients developed 25 different early and late post-operative complications, out of which 15 (23.1%) in open group and 06 (23.3%) in laparoscopy group (p-0.52). One early recurrence was reported after 6 months follow up in laparoscopy group. Chronic groin pain was reported in 7 cases of which 5 (7.7%) cases in open group and only 2 (8.0%) cases in laparoscopy group (p-0.002). Conclusion: In conclusion the surgical outcomes of laparoscopic TAPP performed by a young surgeon in Bangladesh has given a clinically better result than open Lichtenstein repair considering hospital stay, seroma formation, wound infection, scrotal swelling and chronic groin pain. Journal of Current and Advance Medical Research, January 2023;10(1):35-40

Ghosal Hematodiaphyseal Dysplasia: Implications of Late Diagnosis and Unusual Presentation in Adults

Ghosal Hematodiaphyseal Dysplasia (GHDD) is a rare autosomal recessive disorder characterized by bone modeling failure, resulting in thickening of bone cortices with predominant diaphyseal involvement and responsive anemia to steroids. Late diagnosis of GHDD in adulthood can lead to significant morbidity and suboptimal response to steroids. Moreover, GHDD often mimics more common hematological disorders like myelodysplastic syndrome and myelofibrosis, leading to treatments such as transfusions, splenectomy, and hematopoietic stem cell transplantation. Early diagnosis is critical to enable the patient to receive the appropriate treatment. We present a case series of three Indian patients from different families with genetically proven GHDD. Despite experiencing symptoms from early childhood, all patients were diagnosed in adulthood. None of them were born out of a consanguineous marriage . Two of them, aged 43 and 56, are the oldest reported GHDD patients to date. They initiated steroid treatment in their 5th and 6th decades of life, respectively. Unlike previously reported cases, these two patients required additional drugs like Thalidomide along with steroids, and their response to treatment was not as rapid. The first patient, a 43-year-old male, had a history of anemia since childhood and became transfusion dependent after 15 years of age. He developed bicytopenia and later pancytopenia with hypocellular bone marrow , along with splenohepatomegaly and extramedullary hematopoiesis in the paravertebral and presacral areas, a novel finding in GHDD cases. Whole exome sequencing revealed a missense mutation in the TBXA2 gene. The second patient, a 56-year-old male, had a history of anemia since childhood and underwent splenectomy at 46 due to massive splenomegaly and transfusion dependency. However, his transfusion dependency persisted, and bone marrow biopsy suggested myelofibrosis. However he was negativefor myeloid mutations including JAK2. Subsequently, genetic testing revealed a homozygous missense mutation in the TBXAS1 gene. He also developed paraplegia and bladder incontinence, attributed to extramedullary hematopoiesis, which improved with steroid treatment The third patient a 23 year old man with history of anemia, lower limb tenderness and ecchymosis at 14 months of age. Evaluation then had shown hyperostosis of diaphysis of long bones of lower limbs with sparing of metaphysis and bicytopenia. Was on regular transfusions till 9 years. Re-evaluation with bone marrow studies at 9 years revealed a varying cellular marrow with dysplastic megakaryocytes and diagnosed as pediatric myelodysplatic syndrome ,He was on steroids till 13 years and he did not require further transfusions.He stopped steroids for 1 year following which there was a fall in Hb levels and recurrence of pain in both lower limbs with inability to squat. In view of history of steroid responsive anemia and thickening of diaphysis in X-rays GHDD was suspected and confirmed by genetic testing. He was restarted on steroids and there was a good response to steroids within 4 week with normalisation of hemoglobin levels . Late diagnosis of GHDD in adulthood can lead to severe complications and suboptimal treatment response. These cases highlight the importance of early diagnosis to prevent unnecessary interventions and improve patient outcomes. Unusual presentations, like extramedullary hematopoiesis, can further complicate the diagnostic process. Clinicians should maintain a high index of suspicion for GHDD in cases of refractory anemia or myelofibrosis-like features, especially in adults with an earlier history of anemia. Early recognition and appropriate management are crucial to mitigate morbidity and improve patients' quality of life

Concomitant percutaneous coronary intervention and transcatheter aortic valve replacement for aortic stenosis complicated with acute STEMI: a case report and literature review

Aortic stenosis (AS) complicated with acute ST-segment elevation myocardial infarction (STEMI) is a life-threatening emergency with high mortality. A 75-year-old male patient attended the emergency department of Wuhan Asia Heart Hospital in December 2021 with chest pain for 2 days and exacerbation for 1 h. The electrocardiogram (ECG) indicated atrial fibrillation with rapid ventricular response and ST-segment depression. Echocardiography showed severe AS and mild/moderate aortic insufficiency. The patient refused coronary angiography and further invasive procedures and then requested discharge, but he had recurrent chest pain on the third day. The ECG showed an extensive anterior wall STEMI. During preoperative preparation, he suffered from cardiogenic shock (CS). Concomitant percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) was performed, but he died of CS and multiple organ failure 4 days after surgery. Patients with AS and STEMI might be susceptible to CS during perioperative period of concomitant PCI and TAVR, which requires proactive prevention.

