Spinal Morphometry As A Novel Predictor For Recurrent Lumbar Disc Herniation Requiring Revision Surgery: Results of A Case Control Study

Introduction

There is conflicting data on the risk factors for recurrent lumbar disc herniation (rLDH). Most of the predictors for rLDH identified so far are acquired risk factors or radiological factors at the level of the herniation. Whole lumbar spine (WLS) morphometry has not been evaluated as a possible predictor of rLDH.

Objectives

We aimed to evaluate if preoperative spinal morphometry can predict the occurrence of rLDH requiring revision surgery.

Methods

This retrospective case-control study on 250 patients included 45 patients operated for rLDH, 180 controls without rLDH who had previously undergone microdiscectomy for a single level lumbar disc prolapse, and a holdout validation set of 25 patients. Morphometric variables related to the WLS were recorded in addition to previously identified predictors of rLDH. Logistic regression (LR) analysis was performed to identify independent predictors of rLDH.

Results

LR yielded four predictors of which two were WLS morphometric variables. While increasing age and smoking positively predicted rLDH, increasing WLS interfacet distance and WLS dural-sac circumference negatively predicted rLDH. The LR model was statistically significant, χ² (4) =15.98, P = 0.003, and correctly classified 80.3% of cases. On validation, the model demonstrated a fair accuracy in predicting rLDH (accuracy: 0.80, AUC: 0.70).

Conclusions

Larger mean lumbar bony canals and dural sacs protect from the occurrence of symptomatic rLDH. These WLS morphometric variables should be included in future risk stratification algorithms for lumbar disc disease. In addition to the previously recognized risk factors, our study points to an underlying developmental predisposition for rLDH.

Myriad of MR imaging phenotypes of primary central nervous system lymphoma in a cohort of immunocompetent Indian patient population

PCNSL (primary central nervous system lymphoma) is a chemosensitive and radiosensitive tumor, and early diagnosis has a significant impact on management. Unlike many other brain tumors, radical surgical excision of PCNSLs is not indicated because these lesions are highly infiltrative and even partial resection leads to a bad prognosis. The goal of this study is to highlight the unusual radiological presentation of PCNSLs and increase the awareness, familiarity, and global database of our observations that pose a challenge on management.

An Institutional Review of Tuberculosis Spine Mimics on MR Imaging: Cases of Mistaken Identity

Although MRI has a spectrum of findings which help in the diagnosis of tuberculosis (TB) spine, a broad spectrum of spine pathologies resemble Pott's spine on MRI and are often missed due to inadequate clinical details. As a result, patients are often subject to unnecessary biopsy. A blinded radiologist may misdiagnose such mimic cases as TB. Our aim is to enable the reader to learn the main criteria that differentiate spine TB from other spine etiologies that mimic TB. A retrospective search was done and authors collected only MRI spine reports that showed a differential diagnosis or diagnosis of TB spine from the computer-based data records of the institution over a four-year period. This revealed 306 cases of TB spine out of which 78 cases with an alternate diagnosis that resembled TB spine were included. We describe a single institute review of 78 such cases that resemble and mimic Pott's spine on MRI. The cases being: (n = 15) pyogenic spondylitis, (n = 1) brucellar spondylodiscitis, (n = 12) rheumatoid arthritis, (n = 12) metastases, (n = 8) lymphoma, (n = 5) post-trauma fractures, (n = 10) degenerative disc disease, (n = 2) Baastrup's disease, (n = 9) osteoporotic fracture, (n = 3) spinal neuropathic arthritis, and (n = 1) case of Rosai-Dorfman disease. The clinical and radiological findings of all these cases were correlated with lab findings and histopathology wherever necessary. Appropriate recognition of these entities that resemble and mimic TB spine on MRI is important for optimal patient care. This paper exposes radiologists to a variety of spine pathologies for which biopsy is not indicated, and highlights key imaging findings of these entities to facilitate greater diagnostic accuracy in clinical practice.

