Progression of vertebral deformity of prevalent vertebral fractures in the elderly: a population-based study

BACKGROUND

Little is known about the progression pattern of vertebral deformities in elderly patients with prevalent vertebral fractures. This population-based cohort study investigated the incidence, progression pattern, and risk factors of vertebral deformity in prevalent vertebral fractures over a finite period of four years in a population-based cohort study.

METHODS

A total of 224 inhabitants of a typical mountain village underwent medical examinations every second year from 1997 to 2009, and each participant was followed up for four years. The extent (mild, moderate, severe) and type (wedge, biconcave, crush) of prevalent vertebral fractures on spinal radiographs were evaluated using the Genant semi-quantitative method. Of these participants, 116 with prevalent vertebral fractures at baseline (32 men and 84 women; mean age: 70.0 years) were included in this study. The progression patterns of the 187 vertebral fractures with mild and moderate deformities (except severe deformity) were evaluated. Logistic regression analysis was used to identify the risk factors associated with deformity progression.

RESULTS

The progression of vertebral deformities was identified in 13.4% (25 vertebral fractures) of the total 187 prevalent (mild and moderate) vertebral fracture deformities over four years. Among the three deformity types, the prevalence of deformity progression was significantly lower in wedge-type vertebral fractures (P < 0.05). Age and number of prevalent vertebral fractures per participant were independent risk factors associated with the progression of prevalent vertebral deformities.

CONCLUSION

This study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals. Multiple vertebral fractures in the elderly present a risk for the progression of vertebral deformities.

Immediate sciatic nerve reconstruction using an ipsilateral common peroneal nerve graft at the time of sarcoma resection

BACKGROUND

Concomitant resection of the sciatic nerve along with a malignant tumor is no longer a contraindication for limb-sparing surgery, as most of these patients remain ambulatory. However, sciatic nerve reconstruction after sarcoma resection is not commonly performed. Restoration of nerve function can improve patient quality of life. We describe our experience with four patients who underwent sciatic nerve reconstruction using an ipsilateral common peroneal nerve graft at the time of sarcoma resection.

METHODS

Because of the low chance of peroneal nerve recovery, the ipsilateral peroneal trunk was used as a graft to reconstruct the tibial trunk of the sciatic nerve. Two patients were men and two were women. Mean age was 45.3 years (range, 15-62). Mean sciatic nerve defect length was 9.4 cm (range, 8.5-12.0). Proximal thigh defects (three patients) were reconstructed with a double cable; the one patient with a distal thigh defect underwent single cable reconstruction. Mean operation time was 492 min (range, 428-682).

RESULTS

Mean length of the harvested peroneal trunks was 21 cm (range, 11-26). Mean graft length was 11.9 cm (range, 11-13). Postoperative course was uneventful in all four patients. One patient died of sarcoma lung metastasis and could not be evaluated. Three patients were followed for more than 2 years. Two patients achieved British Medical Research Council grade 4 plantar flexion; the remaining patient achieved grade 5 plantar flexion and grade 4 toe flexion. Semmes-Weinstein monofilament sensory testing showed loss of protective sensation on the plantar surface in all three. Musculoskeletal Tumor Society scores at last follow-up were 60.0%, 70.0%, and 43.3%, respectively.

CONCLUSIONS

Immediate sciatic nerve reconstruction using an ipsilateral common peroneal nerve graft avoids reconstruction delay and scar tissue formation, which is advantageous for nerve recovery. This technique may be considered when sciatic nerve resection is anticipated during sarcoma resection.

Central sensitization as a predictive factor for the surgical outcome in patients with lumbar spinal stenosis: a multicenter prospective study

PURPOSE

The impact of central sensitization (CS) on neurological symptoms and surgical outcomes in patients with lumbar spinal stenosis (LSS) remains unknown. This study aimed to investigate the influence of preoperative CS on the surgical outcomes of patients with LSS.

METHODS

A total of 197 consecutive patients with LSS (mean age 69.3) who underwent posterior decompression surgery with or without fusion were included in this study. The participants completed the CS inventory (CSI) scores and the following clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for back pain, JOA back pain evaluation questionnaire, and Oswestry Disability Index (ODI). The association between preoperative CSI scores and preoperative and postoperative COAs was analyzed, and postoperative changes were statistically evaluated.

RESULTS

The preoperative CSI score significantly decreased at 12 months postoperatively and was significantly correlated with all COAs preoperatively and 12 months postoperatively. Higher preoperative CSI showed worse postoperative COAs and inferior postoperative improvement rates in the JOA score, VAS score for neurological symptoms, and ODI. Multiple regression analysis demonstrated that preoperative CSI was significantly associated with postoperative low back pain (LBP), mental health, quality of life (QOL), and neurological symptoms at 12 months postoperatively.

CONCLUSIONS

Preoperative CS evaluated by CSI had a significantly worse impact on surgical outcomes, including neurological symptoms, disability, and QOL, especially related to LBP and psychological factors. CSI can be used clinically as a patient-reported measure for predicting postoperative outcomes in patients with LSS.

Regenerative effects of platelet-rich plasma releasate injection in rabbit discs degenerated by intradiscal injection of condoliase

BACKGROUND

Intradiscal condoliase injection is an alternative therapeutic option for lumbar disc herniation (LDH). However, it is often associated with disc degeneration. Several in vivo studies have demonstrated the regenerative potential of platelet-rich plasma (PRP) in disc degeneration. Thus, we hypothesized that the intradiscal injection of PRP releasate (PRPr), a soluble releasate isolated from PRP, has the potential to regenerate degenerated intervertebral discs (IVDs) induced by condoliase. This study examined the regenerative effects of PRPr on rabbit IVDs degenerated following condoliase injection.

METHODS

Eleven New Zealand white rabbits were used in this study. Condoliase (12.5 mU/10 μl) was injected into two non-contiguous discs (L2-L3 and L4-L5), and L3-L4 disc was left intact as a non-injection control. Saline (20 μl) or PRPr (20 μl) was randomly injected into L2-L3 and L4-L5 discs 4 weeks after the condoliase injection. Disc height (DH) was radiographically monitored biweekly from the day of condoliase injection to 16 weeks post-injection. Changes in DH were expressed as percentage DH (%DH) normalized to the baseline DH. Sixteen weeks after condoliase injection, all rabbits were euthanized, and subjected to MRI and histological analyses.

RESULTS

Intradiscal injection of condoliase induced a significant decrease in %DH (L2-L3 and L4-L5) to 52.0% at week 4. However, the %DH began to return to normal after saline injection and reached 76.3% at week 16. In the PRPr group, %DH began to recover to normal after the PRPr injection and was restored to 95.5% at week 16. The MRI-modified Pfirrmann grade of the PRPr group was significantly lower than that of the saline group (P < 0.01). Histological analyses showed progressive degenerative changes, including reduction of the NP area and condensation of the matrix in the saline and PRPr groups. The histological score of the PRPr group was significantly lower than that of the saline group (P < 0.01).

CONCLUSIONS

PRPr has great potential to enhance the regeneration of degenerated rabbit IVDs induced by condoliase. The results of this preclinical study suggest that PRPr injection therapy may be indicated for patients with LDH who have poor recovery from disc degeneration after chemonucleolysis treatment with condoliase.

