scholarly journals Radiculopathy with concomitant sacroiliac dysfunction and lumbosacral degenerative disease: illustrative case

2021 ◽  
Vol 2 (12) ◽  
Author(s):  
Jeffrey D. Oliver ◽  
Noah L. Lessing ◽  
Harry M. Mushlin ◽  
Joshua R. Olexa ◽  
Kenneth M. Crandall ◽  
...  
Keyword(s):  
Controlled Trial ◽  
Relevant Literature ◽  
Spinal Instrumentation ◽  
Outcome Data ◽  
Degenerative Disease ◽  
Leg Pain ◽  
Illustrative Case ◽  
Risk Patients ◽  
Poor Outcomes ◽  
Referred Leg Pain

BACKGROUND The sacroiliac joint (SIJ) is an important cause of low back pain and referred leg pain (RLP). Pain from SIJ dysfunction may occur in isolation or may result from a combination with lumbosacral area–mediated pain. SIJ fusion is one treatment modality for medically refractory symptoms and may also have a role in the treatment of RLP. OBSERVATIONS The authors present a challenging case of concomitant lumbosacral degenerative disease and SIJ dysfunction in a patient with radiculopathy. They provide clinical characteristics and imaging findings and discuss difficulties in dealing with the intersection of these two distinct diagnoses. In addition, the authors offer a review of the relevant literature, elucidating the role of SIJ dysfunction in causing radicular lower extremity pain, the relationship to concomitant lumbosacral degenerative disease, and outcome data for SIJ fusion as it relates to RLP. LESSONS With increasing numbers of patients undergoing spinal instrumentation in the setting of degenerative lumbosacral arthritis, as well as randomized controlled trial data demonstrating the efficacy of SIJ fusion for medically refractory SIJ dysfunction, it is important to recognize the challenges in understanding how both of these patient groups may present with radiculopathy. Failure to do so may result in incorrect patient selection, poor outcomes, and increased morbidity for at-risk patients.

Percutaneous Full Endoscopic Posterior Decompression for Revision of Lumbar Spinal Dynamic Stabilization

2021 ◽  
Author(s):  
Changkun Zheng ◽  
Zhong Liao ◽  
Weiliang cui
Keyword(s):  
Disc Herniation ◽  
Outcome Data ◽  
Dynamic Stabilization ◽  
Endoscopic Approach ◽  
Leg Pain ◽  
Foraminal Stenosis ◽  
Posterior Decompression ◽  
Endoscopic Discectomy ◽  
Poor Outcomes ◽  
Lumbar Spinal

Abstract Objective: The objective of this article was to analysis the efficacy of percutaneous full endoscopic posterior decompression for revision of lumbar spinal dynamic stabilization.Methods: Twenty consecutive patients with failed lumbar spinal dynamic stabilization presenting with leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections, were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open lumbar spinal dynamic stabilization surgery for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla. The average follow up time was, average 37.9 months, minimum 24 months. Outcome data at each visit included Macnab, VAS and ODI.Results: The average leg Visual Analog Scale improved from 8.9 ± 2.6 to 1.08± 0.7 (p < 0.005). Fifteen patients had excellent outcomes, four had good outcomes, one had fair outcomes, and no had poor outcomes, according to the Macnab criteria (Table 2). Nineteen of 20 patients had excellent or good outcomes, for an overall success rate of 95%. No patients required reoperation. There were no incidental durotomies, infections, vascular or visceral injuries. They were also relieved to be able to avoid "open" decompression.Conclusion: The transforaminal endoscopic approach is effective for failed lumbar spinal dynamic stabilization surgery due to residual/recurrent nucleus pulposus and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve. The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization. It also avoids going through the previous surgical site.

Stroke Prevention in Non-Valvular Atrial Fibrillation

1997 ◽  
Vol 17 (03) ◽  
pp. 166-169
Author(s):  
Judith O’Brien ◽  
Wendy Klittich ◽  
J. Jaime Caro
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Trials ◽  
Care Home ◽  
Relevant Literature ◽  
Clinical Trial Data ◽  
Outcome Data ◽  
Sensitivity Analyses ◽  
Bleeding Events ◽  
Discharge Data ◽  
The Cost

SummaryDespite evidence from 6 major clinical trials that warfarin effectively prevents strokes in atrial fibrillation, clinicians and health care managers may remain reluctant to support anticoagulant prophylaxis because of its perceived costs. Yet, doing nothing also has a price. To assess this, we carried out a pharmacoe-conomic analysis of warfarin use in atrial fibrillation. The course of the disease, including the occurrence of cerebral and systemic emboli, intracranial and other major bleeding events, was modeled and a meta-analysis of the clinical trials and other relevant literature was carried out to estimate the required probabilities with and without warfarin use. The cost of managing each event, including acute and subsequent care, home care equipment and MD costs, was derived by estimating the cost per resource unit, the proportion consuming each resource and the volume of use. Unit costs and volumes of use were determined from established US government databases, all charges were adjusted using cost-to-charge ratios, and a 3% discount rate was applied to costs incurred beyond the first year. The proportions of patients consuming each resource were estimated by fitting a joint distribution to the clinical trial data, stroke outcome data from a recent Swedish study and aggregate ICD-9 specific, Massachusetts discharge data. If nothing is done, 3.2% more patients will suffer serious emboli annually and the expected annual cost of managing a patient will increase by DM 2,544 (1996 German Marks), from DM 4,366 to DM 6,910. Extensive multiway sensitivity analyses revealed that the higher price of doing nothing persists except for very extreme combinations of inputs unsupported by literature or clinical standards. The price of doing nothing is thus so high, both in health and economic terms, that cost-consciousness as well as clinical considerations mandate warfarin prophylaxis in atrial fibrillation.

