Beneficial and harmful effects of physical activity on care-seeking for low back pain: the AUTBACK study

PURPOSE

People who seek more care for low back pain (LBP) tend to experience poorer recovery (e.g. higher pain and disability levels). Understanding the factors associated with care-seeking for LBP might improve patient outcomes and potentially alleviate the burden of LBP on global health systems. This study aimed to investigate the relationship between different intensities, volumes, and domains of physical activity and care-seeking behaviours, in people with a history of LBP.

METHODS

Longitudinal data from adult twins were drawn from the AUstralian Twin BACK study. The primary outcome was the total self-reported frequency (counts) of overall utilisation of care for LBP, over 1 year. Secondary outcomes were the utilisation of health services, and the utilisation of self-management strategies, for LBP (assessed as total frequency over 1 year). Explanatory variables were device-based measures of sedentary behaviour and moderate-to-vigorous intensity physical activity, and self-reported physical workload, and work, transport, household, and leisure domain physical activity, at baseline.

RESULTS

Data from 340 individuals were included. Median age was 56.4 years (IQR 44.9-62.3 years) and 73% of participants were female. Medium-to-high baseline volumes of sedentary behaviour were significantly associated with greater counts of overall care utilisation (IRR 1.60, 95%CI 1.04-2.44) and utilisation of self-management strategies (IRR 1.60, 95%CI 1.02-2.50) for LBP, over 1 year. Medium-to-high baseline volumes of household domain physical activity were significantly associated with greater counts of utilising self-management strategies for LBP over 1 year (IRR 1.62, 95%CI 1.04-2.53). No explanatory variables were associated with the utilisation of health services for LBP.

CONCLUSION

People who engage in higher baseline volumes of sedentary behaviour or physical activity in the household setting (e.g. housework, gardening, yard work, general household maintenance) utilise 1.6 times more care for LBP over 1 year. Findings suggest that higher volumes of these behaviours may be harmful for LBP. No intensities, volumes, or domains of physical activity demonstrated clear benefits for LBP. Where feasible, patients and clinicians should collaborate to screen and develop strategies to reduce engagement in sedentary behaviour or physical activity in the household setting. Contextual factors (e.g. patient symptom severity, sociocultural roles, occupational demands) should be considered when devising appropriate behaviour change strategies.

CAR-T Cell-Mediated B-Cell Depletion in Central Nervous System Autoimmunity

BACKGROUND AND OBJECTIVES

Anti-CD20 monoclonal antibody (mAb) B-cell depletion is a remarkably successful multiple sclerosis (MS) treatment. Chimeric antigen receptor (CAR)-T cells, which target antigens in a non-major histocompatibility complex (MHC)-restricted manner, can penetrate tissues more thoroughly than mAbs. However, a previous study indicated that anti-CD19 CAR-T cells can paradoxically exacerbate experimental autoimmune encephalomyelitis (EAE) disease. We tested anti-CD19 CAR-T cells in a B-cell-dependent EAE model that is responsive to anti-CD20 B-cell depletion similar to the clinical benefit of anti-CD20 mAb treatment in MS.

METHODS

Anti-CD19 CAR-T cells or control cells that overexpressed green fluorescent protein were transferred into C57BL/6 mice pretreated with cyclophosphamide (Cy). Mice were immunized with recombinant human (rh) myelin oligodendrocyte protein (MOG), which causes EAE in a B-cell-dependent manner. Mice were evaluated for B-cell depletion, clinical and histologic signs of EAE, and immune modulation.

RESULTS

Clinical scores and lymphocyte infiltration were reduced in mice treated with either anti-CD19 CAR-T cells with Cy or control cells with Cy, but not with Cy alone. B-cell depletion was observed in peripheral lymphoid tissue and in the CNS of mice treated with anti-CD19 CAR-T cells with Cy pretreatment. Th1 or Th17 populations did not differ in anti-CD19 CAR-T cell, control cell-treated animals, or Cy alone.

DISCUSSION

In contrast to previous data showing that anti-CD19 CAR-T cell treatment exacerbated EAE, we observed that anti-CD19 CAR-T cells ameliorated EAE. In addition, anti-CD19 CAR-T cells thoroughly depleted B cells in peripheral tissues and in the CNS. However, the clinical benefit occurred independently of antigen specificity or B-cell depletion.

CAR-T Cell-Mediated B Cell Depletion in Central Nervous System Autoimmunity

Objective

Evaluate chimeric antigen receptor (CAR)-T cell mediated B cell depletion in experimental autoimmune encephalomyelitis (EAE).

Background

CAR-T cells are autologous T cells expressing a non-MHC target antigen specific receptor. We tested whether anti-CD19 CAR-T cells, which more thoroughly deplete human B cell populations than monoclonal antibodies (mAbs), recapitulated the beneficial effects of B cell depletion in EAE.

Design/Methods

Anti-CD19 CAR-T cells or control T cells that overexpressed green fluorescent protein were transferred into female wild-type C57BL/6 mice that had been pretreated with cyclophosphamide. EAE was induced by immunization with either recombinant human (rh) myelin oligodendrocyte protein (MOG) (B cell-dependent) or MOG peptide (p) 35-55 (B cell-independent). Mice were evaluated daily for clinical signs of EAE and weekly for peripheral B and T cell counts. B cell levels, T cell immune modulation and histology were assessed at peak disease and at termination.

