Large Deletions, Cleavage of the Telomeric Repeat Sequence, and Reverse Transcriptase-Mediated DNA Damage Response Associated with Long Interspersed Element-1 ORF2p Enzymatic Activities.

L1 elements can cause DNA damage and genomic variation via retrotransposition and the generation of endonuclease-dependent DNA breaks. These processes require L1 ORF2p protein that contains an endonuclease domain, which cuts genomic DNA, and a reverse transcriptase domain, which synthesizes cDNA. The complete impact of L1 enzymatic activities on genome stability and cellular function remains understudied, and the spectrum of L1-induced mutations, other than L1 insertions, is mostly unknown. Using an inducible system, we demonstrate that an ORF2p containing functional reverse transcriptase is sufficient to elicit DNA damage response even in the absence of the functional endonuclease. Using a TK/Neo reporter system that captures misrepaired DNA breaks, we demonstrate that L1 expression results in large genomic deletions that lack any signatures of L1 involvement. Using an in vitro cleavage assay, we demonstrate that L1 endonuclease efficiently cuts telomeric repeat sequences. These findings support that L1 could be an unrecognized source of disease-promoting genomic deletions, telomere dysfunction, and an underappreciated source of chronic RT-mediated DNA damage response in mammalian cells. Our findings expand the spectrum of biological processes that can be triggered by functional and nonfunctional L1s, which have impactful evolutionary- and health-relevant consequences.

Baseline immune states (BIS) associated with vaccine responsiveness and factors that shape the BIS.

Vaccines are among the greatest inventions in medicine, leading to the elimination or control of numerous diseases, including smallpox, polio, measles, rubella, and, most recently, COVID-19. Yet, the effectiveness of vaccines varies among individuals. In fact, while some recipients mount a robust response to vaccination that protects them from the disease, others fail to respond. Multiple clinical and epidemiological factors contribute to this heterogeneity in responsiveness. Systems immunology studies fueled by advances in single-cell biology have been instrumental in uncovering pre-vaccination immune cell types and genomic features (i.e., the baseline immune state, BIS) that have been associated with vaccine responsiveness. Here, we review clinical factors that shape the BIS, and the characteristics of the BIS associated with responsiveness to frequently studied vaccines (i.e., influenza, COVID-19, bacterial pneumonia, malaria). Finally, we discuss potential strategies to enhance vaccine responsiveness in high-risk groups, focusing specifically on older adults.

Truncated ORF1 proteins can suppress LINE-1 retrotransposition in trans.

Long interspersed element 1 (L1) is an autonomous non-LTR retroelement that is active in mammalian genomes. Although retrotranspositionally incompetent and functional L1 loci are present in the same genomes, it remains unknown whether non-functional L1s have any trans effect on mobilization of active elements. Using bioinformatic analysis, we identified over a thousand of human L1 loci containing at least one stop codon in their ORF1 sequence. RNAseq analysis confirmed that many of these loci are expressed. We demonstrate that introduction of equivalent stop codons in the full-length human L1 sequence leads to the expression of truncated ORF1 proteins. When supplied in trans some truncated human ORF1 proteins suppress human L1 retrotransposition. This effect requires the N-terminus and coiled-coil domain (C-C) as mutations within the ORF1p C-C domain abolish the suppressive effect of truncated proteins on L1 retrotransposition. We demonstrate that the expression levels and length of truncated ORF1 proteins influence their ability to suppress L1 retrotransposition. Taken together these findings suggest that L1 retrotransposition may be influenced by coexpression of defective L1 loci and that these L1 loci may reduce accumulation of de novo L1 integration events.

Involvement of Conserved Amino Acids in the C-Terminal Region of LINE-1 ORF2p in Retrotransposition.

