Adeeb Derakhshan

The impact of preoperative depression on quality of life outcomes after lumbar surgery

BACKGROUND CONTEXT Some, smaller studies have investigated the effect of preoperative depression on postoperative improvement in quality of life (QOL). However, they have not used the Patient Health Questionnaire 9 (PHQ-9) in self-reported depression. PURPOSE To assess the effect of preoperative depression as measured by the PHQ-9 on postoperative improvement in QOL. STUDY DESIGN A retrospective review at a single tertiary-care referral center. PATIENT SAMPLE Patients who underwent lumbar decompression or fusion between 2008 and 2012. OUTCOMES MEASURES A self-reported EuroQol five-dimensions (EQ-5D) quality-adjusted life-years Index. METHODS Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. The EQ-5D questionnare, PDQ, and PHQ-9 were used. Linear and logistic regression analyses were performed to assess the impact of preoperative depression on QOL improvement. RESULTS Elevated preoperative pain (PDQ, β=-0.0017, p=.0009) and worsened depression (PHQ-9, β=-0.0044, p=.0359) were significantly associated with diminished postoperative improvement in QOL, as measured by the EQ-5D. Furthermore, greater depression (PHQ-9, odds ratio [OR] 0.93, p<.0001) and pain (PDQ, OR 0.99, p=.02) were associated with significantly diminished postoperative improvement exceeding the minimum clinically important difference. CONCLUSIONS Increased preoperative pain and depression were shown to be associated with significantly reduced improvement in postoperative QOL, as measured by the EQ-5D.

Predicting C5 palsy via the use of preoperative anatomic measurements

BACKGROUND CONTEXT C5 nerve root palsy (C5P) is a relatively rare complication after anterior and posterior cervical decompression surgery that leads to a variety of debilitating symptoms. The precise etiology remains obscure, and a clear understanding of preoperative risk factors for C5P development does not exist. PURPOSE To determine whether postoperative C5P can be predicted from preoperative anteroposterior diameter (APD), foraminal diameter (FD), and/or cord-lamina angle (CLA). STUDY DESIGN Retrospective review. PATIENT SAMPLE Consecutive patients who underwent either anterior or posterior decompression surgery at C4-C5 for cervical spondylotic myelopathy. OUTCOME MEASURES Development of C5P. METHODS Blinded reviewers retrospectively assessed magnetic resonance images for each included patients C4-C5 interspace, including the midline APD, the left and right FDs, and the left and right CLA. Multivariable logistic regression was used to model the probability of palsy on the basis of one or more predictors. A jackknife validation was performed to internally validate the model and assess its generalizability. RESULTS A total of 98 patients fit the inclusion criteria; 12% had developed symptoms of C5 palsy postoperatively. Using the three variables in a predictor-model, we found that the odds ratio of having palsy for APD, FD, and CLA was 0.3, 0.02, and 1.4, respectively. For every 1-mm increase in APD and FD, the odds of developing palsy decrease 69% (p<.0001) and decrease 98% (p<.0003), respectively. In contrast, for every 1-degree increase in CLA, the odds of developing palsy increase by 43% (p<.0001). The receiver-operating characteristic curve for this three-variable model predicting development of palsy has an area under the curve (concordance index) of 0.97. After implementing a jackknife validation, the area under the curve was 95%. CONCLUSIONS This study is the first to use the combination of APD, FD, and CLA to predict development of postoperative C5 palsy after decompression surgery for patients with spondylotic myelopathy. This prediction formula may allow for better patient selection and to prepare patients that have an increased probability of developing this complication.

Formation of dimethylketene and methacrolein by reaction of the CH radical with acetone

The reaction of the methylidyne radical (CH) with acetone ((CH(3))(2)C[double bond, length as m-dash]O) is studied at room temperature and at a pressure of 4 Torr (533.3 Pa) using a multiplexed photoionization mass spectrometer coupled to the tunable vacuum ultraviolet synchrotron radiation of the Advanced Light Source at Lawrence Berkeley National Laboratory. The CH radicals are generated by 248 nm multiphoton photolysis of bromoform and react with acetone in an excess of helium and nitrogen gas flow. The main observed reaction exit channel is elimination of a hydrogen atom to form C(4)H(6)O isomers. Analysis of photoionization spectra identifies dimethylketene and methacrolein as the only H-elimination products. The best fit to the data gives branching ratios of 0.68 ± 0.14 for methacrolein and 0.32 ± 0.07 for dimethylketene. A methylketene spectrum measured here is used to reanalyze the photoionization spectrum obtained at m/z = 56 for the CH + acetaldehyde reaction, (Goulay et al., J. Phys. Chem. A, 2012, 116, 6091) yielding new H-loss branching ratios of 0.61 ± 0.12 for acrolein and 0.39 ± 0.08 for methylketene. The contribution from methyleneoxirane to the reaction product distribution is revised to be negligible. Coupled with additional product detection for the CD + acetone reaction, these observations pave the way for development of general set of reaction mechanisms for the addition of CH to compounds containing an acetyl subgroup.

The Impact of Socioeconomic Status on the Utilization of Spinal Imaging.

BACKGROUND Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population. OBJECTIVE To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed. METHODS Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status. RESULTS A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs. CONCLUSION Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.

