Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index.

PURPOSE: Medial patellofemoral ligament reconstruction (MPFL-R) is a recognised surgical procedure for the treatment of recurrent patellofemoral instability with excellent outcomes reported. The aim of this study is to determine if body mass index can influence these outcomes. METHODS: This is a single-centre retrospective analysis of a longitudinal patellofemoral database. Patients with recurrent patellar instability, without patellar alta or severe trochlear dysplasia were treated using a MPFL-R between 2015 and 2019 at The Robert Jones & Agnes Hunt Orthopaedic Hospital. The clinical efficacy following surgery was assessed by Kujula, International Knee Documentation Committee Score (IKDC), and EuroQol-5 score (EQ-5D) at baseline and up to 26 months post-operatively; their safety assessed by complication rate and requirement for further surgery. The effect of Body Mass Index (BMI) on clinical outcome was analysed using linear, curvilinear, and segmented models following propensity score weighting. RESULTS: A total of 97 patients (97 Knees, mean age 25y) were analysed. Of these, 61 patients had a BMI < 30 kg/m2 (mean age 23y, mean BMI 24) of which 7 patients (12.3%) required additional surgery. A further 36 patients had a BMI > 30 kg/m2 (mean age 27y, mean BMI 36) of which 2 patients (5.6%) required additional surgery. The re-dislocation rate was 0% in each BMI group. Both groups had a significantly improved mean outcome following surgery, with improvements in mean IKDC above the minimum clinical important differences (MCID) of 20.5. BMI had an inverted J-shaped association with functional outcome, showing peak outcomes at BMI of 20.5 (95% CI 18.5 to 22.4; IKDC and Kujala) or BMI of 28 (EQ-5D index). No evidence for an association between BMI and complication risk was found. CONCLUSION: BMI influences the functional outcomes in MPFL-R with an inverted J-shaped relation, without evidence it affected the complication or re-dislocation rate. In the absence of patella alta and severe trochlear dysplasia, an isolated MPFL reconstruction is a safe and effective procedure to treat patellar instability, with the best functional outcome in patients with a BMI around 20 to 21. LEVEL OF EVIDENCE: Level III.

2nd and 3rd generation full endoscopic lumbar spine surgery: clinical safety and learning curve.

AIM: 2nd and 3rd generation endoscopic spine surgery techniques offer visualisation of familiar inter-laminar anatomy to spinal surgeons. We have prospectively evaluated the clinical outcome, complications and learning curve associated with these techniques in patients with lumbar spine radiculopathy. METHODS: This is a prospective study of 50 consecutive patients with radicular pain from disc herniation and/or lateral recess stenosis. In 6 patients, endoscopy couldn't be done. Operating times, PROM's (VAS, ODI and EQ-5D scores) and complication rates of 44 patients were evaluated after mean FU of 52 months (range 39-65). MRI was used to divide these into protrusions (n = 19), extrusions (n = 17) and lateral recess stenosis (n = 8). Evidence about the learning curve was gathered by curvilinear regression analyses. RESULTS: Using a composite clinical success criterion, 95% patients had a successful outcome, with no major complications. ODI, VAS and EQ-5D scores had a statistically significant improvement and achieved MCID. Revision discectomy rate was only 4.5% (n = 2). MRI based grouping, case sequence and degree of difficulty influenced the duration of surgery and a learning curve was found for protrusions and lateral recess decompressions, but not for extrusions. A learning curve effect was also observed with respect to the ODI. CONCLUSIONS: Although anatomy visualised in 2nd and 3rd generation endoscopy is familiar to spinal surgeons, our learning curve experience suggests a careful and MRI pathology based take up of this technique in clinical practice, despite its clinical safety in our series. LEVEL OF EVIDENCE: Level 3, prospective cohort study.

Psoriatic arthritis: review of potential biomarkers predicting response to TNF inhibitors.

