Background
Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly ...comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA.
Questions/purposes
This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications.
Methods
One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n = 79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n = 81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications.
Results
Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 SD 2.4; PAI group: 3.0 SD 2.2; 95% confidence interval, −0.8 to 0.6; p = 0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days SD 0.65 versus 2.84 days SD 1.34 for the PNB group; p = 0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents SD 13.1; PNB group: 4.6 mg SD 9.1; p < 0.001), but thereafter, there was no difference. More patients in the PNB group had sequelae of peripheral nerve injury (mainly dysesthesia) at 6-week followup (nine 12% versus one 1%; p = 0.009).
Conclusions
Patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
OBJECTIVES:Determine diagnostic accuracy of a clinical diagnosis of Parkinson disease (PD) using neuropathologic diagnosis as the gold standard.
METHODS:Data from the Arizona Study of Aging and ...Neurodegenerative Disorders were used to determine the predictive value of a clinical PD diagnosis, using 2 clinical diagnostic confidence levels, PossPD (never treated or not clearly responsive) and ProbPD (responsive to medications). Neuropathologic diagnosis was the gold standard.
RESULTS:Based on first visit, 9 of 34 (26%) PossPD cases had neuropathologically confirmed PD while 80 of 97 (82%) ProbPD cases had confirmed PD. PD was confirmed in 8 of 15 (53%) ProbPD cases with <5 years of disease duration and 72 of 82 (88%) with ≥5 years of disease duration. Using final diagnosis at time of death, 91 of 107 (85%) ProbPD cases had confirmed PD. Clinical variables that improved diagnostic accuracy were medication response, motor fluctuations, dyskinesias, and hyposmia.
CONCLUSIONS:Using neuropathologic findings of PD as the gold standard, this study establishes the novel findings of only 26% accuracy for a clinical diagnosis of PD in untreated or not clearly responsive subjects, 53% accuracy in early PD responsive to medication (<5 yearsʼ duration), and >85% diagnostic accuracy of longer duration, medication-responsive PD. Caution is needed when interpreting clinical studies of PD, especially studies of early disease that do not have autopsy confirmation. The need for a tissue or other diagnostic biomarker is reinforced.
CLASSIFICATION OF EVIDENCE:This study provides Class II evidence that a clinical diagnosis of PD identifies patients who will have pathologically confirmed PD with a sensitivity of 88% and specificity of 68%.
Overuse of symptomatic (i.e. acute) medications is common amongst those with chronic migraine. It is associated with developing frequent headaches, medication side effects, and reduced quality of ...life. The optimal treatment strategy for patients with chronic migraine with medication overuse (CMMO) has long been debated. The study objective was to determine if migraine preventive therapy
switching or limiting the frequency of the overused medication was non-inferior to migraine preventive therapy
switching from the overused medication to an alternate medication that could be used on
2 days/week.
The "Medication Overuse Treatment Strategy (MOTS)" trial was an open-label, pragmatic clinical trial, randomizing adult participants 1:1 to migraine preventive medication and a) switching from the overused medication to an alternative used
2 days/week; or b) continuation of the overused medication with no maximum limit. Participants were enrolled between February 2017-December 2020 from 34 clinics in the US, including headache specialty, general neurology, and primary care clinics. The primary outcome was moderate-to-severe headache day frequency during weeks 9-12, and subsequently during weeks 1-2 post-randomization.
720 participants were randomized; average age was 44 (SD 13) years and 87.5% were female. At baseline, participants averaged 22.5 (SD 5.1) headache days/four weeks, including 12.8 (SD 6.7) moderate-to-severe headache days and 21.4 (SD 5.8) days of symptomatic medication use. Migraine preventive medication without switching of the overused medication was not inferior to preventive medication with switching for moderate-to-severe headache day frequency during weeks 9-12 (switching = 9.3 (SD 7.2) vs. no switching = 9.1 (SD 6.8); p = 0.75, 95% CI -1.0 to 1.3). The treatment strategies also provided similar outcomes during the first two weeks (switching = 6.6 (SD 3.7) moderate to severe headaches days vs. no switching = 6.4 (SD 3.6); p = 0.57, 95% CI -0.4 to 0.7).
Using reductions in moderate to severe headache days as the outcome of interest for the management of CMMO, migraine preventive medication without switching or limiting symptomatic medication is not inferior to migraine preventive medication with switching to a different symptomatic medication with a maximum limit of two treatment days/week.
This study provides Class III evidence that, for patients who have CMMO, migraine preventive medication without switching or limiting the overused medication is non-inferior to migraine preventive medication with switching and limiting the overused medication.
Finding a peripheral tissue biopsy site to diagnose early PD would be of value for clinical care, biomarker validation, and as research enrollment criteria. Whereas autopsy and advanced PD studies ...suggest that the submandibular gland is an important biopsy site, there are no studies in early PD. The aim of this study was to determine whether needle biopsy of the submandibular gland reveals Lewy type alpha-synucleinopathy in early PD.
Twenty-five early PD (duration < 5 years) and 10 controls underwent transcutaneous needle core biopsies of the submandibular gland. Tissue was stained for phosphorylated alpha-synuclein, reviewed blind to clinical diagnosis, and only nerve element staining was considered positive.
