Postoperative statin therapy is not associated with reduced incidence of venous thromboembolic events following kidney transplantation

BACKGROUND

The pleiotropic effects of statin therapy on inflammation and coagulation may reduce the risk of venous thromboembolism. This study evaluated whether statin therapy is associated with decreased venous thromboembolic (VTE) events following kidney transplantation.

METHODS

We performed a retrospective analysis of all primary kidney transplants performed between January 2014 and December 2019 at Mayo Clinic Arizona. Patients were divided into two groups depending on sustained statin therapy during the first year following transplantation. Recipient and donor clinical and demographic data were collected. The primary outcome was admission for symptomatic VTE events (deep vein thrombosis [DVT] or pulmonary embolism [PE]).

RESULTS

Sustained statin therapy in the first year following transplant was observed in 16.1% (n = 223) of 1384 kidney transplants. The overall incidence of VTE events in the year following kidney transplant was 3.8%. VTE occurred in 4.1% of recipients treated with statins and 3.8% of the controls - (hazard ratio [HR] .92, 95% confidence interval [95% CI] .39, 2.21, p = .86). However, there were significant differences between the groups in terms of age, sex, race/ethnicity, body mass index, indication for transplant, diagnosis of diabetes and discharge antiplatelet or anticoagulant therapy. Following sensitivity analysis in which cohort matching was performed to account for these differences, there was no difference in VTE event-free survival (HR .89, 95% CI .41, 1.96, p = .78) or overall survival (HR .54, 95% CI .15, 1.94, p = .35) between patients treated with statins compared to controls.

CONCLUSION

Statin therapy in the year following successful kidney transplant was not associated with a reduction in risk of VTE.

Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists

BACKGROUND

Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients.

METHODS

Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence.

RESULTS

Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status.

CONCLUSIONS

These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial

BACKGROUND

Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher.

MATERIALS AND METHODS

A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals.

RESULTS

No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management.

CONCLUSION

When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Evaluation of Clinical Factors Associated with Adverse Drug Events in Patients Receiving Sub-Anesthetic Ketamine Infusions

Introduction

Sub-anesthetic ketamine is frequently used as an analgesic to reduce perioperative opioid consumption and has also been shown to have antidepressant effects. Side effects of ketamine include dizziness, diplopia, nystagmus, and psychomimetic effects. It is unclear what clinical factors may be associated with ketamine-related adverse drug events (ADEs).

Methods

We performed a retrospective review of 95 patients who received sub-anesthetic ketamine infusions at our institution. Data examined associations between ketamine-related ADEs and various clinical characteristics including chronic pain, depression, or psychiatric disorder, patient physical characteristics, chronic opioid use, perioperative opioid use, dose and duration of ketamine infusions, pain scores, and perioperative medications such as serotonergic agents, central nervous system (CNS) depressants, and analgesics.

Results

Overall incidence of ketamine-related ADEs was 29.5% and the incidence of psychomimetic effects was 14.8%. We observed that patients with a history of depression have a lower incidence of ketamine-related ADEs compared to patients without a history of depression (10.3% vs 37.3%; p value = 0.007).

Conclusion

Patients with depression were found to have a statistically significant reduction in the incidence of ketamine-related ADEs. We found no statistically significant positive associations between ketamine-related ADEs and other clinical factors such as a history of chronic pain, psychiatric disease, patient physical characteristics, perioperative opioid use, dose of ketamine infusion, or co-administration of other CNS depressants.

Fatal diffuse pulmonary fat microemboli following reperfusion in liver transplantation with the use of marginal steatotic allografts

Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.

The effect of ampule size of fentanyl on perioperative intravenous opioid dosing

Background and Aims:

There are limited data on the effect of ampule size on drug dosing. The objective of this study is to determine the effect of ampule size on perioperative opioid dosing and post-anesthesia care unit (PACU) outcomes.

Material and Methods:

This was a retrospective review of patients undergoing robotically assisted laparoscopic radical prostatectomy before and after a 5-ml fentanyl ampule was discontinued. The primary outcome was intraoperative opioid administration divided into fentanyl at induction of anesthesia, total fentanyl, and total opioid. Secondary outcomes observed in PACU included the opioid administered, visual analog scale (VAS) pain scores, postoperative nausea and vomiting, and length of stay in PACU.

