CNS Measures of Pain Responses Pre- and Post-Anesthetic Ketamine in a Patient with Complex Regional Pain Syndrome

BACKGROUND

Previous reports have indicated that ketamine anesthesia may produce significant improvement if not complete recovery of patients with complex regional pain syndrome (CRPS).

AIMS

Here we report on a patient who had CRPS affecting mainly the right side of her body who underwent functional magnetic resonance imaging (fMRI) scans prior to and in the months following apparent successful treatment with anesthetic doses of ketamine.

MATERIALS AND METHODS

The patient underwent two imaging sessions: one during her pain state (CRPS+) and 1 month after her ketamine treatment in her pain-free state (CRPS-). Both spontaneous and evoked (brush, cold, and heat) pain scores decreased from 7–9/10 on a visual analog scale prior to the treatment to 0–1 immediately following and for months after the treatment. For each imaging session, the identical mechanical (brush) and thermal (cold and heat) stimuli were applied to the same location (the skin of the dorsum of the right hand).

RESULTS

Comparison of CRPS+ vs CRPS- for the three stimuli showed significant changes throughout the cerebral cortex (frontal, parietal, temporal, cingulate, and hippocampus), in subcortical regions such as caudate nucleus, and in the cerebellum. In addition, resting state network analysis showed a reversal of brain network state, and the recovered state paralleled specific default networks in healthy volunteers.

DISCUSSION

The observed changes in brain response to evoked stimuli provide a readout for the subjective response.

CONCLUSION

Future studies of brain function in these patients may provide novel insight into brain plasticity in response to this treatment for chronic pain.

Interventions that cause weight loss and the impact on cardiovascular risk factors: a systematic review and meta-analysis

Overweight and obesity increase the risks of diabetes and cardiovascular disease (CVD). This has been shown to be reversed with weight loss. A systematic review and meta-analysis were performed to determine the effect of weight loss in the primary prevention of CVD. PubMed, Embase and the Cochrane Library databases were searched electronically through to May 2013. Randomized controlled trials assessing weight loss and cardiovascular risk factors and outcomes were included. A random effects meta-analysis, with sub-group analyses for degree of weight loss, and age were performed. Because few studies reported clinical outcomes of CVD, analyses were limited to cardiovascular risk factors (83 studies). Interventions that caused any weight loss significantly reduced systolic blood pressure (-2.68 mmHg, 95% CI -3.37, -2.11), diastolic blood pressure (-1.34 mmHg, 95% CI -1.71, -0.97), low-density lipoprotein cholesterol (-0.20 mmol L(-1) , 95% CI -0.29, -0.10), triglycerides (-0.13 mmol L(-1) , 95% CI -0.22, -0.03), fasting plasma glucose (-0.32 mmol L(-1) , 95% CI -0.43, -0.22) and haemoglobin A1c(-0.40%, 95% CI -0.52, -0.28) over 6-12 months. Significant changes remained after 2 years for several risk factors. Similar results were seen in sub-group analyses. Interventions that cause weight loss are effective at improving cardiovascular risk factors at least for 2 years. © 2016 World Obesity.

The use of a multidisciplinary rehabilitation assessment clinic as an alternative to hospital admission

An interdisciplinary outpatient rehabilitation clinic was set up to assess patients with severe and complex disabilities. The rehabilitation team consisted of a physician, a nurse, a community liaison occupational therapist, a community physiotherapist and a speech and language therapist. Each patient was assessed in the clinic for half a day. The patients' carers were encouraged to attend. A total of 25 consecutive new patients were studied. The findings of the study suggest that the range of therapeutic interventions carried out during the outpatient clinic visit were comparable to the standard model of care. To evaluate the effectiveness of this service in preventing hospital admissions the case histories of the study patients were presented to three consultants in rehabilitation medicine who were asked to give their management decision on each case, but were not told the objectives of the study. Analysis of the consultants' decisions showed that there was agreement between all consultants that five patients needed admission to hospital for evaluation or treatment and two out of the three physicians said that they would have admitted a further eight patients. In fact, none of our patients was admitted, which suggests that the model of outpatient multi disciplinary assessment service proposed here may reduce the need for admissions to hospital.

