Self-Managing Postoperative Pain with the Use of a Novel, Interactive Device: A Proof of Concept Study.

Background. Pain is commonly experienced following surgical procedures. Suboptimal management is multifactorial. Objectives. The primary objective was to assess whether patients used a device (Navimed) to self-report pain over and above a normal baseline of observations. Secondary outcome measures included comparison of pain scores and patient use of and feedback on the device. Methods. In a prospective randomized controlled trial, elective gynaecological surgery patients received standard postoperative pain care or standard care plus the Navimed, which allowed them to self-report pain and offered interactive self-help options. Results. 52 female patients, 26 in each of device and standard groups, did not differ in the frequency of nurse-documented pain scores or mean pain scores provided to nurses. The device group additionally reported pain on the device (means 18.50 versus 11.90 pain ratings per day, t(32) = 2.75, p < 0.001) that was significantly worse than reported to nurses but retrospectively rated significantly less anxiety. 80% of patients found the device useful. Discussion and Conclusion. This study demonstrates that patients used the Navimed to report pain and to help manage it. Further work is required to investigate the difference in pain scores reported and to develop more sophisticated software.

Rapid improvements in pain and quality of life are sustained after surgery for spinal metastases in a large prospective cohort.

Introduction Metastatic spinal cancer is a common condition that may lead to spinal instability, pain and paralysis. In the 1980s, surgery was discouraged because results showed worse neurological outcomes and pain compared with radiotherapy alone. However, with the advent of modern imaging and spinal stabilisation techniques, the role of surgery has regained centre stage, though few studies have assessed quality of life and functional outcomes after surgery. Objective We investigated whether surgery provides sustained improvement in quality of life and pain relief for patients with symptomatic spinal metastases by analysing the largest reported surgical series of patients with epidural spinal metastases. Methods A prospective cohort study of 922 consecutive patients with spinal metastases who underwent surgery, from the Global Spine Tumour Study Group database. Pre- and post-operative EQ-5D quality of life, visual analogue pain score, Karnofsky physical functioning score, complication rates and survival were recorded. Results Quality of life (EQ-5D), VAS pain score and Karnofsky physical functioning score improved rapidly after surgery and these improvements were sustained in those patients who survived up to 2 years after surgery. In specialised spine centres, the technical intra-operative complication rate of surgery was low, however almost a quarter of patients experienced post-operative systemic adverse events. Conclusion Surgical treatment for spinal metastases produces rapid pain relief, maintains ambulation and improves good quality of life. However, as a group, patients with cancer are vulnerable to post-operative systemic complications, hence the importance of appropriate patient selection.

Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment.

BACKGROUND: Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery. OBJECTIVE: To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases. METHODS: In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival. RESULTS: The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001). CONCLUSION: Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.

Osteosarcoma of the spine: dismal past, any hope for the future?

PURPOSE: The purpose of this study was to analyse all cases of spinal osteosarcoma (OS) treated in a regional bone tumour unit over the last 27 years. We were primarily interested in overall survival following tumour surgery, and if there is a difference in the survival of patients undergoing en bloc resection versus non-en bloc surgery. METHODS: Prospectively maintained tumour databases were searched in a regional bone tumour unit. All cases of surgically managed spinal OS were extracted and inpatient notes, imaging (including staging), histological margin status, and outcomes (neurological deficit and survival curves) were reviewed. RESULTS: Twenty-six patients were identified between 1985 and 2012. The median age was 26.5 years (range 6-78 y). Overall Kaplan-Meier survival was 69.5% (95% CI: 46.3-84.2%) and 10.8% (95% CI: 1.8-29.0%) at 1 and 5 years, respectively. There appears to be improved survival associated with primary spinal OS compared to that of metastatic disease, but this does not reach statistical significance (p = 0.29, Cox proportional hazards analysis). En bloc resection results in a significantly improved survival time compared to non-en bloc (biopsy and debulking): 44.1% alive at 2 years compared to 9.4%, respectively, p = 0.009. CONCLUSIONS: En bloc resection for primary spinal OS is associated with improved survival; there have been major changes in both surgical treatment and chemo/radiotherapy regimens over the period studied, potentially confounding the interpretation.

A prospective study of nutritional status in immunoglobulin light chain amyloidosis.

