Lower estimated glomerular filtration rate at admission is associated with a worse outcome in older patients with hip fracture who undergo surgical treatment.

BACKGROUND: We assessed the relationship of estimated glomerular filtration rate values at hospital admission on the outcome of surgically treated older adults who had suffered a hip fracture. METHODS: Prospective study that included patients > 65 years of age, surgically treated for primary hip fracture, with no pathologic or high-energy trauma aetiology admitted to a tertiary teaching hospital between 2018 and 2019. We stratified patients based on their estimated glomerular filtration rate at admission and examined its association to demographic and clinical variables, including 90-day post-discharge mortality. RESULTS: The study included 942 hip fracture patients. Lowered estimated glomerular filtration rate was significantly associated to a worsening of the functional status, higher incidence of medical postoperative complications, higher postoperative renal dysfunction, and greater number of blood transfusions. Mortality displayed a staircase pattern, increasing with decreasing estimated glomerular filtration rate. Patients with estimated glomerular filtration rate <60 had significantly higher mortality at 90 days after discharge. In-hospital mortality rate was 10.7% in hip fracture patients with chronic kidney disease who experienced a significant variation in the estimated glomerular filtration rate (>5 mL/min/1.73m2) on admission in comparison to baseline values. CONCLUSION: Older adult patients treated for hip fracture with lower glomerular filtration rate values have poorer functional status and worse prognosis. A significant clinical variation of estimated glomerular filtration rate upon hospital admission for hip fracture may be associated with increased in-hospital mortality of chronic kidney disease patients.

Long-Term Results of a Phase I/II Clinical Trial of Autologous Mesenchymal Stem Cell Therapy for Femoral Head Osteonecrosis.

(1) Background: Osteonecrosis of the femoral head (ONFH) is characterized by impaired vascularization with ischemia resulting in bone cell death, leading to the deterioration of the hip joint. Mesenchymal stem/stromal cells (MSCs) are an attractive potential therapeutic approach in this setting. The aim of this study is to evaluate the clinical improvement in terms of pain and quality of life, as well as the safety of the procedure during the follow-up of patients. (2) Methods: A Phase I-II Open-Label Non-Randomized Prospective clinical trial was conducted. Eight patients with idiopathic ONFH and stage < IIC in the ARCO classification were included. Four weeks before therapy, 40 mL of autologous bone marrow was obtained, and MSCs were expanded under Good-Manufacturing-Practice (GMP) standards. Study medication consisted of a suspension of autologous BM-derived MSCs (suspended in a solution of 5-10 mL of saline and 5% human albumin) in a single dose of 0.5-1 × 106 cells/kg of the patient, administered intraosseously with a trocar and under radioscopic control. Per-protocol monitoring of patients included a postoperative period of 12 months, with a clinical and radiological assessment that included the visual analog scale (VAS), the Harris scale, the SF-36, and the radiological evolution of both hips. In addition, all patients were further followed up for eight years to assess the need for long-term total hip replacement (THR) surgery. (3) Results: Median age of patients included was 48.38 ± 7.38 years, and all patients were men. Autologous MSCs were expanded in all cases. There were no adverse effects related to cell administration. Regarding efficacy, both VAS and ODI scores improved after surgery. Radiologically, 12.5% of patients improved at the end of follow-up, whereas 50% improved clinically. No adverse effects related to the procedure were recorded, and none of the patients needed THR surgery within the first year after MSC therapy. (4) Conclusions: The use of autologous MSCs for patients with ONFH disease is feasible, safe in the long term, and potentially effective.

Anterior cruciate ligament innervation in primary knee osteoarthritis.

