Dopaminergic challenge with bromocriptine one month after mild traumatic brain injury: altered working memory and BOLD response.

Catecholamines, particularly dopamine, modulate working memory (WM). Altered sensitivity to dopamine might play a role in WM changes observed after traumatic brain injury (TBI). Thirty-one healthy controls (HC) and 26 individuals with mild TBI (MTBI) 1 month after injury were challenged with bromocriptine versus placebo before administration of a verbal WM functional MRI task. Bromocriptine was associated with improved WM performance in the HC but not the MTBI group. On bromocriptine, the MTBI group showed increased activation outside of a task-specific region of interest. Findings are consistent with the hypothesis that individuals with MTBI have altered responsivity to dopamine.

Lumbar spine: reliability of MR imaging findings.

PURPOSE: To characterize the inter- and intraobserver variability of qualitative, non-disk contour degenerative findings of the lumbar spine at magnetic resonance (MR) imaging. MATERIALS AND METHODS: The case accrual method used to perform this institutional review board-approved, HIPAA-compliant retrospective study was the random selection of 111 interpretable MR examination cases of subjects from the Spine Patient Outcomes Research Trial. The subjects were aged 18-87 years (mean, 53 years +/- 16 [standard deviation]). Four independent readers rated the cases according to defined criteria. A subsample of 40 MR examination cases was selected for reevaluation at least 1 month later. The following findings were assessed: spondylolisthesis, disk degeneration, marrow endplate abnormality (Modic changes), posterior anular hyperintense zone (HIZ), and facet arthropathy. Inter- and intraobserver agreement in rating the data was summarized by using weighted kappa statistics. RESULTS: Interobserver agreement was good (kappa = 0.66) in rating disk degeneration and moderate in rating spondylolisthesis (kappa = 0.55), Modic changes (kappa = 0.59), facet arthropathy (kappa = 0.54), and posterior HIZ (kappa = 0.44). Interobserver agreement in rating the extent of Modic changes was moderate: kappa Values were 0.43 for determining superior anteroposterior extent, 0.47 for determining superior craniocaudal extent, 0.57 for determining inferior anteroposterior extent, and 0.48 for determining inferior craniocaudal extent. Intraobserver agreement was good in rating spondylolisthesis (kappa = 0.66), disk degeneration (kappa = 0.74), Modic changes (kappa = 0.64), facet arthropathy (kappa = 0.69), and posterior HIZ (kappa = 0.67). Intraobserver agreement in rating the extent of Modic changes was moderate, with kappa values of 0.54 for superior anteroposterior, 0.60 for inferior anteroposterior, 0.50 for superior craniocaudal, and 0.60 for inferior craniocaudal extent determinations. CONCLUSION: The interpretation of general lumbar spine MR characteristics has sufficient reliability to warrant the further evaluation of these features as potential prognostic indicators.

Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years.

BACKGROUND: The SPORT (Spine Patient Outcomes Research Trial) reported favorable surgery outcomes over 2 years among patients with stenosis with and without degenerative spondylolisthesis, but the economic value of these surgeries is uncertain. OBJECTIVE: To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis. DESIGN: Prospective cohort study. DATA SOURCES: Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants. TARGET POPULATION: Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis. TIME HORIZON: 2 years. PERSPECTIVE: Societal. INTERVENTION: Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis). OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: Among 634 patients with stenosis, 394 (62%) had surgery, most often decompressive laminectomy (320 of 394 [81%]). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 [95% CI, 0.12 to 0.22]) at a cost of $77,600 (CI, $49,600 to $120,000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 [93%]) and most with instrumentation (269 of 344 [78%]). Degenerative spondylolisthesis surgeries significantly improved health versus nonoperative care (QALY gain, 0.23 [CI, 0.19 to 0.27]), at a cost of $115,600 (CI, $90,800 to $144,900) per QALY gained. RESULT OF SENSITIVITY ANALYSIS: Surgery cost markedly affected the value of surgery. LIMITATION: The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment nonadherence among randomly assigned participants. CONCLUSION: The economic value of spinal stenosis surgery at 2 years compares favorably with many health interventions. Degenerative spondylolisthesis surgery is not highly cost-effective over 2 years but could show value over a longer time horizon.

