An independent agreement study of modified Pfirrmann grading system for cervical inter-vertebral disc degeneration in cervical spondylotic myelopathy

OBJECTIVE

Neck pain, sensory disturbance and motor dysfunction in most patients suffered cervical spondylotic myelopathy (CSM). For CSM surgery, it is necessary to evaluate preoperative inter-vertebral disc degeneration (IDD) which determines whether to adopt fusion strategy, and postoperative IDD which is one of the main reasons for reoperation. Modified Pfirrmann grading system is commonly used to evaluate IDD. The objective of this study is to evaluate its reliability and reproducibility on cervical IDD in CSM patients, and to explore its clinical application value.

METHODS

All 165 patients with CSM were enrolled. 6 physicians (3 spine surgeons and 3 radiologists) who have certain clinical experience were selected. They graded cervical inter-vertebral disc according to modified Pfirrmann grading system, we used intra-class correlation coefficient (ICC) and weighted kappa (wκ) to assess the inter- and intra-observer agreement. After 12 weeks, we repeated the analysis.

RESULTS

The inter-observer reliability of modified Pfirrmann grading system was excellent with an ICC value of 0.76 and near perfect with wκ value of 0.82. The intra-observer reproducibility of modified Pfirrmann grading system was excellent with ICC values ranging from 0.80 to 0.91, and near perfect with wκ values ranging from 0.83-0.92.

CONCLUSION

Modified Pfirrmann grading system has excellent inter-observer reliability and intra-observer reproducibility on cervical IDD in CSM. In addition, it indicates a good appliance among spine surgeons and radiologists, clinical and radiological studies applying it should be deemed accurate. Thus, modified Pfirrmann grading system can be widely used as an appropriate instrument in clinical care.

A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis

PURPOSE

As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster.

METHODS

We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline's quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale.

RESULTS

Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as "recommended," and three guidelines were evaluated as "recommended with modifications." Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn't recommend iliac bone graft and three guidelines recommended PMMA bone cement.

CONCLUSION

Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.

[Clinical guidelines for diagnosis and treatment of cervical spondylotic myelopathy with the integrated traditional Chinese and Western medicine(2023)]

The "Clinical Guidelines for Diagnosis and Treatment of Cervical Spondylotic Myelopathy with the Integrated Traditional Chinese and Western Medicine" were formulated by the Orthopedic and Traumatology Professional Committee of the Chinese Association of Integrative Medicine in accordance with the principles of evidence-based medicine and expert consensus, and provide clinicians with academic guidance on clinical diagnosis and treatment of CSM. The main content includes diagnostic points, disease grading assessment, TCM syndrome differentiation, surgical indications and timing, integrated traditional Chinese and Western medicine treatment, and postoperative rehabilitation. This guideline proposes for the first time that the treatment of CSM should follow the principle of grading, clarify the timing and methods of surgical treatment, establish common TCM syndrome differentiation and classification, attach importance to postoperative integrated rehabilitation of Chinese and Western medicine, and strengthen daily follow-up management. It hopes to promote the standardization, effectiveness, and safety of clinical treatment of CSM.

MicroRNA-206 Contributes to the Progression of Preeclampsia by Suppressing the Viability and Mobility of Trophocytes via the Inhibition of AGTR1

The development of preeclampsia (PE) is associated with the impaired trophoblast motility. MicroRNAs (miRs) contribute to the modulation of trophoblast invasion. In the current study, the role of miR-206/AGTR1 in the TNF-alpha-induced invasion defect of trophoblasts was explored. The levels of miR-206 and ATGR1 in clinical placenta tissues were investigated. Trophoblasts were treated with TNF-alpha, and the levels of miR-206 and ATGR1 were modulated. Changes in cell viability, invasion, and inflammation in trophoblasts were detected. The level of miR-206 was induced, while the level of AGTR1 was suppressed in placenta tissues. In in vitro assays, TNF-alpha suppressed viability, induced inflammatory response, inhibited invasion, upregulated miR-206, and down-regulated AGTR1. The inhibited expression of miR-206 or the overexpression of AGTR1 counteracted the effects of TNF-alpha, indicating the key role of the miR-206/AGTR1 in progression of PE. Collectively, miR-206 suppressed viability, induced inflammatory response, and decreased invasion of trophoblasts by inhibiting AGTR1.

A systematic review and meta-analysis of chondroitinase ABC promotes functional recovery in rat models of spinal cord injury

BACKGROUND

To comprehensively assess the neurologic recovery potential of chondroitinase ABC (ChABC) in rats after spinal cord injury (SCI).

METHODS

The PubMed, Embase, ScienceDirect, Web of Science, and China National Knowledge Infrastructure databases were searched for animal experiments that evaluated the use of ChABC in the treatment of SCI up to November 2022. Studies reporting neurological function using the Basso, Beattie, and Bresnahan (BBB) scale, as well as assessments of cavity area, lesion area, and glial fibrillary acidic protein (GFAP) levels, were included in the analysis.

RESULTS

A total of 46 studies were ultimately selected for inclusion. The results of the study showed that rats with SCI that received ChABC therapy exhibited a significant improvement in locomotor function after 7 days compared with controls (32 studies, weighted mean difference (WMD) = 0.58, [0.33, 0.83], p < 0.00001). Furthermore, the benefits of ChABC therapy were maintained for up to 28 days according to BBB scale. The lesion area was reduced by ChABC (5 studies, WMD = -20.94, [-28.42, -13.46], p < 0.00001). Meanwhile, GFAP levels were reduced in the ChABC treatment group (8 studies, WMD = -29.15, [-41.57, -16.72], p < 0.00001). Cavity area is not statistically significant. The subgroup analysis recommended that a single injection of 10 μL (8 studies, WMD = 2.82, [1.99, 3.65], p < 0.00001) or 20 U/mL (4 studies, WMD = 2.21, [0.73, 3.70], p = 0.003) had a better effect on improving the function. The funnel plot of the BBB scale was found to be essentially symmetrical, indicating a low risk of publication bias.

CONCLUSIONS

This systematic review and meta-analysis has indicated that ChABC could improve functional recovery in rats after SCI.

Comparison of Cervical Sagittal Parameters Between Radiographs and Magnetic Resonance Images in Patients With Cervical Spondylotic Myelopathy

STUDY DESIGN

Observational study.

OBJECTIVE

As an important consideration of surgery, cervical sagittal balance is believed to be better assessed using standing radiograph than supine magnetic resonance imaging (MRI). However, few studies have researched this. Our study aimed to observe the correlations and differences in cervical sagittal parameters between radiograph and MRI in patients with cervical spondylotic myelopathy (CSM), and evaluate whether the change of position affects them.

METHODS

We analyzed 84 patients, measuring Cobb angle (CA), T1 slope (T1S), neck tilt (NT), and thoracic inlet angle (TIA). Inter- and intra-parameter analyses were performed to identify any difference between standing radiograph and supine MRI. Statistical correlations and differences between the parameters were compared.

RESULTS

There were excellent inter-observer agreement for each parameter (interclass correlation coefficient >.75), and significant differences were observed in each parameter between radiograph and magnetic resonance imaging (P < .05). Strong correlations were noted between the same parameters in radiograph and MRI. Cobb angle, T1S, and neck tilt were significantly correlated with thoracic inlet angle on both radiograph and MRI, and CA was significantly correlated with T1S on both radiograph and MRI (r: -1.0 to -.5 or .5 to 1.0).

CONCLUSION

Supine MRI obviously underestimated the value of CA, T1S, and TIA. Therefore, standing cervical radiographs should be obtained in CSM patients to assess and determine surgical strategy, not only supine MRI. Moreover, we observed that NT and TIA were not constant morphological parameters.

Traditional Chinese medicine for frozen shoulder: An evidence-based guideline

BACKGROUND

Frozen shoulder is a common disorder that can lead to long-lasting impairment in shoulder-related daily activities. Traditional Chinese medicine (TCM) has played an important role in the effort to manage frozen shoulder.

PURPOSE

We aimed to develop an evidence-based guideline for treating frozen shoulder with traditional Chinese medicine.

STUDY DESIGN

Evidence-based guideline.

METHODS

We developed this guideline based on internationally recognized and accepted guideline standards. The guideline development group used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to rate the certainty of evidence and the strength of recommendations. The benefits and harms, resources, accessibility, and other factors were fully taken into account, and the GRADE grid method was used to reach consensus on all recommendations.

RESULTS

We established a multidisciplinary guideline development panel. Based on a systematic literature search and a face-to-face meeting, nine clinical questions were identified. Finally, twelve recommendations were reached by consensus, comprehensively considering the balance of benefits and harms, certainty of evidence, costs, clinical feasibility, accessibility, and clinical acceptability.

CONCLUSION

This guideline panel made twelve recommendations, which covered the use of manual therapy, acupuncture, needle knife, Cheezheng Xiaotong plaster, Gutong plaster, exercise therapy and integrated TCM and Western medicine, such as combined modalities and corticosteroid injections. Most of them were weakly recommended or consensus based. The users of this guideline are most likely to be clinicians and health administrators.

