[Oncological outcomes of laparoscopic radical trachelectomy for early stage cervical cancer]

Objective: To analyze and summarize the oncological outcomes after laparoscopic radical trachelectomy (LRT) for early stage cervical cancer. Methods: The clinical data and follow-up results of 148 patients with early stage cervical cancer who underwent LRT in Renji Hospital, School of Medicine, Shanghai Jiao Tong University from July 2014 to June 2023 were collected, while tumor outcomes and postoperative pregnancy were analyzed retrospectively. Results: (1) General situation: the median age of 148 patients with LRT was 33 years (range: 19-42 years). Pathological type: 111 cases of squamous cell carcinoma, 36 cases of adenocarcinoma, 1 case of adenosquamous carcinoma. International Federation of Gynecology and Obstetrics (2018) stage: 17 cases of stage Ⅰa1 with lympho-vascular space invasion, 25 cases of stage Ⅰa2, 102 cases of stage Ⅰb1, and 4 cases of stage Ⅰb2. (2) Tumor outcomes: 148 patients were followed up regularly after LRT, and the median follow-up time was 59 months (range: 2-104 months). During the follow-up period, 5 cases of tumor recurred (including 1 death), and the median recurrence time was 10 months (range: 4-33 months). Among them, there were 3 cases of pelvic metastasis, 1 case of distant metastasis, and 1 case of both pelvic and distant metastasis. Both 3-year and 5-year disease-free survival rates of 148 patients were 94.5%, and the 5-year overall survival rate was 98.9%. (3) Postoperative pregnancy: among 148 patients with LRT, 67 patients had pregnancy requirements, followed up for 1 year, and 20 of them were pregnant, with a pregnancy rate of 29.9% (20/67). Among the 20 pregnant patients, 2 cases early abortion, 1 case mid-term abortion, and 17 cases gave birth (including 4 cases of premature birth and 13 cases of full-term birth). Conclusion: Under the condition of strict control of surgical indications, guaranteed surgical scope and tumor-free operation, LRT in patients with early cervical cancer has a good outcome.

[Plurihormonal PIT1-lineage pituitary neuroendocrine tumors: a clinicopathological study]

Objective: To investigate the clinicopathological characteristics of plurihormonal PIT1-lineage pituitary neuroendocrine tumors. Methods: Forty-eight plurihormonal PIT1-lineage tumors were collected between January 2018 and April 2022 from the pathological database of Sanbo Brain Hospital, Capital Medical University. The related clinical and imaging data were retrieved. H&E, immunohistochemical and special stains were performed. Results: Out of the 48 plurihormonal PIT1-lineage tumors included, 13 cases were mature PIT1-lineage tumors and 35 cases were immature PIT1-lineage tumors. There were some obvious clinicopathological differences between the two groups. Clinically, the mature plurihormonal PIT1-lineage tumor mostly had endocrine symptoms due to increased hormone production, while a small number of immature PIT1-lineage tumors had endocrine symptoms accompanied by low-level increased serum pituitary hormone; patients with the immature PIT1-lineage tumors were younger than the mature PIT1-lineage tumors; the immature PIT1-lineage tumors were larger in size and more likely invasive in imaging. Histopathologically, the mature PIT1-lineage tumors were composed of large eosinophilic cells with high proportion of growth hormone expression, while the immature PIT1-lineage tumors consisted of chromophobe cells with a relatively higher expression of prolactin; the mature PIT1-lineage tumors had consistently diffuse cytoplasmic positive staining for keratin, while the immature PIT1-lineage tumors had various expression for keratin; the immature PIT1-lineage tumors showed more mitotic figures and higher Ki-67 proliferation index; in addition, 25.0% (12/48) of PIT1-positive plurihormonal tumors showed abnormal positive staining for gonadotropin hormones. There was no significant difference in the progression-free survival between the two groups (P=0.648) by Kaplan-Meier analysis. Conclusions: Plurihormonal PIT1-lineage tumor belongs to a rare type of PIT1-lineage pituitary neuroendocrine tumors, most of which are of immature lineage. Clinically increased symptoms owing to pituitary hormone secretion, histopathologically increased number of eosinophilic tumor cells with high proportion of growth hormone expression, diffusely cytoplasmic keratin staining and low proliferative activity can help differentiate the mature plurihormonal PIT1-lineage tumors from the immature PIT1-lineage tumors. The immature PIT1-lineage tumors have more complicated clinicopathological characteristics.

A deep-learning model using enhanced chest CT images to predict PD-L1 expression in non-small-cell lung cancer patients

AIM

To develop a deep-learning model using contrast-enhanced chest computed tomography (CT) images to predict programmed death-ligand 1 (PD-L1) expression in patients with non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

Preoperative enhanced chest CT images and immunohistochemistry results for PD-L1 expression (<1% and ≥1% were defined as negative and positive, respectively) were collected retrospectively from 125 NSCLC patients to train and validate a deep-learning radiomics model (DLRM) for the prediction of PD-L1 expression in tumours. The DLRM was developed by combining the deep-learning signature (DLS) obtained from a convolutional neural network and clinicopathological factors. The indexes of the area under the curve (AUC), integrated discrimination improvement (IDI), and decision curve analysis (DCA) were used to evaluate the efficiency of the DLRM.

RESULTS

DLS and tumour stage were identified as independent predictors of PD-L1 expression by the DLRM. The AUCs of the DLRM were 0.804 (95% confidence interval: 0.697-0.911) and 0.804 (95% confidence interval: 0.679-0.929) in the training and validation cohorts, respectively. IDI analysis showed the DLRM had better diagnostic accuracy than DLS (0.0028 [p<0.05]) in the validation cohort. Additionally, DCA revealed that the DLRM had more net benefit than the DLS for clinical utility.

CONCLUSION

The proposed DLRM using enhanced chest CT images could function as a non-invasive diagnostic tool to differentiate PD-L1 expression in NSCLC patients.

Improved Measurement of the Evolution of the Reactor Antineutrino Flux and Spectrum at Daya Bay

Reactor neutrino experiments play a crucial role in advancing our knowledge of neutrinos. In this Letter, the evolution of the flux and spectrum as a function of the reactor isotopic content is reported in terms of the inverse-beta-decay yield at Daya Bay with 1958 days of data and improved systematic uncertainties. These measurements are compared with two signature model predictions: the Huber-Mueller model based on the conversion method and the SM2018 model based on the summation method. The measured average flux and spectrum, as well as the flux evolution with the ^{239}Pu isotopic fraction, are inconsistent with the predictions of the Huber-Mueller model. In contrast, the SM2018 model is shown to agree with the average flux and its evolution but fails to describe the energy spectrum. Altering the predicted inverse-beta-decay spectrum from ^{239}Pu fission does not improve the agreement with the measurement for either model. The models can be brought into better agreement with the measurements if either the predicted spectrum due to ^{235}U fission is changed or the predicted ^{235}U, ^{238}U, ^{239}Pu, and ^{241}Pu spectra are changed in equal measure.

Precision Measurement of Reactor Antineutrino Oscillation at Kilometer-Scale Baselines by Daya Bay

We present a new determination of the smallest neutrino mixing angle θ_{13} and the mass-squared difference Δm_{32}^{2} using a final sample of 5.55×10^{6} inverse beta-decay (IBD) candidates with the final-state neutron captured on gadolinium. This sample is selected from the complete dataset obtained by the Daya Bay reactor neutrino experiment in 3158 days of operation. Compared to the previous Daya Bay results, selection of IBD candidates has been optimized, energy calibration refined, and treatment of backgrounds further improved. The resulting oscillation parameters are sin^{2}2θ_{13}=0.0851±0.0024, Δm_{32}^{2}=(2.466±0.060)×10^{-3}  eV^{2} for the normal mass ordering or Δm_{32}^{2}=-(2.571±0.060)×10^{-3}  eV^{2} for the inverted mass ordering.