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: a comparison of indications, complications and outcomes in 370 patients.

OBJECTIVE: Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques. METHODS: Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed. RESULTS: 177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group. CONCLUSIONS: Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.

Early discontinuation of treatment for osteoporosis.

PURPOSE: To identify factors associated with early treatment discontinuation of three agents commonly prescribed for women with low bone density. METHODS: A telephone survey was conducted in 2000 to 2001 in a random sample of women aged 45 years or older who had bone density T-scores -1.0 or lower and who had initiated treatment with hormone replacement therapy, raloxifene, oral endronate. Logistic regression was used to estimate adjusted odds ratios for early treatment discontinuation. RESULTS: Among 956 women who were interviewed an average of 7 months after treatment initiation, 334 were taking hormone therapy, and 88 (26%) had discontinued; 256 were taking raloxifene, and 48 (19%) had discontinued (P = 0.03 vs. hormone therapy); and 366 were taking alendronate, and 70(19%) had discontinued (P = 0.02 vs. hormone therapy). Women with bothersome side effects (somewhat bothered: odds ratio [OR] = 4.0; 95% confidence interval [CI]: 2.5 to 6.5; very or extremely bothered: OR = 25; 95% CI: 16 to 39) or who thought that their bone density test results did not show osteoporosis (OR = 1.6; 95% CI: 1.0 to 2.5) were more likely to discontinue therapy, as compared with women reporting regular exercise (OR = 0.7; 95% CI: 0.4 to 1.0) or a willingness to take prescribed medications (OR = 0.6; 95% CI: 0.4 to 0.9). After adjustment for side effects and patient characteristics, the odds of early treatment discontinuation did not differ significantly among treatments. CONCLUSION: Improved adherence to osteoporosis treatment requires that treatment side effects be minimized and women be educated regarding their bone density test results.

Consequences of false-positive screening mammograms.

IMPORTANCE: False-positive mammograms, a common occurrence in breast cancer screening programs, represent a potential screening harm that is currently being evaluated by the US Preventive Services Task Force. OBJECTIVE: To measure the effect of false-positive mammograms on quality of life by measuring personal anxiety, health utility, and attitudes toward future screening. DESIGN, SETTING, AND PARTICIPANTS: The Digital Mammographic Imaging Screening Trial (DMIST) quality-of-life substudy telephone survey was performed shortly after screening and 1 year later at 22 DMIST sites and included randomly selected DMIST participants with positive and negative mammograms. EXPOSURE: Mammogram requiring follow-up testing or referral without a cancer diagnosis. MAIN OUTCOMES AND MEASURES: The 6-question short form of the Spielberger State-Trait Anxiety Inventory state scale (STAI-6) and the EuroQol EQ-5D instrument with US scoring. Attitudes toward future screening as measured by women's self-report of future intention to undergo mammographic screening and willingness to travel and stay overnight to undergo a hypothetical new type of mammography that would identify as many cancers with half the false-positive results. RESULTS: Among 1450 eligible women invited to participate, 1226 (84.6%) were enrolled, with follow-up interviews obtained in 1028 (83.8%). Anxiety was significantly higher for women with false-positive mammograms (STAI-6, 35.2 vs 32.7), but health utility scores did not differ and there were no significant differences between groups at 1 year. Future screening intentions differed by group (25.7% vs 14.2% more likely in false-positive vs negative groups); willingness to travel and stay overnight did not (9.9% vs 10.5% in false-positive vs negative groups). Future screening intention was significantly increased among women with false-positive mammograms (odds ratio, 2.12; 95% CI, 1.54-2.93), younger age (2.78; 1.5-5.0), and poorer health (1.63; 1.09-2.43). Women's anticipated high-level anxiety regarding future false-positive mammograms was associated with willingness to travel overnight (odds ratio, 1.94; 95% CI, 1.28-2.95). CONCLUSIONS AND RELEVANCE: False-positive mammograms were associated with increased short-term anxiety but not long-term anxiety, and there was no measurable health utility decrement. False-positive mammograms increased women's intention to undergo future breast cancer screening and did not increase their stated willingness to travel to avoid a false-positive result. Our finding of time-limited harm after false-positive screening mammograms is relevant for clinicians who counsel women on mammographic screening and for screening guideline development groups.

