Corticosteroid Injections and Risk of Fracture.

Importance: Corticosteroid injections (CSIs) are an important tool for pain relief in many musculoskeletal conditions, but the longitudinal effects of these treatments on bone health and fracture risk are unknown. Objective: To determine whether cumulative doses of corticosteroid injections are associated with higher risk of subsequent osteoporotic and nonosteoporotic fractures. Design, Setting, and Participants: This cohort study included adult patients receiving any CSI from May 1, 2018, through July 1, 2022. Eligible patients resided in Olmsted County, Minnesota, and were empaneled to receive primary care within the Mayo Clinic. Cox proportional hazards regression models were used to evaluate risk of fracture based on cumulative injected corticosteroid dose. Exposure: Receipt of any CSI during the study period. Main Outcomes and Measures: The primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes consisted of risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis. Results: A total of 7197 patients were included in the study (mean [SD] age, 64.4 [14.6] years; 4435 [61.6%] women; 183 [2.5%] Black and 6667 [92.6%] White), and 346 (4.8%) had a new fracture during the study period. Of these fractures, 149 (43.1%) were considered osteoporotic. In the adjusted Cox proportional hazards regression model, there was no association of higher fracture risk based on cumulative CSI dose (adjusted hazard ratio [HR], 1.04 [95% CI, 0.96-1.11]). There was also no associated higher risk of fracture in the non-high-risk (adjusted HR, 1.11 [95% CI, 0.98-1.26]) or osteoporosis (adjusted HR, 1.01 [95% CI, 0.90-1.11]) subgroups. Age, Charleson Comorbidity Index, and previous fracture were the only factors that were associated with higher fracture risk. Conclusions and Relevance: In this cohort study of cumulative injected corticosteroid dose and risk of subsequent fracture, no association was observed, including in patients with a preexisting diagnosis of osteoporosis. Treatment of painful conditions with CSI should not be withheld or delayed owing to concern about fracture risk.

Impact of Intra-Articular Corticosteroid Injection on Glycemic Control: A Population-Based Cohort Study.

This retrospective cohort study investigated the longer-term hyperglycemic effects of intra-articular corticosteroid (IACS) administration by evaluating changes in A1C after large joint IACS injection. Among 1,169 patients (mean age 66.1 ± 12.2 years, 52.8% female), 184 (15.7%) experienced a greater-than-expected rise in A1C (actual A1C ≥0.5% above predicted) after IACS. Greater-than-expected rise in A1C was associated solely with baseline A1C (odds ratio [OR] 1.84, 95% CI 1.08-3.13 for baseline A1C of 7.0-8.0% compared with <7.0% and OR 4.79, 95% CI 2.83-8.14 for baseline A1C >8.0% compared with <7.0%). Although most patients do not experience an increase in A1C after IACS, clinicians should counsel patients with suboptimally controlled diabetes about risks of further hyperglycemia after IACS administration.

Odds of Influenza in Patients Receiving Intra-articular Corticosteroid Injections: A Cohort Study.

OBJECTIVE: Although intra-articular corticosteroid (IACS) is injected locally, some systemic absorption occurs, potentially causing immunosuppression in recipients. This study examined the odds of influenza in patients who received IACS compared with matched controls. DESIGN: Adults in the authors' health system who received IACS from May 2012 through April 2018 were 1:1 matched to adults without IACS. The primary outcome was overall odds of influenza. Secondary analyses examined influenza odds by timing of IACS, joint size, and vaccination status. RESULTS: A total of 23,368 adults (mean age, 63.5 yrs, 62.5% female) received IACS and were matched to a control. Although there was no difference in influenza odds by IACS status overall (odds ratio, 1.13; 95% confidence interval, 0.97-1.32), patients receiving IACS during influenza season had higher odds of influenza than matched controls (odds ratio, 1.34; 95% confidence interval, 1.03-1.74). Furthermore, unvaccinated patients who received IACS during influenza season had higher influenza odds compared with matched controls (odds ratio, 1.41; 95% confidence interval, 1.04-1.91]), whereas there was no difference among vaccinated patients. CONCLUSION: Patients receiving IACS injections during influenza season had higher odds of influenza. However, vaccination seemed to mitigate this risk. Patients receiving IACS injections should be counseled on infection risk and importance of vaccinations. Further research is needed to examine IACS effects on other viral illnesses. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Identify potential adverse effects of intra-articular corticosteroids; (2) Recognize risk factors for influenza diagnosis; and (3) Describe importance of influenza vaccination. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

Spinal region corticosteroid injections are not associated with increased risk for influenza.

