FentAnyl or placebo with KeTamine for emergency department rapid sequence intubation: The FAKT study protocol.

BACKGROUND: Some critically ill patients require rapid sequence intubation in the emergency department, and ketamine is one sedative agent employed, due to its relative haemodynamic stability. Tachycardia and hypertension are frequent side effects, and in less stable patients, shock can be unmasked or exacerbated. The use of fentanyl as a co-induction agent may lead to a smoother haemodynamic profile post-induction, which may lead to reduced mortality in this critically ill cohort. This randomised controlled trial aims to compare the effect of administering fentanyl vs placebo in a standardised induction regimen with ketamine and rocuronium on (a) the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction, (b) the laryngoscopic view, and (c) 30-day mortality. METHODS/DESIGN: Three hundred patients requiring rapid sequence intubation in participating emergency departments will be randomised to receive either fentanyl or placebo (0.9% saline) in addition to ketamine and rocuronium according to a standardised, weight-based induction regimen. The primary outcome measure is the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction. Secondary outcome measures include the laryngoscopic view, percentage of first pass success, 30-day mortality and number of ventilator-free days at 30 days. DISCUSSION: The effect of adding fentanyl to an induction regimen of ketamine and rocuronium will be evaluated, both in terms of post-intubation physiology, the effect on intubating conditions, and 30-day mortality.

Demystifying spasticity in primary care.

OBJECTIVE: To raise awareness of spasticity in primary care and clarify how to identify, diagnose, and manage it effectively and efficiently in patients with pre-existing neurologic conditions. SOURCES OF INFORMATION: PubMed was searched for articles published from 1970 to May 2018 using the terms spasticity, spasticity in physical disability, spasticity in mobility impairment, and spasticity with family medicine or primary care. Other relevant guidelines and resources were reviewed and used. MAIN MESSAGE: Spasticity is a common secondary complication in conditions such as spinal cord injury, multiple sclerosis, stroke, cerebral palsy, and other neuromuscular physical disabilities and can have a negative effect on health and quality of life. Factors such as inconsistent definition, poorly understood mechanism, and relatively low prevalence make spasticity seem like a daunting condition to manage. Furthermore, its variable presentation and effect on a patient's quality of life, and its range of treatments with varying levels of evidence, can make treatment challenging in primary care and in other clinical settings. Family physicians play an important role in recognizing and inquiring about spasticity and its changes, triggers, and effects on function. Ruling out reversible causes is important. Many management strategies can be instituted by family physicians. CONCLUSION: Managing spasticity might be unfamiliar to many practitioners. It is important for physicians to understand spasticity and the potential treatment options available to improve quality of life. The current review provides concise information on the clinical relevance of spasticity in primary care and how to assess and manage it effectively and efficiently in those with chronic neurologic conditions.

Degenerative cervical myelopathy: Diagnosis and management in primary care.

OBJECTIVE: To raise awareness about degenerative cervical myelopathy (DCM) and to help family physicians identify, diagnose, and manage DCM more effectively. SOURCES OF INFORMATION: A PubMed search was conducted for articles published between 1970 and October 2017, using the terms cervical myelopathy and degenerative spinal cord injury with family medicine or primary care. MAIN MESSAGE: Owing to limited knowledge of DCM in primary care, along with the large variability of the disease, the diagnosis of DCM is often missed or delayed. The natural course of DCM presents as a stepwise decline, with symptoms ranging from muscle weakness to complete paralysis. All individuals with signs and symptoms should be referred to a spine surgeon for consideration of surgery; those with mild DCM might be offered conservative treatment but should receive a surgical evaluation and opinion nonetheless. Asymptomatic patients with evidence of cord compression on magnetic resonance imaging might need to be referred for assessment; however, surgery is not advised. It is critical to closely monitor asymptomatic individuals or those with mild DCM for neurologic deterioration. CONCLUSION: Degenerative cervical myelopathy is the most common cause of spinal cord dysfunction in adults. This review helps streamline its diagnosis in primary care, allowing for improved chances of early diagnosis and prevention of further neurologic decline among patients.

Patients living with disabilities: The need for high-quality primary care.

