Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C).

SETTINGS

Multi-institutions in Japan.

METHODS

We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis.

RESULTS

Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness).

CONCLUSIONS

Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL.

SPONSORSHIP

No funding was received for this study.

Impact of malnutrition on mortality and neurological recovery of older patients with spinal cord injury

This retrospective cohort study established malnutrition's impact on mortality and neurological recovery of older patients with cervical spinal cord injury (SCI). It included patients aged ≥ 65 years with traumatic cervical SCI treated conservatively or surgically. The Geriatric Nutritional Risk Index was calculated to assess nutritional-related risk. Overall, 789 patients (mean follow-up: 20.1 months) were examined and 47 had major nutritional-related risks on admission. One-year mortality rate, median survival time, neurological recovery, and activities of daily living (ADL) at 1 year post-injury were compared between patients with major nutrition-related risk and matched controls selected using 1:2 propensity score matching to adjust for age, pre-traumatic neurological impairment, and activity. In the Kaplan-Meier analysis, the median survival times were 44.9 and 76.5 months for patients with major nutrition-related risk and matched controls, respectively (p = 0.015). Matched controls had more individuals with a neurological improvement of American Spinal Injury Association Impairment Scale ≥ 1 grade (p = 0.039) and independence in ADL at 1 year post-injury than patients with major nutrition-related risk (p < 0.05). In conclusion, 6% of older patients with cervical SCI had major nutrition-related risks; they showed a significantly higher 1 year mortality rate, shorter survival time, poorer neurological improvement, and lower ADL at 1 year post-injury than matched controls.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study

BACKGROUND

Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury.

METHODS

In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery.

RESULTS

The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement.

CONCLUSIONS

Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Prognostic Factors for Respiratory Dysfunction for Cervical Spinal Cord Injury and/or Cervical Fractures in Elderly Patients: A Multicenter Survey

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

The purpose of this study was to investigate the prognosis of respiratory function in elderly patients with cervical spinal cord injury (SCI) and to identify predictive factors.

METHODS

We included 1353 cases of elderly cervical SCI patients collected from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were defined as the respiratory disability group. Patients' background characteristics, injury mechanism, injury form, neurological disability, complications, and treatment methods were compared between the disability and non-disability groups. Multiple logistic regression analysis was used to examine the independent factors. Patients who required respiratory management for 6 months or longer after injury and those who died of respiratory complications were classified into the severe disability group and were compared with minor cases who were weaned off the respirator.

RESULTS

A total of 104 patients (7.8%) had impaired respiratory function. Comparisons between the disabled and non-disabled groups and between the severe and mild injury groups yielded distinct trends. In multiple logistic regression analysis, age, blood glucose level, presence of ossification of posterior longitudinal ligament (OPLL), anterior vertebral hematoma, and critical paralysis were selected as independent risk factors.

CONCLUSION

Age, OPLL, severe paralysis, anterior vertebral hematoma, hypoalbuminemia, and blood glucose level at the time of injury were independent factors for respiratory failure. Hyperglycemia may have a negative effect on respiratory function in this condition.

Prognostic impact of respiratory dysfunction in elderly patients with cervical spinal cord injury and/or fractures: a multicenter survey

PURPOSE

To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures.

METHODS

We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups.

RESULTS

Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis.

CONCLUSION

Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor.

Prognosis of Cervical Diffuse Idiopathic Skeletal Hyperostosis-Related Spine Injuries in Elderly Patients: Analyses of Both Fracture and Spinal Cord Injury Without Fracture

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures.

METHODS

The current multicenter study was a retrospective analysis of 140 patients aged 65 years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury.

RESULTS

Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6 months as compared with controls. Fourteen patients died within 3 months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality.

CONCLUSIONS

The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.

Effects of Dementia on Outcomes after Cervical Spine Injuries in Elderly Patients: Evaluation of 1512 Cases in a Nationwide Multicenter Study in Japan

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan-Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

Risk Factors for Early Mortality in Older Patients with Traumatic Cervical Spine Injuries-A Multicenter Retrospective Study of 1512 Cases

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.

Epidemiology of Cervical Fracture/Cervical Spinal Cord Injury and Changes in Surgical Treatment Modalities in Elderly Individuals During a 10-year Period: A Nationwide Multicenter Study in Japan

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate changes over a 10-years period in the profile of cervical spine and spinal cord injuries among the elderly in Japan.

METHODS

The current multicenter study was a retrospective analysis of inpatients aged ≥65 years, suffering cervical fracture (CF) and/or cervical spinal cord injury (CSCI). We analyzed 1413 patients' epidemiology (from 2010 to 2019). Moreover, 727 patients who underwent surgical treatment were analyzed in 2 groups: the early (2010-2014) and late period (2015-2019).

RESULTS

Both the number of patients and number of surgical patients showed a significant increasing trend (P < .001), while the mean age, the distribution of injury levels and paralysis severity, and the proportion of surgical indications remained the same. The number of surgical patients doubled from 228 to 499 from the early to late periods. Posterior surgery was the most common approach (90.4%), instrumentation surgery with screws increased significantly, and the range of fusion was significantly longer in the late period (2.1 vs 2.7 levels, P = .001). Significantly worsening neurological symptoms were recorded in the late period (1.3% vs 5.8%, P = .006), with C5 palsy being the major one. Otherwise, perioperative, major, and other complications, including mortality, did not differ significantly in incidence.

CONCLUSIONS

Both the number of elderly CF and/or CSCI patients and number of patients undergoing surgery increased dramatically over the decade without any change in profile. Instrumentation surgeries with screws increased, without an increase in systemic complications.

Factors Affecting the Waiting Time from Injury to Surgery in Elderly Patients with a Cervical Spine Injury: A Japanese Multicenter Survey

OBJECTIVE

The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with a cervical spine injury.

METHODS

We retrospectively reviewed the case histories of 1512 Japanese patients with a cervical spinal injury, who were seen at 33 institutions. After excluding patients who were not initially receiving a surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery.

RESULTS

The mean time from injury to surgery was 12.3 days. Multivariate analysis revealed delays of 10.7 days for a renal disorder, 7.3 days for anticoagulant use, and 15.2 days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5 days to surgery.

CONCLUSIONS

This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.

