Low back pain patients with Modic type 1 changes exhibit distinct bacterial and non-bacterial subtypes

Objectives

Modic type 1 changes (MC1) are vertebral endplate bone marrow (BM) lesions observed on magnetic resonance images in sub-populations of chronic low back pain (CLBP) patients. The etiopathogenesis remains unknown and treatments that modify the underlying pathomechanisms do not exist. We hypothesized that two biological MC1 subtypes exist: a bacterial and a non-bacterial. This would have important implications for developing treatments targeting the underlying pathomechanisms.

Methods

Intervertebral disc (IVD) samples adjacent to MC1 (n ​= ​34) and control (n ​= ​11) vertebrae were collected from patients undergoing spinal fusion. Cutibacterium acnes (C.acnes) genome copy numbers (GCNs) were quantified in IVD tissues with 16S qPCR, transcriptomic signatures and cytokine profiles were determined in MC1 and control BM by RNA sequencing and immunoassay. Finally, we assessed if C.acnes GCNs are associated with blood plasma cytokines.

Results

IVD tissues from control levels had <870 ​C.acnes GCNs/gram IVD. MC1-adjacent IVDs had either "low" (<870) or "high" (>870) C.acnes GCNs. MC1 patients with "high" C.acnes GCNs had upregulated innate immune cell signatures (neutrophil, macrophage/monocyte) and pro-inflammatory cytokines related to neutrophil and macrophage/monocyte function in the BM, consistent with a host defense against bacterium. MC1 patients with "low" C.acnes GCNs had increased adaptive immune cell signatures (T-and B-cell) in the BM and elevated IL-13 blood plasma levels.

Conclusion

Our study provides the first evidence for the existence of bacterial (C.acnes "high") and non-bacterial (C.acnes "low") subtypes in MC1 patients with CLBP. This supports the need for different treatment strategies.

Real-world analysis of teclistamab in 123 RRMM patients from Germany

Teclistamab, a B-cell maturation antigen (BCMA) × CD3 directed bispecific antibody, has shown high response rates and durable remissions in the MAJESTEC-1 trial in patients with relapsed and refractory multiple myeloma (RRMM). We retrospectively assessed efficacy and tolerability in 123 patients treated at 18 different German centers to determine whether outcome is comparable in the real-world setting. Most patients had triple-class (93%) or penta-drug (60%) refractory disease, 37% of patients had received BCMA-directed pretreatment including idecabtagene vicleucel (ide-cel) CAR-T cell therapy (21/123, 17.1%). With a follow-up of 5.5 months, we observed an overall response rate (ORR) of 59.3% and a median progression-free survival (PFS) of 8.7 months. In subgroup analyses, we found significantly lower ORR and median PFS in patients with extramedullary disease (37%/2.1 months), and/or an ISS of 3 (37%/1.3 months), and ide-cel pretreated patients (33%/1.8 months). Nonetheless, the duration of response in ide-cel pretreated patients was comparable to that of anti-BCMA naive patients. Infections and grade ≥3 cytopenias were the most frequent adverse events. In summary, we found that teclistamab exhibited a comparable efficacy and safety profile in the real-world setting as in the pivotal trial.

FGF2 overrides key pro-fibrotic features of bone marrow stromal cells isolated from Modic type 1 change patients

Extensive extracellular matrix production and increased cell-matrix adhesion by bone marrow stromal cells (BMSCs) are hallmarks of fibrotic alterations in the vertebral bone marrow known as Modic type 1 changes (MC1). MC1 are associated with non-specific chronic low-back pain. To identify treatment targets for MC1, in vitro studies using patient BMSCs are important to reveal pathological mechanisms. For the culture of BMSCs, fibroblast growth factor 2 (FGF2) is widely used. However, FGF2 has been shown to suppress matrix synthesis in various stromal cell populations. The aim of the present study was to investigate whether FGF2 affected the in vitro study of the fibrotic pathomechanisms of MC1-derived BMSCs. Transcriptomic changes and changes in cell-matrix adhesion of MC1-derived BMSCs were compared to intra-patient control BMSCs in response to FGF2. RNA sequencing and quantitative real-time polymerase chain reaction revealed that pro-fibrotic genes and pathways were not detectable in MC1-derived BMSCs when cultured in the presence of FGF2. In addition, significantly increased cell-matrix adhesion of MC1-derived BMSCs was abolished in the presence of FGF2. In conclusion, the data demonstrated that FGF2 overrides key pro-fibrotic features of MC1 BMSCs in vitro. Usage of FGF2-supplemented media in studies of fibrotic mechanisms should be critically evaluated as it could override normally dominant biological and biophysical cues.

Water-window high harmonic generation with 0.8-µm and 2.2-µm OPCPAs at 100 kHz

We compare the generation of high-order harmonics in the water window (283-543 eV) with 0.8-µm and 2.2-µm few-cycle lasers at a pulse repetition rate of 100 kHz. Using conventional phase matching with the 2.2-µm driver and what we attribute to nonadiabatic self-phase-matching with the 0.8-µm driver, photons up to 0.6 keV (2 nm) are generated in both cases. Special attention is paid to the understanding of the generation mechanism with the 0.8-µm laser amplifier system. We use the same beamline and pump laser for both drivers, which allows for a direct flux comparison at the two driving wavelengths. For photon energies around 280 eV, a 10-100 times higher flux is obtained from the 2.2-µm versus the 0.8-µm laser system in helium and neon. The crossover at which the 2.2-µm yields a higher flux compared to the 0.8-µm driver is found to be as high as 0.2 keV. Our study supports the common approach of using long-wavelength lasers in a phase-matched regime for efficient generation of water-window harmonics, but also shows that the more widespread 0.8-µm wavelength can be used to generate water-window harmonics with an efficiency close to the one of a less common 2.2-µm source.

