Associations between biomarkers of matrix metabolism and inflammation with pain and fatigue in participants suspected of early hip and or knee osteoarthritis: data from the CHECK study.

OBJECTIVES: To assess the associations of biomarkers in serum [highsensitivity C-reactive protein (hs-CRP), serum cartilage oligomeric protein (sCOMP), serum propeptide of type I procollagen (sPINP) and serum osteocalcin (sOC)] and urine [urinary type II collagen telopeptide (uCTX-2)] with the extent and progression of nocturnal pain, pain while walking, and fatigue in participants with hip and/or knee pain suspected to be early stage osteoarthritis (OA). METHODS: hs-CRP, uCTX-2, sCOMP, sPINP and sOC were measured at baseline in 1,002 participants of the Cohort Hip and Cohort Knee (CHECK). Nocturnal pain, pain while walking and fatigue were assessed by self-reported questionnaires at baseline and 2-year follow-up. Associations between these biomarkers and symptoms were examined using logistic and linear regression analyses. RESULTS: hs-CRP was significantly associated with mild nocturnal pain (OR 1.18 95% CI 1.01-1.37), with mild and moderate pain while walking (OR 1.17 95% CI 1.01-1.35 and OR 1.56 95% CI 1.29-1.90, respectively) and with progression of nocturnal pain (OR 1.25 95% CI 1.07-1.46). uCTX-2 was associated with mild nocturnal pain (OR 1.40 95% CI 1.05-1.85) and with mild and severe-extreme pain while walking (OR 1.35 95% CI 1.04-1.75 and OR 2.55 95% CI 1.03-6.34, respectively). sPINP was associated with severe-extreme nocturnal pain (OR 0.45 95% CI 0.25-0.82). No significant associations were found for sCOMP and sOC, nor for any of the biomarkers and fatigue. CONCLUSION: This study of biomarkers in a large cohort of participants with hip and/or knee pain suspected to reflect early stage hip and/or knee OA suggests that inflammation and cartilage matrix degeneration play a role in pain, but not in fatigue.

The penetrance of paraganglioma and pheochromocytoma in SDHB germline mutation carriers.

Germline mutations in succinate dehydrogenase B (SDHB) predispose to hereditary paraganglioma (PGL) syndrome type 4. The risk of developing PGL or pheochromocytoma (PHEO) in SDHB mutation carriers is subject of recent debate. In the present nationwide cohort study of SDHB mutation carriers identified by the clinical genetics centers of the Netherlands, we have calculated the penetrance of SDHB associated tumors using a novel maximum likelihood estimator. This estimator addresses ascertainment bias and missing data on pedigree size and structure. A total of 195 SDHB mutation carriers were included, carrying 27 different SDHB mutations. The 2 most prevalent SDHB mutations were Dutch founder mutations: a deletion in exon 3 (31% of mutation carriers) and the c.423+1G>A mutation (24% of mutation carriers). One hundred and twelve carriers (57%) displayed no physical, radiological or biochemical evidence of PGL or PHEO. Fifty-four patients had a head and neck PGL (28%), 4 patients had a PHEO (2%), 26 patients an extra-adrenal PGL (13%). The overall penetrance of SDHB mutations is estimated to be 21% at age 50 and 42% at age 70 when adequately corrected for ascertainment. These estimates are lower than previously reported penetrance estimates of SDHB-linked cohorts. Similar disease risks are found for different SDHB germline mutations as well as for male and female SDHB mutation carriers.

Should every patient diagnosed with a phaeochromocytoma have a ¹²³ I-MIBG scintigraphy?

Localization of phaeochromocytomas and paragangliomas (PPGLs) should involve functional imaging as anatomical imaging modalities can either fail to locate the tumour or can be suboptimal due to an anatomical abnormality or previous surgery. Functional imaging is particularly useful to fully delineate the extent of disease using the whole-body scan and the evaluation of multifocality, metastatic or recurrent disease. An increasing number of radiolabeled tracers have become available for tumour visualization during the past decade. (123) I-meta-iodobenzylguanidine scintigraphy is the most widely used functional imaging modality, and its sensitivity to identify chromaffin cell tumours varies from 85 to 88% for phaeochromocytomas and 56-76% for paragangliomas, while specificity ranges between 70 and 100% and 84-100%, respectively.

