The efficacy of onabotulinumtoxinA in patients with previous failed augmentation cystoplasty: Cohort series and literature review

AIMS

To investigate the role of onabotulinumtoxinA (BTX-A) injections in patients with failed augmentation cystoplasty for neuropathic or idiopathic detrusor overactivity (NDO or IDO).

METHODS

A retrospective review of all cystoplasty patients who underwent onabotulinumtoxinA injection at a tertiary center between 2008 and 2019 was performed. Details including indications and time from cystoplasty, video-urodynamic parameters, onabotulinumtoxinA dose, and clinical outcomes were analyzed. Telephone interview was performed for patients that requested repeat onabotulinumtoxinA injections. The interview included a modified PGIC7 and UDI6 questionnaires. A positive clinical response was considered improvement of overactive symptoms sufficient to merit repeat onabotulinumtoxinA injection and a modified PGIC7 of four or above.

RESULTS

Thirty patients were identified (11 men and 19 women). The indications for augmentation were IDO (n = 18) or NDO (n = 12). Mean age at the time of cystoplasty was 42 years (range, 10-61). Interval between cystoplasty and initial onabotulinumtoxinA was 98 months (range, 3-271). Video-urodynamics before onabotulinumtoxinA revealed low compliance in 13 patients, DO in 22 patients, and combined low compliance/DO in 10. The median maximum cystometric bladder capacity was 338 mL (range, 77-570 mL). Thirteen patients responded to onabotulinumtoxinA injections. Higher peak DO pressure was associated with a significantly higher chance that the patient would experience benefit from the injections P = .026). The patients that responded to onabotulinumtoxin A underwent a total of 115 procedures (mean, 8.8 injections) over a mean 88 months (range, 20-157 months).

CONCLUSIONS

Forty-three percent of patients responded well to intra-detrusor onabotulinumtoxinA injections. This avoided the need for more invasive surgery and had a positive impact on their quality of life.

Augmentation of Meniscal Repair With Platelet-Rich Plasma: A Systematic Review of Comparative Studies

Background:

The effect of platelet-rich plasma (PRP) augmentation for meniscal repair (MR) is unclear, as current evidence is limited to small, mostly nonrandomized studies.

Purpose:

To systematically review the literature to evaluate the efficacy and safety of MR with PRP augmentation.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies (level of evidence 1-3) that compared the clinical efficacy of MR performed with versus without PRP. The search phrase used was platelet-rich plasma meniscus. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the visual analog scale (VAS) for pain, the Lysholm score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the subjective International Knee Documentation Committee (IKDC) score, and treatment failure.

Results:

We identified 6 studies (2 studies with level 1 evidence; 4 studies with level 3 evidence) that met inclusion criteria, for a total of 309 patients undergoing MR with PRP (mean age, 31.9 years) and 445 patients without PRP augmentation (mean age, 29.6 years). The mean follow-up was 32.8 months (range, 12-72 months). Overall, 17.0% of PRP patients experienced MR failure compared with 22.1% of non-PRP patients. No differences in VAS, Lysholm, or subjective IKDC scores were found between groups except in 1 study, in which postoperative subjective IKDC scores were significantly better in the PRP group (P < .01). Another study found significantly better postoperative WOMAC scores among PRP patients, and 2 studies found significantly better KOOS subscores among PRP patients.

Conclusion:

There are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing MR with versus without PRP augmentation. Based on the available evidence, patients undergoing MR with PRP augmentation experience similar clinical outcomes at midterm follow-up when compared with conventional MR, and additional studies are needed to determine the efficacy of MR augmented with PRP.

Augmentation of labor with oxytocin and its association with delivery outcomes: A large-scale cohort study in 12 public hospitals in Nepal

INTRODUCTION

The use of oxytocin to augment labor is increasing in many low-resource settings; however, little is known about the effects of such use in contexts where resources for intrapartum monitoring are scarce. In this study, we sought to assess the association between augmentation of labor with oxytocin and delivery outcomes.

MATERIAL AND METHODS

We conducted a cohort study in 12 public hospitals in Nepal, including all deliveries with and without augmentation of labor with oxytocin, but excluding elective cesarean sections, women with missing information on augmentation of labor, and women without fetal heart rate on admission. Bivariate and multivariate logistic regression calculating the crude and adjusted risk ratio (aRR) with corresponding 95% CI were performed, comparing (a) intrapartum stillbirth and first-day mortality (primary outcome); and (b) intrapartum monitoring, mode of delivery, postpartum hemorrhage, bag-and-mask ventilation of the newborn, Apgar score, and neonatal death before discharge (secondary outcomes) among women with and without oxytocin-augmented labor.

RESULTS

The total cohort consisted of 78 931 women, of whom 28 915 (37%) had labor augmented with oxytocin and 50 016 (63%) did not have labor augmented with oxytocin. Women with augmentation of labor had no increased risk of intrapartum stillbirth and first-day mortality (aRR 1.24, 95% CI 0.65-2.4), but decreased risks of suboptimal partograph use (aRR 0.71, 95% CI 0.68-0.74), suboptimal fetal heart rate monitoring (aRR 0.50, 95% CI 0.48-0.53), and emergency cesarean section (aRR 0.62, 95% CI 0.59-0.66), and increased risks of bag-and-mask ventilation (aRR 2.1, 95% CI 1.8-2.5), Apgar score <7 at 5 minutes (aRR 1.65, 95% CI 1.49-1.86), and neonatal death (aRR 1.93, 95% CI 1.46-2.56).

CONCLUSIONS

Although augmentation of labor with oxytocin might be associated with beneficial effects, such as improved monitoring and a decreased risk of cesarean section, its use may lead to an increased risk of adverse perinatal outcomes. We urge for a cautious use of oxytocin to augment labor in low-resource contexts, and call for evidence-based guidelines on augmentation of labor in low-resource settings.

Autologous Fat Augmentation in the Treatment of Unilateral Vocal Fold Paralysis - A 15-year Experience in a Single Institution

Autologous fat vocal fold augmentation is a widespread surgical procedure that aims to repair glottal incompetence in patients with unilateral vocal fold paralysis (UVFP). However, there are some concerns in the literature about the long-term results of this technique. At the ENT Department of the Zagreb University Hospital Centre, this technique has been in use for more than 15 years, and a retrospective medical chart review was conducted from June 2005 to November 2019. Overall, 78 patients with UVFP met the inclusion criteria for enrolment in the study. All patients underwent at least one preoperative and two postoperative voice assessments, one early (within 3 months from surgery) and one late (at least 1 year after surgery). All tested voice outcome parameters (maximum phonation time (MPT), jitter, shimmer, noise-to-harmonic ratio (NHR)) significantly improved after surgery, both early and late postoperatively (p<0.001). The reoperation rate was only 10.3% (8/78), with the majority of patients in our series experiencing long-term benefits from this surgical procedure. According to the results of our study, autologous fat vocal fold augmentation appears to be a highly useful and effective surgical technique with long-lasting results in the majority of patients suffering from UVFP.

Weakly Labeled Data Augmentation for Deep Learning: A Study on COVID-19 Detection in Chest X-Rays

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a pandemic resulting in over 2.7 million infected individuals and over 190,000 deaths and growing. Assertions in the literature suggest that respiratory disorders due to COVID-19 commonly present with pneumonia-like symptoms which are radiologically confirmed as opacities. Radiology serves as an adjunct to the reverse transcription-polymerase chain reaction test for confirmation and evaluating disease progression. While computed tomography (CT) imaging is more specific than chest X-rays (CXR), its use is limited due to cross-contamination concerns. CXR imaging is commonly used in high-demand situations, placing a significant burden on radiology services. The use of artificial intelligence (AI) has been suggested to alleviate this burden. However, there is a dearth of sufficient training data for developing image-based AI tools. We propose increasing training data for recognizing COVID-19 pneumonia opacities using weakly labeled data augmentation. This follows from a hypothesis that the COVID-19 manifestation would be similar to that caused by other viral pathogens affecting the lungs. We expand the training data distribution for supervised learning through the use of weakly labeled CXR images, automatically pooled from publicly available pneumonia datasets, to classify them into those with bacterial or viral pneumonia opacities. Next, we use these selected images in a stage-wise, strategic approach to train convolutional neural network-based algorithms and compare against those trained with non-augmented data. Weakly labeled data augmentation expands the learned feature space in an attempt to encompass variability in unseen test distributions, enhance inter-class discrimination, and reduce the generalization error. Empirical evaluations demonstrate that simple weakly labeled data augmentation (Acc: 0.5555 and Acc: 0.6536) is better than baseline non-augmented training (Acc: 0.2885 and Acc: 0.5028) in identifying COVID-19 manifestations as viral pneumonia. Interestingly, adding COVID-19 CXRs to simple weakly labeled augmented training data significantly improves the performance (Acc: 0.7095 and Acc: 0.8889), suggesting that COVID-19, though viral in origin, creates a uniquely different presentation in CXRs compared with other viral pneumonia manifestations.

