Subgrouping of facilitatory or inhibitory conditioned pain modulation responses in patients with chronic knee pain. Explorative analysis from a multicentre trial

BACKGROUND

Facilitatory and inhibitory conditioned pain modulation (CPM) responses are observed in healthy volunteers and chronic pain patients, but the clinical implications for phenotyping are unknown. This study aimed to subgroup and compare chronic knee pain patients according to their CPM responses.

METHODS

This explorative, cross-sectional study included 127 patients with chronic knee pain (osteoarthritis or following total knee arthroplasty). Individual CPM responses were categorized as facilitatory (test stimuli pain intensity increased when conditioning stimuli were applied), as inhibitory (test stimuli pain intensity decreased) or as no change (defined as less than 5.3% change in pain intensity). Outcomes were clinical pain intensities, temporal summation, widespread pain, self-reported physical function, PainDETECT questionnaire and Pain Quality Assessment Scale. Data were analysed as comparisons between the inhibitory and the facilitatory groups and using multivariate linear regression models.

RESULTS

Fifty-four patients had facilitatory CPM responses, 49 had inhibitory CPM responses, and 24 showed no change in CPM response. A between-group difference was observed for self-reported physical function, with the facilitatory CPM group reporting better function (54.4 vs. 46.0, p = 0.028) and the facilitatory CPM group reported more deep pain sensations (3.2 vs. 2.0, p = 0.021). The remaining outcomes showed no between-group differences. Higher clinical pain intensity and facilitated temporal summation were associated in the facilitated CPM group but not in the inhibitory CPM group.

CONCLUSION

These explorative findings indicated that quantitative clinical and experimental differences exist between facilitatory or inhibitory CPM responses in a chronic knee pain patient population. Differences in patients' CPM responses should be further investigated to unravel possible clinical importance.

SIGNIFICANCE

Our findings confirm that conditioned pain modulation consist of inhibitory and facilitatory responders among a patient population with chronic knee pain. This explorative study indicates that patients with either facilitatory or inhibitory conditioned pain modulation could exhibit differences in pain outcomes. Subgrouping of chronic pain patients depending on individual conditioned pain modulation responses could be considered in phenotyping patients prior to inclusion in clinical trials or used for personalizing the management regime.

Which patients with chronic low back pain respond favorably to multidisciplinary rehabilitation? A secondary analysis of a randomized controlled trial

OBJECTIVES

The aim of this study was to identify prognostic variables at baseline associated with being responding favorably to multidisciplinary rehabilitation in patients with chronic low back pain (CLBP).

METHODS

A responder analysis was conducted based on data from a randomized controlled trial with 26-week follow-up including 165 patients with CLBP treated at a Danish multidisciplinary rehabilitation center. Patients were dichotomized into responders and non-responders based on the outcome of a minimal clinically important difference of six points on the Oswestry Disability Index. The associations between prognostic variables and responders were analyzed using logistic regression.

RESULTS

A total of 139 patients completed the study, of which 42% were classified as responders. Sex and employment status were statistically significant, with a decreased odds ratio (OR) of being a responder found for males compared to females (OR = 0.09, 95% CI = 0.02-0.48) and for being on temporary or permanent social benefits (OR = 0.28, 95% CI = 0.10-0.75) compared to being self-supporting or receiving retirement benefits. Statistically significant interaction (OR = 8.84, 95% CI = 1.11-70.12) was found between males and being on temporary or permanent social benefits.

CONCLUSIONS

In patients with CLBP, female patients as well as patients who were self-supporting or receiving retirement benefits were significantly more likely than male patients or patients on temporary or permanent social benefits to be a responder to multidisciplinary rehabilitation.

Recommendations for the delivery of therapeutic exercise for people with knee and/or hip osteoarthritis. An international consensus study from the OARSI Rehabilitation Discussion Group

OBJECTIVE

To develop evidence-informed recommendations to support the delivery of best practice therapeutic exercise for people with knee and/or hip osteoarthritis (OA).

