Paulin Andréll

Cost-effectiveness of spinal cord stimulation versus Coronary Artery Bypass grafting in patients with severe Angina pectoris-long-term results from the ESBY study

The present study is a 2-year follow-up of the 104 patients participating in the ESBY study (Electrical Stimulation versus Coronary Artery Bypass Surgery in Severe Angina Pectoris), a randomised prospective study including patients with increased surgical risk and no prognostic benefit from revascularisation. Hospital care costs, morbidity and causes of death after spinal cord stimulation (SCS) and coronary artery bypass grafting (CABG) were assessed, as well as the complication rate of SCS treatment. SCS proved to be a less expensive symptomatic treatment modality of angina pectoris than CABG (p < 0.01). The SCS group had fewer hospitalisation days related to the primary intervention (p < 0.0001) and fewer hospitalisation days due to cardiac events (p < 0.05). The groups did not differ with regard to causes of death. There were no serious complications related to the SCS treatment.

Spinal cord stimulation in severe angina pectoris: a systematic review based on the Swedish Council on Technology assessment in health care report on long-standing pain

Abstract Patients who continue to suffer from lasting and severely disabling angina pectoris despite optimum drug treatment and who are not suitable candidates for invasive procedures, suffer from a condition referred to as “chronic refractory angina pectoris”. Based on the available data, spinal cord stimulation, SCS, is considered as the first‐line additional treatment for these patients by the European Society of Cardiology. However, no systematic review of randomised controlled studies has yet been published. A systematic literature research, 1966–2003, as part of the Swedish Board of Health and Welfare (SBU) report on long‐standing pain, and an additional research covering the years 2003–2007, were carried out. Acute studies, case reports and mechanistic reviews were excluded, and the remaining 43 studies were graded for study quality according to a modified Jadad score. The eight medium‐ to high‐score studies formed the basis for conclusions regarding the scientific evidence (strong, moderately strong or limited) for the efficacy of SCS. There is strong evidence that SCS gives rise to symptomatic benefits (decrease in anginal attacks) and improved quality of life in patients with severe angina pectoris. There is also a strong evidence that SCS can improve the functional status of these patients, as illustrated by the improved exercise time on treadmill or longer walking distance without angina. In addition, SCS does not seem to have any negative effects on mortality in these patients (limited scientific evidence). The complication rate was found to be acceptable.

The incidence of trismus and long-term impact on health-related quality of life in patients with head and neck cancer

Abstract Background. Trismus is a common symptom related to the treatment of head and neck (H&N) cancer. To date there are few prospective studies regarding the incidence of trismus and the patients’ experience of trismus in daily life activities. The aim of the study was to assess the incidence of trismus in H&N cancer patients and the impact on health-related quality of life (HRQL), by evaluating the patients before and after oncological treatment. Material and methods. We used the criteria for trismus of maximum interincisal opening (MIO) ≤ 35 mm and measured the patients at several occasions before and after treatment during one year. The patients answered the HRQL questionnaires EORTC QLQ C30, EORTC QLQ H&N 35, Gothenburg Trismus Questionnaire (GTQ) and the Hospital Anxiety and Depression Scale (HADS). Results. The incidence of trismus was 9% pre-treatment and 28% at the one-year follow-up post-treatment. The highest incidence, 38%, was found six months post-treatment. Patients with tumours of the tonsils were most prone to develop trismus. Patients with trismus reported greater HRQL impairments with regard to the GTQ domains; mouth opening (p < 0.001), jaw-related problems (p < 0.05), eating limitations (p < 0.05) and muscular tension (p < 0.001) six months post-treatment. EORTC QLQ H&N 35 scores indicated clinically significantly more problems with dry mouth, swallowing and pain for patients with trismus, 6–12 months post-treatment. Furthermore, all patients reported pain, anxiety and depression pre- and post-treatment. Conclusion. The incidence of trismus in patients with H&N cancer is non-negligible. Trismus severely impairs HRQL and negatively affects daily life activities in patients with H&N cancer. Further studies regarding symptomatic treatment of patients with trismus are highly warranted. The symptom-specific questionnaire GTQ is useful to identify the problems in this group of patients given it is responsive to showing change over time.

