Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer

PURPOSE

Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications.

METHODS AND MATERIALS

Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis.

RESULTS

Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption.

CONCLUSIONS

This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Comparative Analysis of Tumor Microbiome, Molecular Profile and Immune Cell Abundance by HPV Status in Head and Neck Cancers and Their Impact on Survival

PURPOSE/OBJECTIVE(S)

Traditional clinical and molecular prognostic factors offer valuable insight into the heterogeneous natural history and treatment response of head and neck squamous cell carcinoma (HNSCC) yet fail to explain the full spectrum of observed variability. The tumor microenvironment (TME), comprising microbiome and immune cells can impact treatment response and prognosis. We analyzed The Cancer Genome Atlas (TCGA) to evaluate the association of specific microbes and genes in TME with survival and their differential expression in HPV positive (+) and HPV negative (-) HNSCC.

MATERIALS/METHODS

HNSCC RNA sequencing (RNAseq) samples from TCGA were processed through the Exogenous sequencing in Tumors and Immune Cells (ExoTIC) pipeline to identify gene expression and microbial presence. HPV status was assessed by detection of papillomaviridae family of microbes. Clinical data from TCGA was extracted to compare overall survival (OS) and control for competing variables using Cox proportional hazards regression. Difference in immune cell abundance was evaluated by Kruskal-Wallis test. All statistical analysis was performed using R.

RESULTS

A total of 498 RNAseq samples from TCGA were analyzed. Oral cavity, oropharynx, hypopharynx, and larynx tumors comprised 21.6%, 15%, 1.8%, and 22.2% of specimens, respectively. HPV was detected in 111 patients (22%), most commonly Alpha papillomavirus 9 (90.1%). Of the 5838 enriched microbes, 330 were significantly associated with OS after controlling for tumor stage, smoking, and age. Specifically, the presence of Alpha papillomavirus 9 was associated with significantly improved OS [adjusted HR = 0.60 (95% CI 0.40 - 0.89, p = 0.01)]. Microbial species found in more abundance in HPV- tumors included Citrobacter farmeri, Thermoanaerobacter kivui and Yersinia pestis which are gram negative anaerobes. Genes related to cellular transport and DNA repair were enriched while genes related to proliferation (e.g., SAGE1) were depleted in HPV+ samples. HPV- tumors had a significantly higher number of M0 (p < 0.001) and M2 macrophages (p = 0.035) while HPV+ tumors had more T regulatory cells (p < 0.001) and CD8+ T-cells (p < 0.001).

CONCLUSION

Tumor microenvironment was significantly associated with survival for HNSCC patients, with particular microbes such as Alpha papillomavirus 9 correlating with improved OS. Greater abundance of certain anaerobic microbes was seen in HPV- tumors. These findings suggest TME can be used to predict patient outcomes and potentially guide personalized treatment approaches. We found an abundance of M0 and M2 macrophages in HPV- tumors, which are considered pro-tumorigenic, while anti-tumor M1 macrophages were similar in the two groups. This may help identify mechanism of resistance to immunotherapies and tailor novel immunotherapy combinations in specific patient subgroups. With further prospective research and external validation these findings have the potential to significantly impact the way we treat HNSCC in the future.

Real-World Treatment Patterns of Older Adults with Locally Advanced SCCHN Using SEER-Medicare

PURPOSE/OBJECTIVE(S)

Roughly 50-67% of patients with squamous cell carcinomas of the head and neck (SCCHN) present with locally advanced (LA) disease and 65% of them relapse after initial therapy. The standard of care for LA SCCHN is definitive therapy (DT), a combination of surgery and or radiation therapy (RT), with or without platinum-based chemotherapy/cetuximab (chemo), that has been shown to optimize long term disease control. Few published analyses have characterized recent real-world treatment (Tx) patterns of older adults with LA SCCHN in the US.

MATERIALS/METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, a linkage of cancer registry and claims data, to identify patients diagnosed with LA SCCHN (first and only cancer) from 2010 to 2017 who initiated a relevant Tx (Tx initiation date defined as index date) and were continuously enrolled in Medicare Parts A, B, and D from 12 months pre-index until death or 12 months post-index. We used clinical guidelines regarding timing and frequency of treatments to build an algorithm that used Medicare claims to categorize initial Tx as non-DT, non-surgical DT (concomitant chemo+RT (cCRT) or chemotherapy before RT/cCRT), or surgical DT (surgery then RT/cCRT ± prior chemo).

