Corneal tomography changes following major (6 mm) medial rectus muscle recession: a prospective cohort study using Pentacam®

INTRODUCTION

The aim of this study is to evaluate changes in corneal astigmatism, axial anterior corneal curvature, as well as changes in the anterior chamber depth and central corneal thickness, 2 months following the unilateral recession of medial rectus muscle in children.

METHODS

Thirty-three children with esotropia were prospectively evaluated following unilateral medial rectus muscle recession, using Pentacam®. Comparisons were made between the operated and fellow unoperated eyes, pre, and postoperatively. The assessment was made for changes in the radius of axial curvature on major meridians at 3 and 3.5 mm from the optical corneal center in the mid-peripheral zone. Astigmatism changes of the anterior and posterior corneal surface were calculated using vector analysis software (astigMATIC®). ANOVA model was used to examine the interaction between age or central corneal thickness and postoperative changes in anterior and posterior surface corneal astigmatism.

RESULTS

In the intervention group, changes in anterior and posterior corneal surface astigmatism were statistically significant, with a mean increase of 0.59Dx92 and 0.08Dx91, respectively. In the mid-peripheral corneal zone, there is an increase in the radius of anterior corneal axial curvature more evident nasally 3.5 mm from the corneal center on the horizontal meridian, with corresponding decrease superiorly and inferiorly at 3 and 3.5 mm from the corneal center on the vertical meridian.

DISCUSSION

The changes in total astigmatism of the operated eyes are mainly attributed to the anterior corneal surface. These changes are associated with flattening in the 180 meridian of the cornea, leading to a shift to "with-the-rule" astigmatism.

Sentinel lymph node biopsy versus elective neck dissection in management of the clinically negative (cN0) neck in patients with oral squamous cell carcinoma: A systematic review and meta-analysis

Oral squamous cell carcinoma (OSCC) is the most prevalent type of head and neck cancer, and lymph node metastasis is a crucial prognostic factor that has a direct correlation with the survival rate. The standard procedure for managing clinically negative (cN0) neck in OSCC patients is elective neck dissection (END), but it can lead to various complications that affect the patient's quality of life. Therefore, medical professionals are exploring the use of the sentinel lymph node biopsy (SLNB) to manage cN0 neck in OSCC patients. The aim of this systematic review and meta-analysis was to compare the overall survival (OS) and disease-free survival (DFS) of patients undergoing SLNB and END in the surgical management of early cN0 neck in OSCC patients. To conduct this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to report the systematic reviews. The study included all comparative clinical studies, including randomized clinical trials (RCTs), clinical perspective studies, and retrospective studies that compared END to SLNB for early cN0 neck in OSCC patients. The hazard ratio (HR) and risk ratio (RR) with 95% confidence interval (CI) were calculated using comprehensive meta-analysis. The primary outcome variables were OS, DFS, and disease-specific survival (DSS). The secondary outcome variable was the nodal recurrence rate without local or distant metastasis. The GRADE system was used to assess the evidence's certainty. The meta-analysis included 12 clinical studies, comprising three RCTs and seven non-RCTs. The results showed no statistically significant difference between END and SLNB concerning OS (HR = 0.993, CI: 0.814 to 1.211, P = 0.947, low-quality evidence), DFS (HR = 0.705, CI: 0.408 to 1.29, P = 0.21, low-quality evidence), and nodal recurrence (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). Additionally, SLNB was non-inferior to END regarding DSS (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). In conclusion, this research affirms the safety and precision of SLNB as a means to stage cN0 OSCC patients, with outcomes that are comparable to END in terms of survival and nodal recurrence. Nevertheless, it's crucial to acknowledge that the quality of evidence in this study was relatively low. Therefore, additional RCTs comparing END to SLNB are warranted to validate these results and offer more robust guidance for managing cN0 OSCC patients.

A Preliminary Study of the Role of Endothelial-Mesenchymal Transitory Factor SOX 2 and CD147 in the Microvascularization of Oral Squamous Cell Carcinoma

INTRODUCTION

The aim of this study was to detect the possible endothelial expression of embryonic-type cancer stem cells (CSC) marker SOX2 and the stemness-type CSC marker CD147 in oral potential malignant disorders (OPMDs), oral leukoplakia (OL) in particular, and oral squamous cell carcinoma (OSCC).

METHODS

This study focuses on the immunohistochemical pattern of expression of CSC protein-biomarkers SOX2 and CD147 in paraffin-embedded samples of 21 OSCCs of different grades of differentiation and 30 cases of OLs with different grades of dysplasia, compared to normal oral mucosa.

RESULTS

The protein biomarker SOX2 was expressed in the endothelial cells, but without establishing any statistically significant correlation among OSCC, OL, and normal tissue specimens. However, SOX endothelial staining was noticed in 7/30 (23.3%) cases of OL (one non-dysplastic, one mildly dysplastic, one moderately dysplastic, and four severely dysplastic cases) and 5/21 (23.8%) cases of OSCC (two well-differentiated, one moderately differentiated, and two poorly differentiated cases). Although CD147 is expressed in normal oral epithelium, OL, and OSCC neoplastic cells, its vascular-endothelial expression was noticed in only 2/5 (40%) cases of normal oral epithelium, 1/30 (3.3%) cases of OL (one severely dysplastic case), and 4/21 (19%) cases of OSCC (two well-differentiated, one moderately differentiated, and one poorly differentiated case). Therefore, no statistically significant correlation among OSCC, OL, and normal tissue specimens was established.

CONCLUSION

The endothelial presence of SOX2 both in oral potentially malignant and malignant lesions suggests that SOX2 may be implicated in the microvascularization process and associated with the degree of dysplasia in OL. The expression of CD147 may be attributed both to local inflammation and tumorigenesis. The implementation of CD147 in larger groups of tissue samples will shed some light on its role in cancer and inflammation. The evidence so far supports the need for more studies, which may support the clinical significance of these novel cancer stem cell biomarkers.

Orbital Rhabdomyosarcoma Masquerading as a Dermoid Cyst: A Case Report and Review of the Literature

The purpose of this report is to present a case of orbital rhabdomyosarcoma (RMS) masquerading as a dermoid cyst. A six-year-old boy with an unremarkable medical history presented in the outpatient department with a palpable mass in the superonasal region of the right orbit, which had rapidly grown in the past month. The most likely diagnosis was dermoid cyst and the patient was scheduled for surgical excision. A high index of suspicion was raised intraoperatively based on the appearance of the lesion due to the presence of a feeder vessel. The histopathology examination identified alveolar RMS. The patient was referred to a pediatric oncology department and commenced intravenous chemotherapy. RMS may masquerade as various conditions, including dermoid cysts and chalazion. A high index of suspicion should be raised in cases with rapidly growing lesions.

Foveal Hypoplasia in a Child With Tyrosinase-Positive Albinism

The purpose of this article is to report a case of bilateral foveal hypoplasia in an eight-year-old girl who presented to the ophthalmology department due to poor vision in both eyes. Clinical examination revealed bilateral nystagmus, decreased vision, as well as iris transillumination. Dilated fundus examination indicated the absence of light reflex around the foveal area and optical coherence tomography (OCT) imaging exhibited the absence of the fovea centralis depression. These findings, in addition to the patient's light-colored hair and skin complexion, raised suspicion for albinism. The patient was referred for genetic testing and the results confirmed the diagnosis of tyrosinase-positive oculocutaneous albinism (OCA2).

