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Background: Intrathecal pumps (ITPs) are indicated for refractory cancer pain and decrease systemic opioid requirements. While not yet indicated for cancer pain, spinal cord stimulators (SCSs) are used off-label for cancer pain, with increasing evidence of their efficacy. Materials and Methods: A retrospective chart review was conducted of patients who underwent both ITP and at least SCS trial for cancer pain. Primary outcomes were pain numeric rating scale (NRS) and daily morphine equivalents (MEQs). Results: Seventeen patients were identified. Both ITP and SCS were associated with significant decreases in pain ratings at the 3-month follow-up, but this decrease became nonsignificant subsequently. ITP, but not SCS, was associated with a significant decrease in MEQ. Conclusions: ITP and SCS may both provide efficacy for cancer pain, but the opioid-sparing effects of SCS may be limited. ITP and SCS may potentially be complementary in their ability to provide relief from cancer-related pain.
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PURPOSE OF REVIEW: This review critically analyzes the recent literature on virtual reality's (VR) use in acute and chronic pain management, offering insights into its efficacy, applications, and limitations. RECENT FINDINGS: Recent studies, including meta-analyses and randomized controlled trials, have demonstrated VR's effectiveness in reducing pain intensity in various acute pain scenarios, such as procedural/acute pain and in chronic pain conditions. The role of factors such as immersion and presence in enhancing VR's efficacy has been emphasized. Further benefits have been identified in the use of VR for assessment as well as symptom gathering through conversational avatars. However, studies are limited, and strong conclusions will require further investigation. VR is emerging as a promising non-pharmacological intervention in pain management for acute and chronic pain. However, its long-term efficacy, particularly in chronic pain management, remains an area requiring further research. Key findings highlight that VR programs vary in efficacy depending on the specificity of the origin of pain.
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PURPOSE OF REVIEW: This review provides medical practitioners with an overview of the present and emergent roles of telehealth and associated virtual reality (VR) applications in chronic pain (CP) management, particularly in the post-COVID-19 healthcare landscape. RECENT FINDINGS: Accumulated evidence points to the efficacy of now well-established telehealth modalities, such as videoconferencing, short messaging service (SMS), and mobile health (mHealth) applications in complementing remote CP care. More recently, and although still in early phases of clinical implementation, a wide range of VR-based interventions have demonstrated potential for improving the asynchronous remote management of CP. Additionally, VR-associated technologies at the leading edge of science and engineering, such as VR-assisted biofeedback, haptic technology, high-definition three-dimensional (HD3D) conferencing, VR-enabled interactions in a Metaverse, and the use of wearable monitoring devices, herald a new era for remote, synchronous patient-physician interactions. These advancements hold the potential to facilitate remote physical examinations, personalized remote care, and innovative interventions such as ultra-realistic biofeedback. Despite the promise of VR-associated technologies, several limitations remain, including the paucity of robust long-term effectiveness data, heterogeneity of reported pain-related outcomes, challenges with scalability and insurance coverage, and demographic-specific barriers to patient acceptability. Future research efforts should be directed toward mitigating these limitations to facilitate the integration of telehealth-associated VR into the conventional management of CP. Despite ongoing barriers to widespread adoption, recent evidence suggests that VR-based interventions hold an increasing potential to complement and enhance the remote delivery of CP care.
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COVID-19 , Dolor Crónico , Telemedicina , Realidad Virtual , Humanos , Dolor Crónico/terapia , Telemedicina/métodosRESUMEN
OBJECTIVES: Cancer pain has traditionally been managed with opioids, adjuvant medications, and interventions including injections, neural blockade, and intrathecal pump (ITP). Spinal cord stimulation (SCS), although increasingly used for conditions such as failed back surgery syndrome and complex regional pain syndrome, is not currently recommended for cancer pain. However, patients with cancer-related pain have demonstrated benefit with SCS. We sought to better characterize these patients and the benefit of SCS in exceptional cases of refractory pain secondary to progression of disease or evolving treatment-related complications. MATERIALS AND METHODS: This was a single-center, retrospective case series at a tertiary cancer center. Adults ≥18 years old with active cancer and evolving pain secondary to disease progression or treatment, whose symptoms were refractory to systemic opioids, and who underwent SCS trial followed by percutaneous implantation between 2016 and 2021 were included. Descriptive statistics included mean, SD, median, and interquartile range (IQR). RESULTS: Eight patients met the inclusion criteria. The average age at SCS trial was 60.0 (SD: ±11.6) years, and 50% were men. Compared with baseline, the median (IQR) change in pain score by numeric rating scale (NRS) after trial was -3 (2). At an average of 14 days after implant, the median (IQR) change in NRS and daily oral morphine equivalents were -2 (3.5) and -126 mg (1095 mg), respectively. At a median of 63 days after implant, the corresponding values were -3 (0.75) and -96 mg (711 mg). There was no significant change in adjuvant therapies after SCS implantation at follow-up. Six patients were discharged within two days after implantation. Two patients were readmitted for pain control within the follow-up period. CONCLUSIONS: In patients with cancer-related pain, SCS may significantly relieve pain, reduce systemic daily opioid consumption, and potentially decrease hospital length of stay and readmission for pain control. It may be appropriate to consider an SCS trial before ITP in select cases of cancer-related pain.
