Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation

OBJECTIVES

Placement of a standard paddle lead for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a "skip" laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified.

MATERIALS AND METHODS

Participants who underwent SCS paddle placement at Albany Medical Center between 2016 and 2017 were identified. Operative reports were reviewed to identify the paddle type, level of initial laminotomy, target level, and skip laminotomy level. Preoperative thoracic magnetic resonance images (MRIs) were reviewed, and spinal canal diameter, interpedicular distance, and dorsal cerebral spinal fluid thickness were measured for each participant when available.

RESULTS

A total of 106 participants underwent thoracic SCS placement. Of these, 97 had thoracic MRIs available for review. Thirty-eight participants required a skip laminotomy for placement of the paddle compared with 68 participants who did not. There was no significant difference in demographic features including age, sex, body mass index, and surgical history. Univariate analyses that suggested trends were selected for further analysis using binary logistic regression. Level of initial laminotomy (odds ratio [OR] = 1.51, p = 0.028), spinal canal diameter (OR = 0.71, p = 0.015), and dorsal cerebrospinal fluid thickness (OR = 0.61, p = 0.011) were correlated with skip laminotomy. Target level (OR = 1.27, p = 0.138) and time from trial (1.01, p = 0.117) suggested potential association. The multivariate regression was statistically significant, X2(10) = 28.02, p = 0.002. The model explained 38.3% of the variance (Nagelkerke R2) and predicted skip laminectomy correctly in 73.3% of cases. However, for the multivariate regression, only a decrease in spinal canal diameter (OR = 0.59, p = 0.041) was associated with a greater odds of skip laminotomy.

CONCLUSIONS

This study aims to characterize the patient and radiographic factors that may predict the need to perform a skip laminotomy during the initial placement of SCS paddles. Here, we show that radiographic and anatomic variables, primarily spinal canal diameter, play an important role in predicting the need for a skip laminotomy. Furthermore, we suggest that target level for placement and level of initial laminotomy also may contribute. Further investigation of the predictive factors for performing a skip laminotomy would help optimize surgical planning and preoperative patient selection and counseling.

Determination of TMEn, standardized amino acid digestibility, phosphorus digestibility, and phosphorus bioavailability in conventional and reduced phosphorus distillers dried grains with solubles

The TME_n, amino acid (AA) digestibility, and P availability in 2 conventional corn distillers dried grains with solubles (C-DDGS1 and 2; 0.86 to 1.14% P, DM basis) and reduced phosphorus DDGS (RP-DDGS; 0.39% P) were evaluated. The TME_n of C-DDGS1 and 2 and RP-DDGS were determined in Experiment 1 using conventional adult Leghorn roosters, while standardized AA digestibility was determined in Experiment 2 using cecectomized roosters. Apparent ileal digestibility (AID) of P at different Ca levels was determined using precision-fed (crop intubation) broiler chickens in Experiments 3 and 4. The AID and total tract retention of P in C-DDGS2 were evaluated in Experiment 5 using ad libitum-fed broilers. Phosphorus bioavailability in C-DDGS2 relative to KH₂PO₄ based on bone ash was determined in Experiment 6. Experiments contained 4 to 5 replicates per treatment. In Experiment 1, the TME_n of C-DDGS1 and RP-DDGS was 3,428 and 2,840 kcal/kg, respectively (DM basis). In Experiment 2, there were no differences (P > 0.05) in rooster AA digestibility values between C-DDGS1 and RP-DDGS. In Experiment 3 with precision-fed chicks, AID of P in C-DDGS1 and RP-DDGS was 81 and 59%, respectively; there was no effect (P > 0.05) of increasing dietary Ca level from 0.04 to 1.0% for C-DDGS1 or reducing Ca from 1.5 to 1.0% for RP-DDGS. The AID of P in precision-fed chicks for C-DDGS2 in Experiment 4 was 48 and 80% at 1.3 and 0.3 Ca:total P ratios, respectively (P < 0.05). In Experiment 5, AID of P in C-DDGS2 at Ca:total P ratios of 1.3 and 2.5 was 63 and 42%, respectively, in precision-fed chicks. Regression of bone ash content (mg/tibia) on supplemental P intake in Experiment 6 yielded a P bioavailability of 61% relative to KH₂PO₄ for C-DDGS2. In conclusion, total and digestible P content in RP-DDGS was greatly reduced compared with C-DDGS, and the digestibility and bioavailability of the P in C-DDGS was affected by type of experimental assay and dietary Ca level.

