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PURPOSE: Kyphosis in the lower lumbar spine (L4-S1) significantly affects sagittal alignment. However, the characteristics of the spinopelvic parameters and compensatory mechanisms in patients with lower lumbar degenerative kyphosis (LLDK) have not been described in detail. The objective of this retrospective study was to analyze the morphological characteristics in patients with sagittal imbalance due to LLDK. METHODS: In this retrospective study, we reviewed the clinical records of consecutive patients who underwent corrective surgery for adult spinal deformity (ASD) at a single institution. We defined LLDK as (i) kyphotic deformity in lower lumbar spine (L4-S1) or (ii) inappropriate distribution of lordosis (lordosis distribution index < 40%) in the lower lumbar spine. Global spine parameters of ASD patients and MRI findings were compared between those with LLDK (LLDK group) and without LLDK (control group). RESULTS: A total of 95 patients were enrolled in this study, of which the LLDK group included 14 patients (14.7%). Compared to the control, LLDK presented significantly higher pelvic incidence (62.1° vs 52.6°) and pelvic tilt (40.0° vs 33.4°), larger lordosis at the thoracolumbar junction (12.0° vs -19.6°), and smaller thoracic kyphosis (9.3° vs 26.0°). In LLDK, there was significantly less disc degeneration at L2/3 and L3/4. CONCLUSION: LLDK patients had high pelvic incidence, large pelvic tilt, and a long compensatory curve at the thoracolumbar junction and thoracic spine region.

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OBJECTIVE: Both the Global Alignment and Proportion (GAP) score and Roussouly classification account for the lordosis distribution index (LDI), but the LDI of the GAP score (G-LDI) is typically set to 50%-80%, while the LDI of the Roussouly classification (R-LDI) varies depending on the degree of pelvic incidence (PI). The objective of this study was to validate the ability of the G-LDI to predict mechanical complications and compare it with the predictive probability of R-LDI in patients with long-level fusion surgery. METHODS: A total of 171 patients were divided into two groups: 93 in the nonmechanical complication group (non-MC group) and 78 in the mechanical complication group (MC group). The mean age of the participants was 66.79 ± 8.56 years (range 34-83 years), and the mean follow-up period was 45.49 ± 16.20 months (range 24-62 months). The inclusion criteria for the study were patients who underwent > 4 levels of fusion and had > 2 years of follow-up. The predictive models for mechanical complications using the G-LDI and R-LDI were analyzed using binomial logistic regression and receiver operating characteristic analyses. RESULTS: There was a significant correlation between R-LDI and PI (r = -0.561, p < 0.001), while there was no correlation between G-LDI and PI (r = 0.132, p = 0.495). In reference to G-LDI, most patients in the non-MC group were classified as having alignment (72, 77.4%), while the MC group had an inhomogeneous composition (aligned: 34, 43.6%; hyperlordosis: 37, 47.4%). The agreement between the G-LDI and R-LDI was moderate (κ = 0.536, p < 0.001) to fair (κ = 0.383, p = 0.011) for patients with average or large PI, but poor (κ = -0.255, p = 0.245) for those with small PI. The areas under the curve for the G-LDI and R-LDI were 0.674 (95% CI, 0.592-0.757) and 0.745 (95% CI, 0.671-0.820), respectively. CONCLUSIONS: The R-LDI, which uses a PI-based proportional parameter, enables individual quantification of LL for all PI sizes and has been shown to have a higher accuracy in classifying cases and a stronger correlation with the risk of mechanical complications compared with G-LDI.