Pro-fibrotic phenotype of bone marrow stromal cells in Modic type 1 changes

Modic type 1 changes (MC1) are painful vertebral bone marrow lesions frequently found in patients suffering from chronic low-back pain. Marrow fibrosis is a hallmark of MC1. Bone marrow stromal cells (BMSCs) are key players in other fibrotic bone marrow pathologies, yet their role in MC1 is unknown. The present study aimed to characterise MC1 BMSCs and hypothesised a pro-fibrotic role of BMSCs in MC1. BMSCs were isolated from patients undergoing lumbar spinal fusion from MC1 and adjacent control vertebrae. Frequency of colony-forming unit fibroblast (CFU-F), expression of stem cell surface markers, differentiation capacity, transcriptome, matrix adhesion, cell contractility as well as expression of pro-collagen type I alpha 1, α-smooth muscle actin, integrins and focal adhesion kinase (FAK) were compared. More CFU-F and increased expression of C-X-C-motif-chemokine 12 were found in MC1 BMSCs, possibly indicating overrepresentation of a perisinusoidal BMSC population. RNA sequencing analysis showed enrichment in extracellular matrix proteins and fibrosis-related signalling genes. Increases in pro-collagen type I alpha 1 expression, cell adhesion, cell contractility and phosphorylation of FAK provided further evidence for their pro-fibrotic phenotype. Moreover, a leptin receptor high expressing (LEPRhigh) BMSC population was identified that differentiated under transforming growth factor beta 1 stimulation into myofibroblasts in MC1 but not in control BMSCs. In conclusion, pro-fibrotic changes in MC1 BMSCs and a LEPRhigh MC1 BMSC subpopulation susceptible to myofibroblast differentiation were found. Fibrosis is a hallmark of MC1 and a potential therapeutic target. A causal link between the pro-fibrotic phenotype and clinical characteristics needs to be demonstrated.

OP0083 INFECTIOUS AND AUTOINFLAMMATORY MODIC TYPE 1 CHANGES HAVE DIFFERENT PATHOMECHANISMS

Background:

Modic type 1 changes (MC1) are vertebral bone marrow (BM) edema that associate with non-specific low back pain (LBP). Two etiologies have been described. In the infectious etiology the anaerobic aerotolerant Cutibacterium acnes (C. acnes) invades damaged intervertebral discs (IVDs) resulting in disc infection and endplate damage, which leads to the evocation of an immune response. In the autoinflammatory etiology disc and endplate damage lead to the exposure of immune privileged disc cells and matrix to leukocytes, thereby evoking an immune response in the BM. Different etiologies require different treatment strategies. However, it is unknown if etiology-specific pathological mechanisms exist.

Objectives:

The aim of this study was to identify etiology-specific dysregulated pathways of MC1 and to perform in-depth analysis of immune cell populations of the autoinflammatory etiology.

Methods:

BM aspirates and biopsies were obtained from LBP patients with MC1 undergoing spinal fusion. Aspirates/biopsies were taken prior screw insertion through the pedicle screw trajectory. From each patient, a MC1 and an intra-patient control aspiration/biopsy from the adjacent vertebral level was taken. If C. acnes in IVDs adjacent to MC1 were detected by anaerobic bacterial culture, patients were assigned to the infectious, otherwise to the autoinflammatory etiology.

Total RNA was isolated from aspirates and sequenced (Novaseq) (infectious n=3 + 3, autoinflammatory n=5 + 5). Genes were considered as differentially expressed (DEG) if p-value < 0.01 and log2fc > ± 0.5. Gene ontology (GO) enrichment was performed in R (GOseq), gene set enrichment analysis (GSEA) with GSEA software.

Changes in cell populations of the autoinflammatory etiology were analyzed with single cell RNA sequencing (scRNAseq): Control and MC1 biopsies (n=1 + 1) were digested, CD45+CD66b- mononuclear cells isolated with fluorescence activated cell sorting (FACS), and 10000 cells were sequenced (10x Genomics). Seurat R toolkit was used for quality-control, clustering, and differential expression analysis.

Transcriptomic changes (n=5 + 5) of CD45+CD66b+ neutrophils isolated with flow cytometry from aspirates were analyzed as for total bulk RNAseq. Neutrophil activation (n=3 + 3) was measured as CD66b+ expression with flow cytometry. CD66bhigh and CD66blow fractions in MC1 and control neutrophils were compared with paired t-test.

Results:

Comparing MC1 to control in total bulk RNAseq, 204 DEG in the autoinflammatory and 444 DEG in the infectious etiology were identified with only 67 shared genes (Fig. 1a). GO enrichment revealed “T-cell activation” (p = 2.50E-03) in the autoinflammatory and “complement activation, classical pathway” (p=1.1E-25) in the infectious etiology as top enriched upregulated biological processes (BP) (Fig 1b). ScRNAseq of autoinflammatory MC1 showed an overrepresentation of T-cells (p= 1.00E-34, OR=1.54) and myelocytes (neutrophil progenitor cells) (p=4.00E-05, OR=2.27) indicating an increased demand of these cells (Fig. 1c). Bulk RNAseq analysis of neutrophils from the autoinflammatory etiology revealed an activated, pro-inflammatory phenotype (Fig 1d), which was confirmed with more CD66bhigh neutrophils in MC1 (+11.13 ± 2.71%, p=0.02) (Fig. 1e).

Figure 1.

(a) Venn diagram of DEG from total bulk RNAseq (b) Top enriched upregulated BP of autoinflammatory (left) and infectious (right) etiology (c) Cell clustering of autoinflammatory MC1 BM (d) Enrichment of “inflammatory response” gene set in autoinflammatory MC1 neutrophils (e) Representative histogram of CD66b+ expression in MC1 and control neutrophils.

Conclusion:

Autoinflammatory and infectious etiologies of MC1 have different pathological mechanisms. T-cell and neutrophil activation seem to be important in the autoinflammatory etiology. This has clinical implication as it could be explored for diagnostic approaches to distinguish the two MC1 etiologies and supports developing targeted treatments for both etiologies.

