Epidural Spinal Cord Stimulation for Spinal Cord Injury in Humans: A Systematic Review

(1) Background: Spinal cord injury (SCI) represents a major health challenge, often leading to significant and permanent sensorimotor and autonomic dysfunctions. This study reviews the evolving role of epidural spinal cord stimulation (eSCS) in treating chronic SCI, focusing on its efficacy and safety. The objective was to analyze how eSCS contributes to the recovery of neurological functions in SCI patients. (2) Methods: We utilized the PRISMA guidelines and performed a comprehensive search across MEDLINE/PubMed, Embase, Web of Science, and IEEE Xplore databases up until September 2023. We identified studies relevant to eSCS in SCI and extracted assessments of locomotor, cardiovascular, pulmonary, and genitourinary functions. (3) Results: A total of 64 studies encompassing 306 patients were identified. Studies investigated various stimulation devices, parameters, and rehabilitation methods. Results indicated significant improvements in motor function: 44% of patients achieved assisted or independent stepping or standing; 87% showed enhanced muscle activity; 65% experienced faster walking speeds; and 80% improved in overground walking. Additionally, eSCS led to better autonomic function, evidenced by improvements in bladder and sexual functions, airway pressures, and bowel movements. Notable adverse effects included device migration, infections, and post-implant autonomic dysreflexia, although these were infrequent. (4) Conclusion: Epidural spinal cord stimulation is emerging as an effective and generally safe treatment for chronic SCI, particularly when combined with intensive physical rehabilitation. Future research on standardized stimulation parameters and well-defined therapy regimens will optimize benefits for specific patient populations.

1285 IMPLEMENTATION OF A MEDICINE MANAGEMENT PLAN TO REDUCE MEDICATION-RELATED HARM IN OLDER PEOPLE POST-HOSPITAL DISCHARGE - AN RCT

Introduction

Medication-related harm (MRH) events are increasing among older adults especially in the 8-weeks after hospital discharge. The Discharge Medical Service (DMS), a UK initiative, aims to reduce post-discharge MRH. In this study, we will compare the clinical, economic, and service outcomes of the DMS.

Method

Using a randomised control trial design, 682 older adults ≥ 65years due for hospital-discharge will be recruited. Participants will be randomized to either intervention arm (medicine management plan (MMP) and DMS), or control arm (DMS only) using a 1:1 stratification. The MMP includes patient and carer education about MRH, copy of discharge medications, and MRH risk score calculated using a validated prediction tool (1). Data collection includes patient clinical and social demographics, and admission and discharge medications. At 8-weeks post discharge, study pharmacist will verify MRH through patient telephone interview, and review of patients’ GP records.

Data Analysis

Univariate analysis will be done for baseline variables comparing the intervention and control arms. Variables known to be associated with MRH will be described by the randomisation groups. Further multivariate logistic regression will be done incorporating these variables. Economic evaluation will compare the cost-of-service use among the two arms and modelled to provide national estimates. Qualitative data from focus group interviews at participating hospital sites will explore practitioners’ understanding and acceptance of the DMS and MMP.

Conclusion

This study will inform the use of a validated MRH risk prediction tool, and provide a clinical, and economic evaluation of the DMS and MMP in the NHS. The study has ethics approval and is adopted in the national ageing research portfolio. We are seeking additional sites.

Reference

1. Parekh N, Ali K, Davies JG et al. Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. BMJ Quality and Safety 2020; 29: 142–53.

Long‐term outcomes of outpatient laser ablation for recurrent non‐muscle invasive bladder cancer: A retrospective cohort study

Objectives

The objective of this study is to determine the long‐term efficacy and safety of office‐based Holmium:YAG laser ablation for the treatment of recurrent non‐muscle‐invasive bladder cancer (NMIBC).

Methods

We retrospectively reviewed the medical records of all consecutive patients who underwent office‐based laser ablation for recurrent bladder cancer between 2008 and 2016. The following data were collected: original histology, date of original histology, date of laser ablation, number of repeat laser ablation procedures required, date of tumor recurrence or progression, number of general anesthesia procedures (transurethral resection or cystodiathermy) required after first laser ablation, and number and severity of complications. Kaplan–Meier survival curves were produced for recurrence‐free survival, progression‐free survival, and overall survival.

Results

A total of 97 patients, with an average age of 84 (62–98) years and an average Charlson Comorbidity Index of 6.9 (4–13), were included. The median follow‐up was 61 (2–150) months. Fifty‐five (56.7%) patients presented with tumor recurrence, and the median recurrence‐free survival time was 1.69 years (95% CI 1.20–2.25). Only 9 (9.3%) patients had evidence of tumor progression to a higher grade or stage, 8 (89%) of which initially had low‐grade tumors; however, no patient progressed to muscle‐invasive disease. The median progression‐free survival time was 5.70 years (95% CI 4.10–7.60), and the median overall survival time was 7.60 years (95% CI 4.90–8.70). No patient required emergency inpatient admission after laser ablation.

Conclusion

Office‐based Holmium:YAG laser ablation offers a safe and effective alternative method for treating low‐volume, low‐grade recurrent NMIBC, especially in elderly patients with significant co‐morbidity, while avoiding general anesthesia and inpatient admission.

Safety of "hot" and "cold" site admissions within a high-volume urology department in the United Kingdom at the peak of the COVID-19 pandemic

Objectives

To determine the safety of urological admissions and procedures during the height of the COVID‐19 pandemic using “hot” and “cold” sites. The secondary objective is to determine risk factors of contracting COVID‐19 within our cohort.

Patients and methods

A retrospective cohort study of all consecutive patients admitted from March 1 to May 31, 2020 at a high‐volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a “cold” site requiring a negative COVID‐19 swab 72‐hours prior to admission and patients were required to self‐isolate for 14‐days preoperatively, while all acute admissions were admitted to the “hot” site.

Complications related to COVID‐19 were presented as percentages. Risk factors for developing COVID‐19 infection were determined using multivariate logistic regression analysis.

Results

A total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44‐70) were admitted under the urology team; 101 (16.5%) on the “cold” site and 510 (83.5%) on the “hot” site. Procedures were performed in 495 patients of which eight (1.6%) contracted COVID‐19 postoperatively with one (0.2%) postoperative mortality due to COVID‐19. Overall, COVID‐19 was detected in 20 (3.3%) patients with two (0.3%) deaths. Length of stay was associated with contracting COVID‐19 in our cohort (OR 1.25, 95% CI 1.13‐1.39).

Conclusions

Continuation of urological procedures using “hot” and “cold” sites throughout the COVID‐19 pandemic was safe practice, although the risk of COVID‐19 remained and is underlined by a postoperative mortality.

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)-induced Stevens-Johnson syndrome and gynecomastia in an HIV-infected child: A case report

BACKGROUND

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are antiretroviral drugs often used in the first-line treatment regimen of HIV1 infection worldwide. We report a case of successive gynecomastia and Stevens-Johnson syndrome (SJS) respectively induced by efavirenz and nevirapine in a single patient.

CASE REPORT

A 16-year-old boy, HIV1-infected since birth, was started on antiretroviral treatment (ART) in August 2015 and was taking a regimen comprising abacavir, lamivudine and efavirenz. In April 2016, when his weight reached 35kg, abacavir was replaced with tenofovir. Bilateral breast enlargement, previously hidden by the patient, was diagnosed two years after the start of ART. History-taking, physical examination and laboratory tests ruled out known causes of gynecomastia, and efavirenz was thus considered the most likely cause. This drug was then withdrawn and replaced with nevirapine in July 2017. Thirty-three days after the patient started nevirapine treatment, a skin rash appeared. Physical examination revealed erythematous macules and flaccid bullae with estimated skin detachment of 10%. There were also conjunctival, buccal and genital lesions. A diagnosis was made of SJS induced by nevirapine. Three months after withdrawal of efavirenz, breast size decreased by 3cm on the left breast and 2cm on the right breast; two months after the SJS, cutaneous sequelae alone persisted, such as diffuse hyperchromic macules.

DISCUSSION

Recognition of gynecomastia as a side-effect of efavirenz is important to allow the condition to be treated while it is still potentially reversible. Moreover, when efavirenz is replaced, a protease inhibitor should be preferred to nevirapine.

Improving Compliance With a Single Post-Operative Dose of Intravesical Chemotherapy After Transurethral Resection of Bladder Tumour

Background:

Post-operative single dose intravesical chemotherapy (PSDIVC) in patients with non-muscle invasive bladder cancer has been shown to reduce recurrence rates by up to 39%. However, some studies have suggested poor compliance with PSDIVC stating logistical issues and reluctance to give chemotherapy prior to histological confirmation as some of the reasons.

Objectives:

This study aims to analyse appropriate administration of PSDIVC practice in St. Mary’s Hospital against European Association of Urology guidelines and implement an intervention bundle to improve practice.

Patients and Methods:

All patients that underwent transurethral resection of bladder tumour (TURBT) between March 2012 and February 2013 were analysed retrospectively to review indication for post-operative chemotherapy, instillation rates and limiting factors preventing appropriate instillation. An intervention bundle including pre-operative delivery of mitomycin C (MMC) to the theatre suite, proforma placed in the operative notes and designated roles for PSDIVC induction was introduced to improve instillation and documentation rates. Prospective re-audit data was collected over six months between July 2013 and December 2013 following intervention.

