Putting the Pieces Into Place: A Case of Systemic Polyarteritis Nodosa.

This is a case of systemic polyarteritis nodosa (PAN) in a 43-year-old male who initially presented to the hospital with a puzzling collection of signs and symptoms, including fever, arthralgias, myalgias, abdominal pain, dark urine, and rash. His illness evolved over the course of four weeks, and skin biopsy helped to clinch the diagnosis and lead to appropriate treatment. It is important to consider systemic PAN in the work-up of patients with subtle skin findings in the context of seemingly unrelated constitutional, abdominal, genitourinary, cardiac, and neurological signs and symptoms.

Primary Syphilis Presenting As a Chronic Lip Ulcer.

Syphilis is usually a sexually transmitted infection caused by the spirochete Treponema pallidum. Primary syphilis classically presents as a painless, ulcerated lesion on the genitals. However, the primary lesion is not restricted to this site and appears wherever the spirochete enters through the skin. The symptomatology and appearance of the primary lesion can also vary.  We present a case of a 59-year-old man with a primary syphilitic chancre of the lower lip. The patient was referred to the dermatology clinic by their primary care provider after the ulceration failed to heal with antibiotic therapy. A biopsy of the lesion was taken at this time; the diagnosis of syphilis was then made by histologic examination and immunohistochemical staining. Subsequent serologic tests were also positive. Upon prompting, the patient did report a history of sexually transmitted disease but not of syphilis specifically. The patient was treated with penicillin, and there was clinical improvement of the lesion at the follow-up visit.

Impact of the Economic Downturn on Elective Lumbar Spine Surgery in the United States: A National Trend Analysis, 2003 to 2013.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: The impact of the 2008-2009 economic downtown on elective lumbar spine surgery is unknown. Our objective was to investigate the effect of the economic downturn on the overall trends of elective lumbar spine surgery in the United States. METHODS: The Nationwide Inpatient Sample (NIS) was used in conjunction with US Census and macroeconomic data to determine historical trends. The economic downturn was defined as 2008 to 2009. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), were used in order to identify appropriate procedures. Confidence intervals were determined using subgroup analysis techniques. RESULTS: From 2003 to 2012, there was a 19.8% and 26.1% decrease in the number of lumbar discectomies and laminectomies, respectively. Over the same time period, there was a 56.4% increase in the number of lumbar spinal fusions. The trend of elective lumbar spine surgeries per 100 000 persons in the US population remained consistent from 2008 to 2009. The number of procedures decreased by 4.5% from 2010 to 2011, 7.6% from 2011 to 2012, and 3.1% from 2012 to 2013. The R2 value between the number of surgeries and the S&P 500 Index was statistically significant (P ≤ .05). CONCLUSIONS: The economic downturn did not affect elective lumbar fusions, which increased in total from 2003 to 2013. The relationship between the S&P 500 Index and surgical trends suggests that during recessions, individuals may utilize other means, such as insurance, to cover procedural costs and reduce out-of-pocket expenditures, accounting for no impact of the economic downturn on surgical trends. These findings can assist multiple stakeholders in better understanding the interconnectedness of macroeconomics, policy, and elective lumbar spine surgery trends.

Impact of the Economic Downturn on Elective Cervical Spine Surgery in the United States: A National Trend Analysis, 2003-2013.

OBJECTIVE: To analyze overall trends of elective cervical spine surgery in the United States from 2003 to 2013 with the goal of determining whether the economic downturn had an impact. METHODS: Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification were used to identify elective cervical spine surgery procedures in the Nationwide Inpatient Sample from 2003 to 2013. National Health Expenditure, gross domestic product, and S&P 500 Index were used as measures of economic performance. The economic downturn was defined as 2008-2009. Confidence intervals were determined using subgroup analysis techniques. Linear regressions were completed to determine the association between surgery trends and economic conditions. RESULTS: From 2003 to 2013, posterior cervical fusions saw a 102.7% increase. During the same time frame, there was a 7.4% and 14.7% decrease in the number of anterior cervical diskectomy and fusions (ACDFs) and posterior decompressions, respectively. The trend of elective cervical spine surgeries per 100,000 persons in the U.S. population may have been affected by the economic downturn from 2008 to 2009 (-0.03% growth). The percentage of procedures paid for by private insurance decreased from 2003 to 2013 for all ACDFs, posterior cervical fusions, and posterior decompressions. The linear regression coefficients (ß) and R2 values between the number of surgeries and each of the macroeconomic factors analyzed were not statistically significant. CONCLUSIONS: The overall elective cervical spine surgery trend was not likely impacted by the economic downturn. Posterior cervical fusions grew significantly from 2003 to 2013, whereas ACDFs and posterior decompressions decreased.