OBJECTIVE: To compare the potential risk factors for lower-quality primary care, the potential markers of unmet needs in primary care, and the willingness to participate in future research among primary care patients with versus without physical disabilities. DESIGN: A waiting room survey using a convenience sample. SETTING: A family health team (FHT) in Kitchener-Waterloo, Ont, with a designated Mobility Clinic. PARTICIPANTS: A total of 40 patients seen at the FHT Mobility Clinic and 80 patients from the general patient population of the same FHT. MAIN OUTCOME MEASURES: Socioeconomic status and social capital, number of self-reported emergency department visits and hospitalizations in the preceding year, and willingness of the patients in the 2 groups to participate in future research studies. RESULTS: Patients from the Mobility Clinic were more than twice as likely to be receiving benefits or social assistance (75.0% vs 32.1%, P < .001), were twice as likely to report an annual household income of less than $40000 (58.6% vs 29.2%, P = .006), and were more likely to report their health status to be fair or poor (42.5% vs 16.2%, P = .002). Half of Mobility Clinic patients had visited the emergency department at least once in the preceding year, compared with 29.7% in the general patient population (P = .027). When asked if they would be willing to provide their health card number in the future so that it could be linked to health care data for research, 82.5% of Mobility Clinic patients agreed versus 55.0% of those in the general patient population (P = .004). CONCLUSION: In this study, patients with disabilities were at a social disadvantage compared with their peers without disabilities and were more likely to use the emergency department, suggesting that they had unmet health needs. Future research should continue to explore this patient population and to investigate if an interprofessional primary health care team approach focused on patients with disabilities can help to increase quality of care.

Démythifier la spasticité en première ligne.

OBJECTIF: Sensibiliser les généralistes à la spasticité en première ligne et éclaircir comment la dépister, poser un diagnostic et prendre en charge efficacement les patients atteints d'affections neurologiques préexistantes. SOURCES DE L'INFORMATION: Une recherche d'articles publiés entre 1970 et mai 2018 a été effectuée dans PubMed à l'aide des mots-clés anglais spasticity, spasticity in physical disability, spasticity in mobility impairment et spasticity with family medicine or primary care. D'autres lignes directrices et ressources pertinentes ont été examinées et utilisées. MESSAGE PRINCIPAL: La spasticité est une complication secondaire courante d'affections telles que le traumatisme de la moelle épinière, la sclérose en plaques, l'AVC, la paralysie cérébrale et autres déficiences physiques neuromusculaires; elle aurait des effets négatifs sur la santé et la qualité de vie. Certains facteurs, tels que la définition variable, les mécanismes non élucidés et la prévalence relativement faible, contribuent à la nature intimidante du traitement de la spasticité. En outre, son tableau clinique et ses effets variables sur la qualité de vie, ainsi que la gamme de traitements étayés par divers niveaux de données probantes, compliquent le traitement en première ligne et dans d'autres contextes cliniques. Les médecins de famille jouent un rôle de premier plan pour reconnaître la spasticité et s'informer de ses variations, de ses déclencheurs et de ses effets sur les capacités fonctionnelles. Il importe d'éliminer les causes réversibles. Les médecins de famille peuvent appliquer de nombreuses stratégies de prise en charge. CONCLUSION: Beaucoup de praticiens sont mal à l'aise avec la prise en charge de la spasticité. Les médecins doivent comprendre la spasticité et les options thérapeutiques potentielles qui pourraient améliorer la qualité de vie. Cette revue présente des renseignements concis sur la pertinence clinique de la spasticité en première ligne et sur la façon de la prendre en charge efficacement chez les personnes atteintes d'affections neurologiques chroniques.

Myélopathie cervicale dégénérative: Diagnostic et prise en charge en première ligne.

OBJECTIF: Sensibiliser les médecins de famille à la myélopathie cervicale dégénérative (MCD) afin de les aider à dépister, à diagnostiquer et à traiter la maladie de façon plus efficace. SOURCES DE L'INFORMATION: Une recherche d'articles publiés entre 1970 et octobre 2017 a été effectuée sur PubMed à l'aide des mots-clés anglais cervical myelopathy et degenerative spinal cord injury avec family medicine ou primary care. MESSAGE PRINCIPAL: Le diagnostic de MCD reste souvent omis ou retardé en première ligne en raison du peu de connaissances sur la maladie, de même que de la grande variabilité de ses manifestations. L'évolution naturelle de la MCD accuse un déclin par paliers, les symptômes allant d'une faiblesse musculaire à la paralysie complète. Toutes les personnes qui présentent des signes et des symptômes doivent être recommandées en chirurgie de la colonne vertébrale aux fins d'évaluation; les personnes dont le cas est léger peuvent recevoir un traitement prudent, mais doivent quand même recevoir une évaluation et une opinion chirurgicales. Les patients asymptomatiques qui présentent des signes de compression de la moelle épinière à l'imagerie par résonance magnétique devraient être recommandés aux fins d'évaluation; mais la chirurgie leur est déconseillée. Il est essentiel de surveiller de près les personnes asymptomatiques ou celles atteintes d'un cas léger de MCD afin de détecter toute détérioration neurologique. CONCLUSION: La myélopathie cervicale dégénérative est la cause la plus fréquente de dysfonctionnement de la moelle épinière chez les adultes. Cette révision aide à clarifier le diagnostic en première ligne, ce qui améliore les chances de poser un diagnostic précoce et de prévenir tout déclin neurologique supplémentaire chez les patients.