RESULTS

We identified 1052 older adults with LA SCCHN (median age 73 years, 37% female, and 81% non-Hispanic white) whose initial treatment was started a median of 26 days after initial diagnosis. Of the 610 patients who received a DT as their initial Tx, 23.3% of patients had a subsequent Tx: 3.8% received immunotherapy-containing regimens (IO), and the most common subsequent Tx were surgery only (7.7%), chemotherapy only (3.6%), and RT only (3.4%). The median time to next Tx (TTNT) differed by DT category and primary tumor site. (Table 1) CONCLUSION: In this descriptive analysis, we provided an update on the Tx patterns of older adults with LA SCCHN in the US, for whom there have been no novel FDA approvals in over a decade. We found that a large proportion (42%) of patients did not receive DT regimens in the real-world setting despite known benefits in LA SCCHN. Roughly a quarter of patients required subsequent Tx. Availability of IO was low due to approvals after 2017. These findings suggest a need for novel therapies that can improve outcomes in LA SCCHN.

Scalp Volumetric Modulated Arc Therapy Using 3D Milled Bolus: Dosimetry, Toxicity and Outcome

PURPOSE/OBJECTIVE(S)

Radiotherapy for scalp lesions is frequently challenging due to the competing needs for target volume coverage, sparing of numerous critical nearby OARs, and reproducible bolus setup despite the irregular and highly convex scalp geometry. Here, we evaluate the use of 3D milled bolus in treating such tumors.

MATERIALS/METHODS

A retrospective analysis of scalp patients (pts) treated between 2016-2022 using 3D milled bolus and VMAT. All pts were treated with 6 MV photon beams, IGRT via daily CBCT, and 6-degree of Freedom (6-DOF) couch tops. Pts demographics, tumor characteristics, DVHs, toxicities and outcomes were evaluated. Regional control (RC) defined as control of the disease in the rest of the scalp/neck and local control (LC) defined as disease control within the PTV.

RESULTS

A total of 23 pts were identified. Median age 74 (46-85), ECOG performance status was 0-1 in 20 pts (87%) and 92% were males. The histopathologies were squamous cell carcinoma (SCC) (61%), angiosarcoma (AS) (35%) and melanoma (4%). 35% of pts were treated with definitive intent to gross disease; the remaining 65% were treated post-operatively, 22% with microscopically positive margins and 43% with negative margins. 21% had perineural invasion (PNI), and none had lymphovascular invasion (LVI). 78% had T3/T4 and 13% had N+ disease. Median radiation dose was 66 Gy (60-69.96Gy). 44% received concurrent systemic therapy (Paclitaxel 22%, Cemiplimab 12%, Temozolomide 5%, Nivolumab 5%). In 40% of pts, the whole scalp was treated; in the remaining 60%, the median ratio of PTV volume to scalp volume was 35% (25-90%). 22% of pts (n = 5) had neck irradiation for prophylactic (3pts)/ neck lymph node involvement (2 pts). The median brain Dmax was 65 Gy (52.5-71.9), median brain mean dose was 15.4Gy (1.4-38.4), median eye Dmax was 10.9Gy (0.23-49), median cochlea mean was 8.4Gy (0.1-20.4), median lacrimal gland mean dose was 6.8Gy (0.11-38), median hippocampus Dmin was 5.9Gy (0.1-14.9) and Dmax was 10Gy (0.3-23). Most common acute side effects were grade 1-2 fatigue (100%), grade 1-2 pain (78%), grade 1 dysgeusia (22%), grade 1-2 dermatitis (74%). The only grade > = 3 adverse event was grade 3 dermatitis in 26%. Regarding long-term side effects, one pt had grade 2 osteoradionecrosis and other one developed grade 2 skin ulcer. 17% developed grade 1 memory impairment. 17% had grade 1 eye dryness. None developed brain radionecrosis. At a median follow-up was 14.4 months (1-73.5), the 1-yr LC was 96%. The 1-yr RC was 75% overall, 100% in angiosarcoma vs 62% in SCC (p = 0.18). Of the 4 regional recurrences, 1 pt had marginal recurrence along V1, 2 had neck nodal recurrence, and 1 had recurrence elsewhere in the scalp. 1-yr DMFS was 62% overall. 1-yr OS was 78% overall, 100% for AS vs 64% for SCC (P = 0.097).

