Symptomatic Level Research Articles

ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire.

Support for ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing; however, few studies include refugees or examine the clinical utility of PTSD/CPTSD classifications. This study sought to provide the first evaluations of (i) the factor structure of ICD-11 PTSD/CPTSD amongst refugees in the Middle East; and (ii) the clinical utility of the International Trauma Questionnaire (ITQ) to identify PTSD/CPTSD in a humanitarian context. Participants were 112 treatment-seeking Syrian refugees living in Lebanon. Factorial validity was assessed using confirmatory factor analysis (CFA) based on responses to the ITQ. Clinical utility of the ITQ was assessed through semi-structured interviews with six Lebanese psychotherapists. Complex PTSD (36.1%) was more common than PTSD (25.2%), and no sex or age differences were observed at the prevalence or symptomatic levels. CFA results supported a two-factor higher-order model consistent with ICD-11 PTSD/CPTSD. Qualitative findings indicated that the ITQ is generally positively regarded, with some limitations and suggested modifications noted. This is the first study to support the ICD-11 PTSD/CPTSD amongst refugees in the Middle East and the clinical utility of the ITQ in a humanitarian context. Findings support the growing evidence for the cross-cultural applicability of ICD-11 PTSD/CPTSD.

Dynamic changes in the reflex exam of patients with sub-axial cervical stenosis

Though dynamic changes in the physical exam of patients being evaluated for cervical spine pathology have been reported, there is limited information on the prevalence and clinical features associated with reflex changes in a population undergoing surgical evaluation for cervical spine pathology. Fifty-one patients with at least grade 1 cervical stenosis on MRI underwent initial surgical evaluation for cervical spine pathology. All patients received complete neurologic examinations including dynamic reflex testing in three positions (neck neutral, extended, and flexed) by 2 spine surgeons. The average age was 58.7 years (range, 34–80), with 28 (55%) patients being male. Stenosis at the symptomatic levels was grade 1 in 18 patients (35%), grade 2 in 11 (21%), and grade 3 in 22 (43%). Twenty-one patients (41%) had a dynamic change in reflex exam. The most common change in reflex exam was seen in the Hoffman’s reflex with 14 patients (28%). Patients with grade 3 stenosis were more likely to have a static Hoffman’s reflex (64%) compared with grade 1 (17%) and grade 2 (18%) (p < 0.05). Patients with grade 3 stenosis had a higher rate of either a static or dynamic Hoffman’s reflex (82%) compared with grade 1 (44%) (p < 0.05), but there was no difference between grade 3 and grade 2 (64%) (Table 2). Dynamic changes in reflex exam are commonly seen in patients being evaluated for symptomatic cervical stenosis. The routine neurologic exam can be supplemented with dynamic reflex testing, especially in cases where clinical history or imaging is concerning for cervical myelopathy.

Friday, September 28, 2018 10:30 AM–12:00 PM abstracts: deformity: technical factors: 165. Sagittal imbalance in degenerative scoliosis can be corrected by addressing only the symptomatic levels in carefully selected patients: a retrospective radiographic study

BACKGROUND CONTEXT The optimal method of addressing the positive sagittal imbalance often present in degenerative scoliosis (DS) is controversial. An important distinction is whether or not the etiology of the loss of lumbar lordosis (LL) and positive sagittal imbalance often seen on preoperative radiographs, is truly structural, or whether it is more positional in nature given that spinal stenosis is almost always present in DS patients who require surgery. This distinction directly affects the decision about whether or not, in addition to decompression, the entire curve needs to be addressed (regional or global fusion), or if a lesser local fusion of only the symptomatic levels can be performed with a satisfactory radiographic result. PURPOSE This study aims to determine (1) if the loss of LL often associated with DS is structural or rather largely due to positional factors secondary to spinal stenosis, and (2) if the entire DS curve or a lesser local fusion of only the neurologically symptomatic levels need to be addressed. STUDY DESIGN/SETTING Retrospective case series. PATIENT SAMPLE We obtained radiographic and clinical data on 114 consecutive patients. We included patients if they had loss of normal LL (positive sagittal imbalance) observed on preoperative radiographs and underwent a decompression and instrumented posterolateral inter-transverse process arthrodesis of only their neurologically symptomatic levels in the setting of DS. We excluded patients if they had undergone a previous fusion, concomitant osteotomy procedure, or any type of interbody arthrodesis, or had less than 6 months follow-up. Of the original 114 patients identified, 68 fulfilled the above criteria. OUTCOME MEASURES Pre- and postoperative radiographs were reviewed to measure lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope. Postoperative radiographs were also measured against preoperative extension lumbar radiographs and lumbar magnetic resonance imaging (MRI) to compare changes in radiographic pelvic parameters. METHODS Three independent members of the research team performed all measurements. Inter-rater reliability was calculated using a Pearson coefficient test and a strong correlation was considered if R>0.8. The three sets of measurements were then averaged for final statistical analysis. Relationships were considered significant at p RESULTS Average follow-up was 22 months. In addition to decompression, instrumented fusion was most commonly performed from L4 to S1 (N=17), followed by L3-S1 (N=12). The average PI found preop and postop was 52° and 53°, respectively. The average PT found preop and postop was 24° and 27°, respectively. Preoperative LL had a mean Cobb angle of 32° (range 2°–60°). Preop MRIs and lumbar extension radiographs revealed an average LL of 42° (range 10°–66°) and 48° (range 20°–74°), respectively. Initial postop radiographs (average 3 weeks) revealed that LL was corrected to a mean of 44° (range 14°–68°, p CONCLUSIONS We were able to correct LL to within 10° of the PI in this cohort of symptomatic DS patients with decompression and local instrumented fusion of symptomatic levels only. Loss of LL in symptomatic DS patients has a large positional component likely due to stenosis. Preoperative MRI and extension radiographs can be used to predict achievable postoperative LL correction.

