Behavioral Stage of Change and Dialysis Decision-Making

Background and objectives

Behavioral stage of change (SoC) algorithms classify patients’ readiness for medical treatment decision-making. In the precontemplation stage, patients have no intention to take action within 6 months. In the contemplation stage, action is intended within 6 months. In the preparation stage, patients intend to take action within 30 days. In the action stage, the change has been made. This study examines the influence of SoC on dialysis modality decision-making.

Design, setting, participants, & measurements

SoC and relevant covariates were measured, and associations with dialysis decision-making were determined. In-depth interviews were conducted with 16 patients on dialysis to elicit experiences. Qualitative interview data informed the survey design. Surveys were administered to adults with CKD (eGFR≤25 ml/min/1.73 m²) from August, 2012 to June, 2013. Multivariable logistic regression modeled dialysis decision-making with predictors: SoC, provider connection, and dialysis knowledge score.

Results

Fifty-five patients completed the survey (71% women, 39% white, and 59% black), and median annual income was $17,500. In total, 65% of patients were in the precontemplation/contemplation (thinking) and 35% of patients were in the preparation/maintenance (acting) SoC; 62% of patients had made dialysis modality decisions. Doctors explaining modality options, higher dialysis knowledge scores, and fewer lifestyle barriers were associated with acting versus thinking SoC (all P<0.02). Patients making modality decisions had doctors who explained dialysis options (76% versus 43%), were in the acting versus the thinking SoC (50% versus 10%), had higher dialysis knowledge scores (1.4 versus 0.5), and had lower eGFR (13.9 versus 16.8 ml/min/1.73 m²; all P<0.05). In adjusted analyses, dialysis knowledge was significantly associated with decision-making (odds ratio, 4.2; 95% confidence interval, 1.4 to 12.9; P=0.01), and SoC was of borderline significance (odds ratio, 5.8; 95% confidence interval, 1.0 to 32.6; P=0.05). The model C statistic was 0.87.

Conclusions

Dialysis decision-making was associated with SoC, dialysis knowledge, and physicians discussing treatment options. Future studies determining ways to assist patients with CKD in making satisfying modality decisions are warranted.     

Resting‐state functional connectivity predicts the strength of hemispheric lateralization for language processing in temporal lobe epilepsy and normals

In temporal lobe epilepsy (TLE), determining the hemispheric specialization for language before surgery is critical to preserving a patient's cognitive abilities post‐surgery. To date, the major techniques utilized are limited by the capacity of patients to efficiently realize the task. We determined whether resting‐state functional connectivity (rsFC) is a reliable predictor of language hemispheric dominance in right and left TLE patients, relative to controls. We chose three subregions of the inferior frontal cortex (pars orbitalis, pars triangularis, and pars opercularis) as the seed regions. All participants performed both a verb generation task and a resting‐state fMRI procedure. Based on the language task, we computed a laterality index (LI) for the resulting network. This revealed that 96% of the participants were left‐hemisphere dominant, although there remained a large degree of variability in the strength of left lateralization. We tested whether LI correlated with rsFC values emerging from each seed. We revealed a set of regions that was specific to each group. Unique correlations involving the epileptic mesial temporal lobe were revealed for the right and left TLE patients, but not for the controls. Importantly, for both TLE groups, the rsFC emerging from a contralateral seed was the most predictive of LI. Overall, our data depict the broad patterns of rsFC that support strong versus weak left hemisphere language laterality. This project provides the first evidence that rsFC data may potentially be used on its own to verify the strength of hemispheric dominance for language in impaired or pathologic populations. Hum Brain Mapp, 36:288–303, 2015. © 2014 Wiley Periodicals, Inc.     

High performance liquid chromatography determination of dexamethasone in plasma to evaluate its systemic absorption following intra-space pterygomandibular injection of twin-mix (mixture of 2 % lignocaine with 1:200,000 epinephrine and 4 mg dexamethasone): randomized control trial

Purpose

To determine systemic absorption of dexamethasone by detection of plasma concentration using high performance liquid chromatography following its administration along with local anesthetic agent as a mixture via pterygomandibular space.