Psoriatic arthritis (PsA) is a chronic and painful inflammatory immune-mediated disease. It affects up to 40% of people with psoriasis and it is associated with several comorbidities such as obesity, diabetes, metabolic syndrome, and hypertension. PsA is difficult to diagnose because of its diverse symptoms, namely axial and peripheral arthritis, enthesitis, dactylitis, skin changes, and nail dystrophy. Different drugs exist to treat the inflammation and pain. When patients do not respond to conventional drugs, they are treated with biologic drugs. Tumour necrosis factor inhibitors (TNFi's) are commonly given as the first biologic drug; beside being expensive, they also lack efficacy in 50% of patients. A biomarker predicting individual patient's response to TNFi would help treating them earlier with an appropriate biologic drug. This study aimed to review the literature to identify potential biomarkers that should be investigated for their predictive ability. Several such biomarkers were identified, namely transmembrane TNFα (tmTNF), human serum albumin (HSA) and its half-life receptor, the neonatal Fc receptor (FcRn) which is also involved in IgG lifespan; calprotectin, high mobility group protein B1 (HMGB1) and advanced glycation end products (AGEs) whose overexpression lead to excessive production of pro-inflammatory cytokines; lymphotoxin α (LTα) which induces inflammation by binding to TNF receptor (TNFR); and T helper 17 (Th17) cells which induce inflammation by IL-17A secretion.

Retina-arrestin specific CD8+ T cells are not implicated in HLA-A29-positive birdshot chorioretinitis.

BACKGROUND: HLA-A29-positive birdshot chorioretinitis (BCR) is an inflammatory eye disorder that is generally assumed to be caused by an autoimmune response to HLA-A29-presented peptides from retinal arrestin (SAG), yet the epitopes recognized by CD8+ T cells from patients remain to be identified. OBJECTIVES: The identification of natural ligands of SAG presented by HLA-A29. To quantify CD8+ T cells reactive to antigenic SAG peptides presented by HLA-A29 in patients and controls. METHODS: We performed mass-spectrometry based immunopeptidomics of HLA-A29 of antigen-presenting cell lines from patients engineered to express SAG. MHC-I Dextramer technology was utilised to determine expansion of antigen-specific CD8+ T cells reactive to SAG peptides in complex with HLA-A29 in a cohort of BCR patients, HLA-A29-positive controls, and HLA-A29-negative controls. RESULTS: We report on the naturally presented antigenic SAG peptides identified by sequencing the HLA-A29 immunopeptidome of antigen-presenting cells of patients. We show that the N-terminally extended SAG peptide precursors can be trimmed in vitro by the antigen-processing aminopeptidases ERAP1 and ERAP2. Unexpectedly, no enhanced antigen engagement by CD8+ T cells upon stimulation with SAG peptides was observed in patients or HLA-A29-positive controls. Multiplexed HLA-A29-peptide dextramer profiling of a case-control cohort revealed that CD8+ T cells specific for these SAG peptides were neither detectable in peripheral blood nor in eye biopsies of patients. CONCLUSIONS: Collectively, these findings demonstrate that SAG is not a CD8+ T cell autoantigen and sharply contrast the paradigm in the pathogenesis of BCR. Therefore, the mechanism by which HLA-A29 is associated with BCR does not involve SAG.

Cardiovascular risk factors: The effects of ageing and smoking on the immune system, an observational clinical study.

Currently immunomodulatory compounds are under investigation for use in patients with cardiovascular disease, caused by atherosclerosis. These trials, using recurrent cardiovascular events as endpoint, require enrollment of large patient groups. We investigated the effect of key risk factors for atherosclerosis development, ageing and smoking, on the immune system, with the objective to identify biomarkers differentiating between human populations, and potentially serving as endpoints for future phase 1B trials with immunomodulatory compounds. Blood was collected from young healthy volunteers (aged 18-25 years, n=30), young smokers (18-25 years, n=20), elderly healthy volunteers (>60 years, n=20), heavy smokers (>45 years, 15 packyears, n=11) and patients with stable coronary artery disease (CAD) (>60 years, n=27). Circulating immune cell subsets were characterized by flow cytometry, and collected plasma was evaluated by proteomics (Olink). Clear ageing effects were observed, mostly illustrated by a lower level in CD8+ and naïve CD4+ and CD8+ T cells, with an increase in CD4+ and CD8+ effector memory T cells in elderly healthy volunteers compared to young healthy volunteers. Heavy smokers showed a more inflammatory cellular phenotype, especially a shift in Th1/Th2 ratio: higher Th1 and lower Th2 percentages compared to young healthy volunteers. A significant decrease in circulating atheroprotective oxLDL-specific IgM was found in patients with CAD compared to young healthy volunteers. Elevated pro-inflammatory and chemotactic proteins TREM1 and CCL11 were observed in elderly volunteers compared to young volunteers. In addition, heavy smokers had an increase in pro-inflammatory cytokine IL-6 and lysosomal protein LAMP3. These data show that ageing and smoking are associated with an inflammatory immunophenotype, and that heavy smokers or aged individuals may serve as potential populations for future clinical trials investigating immunomodulatory drugs targeted for cardiovascular disease.

