Spinal Cord Stimulator (SCS) Placement: Examining Outcomes Between the Open and Percutaneous Approach

BackgroundSpinal cord stimulator (SCS) placement has been gaining traction as an approach to modulate pain levels for several different chronic pain conditions. This procedure can be performed via a percutaneous or open approach. Data regarding SCS complications are relatively limited.ObjectiveThe purpose of this study was to leverage a large national database to examine outcomes between the percutaneous and open SCS placement approaches. Outcomes in this study include length of stay (LOS), complication rates, reoperation rates, and 1-year readmission rates.Materials and MethodsInclusion criteria for the current study is SCS placement between 2015 and 2020, with receipt of an SCS using either a percutaneous approach or an open laminectomy based approach. Encounters included were limited to true SCS placement, such that trial placements were not included in the study. Univariate statistics and multivariable logistic regression was performed to compare outcomes between cohorts.ResultsTotal SCS case volumes were 9935 between the percutaneous (n = 4477, 45.1%) and open (n = 5458, 54.9%) approach. Patients receiving the percutaneous approach were found to have a mean decrease in LOS of 9.91 hours when compared to those receiving the open approach. The percutaneous approach was significantly associated with the need for reoperation within one year compared to the open approach (odds ratio [OR]: 0.663, p < 0.001), as well as with the need for readmission within 30 days (51.2% vs 40.2%, OR: 0.759, p < 0.001).ConclusionThe open approach, when compared to the percutaneous approach, had a longer mean LOS, lower outpatient discharge rates, and higher odds of experiencing an operative complication in comparison to the percutaneous approach. The percutaneous approach had relatively increased odds of thirty-day readmission, although no significant difference in one-year readmission or removal was demonstrated.     

A Randomized Trial of Specialty Mental Health Probation: Measuring Implementation and Effectiveness Outcomes

Although the research on specialty mental health probation (SMHP) is promising, there have been no randomized controlled trials (RCT) of the prototypical model advanced in the research literature and little focus on SMHP implementation. This study assesses the adoption of SMHP in two counties and examines its impact on mental health and criminal justice outcomes. Researchers conducted a RCT within a hybrid implementation-effectiveness study to examine intervention adoption as well as mental health treatment engagement and criminal justice outcomes for 100 individuals with serious mental illnesses on probation in one rural and one urban county in a southeastern state. Randomization produced equivalent treatment (n?=?47) and control (n?=?53) groups with no statistically significant differences between groups on demographic or background characteristics. Compared to standard probation officers, SMHP officers addressed the mental health needs of individuals with serious mental illness (i.e., adoption) at higher rates (p?<?0.001). Compared to individuals on standard caseloads, individuals on SMHP had a higher rate of mental health engagement (e.g., mental health assessment, attending treatment appointment; p?<?0.050); however, more individuals on SMHP caseloads had a new crime violation during follow-up compared with individuals on standard caseloads (p?<?0.01). In conclusions, results suggest successful adoption of the intervention and increased mental health engagement among those on SMHP caseloads. Results are consistent with the mixed findings on the impact of SMHP on improving criminal justice outcomes.

     

Influence of Contralateral Carotid Occlusion on Outcomes After Carotid Endarterectomy: A Meta-Analysis

Background

There is a controversy about whether the contralateral carotid occlusion (CO) in patients undergoing carotid endarterectomy (CEA) is associated with worse early and long-term outcomes. The aim of this systematic review and meta-analysis was to investigate the impact of CO on outcomes after CEA.

Rabbit fibrin: Characterization of the separated chains

In preparation for studies of the time course of production $\text{in vivo}$ of the constituent chains of rabbit fibrin, we characterized the structural features of the fibrin molecule. Fibrin was isolated from plasma and reduced and alkylated. The α, β, and γ chains were separated by CM-cellulose chromatography and their molecular weights and amino acid compositions were determined. The γ chain was sequenced 36 steps with 32 positive identifications and the β chain, 12 steps with 12 identifications. No major differences between the sequences of these chains and those of man, chicken, and dog were noted.     