CONCLUSION

VMAT planning with 3D milled bolus permits technically sound radiotherapy for scalp targets with an acceptable toxicity profile and relatively favorable clinical outcomes. This approach warrants further evaluation in a larger prospective study.

Racial Disparities in Survival of Patients with High-Risk LA SCCHN in the U.S

PURPOSE/OBJECTIVE(S)

Approximately 50-67% of patients with squamous cell carcinomas of the head and neck (SCCHN) present with locally advanced (LA) disease. Human papillomavirus (HPV) associated SCCHN has improved survival compared to non-HPV SCCHN. Studies have analyzed racial disparities in LA SCCHN but few have adjusted for HPV status and socio-economic status (SES). Our objective was to characterize disparities in LA SCCHN.

MATERIALS/METHODS

We identified high-risk patients from 2010-2017 with AJCC v8 Stage IVA/IVB SCCHN of the oral cavity, oropharynx (OP), larynx or hypopharynx, or Stage III SCCHN of the OP in the Surveillance, Epidemiology, and End Results (SEER) with HPV Status and Census Tract-level SES/Rurality Combined Database. We excluded OP patients with missing HPV data. SEER-reported treatment was used to classify initial treatment as definitive therapy (DT) categories: surgical DT, non-surgical DT or non-DT. The Kaplan Meier method was used to estimate overall survival (OS) with 95% confidence intervals (CI). Multivariable cox proportional hazard models were used for associations between covariates and hazard ratio (HR) of death, adjusted for age, sex, race, ethnicity, DT category, marital status, rurality, tumor size, cancer stage, and HPV status. We explored the impact of additionally adjusting for Yost SES index quintiles.

RESULTS

We identified 17,818 eligible patients: 79.3% White, 14.4% Black, 5.8% Asian/Pacific Islander (A/PI), and 0.6% American Indian/Alaska Native (AI/AN). Primary tumor sites were oral cavity (36.8%), larynx (29.0%), OP (24.4%), and hypopharynx (9.9%). 10.4% were HPV-associated. Race and SES quintiles were related (chi-squared, p<0.001) and the majority (56.5%) of black patients were in the lowest SES quintile. mOS was shorter and risk of death was significantly higher for black vs white patients in both the all-site and OP-only cohorts. When we added SES to multivariable analyses, Black race was no longer associated with increased risk of death in the all-site or OP-only cohorts. (Table 1) CONCLUSION: We found that when adjusting for sociodemographic and clinical factors, Black race was independently associated with a higher risk of death compared to white patients. When we adjusted for SES in multivariable analysis the association between Black race and risk of death was no longer significant, consistent with previously published analyses and indicative of a complex relationship between race and SES. Further research is needed to identify and address the causative factors of disparities in LA HNSCC.

Brachial Plexus Tolerance to Standard Fractionation Re-Irradiation: The Ohio State University Experience

PURPOSE/OBJECTIVE(S)

Factors contributing to brachial plexopathy (BPP) in the re-irradiation setting need further assessment. Preliminary work revealed that higher the doses and the use of concurrent cisplatin were associated with higher risk of BPP. Here, we expand our cohort and increase our follow-up duration, given the late nature of BPP development.

MATERIALS/METHODS

Sixty-two BP sites with 41 patients (pts), treated between 2015 and 2020 for recurrent H&N cancer, were assessed. Contours and plans were reviewed via a prospective multidisciplinary chart rounds prior to treatment delivery and re-verified by two authors prior to this analysis. Kaplan-Meier and logistic regression were used to test the correlation between variables and outcomes. ROC was used to evaluate the cutoff values. Common terminology criteria of adverse events were used to define BPP.

RESULTS

The median age of pts was 63 (29-78) and 65% were males. Median prescription dose was 70 Gy (60-70) for the 1st course and 66 Gy (44-70) for the 2nd course. 13% received intraoperative radiotherapy (IORT) during salvage treatment ranging from 10-15 Gy. 30% of pts in the 1st course and 80% in the 2nd course of pts had surgery. Concurrent chemotherapy was delivered to 71% of pts in the 1st course (Cisplatin 34%, Cetuximab 22%, Carboplatin +/- Paclitaxel 15%) and 76% in the 2nd course (Carboplatin/Paclitaxel 41%, Cisplatin 19%, Cetuximab 12%, Nivolumab 4%). The median interval between courses was 26.5 months (8-221). The median cumulative Dmax (0.03cc) and mean dose to the BP were 96.5 Gy (51-144) and 61.5 Gy (15-110), respectively. The median V60, V70, V80, V90, and V100 were 3.6cc (0.03-10.4), 2.4cc (0-9.9), 1.3cc (0-9.3), 0.6cc (0-8.4), and 0.0015cc (0-7.2), respectively. The median follow-up after the completion of the 2nd RT course was 19 months (1.4-71.5). The 1-yr incidence of BPP was 17%, with a median time to onset of 8.9 months (1-16.6). Factors associated with development of BPP were cumulative Dmax > 100 Gy (HR 1.06, [CI 1.014-1.1], p = 0.009), cumulative mean dose >70 Gy (HR 1.05, [CI 1.01-1.09], p = 0.03), V80 > 1.6cc (HR 1.2. [CI 0.99- 1.52], p = 0.06), V90 > 1cc (HR 1.3, [CI 1.013-1.58], p = 0.038), V100 > 0.3cc (HR 1.33, [1.044-1.69], p = 0.021) and the usage of concurrent cisplatin during the 2nd course (HR 8.9, [CI 2.36-33.75], p = 0.001). Other factors including gender, age, surgery, treatment interval between the two courses, IORT, V60, and V70 were not associated with increased risk of BPP. The incidence of grade 1, grade 2, and grade 3 BPP were 9.6%, 3% and 2.4%, respectively. The 1-yr OS was 70% and LC was 60%.

CONCLUSION

At a median follow up of 19 months, the 1-yr incidence of grade 2 and 3 BPP was approximately 5%. Cisplatin during the 2nd course, cumulative metrics of Dmax 100 Gy, mean 70 Gy, V80 1.6cc, V90 1cc and V100 0.3cc were associated with development of BPP. Prospective study, longer follow up, and higher numbers are warranted. To our knowledge, this represents the largest cohort and longest follow up yet reported for BPP in the re-irradiation setting.

Toxicity and Outcomes of Definitive Local Therapy in Elderly Patients with HPV-Associated Oropharyngeal Cancer

PURPOSE/OBJECTIVE(S)

The incidence of human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) has increased in elderly patients. It is unclear if survival outcomes in elderly patients are similar to those seen in younger patients with HPV-OPSCC. In this study we evaluated disease outcomes and toxicity in an elderly HPV-OPSCC population treated with curative-intent treatment of radiotherapy with or without chemotherapy.

MATERIALS/METHODS

We performed a retrospective study of elderly patients (≥70 years old) with HPV-OPSCC treated between 2011-2021 with radiation therapy (RT) with or without chemotherapy. Time to event analysis for overall survival (OS), local control, and progression free survival (PFS) were estimated using the Kaplan-Meier method. Univariate and multivariate Cox regression models were used to estimate the hazard ratio associated with the covariates.

RESULTS

We identified 77 elderly HPV-OPSCC patients, of which 60 (78%) were treated with concurrent chemotherapy. Twenty (26%) received concurrent Carboplatin and Taxol, 16 (21%) received Cetuximab, 14 (18%) received Cisplatin,7 (9%) received Carboplatin alone, and 2 (2%) received immunotherapy (Pembrolizumab or Nivolumab). The majority of patients received a radiation dose of 69.96 Gy or 70 Gy (89%). Forty-seven patients (61%) were stage I, 11 (14%) were stage II, 16 (21%) were Stage III, and 3 (4%) had stage IV disease. 50 patients (64%) were former smokers, 27 (35%) were nonsmokers and 1 (1%) is a current smoker. 37 patients (48%) had a ≥10 pack year smoking history. The 5-year OS, LC, and PFS for the entire cohort was 61%, 94%, and 58%, respectively. On univariate analysis, ECOG performance status (HR 0.22, [CI 0.06-0.78], p = 0.019) and Charlson Comorbidity Index (CCI) (HR 1.33, [CI 1.06-1.69], p = 0.014) were significant predictors of OS. On multivariate analysis, only CCI (HR 1.34, [CI 1.02-1.77], p = 0.035) was a significant predictor of OS. The rate of long-term feeding tube dependency was 9%. Late toxicities include osteoradionecrosis in 4 patients (5%), aspiration in 3 patients (4%), and esophageal stricture in 2 patients (3%).