A novel encoding element for robust pose estimation using planar fiducials.

Pose estimation in robotics is often achieved using images from known and purposefully applied markers or fiducials taken by a monocular camera. This low-cost system architecture can provide accurate and precise pose estimation measurements. However, to prevent the restriction of robotic movement and occlusions of features, the fiducial markers are often planar. While numerous planar fiducials exist, the performance of these markers suffers from pose ambiguities and loss of precision under frontal observations. These issues are most prevalent in systems with less-than-ideal specifications such as low-resolution detectors, low field of view optics, far-range measurements etc. To mitigate these issues, encoding markers have been proposed in literature. These markers encode an extra dimension of information in the signal between marker and sensor, thus increasing the robustness of the pose solution. In this work, we provide a survey of these encoding markers and show that existing solutions are complex, require optical elements and are not scalable. Therefore, we present a novel encoding element based on the compound eye of insects such as the Mantis. The encoding element encodes a virtual point in space in its signal without the use of optical elements. The features provided by the encoding element are mathematically equivalent to those of a protrusion. Where existing encoding fiducials require custom software, the projected virtual point can be used with standard pose solving algorithms. The encoding element is simple, can be produced using a consumer 3D printer and is fully scalable. The end-to-end implementation of the encoding element proposed in this work significantly increases the pose estimation performance of existing planar fiducials, enabling robust pose estimation for robotic systems.

Intrathecal morphine in combination with bupivacaine as pre-emptive analgesia in posterior lumbar fusion surgery: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. METHODS: Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1-4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. RESULTS: For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. CONCLUSION: ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).

Sex differences associated with adverse drug reactions resulting in hospital admissions.

BACKGROUND: Adverse drug events, including adverse drug reactions (ADRs), are responsible for approximately 5% of unplanned hospital admissions: a major health concern. Women are 1.5-1.7 times more likely to develop ADRs. The main objective was to identify sex differences in the types and number of ADRs leading to hospital admission. METHODS: ADR-related hospital admissions between 2005 and 2017 were identified from the PHARMO Database Network using hospital discharge diagnoses. Patients aged ≥ 16 years with a drug possibly responsible for the ADR and dispensed within 3 months before admission were included. Age-adjusted odds ratios (OR) with 95% CIs for drug-ADR combinations for women versus men were calculated. RESULTS: A total of 18,469 ADR-related hospital admissions involving women (0.35% of all women admitted) and 14,678 admissions involving men (0.35% of all men admitted) were included. Most substantial differences were seen in ADRs due to anticoagulants and diuretics. Anticoagulants showed a lower risk of admission with persistent haematuria (ORadj 0.31; 95%CI 0.21, 0.45) haemoptysis (ORadj 0.47, 95%CI 0.30,0.74) and subdural haemorrhage (ORadj 0.61; 95%CI 0.42,0.88) in women than in men and a higher risk of rectal bleeding in women (ORadj 1.48; 95%CI 1.04,2.11). Also, there was a higher risk of admission in women using thiazide diuretics causing hypokalaemia (ORadj 3.03; 95%CI 1.58, 5.79) and hyponatraemia (ORadj 3.33, 95%CI 2.31, 4.81) than in men. CONCLUSIONS: There are sex-related differences in the risk of hospital admission in specific drug-ADR combinations. The most substantial differences were due to anticoagulants and diuretics.

Identification of IgG1 isotype phosphorylcholine antibodies for the treatment of inflammatory cardiovascular diseases.

