Persistent pulmonary abnormalities after 18 months of SARS-CoV-2 pneumonia

OBJECTIVE

To describe persistent pulmonary abnormalities detected on HRCT after 18 months of SARS-CoV-2 pneumonia, and to determine their extension and correlation with pulmonary function.

PATIENTS AND METHODS

A prospective cross-sectional study with an initial cohort of 90 patients in follow-up due to persisting lung abnormalities on imaging, functional respiratory impairment and/or respiratory symptoms. Of these, 31 (34%) were selected for analysis due to the persistence of their lung abnormalities on HRCT at 18 months after infection. A double reading was performed for each HRCT (62 observations).

RESULTS

Of the 31 patients included: 20 (65%) were men; mean age was 67 years; 17 (55%) were smokers/ex-smokers. The mean hospitalisation time was 38 days. Eighteen (58%) patients were admitted to intensive care units. Five patients (16%) suffered an acute pulmonary thromboembolism and three (9.7%) had a pneumothorax. The mean time between the onset of pneumonia and the follow-up HRCT was 20.34 months. Nineteen percent of patients suffered from total lung function abnormalities; and ground-glass opacities and reticulation were present in 12% and 4.5% respectively. The findings of the 62 readings were: ground-glass opacities (100%), reticulation (83%), subpleural curvilinear lines (62%), parenchymal bands (34%), traction bronchiectasis (69%), displacement of vessels/fissures (46%) and honeycombing (4.9%). Pulmonary function 18 months after the acute episode revealed a mean FVC of 92% of predicted value, with an FVC < 80% of predicted value in 11 patients (35.4%). Mean DLCO was 71% of predicted value, with a DLCO < 80% in 22 patients (70%). We observed a statistically significant relationship between total lung function abnormalities on HRCT and FVC (P < 0.05), and a trend towards statistical significance with DLCO (P = 0.051); there was a statistically significant relationship between the presence of ground-glass opacities and FEV1/FVC (P < 0.01). The relationships between reticulation and FVC, FVC%, FEV1, FEV1% and DLCO% were also considered statistically significant (P < 0.05).

CONCLUSION

Persistent interstitial lung abnormalities are seen on HRCT for a subset of patients infected with SARS-CoV-2 pneumonia. Seventy percent of these patients suffered a slight decrease in DLCO.

Minimally Invasive Approaches for Lumbosacral Plexus Schwannomas

BACKGROUND AND OBJECTIVES

Lumbosacral plexus schwannomas (LSPSs) are benign, slow-growing tumors that arise from the myelin sheath of the lumbar or sacral plexus nerves. Surgery is the treatment of choice for symptomatic LSPSs. Conventional retroperitoneal or transabdominal approaches provide wide exposure of the lesion but are often associated with complications in the abdominal wall, lumbar or sacral plexus, ureter, and intraperitoneal organs. Advances in technology and minimally invasive (MIS) techniques have provided alternative approaches with reliable efficacy compared with traditional open surgery. We describe 3 MIS approaches using tubular retractor systems according to the lesion level.

METHODS

This was a multicenter, retrospective observational cohort study to evaluate the use of MIS tubular approaches for surgical resection of LSPSs. We included 23 lumbar and upper sacral plexus schwannomas. Clinical presentation, spinal level, surgical duration, degree of resection, days of hospitalization, pathological anatomy of the tumor, approach-related surgical difficulties, and outcomes were collected.

RESULTS

The posterior oblique approach was used in 43.5% of the cases, the transpsoas approach in 39.1%, and the transiliac in 17.4%. The mean operative time was 3.3 hours, and the mean hospitalization was 2.5 days. All tumors were WHO grade 1 schwannoma. Postoperative MRI confirms gross total resection in 91.3% of the patients. No patient requires instrumentation. The pros and cons of each approach were summarized.

CONCLUSION

The MIS approaches adapted to the lumbar level may improve surgeons' comfort allowing a safe resection of retroperitoneal LSPS.

Predictors of Postoperative Segmental and Overall Lumbar Lordosis in Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Consecutive Case Series

STUDY DESIGN

Retrospective Case-Series.

OBJECTIVES

Due to heterogeneity in previous studies, the effect of MI-TLIF on postoperative segmental lordosis (SL) and lumbar lordosis (LL) remains unclear. Therefore, we aim to identify radiographic factors associated with lordosis after surgery in a homogenous series of MI-TLIF patients.

METHODS

A single-center retrospective review identified consecutive patients who underwent single-level MI-TLIF for grade 1 degenerative spondylolisthesis from 2015-2020. All surgeries underwent unilateral facetectomies and a contralateral facet release with expandable interbody cages. PROs included the ODI and NRS-BP for low-back pain. Radiographic measures included SL, disc height, percent spondylolisthesis, cage positioning, LL, PI-LL mismatch, sacral-slope, and pelvic-tilt. Surgeries were considered "lordosing" if the change in postoperative SL was ≥ +4° and "kyphosing" if ≤ -4°. Predictors of change in SL/LL were evaluated using Pearson's correlation and multivariable regression.

RESULTS

A total of 73 patients with an average follow-up of 22.5 (range 12-61) months were included. Patients experienced significant improvements in ODI (29% ± 22% improvement, P < .001) and NRS-BP (3.3 ± 3 point improvement, P < .001). There was a significant increase in mean SL (Δ3.43° ± 4.37°, P < .001) while LL (Δ0.17° ± 6.98°, P > .05) remained stable. Thirty-eight (52%) patients experienced lordosing MI-TLIFs, compared to 4 (5%) kyphosing and 31 (43%) neutral MI-TLIFs. A lower preoperative SL and more anterior cage placement were associated with the greatest improvement in SL (β = -.45° P = .001, β = 15.06° P < .001, respectively).

CONCLUSIONS

In our series, the majority of patients experienced lordosing or neutral MI-TLIFs (n = 69, 95%). Preoperative radiographic alignment and anterior cage placement were significantly associated with target SL following MI-TLIF.

Association Between Neighborhood-Level Socioeconomic Disadvantage and Patient-Reported Outcomes in Lumbar Spine Surgery

BACKGROUND

Despite an increased understanding of the impact of socioeconomic status on neurosurgical outcomes, the impact of neighborhood-level social determinants on lumbar spine surgery patient-reported outcomes remains unknown.

OBJECTIVE

To evaluate the impact of geographic social deprivation on physical and mental health of lumbar surgery patients.

METHODS

A single-center retrospective cohort study analyzing patients undergoing lumbar surgery for degenerative disease from 2015 to 2018 was performed. Surgeries were categorized as decompression only or decompression with fusion. The area deprivation index was used to define social deprivation. Study outcomes included preoperative and change in Patient-Reported Outcomes Measurement (PROMIS) physical function (PF), pain interference (PI), depression, and anxiety (mean follow-up: 43.3 weeks). Multivariable imputation was performed for missing data. One-way analysis of variance and multivariable linear regression were used to evaluate the association between area deprivation index and PROMIS scores.

