Application of Machine Learning Algorithms to Predict Clinically Meaningful Improvement After Arthroscopic Anterior Cruciate Ligament Reconstruction

Background:

Understanding specific risk profiles for each patient and their propensity to experience clinically meaningful improvement after anterior cruciate ligament reconstruction (ACLR) is important for preoperative patient counseling and management of expectations.

Purpose:

To develop machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) on the International Knee Documentation Committee (IKDC) score at a minimum 2-year follow-up after ACLR.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

An ACLR registry of patients from 27 fellowship-trained sports medicine surgeons at a large academic institution was retrospectively analyzed. Thirty-six variables were tested for predictive value. The study population was randomly partitioned into training and independent testing sets using a 70:30 split. Six machine learning algorithms (stochastic gradient boosting, random forest, neural network, support vector machine, adaptive gradient boosting, and elastic-net penalized logistic regression [ENPLR]) were trained using 10-fold cross-validation 3 times and internally validated on the independent set of patients. Algorithm performance was assessed using discrimination, calibration, Brier score, and decision-curve analysis.

Results:

A total of 442 patients, of whom 39 (8.8%) did not achieve the MCID, were included. The 5 most predictive features of achieving the MCID were body mass index ≤27.4, grade 0 medial collateral ligament examination (compared with other grades), intratunnel femoral tunnel fixation (compared with suspensory), no history of previous contralateral knee surgery, and achieving full knee extension preoperatively. The ENPLR algorithm had the best relative performance (C-statistic, 0.82; calibration intercept, 0.10; calibration slope, 1.15; Brier score, 0.068), demonstrating excellent predictive ability in the study’s data set.

Conclusion:

Machine learning, specifically the ENPLR algorithm, demonstrated good performance for predicting a patient’s propensity to achieve the MCID for the IKDC score after ACLR based on preoperative and intraoperative factors. The femoral tunnel fixation method was the only significant intraoperative variable. Range of motion and medial collateral ligament integrity were found to be important physical examination parameters. Increased body mass index and prior contralateral surgery were also significantly predictive of outcome.

Diffuse large B-cell lymphoma: A consensus practice statement from the Australasian Lymphoma Alliance

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype, accounting for 30-40% of lymphoma diagnoses. Though aggressive, cure is achievable in approximately 60% of cases with primary chemo-immunotherapy, and in a further substantial minority by salvage therapy and autologous stem cell transplantation. Despite promising activity in early phase clinical trials, no intensified or novel treatment regimen has improved outcomes over R-CHOP21 in randomised studies. However, there remain several areas of controversy including the most appropriate prognostic markers, CNS prophylaxis and the optimal treatment for patients with high-risk disease. This position statement presents an evidence-based synthesis of the literature for application in Australasian practice. This article is protected by copyright. All rights reserved.

Return to Sport After Bone-Patellar Tendon-Bone Autograft ACL Reconstruction in High School-Aged Athletes

Background:

Anterior cruciate ligament (ACL) injuries are occurring with increasing frequency in the adolescent population. Outcomes after ACL reconstruction (ACLR) are inconsistently reported in homogeneous patient populations.

Purpose/Hypothesis:

To evaluate outcomes after bone–patellar tendon–bone (BTB) autograft ACLR in competitive high school–aged athletes by examining return to sport (RTS), patient satisfaction, and reinjury rates. Our hypothesis was that RTS rates and satisfaction will be high and reinjury rates will be low.

Study Design:

Case series; Level of evidence, 4.

Methods:

An institutional ACL registry was utilized to identify competitive high school–aged athletes (14-18 years old) who underwent primary ACLR using BTB autograft with a minimum 2-year follow-up. A postoperative questionnaire was administered to determine rates and types of RTS, quality of sports performance, reinjury, and satisfaction. Uni- and multivariable analyses were used to identify demographic, sport-specific, and clinical factors related to RTS.

