Learn2Reg: Comprehensive Multi-Task Medical Image Registration Challenge, Dataset and Evaluation in the Era of Deep Learning

Image registration is a fundamental medical image analysis task, and a wide variety of approaches have been proposed. However, only a few studies have comprehensively compared medical image registration approaches on a wide range of clinically relevant tasks. This limits the development of registration methods, the adoption of research advances into practice, and a fair benchmark across competing approaches. The Learn2Reg challenge addresses these limitations by providing a multi-task medical image registration data set for comprehensive characterisation of deformable registration algorithms. A continuous evaluation will be possible at https://learn2reg.grand-challenge.org. Learn2Reg covers a wide range of anatomies (brain, abdomen, and thorax), modalities (ultrasound, CT, MR), availability of annotations, as well as intra- and inter-patient registration evaluation. We established an easily accessible framework for training and validation of 3D registration methods, which enabled the compilation of results of over 65 individual method submissions from more than 20 unique teams. We used a complementary set of metrics, including robustness, accuracy, plausibility, and runtime, enabling unique insight into the current state-of-the-art of medical image registration. This paper describes datasets, tasks, evaluation methods and results of the challenge, as well as results of further analysis of transferability to new datasets, the importance of label supervision, and resulting bias. While no single approach worked best across all tasks, many methodological aspects could be identified that push the performance of medical image registration to new state-of-the-art performance. Furthermore, we demystified the common belief that conventional registration methods have to be much slower than deep-learning-based methods.

Old breeds, new solutions? Effects of two different traditional sire breeds on skin lesions, tail lesions, tail losses, performance and behaviour of rearing pigs

Some studies indicated a relationship between modern, fast-growing, lean-meat-producing hybrid pigs and the occurrence of tail-biting, one of the major issues of conventional pig husbandry. Therefore, this study investigated the effects of different local, traditional sire breeds on the behaviour and performance of rearing pigs. Between December 2019 and November 2020, a total of 1 561 piglets were weaned from hybrid sows (Bundes Hybrid Zucht Programm (BHZP) Landrace × BHZP Large White) that were paired with either Swabian-Hall (SH), Bentheim Black Pied (BB) or BHZP-Piétrain (Pi) boars. Tails of the piglets were left intact (43.5%) or docked (56.5%), and male piglets were castrated. Piglets were conventionally reared on fully slatted plastic flooring in mixed-sex groups. Starting one day after weaning, skin lesions were scored once per pig, and tail lesions and losses were scored weekly until the end of rearing. The average daily gain was documented for the suckling and rearing period. The activity behaviour of eight focal pens was analysed using video recordings. Differences between modern and traditional breeds were found in this study for so-called aggressive and non-aggressive biting pronounced by skin and tail lesions and tail losses. Significantly fewer BB pigs had severe skin lesions on the front body than SH or Pi pigs (P < 0.05). Additionally, piglets that were classified as light (<5.6 kg) at weaning showed skin lesion scores of 0 more often than piglets that were classified with a medium (≥5.6-≤8.3 kg) or heavy (>8.3 kg) weaning weight (P < 0.05). In the first half of the rearing period, significantly more BB pigs were assessed as having no tail lesions and tail losses than SH and Pi pigs (P < 0.01). However, these differences disappeared in the second half of rearing. Either docked or undocked Pi pigs had significantly higher average daily gains than SH and BB pigs (P < 0.05). The activity of the focal pens was not influenced by the sire breed or tail lesion class, which might be due to the limited sample size of eight pens. To conclude, the use of the traditional sire breed BB has the potential to reduce injurious behaviour in the offspring. However, adjustments to the housing and feeding should be taken to further reduce the incidence of tail lesions and losses and to enhance performance.