Results

In rhMOG-induced EAE, clinical scores and histologic lymphocyte infiltration were reduced in mice treated with cyclophosphamide and either anti-CD19 CAR-T cells or control T cells. B cell depletion was observed in peripheral lymphoid tissue and in the central nervous system (CNS) of mice treated with anti-CD19 CAR T cells, similar to effects of anti-CD20 mAbs. There was no difference in T cell modulation including Th1 or Th17 populations, but there was a trend towards increase in Treg populations in the periphery and CNS in the anti-CD19 CAR-T cell and control T cell treated animals. Clinical scores and histology did not differ among treatment groups in p35-55-induced disease.

Conclusions

Anti-CD19 CAR-T cells thoroughly deplete B cells peripherally and within the CNS. Treatment also results in less severe rhMOG-induced disease, but it was independent of B cell depletion. Our results are consistent with human data indicating that anti-CD19 CAR-T cells deplete B cells across compartments, suggesting that they may hold promise for progressive MS.

EXTH-33. PRIMING OF SYNNOTCH CAR T CELLS VIA CNS-SPECIFIC ANTIGEN ALLOWS SPATIAL AND TEMPORAL REGULATION OF CAR EXPRESSION, EFFECTIVE HOMING AND PERSISTENCE OF T CELLS IN THE CNS

One of the key challenges in the development of CAR-T therapy is the absence of target antigens that are tumor-specific and have homogenous expression. To safely target glioblastoma-associated antigens (GAAs) in the tumor without attacking normal tissue expressing the same GAAs outside of the brain, we adapted a novel synthetic Notch (synNotch) receptor system and established a “prime and kill” sequential two-receptor CAR circuit. We used glioblastoma- (GBM) specific neoantigen EGFRvIII as a priming signal for synNotch receptor and have reported robust antitumor response in the mice bearing intracerebral PDX tumor with heterogenous EGFRvIII expression. However, less than 20% of adult GBM cases express EGFRvIII. Furthermore, EGFRvIII expression can diminish over time even after its detection in the primary GBM, and the EGFRvIII-synNotch primed CAR T cells may deplete EGFRvIII-expressing GBM cells via their cytotoxic effects, thereby losing the priming signal. To overcome these inherent challenges of the EGFRvIII-priming strategy, we used CNS tissue-specific antigens as priming signal to drive localized expression of the CAR against EphA2 and IL-13Rα2 and bypassed the need for tumor-specific antigen. We have found BCAN (also known as Brevican) as the most promising priming antigen among several CNS-specific cell surface proteins that we evaluated. When mice bearing intracerebral GBM6 PDX received a single IV infusion of T cells engineered with the α-BCANsynNotch- > α-EphA2/IL-13Rα2 CAR (B-SYNC) circuit, all mice (10/10) demonstrated complete regression of the tumor. Furthermore, these B-SYNC T cells were significantly more efficacious than constitutively expressed EphA2/IL-13Rα2 CAR T cells, associated with superior persistence and less exhausted phenotype. Thus, the B-SYNC approach represents a conceptual novelty of CNS tissue-specific CAR activation. This also enhances the translational significance of synNotch-CAR T cells by widely extending the eligibility to EGFRvIII-negative glioma patients. We will develop and conduct a phase I study to evaluate our hypothesis.

IMMU-14. SynNotch chimeric antigen receptor (CAR) T-cells as a potential treatment for diffuse intrinsic pontine glioma (DIPG)/diffuse midline glioma (DMG)

BACKGROUND: The development of effective chimeric antigen receptor (CAR) T-cell therapies for malignant pediatric brain tumors remains a challenge due to multiple barriers, including antigenic heterogeneity, on-target off-tumor toxicities, and T cell exhaustion. We have adopted a novel synthetic Notch “synNotch” receptor system and developed innovative T-cell circuits that recognize tumor cells based on the “prime-and-kill” strategy.

METHODS: We created a novel synNotch-CAR circuit in which the brain/glioma-specific antigen Brevican (BCAN) primes the T cells to induce expression of a CAR that recognizes interleukin-13 receptor α2 (IL-13Rα2) and ephrin type A receptor (EphA2), thereby eradicating glioma cells expressing either antigen. Immunocompromised mice bearing the SF8628 DIPG cell line in the frontal lobe or brain stem received a single intravenous (IV) infusion of synNotch CAR T-cells (2.5 x 10⁶ each of CD4+ and CD8+ T cells) on day 6 following the tumor inoculation. Mice were monitored for toxicity and tumor growth.

RESULTS: Following this synNotch CAR T-cell dose, although tumors in the brainstem did not regress, 3 of the 5 mice with frontal lobe tumors demonstrated complete and sustained remission. Our histological analyses revealed primed CAR T-cells both within and surrounding the tumor in both settings. By flow cytometry, we confirmed the CAR T-cells in the CNS were primed and mostly did not express an exhaustive phenotype. In the spleen, we also found the CAR T-cells in a more naïve and central memory state.

CONCLUSIONS: Our work so far has demonstrated that synNotch-CAR T-cells are able to traffic to the tumor microenvironment even in the brainstem, are primed to express the CAR, and most do not express an exhaustive phenotype. Future work will include CAR T-cell dose optimization, continued assessments of the tumor microenvironment, and investigating for antigen escape.

Are biomechanics during gait associated with the structural disease onset and progression of lower limb osteoarthritis? A systematic review and meta-analysis

OBJECTIVE

To evaluate if gait biomechanics are associated with increased risk of structurally diagnosed disease onset or progression of lower limb osteoarthritis (OA).

METHOD

A systematic review of Medline and Embase was conducted from inception to July 2021. Two reviewers independently screened records, extracted data and assessed risk of bias. Included studies reported gait biomechanics at baseline, and either structural imaging or joint replacement occurrence in the lower limb at follow-up. The primary outcome was the Odds Ratio (OR) (95% confidence interval (CI)) of the association between biomechanics and structural OA outcomes with data pooled for meta-analysis.

