Tacoma, WA, United States
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Chou R.,Oregon Health And Science University | Hashimoto R.,Spectrum Research | Friedly J.,University of Washington | Fu R.,Oregon Health And Science University | And 4 more authors.
Annals of Internal Medicine | Year: 2015

Purpose: To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration. Data Sources: Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists. Study Selection: Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses. Data Extraction: Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE). Data Synthesis: 30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low). Limitations: The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings. Conclusion: Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.


Coe J.D.,Silicon Valley Spine Institute | Vaccaro A.R.,Rothman Institute | Dailey A.T.,University of Utah | Skolasky Jr. R.L.,Johns Hopkins University | And 4 more authors.
Journal of Bone and Joint Surgery - Series A | Year: 2013

Background: Lateral mass screw fixation with plates or rods has become the standard method of posterior cervical spine fixation and stabilization for a variety of surgical indications. Despite ubiquitous usage, the safety and efficacy of this technique have not yet been established sufficiently to permit"on-label" U.S. Food and Drug Administration approval for lateral mass screw fixation systems. The purpose of this study was to describe the safety profile and effectiveness of such systems when used in stabilizing the posterior cervical spine. Methods: A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for articles published from January 1, 1980, to December 1, 2011. We included all articles evaluating safety and/or clinical outcomes in adult patients undergoing posterior cervical subaxial fusion utilizing lateral mass instrumentation with plates or rods for degenerative disease (spondylosis), trauma, deformity, inflammatory disease, and revision surgery that satisfied our a priori inclusion and exclusion criteria. Results: Twenty articles (two retrospective comparative studies and eighteen case series) satisfied the inclusion and exclusion criteria and were included. Both of the comparative studies involved comparison of lateral mass screw fixation with wiring and indicated that the risk of complications was comparable between treatments (range, 0% to 7.1% compared with 0% to 6.3%, respectively). In one study, the fusion rate reported in the screw fixation group (100%) was similar to that in the wiring group (97%). Complication risks following lateral mass screw fixation were low across the eighteen case series. Nerve root injury attributed to screw placement occurred in 1.0% (95% confidence interval, 0.3% to 1.6%) of patients. No cases of vertebral artery injury were reported. Instrumentation complications such as screw or rod pullout, screw or plate breakage, and screw loosening occurred in <1% of the screws inserted. Fusion was achieved in 97.0% of patients across nine case series. Conclusions: The risks of complications were low and the fusion rate was high when lateral mass screw fixation was used in patients undergoing posterior cervical subaxial fusion. Nerve root injury attributed to screw placement occurred in only 1% of 1041 patients. No cases of vertebral artery injury were identified in 758 patients. Screw or rod pullout, screw or plate breakage, and screw loosening occurred in <1% of the screws inserted. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. COPYRIGHT © 2013 BY THE JOURNAL OF BONE AND JOINT SURGERY.


Dekutoski M.B.,Rochester College | Norvell D.C.,Spectrum Research | Dettori J.R.,Spectrum Research | Fehlings M.G.,University of Toronto | Chapman J.R.,Harborview Medical Center
Spine | Year: 2010

Study Design. Systematic review. Objective. To define the term "complications" from the spine surgery literature and contrast this with definitions from other federal institutions, to summarize the incidence of adverse events in cervical, thoracic, and lumbar spine surgery, to include the factors that contribute to these events, and to determine the relationship between complications and patient centered outcomes. Summary of Background Data. Efforts to understand and reduce complications in medicine, and spine surgery in particular have been hampered as a result of the lack of a meaningful and universally acceptable definition. The complex field of spine surgery has been a particularly challenging area for the development of a consensus to constructively describe these "undesirable/unanticipated developments arising during or out of the delivery of health care." Furthermore, an overall understanding of expected complication rates after major spine surgery is lacking. Methods. A systematic review of the English literature was undertaken for articles published between 1990 and December 2008. Electronic and federal databases and reference lists of key articles were searched to identify articles defining complications and reporting rates of spine surgical complications. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and disagreements were resolved by consensus. Results. The definitions for complications in the spine literature and federal agencies are inconsistent and at times conflicting. Mortality rates for cervical spine and lumbar spine surgery are <1%. For thoracic spine surgery, rates range from 0.3% to 7%. Complication rates range from 5% to 19%, 7% to 18%, and 4% to 14% after cervical, thoracic, and lumbar spine surgery, respectively. Findings from a single study indicate that major complications may have an impact on 1-year self-perceived general health. However, minor complications may not. Conclusion. We define a complication as an unintended and undesirable diagnostic or therapeutic event that may impact the patient's care. Complications should be recorded and analyzed relative to disease severity, patient comorbidities, and ultimately their effect on patient outcomes. Further work needs to be done to develop a complication risk impact index that has the ability to help us assess and communicate the interaction of patient cormobidities and complication severity on patient centered outcomes. © 2010, Lippincott Williams & Wilkins.


