Exertional Rhabdomyolysis: A Retrospective Population-based Study

PURPOSE

This study aimed to evaluate the incidence and characteristics of exertional rhabdomyolysis (ER) in a population-based cohort.

METHODS

A retrospective cohort study was performed in Olmsted County, Minnesota, from 2003 to 2015. Incident ER cases were ascertained through the Rochester Epidemiology Project medical record linkage system through electronic searches of the International Classification of Diseases, Ninth Revision, codes and clinical note text. Population incidence rate was calculated using the corresponding Rochester Epidemiology Project census populations specific to calendar year and sex. Descriptive statistics were used.

RESULTS

Of the 430 patients, 431 cases met the inclusion criteria for rhabdomyolysis; 4.9% of cases (n = 20; males n = 18; Caucasian n = 17) were ER, with one recurrence. There were no deaths secondary to ER. The age- and sex-adjusted incidence rate of ER was 1.06 ± 0.24 (95% confidence interval = 0.59-1.52) per 100,000 person-years. Endurance activity (n = 7), manual labor (n = 5), and weight lifting (n = 4) were common causes. Complications included kidney injury (n = 5), mild electrolyte abnormalities (n = 10), elevated transaminases (n = 12), and minor electrocardiographic abnormalities (n = 4). A majority of patients were hospitalized (n = 16) for a median of 2 d, had mild abnormalities in renal and liver function and electrolytes, and were discharged without sequelae.

CONCLUSION

ER in the civilian population occurs at a much lower incidence than the military population. The most common causes were endurance exercise, manual labor, and weight lifting. The majority of cases were treated conservatively with intravenous fluid resuscitation during a brief hospital stay, and all were discharged without sequela. Only one case of recurrence occurred in this cohort, indicating the recurrence rate was low.

The risk of major cardiovascular events for adults with transfemoral amputation

BACKGROUND

It is well-known that the risk of cardiac disease is increased for those with lower-limb amputations, likely as a result of the etiology of the amputation. Using a longitudinal population-based dataset, we examined the association between transfemoral amputation (TFA) status and the risk of experiencing a major cardiac event for those undergoing either dysvascular or traumatic amputations. The association of receiving a prosthesis with the risk of experiencing a major cardiac event was also examined.

METHODS

Study Population: All individuals with TFA (N 162), i.e. knee disarticulation and transfemoral amputation, residing in Olmsted County, MN, between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency.

DATA ANALYSIS

A competing risk Cox proportional hazard model was used to estimate the relative likelihood of an individual with a TFA experiencing a major cardiac event in a given time period as compared to the matched controls. The cohort was divided by amputation etiology: dysvascular vs trauma/cancer. Additional analysis was performed by combining all individuals with a TFA to look at the relationship between prosthesis receipt and major cardiac events.

RESULTS

Individuals with a dysvascular TFA had an approximately four-fold increased risk of a cardiac event after undergoing an amputation (HR 3.78, 95%CI: 3.07-4.49). These individuals also had an increased risk for non-cardiac mortality (HR 6.27, 95%CI: 6.11-6.58). The risk of a cardiac event was no higher for those with a trauma/cancer TFA relative to the able-bodied controls (HR 1.30, 95%CI: 0.30-5.85). Finally, there was no difference in risk of experiencing a cardiac event for those with or without prosthesis (HR 1.20, 95%CI: 0.55-2.62).

CONCLUSION

The high risk of initial mortality stemming from an amputation event may preclude many amputees from cardiovascular disease progression. Amputation etiology is also an important factor: cardiac events appear to be more likely among patients with a dysvascular TFA. Providing a prosthesis does not appear to be associated with a reduced risk of a major cardiac event following amputation.

Fibrocartilaginous embolic myelopathy: demographics, clinical presentation, and functional outcomes

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To describe the demographics, clinical presentation, and functional outcomes of fibrocartilaginous embolic myelopathy (FCEM).

SETTING

Academic inpatient rehabilitation unit in the midwestern United States.

METHODS

We retrospectively searched our database to identify patients admitted between January 1, 1995 and March 31, 2016, with a high probability of FCEM. Demographic, clinical, and functional outcome measures, including Functional Independence Measure (FIM) information was obtained by chart review.

