Racial Disparities in Depression and Life Satisfaction After Spinal Cord Injury: A Mediational Model

Purpose:

To identify the relationship of race and gender with 3 aspects of life satisfaction and depressive symptoms after spinal cord injury (SCI), evaluating the extent to which socioeconomic factors mediate any observed relationships.

Methods:

Adults with traumatic SCI of at least 1-year duration (N = 1,549) were identified through a Southeastern United States SCI Model System of care, and cross-sectional survey data were collected at a Southeastern United States medical university. Three aspects of life satisfaction (home life satisfaction, vocational satisfaction, global satisfaction) were measured using 20 satisfaction items from the Life Situation Questionnaire-Revised. The Older Adult Health and Mood Questionnaire measured depressive symptoms. MANCOVA assessed mediation of socioeconomic status between race and life satisfaction and depression.

Results:

Home life satisfaction and vocational satisfaction were significantly related to race, with White participants scoring higher than Black participants during the first stage of the regression. However, socioeconomic factors mediated the relationships such that race was no longer significant after considering economic factors. Race was significantly associated with global satisfaction after adjusting for socioeconomic factors. Depression was not significantly related to race. Gender was unrelated to all study outcomes. Of the socioeconomic mediators, family income was a significant predictor of each outcome, whereas education was only predictive of vocational satisfaction.

Conclusion:

Socioeconomic factors are important mediators of the relationship between race and certain aspects of life satisfaction among persons with SCI. Family income and, to a lesser extent, education should be considered when evaluating race differences in life satisfaction after SCI.     

Dysphagia and Associated Respiratory Considerations in Cervical Spinal Cord Injury

Background:

Dysphagia is a relatively common secondary complication that occurs after acute cervical spinal cord injury (SCI). The detrimental consequences of dysphagia in SCI include transient hypoxemia, chemical pneumonitis, atelectasis, bronchospasm, and pneumonia. The expedient diagnosis of dysphagia is imperative to reduce the risk of the development of life-threatening complications.

Objective:

The objective of this study was to identify risk factors for dysphagia after SCI and associated respiratory considerations in acute cervical SCI.

Methods:

Bedside swallow evaluation (BSE) was conducted in 68 individuals with acute cervical SCI who were admitted to an SCI specialty unit. Videofluroscopy swallow study was conducted within 72 hours of BSE when possible.

Results:

This prospective study found dysphagia in 30.9% (21 out of 68) of individuals with acute cervical SCI. Tracheostomy (P = .028), ventilator use (P = .012), and nasogastric tube (P = .049) were found to be significant associated factors for dysphagia. Furthermore, individuals with dysphagia had statistically higher occurrences of pneumonia when compared with persons without dysphagia (P < .001). There was also a trend for individuals with dysphagia to have longer length of stay (P = .087).

Conclusion:

The role of respiratory care practitioners in the care of individuals with SCI who have dysphagia needs to be recognized. Aggressive respiratory care enables individuals with potential dysphagia to be evaluated by a speech pathologist in a timely manner. Early evaluation and intervention for dysphagia could decrease morbidity and improve overall clinical outcomes.     

Limited M1 Disease: A Significant Prognostic Factor for Stage IV Breast Cancer

Purpose

The prognosis of patients with breast cancer presenting with distant metastasis can vary depending on disease extent. This study evaluates a definition of limited M1 disease in association with survival in a cohort of women presenting with metastatic breast cancer.

Methods

The study cohort comprised 692 women referred to the BC Cancer Agency between 1996 and 2005 with M1 breast cancer at presentation. Limited M1 disease was defined as <5 metastatic lesions confined to one anatomic subsite. Extensive M1 disease was defined as ??5 lesions or disease in more than one subsite. Clinicopathologic and treatment characteristics and overall survival (OS) were compared between subjects with limited (n?=?233) versus extensive (n?=?459) M1 disease. Multivariable analysis was performed by Cox regression modeling.

Results

Median follow-up time was 1.9?years. Five-year Kaplan-Meier OS was significantly higher in patients with limited compared to extensive M1 disease (29.7 vs. 13.1?%, p?p?Conclusions Limited M1 disease, defined as <5 metastatic lesions confined to one anatomic subsite, is a relevant favorable prognostic factor in patients with stage IV breast cancer. This definition may be used in conjunction with other clinicopathologic factors to select patients for more aggressive systemic and locoregional treatments.     

