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ABSTRACT: 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.
Pain Practice 10/2012; · 2.21 Impact Factor
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ABSTRACT: 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.
Neuromodulation 08/2012; · 1.19 Impact Factor
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Anesthesiology 05/2012; 117(1):212-5. · 5.36 Impact Factor
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ABSTRACT: Occipital nerve stimulation can be effective therapy for recalcitrant headache disorders. Lead migration remains the primary technical adverse event associated with this therapy. Revision surgery for occipital nerve stimulator leads sometimes requires exposure of all components including internal pulse generator, extension cables, connectors, and leads with multiple incisions. However, minimizing the invasiveness of revision surgery reduces the time, infection risk, and discomfort associated with the procedure. We describe two techniques that attempt to minimize the extent of revision surgery necessary for lead migration.
We describe two minimally invasive revision techniques. One uses a 14-gauge Tuohy needle converted to a slotted needle. The other uses a standard Tuohy needle inserted subcutaneously into the anchor site along the desired course of the lead.
Both techniques allow replacement of a migrated occipital nerve stimulator lead while eliminating the need to access connector or battery sites with multiple incisions. Conclusions: When migration occurs, the techniques described can simplify lead revision while minimizing the invasiveness of the procedure.
Neuromodulation 12/2011; 15(4):387-91. · 1.19 Impact Factor
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ABSTRACT: This report describes a pontine hemorrhage in a patient following implantation of an intrathecal drug delivery system.
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.
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.
Pain Practice 07/2009; 9(4):312-6. · 2.21 Impact Factor
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ABSTRACT: To document the per patient rate of vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections.
Anecdotal observations at our institution suggested that vasovagal reactions are much more common during cervical epidural steroid injections than lumbar injections, and more frequent than previously reported.
Records of 249 patients undergoing their first cervical epidural steroid injection were reviewed for vasovagal reactions and other adverse events. For comparison, a first lumbar epidural steroid injection performed by the same staff physician was matched to each cervical procedure and reviewed for complications.
The incidence of vasovagal reaction was 7 points more common (P < 0.001, 95% confidence interval 0.04-0.12) in the cervical group (8%) than in the lumbar group (1%). This correlates to an additional vasovagal reaction for every 14 patients who were treated with cervical injection in comparison with those treated with lumbar injection.
The risk of vasovagal reaction is significantly higher for cervical translaminar epidural steroid injections than for lumbar injections. The risk of vasovagal reaction remained higher for cervical injection even when adjusting for differences between the two populations. The higher rate of cervical vasovagal reactions may result from a combination of anxiety, the prone position with neck flexed, head drapes, and stimulus from a neck procedure.
Increased vigilance for patients undergoing translaminar cervical epidural steroid injections may be warranted. Clinicians may choose to consider these results when counseling patients regarding risk and the need for conscious sedation during the procedure.
Pain Practice 09/2008; 9(1):59-64. · 2.21 Impact Factor
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ABSTRACT: Drug-eluting coronary stent use is common. Antiplatelet drug use after stent placement is necessary to prevent stent thrombosis. It has been recommended that at the time of stent placement, patients be given instructions regarding stopping antiplatelet drugs before elective surgery. Unfortunately, patients may be given inappropriate preoperative instructions by health care providers or may stop the drugs on their own. This can lead to perioperative myocardial infarctions and death.
Survey.
Preoperative evaluation clinic of 2 teaching hospitals.
One hundred sixteen patients with coronary stents completed a 13-question survey. The questionnaire assessed patient understanding of stent type and the risks of stopping antiplatelet drugs, in addition to communication among the patient, their surgeon, and their treating cardiologist before elective surgery.
None.
The majority of patients stated either they had received no instructions from their implanting cardiologist regarding future surgery and antiplatelet drugs or they were unsure if any instructions had been given. Most patients (57%) received antiplatelet instructions regarding their planned surgery from their surgeon, whereas only 14% received instructions with (known) cardiology input. The majority of patients were unaware or unsure of any risk in prematurely stopping their antiplatelet drugs.
Many patients are unaware of their stent type and the risks of inappropriately stopping antiplatelet drugs. Furthermore, they may have received either inappropriate preoperative instructions or no instructions at all. The opportunity exists to improve preoperative communication with patients in order to minimize perioperative thrombotic risks of coronary stents.
Journal of cardiothoracic and vascular anesthesia 07/2008; 22(6):806-10. · 1.06 Impact Factor
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ABSTRACT: 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.
Survey.
Teaching hospital.
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.
None.
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.
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.
Journal of Cardiothoracic and Vascular Anesthesia 07/2007; 21(3):325-9. · 1.64 Impact Factor
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ABSTRACT: 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.
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.
Prospective, observational feasibility study.
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.
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.
Small, heterogeneous patient population without control group. Not blinded or randomized.
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.
Pain physician 12(3):621-8. · 10.72 Impact Factor
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ABSTRACT: 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.
Pain physician 12(3):639-43. · 10.72 Impact Factor
