Derotational distal femoral osteotomy corrects excessive femoral anteversion in patients with patellofemoral instability: A systematic review

PURPOSE

Patellofemoral instability (PFI) is a common condition that can be caused from multiple factors, including lower limb rotational malalignments. Determining precise criteria for performing corrective torsional osteotomy can be a daunting task due to the lack of consensus on normal and excessive values and the limited evidence-based data in the postoperative results. The purpose was to assess the clinical, functional and imaging outcomes following derotational distal femoral osteotomy (DDFO) in patients with PFI and/or anterior knee pain (AKP) associated with lower limb rotational malalignments.

METHODS

Searches were conducted on PubMed, EMBASE and Web of Science databases up to October 2023. Studies reporting outcomes after DDFO in patients with PFI and/or AKP were eligible for the systematic review. The primary outcome was imaging metrics, especially femoral anteversion. Secondary outcomes included the patient-reported outcome measures (PROMs) (clinical and functional). Quantitative synthesis involved the use of weighted averages to calculate pre- to postoperative mean differences (MD) and compare them against the minimal clinically important difference (MCID).

RESULTS

Ten studies (309 knees) were included with a mean follow-up of 36.1 ± 11.7 months. Imaging outcomes consistently indicated the correction of femoral anteversion (MD = -19.4 degrees, 95% confidence interval: -20.1 to -18.7) following DDFO. PROMs showed significant improvements in most studies, exceeding the MCID. Patient satisfaction with the DDFO was high (93.3%).

CONCLUSIONS

The DDFO was an effective treatment option for correcting excessive femoral anteversion in patients with PFI associated with clinically relevant functional and clinical improvement and a high satisfaction rate.

LEVEL OF EVIDENCE

Level IV, systematic review of level II-IV studies.

Derotational high tibial osteotomy in cases of anterior knee pain and/or patellofemoral instability: a systematic review

IMPORTANCE

Derotational high tibial osteotomy (HTO) is a surgical intervention for correcting rotational malalignments in the lower limb, which may contribute to anterior knee pain (AKP) and/or patellofemoral instability (PFI). This surgical technique is not yet widely implemented and requires a systematic evaluation of its outcomes.

AIM

To assess the effectiveness of derotational HTO in correcting rotational malalignments of the lower limb in patients with AKP and/or PFI through radiological, clinical, and patient-reported outcome measures.

EVIDENCE REVIEW

Searches were conducted in the PubMed, Embase, and Web of Science databases up to March 3, 2023, to identify studies utilizing derotational HTO in patients with AKP and/or PFI. The primary outcome measures of interest were measurements of lower limb angular correction. Other radiological, clinical, and patient-reported outcome measures were also analyzed. The risk of bias was judged with the RoBANS tool.

FINDINGS

A total of 8 studies were included, comprising 215 patients (27.0 ​± ​3.9 years) and 245 knees. The most reported angle was tibial torsion (k ​= ​6 studies, n ​= ​173 knees), with a mean difference between postoperative and preoperative values (postsurgical correction) ranging from -37.8° to -10.8°. Patient-reported outcome measures showed significant improvements in the postoperative moment, exceeding the minimal clinically important difference in almost all cases, and with high patient satisfaction (93.6%).

CONCLUSIONS AND RELEVANCE

Derotational HTO allows the correction of rotational malalignments of the lower limb (tibial torsion) and promotes patient satisfaction.

LEVEL OF EVIDENCE

Level IV.

Meniscal extrusion in knees with and without osteoarticular pathology: A systematic review of normative values and cut-offs for diagnostic criteria

BACKGROUND

Meniscus extrusion is crucial for the diagnosis and treatment of meniscal injury, but the literature on this topic has not yet been systematized. The purpose of this systematic review was to compare diagnostic methods and summarize the data of medial and lateral meniscal extrusion in knees with and without osteoarticular pathology.

METHODS

This systematic review was conducted according to the PRISMA 2020 statement. Searches were conducted on PubMed, EMBASE and Cochrane databases to identify studies that measured meniscal extrusion using magnetic resonance imaging (MRI) or ultrasound (US). Meniscal extrusion data was summarized as weighted mean for medial and lateral meniscus, and stratified according to the method of measurement (MRI or US) and presence of knee osteoarticular pathology.

RESULTS

A total of 26 studies were included in this review. Weighted mean values of meniscal extrusion were always higher for the medial than the lateral meniscus, regardless of the method of measurement. The medial meniscus extrusion was always higher in knees with osteoarticular pathology than those without. For the lateral meniscus extrusion, the mean values were higher in those knees without osteoarticular pathology. When classifying pathological meniscal extrusion with pre-defined cut-off values, the higher the cut-off used, the lower the percentage of knees classified as pathological meniscal extrusion.

CONCLUSIONS

The medial meniscus presents on mean higher extrusion and extrusion is higher in knees with osteoarticular pathology. Based on summary data, the most suitable cut-offs for pathological meniscal extrusion for both MRI and US seem to fall within >2 and >3 mm.

Inconsistency in Shoulder Arthrometers for Measuring Glenohumeral Joint Laxity: A Systematic Review

There is no consensus on how to measure shoulder joint laxity and results reported in the literature are not well systematized for the available shoulder arthrometer devices. This systematic review aims to summarize the results of currently available shoulder arthrometers for measuring glenohumeral laxity in individuals with healthy or injured shoulders. Searches were conducted on the PubMed, EMBASE, and Web of Science databases to identify studies that measure glenohumeral laxity with arthrometer-assisted assessment. The mean and standard deviations of the laxity measurement from each study were compared based on the type of population and arthrometer used. Data were organized according to the testing characteristics. A total of 23 studies were included and comprised 1162 shoulders. Populations were divided into 401 healthy individuals, 278 athletes with asymptomatic shoulder, and 134 individuals with symptomatic shoulder. Sensors were the most used method for measuring glenohumeral laxity and stiffness. Most arthrometers applied an external force to the humeral head or superior humerus by a manual-assisted mechanism. Glenohumeral laxity and stiffness were mostly assessed in the sagittal plane. There is substantial heterogeneity in glenohumeral laxity values that is mostly related to the arthrometer used and the testing conditions. This variability can lead to inconsistent results and influence the diagnosis and treatment decision-making.