Capsular contracture in patients with prior breast augmentation undergoing breast conserving therapy and irradiation

Radiation is considered to be a risk factor for developing capsular contracture in augmented women, but the studies reporting on this subject show conflicting results. In this systematic review we sought to understand the risk of capsular contracture in augmented patients with breast cancer treated with breast conserving surgery and radiotherapy. A search was conducted through PubMed for studies reporting on breast cancer, breast augmentation and radiotherapy, with capsular contracture as our primary outcome. To determine if specific risk factors were significant predictors of the development of capsular contracture, we performed uni- and multivariate analysis. Our search revealed 136 articles, of which 12 were deemed eligible. A total of 237 patients were included in the analysis. Univariate analysis revealed that whole breast irradiation (WBI) was significantly associated with a higher risk of contracture (p < .001), compared to treatment with accelerated partial breast irradiation (APBI). A higher radiotherapy dose regimen was also significantly associated with a risk of capsular contracture (p < .001). When performing the multivariate analysis only the effect of increasing radiation dose remained significant (p < .05). Neither the implant location nor the age of the implant had any significant effect on the development of contracture. In conclusion this review shows that WBI is associated with a higher risk of contracture compared to treatment with APBI. Because of the limitations of the studies included, further studies with larger patient cohorts are needed to establish this correlation and evaluate other potential risk factors.

Training deep learning algorithms with weakly labeled pneumonia chest X-ray data for COVID-19 detection

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has caused a pandemic resulting in over 2.7 million infected individuals and over 190,000 deaths and growing. Respiratory disorders in COVID-19 caused by the virus commonly present as viral pneumonia-like opacities in chest X-ray images which are used as an adjunct to the reverse transcription-polymerase chain reaction test for confirmation and evaluating disease progression. The surge places high demand on medical services including radiology expertise. However, there is a dearth of sufficient training data for developing image-based automated decision support tools to alleviate radiological burden. We address this insufficiency by expanding training data distribution through use of weakly-labeled images pooled from publicly available CXR collections showing pneumonia-related opacities. We use the images in a stage-wise, strategic approach and train convolutional neural network-based algorithms to detect COVID-19 infections in CXRs. It is observed that weakly-labeled data augmentation improves performance with the baseline test data compared to non-augmented training by expanding the learned feature space to encompass variability in the unseen test distribution to enhance inter-class discrimination, reduce intra-class similarity and generalization error. Augmentation with COVID-19 CXRs from individual collections significantly improves performance compared to baseline non-augmented training and weakly-labeled augmentation toward detecting COVID-19 like viral pneumonia in the publicly available COVID-19 CXR collections. This underscores the fact that COVID-19 CXRs have a distinct pattern and hence distribution, unlike non-COVID-19 viral pneumonia and other infectious agents.

Synthetic Bone Substitutes and Mechanical Devices for the Augmentation of Osteoporotic Proximal Humeral Fractures: A Systematic Review of Clinical Studies

BACKGROUND

Different augmentation techniques have been described in the literature in addition to the surgical treatment of proximal humeral fractures. The aim of this systematic review was to analyze the use of cements, bone substitutes, and other devices for the augmentation of proximal humeral fractures.

METHODS

A systematic review was conducted by using PubMed/MEDLINE, ISI Web of Knowledge, Cochrane Library, Scopus/EMBASE, and Google Scholar databases according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines over the years 1966 to 2019. The search term "humeral fracture proximal" was combined with "augmentation"; "polymethylmethacrylate, PMMA"; "cement"; "bone substitutes"; "hydroxyapatite"; "calcium phosphates"; "calcium sulfate"; "cell therapies", and "tissue engineering" to find the literature relevant to the topic under review.

RESULTS

A total of 10 clinical studies considered eligible for the review, with a total of 308 patients, were included. Mean age at the time of injury was 68.8 years (range of 58-92). The most commonly described techniques were reinforcing the screw-bone interface with bone PMMA cement (three studies), filling the metaphyseal void with synthetic bone substitutes (five studies), and enhancing structural support with metallic devices (two studies).

CONCLUSION

PMMA cementation could improve screw-tip fixation. Calcium phosphate and calcium sulfate injectable composites provided good biocompatibility, osteoconductivity, and lower mechanical failure rate when compared to non-augmented fractures. Mechanical devices currently have a limited role. However, the available evidence is provided mainly by level III to IV studies, and none of the proposed techniques have been sufficiently studied.

Augmentation of Tendon Graft-Bone Tunnel Interface Healing by Use of Bioactive Platelet-Rich Fibrin Scaffolds

BACKGROUND

Platelet-rich fibrin (PRF) is a bioactive biomaterial wherein cytokines are enmeshed within the interconnecting fibrin network. PRF can be fabricated into a patch to augment healing of the interface between a tendon graft and bone tunnel.

HYPOTHESIS

The bioactivity of a PRF scaffold is preserved after PRF is mechanically compressed into a patch. A bioactive PRF patch could promote the incorporation of a tendon graft within the bone tunnel through the formation of a tendon-bone healing zone composed of both fibrocartilaginous tissue and new bone.

STUDY DESIGN

Controlled laboratory study.

METHODS

Bioactivity of PRF was evaluated through treatment of rabbit tenocytes with PRF-conditioned medium and cultivation of cells on a PRF patch. Cellular morphologic features, viability, and differentiation were analyzed accordingly. In an animal study, a rabbit tendon-bone healing model was established through use of New Zealand White rabbits. The implanted tendon graft was enveloped circumferentially with a bioactive PRF patch before being pulled through a bone tunnel in the proximal tibia. Micro-computed tomography (micro-CT) imaging and histological and biomechanical analyses of the tendon-bone interface were performed at 12 weeks postoperatively.

RESULTS

PRF improved the viability of the cultured tenocytes. The effects of PRF on in vitro mineralization of tenocytes were comparable with the effects of standard culture medium. The gene expressions of type I collagen and osteopontin were upregulated upon PRF treatment. For the in vivo study, micro-CT images revealed significant new bone synthesis at the tendon-bone interface in the PRF-enveloped group. The tendon-bone healing zone was characterized by abundant fibrocartilage tissue and new bone formation as demonstrated by histological analysis. Biomechanical testing showed significantly higher ultimate loads in the PRF-enveloped group.

CONCLUSION

Bioactive PRF could effectively augment healing of tendon graft to bone by inducing the formation of a transitional tendon-bone healing zone composed of fibrocartilage and bone.

CLINICAL RELEVANCE

Complete healing of the tendon graft in the bone tunnel is a prerequisite for successful ligament reconstruction, which would allow early and aggressive rehabilitation and rapid return to preinjury activity level. From a translational standpoint, the PRF-augmented healing in this rabbit animal model showed a promising biological approach to enhance tendon graft to bone healing via promotion of the functional anchorage between the 2 different materials.

Platelet-Rich Plasma Augmentation to Microfracture Provides a Limited Benefit for the Treatment of Cartilage Lesions: A Meta-analysis

Background:

Microfracture is the most common first-line option for the treatment of small chondral lesions, although increasing evidence shows that the clinical benefit of microfracture decreases over time. Platelet-rich plasma (PRP) has been suggested as an effective biological augmentation to improve clinical outcomes after microfracture.

Purpose:

To evaluate the clinical evidence regarding the application of PRP, documenting safety and efficacy of this augmentation technique to improve microfracture for the treatment of cartilage lesions.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review was performed in PubMed, EBSCOhost database, and the Cochrane Library to identify comparative studies evaluating the clinical efficacy of PRP augmentation to microfracture. A meta-analysis was performed on articles that reported results for visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC), and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Risk of bias was documented through use of the Cochrane Collaboration Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions assessment tools. The quality assessment was performed according to the Grading of Recommendations Assessment, Development and Evaluation guidelines.

Results:

A total of 7 studies met the inclusion criteria and were included in the meta-analysis: 4 randomized controlled trials, 2 prospective comparative studies, and 1 retrospective comparative study, for a total of 234 patients. Of the 7 studies included, 4 studies evaluated the effects of PRP treatment in the knee, and 3 studies evaluated effects in the ankle. The analysis of all scores showed a difference favoring PRP treatment in knees (VAS, P = .002 and P < .001 at 12 and 24 months, respectively; IKDC, P < .001 at both follow-up points) and ankles (both VAS and AOFAS, P < .001 at 12 months). The improvement offered by PRP did not reach the minimal clinically important difference (MCID).

Conclusion:

PRP provided an improvement to microfracture in knees and ankles at short-term follow-up. However, this improvement did not reach the MCID, and thus it was not clinically perceivable by the patients. Moreover, the overall low evidence and the paucity of high-level studies indicate further research is needed to confirm the potential of PRP augmentation to microfracture for the treatment of cartilage lesions.