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Objective: Lordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. Methods: This study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results: 126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was -15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). Conclusions: We found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

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OBJECTIVE: The purpose of this study was to investigate the influence of sagittal alignment according to age-adjusted pelvic incidence minus lumbar lordosis (PI-LL) and lordosis distribution index (LDI) on the occurrence of adjacent-segment disease (ASD) after lumbar fusion surgery. METHODS: This study retrospectively reviewed 234 consecutive patients with lumbar degenerative diseases who underwent 1- or 2-level lumbar fusion surgery. Demographic and radiographic (preoperative and 3-month postoperative) data were collected and compared between ASD and non-ASD groups. Binary logistic regression analysis was performed to evaluate adjusted associations between potential variables and ASD development. A subanalysis was further conducted to assess their relationships in the range of different PI values. RESULTS: With a mean follow-up duration of 70.6 months (range 60-121 months), 118 patients (50.4%) were diagnosed as having cranial radiological ASD. Univariate analyses showed that older age, 2-level fusion, worse preoperative pelvic tilt and LL, lower pre- and postoperative LDI, and more improvement in sagittal vertical axis were significantly correlated with the occurrence of ASD. No significant differences in the PI-LL and age-adjusted PI-LL (offset) were detected between ASD and non-ASD groups. Multivariate analysis identified postoperative LDI (OR 0.971, 95% CI 0.953-0.989, p = 0.002); 2-level fusion (OR 3.477, 95% CI 1.964-6.157, p < 0.001); and improvement of sagittal vertical axis (OR 0.992, 95% CI 0.985-0.998, p = 0.039) as the independent variables for predicting the occurrence of ASD. When stratified by PI, LDI was identified as an independent risk factor in the groups with low and average PI. Lower segmental lordosis (OR 0.841, 95% CI 0.742-0.954, p = 0.007) could significantly increase the incidence of ASD in the patients with high LDI. CONCLUSIONS: Age-adjusted PI-LL may have limited ability to predict the development of ASD. LDI could exert an important effect on diagnosing the occurrence of ASD in the cases with low and average PI, but segmental lordosis was a more significant risk factor than LDI in individuals with high PI.

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PURPOSE: Minimally invasive single position lateral ALIF at L5-S1 with simultaneous robot-assisted posterior fixation has technical and anatomic considerations that need further description. METHODS: This is a retrospective case series of single position lateral ALIF at L5-S1 with robotic assisted fixation. End points included radiographic parameters, lordosis distribution index (LDI), complications, pedicle screw accuracy, and inpatient metrics. RESULTS: There were 17 patients with mean age of 60.5 years. Eight patients underwent interbody fusion at L5-S1, five patients at L4-S1, two patients at L3-S1, and one patient at L2-S1 in single lateral position. Operative times for 1-level and 2-level cases were 193 min and 278 min, respectively. Mean EBL was 71 cc. Mean improvements in L5-S1 segmental lordosis were 11.7 ± 4.0°, L1-S1 lordosis of 4.8 ± 6.4°, sagittal vertical axis of - 0.1 ± 1.7 cm°, pelvic tilt of - 3.1 ± 5.9°, and pelvic incidence lumbar-lordosis mismatch of - 4.6 ± 6.4°. Six patients corrected into a normal LDI (50-80%) and no patients became imbalanced over a mean follow-up period of 14.4 months. Of 100 screws placed in lateral position with robotic assistance, there were three total breaches (two lateral grade 3, one medial grade 2) for a screw accuracy of 97.0%. There were no neurologic, vascular, bowel, or ureteral injuries, and no implant failure or reoperation. CONCLUSION: Single position lateral ALIF at L5-S1 with simultaneous robotic placement of pedicle screws by a second surgeon is a safe and effective technique that improves global alignment and lordosis distribution index.

