Vertebral compression fractures: pain relief, progression and new fracture rate comparing vertebral augmentation with brace

BACKGROUND

Osteoporotic vertebral compression fracture (VCF) is the third most frequent fragility fracture in the world. Conservative treatment, vertebroplasty, and kyphoplasty are all recognized therapies. However, diagnostic and therapeutic recommendations must be more consistent when comparing clinical guidelines. This study aims to compare the efficacy of vertebral augmentation therapy and conservative management for treating VCFs, the risk of subsequent complications, and the length of hospital stay.

METHOD

All patients over 50 years old with a diagnosis of thoracic or lumbar VCF without underlying oncological process, treated conservatively or surgically, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients who missed follow-up or died during the first three months were excluded.

RESULTS

A total of 573 cases were selected for analysis. Most patients were treated conservatively (85.3%). Both groups were homogenous regarding epidemiological and clinical features. The median time elapsed to achieve pain relief was significantly lower in the surgical cohort (4.5 vs. 10 weeks, p < 0.001), and the proportion of patients reporting pain at the first outpatient visit was also significantly lower with a vertebral augmentation procedure (p = 0.004). The new fracture rate and the adjacent level rate did not differ significantly when comparing both treatments, whereas the progression of the diagnosed fracture was more frequent in the conservative group (4.8% vs. 29.7%; p < 0.001). The median hospital stay was significantly lower in the conservative group (3 vs. 10 days; p < 0.001).

CONCLUSION

Surgical treatment (vertebroplasty/kyphoplasty) of VCFs was associated with sooner pain relief without an increased risk of new or adjacent fractures. Moreover, the progression of treated fractures was significantly lower in the surgical cohort. The only unfavorable aspect was the more extended hospital stay compared with the conservative treatment group.

Vertebral compression fractures managed with brace: risk factors for progression

PURPOSE

The aim of this study is to identify risk factors for vertebral compression fracture (VCF) progression in patients treated conservatively with a brace. Then, a case-control study was designed.

METHODS

All patients over 50 years old with diagnosis of thoracic or lumbar VCF (T5 to L5) in absence of underlying oncological process, treated conservatively with brace, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients missed for follow-up or dead during the first 3 months of follow-up were excluded.

RESULTS

Five hundred and eighty-two consecutive patients were recorded. Incomplete follow-up excluded 74 patients and other 19 died in the first three months after diagnosis, so 489 cases were finally analyzed. Median follow-up was 21 (IQR 13;30) weeks. Increased collapse of the vertebral body was found in 29.9% of VCFs with a median time to progression of 9 (IQR 7;13) weeks. Male gender (OR 1.6), type A3 fracture of the AOSpine classification (OR 2.7), thoracolumbar junction location (OR 1.7), and incorrect use of the brace (OR 3.5) were identified as independent risk factors for progression after multivariable analysis.

CONCLUSION

Male gender, type A3 fracture of the AOSpine classification, thoracolumbar junction location, and incorrect use of the brace were identified as independent risk factors for VCF progression, which resulted in worse pain control, when treated with brace. Thus, other treatments such as percutaneous vertebral augmentation could be considered to avoid progression in selected cases, since collapse rate has been demonstrated lower with these procedures.

Flipped classroom applied to Neurosurgery in undergraduate medical education

PURPOSE

To compare the academic achievement obtained in Neurosurgery in a class of undergraduate students according to the pedagogical methodology employed: flipped classroom (FC) versus traditional lecture. Students' satisfaction with the FC model is also analyzed.

METHODS

A quasi-experimental study was designed. The traditional lecture was the pedagogical method employed in teaching units (TUs) 1, 2, and 3 (61, 60, and 66 enrolled students, respectively), whereas TU 4 (69 enrolled students) used the FC methodology.

RESULTS

The dropout rate was lower, whereas the academic achievement and the rate of correct answers were higher in TU 4 compared to the rest of the TUs, but these results were not statistically significant. However, the mean score obtained in Neurosurgery was significantly higher in TU 4 compared to the rest of the TUs (p = 0.042). Active learning activities based on clinical cases were positively emphasized. The main weakness was with the time consumed for video-recorded lecture viewing.

