Patient navigation: an update on the state of the science.

Although patient navigation was introduced 2 decades ago, there remains a lack of consensus regarding its definition, the necessary qualifications of patient navigators, and its impact on the continuum of cancer care. This review provides an update to the 2008 review by Wells et al on patient navigation. Since then, there has been a significant increase in the number of published studies dealing with cancer patient navigation. The authors of the current review conducted a search by using the keywords "navigation" or "navigator" and "cancer." Thirty-three articles published from November 2007 through July 2010 met the search criteria. Consistent with the prior review, there is building evidence of some degree of efficacy of patient navigation in terms of increasing cancer screening rates. However, there is less recent evidence concerning the benefit of patient navigation with regard to diagnostic follow-up and in the treatment setting, and a paucity of research focusing on patient navigation in cancer survivorship remains. Methodological limitations were noted in many studies, including small sample sizes and a lack of control groups. As patient navigation programs continue to develop across North America and beyond, further research will be required to determine the efficacy of cancer patient navigation across all aspects of the cancer care continuum.

Microstructural alterations of major thalamic nuclei in the chronic pediatric spinal cord injured population.

Background: The brain undergoes reorganization following spinal cord injury (SCI), but little is known about how the thalamus is affected in pediatric SCIs. Purpose: To characterize microstructural alterations in the thalamus after SCI with diffusion tensor imaging (DTI) metrics. Methods: 18 pediatric participants with chronic SCI (8-20 years) were stratified using the American Spinal Injury Association Impairment Scale (AIS) into groups: A, B, and C/D. DTI of the brain used a 3 T Siemens Verio MRI using the parameters: 20 directions, number of averages = 3, b = 1000 s/mm2, voxel size = 1.8 mm × 1.8 mm, slice thickness = 5 mm, TE = 95 ms, TR = 4300 ms, 30 slices, FOV = 230 × 230 mm2, matrix = 128 × 128, acquisition time = 4:45 min. Diffusion data was processed to generate DTI metrics FA, MD, AD, and RD. Data analysis: DTI metrics were acquired by superimposing the AAL3 thalamic atlas onto participant diffusion images registered to MNI152 space. We utilized a multiple Mann-Whitney U-test to compare between AIS groups, considering values of p ≤ 0.05 as significant. Results: FA, AD, RD, and MD significantly differed in thalamic nuclei between AIS groups A vs B and B vs C/D. Significant nuclei include the right ventral anterior, left intralaminar, bilateral lateral pulvinar, and right lateral geniculate. Conclusion: Our findings suggest the presence of microstructural alterations based on SCI severity in pediatric patients. These results are encouraging and warrant further study.

Current use of biologic graft extenders for spinal fusion.

Use of biologic graft extenders in spinal fusions is increasing. Multiple allograft alternatives exist to the "gold-standard" autologous bone grafting. The ideal graft extender is osteoconductive, osteoinductive and has osteogenic potential. While the ideal graft extender has yet to be found, available bone graft extenders have varying degrees of predominantly osteoconductive and osteoinductive properties. This review will provide an update on available graft extenders including bone morphogenetic proteins, mesenchymal stem cells, and demineralized bone matrix. The goal is to provide a review of the current use in spinal fusions and future directions in biologics for spinal fusion.

Translating cancer prevention and control research into the community setting: workforce implications.

