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  • PET/MR of pediatric bone tumors: what the radiologist needs to know. Skeletal radiology Padwal, J., Baratto, L., Chakraborty, A., Hawk, K., Spunt, S., Avedian, R., Daldrup-Link, H. E. 2022

    Abstract

    Integrated 2-deoxy-2-[fluorine-18]fluoro-D-glucose (18F-FDG) positron emission tomography (PET)/magnetic resonance (MR) imaging can provide "one stop" local tumor and whole-body staging in one session, thereby streamlining imaging evaluations and avoiding duplicate anesthesia in young children. 18F-FDG PET/MR scans have the benefit of lower radiation, superior soft tissue contrast, and increased patient convenience compared to 18F-FDG PET/computerized tomography scans. This article reviews the 18F-FDG PET/MR imaging technique, reporting requirements, and imaging characteristics of the most common pediatric bone tumors, including osteosarcoma, Ewing sarcoma, primary bone lymphoma, bone and bone marrow metastases, and Langerhans cell histiocytosis.

    View details for DOI 10.1007/s00256-022-04113-6

    View details for PubMedID 35804163

  • Immediate Effects of a Continuous Peripheral Nerve Block on Postamputation Phantom and Residual Limb Pain: Secondary Outcomes From a Multicenter Randomized Controlled Clinical Trial. Anesthesia and analgesia Ilfeld, B. M., Khatibi, B., Maheshwari, K., Madison, S. J., Ali Sakr Esa, W., Mariano, E. R., Kent, M. L., Hanling, S., Sessler, D. I., Eisenach, J. C., Cohen, S. P., Mascha, E. J., Yang, D., Padwal, J. A., Turan, A., PAINfRE Investigators, Morris, B. A., Szmuk, P., Beck, G. J., Abdullah, B., Aleshi, P., Buys, M. J., Cata, J. P., Chen, G., De Oliveira, G. S., Elsharkawy, H., Finneran, J. J., Ganaway, T., Govindarajan, S. R., Kalasbail, P., Kendall, M. C., Zafeer Khan, M., Kopp, S., Loland, V. J., Machi, A. T., Malik, T., Memtsoudis, S. G., Missair, A., Ilfeld, A. M., Mounir-Soliman, L., Braun, B., Vlassakov, K. V., Warren, L., Wen, C. H., Woodworth, G. E., Young, A. C. 2021

    Abstract

    BACKGROUND: We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported.METHODS: Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article.RESULTS: Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance.CONCLUSIONS: This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.

    View details for DOI 10.1213/ANE.0000000000005673

    View details for PubMedID 34314392

  • Ambulatory continuous peripheral nerve blocks to treat post-amputation phantom limb pain a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain Ilfeld, B. M., Khatibi, B. n., Maheshwari, K. n., Madison, S. J., Sakr Esa, W. A., Mariano, E. R., Kent, M. L., Hanling, S. n., Sessler, D. I., Eisenach, J. C., Cohen, S. P., Mascha, E. J., Ma, C. n., Padwal, J. A., Turan, A. n. 2020

    Abstract

    Phantom limb pain is thought to be sustained by reentrant neural pathways which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0-12 weeks. Pretreatment pain scores were similar in both groups, with a median [interquartile range] of 5.0 [4.0, 7.0] for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic versus 4.5 (2.6) in those given placebo (difference (95% CI) 1.3 (0.4, 2.2), P=0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 [0, 5.0] vs. 1.5 [0, 5.0] for the placebo group; there appeared to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

    View details for DOI 10.1097/j.pain.0000000000002087

    View details for PubMedID 33021563

  • The association of neuraxial versus general anesthesia with inpatient admission following arthroscopic knee surgery JOURNAL OF CLINICAL ANESTHESIA Padwal, J. A., Burton, B. N., Fiallo, A. A., Swisher, M. W., Gabriel, R. A. 2019; 56: 145-150