Formation of Re-Aggregated Neonatal Porcine Islet Clusters Improves In Vitro Function and Transplantation Outcome

Neonatal porcine islet-like cell clusters (NPICCs) are a promising source for islet cell transplantation. Excellent islet quality is important to achieve a cure for type 1 diabetes. We investigated formation of cell clusters from dispersed NPICCs on microwell cell culture plates, evaluated the composition of re-aggregated porcine islets (REPIs) and compared in vivo function by transplantation into diabetic NOD-SCID IL2rγ-/- (NSG) mice with native NPICCs. Dissociation of NPICCs into single cells and re-aggregation resulted in the formation of uniform REPI clusters. A higher prevalence of normoglycemia was observed in diabetic NSG mice after transplantation with a limited number (n = 1500) of REPIs (85.7%) versus NPICCs (n = 1500) (33.3%) (p < 0.05). Transplanted REPIs and NPICCs displayed a similar architecture of endocrine and endothelial cells. Intraperitoneal glucose tolerance tests revealed an improved beta cell function after transplantation of 1500 REPIs (AUC glucose 0-120 min 6260 ± 305.3) as compared to transplantation of 3000 native NPICCs (AUC glucose 0-120 min 8073 ± 536.2) (p < 0.01). Re-aggregation of single cells from dissociated NPICCs generates cell clusters with excellent functionality and improved in vivo function as compared to native NPICCs.

Instrument localisation for endovascular aneurysm repair: Comparison of two methods based on tracking systems or using imaging

BACKGROUND

In endovascular aneuysm repair (EVAR) procedures, medical instruments are currently navigated with a two-dimensional imaging based guidance requiring X-rays and contrast agent.

METHODS

Novel approaches for obtaining the three-dimensional instrument positions are introduced. Firstly, a method based on fibre optical shape sensing, one electromagnetic sensor and a preoperative computed tomography (CT) scan is described. Secondly, an approach based on image processing using one 2D fluoroscopic image and a preoperative CT scan is introduced.

RESULTS

For the tracking based method, average errors from 1.81 to 3.13 mm and maximum errors from 3.21 to 5.46 mm were measured. For the image-based approach, average errors from 3.07 to 6.02 mm and maximum errors from 8.05 to 15.75 mm were measured.

CONCLUSION

The tracking based method is promising for usage in EVAR procedures. For the image-based approach are applications in smaller vessels more suitable, since its errors increase with the vessel diameter.

Localization of endovascular tools in X-ray images using a motorized C-arm: visualization on HoloLens

C-arms are medical devices widely used for image-guided minimally invasive endovascular procedures. This technology requires considerable experience for the physicians to position the C-arm to obtain X-ray images of the endovascular tools. In addition, this image-guided therapy is based on two-dimensional images which lack depth information. The purpose of this study was to develop a system that controls the C-arm movements based on the previous position of the tip of a guide wire and the vessel information, and also displays the estimated tip position (specifically, the virtual line that would join the X-ray source and the projected tip in the flat-panel detector) on an augmented reality device (HoloLens). A phantom study was conducted to evaluate the system using intraoperative cone-beam computed tomography scans to obtain the reference tip position. The mean distance between the tip position (ground truth) and the virtual three-dimensional line was 1.18 mm. The proposed system was able to control the C-arm movements based on the position of the tip of the guide wire. The visualization on HoloLens also allowed a more intuitive understanding of the position of the endovascular tool related to the patient’s anatomy during the intervention.

Buckle up!

Die Verkehrsmedizin als Teil der Rechtsmedizin erfüllt in der Schweiz eine wichtige präventive Aufgabe in der Sicherung aller Verkehrsteilnehmer: Sie begutachtet die medizinisch basierte Fahrfähigkeit und Fahreignung. Als empirisch konsolidiertes Querschnittsfach hat sie Informationen aus einer Vielzahl von medizinischen Fachgebieten. Wie reagiert die Verkehrsmedizin aber auf den vermehrten Anspruch evidenzbasierter Gutachten und auf anstehende Herausforderungen?

Über einen historischen Abriss motivierten wir die Vorteile und das Potential einer teilweise durch Fahrsimulation ergänzten Untersuchung und einer dediziert auf Fahrsimulation basierenden, klinisch-prospektiven Forschung.

Neben vorhandener Literatur stützen sich historische Aspekte u.a. auf vorhandene Expertise. Die Bewertung der Fahrsimulation für die Verkehrs- bzw. Rechtsmedizin der Schweiz stützt sich auf die Diskussion selektierter Literatur.

Auftrag und Anspruch der Verkehrsmedizin haben sich mehrfach verändert. Eine übersichtsartige Betrachtung existenter Literatur legt nahe, dass massgeschneiderte Fahrsimulatoren Teil einer modernisierten Verkehrsmedizin sein können, um anstehende Herausforderungen adäquat adressieren zu können. Bisher existiert kein derartiges dediziertes Forschungsinstrument in der Schweiz.