A gap exists between cancer prevention research and its translation into community practice. Two strategies to reduce this gap are community-based participatory research (CBPR) and dissemination research. CBPR offers an avenue to engage academic and community partners, thereby providing mechanisms for joint learning and application of knowledge. Dissemination research examines the movement of evidence-based public health and clinical innovations to practice settings. While applying these approaches may reduce the gap between research and practice, the cancer prevention workforce may be inadequate in size, insufficiently trained, lack resources and incentives, or face structural barriers to effectively participate in CBPR and disseminate evidence-based research findings into practice. Information on translating cancer prevention information to communities and workforce implications was obtained from a panel of experts and through a review of the literature on CBPR and dissemination research. The expert panel and literature review identified major barriers to successfully conducting CBPR and dissemination research in community settings. Barriers included inadequate policies; insufficient networking and communication infrastructures; unsupportive research cultures, climates, and mindsets; inadequate researcher and practitioner education; and limited CBPR and dissemination research with adequate study designs. No specific estimates of the cancer prevention workforce were found; however, indirect evidence for a shortfall were identified. We recommend expanding CBPR training for academic and community partners; increasing funding for dissemination research and practice; supporting proven partnerships; and providing strategic coordination for government agencies, research institutions, nongovernmental organizations, and the private sector to foster better dissemination of information and integration of community-based cancer prevention and control programs and practices. Specific challenges and needs that must be addressed to improve the translation of cancer prevention research into community settings were identified.

Validation of the National Institute of Neurological Disorders and Stroke Spinal Cord Injury MRI Common Data Elements Instrument.

BACKGROUND AND PURPOSE: The National Institute of Neurological Disorders and Stroke common data elements initiative was created to provide a consistent method for recording and reporting observations related to neurologic diseases in clinical trials. The purpose of this study is to validate the subset of common data elements related to MR imaging evaluation of acute spinal cord injury. MATERIALS AND METHODS: Thirty-five cervical and thoracic MR imaging studies of patients with acute spinal cord injury were evaluated independently in 2 rounds by 5 expert reviewers. Intra- and interrater agreement were calculated for 17 distinct MR imaging observations related to spinal cord injury. These included ordinal, categoric, and continuous measures related to the length and location of spinal cord hemorrhage and edema as well as spinal canal and cord measurements. Level of agreement was calculated using the interclass correlation coefficient and kappa. RESULTS: The ordinal common data elements spinal cord injury elements for lesion center and rostral or caudal extent of edema or hemorrhage demonstrated agreement ranging from interclass correlation coefficient 0.68 to 0.99. Reproducibility ranged from 0.95 to 1.00. Moderate agreement was observed for absolute length of hemorrhage and edema (0.54 to 0.60) with good reproducibility (0.78 to 0.83). Agreement for the Brain and Spinal Injury Center score showed the lowest interrater agreement with an overall kappa of 0.27 (0.20, 0.34). For 7 of the 8 variables related to spinal cord injury, agreement improved between the first and second evaluation. Continuous diameter measures of the spinal cord and spinal canal using interclass correlation coefficient varied substantially (0.23 to 0.83). CONCLUSIONS: Agreement was more consistent for the ordinal measures of spinal cord injury than continuous measures. Good to excellent agreement on length and location of spinal cord hemorrhage and edema can be achieved with ordinal measures alone.

Congenital absence of the internal carotid artery in a patient with spinal cord injury: case report.

STUDY DESIGN: Case report. OBJECTIVE: To describe a rare case of congenital absence of the internal carotid artery (ICA) in the setting of acute spinal cord injury and review the existing literature. SETTING: Regional Spinal Cord Injury Center of the Delaware Valley, Philadelphia, PA, USA. CLINICAL PRESENTATION: We report on a 47-year-old male who presented as a T2 ASIA A spinal cord injury with a T2-T3 fracture dislocation injury after a 25-feet fall from a tree. Magnetic resonance angiography imaging of the neck carried out as per routine spinal trauma protocol suggested an acute traumatic injury to the carotid artery. Therefore, computed tomographic angiography imaging of the neck was performed, which revealed absence of the left ICA and a diminutive left carotid canal at the skull base, suggesting congenital absence. Follow-up magnetic resonance imaging of the brain to evaluate for acute infarct showed no diffusion restriction contributing to the evidence that this was a congenital anomaly and not traumatic occlusion of the artery. CONCLUSION: Congenital absence or hypoplasia of the ICA is a rare anomaly. It should be considered in the differential in patients who have absent or diminished carotid arteries on radiologic imaging in the setting of trauma.

Exophytic intramedullary meningioma of the cervical spinal cord.

