Healthcare-associated carbapenem-resistant Klebsiella pneumoniae infections are associated with higher mortality compared to carbapenem-susceptible K. pneumoniae infections in the intensive care unit: a retrospective cohort study

BACKGROUND

Klebsiella pneumoniae (KP) is an opportunistic pathogen causing severe pneumonia and sepsis. Carbapenem-resistant KP (CRKP) has become a major pathogen in many centres.

AIM

To investigate the association between carbapenem resistance and the mortality rate, length of stay, and hospital cost in patients with Klebsiella pneumoniae infection.

METHODS

The retrospective cohort study was conducted in the intensive care units of a large teaching tertiary hospital in southwest China between January 1st, 2020 and December 31st, 2022. To examine the impact of carbapenem resistance on mortality rates and economic burden, multivariate Cox regression and generalized linear models were constructed.

FINDINGS

The study included 282 adult patients with KP infection (135 CSKP; 147 CRKP). CRKP-infected patients demonstrated higher mortality risk (unadjusted hazard ratio (aHR): 1.980; 95% confidence interval (CI): 1.206-3.248; P = 0.007; aHR: 1.767; 95% CI: 1.038-3.005; P = 0.036) compared to CSKP-infected patients. Stratified analysis, according to type of KP infection, revealed that patients with healthcare-associated CRKP infection had a significantly higher mortality risk compared to those with CSKP infection (log-rank P = 0.015). Patients with CRKP infection had longer hospital stays than those infected with CSKP (adjusted mean: 38.74 vs 29.71 days; P = 0.003), and hospital-related expenses were notably higher among CRKP patients than CSKP patients (adjusted cost: £40,126.73 vs 25,713.74; P < 0.001).

CONCLUSION

CRKP infections increase mortality rates, prolong hospital stays, and raise healthcare costs. Healthcare facilities should adopt targeted strategies, including curtailing pre-infection hospitalization periods and managing medications more judiciously.

MRI Guided Adaptive Radiotherapy (MRgART) in Primary and Metastatic Liver Lesions

PURPOSE/OBJECTIVE(S)

The role of stereotactic body radiotherapy (SBRT) in the management of primary hepatic and metastatic tumors has increased significantly over the past few years. MR-Linac is rapidly gaining evidence in the delivery of ablative doses using MR guided adaptive radiotherapy (MRgART) with improved accuracy and dose coverage to the lesions. We report local control and toxicity of patients with primary and metastatic liver lesions treated with MR guided adaptive SBRT.

MATERIALS/METHODS

All patients were treated with MRgART on the Unity 1.5T MR Linacs at two institutions and consented to the ADAPT-MRL study (1). A 4DCT and MRI with abdominal compression were obtained at simulation and the primary MRI sequence used for online treatment included a T2 3D navigated scan. A balanced turbo field echo (btFFE) 2D cine motion scan was also acquired at every fraction to determine movement of the tumor to aid in internal target volume margin. All plans were treated with SBRT prescribed to 3-5 alternate daily fractions. Acute toxicity was reported according to Common Terminology Criteria for Adverse Events version 5 (CTCAE) v.5. Patient demographics, prescribed dose fractionation, acute toxicity and clinical response at 6 months were analyzed. Clinical response to treatment was measured according to RECIST criteria 1.1.

RESULTS

Between February 2021 to January 2023 a total of 30 patients were treated with 149 fractions to the liver. Patients were majority male (70%) with a median age of 66 (range 36-83). 16 patients were treated for primary hepatocellular carcinoma (HCC) of the liver and 14 patients for metastatic liver lesions. The median prescribed dose was 48 Gy (range 30-50Gy) in median 5 fractions (range (3-5 fractions). All patients completed treatment with no interruptions. The mean time from 'patient setup' to 'beam-off' was 52.6 minutes (range 37-73 minutes). Data on acute toxicity at 3 month follow up was available for 28 patients. Of these patients 7/28 (25%) had grade 1 or 2 toxicity and no >/ = grade 3 toxicity was reported. Clinical response at 6 months was available for 18 patients and showed complete response in 44% (8/18), partial response in 22% (4/18), stable disease in 22% (4/18) and progressive disease in 11.1% (2/18).

CONCLUSION

Our experience on MRgART to the liver has shown good local control and minimal acute toxicity in the treatment of primary and metastatic liver lesions. We continue to collect data on patient reported outcomes, clinical response and toxicity to determine the feasibility and safety of this system.

Safety and Efficacy of Stereotactic Body Radiotherapy for Ultra-Central Thoracic Tumors

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is increasingly utilized in the management of ultra-central thoracic tumors, although concerns regarding significant toxicity remain. We sought to evaluate the toxicity and efficacy of SBRT to these tumors at our institution.

MATERIALS/METHODS

Patients with ultra-central lung tumors or nodes treated at our institution with SBRT between 2009 and 2019 were retrospectively reviewed. Ultra-central was defined as having the planning target volume (PTV) overlapping or abutting the central bronchial tree and/or esophagus. All SBRT plans were generated with homogenous dose distributions using target coverage objectives of ITV V100% >99%, PTV V95% >99%, and an ideal PTV Dmax <105% (strict <120%). All plans were reviewed in quality assurance rounds by a team of dosimetrists, physicists, and radiation oncologists. The primary endpoint was incidence of severe toxicity (ST), defined as SBRT-related grade ≥3 toxicities, graded using the Common Terminology Criteria for Adverse Events V5.0. Secondary endpoints included local failure (LF), progression-free survival (PFS) and overall survival (OS). Competing risk analysis was used to estimate incidence and predictors of ST and LF, with death as a competing risk. Kaplan-Meier method was used to estimate PFS and OS.

