Which Scoring System Best Predicts Long-term Survival in Patients with Spinal Metastasis in the Era of Targeted Systemic Treatment? A Comparative Study of Eight Prognostic Models.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To evaluate the accuracy of eight scoring systems, including the Tomita, modified Tokuhashi, modified Bauer, Rades, Oswestry Spinal Risk index (OSRI), Lei, New England Spinal Metastasis Score, and Skeletal Oncology Research Group (SORG) nomogram, for predicting long-term survival of patients with spinal metastasis. SUMMARY OF BACKGROUND DATA: Predicting the prognosis of spinal metastasis is vital for surgical decisions, yet the effectiveness of existing scoring systems in identifying long-term survival remains unclear. METHODS: 456 cases were finally included. Prognostic scores were compared with survival outcomes. Receiver operating characteristic (ROC) curves were analyzed for the entire cohort and across three distinct time periods to evaluate the area under the curve (AUC) for 1-year and 2-year survival, alongside Harrell's C-statistic. RESULTS: The mean patient age was 58.9 years, and the median survival time was 8.6 months. For the entire cohort, the SORG nomogram, OSRI, and modified Tokuhashi scores yielded Harrell's C-index values of 0.64, 0.63, and 0.62, respectively. For 1-year survival prediction, the SORG nomogram, OSRI, and modified Tokuhashi score demonstrated moderate discriminative power, with AUC values of 0.72, 0.71, and 0.70, respectively. Similarly, for 2-year survival prediction, the modified Tokuhashi score, SORG nomogram, and OSRI also revealed moderate discriminative power, with AUC values of 0.73, 0.72, and 0.70, respectively. For patients who underwent surgery in the most recent period, OSRI demonstrated the highest predictive accuracy for 1-year survival, with a Harrell's C-index of 0.63 and an AUC of 0.68, and 2-year survival, with a Harrell's C-index of 0.63 and an AUC of 0.64. CONCLUSION: Most scoring systems exhibited low discriminative power, with only the SORG nomogram, OSRI, and modified Tokuhashi scores demonstrating moderate power for predicting long-term survival. In the most recent period, the OSRI demonstrated the highest predictive accuracy for both 1-year and 2-year survival.

Characterization of Patients with Poor Clinical Outcome after Adult Spinal Deformity Surgery: A Multivariate Analysis of Mean 8-Year Follow-Up Data.

Background/Objective: Limited data exist regarding the long-term clinical outcomes and related factors after adult spinal deformity (ASD) surgery. This study aims to characterize patients who experienced poor clinical outcomes during long-term follow-up after ASD surgery. Methods: Patients who underwent ASD surgery with ≥5-vertebra fusion including the sacrum and ≥5-year follow-up were included. They were divided into two groups according to the Oswestry Disability Index (ODI) at the last follow-up: group P (poor outcome, ODI > 40) and group NP (non-poor outcome, ODI ≤ 40). Clinical variables, including patient factors, surgical factors, radiographic parameters, and mechanical complications (proximal junctional kyphosis [PJK] and rod fracture), were compared between the groups. Results: A total of 105 patients were evaluated, with a mean follow-up of 100.6 months. The mean age was 66.3 years, and 94 patients (89.5%) were women. There were 52 patients in group P and 53 patients in group NP. Univariate analysis showed that low T-score, postoperative correction relative to age-adjusted pelvic incidence-lumbar lordosis, T1 pelvic angle (TPA) at last follow-up, and PJK development were significant factors for poor clinical outcomes. Multivariate analysis identified PJK as the single independent risk factor (odds ratio [OR] = 3.957 for PJK development relative to no PJK, OR = 21.141 for revision surgery for PJK relative to no PJK). Conclusions: PJK development was the single independent factor affecting poor clinical outcomes in long-term follow-up. Therefore, PJK prevention appears crucial for achieving long-term success after ASD surgery.

Different Risk Factors between Bony and Ligamentous Proximal Junctional Failure in Patients Undergoing Thoracolumbar Fusion to Pelvis for Adult Spinal Deformity.

