Publications by authors named "Inamullah Khan"

85 Publications

Perioperative Modifications to the Open TLIF Provide Comparable Short-term Outcomes to the MIS-TLIF.

Clin Spine Surg 2021 Apr 23. Epub 2021 Apr 23.

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN.

Study Design: This study is a retrospective review of patients' charts and data from longitudinally collected clinical outcomes and opioid use.

Objective: In the current study, we aim to compare short-term outcomes data for 139 Open transforaminal interbody fusion (TLIF) patients to recently published data for tubular and endoscopic MIS-TLIF.

Background Context: In response to the downsides associated with Open TLIF, such as large incision, blood loss, delayed ambulation, prolonged hospitalization, and opioid-reliance, spine surgeons developed tubular retractor based "minimally-invasive" TLIF. However, the traditional Open TLIF retains its significance in terms of providing successful fusion and improved patient-reported outcomes (PROs).

Methods: We adapted several techniques with an aim to improve short-term outcomes for our Open TLIF patients that combined extensive perioperative counselling, an emphasis on early mobilization, avoidance of overuse of opioid analgesics, early discharge with home care arrangements, use of a posthospitalization drainage tube with intraoperative surgical modifications using small incisions (4-5 cm), a narrow 20 mm retractor, minimal muscle injury, and use of a cell saver to minimize net blood loss. The demographics and perioperative results were compared with data from recent MIS-TLIF studies using Student t test for continuous and χ2/exact test for categorical variables.

Results: Among the total 139 patients, 115 underwent a single-level procedure, 90% of whom were discharged on the first postoperative day (length of stay=1.13±0.47 d) with an average net estimated blood loss of 176.17±87.88 mL. There were 24 two-level procedures with an average length of stay of 1.57±0.84 days, average net estimated blood loss was 216.96±85.70 mL. The patients had statistically significant improvements in PROs at 3 and 12 months.

Conclusions: The results of this study identify that patients who underwent modified Open TLIF demonstrated favorable short-term outcomes, as compared with the tubular MIS-TLIF, by virtue of avoidance of blood transfusions, shorter hospital stays, and significantly less opioid usage while experiencing satisfactory PROs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BSD.0000000000001181DOI Listing
April 2021

Hemorrhagic complications after decompressive craniectomy.

Surg Neurol Int 2020 11;11:379. Epub 2020 Nov 11.

Department of Surgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan.

Background: Decompressive craniectomy (DC) is the preferred surgical management option for lowering refractory intracranial pressure in cases of traumatic brain injury (TBI). A number of randomized controlled trials have demonstrated decreased mortality but increased morbidity following DC for TBI patients. Here, we reviewed the frequency of postoperative hemorrhagic complications following DC correlating with poor outcomes.

Methods: We retrospectively reviewed the medical records of patients who presented with TBI and underwent DC during the years 2015-2017. The frequency and characteristics of hemorrhagic complications were correlated with the patients' outcomes.

Results: There were 74 patients with TBI included in the study who underwent DC. Of these, 31 patients developed expansion of existing hemorrhagic lesions, 13 had new contusions, three developed new extradural hemorrhages, two developed new subdural hematomas, and one patient developed an intraventricular hemorrhage. Those who developed expansion of existing hemorrhagic lesions following DC had longer ICU stays and poorer outcomes (Glasgow outcome scale).

Conclusion: After 74 DC performed in TBI patients, 67% developed new hemorrhagic lesions or expansion of previously existing hemorrhages. This finding negatively impacted clinical outcomes, including mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.25259/SNI_607_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771395PMC
November 2020

Clinically Meaningful Improvement Following Cervical Spine Surgery: 30% Reduction Versus Absolute Point-change MCID Values.

Spine (Phila Pa 1976) 2021 Jun;46(11):717-725

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN.

Study Design: Retrospective analysis of prospectively collected registry data.

Objective: The aim of this study was to compare the performance of 30% reduction to established absolute point-change values for measures of disability and pain in patients undergoing elective cervical spine surgery.

Summary Of Background Data: Recent studies recommend using a proportional change from baseline instead of an absolute point-change value to define minimum clinically important difference (MCID).

Methods: Analyses included 13,179 patients who underwent cervical spine surgery for degenerative disease between April 2013 and February 2018. Participants completed a baseline and 12-month follow-up assessment that included questionnaires to assess disability (Neck Disability Index [NDI]), neck and arm pain (Numeric Rating Scale [NRS-NP/AP], and satisfaction [NASS scale]). Participants were classified as met or not met 30% reduction from baseline in each of the respective measures. The 30% reduction in scores at 12 months was compared to a wide range of established absolute point-change MCID values using receiver-operating characteristic curves, area under the receiver-operating characteristic curve (AUROC), and logistic regression analyses. These analyses were conducted for the entire patient cohort, as well as for subgroups based on baseline severity and surgical approach.

Results: Thirty percent reduction in NDI and NRS-NP/AP scores predicted satisfaction with more accuracy than absolute point-change values for the total population and ACDF and posterior fusion procedures (P < 0.05). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 16.8%) and bed-bound disability (ODI 81%-100%: 16.6%) categories. For pain, there was a 1.9% to 11% and 1.6% to 9.6% AUROC difference for no/mild neck and arm pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.

Conclusion: A 30% reduction from baseline is a valid method for determining MCID in disability and pain for patients undergoing cervical spine surgery.Level of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003887DOI Listing
June 2021

Lowest Instrumented Vertebra Selection in Posterior Cervical Fusion: Does Cervicothoracic Junction Lowest Instrumented Vertebra Predict Mechanical Failure?

Spine (Phila Pa 1976) 2021 Apr;46(8):E482-E490

Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN.

Study Design: Retrospective.

Objective: The purpose of this study is to evaluate the effect of posterior cervical fusion lowest instrumented vertebra (PCF LIV) selection on incidence of mechanical failure, revision surgery, and patient-reported outcomes (PROs).

Summary Of Background Data: Recent studies indicate that the LIV in PCF may contribute to the risk of mechanical failure. To date, the evidence available to guide spine surgeons in the selection of PCF LIV remains limited.

Methods: All patients undergoing PCF at a single institution were prospectively entered into a spine registry which was retrospectively queried. Data collection included demographics, pathology, operative variables, construct LIV, outcomes of mechanical failure, revision surgery, and patient-reported disability, pain, and quality of life.

Results: Of 438 patients undergoing PCF from 2006 to 2019, 106 patients had an LIV of C7, T1, or T2, a minimum of 1-year follow-up, and met all study inclusion criteria. LIV cohorts were C7 LIV (36), T1 LIV (42), and T2 LIV (28). There were no between-group differences in patient demographics, operative variables, or postoperative follow-up across the three LIV cohorts. Mechanical failure rates for C7, T1, and T2 LIV were 30.6%, 23.8%, and 0%, respectively (P = 0.007). Revision rates for C7, T1, and T2 LIV were 25.0%, 11.9%, and 0%, respectively (P = 0.013). No difference was noted in average time to revision/failure between C7 (39.68 months) and T1 (29.85 months) LIV cohorts. No differences in baseline, 3-month, and 12-month postoperative PRO measures were noted in the C7 and T1 LIV cohort when compared to the T2 LIV cohort.

Conclusion: The findings in this study indicate that PCF LIV selection may play a significant role in the development of mechanical complications and need for revision surgery. T2 LIV selection demonstrated a significantly lower rate of mechanical failure and revision surgery. Postoperative PROs up to 36 months are needed to evaluate effect of LIV selection on PROs.Level of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003819DOI Listing
April 2021

Consanguinity, the driving force behind inheritance of HbS-β thalassemia in Southern Districts of KP.

J Pak Med Assoc 2020 Jun;70(6):978-983

Department of Zoology, Kohat University of Science and Technology, KP, Pakistan.

Objective: To determine the clinical, haematological and genetic factors responsible for variable phenotypes of sickle haemoglobin, sickle haemoglobin-beta, and beta-thalassemia patients.

Methods: The study was conducted in Bannu, Lakki, Tank and Dera Ismail Khan districts of Khyber Pakhtunkhwa province of Pakistan from September 2016 to November 2017, and comprised sickle haemoglobin, sickle haemoglobin-beta, and beta-thalassemia patients. Clinical, haematological and genetic determinants were evaluated using haemoglobin electrophoresis and allele-specific primers through polymerase chain reaction to determine alpha and beta thalassemia, and CgT substitution at position -158 (referred to as Xmn-I polymorphism) in gamma-globin gene. Data was analysed using SPSS 20.

Results: Eight b-thalassemia mutations were identified that included IVS I-5(G C), codon 8/9 (+G), codon 30 (G C), -88 (C T), Cap+1(A G), codon 41/42 (-TCTT), IVS I-1(G T) and codon 16(-C). Codon 30 (G C) and -88 (C T) were found only in Pashtoon subjects, Cap+1(A G) and IVS I-1(G T) in Balochi subjects, while 75% of IVS I-5(G C) mutation cases were found in Punjabi ethnic group. In the Pashtoon group, 13 sickle haemoglobin homozygous patients were identified for the first time. Both alpha thalassemia and Xmn-I polymorphism in homozygous condition were common among those with mild phenotype.

Conclusion: Phenotypic expression of sickle haemoglobin beta thalassemia was found to be extremely variable and alpha thalassemia and Xmn-I polymorphism in homozygous condition were found to be additional genetic modifiers of the disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5455/JPMA.300622DOI Listing
June 2020

Development and Validation of Cervical Prediction Models for Patient-Reported Outcomes at 1 Year After Cervical Spine Surgery for Radiculopathy and Myelopathy.

Spine (Phila Pa 1976) 2020 Nov;45(22):1541-1552

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, Tennessee.

Study Design: Retrospective analysis of prospectively collected registry data.

Objective: To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery.

Summary Of Background Data: Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care.

Methods: This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

Results: Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P < 0.001). Clinical and surgical variables contributed very little to predictive models, with posterior approach being associated with higher odds of having worse 12-month outcome scores in both the radiculopathy and myelopathy cohorts (P < 0.001). The full models overall discriminative performance ranged from 0.654 to 0.725.

Conclusions: These predictive models provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical disease. Predictive models have the potential to be used as a shared decision-making tool for evidence-based preoperative counselling.

Level Of Evidence: 2.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003610DOI Listing
November 2020

β-1,3-glucan Attenuated Chronic Unpredictable Mild Stress-induced Cognitive Impairment in Rodents via Normalizing Corticosterone Levels.

Cent Nerv Syst Agents Med Chem 2020 ;20(3):206-217

Department of Pharmacy, COMSATS University Islamabad, Abbottabad Campus-22060, KP, Pakistan.

Background: Chronic stress elevates the cortisol beyond normal levels, which affects cognition including learning & memory. This injurious effect is primarily mediated via over excitation of metabotropic glucocorticoid receptors (mGR).

Methods: The present study was aimed to appraise the neuroprotective effects of naturally occurring molecule β-1,3-glucan by interfering with stress-cortisol-mGR axis. Our data of virtual screening (in silico) exhibited the promising interactions of β-glucan with the mGR. Therefore, the study was extended to evaluate its efficacy (2.5, 5 and 10 mg/kg/ i.p) in an animal model of chronic unpredictable mild stress (CUMS, 28 days) induced memory impairment.

Results: Results of the current study revealed the β-glucan provided dose dependent protection against deleterious effects of stress on learning and memory associated parameters observed in Morris water maze (MWM) task. At higher tested doses, it has also significantly antagonized the stress induced weight loss and corticosterone elevation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2174/1871524920666200810142359DOI Listing
January 2020

Duration and Dosage of Opioids After Spine Surgery: Implications on Outcomes at 1 Year.

Spine (Phila Pa 1976) 2020 Aug;45(15):1081-1088

Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN.

Study Design: Longitudinal Cohort Study OBJECTIVE.: The aim of this study was to determine whether duration of postoperative opioids is associated with long-term outcomes, and if initial postoperative opioid dosage is associated with opioid cessation after spine surgery.

Summary Of Background Data: Preoperative opioid use is associated with poor outcomes, but little evidence exists regarding the implications of opioid dosage and duration after spine surgery.

Methods: Data from our state's prescription drug database was linked to our prospective clinical spine registry to analyze opioid dispensing and outcomes in elective surgical spine patients between 2010 and 2017. Patients were stratified based on preoperative chronic opioid use and multivariable regression was used to assess associations between duration of postoperative opioids and outcomes at one year, including satisfaction, chronic opioid use, and meaningful improvements in pain, disability, and quality of life. In a secondary aim, a Cox proportional hazards model was used to determine whether initial postoperative opioid dosage was associated with time to opioid cessation.

Results: Of 2172 patients included, 35% had preoperative chronic opioid use. In patients without preoperative chronic opioid use, a postoperative opioid duration of 31 to 60 days was associated with chronic opioid use at 1 year (adjusted odds ratio [aOR]: 4.1 [1.7-9.8]) and no meaningful improvement in extremity pain (aOR: 1.8 [1.3-2.6]) or axial pain (aOR: 1.6 [1.1-2.2]); cessation between 61 and 90 days was associated with no meaningful improvement in disability (aOR: 2 [1.3-3]) and dissatisfaction (aOR:1.8 [1-3.1]). In patients with preoperative chronic opioid use, postoperative opioids for ≥90 days was associated with dissatisfaction. Cox regression analyses showed lower initial postoperative opioid dosages were associated with faster opioid cessation in both groups.

Conclusion: Our results suggest that a shorter duration of postoperative opioids may result in improved 1-year patient-reported outcomes, and that lower postoperative opioid dosages may lead to faster opioid cessation.

Level Of Evidence: 2.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003446DOI Listing
August 2020

Why are patients dissatisfied after spine surgery when improvements in disability and pain are clinically meaningful?

Spine J 2020 10 13;20(10):1535-1543. Epub 2020 Jun 13.