RESULTS

A total of 154 patients who received 162 ultra-central courses of SBRT were included, with a median follow-up of 21.5 months. Treatment intent was most commonly for oligoprogression (46%), oligometastasis (30%), followed by curative (20%). The most frequent tumor histologies were NSCLC (41%) and RCC (26%). SBRT prescription doses ranged from 30-55 Gy in 5 fractions (BED10 range 48-115 Gy). The most common prescription was 50 Gy in 5 fractions (42%). The cumulative incidence of ST was 8.9% at 3-years. The most common ST was pneumonitis (n = 4). Notable toxicities included bronchopleural fistula (n = 2, grade 3 and 4), bronchial stricture (n = 1, grade 3), and esophagitis leading to bleeding (n = 1, grade 4). There were no esophageal strictures or perforations, and no bronchial bleeds. There was 1 possible treatment related death from pneumonitis/pneumonia. Predictors of any ST included increased lung V5 Gy, decreased PTV V95%, and not having prior radiation therapy to the chest. The cumulative incidence of LF was 4.8%, 11% and 14% at 1-, 2-, and 3-years respectively. Predictors of LF included younger age, and greater volume of overlap between the PTV and esophagus. Median PFS was 8.4 months, while median OS was 3.7 years.

CONCLUSION

In one of the largest case series of ultra-central thoracic SBRT reported to date, homogenously prescribed SBRT plans were associated with relatively low rates of ST and LF across a variety of treatment indications. Predictors of ST should be interpreted recognizing the heterogeneity in toxicities observed. Identified predictors of both ST and LF can contribute to future work to optimize the therapeutic ratio in treatment of ultra-central thoracic tumors.

[Landmark vessel in membrane anatomy-based colorectal surgery]

The theory of membrane anatomy has been widely used in the field of colorectal surgery. The key point to perform high quality total mesorectal excision (TME) and complete mesocolic excision (CME) is to identify the correct anatomical plane. Intraoperative identification of the various fasciae and fascial spaces is the key to accessing the correct surgical plane and surgical success. The landmark vessels refer to the small vessels that originate from the original peritoneum on the surface of the abdominal viscera during embryonic development and are produced by the fusion of the fascial space. From the point of view of embryonic development, the abdominopelvic fascial structure is a continuous unit, and the landmark vessels on its surface do not change morphologically with the fusion of fasciae and have a specific pattern. Drawing on previous literature and clinical surgical observations, we believe that tiny vessels could be used to identify various fused fasciae and anatomical planes. This is a specific example of membrane anatomical surgery.

Comparative efficacy and safety of different hemostatic medications during spinal surgery: A network meta-analysis

BACKGROUND

Significant blood loss is still one of the most frequent issues in spinal surgery. There were different hemostatic methods to prevent blood loss during spinal surgery. However, the optimal hemostatic therapy for spinal surgery is controversial. The purpose of this study was to assess the efficacy and safety of different hemostatic therapies in spinal surgery.

METHODS

Two independent reviewers conducted electronic literature searches in 3 electronic databases (PubMed, Embase, and Cochrane library database) as well as a manual search to identify eligible clinical studies from inception to Nov 2022. Studies that including different hemostatic therapy (tranexamic acid [TXA], epsilon-acetyl aminocaproic acid [EACA], and aprotinin [AP]) for spinal surgery were included. The Bayesian network meta-analysis was performed with a random effects model. The surface under the cumulative ranking curve (SUCRA) analysis was performed to determine the ranking order. All analyses were performed by R software and Stata software. P value less than .05 was identified as statistically significant.

RESULTS

Finally, a total of 34 randomized controlled trials met the inclusion criteria and finally included in this network meta-analysis. The SUCRA shows that TXA ranked first (SUCRA, 88.4%), AP ranked second (SUCRA, 71.6%), EACA ranked third (SUCRA, 39.9%), and placebo ranked the last (SUCRA, 0.3%) as for total blood loss. The SUCRA shows that TXA ranked first (SUCRA, 97.7%), AP ranked second (SUCRA, 55.8%), EACA ranked third (SUCRA, 46.2%), and placebo ranked the last (SUCRA, 0.2%) for need for transfusion.

CONCLUSIONS

TXA appears optimal in the reduction of perioperative bleeding and blood transfusion during spinal surgery. However, considering the limitations in this study, more large-scale, well-designed randomized controlled trials are needed to confirm these findings.

[Cognition and reflection on the "lateral ligament of rectum"]

As total mesorectal excision (TME) for rectal cancer is widely carried out in China, lateral ligament of rectum, as an important anatomical structure of the lateral rectum with certain anatomical value and clinical significance, has been the focus of attention. In this paper, by comparing and analyzing the characteristics about ligaments of the abdomen and pelvis, reviewing the membrane anatomy and the theory of primitive gut rotation, and combining clinical observations and histological studies, the author came to a conclusion that lateral ligament of rectum does not exist, but is only a relatively dense space on the rectal side accompanied by numerous tiny nerve plexuses and small blood vessels penetrating through it.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Cost-effectiveness analyses of denosumab for osteoporosis: a systematic review

This paper systematically reviewed and assessed all retrievable pharmacoeconomic studies on denosumab for the treatment of osteoporosis. Denosumab was more cost-effective in patients with older age, prior fracture experience, lower BMD T-scores, and more risk factors. ESCEO-IOF guidelines were more applicable to improve the quality of pharmacoeconomic studies in osteoporosis.

INTRODUCTION

There are many pharmacoeconomic studies on denosumab for osteoporosis. However, the corresponding reviews are outdated or incomplete and need to be updated and refined. This article aims to systematically review and evaluate all retrievable pharmacoeconomic studies of denosumab for osteoporosis.

METHODS

A systematic literature search was performed utilizing PubMed, EMBASE(Ovid), Proquest(EconLit), Chongqing VIP, WanFang Database, and Chinese National Knowledge Infrastructure to identify full-text articles published before September 2021. The quality of full-text articles was evaluated by the Consolidated Health Economic Evaluation Reporting Standards(CHEERS) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases International Osteoporosis Foundation guideline(ESCEO-IOF).

RESULTS

In total, 21 full-text articles were eligible for inclusion. Denosumab for postmenopausal osteoporosis was not dominant compared to zoledronate and teriparatide. However, denosumab was dominant compared with strontium ranelate, raloxifene, and ibandronate in patients over 65 years. The probabilities of denosumab being cost-effective or dominant were more than 85% compared with no treatment and risedronate in patients aged over 70 years. Compared to alendronate, the highest rate of denosumab dominance occurred in patients aged 65 to 75 years, at about 65%. Most of the articles had higher CHEERS scores than ESCEO-IOF scores (converted into percentages).

CONCLUSIONS

The cost-effectiveness of denosumab for the treatment of osteoporosis was influenced by multiple factors. Generally, denosumab was more cost-effective in patients with older age, prior fracture experience, lower BMD T-scores, and more risk factors. ESCEO-IOF guidelines were more applicable to improve the transparency, generalization, and quality of pharmacoeconomic studies in osteoporosis.

Finely-tuned gamma oscillations: Spectral characteristics and links to dyskinesia

Gamma oscillations comprise a loosely defined, heterogeneous group of functionally different activities between 30 and 100 Hz in the cortical and subcortical local field potential (LFP) of the motor network. Two distinct patterns seem to emerge which are easily conflated: Finely-tuned gamma (FTG) oscillations - a narrowband activity with peaks between 60 and 90 Hz - have been observed in multiple movement disorders and are induced by dopaminergic medication or deep brain stimulation (DBS). FTG has been linked with levodopa or DBS-induced dyskinesias, which makes it a putative biomarker for adaptive DBS. On the other hand, gamma activity can also present as a broad phenomenon (30-100 Hz) in the context of motor activation and dynamic processing. Here, we contrast FTG, either levodopa-induced or DBS-induced, from movement-related broadband gamma synchronisation and further elaborate on the functional role of FTG and its potential implications for adaptive DBS. Given the unclear distinction of FTG and broad gamma in literature, we appeal for more careful separation of the two. To better characterise cortical and subcortical FTG as biomarkers for dyskinesia, their sensitivity and specificity need to be investigated in a large clinical trial.

Repurposing Ivermectin to augment chemotherapy's efficacy in osteosarcoma

BACKGROUND

Osteosarcoma is the most frequent malignant bone malignancy and the current treatments are ineffective. Ivermectin, an anti-protozoal drug, has been shown to have anti-cancer activity. This work investigated the potential of repurposing ivermectin to augment chemotherapy's efficacy in osteosarcoma.

METHODS

Proliferation, migration and apoptosis assays were performed in ivermectin-treated osteosarcoma cells. Combination studies were performed. Osteosarcoma xenograft mouse model was established to investigate the in vivo efficacy of ivermectin. Intracellular reactive oxygen species (ROS) and mitochondrial superoxide, membrane potential, ATP, 8-OHdG level, protein carbonylation and lipid peroxidation were determined after ivermectin treatment.

RESULTS

Ivermectin was effective and acted synergistically with doxorubicin in osteosarcoma cells regardless of cellular origin and genetic profiling. This was achieved through suppressing inhibiting growth and migration, and inducing caspase-dependent apoptosis. Ivermectin also significantly inhibited osteosarcoma growth in vivo and its combination with doxorubicin resulted in much greater efficacy than doxorubicin alone. Importantly, the effective dose of ivermectin was clinically feasible and did not cause significant toxicity in mice. Mechanistical analysis showed that ivermectin induced oxidative stress and damage, and mitochondrial dysfunction.

CONCLUSIONS

Our findings indicate that ivermectin has utility in treating patients with osteosarcoma, especially those resistant to chemotherapy.

Assessment of automated craving across substances and across cultures: stability-analysis of the Craving Automated Scale (CAS)

BACKGROUND

The transition from hedonic to compulsive use in Substance Use Disorders (SUD) is a critical point in SUD progression and hence relevant for assessment and treatment. To measure the habitual patterns of substance consumption, the Craving Automated Scales (CAS) for alcohol (CAS-A), substances (CAS-S) and cigarette smoking (CAS-CS) were developed and introduced to different countries. In this study, we aimed to investigate the structural stability of CAS across substances and cultures.