DESIGN

A multi-stage, evidence-informed, international multi-disciplinary consensus process that included: 1) a narrative literature review to synthesise existing evidence; 2) generation of evidence-informed proposition statements about delivery of exercise for people with knee and/or hip OA by an international multi-disciplinary expert panel, with statements refined and analysed thematically; 3) an e-Delphi survey with the expert panel to gain consensus on the most important statements; 4) a final round of statement refinement and thematic analysis to group remaining statements into domains.

RESULTS

The expert panel included 318 members (academics, health care professionals and exercise providers, patient representatives) from 43 countries. Final recommendations comprised 54 specific proposition statements across 11 broad domains: 1) use an evidence-based approach; 2) consider exercise in the context of living with OA and pain; 3) undertake a comprehensive baseline assessment with follow-up; 4) set goals; 5) consider the type of exercise; 6) consider the dose of exercise; 7) modify and progress exercise; 8) individualise exercise; 9) optimise the delivery of exercise; 10) focus on exercise adherence; and 11) provide education about OA and the role of exercise.

CONCLUSION

The breadth of issues identified as important by the international diverse expert panel highlights that delivering therapeutic exercise for OA is multi-dimensional and complex.

Trajectory for 66 patients treated with periacetabular osteotomy (PAO) and subsequent total hip arthroplasty: a follow-up study including 1378 hips from the Aarhus PAO database

INTRODUCTION

Outcomes for patients treated with PAO and subsequent total hip arthroplasty (THA) remain unclear. We evaluated patient-reported outcomes among patients treated with PAO and subsequent THA and investigated differences in the number of additional surgical procedures after PAO among patients treated with PAO and subsequent THA and patients treated with PAO only.

MATERIALS AND METHODS

1378 hips underwent PAO and subsequently 66 hips were treated with THA. We evaluated the Hip disability and Osteoarthritis Outcome Score (HOOS) and physical activity questions for the 66 hips. Additional surgery after PAO was identified through inquiry to the Danish National Patient Registry.

RESULTS

13% undergoing PAO and subsequent THA reported a HOOS pain score ≤ 50 indicating a clinical failure. The risk difference for hip arthroscopy after PAO within 2 and 4 years was 14% (CI 5-23%) and 26% (CI 15-38%) in favor of hips treated with PAO only. Similarly, the risk difference for screw removal within 2 and 4 years was 19% (CI 8-29%) and 23% (CI 12-34%).

CONCLUSION

87% of patients undergoing PAO and subsequent THA had little or no hip pain. However, these patients received a high number of additional surgeries after PAO. Surgeons and patients may consider if additional surgery after PAO may be the first choice in a series of actions leading to conversion to THA.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND

Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program.

METHODS

Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57-80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics.

RESULTS

Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19).

CONCLUSION

Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting.

TRIAL REGISTRATION

According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

The role of interleukin-18 in the diagnosis and monitoring of hemophagocytic lymphohistiocytosis/macrophage activation syndrome - a systematic review

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, hyperinflammatory disorder, characterized by multiorgan failure, fever and cytopenias. The diagnosis of HLH and its subtype Macrophage Activation Syndrome (MAS) remains a challenge. Interleukin 18 (IL-18) is emerging as a potential biomarker for HLH/MAS but is currently not a part of diagnostic criteria. This systematic review aimed to assess the potential role of IL-18 in the diagnosis and monitoring of HLH and MAS, and was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and Embase were searched on 30 January 2020. Studies included all subtypes of HLH and a range of underlying disorders in both children and adults. A total of 14 studies were included. Generally, serum IL-18 was elevated in both primary and secondary HLH (> 1000 pg/ml) compared with other inflammatory conditions and with healthy individuals; thus, serum IL-18 may be able to discriminate between HLH and other inflammatory conditions. Significantly increased IL-18 (> 10 000 pg/ml) was also consistently described in MAS compared with other subtypes of HLH. The ability of IL-18 to distinguish MAS from systemic juvenile idiopathic arthritis (JIA) is less unambiguous, as IL-18 levels > 100 000 pg/ml were described in sJIA patients both with and without MAS. IL-18 may help to differentiate between HLH subtypes and other inflammatory conditions. As HLH and MAS are rare disorders, only few and relatively small studies exist on the subject. Larger, prospective multi-center studies are called for to assess the diagnostic precision of IL-18 for HLH and MAS.

