Use of lumbar ultrasonography to detect occult spinal dysraphism

2012 ◽  
Vol 9 (3) ◽  
pp. 274-279 ◽  
Author(s):  
Joshua J. Chern ◽  
Jennifer L. Kirkman ◽  
Chevis N. Shannon ◽  
R. Shane Tubbs ◽  
Jeffrey D. Stone ◽  
...  
Keyword(s):  
Congenital Anomalies ◽  
Spinal Dysraphism ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Care Providers ◽  
Occult Spinal Dysraphism ◽  
Fetal Ultrasonography ◽  
Tertiary Referral Center ◽  
Private Practitioners ◽  
Skin Tag

Object Various cutaneous stigmata and congenital anomalies are accepted as sufficient reasons to perform lumbar ultrasonography as a screening tool to rule out occult spinal dysraphism (OSD). The purpose of this study was to correlate presenting cutaneous findings with lumbar ultrasonography results based on a large number of lumbar ultrasonography tests obtained by regional primary care providers. Methods Over the course of 5 years, 1273 infants underwent lumbar ultrasonography screening at a major pediatric tertiary referral center. Of these infants, 1116 had adequate documentation for retrospective chart review. Referral sources included urban academic, urban private practice, and surrounding rural private practitioners. Presence of cutaneous stigmata and/or congenital anomalies and lumbar ultrasonography results were reviewed for all patients. When present, surgical findings were reviewed. Results A total of 943 infants were referred for presumed cutaneous stigmata, the most common of which was a sacral dimple (638 patients [68%]) followed by hairy patch (96 patients [10%]). Other reported cutaneous findings included hemangioma, deviated gluteal fold, skin tag, and skin discoloration. In comparison, 173 patients presented with congenital anomalies, such as imperforate anus (56 patients [32%]) and tracheoesophageal fistula/esophageal atresia (37 patients [21%]), most of which were detected prenatally by fetal ultrasonography. A total of 17 infants underwent surgical exploration. Occult spinal dysraphism was diagnosed in 7 infants in the cutaneous stigmata group and in 10 infants in the group with congenital abnormalities. None of the cutaneous stigmata as recorded were found to be indicative of the presence of OSD. Conclusions Cutaneous markers as currently defined by general practitioners are not useful markers for predicting OSD. The vast majority of findings on lumbar ultrasonography studies performed under these circumstances will be negative.

The Effect of Triage Assessments on Identifying Inflammatory Arthritis and Reducing Rheumatology Wait Times in Ontario

2019 ◽  
Vol 47 (3) ◽  
pp. 461-467 ◽  
Author(s):  
Vandana Ahluwalia ◽  
Sydney Lineker ◽  
Raquel Sweezie ◽  
Mary J. Bell ◽  
Tetyana Kendzerska ◽  
...  
Keyword(s):  
Usual Care ◽  
Inflammatory Arthritis ◽  
Retrospective Chart Review ◽  
Wait Time ◽  
Primary Care Providers ◽  
Educational Process ◽  
Wait Times ◽  
Control Group ◽  
Care Providers ◽  
Improve Access

Objective.We evaluated the influence of triage assessments by extended role practitioners (ERP) on improving timeliness of rheumatology consultations for patients with suspected inflammatory arthritis (IA) or systemic autoimmune rheumatic diseases (SARD).Methods.Rheumatologists reviewed primary care providers’ referrals and identified patients with inadequate referral information, so that a decision about priority could not be made. Patients were assessed by an ERP to identify those with IA/SARD requiring an expedited rheumatologist consult. The time from referral to the first consultation was determined comparing patients who were expedited to those who were not, and to similar patients in a usual care control group identified through retrospective chart review.Results.Seven rheumatologists from 5 communities participated in the study. Among 177 patients who received an ERP triage assessment, 75 patients were expedited and 102 were not. Expedited patients had a significantly shorter median (interquartile range) wait time to rheumatologist consult: 37.0 (24.5–55.5) days compared to non-expedited patients [105 (71.0–135.0) days] and controls [58.0 (24.0–104.0) days]. Accuracy comparing the ERP identification of IA/SARD to that of the rheumatologists was fair (κ 0.39, 95% CI 0.25–0.53).Conclusion.Patients triaged and expedited by ERP experienced shorter wait times compared to usual care; however, some patients with IA/SARD were missed and waited longer. Our findings suggest that ERP working in a triage role can improve access to care for those patients correctly identified with IA/SARD. Further research needs to identify an ongoing ERP educational process to ensure the success of the model.