METHODS

This study analyzed the CAS-scores of a sample of 370 participants in Germany, China and the UK, including 262 opioid-users, 65 smokers and 43 alcohol-users. We performed stability analyses to check the stability (i. e. factorial invariance) of factor solutions. Based on confirmed stability of the general factor (gfactor) solution and the calculations rule obtained in the previous validation of CAS-alcohol (CAS-A), the factor structures of CAS-A, CAS-S and CAS-CS were compared.

RESULTS

The gfactor solutions based on calculations rule shows good stability, with the mean stability coefficients of 0.990 and 0.977 for CAS-S and CAS-CS respectively. The gfactor patterns were similar for CAS-A, CAS-S and CAS-CS, as well as across samples (Germany, China and the UK), with most factor-loadings larger than 0.7. Based on these findings, CAS-S and CAS-CS were also associated with established clinical measures of SUD.

CONCLUSIONS

Our findings suggest the two-gfactor solution based on a proposed calculation rule has a high stability across substances and cultures. This could be in line with common neurobiological mechanisms underlying habitual substance use. Moreover, comparing CAS with established clinical tools suggests that CAS might assess the automated behavior in substance consumption in a more sophisticated way.

Repeated exposure to sevoflurane in neonatal rats impairs cognition in adulthood via the PKA-CREB-BDNF signaling pathway

Sevoflurane (Sev) anesthesia is widely used in pediatrics due to its low blood-gas partition coefficient and lack of pungency. However, Sev treatment may lead to cognitive dysfunction in later life. The current study administered Sev to neonatal rats to investigate the effects of Sev treatment on cognitive performance in adulthood. In total, 6-day-old rats received 3% Sev for 2 h daily for 3 consecutive days. The cognitive function of rats in adulthood was evaluated in 56-day-old rats by Morris water maze test. The hippocampal neuron morphology was observed by Nissl staining. Hippocampal brain-derived neurotrophic factor (BDNF) levels were measured by ELISA. The protein expression of protein kinase A (PKA), cAMP response element binding protein (CREB), phosphorylated-CREB (p-CREB) and BDNF in hippocampus were assessed by western blotting. The water maze results demonstrated that neonatal treatment with Sev resulted in a significant impairment of cognition in 56-day-old adult rats. Behavioral analysis revealed that Sev treatment increased latency to first pass the platform and decreased residence in target quadrants and across platform frequency compared with the control group in Morris water maze tests. Furthermore, compared with the control group, neonatal exposure to Sev reduced the number of neurons and the concentration of BDNF in the hippocampus, a brain region important for learning and memory. Additionally, Sev significantly decreased the expression of PKA, p-CREB, BDNF and the p-CREB/CREB ratio. Treatment with bucladesine, a selective PKA agonist, partially reversed the deleterious effects of Sev. In summary, the results indicated that PKA-CREB-BDNF signaling served an important role in the cognitive decline caused by neonatal exposure to Sev.

Clinical study of 3D printed personalized prosthesis in the treatment of bone defect after pelvic tumor resection

Background

/Objective: In recent years, prostheses have been widely used for limb reconstruction after pelvic tumour resection. However, prostheses are associated with problems leading to tumour recurrence, poor implant matching, defects after tumour resection, and easy implant looseness or failure. To achieve a precise preoperative design, complete tumour resection, and better anatomical structure matching and prosthesis stability, this study used three-dimensionally (3D)-printed osteotomy guides and personalised prostheses for reconstruction after pelvic tumour resection. This study aimed to explore the early clinical efficacy of 3D printed personalised prostheses for the reconstruction of bone defects after pelvic tumour resection.

Methods

A total of 20 patients (12 males, 8 females) with pelvic tumours surgically treated at our hospital between October 2014 and October 2019 were selected. There were 10 cases each of giant cell bone tumours and osteochondrosarcomas. According to Enneking zoning, there were 11 and 9 cases with tumours located in zones I and II, respectively. All cases were equally divided into conventional and 3D printing groups. For repair and reconstruction, a nail rod system or a steel plate was used in the conventional group while individualised 3D-printed prostheses were used in the 3D printing group. The surgical incision, duration of surgery, intraoperative blood loss, and the negative rate of resection margins in postoperative tumour specimens were examined. The follow-up focused on tumour recurrence, complications, and the Musculoskeletal Tumor Society (MSTS) score.

Results

All cases were followed-up for 6-24 months. The average incision length, duration of surgery, amount of intraoperative blood loss, and MSTS score of the 3D printing group were 10.0 ± 3.1 cm, 115.2 ± 25.3 min, 213.2 ± 104.6 mL, 23.8 ± 1.3, respectively, and those of the conventional group were 19.8 ± 8.4 cm, 156.8 ± 61.4 min, 361.4 ± 164.2 mL, and 18.3 ± 1.4, respectively. Histological tumour specimen examination showed nine and three cases with negative resection margins in the 3D printing group and the conventional group, respectively. The abovementioned indicators were significantly different between both groups (P < 0.05).

Conclusion

Applying 3D printed surgical guides and personalised prostheses for pelvic tumour resection, repair, and reconstruction, as well as preoperative planning and design, enables more accurate tumour resections and better prosthesis-patient matchings, possibly reducing surgical trauma, shortening the duration of surgery, and promoting the functional recovery of patients postoperatively.

