Does image guidance decrease pedicle screw-related complications in surgical treatment of adolescent idiopathic scoliosis: a systematic review update and meta-analysis.

PURPOSE: Surgical treatment of severe adolescent idiopathic scoliosis (AIS) with posterior spinal instrumentation and fusion with pedicle screws is common, requiring careful screw insertion to prevent pedicle breaches and neurologic complications. Image guidance has been suggested to improve breach rates, though the radiation risk for AIS precludes its common usage. The purpose of this systematic review and meta-analysis was to compare the breach rates and screw-related complications for AIS patients undergoing spine surgery with pedicle screws between freehand screw insertion and image guidance methods. METHODS: A comprehensive search of MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science databases was conducted. Two reviewers independently screened abstracts, full-texts, extracted data and performed risk of bias assessment using the QUIPS quality appraisal tool. Level of evidence summary statements were formulated based on consistency and quality of reporting. RESULTS: Ninety-four studies were found, with 18 studies of moderate risk of bias or better. Moderate evidence from two head-to-head studies shows CT guidance has lower breach rates than freehand methods (OR 0.28 [0.20-0.40, I2 = 1%]), with no complications in either study. From individual studies, moderate evidence showed lower breach rates for image guidance versus freehand methods (13%, I2 = 98% vs. 20%, I2 = 95%). Complication rates were conflicting (0-1.6% for image guidance, 0-1.7% for freehand). Moderate evidence showed increased surgical time for image guidance versus freehand (257.7 min vs. 226.8 min). CONCLUSIONS: Meta-analyzed breach rates show moderate evidence of decreased breaches with CT navigation compared with freehand methods. Complication rates remain unknown due to the low complication rates from small sample sizes. These slides can be retrieved under Electronic Supplementary Material.

Incidence and Management of Clozapine-Induced Myocarditis in a Large Tertiary Hospital.

OBJECTIVE: Clozapine, an antipsychotic reserved for management of treatment-resistant schizophrenia, is associated with severe adverse effects, including myocarditis. This study aims to determine the incidence of clozapine-induced myocarditis at a large tertiary hospital compared to what is reported in the literature. METHODS: Medical records of adult patients admitted to psychiatry units receiving clozapine between January 1, 2010, and July 31, 2016, were retrospectively reviewed. Cases of clozapine-induced myocarditis were defined as having elevated C-reactive protein (CRP) or detectable troponin and at least 1 sign or symptom of myocarditis, in the absence of alternative plausible aetiologies. The primary outcome was incidence of clozapine-induced myocarditis during the study period. Secondary outcomes included rate and description of the management of clozapine-induced myocarditis. RESULTS: In total, 316 patients were screened; 10 patients met the case definition for clozapine-induced myocarditis. The incidence of this adverse drug reaction over the study period was 3.16%. Reduced left ventricular ejection fraction was observed in 60% of cases, and electrocardiography changes were noted in 60% of cases. Clozapine was discontinued in all cases. Rechallenge was performed in 2 patients; recurrent CRP elevation resulted in discontinuation in each case. Medications for management of myocarditis were used in 50% of cases. Although 2 patients required transfer to critical care, the in-hospital mortality rate was 0%. CONCLUSIONS: The incidence of clozapine-induced myocarditis at the study hospital was consistent with the higher range reported in the literature. Further research is necessary to elucidate risk factors, definitive diagnostic criteria, and effective management of clozapine-induced myocarditis.

Management of Supratherapeutic International Normalized Ratio without Bleeding after Warfarin Use: An Evaluation of Vitamin K Administration (SUPRA-WAR-K Study).