Expression of Glial-Cell-Line-Derived Neurotrophic Factor Family Ligands in Human Intervertebral Discs

Glial-cell-line-derived neurotrophic factor (GDNF) family ligands (GFLs) contribute to the sensitization of primary afferents and are involved in the pathogenesis of inflammatory pain. The purpose of this preliminary study was to examine the expression of other GFLs (neurturin (NRTN), artemin (ARTN), persephin (PSPN)) and receptors in human IVD cells and tissues exhibiting early and advanced stages of degeneration. Human IVD cells were cultured as a monolayer after isolation from the nucleus pulposus (NP) and anulus fibrosus (AF) tissues. The mRNA expression of NRTN, ARTN, PSPN, and their receptors (GFRA2-GFRA4) was quantified using real-time PCR. Protein expression was evaluated using immunohistochemistry and Western blotting. The expression of NRTN, ARTN, PSPN, and their co-receptors (GFRA2-GFRA4) was identified in human IVD cells at both mRNA and protein levels. A trend was noted wherein the mRNA expression of ARTN, PSPN, and GFRA2 was upregulated by IL-1β treatment in a dose-dependent manner. The percentages of immunopositive cells in the advanced degenerate stage of ARTN, PSPN, and GFRA2 were significantly higher than those in the early degenerate stage. Their expression was enhanced in advanced tissue degeneration, which suggests that GFLs (ARTN and PSPN) may be involved in the pathogenesis of discogenic pain.

Quantitative Analysis of Lumbar Disc Bulging in Patients with Lumbar Spinal Stenosis: Implication for Surgical Outcomes of Decompression Surgery

This study aimed to quantitatively assess disc bulging using computed tomography (CT) in patients with lumbar spinal stenosis (LSS) and to examine whether disc bulging affects the surgical outcomes of patients with LSS after posterior decompression surgery. Sixty-three patients who underwent posterior decompression surgery for LSS were included. The extent of disc bulging was evaluated as the percentage of the extended area of the disc against the endplate area (%EAD) on axial CT images. The participants completed the following clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the JOA Back Pain Evaluation Questionnaire (JOABPEQ), Oswestry Disability Index (ODI), and Roland-Morris Disability Questionnaire (RDQ). The mean %EAD of 315 intervertebral discs was 18.9 ± 8.0. The %EAD was highest at L4/L5, followed by L3/L4, L2/L3, L1/L2, and L5/S1. The %EAD of the surgical level showed no significant correlation with all the preoperative COAs, but it had significant correlation with lumbar function, walking ability, social function domains of the JOABPEQ, ODI score, and RDQ score 12 months postoperatively. %EAD was significantly associated with the postoperative score in the walking ability domain of the JOABPEQ. %EAD affects postoperative clinical outcomes, including low back pain-related quality of life after decompression surgery.

Evaluation of Central Sensitization Inventory in Patients Undergoing Elective Spine Surgery in a Multicenter Study

STUDY DESIGN

This study is a retrospective review.

OBJECTIVE

Central sensitization (CS) is a neurological phenomenon that involves hypersensitivity of the central nervous system. The central sensitization inventory (CSI) was developed as a screening tool to assess CS-related symptoms. The purpose of this study was to evaluate the association of preoperative CSI scores with patient-reported outcome measures (PROMs) including neurological symptoms for patients who underwent spine surgeries in a multicenter study.

METHODS

A consecutive 673 patients who underwent spine surgery at 8 different institutions were included in this study. Preoperative CSI scores were assessed for all subjects. The participants completed the following PROMs: the Oswestry Disability Index (ODI), the Japanese Orthopaedic Association (JOA) back pain evaluation questionnaire (JOABPEQ) for lumbar spinal diseases, and the JOA cervical myelopathy evaluation questionnaire (JOACMEQ) for cervical spinal diseases. The association of CSI scores with PROMs was statistically evaluated.

RESULTS

The average CSI score for the total subjects was 23.6 ± 13.5. The subjects with CS-related symptoms (CSI ≥ 40) were 13.2% (n = 89). The CSI score showed a significant and weak-to-moderate correlation with the PROMs including neurological symptoms that included all the domains of the JOACMEQ for cervical spinal diseases, and JOABPEQ and ODI for lumbar spinal diseases. Among these, psychological factors had the most influence on the correlation with CSI score.

CONCLUSION

Central sensitization evaluated by the CSI is related to neurological symptoms and health-related quality of life in patients undergoing elective spine surgery.

Daily Physical Training Improved Coronal Imbalance of Adult Degenerative Scoliosis: A Case Report

Background and Objectives: Adult (de novo) degenerative scoliosis (ADS) develops through degenerative changes in the lumbar spine, leading to spinal malalignment, which usually progresses with age. Strong evidence for non-operative care in patients with ADS is lacking, and whether physical exercise can improve the scoliosis curve remains unknown. Materials and Methods: We present a case of early stage ADS in which the coronal imbalance was improved by daily training. A 65-year-old female patient complained of lower back pain (LBP) and bilateral leg pain. She was diagnosed with early stage ADS with lumbar degenerative spondylolisthesis by imaging. She completed six months of daily physical training, including swimming, aerobic bikes, stretching, yoga, and Taijiquan. Results: Her LBP and neurological symptoms improved, and coronal-spinal balance was restored, which was maintained for four years by continued daily physical training. Conclusions: This is the first case of a 65-year-old ADS patient whose coronal balance was significantly restored through daily physical training. Substantial physical training focused on trunk muscle strength is important for spinal stabilization and for improving spinal malalignment in patients with early stage ADS.

Protein-Ligand Interaction Analyses with Nuclear Magnetic Resonance Spectroscopy Enhanced by Dissolution Triplet Dynamic Nuclear Polarization

Solution-state nuclear magnetic resonance spectroscopy (NMR) is a powerful method for the analysis of intermolecular interactions within a biomolecular system. However, low sensitivity is one of the major obstacles of NMR. We improved the sensitivity of solution-state ¹³C NMR for the observation of intermolecular interactions between protein and ligand using hyperpolarized solution samples at room temperature. Eutectic crystals composed of ¹³C-salicylic acid and benzoic acid doped with pentacene were hyperpolarized by dynamic nuclear polarization using photoexcited triplet electrons, and a ¹³C nuclear polarization of 0.72 ± 0.07% was achieved after dissolution. The binding of human serum albumin and ¹³C-salicylate was observed with several hundred times sensitivity enhancement under mild conditions. The established ¹³C NMR was applied for pharmaceutical NMR experiments by observation of the partial return of the ¹³C chemical shift of salicylate by competitive binding with other non-isotope-labeled drugs.

Does Central Sensitization Influence Outcomes of Lumbar Discectomy Surgery in Patients With Lumbar Disc Herniation? A Multicenter Prospective Study

STUDY DESIGN

Multicenter prospective study.

OBJECTIVE

Patients with central sensitization (CS) are reported to be at high risk of poor outcomes after spinal surgery. However, the influence of CS on surgical outcomes for lumbar disc herniation (LDH) remains unknown. This study aimed to examine the association between preoperative CS and surgical outcomes in LDH patients.

METHODS

A total of 100 consecutive patients with LDH (mean age 51.2) who underwent lumbar surgery were included in this study. The extent of CS was evaluated using the central sensitization inventory (CSI), a screening tool for CS-related symptoms. The patients completed the following CSI and clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for back pain, JOA back pain evaluation questionnaire (JOABPEQ), and Oswestry Disability Index (ODI). The association between preoperative CSI scores, and preoperative and postoperative COAs was analyzed, and the postoperative changes were statistically evaluated.

RESULTS

The preoperative CSI score significantly decreased 12 months postoperatively. Preoperative CSI scores showed a significant correlation with most COAs; however, a significant correlation was only identified in the social function and mental health domains of JOABPEC postoperatively. Higher preoperative CSI showed worse preoperative COAs; however, all COAs significantly improved regardless of CSI severity. There were no significant differences in any COAs among the CSI severity groups 12 months postoperatively.

CONCLUSIONS

The results of this study showed that lumbar surgeries significantly improved the COAs regardless of preoperative severity of CS in patients with LDH.

