Implantable Pulse Generator Site May Be Associated With Spinal Cord Stimulation Revision Surgeries

BackgroundThe use of implantable pulse generators (IPG) for spinal cord stimulation (SCS) in patients with chronic pain has been well established. Although IPG-related complications have been reported on, the association between IPG site and SCS complications has not been well studied.ObjectiveTo investigate whether IPG placement site in buttock or flank is associated with SCS complications and, hence, revision surgeries.MethodA retrospective cohort study was performed that included 330 patients (52% female) treated at a single institution who underwent permanent implantation of an SCS system between 2014 and 2018. Patients ranged between 20 and 94 years of age (mean: 57.54 ± 13.25). Statistical analyses were conducted using IBM SPSS Statistics. Tests included independent samples t test, chi-square test, Mann–Whitney U test, Spearman’s rank correlation coefficient, and logistic regression.ResultsThere was a total of 93 revision surgeries (rate of 28%), where 71 out of 330 patients (rate of 21.5%) had had at least one revision surgery. Univariate tests demonstrated a significant association between IPG site and revision surgeries (p = 0.028 [chi-square test] and p = 0.031 [Mann–Whitney U test]); however, multivariate logistic regression demonstrated that neither IPG site was more likely than the other to require revision surgeries (p = 0.286).ConclusionAlthough this study found a significant association between IPG site and revision surgeries, the effect of IPG site was not found to be predictive. The IPG site likely influences whether a patient will require revision surgery, but further investigation is required to establish this association.     

术中目标导向液体治疗在腹膜后巨大恶性肿瘤切除术患儿中的应用

目的:探讨基于脉压变异度（PPV）的目标导向液体治疗（GDFT）在腹膜后巨大恶性肿瘤切除术患儿中的应用。方法:择期行腹膜后巨大恶性肿瘤切除术患儿64例，年龄0.5~3岁，ASA Ⅱ-Ⅲ级。随机将患儿分为目标导向液体治疗组（G组）和常规液体治疗组（C组），每组32例。G组以PPV为指导，根据GDFT方案进行液体管理，C组采用常规液体管理。记录手术开始（T1）、手术开始后1 h（T2）、手术结束（T3）的MAP、CVP、PPV、Lac值、TNF-α、IL-6浓度。记录术中输注晶体液量、胶体液量、液体总量、出血量、尿量、手术时间、多巴胺使用率以及排气时间、术后住院时间和恶心呕吐发生率。结果:G组输注晶体液量显著少于C组（P＜0.05），而输注胶体液量显著多于C组（P＜0.05）。两组术中输注液体总量、出血量、尿量与多巴胺使用率方面差异无统计学意义。T2、T3时刻，G组PPV、TNF-α、IL-6显著低于C组（P＜0.05），而两组间MAP、CVP、Lac在各时点差异无统计学意义。G组术后排气时间明显短于C组（P＜0.05），而在术后恶心呕吐发生率和住院时间方面两组差异无统计学意义。结论:PPV指导的GDFT可以应用于腹膜后巨大恶性肿瘤切除术患儿，能维持其血流动力学稳定，减少炎症因子IL-6、TNF-α释放，促进胃肠功能恢复，但对术后转归无明显影响。     

Neurovascular-modulation: A review of primary vascular responses to transcranial electrical stimulation as a mechanism of action

BackgroundThe ubiquitous vascular response to transcranial electrical stimulation (tES) has been attributed to the secondary effect of neuronal activity forming the classic neurovascular coupling. However, the current density delivered transcranially concentrates in: A) the cerebrospinal fluid of subarachnoid space where cerebral vasculature resides after reaching the dural and pial surfaces and B) across the blood-brain-barrier after reaching the brain parenchyma. Therefore, it is anticipated that tES has a primary vascular influence.ObjectivesFocused review of studies that demonstrated the direct vascular response to electrical stimulation and studies demonstrating evidence for tES-induced vascular effect in coupled neurovascular systems.ResultstES induces both primary and secondary vascular phenomena originating from four cellular elements; the first two mediating a primary vascular phenomenon mainly in the form of an immediate vasodilatory response and the latter two leading to secondary vascular effects and as parts of classic neurovascular coupling: 1) The perivascular nerves of more superficially located dural and pial arteries and medium-sized arterioles with multilayered smooth muscle cells; and 2) The endothelial lining of all vessels including microvasculature of blood-brain barrier; 3) Astrocytes; and 4) Neurons of neurovascular units.ConclusionA primary vascular effect of tES is highly suggested based on various preclinical and clinical studies. We explain how the nature of vascular response can depend on vessel anatomy (size) and physiology and be controlled by stimulation waveform. Further studies are warranted to investigate the mechanisms underlying the vascular response and its contribution to neural activity in both healthy brain and pathological conditions – recognizing many brain diseases are associated with alteration of cerebral hemodynamics and decoupling of neurovascular units.     