RESULTS

Twenty-three studies reporting 25 different biomechanical metrics and 11 OA imaging outcomes were included (quality scores ranged 12-20/21). Twenty studies investigated knee OA progression; three studies investigated knee OA onset. Two studies investigated hip OA progression. 91% of studies reported a significant association between at least one biomechanical variable and OA onset or progression. There was an association between frontal plane biomechanics with medial tibiofemoral and hip OA progression and sagittal plane biomechanics with patellofemoral OA progression. Meta-analyses demonstrated increased odds of medial tibiofemoral OA progression with greater baseline peak knee adduction moment (KAM) (OR: 1.88 [95%CI: 1.08, 3.29]) and varus thrust presence (OR: 1.97 [95%CI: 1.32, 2.96]).

CONCLUSION

Evidence suggests that certain gait biomechanics are associated with an increased odds of OA onset and progression in the knee, and progression in the hip.

REGISTRATION NUMBER

PROSPERO CRD42019133920.

MR-safety in clinical practice at 7T: Evaluation of a multistep screening process in 1819 subjects

INTRODUCTION

MR facilities must implement and maintain adequate screening and safety procedures to ensure safety during MR examinations. The aim of this study was to evaluate a multi-step MR safety screening process used at a 7T facility regarding incidence of different types of safety risks detected during the safety procedure.

METHODS

Subjects scheduled for an MR examination and having entered the 7T facility during 2016-2019 underwent a pre-defined multi-step MR safety screening process. Screening documentation of 1819 included subjects was reviewed, and risks identified during the different screening steps were compiled. These data were also related to documented decisions made by a 7T MR safety committee and reported MR safety incidents.

RESULTS

Passive or active implants (n = 315) were identified in a screening form and/or an additional documented interview in 305 subjects. Additional information not previously self-reported by the subject, regarding implants necessitating safety decisions performed by the staff was revealed in the documented interview in 102 subjects (106 items). In total, the 7T MR safety committee documented a decision in 36 (2%) of the included subjects. All of these subjects were finally cleared for scanning.

CONCLUSION

A multi-step screening process allows a thorough MR screening of subjects, avoiding safety incidents. Different steps in the process allow awareness to rise and items to be detected that were missed in earlier steps.

IMPLICATIONS FOR PRACTICE

Safety questions posed at a single timepoint during an MR screening process might not reveal all safety risks. Repetition and rephrasing of screening questions leads to increased detection of safety risks. This could be effectively mitigated by a multi-step screening process. A multi-disciplinary safety committee is efficient at short notice responding to unexpected safety issues.

IMMU-33. MULTI-ANTIGEN RECOGNITION CIRCUITS OVERCOME CHALLENGES OF SPECIFICITY, HETEROGENEITY, AND DURABILITY IN T-CELL THERAPY FOR GLIOBLASTOMA

Treatment of solid cancers with chimeric antigen receptor (CAR) T-cells is challenging because of a lack of target antigens that are both tumor-specific and homogenously expressed. While epidermal growth factor receptor (EGFR)vIII represents a glioblastoma (GBM)-specific antigen, its expression is heterogeneous within the tumor resulting in tumor escape. In contrast, more homogenously expressed GBM-associated antigens (GAA), such as EphA2, are non-ideal because of expression in other normal organs, yielding potential cross-reactive toxicity. As a way to safely target GAAs in the tumor without attacking normal cells expressing the same GAAs outside of the brain, we adapted a novel synthetic Notch (synNotch) receptor system and established a “prime and kill” sequential two-receptor CAR circuit. A synNotch receptor recognizes a specific priming antigen; the heterogeneous GBM neoantigen EGFRvIII or a brain tissue-specific antigen to prime the local expression of a CAR that mediates cytotoxicity against a GAA (e.g. EphA2). In orthotopic GBM6 glioma model, a patient-derived xenograft (PDX) with heterogeneous expression of EGFRvIII, intravenous infusion of T-cells transduced with EGFRvIII synNotch→anti-IL-13Rα2/EphA2 tandem CAR circuit resulted in long-term (over 100 days) survival and eradication of the heterogeneous tumor in all of 12 mice in two independent experiments. In contrast, constitutive CARs targeting EGFRvIII or IL-13Rα2/EphA2 (as a tandem CAR) failed to exhibit long-term anti-tumor response. Moreover, T-cells transduced with synNotch-regulated CAR maintain a less differentiated state which is associated with higher durability compared with ones with constitutive CAR in vivo. T-cells transduced with a synNotch→CAR circuit primed by a brain-specific antigen, myelin oligodendrocyte glycoprotein (MOG), exhibited a precise and potent local control of intracranial PDX without evidence of priming in extracranial organs. These data support the utility of synNotch→CAR circuits in EGFRvIII-negative GBM cases. By integrating multiple imperfect but complementary antigens, we improve both the specificity and persistence of T-cells directed against GBM.

Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: An extended follow up of pragmatic randomised controlled trial

BACKGROUND

Self-harm in adolescents is common and repetition frequent. Evidence for effective interventions to reduce self-harm is limited. Long term follow-up of existing studies is rare.