[Clinicopathological characteristics of H3K27-altered diffuse midline glioma and evaluation of NTRK as its therapeutic target]

Objective: To investigate the clinicopathological characteristics of H3K27-altered diffuse midline glioma (DMG), and to analyze DMG's prognostic factors, and subsequently, to study the possibility of using NTRK as a therapeutic target for DMG. Methods: A total of 232 DMG diagnosed at the Sanbo Brain Hospital, Capital Medical University, Beijing, China from July 2016 to March 2021 were collected. Their clinical, radiological and pathological features, the ratio of MGMT promoter methylation, expression of NTRK, and characteristics of NTRK gene fusion were analyzed. The prognostic values of different factors were also studied, including age, tumor location, histological grade, gene and protein expression of NTRK, and postoperative adjuvant therapy. Results: Among the 232 DMG cases, there were 8 patients with both primary and relapse tumors on the record. Thus, a total of 224 patients were analyzed, including 118 males and 106 females. There were 126 adults (>18 years of age) and 98 children (≤18 years of age). Notably, the most frequent location was thalamus (41/126, 32.5%) in adults, but brainstem (59/96, 60.2%) in children. The lesions showed T1 hypointensity or isointensity, and T2 hyperintensity. However, contrast enhancement patterns of the tumors varied, with many tumors lacking contrast-enhancing. The histological grades included grade 2 (9/224, 4.0%), grade 3 (41/224, 18.3%) and grade 4 (174/224, 77.7%). Two hundred and twenty-four DMGs were diffusely positive for H3K27M and negative for H3K27me3. The ratio of MGMT promoter methylation was low (1/45, 2.2%). One hundred and seventy-seven of the 224 cases (177/224, 79.0%) were positive for NTRK. Fifty cases were analyzed using fluorescence in situ hybridization. Among them, five DMGs (positive rate, 10.0%) were NTRK fusion positive. This study showed that there were no differences between adult and pediatric DMGs in histological grading, expression of NTRK, and NTRK gene fusion. One hundred and fifty-nine patients were included in the follow-up analysis (P>0.05). During the follow-up period, 109/159 patients (69.6%) died of the disease, with a median survival time of 12 months (range 1 to 55 months). Univariate log-rank analysis showed that age, location, surgical procedure and postoperative adjuvant therapy were associated with overall survivals of the DMG patients (P<0.05). Conclusions: The prognosis of DMG is poor overall. There are differences between adult and pediatric DMGs in anatomic location and prognosis, but not in other features. NTRK1 gene fusion is detected in 10.0% of the tumors. It suggests that TRK inhibitor might be a choice for treating DMG.

First Measurement of High-Energy Reactor Antineutrinos at Daya Bay

This Letter reports the first measurement of high-energy reactor antineutrinos at Daya Bay, with nearly 9000 inverse beta decay candidates in the prompt energy region of 8-12 MeV observed over 1958 days of data collection. A multivariate analysis is used to separate 2500 signal events from background statistically. The hypothesis of no reactor antineutrinos with neutrino energy above 10 MeV is rejected with a significance of 6.2 standard deviations. A 29% antineutrino flux deficit in the prompt energy region of 8-11 MeV is observed compared to a recent model prediction. We provide the unfolded antineutrino spectrum above 7 MeV as a data-based reference for other experiments. This result provides the first direct observation of the production of antineutrinos from several high-Q_{β} isotopes in commercial reactors.

[A real-world study of the efficacy and safety of sofosbuvir and velpatasvir in the treatment of HCV-infected patients in a county in northern China]

Objective: To evaluate the real-world efficacy and safety of sofosbuvir and velpatasvir (SOF/VEL) tablets in the treatment of Chinese patients with chronic HCV infection. Methods: An open-label, single-center, prospective clinical study was conducted in a county in northern China. A total of 299 cases were enrolled. Of these, 161 cases with chronic hepatitis C and 73 cases with compensated cirrhosis received SOF/VEL for 12 weeks. 65 cases with decompensated cirrhosis received SOF/VEL combined with ribavirin for 12 weeks (22 cases) or SOF/VEL for 24 weeks (43 cases). Virological indicators, liver and renal function indexes, and liver stiffness measurement were detected at baseline, the fourth week of treatment, the end of treatment, and the 12-weeks of follow-up. Adverse reactions and laboratory abnormalities were observed during the course of treatment . The primary endpoint was undetectable rate of HCV RNA (SVR12) at 12 weeks of follow-up with the use of modified intention-to-treat (mITT) approach. Measurement data between two groups were compared using t-test. One Way ANOVA was used for comparison between multiple groups. Enumeration data were analyzed by chi-square test or Fisher's exact test. Results: 291 cases had completed treatment. HCV RNA was undetectable after 12 weeks of follow-up, and the SVR12 rate was 97.3% (95% confidence interval: 95.4%-99.3%). Among them, 97.4% of genotype 1b, 96.4% of genotype 2a, and 100% of those with undetected genotype achieved SVR12. The SVR12 rates in patients with chronic hepatitis C, compensated and decompensated liver cirrhosis were 98.1%, 98.6% and 93.8%, respectively. An improvement in alanine aminotransferase, aspartate aminotransferase and other liver biochemical indicators accompanied with virological clearance and reduced liver stiffness measurement was observed in patients with compensated cirrhosis, with statistically significant difference. There was no significant abnormality in renal function before and after treatment. The most common adverse reactions were fatigue, headache, epigastric discomfort and mild diarrhea. The overall adverse reactions were mild. One patient died of decompensated liver cirrhosis combined with massive upper gastrointestinal bleeding, which was unrelated to antiviral treatment. Four patients discontinued treatment prematurely due to adverse events. Relapse was occurred in four cases, and drug-resistance related mutations were detected in three cases. Conclusion: Sofosbuvir and velpatasvir tablets in Chinese HCV-infected patients with different genotypes, different clinical stages or previously treated with pegylated interferon combined with ribavirin resulted in higher SVR12, indicating that the treatment safety profile is good.

Comparison of Oblique Lateral Interbody Fusion (OLIF) and Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF) for Treatment of Lumbar Degeneration Disease: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To assess the differences in the clinical and radiological outcomes between oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

SUMMARY OF BACKGROUND DATA

Nowadays, there is still a controversy regarding whether OLIF is superior to MI-TLIF in the management of degenerative lumbar disease.

METHODS

Between August 3, 2019 and February 3, 2020, 137 patients were assigned to OLIF or MI-TLIF at their request and the surgeon's discretion: 71 in the OLIF group and 66 in the MI-TLIF group. The perioperative data, patient-reported outcomes, radiographic outcomes, and complications were compared between the two groups.

RESULTS

The OLIF group showed shorter operation time (110.5 vs.183.8 minutes, P < 0.001), lesser estimated blood loss (123.1 vs. 232.0 mL, P < 0.001), shorter length of hospital stay (5.5 vs. 6.7 days, P < 0.001), and lower serum creatine kinase (CK) (1 day postoperatively) (376.0 vs. 541.8 IU/L, P < 0.01) than that of MI-TLIF group. Both groups showed no significant differences in the visual analog scale (VAS) scores of lower back and leg pain and the Oswestry Disability Index (ODI) scores preoperatively and at 1, 3, and 12 months postoperatively, respectively (P > 0.05). Compared with the MI-TLIF group, the OLIF group showed better restoration of disc height (DH) (4.7/4.6/4.7 vs. 3.7/3.7/3.7 mm, P < 0.01) and lumbar lordosis angle (LLA) (10.5°/10.8°/11.1° vs. 5.8°/5.7°/5.3°, P < 0.001), but not the value of segmental lordosis angle (SLA) (P > 0.05) at 1 day, 1 month, and 1 year postoperatively, respectively. The complication rate of OLIF was higher than that of MI-TLIF (29.4% vs. 9.7%, P < 0.01).

CONCLUSION

Compared with MI-TLIF, OLIF showed similar results in terms of patient-reported outcomes, restoration of SLA and fusion rate, and superior results with respect to restoration of DH and LLA, operation time, estimated blood loss, length of hospital stay, and serum CK levels (1 day postoperatively). Even though the complication rate of OLIF is higher than that of MI-TLIF, it does not bring persistent and substantial damage to the patients.Level of Evidence: 3.

Joint Determination of Reactor Antineutrino Spectra from ^{235}U and ^{239}Pu Fission by Daya Bay and PROSPECT

A joint determination of the reactor antineutrino spectra resulting from the fission of ^{235}U and ^{239}Pu has been carried out by the Daya Bay and PROSPECT Collaborations. This Letter reports the level of consistency of ^{235}U spectrum measurements from the two experiments and presents new results from a joint analysis of both data sets. The measurements are found to be consistent. The combined analysis reduces the degeneracy between the dominant ^{235}U and ^{239}Pu isotopes and improves the uncertainty of the ^{235}U spectral shape to about 3%. The ^{235}U and ^{239}Pu antineutrino energy spectra are unfolded from the jointly deconvolved reactor spectra using the Wiener-SVD unfolding method, providing a data-based reference for other reactor antineutrino experiments and other applications. This is the first measurement of the ^{235}U and ^{239}Pu spectra based on the combination of experiments at low- and highly enriched uranium reactors.

