Percutaneous Endoscopic Interbody Debridement and Fusion (PEIDF) Decreases Risk of Sepsis and Mortality in Treating Infectious Spondylodiscitis for Patients with Poor Physical Status, a Retrospective Cohort Study.

Background: Postoperative immunosuppression is associated with blood loss and surgical trauma during surgery and subsequently predisposes patients to increased morbidity. Spine endoscopic surgery has been accepted as an effective surgical technique with less surgical trauma and less blood loss for the complication of infectious spondylodiscitis. Therefore, the aim of this study was to investigate whether PEIDF could reduce the morbidity rates for patients with infectious spondylodiscitis. Methods: We launched a retrospective cohort study on the comparison of the perioperative prognosis between PEIDF and conventional open surgery for single-level lumbar infectious spondylodiscitis in patients with poor physical health (ASA ≥ 4) from 2014 to 2019. Results: Forty-four patients were included in this study. Fifteen of them underwent PEIDF, and the rest of the 29 patients were treated with open surgery. Less surgical blood loss (p < 0.001) and intraoperative transfusions (p < 0.001) with a better decline of CRP (p = 0.017) were statistically significant in patients receiving PEIDF. Patients undergoing conventional open surgery encountered more postoperative sepsis (p = 0.030), a higher qSOFA score (p = 0.044), and prolonged-time for CRP normalization (p = 0.001). Conclusions: PEIDF minimizes a poor postoperative outcome due to less surgical trauma, intraoperative blood loss, and the need for a blood transfusion.

Risk Factors of Coexisting Septic Spondylitis and Arthritis: A Case-Control Study in a Tertiary Referral Hospital.

INTRODUCTION: In patients under immunosuppression or severe sepsis, it is sometimes manifested as coexisting septic arthritis and spondylitis. The aim of this study is to evaluate and investigate the risk factors of infectious spondylitis associated with septic arthritis. METHODS: The study retrospectively reviewed the patients diagnosed with infectious spondylitis between January 2010 and September 2018 for risk factors of coexisting major joint septic arthritis. RESULTS: A total of 10 patients with infectious spondylitis and coexisting septic arthritis comprised the study group. Fifty matched patients with solely infectious spondylitis were selected as the control group. Major risk factors include preoperative C-reactive protein (p = 0.001), hypoalbuminemia (p = 0.011), history of total joint replacement (p < 0.001), duration of preoperative antibiotics treatment (p = 0.038) and psoas muscle abscess (p < 0.001). CONCLUSION: Infectious spondylitis and septic arthritis are thought of as medical emergencies due to their high mortality and morbidity. Our study evaluated 5 risk factors as significant major findings: hypoalbuminemia (<3.4 g/dL), higher preoperative CRP (>130 mg/L), psoas muscle abscess, longer preoperative antibiotics treatment (>8 days) and history of total joint replacement. Clinicians should pay attention to the patients with those five factors to detect the coexisting infections as early as possible.

Percutaneous Endoscopic Interbody Debridement and Fusion for Pyogenic Lumbar Spondylodiskitis: Surgical Technique and the Comparison With Percutaneous Endoscopic Drainage and Debridement.

OBJECTIVE: Surgical treatment of severe infectious spondylodiskitis remains challenging. Although minimally invasive percutaneous endoscopic drainage and debridement (PEDD) may yield good results in complicated cases, outcomes of patients with extensive structural damage and mechanical instability may be unsatisfactory. To address severe infectious spondylodiskitis, we have developed a surgical technique called percutaneous endoscopic interbody debridement and fusion (PEIDF), which comprises endoscopic debridement, bonegraft interbody fusion, and percutaneous posterior instrumentation. METHODS: Outcomes of PEIDF in 12 patients and PEDD in 15 patients with infectious spondylodiskitis from April 2014 to July 2018 were reviewed retrospectively. Outcome were compared between 2 kinds of surgical procedures. RESULTS: Patients in PEIDF group had significantly lower rate of revision surgery (8.3% vs. 58.3%), better kyphosis angle (-5.73° ± 8.74 vs. 1.07° ± 2.70 in postoperative; 7.09° ± 7.23 vs. 0.79° ± 4.08 in kyphosis correction at 1 year), and higher fusion rate (83.3% vs. 46.7%) than those who received PEDD. CONCLUSION: PEIDF is an effective approach for treating infectious spondylodiskitis, especially in patients with spinal instability and multiple medical comorbidities.