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine & Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

Background Context: Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery. While the majority of the literature has focused on patients who report both satisfaction and clinical improvement in disability and pain, there remains an important subpopulation of patients who have clinically relevant improvement but report being dissatisfied with surgery.

Purpose: To examine why patients who achieve clinical improvement in disability or pain also report dissatisfaction at 1-year after spinal surgery.

Study Design: Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.

Patient Sample: There were 34,076 participants undergoing elective surgery for degenerative spine pathology who had clinical improvement in disability or pain.

Outcome Measures: Satisfaction with surgery was assessed with 1-item from the North American Spine Society lumbar spine outcome assessment. Participants with answer choices other than "treatment met my expectations" were classified as dissatisfied.

Methods: Patients completed a baseline and 12-month postoperative assessment to evaluate disability, pain, and satisfaction. Clinical improvement was defined as patients who achieved a 30% or greater improvement in spine-related disability (Oswestry/Neck Disability Index) or extremity pain (11-point Numeric Rating Scale) from baseline to 12-month after surgery. A generalized linear mixed model was used to predict the odds of the patient being dissatisfied 1-year after surgery from demographic, clinical and surgical characteristics, postoperative complications and revision, and return to work and previous physical activity. Random effects were included to model the effect of both site and surgeon on dissatisfaction. Sensitivity analyses were conducted on samples who achieved 30% or greater improvement in (1) disability only, (2) axial (back/neck) pain only, (3) extremity (leg/arm)pain only, (4) both disability and axial pain, and (5) both disability and extremity pain. Results showed the same pattern of findings across all samples.

Results: Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% classified as satisfied. For patients with clinical improvement in disability or extremity pain at 1-year, significant predictors of higher odds of dissatisfaction included baseline psychological distress, current smoking status, workers compensation claim, lower education, higher ASA grade, lumbar versus cervical procedure, and increased axial pain, major complication within 30 days, and revision surgery within 12-months. The most important contributors to dissatisfaction were return to work and return to previous physical activity, with the odds of dissatisfaction being over 2 times and 4 times higher for these variables. Site and surgeon explained 3.8% of the variance in dissatisfaction, with more of the variance attributed to site than to surgeon.

Conclusions: Several modifiable factors, including psychological distress, current smoking status, and failure to return to work and physical activity, helped explain why patients report being dissatisfied with surgery despite clinical improvement in disability or pain. The findings of this study have the potential to help providers identify at-risk patients, set realistic expectations during preoperative counseling, and implement postoperative management strategies. A multidisciplinary approach to rehabilitation that includes functional goal setting or restoration may help to improve patients psychological distress as well as return to work and previous physical activity after spine surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2020.06.008DOI Listing
October 2020

Impact of Dominant Symptom on 12-Month Patient-Reported Outcomes for Patients Undergoing Lumbar Spine Surgery.

Neurosurgery 2020 10;87(5):1037-1045

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

Background: The impact of symptom characteristics on outcomes of spine surgery remains elusive.

Objective: To determine the impact of symptom location, severity, and duration on outcomes following lumbar spine surgery.

Methods: We queried the Quality Outcomes Database (QOD) for patients undergoing elective lumbar spine surgery for lumbar degenerative spine disease. Multivariable regression was utilized to determine the impact of preoperative symptom characteristics (location, severity, and duration) on improvement in disability, quality of life, return to work, and patient satisfaction at 1 yr. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom.

Results: A total of 22 022 subjects were analyzed. On adjusted analysis, we found patients with predominant leg pain were more likely to be satisfied (P < .0001), achieve minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) (P = .002), and return to work (P = .03) at 1 yr following surgery without significant difference in Euro-QoL-5D (EQ-5D) (P = .09) [ref = predominant back pain]. Patients with equal leg and back pain were more likely to be satisfied (P < .0001), but showed no significant difference in achieving MCID (P = .22) or return to work (P = .07). Baseline numeric rating scale-leg pain and symptom duration were most important predictors of achieving MCID and change in EQ-5D. Predominant symptom was not found to be an important determinant of return to work. Worker's compensation was found to be most important determinant of satisfaction and return to work.

Conclusion: Predominant symptom location is a significant determinant of functional outcomes following spine surgery. However, pain severity and duration have higher predictive importance. Return to work is more dependent on sociodemographic features as compared to symptom characteristics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyaa240DOI Listing
October 2020

Classifying chronic opioid use before spine surgery: comparison of self-report and prescription drug monitoring program (PDMP) reporting.

Spine J 2020 11 2;20(11):1795-1797. Epub 2020 Jun 2.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21(st) Ave South, MCE South Tower, Suite 4200, Nashville, TN 37232, USA; Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, 2525 West End Ave., 12th floor, Suite 1200, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 Children's Way Suite 1221, Nashville, TN 37212, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2020.05.548DOI Listing
November 2020

Using PROMIS-29 to predict Neck Disability Index (NDI) scores using a national sample of cervical spine surgery patients.

Spine J 2020 08 12;20(8):1305-1315. Epub 2020 May 12.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

Background Context: Patient reported outcome measures (PROMs) are valuable tools for evaluating the success of spine surgery, with the Neck Disability Index (NDI) commonly used to assess pain-related disability. Recently, patient-reported outcomes measurement information system (PROMIS) has gained attention in its ability to measure PROs across general patient populations. However, PROMIS is not condition-specific so spine researchers are reluctant to incorporate it in place of common legacy measures.

Purpose: To compare the PROMIS-29 (v2.0) to the NDI and compute a conversion equation.

Study Design: This study retrospectively analyzes prospectively collected data from the cervical module of national spine registry, the Quality Outcomes Database (QOD).

Patient Sample: The QOD was queried for cervical spine surgery patients with PROMIS-29 and NDI scores. The cervical module of QOD includes patients undergoing primary or revision surgery for cervical degenerative spine diseases. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of cervical-related pain.

Outcome Measures: The outcome of interest for this study was a conversion equation from PROMIS-29 to NDI.

Methods: The PROMIS-29 includes seven 4-item domains each rated on a 5-point scale: Physical function, depression, anxiety, fatigue, sleep disturbance, ability to participate in social roles and activities (social roles), and pain interference plus one stand-alone pain intensity item. The NDI contains 10 pain-related questions scored from 0 (no pain) to 5 (most severe pain). Outcomes were collected prior to surgery and at 3- and 12-month post surgery. Patients were included in the current analysis if they had outcome data available at one or more time points. Multivariable mixed effects regression models predicting NDI scores from PROMIS-29 domains were conducted in a development data set and validated in a separate data set. Predicted NDI scores were plotted against NDI scores to determine how well PROMIS-29 domains predicted NDI. Conversion equations were created from the PROMIS-29 regression coefficients.