Intensive care support and clinical outcomes of patients with Ebola virus disease (EVD) in West Africa

PurposeWe investigate the impact on outcome of different levels of supportive treatment in Ebola virus disease (EVD). The NGO EMERGENCY delivered care sequentially at two Ebola Treatment Centres (ETC) in Sierra Leone: first at Lakka (fluids, symptomatic, antibiotic, antimalaria treatment, and hospital level medical care), and thereafter in Goderich, adding organ support in the only African ETC with an equipped and staffed intensive care unit (ETC-ICU).MethodsThe primary outcome in this retrospective cohort study was in-ETC mortality. Secondarily, we used multivariable logistic regression to investigate the independent impact of the IC on mortality by comparing patients in two ETCs, adjusting for potential confounders, including the viral load (base-10 logarithm in copies/ml) (LVL), modelled as a piecewise linear function. Mortality was plotted versus LVL. Confidence bands were constructed by a bootstrap technique. The number of hospital-free days within 28 was computed to assess the burden of EVD.ResultsData from 229 EVD patients were analysed (123 in Lakka, 106 in Goderich). Crude analysis showed a non-statistically significant difference in mortality (57.7% in Lakka vs 50.0% in Goderich; p = 0.19). Age and LVL were associated with mortality. Adjusted mortality was lower at the Goderich ICU-ETC (p = 0.055). This difference was observed with 80% confidence for patients with LVL between 7.5 and 8.5 copies/ml. Hospital-free days (of 28 days) were greater (7.7 vs 5.5; p = 0.03) for patients treated in the ICU-ETC.ConclusionsProvision of critical care to patients with EVD is feasible in resource-limited settings and was associated with improved survival and less time in hospital.

Androgen replacement therapy in men: current evidence and controversy

The decline in Testosterone (T) levels in the ageing male - known as andropause or late-onset hypogonadism - may be responsible for several aspects of quality of life decline in older men: erectile dysfunction, impaired libido, decreased strength and energy, sarcopenia, osteopenia, fatigue and even depression in some cases. Many of these signs and symptoms represent the same alterations that are usually attributed to the process of ageing. When some individual presents with such symptoms, hypogonadism should be suspected, and serum T level should be evaluated. Men who are symptomatic and present low levels of serum Testosterone (generally below 300 ng/ml) are candidates for T replacement therapy. Current evidence shows that, when correctly selected, patients receiving T replacement may benefit from improvement in libido, erectile function, overall and sexual related quality of life, bone density and muscle mass. Conversely, patients with physiological circulating levels of T who receive hormone, aiming at supraphysiologic levels, may face severe side effects, including testicular atrophy and behavioral changes. Of note, T replacement, regardless of age and pre-therapy levels, leads to fertility impairment which can be transient or persistent. Direct testosterone replacement should not be indicated in men who wish to conceive children, although other options are available. The effect of Testosterone replacement on prostate cancer and on cardiovascular risk is still controversial; hypogonadal men known to have prostate cancer or high cardiovascular risk should be examined individually to have their risks stratified and mitigated.