WITHDRAWN: Characteristics, Treatment and Research Development of Bertolotti's Syndrome: A Bibliometric Analysis and Systematic Review

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.

Olfactory Threshold Test as a Quick Screening Tool for Cognitive Impairment: Analysis of Two Independent Cohorts

BACKGROUND

Olfactory dysfunction appears prior to cognitive decline, and thus it has been suggested to be an early predictor of Alzheimer's disease. However, it is currently not known whether and how olfactory threshold test could serve as a quick screening tool for cognitive impairment.

OBJECTIVE

To define olfactory threshold test for screening cognitive impairment in two independent cohorts.

METHODS

The participants are comprised of two cohorts in China, 1,139 inpatients with type 2 diabetes mellitus (T2DM, Discovery cohort) and 1,236 community-dwelling elderly (Validation cohort). Olfactory and cognitive functions were evaluated by Connecticut Chemosensory Clinical Research Center test and Mini-Mental State Examination (MMSE), respectively. Regression analyses and receiver operating characteristic (ROC) analyses were carried out to determine the relation and discriminative performance of the olfactory threshold score (OTS) regarding identification of cognition impairment.

RESULTS

Regression analysis showed that olfactory deficit (reducing OTS) was correlated with cognitive impairment (reducing MMSE score) in two cohorts. ROC analysis revealed that the OTS could distinguish cognitive impairment from cognitively normal individuals, with mean area under the curve values of 0.71 (0.67, 0.74) and 0.63 (0.60, 0.66), respectively, but it failed to discriminate dementia from mild cognitive impairment. The cut-off point of 3 showed the highest validity for the screening, with the diagnostic accuracy of 73.3% and 69.5%.

CONCLUSION

Reducing OTS is associated with cognitive impairment in T2DM patients and the community-dwelling elderly. Therefore, olfactory threshold test may be used as a readily accessible screening tool for cognitive impairment.

Construction and validation of a novel web-based nomogram for patients with lung cancer with bone metastasis: A real-world analysis based on the SEER database

Purpose

Patients with lung cancer with bone metastasis (LCBM) often have a very poor prognosis. The purpose of this study is to characterize the prevalence and associated factors and to develop a prognostic nomogram to predict the overall survival (OS) and cancer-specific survival (CSS) for patients with LCBM using multicenter population-based data.

Methods

Patients with LCBM at the time of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER) Program database of the National Cancer Institute (NCI) from 2010 to 2015. Multivariable and univariate logistic regression analyses were performed to identify factors associated with all-cause mortality and lung cancer (LC)-specific mortality. The performance of the nomograms was evaluated with the calibration curves, area under the curve (AUC), and decision curve analysis (DCA). Kaplan-Meier analysis and log-rank tests were used to estimate the survival times of patients with LCBM.

Results

We finally identified 26,367 patients with LCBM who were selected for survival analysis. Multivariate analysis demonstrated age, sex, T stage, N stage, grade, histology, radiation therapy, chemotherapy, primary site, primary surgery, liver metastasis, and brain metastasis as independent predictors for LCBM. The AUC values of the nomogram for the OS prediction were 0.755, 0.746, and 0.775 in the training cohort; 0.757, 0.763, and 0.765 in the internal validation cohort; and 0.769, 0.781, and 0.867 in the external validation cohort. For CSS, the values were 0.753, 0.753, and 0.757 in the training cohort; 0.753, 0.753, and 0.757 in the internal validation cohort; and 0.767, 0.774, and 0.872 in the external validation cohort.

Conclusions

Our study constructs a new prognostic model and clearly presents the clinicopathological features and survival analysis of patients with LCBM. The result indicated that the nomograms had favorable discrimination, good consistency, and clinical benefits in patients. In addition, our constructed nomogram prediction models may assist physicians in evaluating individualized prognosis and deciding on treatment for patients.

Cross-cultural adaptation and validation of simplified Chinese version of the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ) 2.0 with its assessment in clinical setting

BACKGROUND CONTEXT

The treatment of spinal metastases (SM) has been significantly improved in recent years, which gives health-related quality of life (HRQOL) further significance in management of SM. The Spine Oncology Study Group Outcomes Questionnaire version 2.0 (SOSGOQ 2.0) was a specific targeted SM HRQOL criterion that was previously reported to pose good reliability and validity. However, there is no culturally adapted, reliable, and validated version of SOSGOQ 2.0 in mainland China.

PURPOSE

The current study aimed to translate the SOSGOQ 2.0 in a cross-cultural fashion, before evaluating the reliability and validity of the adapted simplified Chinese version of (SC-SOSGOQ 2.0) for patients with spinal metastases (SM).

STUDY DESIGN/SETTING

Translation, cross-cultural adaptation, and validation were performed on the Chinese version of the SOSGOQ 2.0.

PATIENT SAMPLE

Patients who were diagnosed with metastatic spinal disease, posing at least 6-years experience of education and the ability to read and speak Chinese.

OUTCOME MEASURES

Reliability and Validity of the SC-SOSGOQ 2.0 were measured to assess HRQOL in patients with SM.

METHODS

The cross-cultural adaptation of the SOSGOQ 2.0 was conducted following international guidelines. The reliability and validity of the SC-SOSGOQ 2.0 was assessed in a multi-center, prospective observational study. The test-retest reliability was assessed by comparing the results of the first and final SC-SOSGOQ 2.0 scales, with 2 weeks apart. The discriminative, concurrent, and construct validity of the cross-culturally adapted questionnaire was individually evaluated. The relationship among the SC-SOSGOQ 2.0, SC-EQ-5D-5L and SC-SF-36 was assessed using the correlation coefficients.

RESULTS

One hundred and twenty patients were included in this study. No floor or ceiling effects were observed for the SC-SOSGOQ 2.0. The Cronbach's α for domains of neurological function, pain, mental health, social function, and post-therapy were 0.825, 0.876, 0.896, 0.897, 0.943, and 0.835, respectively. The value of inter-class correlation coefficient ranged from 0.55 to 0.83, which reflected a satisfactory test-retest reliability. Concurrent assessment of criterion validity demonstrated a moderate-to-strong correlation in all domains of SC-SOSGOQ 2.0 with the SC-EQ-5D-5L (0.34-0.74) and SC-SF-36 (0.33-0.76). The best-correlated domain was physical function (0.741 in the EQ-5D-5L and 0.722 in the SF-36).

CONCLUSIONS

The SC-SOSGOQ 2.0 demonstrated an excellent acceptability, score distribution, internal consistency, test-retest reliability and validity. It was therefore considered as a tool effective for evaluating HRQOL of Chinese patients with SM.

A meta-analysis of resveratrol protects against cerebral ischemia/reperfusion injury: Evidence from rats studies and insight into molecular mechanisms

Objective: To evaluate the neuroprotective effect of resveratrol (RES) in rat models of cerebral ischemia/reperfusion (I/R) injury.

Data sources: PubMed, Embase, MEDLINE, Cochrane Library, and Chinese databases were searched from their inception dates to July 2022. No language restriction was used in the literature search.

Date Selection: Studies were selected that RES were used to treat cerebral I/R injury in vivo. Two reviewers conducted literature screening, data extraction and methodological quality assessment independently.

Outcome measures: Cerebral infarct volume was included as primary outcome. The secondary outcomes included cerebral water content and neurological deficit scores. Malondialdehyde (MDA) and superoxide dismutase (SOD) were used to evaluate oxidative stress during medication.

Results: A total of 41 studies were included, and only a few of them the methodological quality was relatively low. Compared with the control group, RES significantly reduced the cerebral infarct volume (29 studies, standard mean difference (SMD) = −2.88 [−3.23 to −2.53], p < 0.00001) and brain water content (nine studies, MD = −9.49 [−13.58 to −5.40], p < 0.00001) after cerebral I/R injury, then neurological function was improved (15 studies, SMD = −1.96 [−2.26 to −1.65], p < 0.00001). The MDA level (six studies, SMD = −8.97 [−13.60 to −4.34], p = 0.0001) was decreased notably after treatment of RES, while the SOD level (five studies, SMD = 3.13 [−0.16 to 6.43], p = 0.06) was increased unsatisfactory. Consistently, subgroup analysis of cerebral infarct volume suggested that the optimal therapeutic dose is 30 mg/kg (eight studies, SMD = −5.83 [−7.63 to −4.04], p < 0.00001). Meanwhile, 60 min of occlusion (three studies, SMD = −10.89 [−16.35 to −5.42], p < 0.0001) could get maximum benefit from compared with 90 min and 120 min of occlusion. On the other hand, the publication bias cannot be ignored. The pharmacological mechanisms of RES on cerebral I/R injury models as reported have be summarized, which can be used for reference by researchers to further plan their future experiments.

Conclusion: RES might have a good neuroprotective effect on cerebral I/R injury in rats, then 30 mg/kg RES may be the optimal dose for treatment, and early administration of RES should be more neuroprotective. Also it need to be further verified through exploration of dose effect relationship, or delay administration or not.

Safety and Efficacy of Anterior Cervical Discectomy and Fusion with Uncinate Process Resection: A Systematic Review and Meta-Analysis

STUDY DESIGN

This is a meta-analysis and systematic review of the available literature.

