ABSTRACT
The erector spinae plane (ESP) block, initially designed for thoracic analgesia, has evolved into a versatile regional anesthesia technique with literature support for success in numerous contexts. In this case report, we highlight the successful application of ESP to provide postoperative analgesia for pediatric Dega osteotomy involving both the femoral head and acetabulum, in a patient with numerous neurological comorbidities that would have weighed against some more traditional regional anesthesia techniques. This case further highlights the versatility of ESP, demonstrating its use in blocking lumbar nerve roots in a pediatric patient with complex neurological challenges.
ABSTRACT
BACKGROUND: Patients with chronic kidney disease (CKD) are at increased risk for multiple adverse events, several of which have been proven to be less likely with the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). As a result, guidelines now recommend SGLT2i be given to those with mild to moderate CKD and type 2 diabetes. The objective of this study is to evaluate if a pharmacist-driven SGLT2i prescribing initiative among eligible patients with CKD and diabetes within the VA could more rapidly improve the adoption of SGLT2i via a pragmatic approach aligned with learning health systems. METHODS: Eligible patients will be identified through an established VA diabetes dashboard. Veterans with an odd social security number (SSN), which is effectively a random number, will be the intervention group. Those with even SSNs will serve as the control while awaiting a second iteration of the same interventional program. The intervention will be implemented in a rolling fashion across one Veterans Integrated Service Network. Our primary outcome is initiation of an SGLT2i. Secondary outcomes will include medication adherence and safety-related outcomes. DISCUSSION: This project tests the impact of a pharmacist-driven medication outreach initiative as a strategy to accelerate initiation of SGLT2i. The results of this work will not only illustrate the effectiveness of this strategy for SGLT2is but may also have implications for increasing other guideline-concordant care. Furthermore, the utilization of SSNs to select Veterans for the first wave of this program has created a pseudo-randomized interventional trial supporting a pragmatic learning health system approach. TRIAL REGISTRATION: ISRCTN12374636.
Subject(s)
Diabetes Mellitus, Type 2 , Nephrotic Syndrome , Renal Insufficiency, Chronic , Sodium-Glucose Transporter 2 Inhibitors , Humans , Pharmacists , Diabetes Mellitus, Type 2/drug therapy , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Renal Insufficiency, Chronic/drug therapy , Renal Insufficiency, Chronic/epidemiology , Glucose , SodiumABSTRACT
Topiramate is an antiepileptic drug indicated for the treatment of seizure disorders, migraine prophylaxis, and, more recently, weight loss. This new indication will likely increase the use of this agent significantly. As a carbonic anhydrase inhibitor, topiramate can affect the pH of bodily fluids and is known to increase the risk of nephrolithiasis. However, as discussed in the present report, these properties also result in an as yet unaddressed risk of the development of sialoliths, calcified stones formed in the salivary duct or glands. The physiologic mechanisms for stone development in the salivary gland are reviewed and the pharmacologic effects of topiramate on sialolith formation discussed. The present report describes a female patient treated with topiramate for migraine prophylaxis who subsequently presented with a sialolith in the left submandibular duct.
