Immersive interactive virtual walking reduces neuropathic pain in spinal cord injury: findings from a preliminary investigation of feasibility and clinical efficacy

ABSTRACT

Chronic neuropathic pain (NP) is a common and often debilitating secondary condition for persons with spinal cord injury (SCI) and is minimally responsive to existing pharmacological and nonpharmacological treatments. The current preliminary investigation describes the feasibility and initial comparative efficacy of an interactive virtual reality walking intervention, which is a novel extension of visual feedback/illusory walking therapies shown to reduce SCI NP. Virtual reality walking intervention builds on previous research by, for the first time, allowing individuals with SCI NP to volitionally control virtual gait to interact with a fully immersive virtual environment. The current pilot study compared this interactive, virtual walking intervention to a passive, noninteractive virtual walking condition (analogous to previous illusory walking interventions) in 27 individuals with complete paraplegia (interactive condition, n = 17; passive condition, n = 10; nonrandomized design). The intervention was delivered over 2 weeks in individuals' homes. Participants in the interactive condition endorsed significantly greater reductions in NP intensity and NP-related activity interference preintervention to postintervention. Notable improvements in mood and affect were also observed both within individual sessions and in response to the full intervention. These results, although preliminary, highlight the potentially potent effects of an interactive virtual walking intervention for SCI NP. The current study results require replication in a larger, randomized clinical trial and may form a valuable basis for future inquiry regarding the mechanisms and clinical applications of virtual walking therapies.

1290 A Move to Magseed For Breast Conserving Surgery

Aim

Wire guided localisation(WGL) to localise non-palpable breast tumours has been the standard for years. WGL has limitations; patient discomfort, fixed scheduling to facilitate insertion on the day of surgery and wire migration. A 2015 audit in our department found that 51% of patients undergoing wide local excision (WLE) used preoperative localisation techniques; of which 84% was WGL. The overall re-excision rate for WLE was 27%. We altered our practice to Magseed localisation from July 2019 to improve patient experience, and surgical efficiency, as there are similar outcomes between WGL and Magseed in the literature. This audit aims to examine if there are improvements in our re-excision rate. We aim to evaluate which is the best method for localisation in our department.

Method

A retrospective audit was conducted following registration with the local audit office. Patients who underwent breast conserving surgery between September 2019 and September 2020 were identified. The surgical approach, re-excision and complications were recorded and compared to the 2015 results.

Results

100 patients underwent WLE in the study period. The percentage of patients undergoing therapeutic mammaplasty was 26% (14% in 2015). 63% underwent preoperative localisation; of which 71% used Magseed and 5% used wire. The overall re-excision rate was 20%.

Conclusions

Our re-audit has demonstrated an increase in patients requiring pre-operative localisation, probably due to the use of primary endocrine treatment during COVID-19. We gladly observed 26% improvement in re-excision rates suggesting success with Magseed.

407 Requesting, Treatment and Outcomes Following Oncotype DX Testing in Breast Cancer

Aim

Oncotype DX (ODX) is a 21-gene assay for invasive breast cancer that yields a recurrence score (RS) value which indicates the risk of distant recurrence and the benefit from chemotherapy. NICE has laid down guidance regarding the criteria for test requesting which include having early breast cancer at an intermediate risk of distant recurrence that is ER-positive, HER2-negative and LN-negative. The aim of this study was to determine whether ODX was appropriately requested and followed. Treatment and outcomes were also observed.

Method

The study included all patients from The Countess of Chester Hospital who had undertaken ODX testing in the years 2015-2017. Patients were identified and clinicopathological data was obtained from clinic notes and pathology reports. NPI and PREDICT scores were calculated. The ODX original cut-off values were used.

Results

All 65 patients included in the study were ER-positive, 1 was HER2-positive and 1 was LN-positive. 9 patients had ODX requested inappropriately, all of which were low risk on both NPI and PREDICT. Chemotherapy was received by 1/32 low risk patients (RS 0-17), 6/24 intermediate risk patients (RS 18-30) and 5/5 high risk patients (RS 31-100). 57 patients had no recurrence, 2 patients had local recurrence (intermediate RS), 1 patient had distant recurrence (low RS) and 1 patient had metastasis (low RS). Chemotherapy was not received by any of the patients who experienced recurrence.