Better Functional Outcome and Pain Relief in the Far-Lateral-Outside-in Percutaneous Endoscopic Transforaminal Discectomy.

BACKGROUND: Even though percutaneous endoscopic transforaminal discectomy (PETD) has been widely used for the surgical treatment of lumbar herniated disc, there are only a few studies directly comparing the clinical outcomes between microdiscectomy (MD) and PETD. Therefore, further studies are needed in order to compare the clinical outcomes between PETD and MD on a single level more thoroughly. METHODS: We proposed a far-lateral-outside-in technique for PETD to get an entry point without complex planning and facet violation. From September 2017 to September 2019, a total of 155 patients (69 with PETD and 86 with MD) were enrolled for this retrospective study, with the inclusion criteria: single level between L2 and S1, clinical sciatica for at least 6 weeks, and failed attempts with non-surgical treatments. Patients were excluded due to cauda equina syndrome, progressive neurologic deficits, history of lumbar spinal surgery, endplate modic changes, severe disc degeneration and less than 24 months of follow-up. RESULTS: PETD showed significantly shorter surgery time and less intraoperative blood loss compared to MD. The difference between PETD and MD in VAS back pain (but not VAS leg pain) at follow-up time was significant. The ODI improvement in the follow-up time of 6 months between the 2 groups showed a significant difference (PETD: 31.23±6.59, MD: 39.85±7.81, p < 0.001). MD had a significantly higher chance of postoperative wound infection and poor healing, while PETD was more likely to have recurrence of the herniated disc. CONCLUSION: MD has been the gold standard procedure for LDH. However, with the advanced endoscopic technology and surgical technique, PETD has emerged as an alternative method due to higher functional outcome and less wound problems.

The influence of spinopelvic parameters on adjacent-segment degeneration after short spinal fusion for degenerative spondylolisthesis.

OBJECTIVE: Spinopelvic parameters, such as the pelvic incidence (PI) angle, sacral slope angle, and pelvic tilt angle, are important anatomical indices for determining the sagittal curvature of the spine and the individual variability of the lumbar lordosis (LL) curve. The aim of this study was to investigate the influence of spinopelvic parameters and LL on adjacent-segment degeneration (ASD) after short lumbar and lumbosacral fusion for single-level degenerative spondylolisthesis. METHODS: The authors retrospectively reviewed the records of all short lumbar and lumbosacral fusion surgeries performed between August 2003 and July 2010 for single-level degenerative spondylolisthesis in their orthopedic department. RESULTS: A total of 30 patients (21 women and 9 men, mean age 64 years) with ASD after lower lumbar or lumbosacral fusion surgery comprised the study group. Thirty matched patients (21 women and 9 men, mean age 63 years) without ASD comprised the control group, according to the following matching criteria: same diagnosis on admission, similar pathologic level (≤ 1 level difference), similar sex, and age. The average follow-up was 6.8 years (range 5-8 years). The spinopelvic parameters had no significant influence on ASD after short spinal fusion. CONCLUSIONS: Neither the spinopelvic parameters nor a mismatch of PI and LL were significant factors responsible for ASD after short spinal fusion due to single-level degenerative spondylolisthesis.

Genetic Diversity and Drug Susceptibility of Mycobacterium tuberculosis Isolates in a Remote Mountain Area of China.

OBJECTIVE: We determined the genetic diversity of Mycobacterium tuberculosis (MTB) in a remote mountainous area of southwest China and evaluated the resolving ability of single nucleotide polymorphism (SNP) genotyping combined with variable number tandem repeat (VNTR) genotyping for Beijing family strains in association with drug resistance status. METHODS: Three hundred thirty-one MTB strains were isolated from patients living in mountainous regions of southwest China, and 8-loci SNP, VNTR-15 genotyping assays, and drug susceptibility testing of 9 drugs were performed. RESULTS: A total of 183 [55.29% (183/331)] strains were classified into the Beijing family. Of the 183 strains, 111 (60.66%) were defined as modern Beijing strains. The most predominant modern Beijing sub-lineage and ancient Beijing sub-lineage were Bmyc10 [39.34% (72/183)] and Bmyc25 [20.77% (38/183)], respectively. Of the isolates, 19.64% (65/331) were resistant to at least 1 of the 9 anti-TB drugs and 17 [4.98% (17/331)] MTB isolates were multi-drug resistant tuberculosis (MDR-TB). Two hundred sixty-one isolates showed a clustering rate of 14.18% (37/261) and a discriminatory index of 0.9990. The Beijing lineage exhibited a significantly higher prevalence of MDR-TB, as well as resistance to isoniazid (INH), rifampin (RIF), and para-aminosalicylic acid (PAS) when analyzed independently (P = 0.005, P = 0.017, P = 0.014, and P = 0.006 respectively). The Beijing lineage was not associated with genetic clustering or resistance to any drug. In addition, genetic clustering was not associated with drug resistance. CONCLUSION: MTB strains demonstrate high genetic diversity in remote mountainous areas of southwest China. Beijing strains, especially modern Beijing strains, are predominant in remote mountainous area of China. The combination of 8-loci SNPs and VNTR-15 genotyping is a useful tool to study the molecular epidemiology of MTB strains in this area.