Screening and risk assessment for sleep-related breathing disorders in individuals living with spinal cord injury.

OBJECTIVES: This research work was performed: (1) To assess the accessibility of in-laboratory polysomnography for individuals with spinal cord injury (SCI); (2) to evaluate the validity of four screening questionnaires for sleep-related breathing disorders (SRBDs); and (3) to assess the association between anthropometric features and apnea-hypopnea index (AHI). METHODS: An Environmental scan (E-scan) was performed in the province of Ontario, where all sleep clinics were invited to complete the E-scan survey. Furthermore, a cross-sectional study was performed at a rehabilitation hospital (Canada), where consecutive adults with subacute/chronic (>1 month) SCI were recruited. Using a home-based screening sleep test (HBSST), the validity of the Berlin, STOP, Medical Outcomes Study Sleep Scale [MOS-SS], and STOP-Bang screening questionnaires was assessed. The association between AHI and three features (i.e., neck circumference, body mass index [BMI] and oropharynx opening as assessed using the Modified Mallampati classification [MMC]) was evaluated. RESULTS: According to the E-scan, access to polysomnography is limited for the SCI population in Ontario. Of the 28 participants with SCI (11 females, 17 males; mean age: 54.9 years) included in the cross-sectional study, 32.1 % were diagnosed with moderate-to-severe SRBD. The performance of the questionnaires was considered insufficient for screening of individuals living with SCI. AHI was not associated with neck circumference, BMI, or MMC. CONCLUSIONS: Those results suggest that the use of a HBSST could overcome the barriers for individuals with SCI to access diagnostic testing of SRBDs. The use of screening questionnaires and risk assessment for SRBDs in the SCI population is unreliable.

Collaboration within the global vaccine safety surveillance ecosystem during the COVID-19 pandemic: lessons learnt and key recommendations from the COVAX Vaccine Safety Working Group.

This analysis describes the successes, challenges and opportunities to improve global vaccine safety surveillance as observed by the Vaccine Safety Working Group from its role as a platform of exchange for stakeholders responsible for monitoring the safety of vaccines distributed through the COVAX mechanism. Three key elements considered to be essential for ongoing and future pandemic preparedness for vaccine developers in their interaction with other members of the vaccine safety ecosystem are (1) the availability of infrastructure and capacity for active vaccine safety surveillance in low-income and middle-income countries (LMICs), including the advancement of concepts of safety surveillance and risk management to vaccine developers and manufacturers from LMICs; (2) more comprehensive mechanisms to ensure timely exchange of vaccine safety data and/or knowledge gaps between public health authorities and vaccine developers and manufacturers; and (3) further implementation of the concept of regulatory reliance in pharmacovigilance. These aims would both conserve valuable resources and allow for more equitable access to vaccine safety information and for benefit/risk decision-making.

Enhancing care for individuals with mobility impairments: lessons learned in the implementation of a primary care-based mobility clinic.

Persons with mobility impairments experience significant barriers to primary healthcare. This study examines key lessons learned, as derived from interviews with referral sources and Centre for Family Medicine Mobility Clinic team members, in the development and implementation of a primary care-based mobility clinic aimed at reducing these barriers, and it reflects on the implications of this model of care on the system of care. Results highlight the importance of accessibility, specialized equipment, promotional activities and management support as well as challenges reflected by system barriers to care. The results of this study have implications for the application of this model of care in other settings.

A qualitative study to explore the acceptability and feasibility of implementing person-focused evidence-based pain education concepts in pre-registration physiotherapy training.

