Lumbar Spinal Stenosis: Diagnosis and Management.

Lumbar spinal stenosis is a clinical syndrome that affects more than 200,000 people in the United States annually. It is a common cause of chronic insidious low back pain, especially in older patient populations (mean age = 64 years). Lumbar spinal stenosis is a degenerative condition of the spine leading to narrowing in the spaces around the neurovascular bundles and the classic symptom of low back pain that radiates to the buttocks and lower extremities bilaterally. It is typically a progressive waxing and waning process that may deteriorate over years. The pain is typically burning or cramping, which worsens with standing and walking and improves with bending forward or sitting. Magnetic resonance imaging is the recommended diagnostic test because it allows cross-sectional measurement of the spinal canal. Options for nonsurgical management include physical therapy, exercise programs, spinal injections with and without corticosteroids, chiropractic treatment, osteopathic manipulation, acupuncture, and lifestyle modifications; however, few of these treatments have high-quality randomized trials demonstrating effectiveness. Surgery may be considered if nonsurgical management is ineffective.

Injections of the Hip and Knee.

Hip and knee injections are useful diagnostic and therapeutic tools for family physicians. This article reviews anatomic landmark-guided and ultrasound-guided injections and aspiration techniques for greater trochanteric pain syndrome, the hip joint, the knee joint, the pes anserine bursa, and the iliotibial band. Indications for injections include acute and chronic inflammatory conditions, such as rheumatoid arthritis; osteoarthritis; overuse; and traumas. Joint aspirations may be performed to aid in the diagnosis of unexplained effusions and to relieve pain. Technique, injectant, and follow-up timing depend on the physician's comfort, experience, and preference. Infections of the skin or soft tissue are the primary contraindications to injections. The most common complications are local inflammatory reactions to the injectant. These reactions usually cause soreness for 24 to 48 hours, then spontaneously resolve. Follow-up after injections is usually scheduled within two to six weeks.

First-Line Carboplatin, Pemetrexed, and Panitumumab in Patients with Advanced Non-Squamous KRAS Wild Type (WT) Non-Small-Cell Lung Cancer (NSCLC).

BACKGROUND: We added panitumumab to standard combination chemotherapy as first-line treatment for patients with advanced KRAS WT non-squamous NSCLC. METHODS: Patients received panitumumab 9 mg/kg IV, pemetrexed 500 mg/m2 IV, and carboplatin AUC = 6 IV every 21 days. After 6 cycles, maintenance therapy with panitumumab and pemetrexed was administered every 21 days until progressive disease or unacceptable toxicity. RESULTS: 29 of 66 patients (44%) had objective responses. The median TTP was 6 months; median overall survival (OS) was 17 months. Panitumumab increased treatment-related toxicity, notably skin rash. CONCLUSIONS: The addition of panitumumab increased toxicity, and had no discernible impact on efficacy.

Metal hypersensitivity in total joint arthroplasty.

OBJECTIVE: To review the clinical manifestations, testing methods, and treatment options for hypersensitivity reactions to total joint arthroplasty procedures. DATA SOURCES: Studies were identified using MEDLINE and reference lists of key articles. STUDY SELECTIONS: Randomized controlled trials were selected when available. Systematic reviews and meta-analyses of peer-reviewed literature were included, as were case series and observational studies of clinical interest. RESULTS: Total joint arthroplasty procedures are increasing, as are the hypersensitivity reactions to these implants. Evidence is not conclusive as to whether metal joint implants increase metal sensitivity or whether metal sensitivity leads to prosthesis failure. Currently, patch testing is still the most widely used method for determining metal hypersensitivity; however, there are no standardized commercial panels specific for total joint replacements available currently. In vitro testing has shown comparable results in some studies, but its use in the clinical setting may be limited by the cost and need for specialized laboratories. Hypersensitivity testing is generally recommended before surgery for patients with a reported history of metal sensitivity. In cases of metal hypersensitivity-related joint failure, surgical revision ultimately may be required. Knowledge about joint replacement hypersensitivity reactions becomes vital because the approach to the evaluation depends on appropriate testing to guide recommendations for future arthroplasty procedures. CONCLUSION: Evaluation of hypersensitivity reactions after total joint arthroplasty requires a systematic approach, including a careful history, targeted evaluation with skin testing, and in vitro studies.

Trauma-focused treatment in a state system of care: is it worth the cost?

