Medium term results of the cementless Oxford mobile bearing medial unicompartmental knee replacement.

BACKGROUND: Medial Unicompartmental Knee Replacement (UKR) has well-documented benefits over Total Knee Replacement in the treatment of anteromedial osteoarthritis of the knee. There has been an increasing move from cemented to cementless UKR over the last decade. This non-design centre study assesses the initial experience using the cementless Oxford medial partial knee replacement and provides medium term revision data, as well as Patient Reported Outcome Measures (PROMs). METHODS: A cohort of 200 consecutive patients undergoing medial UKR using the cementless Oxford were identified from our knee groups prospectively collected database. Cases were performed in a single centre under the care of one of four surgeons. All patients were beyond the 5-year minimum timepoint following UKR surgery in order to produce medium term results, at a mean of 7.9 years. Eligible patients completed a postal questionnaire to collect PROMs: Oxford Knee Score, WOMAC and modified American Knee Society Score questionnaires in January 2020 and had their clinical records reviewed. RESULTS: The survivorship in our cohort was 94.5% at a mean follow up of 7.9 years following surgery. There were 11 re-operations in total with a three percent risk of re-operation within the first 18 months following surgery. There was a sustained improvement in Oxford Knee Score with a near 20 points improvement on pre-operative scores. CONCLUSIONS: Our results provide further evidence that partial knee replacements using the cementless Oxford produce good clinical outcomes. Revision rates are similar to those published in the National Joint Registry. LEVEL OF EVIDENCE: III.

De novo donor-specific antibodies in belatacept-treated vs cyclosporine-treated kidney-transplant recipients: Post hoc analyses of the randomized phase III BENEFIT and BENEFIT-EXT studies.

Donor-specific antibodies (DSAs) are associated with an increased risk of antibody-mediated rejection and graft failure. In BENEFIT and BENEFIT-EXT, kidney-transplant recipients were randomized to receive belatacept more intense (MI)-based, belatacept less intense (LI)-based, or cyclosporine-based immunosuppression for up to 7 years (84 months). The presence/absence of HLA-specific antibodies was determined at baseline, at months 6, 12, 24, 36, 48, 60, and 84, and at the time of clinically suspected episodes of acute rejection, using solid-phase flow-cytometry screening. Samples from anti-HLA-positive patients were further tested with a single-antigen bead assay to determine antibody specificities, presence/absence of DSAs, and mean fluorescence intensity (MFI) of any DSAs present. In BENEFIT, de novo DSAs developed in 1.4%, 3.5%, and 12.1% of belatacept MI-treated, belatacept LI-treated, and cyclosporine-treated patients, respectively. The corresponding values in BENEFIT-EXT were 3.8%, 1.1%, and 11.2%. Per Kaplan-Meier analysis, de novo DSA incidence was significantly lower in belatacept-treated vs cyclosporine-treated patients over 7 years in both studies (P < .01). In patients who developed de novo DSAs, belatacept-based immunosuppression was associated with numerically lower MFI vs cyclosporine-based immunosuppression. Although derived post hoc, these data suggest that belatacept-based immunosuppression suppresses de novo DSA development more effectively than cyclosporine-based immunosuppression.

Posttransplant reduction in preexisting donor-specific antibody levels after belatacept- versus cyclosporine-based immunosuppression: Post hoc analyses of BENEFIT and BENEFIT-EXT.

BENEFIT and BENEFIT-EXT were phase III studies of cytotoxic T-cell crossmatch-negative kidney transplant recipients randomized to belatacept more intense (MI)-based, belatacept less intense (LI)-based, or cyclosporine-based immunosuppression. Following study completion, presence/absence of HLA-specific antibodies was determined centrally via solid-phase flow cytometry screening. Stored sera from anti-HLA-positive patients were further tested with a single-antigen bead assay to determine antibody specificities, presence/absence of donor-specific antibodies (DSAs), and mean fluorescent intensity (MFI) of any DSAs present. The effect of belatacept-based and cyclosporine-based immunosuppression on MFI was explored post hoc in patients with preexisting DSAs enrolled to BENEFIT and BENEFIT-EXT. In BENEFIT, preexisting DSAs were detected in 4.6%, 4.9%, and 6.3% of belatacept MI-treated, belatacept LI-treated, and cyclosporine-treated patients, respectively. The corresponding values in BENEFIT-EXT were 6.0%, 5.7%, and 9.2%. In both studies, most preexisting DSAs were of class I specificity. Over the first 24 months posttransplant, a greater proportion of preexisting DSAs in belatacept-treated versus cyclosporine-treated patients exhibited decreases or no change in MFI. MFI decline was more apparent with belatacept MI-based versus belatacept LI-based immunosuppression in both studies and more pronounced in BENEFIT-EXT versus BENEFIT. Although derived post hoc, these data suggest that belatacept-based immunosuppression decreases preexisting DSAs more effectively than cyclosporine-based immunosuppression.