Multiple Program Spinal Cord Stimulation in the Treatment of Chronic Pain: Follow-Up of Multiple Program SCS

Objective. Follow-up of 80 patients using multiple program spinal cord stimulation (SCS). Methods. For 30 months, we followed 80 chronic pain patients who had undergone SCS implantations at our center. Thirty-six patients had Failed Back Surgery Syndrome (FBSS). Patients were evaluated in patient-controlled stimulation mode (patients can select one of several specific programs in response to their activities and pain level). We collected visual analog pain scores, patient satisfaction scores, pain maps, and paresthesia maps. Results. We previously reported our preliminary findings (Neuromodulation 1998;1 :30–45). At 24 months all patients were using more than one program. At 30 months, 62 patients (76%) were using more than two programs as their preferred stimulation mode and three patients (4%) were satisfied with only one stimulation program. At 30 months all patients chose patient-controlled stimulation as their preferred mode of stimulation. A total of 18 patients (23%) were explanted. Mean pain scores declined from 8.2 at baseline to 4.8 (p < 0.05, n= 79). Paresthesia overlap was 91% (n= 79). Of the patients with FBSS, 81% reported that they were using their SCS daily. Conclusions. In spinal cord stimulation the use of multiple electrodes and multiple stimulation programs, together with advanced programmability, increases paresthesia overlap, reduces pain scores, and may improve patient satisfaction with SCS therapy. This study indicates a significant patient preference for multiple program SCS, if patients are given the option to choose between a single program SCS system or a multiple program SCS system.     

Down and out in the city: the homeless mentally ill

The plight of the homeless in New York City and other urban areas has become the focus of increasing attention. In an effort to clarify and understand the problems of the homeless, the authors studied the demographic characteristics, psychiatric diagnoses, histories, and dispositions of 100 homeless patients treated at Bellevue Psychiatric Hospital's emergency service. The most striking finding was that 96.6 percent of the sample had had a previous psychiatric hospitalization. Seventy-two percent of these homeless patients were diagnosed as suffering from schizophrenia; the second most common diagnosis was personality disorder, which accounted for 13.3 percent of the sample. The authors discuss other demographic findings of their study and explore the roots of the problem of homelessness, review the psychiatric literature on the subject, and delineate some of the unique treatment needs of this population.     

Brief Report: Sentencing Outcomes for Offenders on the Autism Spectrum

Journal of Autism and Developmental Disorders - Although people diagnosed with autism spectrum disorder (ASD) are not more likely to commit crimes, they are overrepresented in the criminal justice...     

Depression in Down syndrome: a review of the literature

Background

Depression has been frequently reported in individuals with Down Syndrome (DS). The aim of this article is to provide a comprehensive, critical review of the clinically relevant literature concerning depression in DS, with a focus on epidemiology, potential risk factors, diagnosis, course characteristics and treatment.

Methods

We searched the PUBMED database (January 2011) using the keywords (“Depressive Disorder [MESH]” OR “Depression [MESH]” OR “depress* [All Fields]”) AND (“Down Syndrome [MESH]” OR “Down syndrome [All Fields]” OR “Down's syndrome [All Fields]”). Review articles not adding new information, single case reports and papers focusing on subjects other than depression in DS were excluded.

Results

The PUBMED search resulted in 390 articles, of which 30 articles were finally included. Recent information does not support earlier suggestions of an increased prevalence of depression in DS compared to other causes of Intellectual Disability (ID). However, individuals with DS show many vulnerabilities and are exposed to high levels of stressors that could confer an increased risk for the development of depression. Apart from general risk factors, several potential risk factors are more specific for DS, including smaller hippocampal volumes, certain changes in neurotransmitter systems, deficits in language and working memory, attachment behaviours and frequently occurring somatic disorders. Protective factors might play a role in reducing the vulnerability to depression. The diagnosis of depression in DS is mainly based upon observable characteristics, and therefore, the use of modified diagnostic criteria is advised.Although several common treatments, including antidepressants, electroconvulsive therapy and psychotherapy seem effective, there is evidence of undertreatment of depression in DS.

Conclusions

There are important limitations to our current clinical knowledge of depression in DS. Future studies should include systematic evaluations of pharmacotherapeutic and psychotherapeutic interventions.     

Parental Perspectives on Inclusion: Effects of Autism and Down Syndrome

This study examined the effects of the child's diagnosis (autism vs. Down syndrome), age, and current educational placement on parental perceptions toward inclusion for their child with disabilities. Parents of children with autism and with Down syndrome completed surveys regarding their opinions on their child's current educational placement, their desire for changing the current placement, and their views on inclusive education. Results indicated that diagnosis, age, and current placement influenced parental opinion on the ideal educational placement for their child. Parents of children with Down syndrome were significantly more likely to endorse inclusion (full-time placement in general education) as the ideal educational program for their child whereas parents of children with autism were more likely to endorse mainstreaming (consistent part-time placement with general education students). Parents of younger children and parents whose children were already placed in general education programs were more positive towards inclusion than parents of older children or students currently in special education. Findings are discussed in terms of child characteristics and prevailing educational practices.     

