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Takashi Nagaya, Hisao Seo, Akio Kuwayama, Tsuyoshi Sakurai, Nobuhiro Tsukamoto, Toshichi Nakane, Kenichiro Sugita and Nobuo Matsui

diluted samples were applied on a nitrocellulose sheet using a 96-hole Minifold apparatus. † The nitrocellulose sheet was baked for 90 minutes at 80°C to immobilize the RNA and was stored in a desiccator until hybridization. In order to detect pro-opiomelanocortin messenger RNA (mRNA), the third exon of pro-opiomelanocortin deoxyribonucleic acid (DNA) was cloned into the Sma I site of the plasmid pSP 65. The Sma I fragment of pro-opiomelanocortin exon 3 includes all coding regions of ACTH and β -lipotropin ( Fig. 1 shaded area ). 26 Fig. 1. Schematic

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Webster H. Pilcher, Shirley A. Joseph and Joseph V. McDonald

following the stimulation-induced release from nerve terminals of endogenous opioid peptides, including the most potent of the analgesic opioid peptides, β -endorphin, a pro-opiomelanocortin (POMC) peptide. 3, 4, 12, 20, 27, 43, 45 A wealth of data accumulated from investigations in the rat has identified an integrated neuronal system in the brain which is capable of powerfully reducing both the perception of pain and the attendant biobehavioral responses by actions at multiple levels of the nervous system. 7, 8, 14, 26, 29, 35, 47, 48 This “descending pain control

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Masaaki Kouchi, Yuki Shibayama, Daisuke Ogawa, Keisuke Miyake, Akira Nishiyama and Takashi Tamiya

to increased cell proliferation, 20 , 31 stemness, tumorigenicity, 30 , 31 , 45 and tumor malignancy. 20 Therefore, various components of this pathway have attracted attention as potential prognostic markers. 19 Recent studies have shown that loss of endogenous Wnt2 suppresses the growth of glioma cells and induces apoptosis through inactivation of β-catenin, 30 , 45 but the mechanism responsible for regulation of Wnt2 expression has not been explored. The (pro)renin receptor (PRR) was discovered and cloned by Nguyen et al. 24 This receptor is highly

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Vladislav Pavlov, Pascale Varlet, Fabrice Chretien, Geneviève Nguyen and Johan Pallud

TO THE EDITOR: We read with great interest the article by Kouchi et al. 1 ( Kouchi M, Shibayama Y, Ogawa D, et al: (Pro)renin receptor is crucial for glioma development via the Wnt/β-catenin signaling pathway. J Neurosurg [epub ahead of print January 6, 2017; DOI: 10.3171/2016.9.JNS16431] ) concerning (pro)renin receptor (PRR) expression in gliomas and its role in glioma development. In their exciting work, the authors retrospectively analyzed PRR, IDH1 immunoexpression, and Ki-67 labeling separately in paraffin sections of 31 gliomas. They also evaluated

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Andrew B. Harris, Floreana Kebaish, Lee H. Riley III, Khaled M. Kebaish and Richard L. Skolasky


Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.


Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).


While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8–5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5–5.3).


Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

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Carolyn E. Schwartz, Roland B. Stark, Phumeena Balasuberamaniam, Mopina Shrikumar, Abeer Wasim and Joel A. Finkelstein

S pine outcome research has progressed in important ways over the past 2 decades. On Deyo and colleagues’ recommendations of using a standard spine outcome battery of patient-reported outcomes (PROs), 7 study results across clinics and investigators became more directly comparable. This standardization has enabled a more evidence-driven research base on which to make decisions about treatment choices. 1 , 17 Nonetheless, the passage of time has led to a larger selection of measures and methods for detecting outcomes and change over time in clinical research

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Ibrahim Hussain, Ori Barzilai, Anne S. Reiner, Lily McLaughlin, Natalie M. DiStefano, Shahiba Ogilvie, Anne L. Versteeg, Charles G. Fisher, Mark H. Bilsky and Ilya Laufer

“indeterminate” group (SINS 10–12) respond differently to surgery compared to patients with lower SINS in the “indeterminate” group (SINS 7–9). Methods Patient Selection Patients who underwent first-time instrumented fusion for metastatic spine disease were consecutively enrolled between July 2014 and August 2016. Patients without preoperative patient-reported outcome (PRO) data (including emergency cases) and those whose postoperative PRO data were collected less than 14 days or more than 180 days after surgery were excluded. Otherwise, no patients meeting inclusion criteria

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Owoicho Adogwa, Isaac O. Karikari, Aladine A. Elsamadicy, Amanda R. Sergesketter, Diego Galan and Keith H. Bridwell

I n an era of shifting emphasis toward quantifiable measures of quality of care as determinants of physician- and hospital-level performance, patient-reported outcomes (PROs) have become an increasingly popular tool to assess subjective outcomes after surgery. 4 , 26 PROs are especially utilized in spinal surgery, as many spinal deformities have significant implications for patients’ perceptions of health and appearance. 1 , 16 Correction of complex spinal deformities involving multiple (≥ 5) levels has been shown to produce significant improvements in PROs

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Nicholas Dietz, Mayur Sharma, Ahmad Alhourani, Beatrice Ugiliweneza, Dengzhi Wang, Miriam A. Nuño, Doniel Drazin and Maxwell Boakye

T he shift toward value-based interventions to combat the rising costs of healthcare requires the adoption of quantitative quality measures. 12 In spine surgery, patient-reported outcomes (PROs) have come to the forefront as quantitative measures to evaluate pain, functional ability, and quality of life following spine surgery. 21 , 34 While several spinal interventions have been shown to improve PROs through controlled clinical studies, 26 , 27 individual outcomes can be heterogeneous. The ability to predict individual outcomes can facilitate clinical

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Joon S. Yoo, Dil V. Patel, Benjamin C. Mayo, Dustin H. Massel, Sailee S. Karmarkar, Eric H. Lamoutte and Kern Singh

surgeon provided patient counseling, whereas advanced practice providers, fellows, residents, and medical students were not involved in any counseling. In addition to the surveys, data were collected regarding patient demographic characteristics, including sex, age, ethnicity, and insurance status. The surveys administered at the preoperative appointment consisted of 2 parts: preoperative patient-reported outcomes (PROs) and expected postoperative PROs. The preoperative PROs were determined on the basis of patient survey scores for the Oswestry Disability Index (ODI