Radiofrequency denervation of the lumbar facet joints: guidelines for the RADICAL randomised controlled trial

Background and aim:

The RADICAL trial has been funded by the National Institute for Health Research (NIHR) to evaluate the clinical and cost-effectiveness of radiofrequency denervation (RFD) for low back pain. Recommendations have been published which aim to standardise selection of patients and RFD technique. However, it is important to ensure these recommendations are acceptable to clinicians within the context of the trial. The aim of this work was to develop standardised criteria for the trial entry and RFD technique for implementation within the RADICAL trial.

Methods:

Fourteen pain clinicians completed a survey, which involved reviewing the current recommendations and indicating whether they disagreed with any of the recommendations and if so why. Responses were collated and presented at a half-day workshop with 14 attendees. During the workshop, the National Low Back and Radicular Pain Pathway (NLBRPP) guidelines for patient selection and an article by Eldabe and colleagues presenting recommendations on the RFD technique were reviewed. Attendees discussed whether each component of the recommendations should be mandatory, mandatory with alteration or clarification or optional within the RADICAL trial.

Results:

Attendees agreed during the workshop that 5 of the 10 criteria for patient selection described in the NLBRPP should be mandatory within the RADICAL trial. Three were agreed as mandatory criteria but required further clarification, one of which involved defining a positive response to a diagnostic medial branch block as ⩾60% pain relief. Two criteria had optional components. After reviewing the recommendations on the RFD technique from Eldabe and colleagues, seven components were agreed as mandatory, three were mandatory with alterations and three were optional.

Conclusion:

When evaluating complex interventions, such as RFD, it is important to ensure agreement and clarity on the clinical protocol, so that the intervention can be reproduced, if found to be effective.

Best practice in radiofrequency denervation of the lumbar facet joints: a consensus technique

Background

Radiofrequency denervation is used to treat selected people with low back pain. Recent trials have been criticised for using a sub-optimal intervention technique.

Objectives

To achieve consensus on a best practice technique for administering radiofrequency denervation of the lumbar facet joints to selected people with low back pain.

Study design

A consensus of expert professionals in the area of radiofrequency denervation of the lumbar facet joints.

Methods

We invited a clinical member from the 30 most active UK departments in radiofrequency pain procedures and two overseas clinicians with specific expertise to a 1 day consensus meeting. Drawing on the known anatomy of the medial branch, the theoretical basis of radiofrequency procedures, a survey of current practice and collective expertise, delegates were facilitated to reach consensus on the best practice technique.

Results

The day was attended by 24 UK and international clinical experts. Attendees agreed a best practice technique for the conduct of radiofrequency denervation of the lumbar facet joints.

Limitations

This consensus was based on a 1 day meeting of 24 clinical experts who attended and took part in the discussions. The agreed technique has not been subject to input from a wider community of experts.

Conclusions

Current best practice for radiofrequency denervation has been agreed for use in a UK trial. Group members intend immediate implementation in their respective trusts. We propose using this in a planned Randomised Controlled Trial (RCT) of radiofrequency denervation for selected people with low back pain.

A systems analysis of irrigation water quality in environmental assessments related to foodborne outbreaks

Irrigation water quality can affect food safety and health and has been identified as a possible source of pathogens in produce linked to disease outbreaks. Many irrigation water sources are subject to contamination from various sources in surrounding watersheds. A systems-based, watershed scale analysis is therefore necessary to comprehensively identify both sources of contamination and the conditions in the environment that facilitated or created that contamination, termed here 'environmental antecedents'. Three nationwide disease outbreaks linked to produce in the United States (US) are used to illustrate this concept of a watershed scale assessment to investigate potential impacts of irrigation water quality on food safety.

Determination of trace metals abnormalities in patients with vivax malaria

BACKGROUND

In the present study, blood serum level of metals were determined in malarial patients and compared with those in the normal subjects without complication using Atomic Absorption Spectrometer.

METHODS

For the determination of these metals twelve intravenous blood samples each from referred malarial patients and a group of normal subjects were collected and immediately centrifuged to obtain the supernatant liquid, serum of both the groups for analysis.

RESULTS

The blood serum levels of copper in malarial patients determined to be 2.6917 ppm, which is higher as compared to that found 2.045 in normal subjects. Whereas the blood serum levels of iron, magnesium, and zinc found 2.0708 ppm, 12.2467 ppm and 4.9017 ppm respectively in malarial patients, who are lower than those, are determined in the blood serum of normal subjects. Blood serum levels of iron, magnesium, and zinc in normal subjects found 3.950 ppm, 19.4892 ppm, and 5.242 ppm respectively.