OBJECTIVE

In the case of severe foraminal stenosis, conducting uncinate process resection (UPR) during ACDF could achieve complete nerve root decompression and significant relief of neurological symptoms for CR. However, there is some controversy regarding its necessity and safety. This study aims to compare the safety and efficacy of ACDF with UPR and ACDF.

METHODS

The following electronic databases were searched: Medline, PubMed, Embase, the Cochrane Central Register of Controlled Trials, Evidence Based Medicine Reviews, VIP, and CNKI. And the following data items were considered: baseline demographics, efficacy evaluation indicators, radiographic outcome, and surgical details.

RESULTS

10 studies were finally identified, including 746 patients who underwent ACDF with UPR compared to 729 patients who underwent ACDF. The group of ACDF with UPR had statistically longer intraoperative time (95% CI: 4.83, 19.77, P = .001) and more intraoperative blood loss (95% CI: 12.23, 17.76, P < .001). ACDF with UPR obtained a significantly better improvement of Arm VAS at postoperative first follow-up (95% CI: -1.85, -.14 P = .02). There was no significant difference found in improvement of Neck VAS at postoperative latest follow-up (95% CI: -.88, .27, P = .30), improvement of Arm VAS at postoperative latest follow-up (95% CI: -.59, -.01, P = .05), improvement of NDI (95% CI: -2.34, .33, P = .14), JOA (95% CI: -.24, .43, P = .56), change of C2-C7 lordosis (95% CI: -.87, 1.33, P = .68), C2-C7 SVA (95% CI: -.73, 5.08, P = .14), T1 slope (95% CI: -2.25, 1.51, P = .70), and fusion rate (95% CI: .83, 1.90 P = .29).

CONCLUSION

ACDF with UPR is an effective and necessary surgical method for CR patients with severe foraminal stenosis.

A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Study of Jianyao Migu Granules in the Treatment of Osteopenic Low Back Pain

Purpose

This randomized controlled trial aimed to evaluate the clinical efficacy of Jianyao Migu granules (JYMGG) in the treatment of primary osteopenic low back pain (LBP).

Patients and Methods

A total of 108 patients with primary osteopenic LBP were randomly divided into the JYMGG group and placebo group. Both groups took 600 mg of oral Caltrate D daily; in addition, the JYMGG group was given oral JYMGG, while the placebo group was given placebo granules. The treatment period was 6 months for both groups. The pre- to post-treatment changes in the bone mineral density (BMD), visual analogue scale (VAS) score, Oswestry disability index (ODI), and bone turnover markers were compared between the two groups.

Results

The post-treatment VAS score and ODI were significantly lower than baseline in both groups (P<0.05). In the JYMGG group, the lumbar BMD increased from 0.88±0.07 g/cm2 to 0.90±0.13 g/cm2 and the hip BMD increased from 0.77±0.08 g/cm2 to 0.78±0.10 g/cm2, giving increases of 2.70% and 1.96% respectively, but the differences were not statistically significant. The post-treatment levels of ALP, osteocalcin, P1NP, and β-CTX were increased compared with baseline in both groups, but the differences were not statistically significant. The thyrotropin level was significantly increased after treatment in the placebo group (P<0.05). There were no abnormalities detected in routine blood and kidney function tests performed during the observation period. Some patients showed elevated liver enzymes and gastrointestinal reactions.

Conclusion

JYMGG effectively relieved the bone pain, and improved the quality of life of patients with primary osteopenic LBP.

[Expert consensus for diagnosis and treatment of cervical spondylotic myelopathy with the integrated traditional Chinese and western medicine]

Cervical spondylotic myelopathy (CSM) is the most serious subtype, which is characterized by severe clinical symptoms, a high disability rate, and poor prognosis. Traditional Chinese medicine and Western medicine have their own advantages in the diagnosis and treatment of CSM at different stages. In order to further standardize the clinical diagnosis and treatment of CSM and improve the clinical efficacy, based on previous experience and evidence-based medicine, after repeated discussions by the national expert group, the expert consensus on the diagnosis and treatment of integrated traditional Chinese and Western medicine was compiled. This consensus comprehensively introduces the definition, etiology, pathogenesis, diagnosis treatment principles, integrated traditional Chinese and Western medicine treatment, postoperative rehabilitation and nursing care of cervical spondylotic myelopathy, so as to provide reference for clinicians.

Nb and Mn Co-Modified Na0.5Bi4.5Ti4O15 Bismuth-Layered Ceramics for High-Frequency Transducer Applications

Lead-free environmentally friendly piezoelectrical materials with enhanced piezoelectric properties are of great significance for high-resolution ultrasound imaging applications. In this paper, Na_0.5Bi_4.5Ti_3.86Mn_0.06Nb_0.08O_15+y (NBT-Nb-Mn) bismuth-layer-structured ceramics were prepared by solid-phase synthesis. The crystallographic structure, micromorphology, and piezoelectrical and electromechanical properties of NBT-Nb-Mn ceramics were examined, showing their enhanced piezoelectricity (d₃₃ = 33 pC/N) and relatively high electromechanical coupling coefficient (k_t = 0.4). The purpose of this article is to describe the development of single element ultrasonic transducers based on these piezoelectric ceramics. The as-prepared high-frequency tightly focused transducer (ƒ-number = 1.13) had an electromechanical coupling coefficient of 0.48. The center frequency was determined to be 37.4 MHz and the −6 dB bandwidth to be 47.2%. According to the B-mode imaging experiment of 25 μm tungsten wires, lateral resolution of the transducer was calculated as 56 μm. Additionally, the experimental results were highly correlated to the results simulated by COMSOL software. By scanning a coin, the imaging effect of the transducer was further evaluated, demonstrating the application advantages of the prepared transducer in the field of high-sensitivity ultrasound imaging.

Neurological recovery and antioxidant effect of erythropoietin for spinal cord injury: A systematic review and meta-analysis

Background

To critically evaluate the neurological recovery effects and antioxidant effects of erythropoietin (EPO) in rat models of spinal cord injury (SCI).

Methods

The PubMed, EMBASE, MEDLINE, ScienceDirect, and Web of Science were searched for animal experiments applying EPO to treat SCI to January 2022. We included studies which examined neurological function by the Basso, Beattie, and Bresnahan (BBB) scale, as well as cavity area and spared area, and determining the molecular-biological analysis of antioxidative effects by malondialdehyde (MDA) levels in spinal cord tissues. Meta-analysis were performed with Review Manager 5.4 software.

Results

A total of 33 studies were included in this review. The results of the meta-analysis showed that SCI rats receiving EPO therapy showed a significant locomotor function recovery after 14 days compared with control, then the superiority of EPO therapy maintained to 28 days from BBB scale. Compared with the control group, the cavity area was reduced [4 studies, weighted mean difference (WMD) = −16.65, 95% CI (−30.74 to −2.55), P = 0.02] and spared area was increased [3 studies, WMD =11.53, 95% CI (1.34 to 21.72), P = 0.03] by EPO. Meanwhile, MDA levels [2 studies, WMD = −0.63 (−1.09 to −0.18), P = 0.007] were improved in the EPO treatment group compared with control, which indicated its antioxidant effect. The subgroup analysis recommended 5,000 UI/kg is the most effective dose [WMD = 4.05 (2.23, 5.88), P &lt; 0.0001], although its effect was not statistically different from that of 1,000 UI/kg. Meanwhile, the different rat strains (Sprague-Dawley vs. Wistar), and models of animals, as well as administration method (single or multiple administration) of EPO did not affect the neuroprotective effect of EPO for SCI.

Conclusions

This systematic review indicated that EPO can promote the recovery of the locomotor function of SCI rats. The mechanism exploration of EPO needs to be verified by experiments, and then carefully designed randomized controlled trials are needed to explore its neural recovery effects.

Top 50 Most Cited Articles on Thoracic Ossification of Posterior Longitudinal Ligament

Study Design

Bibliometric analysis.

Objective

Over the last several decades, the field of thoracic ossification of the posterior longitudinal ligament (T-OPLL) has evolved unprecedentedly, and the literature on T-OPLL has increased significantly. The purpose of this study is to identify and review the top 50 most cited publications related to T-OPLL.

Methods

The most frequently cited 50 articles in this field until 30 October 2021 were identified by searching Web of Science. We ranked the articles based on the citation number. Through the bibliometric method, we evaluated the following information: article title, first author, year of publication, journal of publication, total number of citations, country, and study topic.

Results

The number of citations of included studies ranged from 20 to 108, with a mean number of 45.4. The journal Spine published most articles (20), followed by Spinal Cord (5), and European Spine (5). All of these articles were contributed by 38 first authors, Yamazaki (4), Fujimura (3), and Aizawa (3) who published more than 2 articles. In the respect of productive countries, Japan (39) contributed most papers. Tomita contributed the most cited article in 1990 on Spine, which was the first-ever report of circumferential decompression for thoracic myelopathy due to T-OPLL.

Conclusion

The top 50 influential articles on T-OPLL were identified and analyzed in this study. It will undoubtedly provide a comprehensive and detailed basis for the orthopedic and neurosurgery physicians to make a clinical decision and assimilate the research focus of spine surgery.