Objectives: The purpose of this study was to engage with physiotherapy clinicians, academics, physiotherapy students and patients to explore the acceptability, feasibility, and practical considerations of implementing person-focused evidence-based pain education concepts, identified from our previous research, in pre-registration physiotherapy training. Design: This qualitative study took a person-focused approach to ground pain education in the perspectives and experiences of people who deliver and use it. Data was collected via focus groups and in-depth semi-structured interviews. Data was analysed using the seven stage Framework approach. Setting: Focus groups and interviews were conducted either face to face, via video conferencing or via telephone. This depended on geographical location, participant preference, and towards the end of data collection the limitations on in-person contact due to the Covid-19 pandemic. Participants: UK based physiotherapy clinicians, physiotherapy students, academics and patients living with pain were purposively sampled and invited to take part. Results: Five focus groups and six semi-structured interviews were conducted with twenty-nine participants. Four key dimensions evolved from the dataset that encapsulate concepts underpinning the acceptability and feasibility of implementing pain education in pre-registration physiotherapy training. These are (1) make pain education authentic to reflect diverse, real patient scenarios, (2) demonstrate the value that pain education adds, (3) be creative by engaging students with content that requires active participation, (4) openly discuss the challenges and embrace scope of practice. Conclusions: These key dimensions shift the focus of pain education towards practically engaging content that reflects people experiencing pain from diverse sociocultural backgrounds. This study highlights the need for creativity in curriculum design and the importance of preparing graduates for the challenges that they will face in clinical practice.

Targeting earlier diagnosis: What symptoms come first in Degenerative Cervical Myelopathy?

BACKGROUND: Degenerative cervical myelopathy (DCM) is a common and disabling condition. Early effective treatment is limited by late diagnosis. Conventional descriptions of DCM focus on motor and sensory limb disability, however, recent work suggests the true impact is much broader. This study aimed to characterise the symptomatic presentation of DCM from the perspective of people with DCM and determine whether any of the reported symptoms, or groups of symptoms, were associated with early diagnosis. METHODS: An internet survey was developed, using an established list of patient-reported effects. Participants (N = 171) were recruited from an online community of people with DCM. Respondents selected their current symptoms and primary presenting symptom. The relationship of symptoms and their relationship to time to diagnosis were explored. This included symptoms not commonly measured today, termed 'non-conventional' symptoms. RESULTS: All listed symptoms were experienced by >10% of respondents, with poor balance being the most commonly reported (84.2%). Non-conventional symptoms accounted for 39.7% of symptomatic burden. 55.4% of the symptoms were reported as an initial symptom, with neck pain the most common (13.5%). Non-conventional symptoms accounted for 11.1% of initial symptoms. 79.5% of the respondents were diagnosed late (>6 months). Heavy legs was the only initial symptom associated with early diagnosis. CONCLUSIONS: A comprehensive description of the self-reported effects of DCM has been established, including the prevalence of symptoms at disease presentation. The experience of DCM is broader than suggested by conventional descriptions and further exploration of non-conventional symptoms may support earlier diagnosis.

Finding the Optimal Resistance Training Intensity for Your Bones: Protocol for a Randomized Controlled Trial.

OBJECTIVE: The purpose of this trial is to evaluate the effect of twice-weekly, moderate-to-high intensity progressive resistance training (PRT) for 1 year on lumbar spine bone mineral density (BMD) in individuals with low BMD, compared to attention control. Secondary analyses will examine if resistance training improves other health outcomes; if high intensity is more effective than moderate intensity resistance training for all outcomes; the cost of intervention versus benefit; the willingness to pay; and harms. METHODS: For this study, 324 men or postmenopausal women aged ≥50 years with a femoral neck, total hip, or lumbar spine BMD T-score of ≤-1, or a Fracture Risk Assessment Tool probability of ≥20% for major osteoporotic fracture or ≥ 3% for hip fracture are being recruited to participate in a randomized controlled trial with 1:1:1 randomization. Participants will be stratified by site (3 centers) to twice-weekly, supervised PRT at moderate intensity (about 10 repetitions maximum), to high intensity PRT (≤6 repetitions maximum), or to a home posture and balance exercise program (attention control) for 1 year (resistance training to comparator allocation ratio of 2:1). The primary outcome is lumbar spine BMD via dual-energy X-ray absorptiometry. Secondary outcomes include trabecular bone score, proximal femur and total hip BMD and structure, bone-free and appendicular lean mass, physical functioning, falls, fractures, glucose metabolism, cost per life-year gained, adverse events, and quality of life. Between-group differences will be tested in intention-to-treat and per-protocol analyses using analysis of covariance, chi-square tests, or negative binomial or logistic regression, adjusting for site and baseline values. IMPACT: The Finding the Optimal Resistance Training Intensity For Your Bones trial will support decision making on resistance training for people at risk of fracture.