[Pediatric SMARCB1/INI1-deficient poorly differentiated chordoma of the skull base: report of five cases and review of literature]

Objective: To investigate the clinicopathological characteristics and differential diagnosis of pediatric SMARCB1/INI1-deficient poorly differentiated chordoma (PDC) of the skull base. Methods: Five cases of SMARCB1/INI1-deficient PDC were identified in 139 cases of chordoma diagnosed in Sanbo Brain Institute, Capital Medical University, Beijing, China from March 2017 to March 2021. The clinical and imaging data of the 5 PDCs were collected. H&E and immunohistochemical staining, and DNA methylation array were used, and the relevant literatures were reviewed. Results: All 5 PDCs were located at the clivus. The average age of the patients was 6.4 years, ranging from 3 to 16 years. Three patients were female and two were male. Morphologically, in contrast with classical chordomas, they presented as epithelioid or spindle tumor cells organized in sheets or nests, with necrosis, active mitoses, and infiltration into surrounding tissue. All cases showed positivity of CKpan, EMA, vimentin and brachyury (nuclear stain), and loss of nuclear SMARCB1/INI1 expression. S-100 protein expression was not frequent (2/5). Ki-67 proliferative index was high (20%-50%). All cases had over-expressed p53. It was necessary to differentiate SMARCB1/INI1-dificient PDC from SMARCB1/INI1-dificient tumors occurring at skull base of children or the tumors with epithelial and spindle cell morphological features. The 3 PDCs with DNA methylation testing showed the methylation profiles different from the pediatric atypical teratoid/rhabdoid tumors. They formed an independent methylation profile cluster. The clinical prognosis of the 5 patients was poor, and the overall survival time was 2-17 months. Conclusions: PDC is a special subtype of chordoma, which often affects children and occurs in the clivus. The PDC shares epithelioid or spindle cell morphologic features which are different from the classic chordoma. Besides the typical immunohistochemical profile of chordoma, PDC also has loss of nuclear SMARCB1/INI1 expression and distinct epigenetic characteristics.

Anteroinferior Psoas Technique for Oblique Lateral Lumbar Interbody Fusion

Oblique lateral lumbar interbody fusion (OLIF) has been extensively used, with satisfactory outcomes for the treatment of degenerative lumbar disease. This article aims to demonstrate a modified lateral approach, also known as the anteroinferior psoas (AIP) technique for OLIF, which is expected to enhance security by operating under direct vision. The core procedures of our technique are as follows. First, a minimal skin incision is recommended 2 cm backward compared with the normal incision of OLIF, facilitating the oblique placement of the working channel and the orthogonal maneuver for the cage placement. Second, two special custom‐made retractors, as an alternative to the index finger, are used to pull the psoas muscle to the dorsal side and pull the abdominal organs together with extraperitoneal fate to the ventral side under direct visualization, making the exposure of the working channel convenient and safe and avoiding radiation exposure. Third, the anterior border of the psoas is bluntly dissected and retracted backwards, obviously enlarging the retroperitoneal anatomic corridor and then expanding clinical indications of OLIF. The benefits of this technique include that it has a short learning curve, satisfactory clinical outcomes, and low risk of perioperative complications.

Anteroinferior Psoas Technique for Oblique Lateral Lumbar Interbody Fusion: Technical Note and Case Series

Objective

The aim of the present paper was to evaluate cases of lumbar degenerative diseases treated with oblique lateral interbody fusion (OLIF) using a modified lateral approach (i.e. anteroinferior psoas exposure under direct vision) and to analyze the effect and safety of this approach.

Methods

From June 2016 to April 2019, a total of 226 patients with an average age of 65.5 ± 16.2 years (98 men and 128 women) with degenerative lumbar diseases who underwent the AIP approach of OLIF were followed up and analyzed retrospectively. Data concerning operative and clinical parameters were collected, including operative time, intraoperative estimated blood loss, duration of postoperative hospital stay, and time to ambulation after surgery. For the assessment of clinical outcomes, the visual analogue scale (VAS) score (for back pain) and the Oswestry disability index (ODI) were calculated. Complications were also recorded as surgical exposure approach‐related complications. More than 6 months after surgery, 132 patients consented to having MRI examinations to evaluate the psoas muscle atrophy when they were followed up.

Results

The mean operative time was 82.5 ± 31.6 min. The mean operative time for each segment of OLIF was 43.3 ± 15.5 min. The mean blood loss was 48.0 ± 11.6 mL. The mean blood loss for each segment of OLIF was 25.3 ± 10.1 mL. No patients needed blood transfusion intraoperatively or postoperatively. The mean hospital stay was 4.1 ± 2.1 days. All patients were followed up for 12–31 months (mean 18.2 months). Clinical assessment showed that the VAS and ODI scores at 6 months after surgery were markedly lower than the preoperative scores (P < 0.001) but did not differ from the scores at the final follow‐up (P > 0.05). There was no significant difference in percentage changes of the cross‐sectional area of the lean psoas muscle and the T2 signal intensity ratio of gross psoas to quadratus lumborum muscles between the left side (operative side) and the right side (nonoperative side) (P > 0.05). A total of 11 surgical exposure approach‐related complications were reported, with an incidence of 4.9%: transient thigh pain/numbness, psoas weakness (2.2%), sympathetic chain injury (1.3%), cage subsidence (0.9%), and segmental artery injury (0.4%). There was no permanent motor neurological deficit, and no injury of vascular, ureter or peritoneal membranes.

Conclusion

The anteroinferior psoas approach for OLIF is safe and can preserve the psoas and lumbar plexus.

Symptomatic Postoperative Discal Pseudocyst After Percutaneous Endoscopic Interlaminar Discectomy: Case Report and Literature Review

Background

A postoperative discal pseudocyst (PDP) is a cystic lesion that is formed in the operation area of the intervertebral disc, leading to recurrence or even worse symptoms. To our knowledge, to date, there is no research focusing specifically on PDP following percutaneous endoscopic interlaminar discectomy (PEID).

Case presentation

We present the case of a 27‐year‐old man with L₅S₁ intervertebral disc herniation who was treated with PEID after failed conservative treatment. His leg pain was relieved immediately but reoccurred on the 40th day. MRI showed a PDP. Because loxoprofen and bedrest were ineffective and the patient was anxious, we performed a cystectomy. The patient's symptoms were significantly relieved, and a 6‐month follow up showed no recurrence both clinically and on MRI.

Conclusion

A PDP is more likely to form using the interlaminar approach than the transforaminal approach. For patients with mental stress, severe pain, and neurological symptoms, surgery is suggested to remove the cyst. Discectomy cannot be performed when disc degeneration is mild.

Improved Constraints on Sterile Neutrino Mixing from Disappearance Searches in the MINOS, MINOS+, Daya Bay, and Bugey-3 Experiments

Searches for electron antineutrino, muon neutrino, and muon antineutrino disappearance driven by sterile neutrino mixing have been carried out by the Daya Bay and MINOS+ collaborations. This Letter presents the combined results of these searches, along with exclusion results from the Bugey-3 reactor experiment, framed in a minimally extended four-neutrino scenario. Significantly improved constraints on the θ_{μe} mixing angle are derived that constitute the most constraining limits to date over five orders of magnitude in the mass-squared splitting Δm_{41}^{2}, excluding the 90% C.L. sterile-neutrino parameter space allowed by the LSND and MiniBooNE observations at 90% CL_{s} for Δm_{41}^{2}<13  eV^{2}. Furthermore, the LSND and MiniBooNE 99% C.L. allowed regions are excluded at 99% CL_{s} for Δm_{41}^{2}<1.6 eV^{2}.