OBJECTIVE: To relate the Anterior Cruciate Ligament (ACL) innervation and histologic degeneration status to the knee osteoarthritis radiologic and functional status. DESIGN: Prospective observational study including 30 consecutive patients affected by primary knee osteoarthritis undergoing Total Knee Arthroplasty (TKA). All patients suffering secondary knee osteoarthritis, an antecedent of an infectious process, malignant process, autoimmune disorder, or previous knee surgery were excluded. We recorded biodemographic, clinical, and radiologic variables of all participants previous to the TKA procedure. ACL tissue was harvested during TKA standard procedure and the obtained sample was fixed in 4% formalin and paraffin-embedded. ACL cross-sections were stained by haematoxylin-eosin and Gallego staining for elastic and collagen fibers, and Sevier-Munger silver staining for nervous tissue. RESULTS: ACL samples histologic degeneration classification reported 15.4% normal, 23.1% slight, 26.9% mild, 11.5% moderate and 23.1% marked. We noted 46.2% large nervous fascicles, 15.4% medium fascicles, 3.8% small fascicles, and no nerve fibers were found in 34.6% ACL samples. No significant correlation was found between the histologic degeneration and the nervous fiber quantification (p>0.05, in all cases). We noted a significant histologic degeneration inverse correlation with the VAS scale (p=0.016), and nervous fiber quantification correlation with Lequesne maximum distance walked punctuation (p=0.043). We also noted greater nervous fiber quantification with minor radiological knee osteoarthritis (Kellgren-Lawrence grade II). CONCLUSIONS: ACL degeneration and innervation deficit may play a role in primary knee osteoarthritis onset, but the lack of a defining relationship among the different parameters assessed justifies further research in greater populations.

Quality assessment of orthopedic surgery referral request letters from primary care consultation: Evaluation of a Spanish healthcare area.

BACKGROUND: One of the most requested referrals for specialist consultations from primary care (PC) is orthopedic surgery (OS). The purpose of this work was to analyze the number, characteristics, and quality of PC referral request letters in a Spanish healthcare area to their OS reference department. MATERIALS AND METHODS: The referral rates for 10 years were collected, and a total of 6,225 referral letters issued during the first half of 2019 were analyzed in detail. Gender, age, patient provenance, as well as priority and other process descriptors (type of pathology, suspected diagnosis, exploratory signs, imaging tests) were assessed. A scoring system was developed to evaluate the quality of the referral to an OS consultation: Quality evaluation in OS (QEOS) model. RESULTS: The rate of referral to OS is rising. The mean age of the referred patient was 53 years and 59.3% were women. Degenerative pathologies justified most referral requests (65.7%), most of which related to the spine (24.2%) or the knee (23.2%). In the QEOS analysis of the referral request letters, we noted that only 36.5% described some physical exploration, 32.9% image tool request, 25.8% indicated the pharmacological treatment, and 11.2% subsequent physiotherapy, resulting in a poor average quality of PC to OS patient referral. CONCLUSION: There is a growing demand for patient referral from PC to OS, however, the number, content, and quality of referral request letters varies greatly. The QEOS tool can be the germ of a simple evaluation system that would help in the improvement of the process of continuous care.

Total Knee Arthroplasty for the Oldest Old.

The present study describes and compares the early functional results after total knee arthroplasty (TKA) of the oldest-old population (aged over 84 years) and a randomly matched younger septuagenarian cohort so treated. We aimed to evaluate the early functional outcomes after patients' rehabilitation and the yearly requirements for hospital readmission and emergency room visits after TKA. We noted a similar length of hospital stay for octogenarian and septuagenarian patients, and we determined that both groups of patients were improving ROM (both flexion and extension) after the rehabilitation program (p < 0.05, in all cases), but there were no significant differences between octogenarian and septuagenarian improvement of the knee function (p > 0.05, in all cases). Patients from both age groups behaved similarly in terms of mobility before starting rehabilitation and after completion of the rehabilitation program. We noted that older octogenarian patients showed a higher one-year hospital readmission rate than younger septuagenarian patients, but similar early emergency room visits for both age groups. The findings of this study allow us to conclude that advanced age in itself should not be a contraindication for TKA.

MSCs from polytrauma patients: preliminary comparative study with MSCs from elective-surgery patients.

BACKGROUND: Polytrauma is a major clinical problem due to its impact on morbidity and mortality, especially among the younger population. Its pathophysiology is not completely elucidated, and the study of the involvement of certain cell populations with therapeutic potential, such as mesenchymal stromal cells (MSCs), is an area of growing interest, as mesenchymal cells have anti-inflammatory, immunoregulatory, and osteogenic potential. METHODS: In the present preliminary work, we have evaluated the characteristics of MSCs in terms of proliferation, immunophenotype, cell cycle, clonogenic capacity, and multilineage differentiation ability in a series of 18 patients with polytrauma and compared them to those from otherwise healthy patients undergoing elective spinal surgery. RESULTS: MSCs from polytrauma patients displayed higher proliferative potential with significantly higher cumulative population doublings, increased expression of some important cell adhesion molecules (CD105, CD166), and an early pre-osteogenic differentiation ability compared to those of the control group. CONCLUSIONS: MSCs could potentially be of help in the repair process of polytrauma patients contribute to both cell-tissue repair and anti-inflammatory response. This potential should be further explored in larger studies.

