Exploring high-throughput synchrotron X-Ray powder diffraction for the structural analysis of pharmaceuticals

Synchrotron radiation offers a host of advanced properties, surpassing conventional laboratory sources with its high brightness, tunable phonon energy, photon beam coherence for advanced X-ray imaging, and a structured time profile, ideal for capturing dynamic atomic and molecular processes. However, these benefits come at the cost of operational complexity and expenses. Three decades ago, synchrotron radiation facilities, while technically open to all scientists, primarily served a limited community. Despite substantial accessibility improvements over the past two decades, synchrotron measurements still do not qualify as routine analyses. The intrinsic complexity of synchrotron science means experiments are pursued only when no alternatives suffice. In recent years, strides have been made in technology transfer offices, intermediate synchrotron-based analytical service companies, and the development of high-throughput synchrotron systems at various facilities, reshaping the perception of synchrotron science. This article investigates the practical application of synchrotron X-Ray Powder Diffraction (s-XRPD) techniques in pharmaceutical analysis. By utilizing concrete examples, we demonstrate how high-throughput systems have the potential to revolutionize s-XRPD applications in the pharmaceutical industry, rapidly generating XRPD patterns of comparable or superior quality to those obtained in state-of-the-art laboratory XRPD, all in less than 5 s. Additional cases featuring well-established pharmaceutical active ingredients (API) and excipients substantiate the concept of high throughput in pharmaceuticals, affirming data quality through structural refinements aligned with literature-derived unit cell parameters. Synchrotron data need not always be state-of-the-art to compete with lab-XRPD data. The key lies in ensuring user-friendliness, reproducibility, accessibility, cost-effectiveness, and the streamlined efforts associated with synchrotron instrumentation to remain highly competitive with their laboratory counterparts.

KiT-GENIE, the French genetic biobank of kidney transplantation

KiT-GENIE is a monocentric DNA biobank set up to consolidate the very rich and homogeneous DIVAT French cohort of kidney donors and recipients (D/R) in order to explore the molecular factors involved in kidney transplantation outcomes. We collected DNA samples for kidney transplantations performed in Nantes, and we leveraged GWAS genotyping data for securing high-quality genetic data with deep SNP and HLA annotations through imputations and for inferring D/R genetic ancestry. Overall, the biobank included 4217 individuals (n = 1945 D + 2,272 R, including 1969 D/R pairs), 7.4 M SNPs and over 200 clinical variables. KiT-GENIE represents an accurate snapshot of kidney transplantation clinical practice in Nantes between 2002 and 2018, with an enrichment in living kidney donors (17%) and recipients with focal segmental glomerulosclerosis (4%). Recipients were predominantly male (63%), of European ancestry (93%), with a mean age of 51yo and 86% experienced their first graft over the study period. D/R pairs were 93% from European ancestry, and 95% pairs exhibited at least one HLA allelic mismatch. The mean follow-up time was 6.7 years with a hindsight up to 25 years. Recipients experienced biopsy-proven rejection and graft loss for 16.6% and 21.3%, respectively. KiT-GENIE constitutes one of the largest kidney transplantation genetic cohorts worldwide to date. It includes homogeneous high-quality clinical and genetic data for donors and recipients, hence offering a unique opportunity to investigate immunogenetic and genetic factors, as well as donor-recipient interactions and mismatches involved in rejection, graft survival, primary disease recurrence and other comorbidities.

OP0126 ARE WOMEN WITH SPONDYLOARTHRITIS AT INCREASED RISK OF ADVERSE MATERNAL AND INFANT OUTCOMES? – A SWEDISH COHORT STUDY

Background

An increased risk of adverse pregnancy and neonatal outcomes has been reported for pregnancies in women with several rheumatic diseases including rheumatoid arthritis and psoriatic arthritis. In spondyloarthritis (SpA), findings have not been uniform, with some studies reporting increased risks of Cesarean delivery, preterm birth, infants born small-for-gestational-age (SGA), and gestational diabetes- and hypertension, while others have failed to identify any significant differences between women with SpA and general population control women. Most studies reporting no differences have either been small or lacked an appropriate comparison group [1].

Objectives

To assess the risk of adverse maternal and infant pregnancy outcomes in women with SpA compared to the general population.

Methods

In this nationwide register-based study, we included singleton births between April 2007 and December 2019 in women diagnosed with ankylosing spondylitis (AS; ICD-10 codes M45 or M08.1) or undifferentiated SpA (uSpA; ICD-10 codes M46.8 or M46.9). This was performed through linkage between the National Patient Register and the Medical Birth Register. Each birth was matched on birth year, maternal age, and parity to ten comparator births in women free from chronic inflammatory arthritis at time of birth. Relative risks (RR) of adverse outcomes were estimated by Poisson regression, adjusting for maternal country of birth, BMI, smoking in early pregnancy, educational level, and disposable income in the year before pregnancy.

Results

Women with SpA (n=1394) were found to be at increased risk of several adverse outcomes compared to general population comparators (n=13932), as displayed in the Figure 1. Women with SpA had an increased risk of gestational diabetes (adjusted RR 1.88 [95% CI 1.10; 2.56]), elective and emergency Cesarean delivery (adjusted RR 1.54 [95% CI 1.32; 1.79] and 1.23 [95% CI 1.02; 1.48], respectively), and moderately preterm birth (adjusted RR 1.52 [95% CI 1.18; 1.97]). An association was seen with both spontaneous and medically indicated preterm birth, but the increase was only significant for spontaneous preterm birth. The risk estimate for preeclampsia was also increased, but failed to reach significance (adjusted RR 1.32 [95% CI 0.96; 1.81]). Infants to mothers with SpA were not more likely to be born SGA, but there was a slightly increased risk estimate of infection during their first year of life (adjusted RR 1.23 [95% CI 0.98; 1.53]).

Figure 1.

Number of events of adverse pregnancy outcomes among a nationwide cohort of births (n=1394) in Swedish women with SpA and comparator births (n=13932, matched 1:10 on birth year, maternal age, and parity). Relative risks from Poisson regression, adjusted for maternal country of birth, BMI, smoking in early pregnancy, educational level, and disposable income in the year before pregnancy.

Conclusion

While most pregnancies in women with SpA are uneventful, there is an increased risk for a number of adverse pregnancy outcomes. The increased risks for both emergency Cesarean delivery and spontaneous preterm birth suggest that these differences are not only driven by a different management of SpA pregnancies.

References

[1]Mokbel A, Lawson DO, Farrokhyar F. Pregnancy outcomes in women with ankylosing spondylitis: a scoping literature and methodological review. Clinical Rheumatology 2021;40(9):3465-80.

Disclosure of Interests

None declared

The granulosa cell response to luteinizing hormone is partly mediated by YAP1-dependent induction of amphiregulin

Background

The LH surge is a pivotal event that triggers multiple key ovarian processes including oocyte maturation, cumulus expansion, follicular wall rupture and luteinization of mural granulosa and theca cells. Recently, LH-dependent activation of the Hippo signaling pathway has been shown to be required for the differentiation of granulosa cells into luteal cells. Still, the precise interactions between Hippo and LH signaling in murine granulosa cells remain to be elucidated.