BACKGROUND: For patients with supratherapeutic international normalized ratio (INR) and no evidence of bleeding, the 2012 guidelines of the American College of Chest Physicians discourage administration of vitamin K. At the study hospital, it was observed that vitamin K was frequently prescribed for patients with INR of 4.5 or higher and no bleeding. OBJECTIVES: To compare efficacy and safety outcomes between holding warfarin alone and holding warfarin with administration of vitamin K and to compare these outcomes among various doses and routes of vitamin K administration in non-critical care inpatients experiencing supratherapeutic INR without evidence of bleeding. METHODS: This single-centre retrospective chart review involved noncritical care inpatients with supratherapeutic INR (4.5-8.9) without evidence of bleeding. The primary outcomes were the change in INR 1 day after implementation of supratherapeutic INR management and the time to reach INR less than 3.0. The secondary outcomes were length of stay, frequency of warfarin resistance, incidence and duration of bridging anticoagulation, incidence of thromboembolism and major bleeding, and death. RESULTS: Regardless of vitamin K dose, the administration of vitamin K combined with holding warfarin, relative to holding warfarin alone, was associated with a greater INR decrease 1 day after the intervention (mean ± standard deviation -3.2 ± 1.9 versus -0.9 ± 1.0, p < 0.001) and a shorter time to reach INR below 3.0 (1.9 ± 1.0 days versus 2.6 ± 1.4 days, p = 0.003). No statistically significant differences in any other outcomes were observed. CONCLUSIONS: In hospitalized non-critical care patients with INR between 4.5 and 8.9 without evidence of bleeding, the combination of holding warfarin and administering vitamin K was associated with greater and faster decreases in INR than holding warfarin alone. No significant differences were found in clinically important outcomes. The practice of administering vitamin K in this population warrants further study and re-evaluation.

CONTEXTE: Dans ses lignes directrices de 2012, l'American College of Chest Physicians déconseille l'administration de vitamine K aux patients ayant des résultats de rapport international normalisé (RIN) suprathérapeutiques et ne présentant aucun saignement. À l'hôpital des auteurs, on a remarqué que l'on prescrivait fréquemment de la vitamine K aux patients répondant aux critères ci-dessus. OBJECTIFS: Comparer l'efficacité et l'innocuité entre un simple arrêt de la warfarine et l'arrêt de la warfarine combiné à l'administration de vitamine K, puis comparer ces résultats thérapeutiques selon différentes doses et voies d'administration de la vitamine K chez des patients hospitalisés qui ne sont pas en phase critique, qui ont un RIN suprathérapeutique et qui ne présentent aucun saignement. MÉTHODES: La présente étude menée dans un seul centre comportait une analyse des dossiers médicaux de patients hospitalisés n'étant pas en phase critique, ayant un RIN suprathérapeutique (4.5­8.9) et ne présentant aucun saignement. Les principaux paramètres d'évaluation étaient le changement du RIN un jour après la mise en œuvre de mesures pour corriger un RIN suprathérapeutique et le temps nécessaire pour atteindre un RIN de moins de 3,0. Les paramètres d'évaluation secondaires étaient la durée du séjour, la fréquence des cas de résistance à la warfarine, le nombre et la durée des relais anticoagulants, l'incidence des cas de thromboembolie et de saignement important et les cas de décès. RÉSULTATS: L'administration de vitamine K, peu importe la dose, combinée à l'arrêt de la warfarine comparativement au simple arrêt de la warfarine était associée à une réduction plus importante du RIN un jour après l'intervention (moyenne ± écart-type −3.2 ± 1,9 contre −0,9 ± 1,0, p < 0,001) et à un plus court délai pour atteindre un RIN de moins de 3,0 (1,9 ± 1,0 jour contre 2,6 ± 1,4 jours, p = 0.003). Aucune différence statistiquement significative n'a été observée pour le reste des paramètres d'évaluation. CONCLUSIONS: Chez les patients hospitalisés n'étant pas en phase critique, ayant un RIN entre 4,5 et 8,9 et ne présentant aucun saignement, l'arrêt de la warfarine combiné à l'administration de vitamine K a été associé à une réduction plus rapide et plus importante du RIN que le simple arrêt de la warfarine. On n'a observé aucune différence significative en ce qui touche aux résultats thérapeutiques cliniquement importants. L'administration de vitamine K pour cette population est une pratique qui nécessite de plus amples études et doit être évaluée à nouveau.

Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal surgery: a systematic review on screw-related complications and breach rates.