Disclosure of Interests:

None declared

OP0085 ALTERED EXPRESSION OF NEUROTROPHINS AND THEIR RECEPTORS IN THE SKIN OF PATIENT WITH COMPLEX REGIONAL PAIN SYNDROME (CRPS)

Background:

Complex regional pain syndrome (CRPS) is a rare painful condition that usually appears after trauma or surgery of the extremities. Symptoms include pain, sensory, sudomotor and vasomotor disturbances, trophic changes and impaired motor function. The course varies from mild to chronic disease with a high impact on daily functioning and quality of life. In skin tissue, sustained inflammatory, fibrotic processes together with reduced epidermal nerve fibers are reported. Neurotrophins and their receptors are mediators in cell-to-cell communication and key mediators of pain signaling

Objectives:

The aim of this study was to identify differential expression of neurotrophins and their receptors in the skin and skin fibroblasts of patients with CRPS

Methods:

Healthy controls (HC) and patients with acute CRPS with symptoms for less than 6 months fulfilling the Budapest criteria were recruited. Pain scores were evaluated by numeric rating scale (0=no pain, 100=maximal) and body perception was assessed using the Bath Body Perception Disturbance Scale (BBPDS) (0=no perception disturbance, 57=maximal perception disturbance).

Skin biopsies of the affected and/or non-affected side were taken. Immunohistochemistry on formalin-fixed, paraffin-embedded skin tissue slides was used to show NT3 expression in skin tissues. Blinded analysis was done by an experienced dermato-pathologist determined staining graduated by 0= none, 1= sparse, 2=moderate, 3= dense.

Skin fibroblast were isolated from skin biopsies by outgrowth cultures (CRPS, affected side, n=6 and HC, n=5). Cells (passage 3-6) were starved and subsequently stimulated with TNFα (10 ng/ml) or TGFβ (10 ng/ml) for 24 h to mimic active disease and total RNA was isolated by miRNeasy kit. Gene expression of neurotrophins (NGF, BDNF, and NT3) and neurotrophin receptors (NGFR, TrkA, TrkB and TrkC) was measured by quantitative real time PCR and quantified using the ΔΔCq method with GAPDH as a reference gene. ELISA was used to analyze NT3 protein expression in cell culture supernatants.

Results:

In 5 of 9 patients with CRPS immunohistological staining of NT3 showed an higher expression (from low to moderate) in the affected side versus the non-affected side. In 4 of 9 patients the expression of NT3 was high in the non-affected side (moderate/dense) and stayed high in the affected side.

Of interest, the patients with increasing expression of NT3 in the affected side showed increased pain scores (max pain 80+/-10.95, n=5 versus 48.16+/-18.16, n=4, p=0.059 and changed body perception 26.8+/-8.68 n=5 versus 6.5+/-3.91, n=4, p=0.016).

Isolated skin fibroblasts from the affected side of patients with CRPS compared to healthy skin fibroblasts showed higher basal gene expression of NT3 (log2 fold-change= 1.9 +/- 0.4, p= 0.005) and NGFR (log2 fold-change= 3.6 +/- 2.1, p=0.014). TNFα stimulated CRPS skin fibroblasts showed higher expression for NT3 (log2 fold-change= 2.1 +/- 1.2, p=0.002) compared to HC. TGFb stimulated skin fibroblasts of patients with CRPS showed higher expression of NT3 (log2 fold-change= 1.4+/-0.8, p=0.019), NGFR (log2 fold-change= 2.6 +/- 1.8, p=0.036) and TrkC (log2 fold-change= 2.3 +/- 1.8, p=0.032) compared to HC.

On protein level, NT3 showed a tendency of upregulation in unstimulated fibroblasts from CRPS patients comparing to HC (CRPS mean= 8.0 +/- 2.2 pg/ml, HC mean= 6.3 +/- 1.8 pg/ml, p=0.25). After TNFα stimulation, protein level of NT3 was significantly higher in CRPS skin fibroblasts (CRPS mean= 10.6 +/- 2.4 pg/ml, HC mean= 4.8 +/- 1.3 pg/ml, p=0.004).

Conclusion:

These data indicate a new role of skin fibroblasts in CRPS. Differential basal and stimulated expression of NT3, the receptor for NT3 (TrkC) and NGFR, the common receptor for all neurotrophins, indicates deregulated communication of fibroblasts with the sensory nerve fibers in CRPS. This might contribute to the dysregulated healing process and sustained pain.

Disclosure of Interests:

Sanne Stroeve: None declared, Stefan Dudli: None declared, Isabel Kolm: None declared, Irina Heggli: None declared, Nick Herger: None declared, Sabrina Catanzaro: None declared, Andreas Schweizer: None declared, Maurizio Calcagni Speakers bureau: Arthrex, Consultant of: Medartis, Arthrex, SilkBiomaterials, Grant/research support from: Medartis, Oliver Distler: None declared, Florian Brunner: None declared, Astrid Juengel: None declared

Autochthonous hepatitis E as a cause of acute-on-chronic liver failure and death: histopathology can be misleading but transaminases may provide a clue

BACKGROUND AND AIM

Acute decompensation and death have been observed in patients with acute hepatitis E virus (HEV) infection and preexisting liver cirrhosis. However, the clinical, laboratory and histological features need to be fully characterised.

METHODS

Some of us recently described the histological presentation of hepatitis E in a large panel of liver tissue specimens. Here, we conducted a case-control study to investigate the clinical and laboratory features of the subset of patients with HEV-related acute-on-chronic liver failure (ACLF) and death. Each patient was matched to three control patients with histologically confirmed severe alcoholic hepatitis based on sex, age, total bilirubin, INR, serum creatinine and MELD score on admission.