Comparison of Clinical Outcomes between Hyaluronic and Polylactic Acid Filler Injections for Penile Augmentation in Men Reporting a Small Penis: A Multicenter, Patient-Blinded/Evaluator-Blinded, Non-Inferiority, Randomized Comparative Trial with 18 Months of Follow-up

Although several types of penile augmentation (PA) fillers have been recently introduced, no long-term follow-up studies have compared them. This study aimed to compare the long-term clinical outcomes of hyaluronic acid (HA) and polylactic acid (PLA) filler injections for PA. Our multicenter, patient-blinded/evaluator-blinded, randomized comparative trial was performed for 18 months after the single injection of fillers. Sixty-seven healthy men reporting a small penis were administered an injection between November 2016 and May 2017. Subjects were divided into the HA group (n = 33) and PLA group (n = 34). At 18 months, the mean penile girths had significantly increased in both groups (each p < 0.001). Changes in the mean penile girth of both groups were not significantly different during the study period. Satisfaction levels at 18 months were significantly higher than those at baseline in both groups (each p < 0.01). Changes in satisfaction levels did not differ significantly during the study period. Injection-associated adverse events (AEs) occurred in three (9.1%) patients in the HA group and in two (5.9%) patients in the PLA group; no serious AEs occurred. In conclusion, HA and PLA filler injections for PA led to significant augmentation and increased satisfaction. Clinical efficacy and safety were comparable between groups.

Emerging Concepts of the Pathophysiology and Adverse Outcomes of Restless Legs Syndrome

Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is a common neurological disorder affecting up to 5% to 10% of the population, but it remains an underdiagnosed condition. RLS/WED is characterized by uncomfortable sensations, mainly in the legs, which appear during inactivity and worsen in the evening or at night. The prevalence of RLS/WED and periodic leg movements (PLMs) is increased in patients with sleep-disordered breathing, particularly in those with OSA, the most common sleep disorder encountered in sleep centers. New advances in the pathophysiology of RLS/WED have shown important implications for various genetic markers, neurotransmitter dysfunction, and iron deficiency. A practical approach to RLS/WED management includes an accurate diagnosis, the identification of reversible contributing factors, and the use of nonpharmacological therapies, including iron substitution (oral or IV) therapy. Many pharmacological agents are effective for the treatment of RLS/WED. Until recently, the first-line treatment of RLS/WED consisted of low-dose dopamine agonists (DA). However, given the fact that DAs cause high rates of augmentation of symptoms, international guidelines recommend that whenever possible the initial treatment of choice should be an α2δ ligand, and avoidance of dopaminergic agents unless absolutely necessary. If necessary, the lowest effective dose should be used for only the shortest possible time. The symptoms of RLS/WED can disrupt the quality of sleep as well as the quality of life. IV iron therapy may be considered in patients with refractory RLS. A better understanding of RLS/WED pathophysiology will allow patients to receive tailored therapy, resulting in an improved quality of life.

Acellular dermal matrix augmentation significantly increases ultimate load to failure of pectoralis major tendon repair: a biomechanical study

BACKGROUND

Biomechanical studies have demonstrated that standard pectoralis major tendon (PMT) repairs have inferior strength compared with native tendon.

HYPOTHESIS

Augmentation of PMT repair with an acellular dermal matrix (ADM) will increase the ultimate load to failure.

METHODS

Eighteen cadaveric specimens were allocated to 3 repair groups: standard repair (SR); augmented repair (AR) with ADM; and intact, native tendon (NT). Specimens were tested for cyclic elongation, linear stiffness, load to 5 mm displacement, maximum load to failure, and method of failure.

RESULTS

Maximum load to failure in AR (1450 ± 295 N) was significantly higher than SR (921 ± 159 N; P = .0042) and equivalent to NT (1289 ± 240 N; P = .49). NT required the highest load to displace 5 mm (709 ± 202 N), which was higher than AR (346 ± 95 N; P < .001) and SR (375 ± 55; P = .0015). NT stiffness (125 ± 42 N/mm) was greater than the AR (69 ± 19 N/mm; P = .0073) or SR (75 ± 11 N/mm; P = .015). The mode of failure for SR was suture pullout from the PMT as opposed to button pullout from the humerus (fracture) for AR.

CONCLUSION

ADM augmentation of PMT repair significantly increases ultimate load to failure.

Modified Iliotibial Band Tenodesis Is Indicated to Correct Intraoperative Residual Pivot Shift After Anterior Cruciate Ligament Reconstruction Using an Autologous Hamstring Tendon Graft: A Prospective Randomized Controlled Trial

BACKGROUND

The indications for the addition of anterolateral soft tissue augmentation to anterior cruciate ligament (ACL) reconstruction and its effectiveness remain uncertain.

PURPOSE

To determine if modified iliotibial band tenodesis (MITBT) can improve clinical outcomes and reduce the recurrence of ACL ruptures when added to ACL reconstruction in patients with a residual pivot shift.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Patients with a primary ACL rupture satisfying the following inclusion criteria were enrolled: first ACL rupture, involved in pivoting sports, skeletally mature, no meniscal repair performed, and residual pivot shift relative to the contralateral uninjured knee immediately after ACL reconstruction. Patients were randomized to group A (no further surgery) or group B (MITBT added) and were followed up for 2 years. The patient-reported outcome (PRO) measures used were the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) subscale of sport/recreation (Sport/Rec), KOOS subscale of quality of life (QoL), Lysholm knee score (LKS), Tegner activity scale (TAS), recurrent ACL ruptures, or need for further surgery in either knee. Analysis of variance was used to compare PROs; the Wilcoxon test was used for the TAS; and the chi-square test was used for recurrence of ACL ruptures, meniscal injuries, and contralateral ACL ruptures (P < .05).

RESULTS

A total of 55 patients were randomized: 27 to group A (female:male ratio = 15:12; mean age, 22.3 ± 3.7 years) and 28 to group B (female:male ratio = 17:11; mean age, 21.8 ± 4.1 years). At 2-year follow-up, group A had a similar IKDC score (90.9 ± 10.7 vs 94.2 ± 11.2; respectively; P = .21), lower KOOS Sport/Rec score (91.5 ± 6.4 vs 95.3 ± 4.4, respectively; P = .02), similar KOOS QoL score (92.0 ± 4.8 vs 95.1 ± 4.3, respectively; P = .14), lower LKS score (92.5 ± 4.8 vs 96.8 ± 8.0, respectively; P = .004), lower TAS score (median, 7 [range, 7-9] vs 8 [range, 8-10], respectively; P = .03), higher rate of recurrence (14.8% vs 0.0%, respectively; P < .001), similar rate of meniscal tears (14.8% vs 3.6%, respectively; P = .14), and similar rate of contralateral ACL ruptures (3.7% vs 3.6%, respectively; P = .99) relative to group B.

CONCLUSION

The augmentation of ACL reconstruction with MITBT reduced the risk of recurrent ACL ruptures in knees with a residual pivot shift after ACL reconstruction and improved KOOS Sport/Rec, LKS, and TAS scores.

REGISTRATION

ACTRN12618001043224 (Australian New Zealand Clinical Trials Registry).

The clinical and radiologic outcome of microfracture on arthroscopic repair for full-thickness rotator cuff tear

BACKGROUND

The persistent incidence of retear despite improvements in techniques led orthopedic surgeons to the application of principles of tissue bioengineering to achieve enhanced repair and functional outcomes. The purpose of this study was to compare clinical and radiologic outcomes of arthroscopic single-row repair augmented with microfracture (SRM) at the greater tuberosity with single-row (SR) and double-row (DR) repair in the treatment of full-thickness rotator cuff tears.

MATERIALS AND METHODS

This is a retrospective comparative study. A total of 123 patients were enrolled for arthroscopic repair of full-thickness rotator cuff tears, with 40 patients treated by SR, 44 by SRM, and 39 by DR. The minimum follow-up was 2 years. The primary outcome was retear rate, which was detected by magnetic resonance imaging, and the secondary outcome was functional outcome.

RESULTS

The mean age of the patients was 59.2 years, 58.1 years, and 60.6 years in the SR, SRM, and DR groups, respectively. The retear rate was 33%, 14%, and 36% in the SR, SRM, and DR groups, respectively (P = .045). The SRM group had significantly improved functional outcomes compared with the SR and DR groups in terms of the postoperative Constant score and visual analog scale score (P = .001 and .002, respectively). Delta Constant scores were nonsignificant for retear and intact tendons (P = .137).

CONCLUSION

SRM has a significantly lower retear rate and better functional outcome than SR and DR repair.

Explainable Deep Learning for Augmentation of Small RNA Expression Profiles

The lack of well-structured metadata annotations complicates the reusability and interpretation of the growing amount of publicly available RNA expression data. The machine learning-based prediction of metadata (data augmentation) can considerably improve the quality of expression data annotation. In this study, we systematically benchmark deep learning (DL) and random forest (RF)-based metadata augmentation of tissue, age, and sex using small RNA (sRNA) expression profiles. We use 4243 annotated sRNA-Seq samples from the sRNA expression atlas database to train and test the augmentation performance. In general, the DL machine learner outperforms the RF method in almost all tested cases. The average cross-validated prediction accuracy of the DL algorithm for tissues is 96.5%, for sex is 77%, and for age is 77.2%. The average tissue prediction accuracy for a completely new data set is 83.1% (DL) and 80.8% (RF). To understand which sRNAs influence DL predictions, we employ backpropagation-based feature importance scores using the DeepLIFT method, which enable us to obtain information on biological relevance of sRNAs.