BACKGROUND: Phosphorylcholine (PC) is an important pro-inflammatory damage-associated molecular pattern. Previous data have shown that natural IgM anti-PC protects against cardiovascular disease. We aimed to develop a monoclonal PC IgG antibody with anti-inflammatory and anti-atherosclerotic properties. METHODS: Using various techniques PC antibodies were validated and optimized. In vivo testing was performed in a femoral artery cuff model in ApoE3*Leiden mice. Safety studies are performed in rats and cynomolgus monkeys. RESULTS: A chimeric anti-PC (PC-mAb(T15), consisting of a human IgG1 Fc and a mouse T15/E06 Fab) was produced, and this was shown to bind specifically to epitopes in human atherosclerotic tissues. The cuff model results in rapid induction of inflammatory genes and altered expression of genes associated with ER stress and choline metabolism in the lesions. Treatment with PC-mAb(T15) reduced accelerated atherosclerosis via reduced expression of endoplasmic reticulum stress markers and CCL2 production. Recombinant anti-PC Fab fragments were identified by phage display and cloned into fully human IgG1 backbones creating a human monoclonal IgG1 anti-PC (PC-mAbs) that specifically bind PC, apoptotic cells and oxLDL. Based on preventing macrophage oxLDL uptake and CCL2 production, four monoclonal PC-mAbs were selected, which to various extent reduced vascular inflammation and lesion development. Additional optimization and validation of two PC-mAb antibodies resulted in selection of PC-mAb X19-A05, which inhibited accelerated atherosclerosis. Clinical grade production of this antibody (ATH3G10) significantly attenuated vascular inflammation and accelerated atherosclerosis and was tolerated in safety studies in rats and cynomolgus monkeys. CONCLUSIONS: Chimeric anti-PCs can prevent accelerated atherosclerosis by inhibiting vascular inflammation directly and through reduced macrophage oxLDL uptake resulting in decreased lesions. PC-mAb represents a novel strategy for cardiovascular disease prevention.

Scoliosis in paediatric onset spinal cord injuries.

STUDY DESIGN: This is a retrospective longitudinal review. OBJECTIVE: The purpose of this review was to identify predictors of developing clinical scoliosis and compare between traumatic and neurological aetiologies of SCI. SETTING: This study was conducted at the Midland Centre of SCI. METHOD: Case notes of all patients injured at an age up to 18 years and admitted between 1971 and 2013 were reviewed. RESULTS: Sixty-nine individuals were identified, of which seven were excluded: three with pre-existing scoliosis and four with spina bifida. The remaining 62 (44 males, 18 females) had a median age at injury of 17 years (inter quartile range 13-17). Of these, 51 (82%) had traumatic and 11 (18%) had neurological injury. Most (42/51; 82%) of the children who had a traumatic injury were older than 13 years. The risk of developing scoliosis was lower for older patients (RR 0.68 per year, 95% CI 0.52-0.83) or following a traumatic injury (RR 0.36, 95% CI 0.20-0.66). A multivariable analysis based on age and trauma showed that only older age decreased the risk. A robust Receiver Operator Curve analysis suggested 14.6 years as the optimal threshold to predict development of scoliosis within 10 years (Area Under the Curve; AUC 0.83 (95% CI 0.73-0.93), sensitivity 70% (95% CI 50-89%), specificity 89% (95% CI 74-100%). CONCLUSION: Our results suggest that age below 14.6 years was a predictor for scoliosis. Once adjustment is made for age, the incidence of scoliosis does not differ between traumatic and neurological aetiologies of paediatric SCI injury.

The IL-12 cytokine family in cardiovascular diseases.

Cytokines of the Interleukin (IL)-12 family, consisting of IL-12, IL-23, IL-27 and IL-35, are important regulators in (chronic) inflammatory disorders such as rheumatoid arthritis and multiple sclerosis, but also in cardiovascular diseases. Cytokines of the IL-12 family consist of two subunits and are known for their regulatory functions in the immunologic response, more specifically in the regulation and differentiation of T-helper (Th) cells such as Th1 and Th17 cells. Binding of these cytokines to its specific heterodimeric receptor results in the activation of the JAK-STAT signaling. Despite similarities in structure, the members of the IL-12 family have diverse, both pro- and anti-inflammatory, effects and functions. Because of the pro-inflammatory effects of IL-12 cytokine family members on immune responses, the IL-12 cytokines have been implicated in the development and progression of cardiovascular diseases such as atherosclerosis, but also in acute cardiovascular syndromes such as myocardial infarction and stroke. For example, patients suffering from cardiovascular disease display increased blood levels of IL-12, IL-23 and IL-27, while decreased IL-35 levels have been linked to a lower cardiovascular risk. In this review, we aim to highlight the current understandings of the IL-12 cytokine family and its specific family members to cardiovascular diseases, including both clinical and experimental studies. We will also discuss the potential of these cytokines as a biomarker in acute cardiovascular syndromes.

