Purpose of Review Meralgia paresthetica (MP) is a condition characterized by paresthesias, neuropathic pain, and alterations in sensorium of the anterolateral thigh secondary to impingement of the lateral femoral cutaneous nerve (LFCN). MP is generally diagnosed by clinical history and is often a diagnosis of exclusion. When diagnosis remains a challenge, diagnostic modalities such as ultrasound, MRI, electromyography, and nerve conduction studies have been utilized as an adjunct. This review summarizes the most recent medical literature regarding MP, its pathophysiology, presentation, and current treatment options. Recent Findings Treatment options for patients with MP range from lifestyle modifications and conservative management to surgical procedures. Initial management is often conservative with symptoms managed with medications. When conservative management fails, the next step is regional blocks followed by surgical management. The conflicting data for treatment options for MP highlight how the evidence available does not point to a single approach that’s universally effective for treating all patients with MP. Summary Despite the apparent success at treating MP with regional blocks and surgical interventions, much remains to be known about the dosing, frequency, and optimal interventions due to the inconclusive results of current studies. Further research including randomized controlled trials are needed to better understand the most optimal treatment options for MP including studies with a larger number of participants.
Burning mouth syndrome is a condition characterized by a painful burning sensation in the oral mucosa lasting at least 3-6 months with no definitive etiology. The pathophysiology is not well understood, though there appears to be a connection with other neuropsychiatric conditions such as depression, anxiety, and mood disorders. We briefly discuss our experience with a patient who suffered from this conidtion and how it was treated with mandibular and maxillary nerve blocks after failing more conservative pharmacological options.
Case: A 68-year-old woman underwent an anterior cervical discectomy and fusion for cervical radiculopathy and subsequently developed a severe contact hypersensitivity reaction in response to Dermabond Prineo, beginning 10 days postoperatively. The Dermabond Prineo mesh was removed, and the patient was treated symptomatically with diphenhydramine, systemic steroids, and oral antibiotics, with complete resolution of her symptoms. Conclusion: This is the first reported contact hypersensitivity reaction to Dermabond Prineo in the context of spine surgery. Surgeons should be able to recognize this presentation and treat this appropriately.
This study evaluated the association between resilience and PrEP use among a population-based sample of Canadian gay, bisexual, and other men who have sex with men (GBM). Sexually active GBM aged ≥ 16 years old were recruited via respondent-driven sampling (RDS) in Toronto, Montreal, and Vancouver from 02/2017 to 07/2019. We conducted a pooled cross-sectional analysis of HIV-negative/unknown GBM who met clinical eligibility for PrEP. We performed multivariable RDS-II-weighted logistic regression to assess the association between scores on the Connor-Davidson Resilience-2 Scale and PrEP. Mediation analyses with weighted logistic and linear regression were used to assess whether the relationship between minority stressors and PrEP use was mediated by resilience. Of 1167 PrEP-eligible GBM, 317 (27%) indicated they took PrEP in the past six months. Our multivariable model found higher resilience scores were associated with greater odds of PrEP use in the past six months (aOR = 1.13, 95%CI = 1.00, 1.28). We found that resilience reduced the effect of the association between heterosexist discrimination and PrEP use. Resilience also mediated the relationship between internalized homonegativity and PrEP use and mediated the effect of the association between LGBI acceptance concern and PrEP use. Overall, PrEP-eligible GBM with higher resilience scores had a greater odds of PrEP use in the past six months. We also found mixed results for the mediating role of resilience between minority stress and PrEP use. These findings underline the continued importance of strength-based factors in HIV prevention.
As a treatment for escape-maintained problem behavior, differential reinforcement of alternative behavior (DRA) is typically initiated by reinforcing compliance on a dense reinforcement schedule. This work schedule is then progressively thinned such that the individual is required to complete more work, up to some socially acceptable terminal goal, before earning access to reinforcement. Two variations of this procedure appear in the literature but have not been compared directly. One variation involves maintaining a fixed reinforcement duration as the work requirements increase; the other involves increasing the reinforcement duration incrementally, coinciding with increases in work requirements. The current study compared these procedures with three children with intellectual and developmental disabilities who exhibited problem behavior maintained by escape from instruction. Schedule thinning evoked less problem behavior when reinforcement durations increased incrementally for all three participants. These reductions in problem behavior allowed more rapid progress toward terminal goals.
