Suzanne Novak

The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review.

OBJECTIVES To determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas. DATA SOURCES A PubMed, Medline (EBSCO), and Cochrane library search (January 1971-December 2005), as well as additional references found from the initial search. STUDY SELECTION There were no studies that specifically addressed the objectives outlined. Eleven randomized controlled trials, 1 prospective controlled trial, and 2 prospective cohort studies were identified that included a protocol involving repeat epidural injections for radicular pain secondary to herniated nucleus pulposus or spinal stenosis. One qualitative survey was also identified. Five review articles were also included that discussed this topic. DATA EXTRACTION Data were extracted from clinical trials if they included the following: (1) protocols in clinical trials on ESIs that included repeat injections and the response required to trigger these injections, (2) any evidence given for establishing these protocols, and (3) similar studies that included only 1 injection. Specific mention of repeat ESIs and partial response that was mentioned in review articles was also included. DATA SYNTHESIS There is limited evidence to suggest guidelines for frequency and timing of ESIs or to help to define what constitutes the appropriate partial response to trigger a repeat injection. No study has specifically evaluated these objectives. Methodologically limited research suggests that repeat injections may improve outcomes, but the evidence is insufficient to make any conclusions. CONCLUSIONS There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design.

A confirmatory factor analysis evaluation of the coronary heart disease risk factors of metabolic syndrome with emphasis on the insulin resistance factor

Aim:  The goals of this study were: (1) to analyse the underlying associations between coronary risk factors and the metabolic syndrome and (2) to evaluate the construct validity of the variables used to measure each factor.

Evaluation and comparison of models of metabolic syndrome using confirmatory factor analysis

The aim of this study was to evaluate and compare three competing models of the underlying factor structure of metabolic syndrome using confirmatory factor analysis (CFA). Data from the Insulin Resistance Atherosclerosis Study (IRAS) was used, which has previously been evaluated using principal components analysis (PCA). The three models that were evaluated consisted of oblique and orthogonal two-factor models with hypothesized underlying “metabolic” and “blood pressure” factors, and a four-factor model theorizing “insulin resistance,” “obesity,” “lipids,” and “blood pressure” as the underlying constructs. Several CFAs were performed using EQS Multivariate Software Version 5.7b with maximum likelihood estimation. The results showed that the four-factor model yielded significantly better data-model fit than two-factor models, with a comparative fit index of 0.963, and standardized root mean square residual of 0.036. Factors exhibited good construct reliability and variance extracted estimates except for the lipids factor. We concluded that the four-factor model of metabolic syndrome was the most plausible model among the three competing models.

How clinically relevant is a meta-analysis of electrical nerve stimulation when based on heterogeneous disease states?

Prof. J. Ochoa has honoured our paper by a letter in which he brilliantly argues against the terms ‘‘CRPS’’ and ‘‘sympathetically maintained pain’’. We absolutely agree that there is an ongoing discussion about the nature of underlying mechanisms and classification of patients which by part of the scientific community are linked to CRPS or sympathetically maintained pain. However, our paper is about nothing but three afferent C-fibers belonging to the class of ‘‘mechano-insensitive C-nociceptors’’, which unexpectedly responded to norepinephrine and sympathetic maneuvers. These fibers were found in a patient with suspected SMP. We agree that control injections of catecholamines in control subjects should be performed and we have included this in our protocol. Unfortunately, this is the only suggestion in the letter we can specifically respond to. The remaining points in our view consist of brilliant polemics against terms Prof. Ochoa does not like expanding to topics only loosely related to our paper. This is fair enough, but the wording of our paper should not be totally ignored. We did not diagnose the patient with CRPS, we describe the clear signs of neuropathy (EMG and QST) in the patient, we do not mention nor speculate about contralateral sensitization in the paper, and finally we did record from sympathetic fibers as noted as sympathetic bursts in the paper. Thus, it appears that in his fervor Prof. Ochoa lost sight of focus and wording of our paper. We accept that Prof. Ochoa does not like our result that mechano-insensitive nociceptors were activated by noradrenaline and sympathetic reflexes, and recognize that he is willing to accept that sensitization of primary nociceptors to catecholamines may exist. Thus, we appreciate this common basis on which we can continue a scientific discussion.

Implications of SARS: Medical Geography and Surveillance in Disease Detection

OBJECTIVE: To expose pharmacy educators and practitioners to concepts of medical geography and medical surveillance. Severe acute respiratory syndrome (SARS) is used as a case example because it is an emerging infection and a prime example of the type of disease that pharmacists may encounter in daily practice (e.g., easily transmitted, resembles the common cold). DATA SOURCES: We retrieved data from publications related to medical geography, medical surveillance, and SARS. Data on current SARS cases in Hong Kong were obtained from the Hong Kong Department of Health Web site. STUDY SELECTION AND DATA EXTRACTION: Variables regarding new cases and deaths due to SARS were evaluated. DATA SYNTHESIS: Background information on medical geography and medical surveillance was reviewed. Descriptive statistics were calculated for incidence, prevalence, and the number of deaths due to SARS in Hong Kong from March 14 to May 31, 2003. CONCLUSIONS: Emerging infections are a serious concern for both the public and healthcare practitioners. The recent global diffusion of SARS highlights the ease in which diseases can diffuse from place to place. Understanding concepts related to medical geography and medical surveillance can help pharmacists be better prepared to anticipate disease diffusion and to evaluate signs of emerging infections. In turn, this can help pharmacists be better prepared to provide information and care to their patients. The long-term benefit of understanding how diseases spread and the specific activities related to disease detection is an opportunity for expanding the scope of pharmacy practice.

PCV18: A CONFIRMATORY FACTOR ANALYSIS EVALUATION OF THE CORONARY HEART DISEASE RISK FACTORS OF METABOLIC SYNDROME AND THE EFFECTIVENESS OF THE CURRENT ATP III GUIDELINES FOR IDENTIFICATION

OBJECTIVES: As part of an environment program (outcomes program) on smoking cessation, it seemed interesting to study young smokers under the age of twenty five. METHOD: A special questionnaire was distributed to them via the «Etudiant» supplement of a French regional weekly newspaper (Tarn Libre), which they were asked to return by post. RESULTS: The first results concerned the first 50 questionnaires returned. Average age: 17.5 years; average weight: 56 kilos; average height: 1.67m. In our sample, 92% were students, 86% declared themselves to be exposed to other people’s smoke and only 37% said they took part in a sporting activity. Age at which tobacco dependency began was 13 years; 98% smoked cigarettes—versus 2% a cigar or pipe); the average daily consumption was 10 cigarettes; of these, 65% wished to stop smoking, but only 38% had already made an attempt at smoking cessation. Only 30%, however, said that they had been asked spontaneously by their doctor about their desire to stop smoking (minimum advice) In the Fagerström test, 48% had low or no dependency; 48% had moderate dependency and only 2% had heavy dependency. CONCLUSIONS: This pilot study confirmed that tobacco dependency is occurring at an increasingly early age; that tobacco dependency in young people is low or moderate, and that there is little management of tobacco dependency in young people by doctors.

DB7 THE EFFECT OF OBESITY ADJUSTMENTS ON COST-EFFECTIVENESS MODELS OF DIABETES PREVENTION

tal for Sick Children, reviews 70 charts representing healthy children who had strabismus surgery and were given ondansetron or dimenhydrinate prophylactically. Cost-consequence analysis is used to compare costs and outcomes. Cost information was obtained from the finance department and the hospital pharmacy. Cost items include the acquisition cost of the antiemetics, the cost of administering the agents, the cost length of stay in the post anesthetic care unit (PACU) and the cost of an episode of emesis, including laundry expense, materials, nursing time, housekeeping time and rescue treatment. The outcome measure used to determine the effectiveness of the antiemetics is the number of POV-free patients. This represents patients that did not experience POV that would have otherwise done so without the prophylactic administration of an antiemetic. RESULTS: In an adjusted cohort of 100, the number of POV-free patients was 45.3 for ondansetron and 38.2 for dimenhydrinate. The costs per patient were CAD

PCV56 EVALUATION AND COMPARISON OF DIFFERENT MODELS OF METABOLIC SYNDROME USING CONFIRMATORY FACTOR ANALYSIS

185.34 for ondansetron and CAD

PDB40 THE USE OF DIABETES PREVENTION PROGRAM RESULTS TO MODEL COST-EFFECTIVENESS OF THE INTERVENTION IN A MORE GENERALIZED HYPOTHETICAL POPULATION

232.34 for dimenhydrinate. The length of stay in the PACU represented over 97% of total costs, and the mean lengths of stay in the PACU for ondansetron and dimenhydrinate were significantly different, 3.43 and 4.41 hours, respectively. CONCLUSION: Ondansetron is more effective in reducing POV and less expensive than dimenhydrinate. However, the dominance ondansetron offers over dimenhydrinate is dependent on the length of stay in the PACU. This study should serve as a pilot for a larger scale investigation on the correlation between the length of stay in the PACU and the antiemetic agent used.

Trends in Medical Use and Abuse of Sustained-Release Opioid Analgesics: A Revisit

plasma glucose (FPG) were obtained. The definition of metabolic syndrome encompasses three or more of the following abnormalities: WHR >0.9 in men and >0.85 in women, BMI >23kg/m, BP >140/>90mmHg, FPG >110mg/dL, HDL <40mg/dL in men and <50mg/dL in women, FTG >150mg/dL. RESULTS: Data were available in 686 Korean American subjects, 62% females. The prevalence of metabolic syndrome in our sample was 25%. Frequency of elevated BP, elevated TG, low HDL, and FPG were 32%, 21%, 29%, and 12%, respectively. Overall obesity, measured by BMI, was 35% and centrally obesity, measured by WHR, was 35%. When compared between men and women, the prevalence of metabolic syndrome in men was 32% and 20% seen among the women (95% CI, 0.061, 0.198; p < 0.001); increased central adiposity was similar in both men (35%) and women (35%); and FPG was significantly elevated in men (18%) than in women 9% (95% CI, 0.035, 0.142; p = 0.001). CONCLUSION: Multiple metabolic disorders are present in the Korean Americans. Early detection and treatment of hypertension, dyslipidemia, obesity, and glucose intolerance can prevent the progression of diabetes mellitus and CVD.