Relationships of emerging biomarkers of cancer cachexia with quality of life, appetite, and cachexia

PURPOSE

Quality of life (QoL), appetite, cachexia, and biomarkers [albumin, hemoglobin (Hb), neutrophils, lymphocytes, platelets, C-reactive protein (CRP), tumor necrosis factor alpha (TNFα), interleukin 6 (IL-6), interleukin 8 (IL-8), C-X-C motif chemokine ligand 5 (CXCL5) and citrullinated histoneH3 (H3Cit)] were compared for 40 cases with advanced cancer and 40 healthy controls. Baseline differences and significant relationships were explored for biomarkers with QoL, appetite, and cachexia.

METHODS

In a prospective case-control, age and sex matched study, the European Organisation for the Research and Treatment of Cancer Quality of Life-C30 questionnaire (EORTC-QLQ-C30) for QoL, the Functional Assessment of Anorexia and Cachexia Therapy assessment (FAACT A/CS-12) for appetite, and a five-factor cachexia assessment tool for cachexia assessment were performed. Routine hematological measurements and blood chemistry analyses together with ELISA procedures and a Multiplex® bead array platform, were used for biomarker analysis. Descriptive statistics and regression analyses were undertaken. P < 0.05 defined statistical significance.

RESULTS

Global health status (QL-G), functional scales (QL-FS), and symptom scales (QL-SS) differed for cases and controls (p < 0.01). In cases, differences were observed for QL-G (p < 0.01), QL-FS (p < 0.01), and QL-SS (p = 0.01) compared to standardized references values. FAACT A/CS-12 scores differed significantly between cases and controls (p < 0.01) and 30% of cases scored "poor" appetites. Cachexia was present in 60% of cases. Albumin, lymphocytes, platelets, Hb, platelet to lymphocyte ratio (PLR), systemic immune-inflammation index (SII), CRP, TNFα, all at p < 0.01, neutrophil to lymphocyte ratio (NLR) (p = 0.02), IL-6 (p < 0.04), and IL-8 (p = 0.02) differed significantly between cases and controls. No difference was found for CXCL5 or H3Cit. Albumin NLR, Hb, PLR, SII, TNFα, IL-8, and CRP showed significant relationships with all aspects of QoL. QL-FS was significantly related to CXCL5 (p = 0.04), significant relationships with FAACT A/CS-12 included: NLR (p = 0.002), Hb (p < 0.001), and PLR (p < 0.01). NLR, PLR, SII, TNFα, IL-6, IL-8, and CRP correlated positively to cachexia and albumin while Hb and lymphocyte count correlated negatively to cachexia.

CONCLUSION

CXCL5 and H3Cit were not reliable biomarkers for cancer cachexia, nor significantly related to QoL, appetite or cachexia. Albumin, NLR, Hb, PLR, SII, TNFα, IL-8, and CRP were reliable indicators of QoL, appetite, and cachexia. Future research should include other novel biomarkers namely growth differentiation factor-15 (GDF-15), fibroblast growth factor 21 (FGF-21), fractakline, interferon gamma (IFN-y), IL-16, macrophage colony stimulating factor (M-CSF), and macrophage procoagulant-inducing factor (MPIF).

Bone support of a custom triflange acetabular component over time

Aims

To investigate the extent of bone development around the scaffold of custom triflange acetabular components (CTACs) over time.

Methods

We performed a single-centre historical prospective cohort study, including all patients with revision THA using the aMace CTAC between January 2017 and March 2021. A total of 18 patients (18 CTACs) were included. Models of the hemipelvis and the scaffold component of the CTACs were created by segmentation of CT scans. The CT scans were performed immediately postoperatively and at least one year after surgery. The amount of bone in contact with the scaffold was analyzed at both times, and the difference was calculated.

Results

The mean time between the implantation and the second CT scan was two years (1 to 5). The mean age of the patients during CTAC implantation was 75 years (60 to 92). The mean scaffold-bone contact area increased from 16% (SD 12.6) to 28% (SD 11.9). The mean scaffold-bone distance decreased from a mean of 6.5 mm (SD 2.0) to 5.5 mm (SD 1.6). None of the CTACs were revised or radiologically loose.

Conclusion

There was a statistically significant increase of scaffold-bone contact area over time, but the total contact area of the scaffold in relation to the acetabular bone remained relatively low. As all implants remained well fixed, the question remains to what extend the scaffold contributes to the observed stability, in relation to the screws. A future design implication might be an elimination of the bulky scaffold component. This design modification would reduce production costs and may optimize the primary fit of the implant.

Diagnosis and treatment of a congenital portosystemic shunt in a ferret (Mustela putorius furo)

A 3-year-old female neutered ferret presented with progressive weight loss was diagnosed with portosystemic shunting based on increased fasting bile acids, rectal ammonia tolerance testing and advanced imaging. Ammonia reference values were determined in 16 healthy ferrets. A congenital extrahepatic spleno-caval shunt was visualised with ultrasonography and CT angiography of the abdomen. Complete surgical shunt closure by suture ligation was performed, without clinical improvement after surgery. Euthanasia was elected 4 months postoperatively because the clinical condition deteriorated. This is a case report of advanced diagnostics and surgical treatment of a congenital extrahepatic portosystemic shunt in a ferret, demonstrating rectal ammonia tolerance testing and imaging as feasible techniques for the diagnosis.

Emerging markers of cancer cachexia and their relationship to sarcopenia

PURPOSE

Emerging biomarkers of cancer cachexia and their roles in sarcopenia and prognosis are poorly understood. Baseline assessments of anthropometrics, sarcopenia, cachexia status and biomarkers of cachexia were measured in patients with advanced cancer and healthy controls. Thereafter, relationships of the biomarkers with cachexia and sarcopenia were explored.

METHODS

A prospective case-control design was used, including 40 patients with advanced cancer and 40 gender, age-matched controls. Bioelectrical impedance [skeletal muscle index (SMI)] and hand dynamometry [hand grip strength (HGS)] assessed sarcopenia and a validated tool classified cancer cachexia. Albumin, lymphocyte and platelet counts, haemoglobin, C-reactive protein (CRP), pro-inflammatory cytokines/chemokines and citrullinated histone H3 (H3Cit) were measured.

RESULTS

Patients had significantly lower SMI (6.67 kg/m2 versus 7.67 kg/m2, p =  < 0.01) and HGS (24.42 kg versus 29.62 kg) compared to controls, with 43% being sarcopenic. Significant differences were found for albumin, lymphocyte and platelet counts, haemoglobin, CRP, and tumour necrosis factor α (TNFα), (p < 0.01). Interleukin (IL)-6 (p < 0.04), IL-8 (p = 0.02), neutrophil/lymphocyte ratio (NLR), p = 0.02, platelet/lymphocyte (PLR) ratio, p < 0.01 and systemic immune inflammatory index (SII), p < 0.01 differed significantly. No difference was observed for CXC motif chemokine ligand 5 [CXCL5 or epithelial neutrophil-activating peptide 78 (ENA78)] or H3Cit. Albumin and haemoglobin correlated negatively with total protein, skeletal muscle mass and SMI (all p < 0.01). The presence of sarcopenia associated significantly with albumin, haemoglobin and CRP.

CONCLUSION

Significant relationships and differences of haemoglobin, CRP and albumin supports future use of these biomarkers in cancer cachexia. CXCL5 and H3Cit as valuable biomarkers in cancer cachexia remains to be defined.

Clinical Feasibility of Daily Online Adaptive Bladder Cancer Radiotherapy with Cone Beam CT, Using Fiducial Makers

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) for muscle invasive bladder cancer is challenging due to varying bladder filling. We assessed the efficacy and feasibility of online adaptive RT (oART), applying a focal boost to the tumor, in terms of dose and workflow.

