Surugadai Nihon University Hospital

Regulated transcription controls the diversity, developmental pathways and spatial organization of the hundreds of cell types that make up a mammal. Using single-molecule cDNA sequencing, we mapped transcription start sites (TSSs) and their usage in human and mouse primary cells, cell lines and tissues to produce a comprehensive overview of mammalian gene expression across the human body. We find that few genes are truly ‘housekeeping’, whereas many mammalian promoters are composite entities composed of several closely separated TSSs, with independent cell-type-specific expression profiles. TSSs specific to different cell types evolve at different rates, whereas promoters of broadly expressed genes are the most conserved. Promoter-based expression analysis reveals key transcription factors defining cell states and links them to binding-site motifs. The functions of identified novel transcripts can be predicted by coexpression and sample ontology enrichment analyses. The functional annotation of the mammalian genome 5 (FANTOM5) project provides comprehensive expression profiles and functional annotation of mammalian cell-type-specific transcriptomes with wide applications in biomedical research. A study from the FANTOM consortium using single-molecule cDNA sequencing of transcription start sites and their usage in human and mouse primary cells, cell lines and tissues reveals insights into the specificity and diversity of transcription patterns across different mammalian cell types. FANTOM5 (standing for functional annotation of the mammalian genome 5) is the fifth major stage of a major international collaboration that aims to dissect the transcriptional regulatory networks that define every human cell type. Two Articles in this issue of Nature present some of the project's latest results. The first paper uses the FANTOM5 panel of tissue and primary cell samples to define an atlas of active, in vivo bidirectionally transcribed enhancers across the human body. These authors show that bidirectional capped RNAs are a signature feature of active enhancers and identify more than 40,000 enhancer candidates from over 800 human cell and tissue samples. The enhancer atlas is used to compare regulatory programs between different cell types and identify disease-associated regulatory SNPs, and will be a resource for studies on cell-type-specific enhancers. In the second paper, single-molecule sequencing is used to map human and mouse transcription start sites and their usage in a panel of distinct human and mouse primary cells, cell lines and tissues to produce the most comprehensive mammalian gene expression atlas to date. The data provide a plethora of insights into open reading frames and promoters across different cell types in addition to valuable annotation of mammalian cell-type-specific transcriptomes.

We have developed a method for the three-dimensional (3D) printing of continuous fiber-reinforced thermoplastics based on fused-deposition modeling. The technique enables direct 3D fabrication without the use of molds and may become the standard next-generation composite fabrication methodology. A thermoplastic filament and continuous fibers were separately supplied to the 3D printer and the fibers were impregnated with the filament within the heated nozzle of the printer immediately before printing. Polylactic acid was used as the matrix while carbon fibers, or twisted yarns of natural jute fibers, were used as the reinforcements. The thermoplastics reinforced with unidirectional jute fibers were examples of plant-sourced composites; those reinforced with unidirectional carbon fiber showed mechanical properties superior to those of both the jute-reinforced and unreinforced thermoplastics. Continuous fiber reinforcement improved the tensile strength of the printed composites relative to the values shown by conventional 3D-printed polymer-based composites.

BACKGROUND: It is unclear whether dissemination of automated external defibrillators (AEDs) in public places can improve the rate of survival among patients who have had an out-of-hospital cardiac arrest. METHODS: From January 1, 2005, through December 31, 2007, we conducted a prospective, population-based, observational study involving consecutive patients across Japan who had an out-of-hospital cardiac arrest and in whom resuscitation was attempted by emergency responders. We evaluated the effect of nationwide dissemination of public-access AEDs on the rate of survival after an out-of-hospital cardiac arrest. The primary outcome measure was the 1-month rate of survival with minimal neurologic impairment. A multivariate logistic-regression analysis was performed to assess factors associated with a good neurologic outcome. RESULTS: A total of 312,319 adults who had an out-of-hospital cardiac arrest were included in the study; 12,631 of these patients had ventricular fibrillation and had an arrest that was of cardiac origin and that was witnessed by bystanders. In 462 of these patients (3.7%), shocks were administered by laypersons with the use of public-access AEDs, and the proportion increased, from 1.2% to 6.2%, as the number of public-access AEDs increased (P<0.001 for trend). Among all patients who had a bystander-witnessed arrest of cardiac origin and who had ventricular fibrillation, 14.4% were alive at 1 month with minimal neurologic impairment; among patients who received shocks from public-access AEDs, 31.6% were alive at 1 month with minimal neurologic impairment. Early defibrillation, regardless of the type of provider (bystander or emergency-medical-services personnel), was associated with a good neurologic outcome after a cardiac arrest with ventricular fibrillation (adjusted odds ratio per 1-minute increase in the time to administration of shock, 0.91; 95% confidence interval, 0.89 to 0.92; P<0.001). The mean time to shock was reduced from 3.7 to 2.2 minutes, and the annual number of patients per 10 million population who survived with minimal neurologic impairment increased from 2.4 to 8.9 as the number of public-access AEDs increased from fewer than 1 per square kilometer of inhabited area to 4 or more. CONCLUSIONS: Nationwide dissemination of public-access AEDs in Japan resulted in earlier administration of shocks by laypersons and in an increase in the 1-month rate of survival with minimal neurologic impairment after an out-of-hospital cardiac arrest.

ABSTRACT A gravitational-wave (GW) transient was identified in data recorded by the Advanced Laser Interferometer Gravitational-wave Observatory (LIGO) detectors on 2015 September 14. The event, initially designated G184098 and later given the name GW150914, is described in detail elsewhere. By prior arrangement, preliminary estimates of the time, significance, and sky location of the event were shared with 63 teams of observers covering radio, optical, near-infrared, X-ray, and gamma-ray wavelengths with ground- and space-based facilities. In this Letter we describe the low-latency analysis of the GW data and present the sky localization of the first observed compact binary merger. We summarize the follow-up observations reported by 25 teams via private Gamma-ray Coordinates Network circulars, giving an overview of the participating facilities, the GW sky localization coverage, the timeline, and depth of the observations. As this event turned out to be a binary black hole merger, there is little expectation of a detectable electromagnetic (EM) signature. Nevertheless, this first broadband campaign to search for a counterpart of an Advanced LIGO source represents a milestone and highlights the broad capabilities of the transient astronomy community and the observing strategies that have been developed to pursue neutron star binary merger events. Detailed investigations of the EM data and results of the EM follow-up campaign are being disseminated in papers by the individual teams.

To date, the literature has focused on synthetic fibre-reinforced composites, but it has not adequately addressed the unique properties that differentiate natural from synthetic fibres, such as their natural variation in microstructure and composition across species. This review paper proposes a critical overview of the current state of 3D printing of natural fibre-reinforced composites or biocomposites for mechanical purposes, as well as an overview of their role in 4D printing for stimuli-responsive applications. The paper is structured as follows: after the first part recalling the specificities of natural fibres and their associated composites, the two main sections are each divided into two parts presenting an analysis of the available data to provide fundamental understandings and a discussion and outlook for the future. Natural discontinuous fibre-reinforced polymers exhibit moderate mechanical properties compared to composites manufactured by conventional processes due to specific factors of the 3D printing process, such as high porosity, low fibre content, and a very low fibre-aspect ratio (L/d). Hygromorph BioComposites (HBC) are categorized into a new class of smart materials that could be used for 4D printing of shape-changing mechanisms. Fibre content, fibre orientation control, and fibre continuity are outlined in relation to known challenges in actuation performance.

We have realized a high-detection-efficiency photon number resolving detector at an operating wavelength of about 850 nm. The detector consists of a titanium superconducting transition edge sensor in an optical cavity, which is directly coupled to an optical fiber using an approximately 300-nm gap. The gap reduces the sensitive area and heat capacity of the device, leading to high photon number resolution of 0.42 eV without sacrificing detection efficiency or signal response speed. Wavelength dependent efficiency in fiber-coupled devices, which is due to optical interference between the fiber and the device, is also decreased to less than 1% in this configuration. The overall system detection efficiency is 98%±1% at wavelengths of around 850 nm, which is the highest value ever reported in this wavelength range.