A multicenter study of 1-year mortality and walking capacity after spinal fusion surgery for cervical fracture in elderly patients

Background

The 1-year mortality and functional prognoses of patients who received surgery for cervical trauma in the elderly remains unclear. The aim of this study is to investigate the rates of, and factors associated with mortality and the deterioration in walking capacity occurring 1 year after spinal fusion surgery for cervical fractures in patients 65 years of age or older.

Methods

Three hundred thirteen patients aged 65 years or more with a traumatic cervical fracture who received spinal fusion surgery were enrolled. The patients were divided into a survival group and a mortality group, or a maintained walking capacity group and a deteriorated walking capacity group. We compared patients’ backgrounds, trauma, and surgical parameters between the two groups. To identify factors associated with mortality or a deteriorated walking capacity 1 year postoperatively, a multivariate logistic regression analysis was conducted.

Results

One year postoperatively, the rate of mortality was 8%. A higher Charlson comorbidity index (CCI) score, a more severe the American Spinal Cord Injury Association impairment scale (AIS), and longer surgical time were identified as independent factors associated with an increase in 1-year mortality. The rate of deterioration in walking capacity between pre-trauma and 1 year postoperatively was 33%. A more severe AIS, lower albumin (Alb) and hemoglobin (Hb) values, and a larger number of fused segments were identified as independent factors associated with the increased risk of deteriorated walking capacity 1 year postoperatively.

Conclusions

The 1-year rate of mortality after spinal fusion surgery for cervical fracture in patients 65 years of age or older was 8%, and its associated factors were a higher CCI score, a more severe AIS, and a longer surgical time. The rate of deterioration in walking capacity was 33%, and its associated factors were a more severe AIS, lower Alb, lower Hb values, and a larger number of fused segments.

Is Blood Loss Greater in Elderly Patients under Antiplatelet or Anticoagulant Medication for Cervical Spine Injury Surgery? A Japanese Multicenter Survey

Introduction

In elderly patients with cervical spinal cord injury, comorbidities such as cardiovascular and cerebrovascular diseases are common, with frequent administration of antiplatelet/anticoagulant (APAC) drugs. Such patients may bleed easily or unexpectedly during surgery despite prior withdrawal of APAC medication. Few reports have examined the precise relationship between intraoperative blood loss and history of APAC use regarding surgery for cervical spine injury in the elderly. The present multicenter database survey aimed to answer the question of whether the use of APAC drugs affected the amount of intraoperative blood loss in elderly patients with cervical spinal cord trauma.

Methods

The case histories of 1512 patients with cervical spine injury at 33 institutes were retrospectively reviewed. After excluding cases without spinal surgery or known blood loss volume, 797 patients were enrolled. Blood volume loss was the outcome of interest. We calculated propensity scores using the inverse probability of treatment weighting (IPTW) method. As an alternative sensitivity analysis, linear mixed model analyses were conducted as well.

Results

Of the 776 patients (mean age: 75.1±6.4 years) eligible for IPTW calculation, 157 (20.2%) were taking APAC medications before the injury. After weighting, mean estimated blood loss was 204 mL for non-APAC patients and 215 mL for APAC patients. APAC use in elderly patients was not significantly associated with surgical blood loss according to the IPTW method with propensity scoring or linear mixed model analyses. Thus, it appeared possible to perform surgery expecting comparable blood loss in APAC and non-APAC cases.

Conclusions

This multicenter study revealed no significant increase in surgical blood loss in elderly patients with cervical trauma taking APAC drugs. Surgeons may be able to prioritize patient background, complications, and preexisting conditions over APAC use before injury when examining the surgical indications for cervical spine trauma in the elderly.

Does surgery improve neurological outcomes in older individuals with cervical spinal cord injury without bone injury? A multicenter study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury.

SETTING

Thirty-three medical institutions in Japan.

METHODS

This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed.

RESULTS

After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was <10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%).

CONCLUSION

Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.

AB0431 THE EFFICACY OF BELIMUMAB (BEL) AS A SPARING CORTICOSTEROID AGENCY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

Patients with SLE are recommended to continue the maintenance therapy with as less glucocorticoid as possible.1) However, tapering glucocorticoid often results in the recurrence of SLE. Current reports suggested that adding BEL to the standard therapy could lead to the reduction of glucocorticoid and the recurrence of SLE.2)

Objectives

The aim of this study is to evaluate the efficacy and the safety of BEL as co-treatment in the standard therapy of SLE.

Methods

Fourteen patients receiving the maintenance therapy of SLE were enrolled in this study. Dose of prednisolone (PSL), titer of anti-DNA antibody, WBC count, serum complement and SLE disease activity index (SLEDAI) were examined retrospectively at baseline and 24 months after administration of BEL.

Results

At the baseline, the mean age of patients was 48 years old, 11 patients were female, and the mean disease duration was 8.6 years. The mean dose of PSL was significantly reduced (meansease apre-administration of BEL:6.1±1.1 mg/day, 24 months after administration of BEL: 1.2 the baseline,p=0.001). Furthermore, six patients (43 %) could withdraw PSL without the flare of the disease. There were also statistical significance about SLEDAI between baseline and after treatment by BEL(2.1patients (43 %) cp=0.03) and the titer of anti-DNA antibody (6.8 withdraw PSL without tp=0.03). There were no statistical significant in WBC count (6177out the fla7e of the dp=0.24) and serum complement (C3 87significant in WBC count (61p=0.78, C4 20erum complement (C3 87signifp=0.54).

As for adverse event, bacterial pneumonia (n=1) and pulmonary cryptococcosis (n=1) was revealed.

Conclusion

Our study is suggested that co-treatment with BEL on standard SLE therapy was enable to prevent the flare of SLE and reduce the dose of PSL with statistical significance among the patients under the maintenance treatment of SLE. In almost half of the cases, patients could withdraw PSL without the flare.

References

[1]Ann Rheum Dis 2019; 78: 736-745.

[2]Ann Rheum Dis 2018; 77: 355-745.