Efficacy of 10 kHz spinal cord stimulation in complex regional pain syndrome: A retrospective analysis

INTRODUCTION

We examine the clinical efficacy of High Frequency 10 kHz (HF10) spinal cord stimulation (SCS) CRPS patients.

MATERIALS AND METHODS

This is a retrospective cohort study of SCS-naïve patients with CRPS treated with HF10-SCS after a successful trial. Patients were evaluated at 2 weeks, 6 weeks, 3 months, and 6 months post-operatively. Outcomes included mean numeric pain rating scale (NRS), mean NRS reduction, NRS percentage improvement (PI), patient reported subjective pain PI (Pain PI), and patients reporting > 50% benefit in symptoms. Pre and post-operative NRS were compared by ordinal regression analysis accounting for the patient's response to the SCS trial.

RESULTS

20 patients met inclusion criteria. 75% were female. Mean age 51 years. Baseline mean NRS was 6.1 for the cohort (1.7). Post-operatively, mean NRS decreased to 4.5 at 2 weeks (p = 0.077), 3.8 at 6 weeks (p = 0.034), 3.7 at 3 months (p = 0.307), and 4.4 at 6 months (p = 0.832). Mean NRS reduction and NRS PI is reported within. Pain PI was 25% at 2 weeks, 55% at 6 weeks, 54% at 3 months, and 53% at 6 months. Greater than 50% reduction in symptoms was reported in 25% of patients at 2 weeks, 85% at 6 weeks, 87% at 3 months, and 64% at 6 months.

CONCLUSIONS

HF10 SCS may represent an effective treatment option for reducing objective and subjective symptoms in CRPS that warrants further study.

Dysphagia, reflux and related sequelae due to altered physiology in scleroderma

Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement, commonly in the esophagus. Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility. However, there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia. The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition, as well as by xerostomia. In the pharyngeal phase of swallowing, pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance. The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility. However, it can also be affected by obstruction from chronic reflux changes, pill-induced esophagitis, or Candida esophagitis. Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis. Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.

Exploring the presence of dental anomalies as a consequence of treatment of malignancy: A case report

Simultaneous presentation of tuberculosis (TB) and lymphoma in a young child is indeed a very rare entity. Malignancy such as Hodgkin's disease (HD) most commonly causes suppression of the cell-mediated immunity, which makes the individual, especially children, more prone to tuberculous infection. One of the non-life threatening complications in these young cancer survivors is the associated dental anomalies. These can seriously impair the quality of life of teenagers and young adults. Higher incidence of caries, discoloration of teeth or even early loss of teeth requiring dental prosthesis, can be associated with the use of cytostatic drugs. These drugs can also disturb odontogenesis, resulting in the absence of tooth buds, microdontia, dilacerations or shortening of tooth roots. Some of the anticancer drugs, including busulfan, cyclophosphamide, doxorubicin etc. May particularly play a significant role in the development of dental anomalies. This paper is a short review and case report of an 11 year old child having oligodontia and secondary dental complications caused as a side effect of treatment of Hodgkin's lymphoma with Tuberculous Lymphadenitis.

Co-morbidity of down syndrome with autism spectrum disorder: Dental implications

Over the past several years, numerous studies have emerged documenting the high incidence (1-11%) of comorbidity of autism spectrum disorders (ASD) in Down syndrome (DS). While children with these health issues are reported to be more cognitively impaired presenting significantly lower IQ scores, they also demonstrate differences in social and expressive language skills when compared to their coequals with DS only. More than that subjects with DS and ASD comorbidity exhibit atypical behaviour manifested by stereotypic anxiety and social withdrawal when compared to DS alone. This article provides a brief understanding of this challenging concurrence along with a case report of a 12-year-old male patient with ASD-DS condition reporting with multiple missing teeth (Oligodontia).

