Development and Assessment of the Feasibility of a Nurse-Led Care Program for Cancer Patients in a Chemotherapy Day Center: Results of the Pilot Study

BACKGROUND

The increasing number of cancer patients and inadequate communication in clinics are posing challenges to cancer patients receiving outpatient-based chemotherapy and healthcare providers. A nurse-led care program was proposed as one way of dealing with at least some of these challenges.

OBJECTIVE

The objectives of the pilot study were to assess the feasibility of the subject recruitment, care, and data collection procedures and to explore the acceptability of this program.

METHODS

A pilot study with a 1-group pretest-posttest design was conducted. Five cancer patients receiving chemotherapy in a chemotherapy day center participated. Each patient had a nurse consultation before chemotherapy and received 2 telephone calls after the first and second cycles of chemotherapy. Four questionnaires were adopted to evaluate the subjects' quality of life, self-efficacy, symptom experiences, and satisfaction with care. Questionnaires were completed before the chemotherapy and after the second cycle. The subjects were also interviewed to understand their comments on the service.

RESULTS

The recruitment, care, and data collection procedures were completed smoothly. Slight changes were observed in quality of life and self-efficacy. All 5 subjects were highly satisfied with the care.

CONCLUSIONS

The nurse-led care program is feasible and acceptable.

IMPLICATIONS FOR PRACTICE

The effect of the nurse-led care program will be evaluated in a single-center, open, randomized controlled trial. If the encouraging results can be confirmed, it may be an effective approach to improving the quality of ambulatory chemotherapy care. It would also shed light on the development of nurse-led care in other areas.

Effect of Superimposed Electromyostimulation on Back Extensor Strengthening: A Pilot Study

Park, JH, Seo, KS, and Lee, S-U. Effect of superimposed electromyostimulation on back extensor strengthening: a pilot study. J Strength Cond Res 30(9): 2470-2475, 2016-Electromyostimulation (EMS) superimposed on voluntary contraction (VC) can increase muscle strength. However, no study has examined the effect of superimposing EMS on back extensor strengthening. The purpose of this study was to determine the effect of superimposed EMS on back extensor strengthening in healthy adults. Twenty healthy men, 20-29 years of age, without low-back pain were recruited. In the EMS group, electrodes were attached to bilateral L2 and L4 paraspinal muscles. Stimulation intensity was set for maximally tolerable intensity. With VC, EMS was superimposed for 10 seconds followed by a 20-second rest period. The same protocol was used in the sham stimulation (SS) group, except that the stimulation intensity was set at the lowest intensity (5 mA). All subjects performed back extension exercise using a Swiss ball, with 10 repetitions per set, 2 sets each day, 5 times a week for 2 weeks. The primary outcome measure was the change in isokinetic strength of the back extensor using an isokinetic dynamometer. Additionally, endurance was measured using the Sorensen test. After 2 weeks of back extension exercise, the peak torque and endurance increased significantly in both groups (p ≤ 0.05). Effect size between the EMS group and the SS group was medium in strength and endurance. However, there was no statistically significant difference between 2 groups. In conclusion, 2 weeks of back extensor strengthening exercise was effective for strength and endurance. Superimposing EMS on back extensor strengthening exercise could provide an additional effect on increasing strength.

Psychometric properties of the Physical Activity Scale for the Elderly in Chinese patients with COPD

BACKGROUND

For patients with COPD, physical activity (PA) is recommended as the core component of pulmonary rehabilitation, but there is lack of a validated questionnaire for assessing the PA effectively.

AIM

To evaluate the reliability and validity of the Chinese version of Physical Activity Scale for the Elderly (PASE-C) in patients with COPD.

METHODS

A cross-sectional study was conducted with 167 outpatients aged 60 years or older with COPD. Test-retest reliability and internal consistency were calculated by intraclass correlation coefficient (ICC) and Cronbach's coefficient α, respectively. Validity was evaluated by correlation with the International Physical Activity Questionnaire-Short (IPAQ-S), data of pedometer, Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES6), Hospital Anxiety and Depression Scale (HADS), Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), grip strength, and disease characteristics.

RESULTS

The PASE-C had an excellent seven-day test-retest reliability (ICC=0.98) and an acceptable internal consistency (Cronbach's α=0.71). The content validity was supported by an item-content validity index, a scale-content validity index/universal agreement, and a scale-content validity index/average value of 0.70-1, 0.70, and 0.93, respectively. Concurrent validity was tested by correlation with IPAQ-S (r=0.651). Criterion validity was confirmed by correlation with the walking steps (r=0.611) and energy expenditure (r=0.493). For construct validity, PASE-C had correlations with SES6 (r=0.396), HADS for depression (r=-0.234), seven subscales of SF-36 (r=0.182-0.525), grip strength (r=0.341), and disease characteristics including the duration of COPD (r=-0.215), modified British Medical Research Council scale (r=-0.354), forced expiratory volume in one second as percentage of predicted (r=0.307), and Global Initiative for Chronic Obstructive Lung Disease grade (r=-0.264), with a good construct validity (all P<0.05).

CONCLUSION

The PASE-C has acceptable reliability and validity for patients aged 60 years or older with COPD, and it can be used as a valid tool to measure the PA of patients with COPD in the People's Republic of China.

TRANSLATION AND VALIDATION OF THE BRAZILIAN PORTUGUESE VERSION OF THE GASTROINTESTINAL SYMPTOM RATING SCALE (GSRS) QUESTIONNAIRE

BACKGROUND

- Bowel function is a widely evaluated parameter in interventional and longitudinal studies since it is associated with good maintenance of health. The evaluation of intestinal function has been performed by many questionnaires, however, there are few options validated in Brazilian Portuguese.

OBJECTIVE

- The aim of this work was to translate and validate into Brazilian Portuguese the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire.

METHODS

- Translation and cultural adaptation were performed according to a previously established methodology followed by reliability calculations.

RESULTS

- The final translated GSRS questionnaire showed an adequate value of overall reliability of Cronbach's alpha of 0.83, and its domains were classified from acceptable to adequate. The overall test-retest reliability by intraclass correlation coefficient (ICC) was 0.84, considered excellent.

CONCLUSION

- The GSRS was translated and validated into Brazilian Portuguese, with appropriate internal consistency and reliability and is available to be used in assessments of bowel function.

Inter-Gender sEMG Evaluation of Central and Peripheral Fatigue in Biceps Brachii of Young Healthy Subjects

Purpose

The purpose of the present study was to evaluate inter-arm and inter-gender differences in fractal dimension (FD) and conduction velocity (CV) obtained from multichannel surface electromyographic (sEMG) recordings during sustained fatiguing contractions of the biceps brachii.

Methods

A total of 20 recreationally active males (24±6 years) and 18 recreationally active females (22±9 years) performed two isometric contractions at 120 degrees elbow joint angle: (1) at 20% maximal voluntary contraction (MVC) for 90 s, and (2) at 60% MVC until exhaustion the time to perform the task has been measured. Signals from sEMG were detected from the biceps brachii using bidimensional arrays of 64 electrodes and initial values and rate of change of CV and FD of the sEMG signal were calculated.

Results

No difference between left and right sides and no statistically significant interaction effect of sides with gender were found for all parameters measured. A significant inter-gender difference was found for MVC (p<0.0001). Initial values of CV were higher in females than in males at both force levels (20% MCV: p<0.0001; 60% MCV: p<0.05) whereas a lower initial estimate of FD was observed in females compared to males (20% MCV: p<0.05; 60% MCV: p<0.0001). No difference in CV and FD slopes was found at 20% MVC between genders. At 60% MVC significantly lower CV and FD slopes (CV and FD: p<0.05) and a more protracted time to exhaustion were found in females than in males (p<0.0001). When considering time to exhaustion at both levels of contraction no difference in percentage change (Δ%) of CV and FD slopes was found between genders (p>0.05). During the sustained 60% MVC no statistical correlation was found between MVC and CV or FD initial estimates nor between MVC and CV or FD slopes both in males and females whereas. A significant positive correlation between CV and FD slopes was found in both genders (males: r = 0,61; females: r = 0,55).

Conclusions

Fatigue determines changes in FD and CV values in biceps brachii during sustained contractions at 60% MVC. In particular males show greater increase in the rate of change of CV and FD than females whereas no difference in percentage change of these sEMG descriptors of fatigue was found. A significant correlation between FD and CV slopes found in both genders highlights that central and peripheral myoelectric components of fatigue may interact during submaximal isometric contractions.