The 100 Most Cited Articles on Lumbar Spinal Stenosis: A Bibliometric Analysis

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

With the increasing literature of spine surgery, some pioneering research studies have had a significant impact on the field of lumbar spinal stenosis (LSS). The objective of the authors was to identify and analyze the most frequently cited 100 articles in this field.

METHODS

Web of Science was searched to identify 100 top-cited articles related to LSS from 2000 to 2019. Articles on the final list were filtered based on their titles and abstracts. The following information were recorded and analyzed with bibliometric method: article title, first author, year of publication, journal of publication, total number of citations, country, institution, and study topic.

RESULTS

The citation count for final articles on the list ranged from 71 to 2162, with a mean number of 207.7. The journal Spine contributed the maximum number of articles (37), followed by European Spine Journal (9) and Pain Physician (8). There were collectively 80 first authors contributing to articles on the final list. Twelve authors were represented multiple times in the top 100 articles. The most prolific years were 2008 and 2009, each had 11 articles published. With regard to country and region of origin, most articles were from the United States (58). The most cited article was published in Spine in 2000 by Fairbank and Pynsent, who discussed the role of the Oswestry Disability Index as an evaluation standard in spinal disorders, including LSS.

CONCLUSION

The current study analyzed the 100 most cited articles on LSS. It no doubt developed a useful resource with detailed information for many, particularly orthopedic and neurosurgery physicians who want to assimilate research focus and advance of LSS within a relatively short period. Researchers may benefit from emphasis on citation count while citing and evaluating articles and realize the deficiencies when high-level articles appear.

Research Progress of Ponticulus Posticus: A Narrative Literature Review

Study Design

Narrative review.

Objective

The purpose of this review was to consolidate the current literature related to ponticulus posticus (PP) and to improve the systematic understanding of this anatomical variant of atlas among spine surgeons.

Methods

Articles reviewed were searched in PubMed, Ovid MEDLINE, and Embase. All articles of any study design discussing on PP were considered for inclusion. Two independent authors read article titles and abstracts and included appropriate articles. The relevant articles were studied in full text.

Results

A total of 113 literatures were reviewed and consolidated in this narrative review. These articles are roughly divided into the following five subcategories: (1) epidemiology, (2) pathology and anatomy, (3) clinical presentation, (4) surgical significance, and (5) radiographic examination.

Conclusion

The PP is non-negligible with a high prevalence. The PP compresses the V3 segment of the artery, the suboccipital nerve, and the venous plexus, consequently contributing to the incidence of neurological pathologies. When a PP is observed or suspected on a lateral radiograph, we recommend that a computed tomography (CT) scan of a patient who is about to receive a C1 lateral mass screw (C1LMS) should be performed, which could determine a safe entry point and the right trajectory of screw insertion.

Global Trends of Researches on Lumbar Spinal Stenosis: A Bibliometric and Visualization Study

STUDY DESIGN

Bibliometric and visualization analysis.

OBJECTIVE

Lumbar spinal stenosis (LSS) has become a common health problem and the most frequent indication for spinal surgery. This study aimed to illustrate the overall knowledge structure, and development trends of LSS, using a bibliometric analysis and newly developed visualization tools.

MATERIALS AND METHODS

Research data sets were acquired from the Web of Science. The time span was defined as "2000-2019". VOS viewer and Citespace software was provided to analyze the data and generate visualization knowledge maps. Annual trend of publications, distribution, H-index status, co-authorship status and research hotspots were analyzed.

RESULTS

A total of 1934 publications met the requirement. The United States published most papers (521, 26.9%), both total citations (17,626) and H-index (61) ranked first of all the countries. The most productive organizations on LSS is Seoul National University (50). Spine (43) published the most papers on LSS. Quality of life, risk factor, disability, double blind trials, and decompression surgery are the research hotspots in the recent years.

CONCLUSION

The number of publications showed an upward trend with a stable rise in recent years. The United States is a country with the highest productivity, not only in quality, but also in quantity. Seoul National University has been the largest contributor in this field. Spine is the best journal related to LSS. Quality of life, risk factor, disability, and decompression surgery are the research hotspots in the recent years. Indeed, this study provides a new insight to the growth and development of LSS. Moreover, it will contribute to the growth of the international frontier of LSS.

Research Progress of Atlantoaxial Osteoarthritis: A Narrative Literature Review

OBJECTIVE

The purpose of this review was to consolidate the current literature related to atlantoaxial osteoarthritis (AAOA) and improve the systematic understanding of this clinical syndrome among spine surgeons.

METHODS

Articles reviewed were searched in PubMed, Ovid MEDLINE, and EMBASE using search terms: [("C1-C2" OR "C1-2" OR "atlantoaxial" OR "atlanto-axial" OR "C2" OR "C1" OR "atlas" OR "axis") AND ("osteoarthritis")]. All articles of any study design discussing on AAOA were considered for inclusion. Two independent authors read article titles, abstracts and the included appropriate articles. The relevant articles were studied in full text.

RESULTS

A total of 54 literatures were reviewed and consolidated in this narrative review. These articles are roughly divided into the following five subcategories: (1) epidemiology and etiology, (2) clinical presentation, (3) radiographic findings, (4) conservative treatment and (5) surgical indications and treatment options.

CONCLUSION

AAOA was a clinically common but often overlooked syndrome characterized by persistent occipitocervical pain. The most common cause of AAOA was joint degeneration, which was closely related to age and occupation. Initial treatment for AAOA was conservative. Atlantoaxial fusion was an option for patients with severe pain who unresponsive to conservative management.

Correlation and Differences in Lumbopelvic Sagittal Alignment Parameters Between Lumbar Radiographs and Magnetic Resonance Images

STUDY DESIGN

Imaging parameter study.

OBJECTIVE

Though lumbar alignment is better evaluated using standing radiograph than supine magnetic resonance imaging (MRI), few studies have researched this. Our study aimed to observe the correlation and difference in alignment between standing radiograph and supine MRI, and assess whether the change of position affects the lumbopelvic parameters.

METHODS

We analyzed 105 patients, measuring lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Inter- and intraparameter analyses were performed to identify any difference between standing radiograph and supine MRI. Statistical differences between the lumbopelvic parameters were compared.

RESULTS

There was excellent interobserver agreement for each parameter (interclass correlation coefficient > 0.75), and significant differences were observed in each parameter between radiograph and MRI (P < .05). Strong correlations were noted between the equivalent parameters in radiograph and MRI, both SS and PI were strongly correlated with LL in radiograph and MRI image, both PT and SS were strongly correlated with PI in radiograph and MRI image (r = -1.0 to -0.5 or 0.5 to 1.0).

CONCLUSION

Supine MRI obviously underestimated the measurements of lumbopelvic sagittal alignment parameters in standing radiograph. Therefore, standing lumbar radiographs should be obtained preoperatively in all surgical patients, not only supine MRI. In addition, we observed that PI was not a constant morphological parameter.

Periphery Biomarkers for Objective Diagnosis of Cognitive Decline in Type 2 Diabetes Patients

Introduction: Type 2 diabetes mellitus (T2DM) is an independent risk factor of Alzheimer’s disease (AD), and populations with mild cognitive impairment (MCI) have high incidence to suffer from AD. Therefore, discerning who may be more vulnerable to MCI, among the increasing T2DM populations, is important for early intervention and eventually decreasing the prevalence rate of AD. This study was to explore whether the change of plasma β-amyloid (Aβ) could be a biomarker to distinguish MCI (T2DM-MCI) from non-MCI (T2DM-nMCI) in T2DM patients.

Methods: Eight hundred fifty-two T2DM patients collected from five medical centers were assigned randomly to training and validation cohorts. Plasma Aβ, platelet glycogen synthase kinase-3β (GSK-3β), apolipoprotein E (ApoE) genotypes, and olfactory and cognitive functions were measured by ELISA, dot blot, RT-PCR, Connecticut Chemosensory Clinical Research Center (CCCRC) olfactory test based on the diluted butanol, and Minimum Mental State Examination (MMSE) test, respectively, and multivariate logistic regression analyses were applied.

Results: Elevation of plasma Aβ1-42/Aβ1-40 is an independent risk factor of MCI in T2DM patients. Although using Aβ1-42/Aβ1-40 alone only reached an AUC of 0.631 for MCI diagnosis, addition of the elevated Aβ1-42/Aβ1-40 to our previous model (i.e., activated platelet GSK-3β, ApoE ε4 genotype, olfactory decline, and aging) significantly increased the discriminating efficiency of T2DM-MCI from T2DM-nMCI, with an AUC of 0.846 (95% CI: 0.794–0.897) to 0.869 (95% CI: 0.822–0.916) in the training cohort and an AUC of 0.848 (95% CI: 0.815–0.882) to 0.867 (95% CI: 0.835–0.899) in the validation cohort, respectively.

Conclusion: A combination of the elevated plasma Aβ1-42/Aβ1-40 with activated platelet GSK-3β, ApoE ε4 genotype, olfactory decline, and aging could efficiently diagnose MCI in T2DM patients. Further longitudinal studies may consummate the model for early prediction of AD.