METHODS

Extended follow up, from 18 to at least 36-months, of the SHIFT trial: a pragmatic, multi-centre, individually-randomised, controlled trial involving young people (11-17) who had self-harmed at least twice and presented to Child & Adolescent Mental Health Services (CAMHS). SHIFT evaluated manualised family therapy (FT) versus treatment as usual (TAU) in reducing repetition of self-harm leading to hospital attendance 18 months post-randomisation.We obtained ONS mortality data, adult mental health data, and further details of hospital attendance from routine Hospital Episode Statistics (HES) data plus researcher follow-up. We assessed longer-term differences in outcome using multivariable Cox Proportional Hazards regression analysis, and assessed all-cause mortality and morbidity relating to hospital attendances for reasons other than self-harm.

STUDY REGISTRATION

ISRCTN 59793150.

OUTCOMES

The original sample of 832 were randomised between April 2010 and December 2013. Extended follow-up continued until February 2017 for a median 55·4 months (range 0-82·5 months), providing post 18-month data for 804 (96·6%) participants, of whom 785 (94·4%) had a minimum of 36-months follow-up.There was no evidence of a between-group difference in the primary outcome during the extended follow-up period (Hazard Ratio (HR) 1·03; 95% CI: 0·83, 1·28; p-value=0·78), consistent with our findings in the original trial with 18 months follow-up (HR 1·14, 95% CI 0·87, 1·49; p-value 0·33). There was a reduced rate of self-harm in older participants aged 15-17 (HR 0·7, 95% CI 0·56, 0·88), as compared with those aged 11-14; and significantly increased rates of self-harm in participants whose index episode combined self-injury and poisoning (HR 1·8, 95% CI 1·2, 2·7). Two deaths were reported during the extended follow up period.

INTERPRETATION

For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, trial FT confers no benefits over TAU in reducing subsequent hospitalisation for self-harm over 18 months or 36 months.

FUNDING

NIHR HTA Reference: 07/33/01.

Antitumour Effect of a Mixture of N-Propyl Polysulfides In Vitro

Copper serves as a limiting factor for multiple steps of tumour progression, including angiogenesis, growth and metastasis. High levels of copper have been found in a wide spectrum of human cancers. Antitumour activities of copper-chelating drugs have been reported in animal models. Organosulfur compounds (diallyl sulfide, DAS; diallyl disulfide, DADS; S-ethylcysteine, SEC; N-acetylcysteine, NAC) derived from garlic exhibit marked copper-chelating activity. We analysed a mixture of fifteen n-propyl polysulfides (DPPS) for potential antitumour activity against several murine tumour cell lines, including colon carcinoma (CT26), mammary carcinoma (4T1) and melanoma cell lines (B16F10), and compared the effects with the antiproliferative effect in highly proliferative murine mesenchymal stem cells (mMSCs). The effects of the mixture of n-propyl polysulfides (100%) on cell viability were determined using MTT assays. Cell apoptosis was analysed using Annexin V-FITC/PI assays.

The results of the MTT assays indicate that this standardized mixture of n-propyl polysulfides has a strong, dose-dependent cytotoxic effect against all three of the tested tumour cell lines (CT26, 4T1, B16F10). The cytotoxic effect of the n-propyl polysulfide mixture against the CT26 and B16F10 cell lines was much stronger than that of cisplatin and was significantly weaker in mMSCs, which are non-cancerous and highly proliferative cells, than in cancer cells. Flow cytometric analysis of CT26 and 4T1 cells revealed that apoptosis was not the dominant mechanism of cell death induced by the n-propyl polysulfide mixture. The n-propyl polysulfide mixture exerted highly cytotoxic activity against murine colon carcinoma and melanoma cell lines, but its antiproliferative activity against mMSCs was significantly lower than that of cisplatin.

Effect of cane use on bone marrow lesion volume in people with medial tibiofemoral knee osteoarthritis: randomized clinical trial

OBJECTIVE

To evaluate effects of daily cane use for 3 months on medial tibiofemoral bone marrow lesion (BML) volumes in people with medial tibiofemoral osteoarthritis (OA).

DESIGN

In this randomized controlled trial (RCT), 79 participants with medial tibiofemoral OA were randomized to either a cane group (using a cane whenever walking) or control group (not using any gait aid) for 3 months. The cane group received a single training session by a physiotherapist, using a biofeedback cane to teach optimal technique and body weight support and motor learning principles to facilitate retention of learning. The primary outcome was change in total medial tibiofemoral BML volume (per unit bone volume) measured from magnetic resonance imaging (MRI) at 3 months. Secondary outcomes were BML volumes (per unit bone volume) of the medial tibia and femur, and patient-reported outcomes of overall knee pain, knee pain on walking, physical function, perceived global symptom changes and health-related quality of life. MRI analyses were performed by a blinded assessor.

RESULTS

Seventy-eight participants (99%) completed the primary outcome. Mean (standard deviation) daily cane use was 2.3 (1.7) hours over 3 months. No evidence of between-group differences was found for change in total medial tibiofemoral BML volume (mean difference: -0.0010 (95% confidence intervals: -0.0022, 0.0003)). Most secondary outcomes showed minimal differences between groups.

CONCLUSION

Daily use of a cane during walking for 3 months aiming to reduce knee joint loading did not change medial tibiofemoral BML volumes compared to no use of gait aids.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry (ACTRN12614000909628).

Sleep interventions for osteoarthritis and spinal pain: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To determine if sleep interventions improve pain and sleep in people with osteoarthritis (OA) and/or spinal pain compared to control/placebo.

DESIGN

Medline, Embase, AMED, PsycINFO, CENTRAL, CINAHL and PEDro were searched from their inception date to July 2017. Keywords relating to "sleep", "OA", "spinal pain", and "randomized controlled trial (RCT)" were combined. Included RCTs investigated the use of sleep interventions for people with OA and/or spinal pain, and measured at least one sleep and health related outcome. Meta-analyses were performed to pool mean differences for pain and sleep quality.