RESULTS

In our cohort of 2010 patients, those with the greatest social deprivation had significantly worse mean preoperative PROMIS scores compared with the least-deprived cohort (mean difference [95% CI]-PF: -2.5 [-3.7 to -1.4]; PI: 3.0 [2.0-4.1]; depression: 5.5 [3.4-7.5]; anxiety: 6.0 [3.8-8.2], all P < .001), without significant differences in change in these domains at latest follow-up (PF: +0.5 [-1.2 to 2.2]; PI: -0.2 [-1.7 to 2.1]; depression: -2 [-4.0 to 0.1]; anxiety: -2.6 [-4.9 to 0.4], all P > .05).

CONCLUSION

Lumbar spine surgery patients with greater social deprivation present with worse preoperative physical and mental health but experience comparable benefit from surgery than patients with less deprivation, emphasizing the need to further understand social and health factors that may affect both disease severity and access to care.

POS0795 EPIDEMIOLOGY, DIAGNOSIS AND CLINICAL CHARACTERISTICS OF GIANT CELL ARTERITIS IN PATIENTS INCLUDED IN THE ARTESER MULTICENTER STUDY

Background

Epidemiological information on Giant Cell Arteritis (GCA) comes mainly from the Scandinavian countries of northern Europe, which show a higher incidence than the countries of southern Europe. GCA clinical manifestations can be divided into cranial, extracranial, and general syndrome.

Objectives

In a large series of GCA from Spain, we studied a) the incidence of GCA, b) clinical manifestations, and c) comorbidities at the time of disease diagnosis.

Methods

ARTESER is a retrospective epidemiological observational study of GCA promoted by the Spanish Society of Rheumatology in which 26 hospitals participate. The inclusion criteria were: all new patients diagnosed with GCA by a) ACR criteria, b) positive diagnostic test (temporal artery biopsy, temporal artery ultrasound or other relevant imaging techniques) and/or c) investigator’s clinical judgment. The patient recruitment period ranged from June 1, 2013 to March 29, 2019. The overall incidence of GCA per 100,000 people ≥50 years for the whole period and the mean annual incidence were evaluated. The clinical variables were collected by reviewing the patient’s medical history.

Results

1675 patients were included. The average annual incidence rate was 7.42 (95% CI: 6.57-8.27). All the cases were older than 50 years, and the age group with the highest annual incidence was that of 80 to 84 years, where it reached a value of 22.63 (95% CI: 22.04 -23.22). The mean annual incidence is higher in women than in men 10.07 (95% CI: 8.74-11.55) vs 4.81 (95% CI 3.84-5.93) (Table 1).

Table 1.

General characteristics, comorbidities and clinical manifestations

Epidemiologic, demographic and diagnosisMenWomenTotalGender, n (%)497 (29.7)1178 (70.3)1675Incidence annual rate (95% CI)4.81 (3.84-5.93)10.07 (8.74-11.55)7.42 (6.57-8.27)Age at diagnosis, years, mean (SD)76.9 (8.3)76.9 (8.0)76.9 (8.1)Diagnosis only by ACR Criteria89 (17.91)266 (22.58)355 (21.19)Diagnosis only with objective tests73 (14.69)140 (11.88)213 (12.72)Diagnosis ACR criteria + diagnosis objective tests311 (62.58)734 (62.31)1045 (62.39)Diagnosis by clinical judgment24 (4.8)38 (3.2)62 (3.7)Comorbidities at diagnosisArterial hypertension, n (%)330 (66.8)749 (63.7)1079 (64.6)Dyslipidemia, n (%)238 (48.3)563 (47.9)801 (48.0)Cranial clinical manifestationsNew-onset headache, n (%)382 (76.9)955 (81.1)1337 (79.9)Visual Clinic, n (%)194 (39.0)411 (34.9)605 (36.1)Extracranial manifestations and general syndromePolymyalgia rheumatica, n (%)178 (35.8)521 (44.3)699 (41.8)Asthenia, n (%)239 (48.1)634 (53.9)873 (52.2)Analysis at diagnosisErythrocyte sedimentation rate mm/h, mean (SD)72.3 (34.7)77.4 (33.0)75.9 (33.6)

The principal clinical characteristics of the population is shown in Table 1, the mean age at diagnosis was 76.9±8.1 years, 1178 (70.3%) were women. 1045 patients (62.39%) had ACR criteria and some positive objective test, 355 patients (21.9%) presented only ACR criteria and 213 (12.72%) only had a positive diagnostic test; 62 (3.7%) of the patients underwent diagnosis based on clinical judgment. The more frequent comorbidity was arterial hypertension (n=1079; 64.6%), followed by dyslipidemia (n=801, 48%). The predominant cranial manifestation was headache (n= 1337; 79.9%) and 605 patients experienced visual symptoms (36.1%). Polymyalgia rheumatica (n=699; 41.8%) and asthenia (n=837; 52.2%) were the most frequent extracranial and general syndrome manifestation, respectively. Regarding laboratory parameters, the most characteristic data was the increase of ESR (75.9±33.6 mm/1st h).

Conclusion

The mean annual incidence of GCA in Spain, 7.42 (95% CI: 6.57-8.27), is lower than that of the Scandinavian countries. It is higher in people older than 80 years. More than 60% of the patients met the ACR criteria and had a positive diagnostic test. Cranial manifestations constituted the most clinical features. The most frequent clinical manifestations are cranial. Up to a third of patients had visual manifestations.

Acknowledgements

This study has been funded by ROCHE Farma. The funder has not participated in the design, analysis, or interpretation of the results

Disclosure of Interests

None declared

POS0100 ACTIVATION OF THE CELLULAR INTEGRATED STRESS RESPONSE IN LABIAL SALIVARY GLANDS FROM SJÖGREN’S SYNDROME PATIENTS

Background

Sjögren’s syndrome (SS) is a chronic autoimmune disease characterized by inflammation of the exocrine glands and severe symptoms of eye and mouth dryness. Disorders in the saliva secretion process have been associated with oxidative and endoplasmic reticulum (ER) stress in combination with inflammatory responses. The integrated stress response (ISR) is a mechanism that allows cells to modify their gene expression program to restore homeostasis and promote their survival against various extrinsic and intrinsic stress signals, such as hypoxia, nutrient deprivation, viral infections, inflammatory factors (cytokines, chemokines, inflammasomes), and accumulation of unfolded proteins in the ER, among others (1). The ISR is regulated by four kinases: PERK, PKR, HRI and GCN2, that dimerize and autophosphorylate to become active and each one responds to different stress stimuli. The signaling pathways that are activated in response to stress factors stimulate the phosphorylation of eIF2α, which causes a transient inhibition of global protein synthesis and induction of synthesis of some specific genes like ATF4 and NRF2. ATF4 induces the transcription of genes involved in metabolism and nutrient uptake, redox status, and regulation of apoptosis. Dephosphorylation of eIF2α is the ISR termination signal to restore protein synthesis and is mediated by the PP1 complex, which recruits the catalytic subunit PP1c and one of its two regulatory subunits: GADD34 or CREP.

