Discrepancies in recommendations for return to regular activities after cervical spine surgery: A survey study

Background

The recommended timing for returning to common activities after cervical spine surgery varies widely among physicians based on training background and personal opinion, without clear guidelines or consensus. The purpose of this study was to analyze spine surgeons' responses about the recommended timing for returning to common activities after different cervical spine procedures.

Methods

This was a survey study including 91 spine surgeons. The participants were asked to complete an anonymous online survey. Questions regarding their recommended time for returning to regular activities (showering, driving, biking, running, swimming, sedentary work, and nonsedentary work) after anterior cervical decompression and fusion (ACDF), cervical disc replacement (CDR), posterior cervical decompression and fusion (PCDF), and laminoplasty were included. Comparisons of recommended times for return to activities after each surgical procedure were made based on surgeons' years in practice.

Results

For ACDF and PCDF, there were no statistically significant differences in recommended times for return to any activity when stratified by years in practice. When considering CDR, return to non-sedentary work differed between surgeons in practice for 10 to 15 years, who recommended return at 3 months, and all other groups of surgeons, who recommended 6 weeks. Laminoplasty surgery yielded the most variability in activity recommendations, with earlier recommended return (6 weeks) to biking, non-sedentary work, and sedentary work in the most experienced surgeon group (>15 years in practice) than in all other surgeon experience groups (3 months).

Conclusions

We observed significant variability in surgeon recommendations for return to regular activities after cervical spine surgery.

Incidental durotomy resulting in a postoperative lumbosacral nerve root with eventration into the adjacent facet joint: illustrative cases

BACKGROUND

Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication.

OBSERVATIONS

Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints.

LESSONS

Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.

Association Between Severity of Cervical Central Spinal Stenosis and Paraspinal Muscle Parameters in Patients Undergoing Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to evaluate the association between severity and level of cervical central stenosis (CCS) and the fat infiltration (FI) of the cervical multifidus/rotatores (MR) at each subaxial levels.

SUMMARY OF BACKGROUND DATA

The relationship between cervical musculature morphology and the severity of CCS is poorly understood.

METHODS

Patients with preoperative cervical magnetic resonance imaging (MRI) who underwent anterior cervical discectomy and fusion (ACDF) were reviewed. The cervical MR were segmented from C3 to C7 and the percent FI was measured using a custom-written Matlab software. The severity of the CCS at each subaxial level was assessed using a previously published classification. Grade 3, representing a loss of cerebrospinal fluid space and deformation of the spinal cord > 25%, was set as the reference and compared to the other gradings. Multivariable linear regression analyses were conducted and adjusted for age, sex, and body mass index.

RESULTS

156 consecutive patients were recruited. A spinal cord compression at a certain level was significantly associated with a greater FI of the MR below that level. After adjustment for the above-mentioned confounders, our results showed that spinal cord compression at C3/4 and C4/5 was significantly associated with greater FI of the MR from C3 to C6 and C5 to C7, respectively. A spinal cord compression at C5/6 or C6/7 was significantly associated with greater FI of the MR at C7.

CONCLUSION

Our results demonstrated significant correlations between the severity of CCS and a greater FI of the MR. Moreover, significant level-specific correlations were found. A significant increase in FI of the MR at the levels below the stenosis was observed in patients presenting with spinal cord compression. Given the segmental innervation of the MR, the increased FI might be attributed to neurogenic atrophy.

LEVEL OF EVIDENCE

3.

Invention of MK-7845, a SARS-CoV-2 3CL Protease Inhibitor Employing a Novel Difluorinated Glutamine Mimic

As SARS-CoV-2 continues to circulate, antiviral treatments are needed to complement vaccines. The virus's main protease, 3CLPro, is an attractive drug target in part because it recognizes a unique cleavage site, which features a glutamine residue at the P1 position and is not utilized by human proteases. Herein, we report the invention of MK-7845, a novel reversible covalent 3CLPro inhibitor. While most covalent inhibitors of SARS-CoV-2 3CLPro reported to date contain an amide as a Gln mimic at P1, MK-7845 bears a difluorobutyl substituent at this position. SAR analysis and X-ray crystallographic studies indicate that this group interacts with His163, the same residue that forms a hydrogen bond with the amide substituents typically found at P1. In addition to promising in vivo efficacy and an acceptable projected human dose with unboosted pharmacokinetics, MK-7845 exhibits favorable properties for both solubility and absorption that may be attributable to the unusual difluorobutyl substituent.

Interim 1-Year Radiographic and Clinical Outcomes Following Anterior Cervical Discectomy and Fusion Using Hydroxyapatite-Infused Polyetheretherketone Interbody Cages

BACKGROUND

This is a multicenter observational registry analysis of 1-year radiographic and clinical outcomes following anterior cervical discectomy and fusion (ACDF) using hydroxyapatite (HA)-infused polyetheretherketone (PEEK) intervertebral cages.

METHODS

Radiographic and clinical outcome data were collected preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. To assess fusion, dynamic flexion-extension radiographs were independently evaluated with a validated method. Clinical outcomes were assessed using the following disease-specific measures: Neck Disability Index (NDI) and visual analog scale (VAS) for neck, left arm, and right arm pain. Patient satisfaction was also evaluated.

RESULTS

A total of 789 ACDF patients (men: 51.5%/women: 48.5%; mean body mass index: 29.9 kg/m2) were included at the time of analysis, and 1565 segments have been operated. Successful fusion was confirmed in 91.3% of all operated levels after 6 months and 92.2% after 12 months. Mean NDI scores improved significantly (P < 0.01) preoperatively (46.3, n = 771) to postoperatively (12 months: 25.2, n = 281). Consistently, mean VAS neck (preoperative: 64.2, n = 770; 12 months: 28.6, n = 278), VAS right arm (preoperative: 42.6, n = 766; 12 months: 20.4, n = 277), and VAS left arm (preoperative: 41.1, n = 768; 12 months: 20.8, n = 277) decreased significantly (P < 0.01). Patients reported high satisfaction rates after surgery with no significant changes in postoperative patient satisfaction between 6 weeks and 12 months (95.1%, n = 273).