National trends in the management of central cord syndrome: an analysis of 16,134 patients.

BACKGROUND CONTEXT: Central cord syndrome (CCS) is a common cause of incomplete spinal cord injury. However, to date, national trends in the management and mortality after CCS are not fully understood. PURPOSE: To analyze how patient, surgical, and institutional factors influence surgical management and mortality after CCS. STUDY DESIGN: A retrospective cohort analysis. PATIENT SAMPLE: The Nationwide Inpatient Sample (NIS) was queried for records of patients with a diagnosis of CCS from 2003 to 2010. OUTCOME MEASURES: They included in hospital mortality and surgical management, including anterior cervical decompression and fusion (ACDF), posterior cervical decompression and fusion (PCDF), and posterior cervical decompression (PCD). METHODS: Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, patient records with a diagnosis of CCS from 2003 to 2010 were selected from the NIS database and sorted by inpatient mortality and surgical management. Demographic information (age, gender, and race) and hospital characteristics were evaluated with χ(2)-tests for categorical variables and t tests for continuous variables. Multivariate logistic regression models controlled for confounding. RESULTS: In this sample of 16,134 patients, a total of 39.7% of patients (6,351) underwent surgery. ACDF was most common (19.4%), followed by PCDF (7.4%) and PCD (6.8%). From 2003 to 2010, surgical management increased by an average of 40% each year. The overall inpatient mortality rate was 2.6%. Increasing age and comorbidities were associated with higher rates of patient mortality and a decreasing surgical rate (p<.01). Hospitals greater than 249 beds (p<.01) and the south (p<.01) were associated with a higher surgical rate. Rural hospitals (p<.01) and people in the second income quartile (p<.01) were associated with higher inpatient mortality. CONCLUSIONS: Elderly patients with medical comorbidities are associated with a lower surgical rate and a higher mortality rate. Surgical management was more prevalent in the south and large hospitals. Mortality was higher in rural hospitals. It is important for surgeons to understand how patient, surgical, and institutional factors influence surgical management and mortality.

Carbidopa/levodopa dose elevation and safety concerns in Parkinson's patients: a cross-sectional and cohort design.

OBJECTIVE: Sinemet, a combination drug containing carbidopa and levodopa is considered the gold standard therapy for the treatment of Parkinson's disease (PD). When approved by the Food and Drug Administration (FDA) in 1988, a maximum daily dosage limit of 800 mg (eight tablets) of the 25/100 carbidopa/levodopa formulation was introduced. Overall, the FDA approval was a historic success; however, the pill limit has been hardcoded into many online medical record systems. This study investigates the 800 mg threshold by using a prospectively collected database of patient information. DESIGN: A retrospective cohort study: (Part I) cross-sectional, (Part II) longitudinal. SETTING AND PARTICIPANTS: PD patients at a Movement Disorders Center in a large academic, tertiary medical setting. OUTCOME MEASURES: An analysis was performed using carbidopa/levodopa at dosages below and above the 800 mg threshold. A secondary analysis was then performed using two consecutive clinic visits to determine the effects of crossing the 800 mg threshold. Comparisons were made on standardised scales. RESULTS: There was no significant difference in motor, mood and quality-of-life scores in patients consuming below and above the 800 mg carbidopa/levodopa threshold, though a mild worsening in dyskinesia duration was noted without worsening in dyskinesia pain and disability. In PD patients who crossed the 800 mg threshold between two consecutive clinic visits, a significant improvement in depressive symptoms and quality-of-life measures was demonstrated, and in these patients there was no worsening of motor fluctuations or dyskinesia. CONCLUSIONS: The data suggest that PD patients have the potential for enhanced clinical benefits when eclipsing the 800 mg carbidopa/levodopa threshold. Many patients will likely need to eclipse the 800 mg threshold and pharmacies and insurance companies should be aware of the requirements that may extend beyond approval limits.