Effect of the Abdominal Hollowing and Bracing Maneuvers on Activity Pattern of the Lumbopelvic Muscles During Prone Hip Extension in Subjects With or Without Chronic Low Back Pain: A Preliminary Study

OBJECTIVE

The purpose of this study was to compare the effect of abdominal hollowing (AH) and abdominal bracing (AB) maneuvers on the activity pattern of lumbopelvic muscles during prone hip extension (PHE) in participants with or without nonspecific chronic low back pain (CLBP).

METHODS

Twenty women with or without CLBP participated in this cross-sectional observational study. The electromyographic activity (amplitude and onset time) of the contralateral erector spinae (CES), ipsilateral erector spinae (IES), gluteus maximus, and biceps femoris muscles was measured during PHE with and without abdominal maneuvers. A 3-way mixed model analysis of variance and post hoc tests were used for statistical analysis.

RESULTS

Between-group comparisons showed that the CES onset delay during PHE alone was greater (P = .03) and the activity level of IES, CES, and biceps femoris in all maneuvers (P < .05) was higher in patients with CLBP than in asymptomatic participants. In asymptomatic participants, PHE + AH significantly decreased the signal amplitude (AMP) of IES (P = .01) and CES (P = .02) muscles. In participants with CLBP, IES muscle AMP was lower during PHE + AH compared with PHE + AB and PHE alone. With regard to onset delay, the results also showed no significant difference between maneuvers within either of the 2 groups (P > .05).

CONCLUSIONS

Performance of the AH maneuver decreased the erector spinae muscle AMP in both groups, and neither maneuver altered the onset delay of any of the muscles in either group. The low back pain group showed higher levels of activity in all muscles (not statistically significant in gluteus maximus during all maneuvers). The groups were similar according to the onset delay of any of the muscles during either maneuver.

The Paracrine Effect of Degenerated Disc Cells on Healthy Human Nucleus Pulposus Cells Is Mediated by MAPK and NF-κB Pathways and Can Be Reduced by TGF-β1

Inflammation is thought to have a major role in the pathogenesis of disc degeneration. Studies have shown that nucleus pulposus cells (NPCs) respond to one or two specific cytokines by regulating cell proliferation or matrix synthesis. However, the effects of a cocktail of factors secreted by degenerated disc cells on transplanted exogenous healthy NPCs remain unknown. Concentrations of multiple cytokines in degenerated disc tissue-conditioned medium (dCM) were measured using enzyme-linked immunosorbent assay (ELISA). 3-(4, 5-Dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay and Ki67 immunofluorescence staining were used to evaluate the proliferation of cells in dCM. The function of exogenous NPCs cultured in dCM was evaluated by examining catabolic markers (ADAMTS-4, ADAMTS-5, MMP-1, MMP-3, and MMP-13), anabolic markers (TIMP-1, TIMP-2, and TIMP-3), and the extracellular matrix protein-aggrecan (ACAN) and collagen II (COL2)-expression with real time polymerase chain reaction (RT-PCR). Mitogen-activated protein kinase (MAPK) and nuclear factor-kappa B (NF-κB) pathway activation was observed using Western blotting. Finally, we examined the role of transforming growth factor (TGF)-β1 in reducing dCM-mediated exogenous NPC dysfunction. Levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-1α, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17, interferon-γ (IFN-γ), and prostaglandin E2 (PGE2) were higher and TGF-β1 levels were lower in dCM compared with the control medium. Treatment with dCM increased the proliferation of healthy NPCs. NPCs exhibited significantly higher expression of ADAMTS-4, ADAMTS-5, MMP-1, MMP-3, and MMP-13 and decreased TIMP-2, ACAN, and COL2 expression in the dCM group in a dose- and time-dependent manner. Treatment with dCM moderately increased TIMP-1 expression and had no effect on TIMP-3 mRNA levels. The MAPK and NF-κB pathways were implicated in dCM-mediated responses of healthy NPCs. TGF-β1 partially reversed the dCM-mediated NPC dysfunction. Increased levels of inflammatory factors and decreased TGF-β1 levels in dCM suggest an inflammatory environment in degenerated disc tissue. The catabolic effect of dCM on human healthy NPCs is mediated by MAPK and NF-κB pathways and can be reduced by TGF-β1.

Characterization of the Antibody Response after Cervical Spinal Cord Injury

The immune system plays a critical and complex role in the pathobiology of spinal cord injury (SCI), exerting both beneficial and detrimental effects. Increasing evidence suggests that there are injury level-dependent differences in the immune response to SCI. Patients with traumatic SCI have elevated levels of circulating autoantibodies against components of the central nervous system, but the role of these antibodies in SCI outcomes remains unknown. In rodent models of mid-thoracic SCI, antibody-mediated autoimmunity appears to be detrimental to recovery. However, whether autoantibodies against the spinal cord are generated following cervical SCI (cSCI), the most common level of injury in humans, remains undetermined. To address this knowledge gap, we investigated the antibody responses following cSCI in a rat model of injury. We found increased immunoglobulin G (IgG) and IgM antibodies in the spinal cord in the subacute phase of injury (2 weeks), but not in more chronic phases (10 and 20 weeks). At 2 weeks post-cSCI, antibodies were detected at the injury epicenter and co-localized with the astroglial scar and neurons of the ventral horn. These increased levels of antibodies corresponded with enhanced activation of immune responses in the spleen. Higher counts of antibody-secreting cells were observed in the spleen of injured rats. Further, increased levels of secreted IgG antibodies and enhanced proliferation of T-cells in splenocyte cultures from injured rats were found. These findings suggest the potential development of autoantibody responses following cSCI in the rat. The impact of the post-traumatic antibody responses on functional outcomes of cSCI is a critical topic that requires further investigation.

Results of Single-Staged Posterior Decompression and Circumferential Fusion Using a Transpedicular Approach to Correct a Kyphotic Deformity due to Thoracolumbar Spinal Tuberculosis

STUDY DESIGN

This is a prospective study.

PURPOSE

The aim of this study was to investigate the results of single-staged posterior decompression and circumferential fusion using a transpedicular approach to correct a kyphotic deformity due to thoracolumbar spinal tuberculosis.

OVERVIEW OF LITERATURE

Surgical management is frequently an imperative choice to achieve spinal decompression and deformity correction due to tuberculosis to relieve pain, improve neurology, and reconstruct the spine stability. Since the time anterior radical debridement and noninstrumented fusion was described, it has become apparent that even anterior debridement and bone grafting was often unsatisfactory in correcting or preventing the progression of kyphosis deformity. With the advent of modern segmental spinal instrumentation systems, isolated posterior instrumentation; combined anterior and posterior fusion; and single-staged posterior decompression and circumferential fusion have been described by many authors for correcting angular deformity and stabilizing the spine; however, there is a lack of consensus regarding the most effective means of correcting the deformity due to thoracolumbar spinal tuberculosis.

METHODS

This is a prospective study of 20 patients with thoracolumbar spinal tuberculosis who underwent surgery at our institute.

RESULTS

Twenty patients who were started on antituberculosis treatment underwent surgery using a single-staged posterior approach involving fixation, decompression, and kyphosis correction. Preoperatively, all patients had varying degrees of neurological deficit and a 27.45° average kyphotic angle, which improved. At the 1-year follow-up, correction was maintained at 6.9°, and 55% of patients showed neurological improvement. None of the patients experienced neurological deterioration. Two patients with lumbar spine tuberculosis underwent revision surgery because of nonunion.

CONCLUSIONS

The procedure of posterior decompression, fixation, and circumferential fusion using a transpedicular approach performed for thoracolumbar spinal tuberculosis is effective, safe, and excellent in correcting and maintaining kyphosis.

Effect of RNA Interference-Mediated Suppression of p75 on the Viability of Rat Notochordal Cells

Study Design

In vitro cell culture model.

Purpose

To investigate the effects of RNA interference (RNAi) on p75 expression and viability of rat notochordal cells treated with serum deprivation.

Overview of Literature

RNAi enables the inhibition of specific genes by sequence-specific gene silencing using a double-stranded RNA.

Methods

Notochordal cells were isolated, cultured, and placed in 10% (control) or 0% (apoptosis-promoting) fetal bovine serum (FBS) for 48 hours. The expression of p75, apoptosis, and cell proliferation were determined. To suppress p75 expression, a small interfering RNA (siRNA) was synthesized against p75 (p75 siRNA) and transfected into cells. The suppression of p75 mRNA expression was investigated using the reverse transcription-polymerase chain reaction. The degree of p75 suppression was semiquantitatively analyzed using densitometry. The effect of p75 siRNA on apoptosis and proliferation of cells was determined. Solutions of an unrelated siRNA and transfection agent alone served as controls.

Results

Serum deprivation significantly increased apoptosis by 40.3%, decreased proliferation of notochordal cells by 45.3% (both, p<0.001), and upregulated p75 expression. The p75 siRNA suppressed p75 expression in cells cultured in 0% FBS. The rate of suppression by p75 siRNA of p75 mRNA was 72.9% (p<0.001). Suppression of p75 expression by p75 siRNA inhibited apoptosis by 7% and increased proliferation by 14% in cells cultured in 0% FBS (both, p<0.05).

Conclusions

siRNA-mediated suppression of p75 inhibited apoptosis and increased proliferation of notochordal cells under conditions of serum deprivation, suggesting that RNAi might serve as a novel therapeutic approach for disc degeneration caused by insufficient viability of disc cells through the suppression of the expression of harmful genes.

Tumor Occupation in the Spinal Canal and Clinical Symptoms of Cauda Equina Schwannoma: An Analysis of 22 Cases

STUDY DESIGN

Retrospective, radiological study.

PURPOSE

To determine the relationship between clinical symptoms and the extent of tumor occupation of the spinal canal by cauda equina schwannoma.

OVERVIEW OF LITERATURE

Little is known about the relationship between the size of tumors of the cauda equina and the manifestation of clinical symptoms. We analyzed this relationship by estimating the percentage of tumor occupation (PTO) in the spinal canal in cauda equina schwannomas and by correlating this parameter with the presence and severity of clinical symptoms.

METHODS

Twenty-two patients (9 men and 13 women; age, 19-79 years; mean age, 55.3 years) who were radiologically diagnosed with schwannomas of the cauda equina between April 2004 and July 2014 were retrospectively analyzed. PTO was measured in axial and sagittal magnetic resonance imaging slices in which the cross-sectional area of the tumor was the largest. Data regarding clinical symptoms and results of physical examinations were collected from patient medical records. PTO differences between symptom-positive and -negative groups were analyzed for each variable.

RESULTS

In the 4 cases in which tumor presence was not related to clinical symptoms, PTO was 5%-10% (mean, 9%) in axial slices and 23%-31% (mean, 30%) in sagittal slices. In the 18 cases in which symptoms were associated with the tumor, PTO was 11%-86% (mean, 50%) in axial slices and 43%-88% (mean, 71%) in sagittal slices. PTO in axial slices was significantly higher in the presence of Déjèrine symptoms and/or muscle weakness, a positive straight leg raise test, and a positive Kemp sign.

CONCLUSIONS

PTO >20% in axial slices and >40% in sagittal slices can be an indication of symptomatic cauda equina schwannoma.

Zero-profile anchored cage reduces risk of postoperative dysphagia compared with cage with plate fixation after anterior cervical discectomy and fusion

PURPOSE

To compare the rate of postoperative dysphagia between zero-profile anchored cage fixation (ZPC group) and cage with plate fixation (CP group) after anterior cervical discectomy and fusion (ACDF).

METHODS

A meta-analysis of cohort studies between zero-profile anchored cage and conventional cage with plate fixation after ACDF for the treatment of cervical diseases from 2008 to May 2016. An extensive search of studies was performed in PubMed, Medline, Embase, Cochrane library and Google Scholar. Dysphagia rate was extracted. Data analysis was conducted with RevMan 5.2.

RESULTS

Sixteen trials involving 1066 patients were included in this meta-analysis. The results suggested that the ZPC group were associated with lower incidences of dysphagia than the CP group at postoperative immediately, 2 weeks, 2, 3, 6 and 12 months. In subgroup analysis, although significant differences were only found in the mild dysphagia at 3 and 6 months postoperatively and in the moderate dysphagia at 2 weeks after surgery; the ZPC group had a lower rate of postoperative dysphagia than the CCP group in short, medium and long term follow-up periods.

CONCLUSIONS

Zero-profile anchored cage had a lower risk of postoperative dysphagia than cage with plate.

Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries: An Analysis of Current Treatment Trends in the United States

Background:

Platelet-rich plasma (PRP) has emerged as a popular biologic treatment for musculoskeletal injuries and conditions. Despite numerous investigations on the efficacy of PRP therapy, current utilization of this treatment within the United States is not widely known.

Purpose:

To investigate the national utilization of PRP, including the incidence and conditions for which it is used in the clinical setting, and to determine the current charges associated with this treatment.

Study Design:

Descriptive epidemiology study.

Methods:

Using a national database (PearlDiver) of private insurance billing records, we conducted a comprehensive search using Current Procedural Terminology (CPT) codes to identify patients who received PRP injections over a 2-year period (2010-2011). Associated International Classification of Diseases, 9th Revision (ICD-9) codes were identified to determine the specific conditions the injection was used to treat. The aggregate patient data were analyzed by yearly quarter, practice setting, geographic region, and demographics. PRP therapy charges were calculated and reported as per-patient average charges (PPACs).

Results:

A total of 2571 patients who received PRP injections were identified; 51% were male and 75% were older than 35 years. The overall incidence ranged from 5.9 to 7.9 per 1000 patients over the study period. PRP was most commonly administered in hospitals (39%) and ambulatory surgical centers (37%) compared with in private offices (26%). The most common conditions treated were knee meniscus/plica disorders, followed by unspecified shoulder conditions, rotator cuff injuries, epicondylitis, and plantar fasciitis. Further evaluation revealed that 25% of all patients received injections for cartilage-related conditions, 25% meniscus, 25% unspecified, 12% tendon, 8% glenoid labrum, and 5% ligament. The PPAC for PRP treatment was US$1755 per injection.

Conclusion:

Despite a lack of consensus regarding PRP indications and efficacy, we observed widespread application of this treatment for a myriad of musculoskeletal injuries. Most treated patients were older than 35 years, and the most commonly treated conditions included cartilage and meniscus disorders. Given the current controversy surrounding this treatment, further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis.

Reliability and validity of the Finnish version of the motor observation questionnaire for teachers

OBJECTIVES

Observational screening instruments are often used as an effective, economical first step in the identification of children with Developmental Coordination Disorder (DCD). The aim was to investigate the psychometric properties of the Finnish version of the Motor Observation Questionnaire for Teachers (MOQ-T-FI).

METHODS

The psychometric properties were tested using two separate samples (S1: age range 6-12, M 9y 5mo, females 101, males 92; S2: age range 6-9, M 7y 7mo, females 404, males 446). Teachers completed the MOQ-T-FI in both samples, and in sample 2 teachers' ratings were compared to student's performance on the Movement Assessment Battery for Children-Second Edition (MABC-2). Internal consistency was investigated by using Cronbach's alpha, predictive validity by receiver operating characteristic (ROC) analysis, concurrent validity by correlation analysis, and construct validity by factor analysis.

RESULTS

The MOQ-T-FI behaves consistently with its original Dutch version. The internal consistency was excellent (α=0.97). The bifactor model, with one general factor and two specific factors, fit the data significantly better than the first-order model. The concurrent validity with the MABC-2 was moderate (r=0.37 p<0.001). Sensitivity was 82.5% and specificity 44.5%, respectively.

CONCLUSION

Notwithstanding the low specificity the MOQ-T-FI can be considered as a promising screening tool in the school environment for Finnish children at risk of motor learning problems.

A Rare Case of Hamartoma Chest Wall Following Trauma in a 42-year-old Man

Background:

Chest wall mesenchymal hamartoma (CWH) is a distinct and extremely rare tumor-like lesion of the thorax. It usually presents in the neonatal period or in infancy. The common presentation is in the form of a visible chest wall mass with or without respiratory distress.

Case presentation:

A 42-year-old man with a history of chest wall trauma since 5 years ago was admitted with a swelling of the anterior of the chest wall and during this period has grown slowly. Physical examination showed a left anterior chest wall deformity. Chest radiographs and chest CT showed a left anterolateral chest wall mass involving the fourth and fifth ribs. Thoracotomy was performed. The tumor and involved ribs were resected with a 5cm safe margin. The histopathologic examination showed hamartoma. The patient has been fallowed up since 60 month ago, and has not had any complaints in this time.

Result:

Despite the rarity of chest wall hematoma, this side effect must always be taken into consideration while studying the chest wall injuries especially in the case of trauma history due to other differential diagnosis and her side effects such as respiratory problems.

Conclusion:

Although rare, this condition ought to be kept in mind while dealing with hamartoma Chest wall following trauma in order to avoid its complications such as respiratory problems. Surgical excision is usually curative in combination with conservative therapy if possible.

Two additional augmenting screws with posterior short-segment instrumentation without fusion for unstable thoracolumbar burst fracture - Comparisons with transpedicular grafting techniques

Background

Transpedicular grafting techniques with posterior short-segment instrumentation have demonstrated to prevent high implant failure in unstable thoracolumbar burst fractures. We tested our hypothesis that short-segment instrumentation with two additional augmenting screws in the injured vertebra could provide stability and was similar to those of the transpedicular grafting technique.