Objectives

To evaluate the presence and functional state (phosphorylation) of the ISR sensing kinases: PERK, PKR, HRI and GCN2; the levels of eIF2α /p-eIF2α and the key ISR transcription factors ATF4 and NRF2, as well as subunits of the complex involved in the ISR termination: PP1c, GADD34 and CREP in labial salivary glands (LSG) of SS-patients.

Methods

Biopsies of LSG from 12 SS-patients and 11 control subjects were studied. The levels of mRNA, protein and phospho (p)-protein of the ISR components were determined by RT-qPCR and Western blotting.

Results

Our results show increased levels of p-PERK/PERK ratio (11/11), PKR (7/11), p-PKR (7/11), p-PKR/PKR ratio (7/11), eIF2α (5/11), p-eIF2α (5/11) and ATF4 (11/11) in LSG from SS-patients compared to control subjects. No significant changes were found in mRNA levels of HRI, GCN2, and GADD34 between LSG from SS-patients and control subjects. Decreased protein levels of HRI (8/12), p-GCN2 (6/11), eIF2α (6/11), p-eIF2α (6/11), NRF2 (11/12), and p-NRF2 (12/12) were found in LSG showing scarce parenchyma and high fibrosis and fat infiltration. On the other hand, PP1c and CREP showed decreased mRNA and protein levels in all SS-patients LSG. Interestingly, Ro autoantibodies and focus score were negatively correlated with PP1c and NRF2 mRNA and protein levels whereas positively correlated with PKR mRNA levels.

Conclusion

The overexpression and activation of some ISR kinases together with the decrease in the PP1c/CREP phosphatase complex suggests a continuous activation of ISR, resulting in p-eIF2α to remain activated in LSG from SS-patients. This would explain the high protein levels of ATF4 and of target genes involved in the antioxidant response in LSG from SS patients suggesting that ISR activation plays a key role in pro-survival response to cellular stress.

References

[1]Pakos-Zebrucka K, Koryga I, Mnich K, Ljujic M, Samali A, Gorman AM. The integrated stress response. EMBO Rep. 2016;17(10):1374-95.

Acknowledgements

This work was supported by Fondecyt-Chile 1210055; Enlace-VID Universidad de Chile [ENL04/20 to MJG]; Fondecyt Iniciacion 11201058 and PhD fellowship Conicyt Chile.

Disclosure of Interests

None declared

POS0455 TOFACITINIB DECREASES INFLAMMATORY MARKERS AND MITOCHONDRIAL MORPHOLOGICAL DAMAGE IN SALIVARY GLANDS OF A MURINE MODEL OF SJÖGREN’S SYNDROME

Background

Altered homeostasis of salivary gland (SG) epithelial cells in Sjögren’s syndrome (SS) patients could be the initiating factor that leads to inflammation, as well as secretory dysfunction. Mitochondria are important organelles involved in cellular metabolism and their dysfunction can induce a loss of homeostasis and inflammation. Altered mitochondrion can release mitochondrial components that can act as damage-associated molecular patterns (DAMPs) and induce an inflammatory response via pattern recognition receptors (PRRs) such as the NLRP3 inflammasome, TLR9, cGAS/STING, and ZBP1 (1). Previously we determined that SG from SS patients showed and altered autophagy, which is associated to an increased pro-inflammatory cytokines expression. Interestingly, increased expression of pro-inflammatory markers such as IL-6, was reversed by JAK inhibitor tofacitinib in three-dimensional (3D)-acini deficient in autophagy (2). It is not clear whether the alterations in autophagy found in SG patients include alterations in mitochondrial clearance (mitophagy) that may lead to the accumulation of damaged mitochondria and enhanced inflammation. In this context, recent results of our laboratory showed, for the first time, severe ultrastructural alterations of mitochondria in SG cells from SS patients (1). However, it remains to be determined if these alterations are related to inflammation and if an anti-inflammatory agent could regulate these processes.

Objectives

To analyze the effect of tofacitinib on the mitochondrial ultrastructure in submandibular glands of a murine model of SS. In addition, to evaluate the effect of tofacitinib on the expression and activation of some PRRs involved in the recognition of mitochondrial DAMPs in the same murine model.

Methods

Six-month-old female NOD.B10Sn-H2b/J mice (Jackson Laboratories, USA) were used with 4-5 mice per group. Procedures were approved by the Universidad de Chile Animal Care and Use Committee. 30 mg/kg/day tofacitinib citrate was administered by oral gavage. After 28 days of tofacitinib or vehicle administration, their submandibular glands were obtained, which were processed to evaluate the mitochondrial ultrastructure by electron microscopy or lysed in RIPA buffer to obtain proteins. The protein levels of PRRs: NLRP3, TLR9, ZBP-1, and cGAs, as well as molecules activated downstream of cGAS and ZBP-1 such as TBK1, pTBK1, pSTING, and STING were determined by Western blotting.

Results

The results show that the mitochondria of the glandular epithelial cells of NOD.B10Sn-H2b/J mice treated with vehicle (control) present alterations such as swelling, disruption of membranes and crest disorganization that previously were reported in patients with SS (1). Interestingly, tofacitinib treatment improves the architecture of mitochondria. On the other hand, the protein levels of PRRs such as NLRP3 and cGAS decreased in mice treated with tofacitinib, as well as pTBK1.

Conclusion

The altered morphology of mitochondria together with the increased protein levels of PRRs and downstream markers of these PRRs suggests release of mitochondrial DAMPs in submandibular glands of NOD.B10Sn-H2b/J mice. The improvement in mitochondrial morphology as well as the decrease in PRRs activation under tofacitinib treatment suggest a potential use of this anti-inflammatory agent in mitochondrial alterations associated with inflammation. Many questions remain to be addressed, such as determining which mitochondrial DAMP might be being released and whether this is associated with impaired mitochondrial function in SS.

References

[1]Barrera, M. J., et al (2021). Dysfunctional mitochondria as critical players in the inflammation of autoimmune diseases: Potential role in Sjögren’s syndrome. Autoimmunity reviews, 20(8), 102867.