The value of a feasibility study into long-term macrolide therapy in chronic rhinosinusitis

OBJECTIVES

There is currently conflicting level 1 evidence in the use of long-term antibiotics for chronic rhinosinusitis without nasal polyps. The primary aim of this feasibility study was to optimise future randomised trial design by assessing recruitment and retention of patients alongside providing preliminary data on symptomatic control.

DESIGN

Prospective, multicentre feasibility (cohort) study with all patients receiving macrolide therapy for 12 weeks and a further subsequent 12-week follow-up. Participants received a 12-week course of clarithromycin 250 mg alongside twice daily topical mometasone and nasal douching. Primary outcomes focused on recruitment, retention and compliance. Clinical and quality-of-life outcomes measures were also recorded.

SETTING

Patients were prospectively recruited from six UK outpatient clinics.

PARTICIPANTS

Adult patients with chronic rhinosinusitis without nasal polyps and no prior endoscopic sinus surgery underwent baseline assessment and then follow-up at 3 and 6 months.

MAIN OUTCOME MEASURES

Six-month recruitment and retention data.

RESULTS

Over 13 months, 55 adults were recruited from five centres. Four patients declined participation. 75% of patients were retained within the study. Dropouts included one medication contraindication, three unable to tolerate medication and 10 not attending full follow-up. Sino Nasal Outcome Test-22 and endoscopic scores showed statistically significant improvement. No other clinical or quality-of-life assessment improvements were seen.

CONCLUSION

Retention and recruitment to a trial using long-term clarithromycin to treat chronic rhinosinusitis without nasal polyps is achievable and this data will support a future randomised controlled trial. The study provides vital insight into trial design, thus informing UK research networks and rhinology researchers internationally.

Quality of life Evaluation in patients receiving Steroids (the QuESt tool): initial development in children and young people with acute lymphoblastic leukaemia

BACKGROUND

The powerful cytotoxic and immunomodulatory effects of corticosteroids are an important element of the success that has been achieved in the treatment of acute lymphoblastic leukaemia (ALL). In addition to physical side effects, corticosteroids can adversely influence behaviour, cognitive function and mood leading to significantly impaired quality of life (QoL). A number of tools exist for assessing QoL, but none of these specifically examines changes attributable to steroids.

METHODS

Children and young adults aged 8-24 years and parents of children receiving maintenance therapy for ALL from four UK centres were invited to participate. The study comprised three stages carried out over 2 years: (1) focus groups and interviews where participants were asked to describe their experiences of dexamethasone; (2) analysis of questionnaires sent to healthcare professionals and patients to evaluate the importance and relevance of the questions; and (3) cognitive interviewing.

RESULTS

Interpretative phenomenological analysis of focus group and interview transcripts identified that dexamethasone adversely influenced behaviour, appetite, body image, mood and family relationships. 157 electronic survey responses were analysed leading to further item development. Cognitive interviewing confirmed face validity and internal consistency. QuESt comprises 28 questions within four domains and has three age-specific versions.

CONCLUSIONS

QuESt is the first treatment-specific QoL measure for children and young adults receiving corticosteroids. It can be completed in 10-15 min by children aged ≥8 years. Further validity and reliability testing will be undertaken. Although the initial application is for ALL, QuESt may also be a valuable tool for understanding the impact of corticosteroids in other paediatric conditions.

Effectiveness and cost-effectiveness of a cardiovascular risk prediction algorithm for people with severe mental illness

Introduction

Cardiovascular risk prediction tools are important for cardiovascular disease (CVD) prevention, however, which algorithms are appropriate for people with severe mental illness (SMI) is unclear.

Objectives/aims

To determine the cost-effectiveness using the net monetary benefit (NMB) approach of two bespoke SMI-specific risk algorithms compared to standard risk algorithms for primary CVD prevention in those with SMI, from an NHS perspective.

Methods

A microsimulation model was populated with 1000 individuals with SMI from The Health Improvement Network Database, aged 30–74 years without CVD. Four cardiovascular risk algorithms were assessed; (1) general population lipid, (2) general population BMI, (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those high-risk (> 10%) were assumed to be prescribed statin therapy, others received usual care. Individuals entered the model in a ‘healthy’ free of CVD health state and with each year could retain their current health state, have cardiovascular events (non-fatal/fatal) or die from other causes according to transition probabilities.