BACKGROUND CONTEXT: Spinal region corticosteroid injections (CSI) are intended to act locally to relieve radicular or axial back pain, however some systemic absorption occurs, potentially placing recipients at risk for immunosuppressive effects of corticosteroids. No previous studies examine whether patients undergoing spinal region CSI are at increased risk for viral infections, particularly influenza-a common viral illness with potentially serious consequences, especially for patients with multimorbidity. PURPOSE: To examine odds of influenza in patients who received spinal region CSI compared to matched controls. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adults (n=9,196) who received a spinal CSI (epidural, facet, sacroiliac, paravertebral block) during influenza seasons occurring from 2000 to 2020 were 1:1 matched to controls without spinal CSI. OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis in spinal CSI patients compared to matched controls. Predetermined subgroup analyses examined odds of influenza diagnosis based on vaccination status and injection location. METHODS: An institutional database was queried to identify patients that received spinal CSI during influenza season (September 1 to April 30) from 2000 to 2020. Patients were matched by age, sex, and influenza vaccination status to controls without spinal CSI within the specified influenza season. Influenza diagnosis was ascertained using International Classification of Disease codes and data was analyzed using multiple logistic regression adjusted for comorbidities associated with increased risk for influenza. RESULTS: A total of 9,196 adults (mean age 60.8 years, 60.4% female) received a spinal CSI and were matched to a control. There were no increased odds of influenza for spinal CSI patients as compared to matched controls (OR 1.13, [95% CI, 0.86-1.48]). When subgroups were examined, there were also no increased odds of influenza for spinal CSI patients based on immunization status (unvaccinated or vaccinated) or spinal injection location (epidural or non-epidural). CONCLUSIONS: Spinal region CSI was not associated with increased odds of influenza or reduced vaccine efficacy. This is reassuring given the analgesic and functional restoration benefits of these injections. Assessing risk of viral infection associated with spinal CSI is particularly relevant in the era of the COVID-19 pandemic, and further work is needed to address this issue.

Spinal corticosteroid injections are not associated with increased influenza risk.

BACKGROUND CONTEXT: Spinal corticosteroid injections (CSI) are often used to treat radicular and axial pain arising from the spine. Systemic corticosteroids are well known to cause immunosuppression, and locally injected spinal CSI are known to have some systemic absorption. However, it is unknown whether spinal CSI increases the risk of systemic viral infections, such as influenza. PURPOSE: To determine whether spinal CSI causes an increased risk for influenza infection and whether they reduce the protective effect of vaccination STUDY DESIGN/SETTING: A retrospective cohort study was performed at Kaiser Permanente Northern California, a large healthcare system with a diverse population. PATIENT SAMPLE: Adults (n=60,880) who received a spinal CSI during influenza seasons from 2016 to 2019. A comparison was made with 121,760 case-matched individuals who did not receive a spinal CSI. OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis following spinal CSI compared with case-matched controls. Secondary analysis examined odds of influenza diagnosis based on vaccination status, multiple same-day injections, and epidural versus non-epidural route of injection. METHODS: The electronic health record and associated research databases were analyzed to identify patients who received a spinal CSI during three consecutive flu seasons, 2016 through 2019. Injections were stratified into epidural versus non-epidural CSI and single injections versus multiple same-day injections. Additionally, the rate of influenza in vaccinated versus non-vaccinated individuals was examined. Inpatient flu diagnosis was used as a proxy for severe disease. After case matching was completed, odds ratios for flu diagnosis were calculated using a logistical regression model. RESULTS: The odds of flu diagnosis following spinal CSI were not increased compared with controls (OR 0.93 [0.87-1.01, 95% Wald CL]). For epidural CSI the OR was 0.91 (0.83-1.00, 95% Wald CL), and non-epidural it was 1.00 (0.89-1.13, 95% Wald CL). There were similar findings for multiple same-day injections and when looking at inpatient flu diagnosis. For vaccinated individuals, the OR for flu following spinal CSI was 0.86 (0.80-0.92, 95% Wald CL), which indicates a protective effect in these patients. CONCLUSIONS: Spinal CSI did not increase the odds of subsequently receiving a diagnosis of influenza, regardless of vaccination status, location of injection, single versus multiple same-day injection, or co-morbidity. Vaccination had a protective effect against influenza, and this was not adversely affected by receiving spinal CSI during the flu season.