Lipocalin-2 contributes to experimental atherosclerosis in a stage-dependent manner.

BACKGROUND AND AIMS: Lipocalin-2 (Lcn2) is a glycoprotein which can be secreted by immune cells. Several studies in humans have suggested Lcn2 can be used as a biomarker for the detection of unstable atherosclerotic lesions, partly as it is known to interact with MMP-9. METHODS: In this study, we generated Ldlr-/-Lcn2-/- mice to assess the functional role of Lcn2 in different stages of atherosclerosis. Atherosclerotic lesions were characterized through histological analysis and myeloid cell populations were examined using flow cytometry. RESULTS: We show that Ldlr-/-Lcn2-/- mice developed larger atherosclerotic lesions during earlier stages of atherosclerosis and had increased circulating Ly6Chi inflammatory monocytes compared to Ldlr-/- mice. Advanced atherosclerotic lesions from Ldlr-/-Lcn2-/- mice had decreased necrotic core area, suggesting Lcn2 deficiency may affect lesion stability. Furthermore, MMP-9 activity was diminished in plaques from Ldlr-/-Lcn2-/- mice. CONCLUSIONS: Altogether, these findings suggest that Lcn2 deficiency promotes lesion growth in earlier stages of the disease while it decreases MMP-9 activity and necrotic core size in advanced atherosclerosis.

Longitudinal evaluation of clustering of chronic sinonasal and related symptoms using exploratory factor analysis.

BACKGROUND: Sinonasal symptoms are common and can have several underlying causes. When symptoms occur in specified patterns lasting 3 months or more they meet criteria for chronic rhinosinusitis (CRS). Approaches to CRS symptom measurement do not specify how to measure symptoms and treat specified sinonasal symptoms as generally interchangeable, suggesting that such symptoms should cluster on 1 or 2 latent factors. METHODS: We used questionnaire responses to 37 questions on the presence, severity, bother, and frequency of cardinal sinonasal and related symptoms lasting 3 months, from 3535 subjects at 3 time points over 16 months. We completed 5 exploratory factor analyses (EFA) to identify symptom clustering, 1 for each time point and 2 for the differences between adjacent questionnaires. The baseline EFA was used to provide factor scores that were described longitudinally and examined by CRS status. RESULTS: Five EFAs identified the same 5 factors (blockage and discharge, pain and pressure, asthma and cold/flu symptoms, smell loss, and ear and eye [mainly allergy] symptoms), with clustering determined by symptom frequency, severity, and degree of bother. Responses to individual questions showed changes over time but when combined into factor scores showed less longitudinal change. All symptom factor scores were progressively higher from never to past to current CRS status. CONCLUSIONS: Although the current approaches to symptom characterization in CRS imply a single underlying latent construct, our results suggest that there are at least 3 latent constructs relevant to CRS. Further studies are needed to evaluate whether these clusters have identifiable underlying pathobiologies.

Impact of human platelet lysate on the expansion and chondrogenic capacity of cultured human chondrocytes for cartilage cell therapy.

High hopes have been pinned on regenerative medicine strategies in order to prevent the progression of cartilage damage to osteoarthritis, particularly by autologous chondrocyte implantation (ACI). The loss of chondrocyte phenotype during in vitro monolayer expansion, a necessary step to obtain sufficient cell numbers, may be a key limitation in ACI. In this study, it was determined whether a shorter monolayer expansion approach could improve chondrogenic differentiation. The effects of two supplement types, foetal bovine serum (FBS) and Stemulate™ (a commercial source of human platelet lysate), on the expansion and re-differentiation potential of human chondrocytes, isolated from five individuals, were compared. Chondrocytes were expanded with 10 % FBS or 10 % Stemulate™. Pellets were cultured for 28 d in chondrogenic differentiation medium and assessed for the presence of cartilage matrix molecules and genes associated with chondrogenicity. Stemulate™ significantly enhanced the proliferation rate [average population doubling times: FBS, 25.07 ± 6.98 d (standard error of the mean, SEM) vs. Stemulate™, 13.10 ± 2.57 d (SEM)]. Sulphated glycosaminoglycans (sGAG), total collagen and qRT-PCR analyses of cartilage genes showed that FBS-expanded chondrocytes demonstrated significantly better chondrogenic capacity than Stemulate™-expanded chondrocytes. Histologically, FBS-expanded chondrocyte pellets appeared to be more stable, with a more intense staining for toluidine blue, indicating a greater chondrogenic capacity. Although Stemulate™ positively influenced chondrocyte proliferation, it had a negative effect on chondrogenic differentiation potential. This suggested that, in the treatment of cartilage defects, Stemulate™ might not be the ideal supplement for expanding chondrocytes (which maintained a chondrocyte phenotype) and, hence, for cell therapies (including ACI).

Prevalence, severity, and risk factors for acute exacerbations of nasal and sinus symptoms by chronic rhinosinusitis status.

BACKGROUND: Nasal and sinus symptoms (NSS) are common to many health conditions, including chronic rhinosinusitis (CRS). Few studies have investigated the occurrence and severity of, and risk factors for, acute exacerbations of NSS (AENSS) by CRS status (current, past, or never met European Position Paper on Rhinosinusitis [EPOS] criteria for CRS). METHODS: Four seasonal questionnaires were mailed to a stratified random sample of Geisinger primary care patients. Logistic regression was used to identify individual characteristics associated with AENSS occurrence and severity by CRS status (current long-term, current recent, past, never) using EPOS subjective symptoms-only (EPOSS ) CRS criteria. We operationalized 3 AENSS definitions based on prescribed antibiotics or oral corticosteroids, symptoms, and symptoms with purulence. RESULTS: Baseline and at least 1 follow-up questionnaires were available from 4736 subjects. Self-reported NSS severity with exacerbation was worst in the current long-term CRS group. AENSS was common in all subgroups examined and generally more common among those with current EPOSS CRS. Seasonal prevalence of AENSS differed by AENSS definition and CRS status. Associations of risk factors with AENSS differed by definition, but CRS status, body mass index, asthma, hay fever, sinus surgery history, and winter season consistently predicted AENSS. CONCLUSIONS: In this first longitudinal, population-based study of 3 AENSS definitions, NSS and AENSS were both common, sometimes severe, and differed by EPOSS CRS status. Contrasting associations of risk factors for AENSS by the different definitions suggest a need for a standardized approach to definition of AENSS.

Association between physical exercise and psychosocial problems in 96 617 Dutch adolescents in secondary education: a cross-sectional study.

Background: Psychosocial problems negatively affect school performance, social skills and mental development. In recent years, researchers have investigated the relationship between physical activity and psychological health. With this large school-based study, we examined whether physically inactive adolescents and slightly active adolescents experience more psychosocial problems compared with active adolescents. Methods: This study is based on the Dutch National Youth Health Monitor. This monitor uses a, school-based, cross-sectional questionnaire conducted among 96 617 adolescents in 2015. To examine the association between physical exercise and psychosocial problems, multi-level linear regression was carried out. Results: The weighted average Strengths and Difficulties Questionnaire score of active adolescents was lower than that of inactive adolescents. Adolescents who are inactive had 12% (ß = 1.12; 95% CI: 1.10-1.14; P <0 .001) more psychosocial problems compared with active adolescents. Further, inactive adolescents had a higher score on the subscales emotional problems (ß = 1.19; 95% CI: 1.17-1.22; P < 0.001) and problems with peers (ß = 1.16; 95% CI: 1.14-1.19; P < 0.001). There was no statistical significant difference in total score of the Strengths and Difficulties Questionnaire between active and slightly active adolescents. Conclusion: Physically active adolescents have fewer psychosocial problems compared with physically inactive adolescents. Not only is this association significant, but there is an indication that it is also of clinical relevance.

Parvimonas micra Spondylodiscitis: A Case Report and Systematic Review of the Literature.