BACKGROUND: The importance of evaluating the outcomes of health care from the standpoint of the patient is now widely recognized. The purpose of this study is to develop and test a Japanese version of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). METHODS: A Japanese version was developed with a previously standardized method. The questionnaire and optional items were completed by 245 patients with cataracts, glaucoma, or age-related macular degeneration, by 110 others before and after cataract surgery, and by a reference group (n = 31). We computed rates of missing data, measured reproducibility and internal consistency reliability, and tested for convergent and discriminant validity, concurrent validity, known-groups validity, factor structure, and responsiveness to change. RESULTS: Based on information from the participants, some items were changed to 2-step items (asking if an activity was done, and if it was done, then asking how difficult it was). The near-vision and distance-vision subscales each had 1 item that was endorsed by very few participants, so these items were replaced with items that were optional in the English version. For example, more than 60% of participants did not drive, so the driving question was excluded. Reliability and validity were adequate for all subscales except driving, ocular pain, color vision, and peripheral vision. With cataract surgery, most scores improved by at least 20 points. CONCLUSION: With minor modifications from the English version, the Japanese NEI VFQ-25 can give reliable, valid, responsive data on vision-related quality of life, for group-level comparisons or for tracking therapeutic outcomes.

BACKGROUND/AIM: There are two theories on the pathogenesis of polypoidal choroidal vasculopathy (PCV): variants in choroidal neovascularisation (CNV) and inner choroidal vessel abnormalities. On indocyanine green angiography (IGA) with a video camera system, PCV has a characteristic appearance, but inadequate image quality has made detailed interpretation difficult. This study aims to improve imaging, using confocal scanning laser ophthalmoscopy (SLO), to elucidate the pathogenesis of PCV. METHODS: High speed IGA with confocal SLO of 45 eyes (44 patients) showed typical PCV findings of a branching vascular network and polypoidal lesions. RESULTS: Vessels comprising branching networks began to fill simultaneously with the surrounding choroidal arteries in 38 eyes. Small numbers of vessels filling within a branching network, in the arterial and arteriovenous phases of IGA, showed focal dilatation, constriction, and tortuousity. Vessel abnormalities, corresponding to polypoidal lesions, existed within a network in eight eyes and included loops similar in calibre to network vessels, and numerous microaneurysmal dilatations of small vessels. Vessel pulsation was seen in 24 eyes. CONCLUSION: PCV is caused by inner choroidal vessel abnormalities, not CNV.

BACKGROUND: Therapeutic hypothermia for comatose survivors of out-of-hospital cardiac arrest has demonstrated neurological benefits. Although early cooling during cardiac arrest enhances efficacy in animal studies, few clinical studies are available. METHODS AND RESULTS: The 171 patients who failed to respond to conventional cardiopulmonary resuscitation were studied prospectively. Patients underwent emergency cardiopulmonary bypass (CPB) plus intra-aortic balloon pumping, with subsequent percutaneous coronary intervention (PCI) if needed. Mild hypothermia (34 degrees C for 3 days) was induced during cardiac arrest or after return of spontaneous circulation. Of the 171 patients, 21 (12.3%) had a favorable neurological outcome at hospital discharge. An unadjusted rate of favorable outcome decreased in a stepwise fashion for increasing quartiles of collapse-to-34 degrees C interval (P=0.016). An adjusted odds ratio for favorable outcome after collapse-to-CPB interval was 0.89 (95% confidence interval (CI) 0.82-0.97) and after CPB-to-34 degrees C interval, 0.99 (95%CI 0.98-0.99) when collapse-to-34 degrees C interval was divided into 2 components. Favorable neurological accuracy of a collapse-to-CPB interval at a cutoff of 55.5 min and CPB-to-34 degrees C interval at a cutoff of 21.5 min was 85.4% and 89.5%, respectively. CONCLUSIONS: Early attainment of a core temperature had neurological benefits for patients with out-of-hospital cardiac arrest who underwent CPB and PCI. (Circ J 2010; 74: 77 - 85).