Expression of the Embryonic Cancer Stem Cells' Biomarkers SOX2 and OCT3/4 in Oral Leukoplakias and Squamous Cell Carcinomas: A Preliminary Study

INTRODUCTION

Cancer stem cells (CSCs) are incriminated for initiating the process of carcinogenesis either de novo or through the transformation of oral potentially malignant disorders (OPMDs) to oral squamous cell carcinoma (OSCC). The aim of this study was to detect the expression of embryonic-type CSC markers OCT3/4 and SOX2 in OSCCs and oral leukoplakias (OLs), the most common of OPMDs.

MATERIALS AND METHODS

The study type is experimental, and the study design is characterized as semiquantitative research, which belongs to the branch of experimental research. The experiment was conducted in the Department of Oral Medicine/Pathology, School of Dentistry, Aristotle University of Thessaloniki, Greece. This study focuses on the semiquantitative immunohistochemical (IHC) pattern of expression of CSCs protein-biomarkers SOX2 and OCT3/4, in paraffin embedded samples of 21 OSCCs of different grades of differentiation and 30 cases of OLs with different grades of dysplasia, compared to five cases of normal oral mucosa in both terms of cells' stain positivity and intensity. Statistical analysis was performed through SPSS 2017 Pearson Chi-square and the significance level was set at 0.05 (p=0.05). The expression of the respective genes of SOX2 and OCT3/4 was studied through quantitative polymerase chain reaction (qPCR), in paraffin-embedded samples of 12 cases of OLs with mild/non dysplasia and 19 cases moderately/poorly differentiated OSCCs(n=19) and five normal mucosa using the Independent Paired T-test.

RESULTS

The genes SOX2 and Oct3/4 were expressed in all examined cases although no statistically significant correlations among normal, OL and OSCC, were established. A nuclear/membrane staining of OCT3/4 was noticed only in three out of 21 OSCCs but in none of OLs or normal cases (without statistical significance). A characteristic nuclear staining of SOX2 was noticed in the majority of the samples, mostly in the basal and parabasal layers of the epithelium. SOX2 was significantly detected in the OSCCs group (strong positivity in 17/21) than in the OL group (30 cases, mostly mildly stained) (p-value=0.007), and the normal oral epithelium (mild stained, p=0.065). Furthermore, SOX2 was overexpressed in well differentiated OSCCs group (5/OSCCs, strongly stained) rather than in mildly dysplastic and non-dysplastic OLs samples (14/OLs, mildly stained) (p-value =0.035).

CONCLUSION

The characteristic expression of SOX2 but not of OCT3/4 in OLs' and OSCCs' lesions suggests the presence of neoplastic cells with certain CSC characteristics whose implication in the early stages of oral tumorigenesis could be further evaluated. The clinical use of SOX2, as prognostic factor, requires further experimental evaluation in larger number of samples.

The Role of 3D-Printed Patient-Specific Instrumentation in Total Knee Arthroplasty: A Literature Review

Total knee arthroplasty (TKA) is currently one of the most common orthopedic surgeries due to the ever-increasing average life expectancy. The constant need for effective and accurate techniques was contributed to the development of three-dimensional (3D) printing in that field, especially for patient-specific instrumentation (PSI) and custom-made implants fabrication. PSI may offer numerous benefits, such as resection accuracy, mechanical axis alignment, cost-effectiveness, and time economy. Nonetheless, the results of existing studies are controversial. For this purpose, a review article of the published articles was conducted to summarize the role of 3D-printed PSI in TKA.

Evaluation of Macular Thickness Changes Following Large Horizontal Rectus Muscle Recession: A Prospective Cohort Study

Aim The aim of the study was to evaluate the long-term effect of large horizontal rectus muscle recession on macula thickness using spectral domain optical coherence tomography (SD-OCT). Material and methods Forty-two children were included in the study. The intervention groups were the medial rectus (MR) group (=20 eyes ) and the lateral rectus (LR) group (=22 eyes), including the eyes that underwent large medial and lateral rectus muscle recession, respectively. The control group included the fellow 42 unoperated eyes of the same children. Each eye was scanned using Topcon Maestro2 OCT-Angiography (OCTA; Topcon, Tokyo, Japan) preoperatively and then two months following surgery. A paired t-test was used to compare the mean difference in macular thickness between the intervention and control groups using the statistical program R (R Foundation for Statistical Computing, Vienna, Austria). Results The mean change in central, parafoveal, and perifoveal macular thickness of the intervention group was not statistically significant. Conclusion The long-term changes in macular thickness, as evaluated using SD-OCT both for the central and peripheral regions of the fovea, following large horizontal rectus muscle recession surgery, are not statistically significant.

Aldehyde Dehydrogenase: An Off-Label Marker of Endothelial Activation in Oral Squamous Cell Carcinoma

The vascular endothelial (VE) expression of aldehyde dehydrogenase (ALDH) 1/2 family in oral leukoplakia (OL) and oral squamous cell carcinoma (OSCC) cases has not been studied so far. The aim of this study was to illustrate the "off-label" endothelial expression of cancer stem cell (CSC) biomarker, ALDH1/2, adjacent to oral potentially malignant and malignant lesions in order to shed some light on the mechanisms leading to oral carcinogenesis.  Materials and methods: The expression of CSC protein-biomarker ALDH1/2 was detected through immunohistochemistry (IHC) in 30 paraffin-embedded samples of OL and 21 samples of OSCC compared to five samples of normal oral mucosa. Statistical analysis was done using SPSS, Pearson Chi-square, and Fischer's exact test. The significance level was set at 0.05 (p≤ 0.05).  Results: In oral mucosal vessels, ALDH1/2 was not expressed. It was expressed significantly more in the vessels of OSCCs compared to the OLs (Fisher's exact test, p-value= 0,001). However, when endothelial expression of ALDH1/2 in the vasculature of OLs was compared with that of the normal oral mucosa, no significant change was noticed (Fisher's exact test, p-value=1.000).  Discussion: The IHC VE expression of ALDH1/2 in OSCC vasculature but not in OL indicates a possible significantly stronger activation of endothelial cells during carcinogenesis, which could be an indicator of the role of inflammation in the development of field cancerization and of prognostic value for (vascular/lymphatic) metastasis.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Comparison of various treatment modalities for the management of bone marrow edema syndrome/transient osteoporosis in men and non-pregnant women: a systematic review

Transient osteoporosis (TO) or bone marrow edema syndrome (BMES) is a self-limited clinical condition, which affects middle-aged men and women. It can be treated with miscellaneous conservative and surgical measures, which are analyzed in this systematic review.

INTRODUCTION

BMES/TO is a transient clinical entity, which can be treated with various therapeutic modalities. The aim of our study was to assess the efficacy of different therapeutic options for the alleviation of pain and reduction of bone marrow edema (BME) in patients with BMES/TO, as well as to propose a therapeutic algorithm.

METHODS

PubMed, Scopus, Cochrane, and Google Scholar were searched. Eligibility and extraction of studies were conducted by two authors. Methodological quality assessment was carried out with the modified Delphi technique, Methodological Index for Non-Randomized Studies (MINORS) criteria, and Cochrane Collaboration's risk of bias tool. Outcomes that were compared were time of pain resolution, VAS pain scores, and BME regression on magnetic resonance imaging (MRI).

RESULTS

A total of 36 articles (880 patients) were included. Bisphosphonates had higher efficiency in less than 1-month outcomes on pain resolution compared with core decompression (CD), while iloprost was more efficient at 1-3 months compared with bisphosphonates and CD. At 3-6 months, all three of the aforementioned showed equal results on pain resolution, and at a period of 6-12 months, CD and extracorporeal shockwave therapy (ESWT) showed excellent results followed by bisphosphonates and the conservative group (CG) consisting of non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics and/or restricted weight bearing. On MRI at 1-3 months, bisphosphonates, iloprost, and CD had relatively the same outcomes on BME resolution, with the least promising being the CG. At 3-6 months, CD seemed to have achieved the best results on the resolution of BME, followed by ESWT, CG, and bisphosphonates group. At 6-12 months, ESWT had the best outcomes compared with the conservative, bisphosphonates, and iloprost groups.