RESULTS

Of 5 patients who died in a context of HEV-related ACLF, 3 (60%) were male and the median age was 66 years (range 51&ndash;76). Median alanine aminotransferase (ALT) at presentation was 2610 U/l (range 705&ndash;3134) and aspartate aminotransferase (AST) 2818 U/l (range 1176&ndash;8611). Liver function was heavily altered in all patients. Histological analyses revealed steatohepatitis on a background of cirrhosis, suggestive of an alcoholic or nonalcoholic origin. Based on histopathology, alcoholic hepatitis was initially suspected in two patients and corticosteroid treatment was initiated. Ribavirin was started in four patients. Median time from hospitalisation to death was 17 days (range 6&ndash;25 days). AST levels in patients with HEV-related ACLF were significantly higher as compared to the matched patients with severe alcoholic hepatitis.

CONCLUSION

Typical histopathological features of viral hepatitis may be absent in ACLF caused by HEV infection. HEV infection should be sought in acute decompensation of cirrhosis and ACLF even in the absence of histological changes suggesting viral infection.

Hepatic manifestations of drug reaction with eosinophilia and systemic symptoms syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening drug reaction, which can affect multiple organs. Patients with DRESS syndrome and hepatic manifestations may present alterations ranging from mild hepatitis to acute liver failure. The diagnosis might be difficult, and the management of these patients is challenging. This report analyzes a series of five cases reporting the clinical presentation, which ranged from acute hepatitis to liver failure, and discussed their treatment.

[Interrater reliability of the criteria-based assessment of criminal responsibility in paraphilic disorders]

BACKGROUND

For the assessment of criminal responsibility in the context of sexual delinquency, the evaluation of the severity of a paraphilic disorder and the ability to be controlled are of particular importance. Established assessment criteria are insufficiently operationalized.

AIM AND METHODS

The existing criteria were tested by experts of various professional groups with respect to the reliability. For this purpose, 14 experts assessed the criteria of 2 different sets of criteria based on 2 case vignettes (see electronic supplementary material).

RESULTS AND CONCLUSION

The interrater reliability (IRR) with reference to the criteria of Briken and Müller was higher than the previously established criteria of Boetticher et al. The evaluation of the subjective importance of the criteria of both assessment scales showed that all criteria were rated as at least of average importance. It could thus be useful to initially include both sets of criteria for a greater transparency in the assessment process and to investigate this procedure in further studies.

High-power few-cycle near-infrared OPCPA for soft X-ray generation at 100 kHz

We present a near-infrared optical parametric chirped-pulse amplifier (OPCPA) and soft X-ray (SXR) high-harmonic generation system. The OPCPA produces few-cycle pulses at a center wavelength of 800 nm and operates at a high repetition rate of 100 kHz. It is seeded by fully programmable amplitude and phase controlled ultra-broadband pulses from a Ti:sapphire oscillator. The output from the OPCPA system was compressed to near-transform-limited 9.3-fs pulses. Fully characterized pulse compression was recorded for an average power of 22.5 W, demonstrating pulses with a peak power greater than 21 GW. Without full temporal characterization, high-power operation was achieved up to 35 W. We demonstrate that at such high repetition rates, spatiotemporally flattened pump pulses can be achieved through a cascaded second-harmonic generation approach with an efficiency of more than 70%. This combination provides a compelling OPCPA architecture for scaling the peak power of high-repetition-rate ultra-broadband systems in the near-infrared. The output of this 800-nm OPCPA system was used to generate SXR radiation reaching 190 eV photon energy through high-harmonic generation in helium.

THU0451 CELL-MATRIX ADHESION OF BONE MARROW STROMAL CELLS IN MODIC TYPE 1 CHANGES IS INCREASED AND RELATES TO INCREASED EXPRESSION OF INTEGRIN Β1

Background:

Modic type 1 changes (MC1) are vertebral bone marrow lesions associated with non-specific low back pain (LBP). The pathophysiology of MC1 includes inflammation, fibrosis, and high bone turnover. Bone marrow stromal cells (BMSCs) are key regulators of these processes: BMSCs contribute to inflammation by regulating myelopoiesis/osteoclastogenesis; BMSCs can differentiate into osteoblasts contributing to high bone turnover, and BMSCs can differentiate into pro-fibrotic myofibroblasts.

Objectives:

To identify dysregulated biological processes in MC1 BMSCs contributing to the pathobiology of MC1.

Methods:

Bone marrow aspirates were obtained from LBP patients with MC1 undergoing lumbar spinal fusion. Aspirates were taken prior to screw insertion. From each patient, a MC1 and a healthy control (HC) aspirate from the adjacent vertebral body was collected. BMSCs were isolated by plastic adherence and expanded. RNA from BMSCs passage 3 was sequenced (n=3 + 3) (Illumina Novaseq) and gene ontology of significantly dysregulated genes (p-value < 0.05) was analyzed. Specificity and rate of BMSC matrix adhesion were quantified: BMSCs (n=8 + 8) were seeded on fibronectin-coated, collagen-I-coated, and non-coated plastic dishes. BMSC adhesion was evaluated from 15min to 30min (Δ 30min - 15min). Percentage of adherent cells of MC1 and HC BMSC was compared with paired t-test. In order to identify integrins responsible for dysregulated cell-matrix adhesion, gene expression of 15 relevant integrins was measured by quantitative real-time PCR (qPCR). Normalized expressions were compared between MC1 and HC BMSC with paired t-test. Integrin β1 protein level was semi quantitatively analyzed by Western Blot (n = 5 + 5) and normalized to β-Actin expression.

Results:

By RNA sequencing, 154 genes were differentially expressed between MC1 and HC BMSCs (p-value ≤ 0.01; log2-ratio ≥ 0.5). Gene ontology enrichment analysis revealed an overrepresentation of the biological process “cell-matrix adhesion” among all significantly regulated genes (p-value < 9.3e-13). A change in cell adhesion was corroborated with adhesion assay. Binding (Δ 30min - 15min) to collagen I (MC1 + 16%, HC +10%, p-value = 0.10), fibronectin (MC1 + 17%, HC +6%, p-value = 0.03), and non-coated surface (MC1 + 46%, HC +35%, p-value = 0.05) was increased in MC1 (Figure 1). Integrin gene expression analysis revealed significant upregulation of integrin beta-1 gene (ITGB1) in MC1 vs. HC (fold change = 1.24, p-value = 0.047), whereas there was no significant difference between the other integrins tested. On protein level, integrin β1 was upregulated in MC1 in four out of five patients (Figure 2).