Green fluorescent protein chromophore derivative suppresses ultraviolet A-induced JNK-signalling and apoptosis in keratinocytes and adverse effects in zebrafish embryos.

Solar ultraviolet (UV) light has been recognized as the important environmental hazard and contributes to diverse skin damage such as cell death, photoageing and even carcinogenesis. Revelation of harmful responses attributed to UVA radiation has promoted the development of photoprotective agents against UVA-induced skin damage. In the present study, we tried to evaluate the potential protective effects of a synthetic green fluorescent protein (GFP) chromophore derivative, 4-chlorobenzyldene-1, 2-dimethylimidazolinone (Cl-BDI, called TC-22) on UVA- and UVB- induced stress responses in skin. The HaCaT keratinocytes were used to evaluate the cellular effects. Zebrafish (Danio rerio), which is regarded as a useful and cost-effective alternative to some mammalian models, was applied as the in vivo animal model. In HaCaT keratinocytes, TC-22 was able to obviously decrease UVA-induced cell death. Dissection of the UVA-induced signalling pathways revealed that TC-22 could suppress the activation of JNK and caspase 3, but not of ERK and p38. Reduction of UVA-induced cleavage of caspase 3 and sub-G1 phase accumulation by pretreatment of TC-22 was also observed. In zebrafish, we showed that UVA irradiation could decrease the survival and hatching rate, suppress heart beats of embryos and enhance the pigmentation of larvae. Pretreatment of TC-22 could significantly reverse UVA-induced the suppression in hatching of eggs and heart beating of embryos and also lowered the UVA-induced pigmentation in zebrafish. Collectively, we demonstrate that TC-22, a GFP chromophore derivative, can ameliorate the UVA-induced stress responses in both epidermal keratinocytes and zebrafish, suggesting the potential use of TC-22 in photoprotection in the future.

Prevalence and Risk Factors of Primary Drug-Resistant Tuberculosis in China.

OBJECTIVE: To investigate the prevalence of primary drug-resistant tuberculosis (TB) and associated risk factors in China. We also explored factors contributing to the transmission of multidrug-resistant tuberculosis (MDR-TB). METHODS: A total of 2794 representative, Mycobacterium tuberculosis isolates from treatment-naive patients were subjected to drug susceptibility testing, and risk factors for drug-resistant TB were analyzed. We also analyzed MDR-TB strain sublineages, drug-resistance-conferring mutations, and risk factors associated with clustered primary MDR strains. RESULTS: Among 2794 Mycobacterium tuberculosis isolates from treatment-naive patients, the prevalence of any resistance to first-line drugs was 33.2% and the prevalence of MDR-TB was 5.7%. We did not find any risk factors significantly associated with resistance to first-line drugs. The 93 primary MDR-TB isolates were classified into six sublineages, of which, 75 (80.6%) isolates were the RD105-deleted Beijing lineage. The largest sublineage included 65 (69.9%) isolates with concurrent deletions of RD105, RD207, and RD181. Twenty-nine (31.2%) primary MDR strains grouped in clusters; MDR isolates in clusters were more likely to have S531L rpoB mutation. CONCLUSION: This study indicates that primary drug-resistant TB and MDR-TB strains are prevalent in China, and multiple measures should be taken to address drug-resistant TB.

The Abbott RealTime MTB assay and the Cepheid GeneXpert assay show comparable performance for the detection of Mycobacterium tuberculosis in sputum specimens.