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze the risk factors for bony proximal junctional failure (B-PJF) and ligamentous PJF (L-PJF) separately after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Despite numerous studies about the risk factors of PJF, it remains unclear whether same risk factors can be applied to both B-PJF and L-PJF. METHODS: Patients who underwent corrective surgery from low thoracic level (T9-T12) to pelvis with minimum follow-up duration of two years were included in this study. Patients with PJF were divided into two groups according to the involvement of bony structure: B-PJF and L-PJF. The control group was created using patients who did not develop PJF for ≥2 years postoperatively (no-PJF group). Risk factors were analyzed by comparing various clinical and radiographic parameters between no PJF versus B-PJF group and between no PJF versus L-PJF groups. RESULTS: The final study cohort comprised 240 patients. The mean age was 68.7 years, and there were 205 women (85.4%). On average, 8.1 levels were fused. PJF developed in 103 patients, with 70 (68.0%) in the B-PJF group and 33 (32.0%) in the L-PJF group. Stepwise logistic regression analyses revealed that older age (odds ratio [OR]=1.088), higher body mass index (BMI) (OR=1.161), osteoporosis (OR=3.293), greater postoperative lumbar distribution index (OR=1.032), and overcorrection relative to the age-adjusted pelvic incidence - lumbar lordosis (OR=3.964) were significant risk factors for B-PJF. Meanwhile, no use of transverse process (TP) hook was the single risk factor for L-PJF (OR=4.724). CONCLUSIONS: Understanding the difference in risk factors between B-PJF and L-PJF will facilitate the optimization of surgical outcome for patients with ASD. Appropriate correction of sagittal malalignment along with use of TP hook is advisable to mitigate both B-PJF and L-PJF development.

Validation of Sagittal age-adjusted Score in Predicting Proximal Junctional Kyphosis/Failure and Clinical Outcomes Following Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVES: To validate the sagittal age-adjusted score (SAAS) in predicting proximal junctional kyphosis/failure (PJK/F) and good clinical outcomes following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: SAAS is a relatively new assessment system that incorporates age-adjusted sagittal parameters of pelvic incidence (PI) - lumbar lordosis (LL), pelvic tilt (PT), and T1 pelvic angle (TPA) to predict the PJK/F. External validation is required to verify its clinical usefulness. METHODS: We included patients with ASD undergoing ≥5-level fusion including the sacrum or pelvis. SAAS was calculated based on the scores of the three components: PI-LL, PT, and TPA. PJK/F rates and clinical outcomes were compared among the correction categories (undercorrection, matched correction, and overcorrection) for the SAAS as well as for each of the three components. PJK/F rates were compared according to the correction groups of the sagittal components and total SAAS using the chi-square test. Receiver operating characteristic (ROC) analysis was performed to evaluate the predictive ability of overcorrection to develop PJK/F for the three sagittal parameters and SAAS. PROMs at final follow-up were compared among correction groups using ANOVA with Bonferroni post-hoc corrections. RESULTS: A total 411 patients were included in the study (mean age: 69.3 y, mean body mass index: 25.9 kg/m2, total levels fused: 7.7 levels, and follow-up duration: 43.3 mo). Postoperative SAAS categories were as follow: undercorrection (13.4%), matched correction (30.2%), and overcorrection (56.4%). The PJK/F rates were significantly higher in the overcorrection group relative to PI-LL component (P=0.001) as well as SAAS (P=0.038) compared to undercorrection or matched correction groups. The clinical outcomes were best in patients who achieved matched correction relative to PI-LL component as well as SAAS compared to the other correction groups. However, the differentiating power of clinical outcomes across the correction categories was greater in the PI-LL component than in the SAAS. CONCLUSION: This study validated the efficacy of SAAS system to differentiate PJK/F development and good clinical outcomes. However, its differentiating power seems to be largely attributable to the function of the PI-LL component, as the PI-LL correction status better predicted PJK/F risk and clinical outcomes than SAAS.

Different characteristics between acute and delayed proximal junctional failure in elderly patients undergoing corrective surgery for adult spinal deformity: comparative analysis of risk factor, failure mode, and clinical consequences.