MATERIALS/METHODS

Bladder cancer patients (N = 15) were treated with oART on a ring-shaped Linac. This system integrates imaging (CBCT) with AI-based organ and tumor segmentation, adaptive treatment planning and delivery. Before treatment the GTV was demarcated with liquid markers. On the planning CT organs-at-risk and the GTV were contoured. The reference treatment plan was optimized with total dose for PTV (elective bladder, lymph nodes) 40Gy/20 fractions and an integrated focal boost to the GTV (15Gy). Margins were 3mm (GTV-CTV) and 5mm (CTV-PTV). Before each daily treatment, a CBCT was acquired. Bladder, rectum and GTV were determined by the AI. Planning CT and CBCT were registered to generate other organs at risk. Subsequently, the dose of the reference plan was calculated for this anatomy (scheduled plan). An adaptive plan was generated by reoptimization. Subsequently, a second pretreatment CBCT (CBCT2) was made to verify and correct the position, when necessary. Target coverage for PTV and GTV (V95%) and dose outside the target were evaluated on CBCT2. Radiation therapists (RTTs) executed the oART workflow with medical physicists (MPs) and radiation oncologists (ROs) on call. The time (median [range]) and personnel involvement were monitored.

RESULTS

For all adaptive plans V95%>98% for CTV and GTV (boost) volumes. For scheduled plans this was 53.5% (CTV boost) and 98.5% (bladder+lymph nodes). For adaptive vs scheduled plans, the volume of dose (40Gy) to tissue outside the PTV reduced with 150cm3(p<0. 01). Median session time (patient entering-leaving) was 32 [25-45] min for the first 5 patients and reduced to 27 [20-61] min for subsequent patients. About 30% of this time was reoptimization. AI-generated GTVs were corrected in 75% for the first 5 patients and 40% for subsequent patients (taking 5min). Fiducial markers were clearly visible on CBCTs supporting GTV localization. ROs and MPs were consulted during each first fraction (5% of total) and 12% of the remaining fractions.

CONCLUSION

The adaptive procedure is well feasible in clinical practice with an RTT-only workflow. The procedure takes longer than conventional RT, with reoptimization as a main factor. Dosimetric result are clearly favorable compared to delivery of non-adaptive plans.

Deep versus moderate neuromuscular blockade during total hip arthroplasty to improve postoperative quality of recovery and immune function: protocol for a randomised controlled study

INTRODUCTION

There is accumulating evidence that deep neuromuscular blockade (NMB) improves intraoperative surgical conditions during laparoscopic surgery. Studies investigating the effects of deep NMB in open surgery are scarce. In theory, by limiting surgical damage through deeper muscle relaxation, postoperative inflammation and concomitant immune suppression can be reduced. Therefore, this study will investigate the effects of deep NMB during total hip arthroplasty, which demands a relatively large exposure of the hip joint through and in between muscles.

METHODS AND ANALYSIS

This study is a monocentre blinded randomised controlled trial in 100 patients undergoing total hip arthroplasty under general anaesthesia. Patients will be randomised in a 1:1 fashion to an intervention group of intraoperative deep NMB (a post-tetanic count of 1-2) or a control group receiving moderate NMB (a train-of-four count of 1-2). NMB will be achieved by continuous or bolus administration of rocuronium, respectively. The primary endpoint is the quality of recovery at postoperative day 1 measured by the Quality of Recovery-40 Questionnaire, analysed by Analysis of Variance. The secondary endpoint is postoperative innate immune function, measured by ex vivo production capacity of tumour necrosis factor and interleukin-1β on endotoxin stimulation of whole blood.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted by the Medical Ethics Committee 'METC Oost-Nederland' (reference number 2022-15754). Informed consent will be obtained prior to study participation. Study results will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov Registry (NCT05562999) and EudraCT Registry (2022-002451-19).

[Decision making in frail patients with a hip fracture]

BACKGROUND

When an older patient presents herself at the emergency department with a femur fracture different doctors are involved: the geriatrician, the orthopaedic or trauma- surgeon and the anaesthesiologist. Together they form an ad hoc team and are in charge of organising the best medical care for the patient.

CASE DESCRIPTION

In this case description we present a patient with cardiovascular comorbidity and dementia. Mis-interpretation or missing information can lead to different treatment decisions and outcomes.

CONCLUSION

Effective cooperation and transfer of information in physical consultation is crucial in the care of frail patients.

Cardiac radioablation does not worsen cardiac function: preliminary safety results of the prospective STARNL-1 trial

Background

Cardiac radioablation for ventricular tachycardia (VT) appears to be highly effective and safe in patients with recurrent VT despite anti-arrhythmic therapy and catheter ablation(s), although global experience is currently very limited. Detailed echocardiographic strain analysis could provide important insights in (subclinical) functional safety. Importantly, current stereotactic cardiac radioablation techniques includes irradiation of the VT substrate but, inherently, also includes irradiation of the VT border zone and some healthy cardiac tissue. The latter particularly may result in detoriation of cardiac function after cardiac radioablation.

Purpose

To evaluate functional echocardiographic safety of cardiac radioablation.

Methods

The STARNL-1 trial is a prospective, monocenter, single-arm, pre-post intervention study. Six patients with recurrent VT despite high dose anti-arrhythmic drugs, after (single or multiple) conventional catheter ablation and deemed unsuited for repeat catheter ablation, were treated with a single fraction 25 Gy radiotherapy dose. Per protocol, patients underwent echocardiograms at baseline, 24 hours after treatment, and 3 months after treatment. Echocardiograms were analysed using 2D-speckle tracking. Mean radiotherapy dose per segment was calculated according to the AHA 17-segment model. Echocardiographic parameters were compared between baseline, 24 hours and 3 months, and correlated to radiotherapy dose.

Results

Patients were all male (age 55–83 years), all suffered from ischaemic cardiomyopathy, and all completed 3 month follow-up. At baseline, median left ventricle ejection fraction (LVEF) was 38% [30; 47] and median global longitudinal strain (GLS) −8% [−12; −5]. Interestingly, LVEF significantly improved 24 hours after treatment (42% [36; 49], p=0.046) but GLS did not change (−7% [−12; −5], p=0.833). At 3 months, both LVEF and GLS were unchanged compared to baseline (LVEF 39% [33; 49%], p=0.463; GLS −6% [−12; −5], p=0.893). The difference in longitudinal strain per segment before and after treatment did not correlate with the mean radiotherapy dose per segment, both 24 hours after treatment (Pearson coefficient −0.082, p=0.410) and 3 months after treatment (Pearson coefficient −0.005, p=0.957). In Figure 1 an illustrative case is presented.

Conclusion(s)

Cardiac radioablation for VT does not worsen (subclinical) cardiac function within the first 3 months after treatment.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation

Thirty years of experience with instrumented femoral impaction bone grafting and a cemented polished Exeter stem : a prospective cohort study of 208 revision arthroplasties performed between 1991 and 2007

AIMS

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

METHODS

We updated the outcomes of our previous study, based on 208 consecutive revisions using IBG and the X-change femoral revision system in combination with a cemented polished stem, performed in our tertiary care institute between 1991 and 2007. Kaplan-Meier survival analyses were used to determine the survival rate of the revisions with endpoint revision for any reason and aseptic loosening. Secondary outcomes were radiological loosening and patient-reported outcome measures.