Evaluation of dosage, safety and effects of methylphenidate on post-traumatic brain injury symptoms with a focus on mental fatigue and pain

Abstract Objective: The neurobehavioural symptoms and pain following traumatic brain injury (TBI) can be long-lasting. The condition impairs the persons’ ability to function in their work, studies and gatherings with family and friends. The aim of this study was to investigate dosage, safety and effects of methylphenidate on mental fatigue and pain. Methods: Twenty-nine physically-well rehabilitated TBI victims, 28 with a mild TBI and one with TBI and also with pain in the neck, shoulders and head were included in the study. Methylphenidate was tested in each patient using three treatment strategies: no medication, low dose (5 mg × 3) and normal dose (20 mg × 3) for 4 weeks using a randomized cross-over design. Results: Twenty-four patients completed the three treatment periods. Five participants discontinued, four females due to adverse reactions and one male due to attenuated motivation. Only minor adverse events were reported. Methylphenidate significantly decreased mental fatigue, as evaluated by the Mental Fatigue Scale (p < 0.001), and the effects on mental fatigue were dose-dependent. No effect on pain was detected. Conclusions: Methylphenidate decreased mental fatigue for subjects suffering a traumatic brain injury, the treatment is considered to be safe and is recommended, starting with a low dose.

High-frequency, high-intensity transcutaneous electrical nerve stimulation as treatment of pain after surgical abortion

&NA; The aim of the study was to compare the pain‐relieving effect and the time spent in the recovery ward after treatment with high‐frequency, high‐intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) conventional pharmacological treatment after surgical abortion. Two‐hundred women who underwent surgical abortion and postoperatively reported a visual analogue scale (VAS) pain score ≥ 3 were included. The patients were randomised to TENS or conventional pharmacological treatment for their postoperative pain. The TENS treatment was given with a stimulus intensity between 20 and 60 mA during 1 min and repeated once if insufficient pain relief (VAS ≥ 3). In the conventional pharmacological treatment group, a maximum dose of 100 &mgr;g fentanyl was given IV. There was no difference between the groups with regard to pain relief according to the VAS pain score (TENS = VAS 1.3 vs. IV opioids = VAS 1.6; p = 0.09) upon discharge from the recovery ward. However, the patients in the TENS group spent shorter time (44 min) in the recovery ward than the conventional pharmacological treatment group (62 min; p < 0.0001). The number of patients who needed additional analgesics in the recovery ward was comparable in both groups, as was the reported VAS pain score upon leaving the hospital (TENS = 2.0 vs. conventional pharmacological treatment = 1.8, NS). These results suggest that the pain‐relieving effect of TENS seems to be comparable to conventional pharmacological treatment with IV opioids. Hence, TENS may be a suitable alternative to conventional pain management with IV opioids after surgical abortion.

Exercise intervention for the treatment of trismus in head and neck cancer.

Abstract Background. The aim of this study was to investigate the impact of structured exercise with jaw mobilizing devices on trismus and its effect on trismus symptomatology and health-related quality of life (HRQL) in head and neck (H&N) cancer patients. Material and methods. Fifty patients with H&N cancer and trismus, i.e. maximum interincisal opening (MIO) ≤ 35 mm participated in a structured intervention program with jaw exercise. The patients in the intervention group underwent a 10-week exercise program with regular follow-up. A control group comprising of 50 patients with trismus and H&N cancer were matched to the intervention group according to gender, tumor location, tumor stage, comorbidity and age. HRQL and trismus-related symptoms were assessed. Results. The mean MIO improvement was 6.4 mm (4.8–8.0) and 0.7 (−0.3–1.7) mm in the intervention group and control group respectively, three months post-intervention commencement (p < 0.001). The intervention group demonstrated a statistically significant improvement in Role functioning, Social functioning and Global quality of life (EORTC QLQ C30) and in all Gothenburg Trismus Questionnaire (GTQ) domains, i.e. jaw-related problems (p < 0.001), eating limitation (p < 0.05) and muscular tension (p < 0.001). Conclusion. We found that a structured jaw exercise program was effective and improved the mouth opening capacity significantly. The objective effect on trismus (MIO) was also reflected in the patient-reported outcome questionnaires where the patients who underwent the structured exercise program after cancer treatment reported improvements in HRQL and less trismus-related symptoms compared to the control group.

