Prediction of the efficacy of surgical intervention in patients with cervical myelopathy by using diffusion tensor 3T-magnetic resonance imaging parameters

Background:

The clinical significance of diffusion tensor (DT) magnetic resonance imaging (MRI) parameters was analyzed to predict postoperative functional recovery in patients with cervical myelopathy.

Materials and Methods:

Sixteen patients with cervical myelopathy caused by cervical spondylosis, disk herniation or ossification of the posterior longitudinal ligament who underwent surgical intervention in our institute were enrolled in this retrospective study. There were 7 men and 9 women, with a mean age of 62.8 years. Clinical assessment was done before surgery and at least 3 months after surgery. All patients underwent whole-body 3.0-Tesla MRI before surgery. DT images (DTIs) were obtained using a single-shot fast spin-echo-based sequence. Mean values of mean diffusivity (MD) and fractional anisotropy (FA) at 6 disk levels of the cervical spine were measured using manual setting of regions of interest. The MD and FA values at the most compressed part were analyzed. Absolute MD and FA values at the most compressed spinal level in patients were transformed into the normalized values with a z-score analysis.

Results:

MD-z may decrease with the severity of cervical myelopathy. Receiver operating characteristic analysis of MD-z and FA-z suggested that both MD-z and FA-z have clinical validity for predicting the efficacy of surgical intervention, but MD-z was considered to be the most appropriate value to predict the efficacy of surgery.

Conclusions:

DTIs may be a promising modality to predict functional recovery after surgery. MD changes may reflect spinal cord condition and its reversibility.

Qualitative analysis of spinal intramedullary lesions using PET/CT

OBJECT Although the usefulness of PET for brain lesions has been established, few reports have examined the use of PET for spinal intramedullary lesions. This study investigated the diagnostic utility of PET/CT for spinal intramedullary lesions. METHODS l-[methyl-¹¹C]-methionine (MET)- or [¹⁸F]-fluorodeoxyglucose (FDG)-PET/CT was performed in 26 patients with spinal intramedullary lesions. The region of interest (ROI) within the spinal cord parenchyma was placed manually in the axial plane. Maximum pixel counts in the ROIs were normalized to the maximum standardized uptake value (SUV_max) using subject body weight. For FDG-PET the SUV_max was corrected for lean body mass (SUL_max) to exclude any influence of the patient's body shape. Each SUV was analyzed based on histopathological results after surgery. The diagnostic validity of the SUV was further compared with the tumor proliferation index using the MIB-1 monoclonal antibody (MIB-1 index). RESULTS A total of 16 patients underwent both FDG-PET and MET-PET, and the remaining 10 patients underwent either FDG-PET or MET-PET. Pathological diagnoses included high-grade malignancy such as glioblastoma multiforme, anaplastic astrocytoma, or anaplastic ependymoma in 5 patients; low-grade malignancy such as hemangioblastoma, diffuse astrocytoma, or ependymoma in 12 patients; and nonneoplastic lesion including cavernous malformation in 9 patients. Both FDG and MET accumulated significantly in high-grade malignancy, and the SUL_max and SUV_max correlated with the tumor proliferation index. Therapeutic response after chemotherapy or radiation in high-grade malignancy was well monitored. However, a significant difference in SUL_max and SUV_max for FDG-PET and MET-PET was not evident between low-grade malignancy and nonneoplastic lesions. CONCLUSIONS Spinal PET/CT using FDG or MET for spinal intramedullary lesions appears useful and practical, particularly for tumors with high-grade malignancy. Differentiation of tumors with low-grade malignancy from nonneoplastic lesions may still prove difficult. Further technological refinement, including the selection of radiotracer or analysis evaluation methods, is needed.

Effects of blood pressure lowering on cardiovascular risk according to baseline body-mass index: a meta-analysis of randomised trials

BACKGROUND

The cardiovascular benefits of blood pressure lowering in obese people compared with people of normal weight might depend on choice of drug. We compared the effects of blood pressure-lowering regimens on cardiovascular risk in groups of patients categorised by baseline body-mass index (BMI).