Developmental titanium dioxide nanoparticle exposure induces oxidative stress and neurobehavioral changes in zebrafish

The widespread commercial application of titanium dioxide nanoparticles (TiO₂ NPs) leads to ubiquitous presence of TiO₂ NPs in the aquatic environment, which highlights the necessity to determine their potential adverse effects on aquatic organisms. The developing nerve system is particularly susceptible to environment perturbation. However, few studies have explored the developmental neurobehavioral toxicity of TiO₂ NPs, especially at smaller particle size ranges (≤20 nm) that have relatively longer retention time in the water column. In this study, zebrafish embryos were exposed to non-teratogenic concentrations of 0.1 and 1 mg/L TiO₂ NPs (average size of 14-20 nm) from 8 to 108 h post-fertilization (hpf) followed by various assessments at different time points up to 12 days post-fertilization (dpf). Our findings revealed that 1 mg/L TiO₂ NPs perturbed the motor and social behaviors in larval zebrafish. These behavioral changes were characterized by decreased swimming speed in a locomotor response test at 5 dpf, increased travel distance in a flash stimulus test at 5 dpf, increased preference to the light zone in a light/dark preference test at 10 dpf, and increased mirror attack and percent time spent in the mirror zone in a mirror stimulus response assay at 12 dpf. Mechanistic examinations at 5 dpf revealed elevated cell apoptosis and oxidative stress. Cell apoptosis was characterized by increased acridine orange (AO) positive cells in the olfactory region and neuromasts of the lateral line system. Oxidative stress was characterized by increased lipid peroxidation, increased ROS production, and upregulated catalase (cat) gene expression. In addition, TiO₂ NP exposure also upregulated genes associated with the developmental nervous system such as the growth associated protein 43 (gap43) and proliferating cell nuclear antigen (pcna). Our results suggest that the neurobehavioral changes in larvae exposed to 1 mg/L TiO₂ NPs during early development may result from cell apoptosis and oxidative stress induced neuronal damages.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol for elderly patients receiving surgery for intertrochanteric fracture: a propensity score-matched analysis

Purpose

Enhanced Recovery After Surgery (ERAS) is a multimodal approach to perioperative care that aims to reduce patient perioperative complications, accelerate patient recovery, and improve patient satisfaction by refining and optimizing all perioperative management processes. By comparing two groups of patients before and after the implementation of ERAS for intertrochanteric fracture (ITF) with a matching analysis of propensity score (PS), we aimed to demonstrate that the implementation of ERAS protocol shortens the length of hospital stay (LOS), reduces pain, decreases the incidence of postoperative complications, and promotes functional recovery of the joint.

Methods

We selected 2 periods of 1 year, before (n=98patients) and after ERAS implementation (n=92patients). Data were collected on patient demographics, operative and perioperative details, LOS, VAS score, Harris score, and 30-day complications. ERAS-trained nurses are engaged to support patients at each step of the pre/per/postoperative process, including completing a satisfaction survey, with the help of a mobile app. PS analyses were used for dealing with confounding bias in this retrospective observational study.

Results

After PS matching, the outcomes of 124 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was significantly reduced from 24.3±3.9 to 15.2±2.9 days (P<0.001). With the same preoperative VAS scores, we found that patients in the ERAS group had significantly lower postoperative VAS scores than those in the conventional group at days 3 and 7 (P<0.001), but the difference was not statistically significant at day 14. patients in the ERAS group had higher Harris scores than those in the conventional group at 1 and 3 months, but the difference was not significant at 6 months. In addition, we found that only one patient in the ERAS group developed complications, while nine patients in the conventional group developed different complications. There was no significant difference concerning the satisfaction survey.

Conclusion

The introduction of ERAS for ITF in our institution has resulted in a significant decrease in LOS, alleviated patient pain, promoted early recovery of patient’s hip function while effectively preventing complications, and obtained patient satisfaction.

Early life stage transient aristolochic acid exposure induces behavioral hyperactivity but not nephrotoxicity in larval zebrafish

Aristolochic acids (AA) are nitrophenanthrene carboxylic acids found in plants of the Aristolochiaceae family. Humans are exposed to AA by deliberately taking herbal medicines or unintentionally as a result of environmental contamination. AA is notorious for its nephrotoxicity, however, fewer studies explore potential neurotoxicity associated with AA exposure. The developing nervous system is vulnerable to xenobiotics, and pregnant women exposed to AA may put their fetuses at risk. In the present study, we used the embryonic zebrafish model to evaluate the developmental neurotoxicity associated with AA exposure. At non-teratogenic concentrations (≤ 4 µM), continuous AA exposure from 8 to 120 hours post fertilization (hpf) resulted in larval hyperactivity that was characterized by increased moving distance, elevated activity and faster swimming speeds in several behavioral assays. Further analysis revealed that 8-24 hpf is the most sensitive exposure window for AA-induced hyperactivity. AA exposures specifically increased motor neuron proliferation, increased apoptosis in the eye, and resulted in cellular oxidative stress. In addition, AA exposures increased larval eye size and perturbed the expression of vision genes. Our study, for the first time, demonstrates that AA is neurotoxic to the developmental zebrafish with a sensitive window distinct from its well-documented nephrotoxicity.

A Bibliometric Analysis and Visualization of Current Research Trends in the Treatment of Cervical Spondylotic Myelopathy

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

Cervical spondylotic myelopathy (CSM) has become the most common cause of spinal cord dysfunction. Many topics of CSM still remain controversial. This study aimed to illustrate the overall knowledge structure and development trends of CSM.

METHODS

Research data sets were acquired from the Web of Science database and the time span was defined as "2000 to 2019." VOS viewer and Citespace software was used to analyze the data and generate visualization knowledge maps. Annual trends of publications, distribution, H-index status, co-authorship status, and research hotspots were analyzed.

RESULTS

A total of 2367 publications met the requirement. The largest number of articles was from the United States, followed by Japan, China, Canada, and India. The highest H-index was found for articles from the United States. The highest number of articles was published in Spine. The cooperation between the countries, institutes, and authors were relatively weak. Cervical sagittal alignment, predictive factor, diffusion tensor imaging, and the natural history of CSM may become a frontier in this research field.

CONCLUSION

The number of publications showed an upward trend with a stable rise. Most of the publications are limited to a few countries and institutions with relatively weak interaction. The United States, Canada, Japan, China, and India have made significant contributions to the field of CSM. The United States is the country with the highest productivity, not only in quality but also in quantity. Cervical sagittal alignment, predictive factor, diffusion tensor imaging, and the natural history of CSM are the research hotspots in the recent years.

Developmental co-exposure of TBBPA and titanium dioxide nanoparticle induced behavioral deficits in larval zebrafish

Both tetrabromobisphenol A (TBBPA) and titanium dioxide nanoparticle (TiO₂ NP) have widespread commercial applications, resulting in their ubiquitous co-presence in the environment and biota. Although environmental chemicals exist as mixtures, toxicity studies are nearly always conducted with single chemicals. Few studies explore potential interactions of different chemical mixtures. In this study, we employ the sensitive developing nerve system in zebrafish to assess the neurotoxicity of TBBPA/TiO₂ NP mixtures. Specifically, zebrafish embryos were exposed to solvent control (0.1% DMSO), 2 μM TBBPA, 0.1 mg/L TiO₂ NP, and their mixture from 8 to 120 h post fertilization (hpf), and motor/social behavioral assessments were conducted on embryos/larvae at different developmental stages. Our results showed that TBBPA/TiO₂ NP single or co-exposures increased spontaneous movement, decreased touch response and swim speed, and affected social behaviors of light/dark preference, shoaling, mirror attack and social contact. In particular, many of these phenotypes were manifested with higher magnitude of changes from the mixture exposure. These behavioral deficits were also accompanied with increased cell death in olfactory region and neuromasts in the lateral line system, increased ROS in gallbladder, pancreas, liver, and intestine, as well as increased lipid peroxidation and decreased ATP levels in whole larval tissue homogenates. Further, genes coding for key cell apoptosis marker and antioxidant enzyme were significantly upregulated by these two chemicals, in particular to their mixture. Interestingly, the co-presence of TBBPA also increased the mean particle size of TiO₂ NP in the exposure solutions and the TiO₂ NP content in larval tissue. Together, our analysis suggests that TBBPA/TiO₂ NP induced behavioral changes may be due to physical accumulation of these two chemicals in the target organs, and TiO₂ NP may serve as carriers for increased accumulation of TBBPA. To conclude, we demonstrated that TBBPA/TiO₂ NP together cause increased bioaccumulation of TiO₂, and heightened responses in behavior, cell apoptosis and oxidative stress. Our findings also highlight the importance of toxicity assessment using chemical mixtures.