Concurrent conventional & high-definition transcranial direct current stimulation for treatment of schizophrenia with co-morbid obsessive-compulsive disorder: A case report

Non-invasive brain stimulation techniques such as conventional transcranial direct current stimulation (tDCS) and high definition tDCS (HD-tDCS) are increasingly being used as add-on treatment options in schizophrenia and obsessive-compulsive disorder (OCD). This is reporting of the use of a novel accelerated, symptom-specific, add-on tDCS (combining conventional and high definition) protocol in a patient with both schizophrenia and OCD. The intervention showed clinical utility by reducing both schizophrenia and OCD symptoms.     

Could non-HDL-cholesterol be a better marker of atherogenic dyslipidemia in obstructive sleep apnea?

Background/objectiveObstructive sleep apnea (OSA) is independently associated with dyslipidemia, a surrogate marker of atherosclerosis. Low-density lipoprotein (LDL)-cholesterol is accepted as a major independent risk factor for cardiovascular disease. However, non-high-density lipoprotein (HDL)-cholesterol is a better marker of atherogenic dyslipidemia and recommended as a target of lipid lowering therapy. We aimed to assess the prevalence of atherogenic dyslipidemia, and relationship between OSA severity and serum LDL-cholesterol and non-HDL cholesterol levels in OSA patients.MethodsWe retrospectively evaluated treatment naïve 2361 subjects admitted to the sleep laboratory of a university hospital for polysomnography. All subjects’ lipid profile including total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, and non-HDL-cholesterol were measured.ResultsOut of 2361 patients (mean age 49.6 ± 11.9 years; 68.9% male, apnea-hypopnea index 36.6 ± 28.4/h), 185 (7.8%) had no OSA and 2176 (92.2%) had OSA. Atherogenic dyslipidemia prevalence was high (57–66%) in OSA patients, and especially increased in severe OSA compared to other groups (p < 0.05). Though total and LDL-cholesterol did not differ between those with and without OSA, non-HDL-cholesterol (p = 0.020), and triglycerides (p = 0.001) were higher and HDL-cholesterol levels (p = 0.018) were lower in OSA patients than non-OSA. Non-HDL-cholesterol was significantly correlated with OSA severity (p < 0.001) and hypoxia parameters (p < 0.01), whereas LDL-cholesterol showed no correlation.ConclusionsAtherogenic dyslipidemia is highly prevalent and non-HDL-cholesterol levels are significantly increased, predominantly in severe OSA patients. Non-HDL-cholesterol but not LDL-cholesterol, is significantly correlated with OSA severity and hypoxia parameters. Therefore, it could be better to use non-HDL-cholesterol, which is a guideline recommended target of lipid therapy, as a marker of atherosclerotic cardiovascular risk in OSA patients.     

The effect of patient ethnicity on the accuracy of peripheral pulse oximetry in patients with COVID-19 pneumonitis: a single-centre,retrospective analysis

Pulse oximetry is used widely to titrate oxygen therapy and for triage in patients who are critically ill. However, there are concerns regarding the accuracy of pulse oximetry in patients with COVID-19 pneumonitis and in patients who have a greater degree of skin pigmentation. We aimed to determine the impact of patient ethnicity on the accuracy of peripheral pulse oximetry in patients who were critically ill with COVID-19 pneumonitis by conducting a retrospective observational study comparing paired measurements of arterial oxygen saturation measured by co-oximetry on arterial blood gas analysis (SaO₂) and the corresponding peripheral oxygenation saturation measured by pulse oximetry (S_pO₂). Bias was calculated as the mean difference between SaO₂ and S_pO₂ measurements and limits of agreement were calculated as bias ±1.96 SD. Data from 194 patients (135 White ethnic origin, 34 Asian ethnic origin, 19 Black ethnic origin and 6 other ethnic origin) were analysed consisting of 6216 paired SaO₂ and S_pO₂ measurements. Bias (limits of agreement) between SaO₂ and S_pO₂ measurements was 0.05% (−2.21–2.30). Patient ethnicity did not alter this to a clinically significant degree: 0.28% (1.79–2.35), −0.33% (−2.47–2.35) and −0.75% (−3.47–1.97) for patients of White, Asian and Black ethnic origin, respectively. In patients with COVID-19 pneumonitis, S_pO₂ measurements showed a level of agreement with SaO₂ values that was in line with previous work, and this was not affected by patient ethnicity.     

