Long term follow-up and development of foot complaints in a surgically treated mirror foot-A case report and review of literature.

BACKGROUND: Mirror foot is a rare anomaly and limited long term follow-up information is available. METHODS: Seven years after operation a mirror foot patient returned with foot complaints and was evaluated using radiographs and clinical examination. A systematic literature search was conducted to study foot complaints in mirror feet. RESULTS: Different origins of foot pain were considered in our patient; tibia length difference, deformed talus and accessory osseous structures in the tarsal region. Literature search resulted in 118 mirror feet. Based on cases reporting osseous structures, 74.2% showed tibia abnormalities and 94.5% an abnormal tarsal region. Only three cases mentioned a normal talus. Nine cases reported a follow-up period of more than five years. CONCLUSION: Osseous abnormalities are not always visible at birth, but are often present. Therefore, detailed examination of the affected limb in mirror foot patients with foot pain is important, in order to localize the origin.

Management and treatment of osteonecrosis in children and adolescents with acute lymphoblastic leukemia.

There is no consensus regarding how to manage osteonecrosis in pediatric acute lymphoblastic leukemia patients. Therefore, we performed a quality assessment of the literature with the result of a search strategy using the MESH terms osteonecrosis, children, childhood cancer, surgery, bisphosphonates, 6 hydroxymethyl-glutaryl CoA reductase inhibitors, anticoagulants and hyperbaric oxygen, and terms related to these MESH terms. A randomized controlled trial showed that osteonecrosis can be prevented by intermittent, instead of continuous, corticosteroid administration. The studies on interventions after onset of osteonecrosis were of low-quality evidence. Seven pediatric acute lymphoblastic leukemia studies described non-surgical interventions; bisphosphonates (n=5), hyperbaric oxygen therapy (n=1), or prostacyclin analogs (n=1). Safety and efficacy studies are lacking. Five studies focused on surgical interventions; none was of sufficient quality to draw definite conclusions. In conclusion, preventing osteonecrosis is feasible in a proportion of the pediatric acute lymphoblastic leukemia patients by discontinuous, instead of continuous, steroid scheduling. The questions as to how to treat childhood acute lymphoblastic leukemia patients with osteonecrosis cannot be answered as good-quality studies are lacking.

Does EU legislation allow the use of the Benchmark Dose (BMD) approach for risk assessment?

Hazard characterisation is largely based on an approach of (statistically) comparing dose groups with the controls in order to derive points of departure such as no-observed-adverse-effect levels (NOAELs) or lowest-observed-adverse-effect levels (LOAELs). This approach suggests the absence of any relevant effect at the NOAEL. The NOAEL approach has been debated for decades. A recent Scientific Opinion by the European Food Safety Authority (EFSA) concluded that the Benchmark Dose (BMD) approach should be preferred over the NOAEL approach for deriving human (health-based) limit or guidance values. Nonetheless, the BMD approach is used infrequently within European regulatory frameworks. The reason for this may lie in legislation or guidelines requiring the use of the NOAEL approach. In this context, various EU regulatory frameworks were examined on such demands. Interestingly, no single legislation was identified containing statutory requirements in conflict with the use of the BMD approach.

Approaches to mixture risk assessment of PFASs in the European population based on human hazard and biomonitoring data.

Per- and polyfluoroalkyl substances (PFASs) are a highly persistent, mobile, and bioaccumulative class of chemicals, of which emissions into the environment result in long-lasting contamination with high probability for causing adverse effects to human health and the environment. Within the European Biomonitoring Initiative HBM4EU, samples and data were collected in a harmonized way from human biomonitoring (HBM) studies in Europe to derive current exposure data across a geographic spread. We performed mixture risk assessments based on recent internal exposure data of PFASs in European teenagers generated in the HBM4EU Aligned Studies (dataset with N = 1957, sampling years 2014-2021). Mixture risk assessments were performed based on three hazard-based approaches: the Hazard Index (HI) approach, the sum value approach as used by the European Food Safety Authority (EFSA) and the Relative Potency Factor (RPF) approach. The HI approach resulted in the highest risk estimates, followed by the RPF approach and the sum value approach. The assessments indicate that PFAS exposure may result in a health risk in a considerable fraction of individuals in the HBM4EU teenager study sample, thereby confirming the conclusion drawn in the recent EFSA scientific opinion. This study underlines that HBM data are of added value in assessing the health risks of aggregate and cumulative exposure to PFASs, as such data are able to reflect exposure from different sources and via different routes.

Aspiration or arthrotomy for paediatric septic arthritis of the shoulder and elbow: a systematic review.

Upper extremity arthritis in children can be treated with joint aspiration, arthroscopy or arthrotomy, followed by antibiotics. The literature seems inconclusive with respect to the optimal drainage technique. Therefore, the objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the upper extremity in children.Two independent investigators systematically searched the electronic MEDLINE, EMBASE and Cochrane databases for original articles that reported outcomes of aspiration, arthroscopy or arthrotomy for septic arthritis of the paediatric shoulder or elbow. Outcome parameters were clinical improvement, need for repetitive surgery or drainage, and complications.Out of 2428 articles, seven studies with a total of 171 patients treated by aspiration or arthrotomy were included in the systematic review. Five studies reported on shoulder septic arthritis, one study on elbow septic arthritis, and one study on both joints. All studies were retrospective, except for one randomized prospective study. No difference was found between type of treatment and radiological or clinical outcomes. Aspiration of the shoulder or elbow joint required an additional procedure in 44% of patients, while arthrotomy required 12% additional procedures.Conclusion: Both aspiration and arthrotomy can achieve good clinical results in children with septic arthritis of the shoulder or elbow joint. However, the scientific quality of the included studies is low. It seems that the first procedure can be aspiration and washout and start of intravenous antibiotics, knowing that aspiration may have a higher risk of additional drainage procedures. Cite this article: EFORT Open Rev 2021;6:651-657. DOI: 10.1302/2058-5241.6.200122.

