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.

Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department

BACKGROUND

The TRAPID-AMI trial study (High-Sensitivity Troponin-T Assay for Rapid Rule-Out of Acute Myocardial Infarction) evaluated high-sensitivity cardiac troponin-T (hs-cTnT) in a 1-hour acute myocardial infarction (AMI) exclusion algorithm. Our study objective was to evaluate the prognostic utility of a modified HEART score (m-HS) within this trial.

METHODS AND RESULTS

Twelve centers evaluated 1282 patients in the emergency department for possible AMI from 2011 to 2013. Measurements of hs-cTnT (99th percentile, 14 ng/L) were performed at 0, 1, 2, and 4 to 14 hours. Evaluation for major adverse cardiac events (MACEs) occurred at 30 days (death or AMI). Low-risk patients had an m-HS≤3 and had either hs-cTnT<14 ng/L over serial testing or had AMI excluded by the 1-hour protocol. By the 1-hour protocol, 777 (60%) patients had an AMI excluded. Of those 777 patients, 515 (66.3%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 262 (33.7%) patients had an m-HS≥4, with 6 (2.3%) patients having MACEs (P=0.007). Over 4 to 14 hours, 661 patients had a hs-cTnT<14 ng/L. Of those 661 patients, 413 (62.5%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 248 (37.5%) patients had an m-HS≥4, with 5 (2.0%) patients having MACEs (P=0.03).

CONCLUSIONS

Serial testing of hs-cTnT over 1 hour along with application of an m-HS identified a low-risk population that might be able to be directly discharged from the emergency department.

Investigation of the Tissue Distribution and Physiological Roles of Indoleamine 2,3-Dioxygenase-2

Indoleamine 2,3-dioxygenase-2 (IDO2) is 1 of the 3 enzymes that can catalyze the first step in the kynurenine pathway of tryptophan metabolism. Of the 2 other enzymes, tryptophan 2,3-dioxygenase is highly expressed in the liver and has a role in tryptophan homeostasis, whereas indoleamine 2,3-dioxygenase-1 (IDO1) expression is induced by inflammatory stimuli. Indoleamine 2,3-dioxygenase-2 is reportedly expressed comparatively narrow, including in liver, kidney, brain, and in certain immune cell types, and it does not appear to contribute significantly to systemic tryptophan catabolism under normal physiological conditions. Here, we report the identification of an alternative splicing pattern, including the use of an alternative first exon, that is conserved in the mouse Ido1 and Ido2 genes. These findings prompted us to assess IDO2 protein expression and enzymatic activity in tissues. Our analysis, undertaken in Ido2^+/+ and Ido2^−/− mice using immunohistochemistry and measurement of tryptophan and kynurenine levels, suggested an even more restricted pattern of tissue expression than previously reported. We found IDO2 protein to be expressed in the liver with a perinuclear/nuclear, rather than cytoplasmic, distribution. Consistent with earlier reports, we found Ido2 ^−/− mice to be phenotypically similar to their Ido2^+/+ counterparts regarding levels of tryptophan and kynurenine in the plasma and liver. Our findings suggest a specialized function or regulatory role for IDO2 associated with its particular subcellular localization.

The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test

BACKGROUND

Recent single-center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia.

OBJECTIVE

We aimed to determine the external validity of those findings in a multicenter study at 12 sites in nine countries.

METHODS

TRAPID-AMI was a prospective diagnostic cohort study including patients with suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on arrival was centrally tested for hs-cTnT (Roche; 99th percentile = 14 ng/L, LoD = 5 ng/L). All patients underwent serial troponin sampling over 4-14 hours. The primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I (Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI, death, or rehospitalization for acute coronary syndrome with coronary revascularization were determined after 30 days.

RESULTS

We included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed MACE. Of 560 (43.7%) patients with initial hs-cTnT levels below the LoD, four (0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs-cTnT levels below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2) probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to 99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%).

CONCLUSIONS

In the absence of ECG ischemia, the detection of very low concentrations of hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.

A literature review of the feasibility of glial fibrillary acidic protein as a biomarker for stroke and traumatic brain injury

Traumatic brain injuries (TBIs) are potentially lethal medical conditions, with symptoms that can overlap with symptoms of injuries outside the brain. In many cases, current diagnostic methods do not fully distinguish acute brain injury from other organ damage. In the management of stroke patients, the choice of treatment depends on whether the stroke is ischemic or hemorrhagic; however, no quick lab diagnostic tests are available to distinguish between the two types of strokes. As a result, patient triage, disposition, and patient management decisions may be delayed for patients with suspected TBI and stroke. Glial fibrillary acidic protein (GFAP), a brain-specific biomarker that is released into the blood following TBI and stroke, is being explored for potential diagnostic and prognostic value in these indications. We therefore conducted a review of MEDLINE-indexed publications from 2004 to 2011 to evaluate the current status of GFAP as a prognostic and diagnostic tool for TBI and stroke within the context of current published guidelines. Our review suggests that GFAP could provide clinically valuable information for the prognosis of TBI and stroke, but it is still at an early stage of development as a biomarker. Several TBI studies have shown elevated GFAP levels following a TBI event to be associated with greater severity of injury, poorer outcomes, and increased mortality. Clinical studies also indicate that GFAP has potential clinical utility in the differential diagnosis of various types of stroke. However, more clinical research will be required to determine the ability of GFAP levels to diagnose TBI in heterogeneous patient populations, as well as the ability of GFAP to differentiate between ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and non-stroke conditions in populations of patients with suspected rather than confirmed stroke. Additional clinical studies will also be required to define the temporal patterns of GFAP release in IS, ICH, SAH, and TBI, and their potential use in the differential diagnosis of these conditions. Finally, such research could demonstrate the ability of GFAP test results to provide unique clinical information that informs management decisions for TBI and stroke patients.

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.

Indoleamine 2,3-dioxygenase-2; a new enzyme in the kynurenine pathway

The kynurenine pathway of tryptophan metabolism converts the amino acid tryptophan into a number of biologically active metabolites. The first and rate-limiting step in this pathway is the conversion of tryptophan to N-formylkynurenine and until recently this reaction was thought to be performed by either of two enzymes, tryptophan 2,3-dioxygenase and indoleamine 2,3-dioxygenase. A third enzyme, indoleamine 2,3-dioxygenase-2, indoleamine 2,3-dioxygenase-like protein or proto-indoleamine 2,3-dioxygenase (IDO2, IDO-2, INDOL1 or proto-IDO), with this activity recently has been described. The gene encoding IDO2 is adjacent and structurally similar to the indoleamine 2,3-dioxygenase gene and both mouse genes use multiple promoters to express transcripts with alternate 5' exons. The IDO2 protein is expressed in the murine kidney, liver, male and female reproductive system. The two IDO enzymes can utilise a similar range of substrates, however they differ in their selectivity for some inhibitors. The selective inhibition of IDO2 by 1-methyl-D-tryptophan suggests that IDO2 activity may have a role in the inhibition of immune responses to tumours.

Characterization of an indoleamine 2,3-dioxygenase-like protein found in humans and mice

Indoleamine 2,3-dioxygenase (INDO) and tryptophan 2,3-dioxygenase (TDO) each catalyze the first step in the kynurenine pathway of tryptophan metabolism. We describe the discovery of another enzyme with this activity, indoleamine 2,3-dioxygenase-like protein (INDOL1), which is closely related to INDO and is expressed in mice and humans. The corresponding genes have a similar genomic structure and are situated adjacent to each other on human and mouse chromosome 8. They are likely to have arisen by gene duplication before the origin of the tetrapods. The expression of INDOL1 is highest in the mouse kidney, followed by epididymis, and liver. Expression of mouse INDOL1 was further localized to the tubular cells in the kidney and the spermatozoa. INDOL1 was assigned its name because of its structural similarity to INDO. We demonstrate that INDOL1 catalyses the conversion of tryptophan to kynurenine therefore a more appropriate nomenclature for the enzymes might be INDO-1 and INDO-2, or the more commonly-used abbreviations, IDO-1 and IDO-2. Although the two proteins have similar enzymatic activities, their different expression patterns within tissues and during malaria infection, suggests a distinct role for each protein. This identification of INDOL1 may help to explain the regulation of the diversity of physiological and patho-physiological processes in which the kynurenine pathway is involved.

Interferon-gamma synergises with tumour necrosis factor and lymphotoxin-alpha to enhance the mRNA and protein expression of adhesion molecules in mouse brain endothelial cells

Changes to the cerebral microvasculature are evident during cerebral malaria (CM). Activation of the endothelium is likely to be due to the actions of cytokines, circulating levels of which are elevated during CM. Endothelial cells are known to up-regulate the expression of cellular adhesion molecules, which can lead to cellular sequestration and obstruction of vessels. However, it is unknown whether cytokines synergise in the up-regulation of the adhesion molecules involved in CM. In this study, the mRNA and/or protein expression of the adhesion molecules vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), P-selectin and E-Selectin were examined in a mouse brain endothelial cell line. Endothelial cells were stimulated with interferon-gamma (IFN-gamma), tumour necrosis factor (TNF) and lymphotoxin-alpha (LT-alpha), alone or in combination. The expression of ICAM-1, VCAM-1, P-selectin and E-Selectin mRNA in mouse brain endothelial cells by TNF and/or LT-alpha was found to be significantly enhanced in the presence of IFN-gamma. The same synergistic effect was found when analyzing ICAM-1 protein expression in cytokine stimulated mouse brain endothelial cells. The findings show that cytokines can synergise to influence gene expression and protein expression in a mouse brain endothelial cell line.

Brain gene expression, metabolism, and bioenergetics: interrelationships in murine models of cerebral and noncerebral malaria

Malaria infection can cause cerebral symptoms without parasite invasion of brain tissue. We examined the relationships between brain biochemistry, bioenergetics, and gene expression in murine models of cerebral (Plasmodium berghei ANKA) and noncerebral (P. berghei K173) malaria using multinuclear NMR spectroscopy, neuropharmacological approaches, and real-time RT-PCR. In cerebral malaria caused by P. berghei ANKA infection, we found biochemical changes consistent with increased glutamatergic activity and decreased flux through the Krebs cycle, followed by increased production of the hypoxia markers lactate and alanine. This was accompanied by compromised brain bioenergetics. There were few significant changes in expression of mRNA for metabolic enzymes or transporters or in the rate of transport of glutamate or glucose. However, in keeping with a role for endogenous cytokines in malaria cerebral pathology, there was significant up-regulation of mRNAs for TNF-alpha, interferon-gamma, and lymphotoxin. These changes are consistent with a state of cytopathic hypoxia. By contrast, in P. berghei K173 infection the brain showed increased metabolic rate, with no deleterious effect on bioenergetics. This was accompanied by mild up-regulation of expression of metabolic enzymes. These changes are consistent with benign hypermetabolism whose cause remains a subject of speculation.

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.