Feline Squamous Cell Carcinoma

Sabattini S, Marconato L, Zoff A et al: Epidermal growth factor receptor expression is predictive of poor prognosis in feline cutaneous squamous cell carcinoma, Journal of Feline Medicine & Surgery 12: 760, 2010. 

Squamous cell carcinoma is the most common malignant skin tumor in cats. The most frequently affected sites include the nasal planum, pinnae (ears), and eyelids. Development of this skin tumor has been associated with chronic sunlight exposure. The purpose of this study was to evaluate epidermal growth factor receptor (EGFR) in feline cutaneous squamous cell carcinoma (SCC) and assess its prognostic role. Nineteen biopsy samples were tested for EGFR expression using immunohistochemistry. Fourteen of 19 tumors (73.7%) were positive for EGFR. EGFR expression was not found to be linked with tumor differentiation and mitotic activity. The data from the study suggest that activation of the EGFR signaling pathway is possibly involved in the progression of SCC. EGFR expression also carries a negative prognostic significance in these tumors. This could indicate that use of EGFR inhibitors in association with conventional treatment may someday be a treatment option. [VT]

Related articles:

Looper JS, Malarkey DE, Ruslander D et al: Epidermal growth factor receptor expression in feline oral squamous cell carcinomas, Vet Comp Oncol 4: 33, 2006.

More on cat health: Winn Feline Foundation Library

Join us on Facebook

Follow us on Twitter

Sabattini S, Marconato L, Zoff A et al: Epidermal growth factor receptor expression is predictive of poor prognosis in feline cutaneous squamous cell carcinoma, Journal of Feline Medicine & Surgery 12: 760, 2010. 

Squamous cell carcinoma is the most common malignant skin tumor in cats. The most frequently affected sites include the nasal planum, pinnae (ears), and eyelids. Development of this skin tumor has been associated with chronic sunlight exposure. The purpose of this study was to evaluate epidermal growth factor receptor (EGFR) in feline cutaneous squamous cell carcinoma (SCC) and assess its prognostic role. Nineteen biopsy samples were tested for EGFR expression using immunohistochemistry. Fourteen of 19 tumors (73.7%) were positive for EGFR. EGFR expression was not found to be linked with tumor differentiation and mitotic activity. The data from the study suggest that activation of the EGFR signaling pathway is possibly involved in the progression of SCC. EGFR expression also carries a negative prognostic significance in these tumors. This could indicate that use of EGFR inhibitors in association with conventional treatment may someday be a treatment option. [VT]

Related articles:

Looper JS, Malarkey DE, Ruslander D et al: Epidermal growth factor receptor expression in feline oral squamous cell carcinomas, Vet Comp Oncol 4: 33, 2006.

More on cat health: Winn Feline Foundation Library

Join us on Facebook

Follow us on Twitter

Read More

Eating Poorly Can Make You Blue: Trans-Fats Increase Risk of Depression, While Olive Oil Helps Avoid Risk

Researchers from the universities of Navarra and Las Palmas de Gran Canaria have demonstrated that the ingestion of trans-fats and saturated fats increase the risk of suffering depression, and that olive oil, on the other hand, protects against this mental illness.

They have confirmed this after studying 12,059 SUN Project volunteers over the course of six years; the volunteers had their diet, lifestyle and ailments analyzed at the beginning of the project, over its course and at the end of the project. In this way the researchers confirmed that despite the fact that at the beginning of the study none of the volunteers suffered from depression, at the end of the study 657 new cases had been detected.

Of all these cases, the participants with an elevated consumption of trans-fats (fats present in artificial form in industrially-produced pastries and fast food, and naturally present in certain whole milk products) "presented up to a 48% increase in the risk of depression when they were compared to participants who did not consume these fats," affirmed Almudena Sánchez-Villegas, Associate Professor of Preventive Medicine at the University of Las Palmas de Gran Canaria, first author of the article.

In addition, the study demonstrated a dose-response relationship, "whereby the more trans-fats were consumed, the greater the harmful effect they produced in the volunteers," the expert stated.

Furthermore, the team, directed by Miguel Ángel Martínez-González, Professor of Preventive Medicine at the University of Navarra, also analyzed the influence of polyunsaturated fats (abundant in fish and vegetable oils) and of olive oil on the occurrence of depression. "In fact, we discovered that this type of healthier fats, together with olive oil, are associated with a lower risk of suffering depression," emphasized the researcher and director of the SUN Project.


150 million persons depressed worldwide


Thus, the results of the study corroborate the hypothesis of a greater incidence of the disease in countries of the north of Europe compared to the countries of the south, where a Mediterranean dietary pattern prevails. Nevertheless, experts have noted that the incidence of the disease has increased in recent years, so that today some 150 million persons are affected worldwide, where it is the principal cause of loss of years of life in those countries with a medium-to-high per capita income.

This due, according to Almudena Sánchez Villegas, "to radical changes in the sources of fats consumed in Western diets, where we have substituted certain types of beneficial fats -- polyunsaturated and monounsaturated in nuts, vegetable oils and fish -- for the saturated and trans-fats found in meats, butter and other products such as mass-produced pastries and fast food."

In addition, the research -- published in the online peer reviewed journal PLoS ONE -- has been performed on a population with a low average intake of trans-fats, given that it made up only 0.4% of the total energy ingested by the volunteers. "Despite this, we observed an increase in the risk of suffering depression of nearly 50%. On this basis," concluded Miguel A. Martínez, "we derive the importance of taking this effect into account in countries like the U.S., where the percentage of energy derived from these foots is around 2.5%."