Selective effects of dorsal raphé nucleus glucocorticoid receptor deletion on depression-like behavior in female C57BL/6J mice

We have shown differing effects of glucocorticoid receptor (GR) deletion from the dorsal raphé nucleus (DRN) and locus coeruleus (LC) on depression-relevant behavior in male mice, but DRN GR deletion has not been tested in female mice. Female floxed GR mice were given DRN injections of AAV2/9 pseudotype viral vectors transducing Cre recombinase to produce DRN GR gene deletion (Cre) and compared with mice receiving DRN injections of AAV2/9 transducing green fluorescent protein (GFP). Social interaction, a measure of depression-like withdrawal, was unaffected by DRN GR deletion, but forced swim immobility, a measure of despair-like passivity, was reduced in female Cre vs. GFP mice. Behavioral effects were not attributable to changes in basal corticosterone or LC GR deletion. Combined with our prior studies, the current findings suggest that DRN GR have sex-independent effects to promote forced swim immobility, but influence social interaction only in male mice. Differential effects of DRN GR deletion in female mice may provide insight into the greater incidence of depression and specific depression symptoms in women.

Marker discovery and associations with β-carotene content in Indian dairy cattle and buffalo breeds

Vitamin A is essential for human health, but current intake levels in many developing countries such as India are too low due to malnutrition. According to the World Health Organization, an estimated 250 million preschool children are vitamin A deficient globally. This number excludes pregnant women and nursing mothers, who are particularly vulnerable. Efforts to improve access to vitamin A are key because supplementation can reduce mortality rates in young children in developing countries by around 23%. Three key genes, BCMO1, BCO2, and SCARB1, have been shown to be associated with the amount of β-carotene (BC) in milk. Whole-genome sequencing reads from the coordinates of these 3 genes in 202 non-Indian cattle (141 Bos taurus, 61 Bos indicus) and 35 non-Indian buffalo (Bubalus bubalis) animals from several breeds were collected from data repositories. The number of SNP detected in the coding regions of these 3 genes ranged from 16 to 26 in the 3 species, with 5 overlapping SNP between B. taurus and B. indicus. All these SNP together with 2 SNP in the upstream part of the gene but already present in dbSNP (https://www.ncbi.nlm.nih.gov/projects/SNP/) were used to build a custom Sequenom array. Blood for DNA and milk samples for BC were obtained from 2,291 Indian cows of 5 different breeds (Gir, Holstein cross, Jersey Cross, Tharparkar, and Sahiwal) and 2,242 Indian buffaloes (Jafarabadi, Murrah, Pandharpuri, and Surti breeds). The DNA was extracted and genotyped with the Sequenom array. For each individual breed and the combined breeds, SNP with an association that had a P-value <0.3 in the first round of linear analysis were included in a second step of regression analyses to determine allele substitution effects to increase the content of BC in milk. Additionally, an F-test for all SNP within gene was performed with the objective of determining if overall the gene had a significant effect on the content of BC in milk. The analyses were repeated using a Bayesian approach to compare and validate the previous frequentist results. Multiple significant SNP were found using both methodologies with allele substitution effects ranging from 6.21 (3.13) to 9.10 (5.43) μg of BC per 100 mL of milk. Total gene effects exceeded the mean BC value for all breeds with both analysis approaches. The custom panel designed for genes related to BC production demonstrated applicability in genotyping of cattle and buffalo in India and may be used for cattle or buffalo from other developing countries. Moreover, the recommendation of selection for significant specific alleles of some gene markers provides a route to effectively increase the BC content in milk in the Indian cattle and buffalo populations.

