Spinal and paraspinal inflammatory reactions after epidural steroid injection in a patient taking disease-modifying antirheumatic drugs.

BackgroundDisease-modifying anti-rheumatic drugs (DMARDs) are used in the management of rheumatoid arthritis (RA) and are classified as conventional DMARDs and biologic agents. A concern with DMARDs is the increased risk of infection after surgery. A practice advisory from the American Society of Anesthesiologists recommend alternatives to neuraxial injections in patients who are immunocompromized. We describe a patient who was on several DMARDs and developed inflammatory reactions in her bilateral paraspinal muscles and lumbar spine after an epidural steroid injection (ESI). CASE PRESENTATION: The patient was a 79-year-old woman; she was taking methotrexate, adalimumab and prednisone for her RA. She had a left L5-S1 paramedian ESI for her L5 radiculitis. After relief of her back and radicular pain for 5 weeks, she had an acute exacerbation of her back pain. MRI showed bilateral paraspinal fluid accumulations and enhancement in her ligamentum flavum. Cultures of the aspirated fluid and biopsy specimens were negative for fungal, aerobic and anaerobic organisms. A repeat MRI 2 months later showed diminution of the fluid collection but with a new fluid accumulation near the left L4-5 facet and left L4 pedicle. Repeat cultures and gram stain of the specimens taken from the pedicle and the paraspinal muscles were negative. The patient was followed by her rheumatologist and in the pain clinic until resolution of her symptoms. CONCLUSIONS: Several society guidelines recommend the continuation of methotrexate but stoppage of the biologic DMARDS before surgery. The occurrence of an intense inflammatory reaction after an ESI in our patient calls for additional research on the subject and shared decision-making between the pain physician, patient and rheumatologist especially in patients on several DMARDs.

The neutrophil to albumin ratio as a predictor of pathological complete response in rectal cancer patients following neoadjuvant chemoradiation.

Pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME), in patients with locally advanced rectal cancer, occurs in 15-27% of patients. Because blood cell counts and albumin are a direct indicator of the host environment, a response to nCRT might be predicted by these markers. This study was carried out to determine whether the neutrophil to albumin ratio (NAR) was predictive of pCR in veteran patients. Ninety-eight patients with rectal cancer who underwent standard nCRT, followed by TME were analyzed. Pre-nCRT and post-nCRT hematologic data were collected. Univariate and multivariate analyses were carried out. Kaplan-Meier curves were constructed with our primary endpoint of pCR. Male patients (99%), age 62.4±9.1 years, BMI=27.4±5.9 kg/m, rectal cancer distance from anal verge=7.1±4.5 cm (SD), interval between nCRT and TME=8 weeks, 55% patients=low anterior resection, 95% received 5-fluorouracil, and all patients received radiation, with 15% achieving a pCR. Univariate analysis showed that pre-nCRT carcinoembryonic antigen (15.8±45.1 vs. 3.5±5.3 ng/dl; P=0.002) and the pre-nCRT NAR (16.4±4.8 vs. 14.2±1.6; P=0.002) were associated with pCR. On multivariate analysis, pre-nCRT carcinoembryonic antigen (odds ratio=0.41, 95% confidence interval 0.22-0.77) and pre-nCRT NAR (odds ratio=0.76, 95% confidence interval 0.60-0.97) remained independent predictors of pCR. Overall survival between nonresponders and pCR patients at 1, 5, and 10 years was 96, 62, and 44% versus 93, 85, and 61%, P=0.13, and disease-free survival was 95, 60, and 47% versus 93, 85, and 61%, P=0.17; respectively. Our study shows that the pre-nCRT NAR is an independent predictor of pCR. These findings should be applied to other cohorts to determine its validity and reliability for use as a potential predictor of pCR.

Predictors of inguinodynia, recurrence, and metachronous hernias after inguinal herniorrhaphy in veteran patients.