Finally, the analysis, headed by the University of Navarra and the University of Las Palmas de Gran Canaria, suggests that both depression as well as cardiovascular disease are influenced in a similar manner by diet, and might share similar mechanisms in their origin. This hypothesis is further suggested by numerous studies that indicate the harmful effect of trans-fats and saturated fats on the risk of cardiovascular disease.

Researchers from the universities of Navarra and Las Palmas de Gran Canaria have demonstrated that the ingestion of trans-fats and saturated fats increase the risk of suffering depression, and that olive oil, on the other hand, protects against this mental illness.

They have confirmed this after studying 12,059 SUN Project volunteers over the course of six years; the volunteers had their diet, lifestyle and ailments analyzed at the beginning of the project, over its course and at the end of the project. In this way the researchers confirmed that despite the fact that at the beginning of the study none of the volunteers suffered from depression, at the end of the study 657 new cases had been detected.

Of all these cases, the participants with an elevated consumption of trans-fats (fats present in artificial form in industrially-produced pastries and fast food, and naturally present in certain whole milk products) "presented up to a 48% increase in the risk of depression when they were compared to participants who did not consume these fats," affirmed Almudena Sánchez-Villegas, Associate Professor of Preventive Medicine at the University of Las Palmas de Gran Canaria, first author of the article.

In addition, the study demonstrated a dose-response relationship, "whereby the more trans-fats were consumed, the greater the harmful effect they produced in the volunteers," the expert stated.

Furthermore, the team, directed by Miguel Ángel Martínez-González, Professor of Preventive Medicine at the University of Navarra, also analyzed the influence of polyunsaturated fats (abundant in fish and vegetable oils) and of olive oil on the occurrence of depression. "In fact, we discovered that this type of healthier fats, together with olive oil, are associated with a lower risk of suffering depression," emphasized the researcher and director of the SUN Project.


150 million persons depressed worldwide


Thus, the results of the study corroborate the hypothesis of a greater incidence of the disease in countries of the north of Europe compared to the countries of the south, where a Mediterranean dietary pattern prevails. Nevertheless, experts have noted that the incidence of the disease has increased in recent years, so that today some 150 million persons are affected worldwide, where it is the principal cause of loss of years of life in those countries with a medium-to-high per capita income.

This due, according to Almudena Sánchez Villegas, "to radical changes in the sources of fats consumed in Western diets, where we have substituted certain types of beneficial fats -- polyunsaturated and monounsaturated in nuts, vegetable oils and fish -- for the saturated and trans-fats found in meats, butter and other products such as mass-produced pastries and fast food."

In addition, the research -- published in the online peer reviewed journal PLoS ONE -- has been performed on a population with a low average intake of trans-fats, given that it made up only 0.4% of the total energy ingested by the volunteers. "Despite this, we observed an increase in the risk of suffering depression of nearly 50%. On this basis," concluded Miguel A. Martínez, "we derive the importance of taking this effect into account in countries like the U.S., where the percentage of energy derived from these foots is around 2.5%."

Finally, the analysis, headed by the University of Navarra and the University of Las Palmas de Gran Canaria, suggests that both depression as well as cardiovascular disease are influenced in a similar manner by diet, and might share similar mechanisms in their origin. This hypothesis is further suggested by numerous studies that indicate the harmful effect of trans-fats and saturated fats on the risk of cardiovascular disease.

Read More

Kidney stones and clogged arteries may be linked

Reuters Health) - Young adults who've had kidney stones may also have an increased risk of clogged arteries, a new study says.

This does not mean that one causes the other, but instead the two conditions might have some common root cause, according to the paper published in the Journal of Urology.

"People who have kidney stones could be sort of the canary in the mine shaft," said Dr. Marshall Stoller, professor of urology at the University of California in San Francisco, and an author on the paper.

Slightly less than four percent of people had kidney stones at some point in the 20 year study. These people had about a 60-percent increased risk of getting clogged arteries later in their lives.

People tend to think of a kidney stone as a urinary problem, "but we need to be cognizant of the fact that the kidney is a blood filter," Stoller said, and can show signs of problems in the arteries as well.

High cholesterol, high blood pressure, smoking, and diabetes can all increase the risk of clogged arteries, which can lead to both heart attacks and strokes. These two diseases combined killed more than 589,000 people in 2005, according to the American Heart Association.

That people with kidney stones have an increased risk of clogged arteries is not really a surprise, said Andrew Evan, professor of medicine at Indiana University-Purdue University in Indianapolis, who was not involved in the study.

Previous studies have linked kidney stones with high blood pressure, which increases the risk of developing clogged arteries. But as far as what can lead to clogged arteries, "is it the higher blood pressure, or is it the kidney stones themselves?" Evan said. "We really don't know that."

About 5 percent of adults in the US have had kidney stones, according to the National Institute of Diabetes and Digestive and Kidney Diseases, a slightly higher proportion than in the study.

The study involved more than 5000 young adults between 18 and 30 years old who came back for exams at regular intervals over the next 20 years.

At the 20-year exam, the researchers analyzed the thickness of the wall of participants' carotid arteries. (A thicker-than-normal artery wall is a sign of the arteries getting clogged up.) And that's when they found that people who'd reported having kidney stones were 60 percent more likely to have clogged arteries, compared to people without kidney stones.

A problem with the study is that it included all people with kidney stones together in one group, Evans said. There are a number of different reasons people can get kidney stones such as too having much calcium in the urine, sustained dehydration, or a hereditary disorder. Not all may have an increased risk of clogged arteries, although more research is needed to shed some light on the issue.

In the meantime, you can reduce your risk of getting kidney stones by drinking enough to urinate about two liters a day and by cutting down on salt and meat, Stoller said.

And the American Heart Association advises that to reduce the risk of clogged arteries, people should exercise, eat a healthy diet, and not smoke.