Figure 1.

Adhesion assay.

Figure 2.

Western Blot analysis.

Conclusion:

Adhesion of BMSCs to matrix and integrin β1 expression are increased in MC1. Integrin β1 is essential for cell-matrix adhesion and an important contributor to the initiation and progression of tissue fibrosis, a hallmark of MC1. Therefore, BMSCs and integrin β1 might be relevant novel targets for the treatment of MC1.

Disclosure of Interests: :

Irina Heggli: None declared, Susanne Epprecht: None declared, Tamara Mengis: None declared, Astrid Juengel: None declared, Michael Betz: None declared, Jose Spirig: None declared, Florian Wanivenhaus: None declared, Florian Brunner: None declared, Mazda Farshad: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Stefan Dudli: None declared

Psychosomatic-psychotherapeutic treatment in an evening clinic: a qualitative examination of patients' expectations and experiences

Background

Over a course of 10 weeks the psychosomatic–psychotherapeutic evening clinic at the University of Heidelberg offers an intensive and multimodal 3-h treatment program on three evenings a week. The clinic aims at accommodating patients who on the one hand do not fit the criteria of partial or full-time inpatient therapy, but on the other hand requires a more intensified therapy dose than the usual German outpatient settings can cater for. In the presented monocentric, qualitative study, we wanted to examine this treatment concept with regard to the patients’ specific concerns, expectations, and individual experiences. By contrasting differences in intensity of outpatient and inpatient treatment, we aimed to identify those characteristics of the evening clinic setting that were perceived as especially helpful.

Method

Each of the 25 patients was interviewed twice, using semi-structured interviews. The interviews took place before (T0) and after (T1) the 10-week treatment interval. A qualitative content analysis of the transcribed interviews was performed using the software “MaxQDA”.

Results

We identified a total of 1609 separate codes and grouped them into 33 topics and 5 overarching categories. Here, we found some aspects independent of the therapeutic setting, and others concerning the patients’ specific expectations and experiences resulting from the particularities of the evening clinic as an outpatient setting including certain inpatient characteristics. This included the possibility of patients continuing to work and being able to fulfil social obligations, i.e. childcare or caring for relatives, while at the same time undergoing intensive psychotherapeutic treatment.

Conclusions

Our results show that the evening clinic concept is particularly suitable for patients with mental and psychosomatic disorders who require intensified multimodal therapy while continuing to meet their obligations in their private and working lives. However, in comparison to other therapeutic methods, this concept generated greater stress and time challenges. Patients should therefore have a reasonably good standard of functioning in everyday life and sufficient coping resources. This is especially important for patients who continue working in their jobs while undergoing treatment. So far, there is a lack of quantitative data which would be needed to evaluate the effectiveness of this novel setting.

Hepatitis E virus as a cause of acute hepatitis acquired in Switzerland

BACKGROUND

Autochthonous hepatitis E is increasingly recognized as zoonotic infection in western countries. Serological assays have varying sensitivity and specificity.

METHODS

We implemented molecular testing to identify and characterize acute hepatitis E acquired in Switzerland.

RESULTS

Ninety-three cases of mostly symptomatic acute hepatitis E acquired in Switzerland were documented by PCR between November 2011 and December 2016. Median HEV RNA was 7.5 x 10⁴ IU/mL (range, 5.3 to 4.7 x 10⁷ IU/mL). HEV genotyping was successful in 78 patients, revealing genotype 3 in 75 and genotype 4 in three patients. Phylogenetic analyses revealed a few limited geographical and temporal clusters. Of the 91 patients with available anti-HEV IgM serology, four were negative; three of these were also IgG-negative, likely as a result of immunosuppression, and one was IgG-positive, a constellation compatible with HEV reinfection. Median age of the patients was 58 years (range, 20-80 years); 71 (76.3%) were men and 49 of these (69.0%) were ≥ 50 years old. The clinical course was particularly severe in patients with underlying chronic liver disease, with fatal outcome in two patients. Six patients (6.5%) presented with neuralgic amyotrophy.

CONCLUSIONS

Nucleic acid-based diagnosis reveals HEV as a relevant cause of acute hepatitis in Switzerland. Middle-aged and elderly men constitute the majority of symptomatic patients. Testing for HEV should be included early in the diagnostic workup of acute hepatitis and of neuralgic amyotrophy, a typical extrahepatic manifestation of HEV genotype 3 infection.

Painful swelling after a noxious event and the development of complex regional pain syndrome 1: A one-year prospective study

BACKGROUND

The timing of diagnosis of complex regional pain syndrome (CRPS) 1 remains a challenge due to the large heterogeneity of clinical presentations. We describe the distribution and differences in outcomes and clinical manifestations between time points and patient groups with and without CRPS 1 following an initiating event.

METHODS

Prospective cohort study with a consecutive registration of patients presenting with painful swelling of the affected extremity after an initiating event and follow-up visits after 3, 6 and 12 months.

RESULTS

Forty-two patients were enrolled (37 females, mean age 55.1 years). At baseline, 35 participants (83%, females n = 30) fulfilled the diagnostic criteria for CRPS 1. At 3 months, 19 out of the initial 35 CRPS 1 patients (54%) did not meet the diagnostic criteria anymore. Besides our inclusion criteria of a painful swelling, early manifestations indicating a CRPS 1 primarily include an impaired quality of life (SF-35, EQ5-D), more pain (NRS, MPQ) and restricted range of motion.

CONCLUSIONS

CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the first 3 months, signs and symptoms do not improve significantly at 1 year. In order to identify prognostic risk factors large prospective cohort studies are needed.

SIGNIFICANCE

This prospective cohort study follows patients with complaints most suspected for complex regional pain syndrome (CRPS) 1. CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the 3 months, symptoms do not improve significantly at 1 year.