Is Complete Re-Osseointegration of an Infected Dental Implant Possible? Histologic Results of a Dog Study: A Short Communication

Complete reosseointegration after treatment of periimplantitis was never published yet. This short scientific communication reports about results of a randomized controlled preclinical study. An electrolytic approach was compared to a classical modality (ablative, cotton pellets soaked with sodium chloride solution and H₂O₂. For electrolytic cleaning a complete reosseointegration was achieved in several cases serving as a proof of concept.

Application of a new polyester patch in arthroscopic massive rotator cuff repair-a prospective cohort study

BACKGROUND

Massive rotator cuff (RC) tears still present a clinically challenging problem, with reported rerupture rates in up to 94%. The study objective was to determine the impact of synthetic patch augmentation for massive RC tears.

METHODS

Between June 2012 and 2014, we performed 50 arthroscopic RC reconstructions augmented with a synthetic polyester patch. Pre- and postoperative imaging methods included arthrographic magnetic resonance imaging, arthrographic computed tomography, and ultrasound examination to determine tendon integrity or rerupture. Clinical outcome was evaluated using the Constant-Murley score and the subjective shoulder value. Mean clinical midterm and final follow-up was 22 months (9-35 months) and 52 months (25-74 months), respectively.

RESULTS

The mean Constant-Murley score increased significantly from 36.5 (±16.4 standard deviation [SD]) preoperatively to a midterm value of 81.2 (±9.6 SD; P < .0001) and further improved to a mean of 83.4 (±10.8 SD) at final follow-up. The mean subjective shoulder value increased from 40.3 (±24.3 SD) to 89.2 (±12.9 SD; P < .0001) at midterm and to 89.6 (±15.2 SD) at final follow-up. We observed 7 complete reruptures (14%). However, reruptures did not correlate with revision surgery, which was performed in 8 patients. The main reason for revision was frozen shoulder or arthrofibrosis with an intact reconstruction and patch, which was performed in 6 cases.

CONCLUSIONS

The retear rate of 14% compared favorably with nonaugmented RC repairs in the literature. Therefore, we conclude that patch augmentation in massive RC tears is feasible to reduce retears and to improve clinical outcome.

Biological Suppression of Populations of Heterodera schachtii Adapted to Different Host Genotypes of Sugar Beet

Productivity of sugar beet and brassica vegetable crops is constrained by the nematode Heterodera schachtii worldwide. In sugar beet cropping areas of Central Europe and North America, H. schachtii is managed by crop rotation, and cultivation of resistant brassica cover crops. The recently released nematode-tolerant sugar beet cultivars suffer less damage than susceptible cultivars at high initial population densities of H. schachtii. Many tolerant cultivars allow for less nematode reproduction than susceptible cultivars. Monoculture of susceptible hosts can facilitate the evolution of suppressive soil. Objectives of this study were to determine if susceptible hosts are required for this process, and if monoculture with sugar beet genotypes of different host status (susceptible, resistant, tolerant) impact this capacity. Additionally, we tested if amending soil with the cyst nematode pathogens Pasteuria nishizawae or Hyalorbilia sp. strain DoUCR50 favored the establishment of soil suppressiveness. In 4-year microplot studies with H. schachtii Schach0 or Schach1, one susceptible, one Schach0-resistant, and one tolerant sugar beet genotype were monocultured. In 2010, plots were amended with P. nishizawae or DoUCR50, the last being introduced into non-treated soil for Schach0, and into previously biocide-treated soil for Schach1. In 2011, respective Schach0 plots received a second amendment with DoUCR50. Nematode population densities and growth and yield parameters were determined annually. Effects of P. nishizawae and DoUCR50 on populations of H. schachtii were limited and not consistent. Starting in the second year of the monoculture, eggs of both H. schachtii pathotypes became diseased. Up to 90% of the total eggs were encumbered by the third cropping cycle, under the susceptible, resistant, and tolerant cultivar. In all years, the tolerant genotype produced the highest and most stable white sugar yields while yields of the other cultivars slowly improved during the monoculture. Results of this study suggested the presence of egg-infecting factors in this sugar beet monoculture that dramatically increased the proportions of diseased eggs. The tolerant cultivar allowed establishment of soil suppressiveness without the initial yield decline observed when susceptible sugar beet genotypes are grown in monoculture.

Induction of labor in women with a scarred uterus: does grand multiparity affect the risk of uterine rupture?

BACKGROUND

Previous cesarean delivery is the most important risk factor for subsequent uterine rupture. Data are inconsistent regarding grand multiparity (≥6th delivery) and a risk for uterine rupture. Specifically, no data exist regarding the risk that is associated with labor induction or augmentation in grand multiparous women after cesarean delivery.

OBJECTIVE

This study aimed to examine whether grand multiparity elevates the risk for uterine rupture in trials of labor after 1 previous cesarean that involved induction or augmentation of labor.

STUDY DESIGN

A retrospective multicenter study was conducted that included all trials of labor after cesarean delivery at 24-42 gestational weeks with vertex presentation between the years 2003-2015. The study groups were defined in the following manner: (1) grand multiparous parturients (current delivery ≥6) who underwent labor induction or augmentation; (2) multiparous parturients (delivery 2-5) who underwent induction or augmentation; (3) grand multiparous parturients with no induction or augmentation of labor. The primary outcome was uterine rupture rate, which was defined as complete separation of all uterine layers. Secondary outcomes were obstetric and neonatal complications.

RESULTS

A total of 12,679 labors were included in the study. The study group included 1304 labors of grand multiparous parturients after 1 previous cesarean delivery, of which 800 parturients underwent induction of labor and 504 parturients received labor augmentation. The multiparous group included 3681 parturients with either labor induction or augmentation. The third group included 7694 grand multiparous parturients without induction or augmentation. Incidence of uterine rupture was similar among the 3 study groups (0.3%, 0.3%, and 0.2%, respectively; P=.847). In the multivariable model that was adjusted for maternal age, ethnicity, diabetes mellitus, birthweight, and prolonged second stage of labor, no association was found between grand multiparity and uterine rupture in women with a scarred uterus who underwent labor induction or augmentation.

CONCLUSION

Labor induction/augmentation during trial of labor after cesarean delivery in grand multiparous parturients appears to be a reasonable option that has a similar uterine rupture risk as in multiparous parturients. Avoiding a mandatory cesarean delivery enables reduction of the risk for future multiple cesarean deliveries.

Changes in labor outcomes after implementing structured use of oxytocin augmentation with a 4-hour action line

Introduction: Oxytocin augmentation is essential in labor management, but how to optimize its use is still debated. Joint international guidelines regarding prolonged labor and the use of oxytocin augmentation are still not available. Due to its potential harmful side effects, a decreased use of oxytocin is encouraged. We aimed to implement a structured protocol on the use of oxytocin augmentation and to observe changes in labor outcomes.Materials and methods: The protocol was implemented at the Obstetric Department of Sørlandet Hospital, Kristiansand, Norway on 1 January 2012; therefore, data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009-2010) and the study period cohort (2012-2013). The structured protocol instructs, and restricts, the birth attendants to diagnose prolonged labor, by protocol definition only, before commencing oxytocin infusion for augmentation. Nulliparous women with singleton, term deliveries (≥37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis. The main outcome was use of oxytocin augmentation.Results: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively.Conclusions: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Osteoimmunology: Inflammatory osteolysis and regeneration of the alveolar bone

AIM

Osteoimmunology covers the cellular and molecular mechanisms responsible for inflammatory osteolysis that culminates in the degradation of alveolar bone. Osteoimmunology also focuses on the interplay of immune cells with bone cells during bone remodelling and regeneration. The aim of this review was to provide insights into how osteoimmunology affects alveolar bone health and disease.

METHOD

This review is based on a narrative approach to assemble mouse models that provide insights into the cellular and molecular mechanisms causing inflammatory osteolysis and on the impact of immune cells on alveolar bone regeneration.

RESULTS

Mouse models have revealed the molecular pathways by which microbial and other factors activate immune cells that initiate an inflammatory response. The inflammation-induced alveolar bone loss occurs with the concomitant suppression of bone formation. Mouse models also showed that immune cells contribute to the resolution of inflammation and bone regeneration, even though studies with a focus on alveolar socket healing are rare.

CONCLUSIONS

Considering that osteoimmunology is evolutionarily conserved, osteolysis removes the cause of inflammation by provoking tooth loss. The impact of immune cells on bone regeneration is presumably a way to reinitiate the developmental mechanisms of intramembranous and endochondral bone formation.