Results: 2,018 patients from 18 US hospitals were included (mean age=57 years (SD=12)) with 48% female, 87% Caucasian, and 11% had revision surgery. Strong correlations were found between NDI and pain interference (r=0.79), pain intensity (r=0.74), social roles (r=-0.71), physical function (r=-0.69), sleep disturbance (r=0.63), fatigue (r=0.63), and anxiety (r=0.54). Correlation between NDI and depression (r=0.49) was slightly weaker. The pattern of correlations was consistent across timepoints. Four conversion equations were created for NDI using (1) only pain interference, (2) only physical function, (3) pain interference and physical function, and (4) the five statistically significant domains of pain interference, physical function, social roles, sleep disturbance, and anxiety, plus the pain intensity item. Equations 1, 3, and 4 were the best predictors of NDI, predicting approximately 80% of NDI scores within 15 points in the validation data set. Equation 4 (NDI=18.897+0.855*[pain interference]-0.694*[physical function]+2.010*[pain intensity]-0.663*[social roles]+0.732*[sleep disturbance]+0.426*[anxiety]) predicted NDI most accurately with an R between the predicted and actual NDI scores of 0.72. Model 1 (R = 0.62; NDI=-4.055+3.164*[pain interference])) and Model 3 (R=0.65; NDI%=17.321+2.543*[pain interference]-1.012*[physical function]) also had good accuracy.

Conclusions: Findings suggest accurate NDI scores can be derived from PROMIS-29 domains. Clinicians who want to move from NDI to PROMIS-29 can use this equation to obtain estimated NDI scores when only collecting PROMIS-29. These results support the use of PROMIS-29 in cervical surgery populations and underscore the idea that PROMIS-29 domains have the potential to replace disease-specific traditional PROMs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2020.04.028DOI Listing
August 2020

Association of Depression with Subclinical Coronary Atherosclerosis: a Systematic Review.

J Cardiovasc Transl Res 2020 Mar 20. Epub 2020 Mar 20.

Pediatric Cardiac Surgery, Vanderbilt University, Nashville, TN, USA.

To assess causal association of depression with subclinical coronary atherosclerosis, we performed computer-based and manual search of literature for studies which had assessed relationship of depression disorder with coronary atherosclerosis. All studies had diagnosed depression with validated tools in patients without diagnosed coronary artery disease. The Bradford Hill criteria of cause-effect association was consistently fulfilled by those studies which achieved statistical significance and further showed incremental strength of association with one or more of the following attributes: (1) prospective cohort study, met cause-effect criteria of "temporality"; (2) relatively severe and/or longer period of depression, met cause-effect criteria of "dose-response"; (3) depression with predominantly somatic symptoms cluster, met cause-effect criteria of "scientific plausibility"; (4) multiethnic larger sample, met cause-effect criteria of "population equivalence"; and (5) multicenter study, met criteria of "environmental equivalence." Our results show that there is a significant association of depression with coronary atherosclerosis at its subclinical stages.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12265-020-09985-4DOI Listing
March 2020

Measuring clinically relevant improvement after lumbar spine surgery: is it time for something new?

Spine J 2020 06 28;20(6):847-856. Epub 2020 Jan 28.

Department of Orthopedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1215 21st Ave South, Medical Center East, South Tower, Suite 4200, Nashville, TN 37232, USA; Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, 2201 Children's Way, Suite 1318, Nashville, TN 37212, USA; Osher Center for Integrative Medicine, Vanderbilt University Medical Center, 3401 West End Avenue, Suite 380, Nashville, TN 37203, USA. Electronic address:

Background Context: Minimum clinically important difference (MCID) for patient-reported outcome measures is commonly used to assess clinical improvement. However, recent literature suggests that an absolute point-change may not be an effective or reliable marker of response to treatment for patients with low or high baseline patient-reported outcome scores. The multitude of established MCIDs also makes it difficult to compare outcomes across studies and different spine surgery procedures.

Purpose: To determine whether a 30% reduction from baseline in disability and pain is a valid method for determining clinical improvement after lumbar spine surgery.

Study Design: Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.

Patient Sample: There were 23,280 participants undergoing elective lumbar spine surgery for degenerative disease who completed a baseline and follow-up assessment at 12 months.

Outcome Measures: Patient-reported disability (Oswestry Disability Index [ODI]), back and leg pain (11-point Numeric Rating Scale [NRS]), and satisfaction (NASS scale).

Methods: Patients completed baseline and a 12-month postoperative assessment to evaluate the outcomes of disability, pain, and satisfaction. The change in ODI and NRS pain scores was categorized as met (≥30%) or not met (<30%) percent reduction MCID. The 30% reduction from baseline was compared with a wide range of well-established absolute point-change MCID values. The relationship between 30% reduction and absolute change values and satisfaction were primarily compared using receiver operating characteristic (ROC) curves, area under the curve (AUROC), and logistic regression analyses. Analyses were conducted for overall scores and for disability and pain severity categories and by surgical procedure.

Results: Thirty percent reduction in ODI and back and leg pain predicted satisfaction with more accuracy than absolute point-change values for the total population and across all procedure categories (p<.001), except for when compared with the highest absolute point-change threshold for leg pain (3.5-point reduction). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 21.8%) and bed-bound disability (ODI 81%-100%: 13.9%) categories. For pain, there was a 3.4%-12.4% and 1.3%-9.8% AUROC difference for no/mild back and leg pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.

Conclusions: A 30% reduction MCID either outperformed or was similar to absolute point-change MCID values. Results indicate that a 30% reduction (baseline to 12 months after surgery) in disability and pain is a valid method for determining clinically relevant improvement in a broad spine surgery population. Furthermore, a 30% reduction was most accurate for patients in the lowest and highest disability and lowest pain severity categories. A 30% reduction MCID allows for a standard cut-off for disability and pain that can be used to compare outcomes across various spine surgery procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2020.01.010DOI Listing
June 2020

Adding 3-month patient data improves prognostic models of 12-month disability, pain, and satisfaction after specific lumbar spine surgical procedures: development and validation of a prediction model.

Spine J 2020 04 19;20(4):600-613. Epub 2019 Dec 19.

Department of Orthopaedic Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, Nashville, TN, USA. Electronic address:

Background Context: Prognostic models including early postoperative variables may provide optimal estimates of long-term outcomes and help direct postoperative care.

Purpose: To develop and validate prognostic models for 12-month disability, back pain, leg pain, and satisfaction among patients undergoing microdiscectomy, laminectomy, and laminectomy with fusion for degenerative lumbar conditions.

Study Design/setting: Retrospective cohort study using the Quality Outcomes Database.

Patient Sample: Patients receiving elective lumbar spine surgery due to degenerative spine conditions.

Outcome Measures: Oswestry Disability Index, pain numerical rating scale, and NASS Patient Satisfaction Index.

Methods: Prognostic models were developed using proportional odds ordinal logistic regression using patient characteristics and baseline and 3-month patient-reported outcome scores. Models were fit for each outcome stratified by type of surgical procedure. Adjusted odds ratio and 95% confidence intervals were reported for all predictors by procedure. Models were internally validated using bootstrap resampling. Discrimination was reported as the c-index and calibration was presented using the calibration slope. We compared the performance of models with and without 3-month patient-reported variables. This research was supported by the Foundation for Physical Therapy's Center of Excellence in Physical Therapy Health Services, and Health Policy Research and Training grant.