585-nm Pulsed Dye Laser in the Treatment of Surgical Scars Starting on the Suture Removal Day

BACKGROUND: The optimal time frame to improve the quality and cosmetic appearance of scars by laser therapy has not been clearly elucidated by prior controlled clinical trials. OBJECTIVE: To determine the efficacy of the 585-nm pulsed dye laser (PDL) in the treatment of surgical scars starting on the day of suture removal. METHODS: Eleven patients (skin types I-IV) with 12 postoperative linear scars that were greater than 2 cm were treated three times on monthly intervals with the 585-nm PDL (450 micro s, 10-mm spot size, 3.5 J/cm2 with 10% overlap) on one scar half, whereas the other half received no treatment. Scars were later evaluated by a blinded examiner using the Vancouver Scar Scale (VSS) for pigmentation, vascularity, pliability, and height. Scars were then blindly examined for cosmetic appearance using a visual analog scale. RESULTS: One month after the last treatment, final scar analysis by the blinded examiner revealed a significant difference between treated and untreated sites, with the treated halves scoring better in all scar parameters in the VSS and in cosmetic appearance. The treated halves demonstrated an overall average improvement in the VSS between the first treatment score and the final score of 54% versus 10% in the controls (P=0.0002). The cosmetic appearance score (0=worst; 10=best) at final assessment was significantly better for the treated scars, scoring 7.3 versus the averaged control score of 5.2 (P=0.016). CONCLUSION: The 585-nm PDL is effective and safe in improving the quality and cosmetic appearance of surgical scars in skin types I-IV starting on the day of suture removal.     

Percutaneous Intradiscal Aspiration of a Lumbar Vacuum Disc Herniation: A Case Report

We report a case of an 83-year-old gentleman presenting with acute low back pain and radicular left lower extremity pain after golfing. A magnetic resonance imaging (MRI) of the lumbar spine revealed a low-signal-density lesion compressing the L5 nerve. A computed tomography scan was then ordered, confirming an extra-foraminal disc protrusion at the L5–S1 level, containing a focus of gas that was compressing the left L5 nerve root and communicating with the vacuum disc at L5–S1. After a failed left L5 transforaminal epidural steroid injection, the patient was brought back for a percutaneous intradiscal aspiration of the vacuum disc gas. This resulted in immediate relief for the patient. A follow-up MRI performed 2 months after the procedure found an approximate 25% reduction in the size of the vacuum disc herniation. Six months after the procedure, the patient remains free of radicular pain. This case report suggests that a percutaneous aspiration of gas from a vacuum disc herniation may assist in the treatment of radicular pain.     

Five Percent Lidocaine Cream Applied Simultaneously to the Skin and Mucosa of the Lips Creates Excellent Anesthesia for Filler Injections

Background. Injection of filler substances into the lips is painful, and many patients also find the injection of local or regional anesthesia into the lips painful.
Objective. To develop a highly effective and painless form of anesthesia to facilitate injection of filler substances into the lips.
Methods. Five percent lidocaine cream was applied simultaneously to the skin, vermilion, and mucosa of the lips (with the use of a barrier to keep the cream in contact with the mucosa and out of the rest of the mouth) for 20 to 30 minutes.
Results. Profound anesthesia of the lips was reliably produced, with no complications.
Conclusions. This "anesthetic cream block" is easier to perform and better tolerated than injectable anesthetics. Use of this technique is likely to expand the range of physicians who perform filler injections on the lips and will probably also expand the range of patients who wish to have filler injections done on their lips and who (because they had little or no discomfort) are willing to return for additional filler injections in the future.     

Mini-open thoracoscopically assisted thoracotomy versus video-assisted thoracoscopic surgery for anterior release in thoracic scoliosis and kyphosis: a comparison of operative and radiographic results