Epidermal growth factor preserves myelin and promotes astrogliosis after intraventricular hemorrhage

Intraventricular hemorrhage (IVH) leads to reduced myelination and astrogliosis of the white matter in premature infants. No therapeutic strategy exists to minimize white matter injury in survivors with IVH. Epidermal growth factor (EGF) enhances myelination, astrogliosis, and neurologic recovery in animal models of white matter injury. Here, we hypothesized that recombinant human (rh) EGF treatment would enhance oligodendrocyte precursor cell (OPC) maturation, myelination, and neurological recovery in preterm rabbits with IVH. In addition, rhEGF would promote astrogliosis by inducing astroglial progenitor proliferation and GFAP transcription. We tested these hypotheses in a preterm rabbit model of IVH and evaluated autopsy samples from human preterm infants. We found that EGF and EGFR expression were more abundant in the ganglionic eminence relative to the cortical plate and white matter of human infants and that the development of IVH reduced EGF levels, but not EGFR expression. Accordingly, rhEGF treatment promoted proliferation and maturation of OPCs, preserved myelin in the white matter, and enhanced neurological recovery in rabbits with IVH. rhEGF treatment inhibited Notch signaling, which conceivably contributed to OPC maturation. rhEGF treatment contributed to astrogliosis by increasing astroglial proliferation and upregulating GFAP as well as Sox9 expression. Hence, IVH results in a decline in EGF expression; and rhEGF treatment preserves myelin, restores neurological recovery, and exacerbates astrogliosis by inducing proliferation of astrocytes and enhancing transcription of GFAP and Sox9 in pups with IVH. rhEGF treatment might improve the neurological outcome of premature infants with IVH. GLIA 2016;64:1987-2004.

Wolcott-Rallison syndrome

Multiple epiphyseal dysplasia with early-onset diabetes mellitus (also known as Wolcott-Rallison syndrome) is a rare autosomal recessive disorder that manifests itself in early infancy with symptoms of diabetes mellitus. Short stature and walking difficulties become evident in the 2 nd year of life when the child starts to walk. These skeletal changes are progressive with age. There is usually a short trunk, excessive lordosis, a short and broad chest, and genu valgum. This report presents a case of Wolcott-Rallison syndrome in a 10 year old child.

Sotos syndrome

Sotos syndrome is a well-defined childhood overgrowth syndrome characterized by pre- and postnatal overgrowth, developmental delay, advanced bone age, and a typical facial gestalt including macrodolichocephaly with frontal bossing, frontoparietal sparseness of hair, apparent hypertelorism, downslanting palpebral fissures, and facial flushing. This report presents a case of Sotos syndrome in a 5½-year-old child.

Allelic variations in CYP2D6 gene and susceptibility to cervical cancer

Epidemiological studies have identified a number of risk factors that contribute to the development of cervical cancer precursors and cervical cancer. These include infection with certain oncogenic types of human papillomaviruses (HPVs) and other socio-economic factors. Tobacco smoking is an independent risk-factor for cervical neoplasia. It has been found that polymorphism at loci that encode carcinogen-metabolizing enzyme such as cytochrome P450 2D6 (CYP2D6) catalyzing the detoxification of carcinogens may determine susceptibility to cervical cancer. Therefore, it is likely that an understanding of these allelic differences is important for determining an individual's risk of cancer and susceptibility to potentially toxic agents. The aim of the present study was to elucidate the role of CYP2D6 polymorphism and susceptibility to squamous cell carcinoma of the uterine cervix in Indian population. Therefore, the genotype frequencies at this locus in females suffering with low-grade CIN, high-grade CIN and squamous cell carcinoma were compared. The control group consisted of 77 females with normal cervical cytology and the cases comprised of 61 mild/moderate dysplasia, 48 severe dysplasia and 45 cases of squamous cell carcinoma of uterine cervix. The individuals were divided into poor metabolizers (PM) and extensive metabolizers (EM) on the basis of their ability to metabolize certain drugs and carcinogens. Comparison of the frequency distribution for the combination of CYP2D6 EM genotype and smoking between mild/moderate and severe dysplasia was statistically significant (p=0.047) suggesting that women with cervical intraepithelial neoplasia I/II (CIN I/ CIN II) and CYP2D6 EM genotype who smoke appears to have more chances for the lesions to progress to CIN III. Whereas, frequency distribution for the same combination between severe dysplasia and squamous cell carcinoma failed to attain any statistical significance suggesting that CIN III with CYP2D6 EM genotype has less chance to progress to cervical cancer. Increased frequency of CYP2D6 EM and tobacco smoking show strong association with CIN III, indicating that not all lesions with the histopathological high grade CIN are premalignant. Conversely some squamous cell carcinomas may not be preceded by CIN.