Abstract P73: Comparison of Hospital-Acquired Anemia and TIMI Bleeding for Mortality Prediction in Patients with Acute Myocardial Infarction

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Adam C Salisbury ◽  
Amit P Amin ◽  
Karen P Alexander ◽  
Frederick A Masoudi ◽  
Yan Li ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
At Risk ◽  
Assessment Tool ◽  
Mortality Prediction ◽  
Logistic Regression Models ◽  
Net Reclassification Improvement ◽  
Risk Patients ◽  
Poor Outcomes ◽  
Hospital Acquired

Background: In-hospital bleeding and new onset, hospital acquired anemia (HAA) are both associated with higher mortality in acute myocardial infarction (AMI). Since bleeding is variably defined and often poorly documented, HAA could be a better method to identify at-risk patients, if its prognostic ability were at least as good as documented bleeding. We directly compared the association of HAA and TIMI bleeding with 1-year mortality. Methods: Among 2,803 AMI patients who were not anemic at admission in the 24-center TRIUMPH registry, the presence and severity of HAA and TIMI bleeding were prospectively collected to identify their relative discrimination of 1-year mortality. Logistic regression models, accounting for clustering using generalized estimating equations, were fit for 1) no bleeding, TIMI minimal, minor and major bleeding and 2) no HAA, mild (hemoglobin (Hgb) > 11 g/dl), moderate (Hgb 9 - 11 g/dl) and severe HAA (Hgb < 9 g/dl). Discrimination was compared using c-statistics and reclassification was assessed using the integrated discrimination improvement (IDI), which measures a model's improvement in average sensitivity without sacrificing average specificity vs. another model, and the continuous net reclassification improvement (NRI), to identify the proportion of patients correctly reclassified by the HAA model. Results: HAA was more common (mild: 33%, moderate: 10%, severe 2%) than TIMI bleeding (minimal: 5%, minor: 3%, major 1%). Over 1-year follow-up, 111 patients (4%) died. The HAA model was superior to TIMI bleeding model for 1-year mortality prediction (c-statistic 0.60 vs. 0.51, p<0.001). The IDI of the HAA vs. the bleeding model was 0.009 (95% CI 0.005 - 0.014) and the relative IDI was 0.26 (26% better average discrimination), with a NRI of 0.32 (0.13-0.50) - 17% of patients with events were correctly reclassified to a higher risk while 14% of patients without events were correctly reclassified to a lower risk by the HAA model. Conclusions: HAA is better than TIMI bleeding for identifying 1-year mortality after AMI hospitalization, and may better identify patients without recognized bleeding who are also at risk for poor outcomes. HAA may be useful to identify high-risk patients and as a quality assessment tool.

A Critical Analysis of the Specific Pharmacist Interventions and Risk Assessments During the 12-Month TRANSAFE Rx Randomized Controlled Trial

2021 ◽  
pp. 106002802110447
Author(s):  
Haley M. Gonzales ◽  
James N. Fleming ◽  
Mulugeta Gebregziabher ◽  
Maria Aurora Posadas Salas ◽  
John W. McGillicuddy ◽  
...  
Keyword(s):  
High Risk ◽  
Medication Reconciliation ◽  
Controlled Trial ◽  
Therapy Monitoring ◽  
Pharmacist Intervention ◽  
Risk Levels ◽  
Medication Therapy ◽  
Risk Patients ◽  
The Impact ◽  
Medication Changes

Background Medication safety issues have detrimental implications on long-term outcomes in the high-risk kidney transplant (KTX) population. Medication errors, adverse drug events, and medication nonadherence are important and modifiable mechanisms of graft loss. Objective To describe the frequency and types of interventions made during a pharmacist-led, mobile health–based intervention in KTX recipients and the impact on patient risk levels. Methods This was a secondary analysis of data collected during a 12-month, parallel-arm, 1:1 randomized clinical controlled trial including 136 KTX recipients. Participants were randomized to receive either usual care or supplemental, pharmacist-driven medication therapy monitoring and management using a smartphone-enabled app integrated with telemonitoring of blood pressure and glucose (when applicable) and risk-based televisits. The primary outcome was pharmacist intervention type. Secondary outcomes included frequency of interventions and changes in risk levels. Results A total of 68 patients were randomized to the intervention and included in this analysis. The mean age at baseline was 50.2 years; 51.5% of participants were male, and 58.8% were black. Primary pharmacist intervention types were medication reconciliation and patient education, followed by medication changes. Medication reconciliation remained high throughout the study period, whereas education and medication changes trended downward. From baseline to month 12, we observed an approximately 15% decrease in high-risk patients and a corresponding 15% increase in medium- or low-risk patients. Conclusion and Relevance A pharmacist-led mHealth intervention may enhance opportunities for pharmacological and nonpharmacological interventions and mitigate risk levels in KTX recipients.

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