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The use of polychromatic immunofluorescent staining on whole-mount skin enables cell type characterization and aids in the delineation of the physiological and immunological strategies used by the skin to combat pathogens. Using whole-mount skin for polychromatic immunofluorescent staining removes the need for histological sectioning and enables the visualization of anatomical structures and immune cell types in three dimensions. Here we present a detailed protocol for immunostaining with fluorescence-conjugated primary antibodies in whole-mount skin to reveal structural landmarks and specific immune cell types using confocal laser scanning microscopy (CLSM) (Basic Protocol 1). The optimized staining panel reveals structural features such as blood vessels (CD31 antibody) and the lymphatic network (LYVE-1 antibody), in combination with MHCII antibodies for antigen-presenting cells (APCs), CD64 for macrophages and monocytes, CD103 for dendritic epidermal T cells (DETC), and CD326 for Langerhans cells (LC). Basic Protocol 2 describes image visualization pipelines using open-source software (ImageJ/FIJI), enabling four visualization options (z-projections, orthogonal views, 3D visualization, and animation). Basic Protocol 3 describes a quantitative analysis pipeline using CellProfiler to characterize the spatial relationship between cell types using mathematical indices such as Spatial Distribution Index (SDI), Neighborhood Frequency (NF), and Normalized Median Evenness (NME). These protocols will enable researchers to stain, record, analyze, and interpret data from whole-mount skin using commercially available reagents in a CLSM-equipped laboratory and freely available analysis software. © 2023 Wiley Periodicals LLC. Basic Protocol 1: Immunofluorescent staining and imaging for whole-mount mouse skin Basic Protocol 2: File rendering and visualization using FIJI Basic Protocol 3: Spatial image analysis using CellProfiler.

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Background: Restoring lumbar lordosis is important for adult spinal deformity surgery. Several reports have suggested that lumbar lordosis distribution has a significant impact on the outcome of surgery, including lumbar distribution index (LDI), proximal lumbar lordosis (PLL), and distal lumbar lordosis (DLL). The features of lumbar lordosis distribution are inconclusive in asymptomatic adults. Questions/Purposes: We sought to evaluate the variation of lumbar lordosis distribution (LDI, PLL, and DLL) and to identify associated factors in asymptomatic adult volunteers. Methods: We performed a systematic review of the Embase and Medline databases to identify studies in asymptomatic adult volunteers to evaluate lumbar lordosis distribution including LDI, PLL, and DLL. Results: Twelve articles met eligibility criteria and were included in our review. The respective pooled estimates of mean and variance, respectively, were 65.10% (95% confidence interval [CI]: 62.61-67.58) and 13.70% in LDI, 16.51° (95% CI: 5.54-27.49) and 11.46° in PLL, and 35.47° (95% CI: 32.79-38.18) and 9.10° in DLL. Lumbar lordosis distribution was associated with race, age, sex, body mass index, pelvic incidence, and Roussouly classification. Conclusions: This systematic review found that despite a wide variation in LDI and PLL, DLL is maintained in a narrower range in asymptomatic adult volunteers, especially in white populations. Distal lumbar lordosis may be a more reliable radiographic parameter to restore the lumbar lordosis distribution in preoperative planning.

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Neonatal respiratory distress syndrome is mainly treated with the intratracheal delivery of pulmonary surfactants. The success of the therapy depends on the uniformity of distribution and efficiency of delivery of the instilled surfactant solution to the respiratory zone of the lungs. Direct imaging of the surfactant distribution and quantifying the efficiency of delivery is not feasible in neonates. To address this major limitation, we designed an eight-generation computational model of neonate lung airway tree using morphometric and geometric data of human lungs and fabricated it using additive manufacturing. Using this model, we performed systematic studies of delivery of a clinical surfactant either at a single aliquot or at two aliquots under different orientations of the airway tree in the gravitational space to mimic rolling a neonate on its side during the procedure. Our study offers both a novel lung airway model and new insights into effects of the orientation of the lung airways and presence of a pre-existing surfactant film on how the instilled surfactant solution distributes in airways.

