By J. Gelford. Capella University.

Retrospective analysis of the outcomes of balloon kyphoplasty to treat vertebral body compression fracture (VCF) refractory to medical management januvia 100 mg sale diabetes diet south africa. Zoarski Prior to the development of imaged-guided percutaneous spine biopsy techniques discount januvia 100 mg with amex diabetes diet schedule, an open biopsy procedure was required for definitive di- agnosis. First, under direct visualization multiple, and larger, tissue samples can be obtained and made available for frozen histopathological analysis. Sec- ond, the open biopsy can be performed as part of a surgical decom- pression and/or stabilization procedure of the spine. Siffert and Arkin utilized a posterolateral approach for spine biopsy using radio- graphic guidance. The percutaneous image-guided procedure is faster and more cost-effective and has an overall lower risk of complications. The decision to perform a spine biopsy procedure is made after close communication between the ra- diologist and the referring clinician. Both individuals must be convinced that the benefit to be gained from the biopsy results firmly outweighs the risks of the procedure. To this end, as a prerequisite, there must be a thorough medical history and physical examination combined with a complete review of all prior imaging and laboratory examinations. This consultation will avoid unnecessary spine biopsies (when they are not indicated or when a more accessible bone biopsy site, such as the iliac bone, is available), ensure patient safety, and identify the optimal loca- tion and level for performing the biopsy procedure. Spine biopsy is often performed to evaluate destructive or space- occupying lesions within the spinal axis (Table 5. Abnormal foci of marrow replacement within the vertebral column that are detected 69 70 Chapter 5 Image-Guided Percutaneous Spine Biopsy TABLE 5. Suspected secondary spine tumor, with a history of two or more preex- isting primary tumors 3. Suspected inflammatory condition that involves the spine with noninvasive imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI), are also often referred for spine biopsy. In every instance, the decision to proceed with a biopsy procedure is based upon a thorough analysis of risks and benefits. The overall benefit of the information gained by the procedure should al- ways favor its performance. The results of the biopsy will affect the subsequent clinical management of the patient and influence treatment decisions in such areas as surgery, chemotherapy, radiation therapy, and antibiotic therapy. Yet even this condition, when properly anticipated and man- aged, can be corrected long enough to permit a surgeon to perform the procedure. When a vascular tumor such as a renal metastasis is sus- pected, a catheter angiogram should be considered in the diagnostic workup. These vascular lesions, however, can be carefully sampled with smaller gauge core needle biopsy systems and with fine-needle aspiration techniques (Figure 5. Informed consent must be obtained prior to the procedure after the patient has received an explanation of the benefits and risks of image- guided percutaneous spine biopsy. The procedure offers the benefit of supplying diagnostic information that will guide subsequent treatment decisions. The general risks of percutaneous spine biopsy include bleeding at or deep to the puncture site manifested as active hemorrhage or hematoma formation (Table 5. Infection is another potential com- plication associated with spine biopsy, hence the requirement for strict aseptic technique when the procedure is performed. The spread of dis- ease by the biopsy procedure, an extremely rare complication that has been described,7 is related to tumor implantation or spread of infec- tion along the biopsy tract. Site-specific biopsy complications that have been reported are related to the spine level (cervical, thoracic, or lumbar spine) that was sampled and the prox- imity to critical structures. Pneumothorax can occur not only during thoracic spine biopsy but also during the attempted biopsy of thora- columbar or cervicothoracic lesions. Neural injury, particularly to the spinal cord, is a devastating complication that has been reported. Nev- ertheless, the incidence of reported complications in percutaneous skeletal biopsy is low, estimated at less than 0. Axial CT image shows a lytic lesion (arrows) that is centered pri- marily within the posterior elements of the thoracic vertebra.