Qualitative and quantitative evaluation of an interprofessional workshop between physical therapy and medical students.

Interprofessional education (IPE) is an important component of medical education, preparing students for the collaboration necessary for high-quality patient care. This study aimed to compare IPE readiness in pre-qualification physical therapy (PT) and medical (MD) students before and after an interprofessional workshop and identify factors influencing the workshop's perceived educational value. In two consecutive years, students were surveyed with the Readiness for Interprofessional Learning Scale (RIPLS) following a four-hour, case-based workshop. During the second year, students were also surveyed before the workshop and answered open-ended questions about its educational value. PT and MD students had similar mean pre-workshop RIPLS scores (83.0, SD 5.3 vs. 80.7, SD 7.9; p = .27), but post-workshop scores were higher among PT students (86.3, SD 6.5 vs. 80.3, SD 8.8; p < .001). Qualitative thematic analysis of responses to open-ended questions revealed students valued IPE within the workshop. However, MD students in particular identified improvement opportunities in workshop delivery, timing, and content. These factors undermined the perceived educational value for MD students and may have contributed to their lower post-workshop RIPLS scores. This study suggests that a brief workshop can improve readiness for IPE among pre-professional students and highlights the importance of content, delivery, and timing to IPE success.

Assessing Utilization of the Cerebrospinal Fluid Venereal Disease Research Laboratory Test for Diagnosis of Neurosyphilis: a Cohort Study.

BACKGROUND: Inappropriate use of diagnostic tests contributes to rising healthcare expenditures, and improving appropriate utilization rates is important for high-value patient care. The Venereal Disease Research Laboratory (VDRL) test performed in cerebrospinal fluid (CSF) has historically been improperly utilized, although there is no recent evaluation of its use in clinical practice. OBJECTIVES: Quantify the rates of appropriate CSF-VDRL testing, determine the CSF-VDRL false-positivity rate, and describe the causes of false-positive CSF-VDRL reactivity. DESIGN: Retrospective cohort study PATIENTS: A total of 32,626 patients with CSF-VDRL testing at one of three Mayo Clinic sites (Rochester, MN; Jacksonville, FL; and Scottsdale, AZ) from January 1, 1994, to February 28, 2018. MAIN MEASURES: Rate of appropriate CSF-VDRL test utilization from January 1, 2011, to December 31, 2017, and CSF-VDRL true- and false-positivity rates from January 1, 1994, to February 28, 2018. KEY RESULTS: Among 8553 persons with negative CSF-VDRL results, testing was inappropriately ordered for 8399 (98.2%) of these patients. The word "syphilis" or "neurosyphilis" appeared in the notes of 1184 (13.8%) individuals with a negative CSF-VDRL result. From January 1994 through February 2018, 33,933 CSF-VDRL tests were performed on 32,626 individual patients. Among the 60 positive CSF-VDRL results, 43 (71.7%) were true-positives and 17 (28.3%) were false-positives. All patients with false-positive CSF-VDRL results were tested unnecessarily. Neoplastic meningitis was a common cause of false-positive CSF-VDRL results. CONCLUSIONS: Inappropriate use of CSF-VDRL testing for the diagnosis of neurosyphilis remains problematic in clinical practice. Following recommended testing algorithms would prevent unnecessary testing and minimize false-positive results.