Results: The sample consisted of 5,840 patients receiving a microdiscectomy (n=2,085), laminectomy (n=1,837), or laminectomy with fusion (n=1,918). The 3-month Oswestry score was the strongest and most consistent predictor associated with 12-month outcomes. All prognostic models performed well with overfitting-corrected c-index values ranging from 0.718 to 0.795 and all optimism corrected calibration slopes over 0.92. The increase in c-index values ranged from 0.09 to 0.21 when adding 3-month patient-reported outcome scores.

Conclusions: Models had good discrimination and were well calibrated for estimating 12-month disability, back pain, leg pain, and satisfaction. Patient-reported outcomes at 3 months after surgery, especially 3-month Oswestry scores, improved the 12-month performance of all prognostic models beyond using only baseline variables.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2019.12.010DOI Listing
April 2020

Viscosine as a Potent and Safe Antipyretic Agent Evaluated by Yeast-Induced Pyrexia Model and Molecular Docking Studies.

ACS Omega 2019 Sep 21;4(10):14188-14192. Epub 2019 Aug 21.

Institute of Biological Sciences, Faculty of Science, University of Malaya, 50603 Kuala Lumpur, Malaysia.

The antipyretic potential of viscosine, a natural product isolated from the medicinal plant , was investigated using yeast-induced pyrexia rat model, and its structure-activity relationship was investigated through molecular docking analyses with the target enzymes cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), and microsomal prostaglandin E synthase-1 (mPGES-1). The in vivo antipyretic experiments showed a progressive dose-dependent reduction in body temperatures of the hyperthermic test animals when injected with viscosine. Comparison of docking analyses with target enzymes showed strongest bonding interactions (binding energy -17.34 kcal/mol) of viscosine with the active-site pocket of mPGES-1. These findings suggest that viscosine shows antipyretic properties by reducing the concentration of prostaglandin E in brain through its mPGES-1 inhibitory action and make it a potential lead compound for developing effective and safer antipyretic drugs for treating fever and related pathological conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1021/acsomega.9b01041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732982PMC
September 2019

Predictors of patient satisfaction following 1- or 2-level anterior cervical discectomy and fusion: insights from the Quality Outcomes Database.

J Neurosurg Spine 2019 Aug 30:1-9. Epub 2019 Aug 30.

3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and.

Objective: Patient satisfaction with treatment outcome is gaining an increasingly important role in assessing the value of surgical spine care delivery. Nationwide data evaluating the predictors of patient satisfaction in elective cervical spine surgery are lacking. The authors sought to decipher the impacts of the patient, surgical practice, and surgeon on satisfaction with outcome following anterior cervical discectomy and fusion (ACDF).

Methods: The authors queried the Quality Outcomes Database for patients undergoing 1- to 2-level ACDF for degenerative spine disease since 2013. Patient satisfaction with the surgical outcome as measured by the North American Spine Society (NASS) scale comprised the primary outcome. A multivariable proportional odds logistic regression model was constructed with adjustments for baseline patient characteristics and surgical practice and surgeon characteristics as fixed effects.

Results: A total of 4148 patients (median age 54 years, 48% males) with complete 12-month NASS satisfaction data were analyzed. Sixty-seven percent of patients answered that "surgery met their expectations" (n = 2803), while 20% reported that they "did not improve as much as they had hoped but they would undergo the same operation for the same results" (n = 836). After adjusting for a multitude of patient-specific as well as hospital- and surgeon-related factors, the authors found baseline Neck Disability Index (NDI) score, US geographic region of hospital, patient race, insurance status, symptom duration, and Workers' compensation status to be the most important predictors of patient satisfaction. The discriminative ability of the model was satisfactory (c-index 0.66, overfitting-corrected estimate 0.64).

Conclusions: The authors' results found baseline NDI score, patient race, insurance status, symptom duration, and Workers' compensation status as well as the geographic region of the hospital to be the most important predictors of long-term patient satisfaction after a 1- to 2-level ACDF. The findings of the present analysis further reinforce the role of preoperative discussion with patients on setting treatment goals and realistic expectations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.6.SPINE19426DOI Listing
August 2019

Impact of occupational characteristics on return to work for employed patients after elective lumbar spine surgery.

Spine J 2019 12 20;19(12):1969-1976. Epub 2019 Aug 20.

Department of Orthopedic Surgery, Vanderbilt University School of Medicine, South Tower, Suite 4200, Nashville, TN, USA; Department of Neurological surgery, Vanderbilt University School of Medicine, South Tower, Suite 4200, Nashville, TN, USA; Orthopedics of Steamboat Springs, Steamboat Springs, CO, USA. Electronic address:

Background Context: Low back pain has an immense impact on the US economy. A significant number of patients undergo surgical management in order to regain meaningful functionality in daily life and in the workplace. Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large.

Purpose: In this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery.

Study Design/setting: This study retrospectively analyzes prospectively collected data from the lumbar module of national spine registry, the Quality Outcomes Database (QOD).

Patient Sample: The lumbar module of QOD includes patients undergoing lumbar surgery for primary stenosis, disc herniation, spondylolisthesis (Grade I) and symptomatic mechanical disc collapse or revision surgery for recurrent same-level disc herniation, pseudarthrosis, and adjacent segment disease. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain.

Outcome Measures: The outcome of interest for this study was the return to work 12-month after surgery.

Methods: The lumbar module of QOD was queried for patients who were employed at the time of surgery. Good outcomes were defined as patients who had no adverse events (readmissions/complications), had achieved 30% improvement in Oswestry disability index (ODI) and were satisfied (NASS satisfaction) at 3-month post-surgery. Distinct multivariable logistic regression models were fitted with 12-month RTW as outcome for a. overall population and b. the patients with good outcomes. The variables included in the models were age, gender, race, insurance type, education level, occupation type, currently working/on-leave status, workers' compensation, ambulatory status, smoking status, anxiety, depression, symptom duration, number of spinal levels, diabetes, motor deficit, and preoperative back-pain, leg-pain and ODI score.

Results: Of the total 12,435 patients, 10,604 (85.3%) had successful RTW at 1-year postsurgery. Among patients who achieved good surgical outcomes, 605 (7%) failed to RTW. For both the overall and subgroup analysis, older patients had lower odds of RTW. Females had lower odds of RTW compared with males and patients with higher back pain and baseline ODI had lower odds of RTW. Patients with longer duration of symptoms, more physically demanding occupations, worker's compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW independent of their good surgical outcomes.

Conclusions: This study identifies certain risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational; hence, involving the patient's employer in treatment process and setting realistic expectations may help improve the patients' work-related functionality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2019.08.007DOI Listing
December 2019

Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy.

Neurosurgery 2020 06;86(6):763-768

Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.

Background: Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored.

Objective: To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM.

Methods: This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest.

Results: A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in.