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The assessment of landscape ecological risk (LER) in different terrain gradients is beneficial to ecological environmental protection and risk management in different terrain gradients. Due to the impact of urban expansion, the landscape pattern of the Dianchi Lake basin (DLB) changed obviously, resulting in significant spatial difference of LER. At present, the LER assessment of the DLB is not clear, and the evolution mechanism of LER in different terrain gradients has not been revealed. Based on the LER assessment model, the geo-information Tupu method, the terrain niche gradient, and distribution index, this paper analyzed the LER and its terrain gradient effect in the DLB of China. The conclusions are as follows: (1) Since 1995, the land use type has mainly changed from grassland and cultivated land to construction land in the DLB of China. (2) The LERs in the DLB of China were mainly low, med low, and med high due to the transformation of land use type. The dominance distribution of the low and high LER was obviously constrained by terrain gradient. While the dominance distribution of med-low LER expanded to med-high terrain gradient, the dominance distribution of the med-high LER decreased to med-low terrain gradient. (3) The Tupu LERs were mainly a stable type of "medium" risk and anaphase change type of "med-high to medium" risk. The dominant distribution regions of the stable type, the prophase change type, and the continuous change type were relatively stable; the anaphase and middle change type expanded to the higher terrain gradient, and the repeated change type decreased to the med-high terrain gradient. In the process of ecological risk management and protection in the DLB, attention should be paid to the water area structure and LER control in med-high and high terrain gradients.

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PURPOSE: This study aimed to evaluate the effect of postoperative reciprocal progression of Lordosis tilt (LT), Lordosis distribution index (LDI) and occurrence of Proximal junctional kyphosis (PJK) following surgery for Degenerative lumbar scoliosis (DLS). METHODS: A total of 122 consecutive patients with ADS were treated with correction of deformity and followed up for a minimum of 2 years. Spinopelvic parameters were measured preoperatively, postoperatively, and at the latest follow-up. The Japanese Orthopaedic Association score, Oswestry Disability Index, and visual analog scale scores were measured at the latest follow-up. Associations between LT, LDI, and PJK were analyzed using receiver operating characteristic analyses. RESULTS: The prevalence of PJK in the present study was 24.6%. The outcomes of patients with PJK were significantly worse than those of patients without PJK. Postoperative reciprocal progression in LT and LDI with lumbar lordosis restorative surgery was observed. Preoperative risk factors for PJK were older age, larger LT, and larger Cobb angle of the curves. Postoperative risk factors for PJK included postoperative LT and postoperative Cobb angle of the curves, which were smaller than those preoperatively. We found a strong correlation between postoperative LT and Cobb angle of the curves resulting in PJK. Patients with LT < - 8° were at a higher risk of PJK. CONCLUSIONS: LT can be used to predict the occurrence of PJK in patients undergoing surgery for DLS. Appropriate postoperative LT is crucial for preventing the progression of PJK.

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BACKGROUND: Adjacent segment disease (ASD) is an acknowledged problem of posterior lumbar interbody fusion (PLIF). Many studies have been reported concerning the role of lordosis distribution index (LDI) in spinal biomechanics. However, few reports have been published about the impact of LDI on ASD following L4-S1 PLIF. METHODS: The study enrolled 200 subjects who underwent L4-S1 PLIF for degenerative spine disease from 2009 to 2014. The average follow-up term was 84 months. Several lower lumbar parameters were measured, including lower lumbar lordosis (LLL), lumbar lordosis (LL), pelvic incidence (PI), and LDI on the pre and postoperative radiograph. Perioperative information, comorbidities, and operative data were documented. Kaplan-Meier curves were plotted for the comparisons of ASD-free survival of 3 different types of postoperative LDI subgroups. RESULTS: The incidence of ASD was found to be 8.5%. LL and LLL increased by 3.96° (38.71° vs 42.67°; P < 0.001) and 3.60° (26.22° vs 28.82°; P < 0.001) after lower lumbar fusion surgery, respectively. Lordosis distribution index (LDI) increased by 0.03 (0.66 vs 0.69, P = 0.004) postoperatively. A significant difference (P = 0.001) was observed when comparing the incidence of ASD among postoperative LDI subgroups. The Kaplan-Meier curves showed a marked difference in ASD-free survival between low and moderate LDI subgroup (log-rank test, P = 0.0012) and high and moderate LDI subgroup (log-rank test, P = 0.0005). CONCLUSION: Patients with abnormal postoperative LDI were statistically more likely to develop ASD than those who had normal postoperative LDI. Moreover, patients with low postoperative LDI were at greater risk for developing ASD than those with high postoperative LDI over time.