RESULTS

Mean age at revision total hip arthroplasty (THA) was 64.9 years (30 to 86). The most prevalent diagnosis for the femoral revision was aseptic loosening. At review in May 2021, 81 patients (85 hips) were still alive and 118 patients (120 hips; 58%) had died. Three patients (3 hips; 1%) were lost to follow-up at 11, 15, and 16 years after surgery, respectively. Data of all deceased and lost patients were included until final follow-up. The mean follow-up was 13.4 years (0 to 28). During the follow-up, 22 re-revisions were performed. The most common reason for re-revision was infection (n = 12; 54%). The survival with endpoint re-revision for any reason was 86% (95% confidence interval (CI) 79 to 91) at 20 years and 74% (95% CI 43 to 89) at 25 years after surgery. The survival for endpoint re-revision for aseptic loosening was 97% (95% CI 91 to 99) after both 20 and 25 years.

CONCLUSION

We conclude that femoral IBG is a valuable technique that can reconstitute femoral bone loss in the long term. After 25 years of follow-up, few re-revisions for aseptic loosening were required. Also, the overall revision rate is very acceptable at a long follow-up. This technique is especially attractive for younger patients facing femoral revisions with extensive bone loss.Cite this article: Bone Joint J 2022;104-B(9):1039-1046.

Standardizing the cardiac radioablation targeting workflow: enabling semi-automated angulation and segmentation of the heart according to the American Heart Association segmented model

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation

Purpose

Cardiac radioablation has evolved as a potential treatment modality for therapy-refractory ventricular tachycardia. To standardize cardiac radioablation treatments, promote accurate communication and target identification, and to assess toxicity, robust and reproducible methods for angulation and cardiac segmentation are paramount. In this study, we developed and evaluated a workflow for semi-automated angulation and segmentation according to the American Heart Association (AHA) 17-segment model.

Methods and materials

The workflow for semi-automated angulation and segmentation of the planning-CT was based on an in-house developed tool requiring placement of only 4 point-markers and a rotation matrix. For angulation, 2 markers defining the cardiac long-axis were placed: at the cardiac apex and at the center of the mitral valve (figure A). A rotation matrix was derived that angulates the CT-volume, resulting in the cardiac short axis (figure B). Segmentation was subsequently performed based on marking the two left ventricular hinge points (figure BC). To evaluate reproducibility, 5 observers independently placed markers in planning-CTs of 6 patients.

Results

The Root-Mean-Square of the standard deviation for the angulation and segmentation marker positions were all below 0.52cm. The 17-segments were subsequently generated and compared between the observers resulting in a median dice coefficient of 0.8 [0.70;0.87] and a median of the mean Hausdorff distance of 0.09cm [0.05;0.17]. Figure D shows the heat maps of two illustrative segments indicating the percentage agreement per voxel between the 5 observers. The interquartile ranges of Euler angles α and β, determined by the angulation markers, was less than 30 for all patients except one. For the γ angle, determined by the hinge point markers, the interquartile range was up to 120.

Conclusion

In this study, a workflow for cardiac radioablation is presented that enables reproducible semi-automatic cardiac angulation and segmentation of the planning-CT according to the AHA 17-segment model. This workflow can be easily implemented and be used to promote communication between radiation oncology and cardiology, enables cardiology-oriented targeting and permits focused toxicity evaluations.

STereotactic Arrhythmia Radioablation in Europe: critical structure contouring benchmark results of the STOPSTORM Consortium

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EU Horizon

Background/Introduction

In patients with refractory ventricular tachycardia (VT), STereotactic Arrhythmia Radioablation (STAR) showed promising results for otherwise untreatable patients [1]. The STOPSTORM.eu project coordinates European efforts to clinically validate STAR.

Purpose

The primary goal of the critical structures benchmark study was to harmonize contouring of organs at risk (OAR) for STAR within the STOPSTORM.eu consortium. The results enable to refine protocols and guidelines to ensure treatment harmonization.

Methods

Three well-selected STAR cases [2] were provided for this benchmark and sent to all radiation oncology centres within the consortium. Every case had a contrast-enhanced cardiac-CT which was already deformed to the primary planning-CT to contour the OAR in detail. Every centre was asked to contour 31 OAR’s according to literature-based guidelines. The resulting structure sets were evaluated within VelocityTM 4.1.

Results

Twenty centres participated in the critical structure contouring benchmark.

Contouring of the structures was performed with high accuracy according to the provided guidelines. The contours of common OAR’s in radiotherapy, such as the heart, lungs, stomach, oesophagus, bronchus, great vessels, and spinal canal were correctly contoured by all centres. In the substructures of the heart (chambers, valves, arteries, and nodes), deviations in the contours occurred more frequently, but no large systematic errors were found (see figure 1-2). The centres that already performed STAR treatments had markedly less difficulties with the contouring of the substructures. However, these structures do not have a consensus for treatment planning purposes and late toxicity but need to be contoured correctly for future analysis within the STOPSTORM project.

Conclusion

This large STOPSTORM.eu multi-centre critical structure benchmark study showed a high accuracy regarding standard critical structures. In the case of heart substructures some deviations occurred, which lead to new definitions for contouring these structures within the consortium. In addition, a close collaboration between radiation oncologist and cardiac electrophysiologist is recommended.

Dual-contrast computed tomography enables detection of equine posttraumatic osteoarthritis in vitro

To prevent the progression of posttraumatic osteoarthritis, assessment of cartilage composition is critical for effective treatment planning. Posttraumatic changes include proteoglycan (PG) loss and elevated water content. Quantitative dual-energy computed tomography (QDECT) provides a means to diagnose these changes. Here, we determine the potential of QDECT to evaluate tissue quality surrounding cartilage lesions in an equine model, hypothesizing that QDECT allows detection of posttraumatic degeneration by providing quantitative information on PG and water contents based on the partitions of cationic and nonionic agents in a contrast mixture. Posttraumatic osteoarthritic samples were obtained from a cartilage repair study in which full-thickness chondral defects were created surgically in both stifles of seven Shetland ponies. Control samples were collected from three nonoperated ponies. The experimental (n = 14) and control samples (n = 6) were immersed in the contrast agent mixture and the distributions of the agents were determined at various diffusion time points. As a reference, equilibrium moduli, dynamic moduli, and PG content were measured. Significant differences (p < 0.05) in partitions between the experimental and control samples were demonstrated with cationic contrast agent at 30 min, 60 min, and 20 h, and with non-ionic agent at 60 and 120 min. Significant Spearman's rank correlations were obtained at 20 and 24 h (ρ = 0.482-0.693) between the partition of cationic contrast agent, cartilage biomechanical properties, and PG content. QDECT enables evaluation of posttraumatic changes surrounding a lesion and quantification of PG content, thus advancing the diagnostics of the extent and severity of cartilage injuries.

Economic evaluation of endometrial scratching before the second IVF/ICSI treatment: a cost-effectiveness analysis of a randomized controlled trial (SCRaTCH trial)

STUDY QUESTION

Is a single endometrial scratch prior to the second fresh IVF/ICSI treatment cost-effective compared to no scratch, when evaluated over a 12-month follow-up period?

SUMMARY ANSWER

The incremental cost-effectiveness ratio (ICER) for an endometrial scratch was €6524 per additional live birth, but due to uncertainty regarding the increase in live birth rate this has to be interpreted with caution.

WHAT IS KNOWN ALREADY

Endometrial scratching is thought to improve the chances of success in couples with previously failed embryo implantation in IVF/ICSI treatment. It has been widely implemented in daily practice, despite the lack of conclusive evidence of its effectiveness and without investigating whether scratching allows for a cost-effective method to reduce the number of IVF/ICSI cycles needed to achieve a live birth.