"This is a warning sign," Stoller said. "The kidney stone is the tip of the iceberg."

Reuters Health) - Young adults who've had kidney stones may also have an increased risk of clogged arteries, a new study says.

This does not mean that one causes the other, but instead the two conditions might have some common root cause, according to the paper published in the Journal of Urology.

"People who have kidney stones could be sort of the canary in the mine shaft," said Dr. Marshall Stoller, professor of urology at the University of California in San Francisco, and an author on the paper.

Slightly less than four percent of people had kidney stones at some point in the 20 year study. These people had about a 60-percent increased risk of getting clogged arteries later in their lives.

People tend to think of a kidney stone as a urinary problem, "but we need to be cognizant of the fact that the kidney is a blood filter," Stoller said, and can show signs of problems in the arteries as well.

High cholesterol, high blood pressure, smoking, and diabetes can all increase the risk of clogged arteries, which can lead to both heart attacks and strokes. These two diseases combined killed more than 589,000 people in 2005, according to the American Heart Association.

That people with kidney stones have an increased risk of clogged arteries is not really a surprise, said Andrew Evan, professor of medicine at Indiana University-Purdue University in Indianapolis, who was not involved in the study.

Previous studies have linked kidney stones with high blood pressure, which increases the risk of developing clogged arteries. But as far as what can lead to clogged arteries, "is it the higher blood pressure, or is it the kidney stones themselves?" Evan said. "We really don't know that."

About 5 percent of adults in the US have had kidney stones, according to the National Institute of Diabetes and Digestive and Kidney Diseases, a slightly higher proportion than in the study.

The study involved more than 5000 young adults between 18 and 30 years old who came back for exams at regular intervals over the next 20 years.

At the 20-year exam, the researchers analyzed the thickness of the wall of participants' carotid arteries. (A thicker-than-normal artery wall is a sign of the arteries getting clogged up.) And that's when they found that people who'd reported having kidney stones were 60 percent more likely to have clogged arteries, compared to people without kidney stones.

A problem with the study is that it included all people with kidney stones together in one group, Evans said. There are a number of different reasons people can get kidney stones such as too having much calcium in the urine, sustained dehydration, or a hereditary disorder. Not all may have an increased risk of clogged arteries, although more research is needed to shed some light on the issue.

In the meantime, you can reduce your risk of getting kidney stones by drinking enough to urinate about two liters a day and by cutting down on salt and meat, Stoller said.

And the American Heart Association advises that to reduce the risk of clogged arteries, people should exercise, eat a healthy diet, and not smoke.

"This is a warning sign," Stoller said. "The kidney stone is the tip of the iceberg."

Read More

Early Antibiotic Use Can Lead to Increased Risk of Childhood Asthma, Study Suggests

When babies are given antibiotics, their risk of developing asthma by age 6 may increase by 50 percent. This relationship between antibiotic use in babies less than six months old and risk of developing asthma was documented in a study conducted by Norwegian University of Science and Technology (NTNU) researcher Kari Risnes.

The research was conducted while Risnes was a visiting researcher at Yale University, and resulted in the recent online publication of the article in the American Journal of Epidemiology.

"Asthma is a very common disease. At the same time, about one-third of infants in our study were treated with antibiotics by the time they were six months old. This proportion is about 30 per cent in other Western countries," says Risnes.

The Yale study followed 1400 children and mothers from the beginning of pregnancy until the children were six years old.

"We found that the risk that children would have asthma as six year olds was 50 per cent higher when they had been given antibiotics as a baby. That is a significant increase," Risnes says.

While previous research has suggested an association between asthma and antibiotics, those studies may have been biased because antibiotics are used to treat respiratory tract infections that could themselves be early symptoms of asthma.

The study sought to eliminate this bias by excluding children who were treated for respiratory infections from the study. The study also considered a long list of other risk factors -- such as whether or not the mother, father or a sibling had asthma. That aspect also brought a surprise, Risnes said.

"We actually found that the relationship between antibiotic use in the first six months of life and asthma was particularly strong in children from families without a history of asthma," said Risnes.

"What we think is that antibiotics interfere with the beneficial bacteria found in the gut. These bacteria aid in helping the baby's immune system to mature. When the bacteria are affected, it can cause the child to have an "immature" immune system, which in turn leads to allergic reactions," says Risnes.

She believes that the results should remind doctors and policymakers of the consequences of overuse of antibiotics. While in Norway, for example, the policy is to limit the prescription of antibiotics "this is an additional reminder to doctors and parents that we should avoid unnecessary use whenever possible," she said.

When babies are given antibiotics, their risk of developing asthma by age 6 may increase by 50 percent. This relationship between antibiotic use in babies less than six months old and risk of developing asthma was documented in a study conducted by Norwegian University of Science and Technology (NTNU) researcher Kari Risnes.

The research was conducted while Risnes was a visiting researcher at Yale University, and resulted in the recent online publication of the article in the American Journal of Epidemiology.

"Asthma is a very common disease. At the same time, about one-third of infants in our study were treated with antibiotics by the time they were six months old. This proportion is about 30 per cent in other Western countries," says Risnes.

The Yale study followed 1400 children and mothers from the beginning of pregnancy until the children were six years old.

"We found that the risk that children would have asthma as six year olds was 50 per cent higher when they had been given antibiotics as a baby. That is a significant increase," Risnes says.

While previous research has suggested an association between asthma and antibiotics, those studies may have been biased because antibiotics are used to treat respiratory tract infections that could themselves be early symptoms of asthma.

The study sought to eliminate this bias by excluding children who were treated for respiratory infections from the study. The study also considered a long list of other risk factors -- such as whether or not the mother, father or a sibling had asthma. That aspect also brought a surprise, Risnes said.

"We actually found that the relationship between antibiotic use in the first six months of life and asthma was particularly strong in children from families without a history of asthma," said Risnes.

"What we think is that antibiotics interfere with the beneficial bacteria found in the gut. These bacteria aid in helping the baby's immune system to mature. When the bacteria are affected, it can cause the child to have an "immature" immune system, which in turn leads to allergic reactions," says Risnes.

She believes that the results should remind doctors and policymakers of the consequences of overuse of antibiotics. While in Norway, for example, the policy is to limit the prescription of antibiotics "this is an additional reminder to doctors and parents that we should avoid unnecessary use whenever possible," she said.

Read More

Community Demographics & Shelter Adoptions

Patronek GJ: Use of geospatial neighborhood control locations for epidemiological analysis of community-level pet adoption patterns, Am J Vet Res 71: 1321, 2010. 

This study explored the joint effect of distance and neighborhood-level demographics on pet adoptions from an animal shelter. The methods used to perform the study were client segmentation, geospatial tools, and epidemiological techniques that evaluated locations of 1,563 adoptions from an animal shelter in eastern Massachusetts. Proximity to the shelter was found to be strongly associated with adoption. Locations that were less than 6 miles (9.7 km) from the shelter having higher block group median income, or having a greater proportion of households that were composed of married couples with children in the block group, were associated with increased odds of being an adoption location. Neighborhood lifestyle characteristics were also noted to profoundly influence shelter adoption patterns. This study explored pet adoptions as one aspect of shelter operations. There are other potential applications of this type of technology and analysis for shelter outreach in identifying underserved areas for mobile spay-neuter programs, improvement of allocation of animal control resources, better targeting of media messages about the shelter, along with other possibilities.  [VT]

Related articles:
Patronek GJ: Mapping and measuring disparities in welfare for cats across neighborhoods in a large US city, J Am Vet Med Assoc 71: 161, 2010.

More on cat health: Winn Feline Foundation Library
Join us on Facebook
Follow us on Twitter

Patronek GJ: Use of geospatial neighborhood control locations for epidemiological analysis of community-level pet adoption patterns, Am J Vet Res 71: 1321, 2010. 

This study explored the joint effect of distance and neighborhood-level demographics on pet adoptions from an animal shelter. The methods used to perform the study were client segmentation, geospatial tools, and epidemiological techniques that evaluated locations of 1,563 adoptions from an animal shelter in eastern Massachusetts. Proximity to the shelter was found to be strongly associated with adoption. Locations that were less than 6 miles (9.7 km) from the shelter having higher block group median income, or having a greater proportion of households that were composed of married couples with children in the block group, were associated with increased odds of being an adoption location. Neighborhood lifestyle characteristics were also noted to profoundly influence shelter adoption patterns. This study explored pet adoptions as one aspect of shelter operations. There are other potential applications of this type of technology and analysis for shelter outreach in identifying underserved areas for mobile spay-neuter programs, improvement of allocation of animal control resources, better targeting of media messages about the shelter, along with other possibilities.  [VT]

Related articles:
Patronek GJ: Mapping and measuring disparities in welfare for cats across neighborhoods in a large US city, J Am Vet Med Assoc 71: 161, 2010.

More on cat health: Winn Feline Foundation Library
Join us on Facebook
Follow us on Twitter

Read More

Surgeons, medical device makers find insurers resisting costly back fusions

Surgeons and medical device makers find insurers are resisting costly back fusions and requiring proof that less risky therapy for pain has been given a chance.

By Christopher Snowbeck
csnowbeck@pioneerpress.com

Updated: 01/29/2011 11:35:39 PM CST

 

There's nothing like back pain.
Just ask Dan Hoxworth, 50, of Mahtomedi. Beyond watching his father and brothers suffer from disc problems over the years, Hoxworth has felt the pain personally with herniated discs in each of the past three decades. The sensation at times is a bit like sticking your finger in an electrical outlet — and not pulling it out, he says.

Still, there are two key reasons Hoxworth considers himself lucky in his spinal struggles.
First, the interval of time between each of his three episodes of back troubles grew. His first two herniated discs were separated by a span of just six years, while it was another 13 years before he suffered from a third disc problem in 2008. So, Hoxworth jokes that his back now should be good for another 20-plus years or so.

The second bit of luck is no joke.

'I've had success in avoiding surgery,' Hoxworth said. 'The doctors I've had always said that surgery is the last option.'

Pushing back on spine surgery is becoming a battle cry for health plans these days, too. Faced with skyrocketing health costs due to surgeries known as spinal fusions, health plans in Minnesota and across the U.S. are intensifying scrutiny of the procedures.

Spine surgeons are feeling the impact. So are companies like Fridley-based Medtronic, which is the largest manufacturer of medical devices used in spine surgery.

'Payers are also implementing new fusion procedure guidelines, which are lengthening the time  required to give pre-approvals,' said Gary Ellis, the chief financial officer at Medtronic, during a conference call with investors last year.
Bloomington-based HealthPartners was one of the first health plans in Minnesota to start scrutinizing spine surgery costs. In February 2009, the insurer started requiring
patients to receive approved decision guides such as booklets or videos to help them learn more about alternatives to surgery before they could receive a common but expensive procedure called 'lumbar fusion.'
Health plans and a growing number of doctors say that too many patients have been getting lumbar fusions without first trying treatment options including physical therapy, exercise and even epidural steroid injections to deal with pain.

As part of its efforts to control spine surgery costs, HealthPartners asked surgeons to document that patients had attempted rehabilitation before surgery and had nonetheless failed to see a significant improvement in their pain levels and back function.

Two years later, what impact has the program had?

"Little to none," acknowledged Dr. Tom Marr, a medical director at HealthPartners. "The number of fusions continues to go up."

HealthPartners paid for 305 lumbar fusions in 2006. The number more than doubled to 684 in 2008. Then, during the first year of the shared decision-making program, the number of lumbar fusions increased to 823. The health plan pays an average of about $54,000 for all the care that goes into a lumbar fusion procedure.

"That cost is an issue, but it's not the main issue," he said. "The main issue is: Are patients getting maximum benefit from this."

The answer at HealthPartners appears to be no, and that's why the health plan is "re-energizing" its policies for scrutinizing lumbar fusion surgeries. Others are doing the same.

A year ago, Minneapolis-based UCare started requiring members to consider other options to spine surgery, said Dr. Craig Christianson, an associate medical director.

Some spine surgeons bristled at the requirement, he said, until the health plan started showing examples of how some Medicare patients in their 80s and 90s were undergoing spinal fusion procedures — an aggressive treatment choice at that age, Christianson said.

Some patients are drawn to the more immediate impact that spine surgery can offer for back pain compared with conservative approaches, Christianson acknowledged. But long-term outcomes are fairly similar for the two groups, he said, at which point spine surgery patients have fewer options.

"The advantage to conservative care is that there are no bridges being burned," Christianson said.
Last month, Blue Cross Blue Shield of North Carolina issued rules that lumbar spinal fusion surgeries required prior review and certification by the insurance company to be covered. Some doctors who have been critical of the growth in spine surgeries for back pain cheered the move.

"The major national concern has to do with the performance of multilevel instrumented fusions to treat low back pain in patients with lumbar degenerative disc disease who are neurologically intact, who do not have spinal deformity and in whom all appropriate conservative treatment measures have not been performed," said Dr. Charles Burton, a surgeon in St. Paul. "Study after study after study has shown that in this population of patients, physical therapy is as good if not better — and there are no complications."

But a group of national spine surgery societies criticized the North Carolina rules as too broad, and cautioned in a December letter that they could block surgeries for patients "who have a high probability of clinical success with fusion."
The concern is echoed locally by Dr. Paul Hartleben, a spine surgeon with Summit Orthopedics in Woodbury.

Spinal fusions were developed as a treatment for a deformity called scoliosis and the surgery can successfully halt the progression of that condition, Hartleben said. In a fusion, surgeons use rods, screws and plates to stabilize otherwise mobile spine segments.

Over the years, doctors started using the tools for other spine problems, including intractable back pain. That's where the controversy comes in — not just with health plans, but even among spine surgeons, said Hartleben.
"There's always a group of surgeons that believes that any fusion done for degenerative disc disease and back pain is inappropriate," he said. "Then there are those that say: What do you do for the patient who is incapacitated and has tried everything else?"

In some cases, the procedure has been "overdone," Hartleben said. But physicians aren't doing it for personal gain, he said, and are willing to work with health plans to improve care — even though navigating pre-authorization rules can take as much time as the spine surgery itself.

"There are many diagnoses where spinal fusion is worth it," Hartleben said. Noting that the federal Medicare program and Blue Cross Blue Shield of Minnesota also are paying more attention to spinal fusion costs, the surgeon added: "They want to make sure it's the right decision for their patients."

Hartleben says that doctors also are working more closely with hospitals, which also have concerns about increasing costs of spine surgery. The St. Paul-based HealthEast system, for example, recently hired Dr. Adam Locketz to promote the use of spine care options that go beyond surgery and are grounded in stronger medical evidence.

"It's not that lumbar fusions are never appropriate," Locketz said, "but they're being utilized too early in the process."
The scrutiny is affecting the bottom line for manufacturers such as Medtronic.
Medtronic is the world's largest manufacturer of medical devices used in spinal surgery, with more than one-third of the $7 billion worldwide market, according to Joanne Wuensch, an analyst with BMO Capital Markets. Still, Wuensch estimated in a recent report that Medtronic's revenue from spine devices will be down slightly for 2010 at about $2.6 billion.

The program at Blue Cross of North Carolina is an example of the challenges facing the industry, Wuensch wrote.

Marybeth Thorsgaard, a spokeswoman at Medtronic, contended the North Carolina policy actually would apply to only "a small percentage of our cases." Still, the manufacturer is responding to pressure from health plans through "the creation of new clinical and economic evidence to support new technologies and therapies," Thorsgaard said.

The scrutiny of spine surgery has come at a time when financial ties between medical device companies and doctors have become more visible.

Last year, Medtronic started disclosing how much it pays doctors in product royalties and consulting fees in three categories: training other doctors in the use of Medtronic products; offering advisory services to the company; and contributing to research and development.

Through the first three quarters of 2010, Medtronic paid between $2 million and $2.2 million to about 20 doctors in Minnesota. The vast majority of the money went to nine spine surgeons for royalties on Medtronic products that the physicians helped design.

Royalty payments to spine surgeons "are what they are," said Marr, the medical director of HealthPartners. But the health plan has more concerns about other financial relationships between doctors and manufacturers — particularly when a doctor is being paid by a manufacturer to lobby HealthPartners to cover a spinal procedure.

"They don't tell us they're being paid," Marr said. Noting other potential conflicts of interest, he adds: "You start to say, 'You might be as pure as the driven snow, but after the plows come through, you're not so pure.' "

Snow removal wasn't the chore that led to Dan Hoxworth's most recent back troubles. He was helping a neighbor in Mahtomedi chop down trees and went too far.

After pain in his back would not go away, he spent weeks in physical therapy before finally being referred to a back specialist for a cortisone injection. The shot knocked down the pain more quickly than it did with his previous herniated discs — imaging technology has improved, he said, so that doctors can more accurately deliver the injection.