Is cestode infection intensity associated with decreased body condition in the Eurasian woodcock Scolopax rusticola?

The Eurasian woodcock Scolopax rusticola is a widespread woodland specialist and a widely harvested quarry species throughout its European wintering areas, including Britain. Woodcock are prone to cestodiasis, but prevalence levels and possible effects on body condition remain under-studied. We studied the prevalence, abundance and intensity of cestodiasis in 161 woodcock harvested in four British regions in December and January during two consecutive winters (2013/14 and 2014/15). Cestodiasis prevalence was 90%, and there was no difference in prevalence between birds harvested in Cornwall, Wessex, East Anglia and Scotland. High prevalence levels were explained by the fact that earthworms (Lumbricidae) are intermediate hosts for some cestode species and also the most important dietary component of woodcock. The distribution of cestodiasis in woodcock was aggregated, such that when using the total length of cestodes per sample to measure abundance, 65% of the birds had less than 80 cm. Cestodiasis abundance varied between sexes across regions but the intensity was not affected by region, sex, age or their interactions. The intensity of cestodiasis was positively correlated with fresh weight and pectoral mass, while no significant correlation was found with the abdominal fat pad. Our results suggest that, despite high prevalence levels and intensity of cestodiasis in woodcock, host body condition is not significantly affected and hence it is unlikely that cestodiasis has a major effect on woodcock population dynamics.

Monorchis lewisi n. sp. (Trematoda: Monorchiidae) from the surf bream, Acanthopagrus australis (Sparidae), in Moreton Bay, Australia.

We describe Monorchis lewisi n. sp. (Monorchiidae) from the surf bream, Acanthopagrus australis (Günther, 1859) (Sparidae), in Moreton Bay, eastern Australia. The new species differs from most existing species of Monorchis Monticelli, 1893 in its possession of an elongate I-shaped excretory vesicle, and from other congeners in the relative configuration of the gut and suckers. Ovipusillus mayu Dove & Cribb, 1998 is re-reported from Gnathanodon speciosus (Forsskål, 1775) (Carangidae) from Moreton Bay. We report new second internal transcribed spacer (ITS2) and 28S rDNA sequence data for both species. Bayesian inference and Maximum Likelihood analyses of the 28S rDNA dataset suggest that existing subfamily and genus concepts within the family require substantial revision.

The decrease in population bone lead levels in Canada between 1993 and 2010 as assessed by in vivo XRF.

Objective and Approach: A study, conducted in Toronto, Canada, between 2009 and 2011, measured the bone lead concentrations of volunteers aged 1-82 years using in vivo x-ray fluorescence (XRF) technology. MAIN RESULTS: Bone lead levels were lower compared to Ontario in vivo XRF studies from the early 1990s. In adults, the slope of tibia lead content versus age was reduced by 36-56%, i.e. bone lead levels for a given age group were approximately half compared to the same age group 17 years prior. Further, bone lead levels of individuals fell over that time period. In 2010, an average person aged 57 years had a bone lead level approximately 1/3 less than their bone lead level age 40 years in 1993. Using this data, the half-lives of lead in the tibia were estimated as 7-26 years. Tibia lead levels were found to be low in children. The reduction in bone tibia content in children was not significant (p = 0.07), but using data from additional north eastern US studies, there is evidence that childhood tibia stores are lower than in the 1990s. SIGNIFICANCE: In vivo XRF analysis shows that there has been a reduction in the level of lead in bone in Canada over the last two decades. Public health measures have been very successful in reducing ongoing exposure to lead and in reducing bone lead stores.

