Since its introduction as a procedure of last resort in a terminally ill patient with intractable cancer-related pain, spinal cord stimulation has been used to effectively treat chronic pain of varied origins. Spinal cord stimulation is commonly used for control of pain secondary to failed back surgery syndrome and complex regional pain syndrome, as well as pain from angina pectoris, peripheral vascular disease, and other causes. By stimulating one or more electrodes implanted in the posterior epidural space, the patient feels paresthesias in their areas of pain, which reduces the level of pain. Pain is reduced without the side effects associated with analgesic medications. Patients have improved quality of life and improved function, with many returning to work. Spinal cord stimulation has been shown to be cost effective as compared with conservative management alone. There is strong evidence for efficacy and cost effectiveness of spinal cord stimulation in the treatment of pain associated with intractable angina, failed back surgery syndrome, and complex regional pain syndrome. In this article, we review the history and pathophysiology of spinal cord stimulation, and the evidence (or lack thereof) for efficacy in common clinical practice.
This article reviews the field of donation after cardiac death, focusing on the history, ethicolegal issues, clinical outcomes, best practices, operative techniques, and emerging strategies to optimize utilization of this resource. Donation after cardiac death is one effective way to decrease the organ shortage and has contributed the largest recent increase in abdominal organ allografts. Currently, donation after cardiac death organs confer an increased risk of ischemic cholangiopathy after liver transplant and of delayed graft function after kidney transplant. As this field matures, risk factors for donation after cardiac death organ transplant will be further identified and clinical outcomes will improve as a result of protocol standardization and ongoing research. Mt Sinai J Med 2012 DOI: 10.1002/msj.21309
As the cost of care rises and fragmentation of health care increases, care transitions have become critical parts of the health care system. Physicians and other inpatient providers have the responsibility to communicate to subsequent providers, but such communication occurs far less than is optimal. Timely discharge summaries for the next-level provider, postdischarge phone calls to patients, and postdischarge follow-up appointments with primary-care physicians or inpatient providers may improve postdischarge health care utilization. Pharmacists may also reduce medication errors, adverse medication events, and even readmissions. The most promising data, however, come from studies of multidisciplinary approaches, some of which have shown large reductions in postdischarge utilization and costs. More study is needed to pinpoint the most cost-effective and efficient strategies to improve transitions from the inpatient setting to other settings.
Mount Sinai Journal of Medicine: A Journal of Translational and Personalized MedicineVolume 79, Issue 6 p. 782-784 Editorial Farewell Message from Penny A. Asbell, MD, FACS, MBA, Editor-in-Chief of the Mount Sinai Journal of Medicine Penny A. Asbell, Corresponding Author Penny A. Asbell Mount Sinai Journal of MedicineMount Sinai Journal of Medicine, Professor of Ophthalmology, Mount Sinai School of MedicineSearch for more papers by this author Penny A. Asbell, Corresponding Author Penny A. Asbell Mount Sinai Journal of MedicineMount Sinai Journal of Medicine, Professor of Ophthalmology, Mount Sinai School of MedicineSearch for more papers by this author First published: 13 December 2012 https://doi.org/10.1002/msj.21356Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume79, Issue6November/December 2012Pages 782-784 RelatedInformation
Peripheral neuropathy is a common complication of many of the systemic amyloidoses. Although the cause of neuropathy is not entirely clear, it is likely related to amyloid deposition within the nerve. This may lead to focal, multifocal, or diffuse neuropathies involving sensory, motor and/or autonomic fibers. The presenting symptoms depend on the distribution of nerves affected. One of the most common phenotypes is sensorimotor polyneuropathy, which is characterized by symptoms of neuropathic pain, numbness, and in advanced cases weakness. Symptoms begin in the feet and ultimately progress to the proximal legs and hands. The most common focal neuropathy is a median neuropathy at the wrist, clinically known as carpal tunnel syndrome. Carpal tunnel symptoms may include pain and sensory disturbances in the lateral palm and fingers; hand weakness may ensue if the focal neuropathy is severe. Autonomic neuropathy may affect a variety of organ systems such as the cardiovascular, gastrointestinal, and genitourinary systems. Symptoms may be non-specific making the diagnosis of autonomic neuropathy more difficult to identify. However, it is important to recognize and distinguish autonomic neuropathy from diseases of the end-organs themselves. This article reviews the inherited and acquired amyloidoses that affect the peripheral nervous system including familial amyloid polyneuropathy, and primary, secondary and senile amyloidosis. We emphasize the clinical presentation of the neurologic aspects of these diseases, physical examination findings, appropriate diagnostic evaluation, treatment and prognosis.