CONCLUSION

BMES/TO has been treated with many non-standardized measures due to the low number of highly reliable studies. Current literature shows promising results with regard to the reduction of the clinical course of BMES/TO, but further large multicenter randomized controlled trials, as well as standardized radiological and clinical scores, are warranted to acquire evidence-based recommendations on the therapeutic algorithm.

Assessment of genetically modified maize MON 87419 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2017-140)

Genetically modified maize MON 87419 was developed to confer tolerance to dicamba- and glufosinate-based herbicides. These properties were achieved by introducing the dmo and pat expression cassettes. The molecular characterisation data and bioinformatic analyses do not identify issues requiring food/feed safety assessment. None of the identified differences in the agronomic/phenotypic and compositional characteristics tested between maize MON 87419 and its conventional counterpart needed further assessment, except for the levels of arginine and protein in grains which did not raise safety and nutritional concerns. The GMO Panel does not identify safety concerns regarding the toxicity and allergenicity of the dicamba mono-oxygenase (DMO) and phosphinothricin N-acetyltransferase (PAT) proteins as expressed in maize MON 87419. The GMO Panel finds no evidence that the genetic modification impacts the overall safety of maize MON 87419. In the context of this application, the consumption of food and feed from maize MON 87419 does not represent a nutritional concern in humans and animals. The GMO Panel concludes that maize MON 87419 is as safe as the conventional counterpart and non-GM maize varieties tested, and no post-market monitoring of food/feed is considered necessary. In the case of accidental release of viable maize MON 87419 grains into the environment, this would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of maize MON 87419. The GMO Panel concludes that maize MON 87419 is as safe as its conventional counterpart and the tested non-GM maize varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified maize GA21 × T25 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-DE-2016-137)

Genetically modified maize GA21 × T25 was developed by crossing to combine two single events: GA21 and T25. The GMO Panel previously assessed the two single maize events and did not identify safety concerns. No new data on the single maize events were identified that could lead to modification of the original conclusions on their safety. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in maize GA21 × T25 does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that maize GA21 × T25, as described in this application, is as safe as its conventional counterpart and the non-GM reference varieties tested, and no post-market monitoring of food and feed is considered necessary. In the case of accidental release of viable maize GA21 × T25 grains into the environment, this would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of maize GA21 × T25. Post-market monitoring of food and feed is not considered necessary. The GMO Panel concludes that maize GA21 × T25 is as safe as its conventional counterpart and the non-GM reference varieties tested, with respect to potential effects on human and animal health and the environment.

Straatsma Syndrome: A Case Series

The aim of this article is to report two cases of Straatsma syndrome, a rare disease characterized by the traditional triad of unilateral myelinated retinal nerve fibres, axial myopia, and amblyopia.

The cases were a five-year-old and a three-year-old girl, both with unilateral myopia, visual acuity of 0.1 (decimal), and myelinated retinal nerve fibres in fundoscopy. Prescription of cycloplegic refraction findings and occlusion of the involved eye was attempted in both cases, but visual acuity did not improve. Poor-prognostic factors of Straatsma syndrome include a high degree of anisometropia and extensive myelination.

Assessment of genetically modified maize MON 89034 × 1507 × MIR162 × NK603 × DAS-40278-9 for food and feed uses, under regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2018-151)

Genetically modified maize MON 89034 × 1507 × MIR162 × NK603 × DAS‐40278‐9 was developed by crossing to combine five single events: MON 89034, 1507, MIR162, NK603 and DAS‐40278‐9. The GMO Panel previously assessed the five single maize events and 16 of the subcombinations and did not identify safety concerns. No new data on the single maize events or the assessed subcombinations were identified that could lead to the modification of the original conclusions on their safety. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the five‐event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that five‐event stack maize, as described in this application, is as safe as the non‐GM comparator and non‐GM maize varieties tested. In the case of accidental release of viable five‐event stack maize grains into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in nine of the maize subcombinations not previously assessed and concludes that these are expected to be as safe as the single events, the previously assessed subcombinations and the five‐event stack maize. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of maize MON 89034 × 1507 × MIR162 × NK603 × DAS‐40278‐9. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the five‐event stack maize and its subcombinations are as safe as its non‐GM comparator and the tested non‐GM maize varieties with respect to potential effects on human and animal health and the environment.

Long-term astigmatism changes following horizontal muscle recession: a prospective cohort study

Strabismus surgery may cause refractive changes, particularly in astigmatism. The aim of this study is to evaluate those changes in astigmatism two and 12 months following unilateral recession of horizontal rectus muscles in children. The authors prospectively evaluated 66 children with esotropia or exotropia, that would undergo a unilateral recession strabismus surgery. Comparisons were made between the 66 eyes that would undergo strabismus surgery and the fellow unoperated 66 eyes of the same children. The 66 eyes that would undergo strabismus surgery were divided into medial (38 eyes) and lateral (28 eyes) rectus muscle subgroups, and further, into subgroups based on the astigmatism axis preoperatively (with-the-rule astigmatism: 35 eyes, no astigmatism: 20 eyes, oblique astigmatism: 10 eyes, against-the-rule astigmatism: 1 eye). All patients were examined one day preoperatively, and then, two and 12 months postoperatively. Paired tests were conducted, and the significant level was set to 0.05 or was adjusted for subgroups. Mean age of children included was 6.73 years (SD = 3.19). Mean astigmatism values preoperatively, 2 and 12 months postoperatively were 0.92D (SD = 0.95), 1.45D (SD = 1.04) and 1.50D (SD = 1.10), respectively, for the eyes that underwent strabismus surgery. A statistically significant mean increase of 0.58D in astigmatism values in the eyes that underwent strabismus surgery was observed 12 months postoperatively (p < .005). Astigmatism values in the eyes that did not undergo strabismus surgery did not statistically significantly change during the observation period. The increase of the absolute values of astigmatism in medial and lateral rectus muscle subgroups was similar, 0.59D (SD = 0.10) and 0.57D (SD = 0.11), respectively. For the eyes that had with-the-rule astigmatism and no astigmatism preoperatively, a statistically significant increase was shown 12 months postoperatively (0.64D and 0.66D respectively) (p < .005). Changes in astigmatism were observed in the eyes which underwent recession of horizontal rectus muscles compared to the fellow eyes, which did not undergo any intervention. An increase in cylindrical power was noted in the eyes that had with-the-rule and no astigmatism prior to surgery. This increase may be interpreted by the decreased tension of the recessed rectus muscle following strabismus surgery. Decreased forces, caused by the recessed horizontal rectus muscle, acting on the sclera on 180-degree meridian may lead to corneal flattening on this particular meridian and consequently, a corneal steepening on the 90-degree meridian. These changes seem to be stable during the first 12 postoperative months.