A Case of Needle-Directed Pulse-Spray Pharmacomechanical Thrombolysis of Acute Brachial Artery Thrombosis

Acute limb ischemia is a serious disabling condition. The management options depend upon the patient symptoms and signs of ischemia in the affected limb. The management options include surgical thrombo-embolectomy and catheter directed thrombolysis. Catheter directed thrombolysis has now become the first line of management in symptomatic cases. Here, we discuss a case of acute left brachial artery thrombosis which was successfully managed by needle-directed pulse-spray thrombolysis.

Digital Subtraction Neuroangiography: What a Resident Should Know

Neuroangiography (NA) is an integral investigation in the management of patients with neurovascular diseases. NA is basically used for diagnosis, but in many instances, it may be followed up with treatment in the same sitting. Indications for diagnostic NA range from extracranial diseases (vertebra-basilar insufficiency from subclavian steal, extracranial carotid stenosis, cavernous-carotid fistula, neck trauma, epistaxis, etc.) to intracranial diseases (nontraumatic subarachnoid hemorrhage, cerebral aneurysms, cerebral arteriovenous malformations, cerebral vasospasm, acute stroke, etc.). A sound understanding of the principles of appropriate periprocedural care and anatomy, catheter technique, and basic disease pathology are vital for the test to be diagnostic. This pictorial review illustrates normal neurovascular anatomy along with an approach to analyze a spectrum of neurovascular pathologies and also explains a step-wise checklist for appropriate preprocedural assessment, technique of procedure, and postprocedural care of the patient. Basic knowledge on how to interpret these images and principles on how to perform it is important.

Recombinant factor VIII Fc fusion protein for the prevention and treatment of bleeding in children with severe hemophilia A

BACKGROUND

Prophylactic factor replacement, which prevents hemarthroses and thereby reduces the musculoskeletal disease burden in children with hemophilia A, requires frequent intravenous infusions (three to four times weekly).

OBJECTIVE

Kids A-LONG was a phase 3 open-label study evaluating the safety, efficacy and pharmacokinetics of a longer-acting factor, recombinant factor VIII Fc fusion protein (rFVIIIFc), in previously treated children with severe hemophilia A (endogenous FVIII level of < 1 IU dL(-1) [< 1%]).

METHODS

The study enrolled 71 subjects. The starting rFVIIIFc regimen was twice-weekly prophylaxis (Day 1, 25 IU kg(-1) ; Day 4, 50 IU kg(-1) ); dose (≤ 80 IU kg(-1) ) and dosing interval (≥ 2 days) were adjusted as needed. A subset of subjects had sequential pharmacokinetic evaluations of FVIII and rFVIIIFc. The primary endpoint was development of inhibitors (neutralizing antibodies). Secondary endpoints included pharmacokinetics, annualized bleeding rate (ABR), and number of infusions required to control a bleed.

RESULTS

No subject developed an inhibitor to rFVIIIFc. Adverse events were typical of a pediatric hemophilic population. The rFVIIIFc half-life was prolonged relative to that of FVIII, consistent with observations in adults and adolescents. The median ABR was 1.96 overall, and 0.00 for spontaneous bleeds; 46.4% of subjects reported no bleeding episodes on study. Ninety-three per cent of bleeding episodes were controlled with one to two infusions. The median average weekly rFVIIIFc prophylactic dose was 88.11 IU kg(-1) . At study end, 62 of 69 subjects (90%) were infusing twice weekly. Among subjects who had been previously receiving FVIII prophylaxis, 74% reduced their dosing frequency with rFVIIIFc.

CONCLUSION

Twice-weekly infusions with rFVIIIFc were well tolerated and yielded low bleeding rates in children with severe hemophilia A.

Recombinant factor VIII Fc fusion protein: extended-interval dosing maintains low bleeding rates and correlates with von Willebrand factor levels

BACKGROUND

Routine prophylaxis with replacement factor VIII (FVIII) - the standard of care for severe hemophilia A - often requires frequent intravenous infusions (three or four times weekly). An FVIII molecule with an extended half-life could reduce infusion frequency. The A-LONG study established the safety, efficacy and prolonged pharmacokinetics of recombinant FVIII Fc fusion protein (rFVIIIFc) in previously treated adolescents and adults with severe hemophilia A.