Conclusion: Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz325DOI Listing
June 2020

Orthopedic versus Neurosurgery-Understanding 90-Day Complications and Costs in Patients Undergoing Elective 1-Level to 2-Level Posterior Lumbar Fusions by Different Specialties.

World Neurosurg 2019 Nov 12;131:e447-e453. Epub 2019 Aug 12.

Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA. Electronic address:

Background: Lumbar fusions are routinely performed by either orthopedic or neurologic spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs. neurosurgery) influences outcomes.

Methods: The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing elective 1-to-2 level posterior lumbar fusions (PLFs) with active enrollment up to 90 days after procedure. Ninety-day complication rates were calculated for the 2 specialties. The surgical and 90-day resource utilization costs for the 2 groups were compared, by studying average reimbursements for acute-care and post-acute-care categories. Ninety-day complications and costs were compared using multivariable logistic and linear regression analyses.

Results: A total of 10,509 patients (5523 orthopedic and 4986 neurosurgery) underwent an elective 1-to-2 level PLF during the period. With the exception of a significantly lower odds of wound complications (odds ratio, 0.81) and a higher odds of dural tears (odds ratio, 1.29) in elective PLFs performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the 2 groups. Total 90-day costs were also similar between orthopedic surgeons and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery versus neurosurgery ($1202 vs. $1372; P < 0.001).

Conclusions: It seems that a provider's specialty does not largely influence 90-day surgical outcomes and costs after elective PLFs. The results of the study promote the formation and acceptance of dual training pathways for entry into spine surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.07.194DOI Listing
November 2019

Does Neck Disability Index Correlate With 12-Month Satisfaction After Elective Surgery for Cervical Radiculopathy? Results From a National Spine Registry.

Neurosurgery 2020 05;86(5):736-741

Department of Orthopaedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.

Background: Modern healthcare reforms focus on identifying and measuring the quality and value of care. Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients' quality of life.

Objective: To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR.

Methods: The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients' demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction.

Results: The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score.

Conclusion: Our study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz231DOI Listing
May 2020

Factors Associated With Return-to-Work Following Cervical Spine Surgery in Non-Worker's Compensation Setting.

Spine (Phila Pa 1976) 2019 Jul;44(13):903-907

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Study Design: This study retrospectively analyzes prospectively collected data.

Objective: Here in this study we aim to determine the factors which impact a patient's ability to return to work (RTW) in the setting of cervical spine surgery in patients without worker's compensation status.

Summary Of Background Data: Surgical management of degenerative cervical disease has proven cost-effectiveness and shown significant improvement in quality of life. However, the ability to RTW is an important clinical outcome for preoperatively employed patients.

Methods: All adult patients undergoing elective surgery for cervical degenerative disease at our institution are enrolled in a prospective, web-based registry. A multivariable Cox proportional hazards regression model was built for time to RTW. The variables included in the model were age, sex, smoking status, occupation type, number of levels operated on, ASA grade, body mass index, history of diabetes, history of coronary artery disease (CAD), history of chronic obstructive pulmonary disease (COPD), anxiety, depression, myelopathy at presentation, duration of symptoms more than 12 months, diagnosis, type of surgery performed, and preoperative Neck Disability Index, EuroQol Five Dimensions, and Numeric Rating Scale pain scores for neck pain and arm pain scores.

Results: Of the total 324 patients with complete 3-month follow-up data 83% (n = 269) returned to work following surgery. The median time to RTW was 35 days (range, 2-90 d). Patients with a labor-intensive occupation, higher ASA grade, history of CAD, and history of COPD were less likely to RTW. The likelihood of RTW was lower in patients with a diagnosis of disc herniation compared with cervical stenosis, patients undergoing cervical corpectomy compared laminectomy and fusion and patient with longer operative time.

Conclusion: Our study identifies the various factors associated with a lower likelihood of RTW at 3 months after cervical spine surgery in the non-worker's compensation setting. This information provides expectations for the patient and employer when undergoing cervical spine surgery.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000002978DOI Listing
July 2019

Prediction of Oswestry Disability Index (ODI) using PROMIS-29 in a national sample of lumbar spine surgery patients.

Qual Life Res 2019 Oct 6;28(10):2839-2850. Epub 2019 Jun 6.

Department of Orthopaedic Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA.

Purpose: The primary purpose was to examine the measurement properties of the PROMIS-29 to better understand its use in patients undergoing spine surgery. A secondary objective was to calculate a predictive equation between PROMIS-29 and ODI, to allow clinicians and researchers to determine a predicted ODI score based on PROMIS short form scores.

Methods: 719 patients with PROMIS v2.0 and ODI responses were queried from the quality outcomes database. Validity was assessed using coefficient omega, ceiling/floor effects, and confirmatory factor analysis. Multivariable regression predicting ODI scores from PROMIS-29 domains was used to create a predictive equation. Predicted ODI scores were plotted against ODI scores to determine how well PROMIS-29 domains predicted ODI.

Results: Results showed good reliability and validity of PROMIS-29 in patients undergoing lumbar spine surgery: convergent and discriminant validity, low floor/ceiling effects, and unidimensional domains. The conversion equation used 6 PROMIS-29 domains (ODI =  37.847- 1.475*[PF] + 1.842*[PAIN] + 0.557*[SD] - 0.642*[SR] + 0.478*[PI] + 0.295*[DEP]). Correlation between the predicted and actual ODI scores was R = 0.88, R = 0.78, suggesting that the equation predicted ODI scores that are strongly correlated with actual ODI scores.

Conclusions: Good measurement properties support the use of PROMIS-29 in spine surgery patients. Findings suggest accurate ODI scores can be derived from PROMIS-29 domains. Clinicians who want to move from ODI to PROMIS-29 can use this equation to obtain estimated ODI scores when only collecting PROMIS-29. These results support the idea that PROMIS-29 domains have the potential to replace disease-specific traditional PROMs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11136-019-02223-8DOI Listing
October 2019

Diffuse Low-Grade Glioma - Changing Concepts in Diagnosis and Management: A Review.

Asian J Neurosurg 2019 Apr-Jun;14(2):356-363

Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan.

Though diffuse low-grade gliomas (dLGGs) represent only 15% of gliomas, they have been receiving increasing attention in the past decade. Significant advances in knowledge of the natural history and clinical diversity have been documented, and an improved pathological classification of gliomas that integrates histological features with molecular markers has been issued by the WHO. Advances in the radiological assessment of dLGG, particularly new magnetic resonance imaging scanning sequences, allow improved diagnostic and prognostic information. The management paradigms are evolving from "wait and watch" of the past to more active interventional therapy to obviate the risk of malignant transformation. New surgical technologies allow more aggressive surgical resections with a reduction of morbidity. Many reports suggest the association of gross total resection with longer overall survival and progression-free survival in addition to better seizure control. The literature also shows the use of chemotherapeutics and radiation therapy as important adjuncts to surgery. The goals of management have has been increasing survival with increasing stress on quality of life. Our review highlights the recent advances in the molecular diagnosis and management of dLGG with trends toward multidisciplinary and multimodality management of dLGG with an aim to surgically resect the primary disease, followed by chemoradiation in cases of progressive or recurrent disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ajns.AJNS_24_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516028PMC
May 2019

Anti-nociceptive and Anti-inflammatory Activities of Asparacosin A Involve Selective Cyclooxygenase 2 and Inflammatory Cytokines Inhibition: An , and Approach.