Eine auf verkehrsmedizinische Fragestellungen massgeschneiderte, realitätsnahe und niedrigschwellige Fahrsimulation als Werkzeug für klinische Studien und Individualuntersuchungen verspricht neben einer wissenschaftlichen Produktivität einen umsetzbaren und vermittelbaren Mehrwert für das übergeordnete Ziel der Sicherheit aller Verkehrsteilnehmer.

Multilevel 2D-3D Intensity-Based Image Registration

2D-3D image registration is an important task for computer-aided minimally invasive vascular therapies. A crucial component for practical image registration is the use of multilevel strategies to avoid local optima and to speed-up runtime. However, due to the different dimensionalities of the 2D fixed and 3D moving image, the setup of multilevel strategies is not straightforward.

In this work, we propose an intensity-driven 2D-3D multiresolution registration approach using the normalized gradient fields (NGF) distance measure. We discuss and empirically analyze the impact on the choice of 2D and 3D image resolutions. Furthermore, we show that our approach produces results that are comparable or superior to other state-of-the-art methods.

The -2549 -2567 del18 Polymorphism in VEGF and Irreversible Bronchoconstriction in Asthmatics

BACKGROUND

While the importance of vascular endothelial growth factor (VEGF) in the pathogenesis of several diseases (eg, neoplasms) has been proven, its role in asthma, especially in terms of the potential associations between genetic variants of VEGF and airway remodeling, has received relatively little attention. Objectives: This study aimed to evaluate the possible connection between a genetic factor, ie, the polymorphism del/ins in the VEGF promoter region, and airway remodeling potential in asthmatics with and without irreversible bronchoconstriction.

MATERIAL AND METHODS

The study population comprised 82 patients with asthma (of whom 42 had irreversible bronchoconstriction) and a group of 40 controls. DNA was isolated from peripheral blood leukocytes. Polymerase chain reaction was used to type the VEGF (18-bp deletion/insertion) gene polymorphism at loci -2549 -2567. Other factors (ie, smoking, disease duration) were also taken into consideration.

RESULTS

The del/del genotype was found in 74.39% of patients with asthma (P=.031; OR=2.38), 80.95% of patients with irreversible bronchoconstriction (P=.012; OR=3.48), and 67.5% patients with reversible bronchoconstriction (P=.251; OR=1.70). The proportion of smokers to nonsmokers was higher (P=.032) and disease duration was longer (P=.041) in patients with irreversible bronchoconstriction than in those with reversible bronchoconstriction.

CONCLUSIONS

Our results showed that the risk of irreversible bronchoconstriction in asthmatics was associated with the presence of the del18 genotype at the -2549 -2567 position in the promoter region of the VEGF gene, as were disease duration and other factors such as smoking.

„Mein Haus, mein Auto, mein Boot“. Zufriedenheit mit dem Lebensstandard als geschlechtsspezifischer Mortalitätsprädiktor

Hintergrund: Männer haben ein höheres Mortalitätsrisiko als Frauen und reagieren wesentlich sensibler auf statusbezogene Stressbelastungen. Mögliche Erklärungen für die stärker ausgeprägte männliche Empfindlichkeit liefert der über die HPA-Achse vermittelte Zusammenhang zwischen hierarchischem Rang und Gesundheit. Viel Aufmerksamkeit hat in diesem Zusammenhang das Konstrukt des Statusunbehagens erfahren, wonach soziale Vergleichsprozesse das generelle Wohlbefinden senken und als wesentliche Risikofaktoren für verschiedene Erkrankungen angesehen werden.

Methodik: Mittels Sekundärdatenanalyse des sozio-ökonomischen Panels (SOEP) soll analysiert werden, inwiefern die subjektive Unzufriedenheit mit dem eigenen Lebensstandard mit einem erhöhten geschlechtsabhängigen Mortalitätsrisiko assoziiert werden kann. Zur statistischen Modellierung der Fragestellung werden geschlechtsdifferenzierte Cox-Regressionsmodelle berechnet. Die unbalancierte Teilstichprobe umfasst 6 963 Männer (764 Todesfälle) und 7 461 Frauen (663 Todesfälle).