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OBJECTIVE: The aim of this study was to investigate sagittal alignment and compensatory mechanisms in patients with monosegmental spondylolysis (mono_lysis) and multisegmental spondylolysis (multi_lysis). METHODS: A total of 453 adult patients treated for symptomatic low-grade spondylolytic spondylolisthesis were retrospectively studied at a single center. Patients were divided into 2 subgroups, the mono_lysis group and the multi_lysis group, based on the number of spondylolysis segments. A total of 158 asymptomatic healthy volunteers were enrolled in this study as the control group. Radiographic parameters measured on standing sagittal radiographs and the ratios of L4-S1 segmental lordosis (SL) to lumbar lordosis (L4-S1 SL/LL) and pelvic tilt to pelvic incidence (PT/PI) were compared between all experimental groups. RESULTS: There were 51 patients (11.3%) with a diagnosis of multi_lysis in the spondylolysis group. When compared with the control group, the spondylolysis group exhibited larger PI (p < 0.001), PT (p < 0.001), LL (p < 0.001), and L4-S1 SL (p = 0.025) and a smaller L4-S1 SL/LL ratio (p < 0.001). When analyzing the specific spondylolysis subgroups, there were no significant differences in PI, but the multi_lysis group had a higher L5 incidence (p = 0.004), PT (p = 0.018), and PT/PI ratio (p = 0.039). The multi_lysis group also had a smaller L4-S1 SL/LL ratio (p = 0.012) and greater sagittal vertical axis (p < 0.001). CONCLUSIONS: A high-PI spinopelvic pattern was involved in the development of spondylolytic spondylolisthesis, and a larger L5 incidence might be associated with the occurrence of consecutive multi_lysis. Unlike patients with mono_lysis, individuals with multi_lysis were characterized by an anterior trunk, insufficiency of L4-S1 SL, and pelvic retroversion.

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BACKGROUND CONTEXT: Proximal junctional failure (PFJ) is a common and dreaded complication of adult spinal deformity. Previous research has identified parameters associated with the development of PJF and the search for radiographic and clinical variables continues in an effort to decrease the incidence of PFJ. The lordosis distribution index (LDI) is a parameter not based on pelvic incidence. Ideal values for LDI have been established in prior literature with demonstrated association with PJF. PURPOSE: The purpose of this study is compare PJF and mechanical failure rates between patients with ideal and nonideal LDI cohort. STUDY DESIGN: This is a retrospective, single-center case-controlled study. PATIENT SAMPLE: Adult patients who underwent surgical treatment for spinal deformity as defined by the SRS-Schwab criteria between 2001 and 2016 were included. Furthermore, fusion constructs spanned at least four vertebral segments with the upper instrumented vertebra (UIV) T9 or caudal. Patients who were under the age of 18, those with radiographic data less than 1 year, and those with neoplastic or trauma etiologies were excluded. Prior thoracolumbar spine surgery was not an exclusion criterion. OUTCOME MEASURES: The outcome measures were physiologic in nature: The primary outcome was defined as PFJ. The International Spine Study Group (ISSG) definition for PJF was used, which includes postoperative fracture of the UIV or UIV+1, instrumentation failure at UIV, PJA increase greater than 15° from preoperative baseline or extension of the construct needed within 6 months. Secondary outcomes included extension of the construct after 6 months or revision due to instrumentation failure, pseudarthrosis or distal junctional failure. METHODS: A portion of this project was funded through National Institute of Health Grant 5UL1TR001067-05. The authors have no conflict of interest related to this study. The records of patients meeting the inclusion criteria were reviewed. Clinical and radiographic data were extracted and analyzed. Univariate cox proportional hazard models were used to identify factors associated with mechanical failure and included in a multivariate Cox proportional hazards model. RESULTS: There were 187 patients that met the inclusion criteria. Univariate analysis demonstrated the number of levels fused, instrumentation to the sacrum or pelvis, PI-LL difference between pre- and postoperative states, T1-SPI, T9-SPI, and postoperative LDI (treated as a continuous variable). When LDI was treated as a categorical variable using an LDI cutoff of less than 0.5 for hypolordotic, 0.5 to 0.8 for aligned and greater than 0.8 for hyperlordotic, there was no difference in failure rates between the two groups. CONCLUSIONS: Lumbar lordosis is an important parameter in adult deformity. However, the LDI is an imperfect variable and previously developed categories did not show differences in failure rates in this cohort.