STUDY DESIGN, SIZE, DURATION

This economic evaluation is based on a multicentre randomized controlled trial carried out in the Netherlands (SCRaTCH trial) that compared a single scratch prior to the second IVF/ICSI treatment with no scratch in couples with a failed full first IVF/ICSI cycle. Follow-up was 12 months after randomization.Economic evaluation was performed from a healthcare and societal perspective by taking both direct medical costs and lost productivity costs into account. It was performed for the primary outcome of biochemical pregnancy leading to live birth after 12 months of follow-up as well as the secondary outcome of live birth after the second fresh IVF/ICSI treatment (i.e. the first after randomization). To allow for worldwide interpretation of the data, cost level scenario analysis and sensitivity analysis was performed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From January 2016 until July 2018, 933 women with a failed first IVF/ICSI cycle were included in the trial. Data on treatment and pregnancy were recorded up until 12 months after randomization, and the resulting live birth outcomes (even if after 12 months) were also recorded.Total costs were calculated for the second fresh IVF/ICSI treatment and for the full 12 month period for each participant. We included costs of all treatments, medication, complications and lost productivity costs. Cost-effectiveness analysis was carried out by calculating ICERs for scratch compared to control. Bootstrap resampling was used to estimate the uncertainty around cost and effect differences and ICERs. In the sensitivity and scenario analyses, various unit costs for a single scratch were introduced, amongst them, unit costs as they apply for the United Kingdom (UK).

MAIN RESULTS AND THE ROLE OF CHANCE

More live births occurred in the scratch group, but this also came with increased costs over a 12-month period. The estimated chance of a live birth after 12 months of follow-up was 44.1% in the scratch group compared to 39.3% in the control group (risk difference 4.8%, 95% CI -1.6% to +11.2%). The mean costs were on average €283 (95% CI: -€299 to €810) higher in the scratch group so that the point average ICER was €5846 per additional live birth. The ICER estimate was surrounded with a high level of uncertainty, as indicated by the fact that the cost-effectiveness acceptability curve (CEAC) showed that there is an 80% chance that endometrial scratching is cost-effective if society is willing to pay ∼€17 500 for each additional live birth.

LIMITATIONS, REASONS FOR CAUTION

There was a high uncertainty surrounding the effects, mainly in the clinical effect, i.e. the difference in the chance of live birth, which meant that a single straightforward conclusion could not be ascertained as for now.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first formal cost-effectiveness analysis of endometrial scratching in women undergoing IVF/ICSI treatment. The results presented in this manuscript cannot provide a clear-cut expenditure for one additional birth, but they do allow for estimating costs per additional live birth in different scenarios once the clinical effectiveness of scratching is known. As the SCRaTCH trial was the only trial with a follow-up of 12 months, it allows for the most complete estimation of costs to date.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by ZonMW, the Dutch organization for funding healthcare research. A.E.P.C., F.J.M.B., E.R.G. and C.B. L. reported having received fees or grants during, but outside of, this trial.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL5193/NTR 5342).

External validation of a frequently used prediction model for ongoing pregnancy in couples with unexplained recurrent pregnancy loss

STUDY QUESTION

What is the predictive performance of a currently recommended prediction model in an external Dutch cohort of couples with unexplained recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

The model shows poor predictive performance on a new population; it overestimates, predicts too extremely and has a poor discriminative ability.

WHAT IS KNOWN ALREADY

In 50-75% of couples with RPL, no risk factor or cause can be determined and RPL remains unexplained. Clinical management in RPL is primarily focused on providing supportive care, in which counselling on prognosis is a main pillar. A frequently used prediction model for unexplained RPL, developed by Brigham et al. in 1999, estimates the chance of a successful pregnancy based on number of previous pregnancy losses and maternal age. This prediction model has never been externally validated.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study consisted of 739 couples with unexplained RPL who visited the RPL clinic of the Leiden University Medical Centre between 2004 and 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Unexplained RPL was defined as the loss of two or more pregnancies before 24 weeks, without the presence of an identifiable cause for the pregnancy losses, according to the ESHRE guideline. Obstetrical history and maternal age were noted at intake at the RPL clinic. The outcome of the first pregnancy after intake was documented. The performance of Brigham's model was evaluated through calibration and discrimination, in which the predicted pregnancy rates were compared to the observed pregnancy rates.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort included 739 women with a mean age of 33.1 years (±4.7 years) and with a median of three pregnancy losses at intake (range 2-10). The mean predicted pregnancy success rate was 9.8 percentage points higher in the Brigham model than the observed pregnancy success rate in the dataset (73.9% vs 64.0% (95% CI for the 9.8% difference 6.3-13.3%)). Calibration showed overestimation of the model and too extreme predictions, with a negative calibration intercept of -0.46 (95% CI -0.62 to -0.31) and a calibration slope of 0.42 (95% CI 0.11-0.73). The discriminative ability of the model was very low with a concordance statistic of 0.55 (95% CI 0.51-0.59). Recalibration of the Brigham model hardly improved the c-statistic (0.57; 95% CI 0.53-0.62).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study in which only the first pregnancy after intake was registered. There was no time frame as inclusion criterium, which is of importance in the counselling of couples with unexplained RPL. Only cases with a known pregnancy outcome were included.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study externally validating the Brigham prognostic model that estimates the chance of a successful pregnancy in couples with unexplained RPL. The results show that the frequently used model overestimates the chances of a successful pregnancy, that predictions are too extreme on both the high and low ends and that they are not much more discriminative than random luck. There is a need for revising the prediction model to estimate the chance of a successful pregnancy in couples with unexplained RPL more accurately.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used and no competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Reducing failures in daily medical practice: Healthcare failure mode and effect analysis combined with computer simulation

This study proposes a risk analysis approach for complex healthcare processes that combines qualitative and quantitative methods to improve patient safety. We combine Healthcare Failure Mode and Effect Analysis with Computer Simulation (HFMEA-CS), to overcome widely recognised HFMEA drawbacks regarding the reproducibility and validity of the outcomes due to human interpretation, and show the application of this methodology in a complex healthcare setting. HFMEA-CS is applied to analyse drug adherence performance in the surgical admission to discharge process of pheochromocytoma patients. The multidisciplinary team identified and scored the failure modes, and the simulation model supported in prioritisation of failure modes, uncovered dependencies between failure modes, and predicted the impact of measures on system behaviour. The results show that drug adherence, defined as the percentage of required drugs received at the right time, can be significantly improved with 12%, to reach a drug adherence of 99%. We conclude that HFMEA-CS is both a viable and effective risk analysis approach, combining strengths of expert opinion and quantitative analysis, for analysing human-system interactions in socio-technical systems. Practitioner summary: We propose combining Healthcare Failure Mode and Effects Analysis with Computer Simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes, to prevent critical incidents from occurring. HFMEA-CS combines expert opinions with quantitative analyses, such that the results are more reliable, reproducible, and fitting for complex healthcare settings.

Is home-based monitoring of ovulation to time frozen embryo transfer a cost-effective alternative for hospital-based monitoring of ovulation? Study protocol of the multicentre, non-inferiority Antarctica-2 randomised controlled trial

STUDY QUESTION

The objective of this trial is to compare the effectiveness and costs of true natural cycle (true NC-) frozen embryo transfer (FET) using urinary LH tests to modified NC-FET using repeated ultrasound monitoring and ovulation trigger to time FET in the NC. Secondary outcomes are the cancellation rates of FET (ovulation before hCG or no dominant follicle, no ovulation by LH urine test, poor embryo survival), pregnancy outcomes (miscarriage rate, clinical pregnancy rates, multiple ongoing pregnancy rates, live birth rates, costs) and neonatal outcomes (including gestational age, birthweight and sex, congenital abnormalities or diseases of babies born).