METHODS

We used individual patient data from trials included in the Blood Pressure Lowering Treatment Trialists' Collaboration to compare the effects of different classes of blood pressure-lowering regimens for the primary outcome of total major cardiovascular events (stroke, coronary heart disease, heart failure, and cardiovascular death). We used meta-analyses and meta-regressions to assess interactions between treatment and BMI when fitted as either a categorical variable (<25 kg/m(2), 25 to <30 kg/m(2), and ≥30 kg/m(2)) or a continuous variable.

FINDINGS

Analyses were based on 135,715 individuals from 22 trials who had 14,353 major cardiovascular events. None of the six primary comparisons showed evidence that protection varied by drug class across the three BMI groups (all p for trend >0·20). When analysed as a continuous variable, angiotensin-converting-enzyme inhibitors gave slightly greater protection for each 5 kg/m(2) higher BMI than did calcium antagonists (hazard ratio 0·93, 95% CI 0·89-0·98; p=0·004) or diuretics (0·93, 0·89-0·98; p=0·002). The meta-regressions showed no relation between BMI category and the risk reduction for a given fall in systolic blood pressure. By contrast with a previous report, we noted no relation between BMI and the efficacy of calcium antagonists compared with diuretics.

INTERPRETATION

We found little evidence that selection of a particular class of blood pressure-lowering drug will lead to substantially different outcomes for individuals who are obese compared with those who are lean.

FUNDING

None.

Six-axis multi-anvil press for high-pressure, high-temperature neutron diffraction experiments

We developed a six-axis multi-anvil press, ATSUHIME, for high-pressure and high-temperature in situ time-of-flight neutron powder diffraction experiments. The press has six orthogonally oriented hydraulic rams that operate individually to compress a cubic sample assembly. Experiments indicate that the press can generate pressures up to 9.3 GPa and temperatures up to 2000 K using a 6-6-type cell assembly, with available sample volume of about 50 mm(3). Using a 6-8-type cell assembly, the available conditions expand to 16 GPa and 1273 K. Because the six-axis press has no guide blocks, there is sufficient space around the sample to use the aperture for diffraction and place an incident slit, radial collimators, and a neutron imaging camera close to the sample. Combination of the six-axis press and the collimation devices realized high-quality diffraction pattern with no contamination from the heater or the sample container surrounding the sample. This press constitutes a new tool for using neutron diffraction to study the structures of crystals and liquids under high pressures and temperatures.

Surgical management of solitary nerve sheath tumors of the cervical spine: a retrospective case analysis based on tumor location and extension

Complete resection of spinal nerve sheath tumors (NSTs) does not always result in significant neurological deficit. The purpose of this retrospective case analysis was to discuss the optimal surgical strategy for spinal NST of the cervical spine. Twenty-four patients who underwent surgery for solitary cervical NST over the past decade were included in this retrospective study. Patients with neurofibromatosis or schwannomatosis were excluded. Seventeen of the 24 cases (70.8%) showed extradural dumbbell extension, most frequently at the C1 or C2 vertebral level. Neurological condition was assessed using the modified McCormick functional schema and sensory pain scale. Total removal of the tumor was achieved in 20 of 24 cases (83.3%). Staged surgery using combined anterior and posterior approaches was applied for 2 of 17 cases with extradural dumbbell extension. Tumor involvement with nerve root fibers critical for upper extremity function (C5–C8) was recognized in 6 of 24 cases (25.0%), with complete resection in all 6 cases. Final assessment of neurological function revealed satisfactory or acceptable recovery in all 6 patients. Spinal NSTs with extradural dumbbell extension are a common condition in the cervical spine. Complete removal of spinal NST of the cervical spine may carry a risk of permanent neurological deficit, but such sequelae appeared to be the exception in the present case analysis. A radical and safe surgical strategy, including staged surgery combining anterior and posterior approaches, should be tailored to the individual case.