Long interspersed element 1 (L1) is the only currently active autonomous retroelement in the human genome. Along with the parasitic SVA and short interspersed element Alu, L1 is the source of DNA damage induced by retrotransposition: a copy-and-paste process that has the potential to disrupt gene function and cause human disease. The retrotransposition process is dependent upon the ORF2 protein (ORF2p). However, it is unknown whether most of the protein is important for retrotransposition. In particular, other than the Cys motif, the C terminus of the protein has not been intensely examined in the context of retrotransposition. Using evolutionary analysis and the Alu retrotransposition assay, we sought to identify additional amino acids in the C terminus important for retrotransposition. Here, we demonstrate that Gal4-tagged and untagged C-terminally truncated ORF2p fragments possess residual potential to drive Alu retrotransposition. Using sight-directed mutagenesis we identify that while the Y1180 amino acid is important for ORF2p- and L1-driven Alu retrotransposition, a mutation at this position improves L1 retrotransposition. Even though the mechanism of the contribution of Y1180 to Alu and L1 mobilization remains unknown, experimental evidence rules out its direct involvement in the ability of the ORF2p reverse transcriptase to generate complementary DNA. Additionally, our data support that ORF2p amino acids 1180 and 1250-1262 may be involved in the reported ORF1p-mediated increase in ORF2p-driven Alu retrotransposition.

The endonuclease domain of the LINE-1 ORF2 protein can tolerate multiple mutations.

BACKGROUND: Approximately 17 % of the human genome is comprised of the Long INterspersed Element-1 (LINE-1 or L1) retrotransposon, the only currently active autonomous family of retroelements. Though L1 elements have helped to shape mammalian genome evolution over millions of years, L1 activity can also be mutagenic and result in human disease. L1 expression has the potential to contribute to genomic instability via retrotransposition and DNA double-strand breaks (DSBs). Additionally, L1 is responsible for structural genomic variations induced by other transposable elements such as Alu and SVA, which rely on the L1 ORF2 protein for their propagation. Most of the genomic damage associated with L1 activity originates with the endonuclease domain of the ORF2 protein, which nicks the DNA in preparation for target-primed reverse transcription. RESULTS: Bioinformatic analysis of full-length L1 loci residing in the human genome identified numerous mutations in the amino acid sequence of the ORF2 endonuclease domain. Some of these mutations were found in residues which were predicted to be phosphorylation sites for cellular kinases. We mutated several of these putative phosphorylation sites in the ORF2 endonuclease domain and investigated the effect of these mutations on the function of the full-length ORF2 protein and the endonuclease domain (ENp) alone. Most of the single and multiple point mutations that were tested did not significantly impact expression of the full-length ORF2p, or alter its ability to drive Alu retrotransposition. Similarly, most of those same mutations did not significantly alter expression of ENp, or impair its ability to induce DNA damage and cause toxicity. CONCLUSIONS: Overall, our data demonstrate that the full-length ORF2p or the ENp alone can tolerate several specific single and multiple point mutations in the endonuclease domain without significant impairment of their ability to support Alu mobilization or induce DNA damage, respectively.

Identification of L1 ORF2p sequence important to retrotransposition using Bipartile Alu retrotransposition (BAR).

Long Interspersed Element 1 (LINE-1 or L1) is capable of causing genomic instability through the activity of the L1 ORF2 protein (ORF2p). This protein contains endonuclease (EN) and reverse transcriptase (RT) domains that are necessary for the retrotransposition of L1 and the Short Interspersed Element (SINE) Alu. The functional importance of approximately 50% of the ORF2p molecule remains unknown, but some of these sequences could play a role in retrotransposition, or be necessary for the enzymatic activities of the EN and/or RT domains. Conventional approaches using the full-length, contiguous ORF2p make it difficult to study the involvement of these unannotated sequences in the function of L1 ORF2p. Our lab has developed a Bipartile Alu Retrotransposition (BAR) assay that relies on separate truncated ORF2p fragments: an EN-containing and an RT-containing fragment. We validated the utility of this method for studying the ORF2p function in retrotransposition by assessing the effect of expression levels and previously characterized mutations on BAR. Using BAR, we identified two pairs of amino acids important for retrotransposition, an FF and a WD. The WD appears to play a role in cDNA synthesis by the ORF2p molecule, despite being outside the canonical RT domain.

Potential for genomic instability associated with retrotranspositionally-incompetent L1 loci.