Cervical cancer screening in India: strategies revisited

With the change in the life styles and demographic profiles of developing countries, noncommunicable diseases are emerging to be important health problems that demand appropriate control program before they assume epidemic proportion. One of these is the problem of cancer. In India, cervical cancer is a significant problem in terms of incidence, mortality and morbidity. Cervical cancer is a disease that can be prevented through both primary prevention and early detection using screening techniques. Several screening modalities are now available for early detection of cervical cancer and its precursor lesions. They all differ with regard to their test characteristics, feasibility and economic considerations. This communication reviews different aspects of these screening modalities and provides different options considering mass application.

Cervical cancer screening in India: strategies revisited

With the change in the life styles and demographic profiles of developing countries, noncommunicable diseases are emerging to be important health problems that demand appropriate control program before they assume epidemic proportion. One of these is the problem of cancer. In India, cervical cancer is a significant problem in terms of incidence, mortality and morbidity. Cervical cancer is a disease that can be prevented through both primary prevention and early detection using screening techniques. Several screening modalities are now available for early detection of cervical cancer and its precursor lesions. They all differ with regard to their test characteristics, feasibility and economic considerations. This communication reviews different aspects of these screening modalities and provides different options considering mass application.

Effectiveness of oral Ginkgo biloba in treating limited, slowly spreading vitiligo

For effective treatment of vitiligo, it is as important to arrest the progression of the disease as it is to induce repigmentation. Recently, oxidative stress has been shown to play an important role in the pathogenesis of vitiligo. Ginkgo biloba extract has been shown to have antioxidant and immunomodulatory properties. In a double-blind placebo-controlled trial, we evaluated the efficacy of G. biloba extract in controlling the activity of the disease process in patients with limited and slow-spreading vitiligo and in inducing repigmentation of vitiliginous areas. Fifty-two patients were assigned to two treatment groups (A and B) in a double-blind fashion, but only 47 patients could be evaluated, because one patient in group A and four patients in group B withdrew for reasons unrelated to the study. Patients in group A were given G. biloba extract 40 mg three times daily whereas patients in group B received placebo in similar doses. A statistically significant cessation of active progression of depigmentation was noted in patients treated with G. biloba (P = 0.006). Marked to complete repigmentation was seen in 10 patients in group A, whereas only two patients in group B showed similar repigmentation. The G. biloba extract was well tolerated. G. biloba extract seems to be a simple, safe and fairly effective therapy for arresting the progression of the disease.

A survey on risk factors associated with cervical cancer

Carcinoma of the cervix is one of the leading malignancies in the developing countries including India. In view of this health care program might have to be redefined. Most of the data are available from the developed countries, which rely mainly on cytology screening on regular basis. This however may not be feasible in developing countries because of various constraints. Thus alternative approaches are needed based on risk reduction modalities. This article while dealing with the control approaches based on secondary prevention, reviews several risk factors associated with cervical cancer. The various articles were approached through Medline search including cross-references. The important life styles associated with cervical cancer and which are amenable to primary prevention strategies through health education, behavioral interventions, legislative approaches and modifying the health care seeking behavior were identified through the review process. These factors mainly pertain to early sexual debut, multiple sexual partners, menstrual hygiene and unprotected sex. Role of male partners has also been delineated in the process of cervical carcinogenesis. These factors are essentially conducive to the transmission of an etiological agent; the high-risk types human papillomaviruses, the more proximal cause in the web of causation. Barrier method of contraception and prophylactic vaccine in future could help to check the transmission of the virus. Role of smoking and oral contraceptives has also been discussed. Till the facilities for mass scale screening are developed in developing countries the primary prevention approaches could certainly help to check the incidence of the disease.