Hoxworth also went through a back-strengthening program at Physicians Neck & Back, a practice that's owned by HealthPartners and promotes exercise as a way to prevent back woes. Hoxworth completed the program about two years ago, but still regularly performs back-strengthening exercises he learned from the medical group.

"I like to chop wood, and I'm fine at doing that again," Hoxworth said. "I just don't do it until exhaustion, which is when you tend to get a back problem."
Christopher Snowbeck can be reached at 651-228-5479.

Surgeons and medical device makers find insurers are resisting costly back fusions and requiring proof that less risky therapy for pain has been given a chance.

By Christopher Snowbeck
csnowbeck@pioneerpress.com

Updated: 01/29/2011 11:35:39 PM CST

 

There's nothing like back pain.
Just ask Dan Hoxworth, 50, of Mahtomedi. Beyond watching his father and brothers suffer from disc problems over the years, Hoxworth has felt the pain personally with herniated discs in each of the past three decades. The sensation at times is a bit like sticking your finger in an electrical outlet — and not pulling it out, he says.

Still, there are two key reasons Hoxworth considers himself lucky in his spinal struggles.
First, the interval of time between each of his three episodes of back troubles grew. His first two herniated discs were separated by a span of just six years, while it was another 13 years before he suffered from a third disc problem in 2008. So, Hoxworth jokes that his back now should be good for another 20-plus years or so.

The second bit of luck is no joke.

'I've had success in avoiding surgery,' Hoxworth said. 'The doctors I've had always said that surgery is the last option.'

Pushing back on spine surgery is becoming a battle cry for health plans these days, too. Faced with skyrocketing health costs due to surgeries known as spinal fusions, health plans in Minnesota and across the U.S. are intensifying scrutiny of the procedures.

Spine surgeons are feeling the impact. So are companies like Fridley-based Medtronic, which is the largest manufacturer of medical devices used in spine surgery.

'Payers are also implementing new fusion procedure guidelines, which are lengthening the time  required to give pre-approvals,' said Gary Ellis, the chief financial officer at Medtronic, during a conference call with investors last year.
Bloomington-based HealthPartners was one of the first health plans in Minnesota to start scrutinizing spine surgery costs. In February 2009, the insurer started requiring
patients to receive approved decision guides such as booklets or videos to help them learn more about alternatives to surgery before they could receive a common but expensive procedure called 'lumbar fusion.'
Health plans and a growing number of doctors say that too many patients have been getting lumbar fusions without first trying treatment options including physical therapy, exercise and even epidural steroid injections to deal with pain.

As part of its efforts to control spine surgery costs, HealthPartners asked surgeons to document that patients had attempted rehabilitation before surgery and had nonetheless failed to see a significant improvement in their pain levels and back function.

Two years later, what impact has the program had?

"Little to none," acknowledged Dr. Tom Marr, a medical director at HealthPartners. "The number of fusions continues to go up."

HealthPartners paid for 305 lumbar fusions in 2006. The number more than doubled to 684 in 2008. Then, during the first year of the shared decision-making program, the number of lumbar fusions increased to 823. The health plan pays an average of about $54,000 for all the care that goes into a lumbar fusion procedure.

"That cost is an issue, but it's not the main issue," he said. "The main issue is: Are patients getting maximum benefit from this."

The answer at HealthPartners appears to be no, and that's why the health plan is "re-energizing" its policies for scrutinizing lumbar fusion surgeries. Others are doing the same.

A year ago, Minneapolis-based UCare started requiring members to consider other options to spine surgery, said Dr. Craig Christianson, an associate medical director.

Some spine surgeons bristled at the requirement, he said, until the health plan started showing examples of how some Medicare patients in their 80s and 90s were undergoing spinal fusion procedures — an aggressive treatment choice at that age, Christianson said.

Some patients are drawn to the more immediate impact that spine surgery can offer for back pain compared with conservative approaches, Christianson acknowledged. But long-term outcomes are fairly similar for the two groups, he said, at which point spine surgery patients have fewer options.

"The advantage to conservative care is that there are no bridges being burned," Christianson said.
Last month, Blue Cross Blue Shield of North Carolina issued rules that lumbar spinal fusion surgeries required prior review and certification by the insurance company to be covered. Some doctors who have been critical of the growth in spine surgeries for back pain cheered the move.

"The major national concern has to do with the performance of multilevel instrumented fusions to treat low back pain in patients with lumbar degenerative disc disease who are neurologically intact, who do not have spinal deformity and in whom all appropriate conservative treatment measures have not been performed," said Dr. Charles Burton, a surgeon in St. Paul. "Study after study after study has shown that in this population of patients, physical therapy is as good if not better — and there are no complications."

But a group of national spine surgery societies criticized the North Carolina rules as too broad, and cautioned in a December letter that they could block surgeries for patients "who have a high probability of clinical success with fusion."
The concern is echoed locally by Dr. Paul Hartleben, a spine surgeon with Summit Orthopedics in Woodbury.

Spinal fusions were developed as a treatment for a deformity called scoliosis and the surgery can successfully halt the progression of that condition, Hartleben said. In a fusion, surgeons use rods, screws and plates to stabilize otherwise mobile spine segments.

Over the years, doctors started using the tools for other spine problems, including intractable back pain. That's where the controversy comes in — not just with health plans, but even among spine surgeons, said Hartleben.
"There's always a group of surgeons that believes that any fusion done for degenerative disc disease and back pain is inappropriate," he said. "Then there are those that say: What do you do for the patient who is incapacitated and has tried everything else?"

In some cases, the procedure has been "overdone," Hartleben said. But physicians aren't doing it for personal gain, he said, and are willing to work with health plans to improve care — even though navigating pre-authorization rules can take as much time as the spine surgery itself.

