The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial

BACKGROUND

The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment.

METHODS

One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group).

RESULTS

There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001).

CONCLUSIONS

Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.

Weighted multiple testing procedures for genomic studies

With the rapid development of biological technology, measurement of thousands of genes or SNPs can be carried out simultaneously. Improved procedures for multiple hypothesis testing when the number of tests is very large are critical for interpreting genomic data. In this paper, we review recent developments on three distinct but closely related methods involving p-value weighting to improve statistical power while also controlling for the false discovery rate or the family wise error rate.

Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes

OBJECTIVE

To determine whether exposure to repetitive head impacts over a single season negatively affects cognitive performance in collegiate contact sport athletes.

METHODS

This is a prospective cohort study at 3 Division I National Collegiate Athletic Association athletic programs. Participants were 214 Division I college varsity football and ice hockey players who wore instrumented helmets that recorded the acceleration-time history of the head following impact, and 45 noncontact sport athletes. All athletes were assessed prior to and shortly after the season with a cognitive screening battery (ImPACT) and a subgroup of athletes also were assessed with 7 measures from a neuropsychological test battery.

RESULTS

Few cognitive differences were found between the athlete groups at the preseason or postseason assessments. However, a higher percentage of the contact sport athletes performed more poorly than predicted postseason on a measure of new learning (California Verbal Learning Test) compared to the noncontact athletes (24% vs 3.6%; p < 0.006). On 2 postseason cognitive measures (ImPACT Reaction Time and Trails 4/B), poorer performance was significantly associated with higher scores on several head impact exposure metrics.

CONCLUSION

Repetitive head impacts over the course of a single season may negatively impact learning in some collegiate athletes. Further work is needed to assess whether such effects are short term or persistent.

Polymorphisms in the brain-derived neurotrophic factor gene influence memory and processing speed one month after brain injury

Brain-derived neurotrophic factor (BDNF) plays a role in cognition, as well as neural survival and plasticity. There are several common polymorphisms in the BDNF gene, one of which (rs6265) is an extensively studied non-synonymous coding polymorphism (Val66Met) which has been linked to cognitive performance in healthy controls and some clinical populations. We hypothesized that the Met allele of rs6265 would be associated with poorer cognitive performance in individuals with mild-to-moderate traumatic brain injury, and that other polymorphisms in the BDNF gene would also affect cognition. Genotype at 9 single-nucleotide polymorphisms (SNPs) in the BDNF gene, and measures of speed of information processing, learning, and memory were assessed in 75 patients with mTBI and 38 healthy subjects. Consistent with previous reports, the Met allele of rs6265 was associated with cognition (slower processing speed) in the entire group. Two other SNPs were associated with processing speed in the mTBI group, but both are in linkage disequilibrium with rs6265, and neither remained significant after adjustment for rs6265 status. Within the mTBI group, but not the controls, 4 SNPs, but not rs6265, were associated with memory measures. These associations were not affected by adjustment for rs6265 status. Polymorphisms in BDNF influence cognitive performance shortly after mTBI. The results raise the possibility that a functional polymorphism other than rs6265 may contribute to memory function after mTBI.

Longitudinal structural mixed models for the analysis of surgical trials with noncompliance

Patient noncompliance complicates the analysis of many randomized trials seeking to evaluate the effect of surgical intervention as compared with a nonsurgical treatment. If selection for treatment depends on intermediate patient characteristics or outcomes, then 'as-treated' analyses may be biased for the estimation of causal effects. Therefore, the selection mechanism for treatment and/or compliance should be carefully considered when conducting analysis of surgical trials. We compare the performance of alternative methods when endogenous processes lead to patient crossover. We adopt an underlying longitudinal structural mixed model that is a natural example of a structural nested model. Likelihood-based methods are not typically used in this context; however, we show that standard linear mixed models will be valid under selection mechanisms that depend only on past covariate and outcome history. If there are underlying patient characteristics that influence selection, then likelihood methods can be extended via maximization of the joint likelihood of exposure and outcomes. Semi-parametric causal estimation methods such as marginal structural models, g-estimation, and instrumental variable approaches can also be valid, and we both review and evaluate their implementation in this setting. The assumptions required for valid estimation vary across approaches; thus, the choice of methods for analysis should be driven by which outcome and selection assumptions are plausible.