Results

The SMI-specific BMI and general population lipid algorithms had the highest NMB of the four algorithms resulting in 12 additional QALYs and a cost saving of approximately £37,000 (US$ 58,000) per 1000 patients with SMI over 10 years.

Conclusions

The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of a SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Epidemiology of drug-resistant tuberculosis among children and adolescents in South Africa, 2005-2010

OBJECTIVE

To describe the demographic and clinical characteristics of children and adolescents diagnosed with resistance to any anti-tuberculosis drug (drug-resistant tuberculosis; DR-TB) in South Africa.

DESIGN

We retrospectively reviewed medical records of all children (<13 years) and adolescents (13 to <18 years) with DR-TB at specialty hospitals in four South African provinces from 2005 to 2010.

RESULTS

During the review period, 774 children and adolescents (median age 11.3 years) were diagnosed with DR-TB at selected facilities. A high proportion of patients had a history of previous TB treatment (285/631; 45.2%), human immunodeficiency virus (HIV) infection (375/685; 54.7%), contact with a TB case (347/454; 76.4%), and smear-positive (443/729; 60.8%), cavitary (253/680, 38.7%) disease. Eighty-two per cent of patients with HIV infection received antiretroviral therapy. Of 626 patients diagnosed with multidrug-resistant TB (MDR-TB), 561 (89.6%) received a regimen consistent with national guidelines; the median length of treatment was 22 months (IQR 16-25). Among 400 patients with any DR-TB and a known outcome, 20.3% died during treatment.

CONCLUSION

Pediatric DR-TB in these provinces is characterized by complex clinical features at diagnosis, with one in five children dying during treatment. History of previous treatment and contact with a TB patient indicate opportunities for earlier diagnosis and treatment to improve outcomes.

What does a diagnostic label of 'polycystic ovary syndrome' really mean in adolescence? A review of current practice recommendations

Polycystic ovary syndrome (PCOS) is the most common female endocrine disorder, with many women initially presenting during adolescence. Diagnosis during this period is particularly challenging, yet many emphasize the importance of an early diagnosis given the long-term metabolic and reproductive health consequences associated with the syndrome. The objective of this study was to review the current literature to determine whether the diagnostic label 'PCOS' is necessary to effectively manage adolescent girls presenting with features of the syndrome. A literature search was conducted (PubMed, Medline, Informit Health and the Cochrane Database of Systematic Reviews) identifying papers addressing the diagnosis and management of PCOS during adolescence. Articles were selected based on date of publication, relevance of material and the quality of evidence presented. A total of 427 papers were screened, with 40 of these selected from the initial search. A subsequent 154 were included from manual review of reference lists from key papers identified in the initial search. Current guidelines recommend treating the individual manifestations of PCOS. In doing so, there is good evidence identifying that this approach adequately targets the underlying metabolic and reproductive changes associated with the syndrome. This suggests that providing a diagnostic label of PCOS is not actually necessary to effectively manage adolescent girls with features of this syndrome.

Changes in the water quality conditions of Kuwait's marine waters: Long term impacts of nutrient enrichment

This work analyses a 30 year water quality data set collated from chemical analyses of Kuwait's marine waters. Spatial patterns across six sites in Kuwait Bay and seven sites located in the Arabian Gulf are explored and discussed in terms of the changing influences associated with point and diffuse sources. Statistical modelling demonstrated significant increases for dissolved nutrients over the time period. Kuwait marine waters have been subject to inputs from urban development, untreated sewage discharges and decreasing river flow from the Shatt al-Arab River. Chlorophyll biomass showed a small but significant reduction; the high sewage content of the coastal waters from sewage discharges likely favouring the presence of smaller phytoplankton taxa. This detailed assessment of temporal data of the impacts of sewage inputs into Kuwait's coastal waters establishes an important baseline permitting future assessments to be made as sewage is upgraded, and the river continues to be extracted upstream.

Baseline survey of marine sediments collected from the State of Kuwait: PAHs, PCBs, brominated flame retardants and metal contamination

A geographically extensive baseline survey of sediment contamination was undertaken at twenty nine locations around Kuwait. Samples were assessed in relation to a wide range of industrial pollutants, including metals, PAHs, PCBs, PBDEs and HBCDs. The data generated indicated that levels of pollutants were generally low and below commonly applied sediment quality guidelines (SQGs). However, naturally high background concentrations of certain metals present in sediment from the region may prohibit the direct assessment against some of the routinely applied SQGs. Hot spots of contamination were identified for PAHs, PCBs and PBDEs, that were mainly associated with the Shuaiba Industrial Area, located south of the city, and known to contain a diverse mix of both light and heavy industry.