Results:

A total of 100 patients (50 PRE and 50 POST) were included. In the intraoperative opioid administration, mean (SD) of fentanyl at induction was 117.0 (49.3) in PRE group and 85.0 (35.4) μg in POST group (P < 0.01). The total fentanyl requirement was 247.0 (31.0) in PRE group and 158.5 (85.1) μg in POST group (P < 0.01). The total opioid in intravenous morphine equivalents (IVME) was 34.1 (5.8) in PRE group and 23.2 (6.8) mg in POST group (P < 0.01). Among the secondary outcomes, mean (SD) of IVME of opioid was 7.7 (8.2) in PRE group and 9.9 (8.1) mg in POST group (P = 0.18). The VAS pain score on arrival was 0.7 (1.4) in PRE group and 3.8 (3.3) in POST group (P < 0.01). The cumulative VAS pain score was 2.3 (2.0) in PRE group and 3.3 (2.2) in POST group (P < 0.01). The length of stay was significantly more in POST group, 193.8 (75.8) minutes, as compared with PRE group, 138.6 (61.0) minutes (P < 0.01).

Conclusions:

A change in the ampule size significantly affected intraoperative dosing, PACU pain scores, and PACU length of stay in patients undergoing robotically assisted laparoscopic radical prostatectomy under general anesthesia. This was explained by clinician's desire to conserve the drug and avoid the complex process of narcotic waste disposal.

Survey of pain specialists regarding conversion of high-dose intravenous to neuraxial opioids

The conversion of high-dose intravenous (IV) opioids to an equianalgesic epidural (EP) or intrathecal (IT) dose is a common clinical dilemma for which there is little evidence to guide practice. Expert opinion varies, though a 100 IV:10:EP:1 IT conversion ratio is commonly cited in the literature, especially for morphine. In this study, the authors surveyed 724 pain specialists to elucidate the ratios that respondents apply to convert high-dose IV morphine, hydromorphone, and fentanyl to both EP and IT routes. Eighty-three respondents completed the survey. Conversion ratios were calculated and entered into graphical scatter plots. The data suggest that there is wide variation in how pain specialists convert high-dose IV opioids to EP and IT routes. The 100 IV:10 EP:1 IT ratio was the most common answer of survey respondent, especially for morphine, though also for hydromorphone and fentanyl. Furthermore, more respondents applied a more aggressive conversion strategy for hydromorphone and fentanyl, likely reflecting less spinal selectivity of those opioids compared with morphine. The authors conclude that there is little consensus on this issue and suggest that in the absence of better data, a conservative approach to opioid conversion between IV and neuraxial routes is warranted.

Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults

BACKGROUND

Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q).

METHODS

Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores.

RESULTS

Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system.

CONCLUSIONS

Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

Intravenous sub-anesthetic ketamine for perioperative analgesia

Ketamine, an N-methyl-d-aspartate antagonist, blunts central pain sensitization at sub-anesthetic doses (0.3 mg/kg or less) and has been studied extensively as an adjunct for perioperative analgesia. At sub-anesthetic doses, ketamine has a minimal physiologic impact though it is associated with a low incidence of mild psychomimetic symptoms as well as nystagmus and double vision. Contraindications to its use do exist and due to ketamine's metabolism, caution should be exercised in patients with renal or hepatic dysfunction. Sub-anesthetic ketamine improves pain scores and reduces perioperative opioid consumption in a broad range of surgical procedures. In addition, there is evidence that ketamine may be useful in patients with opioid tolerance and for preventing chronic postsurgical pain.

Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

Use of botulinum toxin injections to treat peripheral stimulator induced facial muscle twitching: a case report

Background

Facial pain can be a management challenge. Peripheral nerve/field stimulation may be an effective option for refractory cases, but direct muscle stimulation with facial twitching may result. Botulinum toxin injections have been used for blepharospasm and may be effective when facial stimulation results in unacceptable facial muscle twitching due to peripheral stimulation.

