Comparative Analysis of Microendoscopic and Open Laminectomy for Single-Level Lumbar Spinal Stenosis at L1-L2 or L2-L3

BACKGROUND

Several reports have highlighted comparable surgical outcomes between microendoscopic laminectomy (MEL) and open laminectomy (open) for lumbar spinal stenosis. However, the unilateral approach in MEL may present challenges for the upper lumbar levels, where facet joints are located deeper inside. Our objective was to compare surgical outcomes and radiographic evaluations for single-level decompression cases at L1-L2 or L2-L3 between MEL and open laminectomy.

METHODS

We analyzed patients who underwent single-level decompression for upper lumbar spinal stenosis at 12 distinguished spine centers from April 2017 to September 2021. Baseline demographics, preoperative, and 1-year postoperative patient-reported outcomes, along with imaging parameters, were compared between the MEL and open groups. To account for potential confounding, patients' backgrounds were adjusted using the inverse probability weighting method based on propensity scores.

RESULTS

Among the 2487 patients undergoing decompression surgery, 118 patients (4.7%) underwent single-level decompression at L1-L2 or L2-L3. Finally, 80 patients (51 in the MEL group, 29 in the open group) with postoperative data were deemed eligible for analysis. The MEL group exhibited significantly improved postoperative EuroQol 5-Dimension values compared to the open group. Additionally, the MEL group showed a lower facet preservation rate according to computed tomography examination, whereas the open group had a higher incidence of retrolisthesis.

CONCLUSIONS

Although overall surgical outcomes were similar, the MEL group demonstrated potential advantages in enhancing EuroQol 5-Dimension scores. The MEL group's lower facet preservation rate did not translate into a higher postoperative instability rate.

Quality of Life and Postoperative Satisfaction in Patients with Benign Extramedullary Spinal Tumors: A Multicenter Study

STUDY DESIGN

Retrospective cohort study using prospectively collected registry data.

OBJECTIVE

The purpose of this study is to evaluate health-related quality of life (HRQOL) and postoperative satisfaction in patients with different histotypes of benign extramedullary spinal tumors (ESTs).

BACKGROUND

Little is known about how different histotypes influence HRQOL and postoperative satisfaction in EST patients.

MATERIALS AND METHODS

Patients undergoing primary benign EST surgery at 11 tertiary referral hospitals between 2017 and 2021 who completed preoperative and 1-year postoperative questionnaires were included. HRQOL assessment included the Physical Component Summary and Mental Component Summary (MCS) of Short Form-12, EuroQol 5-dimension, Oswestry/Neck Disability Index (ODI/NDI), and Numeric Rating Scales (NRS) for upper/lower extremities (UEP/LEP) and back pain (BP). Patients who answered "very satisfied," "satisfied," or "somewhat satisfied" on a seven-point Likert scale were considered to be satisfied with treatment. Student t -tests or Welch's t -test were used to compare continuous variables between two groups, and one-way analysis of variance was used to compare outcomes between the three groups of EST histotypes (schwannoma, meningioma, atypical). Categorical variables were compared using the χ 2 test or Fisher exact test.

RESULTS

A total of 140 consecutive EST patients were evaluated; 100 (72%) had schwannomas, 30 (21%) had meningiomas, and 10 (7%) had other ESTs. Baseline Physical Component Summary was significantly worse in patients with meningiomas ( P =0.04), and baseline NRS-LEP was significantly worse in patients with schwannomas ( P =0.03). However, there were no significant differences in overall postoperative HRQOL or patient satisfaction between histology types. Overall, 121 (86%) patients were satisfied with surgery. In a subgroup analysis comparing intradural schwannomas and meningiomas adjusted for patient demographics and tumor location with inverse probability weighting, schwannoma patients had worse baseline MCS ( P =0.03), ODI ( P =0.03), NRS-BP ( P <.001), and NRS-LEP ( P =0.001). Schwannoma patients also had worse postoperative MCS ( P =0.03) and NRS-BP ( P =0.001), with no significant difference in the percentage of satisfied patients ( P =0.30).

CONCLUSIONS

Patients who underwent primary benign EST resection had a significant improvement in HRQOL postoperatively, and ~90% of these patients reported being satisfied with their treatment outcomes one year after surgery. EST patients may exhibit a relatively lower threshold for postoperative satisfaction compared with patients undergoing surgery for degenerative spine conditions.

Comparison of clinical outcomes of osimertinib and first-generation EGFR-tyrosine kinase inhibitors (TKIs) in TKI-untreated EGFR-mutated non-small-cell lung cancer with leptomeningeal metastases

BACKGROUND

Leptomeningeal metastases (LM) are devastating complications of epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC). Although osimertinib, a third-generation EGFR-tyrosine kinase inhibitor (TKI), has better penetration into the central nervous system than first-generation EGFR-TKIs, data on the distinct activity of EGFR-TKIs in untreated advanced EGFR-mutated NSCLC with LM are lacking.

PATIENTS AND METHODS

We retrospectively reviewed patients treated with EGFR-TKIs for TKI-untreated common EGFR-mutated NSCLC with LM between July 2002 and July 2021 at the National Cancer Center Hospital. The patients were divided into two groups: patients treated with osimertinib (Osi group) and those treated with gefitinib or erlotinib [first-generation (1G)-TKI group].