Clinical control study of traditional Chinese medicine hot compress combined with traction in the treatment of cervical spondylotic radiculopathy: Study protocol

ABSTRACT

Cervical spondylotic radiculopathy (CSR) is the most common type of cervical spondylosis, accounting for about 60% of the incidence of cervical spondylosis. Both cervical traction and traditional Chinese medicine hot compress are common and effective treatment for CSR. This study will be performed to investigate the effect of a combination of cervical traction and traditional Chinese medicine hot compress on CSR. In this non-blinded, randomized controlled trial, 100 eligible patients will be randomly divided into a treatment group (intermittent cervical traction combines with traditional Chinese medicine hot compress) and a control group (intermittent cervical traction combined with hot compresses). Before and after the intervention, the Visual Analog Scale score, Neck Disability Index score, and 20-score scale of symptoms will be evaluated at baseline and at 7, 14, 21, and 28 days. During the treatment period, any signs of acute adverse events, such as paralysis of aggravated pain, nausea, dizzy, and even syncope, will be recorded at each visit. Although intermittent cervical traction and traditional Chinese medicine hot compress have been used in the treatment of CSR in China for many years, there is no consensus on its effectiveness of combination therapy. This experiment will provide convincing evidence of the efficacy of intermittent cervical traction combined with traditional Chinese medicine hot compress in the treatment of CSR.

A randomized controlled study for the treatment of middle-aged and old-aged lumbar disc herniation by Shis spine balance manipulation combined with bone and muscle guidance

Ninety percent of elderly patients with lumbar disc herniation (LDH) have problems with the mechanics of the spine and muscle tissue. Shi-style spine balance manipulation combined with guidance (Daoyin) of muscle and bone as an alternative therapy for LDH can tone the muscle groups around the spine and maintain optimal mechanical and static sagittal balance of the spine. This study will be performed to investigate the effect of a combination of Shi-style spine balance manipulation and Daoyin therapy on LDH in middle-aged and elderly patients. In this non-blinded, randomized controlled trial, 72 eligible patients will be randomly divided into a treatment group (Shi-style spine balance manipulation combined with Daoyin therapy) and a control group (lumbar mechanical traction). Before and after the intervention, lumbar X-ray and magnetic resonance imaging examinations will be performed to observe the sagittal balance parameters of the spine and pelvis and the lumbar muscle strength. The visual analog scale score, Oswestry disability index score, and pressure pain threshold will be evaluated at baseline and at 2, 4, 12, and 24 weeks. During the treatment period, any signs of acute adverse events, such as paralysis of the lower extremities or cauda equina syndrome, will be recorded at each visit. Although Shi-style spine manipulation combined with Daoyin therapy has been used in the treatment of LDH in middle-aged and elderly people in China for many years, there is no consensus on its effectiveness. This experiment will provide convincing evidence of the efficacy of Shi-style spine manipulation combined with Daoyin therapy in the treatment of LDH in middle-aged and elderly people.

Development and Validation of a Novel Scoring System for Severity of Plantar Fasciitis

OBJECTIVES

Plantar fasciitis (PF) is the most common cause of heel pain. Though PF is self-limited, it can develop into chronic pain and thus treatment is needed. Early and accurate prognostic assessment of patients with PF is critically important for selecting the optimal treatment pathway. Nevertheless, there is no scoring system to determine the severity of PF and no prognostic model in choosing between conservative or surgical treatment. The study aimed to develop a novel scoring system to evaluate the severity of plantar fasciitis and predict the prognosis of conservative treatment.

METHODS

Data of consecutive patients treated from 2014 to 2018 were retrospectively collected. One hundred and eighty patients were eligible for the study. The demographics and clinical characteristics served as independent variables. The least follow-up time was 6 months. A minimal reduction of 60% in the visual analog scale (VAS) score from baseline was considered as minimal clinically important difference (MCID). Those factors significantly associated with achieving MCID in univariate analyses were further analyzed by multivariate logistic regression. A novel scoring system was developed using the best available literature and expert-opinion consensus. Inter-observer reliability and intra-observer reproducibility were evaluated. The appropriate cut-off points for the novel score system were obtained using receiver operating characteristic (ROC) curves.

RESULTS

The system score = VAS (0-3 point = 1; 3.1-7 point = 3; 7.1-10 point = 5) + duration of symptoms (<6 months = 1; ≥1 6 months = 2) + ability to walk without pain (>1 h = 1; ≤1 h = 4) + heel spur in X-ray (No = 0; Yes = 2) + high intensity zone (HIZ) in MRI (No = 0; Yes = 2). The total score was divided in four categories of severity: mild (2-4 points), moderate (5-8 points), severe (9-12 points), and critical (13-15 points). Inter-observer agreement with a value of 0.84 was considered as perfect reliability. Intra-observer reproducibility with a value of 0.92 was considered as perfect reproducibility. The optimum cut-off value was 10 points. The sensitivity of predictive factors was 86.37%, 84.21%, 91.22%, 84.12%, and 89.32%, respectively; the specificity was 64.21%, 53.27%, 67.76%, 62.37%, and 79.58%, respectively; the area under curve was 0.75, 0.71, 0.72, 0.87, and 0.77, respectively. The Hosmer-Lemeshow test showed a good fitting of the score system with an overall accuracy of 90.6%.

CONCLUSIONS

Based on prognostic factors, the present study establishes a novel scoring system which is highly comprehensible, reliable, and reproducible. This score system can be used to identify the severity of plantar fasciitis and predict the prognosis of conservative treatment accurately. The application of this scoring system in clinical settings can significantly improve the decision-making process.

An active and verifiable trust evaluation approach for edge computing

Billions of Internet of Thing (IoT) devices are deployed in edge network. They are used to monitor specific event, process and to collect huge data to control center with smart decision based on the collected data. However, some malicious IoT devices may interrupt and interfere with normal nodes in data collection, causing damage to edge network. Due to the open character of the edge network, how to identify the credibility of these nodes, thereby identifying malicious IoT devices, and ensure reliable data collection in the edge network is a great challenge. In this paper, an Active and Verifiable Trust Evaluation (AVTE) approach is proposed to identify the credibility of IoT devices, so to ensure reliable data collection for Edge Computing with low cost. The main innovations of the AVTE approach compared with the existing work are as follows: (1) In AVTE approach, the trust of the device is obtained by an actively initiated trusted detection routing method. It is fast, accurate and targeted. (2) The acquisition of trust in the AVTE approach is based on a verifiable method and it ensures that the trust degree has higher reliability. (3) The trust acquisition method proposed in this paper is low-cost. An encoding returned verification method is applied to obtain verification messages at a very low cost. This paper proposes an encoding returned verification method, which can obtain verification messages at a very low cost. In addition, the strategy of this paper adopts initiation and verification of adaptive active trust detection according to the different energy consumption of IoT devices, so as to reliably obtain the trust of device under the premise of ensuring network lifetime. Theoretical analysis shows that AVTE approach can improve the data collection rate by 0.5 ~ 23.16% while ensuring long network lifetime compared with the existing scheme.

Clinical study on improving postoperative symptoms of cervical spondylotic myelopathy by Qishe pill

BACKGROUND

Cervical spondylotic myelopathy (CSM) is the most serious type of cervical spondylosis, which is often treated surgically in patients with progressive neurological symptoms following ineffective conservative treatment. However, some patients have residual symptoms such as neck pain, stiffness, and C5 nerve palsy after surgery. The Qishe pill can effectively relieve the symptoms of neck pain and numbness, but there is no evidence showing the efficacy and safety of the Qishe pill in treating symptoms after spinal cord surgery.

METHODS/DESIGN

A multicenter, randomized controlled clinical trial will be conducted to evaluate the efficacy and safety of the Qishe Pill. A total of 330 patients with CSM who receive surgical treatment will be randomly divided into 2 groups, treated for 12 weeks and with a 1-year follow-up. The primary outcome will be Japanese Orthopaedic Association score from the baseline to 4 weeks, 12 weeks, 24 weeks, and 48 weeks after surgery. Secondary outcomes will include Visual Analogue Scale score, Neck Disability Index, and imaging indicators (including magnetic resonance imaging and X-ray). Additionally, adverse reactions will be observed and recorded as safety indicators.

DISCUSSION

Although the Qishe pill can effectively improve the discomfort of the neck and upper limbs in clinical applications, there is a lack of clinical research on postoperative patients. This study will investigate the efficacy and safety of the Qishe pill in treating postoperative symptoms of CSM.

TRIAL REGISTRATION

Clinical Trials.gov ID: ChiCTR1900028173. Registered on 17 December 2019.

A Bibliometric Analysis and Visualization of Current Research Trends in Chinese Medicine for Osteosarcoma

BACKGROUND

To illustrate the research framework, overall knowledge structure, and development trends of Chinese medicine (CM) treatment for osteosarcoma (OS) by using a bibliometric analysis and newly developed visualization tools.

METHODS

Research datasets were acquired from the Web of Science (WOS) database from January 1, 1980 to September 30, 2019. VOS viewer and Citespace software was used to analyze the data and generate visualization knowledge maps. Annual trends of publications, distribution of institutes, distribution of journals, citation and H-index status, co-authorship status, research hotspots and co-citation status were analyzed.

RESULTS

A total of 223 publications in the WOS database met the requirement. The number of published articles showed a rise but the citation frequency and the H-index of China were relatively low. The cooperation between the countries, institutes and authors were relatively weak. Most publications were basic researches. Most of the previous researches focused on basic mechanisms of CM in treating OS, and therapy and improvement of dosage form may become a frontier in this research field.