Growth in the use of PET for six cancer types after coverage by medicare: additive or replacement?

BACKGROUND

In July 2001, PET became a covered service for Medicare beneficiaries when used for the diagnosis, staging, and restaging of non-small-cell lung, esophageal, colorectal, and head and neck cancers as well as lymphoma and melanoma. Whether physicians use PET as a replacement for or in addition to CT, MRI, or bone scintigraphy (BS) is uncertain.

METHODS

A 20% sample of Medicare fee-for-service beneficiaries aged > 64 years from 2004 through 2008 was used. Annually for each cancer type, a cohort of patients was created defined as having at least one admission with a primary cancer diagnosis or two nonhospital claims with a cancer diagnosis ≥7 days apart per calendar year. Each year, imaging claims and claim-days were counted by modality and cancer type. The sequence of PET use was examined as before, after, or instead of other imaging.

RESULTS

About 125,000 beneficiaries (2.5% of the cohort) met the cancer definition each year. In 2008, the combined annual imaging days per person-year were 2.3 for CT, 0.49 for MRI, 0.70 for PET, and 0.13 for BS. The annual rates of imaging from 2004 to 2008 increased by 0.5% for CT, 3.2% for MRI, and 18.0% for PET (range, 14.6%-19.9% by cancer type) and decreased by 12.7% for BS. The growth in PET use was not associated with meaningful changes in body CT. In 2007 and 2008, body CT preceded PET within 30 days in about half of patients, whereas PET preceded CT in only 22%.

CONCLUSIONS

Several years after its introduction, PET continued to grow rapidly, with evidence that it is replacing BS. Growth of PET occurred without evidence of a decline in body CT. About half of PET use occurred shortly after body CT, suggesting an additive or final arbiter role.

δ-aminolevulinic acid-induced protoporphyrin IX concentration correlates with histopathologic markers of malignancy in human gliomas: the need for quantitative fluorescence-guided resection to identify regions of increasing malignancy

Extent of resection is a major goal and prognostic factor in the treatment of gliomas. In this study we evaluate whether quantitative ex vivo tissue measurements of δ-aminolevulinic acid-induced protoporphyrin IX (PpIX) identify regions of increasing malignancy in low- and high-grade gliomas beyond the capabilities of current fluorescence imaging in patients undergoing fluorescence-guided resection (FGR). Surgical specimens were collected from 133 biopsies in 23 patients and processed for ex vivo neuropathological analysis: PpIX fluorimetry to measure PpIX concentrations (C(PpIX)) and Ki-67 immunohistochemistry to assess tissue proliferation. Samples displaying visible levels of fluorescence showed significantly higher levels of C(PpIX) and tissue proliferation. C(PpIX) was strongly correlated with histopathological score (nonparametric) and tissue proliferation (parametric), such that increasing levels of C(PpIX) were identified with regions of increasing malignancy. Furthermore, a large percentage of tumor-positive biopsy sites (∼40%) that were not visibly fluorescent under the operating microscope had levels of C(PpIX) greater than 0.1 µg/mL, which indicates that significant PpIX accumulation exists below the detection threshold of current fluorescence imaging. Although PpIX fluorescence is recognized as a visual biomarker for neurosurgical resection guidance, these data show that it is quantitatively related at the microscopic level to increasing malignancy in both low- and high-grade gliomas. This work suggests a need for improved PpIX fluorescence detection technologies to achieve better sensitivity and quantification of PpIX in tissue during surgery.

Alpha-2 adrenergic challenge with guanfacine one month after mild traumatic brain injury: altered working memory and BOLD response

Alterations in working memory (WM) are common after traumatic brain injury (TBI). Frontal catecholaminergic systems, including the alpha-2 adrenergic system, modulate WM function and may be affected in TBI. We hypothesized that administration of an alpha-2 adrenergic agonist might improve WM after mild TBI (MTBI). Thirteen individuals with MTBI 1month after injury and 14 healthy controls (HC) were challenged with guanfacine and placebo prior to administration of a verbal WM functional MRI task. Guanfacine was associated with improved WM performance in the MTBI but not the HC group. On guanfacine the MTBI group showed increased activation within a WM task-specific region of interest. Findings are consistent with the hypothesis that alterations in WM after MTBI may be improved with the alpha-2 agonist guanfacine.