Front Immunol 2019 26;10:581. Epub 2019 Mar 26.

Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Oman.

Triterpenes possess anti-inflammatory and anti-nociceptive effects. In this study anti-inflammatory activities of Asparacosin A were evaluated' using cyclooxygenases 1 and 2 (COX-1/2) inhibition assays. Moreover, anti-nociceptive activities were assessed by carrageenan-induced paw edema test, xylene-induced ear edema tests, and acetic acid-induced writhing and formalin tests. Additionally molecular docking was conducted to elucidate the binding mechanism of the compound and to correlate the findings with the data. Oral administration of Asparacosin A at the doses of 10, 20, and 40 mg/kg induced significant anti-inflammatory effects ( < 0.05, < 0.01, and < 0.001) in a dose-dependent manner in both models. Asparacosin A also inhibited the human recombinant COX-2 enzyme and caused a dose-dependent decrease in the levels of TNF-α, IL-1β, and PGE2 in the carrageenan-induced paws. Moreover, Asparacosin A displayed significant anti-nociceptive effects ( < 0.05, < 0.01, < 0.001) at the doses of 10, 20, and 40 mg/kg in acetic-acid induced writhing test. However, in formalin test, Asparacosin A (10-40 mg/kg, p.o) produced anti-nociceptive effects only in the late phase, similar to the effect observed with the reference drug celecoxib (50 mg/kg, p.o). Molecular docking was carried out on both COX-1 and COX-2 structures which revealed that Asparacosin A targets allosteric binding site similar to the binding mode of the selective COX inhibitor. In conclusion, Asparacosin A exhibits anti-inflammatory and peripheral anti-nociceptive activities which are likely mediated inhibition of COX-2 enzyme and inflammatory cytokines. Furthermore, Asparacosin A can serve as a model to obtain new and more selective potent anti-inflammatory and anti-nociceptive drugs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fimmu.2019.00581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443962PMC
July 2020

Utility of Anxiety/Depression Domain of EQ-5D to Define Psychological Distress in Spine Surgery.

World Neurosurg 2019 Jun 14;126:e1075-e1080. Epub 2019 Mar 14.

Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. Electronic address:

Background: Prospective patient-reported outcomes (PROs) registries are central to emerging evidence-driven reform models. These registries entail significant operator and responder burden to capture PROs data. It is important to limit the number of PROs administered. We sought to determine whether the anxiety/depression domain of EQ-5D could be used to define preoperative psychological distress in patients undergoing elective spine surgery.

Methods: Patients undergoing elective spine surgery and enrolled into a prospective registry were analyzed. The 12-Item Short-Form Health Survey Mental Component Summary, Zung depression scale, Modified Somatic Perception Questionnaire, and EQ-5D were completed. The anxiety/depression domain of EQ-5D was used to define psychological distress; responses were captured as 1) not anxious or depressed, 2) moderately anxious or depressed, or 3) extremely anxious or depressed. Univariate correlation and proportional odds logistic regression analyses were conducted.

Results: Of 2470 included patients undergoing elective spine surgery, 45% (n = 1109) reported no psychological distress, 47% (n = 1168) reported moderate psychological distress, and 8% (n = 193) reported extreme psychological distress on EQ-5D. Psychological distress on EQ-5D had positive correlation with Zung depression scale (P < 0.0001, r = 0.620) and Modified Somatic Perception Questionnaire (P < 0.0001, r = 0.450) and negative correlation with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, r = -0.662). In proportional odds logistic regression models, EQ-5D psychological distress had significant correlations with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, C-index = 0.831), Zung depression scale (P < 0.0001, C-index = 0.802), and Modified Somatic Perception Questionnaire (P < 0.0001, C-index = 0.711).

Conclusions: The anxiety/depression domain of EQ-5D could be used to categorize preoperative psychological distress. Spine registries could use this information to potentially limit the number of validated PROs administered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.02.211DOI Listing
June 2019

Metabolic and Endocrine Disorders in Pseudarthrosis.

Clin Spine Surg 2019 06;32(5):E252-E257

Departments of Orthopaedics and Rehabilitation.

Study Design: Retrospective Cohort.

Objective: Establish 1-year patient-reported outcomes after spine surgery for symptomatic pseudarthrosis compared with other indications. In the subgroup of pseudarthrosis patients, describe preexisting metabolic and endocrine-related disorders, and identify any new diagnoses or treatments initiated by an endocrine specialist.

Summary Of Background: Despite surgical advances in recent decades, pseudarthrosis remains among the most common complications and indications for revision after fusion spine surgery. A better understanding of the outcomes after revision surgery for pseudarthrosis and risk factors for pseudarthrosis are needed.

Methods: Using data from our institutional spine registry, we retrospectively reviewed patients undergoing elective spine surgery between October 2010 and November 2016. Patients were stratified by surgical indication (pseudarthrosis vs. not pseudarthrosis), and 1-year outcomes for satisfaction, disability, quality of life, and pain were compared. In a descriptive subgroup analysis of pseudarthrosis patients, we identified preexisting endocrine-related disorders, frequency of endocrinology referral, and any new diagnoses and treatments initiated through the referral.

Results: Of 2721 patients included, 169 patients underwent surgery for pseudarthrosis. No significant difference was found in 1-year satisfaction between pseudarthrosis and nonpseudarthrosis groups (77.5% vs. 83.6%, respectively). A preexisting endocrine-related disorder was identified in 82% of pseudarthrosis patients. Endocrinology referral resulted in a new diagnosis or treatment modification in 58 of 59 patients referred. The most common diagnoses identified included osteoporosis, vitamin D deficiency, diabetes, hyperlipidemia, sex-hormone deficiency, and hypothyroidism. The most common treatments initiated through endocrinology were anabolic agents (teriparatide and abaloparatide), calcium, and vitamin D supplementation.

Conclusions: Patients undergoing revision spine surgery for pseudarthrosis had similar 1-year satisfaction rates to other surgical indications. In conjunction with a bone metabolic specialist, our descriptive analysis of endocrine-related disorders among patients with a pseudarthrosis can guide protocols for workup, indications for endocrine referral, and guide prospective studies in this field.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BSD.0000000000000788DOI Listing
June 2019

Comparing different chronic preoperative opioid use definitions on outcomes after spine surgery.

Spine J 2019 06 8;19(6):984-994. Epub 2019 Jan 8.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

Background Context: No consensus exists for defining chronic preoperative opioid use. Most spine studies rely solely on opioid duration to stratify patients into preoperative risk categories.

Purpose: The purpose of this study is to compare established opioid definitions that contain both duration and dosage to opioid models that rely solely on duration, including the CDC Guideline for Prescribing Opioids for Chronic Pain, in patients undergoing spine surgery.