Disclosure of Interests

None declared

Effect of Minimally Invasive Spine Stabilization in Metastatic Spinal Tumors

Background and Objectives: There have been numerous advances in spine surgery for metastatic spinal tumors, and minimally invasive spine stabilization (MISt) is becoming increasingly popular in Japan. MISt is a minimally invasive fixation procedure that temporarily stabilizes the spine, thereby reducing pain, preventing pathological fractures, and improving activities of daily living at an early stage. MISt may be useful given the recent shift toward outpatient cancer treatment. Materials and Methods: This study enrolled 51 patients with metastatic spinal tumors who underwent surgery using MISt between December 2013 and October 2020. The Spinal Instability Neoplastic Score, an assessment of spinal instability, was used to determine the indication for surgery, and the Epidural Spinal Cord Compression scale was used for additional decompression. Results: The patients comprised 34 men and 17 women, and the mean age at surgery was 68.9 years. The mean postoperative follow-up period was 20.8 months, and 35 of 51 patients (67%) had died by the last survey. The mean operative time was 159.8 min, mean blood loss was 115.7 mL, and mean time to ambulation was 3.2 days. No perioperative complications were observed, although two patients required refixation surgery. Preoperatively, 37 patients (72.5%) were classified as Frankel grade E. There were no cases of postoperative exacerbation, and six patients showed improvement of one or more Frankel grades after surgery. The median duration of patient survival was about 22.0 months. Patients with breast, prostate, renal, and thyroid cancers had a good prognosis, whereas those with gastrointestinal and head and neck cancers had a poor prognosis. Conclusions: MISt can benefit patients who are ineligible for conventional, highly invasive surgery and is also suitable because cancer treatment is increasingly performed on an outpatient basis. Furthermore, choosing the right surgery for the right patient at the right time can significantly affect life expectancy.

Prophylactic Effect of Liaison Treatment on the Occurrence of Skeletal-Related Events in Patients with Metastatic Spinal Tumours: An Exploratory Interrupted Time Series Study

Introduction

There is a growing momentum for the collaboration between multiple disciplines for the prevention and treatment of skeletal-related events (SREs) in patients with metastatic spinal tumors. However, the effectiveness of multidisciplinary approaches remains unclear. Hence, we conducted an exploratory study to examine the impact of liaison treatment for metastatic spinal tumor (LMST) on the prevention of SREs among patients with a metastatic spinal tumor.

Methods

This study was an exploratory interrupted time series conducted in a single medical center. Overall, 1,043 patients with a metastatic spinal tumor diagnosed between January 2011 and December 2020 were included. The LMST was implemented in January 2014. The LMST team consisted of the orthopedic surgery, thoracic surgery, breast and thyroid surgery, clinical oncology, urology, and radiology departments. Monthly joint conferences were held for patients with spinal instability, and the incidence of SRE was measured at 6-month intervals.

Results

Throughout the study period, we identified 66 SRE incidences. After the implementation of the LMST, a level change of −5.2% (95% confidence interval [CI]: −11.7 to 1.3, p = 0.11) was observed. Subsequently, a post-implementation trend change of −0.3% (95% CI: −2.0 to 1.5, p = 0.75) beyond the baseline was noted.

Conclusions

We suggest both immediate and gradual effects of the introduction of the LMST on deterring the development of SREs. Our results support the global trend of introducing a multidisciplinary approach for the treatment of metastatic spinal tumors.

POS0603 ANALYSIS OF FACTORS ASSOCIATED WITH THE EFFECTIVENESS OF ABATACEPT IN THE ORIGAMI STUDY

Background:

The ORIGAMI study is a multicenter, observational study to evaluate the effectiveness, safety, and patient-reported outcomes of abatacept (ABA) in Japanese patients with csDMARD-resistant, Simplified Disease Activity Index (SDAI)-moderate, biologic-naïve rheumatoid arthritis (RA). ABA has shown better effectiveness/efficacy in RA patients with anti-cyclic citrullinated peptide antibody (ACPA) positive (1) and high ACPA titer (2) compared to ACPA negative and low ACPA titer, respectively. However, more accurate predictors of effectiveness in clinical practice are needed than ACPA status.

Objectives:

This post-hoc analysis is aimed to determine the association between ACPA and ABA effectiveness (disease activity and physical function) or retention rate and to investigate other factors associated with the effectiveness of ABA in patients enrolled in the ORIGAMI study.

Methods:

Of the 279 patients in the effectiveness analysis set of the ORIGAMI study, 270 patients with baseline ACPA measurement were analyzed. The patients were divided into the ACPA-positive group (ACPA +ve, ≥4.5 U/mL at baseline) and the ACPA-negative group (ACPA –ve, <4.5 U/mL). Patients’ characteristics, changes in disease activity and physical function (Japanese Health Assessment Questionnaire; J-HAQ) through 52 weeks, and retention rates of ABA at week 52 were evaluated. Baseline characteristics and use of concomitant drugs were analyzed as independent variables by multiple regression analysis using a standard linear model adjusted by SDAI at week 0 to identify factors associated with SDAI change at week 52. In addition, the interaction effects among ACPA status, RF status, and the factor that was significantly associated with SDAI change in multiple regression analysis on changes in SDAI were explored.

Results:

The numbers of ACPA +ve and –ve patients were 226 and 44, respectively. ACPA values (mean ± SD, U/mL) were 280.3 ± 376.8 and 0.9 ± 0.7, and rheumatoid factor (RF) values were 174.8 ± 302.6 and 20.9 ± 61.7 in the ACPA +ve and –ve groups, respectively. Mean (95% confidence interval) changes in SDAI at week 52 were −11.3 (−12.4 to −10.3) and −8.0 (−10.5 to −5.5), and those in J-HAQ were −0.27 (−0.34 to −0.20) and −0.16 (−0.34 to 0.01) in the ACPA +ve and –ve groups, respectively. In the Kaplan–Meier analysis, the retention rates of ABA at week 52 in the ACPA +ve and –ve groups were 72.1% and 58.7%, (discontinuation for any reason), and 91.6% and 75.7% (discontinuation because of lack of effectiveness), respectively. In a multiple regression analysis, the duration of disease (< 1 year) was associated with the change in SDAI at week 52. With respect to SDAI changes, the estimated difference of ACPA +ve and disease duration (< 1 year), ACPA +ve and disease duration (≥1 year), and ACPA –ve and disease duration (< 1 year), versus ACPA −ve and disease duration (≥ 1 year), were −4.26 (p = 0.022), −0.82 (p = 0.618), and −0.93 (p = 0.716), respectively (Fig. 1). The estimated difference of ACPA +ve and RF +ve, ACPA +ve and RF –ve, and ACPA –ve and RF +ve, versus ACPA –ve and RF –ve, were −2.48 (p = 0.060), −2.77 (p = 0.107), and −5.48 (p = 0.087), respectively.