Advances in Platelet-Rich Plasma Treatment for Spinal Diseases: A Systematic Review

Spinal diseases are commonly associated with pain and neurological symptoms, which negatively impact patients' quality of life. Platelet-rich plasma (PRP) is an autologous source of multiple growth factors and cytokines, with the potential to promote tissue regeneration. Recently, PRP has been widely used for the treatment of musculoskeletal diseases, including spinal diseases, in clinics. Given the increasing popularity of PRP therapy, this article examines the current literature for basic research and emerging clinical applications of this therapy for treating spinal diseases. First, we review in vitro and in vivo studies, evaluating the potential of PRP in repairing intervertebral disc degeneration, promoting bone union in spinal fusion surgeries, and aiding in neurological recovery from spinal cord injury. Second, we address the clinical applications of PRP in treating degenerative spinal disease, including its analgesic effect on low back pain and radicular pain, as well as accelerating bone union during spinal fusion surgery. Basic research demonstrates the promising regenerative potential of PRP, and clinical studies have reported on the safety and efficacy of PRP therapy for treating several spinal diseases. Nevertheless, further high-quality randomized controlled trials would be required to establish clinical evidence of PRP therapy.

Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20.

BACKGROUND

Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term.

OBJECTIVE

This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs.

METHODS

This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors.

RESULTS

The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]).

CONCLUSIONS

We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Retrospective Analysis of Factors Associated with the Treatment Outcomes of Intradiscal Platelet-Rich Plasma-Releasate Injection Therapy for Patients with Discogenic Low Back Pain

Background and Objectives: Recently, the clinical application of platelet-rich plasma (PRP) has gained popularity for the treatment of degenerative disc diseases. However, the regenerative effects and factors associated with treatment outcomes after intradiscal injection of PRP remain unknown. This study aimed to evaluate time-dependent changes in imaging findings related to intervertebral disc (IVD) degeneration and to identify factors associated with the outcomes of PRP injection therapy. Materials and Methods: A retrospective analysis of a previous randomized clinical trial of intradiscal injection of the releasate isolated from PRP (PRPr) in patients with discogenic low back pain (LBP) was performed. Radiographic parameters (segmental angulation and lumbar lordosis) and MRI phenotypes, including Modic changes, disc bulge, and high-intensity zones (HIZs), were evaluated at baseline and 6 and 12 months post-injection. Treatment outcomes were evaluated based on the degree of LBP and LBP-related disability at 12 months post-injection. Results: A total of 15 patients (mean age: 33.9 ± 9.5 years) were included in this study. Radiographic parameters showed no significant changes after the PRPr injection. There were no remarkable changes in the prevalence or type of MRI phenotype. Treatment outcomes were significantly improved after treatment; however, the number of targeted discs and the presence of posterior HIZs at baseline were significantly but negatively associated with treatment outcomes. Conclusions: Intradiscal injection of PRPr significantly improved LBP and LBP-related disability 12 months post-injection; however, patients with multiple target lesions or posterior HIZs at baseline were significantly associated with poor treatment outcomes.

Expression of GADD45G and CAPRIN1 in Human Nucleus Pulposus: Implications for Intervertebral Disc Degeneration

Marked cellular changes occur in human intervertebral disc (IVD) degeneration during disc degeneration with biochemical changes. Genome-wide analysis of the DNA methylation profile has identified 220 differentially methylated loci associated with human IVD degeneration. Among these, two cell-cycle-associated genes, growth arrest and DNA damage 45 gamma (GADD45G) and cytoplasmic activation/proliferation-associated protein-1 (CAPRIN1), were focused on. The expression of GADD45G and CAPRIN1 in human IVDs remains unknown. We aimed to examine the expression of GADD45G and CAPRIN1 in human nucleus pulposus (NP) cells and evaluate those in human NP tissues in the early and advanced stages of degeneration according to Pfirrmann magnetic resonance imaging (MRI) and histological classifications. Human NP cells were cultured as monolayers after isolation from NP tissues by sequential enzyme digestion. Total RNA was isolated, and the mRNA expression of GADD45G and CAPRIN1 was quantified using real-time polymerase chain reaction. To examine the effects of pro-inflammatory cytokines on mRNA expression, human NP cells were cultured in the presence of IL-1β. Protein expression was evaluated using Western blotting and immunohistochemistry. GADD45G and CAPRIN1 expression was identified in human NP cells at both mRNA and protein levels. The percentage of cells immunopositive for GADD45G and CAPRIN1 significantly increased according to the Pfirrmann grade. A significant correlation between the histological degeneration score and the percentage of GADD45G-immunopositive cells was identified, but not with that of CAPRIN1-immunopositive cells. The expression of cell-cycle-associated proteins (GADD45G and CAPRIN1) was enhanced in human NP cells at an advanced stage of degeneration, suggesting that it may be regulated during the progression of IVD degeneration to maintain the integrity of human NP tissues by controlling cell proliferation and apoptosis under epigenetic alteration.

Health care transition for cerebral palsy with intellectual disabilities: A systematic review

OBJECTIVE

Today, most individuals with cerebral palsy are adults who need a paediatric-to-adult health care transition. However, many remain in paediatric care for treatment of adult-onset health issues. Therefore, a systematic review based on the 'Triple Aim' framework was performed to determine the status of paediatric-to-adult health care transition for people with cerebral palsy. A comprehensive evaluation of transitional care was proposed for using this framework. It consists of 'experience of care', meaning satisfaction with the care, 'population health', meaning the well-being of patients, and 'cost', meaning cost-effectiveness.

METHOD

Electronic database (PubMed) searches were performed. The inclusion criteria were original articles published between 1990 and 2020. The search terms used in this study were ('cerebral palsy' AND 'transition to adult health care') OR ('cerebral palsy' AND 'transition'). The study type had to be epidemiological, case report, case-control, and cross-sectional, but not qualitative. The outcomes of the studies were categorised into 'care experience', 'population health', and 'cost', according to the Triple Aim framework.

RESULTS

Thirteen articles met the abovementioned inclusion criteria. Few studies have examined the effect of the intervention of transition for young adults with cerebral palsy. Participants in some studies had no intellectual disability. Young adults were dissatisfied with the 'care experience', 'population health', and 'cost' and had unmet health needs and inadequate social participation.

INTERPRETATION

Further transition intervention studies with a comprehensive assessment and proactive involvement of individuals are warranted. The presence of an intellectual disability should be considered.

Incidence and Characteristics of Clinical L5-S1 Adjacent Segment Degeneration after L5 Floating Lumbar Fusion: A Multicenter Study

STUDY DESIGN

Retrospective study.

PURPOSE

This study aimed to evaluate the incidence, characteristics, and risk factors for clinical L5-S1 adjacent segment degeneration (ASD) after L5 floating lumbar fusion.

OVERVIEW OF LITERATURE

ASD is known to occur after lumbar spine fusion at a certain frequency. Several studies on radiological L5- S1 ASD have been reported. However, there are only a few studies on L5-S1 ASD with clinical symptoms, including back pain and/or radiculopathy.

METHODS

In total, 306 patients who received L5 floating lumbar fusion were included in this study. Clinical L5-S1 ASD was defined as newly developed radiculopathy in relation to the L5-S1 segment. Patients' medical records and imaging data were retrospectively analyzed. The risk factors for clinical ASD were assessed by an inverse probability of treatment weighting-adjusted logistic regression analysis.

RESULTS

Clinical L5-S1 ASD occurred in 17 patients (5.6%). The mean onset time of L5-S1 ASD was 12.9±7.5 months after the primary surgery. Among these patients, 10 (58.8%) presented with clinical L5-S1 ASD within 12 months. Reoperation was performed in three patients (1.0%). The severity of L5-S1 disk degeneration did not affect the occurrence of L5-S1 ASD. Logistic regression analysis showed that the number of fusion levels was a significant risk factor for clinical L5-S1 ASD.

