Effect of a 2-step probiotic program on digestive health and performance of Holstein heifer calves

Managing the composition of the bacterial communities in the digestive tract with the use of probiotics that enhance protective microflora could result in positive effects on health and performance of calves. The objective of this study was to evaluate a 2-step probiotic program (added to colostrum and milk) on the digestive health and growth of preweaning Holstein heifers. A randomized clinical trial was conducted from July to October 2020 in a calf rearing facility in Colorado. Calves were housed in pairs sharing the same treatment in 2 polyethylene hutches within a common area of 4.50 m². A total of 232 calves were enrolled at birth and randomly allocated into 2 treatment groups [control (CTR) = 116; treatment (PB) = 116] and followed until weaning (64 ± 3 d). Treatment consisted of 2 formulations of a multistrain bacterial-based probiotic added in colostrum (PBF1) and milk (PBF2). Treatment calves received 2 g of PBF1 added to each colostrum feeding, and 1 g of PBF2 added to the milk at the morning feeding 3 times per week up to weaning. Calf weight was collected at birth, at 30 d of age, and at weaning. Serum total protein was determined at age 3 ± 1 d and a health assessment was completed 3 times per week. Statistical analyses were performed using SAS, with calf considered the experimental unit clustered by housing pair. Cox proportional hazard analysis and time to event analysis were used to compare time to the first diarrhea event and time to recovery between treatment groups. The total number of diarrhea events and culling were assessed by Poisson regression and logistic regression analysis, respectively. Linear regression was performed to evaluate differences in average daily gain by treatment group. Overall, the mean (± standard error) temperature humidity index (THI) was 75 (± 0.44) units during the study period, which resulted in continuous exposure to heat stress in the day hours. No difference between treatment groups was observed in serum total protein. The overall incidence of diarrhea was 96.6% (CTR = 99%, PB = 95%); no differences were determined in the hazard of a first diarrhea episode or in the median time to the first diarrhea event (11 d in both groups). Similarly, no differences were found in the likelihood of recovery or in the median time to recovery from diarrhea (7 d in both groups). Likewise, treatment group was not associated with the number of diarrhea events, mean (± standard error, g/d) average daily gain from birth to weaning [CTR = 562.5 (13.9); PB = 570.8 (13.5)], or with the odds of culling. The most prevalent pathogen isolated from feces was Clostridium, which tended to be more frequent in CTR calves than PB calves. In conclusion, the probiotic program did not affect the incidence of enteric disease or the growth of preweaning heifer calves.

A phase II study of retifanlimab (INCMGA00012) in patients with squamous carcinoma of the anal canal who have progressed following platinum-based chemotherapy (POD1UM-202)

Background

Locally advanced or metastatic squamous carcinoma of the anal canal (SCAC) has poor prognosis following platinum-based chemotherapy. Retifanlimab (INCMGA00012), a humanized monoclonal antibody targeting programmed death protein-1 (PD-1), demonstrated clinical activity across a range of solid tumors in clinical trials. We present results from POD1UM-202 (NCT03597295), an open-label, single-arm, multicenter, phase II study evaluating retifanlimab in patients with previously treated advanced or metastatic SCAC.

Patients and methods

Patients ≥18 years of age had measurable disease and had progressed following, or were ineligible for, platinum-based therapy. Retifanlimab 500 mg was administered intravenously every 4 weeks. The primary endpoint was overall response rate (ORR) by independent central review. Secondary endpoints were duration of response (DOR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and safety.

Results

Overall, 94 patients were enrolled. At a median follow-up of 7.1 months (range, 0.9-19.4 months), ORR was 13.8% [95% confidence interval (CI) 7.6% to 22.5%], with one complete response (1.1%) and 12 partial responses (12.8%). Responses were observed regardless of human immunodeficiency virus or human papillomavirus status, programmed death ligand 1 (PD-L1) expression, or liver metastases. Stable disease was observed in 33 patients (35.1%) for a DCR of 48.9% (95% CI 38.5% to 59.5%). Median DOR was 9.5 months (range, 5.6 months-not estimable). Median (95% CI) PFS and OS were 2.3 (1.9-3.6) and 10.1 (7.9-not estimable) months, respectively. Retifanlimab safety in this population was consistent with previous experience for the PD-(L)1 inhibitor class.

