Reto Kofmehl

Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review.

BACKGROUND CONTEXT Psychological factors including catastrophizing thoughts are believed to influence the development of chronic low back pain (LBP). PURPOSE To assess the prognostic importance of catastrophizing as a coping strategy in patients with LBP. STUDY DESIGN This is a systematic review. PATIENT SAMPLE This study included patients with LBP. OUTCOME MEASURES Work-related outcomes and perceived measures including return to work, pain, and disability. METHODS In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, Medline, Scopus, and Web of Science. To ensure completeness of the search, a hand search and a search of bibliographies were conducted and all relevant references included. All observational studies investigating the prognostic value of catastrophizing in patients with LBP were eligible. Included were studies with 100 and more patients and follow-up of at least 3 months. Excluded were studies with poor methodological quality, short follow-up duration, and small sample size. RESULTS A total of 1,473 references were retrieved, and 706 references remained after the removal of duplicates. For 77 references, the full text was assessed and 19 publications based on 16 studies were included. Of four studies that investigated work-related outcomes, two found catastrophizing to be associated with work status. Most studies that investigated self-reported outcome measures (n=8, 66%) found catastrophizing to be associated with pain and disability at follow-up in acute, subacute, and chronic LBP patients. In most studies that applied cutoff values, patients identified as high catastrophizers experienced a worse outcome compared with low catastrophizers (n=5, 83%). CONCLUSIONS There is some evidence that catastrophizing as a coping strategy might lead to delayed recovery. The influence of catastrophizing in patients with LBP is not fully established and should be further investigated. Of particular importance is the establishment of cutoff levels for identifying patients at risk.

Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review.

Study Design. Systematic review. Objective. The aim of this study was to assess the effect of catastrophizing on treatment efficacy and outcome in patients treated for low back pain. Summary of Background Data. Psychological factors including catastrophizing thoughts are thought to increase the risk for chronic low back pain. The influence of catastrophizing is debated. Methods. In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, EMBASE, OTseeker, PeDRO, PsycINFO, MEDLINE, Scopus, and Web of Science. For 50 of 706 references, full text was assessed. Results based on 11 studies were included in this analysis. Results. In the 11 studies, a total of 2269 patients were included. Seven studies were of good and 4 of moderate methodological quality. Heterogeneity in study settings, treatments, outcomes, and patient populations impeded meta-analysis. Catastrophizing at baseline was predictive for disability at follow-up in 4 studies and for pain in 2 studies. Three studies found no predictive effect of catastrophizing. A mediating effect was found in all studies (n = 5) assessing the impact of a decrease in catastrophizing during treatment. A greater decrease was associated with better outcome. Most studies that investigated the moderating effects on treatment efficacy found no effect (n = 5). However, most studies did not look for a direct interaction between the treatment and catastrophizing thoughts. No study investigated the influence of catastrophizing on work-related outcomes including return to work. Conclusion. Catastrophizing predicted degree of pain and disability and mediated treatment efficacy in most studies. The presence of catastrophizing should be considered in patients with persisting back pain. Limited evidence was found for the moderating effects on treatment efficacy. Future research should aim to clarify the role of catastrophizing as a moderator of outcome and investigate its importance for work-related outcomes. Level of Evidence: 1

Anaesthesia in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: retrospective analysis of a single centre three-year experience

BackgroundCytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option for selected patients with peritoneal carcinomatosis. There are limited data available on anaesthesia management and its impact on patients’ outcome. Our aim was to retrospectively analyze and evaluate perioperative management and the clinical course of patients undergoing CRS/HIPEC within a three-year period.MethodsAfter ethic committee approval, patient charts were retrospectively reviewed for patient characteristics, interventions, perioperative management, postoperative course, and complications. Analysis was intervention based. Data are presented as median (range).ResultsBetween 2009 and 2011, 54 consecutive patients underwent 57 interventions; median anaesthesia time was 715 (range 370 to 1135) minutes. HIPEC induced hyperthermia with an overall median peak temperature of 38.1 (35.7-40.2)°C with active cooling. Bleeding, expressed as median blood loss was 0.8 (0 to 6) litre and large fluid shifts occurred, requiring a total fluid input of 8.4 (4.2 to 29.4) litres per patient. Postoperative renal function was dependent on preoperative function and the type of fluids used. Administration of hydroxyethyl starch colloid solution had a significant negative impact on renal function, especially in younger patients. Major complications occurred after 12 procedures leading to death in 2 patients. Procedure time and need for blood transfusion were associated with a significantly higher risk for major complications.ConclusionsCytoreductive surgery with HIPEC is a high-risk surgical procedure associated with major hemodynamic and metabolic changes. As well as primary disease and complexity of surgery, we have shown that anaesthesia management, the type and amount of fluids used, and blood transfusions may also have a significant effect on patients’ outcome.

Elderly age is not a negative predictive factor for virological response to therapy with pegylated interferon‐α and ribavirin in chronic hepatitis C virus patients

Age is frequently discussed as negative host factor to achieve a sustained virological response (SVR) to antiviral therapy of chronic hepatitis C. However, elderly patients often show advanced fibrosis/cirrhosis as known negative predictive factor. The aim of this study was to assess age as an independent predictive factor during antiviral therapy.