Therefore januvia 100mg generic diabetes prevention organizations, while MRA is able to provide images of the cerebral vas- culature noninvasively generic januvia 100 mg with amex metabolic disease panel, cautious interpretation of lumen definition is war- ranted. Although contrast-enhanced MRA of the extracranial arteries appears to be better at defining the degree of stenosis than the time-of- Chapter 9 Neuroimaging in Acute Ischemic Stroke 175 flight MRA technique (131,132), assessment of the intracranial vessels with contrast is limited due to venous contamination. However, while it may be possible to overcome this limitation with new technical development including ultrafast imaging techniques and better timing of the arrival of contrast, data regarding its accuracy has not yet been defined (133). Whether MRA can provide screening for future thrombolytic/interven- tional approaches remains to be seen. Summary of Evidence: Due to the low incidence of stroke in the pediatric population, few studies are available regarding risk factors, recurrence, and outcome. Moreover, the efficacy of acute therapies has not been exam- ined in this population, limiting the utility of acute neuroimaging in pedi- atric stroke for early therapeutic decision making. Supporting Evidence: In contrast to stroke in the adult population, pediatric stroke is an uncommon disorder with a very different pathophysiology. The overall incidence of ischemic stroke is 2 to 13 per 100,000 children, with the highest rate occurring in the perinatal period (26. The incidence of ischemic stroke has increased over the past two decades, probably due to better population-based studies (the Canadian Pediatric Stroke Registry), more sensitive imaging tech- niques (fetal MR, DWI), and an increased survival of immature neonates due to improved treatment modalities (extracorporeal membrane oxy- genation). The etiologies of ischemic stroke in children are due to nonath- erosclerotic causes such as congenital heart disease, sickle cell anemia, coagulation disorders, arterial dissection, varicella zoster infection, inher- ited metabolic disorders, and moyamoya, and is found to be idiopathic in one third of the cases (134,135). To date, there are no randomized clinical trials for the treatment of acute ischemic stroke in the pediatric population. Indeed, there is only one published randomized controlled trial for stroke prevention [the Stroke Prevention Trial (STOP) in Sickle Cell Anemia], which showed that blood transfusions greatly reduced the risk of stroke in children with sickle cell anemia who have peak mean blood flow velocities greater than 200cm per second measured by transcranial Doppler ultrasonography in the ICA or proximal MCA (strong evidence) (136). Though there is no Food and Drug Administration (FDA)-approved treatment for children with acute ischemic stroke, several case reports have documented the use of intravenous tPA in this setting (insufficient evidence) (137– 139). The lack of proven therapeutic interventions for acute pediatric stroke limits the utility of acute neuroimaging for early therapeutic decision making. However, the diagnosis and differentiation of stroke subtypes may still be important for preventative measures. This is true especially in neonates and infants, where neurologic deficits may be subtle and difficult to ascertain. In this regard, MRI (with T1W, T2W, FLAIR, as well as DWI) may be superior to CT in the early identification of ischemic lesions and exclusion of stroke mimics (extrapolated from adult data). Diagnostic performance for patients presenting with acute neurological deficits Sensitivity Specificity Reference Evidence Acute intraparenchymal hemorrhage (<6 hours) CT 100%* 100%* * MRI 100% 100% 61 Strong Acute subarachnoid hemorrhage (<12 hours) CT 98–100% 16,17 Moderate MRI (FLAIR) 92–100% 100% 28–30 Limited Acute ischemic infarction (<6 hours) CT 61% 65% 9 Moderate MRI 91% 95% 9 Moderate * Although the exact sensitivity or specificity of CT for detecting intraparenchymal hemor- rhage is unknown (limited evidence), it serves as the gold standard for detection in compari- son to other modalities. Acute Imaging Protocols Based on the Evidence Head CT: indicated for all patients presenting with acute focal deficits Noncontrast examination Sequential or spiral CT with 5-mm slice thickness from the skull base to the vertex Head MR: indicated if stroke is in doubt Axial DWI (EPI) with ADC map, GRE, or ep T2*, FLAIR, T1W Optional sequences (insufficient evidence for routine clinical practice): MRA of the circle of Willis (3D TOF technique) PWI (EPI FLASH, 12 slices per measurement for 40 measurements, with 10- to 15-sec injection delay, injection rate of 5cc/sec with single or double bolus of gadolinium, followed by a 20-cc saline flush) Axial T1W postcontrast Areas of Future Research • Use of neuroimaging to select patients for acute therapies: Imaging the ischemic penumbra to extend the empirically determined therapeutic windows for certain individuals Predict individuals at high risk for hemorrhagic conversion As more therapies are made available, neuroimaging has the potential to help determine which modality might be most efficacious (e. What is the role of imaging in patients with headache and subarachnoid hemorrhage suspected of having an intracranial aneurysm? What is the recommended neuroimaging examination in adults with headache and known primary neoplasm suspected of having brain metastases? What is the sensitivity and specificity of computed tomography and magnetic resonance imaging? Key Points In adults, benign headache disorders usually start before the age of 65 years. Although most headaches in children are benign in nature, a small percentage is caused by serious diseases, such as brain neoplasm. Computed tomography (CT) imaging remains the initial test of choice for (1) new-onset headache in adults and (2) headache suggestive of subarachnoid hemorrhage (limited evidence). Neuroimaging is recommended in adults with nonacute headache and unexplained abnormal neurologic examination (moderate evidence). The sensitivity of these two examinations drops signifi- cantly for aneurysms less than 5mm (moderate evidence). In adults with headache and known primary neoplasm suspected of having brain metastatic disease, MR imaging with contrast is the neuroimaging study of choice (moderate evidence).