Conclusion:

A higher retention rate as well as better effectiveness of ABA on disease activity and physical function in ACPA +ve group versus ACPA –ve group were shown in the simple subgroup analysis. ABA effectiveness on the SDAI change was significantly better in patients with disease duration <1 year and ACPA +ve compared to those with ACPA −ve and disease duration ≥ 1 year.

References:

[1]Harrold LR et al. J Rheumatol 2018;45(1):32–39.

[2]Sokolove J et al. Ann Rheum Dis 2016;75(4):709–714.

Disclosure of Interests:

Kenta Misaki Speakers bureau: Eisai Co., Ltd., AbbVie GK, Eli Lilly Japan K.K., Ono Pharmaceutical Co., Ltd., Grant/research support from: Ono Pharmaceutical Co., Ltd., Eiichi Tanaka Speakers bureau: AbbVie GK, Asahi Kasei Pharma Corporation, Astellas Pharma Inc, Ayumi Pharmaceutical Corporation, Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kyowa Pharma Chemical Co., Ltd., Janssen Pharmaceutical K.K., Mochida Pharmaceutical Co., Ltd., Pfizer, Takeda Pharmaceutical Co., Ltd, and Teijin Pharma Ltd., Eisuke Inoue Speakers bureau: Pfizer Japan, Bristol-Myers Squibb K.K., Katsuki Tsuritani Employee of: Bristol-Myers Squibb K.K., Shigeru Matsumoto Employee of: Ono Pharmaceutical Co., Ltd., Hisashi Yamanaka Consultant of: Bristol-Myers Squibb K.K., masayoshi harigai Speakers bureau: AbbVie GK, Ayumi Pharmaceutical Corporation, Bristol-Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Pfizer Japan Inc., and Takeda Pharmaceutical Co., Ltd., Consultant of: AbbVie GK, Bristol-Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., and Gilead Sciences Inc., Grant/research support from: AbbVie GK, and Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Corporation, Bristol-Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd. Daiichi-Sankyo, Inc., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Corporation., Nippon Kayaku Co., Ltd., Taisho Pharmaceutical Co., Ltd., and Takeda Pharmaceutical Co., Ltd.

AB0381 THE UTILITY OF HYDROXYCHLOROQUINE (HCQ) THERAPY FOR TWO YEARS AS A SPARING CORTICOSTEROID AGENCY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

Prednisolone (PSL) and HCQ are key drugs in the therapy of SLE. However, since PSL induce many harmful adverse events, PSL is preferred to be reduced especially in the maintenance therapy. The efficacy of HCQ for reducing the dose of PSL has not been revealed yet. So, we focused on the cessation of PSL under the treatment of HCQ with conventional SLE therapy.

Objectives:

The aim of this study is to evaluate the efficacy and the safety of HCQ as co-treatment in the standard therapy of SLE.

Methods:

SLE patients (n=30) under the maintenance therapy were enrolled in this study. Dose of PSL, titer of anti-DNA antibody, WBC count, serum complement and SLE disease activity index (SLEDAI) were examined retrospectively at 0 and 12 months after administration of HCQ.

Results:

Baseline patient-characteristics are as follows (mean±S.E); the age of patients was 54.4±3.2 years old, 21 patients (70%) were female, the disease duration was 108.5±25.2 months, SLEDAI was 4.0±0.9, the dose of PSL was 10.3±1.7 mg/day, the titer of anti-DNA antibody was 7.3±1.8 IU/ml, C3 was 85±4.3 mg/dl and C4 was 18±1.6 mg/dl.

The mean dose of PSL was reduced with statistically significance (pre-administration of HCQ:10.3±1.7 mg/day, 24 months after administration of HCQ:2.2±0.3 mg/day,p<0.0001). Furthermore, in this observation period, 6 patients could achieve the cessation of PSL.

SLEDAI was also significantly reduced (4.0±0.9 vs 1.0±0.3,p<0.01).

There was no statistical significance between before treatment by HCQ and after treatment in the titer of anti-DNA antibody (7.3±1.8 vs 2.8±1.6 IU/ml,p=0.06), WBC count (6208±4.9 vs 5096±3.3 /μl,p=0.06) and serum complement level (C3 85±4.3 mg/dl vs 89±4.0 mg/dl,p=0.52, C4 18±1.6 mg/dl vs 19±1.4 mg/dl,p=0.45). Relapse of SLE was clarified in only one patient.

As for adverse events (AEs), Severe bacterial infection (n=4), herpes zoster (n=1) and patellar tendon rupture (n=1) were revealed. All cases of the AEs were fully recovered.

Conclusion:

Our study suggested that co-treatment with HCQ on standard SLE therapy could be enable to prevent the flare of SLE and reduce the dose of PSL with statistical significance. In some cases, we could achieve the cessation of PSL treatment.

References:

None.

Disclosure of Interests:

None declared

Identification of Vortex Cores in Cerebral Aneurysms on 4D Flow MRI

BACKGROUND AND PURPOSE

The complexity and instability of the vortex flow in aneurysms are factors related to the rupture risk of unruptured cerebral aneurysms. We identified aneurysm vortex cores on 4D flow MR imaging and examined the relationship of these factors with the characteristics of cerebral aneurysms.

MATERIALS AND METHODS

We subjected 40 aneurysms (37 unruptured, 3 ruptured) to 4D flow MR imaging. We visualized streamlines with velocities below the threshold-that is, a percentage value of the aneurysm maximum inflow velocity-and progressively decreased the threshold to identify vortex cores as thin, streamline bundles with minimum velocities. Complexity and stability were compared in aneurysms with a smooth surface and those with blebs or daughter sacs.

RESULTS

The threshold for visualizing vortex cores ranged from 3% to 13% of the maximum inflow velocity. Vortex cores could be visualized in 38 aneurysms; in 2, they were not visualized through the cardiac cycle. A simple flow pattern (single vortex core) was identified in 27 aneurysms; the other 13 exhibited a complex flow pattern. The cores were stable in 32 and unstable in 8 aneurysms. Significantly more aneurysms with-than-without blebs or daughter sacs had a complex flow pattern (P = .006). Of the 3 ruptured aneurysms, 1 aneurysm had an unstable vortex core; in the other 2, the vortex core was not visualized.

