The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: introduction, methodology and recommendation overview

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to develop the first Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada.

METHODS

The guidelines were developed in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The Working Group developed 12 recommendations for screening and diagnosis, 12 recommendations for treatment and 5 recommendations for models of care. Important clinical considerations accompany each recommendation.

CONCLUSIONS

The Working Group recommendations for the management of neuropathic pain after SCI should be used to inform practice.

Targeting the latent cytomegalovirus reservoir with an antiviral fusion toxin protein

Reactivation of human cytomegalovirus (HCMV) in transplant recipients can cause life-threatening disease. Consequently, for transplant recipients, killing latently infected cells could have far-reaching clinical benefits. In vivo, myeloid cells and their progenitors are an important site of HCMV latency, and one viral gene expressed by latently infected myeloid cells is US28. This viral gene encodes a cell surface G protein-coupled receptor (GPCR) that binds chemokines, triggering its endocytosis. We show that the expression of US28 on the surface of latently infected cells allows monocytes and their progenitor CD34+ cells to be targeted and killed by F49A-FTP, a highly specific fusion toxin protein that binds this viral GPCR. As expected, this specific targeting of latently infected cells by F49A-FTP also robustly reduces virus reactivation in vitro. Consequently, such specific fusion toxin proteins could form the basis of a therapeutic strategy for eliminating latently infected cells before haematopoietic stem cell transplantation.

An integrated analysis identifies STAT4 as a key regulator of ovarian cancer metastasis

Epithelial ovarian cancer (EOC) is one of the most common gynecological cancers, with diagnosis often at a late stage. Metastasis is a major cause of death in patients with EOC, but the underlying molecular mechanisms remain obscure. Here, we utilized an integrated approach to find potential key transcription factors involved in ovarian cancer metastasis and identified STAT4 as a critical player in ovarian cancer metastasis. We found that activated STAT4 was overexpressed in epithelial cells of ovarian cancer and STAT4 overexpression was associated with poor outcome of ovarian cancer patients, which promoted metastasis of ovarian cancer in both in vivo and in vitro. Although STAT4 mediated EOC metastasis via inducing epithelial-to-mesenchymal transition (EMT) of ovarian cancer cells in vivo, STAT4 failed to induce EMT directly in vitro, suggesting that STAT4 might mediate EMT process via cancer-stroma interactions. Further functional analysis revealed that STAT4 overexpression induced normal omental fibroblasts and adipose- and bone marrow-derived mesenchymal stem cells to obtain cancer-associated fibroblasts (CAF)-like features via induction of tumor-derived Wnt7a. Reciprocally, increased production of CAF-induced CXCL12, IL6 and VEGFA within tumor microenvironment could enable peritoneal metastasis of ovarian cancer via induction of EMT program. In summary, our study established a model that STAT4 promotes ovarian cancer metastasis via tumor-derived Wnt7a-induced activation of CAFs.

Effect of alcohol consumption on all-cause and liver-related mortality among HIV-infected individuals

OBJECTIVES

The aim of the study was to examine the association between levels of past and current alcohol consumption and all-cause and liver-related mortality among people living with HIV (PLWH).

METHODS

A prospective cohort study of 1855 PLWH in Baltimore, MD was carried out from 2000 to 2013. We ascertained alcohol use by (1) self-report (SR) through a computer-assisted self interview, and (2) medical record abstraction of provider-documented (PD) alcohol use. SR alcohol consumption was categorized as heavy (men: > 4 drinks/day or > 14 drinks/week; women: > 3 drinks/day or > 7 drinks/week), moderate (any alcohol consumption less than heavy), and none. We calculated the cumulative incidence of liver-related mortality and fitted adjusted cause-specific regression models to account for competing risks.

RESULTS

All-cause and liver-related mortality rates (MRs) were 43.0 and 7.2 per 1000 person-years (PY), respectively. All-cause mortality was highest among SR nondrinkers with PD recent (< 6 months) heavy drinking (MR = 85.4 deaths/1000 PY) and lowest among SR moderate drinkers with no PD history of heavy drinking (MR = 23.0 deaths/1000 PY). Compared with SR moderate drinkers with no PD history of heavy drinking, SR nondrinkers and moderate drinkers with PD recent heavy drinking had higher liver-related mortality [hazard ratio (HR) = 7.28 and 3.52, respectively]. However, SR nondrinkers and moderate drinkers with a PD drinking history of > 6 months ago showed similar rates of liver-related mortality (HR = 1.06 and 2.00, respectively).