Conclusions

Retifanlimab demonstrated clinically meaningful and durable antitumor activity, and an acceptable safety profile in patients with previously treated locally advanced or metastatic SCAC who have progressed on or are intolerant to platinum-based chemotherapy.

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Retifanlimab (PD-1 inhibitor) monotherapy demonstrated encouraging results in patients with platinum-refractory SCAC.

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Clinically meaningful antitumor activity was reported with ORR of 13.8% and stable disease in 35.1%, for a DCR of 48.9%.

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Observed responses in advanced SCAC were durable (median 9.5 months).

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Acceptable safety profile consistent with that reported for the PD-(L)1 inhibitor class.

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Promising results warrant further investigation of retifanlimab in advanced SCAC as well as earlier stages of disease.

Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review

BACKGROUND

Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated.

PURPOSE/HYPOTHESIS

The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs.

RESULTS

Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%.

CONCLUSION

This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques.

Outcomes After Repair of Quadriceps Tendon Rupture in Patients Aged 40 Years and Younger

Background:

Injury to the quadriceps tendon is rare and most commonly occurs in middle-aged men. Few reports are available regarding outcomes after quadriceps tendon rupture in younger patients.

Purpose/Hypothesis:

To review the clinical outcomes of patients who underwent quadriceps tendon repair at age ≤40 years. We hypothesized that this cohort would experience better clinical outcomes in comparison to historical older controls.

Study Design:

Case series; Level of evidence, 4.

Methods:

Using an institutional database, we retrospectively identified patients who underwent quadriceps tendon repair between January 2009 and December 2017. Patients were included in the study if they were aged ≤40 years at the time of surgery and had sustained an isolated, complete tendon rupture. Patient and injury characteristics were recorded. Patients were contacted to complete a custom survey, the 2000 International Knee Documentation Committee (IKDC) form, the Lysholm scale, and the Tegner scale.

Results:

Included were 38 patients (86.8% male; mean age, 32.0 ± 6.9 years; age range, 15-40 years), with a mean follow-up of 5.9 ± 2.3 years (range, 2.4-11.3 years). At final follow-up, the mean IKDC score was 74.1 ± 22.6 (range, 26.4-100.0), and the mean Lysholm score was 85.4 ± 20.0 (range, 30-100), which were similar if not inferior to historical controls of patients >40 years. Only 16 patients (42.1%) had unchanged or higher Tegner scores after surgery, whereas 22 patients (57.9%) reported lower postoperative activity level. Overall, 91.2% (31/34) of workers returned at a mean 3.9 months after surgery, whereas 63% (12/19) of athletes were able to return to play at 8.8 months. At final follow-up, 12 patients (31.6%) reported persistent pain and stiffness in their knees. Additionally, 3 patients (7.9%) reported pain without stiffness, and 4 (10.5%) reported stiffness without pain. Patients reporting pain or stiffness had significantly lower IKDC scores, Lysholm scores, postoperative Tegner scores, and change in their Tegner score at final follow-up in comparison to those who did not report pain or stiffness.

Conclusion:

Although patients aged ≤40 years had satisfactory outcomes after quadriceps tendon repair, this injury resulted in significant long-term sequelae in a substantial percentage of patients, despite their youth. Further, this group did not have better outcomes compared with historical controls aged > 40 years.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review

Background

Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation.

Methods

A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation.

Results

Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal.

Conclusion

Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

CT volumetry helps predict prognosis of large hepatocellular carcinoma after resection

AIM

To determine whether the tumour volume measurement on preoperative contrast-enhanced computed tomography (CT) could be used to predict the overall survival patients with large hepatocellular carcinoma (>5 cm) after resection.