Abstract LB-105: Combining CD4+ T cell transfer and immune checkpoint blockade demonstrates the power of combined immunotherapies for treatment of progressed solid carcinomas in mice

Abstract Tumor and immune cells express inhibitory immune checkpoints (ICP) that paralyze tumor infiltrating T cells. ICP-specific antibodies (mAbs) can block and restore T cell functions and promote anti-tumoral effects. Also, tumor-antigen specific IFN-y secreting CD4+ T cells (TA-Th1) mediate strong anti-tumoral effects and can induce senescence in cancer cells. Here, we report on the development and immunological characterization of a highly efficient TA-Th1 and checkpoint-inhibitor based combined immunotherapy (CIT) in a progressed endogenous cancer model. Mice bearing progressed pancreatic islet carcinomas (RIP1-Tag2) and symptomatic low blood glucose levels (BGL; ~80 mg/dl) were treated weekly with TA-Th1 and αPD-L1+αLAG-3 mAbs (PDL1/LAG3) after an initial preparative 2 Gy-whole body radiation. Therapy was monitored by BGL measurements. Additionally, we conducted baseline and follow-up 18F-FDG PET/MRI scans to uncover the splenic glucose metabolism as a consequence of immune cell activation. We performed ex vivo flow cytometry (FC), immunohistochemistry (IHC), and fluorescent microscopy (FM) of tumor tissue and lymphatic organs at early (1 wk) and late (3-4 wks; endpoint of SHAM treated mice) time point of treatment focusing on the immune cell composition, activation patterns and senescence induction. Treatment exclusively with TA-Th1 prolonged the median survival of the mice from 14 to 18 wks (n=14) while ICP blockade without TA-Th1 cells was not efficient at all (PDL1/LAG3; median survival=14wks, n=11). The combination of TA-Th1 and PDL1/LAG3 (CIT) was highly efficient and significantly extended the median survival to 20 wks (n=15, p=0.001). Thus, exclusively CIT-treated mice revealed very small tumors and a strong lymphocytic infiltrate. FC analysis demonstrated early and specific homing of highly activated (CD69) TA-Th1 into the draining LN without impairment of the endogenous CD8+ T cell population. After 4 wks of treatment, we determined an increase in endogenous effector CD4+ and CD8+ T cells exclusively in mice receiving TA-Th1, indicating cross-priming as a possible mechanism of T cell activation. Analysis of p16/Ki67 expression in tumors revealed a strongly enhanced p16 and reduced Ki67 expression exclusively in CIT-treated mice indicating tumor senescence which was not observed in control groups. 18F-FDG-PET/MRI of the spleen showed a significantly increased glucose metabolism in CIT treated mice when compared to SHAM-treatment. In conclusion, our newly developed CIT (2 Gy+TA-Th1+PDL1/LAG3) strongly promoted an anti-tumor immune response in mice with progressed solid cancer. Most importantly, only CIT was able to induce TA-Th1 mediated tumor senescence whereas TA-Th1 or PDL1/LAG3 mAbs alone were inefficient. Moreover, 18F-FDG-PET/MRI of the spleen might represent a novel powerful tool to stratify ICP-blocked responders. Thus, ICP-blockade is applicable to reinforce Th1-cell based immunotherapies and to prolong the lifespan of mice with progressed solid carcinomas. Citation Format: Barbara F. Schörg, Dominik Sonanini, Johannes Schwenck, Christoph Griessinger, Birgit Fehrenbacher, Martin Schaller, Ursula Kohlhofer, Leticia Quintanilla-Martinez, Christian La Fourgère, Martin Röcken, Bernd J. Pichler, Manfred Kneilling. Combining CD4+ T cell transfer and immune checkpoint blockade demonstrates the power of combined immunotherapies for treatment of progressed solid carcinomas in mice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-105.

Relationship between Enlargement of the Cross-Sectional Area of the Dural Sac and Neurological Improvements after Cervical Laminoplasty: Differences between Cervical Spondylotic Myelopathy and Ossification of the Posterior Longitudinal Ligament.

Introduction The purpose of this study was to investigate the relationship between postoperative enlargement of the dural sac cross-sectional area at the symptomatic level and neurological improvements after laminoplasty. Methods The cross-sectional areas of the dural sac at the symptomatic level before and after laminoplasty and the expansion ratio (post-/preoperative cross-sectional area) were measured using magnetic resonance imaging in patients with ossification of the posterior longitudinal ligament (OPLL) (n = 25) and patients with cervical spondylotic myelopathy (CSM) (n = 49). The relationships between the expansion ratio and the Japanese Orthopedic Association (JOA) score, JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), and postoperative laminae morphology were investigated. Results In the OPLL group, the expansion ratio was significantly positively correlated with the postoperative JOA score (P = 0.025), recovery rate of the JOA score (P = 0.026), and postoperative change in lower extremity sensory function according to the JOA score (P = 0.0375); furthermore, patients whose JOACMEQ responses indicated positive outcomes for lower extremity function had a significantly larger expansion ratio than patients with negative results (P = 0.027). In the CSM group, the expansion ratio showed no correlation with the JOA and JOACMEQ scores. The expansion ratio was significantly positively correlated with the width between bilateral gutters in both CSM (P = 0.025) and OPLL (P = 0.0451). In the OPLL group, the expansion ratio in those with a gutter position of less than 0.8 was significantly smaller than that those with a gutter position of more than 0.8 (P = 0.0156). However, there was no correlation between the gutter position and the recovery rate of the JOA score. Conclusions In OPLL, insufficient enlargement of the cross-sectional area of the dural sac at the symptomatic level leads to poor neurological improvements after laminoplasty.