Methods

To detect the expression of effectors of the Hippo pathway, western blot, immunohistochemical and RT-qPCR analyses were performed on granulosa cells treated with LH in vitro or isolated from immature mice treated with eCG and hCG. Cultured granulosa cells were pretreated with pharmacologic inhibitors to identify the signaling pathways involved in Hippo regulation by LH. To study the roles of Yap1 and Taz in the regulation of the LH signaling cascade, RT-qPCR and microarray analyses were done on granulosa cells from Yap1^f/f;Taz^f/f mice treated with an adenovirus to drive cre expression. RT-qPCR was performed to evaluate YAP1 binding to the Areg promoter following chromatin immunoprecipitation of granulosa cells collected from mice prior to or 60 min following hCG treatment.

Results

Granulosa cells showed a transient increase in LATS1, YAP1 and TAZ phosphorylation levels in response to the ovulatory signal. This Hippo activation by LH was mediated by protein kinase A. Furthermore, Yap1 and Taz are required for the induction of several LH target genes such as Areg, Pgr and Ptgs2, and for the activation of the ERK1/2 pathway. Consistent with these results, there was a substantial overlap between genes that are upregulated by LH and those that are downregulated following loss of Yap1/Taz, highlighting a major role for Hippo in mediating LH actions in the ovulation process. Finally, we showed that there is a marked recruitment of YAP1 to the Areg promoter of granulosa cells in response to hCG stimulation.

Conclusions

Overall, these results indicate that Hippo collaborates with the cAMP/PKA and ERK1/2 pathways to participate in the precise regulation of the LH cascade, and that Areg, as a direct transcriptional target of YAP1, is involved in mediating its actions in the ovary.

Is family history a predictor of response to tumour necrosis factor inhibitors in spondyloarthritis? A Swedish nationwide cohort study

Objective: To determine whether a family history of spondyloarthritis (SpA) is associated with clinical presentation at the start of tumour necrosis factor inhibitor (TNFi) treatment, or predictive of TNFi drug survival and treatment response in patients with SpA.Method: Family history of SpA in patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), and undifferentiated SpA (uSpA) from the Swedish Rheumatology Quality register starting a TNFi as their first biologic in 2006-2018 was assessed through national registers. Clinical characteristics at treatment start were compared by family history status. We used Cox regression to estimate hazard ratios for drug discontinuation, and analysed treatment response at 3 and 12 months with linear regression. Multiple imputation was used to address missing data.Results: We included 9608 patients. Patients with family history had an earlier age at onset and longer disease duration at TNFi treatment start, but did not differ regarding disease activity and presence of SpA manifestations. Hazard ratios for drug discontinuation were 1.08 [95% confidence interval (CI) 0.89-1.31] for AS patients with a family history of AS, 1.02 (95% CI 0.89-1.18) for PsA patients with a family history of PsA, and 1.11 (95% CI 0.85-1.45) for uSpA patients with a family history of uSpA, after adjusting for demographic, socioeconomic, and SpA-related factors. Treatment response at 3 and 12 months was similar between groups.Conclusion: Family history of SpA was not found to be associated with clinical presentation at the start of TNFi treatment, nor was it associated with drug survival or treatment response in SpA patients starting a first TNFi.

Basal Ti level in the human placenta and meconium and evidence of a materno-foetal transfer of food-grade TiO2 nanoparticles in an ex vivo placental perfusion model

Background

Titanium dioxide (TiO₂) is broadly used in common consumer goods, including as a food additive (E171 in Europe) for colouring and opacifying properties. The E171 additive contains TiO₂ nanoparticles (NPs), part of them being absorbed in the intestine and accumulated in several systemic organs. Exposure to TiO₂-NPs in rodents during pregnancy resulted in alteration of placental functions and a materno-foetal transfer of NPs, both with toxic effects on the foetus. However, no human data are available for pregnant women exposed to food-grade TiO₂-NPs and their potential transfer to the foetus. In this study, human placentae collected at term from normal pregnancies and meconium (the first stool of newborns) from unpaired mothers/children were analysed using inductively coupled plasma mass spectrometry (ICP-MS) and scanning transmission electron microscopy (STEM) coupled to energy-dispersive X-ray (EDX) spectroscopy for their titanium (Ti) contents and for analysis of TiO₂ particle deposition, respectively. Using an ex vivo placenta perfusion model, we also assessed the transplacental passage of food-grade TiO₂ particles.

Results

By ICP-MS analysis, we evidenced the presence of Ti in all placentae (basal level ranging from 0.01 to 0.48 mg/kg of tissue) and in 50% of the meconium samples (0.02–1.50 mg/kg), suggesting a materno-foetal passage of Ti. STEM-EDX observation of the placental tissues confirmed the presence of TiO₂-NPs in addition to iron (Fe), tin (Sn), aluminium (Al) and silicon (Si) as mixed or isolated particle deposits. TiO₂ particles, as well as Si, Al, Fe and zinc (Zn) particles were also recovered in the meconium. In placenta perfusion experiments, confocal imaging and SEM-EDX analysis of foetal exudate confirmed a low transfer of food-grade TiO₂ particles to the foetal side, which was barely quantifiable by ICP-MS. Diameter measurements showed that 70 to 100% of the TiO₂ particles recovered in the foetal exudate were nanosized.

Conclusions

Altogether, these results show a materno-foetal transfer of TiO₂ particles during pregnancy, with food-grade TiO₂ as a potential source for foetal exposure to NPs. These data emphasize the need for risk assessment of chronic exposure to TiO₂-NPs during pregnancy.

AB0656 IMPACT OF A FAMILY HISTORY OF SPONDYLOARTHRITIS ON TNFi DRUG SURVIVAL AND TREATMENT RESPONSE IN PATIENTS WITH ANKYLOSING SPONDYLITIS AND PSORIATIC ARTHRITIS

Background:

Spondyloarthritis (SpA) is known to have high familial aggregation, with a positive family history of SpA being a strong risk factor for disease development, in particular for ankylosing spondylitis (AS). Despite this well-known characteristic of the disease, whether family history is associated with disease prognosis and treatment outcome has been much less studied. Patient characteristics predicting response to tumour necrosis factor alpha inhibitors (TNFi) in SpA include age, sex and high disease activity, but whether family history is predictive of TNFi treatment outcomes remains unclear.

Objectives:

To assess if a family history of psoriatic arthritis (PsA), AS, or SpA in general is associated with a different drug survival and treatment response to TNFi in patients with AS and PsA.

Methods:

Patients diagnosed with AS (N=1688) or PsA (N=3216) starting their first TNFi treatment between January 2006 and December 2017 were identified in the Swedish Rheumatology Quality Register (SRQ). Disease activity measures were extracted from SRQ at treatment start and at 3 and 12 months of treatment. Data on demographics and comorbidities were available through linkage to other national registries. Multiple imputation was applied to address missing data. Family history was defined as having at least one first-degree relative diagnosed with AS, PsA or any form of SpA in the National Patient Register at start of first TNFi. Analyses were made for AS and PsA index patients separately. Kaplan-Meier plots were used to compare drug survival, and hazard ratios for drug discontinuation were estimated with Cox regression adjusting for age, sex, disease duration and baseline disease activity. The change in disease activity from baseline to 3 months of treatment, and the proportion of patients remaining on treatment at 12 months and reaching low disease activity (LDA) with BASDAI (for AS) and DAS28-CRP (for PsA), were analysed in linear regression adjusting for age, sex, disease duration and baseline disease activity.