Did biogeographical processes shape the monogenean community of butterflyfishes in the tropical Indo-west Pacific region?

Geographical distribution of parasite species can provide insights into the evolution and diversity of parasitic communities. Biogeography of marine parasites is poorly known, especially because it requires an understanding of host-parasite interactions, information that is rare, especially over large spatial scales. Here, we have studied the biogeographical patterns of dactylogyrid parasites of chaetodontids, one of the most well-studied fish families, in the tropical Indo-west Pacific region. Dactylogyrid parasites were collected from gills of 34 butterflyfish species (n=560) at nine localities within an approximate area of 62millionkm2. Thirteen dactylogyrid species were identified, with richness ranging from 6 to 12 species at individual localities. Most dactylogyrid communities were dominated by Haliotrema angelopterum or Haliotrema aurigae, for which relative abundance was negatively correlated (ρ=-0.59). Parasite richness and diversity were highest in French Polynesia and the Great Barrier Reef (Australia) and lowest in Palau. Three biogeographic regions were identified based on dactylogyrid dissimilarities: French Polynesia, characterised by the dominance of H. angelopterum, the western Pacific region dominated by H. aurigae, and Ningaloo Reef (Australia), dominated by Euryhaliotrema berenguelae. Structure of host assemblages was the main factor explaining the dissimilarity (turnover and nestedness components of the Bray-Curtis dissimilarity and overall Bray-Curtis dissimilarity) of parasite communities between localities, while environment was only significant in the turnover of parasite communities and overall dissimilarity. Spatial structure of localities explained only 10% of the turnover of parasite communities. The interaction of the three factors (host assemblages, environment and spatial structure), however, explained the highest amounts of variance of the dactylogyrid communities, indicating a strong colinearity between the factors. Our findings show that spatial arrangement of chaetodontid dactylogyrids in the tropical Indo-west Pacific is primarily characterised by the turnover of the main Haliotrema spp., which is mainly explained by the structure of host assemblages.

The Road to HLA Antibody Evaluation: Do Not Rely on MFI.

Technological advances in HLA laboratory testing undoubtedly improved the sensitivity and specificity of HLA antibody assessment but not without introducing a set of challenges regarding data interpretation. In particular, the introduction of solid-phase single-antigen bead (SAB) antibody assessment brought the belief that mean fluorescence intensity (MFI) was a quantifiable value. As such, MFI levels heavily influenced HLA antibody reporting, monitoring, and clinical practice. However, given that SAB testing was neither intended for nor approved to be quantifiable, is the use of MFI in current clinical and laboratory practice valid? What, if anything, does this numerical value actually reveal about the pathogenic potential of the antibody? What are the pitfalls and caveats associated with reporting MFI? Herein, we travel the road to HLA antibody assessment and explore the reliability of MFI values to make clinical decisions.

Three new species of blood flukes (Digenea: Aporocotylidae) infecting pufferfishes (Teleostei: Tetraodontidae) from off Bali, Indonesia.

We describe three new species of blood flukes (Aporocotylidae) and propose their classification within the genus Psettarium Goto & Ozaki, 1929. All three species were collected from the circulatory systems of pufferfishes caught off Bali, central Indonesia. Psettarium pulchellum n. sp. was found in the gills of both the narrow-lined puffer (Arothron manilensis de Procé) and the spiny blaasop (Tylerius spinosissimus Regan), while P. ogawai n. sp. and P. jimbaranense n. sp. were found in the gills of the reticulated puffer (Arothron reticularis Bloch & Schneider). The morphological characteristics of these taxa necessitated emendation of the diagnosis for the genus Psettarium, to accommodate the presence of an oral sucker, multiple or entirely post-caecal testes and a degenerate posterior testis. Features such as proportion of body length occupied by the oesophagus, and posterior caeca being ≥7× the length of anterior caeca, are no longer regarded as useful genus-level characters. Additionally, Sasala nolani is reassigned to this genus as Psettarium nolani n. comb. In phylogenetic analyses of the 28S and ITS2 rDNA regions, all three new taxa form a well-supported clade, together with Psettarium sinense and Psettarium nolani n. comb., the two other species of tetraodontid-infecting aporocotylids for which comparative rDNA data were available. The short branch lengths within this clade, despite dramatic morphological differences between the five species, suggest that rapid morphological diversification has occurred among the tetraodontid-infecting aporocotylids. The genus Psettarium has long been considered problematic. Further commentary is given on the history of this genus and how the issues presented might be resolved.