The Influence of Pituitary Adenoma Size on Vision and Visual Outcomes after Trans-Sphenoidal Adenectomy: A Report of 78 Cases

Objective

The aims of this study were to investigate the quantitative relationship between pituitary macroadenoma size and degree of visual impairment, and assess visual improvement after surgical resection of the tumor.

Methods

The medical records of patients with pituitary adenoma, who had undergone trans-sphenoidal adenectomy between January 2009 and January 2011, were reviewed. Patients underwent an ocular examination and brain MRI before and after surgery. The visual impairment score (VIS) was derived by combining the scores of best-corrected visual acuity and visual field. The relationship between VIS and tumor size/tumor type/position of the optic chiasm was assessed.

Results

Seventy-eight patients were included (41 male, 37 female). Thirty-two (41%) patients experienced blurred vision or visual field defect as an initial symptom. Receiver operating characteristic curve analysis showed that tumors <2.2 cm tended to cause minimal or no visual impairment. Statistical analysis showed that 1) poor preoperative vision is related to tumor size, displacement of the optic chiasm in the sagittal view on MRI and optic atrophy, and 2) poorer visual prognosis is associated with greater preoperative VIS. In multivariate analysis the only factor significantly related to VIS improvement was increasing pituitary adenoma size, which predicted decreased improvement.

Conclusion

Results from this study show that pituitary adenomas larger than 2 cm cause defects in vision while adenomas 2 cm or smaller do not cause significant visual impairment. Patients with a large macroadenoma or giant adenoma should undergo surgical resection as soon as possible to prevent permanent visual loss.     

Outcomes research: clinical trials in the elderly

Very few clinical trials have been done in the elderly. This report reviews results of two completed studies and describes one in progress. The largest published study was a United States Veterans Affairs Administration study in newly diagnosed patients with epilepsy. It compared carbamazepine to gabapentin and lamotrigine, and found that, although equivalent in efficacy, the newer antiepileptic drugs (AEDs) were better tolerated. This study also highlighted many of the difficulties in recruiting and retaining elderly patients in studies, the large number of comorbidities, and the problems of distinguishing seizures in the elderly from other symptoms. Another study of new-onset epilepsy suggested that a large percentage of elderly patients respond to initial AED therapy, but side effect profiles differ. More studies are needed to better define the risk/benefit relationships in elderly patients.     

Specific entities affecting the craniocervical region: Down’s syndrome

Introduction  The ligamentous laxities and bony abnormalities associated with Down’s syndrome, os odontoideum, achondroplasia, osteogenesis imperfecta, and basilar invagination have been discussed with the imaging of the craniocervical junction. These are significant and require suspicion when dealing with children with the previously mentioned entities. Conclusion  Previous adverse surgical results in managing these patients reflect the lack of understanding of the underlying pathology and the appropriate surgical treatment.     

Outcomes After Seizure Recurrence in People with Well-Controlled Epilepsy and the Factors That Influence It

Summary: Purpose: To determine the risk of further seizures and probability of further remission after a first seizure recurrence in patients in remission of their epilepsy, and to examine the prognostic factors influencing this risk.
Methods: Continued follow-up of a cohort of 409 patients with a recurrence of seizures after randomization to the Medical Research Council (MRC) Antiepileptic Drug Withdrawal Study.
Results: By 3 years after a seizure, 95% of patients have experienced a further 1-year remission of their epilepsy and by 5 years 90% of patients have experienced a further 2-year remission. The most important factors contributing to the risk of further seizures after a first seizure after randomization were the previous seizure-free interval, having partial seizures at recurrence, and having previously experienced seizures while receiving treatment. There was no evidence that the group of patients who had discontinued or reduced treatment before the occurrence of their first seizure after randomization had a different outcome from those patients who continued treatment.
Conclusion: Our results provide no evidence that discontinuation of antiepileptic drugs (AEDs) modifies the long-term prognosis of a person's epilepsy, although it does increase the risk of seizures in the 1- to 2-year period after discontinuation.