Functional Status Geriatric Scores: Single-Handed Tools for 30-Day Mortality Risk After Hip Fracture.

BACKGROUND: The 30-day mortality rate after hip fracture surgery has been considered as an indirect indicator of the quality of care. This work aims to appraise the Barthel Index, Katz Index, Lawton-Brody Index, and Physical Red Cross Scale registered in the Comprehensive Geriatric Assessment at admission on the of 30-day death probability after hip fracture surgery. METHODS: Prospective study including 899 hip fracture patients over 65. Bed-ridden, non-surgically treated patients, and high energy trauma or tumoral etiology fractures were excluded. Variables distribution were assessed by χ2, U-Mann Whitney and we performed binary logistic regression and equal tailed Jeffreys 95% CI for risk assessment. P<0.05 was considered statistically significant. RESULTS: We noted a 30-day mortality rate of 5.9%. We related Barthel Index (OR=0.986 [0.975-0.996], p=0.010), Katz Index (OR=1.254 [1.089-1.444], p=0.002), Lawton-Brody Index (OR=0.885 [0.788-0.992], p=0.037), and Physical Red Cross Scale (OR=1.483 [1.094-2.011], p=0.011) with the 30-day mortality of patients after hip fracture surgery. We also validated the Barthel Index inflection point (0-55) (ORBI(0-55)=2.428 [1.379-4.275], p=0.002) and Katz Index inflection point (A-B) (ORKI(A-B)=0.493 [0.273-0.891], p=0.019) for the assessment of the highest risked patients. CONCLUSION: The geriatric functional status scores would be useful multifunctional and standalone tools in the assessment of hip fracture patients as singly predictors of 30-day mortality.

30-day mortality after hip fracture surgery: Influence of postoperative factors.

PURPOSE: The 30-day mortality rate after hip fracture surgery has been considered as an indirect indicator of the quality of care. The aim of this work is to analyse preoperative and postoperative factors potentially related to early 30-day mortality in patients over 65 undergoing hip fracture surgery. METHODS: Prospective cohort study including all consecutive primary hip fracture patients over 65 admitted to Trauma and Orthopaedics department from January 1, 2018 to December 31, 2019. Bed-ridden, non- surgically treated patients, and high energy trauma or tumoral aetiology fractures were excluded. A total of 943 patients were eligible (attrition rate: 2.1%). Follow-up included 30-days after discharge. We noted the 30-day mortality after hip fracture surgery, analysing 130 potentially related variables including biodemographic, fracture-related, preoperative, and postoperative clinical factors. Qualitative variables were assessed by χ2, and quantitative variables by non-parametric tests. Odds ratio determined by binary logistic regression. We selected preventable candidate variables for multivariate risk assessment by logistic regression. RESULTS: A total of 923 patients were enrolled (mean age 86.22±6.8, 72.9% women). The 30-day mortality rate was 6.0%. We noted significant increased mortality on men (OR = 2.381[1.371-4.136], p = 0.002), ageing patients (ORyear = 1.073[1.025-1.122], p = 0.002), and longer time to surgery (ORday = 1.183[1.039-1146], p<0.001), on other 20 preoperative clinical variables, like lymphopenia (lymphocyte count <103/µl, OR = 1.842[1.063-3.191], p = 0.029), hypoalbuminemia (≤3.5g/dl, OR = 2.474[1.316-4.643], p = 0.005), and oral anticoagulant intake (OR = 2.499[1.415-4.415], p = 0.002), and on 25 postoperative clinical variables, like arrhythmia (OR = 13.937[6.263-31.017], p<0.001), respiratory insufficiency (OR = 7.002[3.947-12.419], p<0.001), hyperkalaemia (OR = 10.378[3.909-27.555], p<0.001), nutritional supply requirement (OR = 3.576[1.894-6.752], p = 0.021), or early arthroplasty dislocation (OR = 6.557[1.206-35.640], p = 0.029). We developed a predictive model for early mortality after hip fracture surgery based on postoperative factors with 96.0% sensitivity and 60.7% specificity (AUC = 0.863). CONCLUSION: We revealed that not only preoperative, but also postoperative factors have a great impact after hip fracture surgery. The influence of post-operative factors on 30-day mortality has a logical basis, albeit so far they have not been identified or quantified before. Our results provide an advantageous picture of the 30-day mortality after hip fracture surgery.