CONCLUSIONS

The FC approach showed better academic results than traditional lectures when comparing students in the same Medical School during the same academic year undergoing the same exam. The students rated the FC approach positively, considering it stimulating and useful for learning.

Clinical outcomes of FOLFIRINOX and gemcitabine-nab paclitaxel for metastatic pancreatic cancer in the real world setting

BACKGROUND/OBJECTIVES

The incidence of pancreatic cancer is increasing in developed countries. The incorporation of new therapies, to the first-line treatment of patients with good performance status led to better survival in clinical trials. However, there is a wide variability in their use and some concerns about the treatment of elderly patients who were not included in the clinical trials.

METHODS

This is a retrospective multicenter study. Data from consecutive patients diagnosed with metastatic pancreatic cancer (mPC) treated with FOLFIRINOX (FFX) or gemcitabine plus nab-paclitaxel (GnP) were analysed to evaluate efficacy (overall survival-OS) and toxicity.

RESULTS

A total of 119 patients were included. 49.6% were treated with FFX and 50.4% with GNP in first-line. The median OS was 12 months with no statistically significant differences between both regimens (12.7 m for FFX vs 10.2 m for GnP). Elevated Ca 19.9 levels and neutrophil-lymphocyte ratio (NLR) increased the risk of death. Patients who received both regimens in first/second line had a median OS longer than 15 months whichever the sequence. 32 patients (27%) were older than 70-y. 54% patients received a second-line treatment, 56% in the FFX group and 44% in the GnP group. The median OS for patients older than 70 was 9.5 m versus 12.3 m for patients younger than 70. Progression of the disease was the cause of death in 67.6% of the patients.

CONCLUSIONS

In our setting, the use of FFX and GnP for treating mPC is quite similar, but superiority could not be demonstrated for any of the schemes in the first line. OS was determined by basal levels of Ca 19.9 and NLR. Patients receiving both regimens in first/second line whichever the sequence, exhibited the best survival rates. In our series, elderly patients had poorer survival rates.

Evaluation of the prognostic value of different methods of calculating the tumour metabolic volume with 18F-FDG PET/CT, in patients with diffuse large cell B-cell lymphoma

INTRODUCTION AND OBJECTIVES

Metabolic tumor volume (MTV) is a promising indicator of prognosis in diffuse large B-cell lymphoma (DLBCL). The aim of the present study is to evaluate the different methods for the calculation of the basal metabolic tumor volume with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in the patients with DLBCL, relating each one of the volumes measured with progression-free survival (PFS) and overall survival (OS).

METHODOLOGY

This is a retrospective analytical cohort study, in which 34 patients underwent to ¹⁸F-FDG PET/CT baseline prior to treatment. We compared three SUV thresholds 2.5, SUV 40% of the maximum SUV and SUV mean hepatic uptake (PERCIST) for the calculation of MTV and total lesion glycolysis (TLG) biomarkers, relating them to the PFS and OS. The best predictive model was selected based on the Akaike's information criterion (AIC) after performing a Cox proportional hazards regression.

RESULTS

In relation to the PFS, they show statistically significant differences: MTV 2.5, TLG 2.5, MTV 40, TLG 40, MTV and TLG calculated with the PERCIST threshold. Among these, the one that has a lower AIC is MTV 2.5, so it is considered the best parameter to predict the PFS. With respect to OS, it shows statistically significant differences: MTV 2.5, VMT and TLG calculated with the PERCIST threshold. Among these three, the one with the lowest AIC is MTV 2.5, which is why it is considered the best parameter to predict OS. In addition, a higher value of MTV and total tumor glycolysis (TLG), is associated with worse PFS and OS CONCLUSION: The MTV calculated with the threshold SUV 2.5 seems to be the best parameter to predict PFS and OS in patients diagnosed with DLBCL with ¹⁸F-FDG PET/CT.

Prognostic significance of metabolic tumor volume and total lesion glycolysis in patients with advanced cervical carcinoma

AIM

18-Fluoro-2-deoxy-d-glucose positron emission tomography (¹⁸F-FDG PET/CT) is considered to be the most accurate image method of detection of node or distant metastases in cervical cancer. Metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of ¹⁸F-FDG PET/CT are volumetric measurements of tumor cells with increased ¹⁸F-FDG uptake. The prognostic value of MTV and TLG in patients with advanced cervical cancer (ACC) were evaluated.