Role of arterial hypertension as a predictive marker for bevacizumab efficacy in recurrent glioblastoma – a prospective analysis

Treatment options are limited for patients who experience a relapse in glioblastoma (gBm) after initial treatment with surgery, radiotherapy and chemotherapy. The use of anti-angiogenic agents has become part of a salvage-treatment in recurrent gBm in many countries, although an internationally standardised salvage regimen is still lacking. antiangiogenic drugs primarily target vascular endothelial growth factors (vEgF) or its receptors. in glioblastoma vEgF is highly expressed, hence, inhibition of vEgF appears to be a rational therapeutic approach. Bevacizumab is a humanised monoclonal antibody specifically inhibiting vEgF, thus preventing the interaction with vEgF receptors on tumour and on vascular endothelial cells. However, anti-angiogenic agents share common adverse effects, including arterial hypertension [1–3]. The causal mechanism behind induced hypertension by anti-angiogenic drugs is still elusive. vEgF upregulates nitric oxide and prostacyclin, leading to vasodilatation, which is counteracted by bevacizumab [4]. Furthermore, bevacizumab counteracts microvascular network formation, which is required for maintenance of normal blood pressure [3]. Blood pressure elevation induced by bevacizumab may predict the efficacy of the drug [5]. in fact, several retrospective series of patients with renal cell carcinoma (n  53) [6], colorectal carcinoma (n  39 and n  181) [7,8] and melanoma (n  35) [9] have postulated a correlation of blood pressure elevation and better outcome with bevacizumab. However, in a retrospective series of patients with recurrent gBm (n  51) this observation could not be confirmed [10]. more recently, Lombardi et al. [11] retrospectively analysed 53 patients with recurrent gBm treated with two distinct antiangiogenic drugs, sorafenib (n  30) and bevacizumab (n  23). Twenty patients (38%) developed grades 2–3 hypertension according to common toxicity criteria of adverse events (CTCaE) version 4, indicating a medical intervention. interestingly hypertension occurred as early as within two months of treatment with bevacizumab. in their study, a significant association was found between hypertension and disease control rate. according to univariate and multivariate analyses, hypertension was related to a longer median survival from anti-angiogenic drug administration, and was reported to be 9.8 versus 4.8 months (p  0.001; hazard ratio  3.5, 95% Ci 1.6–7.6). The authors postulated that the development of hypertension might be a predictive biomarker in patients with recurrent gBm treated with anti-angiogenic drugs. Predictive markers for response to antiangiogenic treatment are urgently needed to guide clinical decision making, to destine therapy towards a well-selected subgroup of patients and to guarantee cost-effectiveness. To compare different study results, definition of hypertension caused by bevacizumab is a key factor. The CTCaE version 4 criteriaand grading system is the most frequent used instrument for toxicity assessment in oncology and thus appropriate for comparison. We aimed to prospectively investigate the role of hypertension induction as a potential predictive marker for bevacizumab efficacy in recurrent highgrade glioma.

Ross procedure: is the root replacement technique superior to the sub-coronary implantation technique? Long-term results

There is controversy over the use of the Ross procedure with regard to the sub-coronary and root replacement technique and its long-term durability. A systematic review of the literature may provide insight into the outcomes of these two surgical subvariants. A systematic review of reports between 1967 and February 2013 on sub-coronary and root replacement Ross procedures was undertaken. Twenty-four articles were included and divided into (i) sub-coronary technique and (ii) root replacement technique. The 10-year survival rate for a mixed-patient population in the sub-coronary procedure was 87.3% with a 95% confidence interval (CI) of 79.7-93.4 and 89.1% (95% CI, 85.3-92.1) in the root replacement technique category. For adults, it was 94 vs 95.3% (CI, 88.9-98.1) and in the paediatric series it was 90 vs 92.7% (CI, 86.9-96.0), respectively. Freedom from reoperation at 10 years was, in the mixed population, 83.3% (95% CI, 69.9-93.4) and 93.3% (95% CI, 89.4-95.9) for sub-coronary versus root replacement technique, respectively. In adults, it was 98 vs 91.2% (95% CI, 82.4-295.8), and in the paediatric series 93.3 vs 92.0% (95% CI, 86.1-96.5) for sub-coronary versus root replacement technique, respectively. The Ross procedure arguably has satisfactory results over 5 and 10 years for both adults and children. The results do not support the advantages of the sub-coronary technique over the root replacement technique. Root replacement was of benefit to patients undergoing reoperations on neoaorta and for long-term survival in mixed series.

Validation of a diagnostic probability function for estimating probabilities of acute coronary syndrome.

BackgroundWe recently reported about the derivation of a diagnostic probability function for acute coronary syndrome (ACS). The present study aims to validate the probability function as a rule-out criterion in a new sample of patients.Methods186 patients presenting with chest pain and/or dyspnea at one of the three participating hospitals’ emergency rooms in Switzerland were included in the study. In these patients, information on a set of pre-specified variables was collected and a predicted probability of ACS was calculated for each patient. Approximately two weeks after the initial visit in the emergency room, patients were contacted by phone to assess whether a diagnosis of ACS was established.ResultsOf the 186 patients included in the study, 31 (17%) had an acute coronary syndrome. A risk probability for ACS below 2% was considered a rule-out criterion for ACS, leading to a sensitivity of 87% and a specificity of 17% of the rule. The characteristics of the study patients were compared to the cases from which the probability function was derived, and considerable deviations were found in some of the variables.ConclusionsThe proposed probability function, with a 2% cut-off for ruling out ACS works quite well if the patient data lie within the ranges of values of the original vignettes. If the observations deviate too much from these ranges, the predicted probabilities for ACS should be seen with caution.