The virtual hallway consult as an effective means of continuing professional development in physiatry

Background: A personal learning project (PLP) is an accredited form of Continuing Professional Development (CPD) in Canada, and is a self-initiated learning activity that is stimulated by a question, issue or dilemma in one’s professional practice. Many complex cases or issues have no answers that are readily available. Many physicians rely day to day on other physician colleagues that they may consult in their institution. Given the paucity of same specialty Physical Medicine and Rehabilitation colleagues in Canadian centres, the idea of Virtual Spinal Cord Injury (SCI) Hallway germinated, to provide a simple tool to extend our hallways to reach colleagues with similar interests across the country.Methods: The Virtual SCI Hallway is a service set up on Yahoo Groups, with no cost to the users. On this invite-only site, members may post a question, and then all members receive the post by email. Any member may respond.Results: The SCI Hallway has been running successfully for over 13 years. As of January 2017, there were 38 members, with 2124 messages within approximately 324 conversations. Activity has been consistent since 2003. Questions and posts are not always medical expert related; there are also advocacy, professional, and scholar-role related posts.Discussion: Communication amongst specialists about practice and management of complicated problems is important for CPD, yet is difficult in subspecialized areas of medicine. Although there are many chat-pages in different areas of medicine on the internet, to our knowledge, there is not another secure, invite-only site that is low-maintenance and no cost

Pharmacological Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury and Multiple Sclerosis: A Systematic Review and Clinical Implications

Neurogenic bowel dysfunction (NBD) is a common problem for people with spinal cord injury (SCI) and multiple sclerosis (MS), which seriously impacts quality of life. Pharmacological management is an important component of conservative bowel management. The objective of this study was to first assemble a list of pharmacological agents (medications and medicated suppositories) used in current practice. Second, we systematically examined the current literature on pharmacological agents to manage neurogenic bowel dysfunction of individuals specifically with SCI or MS. We searched Medline, EMBASE and CINAHL databases up to June 2020. We used the GRADE System to provide a systematic approach for evaluating the evidence. Twenty-eight studies were included in the review. We found a stark discrepancy between the large number of agents currently prescribed and a very limited amount of literature. While there was a small amount of literature in SCI, there was little to no literature available for MS. There was low-quality evidence supporting rectal medications, which are a key component of conservative bowel care in SCI. Based on the findings of the literature and the clinical experience of the authors, we have provided clinical insights on proposed treatments and medications in the form of three case study examples on patients with SCI or MS.Medicine, Faculty ofNon UBCPhysical Therapy, Department ofReviewedFacult

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long-term extension study

Aims: To present final efficacy/safety results from a prospective, long-term extension trial of onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO); patients received treatment for up to 4 years. Methods: Patients who completed a 52-week, phase III trial of onabotulinumtoxinA for NDO were eligible to enter a 3-year, multicenter, open-label extension study of intradetrusor onabotulinumtoxinA (200U or 300U). Patients were treated “as needed” based on their request and fulfillment of prespecified qualification criteria (≥12 weeks since previous treatment and a UI episode threshold). Assessments included change from study baseline in UI episodes/day (primary efficacy measure), volume/void, and Incontinence Quality of Life (I-QOL) total score (week 6); duration of effect; adverse events (AEs); and initiation of de novo clean intermittent catheterization (CIC). Data are presented for up to six treatments. Results: OnabotulinumtoxinA 200U consistently reduced UI episodes/day; reductions from baseline ranged from –3.2 to –4.1 across six treatments. Volume/void consistently increased, nearly doubling after treatment. I-QOL improvements were consistently greater than twice the minimally important difference (+11 points). Overall median duration of effect was 9.0 months (200U). Results were similar for onabotulinumtoxinA 300U. Most common AEs were urinary tract infections and urinary retention. De novo CIC rates were 29.5, 3.4, and 6.0% (200U), and 43.0, 15.0, and 4.8% (300U) for treatments 1–3, respectively; de novo CIC rates were 0% for treatments 4–6. Conclusions: OnabotulinumtoxinA treatments consistently improve UI, volume/void, and QOL in patients with UI due to NDO in this 4-year study, with no new safety signals. Neurourol. Urodynam. 36:368–375, 2017

“The ABCs of AD”: A prospective evaluation of the efficacy of an educational intervention to increase knowledge of autonomic dysreflexia management among emergency health care professionals

<p><b>Context/Objective:</b> Despite the availability of consensus-based resources, first responders and emergency room (ER) health care professionals (HCPs) have limited knowledge regarding autonomic dysreflexia (AD) recognition and treatment. The purpose of this study was to assess the efficacy of “The ABCs of AD” educational seminar for improving HCPs’ short- and long-term knowledge of AD recognition, diagnosis, and management.</p> <p><b>Design:</b> Multi-center prospective pre, post, and follow-up questionnaire study.</p> <p><b>Setting:</b> Level I trauma centers with emergency departments in British Columbia, Manitoba, and Ontario.</p> <p><b>Methods:</b> ER professionals completed measures immediately before and after (<i>n</i> = 108), as well as 3-months following (<i>n</i> = 23), attendance at “The ABCs of AD” seminar.</p> <p><b>Outcome Measures:</b> AD knowledge test; seminar feedback.</p> <p><b>Results:</b> Following the seminar, participants had higher ratings of their AD knowledge and had significantly higher AD knowledge test scores (M ± SD pre = 11.85 ± 3.88, M ± SD post = 18.95 ± 2.39, out of 22; P < 0.001, <i>d</i> = 2.21). Most participants believed the seminar changed their AD knowledge, and rated the seminar information as having the potential to influence and change their practice. AD knowledge test scores significantly decreased between post-seminar and 3-month follow-up (M ± SD 3mo = 17.04 ± 3.28; P = 0.004, <i>d</i> = –0.70); however, 3-month scores remained significantly higher than baseline.</p> <p><b>Conclusion:</b> “The ABCs of AD” seminar improves HCPs’ perceived and actual AD knowledge in the short-term. To enhance knowledge retention in both the short- and long-term, the inclusion of additional active learning strategies and follow-up activities are recommended. The seminar is being translated into an online training module to enhance the dissemination of the AD clinical practice guidelines among first responders, ER staff, and SCI practitioners.</p

A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity.

Objective To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. Design We used the Delphi method. Setting A multiquestion electronic survey. Participants Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. Interventions After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. Main Outcome Measures Not applicable. Results When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. Conclusions These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature