Risk of Nongenitourinary Cancers in Patients With Spinal Cord Injury: A Population-based Cohort Study

Spinal cord injury-induced metabolic impairment and steatohepatitis develops in non-obese rats and is exacerbated by premorbid obesity

Impaired sensorimotor functions are prominent complications of spinal cord injury (SCI). A clinically important but less obvious consequence is development of metabolic syndrome (MetS), including increased adiposity, hyperglycemia/insulin resistance, and hyperlipidemia. MetS predisposes SCI individuals to earlier and more severe diabetes and cardiovascular disease compared to the general population, which trigger life-threatening complications (e.g., stroke, myocardial infarcts). Although each comorbidity is known to be a risk factor for diabetes and other health problems in obese individuals, their relative contribution or perceived importance in propagating systemic pathology after SCI has received less attention. This could be explained by an incomplete understanding of MetS promoted by SCI compared with that from the canonical trigger diet-induced obesity (DIO). Thus, here we compared metabolic-related outcomes after SCI in lean rats to those of uninjured rats with DIO. Surprisingly, SCI-induced MetS features were equal to or greater than those in obese uninjured rats, including insulin resistance, endotoxemia, hyperlipidemia, liver inflammation and steatosis. Considering the endemic nature of obesity, we also evaluated the effect of premorbid obesity in rats receiving SCI; the combination of DIO + SCI exacerbated MetS and liver pathology compared to either alone, suggesting that obese individuals that sustain a SCI are especially vulnerable to metabolic dysfunction. Notably, premorbid obesity also exacerbated intraspinal lesion pathology and worsened locomotor recovery after SCI. Overall, these results highlight that normal metabolic function requires intact spinal circuitry and that SCI is not just a sensory-motor disorder, but also has significant metabolic consequences.

[Oncological relevance of neuro-urological diseases]

Apart from a few exceptions, there is currently little scientific evidence on the oncological relevance of neuro-urological diseases. Most research has been conducted into the association between long-term spinal cord injury with its consequences for the lower urinary tract and the occurrence of bladder cancer. These cancers differ in many ways from bladder cancers in patients without spinal cord injury: patients are 20 years younger on average, tumours are very often already muscle-invasive and poorly differentiated with a high proportion of squamous cell carcinomas, and the prognosis is poor. These characteristics also occur in spinal cord injury patients without permanent catheter drainage of the urinary bladder. Although the pathophysiological association has not been clarified in detail, the presence of a neurogenic bladder appears to be the decisive link between spinal cord injury and the occurrence of bladder cancer. Pathological pressure conditions in the urinary bladder and frequent urinary tract infections or asymptomatic bacteriuria resulting from neurogenic lower urinary tract dysfunction could be the decisive pathophysiological factors. In this respect, urinary bladder cancer in persons with a chronic spinal cord injury represents a model tumour after denervation. The clinically important question of screening requires future interdisciplinary research approaches.

Clinicopathological characteristics and prognostic factors in axial chondroblastomas: a retrospective analysis of 61 cases and comparison with extra-axial chondroblastomas

BACKGROUND

A comprehensive understanding of the clinical characteristics and prognostic factors associated with axial chondroblastoma (ACB) is still lacking. This study aimed to understand the clinical characteristics and prognostic factors of axial chondroblastoma (ACB) and compare them with extra-axial chondroblastoma (EACB).

METHODS

A retrospective review of our institution's local database was conducted, encompassing a total of 132 CB patients, of which 61 were diagnosed with ACB and 71 with EACB. Immunohistochemistry was employed to evaluate the expression levels of vimentin, S100, and cytokeratin.

RESULTS

ACB and EACB shared similar characteristics, with the exception of advanced age, tumor size, elevated Vim expression, incidence of surrounding tissue invasion, and postoperative sensory or motor dysfunction. While wide resection and absence of surrounding tissue invasion consistently showed a favorable association with survival in both ACB and EACB cohorts during univariate analysis, most parameters exhibited differential prognostic significance between the two groups. Notably, the significant prognostic factors for local recurrence-free survival in the ACB cohort included the type of resection and the presence of chicken-wire calcification. In the multivariate analysis of overall survival, the type of resection emerged as a significant predictor in the ACB cohort, whereas in the EACB group, the type of resection and the occurrence of postoperative sensory or motor dysfunction were predictive of overall survival.

CONCLUSION

There may exist distinct biological behaviors between ACB and EACB, thereby providing valuable insights into the prognostic characteristics of ACB patients and contributing to enhanced outcome prediction in this particular patient population.

Clinicopathological and Prognostic Characteristics in Spinal Chondroblastomas: A Pooled Analysis of Individual Patient Data From a Single Institute and 27 Studies

STUDY DESIGN

Retrospective pooled analysis of individual patient data.

OBJECTIVES

Spinal chondroblastoma (CB) is a very rare pathology and its clinicopathological and prognostic features remain unclear. Here, we sought to characterize the clinicopathological data of a large spinal CB cohort and determine factors affecting the local recurrence-free survival (LRFS) and overall survival (OS) of patients.

METHODS

Electronic searches using Medline, Embase, Google Scholar and Wanfang databases were performed to identify eligible studies per predefined criteria. A retrospective review was also conducted to include additional patients at our center.

RESULTS

Twenty-seven studies from the literature and 8 patients from our local institute were identified, yielding a total of 61 patients for analysis. Overall, there were no differences in clinicopathological characteristics between the local and literature cohorts, except for absence or presence of spinal canal invasion by tumor on imagings and chicken-wire calcification in tumor tissues. Univariate Kaplan-Meier analysis revealed that previous treatment, preoperative or postoperative neurological deficits, type of tumor resection, secondary aneurysmal bone cyst (ABC), chicken-wire calcification and radiotherapy correlated closely with LRFS, though only type of tumor resection, chicken-wire calcification and radiotherapy were predictive of outcome based on multivariate Cox analysis. Analyzing OS, we found that a history of preoperative treatment, concurrent ABC, chicken-wire calcification, type of tumor resection and adjuvant radiotherapy had a significant association with survival, whereas only type of tumor resection remained statistically significant after adjusting for other covariables.

CONCLUSION

These data may be helpful in prognostic risk stratification and individualized therapy decision making for patients.

Optimising patients with long-term spinal cord injury for nephrectomy: A review of pre-, peri- and post-operative factors to safeguard outcomes

Objectives:

To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these.

Materials and methods:

Comprehensive literature review via PubMed, MEDLINE® and Google™ Scholar searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists.

Results:

Pre-operative considerations:  - urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury;  - assessing for chronic constipation and distended bowel; and  - considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Peri-operative considerations:  - adequate theatre staffing for safe patient transfer; and  - planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations:  - ensuring attending medical staff are trained to recognise autonomic dysreflexia;  - early re-mobilisation with physiotherapists experienced in treating spinal cord injury; and  - attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections

Conclusions:

Patients with long-term spinal cord injury pose significant potential challenges in the pre-, peri- and post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes.

Level of evidence:

Not applicable for this multicentre audit.

A Primary Care Provider's Guide to Preventive Health After Spinal Cord Injury

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

Barriers to colorectal cancer screening for people with spinal cord injuries and/or disorders: A qualitative study

BACKGROUND

Limited research has shown people with spinal cord injuries and/or disorders (SCID) are less likely to be up to date with colorectal cancer (CRC) screening and therefore more likely to be diagnosed with advanced stage CRC compared to people without SCID.

OBJECTIVE

The aims of this study were to assess knowledge about CRC, CRC screening, and self-reported barriers to CRC screening for people with SCID.

METHODS

Interviews with 30 individuals with SCID were conducted using a semi-structured interview guide, audio recorded, and transcribed. Coding was performed using a hybrid approach of inductive and deductive analysis. Thematic analysis was used to identify, review, and modify themes and sub-themes.

RESULTS

Themes identified included barriers to CRC screening, such as socioeconomic, health system, transportation, psychological, and environmental or accessibility barriers. While most respondents were able to describe one CRC screening method (usually colonoscopy), knowledge of other screening modalities was limited. Low CRC literacy and misinformation about CRC screening appeared to increase respondent association between CRC screening and colonoscopy. While most respondents associated CRC screening with colonoscopy, almost half reported the colonoscopy preparation was the most substantial barrier to screening.

CONCLUSIONS

In addition to addressing identified barriers such as accessibility and transportation, communication, and prevention interventions should be specifically targeted to ensure all people with SCID are informed about appropriate and various modalities and the benefits of screening. Specific, evidence-based guidelines on the use of stool specimens first with follow up direct visualization, if needed, should be developed for this population.

Hepatic dysfunction after spinal cord injury: A vicious cycle of central and peripheral pathology?

The liver is essential for numerous physiological processes, including filtering blood from the intestines, metabolizing fats, proteins, carbohydrates and drugs, and regulating iron storage and release. The liver is also an important immune organ and plays a critical role in response to infection and injury throughout the body. Liver functions are regulated by autonomic parasympathetic innervation from the brainstem and sympathetic innervation from the thoracic spinal cord. Thus, spinal cord injury (SCI) at or above thoracic levels disrupts major regulatory mechanisms for hepatic functions. Work in rodents and humans shows that SCI induces liver pathology, including hepatic inflammation and fat accumulation characteristic of a serious form of non-alcoholic fatty liver disease (NAFLD) called non-alcoholic steatohepatitis (NASH). This hepatic pathology is associated with and likely contributes to indices of metabolic dysfunction often noted in SCI individuals, such as insulin resistance and hyperlipidemia. These occur at greater rates in the SCI population and can negatively impact health and quality of life. In this review, we will: 1) Discuss acute and chronic changes in human and rodent liver pathology and function after SCI; 2) Describe how these hepatic changes affect systemic inflammation, iron regulation and metabolic dysfunction after SCI; 3) Describe how disruption of the hepatic autonomic nervous system may be a key culprit in post-injury chronic liver pathology; and 4) Preview ongoing and future research that aims to elucidate mechanisms driving liver and metabolic dysfunction after SCI.

Parasympathetic Effect Induces Cell Cycle Activation in Upper Limbs of Paraplegic Patients with Spinal Cord Injury

The present study aimed to investigate gene expression changes related to cell cycle activation in patients with spinal cord injury (SCI) and to further evaluate the difference between the upper and lower limbs of SCI patients. Fibroblasts were obtained from the upper and lower limbs of SCI patients and healthy subjects. To investigate gene expression profiling in the fibroblasts from SCI patients compared to the healthy subjects, RNA-Seq transcriptome analysis was performed. To validate the parasympathetic effects on cell cycle activation, fibroblasts from upper or lower limbs of SCI patients were treated with the anticholinergic agents tiotropium or acetylcholine, and quantitative RT-PCR and Western blot were conducted. Cell proliferation was significantly increased in the upper limbs of SCI patients compared with the lower limbs of SCI patients and healthy subjects. The pathway and genes involved in cell cycle were identified by RNA-Seq transcriptome analysis. Expression of cell-cycle-related genes CCNB1, CCNB2, PLK1, BUB1, and CDC20 were significantly higher in the upper limbs of SCI patients compared with the lower limbs of SCI patients and healthy subjects. When the fibroblasts were treated with tiotropium the upper limbs and acetylcholine in the lower limbs, the expression of cell-cycle-related genes and cell proliferation were significantly modulated. This study provided the insight that cell proliferation and cell cycle activation were observed to be significantly increased in the upper limbs of SCI patients via the parasympathetic effect.