Results:

A positive family history of AS was found in 14% of AS patients, and 12% of PsA patients had a family history of PsA. Characteristics such as age, sex and baseline disease activity were similar in AS patients with and without a family history of AS. Among PsA patients, those with a family history of PsA were to a larger extent female, with lower CRP but longer disease duration. No significant differences were seen in drug survival among patients with and without a family history of their respective disease (Figure 1), with hazard ratios for drug discontinuation of 1.03 (95% CI 0.84 to 1.27) in AS patients and 1.08 (95% CI 0.94 to 1.25) in PsA patients. Using family history of any form of SpA as exposure did not change this conclusion. The changes in disease activity at 3 months of treatment compared to baseline were similar between groups. At 12 months, 55.2% of AS patients with a family history were still on treatment and had a BASDAI corresponding to LDA, compared to 56.4% of AS patients without a family history. Among PsA patients, 38.7% of patients with a family history had reached DAS28-CRP LDA, compared to 42.6% for those without a family history. For both AS and PsA, these differences were non-significant.

Conclusion:

While family history of SpA is a strong predictor of disease development, family history was not found to affect neither TNFi drug survival nor treatment response in patients with AS and PsA in this register-based study.

Figure 1.

Disclosure of Interests:

Matilda Morin: None declared, Karin Hellgren Speakers bureau: KH has received speakers fee from Abbvie and UCB Nordic., Ulf Lindström: None declared, Thomas Frisell: None declared

Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause

Objective: This study aims to investigate the mechanism of action of pelvic floor muscle training (PFMT) for the improvement of the signs and symptoms of genitourinary syndrome of menopause (GSM) in postmenopausal women with GSM and urinary incontinence (UI).Methods: Twenty-nine women were included in the secondary analysis of a single-arm feasibility study. Using color Doppler ultrasound, the peak systolic velocity, time-averaged maximum velocity, and pulsatility index of the internal pudendal and dorsal clitoral arteries were measured at rest and after a pelvic floor muscle (PFM) contraction task. PFM function was assessed by dynamometry, and vulvovaginal tissue elasticity was measured using the Vaginal Atrophy Index.Results: PFMT significantly improved blood flow parameters in both arteries (p < 0.05) and significantly increased the speed of PFM relaxation after a contraction (p = 0.003). After the intervention, a marginally significant decrease in PFM tone was observed, as well as an increase in PFM strength (p = 0.060 and p = 0.051, respectively). Finally, improvements in skin elasticity and introitus width were observed as measured by the Vaginal Atrophy Index (p < 0.007).Conclusion: Our findings suggest that PFMT improves blood flow in vulvovaginal tissues, PFM relaxation capacity, and vulvovaginal tissue elasticity in postmenopausal women with GSM and UI.

Lats1 and Lats2 are required for the maintenance of multipotency in the Müllerian duct mesenchyme

WNT signaling plays essential roles in the development and function of the female reproductive tract. Although crosstalk with the Hippo pathway is a key regulator of WNT signaling, whether Hippo itself plays a role in female reproductive biology remains largely unknown. Here, we show that conditional deletion of the key Hippo kinases Lats1 and Lats2 in mouse Müllerian duct mesenchyme cells caused them to adopt the myofibroblast cell fate, resulting in profound reproductive tract developmental defects and sterility. Myofibroblast differentiation was attributed to increased YAP and TAZ expression (but not to altered WNT signaling), leading to the direct transcriptional upregulation of Ctgf and the activation of the myofibroblast genetic program. Müllerian duct mesenchyme cells also became myofibroblasts in male mutant embryos, which impeded the development of the male reproductive tract and resulted in cryptorchidism. The inactivation of Lats1/2 in differentiated uterine stromal cells in vitro did not compromise their ability to decidualize, suggesting that Hippo is dispensable during implantation. We conclude that Hippo signaling is required to suppress the myofibroblast genetic program and maintain multipotency in Müllerian mesenchyme cells.

Lats1 and Lats2 are required for ovarian granulosa cell fate maintenance

Recent reports suggest that the Hippo signaling pathway influences ovarian follicle development; however, its exact roles remain unknown. Here, we examined the ovarian functions of the Hippo kinases large tumor suppressors (LATS)1 and 2, which serve to inactivate the transcriptional coactivators Yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ). Inactivation of Lats1/2 in murine granulosa cells either in vitro or in vivo resulted in a loss of granulosa cell morphology, function, and gene expression. Mutant cells further underwent changes in structure and gene expression suggestive of epithelial-to-mesenchymal transition and transdifferentiation into multiple lineages. In vivo, granulosa cell-specific loss of Lats1/2 caused the ovarian parenchyma to be mostly replaced by bone tissue and seminiferous tubule-like structures. Transdifferentiation into Sertoli-like cells and osteoblasts was attributed in part to the increased recruitment of YAP and TAZ to the promoters of sex-determining region Y box 9 and bone γ-carboxyglutamate protein, key mediators of male sex determination and osteogenesis, respectively. Together, these results demonstrate for the first time a critical role for Lats1/2 in the maintenance of the granulosa cell genetic program and further highlight the remarkable plasticity of granulosa cells.-Tsoi, M., Morin, M., Rico, C., Johnson, R. L., Paquet, M., Gévry, N., Boerboom, D. Lats1 and Lats2 are required for ovarian granulosa cell fate maintenance.

Pertinence des hospitalisations posturgences de moins de 24 heures en dehors des unités d’hospitalisation de courte durée

Objectifs : L’overcrowding — ou surcharge — des services d’urgence hospitaliers est un problème de santé international, qui impacte la qualité des soins et la durée moyenne de séjour (DMS). Cette surpopulation est liée majoritairement au manque d’accès aux lits d’hospitalisation. Notre objectif principal était d’étudier la pertinence des admissions hors unité d’hospitalisation de courte durée (UHCD) ayant une DMS inférieure à 24 heures.

Méthode : Notre étude observationnelle descriptive rétrospective sur l’année 2016 concernait les patients hospitalisés hors UHCD de DMS de moins de 24 heures. La grille AEPf (Appropriateness Evaluation Protocole adaptée en France par la Haute Autorité de santé) utilisée permet de les séparer en trois groupes : hospitalisations pertinentes (gravité clinique ou soins), non pertinentes mais justifiées (organisationnelles), non pertinentes et non justifiées (hébergement). Les comparaisons étaient réalisées par test de Chi2.

Résultats : Sur 1 006 admissions, selon la grille AEPf, 786 (78 %) sont pertinentes (sévérité clinique, actes diagnostiques ou thérapeutiques, surveillance, etc.). Pour les 220 hospitalisations non pertinentes, 210 (95 %) sont justifiées par des contraintes organisationnelles (avis spécialisés, actes d’imagerie, procédures). Quatre-vingt-dix-neuf (47 %) d’entre eux auraient pu rentrer à domicile si l’organisation des soins l’avait permis. Pour 83 (39 %) de ces hospitalisations non pertinentes, la structure la plus adaptée reste l’hôpital. Seulement dix (1 %) de ces 1 006 hospitalisations sont non pertinentes et non justifiées. Le service d’hospitalisation était adéquat pour 805 patients (80 %).