Inpatient infusion treatments of headache in patients with chronic migraine and a reported history of head trauma and endocrine co-morbidities

Neurology ◽  
2020 ◽  
Vol 95 (20 Supplement 1) ◽  
pp. S14.2-S14
Author(s):  
Nina Yakovlevna Riggins ◽  
Henna Sawhney ◽  
Annika Ehrlich ◽  
Mira Parekh ◽  
Morris Levin
Keyword(s):  
Primary Care ◽  
Chronic Migraine ◽  
Head Trauma ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Infusion Therapy ◽  
Case Conference ◽  
Care Providers ◽  
Lifestyle Modifications ◽  
History Of

ObjectiveTo evaluate if inpatient infusion treatments for patients with chronic migraine (CM) and history of head trauma and endocrine abnormalities can lead to headache improvement.BackgroundMany patients with CM and history of head trauma have endocrine co-morbidities that can interfere with successful management of headache. In this study, we evaluated if inpatient infusion treatments improved headache outcomes for this patient population.Design/MethodsRetrospective chart review of patients admitted and treated with 4–5 days of intravenous (IV) Dihydroergotamine (DHE), Chlorpromazine, or Valproate for headache. All cases were presented at the Headache Center Case Conference before admission, and plans for addressing co-morbidities were discussed with appropriate specialists and primary care providers. Co-morbidities addressed included diabetes mellitus, pituitary and thyroid dysfunction and endometriosis. During admission, vital signs and appropriate lab work such as serum glucose, thyroid, liver and renal function were monitored. Lifestyle recommendations provided during admission and appropriate follow ups after discharge were arranged with Headache Clinic, primary care, and specialists, when applicable.Results53 patients with CM were included in the analysis. 12 (22.6%) of the 53 patients had both reported history of head trauma and endocrine comorbidity. Of these 12 patients, 8 (66.7%) had improvement in headache up to 6 weeks after admission. Of the 8 that improved, 6 (75%) received DHE and 2 (25%) received Chlorpromazine.ConclusionsInpatient infusion treatments for patients who have CM with history of head trauma and endocrine abnormalities can lead to headache improvement, potentially due to IV infusion therapy along with holistic approaches which include addressing co-morbidities and education on lifestyle modifications. Future studies are needed to evaluate if specific endocrine system dysfunction can predict outcomes from repetitive infusion therapy for persistent headache in patients with CM and a reported history of head trauma.

scholarly journals Use of magnetic resonance imaging to detect occult spinal dysraphism in infants

2017 ◽  
Vol 19 (2) ◽  
pp. 217-226 ◽  
Author(s):  
Brent R. O'Neill ◽  
Danielle Gallegos ◽  
Alex Herron ◽  
Claire Palmer ◽  
Nicholas V. Stence ◽  
...  
Keyword(s):  
Congenital Anomalies ◽  
Imaging Modality ◽  
Spinal Dysraphism ◽  
Sinus Tract ◽  
Conus Medullaris ◽  
Dermal Sinus ◽  
Occult Spinal Dysraphism ◽  
Disc Space ◽  
Dermal Sinus Tract ◽  
Study Population