Conclusions

Adherence to NICE guidance regarding ODX requesting needs further emphasising. This would help reduce unnecessary patient investigation, costs, and pathology-lab workload.

When driving hurts: characterizing the experience and impact of driving with back pain

OBJECTIVES

Driving is one of the most widespread aspects of daily living to people in the United States and is an active process that requires various cognitive functions, such as attention. Chronic low back pain (CLBP) is one of the more prevalent and costly health conditions in the world, with individuals who report CLBP also reporting significant impairment across different domains of daily life both physically and cognitively. However, despite the prevalence of these two constructs, research detailing the experience of driving in pain remains largely underrepresented. This cross-sectional study sought to characterize the driving experience of people who experience CLBP, focusing on the psychological constructs related to chronic pain like pain catastrophizing, affective responses (irritability, anxiety, fear), and self-reported driving behaviors and outcomes.

METHODS

This study distributed an online questionnaire measuring pain, disability, and other psychological constructs commonly associated with CLBP like pain catastrophizing through M-turk to 307 U.S. participants with recurring CLBP and regular driving activity. Participants also answered questions regarding driving in pain, affective responses to driving in pain (i.e., irritability, anxiety, and fear), driving behaviors and violations, driving avoidance habits as a result of pain, opioid use, using pain medication while driving, and recent vehicle collisions within the past three years. Bivariate correlations were used to compare study variables, and one-way ANOVA's were used to compare means between participants with and without a collision history within the past three years.

RESULTS

Findings demonstrated significant positive associations not only between the psychological factors commonly associated with chronic pain, such as pain intensity, pain disability, pain catastrophizing, and the cognitive intrusion by pain, but also statistically significant relationships between these measures and pain intensity while driving, affective responses to driving in pain, driving violations, and driving avoidance habits. Additionally, in comparison to participants with no collision history within the past three years, participants who had been driving during a vehicle collision reported greater pain catastrophizing and cognitive intrusion by pain scores.

CONCLUSIONS

To our knowledge, the current study is the first to characterize driving experience specifically among individuals with CLBP, with attention to the relationship among key sensory, affective, and cognitive psychological metrics as well as self-reported driving history and behavior. The current findings reinforce multiple associations between pain and cognitive-affective variables that have been observed in literature outside the driving context, including pain intensity, anger, inattention, and behavioral disruption. Given that driving is a pervasive, potentially risky behavior that requires some form of cognitive focus and control, the current findings point to a continued need to examine these associations within this specific life context. We believe we have laid a groundwork for research considering the role of psychological pain variables in a driving performance. However, the nature of our analyses prevents any sort of causality from being inferred, and that future experimental research is warranted to better understand and explain these mechanisms underlying driving in pain while accounting for participant bias and subject interpretation.

Development and validation of a daily Injustice Experience Questionnaire

BACKGROUND

Patterns of cognitive appraisal related to chronic pain may manifest differentially across time due to a variety of factors, but variability of injustice appraisals across time has not been examined. The current study details the validation of a brief, daily version of the Injustice Experience Questionnaire (IEQ), which measures injustice appraisals related to the experience of pain and disability.

METHODS

Injustice Experience Questionnaire items were adapted for daily use and evaluated using cognitive interviews, and the resulting measure was administered for 10 days to two Internet-based samples of US adults with chronic lower back pain.

RESULTS

Study 1 (N = 126) refined the 12-item IEQ measure into a six-item short form; exploratory factor analyses suggested optimal model fit for the two-factor model established in the original IEQ. Using confirmatory factor analyses, Study 2 (N = 131) replicated the two-factor structure and demonstrated significant correlations of the Daily IEQ with other relevant constructs to chronic pain, such as pain catastrophizing, pain intensity, pain-related activity and social interference, depressed mood and anxiety. Daily IEQ items showed a significant degree of clustering (intraclass correlations ranging from .577 to .735) but demonstrated sufficient variability at the daily level to allow for daily-level analysis.