Surgical management of spinal meningiomas: A retrospective case analysis based on preoperative surgical grade

Background:

Although spinal meningiomas respond favorably to surgical excision, their surgical management is impacted by several factors. This study utilized a surgery-based grading system to discuss the optimal surgical strategy.

Methods:

Twenty-three consecutive patients who underwent surgery for spinal meningiomas were included in this retrospective study. The patients’ neurological condition was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS), and tumor removal was assessed using Simpson grade. Major factors contributing to surgical difficulty included; tumor size, extent/severity of cord compression, location of tumor attachment, spinal level, and anatomical relationships plus tumor extending in a dumbbell shape and local postoperative recurrence.

Results:

Fifteen cases were classified as ventral attachment (65.2%). There were two dumbbell-shaped tumors and three local recurrences at the primary site. Simpson grade 1 or 2 resections were performed in 18 of 20 cases (90%) with preoperative surgical grades 0 to 3. Simpson grade 4 resections were achieved in all three cases with preoperative surgical grades 4 to 5. Overall neurological assessment after surgery revealed the satisfactory or acceptable recovery on mMFS and SPS analysis.

Conclusions:

Lower preoperative grade yielded better results, while the higher the preoperative grade, the more likely tumor was insufficiently removed. A preoperative surgical grading system appeared to be helpful when considering the surgical strategy. Ventral meningiomas could be safely resected via the posterolateral or lateral approach using technical modifications. Recurrent tumors, especially with ventral attachment, were hard to resolve, and primary surgery appears to be important.

Abstract 180: The Relation of Timing and Degree of Blood Pressure Control with Hematoma Growth - Secondary Analysis of The Interact2 Trial

Background: Acute blood pressure (BP) lowering therapy has shown clinical benefit in patients with acute intracerebral hemorrhage (ICH), but the effect of timing and degree of BP control on ICH growth has received less study.

Methods: Among the INTERACT2 participants (N=2839) with acute ICH allocated either to intensive BP lowering therapy (IT, systolic target <140mmHg) or standard BP treatment (ST), CT brain imaging at baseline and 24 hours were centrally analysed in a subset of 491 (34%) in the IT and 473 (34%) in the ST groups.

Results: Absolute mean ICH growth was lower in patients reaching BP target in <1h from randomization (1.7ml), as compared to those reaching target in 1-6h (4.2ml), and >6h (4.6ml, p=0.04). Hematoma growth was particularly high (14.4ml, 95%CI:10.0-18.8) in patients admitted with systolic BP>160mmHg who achieved <10mmHg systolic BP lowering over 24h, as compared to those achieving 10-20mmHg (3.7ml, 95%CI:0.3-7.1) or 20-30mmHg BP reduction (2.7ml, 95%CI:1.1-4.3); p<0.01). Patients maintaining target BP at 0-2 measurements over 24h had higher absolute volume increase (3.6ml; 95%CI:1.8-5.4) as compared to those who maintained target BP over 3-4 (1.6ml, 95%CI:-0.3-3.5), or 5-8 measurements (0.4ml, 95%CI:-1.7-2.4; p=0.01).

Conclusion: These findings suggest that early and sustained BP control have favorable effects on hematoma growth. This reinforces the principle for patients with acute ICH to receive BP lowering therapy as early as possible and to achieve a lower level of systolic BP for the most favorable outcome.

Effects of low estimated glomerular filtration rate on outcomes after stroke: a hospital-based stroke registry in China

BACKGROUND AND PURPOSE

As uncertainty persists over the prognostic significance of low estimated glomerular filtration rate (eGFR) in acute stroke, the effects of low eGFR on death/disability amongst participants with acute stroke in China were determined.