Case presentation

A 53-year old female suffered with chronic, refractory facial pain and migraines. Her facial pain began after a root canal of a left upper molar. She was trialed and then permanently implanted with a 1 × 8 sub-compact percutaneous stimulator lead, resulting in improved pain control and reduced medication use. However, she experienced blepharospasm whenever the amplitude was above 2.75 A. Therefore, she was treated with botulinum toxin injections into her bilateral cheek, face, temple and occiput. This treatment provided excellent relief of the facial spasms, allowing her to use her stimulator at high amplitudes, and thereby maximizing her pain relief. She received two subsequent treatments of botulinum toxin injections at 5-month intervals with similar results.

Conclusion

Peripheral nerve/field stimulation is being used for headaches and facial pain. An undesirable side effect of this emerging therapy is direct muscle stimulation. Botulinum toxin injections may be an effective treatment modality when stimulation techniques provide pain relief but also causes muscle twitching.

Painful Ejaculation with Cyclobenzaprine: A Case Report and Literature Review

Introduction

Sexual dysfunction is a well‐known side effect of antidepressants. Painful ejaculation is a rare side effect that has been reported with the use of some psychiatric drugs such as triclyclic antidepressants. Cyclobenzaprine is a muscle relaxant that is structurally similar to tricyclic antidepressants. It is the most commonly prescribed muscle relaxant in the United States and accounts for 18% of all prescriptions written for chronic back pain.

Methods

A 55‐year‐old man was referred to our pain medicine clinic for evaluation and treatment of pain with ejaculation.

Main outcome Measure

The main outcome measure was to review the current published literature and case reports on painful ejaculation from medication use, in particular tricyclic antidepressants.

Results

After discontinuation of cyclobenzaprine, our patient's sexual dysfunction resolved. This result was consistent with the literature reviewed on the topic.

Conclusion

Painful ejaculation is likely an underreported side effect of tricyclic antidepressants and cyclobenzaprine use. Fortunately, these symptoms are reversible and discontinuation of these medications is typically an effective cure. KrausMB,WieCS,GorlinAW,WisenbaughES, andRosenfeldDM. Painful ejaculation with cyclobenzaprine: A case report and literature review.SexMed 2015;3:343–345.

Patient understanding of the importance of statin use in the perioperative period

OBJECTIVE

Perioperative hydroxy-3-methyl glutaryl coenzyme A reductase inhibitors (statins) have been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to assess patient understanding of the potential benefits of perioperative statins in a select population already on chronic therapy. A secondary aim was to determine the frequency with which patients recalled having a discussion with their provider regarding perioperative statins.

DESIGN

Survey.

SETTING

Teaching hospital.

PARTICIPANTS

Patients taking daily statins presenting to a preoperative medical evaluation clinic were offered a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-two patients completed the questionnaire. The mean age was 68.3 years (standard deviation, 9.0); 42% were female. The most frequent surgical referral to the clinic was orthopedics, at 36%. The most common statin prescribed was atorvastatin, in 35% of patients. Twenty-seven percent of patients (n = 36) recognized that perioperative statins are beneficial; 44% of these patients (n = 14) cited decreased cholesterol during the procedure as the reason, representing 12% of the total sampled population. Twenty-two percent (n = 8) of those recognizing the benefit of perioperative statins identified a decrease in the risk of heart attack or death as the reason. This represented only 6% of the total sample. One percent of surgeons mentioned statins in relation to the planned surgery; 2% of primary or prescribing physicians mentioned the medication in relation to surgery.

CONCLUSIONS

This study suggested low patient understanding of the potential importance and reasons for perioperative statins. In addition, this study also suggested that the information regarding the importance of perioperative statins is not being relayed to the patient at the level of the surgeon or primary care physician. All physicians involved in perioperative care can offer improved patient education to promote compliance with statin therapy in hopes of a favorable impact on perioperative outcomes.

Attributes associated with patient perceived outcome in an academic chronic pain clinic

OBJECTIVES

Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient-provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health.

METHODS

A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit.

RESULTS

The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good.

CONCLUSIONS

Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.

Patient satisfaction in an academic chronic pain clinic

OBJECTIVES

Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient-physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from "very good" to "excellent," and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking.