OBJECTIVE Cutaneous stigmata or congenital anomalies often prompt screening for occult spinal dysraphism (OSD) in asymptomatic infants. While a number of studies have examined the results of ultrasonography (US) screening, less is known about the findings when MRI is used as the primary imaging modality. The object of this study was to assess the results of MRI screening for OSD in infants. METHODS The authors undertook a retrospective review of all infants who had undergone MRI of the lumbar spine to screen for OSD over a 6-year period (September 2006–September 2012). All images had been obtained on modern MRI scanners using sequences optimized to detect OSD, which was defined as any fibrolipoma of the filum terminale (FFT), a conus medullaris ending at or below the L2–3 disc space, as well as more complex lesions such as lipomyelomeningocele (LMM). RESULTS Five hundred twenty-two patients with a mean age of 6.2 months at imaging were included in the study. Indications for imaging included isolated dimple in 235 patients (45%), asymmetrically deviated gluteal cleft in 43 (8%), symmetrically deviated (Y-shaped) gluteal cleft in 38 (7%), hemangioma in 28 (5%), other isolated cutaneous stigmata (subcutaneous lipoma, vestigial tail, hairy patch, and dysplastic skin) in 31 (6%), several of the above stigmata in 97 (18%), and congenital anomalies in 50 (10%). Twenty-three percent (122 patients) of the study population had OSD. Lesions in 19% of these 122 patients were complex OSD consisting of LMM, dermal sinus tract extending to the thecal sac, and lipomeningocele. The majority of OSD lesions (99 patients [81%]) were filar abnormalities, a group including FFT and low-lying conus. The rate of OSD ranged from 12% for patients with asymmetrically deviated gluteal crease to 55% for those with other isolated cutaneous stigmata. Isolated midline dimple was the most common indication for imaging. Among this group, 20% (46 of 235) had OSD. There was no difference in the rate of OSD based on dimple location. Those with OSD had a mean dimple position of 15 mm (SD 11.8) above the coccyx. Those without OSD had a mean dimple position of 12.2 mm (SD 19) above the coccyx (p = 0.25). CONCLUSIONS The prevalence of OSD identified with modern high-resolution MRI screening is significantly higher than that reported with US screening, particularly in patients with dimples. The majority of OSD lesions identified are FFT and low conus. The clinical significance of such lesions remains unclear.

scholarly journals Pharmacist-Led Provider Education on Inappropriate NSAID Prescribing Rates

2020 ◽  
Vol 52 (8) ◽  
pp. 592-596
Author(s):  
Jangus B. Whitner ◽  
Nicole A. Fabiili ◽  
Jordan Siewart ◽  
Karen Akasaka ◽  
Anna Nelson
Keyword(s):  
High Risk ◽  
Family Medicine ◽  
Inappropriate Prescribing ◽  
High Risk Patient ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Prescribing Patterns ◽  
Care Providers ◽  
Provider Education ◽  
The Impact

Background and Objectives: Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used pain medications among US adults with about 70 million people regularly taking NSAIDs annually. Despite clear recommendations from current clinical practice guidelines and recent supporting literature, NSAIDs are continually prescribed inappropriately in patients with chronic kidney disease (CKD), hypertension (HTN), and heart failure (HF). The purpose of this project was to determine the impact of direct pharmacist-led education to providers on rates of inappropriate prescribing of NSAIDs in high-risk populations in a family medicine setting. Methods: This study included all adult (aged 18 years or older) patient charts with NSAIDs prescribed, refilled, or recorded within the specified time periods. We defined inappropriate orders as oral and of chronic duration (at least 90 days) with at least one high-risk International Classification of Diseases-10 chart diagnosis (HTN, HF, CKD). This was a single-center, retrospective chart review of prescribing rates during a 3-month period before and after provider education delivered by a pharmacist. Results: We identified a total of 325 charts from preintervention and 489 charts postintervention that met inclusion criteria. Of those, the charts with orders categorized as inappropriate were 90 versus 44, respectively. The rate of inappropriate prescribing of NSAIDs significantly decreased from 27.7% to 9.0% (P<.0001) postintervention. Among chronic NSAID users, both serum creatinine and systolic blood pressure significantly increased following NSAID initiation. Conclusions: A single pharmacist-led education intervention to primary care providers on inappropriate NSAID use in high-risk patient populations had a significant impact on minimizing inappropriate NSAID prescribing patterns within a family medicine outpatient office.