The efficacy of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in treating child traumatic stress inspires nationwide dissemination, yet widespread adoption by state systems of care is lagging. A significant barrier is the cost of implementation and maintenance of evidence-based services. Thus, the current study examined the annual costs of mental health services accrued for 90 publiclyinsured, trauma-exposed children from the time they began participation in a TF-CBT implementation project to 1 year after their admission. These costs were compared to those accrued over that same time period by 90 trauma-exposed control children that were matched by demographics and prior mental health services utilization using a propensity score matching algorithm and provided outpatient treatment as usual. Results indicated that (a) 27.5 % of the total cost was attributed to high-end services utilized by only 1.67 % of children; (b) two times more money was spent on low-end mental health services received by the TF-CBT group than the control group, and (c) five times more money was spent on high-end mental health services received by the control group than the TF-CBT group in that year. These data suggest that providing evidence-based trauma-focused outpatient treatment to children with trauma-related problems may offset the eventual need for services that are more restrictive and costly.

Sorafenib and everolimus in advanced clear cell renal carcinoma: a phase I/II trial of the SCRI Oncology Research Consortium.

PURPOSE: To evaluate the feasibility and efficacy of sorafenib and everolimus in renal cell carcinoma (RCC). METHODS: Patients with advanced RCC and ≤ 1 previous targeted therapy were treated. RESULTS: Maximum tolerated doses were sorafenib 200 mg PO BID, everolimus 35 mg PO once weekly. Dose-limiting toxicity was hand-foot syndrome. The response rate was 13%; median PFS was 5.45 months (95% CI: 3.8-7.6). Skin toxicity, fatigue, hypertension, proteinuria, and mucositis (usually Grade 2) were common. CONCLUSIONS: Fifty percent doses of sorafenib and everolimus were required when these drugs were combined. No increase in efficacy was suggested; toxicity was modestly increased.

Building a consumer base for trauma-focused cognitive behavioral therapy in a state system of care.

This paper documents the scope and limitations of an outreach effort to build a consumer base for Trauma-focused cognitive behavioral therapy in a state public mental health system for children. Three key aspects are discussed: the fostering of an informed referral network, the development of screening and identification services, and the engagement of families. Referral, screening and engagement are each examined against the backdrop of existing literature on implementation and dissemination. Each aspect of the implementation plan is described in detail-as are the barriers encountered and lessons learned during the course of execution. We provide several recommendations to assist other efforts to implement Evidence-Based Treatments into state systems of care.

Adult-diagnosed Chronic Granulomatous Disease: The Need to Increase Awareness.

Chronic granulomatous disease is genetic disorder characterized by the inability of phagocytes to produce sufficient oxidative burst needed to kill intracellular organisms. Patients have recurrent, life-threatening infections involving multiple systems including the lungs, skin, lymph nodes, and liver. The majority of patients with chronic granulomatous disease are diagnosed in childhood although some may present in adulthood due to a milder phenotype. Unfortunately, these patients may also present with concomitant autoimmune diseases. We describe a 48-year-old woman with a history of immune thrombocytopenia and systemic lupus erythematosus on immunosuppressive therapy. She developed subsequent bacterial and fungal infections initially attributed to immunosuppressive drugs. Further evaluation revealed the diagnosis of chronic granulomatous disease. We review the diagnosis and treatment of chronic granulomatous disease in hopes to increase awareness of this disease in adulthood in order to initiate potential life-saving prophylactic antibiotics.

Early intervention in youth psychosis: Novel approaches to understanding change.

Untreated psychosis in adolescents and young adults is associated with significant and progressive impairment. Early intervention to provide support and treatment for those at risk of psychosis is essential. Several early intervention models have been developed for those at-risk and those who are victims of a recent episode - including the Portland Identification and Early Referral model (PIER; McFarlane, 2001). This study extends previous work demonstrating a variety of positive treatment outcomes achieved by PIER in the context of a large-scale implementation across the state of Delaware. The sample included 108 youth and young adults who were either at risk for psychosis or had already experienced a first episode within the past two years. Participants received the PIER treatment model and were followed from baseline to six months after they were discharged from treatment. Researchers predicted that PIER participants would experience an increase in functioning and a decrease in positive psychosis symptoms. Change over time was examined through the lens of two analytic techniques: the Reliable Change Index (RCI) analyses and Growth Curve Modeling (GCM). Results show improvement on a number of outcomes over the course of the intervention as expected. Clinical implications, limitations, and suggestions for further research are discussed.

A phase II trial of preoperative concurrent chemotherapy/radiation therapy plus bevacizumab/erlotinib in the treatment of localized esophageal cancer.