Results:

A total of 53 patients were included (mean ± SD age at the time of surgery, 16.6 ± 1.34 years). Mean follow-up was 3.78 ± 0.70 years (range, 2.60-4.94 years). The overall ipsilateral ACL retear rate was 7.5% (n = 4). There were 10 subsequent ACL tears to the contralateral knee (19%). Forty-four (83%) patients successfully returned to at least their prior level of sport at a mean 10.5 ± 8.7 months (range, 3-48 months). Overall satisfaction was high, with 91% of patients very satisfied with the outcome. Higher confidence levels regarding performance of the reconstructed knee were associated with increased probability of RTS on multivariate analysis.

Conclusion:

BTB autograft ACLR results in high rates of RTS and satisfaction and low rates of subsequent ipsilateral ACL injuries in competitive high school–aged athletes. Patients with higher confidence in performance of the reconstructed knee are more likely to return to at least their prior level of sport.

Complete genome sequence of a German isolate of spartina mottle virus supports its classification as a member of the proposed genus "Sparmovirus" within the family Potyviridae

Spartina mottle virus (SpMV), an unassigned member of the family Potyviridae, has been known since 1980, when it was first described in England and Wales in symptomatic plants of the genus Spartina. In infected cells, flexuous particles and pinwheel inclusion bodies were found that resemble those of potyvirids. To date, the NCBI database contains only two partial sequences of a German (Nessmersiel) and an Italian (Assisi) isolate, suggesting that SpMV could be the first member of a new genus, called "Sparmovirus", in the family Potyviridae. In this study, the first complete genome sequence of the German SpMV isolate (SpMV Ger) was determined. The genome of SpMV is a single-stranded, monopartite, polyadenylated RNA consisting of 9376 nucleotides. Sequence analysis revealed a genome organization similar to that of classical potyviruses, including many conserved features. In phylogenetic analysis, SpMV could not be assigned to any of the known genera, but it showed the closest relationship to rymoviruses and common reed chlorotic stripe virus (CRCSV, unassigned). Sequence comparisons confirmed that a new genus should be established containing SpMV, CRCSV, and three Bermuda grass mosaic virus isolates, which are considered divergent strains of SpMV.

Comparison of different imaging models handling partial coherence for aberration-corrected HRTEM at 40-80 kV

Partial coherence of the electron waves leaving the specimen is taken into account in the high-resolution transmission electron microscopy (HRTEM) image simulation by mainly three methods - the incoherent summation approach, the transmission cross-coefficient (TCC) model, and the quasi-coherent model. In the incoherent summation approach, coherent images are calculated for each point in the effective source and summed up incoherently. The TCC is the transfer function of the microscope obtained based on the incoherent summation approach. An analytical form of the TCC can be derived by assuming a Gaussian distribution for the source radiation and for the variation of the focal length caused by the energy spread of the effective source. In the quasi-coherent model, the partial coherence effect is simplified by multiplying the wave function at the diffraction plane with the envelope functions. Envelope functions suppress the contributions to the image contrast from waves which do not propagate along the optical axis. The quasi-coherent model is usually sufficient for the image simulation of weak phase objects. This model is more computationally efficient than both the incoherent summation approach and the TCC model. For the C_s-corrected and C_c/C_s-corrected microscopes operating at 80 kV, we have compared images simulated by using the three models with the experimental images. The comparison shows that the quasi-coherent model also provides a sufficient approximation for the image simulation of high-Z materials if chromatic aberration is corrected and the samples comprise only several atomic layers. In the case of only C_s-correction, the incoherent summation approach or the TCC model needs to be employed for modelling the imaging of high-Z samples even though it is more computationally consuming.