Patterns of knee osteoarthritis management in general practice: a retrospective cohort study using electronic health records.

OBJECTIVE: This study determined patterns of knee osteoarthritis (OA) management by general practitioners (GPs) using routine healthcare data from Dutch general practices from 2011 to 2019. DESIGN: A retrospective cohort study was conducted using the Integrated Primary Care Information database between 2011 and 2019. Electronic health records (EHRs) of n = 750 randomly selected knee OA patients (with either codified or narrative diagnosis) were reviewed against eligibility criteria and n = 503 patients were included. Recorded information was extracted on GPs' management from six months before to three years after diagnosis and patterns of management were analysed. RESULTS: An X-ray referral was the most widely recorded management modality (63.2%). The next most widely recorded management modalities were a referral to secondary care (56.1%) and medication prescription or advice (48.3%). Records of recommendation of/referral to other primary care practitioners (e.g. physiotherapists) were found in only one third of the patients. Advice to lose weight was least common (1.2%). Records of medication prescriptions or recommendation of/referral to other primary care practitioners were found more frequently in patients with an X-ray referral compared to patients without, while records of secondary care referrals were found less frequently. Records of an X-ray referral were often found in narratively diagnosed knee OA patients before GPs recorded a code for knee OA in their EHR. CONCLUSION: These findings emphasize the importance of better implementing non-surgical management of knee OA in general practice and on initiatives for reducing the overuse of X-rays for diagnosing knee OA in general practice.

Dysregulation of synaptic and developmental transcriptomic/proteomic profiles upon depletion of MUNC18-1.

Absence of presynaptic protein MUNC18-1 (gene: Stxbp1) leads to neuronal cell death at an immature stage before synapse formation. Here, we performed transcriptomic and proteomic profiling of immature Stxbp1 knockout (KO) cells to discover which cellular processes depend on MUNC18-1. Hippocampi of Stxbp1 KO mice showed cell-type specific dysregulation of 2123 transcripts primarily related to synaptic transmission and immune response. To further investigate direct, neuron-specific effects of MUNC18-1 depletion, a proteomic screen was performed on murine neuronal cultures at two developmental timepoints prior to onset of neuron degeneration. 399 proteins were differentially expressed, which were primarily involved in synaptic function (especially synaptic vesicle exocytosis) and neuron development. We further show that many of the downregulated proteins upon loss of MUNC18-1 are normally upregulated during this developmental stage. Thus, absence of MUNC18-1 extensively dysregulates the transcriptome and proteome, primarily affecting synaptic and developmental profiles. Lack of synaptic activity is unlikely to underlie these effects, as the changes were observed in immature neurons without functional synapses, and minimal overlap was found to activity-dependent proteins. We hypothesize that presence of MUNC18-1 is essential to advance neuron development, serving as a 'checkpoint' for neurons to initiate cell death in its absence.Significance StatementPresynaptic protein MUNC18-1 is essential for neuronal functioning. Pathogenic variants in its gene, STXBP1, are among the most common found in patients with developmental delay and epilepsy. To discern the pathogenesis in these patients, a thorough understanding of MUNC18-1's function in neurons is required. Here, we show that loss of MUNC18-1 results in extensive dysregulation of synaptic and developmental proteins in immature neurons before synapse formation. Many of the downregulated proteins are normally upregulated during this developmental stage. This indicates that MUNC18-1 is a critical regulator of neuronal development, which could play an important role in the pathogenesis of STXBP1 variant carriers.

Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer.