CONCLUSIONS

ACDF with HA-infused PEEK cages demonstrates promising radiographic and clinical outcomes, supporting the potential benefits of incorporating HA into PEEK cages to enhance fusion rates and improve patient outcomes.

CLINICAL RELEVANCE

This study demonstrates a >90% fusion rate by level with reliable improvements in patient reported outcomes, along with a high rate of patient satisfaction, in a large patient cohort undergoing ACDF with HA-infused PEEK cages.

LEVEL OF EVIDENCE

2 .

Robot-Assisted Lumbar Pedicle Screw Placement Based on 3D Magnetic Resonance Imaging

STUDY DESIGN

Human Cadaveric Study.

OBJECTIVE

This study aims to explore the feasibility of using preoperative magnetic resonance imaging (MRI), zero-time-echo (ZTE) and spoiled gradient echo (SPGR), as source data for robotic-assisted spine surgery and assess the accuracy of pedicle screws.

METHODS

Zero-time-echo and SPGR MRI scans were conducted on a human cadaver. These images were manually post-processed, producing a computed tomography (CT)-like contrast. The Mazor X robot was used for lumbar pedicle screw-place navigating of MRI. The cadaver underwent a postoperative CT scan to determine the actual position of the navigated screws.

RESULTS

Ten lumbar pedicle screws were robotically navigated of MRI (4 ZTE; 6 SPGR). All MR-navigated screws were graded A on the Gertzbein-Robbins scale. Comparing preoperative robotic planning to postoperative CT scan trajectories: The screws showed a median deviation of overall 0.25 mm (0.0; 1.3), in the axial plane 0.27 mm (0.0; 1.3), and in the sagittal plane 0.24 mm (0.0; 0.7).

CONCLUSION

This study demonstrates the first successful registration of MRI sequences, ZTE and SPGR, in robotic spine surgery here used for intraoperative navigation of lumbar pedicle screws achieving sufficient accuracy, showcasing potential progress toward radiation-free spine surgery.

Targeting RARA overexpression with tamibarotene, a potent and selective RARα agonist, is a novel approach in AML

A superenhancer at the retinoic acid receptor alpha (RARA) gene is associated with RARA mRNA overexpression in ∼30% of non-acute promyelocytic leukemia acute myeloid leukemia (AML) and in ∼50% of myelodysplastic syndromes (MDS). RARA overexpression is an actionable target for treatment with tamibarotene, an oral potent and selective RARα agonist. Sensitivity to the RARα agonist tamibarotene was demonstrated in RARA-high but not RARA-low preclinical AML models. The combination of oral tamibarotene plus azacitidine was evaluated in a phase 2 clinical study in 51 newly diagnosed unfit patients with AML identified as RARA-positive (n = 22) or RARA-negative (n = 29) for RARA mRNA overexpression in peripheral blasts using a blood-based biomarker test. In 18 response-evaluable RARA-positive patients, complete remission (CR)/CR with incomplete hematologic recovery rate was 61%, CR rate was 50%, and time to initial composite CR was rapid at 1.2 months. Transfusion independence was attained by 72% of RARA-positive patients. In contrast, 28 response-evaluable RARA-negative patients had response rates that were consistent with azacitidine monotherapy. Tamibarotene in combination with azacitidine was well tolerated. The majority of nonhematologic adverse events were low grade and hematologic adverse events were comparable to single-agent azacitidine, demonstrating that there was no additional myelosuppression when tamibarotene was combined with azacitidine. These results support further evaluation of tamibarotene-based treatment strategies in patients with AML or MDS with RARA overexpression to provide a targeted approach with the goal of improving patient outcomes. This trial was registered at www.clinicaltrials.gov as #NCT02807558.

Medium-term outcomes in single anaesthetic bilateral total knee replacement surgery: a single surgeon series

BACKGROUND

The lifetime risk of developing symptomatic knee osteoarthritis (OA) is estimated to be 45%, with up to two thirds of patients presenting with bilateral knee symptoms. Patients presenting with end stage bilateral knee OA may benefit from single anaesthetic bilateral total knee replacement (SABTKR). Our study aim was to compare the outcomes of SABTKR with unilateral total knee arthroplasty (TKA) in a single surgeon series over a 20 year period.

METHODS

We performed a retrospective review of a single surgeon's data from the New Zealand Joint Registry (NZJR) over a 20-year period from January 1999 to December 2018. This review reports on patient demographics, functional outcomes, revision rates and mortality rates.

RESULTS

1225 total knee replacements were performed by the senior author (995 TKAs and 115 patients underwent SABTKRs) over the 20 year period reviewed. The mean ages of the TKA and SABTKR groups were 67.7 and 66.7 years, respectively. There was 16.9% mortality rate for the TKA group versus 7.8% in SABTKR group. There were no revisions in the SABTKR group versus 17 revisions in the TKA group representing a revision rate of 0.23/100 component years which can be viewed against a 20 year revision rate of 0.48/100 component years (p < 0.05) for all comers in the NZJR.

CONCLUSION

This NZJR study demonstrates excellent medium term survival outcomes for selected patients having simultaneous bilateral total knee replacements.

Safety Profile of Synthetic Elastic Degradable Matrix for Soft Tissue Reconstruction in Foot & Ankle Surgery

BACKGROUND

Augmentation of soft tissue repairs has been helpful in protecting surgically repaired tissues as they heal. FlexBand (Artelon, Marietta, Georgia) is a synthetic, degradable, polycaprolactone-based polyurethane urea (PUUR) matrix that has been investigated and used for soft tissue repair in a variety of settings. The purpose of this study was to evaluate the safety profile of a PUUR matrix in a large cohort of patients undergoing soft tissue repairs about the foot and ankle.