Reliability Measures in Distorting Body-Image

This study is the first to make a direct comparison between the distorting mirror and the distorting videocamera with the same group of nonclinical subjects. It also establishes the internal consistency, the test-retest reliability and the convergent validity of both techniques. Analysis indicates, as with other studies, that perceived image is consistently over-estimated and ideal image is consistently underestimated by both techniques. With the distorting mirror, the frontal orientation is repeatable over four days and with the video the profile is the more reliable orientation. A comparison between profile and frontal orientations on any single test occasion (internal consistency) indicates that the results correlate well so either orientation is acceptable for experimental purposes. The extent to which both techniques were measuring the same aspect (convergent validity) was more marked for the ideal image. A researcher using the distorting mirror can be confident that the ideal image is reliable over time using either orientation but that the perceived image requires a frontal orientation. The frontal or profile orientation is acceptable for the ideal image using the distorting video, but the profile orientation is advisable if one wishes a reliable perceived image. The researcher should also be cautious in assuming that both techniques are measuring an identical body-image construct.

Magnetic Cc/Cs-corrector compensating for the chromatic aberration and the spherical aberration of electron lenses

Aberration correction in transmission electron microscopy has proven feasible and useful over a large range of acceleration voltages. The spherical aberration has been corrected for beam energies from 15 kV [1] up to 1.2 MeV [2] while the correction of the chromatic aberration has been achieved for beam energies ranging from 20 kV[3] up to 300 kV[4]. Above this threshold the conventional correction principle based on mixed electric and magnetic focusing elements becomes infeasible with present technology [5]. For conventional electron sources at high voltages the relative energy width of the beam gets so small that chromatic correction becomes less important. Nevertheless, for new applications with pulsed electron sources with energy spreads in the order of 100 eV chromatic aberration will become a limiting factor even at high energies [6]. To enable chromatic aberration correction for such systems a novel type of a feasible, purely magnetic multipole aberration corrector with curved optic axis is proposed which is capable of compensating for the chromatic and spherical aberration up to several MeV.

Reply to L.M. Brown et al. "Brief history of the Cambridge STEM aberration correction project and its progeny" in Ultramicroscopy 157, 88 (2015)

We comment on a Short Communication recently published in Ultramicroscopy in which Brown et al. criticize our description of the time sequence of events in the development of aberration correction systems in electron optics during the 1990s put forward in the introduction to the Ultramicroscopy April 2015 Special Issue. We present an analysis of the published literature furnishing evidence that our description is correct.

Transmission of methicillin-resistant Staphylococcus aureus via deceased donor liver transplantation confirmed by whole genome sequencing

Donor-derived bacterial infection is a recognized complication of solid organ transplantation (SOT). The present report describes the clinical details and successful outcome in a liver transplant recipient despite transmission of methicillin-resistant Staphylococcus aureus (MRSA) from a deceased donor with MRSA endocarditis and bacteremia. We further describe whole genome sequencing (WGS) and complete de novo assembly of the donor and recipient MRSA isolate genomes, which confirms that both isolates are genetically 100% identical. We propose that similar application of WGS techniques to future investigations of donor bacterial transmission would strengthen the definition of proven bacterial transmission in SOT, particularly in the presence of highly clonal bacteria such as MRSA. WGS will further improve our understanding of the epidemiology of bacterial transmission in SOT and the risk of adverse patient outcomes when it occurs.

The parasitic phase of Ostertagia ostertagi: quantification of the main life history traits through systematic review and meta-analysis