Cimetidine and levamisole versus cimetidine alone for recalcitrant warts in children

Various immunomodulating agents have been used in the treatment of recalcitrant warts, but none is uniformly effective. Aggressive surgical therapy of warts in children is painful and may require general anesthesia. Drugs such as cimetidine and levamisole have been tried with varying success rates. Given the different target of activities of immunomodulation by cimetidine and levamisole, we questioned whether the combination might be more effective and conducted a double-blind comparative trial of a combination of cimetidine and levamisole versus cimetidine alone. Forty-four patients with multiple recalcitrant warts were assigned to one of two treatment groups (groups A and B) in double-blind fashion. Of the 44 patients, 19 in group A and 20 in group B could be evaluated. At the end of therapy, cure rates (complete clearance) obtained were 31.5% of those in group A and 65% of those in group B (combination treatment). A statistically significant improvement was seen in patients treated with the combination of levamisole and cimetidine (p=0.0150). The rate of regression was faster in group B (average regression period of 7.8 weeks compared with 11 weeks in group A). The present study demonstrated that the combination of cimetidine with levamisole is more effective than cimetidine alone and is a highly effective therapy for the treatment of recalcitrant warts.

Stanozolol in chronic urticaria: a double blind, placebo controlled trial

H1-type antihistamine drugs are mainstays in the management of chronic urticaria. For patients with refractory, chronic, idiopathic urticaria who have failed to benefit from conventional therapy, other safe therapeutic modalities are required. To evaluate the role of stanozolol as an adjunctive therapeutic agent with H1-antihistamine in refractory chronic idiopathic urticaria, we conducted this study. Fifty-eight patients with chronic refractory urticaria were enrolled in this trial and were randomly assigned to two groups (A and B). Patients in group A received 2 mg stanozolol twice daily along with cetrizine 10 mg daily. Patients in group B received cetrizine 10 mg daily and placebo tablets twice daily. The improvement was monitored by estimation of severity score. Of the 58 patients, 26 in group A and 24 in group B could be evaluated. At the end of 12 weeks, 17 patients in group A showed marked to complete resolution as compared to 7 patients in group B (chi-square p<0.01). The intention to treat analysis p value was a found to be <0.007. There was a highly significant decrease in mean severity score at 12 weeks (p<0.001) in group A patients. The present study demonstrated that stanozolol is an effective and safe adjuvant therapy for treatment of chronic refractory urticaria.

Reduction in the cumulative incidence rate of cervical cancer by one life time selective screening

Mass scale cervical cytology which is the most accepted strategy for the control of cervical cancer cannot be undertaken in developing countries in view of paucity of resources, hence a need arises to examine alternate strategy. The present exercise attempts to study the reduction in cumulative incidence rate of cervical cancer by one life time selective screening. The results revealed that cumulative incidence rate (CIR) of cervical cancer per 100,000 in cohort of women during the age of 20 to 64 years was found to be 2555.0 in the absence of screening. One life time selective screening at the age of 40 and 45 years showed the reduction of 11.6 and 17.2% in CIR respectively where as respective estimates in case of complete screening at mentioned age groups were found to be 21.5% and 25%. In order to further conserve the resources the strategy seems to be optimum for developing countries.

Cancer projection by the turn of century-Indian science

This is an attempt to understand the magnitude of cancer problem in India. The incidence data generated by the three population based cancer registries at Bangalore, Bombay and Madras and the population projections of country have been utilised for estimating the present and future load of new cancer cases. It is estimated that the total number of incident cases in males increased from 0.29 million to 0.43 million by the turn of the century as a result of change in size and composition of population and when adjusted for tobacco habits the estimates increased to 0.49 million. In females the incident cases of cancer for three registries increased from 0.32 to 0.42 million by 2001, with cancer of uterine cervix and breast being the major problems. The above results show an urgent need for strengthening and augmenting the existing diagnostic/treatment facilities which are vow fully inadequate to tackle even the present load.