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Dolor en Cáncer , Síndrome de Fracaso de la Cirugía Espinal Lumbar , Neoplasias , Estimulación de la Médula Espinal , Adulto , Masculino , Humanos , Adolescente , Femenino , Dolor en Cáncer/etiología , Dolor en Cáncer/terapia , Estudios Retrospectivos , Analgésicos Opioides/uso terapéutico , Síndrome de Fracaso de la Cirugía Espinal Lumbar/terapia , Médula Espinal , Resultado del Tratamiento , Neoplasias/complicaciones , Neoplasias/terapiaRESUMEN
OBJECTIVES: Spinal cord stimulation (SCS) involves electrical stimulation of the dorsal spinal cord to disrupt the transmission of ascending pain signals. SCS has been used successfully to manage a variety of chronic pain conditions, but its efficacy in the treatment of pain syndromes in patients with cancer has not been established because most studies have involved a limited number of patients. The purpose of this study was to assess the efficacy of SCS in a large group of patients with cancer. MATERIALS AND METHODS: A retrospective review was performed for all patients who had SCS trials and implants placed at Memorial Sloan Kettering Cancer Center between 2003 and 2021. Patients were divided into groups based on whether their pain could be directly attributed to cancer or its treatment (cancer dependent, n = 51) and those who had incidental pain unrelated to cancer (cancer independent, n = 22). The cancer-dependent group was further subdivided into those whose pain was directly related to primary tumor invasion or metastasis (cancer related, n = 26) and those whose pain was a result of cancer treatment such as chemotherapy or surgery (treatment related, n = 25). The primary outcomes were changes in pain scores and daily oral morphine equivalents (OMEs) before intervention to one year after implant. Secondary measures included the SCS trial success rate, change in pain scores immediately after the SCS trial, and change in pain scores immediately after the SCS implant. RESULTS: Most patients in the cancer-dependent pain group (59%) and the cancer-independent pain group (68%) had successful SCS trials and subsequently went on to have SCS implants placed. The patients with cancer-dependent pain as a whole had median reduction of 1.5 points (or 23%) on a 10-point pain score immediately after implant (p = 0.001), with the effect diminishing to a median reduction of 1 point (or 15%) by one year after implant (p = 0.027). The cancer-dependent pain groups did not have a significant reduction in daily OMEs, following implantation (p = 0.30), but the cancer-independent group did have a significant reduction (p = 0.01). CONCLUSIONS: SCS can be considered as a treatment modality for patients with cancer whose pain is not adequately controlled with medical therapy or by less invasive interventions.
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Dolor en Cáncer , Dolor Crónico , Neoplasias , Estimulación de la Médula Espinal , Dolor en Cáncer/etiología , Dolor en Cáncer/terapia , Dolor Crónico/complicaciones , Dolor Crónico/terapia , Humanos , Neoplasias/complicaciones , Neoplasias/terapia , Manejo del Dolor/efectos adversos , Estudios Retrospectivos , Médula Espinal , Estimulación de la Médula Espinal/efectos adversos , Resultado del TratamientoRESUMEN
Background: Assessment of an individual medical school's performance in the match is an important outcome of the educational program. Unfortunately, student rank lists are not public. A method to objectively gauge the quality of an institution's match regardless of student preference has not been described in the literature.Objective: This manuscript serves to determine the relative weights of included variables and derive a statistically valid Match Quality Score (MQS).Design: Between 2016 and 2018, student affairs experts derived from a national cohort validated the MQS by scoring factitious mini-match lists that covered three variables: student's Match Status, specialty Competitiveness, and residency program Reputation.Results: Of the variables assessed, only Match Status and Competitiveness were found to be significant. We derived the resulting coefficients for the Match Quality Score (MQS) as: [3.74A (# students successfully matched) + 2.34B (# students matching into their initial specialty in the SOAP process) + 1.77C (# students who secured a SOAP position in another specialty) + 0.26D (# students matching into a specialty where there are more applicants than spots)]/Total # students.Conclusions: The MQS is a potentially useful educational outcome measurement for US medical schools and may be considered as an outcome measure for continuous quality improvement to tailor future institutional changes to training, mentoring, and student-advising programs.
