Spinal Cord Stimulation for Refractory Angina Pectoris -A Case Report-

Refractory angina pectoris is defined as angina refractory to optimal medical treatment and standard coronary revascularization procedures. Despite recent therapeutic advances, patients with refractory angina pectoris are not adequately treated. Spinal cord stimulation is a minimally invasive and reversible technique which utilizes electrical neuromodulation by means of an electrode implanted in the epidural space. It has been reported to be an effective and safe treatment for refractory angina pectoris. We report a case of spinal cord stimulation which has effectively relieved chest pain due to coronary artery disease in a 40-year-old man. This is the first report of spinal cord stimulation for treatment of refractory angina pectoris in South Korea

A test of the adaptive network explanation of functional disorders using a machine learning analysis of symptoms.

The classification and etiology of functional disorders is controversial. Evidence supports both psychological and biological (disease) models that show, respectively, that functional disorders should be classified as one (bodily distress syndrome) and many (e.g., irritable bowel syndrome (IBS), fibromyalgia syndrome (FMS), and chronic fatigue syndrome (CFS)). Two network models (symptom network and adaptive network) can explain the specificity and covariation of symptomatology, but only the adaptive network model can explain the covariation of the somatic symptoms of functional disorders. The adaptive network model is based on the premise that a network of biological mechanisms has emergent properties and can exhibit adaptation. The purpose of this study was to test the predictions that symptom similarity increases with pathology and that network connection strengths vary with pathology, as this would be consistent with the notion that functional disorder pathology arises from network adaptation. We conducted a symptom internet survey followed by machine learning analysis. Participants were 1751 people reporting IBS, FMS or CFS diagnosis who completed a 61-item symptom questionnaire. Eleven symptom clusters were identified. Differences in symptom clusters between IBS, FMS and CFS groups decreased as overall symptom frequency increased. The strength of outgoing connections between clusters varied as a function of symptom frequency and single versus multiple diagnoses. The findings suggest that the pathology of functional disorders involves an increase in the activity and causal connections between several symptom causing mechanisms. The data provide support for the proposal that the body is capable of complex adaptation and that functional disorders result when rules that normally improve adaptation create maladaptive change

Refractory angina pectoris. Patient characteristics, safety and long-term effects of spinal cord stimulation

Refractory angina pectoris has been defined as severe angina pectoris due to coronary artery disease which cannot be controlled by conventional pharmacological or surgical therapy. The epidemiology of this condition is virtually unknown. During the last decades, additional treatment options have been developed for this condition. One of these is spinal cord stimulation (SCS), which has been used for approximately 20 years as an additional symptom-relieving treatment for patients with severe angina pectoris. SCS has an anti-ischaemic effect and has been shown to be a safe and effective treatment modality. The occurrence of refractory angina pectoris among patients who had undergone coronary angiography was assessed in a defined geographic area. In order to characterise the patients with regard to concurrent diseases, treatment, functional class, quality of life, morbidity and fatality, the refractory angina patients were compared with patients with severe angina pectoris who were accepted for revascularisation. Within three years, 146 patients were identified, comprising 2.1% of all patients undergoing coronary angiography due to stable angina pectoris. The patients with refractory angina pectoris had more severe cardiac disease as well as coronary artery disease than the patients in the revascularisation group. Some of the patients in the refractory group appear to be in a fairly good condition with regard to extracardiac diseases but there is a subpopulation in the refractory group with severe cardiac as well as extracardiac diseases. The main reasons for rejection for revascularisation were unsuitable coronary anatomy and a potential risk of damaging existing grafts. After one year of follow-up the refractory patients had a higher fatality rate but a lower frequency of cerebrovascular morbidity than the revascularisation group. The refractory patients had more severe angina and lower quality of life with regard to physical function and impact of angina symptoms, compared with the revascularisation group. However, the mental health of the refractory patients was not affected compared with the revascularisation group. The patients in the so-called ESBY study (Electrical Stimulation versus Coronary Bypass Surgery in Severe Angina Pectoris, a randomised comparison of SCS and coronary artery bypass grafting (CABG) in 104 patients with severe angina pectoris and increased surgical risk) were followed up with regard to neurological and neuropsychological complications, morbidity and cost-effectiveness. There were more patients in the CABG group who developed neurological and neuropsychological complications than in the SCS group. Furthermore, presence of deep white matter disease on cerebral magnetic resonance imaging was shown to be a predictor of cerebrovascular complications after CABG. During two years of follow-up, health care costs and cardiac morbidity was lower in the SCS group than in the CABG group. However, the groups did not differ with regard to mortality or causes of death. There were no serious complications related to the SCS treatment. CONCLUSION Refractory angina pectoris appears to be a considerable problem. This patient group has a high fatality rate and low quality of life compared with revascularised patients. SCS, which is one of the recommended treatment option for these patients, was found to be safe (in terms of mortality, morbidity and absence of serious complications) and effective (in terms of symptom relief and cost-effectiveness) during long-term treatment. Furthermore, presence of deep white matter disease on cerebral magnetic resonance imaging seems to be a predictor of cerebrovascular complications after CABG