WHAT IS KNOWN ALREADY

FET is at the heart of modern IVF. To allow implantation of the thawed embryo, the endometrium must be prepared either by exogenous oestrogen and progesterone supplementation (artificial cycle (AC)-FET) or by using the NC to produce endogenous oestradiol before and progesterone after ovulation to time the transfer of the thawed embryo (NC-FET). During an NC-FET, women visit the hospital repeatedly and receive an ovulation trigger to time FET (i.e. modified (m)NC-FET or hospital-based monitoring). From the woman’s point of view, a more natural approach using home-based monitoring of the ovulation with LH urine tests to allow a natural ovulation to time FET may be desired (true NC-FET or home-based monitoring).

STUDY DESIGN, SIZE, DURATION

This is a multicentre, non-inferiority prospective randomised controlled trial design. Consenting women will undergo one FET cycle using either true NC-FET or mNC-FET based on randomisation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on our sample size calculation, the study group will consist of 1464 women between 18 and 45 years old who are scheduled for FET. Women with anovulatory cycles, women who need ovulation induction and women with a contra indication for pregnancy will be excluded. The primary outcome is ongoing pregnancy. Secondary outcomes are cancellation rates of FET, pregnancy outcomes (including miscarriage rate, clinical pregnancy, multiple pregnancy rate and live birth rate). Costs will be estimated by counting resource use and calculating unit prices.

STUDY FUNDING/COMPETING INTEREST(S)

The study received a grant from the Dutch Organisation for Health Research and Development (ZonMw 843002807; www.zonmw.nl). ZonMw has no role in the design of the study, collection, analysis, and interpretation of data or writing of the manuscript. F.B. reports personal fees from member of the external advisory board for Merck Serono, grants from Research support grant Merck Serono, outside the submitted work. A.E.P.C. reports and Unrestricted grant of Ferring B.V. to the Center for Reproductive medicine, no personal fee. Author up-to-date on Hyperthecosis. Congress meetings 2019 with Ferring B.V. and Theramex B.V. M.G. reports Department research and educational grants from Guerbet, Merck and Ferring (location VUMC) outside the submitted work. E.R.G. reports personal fees from Titus Health Care, outside the submitted work. C.B.L. reports grants from Ferring, grants from Merck, from Guerbet, outside the submitted work. The other authors have none to declare.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (Trial NL6414 (NTR6590), https://www.trialregister.nl/).

TRIAL REGISTRATION DATE

23 July 2017

DATE OF FIRST PATIENT’S ENROLMENT

10 April 2018

[Arthroscopy for degenerative meniscal tears: from standard to exception]

Osteoarthritis of the knee is often accompanied by degeneration of the meniscus. Worldwide, the arthroscopic partial meniscectomy has been a standard of care for patients with knee pain in the presence a degenerative meniscal tear. However, in recent years, clinical studies have proven that a meniscectomy is not effective in the osteoarthritic knee. Physiotherapy is often as effective. The updated Dutch guidelines for meniscal tears therefore recommend an arthroscopic partial meniscectomy or fixation in case of a locked knee and for traumatic meniscal tears in younger patients. There also is an indication for a meniscectomy after failure of conservative treatment in case of a symptomatic meniscal tear in the absence of osteoarthritis.

Endometrial scratching in women with one failed IVF/ICSI cycle-outcomes of a randomised controlled trial (SCRaTCH)

STUDY QUESTION

Does endometrial scratching in women with one failed IVF/ICSI treatment affect the chance of a live birth of the subsequent fresh IVF/ICSI cycle?

SUMMARY ANSWER

In this study, 4.6% more live births were observed in the scratch group, with a likely certainty range between −0.7% and +9.9%.

WHAT IS KNOWN ALREADY

Since the first suggestion that endometrial scratching might improve embryo implantation during IVF/ICSI, many clinical trials have been conducted. However, due to limitations in sample size and study quality, it remains unclear whether endometrial scratching improves IVF/ICSI outcomes.

STUDY DESIGN, SIZE, DURATION

The SCRaTCH trial was a non-blinded randomised controlled trial in women with one unsuccessful IVF/ICSI cycle and assessed whether a single endometrial scratch using an endometrial biopsy catheter would lead to a higher live birth rate after the subsequent IVF/ICSI treatment compared to no scratch. The study took place in 8 academic and 24 general hospitals. Participants were randomised between January 2016 and July 2018 by a web-based randomisation programme. Secondary outcomes included cumulative 12-month ongoing pregnancy leading to live birth rate.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with one previous failed IVF/ICSI treatment and planning a second fresh IVF/ICSI treatment were eligible. In total, 933 participants out of 1065 eligibles were included (participation rate 88%).

MAIN RESULTS AND THE ROLE OF CHANCE

After the fresh transfer, 4.6% more live births were observed in the scratch compared to control group (110/465 versus 88/461, respectively, risk ratio (RR) 1.24 [95% CI 0.96–1.59]). These data are consistent with a true difference of between −0.7% and +9.9% (95% CI), indicating that while the largest proportion of the 95% CI is positive, scratching could have no or even a small negative effect. Biochemical pregnancy loss and miscarriage rate did not differ between the two groups: in the scratch group 27/153 biochemical pregnancy losses and 14/126 miscarriages occurred, while this was 19/130 and 17/111 for the control group (RR 1.21 (95% CI 0.71–2.07) and RR 0.73 (95% CI 0.38–1.40), respectively). After 12 months of follow-up, 5.1% more live births were observed in the scratch group (202/467 versus 178/466), of which the true difference most likely lies between −1.2% and +11.4% (95% CI).

LIMITATIONS, REASONS FOR CAUTION

This study was not blinded. Knowledge of allocation may have been an incentive for participants allocated to the scratch group to continue treatment in situations where they may otherwise have cancelled or stopped. In addition, this study was powered to detect a difference in live birth rate of 9%.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study are an incentive for further assessment of the efficacy and clinical implications of endometrial scratching. If a true effect exists, it may be smaller than previously anticipated or may be limited to specific groups of women undergoing IVF/ICSI. Studying this will require larger sample sizes, which will be provided by the ongoing international individual participant data-analysis (PROSPERO CRD42017079120). At present, endometrial scratching should not be performed outside of clinical trials.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by ZonMW, the Dutch organisation for funding healthcare research. J.S.E. Laven reports grants and personal fees from AnshLabs (Webster, Tx, USA), Ferring (Hoofddorp, The Netherlands) and Ministry of Health (CIBG, The Hague, The Netherlands) outside the submitted work. A.E.P. Cantineau reports ‘other’ from Ferring BV, personal fees from Up to date Hyperthecosis, ‘other’ from Theramex BV, outside the submitted work. E.R. Groenewoud reports grants from Titus Health Care during the conduct of the study. A.M. van Heusden reports personal fees from Merck Serono, personal fees from Ferring, personal fees from Goodlife, outside the submitted work. F.J.M. Broekmans reports personal fees as Member of the external advisory board for Ferring BV, The Netherlands, personal fees as Member of the external advisory board for Merck Serono, The Netherlands, personal fees as Member of the external advisory for Gedeon Richter, Belgium, personal fees from Educational activities for Ferring BV, The Netherlands, grants from Research support grant Merck Serono, grants from Research support grant Ferring, personal fees from Advisory and consultancy work Roche, outside the submitted work. C.B. Lambalk reports grants from Ferring, grants from Merck, grants from Guerbet, outside the submitted work.

TRIAL REGISTRATION NUMBER

Registered in the Netherlands Trial Register (NL5193/NTR 5342).