BACKGROUND CONTEXT: While numerous studies have been conducted on proximal junctional failure (PJF), the clinical significance of acute and delayed PJF remains poorly understood. PURPOSE: The primary object of this study is to investigate the risk factors separately for acute and delayed PJF. Secondly, we aim to assess the incidence of each failure mode and their clinical consequences in relation to acute and delayed PJF. STUDY DESIGN/SETTING: Retrospective comparative study. PATIENT SAMPLE: Patients aged ≥60 years who underwent deformity correction with ≥5-level fusion to sacrum. OUTCOME MEASURES: Risk factor, failure modes, and patient-reported outcome measure (PROM). METHODS: Acute PJF is defined as PJF occurring within 6 months, while delayed PJF occurring after 6 months. Risk factors were analyzed by comparing various clinical and radiographic parameters among 3 groups: no, acute, and delayed PJF groups. The failure modes, including soft tissue failure, vertebral fracture, fixation failure, and myelopathy, were compared among these groups. The clinical subsequences after PJF development were evaluated by assessing the change in proximal junctional angle (PJA), revision rate, and patient-reported outcome measure (PROM). RESULTS: A study cohort of 363 patients was included in the analysis. Among them, 156 patients experienced PJF, with 87 patients (55.8%) in the acute PJF group and 69 patients (44.2%) in the delayed PJF group. Multivariate analyses showed that older age (Odds ratio [OR] = 1.057, 95% confidence interval [CI] = 1.002-1.118), osteoporosis (OR=2.149, 95% CI = 1.074-4.300), high American Society of Anesthesiology ASA score (OR=2.150, 95% CI = 1.089-4.245), and overcorrection relative to the age-adjusted pelvic incidence - lumbar lordosis target (OR=4.031, 95% CI = 1.962-8.280) were identified as risk factors for the development of acute PJF. On the other hand, a high body mass index (OR=1.150, 95% CI = 1.049-1.251) and an uppermost instrumented vertebra located at ≤T10 (OR=2.267, 95% CI = 1.205-4.268) were found to be associated with delayed occurrence of PJF. No radiographic parameters were found to be related to the development of delayed PJF. In terms of failure modes, vertebral fracture and fixation failure were more commonly observed in acute PJF, while soft tissue failure and myelopathy were more predominant in delayed PJF. The clinical course was more aggressive in the acute PJF group compared to the delayed PJF group, as evidenced by a greater increase in PJA, a higher revision rate, and worse PROM. CONCLUSIONS: This study demonstrated different risk factors between the acute and delayed PJF. It was found that overcorrection relative to the age-adjusted PI-LL target increased the risk of acute PJF, but had no impact on the development of delayed PJF. Therefore, a different surgical strategy needs to be established to mitigate both acute and delayed PJF.

Incidence and Risk Factors for Mechanical Failure after Anterior Column Realignment in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVES: To investigate the incidence and risk factors of mechanical failure (MF) following anterior column realignment (ACR) in patients with severe degenerative sagittal imbalance (DSI). SUMMARY OF BACKGROUND DATA: Considering the biomechanical properties of the procedure, ACR may increase the risk of MF, including proximal junctional kyphosis (PJK) and rod fracture (RF). However, this issue has been poorly documented in the literature. METHODS: We included patients aged ≥60 years with severe DSI radiographically defined by pelvic incidence (PI) - lumbar lordosis (LL) ≥20° undergoing ≥5-level fusion, including the sacrum. PJK was defined radiographically as a proximal junctional angle (PJA)>28° plus Δ PJA of>22°. RF was evaluated at ACR levels performed. Clinical and radiographic variables were compared to identify the risk factors for PJK and RF, then multivariate analysis was performed by combining PJK and RF into a single composite outcome of MF. RESULTS: We included a total of 147 patients in the final study cohort. The mean age was 70.3 years, and there were 126 women (90.6%). The median fusion length was 8 levels. After surgery, PI-LL was corrected from 48.1° to 4.3°. MF developed in 49 patients (33.3%); PJK in 41 (27.9%), RF in 11 (7.5%), and both PJK and RF in 3 (2.0%) patients. Multivariate analyses revealed that osteoporosis (odds ratio [OR]=2.361, 95% confidence interval [CI]=1.270 - 5.590, P=0.048) and an increased number of ACR levels (OR=1.762, 95% CI=1.039 - 3.587, P=0.036) were significant risk factors for MF. CONCLUSION: A considerable number of patients (33.3%) developed MF after deformity correction using ACR procedures. Therefore, appropriate surgical strategies are necessary to prevent MF in patients undergoing deformity correction using ACR, with special attention to the risk factors we identified here.

Hinged Roof Reconstruction of Anterior Iliac Crest after Harvesting Bicortical Strut Graft for Anterior Cervical Fusion.

Introduction: The strut iliac bone graft has been widely used to achieve fusion in various anterior cervical spinal surgeries but some complications often remain, such as pain and gross deformity. Considering these, we designed a new technique to restore the iliac ridge, using the outmost part of the iliac crest. We aim to assess the efficacy of our new restoration technique of the iliac ridge after harvesting strut bone graft for anterior cervical fusion. The clinical and radiological outcomes of our hinged roof method were evaluated. Technical Note: A retrospective review was conducted of 29 patients who underwent hinged roof reconstruction of the iliac ridge after harvesting a bicortical strut bone graft for anterior cervical fusion using a cervical plate system. The clinical outcome for pain and gross appearance and radiological results were evaluated. Three months after the surgery, pain at the donor site became minimal or absent in all cases. At 1 year follow-up, no patient had reported pain and palpable discomfort, such as step-off on the donor site. Final X-ray and follow-up computed tomography revealed a bony union of the reconstructed iliac ridge to both margins. Conclusions: By showing good clinical and radiological outcomes, the authors' hinged roof reconstruction of the iliac crest after harvesting strut bone graft seemed to be a simple and effective technique that can reduce complications, such as pain and deformity on the donor iliac crest.