Conclusion : Le taux d’hospitalisations pertinentes ou justifiées, de DMS de moins de 24 heures, depuis notre service est élevé. Il existerait quelques leviers organisationnels permettant d’éviter le recours à une hospitalisation.

[Targeted screening for pre-eclampsia in the first trimester of pregnancy at Toulouse University Hospital]

GOALS

Preeclampsia (PE) is a leading cause of maternal and neonatal morbidity and mortality. Early treatment by aspirin has been shown to significantly reduce PE risk before 37weeks supporting the implementation of first-trimester screening.

SUBJECTS AND METHODS

A targeted screening was recently implemented at Toulouse University Hospital for women in their first pregnancy or those with personal or familial history of PE. It uses Fetal Medicine Foundation (FMF) algorithm that combines maternal characteristics, clinical, biophysical and biochemical (PAPP-A, Pregnancy Associated Plasma Protein-A, and PlGF, Placental Growth Factor) data. We describe this first population of pregnant women and compare our results with those of a mini-test that excludes PlGF and biophysical data.

RESULTS

Between October 2016 and September 2017, 500women have benefited from this screening. In such targeted population, we identified 3,6 % (n=18) of women at high risk to develop PE before 34weeks and 9,6 % (n=48) of women at high risk to develop PE between 34 and 37weeks. When we recalculated the risk using the mini-test, only 10women (56 %) were identified at high risk of early PE.

CONCLUSION

For the first time in France, we report the result of a targeted screening of PE during the first trimester using the FMF algorithm. We describe the screened population and show that it is more efficient than the mini-test.

The photochemical alkylation and reduction of heteroarenes

The functionalization of heteroarenes has been integral to the structural diversification of medicinally active molecules such as quinolines, pyridines, and phenanthridines. Electron-deficient heteroarenes are electronically compatible to react with relatively nucleophilic free radicals such as hydroxyalkyl. However, the radical functionalization of such heteroarenes has been marked by the use of transition-metal catalyzed processes that require initiators and stoichiometric oxidants. Herein, we describe the photochemical alkylation of quinolines, pyridines and phenanthridines, where through direct excitation of the protonated heterocycle, alcohols and ethers, such as methanol and THF, can serve as alkylating agents. We also report the discovery of a photochemical reduction of these heteroarenes using only iPrOH and HCl. Mechanistic studies to elucidate the underlying mechanism of these transformations, and preliminary results on catalytic methylations are also reported.

Effect of microbial activity on penetrometer resistance and elastic modulus of soil at different temperatures

We explore the effect of microbial activity stimulated by root exudates on the penetrometer resistance of soil and its elastic modulus. This is important because it is a measure of the mechanical strength of soil and it correlates closely with the rate of elongation of roots. A sandy soil was incubated with a synthetic root exudate at different temperatures, for different lengths of time and with selective suppression of either fungi or bacteria. The shape of the temperature response of penetrometer resistance in soil incubated with synthetic exudate was typical of a poikilothermic temperature response. Both penetrometer resistance and small strain shear modulus had maximum values between 25 and 30°C. At temperatures of 20°C and less, there was little effect of incubation with synthetic root exudate on the small strain shear modulus, although penetrometer resistance did increase with temperature over this range (4-20°C). This suggests that in this temperature range the increase in penetrometer resistance was related to a greater resistance to plastic deformation. At higher temperatures (> 25°C) penetrometer resistance decreased. Analysis of the DNA sequence data showed that at 25°C the number of Streptomyces (Gram-positive bacteria) increased, but selective suppression of either fungi or bacteria suggested that fungi have the greater role with respect to penetrometer resistance.

HIGHLIGHTS

Effect of microbial activity stimulated by synthetic root exudates on the mechanical properties.We compared penetrometer measurements and estimates of elastic modulus with microbial community.Penetrometer resistance of soil showed a poikilothermic temperature response.Penetrometer resistance might be affected more by fungi than bacteria.

Polynuclear gold(i) complexes in photoredox catalysis: understanding their reactivity through characterization and kinetic analysis

The light mediated reduction of unactivated carbon–halogen bonds using polynuclear gold(i) complexes provides a mild and temporally controlled route to the generation of C–H, and C–C bonds.

Prenasal thickness to nasal bone length ratio: effectiveness as a second or third trimester marker for Down syndrome

OBJECTIVE

To assess the value of the prenasal thickness to nasal bone length ratio (PT/NBL) for detecting trisomy 21 (T21) after the first trimester.

METHOD

Two examiners blinded to fetal T21 status retrospectively measured prenasal thickness (PT) and nasal bone length (NBL) of T21 and control fetuses at 15-36 weeks' gestational age on two-dimensional images from all T21-screening ultrasounds from November 2010 to April 2013. ROC curve analysis and its diagnostic values determined the best cut-off value for the ratio. Interobserver reproducibility was assessed.

RESULTS

Good quality ultrasound profile images were available for 26 fetuses with T21 compared to 91 normal fetuses. The median PT/NBL ratio was 1.28 for T21 and 0.73 for control fetuses (p<0.0001). The PT/NBL ratio performed significantly better (AUC 0.99; 95%CI 0.97-1) than either PT (0.82; 0.73-0.91) or NBL (0.91; 0.85-0.98). The optimal PT/NBL ratio cut-off was 0.98, with a sensitivity of 88.5% [76.2-100%] and a specificity of 100%. Interobserver variability was low.

CONCLUSION

The PT/NBL ratio is a strong marker for detecting T21 in the second and third trimesters, significantly more effective than either indicator alone.

Novel exons in the tbx5 gene locus generate protein isoforms with distinct expression domains and function

TBX5 is the gene mutated in Holt-Oram syndrome, an autosomal dominant disorder with complex heart and limb deformities. Its protein product is a member of the T-box family of transcription factors and an evolutionarily conserved dosage-sensitive regulator of heart and limb development. Understanding TBX5 regulation is therefore of paramount importance. Here we uncover the existence of novel exons and provide evidence that TBX5 activity may be extensively regulated through alternative splicing to produce protein isoforms with differing N- and C-terminal domains. These isoforms are also present in human heart, indicative of an evolutionarily conserved regulatory mechanism. The newly identified isoforms have different transcriptional properties and can antagonize TBX5a target gene activation. Droplet Digital PCR as well as immunohistochemistry with isoform-specific antibodies reveal differential as well as overlapping expression domains. In particular, we find that the predominant isoform in skeletal myoblasts is Tbx5c, and we show that it is dramatically up-regulated in differentiating myotubes and is essential for myotube formation. Mechanistically, TBX5c antagonizes TBX5a activation of pro-proliferative signals such as IGF-1, FGF-10, and BMP4. The results provide new insight into Tbx5 regulation and function that will further our understanding of its role in health and disease. The finding of new exons in the Tbx5 locus may also be relevant to mutational screening especially in the 30% of Holt-Oram syndrome patients with no mutations in the known TBX5a exons.