Shi-Style Cervical Mobilizations Versus Massage for Cervical Vertigo: A Multicenter, Randomized, Controlled Clinical Trial

Objectives: Large sample and high-quality evidence to evaluate the preliminary safety of the mobilizations and massage for cervical vertigo are not yet available. Thus, the present study aimed to investigate the comparative effectiveness and preliminary safety of Shi-style cervical mobilizations (SCM) compared with traditional massage (TM) in cervical vertigo patients. Design: A prospective, multicenter, open-label, randomized, controlled clinical trial with a 1:1 allocation ratio. Settings: Five academic medical centers. Subjects: A total of 360 adult patients with a diagnosis of cervical vertigo. Interventions: The patients were randomly allocated to either an SCM (n = 180) or TM (n = 180) group. The patients were treated during six sessions over 2 weeks. The primary outcome was the Dizziness Handicap Inventory (DHI) total scale score, and secondary outcomes included the DHI subscales, Chinese version of the Short-Form 36 Health Survey (CSF-36), and adverse events (AEs). Outcomes were assessed in the short term at 2 weeks, 1 month, and 3 months, and in the intermediate term at 6 months after randomization. Results: Significant changes were observed from the baseline in the DHI total scale and subscales at 2 weeks and 1, 3, and 6 months in both groups (all p < 0.05). However, the differences between the two groups were not significant (all p > 0.05). Furthermore, we noted significant changes from the baseline in SF-36 scores at 2 weeks in both groups (all p < 0.05), whereas CSF-36 scores were not significantly higher in the SCM group (all p > 0.05) compared with the TM group. No serious AEs were reported in either of the two groups. Conclusions: No differences in outcomes were detected between the SCM and TM groups in terms of treatment of cervicogenic dizziness. Efficacy trials are required to determine whether the improvement observed for each treatment was causally related to the interventions.

Extraction of the ^{235}U and ^{239}Pu Antineutrino Spectra at Daya Bay

This Letter reports the first extraction of individual antineutrino spectra from ^{235}U and ^{239}Pu fission and an improved measurement of the prompt energy spectrum of reactor antineutrinos at Daya Bay. The analysis uses 3.5×10^{6} inverse beta-decay candidates in four near antineutrino detectors in 1958 days. The individual antineutrino spectra of the two dominant isotopes, ^{235}U and ^{239}Pu, are extracted using the evolution of the prompt spectrum as a function of the isotope fission fractions. In the energy window of 4-6 MeV, a 7% (9%) excess of events is observed for the ^{235}U (^{239}Pu) spectrum compared with the normalized Huber-Mueller model prediction. The significance of discrepancy is 4.0σ for ^{235}U spectral shape compared with the Huber-Mueller model prediction. The shape of the measured inverse beta-decay prompt energy spectrum disagrees with the prediction of the Huber-Mueller model at 5.3σ. In the energy range of 4-6 MeV, a maximal local discrepancy of 6.3σ is observed.

[Application of adaptive statistical iterative reconstruction veo and 80 kv in renal computed tomography angiography]

Objective: To explore the application of adaptive statistical iterative reconstruction Veo (ASIR-V) and 80 kV in renal computed tomography angiography(CTA). Methods: Eighty patients with renal computed tomography angiography were prospectively collected from April 2018 to July 2018 in the Affiliated Hospital of Shaanxi University of Chinese Medicine and randomly divided into group A and group B. The patients in group A adopted tube voltage 120 kV and contrast agent concentration 600 mgI/kg and reconstructed with filtered back projection (FBP), while the patients in group B were scanned with tube voltage 80 kV and contrast agent concentration 350 mgI/kg and reconstructed with FBP and ASIR-V from 10% to 100% with 10% interval. The CT values and standard deviation (SD) of the right renal artery, left renal artery were measured respectively to calculate the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR).The image quality of renal CTA was subjectively scored by two experienced radiologists blindly using a 5-point criteria.The contrast agent,CT volume dose index(CTDI(vol)) and dose length product(DLP) in both groups were recorded and the effective radiation dose(ED) was calculated. Results: The ED ((2.11±0.19)mSv) and contrast agent ((21.9±3.0)g) in group B were 65.1% (P<0.05) and 42.2% (P<0.05) lower than those in group A ((6.04±1.89)mSv and (38.0±3.8)g).With the increase of ASIR-V percentage in group B, CT values showed no significant difference, SD values gradually decreased, SNR values and CNR values gradually increased.The CT values with different reconstruction algorithm showed no statistically significant difference (all P>0.05) between group A and group B. The SD values with 40%ASIR-V to 100%ASIR-V reconstruction in group B were significantly lower than those of group A (all P<0.05).The SNR values with 50% ASIR-V to 100% ASIR-V reconstruction and CNR values with 70%ASIR-V to 100%ASIR-V were significantly higher than those of group A(all P<0.5).Two radiologists had excellent consistency in subjective scores of image quality for renal CTA(all kappa>0.75, P<0.05). The subjective scores with 60% ASIR-V to 90% ASIR-V in group B were significantly higher than those in group A (P<0.05), of which 70%ASIR-V reconstruction achieved the highest subjective score for renal CTA. Conclusion: ASIR-V and 80 kV can significantly reduce radiation dose (about 65.1%) and contrast agent (about 42.2%) in renal CTA, ASIR-V reconstruction can significantly improve the image quality of renal CTA, of which 70% ASIR-V reconstruction achieved the best image quality in 80 kV renal CTA.

[Association of single nucleotide polymorphisms of TBX5 gene and environmental exposure index with susceptibility to oral cancer]

Objective: To explore the association of TBX5 polymorphisms and environmental exposure index with susceptibility to oral cancer. Methods: A case-control study was conducted to collect 300 oral cancer patients hospitalized in the Department of Oral and Maxillofacial Surgery, the First Affiliated Hospital of Fujian Medical University from September 2010 to December 2016. A total of 445 non-tumor patients were selected as the control group. Questionnaires were used to collect the information of all subjects and 5 ml peripheral blood was collected to detect single nucleotide polymorphisms (SNPs) of the rs10492336 locus of TBX5 gene. According to the environmental exposure index score, subjects were divided into two groups, low risk group (0-2.31) and high risk group (2.32-11.76). To analyze the association of TBX5 gene rs10492336 SNPs, environmental exposure index and oral cancer and its interactions. Results: The age of all subjects in the case group and control group were (56.19±13.10) years and (54.56±12.48) years old. Compared with CC genotype, the OR (95%CI) values of the co-dominant genetic model AC genotype and the dominant genetic model AC+AA genotype were 0.69 (0.49-0.98) and 0.70 (0.51-0.97), respectively. Compared with the low risk group, the OR (95%CI) risk of oral cancer in the high risk group was 3.72 (2.55-5.43). The results of gene-environment interaction analysis showed that compared with the group with CC genotype and high risk of environmental exposure index, the OR (95%CI) value of oral cancer in the group with AC+AA genotype and low risk of environmental exposure index was 0.18(0.10-0.31). Furthermore there was a multiplicative interaction between rs10492336 SNPs and environmental exposure index (β=-0.405, P<0.001). Conclusion: This study suggests that the TBX5 gene rs10492336 SNPs and environmental exposure index were associated with oral cancer. And there was a multiplication interaction between rs10492336 SNPs and environmental exposure index.

[Association between the time of neutrophils to the lowest and prognosis of patients with esophageal squamous cell carcinoma treated with non-operative therapy]

Objective: To investigate the association between the time of neutrophils to the lowest and prognosis of patients with esophageal squamous cell carcinoma (ESCC) treated with non-operative therapy. Methods: The clinical data of 325 non-operative treated ESCC patients were collected in this study. The X-title software was applied to establish optimal threshold of neutrophil reduction to the lowest value. According to the optimal threshold, the patients were divided into early group (115 cases) and late group (210 cases). The clinical features and survival time of the two groups were compared, and the factors of prognosis were analyzed by Cox regression model with univariate and multivariate analysis. Results: The X-title software demonstrated the optimal cutoff values for the time of neutrophils to the lowest was 39 days. The median overall survival time was 21.0 months in the early group which was significantly higher than that in the late group (16.0 months). Multivariate Cox regression analysis showed that the treatment methods and the time of neutrophils to the lowest were independent factors for overall survival of patients with ESCC treated by non-surgical therapy. Compared with radiotherapy alone, concurrent chemoradiation could benefit the survival (HR=0.64, P=0.026). The prognosis of patients in the late group of neutrophils to the lowest (HR=1.38, P=0.038) was poor compared with the early group. Furthermore, stratified by treatment methods, the overall survival of two groups showed statistically significant difference only in patients received concurrent chemoradiation. The mortality risk in the late group was higher than that in the early group (HR=3.53, P=0.010). Conclusion: The time of neutrophils to the lowest is an independent prognosis factor for non-operative treated ESCC patients. The prognosis of patients in the early group is better than that in the late group.