Expression of the L1 retrotransposon can damage the genome through insertional mutagenesis and the generation of DNA double-strand breaks (DSBs). The majority of L1 loci in the human genome are 5'-truncated and therefore incapable of retrotransposition. While thousands of full-length L1 loci remain, most are retrotranspositionally-incompetent due to inactivating mutations. However, mutations leading to premature stop codons within the L1 ORF2 sequence may yield truncated proteins that retain a functional endonuclease domain. We demonstrate that some truncated ORF2 proteins cause varying levels of toxicity and DNA damage when chronically overexpressed in mammalian cells. Furthermore, transfection of some ORF2 constructs containing premature stop codons supported low levels of Alu retrotransposition, demonstrating the potential for select retrotranspositionally-incompetent L1 loci to generate genomic instability. This result suggests yet another plausible explanation for the relative success of Alu elements in populating the human genome. Our data suggest that a subset of retrotranspositionally-incompetent L1s, previously considered to be harmless to genomic integrity, may have the potential to cause chronic DNA damage by introducing DSBs and mobilizing Alu. These results imply that the number of known L1 loci in the human genome that potentially threaten its stability may not be limited to the retrotranspositionally active loci.

Regulation of L1 expression and retrotransposition by melatonin and its receptor: implications for cancer risk associated with light exposure at night.

Expression of long interspersed element-1 (L1) is upregulated in many human malignancies. L1 can introduce genomic instability via insertional mutagenesis and DNA double-strand breaks, both of which may promote cancer. Light exposure at night, a recently recognized carcinogen, is associated with an increased risk of cancer in shift workers. We report that melatonin receptor 1 inhibits mobilization of L1 in cultured cells through downregulation of L1 mRNA and ORF1 protein. The addition of melatonin receptor antagonists abolishes the MT1 effect on retrotransposition in a dose-dependent manner. Furthermore, melatonin-rich, but not melatonin-poor, human blood collected at different times during the circadian cycle suppresses endogenous L1 mRNA during in situ perfusion of tissue-isolated xenografts of human cancer. Supplementation of human blood with exogenous melatonin or melatonin receptor antagonist during the in situ perfusion establishes a receptor-mediated action of melatonin on L1 expression. Combined tissue culture and in vivo data support that environmental light exposure of the host regulates expression of L1 elements in tumors. Our data imply that light-induced suppression of melatonin production in shift workers may increase L1-induced genomic instability in their genomes and suggest a possible connection between L1 activity and increased incidence of cancer associated with circadian disruption.

Development of a monoclonal antibody specific to the endonuclease domain of the human LINE-1 ORF2 protein.

BACKGROUND: LINE-1 (L1) retrotransposons are common occupants of mammalian genomes representing about a fifth of the genetic content. Ongoing L1 retrotransposition in the germ line and somatic tissues has contributed to structural genomic variations and disease-causing mutations in the human genome. L1 mobilization relies on the function of two, self-encoded proteins, ORF1 and ORF2. The ORF2 protein contains two characterized domains: endonuclease and reverse transcriptase. RESULTS: Using a bacterially purified endonuclease domain of the human L1 ORF2 protein, we have generated a monoclonal antibody specific to the human ORF2 protein. We determined that the epitope recognized by this monoclonal antibody includes amino acid 205, which is required for the function of the L1 ORF2 protein endonuclease. Using an in vitro L1 cleavage assay, we demonstrate that the monoclonal anti-ORF2 protein antibody partially inhibits L1 endonuclease activity without having any effect on the in vitro activity of the human AP endonuclease. CONCLUSIONS: Overall, our data demonstrate that this anti-ORF2 protein monoclonal antibody is a useful tool for human L1-related studies and that it provides a rationale for the development of antibody-based inhibitors of L1-induced damage.

Characterization of L1 ORF1p self-interaction and cellular localization using a mammalian two-hybrid system.