RESULTS

Of the 967 patients, 71 were eligible, including 29 in the Osi group and 42 in the 1G-TKI group. The median progression-free survival (PFS) and overall survival (OS) in the Osi group were better than those in the 1G-TKI group (PFS: 16.9 months versus 8.6 months, P = 0.007, and OS: 26.6 months versus 20.0 months, P = 0.158). The LM-overall response rate (ORR) and LM-PFS were significantly better in the Osi group than in the 1G-TKI group (LM-ORR: 62.5% versus 25.7%, P = 0.007; LM-PFS: 23.4 months versus 12.1 months, P = 0.021). In the subgroup analysis of EGFR mutation status, LM-PFS for patients with exon 19 deletion was significantly longer in the Osi group than in the 1G-TKI group (32.7 months versus 13.4 months, P = 0.013), whereas those with L858R mutation in exon 21 did not differ between the two groups. In the multivariate analysis, osimertinib and exon 19 deletion were significant factors for better LM-PFS and OS.

CONCLUSION

Osimertinib can be more effective for untreated common EGFR-mutated NSCLC patients with LM, especially those with exon 19 deletion, compared to first-generation TKIs.

Impact of body mass index on outcomes after lumbar spine surgery

The impact of body mass index (BMI) on outcomes after lumbar spine surgery is currently unknown. Previous studies have reported conflicting evidence for patients with high BMI, while little research has been conducted on outcomes for underweight patients. This study aims to examine the impact of BMI on outcomes after lumbar spine surgery. This prospective cohort study enrolled 5622 patients; of which, 194, 5027, and 401 were in the low (< 18.5 kg/m²), normal (18.5-30), and high (≥ 30) BMI groups, respectively. Pain was assessed via the numerical pain rating scale (NPRS) for the lower back, buttock, leg, and plantar area. Quality of life was assessed via the EuroQol 5 Dimension (EQ-5D) and Oswestry Disability Index (ODI). Inverse probability weighting with propensity scores was used to adjust patient demographics and clinical characteristics between the groups. After adjustment, the 1-year postoperative scores differed significantly between groups in terms of leg pain. The proportion of patients who achieved a 50% decrease in postoperative NPRS score for leg pain was also significantly different. Obese patients reported less improvement in leg pain after lumbar spine surgery. The outcomes of patients with low BMI were not inferior to those of patients with normal BMI.

Predictors for hemostatic thrombin-gelatin matrix usage in spine surgery: a multicenter observational study

STUDY DESIGN

A prospective cohort study.

OBJECTIVES

Thrombin-gelatin matrix (TGM) is a rapid and potent hemostatic agent, but it has some limitations, including the cost and its preparation time. The purpose of this study was to investigate the current trend in the use of TGM and to identify the predictors for TGM usage in order to ensure its proper use and optimized resource allocation.

METHODS

A total of 5520 patients who underwent spine surgery in a multicenter study group within a year were included in the study. The demographic factors and the surgical factors including spinal levels operated, emergency surgery, reoperation, approach, durotomy, instrumented fixation, interbody fusion, osteotomy, and microendoscopy-assistance were investigated. TGM usage and whether it was routine or unplanned use for uncontrolled bleeding were also checked. A multivariate logistic regression analysis was used to identify predictors for unplanned use of TGM.

RESULTS

Intraoperative TGM was used in 1934 cases (35.0%), among which 714 were unplanned (12.9%). Predictors of unplanned TGM use were female gender (adjusted odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.02-1.43, p = 0.03), ASA grade ≥ 2 (OR: 1.34, 95% CI: 1.04-1.72, p = 0.02), cervical spine (OR: 1.55, 95% CI: 1.24-1.94, p < 0.001), tumor (OR: 2.02, 95% CI: 1.34-3.03, p < 0.001), posterior approach (OR: 1.66, 95% CI: 1.26-2.18, p < 0.001), durotomy (OR: 1.65, 95% CI: 1.24-2.20, p < 0.001), instrumentation (OR: 1.30, 1.03-1.63, p = 0.02), osteotomy (OR: 5.00, 2.76-9.05, p < 0.001), and microendoscopy (OR: 2.24, 1.84-2.73, p < 0.001).

CONCLUSIONS

Many of the predictors for unplanned TGM use have been previously reported as risk factors for intraoperative massive hemorrhaging and blood transfusion. However, other newly revealed factors can be predictors of bleeding that is technically challenging to control. While routine usage of TGM in these cases will require further justification, these novel findings are valuable for implementing preoperative precautions and optimizing resource allocation.