Results:

Sixty-four patients in group A underwent TURBT prior to introduction of the intervention bundle. Fifty-four patients had non-muscle invasive bladder cancer (NMIBC), which would have been eligible for PSDIVC. Fifteen (28% of NMIBC) were administered PSDIVC. Twenty-three (36% of all patients) were either given PSDIVC or had a documented contraindication. Thirty-one patients in group B underwent TURBT following induction of intervention bundle. Twelve (50% of NMIBC) patients were given PSDIVC. Twenty-eight (90% of all patients) were either given PSDIVC or had a documented contraindication.

Conclusions:

The intervention bundle prompted increased administration of PSDIVC and documentation. Similar centres may benefit from an intervention to improve compliance.

Stapling and Section of the Nasogastric Tube during Sleeve Gastrectomy: How to Prevent and Recover?

Bariatric surgery has become an integral part of morbid obesity treatment with well-defined indications. Some complications, specific or not, due to laparoscopic sleeve gastrectomy (LSG) procedure have recently been described. We report a rare complication unpublished to date: a nasogastric section during great gastric curve stapling. A 44-year-old woman suffered of severe obesity (BMI 36.6 kg/m2) with failure of medical treatments for years. According to already published technique, a LSG was performed. Six hours postoperatively, a nurse removed the nasogastric tube according to the local protocol and the nasogastric tube was abnormally short, with staples at its extremity. Surgery was performed with peroperative endoscopy. In conclusion, this is the first publication of a nasogastric section during LSG. Therefore we report this case and propose a solution to prevent its occurrence. To avoid this kind of accident, we now systematically insert the nasogastric tube by mouth through a Guedel cannula. Then, to insert the calibrating bougie, we entirely withdraw the nasogastric tube.

Previous help sought by patients presenting to mental health services in Kumasi, Ghana

OBJECTIVE

There are four services providing mental health care to the people of Kumasi, Ghana. This study aimed to identify previous help sought by patients presenting to the services for an initial assessment.

METHOD

New patients presenting to each of the four services were asked about distance travelled, previous help sought and time since symptoms of illness started. Staff also recorded basic demographic details and clinical diagnoses.

RESULTS

Of the 322 patients presenting to the four sites,only 6% had seen a traditional healer whereas 14% had seen a pastor before presentation. There was a greater delay in presenting to that service if the patient had seen a traditional healer or pastor. Many patients had previously used one of the other mental health units in Kumasi.

CONCLUSION

It is possible that fewer patients with mental health problems present to traditional healers in modern, urban Africa compared to rural areas. More patients consult with pastors than traditional healers and liaison with these groups may improve mental health care. It is important to maintain liaison between the four services as patients presenting to one clinic may have presented previously to another local clinic.

Entonox as an analgesic agent during panretinal photocoagulation

BACKGROUND/AIMS

Panretinal photocoagulation (PRP) reduces the risk of visual loss in proliferative diabetic retinopathy but some patients cannot tolerate PRP because of pain. Inhaled Entonox was evaluated as an analgesic during PRP.

METHODS

A randomised, crossover, double masked pilot study was performed. Patients inhaled either air or Entonox and half the PRP was applied. The treatment was completed with the alternate inhaled gas. Patients graded pain experienced during both stages of the treatment using a visual analogue scale. Pain scores were compared using a paired t test.

RESULTS

20 patients participated. Mean pain scores from the Entonox and air treatments were 2.94 (SD 2.73) versus 3.73 (SD 3.20) respectively (p<0.03).

CONCLUSION

Entonox can be used as a safe and effective analgesic agent during PRP treatment.

Automated detection of diabetic retinopathy on digital fundus images

AIMS

The aim was to develop an automated screening system to analyse digital colour retinal images for important features of non-proliferative diabetic retinopathy (NPDR).

METHODS

High performance pre-processing of the colour images was performed. Previously described automated image analysis systems were used to detect major landmarks of the retinal image (optic disc, blood vessels and fovea). Recursive region growing segmentation algorithms combined with the use of a new technique, termed a 'Moat Operator', were used to automatically detect features of NPDR. These features included haemorrhages and microaneurysms (HMA), which were treated as one group, and hard exudates as another group. Sensitivity and specificity data were calculated by comparison with an experienced fundoscopist.