Association of Cannabis With Long-Term Clinical Symptoms in Anxiety and Mood Disorders: A Systematic Review of Prospective Studies.

To systematically review studies examining the longitudinal associations between cannabis use and symptomatic outcomes among individuals with an anxiety or mood disorder at baseline. A search of the literature up to May 2017 was conducted using several databases. Search terms related to the exposure (ie, cannabis) and outcome (ie, symptoms) variables of interest. There were no search restrictions. In total, 10,191 citations were screened. Key inclusion criteria related to (1) cohort-based longitudinal study design using adults who met criteria for a mood or anxiety disorder at baseline, (2) an independent variable focusing on at least baseline cannabis use, and (3) a dependent variable focusing on the symptomatic course and/or outcomes in anxiety and mood disorders (AMD). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methodological characteristics and key findings were extracted from each study, and quality assessments were conducted for each study. Twelve studies (with a total of 11,959 individuals) met inclusion criteria related to posttraumatic stress disorder (n = 4), panic disorder (n = 1), bipolar disorder (n = 5), and depressive disorder (n = 2). Across 11 studies, "recent" cannabis use (ie, any/greater frequency of use during the last 6 months) was associated with higher symptomatic levels over time relative to comparison groups (ie, no/lesser frequency of use). Ten of these studies further suggested that cannabis use was associated with less symptomatic improvement from treatment (eg, medication, psychotherapy for AMD). Recent cannabis use was associated with negative long-term symptomatic and treatment outcomes across AMD. The findings should be interpreted with caution, considering the observational designs across studies and the biases associated with the samples (eg, inpatients) and sources of cannabis consumed (ie, unregulated sources). Nonetheless, clinicians can use the insight gained to inform their own and their patients' knowledge concerning potential risks of cannabis with regard to symptoms of AMD.

A comparison of zero-profile anchored spacer (ROI-C) and plate fixation in 2-level noncontiguous anterior cervical discectomy and fusion- a retrospective study

BackgroundAnterior cervical discectomy and fusion (ACDF) is the classic surgical treatment for symptomatic cervical degenerative disc disease (CDDD). However, there is controversy over the best surgical management in patients with two noncontiguous symptomatic levels of CDDD.MethodsFrom April 2011 to May 2014, 44 patients with two noncontiguous symptomatic levels of CDDD underwent skip-level ACDFs. In Group NoPlate, 23 cases underwent 2 noncontiguous levels of ACDF using zero-profile anchored spacer; and in Group Plate, 21 cases underwent 2 noncontiguous levels of ACDF using cages and plates. Operation-related paraeters for each group were recorded and compared. Japanese Orthopedic Association (JOA) scores and Neck Disability Index (NDI) scores at preoperation and postoperation were compared with at least a 2-year follow-up. Cervical lordosis was analyzed before surgery, 1 month after surgery, 3 months after surgery, and at final follow-up.ResultsMean follow-up was 35.4 ± 6.5 (range 24–48) months. Significant improvement on the JOA, NDI scores and cervical lordosis was noted in each group (p < 0.05), and there were no significant difference in terms of JOA, NDI scores, cervical lordosis and fusion rate between the two groups (P > 0.05). The operation time in Group NoPlate was significantly shorter than in Group Plate (p < 0.05), and the incidence of dysphagia and adjacent segment degeneration in Group NoPlate was significantly lower than in Group Plate (p < 0.05).ConclusionsROI-C and cages with plate fixation were both effective in two-level noncontiguous ACDF, and there were no significant difference in clinical outcomes, fusion rate, and cervical lordosis. However, ROI-C was associated with shorter operative time, lower incidence of dysphagia and adjacent segment degeneration.