"Slowed Down but Not Stopped": A Spiritual Life Review Intervention in Patients with Neurodegenerative Disease.

Spiritual health is important in managing and coping with chronic and debilitating illnesses, such as neurodegenerative diseases. However, few spiritual interventions have addressed this population. This article quantitatively and qualitatively evaluates outcomes of a spiritual life review in neurodegenerative diseases patients. The majority of participants improved or maintained quality of life and spiritual/emotional well-being following the intervention. Spiritual life review may be an important intervention in the comprehensive care of patients with neurodegenerative diseases.

Hearing and Heeding the Voices of those With Advanced Illnesses.

OBJECTIVES: To describe the feasibility of a chaplain-led spiritually focused life review interview and the development of a spiritual legacy document (SLD) for patients with advanced diseases and to describe changes in spiritual well-being (SWB), spiritual coping strategies (SC), and quality of life (QOL) after receiving the SLD. PATIENTS AND METHODS: In all, 130 patients and support person (SP) pairs were recruited from July 2012 to January 2019. Following enrollment, demographic information was gathered and baseline questionnaires were administered. Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp-12) and a linear analog scale assessment (LASA) measured SWB. LASAs also measured QOL and emotional well-being (EWB). Positive Religious Coping Scale (RCOPE) measured SC. After completion of baseline forms, participants were interviewed (individually) by a chaplain. Interviews were digitally recorded, transcribed, and verified. Transcripts were edited and participants were given the opportunity to make adaptations. The participant-approved draft was then developed into a professionally printed SLD. Follow-up questionnaires were administered to assess change. RESULTS: Significant improvements from baseline to post-SLD follow-up were found for patients on the LASAs: SWB (average 7.7-8.3, P = .01), QOL (average 6.7-7.3, P = .03), EWB (average 6.9-7.5, P = .01), and on the positive RCOPE (average 1.8-2.0, P = .007). Effect sizes were approximately 0.25. Considering any improvement, 61.0% improved their positive RCOPE score, 46.6% improved EWB, and 39.7% improved SWB. No significant changes were found on the FACIT-Sp-12. No significant changes were found for SPs. CONCLUSION: The results suggest that the primary participants who completed the study benefited by significantly increasing their QOL, SWB, EWB, and SC.

Rethinking Viscosupplementation: Ultrasound- Versus Landmark-Guided Injection for Knee Osteoarthritis.

OBJECTIVES: Viscosupplementation, intra-articular injection of hyaluronic acid (HA), for knee osteoarthritis has fallen somewhat out of favor, with studies failing to show consistent benefits in pain reduction. Hyaluronic acid must enter the joint space to be beneficial; however, landmark-guided injection can be substantially inaccurate, especially in obese patients. We aimed to determine whether ultrasound (US) guidance to ensure needle placement for HA knee injection resulted in improved outcomes as reflected by surgery-free survival compared to landmark-guided HA knee injection. METHODS: All community-dwelling patients in 6 contiguous surrounding counties receiving HA knee injection either by landmark guidance (n = 647) or by US guidance (n = 500) were analyzed for the degree of arthritis, body mass index, follow-up injection, and subsequent need for knee arthroplasty. A subgroup analysis of obese patients was also performed. RESULTS: The US- and landmark-guided HA injection cohorts were similar with respect to sex, body mass index, and the degree of arthritis. Of 1147 patients receiving knee HA injection, 462 subsequently underwent knee arthroplasty. Significantly fewer patients in the US-guided HA injection cohort went to surgery (33.2%) compared to the landmark-guided cohort (45.8%; P < .001). The subgroup analysis for obese patients showed even larger differences (34.8% versus 51.8%; P < .001). CONCLUSIONS: Knee osteoarthritis treatment by viscosupplementation can be optimized by US guidance, ensuring intra-articular needle placement. Using an objective surgical outcome, our study shows that rethinking viscosupplementation to ensure intra-articular delivery improves effectiveness. Patients receiving US-guided knee HA injection were significantly less likely to undergo subsequent knee arthroplasty than patients receiving landmark-guided HA injection.