CONCLUSION

Elderly HPV-OPSCC patients treated with definitive intent radiotherapy with or without chemotherapy have favorable disease outcomes with low rates of late toxicity. The Charlson-Comorbidity Index can identify a subset of patients who may have a prolonged OS, and therefore may benefit from more aggressive treatment.

How to spot the recurring lumbar disc? Risk factors for recurrent lumbar disc herniation (rLDH) in adult patients with lumbar disc prolapse: a systematic review and meta-analysis

Despite a fast-growing evidence-base examining the relationship of certain clinical and radiological factors such as smoking, BMI and herniation-type with rLDH, there remains much debate around which factors are clinically important. We conducted a systematic review and meta-analysis to identify risk factors for recurrent lumbar disc herniation (rLDH) in adults after primary discectomy. A systematic literature search was carried out using Ovid-Medline, EMBASE, Cochrane library and Web of Science databases from inception to 23rd June-2022. Observational studies of adult patients with radiologically-confirmed rLDH after ≥3 months of the initial surgery were included, and their quality assessed using the Quality-In-Prognostic-Studies (QUIPS) appraisal tool. Meta-analyses of univariate and multivariate data and a sensitivity-analysis for rLDH post-microdiscectomy were performed. Twelve studies (n=4497, mean age:47.3; 34.5% female) were included, and 11 studies (n=4235) meta-analysed. The mean follow-up was 38.4 months. Mean recurrence rate was 13.1% and mean time-to-recurrence was 24.1 months (range: 6-90 months). Clinically, older age (OR:1.04, 95%CI:1.00-1.08, n=1014), diabetes mellitus (OR:3.82, 95%CI:1.58-9.26, n=2330) and smoking (OR:1.80, 95%CI:1.03- 3.14, n=3425) increased likelihood of recurrence. Radiologically, Modic-change type-2 (OR:7.93, 95%CI:5.70-11.05, n=1706) and disc extrusion (OR:12.23, 95%CI:8.60-17.38, n=1706) increased likelihood of recurrence. The evidence did not support an association between rLDH and sex; BMI; occupational labour/driving; alcohol-consumption; Pfirmann- grade, or herniation-level. Older patients, smokers, patients with diabetes, those with type-2 Modic-changes or disc extrusion are more likely to experience rLDH. Higher quality studies with robust adjustment of confounders are required to determine the clinical bearing of all other potential risk factors for rLDH.

327 To Fuse or Not to Fuse: The Elderly Patient with Lumbar Stenosis and Low-Grade Spondylolisthesis. Systematic Review and Meta-Analysis of Randomised Controlled Trials

Aim

The optimum surgical intervention for elderly patients with lumbar spinal stenosis(LSS) and low-grade degenerative-spondylolisthesis(LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials(RCTs) comparing the effectiveness of decompression-alone against gold-standard decompression-with-fusion(D+F) in elderly patients with LSS and LGDS.

Method

A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D+F were included. The quality and weight of evidence was assessed, and a meta-analysis performed.

Results

Seven RCTs (n=581; mean age:65.9 years; 59.9% female) were included. There was no difference in visual-analogue-scale(VAS) scores of back-pain(BP) or leg-pain(LP) at mean follow-up of 28.6 months between both DA and D+F groups (BP: mean-difference (MD)-0.22, 95%CI:-0.76–0.32; LP: MD:-0.26, 95%CI:-0.79–0.27). In addition, subgroup analysis of long-term follow-up (&gt;3 years) showed lower VAS scores for BP and LP in patients who underwent DA (BP MD:-1.70, 95%CI:-2.8-(-0.60); LP MD:-1.00, 95%CI:-1.77-(-0.23)). No difference in disability, measured by Oswestry-Disability-Index(ODI) scores, was found between both groups (MD:0.50, 95%CI: -3.31–4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR:0.57, 95%CI:0.36–0.90), despite a higher rate of post-operative DS (OR:8.63, 95%CI:3.35–22.26).