CONCLUSIONS

The incidence and characteristics of clinical L5-S1 ASD after L5 floating lumbar fusion were retrospectively investigated. This study established that the number of fusion levels was a significant candidate factor for clinical L5-S1 ASD. Careful clinical follow-up is deemed necessary after L5 floating lumbar fusion surgery, especially for patients who received multiple-level fusions.

Change in prevalence of vertebral fractures over two decades: a Japanese medical examination-based study

INTRODUCTION

Although remarkable progress has been made in osteoporosis treatment over the last two decades, no study has reported the change in the prevalence of vertebral fractures (VFs) during this time. This study aimed to compare the prevalence and pattern of VFs at three time points from 1997 to 2019 in a Japanese medical examination-based study.

MATERIALS AND METHODS

The participants of this study were inhabitants of a typical Japanese mountain village who participated in these surveys at three time points: 1997 (group A), 2009 or 2011 (group B), and 2019 (group C). The age- and sex-adjusted groups were defined as groups A', B', and C', respectively (39 men and 85 women; mean age 73.6-74.0 years old). The type and extent of deformities of the prevalent fractures from T4 to L4 on the lateral thoracic and lumbar spine radiographs were semiquantitatively evaluated.

RESULTS

The prevalence of VFs has significantly decreased over the past two decades. In group A, the percentages of thoracic level, biconcave type, and severe deformity of VFs were significantly higher than expected. The bone mineral density of the participants increased significantly over time. The treatment rate for osteoporosis in participants with osteoporosis has improved over the past two decades.

CONCLUSION

This study demonstrated that the prevalence of VFs has decreased, and the pattern of VFs has changed over the last two decades in a typical Japanese mountain village due to multifactorial improvements in skeletal fragility, including improvement in osteoporosis treatment rate.

Influence of Central Sensitization on Surgical Outcomes of Patients With Degenerative Cervical Myelopathy After Posterior Decompression Surgery: A Multicenter Prospective Study

STUDY DESIGN

Multicenter prospective study.

OBJECTIVE

The influence of central sensitization (CS) on neurological symptoms and surgical outcomes in patients with degenerative cervical myelopathy (DCM) remains unknown. This study aimed to investigate the effects of preoperative CS on surgical outcomes of patients with DCM following posterior decompression surgery.

METHODS

77 consecutive patients with DCM (mean age 67.1) who received posterior decompression surgery were included in this study. The participants completed CS inventory (CSI) scores and the following patient-reported outcome measures (PROMs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for cervical myelopathy and JOA cervical myelopathy evaluation questionnaire (JOACMEQ) for cervical spinal diseases. The association of preoperative CSI scores with preoperative and postoperative PROMs was analyzed, and their changes were statistically evaluated.

RESULTS

The preoperative CSI score was significantly decreased at 12 months postoperatively, and it was significantly associated with the JOA score and JOACMEQ preoperatively and at 12 months postoperatively. However, no significant association was observed between preoperative CSI and the postoperative change of any PROMs at 12 months. The posterior decompression surgery significantly improved the JOA scores and 'lower extremity function' and 'quality of life (QOL)' domains of the JOACMEQ, independent of the severity of preoperative CSI score. Multiple regression analysis demonstrated that preoperative CSI was significantly associated with the 'QOL' domain of JOACMEQ and original JOA score at 12 months postoperatively.

CONCLUSION

The CSI score can be an auxiliary indicator of surgical outcomes of patients with DCM following posterior decompression surgery.

High accuracy spectroscopy of 3- and 4-body Λ hypernuclei at Jefferson Lab

JLab E12-19-002 Experiment is planned to measure the Λ-binding energies of 3ΛH [Jπ = 1/2+ or 3/2+(T = 0)] and 4ΛH (1+) at JLab Hall C. The expected accuracy for the binding-energy measurement is |ΔBtotal Λ | ≃ 70 keV. The accurate spectroscopy for these light hypernuclei would shed light on the puzzle of the small binding energy and short lifetime of 3ΛH, and the chargesymmetry breaking in the ΛN interaction. We aim to perform the experiment in 2025.

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.

Central Sensitization in Chronic Low Back Pain: A Population-Based Study of a Japanese Mountain Village

Purpose

Central sensitization (CS) is defined as the increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold afferent input. CS has been proposed as an underlying mechanism of chronic pain in musculoskeletal disorders including low back pain (LBP). A Central Sensitization Inventory (CSI) has recently been developed for screening participants with CS. However, the association of CS with chronic LBP (cLBP) in the general population remains unknown. The purpose of this study was to investigate the association of CS with cLBP using the CSI in a population-based cohort of a Japanese mountain village.

Participants and Methods

Participants aged more than 50 years were recruited from the inhabitants of a mountain village in Japan. Participants completed the following patient-reported outcome measures. Severity of CS was assessed by the CSI. LBP intensity was measured on a numerical rating scale (NRS). Health-related quality of life (QOL) was measured using the EuroQol 5-dimension (EQ-5D), EuroQol-visual analogue scales (EQ-VAS), and the Oswestry Disability Index (ODI). The association of CS and each parameter was statistically evaluated.

Results

A total of 272 participants (average age: 72.1 years-old) were analyzed in this study, and 28.3% had cLBP. Average NRS, ODI and CSI scores were significantly higher in the cLBP group than in the without LBP (LBP-) group. There was a significant correlation between CSI and NRS scores (r=0.34, P<0.0001), ODI (r=0.60, P<0.0001), EQ5D (r=-0.55, P<0.0001) and EQ-VAS (r=-0.52, P<0.0001). A multiple regression analysis identified that ODI, EQ-VAS and age were factors significantly associated with CSI.

Conclusion

The results of this study suggest that CS is involved in the pathological condition of cLBP in the local residents of a Japanese mountain village.

A novel three-dimensional visualization system revealed an essential adaptive angiogenic response during the early phase of pulmonary hypertension

Background

Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance and right heart failure with progressive narrowing or occlusion of the pulmonary artery. However, the assessment of vascular remodeling is mostly limited to averaged increases in wall thickening, and even the role of vascular endothelial growth factor (VEGF), remains incompletely understood; Although abundantly expressed VEGF is expected to elicit angio-obliteration and the knockout of hypoxia inducible factor (HIF) prevents PH in mice, VEGF inhibitor Sugen exacerbates hypoxia (Hx)-induced PH model, which is referred to as VEGF paradox.

Purpose

To analyze three-dimensional (3D) spatiotemporal changes of pulmonary microstructure and function, which reflect the disease activity and lead to resolve the paradox.

Methods and results

We developed a novel 3D visualization system of microstructural networks in whole mouse organ with single-cell resolution, using combined tissue clearing technique called CUBIC and multiphoton excitation microscope. The system enabled the simultaneous 3D evaluation of microvascular structure, invaded macrophages and fibrosis with effective penetration of several mm (whole organ). Three-dimensional observations of PH mice models including Hx, Sugen/Hx, and human-like Alk1+/− hereditary PH models, revealed that not only inward (negative) microvessel remodeling with stenosis, but also marked elongation of microvascular ECs, was evident except Sugen/Hx model at the early phase, which had not been detected by 2D histological sections. Comparable transcriptome analysis revealed that PGC1α, which regulates HIF-independent VEGF expression and angiogenesis, plays an important role in the characteristic response for mitochondrial and microvascular maintenance. PGC1α was up-regulated in the early phage in Hx and Alk1+/− PH models with microvascular angiogenetic change, whereas Sugen/Hx-model did not increase PGC1α expression and did not show microvascular remodeling. Furthermore pulmonary ECs-specific PGC1α-deficient mice exacerbated Hx-PH model with decreased VEGF expression and microvessel density, and administration of Baicalin, a flavonoid enhancing PGC1α expression, ameliorated Hx-PH model with increased VEGF expression.