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Evaluación Educacional/métodos , Internado y Residencia/organización & administración , Facultades de Medicina/organización & administración , Estudiantes de Medicina/psicología , Adulto , Selección de Profesión , Femenino , Humanos , Masculino , Grupo Paritario , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Bile duct injury during laparoscopic cholecystectomy persists as a significant problem in general surgery, resulting in complex injuries, arterial damage, and post repair strictures. METHODS: We performed a retrospective analysis between 2 eras of bile duct injury repairs: 1987 to 2001 (n = 58) and 2002 to 2016 (n = 52) using logistic regression analyses to assess presentation, repair complexity, and outcomes. RESULTS: No differences in demographics, incidence of cholecystitis, conversion, time to presentation, level of injury, or arterial injury were identified. The second era had an increase in patient age, transhepatic catheter use, prior repair, and utilization of complex repairs. This approach resulted in equivalent complications and mortality rates with increased resource utilization but a lesser incidence of post-repair strictures (P = .004). Regression modeling correlated strictures to prior operative repairs (OR 4.25; P = .016) and a protective effect of repairs performed in the second era (OR 0.23; P = .045). CONCLUSION: The second era identified a decreasing trend of attempted repairs by referring surgeons but an increase in transhepatic catheters and complex repairs resulting in lesser rates of post-repair stricture. Final regression modeling confirmed increased operative experience decreased post-repair stricture reaffirming the benefits of early identification and referral of bile duct injuries to an experienced hepatobiliary surgeon at a specialty center.
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Conductos Biliares/lesiones , Colecistectomía Laparoscópica/efectos adversos , Enfermedad Iatrogénica/epidemiología , Complicaciones Intraoperatorias/cirugía , Adulto , Anciano , Conductos Biliares/cirugía , Colecistectomía Laparoscópica/métodos , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Complicaciones Intraoperatorias/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Reoperación/métodos , Estudios Retrospectivos , Medición de Riesgo , Centros de Atención Terciaria , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: We hypothesize that students exposed to both academic and community surgery clerkship sites will have higher National Board of Medical Examiners Subject Exam in Surgery (NBME SES) scores and be more likely to pursue a career in a surgical specialty. DESIGN: The NBME surgery subject exam scores and National Resident Matching Program (NRMP) results were collected for all medical students rotating through the surgery clerkship over 4 years. Permutations of sites were analyzed against exam scores and match rates into surgical and nonsurgical specialties. SETTING: This study was performed at the Tulane University School of Medicine, in New Orleans, Louisiana, United States of America. PARTICIPANTS: Data for a total of 910 students rotating through the surgery clerkship over a period of 4 years was collected and analyzed. RESULTS: There was no statistical difference in NBME subject exam scores (pâ¯=â¯0.44) or match rates into a surgical specialty (pâ¯=â¯0.13) as stratified by site placement. Average NBME surgery subject exam scores were higher for those pursuing a surgical specialty (p < 0.001). CONCLUSIONS: The combination of sites experienced during the surgery clerkship did not affect NBME surgery subject exam scores nor lead to a tendency to match into a surgical specialty.