Assessment of genetically modified maize DP4114 × MON 810 × MIR604 × NK603 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA‐GMO‐NL‐2018‐150)

Maize DP4114 × MON 810 × MIR604 × NK603 (four‐event stack maize) was produced by conventional crossing to combine four single events: DP4114, MON 810, MIR604 and NK603. The GMO Panel previously assessed the four single maize events and one of the subcombinations and did not identify safety concerns. No new data on the single maize events or the assessed subcombination were identified that could lead to modification of the original conclusions on their safety. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the four‐event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the four‐event stack maize, is as safe as the comparator and the selected non‐GM reference varieties. In the case of accidental release of viable grains of the four‐event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in nine of the maize subcombinations not previously assessed and concludes that these are expected to be as safe as the single events, the previously assessed subcombination and the four‐event stack maize. Post‐market monitoring of food/feed is not considered necessary. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the four‐event stack maize. The GMO Panel concludes that the four‐event stack maize and its subcombinations are as safe as the non‐GM comparator and the selected non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified maize NK603 × T25 × DAS-40278-9 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2019-164)

Maize NK603 × T25 × DAS-40278-9 (three-event stack maize) was produced by conventional crossing to combine three single events: NK603, T25 and DAS-40278-9. The GMO Panel previously assessed the three single maize events and two of the subcombinations and did not identify safety concerns. No new data on the single maize events or the two subcombinations were identified that could lead to modification of the original conclusions on their safety. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the three-event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the three-event stack maize, as described in this application, is as safe as the non-GM comparator and the selected non-GM reference varieties. In the case of accidental release of viable grains of the three-event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in one of the maize subcombinations not previously assessed and concludes that these are expected to be as safe as the single events, the previously assessed subcombinations and the three-event stack maize. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of the three-event stack maize. Post-market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the three-event stack maize and its subcombinations are as safe as the non-GM comparator and the selected non-GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified cotton GHB811 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-ES-2018-154)

Cotton GHB811 was developed to confer tolerance to glyphosate and HPPD inhibitor herbicides. The molecular characterisation data and bioinformatic analyses do not identify issues requiring food/feed safety assessment. None of the identified differences in the agronomic/phenotypic and compositional characteristics tested between cotton GHB811 and its conventional counterpart needs further assessment, except for % lint, lint length and dihydrosterculic acid, which do not raise nutritional and safety concerns. The GMO Panel does not identify safety concerns regarding the toxicity and allergenicity of the 2mEPSPS and HPPD W336 proteins as expressed in cotton GHB811 and finds no evidence that the genetic modification would change the overall allergenicity of cotton GHB811. In the context of this application, the consumption of food and feed from cotton GHB811 does not represent a nutritional concern in humans and animals. The GMO Panel concludes that cotton GHB811 is as safe as the conventional counterpart and non-GM cotton reference varieties tested, and no post-market monitoring of food/feed is considered necessary. In the case of accidental release of viable cotton GHB811 seeds into the environment, this would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of cotton GHB811. The GMO Panel concludes that cotton GHB811 is as safe as its conventional counterpart and the tested non-GM cotton reference varieties with respect to potential effects on human and animal health and the environment.

Changes in astigmatism after horizontal muscle recession strabismus surgery: A retrospective cohort study

Purpose:

The aim of this study was to evaluate the changes in astigmatism after unilateral recession of horizontal rectus muscles in pediatric patients.

Methods:

The authors retrospectively evaluated the medical history of 52 children with esotropia or exotropia, that underwent a unilateral recession strabismus surgery. The intervention group consisted of the 52 eyes that underwent strabismus surgery, and the control group consisted of the other 52 fellow unoperated eyes of the same participants. The intervention group was divided into medial and lateral rectus muscle subgroups, and four subgroups based on the astigmatism axis preoperatively (A: with-the-rule astigmatism, B: no astigmatism, C: intermediate meridians, D: against-the-rule astigmatism). All patients were examined one day preoperatively, and then, six weeks postoperatively. Paired tests were conducted, and the significant level was set to 0.05 or was adjusted for subgroups.

Results:

A mean difference 0.43 D of astigmatism (95% CI: 0.27, 0.59) was observed after the surgery between intervention and control group (P < 0.001). Astigmatism change (postoperative - preoperative) in subgroup A was 0.50 D (P < 0.001) and in subgroup B was 0.75 D (P < 0.001). Moreover, astigmatism changes of 0.50 D were found in both lateral (P < 0.001) and medial rectus muscle group (P = 0.002).

Conclusion:

Strabismus surgery appears to be associated with alterations in astigmatism, and in particular increase in cylindrical power in the eyes that had with-the-rule astigmatism or no astigmatism preoperatively. Those changes should be considered when planning the operation, to avoid transforming clinically non-significant astigmatism into clinically significant.

Potential use of gene drive modified insects against disease vectors, agricultural pests and invasive species poses new challenges for risk assessment

Potential future application of engineered gene drives (GDs), which bias their own inheritance and can spread genetic modifications in wild target populations, has sparked both enthusiasm and concern. Engineered GDs in insects could potentially be used to address long-standing challenges in control of disease vectors, agricultural pests and invasive species, or help to rescue endangered species, and thus provide important public benefits. However, there are concerns that the deliberate environmental release of GD modified insects may pose different or new harms to animal and human health and the wider environment, and raise novel challenges for risk assessment. Risk assessors, risk managers, developers, potential applicants and other stakeholders at many levels are currently discussing whether there is a need to develop new or additional risk assessment guidance for the environmental release of GD modified organisms, including insects. Developing new or additional guidance that is useful and practical is a challenge, especially at an international level, as risk assessors, risk managers and many other stakeholders have different, often contrasting, opinions and perspectives toward the environmental release of GD modified organisms, and on the adequacy of current risk assessment frameworks for such organisms. Here, we offer recommendations to overcome some of the challenges associated with the potential future development of new or additional risk assessment guidance for GD modified insects and provide considerations on areas where further risk assessment guidance may be required.

Extreme stiff knee recurvatum following manipulation under anesthesia and botulinum neurotoxin injection

In this article we report a case of stiff, neglected extreme recurvatum knee deformity in a 17-year-old female. This is the first reported case in the literature of an acquired ligamentous stiff extreme knee recurvatum following manipulation under anesthesia and botulinum neurotoxin injection. Μodified Judet quadricepsplasty combined with Ilizarov external hinged frame fixation was implemented. This dual technique can be considered as a rational approach for such an extreme deformity as it stabilizes, progressively corrects, and prevents recurrence. A patellar tendon rupture caused by the increasing tension of the extensor mechanism following the correction was treated successfully using a cadaveric Achilles tendon allograft.

Assessment of genetically modified oilseed rape 73496 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2012-109)

Oilseed rape 73496 was developed to confer tolerance to the herbicidal active substance glyphosate through the expression of the glyphosate acetyltransferase protein GAT4621. The molecular characterisation data and bioinformatic analyses identify no issues requiring food/feed safety assessment. None of the identified differences between oilseed rape 73496 and its conventional counterpart in the agronomic/phenotypic endpoints tested needs further assessment. Differences identified in seed composition of oilseed rape 73496 as compared to its conventional counterpart raise no safety and nutritional concerns in the context of the scope of this application. No safety concerns are identified regarding toxicity and allergenicity of the GAT4621 protein as expressed in oilseed rape 73496. No evidence is found that the genetic modification would change the overall allergenicity of oilseed rape 73496. Based on the outcome of the comparative and nutritional assessments, the consumption of oilseed rape 73496 does not represent any nutritional concern, in the context of the scope of this application. The implementation of a post-market monitoring plan is recommended to confirm the predicted consumption data and to verify that the conditions of use are those considered during the pre-market risk assessment. In the case of accidental release of viable oilseed rape 73496 seeds into the environment, oilseed rape 73496 would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of oilseed rape 73496. The GMO Panel concludes that oilseed rape 73496, as described in this application, is as safe as its conventional counterpart and the non-genetically modified oilseed rape reference varieties tested with respect to potential effects on human and animal health and the environment.