Mean (standard deviation) age was 69.5 (8.3) for the PD group, 64.8 (8.0) years for controls, and disease duration 2.6 (1.1) years. Six PD and 1 control subject had inadequate glandular tissue. Positive staining was found in 14 of 19 (74%) PD and 2 of 9 (22%) control subjects. PD-positive and -negative cases did not differ clinically. Adverse events (mainly swelling and bruising) were common (77% of cases), but were minor and transient.
Submandibular gland needle biopsies identified phosphorylated alpha-synuclein staining in 74% of early PD subjects. False positives may be true false positives or may represent prodromal PD. If confirmed in larger studies with eventual autopsy confirmation, the potential value of submandibular gland biopsies for early PD may be to aid in clinical trial inclusion/exclusion and eventually serve as a gold standard for biomarker studies short of autopsy confirmation.
Abstract
This study was designed to correlate clinical findings with the extent of pathologic a-synuclein (aSyn) in the brain using the Unified Staging System for Lewy Body disorders (USSLB). Data ...from 280 cases from the Arizona Study of Aging and Neurodegenerative Disorders are presented. Each case had a complete USSLB staging and at least 1 full research clinical assessment, including subspecialty neurologist-administered movement and cognitive evaluation. Of the 280, 25.7% were cognitively normal, 8.6% had mild cognitive impairment, and 65.7% had dementia. All cases could be categorized into 1 of 5 USSLB stages (8.6% stage I—olfactory bulb only; 15.4% IIa—brainstem predominant; 13.6% IIb—limbic predominant; 31.8% III—brainstem and limbic; and 30.7% IV—neocortical) yet using the Braak staging system 70 cases (25.3%) could not be classified. Those with USSLB stages III and IV died at a younger age. Multiple measures of motor parkinsonism, cognitive impairment, hyposmia, and probable RBD were significantly correlated with increasing USSLB stage. We conclude that the USSLB is the most comprehensive staging system for all Lewy body disorders and allows for categorization and ranking of all brains with significant correlations to many motor and nonmotor clinical signs and symptoms.
OBJECTIVE:To assess the feasibility and accuracy of telemedical concussion evaluations (teleconcussion) for real-time athletic sideline assessment of concussion, as such assessment may address the ...gap in access some populations of athletes have to providers with expertise in concussion evaluation.
METHODS:A cohort of 11 consecutive male collegiate football players with suspected concussion was assessed using Standardized Assessment of Concussion (SAC), King-Devick test (K-D), and modified Balance Error Scoring System (mBESS). A remote neurologist assessed each athlete using a telemedicine robot with real-time, 2-way audiovisual capabilities, while a sideline provider performed a simultaneous face-to-face assessment. After the assessment, a remove-from-play (RFP) determination was made. The remote and the face-to-face providers were blinded to each other’s examination findings and RFP decision until the end of the assessment.
RESULTS:The teleconcussion and face-to-face SAC were in agreement 100% of the time (6/6; 95% confidence interval CI 54%–100%). The mean (SD) difference between remote and sideline K-D times was 0.7 (1.4) seconds. Remote and sideline K-D times were within a 3-second difference 100% of the time (11/11; 95% CI 72%–100%). Remote and sideline mBESS scores were within 3 points 100% of the time (6/6; 95% CI 54%–100%). RFP decisions were in agreement 100% of the time (11/11; 95% CI 72%–100%).
CONCLUSIONS:The aim of this study was to investigate the feasibility of teleconcussion for sideline concussion assessments. These data suggest a high level of agreement between remote and face-to-face providers with regard to examination findings and RFP determinations.
Telestroke reduces acute stroke care disparities between urban stroke centers and rural hospitals. Current technologies used to conduct remote patient assessments have high start-up costs, yet they ...cannot consistently establish quality timely connections. Smartphones can be used for high-quality video teleconferencing. They are inexpensive and ubiquitous among health care providers. We aimed to study the reliability of high-quality video teleconferencing using smartphones for conducting the National Institutes of Health Stroke Scale (NIHSS).
Two vascular neurologists assessed 100 stroke patients with the NIHSS. The remote vascular neurologist assessed subjects using smartphone videoconferencing with the assistance of a bedside medical aide. The bedside vascular neurologist scored patients contemporaneously. Each vascular neurologist was blinded to the other's NIHSS scores. We tested the inter-method agreement and physician satisfaction with the device.
We demonstrated high total NIHSS score correlation between the methods (r=0.949; P<0.001). The mean total NIHSS scores for bedside and remote assessments were 7.93±8.10 and 7.28±7.85, with ranges, of 0 to 35 and 0 to 37, respectively. Eight categories had high agreement: level of consciousness (questions), level of consciousness (commands), visual fields, motor left and right (arm and leg), and best language. Six categories had moderate agreement: level of consciousness (consciousness), best gaze, facial palsy, sensory, dysarthria, and extinction/inattention. Ataxia had poor agreement. There was high physician satisfaction with the smartphone.
Smartphone high-quality video teleconferencing is reliable, easy to use, affordable for telestroke NIHSS administration, and has high physician satisfaction.
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