CONCLUSIONS

Injustice appraisals show a sufficient degree of daily variability to warrant their measurement as a time-varying construct. Further examination of antecedents and correlates of daily injustice appraisals, as well as their potential role as mechanisms of effect, may better explain the dynamics of affective and behavioral responses to chronic pain.

SIGNIFICANCE

The current study presents a validation of a daily version of the Injustice Experience Questionnaire in chronic low back pain. Results indicate that injustice appraisals vary significantly from day to day, and daily variability in injustice perception shows robust associations with pain intensity, pain-related interference in physical and social activity, and mood in chronic low back pain. These results emphasize the importance of assessing injustice perception as a time-varying, rather than stable construct in future empirical and clinical studies.

Influence of muscle training on resting blood flow and forearm vessel diameter in patients with chronic renal failure

Background

Blood flow and vessel diameter are predictors of the success of vascular access procedures. This study investigated whether a simple exercise programme could influence these variables.

Methods

Twenty-three patients with chronic kidney disease were prescribed a simple exercise programme for one arm only; the investigators were blinded to the patients' choice. All underwent arterial and venous duplex imaging, handgrip strength and blood pressure measurements before and 1 month after the exercise programme.

Results

Twelve patients exercised their dominant and 11 their non-dominant arm. In the trained arm, the exercise programme resulted in a significant increase in handgrip strength, by a median (interquartile range) of 4 (0–8) kg (P < 0·001), and in the diameter of the brachial artery (0·2 (0·1–0·3) mm; P < 0·001), radial artery (0·3 (0·2–0·4) mm; P < 0·001), and cephalic vein (0·6 (0·4–1·2) mm in the forearm and 1·1 (0·4–1·2) mm above the elbow; P < 0·001). There was an increase in brachial artery mean velocity (3 (1–7) cm/s; P = 0·009) and peak systolic velocity (8 (1–15) cm/s; P = 0·020), despite a marginally lower systolic blood pressure (−8 (−16 to 0) mmHg; P = 0·007). There was no change in any of these parameters in the non-exercised arm.

Conclusion

In patients with chronic kidney disease, forearm exercise increased blood flow and vessel diameters. This may be beneficial before vascular access formation.

Varicella vaccine exposure during pregnancy: data from the first 5 years of the pregnancy registry

OBJECTIVE

To assess the risks of congenital varicella syndrome and other birth defects in offspring of women who inadvertently received varicella vaccine during pregnancy or within 3 months of conception.

METHODS

Pregnant women inadvertently exposed to varicella vaccine, reported voluntarily, were enrolled in the Pregnancy Registry for VARIVAX (Merck & Co., Inc., West Point, PA). The pregnancies were monitored and the outcomes ascertained from questionnaires completed voluntarily by the health care providers. The rates of congenital varicella syndrome and congenital anomalies were calculated for seronegative women prospectively reported to the registry.

RESULTS

From March 17, 1995 through March 16, 2000, 362 pregnancy outcomes were identified from prospective reports. Ninety-two women were known to be seronegative to varicella, of whom 58 received their first dose of vaccine during the first or second trimester. No cases of congenital varicella syndrome were identified among 56 live births (rate 0%, 95% confidence interval [CI] 0, 15.6). Among all the prospective reports of live births, five congenital anomalies were reported. No specific pattern was identified in either the susceptible cohort or the sample population as a whole.

CONCLUSION

No abnormal features have been reported that suggested the occurrence of congenital varicella syndrome or other birth defects related to vaccine exposure during pregnancy. Because of the small numbers, this study has limited precision, so continued surveillance is warranted. However, these results should provide some assurance to health care providers and women with inadvertent exposure before or during pregnancy.

The use of school-based vaccination clinics to control varicella outbreaks in two schools

School-based vaccination clinics were offered in 2 schools experiencing varicella outbreaks. The clinics raised coverage of susceptible children from 52.9% to 92.2% and from 68.8% to 85.3% in the 2 schools, respectively. Although routine immunization and school-entry requirements are the best strategies for preventing outbreaks, school-based vaccination clinics may greatly increase coverage and shorten outbreaks.