CONCLUSIONS

The identification of vortex cores on 4D flow MR imaging may help to stratify the rupture risk of unruptured cerebral aneurysms.

Inflow Jet Patterns of Unruptured Cerebral Aneurysms Based on the Flow Velocity in the Parent Artery: Evaluation Using 4D Flow MRI

BACKGROUND AND PURPOSE

Inflow jet characteristics may be related to aneurysmal bleb formation and rupture. We investigated the visualization threshold on the basis of the flow velocity in the parent artery to classify the inflow jet patterns observed on 4D flow MR imaging.

MATERIALS AND METHODS

Fifty-seven unruptured aneurysms (24 bifurcation and 33 sidewall aneurysms) were subjected to 4D flow MR imaging to visualize inflow streamline bundles whose velocity exceeded visualization thresholds corresponding to 60%, 75%, and 90% of the maximum flow velocity in the parent artery. The shape of the streamline bundle was determined visually, and the inflow jet patterns were classified as concentrated, diffuse, neck-limited, and unvisualized.

RESULTS

At the 75% threshold, bifurcation aneurysms exhibited a concentrated inflow jet pattern at the highest rate. At this threshold, the inflow jets were concentrated in 13 aneurysms (group C, 22.8%), diffuse in 18 (group D, 31.6%), neck-limited in 11 (group N, 19.3%), and unvisualized in 15 (group U, 26.3%). In 16 (28.1%) of the 57 aneurysms, the inflow jet pattern was different at various thresholds. Most inflow parameters, including the maximum inflow velocity and rate, the inflow velocity ratio, and the inflow rate ratio, were significantly higher in groups C and D than in groups N and U.

CONCLUSIONS

The inflow jet pattern may depend on the threshold applied to visualize the inflow streamlines on 4D flow MR imaging. For the classification of the inflow jet patterns on 4D flow MR imaging, the 75% threshold may be optimal among the 3 thresholds corresponding to 60%, 75%, and 90% of the maximum flow velocity in the parent artery.

Parent artery curvature influences inflow zone location of unruptured sidewall internal carotid artery aneurysms

BACKGROUND AND PURPOSE

Future aneurysmal behaviors or treatment outcomes of cerebral aneurysms may be related to the hemodynamics around the inflow zone. Here we investigated the influence of parent artery curvature on the inflow zone location of unruptured sidewall internal carotid artery aneurysms.

MATERIALS AND METHODS

In 32 aneurysms, the inflow zone location was decided by 4D flow MR imaging, and the radius of the parent artery curvature was measured in 2D on an en face image of the section plane corresponding to the aneurysm orifice.

RESULTS

The inflow zone was on the distal neck in 10 (group 1, 31.3%), on the lateral side in 19 (group 2, 59.4%), and on the proximal neck in 3 (group 3, 9.4%) aneurysms. The radius in group 1 was significantly larger than that in group 2 (8.3 mm [4.5 mm] versus 4.5 mm [1.9 mm]; median [interquartile range]; P < .0001). All 7 aneurysms with a radius of >8.0 mm were in group 1. All 18 aneurysms with a radius of <6.0 mm were in group 2 or 3. In two group 3 aneurysms, the inflow zone was located in a part of the neck extending beyond the central axis of the parent artery.

CONCLUSIONS

The inflow zone locations of sidewall aneurysms can be influenced by the parent artery curvature evaluated in 2D on an en face image of the section plane corresponding to the aneurysm orifice.

Identification of the inflow zone of unruptured cerebral aneurysms: comparison of 4D flow MRI and 3D TOF MRA data

BACKGROUND AND PURPOSE

The hemodynamics of the inflow zone of cerebral aneurysms may be a key factor in coil compaction and recanalization after endovascular coil embolization. We performed 4D flow MR imaging in conjunction with 3D TOF MRA and compared their ability to identify the inflow zone of unruptured cerebral aneurysms.

MATERIALS AND METHODS

This series comprised 50 unruptured saccular cerebral aneurysms in 44 patients. Transluminal color-coded 3D MRA images were created by selecting the signal-intensity ranges on 3D TOF MRA images that corresponded with both the luminal margin and the putative inflow.

RESULTS

4D flow MR imaging demonstrated the inflow zone and yielded inflow velocity profiles for all 50 aneurysms. In 18 of 24 lateral-projection aneurysms (75%), the inflow zone was located distally on the aneurysmal neck. The maximum inflow velocity ranged from 285 to 922 mm/s. On 4D flow MR imaging and transluminal color-coded 3D MRA studies, the inflow zone of 32 aneurysms (64%) was at a similar location. In 91% of aneurysms whose neck section plane angle was <30° with respect to the imaging section direction on 3D TOF MRA, depiction of the inflow zone was similar on transluminal color-coded 3D MRA and 4D flow MR images.

CONCLUSIONS

4D flow MR imaging can demonstrate the inflow zone and provide inflow velocity profiles. In aneurysms whose angle of the neck-section plane is obtuse vis-a-vis the imaging section on 3D TOF MRA scans, transluminal color-coded 3D MRA may depict the inflow zone reliably.

Abnormal distributions of callosal commissural and corticothalamic neurons in the cerebral neocortex of Shaking Rat Kawasaki

Shaking Rat Kawasaki (SRK) is an autosomal recessive mutant rat recognized by unstable gait and tremor and by early death around the time of weaning. We previously reported that corticospinal tract neurons are malpositioned in the motor cortex of the SRK rat [Ikeda and Terashima (1997) J. Comp. Neurol. 383, 370-380]. In the present study, we examined the distribution pattern of callosal commissural (CC) and corticothalamic (CT) neurons of SRK and normal rats with the injection of horseradish peroxidase (HRP) into the contralateral hemisphere or wheat germ agglutinin-conjugated HRP into the ventral lateral thalamic nucleus. The intracortical distribution pattern of retrogradely labeled CC and CT neurons in the motor cortex of SRK rat was abnormal: CC neurons were more deeply situated and CT neurons were more superficially situated in the SRK cortex than the corresponding components in the normal cortex. Most of labeled CC and CT neurons had abnormal dendritic configurations. Statistical analysis revealed that the difference of the mean intracortical position of CC and CT neurons of the SRK was significantly different from the normal counterparts (Student's t-test, P<0.01). Taken together with previous findings, our data demonstrate that the abnormal cytoarchitecture of SRK cortex resembles the reeler cortex.