Apolipoprotein L1 gene variants in deceased organ donors are associated with renal allograft failure.

Apolipoprotein L1 gene (APOL1) nephropathy variants in African American deceased kidney donors were associated with shorter renal allograft survival in a prior single-center report. APOL1 G1 and G2 variants were genotyped in newly accrued DNA samples from African American deceased donors of kidneys recovered and/or transplanted in Alabama and North Carolina. APOL1 genotypes and allograft outcomes in subsequent transplants from 55 U.S. centers were linked, adjusting for age, sex and race/ethnicity of recipients, HLA match, cold ischemia time, panel reactive antibody levels, and donor type. For 221 transplantations from kidneys recovered in Alabama, there was a statistical trend toward shorter allograft survival in recipients of two-APOL1-nephropathy-variant kidneys (hazard ratio [HR] 2.71; p = 0.06). For all 675 kidneys transplanted from donors at both centers, APOL1 genotype (HR 2.26; p = 0.001) and African American recipient race/ethnicity (HR 1.60; p = 0.03) were associated with allograft failure. Kidneys from African American deceased donors with two APOL1 nephropathy variants reproducibly associate with higher risk for allograft failure after transplantation. These findings warrant consideration of rapidly genotyping deceased African American kidney donors for APOL1 risk variants at organ recovery and incorporation of results into allocation and informed-consent processes.

Should HLA mismatch acceptability for sensitized transplant candidates be determined at the high-resolution rather than the antigen level?

Defining HLA mismatch acceptability of organ transplant donors for sensitized recipients has traditionally been based on serologically defined HLA antigens. Now, however, it is well accepted that HLA antibodies specifically recognize a wide range of epitopes present on HLA antigens and that molecularly defined high resolution alleles corresponding to the same low resolution antigen can possess different epitope repertoires. Hence, determination of HLA compatibility at the allele level represents a more accurate approach to identify suitable donors for sensitized patients. This approach would offer opportunities for increased transplant rates and improved long term graft survivals.

Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report.

Vascularized composite allotransplantation (VCA) has emerged as a viable limb replacement strategy for selected patients with upper limb amputation. However, allograft rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy. Calcineurin inhibitors have served as the centerpiece agent in all reported cases, and CNI-associated complications associated with the broad therapeutic effects and side effects of calcineurin inhibitors have been similarly common. Recently, belatacept has been approved as a calcineurin inhibitor replacement in kidney transplantation, but to date, its use in VCA has not been reported. Herein, we report on the case of a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant calcineurin inhibitor nephrotoxicity, all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. This case indicates that belatacept may be a reasonable maintenance immunosuppressive alternative for use in VCA, providing sufficient prophylaxis from rejection with a reduced side effect profile, the latter being particularly relevant for nonlife threatening conditions typically treated by VCA.

HLA antibody detection with solid phase assays: great expectations or expectations too great?

Alloantibodies directed against HLA antigens, are a barrier to long-term solid organ allograft survival. The clinical impact of preformed, donor-directed HLA alloantibodies range from acceptable risk to unequivocal contraindication for organ transplantation. HLA antibodies are key factors that limit patient access to donor organs. Serological methods were once the only approach to identify HLA antigens and antibodies. Limitations in these technologies led to the development of solid phase approaches. In the early 1990s, the development of the polymerase chain reaction enabled DNA-based HLA antigen testing to be performed. By the mid-1990s, microparticle-based technology that utilized flow cytometry for analysis was developed to detect both classes I and II HLA antibodies. These methodologies revolutionized clinical histocompatibility testing. The strengths and weaknesses of these assays are described in detail in this review.

Solid-phase assays for the detection of alloantibody against human leukocyte antigens: panacea or Pandora?