THRIVE score predicts clinical and radiological outcome after endovascular therapy or thrombolysis in patients with anterior circulation stroke in everyday clinical practice

BACKGROUND AND PURPOSE

Based on the data of several trials the Totaled Health Risks in Vascular Events (THRIVE) score has been shown to predict outcome after either intravenous thrombolysis (IVT) or endovascular therapy (ET) in acute stroke patients. It is unknown whether the THRIVE score can also predict outcome in everyday clinical practice. Using our prospectively obtained stroke database the utility of the THRIVE score to predict clinical and radiological outcome in everyday clinical practice was analysed.

METHODS

The relationships between THRIVE and good outcome (modified Rankin Scale ≤ 2 at discharge), poor outcome (modified Rankin Scale 5-6), in-hospital death, symptomatic intracranial haemorrhage (SICH) as well as infarct size were examined in patients with distal intracranial carotid artery, M1 and M2 occlusions after either IVT or ET.

RESULTS

From January 2008 to October 2016 a total of 546 patients were treated with IVT and 492 patients received ET with stent retrievers (with or without IVT). In both treatment groups the THRIVE score predicted clinical outcome (Mantel-Haenszel chi-squared tests for trend P < 0.001 for good outcome, P < 0.001 for poor outcome and P < 0.001 for in-hospital death). In the ET group the THRIVE score remained an independent predictor of outcome after controlling for recanalization. The THRIVE score was associated with the infarct size after IVT or ET, whereas it did not predict SICH rates in either treatment group.

CONCLUSIONS

In everyday clinical practice the THRIVE score strongly predicts clinical outcome and the extent of ischaemia after ET or IVT in patients with anterior circulation large vessel occlusions.

Prevention and treatment of variceal haemorrhage in 2017

Variceal haemorrhage is a major complication of portal hypertension that still causes high mortality in patients with cirrhosis. Improved knowledge of the pathophysiology of portal hypertension has recently led to a more comprehensive approach to prevent all the complications of this condition. Thus, optimal treatment of portal hypertension requires a strategy that takes into account the clinical stage of the disease and all the major variables that affect the risk of progression to the next stage and death. In patients with compensated liver disease, the correction of factors influencing the progression of fibrosis, in particular aetiologic factors, is now feasible in many cases and should be achieved to prevent the development or progression of gastroesophageal varices and hepatic decompensation. Once gastroesophageal varices have developed, non-selective beta-blockers remain the cornerstone of therapy. Carvedilol provides a greater decrease in portal pressure and is currently indicated as a first-choice therapy for primary prophylaxis. The treatment of acute variceal haemorrhage includes a combination of vasoactive drugs, antibiotics and endoscopic variceal band ligation. In high-risk patients, the early use of transjugular intrahepatic portosystemic shunt (TIPS) lowers the risk of re-bleeding and improves survival. Transjugular intrahepatic portosystemic shunt is the choice for uncontrolled variceal bleeding; a self-expandable metal stent or balloon tamponade can be used as a bridging measure. The combination of non-selective beta-blockers and endoscopic variceal band ligation reduces the risk of recurrent variceal bleeding and improves survival. In these cases, statins seem to further improve survival. Transjugular intrahepatic portosystemic shunt is indicated in patients who rebleed during secondary prophylaxis.

Impact of ASPECTS on computed tomography angiography source images on outcome after thrombolysis or endovascular therapy in large vessel occlusions

BACKGROUND AND PURPOSE

Endovascular therapy (ET) is superior to intravenous thrombolysis (IVT) in selected patients with anterior circulation large vessel occlusions. However, it is unclear if this positive effect also applies to patients with extensive early ischaemic changes. The aim of this study was to analyze the impact of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on the CT angiography source images (SI) on outcome after ET or IVT.

METHODS

Using our prospectively obtained stroke database and the admission SI-ASPECTS divided into three groups (0-5, 6-7 and 8-10), primarily the rates of good outcome [modified Rankin Scale (mRS) ≤2 at discharge] after either ET (n = 255) or IVT (n = 479) were compared.

RESULTS

A favorable SI-ASPECTS (8-10) was present in 501 patients, 132 patients had a moderately favorable SI-ASPECTS (6-7) and 101 patients had an unfavorable SI-ASPECTS (0-5). Irrespective of the treatment modality, no patient with an unfavorable SI-ASPECTS had a good outcome and 38% died during hospital stay. Whilst significantly more patients with a favorable SI-ASPECTS had a good outcome after ET than after IVT (51% vs. 35%, P < 0.01), there was only a non-significant trend towards a good outcome after ET than after IVT in patients with a moderately favorable ASPECTS (25% vs. 14%, P = 0.1).

CONCLUSION

Patients with extensive early ischaemic changes on CT scans (SI- ASPECTS ≤5) might not profit from ET. The impact of ET on outcome in patients with moderately favorable SI-ASPECTS should be addressed in further trials.

Ultrasonographic, CTI and MRI of Aberrant Internal Carotid Artery: Infrequent but Important to Know

This article describes the aberrant course of the internal carotid artery (ICA) through the middle ear as an extremely rare vascular anomaly. On the basis of a case report, the findings of magnetic resonance imaging, computed tomography imaging, and especially color-coded duplex sonography are presented. The diagnosis of an aberrant ICA is important to avoid severe surgical complications of a retrotympanic mass as well as unnecessary diagnostic or therapeutic approaches in expectation of a stroke.

Two-photon fluorescence imaging with 30 fs laser system tunable around 1 micron

We developed a low-cost, low-noise, tunable, high-peak-power, ultrafast laser system based on a SESAM-modelocked, solid-state Yb tungstate laser plus spectral broadening via a microstructured fiber followed by pulse compression. The spectral selection, tuning, and pulse compression are performed with a simple prism compressor. The output pulses are tunable from 800 to 1250 nm, with the pulse duration down to 25 fs, and average output power up to 150 mW, at 80 MHz pulse repetition rate. We introduce the figure of merit (FOM) for the two-photon and multi-photon imaging (or other nonlinear processes), which is a useful guideline in discussions and for designing the lasers for an improved microscopy signal. Using a 40 MHz pulse repetition rate laser system, with twice lower FOM, we obtained high signal-to-noise ratio two-photon fluorescence images with or without averaging, of mouse intestine section and zebra fish embryo. The obtained images demonstrate that the developed system is capable of nonlinear (TPE, SHG) imaging in a multimodal operation. The system could be potentially used in a variety of other techniques including, THG, CARS and applications such as nanosurgery.