Single-cell RNA sequencing identifies Fgf23-expressing osteocytes in response to 1,25-dihydroxyvitamin D3 treatment

Fibroblast growth factor 23 (FGF23), a hormone, mainly produced by osteocytes, regulates phosphate and vitamin D metabolism. By contrast, 1,25-dihydroxyvitamin D₃, the active form of vitamin D, has been shown to enhance FGF23 production. While it is likely that osteocytes are heterogenous in terms of gene expression profiles, specific subpopulations of Fgf23-expressing osteocytes have not been identified. Single-cell RNA sequencing (scRNA-seq) technology can characterize the transcriptome of an individual cell. Recently, scRNA-seq has been used for bone tissue analysis. However, owing to technical difficulties associated with isolation of osteocytes, studies using scRNA-seq analysis to characterize FGF23-producing osteocytes are lacking. In this study, we characterized osteocytes secreting FGF23 from murine femurs in response to calcitriol (1,25-dihydroxyvitamin D₃) using scRNA-seq. We first detected Dmp1, Mepe, and Phex expression in murine osteocytes by in situ hybridization and used these as marker genes of osteocytes. After decalcification, enzyme digestion, and removal of CD45⁺ cells, femoral bone cells were subjected to scRNA-seq. We identified cell clusters containing osteocytes using marker gene expression. While Fgf23 expression was observed in some osteocytes isolated from femurs of calcitriol-injected mice, no Fgf23 expression was detected in untreated mice. In addition, the expression of several genes which are known to be changed after 1,25-dihydroxyvitamin D₃ treatment such as Ccnd2, Fn1, Igfbp7, Pdgfa, and Timp1 was also affected by calcitriol treatment in Fgf23-expressing osteocytes, but not in those lacking Fgf23 expression, even after calcitriol administration. Furthermore, box-and-whisker plots indicated that Fgf23 expression was observed in osteocytes with higher expression levels of the Fam20c, Dmp1, and Phex genes, whose inactivating mutations have been shown to cause FGF23-related hypophosphatemic diseases. These results indicate that osteocytes are heterogeneous with respect to their responsiveness to 1,25-dihydroxyvitamin D₃, and sensitivity to 1,25-dihydroxyvitamin D₃ is one of the characteristics of osteocytes with Fgf23 expression. It is likely that there is a subpopulation of osteocytes expressing several genes, including Fgf23, involved in phosphate metabolism.

A novel mouse model of cutaneous T-cell lymphoma revealed the combined effect of mogamulizumab with psoralen and ultraviolet a therapy

Mycosis fungoides (MF) is a subtype of cutaneous T-cell lymphoma (CTCL). Topical or systemic treatment with psoralen, such as 8-methoxypsoralen (8-MOP), followed by ultraviolet A (UVA) irradiation (PUVA therapy) is an effective phototherapy for early-stage MF. However, the efficacy of PUVA therapy for advanced-stage MF is not satisfactory, and the ideal combination partner for PUVA therapy has not yet been found. In this study, we developed a new mouse model of CTCL in which efficacy of PUVA was detected and further evaluated the efficacy of combination treatment of PUVA and mogamulizumab, an anti-CCR4 monoclonal antibody. Cytotoxicity of PUVA therapy against HH cells, a CTCL cell line, was observed in vitro. The cytotoxicity was dependent on both 8-MOP and UVA. Using HH cells, we developed a mouse model in which HH cells were subcutaneously inoculated in the ear. In this model, PUVA therapy suppressed tumour growth with statistical significance, while 8-MOP or UVA alone did not. Combination therapy of PUVA and mogamulizumab showed greater antitumor activity than either monotherapy with statistical significance. In the histological analysis of the tumour tissue, PUVA accelerated tumour necrosis and then induced the infiltration inflammatory cells in the necrotic area, suggesting that these cells served as effector cells for mogamulizumab. This combination therapy is expected to be a beneficial option for CTCL therapy.

Postoperative outcomes after degenerative lumbar spine surgery in rheumatoid arthritis patients -a propensity score-matched analysis

Background

Although treatment options for rheumatoid arthritis (RA) have evolved significantly since the introduction of biologic agents, degenerative lumbar disease in RA patients remains a major challenge. Well-controlled comparisons between RA patients and their non-RA counterparts have not yet been reported. The objective of the present study was to compare postoperative outcomes of lumbar spine surgery between RA and non-RA patients by a retrospective propensity score-matched analysis.

Methods

Patients who underwent primary posterior spine surgery for degenerative lumbar disease in our prospective multicenter study group between 2017 and 2020 were enrolled. Demographic data including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, diabetes mellitus, smoking, steroid usage, number of spinal levels involved, and preoperative patient-reported outcome (PRO) scores (numerical rating scale [NRS] for back pain and leg pain, Short Form-12 physical component summary [PCS], EuroQOL 5-dimension [EQ-5D], and Oswestry Disability Index [ODI]) were used to calculate a propensity score for RA diagnosis. One-to-one matching was performed and 1-year postoperative outcomes were compared between groups.

Results

Among the 4567 patients included, 90 had RA (2.0%). RA patients in our cohort were more likely to be female, with lower BMI, higher ASA grade and lower current smoking rate than non-RA patients. Preoperative NRS scores for leg pain, PCS, EQ-5D, and ODI were worse in RA patients. Propensity score matching generated 61 pairs of RA and non-RA patients who underwent posterior lumbar surgery. After background adjustment, RA patients reported worse postoperative PCS (28.4 vs. 37.2, p = 0.008) and EQ-5D (0.640 vs. 0.738, p = 0.03), although these differences were not significant between RA and non-RA patients not on steroids.

Conclusions

RA patients showed worse postoperative quality of life outcomes after posterior surgery for degenerative lumbar disease, while steroid-independent RA cases showed equivalent outcomes to non-RA patients.

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial

IMPORTANCE

The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown.

OBJECTIVE

To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020.

INTERVENTIONS

Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment.