Long INterspersed Element-1 (LINE-1, L1) is an active retrotransposon that mobilizes using a ribonucleoprotein particle (RNP) intermediate composed of the full-length bicistronic L1 mRNA and the two proteins (ORF1p and ORF2p) encoded by that mRNA. ORF1p and ORF2p demonstrate cis-preference for their encoding mRNA. Previous studies of ORF1p, purified from bacterial and insect cells demonstrated that this protein forms trimers in vitro. While valuable for understanding ORF1p function, these in vitro approaches do not provide any information on ORF1p self-interaction in the context of mammalian cells. We used a mammalian two-hybrid (M2H) system in order to study L1 ORF1p self-interaction in human and mouse cells. We demonstrate that the M2H system successfully detects human and mouse ORF1p self-interactions in transiently transfected mammalian cells. We also generated mouse and human ORF1p-specific antibodies to characterize the expression of ORF1p fusion proteins used in the M2H system. Using these antibodies, we demonstrate that ORF1p interaction in trans leads to the formation of heterodimers that are expected to produce a positive signal in the M2H system. Although the role for L1 ORF1p cis-preference in L1 mobilization is established, the impact of ability of ORF1pto interact in trans on the L1 replication cycle is not known. Furthermore, western blot analysis of ORF1p generated by a full-length L1, wild type ORF1, or a codon-optimized ORF1 expression vector is detected in the nucleus. In contrast, the addition of a tag to the N-terminus of the mouse and human ORF1 proteins can significantly alter the subcellular localization in a tag-specific manner. These data support that nuclear localization of ORF1p may contribute to L1 (and potentially the SINE Alu) RNP nuclear access in the host cell.

MRI measurement of neuroforaminal dimension at the index and supradjacent levels after anterior lumbar interbody fusion: a prospective study.

BACKGROUND: Anterior interbody fusion has previously been demonstrated to increase neuroforaminal height in a cadaveric model using cages. No prior study has prospectively assessed the relative change in magnetic resonance imaging (MRI) demonstrated neuroforaminal dimensions at the index and supradjacent levels, after anterior interbody fusion with a corticocancellous allograft in a series of patients without posterior decompression. The objective of this study was to determine how much foraminal dimension can be increased with indirect foraminal decompression alone via anterior interbody fusion, and to determine the effect of anterior lumbar interbody fusion on the dimensions of the supradjacent neuroforamina. METHODS: A prospective study comparing pre- and postoperative neuroforaminal dimensions on MRI scan among 26 consecutive patients undergoing anterior lumbar interbody fusion without posterior decompression was performed. We studies 26 consecutive patients (50 index levels) that had undergone anterior interbody fusion followed by posterior pedicle screw fixation without distraction or foraminotomy. We used preoperative and postoperative MRI imaging to assess the foraminal dimensions at each operated level on which the lumbar spine had been operated. The relative indirect foraminal decompression achieved was calculated. The foraminal dimension of the 26 supradjacent untreated levels was measured pre- and postoperatively to serve as a control and to determine any effects after anterior interbody fusion. RESULTS: In this study, 8 patients underwent 1 level fusion (L5-S1), 12 patients had 2 levels (L4-S1) and 6 patients had 3 levels (L3-S1). The average increase in foraminal dimension was 43.3% (p < 0.05)-19.2% for L3-4, 57.1% for L4-5, and 40.1% for L5-S1. Mean pre- and postoperative supradjacent neuroforaminal dimension measurements were 125.84 mm(2) and 124.89 mm(2), respectively. No significant difference was noted (p > 0.05). CONCLUSIONS: Anterior interbody fusion with a coriticocancellous allograft can significantly increase neuroforaminal dimension even in the absence of formal posterior distraction or foraminotomy; anterior interbody fusion with a coriticocancellous allograft has little effect on supradjacent neuroforaminal dimensions.

Load sharing properties of cervical pedicle screw-rod constructs versus lateral mass screw-rod constructs.