Insomnia Symptoms and Chronic Pain among Patients Participating in a Pain Rehabilitation Program—A Registry Study

Insomnia and chronic pain are prevalent health complaints. Previous research has shown that they are closely associated, but their interaction and causality are not completely understood. Further research is needed to uncover the extent to which a treatment strategy focusing on one of the conditions affects the other. This study aimed to map the prevalence of insomnia symptoms among patients in interdisciplinary pain rehabilitation program (IPRP) and investigate associations between the degree of insomnia at baseline and the treatment outcome regarding pain intensity, physical function, social function, mental well-being, anxiety, and depression. Of the 8515 patients with chronic pain, aged 15–81 who were registered in the Swedish Quality Registry for Pain Rehabilitation during 2016–2019 and participated in IPRP, 7261 had follow-up data after treatment. Logistic regression analysis was used to investigate associations. The prevalence of clinical insomnia, according to Insomnia Severity Index (ISI), among chronic pain patients in IPRP was 66%, and insomnia symptoms were associated with both country of birth and educational level. After IPRP, the prevalence of clinical insomnia decreased to 47%. There were statistically significant associations between the degree of insomnia symptoms before IPRP and physical function (p < 0.001), social function (p = 0.004) and mental well-being (p < 0.001). A higher degree of insomnia symptoms at baseline was associated with improvement after IPRP. In conclusion, IPRP seem to have beneficial effects on insomnia symptoms in chronic pain patients. Nevertheless, almost half of the patients still suffer from clinical insomnia after IPRP. The possible effect of systematic screening and treatment of insomnia for improving the effect of IPRP on pain is an important area for future research

How theories of complexity and resilience affect interprofessional simulation-based education: a qualitative analysis of facilitators’ perspectives

Abstract Background Quality of care and patient safety rely on the ability of interprofessional teams to collaborate effectively. This can be trained through interprofessional simulation-based education (IPSE). Patient safety also relies on the ability to adapt to the complexity of such situations, an ability termed resilience. Since these needs are not explicitly addressed in IPSE, the aim of this study was to explore how central concepts from complexity-theory and resilience affect IPSE, from facilitators’ perspective, when applied in debriefings. Methods A set of central concepts in complexity-theory and resilience were introduced to facilitators on an IPSE course for nursing and medical students. In five iterations of focus groups interviews the facilitators discussed their application of these concepts by reviewing video recordings of their own debriefings. Video recordings of the interviews were subjected to coding and thematic analysis. Results Three themes were identified. The first, Concepts of complexity and resilience are relevant for IPSE, points to the applicability of these concepts and to the fact that students often need to deviate from prescribed guidelines/algorithms in order to solve cases. The second theme, Exploring complexity, shows how uncertainty could be used as a cue to explore complexity. Further, that individual performance needs to account for the context of actions and how this may lead to certain outcomes. Moreover, it was suggested that several ways to approach a challenge can contribute to important insight in the conditions for teamwork. The third theme, Unpacking how solutions are achieved, turns to needs for handling the aforementioned complexity. It illustrates the importance of addressing self-criticism by highlighting how students were often able to overcome challenges and find solutions. Finally, this theme highlights how pre-defined guidelines and algorithms still work as important resources to help students in transforming perceived messiness into clarity. Conclusions This study suggests that IPSE provides the possibility to explore complexity and highlight resilience so that such capability can be trained and improved. Further studies are needed to develop more concrete ways of using IPSE to account for complexity and developing resilience capacity and to evaluate to what extent IPSE can provide such an effect