TRIAL REGISTRATION DATE

31 July 2015.

DATE OF FIRST PATIENT’S ENROLMENT

26 January 2016.

Aspergillus niger uses the peroxisomal CoA-dependent β-oxidative genes to degrade the hydroxycinnamic acids caffeic acid, ferulic acid, and p-coumaric acid

Abstract

Aromatic compounds are important molecules which are widely applied in many industries and are mainly produced from nonrenewable sources. Renewable sources such as plant biomass are interesting alternatives for the production of aromatic compounds. Ferulic acid and p-coumaric acid, a precursor for vanillin and p-vinyl phenol, respectively, can be released from plant biomass by the fungus Aspergillus niger. The degradation of hydroxycinnamic acids such as caffeic acid, ferulic acid, and p-coumaric acid has been observed in many fungi. In A. niger, multiple metabolic pathways were suggested for the degradation of hydroxycinnamic acids. However, no genes were identified for these hydroxycinnamic acid metabolic pathways. In this study, several pathway genes were identified using whole-genome transcriptomic data of A. niger grown on different hydroxycinnamic acids. The genes are involved in the CoA-dependent β-oxidative pathway in fungi. This pathway is well known for the degradation of fatty acids, but not for hydroxycinnamic acids. However, in plants, it has been shown that hydroxycinnamic acids are degraded through this pathway. We identified genes encoding hydroxycinnamate-CoA synthase (hcsA), multifunctional β-oxidation hydratase/dehydrogenase (foxA), 3-ketoacyl CoA thiolase (katA), and four thioesterases (theA-D) of A. niger, which were highly induced by all three tested hydroxycinnamic acids. Deletion mutants revealed that these genes were indeed involved in the degradation of several hydroxycinnamic acids. In addition, foxA and theB are also involved in the degradation of fatty acids. HcsA, FoxA, and KatA contained a peroxisomal targeting signal and are therefore predicted to be localized in peroxisomes.

Key points

• Metabolism of hydroxycinnamic acid was investigated in Aspergillus niger

• Using transcriptome data, multiple CoA-dependent β-oxidative genes were identified.

• Both foxA and theB are involved in hydroxycinnamate but also fatty acid metabolism.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00253-021-11311-0.

Accuracy of an MR-only workflow for prostate radiotherapy using semi-automatically burned-in fiducial markers

BACKGROUND

The benefit of MR-only workflow compared to current CT-based workflow for prostate radiotherapy is reduction of systematic errors in the radiotherapy chain by 2-3 mm. Nowadays, MRI is used for target delineation while CT is needed for position verification. In MR-only workflows, MRI based synthetic CT (sCT) replaces CT. Intraprostatic fiducial markers (FMs) are used as a surrogate for the position of the prostate improving targeting. However, FMs are not visible on sCT. Therefore, a semi-automatic method for burning-in FMs on sCT was developed. Accuracy of MR-only workflow using semi-automatically burned-in FMs was assessed and compared to CT/MR workflow.

METHODS

Thirty-one prostate cancer patients receiving radiotherapy, underwent an additional MR sequence (mDIXON) to create an sCT for MR-only workflow simulation. Three sources of accuracy in the CT/MR- and MR-only workflow were investigated. To compare image registrations for target delineation, the inter-observer error (IOE) of FM-based CT-to-MR image registrations and soft-tissue-based MR-to-MR image registrations were determined on twenty patients. Secondly, the inter-observer variation of the resulting FM positions was determined on twenty patients. Thirdly, on 26 patients CBCTs were retrospectively registered on sCT with burned-in FMs and compared to CT-CBCT registrations.

RESULTS

Image registration for target delineation shows a three times smaller IOE for MR-only workflow compared to CT/MR workflow. All observers agreed in correctly identifying all FMs for 18 out of 20 patients (90%). The IOE in CC direction of the center of mass (COM) position of the markers was within the CT slice thickness (2.5 mm), the IOE in AP and RL direction were below 1.0 mm and 1.5 mm, respectively. Registrations for IGRT position verification in MR-only workflow compared to CT/MR workflow were equivalent in RL-, CC- and AP-direction, except for a significant difference for random error in rotation.

CONCLUSIONS

MR-only workflow using sCT with burned-in FMs is an improvement compared to the current CT/MR workflow, with a three times smaller inter observer error in CT-MR registration and comparable CBCT registration results between CT and sCT reference scans. Trial registry Medical Research Involving Human Subjects Act (WMO) does apply to this study and was approved by the Medical Ethics review Committee of the Academic Medical Center. Registration number: NL65414.018.18. Date of registration: 21-08-2018.

Evaluation of articular cartilage with quantitative MRI in an equine model of post-traumatic osteoarthritis

Chondral lesions lead to degenerative changes in the surrounding cartilage tissue, increasing the risk of developing post-traumatic osteoarthritis (PTOA). This study aimed to investigate the feasibility of quantitative magnetic resonance imaging (qMRI) for evaluation of articular cartilage in PTOA. Articular explants containing surgically induced and repaired chondral lesions were obtained from the stifle joints of seven Shetland ponies (14 samples). Three age-matched nonoperated ponies served as controls (six samples). The samples were imaged at 9.4 T. The measured qMRI parameters included T₁ , T₂ , continuous-wave T_1ρ (CWT_1ρ ), adiabatic T_1ρ (AdT_1ρ ), and T_2ρ (AdT_2ρ ) and relaxation along a fictitious field (T_RAFF ). For reference, cartilage equilibrium and dynamic moduli, proteoglycan content and collagen fiber orientation were determined. Mean values and profiles from full-thickness cartilage regions of interest, at increasing distances from the lesions, were used to compare experimental against control and to correlate qMRI with the references. Significant alterations were detected by qMRI parameters, including prolonged T₁ , CWT_1ρ , and AdT_1ρ in the regions adjacent to the lesions. The changes were confirmed by the reference methods. CWT_1ρ was more strongly associated with the reference measurements and prolonged in the affected regions at lower spin-locking amplitudes. Moderate to strong correlations were found between all qMRI parameters and the reference parameters (ρ = -0.531 to -0.757). T₁ , low spin-lock amplitude CWT_1ρ , and AdT_1ρ were most responsive to changes in visually intact cartilage adjacent to the lesions. In the context of PTOA, these findings highlight the potential of T₁ , CWT_1ρ , and AdT_1ρ in evaluation of compositional and structural changes in cartilage.

Online adaptive radiotherapy compared to plan selection for rectal cancer: quantifying the benefit

Background

To compare online adaptive radiation therapy (ART) to a clinically implemented plan selection strategy (PS) with respect to dose to the organs at risk (OAR) for rectal cancer.

Methods

The first 20 patients treated with PS between May–September 2016 were included. This resulted in 10 short (SCRT) and 10 long (LCRT) course radiotherapy treatment schedules with a total of 300 Conebeam CT scans (CBCT). New dual arc VMAT plans were generated using auto-planning for both the online ART and PS strategy.

For each fraction bowel bag, bladder and mesorectum were delineated on daily Conebeam CTs. The dose distribution planned was used to calculate daily DVHs. Coverage of the CTV was calculated, as defined by the dose received by 99% of the CTV volume (D99%). The volume of normal tissue irradiated with 95% of the prescribed fraction dose was calculated by calculating the volume receiving 95% of the prescribed fraction or more dose minus the volume of the CTV. For each fraction the difference between the plan selection and online adaptive strategy of each DVH parameter was calculated, as well as the average difference per patient.

Results

Target coverage remained the same for online ART. The median volume of the normal tissue irradiated with 95% of the prescribed dose dropped from 642 cm3 (PS) to 237 cm3 (online-ART)(p < 0.001). Online ART reduced dose to the OARs for all tested dose levels for SCRT and LCRT (p < 0.001). For V15Gy of the bowel bag the median difference over all fractions of all patients was − 126 cm³ in LCRT, while the average difference per patient ranged from − 206 cm³ to − 40 cm³. For SCRT the median difference was − 62 cm³, while the range of the average difference per patient was − 105 cm3 to − 51 cm³.