Weight loss is common in systemic immunoglobulin light chain amyloidosis but there are limited data on the impact of nutritional status on outcome. Using the Patient-Generated Subjective Global Assessment (PG-SGA) score, we prospectively examined nutritional status in 110 consecutive newly-diagnosed, treatment-naïve patients with immunoglobulin light chain amyloidosis attending the UK National Amyloidosis Centre. At study entry, 72 of 110 (66%) patients had a PG-SGA score of 4 or over, indicating malnutrition requiring specialist nutritional intervention. Number of amyloidotic organs, elevated alkaline phosphatase, presence of autonomic neuropathy and advanced Mayo disease stage were independently associated with poor nutritional status (P<0.05). Quality of life was substantially poorer among those with higher PG-SGA scores (P<0.001). Furthermore, PG-SGA score was a powerful independent predictor of patient survival (P=0.02). Malnutrition is prevalent and is associated with poor quality of life and reduced survival among patients with systemic immunoglobulin light chain amyloidosis. The PG-SGA score would be an appropriate tool to evaluate whether nutritional intervention could improve patient outcomes.

Rate of CD4 decline and HIV-RNA change following HIV seroconversion in men who have sex with men: a comparison between the Beijing PRIMO and CASCADE cohorts.

OBJECTIVE: Little is known about the natural history of the HIV infection in men who have sex with men (MSM) in China. METHODS: We compared changes in CD4+ T-cell count and HIV-RNA following seroconversion before starting antiretroviral therapy between MSM in China and in resource-rich countries using data from the Beijing PRIMO cohort and Concerted Action on SeroConversion to AIDS and Death in Europe (CASCADE), respectively. Linear mixed models were used to compare rates of CD4 decline (cubic root scale) and changes in HIV-RNA (log10 scale) in the first 3 years following seroconversion. RESULTS: For 131 PRIMO and 3171 CASCADE MSM infected in 2001-2010, estimated CD4+ T-cell count at seroconversion was lower in PRIMO (504 cells/mm3; 95% confidence interval: 463 to 547) compared with CASCADE (554 cells/mm3; 544 to 564). CD4 decline was significantly faster for PRIMO men [-0.59 (-0.72 to -0.47) and - 0.41 (-0.44 to -0.38) cubic root of CD4 count/year for PRIMO and CASCADE, respectively], even after restricting to subtype B (P = 0.01). HIV-RNA at seroconversion was lower in PRIMO compared with CASCADE MSM [difference 0.425 log10/mL (0.249 to 0.603), P < 0.001]. After the first year of seroconversion, PRIMO MSM experienced a faster increase in HIV-RNA [0.830 log10/mL per year; (0.484 to 1.168)] compared with CASCADE MSM [0.018 (-0.035 to 0.067)] (P < 0.001). CONCLUSIONS: CD4 decline and HIV-RNA increase are faster between MSM in China compared with MSM from resource-rich settings. Whether this is due to differences in host immunity or viral characteristics requires further exploration.

Predictors of psychiatric and seizure outcome following temporal lobe epilepsy surgery.

PURPOSE: Neurosurgery is an effective therapy for selected individuals with medically refractory temporal lobe epilepsy (TLE). De novo psychopathology may complicate the postsurgical outcome. Our aims were to identify predictors of de novo psychiatric and seizure outcome following TLE surgery. METHODS: Medical records of 280 patients who underwent TLE surgery were reviewed. Preoperative and postoperative psychiatric diagnoses were identified, in addition to information on seizure recurrence and neuropsychological status. Logistic regression analysis was used to identify predictors of having a de novo psychiatric diagnosis and remaining seizure-free within 4 years following surgery. KEY FINDINGS: One hundred five patients (38%) had significant psychiatric problems within 4 years following TLE surgery. Fifty-one patients (18%) developed de novo psychopathology; half of cases presented within 6 months and 90% of psychopathologies persisted 6 months or longer. A preoperative history of secondary generalized tonic-clonic seizure(s) (SGTCS) was an independent predictor of de novo psychopathology (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.14-6.59, p = 0.02). From patients with available seizure data, 49% (127 of 258) remained seizure-free for 4 years after surgery. Patients with a history of SGTCS (OR 0.47, 95% CI 0.25-0.90, p = 0.02) and those with a preoperative psychiatric diagnosis (OR 0.53, 95% CI 0.28-0.98, p = 0.04) were significantly less likely to remain seizure-free. SIGNIFICANCE: De novo psychopathology is a significant complication of TLE surgery. Inclusion of neuropsychiatric assessments in the presurgical evaluation may lead to increase in the power of prognostic models used to predict the neurologic outcome of TLE surgery.