Lateral mass screws have a history of successful clinical use, but cannot always be used in the subaxial cervical spine. Despite safety concerns, cervical pedicle screws have been proposed as an alternative. Pedicle screws have been shown to be biomechanically stronger than lateral mass screws. No study, however, has investigated the load sharing properties comparing constructs using these screws. To investigate this, 12 fresh-frozen single cervical spine motion segments (C4-5 and C6-7) from six cadavers were isolated. They were randomized to receive either lateral mass or pedicle screw-rod constructs. After preloading, the segments were cyclically loaded with a uniplanar axial load from 0 to 90 N both with and without the construct in place. Pressure data at the disc space were continuously collected using a dynamic pressure sensor. The reduction in disc space pressure between the two constructs was calculated to see if pedicle screw and lateral mass screw-rod constructs differed in their load sharing properties. In both the pedicle screw and lateral mass screw-rod constructs, there was a significant reduction in the disc space pressures from the no-construct to construct conditions. The percentage decrease for the pedicle screw constructs was significantly greater than the percentage decrease for the lateral mass screw constructs for average pressure (p < or = 0.002), peak pressure (p < or = 0.03) and force (p < or = 0.04). We conclude that cervical pedicle screw-rod constructs demonstrated a greater reduction in axial load transfer through the intervertebral disc than lateral mass screw-rod constructs. Though there are dangers associated with the insertion of cervical pedicle screws, their use might be advantageous in some clinical conditions when increased load sharing is necessary.

Revision of loosened iliac screws: a biomechanical study of longer and bigger screws.

STUDY DESIGN: The present study compared the biomechanics of 2 revision iliac screws: longer and bigger screws, on human cadaveric pelves. OBJECTIVE: To determine if a bigger screw resists loosening under cyclic loading better than a longer screw in revising loosened iliac screws. SUMMARY OF BACKGROUND DATA: Iliac screws have been used in treating spinal deformity, spondylolisthesis and many other spinal diseases. Because of the cancellous bone along the screw trajectory, screw loosening over cyclic loading has been experienced in clinical applications. Two popular revision choices are: a longer screw and a bigger screw. However, their biomechanics has not been characterized. The objective of this study is to determine the rate of loosening of longer or larger revision iliac screws under cyclic loading. METHODS: Eight pairs of human cadaver pelves were harvested. Each side was randomly assigned for a longer revision screw or a larger revision screw. Because of different bone quality in each specimen, applied load was varied according to the peak insertion torque of the primary iliac screws. The load was applied at an anatomic angle with a frequency of 2 Hz. The motion of screw with respect to the pelvis at the bone entry point was recorded with a motion tracking system. The amount of loosening after a specific number of cycles was determined from the screw motion data. RESULTS: The average maximal insertion torque of bigger revision screws (3.2 Nm) was greater than that of longer revision screws (2.7 Nm) with P = 0.03. The average loosening rate was 0.28 +/- 0.13 (SE) mm/thousand cycles for longer revision screws and 0.06 +/- 0.05 (SE) mm/thousand cycles for bigger revision screws. The difference between these 2 revision screws was significant (P = 0.03). In addition, the bigger revision screws had a lower loosening rate than that of the primary screws (P = 0.03). CONCLUSION: Iliac screws are susceptible to loosening under cyclic loading due to the cancellous bone structure surrounding the screw body. Experimental data showed that the bigger revision iliac screw resists loosening better than the longer screw and the primary screw. Thus, the bigger revision screw is favored if the patient's anatomy allows such operation.

Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors.