For V15Gy of the bladder the median difference over all fractions of all patients was 26% in LCRT, while the average difference per patient ranged from − 34 to 12%. For SCRT the median difference of V95% was − 8%, while the range of the average difference per patient was − 29 to 0%.

Conclusions

Online ART for rectal cancer reduces dose the OARs significantly compared to a clinically implemented plan selection strategy, without compromising target coverage.

Trial registration

Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center (W19_357 # 19.420; Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands).

Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy

BACKGROUND

To compare target coverage and dose to the organs at risk in two approaches to rectal cancer: a clinically implemented adaptive radiotherapy (ART) strategy using plan selection, and a non-adaptive (non-ART) strategy.

METHODS

The inclusion of the first 20 patients receiving adaptive radiotherapy produced 10 patients with a long treatment schedule (25x2Gy) and 10 patients with a short schedule (5X5Gy). We prepared a library of three plans with different anterior PTV margins to the upper mesorectum, and selected the most appropriate plan on daily Conebeam CT scans (CBCT). We also created a non-adaptive treatment plan with a 20 mm margin. Bowel bag, bladder and target volume were delineated on CBCT. Daily DHVs were calculated based on the dose distribution of the selected and non-adaptive plans. Coverage of the target volume was compared per fraction between the ART and non-ART plans, as was the dose to the bladder and small bowel, assessing the following dose levels: V15Gy, V30Gy, V40Gy, V15Gy and V95% for long treatment schedules, and V15Gy and V95% for short ones.

RESULTS

Target volume coverage was maintained from 98.3% (non-ART) to 99.0% (ART)(p = 0.878). In the small bowel, ART appeared to have produced significant reductions in the long treatment schedule at V15Gy, V40Gy, V45Gy and V95% (p <  0.05), but with small absolute differences. The DVH parameters tested for the short treatment schedule did not differ significantly. In the bladder, all DVH parameters in both schedules showed significant reductions (p <  0.05), also with small absolute differences.

CONCLUSIONS

The adaptive treatment maintained target coverage and reduced dose to the organs at risk.

TRIAL REGISTRATION

Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center, W19_194 # 19.233.

T2* and quantitative susceptibility mapping in an equine model of post-traumatic osteoarthritis: assessment of mechanical and structural properties of articular cartilage

OBJECTIVE

To investigate the potential of quantitative susceptibility mapping (QSM) and T2* relaxation time mapping to determine mechanical and structural properties of articular cartilage via univariate and multivariate analysis.

METHODS

Samples were obtained from a cartilage repair study, in which surgically induced full-thickness chondral defects in the stifle joints of seven Shetland ponies caused post-traumatic osteoarthritis (14 samples). Control samples were collected from non-operated joints of three animals (6 samples). Magnetic resonance imaging (MRI) was performed at 9.4 T, using a 3-D multi-echo gradient echo sequence. Biomechanical testing, digital densitometry (DD) and polarized light microscopy (PLM) were utilized as reference methods. To compare MRI parameters with reference parameters (equilibrium and dynamic moduli, proteoglycan content, collagen fiber angle and -anisotropy), depth-wise profiles of MRI parameters were acquired at the biomechanical testing locations. Partial least squares regression (PLSR) and Spearman's rank correlation were utilized in data analysis.

RESULTS

PLSR indicated a moderate-to-strong correlation (ρ = 0.49-0.66) and a moderate correlation (ρ = 0.41-0.55) between the reference values and T2* relaxation time and QSM profiles, respectively (excluding superficial-only results). PLSR correlations were noticeably higher than direct correlations between bulk MRI and reference parameters. 3-D parametric surface maps revealed spatial variations in the MRI parameters between experimental and control groups.

CONCLUSION

Quantitative parameters from 3-D multi-echo gradient echo MRI can be utilized to predict the properties of articular cartilage. With PLSR, especially the T2* relaxation time profile appeared to correlate with the properties of cartilage. Furthermore, the results suggest that degeneration affects the QSM-contrast in the cartilage. However, this change in contrast is not easy to quantify.

Determinants of serum 25-hydroxyvitamin D levels in healthy young adults living in the Western Cape, South Africa

Background: Vitamin D deficiency is fast emerging as a global pandemic. In South Africa few studies have been conducted to determine the vitamin D status of the healthy population.Methods: This prospective study with an analytical component investigated vitamin D status of healthy undergraduate students at two time points (winter and summer) at Stellenbosch University. Serum 25(OH)D was determined, anthropometric measurements taken and dietary vitamin D intake estimated (food-frequency questionnaire). Skin tone was determined (Fitzpatrick skin type classification), and a skin reflectometry device used to measure dermal melanin content.Results: Results of 242 students indicated a mean serum 25(OH)D of 63.80 ± 41.35 ng/ml and a high prevalence of vitamin D sufficiency (88%). Significantly more females experienced suboptimal vitamin D levels than males (18 vs. 5%; p 0.01). Participants with lighter skin tones had higher levels of 25(OH)D than those with darker skin tones (chi-square = 24.02; p = 0.02). The majority (60.74%) had a normal BMI, although there was no significant relationship between BMI and serum 25 (OH)D (Spearman’s r=–0.11; p = 0.09). Total mean dietary vitamin D intake was 7.99 ± 13.81 mcg, with 87.2% having inadequate intake ( 15 mcg). The relationship between total vitamin D intake and serum 25(OH)D was found to be significant in winter (p 0.001) and summer (p = 0.01). Serum vitamin D levels were significantly higher in the winter phase (p 0.001).Conclusions: A low prevalence of vitamin D deficiency was found amongst healthy young adults, despite low dietary vitamin D intakes. Significant relationships were found between serum 25(OH)D and gender, skin tone and vitamin D intake. Further studies need to be conducted, especially in high-risk groups, before results are applied to the greater South African public.

Dosimetric comparison of library of plans and online MRI-guided radiotherapy of cervical cancer in the presence of intrafraction anatomical changes

Background

Online magnetic resonance imaging (MRI)-guided radiotherapy of cervical cancer has the potential to further reduce dose to organs at risk (OAR) as compared to a library of plans (LOP) approach. This study presents a dosimetric comparison of an MRI-guided strategy with a LOP strategy taking intrafraction anatomical changes into account.

Methods

The 14 patients included in this study were treated with chemo radiation at our institute and received weekly MRIs after informed consent. The MRI-guided strategy consisted of treatment plans created on the weekly sagittal MRI with 3 mm and 5 mm planning target volume (PTV) margin for clinical target volume (CTV) cervix-uterus (MRI_3mm and MRI_5mm). The plans for the LOP strategy were based on interpolations of CTV cervix-uterus on pretreatment full and empty bladder scans. Dose volume histogram (DVH) parameters were compared for targets and OARs as delineated on the weekly transversal MRI, which was acquired on average 10 min after the sagittal MRI.

Results

For the MRI_5mm strategy D_98% of the high-risk CTV was at least 95% for all weekly MRIs of all patients, while for the LOP and MRI_3mm strategy this requirement was not satisfied for at least one weekly MRI for 1 and 3 patients, respectively. The average reduction of the volume of the reference dose (95% of the prescribed dose) as compared to the LOP strategy was 464 cm³ for the MRI_3mm strategy, and 422 cm³ for the MRI_5mm strategy. The bowel bag constraint V_40Gy < 350 cm³ was violated for 13 patients for the LOP strategy and for 5 patients for both MRI_3mm and MRI_5mm strategy.