CONCLUSIONS

Compared with other fields, the field of CM treatment for osteosarcome is still in infancy. The distribution of researches is imbalanced and cooperation between countries, institutions and authors remains to be strengthened. Furthermore, basic research occupies an absolute dominant position, and the exploration of the molecular mechanism of CM in preventing and treating OS may become a key point in the future.

A randomized, double-blind, placebo-controlled trial for Yi-Qi Hua-Yu tong-sui granule in the treatment of mild or moderate cervical spondylotic myelopathy

BACKGROUND

Neck pain, sensory disturbance and motor dysfunction in most patients suffered cervical spondylotic myelopathy (CSM). However, some conservative treatments are limited by their modest effectiveness. In the other hand, surgical treatment is necessary when symptoms are refractory to conservative treatments and neurological function of the patients has deteriorated. Many patients use complementary and alternative medicine, including traditional Chinese medicine, to address their symptoms. The purpose of the present study is to examine effectiveness and safety of Yiqi-Huayu-Tongsui (YQHYTS) granule, a compound traditional Chinese herbal medicine, on symptoms in patients with mild or moderate CSM.

METHODS/DESIGN

A randomized, double blinded, placebo-controlled clinical trial to evaluate the efficacy and safety of YQHYTS granule is proposed. 72 patients in Longhua Hospital with the diagnosis of mild or moderate CSM will be randomly allocated into 2 groups, and treated with YQHYTS granule or placebo. The prescription of the trial drugs (YQHYTS granule/placebo) is 20 grams twice a day for 3 months. The primary outcome measurements include visual analog scale, Japanese Orthopedic Association, and Neck Disability Index score. The secondary outcome measurements are electromyogram and Pfirrmann classification.

DISCUSSION

YQHYTS granule has been established and applied in Longhua Hospital for many years. As it has a potential benefit in treating mild or moderate CSM, we designed a double-blind, prospective, randomized controlled trial and would like to publish the results and conclusions later. If YQHYTS granule can alleviate neck pain, sensory disturbance, and even motor dysfunction without adverse effects, it may be a unique strategy for the treatment of mild or moderate CSM.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ID: ChiCTR1900028192. Registered 15 December 2019, Available at: http://www.chictr.org.cn/edit.aspx?pid=46913&htm=4.

The efficacy of Enhanced Recovery after Surgery (ERAS) for elderly patients with intertrochanteric fractures who received surgery: study protocol for a randomized, blinded, controlled trial

Background

Intertrochanteric fracture (ITF) is increasing with the rapid increase in the aging population, often causes a high mortality rate in old patients and increases the economic burden of the family and society. ERAS (Enhanced Recovery after Surgery) is a powerful guarantee for patients to accelerate their recovery after surgery. TCM (traditional Chinese medicine) promotes repair of injured tissues and eliminates traumatic aseptic inflammation. Therefore, this prospective randomized controlled clinical trial aims to evaluate the clinical effect of the evidence-based ERAS pathway of integrating TCM with western medicine on perioperative outcomes in ITF patients undergoing intramedullary fixation and provide reliable evidence-based data for applying the program to clinical practice.

Methods/design

We will conduct a prospective randomized, blinded, controlled trial to compare the effectiveness of ERAS care pathway with traditional care pathway and to investigate whether the ERAS care pathway can improve the perioperative outcome in ITF patients undergoing intramedullary fixation. A total of 60 patients with ITF will be enrolled and treated with the two care pathway, respectively. Length of stay, economic indicators, Harris score, VAS score, time to get out of bed, 30-day readmission rates, postoperative transfusion rates, discharge to home, and mortality will be evaluated. Any signs of acute adverse reactions will be recorded at each visit during treatment.

Discussion

Although an evidence-based process using the best available literature and Delphi expert-opinion method has been used to establish an ERAS pathway of integrating TCM with western medicine, there is a lack of consensus about its effectiveness. This trial will provide convincing evidence about the effect of ERAS pathway.

Trial registration

Registered on 12 October 2019. Trial number is ChiCTR1900026487.

[A method to create a new rat model of combination of disease and syndrome with cervical vertigo hyperactivity of liver yang syndrome]

OBJECTIVE

To establish a simple and reliable model of cervical vertigo in rats with hyperactivity of liver-yang syndrome, and to establish a simple and feasible method for evaluating the degree of vertigo in animals.

METHODS

SPF male SD rats (aged 8 weeks, weighing 280 to 320 g) were randomly divided into 4 groups (6 rats in each group). The model of cervical vertigo of hyperactivity of liver yang syndrome (joint modeling group) was established by combining local injection of lauromacrogol (hardener) and receiving fuzi decoction by gavage. The joint modeling group was compared with the hardener group, the fuzi decoction group and the blank control group. The vertigo degree of rats was measured by the time of passing through a glass tube (running time) before modeling, 2 weeks and 3 weeks after the established model.

RESULTS

There was no statistical difference in the running time between control group and fuzi decoction group, between joint modeling group and hardener group. The running time in the hardener group and the joint modeling group was longer than that in the control group (P< 0.05), and was even longer than that in the fuzi decoction group (P<0.01). There was significant difference in running time after modeling compared with that before modeling (P<0.05); there was no significant difference in running time between 2 and 3 weeks after modeling (P>0.05).

CONCLUSION

This method can effectively establish a rat model of cervical vertigo with hyperactivity of liver-yang syndrome, and the running time can reflect the degree of vertigo in rats to a certain extent. This experiment provides a simple and feasible animal model and detection method for research of cervical vertigo in the future.

An Independent Interobserver Reliability and Intraobserver Reproducibility Evaluation of Spinal Instability Neoplastic Score and Kostuik Classification Systems for Spinal Tumor

BACKGROUND

Most patients with spinal tumors suffer no symptoms or have mild symptoms, but about 14% of patients have refractory pain caused by mechanical instability, or symptoms of spinal cord damage caused by epidural spinal cord compression. The Spinal Instability Neoplastic Score (SINS) and Kostuik classification are commonly used to evaluate spinal stability, and help to make a more detailed operation plan. The objectives of this study are to evaluate the reliability and reproducibility of the SINS and Kostuik classification, and to explore their clinical application value.

METHODS

All 80 patients with spinal tumors were enrolled. Six spine surgeons who have certain clinical experience were selected. Patients were scored according to the SINS scoring system and classification was determined according to the Kostuik system. We used Fleiss and Cohen κ values to check the coefficient consistency for multifactors. We used Cohen κ value to check the interobserver reliability and intraobserver reproducibility. After 12 weeks, we repeated the analysis.

RESULTS

The interobserver reliability and intraobserver reproducibility of the SINS scoring system were near perfect with values of 0.831 and 0.874, respectively. The interobserver reliability and intraobserver reproducibility of the Kostuik classification system were moderate with values of 0.505 and 0.595, respectively.

CONCLUSIONS

Compared with the Kostuik classification system, the SINS scoring system has better interobserver reliability and intraobserver reproducibility, which can be widely used in clinical practice and has great significance in the decision-making of spinal tumor treatment. Although the Kostuik classification system is often used in clinical practice, it shows inferior reliability and reproducibility in our study.

The clinical efficacy of Shi-style lumbar manipulations for symptomatic degenerative lumbar spondylolisthesis: protocol for a randomized, blinded, controlled trial

BACKGROUND

Symptomatic degenerative lumbar spondylolisthesis (DLS) presents spinal problems in daily life. Shi-style lumbar manipulation (SLM), as an alternative treatment for DLS, is popular in China. SLM is based on the channels and collaterals theory of the traditional Chinese medicine, in which the symptoms are believed to result from channel blockage and joint displacement. However, there is no solid evidence to show the effect of the SLM on the management of symptomatic DLS.

METHODS/DESIGN

We conduct a prospective randomized, blinded, controlled trial to compare the effectiveness of SLM with mechanical lumbar traction and explore whether it could be a potential therapy for symptomatic DLS. A total of 60 patients with symptomatic DLS will be enrolled and treated with the SLM or mechanical lumbar traction for 2 weeks. VAS score and SF-36 questionnaire were assessed at baseline and at 2, 4, 12, and 24 weeks. Any signs of acute adverse reactions, such as lower limb paralysis or syndrome of cauda equina, will be recorded at each visit during treatment.

DISCUSSION

Although the SLM has been used in China for many years to treat symptomatic DLS, there is a lack of consensus about its effectiveness. This trial will provide convincing evidence about the effect of SLM on symptomatic DLS.

TRIAL REGISTRATION

Registered on 6 January 2019; the trial number is ChiCTR1900020519 .

8-Year Follow-up for Woman with Spinal Meningeal Melanocytoma in S1 Nerve Root: Case Report and Literature Review

BACKGROUND

Primary melanocytic neoplasms in the central nervous system are rare lesions arising from leptomeningeal melanocytes. These lesions produce neural deficits that resemble those of a meningioma or a schwannoma radiologically.