Skimming flows in stepped channels are systematically investigated under a wide range of channel slopes (5.7°⩽θ⩽55°). The flow conditions of skimming flows are classified into two flow regimes, and the hydraulic conditions required to form a quasi-uniform flow are determined. An aerated flow depth of a skimming flow is estimated from the assumption that the residual energy at the end of a stepped channel coincides with the energy at the toe of the jump formed immediately downstream of the stepped channel. In a quasi-uniform flow region, the friction factor of skimming flows is represented by the relative step height and the channel slope. The friction factor for the channel slope of θ=19° appears to have a maximum. The residual energy of skimming flows is formulated for both nonuniform and quasi-uniform flow regions. Further, a hydraulic-design chart for a stepped channel is presented.

Human endothelial as well as epithelial cells were shown to respond to lipopolysaccharides (LPSs). However, the expression and release of CD14 by these so-called CD14-negative cells have not been studied in detail. We investigated three human intestinal epithelial cell lines (ECLs), SW-480, HT-29, and Caco-2, for their expression of CD14 and CD11c/CD18 as well as their responsiveness to endotoxins. Fluorescence-activated cell sorter analysis revealed no expression of CD11c/CD18, but there was low expression of membrane-bound CD14 on HT-29, Caco-2, and SW-480 ECLs. Both Western blotting and reverse transcription-PCR confirmed the CD14 positivity of all three intestinal ECLs. No substantial modulation of CD14 expression was achieved after 6, 8, 18, 24, and 48 h of cultivation with 10-fold serial dilutions of LPS ranging from 0.01 ng/ml to 100 microg/ml. Interestingly, soluble CD14 was found in the tissue culture supernatants of all three ECLs. Finally, only HT-29 and SW-480, and not Caco-2, cells responded to LPS exposure (range, 0.01 ng/ml to 100 microg/ml) by interleukin 8 release. Thus, we show that HT-29, SW-480, and Caco-2 human intestinal ECLs express membrane-bound CD14. As Caco-2 cells did not respond to LPS, these cell lines might be an interesting model for studying the receptor complex for LPS. The fact that human intestinal epithelial cells are capable not only of expression but also of release of soluble CD14 may have important implications in vivo, e.g., in shaping the interaction between the mucosal immune system and bacteria in the gut and/or in the pathogenesis of endotoxin shock.

BACKGROUND: Information has been sparse on the comparison of 4 blood pressure (BP) indexes (systolic BP [SBP], diastolic BP, pulse pressure, and mean BP [MBP]) in relation to long-term incidence of stroke and myocardial infarction, particularly in middle-aged and older Asians. METHODS AND RESULTS: The Japan Arteriosclerosis Longitudinal Study Group conducted a meta-analysis of 16 cohort studies in Japan. A total of 48,224 men and women 40 to 89 years of age participated at baseline, and 1231 stroke events and 220 myocardial infarction events occurred during an average 8.4-year follow-up. Multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index were determined by Poisson regression. Analyses were also done in 4 age-sex groups. All 4 BP indexes were significantly related to all stroke risk. Stroke risk was most strongly related to MBP and SBP in both sexes and most weakly related to pulse pressure. Both stroke subtypes, ischemic and hemorrhagic, were most strongly related to MBP and SBP in both sexes. In addition, in men and women 70 to 89 years of age, MBP or SBP showed the strongest relation to all stroke risk. Myocardial infarction risk was most strongly related to SBP or MBP in both sexes. For any end points in any age-sex groups, pulse pressure was not the strongest predictor. CONCLUSIONS: The long-term incident risk of stroke and myocardial infarction associated with high BP in East Asian populations should be assessed mainly on the basis of SBP. MBP also may be an important predictor, but pulse pressure is a less important predictor for cardiovascular disease risk.