BACKGROUND AND STUDY AIMS: The introduction of self-expandable metal stents has offered a promising alternative for palliation of malignant left-sided colonic obstruction. This randomized clinical trial aimed to assess whether a nonsurgical policy, with endoluminal stenting, is superior to surgical treatment in patients with stage IV left-sided colorectal cancer and imminent obstruction. PATIENTS AND METHODS: Patients with incurable left-sided colorectal cancer who fulfilled the study criteria were randomly assigned to nonsurgical or surgical treatment. The primary outcome measure was survival in good health out of hospital (World Health Organization performance scores 0 or 1). RESULTS: A high number of serious adverse events in the nonsurgical arm led to premature closure of the trial. Ten patients were allocated to surgical treatment and 11 patients to nonsurgical palliation. The median survival in good health out of hospital during the first year was 56 days (interquartile range 7.5 - 338.5 days) in the surgical arm vs. 38 days (interquartile range 5.25 - 288.75 days) in the nonsurgical arm (P = 0.68). Eleven adverse events (six perforations) occurred in the nonsurgical arm vs. one adverse event in the surgical arm (P < 0.001). Of the six perforations, two were stent-related because they occurred at the proximal edge of the stent by erosion through a normal colon wall; one was probably stent-related (it was located in the region of the proximal half of the stent); one was a colon blowout; and two were late tumor perforations in patients on chemotherapy. CONCLUSIONS: The unexpected high rate of perforation in the nonsurgical arm might be specifically WallFlex-related or enteral stent-related in patients on chemotherapy and warrants attention.

Nationwide study of patients with head and neck paragangliomas carrying SDHB germline mutations.

BACKGROUND: Germline mutations in the succinate dehydrogenase B (SDHB) gene predispose to hereditary paraganglioma (PGL) syndrome type 4. The aim of this study was to evaluate the clinical characteristics and outcome of treatment strategies for patients with head and neck paraganglioma (HNPGL) carrying SDHB germline mutations. METHODS: This was a retrospective evaluation of patients with HNPGL carrying SDHB germline mutations in the Netherlands. RESULTS: In a Dutch nationwide cohort study of SDHB germline mutation carriers, 54 patients with a total of 62 HNPGLs were identified. Forty-one of 54 patients (76 per cent) visited the outpatient clinic because of associated complaints. Eight patients (15 per cent) had multiple PGLs. One patient (2 per cent) developed a phaeochromocytoma and three (6 per cent) developed a malignant PGL. Twenty-seven patients (50 per cent) had an operation for their HNPGL and 15 (28 per cent) received radiotherapy. Three patients with HNPGL (6 per cent) were diagnosed with additional non-paraganglionic tumours. CONCLUSION: If an SDHB germline mutation is identified in a patient with HNPGL, the clinician should be aware of the variable manifestations of the SDHB-linked tumour syndrome, the risk of catecholamine excess, concurrent phaeochromocytoma, and association with non-paraganglionic tumours.

Magnification endoscopy for diagnosis of nonerosive reflux disease: a proposal of diagnostic criteria and critical analysis of observer variability.

BACKGROUND AND STUDY AIMS: This study tested the diagnostic value of high-resolution endoscopy for the recognition of subtle diagnostic esophageal mucosal changes in nonerosive reflux disease. PATIENTS AND METHODS: Ten control subjects and eleven patients with nonerosive reflux disease confirmed by a validated questionnaire, standard endoscopy, and 24-hour pH-metry participated in the study. Still images were collected by high-resolution endoscopes from the distal esophagus in a standardized manner, incorporating iodine staining. Assessments were repeated in the patients with reflux disease after 4 weeks of esomeprazole therapy. Interobserver variability in the recognition of the proposed criteria was initially evaluated by 27 endoscopists using an Internet-based process. After optimisation of image quality the evaluation was repeated face-to-face with six expert endoscopists. RESULTS: No criterion was identified in either assessment that was sufficiently sensitive and specific to patients with reflux disease to be clinically useful. The kappa value, used to assess interobserver variation, was acceptably high only for invisibility of palisade vessels (0.59). Triangular indentations, apical mucosal breaks, and pinpoint blood vessels at the squamocolumnar junction were identified more frequently in the patients with reflux disease ( P < 0.05). These changes and the invisibility of the palisade vessels were significantly less prevalent in reflux patients after therapy ( P < 0.01). CONCLUSIONS: Though some distal esophageal mucosal appearances observed with the high-resolution endoscope appeared to be related to nonerosive esophageal mucosal injury, none of these changes proved to be sufficiently sensitive and specific to justify their use as a diagnostic criterion for nonerosive reflux disease.

A rat lung cancer model based on intrapulmonary implantation of tumour material.

