The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND

Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations.

RESEARCH QUESTION

Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease?

MATERIALS AND METHODS

Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses.

RESULTS

47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m²). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001).

DISCUSSION AND CONCLUSION

Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated.

LEVEL OF EVIDENCE

Level III.

Biomarker discovery: success as a function of risk mitigation

Protein biomarker discovery is a fascinating enterprise; however, success in terms of products for in vitro diagnostic use is sparse. New developments in mass spectrometry-based quantitative proteomics as discovery technology have opened up new avenues for this endeavor. In addition to choice of technology, sample properties, study design and validation strategy are potent pillars required for project success. The challenge for successful biomarker discovery can be described by a series of risks that need to be mitigated. This article intends to describe the major risks along with possible solutions.

Abstract A156: Anti-p53 auto-antibody serum profiling using high-density peptide arrays

Cancer is a result of a number of genetic alterations that disturb normal, controlled cell growth and differentiation. Mutational events leading to the activation of oncogenes or the inactivation of tumor-suppressor genes have been linked causally to the formation of tumors. p53 is one of the most important regulators of transcription, cellular cycle, DNA repair and apoptosis detected to date. Anti-p53 antibodies have been detected in the serum of cancer patients. This immune response is probably due to a self-immunization process linked to the strong immunogenicity of the p53 protein, and is associated predominantly with p53 missense mutation and p53 accumulation in the tumor. Auto-antibodies have also been proposed as potential diagnostic biomarkers for early stage diagnosis of cancers, since an increase in serum levels of certain auto-antibodies has been shown to precede the development of disease symptoms and correlate with cancer incidence for various cancers including breast and lung cancer.

Here we systematically evaluate reactivity of antibodies in p53 positive serum samples and identify reactive epitopes to normal and mutant peptides using a high-density (2.9 Million) peptide microarray. We assess the effect of linker length, peptide length, and flanking serines on antibody detection. We propose peptide array design parameters that can be applied to a whole proteome level to enable biomarker discovery and validation of novel auto-antibody epitopes associated with cancer.

Citation Format: Ken C. Lo, John C. Tan, Eric Sullivan, Ryan Bannen, Todd Richmond, Florian Grupp, Stefan Weiser, Dieter Heindl, Klaus-Peter Stengele, Albert Thomas. Anti-p53 auto-antibody serum profiling using high-density peptide arrays. [abstract]. In: Proceedings of the CRI-CIMT-EATI-AACR Inaugural International Cancer Immunotherapy Conference: Translating Science into Survival; September 16-19, 2015; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(1 Suppl):Abstract nr A156.

Spin-orbit coupling in ferromagnetic nickel

We use the Gutzwiller variational theory to investigate the electronic and magnetic properties of fcc nickel. Our particular focus is on the effects of the spin-orbit coupling. Unlike standard relativistic band-structure theories, we reproduce the experimental magnetic-moment direction and we explain the change of the Fermi-surface topology that occurs when the magnetic-moment direction is rotated by an external magnetic field. The Fermi surface in our calculation deviates from early de Haas-van Alphen results. We attribute these discrepancies to an incorrect interpretation of the raw de Haas-van Alphen data.

Cell cycle-dependent dynamic localization of a bacterial response regulator with a novel di-guanylate cyclase output domain

Pole development is coordinated with the Caulobacter crescentus cell cycle by two-component signaling proteins. We show that an unusual response regulator, PleD, is required for polar differentiation and is sequestered to the cell pole only when it is activated by phosphorylation. Dynamic localization of PleD to the cell pole provides a mechanism to temporally and spatially control the signaling output of PleD during development. Targeting of PleD to the cell pole is coupled to the activation of a C-terminal guanylate cyclase domain, which catalyzes the synthesis of cyclic di-guanosine monophosphate. We propose that the local action of this novel-type guanylate cyclase might constitute a general regulatory principle in bacterial growth and development.

Yhh1p/Cft1p directly links poly(A) site recognition and RNA polymerase II transcription termination

RNA polymerase II (pol II) transcription termination requires co-transcriptional recognition of a functional polyadenylation signal, but the molecular mechanisms that transduce this signal to pol II remain unclear. We show that Yhh1p/Cft1p, the yeast homologue of the mammalian AAUAAA interacting protein CPSF 160, is an RNA-binding protein and provide evidence that it participates in poly(A) site recognition. Interestingly, RNA binding is mediated by a central domain composed of predicted beta-propeller-forming repeats, which occurs in proteins of diverse cellular functions. We also found that Yhh1p/Cft1p bound specifically to the phosphorylated C-terminal domain (CTD) of pol II in vitro and in a two-hybrid test in vivo. Furthermore, transcriptional run-on analysis demonstrated that yhh1 mutants were defective in transcription termination, suggesting that Yhh1p/Cft1p functions in the coupling of transcription and 3'-end formation. We propose that direct interactions of Yhh1p/Cft1p with both the RNA transcript and the CTD are required to communicate poly(A) site recognition to elongating pol II to initiate transcription termination.

Medicine betrayed: hemophilia patients and HIV in the US

The contamination of blood products by HIV in the early 1980s resulted in thousands of deaths among people with hemophilia in the United States and elsewhere. In the US, industry, government, physicians, and advocacy groups were implicated in this tragedy. In response to pleas from members of the US hemophilia community, the Institute of Medicine (IOM) of the National Academy of Science convened a public hearing to identify the institutional determinants of the HIV/AIDS epidemic among US hemophilia patients. The resulting IOM Report (1995) established a narrative of the crisis and indicated necessary improvements to the management of the US blood supply. The Report, however, failed to address the hemophilia community's demands for accountability and retribution. In this paper we explore the moral and social dimensions of this tragedy through narrative analysis of the original testimonies of hemophilia sufferers, interviews with some patients and their families, and a re-examination of the text of the IOM Report itself. We examine the process by which this crisis was addressed--through the discourses of science and law--and how it was ultimately framed as a failure of management and oversight rather than a moral failure of the for-profit health-care system. Thus, while the Report and its aftermath demonstrate powerfully how testimonials of suffering can influence public policy, by not addressing what is at stake for the victims--failure to protect patients in an era of increasingly commodified health care--it led to an exculpatory solution that obfuscated the moral dimensions of suffering.