OBJECTIVE

In this post hoc analysis, we investigated the relationship between subjects' prestudy (FVIII) and on-study (rFVIIIFc) regimens.

METHODS

We analyzed two subgroups of subjects: prior prophylaxis and on-study individualized prophylaxis (n = 80), and prior episodic treatment and on-study weekly prophylaxis (n = 16). Subjects' prestudy dosing regimens and bleeding rates were compared with their final rFVIIIFc regimens and annualized bleeding rates (ABRs) in the last 3 months on-study. Dosing regimen simulations based on population pharmacokinetics models for rFVIII and rFVIIIFc were performed.

RESULTS

As compared with their prestudy regimen, 79 of 80 (98.8%) subjects on individualized rFVIIIFc prophylaxis decreased their infusion frequency. Overall ABRs were low, with comparable factor consumption. Longer dosing intervals, including 5-day dosing, were associated with higher baseline von Willebrand factor antigen levels. Simulated dosing regimens predicted a greater proportion of subjects with steady-state FVIII activity trough levels of ≥ 1 IU dL(-1) (1%) with rFVIIIFc than with equivalent rFVIII regimens.

CONCLUSION

These results suggest that patients on rFVIIIFc prophylaxis can reduce their infusion frequency as compared with their prior FVIII regimen while maintaining low bleeding rates, affording more patients trough levels of ≥ 1 IU dL(-1) than with rFVIII products requiring more frequent dosing regimens.

Effect of nutritional factors on cellulase enzyme and microbial protein production by Aspergillus terreus and its evaluation

The biomass yield, cellulolytic activity, and protein recovery using Aspergillus terreus GN1 with alkali-treated sugarcane bagasse was studied using different levels (250-600 mg of N/L of broth) of organic and inorganic nitrogen sources. e.g., cattle urine, urea, cornsteep liquor, ammonium sulfate, ammonium nitrate, ammonium iron sulfate, ammonium chloride, and sodium nitrate. Among different levels of alkali-treated bagasse substrate concentrations (0.5-4.0% w/v) tested, 1.0% substrate yielded the highest crude protein content, protein recovery, and cellulolytic activity. The biomass recovery with 1.0% substrate ranged from 290-380 mg/500 mg bagasse substrate in a 50-mL broth with a nitrogen level of 250-600 mg of N/L in all the sources except ammonium iron sulfate, which yielded 402-439 mg/500 mg bagasse substrate. However, crude protein content of biomass obtained with an ammonium iron sulfate nitrogen source was the lowest. Cornsteep liquor nitrogen source at the rate of 600 mg of N/L yielded the maximum crude protein of 32.9%, protein recovery of 22.2 g/100 g of bagasse, and carboxymethyl cellulase and filter paper enzyme activities of 1.1 and 0.09 units/mL, among the organic and inorganic nitrogen sources studied. In general, the organic nitrogen sources and inorganic nonammonium nitrogen sources were utilized preferentially for protein production over the inorganic ammonium nitrogen sources. The fermentation time required under optimum cultural and nutritional conditions for A. terreus GN1 was also evaluated. The crude protein content of the biomass increased gradually up to the seventh day of fermentation, but the protein recovery rate was high up to two or three days. It was observed that the cellulose utilization rate increased after an initial lag of one day up to the third day and gradually increased further, which corresponded positively with protein content, biomass protein recovery, and cellulase enzyme activity. On the seventh day of fermentation, the crude protein content, biomass protein recovery, water-soluble carbohydrate, bagasse cellulose utilization, CMCase, and FPase activities were 32.8%, 20.1 g/100 g of bagasse, 6.2%, 82.7%, 1.0. and 0.08 U/mL, respectively. The final biomass recovered contained 32.8% crude protein content and had an in vitro rumen digestibility (IVRD) coefficient of 68.8%. The biomass contained almost all the essential and nonessential amino acids and was comparable with FAO reference protein. It is concluded that a fermentation time of 72 h gave a faster rate of protein production of 16.9 g/100 g of bagasse with 69.8% bagasse cellulose utilization with 76.0% IVRD. and contained almost all the essential and nonessential amino acids.