Perception of Nutrition in Adults with Sickle Cell Disease: Concept Elicitation of Nutritional Status and the Mini Nutrition Assessment

Introduction Sickle Cell Disease (SCD) is a genetic disorder that causes recurrent vaso-occlusive pain events, functional impairment, and nutritional deficiencies due to increased metabolic demands. Prior studies have highlighted nutritional issues in people with SCD, such as micronutrient and macronutrient deficiencies, low body mass index (BMI), and a recent rise in obese adults with SCD. In older adults in the general population, evaluation and management of nutritional status is essential since malnutrition can weaken the immune system and increase the risk of hospitalization and death. Despite the importance of nutrition, little is known about the best way to evaluate nutritional status in older adults with SCD. To identify a relevant yet efficient method to evaluate nutritional status, we conducted content elicitation interviews to describe how younger and older adults conceptualized nutrition. Based on the content of the interviews, we piloted a brief nutritional survey called the Mini Nutritional Assessment (MNA); a common nutritional measure in geriatric assessments. Methods As standard practice for concept elicitation, we conducted semi-structured interviews with adults SCD in 4 separate focus groups: two groups of young adults age 18-39 and two groups of older adults age ≥ 40 years. Participants were asked about their perception of the construct of nutrition as part of a longer concept elicitation interview assessing the content validity of the Sickle Cell Disease Functional Assessment (SCD-FA), which is the geriatric assessment for adults with SCD. After focus group transcripts were analyzed using rapid qualitative analysis, we administered the MNA to a separate cohort of adults with SCD, since its content on macronutrients and hydration was consistent with how adults with SCD conceptualized nutrition. The scores on the 6-item MNA-Short Form (MNA-SF) range from 0 to 14 with higher scores indicating better nutritional status. Scores 12-14 indicate a normal nutritional status, 8-11 indicate at risk for malnutrition, and 0-7 indicate a malnourished state. Results The 4 focus group interviews included 6 younger adults (age 18-39) and 8 older adults (age ≥ 40 years) with SCD. Participants were 57% females and 79% had severe SCD genotype (HbSS or HbSβnull-thalassemia). In the focus groups, participants described a healthy diet as one that included the major food groups, which were generally defined as protein, fruits and vegetables, and starches/carbs. The majority discussed the importance of adequate hydration to reduce the risk of pain crises. Additionally, participants reported trying to substitute water for soda, juice, and caffeine containing beverages. Many participants stated that a healthy diet involved limited processed foods and sugars. Despite knowledge of the characteristics of a “healthy” diet, some participants expressed difficulty maintaining this diet. Based on these qualitative results, we selected the MNA to evaluate nutrition since it included items on hydration and assessed intake of various food groups as described by focus group participants. We administered the MNA-SF to a cohort of 88 adults with SCD and 81 had complete data to score the MNA-SF. The mean score for the MNA-SF for all participants was 11.7 ± 1.8 (younger adults 11.6 ± 1.9 and older adults 11.9 ± 1.8; p= 0.44). The MNA-SF identified 40% (n=34) as being at risk of malnutrition [36% of older adults and 46% younger adults]. Two participants were identified as being malnourished (1 younger and 1 older adult). On remaining MNA items (Table 1), 25% of participants reported decreased food intake with 17% having only 1 meal/day. Most participants (85%) consumed ≥ 1 serving of protein/day and 75% had ≥ 2 servings of fruits or vegetables/day. Most participants (68%) drank > 5 cups of water/day. Results were similar for younger and older adults with SCD. Conclusion Data from the focus group interviews revealed that BMI and unintentional weight loss measures alone did not comprehensively capture how people with SCD perceived the concept of nutrition. Incorporating the MNA-SF enhanced measurement of the nutritional domain in the SCD-FA by capturing data on food intake and hydration. In future studies we will assess the construct validity of the full MNA in a larger sample to identify older adults with SCD who would benefit most from nutritional interventions.