INTRODUCTION: Treatment and risk factors for Parvimonas micra spinal infections are scarcely researched. This study reports a case and presents a systematic review of the literature to provide evidence-based ground for diagnosis and treatment of P. micra spinal infections. CASE REPORT: This is a case of a 78-year-old male with severe back and leg pain. Advanced imaging demonstrated the destruction of L2-L3 with an extensive fluid collection in the remaining intervertebral space, paravertebral myositis, and multiple abscesses. A decompression of L2 and L3 and a posterior spondylodesis from T12 to L5 was performed. Intraoperative cultures showed P. micra. The postoperative treatment consisted of intravenous penicillin for 2 weeks and subsequent oral clindamycin for 4 weeks. At 1-year follow-up, the patient was in good health and reported only occasional back pain. CONCLUSIONS: A total of 15 additional cases of P. micraspinal infections were identified. The antibiotic treatment showed a great variety in the treated patients. Nevertheless, the outcome of these patients was good concerning relapse of the infection and pain. Spinal infections caused by P. micra are rare, but can be successfully treated according to the guidelines for spinal infection.

Overall survival in EGFR mutated non-small-cell lung cancer patients treated with afatinib after EGFR TKI and resistant mechanisms upon disease progression.

PURPOSE: To determine survival in afatinib-treated patients after treatment with first-generation EGFR tyrosine kinase inhibitors (TKIs) and to study resistance mechanisms in afatinib-resistant tumors. METHODS: Characteristics and survival of patients treated with afatinib after resistance to erlotinib or gefitinib in two large Dutch centers were collected. Whole exome sequencing (WES) and pathway analysis was performed on available pre- and post-afatinib tumor biopsies and normal tissue. RESULTS: A total of 38 patients were treated with afatinib. T790M mutations were identified in 22/29 (76%) pre-afatinib treatment tumor samples. No difference in median progression-free-survival (2.8 months (95% CI 2.3-3.3) and 2.7 months (95% CI 0.9-4.6), p = 0.55) and median overall-survival (8.8 months (95% CI 4.2-13.4) and 3.6 months (95% CI 2.3-5.0), p = 0.14) were observed in T790M+ patients compared to T790M- mutations. Somatic mutations in TP53, ADAMTS2, CNN2 and multiple genes in the Wnt and PI3K-AKT pathway were observed in post-afatinib tumors of six afatinib-responding and in one non-responding patient. No new EGFR mutations were found in the post-afatinib samples of the six responding patients. Further analyses of post-afatinib progressive tumors revealed 28 resistant specific mutations in six genes (HLA-DRB1, AQP7, FAM198A, SEC31A, CNTLN, and ESX1) in three afatinib responding patients. No known EGFR-TKI resistant-associated copy number gains were acquired in the post-afatinib samples. CONCLUSION: No differences in survival were observed in patients with EGFR-T790M treated with afatinib compared to those without T790M. Tumors from patients who had progressive disease during afatinib treatment were enriched for mutations in genes involved in Wnt and PI3K-AKT pathways.

Classical determinants of coronary artery disease as predictors of complexity of coronary lesions, assessed with the SYNTAX score.

BACKGROUND: We need new biomarkers that can predict cardiovascular disease to improve both diagnosis and therapeutic strategies. The CIRCULATING CELLS study was designed to study the role of several cellular mediators of atherosclerosis as biomarkers of coronary artery disease (CAD). An objective and reproducible method for the quantification of CAD extension is required to establish relationships with these potential biomarkers. We sought to analyse the correlation of the SYNTAX score with known CAD risk factors to test it as a valid marker of CAD extension. METHODS AND RESULTS: A subgroup of 279 patients (67.4% males) were included in our analysis. Main exclusion criteria were a history of previous percutaneous coronary intervention or surgical revascularisation that prevent an accurate assessment of the SS. Diabetes mellitus, smoking, renal insufficiency, body mass index and a history of CAD and myocardial infarction were all positively and strongly associated with a higher SYNTAX score after adjustment for the non-modifiable biological factors (age and sex). In the multivariate model, age and male sex, along with smoking and renal insufficiency, remain statistical significantly associated with the SYNTAX score. CONCLUSION: In a selected cohort of revascularisation-naive patients with CAD undergoing coronary angiography, non-modifiable cardiovascular risk factors such as advanced age, male sex, as well as smoking and renal failure were independently associated with CAD complexity assessed by the SYNTAX score. The SYNTAX score may be a valid marker of CAD extension to establish relationships with potential novel biomarkers of coronary atherosclerosis.