Neglected Stiff Equinocavus Foot Deformity Treated with Cole Osteotomy, Combined with External Ilizarov Hinged Frame Fixation, Soft-Tissue Release, and Achilles Tendon Lengthening: A Case Report

Stiff equinocavus foot deformities are challenging clinical entities that may be treated with osteotomies and extensive soft-tissue release. The most common causes of such lesions are neglected trauma and Charcot-Marie-Tooth disease; other causes include burns, neurologic diseases, and compartment leg syndrome. Conventional treatments, including extensive soft-tissue release, osteotomies, and arthrodesis combined with or without internal splinting, may result in severe complications such as neurovascular or soft-tissue damage and shortening of the foot. The Ilizarov technique may be superior to the traditional approach, because it allows surgeons to apply gradual and titrated correction of individual components of complex deformities and results in minimal surgical morbidity without shortening of the foot. This is the first case report in the literature describing the simultaneous use of Cole osteotomy, combined with external Ilizarov hinged frame fixation, soft-tissue release, and Achilles tendon lengthening for the treatment of an extreme neglected stiff equinocavus foot deformity.

Assessment of genetically modified soybean GMB151 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2018-153)

Soybean GMB151 was developed to confer tolerance to 4-hydroxyphenylpyruvate dioxygenase (HPPD) inhibitor herbicides and resistance to nematodes. The molecular characterisation data and bioinformatic analyses do not identify issues requiring food/feed safety assessment. None of the identified differences in the agronomic/phenotypic and compositional characteristics tested between soybean GMB151 and its conventional counterpart needs further assessment, except for palmitic acid and heptadecenoic acid in seeds and carbohydrate and crude protein in forage, which does not raise nutritional and safety concerns. The GMO Panel does not identify safety concerns regarding the toxicity and allergenicity of the HPPD-4 and Cry14Ab-1 proteins as expressed in soybean GMB151, and finds no evidence that the genetic modification would change the overall allergenicity of soybean GMB151. In the context of this application, the consumption of food and feed from soybean GMB151 does not represent a nutritional concern in humans and animals. The GMO Panel concludes that soybean GMB151 is as safe as the conventional counterpart and non-GM soybean reference varieties tested, and no post-market monitoring of food/feed is considered necessary. In the case of accidental release of viable soybean GMB151 seeds into the environment, this would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of soybean GMB151. The GMO Panel concludes that soybean GMB151 is as safe as its conventional counterpart and the tested non-GM soybean reference varieties with respect to potential effects on human and animal health and the environment.

Overview of EFSA and European national authorities' scientific opinions on the risk assessment of plants developed through New Genomic Techniques

The European Commission requested EFSA to provide an overview on the risk assessment of plants developed through new genomic techniques (NGTs), taking into account its previous scientific opinions, its ongoing work on the topic as well as opinions published by competent authorities and national institutions since 2012, where available. In this report, NGTs are defined as techniques capable to change the genetic material of an organism and have emerged or developed since the adoption of the 2001 genetically modified organism (GMO) legislation. EFSA considered 16 scientific opinions issued by European member states ('MS opinions') as well as three EFSA GMO Panel scientific opinions on NGTs. A procurement to evaluate and summarise the MS opinions was conducted. Relevant information on the description of each NGT and information on the risk assessment of plants developed through one or a combination of the defined NGTs was extracted and summarised. The baseline for the types and nature of NGTs to be included in this report was defined based on the JRC, 2011 report on new plant breeding techniques as well as on the Explanatory Note on New Techniques in Agricultural Biotechnology from the European Commissioner for Health and Food Safety (EC-SAM, 2017) for some more recently developed NGTs, taking into account the NGT definition provided by the European Commission for this mandate. EFSA was not requested to develop new opinions on plants developed through specific NGTs, and thus, no critical appraisal of the reviewed scientific opinions was carried out.

Assessment of genetically modified maize 1507 × MIR162 × MON810 × NK603 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2015-127)

Maize 1507 × MIR162 × MON810 × NK603 (four‐event stack maize) was produced by conventional crossing to combine four single events: 1507, MIR162, MON810 and NK603. The GMO Panel previously assessed the four single events and six of the subcombinations and did not identify safety concerns. No new data on the single events or the six subcombinations that could lead to modification of the original conclusions on their safety were identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the four‐event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the four‐event stack maize, as described in this application, is as safe as its non‐GM comparator and the non‐GM reference varieties tested. In the case of accidental release of viable seeds of the four‐event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in the four maize subcombinations not previously assessed and concludes that these are expected to be as safe as the single events, the previously assessed subcombinations and the four‐event stack maize. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the four‐event stack maize. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the four‐event stack maize and its subcombinations are as safe as the non‐GM comparator and the tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified maize MON 87427 × MON 87460 × MON 89034 × 1507 × MON 87411 × 59122 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2017-139)

Maize MON 87427 × MON 87460 × MON 89034 × 1507 × MON 87411 × 59122 (six-event stack maize) was produced by conventional crossing to combine six single events: MON 87427, MON 87460, MON 89034, 1507, MON 87411 and 59122. The GMO Panel previously assessed the six single maize events and 17 of the subcombinations and did not identify safety concerns. No new data on the single maize events or the 17 subcombinations were identified that could lead to modification of the original conclusions on their safety. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins and dsRNA in the six-event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the six-event stack maize, as described in this application, is as safe as its non-GM comparator and the selected non-GM reference varieties. In the case of accidental release of viable grains of the six-event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in the 39 maize subcombinations not previously assessed and concludes that these are expected to be as safe as the single events, the previously assessed subcombinations and the six-event stack maize. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of the six-event stack maize. Post-market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the six-event stack maize and its subcombinations are as safe as the non-GM comparator and the selected non-GM reference varieties with respect to potential effects on human and animal health and the environment.

Iatrogenic displacement of impacted mandibular third molars or their roots into adjacent soft tissues and spaces: A report of three cases

Iatrogenic tooth displacement is a rather unusual but significant complication during extractions' procedures. The most common anatomic positions of displacement for the lower teeth include the pterygomandibular, submandibular, sublingual, and lateral pharyngeal spaces. A retrospective analysis of three cases of tooth displacement to adjacent anatomic sites is presented. These patients were treated at the Oral and Maxillofacial Surgery Department, G. Papanikolaou General Hospital of Thessaloniki, Greece. Two cases refer to displaced roots in the submandibular space, and one refers to a lower third molar displaced in the lateral pharyngeal space. Third molar displacement is a clinical complication that should be considered during mandibular third molar extraction, and proper preventive measures should be taken into consideration.

The efficacy and safety of bisphosphonates in patients with bone marrow edema syndrome/transient osteoporosis: A systematic literature review

Background

The purpose of our systematic literature review study was to critically analyze all current data including time to achieve pain relief and resolution of bone marrow edema (BME) on magnetic resonance imaging (MRI) in patients with bone marrow edema syndrome (BMES) when using bisphosphonates.

Methods

A systematic review was performed to address studies which concerned the efficacy and safety of bisphosphonates in patients with BMES. A systematic search was conducted by two investigators using databases including Pubmed and Scopus.

Results

Nine studies were included between July 2002 and June 2019 with a total of 187 patients out of whom 150 had been treated with bisphosphonates. Mean age of patients was 44,14 (mean ranges 34.9-54.0), 113 males and 54 females (excluding one study which did not mention ages). Five studies described the outcomes from MRI on follow-up (42 out of 78 patients achieved resolution with time ranging from 3 to 12 months with a mean of 3.85 months) and eight studies described the outcomes regarding pain resolution (128 out of 140 achieved resolution with mean time 4.20 months, ranging from 0.7 months to 12 months). Adverse events related to the administration of bisphosphonates included flue-like symptoms in 6 patients, musculoskeletal pain in 1 patient, arthralgias and fever in 9 patients.

Conclusions

The outcome of this systematic review indicated that the effect of bisphosphonates on pain relief and on regression of BME on MRI is controversial, but due to the low level of evidence of the included studies, no definite conclusions can be acquired and no evidence based recommendation could be given.

Scientific Opinion on application EFSA-GMO-NL-2016-132 for authorisation of genetically modified of insect-resistant and herbicide-tolerant soybean DAS-81419-2 × DAS-44406-6 for food and feed uses, import and processing submitted in accordance with Regulation (EC) No 1829/2003 by Dow Agrosciences LCC

Soybean DAS-8419-2 × DAS-44406-6 was developed to provide protection against certain lepidopteran pests and tolerance to 2,4-dichlorophenoxyacetic acid and other related phenoxy herbicides, and glyphosate- and glufosinate ammonium-containing herbicides. The Genetically Modified Organisms (GMO) Panel previously assessed the two single soybean events and did not identify safety concerns. No new data on the single soybean events, leading to modification of the original conclusions on their safety have been identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single soybean events and of the newly expressed proteins in the two-event stack soybean does not give rise to food and feed safety and nutritional concerns. In the case of accidental release of viable DAS-8419-2 × DAS-44406-6 seeds into the environment, soybean DAS-8419-2 × DAS-44406-6 would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of soybean DAS-8419-2 × DAS-44406-6. In conclusion, the GMO Panel considers that soybean DAS-8419-2 × DAS-44406-6, as described in this application, is as safe as its conventional counterpart and the non-genetically modified soybean reference varieties tested with respect to potential effects on human and animal health and the environment.

Adequacy and sufficiency evaluation of existing EFSA guidelines for the molecular characterisation, environmental risk assessment and post-market environmental monitoring of genetically modified insects containing engineered gene drives

Advances in molecular and synthetic biology are enabling the engineering of gene drives in insects for disease vector/pest control. Engineered gene drives (that bias their own inheritance) can be designed either to suppress interbreeding target populations or modify them with a new genotype. Depending on the engineered gene drive system, theoretically, a genetic modification of interest could spread through target populations and persist indefinitely, or be restricted in its spread or persistence. While research on engineered gene drives and their applications in insects is advancing at a fast pace, it will take several years for technological developments to move to practical applications for deliberate release into the environment. Some gene drive modified insects (GDMIs) have been tested experimentally in the laboratory, but none has been assessed in small-scale confined field trials or in open release trials as yet. There is concern that the deliberate release of GDMIs in the environment may have possible irreversible and unintended consequences. As a proactive measure, the European Food Safety Authority (EFSA) has been requested by the European Commission to review whether its previously published guidelines for the risk assessment of genetically modified animals (EFSA, 2012 and 2013), including insects (GMIs), are adequate and sufficient for GDMIs, primarily disease vectors, agricultural pests and invasive species, for deliberate release into the environment. Under this mandate, EFSA was not requested to develop risk assessment guidelines for GDMIs. In this Scientific Opinion, the Panel on Genetically Modified Organisms (GMO) concludes that EFSA's guidelines are adequate, but insufficient for the molecular characterisation (MC), environmental risk assessment (ERA) and post-market environmental monitoring (PMEM) of GDMIs. While the MC,ERA and PMEM of GDMIs can build on the existing risk assessment framework for GMIs that do not contain engineered gene drives, there are specific areas where further guidance is needed for GDMIs.

Applicability of the EFSA Opinion on site-directed nucleases type 3 for the safety assessment of plants developed using site-directed nucleases type 1 and 2 and oligonucleotide-directed mutagenesis

The European Commission requested the EFSA Panel on Genetically Modified Organisms (GMO) to assess whether section 4 (hazard identification) and the conclusions of EFSA's Scientific opinion on the risk assessment of plants developed using zinc finger nuclease type 3 technique (ZFN-3) and other site-directed nucleases (SDN) with similar function are valid for plants developed via SDN-1, SDN-2 and oligonucleotide-directed mutagenesis (ODM). In delivering this Opinion, the GMO Panel compared the hazards associated with plants produced via SDN-1, SDN-2 and ODM with those associated with plants obtained via both SDN-3 and conventional breeding. Unlike for SDN-3 methods, the application of SDN-1, SDN-2 and ODM approaches aims to modify genomic sequences in a way which can result in plants not containing any transgene, intragene or cisgene. Consequently, the GMO Panel concludes that those considerations which are specifically related to the presence of a transgene, intragene or cisgene included in section 4 and the conclusions of the Opinion on SDN-3 are not relevant to plants obtained via SDN-1, SDN-2 or ODM as defined in this Opinion. Overall, the GMO Panel did not identify new hazards specifically linked to the genomic modification produced via SDN-1, SDN-2 or ODM as compared with both SDN-3 and conventional breeding. Furthermore, the GMO Panel considers that the existing Guidance for risk assessment of food and feed from genetically modified plants and the Guidance on the environmental risk assessment of genetically modified plants are sufficient but are only partially applicable to plants generated via SDN-1, SDN-2 or ODM. Indeed, those guidance documents' requirements that are linked to the presence of exogenous DNA are not relevant for the risk assessment of plants developed via SDN-1, SDN-2 or ODM approaches if the genome of the final product does not contain exogenous DNA.

Assessment of genetically modified soybean MON 87708 × MON 89788 × A5547-127, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2016-135)

Soybean MON 87708 × MON 89788 × A5547‐127 (three‐event stack soybean) was produced by conventional crossing to combine three single events: MON 87708, MON 89788 and A5547‐127. The GMO Panel previously assessed the three single events and did not identify safety concerns. No new data on the single events, leading to modification of the original conclusions on their safety have been identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single soybean events and of the newly expressed proteins in the three‐event stack soybean does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the three‐event stack soybean, as described in this application, is as safe as and nutritionally equivalent to its conventional counterpart and the non‐GM reference varieties tested. The nutritional impact of food/feed derived from the three‐event stack soybean is expected to be the same as that of food/feed derived from the conventional counterpart and non‐GM reference varieties. In the case of accidental release of viable seeds of the three‐event stack soybean into the environment, this would not raise environmental safety concerns. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the three‐event stack soybean. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the three‐event stack soybean is as safe as its conventional counterpart and the tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified soybean MON 87751 × MON 87701 × MON 87708 × MON 89788 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2016-128)

Soybean MON 87751 × MON 87701 × MON 87708 × MON 89788 (four‐event stack soybean) was produced by conventional crossing to combine four single events: MON 87751, MON 87701, MON 87708 and MON 89788. The GMO Panel previously assessed the four single events and did not identify safety concerns. No new data on the single events have been identified that would lead to modification of the original conclusions on their safety. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological and allergenicity assessment indicate that the combination of the single soybean events and of the newly expressed proteins in the four‐event stack soybean does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the four‐event stack soybean, as described in this application, is as safe as and nutritionally equivalent to the non‐GM comparator and the non‐GM reference varieties tested. In the case of accidental release of viable seeds of the four‐event stack soybean into the environment, this would not raise environmental safety concerns. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the four‐event stack soybean. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the four‐event stack soybean is as safe as the non‐GM comparator and the tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified maize MON 87427 × MON 89034 × MIR162 × MON 87411 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2017-144)

Maize MON 87427 × MON 89034 × MIR162 × MON 87411 (four‐event stack maize) was produced by conventional crossing to combine four single events: MON 87427, MON 89034, MIR162 and MON 87411. The genetically modified organism (GMO) Panel previously assessed the four single maize events and four of the subcombinations and did not identify safety concerns. No new data on the single maize events or the four subcombinations that could lead to modification of the original conclusions on their safety were identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins and dsRNA in the four‐event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the four‐event stack maize, as described in this application, is as safe as and nutritionally equivalent to its non‐GM comparator and the non‐GM reference varieties tested. In the case of accidental release of viable grains of the four‐event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in the six maize subcombinations not previously assessed and concludes that these are expected to be as safe as and nutritionally equivalent to the single events, the previously assessed subcombinations and the four‐event stack maize. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the four‐event stack maize. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the four‐event stack maize and its subcombinations are as safe as its non‐GM comparator and tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified maize MON 87427 × MON 89034 × MIR162 × NK603 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2016-131)

Maize MON 87427 × MON 89034 × MIR162 × NK603 (four‐event stack maize) was produced by conventional crossing to combine four single events: MON 87427, MON 89034, MIR162 and NK603. The GMO Panel previously assessed the four single maize events and four of the subcombinations did not identify safety concerns. No new data on the single maize events or the four subcombinations that could lead to modification of the original conclusions on their safety were identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the four‐event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the four‐event stack maize, as described in this application, is as safe as and nutritionally equivalent to its non‐GM comparator and the non‐GM reference varieties tested. In the case of accidental release of viable grains of the four‐event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in the six maize subcombinations not previously assessed and concludes that these are expected to be as safe as and nutritionally equivalent to the single events, the previously assessed subcombinations and the four‐event stack maize. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the four‐event stack maize. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the four‐event stack maize and its subcombinations are as safe as its non‐GM comparator and the tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified maize MON 87427 × MON 87460 × MON 89034 × MIR162 × NK603 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2016-134)

Maize MON 87427 ×MON 87460 × MON 89034 × MIR162 × NK603 (five‐event stack maize) was produced by conventional crossing to combine five single events: MON 87427, MON 87460, MON 89034, MIR162 and NK603. The GMO Panel previously assessed the five single maize events and eleven of the subcombinations and did not identify safety concerns. No new data on the single maize events or the 11 subcombinations that could lead to modification of the original conclusions on their safety were identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the five‐event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the five‐event stack maize, as described in this application, is as safe as and nutritionally equivalent to its non‐GM comparator and the non‐GM reference varieties tested. In the case of accidental release of viable grains of the five‐event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in the 14 maize subcombinations not previously assessed and concludes that these are expected to be as safe as and nutritionally equivalent to the single events, the previously assessed subcombinations and the five‐event stack maize. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the five‐event stack maize. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the five‐event stack maize and its subcombinations are as safe as its non‐GM comparator and the tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.

Statement complementing the EFSA Scientific Opinion on application (EFSA-GMO-NL-2009-75) for placing on the market of genetically modified oilseed rape Ms8 × Rf3 × GT73 and subcombinations, which have not been authorised previously (i.e. Ms8 × GT73 and Rf3 × GT73) independently of their origin, for food and feed uses, import and processing, with the exception of isolated seed protein for food, under Regulation (EC) No 1829/2003), taking into consideration additional information

The EFSA Panel on Genetically Modified Organisms (GMO) previously assessed oilseed rape Ms8 × Rf3 × GT73 and its subcombinations Ms8 × GT73 and Rf3 × GT73 according to the scope as defined in the application EFSA-GMO-NL-2009-75, and was not in the position to complete the safety assessment of products rich in protein, such as rapeseed protein isolates or products of this nature in animal feeding. Following a mandate from the European Commission, the GMO Panel assessed a 28-day toxicity study in mice with the glyphosate oxidoreductase (GOXv247) protein, provided to complement information related to application EFSA-GMO-NL-2009-75 for the placing on the market of oilseed rape Ms8 × Rf3 × GT73 and its subcombinations Ms8 × GT73 and Rf3 × GT73, for food and feed uses, import and processing, with the exception of isolated seed protein for food. The 28-day toxicity study on Escherichia coli- produced GOXv247 protein did not show adverse effects in mice, at the gavage doses up to 1000 mg/kg body weight (bw) per day. Taking into account its previous assessment on EFSA-GMO-NL-2009-75 and the outcome of the 28-day toxicity study in mice with the GOXv247 protein provided in this mandate, the GMO Panel, based on a weight of evidence approach, concludes that food and feed containing, consisting and produced from genetically modified oilseed rape Ms8 × Rf3 × GT73 and its sub combinations Ms8 × GT73 and Rf3 × GT73, are as safe as its conventional counterpart, according to the scope as defined in the application EFSA-GMO-NL-2009-75.

Assessment of genetically modified maize MZIR098 for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-DE-2017-142)

Maize MZIR098 was developed to confer tolerance to glufosinate-ammonium-containing herbicides and resistance to certain coleopteran pests. The molecular characterisation data and bioinformatic analyses do not identify issues requiring food/feed safety assessment. None of the identified differences in the agronomic/phenotypic and compositional characteristics tested between maize MZIR098 and its conventional counterpart needs further assessment, except for neutral detergent fibre (NDF) in grains, which does not raise nutritional and safety concerns. The GMO Panel does not identify safety concerns regarding the toxicity and allergenicity of the eCry3.1Ab, mCry3A and PAT proteins as expressed in maize MZIR098, and finds no evidence that the genetic modification would change the overall allergenicity of maize MZIR098. In the context of this application, the consumption of food and feed from maize MZIR098 does not represent a nutritional concern in humans and animals. The GMO Panel concludes that maize MZIR098 is as safe as the conventional counterpart and non-GM maize reference varieties tested, and no post-market monitoring of food/feed is considered necessary. In the case of accidental release of viable maize MZIR098 grains into the environment, maize MZIR098 would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of maize MZIR098. In conclusion, the GMO Panel considers that maize MZIR098, as described in this application, is as safe as its conventional counterpart and the non-GM maize reference varieties tested with respect to potential effects on human and animal health and the environment.

Assessment of genetically modified oilseed rape MS11 for food and feed uses, import and processing, under Regulation (EC) No 1829/2003 (application EFSA-GMO-BE-2016-138)

Oilseed rape MS11 has been developed to confer male sterility and tolerance to glufosinate-ammonium-containing herbicides. Based on the information provided in the application and in line with the scope of application EFSA-GMO-BE-2016-138, the genetically modified organism (GMO) Panel concludes that the molecular characterisation data and bioinformatic analyses do not identify issues requiring food/feed safety assessment. None of the identified differences in the agronomic/phenotypic characteristics tested between oilseed rape MS11 and its conventional counterpart needs further assessment. No conclusions can be drawn for the compositional analysis due to the lack of an appropriate compositional data set. No toxicological or allergenicity concerns are identified for the Barnase, Barstar and PAT/bar proteins expressed in oilseed rape MS11. Owing to the incompleteness of the compositional analysis, the toxicological, allergenicity and nutritional assessment of oilseed rape MS11 cannot be completed. In the case of accidental release of viable oilseed rape MS11 seeds into the environment, oilseed rape MS11 would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the scope of the application. Since oilseed rape MS11 is designed to be used only for the production of hybrid seed, it is not expected to be commercialised as a stand-alone product for food/feed uses. Thus, seeds harvested from oilseed rape MS11 are not expected to enter the food/feed chain, except accidentally. In this context, the GMO Panel notes that, oilseed rape MS11 would not pose risk to humans and animals, while the scale of environmental exposure will be substantially reduced compared to a stand-alone product.

Assessment of genetically modified soybean MON 87705 × MON 87708 × MON 89788, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2015-126)

Soybean MON 87705 × MON 87708 × MON 89788 (three-event stack soybean) was produced by conventional crossing to combine three single soybean events: MON 87705, MON 87708 and MON 89788. This combination is intended to alter the fatty acid profile in the seed (in particular increasing the levels of oleic acid) and tolerance to glyphosate-based and dicamba herbicides. The Genetically Modified Organisms Panel previously assessed the three single soybean events and did not identify safety concerns. No new data on the single soybean events, leading to modification of the original conclusions on their safety have been identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single soybean events and of the newly expressed proteins in the three-event stack soybean does not give rise to food and feed safety and nutritional concerns. In the case of accidental release of viable three-event stack soybean seeds into the environment, this would not raise environmental safety concerns. The post-market environmental monitoring plan and the reporting intervals are in line with the intended uses of soybean MON 87705 × MON 87708 × MON 89788. Considering the altered fatty acid profile of the three-event stack soybean, a proposal for post-market monitoring needs to be provided by the applicant. The GMO Panel notes that in the context of this application EFSA-GMO-NL-2015-126 the applicant did not provide a 90-day study on MON 87705 soybean in line with the applicable legal requirements. Therefore, the GMO Panel is not in the position to finalise the risk assessment of soybean MON 87705 × MON 87708 × MON 89788 under the current regulatory frame.

Bone marrow edema syndrome/transient osteoporosis of the hip joint and management with the utilization of hyperbaric oxygen therapy

Transient osteoporosis of hip (TOH) is a self-limited condition that affects young and middle aged women or men. The clinical manifestation is characterized by sudden or gradual onset of pain that is exacerbated on weight-bearing and at night. The treatment of TOH is either conservative or surgical. Conservative regimens include restriction of weight-bearing, pharmacological agents such as prostacyclin analogues (iloprost), non-steroid anti-inflammatory drugs (NSAIDs), extracorporeal shock wave and hyperbaric oxygen therapy (HBOT). Surgical intervention includes drilling or core decompression. The aim of this article is to review the clinical entity of TOH (clinical presentation, pathophysiology, diagnosis) and to further discuss the off-label utilization of HBOT as an alternative treatment regimen in patients suffering from TOH that fail to respond to other conservative methods.

Assessment of genetically modified soybean SYHT0H2 for food and feed uses, import and processing, under Regulation (EC) No 1829/2003 (application EFSA-GMO-DE-2012-111)

The scope of application EFSA‐GMO‐DE‐2012‐111 is for food and feed uses, import and processing of genetically modified (GM) soybean SYHT0H2 in the European Union. Soybean SYHT0H2 was developed to confer tolerance to the herbicidal active substances mesotrione and other p‐hydroxyphenylpyruvate dioxygenase (HPPD)‐inhibiting herbicides and glufosinate ammonium. The molecular characterisation data and bioinformatic analyses do not identify issues except for sequence similarity of AvHPPD‐03 to bacterial haemolysins that was considered in food/feed safety assessment. The outcome of the comparative analysis (agronomic/phenotypic and compositional characteristics) did not need further assessment except for the changes in seed levels of α‐tocopherol and γ‐tocopherol that were assessed for food and feed relevance. The GMO Panel does not identify toxicological and allergenicity concerns for the AvHPPD‐03 and PAT proteins expressed in soybean SYHT0H2 and finds no evidence that the genetic modification would change the overall allergenicity of soybean SYHT0H2. The nutritional impact of food/feed from soybean SYHT0H2 is expected to be the same as that of food/feed from the conventional counterpart and commercial non‐GM soybean reference varieties. The GMO Panel concludes that soybean SYHT0H2 is as safe as and nutritionally equivalent to the conventional counterpart and the tested non‐GM soybean reference varieties, and no post‐market monitoring of food/feed is considered necessary. In the case of accidental release of viable soybean SYHT0H2 grains into the environment, soybean SYHT0H2 would not raise environmental safety concerns. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of soybean SYHT0H2. In conclusion, the GMO Panel considers that soybean SYHT0H2, as described in this application, is as safe as its conventional counterpart and the tested non‐GM soybean reference varieties with respect to potential effects on human and animal health and the environment.

Surgical modalities for the management of bone marrow edema of the knee joint

Background

Bone marrow edema (BME) is a radiological term which can be found in many conditions with varied pathogenesis and histopathological images. It usually presents with pain in the affected joint and is diagnosed with MRI. Subchondroplasty (SCP) and core decompression (CD) are the surgical methods that are available to achieve pain relief and functional improvement. Both surgical methods have their own indications and are used depending on the patient's history. The aim of this literature review article is to discuss the surgical modalities for the management of bone marrow edema focusing on the knee joint. Such topic which analyzes both surgical methods for treatment of bone marrow edema of the knee joint has never been described in a review article before.

Materials and methods

For the purpose of our manuscript we thoroughly searched electronic databases such as Pubmed and Medline to acquire the appropriate material for our review paper. Only English articles were used in this review. In our study we included every article that had described the surgical management of BME of the knee by CD and SCP. In the discussion we included 18 studies (9 CD and 9 SCP) with a total number of patients equal to 397, while 206/397 had undergone surgical intervention (169 underwent SCP and 37 CD).

Results

Follow-up of 180 patients out of 206 were available for our review. A total number of 166 patients (92.2%) were successfully treated. Specifically, 29 (100%) patients were treated by CD and 137 (90.7%) by SCP. In a study, 10 patients who underwent SCP for BME secondary to advanced osteoarthritis (OA) yielded poor results. In other studies, pain persistency was observed in 2 patients, 1 patient had postoperative infection and another patient eventually underwent total knee arthroplasty (TKA). 70% prevention of TKA was achieved by SCP in a study of 66 patients with BME secondary to advanced OA. Thus, a total number of 166 patients were considered as clinical success and 14 patients as clinical failure.

Conclusions

The included studies that have been published referred to the surgical methods of CD or SCP for the management of BME of the knee but none of that summarizes all current studies on both methods. Those studies seem that CD is a surgical technique that is proposed to perform in patients without findings of OA that usually fail to respond to conservative treatment. On the other hand, the option of SCP technique is carried out in patients with varied stage of OA associated with subchondral BME. Both methods aim to reduce the pain and to improve function in the setting of subchondral BME. Nevertheless it is not clear in literature which method is the best according to the criteria of the use. This literature review shows a lack of standardized guidelines with respect to diagnosis and surgical treatment.

Assessment of genetically modified maize Bt11 × MIR162 × MIR604 × 1507 × 5307 × GA21 and subcombinations, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-DE-2011-103)

Maize Bt11 × MIR162 × MIR604 × 1507 × 5307 × GA21 (six‐event stack maize) was produced by conventional crossing to combine six single events: Bt11, MIR162, MIR604, 1507, 5307 and GA21. The GMO Panel previously assessed the six single events and 22 of their combinations and did not identify safety concerns. No new data on the maize single events or their 22 combinations that could lead to modification of the original conclusions on their safety have been identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single maize events and of the newly expressed proteins in the six–event stack maize does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the six‐event stack maize, as described in this application, is as safe as and nutritionally equivalent to its non‐GM comparator and the non‐GM reference varieties tested. In the case of accidental release of viable grains of the six‐event stack maize into the environment, this would not raise environmental safety concerns. The GMO Panel assessed the likelihood of interactions among the single events in the 34 maize subcombinations not previously assessed and concludes that these are expected to be as safe as and nutritionally equivalent to the single events, the previously assessed subcombinations and the six‐event stack maize. The post‐market environmental monitoring plan and reporting intervals are in line with the intended uses of the six‐event stack maize. Post‐market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the six‐event stack maize and its subcombinations are as safe as its non‐GM comparator and the tested non‐GM reference varieties with respect to potential effects on human and animal health and the environment.