PURPOSE: To evaluate the efficacy of bevacizumab (Avastin, Genentech) and erlotinib (Tarceva, Genentech/Roche) when added to preoperative chemoradiation therapy with paclitaxel, carboplatin, and infusional 5-fluorouracil (5-FU) in the treatment of localized cancers of the esophagus or gastroesophageal (GE) junction. The primary endpoint was the pathologic complete response (pCR) rate. METHODS: Eligible patients had previously untreated localized squamous cell, adenocarcinoma, or adenosquamous carcinoma of the esophagus or GE junction, and were considered surgical candidates at enrollment. Daily erlotinib (100 mg orally) was administered on days 1-42 of preoperative treatment. Patients received paclitaxel (200 mg/m2 intravenously [IV]), carboplatin (area under the curve [AUC] 5.0 IV), and bevacizumab (15 mg/kg IV) on days 1 and 22, and 5-FU by continuous infusion (225 mg/m2/day IV) on days 1-35, with radiation therapy in 1.8-Gy single fractions, Monday-Friday (to a total of 45 Gy). Those who were deemed surgical candidates proceeded to resection during weeks 12-14. RESULTS: Between February 2007 and September 2009, 62 patients (median age, 64 years; 92% male; 94% adenocarcinoma) were enrolled; 44 patients (71%) completed neoadjuvant treatment and proceeded to surgery. Eighteen patients (29%) achieved pCR, with partial pathologic remission in an additional 22 patients (35%). Common grade 3/4 toxicities included leukopenia (64%), neutropenia (44%), mucositis/stomatitis (42%), diarrhea (27%), and esophagitis (27%). There were 40 instances of treatment-related hospitalization, and 2 postoperative deaths. CONCLUSIONS: The addition of bevacizumab and erlotinib to neoadjuvant chemoradiation did not demonstrate survival benefit or improved pCR rate over similar regimens. While the overall rates of toxicity were not increased, targeted agent-specific toxicity was evident. Further study of this specific regimen is not warranted.

34-year-old man • chronic lower back pain • peripheral neuropathy • leg spasms with increasing weakness • Dx?

► Chronic lower back pain ► peripheral neuropathy ►leg spasms with increasing weakness.

Persistent fibrosis and decreased cardiac function following cardiac injury in the Ctenopharyngodon idella (grass carp).

Following the discovery of heart regeneration in zebrafish, several more species within the Cyprinidae family have been found to have the same capability, suggesting heart regeneration may be conserved within this family. Although gonad regeneration has been observed in grass carp (Ctenopharyngodon idella), one of the largest cyprinid fish, the species' response to cardiac injury has not been characterized. Surprisingly, we found cardiomyocytes do not repopulate the injured region following cryoinjury to the ventricle, instead exhibiting unresolved fibrosis and decreased cardiac function that persists for the 8-week duration of this study. Additionally, fibroblasts are likely depleted following injury, a phenomenon not previously described in any cardiac model. The data collected in this study indicate that heart regeneration is unlikely in grass carp (C. idella). It is possible that not all members of the Cyprinidae family possesses regenerative capability observed in zebrafish. Further study of these phenomenon may reveal the underlying differences between regeneration versus unresolved fibrosis in heart disease.

Caregiver Behaviors and Child Distress in Trauma Narration and Processing Sessions of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an effective treatment for children impacted by trauma, and non-offending caregivers play an important role in this treatment. This study aims to identify correlates of four caregiver variables that have been identified as predictors of child outcomes in TF-CBT: support, cognitive-emotional processing, avoidance, and blame/criticism. Audio recorded sessions were coded from a community effectiveness trial of TF-CBT that included 71 child-caregiver dyads participating in the trauma narration and processing phase of treatment. Regression analyses were conducted to examine caregiver trauma history and child baseline symptoms (internalizing, externalizing, and posttraumatic stress disorder [PTSD] symptoms) as predictors of caregiver behavior during the trauma processing sessions. Caregivers who reported exposure to more trauma types exhibited more in-session avoidance and also processing during the trauma processing phase of treatment. Child symptoms at baseline did not predict caregiver in-session behaviors. Bivariate correlations were used to investigate concurrent associations between mean levels of in-session caregiver behaviors and in-session child distress (negative emotion, hopelessness, negative behaviors). More caregiver blame/criticism was associated with more in-session child distress on all three measures. Caregiver avoidance was associated with more child negative emotion and hopelessness. Findings may help identify therapeutic targets when working with caregivers to promote change and enhance TF-CBT outcomes.

Processes of Change in Trauma-Focused Cognitive Behavioral Therapy for Youth: An Emotional Processing Theory Informed Approach.