Conclusions

The 3D visualization system disclosed an unexpected change of angiogenic microvascular structure in the early phage of PH, which is regulated by EC PGC1α. Microvascular angiogenesis which is induced by up-regulation in PGC1α -VEGF pathway is a crucial factor for compensation of PH in the early phase, which provides a potential novel therapeutic target for PH.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): JSJP

Effectiveness of an app for perinatal home visitation by nurses in preventing infant abuse in Japan

Background

In Japan, public health nurses provide home visitation with pregnant women who are at high risk for child maltreatment, but its effectiveness in preventing child maltreatment has not been evaluated because contents and quality of home visitation vary from municipality to municipality. This study aims to evaluate whether the tablet app developed to standardize and assist perinatal home visitation by public health nurses is effective in preventing child maltreatment.

Methods

An intervention study was conducted in 2018 in Adachi City, Tokyo, Japan. Public health nurses at two public health centers used the tablet app when they support high-risk pregnant women through home visitation and interviews, while public health nurses at the other three public health centers provided support as in the past. Because two public health centers were different in usage of the app, the treatment group was further divided into two groups: active and inactive. As fatal abuse among infants, frequency of shaking and smothering was assessed as an outcome through a self-reported questionnaire at the 4-month health check, and compared between the active treatment group, inactive treatment group, and control group, using multiple logistic regression (N = 5,651).

Results

Prevalence of infant abuse was 0.82% in the active treatment group, 1.34% in the inactive treatment group, and 1.50% in the control group. When adjusted for parental demographics and parenting situations, mothers in the active treatment group were less likely to shake or smother their baby than those in the control group (Odds ratio: 0.51, p = 0.093).

Conclusions

It possibly suggests that the tablet app developed to assist perinatal home visitation by public health nurses was effective in preventing infant abuse.

Key messages

An intervention study was conducted at public health centers in Adachi City, Tokyo, Japan, using the tablet app developed to standardize and assist perinatal home visitation by public health nurses. The finding suggested that the tablet app may be effective in preventing shaking and smothering among 4-month old infants.

Prevention of dental caries by eating vegetables at the beginning of a meal in Japanese children

Backgrounds

Dental caries is still a worldwide serious problem among children. Previous studies showed that higher consumption of vegetables prevents dental caries. Eating order habits, such as eating vegetables at the beginning of a meal, called “Vege-first”, may increase the amount of vegetable consumption, and in turn, prevent dental caries. We used cross-sectional data in our previous study to show the association between “Vege-first” and dental caries. However, the causal relationship of “Vege-first” on dental caries is not clear. The aim of this study to investigate the effect of “Vege-first” on dental caries, using cohort data of Japanese elementary students.

Methods

We used cohort data from 2015 to 2016 by the Adachi Child Health Impact of Living Difficulty (A-CHILD) study, a population-based study of all first- and Second- grade students in Adachi City, Tokyo, Japan. The number of DMFT (decayed, missed due to decay, and filled teeth) in 2016 was used as an outcome. Poisson regression analyses were applied to determine the independent association between keeping the “Vege-first” habit over one year and the number of DMFT in 2016 after controlling for the effects of a child's sex, parental marital status, socioeconomic status, and child's dental caries status in 2015.

Results

Of 3,164 valid participants, 45.0% had dental caries and 6.3% kept the “Vege-first” habit. Children who kept the “Vege-first” habit had fewer DMFTs in 2016 than children who did not (p &lt; 0.001). After controlled for covariates, children with having a continuous “Vege-first” habit were still significantly and independently decreased the number of DMFT in 2016 (Incidence-rate ratios=0.87 (95% confidential interval [0.75-0.98])).

Conclusions

This study showed that having the continuous “Vege-first” habit was associated with preventive dental caries even after accounting for socioeconomic status. Health policy introducing the “Vege-first” habit may be effective to prevent pediatric dental caries.

Key messages

The practice of eating vegetables at the beginning of a meal, called “Vege-first” may increase vegetable consumption and reduce dental caries. The continuous habit of 'Vege-first' was effective in preventing a child’s dental caries even if after accounting for socioeconomic status.

Preventing postpartum depression using an educational video on infant crying

Background

Perception of and reactive behaviors towards infant crying is one of the modifiable risk factors for postpartum depression. The aim of this study was to examine the impact of watching an educational video on infant crying within 1 week of age after delivery at maternity wards to reduce the prevalence of postpartum depressive symptoms at 1 month after giving birth.

Methods

Study design was a cluster randomized controlled trial (UMIN000015558). The intervention hospitals were randomly assigned, stratified by area and function of the hospital. Participants included 47 obstetrics hospitals or clinics out of 150 hospitals or clinics in Osaka Prefecture, Japan. In total, 44 hospitals or clinics completed the trial and 2,601 (intervention group=1,040, control group=1,561) caregivers responded to the questionnaire on postpartum depression. Mothers in the intervention group watched a 11-minute educational video, within 1 week of age, during hospitalization at maternity wards. Primary outcome in this study was postpartum depression assessed by the Edinburgh Postnatal Depression Scale as 9+, and assessed via questionnaire at a 1-month health checkup.

Results

In the intervention group, 142 (13.7%) mothers reported postpartum depression compared to 250 (16.0%) in the control group. Intention-to-treat analysis showed no significant difference in the prevalence of postpartum depression between the groups. However, among young mothers (&lt;25 years old), the analysis showed a 67% reduction in postpartum depression (OR:0.33, 95%CI:0.15-0.72).

Conclusions

Watching an educational video on infant crying did not reduce postpartum depression at 1 month after giving birth, but it was effective for young mothers aged less than 25 years old. It may be easier to introduce our approach to any opportunity for meeting mothers during perinatal period because it does not require specialized manpower and a significant amount of time for the intervention.

Key messages

The educational video on infant crying, “Baby Doesn't Stop Crying,” had no effect in preventing postpartum depressive symptoms. Among young mothers aged &lt;25 years, the educational video had a protective effect on postpartum depressive symptoms, which was not observed for mothers aged ≥25 years.

The effects of paternal childcare in early childhood on later behavioral problems in Japan

Background

Parenting by primary caregivers in early childhood is important for the psycho-social development of children. Previous studies reported that the effect of maternal childcare on child behavioral problems. However, the research about the paternal childcare was limited. This study aims to clarify the impact of paternal childcare during infant-period on behavioral problems in later childhood, in terms of 1) childcare hours and 2) type of involvement in childcare.

Methods

We used the data of the Longitudinal Survey of Newborns in the 21st Century (2001-2006), which was a population-based survey in Japan. We analyzed 35,082 samples, excluding single parents. Paternal childcare was assessed by the following; paternal childcare hours on weekdays or weekends at 18 months old, and frequency of each type of childcare (feeding, diaper change, bathing, putting the child to sleep, playing at home, and taking the child outside) at 6 and 18 months old. We evaluated child behavioral problems by the caregiver's answer at 5 years old. Multivariate logistic regression was conducted for analysis.

Results

Children with paternal childcare for ≥ 6 hours on weekends at 18 months old were had fewer behavioral problems at 5 years old than children with paternal childcare for &lt; 4 hours (odds ratio (OR): 0.83, 95% confidence interval (CI): 0.77 to 0,89), while there was no clear association between paternal childcare hours on weekdays and child outcomes. Children with frequent paternal childcare at 6 and 18 months old also had fewer behavioral problems than children with less paternal childcare (OR: 0.83, 95% CI: 0.76 to 0.90). Some types of paternal childcare (feeding, playing at home, and taking the child outside) strongly reduced child behavioral problems at 5 years old, and dose-effect relations were observed (p for trend &lt; 0.001).