MAIN OUTCOMES AND MEASURES

The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury.

RESULTS

Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients).

CONCLUSIONS AND RELEVANCE

These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

Loss of apical suction assessed by noninvasive pressure differences and twist in acute heart failure: a novel method using vector flow mapping

Background

Early diastolic intraventricular pressure difference (IVPD) reflects left ventricular (LV) apical suction, and IVPD is closely related to cardiac function, especially LV twist. Vector Flow Mapping (VFM) allows visualization of regional pressure distribution and noninvasive quantification of IVPD. The purpose of the present study was to investigate if and how IVPDs are related to LV twist in a model of acute heart failure (HF).

Methods

In 15 open-chest dogs, HF was induced by intracoronary injection of microspheres. The HF model was classified into two groups based on the LV end-diastolic pressure (LVEDP) (group1: LVEDP&lt;18 mmHg (n=10), group2: LVEDP≥18 mmHg (n=8)).

Color Doppler images from apical long-axis views were acquired at baseline and during HF. From these images, pressure differences (ΔP) were calculated along the LV inflow tract throughout the cardiac cycle. For the purpose of this study, the differences between apex and base during isovolumic relaxation time (ΔPIRT) and rapid early inflow period (ΔPE) were used for analyses. Furthermore, apical and basal short axis high frame rate 2D images were acquired, and peak rotation and peak twist were analyzed.

Results

LVEDP was 7±9, 14±2, 21±3 mmHg for baseline, group1 HF, and group2 HF, respectively. Pressure differences (both ΔPIRT and ΔPE) were visibly changed by the increase of LVEDP (Figure), and the magnitude of ΔPIRT, ΔPE and peak twist decreased significantly with the severity of heart failure. There were significant relationships between pressure differences (ΔPIRT and ΔPE) and dP/dtmin, tau, EF and peak twist (Table). In multivariate analyses, tau and peak twist were independent predictors for ΔPIRT and peak twist was independent predictor for ΔPE.

Conclusion

VFM analysis is feasible to noninvasively assess the IVPDs in acute heart failure. The IVPDs are closely related to the twisting motion of the LV, and reflect loss of apical suction during severe HF.

Funding Acknowledgement

Type of funding sources: None. VFM images of pressure differencesCorrelations of pressure differences

NF-kB decoy oligodeoxynucleotide preserves disc height in a rabbit anular-puncture model and reduces pain induction in a rat xenograft-radiculopathy model

While it is known that the degenerated intervertebral disc (IVD) is one of the primary reasons for low-back pain and subsequent need for medical care, there are currently no established effective methods for direct treatment. Nuclear factor-κB (NF-κB) is a transcription factor that regulates various genes' expression, among which are inflammatory cytokines, in many tissues including the IVD. NF-κB decoy is an oligodeoxynucleotide containing the NF-κB binding site that entraps NF-κB subunits, resulting in suppression of NF-κB activity. In the present preclinical study, NF-κB decoy was injected into degenerated IVDs using the rabbit anular-puncture model. In terms of distribution, NF-κB decoy persisted in the IVDs up to at least 4 weeks after injection. The remaining amount of NF-κB decoy indicated that it fit a double-exponential-decay equation. Investigation of puncture-caused degeneration of IVDs showed that NF-κB decoy injection recovered, dose-dependently, the reduced disc height that was associated with reparative cell cloning and morphological changes, as assessed through histology. Gene expression, by quantitative real-time polymerase chain reaction (qRT-PCR), showed that NF-κB decoy attenuated inflammatory gene expression, such as that of interleukin-1 and tumor necrosis factor-α, in rabbit degenerated IVDs. NF-κB decoy also reduced the pain response as seen using the "pain sensor" nude rat xenograft-radiculopathy model. This is the first report demonstrating that NF-κB decoy suppresses the inflammatory response in degenerated IVDs and restores IVD disc height loss. Therefore, the intradiscal injection of NF-κB decoy may have the potential as an effective therapeutic strategy for discogenic pain associated with degenerated IVDs.

Observation of Nonlinear Spin-Charge Conversion in the Thin Film of Nominally Centrosymmetric Dirac Semimetal SrIrO_{3} at Room Temperature

Spin-charge conversion via spin-orbit interaction is one of the core concepts in the current spintronics research. The efficiency of the interconversion between charge and spin current is estimated based on Berry curvature of Bloch wave function in the linear-response regime. Beyond the linear regime, nonlinear spin-charge conversion in the higher-order electric field terms has recently been demonstrated in noncentrosymmetric materials with nontrivial spin texture in the momentum space. Here, we report the observation of the nonlinear charge-spin conversion in a nominally centrosymmetric oxide material SrIrO_{3} by breaking inversion symmetry at the interface. A large second-order magnetoelectric coefficient is observed at room temperature because of the antisymmetric spin-orbit interaction at the interface of Dirac semimetallic bands, which is subject to the symmetry constraint of the substrates. Our study suggests that nonlinear spin-charge conversion can be induced in many materials with strong spin-orbit interaction at the interface by breaking the local inversion symmetry to give rise to spin splitting in otherwise spin degenerate systems.