Effect of pharmacological treatment prior to admission on the outcome of older hip fracture patients.

PURPOSE: We aim to relate the pharmacological treatment at admission of hip fracture patients with their prognosis. METHODS: We designed a prospective study including 436 hip fracture patients. We classified all the pharmacological treatment prior to admission of each patient into 25 groups according to their active agent and indications. We followed-up patients for one year for survival, emergency department visits (EDV), and in-hospital re-admissions (RAD). Differential analysis was performed by chi-square test, U-Mann Whitney test, and logistic regression. In all cases, p ≤ 0.05 was considered statistically significant. RESULTS: At 30-day follow-up, 14.9% patients noted EDV, 9.2% RAD, and 3.2% dead. Patients taking beta-blockers (p = 0.046), loop diuretics (p = 0.018) or antiparkinsonian (p = 0.009) showed an increased 30-day EDV; patients taking benzodiazepines (p = 0.014), loop diuretics (p = 0.009) or antiparkinsonian (p = 0.009), an increased 30-day RAD. At one-year follow-up, 50.7% patients noted EDV, 30.7% RAD, and 22.7% dead. Patients taking oral antidiabetics (p = 0.006) noted a greater one-year EDV; patients taking major opioids (p = 0.001), benzodiazepines (p = 0.016), cardiac agents (p = 0.046), loop diuretics (p = 0.042), beta-blockers (p = 0.018), oral anticoagulants (p = 0.013) or gastric prophylaxis (p = 0.020), greater RAD; patients taking cardiac agents (p = 0.024), loop diuretics (p = 0.006) or oral anticoagulants (p = 0.015), increased 1-year mortality rate. CONCLUSIONS: The pharmacological treatment noted at admission for hip fracture patients is related to the outcome, in a dose-independent way. The pharmacological treatment could be an additional parameter that could help us to improve the decision-making process and the resource assignation of hip fracture patients. A proper medication review upon admission because of a hip fracture is warranted.

The impact of antithrombotic therapy on surgical delay and 2-year mortality in older patients with hip fracture: a prospective observational study.

PURPOSE: To analyze the associations of oral anticoagulant and antiplatelet treatments in older patients requiring surgical treatment for hip fracture with mortality, length of stay, waiting time to surgery and postsurgical immediate complications. METHODS: A prospective observational study, including surgically treated hip fracture patients aged 65 years and older. We analyzed admission status variables, and time to surgery, length of stay and immediate surgical and medical complications. We recorded a 2-year survival follow-up. RESULTS: Of the 237 patients studied, 32.5% received antiplatelet treatment and 17.7% received oral anticoagulant treatment. The overall 2-year mortality was 29.1%. The 2-year mortality rate reached the 33.8% for antiplatelet-treated patients (n.s.) and 45.2% for oral anticoagulated patients (p = 0.011). The length of stay increased significantly associated with the oral anticoagulant or high-dose antiplatelet treatment (p < 0.001). The same happened for the time to surgery (p < 0.001), but no delay was observed for patients with low-dose antiplatelet treatment. Oral anticoagulated and antiplatelet-treated patients had a higher Charlson comorbidity index (p = 0.004, p = 0.019) and ASA score (p = 0.006, p = 0.011). Those treatments were also associated with a higher rate of some immediate postsurgical medical complications. We found a relationship between low hemoglobin at admission and high-dose antiplatelet treatment (p = 0.044). CONCLUSIONS: Hip fracture patients following previous oral anticoagulant treatment have a higher 2-year mortality rate. The oral anticoagulant or high-dose antiplatelet treatments are significantly associated with an increase in the length of stay, related to time to surgery, but we could not demonstrate an effect on early mortality.

Time to Surgery Reduction in Hip Fracture Patients on an Integrated Orthogeriatric Unit: A Comparative Study of Three Healthcare Models.