Changes in Dosing and Dose Timing of D-Cycloserine Explain Its Apparent Declining Efficacy for Augmenting Exposure Therapy for Anxiety-related Disorders: An Individual Participant-data Meta-analysis

The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/).

Clozapine augmentation strategies

Clozapine is established as the gold standard for antipsychotic treatment of patients suffering from treatment-resistant schizophrenia. Over virtually 3 decades, the level of inadequate response to clozapine was found to range from 40% to 60%. A heightened interest developed in the augmentation of clozapine to try to achieve response or maximize partial response. A large variety of drug groups have been investigated. This article focuses on the meta-analyses of these trials to discover reasonable evidence-based approaches to the management of patients not responding to clozapine.

The Influence of Thrust Force on the Vitality of Bone Chips Harvested for Autologous Augmentation during Dental Implantation

Bone drill chips that are collected during implant site preparation can be reused as autologous bone-grafting material for alveolar ridge augmentation. This study characterized five market-leading implant drill sets regarding their geometric properties and ability to produce vital bone chips. The drill geometry of each tool of five commercial implant drill sets was characterized while using optical profile projector devices and SEM. Bone chips were collected during the in vitro preparation of porcine jaw bone with the various drill sets. Produced bone chip masses were measured. The bone chips were cultured in vitro and the number of outgrown cells was determined and measurand for vitality. Furthermore, the thrust force and cutting torque were recorded to examine the mechanical loads of the manual drilling process. The tool geometry and set configuration of one out of five implant drill sets appears to be superior regarding chip mass, vitality, and thrust force. It could be proven that there is a correlation between vitality and thrust force. The thrust force is influenced by the cutting behavior of the tool, which in turn depends on the geometry of the tool. The tool geometry has an influence on the vitality of the augmentation material due to this relationship.

Treatment of Peri-implantitis-Electrolytic Cleaning Versus Mechanical and Electrolytic Cleaning-A Randomized Controlled Clinical Trial-Six-Month Results

OBJECTIVES

The present randomized clinical trial assesses the six-month outcomes following surgical regenerative therapy of periimplantitis lesions using either an electrolytic method (EC) to remove biofilms or a combination of powder spray and electrolytic method (PEC).

MATERIALS AND METHODS

24 patients with 24 implants suffering from peri-implantitis with any type of bone defect were randomly treated by EC or PEC. Bone defects were augmented with a mixture of natural bone mineral and autogenous bone and left for submerged healing. The distance from implant shoulder to bone was assessed at six defined points at baseline (T0) and after six months at uncovering surgery (T1) by periodontal probe and standardized x-rays.

RESULTS

One implant had to be removed at T1 because of reinfection and other obstacles. None of the other implants showed signs of inflammation. Bone gain was 2.71 ± 1.70 mm for EC and 2.81 ± 2.15 mm for PEC. No statistically significant difference between EC and PEC was detected. Significant clinical bone fill was observed for all 24 implants. Complete regeneration of bone was achieved in 12 implants. Defect morphology impacted the amount of regeneration.

CONCLUSION

EC needs no further mechanical cleaning by powder spray. Complete re-osseointegration in peri-implantitis cases is possible.

ACL Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Provides Good Clinical Scores, High Levels of Satisfaction and Return to Sport, and a Low Retear Rate at 2 Years

Background:

There are a number of surgical methods for undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although relatively high rates of ipsilateral retears and contralateral tears exist, with only 65% of patients returning to their preinjury level of sport. ACLR techniques adopting synthetic augmentation have been proposed in an attempt to improve clinical outcomes and reduce reinjury rates.

Purpose:

To determine the efficacy of ACLR using autologous hamstrings augmented with the Ligament Augmentation and Reconstruction System (LARS).

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 65 patients were prospectively treated with arthroscopically assisted single-bundle ACLR using hamstrings augmented with the LARS, of whom 50 were available for 1- and 2-year reviews. Patient-reported outcome measures (PROMs), KT-1000 arthrometer testing, knee range of motion, peak isokinetic knee strength testing, and a battery of 4 hop tests were employed. Limb symmetry indices (LSIs) were calculated. Analysis of variance was used to evaluate differences over time and between limbs. Data on return to the preinjury level of sport, retears, and reoperations were collected.

Results:

High PROM scores were demonstrated at 1 and 2 years. Before the injury, 47 patients (94%) were actively participating in level 1 or 2 sports, with 38 (76%) and 43 (86%) patients having returned at 1 and 2 years, respectively. Normal (<3 mm; 90%) or nearly normal (3-5 mm; 10%) KT-1000 arthrometer side-to-side differences were observed at 2 years. Apart from knee flexion (P < .0001), extension (P = .001), and the 6-m timed hop (P = .039), there were no between-limb differences at 1 year, and there were no differences on any objective measures at 2 years (all P > .05). Mean LSIs across all measures were ≥90%. At 2 years, 84% to 90% of patients were ≥90% on the hop tests, with 72% and 76% of patients having ≥90% for extension and flexion strength, respectively. Two reoperations were undertaken for meniscal tears (7 and 8.5 months), 1 patient (2%) suffered a retear at 7 months, and 2 patients (3%) suffered a contralateral tear (8 and 12 months).

Conclusion:

This augmented ACLR technique demonstrated good clinical scores, a high rate of return to sport, and low rates of secondary ruptures and contralateral ACL tears at 2 years. Some caution should be noted in interpreting these results, as 15 of 65 patients (23%) were not included in the 2-year follow-up.

Augmentation with pre-emptive macrogol-based osmotic laxative does not significantly improve standard bowel preparation in unselected patients: A randomized trial

Background and Aim

The addition of a laxative prior to a standard bowel preparation (BP) has shown variable results in efficacy, safety, and tolerability of the BP. This study compared the efficacy and tolerability of a macrogol-augmented BP (M-BP) with standard BP for routine colonoscopy in unselected patients.

Methods

Adults undergoing outpatient colonoscopy were randomized to either M-BP (one sachet of macrogol-based osmotic laxative (MBOL) twice daily for eight doses prior to standard preparation) or BP (split-dose of polyethylene glycol and sodium picosulfate). Bowel cleansing was assessed using the Ottawa BP scale. Risk factors for poor BP, patient satisfaction, and tolerance were recorded.

Results

This randomized trial was stopped due to futility after 14 months; at that point, 92 subjects were randomized to the study arm and 102 to the control arm. M-BP had a success rate of 71.7% (95% CI: 58.5-82.7%), while the BP had a success rate of 67.7% (95% CI: 54.9-78.8%), with a Pearson χ ² test P-value of 0.639, which exceeded the cut-off for futility (0.313). In subgroup analyses, there were statistically significant decreases in the rates of successful BP in patients taking regular opioids and regular laxatives. Both preparations were well tolerated, with no difference between groups (BP - 5.3% and M-BP - 6.6% P = 0.66).

Conclusion

The addition of MBOL prior to a standard BP in unselected subjects does not significantly improve bowel cleanliness at routine colonoscopy. The role of this laxative in patients at high risk of poor preparation warrants further investigation.

Laboratory Monitoring of Bone Tissue Remodeling after Augmentation of Impression Intraarticular Fracture with Different Types of Bone Graft

The effects of bone graft materials on the inflammatory response and biochemical markers of bone remodeling were studied on a rabbit model of fracture augmentation with the following grafts: β-tricalcium phosphate, demineralized bone matrix, nanostructured carbon implant, and porous titanium implant made by additive 3D printing. The markers of bone remodeling and the blood system response in the postoperative period were studied. It was found that porous titanium implant and β-tricalcium phosphate induced osteogenesis and minimized osteoclastic resorption. Augmentation with nanostructured carbon implant and demineralized bone matrix stimulated the processes of osteoclastic resorption.

Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM): Study Design and Treatment Characteristics of the First 396 Participants Randomized

OBJECTIVE

Evidence from clinical trials comparing effectiveness and safety of pharmacological strategies in older adults unresponsive to first-line antidepressants is limited. The study, Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM), tests three hypotheses concerning pharmacotherapy strategies for treatment-resistant late-life depression: 1) augmentation strategies will provide greater improvement than switching monotherapies; 2) augmentation strategies will have lower tolerability and more safety concerns than switching monotherapies; and 3) age will moderate the effectiveness and safety differences between treatment strategies. The authors describe the methodology, processes for stakeholder engagement, challenges, and lessons learned in the early phases of OPTIMUM.

METHODS

This pragmatic randomized clinical trial located in five North American regions will enroll 1,500 participants aged 60 years and older unresponsive to two or more antidepressant trials. The authors evaluate two strategies (medication augmentation versus switch) using four medications (aripiprazole, bupropion, lithium, and nortriptyline) via a stepwise, prespecified protocol. Primary outcomes include: 1) symptom remission (Montgomery Asberg Depression scale ≤10); 2) psychological well-being, comprising positive affect, general life satisfaction, and purpose; and 3) safety (rates of serious adverse events and prevalence of falls and fall-related injuries).