14-year hip survivorship after periacetabular osteotomy: a follow-up study on 1,385 hips

Background and purpose - Few studies have evaluated the long- and mid-term outcomes after minimally invasive periacetabular osteotomy (PAO). We investigated: (1) the long-term hip survival rate after PAO; (2) the risk of complications and additional surgery after PAO; and (3) the hip function at different follow-up points.Patients and methods - We reviewed 1,385 hips (1,126 patients) who underwent PAO between January 2004 and December 2017. Through inquiry to the Danish National Patient Registry we identified conversions to total hip arthroplasty (THA) and complications after PAO. We evaluated the Hip disability and Osteoarthritis Outcome Score (HOOS) obtained preoperatively, and at 6 months, 2-, 5-, and 10-years' follow-up.Results - 73 of the 1,385 hips were converted to THA. The overall Kaplan-Meier hip survival rate was 80% (95% CI 68-88) at 14 years with a mean follow-up of 5 years (0.03-14). 1.1% of the hips had a complication requiring surgical intervention. The most common additional surgery was removal of screws (13%) and 11% received a hip arthroscopy. At the 2-year follow-up, HOOS pain improved by a mean of 26 points (CI 24-28) and a HOOS pain score > 50 was observed in 86%.Interpretation - PAO preserved 4 of 5 hips at 14 years, with higher age leading to lower survivorship. The PAO technique was shown to be safe; 1.1% of patients had a complication that demanded surgical intervention. The majority of the patients with preserved hips have no or low pain. The operation is effective with a good clinical outcome.

PO-20 - Crosstalk between the lectin pathway and haemostasis in patients with pulmonary cancer

INTRODUCTION

Recent research has focused on the complement system in cancer, including the lectin pathway of complement activation. Mannose-binding lectin (MBL), a key activator of the lectin pathway, can bind to tumor cell surfaces in vitro, and lectin pathway activation is increased in several types of cancer. The exact role of the complement system in cancer is currently discussed. However, one possible consequence of the increased complement activation could be contribution to the increased thrombosis risk which cancer patients experience. Proteins of the lectin pathway can activate coagulation and impair fibrinolysis in vitro, but the significance of this in a clinical setting is not well understood.

AIM

We aim to investigate associations between lectin pathway and haemostatic activation in patients with lung cancer undergoing thoracoscopic surgery.

MATERIALS AND METHODS

Patients with lung cancer (n=60) eligible for thoracoscopic tumor resection were included as part of a randomized controlled trial, the COPPVATS project (EudraCT no: 2012-002409-23), conducted at the Department of Thoracic Surgery, Aarhus University Hospital. Exclusion criteria were arterial or venous thrombosis within the last three months, other systemic disease than cancer, and anticoagulant treatment prior to inclusion. Blood samples were obtained the day before surgery, perioperatively, and on the 1st and 2nd postoperative days. Laboratory analyses on the complement system include MBL, MBL-associated protease (MASP)-1 and -2, MBL-MASP complex, ficolin-1, -2, and -3 and complement factor C3b. Haemostasis was evaluated with routine coagulation parameters (INR, APTT, fibrinogen, fibrin d-dimer), platelet function, and tissue factor-induced thrombin generation.

RESULTS

Recruitment of the study subjects is concluded, and laboratory work is in progress. The complement analyses and data processing will be performed during early spring 2016, so that results will be ready for presentation on the conference.

CONCLUSIONS

The present project will provide new knowledge on lectin pathway activation and the pathogenesis of thrombosis in cancer patients. In the long term, this will help improve the individual risk assessment and lead to new studies on thromboprophylaxis and treatment in conditions with increased complement activation.

