Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta-analysis

BACKGROUND

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis.

METHODS

We searched nine international biomedical databases for published, in-progress, and unpublished evidence. Studies were independently screened by two reviewers against predefined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication, and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses.

RESULTS

We identified 5960 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95% CI -0.63, -0.42), medication (SMD -0.37, 95% CI -0.49, -0.26), and combined symptom and medication (SMD -0.49, 95% CI -0.69, -0.30) scores while on treatment that were robust to prespecified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, suggesting a benefit in relation to symptom scores.

CONCLUSIONS

AIT is effective in improving symptom, medication, and combined symptom and medication scores in patients with allergic rhinoconjunctivitis while on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy.

The variability in Oxford hip and knee scores in the preoperative period: is there an ideal time to score?

Background All NHS-funded providers are required to collect and report patient-reported outcome measures for hip and knee arthroplasty. Although there are established guidelines for timing such measures following arthroplasty, there are no specific time-points for collection in the preoperative period. The primary aim of this study was to identify whether there was a significant amount of variability in the Oxford hip and knee scores prior to surgical intervention when completed in the outpatient clinic at the time of listing for arthroplasty or when completed at the preoperative assessment clinic. Methods A prospective cohort study of patients listed for primary hip or knee arthroplasty was conducted. Patients were asked to fill in a preoperative Oxford score in the outpatient clinic at the time of listing. They were then invited to fill in the official outcome measures questionnaire at the preoperative assessment clinic. The postoperative Oxford score was then completed when the patient was seen again at their postoperative follow up in clinic. Results Of the total of 109 patients included in this study period, there were 18 (17%) who had a worse score of 4 or more points difference and 43 (39.4%) who had an improvement of 4 or more points difference when the scores were compared between time of listing at the outpatient and at the preoperative assessment clinic. There was a statistically significant difference (P = 0.0054) in the mean Oxford scores. Conclusions The results of our study suggest that there should be standardisation of timing for completing the preoperative patient-reported outcome measures.

Heterocyclic boronic acids display sialic acid selective binding in a hypoxic tumor relevant acidic environment

A group of heterocyclic boronic acids demonstrating unusually high affinity and selectivity for sialic acids are described, with strong interactions under the weakly acidic pH conditions associated with a hypoxic tumoral microenvironment.

Boronic acids are well known for their ability to reversibly interact with the diol groups found in sugars and glycoproteins. However, they are generally indiscriminate in their binding. Herein we describe the discovery of a group of heterocyclic boronic acids demonstrating unusually high affinity and selectivity for sialic acids (SAs or N-acetylneuraminic acid), which are sugar residues that are intimately linked with tumor growth and cancer progression. Remarkably, these interactions strengthen under the weakly acidic pH conditions associated with a hypoxic tumoral microenvironment. In vitro competitive binding assays uncovered a significantly higher ability of 5-boronopicolinic acid, one of the derivatives identified in this work as a strong SA-binder, to interact with cell surface SA in comparison to a gold-standard structure, 3-propionamidophenylboronic acid, which has proven to be an efficient SA-binder in numerous reports. This structure also proved to be suitable for further chemical conjugation with a well-preserved SA-binding capability. These findings suggest an attractive alternative to other ongoing boronic acid based chemistry techniques aiming to achieve tumor-specific chemotherapies and diagnoses.

A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures

Aims

The aim of this study was to investigate the outcomes of Vancouver type B2 and B3 fractures by performing a systematic review of the methods of surgical treatment which have been reported.

Materials and Methods

A systematic search was performed in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. For inclusion, studies required a minimum of ten patients with a Vancouver type B2 and/or ten patients with a Vancouver type B3 fracture, a minimum mean follow-up of two years and outcomes which were matched to the type of fracture. Studies were also required to report the rate of re-operation as an outcome measure. The protocol was registered in the PROSPERO database.

Results

A total of 22 studies were included based on the eligibility criteria, including 343 B2 fractures and 167 B3 fractures. The mean follow-up ranged from 32 months to 74 months. Of 343 Vancouver B2 fractures, the treatment in 298 (86.8%) involved revision arthroplasty and 45 (12.6%) were treated with internal fixation alone. A total of 37 patients (12.4%) treated with revision arthroplasty and six (13.3%) treated by internal fixation only underwent further re-operation. Of 167 Vancouver B3 fractures, the treatment in 160 (95.8%) involved revision arthroplasty and eight (4.8%) were treated with internal fixation without revision. A total of 23 patients (14.4%) treated with revision arthroplasty and two (28.6%) treated only with internal fixation required re-operation.

Conclusion

A significant proportion, particularly of B2 fractures, were treated without revision of the stem. These were associated with a higher rate of re-operation. The treatment of B3 fractures without revision of the stem resulted in a high rate of re-operation. This demonstrates the importance of careful evaluation and accurate characterisation of the fracture at the time of presentation to ensure the correct management. There is a need for improvement in the reporting of data in case series recording the outcome of the surgical treatment of periprosthetic fractures. We have suggested a minimum dataset to improve the quality of data in studies dealing with these fractures. Cite this article: Bone Joint J 2017;99-B(4 Supple B):17–25.

Synthetic studies en route to the first total synthesis of a naturally occurring quinone from Acorus gramineus, iso-merrilliaquinone, iso-magnoshinin and 2-epi-3,4-dihydro magnoshinin

An elegant Diels–Alder based approach has been demonstrated for the first racemic total synthesis of gramineusquinone B, iso-merrilliaquinone, iso-magnoshinin and 2-epi-3,4-dihydro magnoshinin.