Comparison of experimental and calculated calibration coefficients for a high sensitivity ionization chamber

The response of a Vacutec 70129 ionization chamber was calculated using the PENELOPE-2008 Monte Carlo code and compared to experimental data. The filling gas mixture composition and its pressure have been determined using IC simulated response adjustment to experimental results. The Monte Carlo simulation revealed a physical effect in the detector response to photons due to the presence of xenon in the chamber. A very good agreement is found between calculated and experimental calibration coefficients for 17 radionuclides.

[Antenatal screening for HIV: knowledge, attitudes, beliefs and practices of pregnant women. Analysis of current practices and the impact of setting up an informative brochure]

OBJECTIVES

To assess the impact of an information leaflet on the behavior and knowledge of pregnant women about the risks of HIV infection during pregnancy.

PATIENTS AND METHODS

Comparative prospective study conducted in two phases from March 1 to September 30, 2007 on patients presenting for the first time in antenatal care at the Maternity Hospital of Tours (n=539). During the first phase, only a self-questionnaire was given during the second an informative brochure has been attached to the questionnaire.

RESULTS

Currently 25.1% of pregnant women have not made a test during their pregnancy. This rate decreases to 12.9% when the test is routinely offered. It falls to 8.2% with the introduction of an informative brochure. The test was imposed in 28.7% of patients. Some risks of transmission of HIV, including those specific to pregnancy, are undervalued. A negative test before the pregnancy is the main reason for refusal of antenatal screening. A high level of education was the only risk factor identified for refusal. They are better informed as shown by the higher rate of correct answers about the risks of HIV transmission and antenatal screening. We hypothesize that the women who pursued graduate studies evaluate the risk of infection before accepting or refusing the test.

CONCLUSION

The study shows that the distribution of an informative brochure on advanced prenatal screening, increased the number of women performing the test and improved their knowledge about risks of transmission, especially from mother to the child.

Health-related quality of life and patient–provider relationships in HIV-infected patients during the first three years after starting PI-containing antiretroviral treatment

The aim of this study was to investigate factors associated with better health-related quality of life (HRQL) during the first three years after starting PI-containing antiretroviral treatment. Clinical, social and behavioural data from the APROCO cohort enabled us to analyze simultaneously the association between HRQL and patients' relationships with their health care providers. A self-administered questionnaire collected information about HRQL (MOS-SF36) and relationships with medical staff (trust and satisfaction with information). Two aggregate scores, the physical (PCS) and mental (MCS) component summaries (adjusted for baseline HRQL), were used as dependent variables in the linear regressions to identify factors associated with HRQL. We had complete longitudinal data for 360 of the 611 patients followed through M36. Factors independently associated with a high MCS were (male) gender, no more than one change in treatment, (few) self-reported symptoms and trust in the physician. Factors independently associated with high PCS levels were employment, no children, (few) self-reported symptoms and satisfaction with the information and explanations provided by the medical staff. These results underline the need to improve patient-provider relationships to optimize long-term HRQL. Socio-behavioural interventions should focus on this goal.

WITHDRAWN: Low level laser therapy (Classes III) for treating osteoarthritis

BACKGROUND

Osteoarthritis (OA) affects a large portion of the population. Low Level Laser Therapy (LLLT) is a light source that generates extremely pure light, of a single wavelength. The effect is not thermal, but rather related to photochemical reactions in the cells. LLLT was introduced as an alternative non-invasive treatment for OA about 30 years ago, but its effectiveness has to be examined more closely, especially in the treatment of OA.

OBJECTIVES

To assess the effectiveness of class III LLLT for osteoarthritis when irradiation is directed at the osteoarthritic joint capsule.

SEARCH STRATEGY

Searches were conducted in the following databases: MEDLINE, EMBASE, the Cochrane Musculoskeletal registry, the Rehabilitation and Related Therapies field registry and the Cochrane Controlled Trials Register up to May, 2005.

SELECTION CRITERIA

Following an a prior protocol, only controlled clinical trials of LLLT for the treatment of patients with a clinical diagnosis of OA were eligible. Abstracts lacking data were excluded unless further data could be obtained from the authors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials and extracted data using predetermined forms. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed; in which case, a random effects model was used. Results were analyzed as weighted mean differences (WMD) with 95% confidence intervals (CI), whereas the difference between the treatment and control groups was weighted by the inverse of the variance. Standardized mean differences (SMD) were calculated by dividing the difference between treatment and control by the baseline variance, and were used in the analysis of pain because different scales were used to measure it. Dichotomous outcomes were analyzed with relative risk (RR).

MAIN RESULTS

Eight trials were included with 233 patients randomized to laser and 172 patients to placebo laser. Treatment duration ranged from two to six weeks. Pain was assessed in seven trials. When the results were pooled from different pain scales used in these seven trials, a statistically significant difference in favor of laser treatment was found with a SMD of -0.28 (95% CI: -0.48 to -0.09). One of these studies also measured pain during movement and found a statistically significant difference in favor of laser treatment with a WMD of -1.16 (95% CI: -2.02 to -0.30). Two studies found significant results for increased knee range of motion. Two others studies found a statistically significant difference in favor of laser treatment for patient-assessed global disease activity with laser compared to placebo (RR 1.70, 95%CI: 1.1. to 2.63). One trial evaluated the effectiveness of laser treatment in temporomandibular joint OA and found a statistically significant difference (WMD 38.69, 95% CI: 29.25 to 48.13) using the change in VAS score to measure pain. One study found a statistically significant difference in favor of laser treatment at the end of treatment and at 4 and 8 weeks post-treatment for morning stiffness. Other outcome measures of joint tenderness and strength did not yield significant differences.

AUTHORS' CONCLUSIONS

Five trials included in this review showed a statistically significant difference favoring laser treatment when compared to placebo for at least one outcome measure. Three trials did not report beneficial effects. The varying results of these trials may be due to the method of laser application and/or other features of LLLT application. Clinicians and researchers should consistently report the characteristics of LLLT devices and application techniques used. New trials on LLLT should make use of standardized, validated outcomes. There is clearly a need to investigate the effects of different dosages on LLLT effectiveness for OA in future randomized, controlled clinical trials. Also, more studies should be done to investigate the anti-inflammatory action of laser as well as the appropriate parameters needed to achieve an anti-inflammatory effect.

Reliability of speed of contraction and endurance dynamometric measurements of the pelvic floor musculature in stress incontinent parous women

AIMS

To evaluate the test-retest reliability of dynamometric measurements of the pelvic floor muscles (PFM) during speed and endurance tests.

METHODS

Nineteen parous women suffering from stress urinary incontinence (SUI) participated in the study. Two PFM evaluation sessions were conducted using the dynamometric speculum. For the speed test, the women were instructed to contract maximally and relax as quickly as possible during a 15-s test period. The speed of contraction was quantified by the rate of force development of the first contraction and the number of contractions performed. The maximal strength value attained during the speed test was also extracted from the curves. For the endurance test, the subjects were asked to maintain a maximal contraction for 90 s. The normalized area under the force curve was utilized as the endurance parameter. The reliability of the data was evaluated using the generalizability theory. Two reliability estimates were calculated, the dependability indices (Phi) and the standard error of measurement (SEM), for one measurement session involving one trial.