OBJECTIVE: To investigate the clinical efficacy of three different healthcare models (Traditional Model, Geriatric Consultant Model, and Orthogeriatric Unit Model) consecutively applied to a single academic center (University Hospital of Salamanca, Spain) for older hip fracture patients. METHODS: We performed a retrospective study, including 2741 hip fracture patients older than 64 years, admitted between 1 January 2003 and 31 December 2014 to the University Hospital of Salamanca. Patients were divided into three groups according to the healthcare model applied. There were 983 patients on the Traditional Model, 945 patients on the Geriatric Consultant Model, and 813 patients on the Orthogeriatric Unit Model. We recorded age and gender of patients, functional status at admission (Barthel Index, Katz Index, and Physical Red Cross Scale), type of fracture, and intervention, and we analyzed the length of stay, time to surgery, post-surgical stay, and in-hospital mortality according to the healthcare model applied. RESULTS: Hip fractures are much more frequent in women, and an increase in the average age of patients was observed along with the study (P < 0.001). The most common type of fracture in the three models studied was an extracapsular fracture, for which the most common surgical procedure used was osteosynthesis. On the functional status of patients, there were no differences on the ambulatory ability previous to fracture, measured by the Physical Red Cross Scale, and the percentage of patients with a slight dependence determined by the Barthel Index (>60) was similar in both groups, but considering the Katz Index, the percentage of patients with a high degree of independence (A-B) was significantly higher for the group of patients treated on the Orthogeriatric Unit Model period (56%, P = 0.009). The Orthogeriatric Unit Model registered the greatest percentage of patients undergoing surgery (96.1%, P < 0.001) and the greatest number of early surgical procedures (<24 h) (24.8%, P < 0.001). The orthogeriatric unit model showed the shortest duration of stay (9 days median), decreasing by one day in respect of each of the other models studied (P < 0.001). Time to surgery was also significantly reduced with the Orthogeriatric Unit Model (median of 3 days, P < 0.001). With regard to in-hospital follow-up, there was a reduction in in-hospital mortality during the study period. We observed differences among the three healthcare models, but without statistical significance. CONCLUSIONS: The healthcare model based on an Orthogeriatric Unit seems to be the most efficient, because it reaches a reduction in time to surgery, with an increased number of patients surgically treated on in the first 24 h, and the greatest frequency of surgically-treated patients.

Oldest old hip fracture patients: centenarians as the lowest complexity patients.

BACKGROUND: Hip fracture leads to an increase in mortality and deterioration in the quality of life. The increase in life expectancy results in an increase in the number of oldest old patients. AIMS: To analyze the characteristics of centenarian hip fracture patients and compare them with younger hip fracture patients. METHODS: Retrospective study, including 176 patients (48 centenarians, 65 nonagenarians and 63 octogenarians) undergoing surgery after hip from 2009 to 2018 and followed for 1-year survival. Qualitative variables were compared by Chi-square test and quantitative variables, by Kruskal-Wallis test. Survival analysis was performed by Kaplan-Meier test and statistical differences were assessed by log-rank test. p value < 0.05 was considered statistically significant. RESULTS: Centenarians showed the lowest Charlson index (p = 0.001), cognitive impairment (p < 0.001), and daily drug intake (p = 0.034). The in-hospital, 30-day and 1-year mortality rates did not show statistical significant differences. The 1-year survival analysis showed that patients died in order of age (p = 0.045). No differences were found regarding readmissions. DISCUSSION: Hip fracture incidence in centenarians is increasing. Our study states the lowest complexity for centenarians. Hip fracture mortality rates have been linked to patients' age. In-hospital mortality rate has been reduced, and for the 30-day and 1-year mortality rates, we noted that mortality follows a pattern clearly related to age. CONCLUSIONS: Centenarians showed the lowest comorbidity and complexity. Readmissions before 1 year, mortality rates at discharge, 30-day and 1-year follow-up were not significantly different, but 1-year survival analysis showed that patients are dying as they are ageing.

Risk factors for periprosthetic joint infection after total knee arthroplasty.