Factors associated with poor outcomes in patients with lupus nephritis

The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome ( P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 ± 6 versus 5 ± 5, P<0.05), chronicity index (CI) score (4 ± 3 versus 2 ± 2 unit, P<0.025), higher baseline mean arterial pressure (MAP) (111 ± 21 versus 102 ± 14 mmHg, P<0.025) and serum creatinine (1.9 ± 1.3 versus 1.3 ± 1.0 mg/dL, P<0.025), but lower baseline hematocrit (29 ± 6 versus 31 + 5%, P<0.025) and complement C3 (54 ± 26 versus 65 + 33 mg/dL, P<0.025) compared to controls. More patients reaching the composite outcome had nephrotic range proteinuria compared to controls (74% versus 56%, P<0.025). By multivariate analysis, CI (hazard ratio [95% CI] 1.18 [1.07-1.30] per point), MAP (HR 1.02 [1.00-1.03] per mmHg), and baseline serum creatinine (HR 1.26 [1.04-1.54] per mg/dL) were independently associated with the composite outcome. We concluded that hypertension and elevated serum creatinine at the time of the kidney biopsy as well as a high CI are associated with an increased the risk for chronic renal failure or death in patients with lupus nephritis.

A Fellowship Further Afield

In the current climate of uncertainty over trainee working conditions and uneasy medical politics, more and more trainees are choosing to take planned time out of training. This is no longer considered an activity that unnecessarily prolongs one's training, and is generally welcomed by trainees and training programme directors alike.

Total Synthesis and Structural Revision of Antibiotic CJ-16,264

The total synthesis and structural revision of antibiotic CJ-16,264 is described. Starting with citronellal, the quest for the target molecule featured a novel bis-transannular Diels-Alder reaction that casted stereoselectively the decalin system and included the synthesis of six isomers before demystification of its true structure.

Otolaryngological complications of occipitocervical injury

Occipitocervical injuries are rare, accounting for 15% of all fatal spinal trauma. In patients who survive the initial incident, early detection and appropriate management is vital to avoid significant neurological disability and mortality. We present the case of a patient with neck trauma who was initially cleared of spinal injuries in the emergency department but who later developed acute hearing loss. We describe how the investigation of the hearing loss led to the detection of this devastating injury and report its successful management. Patients with persistent neck pain following trauma, particularly in the presence of degenerative spinal disease, should have cervical spine computed tomography to exclude occipitocervical injuries and other occult injuries.

Interaction of nanomaterials with cells and their medical applications

Many studies have been conducted on the development of nanomaterials for medical applications. The interaction of nanomaterials with human cells is the most important criterion for biomedical application and has been studied in detail. Three common approaches have been suggested for nanomaterial mechanisms for cellular interaction and internalization: direct diffusion or disruption to the plasma membrane, endocytosis, and entry through ion channels and transporter proteins. Several important factors affect the interaction and cellular uptake of nanomaterials: size, shape, rigidity, surface properties, cell type, and endocytotic pathways. In this review, we summarize the mechanisms of cell-nanomaterial interactions, and the various factors that influence these interactions. The importance of proper cell-nanomaterial interaction for medical research applications is also highlighted. The results summarized in this review may add new dimensions to our understanding of cell-nanomaterial interactions and their applications in therapeutic and diagnostic techniques for biomedical, academic, and industrial research.

The outcome of paediatric LCP hip plate use in children with and without neuromuscular disease

BACKGROUND

The relatively new paediatric LCP hip plate (Synthes GmBH Eimattstrasse 3 CH-4436 Oberdorff) is used in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications.

MATERIALS AND METHODS

We retrospectively reviewed the notes and radiographs of all those children who have had paediatric LCP device for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution (Royal Manchester Children's Hospital), between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications.

RESULTS

Forty-three paediatric LCP hip plates were used in 40 patients (27 males and 13 females) for the fixation of 40 proximal femoral osteotomies and three proximal femur fractures. This included 13 children with underlying neuromuscular pathology and 27 children without neuromuscular disease. All osteotomies and fractures radiologically healed within 6 months [majority (n = 40) within 3 months]. There was no statistically significant difference (p = 0.45) in the neck shaft angle between the immediately post-operative and final X-rays after completion of bone healing. There were no implant-related complications both in patients with and without neuromuscular disease. No metalwork loosening was observed and no plate revisions were required. Three post-operative fractures occurred in patients with neuromuscular pathology treated with post-operative plaster immobilisation.

CONCLUSION

The paediatric LCP hip plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions.

Identification of genome regions controlling cotyledon, pod wall/seed coat and pod wall resistance to pea weevil through QTL mapping

Pea weevil, Bruchus pisorum, is one of the limiting factors for field pea (Pisum sativum) cultivation in the world with pesticide application the only available method for its control. Resistance to pea weevil has been found in an accession of Pisum fulvum but transfer of this resistance to cultivated pea (P. sativum) is limited due to a lack of easy-to-use techniques for screening interspecific breeding populations. To address this problem, an interspecific population was created from a cross between cultivated field pea and P. fulvum (resistance source). Quantitative trait locus (QTL) mapping was performed to discover the regions associated with resistance to cotyledon, pod wall/seed coat and pod wall resistance. Three major QTLs, located on linkage groups LG2, LG4 and LG5 were found for cotyledon resistance explaining approximately 80 % of the phenotypic variation. Two major QTLs were found for pod wall/seed coat resistance on LG2 and LG5 explaining approximately 70 % of the phenotypic variation. Co-linearity of QTLs for cotyledon and pod wall/seed coat resistance suggested that the mechanism of resistance for these two traits might act through the same pathways. Only one QTL was found for pod wall resistance on LG7 explaining approximately 9 % of the phenotypic variation. This is the first report on the development of QTL markers to probe Pisum germplasm for pea weevil resistance genes. These flanking markers will be useful in accelerating the process of screening when breeding for pea weevil resistance.