Conclusions

Paternal childcare for a longer time on weekends in the infant-period could reduce the child behavioral problems at 5 years old.

Key messages

High paternal involvement in childcare during infant age, such as taking the child outside the home on weekends, could have protective effects on behavioral problems in later childhood. The promotion of paternal involvement in childcare in early childhood should be useful for adequate child development.

Exploratory open-label clinical study to determine the S-588410 cancer peptide vaccine-induced tumor-infiltrating lymphocytes and changes in the tumor microenvironment in esophageal cancer patients

Cancer vaccines induce cancer-specific T-cells capable of eradicating cancer cells. The impact of cancer peptide vaccines (CPV) on the tumor microenvironment (TME) remains unclear. S-588410 is a CPV comprising five human leukocyte antigen (HLA)-A*24:02-restricted peptides derived from five cancer testis antigens, DEPDC1, MPHOSPH1, URLC10, CDCA1 and KOC1, which are overexpressed in esophageal cancer. This exploratory study investigated the immunologic mechanism of action of subcutaneous S-588410 emulsified with MONTANIDE ISA51VG adjuvant (median: 5 doses) by analyzing the expression of immune-related molecules, cytotoxic T-lymphocyte (CTL) response and T-lymphocytes bearing peptide-specific T-cell receptor (TCR) sequencing in tumor tissue or blood samples from 15 participants with HLA-A*24:02-positive esophageal cancer. Densities of CD8+, CD8+ Granzyme B+, CD8+ programmed death-1-positive (PD-1+) and programmed death-ligand 1-positive (PD-L1+) cells were higher in post- versus pre-vaccination tumor tissue. CTL response was induced in all patients for at least one of five peptides. The same sequences of peptide-specific TCRs were identified in post-vaccination T-lymphocytes derived from both tumor tissue and blood, suggesting that functional peptide-specific CTLs infiltrate tumor tissue after vaccination. Twelve (80%) participants had treatment-related adverse events (AEs). Injection site reaction was the most frequently reported AE (grade 1, n = 1; grade 2, n = 11). In conclusion, S-588410 induces a tumor immune response in esophageal cancer. Induction of CD8+ PD-1+ tumor-infiltrating lymphocytes and PD-L1 expression in the TME by vaccination suggests S-588410 in combination with anti-PD-(L)1 antibodies may offer a clinically useful therapy.Trial registration UMIN-CTR registration identifier: UMIN000023324.

Magnetic Stimulus Responsive DDS Based on Chitosan Microbeads Embedded with Magnetic Nanoparticles

In this paper, we have presented a novel Drug Delivery Substrate (DDS) that that is responsive to external stimuli of high-frequency alternating magnetic fields. The DDS is constituted of chitosan crosslinked with PEGDMA (polyethylene glycol dimethacrylate), loaded with Fe₃O₄ magnetic nanoparticles and vancomycin. In another experiment, a 19-hour elution was observed where three magnetic stimuli of 25 mT, 109.9 kHz were given for 60 min to the test samples. The stimuli were separated by several hours. After excitation span, it was observed that the stimulated samples released a significantly higher amount of vancomycin by as much as 21% compared to non-stimulated samples. In another study, preliminary results showing the effect of different PEGDMA chain lengths have been discussed. These results show evidence of a smart, controllable DDS that allows modulation of its normal passive antibiotic elution by applying external stimuli per personalized needs.

Medical costs associated with childhood maltreatment history among Japanese older people

Background

Childhood maltreatment can have a significant impact on health across the life course, but its impact on health care costs in later life is unknown in Japan. This study aims to assess additional medical costs of Japanese older people with childhood maltreatment history.

Methods

Data from the Japan Gerontological Evaluation Study (JAGES) 2013, a population-based cohort of independent people aged 65 years or older across Japan were used and linked uniquely with the database of health insurance claims for residents of a city with more than 1.5 million citizens, aged 75 years or younger (N = 978). Average annual medical costs for April 2012 and March 2013 and April 2013 and March 2014 were calculated and compared between those who experienced childhood maltreatment and those who did not, using generalized linear models.

Results

4.5% of our sample witnessed their father physically abusing their mother, 1.9% were physically abused, 10.6% were emotionally neglected, and 5.7% were emotionally abused in their childhood. Average medical costs of those with any childhood maltreatment (N = 176, 18.0% of the sample) were significantly higher than those without maltreatment (549,468JPY vs. 413,013JPY (1USD is equivalent to 110JPY); p = 0.007). When examining the effect of each type of maltreatment, average costs of those with emotional neglect were higher than the counterpart (573,481JPY vs. 412,082JPY; p = 0.008). Average costs of those who experienced physical abuse were also higher than those who did not (726,254JPY vs 431,106JPY; p = 0.035). The effect of any childhood maltreatment remained statistically significant after older adults’ age and gender were controlled (p = 0.03).

Conclusions

Our findings suggest that childhood maltreatment is strongly associated with additional medical costs among older Japanese. If it was truly causal, it can be estimated that additional medical costs associated with childhood maltreatment can be more than 333 billion JPY per year nationwide.

Key messages

Average annual medical costs of older adults with any childhood maltreatment history were significantly 116,098 JPY greater than those with no maltreatment history. As for each type of childhood maltreatment, emotional neglect tends to increase medical costs in late adulthood.

The association between eating vegetables at start of meal and dental caries among Japanese children

Background

Dental caries is still serious problem among Japanese children. Previous studies suggested that higher consumption of vegetables prevent dental caries. Eating order habit, such as eating vegetables at start of meal, called “Vege-first”, may increase the amount of vegetable consumption, and in turn, prevent dental caries. However, no published studies have examined the impact of “Vege-first” habit on dental caries. The aim of this study to investigate the association between “Vege-first” and dental caries among Japanese children.

Methods

We used the 2015 cross-sectional data from the Adachi Child Health Impact of Living Difficulty (A-CHILD) study, a population-based study of all first-grade students in Adachi City, Tokyo, Japan. The number of DMFT (decayed, missed due to decay, and filled teeth) was used as an outcome. Poisson regression analyses were applied to determine the independent association between “Vege-first” habit and the number of DMFT after controlling for the effects from child’s sex, parents’ marital status, socioeconomic status, and frequency of tooth brushing, drinking sweet beverages, and snacking.

Results

Of 3,689 valid Japanese children participants, 38.2% had DMFT and 11.6% were having the “Vege-first” habit. The number of DMFT decreased linearly with “Vege-first” habit (p &lt; 0.001). After controlled for covariates, the number of DMFT was still significantly and independently decreased with “Vege-first” habit (prevalence ratio=0.89 (95% confidential interval [0.81-0.98])).

Conclusions

This study showed that having the “Vege-first” habit was associated with dental caries even accounting for socioeconomic status, dental health behavior, and dietary habits. Health policy introducing “Vege-first” habit may be effective to prevent pediatric dental caries.

Key messages

Eating habit which vegetables at start of meal called “Vege-first” may increase the amount of vegetable consumption and possibly reduce dental caries. The habituation of Vege-first was likely to reduce child’s dental caries even accounting for socioeconomic status, dental health behavior and dietary habits.

Combined effect of adverse childhood experiences and young age on self-harm ideation after birth

Background

Suicide among postpartum women is a new and emerging issue in developed countries. However, little is known about the combined effect of risk factors on self-harm ideation, although various risk factors have been found. The aim of this study is to examine the combined effect of maternal adverse childhood experiences and maternal age on self-harm ideation among postpartum women.