MATERIALS AND METHODS

This study included 171 patients with surgically confirmed hepatocellular carcinoma who underwent preoperative CT. The largest diameter, the product of the axial dimension, tumour volume, and tumour-to-liver volume ratio (TTLVR) on CT images were measured and calculated. The univariate and multivariate Cox proportional hazard ratio regression models were used to identify the impact of the tumour burden-related risk factors on overall survival.

RESULTS

In multivariate analysis, TTLVR (p=0.042) and major vascular invasion (p=0.006) were independently associated with overall survival of patients with hepatocellular carcinoma after the resection. The group in which the patients had a low TTLVR showed higher cumulative survival rates than patients with a TTLVR (p=0.004). Patients with a low TTLVR (≤26.23%) and absence of major vascular invasion had significantly higher cumulative survival rates compared to those patients with hepatocellular carcinoma with either or both the risk factors (p=0.001).

CONCLUSION

A higher TTLVR in combination with the presence of major vascular invasion was associated with poorer overall survival in patients with large hepatocellular carcinoma after resection.

Safer Return to Play After Anterior Cruciate Ligament Reconstruction: Evaluation of a Return-to-Play Checklist

Background:

Questions remain regarding the traditional protocols used in rehabilitation and clearance for return to sports after anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis:

To investigate the impact on injury rates after return to sports by developing and validating a Safer Return to Play Following ACL Reconstruction Checklist consisting of subjective and objective functional tests that can be quickly and easily implemented into a sports medicine practice. It was hypothesized that patients who successfully passed the checklist before returning to sports would experience lower rates of ipsilateral and contralateral knee injuries at a 2-year follow-up as compared with patients who returned to play before completing the checklist.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

First, a systematic review was performed to generate a list of the most common outcome measures used to assess return to play after ACLR. To refine our checklist, we conducted a survey with an expert panel of 10 medical professionals utilizing the Delphi technique. After the creation of the checklist, validation was performed by prospectively evaluating patients who had undergone ACLR for injury of the ipsilateral or contralateral knee, with a minimum 2-year follow-up.

Results:

After our systematic review of 60 studies, 7 criteria were included in the final checklist. During the period studied, October 2014 to December 2017, a total of 222 patients met the inclusion criteria and were enrolled in the study. At a minimum 2 years of follow-up, there were 146 patients who successfully passed the checklist and 38 who did not. Overall, 24 (16.4%) patients who had passed the checklist sustained an injury to either knee, as compared with 10 (26.3%) from the group that did not pass the checklist (P = .162). Of the group that passed the checklist, 8 (5.5%) patients sustained an injury to the ipsilateral knee, as compared with 7 (18.4%) in the group that did not pass (P = .017).

Conclusion:

Prospective validation of our checklist demonstrated that patients who successfully passed the checklist before returning to play experienced a significantly lower incidence of ipsilateral anterior cruciate ligament injury as compared with patients who did not pass the checklist.

Articular Cartilage Damage Worsens from First-time to Recurrent Patellar Dislocation—A Longitudinal Magnetic Resonance Imaging Study

Purpose

To compare the frequency and severity of articular cartilage injury on longitudinal magnetic resonance imaging (MRI) in patients after their initial dislocation and subsequent recurrent dislocations for those undergoing patellar stabilization surgery.

Methods

Between January 2012 and December 2017, patients undergoing patellar stabilization surgery were retrospectively reviewed. Only patients with an MRI after both the initial dislocation and subsequent dislocation events were included. The MRI scans were blindly examined to assess the Outerbridge classification grade of articular cartilage injury following each dislocation. Comparison was performed of each MRI for grade of articular cartilage damage and location.

Results

Thirty-five patients undergoing patellar stabilization surgery with recurrent instability were eligible. The incidence of articular cartilage injury following initial dislocation was 45.7%. Following a second dislocation, the incidence of articular cartilage injury increased to 62.9%, a statistically significant increase of 17.2% (P = .031). Furthermore, of the 16 patients with articular cartilage injury following their initial dislocation, 56.2% of patients (9) had an increase in grade of articular cartilage injury following the second dislocation, whereas 43.8% (7) of patients had no progression in their articular cartilage injury. Six (17.1%) patients had no articular cartilage injury following their initial dislocation but did have articular cartilage injury following their second dislocation.

Conclusions

Articular cartilage injury following patellar dislocation is common, and delayed surgical treatment may lead to an increase in articular cartilage damage. The incidence of articular cartilage injury following recurrent patellar dislocation was high (62.9%), and the majority of patients experienced an increase in their articular cartilage injury grade between their initial and recurrent dislocation on MRI evaluation.

Level of Evidence

Level IV, retrospective case series.

Adolescent Quadriceps Tendon Rupture, an Early Complication After ACL Reconstruction: A Case Report

CASE

A healthy adolescent male patient initially presented with complete rupture of the anterior cruciate ligament (ACL) after a plant-twist injury during a high school football game. Four weeks after ACL reconstruction with autograft bone-patella tendon-bone, the patient slipped and fell, sustaining hyperflexion of the knee, resulting in rupture of the ipsilateral quadriceps tendon.

CONCLUSION

Although this rare complication has previously been reported in the adult population, to the best of our knowledge, this is the first known report of an adolescent patient sustaining a quadriceps tendon rupture after ACL reconstruction.

Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes

BACKGROUND

Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers.

PURPOSE

To report outcomes after UCLR in javelin throwers.

HYPOTHESIS

UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports.

METHODS

All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications.

RESULTS

Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery.

CONCLUSION

UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.

OUTCOMES OF NEONATAL CHYLOUS EFFUSIONS: A 20-YEAR WEST-AUSTRALIAN TERTIARY CENTER EXPERIENCE

Neonatal chylous effusions are rare entity with limited evidence-based management. We conducted a retrospective review of neonates admitted to King Edward Memorial and Princess Margaret/Perth Children's Hospital over 20 years with laboratory-confirmed chylous effusions. A total of 51 infants with chylous effusion were identified. Median gestational age and birth weight were 35.5 weeks and 2620 grams respectively. Congenital [27/51] and acquired [24/51] cases were included. Antenatal interventions were performed in 17/22 with antenatal hydrops and 50/51 needed postnatal drains. Effusions were monitored with serial (≥2) chest ultrasounds in 29/51 infants and multiple (≥5) x-rays in 45/51 infants. Median duration of mechanical ventilation, oxygen requirement, and hospital stay was 294.5 hours, 400 hours, and 49 days respectively. 39/51 received medium chain triglyceride (MCT) diet while 8/51 received octreotide. Six infants died during hospital stay. 12/19 had normal developmental assessment at one-year. The acquired group had higher number of xrays done, need for MCT diet and inotropes, and hospital stay vs congenital group. Duration of drains, radiological investigations and immunoglobulin administration were higher in neonates who received octreotide. Syndromic association, duration of ventilation and oxygenation were risk factors for mortality. In our setting, neonatal chylous effusions are associated with significant morbidity and mortality.

Sub-structure-based category formation for the prioritisation of genotoxicity hazard assessment for pesticide residues: Sulphonyl ureas

In dietary risk assessment, residues of pesticidal ingredients or their metabolites need to be evaluated for their genotoxic potential. The European Food Safety Authority recommend a tiered approach focussing assessment and testing on classes of similar chemicals. To characterise similarity and to identify structural alerts associated with genotoxic concern, a set of chemical sub-structures was derived for an example dataset of 74 sulphonyl urea agrochemicals for which either Ames, chromosomal aberration or micronucleus test results are publicly available. This analysis resulted in a set of seven structural alerts that define the chemical space, in terms of the common parent and metabolic scaffolds, associated with the sulphonyl urea chemical class. An analysis of the available profiling schemes for DNA and protein reactivity shows the importance of investigating the predictivity of such schemes within a well-defined area of structural space. Structural space alerts, covalent chemistry profiling and physico-chemistry properties were combined to develop chemical categories suitable for chemical prioritisation. The method is a robust and reproducible approach to such read-across predictions, with the potential to reduce unnecessary testing. The key challenge in the approach was identified as being the need for pesticide-class specific metabolism data as the basis for structural space alert development.