Predictive models of parasite life cycles increase our understanding of how parasite epidemiology is influenced by global changes and can be used to support decisions for more targeted worm control. Estimates of parasite population dynamics are needed to parameterize such models. The aim of this study was to quantify the main life history traits of Ostertagia ostertagi, economically the most important nematode of cattle in temperate regions. The main parameters determining parasite density during the parasitic phase of O. ostertagi are (i) the larval establishment rate, (ii) hypobiosis rate, (iii) adult mortality and (iv) female fecundity (number of eggs laid per day per female). A systematic review was performed covering studies from 1962 to 2007, in which helminth-naïve calves were artificially infected with O. ostertagi. The database was further extended with results of unpublished trials conducted at the Laboratory for Parasitology of Ghent University, Belgium. Overall inverse variance weighted estimates were computed for each of the traits through random effects models. An average establishment rate (±S.E.) of 0.269±0.022 was calculated based on data of 27 studies (46 experiments). The establishment rate declined when infection dose increased and was lower in younger animals. An average proportion of larvae entering hypobiosis (±S.E.) of 0.041 (±0.009) was calculated based on 27 studies (54 experiments). The proportion of ingested larvae that went into hypobiosis was higher in animals that received concomitant infections with nematode species other than O. ostertagi (mixed infections). An average daily adult mortality (±S.E.) of 0.028 (±0.002) was computed based on data from 28 studies (70 experiments). Adult mortality was positively correlated with infection dose. A daily fecundity (±S.E.) of 284 (±45) eggs per female was found based on nine studies (10 experiments). The average female sex ratio of O. ostertagi based on individual animal data (n=75) from six different studies was estimated to be 0.55. We believe that this systematic review is the first to summarise the available data on the main life history traits of the parasitic phase of O. ostertagi. In conclusion, this meta-analysis provides novel estimates for the parameterization of life cycle-based transmission models, explicitly reports measures of variance around these estimates, gives evidence for density dependence of larval establishment and adult mortality, shows that host age affects larval establishment and, to our knowledge, provides the first evidence for O. ostertagi of a female-biased sex ratio.

Immune regulation by intralymphatic immunotherapy with modular allergen translocation MAT vaccine

BACKGROUND

Allergen-specific immunotherapy (SIT) faces problems related to side effects and limited efficacy. Direct administration of allergen extracts into lymph nodes induces increased specific IgG production and T-cell responses using significantly lower allergen doses.

METHODS

In this study, mechanisms of immune regulation by MAT vaccines in vitro and in allergen-SIT of cat-allergic rhinitis patients, who received 3 inguinal intra-lymph node injections of MAT-Fel d 1 vaccine, were investigated in PBMC and cell cultures for specific T-cell proliferation, Fel d 1-tetramer-specific responses, and multiple immune regulatory molecules.

RESULTS

MAT-Fel d 1 vaccine was efficiently internalized by antigen-presenting cells. This was followed by precaspase 1 cleavage to caspase 1 and secretion of IL-1β, indicating inflammasome activation. Mat-Fel d 1 induced specific T-cell proliferation and an IL-10- and IFN-γ-dominated T-cell responses with decreased Th2 cytokines at 100 times lower doses than Fel d 1. Induction of immune tolerance by MAT-Fel d 1-ILIT involved multiple mechanisms of immune suppression. Early Fel d 1-specific T-cell activation was followed by full T-cell unresponsiveness to allergen after 1 year in the MAT-Fel d 1 group, characterized by increased allergen-specific T regulatory cells, decreased circulating Fel d 1 tetramer-positive cells, increased IL-10 and FOXP3 expression, and change in the HR2/HR1 ratio toward HR2.

CONCLUSIONS

This study demonstrates the induction of allergen tolerance after 3 intra-lymph node injections of MAT-Fel d 1 vaccine, mediated by increased cellular internalization of the allergen, activation of inflammasome, and generation of allergen-specific peripheral T-cell tolerance.

A critical appraisal of analyzing nasal provocation test results in allergen immunotherapy trials

BACKGROUND

The statistical analysis of nasal provocation tests is very complex. We compared the conventional analysis with the maximally selected test statistics and the hierarchical ordered logistic model.

METHODS

We re-analyzed data from a trial with 112 patients suffering from grass pollen allergy. The patients had been randomized to receive either intralymphatic immunotherapy (ILIT) or subcutaneous immunotherapy (SCIT).

RESULTS

The conventional analysis indicated that the logarithmized ratio between the pre- and the post-treatment threshold concentration was significantly lower for ILIT than for SCIT. The maximally selected test statistics was used to test different threshold symptom scores that would imply positive clinical symptoms at the given allergen concentration. A threshold score of 3 maximised the difference in improvement between the ILIT and the SCIT groups. The hierarchical ordered logistic model does not take threshold allergen concentrations as the basis for analysis, but the single scores measured at each concentration. This approach simultaneously considers the treatment effect (ILIT versus SCIT), the time effect (pre- versus post-treatment), and the dose effect (different allergen concentrations). The hierarchical ordered logistic model revealed that the clinical improvement was greater after ILIT than after SCIT.