RESULTS

To date, 396 participants have been randomized. The authors report on four challenges: 1) engagement and recruitment; 2) increasing polypharmacy in older adults, resulting in potentially hazardous scenarios; 3) reporting adverse events and procedure standardization across sites; and 4) dissemination of results.

CONCLUSION

Solutions to these challenges, including early inclusion of stake holders, will inform future pragmatic studies in older adults with depression.

Patient related outcome measures for breast augmentation mammoplasty: a systematic review

We review the current literature for validated patient related outcome measures (PROM) in breast augmentation mammoplasty (BAM). Using Medline search between 1966 to 2018, using the search strategy ("patient reported outcome measure" OR "surveys or questionnaires") AND "breast" AND ("augment" OR "implant") was performed. A manual search with Google Scholar using the search term "Patient Reported Outcome Measures in Bilateral Augmentation Mammaplasty" was also performed. Once the search yielded its results, a further search of bibliographic references within the articles was also performed. The Medline computer search produced 72 results, with a Google Scholar search yielding two results and a bibliographic search of all articles revealing a further single result. Ten studies were included as they used validated PROM. Three articles used the same PROM (Breast-Q) and seven used different PROM, therefore 8 validated PROM were discovered. Bilateral augmentation mammoplasty has been demonstrated to confer an increase in patient reported outcomes in domains of satisfaction with breasts and psychological well-being. There is some decrease in physical well-being following this procedure. Validated PROMs provide objective data relating to different aspects of BAM. Combined with traditional surgeon-based outcome measures and implant registry data, they may provide a more comprehensive insight into the patient journey.

One-Stage Vertical Ridge Augmentation and Dental Implantation With Allograft Bonerings: Results 1 Year After Surgery

The aim of this study was to analyze the success rate of dental implants and the graft shrinkage rate after vertical ridge augmentation and simultaneous implantation with an allograft bonering. Fifty-one patients (81 augmentations and simultaneous implantations) were included. The bonering technique followed a standardized protocol. The alveolar ridge was prepared using a congruent trephine, and depending on the defect size, an allograft bonering with an outer diameter of 6-7 mm was placed. The height of the bonering was trimmed with a diamond disc to the required length. The average height of vertical augmentation was 5.5 mm. Implants were inserted through the bonering into the native bone of alveolar ridge. After 6 months, dental implants were exposed, and dental prosthetics were placed. Of 81 implants placed with the bonering technique, two failed during a 12-month follow-up, corresponding to a success rate of 97.5%. One year after surgery, the allograft bonering exhibited an average vertical graft shrinkage rate of 8.6%. In conclusion, the allograft bonering technique was associated with a favorable outcome, and in cases with large vertical defects, both treatment time and donor site morbidity could be reduced.

What Do We Find Attractive about the Face?: Survey Study with Application to Aesthetic Surgery

The appearance of the face is one of the most important factors influencing our perception of beauty. However, few studies have attempted to quantitate what one perceives as beauty. Therefore, this study was conducted with the goal of providing physicians with anatomical data that demonstrate which facial traits most influence our perception of one's attractiveness. In the first phase of the study, faces of 60 participants (30 males and 30 females) were photographed. Next, the photographs were shown to another group of 120 study members (60 males and 60 females), who evaluated the facial features using a Visual Analogue Scale. The highest rated facial parts were then measured using the ImageJ program. In men, the most attractive parts of the face were Type 1:2 lips, a Type IV nose of medium width, blue eyes, brown hair, and a very narrow face. Among females, the most attractive parts of the face were Type 2:1 lips, Type III and V noses of medium width, dark brown eyes, blonde hair, and a narrow face. This is the first study in which the most aesthetically important facial parts have been comprehensively examined. The results obtained in our study show a higher degree of representativeness compared to other studies due to a different methodological approach and can be used as an aesthetic guide and can help in the planning of aesthetic surgery such as lip augmentation and rhinoplasty. Clin. Anat. 33:214-222, 2020. © 2019 Wiley Periodicals, Inc.

Characterizing population and individual migration patterns among native and restored bighorn sheep (Ovis canadensis)

Migration evolved as a behavior to enhance fitness through exploiting spatially and temporally variable resources and avoiding predation or other threats. Globally, landscape alterations have resulted in declines to migratory populations across taxa. Given the long time periods over which migrations evolved in native systems, it is unlikely that restored populations embody the same migratory complexity that existed before population reductions or regional extirpation.We used GPS location data collected from 209 female bighorn sheep (Ovis canadensis) to characterize population and individual migration patterns along elevation and geographic continuums for 18 populations of bighorn sheep with different management histories (i.e., restored, augmented, and native) across the western United States.Individuals with resident behaviors were present in all management histories. Elevational migrations were the most common population-level migratory behavior. There were notable differences in the degree of individual variation within a population across the three management histories. Relative to native populations, restored and augmented populations had less variation among individuals with respect to elevation and geographic migration distances. Differences in migratory behavior were most pronounced for geographic distances, where the majority of native populations had a range of variation that was 2-4 times greater than restored or augmented populations. Synthesis and applications. Migrations within native populations include a variety of patterns that translocation efforts have not been able to fully recreate within restored and augmented populations. Theoretical and empirical research has highlighted the benefits of migratory diversity in promoting resilience and population stability. Limited migratory diversity may serve as an additional factor limiting demographic performance and range expansion. We suggest preserving native systems with intact migratory portfolios and a more nuanced approach to restoration and augmentation in which source populations are identified based on a suite of criteria that includes matching migratory patterns of source populations with local landscape attributes.

A Comparative Analysis Between Primary and Secondary Nasal Tip Drooping

OBJECTIVE

Recently, many commercial one-piece alloplastic materials are used in nasal dorsum augmentation and increased nasal tip projection, but there is no study about their effects with regard to size on nasal shape so far. The aim of this study is to evaluate the impact of oversized one-piece alloplastic implant on nasal tip projection.

METHODS

We categorized nasal tip drooping as primary (group 1: no rhinoplasty or trauma history) and secondary (group 2: previous history of augmentation rhinoplasty with one-piece alloplastic materials), and retrospectively compared the characteristics of primary and secondary nasal tip drooping on the basis of pre- and postoperative rhinological parameters (nasolabial angle [NLA], rotation angle, nasofrontal angle [NFA], and Goode ratio).

RESULTS

A total of 50 patients were enrolled and completely reviewed. The mean age was 27.46 years (ranging from 19 to 49 years) in group 1 and 31.33 years (ranging from 20 to 47 years) in group 2. The postoperative NLA and rotation angle were not statistically different between 2 groups, but the postoperative NFA and postoperative Goode ratio were statistically different between 2 groups by independent t test. When we further performed univariate and multivariate analysis, the postoperative Goode ratio was the only factor that was significantly different between the 2 groups.

CONCLUSION

Insertion of one-piece alloplastic implants from nasal tip glabella to dome of nasal tip may induce secondary nasal tip drooping. The degree of recovery of nasal tip projection is different between 2 groups and may be obtained by a more delicate surgical techniques.

Screw-tip augmentation versus standard locked plating of displaced proximal humeral fractures: a retrospective comparative cohort study

BACKGROUND

This study compared the clinical and radiologic outcomes of screw tip-augmented locking plate osteosynthesis vs. standard locked plating in elderly patients with displaced proximal humeral fractures.

METHODS

Of the 94 patients older than 65 years with displaced proximal humeral fractures, 55 underwent fixation with a locking plate only whereas 39 underwent fixation using a locking plate with fluoroscopy-controlled polymethyl methacrylate augmentation of screw tips.

RESULTS

At 2 years' follow-up, the locking plate-only group showed a mean Constant score (CS) of 62.6 ± 17.4 points, mean CS as a percentage of the uninjured side of 78.2% ± 18.9%, and mean age- and sex-adjusted CS of 72.4 ± 20.5 points. Among the 39 patients who underwent locked plating with polymethyl methacrylate augmentation of screw tips, the mean CS was 63.7 ± 18.5 points (P = .28), the mean CS as a percentage of the uninjured side was 79.5% ± 20.4% (P = .36), and the mean age- and sex-adjusted CS was 76.8 ± 26.2 points (P = .11). The mean Disabilities of the Arm, Shoulder and Hand score was 26.4 ± 21.3 in the locking plate-only group compared with 23.6 ± 19.2 in the group with screw tip-augmented locking plate osteosynthesis (P = .41). The overall complication rate was 16.3% in the locking plate-only group compared with 12.8% in the group with screw tip-augmented osteosynthesis (P = .86); loss of fixation occurred in 10.9% vs. 5.1% (P = .74). The follow-up rate was 81%.

CONCLUSIONS

Loss of fixation was less frequent when augmentation of screw tips was performed; however, at the 2-year follow-up, the clinical and radiologic outcomes were not significantly different compared with standard locked plating without augmentation.