Personalized Exercise Intervention for Older Adults with Sickle Cell Disease: The Sicklefit Study

Background Older adults with sickle cell disease (SCD) (defined as age ≥ 40 years) experience both SCD and age-related conditions such as recurrent pain episodes, avascular necrosis of the joints, and cardiopulmonary disease that can result in accelerated functional decline. Individuals with SCD experience vaso-occlusive events that lead to reduced oxygen delivery to organs such as bones, muscles, and lungs. Due to these unique risk factors, existing generic exercise programs may be too intense– and even detrimental– for older adults with SCD. Gerofit is a supervised exercise program designed for veterans age ≥ 65 years with chronic disease and/or impaired mobility that has been shown to improve physical function, mental health, quality of life, and survival. The purpose of the study is a pilot evaluation of the feasibility and safety of SickleFit, an exercise training program for older adults with SCD adapted from Gerofit. Methods SickleFit is a group exercise program held on Zoom 3 days a week and includes a safety check in, warm-up, cardio segment, strength training, flexibility, balance, and mindfulness. Our primary endpoint is feasibility measured by proportion of participants attending at least 50% of the sessions over 6 weeks. The secondary outcomes are safety and acceptability. We measured safety as the number of moderate or severe adverse events within 48 hours after each exercise session. Acceptability was measured as the proportion of participants reporting the intervention as satisfactory. Exploratory outcomes were changes in physical performance in a battery of physical assessments including: Usual Gait Speed, 6 Minute Walk Distance (6MWD), Plank duration, Timed Up-and-go (TUG), Seated Grip Strength, Weight, and Neck Circumference. Results Cohort 1 consisted of 2 male (aged 55 and 66 both with SS genotype) and 2 female participants (aged 43 and 53 with Beta + Thalassemia and SS genotype). All 4 participants met the feasibility endpoint of attending at least 50% of exercise sessions, with a mean attendance of 83%. The majority of absences were due to schedule conflicts (2), property maintenance (2), and general malaise (4). Over a third of the missed sessions were due to minor (2) or major (3) adverse events unrelated to the intervention (motor vehicle incident, work-related injury). There were no major or life-threatening adverse events as a result of the exercise intervention. Minor adverse events related to exercise were knee, shoulder, and back soreness and pain. All participants responded as either ‘Pleased’ (50%) or ‘Delighted’ (50%) with the program on the acceptability survey. In addition, all participants saw a positive increase in their performance of the Usual Gait Speed, TUG, 6MWD, and plank duration. Minor improvement in grip strength was seen in 3 participants, but a slight loss in grip strength occurred in one individual whom also lost the most weight. While no significant change occurred in the BMI of the participants, a reduction in neck circumference did occur. Conclusion In cohort 1, we found that the SickleFit exercise program is feasible, acceptable, and safe for older adults with SCD. Participants demonstrated improvements in Usual Gait Speed, TUG, 6MWD, and plank duration, among other physical metrics. Participants expressed satisfaction in the program and a desire to continue in the program, even after the program ended. Based on patient feedback, The Sicklefit program is being optimized further to better meet the needs of older adults with SCD. Optimizations include shortening of the cardio section for the initial weeks of the program, dedicating more time to discussing the biomechanics and form involved in the exercises, integration of more ground-based and vertical pulling patterns with resistance bands, and adding further diversity in the movement practices included in the sessions.

SPECT/CT and PET/CT for the Evaluation of Persistent or Recurrent Pain After Spine Surgery: A Systematic Review and Case Series

ObjectiveThe differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery. MethodsA systematic review was conducted according to PRISMA guidelines across 5databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies. ResultsA total of 2444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine. ConclusionsPET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging.

Surgical Treatment of Posterolateral Rotational Instability of the Elbow: a Systematic Review

Posterolateral rotational instability (PLRI) of the elbow joint can occur acutely as a result of dislocation of the bones of the forearm, and also be chronic, for example, after inadequate healing of a previous rupture of the lateral ligamentous complex, in particular the lateral ulnar collateral ligament (LUCL). It is necessary to take into account that, as a result of repeated microtraumas, persistent pain syndrome and recurrence of dislocation develop, which can lead to disability. We conducted a systematic review of the literature according to the protocol outlined in the PRISMA guidelines. From 1,903 publications, 11 studies were selected that met our criteria and assessed the results of treatment of 181 patients. The main reason for the development of PLRI was simple traumatic dislocation of the forearm bones (37.5%). Of the studies that assessed the elbow joint using the MEPS, 86.5% of patients had excellent or good results, with a mean MEBS score of 91 points. Before surgery, pain syndrome was present in 131 patients (87.3%) out of 150, and in the postoperative period it was observed in 55 (36.6%) out of 150 (p=0.01). The incidence of recurrent instability after surgery was observed in 6.6% of patients. A review of the literature on the problem of the elbow joint shows that this problem has not been fully studied, treatment strategies differ and should be performed based on the surgeon’s experience and available data, however, it has been proven that the key to the stability of the elbow joint is the LUCL, which requires its restoration through its refixation or plastic surgery.