CONCLUSION

As the choice of method can affect the outcome, guidelines for analysis are highly needed.

Notizen: Stereospecific Four-Bond Phosphorus-Phosphorus Spin Couplings in Phosphazenyl-Phosphazenes

Four-bond phosphorus-phosphorus coupling constants have been measured from the 31P NMR spectra of phosphazenylcyclophosphazenes. Their magnitude appears to be related to the conformation adopted by the phosphazenyl-group relative to the phosphazene ring.

Transmission electron microscopy at 20 kV for imaging and spectroscopy

The electron optical performance of a transmission electron microscope (TEM) is characterized for direct spatial imaging and spectroscopy using electrons with energies as low as 20 keV. The highly stable instrument is equipped with an electrostatic monochromator and a C(S)-corrector. At 20 kV it shows high image contrast even for single-layer graphene with a lattice transfer of 213 pm (tilted illumination). For 4 nm thick Si, the 200 reflections (271.5 pm) were directly transferred (axial illumination). We show at 20 kV that radiation-sensitive fullerenes (C(60)) within a carbon nanotube container withstand an about two orders of magnitude higher electron dose than at 80 kV. In spectroscopy mode, the monochromated low-energy electron beam enables the acquisition of EELS spectra up to very high energy losses with exceptionally low background noise. Using Si and Ge, we show that 20 kV TEM allows the determination of dielectric properties and narrow band gaps, which were not accessible by TEM so far. These very first results demonstrate that low kV TEM is an exciting new tool for determination of structural and electronic properties of different types of nano-materials.

Pathogenicity of biological control agents for livestock ectoparasites: a simulation analysis

The management of arthropod ectoparasites of livestock currently relies largely on the use of neurotoxic chemicals. However, concerns over the development of resistance, as well as operator and environmental contamination, have stimulated research into alternative approaches to their control, including the use of biological pathogens. The search for suitable pathogens often focuses on identifying the most highly virulent agents for application. However, practical issues such as the ability of a pathogen to penetrate to the skin through hair or wool, tolerance of high skin surface temperatures and high residual activity may mean that the most virulent pathogens are not necessarily the most appropriate for commercial application. Here, a simulation model is constructed and used to highlight a range of key features which characterize suitable pathogens for such application. Sensitivity analysis shows that even a relatively low probability of infection following contact between infectious and susceptible individuals may give acceptable control, providing it is counterbalanced by higher survival of both infected and infectious parasite hosts in order to allow the rate of transmission to exceed the threshold required to suppress parasite population growth. The model highlights the need for studies attempting to identify sustainable biocontrol agents to explore the use of pathogens which have a range of the characteristics that contribute to overall pathogenicity, but which are also most compatible with practical application systems.

Mapping risk foci for endemic sheep scab

Psoroptic mange in sheep, resulting from infestation by the astigmatid mite Psoroptes ovis, is increasingly prevalent in Europe and other parts of the world. As a step towards improved national control, regional or local scab management programmes that target high-risk areas and aim to maintain the number of outbreaks below an acceptable level may be an effective initial use of time and resource. To facilitate such a management approach, in this paper scab outbreak farms are identified using a questionnaire survey of sheep farmers, the data from which are then used to build a national scab risk model for Great Britain. The questionnaire results indicate a national prevalence of scab, between March 2007 and February 2008, of 8.6% (+/-1.98). However, previous exposure to sheep scab significantly affected the respondent's probability of reporting a scab outbreak during the survey period (chi(2)=53.2, d.f.=1, P<0.001); 85% of the farms that reported at least one scab outbreak had experienced outbreaks in previous years, 27% had experienced outbreaks in more than five of the previous 10 years. In contrast, 76% of farms that did not report scab had not had a previous outbreak. The highest prevalence areas were in Northern England, Wales, Southwest England and Scotland. Modelling the distribution of the reported scab outbreaks identified height above sea level, temperature and rainfall as significant predictors of the probability of an outbreak, superimposed on an underlying pattern of sheep abundance. It is argued that scab management programmes directed at these foci have the potential to allow a more targeted approach to scab control and significantly reduce the prevalence of scab in the UK and other European countries.

