A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity

OBJECTIVE

To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity.

DESIGN

We used the Delphi method.

SETTING

A multiquestion electronic survey.

PARTICIPANTS

Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice.

INTERVENTIONS

After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections.

CONCLUSIONS

These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

Osteoporosis in a postpolio clinic population

OBJECTIVES

To determine (1) the frequency of osteoporosis at the hip and lumbar spine in a postpolio clinic population and (2) the association of lower-extremity muscle strength and other potential contributing factors to osteoporosis with bone density measured at the hip.

DESIGN

Cross-sectional study involving a chart review.

SETTING

A university-affiliated hospital postpolio clinic.

PARTICIPANTS

Patient charts (N=379) were reviewed; 164 (26%) were included, and 215 (74%) were not included primarily (74%) because of the unavailability of bone density results.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Bone density (in g/cm(2)) and T score were assessed at the femoral neck and lumbar spine. Muscle strength was evaluated by manual muscle testing in 7 bilateral lower-extremity muscles.

RESULTS

The occurrence of osteoporosis at the hip and lumbar spine was 20 (32%) of 62 and 6 (10%) of 61 in men, 3 (9%) of 33 and 2 (6%) of 32 in premenopausal women, and 18 (27%) of 67 and 7 (11%) of 65 in postmenopausal women, respectively. In a logistic regression model, the presence of osteoporosis at the hip was significantly associated with strength sum score in the same extremity in which the bone density was performed after adjusting for other important risk factors (age, body mass index, time since polio).

CONCLUSIONS

Osteoporosis occurred commonly at the hip in a postpolio clinic population. Hip bone density was associated with muscle strength in the same lower extremity.

[Aneurysm of the interauricular septum]

In reference to three personal cases of interatrial septum aneurysm discovered on ultrasonography performed for the diagnosis of a cerebral embolism, the authors describe the positive diagnosis criteria, in mono- and bi-dimensional mode, of this abnormality, as well as related data obtained from catheterization, angiocardiography, and phonocardiography. This malformation, the frequency and pathogenesis of which still remain, today, difficult to evaluate, may be at the origin of complications, especially embolic migrations, systemic and also pulmonary, supraventricular rhythm disorders, interatrial shunt, reduced ventricular filling. Once established, the diagnosis is the subject of many controversies: if plain monitoring appears logical in asymptomatic forms, the occurrence of a systemic embolism makes it difficult to choose between surgical treatment and long-term anticoagulant therapy.