METHODS

38 patients with ACC from one tertiary university hospital underwent ¹⁸F-FDG PET/CT between June 2009 and December 2015. Clinicopathologic factors and various PET parameters were analyzed to evaluate their relationship with recurrence-free survival (RFS) and overall survival (OS). These parameters were: maximum standardized uptake value (SUVmax), mean standardized uptake value (SUV mean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the primary tumor, of the pelvic nodes, of the paraaortic nodes and the metabolic volume of the metastases if any.

RESULTS

A total of 38 patients with ACC fulfilled the inclusion criteria. All of them underwent a ¹⁸F-FDG PET/CT before definitive chemoradiotherapy. In the univariate analyses higher tumor size, pelvic lymph node metastasis and both MTV and TLG showed a significant association with OS and with RFS (MTV HR=1.55, p=0.011 and TLG HR=1.43, p=0.017 for RFS and MTV HR=1.82, p=0.006 and TLG HR=1.67, p=0.007 for OS).

CONCLUSION

Pretreatment TLG sum and MTV sum seem to be independent prognostic factors for OS and RFS in patients with advanced cervical cancer treated with definitive chemoradiotherapy and they are better than the classic measurement of SUVmax.

The association between sleep quality, low back pain and disability: A prospective study in routine practice

BACKGROUND

The objective of this study was to estimate the association between sleep quality (SQ) and improvements in low back pain (LBP) and disability, among patients treated for LBP in routine practice.

METHODS

This prospective cohort study included 461 subacute and chronic LBP patients treated in 11 specialized centres, 14 primary care centres and eight physical therapy practices across 12 Spanish regions. LBP, leg pain, disability, catastrophizing, depression and SQ were assessed through validated questionnaires upon recruitment and 3 months later. Logistic regression models were developed to assess: (1) the association between the baseline score for SQ and improvements in LBP and disability at 3 months, and (2) the association between improvement in SQ and improvements in LBP and disability during the follow-up period.

RESULTS

Seventy-three per cent of patients were subacute. Median scores at baseline were four points for both pain and disability, as assessed with a visual analog scale and the Roland-Morris Questionnaire, respectively. Regression models showed (OR [95% CI]) that baseline SQ was not associated with improvements in LBP (0.99 [0.94; 1.06]) or in disability (0.99 [0.93; 1.05]), although associations existed between 'improvement in SQ' and 'improvement in LBP' (4.34 [2.21; 8.51]), and 'improvement in SQ' and 'improvement in disability' (4.60 [2.29; 9.27]).

CONCLUSIONS

Improvement in SQ is associated with improvements in LBP and in disability at 3-month follow-up, suggesting that they may reflect or be influenced by common factors. However, baseline SQ does not predict improvements in pain or disability.

SIGNIFICANCE

In clinical practice, sleep quality, low back pain and disability are associated. However, sleep quality at baseline does not predict improvement in pain and disability.

WITHDRAWN: Response from original author: Reproducibility of first trimester three-dimensional placental measurements; a methodological issue

The Publisher regrets that this article is an accidental duplication of an article that has already been published, DOI of original article: http://dx.doi.org/10.1016/j.ejogrb.2016.07.485. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Educational effectiveness of gynaecological teaching associates: a multi-centre randomised controlled trial

OBJECTIVE

To evaluate, among medical students learning the female pelvic examination, the added benefits of training by gynaecological teaching associates compared with training involving a manikin only.

DESIGN

Randomised controlled trial.

SETTING

Nine university teaching hospitals.

POPULATION

Ninety-four medical students recruited prior to commencing a 4-week obstetrics and gynaecology rotation.

METHODS

The control training consisted of lectures, demonstration of the pelvic examination on a manikin, and opportunities to practise on this low-fidelity simulation (n = 40). The experimental group received additional gynaecological teaching associate training, delivered by pairs of experienced associates to groups of four medical students (n = 54).