Association between respiratory clinical signs and respiratory localization in dogs and cats with abnormal breathing patterns

The diagnostic values of respiratory signs have been under-investigated in pets. The study aim was to explore commonly assumed associations between respiratory signs and disease localization in pets with abnormal breathing patterns (ABP). Dogs and cats with ABP presenting to three hospitals were included if investigations permitted disease localization. Hypothesized associations between respiratory signs and disease location were evaluated via mixed-effects logistic regression. Sensitivity, specificity, and positive diagnostic likelihood ratio were calculated. One-hundred and fifteen dogs and 49 cats with ABP were recruited. Confirmed associations included: inspiratory effort with extra-thoracic airway disease (odds ratio [OR], 9.1; 95% confidence interval [95% CI] 3.0-27.2); expiratory effort with intra-thoracic airway disease (OR, 6.5; 95% CI, 2.3-18.1); paradoxical breathing and attenuation of heart/lung sounds with pleural space disease (paradoxical breathing: OR, 4.5; 95% CI 1.7-12.1; sound attenuation: OR, 11.5; 95% CI 4.0-33.3); decreased nasal airflow and stertor with nasal/pharyngeal disease (nasal airflow: OR, 26.2; 95% CI 8.1-84.8; stertor: OR, 155.2; 95% CI 24.9-968.8); stridor with laryngeal or tracheal disease (laryngeal disease: OR, 39.9; 95% CI 7.6-209.0; tracheal disease: OR, 32.4; 95% CI 4.2-248.0); tracheal sensitivity with bronchial disease (OR, 3.8; 95% CI 1.5-9.6); crackles with pulmonary or bronchial disease (pulmonary disease: OR, 5.4; 95% CI 2.1-13.8; bronchial disease: OR, 3.9; 95% CI 1.6-9.8); and goose honking with tracheal disease (all dogs with goose honking had tracheal involvement). Select respiratory signs provide guidance to localize and prioritize causes of the underlying respiratory disease in pets, allowing targeted interventions in animals with ABP.

Physical Activity During the COVID-19 Pandemic in People with Severe Mental Disorders: An Overview of the Portuguese Reality

N/a.

Anaphylaxis: A Decade of a Nationwide Allergy Society Registry

BACKGROUND AND OBJECTIVES

Anaphylaxis is an acute, life-threatening, multiorgan hypersensitivity reaction. Objective: The aim of this study was to identify the causes of anaphylaxis in Portugal in order to improve our knowledge of epidemiology and management.

METHODS

We implemented a nationwide notification system for anaphylaxis over a 10-year period, with voluntary reporting by allergists. Data on 1783 patients with anaphylaxis were included. Etiopathogenesis, manifestations, and clinical management were characterized in detail for both children and adults.

RESULTS

The mean age was 32.7 (20.3) years, and 30% were under 18 years of age; 58% were female. The mean age at the first anaphylaxis episode was 27.5 (20.4) years (ranging from 1 month to 88 years). The main culprits of anaphylaxis were foods (48%), drugs (37%) (main trigger in adults, 48%), and hymenoptera venom (7%). The main culprit foods were shellfish (27%), fresh fruit (17%), cow's milk (16%), tree nuts (15%), fish (8%), egg (7%), and peanut (7%). The main drugs were nonsteroidal anti-inflammatory drugs (43%), antibiotics (39%), and anesthetic agents (6%). Other causes included exercise (3%), latex (2%), cold-induced anaphylaxis (2%), and idiopathic anaphylaxis (2%). Most patients (80%) were admitted to the emergency department; only 43% received adrenaline. Anaphylaxis recurred in 41% of patients (21% with ≥3 anaphylactic episodes); 7% used an adrenaline autoinjector device.

CONCLUSION

Food is the leading cause of anaphylaxis in Portugal, while drugs were the main elicitors in adults. We emphasize undertreatment with adrenaline and recurrent episodes, highlighting the need to improve diagnostic and therapeutic approaches to anaphylaxis.

Growth kinetics of Myceliophthora thermophila M.7·7 in solid-state cultivation

AIMS

This work aimed to estimate the growth of Myceliophthora thermophila M.7·7 in solid-state cultivation (SSC) through quantification of N-acetyl-d-glucosamine (NAG) and enzyme activity.

METHODS AND RESULTS

The fungus was cultivated in sugarcane bagasse and wheat bran. A consistent statistical analysis was done to assess the reliability of experimental data. Logistic model equation was fitted to experimental data and growth parameters were estimated. The results showed strong influence of the sample size on NAG and a minimum recommended sample size was identified. Scanning electron microscopy (SEM) was used to identify the strategy of substrate colonization. Wheat bran was attacked firstly, while sugarcane bagasse was consumed after wheat bran depletion. The biomass growth was poorly estimated by secretion kinetics of α-amylase, endoglucanase, protease and xylanase, but enzyme kinetics were important for understanding substrate colonization.

CONCLUSIONS

In conclusion, the NAG concentration was strongly affected by the sample size and sampling procedure. The strategy of fungal colonization on the substrates was well characterized through SEM analysis. The colonization strategy has direct influence on the kinetic parameters of the logistic model. Myceliophthora thermophila has a well-defined dynamic of enzyme secretion to degrade the substrate, although the kinetics of enzyme secretion has shown not adequate to characterize the kinetics of fungal growth.

SIGNIFICANCE AND IMPACT OF THE STUDY

The paper provides reliable growth kinetic parameters in the SSC of the cellulase producer fungus M. thermophila M.7·7, as well as a robust analysis on three indirect methods (NAG, enzymes and SEM) for estimation of fungal development.

