Analysis of seven prognostic scores in patients with surgically treated epidural metastatic spine disease.

BACKGROUND: Prognostic scores have been proposed to guide the treatment of patients with metastatic spine disease (MSD), but their accuracy and usefulness are controversial. The aim of this study was to evaluate seven such prognostic scoring systems. The following prognostic scores were compared: Tomita, Van der Linden (VDL), Bauer modified (BM), Oswestry Spinal Risk Index (OSRI), Tokuhashi original (T90), Tokuhashi revised (TR05), and modified Tokuhashi revised (TR17). METHODS: We retrospectively reviewed all our patients who underwent surgery for spinal metastases, February 2008-January 2015. We classified all 223 patients into the predicted survival-time categories of each of the 7 scoring systems and then tallied how often this was correct vis-à-vis the actual survival time. Accuracy was also assessed using receiver operating characteristic (ROC) analysis at 1, 3, and 12 months. RESULTS: The median (95% CI) survival of the 223 patients was 13.6 (7.9-19.3) months. A groupwise ROC analysis showed sufficient accuracy for 3-month survival only for TR17 (area under the curve [AUC] 0.71) and for 1-year survival for T90 (AUC 0.73), TR05 (AUC 0.76), TR17 (AUC 0.76), Tomita (AUC 0.77), and OSRI (AUC 0.71). A pointwise ROC score analysis showed poor prognostic ability for short-term survival (1 and 3 months) with sufficient accuracy for T90 (AUC 0.71), TR05 (AUC 0.71), TR17 (AUC 0.71), and the Tomita score (AUC 0.77) for 1-year survival. CONCLUSION: The TR17 was the only prognostic system with acceptable performance here. More sophisticated assessment tools are required to keep up with present and future changes in tumor diagnostics and treatment.

Quality of life and functional outcomes after surgery for spinal metastases: Results of a cohort study.

BACKGROUND: Spinal metastases are being diagnosed more frequently because of increasing life expectancies and advances in the diagnosis and therapy of primary tumours. OBJECTIVE: This aim of this study was to assess the quality of life (QoL) and functional outcomes after surgical intervention for spinal metastases in a large cohort. METHODS: A single-centre, prospective, observational study was conducted from June 2016 to February 2018. Patients treated surgically for spinal metastasis were included. Primary endpoints were the Core Outcome Measure Index (COMI), Oswestry Disability Index (ODI), and QoL questionnaire (EuroQoL-5D) scores recorded preoperatively, 6 weeks postoperatively, and 3, 6, and 12 months postoperatively. RESULTS: Ninety-two patients (mean age, 62.7 ± 12.8 years) were included. The most frequent neoplasms were multiple myeloma (n= 18; 19.6%), lung cancer (n= 16; 17.4%), prostate cancer (n= 14; 15.2%), and breast cancer (n= 11; 12.0%). During the observation period, 44.6% of patients died. The COMI score improved significantly from preoperatively (mean, 7.1; 95% CI, 6.6-7.6) to 3 months (mean, 5.5; 95% CI, 4.8-6.2; p= 0.01) and 12 months (mean, 4.6; 95% CI, 3.7-5.5; p= 0.001) postoperatively. The ODI showed a significant improvement from preoperatively (mean, 52.9; 95% CI, 48.5-57.4) to 6 weeks (mean, 43.4; 95% CI, 37.1-49.6; p= 0.03), 3 months (mean, 37.0; 95% CI, 31.0-42.9) 6 months mean, 40.5; 95% CI, 34.2-46.8; p= 0.01), and 12 months (mean, 31.9; 95% CI, 24.8-39.1; p= 0.005) postoperatively. Improvements in the COMI at 6 weeks (p= 0.05), and 6 months (p= 0.05) postoperatively were not statistically significant. QoL improved from preoperatively to 6 weeks (mean, 0.48; 95% CI, 0.38-0.59; p= 0.002), 3 months (mean, 0.50; 95% CI, 0.38-0.61; p= 0.009), and 12 months (mean, 0.61; 95% CI, 0.51-0.71; p= 0.001) postoperatively. After 6 months, the difference was not significant (p= 0.08). CONCLUSION: Short-term and long-term improvements in functional outcomes and QoL were observed after surgical treatment of spinal metastases. Surgery is a good option for patients with an estimated life expectancy of more than 3 months.