Joint Corticosteroid Injection Associated With Increased Influenza Risk.

Aging and immunocompromising conditions or medications may reduce influenza vaccine effectiveness. The high-dose vaccine has been used to improve vaccine response in patients 65 years and older. Because of systemic immunosuppressive effects, oral corticosteroids may reduce vaccine effectiveness; however, despite over half a century of use, no data are available regarding the effect of joint and bursa corticosteroid injection on influenza vaccine effectiveness. The aim of this retrospective study was to determine whether joint corticosteroid injection was associated with reduced influenza vaccine effectiveness. During the 5 influenza seasons between August 1, 2012, and March 31, 2017, a total of 15,068 major joint corticosteroid injections were given to patients residing in Olmsted County, Minnesota. Vaccinated patients receiving a major joint corticosteroid injection (n=4804) were at increased risk (relative risk, 1.52; 95% CI, 1.20-1.93) for developing influenza compared with vaccinated control patients. Women younger than 65 years were at the highest risk, suggesting that perhaps the high-dose vaccine should be considered for this group to enhance protection when possible.

Anatomic Relationship Between the Hook of the Hamate and the Distal Transverse Carpal Ligament: Implications for Ultrasound-Guided Carpal Tunnel Release.

OBJECTIVE: During ultrasound-guided carpal tunnel release, osseous landmarks may supplement direct visualization of the distal transverse carpal ligament (dTCL) to ensure a complete release. The purpose of this study was to determine the relationship between the apex of the hook of the hamate (aHH) and the dTCL within the transverse safe zone (TSZ) of the carpal tunnel. DESIGN: Twenty unembalmed cadaveric specimens were dissected to determine the aHH-dTCL distance and the aHH-SPA distance (the distance between the aHH and the superficial palmar arch) at the ulnar and radial limits of the TSZ (the distance between the hook of the hamate or ulnar artery to the median nerve). RESULTS: The aHH-dTCL distance averaged 11-12 mm across the TSZ (maximum, 18.2 mm), whereas the aHH-SPA distance was significantly greater on the radial side of the TSZ compared with the ulnar side (22.6 ± 3.6 mm vs. 14.0 ± 4.0 mm). CONCLUSIONS: The dTCL lies approximately 11-12 mm distal to the aHH across the TSZ, with an upper limit of 18.2 mm. Along with direct sonographic visualization of the dTCL, the aHH can be used with other osseous landmarks to estimate the position of the dTCL during ultrasound-guided carpal tunnel release.

Perceived Barriers to Exercise in the First Trimester of Pregnancy.

Regular physical activity has been shown to improve pregnancy outcomes. We sought to identify barriers to exercise during the first trimester of pregnancy. Five hundred forty-nine pregnant women in their first trimester rated barriers to exercise on a scale of 1 (not a barrier) to 5 (a huge barrier) and recorded physical activity (minutes/week). Women were placed into one of three classifications, nonexercisers (zero exercise), infrequent exercisers (<150 minutes/week), or exercisers (≥150 minutes/week). The greatest barriers (mean) were nausea/fatigue (3.0) and lack of time (2.6). Exercisers reported significantly lower barrier levels. Nausea/fatigue was a greater barrier for nonexercisers compared to exercisers (3.6 vs 2.8, p < .001). Focusing education and interventions on these barriers may help pregnant women achieve healthy exercise levels.

The impact of a spiritual legacy intervention in patients with brain cancers and other neurologic illnesses and their support persons.