METHODS

A retrospective chart review of consecutive patients who underwent surgery using FlexBand to augment a soft tissue repair was performed to evaluate for major and minor complications related to the PUUR matrix. Results. A total of 105 patients with an average >6 months follow-up were included. The most common procedures were spring ligament repair, Achilles tendon repair, and Brostrom. There were 12 complications. Four major complications occurred with only 1 requiring PUUR matrix removal. Patients with wound complications had a higher body mass index (BMI) and rate of smoking.

CONCLUSION

Complication rates involving PUUR matrix in soft tissue foot and ankle reconstruction procedures are low and comparable with historical complication rates. The PUUR matrix is safe for use in a variety of soft tissue procedures about the foot and ankle.Level of Evidence: Level 4, Retrospective case-series.

Tendon Transfer versus Allograft Reconstruction in Progressive Collapsing Foot Deformity

The posterior tibial tendon (PTT) is the principal dynamic stabilizer of the medial longitudinal arch of the foot. The basic goal of surgically reconstructing PCFD is to restore the foot's medial longitudinal arch, often through a combination of bony and soft tissue procedures. While the FDL transfer has long been the gold standard for reconstruction, allograft reconstruction of the PTT has recently been increasing in popularity.

Discovery of Arylsulfonamide Nav1.7 Inhibitors: IVIVC, MPO Methods, and Optimization of Selectivity Profile

The voltage-gated sodium channel Nav1.7 continues to be a high-profile target for the treatment of various pain afflictions due to its strong human genetic validation. While isoform selective molecules have been discovered and advanced into the clinic, to date, this target has yet to bear fruit in the form of marketed therapeutics for the treatment of pain. Lead optimization efforts over the past decade have focused on selectivity over Nav1.5 due to its link to cardiac side effects as well as the translation of preclinical efficacy to man. Inhibition of Nav1.6 was recently reported to yield potential respiratory side effects preclinically, and this finding necessitated a modified target selectivity profile. Herein, we report the continued optimization of a novel series of arylsulfonamide Nav1.7 inhibitors to afford improved selectivity over Nav1.6 while maintaining rodent oral bioavailability through the use of a novel multiparameter optimization (MPO) paradigm. We also report in vitro-in vivo correlations from Nav1.7 electrophysiology protocols to preclinical models of efficacy to assist in projecting clinical doses. These efforts produced inhibitors such as compound 19 with potency against Nav1.7, selectivity over Nav1.5 and Nav1.6, and efficacy in behavioral models of pain in rodents as well as inhibition of rhesus olfactory response indicative of target modulation.

Paediatric Strategy Forum for medicinal product development of epigenetic modifiers for children: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration

The fifth multistakeholder Paediatric Strategy Forum focussed on epigenetic modifier therapies for children and adolescents with cancer. As most mutations in paediatric malignancies influence chromatin-associated proteins or transcription and paediatric cancers are driven by developmental gene expression programs, targeting epigenetic mechanisms is predicted to be a very important therapeutic approach in paediatric cancer. The Research to Accelerate Cures and Equity (RACE) for Children Act FDARA amendments to section 505B of the FD&C Act was implemented in August 2020, and as there are many epigenetic targets on the FDA Paediatric Molecular Targets List, clinical evaluation of epigenetic modifiers in paediatric cancers should be considered early in drug development. Companies are also required to submit to the EMA paediatric investigation plans aiming to ensure that the necessary data to support the authorisation of a medicine for children in EU are of high quality and ethically researched. The specific aims of the forum were i) to identify epigenetic targets or mechanisms of action associated with epigenetic modification relevant to paediatric cancers and ii) to define the landscape for paediatric drug development of epigenetic modifier therapies. DNA methyltransferase inhibitors/hypomethylating agents and histone deacetylase inhibitors were largely excluded from discussion as the aim was to discuss those targets for which therapeutic agents are currently in early paediatric and adult development. Epigenetics is an evolving field and could be highly relevant to many paediatric cancers; the biology is multifaceted and new targets are frequently emerging. Targeting epigenetic mechanisms in paediatric malignancy has in most circumstances yet to reach or extend beyond clinical proof of concept, as many targets do not yet have available investigational drugs developed. Eight classes of medicinal products were discussed and prioritised based on the existing level of science to support early evaluation in children: inhibitors of menin, DOT1L, EZH2, EED, BET, PRMT5 and LSD1 and a retinoic acid receptor alpha agonist. Menin inhibitors should be moved rapidly into paediatric development, in view of their biological rationale, strong preclinical activity and ability to fulfil an unmet clinical need. A combination approach is critical for successful utilisation of any epigenetic modifiers (e.g. EZH2 and EED) and exploration of the optimum combination(s) should be supported by preclinical research and, where possible, molecular biomarker validation in advance of clinical translation. A follow-up multistakeholder meeting focussing on BET inhibitors will be held to define how to prioritise the multiple compounds in clinical development that could be evaluated in children with cancer. As epigenetic modifiers are relatively early in development in paediatrics, there is a clear opportunity to shape the landscape of therapies targeting the epigenome in order that efficient and optimum plans for their evaluation in children and adolescents are developed in a timely manner.