PROSPERO

CRD42016036315.

RESULTS

Of 1445 unique records, 24 studies were included. Sixteen studies included participants with spinal pain, seven with OA, and one included a mixed population. Sleep interventions included established sleep interventions (ESI) [cognitive behavioural therapy (CBT) and pharmacological interventions], and a range of others. Intervention periods ranged from 4 to 10 weeks. Thirteen studies were of moderate to high quality (PEDro ≥ 6/10). Due to high heterogeneity between studies we also performed sub-group and sensitivity analyses. ESI decreased Insomnia Severity Index (ISI) for people with low back pain (LBP) (pooled mean difference: -6.78/28, 95% confidence interval (95% CI): [-9.47, -4.09], I² = 40%) and OA (-2.41, [-4.19, -0.63], 0%). However ESI decreased pain for people with LBP (pooled mean difference: visual analogue scale (VAS) -12.77/100, 95% CI: [-17.57, -7.97], I² = 0%), but not OA (-2.32, [-7.18, 2.54], 27%).

CONCLUSION

ESI appeared to improve sleep and pain for people with LBP, and sleep for people with OA. However more vigorous studies need to be conducted.

Knee thrust prevalence and normative hip-knee-ankle angle deviation values among healthy individuals across the lifespan

OBJECTIVE

To report the prevalence of varus thrust and normative values for hip-knee-ankle (HKA) angle deviation across the lifespan, and to explore associations between HKA angle deviation and selected clinical factors.

DESIGN

This was a cross-sectional observational study of 572 participants from the 1000 Norms Project, aged 3-101 years and who self-reported as being healthy. Video recordings (2D) of frontal plane gait were reviewed by physiotherapists for presence of knee thrust and quantification of HKA angle deviation (the difference between HKA angle at initial contact and mid-stance). Age and sex-stratified normative HKA angle deviation values were presented as means and 95% confidence intervals (CIs). Correlations were calculated between HKA angle and clinical measures (age, sex, body mass index (BMI), alignment, knee and hip strength, Knee Injury and Osteoarthritis Outcomes Scores (KOOS), foot posture index, temporo-spatial gait, and hypermobility).

RESULTS

Overall, 31% of the cohort had varus thrust, most prevalent among adults older than 60 years (42%) and children aged 3-9 (41%). Varus thrust was common in adolescents (25%) and adults aged 20-59 (23%). Mean HKA angle deviation for the entire cohort was 1.2° (95%CI: 1.07, 1.36) towards varus, and 2.1° (95%CI: 1.84, 2.36) among people with clinical varus thrust. Weak associations were identified between HKA angle deviation and BMI, stride width, and KOOS-Sports among adolescents, and in adults weakly associated with height.

CONCLUSIONS

Prevalence of varus thrust is common across the lifespan. Normative values established here can be readily used by clinicians and researchers in monitoring this gait deviation.

Self-reported knee pain and disability among healthy individuals: reference data and factors associated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child

OBJECTIVE

To develop normative reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child, as well as investigate socio-demographic, psychological and physical factors associated with knee pain and disability among healthy adults.

METHOD

The KOOS or KOOS-Child (each containing five subscales) was administered to participants aged 8-101 years within the 1000 Norms Project, an observational study of 1000 self-reported healthy individuals. Self-efficacy, physical activity, body mass index (BMI), lower limb alignment, knee frontal plane projection angle (FPPA), knee range of motion (ROM), knee and hip strength, six-minute walk, 30-second chair stand and timed up and down stairs tests were collected. KOOS data were dichotomised using established cut-off scores and logistic regression analyses were conducted for each subscale.

RESULTS

Socio-demographic characteristics were similar to the Australian population. Normative reference data were generated for children (8-17 years) and adults (18-101 years). Female adults were up to twice as likely to report knee pain, symptoms and sport/recreation (Sport/Rec) limitations compared to males (P < .05). Older age, lower self-efficacy, greater BMI, varus lower limb alignment, lower knee flexion ROM and lower hip external rotation (ER) strength were independently associated with knee pain and disability among adults.

CONCLUSIONS

Age- and gender-stratified reference data for the KOOS and KOOS-Child have been developed to guide interpretation of results in practice and research for individuals with knee disorders. Psychological and physical factors are linked with self-reported knee pain/disability among adults, and longitudinal studies to investigate causation are required.

The prevalence of patellofemoral osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of radiographic patellofemoral osteoarthritis (OA) from population- and symptom-based cohorts and to evaluate if knee pain, physical function and quality of life (QOL) differ between people with isolated patellofemoral OA, isolated tibiofemoral OA and combined patellofemoral and tibiofemoral OA.

METHOD

Terms associated with "patellofemoral OA", "prevalence" and "clinical features" were used to search Medline, EMBASE, CINAHL, SCOPUS, AMED and Web of Science databases with no language restriction' from inception to August 2014. Two independent reviewers screened papers for eligibility. Studies were included if they reported prevalence of compartmental patterns of radiographic knee OA in population- or symptom-based cohorts. Studies were excluded if they evaluated a targeted sample (e.g., occupation-specific participants) or repeated already reported data from the same cohorts. Point prevalence estimates of patellofemoral OA were extracted from eligible studies, pooled and quantitatively analysed. A critical appraisal tool was used to evaluate methodological quality.

RESULTS

The search yielded 1891 records. The inclusion criteria were met by 32 studies. The crude prevalence of patellofemoral OA was 25% in the population-based cohorts (aged >20 years) and 39% in the symptom-based cohorts (aged >30 years). Eight studies reported knee pain, physical function and QOL in people with different compartmental disease; however no significant differences were found.