Quantitative fluorescence in intracranial tumor: implications for ALA-induced PpIX as an intraoperative biomarker

OBJECT

Accurate discrimination between tumor and normal tissue is crucial for optimal tumor resection. Qualitative fluorescence of protoporphyrin IX (PpIX), synthesized endogenously following δ-aminolevulinic acid (ALA) administration, has been used for this purpose in high-grade glioma (HGG). The authors show that diagnostically significant but visually imperceptible concentrations of PpIX can be quantitatively measured in vivo and used to discriminate normal from neoplastic brain tissue across a range of tumor histologies.

METHODS

The authors studied 14 patients with diagnoses of low-grade glioma (LGG), HGG, meningioma, and metastasis under an institutional review board-approved protocol for fluorescence-guided resection. The primary aim of the study was to compare the diagnostic capabilities of a highly sensitive, spectrally resolved quantitative fluorescence approach to conventional fluorescence imaging for detection of neoplastic tissue in vivo.

RESULTS

A significant difference in the quantitative measurements of PpIX concentration occurred in all tumor groups compared with normal brain tissue. Receiver operating characteristic (ROC) curve analysis of PpIX concentration as a diagnostic variable for detection of neoplastic tissue yielded a classification efficiency of 87% (AUC = 0.95, specificity = 92%, sensitivity = 84%) compared with 66% (AUC = 0.73, specificity = 100%, sensitivity = 47%) for conventional fluorescence imaging (p < 0.0001). More than 81% (57 of 70) of the quantitative fluorescence measurements that were below the threshold of the surgeon's visual perception were classified correctly in an analysis of all tumors.

CONCLUSIONS

These findings are clinically profound because they demonstrate that ALA-induced PpIX is a targeting biomarker for a variety of intracranial tumors beyond HGGs. This study is the first to measure quantitative ALA-induced PpIX concentrations in vivo, and the results have broad implications for guidance during resection of intracranial tumors.

Tumor angiogenesis change estimated by using diffuse optical spectroscopic tomography: demonstrated correlation in women undergoing neoadjuvant chemotherapy for invasive breast cancer?

PURPOSE

To investigate if changes in tumor angiogenesis associated with complete pathologic response (pCR) or partial pathologic response (pPR) to treatment can be demonstrated by using diffuse optical spectroscopic (DOS) tomography.

MATERIALS AND METHODS

All participants in this prospective, HIPAA-compliant, institutional review board-approved study provided written informed consent. Eleven women with invasive breast carcinoma were imaged with DOS tomography prior to, during, and at completion of neoadjuvant chemotherapeutic regimens. By using region of interest (ROI) analysis, the DOS measure of total tissue hemoglobin (Hb(T)) was temporally correlated with quantitative measures of existing (CD31-expressing) and tumor-induced (CD105-expressing) vessels, in pretreatment and posttreatment tissue specimens, to assess change.

RESULTS

Quantified angiogenesis alone in pretreatment core biopsy specimens did not predict treatment response, but mean vessel density (MVD) and mean vessel area (MVA) of CD105-expressing vessels were significantly decreased in women with pCR (n = 7) (P < .001 and P = .003, respectively). MVA of CD105-expressing vessels was also significantly reduced at comparison of pre- and posttreatment residual tumor for women with pPR (n = 4) (P = .033). A longitudinal analysis showed significant decreases (P = .001) in mean Hb(T) levels during neoadjuvant chemotherapy in breast abnormality ROIs for women with pCR but not women with pPR. For women with pCR, but not women with pPR, pretreatment MVD of CD105-expressing vessels correlated with pretreatment Hb(T) (P ≤ .001).