MAIN OUTCOME MEASURES

Outcomes measured at the end of the rotation included knowledge of the correct order of examination components (Yes/No), and student comfort [Likert scales anchored between 1 (very uncomfortable) and 4 (very comfortable) on four items] and confidence [Likert scales anchored between 1 (No) and 3 (Yes) on six items]. The primary outcome, measured at the end of the academic year, was the objective structured clinical examination of a female pelvis (score range 0-54).

RESULTS

At baseline, the groups were similar in age, gender, and ethnicity. At the end of the clinical rotation, when compared with the control intervention, the experimental intervention had a moderate effect on student knowledge [difference 29.9% (95% CI 11.2-48.6%); P = 0.002] and confidence [difference 1 (95% CI 0-2); P < 0.001], and a large effect on student comfort [difference 1.8 (95% CI 0.6-3.0); P = 0.004]. At the end of the academic year, the experimental intervention had no impact on skills compared with the control [difference 2 (95% CI-1 to 4); P = 0.26].

CONCLUSIONS

Among medical students taught the female pelvic examination by low-fidelity simulation, additional training by gynaecology teaching associates improved knowledge, comfort, and confidence at the end of the clinical rotation but did not improve examination skills at end of the academic year.

Spanish adaptation of the Quality of Life Index-Spinal Cord Injury version

STUDY DESIGN

A cross-sectional, validation study.

OBJECTIVES

To (a) develop the Spanish version of the Quality of Life Index-Spinal Cord Injury version (SV-QLI/SCI) and (b) assess its psychometric characteristics among permanent wheelchair users and specifically among those with SCI.

SETTING

Associations of wheelchair users in Mallorca (Spain).

METHODS

Two forward and backward translations of the QLI/SCI into Spanish were carried out separately. Seventy-seven subjects were randomly selected among the members of the associations. They completed the SV-QLI/SCI and validated instruments to measure depression and spinal pain upon recruitment and 14 days later. Assessments included comprehensibility, reproducibility, floor and ceiling effects and correlations between quality of life, pain and depression (Spearman's correlation coefficient). Analyses were repeated excluding data from subjects without SCI.

RESULTS

Three items of the SV-QLI/SCI required rephrasing. Reproducibility was 'almost perfect' for the entire questionnaire and its 'Health and functioning' subscale, 'substantial' for the 'Social and economic' and 'Family' subscales and 'moderate' for the 'Psychological/spiritual' subscale. Floor effect was not observed, and only for the 'Family' subscale >3% of the subjects reached the maximum possible score. The correlation between quality of life and depression was the strongest (r=-0.628). Results were virtually identical in the subsample with SCI.

CONCLUSION

These results support the use of the SV-QLI/SCI among Spanish-speaking wheelchair users.

Vertebral endplate changes are not associated with chronic low back pain among Southern European subjects: a case control study

BACKGROUND AND PURPOSE

Data on the association between vertebral endplate changes and low back pain are contradictory. This study was designed to assess whether this association exists among Southern European subjects.

MATERIALS AND METHODS

Patients in this study serving as cases were 35-50 years of age with low back pain lasting >90 days, for whom a lumbar MR imaging had been prescribed. Controls were subjects 35-50 years of age, having a cranial MR imaging for headache with normal findings, and no history of clinically relevant LBP. Two hundred forty cases and 64 controls were recruited consecutively in the radiology services across 6 cities in Spain. Imaging findings and subject characteristics were gathered through previously validated instruments. Radiologists who interpreted MRI were blinded to the subject characteristics. A multivariate logistic regression model was developed to assess the association of vertebral endplate changes with LBP, adjusting for sex, age, body mass index, lifetime exposure to smoking, physical activity, disk degeneration, and the interaction between disk degeneration and vertebral endplate changes.

RESULTS

Vertebral endplate changes were found in 80.4% of the cases and in 87.5% of the controls. In the regression model, disk degeneration was the only variable showing a confounding effect. Results showed that after adjusting for disk degeneration, the presence of vertebral endplate changes is associated with the absence of chronic LBP (OR for LBP: 0.31; 95% CI, 0.10-0.95).

CONCLUSIONS

In Southern European subjects, vertebral endplate changes are not associated with chronic LBP.