Toward Shared Decision-Making in Degenerative Cervical Myelopathy: Protocol for a Mixed Methods Study.

BACKGROUND: Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this. OBJECTIVE: The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes. METHODS: Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders. RESULTS: Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway. CONCLUSIONS: This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46809.

Cardiac imaging approaches to evaluate drug-induced myocardial dysfunction.

The ability to make informed benefit-risk assessments for potentially cardiotoxic new compounds is of considerable interest and importance at the public health, drug development, and individual patient levels. Cardiac imaging approaches in the evaluation of drug-induced myocardial dysfunction will likely play an increasing role. However, the optimal choice of myocardial imaging modality and the recommended frequency of monitoring are undefined. These decisions are complicated by the array of imaging techniques, which have varying sensitivities, specificities, availabilities, local expertise, safety, and costs, and by the variable time-course of tissue damage, functional myocardial depression, or recovery of function. This White Paper summarizes scientific discussions of members of the Cardiac Safety Research Consortium on the main factors to consider when selecting nonclinical and clinical cardiac function imaging techniques in drug development. We focus on 3 commonly used imaging modalities in the evaluation of cardiac function: echocardiography, magnetic resonance imaging, and radionuclide (nuclear) imaging and highlight areas for future research.

Autonomic dysreflexia: recognizing a common serious condition in patients with spinal cord injury.

OBJECTIVE: To raise family physicians' awareness of autonomic dysreflexia (AD) in patients with spinal cord injury (SCI) and to provide some suggestions for intervention. SOURCES OF INFORMATION: MEDLINE was searched from 1970 to July 2011 using the terms autonomic dysreflexia and spinal cord injury with family medicine or primary care. Other relevant guidelines and resources were reviewed and used. MAIN MESSAGE: Family physicians often lack confidence in treating patients with SCI, see them as complex and time-consuming, and feel undertrained to meet their needs. Family physicians provide a vital component of the health care of such patients, and understanding of the unique medical conditions related to SCI is important. Autonomic dysreflexia is an important, common, and potentially serious condition with which many family physicians are unfamiliar. This article will review the signs and symptoms of AD and offer some acute management options and preventive strategies for family physicians. CONCLUSION: Family physicians should be aware of which patients with SCI are susceptible to AD and monitor those affected by it. Outlined is an approach to acute management. Family physicians play a pivotal role in prevention of AD through education (of the patient and other health care providers) and incorporation of strategies such as appropriate bladder, bowel, and skin care practices and warnings and management plans in the medical chart.

Rethinking pain education from the perspectives of people experiencing pain: a meta-ethnography to inform physiotherapy training.

BACKGROUND: Pain is a complex, global and multidimensional phenomena that impacts the lives of millions of people. Chronic pain (lasting more than 3 months) is particularly burdensome for individuals, health and social care systems. Physiotherapists have a fundamental role in supporting people who are experiencing pain. However, the appropriateness of pain education in pre-registration physiotherapy training programmes has been questioned.Recent research reports identify the need to integrate the voice of patients to inform the development of the pre-registration curriculum. The aim of this meta-ethnography was to develop new conceptual understanding of patients' needs when accessing physiotherapy for pain management. The concepts were viewed through an educational lens to create a patient needs-based model to inform physiotherapy training. METHODS: Noblit and Hare's seven-stage meta-ethnography was used to conduct this qualitative systematic review. Five databases (MEDLINE, CINAHL Complete, ERIC, PsycINFO and AMED) were searched with eligibility criteria: qualitative methodology, reports patient experience of physiotherapy, adult participants with musculoskeletal pain, reported in English. Databases were searched to January 2018. Emerge reporting guidelines guided the preparation of this manuscript. RESULTS: A total of 366 citations were screened, 43 full texts retrieved and 18 studies included in the final synthesis. Interpretive qualitative synthesis resulted in six distinct categories that represent patients' needs when in pain. Analysing categories through an education lens resulted in three overall lines of argument to inform physiotherapy training. The categories and lines of argument are represented in a 'needs-based' model to inform pre-registration physiotherapy training. DISCUSSION: The findings provide new and novel interpretations of qualitative data in an area of research that lacks patient input. This is a valuable addition to pain education research. Findings support the work of others relative to patient centredness in physiotherapy.

Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial.

OBJECTIVE: The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre-specified target range of 100-150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight-based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100-150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first-pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator-free days 30 days following enrollment. RESULTS: A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = -10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First-pass success rate, 30 day mortality, and ventilator-free days were similar. CONCLUSIONS AND RELEVANCE: There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.