BACKGROUND CONTEXT: Severe adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity requiring surgery to stop curve progression. Posterior spinal instrumentation and fusion with pedicle screws is the standard surgery for AIS curve correction. Vascular and neurologic complications related to screw malpositioning are concerns in surgeries for AIS. Breach rates are reported at 15.7%, implant-related complications at 1.1%, and neurologic deficit at 0.8%. Free-hand screw insertion remains the prevailing method of screw placement, whereas image guidance has been suggested to improve placement accuracy. PURPOSE: This study aimed to systematically review the screw-related complication and breach rates from posterior spinal instrumentation and fusion with pedicle screws for patients with AIS when using free-hand methods for screw insertion compared with image guidance methods. STUDY DESIGN: This is a systematic review of prognosis, comparing image guidance with no image guidance in surgery. PATIENT SAMPLE: One randomized controlled trial and multiple prospective cohort studies that reported complication or breach rates in posterior spinal instrumentation and fusion with pedicle screws for AIS. OUTCOME MEASURES: Number of complications and breaches reported in databases or recorded from postoperative imaging. METHODS: Databases searched included MEDLINE, Embase, CINAHL, CENTRAL, and Web of Science. Studies of Level 3 evidence or greater as defined by the Centre for Evidence-Based Medicine were included. Articles were screened to focus on patients with AIS undergoing posterior fusion with pedicle screws or hybrid systems. Two independent reviewers screened abstracts, full texts, and extracted data. The Quality in Prognostic Studies (QUIPS) appraisal tool was used to determine studyrisk of bias (ROB). Level of evidence summary statements were formulated based on consistency and quality of reporting. RESULTS: Seventy-nine cohort studies were identified, including four comparing computed tomography (CT) guidance with free-hand methods head-to-head, eight on image guidance, and 671. on free-hand methods alone. Moderate evidence from individual head-to-head studies show CT guidance has lower breach rates than free-hand methods. No complications were found in these studies. From individual cohort studies, moderate evidence shows CT guidance has lower point estimates of breach rates than free-hand methods at 7.9% compared with 9.7%-17.1%. Screw-related complication rates are conflicting at 0% in CT navigation compared with 0%-1.7% in 13 low- and moderate-quality studies. CONCLUSIONS: Although point estimates on breach rates are decreased with CT navigation compared with free-hand methods, complication rates remain conflicting between the two methods. Current evidence is limited by small sample sizes, lack of comparison groups, and poorly predefined complications. Randomized controlled trials with larger samples with standardized definitions and recording of predefined breach and complication occurrences are recommended.

Impact of PharmaNet-Based Admission Medication Reconciliation on Best Possible Medication Histories for Warfarin.

BACKGROUND: Inaccurate documentation of medication histories may lead to medication discrepancies during hospital admissions. Obtaining a best possible medication history (BPMH) for warfarin can be challenging because of frequent dosage changes and nonspecific directions of use (e.g., "take as directed"). On February 27, 2012, the study hospital implemented an admission medication reconciliation (MedRec) process using a form that compiled the most recent 6 months of outpatient prescription dispensing history from a provincial electronic database called PharmaNet. It was unclear whether admission MedRec had improved the process of obtaining warfarin BPMHs and the quality of their documentation. OBJECTIVE: To compare the rates of complete warfarin BPMH documentation before and after implementation of PharmaNet-based admission MedRec. METHODS: A single-centre, retrospective chart review was conducted using the health records of patients receiving warfarin who were admitted to the hospital's Internal Medicine service before and after implementation of admission MedRec. The study periods were October 1, 2009, to February 26, 2012, and February 27, 2012, to July 31, 2014, respectively. The primary outcome was the rate of complete warfarin BPMH documentation during each period. RESULTS: Data were recorded for 100 patients in the pre-implementation phase and 100 patients in the post-implementation phase. The rates of complete warfarin BPMH documentation were 65% and 84% in these 2 phases, respectively (p = 0.002). CONCLUSION: Implementation of PharmaNet-based admission MedRec was associated with a statistically significant increase in the rate of complete warfarin BPMH documentation.

La consignation inexacte des schémas thérapeutiques peut mener à des divergences au chapitre des médicaments durant l'hospitalisation. Il peut être difficile d'établir un meilleur schéma thérapeutique possible (MSTP) pour la warfarine à cause de fréquents changements de posologie et de modes d'emploi imprécis (par exemple, « usage connu ¼). Le 27 février 2012, l'hôpital où s'est déroulée l'étude a mis en place un processus de bilan comparatif des médicaments (BCM) à l'admission. Celui-ci emploie un formulaire dressant la liste des médicaments d'ordonnance délivrés aux patients externes au cours des six derniers mois selon PharmaNet, une base de données numérique provinciale. On ignorait si les BCM à l'admission avaient amélioré le processus d'obtention et la qualité de la consignation des MSTP liés à la warfarine.