Influence of nomenclature in the interpretation of lumbar disk contour on MR imaging: a comparison of the agreement using the combined task force and the nordic nomenclatures

BACKGROUND AND PURPOSE

The CTF nomenclature had not been tested in clinical practice. The purpose of this study was to compare the reliability and diagnostic confidence in the interpretation of disk contours on lumbar 1.5T MR imaging when using the CTF and the Nordic nomenclatures.

MATERIALS AND METHODS

Five general radiologists from 3 hospitals blindly and independently assessed intravertebral herniations (Schmorl node) and disk contours on the lumbar MR imaging of 53 patients with low back pain, on 4 occasions. Measures were taken to minimize the risk of recall bias. The Nordic nomenclature was used for the first 2 assessments, and the CTF nomenclature, in the remaining 2. Radiologists had not previously used either of the 2 nomenclatures. κ statistics were calculated separately for reports deriving from each nomenclature and were categorized as almost perfect (0.81-1.00), substantial (0.61-0.80), moderate (0.41-0.60), fair (0.21-0.40), slight (0.00-0.20), and poor (<0.00).

RESULTS

Categorization of intra- and interobserver agreement was the same across nomenclatures. Intraobserver reliability was substantial for intravertebral herniations and disk contour abnormalities. Interobserver reliability was moderate for intravertebral herniations and fair to moderate for disk contour.

CONCLUSIONS

In conditions close to clinical practice, regardless of the specific nomenclature used, a standardized nomenclature supports only moderate interobserver agreement. The Nordic nomenclature increases self-confidence in an individual observer's report but is less clear regarding the classification of disks as normal versus bulged.

Agreement in the interpretation of magnetic resonance images of the lumbar spine

BACKGROUND

Correlation between clinical features and magnetic resonance imaging (MRI) findings is essential in low-back-pain patients. Most previous studies have analyzed concordance in the interpretation of lumbar MRI among a few radiologists who worked together. This may have overestimated concordance.

PURPOSE

To evaluate intra- and interobserver agreement in the interpretation of lumbar MRI performed in an open 0.2 T system.

MATERIAL AND METHODS

Seven radiologists from two different geographic settings in Spain interpreted the lumbar MRIs of 50 subjects representative of the general Danish population aged 40 years. The radiologists interpreted the images in routine clinical practice, having no knowledge of the clinical and demographic characteristics of the subjects and blinded to their colleagues' assessments. Six of the radiologists evaluated the same MRIs 14 days later, having no knowledge of the previous results. Data on the existence of disc degeneration, high-intensity zones, disc contour, Schmorl nodes, Modic changes, osteophytes, spondylolisthesis, and spinal stenosis were collected in the Nordic Modic Consensus Group Classification form. Intra- and interobserver agreement was analyzed for variables with a prevalence >or=10% and <or=90% by means of the kappa statistic.

RESULTS

Intra- and interobserver agreement was excellent for variables related to Modic changes, and fair to good for disc contour, high-intensity zones, and Schmorl nodes. The evaluations for disc degeneration and osteophytes were found to have fair to good intraobserver agreement and poor interobserver agreement. The agreement for the evaluations of spondylolisthesis and spinal stenosis was not analyzed because they were observed in <10% of reports.

CONCLUSION

Images from 0.2 T MRIs appear to lead to good agreement in the reporting of disc contour, high-intensity zones, Schmorl nodes, and, in particular, Modic changes, suggesting that they can possibly be reliably used for clinical research purposes. In contrast, assessment of osteophytes and disc degeneration is not reliable.

[Are IL2 receptor antagonist useful in high risk acute tubular necrosis kidney recipients?]

The questions are if old recipients from old donor have more incidence of delayed graft function and if antagonists of Il-2 receptors use decreased the incidence of NTA post-transplant. To answer the first question we have come to information from registry and uni or multicenter studies. We have used the Irish normograme that included 16 clinical questions from donors, recipients and kidney transplant. We concluded that age of donors increases likelihood of delayed graft function. The second question is answered in the literature with information of a meta-analysis with 38 clinical studies. Of them 9 (1.380 patients) studied delayed graft function and are against placebo. The odds ratio for delayed graft function was 0.87(IC 95% 0,72 a 1,06). Therefore, at the moment, we can conclude that the utilization of antagonists of Il-2 receptors does not have protective effect to NTA.