Huillet A.,U.S. Army | Erdie-Lalena C.,U.S. Army | Norvell D.,Spectrum Research | Davis B.E.,U.S. Army
Journal of Alternative and Complementary Medicine | Year: 2011

Objectives: The objective of this study was to evaluate the prevalence, types, perceived effects, and factors that influence the use of complementary and alternative medicine (CAM) by military children. Design: A parent survey was administered in two military general pediatric clinics from June to September 2009. Parents completed surveys about their children including the following items: demographic information, a list of specific CAM therapies, family CAM use, and child health status. Results: Caregivers completed 278 surveys. The overall use of CAM was 23%. The most common type of CAM used was herbal therapy (34%). The CAM therapies most commonly reported to be very helpful were special diets (67%), melatonin (57%), vitamins and minerals used at doses higher than the recommended daily allowance (50%), and massage therapy (50%). The majority of users reported no side-effects (96%). Among CAM users, 53% had discussed their CAM use with a physician and 47% had seen a CAM practitioner. Factors associated with CAM use in multiple regression analysis included chronic conditions (p=0.001), parent/sibling use of CAM (p<0.001), and parent age over 30 years (p=0.02). Primary sources of CAM information were friends and family (68%) and doctors (44%). Common reasons for using CAM were to promote general health (70%), to relieve symptoms (56%), and to improve quality of life (48%). Eighty percent (80%) of all respondents indicated they would use CAM if recommended by a physician. Conclusions: In this military population with access to universal health care, CAM use is higher than the U.S. national average and nearly double that of the 2007 National Health Interview Survey study. Patients with chronic conditions, family members using CAM, and parental age over 30 years are more likely to use CAM. CAM is perceived as helpful with minimal to no side-effects. Pediatricians should inquire about CAM use and be prepared to provide guidance on this topic. © 2011 Mary Ann Liebert, Inc.


Gautam N.K.,University of Arkansas for Medical Sciences | Schmitz M.L.,University of Arkansas for Medical Sciences | Harrison D.,University of Arkansas for Medical Sciences | Zabala L.M.,University of Arkansas for Medical Sciences | And 5 more authors.
Paediatric Anaesthesia | Year: 2013

Objectives: To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG). Background Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients. Methods: A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV. Results: Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups. Conclusion: Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG. © 2013 Blackwell Publishing Ltd.


King K.W.,U.S. Department of Agriculture | Balogh J.C.,Spectrum Research
Environmental Toxicology and Chemistry | Year: 2013