Scalable Quantum Integrated Circuits on Superconducting Two-Dimensional Electron Gas Platform

To form a coherent quantum transport in hybrid superconductor-semiconductor (S-Sm) junctions, the formation of a homogeneous and barrier-free interface between two different materials is necessary. The S-Sm junction with high interface transparency will then facilitate the observation of the induced hard superconducting gap, which is the key requirement to access the topological phases (TPs) and observation of exotic quasiparticles such as Majorana zero modes (MZM) in hybrid systems. A material platform that can support observation of TPs and allows the realization of complex and branched geometries is therefore highly demanding in quantum processing and computing science and technology. Here, we introduce a two-dimensional material system and study the proximity induced superconductivity in semiconducting two-dimensional electron gas (2DEG) that is the basis of a hybrid quantum integrated circuit (QIC). The 2DEG is a 30 nm thick In0.75Ga0.25As quantum well that is buried between two In0.75Al0.25As barriers in a heterostructure. Niobium (Nb) films are used as the superconducting electrodes to form Nb- In0.75Ga0.25As -Nb Josephson junctions (JJs) that are symmetric, planar and ballistic. Two different approaches were used to form the JJs and QICs. The long junctions were fabricated photolithographically, but e-beam lithography was used for short junctions' fabrication. The coherent quantum transport measurements as a function of temperature in the presence/absence of magnetic field B are discussed. In both device fabrication approaches, the proximity induced superconducting properties were observed in the In0.75Ga0.25As 2DEG. It was found that e-beam lithographically patterned JJs of shorter lengths result in observation of induced superconducting gap at much higher temperature ranges. The results that are reproducible and clean suggesting that the hybrid 2D JJs and QICs based on In0.75Ga0.25As quantum wells could be a promising material platform to realize the real complex and scalable electronic and photonic quantum circuitry and devices.

Identifying clinical practice guidelines for the supportive care of children with cancer: A report from the Children's Oncology Group

Providing evidence-based supportive care for children with cancer has the potential to optimize treatment outcomes and improve quality of life. The Children's Oncology Group (COG) Supportive Care Guidelines Subcommittee conducted a systematic review to identify current supportive care clinical practice guidelines (CPGs) relevant to childhood cancer or pediatric hematopoietic stem cell transplant. Only 22 papers met the 2011 Institute of Medicine criteria to be considered a CPG. The results highlight the paucity of CPGs available to pediatric oncology healthcare professionals and the pressing need to create CPGs using current methodological standards.

Early-stage Hodgkin lymphoma in the modern era: simulation modelling to delineate long-term patient outcomes

We developed a novel simulation model integrating multiple data sets to project long-term outcomes with contemporary therapy for early-stage Hodgkin lymphoma (ESHL), namely combined modality therapy (CMT) versus chemotherapy alone (CA) via ¹⁸ F-fluorodeoxyglucose positron emission tomography response-adaption. The model incorporated 3-year progression-free survival (PFS), probability of cure with/without relapse, frequency of severe late effects (LEs), and 35-year probability of LEs. Furthermore, we generated estimates for quality-adjusted life years (QALYs) and unadjusted survival (life years, LY) and used model projections to compare outcomes for CMTversusCA for two index patients. Patient 1: a 25-year-old male with favourable ESHL (stage IA); Patient 2: a 25-year-old female with unfavourable ESHL (stage IIB). Sensitivity analyses assessed the impact of alternative assumptions for LE probabilities. For Patient 1, CMT was superior to CA (CMT incremental gain = 0·11 QALYs, 0·21 LYs). For Patient 2, CA was superior to CMT (CA incremental gain = 0·37 QALYs, 0·92 LYs). For Patient 1, the advantage of CMT changed minimally when the proportion of severe LEs was reduced from 20% to 5% (0·15 QALYs, 0·43 LYs), whereas increasing the severity proportion for Patient 2's LEs from 20% to 80% enhanced the advantage of CA (1·1 QALYs, 6·5 LYs). Collectively, this detailed simulation model quantified the long-term impact that varied host factors and alternative contemporary treatments have in ESHL.

Use of the Urological Resectoscope in Benign and Malignant Rectal Lesions-Review of 12 Cases

The urological resectoscope was used over three years for 27 transanal operations in 12 patients. The procedure was quick, safe and effective. Haemorrhage was not a problem, and histology was obtained in every case. It seemed to be the treatment of choice for low anastomotic strictures in the rectum (two cases) and for palliation of inoperable low carcinomas (three cases). Its use for villous adenomas (six cases) both alone and as an adjunct to open surgery is discussed in detail.

Undergraduate urology teaching: Results of a pre-examination revision quiz

A ‘revision quiz’ using some 20 projected photographic slides and a structured open-ended answer sheet was administered to, and marked for, 75 Final MB candidates and 7 Final FRCS candidates at Bristol. Despite only a modest exposure to specialist urological teaching, the undergraduates were judged to have achieved an acceptable level of performance in most areas except for the treatment of urinary infections. The performance of the senior house officers was not better than that of the undergraduates. Nearly all candidates in both groups undermarked their own scripts compared to the marks given by their teachers, thus fuelling, perhaps needlessly, their anxieties about examinations.

Frustrated Lewis pairs incorporating the bifunctional Lewis acid 1,1'-fc{B(C6F5)2}2: reactivity towards small molecules

Applications of the bifunctional ferrocenediyl Lewis acid 1,1'-fc{B(C₆F₅)₂}₂ in frustrated Lewis pair (FLP) chemistry are described. The coordination (or otherwise) of a range of sterically encumbered C-, N- and P-centred Lewis bases has been investigated, with lutidine, tetramethylpiperidine, PPh₃, P^tBu₃ and the expanded ring carbene 6Dipp being found to be sterically incapable of coordinate bond formation. The chemistry of a range of these FLPs in the presence of H₂O, NH₃, CO₂ and cyclohexylisocyanate (CyNCO) has been investigated, with the patterns of reactivity identified including simple coordination chemistry, E-H bond cleavage and C-B insertion.