Early Patient Outcomes After Primary Total Knee Arthroplasty with Quadriceps-Sparing Subvastus and Medial Parapatellar Techniques: A Randomized, Double-Blind Clinical Trial.

BACKGROUND: Techniques that reduce injury to the knee extensor mechanism may cause less pain and allow faster recovery of knee function after primary total knee arthroplasty. A quadriceps-sparing (QS) subvastus technique of total knee arthroplasty was compared with medial parapatellar arthrotomy (MPPA) to determine which surgical technique led to better patient-reported function and less postoperative pain and opioid utilization. METHODS: In this prospective, double-blind study, 129 patients undergoing total knee arthroplasty were randomized to the QS or the MPPA group after skin incision. All surgical procedures utilized minimally invasive surgery principles and standardized anesthesia, implants, analgesia, and rehabilitation. The Knee Society Score (KSS) was obtained at baseline and one and three months after surgery. Weekly telephone interviews were used to collect patient-reported outcomes including ambulatory device use, the UCLA (University of California Los Angeles) activity score, performance of daily living activities, and opioid utilization. RESULTS: No differences between groups were seen in opioid utilization, either during the acute hospitalization or in the eight weeks after surgery. The QS group reported significantly less pain at rest on postoperative day one and with activity on day three (p = 0.04 for each). Compared with baseline, both groups showed significant improvements in the KSS at one month (MPPA, p = 0.0278; QS, p = 0.0021) and three months (p < 0.0001 for each) as well as week-to-week gains in walking independence through five weeks after surgery. Independence from ambulatory devices outside the home lagged behind independence indoors by about two weeks in both groups. CONCLUSIONS: When primary total knee arthroplasty was performed with contemporary minimally invasive surgery principles and standardized implants, anesthesia, and postoperative pathways, the QS technique yielded no significant early functional advantages or differences in opioid utilization compared with the MPPA technique. However, the mean pain scores reported by patients in the QS group were slightly lower at rest on postoperative day one and during activity on day three. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A longitudinal comparison of 5 preference-weighted health state classification systems in persons with intervertebral disk herniation.

OBJECTIVE: To assess the longitudinal validity of widely used preference-weighted measurement systems for economic studies of intervertebral disk herniation (IDH). METHODS: Using data at baseline and 1 year from 1000 Spine Patient Outcomes Research Trial (SPORT) participants with IDH and complete data, the authors considered the EQ-5D with UK and US values (EQ-5D-UK and EQ-5D-US), 2 versions of the Health Utilities Index (HUI3 and HUI2), the SF-6D, and a regression-estimated quality of well-being score (eQWB). Differences in mean change scores (MCS) were assessed using signed rank tests, and Spearman correlations were calculated for change scores by system pairs. Using the Oswestry Disability Index, symptom satisfaction, progress rating, and self-perceived health ratings as criterion measures, the authors tested for trend in MCS across levels of change in criteria. They calculated floor and ceiling effects, effect size (ES), standardized response mean, and minimal important difference estimates. RESULTS: All systems demonstrated linear trends with external criteria and moderate to strong correlations between systems. However, differences in performance were evident. SF-6D and eQWB were most responsive (ES: 1.9 and 2.3, respectively), whereas EQ-5D-US and EQ-5D-UK were least responsive (ES: 1.23/1.20). Ceiling and floor effects were noted for all systems within key dimensions and for EQ-5D-UK and EQ-5D-US for overall score. MCS ranged from 0.40 (0.38) for EQ-5D-UK to 0.13 (0.09) for eQWB and differed significantly, except between EQ-5D-US and HUI2. CONCLUSIONS: This research supports the validity of all systems for measuring change in persons with IDH, without finding a clearly superior system. The unique characteristics of each system revealed in this study should guide system choice.