Study Design: This was a retrospective cohort study that used opioid data from the Tennessee Controlled Substance Monitoring Database and prospective clinical data from a single-center academic spine registry.

Patient Sample: The study cohort consisted of 2,373 patients who underwent elective spine surgery for degenerative conditions between January 2011 and February 2017 and who completed a follow-up assessment at 12 months after surgery.

Outcome Measures: Postoperative opioid use and patient-reported satisfaction (NASS Satisfaction Scale), disability (Oswestry/Neck Disability Index), and pain (Numeric Rating Scale) at 12 month follow-up.

Methods: Six different chronic preoperative opioid use variables were created based on the number of times a prescription was filled and/or daily morphine milligram equivalent for the one year before surgery. These variables defined chronic opioid use as 1) most days for > 3 months (CDC), 2) continuous use for ≥ 6 months (Schoenfeld), 3) >4,500 mg for at least 9 months (Svendsen wide), 4) >9,000 mg for 12 months (Svendsen intermediary), 5) >18,000 mg for 12 months (Svendsen strict), 6) low-dose chronic (1-36 mg for >91 days), medium-dose chronic (36-120 mg for >91 days), and high-dose chronic (>120 mg for >91 days) (Edlund). Multivariable regression models yielding C-index and R values were used to compare chronic preoperative opioid use definitions by postoperative outcomes, adjusting for type of surgery.

Results: Chronic preoperative opioid use was reported in 470 to 725 (19.8% to 30.6%) patients, depending on definition. The Edlund definition, accounting for duration and dosage, had the highest predictive ability for postoperative opioid use (77.5%), followed by Schoenfeld (75.7%), CDC (72.6%), and Svendsen (59.9% to 72.5%) definitions. A combined Edlund and Schoenfeld duration and dosage definition in post-hoc analysis, that included 3 and 6 month duration cut-offs, performed the best overall with a C-index of 78.4%. Both Edlund and Schoenfeld definitions explained similar amounts of variance in satisfaction, disability, and pain (4.2% to 8.5%). Svendsen and CDC definitions demonstrated poorer performance for patient-reported outcomes (1.4% to 7.2%).

Conclusions: The Edlund definition is recommended for identifying patients at highest risk for postoperative opioid use. When opioid dosage is unavailable, the Schoenfeld definition is a reasonable choice with similar predictive ability. For patient-reported outcomes, either the Edlund or Schoenfeld definition is recommended. Future work should consider combing dosage and duration, with 3 and 6 month cutoffs, into chronic opioid use definitions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2018.12.014DOI Listing
June 2019

Preoperative Opioids and 1-year Patient-reported Outcomes After Spine Surgery.

Spine (Phila Pa 1976) 2019 Jun;44(12):887-895

Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN.

Study Design: Longitudinal Cohort Study.

Objective: Determine 1-year patient-reported outcomes associated with preoperative chronic opioid therapy and high-preoperative opioid dosages in patients undergoing elective spine surgery.

Summary Of Background Data: Back pain is the most disabling condition worldwide and over half of patients presenting for spine surgery report using opioids. Preoperative dosage has been correlated with poor outcomes, but published studies have not assessed the relationship of both preoperative chronic opioids and opioid dosage with patient-reported outcomes.

Methods: For patients undergoing elective spine surgery between 2010 and 2017, our prospective institutional spine registry data was linked to opioid prescription data collected from our state's Prescription Drug Monitoring Program to analyze outcomes associated with preoperative chronic opioid therapy and high-preoperative opioid dosage, while adjusting for confounders through multivariable regression analyses. Outcomes included 1-year meaningful improvements in pain, function, and quality of life. Additional outcomes included 1-year satisfaction, return to work, 90-day complications, and postoperative chronic opioid use.

Results: Of 2128 patients included, preoperative chronic opioid therapy was identified in 21% and was associated with significantly higher odds (adjusted odds ratio [95% confidence interval]) of not achieving meaningful improvements at 1-year in extremity pain (aOR:1.5 [1.2-2]), axial pain (aOR:1.7 [1.4-2.2]), function (aOR:1.7 [1.4-2.2]), and quality of life (aOR:1.4 [1.2-1.9]); dissatisfaction (aOR:1.7 [1.3-2.2]); 90-day complications (aOR:2.9 [1.7-4.9]); and postoperative chronic opioid use (aOR:15 [11.4-19.7]). High-preoperative opioid dosage was only associated with postoperative chronic opioid use (aOR:4.9 [3-7.9]).

Conclusion: Patients treated with chronic opioids prior to spine surgery are significantly less likely to achieve meaningful improvements at 1-year in pain, function, and quality of life; and less likely to be satisfied at 1-year with higher odds of 90-day complications, regardless of dosage. Both preoperative chronic opioid therapy and high-preoperative dosage are independently associated with postoperative chronic opioid use.

Level Of Evidence: 2.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000002964DOI Listing
June 2019

Comparison of 3 Days Amoxicillin Versus 5 Days Co-Trimoxazole for Treatment of Fast-breathing Pneumonia by Community Health Workers in Children Aged 2-59 Months in Pakistan: A Cluster-randomized Trial.

Clin Infect Dis 2019 07;69(3):397-404

Independent Consultant, Geneva, Switzerland.

Background: Globally, most deaths due to childhood pneumonia occur at the community level. Some countries are still using oral co-trimoxazole, despite a World Health Organization recommendation of oral amoxicillin for the treatment of fast-breathing pneumonia in children at the community level.

Methods: We conducted an unblinded, cluster-randomized, controlled-equivalency trial in Haripur District, Pakistan. Children 2-59 months of age with fast-breathing pneumonia were treated with oral amoxicillin suspension (50 mg/kg/day) for 3 days in 14 intervention clusters and oral co-trimoxazole suspension (8 mg trimethoprim/kg and 40 mg sulfamethoxazole/kg/day) for 5 days in 14 control clusters by lady health workers (LHW). The primary outcome was treatment failure by day 4 for intervention clusters and by day 6 for control clusters. The analysis was per protocol.

Results: Out of the 15 749 cases enrolled in the study, 9153 cases in intervention and 6509 cases in control clusters were included in the analysis. Treatment failure rates were 3.6% (326) in intervention clusters and 9.1% (592) in control clusters. After adjusting for clustering, the risk of treatment failure was lower in intervention clusters (risk difference [RD] -5.5%, 95% confidence interval [CI] -7.4--3.7%) than in control clusters. Children with incomplete adherence had a small increase in treatment failure versus those with complete adherence (RD 2.9%, 95% CI 1.6-4.1%). No deaths or serious adverse events occurred.

Conclusions: A 3-day course of oral amoxicillin, administered by LHWs, is an effective and safe treatment for fast-breathing pneumonia in children 2-59 months of age. A shorter course of amoxicillin improves adherence to therapy, is low in cost, and puts less pressure on antimicrobial resistance.

Clinical Trials Registration: ISRCTN10618300.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/cid/ciy918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637273PMC
July 2019