Effectiveness of Positron Emission Tomography/Computed Tomography as a Guide for Palliative Radiation Therapy for Spinal Metastases

As back pain is the presenting symptom in 95% of patients with epidural spinal metastases, appropriately identifying and treating the most symptomatic levels can provide significant palliation. The purpose of this study was to analyze the ability of combined positron emission tomography (PET)/computed tomography (CT) to identify spinal metastases with high metabolic activity and guide radiotherapy. We sought to correlate improvement in back pain with reduction in standard uptake value (SUV) after treatment. Retrospective review was performed of 72 patients with spinal metastases treated with stereotactic ablative radiation therapy at a single center between 2002 and 2014. PET/CT was used to calculate SUVs for spinal metastases, and treatment planning was based on PET/CT results. Preoperative and postoperative pain levels were assessed in all patients. Reduction in pain scores was found in 78% of treated patients. A significant reduction in pain was identified in patients with >5 metastases compared with fewer lesions (P < 0.05). Degree of change in SUV did not correlate significantly with pain relief. However, comparing pretreatment and posttreatment PET/CT, patients with improved pain consistently displayed decreased SUV. PET/CT was shown to be a useful adjunct in radiation treatment planning with change in SUV correlating with symptomatic improvement. This study paves the way for future prospective studies to further assess utility and cost-effectiveness of this imaging modality in radiation treatment planning for spinal metastases.

Serotonergic Dysfunction in Amyotrophic Lateral Sclerosis and Parkinson's Disease: Similar Mechanisms, Dissimilar Outcomes.

Amyotrophic lateral sclerosis (ALS) and Parkinson's disease (PD) share similar pathophysiological mechanisms. From a neurochemical point of view, the serotonin (5-hydroxytryptamine; 5-HT) dysfunction in both movement disorders—related to probable lesioning of the raphe nuclei—is profound, and, therefore, may be partially responsible for motor as well as non-motor disturbances. More specifically, in ALS, it has been hypothesized that serotonergic denervation leads to loss of its inhibitory control on glutamate release, resulting into glutamate-induced neurotoxicity in lower and/or upper motor neurons, combined with a detrimental decrease of its facilitatory effects on glutamatergic motor neuron excitation. Both events then may eventually give rise to the well-known clinical motor phenotype. Similarly, disruption of the organized serotonergic control on complex mesencephalic dopaminergic connections between basal ganglia (BG) nuclei and across the BG-cortico-thalamic circuits, has shown to be closely involved in the onset of parkinsonian symptoms. Levodopa (L-DOPA) therapy in PD largely seems to confirm the influential role of 5-HT, since serotonergic rather than dopaminergic projections release L-DOPA-derived dopamine, particularly in extrastriatal regions, emphasizing the strongly interwoven interactions between both monoamine systems. Apart from its orchestrating function, the 5-HT system also exerts neuroprotective and anti-inflammatory effects. In line with this observation, emerging therapies have recently focused on boosting the serotonergic system in ALS and PD, which may provide novel rationale for treating these devastating conditions both on the disease-modifying, as well as symptomatic level.

Exploring emotion regulation and emotion recognition in people with presymptomatic Huntington's disease: The role of emotional awareness

Interest in the role of both emotion regulation and recognition in our understanding of mental health has been steadily increasing, especially in people with chronic illness who also have psychological difficulties. One illness which belongs to this category is Huntington's disease. Huntington's disease (HD) is a chronic neurodegenerative disorder that can cause a number of cognitive and psychological difficulties, including emotion recognition deficits, even before the onset of the symptoms required to make a formal diagnosis. Despite the lack of definite evidence, recent studies have suggested that deficits of emotion regulation and recognition may be expected to play a pivotal role in the early cognitive manifestations of HD.In this study, we hypothesised that the ability to regulate emotions can be impaired in people with presymptomatic HD, and that such impairment may be associated with a deficit of emotion recognition. To test this, an online survey was carried out with 117 English and Italian-speaking people with presymptomatic HD, compared to 217 controls matched for age and education.The results suggest that, in presymptomatic participants, emotion regulation and emotion recognition are generally not significantly impaired, and no significant relationships between performances on the two constructs were observed. However, a specific impairment in emotional awareness (a subscale on the Difficulties in Emotion Regulation Scale, DERS) was observed, which appears to be enhanced by the co-occurrence of depressive symptoms, even at a subclinical level. Consequently, it is suggested that difficulties in emotional awareness may represent a precursor of more general emotion recognition impairments, which only become apparent as the disease reaches a more symptomatic level. Clinical implications of the findings are discussed and directions for future research are proposed.

ISSLS PRIZE IN BIOENGINEERING SCIENCE 2018: dynamic imaging of degenerative spondylolisthesis reveals mid-range dynamic lumbar instability not evident on static clinical radiographs.