[2]Barrera, M. J., et al (2021). Tofacitinib counteracts IL-6 overexpression induced by deficient autophagy: implications in Sjögren’s syndrome. Rheumatology (Oxford, England), 60(4), 1951–1962.

Acknowledgements

This work was supported by Fondecyt Iniciación 11201058 and Fondecyt-Chile 1210055.

Disclosure of Interests

None declared.

Comparison of local and regional radiographic outcomes in minimally invasive and open TLIF: a propensity score-matched cohort

OBJECTIVE

Local and regional radiographic outcomes following minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) versus open TLIF remain unclear. The purpose of this study was to provide a comprehensive assessment of local and regional radiographic parameters following MI-TLIF and open TLIF. The authors hypothesized that open TLIF provides greater segmental and global lordosis correction than MI-TLIF.

METHODS

A single-center retrospective cohort study of consecutive patients undergoing MI- or open TLIF for grade I degenerative spondylolisthesis was performed. One-to-one nearest-neighbor propensity score matching (PSM) was used to match patients who underwent open TLIF to those who underwent MI-TLIF. Sagittal segmental radiographic measures included segmental lordosis (SL), anterior disc height (ADH), posterior disc height (PDH), foraminal height (FH), percent spondylolisthesis, and cage position. Lumbopelvic radiographic parameters included overall lumbar lordosis (LL), pelvic incidence (PI)-lumbar lordosis (PI-LL) mismatch, sacral slope (SS), and pelvic tilt (PT). Change in segmental or overall lordosis after surgery was considered "lordosing" if the change was > 0° and "kyphosing" if it was ≤ 0°. Student t-tests or Wilcoxon rank-sum tests were used to compare outcomes between MI-TLIF and open-TLIF groups.

RESULTS

A total of 267 patients were included in the study, 114 (43%) who underwent MI-TLIF and 153 (57%) who underwent open TLIF, with an average follow-up of 56.6 weeks (SD 23.5 weeks). After PSM, there were 75 patients in each group. At the latest follow-up both MI- and open-TLIF patients experienced significant improvements in assessment scores obtained with the Oswestry Disability Index (ODI) and the numeric rating scale for low-back pain (NRS-BP), without significant differences between groups (p > 0.05). Both MI- and open-TLIF patients experienced significant improvements in SL, ADH, and percent corrected spondylolisthesis compared to baseline (p < 0.001). However, the MI-TLIF group experienced significantly larger magnitudes of correction with respect to these metrics (ΔSL 4.14° ± 4.35° vs 1.15° ± 3.88°, p < 0.001; ΔADH 4.25 ± 3.68 vs 1.41 ± 3.77 mm, p < 0.001; percent corrected spondylolisthesis: -10.82% ± 6.47% vs -5.87% ± 8.32%, p < 0.001). In the MI-TLIF group, LL improved in 44% (0.3° ± 8.5°) of the cases, compared to 48% (0.9° ± 6.4°) of the cases in the open-TLIF group (p > 0.05). Stratification by operative technique (unilateral vs bilateral facetectomy) and by interbody device (static vs expandable) did not yield statistically significant differences (p > 0.05).

CONCLUSIONS

Both MI- and open-TLIF patients experienced significant improvements in patient-reported outcome (PRO) measures and local radiographic parameters, with neutral effects on regional alignment. Surprisingly, in our cohort, change in SL was significantly greater in MI-TLIF patients, perhaps reflecting the effect of operative techniques, technological innovations, and the preservation of the posterior tension band. Taking these results together, no significant overall differences in LL between groups were demonstrated, which suggests that MI-TLIF is comparable to open approaches in providing radiographic correction after surgery. These findings suggest that alignment targets can be achieved by either MI- or open-TLIF approaches, highlighting the importance of surgeon attention to these variables.

Augmented Reality in Spinal Surgery: Highlights From Augmented Reality Lectures at the Emerging Technologies Annual Meetings

Introduction

Augmented reality (AR) is an advanced technology and emerging field that has been adopted into spine surgery to enhance care and outcomes. AR superimposes a three-dimensional computer-generated image over the normal anatomy of interest in order to facilitate visualization of deep structures without the ability to directly see them.

Objective

To summarize the latest literature and highlight AR from the annual “Spinal Navigation, Emerging Technologies and Systems Integration” meeting lectures presented by the Seattle Science Foundation (SSF) on the development and use of augmented reality in spinal surgery. 

Methods

 We performed a comprehensive literature review from 2016 to 2020 on PubMed to correlate with lectures given at the annual “Emerging Technologies” conferences. After the exclusion of papers that concerned non-spine surgery specialties, a total of 54 papers concerning AR in spinal applications were found. The articles were then categorized by content and focus.

Results

The 54 papers were divided into six major focused topics: training, proof of concept, feasibility and usability, clinical evaluation, state of technology, and nonsurgical applications. The greatest number of papers were published during 2020. Each paper discussed varied topics such as patient rehabilitation, proof of concept, workflow, applications in neurological and orthopedic spine surgery, and outcomes data.

Conclusions

The recent literature and SSF lectures on AR provide a solid base and demonstrate the emergence of an advanced technology that offers a platform for an advantageous technique that is superior, in that it allows the operating surgeon to focus directly on the patient rather than a guidance screen.

Extended tulip cervical reduction screws to restore alignment in traumatic atlantoaxial dislocation after type 3 odontoid fracture: illustrative case

BACKGROUND

Traumatic atlantoaxial rotatory subluxation after type 3 odontoid fracture is an uncommon presentation that may require complex intraoperative reduction maneuvers and presents challenges to successful instrumentation and fusion.

OBSERVATIONS

The authors report a case of a 39-year-old female patient who sustained a type 3 odontoid fracture. She was neurologically intact and managed in a rigid collar. Four months later, she presented again after a second trauma with acute torticollis and type 2 atlantoaxial subluxation, again neurologically intact. Serial cervical traction was placed with minimal radiographic reduction. Ultimately, she underwent intraoperative reduction, instrumentation, and fusion. Freehand C1 lateral mass reduction screws were placed, then C2 translaminar screws, and finally lateral mass screws at C3 and C4. The C2–4 instrumentation was used as bilateral rod anchors to reduce the C1 lateral mass reduction screws engaged onto the subluxated atlantodental complex. As a final step, cortical allograft spacers were inserted at C1–2 under compression to facilitate long-term stability and fusion.

LESSONS

This is the first description of a technique using extended tulip cervical reduction screws to correct traction-irreducible atlantoaxial subluxation. This case is a demonstration of using intraoperative tools available for the spine surgeon managing complex cervical injuries requiring intraoperative reduction that is resistant to traction reduction.