Alpha-2 adrenergic challenge with guanfacine one month after mild traumatic brain injury: altered working memory and BOLD response.

Alterations in working memory (WM) are common after traumatic brain injury (TBI). Frontal catecholaminergic systems, including the alpha-2 adrenergic system, modulate WM function and may be affected in TBI. We hypothesized that administration of an alpha-2 adrenergic agonist might improve WM after mild TBI (MTBI). Thirteen individuals with MTBI 1month after injury and 14 healthy controls (HC) were challenged with guanfacine and placebo prior to administration of a verbal WM functional MRI task. Guanfacine was associated with improved WM performance in the MTBI but not the HC group. On guanfacine the MTBI group showed increased activation within a WM task-specific region of interest. Findings are consistent with the hypothesis that alterations in WM after MTBI may be improved with the alpha-2 agonist guanfacine.

Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation.

STUDY DESIGN: Cost-effectiveness analysis of a randomized plus observational cohort trial. OBJECTIVE: Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH). SUMMARY OF BACKGROUND DATA: Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain. METHODS: Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year. RESULTS: Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088). CONCLUSION: Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.

Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures?

BACKGROUND: In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction. METHODS: A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values. RESULTS: Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios. CONCLUSIONS: Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment.

The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Spine Patient Outcomes Research Trial observational and randomized cohort participants with a confirmed diagnosis of intervertebral disc herniation (IDH) who received either usual nonoperative care and/or standard open discectomy were followed from baseline at 6 weeks, 3, 6, 12, and 24 months at 13 spine clinics in 11 US states. OBJECTIVE: To evaluate the cost-effectiveness of surgery relative to nonoperative care among patients with a confirmed diagnosis of lumbar IDH. SUMMARY OF BACKGROUND DATA: The cost-effectiveness of surgery as a treatment for conditions associated with low back and leg symptoms remains poorly understood. METHODS: Incremental cost-effectiveness ratio, reported as discounted cost per quality adjusted life year (QALY) gained in 2004 US dollars based on EuroQol EQ-5D health state values with US scoring, and information on resource utilization and time away from work. RESULTS: Among 775 patients who underwent surgery and 416 who were treated nonoperatively, the mean difference in QALYs over 2 years was 0.21 (95% CI: 0.16-0.25) in favor of surgery. Surgery was more costly than nonoperative care; the mean difference in total cost was $14,137(95% CI: $11,737-16,770). The cost per QALY gained for surgery relative to nonoperative care was $69,403 (95% CI: $49,523-94,999) using general adult surgery costs and $34,355 (95% CI: $20,419-52,512) using Medicare population surgery costs. CONCLUSION: Surgery for IDH was moderately cost-effective when evaluated over 2 years. The estimated economic value of surgery varied considerably according to the method used for assigning surgical costs.

Reliability of readings of magnetic resonance imaging features of lumbar spinal stenosis.