Improving medical emergency system: Results of a multi-professional questionnaire

OBJECTIVE

This study aimed to identify ways to improve the Medical Emergency System (MES) in its different components and infer Medical Emergency Team (MET) activation failure causes.

METHODS

A questionnaire regarding opinions and attitudes towards the MES was conducted, targeting all professionals at the hospital, which has an implemented MES with Basic Life Support (BLS) since 1998.

RESULTS

Thirty two percent (n=585) of hospital professionals answered, from these 37.8% were neither doctors nor nurses. In mean six years passed since the BLS certification, yet 102 professionals (17.4%) had not done it. A relevant percentage admitted to not being familiarized with the different components of the MES (activation criteria 16.4%, telephone number 4.1%, content of the resuscitation trolleys 42.4% and defibrillator-monitor 47.4%), percentages lessened among those had taken the BLS course. The majority highly valued MET, however 83 (23%) could not confirm that debriefingand 17 (4.4%) that allocation of tasks happened after and during activation, respectively. When activating MET 52 (18.1%) admitted fear of criticism and 38 (13.3%) agreed that they needed validation by another professional, factors not influenced by BLS course completion. Excessive workload as a barrier to recognize ill patients was pointed by 127 (45.7%) of the respondents.

CONCLUSION

Despite educational and auditing efforts, the MES is not fully integrated into hospital culture. BLS certification for all professionals and non-technical skills of MET were identified has major areas for MES improvement. Unfamiliarity with activation criteria, fear of criticism and excessive workload were identified as failure of activation causes.

Structure, conductivity and magnetism of orthorhombic and fluorite polymorphs in MoO3-Ln2O3 (Ln = Gd, Dy, Ho) systems

Phase-pure orthorhombic compositions at a Ln/Mo ratio ∼ 5.2-5.7 (Ln = Gd, Dy, Ho) have been obtained for the first time by prolonged (40-160 h) heat treatment of mechanically activated 5Ln2O3 + 2MoO3 (Ln = Gd, Dy, Ho) oxide mixtures at 1200 °C. Although the starting Ln : Mo ratio was 5 : 1 (Ln10Mo2O21 (Ln = Dy, Ho)), it changed slightly in the final product due to the volatility of molybdenum oxide at 1200 °C (40-160 h) (ICP-MS analysis). Brief high-temperature firing (1600 °C, 3 h) of 5Ln2O3 + 2MoO3 (Ln = Gd, Dy, Ho) oxide mixtures leads to the formation of phase-pure fluorites with compositions close to Ln10Mo2O21 (Ln = Gd, Dy, Ho). Gd10Mo2O21 molybdate seems to undergo an order-disorder (orthorhombic-fluorite) phase transition in the range of 1200-1600 °C. For the first time, using the neutron diffraction method, it was shown that low-temperature phases with a Ln/Mo ratio ∼ 5.2-5.7 (Ln = Gd, Dy, Ho) have an orthorhombic structure rather than a tetragonal structure. Proton contribution to the total conductivity of Ln10Mo2O21 (Ln = Gd, Dy, Ho) fluorites and gadolinium and dysprosium orthorhombic phases in a wet atmosphere was observed for the first time. In both orthorhombic and fluorite phases, the total conductivity in wet air decreases with decreasing lanthanide ionic radii. In a wide temperature range, the compounds under study exhibit paramagnetic behaviour. However, the orthorhombic phases of Dy and Ho compounds reach the antiferromagnetic state at 2.4 K and 2.6 K, respectively.

Challenges in handling congenital anomalies clusters: a recent mediatic example in France

Issue

In 2018 in France, reports of aggregated cases of isolated transverse limb reduction defects, a rare congenital anomaly (1.7 for 10,000 total births) generated a large mediatic interest with environmental factors overtly pointed out. Our aim is to describe the investigations carried out and to share the challenges we met.

Description of the response

Over a period of 5 years (2010-2015), 3 aggregates were signaled by health professionals in 3 different areas in France. Investigations included case ascertainment, epidemiological analyses, and search for a common exposure. Standardized Incidence Ratios were computed using the 6 French registries’s data as reference. In one area, the local registry performed a concurrent analysis using satscan. Parents filled a questionnaire addressing environmental and occupational exposures. Environmental databases were consulted as well as animal health surveillance data.

Results

Fourteen cases met the case definition. The excess of cases was ascertained in two aggregates located in a two small towns in the western part of France and comprising respectively 3 children born in 2007-2008 (SIR: 87.8 CI95%:[17-256]) and 4 children born in 2011-2013 (79.8 [2.5-204.2]). The third signal included 7 cases born between 2009 and 2014 residing in 7 towns located above the Alps and did not yield a significant excess when related to expected cases in the administrative subdivision (0.94 [0.38-1.95]). The concurrent analysis found a significant excess, generating a lengthy debate. None of the investigations identified a common cause or notable exposure. Delayed feedback and negative conclusions led to incomprehension among families.

Lessons

Informing stakeholders timely is crucial but communicating effectively about methods used and negative results can be challenging.

Key messages

Congenital anomalies clusters are sensitive topics. Cluster investigations involve a scientific and a societal component that must both be taken into account in organizing the public health response.