Bioinformatics analysis of circulating miRNAs related to cancer following spinal cord injury

Patients with spinal cord injury (SCI) have an increased risk of developing esophageal, bladder and hematologic malignancies compared with the normal population. In the present study, we aimed to identify, through in silico analysis, miRNAs and their target genes related to the three most frequent types of cancer in individuals with SCI. In a previous study, we reported a pattern of expression of miRNAs in 17 sedentary SCI males compared with 22 healthy able-bodied males by TaqMan OpenArray. This list of miRNAs deregulated in SCI patients was uploaded to miRWALK2.0 to predict the target genes and pathways of selected miRNAs. We used Cytoscape software to construct the network displaying the miRNAs and their gene targets. Among the down-regulated miRNAs in SCI, 21, 19 and 20 miRNAs were potentially associated with hematological, bladder and esophageal cancer, respectively, and three target genes (TP53, CCND1 and KRAS) were common to all three types of cancer. The three up-regulated miRNAs were potentially targeted by 18, 15 and 10 genes associated with all three types of cancer. Our current bioinformatics analysis suggests the potential influence of several miRNAs on the development of cancer in SCI. In general, these data may provide novel information regarding potential molecular mechanisms involved in the development of cancer among individuals with SCI. Further studies aiming at understanding how miRNAs contribute to the development of the major cancers that affect patients after SCI may help elucidate the role of these molecules in the pathophysiology of the disease.

Dietary Green Tea Extract Prior to Spinal Cord Injury Prevents Hepatic Iron Overload but Does Not Improve Chronic Hepatic and Spinal Cord Pathology in Rats

Spinal cord injury (SCI) disrupts autonomic regulation of visceral organs. As a result, a leading cause of mortality in the SCI population is metabolic dysfunction, and an organ central to metabolic control is the liver. Our recent work showed that rodent SCI promotes Kupffer cell (hepatic macrophage) activation, pro-inflammatory cytokine expression, and liver steatosis. These are symptoms of nonalcoholic steatohepatitis (NASH), the hepatic manifestation of metabolic syndrome, and these pre-clinical data replicate aspects of post-SCI human metabolic dysfunction. Because metabolic profile is highly dependent on lifestyle, including diet, it is likely that lifestyle choices prior to injury influence metabolic and hepatic outcomes after SCI. Therefore, in this study we tested if a diet rich in green tea extract (GTE), a known hepatoprotective agent, that began 3 weeks before SCI and was maintained after injury, reduced indices of liver pathology or metabolic dysfunction. GTE treatment significantly reduced post-SCI hepatic iron accumulation and blunted circulating glucose elevation compared with control-diet rats. However, GTE pre-treatment did not prevent Kupffer cell activation, hepatic lipid accumulation, increased serum alanine transaminase, or circulating non-esterified fatty acids, which were all significantly increased 6 weeks post-injury. Spinal cord pathology also was unchanged by GTE. Thus, dietary GTE prior to and after SCI had only a minor hepatoprotective effect. In general, for optimal health of SCI individuals, it will be important for future studies to evaluate how other lifestyle choices made before or after SCI positively or negatively impact systemic and intraspinal outcomes and the overall metabolic health of SCI individuals.

Colorectal cancer screening in patients with spinal cord injury yields similar results to the general population with an effective bowel preparation: a retrospective chart audit

STUDY DESIGN

Retrospective chart audit.

OBJECTIVES

To compare adequacy of colonoscopy bowel preparation and diagnostic findings between persons with SCI receiving an extended inpatient bowel preparation and the general population.

SETTING

Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.

METHODS

We reviewed an electronic database of all colonoscopies performed at a tertiary Veterans Affairs medical center between 7/12/13 and 15/10/15. Patients with SCI received a multi-day bowel preparation with magnesium citrate, and 8-10 liters of polyethylene glycol-3350 and electrolyte colonic lavage solution (PEG-ELS) over two and one half days. The control population received a standard bowel preparation consisting of magnesium citrate and 4 liters of PEG-ELS over 1 day.

RESULTS

Two hundred and fifty-five patients were included in the study, including 85 patients with SCI. Average risk screening was a more common colonoscopy indication in patients with SCI vs. the control population (24 vs. 13% p = 0.03). There was no difference in adequacy of bowel preparation (87 vs. 85%, p = 0.73) or adenoma detection rate (55 vs. 51%, p = 0.59) when comparing patients with SCI with the control population. No difference in polyp histopathology was detected (p = 0.748).

CONCLUSIONS

Our study demonstrated that an extended bowel preparation for patients with SCI produces similar bowel preparation results and diagnostic yield when compared to patients without SCI undergoing colonoscopy.