Referral Patterns To Pediatric Pulmonology For Asthma-Like Symptoms

2021 ◽  
Author(s):  
Tory A. Prynn ◽  
Gretchen Garland ◽  
Lucia Mirea ◽  
Rupali Drewek
Keyword(s):  
Health Care Quality ◽  
Asthma Management ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Care Quality ◽  
Specialty Care ◽  
Care Providers ◽  
Asthma Diagnosis ◽  
Patients Âgés ◽  
Pediatric Pulmonology

Abstract Background: The decision to refer a sick child to a pediatric specialist is important for health care quality, however access to specialty care is worsening. Referrals from primary to specialty care are a critical first step in coordinating specialty care, but there are often shortcomings in the appropriateness, clarity, and completeness of referrals. This study aimed to characterize referrals for asthma-like symptoms to a pediatric pulmonology clinic, evaluate consult interventions, and identify opportunities for improving access. Methods: A retrospective chart review examined patients ages 5-18 years, referred to the pulmonology clinic at Phoenix Children’s Hospital between July 2016 and July 2019. Descriptive statistics summarized demographics, prior asthma diagnosis, ICS use and compliance, reason for referral and intervention during consult. An appropriate referral was defined as prior asthma and ICS Step 3. Results: The total 171 study subjects had mean (standard deviation) age of 9.4 (3.8) years, with 100 (58%) males, and prior asthma diagnosis in 105 (61%). The most common reason for pulmonology referral was asthma in 90 (53%) patients, of which 70 (78% of 90) had prior asthma. Among 105 patients with asthma, 79 (76%) had a history of ICS, with 33 (42% of 79) patients reporting spacer compliance issues. The rate of appropriate referrals was 0.11 (95% confidence interval: 0.06-0.16). During the pulmonology consult, nearly half 10 (53%) of 19 patients appropriately referred received an ICS step up. Among 151 inappropriate referrals, ICS was initiated for 91 (60%) and increased for 45 (30%). Education was provided to all patients during pulmonology consult. Conclusions: Mild-to-moderate asthma can be effectively treated by primary care providers (PCPs) with implementation of ICS, thus prioritizing healthcare resource utilization by enabling the pulmonologist to see higher acuity patients sooner. Further study is warranted to identify strategies and tools for PCPs to optimize asthma management.

scholarly journals Assessing the utility of screening electrocardiograms in pediatric patients following COVID-19

2021 ◽  
pp. 1-19
Author(s):  
Ari J. Gartenberg ◽  
Travus J. White ◽  
Khoi Dang ◽  
Maully Shah ◽  
Stephen M. Paridon ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Stress Test ◽  
Severe Disease ◽  
Retrospective Chart Review ◽  
Exercise Stress Test ◽  
Primary Care Providers ◽  
Exercise Stress ◽  
Care Providers ◽  
Premature Ventricular Contractions ◽  
Small Cohort

Abstract Objective: To determine the utility of screening electrocardiograms after SARS-CoV-2 infection among pediatric patients in detecting myocarditis related to COVID-19. Study Design: A retrospective chart review was performed at a large pediatric academic institution to identify patients with prior SARS-CoV-2 infection who received a screening electrocardiogram by their primary care providers and were subsequently referred for outpatient cardiology consultation due to an abnormal electrocardiogram. The outcomes were the results from their cardiology evaluations, including testing and final diagnoses. Results: Among 46 patients, during their preceding COVID-19 illness, the majority had mild symptoms, four were asymptomatic, and one had moderate symptoms. The median length of time from positive SARS-CoV-2 test to screening electrocardiogram was 22 days, and many electrocardiogram findings that prompted cardiology consultation were normal variants in asymptomatic adolescent athletes. Patients underwent frequent additional testing at their cardiology appointments: repeat electrocardiogram (72%), echocardiogram (59%), Holter monitor (11%), exercise stress test (7%), and cardiac MRI (2%). Five patients were incidentally diagnosed with congenital heart disease or structural cardiac abnormalities, and three patients had conduction abnormalities (premature atrial contractions, premature ventricular contractions, borderline prolonged QTc), although potentially incidental to COVID-19. No patients were diagnosed with myocarditis or ventricular dysfunction. Conclusion: In a small cohort of pediatric patients with prior COVID-19, who were primarily either asymptomatic or mildly symptomatic, subsequent screening electrocardiograms identified various potential abnormalities prompting cardiology consultation, but no patient was diagnosed with myocarditis. Larger multi-center studies are necessary to confirm these results and to evaluate those with more severe disease.