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People who have primary symptoms sometimes also suffer from problems that are only indirectly caused by the disease; these are called secondary symptoms buy generic januvia 100mg on line diabetic diet understanding. For example buy generic januvia 100mg online diabetes symptoms child, some people who are weak and stiff develop decreased movement at the joints, which are called contractures, and immobility can lead to osteoporosis or skin breakdown. Chronic disease may lead to changes in how one looks at life and tackles life’s stresses. Thus, to really tackle MS, the disease process should be modi- fied whenever it is possible to do so; the symptoms of the disease should be managed to allow better function; and the person with the disease should be helped to improve his or her quality of life. Part of the reason that fatigue is so common and potentially disabling relates to the fact that many different kinds of fatigue are experienced by people with MS, and it is possi- ble to have none or all of the forms at the same time. Obviously, MS does not protect you from the normal fatigue that anyone else may experience. However, a person with MS some- times may have a "short-circuiting" type of fatigue. The limb will recover when the arm or leg is rested, but it may be both- ersome when activities require its ongoing use. Repeatedly asking the demyelinated nerve to perform when it is repeatedly short-cir- cuiting causes fatigue. The judicious use of aerobic exercise (see Chapter 20) may help build endurance, if not strength, and thus may decease this form of fatigue. However overexercising with weights increases both fatigue and weakness, so a careful balance must be sought. Management strategies include the appropriate use of exercise and rest, with the understanding that "no pain, no gain" is simply 25 PART II • Managing MS Symptoms wrong and that rest should come before short-circuiting fatigue becomes significant. The appropriate management strategy for this type of fatigue is exercise and maintaining of mobility. Depression (see also Chapter 22) may be associated with MS and may cause sig- nificant fatigue. This may result from not eating or sleeping well, or it may be associated with a general feeling of depression. It should be managed by aggressively treating the depression with medica- tion and counseling. This form of fatigue likely is bio- chemical in origin, and medications that modify brain chemistry may be helpful. Amantidine (Symmetrel®) is an example of a med- ication that affects the nervous system and also has antiviral effects. The antidepressants, including fluoxetine (Prozac®), paroxetine (Paxil®), and sertraline (Zoloft®), may be useful for this type of fatigue, even in those who are not depressed. These med- ications may not be interchangeable, with one working better for one person and a different one for another. Lassitude is a bother- some form of fatigue because a person may look well and yet not be able to function. A new, novel medication, modafinil (Provigil®) has been shown to decrease MS fatigue and has become a com- monly used treatment for this problem. Its mode of action is not clear but it does work by altering the brain’s neurochemistry. It has a potential side effect of agitation, which should be reported to your physician immediately. These include pemoline (Cylert®), methylphenidate (Ritalin®), and occa- sionally dextroamphetamine (Dexedrine®). These medications 26 CHAPTER 3 • Fatigue should be used with caution because they may be habit-forming and may lead to agitation. The management strategy for this form of fatigue includes rest and the use of antidepressant and stimulant medications. Even though fatigue is common and potentially disabling, it is clear that people who have MS are not fragile. Although rest may be helpful, the idea that fatigue leads to increased demyelination has not been proven.