[Study on characteristics and prognosis of organ failure in patients with hepatitis B virus-associated acute-on-chronic liver failure]

Objective: To evaluate the incidence, and the characteristics of organ failure in relationship to prognosis in hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF) patients using chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score for judgments of clinical treatment and prognosis. Methods: Clinical data of 316 patients who were diagnosed as HBV-ACLF during hospitalization from February 2015 to February 2016 were retrospectively analyzed. Intrahepatic and extrahepatic organ failures were assessed according to CLIF-SOFA score, and the relationship between clinical characteristics and prognosis was analyzed. Continuity variables were analyzed by analysis of variance, or Kruskal-Wallis H test. Comparison of the categorical data were done using χ (2) or Fisher's exact test, and the predictive efficacy of various prognostic scores was compared using the area under the receiver operating characteristic curve (AUROC) and Z-test. Results: Of 316 cases (87.3% men) of HBV-ACLF, the mean age was (45 ± 11) years old. 78.8% of patients with underlying liver disease had hepatitis B virus induced cirrhosis. Mortality rates in patients without liver transplantation at 28 days, 90 days and 180 days were 20.5% (63/307), 36.7% (110/300) and 39.2% (116/296), respectively. According to the CLIF-SOFA score, 89.9% (284 patients) had organ failure at baseline, of which 97.5% had liver failure (Total bilirubin ≥ 12 mg/dl) and only 2.5% had coagulation, kidney, circulation or respiratory failure without liver failure. Besides liver failure, the incidence of extrahepatic organ failure was coagulation (23.1%), kidney (5.7%), brain (3.8%), circulation (1.3%) and respiratory failure (0.3%). With increasing number of organ failure, the mortality rate of two and three or more organ failures were 69.6% and 69.2%, respectively, which was significantly higher than that of single organ failure and non-organ failure patients (27% and 6.9%, respectively; P < 0.001). Liver failure with coagulation failure (International normalized ratio≥2.5 or platelet count≤20×10(9)/L) had worst prognosis with a mortality rate of up to 75% at 90 days. Conclusion: According to the CLIF-SOFA score, the main organ failure in patients with HBV-ACLF in China is liver failure. The mortality rate in patients with two or more organ failures is as high as 70% within 3 months. Therefore, timely manner liver transplantation should be considered.

Measurement of the Electron Antineutrino Oscillation with 1958 Days of Operation at Daya Bay

We report a measurement of electron antineutrino oscillation from the Daya Bay Reactor Neutrino Experiment with nearly 4 million reactor ν[over ¯]_{e} inverse β decay candidates observed over 1958 days of data collection. The installation of a flash analog-to-digital converter readout system and a special calibration campaign using different source enclosures reduce uncertainties in the absolute energy calibration to less than 0.5% for visible energies larger than 2 MeV. The uncertainty in the cosmogenic ^{9}Li and ^{8}He background is reduced from 45% to 30% in the near detectors. A detailed investigation of the spent nuclear fuel history improves its uncertainty from 100% to 30%. Analysis of the relative ν[over ¯]_{e} rates and energy spectra among detectors yields sin^{2}2θ_{13}=0.0856±0.0029 and Δm_{32}^{2}=(2.471_{-0.070}^{+0.068})×10^{-3}  eV^{2} assuming the normal hierarchy, and Δm_{32}^{2}=-(2.575_{-0.070}^{+0.068})×10^{-3}  eV^{2} assuming the inverted hierarchy.

Ascorbic Acid Attenuates Multifidus Muscles Injury and Atrophy After Posterior Lumbar Spine Surgery by Suppressing Inflammation and Oxidative Stress in a Rat Model

STUDY DESIGN

A rat model of multifidus muscles injury and atrophy after posterior lumbar spine surgery.

OBJECTIVE

We determined the effect of ascorbic acid (AA) on the postoperative multifidus muscles in rat model.

SUMMARY OF BACKGROUND DATA

Previous studies show oxidative stress and inflammation are two main molecular mechanisms in multifidus muscle injury and atrophy after posterior lumbar surgery. AA may have a protective effect in postoperative multifidus muscles.

METHODS

Rats were divided into sham surgery, control surgery, and surgery plus AA groups. Multifidus muscles of the control and AA groups were excised from the osseous structures. The muscles were retracted continuously for 2 hours. In the sham and AA groups, AA was administered via oral gavage daily in the first week. In each group, the oxidative stress was evaluated by measuring malondialdehyde (MDA) and Total superoxide dismutase (T-SOD). The inflammation, fat degeneration, or fibrosis of multifidus muscle were evaluated by quantitative real-time polymerase chain reaction (q-PCR), histology, or immunohistochemical analysis.

RESULTS

T-SOD activity was significantly lower in the control group than that in the AA group in the first week. MDA levels were significantly higher in the AA group. Interleukin-6 and tumor necrosis factor-α in multifidus muscles also showed significant differences when treated with AA. The inflammation score on histology was significantly lower in the AA group postoperatively in the first week. In the long run, marker genes for fibrosis and fat degeneration, and fibrosis and fat degeneration scores, were significantly lower in the AA than the control group on days 14 and 28 postoperatively.

CONCLUSION

In conclusion, AA attenuated the oxidative stress and inflammation response in the postoperative multifidus muscles, and remarkable differences were observed from the histological assessment and related marker genes expression. Our results provided important insight into the anti-inflammatory and anti-oxidative effects of AA in the postoperative multifidus muscles.

LEVEL OF EVIDENCE

N/A.

[Technical specification for clinical application of critical ultrasonography]

Critical ultrasonography(CUS) is different from the traditional diagnostic ultrasound, the examiner and interpreter of the image are critical care medicine physicians. The core content of CUS is to evaluate the pathophysiological changes of organs and systems and etiology changes. With the idea of critical care medicine as the soul, it can integrate the above information and clinical information, bedside real-time diagnosis and titration treatment, and evaluate the therapeutic effect so as to improve the outcome. CUS is a traditional technique which is applied as a new application method. The consensus of experts on critical ultrasonography in China released in 2016 put forward consensus suggestions on the concept, implementation and application of CUS. It should be further emphasized that the accurate and objective assessment and implementation of CUS requires the standardization of ultrasound image acquisition and the need to establish a CUS procedure. At the same time, the standardized training for CUS accepted by critical care medicine physicians requires the application of technical specifications, and the establishment of technical specifications is the basis for the quality control and continuous improvement of CUS. Chinese Critical Ultrasound Study Group and Critical Hemodynamic Therapy Collabration Group, based on the rich experience of clinical practice in critical care and research, combined with the essence of CUS, to learn the traditional ultrasonic essence, established the clinical application technical specifications of CUS, including in five parts: basic view and relevant indicators to obtain in CUS; basic norms for viscera organ assessment and special assessment; standardized processes and systematic inspection programs; examples of CUS applications; CUS training and the application of qualification certification. The establishment of applied technology standard is helpful for standardized training and clinical correct implementation. It is helpful for clinical evaluation and correct guidance treatment, and is also helpful for quality control and continuous improvement of CUS application.

Honokiol alleviates the degeneration of intervertebral disc via suppressing the activation of TXNIP-NLRP3 inflammasome signal pathway

Intervertebral disc degeneration (IVDD) is a multifactorial disease and responsible for many spine related disorders, causes disability in the workforce and heavy social costs all over the world. Honokiol, a low molecular weight natural product, could penetrate into and distribute in IVDs to achieve therapeutic effect in a rat tail model. Therefore, the present study was undertaken to examine the antiinflammatory, antioxidation and IVD-protective effect of honokiol using nucleus pulposus cells and investigate its mechanisms to provide a new basis for future clinical treatment of IVDD. In the current study, we demonstrated that honokiol inhibits the H₂O₂-induced apoptosis (caspase-9, caspase-3, and bax), levels of oxidative stress mediators (ROS, MDA), expression of inflammatory mediators (Interleukin-6, COX-2, and iNOS), major matrix degrading proteases (MMP-3, MMP-13, ADAMTS5, and ADAMTS4) associated with nucleus pulposus degradation. Furthermore, we found nucleus pulposus protective ability of honokiol by up-regulating extra cellular matrix anabolic factors like type II collagen (Col II) and SOX9 in nucleus pulposus. We also found that honokiol suppressed the phosphorylation of NF-kB and JNK, and activation of TXNIP-NLRP3 inflammasome in H₂O₂-stimulated nucleus pulposus cells, thereby inhibiting the activation of downstream inflammatory mediators such as Interleukin-1β. Furthermore, honokiol showed a cartilage protective effect in the progression of IVDD in a rat model induced by puncture. Thus, our results demonstrate that honokiol inhibited the H₂O₂ induced apoptosis, oxidative stress, and inflammatory responses through the depression of TXNIP/NLRP3/caspase-1/ Interleukin - 1β signaling axis and the activation of NF-kB and JNK. Honokiol possess nucleus pulposus protective properties and may be of value in suppressing the pathogenesis of IVDD.