Methods

A prospective randomized double-blind clinical study was undertaken to analyze the plasma concentration of dexamethasone after intra-space pterygomandibular injection along with local anesthesia. The study was performed as per split mouth model where the mandibular quadrant allocation was done on a random basis considering each of the 30 patients is included in the two study interventions (SS and CS). For the study site (SS) procedures, dexamethasone was administered as a mixture (2 % lignocaine with 1:200,000 epinephrine and 4 mg dexamethasone) intra-space. In the control site (CS) procedures, a regular standard inferior alveolar nerve block was administered, and dexamethasone was given as intramuscular injection. The plasma dexamethasone determination was done in venous blood 30- and 60-min post injection using high performance liquid chromatography (HPLC). The clinical parameters like pain; swelling; and mouth opening on the first, third, and seventh post-operative day were analyzed and compared.

Results

No significant difference was found in the clinical parameters assessed; comparative evaluation showed less swelling in the SS interventions. The plasma concentration of dexamethasone for the CS interventions was 226?±?47 ng/ml at 30-min and 316?±?81.6 ng/ml at 60-min post injection, and for SS, it was 221?±?81.6 ng/ml at 30-min and 340?±?105 ng/ml at 60-min post injection. On inter-site (CS and SS) comparison, no statistically significant difference was ascertained in dexamethasone plasma concentration at 30-min post injection (P?=?0.77) and at 60-min post injection. (P?=?0.32).

Conclusion

Intra-space (pterygomandibular space) administration of dexamethasone can achieve statistically similar plasma concentration of the drug as when the same dose is administered intramuscularly with demonstration of similar clinical effects.

     

Disparity in the management of Graves' disease observed at an urban county hospital: a decade-long experience

BackgroundThe objective of this study was to determine whether health care disparities exist in management of Graves' disease.MethodsPatients treated for Graves' disease from 1999 to 2009 were divided into medical and surgical treatment groups. A comparative analysis of age, sex, race, health insurance, and income was completed. Address and/or zip code were geocoded and median income was determined from census data.ResultsA total of 634 patients were treated for Graves' disease; 535 (84%) medically and 99 (16%) surgically. Mean age (40 ± 15 vs 43 ± 11 y), percentage of women (84% vs 91%), and racial distribution were similar in the 2 groups (P > .05). In the surgical group, median income was lower ($31,530 vs $34,404; P = .07) and 52% of patients were uninsured compared with 30% of patients treated medically (P < .0001).ConclusionsA disproportionate number of uninsured patients underwent thyroidectomy for Graves' disease. Social and economic factors may have a role in determining definitive therapy for Graves' disease.     

Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis

Aim  

We aimed to study the clinical profile, prognostic factors, and the 6-month outcome of patients with emphysematous pyelonephritis (EPN)     

Evolving Patterns of Spinal Cord Stimulation in Patients Implanted for Intractable Low Back and Leg Pain

The objective of this study was to examine the programming strategies used in patients with intractable low‐back pain treated with epidural spinal cord stimulation (SCS) utilizing paddle electrodes and a radio frequency (RF) stimulator. Programming strategies were examined in a group of patients implanted with a 16‐contact paddle electrode and a dual channel RF receiver to treat chronic low‐back pain. Baseline data included previous surgical history information, leg and low back pain severity and characteristics, and routine demographic information. Outcome measurements included the visual analog scale (VAS) 1 , patient pain relief rating scale, and programming parameters. Patients rated their pain relief on a 5‐point scale where 4 = excellent, 3 = good, 2 = fair, 1 = poor and 0 = none. Success was determined to be a pain relief score of “fair” or above. Data were collected during patient visits or by mail, at approximately 6, 12, and 24 months, postoperatively. Immediate postop data were available in 16 patients, 6‐month data in 21 patients, 1‐year data in 20 patients, and 2‐year data in 10 patients, and analyzed for the purposes of examining programming strategies. The most common location for the tip of the electrode (lead) was found to be in the middle of the 8th thoracic vertebrae (N = 26). At the immediate postop assessment, the majority of cathodes were activated in the upper half of T9. By the 6‐month follow‐up, the majority of cathodes had shifted to the bottom of T9 and top of T10. Overall 88% of cathode locations were changed at one or more study visits. At 2 years, 86% of the programs used four or more active contacts. At 6 months, 83% of the patients reported that the therapy was a success, at 1 year, success was 94%, and by 2 years, success was 75%. Both SCS and chronic pain are dynamic processes. Complex pain patterns, such as the ones of patients who have pain in the low back and in one or both lower extremities, require a high degree of flexibility in the implanted SCS system. The system must provide the capability to redirect the current electronically over at least two segments of the spinal canal, to electronically steer the current in a medio‐lateral direction, and to activate multiple electrical contacts simultaneously. The willingness and ability to provide extensive reprogramming in the long term follow‐up is also of the utmost importance. Pain and its treatment with SCS is a dynamic process.     