Genomic sequence and analysis of EhV-99B1, a new coccolithovirus from the Norwegian fjords

Coccolithoviruses are giant dsDNA viruses that infect Emiliania huxleyi, the most ubiquitous marine microalga. Here, we present the genome of the latest coccolithovirus strain to be sequenced, EhV-99B1, and compare it with two other coccolithovirus genomes (EhV-86 and EhV-163). EhV-99B1 shares a pairwise nucleotide identity of 98% with EhV-163 (the two strains were isolated from the same Norwegian fjord but in different years), and just 96.5% with EhV-86 (isolated in the same spring as EhV-99B1 but in the English Channel). We confirmed and extended the list of relevant genomic differences between these EhVs from the Norwegian fjord and EhVs from the English Channel, namely the removal/insertions of: a phosphate permease, an endonuclease, a transposase, and two specific tRNAs. As a whole, this study provided new clues and insights into the diversity and mechanisms driving the evolution of these large oceanic viruses, in particular those processes involving selfish genetic elements.

Fetal antigen 1 in healthy adults and patients with pituitary disease: relation to physiological, pathological, and pharmacological GH levels

Immunohistochemical analysis of the distribution of human fetal antigen 1 (FA1) in adult human tissues has demonstrated a strong association between FA1 and (neuro)endocrine structures. In the anterior pituitary gland FA1 was colocalized with GH, and the present study was performed to evaluate a possible relationship between GH and FA1. FA1 and GH levels were measured during a 24-h period at 20-min intervals. In contrast to the known GH peaks during 24-h sampling, there was no detectable FA1 peak. The FA1 responses to placebo were not significantly different from the responses to the combination of pyridostigmine and GHRH. No significant difference was found between basal FA1 (nanograms per ml) levels [median (minimum-maximum)] in healthy adults [n = 40; 28.6 ng/ml (12.5-72.0)], acromegalic patients [n = 11; 31.0 ng/ml (21.6-56.3)], and patients with GH deficiency [n = 22; 32.1 ng/ml (13.4-108.7)]. FA1 levels were significantly reduced, in the six of seven acromegalic GH responders to octreotide, from [median (minimum-maximum)] 30.6 ng/ml (20.0-43.1) to 20.3 (13.9-30.2; P < 0.02). There was no significant change during placebo. FA1 levels were significantly increased compared with placebo values during 3 months of GH therapy. The increase in FA1 levels was significantly higher than the change during placebo (P < 0.003). In conclusion, a common secretory and stimulatory pathway for FA1 and GH in healthy adults has been ruled out. However, we found that pharmacologically induced changes in GH levels during weeks to months had a corresponding direct or indirect effect on FA1 levels in patients with GH deficiency or acromegaly. However, a direct effect of octreotide on FA1 levels, independent of GH levels, has not been ruled out.

Maximal oxygen uptake, muscle strength and walking speed in 85-year-old women: effects of increased physical activity

This study explores the effect of regular training on blood pressure, maximal oxygen uptake, maximal isometric muscle strength, and walking speed in the very old. A total of 55 community-dwelling women, 85-year-old, were enrolled in a training group (N = 22) or a control group (N = 33). These groups were reduced to 19 and 26 subjects, respectively, after the training period. Training was performed once a week over eight months, and consisted of various exercises with particular attention to movements important for everyday activities. Training reduced diastolic blood pressure (p < 0.05), and showed a similar trend for systolic blood pressure. Measurements of maximal oxygen uptake before the start of the training (15 mL min-1 kg-1) revealed a level close to the presumed limit for independent living (13 mL min-1 kg-1). Training improved VO2 max by 18% (p < 0.05), whereas the control group experienced a trend towards a reduction. Maximal isometric muscle strength of both the right and left leg showed a tendency to increase with training, but no significant changes were evident in the trunk flexor and extensor muscles. The training group showed a significant increase of 17% in maximal walking speed after the training period. However, one year later, without training, this improvement was reduced to 8% (p < 0.05). No major changes were observed in the control group for any of these parameters. This study demonstrates a maximal oxygen capacity in very old community-dwelling women close to a threshold level indicating dependency. Furthermore, 8 months of regular training appears to lower blood pressure, and to increase maximal oxygen uptake and maximal walking speed. This suggests that physical reactivation of the very old may reduce the risk for acquiring age-related diseases associated with an elevated blood pressure, and may improve parameters crucial for independence.