Serological assessments of antibodies directed against human leucocyte antigens (HLA) formed the basis of early histocompatibility testing (Patel & Terasaki, 1969 N Engl J Med, 280, 735). However, over the past decade, significant advances in HLA antibody detection technologies have emerged. The development and implementation of solid-phase assays has led to safer and more efficient allocation of organs by effectively distinguishing HLA from non-HLA antibodies. Although solid-phase assays are not standardized, they are widely accepted as the new 'gold standard'. However, this technology is not without its challenges. This review is intended to provide a better understanding of solid-phase HLA antibody testing and will focus on important caveats associated with this evolving technology. Examples of the limitations of the technology as well as common data misinterpretations will be shown. Both of which could pose potential harm to transplant recipients (Tait et al., Transplantation, 95, 19).

New digeneans (Opecoelidae) from hydrothermal vent fishes in the south eastern Pacific Ocean, including one new genus and five new species.

A new genus and five new species of digeneans are reported from fishes at hydrothermal vent sites in the South East Pacific Rise region. Biospeedotrema n. gen. (Opecoelidae: Stenakrinae) is distinguished from other stenakrines by the more or less symmetrical testicular configuration, with the uterus passing between the testes, sometimes distinctly into the post-testicular region. Biospeedotrema jolliveti n. gen., n. sp. from Ventichthys biospeedoi (Ophidiidae) is distinguished by the vitelline fields which extend only slightly into the post-testicular region, the intestinal bifurcation is dorsal to the ventral sucker, the genital pore is slightly dextrally submedian or median, the cirrus sac is short and the caeca are broad and overlap the testes, usually reaching into the post-testicular region. Biospeedotrema parajolliveti n. sp. from Thermichthys hollisi differs from Biospeedotrema jolliveti in being squat, always just wider than long, the tegument is wrinkled, the testes are lobate, and the caeca only just reach to the testes. Biospeedotrema biospeedoi n. sp. from T. hollisi differs from its congeners in its body-shape, uterine extent posterior to the testes and the small vitellarium. Caudotestis ventichthysi n. sp. (Opecoelidae: Stenakrinae) from V. biospeedoi is distinguished from its five congeners in various combinations of caecal length, cirrus sac length, internal seminal vesicle shape, vitelline extent and distribution, forebody length and egg-size. Buticulotrema thermichthysi n. sp. (Opecoelidae: Opecoelininae) from T. hollisi (Bythitidae) is distinguished from its only congener by its very long, very strongly muscular oesophagus, bifurcating dorsally to the posterior part of the ventral sucker, the long, narrow pars prostatica and distal male duct and the sinistral genital pore at the level of the pharynx. The phylogenetic position for three of these species, Buticulotrema thermichthysi, Biospeedotrema jolliveti and Biospeedotrema biospeedoi, is assessed based on ssrDNA and lsrDNA sequences, which verify the position of these species in the Opecoelidae. 

Renal transplantation using belatacept without maintenance steroids or calcineurin inhibitors.

Kidney transplantation remains limited by toxicities of calcineurin inhibitors (CNIs) and steroids. Belatacept is a less toxic CNI alternative, but existing regimens rely on steroids and have higher rejection rates. Experimentally, donor bone marrow and sirolimus promote belatacept's efficacy. To investigate a belatacept-based regimen without CNIs or steroids, we transplanted recipients of live donor kidneys using alemtuzumab induction, monthly belatacept and daily sirolimus. Patients were randomized 1:1 to receive unfractionated donor bone marrow. After 1 year, patients were allowed to wean from sirolimus. Patients were followed clinically and with surveillance biopsies. Twenty patients were transplanted, all successfully. Mean creatinine (estimated GFR) was 1.10 ± 0.07 mg/dL (89 ± 3.56 mL/min) and 1.13 ± 0.07 mg/dL (and 88 ± 3.48 mL/min) at 12 and 36 months, respectively. Excellent results were achieved irrespective of bone marrow infusion. Ten patients elected oral immunosuppressant weaning, seven of whom were maintained rejection-free on monotherapy belatacept. Those failing to wean were successfully maintained on belatacept-based regimens supplemented by oral immunosuppression. Seven patients declined immunosuppressant weaning and three patients were denied weaning for associated medical conditions; all remained rejection-free. Belatacept and sirolimus effectively prevent kidney allograft rejection without CNIs or steroids when used following alemtuzumab induction. Selected, immunologically low-risk patients can be maintained solely on once monthly intravenous belatacept.