Postexposure effectiveness of varicella vaccine

OBJECTIVE

1) To describe the postexposure effectiveness of varicella vaccine in a homeless shelter; and 2) to demonstrate an effective public health intervention and its implications.

DESIGN

A prospective observational study.

SETTING

A women and children's shelter in Philadelphia with 2 cases of varicella before intervention.

OUTCOME MEASURES

Varicella in vaccinated and unvaccinated shelter residents; vaccine effectiveness for prevention of varicella when administered after exposure among children <13 years of age.

RESULTS

Sixty-seven shelter residents received varicella vaccine after exposure, including 42 children <13 years of age. One child who was unvaccinated developed varicella, but no vaccinated child developed typical disease. Vaccine effectiveness was 95.2% (95% CI, 81.6%-98.8%) for prevention of any disease and 100% for prevention of moderate or severe disease among the children <13 years of age.

CONCLUSION

When used within 36 hours after exposure to varicella in a setting where close contact occurred, varicella vaccine was highly effective in preventing further disease. This study provides support for the recent recommendation by the Advisory Committee on Immunization Practices to administer varicella vaccine after exposure: this practice should minimize the number of moderate or severe cases of disease and prevent prolonged outbreaks.

Recommendations for training in performance and interpretation of stress echocardiography. Committee on Physician Training and Education of the American Society of Echocardiography

Stress echocardiography has emerged as a clinically useful procedure in the management of patients with ischemic heart disease and other conditions. However, the accuracy of this test relies on the ability of those who carry out the technical aspects of the test and depends critically on proper interpretation of the images. Appreciation of wall motion abnormalities is generally acknowledged as one of the most difficult skills to master in echocardiography. There is consensus that this is also one of the most difficult skills to teach. Appreciating stress-induced changes in wall motion, which sometimes are subtle, requires a significant commitment to initial training in this skill and its maintenance. This document provides recommendations for physician training in stress echocardiography.

Feasibility of generating hemodynamic pressure curves from noninvasive Doppler echocardiographic signals

OBJECTIVES

This study was designed to determine the feasibility of Doppler generation of accurate, complete right ventricular and pulmonary artery pressure curves in patients with Doppler-measurable tricuspid and pulmonary regurgitation.

BACKGROUND

Doppler-derived flow velocities have been used to assess right ventricular systolic pressure; pulmonary artery systolic, diastolic and mean pressures, and left ventricular systolic and diastolic pressures. Instantaneous gradient across any area of discrete narrowing is accurately derived using the simplified Bernoulli equation (4V2). Invasive catheterization is currently the only means of generating intracardiac pressure curves. Noninvasively derived pressure curves using Doppler echocardiography would be a considerable advance in the assessment of normal and pathologic cardiac hemodynamics.

METHODS

Right ventricular and pulmonary artery pressure curves were generated in 18 of 22 patients with measurable tricuspid and pulmonary valve regurgitation using superimposition of Doppler-measured tricuspid and pulmonary valve blood flow velocities on an assumed right atrial pressure. Doppler-measured right ventricular and pulmonary artery pressure curves were compared with simultaneous catheterization-measured curves.

RESULTS

Doppler-derived pulmonary artery systolic pressure (Doppler PAP) correlated with simultaneous catheter-measured pulmonary artery pressure (Cath PAP) by the equation Doppler PAP = 0.92(Cath PAP) + 4.5, r = 0.98. Other Doppler-derived pressure measurements that correlated at near identity with the catheterization-measured corresponding measurement include Doppler-derived pulmonary artery mean pressure (Doppler mean PAP) [Doppler mean PAP = 0.85(Cath mean PAP) + 2.6, r = 0.97], and Doppler-derived right ventricular pressure (Doppler RVP) [Doppler RVP = 0.84(Cath measured RVP) + 7.9, r = 0.98]. Doppler-derived pulmonary, artery diastolic pressure (Doppler PAP diast) did not correspond as well in this study [Doppler PAP diast = 0.45(Cath PAP diast) + 6.6, r = 0.83].

CONCLUSIONS

Clinically usable right ventricular and pulmonary artery pressure curves can be derived by superimposing Doppler-measured tricuspid and pulmonary valve blood flow velocities in patients with tricuspid and pulmonary valve regurgitation.