Contrast-enhanced fluid-attenuated inversion recovery MRI is useful to detect the CSF dissemination of glioblastoma

We present three cases of glioblastoma with CSF dissemination that contrast-enhanced fluid-attenuated inversion recovery MRI was sensitive enough to detect compared with contrast-enhanced T1-weighted MRI. An autopsy was performed on one patient, and its histologic findings proved the existence of CSF dissemination.

Microglial signaling by amyloid beta protein through mitogen-activated protein kinase mediating phosphorylation of MARCKS

Myristoylated alanine-rich C kinase substrate (MARCKS), an acidic protein associated with cell motility and phagocytosis, is activated upon phosphorylation by protein kinase C (PKC) and proline-directed protein kinases. In Alzheimer disease (AD), activated microglia expressing MARCKS migrates around senile plaques. We reported that amyloid beta protein (A beta), a major component of senile plaques, activated MARCKS through a tyrosine kinase and PKC-delta. We have now identified another A beta signaling pathway through a mitogen-activated protein kinase (MAPK) involved in the phosphorylation of MARCKS and analysed cross-talk between PKC and MAPK pathways in primary cultured rat microglia. A selective inhibitor for MAPK kinase, PD098059, significantly inhibited the phosphorylation of MARCKS induced by A beta. Extracellulary regulated kinases, the activities of which were induced by A beta, directly phosphorylated a recombinant MARCKS in vitro. The MAPK pathway was sensitive to wortmannin, but not to a PKC inhibitor or to tyrosine kinase inhibitors. The activation of PKC by A beta was not sensitive to wortmannin. Our findings suggest involvement of the MAPK pathway through phosphoinositol 3-kinase in the phosphorylation of MARCKS in rat cultured microglia, an event may be associated with mechanisms activating microglia in AD.

X-Ray Telescope Onboard Astro-E. II. Ground-Based X-Ray Characterization

X-ray characterization measurements of the x-ray telescope (XRT) onboard the Astro-E satellite were carried out at the Institute of Space and Astronautical Science (Japan) x-ray beam facility by means of a raster scan with a narrow x-ray pencil beam. The on-axis half-power diameter (HPD) was evaluated to be 1.8?-2.2?, irrespective of the x-ray energy. The on-axis effective areas of the XRTs for x-ray imaging spectrometers (XISs) were approximately 440, 320, 240, and 170 cm(2) at energies of 1.49, 4.51, 8.04, and 9.44 keV, respectively. Those of the x-ray spectrometer (XRS) were larger by 5-10%. The replication method introduced for reflector production significantly improved the imaging capability of the Advanced Satellite for Cosmology and Astrophyics (ASCA) XRT, whose HPD is ~3.6?. The increase in the effective area by a factor of 1.5-2.5, depending upon the x-ray energy, compared with that of the ASCA, was brought about by mechanical scale up and longer focal lengths. The off-axis HPDs were almost the same as those obtained on the optical axis. The field of view is defined as the off-axis angle at which the effective area becomes half of the on-axis value. The diameter of the field of view was ~19? at 1.49 keV, decreasing with increasing x-ray energy, and became ~13? at 9.44 keV. The intensity of stray light and the distribution of this kind of light on the focal plane were measured at the large off-axis angles 30? and 60?. In the entire XIS field of view (25.4 mm x 25.4 mm), the intensity of the stray light caused by a pointlike x-ray source became at most 1% of the same pointlike source that was on the optical axis.

Human sleep EEG analysis using the correlation dimension

Sleep electroencephalograms (EEG) were analyzed by non-linear analysis. Polysomnography (PSG) of nine healthy male subjects was analyzed and the correlation dimension (D2) was calculated. The D2 characterizes the dynamics of the sleep EEG, estimates the degrees of freedom, and describes the complexity of the signal. The mean D2 decreased from the awake stage to stages 1, 2, 3 and 4 increased during rapid eye movement (REM) sleep. The D2 during each REM sleep stage were high and those during each slow wave sleep stage were low, respectively, for each sleep cycle. The mean D2 of the sleep EEG in the second half of the night was significantly higher than those in the first half of the night. Significant changes were also observed during sleep stage 2, but were not seen during REM sleep and sleep stages 3 and 4. The D2 may be a useful method in the analysis of the entire sleep EEG.

Ethanol effect on sleep electroencephalogram by the correlation dimension

The influence on sleep of alcohol (ethanol) was investigated in nine males using the correlation dimension (CD). Polysomnography (PSG) was recorded on a baseline night (BL-N) and on an ethanol (0.8 g/kg) night (Et-N). The mean correlation dimensions on Et-N, as well as on BL-N, significantly decreased from sleep stage 'awake' to sleep Stages 1, 2 and 3 and increased during rapid eye movement (REM) sleep. The mean correlation dimensions of the sleep EEG during sleep Stage 2 and those for the second sleep cycle on the Et-N were significantly higher than those on the BL-N. The changes in the correlation dimensions between sleep cycles were reduced on Et-N as compared to BL-N.

X-ray telescope onboard Astro-E: optical design and fabrication of thin foil mirrors

X-ray telescopes (XRT's) of nested thin foil mirrors are developed for Astro-E, the fifth Japanese x-ray astronomy satellite. Although the launch was not successful, the design concept, fabrication, and alignment procedure are summarized. The main purpose of the Astro-E XRT is to collect hard x rays up to 10 keV with high efficiency and to provide medium spatial resolution in limited weight and volume. Compared with the previous mission, Advanced Satellite for Cosmology and Astrophysics (ASCA), a slightly longer focal length of 4.5-4.75 m and a larger diameter of 40 cm yields an effective area of 1750 cm2 at 8 keV with five telescopes. The image quality is also improved to 2-arc min half-power diameter by introduction of a replication process. Platinum is used instead of gold for the reflectors of one of the five telescopes to enhance the high-energy response. The fabrication and alignment procedure is also summarized. Several methods for improvement are suggested for the reflight Astro-E II mission and for other future missions. Preflight calibration results will be described in a forthcoming second paper, and a detailed study of images will be presented in a third paper.