Neural correlates of saccadic inhibition in healthy elderly and patients with amnestic mild cognitive impairment

Performance on tasks that require saccadic inhibition declines with age and altered inhibitory functioning has also been reported in patients with Alzheimer's disease. Although mild cognitive impairment (MCI) is assumed to be a high-risk factor for conversion to AD, little is known about changes in saccadic inhibition and its neural correlates in this condition. Our study determined whether the neural activation associated with saccadic inhibition is altered in persons with amnestic mild cognitive impairment (aMCI). Functional magnetic resonance imaging (fMRI) revealed decreased activation in parietal lobe in healthy elderly persons compared to young persons and decreased activation in frontal eye fields in aMCI patients compared to healthy elderly persons during the execution of anti-saccades. These results illustrate that the decline in inhibitory functions is associated with impaired frontal activation in aMCI. This alteration in function might reflect early manifestations of AD and provide new insights in the neural activation changes that occur in pathological ageing.

How do Individuals with Complete Androgen Insensitivity Syndrome, Mayer-Rokitansky-Küster-Hauser Syndrome or Polycystic Ovary Syndrome Experience Contact to Other Affected Persons?

Persons with different sex characteristics may suffer from a feeling of being "different" or "not normal". In this study, persons with one of 3 diagnoses (complete androgen insensitivity syndrome [CAIS]; Mayer-Rokitansky-Küster-Hauser syndrome [MRKHS], polycystic ovary syndrome [PCOS]) were asked whether they had contact to other affected persons and how they assessed this contact. The correlation between contact and psychological distress was evaluated. Material and Methods: Information on contacts to other affected individuals was obtained using a written questionnaire. Psychological distress was measured using the German version of the BSI (Brief Symptom Inventory). Results: Data from 11 individuals with CAIS, 49 women with MRKHS and 55 women with PCOS was analysed. The frequency of contacts to other affected individuals differed between the different diagnostic groups (with the highest frequency reported for the group with CAIS, and the lowest for the group with PCOS). Overall, the majority of individuals considered such contacts beneficial (CAIS 81.8 %; MRKHS 90 %; PCOS 83.3 %). The frequency of contacts and their assessment were not found to be correlated with psychological distress. The three diagnostic groups differed in the proportion of people who indicated a wish for contact with other affected persons. The desire to have contact with other affected persons was most commonly expressed by women with PCOS and high levels of psychological distress (60.9 %). Conclusion: Persons with different sex characteristics can benefit from contact to other affected individuals. Particularly women with PCOS and increased levels of psychological distress may benefit if the issue of support groups is addressed during treatment.

Concordance of qualitative bone scintigraphy results with presence of clinical complex regional pain syndrome 1: meta-analysis of test accuracy studies

BACKGROUND

To date, no attempt has been made to investigate the agreement between qualitative bone scintigraphy (BS) and the presence of complex regional pain syndrome 1 (CRPS 1) and the agreement between a negative BS in the absence of CRPS 1.

AIMS

To summarize the existing evidence quantifying the concordance of qualitative BS in the presence or absence of clinical CRPS 1.

DATA SOURCES

We searched Medline, Embase, Dare and the Cochrane Library and screened bibliographies of all included studies.

STUDY ELIGIBILITY CRITERIA

We selected diagnostic studies investigating the association between qualitative BS results and the clinical diagnosis of CRPS 1. The minimum requirement for inclusion was enough information to fill the two-by-two tables.

RESULTS

Twelve studies met our inclusion criteria and were included in the meta-analysis. The pooled mean sensitivity of 12 two-by-two tables was 0.87 (95% CI, 0.68-0.97) and specificity was 0.69 (95% CI, 0.47-0.85). The pooled mean sensitivity for the subgroup with clearly defined diagnostic criteria (seven two-by-two tables) was 0.80 (95% CI, 0.44-0.95) and specificity was 0.73 (95% CI, 0.40-0.91).

CONCLUSIONS

Based on this study, clinicians must be advised that a positive BS is not necessarily concordant with presence of absence or CRPS 1. Given the moderate level of concordance between a positive BS in the absence of clinical CRPS 1, discordant results potentially impede the diagnosis of CRPS 1.

Femtosecond laser nanosurgery of sub-cellular structures in HeLa cells by employing Third Harmonic Generation imaging modality as diagnostic tool

Femtosecond laser assisted nanosurgery of microscopic biological specimens is a relatively new technique which allows the selective disruption of sub-cellular structures without causing any undesirable damage to the surrounding regions. The targeted structures have to be stained in order to be clearly visualized for the nanosurgery procedure. However, the validation of the final nanosurgery result is difficult, since the targeted structure could be simply photobleached rather than selectively destroyed. This fact comprises a main drawback of this technique. In our study we employed a multimodal system which integrates non-linear imaging modalities with nanosurgery capabilities, for the selective disruption of sub-cellular structures in HeLa cancer cells. Third Harmonic Generation (THG) imaging modality was used as a tool for the identification of structures that were subjected to nanosurgery experiments. No staining of the biological samples was required, since THG is an intrinsic property of matter. Furthermore, cells' viability after nanosurgery processing was verified via Two Photon Excitation Fluorescence (TPEF) measurements.

Subcutaneous injection of liquid and foamed polidocanol: extravasation is not responsible for skin necrosis during reticular and spider vein sclerotherapy

BACKGROUND

Cutaneous necrosis is one of the most annoying complications of reticular and spider vein sclerotherapy. The precise incidence of the complication is not known, although various sources reported incidence between 0.2% and 1.2%. Among a few mechanisms proposed to explain it, extravasation of the sclerosant into the perivascular tissue has been cited as the major cause.