METHODS

Nanjing First Hospital stroke registry was a prospective cohort study of stroke patients. Patients with acute stroke (brain infarction, intracerebral hemorrhage or subarachnoid hemorrhage) within 7 days of onset were recruited consecutively from 2004 to 2008. Baseline eGFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. Outcomes were death/disability, defined by scores 3-6 on the modified Rankin Scale at 90 days.

RESULTS

A total of 1909 participants were included in the present analyses. Of them, 112 (5.9%) had baseline moderate to severe decrease in eGFR (G3b-4) and increasing risk of higher National Institutes of Health Stroke Scale (NIHSS) scores. Low eGFR was associated with increasing risk of death/disability at 90 days [G3b-4, odds ratio 2.58 (95% confidence interval 1.71-3.91); G3a, 1.86 (1.35-2.56); G2, 1.21 (0.96-1.52); P trend <0.001). However, the association was not statistically significant after adjustment for demographic and clinical factors including NIHSS scores.

CONCLUSIONS

There were no appreciable effects of low eGFR on death/disability at 90 days independent of other prognostic factors in Chinese patients with acute stroke.

Intraoperative assessment of spinal vascular flow in the surgery of spinal intramedullary tumors using indocyanine green videoangiography

Background:

The authors demonstrate the utility of indocyanine green videoangiography (ICG-VA) for intraoperative vascular flow assessment in the surgery of a variety of spinal intramedullary tumors to achieve an additional level of safety as well as precision with the surgical procedure.

Methods:

Fourteen patients with spinal intramedullary tumors (nine cervical and five thoracic) operated on between August 2011 and April 2013 were included in the present study. A fluorescence surgical microscope was used to perform ICG-VA after standard exposure of the lesion to assess the dynamic flow of the spinal microvasculature.

Results:

Twenty-seven ICG-VA injections were performed in 14 cases. Pathological diagnosis of the tumors included ependymoa, astrocytoma, cavernous malformation, or hemagioblastoma. There were no complications or side-effects related to ICG-VA. Intraoperative ICG-VA provided dynamic flow images of the spinal microvasculature in accordance with the progress of surgical procedures. Angiographic images could be divided into arterial, capillary, and venous phases. All angiographic images were well integrated into the microscopic view. The utility of ICG-VA could be summarized into three categories: (1) Localization of normal spinal arteries and veins, (2) assessment of posterior spinal venous circulation, and (3) differentiation of feeding arteries, tumor, and draining veins.

Conclusions:

Intraoperative vascular flow assessment using ICG-VA was easy, repeatable, and practical without any significant procedure-related risks. ICG-VA can be used for careful analysis of spinal microvascular flow or anatomical orientation, which is necessary to ensure safe and precise resection of spinal intramedullary tumors.

Impact of antihypertensive medication adherence on blood pressure control in hypertension: the COMFORT study

BACKGROUND

It has not been fully elucidated whether antihypertensive medication adherence affects blood pressure (BP) control in hypertension cases.

AIM

To investigate the association of adherence to antihypertensive drug regimens and BP control using data from the Combination Pill of Losartan Potassium and Hydrochlorothiazide for Improvement of Medication Compliance Trial (COMFORT) study.

DESIGN

An observational analysis from a randomized controlled trial.

METHODS

A total of 203 hypertensive subjects were randomly assigned to a daily regimen of a combination pill (losartan 50 mg/hydrochlorothiazide 12.5 mg) or two pills, an angiotensin II receptor blocker and a thiazide diuretic. Medication adherence calculated based on pill counts and BPs was evaluated at 1, 3 and 6 months after randomization.

RESULTS

The subjects were divided into three groups according to their adherence, i.e. relatively low-adherence (<90%; n = 19), moderate-adherence (90-99%; n = 71) and high-adherence (100%; n = 113) groups. Clinical characteristics of the subjects including BP, sex, randomized treatments and past medical history did not differ significantly among the three groups. Achieved follow-up BPs over the 6-month treatment period, which were adjusted for age, sex, baseline BP and randomized treatment, were significantly higher in the low-adherence group (135/78 mmHg) compared with the high-adherence (130/74 mmHg; P = 0.02/0.02) and the moderate-adherence (128/74 mmHg; P = 0.003/0.02) groups.