CONCLUSIONS

Any heavy alcohol consumption was associated with all-cause mortality among HIV-infected individuals, while only recent heavy consumption was associated with liver-related mortality. Because mortality risk among nondrinkers varies substantially by drinking history, current consumption alone is insufficient to assess risk.

Transient activation of human cytomegalovirus lytic gene expression during latency allows cytotoxic T cell killing of latently infected cells

Human cytomegalovirus (HCMV) latency in the myeloid lineage is maintained by repressive histone modifications around the major immediate early promoter (MIEP), which results in inhibition of the lytic viral life cycle. We now show that pharmacological inhibition of histone deacetylases (HDACs) relieves this repression of the MIEP and induces transient expression of the viral lytic immediate early (IE) antigens but, importantly, not full virus reactivation. In turn, these latently infected cells now become targets for IE-specific cytotoxic T cells (CTLs) which are present at high frequency in all normal healthy HCMV positive carriers but would normally be unable to target latent (lytic antigen-negative) cells. This approach of transiently inducing viral lytic gene expression by HDAC inhibition, in otherwise latently infected cells, offers a window of opportunity to target and purge the latent myeloid cell reservoir by making these normally immunologically undetectable cells visible to pre-existing host immune responses to viral lytic antigens.

Short-term Outcomes of Laparoscopic versus Open Formal Anatomical Hepatectomy: A Case Matched Control Study

Variability in extent and complexity of hepatic resection complicates prior laparoscopic (LH) and open (OH) hepatectomy comparisons. This study compares the 30-day outcomes of formal anatomical LH and OH by matching patients by location and extent of resection. A retrospective review was conducted for patients undergoing formal anatomical hepatectomies from January 2008 to November 2014. Of 580 liver procedures, 78 formal OH and 47 LH meeting criteria were identified. A total of 26 pairs were strictly matched based on resection extent and location, underlying pathology, age, and gender. The primary outcome was complication rate. Secondary outcomes were intraoperative blood loss estimated blood loss, procedure time, transfusion, and hospital stay. The groups were similar with regard to patient demographics. Right or left hepatectomy were most common (14 pairs, 53.8%). On average, 2.8 liver segments were resected. Nine LH cases (36%) were converted to open. Using intention to treat analysis, there were no significant differences in overall complications (46% vs 54%, P = 0.274) or major (Clavien ≥ 3) complications (19% vs 8%, P = 0.223), mean estimated blood loss (386 vs 556 mL, P = 0.216), procedure time (269 vs 255 minutes, P = 0.406, or hospital stay (6.0 vs 5.6 days, P = 0.643). When appropriately matched, there were equivalent short-term outcomes between formal LH and OH.

Measurement Properties of the Nordic Questionnaire for Psychological and Social Factors at Work: A Rasch Analysis

The main aim of this study was to evaluate the measurement properties of the Nordic Questionnaire for Psychological and Social Factors at Work (QPS Nordic) and the domains of demand, control and support. The Rasch analysis (RUMM 2030) was based on responses from 226 subjects with back pain who completed the QPS Nordic dimensions of demand, control, and social support (30 items) at one year follow up. The Rasch analysis revealed disordered thresholds in a total of 25 of the 30 items. The domains of demand, control and support fit the Rasch model when analyzed separately. The demand domain was well targeted, whereas patients with current neck and back pain had lower control and higher support than reflected by the questions. Two items revealed DIF by gender, otherwise invariance to age, gender, occupation and sick-leave was documented. The demand, control support domains of QPS Nordic comprised unidimensional constructs with adequate measurement properties.

Body mass index and early CD4 T-cell recovery among adults initiating antiretroviral therapy in North America, 1998-2010

OBJECTIVES

Adipose tissue affects several aspects of the cellular immune system, but prior epidemiological studies have differed on whether a higher body mass index (BMI) promotes CD4 T-cell recovery on antiretroviral therapy (ART). The objective of this analysis was to assess the relationship between BMI at ART initiation and early changes in CD4 T-cell count.

METHODS

We used the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data set to analyse the relationship between pre-treatment BMI and 12-month CD4 T-cell recovery among adults who started ART between 1998 and 2010 and maintained HIV-1 RNA levels < 400 copies/mL for at least 6 months. Multivariable regression models were adjusted for age, race, sex, baseline CD4 count and HIV RNA level, year of ART initiation, ART regimen and clinical site.