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Selección de Profesión , Prácticas Clínicas/organización & administración , Educación de Pregrado en Medicina/métodos , Evaluación Educacional , Cirugía General/educación , Centros Médicos Académicos/estadística & datos numéricos , Competencia Clínica , Estudios de Cohortes , Femenino , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Louisiana , Masculino , Estudios Retrospectivos , Facultades de Medicina/organización & administración , Estudiantes de Medicina/estadística & datos numéricos , Análisis y Desempeño de Tareas , Adulto JovenRESUMEN
Intraoperative neuromonitoring during thyroid surgery has been used to successfully prevent permanent neurological injury by early identification of anatomical variants. Proper interpretation of neuromonitoring data requires knowledge of what factors might affect the data. In this study, we examined the effect of surgical positioning on the latency and amplitude of neural recordings made from the vocalis muscle during thyroid surgery. A retrospective review was performed of 145 patients who underwent thyroid surgery. Eighty-three had open cervical procedures, and 62 had robotic-assisted transaxillary procedures. Intraoperative neuromonitoring recordings were made by stimulation of the vagus and recurrent laryngeal nerves for both groups. Ultrasound measurements were made of a subset of the transaxillary patients immediately before and after arm positioning. Groups differed only on right-sided recordings. Patients with transaxillary surgeries had significantly shorter latencies evoked from the vagus nerve. We found that vagus nerve-evoked latencies were also correlated to ultrasound measurements of the nerves. Surgical positioning during thyroid surgery is a factor that may affect intraoperative neuromonitoring data and should be taken into account by the surgeon during interpretation.
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Complicaciones Intraoperatorias/prevención & control , Neuronavegación , Posicionamiento del Paciente/métodos , Traumatismos del Nervio Laríngeo Recurrente/prevención & control , Procedimientos Quirúrgicos Robotizados/efectos adversos , Tiroidectomía/efectos adversos , Adulto , Anciano , Estudios de Cohortes , Bases de Datos Factuales , Electromiografía/métodos , Femenino , Estudios de Seguimiento , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Traumatismos del Nervio Laríngeo Recurrente/diagnóstico por imagen , Traumatismos del Nervio Laríngeo Recurrente/etiología , Estudios Retrospectivos , Medición de Riesgo , Procedimientos Quirúrgicos Robotizados/métodos , Glándula Tiroides/patología , Glándula Tiroides/cirugía , Tiroidectomía/métodos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND/AIM: Immunotherapy combined with surgery is associated with better survival than surgery alone in patients with advanced melanoma. This study examined the utilization of immunotherapy in relation to population characteristics and the associated survival benefit. MATERIALS AND METHODS: This was a retrospective cohort study utilizing the US National Cancer Database. The study population included 6,165 adult patients (≥18 years) with stage III cutaneous melanoma (median follow-up=32 months). RESULTS: A total of 1,854 patients underwent immunotherapy in addition to surgery, which was associated with a survival benefit over surgery alone (hazard ratio(HR)=0.66, 95% confidence interval(CI)=0.56-0.77, p<0.001). Older age, presence of comorbidities, Medicaid/Medicare insurance, and living in a community with lower average education level were associated with less immunotherapy utilization (all p<0.05). No statistically significant racial disparity in immunotherapy usage was found (p=0.07). CONCLUSION: Compared to other demographic factors, insurance status was associated with the greatest disparities in immunotherapy utilization and mortality for patients who underwent surgery for advanced melanoma.
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Inmunoterapia/estadística & datos numéricos , Melanoma/terapia , Neoplasias Cutáneas/terapia , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Melanoma/mortalidad , Persona de Mediana Edad , Estadificación de Neoplasias , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Neoplasias Cutáneas/mortalidad , Resultado del Tratamiento , Estados Unidos , Melanoma Cutáneo MalignoRESUMEN
Studies of semantic interference in language production have provided evidence for a role of cognitive control mechanisms in regulating the activation of semantic competitors during naming. The present study investigated the relationship between individual differences in cognitive control abilities, for both younger and older adults, and the degree of semantic interference in a blocked cyclic naming task. We predicted that individuals with lower working memory capacity (as measured by word span), lesser ability to inhibit distracting responses (as measured by Stroop interference), and a lesser ability to resolve proactive interference (as measured by a recent negatives task) would show a greater increase in semantic interference in naming, with effects being larger for older adults. Instead, measures of cognitive control were found to relate to specific indices of semantic interference in the naming task, rather than overall degree of semantic interference, and few interactions with age were found, with younger and older adults performing similarly. The increase in naming latencies across naming trials within a cycle were negatively correlated with word span for both related and unrelated conditions, suggesting a strategy of narrowing response alternatives based upon memory for the set of item names. Evidence for a role of inhibition in response selection was obtained, as Stroop interference correlated positively with the change in naming latencies across cycles for the related, but not unrelated, condition. In contrast, recent negatives interference correlated negatively with the change in naming latencies across unrelated cycles, suggesting that individual differences in this tap the degree of strengthening of links in a lexical network based upon prior exposure. Results are discussed in terms of current models of lexical selection and consequences for word retrieval in more naturalistic production.
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OBJECTIVE: To assess postinjury changes in learning, memory, and metamemory abilities following childhood traumatic brain injury. DESIGN: Prospective, longitudinal with 5 assessments made from baseline to 24 months postinjury. PARTICIPANTS: A total of 167 children (aged 5-15 years) with traumatic brain injury (TBI; 64 severe, 55 moderate, and 48 mild). METHODS: Children completed a judgment of learning task with 4 recall trials and made 3 metamemory judgments. RESULTS: Relative to those with mild TBI, children with moderate or severe TBI performed worse at earlier times postinjury and had a greater change in performance over time. Performance for moderate and severe groups peaked at 12 months and the performance gap between them and mild TBI group increased slightly from 12 to 24 months. Traumatic brain injury severity did not affect initial study-recall trial performance, but groups did diverge in performance with repeated study. Greater TBI severity was associated with poorer performance on prospective metamemory judgments, but not retrospective judgments. CONCLUSIONS: Traumatic brain injury severity affected prospective judgments of memory performance and learning strategies, but did not appear to affect either word retention or the forgetting of words over a delay. Implications for rehabilitation are discussed.
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Amnesia/rehabilitación , Traumatismos Craneocerebrales/rehabilitación , Discapacidades para el Aprendizaje/rehabilitación , Adolescente , Amnesia/diagnóstico , Amnesia/psicología , Lesión Encefálica Crónica/diagnóstico , Lesión Encefálica Crónica/psicología , Lesión Encefálica Crónica/rehabilitación , Niño , Preescolar , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/psicología , Femenino , Escala de Coma de Glasgow , Humanos , Intención , Juicio , Discapacidades para el Aprendizaje/diagnóstico , Discapacidades para el Aprendizaje/psicología , Estudios Longitudinales , Masculino , Recuerdo Mental , Pruebas Neuropsicológicas/estadística & datos numéricos , Estudios Prospectivos , Psicometría , Retención en PsicologíaRESUMEN
Controversy remains as to the scope of advanced planning in language production. Smith and Wheeldon (1999) found significantly longer onset latencies when subjects described moving-picture displays by producing sentences beginning with a complex noun phrase than for matched sentences beginning with a simple noun phrase. While these findings are consistent with a phrasal scope of planning, they might also be explained on the basis of: (1) greater retrieval fluency for the second content word in the simple initial noun phrase sentences and (2) visual grouping factors. In Experiments 1 and 2, retrieval fluency for the second content word was equated for the complex and simple initial noun phrase conditions. Experiments 3 and 4 addressed the visual grouping hypothesis by using stationary displays and by comparing onset latencies for the same display for sentence and list productions. Longer onset latencies for the sentences beginning with a complex noun phrase were obtained in all experiments, supporting the phrasal scope of planning hypothesis. The results indicate that in speech, as in other motor production domains, planning occurs beyond the minimal production unit.
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Toma de Decisiones/fisiología , Habla/fisiología , Conducta Verbal/fisiología , Femenino , Humanos , Masculino , Memoria/fisiología , Estimulación Luminosa , Psicolingüística , Desempeño Psicomotor/fisiología , Adulto JovenRESUMEN
We investigated the semantic blocking effect in picture naming and word-picture matching for two nonfluent aphasic patients who show evidence of a deficit in inhibiting verbal representations (M.L. and B.Q), one fluent aphasic patient (K.V.), and neurologically intact control participants. In two picture-naming tasks (Experiments 1A and 1B), M.L. and B.Q, relative to controls, showed a greatly exaggerated semantic blocking effect in naming latencies that increased dramatically across repeated presentations. On two corresponding word-picture matching tasks (Experiments 2A and 2B), both also showed an increasing semantic blocking effect, though the effects were not as large nor as consistent as those in naming. The fluent patient, K.V., showed a pattern like controls on both tasks. On an associated word-picture matching task, both M.L. and B.Q showed results paralleling those of controls. The contrast between the production and comprehension patterns for M.L. and B.Q. supports the conclusion that their exaggerated blocking effect in production arises during lexical rather than semantic selection. We postulate that M.L.'s (and potentially B.Q's) production effect is due to difficulties in postselection inhibition, which results in overactivation of lexical representations. This overactivation is likely to be one source of their nonfluency in spontaneous speech.