Four triterpene acetates, alpha-amyrin acetate (1a), beta-amyrin acetate (2a), lupeol acetate (3a), and butyrospermol acetate (4a), and four triterpene cinnamates, alpha-amyrin cinnamate (1c), beta-amyrin cinnamate (2c), lupeol cinnamate (3c), and butyrospermol cinnamate (4c), were isolated from the kernel fat (n-hexane extract) of the shea tree (Vitellaria paradoxa; Sapotaceae). Upon evaluation of these eight triterpene esters for inhibitory activity against 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced inflammation (1 microg/ear) in mice, all of the compounds tested exhibited marked anti-inflammatory activity, with ID50 values in the range of 0.15-0.75 micromol/ear, and among which compound 3c showed the highest activity with ID(50) of 0.15 micromol/ear. Compound 3c (10 mg/kg) further exhibited anti-inflammatory activity on rat hind paw edema induced by carrageenan, with the percentage of inflammation at 1, 3, and 5 h of 35.4, 41.5, and 45.5%, respectively. The eight triterpene esters were then evaluated for their inhibitory effects on Epstein-Barr virus early antigen (EBV-EA) in Raji cells as a primary screening test for inhibitors of tumor promoters. All the compounds showed moderate inhibitory effects. Furthermore, compound 3c exhibited inhibitory effect on skin tumor promotion in an in vivo two-stage carcinogenesis test using 7,12-dimethylbenz [a] anthracene (DMBA) as an initiator and TPA as a promoter. The biological activities of triterpene acetate and cinnamate esters, together with the exceptionally high levels of these triterpenes in shea fat, indicate that shea nuts and shea fat (shea butter) constitute a significant source of anti-inflammatory and anti-tumor promoting compounds.

Abstract The unsaponifiables from 19 vegetable oils were divided into 4‐methylsterol fraction, triterpene alcohol fraction and two other fractions by thin layer chromatography. The 4‐methylsterol and triterpene alcohol fractions were analyzed by gas liquid chromatography, and identification of major components was carried out by gas liquid chromatography and combined gas chromatography‐mass spectrometry. Gramisterol(24‐methylenelophenol), citrostadienol and obtusifoliol were present in all oils, and the presence of a 4‐methylsterol, presumably cycloeucalenol, was indicated in most of the oils. Cycloartenol and 24‐methylenecycloartanol were found as common triterpene alcohols in all oils, and the occurrence of cyclobranol(24‐methylcycloartenol), cycloartanol, and α‐ and β‐amyrins was demonstrated in most of the oils.

PURPOSE: To compare the 1-year results of initial or deferred photodynamic therapy (PDT) combined with intravitreal ranibizumab (IVR) for eyes with polypoidal choroidal vasculopathy. METHODS: Prospectively, 72 men with treatment-naive polypoidal choroidal vasculopathy were randomized to initial or later PDT combined with IVR. In both groups, 2 additional monthly IVR followed. From Month 3, PDT and IVR were administered according to the retreatment criteria. Mean changes in the best-corrected visual acuity between baseline and Month 12 and central retinal thickness, the rate of eyes showing regression of polypoidal lesions, and number of additional treatments were compared. RESULTS: The best-corrected visual acuity increased by a mean of 8.1 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters in the initial PDT group and 8.8 ETDRS letters in the later PDT group, and there was a no significant difference (P = 0.59). The mean central retinal thickness decreased significantly in both groups but more so with combination therapy within the first 4 months; the difference was not significant at Month 12 (P = 0.30). The rate of eyes showing resolution of polypoidal lesions at 12 months was 62.1% in the initial PDT group and 54.8% in the later PDT group and again, there was no significant difference (P = 0.53). The mean number of additional IVR was 1.5 in initial PDT and 3.8 in later PDT; that of additional PDTs was 0.14 and 0.45, respectively, and they were significantly different (P < 0.001 and P = 0.013, respectively). CONCLUSION: Both initial and deferred PDT combined with IVR to treat polypoidal choroidal vasculopathy show the similar visual and anatomical improvements at 12 months. Initial PDT combination leads to significantly fewer additional treatments.

The most efficient modern optical communication is known as coherent communication, and its standard quantum limit is almost reachable with current technology. Though it has been predicted for a long time that this standard quantum limit could be overcome via quantum mechanically optimized receivers, such a performance has not been experimentally realized so far. Here we demonstrate the first unconditional evidence surpassing the standard quantum limit of coherent optical communication. We implement a quantum receiver with a simple linear optics configuration and achieve more than 90% of the total detection efficiency of the system. Such an efficient quantum receiver will provide a new way of extending the distance of amplification-free channels, as well as of realizing quantum information protocols based on coherent states and the loophole-free test of quantum mechanics.