The sensitivity of the Mini-Mental State Exam in the white matter dementia of multiple sclerosis

Fifty-six patients diagnosed with definite multiple sclerosis (MS) according to Poser criteria were administered the Mini-Mental State Examination (MMSE) and a comprehensive battery of neuropsychological tests. Extent of cerebral lesion involvement was determined by quantitative magnetic resonance imaging (MRI) ratings. The MMSE correlated with overall levels of physical disability, but did not correlate with total lesion area on MRI. Sensitivity of the MMSE to the subcortical dementia of MS was low (28%) when performance on the neuropsychological testing battery was used as the criterion. Impairment on tests of memory, speed of information processing, abstract reasoning, naming/verbal fluency, as well as visuoperceptual organization, were correlated highly with total lesion area on MRI. The low sensitivity of the MMSE to cognitive impairment in MS is discussed in terms of its item composition and the characteristic pattern of deficits found in MS.

Neuropsychological and structural brain lesions in multiple sclerosis: a regional analysis

Quantified lesion scores derived from MRI correlate significantly with neuropsychological testing in patients with multiple sclerosis (MS). Variables used to reflect disease severity include total lesion area (TLA), ventricular-brain ratio, and size of the corpus callosum. We used these general measures of cerebral lesion involvement as well as specific ratings of lesion involvement by frontal, temporal, and parieto-occipital regions to quantify the topographic distribution of lesions and consequent effects upon cognitive function. Lesions were heavily distributed in the parieto-occipital regions bilaterally. Neuropsychological tests were highly related to all generalized measures of cerebral involvement, with TLA being the best predictor of neuropsychological deficit. Mean TLA for the cognitively impaired group was 28.30 cm2 versus 7.41 cm2 for the cognitively intact group (p less than 0.0001). Multiple regression analyses revealed that left frontal lobe involvement best predicted impaired abstract problem solving, memory, and word fluency. Left parieto-occipital lesion involvement best predicted deficits in verbal learning and complex visual-integrative skills. Analysis of regional cerebral lesion load may assist in understanding the particular pattern and course of cognitive deficits in MS.

Left ventricular preparation with an extrathoracically adjustable balloon occluder

We developed a hydraulic occluder that could be adjusted percutaneously through a subcutaneous reservoir. Because of the potentially high pressures that may occur in preparing patients with transposition of the great vessels for an atrial switch procedure, the band on that hydrauler was modified to withstand arterial pressure and was subjected to studies involving banding of the aorta. Data indicate the suitability of this hydraulic occluder to withstand and maintain pressure in the systemic circulation.

Seasonal differences in breast-feeding in rural Egypt

Two surveys in Upper and Lower rural Egypt allowed an analysis of the seasonality of infant feeding. The first, including 937 children, was conducted during the relatively cool season of low diarrhea incidence in January-April 1978; the second, including 976 children, took place during the hot season of high diarrhea incidence in August-September 1980. Of infants 6-11 mo old, the proportion exclusively breast-feeding was greater in the hot-season survey (40% vs 16% in Lower Egypt, p less than 0.01; 36% vs 22% in Upper Egypt, p less than 0.01). Of children 12-17 mo old, a higher proportion were completely weaned during the hot season in Lower Egypt only (28% vs 14%, p less than 0.01). This difference was explained by an increase in pregnancy rates during the hot season resulting in less breast-feeding. Seasonal variation must be considered in the interpretation of infant-feeding surveys.

Amanita phalloides-type mushroom poisoning

In the fall of 1981 the San Francisco Bay Area Regional Poison Control Center received more than 100 calls regarding wild mushroom ingestion. Ten cases, including three fatalities, had all the features of Amanita phalloides poisoning. Encephalopathy, coma and renal insufficiency occurred in all three patients who died, but did not occur in those who survived. Two of the three patients who died arrived at the hospital late in the course of their illness, and severe gastroenteritis with accompanying dehydration probably contributed to their deaths. The poison control center promoted public awareness of the mushroom hazard through newspaper and television stories and by notifying local health departments. It also has devised a simple form to improve the quality of data collection and to assist in later verification of suspected A phalloides poisoning.