A novel orexin antagonist from a natural plant was discovered using zebrafish behavioural analysis

OBJECTIVE

Phenotypic screening is one of the most practical approaches to the identification of mediators of behaviour, since it is difficult to model brain function in vitro, at a cellular level. We used a zebrafish (Danio rerio) behavioural assay to discover novel, natural, neuroactive compounds.

MATERIALS AND METHODS

A zebrafish behavioural assay was performed for seven natural compounds, obtained from plants. The behavioural profiles were compared to those of known psychoactive drugs. We characterised a natural compound exhibiting a behaviour profile similar to that of suvorexant, using in silico, in vitro and microarray expression analysis.

RESULTS

The behavioural analysis performed in this study classified central nervous system drugs according to their mechanism. Zebrafish treated with a natural compound, 8b-(4'-Hydroxytigloyloxy) costunolide (8b), showed behaviour profiles similar to those of zebrafish treated with suvorexant, a known orexin antagonist. This behavioural assay was validated using in silico and in vitro assays, which revealed that the new compound was a dual orexin receptor antagonist. In addition, transcriptome analysis suggested that 8b might regulate the nuclear factor-κB (NF-κB) related pathway.

CONCLUSIONS

We conclude that zebrafish phenotypic screening, combined with in silico assays and gene expression profiling, is a useful strategy to discover and characterize novel therapeutic compounds, including natural products.

Lactulose ingestion causes an increase in the abundance of gut-resident bifidobacteria in Japanese women: a randomised, double-blind, placebo-controlled crossover trial

The genus Bifidobacterium comprises various bacterial species, and the complement of species within the human intestinal tract differs from individual to individual. The balance of these bifidobacterial species remains poorly understood, although it is known that the abundance of bifidobacteria increases following the ingestion of prebiotics. We previously conducted a randomised, placebo-controlled, double-blind, crossover study of 2 g/day lactulose ingestion for 2 weeks in 60 Japanese women. To study the effect of lactulose ingestion on each bifidobacterial species, here, we measured the abundance of each of the principal bifidobacterial species. After lactulose ingestion, the log cell counts of the Bifidobacterium adolescentis group (8.97±0.08 vs 9.39±0.08, P=0.0019), Bifidobacterium catenulatum group (9.45±0.10 vs 9.65±0.10, P=0.0032) and Bifidobacterium longum group (9.01±0.07 vs 9.29±0.07, P=0.0012) were significantly higher than in the placebo ingestion control group. However, the log cell counts were similar for Bifidobacterium breve (8.12±0.12 vs 8.33±0.12, P=0.20), Bifidobacterium bifidum (9.08±0.12 vs 9.42±0.14, P=0.095) and Bifidobacterium animalis subspecies lactis (8.65±0.53 vs 8.46±0.46, P=0.77). Cluster analysis of the log cell count data at the bifidobacterial species level revealed three distinct clusters, but the combinations and ratios of the constituent bifidobacteria were not affected by lactulose ingestion. Furthermore, principal coordinate analysis of the intestinal microbiota in the lactulose and placebo ingestion groups using Illumina MiSeq showed no significant differences in the intestinal microbiota as a whole. These results suggest that 2 g/day lactulose ingestion for 2 weeks significantly increases the abundance of intestinal bifidobacteria, but does not affect the intestinal microbiota as a whole.

Outcomes of an Intraoperative Povidone-Iodine Irrigation Protocol in Spinal Surgery for Surgical Site Infection Prevention

STUDY DESIGN

This was a retrospective observational study.

OBJECTIVE

The aim of this study was to evaluate the efficacy of our new protocol for preventing postoperative surgical site infection (SSI) following spinal surgery.

SUMMARY OF BACKGROUND DATA

SSI following spinal surgery is a serious postoperative complication. Several studies have recently assessed the effectiveness of wound irrigation with povidone-iodine (PVP-I) for SSI prevention, but no consensus has been reached as to how PVP-I should be used in clinical practice. We formed a PVP-I irrigation protocol focusing on the pharmacological properties of PVP-I. This study aimed to evaluate the efficacy and safety of our protocol for preventing SSI.

MATERIALS AND METHODS

All cases of spinal surgery at our hospital between October 2011 and September 2016 were retrospectively reviewed. The exclusion criteria were PVP-I allergy, prior surgical debridement for infection, and implant removal surgery. The patients were subdivided into those who had received normal saline irrigation after 90 seconds of 1% PVP-I pooling every 1.5 hours (study group) or only routine saline irrigation every 1.5 hours (control group). The study and control groups comprised of 177 and 146 patients, respectively. This study compared the rate of SSI with and without the use of the PVP-I irrigation protocol.

RESULTS

The SSI rates were 1.7% for the study group (3/177 patients) and 3.4% for the control group (5/146 patients), showing no significant statistical difference (P=0.32). There were no cases of deep SSI in the study group, whereas there were 4 cases in the control group. The deep SSI rate significantly decreased in the study group (P=0.027). No adverse events occurred in the study group.

CONCLUSION

In this study, 90 seconds of 1% PVP-I pooling every 1.5 hours followed by saline irrigation demonstrated the effectiveness of our protocol for the prevention of postoperative deep SSI after spinal surgery.