The Translation Potential of this Article

Contrary to existing studies on 3D printed personalised prostheses, this study reports the clinical efficacy of the aforementioned technology in treating bone defects in a series of patients who underwent pelvic tumour resection. Moreover, it presents a comprehensive comparison of this technology with conventional procedures, thus strengthening its importance in treatment regimens for reconstructing bone defects.

Cannabis and orofacial pain: a systematic review

The naturally occurring cannabis plant has played an established role in pain management throughout recorded history. However, in recent years, both natural and synthetic cannabis-based products for medicinal use (CBPM) have gained increasing worldwide attention due to growing evidence supporting their use in alleviating chronic inflammatory and neuropathic pain associated with an array of conditions. In view of these products' growing popularity in both the medical and commercial fields, we carried out a systematic review to ascertain the effects of cannabis and its synthetically derived products on orofacial pain and inflammation. The application of topical dermal cannabidiol formulation has shown positive findings such as reducing pain and improving muscle function in patients suffering from myofascial pain. Conversely, two orally-administered synthetic cannabinoid receptor agonists (AZD1940 and GW842166) failed to demonstrate significant analgesic effects following surgical third molar removal. There is a paucity of literature pertaining to the effects of cannabis-based products in the orofacial region; however, there is a wealth of high-quality evidence supporting their use for treating chronic nociceptive and neuropathic pain conditions in other areas. Further research is warranted to explore and substantiate the therapeutic role of CBPMs in the context of orofacial pain and inflammation. As evidence supporting their use expands, healthcare professionals should pay close attention to outcomes and changes to legislation that may impact and potentially benefit their patients.

Mini-Open Lateral Corpectomy for Thoracolumbar Junction Lesions

BACKGROUND

Neoplastic, traumatic, infectious, and degenerative pathologies affecting the thoracolumbar junction pose a unique challenge to spine surgeons. Posterior or anterior approaches have traditionally been utilized to treat these lesions. Although minimally invasive surgeries through a lateral approach to the thoracic or lumbar spine have gained popularity, lateral access to the thoracolumbar junction remains technically challenging due to the overlying diaphragm positioned at the interface of the peritoneum and pleura.

OBJECTIVE

To describe a mini-open lateral retropleural retroperitoneal approach for pathologies with spinal cord/cauda equina compression at the thoracolumbar junction.

METHODS

A mini-open lateral corpectomy is described in detail in a patient with an L1 metastatic tumor.

RESULTS

Satisfactory decompression and spinal column reconstruction were achieved. The patient obtained neural function recovery following the procedure with no intra- or postoperative complications.

CONCLUSION

The morbidities associated with traditional posterior or anterior approaches to thoracolumbar junction pathologies have led to a growing interest in minimally invasive alternatives. The mini-open lateral approach allows for a safe and efficacious corpectomy and reconstruction for thoracolumbar junction pathologies. Thorough understanding of the anatomy, particularly of the diaphragm, is critical. This approach will have expanded roles in the management of patients with thoracolumbar neoplasms, fractures, infections, deformities, or degenerative diseases.

O-arm navigation for sacroiliac screw placement in the treatment for posterior pelvic ring injury

PURPOSE

This study aims to investigate the application value of O-arm navigation system in sacroiliac screw placement for the treatment of unstable pelvic ring injury.

METHODS

A total of 40 patients (mean age = 30.75 ± 14.99 years, 25 males, 15 females) were included. From January 2016 to July 2018, 40 patients with posterior pelvic ring injury treated in our hospital were included. Of them, 19 patients underwent O-arm navigation for screw placement (O-arm group) while the other 21 received C-arm fluoroscopy guidance (C-arm group) for sacroiliac screw placement. Intraoperative outcomes and the outcome of screw placement were compared between groups. The quality of radiological images was assessed by Matta's radiological outcome grade. The outcome of complex pelvic fracture treatment was evaluated by Majeed Functional score.

RESULTS

All demographic and clinical characteristics were comparable between the two groups. Compared with the C-arm groups, the O-arm group had a shorter surgery time (33.19 ± 3.14 vs. 48.35 ± 4.38 min, P < 0.001), a higher overall good outcome "excellent + good" rate of screw placement (95.45% vs. 73.91%, P < 0.05), and a significantly higher Majeed Functional score better outcome of complex pelvic fracture treatment at 1 and 3 months postoperation (both P < 0.05).

CONCLUSION

Our results demonstrated that O-arm navigation system is feasible and safe for the treatment of posterior pelvic ring injury and can effectively improve the accuracy and safety of sacroiliac screw placement, shorten the operation time, and help rapid postoperative functional recovery.

Application of computed tomography angiography-assisted classification of arterial branches in the first web space of the foot for thumb reconstruction

BACKGROUND

Computed tomography angiography (CTA) has become a widely used imaging modality in vascular surgery. The first web arterial branches of the foot are significant for surgical planning of the donor site for thumb reconstruction.

METHODS

We retrospectively analysed 30 thumb reconstructions with free second toe/great toe wrap-around flap transfer, performed between January 2016 and January 2019. The mean patient age was 30 (2-45) years. The causes of hand injury were: 20 machine strangulation injuries, 6 heavy weight smash injuries, and 4 crush injuries. Patients with iodine allergy were excluded preoperatively. We evaluated the effectiveness of CTA in visualizing first web arterial branches and compared it with intraoperative findings. Surgical plan for donor sites was prepared based on the classification of the first web arterial branches.

RESULTS

The arterial branches of the patients were classified based on CTA findings as follows: (1) fork type: 24 patients (48 feet, 80%); (2) main trunk type: four patients (8 feet, 13.33%); and (3) side branch type: one patient (2 feet, 3.33%). One case of poor vascular continuity and artifacts in CTA underwent thumb reconstruction with free great toe wrap-around flap transfer. Tissue survival was achieved in all reconstructed thumbs. During the follow-up period (average, 12 months), all reconstructed thumbs exhibited good outcomes. The donor sites on the feet of all patients recovered well.

CONCLUSION

CTA allows preoperative assessment of blood supply and planning of donor site. Our results can serve as a reference for surgical planning of the donor site while reducing the occurrence of adverse events.

Letter to the Editor: COVID-19 and Persons with Dementia in Acute Care Settings: How to "EVADE" Challenging Behaviors

The double whammy of dementia and coronavirus disease 2019 (COVID-19) has raised huge concerns for healthcare systems which are already struggling to cope with care demands of persons with dementia (PWD) in non-pandemic times (1). PWD who are admitted to acute care services are particularly vulnerable to behavioural changes and adverse outcomes from delirium (2, 3). During the COVID-19 period, ward relocation is frequently encountered due to COVID-19 screening and segregation; this constant changing of environment and care teams puts PWD at risk of behavioural exacerbations. This is aggravated by restrictive visitor policies in hospitals, depriving PWD of the reassuring presence of family members. Not surprisingly, caring for persons with dementia (PWD) with behavioral issues in acute care settings has become extremely challenging.

MiRNA-300 suppresses proliferation, migration and invasion of non-small cell lung cancer via targeting ETS1

OBJECTIVE

To elucidate the biological function of microRNA-300 (miRNA-300) in influencing the progression of non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

The relative level of miRNA-300 in NSCLC tissues and cells was determined by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). The influences of miRNA-300 on the proliferative, migratory, and invasive potentials of A549 cells were assessed. The binding relationship between miRNA-300 and ETS1 was verified by the Dual-Luciferase Reporter Gene Assay. Finally, the regulatory effect of the interactive miRNA-300 and ETS1 on the progression of NSCLC was identified.

RESULTS

MiRNA-300 was downregulated in NSCLC tissues and cells. The overexpression of miRNA-300 suppressed A549 cells to proliferate, migrate, and invade. MiRNA-300 could bind to ETS1 3'UTR and suppress its level in A549 cells. Notably, the knockdown of miRNA-300 could reverse the regulatory role of ETS1 in the cellular behaviors of NSCLC.

CONCLUSIONS

MiRNA-300 suppresses NSCLC to proliferate, migrate, and invade by targeting ETS1.

Kinetics of viral load and antibody response in relation to COVID-19 severity

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent for coronavirus 2019 (COVID-19) pneumonia. Little is known about the kinetics, tissue distribution, cross-reactivity, and neutralization antibody response in patients with COVID-19. Two groups of patients with RT-PCR-confirmed COVID-19 were enrolled in this study: 12 severely ill patients in intensive care units who needed mechanical ventilation and 11 mildly ill patients in isolation wards. Serial clinical samples were collected for laboratory detection. Results showed that most of the severely ill patients had viral shedding in a variety of tissues for 20-40 days after onset of disease (8/12, 66.7%), while the majority of mildly ill patients had viral shedding restricted to the respiratory tract and had no detectable virus RNA 10 days after onset (9/11, 81.8%). Mildly ill patients showed significantly lower IgM response compared with that of the severe group. IgG responses were detected in most patients in both the severe and mild groups at 9 days after onset, and remained at a high level throughout the study. Antibodies cross-reactive to SARS-CoV and SARS-CoV-2 were detected in patients with COVID-19 but not in patients with MERS. High levels of neutralizing antibodies were induced after about 10 days after onset in both severely and mildly ill patients which were higher in the severe group. SARS-CoV-2 pseudotype neutralization test and focus reduction neutralization test with authentic virus showed consistent results. Sera from patients with COVID-19 inhibited SARS-CoV-2 entry. Sera from convalescent patients with SARS or Middle East respiratory syndrome (MERS) did not. Anti-SARS-CoV-2 S and N IgG levels exhibited a moderate correlation with neutralization titers in patients' plasma. This study improves our understanding of immune response in humans after SARS-CoV-2 infection.

Local field potential activity dynamics in response to deep brain stimulation of the subthalamic nucleus in Parkinson's disease

Local field potentials (LFPs) may afford insight into the mechanisms of action of deep brain stimulation (DBS) and potential feedback signals for adaptive DBS. In Parkinson's disease (PD) DBS of the subthalamic nucleus (STN) suppresses spontaneous activity in the beta band and drives evoked resonant neural activity (ERNA). Here, we investigate how STN LFP activities change over time following the onset and offset of DBS. To this end we recorded LFPs from the STN in 14 PD patients during long (mean: 181.2 s) and short (14.2 s) blocks of continuous stimulation at 130 Hz. LFP activities were evaluated in the temporal and spectral domains. During long stimulation blocks, the frequency and amplitude of the ERNA decreased before reaching a steady state after ~70 s. Maximal ERNA amplitudes diminished over repeated stimulation blocks. Upon DBS cessation, the ERNA was revealed as an under-damped oscillation, and was more marked and lasted longer after short duration stimulation blocks. In contrast, activity in the beta band suppressed within 0.5 s of continuous DBS onset and drifted less over time. Spontaneous activity was also suppressed in the low gamma band, suggesting that the effects of high frequency stimulation on spontaneous oscillations may not be selective for pathological beta activity. High frequency oscillations were present in only six STN recordings before stimulation onset and their frequency was depressed by stimulation. The different dynamics of the ERNA and beta activity with stimulation imply different DBS mechanisms and may impact how these activities may be used in adaptive feedback.