RESULTS

The indices of dependability obtained indicate that the reliability of the speed of contraction and endurance parameters are good (Phi=0.79-0.92). The corresponding SEMs were 1.39 N/s, 1 contraction, 1.00 N, and 298%*s for the rate of force development, number of contractions, maximal strength and normalized area, respectively.

CONCLUSION

This study indicates that the speed of contraction and endurance parameters possess good test-retest reliability. The inclusion of these parameters in the PFM assessment is therefore highly recommended for assessing changes in PFM in incontinent women.

Cytomegalovirus Infection in Kidney Transplant Recipients: Evolution of Approach Through Three Eras

Cytomegalovirus (CMV) prophylaxis is recommended for high-risk patients, while preemptive therapy is considered acceptable for patients at moderate/low risk. After reviewing kidney transplant patients from 1992-1995 and 1996-1999, we decided to replace prophylaxis by preemptive therapy. Herein we have presented our data. From 1996-1999 we treated 129 patients with ganciclovir prophylaxis for 3 months if D+/R- or if they received depleting antibodies. The incidence of CMV was 13.2% versus 3.7% in the 1992-1995 cohort. The increase was associated with mycophenolate mofetil (MMF) use (P = .002). Forty-two percent of the D+/R- developed an infection with 89% of bouts occurring in the first month after cessation of prophylaxis. From 2002-2004, we never gave prophylaxis to 129 patients except when they received thymoglobulin. High-risk D+/R- patients were monitored by polymerase chain reaction (PCR) CMV for 3 months. The incidence of CMV was 17.1% with 54% of the D+/R- developing CMV. CMV infection occurred mostly during the first trimester posttransplantation. Creatinine at 1 year posttransplantation was worse in the presence of CMV infection (154.3 mumol/L-1.75 mg % versus 130.2 mumol/L-1.47 mg %, P = .03). Time to cure CMV infection was longer when MMF was discontinued: 36.7 days versus 69.9 days (P = .026). Our results indicated that CMV incidence is increasing: 3.7% (1992-1995) --> 13.2% (1996-1999) -->17.1% (2002-2004) and that it impairs 1 year graft function. Recovery was faster among patients still receiving MMF compared with those discontinuing MMF. Although MMF inhibits synthesis of anti-CMV IgM, it increases the anti-herpes virus effect of ganciclovir and may protect against chronic allograft nephropathy. Based on our experience, we plan to reintroduce prophylaxis in high-risk patients and to continue MMF when treating CMV infection.

Qualité de vie et syndrome lipodystrophique chez les patients infectés par le VIH

AIM OF THE STUDY

The aim of this work is to show to what extent a psychosocial evaluation can lead bring to comprehension of the subjectivity of Quality of Life (QoL) among HIV-infected patients. Evaluation of QoL makes it possible to understand the link between the therapeutic effectiveness and the subjective evaluation of the treatment, but also to estimate more precisely how people live and take their treatment in the context of HIV infection.

METHOD

This work confronts the variation of QoL with the variation of several social and psychosocial parameters identified as of the components of the system, which is the subjective evaluation, and more precisely to a specific side effect of Highly Active AntiRetroviral Therapies (HAART): lipodystrophy syndrome that consists in body fat redistribution. This side effect could consist in an accumulation of body fat, or a loss of body fat or a combination of both symptoms. The analysis was made on the data from APROCO-COPILOTE cohort composed of HIV-infected patients initiating HAART.

RESULTS

Among a sample of 706 patients follow-up for three years and with available QoL data, we identified the variations of QoL according to the variation of this specific side effect and according to gender. Results show that lipodystrophy syndrome has a determinant impact on QoL different among male and female patients. Adjusted on clinical and socio-demographic characteristics, impaired women's QoL is associated with accumulation of body fat and impaired men's QoL is associated with loss of body fat.

CONCLUSION

These results underline the role of body image on subjective evaluation of QoL. The analysis of empirical data made it possible to highlight the social implication of the evaluation of QoL from the role of the social support, patient-provider relationship and the social context.

[Tricuspid valve endocarditis after umbilical piercing]

We report a case of a 16 years old girl who was affected by a septicemia with a septic arthritis of the wrist and a tricuspid endocarditis, 3 months after a navel piercing. The blood culture and the liquid of puncture showed Staphylococcus aureus. A treatment prolonged by intravenous antibiotics permitted a progressive regression of endocarditis, without surgical intervention. The piercing must be achieved in conditions of strict asepsis, it must be advised against to the patient with congenital heart disease. In case of realization of a piercing an antibiotic prophylaxis must be achieved, while using preference pristinamycin in case of cutaneous piercing and amoxicillin in case of mucous piercing. Indeed, infective endocarditis after body piercing are more often brought back with a generally sterner evolution that in our observation.

Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) affects a large proportion of the population. Low Level Laser Therapy (LLLT) was introduced as an alternative non-invasive treatment for RA about ten years ago. LLLT is a light source that generates extremely pure light, of a single wavelength. The effect is not thermal, but rather related to photochemical reactions in the cells. The effectiveness of LLLT for rheumatoid arthritis is still controversial. This review is an update of the original review published in October 1998.

OBJECTIVES

To assess the effectiveness of LLLT in the treatment of RA.

SEARCH STRATEGY

We initially searched MEDLINE, EMBASE (from 1998), the registries of the Cochrane Musculoskeletal Group and the field of Rehabilitation and Related Therapies as well as the Cochrane Central Register of Controlled Trials (CENTRAL) up to June 2001. This search has now been updated to include articles published up to June 2005.

SELECTION CRITERIA

Following an a priori protocol, only randomized controlled trials of LLLT for the treatment of patients with a clinical diagnosis of RA were eligible. Abstracts were excluded unless further data could be obtained from the authors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, then extracted data and assessed quality using predetermined forms. Heterogeneity was tested using chi-squared. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results were analyzed as weighted mean differences (WMD) with 95% confidence intervals (CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Dichotomous outcomes were analyzed with relative risks.

MAIN RESULTS

A total of 222 patients were included in the five placebo-controlled trials, with 130 randomized to laser therapy. Relative to a separate control group, LLLT reduced pain by 1.10 points (95% CI: 1.82, 0.39) on visual analogue scale relative to placebo, reduced morning stiffness duration by 27.5 minutes (95%CI: 2.9 to 52 minutes) and increased tip to palm flexibility by 1.3 cm (95% CI: 0.8 to 1.7). Other outcomes such as functional assessment, range of motion and local swelling did not differ between groups. There were no significant differences between subgroups based on LLLT dosage, wavelength, site of application or treatment length. For RA, relative to a control group using the opposite hand, there was no difference observed between the control and treatment hand for morning stiffness duration, and also no significant improvement in pain relief RR 13.00 (95% CI: 0.79 to 214.06). However, only one study was included as using the contralateral limb as control. .

AUTHORS' CONCLUSIONS

LLLT could be considered for short-term treatment for relief of pain and morning stiffness for RA patients, particularly since it has few side-effects. Clinicians and researchers should consistently report the characteristics of the LLLT device and the application techniques used. New trials on LLLT should make use of standardized, validated outcomes. Despite some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected by four important factors: wavelength, treatment duration of LLLT, dosage and site of application over nerves instead of joints. There is clearly a need to investigate the effects of these factors on LLLT effectiveness for RA in randomized controlled clinical trials.

