In this randomized trial involving patients with osteoporotic vertebral compression fractures, patients who underwent vertebroplasty had improvements in pain and disability measures that were similar ...to those in patients who underwent a sham procedure.
Patients who underwent vertebroplasty had improvements in pain and disability measures that were similar to those in patients who underwent a sham procedure.
Spontaneous vertebral fractures are associated with pain, disability, and death in patients with osteoporosis. Percutaneous vertebroplasty, the injection of medical cement, or polymethylmethacrylate (PMMA), into the fractured vertebral body has gained widespread acceptance as an effective method of pain relief and has become routine therapy for osteoporotic vertebral fractures. Guidelines recommend vertebroplasty for fractures that have not responded to medical treatment.
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Typically, the duration of such fractures ranges from several weeks to several months or longer for fractures that have not healed.
Numerous case series and several small, unblinded, nonrandomized, controlled studies have suggested the effectiveness of vertebroplasty in relieving . . .
To determine if multiple doses of erythropoietin (Epo) administered with hypothermia improve neuroradiographic and short-term outcomes of newborns with hypoxic-ischemic encephalopathy.
In a phase II ...double-blinded, placebo-controlled trial, we randomized newborns to receive Epo (1000 U/kg intravenously; n = 24) or placebo (n = 26) at 1, 2, 3, 5, and 7 days of age. All infants had moderate/severe encephalopathy; perinatal depression (10 minute Apgar <5, pH <7.00 or base deficit ≥15, or resuscitation at 10 minutes); and received hypothermia. Primary outcome was neurodevelopment at 12 months assessed by the Alberta Infant Motor Scale and Warner Initial Developmental Evaluation. Two independent observers rated MRI brain injury severity by using an established scoring system.
The mean age at first study drug was 16.5 hours (SD, 5.9). Neonatal deaths did not significantly differ between Epo and placebo groups (8% vs 19%, P = .42). Brain MRI at mean 5.1 days (SD, 2.3) showed a lower global brain injury score in Epo-treated infants (median, 2 vs 11, P = .01). Moderate/severe brain injury (4% vs 44%, P = .002), subcortical (30% vs 68%, P = .02), and cerebellar injury (0% vs 20%, P = .05) were less frequent in the Epo than placebo group. At mean age 12.7 months (SD, 0.9), motor performance in Epo-treated (n = 21) versus placebo-treated (n = 20) infants were as follows: Alberta Infant Motor Scale (53.2 vs 42.8, P = .03); Warner Initial Developmental Evaluation (28.6 vs 23.8, P = .05).
High doses of Epo given with hypothermia for hypoxic-ischemic encephalopathy may result in less MRI brain injury and improved 1-year motor function.
This analysis of the lumbar epidural steroid injections for spinal stenosis multicenter randomized controlled trial data identifies the degree of and risk factors for cortisol suppression after ...epidural steroid injections in older adults with spinal stenosis. Four hundred patients aged 50 years and older with back or leg pain and central lumbar spinal stenosis completed baseline demographic and psychosocial measures. Morning serum cortisol levels were measured at baseline and 3 weeks after initial injection. Patients were randomized to receive epidural injections of either local anesthetic with corticosteroid (n = 200) or local anesthetic only (n = 200). The specific corticosteroid was chosen at the treating physician's discretion (methylprednisolone, betamethasone, triamcinolone, or dexamethasone). Thirty-two patients (20.3%) treated with corticosteroid experienced cortisol reduction at 3 weeks of >50% compared with 10 patients (6.7%) treated with lidocaine only (adjusted treatment effect = 3.5, 95% confidence interval: 1.6-7.9, P = 0.002). The effect on 3-week cortisol changes did not differ by demographic or patient-level characteristics. Those treated with methylprednisolone or triamcinolone had an average 3-week cortisol reduction of 41.0% (P = 0.005) and 41.6% (P < 0.001) from baseline, respectively, whereas patients treated with betamethasone or dexamethasone were not significantly different than comparable patients in the lidocaine arm. The higher rates of cortisol suppression at 3 weeks in those receiving epidural corticosteroid injections, particularly with longer-acting insoluble corticosteroid formulations, are consistent with sustained systemic absorption of corticosteroid.