Suffering out of sight but not out of mind - interpreting experiences of sick leave due to chronic pain in a community setting : A qualitative study

OBJECTIVE: Chronic pain is a complex health problem affecting about one-fifth of the European population. It is a leading cause of years lived with disability worldwide, with serious personal, relational and socioeconomic consequences. Chronic pain and sick leave adversely affect health and quality of life. Thus, understanding this phenomenon is essential for reducing suffering, understanding the need for support and promoting a rapid return to work and an active lifestyle. This study aimed to describe and interpret persons' experiences of being on sick leave due to chronic pain. DESIGN: A qualitative study with semistructured interviews analysed using a phenomenological hermeneutic approach. SETTING: Participants were recruited from a community setting in Sweden. PARTICIPANTS: Fourteen participants (12 women) with experiences of part-time or full-time sick leave from work due to chronic pain were included in the study. RESULTS: Suffering out of sight but not out of mind was the main theme of the qualitative analysis. This theme implies that the participants' constant suffering was invisible to others, causing them to feel they were not being justly treated in society. Feeling overlooked led to a continuous struggle for recognition. Moreover, the participants' identities and their trust in themselves and their bodies were challenged. However, our study also revealed a nuanced understanding of the experiences of sick leave as a consequence of chronic pain, where the participants learnt important lessons, including coping strategies and re-evaluated priorities. CONCLUSIONS: Being on sick leave due to chronic pain threatens a person's integrity and leads to substantial suffering. An enhanced understanding of the meaning of sick leave due to chronic pain provides important considerations for their care and support. This study highlights the importance of feeling acknowledged and being met with justice in encounters with others

All else equal : Examining treatment bias and stereotypes based on patient ethnicity and socioeconomic status using in-hospital cardiac arrest clinical vignettes

BackgroundResearch on ethnic and socioeconomic treatment differences following in-hospital cardiac arrest (IHCA) largely draws on register data. Due to the correlational nature of such data, it cannot be concluded whether detected differences reflect treatment bias/discrimination – whereby otherwise identical patients are treated differently solely due to sociodemographic factors. To be able to establish discrimination, experimental research is needed.ObjectiveThe primary aim of this experimental study was to examine whether simulated IHCA patients receive different treatment recommendations based on ethnicity and socioeconomic status (SES), holding all other factors (e.g., health status) constant. Another aim was to examine health care professionals’ (HCP) stereotypical beliefs about these groups.MethodsHCP (N = 235) working in acute care made anonymous treatment recommendations while reading IHCA clinical vignettes wherein the patient's ethnicity (Swedish vs. Middle Eastern) and SES had been manipulated. Afterwards they estimated to what extent hospital staff associate these patient groups with certain traits (stereotypes).ResultsNo significant differences in treatment recommendations for Swedish versus Middle Eastern or high versus low SES patients were found. Reported stereotypes about Middle Eastern patients were uniformly negative. SES-related stereotypes, however, were mixed. High SES patients were believed to be more competent (e.g., respected), but less warm (e.g., friendly) than low SES patients.ConclusionsSwedish HCP do not seem to discriminate against patients with Middle Eastern or low SES backgrounds when recommending treatment for simulated IHCA cases, despite the existence of negative stereotypes about these groups. Implications for health care equality and quality are discussed