Balloon Pulmonary Angioplasty for the Treatment of Nonoperable Chronic Thromboembolic Pulmonary Hypertension: Single-Center Experience with Low Initial Complication Rate

PurposeTo evaluate the safety and efficacy of balloon pulmonary angioplasty (BPA) for nonoperable chronic thromboembolic pulmonary hypertension (CTEPH) patients during the initial experience of a single center.MethodsA total of 18 CTEPH patients (5 with residual pulmonary hypertension after pulmonary endarterectomy) were treated with BPA during the period 2014–2018 and were retrospectively reviewed. Mean age was 61 ± 19 years; 55% were female; mean pulmonary artery pressure was 44 ± 12 mmHg; cardiac output was 4.3 ± 1.0 l/min; and pulmonary vascular resistance was 8.4 ± 3.6 WU. Patients were evaluated by New York Heart Association functional class, 6-minute walk distance, N-terminal pro b-type natriuretic peptide, echocardiography, right heart catheterization, and before and after completions of BPA.ResultsA total of 91 procedures were performed, with a median number of 4 BPA sessions per patient (range, 2–8). There were no deaths or major complications requiring extracorporeal support or (non)invasive ventilation. The most common complication was self-limiting hemoptysis (3%). According to Society of Interventional Radiology classification, 4 mild, 4 moderate, and 1 severe adverse events were noted. Invasive hemodynamics significantly improved, with a cardiac index increase of 15% (P = .0333), decrease of mean pulmonary artery pressure of 30% (P = .0013), and decrease of pulmonary vascular resistance of 45% (P = .0048). Stroke volume index (P = .0171) and pulmonary arterial compliance (P = .0004) were also significantly enhanced.ConclusionsBPA significantly improves cardiopulmonary hemodynamics with an acceptable safety profile. Further studies assessing the long-term efficacy of BPA are required.     

Bayesian adaptive lasso for additive hazard regression with current status data

Variable selection is a crucial issue in model building and it has received considerable attention in the literature of survival analysis. However, available approaches in this direction have mainly focused on time-to-event data with right censoring. Moreover, a majority of existing variable selection procedures for survival models are developed in a frequentist framework. In this article, we consider additive hazards model in the presence of current status data. We propose a Bayesian adaptive least absolute shrinkage and selection operator procedure to conduct a simultaneous variable selection and parameter estimation. Efficient Markov chain Monte Carlo methods are developed to implement posterior sampling and inference. The empirical performance of the proposed method is demonstrated by simulation studies. An application to a study on the risk factors of heart failure disease for type 2 diabetes patients is presented.     

Excitability of motor and sensory axons in multifocal motor neuropathy

ObjectiveTo assess excitability differences between motor and sensory axons of affected nerves in patients with multifocal motor neuropathy (MMN).MethodsWe performed motor and sensory excitability tests in affected median nerves of 20 MMN patients and in 20 age-matched normal subjects. CMAPs were recorded from the thenar and SNAPs from the 3rd digit. Clinical tests included assessment of muscle strength, two-point discrimination and joint position.ResultsAll MMN patients had weakness of the thenar muscle and normal sensory tests. Motor excitability testing in MMN showed an increased threshold for a 50% CMAP, increased rheobase, decreased stimulus-response slope, fanning-out of threshold electrotonus, decreased resting I/V slope, shortened refractory period, and more pronounced superexcitability. Sensory excitability testing in MMN revealed decreased accommodation half-time and S2-accommodation and less pronounced subexcitability. Mathematical modeling indicated increased Barrett-Barrett conductance for motor fibers and increase in internodal fast potassium conductance for sensory fibers.ConclusionsExcitability findings in MMN suggest myelin sheath or paranodal seal involvement in motor fibers and, possibly, paranodal detachment in sensory fibers.SignificanceExcitability properties of affected nerves in MMN differ between motor and sensory nerve fibers.     

超脉冲CO2点阵激光联合PRP治疗面部痤疮凹陷性瘢痕疗效分析

目的:探究超脉冲CO2点阵激光联合富血小板血浆(PRP)治疗面部痤疮凹陷性瘢痕的疗效。方法:72例面部痤疮凹陷性瘢痕患者,随机分为观察组(36例)和对照组(36例)。对照组采用超脉冲CO2点阵激光治疗,观察组采用超脉冲CO2点阵激光联合PRP治疗。比较两组患者的灰度差异、时间指标、瘢痕程度、疼痛、不良反应及视觉评估。结果:观察组的并发症发生率为11.11%,低于对照组的36.11%,差异具有统计学意义(P<0.05)。治疗后,两组患者的灰度差异率均减小,且观察组患者的灰度差异率显著低于对照组,差异具有统计学意义(P<0.05)。治疗后,观察组的炎性渗出时间、红肿时间、愈合时间、停工时间及瘢痕程度评分均低于对照组,差异均具有统计学意义(P<0.05);但疼痛度评分组间比较,差异无统计学意义(P>0.05)。结论:超脉冲CO2点阵激光联合PRP治疗面部痤疮凹陷性瘢痕效果较好,可有效降低瘢痕程度,减少治疗时间及并发症的发生,帮助患者迅速回归正常工作与生活,值得临床推广使用。