The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures - is refixation of the lesser trochanter worth the effort?

BACKGROUND: Instability of osteoporotic pertrochanteric fractures is defined by loss of medial/lateral cortical integrity with the posteromedial fragment including the lesser trochanter being pivotal for load distribution. Literature addressing the importance of lesser trochanter refixation is scarce. To clarify the effect of lesser trochanter refixation on primary stability in these fractures, following study was performed. METHODS: 21 femora were match-paired in 3 groups and osteotomized, creating pertrochanteric fractures (AO-31A2). Group 1 was stabilized with a proximal femoral nail, group 2 with a dynamic hip screw and group 3 with an augmented proximal femoral nail. Each femur was tested non-destructively at 200 and 400N with and without refixation of the lesser trochanter (configuration A/B). The overall stiffness and movement of the femoral neck was recorded. FINDINGS: At 200N, refixation reduced movement of the femoral neck and increased overall stiffness significantly in group 1 and 3. At 400N, refixation decreased movement of the femoral neck not significantly in all groups (1=38%, 2=36%, 3=43%). The augmented proximal femoral nail after refixation showed the highest stability of all constructs. INTERPRETATION: Refixation of the lesser trochanter may increase the primary stability of pertrochanteric fracture osteosynthesis as all groups showed a higher primary stability. Therefore, refixation should be considered in unstable, osteoporotic fractures. If additional trauma through refixation appears inappropriate, cement augmentation should be performed as it showed only 9% less stability than a non-augmented proximal femoral nail with refixation of the lesser trochanter.

Pelvic X-ray misses out on detecting sacral fractures in the elderly - Importance of CT imaging in blunt pelvic trauma.

Patients aged 75 years and older with blunt pelvic trauma are frequently seen in the ER. The standard diagnostic tool in these patients is the plain a.p.-radiograph of the pelvis. Especially lesions of the posterior pelvic ring are often missed due to e.g. bowel gas projection and enteric overlay. With a retrospective study covering these patients over a 3 year period in our level I trauma centre, we were able to evaluate the rate of missed injuries in the a.p.-radiograph whenever a corresponding CT scan was performed. Age, gender, and accompanying fractures of the pelvic ring were recorded. The intrinsic test characteristics and the performance in the population were calculated according to standard formulas. Thus, 233 consecutive patients with blunt pelvic trauma with both conventional radiographic examination and computed tomography (CT) were included. Thereof, 56 (23%) showed a sacral fracture in the CT scan. Of 233 pelvic X-ray-images taken, 227 showed no sacral fracture. 51 (21.7%) of these were false negative, yielding a sensitivity of just 10.5%. Average age of patients with sacral fractures was 85.1±6.1 years, with 88% being female. Sacral fractures were often accompanied by lesions of the anterior pelvic ring with pubic bone fractures in 75% of sacrum fracture cases. Second most concomitant fractures are found at the acetabulum (23.3%). Plain radiographic imaging is especially likely to miss out fractures of the posterior pelvic ring, which nowadays can be of therapeutic consequence. Besides the physicians experience in the ED, profound knowledge of insensitivity of plain radiographs in finding posterior pelvic ring lesions is crucial for a reliable diagnostic routine. Since the high mortality caused by prolonged immobilisation due to pelvic ring injuries, all fractures should be identified. We therefore provide a diagnostic algorithm for blunt pelvic trauma in the elderly.

Soil biochemical properties and microbial resilience in agroforestry systems: effects on wheat growth under controlled drought and flooding conditions.