Degenerative spondylolisthesis (DS) in the setting of symptomatic lumbar spinal stenosis is commonly treated with spinal fusion in addition to decompression with laminectomy. However, recent studies have shown similar clinical outcomes after decompression alone, suggesting that a subset of DS patients may not require spinal fusion. Identification of dynamic instability could prove useful for predicting which patients are at higher risk of post-laminectomy destabilization necessitating fusion. The goal of this study was to determine if static clinical radiographs adequately characterize dynamic instability in patients with lumbar degenerative spondylolisthesis (DS) and to compare the rotational and translational kinematics in vivo during continuous dynamic flexion activity in DS versus asymptomatic age-matched controls. Seven patients with symptomatic single level lumbar DS (6M, 1 F; 66±5.0years) and seven age-matched asymptomatic controls (5M, 2 F age 63.9±6.4years) underwent biplane radiographic imaging during continuous torso flexion. A volumetric model-based tracking system was used to track each vertebra in the radiographic images using subject-specific 3D bone models from high-resolution computed tomography (CT). In vivo continuous dynamic sagittal rotation (flexion/extension) and AP translation (slip) were calculated and compared to clinical measures of intervertebral flexion/extension and AP translation obtained from standard lateral flexion/extension radiographs. Static clinical radiographs underestimate the degree of AP translation seen on dynamic in vivo imaging (1.0 vs 3.1mm; p=0.03). DS patients demonstrated three primary motion patterns compared to a single kinematic pattern in asymptomatic controls when analyzing continuous dynamic in vivo imaging. 3/7 (42%) of patients with DS demonstrated aberrant mid-range motion. Continuous in vivo dynamic imaging in DS reveals a spectrum of aberrant motion with significantly greater kinematic heterogeneity than previously realized that is not readily seen on current clinical imaging. Level V data These slides can be retrieved under Electronic Supplementary Material.

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review.

OBJECTIVE: To review and update the evidence for different forms of manual therapy (MT) and exercise for patients with different stages of non-specific neck pain (NP). Data sources: MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE.METHOD: A qualitative systematic review covering a period from January 2000 to December 2015 was conducted according to updated-guidelines. Specific inclusion criteria only on RCTs were used; including differentiation according to stages of NP (acute – subacute [ASNP] or chronic [CNP]), as well as sub-classification based on type of MT interventions: MT1 (HVLA manipulation); MT2 (mobilization and/or soft-tissue-techniques); MT3 (MT1 MT2); and MT4 (Mobilization-with-Movement). In each sub-category, MT could be combined or not with exercise and/or usual medical care.RESULTS: Initially 121 studies were identified for potential inclusion. Based on qualitative and quantitative evaluation criteria, 23 RCTs were identified for review. Evidence for ASNP: MODERATE-evidence: In favour of (i) MT1 to the cervical spine (Cx) combined with exercises when compared to MT1 to the thoracic spine (Tx) combined with exercises; (ii) MT3 to the Cx and Tx combined with exercise compared to MT2 to the Cx with exercise or compared to usual medical care for pain and satisfaction with care from short to long-term. Evidence for CNP: STRONG-evidence: Of no difference of efficacy between MT2 at the symptomatic Cx level(s) in comparison to MT2 on asymptomatic Cx level(s) for pain and function. MODERATE to STRONG-evidence: In favour of MT1 and MT3 on Cx and Tx with exercise in comparison to exercise or MT alone for pain, function, satisfaction with care and general-health from short to moderate-terms. MODERATE-evidence: In favour (i) of MT1 as compared to MT2 and MT4, all applied to the Cx, for neck mobility, and pain in the very short term; (ii) of MT2 using sof-tissue-techniques to the Cx and Tx or MT3 to the Cx and Tx in comparison to no-treatment in the short-term for pain and disability.CONCLUSION: This systematic review updates the evidence for MT combined or not with exercise and/or usual medical care for different stages of NP and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.

Pragmatically Applied Cervical and Thoracic Nonthrust Manipulation Versus Thrust Manipulation for Patients With Mechanical Neck Pain: A Multicenter Randomized Clinical Trial.