Anesthesia has developed to the point where long-term outcomes are important endpoints. Elderly patients are becoming an increasingly large part of most surgical practices, consistent with demographic shifts. Long-term outcomes are particularly important for this group. In this review, we discuss functional outcomes in the elderly. We describe the areas of cognitive change and frailty, both of which are specific to the elderly. We also discuss prevention of surgical infections and emerging evidence around hemodynamic alterations in the operating room and their impact on long-term outcomes.
Mount Sinai Journal of Medicine: A Journal of Translational and Personalized MedicineVolume 79, Issue 3 p. 303-304 Theme Introduction Organ Transplantation Update, Part II: Heart and Kidney Sander Florman MD, Corresponding Author Sander Florman MD sander.florman@mountsinai.org Mount Sinai Medical Center, New York, NYFPA-Recanati/Miller Transplant Institute New York, NYSearch for more papers by this authorLeona Kim-Schluger MD, Leona Kim-Schluger MD Mount Sinai Medical Center, New York, NYSearch for more papers by this author Sander Florman MD, Corresponding Author Sander Florman MD sander.florman@mountsinai.org Mount Sinai Medical Center, New York, NYFPA-Recanati/Miller Transplant Institute New York, NYSearch for more papers by this authorLeona Kim-Schluger MD, Leona Kim-Schluger MD Mount Sinai Medical Center, New York, NYSearch for more papers by this author First published: 07 June 2012 https://doi.org/10.1002/msj.21319Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume79, Issue3May/June 2012Pages 303-304 RelatedInformation
Mount Sinai Journal of Medicine: A Journal of Translational and Personalized MedicineVolume 79, Issue 2 p. 167-168 Theme Introduction Organ Transplantation Update, Part I: Liver, Intestine, and Pancreas Sander Florman MD, Corresponding Author Sander Florman MD [email protected] Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NYRecanati/Miller Transplantation Institute Mount Sinai School of Medicine New York, NYSearch for more papers by this authorLeona Kim-Schluger MD, Leona Kim-Schluger MD Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NYSearch for more papers by this author Sander Florman MD, Corresponding Author Sander Florman MD [email protected] Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NYRecanati/Miller Transplantation Institute Mount Sinai School of Medicine New York, NYSearch for more papers by this authorLeona Kim-Schluger MD, Leona Kim-Schluger MD Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NYSearch for more papers by this author First published: 12 April 2012 https://doi.org/10.1002/msj.21308Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume79, Issue2March/April 2012Pages 167-168 RelatedInformation
Liver transplantation is the definitive treatment for end-stage liver disease in both children and adults. Advances over the last 2 decades have resulted in excellent patient and graft survival rates in what were previously cases of fatal disorders. These developments have been due to innovations in surgical technique, increased surgical experience, refinements in immunosuppressive regimens, quality improvements in intraoperative anesthetic management, better understanding of the pathophysiology of the liver diseases, and better preoperative and postoperative care. Remarkably, the use of split-liver and living-related liver transplantation surgical techniques has helped mitigate the well-recognized national organ shortage. This review will discuss the major aspects of pediatric liver transplantation as it pertains to indication for transplantation, recipient selection and listing for orthotopic liver transplantation, pre-orthotopic liver transplantation care of children, optimal timing of orthotopic liver transplantation, surgical technical considerations, postoperative care and complications, and patient and graft survival outcomes.
The American Society of Anesthesiologists Physical Status classification system has been shown to predict the frequency of perioperative morbidity and mortality despite known subjectivity, inconsistent application, and exclusion of many perioperative confounding variables. The authors examined the relationship between the American Society of Anesthesiologists Physical Status and both the frequency and the severity of adverse events over a 10-year period in an academic anesthesiology practice. The American Society of Anesthesiologists Physical Status is predictive of not only the frequency of adverse perioperative events, but also the severity of adverse events. These nonlinear mathematical relationships can provide meaningful information on performance and risk. Calculated odds ratios allow discussion about individualized anesthesia risks based on the American Society of Anesthesiologists Physical Status because the added complexity of the surgical or diagnostic procedure, and other perioperative confounding variables, is indirectly factored into the Physical Status classification. The ability of the American Society of Anesthesiologists Physical Status to predict adverse outcome frequency and severity in a nonlinear relationship can be fully explained by applying the Normal Accident Theory, a well-known theory of system failure that relates the interactive complexity of system components to the frequency and the severity of system failures or adverse events.
