Multimorbidity, the Predominant Predictor of Quality-of-Life, Following Successful Spinal Cord Stimulation for Angina Pectoris

Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain

Spinal cord stimulation (SCS) has demonstrated effectiveness for neuropathic pain. Unfortunately, some patients report inadequate long-term pain relief. Patient selection is emphasized for this therapy; however, the prognostic capabilities and deployment strategies of existing selection techniques, including an SCS trial, have been questioned. After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, a steering committee was formed to develop evidence-based guidelines for patient selection and the role of an SCS trial. Representatives of professional organizations with clinical expertize were invited to participate as committee members. A comprehensive literature review was carried out by the steering committee, and the results organized into narrative reports, which were circulated to all the committee members. Individual statements and recommendations within each of seven sections were formulated by the steering committee and circulated to members for voting. We used a modified Delphi method wherein drafts were circulated to each member in a blinded fashion for voting. Comments were incorporated in the subsequent revisions, which were recirculated for voting to achieve consensus. Seven sections with a total of 39 recommendations were approved with 100% consensus from all the members. Sections included definitions and terminology of SCS trial; benefits of SCS trial; screening for psychosocial characteristics; patient perceptions on SCS therapy and the use of trial; other patient predictors of SCS therapy; conduct of SCS trials; and evaluation of SCS trials including minimum criteria for success. Recommendations included that SCS trial should be performed before a definitive SCS implant except in anginal pain (grade B). All patients must be screened with an objective validated instrument for psychosocial factors, and this must include depression (grade B). Despite some limitations, a trial helps patient selection and provides patients with an opportunity to experience the therapy. These recommendations are expected to guide practicing physicians and other stakeholders and should not be mistaken as practice standards. Physicians should continue to make their best judgment based on individual patient considerations and preferences.

Multimorbidity and adverse longitudinal outcomes among patients attending chronic outpatient medical care in Bahir Dar, Northwest Ethiopia

Background

Multimorbidity is becoming more prevalent in low-and middle-income countries (LMICs). However, the evidence base on the burden and its longitudinal outcomes are limited. This study aimed to determine the longitudinal outcomes of patients with multimorbidity among a sample of individuals attending chronic outpatient non communicable diseases (NCDs) care in Bahir Dar, northwest Ethiopia.

Methods

A facility-based longitudinal study was conducted among 1,123 participants aged 40+ attending care for single NCD (n = 491) or multimorbidity (n = 633). Data were collected both at baseline and after 1 year through standardized interviews and record reviews. Data were analyzed using Stata V.16. Descriptive statistics and longitudinal panel data analyzes were run to describe independent variables and identify factors predicting outcomes. Statistical significance was considered at p-value <0.05.

Results

The magnitude of multimorbidity has increased from 54.8% at baseline to 56.8% at 1 year. Four percent (n = 44) of patients were diagnosed with one or more NCDs and those having multimorbidity at baseline were more likely than those without multimorbidity to develop new NCDs. In addition, 106 (9.4%) and 22 (2%) individuals, respectively were hospitalized and died during the follow up period. In this study, about one-third of the participants had higher quality of life (QoL), and those having higher high activation status were more likely to be in the higher versus the combined moderate and lower QoL [AOR1 = 2.35, 95%CI: (1.93, 2.87)] and in the combined higher and moderate versus lower level of QoL [AOR2 = 1.53, 95%CI: (1.25, 1.88)].

Conclusion

Developing new NCDs is a frequent occurrence and the prevalence of multimorbidity is high. Living with multimorbidity was associated with poor progress, hospitalization and mortality. Patients having a higher activation level were more likely than those with low activation to have better QoL. If health systems are to meet the needs of the people with chronic conditions and multimorbidity, it is essential to understand diseases trajectories and of impact of multimorbidity on QoL, and determinants and individual capacities, and to increase their activation levels for better health improve outcomes through education and activation.

Multimorbidity of chronic non-communicable diseases in low- and middle-income countries: A scoping review

BACKGROUND

Multimorbidity is rising in low- and middle-income countries (LMICs). However, the evidence on its epidemiology from LMICs settings is limited and the available literature has not been synthesized as yet.

OBJECTIVES

To review the available evidence on the epidemiology of multimorbidity in LMICs.

METHODS

PubMed, Scopus, PsycINFO and Grey literature databases were searched. We followed the PRISMA-ScR reporting guideline.

RESULTS

Of 33, 110 articles retrieved, 76 studies were eligible for the epidemiology of multimorbidity. Of these 76 studies, 66 (86.8%) were individual country studies. Fifty-two (78.8%) of which were confined to only six middle-income countries: Brazil, China, South Africa, India, Mexico and Iran. The majority (n = 68, 89.5%) of the studies were crosssectional in nature. The sample size varied from 103 to 242, 952. The largest proportion (n = 33, 43.4%) of the studies enrolled adults. Marked variations existed in defining and measuring multimorbidity. The prevalence of multimorbidity in LMICs ranged from 3.2% to 90.5%.

CONCLUSION AND RECOMMENDATIONS

Studies on the epidemiology of multimorbidity in LMICs are limited and the available ones are concentrated in few countries. Despite variations in measurement and definition, studies consistently reported high prevalence of multimorbidity. Further research is urgently required to better understand the epidemiology of multimorbidity and define the best possible interventions to improve outcomes of patients with multimorbidity in LMICs.

Spinal Cord Stimulation

Spinal cord stimulation (SCS) has been well established as a safe and effective treatment of pain derived from a wide variety of etiologies. Careful patient selection including a rigorous trial period and psychological evaluation are essential. When patients proceed to permanent implantation, various considerations should be made, such as the type of lead, type of anesthesia, and waveform patterns for SCS. This article discusses the common indications for SCS, patient selection criteria, and pertinent outcomes from randomized clinical trials related to common indications treated with SCS. Technical considerations, such as type of implant, anesthesia, and programming, are also discussed.