PKN delays mitotic timing by inhibition of Cdc25C: Possible involvement of PKN in the regulation of cell division

The role of PKN, a fatty acid- and Rho small GTPase-activated protein kinase, in cell-cycle regulation was analyzed. Microinjection of the active form of PKN into a Xenopus embryo caused cleavage arrest, whereas normal cell division proceeded in the control embryo microinjected with buffer or the inactive form of PKN. Exogenous addition of the active form of PKN delayed mitotic timing in Xenopus egg cycling extracts judging by morphology of sperm nuclei and Cdc2/cyclin B histone H1 kinase activity. The kinase-negative form of PKN did not affect the timing, suggesting that delayed mitotic timing depends on the kinase activity of PKN. The dephosphorylation of Tyr-15 of Cdc2 was also delayed in correlation with Cdc2/cyclin B histone H1 kinase activation in extracts containing active PKN. The Cdc25C activity for the dephosphorylation of Tyr-15 in Cdc2 was suppressed by pretreatment with the active form of PKN. Furthermore, PKN efficiently phosphorylated Cdc25C in vitro, indicating that PKN directly inhibits Cdc25C activity by phosphorylation. These results suggest that PKN plays a significant role in the control of mitotic timing by inhibition of Cdc25C.

Iron K Line Variability in the Low-Luminosity Active Galactic Nucleus NGC 4579

We present results of new ASCA observations of the low-luminosity active galactic nucleus (LLAGN) NGC 4579 obtained on 1998 December 18 and 28, and we report on the detection of variability of an iron K emission line. The X-ray luminosities in the 2-10 keV band for the two observations are nearly identical (LX approximately 2x1041 ergs s(-1)), but they are approximately 35% larger than that measured in 1995 July by Terashima et al. An Fe K emission line is detected at 6.39+/-0.09 keV (source rest frame), which is lower than the line energy 6.73+0.13-0.12 keV in the 1995 observation. If we fit the Fe lines with a blend of two Gaussians centered at 6.39 and 6.73 keV, the intensity of the 6.7 keV line decreases, while the intensity of the 6.4 keV line increases, within an interval of 3.5 yr. This variability rules out thermal plasmas in the host galaxy as the origin of the ionized Fe line in this LLAGN. The detection and variability of the 6.4 keV line indicates that cold matter subtends a large solid angle viewed from the nucleus and that it is located within approximately 1 pc from the nucleus. It could be identified with an optically thick standard accretion disk. If this is the case, a standard accretion disk is present at the Eddington ratio of Lbol/LEdd approximately 2x10-3. A broad disk-line profile is not clearly seen, and the structure of the innermost part of accretion disk remains unclear.

Analysis of the human sleep electroencephalogram by the correlation dimension

Sleep electroencephalograms (EEG) of healthy male subjects were analyzed by the correlation dimension. The mean correlation dimensions significantly decreased from stage 'awake' to stages 1, 2 and 3 and increased during rapid eye movement sleep. The mean correlation dimensions of the sleep EEG in the second half of the night were significantly higher than those in the first half of the night. These significant changes were also seen during sleep stage 2.

[Treatment of 522 patients with sudden deafness performed oxygenation at high pressure]

INTRODUCTION

Oxygenation at high pressure (OHP) is thought to be useful, even though regional blood flow is decreased, because increasing dissolved oxygen prevents the death of nerve tissue. In this report, we retrospectively investigated the effect of OHP on sudden deafness.

OBJECT AND METHOD

We reviewed 522 patients treated with OHP at Kagawa Rosai Hospital over a ten-year period (January 1989 to December 1998). We discussed some prognostic factors: comparison between cases which had been treated with OHP previously and those which had not, number of days between onset and beginning of the treatment which included OHP, age, initial averaged five-frequency hearing level, vertigo, tinnitus, complications of OHP, cases of relapse and the time of the onset, which is about season, month and week. OHP was administered at a pressure of 2.5 atmospheres for 80 minutes a day from 10 to 15 times. All patients also received a course of intravenous administration of steroid, vitamin B12, Prostaglandin E1, ATP, and low-molecular dextran.

RESULTS

Overall, complete recovery occurred in 19.7% of the patients, definite improvement in 34.9% (complete recovery included), and slight improvement in 58.1% (definite improvement included). Most of the patients (78.0%) were referred by other hospitals, because our hospital was the only one in the Sikoku area which had a big equipment of OHP. All 161 patients had already been treated in other hospitals over 8 days, but they had shown little improvement after the initial therapy. Of this group, complete recovery after the second course of treatment occurred in 13.0% of the patients, definite improvement in 19.3%, and slight improvement in 39.1%. OHP was thus effective for about 40% of patients who had been unresponsive to the initial therapy. Delay in treatment usually produces poor hearing recovery. There was a significant difference between those patients treated within 14 days and those treated 15 days or more after onset. The improvement rate also decreased with age. The prognosis of patients with vertigo was worse than those without vertigo. Tinnitus had no influence on the prognosis. There were no severe complications during the course of OHP, but otitis media with effusion occurred in 90 patients, and paracentesis was performed for 53 patients.

CONCLUSION

The treatment of sudden deafness with OHP has been discussed in this report. Important prognostic factors were time between onset and beginning of the treatment which included OHP, age, vertigo, and the initial averaged five-frequency hearing level. We conclude that OHP should be performed within 14 days from onset, and that OHP was able to achieve hearing improvement in many cases unresponsive to the initial therapy if it was performed very early.

Correlation dimension of the human sleep electroencephalogram

Sleep electroencephalogram (EEG) was analyzed by nonlinear analysis. Polysomnography of a healthy male subject was analyzed and the correlation dimension was calculated. The mean correlation dimensions decreased from stage 'awake' to stages 1, 2 and 3, and increased during rapid eye movement (REM) sleep. These results were also seen at every sleep cycle. During each sleep cycle the correlation dimensions decreased for slow wave sleep, then increased for REM sleep. The mean correlation dimension of the sleep EEG in the second half of the night was significantly higher than those in the first half of the night. A significant change was seen both during REM sleep as well as in sleep stage 2. Nonlinear analysis may be a useful method in the analysis of the entire sleep electroencephalogram.