Methods

Twenty patients belonged to group A; treated with short-segment pedicle screw fixation and reinforced by two augmenting screws at the fractured vertebra. Group B had thirty-one patients; the fractured vertebra was augmented with transpedicular autogenous bone graft. Group C had twenty patients; the injured vertebra was strengthened with calcium sulfate cement. Clinical outcome and radiographic parameters were compared.

Results

Group A had the least blood loss (101.7 ± 72.5 vs. 600 ± 403.1 vs. 247.5 ± 164.2 ml, p < 0.001) and the least operation time (142.0 ± 57.2 vs. 227.2 ± 43.6 vs. 161.6 ± 28.5 min, p < 0.001). However, group A had the highest collapsed rate of the body height at the 18-month follow-up (10.5 ± 7.0 vs. 4.6 ± 4.8 vs. 7.2 ± 8.5%, p = 0.002). The failure rate, include implant failure or loss of 10° or more of correction, group B had the lowest failure rate (10% vs. 3.2% vs. 10%, p = 0.542). The group A had the highest rate of return to their previous employment (50% vs. 38% vs. 35%, p = 0.265).

Conclusions

Compared with transpedicular grafting techniques, additional two “augmenting screws” in the fracture vertebra with short-segment instrumentation are sufficient for one-level thoracolumbar burst fracture.

A New Radiological Sign for Severe Angular Kyphosis: "The Baltalimani Sign"

STUDY DESIGN

Retrospective diagnostic study.

PURPOSE

To define a new radiological sign, "Baltalimani sign," in severe angular kyphosis (SAK) and to report its relationship with the risk of neurological deficits and deformity severity.

OVERVIEW OF LITERATURE

Baltalimani sign was previously undefined in the literature.

METHODS

We propose Baltalimani sign as the axial orientation of the vertebrae that are located above or below the apex of angular kyphosis on anteroposterior radiographs. Patients with SAK of various etiologies with kyphotic angles ≥90° were selected and evaluated for the presence of Baltalimani sign. Demographic data of the patients including age, gender, etiology, neurological status, local kyphosis angles, and the location of the kyphosis apex were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of Baltalimani sign for the risk of the neurological deficits were evaluated by the IBM SPSS ver. 20.0. A p-values of <0.05 were considered statistically significant. Cohen's kappa was used for analysis of interrater agreement.

RESULTS

The mean local kyphosis angle in all patients was 124.2° (range, 90°-169°), and 15 of 40 (37.5%) patients had neurological deficits. Baltalimani sign was seen in 13 of 15 patients with neurological deficits (p=0.001). Baltalimani sign showed a sensitivity and specificity PPV and NPV of 61.9%, 86.7%, 89.5%, and 68.8% for the risk of the neurological deficits in SAK patients, respectively. Cohen's kappa value was moderate (κ=0.506).

CONCLUSIONS

The detection of Baltalimani sign in SAK may indicate severity of deformity and the risk of neurological deficits.

Developing and Pilot Testing a Spanish Translation of CollaboRATE for Use in the United States

BACKGROUND/AIM

Given the need for access to patient-facing materials in multiple languages, this study aimed to develop and pilot test an accurate and understandable translation of CollaboRATE, a three-item patient-reported measure of shared decision-making, for Spanish-speaking patients in the United States (US).

METHOD

We followed the Translate, Review, Adjudicate, Pre-test, Document (TRAPD) survey translation protocol. Cognitive interviews were conducted with Spanish-speaking adults within an urban Massachusetts internal medicine clinic. For the pilot test, all patients with weekday appointments between May 1 and May 29, 2015 were invited to complete CollaboRATE in either English or Spanish upon exit. We calculated the proportion of respondents giving the best score possible on CollaboRATE and compared scores across key patient subgroups.

RESULTS

Four rounds of cognitive interviews with 26 people were completed between January and April 2015. Extensive, iterative refinements to survey items between interview rounds led to final items that were generally understood by participants with diverse educational backgrounds. Pilot data collection achieved an overall response rate of 73 percent, with 606 (49%) patients completing Spanish CollaboRATE questionnaires and 624 (51%) patients completing English CollaboRATE questionnaires. The proportion of respondents giving the best score possible on CollaboRATE was the same (86%) for both the English and Spanish versions of the instrument.

DISCUSSION

Our translation method, guided by emerging best practices in survey and health measurement translation, encompassed multiple levels of review. By conducting four rounds of cognitive interviews with iterative item refinement between each round, we arrived at a Spanish language version of CollaboRATE that was understandable to a majority of cognitive interview participants and was completed by more than 600 pilot questionnaire respondents.

Single Posterior Approach for En-Bloc Resection and Stabilization for Locally Advanced Pancoast Tumors Involving the Spine: Single Centre Experience

STUDY DESIGN

Monocentric prospective study.

PURPOSE

To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors.

OVERVIEW OF LITERATURE

In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach.

METHODS

We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation.

RESULTS

Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment.

CONCLUSIONS

The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Gender differences after lumbar sequestrectomy: a prospective clinical trial using quantitative sensory testing

BACKGROUND

Quantitative sensory testing (QST) gained popularity to evaluate the time course of recovery in sensory dysfunction and the results of different treatment options. Concerning sex differences in lumbar spine surgery, female gender seems to play a major role as a negative prognostic factor in different spinal disorders. For this purpose, we hypothesised that there are also comparable differences in pain patterns in men and women after lumbar sequestrectomy using QST.

METHODS

We applied the QST protocol of the German Research Network on Neuropathic Pain in 53 patients (21 women and 32 men) with a single lumbar disc herniation confirmed on MRI treated by a lumbar sequestrectomy. Further evaluation included a detailed medical history, a physical examination, and various questionnaires: Beck-Depression-Inventory, Oswestry Disability Index, Core Outcome Measure Index, painDETECT-Questionnaire and EQ-5D thermometer.

RESULTS

Our analyses showed lower heat thresholds in females preoperatively, that adjusted to that of males 1 week postoperatively. Pressure pain thresholds were lower in women as well, but differed between genders throughout the study. Vibration perception deficits resolve earlier in female than in male patients. Both, women and men, had an excellent overall improvement, postoperatively.

CONCLUSION

Our results clearly revealed pre- and postoperative differences in pain perception between genders. These differences have to be taken into account in the evaluation of outcome between genders. Therefore, QST seems to be a good method to evaluate the time course of recovery after surgery.

Posterior short-segment fixation in thoracolumbar unstable burst fractures - Transpedicular grafting or six-screw construct?

OBJECTIVES

Early implant failure and donor-site complication remain a concern in patients with thoracolumbar burst fracture underwent one-above and-below short-segment posterior pedicle screw fixation with fusion. Our aim was to evaluate the results of short-segment pedicle instrumentation enforced by two augmenting screws or injectable artificial bone cement in the fractured vertebra, and compare the differences between these two PATIENTS AND METHODS: We conducted a retrospective clinical and radiographic study. Twenty-seven patients were treated with a six-screw construct (group 1), and twenty-nine patients underwenta four-screw construct and fractured vertebra augmentation by injectable calcium sulfate/phosphate cement (group 2). Posterior or posterolateral fusions were not performed in both groups. The severity of the fractured vertebra was evaluated by the load-sharing classification (LSC). Local kyphosis and anterior body height of the fractured vertebra were measured and were follow-up at least 2 years. Any implant failure or loss of correction >10° degrees at the final was defined as failure of surgery. Patients' clinical results were assessed by the Denis scale.

RESULTS

Blood loss and operation time were less in group 1 (126.2±9.7 vs. 267.6±126.1ml, p<0.001 and 141.2±48.7 vs. 189.8±16.4min, p<0.001). Immediately after surgery, group 2 had a better local kyphosis angle (3.7±5.3 vs.6.0±4.1°, p=0.047) and acquired more anterior body height (94.9%±7.6% vs. 84.9%±10.0%, p<0.001). Both groups had similar clinical results (pain score: 1.5±0.8vs. 1.4±0.6, p=0.706; work score: 1.7±0.9 vs. 1.6±1.0, p=0.854). Group 1 had 3 cases of surgery failure; group 2 had 8 cases of implant failure (p=0.121). The average LSC score of these 11 patients with surgical failure was 7.2.

CONCLUSION

Thesix-screw construct had the advantage of shorter operating time, less blood loss, and lower failure rate. For those patients with anLSC score ≧7, posterior short-segment instrumentation should be used cautiously.