Evolution of Oxygen-Ion and Proton Conductivity in Ca-Doped Ln2Zr2O7 (Ln = Sm, Gd), Located Near Pyrochlore-Fluorite Phase Boundary

Sm_2-xCa_xZr₂O_7-x/2 (x = 0, 0.05, 0.1) and Gd_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) mixed oxides in a pyrochlore-fluorite morphotropic phase region were prepared via the mechanical activation of oxide mixtures, followed by annealing at 1600 °C. The structure of the solid solutions was studied by X-ray diffraction and refined by the Rietveld method, water content was determined by thermogravimetry (TG), their bulk and grain-boundary conductivity was determined by impedance spectroscopy in dry and wet air (100-900 °C), and their total conductivity was measured as a function of oxygen partial pressure in the temperature range: 700-950 °C. The Sm_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) pyrochlore solid solutions, lying near the morphotropic phase boundary, have proton conductivity contribution both in the grain bulk and on grain boundaries below 600 °C, and pure oxygen-ion conductivity above 700 °C. The 500 °C proton conductivity contribution of Sm_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) is ~ 1 × 10^-4 S/cm. The fluorite-like Gd_2-xCa_xZr₂O_7-x/2 (x = 0.1) solid solution has oxygen-ion bulk conductivity in entire temperature range studied, whereas proton transport contributes to its grain-boundary conductivity below 700 °C. As a result, of the morphotropic phase transition from pyrochlore Sm_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) to fluorite-like Gd_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1), the bulk proton conductivity disappears and oxygen-ion conductivity decreases. The loss of bulk proton conductivity of Gd_2-xCa_xZr₂O_7-x/2 (x = 0.05, 0.1) can be associated with the fluorite structure formation. It is important to note that the degree of Ca substitution in such solid solutions (Ln_2-xCa_x)Zr₂O_7-δ (Ln = Sm, Gd) is low, x < 0.1. In both series, grain-boundary conductivity usually exceeds bulk conductivity. The high grain-boundary proton conductivity of Ln_2-xCa_xZr₂O_7-x/2 (Ln = Sm, Gd; x = 0.1) is attributable to the formation of an intergranular CaZrO₃-based cubic perovskite phase doped with Sm or Gd in Zr sublattice.

Structure and conductivity of Nd6MoO12-based potential electron–proton conductors under dry and wet redox conditions

Based on rhombohedral structure (R3̄) complex Nd₁₀Mo₂O₂₁ compound has proton conductivity ∼8 × 10⁻⁴ S cm⁻¹ at 600 °C.

Ultrasound-guided removal of vegetal foreign bodies in the lower extremities of dogs: a retrospective study of 19 cases

Subcutaneous abscesses or granulomas in the lower extremities of dogs commonly occur secondary to the penetration and migration of vegetal foreign bodies (FBs). The aim of this study was to describe the clinical presentation and ultrasonographic appearance of intact grass awn FBs in the lower extremities of dogs, and their ultrasound-guided retrieval with particular emphasis on the feasibility, effectiveness and prognosis associated with this technique. In this retrospective study, 22 FBs were identified ultrasonographically in 19 dogs. The procedure resulted in the successful retrieval of the FB in 100% of dogs, and the clinical signs resolved in 90% (n=17) in less than ten days. No complications or recurrence were encountered. This study shows that ultrasonographic examination should be the first-choice modality when a vegetal FB is suspected within the distal extremity, as it allows both identification and removal of the FB with a minimally invasive procedure, with short- and long-term effectiveness and good prognosis.

The impact of the patient post-intensive care syndrome components upon caregiver burden

OBJECTIVE

To evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden.

DESIGN

A prospective observational study was conducted over 26 months (January 2013-February 2015).

SETTING

Medical-surgical ICU and follow-up consultation in Portugal.

PATIENTS OR PARTICIPANTS

Patients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study.

MAIN VARIABLES OF INTEREST

In ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder).

RESULTS

A total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden. Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008). When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden.

CONCLUSIONS

The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

Non-steroidal anti-inflammatory drug hypersensitivity in children

INTRODUCTION

There are rather few publications about hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAID) in the paediatric age. In this study, we aimed to assess the frequency of confirmed NSAID hypersensitivity in children with a previous reported reaction to NSAID in order to investigate the role of the drug provocation test (DPT) in the diagnostic workup and to explore the factors associated with confirmed NSAID hypersensitivity.

METHODS

We conducted a retrospective analysis of the clinical files from every patient under 18 years old who attended two Portuguese paediatric allergy outpatient clinics, from January 2009 to August 2014, due to a suspected NSAID hypersensitivity.

RESULTS

We included 119 patients, with a median age of nine years (P₂₅-P₇₅: 5-14). Ibuprofen was the commonest implicated NSAID in the patients' reports (n=94-79%). After DPT, NSAID hypersensitivity was confirmed in nine (7.6%) patients, excluded in 93 (78.2%) and was inconclusive in 17 (14.3%). In the majority (n=95-79.8%), the reaction occurred in the first 24h after intake. Eighty-four patients (70.6%) reported only cutaneous manifestations and 18 (15.1%) had systemic symptoms. Anaphylaxis represented a relative risk to NSAID hypersensitivity confirmation. No association was found for atopy and the number of previous reactions.

CONCLUSION

In our study, NSAID hypersensitivity was confirmed in a small proportion of the patients with a previous reported reaction. Ibuprofen was the most implicated drug with urticaria/angio-oedema as the commonest manifestation. Anaphylaxis was associated with confirmed drug hypersensitivity. The drug provocation test was essential to establish the diagnosis.

Quality of life and physical activity levels in outpatients with schizophrenia

Objectives:

To assess quality of life (QoL) and physical activity (PA) levels of outpatients with schizophrenia and healthy controls matched for age, gender, body mass index (BMI), hip circumference, waist circumference, and waist-to-hip ratio. Additionally, the present study investigated associations between PA levels, QoL, and anthropometric and behavioral measures among outpatients with schizophrenia.

Methods:

Thirty-two outpatients with schizophrenia and 32 individuals without mental illness were included in the study. QoL and PA levels were assessed by the World Health Organization Quality of Life Instrument - Abbreviated version (WHOQOL-Bref) and by GT3X triaxial accelerometers, respectively.

Results:

Outpatients with schizophrenia had poorer QoL and lower vigorous PA levels compared with healthy controls (p < 0.05). The group with schizophrenia showed a significant association between higher weight and lower scores in the mental health domain of the WHOQOL-Bref. A higher BMI was also significantly associated with lower scores in the physical health domain of the WHOQOL-Bref. Schizophrenic patients with smoking behaviors were associated with fewer steps per day and with less moderate to vigorous PA.

Conclusions:

This study seeks to shed some light upon the lifestyle of patients with schizophrenia. New psychosocial approaches should focus on PA, weight, and smoking management, thereby helping these patients to improve their QoL.

Drug allergy passport and other documentation for patients with drug hypersensitivity - An ENDA/EAACI Drug Allergy Interest Group Position Paper

The strongest and best-documented risk factor for drug hypersensitivity (DH) is the history of a previous reaction. Accidental exposures to drugs may lead to severe or even fatal reactions in sensitized patients. Preventable prescription errors are common. They are often due to inadequate medical history or poor risk assessment of recurrence of drug reaction. Proper documentation is essential information for the doctor to make sound therapeutic decision. The European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology have formed a task force and developed a drug allergy passport as well as general guidelines of drug allergy documentation. A drug allergy passport, a drug allergy alert card, a certificate, and a discharge letter after medical evaluation are adequate means to document DH in a patient. They are to be handed to the patient who is advised to carry the documentation at all times especially when away from home. A drug allergy passport should at least contain information on the culprit drug(s) including international nonproprietary name, clinical manifestations including severity, diagnostic measures, potential cross-reactivity, alternative drugs to prescribe, and where more detailed information can be obtained from the issuer. It should be given to patients only after full allergy workup. In the future, electronic prescription systems with alert functions will become more common and should include the same information as in paper-based documentation.

Reliability and validity of 6MWT for outpatients with schizophrenia: A preliminary study

Although the 6-minute walk test (6MWT) has been widely used in patients with schizophrenia, there is a lack of scientific evidence about its reliability and validity in this population. The first goal of this study was to explore the test-retest reliability of the 6MWT and to identify the associated parameters that contribute to the variability of the distance walked during the 6MWT in outpatients with schizophrenia. The second goal was to assess the criterion validity of the 6MWT in men with schizophrenia. Fifty one outpatients with schizophrenia participated in the study. To test-retest reliability (men=39; women=12), participants performed the 6MWT twice within 3 days interval. To test criterion validity (men=13), peak oxygen uptake (VO2peak) was measured on a treadmill. For the associated parameters with the distance walked (n=51), medications use, smoking behavior, body and bone composition, and physical activity levels were analyzed. No significant differences between the means of the two 6MWTs were found. The intraclass correlation coefficient was 0.94 indicating good reliability. 6MWT correlated significantly with VO2peak (r=0.67) indicating criterion validity. Height, body fat mass, smoking behavior and minutes of PA/week were significantly associated with the 6MWT. Results suggest that 6MWT shows good reliability for individuals with schizophrenia and good validity for the small sample of male participants in this study.

106 COMPARISON OF IN VITRO EMBRYO PRODUCTION IN PANAMA USING HOLSTEIN OOCYTES WITH BOS INDICUS SEXED SEMEN FROM DONORS IN DIFFERENT LOCATIONS: FIELD DATA

The objective of this work was to compare in vitro embryo production of Bos taurus × Bos indicus cross embryos using oocytes from Holstein donors under different production and environment systems. This study also examined the possibility for in vitro production using oocytes imported and transported fresh between the USA and Panama. All animals were mature Holstein cows going through a normal lactation. The first group of donors was from the University of Illinois dairy herd and went through 3 ovum pickup sessions. The second group of donors were Holstein cows already adapted to Panama and went through 10 ovum pickup sessions. The Panamanian herd of Holstein donors were born and raised in Panama in an area of mountains, on average 1300 m above sea level. This environment does not have the typical hot and humid tropical weather seen in other regions of Panama. Both groups of donors were aspirated without stimulation during the years 2013 and 2014. Oocytes recovered from donors in Illinois were imported fresh under a special sanitary research protocol between Panama and the University of Illinois. The transport of fresh oocytes from the USA to Panama was done using a portable incubator set at 39°C (Minutube of America). Oocytes were matured during transport in 5-mL tubes (~30–35 oocytes per tube) containing 400 µL of maturation media (TCM-199) that had been equilibrated with 5% CO2. Oocytes recovered from donors in Panama were matured using the same media. For both groups, oocytes were inseminated 24 h after ovum pickup using sexed semen from the same bull. All embryo production procedures followed the protocols of the In vitro Brasil™ commercial system. At 72 h postinsemination, cleavage was evaluated. On Day 7 after insemination, embryo development to the blastocyst stage (early to expanded) was recorded. Data were analysed using Chi-squared. As shown in Table 1, there was no effect of oocyte collection location on embryo development. These results indicate that it is possible to produce a viable in vitro-produced embryo using fresh oocytes collected and transported from different countries. This work opens the possibility to access superior genetics and improve herds in countries seeking to increase their production systems and potentially improve their quality of life. Table 1.Effect of oocyte collection location on embryo development This project was supported by Programa de Competitividad ProCom Senacyt, Panama.

Breast cancer under age 40: a different approach

Breast cancer (BC) under age 40 is a complex disease to manage due to the additionally fertility-related factors to be taken in consideration. More than 90% of young patients with BC are symptomatic. Women<40 years are more likely to develop BC with worse clinicopathological features and more aggressive subtype. This has been frequently associated with inferior outcomes. Recently, the prognostic significance of age<40 has been shown to differ according to the BC subtype, being associated with worst recurrence-free survival (RFS) and overall survival (OS) for luminal BC. The biology of BC<40 has also been explored through analysis of large genomic data set, and specific pathways overexpressed in these tumors have been identified which can lead to the development of targeted therapy in the future. A multidisciplinary tumor board should determine the optimal locoregional and systemic management strategies for every individual patient with BC before the start of any therapy including surgery. This applies to both early (early breast cancer (EBC)) and advanced (advanced breast cancer (ABC)) disease, before the start of any therapy. Mastectomy even in young patients confers no overall survival advantage when compared to breast-conserving treatment (BCT), followed by radiotherapy. Regarding axillary approach, indications are identical to other age groups. Young age is one of the most important risk factors for local recurrence after both breast-conserving surgery (BCS) and mastectomy, associated with a higher risk of distant metastasis and death. Radiation after BCS reduces local recurrence from 19.5 to 10.2% in BC patients 40 years and younger. The indications for and the choice of systemic treatment for invasive BC (both early and advanced disease) should not be based on age alone but driven by the biological characteristics of the individual tumor (including hormone receptor status, human epidermal growth factor receptor 2 (HER-2) status, grade, and proliferative activity), disease stage, and patient's comorbidities. Recommendations regarding the use of genomic profiles such as MammaPrint, Oncotype Dx, and Genomic grade index in young women are similar to the general BC population. Especially in the metastatic setting, patient preferences should always be taken into account, as the disease is incurable. The best strategy for these patients is the inclusion into well-designed, independent, prospective randomized clinical trials. Metastatic disease should always be biopsied whenever feasible for histological confirmation and reassessment of biology. Endocrine therapy is the preferred option for hormone receptor-positive disease (HR+ve), even in presence of visceral metastases, unless there is concern or proof of endocrine resistance or there is a need for rapid disease response and/or symptom control. Recommendations for chemotherapy (CT) should not differ from those for older patients with the same characteristics of the metastatic disease and its extent. Young age by itself should not be an indication to prescribe more intensive and combination CT regimens over the sequential use of monotherapy. Poly(ADP-ribose) polymerase inhibitors (PARP inhibitors) represent an important group of promising drugs in managing patients with breast cancer susceptibility gene (BRCA)-1- or BRCA-2-associated BC. Specific age-related side effects of systemic treatment (e.g., menopausal symptoms, change in body image, bone morbidity, cognitive function impairment, fertility damage, sexual dysfunction) and the social impact of diagnosis and treatment (job discrimination, taking care for children) should also be carefully addressed when planning systemic long-lasting therapy, such as endocrine therapy. Survivorship concerns for young women are different compared to older women, including issues of fertility, preservation, and pregnancy.

In vivo diagnosis of allergic diseases--allergen provocation tests

The allergen challenge test has been the mainstay of diagnosis of allergic diseases for a long time since it offers a direct proof of the clinical relevance of a particular allergen for the allergic disease symptoms and severity. Standardisation and availability for daily practice (including safety issues) are still to be refined but most of the challenge tests have safely crossed the border from research tools to diagnostic tests available for daily practice for a well trained clinical staff.

Halotolerance, ligninase production and herbicide degradation ability of basidiomycetes strains

Fungi have been recently recognized as organisms able to grow in presence of high salt concentration with halophilic and halotolerance properties and their ligninolytic enzyme complex have an unspecific action enabling their use to degradation of a number of xenobiotic compounds. In this work, both the effect of salt and polyols on growth of the basidiomycetes strains, on their ability to produce ligninolytic enzyme and diuron degradation were evaluated. Results showed that the presence of NaCl in the culture medium affected fungal specimens in different ways. Seven out of ten tested strains had growth inhibited by salt while Dacryopinax elegans SXS323, Polyporus sp MCA128 and Datronia stereoides MCA167 fungi exhibited higher biomass production in medium containing 0.5 and 0.6 mol.L⁻¹ of NaCl, suggesting to be halotolerant. Polyols such as glycerol and mannitol added into the culture media improved the biomass and ligninases production by D. elegans but the fungus did not reveal consumption of these polyols from media. This fungus degraded diuron in medium control, in presence of NaCl as well as polyols, produced MnP, LiP and laccase.

143 COMPARISON OF COMMERCIAL IN VITRO EMBRYO PRODUCTION AND PREGNANCY RATES OF BRAHMAN DONORS IN PANAMA VERSUS DOMINICAN REPUBLIC

It has been previously demonstrated (IETS 2011) that Panama is applying the biotechnology of in vitro embryo production (IVP) to their bovine reproduction management systems. The present work demonstrates the ability to apply the IVP technology across 2 distant country borders. Herein, we demonstrate that a country (Dominican Republic; DR) that does not have a bovine IVP laboratory can take advantage of fresh bovine IVP embryos for transfer using distant IVP facilities in another country (Panama; ~1500 km away). The objective of this study was to demonstrate that a model system for large-scale commercial in vitro bovine embryo production for beef and dairy producers, that do not have IVP technology in their home country, could be developed producing comparable results. As the same laboratory provides IVP services to the both countries, a special sanitary protocol was developed in order to legalize the exchange of biological materials (oocytes or embryos). The data obtained in DR was compared to Panamanian client data because identical conditions were utilised for IVP. Cattle production systems were similar, as Brahman (a Zebu type of cattle) is the most popular breed in both countries. Oocytes were collected from 10 different herds in Panama and 4 different herds in DR. The oocytes were transported in an oocyte transporter in both instances. However, oocytes from DR were transported in InVitro Brasil™ maturation medium from 12 to 18 h and in Panama from 6 to 12 h before they were placed in a standard CO2 incubator. In both cases, the oocytes were matured for 24 h before fertilization with conventionally frozen Brahman semen in InVitro Brasil™ fertilization medium, followed by culture for up to 7 days in InVitro Brasil™ embryo culture medium. The embryos were transferred on Day 7, either in Panama or DR. They were transported by car in Panama and via airplane back to DR. A comparison of oocyte number and quality, cleavage, embryo production, and pregnancy rate, was made using the same in vitro production system for Brahman donors from September 2012 until May 2013. The difference between sites in the relative number of viable oocytes, relative number of cleaved oocytes among viable oocytes, relative number of embryos produced among cleaved oocytes, and relative number of embryos produced among viable oocytes was tested using Fisher's exact test. Pregnancy rate was analysed with chi-squared. We realise these results represent field data; however, we believe the present work is a significant step in demonstrating the potential for wide commercial-scale dissemination of IVP technology between distant countries. The number of embryos produced in Panama was slightly, but significantly, higher than those produced in DR; this is likely due to the larger number of donors and oocytes from the Panamanian herds. However, the pregnancy rate was higher in DR, likely due to the health status of DR recipients. These data illustrate that IVP using Brahman donors could be used as a tool to improve and spread superior genetics. Furthermore, this technique can serve as a model for other Central American and Caribbean countries under similar management systems. Table 1.Panama and the Dominican Republic in vitro Brahman embryo production and pregnancy (September 2012 through May 2013)

Drug-induced anaphylaxis survey in Portuguese Allergy Departments

BACKGROUND AND OBJECTIVE

Drug-induced anaphylaxis is an unpredictable and potentially fatal adverse drug reaction. The aim of this study was to identify the causes of drug-induced anaphylaxis in Portugal.