OBJECTIVES: To evaluate the performance of the newly developed technology Abbott RealTime MTB assay (RealTime MTB assay) for the detection of Mycobacterium tuberculosis in sputum specimens and to compare its performance with that of the Cepheid GeneXpert assay. METHODS: Sputum specimens were collected from 270 subjects suspected to have tuberculosis (TB). Smear microscopy, culture, identification, RealTime MTB, and GeneXpert assays were performed according to standard protocols. Accuracy measures of the method evaluated were determined using solid culture as the reference standard. RESULTS: The RealTime MTB assay showed similar positive detection rates as the GeneXpert assay in smear-positive, culture-positive, and smear/culture-negative groups; no significant differences were found in these groups between the two assays. The RealTime MTB assay demonstrated a sensitivity of 100% and a specificity of 84.4%; the GeneXpert assay had a sensitivity of 96.9% and specificity of 89.6%. After the resolution of discordant results by PCR-based molecular method, the sensitivities and specificities of the RealTime MTB and GeneXpert assays were 100% vs. 97% and 90.0% vs. 95.6%, respectively; no significant difference in sensitivity or specificity was found between the RealTime MTB and GeneXpert assays. CONCLUSIONS: This study demonstrated that the Abbott RealTime MTB and Cepheid GeneXpert assays have similar sensitivity and specificity. The Abbott RealTime MTB assay is a highly promising method for the diagnosis of TB.

[Relationship between Beijing genotypes of Mycobacterium tuberculosis and drug-resistant phenotypes].

OBJECTIVE: To investigate the distribution of the Beijing genotypes of Mycobacterium tuberculosis (M. tuberculosis) and the relationships between Beijing genotype strains and drug-resistant phenotypes in China. METHODS: Clinical isolates were collected during a 9-month research period from April to December in 2008 in six geographic regions of China. One isolate that had been biochemically confirmed to be a member of the M. tuberculosis complex was collected from each patient. The demographic data of the patients (eg. sex, age, and history of tuberculosis) as well as the drug resistance patterns and sources of the clinical isolates were collected. Drug susceptibility testing was performed using proportion method. Beijing genotypes of M. tuberculosis were identified by spacer oligonucleotide typing or insertion of IS6110 in the genomic dnaA-dnaN locus. RESULTS: Among the 410 M. tuberculosis clinical isolates, 67.1% (275/410) isolates were Beijing genotypes of M. tuberculosis. Significantly larger proportions of tuberculosis patients were infected with Beijing genotypes in the northeastern regions of China than that of in the central-western regions (chi2 = 20.50, P = 0.000). No significant associations were found either between Beijing genotype strains and patients' age, sex, or treatment history. Multidrug-resistant isolates and rifampin-resistant isolates were more common among Beijing genotype strains than among non-Beijing strains (P = 0.002, P = 0.005). CONCLUSIONS: About two third of the clinical isolates of M. tuberculosis in China are Beijing genotypes. Beijing genotype strains are not correlated with patients' age, sex, treatment history. People living in the northeastern regions of China are more susceptible to Beijing genotypes than those living in the central-western of China. Beijing genotype strains tend to be rifampin-resistant or multidrug-resistant.

Prevalence of tuberculosis drug resistance in 10 provinces of China.

BACKGROUND: The emergence of drug-resistant tuberculosis (TB) hampers TB control. Ten provinces in China performed drug resistance surveys among tuberculosis (TB) patients in 1996-2004 to assess levels of drug resistance. METHODS: Provincial drug resistance surveys included all isolates from newly diagnosed, smear-positive TB patients. Drug susceptibility testing (DST) against isoniazid, rifampicin, streptomycin and ethambutol was carried out in the provincial laboratories. For purposes of quality assurance, a random sample (11.6%) was re-tested by the national reference laboratory (NRL). RESULTS: Of 14,059 patients tested 11,052 (79%) were new TB cases. The weighted mean prevalence of multi-drug resistant tuberculosis (MDR-TB) among all cases was 9.3% (range 2.2%-10.4%); 5.4% (range 2.1% - 10.4%) among new cases and 25.6% (range 11.7%-36.9%) among previously treated cases. Adjusting the drug resistance proportions using the re-testing results did not change the estimated national mean prevalence significantly. However, in some individual provinces the estimated resistance proportions were greatly influenced, especially among re-treatment patients. CONCLUSION: MDR-TB levels varied greatly between provinces in China, but on average were high compared to the global estimated average of 4.8%. This study shows the importance of quality-assured laboratory performance. Programmatic management of drug-resistant TB, including high quality DST for patients at high risk of resistance and treatment with second-line drugs, should become the standard, especially in high MDR-TB settings.