Ergebnisse: Unzufriedenheit mit dem eigenen Lebensstandard hat einen signifikanten Einfluss auf das Mortalitätsrisiko von Männern nicht jedoch von Frauen. Unzufriedene Männer weisen ein nahezu doppelt so hohes Mortalitätsrisiko auf als die Referenzgruppe (HR=1,95, 95% KI 1,48–2,58), Männer mit mittlerer Zufriedenheit ein um 25% höheres Mortalitätsrisiko (HR=1,26, 95% KI 1,08–1,49). Außerdem zeigt der subjektive Statusindikator stärkere Dosis-Wirkungs-Beziehungen als die klassischen objektiven Statusparameter.

Schlussfolgerung: Unzufriedenheit mit dem eigenen Lebensstandard kann mit einem erhöhten geschlechtsabhängigen Mortalitätsrisiko in Verbindung gebracht werden und erweist sich als klarer Prädiktor insbesondere für die männliche Mortalität. Eine zentrale Ursache können über die HPA-Achse vermittelte Stressreaktionen aufgrund von herabsetzenden sozialen Vergleichsprozessen zu sein. Die Ergebnisse sprechen für eine standardisierte Einbeziehung subjektiver Statusindikatoren; der ausgeprägte Geschlechterunterschied legt darüber hinaus eine geschlechtergerechte epidemiologische Datenanalyse nahe.

[Willingness of Students of Economics to Pay for Predictive Oncological Genetic Testing - An Empirical Analysis]

Objectives: The present study aims to investigate the interest of young adults in predictive oncological genetic testing and their willingness to pay for such a test. Furthermore, major determinants of the 2 variables of interest were identified. Methods: 348 students of economics from the Leibniz University of Hanover were queried in July 2013 using an extensive questionnaire. Among other things, the participants were asked if they are interested in information about the probability to develop cancer in the future and their willingness to pay for such information. Data were analysed using descriptive statistics and ordinal probit regressions. Additionally marginal effects were calculated. Results: About 50% of the students were interested in predictive oncological genetic testing and were willing to pay for the test. Moreover, the participants who were willing to pay for the test partly attach high monetary values to the information that could so be obtained. The study shows that the interest of the students and their willingness to pay were primarily influenced by individual attitudes and perceptions. Conclusions: The study proves that young adults were interested in predictive genetic testing and appreciate information about their probability of develop cancer someday.

Does Internet-based guided-self-help for depression cause harm? An individual participant data meta-analysis on deterioration rates and its moderators in randomized controlled trials

BACKGROUND

Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach.

METHOD

Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data.

RESULTS

A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29-0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit-risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.

CONCLUSIONS

Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.

Nursing Practicum in Gynaecology and Obstetrics - Early Influence Possibilities for a Specialty

Background: The shortage of skilled personnel is ubiquitous, basic and further training is a key aspect in the recruitment of new medical colleagues. The significance of the nursing practicum in its function as gateway to the gynaecology and obstetrics discipline is practically unexplored. Methods: In an online questionnaire, medical students in all German faculties were questioned about the practica in their courses. The questionnaire reached 9079 medical students. 149 participants in nursing practica were selectively asked to answer 140 questions. We analysed those students who could, on the basis of their experiences in nursing practica, imagine undertaking an internship (clinical elective) in gynaecology (internship yes "Iy") separately from those who could not or were still undecided (internship no "In" or, respectively, internship perhaps "Ip"). Results: Altogether 149 medical students who participated in a nursing practicum in the gynaecology discipline were selected, of these 94.9 % were female. 92 (61.7 %) of the students replied that, after their gynaecological nursing practicum, they wanted to undertake an internship in gynaecology (Iy); 39 (26.2 %) answered negatively (In) and 18 (12.1 %) were still undecided (Ip). With regard to the parameters gender, age and duration of study, there were no significant differences among the 3 groups (χ² 0.83). Besides the didactic and professional quality of the training, Iy also mentioned having had a higher practical orientation. They attained their aims more frequently, were better integrated in the health-care team and acquired more practical competences. Satisfaction with the practicum was evaluated as highest among the Iy. Discussion: Those students who could imagine taking an internship in gynaecology were seen to be more satisfied with their practica than those participants who declined or were undecided. The high proportion of females is an early indicator for a feminisation of the specialty. If necessary this could be countered with the help of nursing management.

The macrophage activation marker sCD163 is associated with changes in NAFLD and metabolic profile during lifestyle intervention in obese children

BACKGROUND

Obesity is associated with metabolic derangement and non-alcoholic fatty liver disease (NAFLD). Macrophages are involved in liver inflammation and fibrosis, and soluble (s)CD163 is a macrophage activation marker.