FRI0022 THE ANALYSIS OF THE INVOLVEMENT OF TRANSFORMING-GROWTH INTERACTING FACTOR POLYMORPHISMS IN THE BONE METABOLISM OF RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is an autoimmune disease that mainly invades synovial membranes and further damage to articular cartilage and bone. The abnormal activation of transforming-growth factor β (TGF-β) in the subchondral bone is related to the onset of RA joint cartilage degeneration and transforming-growth interacting factor (TGIF) is a negative regulator of TGF-β signaling, while there is no literature addressing the relationship between TGIF polymorphisms and the bone metabolism of RA.

Objectives:

The aim of the study was to comprehensively explore the possible association for single nucleotide polymorphisms (SNPs) in the TGIF gene with serum bone metabolism markers and RA susceptibility.

Methods:

Three SNPs within the TGIF gene were genotyped in 155 RA patients and 168 healthy controls by high resolution melting (HRM) analysis in a case-control study. The serum levels of osteocalcin, bone alkaline phosphatase (BALP) and β type I collagen-crosslinked C telopeptide (β-CTX) were detected by electrochemical luminescence in 108 RA patients randomly selected from RA patients group.

Results:

Genotypes and alleles frequency analysis showed rs7362020 was associated with bone erosion in RA (P=0.012, P=0.003, respectively) and individuals carrying T allele for rs7362020 showed a decreased RA risk (OR=0.59, 95% CI = 0.42-0.84; P= 0.003). In the gender-specific analysis, rs73620203 polymorphism was associated with bone erosion of female RA patients (P values of the distribution of genotypes and alleles were 0.022 and 0.006, respectively). In addition, RA patients with CC, CT and TT genotypes at rs73620203 locus had statistically significant differences in serum osteocalcin and BALP (P=0.006, P=0.037, respectively) and the serum levels in TT genotype RA patients were significantly lower than CC and CT genotype RA patients. The serum levels of β-CTX in rs85440 AA genotype male RA patients were significantly higher than female RA patients (P=0.001), while the serum levels of osteocalcin and BALP in genotype AA, AG and GG female and male RA patients were not significantly different (P all>0.05).

Conclusion:

Our study provided the first evidence that rs73620203 is associated with bone erosion of RA and provided new insight into the relationship between three SNPs within TGIF gene and regulation of bone metabolism in RA patients of different genders.

Acknowledgments:

This work was supported by the National Natural Science Foundation of China (Nos. 81772258) and Science and Technology Agency of Sichuan Province (Nos. 2019YFS0310, 2018FZ0106).

Disclosure of Interests:

None declared

[HIV/AIDS related frailty syndrome in the elderly and related research progress]

Frailty syndrome, caused by degenerative changes in the body and the body vulnerability due to a variety of chronic diseases, is associated with adverse outcomes, such as fall, disability and mortality. With the development of antiretroviral therapy, the average life span of HIV/AIDS patients is extended, the number of elderly living with HIV/AIDS has increased, resulting the increase of the incidence of frailty syndrome in this population. The incidence of frailty syndrome in the elderly is associated with HIV infection and adverse reaction of antiretroviral therapy. Early assessment and intervention of frailty syndrome in elderly HIV/AIDS patients can reduce adverse clinical events and improve the quality of life.

Effect of altered proximal femoral geometry on predicting femoral stem anteversion in patients with developmental dysplasia of the hip

Background

The deformity of the proximal femur and acetabular in patients with developmental dysplasia of the hip (DDH) renders an intraoperative decision for ideal component placement challenging. We hypothesized that the altered morphology of calcar femorale (CF) in DDH patients changed the fixation mechanism of the cementless metaphyseal-filling stem and aimed to predict stem anteversion using proximal femoral anatomical parameters from preoperative CT.

Methods

Preoperative and postoperative CT scans of 34 DDHs with a metaphyseal-filling stem in THA were retrospectively analyzed. Proximal femoral anatomical parameters, including the femoral anteversion (FA) and the CF angles at the low femoral neck (LFN) and the center of the lesser trochanter (CLT) levels (FA-LFN, FA-CLT, CF-LFN, and CF-CLT) were measured. The dysplastic hips were divided into the CF group (n = 21) and the non-CF group (n = 13) according to the presence of the CF-LFN. The association between the anatomical parameters and the postoperative stem anteversion was statistically analyzed, and the predicted stem anteversion was compared with postoperative stem anteversion.

Results

In the CF group, the combination of the CF-LFN and FA-CLT exhibited a strong positive correlation (R = 0.870, p < 0.001) with the postoperative stem anteversion. In the non-CF group, only the FA-LFN had a strong positive correlation (R = 0.864, p < 0.001). Average prediction errors were 5.9° and 6.4° in the CF and non-CF groups.