Degenerative Cervical Myelopathy: A Practical Approach to Diagnosis.

STUDY DESIGN: Narrative Review. OBJECTIVES: The objective of this review is to provide a stepwise approach to the assessment of patients with potential symptoms of degenerative cervical myelopathy (DCM). METHODS: N/A. RESULTS: DCM is an overarching term used to describe progressive compression of the cervical spinal cord by age-related changes to the spinal axis. These alterations to normal anatomy narrow the spinal canal, reduce the space available for the spinal cord, and may ultimately compress the ascending and descending neural tracts. Patients with DCM present with a wide range of symptoms that can significantly impact quality of life, including bilateral hand numbness and paresthesia, gait impairment, motor weakness of the upper and lower extremities, and bladder and bowel dysfunction. Unfortunately, DCM is often misdiagnosed, resulting in delayed assessment and management by the appropriate specialist. The proper evaluation of a patient with suspected DCM includes obtaining a detailed patient history, conducting a comprehensive neurological examination, and ordering appropriate tests to rule in or out other diagnoses. CONCLUSION: This review summarizes a stepwise approach to the diagnosis of patients with DCM.

Improving Assessment of Disease Severity and Strategies for Monitoring Progression in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 4].

STUDY DESIGN: Narrative Review. OBJECTIVE: To (i) discuss why assessment and monitoring of disease progression is critical in Degenerative cervical myelopathy (DCM); (ii) outline the important features of an ideal assessment tool and (iii) discuss current and novel strategies for detecting subtle deterioration in DCM. METHODS: Literature review. RESULTS: Degenerative cervical myelopathy is an overarching term used to describe progressive injury to the cervical spinal cord by age-related changes of the spinal axis. Based on a study by Smith et al (2020), the prevalence of DCM is approximately 2.3% and is expected to rise as the global population ages. Given the global impact of this disease, it is essential to address important knowledge gaps and prioritize areas for future investigation. As part of the AO Spine RECODE-DCM (Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy) project, a priority setting partnership was initiated to increase research efficiency by identifying the top ten research priorities for DCM. One of the top ten priorities for future DCM research was: What assessment tools can be used to evaluate functional impairment, disability and quality of life in people with DCM? What instruments, tools or methods can be used or developed to monitor people with DCM for disease progression or improvement either before or after surgical treatment? CONCLUSIONS: With the increasing prevalence of DCM, effective surveillance of this population will require both the implementation of a monitoring framework as well as the development of new assessment tools.

Clinical outcome measures and their evidence base in degenerative cervical myelopathy: a systematic review to inform a core measurement set (AO Spine RECODE-DCM).

OBJECTIVES: To evaluate the measurement properties of outcome measures currently used in the assessment of degenerative cervical myelopathy (DCM) for clinical research. DESIGN: Systematic review DATA SOURCES: MEDLINE and EMBASE were searched through 4 August 2020. ELIGIBILITY CRITERIA: Primary clinical research published in English and whose primary purpose was to evaluate the measurement properties or clinically important differences of instruments used in DCM. DATA EXTRACTION AND SYNTHESIS: Psychometric properties and clinically important differences were both extracted from each study, assessed for risk of bias and presented in accordance with the Consensus-based Standards for the selection of health Measurement Instruments criteria. RESULTS: Twenty-nine outcome instruments were identified from 52 studies published between 1999 and 2020. They measured neuromuscular function (16 instruments), life impact (five instruments), pain (five instruments) and radiological scoring (five instruments). No instrument had evaluations for all 10 measurement properties and <50% had assessments for all three domains (ie, reliability, validity and responsiveness). There was a paucity of high-quality evidence. Notably, there were no studies that reported on structural validity and no high-quality evidence that discussed content validity. In this context, we identified nine instruments that are interpretable by clinicians: the arm and neck pain scores; the 12-item and 36-item short form health surveys; the Japanese Orthopaedic Association (JOA) score, modified JOA and JOA Cervical Myelopathy Evaluation Questionnaire; the neck disability index; and the visual analogue scale for pain. These include six scores with barriers to application and one score with insufficient criterion and construct validity. CONCLUSIONS: This review aggregates studies evaluating outcome measures used to assess patients with DCM. Overall, there is a need for a set of agreed tools to measure outcomes in DCM. These findings will be used to inform the development of a core measurement set as part of AO Spine RECODE-DCM.