CONCLUSION

DOS tomographic examinations in women with breast cancer who are receiving neoadjuvant chemotherapy show a mean decrease in Hb(T) with time in patients with pCR only. Observed pretreatment and posttreatment correlates with quantified angiogenesis markers confirm the likely biologic origin for this DOS signature and support its potential to predict angiogenic tissue response early in the treatment cycle.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11100699/-/DC1.

Outcomes after incidental durotomy during first-time lumbar discectomy

OBJECT

Incidental durotomy is an infrequent but well-recognized complication during lumbar disc surgery. The effect of a durotomy on long-term outcomes is, however, controversial. The authors sought to examine whether the occurrence of durotomy during surgery impacts long-term clinical outcome.

METHODS

Spine Patient Outcomes Research Trial (SPORT) participants who had a confirmed diagnosis of intervertebral disc herniation and were undergoing standard first-time open discectomy were followed up at 6 weeks and at 3, 6, and 12 months after surgery and annually thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (± SD) duration of follow-up among all of the intervertebral disc herniation patients whose data were analyzed was 41.5 ± 14.5 months (41.4 months in those with no durotomy vs 40.2 months in those with durotomy, p < 0.68). The median duration of follow-up among all of these patients was 47 months (range 1-95 months).

RESULTS

A total of 799 patients underwent first-time lumbar discectomy. There was an incidental durotomy in 25 (3.1%) of these cases. There were no significant differences between the durotomy and no-durotomy groups with respect to age, sex, race, body mass index, herniation level or type, or the prevalence of smoking, diabetes, or hypertension. When outcome differences between the groups were analyzed, the durotomy group was found to have significantly increased operative duration, operative blood loss, and length of inpatient stay. However, there were no significant differences in incidence rates for nerve root injury, postoperative mortality, additional surgeries, or SF-36 scores for Bodily Pain or Physical Function, or Oswestry Disability Index scores at 1, 2, 3, or 4 years.

CONCLUSIONS

Incidental durotomy during first-time lumbar discectomy does not appear to impact long-term outcome in affected patients.

A longitudinal comparison of 5 preference-weighted health state classification systems in persons with intervertebral disk herniation

OBJECTIVE

To assess the longitudinal validity of widely used preference-weighted measurement systems for economic studies of intervertebral disk herniation (IDH).

METHODS

Using data at baseline and 1 year from 1000 Spine Patient Outcomes Research Trial (SPORT) participants with IDH and complete data, the authors considered the EQ-5D with UK and US values (EQ-5D-UK and EQ-5D-US), 2 versions of the Health Utilities Index (HUI3 and HUI2), the SF-6D, and a regression-estimated quality of well-being score (eQWB). Differences in mean change scores (MCS) were assessed using signed rank tests, and Spearman correlations were calculated for change scores by system pairs. Using the Oswestry Disability Index, symptom satisfaction, progress rating, and self-perceived health ratings as criterion measures, the authors tested for trend in MCS across levels of change in criteria. They calculated floor and ceiling effects, effect size (ES), standardized response mean, and minimal important difference estimates.

RESULTS

All systems demonstrated linear trends with external criteria and moderate to strong correlations between systems. However, differences in performance were evident. SF-6D and eQWB were most responsive (ES: 1.9 and 2.3, respectively), whereas EQ-5D-US and EQ-5D-UK were least responsive (ES: 1.23/1.20). Ceiling and floor effects were noted for all systems within key dimensions and for EQ-5D-UK and EQ-5D-US for overall score. MCS ranged from 0.40 (0.38) for EQ-5D-UK to 0.13 (0.09) for eQWB and differed significantly, except between EQ-5D-US and HUI2.

CONCLUSIONS

This research supports the validity of all systems for measuring change in persons with IDH, without finding a clearly superior system. The unique characteristics of each system revealed in this study should guide system choice.

Dopaminergic challenge with bromocriptine one month after mild traumatic brain injury: altered working memory and BOLD response

Catecholamines, particularly dopamine, modulate working memory (WM). Altered sensitivity to dopamine might play a role in WM changes observed after traumatic brain injury (TBI). Thirty-one healthy controls (HC) and 26 individuals with mild TBI (MTBI) 1 month after injury were challenged with bromocriptine versus placebo before administration of a verbal WM functional MRI task. Bromocriptine was associated with improved WM performance in the HC but not the MTBI group. On bromocriptine, the MTBI group showed increased activation outside of a task-specific region of interest. Findings are consistent with the hypothesis that individuals with MTBI have altered responsivity to dopamine.

