GW25-e0848 The effects of anticoagulant therapy on coagulant state and platelet function following transcatheter closure of atrial septal defect

BACKGROUND: Motor cortex stimulation (MCS) was introduced in the early 1990s by Tsubokawa and his group for patients diagnosed with drug-resistant, central neuropathic pain. Inconsistencies concerning the details of this therapy and its outcomes and poor methodology of most clinical essays divide the neuromodulation society worldwide into "believers" and "nonbelievers." A European expert meeting was organized in Brussels, Belgium by the Benelux Neuromodulation Society in order to develop uniform MCS protocols in the preoperative, intraoperative, and postoperative courses. METHODS: An expert meeting was organized, and a questionnaire was sent out to all the invited participants before this expert meeting. An extensive literature research was conducted in order to enrich the results. RESULTS: Topics that were addressed during the expert meeting were 1) inclusion and exclusion criteria, 2) targeting and methods of stimulation, 3) effects of MCS, and 4) results from the questionnaire. CONCLUSIONS: Substantial commonalities but also important methodologic divergencies emerged from the discussion of MCS experts from 7 European Centers. From this meeting and questionnaire, all participants concluded that there is a need for more homogenous standardized protocols for MCS regarding patient selection, implantation procedure, stimulation parameters, and follow-up-course

A Practical Approach to the Diagnosis and Understanding of Chronic Low Back Pain, Based on Its Pathophysiology.

As outlined abundantly in this book, chronic low back pain is not a diagnosis, but a symptom. Thorough knowledge of the cause and nature of the pain might help when looking for a correct diagnosis. Often, this clinical knowledge is more important with respect to therapeutic strategies than advanced medical tools such as imaging. When evaluating the cause of the pain, one should always be aware that much of the pain presented by the patients might be referred pain, by which pain patterns from various sources (e.g., lumbar facet joints and sacroiliac joint) may mimic each other. Thus, deep somatic pain derived from spinal structures may refer to the legs, even beyond the knee, and is not Always restricted to the back. However, it is clear that the location of the pain provides no reliable identification of the primary source of pain. Even identification of the tissue source of pain is hazardous. This might be a major additional explanatory factor for the reason why the specifi city of pain/tissue source vs. pain symptomatology is low. Although diagnostic nerve blocks may be helpful, several limitations (technical, sensitivity, and specificity) have been reported. The same accounts for advanced medical imaging, such as MRI and single-photon emission tomography (SPECT)-CT. Thus, the certainty by which a diagnosis can be made is not so high as the physician and the patient would wish it to be, but that is something we will have to live with for a few more decades. Furthermore, this overlap in symptoms and diagnoses caused by the multisegmental innervation of spinal structures also leads to a poor homogeneity in patient groups in randomized controlled trials, especially when patient numbers are low. Often we compare apples with pears and are surprised that our results do not correspond to what we expect. A more proper diagnosis is the only correct answer to this problem. Much more research should be directed toward diagnosis, rather than to more fancy therapeutic tools. We should search for biomarkers that can be correlated with a specifi c treatment and excellent clinical outcome. We are afraid, however, that research for more fl ashy implants is more rewarding than the one for a proper diagnosis. Finally, pain should be considered as the resulting experience of activation of the peripheral nerve endings and neurons at the spinal ganglions, the spinal cord, the brain stem, and the brain. At the level of the brain, these neurons deal with the translation of nociceptive stimuli and value the unpleasantness of incoming signals. The balanced end result can be experienced as pain, but not always, since this interpretation process may be influenced by many other factors. We are just at the beginning of the exploration of this very complex and multifaceted pathophysiology of pain. While therapies have changed very little in the past decades, clinical practice of chronic pain management has undergone a paradigm shift. The emerging focus is on helping people to live with their pain. Providing pain relief for alle patients is abandoned, since not realistic today

Single-port videoscopic splanchnotomy for palliation of refractory chronic pancreatitis

OBJECTIVES: Interrupting the afferent signals that travel through the splanchnic nerves by multiportal thoracoscopic splanchnotomy can offer effective palliation in chronic pancreatitis. However, obtained results weaken after time, possibly necessitating repeat procedures. Given the palliative nature of this procedure, potential for iatrogenic damage should be kept at a minimum. So, in order to minimize invasiveness while optimizing repeatability, we sought to create an easily reproducible single-access port operative strategy. METHODS: Four patients suffering from intractable pain due to chronic pancreatitis for > 10 years (12.8 +/- 5.9) underwent a single-port unilateral R5-R11 splanchnotomy. RESULTS: Postoperative recovery was uneventful. No operative complications were observed. All 4 patients experienced excellent pain relief with a significant improvement of Visual Analogue Scale pain scores (8.8 +/- 1.0 preoperatively to 3.0 +/- 1.2 postoperatively, P = 0.003). CONCLUSIONS: We report the first series of single-port video-assisted thoracoscopic surgical (VATS) splanchnotomy for palliation of intractable pain due to chronic pancreatitis. From this small study, single-port VATS splanchnotomy seems to be a safe and effective alternative to multiportal or open procedures