CONCLUSION

These findings confirm the substantial prevalence of patellofemoral OA, demonstrating the need to specifically consider the patellofemoral joint in knee OA research and clinical settings.

Serotonin transporter gene polymorphisms: Relation with platelet serotonin level in patients with primary Sjogren's syndrome

Significantly lower platelet serotonin level (PSL) in patients with primary Sjogren's syndrome (pSS) than in healthy controls has been reported in our prior studies. In the present report, we demonstrated effect of functional polymorphisms in the serotonin transporter gene (5-HTT) on PSL. We describe a group of 61 pSS patients and 100 healthy individuals subjects, who received PSL measurement in our prior study. All subjects were genotyped for the promoter 5-HTTLPR (L/S), rs25531 (A/G) and intronic 5-HTTVNTRin2 (l/s) polymorphisms. Overall, the presence of 5-HTTVNTRin2 ss genotype was associated with significantly lower PSL in pSS patients, not in healthy controls. Reduced PSL in pSS patients is in line with hypothesis of association between chronic immunoinflammation and 5-HT system dysregulation, identifying additional mechanisms such as altered 5-HT transport as potential genetic factor contributing to PSL depletion.

Altering foot progression angle in people with medial knee osteoarthritis: the effects of varying toe-in and toe-out angles are mediated by pain and malalignment

OBJECTIVES

To evaluate if altering the foot progression angle (FPA) by varying magnitudes during gait alters the external knee adduction moment (KAM), knee flexion moment (KFM), knee extension moment (KEM) and/or symptoms in people with medial knee osteoarthritis (OA). Potential influence of pain and knee malalignment on load-modifying effects of FPA was investigated.

DESIGN

Participants (n = 22) underwent 3-dimensional gait analysis to measure KAM peaks, KAM impulse, KFM and KEM peaks. Following natural gait, five altered FPA conditions were performed in random order (10° toe-in, 0° FPA, 10° toe-out, 20° toe-out and 30° toe-out). A projection screen displayed their real-time FPA. Pain/discomfort at knees and feet/ankles were evaluated for each condition. Linear mixed models were used for statistical analysis.

RESULTS

Toe-in reduced the early stance peak KAM and KEM but increased the KAM impulse, late stance peak and KFM. Toe-out reduced the KAM impulse, late stance peak and KFM (P < 0.001) but increased the early stance peak KAM and KEM. All effects were greater in participants with more varus knees. Pain significantly mediated the effect of altered FPA on the KAM impulse and late stance peak. In more painful individuals, toe-in was predicted to reduce the KAM impulse and late stance peak, and increase them for toe-out gait. There were no immediate symptomatic changes.

CONCLUSIONS

Effects of altered FPA vary across all medial knee load parameters and it is difficult to determine an optimal direction of FPA change. Future studies should consider Western Ontario McMaster Universities OA Index (WOMAC) pain to judge the likely effects of altered FPA.

Medial arch supports do not significantly alter the knee adduction moment in people with knee osteoarthritis

OBJECTIVE

This study aimed to evaluate the immediate effects of medial arch supports on indices of medial knee joint load (the peak external knee adduction moment (KAM) and knee adduction angular (KAA) impulse) and knee pain during walking in people with medial knee osteoarthritis (OA).

DESIGN

Twenty-one people with medial compartment OA underwent gait analysis in standardised athletic shoes wearing (1) no medial arch supports and (2) prefabricated medial arch supports, in random order. Outcomes were the first and second peaks in the external KAM, the KAA impulse and severity of knee pain during testing. Outcomes were compared across conditions using paired t tests (gait data) and Wilcoxon Signed Ranks test (pain data).

RESULTS

There were no significant changes in either first or second peak KAM, or in the KAA impulse, with the addition of medial arch supports (all P > 0.05). Considerable individual variation in response to the arch supports was observed across participants. There was no immediate change in knee pain during walking when medial arch supports were worn (P = 0.56).

CONCLUSIONS

This study showed no mean change in any of the measured indices of medial knee load with medial arch supports. No immediate changes in knee pain were evident.

Effect of various dating formulae on sonographic estimation of gestational age in extremely preterm infants

OBJECTIVES

Gestational age (GA) is one of the most important obstetric factors and prediction of date of delivery is usually based on ultrasonographic fetal measurements. Our aim was to determine whether applying three different dating formulae to a cohort of extremely preterm infants influenced the estimation of their GA.

METHODS

This was a study of 513 infants delivered before 27 gestational weeks, included in a Swedish national population study (EXPRESS), with information available on mid-trimester ultrasonographically measured biparietal diameter and femur length. We applied using these parameters three dating formulae, the Persson & Weldner formula, commonly used in Sweden, the Hadlock formula and the Mul formula, and compared their GA estimates to the clinically reported GA (recorded at delivery) and the last menstrual period (LMP)-based GA.

RESULTS

The mean reported GA was 173.2 days, corresponding well to the GA according to the Persson & Weldner dating formula (173.3). The mean GA according to LMP, the Hadlock formula and the Mul formula were 176.8, 175.3 and 175.6 days, respectively. The Hadlock and Mul GA estimates differed significantly from that based on the Persson & Weldner formula (both P-values < 10(-6)). Among 68 pregnancies with a reported duration of 22 weeks, 33 (49%) had a duration of 23 weeks or more when GA was calculated according to LMP and 22 (32%) when GA was calculated according to the Hadlock formula.