Safety evaluation of drowsy driving advisory system: Alabama case study.

INTRODUCTION: The present study discusses roles, characteristics, and safety assessment of a drowsy driving advisory (DDA) system, implemented on rural interstates of Alabama. The DDA system is an engineering countermeasure designed to reduce the likelihood of drowsy driving crashes. It consists of a series of roadside signs with warning and advisory messages for drowsy drivers. The DDA system was implemented upstream of rural rest areas based on a comprehensive crash analysis. METHOD: A post-implementation study was conducted three years after the DDA system implementation to assess its safety effects. An empirical bayes (EB) method along with predictive methods of the Highway Safety Manual was used in the safety assessment. To overcome the underreported issue of drowsy driving crashes in the crash analysis, the present study used a concept called, expanded definition of drowsy driving (EDD) crashes. RESULT: The analysis found that the DDA system could reduce total and EDD crashes by 64% and 49%, respectively. It is important to note that such huge crash reduction effects are due to a combined effect of both rest areas and the DDA system, not because of a single treatment. The safety effect of a rest area itself, without considering the effect of the DDA system, was also investigated. Results show that total and EDD crashes would increase about 12-45% and 5-33%, respectively if there is no presence of a rest area. CONCLUSION: Our findings conclude that the DDA system could significantly reduce both total and drowsy driving crashes when it cooperates with a rest area facility. Practical Application: The findings also provide the guidance of using the DDA system on high-speed roads as a safety countermeasure of drowsy driving crashes. Readers can find details of the DDA system used in this study with its layout, dimension, and roadside safety messages.

Pseudo actinometry for the measurement of reactive species density.

To compensate for the effect of plasma parameters in the signal of optical emission spectroscopy, we should normalize the emission intensity from the species against that of an inert gas (i.e., the actinometer). In many plasma processes in the semiconductor industry, plasma etching without using a neutral gas for the actinometer has become popular to achieve better critical dimension uniformity. We propose "pseudo actinometry" for normalization in the absence of an inert gas in the process plasma. Based on the theory of optical actinometry, we define a correction factor as the ratio of the emission intensity to the number density of the inert gas. As we reduced the density of the inert gas, we experimentally determined the correction factor by taking its convergence when the concentration of the inert gas was zero. As proof of concept, we applied pseudo actinometry to measure the density distribution of atomic chlorine in a photomask etching process without an inert gas. By comparing the distributions of chlorine radicals and the etch rate as measured by an ellipsometer, we calculated the correlation coefficient between the distributions. The correlation coefficient rapidly decreased to 0.60 when we used the correction factor determined at a flow rate for the inert gas of 20 standard cubic centimeters per minute at STP. By using pseudo actinometry, we successfully determined the distribution of chlorine radicals with a correlation coefficient of 0.98 in a plasma etching process without an inert gas.

Analytical calculation of the light-collection efficiency of an optical emission spectrometer with the effective solid-angle method.

A method is proposed for calculating the optical emission spectrometer (OES) light-collection efficiency using the effective solid angle from an arbitrary point source. Based on the point source-OES relative positioning, the effective solid angle is derived for four cases: (1) on axis and on the object plane; (2) on axis and outside the object plane; (3) off axis and on the object plane; and (4) off axis and outside the object plane. The results were in good agreement with those obtained through Monte Carlo ray tracing. After calculating the OES geometrical collection efficiency with respect to the object plane distance in three different-sized cylindrical volume sources, we suggest a simple strategy to increase this efficiency in plasma process monitoring.

Ultrasensitive Detection of Single-Walled Carbon Nanotubes Using Surface Plasmon Resonance.