P2477Assessment of intraventricular flow dynamics in acute heart failure studied by Vector Flow Mapping

Background

Although left ventricular (LV) flow dynamics should be closely related to LV morphology and function, little is known about how heart failure (HF) changes it. Pathline Analysis (PA), a recently developed software based on Vector Flow Mapping (VFM, Hitachi), enables us to trace the virtual blood particles entering to the LV in diastole and being ejected in systole. We investigated the change of flow dynamics in HF induced in dogs using PA.

Methods

In 15 open-chest dogs, HF was induced by intracoronary injection of microspheres. Color Doppler images of apical long-axis view were acquired using Prosound F75 (Hitachi) before and after HF and were analyzed by PA. We calculated the ratio of the numbers of entering particles in diastole and ejected particles in systole (ejection rate) and the distance reached by the particles in diastole corrected by the LV long-axis diameter (propagation distance). Apical and basal short axis images were acquired using GE Vivid E9 and were analyzed for peak rotation and peak twist.

Results

After inducing HF, LV end-diastolic pressure increased from 6±2 to 15±5 mmHg (p<0.001) and ejection fraction (EF), apical peak rotation and peak twist decreased significantly (EF; 58±5 to 36±8%, apical peak rotation; 14±5 to 3±2 degree, peak twist; 19±5 to 6±3 degree, p<0.05, respectively). PA showed most of the entering particles to the LV were ejected in the following systole at the control stage, but in HF, a significant part of the entering particles were not ejected and remained in the LV (Figure). Ejection rate decreased from 50±11 to 26±11% (p<0.001) and the propagation distance decreased from 85±9 to 66±13% (p<0.001) after inducing HF. There were significant relationships between indices obtained by PA and EF and peak twist (Table).

Conclusion

A significant part of inflow is not ejected directly to the outflow in the next systole and remains in the LV in HF, suggesting inefficient flow dynamics.

P1470Myocardial dysfunction index: a novel myocardial strain parameter for diagnosing myocardial ischemia

Background and purpose

Peak systolic strain (ε-sys) derived from speckle tracking echocardiography (STE) is a useful parameter for assessing regional contractile dysfunction during acute ischemia. However, low ε-sys does not always indicate myocardial ischemia because of its relatively large variation in segmental normal ranges and intervendor differences. Therefore, comparison of strain before and after an ischemic event and demonstration of a decrease in ε-sys should be necessary to confirm myocardial ischemia, which is not always possible in clinical situations. It is well known that early systolic lengthening (ESL) and post-systolic shortening (PSS) occur during acute ischemia. We hypothesized that ESL and PSS would correlate with the decrease in ε-sys and integrated analysis of ESL and PSS could be useful to diagnose the presence of myocardial ischemia.

Methods

2D short-axis or 3D full-volume images were acquired by Artida at baseline, during flow-limiting stenosis (mean 50±20% flow reduction), and during complete occlusion of the left circumflex coronary artery in 22 dogs (2D-STE = 12, 3D-STE = 10).Circumferential strain was analyzed in the center of risk area, and the absolute value of peak systolic strain (ε-sys), post-systolic strain index (PSI) as a parameter of PSS, and early systolic strain index (ESI) as a parameter of ESL were measured. A new parameter, myocardial dysfunction index (MDI), which was calculated as follows: (ESL amplitude + PSS amplitude)/maximal strain amplitude during the cardiac cycle, was also calculated. The difference in ε-sys between at baseline and during ischemia (Δε-sys) was measured and the diagnostic accuracy for estimating Δε-sys < −3% was assessed by the receiver operating characteristics (ROC) curve analysis.

Results

During ischemia, ε-sys decreased from 19±3 to 12±6% and MDI increased from 2±4 to 27±30%. MDI was significantly correlated with Δε-sys (2D-STE: r=−0.80, 3D-STE: r=−0.83, p<0.01, respectively) (Figure). The area under the curve (AUC) of MDI for estimating Δε-sys < −3% tended to be larger than those of ESI and PSI (MDI: 0.9, ESI: 0.73, PSI: 0.85).

Figure 1

Conclusions

The novel parameter, MDI was correlated with the decrease in ε-sys during acute ischemia. Integrated analysis of ESL and PSS may be useful for diagnosing the presence of myocardial ischemia.

Impact of Different Selectivity between Soluble and Membrane-bound Forms of Carcinoembryonic Antigen (CEA) on the Target-mediated Disposition of Anti-CEA Monoclonal Antibodies

