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   Table of Contents - Current issue
April-June 2019
Volume 2 | Issue 3
Page Nos. 77-105

Online since Thursday, August 29, 2019

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The impact of a complex consulting process with physiatry on emergency department management of back pain Highly accessed article p. 77
Andrew John Haig, Bradley Uren, Sierra Loar, Katrina Diaz, Melissa Riba, Kerby Shedden, David Share
Objectives and Design: Prospective interventional trial. Setting: An university hospital emergency department. Patients: Two hundred consecutive persons admitted for back pain before, during, and 6 months after the process was begun. Interventions: Institution of a coordinated process of Emergency physician and patient education, standardized intake and order protocols, and rapid access to Physiatry and physical therapy. Patient characteristics, ED evaluation, ED orders, and 1-month rate of return were measured. Main Outcome Measures: Change in medication, imaging, referral to Physiatry and therapy, and 30-day readmission. Results: Most patients had red flags for danger and yellow flags for disability risk, 19-25% had objective radicular signs, and 14-24% had a second non-spinal complaint. There were no important demographic or pain characteristic changes. Compliance with study paperwork was low (20% patients, 6% physicians). There were significant increases in Physiatry and therapy referrals and a decrease in work restrictions. Medication prescriptions decreased overall, notably NSAID and diazepam prescriptions. Imaging orders did not change significantly. Return visits to the ED for back pain decreased from 16% to 4%, P = 0.02. Physician belief that patients had sciatica decreases (10% to 3%, P = 0.02), and detection of actual dangerous disease increased (3.5% to 6.5%). Conclusions: Even without full compliance with the protocol, this complex consultation process changed emergency management of back pain, most significantly by detecting more dangerous diseases, altering medication prescription habits, and decreasing return visits.
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Rehabilitation outcomes in patients with guillain–barré syndrome caused by zika virus p. 88
Coral Candelario-Velazquez, Raúl Rosario-Concepcion, Néstor Diaz, Myriam Crespo
Introduction: Zika virus (ZIKV) is transmitted by the bite of the Aedes species mosquito. Infected patients may present flu-like symptoms or even neurological deficits. In Puerto Rico (PR), an increased number of cases of ZIKV were noted in 2016 and a surveillance system was established for monitoring. As of August 2018, a total of 36,097 symptomatic cases of ZIKV had been reported in PR by the Centers for Disease Control and Prevention of the United States. One of the neurological complications secondary to ZIKV was Guillain–Barré syndrome (GBS). The surveillance system reported that 66% of patients with GBS who were tested were positive for ZIKV. This study aims to identify the functional outcomes of GBS patients related to ZIKV as compared to patients with GBS nonrelated to ZIKV during inpatient rehabilitation using functional independence measure (FIM) score. Materials and Methods: A retrospective case–control study design was used. Patients with a diagnosis of GBS admitted to an inpatient rehabilitation unit between January 1, 2016, and August 15, 2017, were deemed eligible. Patients were divided in two groups: (1) GBS-positive ZIKV (experimental) group and (2) GBS-negative ZIKV (control) group. A total of 21 patients were identified; 16 qualified for the study. The primary outcome was the admission and discharge FIM score. Results: A total of 11 (69%) patients were ZIKV positive or presumptive positive and 5 (31%) were ZIKV negative. One hundred (100%) of the patients had significantly improved FIM scores upon discharge. No significant differences between the ZIKV groups were noted on admission or discharge FIM scores. Conclusion: This study demonstrated that all GBS patients benefit from inpatient rehabilitation facility admission and therapy regardless of ZIKV status. Rehabilitation outcome is not determined by ZIKV status.
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Management of spasticity with intrathecal phenol injections: The past and the present p. 93
Fahim Anwar, Silvia Antiga, Harry Mee, Ahmad Al Khayer
Introduction: Spasticity is increased, involuntary, velocity-dependent muscle tone that causes resistance to movement. Intrathecal injection of phenol is a form of treatment used in a very selective group of patients with spasticity. Aim: This study aims to highlight current evidence in the treatment of spasticity with intrathecal neurolytic phenol injections. Materials and Methods: A computer-based literature search was performed using MEDLINE, EMBASE, CINAHL, and the Cochrane Library using the following key words: intrathecal, phenol, spasticity, and pain. Results: The search identified 83 articles. Of 16 articles met the inclusion criteria of being specifically relating to the use of intrathecal phenol injections in spasticity. There was a lack of randomized controlled studies addressing intrathecal phenol injections in our search. Conclusions: Intrathecal phenol can be valuable for the treatment of spasticity when adapted for each individual, and used as part of an overall program that includes multidisciplinary team assessment and goal planning.
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Oropharyngeal recovery in a patient with the pharyngeal cervical brachial variant of Guillain–Barré syndrome p. 99
Matthew Rong Jie Tay, Shuen-Loong Tham
Patients with the rare pharyngeal cervical brachial variant of Guillain–Barré Syndrome present with a sudden and progressive onset in weakness of the pharyngeal, cervical, and brachial muscles, but usually make a rapid recovery. However, in a patient with delayed oropharyngeal recovery, early identification of poor clinical and electrophysiological prognostic factors can guide rehabilitation planning to optimize functional outcomes.
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Platelet-rich plasma protocols can potentiate vascular emboli: Contraindications to platelet-rich plasma p. 103
Prathap Jayaram, Peter C Yeh, John Cianca
Platelet-rich plasma (PRP) is a regenerative therapy strategy used to address surgical wounds, dermatological conditions, and musculoskeletal conditions, such as lateral epicondylosis. However, there exists significant uncertainty and speculation about antiplatelet agents' effects on PRP and optimal approaches to cessation of agents such as aspirin prior to PRP therapy. We present a rare case report that provides an example of temporary antiplatelet agent cessation complications in the context of a PRP therapy regimen for lateral epicondylosis, which was followed by microemboli to the brain. Given Class B evidence for PRP for lateral epicondylosis, we feel that this case of a nontraumatic brain injury sequelae can present more frequently given the increased popularity of this regenerative strategy, particularly if certain precautions are not evaluated.
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