Next generation physiologically based kinetic (NG-PBK) models in support of regulatory decision making.

The fields of toxicology and chemical risk assessment seek to reduce, and eventually replace, the use of animals for the prediction of toxicity in humans. In this context, physiologically based kinetic (PBK) modelling based on in vitro and in silico kinetic data has the potential to a play significant role in reducing animal testing, by providing a methodology capable of incorporating in vitro human data to facilitate the development of in vitro to in vivo extrapolation of hazard information. In the present article, we discuss the challenges in: 1) applying PBK modelling to support regulatory decision making under the toxicology and risk-assessment paradigm shift towards animal replacement; 2) constructing PBK models without in vivo animal kinetic data, while relying solely on in vitro or in silico methods for model parameterization; and 3) assessing the validity and credibility of PBK models built largely using non-animal data. The strengths, uncertainties, and limitations of PBK models developed using in vitro or in silico data are discussed in an effort to establish a higher degree of confidence in the application of such models in a regulatory context. The article summarises the outcome of an expert workshop hosted by the European Commission Joint Research Centre (EC-JRC) - European Union Reference Laboratory for Alternatives to Animal Testing (EURL ECVAM), on "Physiologically-Based Kinetic modelling in risk assessment - reaching a whole new level in regulatory decision-making" held in Ispra, Italy, in November 2016, along with results from an international survey conducted in 2017 and recently reported activities occurring within the PBK modelling field. The discussions presented herein highlight the potential applications of next generation (NG)-PBK modelling, based on new data streams.

Improving the applicability of (Q)SARs for percutaneous penetration in regulatory risk assessment.

The new regulatory framework REACH (Registration, Evaluation, and Authorisation of Chemicals) foresees the use of non-testing approaches, such as read-across, chemical categories, structure-activity relationships (SARs) and quantitative structure-activity relationships (QSARs). Although information on skin absorption data are not a formal requirement under REACH, data on dermal absorption are an integral part of risk assessment of substances/products to which man is predominantly exposed via the dermal route. In this study, we assess the present applicability of publicly available QSARs on skin absorption for risk assessment purposes. We explicitly did not aim to give scientific judgments on individual QSARs. A total of 33 QSARs selected from the public domain were evaluated using the OECD (Organisation for Economic Co-operation and Development) Principles for the Validation of (Q)SAR Models. Additionally, several pragmatic criteria were formulated to select QSARs that are most suitable for their use in regulatory risk assessment. Based on these criteria, four QSARs were selected. The predictivity of these QSARs was evaluated by comparing their outcomes with experimentally derived skin absorption data (for 62 compounds). The predictivity was low for three of four QSARs, whereas one model gave reasonable predictions. Several suggestions are made to increase the applicability of QSARs for skin absorption for risk assessment purposes.

[Distraction osteogenesis in orthopaedics]. / Distractieosteogenese in de orthopedie.

For several decades, distraction osteogenesis has been applied in orthopaedics for lengthening limbs. Other indications for distraction osteogenesis in orthopaedics are nonunions, open fractures, oncologic defects, and ankle osteoarthritis. The main principle of distraction osteogenesis is that, with a certain degree of distraction of 2 bone segments, linear bone generation will take place between the 2 segments. The most frequent complications are infection, loosening and breaking of the introduced pins, osteomyelitis, and fracture of the newly generated bone. Disadvantages of distraction appliances are expensiveness, degree of technical difficulty, and a long training period. Distraction osteogenesis in orthopaedics is a very intensive treatment. Therefore, only patients who are motivated and well instructed and who are physically and mentally capable of coping with the fixtures are suitable.

Development of a QSAR for worst case estimates of acute toxicity of chemically reactive compounds.

Future EU legislations enforce a fast hazard and risk assessment of thousands of existing chemicals. If conducted by means of present data requirements, this assessment will use a huge number of test animals and will be neither cost nor time effective. The purpose of the current research was to develop methods to increase the acceptability of in vitro data for classification and labelling regarding acute toxicity. For this purpose, a large existing database containing in vitro and in vivo data was analysed. For more than 300 compounds in the database, relations between in vitro cytotoxicity and rat or mouse intravenous and oral in vivo LD50 values were re-evaluated and the possibilities for definition of mechanism based chemical subclasses were investigated. A high in vitro-in vivo correlation was found for chemicals classified as irritants. This can be explained by a shared unspecific cytotoxicity of these compounds which will act as the predominant mode of action for both endpoints, irritation and acute toxicity. For this subclass, which covered almost 40% of all compounds in the database, the LD50 values after intravenous dosing could be predicted with high accuracy. A somewhat lower accuracy was found for the prediction of oral LD50 values based on in vitro cytotoxicity data. Based on this successful correlation, a classification and labelling scheme was developed, that includes a hazard based definition of the applicability domain (irritants) and a prediction of the labelling of compounds for their acute iv and oral toxicity. The scheme was tested by an external validation.

The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment.

METHODS AND FINDINGS: Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage. RESULTS: The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT). CONCLUSIONS: The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction.