Spinal Pathology and Muscle Morphologies with Chronic Low Back Pain and Lower Limb Amputation.

INTRODUCTION: Low back pain (LBP) is highly prevalent after lower limb amputation (LLA) and contributes to substantial reductions in quality of life and function. Towards understanding pathophysiological mechanisms underlying LBP after LLA, this article compares lumbar spine pathologies and muscle morphologies between individuals with LBP, with and without LLA. MATERIALS AND METHODS: We queried electronic medical records of Service members with and without LLA who sought care for LBP at military treatment facilities between January 2002 and May 2020. Two groups with cLBP, one with (n = 15) and one without unilateral transtibial LLA (n = 15), were identified and randomly chosen from a larger sample. Groups were matched by age, mass, and sex. Lumbar muscle morphology, Pfirrmann grades, Modic changes, facet arthrosis, Meyerding grades, and lordosis angle were determined from radiographs and magnetic resonance images available in the medical record. Independent t-tests compared variables between cohorts while multiple regression models determined if intramuscular fat influenced Pfirrmann grades. Chi-square determined differences in presence of spondylolysis and facet arthrosis. RESULTS: Lordosis angle was larger with LLA (P = 0.01). Spondylolysis was more prevalent with LLA (P = 0.008; 40%) whereas facet arthrosis was similar between cohorts (P = 0.3). Muscle area was not different between cohorts, yet intramuscular fat was greater with LLA (P ≤ 0.05). Intramuscular fat did not influence Pfirrmann grades (P > 0.15). CONCLUSIONS: Despite similar lumbar muscle size, those with unilateral LLA may be predisposed to progress to symptomatic spondylolisthesis and intramuscular fat. Surgical and/or rehabilitation interventions may mitigate long-term effects of diminished spinal health, decrease LBP-related disability, and improve function for individuals with LLA.

Lumbar Degenerative Disease and Muscle Morphology Before and After Lower Limb Loss in Four Military Patients.

INTRODUCTION: Low back pain (LBP) is highly prevalent after lower limb amputation (LLA). Reports describing longitudinal changes in spine health before and after amputation are rare. This study describes lumbar spine pathology, muscle morphology, and the continuum of care for LBP before and after LLA. MATERIALS AND METHODS: We queried electronic medical records of patients who sought care for LBP before and after unilateral LLA between January 2002 and April 2020 and who had documented lumbar imaging pre- and post-LLA. Patient demographics, muscle morphology, spinal pathology, premorbid and comorbid conditions, self-reported pain, and treatment interventions were assessed. RESULTS: Four patients with LBP and imaging before and after LLA were identified. Intervertebral disc degeneration progressed after amputation in three patients, whereas facet arthrosis progressed in both female patients. The fat content of lumbar musculature generally increased after amputation. Conservative management of LBP before and after amputation was standard, with progression to steroidal injections. CONCLUSIONS: Lumbar spine health may degrade after amputation. Here, lumbar muscle size did not change after LLA, yet the fat content increased in combination with increases in facet and intervertebral disc degeneration.

Academic oncology clinicians' understanding of biosimilars and information needed before prescribing.

BACKGROUND: With increasing numbers of oncology biosimilars in the approval pipeline, it is important to investigate oncology clinicians' understanding of biosimilars and what information they need prior to adoption. METHODS: Between January and May 2018, 77 oncology clinicians (52 physicians, 16 pharmacists, and 9 advanced practice providers) completed a survey covering three domains: clinician understanding, prescription preferences, and patient involvement. An in-depth interview was designed based on themes identified in the first 50 surveys: cost, safety and efficacy, patient preference, and disease stage. Participants were chosen to participate in the interview based on outlying responses to survey questions. RESULTS: When asked to define a biosimilar, 74% (57/77) of respondents could not give a satisfactory definition, and 40.3% (31/77) considered a biosimilar the same as a generic drug. The most important factor in biosimilar prescription was safety and efficacy (4.51 out of 5) followed closely by cost differences (4.34 out of 5). A 40% increase (53.2-94.8%) in clinicians' prescribing likelihood was seen after a biosimilar is designated as interchangeable. Participants in this study were split regarding the importance of shared decision-making with patients [50.7% (39/77) important or extremely important, 39.0% (30/77) somewhat or not at all important]. Clinicians were also split concerning the role that pharmacists should play in the decision to prescribe or substitute biosimilars. CONCLUSION: Understanding of biosimilars is low, and educational needs are high. The information that clinicians deem important to assess, such as safety, efficacy and cost, will need to be provided before they are comfortable prescribing biosimilars.

Caring for Colleagues and Loved Ones With Cancer.

Throughout the arc of a career in medicine, physicians are universally faced with the difficult decision of when to provide care for a colleague and when to refer to another physician. Gauging the magnitude of your relationship, both professionally and personally, and then weighing how to add the roles of physician and patient to your preexisting relationship is complex. We review and discuss care of family and colleagues, address ethical boundaries both firm and flexible, and explore the emotional weight of those relationships.