STUDY DESIGN: Prospective clinical series. OBJECTIVE: To determine the incidence, volume, and extent of postoperative epidural hematoma resulting in thecal sac compression, and to identify risk factors correlated with measured hematoma volumes. SUMMARY OF BACKGROUND DATA: Risk factors for postoperative hematoma development have been retrospectively determined in small populations of symptomatic patients. A prospective study of hematoma characteristics and associated risk factors in a consecutive series of patients could significantly enhance our understanding of postoperative hematoma. METHODS: Preoperative magnetic resonance imaging and clinical data on 13 pre- and intraoperative risk factors were prospectively collected on 50 consecutive patients undergoing lumbar decompression surgery with or without fusion. Postoperative magnetic resonance imagings were performed within 2 to 5 days of surgery. Thecal sac cross-sectional area was calculated at each disc space. Relative thecal sac compression due to hematoma was calculated at all levels where postoperative cross-sectional area was smaller than preoperative. Hematoma volumes were calculated. Multivariate analysis identified risk factors associated with postoperative hematoma volume. RESULTS: After decompression, 58% of patients developed epidural hematoma of sufficient magnitude to compress the thecal sac beyond its preoperative state at one or more levels. None developed new postoperative neurologic deficits. A mean of 1.4 levels were decompressed. Hematoma extended over a mean of 1.9 levels. Maximal thecal sac compression due to hematoma occurred at an adjacent, nondecompressed level in 28% of patients. Multivariate analysis found age greater than 60, multilevel procedures, and preoperative international normalized ratio to be associated with larger hematoma volumes. CONCLUSION: Lumbar decompression surgery results in a 58% incidence of asymptomatic compressive postoperative epidural hematoma. Adjacent level compression by hematoma occurs in 28% of patients. Advanced age, multilevel procedures, and international normalized ratio are independently associated with postoperative hematoma volume.

Postoperative lumbar epidural hematoma: does size really matter?

STUDY DESIGN: Prospective clinical series with comparison to retrospectively collected data. OBJECTIVE: To compare direct measures of postoperative hematoma volume against a new measure of hematoma effect on the thecal sac: the critical ratio. SUMMARY OF BACKGROUND DATA: Asymptomatic epidural hematoma is common after lumbar surgery. Symptomatic patients demonstrate a typical progression from sharp peri-incisional pain to bilateral neurologic deficits. Little is known about what differentiates symptomatic and asymptomatic patients. Magnetic resonance imaging (MRI) measures of hematoma size or mass effect may correlate with postoperative symptoms. METHODS: The study population consisted of 3 patient groups evaluated by MRI 2 to 5 days after lumbar decompression with or without fusion. Fifty-seven consecutive prospectively enrolled patients comprised the asymptomatic group. No patient developed severe postoperative pain or neurologic deficit. Search of our institutional database identified 4978 surgical patients within the last 24 months. Seventeen developed new postoperative symptoms. The painful group included 12 patients with severe peri-incisional pain without neurologic deficit. The cauda equina (CE) group included 5 patients with postoperative CE syndrome. Digital imaging software was used to calculate thecal sac cross sectional area on pre- and postoperative MRI at each level, hematoma volume, volume per level decompressed, and critical ratio for each patient. Critical ratio was defined as the smallest ratio of postoperative to preoperative cross sectional area within the lumbar spine. RESULTS.: The critical ratio was the only measure found to differ significantly (P < 0.05) among all 3 groups. Mean critical ratios were asymptomatic (0.8), painful (0.5), and CE (0.2). CONCLUSION: The critical ratio correlates more closely with the presence or absence of postoperative symptoms than measures of hematoma volume, and is consistent with the clinical expectation that greater thecal sac compression may result in more severe symptoms. Few guidelines exist for postoperative lumbar MRI interpretation. The critical ratio is an important contribution.

Acute outcomes of cervical spine injuries in the elderly: atlantaxial vs subaxial injuries.

BACKGROUND/OBJECTIVE: Recent studies have reported on the outcomes of spinal cord injuries in the elderly. Our aim was to identify acute survival differences between elderly patients with atlantoaxial injuries relative to subaxial injuries at our institution and to determine whether operative treatment is associated with improved survival rates in either population. STUDY DESIGN: Retrospective database review of all traumatic cervical spine injuries in patients at least 65 years of age at a single tertiary care center. METHODS: A total of 193 consecutive patients at least 65 years of age treated at a single tertiary care center over a 12-year period were identified. Initial hospitalization records were reviewed. Patients were divided by anatomic level of injury: atlantoaxial (C1 or C2) and subaxial (C3 or below). Demographics, mechanism, and mortality rates were compared. Each group was further divided by treatment (operative or nonoperative), and inpatient survival rates were compared. RESULTS: Statistically similar survival rates were observed among patients with atlantoaxial and subaxial injuries (P = 0.10). Patients with nonoperatively treated subaxial injuries died at significantly higher rates than did their operatively treated peers (P < 0.05). CONCLUSIONS: In this large comprehensive series of elderly patients with cervical spine injuries, survival rates were comparable regardless of anatomic level of injury. The operative treatment of subaxial injuries was associated with an improved acute survival rate vs nonoperative management. Further prospective study is needed to better assess this relationship.