CONCLUSION

In this study the metal content of copper, iron, magnesium and zinc in vary in malarial patients as compared those in the normal subjects. It may suggest that the decreased levels of iron, magnesium, and zinc can be maintained by giving as supplement of these metals in therapy.

Analysis and modelling of land-based nutrient pollution by watershed models coupled with GIS: a case study from Turkey

Diffuse pollution is usually temporally and spatially uncertain, and thus hard to analyze. In many cases, discretizing a diffuse source of pollution into individual point sources can ease diffuse pollution modelling and analysis, and therefore reduce high uncertainty especially in the spatial distribution of pollution loads. This is however a difficult task, since quite a number of sub-drainage areas, with complex structures and land-use properties, has to be delineated. Watershed models can be used to delineate the sub-drainage areas in a watershed with high accuracy and locate the related outlets which connect the sub-drainage areas to the main waterbody in a watershed. In this study, such an approach has been used on a case study to model the diffuse nutrient loads carried to streams that reach to a medium-sized lake in Turkey. The annual nutrient loads, which were calculated by using mathematical models, were then converted to a load-map with the help of a geographical information system.

Reducing cardiovascular responses to laryngoscopy and tracheal intubation: a comparison of equipotent doses of tramadol, nalbuphine and pethidine, with placebo

The stress response to tracheal intubation may be obtunded by opioids given with induction of anesthesia. Tramadol is an opioid acting on mu-receptors and the monoaminergic pain modulating systems. This study examined vasomotor responses to tracheal intubation after equipotent doses of tramadol, nalbuphine and pethidine (3.0, 0.3 mg/kg(-1), and 1.5 mg/kg(-1), respectively), and placebo, given prior to induction of anesthesia in 118 healthy patients. Premedication and induction of anesthesia were standardized. Recordings of HR and SAP were made prior and subsequent to induction of anesthesia, and at 1, 3, 5 and 7 minutes after tracheal intubation. Prior to laryngoscopy and intubation, HR increased in all groups (p < or = 01, all comparisons), but least so after nalbuphine, whilst SAP remained unchanged after placebo, tramadol and pethidine, but fell after nalbuphine (p < 0.025). Maximum increases in HR (p < or = 0.005, all comparisons) and SAP (p < or = 0.02, all comparisons) occurred one minute after intubation. Maximum HR after placebo (108 SD 15 bpm), tramadol (107 SD 20 bpm), pethidine (113 SD 16 bpm) and nalbuphine (110 SD 26 bpm) was similar; with placebo HR remained faster than baseline until the seventh minute but had returned to baseline by the fifth minute with the opioids. Maximum SAP with tramadol (151 SD 26 mmHg) was similar to that with placebo (157 SD 20 mmHg), but was greater than after pethidine (136 SD 27 mmHg; p < 0.05) and nalbuphine (135 SD 19 mmHg; p < 0.02). With each test drug SAP returned to baseline by the third minute. It is concluded that, in these doses, 1) tramadol does not attenuate the chronotropic nor the inotropic response to tracheal intubation, and 2) pethidine and nalbuphine reduce only the inotropic response to airway instrumentation.

Evidence that Ca2+-activated K+ channels play a major role in mediating the vascular effects of iloprost and cicaprost

The role of K+ channels in mediating vasorelaxation induced by two prostacyclin analogues was investigated in guinea-pig aorta. Iloprost caused substantial relaxation of tissues contracted with phenylephrine or 25 mM K+ but not 60 mM K+. In endothelial-denuded tissues, maximal relaxations to iloprost, cicaprost or isoprenaline were inhibited by approximately 40-50% with tetraethylammonium or iberiotoxin, both blockers of large conductance Ca2+-activated K+ (BKCa) channels. In contrast, the response to forskolin, an activator of adenylate cyclase was marginally inhibited by tetraethylammonium. The K(ATP) channel blocker, glibenclamide significantly augmented the response to iloprost but not cicaprost. These effects were largely inhibited by the EP1 receptor antagonist, 8-chlorodibenz[b,f][1,4]oxazepine-10(11H)-carboxylic acid 2-[1-oxo-3(4-pyridinyl)propyl]hydrazide, monohydrochloride (SC-51089) and partially by indomethacin, suggesting that iloprost relaxation is counterbalanced by activation of EP1 receptors, in part through a constrictor prostaglandin. We conclude that BKCa channels play an important role in mediating the effects of iloprost and cicaprost and raises the possibility that cyclic AMP-independent pathways might be involved.