Consistency and construct validity of the Activity Card Sort (modified) in measuring activity resumption after stem cell transplantation

OBJECTIVE

We assessed the psychometrics of a self-administered survey modification of the Activity Card Sort (modified; ACSm) when used to track activity resumption after stem cell transplantation (SCT).

METHOD

Thirty-six participants completed the ACSm for a descriptive pilot study of recovery after SCT. Reliability was assessed by determining the longitudinal consistency of participants' designation of an activity as never done versus done previously and by calculating internal consistency. Construct validity was assessed by correlating the ACSm scores with measures of quality of life, performance status, and perceived cognitive impairment.

RESULTS

Participants gave consistent designations for 72% of items. Internal consistency of the total score was alpha > 0.86 at all assessments. The ACSm scores were correlated with quality of life (r = 0.51, p = .0019), functional well-being (r = 0.59, p = .0002), and performance status (r = 0.42, p = 0.011) and not associated with cognitive impairment (r = .22, p = .19).

CONCLUSION

The ACSm demonstrated provisional evidence of reliability, internal consistency, and construct validity.

Coregistered fluorescence-enhanced tumor resection of malignant glioma: relationships between δ-aminolevulinic acid-induced protoporphyrin IX fluorescence, magnetic resonance imaging enhancement, and neuropathological parameters. Clinical article

OBJECT

The aim of this study was to investigate the relationships between intraoperative fluorescence, features on MR imaging, and neuropathological parameters in 11 cases of newly diagnosed glioblastoma multiforme (GBM) treated using protoporphyrin IX (PpIX) fluorescence-guided resection.

METHODS

In 11 patients with a newly diagnosed GBM, δ-aminolevulinic acid (ALA) was administered to enhance endogenous synthesis of the fluorophore PpIX. The patients then underwent fluorescence-guided resection, coregistered with conventional neuronavigational image guidance. Biopsy specimens were collected at different times during surgery and assigned a fluorescence level of 0-3 (0, no fluorescence; 1, low fluorescence; 2, moderate fluorescence; or 3, high fluorescence). Contrast enhancement on MR imaging was quantified using two image metrics: 1) Gd-enhanced signal intensity (GdE) on T1-weighted subtraction MR image volumes, and 2) normalized contrast ratios (nCRs) in T1-weighted, postGd-injection MR image volumes for each biopsy specimen, using the biopsy-specific image-space coordinate transformation provided by the navigation system. Subsequently, each GdE and nCR value was grouped into one of two fluorescence categories, defined by its corresponding biopsy specimen fluorescence assessment as negative fluorescence (fluorescence level 0) or positive fluorescence (fluorescence level 1, 2, or 3). A single neuropathologist analyzed the H & E-stained tissue slides of each biopsy specimen and measured three neuropathological parameters: 1) histopathological score (0-IV); 2) tumor burden score (0-III); and 3) necrotic burden score (0-III).

RESULTS

Mixed-model analyses with random effects for individuals show a highly statistically significant difference between fluorescing and nonfluorescing tissue in GdE (mean difference 8.33, p = 0.018) and nCRs (mean difference 5.15, p < 0.001). An analysis of association demonstrated a significant relationship between the levels of intraoperative fluorescence and histopathological score (χ(2) = 58.8, p < 0.001), between fluorescence levels and tumor burden (χ(2) = 42.7, p < 0.001), and between fluorescence levels and necrotic burden (χ(2) = 30.9, p < 0.001). The corresponding Spearman rank correlation coefficients were 0.51 (p < 0.001) for fluorescence and histopathological score, and 0.49 (p < 0.001) for fluorescence and tumor burden, suggesting a strongly positive relationship for each of these variables.