Conclusions

With online MRI-guided radiotherapy of cervical cancer considerable sparing of OARs can be achieved. If a new treatment plan can be generated and delivered within 10 min, an online MRI-guided strategy with a 5 mm PTV margin for CTV cervix-uterus is sufficient to account for intrafraction anatomical changes.

Trial registration

NL44492.018.13.

Electronic supplementary material

The online version of this article (10.1186/s13014-019-1322-0) contains supplementary material, which is available to authorized users.

Follicle stimulating hormone versus clomiphene citrate in intrauterine insemination for unexplained subfertility: a randomized controlled trial

STUDY QUESTION

Is FSH or clomiphene citrate (CC) the most effective stimulation regimen in terms of ongoing pregnancies in couples with unexplained subfertility undergoing IUI with adherence to strict cancellation criteria as a measure to reduce the number of multiple pregnancies?

SUMMARY ANSWER

In IUI with adherence to strict cancellation criteria, ovarian stimulation with FSH is not superior to CC in terms of the cumulative ongoing pregnancy rate, and yields a similar, low multiple pregnancy rate.

WHAT IS ALREADY KNOWN

FSH has been shown to result in higher pregnancy rates compared to CC, but at the cost of high multiple pregnancy rates. To reduce the risk of multiple pregnancy, new ovarian stimulation regimens have been suggested, these include strict cancellation criteria to limit the number of dominant follicles per cycle i.e. withholding insemination when more than three dominant follicles develop. With such a strategy, it is unclear whether the ovarian stimulation should be done with FSH or with CC.

STUDY DESIGN, SIZE, DURATION

We performed an open-label multicenter randomized superiority controlled trial in the Netherlands (NTR 4057).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We randomized couples diagnosed with unexplained subfertility and scheduled for a maximum of four cycles of IUI with ovarian stimulation with 75 IU FSH or 100 mg CC. Cycles were cancelled when more then three dominant follicles developed. The primary outcome was cumulative ongoing pregnancy rate. Multiple pregnancy was a secondary outcome. We analysed the data on intention to treat basis. We calculated relative risks and absolute risk difference with 95% CI.

MAIN RESULTS AND THE ROLE OF CHANCE

Between July 2013 and March 2016, we allocated 369 women to ovarian stimulation with FSH and 369 women to ovarian stimulation with CC. A total of 113 women (31%) had an ongoing pregnancy following ovarian stimulation with FSH and 97 women (26%) had an ongoing pregnancy following ovarian stimulation with CC (RR = 1.16, 95% CI: 0.93-1.47, ARD = 0.04, 95% CI: -0.02 to 0.11). Five women (1.4%) had a multiple pregnancy following ovarian stimulation with FSH and eight women (2.2%) had a multiple pregnancy following ovarian stimulation with CC (RR = 0.63, 95% CI: 0.21-1.89, ARD = -0.01, 95% CI: -0.03 to 0.01).

LIMITATIONS, REASONS FOR CAUTION

We were not able to blind this study due to the nature of the interventions. We consider it unlikely that this has introduced performance bias, since pregnancy outcomes are objective outcome measures.

WIDER IMPLICATIONS OF THE FINDINGS

We revealed that adherence to strict cancellation criteria is a successful solution to reduce the number of multiple pregnancies in IUI. To decide whether ovarian stimulation with FSH or with CC should be the regimen of choice, costs and patients' preferences should be taken into account.

STUDY FUNDING/COMPETING INTEREST(S)

This trial received funding from the Dutch Organization for Health Research and Development (ZonMw). Prof. Dr B.W.J. Mol is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for Merck, ObsEva and Guerbet. The other authors declare that they have no competing interests.

TRIAL REGISTRATION NUMBER

Nederlands Trial Register NTR4057.

TRIAL REGISTRATION DATE

1 July 2013.

DATE OF FIRST PATIENT’S ENROLMENT

The first patient was randomized at 27 August 2013.

[Applications of 3D printing in medicine; 5 years later]

5 years ago, we described the emergence of 3D printing in medicine. It was about 3D printing of anatomical structures, patient-specific drilling guides, cutting templates and implants and printing of living cells, growth factors and biomaterials ('bioprinting'). Surgeons are increasingly making use of 3D printing possibilities in preparation of surgeries on patients with complicated anatomies. Using tangible 3D models, it is easier for surgeons to prepare for surgeries and discussions with patients. They can also use 3D models as a tool to help with the training of young surgeons. Permanent titanium implants are increasingly being printed. Bioprinting is still in its infancy and there are no direct clinical applications yet. As we already predicted 5 years ago, many hurdles still have to be taken before broad clinical application of bioprinted products will become a reality.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Staff and student health and wellness at the Faculty of Medicine and Health Sciences, Stellenbosch University: current status and needs assessment

Background: Emphasis is currently placed on the importance of employee and student wellness initiatives. The aim was to assess staff and student health status at the Faculty of Medicine and Health Sciences (FMHS), Stellenbosch University (SU), and to conduct a wellness needs assessment.Methods: Online, self-administered questionnaires were used to collect data concerning staff and students. Additionally, students’ anthropometric and biochemical parameters were assessed. Summary statistics, correlation coefficients and appropriate analysis of variance were used for data analyses.Results: Data were obtained from staff (survey: n = 300) and students (screening: n = 536; survey: n = 330). Some 58% (n = 174) of staff had a self-reported BMI of ≥ 25 kg/m2 whilst mean screening values for all variables fell within normal reference ranges for students. In all, 78% (n = 232) of staff reported to exercise 150 min/week and 28% (n = 91) of students were sedentary for 8 h/day; 63% (n = 188) of staff expressed the need to make better food choices, 17% (n = 55) of students were aware of the need to change but experienced reluctance, and both staff and students felt dietary assistance would be beneficial (43% vs. 46%). In addition, 79% of staff (n = 208) and 42% of students (n = 138) reported being under constant pressure.Conclusion: Much can be done to improve the health and well-being of both staff and students at the FMHS, SU. Wellness is a multifactorial concept; as such, health-promotional strategies for classrooms and workplaces should consider all factors in order to provide a holistic approach and potentially identify those who are at risk of a sub-optimal wellness status.

Low sensitivity of a-defensin (Synovasure) test for intra-operative exclusion of prosthetic joint infection

Background and purpose - The Synovasure lateral flow test was developed as a rapid test for the detection or exclusion of periprosthetic joint infection (PJI). 3 studies have reported promising results on its diagnostic value in total joint revision surgery. We aimed to assess the sensitivity and specificity of the Synovasure test to exclude infection in patients undergoing revision surgery for suspected early aseptic loosening of a total hip or knee arthroplasty. Patients and methods - In a prospective study design, 37 patients who underwent revision surgery for suspected early aseptic loosening (< 3 years after primary arthroplasty) were included. The Synovasure test was used intraoperatively to confirm the aseptic nature of the loosening and 6 tissue cultures were obtained in all cases. Exclusion criteria were patients with a preoperatively confirmed PJI, acute revisions (< 90 days after primary arthroplasty) and cases with malpositioning, wear, or instability of the prosthesis. Results - 5 of the 37 patients were diagnosed with a PJI based on the intraoperative tissue cultures. In only 1 out of these 5 cases this was confirmed by the intraoperative Synovasure test. No tests were falsely positive. Interpretation - In this case series the Synovasure lateral flow test had a low sensitivity to exclude PJI in patients with suspected aseptic loosening. The role of the Synovasure lateral flow test in the intraoperative exclusion of PJI during revision surgery for suspected early aseptic loosening appears to be more limited than previously indicated.