A mouse model of hindlimb ischemia is an important tool for studying diverse therapeutic approaches for vascularization with high surgical success and low mortality rates. Here, we present a protocol for the induction of hindlimb ischemia in mice, including the surgery procedure and steps to analyze blood perfusion in the ischemic area using a laser speckle contrast analyzer. We also detail the isolation of endothelial cells from thigh muscles using flow cytometry after ischemic surgery. For complete details on the use and execution of this protocol, please refer to Park et al. (2016).
Objective: Pedicle screw fixation is a commonly utilized adjunct for lumbar interbody fusion, yet risks include screw malposition, pullout, loosening, neurovascular injury, and stress transfers leading to adjacent segment degeneration. This report describes the preclinical and initial clinical results of a minimally invasive, metal-free cortico-pedicular fixation device used for supplemental posterior fixation in lumbar interbody fusion. Methods: Safety of arcuate tunnel creation was evaluated in cadaveric lumbar (L1 to S1) specimens. A finite element analysis (FEA) study evaluated clinical stability of the device to pedicular screw-rod fixation at L4-L5. Preliminary clinical results were assessed by analysis of Manufacturer and User Facility Device Experience (MAUDE) database complications, and 6-month outcomes in 13 patients treated with the device. Results: Among 35 curved drill holes in 5 lumbar specimens, no breaches of the anterior cortex were identified. The mean minimum distance from the anterior surface of the hole to the spinal canal ranged from 5.1 mm at L1-L2 to 9.8 mm at L5-S1. In the FEA study, the PEEK strap provided comparable clinical stability and reduced anterior stress shielding compared to the conventional screw-rod construct. The MAUDE database identified one device fracture with no clinical sequelae among 227 procedures. Initial clinical experience showed a 53% decrease in pain severity (p=0.009), a 50% decrease in Oswestry Disability Index (p<0.001), and no device-related complications. Conclusions: Cortico-pedicular fixation is a safe and reproducible procedure that may address limitations of pedicle screw fixation. Longer term clinical data in large clinical studies are recommended to confirm these promising early results.
Methamphetamine use disorder is a chronic relapsing condition associated with substantial mental, physical, and social harms and increasing rates of mortality. Contingency management and psychotherapy interventions are the mainstays of treatment but are modestly effective with high relapse rates, while pharmacological treatments have shown little to no efficacy. Psilocybin-assisted psychotherapy is emerging as a promising treatment for a range of difficult-to-treat conditions, including substance use disorders; however, no studies have yet been published looking at psilocybin-assisted psychotherapy in the treatment of methamphetamine use disorder. Here we review the rationale for psilocybin-assisted psychotherapy as a potential treatment for this indication, and describe practical considerations based on our early experience designing and implementing four separate clinical trials of psilocybin-assisted psychotherapy for methamphetamine use disorder.
Acute aortic dissection is one of the most lethal diseases, affecting the lining of the aortic wall. We describe a case of Stanford Type A aortic dissection in a patient with underlying primary antiphospholipid syndrome (APS) complicated by coronavirus disease 2019 (COVID-19). APS is characterized by recurrent venous and/or arterial thrombosis, thrombocytopenia, and rarely vascular aneurysms. The hypercoagulable milieu attributable to APS and the prothrombotic state from COVID-19 posed a challenge in achieving optimal postoperative anticoagulation in our patient.
Background: To date, no data exist on gender-related publication biases in nephrology. This study was conducted to determine whether gender differences exist in the current literature published in high-ranking US nephrology journals, and how they may have changed over time. Methods: The PubMed search was performed using the easyPubMed package in R, which extracted all articles indexed in PubMed from 2011 to 2021 from the US nephrology journals with the highest impact factors, i.e., Journal of the American Society of Nephrology (JASN), American Journal of Nephrology (AJN), American Journal of Kidney diseases (AJKD), and the Clinical Journal of the American Society of Nephrology (CJASN). Gender with predictions > 90% were accepted and the remaining were manually identified. Descriptive statistical analysis was carried out on the data. Results: We identified 11,608 articles. On average, the ratio of male to female first authors decreased from 1.9 to 1.5 (p < 0.05). Additionally, in 2011, women accounted for 32% of first authors, a number that rose to 40% in 2021. All but the American Journal of Nephrology showed a variation in the ratio of men to women first authors. For the JASN, the ratio changed from 1.81 to 1.58, p = 0.001, for CJASN, the ratio declined from 1.91 to 1.15, p = 0.005 and for AJKD, the ratio declined from 2.19 to 1.19, p = 0.002. Discussion and conclusions: Our study shows that gender biases in publications continue to exist in first-author publications in high-ranking Nephrology journals published in the US; the gap is however closing. We hope this study lays the groundwork to continue following and evaluating gender trends in publication.