CONCLUSIONS

These results demonstrate a significant relationship between contrast enhancement on preoperative MR imaging and observable intraoperative PpIX fluorescence. The finding that preoperative MR image signatures are predictive of intraoperative PpIX fluorescence is of practical importance for identifying candidates for the procedure. Furthermore, this study provides evidence that a strong relationship exists between tumor aggressiveness and the degree of tissue fluorescence that is observable intraoperatively, and that observable fluorescence has an excellent positive predictive value but a low negative predictive value.

Malignancy is associated with dermatomyositis but not polymyositis in Northern New England, USA

OBJECTIVE

To retrospectively evaluate the association of idiopathic inflammatory myopathy (IIM) and malignancy in patients seen at 1 academic center over a 23-year period.

METHODS

Patients were identified using the International Classification of Diseases, 9th edition (ICD-9) codes and diagnoses, then confirmed by chart review. Population cancer statistics obtained from the US Centers for Disease Control for Vermont and New Hampshire were used for comparison.

RESULTS

Chart review confirmed IIM in 198 of 483 patients initially identified by ICD-9 codes. Within 5 years of diagnosis with IIM, malignancy developed in 32 patients (16.2%), 24 of whom (75%) had dermatomyositis (DM). Malignancy and DM developed within 1 year in 75%. The cancer risk associated with DM was much greater than the risk associated with other IIM. The most frequent tumor types were breast, lung, pancreas, and colon. DM patients with cancer were more frequently male and >or= 45 years of age than those without cancer. There were no cases of interstitial lung disease among patients with cancer and any form of IIM. The incidence of cancer was increased in patients with DM compared to age- and sex-matched population controls, both over a 5-year interval surrounding the diagnosis of DM and over the lifetime interval following diagnosis.

CONCLUSION

The risk of cancer in IIM is concentrated among patients with DM. The association between DM and cancer was enhanced by its temporal relationship (< 1 year) in 87.5% of these cases. Patients with malignancy-associated DM were more frequently male and over age 45 and less likely to have interstitial lung disease.

Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial

CONTEXT

There are few randomized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer.

OBJECTIVE

To determine the effect of a nursing-led intervention on quality of life, symptom intensity, mood, and resource use in patients with advanced cancer.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted from November 2003 through May 2008 of 322 patients with advanced cancer in a rural, National Cancer Institute-designated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a VA medical center in Vermont.

INTERVENTIONS

A multicomponent, psychoeducational intervention (Project ENABLE [Educate, Nurture, Advise, Before Life Ends]) conducted by advanced practice nurses consisting of 4 weekly educational sessions and monthly follow-up sessions until death or study completion (n = 161) vs usual care (n = 161).

MAIN OUTCOME MEASURES

Quality of life was measured by the Functional Assessment of Chronic Illness Therapy for Palliative Care (score range, 0-184). Symptom intensity was measured by the Edmonton Symptom Assessment Scale (score range, 0-900). Mood was measured by the Center for Epidemiological Studies Depression Scale (range, 0-60). These measures were assessed at baseline, 1 month, and every 3 months until death or study completion. Intensity of service was measured as the number of days in the hospital and in the intensive care unit (ICU) and the number of emergency department visits recorded in the electronic medical record.

RESULTS

A total of 322 participants with cancer of the gastrointestinal tract (41%; 67 in the usual care group vs 66 in the intervention group), lung (36%; 58 vs 59), genitourinary tract (12%; 20 vs 19), and breast (10%; 16 vs 17) were randomized. The estimated treatment effects (intervention minus usual care) for all participants were a mean (SE) of 4.6 (2) for quality of life (P = .02), -27.8 (15) for symptom intensity (P = .06), and -1.8 (0.81) for depressed mood (P = .02). The estimated treatment effects in participants who died during the study were a mean (SE) of 8.6 (3.6) for quality of life (P = .02), -24.2 (20.5) for symptom intensity (P = .24), and -2.7 (1.2) for depressed mood (P = .03). Intensity of service did not differ between the 2 groups.

CONCLUSION

Compared with participants receiving usual oncology care, those receiving a nurse-led, palliative care-focused intervention addressing physical, psychosocial, and care coordination provided concurrently with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or emergency department visits.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00253383.