METHODS

Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit.

RESULTS

A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of "very good" vs. "excellent" patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making.

CONCLUSIONS

These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.

Long-term outcome in occipital nerve stimulation patients with medically intractable primary headache disorders

INTRODUCTION

€‚ Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-€term ONS outcomes.

METHODS

€‚ The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records.

RESULTS

€‚ Twenty-nine patients underwent a trial of ONS during the 8.5-€year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-€eight percent of patients required at least one lead revision.

DISCUSSION

€‚ These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS.

CONCLUSIONS

€‚ Randomized controlled long-€term studies in specific, intractable, primary headache disorders are indicated.

Pontine hemorrhage following a recently implanted intrathecal drug delivery system

BACKGROUND

This report describes a pontine hemorrhage in a patient following implantation of an intrathecal drug delivery system.

CASE REPORT

A 70-year-old old female patient with metastatic breast carcinoma underwent placement of an implantable intrathecal drug delivery system. Before implant she was neurologically intact with only mild memory deficiencies attributed to narcotics and malignancy. No recent brain magnetic resonance imaging (MRI) was on record. On post-implant day 2 after the initiation of intrathecal hydromorphone 0.45 mg/day and bupivacaine 2.7 mg/day, she developed dizziness, lethargy, and mild gait instability. Despite decreasing drug dosages, these symptoms progressed over the ensuing days, and subsequently the patient developed upper extremity numbness and tinnitus. The device was turned off on post-implant day 9 with the patient showing no signs of improvement. She underwent computerized tomography scan of the head, which identified an acute pontine hemorrhage. A follow-up MRI scan confirmed the hemorrhage and revealed a previously undiagnosed underlying metastatic lesion with surrounding vasogenic edema. She was treated with supportive measures in hospice and expired 20 days after implantation.

CONCLUSIONS

This case emphasizes several important points. First, changes in neurologic and mental status after initiating intrathecal drug therapy may be related to new or pre-existing pathology and not due to intrathecal medications. Second, consideration should be given to central nervous system imaging before intrathecal pump insertion in patients with widely metastatic malignancies. Finally, cerebral spinal fluid hypotension from dural puncture may have contributed to the timing of the hemorrhage in this patient.

Allogeneic epidural blood patch in the setting of persistent spinal headache and disseminated coccidioidomycosis

In most cases of post-dural puncture headache, the positional symptoms will resolve spontaneously within 2 weeks. Conservative therapies include oral analgesics and hydration, bed rest, and abdominal binders. For refractory cases, an autologous epidural blood patch remains the treatment of choice. However, in certain cases the use of autologous blood for the blood patch may place the patient at risk for infectious or malignant contamination of the central nervous system. Coccidioidomycosis results from inhalation of the arthroconidia (spore) stage of the fungal lifecycle. The most common manifestation of coccidioidomycosis is acute pulmonary symptoms, while the most feared complication is meningitis. Immunocompromised patients are at increased risk of fungemia; therefore, introduction of fungal elements into the central nervous system can occur if autologous blood is used for an epidural blood patch. We report a case of persistent dural-puncture headache in the setting of disseminated coccidioidomycosis. An autologous blood epidural blood patch was considered but deferred due to risk of coccidioidomycosis meningitis. Other epidural space interventions such as fibrin glue injection or saline infusions were judged to be too imprecise or ineffective. The patient was successfully treated with allogeneic blood donated by his wife, but only after testing of her blood as is required for any directed blood donation. Allogeneic epidural blood patches are an option for refractory dural puncture headaches when autologous blood may cause meningitis or malignant seeding of the central nervous system.

Greater occipital nerve stimulation via the Bion microstimulator: implantation technique and stimulation parameters. Clinical trial: NCT00205894

BACKGROUND

Millions of patients suffer from medically refractory and disabling primary headache disorders. This problem has led to a search for new and innovative treatment modalities, including neuromodulation of the occipital nerves.

OBJECTIVES

The primary aim of this study is to describe an implantation technique for the Bion microstimulator and document stimulation parameters and stimulation maps after Bion placement adjacent to the greater occipital nerve. The secondary aim is to document outcome measures one year post-implant.

