The Efficacy of Medical Marijuana in the Treatment of Cancer-Related Pain.

Background: The opioid epidemic has spurred investigations for nonopioid options, yet limited research persists on medical marijuana's (MMJ) efficacy in managing cancer-related symptoms. Objective: We sought to characterize MMJ's role on symptomatic relief and opioid consumption in the oncologic population. Design: Retrospective chart review of MMJ-certified oncology patients was performed. Divided patients into MMJ use [MMJ(+)] versus no use [MMJ(-)], and Edmonton Symptom Assessment System (ESAS)-reported pain cohorts: "mild-moderate" versus "severe." Measurements: Medical records were reviewed for ESAS, to measure physical and emotional symptoms, and opiate consumption, converted into morphine milligram equivalents (MME). Minimal clinically important differences were determined. Wilcoxon signed-rank tests determined statistical significance between MMJ-certification and most recent palliative care visit. Results: Identified 232 patients [95/232 MMJ(-); 137/232 MMJ(+)]. Pain, physical and total ESAS significantly improved for total MMJ(-) and MMJ(+); however, only MMJ(+) significantly improved emotional ESAS. MMJ(-) opioid consumption increased by 23% (97.5-120 mg/day MME, p = 0.004), while it remained constant (45-45 mg/day MME, p = 0.522) in MMJ(+). Physical and total ESAS improved in mild-moderate-MMJ(-) and MMJ(+). Pain and emotional symptoms worsened in MMJ(-); while MMJ(+)'s pain remained unchanged and emotional symptoms improved. MMJ(-) opioid consumption increased by 29% (90-126 mg/day MME, p = 0.012); while MMJ(+)'s decreased by 33% (45-30 mg/day MME, p = 0.935). Pain, physical, emotional, and total ESAS scores improved in severe-MMJ(-) and MMJ(+); opioid consumption reduced by 22% in MMJ(-) (135-106 mg/day MME, p = 0.124) and 33% in MMJ(+) (90-60 mg/day MME, p = 0.421). Conclusions: MMJ(+) improved oncology patients' ESAS scores despite opioid dose reductions and should be considered a viable adjuvant therapy for palliative management.

Point pressure sensitivity in early stage Parkinson's disease.

A number of sensory changes occur in the earliest stages of Parkinson's disease (PD), some of which precede the expression of the classic motor phenotype by years (e.g., olfactory dysfunction). Whether point pressure sensitivity (PPS), a cutaneous measure of light touch mediated by myelinated Aß fibers, is altered in early PD is not clear. Prior studies on this point are contradictory and are based on non-forced-choice threshold tests that confound the sensitivity measure with the response criterion. While α-synuclein pathology, a defining feature of PD, is present in the skin of PD patients, it is restricted to unmyelinated nerve fibers, suggesting PPS may be spared in this disease. We determined PPS thresholds using a state-of-the-art forced-choice staircase threshold test paradigm in 29 early stage PD patients and 29 matched controls at 11 body sites: the center of the forehead and the left and right forearms, index fingers, palms, medial soles of the feet, and plantar halluces. The patients were tested, in counterbalanced sessions, both on and off dopamine-related medications (DRMs). PPS was not influenced by PD and did not correlate with DRM l-DOPA equivalents, scores on the Unified Parkinson's Disease Rating Scale, side of the major motor disturbances, or SPECT imaging of the striatal dopamine transporter, as measured by technetium-99m TRODAT. However, PPS thresholds were lower on the left than on the right side of the body (p=0.008) and on the upper extremities relative to the toes and feet (ps<0.0001). Positive correlations were evident among the thresholds obtained across all body sectors, even though disparate regions of the body differed in terms of absolute sensitivity. This study indicates that PPS is not influenced in early stage PD regardless of whether patients are on or off DRMs.

Taste function in early stage treated and untreated Parkinson's disease.

Since brain stem regions associated with early Parkinson's disease (PD) pathology encroach upon those involved in taste function, the ability to taste may be compromised in PD. However, studies on this point have been contradictory. We administered well-validated whole-mouth and regional taste tests that incorporated multiple concentrations of sucrose, citric acid, caffeine, and sodium chloride to 29 early stage PD patients and 29 age-, sex-, and race-matched controls. Electrogustometry was also performed on the anterior tongue. The PD cohort was tested both on and off dopamine-related medications in counterbalanced test sessions. While whole-mouth taste identification test scores for all stimuli were, on average, nominally lower for the PD patients than for the controls, a trend in the opposite direction was noted for the intensity ratings at the lower stimulus concentrations for all stimuli except caffeine. Moreover, regional testing found that PD subjects tended to rate the stimuli, relative to the controls, as more intense on the anterior tongue and less intense on the posterior tongue. No significant associations were evident between taste test scores and UPDRS scores, L-DOPA medication equivalency values, or [(99m)Tc]TRODAT-1 SPECT imaging of dopamine transporter uptake within the striatum and associated regions. Our findings suggest that suprathreshold measures of taste function are influenced by PD and that this disease differentially influences taste function on anterior (CN VII) and posterior (CN IX) tongue regions. Conceivably PD-related damage to CN IX releases central inhibition on CN VII at the level of the brainstem, resulting in enhanced taste intensity on the anterior tongue.

Total joint arthroplasty in patients with a history of cancer.

In this review, we describe the pertinent issues that reconstructive surgeons face when treating patients with cancer. These issues include the various cancer management options and their influence on total joint arthroplasty outcomes, as well as prosthesis types and fixation types. We also present a strategy for reducing morbidity and complications during the perioperative period.

Limitations of the Knee Society Score in evaluating outcomes following revision total knee arthroplasty.

BACKGROUND: Traditionally, the results of revision total knee arthroplasty have been determined with use of surgeon-based measures such as the Knee Society rating system. Recently, outcome and quality-of-life measures have shifted toward a greater emphasis on patient-based evaluation. The aim of our study was to determine the validity and responsiveness of the Knee Society rating system compared with the Short Form-36 health survey (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a four-question 4-point Likert scale satisfaction questionnaire following revision total knee arthroplasty. METHODS: A total of 152 patients underwent revision total knee arthroplasty at our institution, between August 2003 and January 2007, and had a two-year follow-up evaluation after revision surgery. The SF-36, WOMAC, Knee Society rating system, and satisfaction scores were completed preoperatively and postoperatively. Spearman correlation coefficients were calculated to determine the degree of correlation for each outcome scale. The SF-36, WOMAC, and patient satisfaction were correlated with the Knee Society rating system. RESULTS: Both before and after surgery, the correlation among items of the Knee Society rating system displayed low to negligible levels of association. The Knee Society rating system pain score showed modest levels of convergent construct validity with the WOMAC and SF-36. However, the Knee Society functional score displayed negligible to low correlation with its WOMAC functional counterpart preoperatively. The Knee Society pain and functional scores, respectively, showed marked and moderate association with satisfaction. The change in the Knee Society pain and functional scores had moderate association with the SF-36 and WOMAC counterparts, except low correlation was displayed between the pain scores for the Knee Society rating system and the SF-36. The Knee Society rating system pain score was found to be the most responsive of the measures with a standardized response mean of 1.6, whereas the Knee Society rating system functional score was found to be the least responsive at 0.7. CONCLUSIONS: Currently, there is no so-called gold standard that optimally reflects the status of the knee, as well as the patient, prior to and following revision total knee arthroplasty. Ideally, numerous assessment scales should be administered to the patient in order to accurately reflect the patient characteristics for the purpose of academic study, but from a practical standpoint, this may not be feasible. We encourage further research and development of a simple and concise standardized questionnaire for use before and after revision total knee arthroplasty.

Periprosthetic joint infection: the economic impact of methicillin-resistant infections.

The orthopedic community has begun to witness a worrisome rise in the incidence of periprosthetic joint infections (PJIs) caused by resistant organisms. Besides other challenges associated with treating these infections, it appears that these infections may pose a higher cost compared to infections caused by sensitive organisms. Significantly higher cost of care for treatment of infections due to methicillin-resistant organisms were seen at a mean of $107,264 per case compared to $68,053 for treating PJI caused by sensitive strains (P < .0001). More effective strategies for preventing the spread of infections caused by resistant organisms need to be implemented to ease the social and economic strains facing the orthopedic community due to resistant organisms.