Predictors of long-term opioid use among patients with painful lumbar spine conditions

Our objective was to assess predictors of self-reported opioid use among patients with back pain due to lumbar disc herniation or spinal stenosis. Data were from the Spine Patient Outcomes Research Trial (SPORT), a multi-site observational study and randomized trial. We examined characteristics shown or hypothesized to be associated with opioid use. Using generalized estimating equations, we modeled associations of each potential predictor with opioid use at 12 and 24 months. At baseline, 42% of participants reported opioid use. Of these participants, 25% reported continued use at 12 months and 21% reported use at 24 months. In adjusted models, smoking (RR = 1.9, P < .001 at 12 months; RR = 1.5, P = .043 at 24 months) and nonsurgical treatment (RR = 1.7, P < .001 at 12 months; RR = 1.8, P = .003 at 24 months) predicted long-term opioid continuation. Among participants not using opioids at baseline, incident use was reported by 8% at 12 months and 7% at 24 months. We found no significant predictors of incident use at 12 or 24 months in the main models. In conclusion, nonsurgical treatment and smoking independently predicted long-term continued opioid use. To our knowledge, this is the first longitudinal study to assess predictors of long-term and incident opioid use among patients with lumbar spine conditions.

PERSPECTIVE

This longitudinal study of patients with disc herniation or spinal stenosis found that nonsurgical treatment and smoking predicted long-term self-reported opioid use. The greater risk of opioid continuation with nonsurgical therapy may be helpful in decision-making about treatment. The relationship between opioid use, smoking, and other substance use deserves further study.

Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts

BACKGROUND

The management of degenerative spondylolisthesis associated with spinal stenosis remains controversial. Surgery is widely used and has recently been shown to be more effective than nonoperative treatment when the results were followed over two years. Questions remain regarding the long-term effects of surgical treatment compared with those of nonoperative treatment.

METHODS

Surgical candidates from thirteen centers with symptoms of at least twelve weeks' duration as well as confirmatory imaging showing degenerative spondylolisthesis with spinal stenosis were offered enrollment in a randomized cohort or observational cohort. Treatment consisted of standard decompressive laminectomy (with or without fusion) or usual nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at six weeks, three months, six months, and yearly up to four years.

RESULTS

In the randomized cohort (304 patients enrolled), 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. In the observational cohort (303 patients enrolled), 97% of those who chose surgery received it whereas 33% of those who chose nonoperative care eventually received surgery. The intent-to-treat analysis of the randomized cohort, which was limited by nonadherence to the assigned treatment, showed no significant differences in treatment outcomes between the operative and nonoperative groups at three or four years. An as-treated analysis combining the randomized and observational cohorts that adjusted for potential confounders demonstrated that the clinically relevant advantages of surgery that had been previously reported through two years were maintained at four years, with treatment effects of 15.3 (95% confidence interval, 11 to 19.7) for bodily pain, 18.9 (95% confidence interval, 14.8 to 23) for physical function, and -14.3 (95% confidence interval, -17.5 to -11.1) for the Oswestry Disability Index. Early advantages (at two years) of surgical treatment in terms of the secondary measures of bothersomeness of back and leg symptoms, overall satisfaction with current symptoms, and self-rated progress were also maintained at four years.

CONCLUSIONS

Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years.

Brain metastases from colorectal cancer: risk factors, incidence, and the possible role of chemokines

Background: Brain metastases from colorectal cancer (CRC) are uncommon. There has been relatively little published on the host and tumor factors that might lead to this clinical scenario. We reviewed all cases of brain metastases from CRC at Dartmouth-Hitchcock Medical Center over a more than 20-year period to establish incidence and to identify patient and cancer characteristics which were associated with their development. Patients and Methods: We present a retrospective review of 39 confirmed cases of brain metastases from CRC diagnosed between 1984 and 2006. Immunohistochemical staining for CXCR4 was performed on all available brain metastasis biopsy specimens. Results: The incidence of brain metastases from CRC was 2.3%. Left-sided primary colon tumors predominated. The majority of patients had pulmonary metastases at the time brain metastases were identified, and those with preexisting pulmonary metastases had progression of that disease. All patients were symptomatic from brain metastases, and the cerebellum was the most common area of brain involvement. Immunohistochemical analysis confirmed strong expression of CXCR4 in all brain metastases sampled. Conclusion: The incidence of brain metastases from CRC is low. Primary tumor in the left colon, long-standing pulmonary metastases, especially those with recent progression, and CXCR4 expression by tumor cells are all associated with increased risk of brain metastases. Increased survival among patients with metastatic CRC will likely result in an increased incidence of brain metastases. Further characterization of the role of tumor and host factors might yield better insight into the development, and potentially the prevention, of this devastating situation.