OBJECTIVES

To associate sCD163 with parameters of paediatric obesity and NAFLD, as well as changes in these parameters during lifestyle intervention.

METHODS

We studied 117 obese children during a 10-week lifestyle intervention; 71 completed the 12-month follow-up. We recorded clinical and biochemical data, and performed liver ultrasonography.

RESULTS

Baseline sCD163 was higher in children with elevated alanine transaminase (ALT) (2.3 ± 0.7 vs. 2.0 ± 0.6 mg L(-1), P = 0.03), steatosis (2.3 ± 0.7 vs. 2.0 ± 0.6 mg L(-1), P = 0.01) and high paediatric NAFLD fibrosis index (2.3 ± 0.7 vs. 1.9 ± 0.6 mg L(-1) , P = 0.03). Baseline sCD163 was independently associated with ALT, cholesterol and high-sensitivity C-reactive protein (hs-CRP). The change in sCD163 during lifestyle intervention was associated with changes in ALT, homeostatic model assessment of insulin resistance (HOMA-IR), hs-CRP and cholesterol, and inversely associated with the change in high-density lipoprotein cholesterol.

CONCLUSION

sCD163 was associated with markers of liver injury and metabolic parameters in obese children, and changes in these parameters during lifestyle intervention. This may suggest that activated macrophages play a role in NAFLD and sCD163 may serve as a marker of liver disease severity and treatment effect.

IL-10 promoter polymorphisms influence susceptibility to aGvHD and are associated with proportions of CD4+FoxP3+ lymphocytes in blood after hematopoietic stem cell transplantation

Four hundred and ninety-five patients (390 and 105 grafted from unrelated and sibling (SIB) donors, respectively) and their donors were analyzed for the impact of interleukin-10 (IL-10) promoter genotype [rs18000896 (-1082 G/A), rs18000871 (-819 C/T) and rs18000872 (-592 C/A)] on the outcome of hematopoietic stem cell transplantation (HSCT). Patients having ACC haplotype were at a lower risk of acute graft versus host disease (aGvHD, grade > I) if transplanted from human leukocyte antigen (HLA) well-matched (10/10) unrelated donors (20/135 vs 39/117, P < 0.001, Pcorr = 0.002), which was not seen if patients were transplanted from either sibling (SIB) or poorly matched (<10/10) unrelated donors (MUD). In addition, GCC haplotype positive recipients of unrelated donor transplants tended to be more susceptible to aGvHD (68/199 vs 39/169, P = 0.019, Pcorr = 0.057). Multivariate logistic regression analysis in the MUD transplanted group showed that donor-recipient human leukocyte antigen (HLA) mismatch [odds ratio (OR) = 3.937, P = 0.001] and a lack of ACC haplotype in recipients (OR = 0.417, P = 0.013) played a significant role as independent risk factors of aGvHD grade > I. ACC carriers had higher proportions of FoxP3+ lymphocytes gated in CD4+ lymphocytes as compared with patients with other IL-10 haplotypes. It was seen at the time of hematological recovery (mean ± SEM: 3.80 ± 0.91% vs 2.06 ± 0.98%, P = 0.012) and 2 weeks later (5.32 ± 0.87% vs 2.50 ± 0.83%, P = 0.013); -592 C/A polymorphism was separately analyzed and it was found that AA homozygotes tended to have a higher incidence of aGvHD (8/15 vs 116/456, P = 0.034) and low proportions of FoxP3 CD4+ lymphocytes in blood (0.43 ± 0.22% vs 4.32 ± 0.71%, P = 0.051) measured 2 weeks after hematological recovery. Functional IL-10 polymorphism associated features influenced the risk of aGvHD with a positive effect of ACC on the pool of Treg in blood.

One-year disease-related health care costs of incident vertebral fractures in osteoporotic patients

SUMMARY

The study aims to estimate the direct disease-related costs of osteoporotic vertebral compression fractures (OVCF) in patients with newly diagnosed fracture in the first year after index in Germany. Analyses reveal that OVCFs are associated with significant costs. In light of high and increasing incidence, the results emphasize importance of research in this field.