POS0180 TYPE I INTERFERON DEPENDENT HSA-MIR-145-5P DOWNREGULATION MODULATES MUC1 AND TLR4 OVEREXPRESSION IN SALIVARY GLANDS FROM PRIMARY SJÖGREN’S SYNDROME PATIENTS

Background:

Primary Sjögren’s syndrome (pSS) is an autoimmune and inflammatory disease that mainly affects the salivary glands (SG) and is characterized by an overactivation of the type I interferon pathway (IFNs I). IFNs I are known to regulate the levels of microRNAs (miRNAs), non-coding RNAs whose levels are altered in pSS. IFNs I can decrease the levels of miR-145-5p, a miRNA with anti-inflammatory roles that has been reported downregulated in SG of from pSS patients [1]. This miRNA has TLR4 and MUC1 transcripts as predicted targets. MUC1 and TLR4 are two proteins overexpressed in SG of pSS patients that contribute, through various mechanisms, to the inflammatory state and glandular dysfunction [2-3]. Thus, we propose that IFNs I may contribute to a self-perpetuating inflammation loop through a hsa-miR-145-5p dependent MUC1 and TLR4 overexpression in the SG of pSS patients.

Objectives:

to evaluate whether mRNA levels of MUC1 and TLR4 are modulated by hsa-miR-145-5p in a IFNs I dependent manner.

Methods:

13 pSS patients and 9 controls SG biopsies were analyzed. hsa-miR-145-5p levels were determined by TaqMan assays and MUC1, TLR4, IFN-α and IFN-β mRNA levels by RT-qPCR. Additionally, in vitro assays using type I IFNs and chemically synthesized hsa-miR-145-5p mimics and inhibitors were performed to study its effect on MUC1 and TLR4 expression. JAK1 and STAT1 mRNA levels were also measured.

Results:

By Taqman assays we validated the decreased hsa-miR-145-5p levels (p=0.0001) in SG of pSS patients compared to controls. The decreased hsa-miR-145-5p levels correlated inversely with the increased mRNA levels of IFN-β (p=0.0192) in SG of pSS-patients. The hsa-miR-145-5p downregulation also correlated inversely with the overexpression of its predicted targets MUC1 (p=0.010) and TLR4 (p=0.0004). In vitro assays showed that IFN-β induces the overexpression of JAK1 (<p=0.0001) and STAT1 (p=<0.0001) leading to the downregulation of hsa-mir-145-5p (p=<0.0001) and increased MUC1 (p=<0.0001) and TLR4 mRNA levels (p=<0.0001). Functional assays suggest a regulation of hsa-miR-145-5p on MUC1 and TLR4 expression as MUC1 and TLR4 mRNA levels were decreased in HSG cells transfected with hsa-miR-513c-3p mimic and increased in HSG cells transfected with the miRNA inhibitor.

Conclusion:

Our findings suggest that IFNs I could induce the downregulation of hsa-miR-145-5p leading to the overexpression of MUC1 and TLR4 in SG from pSS patients. TLR4 is activated by ectopic mucins in the SG extracellular matrix from pSS patients which induces pro-inflammatory cytokines secretion [3]. Furthermore, the high levels of the MUC1-SEC and MUC1-Y isoforms observed in SG from pSS patients may favor cytokine synthesis through the immuno-enhancing peptide of MUC1-SEC or through the formation of a MUC1-SEC/MUC1-Y complex [4]. Therefore, IFNs I may contribute to the development of SS through amplification and perpetuation of inflammation due to a hsa-miR-145-5p dependent MUC1 and TLR4 overexpression.

References:

[1]I. Alevizos, et al,. Arthritis Rheum, 2011;63:535-44.

[2]HH. Sung, et al,. Oral Dis. 2015;21(6):730-8.

[3]MJ. Barrera, et al,. Rheumatology (Oxford). 2015;54(8):1518-27

[4]LM. Herbert, et al,. Cancer Res. 2004;64(21):8077-84.

Acknowledgements:

Fondecyt 1210055, Fondecyt 1160015, Fondecyt Iniciación 11170049, Fondecyt Iniciación 11201058, CONICYT fellowship (DJ, PC)

Disclosure of Interests:

None declared

[Optimizing the detection of subclinical atrial fibrillation after ESUS]

INTRODUCTION

It has been estimated that approximately 20% of ischemic strokes have a cardioembolic origin and the cause is not detected or there are more than one in 9-25% of ischemic strokes. An adequate diagnostic approach of ESUS would allow an optimization of antithrombotic treatment.

OBJECTIVE

Narrative update about the available evidence on the best diagnostic and therapeutic approach among patients with ESUS and how to optimize the detection of atrial fibrillation as a potential cause is reviewed.

DEVELOPMENT

A search was conducted on PubMed (MEDLINE), using the MeSH terms [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Original data from clinical trials, prospective and retrospective studies and reviews were selected.

CONCLUSIONS

The detection of atrial fibrillation after ESUS is mandatory to optimize the treatment. However, not all patients have the same risk of developing silent atrial fibrillation. There are some factors that increase this risk (left atrium enlargement, elderly, frequent premature supraventricular complexes). In these patients, a more prolonged monitorization could increase the possibility of detecting atrial fibrillation, and consequently, to benefit more from anticoagulant treatment.

AB0698 REAL CLINICAL PRACTICE IN THE CONTROL OF REPORTED OUTCOMES BY THE PATIENT (PROS) DIAGNOSED WITH PSORIATIC ARTHRITIS AND/OR ANKYLOSING SPONDYLITIS WHO BEGIN TREATMENT WITH SECUKINUMAB. A PROSPECTIVE MULTICENTRIC STUDY

Background:

Objectives:

Analyse the effect of secukinumab in terms of the patient´s own variables, specifically: fatigue, sleep, pain and quality of life in patients with psoriatic arthritis or spondyloarthritis.

Methods:

A multicentric longtitudinal observational prospective study was carried out at 6 months in patients who begin treatment with secukinumab. At the start and after 6 months the following data was collected on the outcome: pain through an visual analogue scale (VAS), fatigue using the FACIT-fatigue scale, sleeping problems using the insomnia severity index (ISI) and quality of life with the EuroQol-3L-5D and the PsAQoL.

The sample can be described in terms of the distribution of the variables through measures of central tendency.It was analysed if the change after 6 months was statistically relevant using Student´s t-test for paired data in the case of FACIT, VAS, PsAQoL and ISI and chi-squared for the dimensions of the EQ-5D. The size of the effect of each of the measurements taken was calculated using Cohen’s D. the results are given grouped by disease and globally. The analysis was carried out using Stata v12 (College Station Tx, USA)

Results:

In table 1, the changes in the scales of normal distribution can be seen. Apart from general VAS, all the scales experience significant relevant changes. The PROs preferred by the patient with the best therapeutic response is the quality of sleep. The adjustment of the regression models does not produce changes in the results, apart from small adjustments to the condidence intervals (final column table 1). The subdomain in which the most significant change in the EQ-5D is produced is in that of pain and discomfort.