Introduction and hypothesis: The incidence of trocar bladder puncture during midurethral sling (MUS) surgery varies widely. We aim to further characterize risk factors for bladder puncture and examine its long-term impact on storage and emptying. Methods: This is an Institutional Review Board-approved, retrospective chart review of women who underwent MUS surgery at our institution from 2004 to 2018 with ≥12 months of follow-up. Unless prolonged catheterization was necessary, a voiding trial was performed prior to discharge, or the next morning in outpatients, regardless of puncture. Preoperative and postoperative details were obtained from office charts and operative records. Results: Of 1,500 women, 1,063 (71%) had retropubic (RP) and 437 (29%) had transobturator MUS surgery. Mean follow-up was 34 months. Thirty-five women (2.3%) sustained a bladder puncture. RP approach and lower BMI were significantly associated with puncture. No statistical association was found between bladder puncture and age, previous pelvic surgery, or concomitant surgery. Mean day of discharge and day of successful voiding trial were not statistically different between the puncture and nonpuncture groups. There was no statistically significant difference in de novo storage and emptying symptoms between the two groups. Fifteen women in the puncture group had cystoscopy during follow-up and none had bladder exposure. Level of the resident performing trocar passage was not associated with bladder puncture. Conclusions: Lower BMI and RP approach are associated with bladder puncture during MUS surgery. Bladder puncture is not associated with additional perioperative complications, long-term urinary storage/voiding sequelae, or delayed bladder sling exposure. Standardized training minimizes bladder punctures in trainees of all levels.
This qualitative narrative study aimed to examine how a family of origin influenced the professional self of Colombian students pursuing a profession in family therapy. Few research studies have investigated the development of self among native Spanish speakers from Colombia. Undergraduate and graduate students enrolled in clinical psychology and family therapy internships (N = 16) from the Colombian cities of Medellín, Pereira, and Santa Marta participated in this study. Data collection using personal diaries, family albums, autobiographies, and in-depth interviews served as sources for narrative analysis. Two themes and four subthemes representing positive and negative aspects of influences of families of origin helped organize the findings. Student experiences illustrate abilities, skills, and potentialities in the narratives. Implications for clinical training and future research recommendations highlight a path forward.
Wilson disease is a hereditary disorder which involves anomalous copper metabolism. Typically, the presentation is systemic, involving vital organs such as the liver, kidney, and brain, among others. We report a unique case presenting with solitary organ involvement as acute liver failure with novel ATP7B gene mutation, which has never been reported before.
A papillary tumor of the pineal region (PTPR) is a rare tumor of neuroepithelial origin formed from specialized ependymocytes of the subcommissural organ located in the lining of the posterior commissure, not the pineal gland itself. Patients with this type of tumor generally present with nonspecific symptoms secondary to obstructive hydrocephalus such as headache and vision changes. The mean age of patient presentation is 31, with a slight predominance in females. This type of tumor has a high rate of recurrence (56%) following surgical resection. This case study describes the presentation of this uncommon tumor in a 61-year-old woman, including presentation, imaging, surgery, and pathology findings.
Importance: Limited research has focused on patient perceptions and barriers to integration of virtual care in the pelvic health arena. Objectives: The purpose of this study was to determine the willingness of patients to consider telehealth as a means to seek pelvic floor physical therapy (PFPT) care and the promoters and deterrents for deployment in this treatment modality. Methods: This is a cross-sectional study of patients (≥18 years of age) at a multidisciplinary pelvic health service in an academic medical center in Northwest Ohio. The data collection occurred over 6 months in the latter half of 2021 using a novel 21-question survey based on focus group perceived patient requests, needs, and concerns that were aligned and cross-referenced with published literature. Results: The survey was completed by 210 patients, with up to 40% (n = 83) being new PFPT patients. Of those interested in telehealth being a component of their PFPT therapeutic regimen (n = 142 [68%]), interest was driven by convenience (78%). Privacy (n = 52 [76%]) was the main barrier impeding interest in this modality. Up to 80% (n = 169) preferred to establish care through in-person visits before initiating PFPT regimens remotely, with 44% (n = 93) suggesting that incorporation of telehealth would positively affect their adherence with care regimens. Conclusion: Offering patients in-person visits or hybrid alternatives may be optimal for improving adherence to therapeutic regimens especially when considering access to care.
Importance: There have been no randomized trials assessing the benefits of integration of transversus abdominis plane (TAP) blocks in sacrocolpopexy procedure postoperative pain management. Objective: The aim of this study was to assess the variation in pain perception upon adding TAP blocks to conventional oral pain medications in patients undergoing sacrocolpopexy. The primary outcome was the reduction in pain reported using the numeric rating scale (NRS) among patient groups. The secondary outcome was the change in narcotic analgesic use postoperatively. Study design: This was a prospective double-blind, pilot randomized controlled trial of women undergoing robotic sacrocolpopexy, with and without supracervical hysterectomy, with 20 patients enrolled in each arm. Randomization included receiving a TAP block in addition to the conventional analgesic regimen. Results: A total of 48 women were approached to participate in the study; 40 women provided consent (20 per study arm) and completed the 7-day follow-up. Patients receiving a TAP block had lower NRS pain scores at 4 hours postoperatively (4.95 ± 0.76 vs 5.50 ± 0.61, P = 0.02), 7 days postoperatively (2.20 ± 1.11 vs 3.15 ± 1.04, P = 0.008), and lower cumulative NRS pain scores at 48 hours postoperatively (14.90 ± 2.2 vs 16.60 ± 2.04, P = 0.02) and 7 days postoperatively (17.10 ± 2.63 vs 19.75 ± 2.65, P = 0.003) than patients not receiving a block. Patients in the intervention group also had lower cumulative morphine milliequivalents at 7 days postoperatively (17.25 ± 10.7 vs 29.25 ± 14.53, P = 0.005). Conclusion: Use of TAP blocks in robotic sacrocolpopexy cases, with or without concurrent hysterectomy, may reduce postoperative pain and narcotic medication needs.
Background Reducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy. Methods This is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade. Results The study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, P<0.0001), PH1 (OR 1.9053, P=0.0195), and PH2 (OR 2.7347, P=0.0004). Race also independently predicted any ICH (black: OR 0.5180, P=0.0017; Hispanic: OR 0.4615, P=0.0148), sICH (non-white: OR 0.4349, P=0.0107), PH1 (non-white: OR 3.1668, P<0.0001), and PH2 (non-white: OR 1.8689, P=0.0176), with white as the reference. Primary mechanical thrombectomy technique also independently predicted ICH. ADAPT (A Direct Aspiration First Pass Technique) was a negative predictor of sICH (OR 0.2501, P<0.0001), with stent retriever as the reference. Conclusions This study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted.
Introduction: Small vessel disease (SVD) is a condition associated with aging and vascular risk factors to which the brain and kidney are susceptible. However, whether kidney dysfunction may directly contribute to brain SVD as opposed to both organs being affected as an epiphenomenon of aging is less clear. We hypothesize that impaired kidney function is differentially associated with brain markers of SVD, and the association is greater with SVD markers restricted to deep, penetrating arteries. Methods: We leveraged existing data from the Columbia University Irving Medical Center/ New York Presbyterian Hospital Stroke Registry. Odds ratio (OR), estimate, confidence intervals (CI), and p values were calculated. We rated visually the presence an anatomical location of cerebral microbleeds and chronic lacunar infarcts and used the Fazekas scale to semi-quantitate white matter hyperintensities. We created linear regression models adjusted for age, sex, race/ethnicity and vascular risk factors to evaluate the relationship between kidney function (defined as self-reported chronic kidney disease or creatinine on admission). Results: We included 973 patients (mean age 65±16 years, 51 % female). The prevalence of self-reported CKD/ESRD was 14% and the mean creatinine on admission was 1.61±2.04 mg/dl. The prevalence of chronic brain infarct was 40%, cerebral microbleeds 24%, and all had some degree of white matter hyperintensity. Conclusion: There is association between previous history of CKD-ESRD and creatinine levels on admission with periventricular WMH. These data also hint a possible association between CMB of deep location with history of CKD-ESRD, but a bigger sample is required for significance.
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Shreveport, United States