Young patient with treatment-resistant schizophrenia drastically improved by combination of clozapine and maintenance electroconvulsive therapy: a case report

Objectives: Although clozapine is considered the only effective pharmacological option for patients with treatment-resistant schizophrenia (TRS), around 30–40% of patients show clozapine resistance. Modified electroconvulsive therapy augmentation is reportedly clinically effective for clozapine-resistant schizophrenia, but few case reports have described the efficacy of combining clozapine and continuous/maintenance ECT for patients with TRS.

Methods: We present the case of a young patient with TRS who was treated using combination therapy with clozapine and maintenance ECT (m-ECT).

Results: The patient achieved drastic improvement under combination therapy with clozapine and m-ECT. Total Positive and Negative Syndrome Scale (PANSS) score fell markedly by 36 (from 108 to 72) using the combination of clozapine and m-ECT. Behaviors not reflected directly by PANSS score also improved. For example, the problem of being unable to take oral drugs stably because of delusions of poisoning was resolved. Furthermore, the patient maintained improvement under m-ECT, and long-term homestays became possible.

Conclusion: Combination therapy with clozapine and m-ECT proved greatly effective in this case. Further clinical trials of this combination therapy for TRS are needed to confirm the effectiveness. Further studies are also expected to examine effective periods for this therapy.

Machine learning methods for leveraging baseline covariate information to improve the efficiency of clinical trials

Clinical trials are widely considered the gold standard for treatment evaluation, and they can be highly expensive in terms of time and money. The efficiency of clinical trials can be improved by incorporating information from baseline covariates that are related to clinical outcomes. This can be done by modifying an unadjusted treatment effect estimator with an augmentation term that involves a function of covariates. The optimal augmentation is well characterized in theory but must be estimated in practice. In this article, we investigate the use of machine learning methods to estimate the optimal augmentation. We consider and compare an indirect approach based on an estimated regression function and a direct approach that aims directly to minimize the asymptotic variance of the treatment effect estimator. Theoretical considerations and simulation results indicate that the direct approach is generally preferable over the indirect approach. The direct approach can be implemented using any existing prediction algorithm that can minimize a weighted sum of squared prediction errors. Many such prediction algorithms are available, and the super learning principle can be used to combine multiple algorithms into a super learner under the direct approach. The resulting direct super learner has a desirable oracle property, is easy to implement, and performs well in realistic settings. The proposed methodology is illustrated with real data from a stroke trial.

Biomechanical in vitro evaluation of a ready-to-use calcium phosphate cement implanted to augment intramedullary nail fixation of a three-part humeral head fracture model

The aim of this study was the dynamic biomechanical evaluation of a ready-to-use oil-based calcium phosphate cement paste implanted to augment intramedullary nail fixation of a three-part humeral head fracture model. Fractures in the osteoporotic bone are often fractures of the proximal humerus. Secondary fracture displacements due to cut-out in osteoporotic bone have been observed in up to 13% of cases. Procedures have been developed to augment fracture fixation with polymethylmethacrylate to increase stability, but there are still unsolved challenges relating to its material-specific properties. Calcium phosphate cement could be a biological alternative in the augmentation of osteoporotic fractures because of its more favourable material properties. Fracture fixation was performed on eight pairs of human cadaveric bones to stabilize a standardized three-part humeral head fracture model by implantation of the Targon^® PH (Braun-Aesculap AG, Tuttlingen, Germany) intramedullary nail and insertion of three head screws and two bicortical shaft screws. The procedure was randomized, and one bone of each pair received calcium phosphate cement augmentation. Custom-made cannulated screws with an open lateral slot facilitated augmentation, making it possible to cement the threaded portion of the screw (1-mL calcium phosphate cement/screw). After the calcium phosphate cement had hardened, the humeri were subjected to dynamic axial loading. Load was progressively increased, monitored by ultrasound-based motion analysis, and total deformation was recorded. Load testing continued until implant failure. The augmented group withstood significantly more cycles before implant failure. The average initial stiffness showed a significant difference between the two study groups. Ultrasonic sensor technology was used to measure angular displacement during testing and a significant difference was found. Calcium phosphate cement offers a potential alternative to implant augmentation in the treatment of osteoporotic humeral head fractures. Future studies are required to confirm these observations clinically in vivo.

Augmented latissimus dorsi transfer: initial results in patients with massive irreparable posterosuperior rotator cuff tears

BACKGROUND

The surgical treatment of irreparable massive rotator cuff tears is challenging. The purpose of the present study was to report the initial outcomes after a modified latissimus dorsi transfer (LDT) augmented by acellular dermal allograft (ADA).

METHODS

This retrospective study includes 24 patients managed with LDT using ADA augmentation as a bursal-sided onlay between March 2009 and December 2015.

RESULTS

All patients were men with a mean age of 57 years (range 48 years to 70 years). Seven patients had a previously failed rotator cuff repair and ten patients presented with a deficient subscapularis tendon. At last follow-up (mean 27 months), there was a significant improvement in active forward flexion (mean increase 31°; p = 0.016), and abduction by 25° (p = 0.059). The acromiohumeral distance remained stable and the failure rate was low (4%). Neither a history of previous rotator cuff surgery, nor the presence of a subscapularis tear had a negative impact on functional outcome.

CONCLUSIONS

In our cohort of patients, LDT augmented with ADA was a reasonable option for patients with previously failed rotator cuff repair, as well as in the subgroup of patients with a deficient subscapularis tendon.

LEVEL OF EVIDENCE

Level IV: Therapeutic study (case series).

Anterior Rectus Sheath Autograft in WRAP-Augmentation of Achilles Tendon Rupture

Achilles tendon ruptures can be counted as the most common traumatic ankle injuries. As such, there is a comparatively large set of treatment options including surgical and nonsurgical approaches. The purpose of this case report is to demonstrate a new technique for a specific subgroup of Achilles tendon ruptures that present with a large tendinous gap. We used a 2-step procedure designed to grant additional stability through an autograft from the anterior rectus sheath of the patient. Two patients were treated after suffering traumatic Achilles tendon ruptures on the left side with a gap of >3.5 cm and a high demand in daily activities. The reconstruction was performed using an upper quadrant recuts sheath as a WRAP-augmentation. After securing the transplant tissue, the abdominal wall was reconstructed using a Vicryl™-Prolene™ mesh (VYPRO^®, Johnson & Johnson Medical GmbH, Ethicon Deutschland, Norderstedt, Germany). After, a standard approach to the Achilles tendon was performed with a Kirchmayr-Kessler suture. The end result was then stabilized with a rectus sheath WRAP over a length of 14 to 15 cm. On the cases reported here, multiple clinical follow-ups were performed over a 5-year period. We can report highly satisfying results, with a return to sports activity after 6 months and no complications. As such we believe the rectus sheath autograft an effective solution for Achilles tendon ruptures with large gaps in healthy patients that demonstrate a high demand in daily activities.

Rotator Cuff Matrix Augmentation and Interposition: A Systematic Review and Meta-analysis

BACKGROUND

Surgical management of rotator cuff tears is controversial and complex, ranging from nonoperative management to reverse shoulder arthroplasty.

PURPOSE

To systematically review and evaluate the outcomes of graft augmentation or interposition versus rotator cuff repair (RCR) alone and evaluate via meta-analysis whether the use of a graft leads to superior outcomes versus RCR alone.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

An electronic literature search (Medline, Embase, CINAHL) was conducted. Studies with a minimum follow-up of 1 year and minimum sample size of 10 that provided clinical results of RCR or rotator cuff reconstruction using any type of augmentation tissue or matrix were included. Methodological quality was evaluated by assessment of the risk of bias in the included studies. Studies comparing outcomes of RCR with graft augmentation or interposition versus repair alone (control group) were subjected to meta-analysis.

RESULTS

The authors identified 774 articles and included 36 in the systematic review; 5 of the 36 studies underwent meta-analysis. Except for one outcome measure in a single study, all surgical interventions (RCR alone, RCR with augmentation, and RCR with interposition) improved clinical scores and outcome measures. Because of variability in study outcomes, no graft option was found to be superior. Compared with RCR alone, graft augmentation or interposition provided significantly lower retear rates ( P = .05) and higher American Shoulder and Elbow Surgeons (ASES) scores ( P = .005), but improvements in UCLA (University of California, Los Angeles) scores ( P = .29) and pain scores ( P = .1) did not reach statistical significance.

CONCLUSION

In the meta-analysis, graft augmentation or interposition appeared to provide a lower retear rate and improved ASES scores when compared with RCR alone. Future prospective, randomized, controlled, and appropriately powered trials are needed for more definitive recommendations.

Treatment options for clozapine resistance

BACKGROUND

Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse.

AIMS

We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice.

METHODS

We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified.

RESULTS

Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only.

CONCLUSION

More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.

Group 4 ITI Consensus Report: Risks and biologic complications associated with implant dentistry

OBJECTIVES

The aim of Working Group 4 was to address topics related to biologic risks and complications associated with implant dentistry. Focused questions on (a) diagnosis of peri-implantitis, (b) complications associated with implants in augmented sites, (c) outcomes following treatment of peri-implantitis, and (d) implant therapy in geriatric patients and/or patients with systemic diseases were addressed.