Chlorothalonil concentrations exceeding acute toxicity levels for certain organisms have been measured in surface water discharge events from managed turf watersheds. The duration of exceedence and the timing of these events related to precipitation/runoff and time since application, however, have not been explored. Chlorothalonil concentrations were measured from discharge waters draining a managed turf watershed in Duluth, Minnesota, USA, between 2003 and 2009. The median chlorothalonil concentration was 0.58μg/L. Approximately 2% of all measured concentrations exceeded the 7.6μg/L median lethal concentration (LC50) acute toxicity level for rainbow trout. One-twentieth the LC50 concentration, equivalent to the level of concern (0.38μg/L) for endangered species, was exceeded 31% of the time during the present study. The concentrations that exceeded the LC50 threshold were associated with eight rainfall/runoff events. Low dose exposures are a more important biological concern than acute occurrences. Exceedence concentrations associated with acute effects were significantly (p<0.05) correlated to time since application and were measured only in the fall following extensive application. A conflict exists between the transportability of chlorothalonil as suggested by its chemical properties and the data collected in the present study. With respect to course-wide golf course application, avoiding application until after the major autumn rainfall period but before the first snow coverage is recommended to reduce occurrence of chlorothalonil concentrations that exceed toxic levels associated with acute and chronic levels of concern. Environ. Toxicol. Chem. 2013;32:684-691. © 2012 SETAC.


Peredo D.E.,U.S. Army | Davis B.E.,U.S. Army | Norvell D.C.,Spectrum Research | Kelly P.C.,U.S. Army
Journal of Pediatric Rehabilitation Medicine | Year: 2010

Objective: To investigate the use of medical equipment by children with disabilities, the reasons for use, and prescribers of equipment. Methods: A convenience sample. Setting: Referral clinic for children with developmental conditions. Participants: Caregivers of children with motor disabilities completed an interview survey for children 0-21 years. Results: 108 parents/caregivers reported 467 (mean=4.3 per patient) pieces of owned equipment. The mean age of children was 7.1 years (± 5.0), and 49% were female. The most common diagnoses were cerebral palsy (45%), 'Other' diagnoses including intellectual disability (19%), genetic abnormality (13%), spina bifida (13%), and neuromuscular diseases (7%). Survey participants described use of the following types of equipment: orthotics (82%), bath chair (37%), seating device (34%), stander (19%), augmentative communication devices (17%), walker (14%), and gait trainer (10%). Reasons for "non-use" of equipment included: outgrown (19%), not useful (14%), and child refusal (15%). Physicians were the sole prescriber for 15% of families, whereas physical or occupational therapists most commonly recommended new equipment (76%). Conclusion: Based on parental report, children with neuromuscular disabilities use most equipment that is medically recommended. The majority of equipment needs are identified by therapists. Pediatricians can benefit from additional expertise in the provision of medical equipment for children. © 2010 - IOS Press and the authors. All rights reserved.


Rosenberg D.E.,VA Puget Sound Health Care System | Rosenberg D.E.,Group Health Research Institute | Turner A.P.,VA Puget Sound Health Care System | Turner A.P.,University of Washington | And 9 more authors.
Disability and Rehabilitation | Year: 2013

Purpose: Using preliminary data, we examined: (i) patterns of body mass index (BMI) over the year following amputation by amputation level and (ii) the association between BMI and mobility and prosthetic device use. Method: Patients from three medical centers undergoing dysvascular amputation (N = 87; M age = 62) participated in interviews pre-surgically and at 6 weeks, 4 months, and 12 months following amputation. The main outcome was self-reported BMI, adjusting for limb weight lost due to amputation. Additional outcomes were mobility and time spent using and walking in a prosthetic device. Results: Adjusted BMI slightly decreased at 6 weeks (pre-surgery M = 31.2; 6 weeks M = 30.3) and 4 months (M = 30.7) but exceeded baseline levels by 12 months (M = 31.7). There were no significant BMI differences by amputation level. In multivariable analyses, higher pre-surgical BMI was associated with fewer hours of prosthetic device walking at month 4 (β =-0.49) and poorer overall mobility at month 12 (β =-0.22). Conclusions: BMI increased at one year following amputation surgery. Higher pre-surgical BMI was associated with poorer mobility and prosthetic device use. Interventions are needed to prevent excess weight gain in the year following amputation. Implications for Rehabilitation People undergoing lower-extremity amputation have high rates of overweight and obesity and continue to gain weight in the year following amputation. Objective assessment of body mass index (both with and without a prosthetic device) and waist circumference would help future research efforts. Targeting weight loss post-amputation could improve the health of people with lower-extremity amputations. © 2013 Informa UK, Ltd.

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