CONCLUSION

Low adherence to an antihypertensive-drug regimen was associated with poor BP control.

Formation of NaCl-type monodeuteride LaD by the disproportionation reaction of LaD2

Previous x-ray diffraction measurements revealed the pressure-induced decomposition of an fcc LaH2.3 into H-rich and H-poor fcc phases around 11 GPa. The present neutron diffraction measurements on LaD2 confirm the formation of NaCl-type LaD as a counterpart of the D-rich LaD2+δ by disproportionation. First-principles enthalpy and lattice dynamic calculations demonstrate that the NaCl-type LaH is stabilized at high pressures and can be recovered at ambient conditions. Finding the NaCl-type LaH will pave the way for investigations on the site-dependent nature of hydrogen-metal interactions.

Reduction of insulin signaling upregulates angiopoietin-like protein 4 through elevated free fatty acids in diabetic mice

BACKGROUND

Angiopoietin-like protein 4 (Angptl4) is thought to cause an increase in serum triglyceride levels. In the present study, we elucidated Angptl4 expression in the mouse models of type 1 and type 2 diabetes mellitus, and investigated the possible mechanisms involved.

METHODS

Type 1 diabetes was induced in C57BL/6 J mice by treating them with streptozotocin (STZ). Type 2 diabetes was induced by feeding the mice a high-fat diet (HFD) for 18 weeks.

RESULTS

The levels of Angptl4 mRNA expression in liver, white adipose tissue (WAT), and brown adipose tissue (BAT) were found to increase in the STZ diabetic mice relative to control mice. This effect was attenuated by insulin administration. In the HFD diabetic mice, the Angptl4 mRNA expression levels were increased in liver, WAT, and BAT. Treatment with metformin for 4 weeks attenuated the increased levels of Angptl4 mRNA. Fatty acids (FAs) such as palmitate and linoleate induced Angptl4 mRNA expression in H4IIE hepatoma cells and 3T3-L1 adipocytes. Treatment with insulin but not metformin attenuated FA-induced Angptl4 mRNA expression in H4IIE. Both insulin and metformin did not influence the effect of FAs in 3T3-L1 cells.

CONCLUSION

These observations demonstrated that Angptl4 mRNA expression was increased through the elevated free FAs in diabetic mice.

Trends in prevalence of Alzheimer's disease and vascular dementia in a Japanese community: the Hisayama Study

OBJECTIVE

To examine secular trends in the prevalence of Alzheimer's disease (AD) and vascular dementia (VD) in a general Japanese population.

METHOD

Four cross-sectional examinations were conducted among residents of a Japanese community aged >or=65 in 1985, 1992, 1998 and 2005.

RESULTS

The age- and sex-adjusted prevalence of all-cause dementia significantly increased with time (6.0% in 1985, 4.4% in 1992, 5.3% in 1998 and 8.3% in 2005; P for trend = 0.002). A similar trend was observed for AD (1.1%, 1.3%, 2.3% and 3.8% respectively; P for trend < 0.001), while the age- and sex-adjusted prevalence of VD and other/unclassified dementia showed J-shaped patterns (for VD: 2.3%, 1.5%, 1.5% and 2.5%, respectively, P for trend = 0.82; for other/unclassified dementia: 2.6%, 1.7%, 1.5% and 2.0%, P for trend = 0.26). The prevalence of AD was likely to increase with time from 1985 to 2005 among subjects aged 75 or older. The ratio of the prevalence of VD to that of AD decreased with time (2.1 in 1985, 1.2 in 1992, 0.7 in 1998 and 0.7 in 2005).

CONCLUSION

Our findings suggest that the prevalence of all-cause dementia and AD significantly increased over the past two decades in the general Japanese population.