Intramedullary spinal cord neoplasms are relatively uncommon. The most common intramedullary tumors are astrocytomas and ependymomas. Meningiomas can occur as an intradural tumor; however, they are typically in the extramedullary compartment. A 42-year-old male presented with progressive sensory loss in the upper extremities and lower extremity weakness. Pre-operative imaging suggested an intramedullary cervical lesion. To treat the progressive neurological abnormality, surgical resection was planned. At surgery, it was noted that the tumor originated in the cervical spinal cord and extended into the extramedullary region. Histology confirmed the lesion to be a meningioma. This meningioma variant has not previously been described. Spinal meningiomas may occur in locations other than intradural, extramedullary locations, and should be included in the differential diagnosis of intramedullary lesions. Intramedullary meningiomas can be successfully treated with surgery.

Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery!

BACKGROUND: With recent advances in oncologic treatments, there has been an increase in patient survival rates and concurrently an increase in the number of incidence of symptomatic spinal metastases. Because elderly patients are a substantial part of the oncology population, their types of treatment as well as the possible impact their treatment will have on healthcare resources need to be further examined. PURPOSE: We studied whether age has a significant influence on quality of life and survival in surgical interventions for spinal metastases. STUDY DESIGN: We used data from a multicenter prospective study by the Global Spine Tumor Study Group (GSTSG). This GSTSG study involved 1,266 patients who were admitted for surgical treatments of symptomatic spinal metastases at 22 spinal centers from different countries and followed up for 2 years after surgery. PATIENT SAMPLE: There were 1,266 patients recruited between March 2001 and October 2014. OUTCOME MEASURES: Patient demographics were collected along with outcome measures, including European Quality of Life-5 Dimensions (EQ-5D), neurologic functions, complications, and survival rates. METHODS: We realized a multicenter prospective study of 1,266 patients admitted for surgical treatment of symptomatic spinal metastases. They were divided and studied into three different age groups: <70, 70-80, and >80 years. RESULTS: Despite a lack of statistical difference in American Society of Anesthesiologists (ASA) score, Frankel neurologic score, or Karnofsky functional score at presentation, patients >80 years were more likely to undergo emergency surgery and palliative procedures compared with younger patients. Postoperative complications were more common in the oldest age group (33.3% in the >80, 23.9% in the 70-80, and 17.9% for patients <70 years, p=.004). EQ-5D improved in all groups, but survival expectancy was significantly longer in patients <70 years old (p=.02). Furthermore, neurologic recovery after surgery was lower in patients >80 years old. CONCLUSIONS: Surgeons should not be biased against operating elderly patients. Although survival rates and neurologic improvements in the elderly patients are lower than for younger patients, operating the elderly is compounded by the fact that they undergo more emergency and palliative procedures, despite good ASA scores and functional status. Age in itself should not be a determinant of whether to operate or not, and operations should not be avoided in the elderly when indicated.

Characterization of a novel TNF-like ligand and recently described TNF ligand and TNF receptor superfamily genes and their constitutive and inducible expression in hematopoietic and non-hematopoietic cells.

A novel (TL1), a recently described (TL2) TNF-like, and three recently described TNF receptor-like (TR1, TR2, TR3) molecules were identified by searching a cDNA database. TL1 and TL2 are type-II membrane proteins. TR2 and TR3 are type-I membrane proteins whereas TR1 appears to be a secreted protein. TL1, TL2, TR2 and TR3 were expressed in hematopoietic cells, whereas TR1 was not. Northern blots hybridized with the cDNA probes revealed multiple forms of RNA as well as inducible expression of TL1, TL2, TR2 and TR3. TL2 and TR3, in particular, were highly induced in activated CD4+ T cells. Radiation hybrid mapping localized TR1 and TL2 to 8q24 and 3q26, respectively, which are not near any known superfamily members. TL1 was mapped to 9q32, near CD30L (9q33) and TR2 and TR3 mapped to the region of chromosome 1 that contains the TNFR-II, 4-1BB, OX40 and CD30 gene cluster at 1p36. Only TR3 in this cluster possesses a death domain. Southern blot analysis revealed the presence of TL and TR genes in different mammalian species. TL2, TR1, TR2 and TR3 were recently described by others as TRAIL/Apo-2L, OPG, HVEM and DR3/WSL-1/Apo-3/TRAMP/LARD, respectively.