Tumour necrosis factor-α up-regulates macrophage migration inhibitory factor expression in endometrial stromal cells via the nuclear transcription factor NF-κB

BACKGROUND

A series of controlled changes including proliferation, secretion and menstrual shedding occur in the human endometrium during every normal menstrual cycle. Macrophage migration inhibitory factor (MIF), a multifunctional cytokine with numerous proinflammatory, immunomodulatory and angiogenic properties, appears to be expressed in the human endometrium and to follow a regulated cycle phase-dependent expression, but the mechanisms underlying endometrial MIF expression remain to be fully elucidated.

METHODS AND RESULTS

Results from enzyme-linked immunosorbent assay (ELISA) demonstrated a significant dose- and time-dependent increase in MIF secretion by human endometrial cells in response to tumour necrosis factor-alpha (TNF-alpha) (0.1-100 ng/ml). This increase was also observed at the mRNA level as shown by reverse transcription (RT)-PCR. Curcumin (10(-8) mol/l), a known nuclear factor (NF)-kappaB inhibitor, inhibited the TNF-alpha-induced pIkappaB phosphorylation as shown by western blotting, NF-kappaB translocation into the nucleus as shown by electrophoretic mobility shift assay, and MIF synthesis and secretion as measured by ELISA and RT-PCR. The expression of a dominant-negative NF-kappaB inhibitor (IkappaB) significantly decreased the TNF-alpha-induced MIF promoter activity as analysed by transient cell transfection.

CONCLUSIONS

These results indicate clearly that TNF-alpha up-regulates the expression of MIF in endometrial stromal cells. This took place possibly through NF-kappaB activation, and may play an important role in the physiology of the human endometrium.

Stimulation of Macrophage Migration Inhibitory Factor Expression in Endometrial Stromal Cells by Interleukin 1, beta Involving the Nuclear Transcription Factor NFκB1

Endometriosis, the ectopic development of endometrial tissue, is, particularly in peritoneal endometriosis, believed to result from tubal reflux of menstrual tissue. The release of cytokines and growth factors by refluxed endometrial cells in response to peritoneal inflammatory stimuli may enhance the capability of endometrial cells to implant and grow into the peritoneal host tissue. Herein we report that interleukin 1 (IL1), a major proinflammatory cytokine that is overproduced by endometriosis women-derived peritoneal macrophages and found in elevated concentrations in the peritoneal fluid of patients with endometriosis, stimulates the synthesis and the secretion of macrophage migration inhibitory factor (MIF) by human endometrial stromal cells. IL1B (0.1-100 ng/ml) exerted dose- and time-dependent effects of MIF protein secretion and mRNA synthesis, as shown by ELISA and reverse transcription-polymerase chain reaction, respectively. IL1B appeared to induce MIF gene transcription via the kappaB nuclear transcription factor (NFkappaB), as shown by electrophoretic mobility shift assay and Western blot analysis of IkappaB phosphorylation. Curcumin (10(-8) M), which is known for inhibiting NFkappaB activation, inhibited IL1B-induced MIF secretion as well as NFkappaB nuclear translocation and DNA binding. Taken together, these findings clearly show that IL1B up-regulates the expression of MIF in endometrial stromal cells in vitro and acts via NFkappaB. This may play an important role in the physiology of the human endometrium and the pathophysiology of endometriosis considering the immunomodulatory properties of MIF as well as its role in cell growth, angiogenesis and tissue remodeling.

Information-seeking behaviour and psycho-social interactions during the genetic testing process

OBJECTIVES

The first aim of this study was to investigate the information-seeking behaviour (ISB) of women attending cancer genetic consultations at which the possibility of BRCA testing is considered. We focused here specifically on ISB apart from the cancer genetic consultation, i.e. on what complementary sources of information about genetic testing were consulted and what factors were involved in this behaviour. The second aim was to study the role of the social network used by the patients to collect various opinions on which to base their decisions about being tested.

METHODS

A prospective cohort study (2000-2002) was therefore carried out on all women attending a single cancer genetic clinic in France after a BRCA1/2 analysis had been proposed. Closed questionnaires were administered before and after the second cancer genetic consultation. The purpose of this consultation was to confirm the patient's decision to be tested.

RESULTS

Results were analysed in 108 subjects (mean age 47 years, SD 11 years; 74% affected by breast/ovarian cancer). Prior to the 2nd consultation, 35.2% of the women had actively looked for information about BRCA1/2 testing, as compared to 25.0% afterwards. After multivariate adjustment by logistic regression, the pre-consultation ISB was found to be associated with greater satisfaction with the information about the psycho-social consequences of genetic testing [adjusted odds ratio (ORadj) 1.03, 95% confidence interval (CI) 1.01-1.06] (scale from 0 to 100) and about the certainty of being a gene carrier (ORadj 3.04, 95% CI 1.16-7.98). Those who actively looked for complementary information were also more often accompanied at the consultation by a family member (ORadj 4.82, 95% CI 1.85-12.56). The other variables tested (depression, coping, socio-demographic and medical characteristics) were not significant (p > 0.05). The role of the social network in the decision making process was perceived as being less helpful when the persons consulted tended to have neutral or unfavourable opinions about genetic testing.

CONCLUSIONS

Few women actively sought complementary information about BRCA genetic testing in addition to the cancer genetic consultation. Those who did so differed from the others in terms of their social network and their satisfaction with the consultation. The cancer geneticist is the key actor in women's decision making about genetic testing.

[Could we trust clinical statistics from data banks of the National Health Service (NHS)?]

Can we accept the statistics provided by the Ministry of Health, which uses large computerized databases? Through MEDECHO, the Ministry provides to hospital managers, reports cards on different interventions. These reports compare different hospitals performances. Surgeons involved in the process hesitate to accept this information. Using the results of the performance of cholecystectomy provided by this system (Gr: A), we compared the same cohort (1 April-31 December 1996 = 346 cholecystectomies) but using specific criteria determined as relevant to our surgeons (Gr: B). The rate of complication gives a crude aftermath and no attempt was used to adjust for severity. The MEDECHO data are adjusted for severity. The global rate of complications is similar Gr: A 11%, Gr: B 12%. Major complication rate for pulmonary embolism, hemorrhage and biliary duct trauma are identical. The rate of surgical site infection is higher in Gr: B (5% vs. 2%). The patients are seen in the outpatient clinic and these observations are not included by the analytical system unless the patient has been readmitted. For our hospital, the MEDECHO data are valid and reliable even though they underestimated the wound infection rate. These results could be explained by an appropriate interpretation of the code system by the archivist and by the surgeons' precision to complete the summary sheet of hospitalization. We can conclude that these data can be used as a means to evaluate the quality of outcome of a surgical service.

Low level laser therapy (Classes I, II and III) for treating osteoarthritis

BACKGROUND

Osteoarthritis (OA) affects a large proportion of the population. Low Level Laser Therapy (LLLT) is a light source that generates extremely pure light, of a single wavelength. The effect is not thermal, but rather related to photochemical reactions in the cells. LLLT was introduced as an alternative non-invasive treatment for OA about 20 years ago, but its effectiveness is still controversial.

