Anticoagulation during extracorporeal membrane oxygenation (ECMO) requires balancing thrombotic and bleeding risks, yet early coagulation dynamics may differ between venovenous (VV) and venoarterial (VA) support. This study prospectively characterized standard coagulation tests and viscoelastic profiles during the first 48 h of ECMO and related these to early bleeding and transfusion need. Multicenter, prospective cohort in four Belgian ICUs (03/2021–01/2023; NCT04912336). Adults initiated on VV- or VA-ECMO were enrolled immediately before cannulation and sampled at inclusion, + 2 h, + 24 h, and + 48 h. Laboratory tests (aPTT, PT/INR, fibrinogen, platelets, anti-Xa, D-dimer, AT), ROTEM, bleeding (BARC, GUSTO), and transfusions were recorded. Forty-three patients were included (23 VV, 20 VA). At inclusion, platelet counts were higher in VV than in VA (median 292 vs. 145·109/L). Thrombocytopenia was present at enrollment in 30
Delirium is a common complication of ischemic stroke (IS). Previous quantitative EEG (qEEG) studies have linked delirium to increased delta and theta power and reduced alpha band functional connectivity. Most excluded patients with structural brain lesions, limiting extrapolation to post-stroke delirium (PSD). This study aims to compare qEEG measures in IS patients with and without PSD. IS patients hospitalized within 24 h after symptom onset were included. The presence of delirium was evaluated by two raters based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, using a retrospective chart review method. When no consensus was reached, a third rater was consulted. PSD cases were matched to non-PSD patients based on stroke location, severity (NIHSS) and age. Spectral and connectivity EEG results were compared using Mann-Whitney U tests. Relative delta power was significantly higher in PSD patients (n = 40; median(M) = 0,541; IQR = 0,404-0,631) compared to non-PSD patients (n = 40; M = 0,451; IQR = 0,358-0,534; p-value 0,022; r = 0.256). In the alpha band, functional connectivity strength was significantly lower in PSD patients based on phase lag index (PLI M = 0,130 (IQR = 0,118-0,155) versus M = 0,149 (IQR = 0,120-0,174); p-value 0,044; r = 0.157) and amplitude envelope correlation (AEC-c M = 0,517 (IQR = 0,506-0,535) versus M = 0,526 (IQR = 0,514-0,544); p-value 0,029; r = 0.244). PSD is associated with increased delta power and reduced alpha connectivity. Results align with prior qEEG studies in delirium due to other etiologies, suggesting common pathophysiological mechanisms.
BACKGROUND/IMPORTANCE:Both percutaneous and paddle leads are utilized when implanting spinal cord stimulation (SCS). Both leads appear to be safe and effective, yet, there is a scarcity of guidelines for deciding which type of lead a physician should use. OBJECTIVE:The main goal is to provide an overview of clinical indications for percutaneous and paddle leads for SCS in patients with chronic spinal pain. EVIDENCE REVIEW:Databases consulted for this systematic review were PubMed, Web of Science, Scopus and Embase. Only studies evaluating SCS in chronic spinal pain patients, with or without previous spine surgery, were eligible. The study protocol was prospectively registered (PROSPERO, CRD42022347329). FINDINGS:Of the 102 included studies, 66.67% studies (n=68) implanted percutaneous leads, 30.4% (n=31) paddle leads and 2.9% (n=3) paddle leads with a percutaneous approach. Percutaneous leads are implanted when patients have no anatomic abnormalities, including no previous spinal interventions at the target location or thoracolumbar junction, and no previous experience with SCS or intrathecal drug delivery. Percutaneous leads may be considered for patients without a history of spinal surgery. Paddle leads are preferred when percutaneous lead placement is technically too difficult, including patients with a history of previous spine surgeries, or as a rescue therapy for failed percutaneous trials. CONCLUSIONS:Lead-specific indications were revealed for patients with chronic spinal pain, yet, the experience of the physician or affiliated department is suggested to have an important role. A clinical flowchart is proposed to help physicians in the decision-making process in daily clinical practice. PROSPERO REGISTRATION NUMBER:CRD42022347329.
BACKGROUND/IMPORTANCE:Existing systematic reviews and meta-analyses of randomized trials of spinal cord stimulation (SCS) for people with chronic pain have consistently excluded direct comparisons between different types of SCS and are therefore at major risk of publication bias. OBJECTIVE:The aim of this systematic review and network meta-analysis (NMA) was to combine both direct and indirect randomized trial evidence on treatment effects of SCS for pain intensity, physical function, and health-related quality of life (HRQoL). EVIDENCE REVIEW:MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and WikiStim were searched from inception to December 19, 2024 for parallel-arm randomized trials comparing SCS to conventional medical management (CMM), an active intervention (including other types of SCS) or placebo for adults with chronic pain. The measure of treatment effect for the primary outcome (pain intensity) and for secondary outcomes (physical function, HRQoL) was mean difference (MD) and 95% CI, and for responder rate was OR and 95% CI. NMA was performed in a frequentist framework. FINDINGS:23 reports of 16 unique randomized trials were included. All but one trial was assessed as having a high risk of bias. Results of NMA show significant reductions in pain intensity scores (0-10) at last follow-up (within the first 24 months) were observed with all types of SCS compared with CMM, with MD range from -2.37 (95% CI -3.54 to -1.20) to -5.55 (95% CI -7.34 to -3.76; 15 trials, 1479 participants; low certainty evidence). Improvements in physical function (MD range from -0.20, 95% CI -10.24 to 9.85) to -31.04 (95% CI -44.36 to -17.33; 8 trials, 837 participants; low certainty evidence) and HRQoL (MD range from 0.15 (95% CI 0.09 to 0.20) to 0.29 (95% CI 0.20 to 0.37; 8 trials, 942 participants; moderate certainty evidence) were observed for SCS compared with CMM at 6 months. Patients were found to have a higher likelihood to be a responder to treatment (ie, ≥50% reduction in pain intensity) with all forms of SCS in comparison to CMM at last follow-up (OR range from 9.75 (95% CI 4.07 to 23.25) to OR 63.4 (18.76 to 212.55; 13 trials, 1887 participants; very low certainty evidence). Clinically meaningful improvements were observed for pain intensity, HRQoL, and in some comparisons for physical function. CONCLUSIONS:There is low to moderate certainty of evidence that all types of SCS are superior to CMM for the management of chronic pain conditions.