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PURPOSE: The global alignment and proportion (GAP) score was recently developed to consider proportional analysis of spinopelvic alignment and has been indicated for setting surgical goals to decrease the prevalence of mechanical complications. The goal of this study was to clarify the limitations and problems with spinal corrective surgery with minimally invasive lateral lumbar interbody fusion (LLIF) without osteotomy using GAP score, and to establish a preoperative radiographical evaluation to understand the necessity for three-column osteotomy. METHODS: We included data from 57 consecutive patients treated with spinal corrective surgery with LLIF and without Schwab grade 3-6 osteotomy for ASD. To evaluate flexibility of the pelvis and lumbar spine, we examined full-length lateral radiographs with patients standing and prone. Correlations between pre- and postoperative radiographic parameters and GAP score were determined. RESULTS: Most patients achieved a sufficiently ideal lumbar lordosis (87.7%), but ideal sacral slope (SS) was achieved in only 50.8% of patients. Preoperative prone SS showed a significant positive correlation with postoperative SS and a significant negative correlation with GAP score. Patients whose preoperative prone SS was larger than pelvic incidence × 0.59-7.5 tended to achieve proportioned spinopelvic alignment by using LLIF. CONCLUSIONS: The cause of poor outcome of GAP score for ASD corrective surgery with LLIF without osteotomy is a postoperative small SS. Preoperative prone SS is useful for predicting postoperative SS. When preoperative SS in prone patients is relatively small to ideal as calculated using PI, osteotomy or other correctors should be considered to achieve satisfactory spinopelvic parameters. LEVEL OF EVIDENCE: III. These slides can be retrieved under Electronic Supplementary Material.

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To investigate the changes of Zn availability and transformation in calcareous soil, orga-nic materials (maize straw, biofertilizer, fulvic acids, and chicken manure) were thoroughly mixed with the soils amended with Zn fertilizer in the nylon net bags and buried in a field. Results showed that compared with control (neither Zn nor organic materials), Zn fertilizer alone and combined addition with organic materials significantly increased soil total Zn concentration (7.2%-13.8%) and DTPA-Zn concentration (2.1-2.8 folds). For the Zn amended treatments, the contributions of organic amendments to soil total Zn and DTPA-Zn concentration decreased in the order of chicken manure > biofertilizer > maize straw > fulvic acids. The highest conversion rate of exogenous Zn into DTPA-Zn occurred in the treatments with straw and biofertilizer. In comparison with single Zn application, combination of Zn fertilizer with organic materials increased soil organic matter and stimulated more Zn weakly bound to organic matter, enhanced mobility factor and reduced distribution index of Zn in soil. The differences in soil Zn availability and transformation among the combinations of Zn fertilizer and organic materials were likely linked to the inherent properties of organic materials such as maturity degree and Zn content. Considering the environment safety and cost reduction, combining Zn fertilizer and straw return was the best practice to enhance Zn availability in the Zn-deficient calcareous soil, although its contribution to Zn availability was less than the combination of biofertilizer or chicken manure with Zn fertilizer.