Analysis of nationally representative survey data for spine-related health care expenditures, utilization and self-reported health status.
To study trends from 1997 to 2006 in per-user expenditures ...for spine-related inpatient, outpatient, pharmacy, and emergency services; and to compare these trends to changes in health status.
Although prior work has shown overall spine-related expenditures accounted for $86 billion in 2005, increasing 65% since 1997, the study did not report per-user expenditures. Understanding population-level per-user expenditure for specific services relative to changes in the health status may help assess the value of these services.
We analyzed data from the Medical Expenditure Panel Survey, a multistage survey sample designed to produce unbiased national estimates of health care utilization and expenditure. Spine-related hospitalizations, outpatient visits, prescription medications and emergency department visits were identified using ICD-9-CM diagnosis codes. Regression analyses controlling for age, sex, comorbidity, and time (years) were used to examine trends from 1997 to 2006 in inflation-adjusted per-user expenditures, and utilization, and self-reported health status.
An average of 1774 respondents with spine problems was surveyed per year; the proportion suggested an increase in the number of people who sought treatment for spine problems in the United States from 14.8 million in 1997 to 21.9 million in 2006. From 1997 to 2006, the mean adjusted per-user expenditures were the largest component of increasing total costs for inpatient hospitalizations, prescription medications, andemergency department visits, increasing 37% (from $13,040 in 1997 to $17,909 in 2006), 139% (from $166 to $397), and 84% (from $81 to $149), respectively. A 49% increase in the number of patients seeking spine-related care (from 12.2 million in 1997 to 18.2 million in 2006) was the largest contributing factor to increased outpatient expenditures. Population measures of mental health and work, social, and physical limitations worsened over time among people with spine problems.
Expenditure increases for spine-related inpatient, prescription, and emergency services were primarily the result of increasing per-user expenditures, while those related to outpatient visits were primarily due to an increase in the number of users of ambulatory services.
In a randomized trial comparing antibiotic therapy with appendectomy in patients with appendicitis, antibiotics were noninferior on the basis of EQ-5D scores. In the antibiotics group, nearly 3 in 10 ...participants had undergone appendectomy by 90 days, and complications were more common, especially in those with an appendicolith.
Sequential cross-sectional study.
To quantify patterns of outpatient lumbar spine surgery.
Outpatient lumbar spine surgery patterns are undocumented.
We used CPT-4 and ICD-9-CM diagnosis/procedure ...codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUP's State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates.
Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000.
While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.
The incidence of sports- and recreation-related concussions (SRRCs) in the United States is unknown. More than 44 million youth participate in sports annually, thus understanding the frequency of ...SRRCs in children is important on a population level. Our objective was to determine the number of SRRCs occurring annually among US youth ≤18 years old.
We identified SRRCs using 3 national databases: MarketScan, National Electronic Injury Surveillance System, and National High School Sports Related Injury Surveillance System, Reporting Injury Online. We determined the number of SRRCs seen in health care settings (outpatient, inpatient, and emergency department) and SRRCs reported to certified high school athletic trainers (ATCs). We used these data and findings in recently published literature to generate a national estimate of SRRCs.
We estimate that between 1.1 and 1.9 million SRRCs occur annually in US children aged ≤18 years. Most children with SRRCs, 511 590 to 1 240 972, were not seen in health care settings. Of children with SRRCs seen in health care settings, most were seen as outpatients with 377 978 visits, compared with between 115 479 and 166 929 ED visits, and between 2886 and 4936 hospitalizations.