CASE DESCRIPTION

A tumor around the left S1 root with an extension into the left paraspinal compartment was identified in a 32-year-old female with persistent left leg pain for 6 months. The tumor was hyperintense on T1-weighted image and hypointense on T2-weighted image with a homogeneous enhancement. The clinical features, radiologic presentations, treatment choice, and pathologic characteristic were illustrated. The treatment outcome was compared with those reported in the previous literature. The tumor was en-bloc resected with the S1 nerve root reserved. Grossly, the tumor was a soft, capsulated, well-circumscribed, black pigmented lesion. Immunohistochemistry revealed that the tumor cells were positive for HMB-45, S-100 protein, and vimentin. The patient's symptoms were greatly relieved postoperatively. No signs of local recurrence were observed.

CONCLUSIONS

Spinal meningeal melanocytoma inside the nerve root is rare and benign. It is difficult to diagnose and often misdiagnosed as schwannoma or meningioma. HMB-45 has been suggested as a significant marker for the diagnosis of meningeal melanocytoma. Complete surgical resection is recommended as the primary treatment. Radiotherapy, chemotherapy, and other treatments can be selected as adjuvant therapies, but their effects are controversial. The recurrence and metastasis rates also remain unclear.

Radiological Characteristics and Surgical Outcome of Patients with Long Ossification of the Posterior Longitudinal Ligament Resulting in Ossified Lesions in the Upper Cervical Spine

OBJECTIVE

Designing surgical strategies for ossified lesions in the upper cervical spine is challenging owing to the complex anatomic structures. The present study aimed to clarify the prevalence of ossified lesions in the upper cervical spine in patients with ossification in the posterior longitudinal ligament and illustrate the clinical features, radiological findings, and surgical outcomes of this abnormality.

METHODS

Demographic and clinical data were collected for all patients preoperatively and included age, gender, body mass index, alcohol and tobacco use, history of diabetes, visual analog score, and Japanese Orthopaedic Association score. The cervical angle, morphology of ossification in the posterior longitudinal ligament, K-line, occupation ratio, space available for the spinal cord, high-intensity zone, and compression ratio of the spinal cord were calculated. The operative approach, technique used, and complications were recorded.

RESULTS

A total of 38 patients were enrolled. The upper cervical segment in 23 patients was not surgically addressed. In the group with the upper cervical segment addressed surgically, 10 patients were treated with C3-C6 open-door laminoplasty and C2 partial laminectomy, 1 with C1-C7 laminoplasty, 1 with C2-C7 laminoplasty, 2 with C3-C6 total and C2 partial laminectomy, and 1 with C1-C5 laminectomy and occipitocervical fusion.

CONCLUSIONS

The development of ossified lesions in the upper cervical spine has a high incidence. Decompressive surgery for upper cervical spine segments should be recommended for patients with severe narrowing of the spinal canal and a high signal intensity that extends to the upper cervical segment of the spinal cord. We hope that the findings from the present study will aid in clinical decision-making and provide useful information that can be incorporated into future guidelines.

Hidden blood loss during perioperative period and the influential factors after surgery of thoracolumbar burst fracture: A retrospective case series

Surgical therapy is vital for thoracolumbar burst fracture in restoring vertebral height, correcting kyphosis, decompressing nervous, and maintaining stability. Patients have unexpectedly lower hemoglobin levels postoperatively, which is remarkably inconsistent with the measured blood loss. However, hidden blood loss (HBL) is often neglected.To investigate HBL during perioperative period and determine its influential factors after surgery.A total of 68 patients who underwent surgery in our institution between January 2015 and January 2017 were included in the study. The demographic information, including the patients' age, gender, weight, height, duration of symptoms, surgery approach, time of operation, volume of drainage, classification of fracture, percentage of vertebral height loss and restoration, was collected. HBL was calculated according to the Gross formula. Influential factors were further analyzed using multivariate linear regression analysis.The mean HBL was 303.5 (range 18.4-803.5) mL, accounting for 67.5% of total blood loss. It indicated that the amount of HBL was much higher than we expected. Multiple and stepwise regression analysis revealed that blood loss, preoperative activated partial prothrombin time (APPT), percentage of anterior and medium vertebral height restoration were positively correlated with HBL. The association between HBL and the influential factors was analyzed based on the regression model equation: HBL = [1 + e [216.737 + 0.627*blood loss + 10.817*APTT + 207.549*anterior height restoration + 20.002*medium height restoration]]-1.HBL during perioperative period accounted for a substantial portion of the total blood loss and was much larger than what we thought. The blood loss, preoperative APPT, percentage of anterior and medium vertebral height restoration were positively correlated with HBL. Therefore, more attention needs to be paid to HBL to ensure patients' safety.

Can we assess severity of Guillain-Barré syndrome using absolute monocyte count?

INTRODUCTION

Guillain-Barré syndrome (GBS) is an inflammatory demyelinating autoimmune disease, associated with blood-nerve barrier breakdown, inflammatory cells infiltration, and cytokine leakage in the peripheral nervous system. Currently, it has been revealed that monocytes play key roles in the inflammatory response. Therefore, we aimed to assess the correlation between monocyte count and GBS in this study.

METHODS

Retrospective study was conducted in 114 patients with GBS and 120 age- and gender-matched individuals.

RESULTS

Absolute monocyte count in patients with GBS was higher than that in healthy controls (0.61 ± 0.24 vs 0.41 ± 0.10; P  < .001). Interestingly, monocyte count had significant positive correlations with CRP, ESR, and disease severity of GBS (r = .244, P = .009; r = .269, P = .004; r = .322, P < .001). A cutoff value of 0.515 for monocyte count was observed in patients with GBS (areas under the curve = 0.808, 95% confidence interval = 0.749-0.868, P  < .001). Meanwhile, absolute monocyte count was independently associated with GBS in logistic regression analysis (odds ratio = 2.291, 95% confidence interval = 3.557-27.493, P < .001).

CONCLUSION

Our findings demonstrated that elevated monocyte count is independently associated with GBS patients, and suggested monocyte count is positively associated with disease severity of GBS.

Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial

BACKGROUND

Lumbar disk herniation (LDH) is considered a common cause of lumbosacral radiculopathy. Epidural steroid injection is a common method to treat inflammation associated with low back-related leg pain. Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos.

OBJECTIVE

Due to the absence of clinical evidence, we designed a prospective, randomized, single-blind controlled trial in patients with LDH with radiculopathy, aiming to detect the safety and clinical efficacy of targeted indwelling catheter combined with "4-step" manipulative therapy in patients with LDH.

METHODS

Patient visits were performed at baseline and days 1, 3, 7, and 28 after treatment. Clinical outcomes were measured using visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and clinical symptom scores of the Japanese Orthopedic Association (JAO).

RESULTS

The study included 85 eligible patients. They were categorized with a randomization schedule into a Catheter Group (N = 43) and No-Catheter Group (N = 42). Between the measurement points, there was a statistically significant difference in the visual analog scale (back) at days 1, 3, and 7 of follow-up after treatment between the 2 groups. The change was statistically different at days 1 and 3, and a higher change was observed in the Catheter Group compared with the No-Catheter Group. There was a statistically significant difference in change of JOA and ODI scores at day 1 of follow-up after treatment between the 2 groups, and a greater change was seen in the Catheter Group at days 1 and 3 compared with the No-Catheter Group.

LIMITATIONS

The small sample size was small, and the follow-up time was short. The study also lacked documents of adjuvant therapies, like individual patient exercise routines and analgesic drug therapy.

CONCLUSION

Both methods were effective in reducing pain intensity and functional disability compared with pretreatment. The Catheter Group showed a more significant decrease in visual analog scale and greater changes in JOA and ODI scores of short/term follow-up, compared with the No-Catheter Group. The therapy project was safe.

Clinical characteristics and surgical treatment of spinal paraganglioma: A case series of 18 patients

BACKGROUND AND OBJECTIVES

Paraganglioma rarely develops in the spine. With few cases reported, little knowledge about this disease was known. The objective of this study is to illustrate the clinical features, imaging manifestations, pathological appearances and long-term outcomes of the consecutive surgeries by literature review.

METHODS

The clinical and follow-up data of 18 patients who were diagnosed of spinal paraganglioma and treated with surgeries in our hospitals from 2003 to 2014 were retrospectively analyzed.

RESULT

A total of fourteen patients radiographed of intra-spinal tumor underwent extra-capsular tumor resection. Of five patients with obvious vertebral bone damage, four cases underwent piecemeal resection, and the left one with sacral tumor underwent en bloc tumor excision. Spinal reconstruction was performed in all cases. Follow-up lasted for 16-96 months (44.1 months on average). There was no local recurrence or distant metastasis in cases without obvious bone invasion. Of those five cases with vertebral bone damage, one case suffered and survived from the repeat relapse of T1 vertebral body tumor. Local recurrence was not observed in one case with T10 vertebral tumor after tumor resection, but the tumor metastasized to T2 attachment during the follow-up and was finally eradicated by re-operation. No tumor recurrence was observed in the left three cases.

CONCLUSION

Paraganglioma, usually benign, rarely occurs. Surgical resection, especially complete surgical resection, is preferred to treat spinal paraganglioma. Chemotherapy, radiotherapy, use of octreotide and other somatostatin are selected as adjuvant therapies, but their effects remain unknown.