Neuroimaging Findings in Pediatric Genetic Skeletal Disorders: A Review

Genetic skeletal disorders (GSDs) are a heterogeneous group characterized by an intrinsic abnormality in growth and (re-)modeling of cartilage and bone. A large subgroup of GSDs has additional involvement of other structures/organs beside the skeleton, such as the central nervous system (CNS). CNS abnormalities have an important role in long-term prognosis of children with GSDs and should consequently not be missed. Sensitive and specific identification of CNS lesions while evaluating a child with a GSD requires a detailed knowledge of the possible associated CNS abnormalities. Here, we provide a pattern-recognition approach for neuroimaging findings in GSDs guided by the obvious skeletal manifestations of GSD. In particular, we summarize which CNS findings should be ruled out with each GSD. The diseases (n = 180) are classified based on the skeletal involvement (1. abnormal metaphysis or epiphysis, 2. abnormal size/number of bones, 3. abnormal shape of bones and joints, and 4. abnormal dynamic or structural changes). For each disease, skeletal involvement was defined in accordance with Online Mendelian Inheritance in Man. Morphological CNS involvement has been described based on extensive literature search. Selected examples will be shown based on prevalence of the diseases and significance of the CNS involvement. CNS involvement is common in GSDs. A wide spectrum of morphological abnormalities is associated with GSDs. Early diagnosis of CNS involvement is important in the management of children with GSDs. This pattern-recognition approach aims to assist and guide physicians in the diagnostic work-up of CNS involvement in children with GSDs and their management.

Characteristics and Clinical Relevance of the Osseous Spur in Patients with Congenital Scoliosis and Split Spinal Cord Malformation

BACKGROUND

The natural history of split spinal cord malformation (SCM) is still unclear. Knowledge of the characteristics of the osseous spur and its relationship with the spinal deformity may allow early identification of patients with a higher risk of a neurological deficit and enhance surgical decision-making.

METHODS

Eighty-five consecutive patients with congenital scoliosis and type-I SCM who had undergone surgical treatment at our hospital from May 2000 to December 2013 were identified retrospectively. There were 22 male and 63 female patients with an average age of 13.9 years at the time of surgery. Preoperative clinical and radiographic data were collected to investigate the characteristics of the scoliosis and the osseous spur. Two groups were identified on the basis of whether the patients had intact neurological function (Group A) or a neurological deficit (Group B).

RESULTS

There were 52 patients (61%) in Group A (intact neurological function) and 33 patients (39%) in Group B (neurological deficit). There were no significant differences in the demographic distribution, curve magnitude, or length and thickness of the osseous spur between the 2 groups. In Group A, the location of the osseous spur relative to the apex of the major curve was proximal in 13 patients (25%), distal in 28 (54%), and central in 11 (21%). In Group B, the osseous spur was proximal in 7 (21%), distal in 8 (24%), and central in 18 (55%). The 2 groups differed significantly with respect to the location of the osseous spur (chi square = 10.898, p = 0.004). Group-B patients had a higher proportion of patients with kyphotic deformity (42%) than Group A (10%). The ratio of the diameters of the hemicords (concave side divided by convex side) differed significantly between the 2 groups (0.98 for Group A versus 0.89 for Group B, p = 0.030).

CONCLUSIONS

The neurological status in patients with congenital scoliosis and type-I SCM appears to be closely related to the location of the osseous spur relative to the congenital scoliosis. An osseous spur at the apex of the scoliosis may be related to a higher risk of developing a neurological deficit, especially in patients with kyphotic deformity. Asymmetric splitting of the spinal cord may contribute to neurological deficits.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study

OBJECTIVES

Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting.

METHODS

A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting.

RESULTS

Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (-0.97; 95% CI -1.89 to -0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (-3.7; 95% CI -7.4 to -0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.

CONCLUSIONS

Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.

Global Forum: Spine Research and Training in Underserved, Low and Middle-Income, Culturally Unique Communities: The World Spine Care Charity Research Program's Challenges and Facilitators

The World Spine Care (WSC), established by volunteers from 5 continents, is dedicated to providing sustainable, evidence-based spine care to individuals and communities in low and middle-income countries consistent with available health-care resources and integrated within the local culture. The research committee approves and oversees the WSC's collaborative research and training projects worldwide and serves to create a sustainable research community for underserved populations focused on preventing disability from spinal disorders. The purpose of this article is to describe 4 projects overseen by the WSC research committee and to discuss several challenges and specific facilitators that allowed successful completion of initiatives. These novel projects, which involved establishing spine surgery expertise and data collection in the WSC clinics and surrounding communities, all met their aims. This was achieved by overcoming language and resource challenges, adapting to local customs, and taking time to build mutual respect and to nurture relationships with local investigators and stakeholders.

Effect of Body Mass Index on Reoperation and Complications After Total Knee Arthroplasty

BACKGROUND

High body mass index (BMI) is associated with increased rates of complications after total knee arthroplasty. To date, to our knowledge, studies have examined risk as a dichotomous variable using specific BMI thresholds. The purpose of this investigation was to quantify implant survival and the risk of common complications after total knee arthroplasty using BMI as a continuous variable.

METHODS

Using prospectively collected data from our institutional total joint registry, we analyzed 22,289 consecutive knees, in 16,136 patients, treated with primary total knee arthroplasty from 1985 to 2012. The mean BMI of these patients at the time of the surgical procedure was 31.3 kg/m (range, 11 to 69 kg/m). The Kaplan-Meier survival method was used to estimate survivorship, reoperations, and common complications, with associations of outcomes assessed using a Cox regression model.

RESULTS

Utilizing smoothing spline parameterization, we found that reoperation (p < 0.001) and implant revision or removal rates (p < 0.001) increased with increasing BMI after total knee arthroplasty. Increasing BMI also was associated with increased rates of wound infection (hazard ratio [HR], 1.07; p < 0.001) and deep infection (HR, 1.08; p < 0.001) per unit of BMI over 35 kg/m. A BMI of 35 to 40 kg/m was associated with a higher rate of implant revision for aseptic loosening (p < 0.001) and for polyethylene wear (p < 0.001) compared with a BMI of 18 to 24.99 kg/m. There was no correlation between BMI and risk of venous thromboembolism, tibiofemoral instability, or need for knee manipulation.

CONCLUSIONS

The rates of reoperation, implant revision or removal, and many common complications after total knee arthroplasty were strongly associated with BMI.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Betulin suppressed interleukin-1β-induced gene expression, secretion and proteolytic activity of matrix metalloproteinase in cultured articular chondrocytes and production of matrix metalloproteinase in the knee joint of rat

We investigated whether betulin affects the gene expression, secretion and proteolytic activity of matrix metalloproteinase-3 (MMP-3) in primary cultured rabbit articular chondrocytes, as well as in vivo production of MMP-3 in the rat knee joint to evaluate the potential chondroprotective effect of betulin. Rabbit articular chondrocytes were cultured and reverse transcription-polymerase chain reaction (RT-PCR) was used to measure interleukin-1β (IL-1β)-induced gene expression of MMP-3, MMP-1, MMP-13, a disintegrin and metalloproteinase with thrombospondin motifs-4 (ADAMTS-4), ADAMTS-5 and type II collagen. Effect of betulin on IL-1β-induced secretion and proteolytic activity of MMP-3 was investigated using western blot analysis and casein zymography, respectively. Effect of betulin on MMP-3 protein production was also examined in vivo. The results were as follows: (1) betulin inhibited the gene expression of MMP-3, MMP-1, MMP-13, ADAMTS-4, and ADAMTS-5, but increased the gene expression of type II collagen; (2) betulin inhibited the secretion and proteolytic activity of MMP-3; (3) betulin suppressed the production of MMP-3 protein in vivo. These results suggest that betulin can regulate the gene expression, secretion, and proteolytic activity of MMP-3, by directly acting on articular chondrocytes.

A low invasiveness patient’s specific template for spine surgery

Free-hand pedicle screw placement is still conventional in surgery, although it has potentially high risks. The surgical procedures such as pedicle screw placement are usually designed based on medical imaging, but during surgery, the procedures are not normally followed due to the fact that some points are missed in two-dimensional images and seen only during surgery. In this regards, some highly accurate computer-assisted systems have been proposed and are currently used. Moreover, it is possible to reduce or completely avoid hand working by applying modern digital technology. Therefore, using these technologies has remarkable advantages. In this study, we have presented a new approach of pedicle screw placement in the lumbar and sacral regions using a specific drill guide template. The template was created by additive manufacturing technology and was verified in a clinical study as well. The main aim of this research includes the following: design, analyze, manufacture and evaluate the accuracy of a new patient-specific drill guide template, for lumbar pedicle screw placement, and compare the template to the free-hand technique under fluoroscopy supervision. Our results show that the incidence of cortex perforation is substantially reduced compared to existing methods. Finally, we believe that this approach remarkably lowers the incidence of cortex perforation and could be potentially used in clinical applications, particularly in certain selected cases.