INTRODUCTION

OVCF are among the most common fractures related to osteoporosis. They have been shown to be associated with excess mortality and meaningful healthcare costs. Costs calculations have illustrated the significant financial burden to society and national social security systems. However, this information is not available for Germany. Therefore, aim of the study was to estimate the direct disease-related costs of OVCF in patients with newly diagnosed fracture in the first year after index in Germany.

METHODS

Data were obtained from a claims dataset of a large German health insurance fund. Subjects ≥ 60 years with a new vertebral fracture between 2006 and 2010 were studied retrospectively compared to a matched paired OVCF-free patient group. All-cause and fracture-specific medical costs were calculated in the 1-year baseline and follow-up period. Generalized linear model (GLM) was estimated for total follow-up healthcare cost.

RESULTS

A total of 2,277 pairs of matched OVCF and OVCF-free patients were included in the analysis. Baseline costs were higher in the OVCF group. Mean unadjusted all-cause healthcare cost difference in the four quarters following the index date between OVCF and OVCF-free patients was 8,200 <euro> (p < 0.001). Of the difference, almost two third was attributable to inpatient services and one quarter to prescription drug costs. The GLM procedure revealed that OVCF-related costs in the first year after the index date add up to 6,490 <euro> (p < 0.001; CI 5,809 <euro>-6,731 <euro>).

CONCLUSIONS

Despite limitations of this study, our results are consistent with other research and demonstrate that OVCFs are associated with significant costs. The results underline the importance of medical interventions that can help to prevent fractures and treatments, which are cost-effective and can prevent recurrent fractures.

Lipidspeicherung in permanenten Mäusefibroblasten (L-strain, Earle) in Abhängigkeit von der Serumkonzentration Histochemische und quantitative Untersuchungen

Es wird über Untersuchungen an einem permanenten Zellstamm (Mäusefibroblasten, L-strain, Earle) in der Gewebekultur berichtet, die sich mit der Lipidspeicherung dieser Zellen in Abhängigkeit von der Serumkonzentration befassen. Die Untersuchungen wurden morphologisch im Phasenkontrastmikroskop, histochemisch mittels der Sudanschwarz-B-Färbung sowie quantitativ vorgenommen.

Bei steigender Serumzugabe zeigt sich eine zunehmende Lipideinlagerung, die als Speicherungsprozeß gedeutet wird. Eine gewisse Absättigung der Lipidaufnahme scheint mit 20-proz. Serumzusatz erreicht zu sein, da sich darüber hinaus keine Zunahme mehr beobachten ließ.

Bei hohem Serumzusatz (ca. 40%) zum Nährmedium kommt es zu einer relativ verringerten Aufnahme von Phospholipiden bei Zunahme der Neutralfette.

[Tibiocalcaneal arthrodesis with retrograde nails. Description of a hindfoot procedure after massive talus destruction]

Following loss of the talus, tibiocalcaneal fusion is often the only available means of obtaining weight-bearing ability in the lower limb. Length discrepancy may be managed with an allograft. This casuistic describes 6 patients with tibiocalcaneal fusion (mean age 64 years) who had received a structural femoral head allograft fusion for failed total ankle arthroplasty (3 cases), Charcot arthropathy (2 cases) and osteomyelitis (1 case). The mean follow-up was 33 months and all limbs could be salvaged. There were two cases of non-union (one with infection). The mean AOFAS score was 51 and the mean Mazur score was 37. In the SF-36 the mean PCS was 34.4 and the mean MCS was 48.4. It was shown that in the hindfoot, as at other sites, allografts may be used for the filling of major bone defects; however, the patient function will still be massively impaired. Therefore, the procedure should be confined to cases where less complex and less invasive techniques are unlikely to be of benefit.

How to become a tree without wood--biomechanical analysis of the stem of Carica papaya L

Carica papaya L. does not contain wood, according to the botanical definition of wood as lignified secondary xylem. Despite its parenchymatous secondary xylem, these plants are able to grow up to 10-m high. This is surprising, as wooden structural elements are the ubiquitous strategy for supporting height growth in plants. Proposed possible alternative principles to explain the compensation for lack of wood in C. papaya are turgor pressure of the parenchyma, lignified phloem fibres in the bark, or a combination of the two. Interestingly, lignified tissue comprises only 5-8% of the entire stem mass. Furthermore, the phloem fibres do not form a compact tube enclosing the xylem, but instead form a mesh tubular structure. To investigate the mechanism of papaya's unusually high mechanical strength, a set of mechanical measurements were undertaken on whole stems and tissue sections of secondary phloem and xylem. The structural Young's modulus of mature stems reached 2.5 GPa. Since this is low compared to woody plants, the flexural rigidity of papaya stem construction may mainly be based on a higher second moment of inertia. Additionally, stem turgor pressure was determined indirectly by immersing specimens in sucrose solutions of different osmolalities, followed by mechanical tests; turgor pressure was between 0.82 and 1.25 MPa, indicating that turgor is essential for flexural rigidity of the entire stem.