A lung cancer model based on implantation of tumour fragments in the posterior lobe of the right lung of WAG/Rij rats by a surgical procedure has been developed. Two transplantable squamous cell carcinomas which were induced by implanted iridium-192 wires in the lung, were used in this study. The characteristics of these tumours following intrapulmonary implantation are reported with respect to growth rate, invasiveness and metastasizing capacity. The tumour volumes are determined by X-ray chest radiographs. Mean tumour volume doubling times are about 9 days. This system provides a means to evaluate treatment regimens involving irradiation and chemotherapeutic drugs.

Treatment of the rat R-1 rhabdomyosarcoma with methotrexate and radiation; effects of timing on cell survival and tumour growth delay.

The interaction of radiation (10 Gy 300-kV X-rays) and methotrexate (MTX; 3 x 10 mg/kg at 3.5-h intervals) was investigated with respect to effects on cell survival and tumour regrowth of the transplantable rat R-1 rhabdomyosarcoma. The treatment with MTX alone caused acceptable toxicity and no lethality. On day 3 after treatment with MTX alone a maximum decrease in the fraction of clonogenic cells was observed, which is in accordance with data on MTX concentrations in tumour tissue, indicating that MTX is active in the tumour for at least 3 days after injection. The clonogenic capacity after combined treatments, i.e. MTX before or after radiation, was assessed 3 days after the MTX administration. The fractions of clonogenic cells determined after combined therapy with intervals of up to 4 days were not significantly different from those expected on the basis of simple addition of the effects from individual treatments. However, the excess growth delay was positive at specific intervals (6-8 days after X-rays plus MTX and 5-6 days after MTX plus X-rays), whereas negative excess delays were observed when the two treatments were separated by less than 3 days. It is concluded that expectations with respect to clinical application of the combination must be modest in view of the short duration of favourable intervals and the observed absence of synergistic effects with respect to cell killing. The discrepancy between the two assays indicates that erroneous conclusions can be obtained if one endpoint only is assessed.

Growth rate, morphology and drug responses of rat lung tumours growing at different sites.

Three rat squamous cell carcinomas and an adenocarcinoma were grown in the spleen to investigate whether the spleen is a suitable site for tumours to be grown without cyst formation for treatments such as interstitial brachytherapy. Morphological features and growth rate were compared with those of tumours growing subcutaneously and intrapulmonarily. Tumours were also subjected to cytostatic drugs. Spleen tumours grew without cyst formation. Volume doubling times of spleen tumours were shorter than those of flank tumours, while flank tumours grew faster than lung tumours. Specific growth delays of spleen tumours were not different from those of flank tumours and those of lung tumours were smaller or not significantly different from those of flank tumours.

Response to chemotherapy of non-small cell bronchial rat tumours growing subcutaneously or in the lung.

Seven rat bronchial cancers of various grades of differentiation were used to study responses to single doses of cytostatic drugs (mitomycin C, cisplatin, methotrexate, TCNU, CCNU, ifosfamide) when growing subcutaneously or in the lung. The endpoint was growth delay as calculated from tumour volume measurements using vernier callipers or radiography. Substantial differences were observed between the tumour lines in their response to the chemotherapeutic agents. The response of tumours implanted in the lung was less than that of flank implants of the same tumour line. TCNU and ifosfamide were the most consistently effective drugs, yielding growth delays of at least two tumour volume doubling times in the majority of the lines studied.

Responses of experimental rat tumours and a mouse colon tumour to flavone acetic acid.

The toxicity in rats and mice and the responses of 5 rat lung tumours, a rat rhabdomyosarcoma and a mouse colon tumour to flavone acetic acid, FAA, were studied. The LD50 values of FAA in WAG/Rij and BN rats were about 350 and 525 mg/kg respectively, independent of whether the animals were tumour bearing or not. In contrast, the LD50 value of tumour bearing BCBA mice was 50 percent of that of non-tumour bearing mice. Neither tumour volume regression nor growth delay were observed in the rat tumours growing in syngeneic rats or in nude mice, in contrast to the response of colon 38 tumours in mice. Light microscopy revealed massive tumour necrosis in the mouse tumour while no significant changes were observed in the rat tumours.

Unexpected prolonged extreme hypocalcaemia and an inadequate PTH response in a patient with metastatic breast carcinoma.