INTRODUCTION: Periprosthetic joint infection (PJI) is the most serious and feared complication in total knee arthroplasty (TKA) and can have catastrophic consequences. The number of total knee arthroplasties is increasing, so infections could also be greater in the future. The aim of this study is to identify the most relevant risk factors associated with infection after a total knee arthroplasty. METHODS: This is a case-control study of patients who underwent total knee arthroplasty at the University Hospital of Salamanca. We included 66 TKA PJI patients and 66 control TKA patients. Demographic and clinical variables were collected. A descriptive and inferential analysis was performed by logistic regression and attributable risk fraction assessed. RESULTS: Prolonged operative time (> 90') and tourniquet time (> 60') were the most relevant risk factors described (OR 40.77, AFE 0.97, p > 0.001 and OR 37.14, AFE 0.97, p < 0.001, respectively). The use of non-antibiotic-laded cement (OR 3.62), obesity (BMI > 30, OR 8.86), diabetes (OR 2.33), high ASA grade (III-IV, OR 15.30), and blood transfusion requirement (OR 4.60) were also statistically significant risk factors for TKA PJI. CONCLUSIONS: Our study provides evidence concerning that operative time, tourniquet time, cement type, diabetes, obesity, ASA grade, and blood transfusion requirement as independently associated risk factors for TKA PJI. Modifiable risk factors were specifically relevant, so we should be able to reduce the infection rate.

Geriatric scores can predict long-term survival rate after hip fracture surgery.

BACKGROUND: The management of hip fractures is nowadays mainly performed in Orthogeriatric Units, one of whose fundamental tools is the application of geriatric scores. The purpose of this study is to establish the potential usefulness of Barthel Index, Katz Index, Lawton-Brody Index and Physical Red Cross Scale geriatric scores as predictors of survival rate and readmission rate in older patients after hip fracture surgery. METHODS: We designed a prospective single-center observational study, including 207 older adults over age 65 who underwent hip fracture surgery in the first half of 2014 and followed up to September 2018. Cumulative survival and readmission rates were analyzed by Kaplan-Meier; group comparison, by Log-Rank and hazard ratio, by Cox regression. RESULTS: We found statistical differences (p < 0.001) for cumulative survival rate by every geriatric score analyzed (BI HR = 0.98 [0.97,0.99]; KI HR = 1.24 [1.13-1.37]; LBI HR = 1.25 [1.16, 1.36]; PCRS HR = 1.67 [1.37,2.04]). Furthermore, we could determinate an inflection point for survival estimation by Barthel Index (BI 0-55/60-100*, p < 0.001, HR = 2.37 [1.59,3.53]), Katz Index (KI A-B*/C-G, p < 0.001, HR = 2.66 [1.80, 3.93], and Lawton-Brody Index (LBI 0-3/4-8*, p < 0.001, HR = 3.40 [2.09,5.25]). We reveal a correlation of the Charlson Index (p = 0.002) and Katz Index (p = 0.041) with number of readmissions for the study period. CONCLUSIONS: The geriatric scores analyzed are related to the cumulative survival rate after hip fracture surgery for more than 4 years, independently of other clinical and demographic factors. Katz Index in combination with Charlson Index could also be a potential predictor of the number of readmissions after surgery for hip fracture patients.

Autologous mesenchymal stromal cells embedded in tricalcium phosphate for posterolateral spinal fusion: results of a prospective phase I/II clinical trial with long-term follow-up.

BACKGROUND: Posterolateral spinal fusion with autologous bone graft is considered the "gold standard" for lumbar degenerative disc disease (DDD) when surgical treatment is indicated. The potential role of mesenchymal stromal cells (MSCs) to replace the bone graft in this setting has not been fully addressed. OBJECTIVE: To analyze the safety, feasibility and potential clinical efficacy of the implantation of autologous MSCs embedded with tricalcium phosphate as a therapeutic alternative to bone graft in patients with DDD during posterolateral spine fusion. STUDY DESIGN: Phase I/II single-arm prospective clinical trial. METHODS: Eleven patients with monosegmental DDD at L4-L5 or L5-S1 level were included. Autologous bone marrow-derived MSC were expanded in our Good Manufacturing Practice (GMP) Facility and implanted during spinal surgery embedded in a tricalcium phosphate carrier. Monitoring of patients included a postoperative period of 12 months with four visits (after the 1st, 3rd, 6th, and 12th month), with clinical and radiological assessment that included the visual analog scale (VAS), the Oswestry disability index (ODI), the Short-Form Health Survey (SF-36), the vertebral fusion grade observed through a simple Rx, and the evaluation of possible complications or adverse reactions. In addition, all patients were further followed up to 5 years for outcome. RESULTS: Median age of patients included was 44 years (range 30-58 years), and male/female ratio was (6/5) L4-L5 and L5-S1 DDD was present five and six patients, respectively. Autologous MSCs were expanded in all cases. There were no adverse effects related to cell implantation. Regarding efficacy, both VAS and ODI scores improved after surgery. Radiologically, 80% of patients achieved lumbar fusion at the end of the follow-up. No adverse effects related to the procedure were recorded. CONCLUSIONS: The use of autologous MSCs for spine fusion in patients with monosegmental degenerative disc disease is feasible, safe, and potentially effective. TRIAL REGISTRATION: no. EudraCT: 2010-018335-17 ; code Identifier: NCT01513694 ( clinicaltrials.gov ).