A systematic review of cost-effectiveness of monoclonal antibodies for metastatic colorectal cancer

Metastatic colorectal cancer (mCRC) imposes a substantial health burden on patients and society. In recent years, advances in the treatment of mCRC have mainly resulted from the introduction of monoclonal antibodies (MoAbs). However, the application of these MoAbs considerably increases treatment costs. The objective of this article is to review and assess the economic evidence of MoAB treatment in mCRC. A systematic literature review was conducted and cost-effectiveness (CE) as well as cost-utility-studies were identified. For this, Medline, Embase, SciSearch, Cochrane, and nine other databases were searched from 2000 through February 2013 for full-text publications. The quality of the studies was assessed via a validated assessment tool (Quality of Health Economic Studies (QHES)). A total of 843 publications were screened. Of those, 15 studies involving the MoAbs bevacizumab, cetuximab and panitumumab met all inclusion criteria. Four studies analysed the CE of first-line treatment with bevacizumab and nine the CE of cetuximab in subsequent treatment lines. Two studies dealt with the CE of panitumumab. The analysis of sequential regimes and the direct comparison of two MoABs were analysed by only one study each. The quality of the included studies was high with the exception of one study.

CONCLUSIONS

The treatment with bevacizumab, cetuximab and panitumumab is mainly considered to be not cost-effective in patients with mCRC. However, testing for Kirsten ras oncogene (KRAS) mutation prior to the treatment with cetuximab or panitumumab is found to be clearly cost-effective compared to no testing. Future research should focus on the CE of first-line treatment with cetuximab or panitumumab and studies on upcoming agents like regorafenib and aflibercept.

'Immunogenetics of Aging': report on the activities of the 15th International HLA and Immunogenetics Working Group and 15th International HLA and Immunogenetics Workshop

'Immunogenetics of Aging' is a component that was first included in the 14th International HLA and Immunogenetics Workshop (IHIWS) and developed further within the 15th Workshop. The aim of this component was to assess the impact of human leukocyte antigen (HLA) genes, cytokine genes, and some innate immunity genes such as killer-cell immunoglobulin-like receptors (KIRs) and mannose-binding lectin 2 (MBL2) in successful aging and their contribution to the better understanding of immune dysfunction in old age. Within the 15th IHIWS new populations were included in the analysis. Additional cytokine gene polymorphisms were assessed and innate immunity genes were analyzed for possible relevance in longevity. The results showed that longevity might be associated with anti-inflammatory cytokine gene profiles, decreased frequency of interleukin-10 (IL-10) and transforming growth factor-B1 haplotypes associated with a low level of gene expression, and increased frequency of haplotypes determining a high level of expression. Extended tumor necrosis factor-A and IL-12B genotypes were also likely relevant to longevity. Data also showed that innate immunity genes are associated with susceptibility to infections in the elderly and showed that these genes might be an important genetic marker in aging. Decreased frequencies of KIR2DS5 and A1B10 haplotypes, and an increased proportion of MBL2-deficient haplotypes were found in the group with higher cytomegalovirus-specific IgG antibody levels. Together, these studies emphasize the relevance of genes regulating immune functions in maintaining human longevity and stress the importance of further clarifying their impact on successful aging.