Cardiac phenotype and clinical outcome of familial amyloid polyneuropathy associated with transthyretin alanine 60 variant.

AIMS: Familial amyloid polyneuropathy (FAP) is a dominantly inherited multi-system disease associated with transthyretin (TTR) mutations. Previous series have predominantly described patients with the TTR variant Val30Met (V30M), which is the most prevalent cause of FAP worldwide. Here, we report the dominant cardiac phenotype and outcome of FAP associated with TTR Thr60Ala (T60A), the most common UK variant. METHODS AND RESULTS: Sixty consecutive patients with FAP associated with TTR T60A (FAP T60A) were prospectively evaluated in two centres between 1992 and 2009. Median (range) age of symptom development was 63 (45-78) years. A family history of amyloidosis was present in only 37%. Autonomic and peripheral neuropathy were present in 44 and 32 patients, respectively, at diagnosis. Cardiac involvement was evident on echocardiography at diagnosis in 56 patients, but was associated with reduced QRS voltages on electrocardiography in only 16% evaluable cases. Seventeen patients received implantable anti-arrhythmic devices. Median survival was 6.6 years following onset of symptoms and 3.4 years from diagnosis, and correlated with serum N-terminal prohormone brain natriuretic peptide (NT-proBNP) concentration and certain echocardiographic parameters at the latter. Orthotopic liver transplantation (OLT), performed to eliminate the predominant hepatic source of variant TTR T60A protein, was performed in eight patients including one who received a concomitant cardiac transplant. Cardiac amyloidosis progressed in all lone OLT recipients, of whom four died within 5 years. CONCLUSION: Cardiac amyloidosis is almost always present at diagnosis in FAP T60A, and is a major determinant of its poor prognosis. Outcome of liver transplantation in FAP T60A has been discouraging.

Activation and coagulation biomarkers are independent predictors of the development of opportunistic disease in patients with HIV infection.

BACKGROUND: Activation and coagulation biomarkers were measured within the Strategies for Management of Antiretroviral Therapy (SMART) trial. Their associations with opportunistic disease (OD) in human immunodeficiency virus (HIV)-positive patients were examined. METHODS: Inflammatory (high-sensitivity C-reactive protein [hsCRP], interleukin-6 [IL-6], amyloid-A, and amyloid-P) and coagulation (D-dimer and prothrombin-fragment 1+2) markers were determined. Conditional logistic regression analyses were used to assess associations between these biomarkers and risk of OD. RESULTS: The 91 patients who developed an OD were matched to 182 control subjects. Patients with an hsCRP level > or =5 microg/mL at baseline had a 3.5 higher odds of OD (95% confidence interval [CI], 1.5-8.1) than did those with an hsCRP level <1 microg/mL (P=.003, by test for trend) and patients with an IL-6 level > or =3 pg/mL at baseline had a 2.4 higher odds of OD (95% CI, 1.0-5.4) than did those with an IL-6 level <1.5 pg/mL (P=.02, by test for trend). No other baseline biomarkers predicted development of an OD. Latest follow-up hsCRP level for those with an hsCRP level > or =5 microg/mL (compared with a level <1 microg/mL; odds ratio [OR], 7.6; 95% CI, 2.0-28.5; [P=.002, by test for trend), latest amyloid-A level for those with an amyloid-A level > or =6 mg/L (compared with a level <2 mg/L; OR, 3.8; 95% CI, 1.1-13.4; P=.03, by test for trend), and latest IL-6 level for those with an IL-6 level > or =3 pg/mL (compared with a level <1.5 pg/mL; OR 2.4; 95% CI, 0.7-8.8; P=.04, by test for trend) were also associated with development of an OD. CONCLUSIONS: Higher IL-6 and hsCRP levels independently predicted development of OD. These biomarkers could provide additional prognostic information for predicting the risk of OD.

Our cancer courses benefit people in all income groups.

In response to Gill Oliver's comments about our website (reviews May 2), what we offer at Penny Brohn Cancer Care benefits people with cancer and their supporters at many levels, irrespective of background or financial status.