Study Design Randomized clinical trial. Background The comparative effectiveness between nonthrust manipulation (NTM) and thrust manipulation (TM) for mechanical neck pain has been investigated, with inconsistent results. Objective To compare the clinical effectiveness of concordant cervical and thoracic NTM and TM for patients with mechanical neck pain. Methods The Neck Disability Index (NDI) was the primary outcome. Secondary outcomes included the Patient-Specific Functional Scale (PSFS), numeric pain-rating scale (NPRS), deep cervical flexion endurance (DCF), global rating of change (GROC), number of visits, and duration of care. The covariate was clinical equipoise for intervention. Outcomes were collected at baseline, visit 2, and discharge. Patients were randomly assigned to receive either NTM or TM directed at the cervical and thoracic spines. Techniques and dosages were selected pragmatically and applied to the most symptomatic level. Two-way mixed-model analyses of covariance were used to assess clinical outcomes at 3 time points. Analyses of covariance were used to assess between-group differences for the GROC, number of visits, and duration of care at discharge. Results One hundred three patients were included in the analyses (NTM, n = 55 and TM, n = 48). The between-group analyses revealed no differences in outcomes on the NDI (P = .67), PSFS (P = .26), NPRS (P = .25), DCF (P = .98), GROC (P = .77), number of visits (P = .21), and duration of care (P = .61) for patients with mechanical neck pain who received either NTM or TM. Conclusion NTM and TM produce equivalent outcomes for patients with mechanical neck pain. The trial was registered with ClinicalTrials.gov (NCT02619500). Level of Evidence Therapy, level 1b. J Orthop Sports Phys Ther 2018;48(3):137-145. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7738.

Dissociative symptoms mediate the relation between PTSD symptoms and functional impairment in a sample of military members, veterans, and first responders with PTSD

ABSTRACTBackground: Posttraumatic Stress Disorder (PTSD) is associated with significant functional impairment in important areas, including interpersonal relationships and occupational or educational roles. Preliminary evidence suggests that the dissociative subtype of PTSD (PTSD+DS), characterized by marked symptoms of depersonalization and derealization, is associated with increased functional impairment and disease severity, including among military members and veterans diagnosed with PTSD. Similarly, first responders (e.g. police, fire, paramedics) have also been found to experience dissociative symptoms. Despite these findings, little work has investigated whether dissociative symptoms are related to heightened functional impairment among these populations.Objective: We examined the relation between functional impairment and symptom level variables, including dissociative symptoms of depersonalization and derealization among military members, veterans, and first responders with probable PTSD. We further investigated the hypothesis that dissociative symptoms mediate the relation between PTSD symptomatology and functional impairment.Method: Eighty-one medical charts of inpatients at a residential PTSD treatment programme were accessed via retrospective review. Sixty-two were included in the present analyses. Comparison of means on symptom measures between first responders and military members/veterans were conducted, followed by correlational and mediation analyses.Results: Compared with first responders, military members and veterans showed higher levels of derealization, functional impairment, alexithymia, anxiety, and depression. Within the total sample, dissociative symptoms emerged as the strongest correlate of functional impairment and, among the dissociative symptom clusters, derealization symptoms demonstrated the strongest relation with impairment. Mediation analyses revealed that total dissociative symptoms and derealization symptoms significantly mediated the relation between PTSD symptoms and functional impairment.Conclusions: These findings highlight the importance of assessing and treating dissociative symptoms, consistent with the dissociative subtype of PTSD, among military members, veterans, and first responders with PTSD. Successful recovery on a functional and symptomatic level may necessitate treatment of dissociative symptoms, particularly derealization.

The Incidence and Association of Mental Depression with Symptomatic Lumbar Degenerative Disc Disease and Treatment Outcome

Study Design: Prospective analytical study. Objectives: The aim was to determine the association between mental depression and symptomatic Lumbar Degenerative Disc Disease (LDDD) in patients with no previous background of mental disorder. We also aimed at determining the incidence of mental depressions in patients with LDDD and the effects of the treatment on the mental depression. Methodology: One hundred and sixty patients with no prior history of mental or behavioral disorders who presented with low back pains arising from LDDD and met inclusion criteria were studied. The clinical findings and Depression Screening Test pro-forma were completed for each. The extracted information was analyzed using Statistical Package for Social Science (SPSS) version 24.0. The statistical significance was set at P < 0.05. Results: One hundred and fifty-three patients completed the study, with a male to female ratio of 1:1.5 and the mean age of the patients was 48.5 years. The marital status was 4.4% single, 86.9% married, 3.8% divorce/separate and 5% widow/widower. Their levels of education were: no formal education (10.00%), primary school level (8.10%), secondary level (27.50%) and Tertiary level (54.40%). Conclusions: This study showed the incidence of mental depression in 32% of the patients with LDDD. We also noted a statistically significant relationship between symptomatic LDDD and level of mental depression with significant improvement in the level of depression at 6th month after treatment. Hence, assessment of the patients’ mental health is important in the management of LDDD.