Simple numerical chromosome aberrations characterize pituitary adenomas

Although pituitary adenomas are among the most frequent intracranial neoplasms, only very few have been cytogenetically analyzed. We have short-term cultured and karyotyped 28 consecutive pituitary adenomas (16 clinically nonfunctioning adenomas and 12 clinically functioning adenomas), finding a normal karyotype in 22, whereas 6 had clonal chromosome aberrations (5 nonfunctioning pituitary adenomas and 1 prolactinoma). The abnormal karyotypes were relatively simple. Most anomalies were numerical, with a structural rearrangement, t(6;19), being found in only one tumor. The most common aberrations were trisomy 7 (3 adenomas), trisomy 9 (2 adenomas), trisomy 12 (2 adenomas), trisomy 20 (2 adenomas), and loss and gain in 2 separate clones of one X chromosome (2 adenomas).

Body composition in 85 year-old women: effects of increased physical activity

This study explores whether regular training alters body composition and resting metabolism in the very old. A total of 55 community-dwelling women, 85 years old, were enrolled in a training group (N = 22) and a control group (N = 33). Training was performed once a week for eight months, and consisted of various exercises with particular attention to movements important for everyday activities. Before, immediately after, and one year after cessation of training, body composition was evaluated both by an impedance measurement and a whole body scan by dual-photon X-ray absorptiometry. Resting metabolism, assessed as energy expenditure at rest, was measured with standardized protocols by analyzing oxygen consumption and carbon dioxide production. Height declined in both groups throughout the study. Immediately after the training period, body weight showed a trend towards reduced levels in the training group, and an opposite trend in the control group. The control group showed an increased body mass index (p < 0.05) related to an increase in fat mass immediately after the training period; these parameters were unaltered in the training group. A reduction in fat free mass (p < 0.05) and bone mineral content (p < 0.05), and unaltered energy expenditure at rest were evident in both groups during the course of the study. These results suggest that regular training can counteract the age-related accumulation of fat in the very old. Physical reactivation, therefore, may possess an important potential for reducing morbidity in the very old by lowering fat mass, and thereby reducing the risk of acquiring several age-related diseases.

Significant envenomation by Aurelia aurita, the moon jellyfish

The case of a patient envenomated by Aurelia aurita, who developed significant local cutaneous lesions and immunospecific serum antibodies is reported. The lesions required more than ten days to heal. The patient developed significant cross-reacting antibodies to Chrysaora quinquecirrha antigens.

Glycosylated hemoglobin A1 used in quality-control of diabetes care: a cross-sectional study in an outpatient clinic

HBA1 was used to evaluate the quality of treatment and regulation in 163 insulin treated diabetes patients. The mean of HBA1 in all patients was 11.2 +/- 2.4%. Only 24% of the patients had HBA1 values below the mean + 3 SD of non diabetics. Patients with high values of HBA1 were controlled and treated more intensively than those with lower or normal values. They were also seen more frequently at the outpatient clinic, their insulin doses were larger, and they took more frequent insulin injections. 63% of the patients practised home monitoring of blood glucose, but they were not better controlled than those, who did not. In some of the patients conspicuous discrepancies were found between high HBA1 percentages and low blood glucose values measured at the outpatient clinic. It is concluded, that home monitoring of blood glucose, frequent visits to an outpatient clinic, and 2 daily insulin injections do not appreciably improve diabetes control, and that other approaches are needed, e.g., greater co-operation by the patients in frequent adjustments of treatment between clinic visits.

Colchicine alters the nerve birefringence response

The internal perfusion of squid axons with colchicine reversibly and selectively reduces the transient sodium current and the birefringence response to a brief depolarizing voltage pulse.