Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction.

BACKGROUND: Two-thirds of adults worldwide will experience low back pain at some point in their life. In the following case series, we present four patients with sacroiliac (SI) joint instability and severe chronic low back pain, which was refractory to other treatment modalities. OBJECTIVE: We investigated the efficacy of platelet-rich plasma (PRP) injections, a novel orthobiologic therapy, for reducing SI joint pain, improving quality of life, and maintaining a clinical effect. METHODS: Short-form McGill Pain Questionnaire (SFM), Numeric Rating Scale (NRS), and Oswestry Low Back Pain and Disability Index were used for evaluation of treatment at pretreatment, 12-months and 48-months after treatment. RESULTS: At follow-up 12-months post-treatment, pooled data from all patients reported a marked improvement in joint stability, a statistically significant reduction in pain, and improvement in quality of life. The clinical benefits of PRP were still significant at 4-years post-treatment. CONCLUSIONS: Platelet-rich plasma therapy exhibits clinical usefulness in both pain reduction and for functional improvement in patients with chronic SI joint pain. The improvement in joint stability and low back pain was maintained at 1- and 4-years post-treatment.

Presentation and outcomes of necrotizing soft tissue infections.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are aggressive infections associated with significant morbidity, including amputation and organ failure, and high mortality. The rapid progression and significant risk of morbidity and mortality associated with NSTIs makes quick diagnosis and treatment critical. The objective of this study was to determine the presentation of patients diagnosed with NSTIs and their in-hospital outcomes. METHODS: This was a retrospective review of adult (>17 years) patients with a discharge diagnosis of necrotizing fasciitis at London Health Sciences Centre (annual census 125,000) over a 5-year period (April 2008-March 2013). RESULTS: Sixty patients with confirmed NSTI were included in this study. Common comorbidities at presentation included immunocompromise (58.3%), diabetes mellitus (41.7%), vascular disease (45.0%), and obesity (24.6%). Initial presentations included swelling (91.7%), erythema (86.7%), bullae (28.3%), petechiae (8.3%), and bruising (45.0%). Fifty (83.3%) underwent surgery, with a median (interquartile range) time from initial emergency department presentation to surgery of 15.5 hours (7.8, 74.9). In-hospital mortality among those who had surgical intervention was 14.0%, compared to 60.0% for patients who did not have surgery (Δ46.0%; 95% CI: 14.8% to 70.2%). CONCLUSION: Diabetes mellitus, immune-compromise, vascular disease, and obesity are common comorbidities of NSTIs. Survival is higher among patients who receive surgical treatment. Patients presenting with this clinical picture warrant a high degree of suspicion.

Controlled Study of Obesity Among Adolescents with Bipolar Disorder.

OBJECTIVE: Despite numerous studies regarding obesity (OB) in adult bipolar disorder (BP), there are few studies on this topic among adolescents. The current study attempts to extend the literature on prevalence and correlates of OB in adolescent BP by including control participants, and determining OB by direct measurement. METHODS: Participants were 75 treatment-seeking adolescents, ages 13-19 years, with BP-I, -II, or -not otherwise specified, and 47 adolescents without major psychiatric illness. Diagnoses and clinical characteristics were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime version (KSADS-PL). Family psychiatric history was assessed using the Family History Screen. OB was defined as adjusted body-mass index ≥95th percentile. Variables associated with OB in univariate analyses informed variable selection for within-group logistic regression analysis among BP adolescents. RESULTS: BP participants had a significantly higher rate of OB (18%) compared to controls (4%; χ2 = 5.3; p = 0.02). BP remained a significant predictor for OB when controlling for race (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.1-24.0, p = 0.04). In univariate analyses among BP adolescents, OB was significantly associated with suicide attempt, self-injurious behavior, and oppositional defiant disorder. In multivariable analyses, suicide attempt and antidepressants that were not selective serotonin reuptake inhibitors were significantly associated with OB. CONCLUSIONS: OB is excessively prevalent among adolescents with BP and is associated with proxies for illness severity, including suicide attempts. Additional research is warranted to identify strategies to prevent and treat OB among BP adolescents, and to elucidate processes underlying the elevated risk of suicide attempts.

Medical cannabis - the Canadian perspective.

Cannabis has been widely used as a medicinal agent in Eastern medicine with earliest evidence in ancient Chinese practice dating back to 2700 BC. Over time, the use of medical cannabis has been increasingly adopted by Western medicine and is thus a rapidly emerging field that all pain physicians need to be aware of. Several randomized controlled trials have shown a significant and dose-dependent relationship between neuropathic pain relief and tetrahydrocannabinol - the principal psychoactive component of cannabis. Despite this, barriers exist to use from both the patient perspective (cost, addiction, social stigma, lack of understanding regarding safe administration) and the physician perspective (credibility, criminality, clinical evidence, patient addiction, and policy from the governing medical colleges). This review addresses these barriers and draws attention to key concerns in the Canadian medical system, providing updated treatment approaches to help clinicians work with their patients in achieving adequate pain control, reduced narcotic medication use, and enhanced quality of life. This review also includes case studies demonstrating the use of medical marijuana by patients with neuropathic low-back pain, neuropathic pain in fibromyalgia, and neuropathic pain in multiple sclerosis. While significant preclinical data have demonstrated the potential therapeutic benefits of cannabis for treating pain in osteoarthritis, rheumatoid arthritis, fibromyalgia, and cancer, further studies are needed with randomized controlled trials and larger study populations to identify the specific strains and concentrations that will work best with selected cohorts.

Student perceptions of independent versus facilitated small group learning approaches to compressed medical anatomy education.

The purpose of this study was to compare student perceptions regarding two, small group learning approaches to compressed (46.5 prosection-based laboratory hours), integrated anatomy education at the University of Ottawa medical program. In the facilitated active learning (FAL) approach, tutors engage students and are expected to enable and balance both active learning and progression through laboratory objectives. In contrast, the emphasized independent learning (EIL) approach stresses elements from the "flipped classroom" educational model: prelaboratory preparation, independent laboratory learning, and limited tutor involvement. Quantitative (Likert-style questions) and qualitative data (independent thematic analysis of open-ended commentary) from a survey of students who had completed the preclerkship curriculum identified strengths from the EIL (promoting student collaboration and communication) and FAL (successful progression through objectives) approaches. However, EIL led to student frustration related to a lack of direction and impaired completion of objectives, whereas active learning opportunities in FAL were highly variable and dependent on tutor teaching style. A "hidden curriculum" was also identified, where students (particularly EIL and clerkship students) commonly compared their compressed anatomy education or their anatomy learning environment with other approaches. Finally, while both groups highly regarded the efficiency of prosection-based learning and expressed value for cadaveric-based learning, student commentary noted that the lack of grade value dedicated to anatomy assessment limited student accountability. This study revealed critical insights into small group learning in compressed anatomy education, including the need to balance student active learning opportunities with appropriate direction and feedback (including assessment).