Multiple-trait genomewide mapping and gene network analysis for scrotal circumference growth curves in Brahman cattle

Fertility traits are economically important in cattle breeding programs. Scrotal circumference (SC) measures are repeatable, easily obtained, highly heritable, and positively correlated with female fertility traits and sperm quality traits in males. A useful approach to summarize SC measures over time is using nonlinear models, which summarize specific measures of SC in a few parameters with biological interpretation. This approach facilitates the selection of bulls with larger SC and maturity index (K), that is, early maturing animals. Because SC is a sex-limited trait, identifying the underlying genomics of growth curve parameters will allow selection across both males and females. We reported the first multitrait genomewide association study (GWAS) of estimated growth curve parameters for SC data in Brahman cattle. Five widely used nonlinear models were tested to fit a total of 3,612 SC records, measured at 6, 12, 18, and 24 mo of age. The von Bertalanffy model, individually fitted for each animal, best fit this SC data. Parameter estimates SC at maturity (A) and K as well as SC at all ages were jointly analyzed in a GWAS to identify 1-Mb regions most strongly associated with each trait. Heritabilities were 0.25 for K and 0.32 for A and ranged from 0.51 to 0.72 for SC at 6 (SC6), 12 (SC12), 18 (SC18), and 24 mo of age (SC24). An overlapping window on chromosome 14 explaining around 0.8% of genetic variance for K, SC12, SC18, and SC24 was observed. The major positional candidate genes within 1 Mb upstream and downstream of this overlapping window were , , , and . Windows of 1 Mb explaining more than 0.4% of each trait on chromosomes 1, 3, 6, 7, 14, 17, 18, 24, 25, and 26 were identified. Pathways and net-work analyses were indicated through transcription factors playing a role on fertility traits: , , , , , , and . Further validation studies on larger populations or other breeds are required to validate these findings and to improve our understanding of the biology and complex genetic architecture of traits associated with scrotal growth and male fertility in cattle.

On-Chip Andreev Devices: Hard Superconducting Gap and Quantum Transport in Ballistic Nb-In0.75 Ga0.25 As-Quantum-Well-Nb Josephson Junctions

A superconducting hard gap in hybrid superconductor-semiconductor devices has been found to be necessary to access topological superconductivity that hosts Majorana modes (non-Abelian excitation). This requires the formation of homogeneous and barrier-free interfaces between the superconductor and semiconductor. Here, a new platform is reported for topological superconductivity based on hybrid Nb-In_0.75 Ga_0.25 As-quantum-well-Nb that results in hard superconducting gap detection in symmetric, planar, and ballistic Josephson junctions. It is shown that with careful etching, sputtered Nb films can make high-quality and transparent contacts to the In_0.75 Ga_0.25 As quantum well, and the differential resistance and critical current measurements of these devices are discussed as a function of temperature and magnetic field. It is demonstrated that proximity-induced superconductivity in the In_0.75 Ga_0.25 As-quantum-well 2D electron gas results in the detection of a hard gap in four out of seven junctions on a chip with critical current values of up to 0.2 µA and transmission probabilities of >0.96. The results, together with the large g-factor and Rashba spin-orbit coupling in In_0.75 Ga_0.25 As quantum wells, which indeed can be tuned by the indium composition, suggest that the Nb-In_0.75 Ga_0.25 As-Nb system can be an excellent candidate to achieve topological phase and to realize hybrid topological superconducting devices.

Early Nutrition and Physical Activity Interventions in Childhood Cancer Survivors

PURPOSE OF REVIEW

Childhood cancer survivors experience excessive weight gain early in treatment. Lifestyle interventions need to be initiated early in cancer care to prevent the early onset of obesity and cardiovascular disease (CVD). We reviewed the existing literature on early lifestyle interventions in childhood cancer survivors and consider implications for clinical care.

RECENT FINDINGS

Few lifestyle interventions focus on improving nutrition in childhood cancer survivors. A consistent effect on reducing obesity and CVD risk factors is not evident from the limited number of studies with heterogeneous intervention characteristics, although interventions with a longer duration and follow-up show more promising trends. Future lifestyle interventions should be of a longer duration and include a nutrition component. Interventions with a longer duration and follow-up are needed to assess the timing and sustainability of the intervention effect. Lifestyle interventions introduced early in cancer care are both safe and feasible.

Multisite external validation of a risk prediction model for the diagnosis of blood stream infections in febrile pediatric oncology patients without severe neutropenia

BACKGROUND

Pediatric oncology patients are at an increased risk of invasive bacterial infection due to immunosuppression. The risk of such infection in the absence of severe neutropenia (absolute neutrophil count ≥ 500/μL) is not well established and a validated prediction model for blood stream infection (BSI) risk offers clinical usefulness.

METHODS

A 6-site retrospective external validation was conducted using a previously published risk prediction model for BSI in febrile pediatric oncology patients without severe neutropenia: the Esbenshade/Vanderbilt (EsVan) model. A reduced model (EsVan2) excluding 2 less clinically reliable variables also was created using the initial EsVan model derivative cohort, and was validated using all 5 external validation cohorts. One data set was used only in sensitivity analyses due to missing some variables.

RESULTS

From the 5 primary data sets, there were a total of 1197 febrile episodes and 76 episodes of bacteremia. The overall C statistic for predicting bacteremia was 0.695, with a calibration slope of 0.50 for the original model and a calibration slope of 1.0 when recalibration was applied to the model. The model performed better in predicting high-risk bacteremia (gram-negative or Staphylococcus aureus infection) versus BSI alone, with a C statistic of 0.801 and a calibration slope of 0.65. The EsVan2 model outperformed the EsVan model across data sets with a C statistic of 0.733 for predicting BSI and a C statistic of 0.841 for high-risk BSI.

CONCLUSIONS

The results of this external validation demonstrated that the EsVan and EsVan2 models are able to predict BSI across multiple performance sites and, once validated and implemented prospectively, could assist in decision making in clinical practice. Cancer 2017;123:3781-3790. © 2017 American Cancer Society.