METHODS

During a 4-year period a nationwide notification system for anaphylaxis was implemented, with voluntary reporting by allergists. Data on 313 patients with drug anaphylaxis were received and reviewed. Statistical analysis included distribution tests and multiple logistic regression analysis to investigate significance, regression coefficients, and marginal effects.

RESULTS

The mean (SD) age of the patients was 43.8 (17.4) years, and 8.3% were younger than 18 years. The female to male ratio was 2:1.The main culprits were nonsteroidal anti-inflammatory drugs (NSAIDs) (47.9% of cases), antibiotics (35.5%), and anesthetic agents (6.1%). There was a predominance of mucocutaneous symptoms (92.2%), followed by respiratory symptoms (80.4%) and cardiovascular symptoms (49.0%). Patients with NSAID-induced anaphylaxis showed a tendency towards respiratory and mucocutaneous manifestations. We found no significant associations between age, sex, or atopy and type of drug. Anaphylaxis recurrence was observed in 25.6% of cases, and the risk was higher when NSAIDs were involved.

CONCLUSIONS

NSAIDs were the most common cause of anaphylaxis in this study and were also associated with a higher rate of recurrence. We stress the need for better therapeutic management and prevention of recurring episodes of drug-induced anaphylaxis.

Production and characterization of a milk-clotting protease produced in submerged fermentation by the thermophilic fungus Thermomucor indicae-seudaticae N31

Proteases are some of the most important industrial enzymes, and one of their main applications is for the production of cheese in the dairy industry. Due to a shortage of animal rennet, microbial coagulant proteases are being sought. In this work, the production of microbial rennet from Thermomucor indicae-seudaticae N31 was studied in submerged fermentation. The best enzyme production was obtained in a fermentation medium containing 4 % wheat bran as the substrate in 0.3 % saline solution, incubated for 72 h at 45 °C and 150 rpm. The value of the milk clotting activity (MCA) was 60.5 U/mL, and the ratio to proteolytic activity (MCA/PA) was 510. The crude enzyme showed optimum pH at 5.5 and two peaks of optimum temperature (MCA at 65 °C and PA at 60 °C). The MCA was stable in the pH range 4.0-4.5 for 24 h and up to 55 °C for 1 h. It was stable during storage at different temperatures (-20 to 25 °C) for 10 weeks. Based on these results, we conclude that microbial rennet from T. indicae-seudaticae N31 produced by submerged fermentation showed good prospects of replacing traditional rennet.

Yield, changes in proteolysis, and sensory quality of Prato cheese produced with different coagulants

The objective of this research was to compare the effect of 2 fungal proteases, one that is already commercially established as a milk-clotting agent and another produced at the laboratory scale, on Prato cheese composition, protein and fat recovery, yield, and sensory characteristics. Cheeses were produced according to the traditional protocol, using protease from the fungus Thermomucor indicae-seudaticae N31 and commercial coagulant from Rhizomucor spp. as clotting agents. A 2×6 factorial design with 3 replications was performed: 2 levels of coagulants and 6 levels of storage time. After 5, 12, 19, 33, 43, and 53d of refrigerated storage (12°C), cheeses were monitored for proteolysis, firmness, and casein degradation by capillary electrophoresis. Sensory acceptance was evaluated after 29d of manufacturing. The different coagulants did not statistically affect Prato cheese composition, protein and fat recovery, and yield. Both cheeses presented good sensory acceptance. Proteolysis increased and firmness decreased for both cheeses during the storage time, as expected for Prato cheese. Caseins were well separated by capillary electrophoresis and the results showed, with good resolution, that the cheeses exhibited similar protein hydrolysis profile. Both cheeses presented good sensory acceptance. The gathered data showed that the protease from T. indicae-seudaticae N31 presented similar action compared with the commercial enzyme, indicating its efficiency as clotting agent for Prato cheese manufacture.

Classification and practical approach to the diagnosis and management of hypersensitivity to nonsteroidal anti-inflammatory drugs

Hypersensitivity reactions to aspirin (acetylsalicylic acid) and other nonsteroidal anti-inflammatory drugs (NSAIDs) constitute only a subset of all adverse reactions to these drugs, but due to their severity pose a significant burden to patients and are a challenge to the allergist. In susceptible individuals, NSAIDs induce a wide spectrum of hypersensitivity reactions with various timing, organ manifestations, and severity, involving either immunological (allergic) or nonimmunological mechanisms. Proper classification of reactions based on clinical manifestations and suspected mechanism is a prerequisite for the implementation of rational diagnostic procedures and adequate patient management. This document, prepared by a panel of experts from the European Academy of Allergy and Clinical Immunology Task Force on NSAIDs Hypersensitivity, aims at reviewing the current knowledge in the field and proposes uniform definitions and clinically useful classification of hypersensitivity reactions to NSAIDs. The document proposes also practical algorithms for the diagnosis of specific types of NSAIDs hypersensitivity (which include drug provocations, skin testing and in vitro testing) and provides, when data are available, evidence-based recommendations for the management of hypersensitive patients, including drug avoidance and drug desensitization.

Scrub typhus in patients reporting with acute febrile illness at a tertiary health care institution in Goa

BACKGROUND & OBJECTIVES

Scrub typhus is one of the differential diagnoses of haemorrhagic fevers especially if associated with jaundice and/or renal failure. Goa State in the western region of India has been witnessing increased incidence of such fevers, therefore, the present study was undertaken to identify whether scrub typhus is the aetiological agent.