Because single-walled carbon nanotubes (SWNTs) are known to be a potentially dangerous material, inducing cancers and other diseases, any possible leakage of SWNTs through an aquatic medium such as drinking water will result in a major public threat. To solve this problem, for the present study, a highly sensitive, quantitative detection method of SWNTs in an aqueous solution was developed using surface plasmon resonance (SPR) spectroscopy. For a highly sensitive and specific detection, a strong affinity conjugation with biotin-streptavidin was adopted on an SPR sensing mechanism. During the pretreatment process, the SWNT surface was functionalized and hydrophilized using a thymine-chain based biotinylated single-strand DNA linker (B-ssDNA) and bovine serum albumin (BSA). The pretreated SWNTs were captured on a sensing film, the surface of which was immobilized with streptavidin on biotinylated gold film. The captured SWNTs were measured in real-time using SPR spectroscopy. Specific binding with SWNTs was verified through several validation experiments. The present method using an SPR sensor is capable of detecting SWNTs of as low as 100 fg/mL, which is the lowest level reported thus far for carbon-nanotube detection. In addition, the SPR sensor showed a linear characteristic within the range of 100 pg/mL to 200 ng/mL. These findings imply that the present SPR sensing method can detect an extremely low level of SWNTs in an aquatic environment with high sensitivity and high specificity, and thus any potential leakage of SWNTs into an aquatic environment can be precisely monitored within a couple of hours.

Characterization of linearity and uniformity of fiber-based endoscopes for 3D combustion measurements.

This work reports the application of fiber-based endoscopes (FBEs) for instantaneous three-dimensional (3D) flow and combustion measurements, with an emphasis on characterizing the linearity and uniformity of the FBEs and exploring their potential for obtaining quantitative measurements. Controlled experiments were performed using a uniform illuminator to characterize the linearity and uniformity of the FBEs. Based on such characterization, 3D instantaneous measurements of flames were demonstrated by a combined use of FBEs and tomography. To obtain 3D flame measurement, 3D tomographic reconstructions were made from multiple projections of the target flames collected from various orientations by the FBEs. The results illustrate the potential of FBEs to obtain quantitative 3D flow and combustion measurements and also the advantages FBEs offer, including overcoming optical access restrictions and equipment cost.

Measuring two-dimensional profiles of beam spots in a high-density spot array for a maskless lithography system.

We measure two-dimensional (2D) profiles of beam spots in a high-density spot array for a maskless lithography system. Since the size of each spot is comparable to that of a pixel in a charge-coupled device (CCD), we detect image frame data, which are the distribution of the intensity of the spot overlapped on the active area of the pixel in the CCD, by scanning with a nano-stage. Using the image frame data of the scanning CCD we determine reconstructed images of the beam spot array. We calculate the 2D profile of each spot by taking the deconvolution of the reconstructed image of the spot with the active area of the CCD pixel. We theoretically analyze the uncertainty in the measurement of profiles in terms of spot size for the variation of the scanning step of the nano-stage and determine the step size to achieve uncertainty of less than 100 nm. We experimentally demonstrate the measurement of profiles of an 11×11 spot array for the proof of concept. Also, we analyze various parameters of the spot array, such as ellipticity, rotation of the spot profile, spot size, intensity distribution, and position.

Accurate position measurement of a high-density beam spot array in digital maskless lithography.

Since patterns in digital maskless lithography are formed by accumulating the exposure energy of a high-density beam spot array, the accurate position measurement of the spot array is essential for the precise operation of the system. We propose a measurement technique for detecting the position of a high-density, subpixel size beam spot array with a charge-coupled device (CCD). In order to determine the position of each beam spot with a small number of CCD pixels, we assign 3×3 pixels of the CCD for each spot and scan the CCD to determine the signal of a center pixel. We numerically analyze the measurement uncertainty in the pixel position for various scanning conditions. We set up an experimental system for proof of concept and to detect the position of a 10×10 beam spot array with an uncertainty less than 100 nm. Additionally, the measurement uncertainty quantitatively matches the numerical analysis results.

Structure and expression analysis of the cecropin-E gene from the silkworm, Bombyx mori.

Cecropins belong to the antibacterial peptides family and are induced after injection of bacteria or their cell-wall components. By silkworm cDNA microarray analysis, a novel type of Cecropin family gene was identified as a cDNA up-regulated in early embryo, 1 day after oviposition. The cDNA isolated was 394 bp with 198 ORF translating 65 amino acids, encoding BmCecropin-E (BmCec-E). Using Southern hybridization and genome search analysis, the number of BmCec-E gene was estimated to be at least two per haploid, which consisted of two exons, as in other Cecropin family members. BmCec-E mRNA was expressed transiently 1 day after egg-laying (AEL, germ-band formation stage), and was specifically expressed in the degenerating intestine during the pre-pupal and pupal stages, unlike other Cecropin family genes. Immune challenge analysis showed that BmCec-E gene expression was more strongly induced by Escherichia coli (gram-negative) than by Micrococus luteus (gram-positive), and not by virus injection. By bacterial challenge, expression of BmCec-E mRNA was induced 12 h after injection, and was maintained for 24 h. Expression of BmCec-E after immune challenge was observed strongly in excretory organs, such as hindgut and malphigian, slightly in fat body, skin, and midgut.