Methods

The study comprised a cross-sectional study of 8,074 mothers participating in a 3-month health checkup between September 2013 and August 2014 in City A, Prefecture A, Japan. Main outcome was self-harm ideation assessed using the Edinburgh Postnatal Depression Scale (EPDS), item 10. Possible risk factors were maternal adverse childhood experiences (ACEs), maternal characteristics, relationship with husband/partner (e.g., feelings when pregnancy was confirmed), household characteristics, child characteristics (e.g., age, sex, birth weight), and postpartum characteristics, and postpartum depression status other than self-harm ideation.

Results

Postpartum women with 3 or more ACEs and younger age (&lt;25 years old) were 10.3 times more likely than those with no ACEs and older age to have self-harm ideation (95%CI=5.3-20.2). This combined effect was also found in first-time mothers (OR = 7.6, 95%CI=3.2-17.9).

Conclusions

Postpartum women with 3 or more ACEs and who were younger than 25 years old were at a high risk for self-harm ideation. Providing prevention strategies aimed at mothers with multiple risk factors, especially younger age and ACEs, is warranted.

Key messages

Mothers with 3 or more ACEs and younger age had a high self-harm ideation risk. Providing prevention strategies for mothers with multiple risk factors is warranted.

Association of maternal developmental disorder traits with child maltreatment

Objective

Maternal mental disorders are known risk factors for child mistreatment. However, little is known about the involvement of maternal developmental disorder traits. The aim of this study was to examine maternal traits related to Pervasive Developmental Disorder (PDD) and Attention Deficit Hyperactivity Disorder (ADHD), and their possible association with child maltreatment.

Methods

Maternal PDD and ADHD were assessed through a self-administered questionnaire (N = 846) during mid-pregnancy using the Pervasive Developmental Disorders Autism Society Japan Rating Scale (PARS) and Adult ADHD Self-Report Scale (ASRS). The mothers completed another questionnaire on child mistreatment when the offspring was approximately 18 months of age. The associations between maternal PDD and ADHD traits and child maltreatment score were analyzed using linear regression models adjusted for covariates.

Results

Mothers who exhibited stronger PDD traits showed significantly higher child maltreatment score, even after adjustment for maternal characteristics at baseline and ADHD traits. At the same time, ADHD traits were significantly associated with child maltreatment after adjustment of covariates, although the association became non-significant after adjustment of PDD traits.

Conclusions

Mothers who showed PDD and ADHD traits during pregnancy were more likely to maltreat their children. It is essential to educate mothers with such traits with appropriate, easy-to-follow childcare instructions, preferably in simple language combined with pictorial aids.

Key messages

Maternal developmental disorder traits are risk factor of child maltreatment. Specific parenting training intervention for mothers with developmental disorders are needed.

P6209Relationship between skin autofluorescence levels and clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Advanced glycation end-products, indicated by skin autofluorescence (SAF) levels, could be prognostic predictors of all-cause and cardiovascular mortality in patients with diabetes mellitus (DM) and renal disease. However, the clinical usefulness of SAF levels in patients with heart failure (HF) who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

The purpose of this study was to investigate the prognostic value of SAF levels in patients with HF who underwent CR.

Methods

This study enrolled 204 consecutive patients with HF who had undergone CR at our university hospital between November 2015 and October 2017. Clinical characteristics and anthropometric data were collected at the beginning of CR. SAF levels were noninvasively measured with an autofluorescence reader. The major adverse cardiovascular event (MACE) was a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data concerning primary endpoints were collected until November 2018.

Results

Patients' mean age was 68.1 years, and 61% were males. Patients were divided into two groups according to the median SAF levels (high and low SAF groups). Patients in the high SAF group were significantly older, had a higher prevalence of chronic kidney disease, and histories of coronary artery bypass surgery; however, there were no significant between-group differences in sex, prevalence of DM, left ventricular ejection fraction, and physical function. During a median follow-up period of 623 days, 25 patients experienced all-cause mortality and 34 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the high SAF group had a higher incidence of MACE (log-rank P<0.05), whereas when patients were divided into two groups according to the median hemoglobin A1c level, no significant between-group difference was observed for the incidence of MACE (Figure). After adjusting for confounding factors, Cox regression multivariate analysis revealed that SAF levels were independently associated with the incidence of MACE (hazard ratio: 1.74, 95% confidence interval: 1.12–2.65, P<0.05).

Figure 1

Conclusion

SAF levels were significantly associated with the incidence of MACE in patients with HF and may be useful for risk stratification in patients with HF who undergo CR.

Physeal-preserving endoprosthetic replacement with short segment fixation in children with bone sarcomas

AIMS

The aim of this study was to report the results of custom-made endoprostheses with extracortical plates plus or minus a short, intramedullary stem aimed at preserving the physis after resection of bone sarcomas in children.

PATIENTS AND METHODS

Between 2007 and 2017, 18 children aged less than 16 years old who underwent resection of bone sarcomas, leaving ≤ 5 cm of bone from the physis, and reconstruction with a custom-made endoprosthesis were reviewed. Median follow-up was 67 months (interquartile range 45 to 91). The tumours were located in the femur in 11 patients, proximal humerus in six, and proximal tibia in one.

RESULTS

The five-year overall survival rate was 78%. No patient developed local recurrence. The five-year implant survival rate was 79%. In all, 11 patients (61%) developed a complication. Seven patients (39%) required further surgery to treat the complications. Implant failures occurred in three patients (17%) including one patient with aseptic loosening and two patients with implant or periprosthetic fracture. The preserved physis continued to grow at mean 3.3 cm (0 to 14). The mean Musculoskeletal Society score was 88% (67% to 97%).

CONCLUSION

Custom-made endoprostheses that aim to preserve the physis are a safe and effective option for preserving physeal growth, limb length, and joint function with an acceptable rate of complications. Cite this article: Bone Joint J 2019;101-B:1144-1150.

Preoperative surgical risk stratification in osteosarcoma based on the proximity to the major vessels

Aims

The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels.

Patients and Methods

A total of 226 patients with high-grade non-metastatic osteosarcoma in the limbs were investigated. Median age at diagnosis was 15 years (4 to 67) with the ratio of male to female patients being 1.5:1. The most common site of the tumour was the femur (n = 103) followed by tibia (n = 66). The vascular proximity was categorized based on the preoperative MRI after neoadjuvant chemotherapy into four types: type 1 > 5 mm; type 2 ≤ 5 mm, > 0 mm; type 3 attached; type 4 surrounded.

Results

Limb salvage rate based on the proximity type was 92%, 88%, 51%, and 0% for types 1 to 4, respectively, and the overall survival at five years was 82%, 77%, 57%, and 67%, respectively (p < 0.001). Local recurrence rate in patients with limb-salvage surgery was 7%, 8%, and 22% for the types 1 to 3, respectively (p = 0.041), and local recurrence at the perivascular area was observed in 1% and 4% for type 2 and 3, respectively. The mean microscopic margin to the major vessels was 6.9 mm, 3.0 mm, and 1.4 mm for types 1 to 3, respectively. In type 3, local recurrence-free survival with limb salvage was significantly poorer compared with amputation (p = 0.025), while the latter offered no overall survival benefit. In this group of patients, factors such as good response to chemotherapy or limited vascular attachment to less than half circumference or longitudinal 10 mm reduced the risk of local recurrence.

Conclusion

The proximity of osteosarcoma to major blood vessels is a poor prognostic factor for local control and survival. Amputation offers better local control for tumours attached to the blood vessels but does not improve survival. Limb salvage surgery offers similar local control if the tumour attachment to blood vessels is limited. Cite this article: Bone Joint J 2019;101-B:1024–1031.

Endplate and intervertebral disc injuries in acute and single level osteoporotic vertebral fractures: is there any association with the process of bone healing?