Incidence of hypercalcaemia and primary hyperparathyroidism in relation to the biochemical profile.

Over a period of one year, 24500 patients underwent a biochemical profile investigation. Seven hundred and thirty-eight (3%) patients had a plasma calcium concentration of greater than 2.60 mmol/l, and hypercalcaemia was confirmed in 49.8% of those subjects from whom a second fasting sample was received. Primary hyperparathyroidism and malignant disease were the two commonest causes of hypercalcaemia, occurring with equal frequency. The overall incidence of primary hyperparathyroidism in our population was 1:680. Over 75% of the patients with primary hyperparathyroidism appeared to have asymptomatic disease. The merits of including a plasma calcium determination in a biochemical profile would seem to depend particularly on the natural history of asymptomatic primary hyperparathyroidism.

The metabolic and hormonal response to glucagon. Part 1. Normal subjects.

Significant increases in mean plasma noradrenaline levels were observed 30-60 min and 150-180 min after a subcutaneous injection of 1 mg glucagon. The first peak coincided with the maximum blood glucose and plasma insulin levels and the second peak occurred after plasma growth hormone (GH) and cortisol levels had begun to rise. The first plasma noradrenaline peak may be important in inhibiting further insulin secretion. There was no evidence that glucagon stimulates adrenaline secretion in normal human subjects. It was also confirmed that there are significant increases in the levels of glucose, insulin, GH and cortisol and a significant decrease in FFA levels following subcutaneous injection of glucagon in normal human subjects.

The metabolic and hormonal response to glucagon. Part 2. In patients with migraine.

The hormonal and metabolic changes following the subcutaneous injection of 1 mg glucagon have been studied in a group of 6 migraine patients, and the results indicate that the responses of these subjects differ from those of a control group. Three of the migraine subjects had raised basal plasma noradrenaline levels but all had been taking clonidine up to 12-24 hr before the test and the increased plasma noradrenaline levels were probably due to the effect of withdrawal of the drug.

Prevention of carotid angioplasty-induced bradycardia and hypotension with temporary venous pacemakers.

OBJECTIVE: Carotid angioplasty with stent placement is becoming an established treatment modality for patients with high-risk carotid stenosis. Unlike carotid endarterectomy, angioplasty causes direct mechanical dilation of the stenotic carotid artery and bulb. Stimulation of the sinus baroreceptors induces a reflexive response that consists of increased parasympathetic discharge and inhibition of sympathetic tone, which results in bradycardia and subsequent cardiogenic hypotension. METHODS: At a single institution, the experience with 43 patients treated from November 1994 to January 2000 with 47 angioplasty and stent procedures for occlusive carotid artery disease was retrospectively reviewed. Prophylactic temporary venous pacemakers were used to prevent hypotension from possible angioplasty-induced bradycardia. Pacemakers were set to capture a heart rate decrease below 60 beats per minute. Variables analyzed included demographics, etiology of disease, side of the lesion, the presence of symptoms, history of coronary artery disease, percent stenosis, type of stent used, number of dilations, pressure of dilation, and angioplasty balloon diameter. RESULTS: Ten patients were excluded because pacemakers were not used during their angioplasty procedures, and these included three emergencies and a lesion that was unrelated anatomically to the carotid sinus (petrous carotid). The remaining 37 procedures were performed in 33 patients with a mean age of 67 years, and consisted of 17 men, 16 women, 20 right and 17 left-sided lesions. The pacemakers maintained a cardiac rhythm in 23 (62%) of the 37 procedures and in no case did the pacemaker fail to respond when activated. Recurrent (56%; 10 of 18), radiation-induced (78%; 7 of 9), and medically refractory carotid stenosis (67%; 6 of 9) required intraprocedural pacing. Two patients with recurrent stenosis became hypotensive despite the aid of the pacing device but were not symptomatic. Seventy-nine percent (15 of 19) of symptomatic lesions and 57% (8 of 14) of nonsymptomatic lesions required pacing, which was statistically significant (P = 0.049). No patient experienced an operative morbidity or mortality as a consequence of the temporary pacing devices. CONCLUSION: Angioplasty-induced bradycardia is a common condition, and it is more prevalent in radiation-induced stenosis and with symptomatic lesions. Temporary venous demand pacing is a safe procedure and may prevent life-threatening, baroreceptor-induced hypotension.