Rheumatoid arthritis is a risk factor for dry eye in the Indian population

PURPOSE: To compare the prevalence and severity of dry eye in patients with rheumatoid arthritis (RA) with that in age- and sex-matched controls in the Indian population. METHODS: A cross-sectional study was performed on 84 randomly selected eyes of 84 adult patients with well-documented rheumatoid arthritis and 84 eyes of 84 age- and sex-matched controls in the Department of Ophthalmology, Seth G.S. Medical College and K.E.M. Hospital. McMonnie's dry eye questionnaire was used to classify the patients on the basis of their symptoms. Dry eye was diagnosed if the wetting on Schirmer filter paper test was < or =5 mm at 5 minutes and the tear film breakup time was < 10 seconds on slit-lamp examination after fluorescein staining. RESULTS: Twenty three patients (27.3%) with rheumatoid arthritis had dry eyes based on the Schirmer test as compared to 10 (12%) age- and sex-matched controls; 19 (22.62%) patients with RA had a tear film breakup time of < 10 sec. on slit-lamp examination, compared to 8 (9.52%) patients without RA. The difference in the mean wetting (p = 0.003) and mean tear film breakup time (p < 0.001) between RA and non-RA patients was statistically significant. Ocular symptoms had a limited correlation with the results of these tests. CONCLUSIONS: Patients with RA in the Indian population have a significantly higher prevalence and severity of dry eye when compared to age- and sex-matched controls.     

Recurrent laryngeal nerve palsy after anterior cervical spine surgery: the impact of endotracheal tube cuff deflation, reinflation, and pressure adjustment

BACKGROUND: Vocal fold immobility (paresis or paralysis) from recurrent laryngeal nerve injury remains an important cause of morbidity after anterior cervical spine surgery. A maneuver involving endotracheal tube (ETT) cuff manipulation has been proposed to reduce its incidence. This study is a randomized, prospective, double-blind investigation to test the hypothesis that ETT cuff manipulation reduces the incidence of postoperative vocal fold immobility after anterior cervical spine surgery. METHODS: One hundred patients scheduled to undergo anterior cervical spine surgery were randomly assigned to one of two groups. After inducing general endotracheal anesthesia, patients in the intervention group had their ETT cuff pressures maintained at 20 mmHg or less. After placement of self-retaining retractors, the ETT cuff was deflated for 5 s and then reinflated. Patients in the control group had no further manipulation of their ETT once the cuff was inflated after intubation. Cuff pressures in both groups were recorded before skin incision (baseline) and after placement of self-retaining retractors (peak). Patients' vocal fold motion was evaluated by indirect laryngoscopy performed preoperatively and postoperatively. The examination was videotaped and reviewed by a blinded otolaryngologist. Postoperative vocal fold motion was graded as normal, paretic, or paralyzed. RESULTS: Complete data were available in 94 patients. The incidence of vocal fold paralysis was 3.2% (95% confidence interval, 0.7-9.4%). Cuff manipulation decreased ETT cuff pressure but did not reduce the incidence of vocal fold immobility (15.4% vs. 14.5%). CONCLUSION: Endotracheal tube cuff deflation/reinflation and pressure adjustment do not reduce the incidence of vocal fold immobility in anterior cervical spine surgery.