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Psoriasis is a chronic immune-mediated inflammatory skin disorder. Heat shock proteins (HSPs) have been witnessed as a potential drug target for inhibition of psoriatic cell differentiation. The expression level of HSP is increased when the cells get exposed to elevated temperature, oxidative stress and nutritional deficiencies and thus plays major role in psoriatic progression pathway. Immunoreactivity intensity distribution index scores for HSP70 expression is significantly higher in psoriatic patients compared to normal. In the present work, the 3D structure of human Hsp70 has been taken. Inhibition of HSP70 can control the severity of psoriasis up to many folds; thus, virtual screening was performed against lead-like, drug-like and some natural product of ZINC database. The screened ligands were further introduced to ADMET prediction and simulations to see the drug proficiency and likeness property. The molecular dynamic of system was found stable during simulation trajectory and not much of significant changes occurred in the conformation of the protein-ligand complex. Thus, present study in all probability might prove useful for future design of new derivatives with higher potency and specificity.

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OBJECTIVE The subtraction of lumbar lordosis (LL) from the pelvic incidence (PI) offers an estimate of the LL required for a given PI value. Relative LL (RLL) and the lordosis distribution index (LDI) are PI-based individualized measures. RLL quantifies the magnitude of lordosis relative to the ideal lordosis as defined by the magnitude of PI. LDI defines the magnitude of lower arc lordosis in proportion to total lordosis. The aim of this study was to compare RLL and PI - LL for their ability to predict postoperative complications and their correlations with health-related quality of life (HRQOL) scores. METHODS Inclusion criteria were ≥ 4 levels of fusion and ≥ 2 years of follow-up. Mechanical complications were proximal junctional kyphosis/proximal junctional failure, distal junctional kyphosis/distal junctional failure, rod breakage, and implant-related complications. Correlations between PI - LL, RLL, PI, and HRQOL were analyzed using the Pearson correlation coefficient. Mechanical complication rates in PI - LL, RLL, LDI, RLL, and LDI interpreted together, and RLL subgroups for each PI - LL category were compared using chi-square tests and the exact test. Predictive models for mechanical complications with RLL and PI - LL were analyzed using binomial logistic regressions. RESULTS Two hundred twenty-two patients (168 women, 54 men) were included. The mean age was 52.2 ± 19.3 years (range 18-84 years). The mean follow-up was 28.8 ± 8.2 months (range 24-62 months). There was a significant correlation between PI - LL and PI (r = 0.441, p < 0.001), threatening the use of PI - LL to quantify spinopelvic mismatch for different PI values. RLL was not correlated with PI (r = -0.093, p > 0.05); therefore, it was able to quantify divergence from ideal lordosis for all PI values. Compared with PI - LL, RLL had stronger correlations with HRQOL scores (p < 0.05). Discrimination performance was better for the model with RLL than for PI - LL. The agreement between RLL and PI - LL was high (κ = 0.943, p < 0.001), moderate (κ = 0.455, p < 0.001), and poor (κ = -0.154, p = 0.343), respectively, for large, average, and small PI sizes. When analyzed by RLL, each PI - LL category was further divided into distinct groups of patients who had different mechanical complication rates (p < 0.001). CONCLUSIONS Using the formula of PI - LL may be insufficient to quantify normolordosis for the whole spectrum of PI values when applied as an absolute numeric value in conjunction with previously reported population-based average thresholds of 10° and 20°. Schwab PI - LL groups were found to constitute an inhomogeneous group of patients. RLL offers an individualized quantification of LL for all PI sizes. Compared with PI - LL, RLL showed a greater association with both mechanical complications and HRQOL. The use of RLL and LDI together, instead of PI - LL, for surgical planning may result in lower mechanical complication rates and better long-term HRQOL.