Therapeutic modalities for the management of cerebral vasospasm: timing of endovascular options.

OBJECTIVES: To determine if a window of time could be defined during which angioplasty would be most effective in reversing neurological decline and ultimately improving outcome. METHODS: Of a group of 466 patients, 93 underwent endovascular management of clinical vasospasm that was medically refractory. Eighty-four of the 93 patients were available for follow-up for at least 6 months. All patients underwent mechanical angioplasty using compliant microballoon systems and, if distal spasm was present, the administration of papaverine. RESULTS: Fifty-one patients underwent endovascular management within a 2-hour window, and 33 patients underwent treatment more than 2 hours after the development of their symptoms. Compared with the group treated more than 2 hours after neurological decline (P < 0.01; chi2 = 8.02), the group that underwent endovascular management within a 2-hour window after the development of symptoms demonstrated sustained clinical improvement. CONCLUSION: When a patient develops symptomatic vasospasm and is unresponsive to traditional measures of critical care management, angioplasty may be effective in improving the patient's neurological status if this procedure is performed as early as possible. The results indicate that a 2-hour window may exist for restoration of blood flow to ultimately improve the patient's outcome.

Serum free thyroxine concentrations in subjects with high circulating levels of thyroxine-binding globulin.

Serum free thyroxine (FT4) and thyroid hormone-binding protein concentrations were measured in pregnant women, stilboestrol-treated patients, and subjects with congenital thyroxine-binding-globulin (TBG) excess. In pregnant and stilboestrol-treated patients matched for TBG concentrations, serum FT4 concentrations measured by the Amerlex technique and by calculation, were reduced, as also was the total thyroxine (TT4)/TBG ratio. In congenital TBG excess Amerlex and calculated FT4 concentrations were normal whereas the TT4/TBG ratio was low. In contrast to the Amerlex method, FT4 concentrations by the Immophase procedure were normal in pregnant and stilboestrol-treated individuals and high in congenital TBG excess. We conclude that (i) reduced FT4 concentrations in pregnancy are related to an oestrogen effect rather than to some other pregnancy-associated factor, (ii) the TT4/TBG ratio gives a misleading indication of FT4 concentration in congenital TBG excess, and (iii) that when TBG concentrations are raised Immophase gives higher FT4 values than Amerlex or calculation when each is compared to FT4 values in their normal respective control group.

Circannual and within-individual variation of thyroid function tests in normal subjects.

Blood was taken from normal subjects at monthly intervals over a period of one year for subsequent determination of serum thyroid hormone concentrations. Thyroid-stimulating hormone (TSH) responses to TSH-releasing hormone were performed at 3-monthly intervals. This study provided data on within-individual variation and on seasonally-related changes of these thyroid function tests. The results showed that, within an individual, thyroid hormone concentrations are maintained within narrow limits. For both thyroxine and triiodothyronine the component contribution of within-individual variation to the population-based variation (the latter also termed the 'reference interval', or colloquially the 'normal range') was small. This high degree of individuality implies that rigorous comparison of thyroid hormone results against a population-based 'normal range' can be potentially misleading. Despite the limited within-individual variation, seasonally-related changes in thyroid hormone concentrations were apparent, with higher thyroxine and triiodothyronine values seen in winter months. A tendency to a greater TSH response to TSH-releasing hormone was also noted at this time. Conceivably these changes could reflect a centrally-mediated response of the hypothalamic-pituitary-thyroid axis to environmental temperature.

Concentration of serum thyroid hormone binding proteins after 131I treatment of hyperthyroidism.