Addressing Stretch Myelopathy in Multilevel Cervical Kyphosis with Posterior Surgery Using Cervical Pedicle Screws

Study Design

Technique description and retrospective data analysis.

Purpose

To describe the technique of cervical kyphosis correction with partial facetectomies and evaluate the outcome of single-stage posterior decompression and kyphosis correction in multilevel cervical myelopathy.

Overview of Literature

Kyphosis correction in multilevel cervical myelopathy involves anterior and posterior surgery. With the advent of cervical pedicle screw-rod instrumentation, single-stage posterior kyphosis correction is feasible and can address stretch myelopathy by posterior shortening.

Methods

Nine patients underwent single-stage posterior decompression and kyphosis correction for multilevel cervical myelopathy using cervical pedicle screw instrumentation from March 2011 to February 2014 and were evaluated preoperatively and postoperatively with modified Japanese Orthopaedic Association (mJOA) scoring and computed tomography scans for radiological measurements. Kyphosis assessment was made with Ishihara curvature index and C2–C7 Cobb's angle. The linear length of the spinal canal and the actual spinal canal length were also evaluated. The average follow-up was 40.56 months (range, 20 to 53 months).

Results

The average preoperative C2–7 Cobb's angle of 6.3° (1° to 12°) improved to 2° (10° to −9°). Ishihara index improved from −15.8% (−30.5% to −4.7%) to −3.66% (−14.5% to +12.6%). The actual spinal canal length decreased from 83.64 mm (range, 76.8 to 91.82 mm) to 82.68 mm (range, 75.85 to 90.78 mm). The preoperative mJOA score of 7.8 (range, 3 to 11) improved to 15.0 (range, 13 to 17).

Conclusions

Single-stage posterior decompression and kyphosis correction using cervical pedicle screws for multilevel cervical myelopathy may address stretch myelopathy, in addition to decompression in the transverse plane. However, cervical lordosis was not achieved with this method as predictably as by the anterior approach. The present study shows evidence of mild shortening of cervical spinal canal and a positive correlation between canal shortening and clinical improvement.

Repairing the ruptured annular fibrosus by using type I collagen combined with citric acid, EDC and NHS: an in vivo study

OBJECTIVES

To explore the effect of citric acid (CA)-1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC)/N-hydroxysuccinimide (NHS) collagen gel on repairing annular defects.

METHODS

Type I collagen was extracted from the rat-tail tendon and crosslinked with CA at different mass ratio using EDC and NHS as crosslinking reagents to prepare four kinds of collagen gels. Forty-eight adult SD rats were divided into first sham group (n = 8), second group (n = 10) which was punctured and injected with CA-EDC/NHS collagen gel, third group (n = 10) which was punctured and injected with CA-EDC/NHS collagen gel, fourth group (n = 10) which was punctured and injected with EDC/NHS collagen gel, and fifth group (n = 10) which was punctured and untreated. X-ray images and magnetic resonance imaging images were obtained before puncture and at the 1st, 2nd, and 4th week after puncture. At each time point, disc height index (%DHI), voxel count and modified MRI Pfirrmann grading were collected and analyzed. All animals were killed at the 4th week to study the morphology.

RESULTS

The discs in the second group showed only slight degeneration compared with the healthy discs, and the results of %DHI (average 79%), voxel count (average 126.9), Pfirrmann grading (average grade 1.3) and morphology in the second group indicated less degeneration tendency compared with the other three puncture groups at the 4th week (P < 0.05). The annular fibrosus was partially repaired by the collagen gels that bridged the defects.

CONCLUSIONS

CA-EDC/NHS collagen gel is capable of repairing annular defects induced by needle puncture, which may be closely related to the dose of CA.

Transient Local Bone Remodeling Effects of rhBMP-2 in an Ovine Interbody Spine Fusion Model

BACKGROUND

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a powerful osteoinductive morphogen capable of stimulating the migration of mesenchymal stem cells (MSCs) to the site of implantation and inducing the proliferation and differentiation of these MSCs into osteoblasts. Vertebral end-plate and vertebral body resorption has been reported after interbody fusion with high doses of rhBMP-2. In this study, we investigated the effects of 2 rhBMP-2 doses on peri-implant bone resorption and bone remodeling at 7 time points in an end-plate-sparing ovine interbody fusion model.

METHODS

Twenty-one female sheep underwent an end-plate-sparing discectomy followed by interbody fusion at L2-L3 and L4-L5 using a custom polyetheretherketone (PEEK) interbody fusion device. The PEEK interbody device was filled with 1 of 2 different doses of rhBMP-2 on an absorbable collagen sponge (ACS): 0.13 mg (1×) or 0.90 mg (7×). Bone remodeling and interbody fusion were assessed via high-resolution radiography and histological analyses at 1, 2, 3, 4, 8, 12, and 20 weeks postoperatively.

RESULTS

Peri-implant bone resorption peaked between 3 and 8 weeks in both the 1× and the 7× rhBMP-2/ACS-dose group. Osteoclastic activity and corresponding peri-implant bone resorption was dose-dependent, with moderate-to-marked resorption at the 7×-dose level and less resorption at the 1×-dose level. Both dose (p < 0.0007) and time (p < 0.0025) affected bone resorption significantly. Transient bone-resorption areas were fully healed by 12 weeks. Osseous bridging was seen at all but 1 spinal level at 12 and at 20 weeks.

CONCLUSIONS

In the ovine end-plate-sparing interbody fusion model, rhBMP-2 dose-dependent osteoclastic resorption is a transient phenomenon that peaks at 4 weeks postoperatively.

CLINICAL RELEVANCE

Using the U.S. Food and Drug Administration (FDA)-approved rhBMP-2 concentration and matching the volume of rhBMP-2/ACS with the volume of desired bone formation within the interbody construct may limit the occurrence of transient bone resorption.

Analysis of Risk Factors for Secondary New Vertebral Compression Fracture Following Percutaneous Vertebroplasty in Patients with Osteoporosis

OBJECTIVE

The aim of this article was to analyze risk factors for secondary new vertebral compression fractures (SNVCFs) after percutaneous vertebroplasty in patients with osteoporosis.

METHODS

We investigated medical records and radiologic images of patients undergoing percutaneous vertebroplasty for osteoporotic vertebral compression fracture between October 2009 and September 2014. We assessed patients' age, past medical history, and bone mineral content using computed tomography. Procedure-specific outcomes were assessed, including ratio of injected bone cement to vertebral body volume, bone cement distribution in the vertebral body (to identify degree of consistency in bone cement injection), presence of bone cement leakage into adjacent disc space, segmental kyphosis, and time interval between first and second fracture events.

RESULTS

Percutaneous vertebroplasty was performed in 293 patients (60 men and 233 women) with 336 affected levels. Of this cohort, 34 (14.6%) patients sustained SNVCFs. We compared patients in 2 groups: patients who experienced SNVCFs, and patients who did not experience fractures. Significant differences were identified in bone mineral content (P = 0.000) and bone cement distribution (P = 0.000). Patients exhibiting bone cement leakage into disc space revealed a higher incidence of SNVCF than patients without leakage (P = 0.039).

CONCLUSIONS

Poor bone mineral content can be a predictive factor of SNVCFs. To prevent SNVCFs, bone cement should be injected as evenly as possible into the vertebral body. Bone cement leakage into the disc space should be avoided.

Subacute posttraumatic ascending myelopathy: a literature review

Study design:

A literature review.

Objectives:

Our aim was to summarise the history, epidemiology, aetiological mechanism, pathological study, clinical and radiological evaluation, treatment and prognosis of subacute posttraumatic ascending myelopathy (SPAM).

Methods:

Medical literature on SPAM were searched in the PubMed, Medline, Ovid and Embase databases. The cases of SPAM reported in literature were analysed, and the history, epidemiology, aetiological mechanism, pathological study, clinical and radiological evaluation, treatment and prognosis of SPAM were summarised.

Results:

SPAM remains a relatively rare disorder occurring within the first few weeks after spinal cord injury (SCI). The incidence rate ranges from 0.42% to 1% among all SCI. SPAM is likely to occur in young and middle-aged male patients. Risk factors of SPAM include complete injury, low blood pressure, early postoperative mobilisation and nonsurgical treatment.

Conclusions:

SPAM is well recognised according to typical clinical manifestation and magnetic resonance imaging characteristics. There is no effective therapy for this neurological deterioration. The prognosis of SPAM is poor. There is usually a slight improvement of one or more level(s) below the maximal level of deterioration. The mortality rate is approximately 10%.