Conclusions

DA is not inferior to D+F in elderly patients with LSS and LGDS. DA has better pain outcomes at three-years follow-up and carries lower risk hospital-complications and fewer adverse-events. Surgeons should weigh these findings with increased risk of DS-progression.

565 Predictors of Single Versus Multi-Level Lumbar Spinal Fusion: A Retrospective Cohort Study

Aim

Degenerative spine disease (DSD) of the lumbar spine is a common disorder among the aging population in the world, with a substantial humanistic and economic burden. Although lumbar spinal fusion is currently the mainstay surgical management of DSD, surgery is also associated with adjacent segment disease due to the modification of spinal biomechanics. Therefore, it is important to identify potential risk factors of DSD in order to prevent progressive deterioration and provide early intervention before the surgical option is absolutely necessary.

Method

Adult patients who underwent posterior lumbar spinal fusion from 2006-2016 were identified via OPCS-4codes. Smoking status, weight, age of operation, gender, diagnosis of ischaemic heart disease (IHD) were obtained via TrakCare®. The degree of deprivation was extrapolated using the Scottish Index of Multiple Deprivation (SIMD) 2020 quintile score. Data were analysed using logistic regression.

Results

In total, 313 met inclusion criteria and had data available, of which 205 and 108 patients underwent single and multi-level lumbar fusion respectively. Within the study population, 66.8% (206) and 33.2% (104) were female and male. Adjusted for all outcome measures, age of operation achieved statistical significance (p = 0.040). There was a 1.021-fold increase in risk of multi-level spinal fusion with each additional year of age. Weight was approaching statistical significance (p = 0.068).

Conclusions

Lumbar spinal health declines over time, but some patients experience more progressive deterioration. While some components of the spine are irreparable, early prescription of regimented exercise programs may strengthen spinal musculature to maintain a healthy sagittal balance, particularly in older, overweight, female patients.

A case report of an unusual cause of postoperative leg pain after posterior lumbar fusion

We report the case of a 36-year old man who underwent elective posterior lumbar spinal fusion after presenting with bilateral leg pain with associated back pain. He had undergone a L5/S1 discectomy in 2001, which provided good symptomatic relief. On this admission, he underwent elective L4-S1 posterolateral fusion and bilateral L4/5 and L5/S1 decompression. Intra-operatively a pedicle screw had to be re-inserted after fluoroscopy confirmed a lateral breech. The patient had no major postoperative complications until the sixth day when the patient re-presented with acute leg pain and weakness. Following a local multidisciplinary meeting (MDT) an MRI showed a large haematoma at the right psoas muscle. CT angiogram confirmed a bleeding lumbar segmental vessel at the site of the previous misplaced screw and an emergency fluoroscopic guided embolisation of the vessel was performed. The patient recovered well post operatively and was discharged back to the community 12 days later. Haemorrhage, as in this case a psoas haematoma should be considered as one of the differentials in patients with recurrent post-operative radiculopathy following posterior lumbar spine fusion. This should be suspected particularly if there has been a misplacement of one or more screws as this can cause injury to blood vessels and be fatal for the patient.

Knee osteoarthritis: a review of management options

Osteoarthritis of the knee is a complex peripheral joint disorder with multiple risk factors. The molecular basis of osteoarthritis has been generally accepted; however, the exact pathogenesis is still not known. Management of patients with osteoarthritis involves a comprehensive history, thorough physical examination and appropriate radiological investigation. The relative slow progress in the disease allows a stepwise algorithmic approach in treatment. Non-surgical treatment involves patient education, lifestyle modification and the use of orthotic devises. These can be achieved in the community. Surgical options include joint sparing procedures such as arthroscopyando osteotomy or joint-replacing procedures. Joint-replacing procedures can be isolated to a single compartment such as patellofemoral arthroplasty or unicompartmental knee replacement or total knee arthroplasty. The key to a successful long-term outcome is optimal patient selection, preoperative counselling and good surgical technique.