RESULTS

A total of 8381 participants from 13 cohorts contributed data; 85% were male, 52% were nonwhite, 32% were overweight (BMI 25-29.9 kg/m(2) ) and 15% were obese (BMI > 30 kg/m(2) ). Pretreatment BMI was associated with 12-month CD4 T-cell change (P < 0.001), but the relationship was nonlinear (P < 0.001). Compared with a reference of 22 kg/m(2) , a BMI of 30 kg/m(2) was associated with a 36 cells/μL [95% confidence interval (CI) 14, 59 cells/μL] greater CD4 T-cell count recovery among women and a 19 cells/μL (95% CI 9, 30 cells/μL) greater recovery among men at 12 months. At a BMI > 30 kg/m(2) , the observed benefit was attenuated among men to a greater degree than among women, although this difference was not statistically significant.

CONCLUSIONS

A BMI of approximately 30 kg/m(2) at ART initiation was associated with greater CD4 T-cell recovery at 12 months compared with higher or lower BMI values, suggesting that body composition may affect peripheral CD4 T-cell recovery.

The association between use of a clinical decision support tool and adherence to monitoring for medication-laboratory guidelines in the ambulatory setting

BACKGROUND

Stage 2 Meaningful Use criteria require the use of clinical decision support systems (CDSS) on high priority health conditions to improve clinical quality measures. Although CDSS hold great promise, implementation has been fraught with challenges, evidence of their impact is mixed, and the optimal method of content delivery is unknown.

OBJECTIVE

The authors investigated whether implementation of a simple clinical decision support (CDS) tool was associated with improved prescriber adherence to national medication-laboratory monitoring guidelines for safety (hepatic function, renal function, myalgias/rhabdomyolysis) and intermediate outcomes for antidiabetic (Hemoglobin A(1c); HbA(1c)) and antihyperlipidemic (low density lipoprotein; LDL) medications prescribed within a diabetes registry.

METHODS

This was a retrospective observational study conducted in three phases of CDS implementation (2008-2009): pre-, transition-, and post-Prescriptions evaluated were ordered from an electronic health record within a multispecialty medical group. Adherence was evaluated within and without applying guideline-imposed time constraints.

RESULTS

Forty-thousand prescriptions were ordered over three timeframes. For hepatic and renal function, the proportion of prescriptions for which labs were monitored at any time increased from 52% to 65% (p<0.001); those that met time guidelines, from 14% to 21% (p<0.001). Only 6% of required labs were drawn to monitor for myalgias/rhabdomyolysis, regardless of timeframe. Over 90% of safety labs were within normal limits. The proportion of labs monitored at any time for LDL increased from 56% to 64% (p<0.001); those that met time guidelines from 11% to 17% (p<0.001). The proportion of labs monitored at any time for HbA(1c) remained the same (72%); those that met time guidelines decreased from 45% to 41% (p<0.001).

CONCLUSION

A simple CDS tool may be associated with improved adherence to guidelines. Efforts are needed to confirm findings and improve the timeliness of monitoring; investigations to optimize alerts should be ongoing.

Obesity Increases the Odds of Acquiring and Incarcerating Noninguinal Abdominal Wall Hernias

The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 ( P < 0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P < 0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 ( P < 0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.

Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias

The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 (P<0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P<0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 (P<0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.

Does Preoperative Magnetic Resonance Imaging Beneficially Alter Surgical Management of Invasive Lobular Carcinoma?

The role of breast magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer remains controversial. The objective of this study is to determine the impact of preoperative breast MRI on patients with biopsy-proven invasive lobular carcinoma (ILC) initially deemed eligible for breast conserving therapy. We analyzed a prospective cohort study of patients with biopsy-proven ILC that consented to undergo preoperative diagnostic MRI at our institution. Data analysis of 20 patients accrued from January 2010 through January 2011 was performed. Outcome measures included discovery of occult lesions, need for additional biopsies, change in surgical management, and need for surgical reexcision. MRI found an additional cancer in 40 per cent of patients and increased extent of disease in one patient. MRI led to eight biopsies, for a pathologically confirmed true positive rate of 82 per cent [95% confidence interval (CI) 62-101%] and only two unnecessary biopsies. Preoperative MRI beneficially altered surgical management in 42 per cent of patients (95% CI 19-65%) without leading to unnecessary surgery, and only one patient required reexcision for positive margins (5.8%, CI -5.8-17.4%). In conclusion, preoperative MRI in patients with ILC can detect additional disease that was missed by conventional workup, allowing for better preoperative planning and more appropriate oncologic resection.