[Experts consensus on the management of the right heart function in critically ill patients]

To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion (TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. (25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

[The value of the excursion of diaphragm tested by ultrosonography to predict weaning from mechanical ventilation in ICU patients]

Objective: To evaluate the excursion of the diaphragm and analyze the value in predicting weaning from mechanical ventilation in intensive care unit patients. Methods: The patients with mechanical ventilation (>48 hours) in ICU at Hebei Forth Medical University Hospital from June 2014 to December were classified into a success group or a failure group according to the weaning outcome. T-piece spontaneous breathing (SBT), airway occlusion pressure at 0.1 sec (P(0.1)) and maximal inspiratory pressure (MIP), rapid shallow breathing index (RSBI) and P(0.1)/MIP were measured or calculated. During the period of the 1st hour SBT, the excursion of diaphragm was measured with ultrasonography. The predictive value of each parameter to weaning was evaluated with ROC curve. Results: A total of 98 patients were enrolled in this study, including 74 successfully weaning and 24 failed. There were significant differences between two groups(success group and failure group) in P(0.1)[(2.00±2.00)cmH(2)O (1 cmH(2)O=0.098 kPa) vs (3.00±2.75)cmH(2)O, P<0.05], RSBI (39.14±16.81 vs 52.00±19.18, P<0.05), left diaphragmatic excursion [(1.12±0.97)cm vs (0.69±1.00)cm, P<0.001], right diaphragmatic excursion(1.87±0.75)cm vs (1.17±0.76)cm, P<0.001] and mean value of left and right diaphragmatic excursion [(1.57±0.52)cm vs (0.83±0.53)cm, and P<0.001]. The ventilation time [2.00(2.00-4.00)d vs 4.00(2.00-5.00)d], ICU hospital lengths of stay [4.50(3.00-7.25)d vs 8.50(6.25-15.25)d] and total hospital lengths of stay[20.00(15.00-25.25)d vs 25.00(20.25-37.25)d] were also statistically significant in success group and failure group respectively (all P<0.05). The cutoff value of diaphragmatic excursion for predicting successful extubation was determined to be 1.14 cm by ROC curve analysis. The sensitivity of diaphragmatic excursion to predict successful weaning was 89.2% and the specificity was 75.0%, the AUC(ROC) was 0.849. Conclusion: As an early predictor of diaphragmatic dysfunction, diaphragmatic excursion is probably superior to the traditional parameters in predicting weaning from ventilator in ICU patients.

[The effects of different tidal volume ventilation on right ventricular function in critical respiratory failure patients]

Objective: To observe and explore the effects of different tidal volume (VT) ventilation on right ventricular (RV) function in patients with critical respiratory failure. Methods: Consecutive respiratory failure patients who were treated with invasive ventilator over 24 h in the Department of Critical Care Medicine at the Fourth Hospital of Hebei Medical University from June to December in 2015 were enrolled in this study.Clinical data including patients' vital signs, ventilator parameters and RV echocardiography were collected within 6 h (D0), day1(D1), day2 (D2) and day3 (D3) after ventilation started.According to the VT, patients with acute respiratory distress syndrome (ARDS) were assigned to low VT group [S6, ≤6 ml/kg predicted body weight (PBW)] and high VT group (L6, >6 ml/kg PBW), while non-ARDS patients were also assigned to low VT group (S8, ≤8 ml/kg PBW) and high VT group (L8, >8 ml/kg PBW). Results: A total of 84 patients were enrolled in this study.44.2% ARDS patients and 58.5% non-ARDS patients were in low VT groups.After ventilation, tricuspid annulus plane systolic excursion(TAPSE)decreased progressively in S6 [from 18.30(16.70, 20.70) mm to 17.55(15.70, 19.50) mm, P=0.001], L6 [from 19.50(17.00, 21.00) mm to 16.30(15.00, 18.00) mm P=0.001], S8[from 18.00(16.00, 21.00) mm to 16.50(15.50, 18.00) mm, P=0.001] and L8 [from 19.00(17.50, 21.50) mm to 16.35(15.15, 17.00) mm, P=0.001] groups.However, TAPSE decreased less in small VT groups (S6 and S8) than those of in large VT groups (S8 and L8) without significant differences.There were not statistical differences between different VT groups in terms of ventilation days, including right ventricle area/left ventricle area (RV(area)/LV(area)), TAPSE, peak mitral flow velocity of the early rapid filling wave (E), peak mitral flow velocity of the late rapid filling wave (A), early diastolic velocity of the tricuspid annulus (e'), pulmonary artery systolic pressure, inferior vena cava diameter (all P>0.05). Compared to L6 group, low VT (S6 group) resulted in decreased mortality at 28 days [1/19 vs 37.5%(9/24), P=0.014]. There were not statistical differences between different VT groups in terms of ventilation days, length of intensive care unit stay, length of hospital stay (all P>0.05). Logistic regression analysis showed that VT could be the independent factor of TAPSE (OR=1.104, 95%CI 0.100-1.003, P=0.049). Conclusions: Positive pressure mechanical ventilation resulted in RV systolic dysfunction .Lower VT may have the protective effect on RV function. Trial registration: Chinese Clinical Trial Registry, ChiCTR-POC-15007563.

Facet orientation and tropism: Associations with asymmetric lumbar paraspinal and psoas muscle parameters in patients with chronic low back pain

BACKGROUND

Many studies have explored the relationship between facet tropism and facet joint osteoarthritis, disc degeneration and degenerative spondylolisthesis. However, the associations between facet orientation and tropism, and paraspinal muscles have not been studied.

OBJECTIVE

To analyze the associations between facet orientation and tropism, and parameters of paraspinal muscles in patients with chronic low back pain.

METHODS

Ninety-five patients with chronic low back pain were consecutively enrolled. Their facet joint angles were measured on computed tomography (CT) while gross cross-sectional area (GCSA), functional cross-sectional area (FCSA) and T2 signal intensity of lumbar paraspinal and psoas muscle were evaluated on magnetic resonance imaging (MRI).

RESULTS

The GCSA and FCSA were significantly smaller for multifidus muscle (P< 0.001), but significantly larger for erector spinae and psoas muscles (P< 0.001), in coronally-orientated group than those in sagittally-orientated group. The differences of bilateral GCSA and FCSA of multifidus muscle were significantly larger in facet tropism group than those in no facet tropism group (P= 0.009 and P= 0.019).

CONCLUSIONS

Muscular asymmetries may develop in the lumbar region of the spine, which are associated with facet asymmetry in patients with chronic low back pain. Longitudinal studies are needed to understand the causal relationship between facet orientation and tropism and muscular asymmetry in future.

[Management of endo-graft infection following endovascular repair of abdominal aortic aneurysm]

OBJECTIVE

To summarize our experience in the management of stent-graft infection after endo-vascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA).

METHODS

Data of patients who were diagnosed as endo-graft infection following EVAR and admitted in our center between January 2000 and December 2015 were reviewed. Clinical records including causes of infection, medical history, re-operative procedures, and prognostic data were analysed.

RESULTS

A total of 10 male patients, aged 45-72 years (averaged 62.5 years), were enrolled. Two patients received previous EVAR in our center, accounting for 0.23% of all the 885 EVAR procedures we conducted during the same period. The symptoms related to stent infection, including recurrent fever (100%) and persistent back pain (40%), occured 0 to 27 months (averaged 6.9 months) after EVAR procedure. Eight patients were found to have apparent causes (80%), including 1 case with upper respiratory infection and sepsis, 4 cases with aorto-enteric fistula (AEF) and 3 cases with inflammatory AAA. Except one DNR, other 9 patients received re-operation, including 1 procedure of open debridement and drainage, 1 procedure of endo-graft excision and bilateral axillary-femoral bypass, 7 procedures of endograft excision and axillary-bifemoral bypass. During the follow-up period(2-60 months, averaged 24.1 months), 1 patient was lost, 1 patient died from aortic stump rupture (12.5%) and other 7 patients survived. Bypass occlusion was observed in 1 patient (12.5%) without severe limb ischemia.

CONCLUSIONS

AEF and inflammatory AAA are two leading causes of endo-graft infection following EVAR in our patients. Graft excision and axillofemoral bypass is an acceptable management for this life-threatening morbidity.