RESULTS

The algorithm for exudate recognition was applied to 30 retinal images of which 21 contained exudates and nine were without pathology. The sensitivity and specificity for exudate detection were 88.5% and 99.7%, respectively, when compared with the ophthalmologist. HMA were present in 14 retinal images. The algorithm achieved a sensitivity of 77.5% and specificity of 88.7% for detection of HMA.

CONCLUSIONS

Fully automated computer algorithms were able to detect hard exudates and HMA. This paper presents encouraging results in automatic identification of important features of NPDR.

Mitochondrial oxygen consumption is synergistically inhibited by metallothionein and calcium

OBJECTIVE

To determine the combined effect of metallothionein and calcium on the oxygen consumption of mitochondria.

BACKGROUND

We previously showed that mitochondrial oxygen consumption was inhibited by the intracellular acute-phase reactant, metallothionein, which is rapidly induced by nearly all stressed cells. Other investigators have demonstrated that calcium also inhibited oxygen consumption. However, the calcium concentrations used in their experiments were supraphysiologic. Our hypothesis was that metallothionein would enhance the effect of calcium.

METHODS

We conducted these experiments, of a paired design, on the effects of combinations of metallothionein and calcium using mitochondria isolated from rat liver. An oxygen electrode implanted into a 600-microliter chamber with a stir bar was used to measure oxygen consumption. Various concentrations of calcium, metallothionein, and other reagents were added while oxygen consumption was being continuously recorded. Metals were removed from metallothionein by gel filtration to produce apometallothionein.

RESULTS

Physiological levels of metallothionein synergistically enhanced the inhibitory effect of calcium so that its action occurred at physiological concentrations. Metallothionein devoid of its metals, zinc and cadmium, had no effect on oxygen consumption.

CONCLUSION

In isolated mitochondria metallothionein inhibits ADP-initiated oxygen consumption. This effect is synergistic with the inhibitory action of calcium. These observations suggest a possible enhancement by metallothionein of the effect of fluxes in intracellular calcium in stressed cells.

A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma

BACKGROUND

Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy.

OBJECTIVE

To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care.

METHODS

A prospective, randomized clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomization or with routine therapy in a hospital ward. Patients were followed up for 8 weeks.

MAIN OUTCOME MEASURES

Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patients satisfaction, and patient quality of life.

RESULTS

The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P = .74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favoring EDTU care. The mean (+/-SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P < .001).

CONCLUSIONS

Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.

Opposite effects of metallothionein I and spermine on mitochondrial function

Previously, we reported that the stress-induced protein metallothionein I (MT) modulated the oxygen consumption (VO2) of isolated rat liver mitochondria [Life Sci. 55 221-226, 1994]. We now present confirmation of this finding, and the additional observations that in rat liver mitochondria, MT caused swelling and depolarization. These actions of MT were inhibited by the aliphatic polyamine, spermine. Our findings suggest that mitochondrial function could be influenced by the balance between MT and spermine.

Body mass index and coronary artery disease in African-Americans

There are limited data available concerning the influence of obesity, a major cardiovascular disease risk factor, in relationship to coronary artery disease (CAD). This is of considerable importance to African-Americans since African-Americans have one of the world's highest CAD mortality rates coupled with the fact that obesity is extremely prevalent in this population. The present study assessed the relationship between body mass index and CAD in African-Americans undergoing coronary angiography. Eight hundred sixty-six available cardiac catheterization reports between the years 1983 through 1990 were retrospectively reviewed at Howard University Hospital in Washington, D.C. CAD was prevalent in 59.6% and 41.2%, males and females, respectively. Among the males overweight and obesity were found in 22.4% and 20.9%, respectively, compared to 39.6% and 30.6% for females. An upside-down U-shaped relationship between BMI and CAD was found. The interpretation of this finding is that being overweight is associated with increased risk of CAD compared to the lean and obese.

Coronary arteriographic findings in black patients and risk markers for coronary artery disease

Coronary arteriographic results are reported in 1535 black patients: 751 men (mean age 57 +/- 11) and 784 women (mean age 59 +/- 11). Among the black men 19%, 15%, 21%, and 4% had single-, double-, and triple-vessel and left main disease, respectively. Among the black women there were 12%, 10%, 15%, and 3% with similar involvement. Logistic regression models showed that most of the recognized risk factors were positively correlated with significant (at least one artery with > or = 50% stenosis) coronary disease, but a history of hypertension was not a significant independent predictor in either sex. ECG evidence of previous infarction increased the odds of detecting significant coronary disease by the greatest amount when controlling for other significant risk markers in women. In men both previous infarction and atypical pain (negative) were equally important. This study confirms but does not explain previous reports that have revealed less than expected angiographic evidence of significant coronary artery disease in black compared with white persons.