Serum concentrations of the thyroid hormone binding proteins, thyroxine binding globulin, prealbumin, and albumin were determined in 30 thyrotoxic patients before and after 131I treatment. Each patient was placed into one of three groups according to response to treatment. The serum concentration of all three proteins rose significantly in 10 patients who became euthyroid, and a greater increase was seen in 10 patients who developed hypothyroidism. There was no significant change in thyroid hormone binding protein concentrations in 10 subjects who remained hyperthyroid. Changes in the concentration of thyroid hormone binding proteins should be borne in mind when total thyroid hormone concentrations are used to monitor the progress of patients receiving treatment for hyperthyroidism.

Performance and clinical utility of a commercially available 'C-terminal' PTH assay.

The performance and clinical utility of a 'C-terminal' parathyroid hormone (PTH) radioimmunoassay (Dac-Cel, Wellcome Diagnostics) is described. Parathyroid hormone, as measured by the Dac-Cel method, is stable in whole blood samples for at least 24 h. 84% of patients with hypercalcaemia due to primary hyperparathyroidism have values above the upper limit seen in normocalcaemic subjects (0.5 micrograms/L), with detectable serum PTH demonstrable in the remaining 16%. In patients with hypocalcaemia due to hypoparathyroidism serum PTH was undetectable in 73% and 'inappropriately' low in the remainder. In 50% of patients with malignancy-associated hypercalcaemia serum PTH was undetectable, but was above 0.5 micrograms/L in 13%. Increased PTH concentrations were invariably found in patients with renal failure. The Dac-Cel method is a reliable and robust technique for measurement of PTH and in conjunction with determination of calcium facilitates the diagnosis of primary parathyroid disorders. Caution is required in the interpretation of PTH measurements in patients with renal failure; the significance of detectable PTH in some patients with malignancy-associated hypercalcaemia is not clear.

Acute respiratory compromise associated with flexed cervical traction after C2 fractures.

STUDY DESIGN: Acute respiratory compromise is occasionally observed in a subgroup of patients with upper spinal injuries involving the C2 vertebrae. A retrospective review was performed to identify fracture types and risk factors for early respiratory deterioration following injury to the upper cervical spine. OBJECTIVES: To examine the frequency of respiratory complications encountered following traction manipulation of specific upper cervical spinal injuries involving the C2 vertebrae. SUMMARY OF BACKGROUND DATA: Major complications related to cervical skeletal traction are uncommon. Respiratory compromise with occasional mortality has been observed. Risk factors for acute respiratory failure are unknown. METHODS: The medical records of 166 consecutive patients with fractures of the C2 vertebrae admitted between January 1994 and July 1998 to a regional spinal cord injury center were examined. Demographic data, injury subtype, fracture displacement, respiratory status, treatment method, and outcome at discharge were examined. Patients with comorbidities compromising respiratory function were excluded. RESULTS: One hundred fifty-five patients met the inclusion criteria of this study. Sixty-one patients had Type II odontoid fractures of which 53 were displaced (32 posteriorly and 21 anteriorly). In addition, there were 21 patients with Type III odontoid fractures, 33 with axis C2 body fractures, 32 with Hangman's fractures, and eight patients with an os odontoideum. Thirteen of 32 patients with posteriorly displaced odontoid fractures experienced acute respiratory compromise following reduction with cervical skeletal traction and immobilization, while only three of the remaining 123 patients had respiratory difficulties. Respiratory distress as a consequence of cervical spine fractures resulted in three deaths. Two of these patients had posteriorly displaced Type II odontoid fractures whose airway could not be emergently intubated. CONCLUSION: Frequent respiratory deterioration (40% of patients) during acute management of posteriorly displaced Type II odontoid fractures after reduction was observed. Physicians must be aware that cervical flexion in the treatment of posteriorly displaced odontoid fractures may significantly increase the risk of airway obstruction due to the presence of acute retropharyngeal swelling. This may be avoided with elective nasotracheal intubation in this upper cervical spine fracture subtype.