Effects of Voice Rehabilitation After Radiation Therapy for Laryngeal Cancer: A Randomized Controlled Study

BACKGROUND Patients treated with radiation therapy for laryngeal cancer often experience voice problems. The aim of this randomized controlled trial was to assess the efficacy of voice rehabilitation for laryngeal cancer patients after having undergone radiation therapy and to investigate whether differences between different tumor localizations with regard to rehabilitation outcomes exist. METHODS AND MATERIALS Sixty-nine male patients irradiated for laryngeal cancer participated. Voice recordings and self-assessments of communicative dysfunction were performed 1 and 6 months after radiation therapy. Thirty-three patients were randomized to structured voice rehabilitation with a speech-language pathologist and 36 to a control group. Furthermore, comparisons with 23 healthy control individuals were made. Acoustic analyses were performed for all patients, including the healthy control individuals. The Swedish version of the Self Evaluation of Communication Experiences after Laryngeal Cancer and self-ratings of voice function were used to assess vocal and communicative function. RESULTS The patients who received vocal rehabilitation experienced improved self-rated vocal function after rehabilitation. Patients with supraglottic tumors who received voice rehabilitation had statistically significant improvements in voice quality and self-rated vocal function, whereas the control group did not. CONCLUSION Voice rehabilitation for male patients with laryngeal cancer is efficacious regarding patient-reported outcome measurements. The patients experienced better voice function after rehabilitation. Patients with supraglottic tumors also showed an improvement in terms of acoustic voice outcomes. Rehabilitation with a speech-language pathologist is recommended for laryngeal cancer patients after radiation therapy, particularly for patients with supraglottic tumors.

Treating trismus: A prospective study on effect and compliance to jaw exercise therapy in head and neck cancer

Trismus after head and neck cancer is a symptom associated with pain and negatively affected health‐related quality of life. The purpose of this study was to compare two different jaw exercise devices and the compliance to exercise.

Interference of transcutaneous electrical nerve stimulation with permanent ventricular stimulation: a new clinical problem?

AIMS To assess the compatibility of thoracic TENS and permanent PM treatment and to identify any signs of interference of TENS with the PM function. METHODS AND RESULTS Twenty-seven patients treated with PM were tested. Transcutaneous electric nerve stimulation electrodes were placed above each mamilla, and the stimulation intensity was increased to the maximum level tolerated for 30 s or until electrocardiogram revealed signs of interference. Transcutaneous electric nerve stimulation of 2 and 80 Hz was tested with the PM ventricular sensing level set to the clinically chosen level as well as to maximal sensitivity. Interference was detected in 22 of 27 patients (81%). Low-frequency (2 Hz) stimulation was more associated with PM interference (52% at normal vs. 81% at maximal ventricular sensitivity) than high-frequency (80 Hz) stimulation (33% at normal vs. 63% at maximal ventricular sensitivity); although the differences were not statistically significant. CONCLUSION Transcutaneous electric nerve stimulation frequently induces inhibition of the PM function already at the clinically set ventricular sensitivity. Therefore, individual testing is warranted before TENS treatment is considered in patients with a PM. A test protocol for TENS and PM interaction is proposed.

Effects of voice rehabilitation on health-related quality of life, communication and voice in laryngeal cancer patients treated with radiotherapy: a randomised controlled trial.

Abstract Objective. This study aims to assess the effect of voice rehabilitation on health-related quality of life (HRQL) and communication experience for laryngeal cancer patients treated with radiotherapy. Method. This prospective randomised controlled trial included 74 patients with Tis-T4 laryngeal cancer treated curatively by radiotherapy, of which 37 constituted the intervention group receiving voice rehabilitation and 37 patients as a control group. Patients were followed at one and six months post-radiotherapy, with voice rehabilitation conducted between these time-points. Endpoints included patient reported outcomes, including HRQL as measured by European Organisation for Research and Treatment of Cancer (EORTC) Core30 (C30) and Head & Neck35 (H&N35) as well as communication function as measured by Swedish Self-Evaluation of Communication Experiences after Laryngeal cancer (S-SECEL). Results. The intervention group reported statistically significant improvements in communication experience as measured by S-SECEL environmental, attitudinal and total score domains compared to the control group. Similar improvements were seen in EORTC H&N35 Speech domain and the EORTC C30 domain Global quality of life. Moderate correlations were noted (r = 0.51–0.59) between three of four S-SECEL domains and the EORTC domains Speech and Global quality of life. Conclusion. Laryngeal cancer patients treated with radiotherapy who receive voice rehabilitation appear to experience beneficial effects on communication function and selected HRQL domains. Voice rehabilitation following radiotherapy is recommended but further research investigating potential target groups and long-term effects is required.