Instrumented Posterolateral Spinal Arthrodesis as an Effective Treatment for Single Level Symptomatic Vacuum Lumbar Disc Degeneration in Elderly Patients

Background Data: Lumbar intervertebral disc vacuum phenomenon is an advanced form of spinal destabilizing degenerative changes. It is common in the elderly population and can cause refractory low back pain.Purpose: To evaluate the efficacy and safety of instrumented posterolateral fusion in treating symptomatic lumbar single level vacuum phenomenon in elderly population.Study Design: Retrospective descriptive clinical case series.Patients and Methods: Twenty-one patients (16 males & 5 females), aging more than 65 years, had all their files reviewed. They were operated by instrumented posterolateral fusion to treat chronic refractory low back pain due to single level intervertebral lumbar disc vacuum phenomenon. They underwent operation after failure of adequate 6 months conservative management. Age, gender, symptoms duration, spinal level affected, surgery duration, length of hospital stay, intra or post-operative complications, visual analogue scale VAS for pain, and Lenke’s graft fusion classification at 1, 3 & 6 months postoperatively were all recorded.Results: The results of this study showed the most affected level was L4/L5, mean age was 73±7 years, mean symptoms duration was 11 years, mean surgery duration was 137±29 minutes, and mean VAS for preoperative-postoperative pain improvement was 5.9±1.2. Good fusion (Lenke’s grades A & B) was reported in 81% of patients. No major intra or postoperative complications.Conclusion: Instrumented posterolateral fusion in elderly population patients with mono-segmental advanced disc degeneration may yield clinical outcome with low operative risk. (2017ESJ150)

Relationship between ADAMTS4 and carotid atherosclerotic plaque vulnerability in humans

BackgroundRupture of atherosclerotic plaques and the resulting thrombosis are vital causes of clinical ischemic events. Recent studies have shown that ADAMTS4 (a disintegrin and metalloproteinase with thrombospondin motifs 4) is a pathogenic factor of plaque vulnerability in mice. However, the relationship between ADAMTS4 and carotid atherosclerotic vulnerable plaques in humans remains unclear. MethodsForty-eight carotid atherosclerotic plaque specimens were obtained from 48 carotid artery stenosis inpatients undergoing carotid endarterectomy. We performed hematoxylin and eosin and Movat pentachrome staining for histologic characteristics; immunohistochemical staining for ADAMTS4, versican, and macrophages; and serologic tests for ADAMTS4. Patients were divided into stable and vulnerable groups on the basis of histologic characterization according to the classification criteria of the American Heart Association. Comparison between the groups was carried out using SPSS 17.0 (SPSS Inc, Chicago, Ill). ResultsExpression of ADAMTS4 in the plaque and its serum concentration were significantly higher in the vulnerable group compared with the stable one (P = .004 and P = .021, respectively), whereas the expression of versican was lower in the vulnerable group than in the stable group (P = .015). Univariate analysis revealed that the incidence of symptomatic cerebral ischemic events and ADAMTS4 serum levels were statistically higher in the vulnerable group compared with the stable group (P = .021 and P = .029, respectively). Multivariate analysis showed that ADAMTS4 was an independent risk factor (odds ratio, 1.14; P = .038). ConclusionsOur study revealed that ADAMTS4 expression was upregulated during carotid atherosclerotic plaque development. Serum levels of ADAMTS4 were associated with increased plaque vulnerability in both symptomatic and asymptomatic patients with carotid artery stenosis. ADAMTS4 may be a potential biomarker for plaque vulnerability.

Interactions between obsessional symptoms and interpersonal dynamics: An empirical single case study.

Both classical and contemporary psychoanalytic theories stress the importance of interpersonal dynamics in treating neurotic symptoms. Associations between the symptomatic and interpersonal level were formally represented in the symptom specificity hypothesis (Blatt, 1974, 2004), which linked obsessional symptoms to an autonomous interpersonal stance. Findings from cross-sectional group studies on symptom specificity, however, do not converge, possibly indicating that the complexity of associations is underestimated. This article presents a theory-building case study specifically aiming at refinement of the classical symptom specificity hypothesis by quantitatively and qualitatively describing the longitudinal clinical interplay between obsessional symptoms and interpersonal dynamics throughout a psychodynamic psychotherapy. Interpersonal functioning was assessed by means of the core conflictual relationship theme method (Luborsky & Crits-Cristoph, 1998). Findings affirm a close association between symptoms and interpersonal dynamics. However, obsessional symptoms proved to be determined by profound ambivalences-manifesting both within and between relationships- between dependent and autonomous interpersonal behavior. Psychodynamic interventions focusing on interpersonal conflicts were associated with symptomatic alterations. Conceptual and methodological considerations, limitations and future research indications are discussed.