Carcinoembryonic antigen (CEA) is a tumor-specific antigen overexpressed in multiple cancers. CEA is expressed as a membrane protein, a part of which is cleaved from the cell membrane and secreted into blood. The soluble form of CEA (sCEA) has been shown to accelerate the clearance of anti-CEA antibody, which limits the antibody distribution in the tumor. To overcome this issue, we developed an anti-CEA monoclonal antibody, 15-1-32, which shows a strong affinity for membrane-bound CEA (mCEA) and relatively weak affinity for sCEA. In this study, we compared the effect of sCEA on the pharmacokinetics of 15-1-32 in mice with that of another anti-CEA monoclonal antibody, labetuzumab, showing less selectivity to mCEA than 15-1-32. As expected, the effect of sCEA on the serum concentration of 15-1-32 was much smaller than that of labetuzumab. The decrease in the area under the curve (AUC) of serum concentration was 22.5% for 15-1-32 when it was coadministered with sCEA, while that of labetuzumab was 79.9%. We also compared the pharmacokinetics of these two antibodies in CEA-positive tumor-bearing mice. The AUCs of 15-1-32 and labetuzumab were decreased in tumor-bearing mice compared with non-tumor-bearing mice to a similar extent (approximately 40% decrease). These results suggested that mCEA also contributes to the clearance of anti-CEA antibodies in CEA-positive tumor-bearing mice. Although the increased selectivity to mCEA minimized the effect of sCEA on the pharmacokinetics of 15-1-32, it may be insufficient to improve the pharmacokinetics in CEA-positive cancer patients. SIGNIFICANCE STATEMENT: Because previous studies reported the rapid clearance of anti-CEA antibodies mediated by soluble CEA, we obtained a monoclonal antibody, 15-1-32, selective to membrane-bound CEA and evaluated the effects of CEA on its pharmacokinetics. Although the effect of soluble CEA on the serum concentration of 15-1-32 was very small, the clearance of 15-1-32 in CEA-positive tumor-bearing mice was still rapid, suggesting membrane-bound CEA also contributes to the clearance of anti-CEA antibodies. These results indicated that increasing selectivity to membrane-bound CEA is not enough to improve the pharmacokinetics of anti-CEA antibody.

Prebiotic effect of two grams of lactulose in healthy Japanese women: a randomised, double-blind, placebo-controlled crossover trial

Sixty healthy Japanese women with a defaecation frequency of 2-4 times/week participated in this randomised, double-blind crossover trial. Participants received 2 g/day lactulose for 2 weeks and placebo in a random order, separated by a washout period of 3 weeks. Eight participants were excluded who did not satisfy the conditions, and therefore data from 52 were analysed. The primary outcome was defaecation frequency and the secondary outcomes were the number of defaecation days, faecal consistency, faecal volume, and the number and percentage of Bifidobacterium in faeces. The defaecation frequency (times/week) was significantly higher during lactulose (4.28±0.23) than placebo (3.83±0.23) treatment (delta (Δ) 0.45 [95% confidence interval (CI) 0.10-0.80], P=0.013). The defaecation days (days/week) was significantly higher during lactulose (3.77±0.17) than placebo (3.47±0.17) treatment (Δ0.30 [95% CI 0.04-0.56], P=0.024). Faecal consistency using the Bristol Stool Scale (/defaecation) was significantly higher during lactulose (3.84±0.10) than placebo (3.68±0.10) treatment (Δ0.16 [95% CI 0.00-0.31], P=0.044). Faecal volume (/week) was significantly higher during lactulose (21.73±3.07) than placebo (17.65±3.07) treatment (Δ4.08 [95% CI 0.57-7.60], P=0.024). The number of Bifidobacterium in faeces (log colony forming units/g faeces) was significantly higher during lactulose (9.53±0.06) than placebo (9.16±0.06) treatment (Δ0.37 [95% CI 0.23-0.49], P<0.0001). The percentage of Bifidobacterium in faeces was also significantly higher during lactulose (25.3±1.4) than placebo (18.2±1.4) treatment (Δ7.1 [95% CI 2.9-11.4], P=0.0014). Finally, straining at defaecation (/defaecation) during lactulose (3.62±0.24) treatment was significantly lower than during placebo (3.97±0.24) treatment (Δ0.35 [95% CI -0.69 – -0.02], P=0.037). No significant difference was observed between lactulose and placebo with regard to flatulence. Severe adverse effects did not occur. Thus, oral ingestion of 2 g/day lactulose had a prebiotic effect, increasing the number and percentage of bifidobacteria in faeces, softening the faeces, and increasing defaecation frequency, but without increasing flatulence.

Recent results from the LHCf and RHICf experiments

The Large Hadron Collider forward and the Relativistic Heavy Ion Collider forward experiments measured forward particles produced in high-energy hadron collisions at the LHC and RHIC. Using compact calorimeters neutral particles produced in pseudorapidities η >8.4 and η >6.0 are observed by the respective experiments. Because the collision energies ranging from 0.51 TeV to 13 TeV correspond to the cosmic-ray equivalent energies of 1014 to 1017 eV, the measurements are important to understand the hadronic interaction relevant to extensive air shower measurements. This paper reviews recent results of LHCf and initial performance of RHICf that took data in the 2017 RHIC operation.

Short- and Long-Term Outcomes of Live Donor Renal Allografts From Older and Younger Donors

BACKGROUND

The rising demand for living renal donors has led to the recruitment of older donors. Findings vary, but these grafts appear to survive as long as grafts from standard criteria deceased and expanded criteria deceased donors. We investigated the effects of donor age ≥65 years and the presence or absence of donor antihypertensive therapy on patient condition 1 year after transplantation, and retrospectively examined 1-year (273 patients), 3-year (217 patients), and 5-year (140 patients) patient and graft survival.

METHODS

We divided 273 donor-recipient pairs into Group Y (donor age <65 years, n = 224) and Group O (donor age ≥65 years, n = 49). Group O was subdivided into donors receiving treatment for hypertension (subgroup O-1, n = 16) and those not receiving treatment for hypertension (subgroup O-2, n = 33). We compared results of 1 hour post-transplant biopsies and looked at a small number of 1 year post-transplant biopsies.