BACKGROUND CONTEXT: Combining anterior release and interbody fusion with posterior instrumented fusion is an accepted treatment for severe rigid spinal deformity. Video-assisted thoracoscopic surgery (VATS) and mini-open thoracoscopically assisted thoracotomy (MOTA) are two minimally invasive approaches to the thoracic spine. Both reduce surgical trauma, improve cosmesis and provide effective exposure for release and fusion. Published data and the authors' surgical experience have demonstrated that both techniques are equivalent in degree of release to traditional open thoracotomy, but no comparison between these two minimally invasive alternatives has been published to our knowledge. PURPOSE: This study compared MOTA and VATS under the hypothesis that both result in similar corrections and comparable operative parameters when used in conjunction with posterior instrumented fusion. STUDY DESIGN/SETTING: Retrospective chart review of consecutive case series by two surgeons. PATIENT SAMPLE: Twenty-one (13 female, 8 male) patients underwent MOTA and 24 patients (17 female, 7 male) underwent VATS for anterior release, discectomy and fusion prior to posterior instrumented fusion. OUTCOME MEASURES: Outcomes were measured at a minimum of 1-year follow-up and included radiographic Cobb measurements and operative parameters. METHODS: The indications for surgery included rigid and severe scoliosis or thoracic kyphosis. Data collection included preoperative demographics, number of levels released, primary curve correction, operative time and blood loss. Data were normalized per number of levels released anteriorly. Statistical analysis of results was done using a two-sample t test assuming equal variances with two-tail p values less than .05. RESULTS: More anterior levels were operated on average in the VATS group (6.33 vs. 4.38 levels). Curve correction per anterior level released was similar in both groups (8.7 and 8.8 degrees/level for MOTA and VATS, respectively). There was a significant difference in operative time with MOTA averaging 131.7 minutes and VATS averaging 162.8 minutes. However, a comparison of the operative time per anterior level operated, approached statistical significance in favor of VATS (33.0 vs. 28.4 minutes, p=.08). There was no significant difference in estimated blood loss during the anterior portion of the surgeries. There was a trend toward decreased blood loss per operated level favoring VATS (68.4 vs. 38.9 cc, p=.09). CONCLUSIONS: Both approaches resulted in corrections that compare favorably with open thoracotomy. We suggest that a factor in choosing between these two minimally invasive techniques is the number of thoracic levels requiring release. For four levels or less, MOTA provides an excellent alternative to standard thoracotomy. For five or more levels, VATS provides for excellent exposure of additional levels with the advantages of less operative time and blood loss per operated level.     

小肠间质瘤20例诊治分析

目的　总结小肠间质瘤诊断和治疗经验。方法　对1993—2 0 0 4年收治的2 0例小肠间质瘤的临床资料进行回顾性分析。结果　临床表现为黑便、果酱样血便14例、头晕9例、贫血3例,伴腹部疼痛11例,发病时间2个月至7年。确诊方式:剖腹探查12例,腹腔镜探查6例,小肠镜检查2例;手术方式:小肠间质瘤切除18例,胰十二指肠切除术1例,肿瘤无法切除行保守治疗1例。随访6个月至9年,除1例死于脑干出血、2例长期服用甲磺酸伊马替尼(Gleevec)症状部分缓解外,其余17例均健在,间质瘤无复发。结论　小肠间质瘤预后较好,但对不明原因的消化道出血应及早探查,以避免误诊;Gleevec对晚期小肠间质瘤有较好疗效     

Quality of recovery from two types of general anesthesia for ambulatory dental surgery in children: a double-blind, randomized trial

Background:  Pediatric dental procedures are increasingly performed under general anesthesia because of the inability to cooperate, situational anxiety, or other behavioral problems. Volatile anesthetics have been associated with emergence delirium in children, whereas the use of propofol for anesthetic maintenance has been shown to reduce the incidence of emergence delirium after other types of surgeries. The aim of this study is to compare a sevoflurane-based anesthetic with a propofol-based technique as it relates to the incidence of emergence delirium and the quality of recovery after pediatric dental surgery, in patients who present with risk factors for perioperative behavioral issues.
Methods:  We prospectively collected data of 179 pediatric patients scheduled for ambulatory dental surgery using a double-blind and randomized trial design. Subjects were anesthetized following standardized protocols for either a sevoflurane- or a propofol-based technique. The incidence of emergency delirium, as measured by the Pediatric Anesthesia Emergence Delirium score, was the primary outcome. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), number of nursing interventions in the recovery room, time to discharge readiness, and parental satisfaction.
Results:  We found no difference in the incidence of emergence delirium after both types of anesthesia. However, use of sevoflurane significantly increased both the risk of PONV and the number of postoperative nursing interventions. Discharge criteria were met about 10 min earlier in patients anesthetized with sevoflurane. Parental satisfaction was equally high with both anesthesia regimens.
Conclusions:  A propofol-based anesthetic technique did not lead to a lower incidence of emergence delirium after dental surgery in children but did result in significantly less PONV and fewer postoperative nursing interventions.