Conclusion:

After 6 months patients who begin treatment with secukinumab, present with improvements in all sizes of the effects of the treatment in the various studied scales. The improvement achieves global and generalised statistical significance after 6 months of study. The greatest effect is on sleep, quality of life and fatigue.

The measurements of the outcomes reported by the patients are a clinical value added to our objective evaluations of the health and activity of the disease, and allow us, in a more integrated and comprehensive manner, to undertake a more exact and close evaluation of their state of health and wellbeing.

Disclosure of Interests:

JUAN JOSE LERMA: None declared, Antonio Gracia: None declared, Antonio Perez: None declared, Amalia Rueda: None declared, Clara Molina: None declared, M. Dolores Pastor: None declared, Isabel Balaguer Trull: None declared, Inmaculada Valiente: None declared, Cristina Campos Fernández: None declared, Javier Calvo: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

THU0229 HSA-MIR-513C-3P OVEREXPRESSION DECREASES XBP-1S CORRELATING WITH INCREASED INFLAMMATION AND AUTOANTIBODIES IN SALIVARY GLANDS FROM SJÖGREN’S SYNDROME PATIENTS

Background:

Endoplasmic reticulum (ER) stress and the Unfolded Protein Response (UPR) are linked to inflammation in a variety of human pathologies including autoimmune diseases. Salivary glands (SG) from Sjögren’s syndrome (SS) patients have high levels of IFN-gamma among other cytokines, which trigger or exacerbate protein unfolding or misfolding, inducing ER stress. In this study, we focused on the IRE1α/XBP-1 pathway of the UPR, whose transcription factor is XBP-1s, which induces genes linked to regulation of the secretory pathway. We recently found that SG of SS patients have reduced levels of XBP-1s transcripts associated with an increased DNA methylation of XBP-1 promoter [1]. We postulate that other epigenetic mechanisms, such as miRNAs, could coexist with promoter DNA hyper-methylation to regulate XBP-1s expression.

Objectives:

Due to hsa-miR-513c-3p overexpression has been reported in SG from SS patients [2] and that XBP-1 is a predicted target of hsa-miR-513c-3p, the aim of this study was to evaluate whether mRNA levels of XBP-1s is modulated by hsa-miR-513c-3p and also if IFN-gamma modify the expression hsa-miR-513c-3p and XBP-1s.

Methods:

SG biopsies from 16 SS-patients with low and high focus score and 5 controls were analyzed. hsa-miR-513c-3p levels were measured by Taqman miRNA assays, whereas XBP-1s mRNA levels were determined by qRT-PCR. Additionally,in vitroassays using IFN-gamma and chemically synthesized hsa-miR-513c-3p mimics and inhibitors were performed to study its effect on XBP-1s expression.

Results:

By Taqman assays we validated the overexpression of hsa-miR-513c-3p in SG from 8 SS patients with low (p=0.03) and 8 SS-patients with high (p=0.003) focus score, compared with SG from 5 controls. In the same samples, a decrease of XBP-1s transcript levels was observed in SG from SS-patients with low (p=0.002) and high (p=0.026) focus score. XBP1s transcript levels were negatively correlated with hsa-miR-513c-3p (r=-0.47, p=0.014), Ro (r=-0.73, p=0.0009), ANA (r=-0.7, p=0.0033) and focus score (r=-0.72, p=0.001). Stimulation of 3D-acini with 1 ng/mL IFN-gamma increase the hsa-miR-513c-3p levels (p=0.014) and decrease the XBP-1s transcript levels (p=0.027). A negative correlation was found between hsa-miR-513c-3p and XBP-1s transcript levels in 3D-acini stimulated with IFN-gamma (r=-0.87, p=0.0001). The XBP-1s transcript levels were decreased in HSG cells transfected with hsa-miR-513c-3p mimic and increased in HSG cells transfected with the miRNA inhibitor.

Conclusion:

IFN-gamma-induced upregulation of hsa-miR-513c-3p is consistent with the presence of STAT1-binding elements in its promoter region. Our findings suggest that the combined action of miRNAs and DNA methylation modulated by IFN-gamma could explain the altered expression of XBP-1s, a key transcription factor involved in cellular proteostasis, affecting secretory function in LSG from SS-patients. Our results confirm previous correlations found between XBP-1s protein levels and clinical parameters of SS-patients, suggesting an association of XBP-1s with inflammation and impaired SG function.

References:

[1]D. Sepúlveda,et al, Rheumatology (Oxford), 2018;57:1021-32.

[2]I. Alevizos,et al,. Arthritis Rheum, 2011;63:535-44.

Acknowledgments :

Fondecyt 1160015, Fondecyt Iniciación 11170049, Fondecyt Postdoctorado 3170023, CONICYT fellowship (PC, DJ).

Disclosure of Interests: :

None declared

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Protocol for Urgent and Emergent Cases at a Large Academic Level 1 Trauma Center

Background

Level 1 trauma centers are capable of caring for every aspect of injury and contain 24-hour in-house coverage by general surgeons, with prompt availability of nearly all other disciplines upon request. Despite the wide variety of trauma, currently reported protocols often focus on a single surgical service and studies describing their implementation are lacking. The aim of the current study was to characterize all urgent and emergent cases at a large academic Level 1 trauma center, characterize the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on timing of surgery.

Methods

For this retrospective review, all urgent and emergent cases treated at a single institution, during a 34-month period (January 1, 2015–October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Demographic characteristics for non-elective surgical emergent cases were compiled by level of urgency and operating room (OR) waiting times were compared by year, department, and Level.

Results

A total of 11,206 urgent and emergent operative cases were included, among over 16 surgical departments. Level 2 cases represented the majority of urgent/emergent cases (33%–36%), followed by Level 3 (25%–26%), Level 1 (21%–22%), Level 4 (12%–16%), and Level 5 (2%–4%). Univariate analysis demonstrated that the proportion of urgent and emergent cases, by level of urgency, did not significantly differ between each year. Operating room waiting time decreased significantly over each year from 2015, 2016, and 2017: 193.40 ± 4.78, 177.20 ± 3.29, and 82.01 ± 2.98 minutes, respectively.

Conclusions

To the authors’ knowledge, this is the first study to characterize all urgent and emergent cases at a large academic Level 1 trauma center, outline the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on surgical waiting times over a 34-month period.