RESULTS

Although a significantly larger percentage of recipients from younger donors were undergoing preemptive transplantation, and the incidence of arteriosclerosis was significantly higher in the Group O kidneys, there were no significant differences between the 2 groups in terms of patient or graft survival at 1, 3, or 5 years; serum creatinine levels; or number of episodes of acute rejection. The presence or absence of donor antihypertensive treatment had no effect.

CONCLUSIONS

We found that donor age ≥65, with or without antihypertensive treatment, had no effect on graft or patient survival.

Development and evaluation of a novel antibody-photon absorber conjugate reveals the possibility of photoimmunotherapy-induced vascular occlusion during treatment in vivo

Photodynamic therapy (PDT) utilize a photosensitizing agent and light for cancer therapy. It exerts anti-cancer effect mainly by inducing vascular occlusion at the irradiated site. By controlling the irradiation area, PDT can be used in a tumor-specific manner. However, the non-specific cellular damage in the surrounding normal tissue is still a serious concern. Photoimmunotherapy (PIT) is a new type of targeted cancer therapy that uses an antibody-photon absorber conjugate (APC). The superiority of PIT to PDT is the improved target specificity, thereby reducing the damage to normal tissues. Here, we developed a novel APC targeting epithelial cell adhesion molecule (EpCAM) as well as a negative control APC that does not bind to the EpCAM antigen. Our in vitro analysis of APC cytotoxicity demonstrated that the EpCAM APC, but not the negative control, was cytotoxic to EpCAM expressing COLO 205 cells after photoirradiation, suggesting that the cytotoxicity is antigen-dependent. However, in our in vivo analysis using a mouse xenograft tumor model, decreased volume of the tumors was observed in all the mice treated with irradiation, regardless of whether they were treated with the EpCAM APC or the negative control. Detailed investigation of the mechanism of these in vivo reveal that both APCs induce vascular occlusion at the irradiation site. Furthermore, the level of vascular occlusion was correlated with the blood concentration of APC, not the tumor concentration. These results imply that, similar to PDT, PIT can also induce non-targeted vascular occlusion and further optimization is required before widespread clinical use.

Effective Treatment With Daclatasvir and Asunaprevir in Kidney Transplant Patients Infected With Hepatitis C Virus: A Report of Two Cases

BACKGROUND

Hepatitis C virus (HCV) infection is known to affect long-term patient and graft survivals after kidney transplantation (KT). Recently, combination therapy with the use of 2 oral direct-acting antivirals, daclatasvir (DCV) and asunaprevir (ASV) reportedly showed a high rate of HCV eradication. We report the safety and efficacy of DCV and ASV therapy in 2 KT patients.

METHODS

The safety and viral responses were investigated in a prospective study of KT patients infected with HCV genotype 1. Two patients received 60 mg DCV once daily plus 100 mg ASV twice daily for 24 weeks.

RESULTS

A 69-year-old woman and a 57-year-old man underwent DCV and ASV therapy for 24 weeks. In both cases, the HCV genotype was 1b. Case 1 had undergone KT twice and had received treatment with pegylated interferon and ribavirin. She received DCV and ASV therapy 12 years after the 2nd KT, and had undetectable virus after only 6 weeks of treatment and at 24 weeks after the end of treatment (SVR24). The post-transplantation immunosuppressive therapy at that time comprised tacrolimus, mycophenolate mofetil, and prednisolone. The other case, after failure of interferon treatment, received DCV and ASV therapy 27 years after his KT and achieved SVR24. His immunosuppressive regimen at that time was mizoribine and prednisolone. DCV and ASV therapy did not affect renal graft function or tacrolimus blood concentrations.

CONCLUSIONS

DCV and ASV therapy had high antiviral effect and a low rate of adverse events in KT patients.

Living Donor Kidney Transplantation After Brachytherapy for Prostate Cancer: Case Report

INTRODUCTION

There is no obvious criterion about kidney transplantation for patients with pretransplant malignancy. Minimum tumor-free waiting periods differ according to type of cancer, staging, site of occurrence, response to therapy, and risk of cancer recurrence. We report a case of living donor kidney transplantation (LDKT) in a patient after brachytherapy for prostate cancer.

CASE REPORT

The patient was a 65-year-old man with chronic kidney disease due to chronic glomerular nephritis. He received hemodialysis 3 times a week. His prostate-specific antigen level (PSA) was high (6.57 ng/mL), and he was diagnosed with prostate cancer (T1cN0M0, Gleason Score 3 + 4 = 7, 3/10) by needle biopsy in urology. He was treated with maximum androgen blockade (MAB) therapy and brachytherapy in May 2014. He underwent LDKT from a spousal donor at our department in December 2015, because urologists concluded that the prostate cancer was completely cured. Immunosuppression consisted of induction with basiliximab and maintenance with tacrolimus, mizoribine, and steroids. The postoperative course was uneventful. He discharged at postoperative day 29 with a serum creatinine level of 1.30 mg/dL. Three months after LDKT, his PSA level was 0.477 ng/mL, and there was no evidence of prostate cancer recurrence.

CONCLUSION

This is the first case of LDKT for patients with prostate cancer after brachytherapy in combination with MAB. There is no recurrence of prostate cancer so far; however, careful follow-up including PSA is necessary and important.