Obesity is a worldwide epidemic leading to severe comorbidity that damages end-organ function. Overall transplant outcomes in this population are inferior to those in nonobese patients. Large population studies show decreased patient and graft survival in obese kidney transplant patients. Despite the poorer outcomes, kidney transplantation is considered because of the survival benefit as compared with the wait-listed dialysis patients. In liver transplantation, the benefit to transplantation as compared with remaining on the list is obvious, as there is no viable liver dialysis at this time. Obesity in potential organ donors impacts both medical and surgical issues. Obesity-related kidney disease affects both the remaining and transplanted kidney. Pancreas donor organs are associated with decreased early graft survival. Liver donor organs with significant steatosis lead to an increased risk for delayed or nonfunction of the organ. Immunosuppressive drugs with variable lipophilicity and altered volume of distribution can greatly affect the therapeutic usefulness of these drugs. Transplant candidates benefit from a multidisciplinary team approach to their care. As the epidemic progresses and less-invasive treatments for metabolic surgery evolve, we are likely to require more patients to lose weight prior to transplantation as we continue to strive for improved outcomes. Mt Sinai J Med 2012 DOI: 10.1002/msj.21315
Hepatitis C is a widespread problem, and the prevalence is higher in patients on hemodialysis than in the general population. In addition, hepatitis C reduces survival in dialysis patients and renal-transplant recipients. Kidney transplantation offers a survival advantage to those patients with chronic hepatitis C infection faced with the alternative of remaining on dialysis. Kidney transplantation should therefore be considered the treatment of choice for patients with end-stage renal disease and hepatitis C infection. However, these patients need to be chosen appropriately, and there are no well-established guidelines for the workup or selection of these of these patients. Liver biopsy is an essential tool to determine the degree of fibrosis in these patients and also will prove useful in the management of the patients after transplantation. Transplantation of kidneys from hepatitis C-positive donors to hepatitis C-positive recipients has been shown to be safe and confers a significant advantage in terms of waiting time in this population where death on the waiting list is significant. Treatment prior to transplantation should be considered by the hepatology team, although it is often more difficult to treat given the constraints of a patient in renal failure. Although interferon treatment in hepatitis C-positive kidney-transplant candidates is recommended, treatment posttransplant remains controversial. Simultaneous kidney/liver transplantation should be considered for those candidates with evidence of portal hypertension or decompensated cirrhosis.
Liver transplantation is a life-saving therapy for patients with end-stage liver disease, acute liver failure, and liver tumors. Over the past 4 decades, improvements in surgical techniques, peritransplant intensive care, and immunosuppressive regimens have resulted in significant improvements in short-term survival. Focus has now shifted to addressing long-term complications and improving quality of life in liver recipients. These include adverse effects of immunosuppression; recurrence of the primary liver disease; and management of diabetes, hypertension, dyslipidemia, obesity, metabolic syndrome, cardiovascular disease, renal dysfunction, osteoporosis, and de novo malignancy. Issues such as posttransplant depression, employment, sexual function, fertility, and pregnancy must not be overlooked, as they have a direct impact on the liver recipient's quality of life. This review summarizes the latest data in long-term outcome after liver transplantation.
The major causes of impaired vision in the elderly population of the United States are cataracts, macular degeneration, and open-angle glaucoma. Cataracts and macular degeneration usually reduce central vision, especially reading and near activities, whereas chronic glaucoma characteristically attacks peripheral vision in a silent way, impacting balance, walking, and driving. Untreated, these visual problems lead to issues with regard to taking medications, keeping track of finances and personal information, walking, watching television, and attending the theater, and often create social isolation. Thus, visually impaired individuals enter nursing homes 3 years earlier, have twice the risk of falling, and have 4× the risk of hip fracture. Consequently, many elderly with low vision exercise greater demands on community services. With the prospect of little improvement and sustained visual loss, in the face of poor tolerance of low-vision services and not accepting magnification as the only way to read, clinical depression is common. In many instances, however, early and accurate diagnosis can result in timely treatment and can preserve quality of life. This review will look at current diagnostic and therapeutic considerations. Currently, about 20.5 million people in the United States have cataracts. The number will reach 30 million by 2020. About 1.75 million Americans currently have some form of macular degeneration, and the number is estimated to increase to 2.95 million in 2020. Approximately 2.2 million Americans have glaucoma, and by 2020 that number is estimated to be close to 3.4 million people. It is projected that by 2030 there will be 72.1 million seniors. With some overlap of the above 3 groups conservatively estimated (if you add the 2030 cataract group to the macular degeneration and glaucoma groups), then about 1 in 2 senior individuals by 2030 may have some significant ocular disease, which could account for about 50% of the healthcare budget for the elderly.
Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma and remains among the most difficult management problems faced by surgeons. Curative surgery is achieved in only 25% to 30% of patients. Local tumor extent, such as portal vein invasion and hepatic lobar atrophy, does not preclude resection. Long-term survival has been seen only in patients who underwent extensive liver resections, suggesting that bile-duct excision alone is less effective. The majority of patients have unresectable disease, with 20% to 30% incidence of distant metastasis at presentation. Unresectable patients should be referred for nonsurgical biliary decompression, and in potential curative resection candidates the use of biliary stents should be reduced. Liver transplantation provides the option of wide resection margins, expanding the indication of surgical intervention for selected patients who otherwise are not surgical candidates due to lack of functional hepatic reserve.
Computer-assisted detection systems are widely used in many areas of radiology. Coronary computed tomography angiography is a growing area of clinical cardiology and computer-assisted detection systems play an integral part in analysis. Truly automated systems are still in clinical-trial stages, but manually assisted programs are in clinical use today for calcium scoring as well as plaque burden, composition, and stenosis analysis. They are being used as a tool for confirmation more than for diagnosis. Accurate plaque-composition analysis would be a critical tool for better understanding the mechanisms and effectiveness of novel therapies for coronary atherosclerosis. A need for a complete quick, safe, noninvasive plaque analysis is the goal of automated coronary stenosis detection systems; however, their potential clinical benefit remains unknown.
Type 1 diabetes affects >1 million people in the United States, where it accounts for up to 10% of all diabetes cases. Glycemic control via the use of exogenous insulin injections in diabetic patients is incomplete, resulting in multiple long-term complications such as retinopathy, neuropathy, vasculopathy, and nephropathy. The goal of beta-cell replacement by whole-pancreas or islet transplantation is to achieve long-term insulin independence, and the proposed benefits are improved quality of life, prevention of recurrent diabetic nephropathy, stabilization or improvement in secondary complications, and improved mortality. No other regimen of insulin delivery can achieve this level of physiologic regulation.
Hepatocellular carcinoma is the sixth most common cancer worldwide and its incidence is rising in Western countries. Liver resection is the treatment of choice in noncirrhotic patients and in cirrhotic patients with well-preserved liver function. Postresection survival rates are in the range of 41-74% at 5 years. Predictors of recurrence include tumor grade, vascular invasion, tumor size, number of tumors, presence of satellites, alpha-fetoprotein level, transfusion, and positive surgical margin. Second hepatic resection for recurrent hepatocellular carcinoma is applicable in about 15% of patients with recurrence. Liver transplantation has become an important element of the therapeutic strategy for hepatocellular carcinoma. Liver transplantation provides excellent outcomes applying the Milan criteria with 5-year survival rates of 70% and low recurrence rates. Intention-to-treat analysis has shown that wide extended indications lead to 25% 5-year survival rates. Expansion of indications beyond the Milan Criteria and use of bridging/downstaging procedures, to convert intermediate advanced stages of hepatocellular cancer within the Milan criteria limits, are counterbalanced by graft shortage and increasing use of marginal donors. Living donor transplantation is an alternative that can eliminate the waiting time and the attendant risk of drop-out.
The management of intestinal failure has evolved dramatically in the last decade. This evolution has been in equal part due to continued improvements in outcomes of intestinal transplantation and to recognition of the need for multidisciplinary management of the patient with intestinal failure. This has led to establishment of intestinal rehabilitation programs, centered only in some instances at institutions with established intestinal transplant programs. Alongside this, improved management of parenteral nutrition-associated liver disease is creating a paradigm shift in both intestinal-failure management and in the evolving indications for intestinal transplantation. Unsolved challenges remain: A persistent mortality on the waiting list, especially for patients awaiting combined liver-intestine transplant; late graft loss to chronic rejection, especially in isolated intestine transplant; the role of antibody-mediated rejection; and transplantation in the highly sensitized patient continue to defy satisfactory solution. Notwithstanding these challenges, overall outcomes for patients with intestinal failure are vastly improved today and are approaching those for patients with end-stage renal and liver disease. This review will focus on a comprehensive approach to the patient with intestinal failure, including an overview of intestinal rehabilitation and transplantation. Transplantation outcomes and transplantation of the patient with liver disease are covered elsewhere.