Targeting the MHC class II pathway of antigen presentation enhances immunogenicity and safety of allergen immunotherapy

BACKGROUND

Current s.c. allergen-specific immunotherapy (SIT) leads to amelioration of IgE-mediated allergy, but it requires numerous allergen injections over several years and is frequently associated with severe side-effects. The aim of this study was to test whether modified recombinant allergens can improve therapeutic efficacy in SIT while reducing allergic side-effects.

METHODS

The major cat allergen Fel d 1 was fused to a TAT-derived protein translocation domain and to a truncated invariant chain for targeting the MHC class II pathway (MAT-Fel d 1). The immunogenicity was evaluated in mice, while potential safety issues were assessed by cellular antigen stimulation test (CAST) using basophils from cat-dander-allergic patients.

RESULTS

MAT-Fel d 1 enhanced induction of Fel d 1-specific IgG2a antibody responses as well as the secretion of IFN-gamma and IL-2 from T cells. Subcutaneous allergen-specific immunotherapy of mice using the modified Fel d 1 provided stronger protection against anaphylaxis than SIT with unmodified Fel d 1, and MAT-Fel d 1 caused less degranulation of human basophils than native Fel d 1.

CONCLUSION

MAT-Fel d 1 allergen enhanced protective antibody and Th1 responses in mice, while reducing human basophil degranulation. Immunotherapy using MAT-Fel d 1 allergen therefore has the potential to enhance SIT efficacy and safety, thus, shortening SIT. This should increase patient compliance and lower treatment costs.

Prospects for aberration-free electron microscopy

Future aberration-corrected electron microscopes that will enable sub-Angstroem spatial and sub-eV energy resolution are outlined . The sub-Angstroem transmission electron microscope (SATEM) only compensates for the spherical aberration and reduces the chromatic aberration disc by means of a monochromator. In order to correct for both aberrations, two novel correctors, the ultracorrector and the superaplanator are proposed which will yield a resolution limit of about 0.5A and a large field of view of more than 4 x 10(6) image points. The superaplanator is best suited for obtaining an achromatic aplanat required for the realization of the high-performance in situ electron microscope of the TEAM project.

The most common chromosome aberration detected by high-resolution comparative genomic hybridization in vulvar intraepithelial neoplasia is not seen in vulvar squamous cell carcinoma

We analyzed genetic changes in condylomas (four cases), vulvar intraepithelial neoplasia I-III (VIN I-III, eleven cases), and primary vulvar squamous cell carcinomas (VSCC, ten cases) by high-resolution comparative genomic hybridization (HR-CGH) and flowcytometry. All samples were also human papilloma virus (HPV)-genotyped. Gain of chromosome 1, the aberration most often seen in VIN III (67%), was not seen in HPV-positive or -negative VSCCs (0%). Both VIN III and VSCC frequently showed gain of 3q (56 and 70%, respectively). The VIN III samples often demonstrated gain of 20q (56%) and 20p (44%), and the VSCC samples gain of 8q (60%), loss of 3p (50%), and 8p (40%). None of the four most frequent changes in the VSCC samples occurred exclusively in the HPV-positive or -negative samples. As expected, we did not find any cytogenetic changes in condylomas and nearly any changes in VIN I-II.

Theory of electron-optical achromats and apochromats

A detailed theoretical formulation of the primary and secondary chromatic aberrations of electron-optical systems with a straight optic axis is outlined. To simplify the mathematical expenditure only systems composed of magnetic round lenses and magnetic and electrostatic quadrupoles are taken into account. By appropriately arranging these elements, it is possible to construct feasible electron-optical analogues of light-optical achromats and apochromats.