RESULTS

We identified 31 patients with findings suggestive of FCEM (52% male), which was 2% of the nontraumatic spinal cord injury population admitted to inpatient rehabilitation. The age distribution was bimodal, with peaks in the second and sixth-to-seventh decades. The most common clinical presentation was acute pain and rapid progression of neurologic deficits consistent with a vascular myelopathy. Only three patients (10%) had FCEM documented as a diagnostic possibility. Most patients had paraplegia and neurologically incomplete injuries and were discharged to home. Nearly half of the patients required no assistive device for bladder management at discharge, but most were discharged with medications for bowel management. Median FIM walking locomotion score for all patients was 5, but most patients were discharged using a wheelchair for primary mobility. Median motor FIM subscale score was 36 at admission and 69 at discharge, with a median motor efficiency of 1.41.

CONCLUSIONS

FCEM may be underdiagnosed and should be considered in those with the appropriate clinical presentation, because their functional outcomes may be more favorable than those with other causes of spinal cord infarction.

Simulating the multi-disciplinary care team approach: Enhancing student understanding of anatomy through an ultrasound-anchored interprofessional session

Quality of healthcare delivery is dependent on collaboration between professional disciplines. Integrating opportunities for interprofessional learning in health science education programs prepares future clinicians to function as effective members of a multi-disciplinary care team. This study aimed to create a modified team-based learning (TBL) environment utilizing ultrasound technology during an interprofessional learning activity to enhance musculoskeletal anatomy knowledge of first year medical (MD) and physical therapy (PT) students. An ultrasound demonstration of structures of the upper limb was incorporated into the gross anatomy courses for first-year MD (n = 53) and PT (n = 28) students. Immediately before the learning experience, all students took an individual readiness assurance test (iRAT) based on clinical concepts regarding the assigned study material. Students observed while a physical medicine and rehabilitation physician demonstrated the use of ultrasound as a diagnostic and procedural tool for the shoulder and elbow. Following the demonstration, students worked within interprofessional teams (n = 14 teams, 5-6 students per team) to review the related anatomy on dissected specimens. At the end of the session, students worked within interprofessional teams to complete a collaborative clinical case-based multiple choice post-test. Team scores were compared to the mean individual score within each team with the Wilcoxon signed-rank test. Students scored higher on the collaborative post-test (95.2 ±10.2%) than on the iRAT (66.1 ± 13.9% for MD students and 76.2 ±14.2% for PT students, P < 0.0001). Results suggest that this interprofessional team activity facilitated an improved understanding and clinical application of anatomy. Anat Sci Educ 11: 94-99. © 2017 American Association of Anatomists.

Increasing neuroradiology exam volumes on-call do not result in increased major discrepancies in primary reads performed by residents

Background and Purpose:

A common perception is that increased on-call workload leads to increased resident mistakes. To test this, we evaluated whether increased imaging volume has led to increased errors by residents.

Materials and Methods:

A retrospective review was made of all overnight neuroradiology CT exams with a primary resident read from 2006-2010. All studies were over-read by staff neuroradiologists next morning. As the volume is higher on Friday through Sunday nights, weekend studies were examined separately. Discrepancies were classified as either minor or major. “Major” discrepancy was defined as a discrepancy that the staff radiologist felt was significant enough to potentially affect patient care, necessitating a corrected report and phone contact with the ordering physician and documentation. The total number of major discrepancies was recorded by quarter. In addition, the total number of neuroradiology CT studies read overnight on-call was noted.

Results:

The mean number of cases per night during the weekday increased from 3.0 in 2006 to 5.2 in 2010 (p<0.001). During the weekend, the mean number of cases per night increased from 5.4 in 2006 to 7.6 in 2010 (p<0.001). Despite this increase, the major discrepancy rate decreased from 2.7% in 2006 to 2.3% in 2010 (p=0.34).

Conclusion:

Despite an increase in neuroradiology exam volumes, there continues to be a low major discrepancy rate for primary resident interpretations. While continued surveillance of on-call volumes is crucial to the educational environment, concern of increased major errors should not be used as sole justification to limit autonomy.