Rotenone Induces the Formation of 4-Hydroxynonenal Aggresomes. Role of ROS-Mediated Tubulin Hyperacetylation and Autophagic Flux Disruption.

Oxidative stress causes cellular damage by (i) altering protein stability, (ii) impairing organelle function, or (iii) triggering the formation of 4-HNE protein aggregates. The catabolic process known as autophagy is an antioxidant cellular response aimed to counteract these stressful conditions. Therefore, autophagy might act as a cytoprotective response by removing impaired organelles and aggregated proteins. In the present study, we sought to understand the role of autophagy in the clearance of 4-HNE protein aggregates in ARPE-19 cells under rotenone exposure. Rotenone induced an overproduction of reactive oxygen species (ROS), which led to an accumulation of 4-HNE inclusions, and an increase in the number of autophagosomes. The latter resulted from a disturbed autophagic flux rather than an activation of the autophagic synthesis pathway. In compliance with this, rotenone treatment induced an increase in LC3-II while upstream autophagy markers such as Beclin- 1, Vsp34 or Atg5-Atg12, were decreased. Rotenone reduced the autophagosome-to-lysosome fusion step by increasing tubulin acetylation levels through a ROS-mediated pathway. Proof of this is the finding that the free radical scavenger, N-acetylcysteine, restored autophagy flux and reduced rotenone-induced tubulin hyperacetylation. Indeed, this dysfunctional autophagic response exacerbates cell death triggered by rotenone, since 3-methyladenine, an autophagy inhibitor, reduced cell mortality, while rapamycin, an inductor of autophagy, caused opposite effects. In summary, we shed new light on the mechanisms involved in the autophagic responses disrupted by oxidative stress, which take place in neurodegenerative diseases such as Huntington or Parkinson diseases, and age-related macular degeneration.

Bcl-xL-mediated antioxidant function abrogates the disruption of mitochondrial dynamics induced by LRRK2 inhibition.

We have used the human neuroblastoma cell line SH-SY5Y overexpressing Bcl-xL (SH-SY5Y/Bcl-xL) to clarify the effects of this mitochondrial protein on the control of mitochondrial dynamics and the autophagic processes which occur after the inhibition of leucine-rich repeat kinase 2 (LRRK2) with GSK2578215A. In wild type (SH-SY5Y/Neo) cells, GSK2578215A (1nM) caused a disruption of mitochondrial morphology and an imbalance in intracellular reactive oxygen species (ROS) as indicated by an increase in dichlorofluorescein fluorescence and 4-hydroxynonenal. However, SH-SY5Y/Bcl-xL cells under GSK2578215A treatment, unlike the wild type, preserved a high mitochondrial membrane potential and did not exhibit apoptotical chromatins. In contrast to wild type cells, in SH-SY5Y/Bcl-xL cells, GSK2578215A did not induce mitochondrial translocation of neither dynamin related protein-1 nor the proapoptotic protein, Bax. In SH-SY5Y/Neo, but not SH-SY5Y/Bcl-xL cells, mitochondrial fragmentation elicited by GSK2578215A precedes an autophagic response. Furthermore, the overexpression of Bcl-xL protein restores the autophagic flux pathway disrupted by this inhibitor. SH-SY5Y/Neo, but not SH-SY5Y/Bcl-xL cells, responded to LRRK2 inhibition by an increase in the levels of acetylated tubulin, indicating that this was abrogated by Bcl-xL overexpression. This hyperacetylation of tubulin took place earlier than any of the above-mentioned events suggesting that it is involved in the autophagic flux interruption. Pre-treatment with tempol prevented the GSK2578215A-induced mitochondrial fragmentation, autophagy and the rise in acetylated tubulin in SH-SY5Y/Neo cells. Thus, these data support the notion that ROS act as a second messenger connexion between LRRK2 inhibition and these deleterious responses, which are markedly alleviated by the Bcl-xL-mediated ROS generation blockade.