Currarino syndrome and spinal dysraphism

2014 ◽  
Vol 13 (6) ◽  
pp. 685-689 ◽  
Author(s):  
Matthew J. Kole ◽  
Jared S. Fridley ◽  
Andrew Jea ◽  
Robert J. Bollo
Keyword(s):  
Imperforate Anus ◽  
Congenital Anomalies ◽  
Rare Case ◽  
Spinal Dysraphism ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Presacral Mass ◽  
Occult Spinal Dysraphism ◽  
Spinal Lipoma ◽  
Currarino Syndrome

Currarino syndrome is a rare constellation of congenital anomalies characterized by the triad of sacral dysgenesis, presacral mass, and anorectal malformation. It is frequently associated with other congenital anomalies, often including occult spinal dysraphism. Mutations in the MNX1 gene are identified in the majority of cases. The authors report a rare case of Currarino syndrome in an infant with tethered cord syndrome and a dorsal lipomyelomeningocele continuous with a presacral intradural spinal lipoma, in addition to an imperforate anus and a scimitar sacrum. They review the literature to highlight patterns of occult spinal dysraphism in patients with Currarino syndrome and their relationship to tethered cord syndrome. Approximately 60% of the patients with Currarino syndrome reported in the literature have an occult spinal dysraphism. Published studies suggest that the risk of tethered cord syndrome may be higher among patients with a lipoma and lower among those with a teratoma or anterior meningocele.

scholarly journals 2077. Fluoroquinolone Usage Reduction in the Outpatient Setting

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S700-S700
Author(s):  
Kevin Lin ◽  
Yorgo Zahlanie ◽  
Jessica Ortwine ◽  
Norman Mang ◽  
Wenjing Wei ◽  
...  
Keyword(s):  
Inappropriate Prescribing ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Outpatient Setting ◽  
Urgent Care ◽  
System Level ◽  
Outpatient Clinics ◽  
Resistant Organism ◽  
Care Providers ◽  
Provider Education

Abstract Background Fluoroquinolones (FQs) are the third most commonly prescribed outpatient antibiotic due to ease of dosing, broad spectrum of activity, and favorable pharmacokinetics. However, since 2016, the Food and Drug Administration (FDA) has released warnings about adverse effects, concluding that risks outweigh benefits especially for uncomplicated sinusitis, bronchitis, and cystitis. In fall 2016, our antimicrobial stewardship team began an initiative to decrease outpatient FQ usage involving provider education, addition of FDA warnings to oral FQ orders in Epic, and suppression of FQ susceptibilities. This evaluated the effectiveness of these initiatives in decreasing inappropriate outpatient FQ usage. Methods Retrospective chart review of FQ prescription was performed on all outpatient clinic, emergency department (ED), and urgent care emergency center (UCEC) visits during October 2016, 2017, and 2018. Inappropriate use was defined as an indication for cystitis, bronchitis, or sinusitis without a history of Pseudomonas aeruginosa or other multi-drug-resistant organism, or drug allergies precluding the use of non-FQs. Results 1,033 outpatient FQ prescriptions were reviewed. Total FQ prescribing decreased 34% from 405 in October 2016 to 267 in October 2018, with the proportion of inappropriate FQ use decreasing from 53% to 34%. Over 90% of the inappropriate FQ use was for cystitis. Inappropriate prescribing for cystitis and sinusitis decreased by 58% and 33%, respectively, but increased for bronchitis by 25%. The outpatient clinics, ED, and UCEC saw declines in the percentage of inappropriate FQ use of 10%, 15% and 22%, respectively, from October 2016 to October 2018. Despite these decreases, rates of inappropriate FQ utilization for the outpatient clinics, ED, and UCEC were 64%, 25%, and 31%, respectively, at the end of the last study period. Conclusion A multi-modal FQ stewardship initiative effectively reduced the volume of outpatient FQ utilization and inappropriate FQ usage. Continued efforts to educate providers about the risks of FQ use and implement system-level initiatives are likely necessary to improve the rates of appropriate use and sustain the effects demonstrated in this study, especially for primary care providers in the outpatient setting. Disclosures All authors: No reported disclosures.