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Evaluation of depth of anaesthesia (DoA) is critical in clinical surgery. Indices derived from electroencephalogram (EEG) are currently widely used to quantify DoA. However, there are known to be inaccurate under certain conditions; therefore, experienced anaesthesiologists rely on the monitoring of vital signs such as body temperature, pulse rate, respiration rate, and blood pressure to control the procedure. Because of the lack of an ideal approach for quantifying level of consciousness, studies have been conducted to develop improved methods of measuring DoA. In this study, a short-term index known as the similarity and distribution index (SDI) is proposed. The SDI is generated using heart rate variability (HRV) in the time domain and is based on observations of data distribution differences between two consecutive 32 s HRV data segments. A comparison between SDI results and expert assessments of consciousness level revealed that the SDI has strong correlation with anaesthetic depth. To optimise the effect, artificial neural network (ANN) models were constructed to fit the SDI, and ANN blind cross-validation was conducted to overcome random errors and overfitting problems. An ensemble ANN was then employed and was discovered to provide favourable DoA assessment in comparison with commonly used Bispectral Index. This study demonstrated the effectiveness of this method of DoA assessment, and the results imply that it is feasible and meaningful to use the SDI to measure DoA with the additional use of other measurement methods, if appropriate.

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[Purpose] The purpose of this study was to compare the effects of transcutaneous electrical nerve stimulation (TENS), with and without visual input, on weight distribution following exercise-induced fatigue in the dorsiflexor and plantar flexor muscles of the ankle. [Subjects and Methods] This study had a cross-sectional design. Nineteen healthy adults (10 males, 9 females; mean age 21±0.8 years) were recruited to participate in a single group repeated measurements study lasting three days. On the first day, following exercise-induced fatigue, the standing position was maintained for 30 minutes, after which the postural sway was measured with eyes open (EO) and eyes closed (EC). On the second day, TENS was applied to the ankle dorsiflexors in the standing position for 30 minutes following exercise-induced fatigue. On the last day, TENS was applied to the plantar flexors, and the postural sway was measured with EO and EC following the same exercise-induced fatigue. [Results] On level terrain, with and without visual input, there was a significant difference between the baseline values and those following TENS on the tibialis anterior. On uneven terrain (simulated by a cushion), with and without visual input, there was a significant difference between the baseline values and those following TENS on the gastrocnemius. [Conclusion] Clinically, during walking on a flat surface for only a short period of time, TENS should be applied to the tibialis anterior. If walking training is performed on a variety of terrains for a longer time, TENS should be applied to the gastrocnemius.

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The aim of the study was (1) to perform an automated segmentation of hot spot regions of the hand from thermograph using the k-means algorithm and (2) to test the potential of features extracted from the hand thermograph and its measured skin temperature indices in the evaluation of rheumatoid arthritis. Thermal image analysis based on skin temperature measurement, heat distribution index and thermographic index was analyzed in rheumatoid arthritis patients and controls. The k-means algorithm was used for image segmentation, and features were extracted from the segmented output image using the gray-level co-occurrence matrix method. In metacarpo-phalangeal, proximal inter-phalangeal and distal inter-phalangeal regions, the calculated percentage difference in the mean values of skin temperatures was found to be higher in rheumatoid arthritis patients (5.3%, 4.9% and 4.8% in MCP3, PIP3 and DIP3 joints, respectively) as compared to the normal group. k-Means algorithm applied in the thermal imaging provided better segmentation results in evaluating the disease. In the total population studied, the measured mean average skin temperature of the MCP3 joint was highly correlated with most of the extracted features of the hand. In the total population studied, the statistical feature extracted parameters correlated significantly with skin surface temperature measurements and measured temperature indices. Hence, the developed computer-aided diagnostic tool using MATLAB could be used as a reliable method in diagnosing and analyzing the arthritis in hand thermal images.

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