METHODS

Adult patients presenting with undiagnosed febrile illness between June 2009 to October 2010, were evaluated. Testing was done using a commercial ELISA kit for specific IgM antibodies against Orientia tsutsugamushi.

RESULTS

Of the 44 patients included in the study, 15 (34%) were found to be positive for IGM antibodies against O. tsutsugamushi. The cases were seen mainly in the months between July to November. The common symptoms noted were fever, myalgias, gastrointestinal complaints, followed by breathlessness, rash and jaundice. The pathognomonic features such as eschar and lymphadenopathy were seen only in two patients. Nearly two third of the patients had leukocytosis (67%) and low serum albumin (60%). The most common complication noticed was hepatitis (80%) followed by acute respiratory distress syndrome (ARDS) (60%), thrombocytopenia (40%) and acute renal failure (33%). Five patients died in the course of illness.

INTERPRETATION & CONCLUSIONS

Our results showed that scrub typhus should be considered in the differential diagnosis of acute febrile illness associated with gastrointestinal symptoms, rash, myalgia , including those with organ dysfunctions such as hepatorenal syndrome, coagulopathy or ARDS. Empirical treatment with doxycycline or macrolides may be given in cases with strong suspicion of scrub typhus.

Endoglucanase production with the newly isolated Myceliophtora sp. i-1d3b in a packed bed solid state fermentor

This work is aimed to produce endoglucanase through solid state fermentation in a packed bed bioreactor with the use of the fungus Myceliophtora sp. I-1D3b using a mixture of wheat bran (WB) and sugar cane bagasse (SCB) as culture medium. Preliminary tests were performed in polypropylene plastic bags, controlling the variables temperature (40, 45, and 50°C), initial moisture content (75, 80, and 85%, w.b.), and weight proportion SCB/WB (1:1, 7:3, and 9:1). The highest enzyme activities in plastic bags were obtained using the substrate proportion of 7:3, 50°C temperature, and 80% initial moisture content (878 U/grams of dry solid). High activities of filter-paper cellulase and xylanase were also obtained in plastic bags and some results are reported. For the packed bed experiments, the temperature (45 and 50°C) and the air flow rate (80, 100 and 120L/h) were the controlled variables. Activity of endoglucanase was similar to plastic bag tests. A longitudinal gradient of moisture content, was observed increasing from the bottom to the top of the reactor, even though the longitudinal enzyme activity profile was flat for almost the whole bed. Air flow rate did not affect enzyme activity, while experiments carried out at 50°C showed higher enzyme activities. The maximum temperature peak observed was at about 6°C above the process temperature.

Anaphylaxis in children: a nine years retrospective study (2001-2009)

BACKGROUND

Anaphylaxis is an acute multisystemic and potentially fatal reaction, resulting from the rapid release of inflammatory mediators. Its exact prevalence is unknown. In children, foods are the most significant triggers for IgE-mediated anaphylaxis.

OBJECTIVES

To characterise the cases of anaphylaxis evaluated in an Allergy Division of a Central Paediatric Hospital.

MATERIAL AND METHODS

A review of all cases of anaphylaxis evaluated from 2001 to 2009. Anaphylaxis was defined according to Sampson's 2006 criteria.

RESULTS

Seventy-three children had anaphylactic reactions (47 male), of which 64% had history of atopy. Age at time of reaction ranged between 17 days and 15 years old (median: four years). Food was the most frequently identified cause (n=57), followed by drugs (n=8), hymenoptera venom (n=2), and cold (n=1). In five cases there was no identifiable cause. Among foods, cow's milk was the culprit agent in 27 children. The most severe reaction was a cardiorespiratory arrest. The most frequent symptoms were respiratory and cutaneous in 51 cases. Hypotension was present in nine cases. There were no fatalities. Most acute reactions were treated with corticosteroids and/or antihistamines. Adrenaline was used in only about one quarter of children.

CONCLUSIONS

The most important causes of anaphylaxis in our study were foods, and the most common symptoms were respiratory and cutaneous. The prevalence of anaphylaxis was higher in males and, in two thirds of patients there was a history of atopy. Despite being the primary and most important treatment for anaphylaxis, adrenaline is still used in only a minority of these cases.

Results of drug hypersensitivity evaluations in a large group of children and adults

BACKGROUND

Proven IgE or T-cell mediated drug hypersensitivity reactions (DHRs) seem less common in children compared with adults. However, this has never been proved by data.

OBJECTIVE

To determine and compare proven DHR prevalence in children and adults.

METHODS

Using the DAHD (Drug Allergy and Hypersensitivity Database) cohort, children with proven DHRs were compared with adults. The international EAACI-ENDA recommendations were followed. Patients were divided into four groups: index reaction and test during childhood (C/C), index reaction at childhood and test at adulthood (C/A), index reactions at childhood and adulthood and test at adulthood (CA/A), index reaction and test at adulthood (A/A).

RESULTS

A total of 3275 patients (67.9% female), comprising a total of 4370 patient-episodes, were evaluated (74.5% belonged to the A/A group). Prevalence of positive tests was 15.2% (95%CI, 14.1-16.2) for all tested classes, 10.6% (8.3-13.0) for C/C, 10.6% (7.5-13.6) for C/A, 22.1% (12.8-31.3) for CA/A and 16.5% (15.2-17.8) for A/A. The prevalence was lower in group C/C compared with groups A/A (P < 0.0001) and CA/A (P = 0.003). It was also lower in group C/A compared with the two latter groups (respectively P = 0.003 and P = 0.005). Significant differences were found for maculopapular exanthemas only, and not for urticaria/angiœdema and anaphylaxis. The difference was mainly observed with β-lactams and not for NSAIDs.

CONCLUSION AND CLINICAL RELEVANCE

Suspicions of DHRs are less likely to be confirmed in children.