BACKGROUND: The present single-institution, single-surgeon experience interrogated morbidity as well as predictors of inguinodynia, recurrence, and metachronous hernias in 953 consecutive inguinal herniorrhaphies between 2005 and 2015. METHODS: Data were prospectively collected and retrospectively analyzed from patient medical records at the VA North Texas Health Care System. RESULTS: Ninety-nine percent of our patients were male, 73% Caucasian, 60.4 ± 1.4 years old, body mass index = 26.7 ± 4.2 kg/m(2). Overall morbidity was 11.9%. The most common complication was urinary retention (2.3%). Inguinodynia and recurrence occurred at a rate of 1.5% and .8%, respectively. If a patient had a hernia repair, he had a 12% chance of needing a contralateral repair within 7.6 years. Younger age (odds ratio [OR], .96; 95% confidence interval [CI], .91 to 1.0), current history of smoking (OR, 5.3; 95% CI, 1.3 to 22.3), and a previous contralateral hernia repair (OR, 5.5; 95% CI, 1.2 to 25.0) were independent predictors of inguinodynia. A direct hernia was associated with recurrence (45% vs 100%; P = .02). Current smoking was an independent predictor of recurrence (OR, 5.4; 95% CI 1.0 to 29.3). Age (55- to 75-year old; OR, 2.0; 95% CI, 1.1 to 3.9), age (>75-year old; OR, 2.6; 95% CI, 1.1 to 6.1), an indirect hernia repair (OR, 1.9; 95% CI, 1.2 to 3.1), a pantaloon hernia repair (OR, 2.0; 95% CI, 1.0 to 3.8), and current consumption of alcohol (OR, 1.6; 95% CI, 1.0 to 2.5) were independent predictors of a metachronous hernia. CONCLUSIONS: The following study presents several factors predictive of outcomes in patients with inguinal hernias that might be useful in preventing complications and providing informed consent to this patient population.

Biological Mesh Implants for Abdominal Hernia Repair: US Food and Drug Administration Approval Process and Systematic Review of Its Efficacy.

IMPORTANCE: Expensive biological mesh materials are increasingly used to reinforce abdominal wall hernia repairs. The clinical and cost benefit of these materials are unknown. OBJECTIVES: To review the published evidence on the use of biological mesh materials and to examine the US Food and Drug Administration (FDA) approval history for these devices. EVIDENCE ACQUISITION: Search of multiple electronic databases (Ovid, MEDLINE, EMBASE, Cochrane Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Cochrane National Health Service Economic Evaluation Database) to identify articles published between 1948 and June 30, 2015, on the use of biological mesh materials used to reinforce abdominal wall hernia repair. Keywords searched included surgical mesh, abdominal hernia, recurrence, infection, fistula, bioprosthesis, biocompatible materials, absorbable implants, dermis, and collagen. The FDA online database for 510(k) clearances was reviewed for all commercially available biological mesh materials. The median national price for mesh materials was established by a benchmarking query through several Integrated Delivery Network and Group Purchasing Organization tools. EVIDENCE SYNTHESIS: Of 274 screened articles, 20 met the search criteria. Most were case series that reported results of convenience samples of patients at single institutions with a variety of clinical problems. Only 3 of the 20 were comparative studies. There were no randomized clinical trials. In total, outcomes for 1033 patients were described. Studies varied widely in follow-up time, operative technique, meshes used, and patient selection criteria. Reported outcomes and clinical outcomes, such as fistula formation and infection, were inconsistently reported across studies. Conflicts of interest were not reported in 16 of the 20 studies. Recurrence rates ranged from 0% to 80%. All biological mesh devices were approved by the FDA based on substantial equivalence to a group of nonbiological predicate devices that, on average, were one-third less costly. CONCLUSIONS AND RELEVANCE: There is insufficient evidence to determine the extra costs associated with or the clinical efficacy of biological mesh materials for the repair of abdominal wall hernia.

Clinical and molecular diagnosis of pathologic complete response in rectal cancer.

The current standard approach to locally advanced rectal cancer involves pre-operative chemoradiotherapy followed by total mesorectal excision. This practice is supported by several studies that have demonstrated superior local control with this approach. This strategy, leads to a pathologic complete response (pCR) in a substantial proportion of patients treated with neoadjuvant therapy. Furthermore, pCR has been shown to be a reliable predictor of improved oncologic outcomes. This observation has led to an increased interest in the pursuit of identifying clinical, radiographic, pathologic and biochemical predictors of pCR. This review discusses the promising approaches to and most recent advancements in predicting pCR in rectal cancer.