Practice Parameter: Pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society
Delgado M.R.,University of Texas Southwestern Medical Center |
Hirtz D.,U.S. National Institutes of Health |
Aisen M.,United Cerebral Palsy Research Foundation |
Ashwal S.,Loma Linda University |
And 6 more authors.
Neurology | Year: 2010
OBJECTIVE: To evaluate published evidence of efficacy and safety of pharmacologic treatments for childhood spasticity due to cerebral palsy. METHODS: A multidisciplinary panel systematically reviewed relevant literature from 1966 to July 2008. RESULTS: For localized/segmental spasticity, botulinum toxin type A is established as an effective treatment to reduce spasticity in the upper and lower extremities. There is conflicting evidence regarding functional improvement. Botulinum toxin type A was found to be generally safe in children with cerebral palsy; however, the Food and Drug Administration is presently investigating isolated cases of generalized weakness resulting in poor outcomes. No studies that met criteria are available on the use of phenol, alcohol, or botulinum toxin type B injections. For generalized spasticity, diazepam is probably effective in reducing spasticity, but there are insufficient data on its effect on motor function and its side-effect profile. Tizanidine is possibly effective, but there are insufficient data on its effect on function and its side-effect profile. There were insufficient data on the use of dantrolene, oral baclofen, and intrathecal baclofen, and toxicity was frequently reported. RECOMMENDATIONS: For localized/segmental spasticity that warrants treatment, botulinum toxin type A should be offered as an effective and generally safe treatment (Level A). There are insufficient data to support or refute the use of phenol, alcohol, or botulinum toxin type B (Level U). For generalized spasticity that warrants treatment, diazepam should be considered for short-term treatment, with caution regarding toxicity (Level B), and tizanidine may be considered (Level C). There are insufficient data to support or refute use of dantrolene, oral baclofen, or continuous intrathecal baclofen (Level U). Copyright © 2010 by AAN Enterprises, Inc.
Jacofsky D.,Core Institute
Orthopedics | Year: 2013
Each month, this column summarizes a Level I article and provides a thought-provoking review on how the treatment in the article has either stood the test of time or serves as an example of how conventional wisdom has changed.
Loftus T.,Banner Health |
Dahl D.,Banner Health |
Ohare B.,Banner Health |
Power K.,Perioperative Services |
And 4 more authors.
Journal of the American College of Surgeons | Year: 2015
Background Patient safety in the perioperative period is essential for delivery of quality patient care. Mainstream quality organizations have implemented safe surgery recommended practices for ensuring patient safety. Effectively implementing safe surgery practices should result in a reduction in serious reportable event (SRE) rates.Study Design This retrospective cohort study compared results before and after implementation of a standardized safe surgery program across a large health care system. Observational audits were performed to assure adoption of the new process. Serious reportable event rates (retained surgical item, wrong site, wrong patient, and wrong procedure) were tracked. Statistical analyses were performed on the SRE rate and days between SREs.Results A total of 683,193 cases in the operating room and labor and delivery were evaluated over a 4-year period. The SRE rate before implementation was 0.075/1,000 cases and after implementation was 0.037/1,000 cases. There was a 52% reduction in the SRE rate (p < 0.05). The mean time between SREs increased from 27.4 days to 60.6 days (p < 0.05). Robotic and nonrobotic cases were affected equally; however, a significant difference in SRE rate persisted between robotic and non-robotic cases (p < 0.05). Robotic cases are 7 times more likely to incur an SRE. Audits demonstrated that the compliance rates for the program improved to 96% after complete system implementation.Conclusions An effectively implemented standardized safe surgery program results in a significant reduction in SREs. Robotic cases are at high risk for an SRE.
Scott R.T.,Core Institute |
Hyer C.F.,Orthopedic Foot and Ankle Center |
Berlet G.C.,Orthopedic Foot and Ankle Center
Foot and Ankle Specialist | Year: 2013
Hammertoe digital deformity correction is a very controversial topic among foot and ankle surgeons. Hammertoes are characterized by an extension deformity at the metatarsophalangeal joint (MTPJ) and flexion deformity at the proximal interphalangeal joint (PIPJ). Current treatment options are often guided by the patient's discomfort as well as the reducibility of the affected digit. Kirschner wires (K-wires) have long been considered the gold standard for hammertoe digital repair. Although K-wires are simplistic to use as fixation, they carry inherit risks such as pin tract infections, migration, and breakage. This has lead to multiple intramedullary hammertoe devices including the PROTOE intramedullary device. This paper will discuss the usage and benefits the PROTOE has to offer over the conventional K - wire.Level of Evidence: IV © 2013 The Author(s).
Scalise J.J.,Core Institute |
Ciccone J.,Cleveland Clinic |
Iannotti J.P.,Cleveland Clinic
Journal of Bone and Joint Surgery - Series A | Year: 2010
Background: Recently, a lesser tuberosity osteotomy has been promoted as an alternative to tenotomy for release of the subscapularis during shoulder arthroplasty. To our knowledge, no direct comparison of the clinical results of the two techniques has been presented. Methods: Thirty-five shoulders in thirty-four consecutive patients with osteoarthritis who had a primary total shoulder arthroplasty, performed with use of a standard subscapularis tenotomy (Group 1) or lesser tuberosity osteotomy (Group 2) to release the subscapularis, were evaluated retrospectively at an average of thirty-three months. Group 1 consisted of fifteen shoulders in fourteen patients (seven in males and eight in females, with an average age of sixty-seven years). Group 2 consisted of twenty shoulders in twenty patients (fourteen males and six females, with an average age of sixty-nine years). Assessment included a physical examination, clinical outcome questionnaires, conventional radiography, ultrasound examination of the subscapularis, and measurement of internal rotation strength. Results: The postoperative total Penn Shoulder Scores improved significantly from the preoperative levels in both groups (mean and standard deviation, 29 ± 15 points to 81 ± 20 points [p < 0.00001] in Group 1 and 29 ± 16 points to 92 ± 11 points [p < 0.00001] in Group 2). However, the postoperative mean total Penn Shoulder Score was higher in Group 2 (92 ± 11 points) than in Group 1 (81 ± 20 points) (p = 0.04). At one year, an abnormal subscapularis on ultrasound was associated with a lower mean Penn Shoulder Score in Group 1 (73 ± 19 points compared with 92 ± 3 points; p = 0.01). However, at a minimum two-year follow-up, this difference was not significant (mean, 74 ± 24 points and 86 ± 15 points, respectively; p = 0.25). There were more abnormal subscapularis tendons in Group 1 (six attenuated tendons and one full-thickness tear) than in Group 2 (two attenuated tendons). Internal rotation strength did not differ between the groups when controlled for sex (mean, 117 ± 8 N and 127 ± 21 N for males in Group 1 and Group 2, respectively [p = 0.22] and 77 ± 27 N and 101 ± 26 N, respectively, for females [p = 0.1]). Conclusions: Both techniques resulted in improved clinical outcome scores. The lesser tuberosity osteotomy resulted in higher clinical outcome scores, a lower rate of subscapularis tendon tears, and universal healing of the osteotomy. This technique offers a means by which the rate of postoperative subscapularis tears may be reduced in patients undergoing total shoulder arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2010 by The Journal of Bone and Joint Surgery, Incorporated.