Brain metastases from colorectal cancer: risk factors, incidence, and the possible role of chemokines

BACKGROUND

Brain metastases from colorectal cancer (CRC) are uncommon. There has been relatively little published on the host and tumor factors that might lead to this clinical scenario. We reviewed all cases of brain metastases from CRC at Dartmouth-Hitchcock Medical Center over a more than 20-year period to establish incidence and to identify patient and cancer characteristics which were associated with their development.

PATIENTS AND METHODS

We present a retrospective review of 39 confirmed cases of brain metastases from CRC diagnosed between 1984 and 2006. Immunohistochemical staining for CXCR4 was performed on all available brain metastasis biopsy specimens.

RESULTS

The incidence of brain metastases from CRC was 2.3%. Left-sided primary colon tumors predominated. The majority of patients had pulmonary metastases at the time brain metastases were identified, and those with preexisting pulmonary metastases had progression of that disease. All patients were symptomatic from brain metastases, and the cerebellum was the most common area of brain involvement. Immunohistochemical analysis confirmed strong expression of CXCR4 in all brain metastases sampled.

CONCLUSION

The incidence of brain metastases from CRC is low. Primary tumor in the left colon, long-standing pulmonary metastases, especially those with recent progression, and CXCR4 expression by tumor cells are all associated with increased risk of brain metastases. Increased survival among patients with metastatic CRC will likely result in an increased incidence of brain metastases. Further characterization of the role of tumor and host factors might yield better insight into the development, and potentially the prevention, of this devastating situation.

Single nucleotide polymorphisms in ANKK1 and the dopamine D2 receptor gene affect cognitive outcome shortly after traumatic brain injury: a replication and extension study

OBJECTIVE

The two objectives of this study were (1) to replicate the previous finding that a single nucleotide polymorphism (SNP) in the ANKK1 gene (SNP rs1800497 formerly known as the DRD2 TAQ1 A allele) is associated with measures of learning and response latency after traumatic brain injury (TBI) and (2) to further characterize the genetic basis of the effect by testing the strength of association and degree of linkage disequilibrium between the cognitive outcome measures and a selected ensemble of 31 polymorphisms from three adjacent genes in the region of rs1800497.

METHOD

A cohort of 54 patients with TBI and 21 comparison subjects were genotyped for the DRD2 TAQ1 A polymorphism (rs1800497). Ninety-three patients with TBI and 48 comparison subjects (the current cohort and an earlier independent cohort) were also genotyped for 31 additional neighbouring polymorphisms in NCAM, ANKK1 and DRD2. TBI patients were studied 1 month after injury. All subjects completed memory and attention tests, including the California Verbal Learning Test (CVLT) recognition task and the Gordon Continuous Performance Test (CPT).

RESULTS

As in a previous study the T allele of TAQ1 A (rs1800497) was associated with poorer performance on the CVLT recognition trial in both TBI and control subjects. There was also a significant diagnosis-by-allele interaction on CPT measures of response latency, largely driven by slower performance in the TBI participants with the T allele. Analysis of 31 additional neighbouring polymorphisms from NCAM, ANKK1 and DRD2 in the TBI patients showed four haploblocks. A haploblock of three SNPs in ANKK1 (rs11604671, rs4938016 and rs1800497 (TAQ1A)) showed the greatest association with cognitive outcome measures.

CONCLUSIONS

The results confirm a previously published association between the TAQ1 A (rs1800497) T allele and cognitive outcome measures 1 month after TBI and suggest that a haploblock of polymorphisms in ANKK1, rather than the adjacent DRD2 gene, has the highest association with these measures after TBI.