[A retrospective study on the outcomes of the oncology, fertility and pregnancy in patients with early-stage cervical cancer after undergoing the fertility-sparing treatments]

OBJECTIVE

To explore the outcomes of the oncology, the fertility and pregnancy on patients with early-stage cervical cancer after undergoing fertility-sparing treatments, and to investigate its value on clinical treatment.

METHODS

A total of 29 patients with cervical cancer (stage Ⅰa2-Ⅰb1) who had undergone the fertility- sparing treatments in Renji Hospital, School of Medicine, Shanghai Jiaotong University from February 2010 to September 2015 were analyzed retrospectively. Surgical procedures included transvaginal cervical cold knife conization (CKC) + laparoscopic pelvic lymphadenectomy (PLD) or total laparoscopic uterine cervix extensive resection (RT; contains PLD); 48 patients with early cervical cancer under going laparoscopic uterine extensive resection (RH; contains PLD) by the same group of physicians in the same period were chosen as the control group. The perioperative related indicators, postoperative specimen examination, pregnancies after surgery and postoperative tumor follow- up results were retrospectively analyzed and compared between the two groups.

RESULTS

(1) Among these 29 patients in the study group, 26 cases were underwent the fertility-sparing surgery quick frozen pathological examinations were positive in 3 cases, which underwent total laparoscopic RT eventually. (2) The perioperative related indicators: compared with the study group and the control group, the operation time [(182±21), (147±24) minutes, respectively] has significant difference (t=6.563, P<0.01). There were no significant difference (P> 0.05) in intra-operative blood loss [(102±26), (99±34) ml], postoperative aerofluxus time [(1.3±0.4), (1.1±0.9) days], the average length of hospital stay [(11.2±2.1), (10.6±3.5) days], rate of urine retention [10%(3/29), 10%(5/48)] and rate of postoperative infection [3% (1/29), 2%(1/48)]. (3)Postoperative specimen examination: compared with the study group and the control group, there were no significant difference (P>0.05) innumber of removed lymphatic nodes (23.4±4.1, 22.8±3.9), length of cardinal ligament [(2.9±0.5), (3.0±0.6) cm], lengthof uterosacral ligament [(2.6±0.7), (2.8±0.4) cm], length of removed vaginal [(3.4±0.3), (3.5±0.3) cm]. (4) Pregnancies after surgery and postoperative tumor follow-up results: in the study group, only 14 patients had fertility requirement after treatments. Pregnancies occurred in 5 women (5/14), which included1 case of full-term labor, 1 case of preterm labor, and 3 cases of spontaneous abortion. The Average follow-up time in postoperative patients of the study group and control group was 29.4, and 30.2 months respectively. In follow- up period, compare with study group and the control group, there was no significant difference (χ(2)=0.004, P> 0.05) in the recurrence rate [4% (1/26), 4% (2/48)].

CONCLUSION

Fertility-sparing surgery of early-stage cervical cancer is safe but the outcome of the fertility and pregnancy is still need toimprove.

Apodized waveguide arrays induced by photorefractive nonlinear surface waves

A new type of nonlinear waveguides, photorefractive surface optical waveguides is suggested, which can be induced by photorefractive surface waves on the boundary of photorefractive crystal. The disturbed refractive index distribution of such waveguides behaves as a periodic lattice with apodized envelope, thus we call them photorefractive surface apodized waveguide arrays. Moreover, the dispersion relation and corresponding modes are analyzed. It is very interesting that the dispersion curves of index-guided modes and Bragg-guided modes couple and intertwine with each other, and anti-crossings instead of crossings between them hence generate some mini-gaps. Moreover there exists a type of extraordinary modes constituted by the splice of index-guided modes and Bragg-guided modes.

Evaluation of 12 Novel Molecular Markers for Degenerated Nucleus Pulposus in a Chinese Population

STUDY DESIGN

A transcriptional expression assessment of human samples.

OBJECTIVE

To evaluate 12 new candidate nucleus pulposus (NP) markers in degenerative disc disease in a Chinese population.

SUMMARY OF BACKGROUND DATA

Disc degeneration is a major contributor of low back pain. However, no specific and reliable markers of degeneration of NP are available.

METHODS

Specimens of NP were collected from 81 patients and grouped into the degenerated disc group (undergoing discectomy and fusion with significant signs of disc degeneration) and the trauma control group (undergoing anterior vertebral body and disc excision and fusion without signs of disc degeneration). Lumbar spine magnetic resonance imaging, hematoxylin-eosin staining, and safranin O staining of sections of NP tissues were conducted to evaluate the severity of the disc degeneration in all samples. Quantitative reverse transcription polymerase chain reaction was performed to investigate the levels of mRNA expression of these genes, as well as those of aggrecan, type II collagen, and SRY-box 9 (SOX-9). Degenerated samples were also divided into groups according to Pfirrmann grading system to elucidate the association of severity of degeneration and gene transcriptional levels. We also tested the relationship between mRNA levels of these genes and clinical characteristics such as hypertension and diabetes mellitus.

RESULTS

We demonstrated that 11 of the 12 candidates showed significant differential expression in degenerated discs. Changes in the expression of these 11 genes were determined to be risk factors in degenerative disc diseases. The expression of neurochondrin (NCDN), keratin 8 (KRT8), and matrix Gla protein (MGP) even showed significant changes among subgroups of patients with degenerative disc disease stratified according to the Pfirrmann grading system. The expression of keratin 18 (KRT18), cadherin 2 (CDH2), synaptosomal-associated protein 25 (SNAP25), KRT8, and NCDN was significantly decreased in patients with hypertension. In contrast, the expression of MGP and cartilage oligomeric matrix protein was significantly upregulated in patients with diabetes mellitus.

CONCLUSION

Overall, we demonstrated the clinical utility of 11 novel NP markers for degenerative disc disease. Among them, the expression of NCDN, KRT8, and MGP may indicate the severity of disc degeneration.

LEVEL OF EVIDENCE

N/A.

Lycorine suppresses RANKL-induced osteoclastogenesis in vitro and prevents ovariectomy-induced osteoporosis and titanium particle-induced osteolysis in vivo

Osteoclasts play an important role in diseases involving bone loss. In this study, we assessed the effect of a plant-derived natural alkaloid (lycorine, or LY) on osteoclastogenesis in vitro and in vivo. Our in vitro study showed that receptor activator of nuclear factor-κB ligand (RANKL)-induced osteoclastogenesis could be inhibited by LY; this effect was due to inhibition of mitogen-activated protein kinase (MAPK) signalling via MAP kinase kinases (MKKs). The MAPK agonist anisomycin could partially rescue the inhibitory effect of LY. Furthermore, LY also played a protective role in both a murine ovariectomy (OVX)-induced osteoporosis model and a titanium particle-induced osteolysis model. These results confirmed that LY was effective in preventing osteoclast-related diseases in vivo. In conclusion, our results show that LY is effective in suppressing osteoclastogenesis and therefore could be used to treat OVX-induced osteoporosis and wear particle-induced osteolysis.

Metal complex modified azo polymers for multilevel organic memories

Multilevel organic memories have attracted considerable interest due to their high capacity of data storage. Despite advances, the search for multilevel memory materials still remains a formidable challenge. Herein, we present a rational design and synthesis of a class of polymers containing an azobenzene-pyridine group (PAzo-py) and its derivatives, for multilevel organic memory storage. In this design, a metal complex (M(Phen)Cl2, M = Cu, Pd) is employed to modify the HOMO-LUMO energy levels of azo polymers, thereby converting the memory state from binary to ternary. More importantly, this approach enables modulating the energy levels of azo polymers by varying the coordination metal ions. This makes the achievement of high performance multilevel memories possible. The ability to tune the bandgap energy of azo polymers provides new exciting opportunities to develop new materials for high-density data storage.

[Influencing of chronic low back pain on multifidus muscle atrophy]

OBJECTIVE

To identify the affect of chronic low back pain on multifidus muscle atrophy and fatty infiltration.

METHODS

From March 2010 to August 2013, a retrospective study were carried out in the department of orthopedics of patients with low back pain. Finally 31 cases were selected to this study including 19 males and 12 females with an average age of 36.4 years ranging from 23 to 55 years. The main symptoms of these patients were repeated back pain. Duration was more than 1 year. X-ray, CT, MRI showed no obvious abnormalities. The changes of net cross-sectional area of multifidus and T2 signal ratio of the same patient were measured at different time by MRI. VAS and Oswestry disability scores were recorded in two MRI examination. Correlation between these change of multifidus net area and T2 signal ratio in two times measurement and duration of low back pain, VAS, Oswestry disability scores were analyzed to find the affection of low back pain on paraspinal multifidus muscle.