MATERIALS AND METHODS

Four systematic reviews formed the basis for discussion in Group 4. Participants developed statements and recommendations determined by group consensus based on the findings of the systematic reviews. These were then presented and accepted following further discussion and modifications as required by the plenary.

RESULTS

Bleeding on probing (BOP) alone is insufficient for the diagnosis of peri-implantitis. The positive predictive value of BOP alone for the diagnosis of peri-implantitis varies and is dependent on the prevalence of peri-implantitis within the population. For patients with implants in augmented sites, the prevalence of peri-implantitis and implant loss is low over the medium to long term. Peri-implantitis treatment protocols which include individualized supportive care result in high survival of implants after 5 years with about three-quarters of implants still present. Advanced age alone is not a contraindication for implant therapy. Implant placement in patients with cancer receiving high-dose antiresorptive therapy is contraindicated due to the associated high risk for complications.

CONCLUSIONS

Diagnosis of peri-implantitis requires the presence of BOP as well as progressive bone loss. Prevalence of peri-implantitis for implants in augmented sites is low. Peri-implantitis treatment should be followed by individualized supportive care. Implant therapy for geriatric patients is not contraindicated; however, comorbidities and autonomy should be considered.

Crossover to Bilateral Repetitive Transcranial Magnetic Stimulation: A Potential Strategy When Patients Are Not Responding to Unilateral Left-Sided High-Frequency Repetitive Transcranial Magnetic Stimulation

Clinical trials using left-sided repetitive transcranial magnetic stimulation (rTMS) report remission rates of 14% to 32.6%. A large percentage of patients would not achieve remission with standard rTMS treatment. The question of what clinicians should do when a patient is not responding to standard high-frequency (HF) left-sided rTMS remains unanswered. This prospective case series examines whether crossover to bilateral stimulation enhances antidepressant outcomes in patients not responding to unilateral rTMS. Patients in a major depressive episode received an rTMS clinical protocol of 4 to 6 weeks' duration. Stimulation began with HF rTMS (10 Hz) over the left dorsolateral prefrontal cortex (range, 3000-5000 pulses per session). A total of 17 patients without sufficient clinical improvement early in their rTMS course received 1-Hz rTMS (range, 600-1200 pps) over the right dorsolateral prefrontal cortex (added to the HF left-sided stimulation). Hamilton Depression Rating Scale scores decreased from 13.9 ± 3.9 (mean ± SD) from the start of augmentation to 12.2 ± 5.8 at the end of acute treatment, a 1.7-point change, Cohen d effect size = -0.35, 95% confidence interval, -1.01 to - 0.34, suggesting improvement. Remission rate in this sample was 24% (4/17). This case series indicates that crossover to bilateral stimulation is a feasible and potentially effective strategy when patients are not improving with standard rTMS. A randomized controlled trial comparing crossover versus standard rTMS is needed to determine the efficacy of this paradigm.

Allergic reaction to platelet-rich plasma (PRP): Case report

RATIONALE

In the recent years, growing interest is focused on the use of platelet-rich plasma (PRP) in wound healing and tissue regeneration. There are a number of papers regarding the usefulness of PRP in the healing of ulcerations, skin injures, bone loss or distraction osteogenesis. Most authors emphasize the safety of PRP usage due to its authogenic nature.

PATIENT CONCERNS

We present a case of a 14 -year-old boy admitted to our department due to simple bone cyst of the distal tibia, qualified for injection of PRP into the cyst. PRP was separated with the use of Magellan Autologous Platelet Separator System (Arteriocyte Medical Systems Hopkington, MA) according to the manufacturers' manual. Immediately after separation during short-term IV anaesthesia, 3 mL of PRP was installed to the bone cyst under image intensifier control.

DIAGNOSES

Within the first 24 hours after exposure to PRP, the skin rash appeared. Physical examination revealed the small red papular, regionally purpuric eruptions, mainly concentrated on the upper extremities and on more warmed regions of skin, in association with pharyngitis, tonsillar enlargement, mucopurulent discharge in the posterior pharynx and swelling of the eyelids.

INTERVENTIONS

As the patient received calcium citrate with the PRP injection additional calcium citrate test were performed. Skin prick testing (negative) was and an intradermal test was positive (10×13 mm). Treatment included Claritine (Loratidinum) and Clemastin (Clemastinum)-both antihistaminic drugs.

OUTCOMES

All symptoms withdrew and the patient was released home after 4 days. The patient is in 6 years follow-up without any symptoms of allergic disease.

LESSONS

Our case shows that safety of use of PRP is not absolutely sure. The pure autologous tissue is safe, but preparation for its use can substantially decrease this safety. In our patient, only limited skin reaction to calcium citrate was observed, but general reaction leading to anaphylactic shock cannot be excluded. In order to reduce the risk of side effects skin test should be performed but as there were no records of allergic diseases on family and patients medical history this should apply to all patients.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With a Modified Docking Technique With and Without Suture Augmentation

BACKGROUND

Throwing athletes with ulnar collateral ligament (UCL) injury and symptomatic valgus instability can expect to return to the same or higher level of play. Reconstruction with tendon graft is the dominant method of surgical treatment. Recent evidence suggests that spanning the joint with a suture anchored on both sides is biomechanically equivalent to reconstruction, with faster time to return to play. The authors developed a hybrid UCL reconstruction technique augmented with a suture brace to improve joint stability.

PURPOSE/HYPOTHESIS

The purpose of this study was to biomechanically evaluate a hybrid reconstruction technique and compare its performance to reconstruction without augmentation. The authors hypothesized that (1) both groups would lose stability after the simulated tear and regain stability with treatment, (2) the suture augmentation would improve stability, and (3) the addition of the suture anchors near the bone tunnels would not decrease the strength of the hybrid reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten matched pairs of cadaveric arms were dissected to expose the UCL. Each elbow was mounted on a test frame at 90° of flexion. A cyclic valgus rotational torque was applied to the humerus with the UCL in its intact state and repeated in its surgically torn state. Finally, each specimen received either a hybrid reconstruction with suture brace or a reconstruction and was again put through the cyclic protocol, followed by a valgus rotation load-to-fail protocol.

RESULTS

Gap formation in the torn state for the reconstruction and hybrid reconstruction groups (0.9 ± 0.1 mm and 0.8 ± 0.1 mm, respectively) was significantly higher ( P = .009 and P = .0002) than in the intact state (0.6 ± 0.2 mm and 0.6 ± 0.3 mm, respectively). After the procedures, the hybrid group showed greater resistance to gapping ( P = .017) as compared with the reconstruction group (0.4 ± 0.2 mm and 0.6 ± 0.1 mm). During load to failure, no hybrid reconstructions failed from bone fracture or screw pullout. No statistical differences were found for failure torque ( P = .058) and stiffness ( P = .101). Gap at 10 N·m was significantly lower ( P = .014) for the hybrid reconstruction group than for the reconstruction group.

CONCLUSION

The current study showed that hybrid reconstruction with suture bracing replicated the time-zero strength of traditional UCL reconstruction and may be more resistant to joint gapping during low cyclic load and load to failure. The combination of the bone tunnels and fixation screw holes did not appear to weaken the construct.

CLINICAL RELEVANCE

This study demonstrated that reconstruction with suture bracing has important time-zero stability and strength as compared with the gold standard of UCL reconstruction. This technique may be useful for throwing athletes who need UCL reconstruction.

Augmentation of Saporin-Based Immunotoxins for Human Leukaemia and Lymphoma Cells by Triterpenoid Saponins: The Modifying Effects of Small Molecule Pharmacological Agents

Triterpenoid saponins from Saponinum album (SA) significantly augment the cytotoxicity of saporin-based immunotoxins but the mechanism of augmentation is not fully understood. We investigated the effects of six small molecule pharmacological agents, which interfere with endocytic and other processes, on SA-mediated augmentation of saporin and saporin-based immunotoxins (ITs) directed against CD7, CD19, CD22 and CD38 on human lymphoma and leukaemia cell lines. Inhibition of clathrin-mediated endocytosis or endosomal acidification abolished the SA augmentation of saporin and of all four immunotoxins tested but the cytotoxicity of each IT or saporin alone was largely unaffected. The data support the hypothesis that endocytic processes are involved in the augmentative action of SA for saporin ITs targeted against a range of antigens expressed by leukaemia and lymphoma cells. In addition, the reactive oxygen species (ROS) scavenger tiron reduced the cytotoxicity of BU12-SAP and OKT10-SAP but had no effect on 4KB128-SAP or saporin cytotoxicity. Tiron also had no effect on SA-mediated augmentation of the saporin-based ITs or unconjugated saporin. These results suggest that ROS are not involved in the augmentation of saporin ITs and that ROS induction is target antigen-dependent and not directly due to the cytotoxic action of the toxin moiety.