Background

The endplate-intervertebral disc (IVD) complex is closely interrelated with the vertebral body (VB) in the structural integrity of the anterior spinal column, including biomechanical and biological functions. Endplate and IVD injuries are usually found in association with vertebral fractures (VFs); however, little is known about their relevance to the healing of osteoporotic VFs (OVFs). The first purpose of this study was to evaluate the incidence and occurrence pattern of endplate and IVD injuries associated with single- and acute-OVFs, and the second was to evaluate the influence of endplate and IVD injuries on the occurrence of delayed union.

Methods

Endplate and IVD injuries associated with single- and acute-OVFs were retrospectively evaluated using magnetic resonance imaging (MRI). Vertebrae of 168 patients were included in the study. The occurrence rate and type of endplate and IVD injuries were radiologically evaluated, and the association between endplate and IVD injuries was statistically analyzed. Vertebrae of 85 patients, who received conservative treatment for acute OVFs, were included in the study and classified into two groups, union and delayed union, at 6 months after injury. To identify factors predicting delayed union, uni- and multivariate statistical analyses were performed. Vertebral MRI signal alternation patterns and endplate and IVD injuries were included as candidate factors in the logistic model.

Results

In association with OVFs, endplate injuries were observed in 103 of the 168 vertebrae (61%), and IVDs lesions were observed in 101 of 168 OVFs (60%); the occurrence of both injuries was significantly associated. Although no significant association with endplate and IVD injuries was identified, multivariate analysis demonstrated that intravertebral signal alternation (focal high signal intensity) and posterior wall injury were independent risk factors that predicted delayed union.

Conclusions

The results of this study showed that endplate and IVD injuries were found in approximately 60% of single and acute OVFs. These results suggest that fracture healing of OVFs would be mainly attributed to vertebral factors, including mechanical stress and metabolic status, among the three components of the anterior spinal column.

Mechanisms of failure and survival of total femoral endoprosthetic replacements

AIMS

The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR).

PATIENTS AND METHODS

In all, 81 patients treated with TFEPR from 1976 to 2017 were retrospectively evaluated and failures were categorized according to the Henderson classification. There were 38 female patients (47%) and 43 male patients (53%) with a mean age at diagnosis of 43 years (12 to 86). The mean follow-up time was 10.3 years (0 to 31.7). A survival analysis was performed followed by univariate and multivariate Cox regression to identify independent implant survival factors.

RESULTS

The revision-free survival of the implant was 71% at five years and 63.3% at ten years. Three prostheses reached 15 years without revision. The mean Musculoskeletal Tumor Society score in the group was 26 (23 to 28). The mechanisms of failure were infection in 18%, structural failures in 6%, tumour progression in 5%, aseptic loosening in 2%, and soft-tissue failures in 1%. Prostheses used for primary reconstruction after oncological resections had lower infection rates than revision implants (8% vs 25%; p = 0.001). The rates of infection in silver-coated and non-silver-coated prosthesis were similar (17.4% vs 19.%; p = 0.869). The incidence of hip dislocation was 10%. Rotating hinge prosthesis had a lower failure rate than fixed hinge prosthesis (5.3% vs 11%). After Cox regression, the independent factors associated with failures were the history of previous operations (hazard ratio (HR) 3.7; p = 0.041), and the associated arthroplasty of the proximal tibia (HR 3.8; p = 0.034). At last follow-up, 11 patients (13%) required amputation.

CONCLUSION

TFEPR offers a reliable reconstruction option for massive bone loss of the femur, with a good survival when the prosthesis is used as a primary implant. The use of a rotating hinge at the knee and dual mobility bearing at the hip may be adequate to reduce the risk of mechanical and soft-tissue failures. Infection remains the main concern and there is insufficient evidence to support the routine use of silver-coated endoprosthesis. Cite this article: Bone Joint J 2019;101-B:522-528.

Prognostic factors for local recurrence in extremity-located giant cell tumours of bone with pathological fracture

AIMS

The aim of this paper was to investigate the prognostic factors for local recurrence in patients with pathological fracture through giant cell tumours of bone (GCTB).

PATIENTS AND METHODS

A total of 107 patients presenting with fractures through GCTB treated at our institution (Royal Orthopaedic Hospital, Birmingham, United Kingdom) between 1995 and 2016 were retrospectively studied. Of these patients, 57 were female (53%) and 50 were male (47%).The mean age at diagnosis was 33 years (14 to 86). A univariate analysis was performed, followed by multivariate analysis to identify risk factors based on the treatment and clinical characteristics.

RESULTS

The initial surgical treatment was curettage with or without adjuvants in 55 patients (51%), en bloc resection with or without reconstruction in 45 patients (42%), and neoadjuvant denosumab, followed by resection (n = 3, 3%) or curettage (n = 4, 4%). The choice of treatment depended on tumour location, Campanacci tumour staging, intra-articular involvement, and fracture displacement. Neoadjuvant denosumab was used only in fractures through Campanacci stage 3 tumours. Local recurrence occurred in 28 patients (25%). Surgery more than six weeks after the fracture did not affect the risk of recurrence in any of the groups. In Campanacci stage 3 tumours not treated with denosumab, en bloc resection had lower local recurrences (13%), compared with curettage (39%). In tumours classified as Campanacci 2, intralesional curettage and en bloc resections had similar recurrence rates (21% and 24%, respectively). After univariate analysis, the type of surgical intervention, location, and the use of denosumab were independent factors predicting local recurrence. Further surgery was required 33% more often after intralesional curettage in comparison with resections (mean 1.59, 0 to 5 vs 1.06, 0 to 3 operations). All patients treated with denosumab followed by intralesional curettage developed local recurrence.

CONCLUSION

In patients with pathological fractures through GCTB not treated with denosumab, en bloc resection offers lower risks of local recurrence in tumours classified as Campanacci stage 3. Curettage or resections are both similar options in terms of the risk of local recurrence for tumours classified as Campanacci stage 2. The benefits of denosumab followed by intralesional curettage in these patients still remains unclear.

Comparison of minimally invasive and non-invasive systems in lengthening total femoral prostheses

Aims

The aim of this study was to describe, analyze, and compare the survival, functional outcome, and complications of minimally invasive (MI) and non-invasive (NI) lengthening total femoral prostheses.

Patients and Methods

A total of 24 lengthening total femoral prostheses, 11 MI and 13 NI, were implanted between 1991 and 2016. The characteristics, complications, and functional results were recorded. There were ten female patients and ten male patients. Their mean age at the time of surgery was 11 years (2 to 41). The mean follow-up was 13.2 years (seven months to 29.25 years). A survival analysis was performed, and the failures were classified according to the Modified Henderson System.

Results

The overall implant survival was 79% at five, ten, and 20 years for MI prostheses, and 84% at five years and 70% at ten years for NI prostheses. At the final follow-up, 13 prostheses did not require further surgery. The overall complication rate was 46%. The mean revision-free implant survival for MI and NI prostheses was 59 months and 49 months, respectively. There were no statistically significant differences in the overall implant survival, revision-free survival, or the distribution of complications between the two types of prosthesis. Infection rates were also comparable in the groups (9% vs 7%; p = 0.902). The rate of leg-length discrepancy was 54% in MI prostheses and 23% in NI prostheses. In those with a MI prosthesis, there was a smaller mean range of movement of the knee (0° to 62° vs 0° to 83°; p = 0.047), the flexion contracture took a longer mean time to resolve after lengthening (3.3 months vs 1.07 months; p < 0.001) and there was a lower mean Musculoskeletal Tumor Society (MSTS) score (24.7 vs 27; p = 0.295).

Conclusion

The survival and complications of MI and NI lengthening total femoral prostheses are comparable. However, patients with NI prosthesis have more accurate correction of leg-length discrepancy, a better range of movement of the knee and an improved overall function.