Although hypercalcaemia is often encountered during the course of malignant disease, hypocalcaemia appears to be rather rare. We describe a 37-year-old patient with metastatic carcinoma of the breast, who developed extreme hypocalcaemia (as low as 0.75 mmol calcium per litre) after chemotherapy. This is caused by a combination of hungry-bone syndrome and an insufficient parathyroid response. The latter may be the result of a direct toxic effect of chemotherapy on parathyroid hormone (PTH) synthesis possibly in combination with microscopic tumour infiltration in the parathyroid glands. Correction of the extreme hypocalcaemia over a period of 100 days by oral and intravenous calcium supplementation, corresponding to a total of 352 gram elemental calcium (1/3 of the total body calcium), resulted in gradual symptomatic relief. The possible mechanisms for these findings are discussed and the literature is briefly reviewed.

Diagnosis of endocrine disease: Biochemical diagnosis of phaeochromocytoma and paraganglioma.

Adrenal phaechromocytomas and extra-adrenal sympathetic paragangliomas (PPGLs) are rare neuroendocrine tumours, characterised by production of the catecholamines: noradrenaline, adrenaline and dopamine. Tumoural secretion of catecholamines determines their clinical presentation which is highly variable among patients. Up to 10-15% of patients present entirely asymptomatic and in 5% of all adrenal incidentalomas a PPGL is found. Therefore, prompt diagnosis of PPGL remains a challenge for every clinician. Early consideration of the presence of a PPGL is of utmost importance, because missing the diagnosis can be devastating due to potential lethal cardiovascular complications of disease. First step in diagnosis is proper biochemical analysis to confirm or refute the presence of excess production of catecholamines or their metabolites. Biochemical testing is not only indicated in symptomatic patients but also in asymptomatic patients with adrenal incidentalomas or identified genetic predispositions. Measurements of metanephrines in plasma or urine offer the best diagnostic performance and are the tests of first choice. Paying attention to sampling conditions, patient preparation and use of interfering medications is important, as these factors can largely influence test results. When initial test results are inconclusive, additional tests can be performed, such as the clonidine suppression test. Test results can also be used for estimation of tumour size or prediction of tumour location and underlying genotype. Furthermore, tumoural production of 3-methoxytyramine is associated with presence of an underlying SDHB mutation and may be a biomarker of malignancy.

Causes of death in intensive care patients with a low APACHE II score.

BACKGROUND: Little is known about the actual causes of death of patients with a low APACHE II score, but iatrogenic reasons may play a role. The aim of this study was to evaluate the demographics, course of disease, and causes of death in this specific group of ICU patients. METHODS: For this retrospective observational study, adult patients (>18 years) admitted to the ICU were included. RESULTS: During the 47-month study period, 9279 patients were admitted to our ICU, of which 3753 patients had an APACHE II score ≤15. Of the latter group of patients, 131 (3.5%) died during their hospital stay. Their median (IQR) APACHE II was 12 (11-14) and their main reason for ICU admission was respiratory insufficiency (47%). Both in patients with and without limited therapy, haemodynamic insufficiency was the main cause of death (50 and 69%, respectively). Three patients died directly related to medical interventions. CONCLUSION: Most patients with an APACHE II score lower than 15 who died were admitted to the ICU because of respiratory insufficiency. The main cause of death was haemodynamic insufficiency following limited therapy because of an unfavourable prognosis. In less than one out of 1000 cases of this low-risk group of patients death was related to iatrogenic injury.

Circumferential and axial distribution of esophageal mucosal damage in reflux disease.

The aim of this study was to evaluate the axial and radial distribution of histological markers including hyperplasia of the basal cell layer, elongation of the papillae and dilatation of the intercellular spaces of the squamous epithelium in patients with nonerosive reflux disease compared to controls and to relate this to the macroscopic topography in erosive reflux disease. Two different study populations were included in this report. Endoscopic esophageal biopsies were taken from 21 healthy control subjects and 21 nonerosive reflux disease patients before and after 4 weeks of esomeprazole therapy. Endoscopic still images from 50 erosive reflux disease patients were reviewed for the radial orientation of LA grade A and/or B esophagitis (Los Angeles criteria for grading of reflux esophagitis). The 3 o'clock position of the squamocolumnar junction showed significantly thicker basal cell layer (P=0.011) and more intercellular space dilatation (P=0.01) in nonerosive reflux disease patients compared to the 9 o'clock position. Only a significant difference in dilatation of the intercellular spaces (P=0.018) between nonerosive reflux disease patients and controls were observed in the 3 o'clock region at the squamocolumnar junction, whereas 1-2 cm orally, all three histological criteria differed significantly (P

Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy.