Air Combat Maneuvering Performance Measurement

Due to the complex, dynamic and fast-moving nature of the air combat task, performance assessment during air-to-air combat provides many unique measurement problems. A combined analytical and empirical technical approach was used to develop a candidate measurement structure and algorithm for the measurement of pilot performance during one-versus-one air combat maneuvering. Nearly all of 28 candidate measures were found to discriminate between high and low skilled pilots during free engagements on the Simulator for Air-to-Air Combat. Discriminant analyses provided a measurement algorithm consisting of 13 measures which accounted for 51% of the variance in the performance data and which predicted membership in high or low skill groups with 92% accuracy.

Dynamic Simulation of the Effects of Graft Fixation Errors During Medial Patellofemoral Ligament Reconstruction

Background:

Medial patellofemoral ligament (MPFL) reconstruction is performed to prevent recurrent instability, but errors in femoral fixation can elevate graft tension.

Hypothesis:

Errors related to femoral fixation will overconstrain the patella and increase medial patellofemoral pressures.

Study Design:

Controlled laboratory study.

Methods:

Five knees with patellar instability were represented with computational models. Kinematics during knee extension were characterized from computational reconstruction of motion performed within a dynamic computed tomography (CT) scanner. Multibody dynamic simulation of knee extension, with discrete element analysis used to quantify contact pressures, was performed for the preoperative condition and after MPFL reconstruction. A standard femoral attachment and graft resting length were set for each knee. The resting length was decreased by 2 mm, and the femoral attachment was shifted 5 mm posteriorly. The simulated errors were also combined. Root-mean-square errors were quantified for the comparison of preoperative patellar lateral shift and tilt between computationally reconstructed motion and dynamic simulation. Simulation output was compared between the preoperative and MPFL reconstruction conditions with repeated-measures Friedman tests and Dunnett comparisons against a control, which was the standard MPFL condition, with statistical significance set at P < .05.

Results:

Root-mean-square errors for simulated patellar tilt and shift were 5.8° and 3.3 mm, respectively. Patellar lateral tracking for the preoperative condition was significantly larger near full extension compared with the standard MPFL reconstruction (mean differences of 8 mm and 13° for shift and tilt, respectively, at 0°), and lateral tracking was significantly smaller for a posterior femoral attachment (mean differences of 3 mm and 4° for shift and tilt, respectively, at 0°). The maximum medial pressure was also larger for the short graft with a posterior femoral attachment than for standard MPFL reconstruction, with a significant increase in the mean value of 1.6 MPa at 30°.

Conclusion:

MPFL reconstruction reduces lateral tracking, but nonanatomic femoral fixation and overtensioning the graft overcorrect patellar tracking and increase pressure applied to medial patellar cartilage.

Clinical Relevance:

Errors in femoral fixation and graft tensioning can lead to postoperative loss of flexion and overloading of medial cartilage.

Difenacoum Poisoning as a cause of Haematuria

A man presented with frank haematuria and a grossly prolonged prothrombin time. He was later found to have taken an overdose of difenacoum — a 'superwarfarin' rodenticide. The diagnosis was confirmed by a serum concentration of difenacoum of 0.6 μg ml-1. Overdosage with superwarfarins is discussed and the need for prolonged treatment with vitamin K1 highlighted.

A specific nanomanufacturing challenge

For a science to become a technology, a certain level of control has to have been established over the way items are fabricated for manufacture and use. Here we first consider the challenge of making and using a LEGO(®) brick scaled down by a factor of 10(n) for n = 0-6 in each spatial dimension, i.e. from millimetres to nanometres. We consider both the manufacture and the subsequent properties of the nanobricks that pertain to their use in constructing and dismantling structures. As n increases, the ability to use fails first, to manufacture fails second and to fabricate fails last. Applied to the vast literature in nanoscience, this process emphasises the unmanufacturability of most nanoscale artefacts.

Optimization of Novel Aza-benzimidazolone mGluR2 PAMs with Respect to LLE and PK Properties and Mitigation of CYP TDI

Investigation of a novel amino-aza-benzimidazolone structural class of positive allosteric modulators (PAMs) of metabotropic glutamate receptor 2 (mGluR2) identified [2.2.2]-bicyclic amine 12 as an intriguing lead structure due to its promising physicochemical properties and lipophilic ligand efficiency (LLE). Further optimization led to chiral amide 18, which exhibited strong in vitro activity and attractive pharmacokinetic (PK) properties. Hypothesis-driven target design identified compound 21 as a potent, highly selective, orally bioavailable mGluR2 PAM, which addressed a CYP time-dependent inhibition (TDI) liability of 18, while maintaining excellent drug-like properties with robust in vivo activity in a clinically validated model of antipsychotic potential.

Food craving and obesity in survivors of pediatric ALL and lymphoma

Cancer treatment can impact the hypothalamic-pituitary region of the developing brain, impairing appetite regulation and causing food craving in children who have survived cancer. We assessed food craving using a modified Food Craving Inventory in 22 survivors of pediatric acute lymphoblastic leukemia (ALL) and lymphoma (median age = 11.7 years) and evaluated its association with treatment exposure and changes in weight status over a one-year period. Mean total craving score was 2.1 (SD = 0.7). Survivors reported significantly higher mean craving score for fast-foods [2.6 (SD = 0.9)] than for sweets [2.1 (SD = 0.8)], carbohydrates [2.0 (SD = 0.6)], and fats [1.8 (SD = 0.7)] (all P values < 0.05). Results from multivariate linear regression indicated that survivors diagnosed at an older age (≥4.5 years) experienced higher frequencies of food craving than those diagnosed at a younger age (<4.5 years) (β = 0.88, 95% CI: 0.42, 1.34). Food craving, however, was not significantly associated with survivors' weight status over 12 months of follow-up. Food craving alone does not appear to explain the obesity risk in this sample of childhood cancer survivors. The role of food craving in shaping eating behavior and obesity risk needs to be further evaluated in a large cohort of childhood cancer survivors.

Clinical negligence in hospitals in France and England

This article arose from the back-to-back presentations by Michael Kelly and Patrice Métayer to the Anglo-French Medical Society in 2013 on the French and English legal systems handling a case of alleged clinical negligence as it proceeds from complaint to settlement or judgment in the two jurisdictions. Both systems have a hospital-based first stage with various avenues being available for amicable resolution, the French version being more regulated and prescribed than the English one. In both jurisdictions fewer than 5% cases go down the criminal route. Before the court is involved, in England there is an elaborate lawyer-controlled phase involving negotiations between the two sides and their experts which is expensive but often leads to pre-trial settlement for significant sums of money. Medical experts are central to all of this. In England they are largely unregulated and entirely advisory in an open market, in France they are both regulated and supervised by judges, being placed on official lists. These experts take a major inquisitorial role in a Debate between the two sides, combining the functions of Single Joint Expert (SJE), arbiter and mentor. If agreement is not reached, a second Debate before a different Expert is arranged. In both countries fewer than 5% cases reach a court for a hearing before a judge. In England a trial is an elaborate lengthy, expensive adversarial contest where all of the issues are rehearsed in full with factual and expert evidence, whereas in France in a contested case the judge reviews the reports of the two Debates with the lawyers who were involved (and not the experts, factual witnesses or parties).

Accuracy of genomic selection for age at puberty in a multi-breed population of tropically adapted beef cattle

Genomic selection is becoming a standard tool in livestock breeding programs, particularly for traits that are hard to measure. Accuracy of genomic selection can be improved by increasing the quantity and quality of data and potentially by improving analytical methods. Adding genotypes and phenotypes from additional breeds or crosses often improves the accuracy of genomic predictions but requires specific methodology. A model was developed to incorporate breed composition estimated from genotypes into genomic selection models. This method was applied to age at puberty data in female beef cattle (as estimated from age at first observation of a corpus luteum) from a mix of Brahman and Tropical Composite beef cattle. In this dataset, the new model incorporating breed composition did not increase the accuracy of genomic selection. However, the breeding values exhibited slightly less bias (as assessed by deviation of regression of phenotype on genomic breeding values from the expected value of 1). Adding additional Brahman animals to the Tropical Composite analysis increased the accuracy of genomic predictions and did not affect the accuracy of the Brahman predictions.

Comparison of childhood cancer survivors' nutritional intake with US dietary guidelines

BACKGROUND

Despite improved survival, childhood cancer survivors experience significantly elevated risk of premature mortality and serious morbidity due to chronic health conditions. Poor diet quality can exacerbate chronic health conditions in the survivors but their nutritional intake has not been adequately studied.

PROCEDURE

We assessed the Healthy Eating Index 2010 (HEI-2010) in 22 survivors of pediatric acute lymphoblastic leukemia and lymphoma (median age = 11.7 years) and compared survivors' dietary intake to the 2010 Dietary Guidelines for Americans. Dietary data were collected using repeated 24 hr dietary recalls over a 1-year period, which were averaged to estimate habitual intake.

RESULTS

The mean HEI-2010 in childhood cancer survivors was 52.7, about 50 percent of the maximum score. Long-term survivors (time from diagnosis ≥10 years) had a significantly lower HEI-2010 than recent survivors (time from diagnosis <5 years) (β = -11.5, 95% CI: -22.1, -0.9, P = 0.047). For individual food groups and nutrients, survivors had a particularly poor adherence to green vegetables and beans, total vegetables, and whole fruits. None of the survivors met the guidelines for dietary fiber and potassium intake. Only 4%, 19%, 24%, and 29% met the guidelines for vitamin D, sodium, calcium, and saturated fat intake. The average intake in relative to the recommended intake was 32% for vitamin D, 50% for potassium, 63% for fiber, and 85% for calcium, but was 115% for saturated fat and 143% for sodium.

CONCLUSIONS

Childhood cancer survivors, in particular long-term survivors, have a poor adherence to the US dietary guidelines.

Growth patterns during and after treatment in patients with pediatric ALL: A meta-analysis

BACKGROUND

Survivors of pediatric acute lymphoblastic leukemia (ALL) have a significantly higher body mass index (BMI) than their peers. Understanding the critical time periods in which patients with pediatric ALL are vulnerable to unhealthy weight gain will lay the groundwork for developing effectively timed interventions.

PROCEDURE

We determined the growth patterns of patients with pediatric ALL during and after treatment through the conduct of a systematic review and meta-analysis. A search of MEDLINE, Scopus, and Web of Science was performed from its inception through May 2014. Studies met the inclusion criteria if they included at least 10 patients of pediatric ALL, and longitudinally assessed BMI at diagnosis and at least one time point after diagnosis

RESULTS

Twenty-one studies met the inclusion criteria for the systematic review and 16 were included in meta-analysis. The mean increase in BMI z-score during treatment in 1,514 patients with pediatric ALL was 0.81 (95% CI: 0.25-1.38). Specifically, patients experienced substantial weight gain in early treatment (Δ = 0.41, 95% CI: -0.34, 1.17) and again during maintenance (Δ = 0.34, 95% CI:-0.22, 0.90). The mean increase in BMI z-score ranged between 0.52 and 0.89 beyond treatment completion. Subgroup analyses found unhealthy weight gain occurred regardless of patients' receipt of cranial radiation therapy, sex, and, weight status at diagnosis.

CONCLUSIONS

Patients with pediatric ALL experience unhealthy weight gain early in treatment, and increases in weight are maintained beyond treatment completion. Preventing early onset of obesity is a priority for improving the care and outcomes for patients with pediatric ALL.

Using nonrandomized studies to inform complex clinical decisions: the thorny issue of cranial radiation therapy for T-cell acute lymphoblastic leukemia

BACKGROUND

There are no randomized controlled trials to inform the decision of which cranial radiation therapy (CRT) strategy to apply to pediatric patients with T-cell acute lymphoblastic leukemia (ALL).

PROCEDURE

We performed a decision analysis using a Markov model in which we compared the life expectancy and quality-adjusted life expectancy when administering one of three CRT strategies to a cohort of patients with T-cell ALL: (1) omission of CRT for all patients; (2) CRT only for those with evidence of leukemic involvement in the central nervous system at diagnosis (therapeutic strategy); or (3) CRT for all (prophylactic strategy).

RESULTS

When considering plausible event-free survival rates and late mortality after cure for groups of pediatric patients with T-cell ALL, the strategies of omitting CRT, administering therapeutic CRT, and administering prophylactic CRT result in similar short-term (7-year) survival. When considering the increased contribution of deaths from late effects, the strategy of prophylactic CRT is associated with lower life expectancy when compared to the other two strategies. The Monte Carlo probabilistic sensitivity analysis demonstrated that the strategy of prophylactic CRT was the preferred strategy only 5% of the time.

CONCLUSIONS

Similar short-term survival may be expected when comparing the strategies of total omission of CRT, therapeutic CRT, and prophylactic CRT for patients with T-cell ALL. Long-term survival is likely inferior for the strategy of prophylactic CRT. The synthesis of nonrandomized trials and the application of decision analysis can help inform complex decision making in pediatric oncology.

Low Levels of Energy Expenditure in Childhood Cancer Survivors: Implications for Obesity Prevention

Childhood cancer survivors are at an increased risk of obesity but causes for this elevated risk are uncertain. We evaluated total energy expenditure in childhood cancer survivors using the doubly labeled water method in a cross-sectional study of 17 survivors of pediatric leukemia or lymphoma (median age, 11.5 y). Mean total energy expenditure was 2073 kcal/d, which was nearly 500 kcal/d lower than estimated energy requirements with recommended levels of physical activity. This energy gap is likely to contribute to the risk of obesity in this population and future trials are needed to assess implications and potential treatment strategies.

Cranial radiation for pediatric T-lineage acute lymphoblastic leukemia: a systematic review and meta-analysis

There are heterogeneous approaches to cranial radiation therapy (CRT) for T-lineage acute lymphoblastic leukemia (T-ALL). We performed a systematic review of studies that specified a radiation strategy and reported survival for pediatric T-ALL. Our analysis included 62 publications reporting 78 treatment groups (patient n = 5844). The average event-free survival (EFS) was higher by 6% per 5 years (P < 0.001). Adjusting for year, EFS differed by radiation strategy. Compared to the reference group (CRT for all) which had a year-adjusted EFS of 65% (95% confidence interval, CI: 61-69%) the adjusted EFS was significantly worse (rate difference (RD) = -9%, 95% CI: -15 to -2%) among studies that used a risk-directed approach to CRT (P = 0.004). The adjusted EFS for the other strategies were not significantly different compared to the reference group: CRT for central nervous system positive patients only (RD = -3%, 95% CI: -14 to 7%, P = 0.49); CRT omitted for all patients (RD = 5%, 95% CI: -4 to 15%, P = 0.33). CRT may not be necessary with current chemotherapy for T-ALL. These findings, however, are susceptible to bias and caution should be applied in drawing conclusions on the comparative effectiveness of alternative CRT strategies.

Supervised independent component analysis as an alternative method for genomic selection in pigs

The objective of this work was to evaluate the efficiency of the supervised independent component regression (SICR) method for the estimation of genomic values and the SNP marker effects for boar taint and carcass traits in pigs. The methods were evaluated via the agreement between the predicted genetic values and the corrected phenotypes observed by cross-validation. These values were also compared with other methods generally used for the same purposes, such as RR-BLUP, SPCR, SPLS, ICR, PCR and PLS. The SICR method was found to have the most accurate prediction values.

Predictors of being overweight or obese in survivors of pediatric acute lymphoblastic leukemia (ALL)

BACKGROUND

A high prevalence of obesity has been increasingly recognized in survivors of pediatric ALL. However, longitudinal patterns of weight change during and after treatment, and associated factors, are less well elucidated.

PROCEDURE

In a retrospective cohort of 83 pediatric patients with ALL diagnosed between 1985 and 2010, we examined body mass index (BMI) status at several key time points: diagnosis; end of induction; end of consolidation; every 6 months during maintenance; and yearly for up to 5 years post-treatment.

RESULTS

At diagnosis, 21% were overweight (BMI = 85-94.9th percentile) or obese (BMI ≥ 95th percentile). At the end of treatment and 5 years post-treatment, approximately 40% were overweight or obese. The mean BMI z-score was 0.2 (58th percentile) at diagnosis and increased significantly during induction (Δ = 0.5, P < 0.0001). It increased again during the first 6 months of maintenance (Δ = 0.2, P < 0.01) and did not significantly change over the remainder of maintenance (BMI z-score at the end of treatment = 0.8, 79th percentile) and 5 years post-treatment (BMI z-score = 0.7, 76th percentile). High BMI z-score at diagnosis was associated with an increased risk of being overweight/obese at treatment completion (OR = 2.9, 95% CI: 1.6-5.1). Weight gain during treatment was associated with being overweight/obese 5 years post-treatment (OR = 3.8, 95% CI: 1.1-12.5).

CONCLUSION

Children with ALL are at risk of becoming overweight/obese early in treatment. Increases in weight are maintained throughout treatment and beyond. Lifestyle interventions are needed targeting weight control early during treatment, particularly for patients overweight/obese at diagnosis and those who experience substantial weight gain during treatment.