OBJECTIVES

To assess the effectiveness of LLLT in the treatment of OA.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, the Cochrane Musculoskeletal registry, the registry of the Rehabilitation and Related Therapies field and the Cochrane Controlled Trials Register up to January 30, 2004.

SELECTION CRITERIA

Following an a priori protocol, only controlled clinical trials of LLLT for the treatment of patients with a clinical diagnosis of OA were eligible. Abstracts were excluded unless further data could be obtained from the authors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials and abstracted data using predetermined forms. Heterogeneity was tested with Cochran's Q test. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results were analyzed as weighted mean differences (WMD) with 95% confidence intervals (CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences (SMD) were calculated by dividing the difference between treated and control by the baseline variance. SMD were used when different scales were used to measure the same concept (e.g. pain). Dichotomous outcomes were analyzed with odds ratios.

MAIN RESULTS

Seven trials were included, with 184 patients randomized to laser, 161 patients to placebo laser. Treatment duration ranged from 4 to 12 weeks. Pain was assessed by four trials. The pooled estimate (random effects) of three trials showed no effect on pain measured using a scale (SMD: -0.2, 95% CI: -1.0, +0.6), but there was statistically significant heterogeneity (p>0,05). Three of the trials showed no effect and two demonstrated very beneficial effects with laser. In another trial, with no scale-based pain outcome, significantly more patients reported pain relief (yes/no) with laser with an odds ratio of 0.05, (95% CI: 0.0 to 1.56). Only one study found significant results for increased knee range of motion (WMD: -10.62 degrees, 95% CI: -14.07,-7.17). Other outcomes of joint tenderness and strength were not significant. Lower dosage of LLLT was found as effective than higher dosage for reducing pain and improving knee range of motion.

REVIEWERS' CONCLUSIONS

For OA, the results are conflicting in different studies and may depend on the method of application and other features of the LLLT application. Clinicians and researchers should consistently report the characteristics of the LLLT device and the application techniques used. New trials on LLLT should make use of standardized, validated outcomes. Despite some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected by four important factors: wavelength, treatment duration of LLLT, dosage and site of application over nerves instead of joints. There is clearly a need to investigate the effects of these factors on LLLT effectiveness for OA in randomized controlled clinical trials.

Reliability of dynamometric measurements of the pelvic floor musculature

AIMS

The objective of this study was to evaluate the reliability of strength and endurance dynamometric measurements of the pelvic floor musculature (PFM).

MATERIALS AND METHODS

Twenty-nine female participants, primipara and multipara, aged between 27 and 42 and presenting different severity levels of stress urinary incontinence (SUI), participated in the study. They were evaluated using a new pelvic floor dynamometer, an instrumented speculum based on strain-gauged technology. Strength and endurance evaluations were repeated in three successive sessions, each followed by a 4-week period. Maximal strength values were recorded at three dynamometer openings (5 mm, 1 cm, and 1.5 cm between the two dynamometer branches). The maximal rate of force development (MRFD) and percentage of strength lost after 10 and 60 sec were computed from the endurance trial. The generalizability theory was applied to estimate the reliability of the PFM measurements. The reliability was quantified by the index of dependability and the corresponding standard error of measurement (SEM) for one and the mean of three trials performed in one session for the strength measurements and one trial completed in one session for the MRFD and endurance measurements.

RESULTS

For the maximal strength measurements, the largest coefficient of dependability was obtained at the 1 cm opening, with a value of 0.88. The corresponding SEM reached 1.49 N. The reliability of the MRFD was also very good with a coefficient of 0.86 and an SEM of 0.056 N/sec. The reliability was minimally affected by the number of trials. The strength loss measurements at 10 and 60 sec were unreliable, with coefficient values of 0.38 and 0.10, respectively.

CONCLUSIONS

The results of the present study indicate that the reliability of the strength parameters (maximal strength and MRTD measurements) was high enough for future investigations on pelvic floor rehabilitation programs.

Pelvic floor maximal strength using vaginal digital assessment compared to dynamometric measurements

AIM

To compare vaginal digital assessment with dynamometric measurements for determining the maximal strength of the pelvic floor muscles (PFM).

MATERIALS AND METHODS

Eighty-nine women aged between 21 and 44 participated in the study. An experienced physiotherapist evaluated the maximal strength of the PFM of these women using the modified Oxford grading system (six categories, range 0-5) and dynamometric measurements. The mean maximal forces obtained for all women with the instrumented speculum for each category of digital assessment were compared using ANOVAs. Spearman's rho coefficients were calculated to assess the correlation between the dynamometric and the digital assessments.

RESULTS

According to their symptoms and pad test results, 30 women were continent and 59 had stress urinary incontinence (SUI). Based on dynamometric measurements, important overlaps were observed between each category of digital assessment. The ANOVAs indicated that force values differ across categories (F = 10.08; P < 0.001), although contrast analyses revealed no differences in the mean maximal forces between adjacent digital-assessment categories (1-2, 2-3, 3-4, 4-5). Mean force values differed significantly only between non-adjacent levels in digital assessment, for example, between 1 and 3; 1 and 4; 1 and 5; 2 and 4; 2 and 5 (P < 0.05). Significant correlations were found between the two measurements with coefficients of r = 0.727, r = 0.450, and r = 0.564 for continent, incontinent, and all women, respectively (P < 0.01).

CONCLUSIONS

Even if the dynamometric mean forces of the PFM increased across subsequent categories of digital assessment, the force values between two adjacent categories do not differ. This limitation of digital assessment should be considered by clinicians and researchers when choosing treatment orientation and evaluating treatment outcomes.

Increased expression and localization of the RNA-binding protein HuD and GAP-43 mRNA to cytoplasmic granules in DRG neurons during nerve regeneration

The neuronal-specific RNA-binding protein, HuD, binds to a U-rich regulatory element of the 3' untranslated region (3' UTR) of the GAP-43 mRNA and delays the onset of its degradation. We have recently shown that overexpression of HuD in embryonic rat cortical cells accelerated the time course of normal neurite outgrowth and resulted in a twofold increase in GAP-43 mRNA levels. Given this evidence, we sought to investigate the involvement of HuD during nerve regeneration. It is known that HuD protein and GAP-43 mRNA are expressed in the dorsal root ganglia (DRG) of adult rat and that GAP-43 is upregulated in DRG neurons during regeneration. In this study, we examined the expression patterns and levels of HuD and GAP-43 mRNA in DRG neurons following sciatic nerve injury using a combination of in situ hybridization, immunocytochemistry, and quantitative RT-PCR. GAP-43 and HuD expression increased in the ipsilateral DRG during the first 3 weeks of regeneration, with peak values seen at 7 days postcrush. At this time point, the levels of HuD and GAP-43 mRNAs in the ipsilateral DRG increased by twofold and sixfold, respectively, relative to the contralateral DRG. Not only were the temporal patterns of expression of HuD protein and GAP-43 mRNA similar, but also they were found to colocalize in the cytoplasm of DRG neurons. Moreover, both molecules were distributed in cytoplasmic granules containing ribosomal RNA. In conclusion, our results suggest that HuD is involved in the upregulation of GAP-43 expression observed at early stages of peripheral nerve regeneration.