Agroforestry is increasingly viewed as an effective means of maintaining or even increasing crop and tree productivity under climate change while promoting other ecosystem functions and services. This study focused on soil biochemical properties and resilience following disturbance within agroforestry and conventional agricultural systems and aimed to determine whether soil differences in terms of these biochemical properties and resilience would subsequently affect crop productivity under extreme soil water conditions. Two research sites that had been established on agricultural land were selected for this study. The first site included an 18-year-old windbreak, while the second site consisted in an 8-year-old tree-based intercropping system. In each site, soil samples were used for the determination of soil nutrient availability, microbial dynamics and microbial resilience to different wetting-drying perturbations and for a greenhouse pot experiment with wheat. Drying and flooding were selected as water stress treatments and compared to a control. These treatments were initiated at the beginning of the wheat anthesis period and maintained over 10 days. Trees contributed to increase soil nutrient pools, as evidenced by the higher extractable-P (both sites), and the higher total N and mineralizable N (tree-based intercropping site) found in the agroforestry compared to the conventional agricultural system. Metabolic quotient (qCO2) was lower in the agroforestry than in the conventional agricultural system, suggesting higher microbial substrate use efficiency in agroforestry systems. Microbial resilience was higher in the agroforestry soils compared to soils from the conventional agricultural system (windbreak site only). At the windbreak site, wheat growing in soils from agroforestry system exhibited higher aboveground biomass and number of grains per spike than in conventional agricultural system soils in the three water stress treatments. At the tree-based intercropping site, higher wheat biomass, grain yield and number of grains per spike were observed in agroforestry than in conventional agricultural system soils, but in the drought treatment only. Drought (windbreak site) and flooding (both sites) treatments significantly reduced wheat yield and 1000-grain weight in both types of system. Relationships between soil biochemical properties and soil microbial resilience or wheat productivity were strongly dependent on site. This study suggests that agroforestry systems may have a positive effect on soil biochemical properties and microbial resilience, which could operate positively on crop productivity and tolerance to severe water stress.

Tree-based intercropping systems increase growth and nutrient status of hybrid poplar: a case study from two Northeastern American experiments.

Tree-based intercropping is considered to be a potentially useful land use system for mitigating negative environmental impacts from intensive agriculture such as nutrient leaching and greenhouse gas emissions. Rapid early growth of trees is critical for rapidly accruing environmental benefits provided by the trees. We tested the hypothesis that intercropping increases the growth and nutrient status of young hybrid poplars (Populus spp.), compared to a harrowing alley treatment (i.e., no intercrop), in two experimental sites (St-Rémi and St-Edouard) in southern Québec, Canada. Three hybrid poplar clones (TD3230, Populus trichocarpa x deltoides; DN3308, P. deltoides x nigra; and NM3729, P. nigra x maximowiczii) were planted at St-Rémi. Clones DN3333 and DN3570 were planted at St-Edouard. At St-Rémi, intercropping comprised a 4-year succession of three crops of soybean (Glycine max (L.) Merr.) and barley (Hordeum vulgare L.). At St-Edouard, intercropping comprised a 3-year succession of buckwheat (Fagopyrum esculentum Moench), winter rye (Secale cereale L.), and winter wheat (Triticum aestivum L.). At St-Rémi, four years after treatment began, leafless aboveground biomass of hybrid poplars in the intercropping treatment was 37% higher compared to that in the harrowing treatment. At St-Edouard, after the third growing season, leafless aboveground biomass of hybrid poplars in the intercropping treatment was significantly higher by 40%. Vector analysis of foliar nutrient concentrations and comparison with critical concentration values showed that N (both sites) and K (St-Edouard) were the most limiting nutrients. Hybrid poplar clones responded similarly to treatments, with no consistent differences in tree growth observed between clones. We conclude that tree-based intercropping systems may offer an effective means of improving the early growth of hybrid poplars planted to provide both environmental services and high-value timber.