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He recognised that doctors did not have ready access to reliable reviews of available evidence order 100mg januvia visa diabetes type 1 jewelry. In a 1979 article he said: ‘It is surely a great criticism of our profession that we have not organised a critical Te Cochrane Collaboration summary discount 100 mg januvia with visa blood glucose greater than 400, by speciality or subspeciality, adapted periodically, of all relevant was found in response to randomised controlled trials. Random Reflections on Health Services, In the early 1990s, funds were Nuffield Provincial Hospital Trust, London (reprinted in 1989 in association with the provided by the UK National British Medical Journal). Te approach was further outlined at an international meeting organised by the New York Academy of Sciences in 1993 and at the first Cochrane Cochrane proposed that researchers and practitioners should collaborate Colloquium in October internationally to systematically review all the best clinical trials (that is, 1993, when ‘Te Cochrane randomised controlled trials, or RCTs), specialty by specialty. Systematic reviews of RCTs of different aspects of obstetric care soon Cochrane logo produced with showed some anomalies between the clinical trial evidence and established permission from Te Cochrane practice. Tis highlighted the gaps that existed between research and clinical Collaboration practice and started to convince some doctors of the benefits of an evidence- based approach to bridge this gap. Tis database, which we will be looking at in detail later in the workshop, is available free online in many countries: http://www. CORTICOSTEROIDS FOR PRETERM BIRTH 1972 A RCT was reported showing improved outcomes for preterm babies when mothers were given a short course of corticosteroid before the birth. During this time, most obstetricians were still unaware that corticosteroid treatment was so effective and so did not treat women about to give birth early with corticosteroids. Corticosteroid treatment reduces the odds of babies dying from complications of immaturity by 30 to 50% but thousands of babies have died or suffered unnecessarily since 1972 because doctors did not know about the effectiveness of the treatment. In 1979, the inventor of the defibrillator, Bernard Lown, pointed out in an address to the American College of Cardiology that one of the biggest causes of death was heart attack, particularly among young and middle-aged men (20–64-year-olds). He suggested that a ‘safe and long-acting antiarrhythmic drug that protects against ventricular fibrillation’ would save millions of lives. In response to this challenge, a paper was published in the New England Journal of Medicine introducing a new drug called flecainide — a local anaesthetic derivative that suppresses arrhythmia. Te paper described a study in which patients who had just had heart attacks randomly received placebo or flecainide and were then switched from one to the other (a cross-over trial). Te researchers counted the number of preventricular contractions (PVCs) as a measure of arrhythmias. When the flecainide patients were ‘crossed over’ to the placebo, the PVCs increased again. Suppression of arrythmias in 9 patients (PVCs = preventricular contractions) 50 45 40 35 30 25 20 15 10 5 0 Placebo Flecainide Placebo Flecainide Te conclusion was straightforward: flecainide reduces arrythmias and arrythmias cause heart attacks (the mechanism); therefore, people who have had heart attacks should be given flecainide. Te results were published in the New England Journal of Medicine and flecainide was approved by the United States Food and Drug Adminstration and became fairly standard treatment for heart attack in the United States (although it did not catch on in Europe or Australia). Tis showed that over raises two important issues: the 18 months following treatment, more than 10% of people who were given flecainide died, which was double the rate of deaths among a placebo group. In other words, up- Cardiac arrythmia suppression trial (CAST) to-date, good-quality research findings need to be available to all 100 medical practitioners on a routine basis. We must 90 move away from a flecaininde traditional mechanistic approach and look 85 for empirical evidence of effectiveness using 80 a clinically relevant 0 200 400 600 outcome (eg survival, improved quality of life). Days Unfortunately, because the initial studies had been widely published in medical texts, it was a long time before doctors caught up with the subsequent poor outcome data, which did not attract as much attention. Meanwhile, about 200,000 people were being treated with flecainide in the United States by 1989. Based on the trial evidence, this would have caused tens of thousands of additional heart attack deaths due to the use of flecainide. Although there References (flecainide): was published information, doctors were systematically killing people with Anderson JL, Stewart JR, Perry BA et flecainide because they did not know about the good quality outcome-based al (1981). Echt DS, Liebson PR, Mitchell LB et al In the flecainide example, the initial research was widely disseminated because (1991). Mortality and morbidity it was based on a traditional mechanistic approach to medicine and because in patients receiving ecainide, it offered a ‘cure’. Te Cardiac widely disseminated because it was counterintuitive and negative in terms Arrythmia Suppression Trial. Doctors continued to prescribe flecainide because England Journal of Medicine 324: they believed that it worked. However, most medical practitioners, particularly GPs, are overloaded with A book by physician and information.

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Single pho- ton emission computed tomography in the diagnosis of inflammatory spondyloarthropathies generic januvia 100 mg with amex diabetes 76. Early recognition of sacroiliitis by magnetic resonance imaging and single photon emission computed tomography discount januvia 100 mg on line diabetes symptoms glucose in urine. Com- parison of bone scan, computed tomography, and magnetic resonance im- aging in the diagnosis of active sacroiliitis. Early sacroiliitis in patients with spondyloarthropathy: evaluation with dy- namic gadolinium-enhanced MR imaging. Bollow M, Braun J, Taupitz M, Haberle J, Reibhauer BH, Paris S, Mutze S, Seyrekbasan F, Wolf KJ, Hamm B. CT-guided intraarticular corticosteroid injection into the sacroiliac joints in patients with spondyloarthropathy: in- dication and follow-up with contrast-enhanced MRI. Braun J, Bollow M, Seyrekbasan F, Haberle HJ, Eggens U, Mertz A, Dis- tler A, Sieper J. Computed tomography guided corticosteroid injection of the sacroiliac joint in patients with spondyloarthropathy with sacroiliitis: clinical outcome and followup by dynamic magnetic resonance imaging. The diagnosis and treatment of sacroiliac condi- tions involving injection of procaine (Novocaine). Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Vresilovic EJ, Lenrow DA, Braverman DL. Fluoroscopically guided therapeutic sacroiliac joint in- jections for sacroiliac joint syndrome. Efficacy of cor- ticosteroid injections in patients with inflammatory spondyloarthropathy: results of a six-month controlled study. Pereira PL, Gunaydin I, Trubenbach F, Dammann F, Remy CT, Kotter I, Schick F, Koenig CW, Claussen CD. Interventional MR imaging for injec- tion of sacroiliac joints in patients with sacroiliitis. Computerized tomographic lo- calization of clinically-guided sacroiliac joint injections. Viscosupplementation: a new concept in the treatment of sacroiliac joint syndrome: a preliminary report of four cases. Mathis Vertebroplasty is a term that describes a surgical therapy that has been performed as an open operative procedure for decades, using bone graft, cement, or metal implants to modify or reconstruct damaged or destroyed vertebra. In 1993, PV was introduced into the United States at the University of Virginia by Dion and colleagues (Jensen, DeNardo, and Mathis). These investigators focused their work primarily on osteoporotic com- pression fractures and subsequently provided the first clinical series from the United States in which PV was used. Since that time, the procedure has grown in popularity and is now becoming the standard of care for pain pro- duced by osteoporotic compression fractures of the spine. Percutaneous vertebroplasty is indicated in patients who exhibit pain resulting from vertebral compression fractures (VCFs) that are due to the weakening associated with bone mineral loss secondary to osteo- porosis and who are not effectively treated by medical or conservative therapy (i. Recent data reveal that vertebral compression fractures are associated with an increased mortality of 25 to 30% compared with age-matched controls. These fractures can be associated with primary malignant or metastatic lesions, myeloma, and with ag- gressive benign tumors such as hemangiomas. Painful compression fractures may have a clinical picture similar to that of the osteoporotic variety. If the etiology is in question, biopsy should precede or ac- company the PV, which will not alter or impair other therapeutic mea- sures such as chemotherapy or radiotherapy. The risk of cement leak is higher with a tumor etiology for VCF than with osteoporosis, gener- ally because the vertebra is less intact. The risk of significant cement leak (or tumor extrusion by the cement) is increased with destruction of the posterior wall of the vertebra. With tumor extension into the spinal canal (even without symptoms), PV will have a high risk of cre- ating or exacerbating neural compression and should generally be avoided. Patient Workup and Selection Some osteoporotic fractures may generate only mild pain, or there may be a rapid decrease in the initially severe pain after VCF. However, persistent pain that limits the activities of daily living or requires narcotic analgesics (with or without hospitalization) may be rapidly diminished with the use of PV.

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