This study examines processes of change in trauma-focused cognitive behavioral therapy (TF-CBT) delivered to a community sample of 81 youth. Emotional processing theory (EPT) is used as an organizational framework. EPT highlights activating and changing pathological trauma-related responses and increasing adaptive responses across cognitive, emotional, behavioral, and physiological domains. We coded sessions during the trauma processing phase of TF-CBT to examine the extent to which pathological and adaptive trauma-related responses were activated across domains. Higher scores indicate that more domains (0-4) were activated at a threshold of moderate to high intensity. Curvilinear change (inverted U, increase then decrease) in multimodal negative response scores across sessions predicted improvement in internalizing and PTSD symptoms at posttreatment. Linear increases in multimodal positive responses predicted improvement in externalizing symptoms. Findings suggest value in activating and changing both pathological and adaptive trauma responses across multiple domains and examining nonlinear patterns of change.

Patient and general practitioner attitudes to healthy lifestyle behaviours and medication following coronary heart disease: an exploratory study.

Patients with coronary heart disease often engage in unhealthy lifestyle behaviours. We explored patients' and general practitioners' (GPs') perceptions about the effectiveness of healthy behaviours and medications for the prevention of further cardiovascular disease. This exploratory study used semi-structured interviews with eight Sydney GPs and 13 of their patients with coronary heart disease. Patients perceived medications to be more effective than healthy behaviours in improving specific aspects of cardiovascular health, such as angina symptoms, cholesterol and blood pressure, whilst GPs perceived that medications were more effective in patients they considered at highest cardiovascular risk, patients with uncontrolled risk factors, or where adherence to healthy behaviours was poor. Among patients we found a negative perception of the effort required to adhere to healthy behaviours and possible underestimation of their future cardiovascular risk. Patients valued support from peers and family. This study opens up avenues for investigation in further research, including whether patient adherence to healthy behaviours may be enhanced by the exploration oftheir perceptions about behaviour effectiveness, barriers and cardiovascular risk and by GP facilitation of practical supports.

Phase II trial of weekly docetaxel, vinorelbine, and trastuzumab in the first-line treatment of patients with HER2-positive metastatic breast cancer.

BACKGROUND: The combinations of trastuzumab/docetaxel and trastuzumab/vinorelbine are highly active in the treatment of patients with HER2-positive metastatic breast cancer (MBC). We investigated the feasibility and safety of a 3-drug combination of trastuzumab, docetaxel, and vinorelbine as first-line therapy in this patient group. PATIENTS AND METHODS: Sixty patients with previously untreated, measurable HER2-positive MBC (immunohistochemistry 3+ and/or fluorescence in situ hybridization positive) were treated with docetaxel 30 mg/m2 intravenously (I.V.) and vinorelbine 25 mg/m2 I.V. on days 1 and 8 of each 3-week cycle. Trastuzumab was given weekly (4-mg/kg loading dose followed by 2 mg/kg/week). Patients were evaluated after 6 weeks; responders/stable patients continued treatment until progression. RESULTS: Patients received a median of 11 treatment cycles (range, 1-22 cycles). Forty-one of 60 patients (68%) had major responses (16 complete responses [27%], 25 partial responses [42%]). An additional 13 patients (22%) had stable disease for > or = 6 months. After a median follow-up of 58 months, median progression-free survival was 12 months (95% CI, 9.1-16.3 months), and the median overall survival was 40.8 months (95% CI, 25-not reached). Neutropenia (72% grade 4) was the most common hematologic toxicity; 8 patients were hospitalized for febrile neutropenia. A total of 67% of patients required dose modifications for neutropenia during cycles 1 or 2. Other grade 3/4 toxicities included fatigue (12%), hyperglycemia (7%), and myalgias (7%). There were no treatment-related deaths. CONCLUSION: The combination of trastuzumab, docetaxel, and vinorelbine is highly active as first-line treatment for patients with HER2-positive MBC. However, this regimen offers no obvious advantages over other less myelosuppressive trastuzumab-containing regimens, and its routine use is not supported by the study.

Exercise, fluid, and nutrition recommendations for the postgastric bypass exerciser.

UNLABELLED: To review the literature for nutritional, fluid, and exercise recommendations in patients who have undergone bariatric surgery. DATA SOURCES: PubMed (1980 - October 2008). The bibliographies of selected literature were reviewed for additional sources. A systematic review of the literature is presented. There is little high-quality evidence to support any recommendations currently. Most recommendations are expert opinion. Nutritional deficiencies are common. Routine screening and nutrient replacement is adequate for most deficiencies. Increased physical activity before surgery is associated with improved quality of life. Walking is adequate as a primary activity after surgery. Pedometers may serve as a useful tool to help guide exercise recommendations. There is need for further research upon specific exercise recommendations.

Lessons from the TAPS study--managing investigation results--is your practice system safe?

The TAPS study found that errors in the process of providing health care were reported by general practitioners more than twice as often as deficiencies in a clinician's knowledge or skills. Approximately 20% of these process error events concerned investigations. In addition, some reported events that related to investigations included filing system and recall errors, which accounted for a further 10% of reported error events.