Community-Acquired Methicillin Resistant Staphylococcus aureus Bacteremia: Case Series

Community-acquired methicillin resistant Staphylococcus aureus (MRSA) usually causes skin and soft tissue infections. However, community-acquired methicillin resistant S.aureus has been identified as a causative agent of many invasive infections like necrotizing fasciitis, pneumonia and bacteremia. Risk factors such as immunodeficiency and skin and soft tissue infections have been identified for acquiring bacteremia. We present four cases of bacteremia caused by community-acquired methicillin resistant S.aureus, risk factors and outcome.Kathmandu University Medical Journal Vol.13(1) 2015; 77-79

Prevalence of Hepatitis A virus (HAV) and Hepatitis E virus (HEV) in the patients presenting with acute viral hepatitis

BACKGROUND

Hepatitis A virus (HAV) and Hepatitis E virus (HEV) are both enterically transmitted, resulting in acute viral hepatitis (AVH) in developing countries. They pose major health problems in our country. This study was done to determine prevalence of HAV and HEV in patients presenting with AVH and the co-infection of HAV and HEV in these patients.

MATERIALS AND METHODS

A cross-sectional study of 2-years duration was conducted in the Department of Microbiology, KMC, Mangalore. A non-random sampling of 958 patients presenting with AVH was considered in the study. On the basis of history, serum samples were analysed for IgM anti-HAV and IgM anti-HEV for the detection of HAV and HEV, respectively using commercially available ELISA kits. Data collected was analysed by using Statistical Package for the Social Sciences (SPSS) version 11.5.

RESULTS

The seroprevalence of HAV- and HEV-positive patients were 19.31% and 10.54%, respectively. The seroprevalence of both HAV and HEV in patients with acute viral hepatitis was 11.5%. The prevalence of HAV and HEV among males (68% and 31%) was higher than in females (31% and 20%) and was predominantly seen among young adults. These infections were predominantly seen during end of monsoons and beginning of winter.

CONCLUSION

Though the prevalence of HAV is much higher than that of HEV, co-infection rate of 11.5% mandates the screening for HEV which will be of immense importance in pregnant women and improving levels of personal hygiene among higher socio-economic population. These data will be essential for planning of future vaccination strategies and for better sanitation programme in this part of the country.

Characterization of Escherichia coli Phylogenetic Groups Associated with Extraintestinal Infections in South Indian Population

Background:

Escherichia coli strains mainly fall into four phylogenetic groups (A, B1, B2, and D) and that virulent extra-intestinal strains mainly belong to groups B2 and D.

Aim:

The aim was to determine the association between phylogenetic groups of E. coli causing extraintestinal infections (ExPEC) regarding the site of infection, expression of virulence factors, antimicrobial resistance patterns, and clinical outcome. This descriptive study was carried out in a multi-specialty Tertiary Care Hospital.

Materials and Methods:

A total of 300 E. coli causing ExPEC were studied. Triplex polymerase chain reaction was used to classify the phylogenetic groups; hemolysin production was assessed on sheep blood agar and biofilm production in a microtiter plate assay. Production of extended spectrum of beta-lactamase (ESBLs) was detected by combination disk method; AmpC was detected by AmpC disk test, Carbapenemase production was detected by modified Hodge test and metallo-β-lactamase by metallo-beta-lactamases (MBL) E-test.

Results:

Of 300 isolates, 61/300 (20%) belonged to phylogroup A, 27/300 (9%) to phylogroup B1, 104/300 (35%) were B2 and 108/300 (36%) belonged to group D, respectively. Phylogroups B2 and D were the most predominant groups in urinary tract infection and sepsis. Prognoses were better in infections with group A and B1 isolates, and relapses and death were common in infections with B2 and D. Expression of biofilm was greatest in B1 and hemolysin in group B2. Group A and B1 showed higher resistance to ciprofloxacin and were most frequent β-lactamase (ESBL, AmpC, Carbapenemase and MBL) producers.

Conclusions:

Phylogenetic group B2 and D were predominant in ExPEC and exhibited least antimicrobial resistance among the groups. Resistance to multiple antibiotics was most prevalent in group A and B1. Regular monitoring of antimicrobial susceptibility in commensal strains is essential as they might transfer the property of antimicrobial resistance to pathogenic strains.

The Prevalence and Severity of Joint Problems and Disability in Patients with Poliomyelitis in Urban India

Poliomyelitis is caused by an enterovirus infection of the anterior horn cells in the spinal cord. Up to 40% of survivors recover full muscle strength, however 60–90% are left with varying degrees of residual paralysis, where the patient suffers from cramping myalgia and lower motor neuron pattern weakness. This study aimed to identify and quantify, in terms of prevalence and severity of the types of joint deformities encountered in polio sufferers. It also aimed to assess the disability caused by such problems. Finally we documented the provision and use of mobility aids, orthotics and surgery in the patient group.