Conclusions

The presence of CF-LFN is related to the press-fit mechanism of the metaphyseal-filling stem, and the preoperative measurements from CT images can be employed as a tool to predict postoperative stem anteversion in DDH patients.

[Application of pegylated recombinant human granulocyte colony-stimulating factor to prevent chemotherapy-induced neutropenia in patients with lymphoma: a prospective, multicenter, open-label clinical trial]

目的

评价聚乙二醇化重组人粒细胞刺激因子（PEG-rhG-CSF）预防淋巴瘤患者化疗后发生中性粒细胞减少症的有效性和安全性。

方法

本研究为多中心、开放、单臂、Ⅳ期临床试验。纳入410例淋巴瘤患者接受多周期化疗并预防性使用PEG-rhG-CSF。主要观察患者各化疗周期Ⅲ/Ⅳ度中性粒细胞减少症和发热性中性粒细胞减少（FN）的发生率，同时观察患者整个化疗期间抗生素的使用率。

结果

①410例患者中，违背入选标准8例（1.95%），失访35例（8.54%），发生不良事件19例（4.63%），出现符合终止研究标准者12例（2.93%），疾病进展或复发15例（3.66%），故最终321例（78.29%）进入符合方案集。②在第1~4个治疗周期，初级预防给予PEG-rhG-CSF后，Ⅳ度中性粒细胞减少症的发生率分别为19.14%（49/256）、12.50%（32/256）、12.18%（24/197）、13.61%（20/147），FN的发生率分别为3.52%（9/256）、0.39%（1/256）、2.54%（5/197）、2.04%（3/147）；次级预防给药后，Ⅳ度中性粒细胞减少症的发生率从61.54%（40/65）降至16.92%（11/65）、18.46%（12/65）、20.75%（11/53），FN的发生率从16.92%（11/65）降至1.54%（1/65）、4.62%（3/65）、3.77%（2/53）。③整个化疗期间接受抗生素治疗的受试者比例为34.39%（141/410）。④与PEG-rhG-CSF相关的不良事件发生率为4.63%（19/410），最常见的不良反应为骨痛[3.90%（16/410）]、乏力（0.49%）和发热（0.24%）。

结论

在淋巴瘤患者化疗过程中，预防性使用PEG-rhG-CSF能够有效降低化疗过程中Ⅲ/Ⅳ度中性粒细胞减少症和FN的发生率，确保淋巴瘤患者接受标准剂量化疗，提高治愈率。

[HSP90 inhibitor 17-AAG plays an important role in JAK3/STAT5 signaling pathways in HTLV-1 infection cell line HUT-102]

Objective: To analyze whether heat-shock protein 90 (HSP90) be involved in a permanently abnormal activated JAK/STAT signaling in ATL cells in vitro. Methods: The effect of 17-AAG on proliferation of ATL cell lines HUT-102 was assessed using CCK8 at different time points. Cell apoptosis was measured by flow cytometry. The specific proteins HSP90, STAT5, p-STAT5 and JAK3 were detected by Western blotting. Results: Overexpression of HSP90 in HUT-102 cell lines was disclosed (P<0.05) , and constitutive activation of JAK3/STAT5 signaling was observed in HTLV-1-infected T-cell lines but not in normal PBMCs; Treatment of ATL cell lines with 17-AAG led to reduced cell proliferation, but there was no significant change in terms of cell proliferation when the concentration of 17-AAG between 2 000-8 000 nmol/L (P>0.05) . 17-AAG induced cell apoptosis in different time-points and concentrations. 17-AAG don't affect the expression of JAK3 gene. Conclusion: This study indicated that JAK3 as HSP90 client protein was aberrantly activated in HTLV-1-infected T-cell lines, leading to constitutive activation of p-STAT5 in JAK/STAT signal pathway, which demonstrated that HSP90-inhibitors 17-AAG inhibited the growth of HTLV-1-infected T-cell lines by reducing cell proliferation and inducing cell apoptosis.

Effect of computer navigation-assisted minimally invasive direct lateral interbody fusion in the treatment of patients with lumbar tuberculosis: A retrospective study

The benefits of navigation-assisted technologies are not entirely understood. Therefore, this study aimed to examine the outcomes of patients with lumbar tuberculosis who received computer navigation-assisted minimally invasive direct lateral interbody fusion (DLIF).This was a retrospective study of 33 patients with lumbar tuberculosis who underwent minimally invasive DLIF at the Department of Spine and Orthopedics of Guigang People's Hospital (Guangxi, China) between January 2015 and December 2016. The patients were pathologically diagnosed as lumbar tuberculosis and grouped into the navigation-assisted fluoroscopy (NAV; n = 18) and non-navigation-assisted fluoroscopy (non-NAV; n = 15) groups. X-ray exposure and operation times were assessed in all patients.All surgical procedures were successfully completed. No case was converted into open surgery. The NAV group had longer surgical preparation time but shorter operation time compared with the non-NAV group (both P <.01). Total operation time showed no significant difference between the 2 groups (P = .1). The time of radiation exposure in the non-NAV group was longer compared with that of the NAV group (53.2 ± 9.9 vs 13.5 ± 2.6 s; P <.01). There were no significant differences regarding intraoperative blood loss, postoperative drainage volume, length of hospital stay, bone fusion and complications between the 2 groups (all P >.05).Computer navigation-assisted minimally invasive DLIF could significantly reduce intraoperative radiation exposure, with no increase in total operation time.