Acute mortality and complications of cervical spine injuries in the elderly at a single tertiary care center.

STUDY DESIGN: Retrospective database review of all traumatic cervical spine injuries at a single tertiary care center. OBJECTIVE: To determine the acute survival of patients aged 65 and over with a variety of cervical spine injuries, regardless of operative or conservative treatment. SUMMARY OF BACKGROUND DATA: Elderly patients with cervical spine injuries have historically suffered from high mortality rates. More recent literature has demonstrated improved outcomes among operatively treated elderly, but has suggested that the nonoperative treatment of cervical injuries in this population may itself contribute to increased mortality rates. METHODS: One thousand seventy-three consecutive patients were identified and initial hospitalization records reviewed. Ninety-four patients were excluded for incomplete data. The remaining 979 patients were divided by age into young and elderly groups. Sex distribution, mechanism, injury type, comorbidities, and mortality and complication rates were compared. Elderly patients were further divided into operative and nonoperative groups and acute outcomes were compared. RESULTS: The overall acute mortality rate for all patients with cervical spine injuries was 5.92%. Eighty-six percent of all patients 65 and over survived, as did 96.1% of younger patients. Seventy-three percent of elderly patients with complete injuries survived, as did 80% of those with incomplete injuries, and 95.6% of intact elderly. Acute mortality rates were statistically comparable in both the operatively and nonoperatively treated groups of elderly. CONCLUSIONS: In this large comprehensive series of elderly patients with cervical spine injuries, statistically comparable survival rates were achieved in both operatively treated and nonoperatively treated patient populations. This finding challenges the conclusion that the nonoperative treatment of the elderly necessarily results in increased acute mortality.

Delayed epidural hematoma after spinal surgery: a report of 4 cases.

Symptomatic postoperative epidural hematoma is a rare and potentially devastating complication of spinal surgery. The overwhelming majority of reported cases have occurred in the immediate postoperative period. A recent publication defined the clinical entity of delayed postoperative epidural spinal hematoma as neurologic deterioration due to an epidural hematoma occurring at least 3 days after the index procedure. Only 2 such cases have been reported in the lumbar spine to date. Four cases of delayed postoperative spinal epidural hematoma were identified over a 6-year period among the spine surgeons at a single large academic institution. Each case involved the lumbar spine. The details of each patient's initial surgery, presentation, and hospital course were then gathered from a retrospective chart review. The 4 patients presented are unusual in their delayed symptomatic presentations of postoperative spinal epidural hematoma. Despite the longer time to onset, however, our patients exhibited many of the characteristics common to cases that presented in the acute postoperative period. The spine surgeon must remain vigilant for the possibility of postoperative spinal epidural hematoma in at-risk patients, even weeks after the original surgical procedure.

Histopathological Examination of Wild American Eels Infected with Anguillicola crassus.

We describe for the first time the histopathology caused in wild American eels Anguilla rostrata by the introduced nematode Anguillicola crassus. All of the American eels examined showed signs of previous or ongoing infections with A. crassus. Gross observations included opacity of the normally translucent swim bladder and dilation of blood vessels. The swim bladders of infected American eels showed focal, multifocal, and diffuse histological changes. Consistently observed pathologies included abnormal papillose appearance of the mucosa; hyperplasia of the lamina propria, muscularis mucosa, and submucosa; edema of the mucosa and muscularis mucosa; dilation of the blood vessels; and damage in the submucosa caused by migrating A. crassus L3 and L4 larvae. Less-common pathologies included fibrosis and lymphocytic aggregates around L3 and L4 larvae in the submucosa; destruction of the mucosa, which in some cases completely exposed the mucosal blood vessels; L2 larval penetration of the tissues of the swim bladder; bacterial infections in the submucosa and muscularis mucosa; and migration of an L4 larva through the rete mirabile.