Clinical Translation of the LevelCheck Decision Support Algorithm for Target Localization in Spine Surgery

Recent work has yielded a method for automatic labeling of vertebrae in intraoperative radiographs as an assistant to manual level counting. The method, called LevelCheck, previously demonstrated promise in phantom studies and retrospective studies. This study aims to: (#1) Analyze the effect of LevelCheck on accuracy and confidence of localization in two modes: (a) Independent Check (labels displayed after the surgeon's decision) and (b) Active Assistant (labels presented before the surgeon's decision). (#2) Assess the feasibility and utility of LevelCheck in the operating room. Two studies were conducted: a laboratory study investigating these two workflow implementations in a simulated operating environment with 5 surgeons, reviewing 62 cases selected from a dataset of radiographs exhibiting a challenge to vertebral localization; and a clinical study involving 20 patients undergoing spine surgery. In Study #1, the median localization error without assistance was 30.4% (IQR = 5.2%) due to the challenging nature of the cases. LevelCheck reduced the median error to 2.4% for both the Independent Check and Active Assistant modes (p < 0.01). Surgeons found LevelCheck to increase confidence in 91% of cases. Study #2 demonstrated accuracy in all cases. The algorithm runtime varied from 17 to 72 s in its current implementation. The algorithm was shown to be feasible, accurate, and to improve confidence during surgery.

Disturbed testicular expression of the estrogen-metabolizing enzymes CYP1A1 and COMT in infertile men with primary spermatogenic failure: possible negative implications on Sertoli cells

Estradiol (E₂ ) is normally metabolized to hydroxyestradiols and methoxyestradiols by CYP1A1, CYP1B1 and COMT. However, an altered production of these metabolites by a disturbed expression of these enzymes is associated with reproductive and non-reproductive pathologies. In vitro studies suggest that increased hydroxyestradiols and methoxyestradiols intratesticular generation is related to male infertility, but no studies have explored whether infertile men have a disturbed testicular expression of the enzymes that generate these E₂ metabolites. The aim of this study was to assess CYP1A1, CYP1B1 and COMT testicular expression at mRNA and protein level in men with spermatogenic impairment. Seventeen men with primary spermatogenic failure (13 with Sertoli cell-only syndrome and four with maturation arrest) and nine controls with normal spermatogenesis were subjected to testicular biopsy. mRNA was quantified using real-time RT-PCR and protein expression was evaluated using western blot and immunohistochemistry followed by integrated optic density analysis. Besides, the effects of hydroxyestradiols and methoxyestradiols on testosterone-induced transcriptional activity were evaluated in TM4 cells using a luciferase reporter assay system. Our results show that patients with Sertoli cell-only syndrome had significantly elevated COMT expression at the mRNA level, higher COMT immunoreactivity in their seminiferous tubules and increased protein expression of the soluble COMT isoform (S-COMT), whereas patients with maturation arrest had significantly elevated CYP1A1 mRNA levels and higher CYP1A1 immunoreactivity in interstitial space. Finally, 2-hydroxyestradiol decreased testosterone-induced transcriptional activity in Sertoli cells in vitro. In conclusion, male infertility is related to disturbed testicular expression of the enzymes responsible for producing hydroxyestradiols and/or methoxyestradiols. If these changes are related with increased intratesticular hydroxyestradiols and methoxyestradiols concentrations, they could elicit an impaired Sertoli cell function. Our results suggest CYP1A1 and COMT as new potential targets in treating male infertility.

Outcomes After Direct Thrombectomy or Combined Intravenous and Endovascular Treatment Are Not Different

Background and Purpose—

Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients.

Methods—

Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel–Haenszel test statistic.

Results—

We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74–1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74–1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25–1.27).

Conclusions—

This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.

Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage

Background and Purpose: Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately.

Methods: This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed.

Results: We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001).

Conclusions: In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.

A Comparative Biomechanical Analysis of Stand Alone Versus Facet Screw and Pedicle Screw Augmented Lateral Interbody Arthrodesis: An In Vitro Human Cadaveric Model

STUDY DESIGN

Cadaveric biomechanical study.

OBJECTIVE

To investigate the kinematic response of a stand-alone lateral lumbar interbody cage compared with supplemental posterior fixation with either facet or pedicle screws after lateral discectomy.

SUMMARY OF BACKGROUND DATA

Lateral interbody fusion is a promising minimally invasive fixation technique for lumbar interbody arthrodesis. The biomechanical stability of stand-alone cage placement compared with supplemental posterior fixation with either facet or bilateral pedicle screws remains unclear.

METHODS

A 6-degree of freedom spine simulator was used to test flexibility in 7 human cadaveric specimens. Flexion-extension, lateral-bending, and axial-rotation were tested in the intact condition, followed by destabilization through a lateral discectomy at L2-L3 and L4-L5. Specimens were then reconstructed at both operative segments in the following sequence: (1) lateral interbody cage placement; (2) either Discovery facet screws or the Viper F2 system using a transfacet-pedicular trajectory randomized to L2-L3 or L4-L5; and (3) removal of facet screw fixation followed by placement of bilateral pedicle screw instrumentation. Acute range of motion (ROM) was quantified and analyzed.

RESULTS

All 4 reconstruction groups, including stand-alone interbody cage placement, bilateral Discovery facet screws, the Viper F2 system, and bilateral pedicle screw-rod stabilization, resulted in a significant decrease in acute ROM in all loading modes tested (P<0.05). There were no significant differences observed between the 4 instrumentation groups (P>0.05). Although not statistically significant, the Viper F2 system resulted in greatest reduction of acute ROM in both flexion-extension and axial rotation versus all other treatments (P>0.05).

CONCLUSIONS

Stand-alone interbody cage placement results in a significant reduction in acute ROM at the operative segment in the absence of posterior supplemental fixation. If added fixation is desired, facet screw placement, including the Viper F2 facet screw system using an integrated compression washer and transfacet-pedicular trajectory, provides similar acute stability to the spinal segment compared with traditional bilateral pedicle screw fixation in the setting of lateral interbody cage deployment.

Posterior approaches for symptomatic metastatic spinal cord compression

Surgical interventions for spinal metastasis are commonly performed for mechanical stabilization, pain relief, preservation of neurological function, and local tumor reduction. Although multiple surgical approaches can be used for the treatment of metastatic spinal lesions, posterior approaches are commonly performed. In this study, the role of posterior surgical procedures in the treatment of spinal metastases was reviewed, including posterior laminectomy with and without instrumentation for stabilization, transpedicular corpectomy, and costotransversectomy. A review of the literature from 1980 to 2015 was performed using Medline, as was a review of the bibliographies of articles meeting preset inclusion criteria, to identify studies on the role of these posterior approaches among adults with spinal metastasis. Thirty-four articles were ultimately analyzed, including 1 randomized controlled trial, 6 prospective cohort studies, and 27 retrospective case reports and/or series. Some of the reviewed articles had Level II evidence indicating that laminectomy with stabilization can be recommended for improvement in neurological outcome and reduction of pain in selected patients. However, the use of laminectomy alone should be carefully considered. Additionally, transpedicular corpectomy and costotransversectomy can be recommended with the expectation of improving neurological outcomes and reducing pain in properly selected patients with spinal metastases. With improvements in the treatment paradigms for patients with spinal metastasis, as well as survival, surgical therapy will continue to play an important role in the management of spinal metastasis. While this review presents a window into determining the utility of posterior approaches, future prospective studies will provide essential data to better define the roles of the various options now available to surgeons in treating spinal metastases.