Management Landscape of Pediatric Hidradenitis Suppurativa

2021 ◽  
pp. 1-4
Author(s):  
Justine R. Seivright ◽  
Erin Collier ◽  
Tristan Grogan ◽  
Terri Shih ◽  
Marcia Hogeling ◽  
...  
Keyword(s):  
Primary Care ◽  
Hidradenitis Suppurativa ◽  
Chart Review ◽  
Age Of Onset ◽  
Severe Disease ◽  
Retrospective Chart Review ◽  
Primary Care Providers ◽  
Care Providers ◽  
Delay In Diagnosis ◽  
Mean Delay

<b><i>Introduction:</i></b> Pediatric hidradenitis suppurativa (HS) is an understudied condition, and the literature describing the provider landscape for this disease is limited. We aim to characterize healthcare utilization in a cohort of pediatric HS patients at an academic institution. <b><i>Methods:</i></b> Patients diagnosed with HS before age 18 were identified via retrospective chart review using ICD-9/10 codes for HS. Data on demographics and HS providers were collected. <b><i>Results:</i></b> We found that half of the pediatric HS patients first presented to primary care with their HS symptoms. There was a mean delay in diagnosis of 2 years. Dermatologists and pediatricians were the principal HS care providers, and dermatologists most frequently prescribed treatment or procedures (63%). We also found a low rate of utilization of the HS specialty clinic (11%). Females, patients with more severe disease, and patients with earlier age of onset were more likely to be seen by a dermatologist. <b><i>Conclusions:</i></b> Dermatologists play a pivotal role in pediatric HS management as principal care providers for patients. Increasing HS awareness among primary care providers, including pediatricians, is critical for early diagnosis and initiation of treatment.

The accuracy of abnormal lumbar sonography findings in detecting occult spinal dysraphism: a comparison with magnetic resonance imaging

2012 ◽  
Vol 10 (2) ◽  
pp. 150-153 ◽  
Author(s):  
Joshua J. Chern ◽  
Baran Aksut ◽  
Jennifer L. Kirkman ◽  
Mohammadali M. Shoja ◽  
R. Shane Tubbs ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Patient Population ◽  
Spinal Dysraphism ◽  
Congenital Defects ◽  
Resonance Imaging ◽  
Occult Spinal Dysraphism ◽  
Tertiary Referral ◽  
Mri Findings ◽  
Tertiary Referral Center

Object The purpose of this study was to correlate lumbar ultrasound (LUS) and MRI findings in patients suspected of having occult spinal dysraphism (OSD). Methods Over a 5-year period, 1273 consecutive infants underwent an LUS study at a major pediatric tertiary referral center. Of these, 106 patients had abnormal LUS findings suggestive of an OSD, and 103 underwent subsequent MRI studies. The anatomical descriptions of the 2 studies were compared for agreement. Results The average age of the infants was 34 days at the time of the LUS study; OSD was suspected in these patients because of the presence of cutaneous stigmata and congenital defects. The most common anatomical descriptions from the LUS study included a thickened or fatty filum (32 cases), filum cyst (11 cases), and presence of a terminal ventricle or syrinx (9 cases). Using MRI findings as the standard reference, the sensitivity of LUS in detecting a thickened or fatty filum was 20%. The sensitivity of detecting an abnormal conus level at or below L-3 was 76.9%. Conclusions In the patient population chosen to undergo LUS studies, abnormal findings had poor sensitivity at detecting anatomical findings consistent with OSD.

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