RESULTS

The net multifidus cross-sectional area in same case by the second follow-up MRI is significantly smaller than that of the first follow-up, T2 signal ratio at second was significantly higher than that of the first (P < 0.05). The net cross sectional area of multifidus muscles reduced rate were positively correlated with VAS scores, duration and of Oswestry disabilitry scores (P < 0.001). The rate of increase in T2 signal ratio was not correlated with VAS scores,duration and the Oswestry disability scores (P > 0.05).

CONCLUSION

Chronic low back pain is one of the most important reasons of paraspinal multifidus muscle atrophy and fatty. The duration, VAS and Oswestry disability scores of chronic low back pain were positively correlated with the multifidus muscle atrophy.

Effect and possible mechanism of muscle-splitting approach on multifidus muscle injury and atrophy after posterior lumbar spine surgery

BACKGROUND

Multifidus muscle injury and atrophy are common after posterior lumbar spine surgery and are associated with low back pain and functional disability. In theory, muscle-splitting and retraction with a self-retaining retractor are considered to be the major surgical factors. The effects and mechanisms of retraction have been well studied, but the exact effect and possible mechanism of injury and atrophy after muscle-splitting still lack experimental evidence.

METHODS

New Zealand White rabbits were divided into two groups. In group S, through a skin and lumbodorsal fascial incision, the bilateral multifidus muscles were dissected from the osseous structures in the standard fashion, while in group C, only a skin and lumbodorsal fascial incision was made. In each group, the multifidus muscle was evaluated by magnetic resonance imaging (MRI) and by histological analysis at three and forty-eight hours and at one, three, six, twelve, and twenty-four weeks after surgery.

RESULTS

In group C, there was no injury or atrophy of the multifidus muscle after surgery. In group S, the mean T2-weighted signal intensity ratios of gross multifidus to psoas on fat-suppressed T2-weighted cross-sectional MRI scans peaked on week 3 and returned to baseline on week 24. Necrosis and inflammation of the multifidus muscle were evident and became more severe at one week. Fibrotic change was mainly seen at three and six weeks after surgery, and fatty degeneration mainly occurred at twelve and twenty-four weeks. Decreased acetylcholine activity and granular degeneration of the neuromuscular junction were observed at all follow-up times, and the numbers of degenerating neuromuscular junctions increased significantly with time after surgery.

CONCLUSIONS

The splitting approach is an important cause of multifidus muscle injury and atrophy in posterior lumbar spine surgery. Denervation and disuse may be important factors in multifidus muscle atrophy in the splitting approach.

CLINICAL RELEVANCE

This study provides a basis for the prevention of multifidus muscle injury and atrophy after posterior lumbar surgery.

[Case-control study on effects of two approaches on multifidus muscle injuries during lumbar interbody fusion of lumbar vertebrae]

OBJECTIVE

To study differences of multifidus muscle injury between Wiltse intermuscular approach and intramuscular stripping approach in one-level small incision transforaminal lumbar interbody fusion (TLIF) surgery.

METHODS

A total of 46 patients with unilateral lumbar degenerative disease underwent small incision TLIF from August 2009 to February 2011 by one group of surgeons at a single institution. The decompression side of all patients adopted intra-muscular stripping approach; for the non-decompression side, 22 patients adopted Wiltse intermuscular approach (group A),and 24 patients adopted intra-muscular striping approach (group B). In group A, there were 13 males and 9 females, ranging in age from 36 to 74 years old,averaged 52.7 +/- 9.2; 1 patient had disease in L3, 4 12 in L4,5 and 9 in L5S1. In group B,there were 11 males and 13 females,ranging in age from 32 tio 72 years old, averaged 51.8 +/- 8.7; two patients had disease in L3,4, 14 in L4,5, and 8 in L5S1. The following data were compared between the 2 groups: surgical time from skin incision to completion of pedicle screw placement, suturation time, blood loss. Clinical effects were evaluated by VAS score pre-operatively, as well as 1, 6 and 12 months post-operatively. At the latest follow-up, all the patients were evaluated by MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative level.

RESULTS

There was no obvious difference in suturation time, but less surgical time from skin incision to completion of pedicle screw placement, less blood loss, less postoperative back pain in Wiltse intermuscular approach group. For the comparison between the two groups or paired comparison between sides in the Wiltse group, the reduction of lean CSA and increase in the multifidus:psoas T2 signal intensity ratio were all significant lower in Wiltse intermuscular approach group or side.

CONCLUSION

The Wiltse intermuscular approach is an easy way for pedicle screw placement, and caused less paraspinal muscle damage than intra-muscular stripping approach, and had positive effects on less back pain.

Iatrogenic injury to the erector spinae during posterior lumbar spine surgery: underlying anatomical considerations, preventable root causes, and surgical tips and tricks

The approach-related morbidity resulting from iatrogenic erector spinae injury in posterior lumbar surgery has become an increasing concern for spine surgeons. Many studies have explained the injury mechanisms and reported new surgical approaches to prevent this iatrogenic injury from their own point of views, but there is still no systemic information for a thorough understanding of this iatrogenic erector spinae injury that may give spine surgeons practical advices in their individual operations. We consequently reviewed the literature on the anatomy of erector spinae, causes of injury, and relative minimally invasive approaches. We found that the local anatomic structures make the erector spinae vulnerable to injury during posterior lumbar surgery, especially the medial multifidus which is innervated only by the medial branch of the dorsal ramus, with no intersegmental nerve supply as in the other paraspinal muscles, and the injury factors mainly include dissection, retraction, denervation, and immobility. Studies suggest that the goal of prevention is to preserve the physiological structure of erector spinae and to avoid or limit the injury causes: approaches through spatium intermusculare and approaches with endoscope and tubular retractor system can prevent the erector spinae from injury by less dissection and retraction; non-fusion techniques may prevent the erector spinae from disuse atrophy by preserving the segmental motion and the adjacent erector spinae activity.

Visualizing orbital angular momentum of plasmonic vortices

Plasmonic vortices (PVs) are generated by focusing a radially polarized optical vortex (OV) beam onto a metal surface. The intensity distribution of the PV is registered with a near-field scanning optical microscopy and agrees well with a theoretical prediction as well as numerical calculation. Beside the dark central spot, the numerical calculation also shows an azimuthal Poynting vector belonging to the PV, implying that the orbital angular momentum (OAM) was transferred from the radially polarized OV. To directly verify the OAM, plasmonic trapping experiments with gold micrometer particles are performed and the particle rotation is visualized. Further experiments by varying the topological charge of radially polarized OVs show the corresponding changes in rotation in terms of speed and radius.

Quantitative MRI analysis of the surface area, signal intensity and MRI index of the central bright area for the evaluation of early adjacent disc degeneration after lumbar fusion

PURPOSE

The aim of this study was to evaluate early ASD at short-term follow-up in fused and unoperated patients with degenerative disc disease, using quantitative magnetic resonance imaging (MRI) analysis of the area, signal intensity and their product, i.e., MRI index of the central bright area of the disc as well as measures of intervertebral disc height and Pfirrmann grading scale. The further purpose was to determine whether fusion accelerates ASD compared with non-surgical treatment in short-term follow-up.

METHODS

One hundred and eight chronic low back patients diagnosed as L4/L5 degeneration undertook either one-level instrumented posterior lumbar interbody fusion or conservative treatment. They were followed up for about 1 year. Finally 46 fused and 45 conservatively treated patients with MRI follow-up were included. Pre- and post-treatment MRIs were compared to determine the progression of disc degeneration at the two cranial adjacent segments.

RESULTS

The area, signal intensity and MRI index of the central bright area of the adjacent discs decreased in the operated and unoperated groups from pre-treatment to follow-up, except for an insignificant decrease of signal intensity at the second adjacent segment in the unoperated group. The changes in these parameters were statistically greater at the first than the second adjacent segment in the fused group, but not in the unoperated group. And the changes in the fused group were more pronounced than those at both neighbouring levels in the unoperated group. However, the Pfirrmann grading scale and intervertebral disc height did not detect any changes at adjacent discs in either group.

CONCLUSIONS

Decrease in the parameters of quantitative MRI analysis indicated early degeneration at discs adjacent to lumbar spinal fusion. Fusion had an independent effect on the natural history of ASD during short-term follow-up. Continued longitudinal follow-up is required to determine whether these MRI changes lead to pathologic changes.