"There are many diagnoses where spinal fusion is worth it," Hartleben said. Noting that the federal Medicare program and Blue Cross Blue Shield of Minnesota also are paying more attention to spinal fusion costs, the surgeon added: "They want to make sure it's the right decision for their patients."

Hartleben says that doctors also are working more closely with hospitals, which also have concerns about increasing costs of spine surgery. The St. Paul-based HealthEast system, for example, recently hired Dr. Adam Locketz to promote the use of spine care options that go beyond surgery and are grounded in stronger medical evidence.

"It's not that lumbar fusions are never appropriate," Locketz said, "but they're being utilized too early in the process."
The scrutiny is affecting the bottom line for manufacturers such as Medtronic.
Medtronic is the world's largest manufacturer of medical devices used in spinal surgery, with more than one-third of the $7 billion worldwide market, according to Joanne Wuensch, an analyst with BMO Capital Markets. Still, Wuensch estimated in a recent report that Medtronic's revenue from spine devices will be down slightly for 2010 at about $2.6 billion.

The program at Blue Cross of North Carolina is an example of the challenges facing the industry, Wuensch wrote.

Marybeth Thorsgaard, a spokeswoman at Medtronic, contended the North Carolina policy actually would apply to only "a small percentage of our cases." Still, the manufacturer is responding to pressure from health plans through "the creation of new clinical and economic evidence to support new technologies and therapies," Thorsgaard said.

The scrutiny of spine surgery has come at a time when financial ties between medical device companies and doctors have become more visible.

Last year, Medtronic started disclosing how much it pays doctors in product royalties and consulting fees in three categories: training other doctors in the use of Medtronic products; offering advisory services to the company; and contributing to research and development.

Through the first three quarters of 2010, Medtronic paid between $2 million and $2.2 million to about 20 doctors in Minnesota. The vast majority of the money went to nine spine surgeons for royalties on Medtronic products that the physicians helped design.

Royalty payments to spine surgeons "are what they are," said Marr, the medical director of HealthPartners. But the health plan has more concerns about other financial relationships between doctors and manufacturers — particularly when a doctor is being paid by a manufacturer to lobby HealthPartners to cover a spinal procedure.

"They don't tell us they're being paid," Marr said. Noting other potential conflicts of interest, he adds: "You start to say, 'You might be as pure as the driven snow, but after the plows come through, you're not so pure.' "

Snow removal wasn't the chore that led to Dan Hoxworth's most recent back troubles. He was helping a neighbor in Mahtomedi chop down trees and went too far.

After pain in his back would not go away, he spent weeks in physical therapy before finally being referred to a back specialist for a cortisone injection. The shot knocked down the pain more quickly than it did with his previous herniated discs — imaging technology has improved, he said, so that doctors can more accurately deliver the injection.

Hoxworth also went through a back-strengthening program at Physicians Neck & Back, a practice that's owned by HealthPartners and promotes exercise as a way to prevent back woes. Hoxworth completed the program about two years ago, but still regularly performs back-strengthening exercises he learned from the medical group.

"I like to chop wood, and I'm fine at doing that again," Hoxworth said. "I just don't do it until exhaustion, which is when you tend to get a back problem."
Christopher Snowbeck can be reached at 651-228-5479.

Read More

Government opens investigation into adult scoliosis treatments

The federal government has launched an investigation into the treatment used in adult scoliosis.

Posted: 6:20 PM Jan 24, 2011
Reporter: Maureen McFadden




The federal government has launched an investigation into the treatment used in adult scoliosis.
Julia Epper, an adult scoliosis patient, used to backstitch, until she developed adult scoliosis.
"I've had back pain since I was 14," said Epper, “It was very frustrating and I felt very limited.”
Diagnosed at age 20 her spine curve grew from 24 degrees, to 54.

Attempts at physical therapy and injections have done nothing for her pain either.
The Hospital for Special Surgery reports that half a million people have adult scoliosis in the United States, and 40 percent will feel more pain each year.

“Many people, as the spine begins to age, and the discs degenerate, beginning to experience more back and even leg pain,” says Charles C. Edwards II, a doctor at the Maryland Spine Center.
A new study shows spinal surgery may be the only true option.

"While we may try medicines and injections first, oftentimes we will move onto surgery because those other methods just are not making a difference for them," says Edwards.

In the United States alone, $860 billion are spent on therapy, braces, and pain injections.
The study, which includes patients from 40 to 80 years old, shows operative patients saw a significant boost in function and quality of life, while non-operative patients reported no improvement at all.
Decompression and fusion surgery worked for Epper, who says, "I no longer have this sharp, burning, debilitating pain. The difference has been remarkable."
Six centers across the US are currently involved in the government's adult scoliosis study.
All six centers are currently enrolling patients with results expected in 2015.