DESIGN

Prospective, observational feasibility study.

METHODS

Nine patients with medically refractory primary headache disorders participated in this study. Approximately 6 months after Bion insertion, stimulation parameters and maps were documented for all patients. At one year, outcome measures were collected including the Migraine Disability Assessment Score.

RESULTS

At 6 months, the mean perception threshold was 0.47 mA, while the mean discomfort threshold was 6.8 mA (stimulation range 0.47-6.8 mA). The mean paresthesia threshold was 1.64 mA and the mean usage range was 16.0. There were no major complications reported such as device migration, infection, or erosion. One patient stopped using her Bion before the 12-month follow-up visit. At one year, 7 of the 8 patients were judged as having obtained fair or better results in terms of reduction of disability; 5 patients had greater than a 90% reduction in disability.

LIMITATIONS

Small, heterogeneous patient population without control group. Not blinded or randomized.

CONCLUSION

The Bion can be successfully inserted adjacent to the greater occipital nerve in an effort to treat refractory primary headache disorders. This microstimulator may provide effective occipital stimulation and headache control while minimizing the risks associated with percutaneous or paddle leads implanted subcutaneously in the occipital region.

Patient Understanding of the Importance of β-Blocker Use in the Perioperative Period

OBJECTIVE

Perioperative beta-adrenergic blockade has been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to determine patient knowledge of the importance of perioperative beta-blockade in a population already taking chronic therapy and to assess the effectiveness of medical and surgical providers in patient education regarding these benefits.

DESIGN

Survey.

SETTING

Teaching hospital.

PARTICIPANTS

One hundred twenty-six patients taking daily beta-blockers presenting to a preoperative medical evaluation clinic completed a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Mean coronary artery disease risk factors per individual were 3.2 (standard deviation, 1.5). Forty-nine percent indicated that beta-blockers are beneficial in the perioperative period. Of those identifying benefit, 8% recognized decrease in myocardial infarction or decrease in mortality as the reason. Sixty-nine percent of patients who identified perioperative benefit cited blood pressure control as the reason. This correlated to the 67% of the total sample who identified their indication for the medication as antihypertensive. Only 7% recalled their prescribing physician ever mentioning the beta-blocker in relation to surgery. The same percentage recalled their surgeon mentioning it in relation to the planned procedure.

CONCLUSIONS

This study suggests low patient understanding of the potential importance and reasons for perioperative beta-blockade. Patients who recognized perioperative benefit identified antihypertensive versus cardioprotective effects. Clinicians can improve education of patients already taking daily beta-blockers regarding these potential benefits.

Whose decision is it anyway?: identifying the Medicaid planning client

In the Medicaid planning context, the answers to seemingly easy questions are often quite elusive. Client identification is fundamental to every attorney-client relationship, yet resolving this basic question for Medicaid planners has sparked some debate. This essay explores the difficult question Medicaid planners encounter regarding client identification. The author, Mr. Rosenfeld, reveals the lack of guidance provided by contemporary legal ethic codes and then investigates some of the client representation models currently used by practitioners. Upon identifying the inherent conflict of interest that often develops in estate planning, Mr. Rosenfeld argues that individual client representation is the only ethically acceptable model of representation.

The usefulness of a predictive instrument to reduce inappropriate admissions to the coronary care unit

A mathematical instrument was developed to supplement the diagnostic information available to physicians in the emergency room to improve physicians' diagnostic accuracy in managing patients with acute ischemic heart disease and thereby reduce inappropriate coronary care unit admissions. The instrument was empirically derived and is based on nine clinical, historical, and electrocardiographic predictive variables. Probabilities of acute ischemic heart disease generated by the instrument were given to the house staff in an emergency room during alternate months. Comparison of the control months (455 patients) with the experimental months (401 patients) showed the following: The overall diagnostic accuracy increased from 83% to 91% (P less than 0.005), the overdiagnostic accuracy increased from 51% to 33% (P less than 0.01), and the admission rate to the coronary care unit fell from 26% to 14% (P less than 0.001), while the inappropriate discharge rate from the emergency room did not change, 3% versus 3% (not significant).