Although angiotensin converting enzyme inhibitors and alpha 1-blockers have been reported to improve insulin sensitivity, their mechanisms of action have not been elucidated. To investigate the role of kinins in insulin sensitivity, we treated 4-week-old spontaneously hypertensive rats with either an angiotensin converting enzyme inhibitor (enalapril), an alpha 1-blocker (doxazosin), or an angiotensin II antagonist (losartan) for 3 weeks. A control group received no drugs. In addition, 18 rats treated with enalapril or doxazosin received a simultaneous administration of a kinin antagonist (Hoe 140). Glucose clamp testing was performed in each group. Enalapril (128 +/- 1 mmHg) and doxazosin (132 +/- 2 mmHg) decreased mean blood pressure compared with control levels (148 +/- 1 mmHg) (P &lt; .01). The glucose requirement for the clamp test during the administration of enalapril (25.8 +/- 0.5 mg/kg per minute) or doxazosin (28.6 +/- 0.7 mg/kg per minute) was higher than that of the control group (19.8 +/- 0.5 mg/kg per minute) (P &lt; .05). Although Hoe 140 did not alter the glucose requirement of doxazosin (27.8 +/- 0.5 mg/kg per minute), it decreased that of enalapril (22.6 +/- 0.9 mg/kg per minute) (P &lt; .05) without affecting the changes in mean blood pressure induced by enalapril. In addition, losartan decreased mean blood pressure but did not affect the glucose requirement. Thus, the improvement in insulin sensitivity produced by an angiotensin converting enzyme inhibitor is mostly dependent on kinins but not on angiotensin II antagonism, and an alpha 1-blocker improves insulin sensitivity irrespective of kinins.

Abstract The unsaponifiables from three Theaceae (Camellia japonica L., Camellia Sasanqua Thunb., and Thea sinensis L.) oils and alfalfa, garden balsam, and spinach seed oils and shea fat were separated into four fractions: sterols, 4‐methylsterols, triterpene alcohols, and less polar compounds by thin layer chromatography. While the sterol fraction was the major one for the unsaponifiables from alfalfa and spinach seed oils, the triterpene alcohol fraction was predominant for the unsaponifiables from all other oils. The sterol, 4‐methylsterol, and triterpene alcohol fractions were analyzed by gas chromatography. All the sterol fractions were alike in their compositions, consisting exclusively of Δ 7 ‐sterols, such as α‐spinasterol and Δ 7 ‐stigmastenol as predominant components together with Δ 7 ‐avenasterol and 24‐methylcholest‐7‐enol. Obtusifoliol, gramisterol (occasionally accompanied with cycloeucalenol), and citrostadienol, together with several other unidentified components, were found in the 4‐methylsterol fractions from all of the oils except shea fat. The 4‐methylsterol fraction from shea fat showed a characteristic composition containing a large proportion of unidentified components which had relative retention time greater than that of citrostadienol, while no citrostadienol was detected. β‐Amyrin, lupeol, and butyospermol were major components of the triterpene alcohol fractions from most of the oils, but the fraction from spinach seed oil contained cycloartenol and 24‐methylene‐cycloartanol as predominant components. There is a close similarity in the compositions of unsaponifiables (sterols, 4‐methylsterols, and triterpene alcohols) of the three Theaceae oils. Two sterols, α‐spinasterol and Δ 7 ‐stigmastenol, and five triterpene alcohols were isolated from tea seed oil. Moreover, five unidentified components beside parkeol, butyrospermol, α‐amyrin, and lupeol were isolated from the triterpene alcohol fraction of shea fat.