Interaction of PKN with a neuron-specific basic helix-loop-helix transcription factor, NDRF/NeuroD2

By the yeast two-hybrid screening of a human brain cDNA library with the amino-terminal regulatory region of PKN as a bait, a clone encoding a neuron-specific basic Helix-Loop-Helix (bHLH) transcription factor, NDRF/NeuroD2 was isolated. NDRF/NeuroD2 was co-precipitated with PKN from the lysate of COS-7 cells transfected with both expression constructs for NDRF/NeuroD2 and PKN. In vitro binding studies using the deletion mutants of NDRF/NeuroD2 synthesized in a rabbit reticulocyte lysate indicated that the internal region containing the bHLH domain of NDRF/NeuroD2 was necessary and sufficient for the interaction with PKN. In addition, recombinant NDRF/NeuroD2 purified from Escherichia coli could bind PKN, suggesting the direct interaction between NDRF/NeuroD2 and PKN. Transient transfection assays using P19 cells revealed that expression of NDRF/NeuroD2 increased the transactivation of the rat insulin promoter element 3 (RIPE3) enhancer up to approximately 12-fold and that co-expression of catalytically active form of PKN, but not kinase-deficient derivative, resulted in a further threefold increase of NDRF/NeuroD2-mediated transcription. These findings suggest that PKN may contribute to transcriptional responses through the post-translational modification of the NDRF/NeuroD2-dependent transcriptional machinery.

Non-linear analysis of the sleep EEG

A sleep electroencephalogram was analyzed by non-linear analysis. The polysomnography of a healthy male subject was analyzed and the correlation dimensions calculated. The correlation dimensions decreased from the 'awake' stage to sleep stages 1-3 and increased during rapid eye movement (REM) sleep. These results were seen during each sleep cycle. In each sleep cycle, the correlation dimensions decrease for slow wave sleep, and increase for REM sleep.

Scar tissue distribution on palates and its relation to maxillary dental arch form

OBJECTIVE

This study investigated the relationship between maxillary dental arch form and distribution of postsurgical scar tissue on previously denuded bone in isolated cleft palate patients.

METHOD

The palatal blood flow of 21 Japanese isolated cleft palate patients (6 males, 15 females) was examined by laser doppler flowmetry to determine the scar tissue areas. All had undergone pushback operations for palatal repair at around 18 months of age. Tissue blood flow was examined at a time ranging from 11 years, 5 months to 19 years, 9 months of age. To evaluate the maxillary dental arch form, dental casts obtained at the start of orthodontic treatment (a mean age of 8 years, 4 months) were analyzed.

RESULTS/CONCLUSIONS

Scar tissue distribution in the 21 cases was classified into five types. Characteristic features in the maxillary dental arch form were found in each of the five types according to the extent of the scar tissue. It was evident that the severity of the maxillary dental arch constriction was closely related to the scar tissue distribution on palates.

Effect of flunitrazepam on sleep and memory

Flunitrazepam's (FNZ) effect on sleep and memory 1 mg and 2 mg was investigated in 6 healthy volunteers (mean age 21.5 +/- 0.8 years) by polysomnography (PSG) and memory testing. A PSG was recorded on each study night. Memory testing was done before sleep (40 min after taking FNZ or placebo), and after waking (560 min after medication). Rapid eye movement (REM) latency was found to be prolonged on the FNZ 2 mg night (FNZ2N) compared to the baseline night (BN). Percentage of stage 2 sleep was increased in the FNZ2N as compared to BN, while REM percentage on both FNZ nights did not significantly differ from BN. The number of total REM and REM density were decreased in the FNZ2N compared to BN. Memory testing showed significant differences between before sleep and after waking on the FNZ2N. There was a significant correlation between the degree of impairment on memory testing and the rate of reduced REM density, but there was no significant correlation between degree of impairment on memory testing and the rate of increased non-REM sleep on the FNZ2N. The results of this study suggest that impairments in memory result from the dose of FNZ, and that there is a possibility of a relationship between memory disturbance and REM sleep suppression caused by this benzodiazepine.

Alcohol effect on sleep electroencephalography by fast Fourier transformation

The influence of alcohol (ethanol) on sleep was investigated in 10 men. Polysomnography (PS) was recorded on a baseline night (BL-N) and an ethanol (0.8 g/kg) night (Et-N). On visual score rapid eye movement (REM) sleep was reduced, REM latency was prolonged on Et-N as compared to BL-N. Using the fast Fourier transformation method, electroencephalographic power density of REM sleep in delta frequencies band and in the 10-12 Hz range of non-REM sleep were enhanced. REM sleep and non-REM sleep changes were prominent in the second-half and first-half of the night, respectively.

[Limited operation for stage I lung cancer: a retrospective study]

Although lobectomy is standard therapy for Stage I non-small cell lung cancer, it often cannot be performed in poor-risk patients. In this report, we describe the results of a retrospective study to assess the usefulness of limited operation for stage I lung cancer. Over a 21-year period, 1,286 lung cancers were resected at our center. Among the 497 patients with stage I lung cancer, 36 sublobar resections were performed. There was only one surgery-related death, and the 5-year survival rate was 46% for all patients. At 5 years, survival was 69.2% for patients with squamous cell carcinoma and 33.7% for patients with adenocarcinoma. Survival rates were higher in patients who underwent mediastinoscopy than those who did not, and depended on histological findings and accurate pathological staging.

Nocturnal melatonin profiles before and one year after beginning shift-work

Nocturnal serum melatonin profiles were determined twice for seven single women, during their time of employment as nurses (baseline), and after one year (follow up), in order to investigate the effects of shift-work on nocturnal melatonin secretion. All subjects were working in the same hospital under an irregularly rotating three-shift system. Five (5) mL blood samples were drawn six times at 2 h intervals between 20:00-06:00 hours under dim light conditions (< 50 lux). The same sampling procedures were repeated the following year. The results showed pronounced inter-individual differences in melatonin concentrations. There was a trend towards increasing maximum melatonin concentration (MAX melatonin) at follow up, with a similar tendency seen in summed melatonin (the sum of six measured melatonin concentrations). A trend was also seen towards increasing melatonin ratio at 06:00 hours (the percentage of melatonin concentration at 06:00 hours by summed melatonin) at follow up. Melatonin concentration at 06:00 hours was significantly higher at follow up, and a significant correlation between Morningness-Eveningness score (M-E score) at baseline and increased summed melatonin at follow up was also seen. These results suggest that: nocturnal melatonin secretion does not significantly increase after beginning shift-work; and that greater increases in melatonin secretion at follow up are found in subjects with higher M-E scones (increased morning type). With more subjects, however, there may be significant increase in MAX melatonin and/or summed melatonin in the follow-up study.