CONCLUSION

Estimated GA among infants delivered before 27 gestational weeks varied significantly depending on the dating formula used to calculate the estimated date of delivery; this might influence the clinical management of extremely preterm fetuses and infants.

Contralateral cane use and knee joint load in people with medial knee osteoarthritis: the effect of varying body weight support

OBJECTIVE

To evaluate the effect of varying body weight support (BWS) with contralateral cane use on medial knee load, measured by external knee adduction moment (KAM), in medial knee osteoarthritis (OA) participants. Influences of cane use technique, pain and malalignment on the cane's load-reducing effects were investigated.

METHOD

Participants (n=23) underwent three-dimensional gait analysis to measure KAM peaks (early and late stance) and impulse. Unaided walking was firstly analyzed. Following cane use training, participants placed pre-determined magnitudes of BWS through the cane (10%, 15% and 20% in random order), with visual feedback provided via a force-instrumented cane and projection screen. Contributions of cane use technique (peak BWS magnitude and timing, cane impulse (BWS∗time) anterior and lateral cane distance from limb) and Western Ontario McMaster Universities OA Index (WOMAC) pain and malalignment to KAM outcomes were evaluated using linear mixed models.

RESULTS

Cane use reduced all KAM variables, with a dose-response effect apparent. Cane BWS impulse was important in reducing the early stance peak KAM (P<0.001), peak BWS for late stance KAM (P<0.001) and both BWS measures for KAM impulse reductions (P<0.001). Variables contributing to efficacy of load-reduction differed across outcomes. Generally, greater reductions were achieved with longer lateral cane distances, peak BWS timing similar to KAM peaks, and shorter anterior cane distances. Greater pain and varus alignment improved load-reduction for some outcomes.

CONCLUSION

Contralateral cane use significantly reduced medial knee load, with a dose-response effect. Medial knee OA patients should be encouraged to maintain greater BWS across stance, with cane placement more lateral for optimum benefit.

Maternal obesity is a potential source of error in mid-trimester ultrasound estimation of gestational age

OBJECTIVES

To investigate the possible impact of maternal obesity on ultrasonographic dating of pregnancy.

METHODS

The Swedish Medical Birth Registry was used to identify 842 083 singleton pregnancies for which the estimated date of delivery (EDD) according to last menstrual period (EDD-LMP) and according to ultrasound examination (EDD-US) and maternal body mass index (BMI) in early pregnancy were known. Dates were adjusted following ultrasound examination, negative adjustment representing pregnancies that were shorter according to ultrasound examination than they were according to LMP. Odds ratios (OR) were adjusted for year of birth, maternal age, parity and smoking.

RESULTS

The EDD was postponed at least 7 days (discrepancy between EDD-LMP and EDD-US of < or = -7 days) in 25.2% of all pregnancies. There was a statistically significant association between maternal BMI and discrepancy between EDD-LMP and EDD-US. Among pregnant women with a BMI > or = 30.0 kg/m(2), the risk of postponed EDD was significantly greater compared with women with a BMI of 20.0-24.9 kg/m(2). The EDD was more often postponed > or = 14 days (OR, 1.65; 95% CI, 1.60-1.70) or 7-13 days (OR, 1.45; 95% CI, 1.42-1.48) among women with a BMI > or = 30 kg/m(2) than among women with normal weight. Similar risk was observed among women with a BMI of 25.0-29.9 kg/m(2), but was less pronounced.

CONCLUSIONS

High maternal BMI increases the risk of postponing the EDD at mid-trimester ultrasound examination.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery

BACKGROUND

The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited.

AIMS

To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology.

METHOD

101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined.

RESULTS

There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive.

CONCLUSIONS

The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

Decision making and problem solving in adolescents who deliberately self-harm

BACKGROUND

Healthy adolescents, and adults who engage in reward-driven, risky behaviours, demonstrate poor decision-making ability. Decision making in deliberate self-harm (DSH), a reward-driven, high-risk behaviour, has received little attention. This study assessed decision making and problem solving in adolescents with current or past SH.

METHOD

Decision making and problem solving were assessed using the Iowa Gambling Task (IGT) and the Means-Ends Problem-Solving Procedure (MEPS) respectively in 133 adolescents (57 healthy and 22 depressed controls with no SH history and 54 with SH history). A second analysis separated the SH group into current (n=30) and past (n=24) SH.

RESULTS

The collective performance of adolescents with SH history did not differ from depressed or healthy adolescents on the IGT. However, current self-harming adolescents had a trend towards more high-risk choices (p=0.06) than those with previous SH history and were the only group not to significantly improve over time, persisting with high-risk strategy throughout. Those who no longer self-harmed learnt to use a low-risk strategy similar to healthy and depressed controls. Recency of last SH episode correlated with IGT performance. Depressed participants performed well on the IGT but poorly on the MEPS. By contrast, both collective and divided SH groups had comparable MEPS scores to healthy controls, all performing better than depressed participants.

CONCLUSION

Poor decision making is present in adolescents who currently self-harm but not in those with previous history; improvement in decision-making skills may therefore be linked to cessation of self-harm. Depressed adolescents who do and do not self-harm may have distinct characteristics.

Increased activity of interleukin-23/interleukin-17 proinflammatory axis in obese women

OBJECTIVE

To compare the concentrations of cytokines belonging to Th17 axis (interleukin (IL)-17 and IL-23) and Th1 axis (IL-12 and interferon (IFN)-gamma) in obese and lean women, and to investigate their relationships with the proinflammatory adipokine leptin, proinflammatory cytokine macrophage migration inhibitory factor (MIF) and anthropometric and metabolic parameters of obesity.