Abstract We report the discovery of the unusually bright long-duration gamma-ray burst (GRB), GRB 221009A, as observed by the Neil Gehrels Swift Observatory (Swift), Monitor of All-sky X-ray Image, and Neutron Star Interior Composition Explorer Mission. This energetic GRB was located relatively nearby ( z = 0.151), allowing for sustained observations of the afterglow. The large X-ray luminosity and low Galactic latitude ( b = 4.°3) make GRB 221009A a powerful probe of dust in the Milky Way. Using echo tomography, we map the line-of-sight dust distribution and find evidence for significant column densities at large distances (≳10 kpc). We present analysis of the light curves and spectra at X-ray and UV–optical wavelengths, and find that the X-ray afterglow of GRB 221009A is more than an order of magnitude brighter at T 0 + 4.5 ks than that from any previous GRB observed by Swift. In its rest frame, GRB 221009A is at the high end of the afterglow luminosity distribution, but not uniquely so. In a simulation of randomly generated bursts, only 1 in 10 4 long GRBs were as energetic as GRB 221009A; such a large E γ ,iso implies a narrow jet structure, but the afterglow light curve is inconsistent with simple top-hat jet models. Using the sample of Swift GRBs with redshifts, we estimate that GRBs as energetic and nearby as GRB 221009A occur at a rate of ≲1 per 1000 yr—making this a truly remarkable opportunity unlikely to be repeated in our lifetime.

STUDY DESIGN: A retrospective clinical review of patients with thoracolumbar junction disc herniation. OBJECTIVES: To evaluate the clinical features of thoracolumbar junction disc herniation and to prepare a chart for the level diagnosis in the neurologic findings and symptoms. SUMMARY OF BACKGROUND DATA: Thoracolumbar junction disc herniations show a variety of signs and symptoms because of the complexity of the upper and lower neurons of the spinal cord, cauda equina, and nerve roots. Furthermore, much is still unknown about thoracolumbar junction disc herniations because of their rare frequency. METHODS: The clinical features of 26 patients who had undergone operations for single disc herniations at T10-T11 through L2-L3 were investigated. Affected levels were as follows: 2 patients with disc herniation at T10-T11 disc, 4 patients at T11-T12, 3 patients at T12-L1, 6 patients at L1-L2, and 11 patients at L2-L3. The level of disc space of interest was confirmed with whole-spine plain roentgenograms. The caudal end of the cord was judged by magnetic resonance imaging and computed tomographic myelogram. RESULTS: Two patients with T10-T11 disc herniation showed moderate lower extremity weakness, increased patellar tendon reflex, and sensory disturbance of the entire lower extremities. Three of four patients with T11-T12 disc herniation experienced lower extremity weakness, and three patients had accentuated patellar tendon reflex. Sensory disturbance was observed in the anterolateral aspect of the thigh in one patient and on the entire leg in three patients. Bowel and bladder dysfunction was noted in three patients. In the T12-L1 disc herniation group (n = 3), muscle weakness and atrophy below the leg were advanced, and bowel and bladder dysfunction were also noted. Two of these three patients had bilateral drop foot, and one patient had unilateral drop foot; sensory disturbance was noted in the sole or foot and around the circumference of the anus, and the patellar tendon reflex and Achilles tendon reflex were absent. All six patients with L1-L2 disc herniation showed severe thigh pain and sensory disturbance at the anterior aspect or lateral aspect of the thigh. On the other hand, there were no clear signs of lower extremity weakness, muscle atrophy, deep tendon reflex, or bowel and bladder dysfunction in these patients. In the L2-L3 disc herniation group (n = 11), all patients had severe thigh pain and sensory disturbance of the anterior aspect or the lateral aspect of the thigh. Weakness in the quadriceps was noted in five patients and weakness in the tibialis anterior in two patients. Decreased or absence of patellar tendon reflex was observed in nine patients. Five patients had positive straight leg raising test results, and eight patients showed positive femoral nerve stretch test results. CONCLUSION: Among thoracolumbar junction disc herniations, T10-T11 and T11-T12 disc herniations were considered upper neuron disorders, T12-L1 disc herniations were considered lower neuron disorders, L1-L2 disc herniations were considered mild disorders of the cauda equina and radiculopathy, and L2-L3 disc herniations were considered radiculopathy. These findings had relatively distinct differences among herniated disc levels.