STUDY DESIGN: A reliability assessment of standardized magnetic resonance imaging (MRI) interpretations and measurements. OBJECTIVE: To determine the intra- and inter-reader reliability of MRI features of lumbar spinal stenosis (SPS), including severity of central, subarticular, and foraminal stenoses, grading of nerve root impingement, and measurements of cross-sectional area of the spinal canal and thecal sac. SUMMARY OF BACKGROUND DATA: MRI is commonly used to assess patients with spinal stenosis. Although a number of studies have evaluated the reliability of certain MRI characteristics, comprehensive evaluation of the reliability of MRI readings in spinal stenosis is lacking. METHODS: Fifty-eight randomly selected MR images from patients with SPS enrolled in the Spine Patient Outcomes Research Trial were evaluated. Qualitative ratings of imaging features were performed according to defined criteria by 4 independent readers (3 radiologists and 1 orthopedic surgeon). A sample of 20 MRIs was reevaluated by each reader at least 1 month later. Weighted kappa statistics were used to characterize intra- and inter-reader reliability for qualitative rating data. Separate quantitative measurements were performed by 2 other radiologists. Intraclass correlation coefficients and summaries of measurement error were used to characterize reliability for quantitative measurements. RESULTS: Intra-reader reliability was higher than inter-reader reliability for all features. Inter-reader reliability in assessing central stenosis was substantial, with an overall kappa of 0.73 (95% CI 0.69-0.77). Foraminal stenosis and nerve root impingement showed moderate to substantial agreement with overall kappa of 0.58 (95% CI 0.53-0.63) and 0.51 (95% CI 0.42-0.59), respectively. Subarticular zone stenosis yielded the poorest agreement (overall kappa 0.49; 95% CI 0.42-0.55) and showed marked variability in agreement between reader pairs. Quantitative measures showed inter-reader intraclass correlation coefficients ranging from 0.58 to 0.90. The mean absolute difference between readers in measured thecal sac area was 128 mm (13%). CONCLUSION: The imaging characteristics of spinal stenosis assessed in this study showed moderate to substantial reliability; future studies should assess whether these findings have prognostic significance in SPS patients.

Reliability of magnetic resonance imaging readings for lumbar disc herniation in the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Assessment of the reliability of standardized magnetic resonance imaging (MRI) interpretations and measurements. OBJECTIVE: To determine the intra- and inter-reader reliability of MRI parameters relevant to patients with intervertebral disc herniation (IDH), including disc morphology classification, degree of thecal sac compromise, grading of nerve root impingement, and measurements of cross-sectional area of the spinal canal, thecal sac, and disc fragment. SUMMARY OF BACKGROUND DATA: MRI is increasingly used to assess patients with sciatica and IDH, but the relationship between specific imaging characteristics and patient outcomes remains uncertain. Although other studies have evaluated the reliability of certain MRI characteristics, comprehensive evaluation of the reliability of readings of herniated disc features on MRI is lacking. METHODS: Sixty randomly selected MR images from patients with IDH enrolled in the Spine Patient Outcomes Research Trial were each rated according to defined criteria by 4 independent readers (3 radiologists and 1 orthopedic surgeon). Quantitative measurements were performed separately by 2 other radiologists. A sample of 20 MRIs was re-evaluated by each reader at least 1 month later. Agreement for rating data were assessed with kappa statistics using linear weights. Reliability of the quantitative measurements was assessed using intraclass correlation coefficients (ICCs) and summaries of measurement error. RESULTS: Inter-reader reliability was substantial for disc morphology [overall kappa 0.81 (95% confidence interval (CI): 0.78, 0.85)], moderate for thecal sac compression [overall kappa 0.54 (95% CI: 0.37, 0.68)], and moderate for grading nerve root impingement [overall kappa 0.47 (95% CI: 0.36, 0.56)]. Quantitative measures showed high ICCs of 0.87 to 0.96 for spinal canal and thecal sac cross-sectional areas. Measures of disc fragment area had moderate ICCs of 0.65 to 0.83. Mean absolute differences between measurements ranged from approximately 15% to 20%. CONCLUSION: Classification of disc morphology showed substantial intra- and inter-reader agreement, whereas thecal sac and nerve root compression showed more moderate reader reliability. Quantitative measures of canal and thecal sac area showed good reliability, whereas measurement of disc fragment area showed more modest reliability.

Comparison of EQ-5D, HUI, and SF-36-derived societal health state values among spine patient outcomes research trial (SPORT) participants.