Approaches to improve the outcome of patients with delayed recovery

The purpose of this chapter is to promote a model to prevent chronicity and disability from non-specific low back pain (NSLBP). Delayed recovery is defined in this chapter as the period between 4 and 8 weeks after onset of NSLBP during which a patient has not yet returned to work. The recognition of predictors associated with delayed recovery at onset of the problem helps health care providers in their treatment plan. An algorithm can be useful for health care providers and employers in guiding the employee back to work. A multidisciplinary return to work programme is an essential part of the algorithm.

Low back pain assessment training of industry-based physicians

We have developed an educational program to train industry-based physicians in a new low back pain assessment procedure based on the recommendation of The Clinical Practice Guidelines on Acute Low Back Pain Problems in Adults published by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. The clinical classification system based on the findings from the Quebec Task Force was used to categorize the subjects. The educational program included group and individual sessions with an extensive period of active follow-up. Protocol compliance was measured through a computer-based surveillance system that monitored evaluation form completion. The results showed significant change (p < 0.001) in physician compliance in completing a standardized examination following an administrative mandate to change. Little change in clinical practice was recorded with an educational training program only. Further research into the factors responsible for the results is suggested.

Physical exercise and low back pain

Health care providers often prescribe exercises as treatment for nonspecific low back pain. However, the effectiveness of this treatment is poorly documented in the literature. While the evidence suggests that exercise in general is beneficial, there is a lack of knowledge about the types, frequency and duration of exercises that should be prescribed and at what stage of injury they are most helpful. In addition, few studies have dealt with exercise treatment alone rather than in combination with other treatments, making it hard to decipher the unique contribution of exercise. Inadequate study designs also make conclusions difficult. Conversely, the literature clearly shows that inactivity has detrimental effects (i.e. delayed return to normal activity, and negative physiological and psychological effects) for low back pain patients.

Psychosocial issues in the prevention of chronic low back pain--a literature review

This chapter has reviewed research on psychological and social factors associated with the onset and progression of low back pain. From this review it can be concluded that psychosocial traits appear to be important contributors to the course of pain and disability though methodologically well-designed longitudinal studies are rare. For this reason it is difficult to assess the relative importance of, for example, psychological distress compared with work stress. Furthermore, the mechanisms by which specific variables effect back pain remain unknown. The answer, no doubt, lies in longitudinal studies which employ multicausal models. It has been noted the psychosocial treatments which have proven effective for chronic pain populations are rarely assessed with acute pain patients. Some problems are the inaccessibility of acute back pain sufferers to psychologists, the difficulty of isolating the effect of one component of a multidisciplinary programme and the lack of uniform practice of psychosocial techniques. None the less, programmes which include psychosocial interventions appear to have superior results to those which do not. Since these techniques are often simple and inexpensive to include they should be incorporated into all treatment programmes where the potential for chronic pain syndrome exists. Gaps and flaws in current research methodologies have been identified and suggestions for future investigations have been proposed. In addition we have attempted to provide some practical guidelines for health care professionals to help them identify salient psychosocial issues which may effect the course of their patient's treatment. Recommendations for assessment and referral are also provided.

Lateral electrical surface stimulation (LESS) compliance in adolescent female scoliosis patients

This retrospective study of lateral electrical surface stimulation (LESS) treatment for patients with progressive idiopathic scoliosis was performed to document patient compliance in the standard electrical stimulation program and to gain objective data to perform a relative comparison of electrical stimulation and bracing compliance. Forty mothers of adolescent female patients participating in the electrical stimulation program of one of the authors (NK) were interviewed confidentially by an independent observer (SW). Patients whose compliance was rated good or total were thought to have acceptable compliance rates. Overall, 50% showed good or total compliance, 10% fair, 5% poor, and 35% failures. It appeared that the failures tended to exaggerate their symptoms and use "skin irritation" as an excuse to discontinue treatment. The longer patients used the LESS (scolitron) device, the more compliant they became (P less than 0.0). This is opposite to the findings about brace compliance. Confidence of the mother in the device showed a positive correlation (P less than 0.008) with compliance, and a mother's concern of how others would react to her child's scoliosis had a negative correlation (P less than 0.003). From the results of this study, overall compliance appears to be somewhat better for electrical stimulation programs than for bracing programs. However, the high failure rate was both disappointing and surprising.

Oral fat loading test: a reliable procedure for the study of fat malabsorption in children

Oral triglyceride (TG) loading tests were performed in four groups of children: normal controls, patients with chronic nonspecific diarrhoea (CND), biopsy-proved mucosal pathology (MP), and disturbed intraluminal fat malabsorption (IFM). The rise of plasma TG levels greater than or equal to 55 mg/100 ml (greater than or equal to 0.6 mmol/l) can discriminate between patients with gastrointestinal disease and normal controls or patients with functional disturbances. The postmeal plasma TG rise correlates well with the coefficient of fat absorption (CFA) in normal subjects, patients with CND, and patients with IFM, but not in patients with MP who showed a disproportionally low plasma TG rise compared with their CFA. This test can serve as a useful tool in diagnosis and clinical evaluation for children with gastrointestinal disorders.