Does preoperative magnetic resonance imaging beneficially alter surgical management of invasive lobular carcinoma?

The role of breast magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer remains controversial. The objective of this study is to determine the impact of preoperative breast MRI on patients with biopsy-proven invasive lobular carcinoma (ILC) initially deemed eligible for breast conserving therapy. We analyzed a prospective cohort study of patients with biopsy-proven ILC that consented to undergo preoperative diagnostic MRI at our institution. Data analysis of 20 patients accrued from January 2010 through January 2011 was performed. Outcome measures included discovery of occult lesions, need for additional biopsies, change in surgical management, and need for surgical reexcision. MRI found an additional cancer in 40 per cent of patients and increased extent of disease in one patient. MRI led to eight biopsies, for a pathologically confirmed true positive rate of 82 per cent [95% confidence interval (CI) 62-101%] and only two unnecessary biopsies. Preoperative MRI beneficially altered surgical management in 42 per cent of patients (95% CI 19-65%) without leading to unnecessary surgery, and only one patient required reexcision for positive margins (5.8%, CI -5.8-17.4%). In conclusion, preoperative MRI in patients with ILC can detect additional disease that was missed by conventional workup, allowing for better preoperative planning and more appropriate oncologic resection.

An Acute Care Surgery Model Improves Timeliness of Care and Reduces Hospital Stay for Patients with Acute Cholecystitis

In October 2009, an acute care surgery (ACS) model was implemented to facilitate urgent surgical consults. This study examines the impact of ACS on the timeliness of care and length of hospitalization for patients with acute cholecystitis. A retrospective cohort study was performed of patients presenting to the emergency department (ED) with acute cholecystitis who underwent early cholecystectomy. Patients with choledocholithiasis, pancreatitis, biliary colic, or cholelithiasis without cholecystitis were excluded. There were two study cohorts: ACS (October 2009 to July 2010) and pre-ACS (October 2008 to September 2009). Primary outcome measures were length of stay (LOS) and time from the ED to the operating room (OR). One hundred fifty-two cases were identified: 71 in the ACS group and 81 in the pre-ACS group. Patient demographics were similar. The ACS group had a significantly shorter average time from the ED to the OR (24.6 vs 35.0 hours, P = 0.0276). Overall LOS was reduced by a mean of 14.7 hours in the ACS group (mean 3.23 vs 2.63 days, P = 0.11). There was no significant difference in OR time (2.45 vs 2.38 hours, P = 0.562). There was a significant decrease in after-hours cases in the ACS group (5.6 vs 21%, P = 0.004) and a decrease in complication rates (18.5 vs 7.0%, P = 0.032). In conclusion, the ACS model decreased time from the ED to the OR, decreased after-hours cases, decreased length of hospitalization, and decreased complications for patients with acute cholecystitis.

An acute care surgery model improves timeliness of care and reduces hospital stay for patients with acute cholecystitis

In October 2009, an acute care surgery (ACS) model was implemented to facilitate urgent surgical consults. This study examines the impact of ACS on the timeliness of care and length of hospitalization for patients with acute cholecystitis. A retrospective cohort study was performed of patients presenting to the emergency department (ED) with acute cholecystitis who underwent early cholecystectomy. Patients with choledocholithiasis, pancreatitis, biliary colic, or cholelithiasis without cholecystitis were excluded. There were two study cohorts: ACS (October 2009 to July 2010) and pre-ACS (October 2008 to September 2009). Primary outcome measures were length of stay (LOS) and time from the ED to the operating room (OR). One hundred fifty-two cases were identified: 71 in the ACS group and 81 in the pre-ACS group. Patient demographics were similar. The ACS group had a significantly shorter average time from the ED to the OR (24.6 vs 35.0 hours, P = 0.0276). Overall LOS was reduced by a mean of 14.7 hours in the ACS group (mean 3.23 vs 2.63 days, P = 0.11). There was no significant difference in OR time (2.45 vs 2.38 hours, P = 0.562). There was a significant decrease in after-hours cases in the ACS group (5.6 vs 21%, P = 0.004) and a decrease in complication rates (18.5 vs 7.0%, P = 0.032). In conclusion, the ACS model decreased time from the ED to the OR, decreased after-hours cases, decreased length of hospitalization, and decreased complications for patients with acute cholecystitis.