Impairment was confined to one lower limb, and this is consistent, as the majority of patients were infected in infancy. The study found that pes cavus, scoliosis, flexion deformity of the knee and true lower-limb shortening accounted for over half of the deformities found. The mean Barthel Disability score was 19 and over 80% of patients used at least one aid, usually in the form of a Knee-Ankle-Foot Orthosis (KAFO). Surgery also plays a large in role in the management of polio patients, however necessity needs to be assessed on an individual basis taking into account many aspects of the patient’s life.

Saliva as a Diagnostic Tool for Measurement of Total Antioxidant Capacity in Children with Leprosy and Born to Leprosy Parent

The aim of the study is to assess the role of saliva as a diagnostic tool for measurement of total antioxidant capacity in children with leprosy and children born to leprosy parent. One hundred fifty children in the age group of 4-15 years were split into three equal groups: children with leprosy (CL) and children born to leprotic parents (CLP) and healthy children. Vitamin C level was measured in saliva of children spectrophotometrically at 695nm by Phosphomolybdenum method. Data were determined with student's unpaired t test and one way ANOVA. The result of the study showed that children with leprosy exhibited significantly decreased salivary total antioxidant capacity as compared to healthy controls. Antioxidant Vitamin C was higher in the Paucibacillary leprosy (PB) than those of Multibacillary type (MB) (P < 0.001). As age advanced, there was a gradual increase in total antioxidant capacity in both the control and study groups and the results were highly significant statistically. Saliva is an easy medium.

Does circumpatellar electrocautery improve the outcome after total knee replacement?: a prospective, randomised, blinded controlled trial

The incidence of anterior knee pain following total knee replacement (TKR) is reported to be as high as 49%. The source of the pain is poorly understood but the soft tissues around the patella have been implicated. In theory circumferential electrocautery denervates the patella thereby reducing efferent pain signals. However, there is mixed evidence that this practice translates into improved outcomes. We aimed to investigate the clinical effect of intra-operative circumpatellar electrocautery in patients undergoing TKR using the LCS mobile bearing or Kinemax fixed bearing TKR. A total of 200 patients were randomised to receive either circumpatellar electrocautery (diathermy) or not (control). Patients were assessed by visual analogue scale (VAS) for anterior knee pain and Oxford knee score (OKS) pre-operatively and three months, six months and one year post-operatively. Patients and assessors were blinded. There were 91 patients in the diathermy group and 94 in the control. The mean VAS improvement at one year was 3.9 in both groups (control; -10 to 6, diathermy; -9 to 8, p < 0.001 in both cases, paired, two-tailed t-test). There was no significant difference in VAS between the groups at any other time. The mean OKS improvement was 17.7 points (0 to 34) in the intervention group and 16.6 (0 to 42) points in the control (p = 0.36). There was no significant difference between the two groups in OKS at any other time. We found no relevant effect of patellar electrocautery on either VAS anterior knee pain or OKS for patients undergoing LCS and Kinemax TKR.

Conventional surgical treatment of oral mucocele: a series of 23 cases

AIM

Mucocele is a common lesion of the oral mucosa that results from alterations of the minor salivary glands due to mucous accumulation, causing swelling. Conventional surgical treatment was planned for these lesions in a group of children and the success rates of the therapy during the transitional period from mixed to permanent dentition were assessed with a series of follow-ups.

MATERIALS AND METHODS

A series of 23 cases of mucocele was observed in children under 10 years of age. Clinically the lesions consisted of a soft, bluish and transparent cystic swelling which normally resolved spontaneously and reappeared after rupture in few days. All cases were treated by conventional surgical procedure with excision of minor salivary glands and underwent a 3-year follow-up.

RESULTS

Out of the 23 cases, 19 (82.6%) were in the lower lip, 2 (8.6%) in the cheek, 1 (4.3%) in the retromolar area and 1 (4.3%) in the upper lip. Those in the lower lip, 15 (79%) were away from the midline and 4 (21%) at midline. One (4.3%) recurrence was seen at the 6-month follow-up. After 3 years, recurrence rate remained the same.

CONCLUSION

Conventional surgical excision with removal of affected minor salivary glands in paediatric patients is a definite treatment for mucocele.