OBJECTIVES

The aim of the experimental study in rats was to examine the potential of various concentrations and volumes of polidocanol in both liquid and foam forms to cause cutaneous necrosis after superficial subcutaneous injection.

METHODS

Twenty-four female Sprague Dawley rats were injected subcutaneously different concentrations (0.5%, 1%, 2% and 3%) of polidocanol as well as different preparations of polidocanol (liquid vs. foam) and volumes (0.1-0.5 mL). The animals were sacrificed 10 days after injections and biopsy specimens were obtained.

RESULTS

Cutaneous necrosis was not seen at volumes <0.5 mL regardless of the concentration or form of polidocanol injected. Foam preparation was shown to be less potent in inducing necrosis with a minimal strength being 2% in comparison with the liquid form where 1% was sufficient to produce overt cutaneous necrosis.

CONCLUSIONS

This experimental study shows that extravasation of polidocal in usual circumstances of sclerotherapy of spider and reticular veins cannot be a significant cause of cutaneous necrosis rarely observed in this setting. It is particularly true for the foamed polidocanol where 1% strength seems safe if injected extravascularly in volumes up to 0.5 mL.

Chronic endothelin-A receptor antagonism is as protective as angiotensin converting enzyme inhibition against cardiac dysfunction in diabetic rats

BACKGROUND AND PURPOSE

Diabetes mellitus is associated with a specific cardiomyopathy. We compared the cardioprotective effects of an endothelin-A receptor blocker (ET(A)-RB) with those of an angiotensin-converting enzyme inhibitor (ACE-I) in rats with streptozotocin (STZ)-induced diabetes.

EXPERIMENTAL APPROACH

Diabetic rats were left untreated or received either the ET(A)-RB atrasentan or the ACE-I ramipril (each 3 mg kg(-1) per day) orally for 8 weeks. Isolated isovolumic heart function was studied during normoxia and in response to ischaemia-reperfusion. Cardiac fibrosis, tissue oxidative stress and tissue nitric oxide synthase (NOS) activity were determined.

KEY RESULTS

Basal left ventricular systolic contractility was lower in diabetic compared to nondiabetic hearts and ET(A)-RB or ACE-I treatment significantly antagonised the decline. Following 15 min of no-flow ischaemia, reperfusion systolic function was depressed and left-ventricular end-diastolic pressure (LVEDP) was elevated in diabetic hearts. ET(A)-RB or ACE-I treatment significantly improved recovery of reperfusion systolic and diastolic function, without differences between groups. Hydroxyproline (an index of tissue fibrosis) and malondialdehyde (a measure of tissue oxidative stress) were elevated at the end of reperfusion in diabetic, compared to nondiabetic hearts. Either treatment reduced hydroxyproline and malondialdehyde to control level. Constitutive NOS activity was similar in nondiabetic and diabetic hearts and unaffected by ET(A)-RB or ACE-I treatment.

CONCLUSIONS AND IMPLICATIONS

These results suggest that in experimental type 1 diabetes ET(A)-RB is as effective as an ACE-I in ameliorating myocardial functions during normoxia and ischaemia-reperfusion. Combining the two treatments neither afforded additive effects, nor diminished any protection effect seen with either drug.

Plating in Proximal Humeral Fractures

Improved imaging, updated knowledge regarding humeral head perfusion and adapted fixation techniques with implants having better purchase also in osteopenic bone, have influenced the treatment of proximal humeral fractures in recent years. Demographic evolution and a more active population even among the older age groups will increase the incidence of this fracture, which is already the third most frequent fracture after hip and distal radius fractures in elderly patients. Long-term morbidity related to the treatment of these fractures like avascular humeral head necrosis, non-union, malunion, shoulder stiffness, persistent pain and functional disability are the challenging factors to be overcome. Plate osteosynthesis with angular stable implants have shown to address some of these problems and to broaden the spectrum of indication towards anatomic fracture stabilization even for severely displaced three- and four-part fractures instead of replacing the humeral head with an endoprosthesis, as long as a stable fixation is possible. Open access surgery is often needed for anatomic reconstruction of complex and displaced fractures. This calls for immediate postoperative mobilization with active-assisted ROM exercise to prevent subdeltoidal adhesions. Even though plating of proximal humeral fractures with angular stable implants has shown promising first clinical results, there still remain elevated complication rates especially in the elderly osteoporotic patient population. Recent clinical reports using angular stable plates provided only data with a low level of evidence to help in decision-making. The comparison with historical series using non-angular stable plates in respect to the long-term morbidity should help to better evaluate the value of locked plates inserted with less-extensive soft-tissue exposure.

[Effects of Maitland's manual mobilization on the thoracic spine]

The goal of manual therapy is to decrease pain and to increase function of the spine and peripheral joints. The method introduced by Maitland is widely used in manual medicine. However, no objective changes in the mobility of the thoracic spine after performing manual mobilization have been published in the literature. The aim of this study is to reveal possible changes in the segmental mobility of the thoracic spine after posterior-anterior manipulations without thrust in comparison with a control group. In addition, significant changes within the treatment group were examined. Thirty-six volunteers were randomized into an intervention (16) and a control group (20). The intervention group was treated two times a week for three weeks. The control group received no treatment. The mobility was objectively measured by using Medimouse. No significant difference in the mobility of the thoracic spine could be shown within the intervention group and in comparison with the control group.

Femtosecond pulse generation with a diode-pumped Yb3+:YVO4 laser

A diode-pumped Yb:YVO4 laser has been passively mode locked for the first time, to our knowledge. 120 fs pulses with an average output power of 300 mW and a peak power as high as 14.5 kW are obtained by use of a semiconductor saturable-absorber mirror for passive mode locking. The optical spectrum has a 10 nm bandwidth (full width at half-maximum) and is centered at 1021 nm.