2-hydroxyoestradiol and 2-methoxyoestradiol, two endogenous oestradiol metabolites, induce DNA fragmentation in Sertoli cells

Elevated intratesticular levels of hydroxyoestradiols and methoxyoestradiols, two classes of endogenous oestradiol metabolites, have been associated with male infertility. The aim of this study was to explore the effects of 2-hydroxyoestradiol (2OHE₂ ), 4-hydroxyoestradiol (4OHE₂ ), 2-methoxyoestradiol (2ME₂ ) and 4-methoxyoestradiol (4ME₂ ) on Sertoli cell viability. For this, TM4 cells were incubated with different concentrations of these metabolites for 24 h to then evaluate the viability and DNA integrity by MTS and TUNEL assay respectively. The participation of classical oestrogen receptors and the involvement of oxidative stress and apoptotic mechanisms were also evaluated co-incubating TM4 cells with these estradiol metabolites and with the drugs ICI182780, N-acetylcysteine and Z-VAD-FMK respectively. Only high concentrations of 2OHE₂ and 2ME₂ decreased cell viability inducing DNA fragmentation. In addition, ICI182780 did not block the effect of 2OHE₂ and 2ME₂ , while N-Acetylcysteine and Z-VAD-FMK only blocked the effect of 2OHE₂ . Moreover, 2OHE₂ but not 2ME₂ induced PARP and caspase-3 cleavage. Finally, lower 2OHE₂ and 2ME₂ concentrations (0.01-0.1-1.0 μmol l^-1 ) decreased Sertoli cell viability 48 h post-treatment. Our results support the hypothesis that elevated intratesticular 2OHE₂ or 2ME₂ concentrations could be related to male infertility since 2OHE₂ by apoptosis and 2ME₂ by undetermined mechanisms induce DNA fragmentation in Sertoli cells.

[Medication errors related to computerized physician order entry at the hospital: Record and analysis over a period of 4 years]

OBJECTIVES

Computerized physician order entry (CPOE) can generate medication errors. It is necessary to identify them and analyse their causes in order to secure the medication use system.

METHODS

Errors were recorded during the pharmaceutical analysis of prescriptions over a period of 4 years on 425 beds. A code frame was provided. Errors were classified according to type, causes and time of detection. The most often drug implicated and the error correction rate were studied. Deep causes were determined and contributing factors were listed.

RESULTS

Among 99,536 prescriptions analyzed, 2636 errors were detected (2.65 errors per 100 orders analyzed). The most common error was omission (31.49%). The most represented cause was redundancy requirement (11.34%). Antibacterials were most commonly involved (224 errors). Exactly 65.9% of the prescriptions were modified by physicians. Three root causes were identified: (1) configuration issues; (2) misuse; (3) design problem. Three types of contributing factors have also been detailed: economic, human and technical factors.

CONCLUSIONS

Identifying root causes has targeted three types of improvement actions: (1) software settings; (2) training of users; (3) requests for improvements. Contributing factors have to be identified to control the generated risk. Some errors related to CPOE may lead to serious side effects for the patient. That is why it is necessary to identify these errors and analyze them in order to implement improvement actions and prevention to secure the prescription.

MUC1/SEC and MUC1/Y overexpression is associated with inflammation in Sjögren's syndrome

OBJECTIVES

To evaluate the expression and localization of MUC1/SEC and MUC1/Y isoforms in labial salivary glands (LSG) from Sjögren's syndrome patients (SS patients), as well as their in vitro expression induced by cytokines.

SUBJECTS AND METHODS

Labial salivary gland from 27 primary SS patients and 22 non-SS sicca subjects were studied. Relative MUC1/SEC and MUC1/Y mRNA levels were determined by qPCR and protein levels by Western blotting. Induction of mucin mRNAs was assayed in vitro. Immunohistochemistry was used for localization.

RESULTS

Relative MUC1/SEC and MUC1/Y mRNA and protein levels were significantly higher in LSG from SS patients. These mRNAs were induced by cytokines. MUC1/SEC and MUC1/Y were detected in acini apical region of control LSGs, and significant cytoplasmic accumulation was observed in acini of SS patients. MUC1/Y localized in acinar nuclei and cytoplasm of inflammatory cells of LSG from SS patients. A strong positive correlation was observed between cellular MUC1/SEC levels and glandular function determined by scintigraphy.

CONCLUSIONS

We show for the first time that MUC1/SEC and MUC1/Y are expressed in LSG of both SS patients and non-SS sicca subjects. The observed overexpression and aberrant localization of MUC1/SEC and MUC1/Y and their induction by pro-inflammatory cytokines may favor the perpetuation of the inflammatory environment that disrupts the salivary glandular homeostasis in SS patients.

Retained transcranial knife blade with transection of the internal carotid artery treated by staged endovascular and surgical therapy: technical case report

BACKGROUND AND IMPORTANCE

We describe the use of proximal and distal endovascular coil embolization of the internal carotid artery followed by operative removal of a retained foreign object transecting the petrocavernous portion of the internal carotid artery.

CLINICAL PRESENTATION

A 20-year-old man sustained a stab wound to the left temporal skull and presented with a retained knife blade. He reported a headache at presentation, but remained neurologically intact with a Glasgow Coma Scale of 15. Computed tomography imaging and subsequent angiography confirmed complete transection of the petrocavernous segment of the left internal carotid artery with effective tamponade by the knife blade in situ and satisfactory collateral flow across the Circle of Willis. Coil embolization of the left internal carotid artery was performed. Retrograde embolization of the petrocavernous internal carotid segment distal to the injury was performed via vertebral and posterior communicating artery access. Antegrade embolization of the internal carotid artery proximal to the injury was completed and the patient was transferred to the operating room for craniectomy and foreign body extraction. Postoperative computed tomography angiography revealed no parenchymal hemorrhage, mass effect, or midline shift, and successful embolization of the internal carotid artery. At 6-week follow-up, the patient remained neurologically intact with no infectious or vascular complications.

CONCLUSION

Staged endovascular and surgical therapy provides complete assessment and effective control of damaged vessels when retained intracranial foreign bodies are present. Given the high risk of vascular injury with retained transcranial foreign bodies, this strategy should be considered a safe approach for these challenging cases.