This study provides the most accurate and precise estimate to date of the number of concussions among US children annually. SRRCs are a common injury in children. Providers in all health care settings need to be trained in concussion care. There is a need for better surveillance to enhance our understanding of the epidemiology of concussions in youth.
CONTEXT Back and neck problems are among the symptoms most commonly encountered in clinical practice. However, few studies have examined national trends in expenditures for back and neck problems or ...related these trends to health status measures. OBJECTIVES To estimate inpatient, outpatient, emergency department, and pharmacy expenditures related to back and neck problems in the United States from 1997 through 2005 and to examine associated trends in health status. DESIGN AND SETTING Age- and sex-adjusted analysis of the nationally representative Medical Expenditure Panel Survey (MEPS) from 1997 to 2005 using complex survey regression methods. The MEPS is a household survey of medical expenditures weighted to represent national estimates. Respondents were US adults (> 17 years) who self-reported back and neck problems (referred to as “spine problems” based on MEPS descriptions and International Classification of Diseases, Ninth Revision, Clinical Modification definitions). MAIN OUTCOME MEASURES Spine-related expenditures for health services (inflation-adjusted);
annual surveys of self-reported health status. RESULTS National estimates were based on annual samples of survey respondents with and without self-reported spine problems from 1997 through 2005.
A total of 23 045 respondents were sampled in 1997, including 3139 who reported spine problems. In 2005, the sample included 22 258
respondents, including 3187 who reported spine problems. In 1997,
the mean age- and sex-adjusted medical costs for respondents with spine problems was $4695 (95% confidence interval CI, $4181-$5209),
compared with $2731 (95% CI, $2557-$2904) among those without spine problems (inflation-adjusted to 2005 dollars). In 2005, the mean age-
and sex- adjusted medical expenditure among respondents with spine problems was $6096 (95% CI, $5670-$6522), compared with $3516 (95%
CI, $3266-$3765) among those without spine problems. Total estimated expenditures among respondents with spine problems increased 65% (adjusted for inflation) from 1997 to 2005, more rapidly than overall health expenditures. The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7% (95% CI, 19.9%-21.4%) to 24.7% (95% CI, 23.7%-25.6%) from 1997 to 2005. Age- and sex-adjusted self-reported measures of mental health, physical functioning, work or school limitations, and social limitations among adults with spine problems were worse in 2005 than in 1997. CONCLUSIONS In this survey population, self-reported back and neck problems accounted for a large proportion of health care expenditures. These spine-related expenditures have increased substantially from 1997
to 2005, without evidence of corresponding improvement in self-assessed health status.
Retrospective cohort study using a hospital discharge registry of all nonfederal acute care hospitals in Washington state.
To determine the cumulative incidence of reoperation following lumbar ...surgery for degenerative disease and, for specific diagnoses, to compare the frequency of reoperation following fusion with that following decompression alone.
Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Compared to decompression alone, spine fusion is commonly viewed as a stabilizing treatment that may reduce the need for additional surgery. However, indications for fusion surgery in degenerative spine disorders remain controversial, and the effects of fusion on reoperation rates are unclear.
Adults who underwent inpatient lumbar surgery for degenerative spine disorders in 1990-1993 (n = 24,882) were identified from International Classification of Diseases ninth Revision, Clinical Modification codes and then categorized as having either a lumbar decompression surgery or lumbar fusion surgery. We then compared the subsequent incidence of lumbar spine surgery between these groups.
Patients who had surgery in 1990-93 had a 19% cumulative incidence of reoperation during the subsequent 11 years. Patients with spondylolisthesis had a lower cumulative incidence of reoperation after fusion surgery than after decompression alone (17.1% vs. 28.0%, P = 0.002). For other diagnoses combined, the cumulative incidence of reoperation was higher following fusion than following decompression alone (21.5% vs. 18.8%, P = 0.008). After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis.
Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. For spondylolisthesis, reoperation is less likely following fusion than following decompression alone. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.
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