Interleukin-17-producing cells increase among CD4+ lymphocytes before overt manifestation of acute graft-versus-host disease

Interleukin-17A is a hallmark of a subset of CD4+ lymphocytes called T(H)17. Allogeneic hematopoietic stem cell transplantation (HSCT) induces an immune response that facilitates graft acceptance, but if clinically apparent as acute graft-versus-host disease (aGvHD), it may adversely affect transplantation outcomes. TH17 cells are involved in the inflammatory processes associated with several diseases, including inflammatory bowel disease (IBD) as a prototype. In this study we investigated the presence of IL-17-producing cells among peripheral blood mononuclear cells (PBMC) of patients after HSCT. The 48 patients of median age 45 years (range, 1.0-64 years), experienced hematologic malignancies (n=45) or nonmalignant disorders (n=3), treated with matched unrelated (n=24) or sibling (n=24) transplants. We examined IL-17-producing cells in alloreactive reactions after HSCT. PBMC were stimulated with BD Leukocyte Activation Cocktail (Ionomycin, Brefeldin A, and phorbol myristic acetate (PMA)) in the presence of BD GolgiStop. After stimulation the cells were labeled with anti-CD4 and intracellular anti-IL-17A monoclonal antibodies. IL-17+ cell proportions were analyzed in the CD4+ lymphocyte gate. We observed that patients at the time of hematologic reconstitution had higher proportions of IL-17-producing cells than healthy control subjects (0.73±0.13 vs 0.19±0.06%; P=.019). Fourteen patients displayed the first symptoms of aGvHD at the time of hematologic reconstitution, when they showed lower proportions of IL-17+ cells among CD4+ lymphocytes than their counterparts lacking aGvHD at a similar time after transplantation (0.29±0.09 vs 0.73±0.13%; P=.024). Eight patients developed aGvHD after hematologic reconstitution (median, 34 days). All of these patients displayed lower proportions of IL-17-producing CD4+ cells on the day of aGvHD compared with their initial measurements preceding this complication (0.34±0.14 vs 1.07±0.37%; P=.01).

Effect of weight reduction on insulin sensitivity, sex hormone-binding globulin, sex hormones and gonadotrophins in obese children

OBJECTIVE

Obesity in men is associated with reduced insulin sensitivity and hypoandrogenism, while obesity in women is associated with reduced insulin sensitivity and hyperandrogenism. In children, the effect of obesity and weight reduction on the hypothalamo-pituitary-gonadal axis is rarely investigated. The aim of the present study was to investigate the effect of weight reduction in obese Caucasian children on insulin sensitivity, sex hormone-binding globulin (SHBG), DHEAS and the hypothalamo-pituitary-gonadal axis.

METHODS

One hundred and sixteen (65 females) obese children with a median age of 12.3 (7-15) years were examined before and after a 10-week stay at a weight loss camp. Examination included anthropometry and fasting blood samples measuring plasma glucose, serum insulin, SHBG, DHEAS, testosterone, 17β-oestradiol, FSH and LH.

RESULTS

Body mass index (BMI) decreased (P<0.01), insulin sensitivity and SHBG increased (P<0.01), independent of gender and puberty. The changes in insulin sensitivity and the changes in SHBG correlated significantly (P<0.01) independent of gender, puberty and the changes in BMI. Testosterone increased in boys (P<0.01) and tended to decrease in girls (P=0.05, in girls after menarche (P=0.03)). FSH increased in boys and girls. LH increased in boys and was unchanged in girls.

CONCLUSIONS

During weight loss, insulin sensitivity and SHBG increased significantly in obese children, and the changes in insulin sensitivity and the changes in SHBG correlated significantly independent of gender, puberty and the changes in BMI. There was sexual dimorphism in the changes of testosterone, with the changes in boys towards increased virilisation and the changes in girls towards less virilisation.

Activity of the National Polish Bone Marrow Donor Registry--analysis of the matching process successfully completed with hematopoietic stem cell transplantation

The activity of the National Polish Bone Marrow Donor Registry includes: (1) recruitment and typing of volunteer donors for the registry; (2) primary and confirmatory typing of patients and their families for sibling and family alternative donor transplantations; and (3) donor-recipient matching. There has been an improvement regarding the number of procedures (184 vs 201) and the successfully completed matches (102 vs 145) in 2006-2007 vs 2008-2009, respectively. The success rate of conclusive matching depended on the number of donors in a given registry and the incidence of rare HLA B-C or DR-DQ associations and specificities. In 2008-2009, Polish, German and all European registries, finally matched 129 (out of all 145) donors including 3, 18, 4 donors for patients with and 30, 68, 6 donors for patients without difficult HLA specificities and associations, respectively. Among the HLA-difficult patient group those lacking a donor in Europe and Israel were successfully matched in the USA (10/11 patients); the only one other subject was matched with a donor from Australia.