DESIGN

Cross-sectional study.

SUBJECTS

Twenty-six obese women (age 20-52 years, body mass index (BMI): 30-48 kg/m(2)) and 20 healthy lean women (age 23-46 years, BMI: 18-25 kg/m(2)).

MEASUREMENTS

Plasma levels of cytokines and leptin, BMI, waist circumference (WC) and insulin resistance index HOMA (homeostatic model assessment).

RESULTS

Blood concentrations of IL-17, IL-23, MIF and leptin, but not IL-12 or IFN-gamma, were higher in obese compared with lean women (P=0.002, 0.046, 0.006 and 0.002, respectively). There was a positive correlation between IL-17 and IL-23 (r(s)=0.530), which was at the border of statistical significance (P=0.065). Neither IL-17 nor IL-23 correlated with leptin or MIF, and there was no association between IL-17 and IL-23 levels with BMI, WC or HOMA index.

CONCLUSION

Interleukin-23/IL-17 axis is stimulated in obese women independently of the increase in abdominal fat, insulin resistance, leptin and MIF levels.

The relationship between alcohol elimination rate and increasing blood alcohol concentration—Calculated from two consecutive blood specimens

In the period 1991-2005, a blood-alcohol concentration (BAC) analysis was carried out at the Institute of forensic medicine in Novi Sad including 2023 two consecutive blood specimens using the Headspace Gas Chromatography method. Cases with no alcohol concentration values, as well as cases where blood samples were taken within 1 h after the criminal act, were not taken into consideration. Following this rule, 1198 cases were considered in this study and all samples were grouped in 29 ranges of BAC1 of delta(BAC) = 0.1 g/kg, starting from 0.1-0.19 g/kg to 2.9-2.99 g/kg of absolute alcohol. Gathered results and elimination curve differ from the zero-order model of elimination proposed by Widmark and point to an elimination process similar to a well-known Michaelis-Menten elimination kinetics model and its variants. Results reported in this study show dependence of alcohol elimination rate (beta-slope) and BAC value. The analysis of beta60-slope versus BAC shows that a correlation between beta60 (y) and BAC (x) has a logarithmic trend line. The value of alcohol elimination rate shows a slight increment with increase of BAC alcohol, with the mean value of beta60 = 0.221 +/- 0.075 g/kg. Differences in values of beta60 among consecutive intervals of delta(BAC) = 0.1 g/kg are not significant (p>0.05). When obtained samples were grouped into ranges of 0.5 g/kg each in these intervals beta60 had the following values by range: 0.1-0.49 g/kg = 0.139 g/kg +/- 0.035; 0.5-0.99 g/kg = 0.184 g/kg +/- 0.043; 1-1.49 g/kg = 0.213 g/kg +/- 0.052; 1.5-1.99 g/kg = 0.239 g/kg +/- 0.058; 2-2.49 g/kg = 0.265 g/kg +/- 0.073; 2.5-2.99 g/kg = 0.306 g/kg +/- 0.096. Differences in values of beta slope among consecutive intervals of delta(BAC) = 0.5 g/kg are significant (p<0.01). The elimination curve in the BAC interval 0.5-2.5 g/kg has a linear trend, while beta-slope (y)/BAC (x) correlation is given as beta60 = 0.15 g/kg + (0.05 g/kg x BAC). Retrograde calculation of the blood alcohol concentration in tempore criminis (BAC(tc)) based on the determined alcohol concentration in the blood specimen (BAC(t)) shows a statistically significant difference between BAC(tc) calculated using a standard zero-order model versus corrected methodology. The higher the BAC(t) and the longer the calculation time, the greater and statistically more significant (p<0.01) is the difference between the calculated values of BAC(tc).

HELLP syndrome as a cause of unexpected rapid maternal death?A case report and review of the literature

Unexpected rapid death after delivery due to HELLP syndrome (HS) may become the subject of a forensic expertise. Since this syndrome is rarely encountered in forensic pathology, our objective was to point to some specific findings which might present forensic aspects of HS. These include unexpectedness, suddenness and fulminant course of this syndrome, which may confuse physicians, and on the other hand these characteristics cast doubt on violent injury, diagnostic oversights or iatrogenic injuries. Absence of classical signs of preeclampsia and non-specific clinical symptoms cause considerable differential diagnostic problems leading to a diagnostic delay or initial wrong non-obstetric diagnosis. A definitive postmortem diagnosis of HS in questionable cases of maternal death and consecutive forensic expertise of suspected medical malpractice should be based on accepted laboratory criteria and characteristic histopathological alterations.

"Cognac alibi" as a drunk-driving defense and medico-legal challenge

Some drivers with positive forensic ethanol analyses, offer an explanation that they consumed alcohol a short time before a traffic accident or after driving. In medico legal practice this is commonly known as hip-flask defense, but to us as "cognac alibi" defense. In these cases, the lawyers require the medico legal experts to offer as much information as possible so that the court may come to the most reliable conclusions about the driver's blood alcohol concentration at the moment of the traffic accident (BAC(Acc)). At the Institute of Forensic Medicine our own analytical approach was established to study this medico legal problem. It consists of three inter-related phases in which it combines the obtained BAC values, with testimonies of the drunk driving suspect andalso witnesses. A specific algorithm was designed for calculating absorption and elimination of consumed alcohol. All the above-mentioned elements and blood-ethanol values calculated according to Widmark's method were inserted into appropriate cells of MS Excel software in order to calculate BAC in the function of time. The result is a relevant analysis of the drunk driving suspect's BAC in 5-minute intervals, as well as a graphic representation in chart form.