A 'bottom-up' approach for endo-PK/PD analysis

A 'bottom-up' PK/PD analysis approach employing system analysis principles of convolution/deconvolution and special nonparametric estimation procedures is presented to resolve the complex 'endo-PK/PD' of the endogenous form of recombinant drugs using erythropoietin (EPO) as an example. A novel cellular deconvolution algorithm is presented that facilitates the identification of the functional relationship between the variables involved in EPO's complex PK/PD. Five sheep each underwent two phlebotomies spaced 4-6 weeks apart when their hemoglobin levels were reduced from 12 g/dl to 3-4 g/dl. EPO levels and reticulocyte counts were frequently sampled. The data were analysed using end-constrained cubic splines. The rate of reticulocyte production was determined using the novel deconvolution methodology. The erythroid progenitor cells activation rate by EPO was estimated from the reticulocyte production rate using a lag-time parameter which determines the delay in the reticulocyte appearance in the blood relative to the activation of erythroid progenitors. Hysteresis minimization combined with cellular deconvolution was employed to determine the population PK/PD transduction function relating the progenitor activation rate to EPO concentrations in a nonparametric manner without assuming a specific structure. The proposed approach provides a rational informative starting point for developing parametric PK/PD models to resolve the complex endo-PK/PD of recombinant drugs.

Determination of drug absorption rate in time-variant disposition by direct deconvolution using beta clearance correction and end-constrained non-parametric regression

A novel numerical deconvolution method is presented that enables the estimation of drug absorption rates under time-variant disposition conditions. The method involves two components. (1) A disposition decomposition-recomposition (DDR) enabling exact changes in the unit impulse response (UIR) to be constructed based on centrally based clearance changes iteratively determined. (2) A non-parametric, end-constrained cubic spline (ECS) input response function estimated by cross-validation. The proposed DDR-ECS method compensates for disposition changes between the test and the reference administrations by using a "beta" clearance correction based on DDR analysis. The representation of the input response by the ECS method takes into consideration the complex absorption process and also ensures physiologically realistic approximations of the response. The stability of the new method to noisy data was evaluated by comprehensive simulations that considered different UIRs, various input functions, clearance changes and a novel scaling of the input function that includes the "flip-flop" absorption phenomena. The simulated input response was also analysed by two other methods and all three methods were compared for their relative performances. The DDR-ECS method provides better estimation of the input profile under significant clearance changes but tends to overestimate the input when there were only small changes in the clearance.

Production of antifungal substance by Lactococcus lactis subsp. lactis CHD-28.3

Six of the 2100 colonies of lactic acid bacteria isolated from 4 month old Cheddar cheese and raw buffalo milk showed antifungal activity against Aspergillus flavus IARI when tested by the well agar diffusion assay on Potato Dextrose Agar containing 0.1% Triton X-100. Out of these, the most promising isolate having a broad spectrum of antifungal activity including Aspergillus flavus IARI, A. flavus NCIM 555, A. parasiticus NCIM 898 and Fusarium spp. was identified as Lactococcus lactis subsp. lactis CHD-28.3. Among the mold cultures used as indicator strains, the most sensitive towards antifungal substance produced by the test culture was A. flavus IARI. The cell-free supernatant of the test culture in Elliker's broth adjusted to pH 6.8 produced an inhibition zone of 15-19 mm against A. flavus IARI, A. flavus NCIM555 and A. parasiticus NCIM898. The isolate when grown at 30 degrees C for 48 h in Elliker's broth showed optimum antifungal activity. When the supernatant was neutralized to pH 7.0 or 7.5, there was little reduction in activity. However, after enzymatic treatment of supernatant with chymotrypsin, trypsin and pronase E, the antifungal activity disappeared which indicated the proteinaceous nature of the antifungal substance.