Microbial water quality and sedimentary faecal sterols as markers of sewage contamination in Kuwait

Microbial water quality and concentrations of faecal sterols in sediment have been used to assess the degree of sewage contamination in Kuwait's marine environment. A review of microbial (faecal coliform, faecal streptococci and Escherichia coli) water quality data identified temporal and spatial sources of pollution around the coastline. Results indicated that bacterial counts regularly breach regional water quality guidelines. Sediments collected from a total of 29 sites contained detectable levels of coprostanol with values ranging from 29 to 2420 ng g(-1) (dry weight). Hot spots based on faecal sterol sediment contamination were identified in Doha Bay and Sulaibikhat Bay, which are both smaller embayments of Kuwait Bay. The ratio of epicoprostanol/coprostanol indicates that a proportion of the contamination was from raw or partially treated sewage. Sewage pollution in these areas are thought to result from illegal connections and discharges from storm drains, such as that sited at Al-Ghazali.

Auditing HIV Testing Rates across Europe: Results from the HIDES 2 Study

European guidelines recommend the routine offer of an HIV test in patients with a number of AIDS-defining and non-AIDS conditions believed to share an association with HIV; so called indicator conditions (IC). Adherence with this guidance across Europe is not known. We audited HIV testing behaviour in patients accessing care for a number of ICs. Participating centres reviewed the case notes of either 100 patients or of all consecutive patients in one year, presenting for each of the following ICs: tuberculosis, non-Hodgkins lymphoma, anal and cervical cancer, hepatitis B and C and oesophageal candidiasis. Observed HIV-positive rates were applied by region and IC to estimate the number of HIV diagnoses potentially missed. Outcomes examined were: HIV test rate (% of total patients with IC), HIV test accepted (% of tests performed/% of tests offered) and new HIV diagnosis rate (%). There were 49 audits from 23 centres, representing 7037 patients. The median test rate across audits was 72% (IQR 32–97), lowest in Northern Europe (median 44%, IQR 22–68%) and highest in Eastern Europe (median 99%, IQR 86–100). Uptake of testing was close to 100% in all regions. The median HIV+ rate was 0.9% (IQR 0.0–4.9), with 29 audits (60.4%) having an HIV+ rate >0.1%. After adjustment, there were no differences between regions of Europe in the proportion with >0.1% testing positive (global p = 0.14). A total of 113 patients tested HIV+. Applying the observed rates of testing HIV+ within individual ICs and regions to all persons presenting with an IC suggested that 105 diagnoses were potentially missed. Testing rates in well-established HIV ICs remained low across Europe, despite high prevalence rates, reflecting missed opportunities for earlier HIV diagnosis and care. Significant numbers may have had an opportunity for HIV diagnosis if all persons included in IC audits had been tested.

Management of cutaneous squamous cell carcinoma in patients with epidermolysis bullosa: best clinical practice guidelines

This article summarizes recommendations reached following a systematic literature review and expert consensus on the diagnosis and management of cutaneous squamous cell carcinomas in people with epidermolysis bullosa. The guidelines are intended to help inform decision making by clinicians dealing with this complex complication of a devastating disease.

Review of Time to Surgical Decompression in Traumatic Spinal Cord Injured Patients

Interventions which may improve neurological outcomes, including time to surgical decompression, in traumatic spinal cord injury (TSCI) evoke much interest. The majority of TSCI patients in Ireland are managed acutely at the National Spinal Injuries Unit (NSIU). A retrospective review of healthcare records of TSCI patients, who had surgical management there, in 2010, 2011, 2012, was performed. From the information gathered, the duration of each stage of the patient pathway was calculated. Median duration between onset of injury and time of arrival at local hospital was 1 hour 25 minutes, between arrival at local hospital and referral to NSIU was 4 hours 17 minutes, between referral to and arrival at NSIU was 6 hours 25 minutes, between onset of injury and arrival at NSIU was 13 hours 7 minutes, between onset of injury and surgical decompression was 27 hours. A number of factors have been identified which could influence these time durations.