The association between the duration of preoperative pain and pain improvement in vertebral augmentation: a meta-analysis

BACKGROUND AND PURPOSE

Most physicians consider length of preoperative pain as an important factor to include patients for SA. Our aim was to synthesize the available evidence regarding the influence of preprocedural pain duration on the outcome of vertebral augmentation procedures.

MATERIALS AND METHODS

The MEDLINE data base was reviewed up to March 2010. Meta-regression and mixed-effect subgroup analyses were performed to evaluate the association between the outcome of interest, which was pain improvement assessed by a VAS (0-10) and the duration of preoperative pain (independent variable).

RESULTS

We included 17 articles. The mean VAS improvements for subgroups of ≤6 weeks (n = 12), 6-24 weeks (n = 5), and >24 weeks (n = 3) were 5.18, 4.90, and 5.04, respectively (P = .86). The regression coefficient was -0.024, suggesting trivial association of the duration of preoperative pain and pain improvement.

CONCLUSIONS

Pain relief following spine augmentation was similar among groups of patients with varying lengths of preoperative pain duration.

Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty

BACKGROUND AND PURPOSE

Cement PE represents a potentially serious complication following vertebroplasty. To determine the frequency and extent of cement PE during percutaneous vertebroplasty, we performed a retrospective review of chest CT scans obtained in patients who had previously undergone ≥1 vertebroplasty procedure.

MATERIALS AND METHODS

After approval by our local institutional review board, we retrospectively evaluated 244 patients who had undergone vertebroplasty at 465 levels and subsequently underwent chest CT. A thoracic radiologist evaluated the presence, number, size, and location of discrete cement PEs. We catalogued the following data: age, sex, number of treated vertebrae, cement volume per vertebra, operator, presence of cement leakage noted by the operator during the procedure, and clinical presentation at postvertebroplasty CT.

RESULTS

At least 1 cement PE was detected in 23 (9.4%; 95% CI, 6%-13%) of 244 patients; 1 patient was symptomatic from a cement PE. The mean number of discrete cement PEs was 3.2 ± 3.4 (median, 2; range, 1-12). There was no correlation among the total number of treatment sessions, number of levels treated per session, cement volume per level, operator, or time between vertebroplasty and chest CT in the detection of cement PE. Those with PE were significantly younger (P=.0229) and had significantly more total levels treated (P=.0260). Cement PE was recognized by the operator during the vertebroplasty in 2 (8.7%) of 23 patients found to have it on CT.

CONCLUSIONS

Small asymptomatic cement PEs are common during vertebroplasty and usually are not recognized by the operator during the procedure.

Have referral patterns for vertebroplasty changed since publication of the placebo-controlled trials?

BACKGROUND AND PURPOSE

Our aim was to determine whether referral patterns and rates of vertebroplasties at the Mayo Clinic have changed after the publication of the INVEST and the Australian Trial. In August of 2009, we performed a retrospective review of patients undergoing vertebroplasties and those patients who were referred for but did not receive vertebroplasties before and after the recently published placebo-controlled vertebroplasty trials.

MATERIALS AND METHODS

After approval by our local institutional review board, we retrospectively evaluated all patients referred for vertebroplasty between January 5, 2004, and June 2, 2010. We catalogued age, sex, number of treated vertebrae, physician referring the patient for vertebroplasty, and the referring department. We calculated the mean number of referrals per month before and after August 2009, which was the month of publication for both trials. We also calculated rates for specific referring physician types.

RESULTS

During the full study, 1188 patients were referred, of whom 807 underwent treatment at 1378 levels for a total of 943 separate vertebroplasty procedures. The mean number of vertebroplasty referrals per month has dropped significantly from 18.9 ± 5.3 (95% CI, 17.7-20.2) before publication to 11.3 ± 3.1 (95% CI, 9.1-13.5) referrals per month after publication (P=.0001). Before publication, 67.3 ± 14.0% (95% CI, 64.0%-70.7%) of patients referred for vertebroplasty underwent vertebroplasty, compared with 76.0 ± 14.9% (95% CI, 65.4%-86.6%) after publication (P=.11).

CONCLUSIONS

The number of vertebroplasty referrals at our center has decreased significantly since the publication of INVEST and the Australian Trial, yet we continue to offer the procedure to a high proportion of referred patients.