SMAC Mimetic Birinapant plus Radiation Eradicates Human Head and Neck Cancers with Genomic Amplifications of Cell Death Genes FADD and BIRC2

Comparison of tumors from The Cancer Genome Atlas (TCGA) reveals that head and neck squamous cell carcinomas (HNSCC) harbor the most frequent genomic amplifications of Fas-associated death domain (FADD), with or without Baculovirus inhibitor of apoptosis repeat containing BIRC2 (cIAP1), affecting about 30% of patients in association with worse prognosis. Here, we identified HNSCC cell lines harboring FADD/BIRC2 amplifications and overexpression by exome sequencing, RT-PCR, and Western blotting. In vitro, FADD or BIRC2 siRNA knockdown inhibited HNSCC displaying amplification and increased expression of these genes, supporting their functional importance in promoting proliferation. Birinapant, a novel SMAC mimetic, sensitized multiple HNSCC lines to cell death by agonists TNFα or TRAIL and inhibited cIAP1>XIAP>IAP2. Combination of birinapant and TNFα induced sub-G0 DNA fragmentation in sensitive lines and birinapant alone also induced significant G2-M cell-cycle arrest and cell death in UM-SCC-46 cells. Gene transfer and expression of FADD sensitized resistant UM-SCC-38 cells lacking FADD amplification to birinapant and TNFα, supporting a role for FADD in sensitization to IAP inhibitor and death ligands. HNSCC varied in mechanisms of cell death, as indicated by reversal by inhibitors or protein markers of caspase-dependent apoptosis and/or RIPK1/MLKL-mediated necroptosis. In vivo, birinapant inhibited tumor growth and enhanced radiation-induced TNFα, tumor responses, and host survival in UM-SCC-46 and -11B xenograft models displaying amplification and overexpression of FADD+/- BIRC2 These findings suggest that combination of SMAC mimetics such as birinapant plus radiation may be particularly active in HNSCC, which harbor frequent FADD/BIRC2 genomic alterations. Cancer Res; 76(18); 5442-54. ©2016 AACR.

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases.

Study Design: A multicenter, retrospective review of C5 palsy after cervical spine surgery. Objective: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery. Methods: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ2 tests or Fisher exact tests for categorical variables. Results: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%). Conclusion: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date.

Neurologic complications, reoperation, and clinical outcomes after surgery for vertebral osteomyelitis

Study Design. A consecutive retrospective cohort study from 2008 to 2013 at a single tertiary-care institution was conducted. Objective. The aim of the study was to characterize recovery from pain and neurologic deficit after surgery for vertebral osteomyelitis (VO), and identify incidence of postoperative adverse events. Summary of Background Data. A minority of patients with VO require surgery. Although prior studies have characterized outcomes after medical management, the morbidity after surgery is poorly defined. Methods. The primary outcome was change from baseline in a Modified McCormick Scale (MMS, 1–5 scale), whereas secondary outcomes included reoperation and change in self-reported pain Visual Analog Scale (VAS, 0–10 scale). MMS and VAS were collected throughout the postoperative course as surrogates for neurologic function and degree of pain. Intraoperative, short-term postoperative (<30 d), and long-term neurologic complications were recorded. New-onset neurologic deficits in the postoperative period were considered neurologic complications. Results. Fifty patients were included; a majority (52%) presented with a neurologic deficit. The median length of follow-up was 18 months. A statistically significant improvement in MMS was observed by 12 months postoperatively, whereas an improvement in VAS was observed by 3 months. The mean improvement in MMS at last follow-up was 0.35, whereas the mean improvement in VAS was 3.40. One quarter of patients required reoperation. At 24 months postoperatively, 10% died, 26% underwent reoperation, 42% experienced a neurologic complication, and 60% experienced at least one of these 3 adverse events. Conclusion. This is the first study to investigate neurologic complications, reoperation, and pain in a longitudinal manner after surgery for VO. We observed statistically significant improvements in MMS and VAS in the postoperative period. Despite these improvements, the 24-month incidence of overall adverse events was 60%. Patients and clinicians should be aware of the clinical improvement but high incidence of adverse events after surgical management of VO. Level of Evidence: 4

Cost-Utility Analysis of 1- and 2-Level Dorsal Lumbar Fusions With and Without Recombinant Human Bone Morphogenic Protein-2 at 1-Year Follow-Up.

Study Design: A retrospective 1-year cost-utility analysis. Objective: To determine the cost-effectiveness of using recombinant human bone morphogenic protein (rhBMP-2) in addition to autograft for 1- and 2-level lumbar fusions. Summary of Background Data: rhBMP-2 has been studied extensively to identify its benefits, risks, patient outcomes, and costs relative to autograft [local bone or iliac crest bone graft (ICBG)]. This study seeks to analyze the cost-effectiveness of adding rhBMP-2 to autograft versus without rhBMP-2 in lumbar fusions. Methods: Thirty-three patients receiving rhBMP-2 in addition to either local bone autograft or ICBG (rhBMP-2 cohort) and 42 patients receiving only local bone autograft or ICBG (control cohort) for 1- or 2-level dorsal lumbar fusion were analyzed. This included posterolateral fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion. One-year postoperative health outcomes were assessed based on Visual Analogue Scale, Pain Disability Questionnaire, Patient Health Questionnaire, and EuroQol-5 Dimensions questionnaires. Direct medical costs were estimated using Medicare national payment amounts and indirect costs were based on patient missed work days and patient income. Postoperative 1-year cost-utility ratios and the incremental cost-effectiveness ratio (ICER) were calculated to assess for cost-effectiveness using a threshold of

A Multicenter Study of the Presentation, Treatment, and Outcomes of Cervical Dural Tears

100,000/QALY gained. Results: The 1-year cost-utility ratio (total cost/&Dgr;QALY) for the control cohort was significantly lower (

Abstract 3821: Targeted therapy for head and neck squamous cell carcinoma using the novel SMAC-mimetic birinapant

143,251/QALY gained) than that of the rhBMP-2 cohort (