BACKGROUND AND STUDY AIMS: Endoscopic insertion of plastic biliary endoprostheses is a well-established treatment for obstructive jaundice. The major limitation of this technique is late stent occlusion. In order to compare events involved in biliary stent clogging and identify the distribution of bacteria in unblocked stents, confocal laser scanning (CLS) and scanning electron microscopy (SEM) were carried out on two different stent materials - polyethylene (PE) and hydrophilic polymer-coated polyurethane (HCPC). PATIENTS AND METHODS: Ten consecutive patients with postoperative benign biliary strictures were included in the study. Two 10-Fr stents 9 cm in length, one made of PE and the other of HCPC, were inserted. The stents were electively exchanged after 3 months and examined using CLS and SEM. RESULTS: No differences were seen between the two types of stent. The inner stent surface was covered with a uniform amorphous layer. On top of this layer, a biofilm of living and dead bacteria was found, which in most cases was unstructured. The lumen was filled with free-floating colonies of bacteria and crystals, surrounded by mobile laminar structures of mucus. An open network of large dietary fibers was seen in all of the stents. CONCLUSIONS: The same clogging events occurred in both PE and HCPC stents. The most remarkable observation was the identification of networks of large dietary fibers, resulting from duodenal reflux, acting as a filter. The build-up of this intraluminal framework of dietary fibers appears to be a major factor contributing to the multifactorial process of stent clogging.

Lung tumour growth delay and normal tissue toxicity induced by three cytotoxic platinum drugs.

Single doses of the drug cisplatin and its analogues carboplatin and iproplatin were administered to tumour-bearing rats. The tumours used were two bronchial squamous cell carcinomas, that are part of a panel of experimental lung tumours developed at this institute. Cisplatin resulted in severe nephrotoxicity. Carboplatin and iproplatin were less nephrotoxic, but resulted in acute gastrointestinal and (probably) hematological toxicity. Carboplatin also caused late occurring liver damage. The responses of the tumours were compared at the level of maximum tolerated drug doses for early toxicity. The level of response was different for the two tumours. One was more sensitive to the drugs than the other. The effects of cisplatin and carboplatin were approximately similar. Iproplatin was less effective. Because cisplatin caused more severe late toxicity, it is concluded that carboplatin has the best therapeutic index for these two lung tumours.

Wallstents for metastatic biliary obstruction.

BACKGROUND AND STUDY AIMS: In patients with obstruction of the common bile duct caused by primary pancreaticoblliary tumors, Wallstents have been shown to remain patent for a median duration of 273 days (range: 14-363). However, in one study that included both patients with primary pancreaticobillary malignancies and patients with metastatic malignant disease, the reported median Wallstent patency was found to be significantly shorter. We have studied the patency of Wall-stents in patients with metastatic billary obstruction. PATIENTS AND METHODS: All patients who had received a Wallstent for metastatic biliary obstruction between January 1990 and August 1994 were analyzed retrospectively. Follow-up was achieved by contacting referring physicians and general practitioners, and lasted up to the end of the study period (November 1994) or death of the patient. Follow-up was discontinued if a polyethylene stent was inserted through the Wallstent for treatment of stent dysfunction. RESULTS: 28 patients were identified, including 14 men and 14 women, with a mean age of 61.3 years (range 24-87). Long-term follow-up was possible in 27 patients (96%), for a median duration of 140 days (range 29- 561). Eleven patients died during the study period, and there were three deaths related to Wallstent dysfunction. The median duration of Wallstent patency was 265 days (range 11-519). Wallstent obstruction occurred in 13 patients; seven patients presented with cholangitis, six patients had jaundice. The cause of obstruction was established at endoscopic retrograde cholangiopancreatography in ten patients: seven had tumor ingrowth, and three had tumor overgrowth. Treatment consisted of insertion of a polyethylene stent in seven and placement of a second Wallstent in three patients. CONCLUSION: In patients with metastatic obstruction of the common bile duct, the duration of patency of Wallstents is comparable to that reported in series of Wallstents for primary pancreaticobiliary malignancies.