Single Intradiscal Administration of the Tumor Necrosis Factor-Alpha Inhibitor, Etanercept, for Patients with Discogenic Low Back Pain

OBJECTIVE

To examine the analgesic effect of intradiscal administration of a tumor necrosis factor-αα (TNF-α) inhibitor in patients with discogenic low back pain (LBP).

DESIGN

Prospective, randomized study.

SETTING

Department of Orthopaedic Surgery, Chiba (Japan) University Hospital.

SUBJECTS

Seventy-seven patients diagnosed with discogenic LBP.

METHODS

Discogenic LBP patients were randomly assigned to the etanercept (n = 38; bupivacaine [2 mL] with etanercept [10 mg]) or control (n = 39; bupivacaine [2 mL]) groups. Patients received a single intradiscal injection. Numerical rating scale (NRS) scores for LBP at baseline, 1 day, and 1, 2, 4, and 8 weeks after the injection were recorded. The Oswestry disability index (ODI) scores at baseline and at 4 and 8 weeks after injection were evaluated. Postinjection complications were recorded and evaluated.

RESULTS

In the etanercept group, the NRS scores were significantly lower than in the control group at every time point after the injection for 8 weeks (P < 0.05). Similarly, 4 weeks after the injection, the ODI score was lower in the etanercept group than in the control group (P < 0.05). However, the ODI scores were not significantly different at 8 weeks. Complications were not observed.

CONCLUSIONS

Single intradiscal administration of a TNF-α inhibitor can alleviate intractable discogenic LBP for up to 8 weeks. TNF-α may be involved in discogenic pain pathogenesis. This procedure is a novel potential treatment; longer-term effectiveness trials are required in the future.

Psychometric properties of the Anxiety Inventory for Respiratory Disease in patients with COPD in China

BACKGROUND

Anxiety is a common comorbidity in patients with COPD in China, and it can significantly decrease patients' quality of life. Almost all anxiety measurements contain somatic items that can overlap with symptoms of COPD and side effects of medicines, which can lead to bias in measuring anxiety in patients with COPD. Therefore, a brief and disease-specific non-somatic anxiety measurement scale, the Anxiety Inventory for Respiratory Disease (AIR), which has been developed and validated in its English version, is needed for patients with COPD in China.

METHODS

A two-center study was conducted in two tertiary hospitals in Tianjin, China. A total of 181 outpatients with COPD (mean age 67.21±8.10 years, 32.6% women), who met the inclusion and exclusion criteria, were enrolled in the study. Test-retest reliability was examined using intraclass correlation coefficients. The internal consistency was calculated by Cronbach's α. Content validity was examined using the Content Validity Index (CVI), scale-level CVI/universal agreement, and scale-level CVI/average agreement (S-CVI/Ave). Besides, convergent validity and construct validity were also examined.

RESULTS

The AIR-C (AIR-Chinese version) scale had high test-retest reliability (intraclass correlation coefficient =0.904) and internal consistency (Cronbach's α=0.914); the content validity of the AIR-C scale was calculated by CVI, scale-level CVI/universal agreement, and S-CVI/Ave at values of 0.89-1, 0.90, and 0.98, respectively. Meanwhile, the AIR-C scale had good convergent validity, correlating with the Hospital Anxiety and Depression Scale-Anxiety (r=0.81, P<0.01), and there were significant correlations between the AIR-C and Clinical COPD Questionnaire (CCQ; r=0.44, P<0.01) and Activities of Daily Living Scale (ADLS; r=0.36, P<0.01). A two-factor model of general anxiety and panic symptoms in the AIR-C scale had the best fit according to Confirmatory Factor Analysis (CFA).

CONCLUSION

The AIR-C scale had a good reliability and validity for patients with COPD and can be used as a user-friendly and valid tool for measuring anxiety symptoms among patients with COPD in China.

Dural ossification associated with ossification of ligamentum flavum in the thoracic spine: a retrospective analysis

OBJECTIVES

To investigate the incidence, distribution and radiological characteristics of dural ossification (DO) associated with ossification of ligamentum flavum (OLF) in the thoracic spine.

DESIGN

A retrospective radiographical analysis.

SETTING

This study was conducted at a single institution in China.

PARTICIPANTS

53 patients with OLF who underwent posterior decompression surgery between January 2011 and July 2015 in a single institution were enrolled in this study. The decompression segments were grouped according to imaging evaluation and intraoperative evidences.

OUTCOME MEASURES

The demographic distribution, radiological data and detailed surgical records were collected. First, preoperative CT images of decompressed segments were evaluated to identify imaging signs of DO. The 'tram tack sign' (TTS), 'comma sign' and 'bridge sign' were considered as characteristic imaging findings of DO in OLF. 4 kinds of confusing signs (false TTS) were identified and excluded. Then detailed surgical records were reviewed to finally identify segments with DO.

RESULTS

The incidence of DO in patients with OLF was 43.4%. The incidence of DO in OLF segments was 21.5%. OLF was more common in the lower thoracic spine, and more than half (53.8%) of the DO was located in T9-T12. TTS was the most common sign, but it might be misdiagnosed. After excluding 4 kinds of false TTS, the sensitivity and specificity of imaging diagnosis were 94.23% and 94.21%, respectively.

CONCLUSIONS

DO was relatively common in thoracic OLF, especially in T9-T12. TTS might be misdiagnosed. After excluding 4 kinds of false TTS, the accuracy of imaging diagnosis was relatively high.

Factors Associated with Long-Term Control of Type 2 Diabetes Mellitus

Aims. This study assessed factors associated with glycemic control among Saudi patients with Type 2 diabetes mellitus (T2DM). Methods. We conducted an analytical cross-sectional study, which included a random sample of 288 patients with T2DM proportional to the diabetes population of each primary health care center in Jazan city, Kingdom of Saudi Arabia. Results. More than two-thirds (74%) of patients had poor glycemic control. Lack of education, polypharmacy, and duration of diabetes ≥ 7 years were significantly associated with higher glycated hemoglobin (HbA1c). Moreover, patients who were smoker or divorced were significantly more likely to have higher HbA1c. The patients who did not comply with diet or take their medications as prescribed had poor glycemic control. The study found lower HbA1c levels among patients who received family support or had close relationship with their physicians. Similarly, knowledgeable patients towards diabetes or those with greater confidence in ability to manage self-care behaviors had a lower HbA1c. In contrast, risk factors such as depression or stress were significantly correlated with poorer glycemic control. Conclusion. The majority of T2DM patients had poor glycemic control. The study identified several factors associated with glycemic control. Effective and tailored interventions are needed to mitigate exposure to these risk factors. This would improve glycemic control and reduce the risks inherent to diabetes complications.

Differences in Neural Mechanosensitivity Between Patients with Chronic Nonspecific Neck Pain With and Without Neuropathic Features. A Descriptive Cross-Sectional Study

OBJECTIVE

To assess differences in neural mechanosensitivity between patients with chronic nonspecific neck pain with and without neuropathic features (NF and No-NF, respectively).

DESIGN

Descriptive, cross-sectional study.

SETTING

A primary care center, a hospital physiotherapy outpatient department, and a university campus.

SUBJECTS

Chronic nonspecific neck pain patients classified by the self-completed leeds assessment of neuropathic symptoms and signs pain scale (S-LANSS; 49 patients with NF [S-LANSS ≥ 12] and 50 patients with No-NF [S-LANSS < 12]) and a healthy control group (n = 48).

METHODS

The primary measurements were the mechanosensitivity of the median nerve and cervical region, specifically the assessment of the onset of symptoms and submaximal pain intensity according to the upper limb neural test 1 (ULNT1) for the median nerve and the modified passive neck flexion test (MPNFT) for the cervical region; secondary measurements included pain intensity, neck disability, kinesiophobia, and pain catastrophizing.

RESULTS

Statistically significant differences between the NF and No-NF groups were found with respect to the onset of symptoms of ULNT1 (-15.11 [-23.19 to -7.03]) and MPNFT (-6.58 [-11.54 to -1.62]), as well as the outcomes of the visual analogue scale (Mean difference [95% Confidence Interval]; 7.12 [1.81-12.42]) and neck disability index (3.72 [1.72-5.71]). Both chronic nonspecific neck pain groups showed statistically significant differences compared with the control group for all outcomes assessed (P < 0.01) except for the onset of symptoms of ULNT1 in the No-NF group.

CONCLUSIONS

The findings of this study suggest that chronic nonspecific neck pain patients with NF have greater neural mechanosensitivity, pain intensity, and neck disability than those with No-NF.

Deconstructing Chronic Low Back Pain in the Older Adult--Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part V: Maladaptive Coping

OBJECTIVE

As part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on maladaptive coping--a significant contributor of psychological distress, increased pain, and heightened disability in older adults with CLBP.

METHODS

A modified Delphi technique was used to develop a maladaptive coping algorithm and table providing the rationale for the various components of the algorithm. A seven-member content expert panel and a nine-member primary care panel were involved in the iterative development of the materials. While the algorithm was developed keeping in mind resources available within the Veterans Health Administration (VHA) facilities, panelists were not exclusive to the VHA, and therefore, materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors' clinical practice.

RESULTS

We present a treatment algorithm and supporting table to be used by providers treating older adults who have CLBP and engage in maladaptive coping strategies. A case of an older adult with CLBP and maladaptive coping is provided to illustrate the approach to management.

CONCLUSIONS

To promote early engagement in skill-focused treatments, providers can routinely evaluate pain coping strategies in older adults with CLBP using a treatment algorithm.

Stereotactic body radiotherapy for recurrent head and neck cancer: A critical review

The management of patients with recurrent head and neck cancers remains a challenging clinical dilemma. Concerns over toxicity with re-irradiation have limited its use in the clinical setting. Stereotactic Body Radiation Therapy (SBRT) has emerged as a highly conformal and precise type of radiotherapy and has the advantage of sparing normal tissue. Although SBRT is an attractive treatment modality, its use in the clinic is limited, given the technically challenging nature of the procedure. In this review, we attempt to provide a comprehensive overview of the role of re-irradiation in patients with recurrent head and neck cancers, with particular attention to the advent of SBRT and its use with systemic therapies such as cetuximab. In the second portion of this review, we present our systematic review of published experiences with SBRT in recurrent head and neck cancers in an attempt to provide data on response rates (RR), overall survival and toxicity. © 2016 Wiley Periodicals, Inc. Head Neck 39: 595-601, 2017.

Supraspinal Control Predicts Locomotor Function and Forecasts Responsiveness to Training after Spinal Cord Injury

Restoration of walking ability is an area of great interest in the rehabilitation of persons with spinal cord injury. Because many cortical, subcortical, and spinal neural centers contribute to locomotor function, it is important that intervention strategies be designed to target neural elements at all levels of the neuraxis that are important for walking ability. While to date most strategies have focused on activation of spinal circuits, more recent studies are investigating the value of engaging supraspinal circuits. Despite the apparent potential of pharmacological, biological, and genetic approaches, as yet none has proved more effective than physical therapeutic rehabilitation strategies. By making optimal use of the potential of the nervous system to respond to training, strategies can be developed that meet the unique needs of each person. To complement the development of optimal training interventions, it is valuable to have the ability to predict future walking function based on early clinical presentation, and to forecast responsiveness to training. A number of clinical prediction rules and association models based on common clinical measures have been developed with the intent, respectively, to predict future walking function based on early clinical presentation, and to delineate characteristics associated with responsiveness to training. Further, a number of variables that are correlated with walking function have been identified. Not surprisingly, most of these prediction rules, association models, and correlated variables incorporate measures of volitional lower extremity strength, illustrating the important influence of supraspinal centers in the production of walking behavior in humans.

The reliability of spinal motion palpation determination of the location of the stiffest spinal site is influenced by confidence ratings: a secondary analysis of three studies

Background

This is a secondary analysis of three previous studies on the cervical, thoracic, and lumbar spines. It uses continuous analysis of the stiffest spinal site rather than more typical level-by-level analysis to assess interexaminer reliability, and the impacts of examiner confidence and spinal region. The primary goal was secondary analysis of the combined data; secondary goal was de novo analysis of combined data emphasizing absolute indices of examiner agreement; and tertiary goal was analysis of actual vs. simulated data to determine to what degree the information provided by motion palpation impacted interexaminer reliability.

Methods

This study emphasized Median Absolute Examiner Differences and Bland-Altman Limits of Agreement to calculate examiner differences, which are immune to subject homogeneity, and de-emphasized intraclass correlation, which is not. It calculated Median Absolute Deviation to determine data dispersion. The study analyzed the entire n = 113 combined dataset, as well as subgroups stratified by examiner confidence and spinal region. Simulations were run using a random number generator to provide chance data for examiners' findings of the stiffest spinal site, the analysis of which was compared with that of the actual data.

Results

Median Absolute Examiner Differences for the combined dataset were 0.7 of one vertebral level, suggesting examiners usually agreed on the stiffest spinal site or the motion segment including it. When both examiners were confident in their findings (53.4%), the median examiner difference decreased to 0.6 levels, increasing to 1.0 levels when one lacked confidence and to 1.8 levels when both lacked confidence. Reliability was greater in the cervical and lumbar spines (each 0.6 vertebral levels examiner differences) than in the thoracic spine (1.1 levels examiner differences). The actual information provided by motion palpation compared to simulated data improved interexaminer reliability by a factor ranging from 1.8 times to 4.7 times, depending on the regional subset analyzed.

Conclusions

Examiner decisions regarding the location of the stiffest spinal site were deemed adequately reliable, especially when the examiners were confident. Researchers and clinicians alike might best design their study protocols and practice methods using the stiffest segment protocol as an alternative to level-by-level spinal analysis.

Participatory organizational intervention for improved use of assistive devices for patient transfer: study protocol for a single-blinded cluster randomized controlled trial

Background

Epidemiological studies have shown that patient transfer is a risk factor for back pain, back injuries and long term sickness absence, whereas consistent use of assistive devices during patient transfer seems to be protective. While classical ergonomic interventions based on education and training in lifting and transferring techniques have not proven to be effective in preventing back pain, participatory ergonomics, that is meant to engage and motivate the involved parties while at the same time making the intervention maximally relevant, may represent a better solution. However, these findings are largely based on uncontrolled studies and thus lack to be confirmed by studies with better study designs. In this article, we present the design of a study which aims to evaluate the effect and process of a participatory organizational intervention for improved use of assistive devices.

Methods

The study was performed as a cluster randomized controlled trial. We recruited 27 departments (clusters) from five hospitals in Denmark to participate in the study. Prior to randomization, interviews, observations and questionnaire answers (baseline questionnaire) were collected to gain knowledge of barriers and potential solutions for better use of assistive devices. In April 2016, the 27 departments were randomly allocated using a random numbers table to a participatory intervention (14 clusters, 324 healthcare workers) or a control group (13 clusters, 318 healthcare workers). The participatory intervention will consist of workshops with leaders and selected healthcare workers of each department. Workshop participants will be asked to discuss the identified barriers, develop solutions for increasing the use of assistive devices and implement them in their department. Use of assistive devices (using digital counters -, primary outcome, and accelerometers and questionnaire - secondary outcome), perceived physical exertion during patient transfer, pain intensity in the lower back, occurrence of work-related back injuries during patient transfer, organizational readiness to change, knowledge on how to perform proper patient transfer, social capital and work ability (secondary outcomes) were assessed at baseline and will also be assessed at 1 year follow-up. Process evaluation will be based on qualitative and quantitative data to assess the implementation, the change process, and the impact of context aspects.

Discussion

The study will evaluate the effect and process of a participatory intervention on improving the use of assistive devices for patient transfer among hospital healthcare workers. By using cluster-randomization, as well as process- and effect evaluation based on objective measures we will contribute to the evidence base of a promising intervention approach.

Trial registration

ClinicalTrials.gov (NCT02708550). March, 2016.

Effect of hypoxia on the proliferation of porcine bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells in 2- and 3-dimensional culture

OBJECTIVE

Bone marrow-derived mesenchymal stem cells (MSCs) and adipose-derived mesenchymal stem cells (ASCs) currently represent a promising tool for the regeneration of large bony defects. Therefore, it is pivotal to find the best cell source within the body and the best conditions for in vitro cellular expansion. This study compared cellular response of MSCs and ASCs from a porcine animal in normoxic (21% O2) and hypoxic (2% O2) cell culture conditions via 2D and 3D experimental settings.

MATERIALS AND METHODS

The effect of constant exposure to hypoxia on primary pig stem cells was evaluated by two methods. First, a cumulative population doublings (cumPD) over a period of 40 days, a metabolic activity assay in both 2D and 3D beta-TCP-PHB scaffolds, followed by analysis of osteogenic differentiation potential in cell monolayers.

RESULTS

Our results displayed enhanced cell culture proliferation in 2% O2 for both MSCs and ASCs, with impaired osteogenic differentiation of MSCs. The impact of constant hypoxia on porcine MSCs and ASCs exhibited a statistically significant decrease in osteogenic differentiation under hypoxic conditions with the MSCs.

CONCLUSIONS

Our data suggest that MSCs and ASCs expanded in hypoxic culture conditions, might be more suitable for use in the clinical setting where large cell numbers are required. When differentiated in normoxic conditions, MSCs showed the highest osteogenic differentiation potential and might be the best choice of cells with consideration to bone repair.