OBJECTIVE: The objectives were to assess the feasibility of using a novel, comprehensive chaplain-led spiritual life review interview to develop a personal Spiritual Legacy Document (SLD) for persons with brain tumors and other neurodegenerative diseases and to describe spiritual well-being (SWB), spiritual coping, and quality of life (QOL) of patients and their support persons (SP) before and after receipt of the SLD. METHODS: Patient-SP pairs were enrolled over a 2-year period. Assessments included the Functional Assessment of Chronic Illness Therapy-Spiritual Expanded Version, Brief Religious Coping Scale, Brief COPE Inventory, and QOL Linear Analog Scale. Baseline assessments were completed prior to an audio-recorded spiritual life review interview with a chaplain. RESULTS: Thirty-two patient/SP pairs were enrolled; 27 completed baseline assessments and the interview. Twenty-four reviewed their SLD and were eligible for follow-up. A total of 15 patients and 12 SPs completed the 1-month follow-up; 10 patients and seven SPs completed the 3-month follow-up. Patients endorsed high levels of SWB and spiritual coping at baseline. Both patients and SPs evidenced improvement on several aspects of SWB, spiritual coping, and QOL at 1 month, but patients' decreased financial well-being was also observed. Patients and SPs demonstrated favorable changes in peacefulness and positive religious coping at both time points. CONCLUSIONS: A chaplain-led spiritual life review is a feasible intervention for patients with neurodegenerative disease and results in beneficial effects on patients and SPs. Copyright © 2015 John Wiley & Sons, Ltd.

Custom neck orthosis in combination with onabotulinumtoxinA for the treatment of refractory congenital muscular torticollis: A case report.

PURPOSE: This case report examines the use of a custom neck orthosis following onabotulinumtoxinA (BoNT-A) injections for the treatment of congenital muscular torticollis (CMT) that has not been responsive to conservative treatment or previous injections. METHODS: The patient was fitted for a custom neck orthosis following BoNT-A injections for refractory CMT. Clinical outcomes were evaluated with head tilt, cervical rotation, and neck passive range of motion (PROM) measurements. Parental reports of patient tolerance of the orthosis and family satisfaction of results were obtained through survey. RESULTS: With use of the orthosis following BoNT-A injections, the patient's head tilt improved from 45° to an intermittent tilt of 10° and neck PROM to the left improved from 70° to 90°. He wore the neck orthosis for 8 to 10 hours per day for 3 months, experienced no major complications, and tolerated it well. On follow-up survey, the family reported satisfaction with the results. CONCLUSION: This case provides evidence that a custom neck orthosis after BoNT-A injection may be an effective treatment of refractory CMT before or replacing surgical intervention.

Improving Spiritual Well-Being in Patients with Lung Cancers.

Patients with lung cancer report more disease burden and lower spiritual well-being (SWB) compared with other cancer patients. Understanding variables that lessen disease burden and improve SWB is essential. The aim of this study was to explore the relationship between motivational level for physical activity and SWB in patients with lung cancer. Linear regression showed increased SWB as stage of change for physical activity increased (p < 0.0001), even after adjusting for multiple demographic variables.

Long-term effect of a short interprofessional education interaction between medical and physical therapy students.

Medicine is increasingly focused on team-based practice as interprofessional cooperation leads to better patient care. Thus, it is necessary to teach teamwork and collaboration with other health care professionals in undergraduate medical education to ensure that trainees entering the workforce are prepared to work in teams. Gross anatomy provides an opportunity to expose students to interprofessional education (IPE) early in their training. The purpose of this study is to describe an IPE experience and report if the experience has lasting influence on the participating students. The Readiness for Interprofessional Learning Scale (RIPLS) questionnaire was administered to first year medical (MD) and physical therapy (PT) students at Mayo Medical School and Mayo School of Health Sciences. Results demonstrated an openness on the part of the students to IPE. Interprofessional education experiences were incorporated into gross anatomy courses in both medical and PT curricula. The IPE experiences included a social event, peer-teaching, and collaborative clinical problem-solving sessions. These sessions enhanced gross anatomy education by reinforcing previous material and providing the opportunity to work on clinical cases from the perspective of two healthcare disciplines. After course completion, students again completed the RIPLS. Finally, one year after course completion, students were asked to provide feedback on their experience. The post-curricular RIPLS, similar to the pre-curricular RIPLS, illustrated openness to IPE from both MD and PT students. There were however, significant differences in MD and PT perceptions of roles and responsibilities. One-year follow-up indicated long-term retention of lessons learned during IPE.