    Abstract

    Arthroscopic knee procedures are increasingly being performed in an outpatient setting. Appropriate intraoperative anesthesia is vital to prevent complications such as unanticipated hospital admission. We examined differences in complications between general (GA) vs neuraxial anesthesia (NA) as the primary anesthetic for patients undergoing arthroscopic knee procedures.This was a retrospective cohort study. We queried the National Surgical Quality Improvement Program for arthroscopic knee procedures performed between 2007 and 2016. We compared postoperative complication rates between propensity-matched cohorts (NA vs GA). The anesthesia groups were matched based on age, race, BMI, gender, diabetes, smoking history, COPD, CHF, functional status, HTN, ASA class, steroid use, bleeding disorder history, and readmission status. Univariable and multivariable logistic regression were used to compare factors associated with inpatient admission - defined as hospital length of stay >1 day.A total of 57,494 patients were included - 55,257 GA and 2237 NA patients.Among the matched cohorts, NA patients were significantly more likely to be admitted to the hospital postoperatively (p < 0.001). Neuraxial anesthesia (OR 5.93, 95% CI 4.90-7.21) use was also significant in the final multivariable regression model for inpatient admission. Additional significant predictors for inpatient admission included history of bleeding disorder (OR 5.44, 95% CI 2.14-12.76), Asian race (OR 6.47, 95% CI 4.90-8.56), COPD (OR 3.10, 95% CI 1.94-4.82), diabetes (OR 1.90, 95% CI 1.43-2.49), and increased operation time (OR 3.01, 95% CI 2.69-3.37).NA was significantly associated with inpatient admission following knee arthroscopy. Further research should focus on examining the reason for this association and methods to reduce inpatient admission for patients undergoing arthroscopic knee procedures using neuraxial anesthesia.

    View details for DOI 10.1016/j.jclinane.2019.01.045

    View details for Web of Science ID 000468713500051

    View details for PubMedID 30807886

  • Continuous Popliteal-Sciatic Blocks for Postoperative Analgesia: Traditional Proximal Catheter Insertion Superficial to the Paraneural Sheath Versus a New Distal Insertion Site Deep to the Paraneural Sheath ANESTHESIA AND ANALGESIA Sztain, J. F., Finneran, J. J., Monahan, A. M., Khatibi, B., Nguyen, P. L., Madison, S. J., Bellars, R. H., Gabriel, R. A., Ahmed, S. S., Schwartz, A. K., Kent, W. T., Donohue, M. C., Padwal, J. A., Ilfeld, B. M. 2019; 128 (6): E104–E108
  • Cost-effectiveness of Intraoperative MRI for Treatment of High-Grade Gliomas RADIOLOGY Abraham, P., Sarkar, R., Brandel, M. G., Wali, A. R., Rennert, R. C., Ramos, C., Padwal, J., Steinberg, J. A., Santiago-Dieppa, D. R., Cheung, V., Pannell, J., Murphy, J. D., Khalessi, A. A. 2019; 291 (3): 689-697

    Abstract

    Background Intraoperative MRI has been shown to improve gross-total resection of high-grade glioma. However, to the knowledge of the authors, the cost-effectiveness of intraoperative MRI has not been established. Purpose To construct a clinical decision analysis model for assessing intraoperative MRI in the treatment of high-grade glioma. Materials and Methods An integrated five-state microsimulation model was constructed to follow patients with high-grade glioma. One-hundred-thousand patients treated with intraoperative MRI were compared with 100 000 patients who were treated without intraoperative MRI from initial resection and debulking until death (median age at initial resection, 55 years). After the operation and treatment of complications, patients existed in one of three health states: progression-free survival (PFS), progressive disease, or dead. Patients with recurrence were offered up to two repeated resections. PFS, valuation of health states (utility values), probabilities, and costs were obtained from randomized controlled trials whenever possible. Otherwise, national databases, registries, and nonrandomized trials were used. Uncertainty in model inputs was assessed by using deterministic and probabilistic sensitivity analyses. A health care perspective was used for this analysis. A willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained was used to determine cost efficacy. Results Intraoperative MRI yielded an incremental benefit of 0.18 QALYs (1.34 QALYs with intraoperative MRI vs 1.16 QALYs without) at an incremental cost of $13 447 ($176 460 with intraoperative MRI vs $163 013 without) in microsimulation modeling, resulting in an incremental cost-effectiveness ratio of $76 442 per QALY. Because of parameter distributions, probabilistic sensitivity analysis demonstrated that intraoperative MRI had a 99.5% chance of cost-effectiveness at a willingness-to-pay threshold of $100 000 per QALY. Conclusion Intraoperative MRI is likely to be a cost-effective modality in the treatment of high-grade glioma. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Bettmann in this issue.

    View details for DOI 10.1148/radiol.2019182095

    View details for Web of Science ID 000468618200022

    View details for PubMedID 30912721

    View details for PubMedCentralID PMC6543900