PURPOSE: To compare societal values across health-state classification systems and to describe the performance of these systems at baseline in a large population of persons with confirmed diagnosis of intervertebral disc herniation (IDH), spinal stenosis (SpS), or degenerative spondylolisthesis (DS). METHODS: We compared values for EQ-5D (York weights), HUI (Mark 2 and 3), SF-6D, and the SF-36-derived estimate of the Quality of Well Being (eQWB) score using signed rank tests. We tested each instrument's ability to discriminate between health categories and level of symptom satisfaction. Correlations were assessed with Spearman rank correlations. We evaluated ceiling and floor effects by comparing the proportion at the highest and the lowest possible score for each tool. In addition, we compared proportions at the highest and lowest levels by dimension. The number of unique health states assigned was compared across instruments. We calculated the difference between those who were very dissatisfied and all others. RESULTS: Mean values ranged from 0.39 to 0.63 among 2097 participants ages 18-93 (mean age 53, 47% female) with significant differences in pair-wise comparisons noted for all systems. Correlations ranged from 0.30 to 0.78. Although all systems showed statistically significant differences in health state values when baseline comparisons were made between those who were very dissatisfied with their symptoms and those who were not, the magnitude of this difference ranged widely across systems. Mean differences (95% CI) between those very dissatisfied and all others were 0.30 (0.269, 0.329) for EQ-5D, 0.22 (0.190, 0.241) for HUI(3), 0.18 (0.161, 0.201) for HUI(2), 0.11 (0.095, 0.117) for SF-6D, 0.04 (0.039, 0.049) for eQWB, and 0.07 (0.056, 0.077) for VAS (with transformation applied to group means). CONCLUSION: Differences in preference-weighted health state classification systems are evident at baseline in a population with confirmed IDH, SpS, and DS. Caution should be used when comparing health state values derived from various systems.

Analysis of the microvasculature and tissue type ratios in normal vs. benign and malignant breast tissue.

OBJECTIVE: To analyze the microvasculature and tissue type ratios in normal vs. benign and malignant breast tissue to establish a baseline for expected values against which future imaging studies can be benchmarked. STUDY DESIGN: Using computer-assisted techniques on immunostained breast tissue (normal [n = 28], fibrocystic [n = 37], fibroadenomas [n = 19], invasive carcinomas [n = 19]), values were obtained for microvessel density (MVD), mean vessel area (MVA), vessel orientation (shape) and epithelial:stromal ratio (E:S). Measurement reproducibility and the effects of fibroadenoma stromal hyalinization and fibrocystic disease severity were also tested. RESULTS: Value ranges for the 4 diagnostic groups were significantly different (P < .001). For invasive breast carcinomas, E:S and MVD were significantly higher (P < .001) but MVA was smaller as compared to that in fibroadenomas. Peripherally vs. centrally there was no significant difference in MVD, MVA or vessel shape in the neoplasms. Decreases in E:S and MVD correlated with fibroadenoma stromal hyalinization. Increases in E:S and MVA correlated with more severe fibrocystic disease. Correlation coefficients for measurement reproducibility were high across the diagnostic categories. CONCLUSION: This study established a specific, reproducible, computer-assisted technique and baseline of expected values for morphologic criteria in normal, benign and malignant breast tissue that may be used in the future to correlate new breast imaging responses with these underlying biologic properties.

Electromagnetic breast imaging: average tissue property values in women with negative clinical findings.

Representative data are provided for three electromagnetic breast imaging techniques-near-infrared spectroscopy, electrical impedance spectroscopy, and microwave imaging spectroscopy-to serve as potential benchmarks for future investigation. The breasts of 23 women without clinical or mammographic findings of disease were imaged in the coronal plane with nonionizing radiation of varying frequencies. Average electromagnetic property values were reconstructed at each frequency on the basis of computational models of light diffusion, current flow, and microwave propagation. Electromagnetic properties were correlated with subject characteristics and between techniques. Each technique yielded information on breast tissue features (eg, conductivity, permittivity, light scattering, and absorption) that had not previously all been measured in the same individuals.