Research Summary:
BENT OUT OF SHAPE: THE ADULT SCOLIOSIS DEBATE
REPORT # 1744

BACKGROUND: Any individual over the age of 18 who has experienced spinal deformity is considered to have adult scoliosis. Scoliosis is defined as an abnormal, side-to-side, curvature of the spine. There are varying causes of spinal deformity including; idiopathic scoliosis, congenital anomalies, degenerative scoliosis, posttraumatic scoliosis and neuro-muscular scoliosis. Idiopathic scoliosis is the most common form of spinal deformity doctors see, affecting about three percent of the general population. (SOURCE: Adult Scoliosis and Spine Associates)

THE BIRTH OF PAIN: It begins in childhood but advances in pain and deformity in adulthood. Congenital anomalies form in the uterus while degenerative scoliosis is caused by disc degeneration. As a result of spine fractures, posttraumatic scoliosis comes into existence and neuro-muscular scoliosis has been found to develop in patients with neuromuscular disorders like polio or muscular dystrophies. (SOURCE: Adult Scoliosis and Spine Associates)

SYMPTOMS OF SCOLIOSIS: Scoliosis is often painless with back pain eventually developing only as the condition progresses. Deformities may place unnecessary pressure on ones nerves and possibly even on the spinal cord. This can lead to weakness, numbness, and pain in the lower extremities. In severe, often very rare cases, pressure on the spinal cord may cause loss of coordination in the leg muscles, making it difficult to walk normally. If the chest is deformed due to scoliosis, the lungs and heart may also be affected. This can promote breathing problems, fatigue, and even heart failure. (SOURCE: www.allaboutbackandneckpain.com)

SIMPLE SCOLIOSIS TEST: Aside from experiencing back discomfort, what'll typically bring a patient to the doctor are the noticeable changes in ones back. Some signs that may lead an individual to the doctor include one shoulder or hip higher than the other, one shoulder blade higher or sticking out farther than the other, a hump in the back that sticks up when bending forward, one arm hanging longer than the other or the waist appearing asymmetrical. (SOURCE: www.iscoliosis.com)

TREATMENT: Some adult scoliosis treatment doesn't require surgery. A combination of physical therapy, exercise and Ibuprofen can serve as a recommended treatment. Steroid injections are sometimes used to treat pinched nerves. Surgery is only recommended if pain is unresponsive to non-operative treatment. (SOURCE: www.healthcentral.com)

* For More Information, Contact:
Mr. Ryan Andrews
Research Assistant
(410) 539-3434
rkandrews87@gmail.com

The federal government has launched an investigation into the treatment used in adult scoliosis.

Posted: 6:20 PM Jan 24, 2011
Reporter: Maureen McFadden




The federal government has launched an investigation into the treatment used in adult scoliosis.
Julia Epper, an adult scoliosis patient, used to backstitch, until she developed adult scoliosis.
"I've had back pain since I was 14," said Epper, “It was very frustrating and I felt very limited.”
Diagnosed at age 20 her spine curve grew from 24 degrees, to 54.

Attempts at physical therapy and injections have done nothing for her pain either.
The Hospital for Special Surgery reports that half a million people have adult scoliosis in the United States, and 40 percent will feel more pain each year.

“Many people, as the spine begins to age, and the discs degenerate, beginning to experience more back and even leg pain,” says Charles C. Edwards II, a doctor at the Maryland Spine Center.
A new study shows spinal surgery may be the only true option.

"While we may try medicines and injections first, oftentimes we will move onto surgery because those other methods just are not making a difference for them," says Edwards.

In the United States alone, $860 billion are spent on therapy, braces, and pain injections.
The study, which includes patients from 40 to 80 years old, shows operative patients saw a significant boost in function and quality of life, while non-operative patients reported no improvement at all.
Decompression and fusion surgery worked for Epper, who says, "I no longer have this sharp, burning, debilitating pain. The difference has been remarkable."
Six centers across the US are currently involved in the government's adult scoliosis study.
All six centers are currently enrolling patients with results expected in 2015.

Research Summary:
BENT OUT OF SHAPE: THE ADULT SCOLIOSIS DEBATE
REPORT # 1744

BACKGROUND: Any individual over the age of 18 who has experienced spinal deformity is considered to have adult scoliosis. Scoliosis is defined as an abnormal, side-to-side, curvature of the spine. There are varying causes of spinal deformity including; idiopathic scoliosis, congenital anomalies, degenerative scoliosis, posttraumatic scoliosis and neuro-muscular scoliosis. Idiopathic scoliosis is the most common form of spinal deformity doctors see, affecting about three percent of the general population. (SOURCE: Adult Scoliosis and Spine Associates)

THE BIRTH OF PAIN: It begins in childhood but advances in pain and deformity in adulthood. Congenital anomalies form in the uterus while degenerative scoliosis is caused by disc degeneration. As a result of spine fractures, posttraumatic scoliosis comes into existence and neuro-muscular scoliosis has been found to develop in patients with neuromuscular disorders like polio or muscular dystrophies. (SOURCE: Adult Scoliosis and Spine Associates)

SYMPTOMS OF SCOLIOSIS: Scoliosis is often painless with back pain eventually developing only as the condition progresses. Deformities may place unnecessary pressure on ones nerves and possibly even on the spinal cord. This can lead to weakness, numbness, and pain in the lower extremities. In severe, often very rare cases, pressure on the spinal cord may cause loss of coordination in the leg muscles, making it difficult to walk normally. If the chest is deformed due to scoliosis, the lungs and heart may also be affected. This can promote breathing problems, fatigue, and even heart failure. (SOURCE: www.allaboutbackandneckpain.com)

SIMPLE SCOLIOSIS TEST: Aside from experiencing back discomfort, what'll typically bring a patient to the doctor are the noticeable changes in ones back. Some signs that may lead an individual to the doctor include one shoulder or hip higher than the other, one shoulder blade higher or sticking out farther than the other, a hump in the back that sticks up when bending forward, one arm hanging longer than the other or the waist appearing asymmetrical. (SOURCE: www.iscoliosis.com)

TREATMENT: Some adult scoliosis treatment doesn't require surgery. A combination of physical therapy, exercise and Ibuprofen can serve as a recommended treatment. Steroid injections are sometimes used to treat pinched nerves. Surgery is only recommended if pain is unresponsive to non-operative treatment. (SOURCE: www.healthcentral.com)

* For More Information, Contact:
Mr. Ryan Andrews
Research Assistant
(410) 539-3434
rkandrews87@gmail.com

Read More