A randomized controlled trial comparing conservative versus surgical treatment in patients with foot drop due to peroneal nerve entrapment: results of an internal feasibility pilot study

BACKGROUND

Based on the lack of literature to support any treatment strategy in patients with foot drop due to peroneal nerve entrapment, a prospective study randomizing patients between surgery and conservative treatment is warranted. Since studies comparing surgery to no surgery are often challenging, we first examined the feasibility of such a randomized controlled trial.

METHODS/DESIGN

An internal feasibility pilot study was conducted to assess several aspects of process, resource, management, and scientific feasibility. The main objective was the assessment of the recruitment rate. The criterion to embark on a full study was the recruitment of at least 14 patients in 6 participating centers within 6 months. Cross-over rate, blinding measures, training strategies, and trial assessments were evaluated. The trial was entirely funded by the KCE Trials public funding program of the Belgian Health Care Knowledge Centre (ID KCE19-1232).

RESULTS

The initial duration was prolonged due to the COVID-19 pandemic. Between April 2021 and October 2022, we included 19 patients of which 15 were randomized. Fourteen patients were treated as randomized. One drop-out occurred after randomization, prior to surgery. We did not document any cross-over or accidental unblinding. Training strategies were successful. Patients perceived the quality of life questionnaire as the least relevant assessment. Assessment of ankle dorsiflexion range of motion was prone to interobserver variability. All other trial assessments were adequate.

DISCUSSION

Recruitment of the anticipated 14 patients was feasible although slower than expected. The Short-Form Health Survey (SF-36) and assessment of ankle dorsiflexion range of motion will no longer be included in the full-scale FOOTDROP trial.

CONCLUSION

The FOOTDROP study is feasible.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT04695834 . Registered 4 January 2021.

Spinal Cord Stimulation-Naïve Patients vs Patients With Failed Previous Experiences With Standard Spinal Cord Stimulation: Two Distinct Entities or One Population?

INTRODUCTION

Nowadays, the success of spinal cord stimulation (SCS) is evaluated separately in patients who have previous experiences with standard SCS and in SCS-naïve patients. Nevertheless, it is yet to be evaluated whether both patient groups are effectively distinct patient groups. Therefore, the aims of this study are twofold: 1) Are there clusters in the data to distinguish between both patient groups? 2) Can we discriminate both patient groups based on routinely collected clinical parameters?

MATERIALS AND METHODS

Baseline data from the Discover study were used, in which 263 patients with persistent spinal pain syndrome type 2 were included (185 neurostimulation-naïve patients and 78 patients with previous SCS experience). Pain intensity scores for low back and leg pain, functional disability, medication use, and health-related quality of life utility scores were used in the analysis. Model-based clustering was performed on standardized data. Discriminant analysis was performed with linear and quadratic discriminant analysis, with leave-one-out cross-validation to evaluate model performance.

RESULTS

Model-based clustering revealed two different clusters in the data. None of the clusters clearly separated SCS-naïve patients from patients with previous SCS experience. Linear discriminant analysis resulted in a leave-one-out cross-validation error rate of 30.0% to discriminate between both patient groups, based on routinely collected clinical parameters.

CONCLUSIONS

Clustering analysis did not result in clusters that separate SCS-naïve patients from patients with previous SCS experience. This may suggest that both patient groups should not be considered as two different patient groups when comparing them on routine clinical parameters, with potentially profound implications for research and clinical settings.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the Discover study is NCT02787265.

Generalization of fear of movement-related pain and avoidance behavior as predictors of work resumption after back surgery: a study protocol for a prospective study (WABS)

Background

Previous studies indicated that about 20% of the individuals undergoing back surgery are unable to return to work 3 months to 1 year after surgery. The specific factors that predict individual trajectories in postoperative pain, recovery, and work resumption are largely unknown. The aim of this study is to identify modifiable predictors of work resumption after back surgery.

Methods

In this multisite, prospective, longitudinal study, 300 individuals with radicular pain undergoing a lumbar decompression will be followed until 1-year post-surgery. Prior to surgery, participants will perform a computer task to assess fear of movement-related pain, avoidance behavior, and their generalization to novel situations. Before and immediately after surgery, participants will additionally complete questionnaires to assess fear of movement-related pain, avoidance behavior, optimism, expectancies towards recovery and work resumption, and the duration and severity of the pain. Six weeks, 3 months, 6 months, and 12 months after surgery, they will again complete questionnaires to assess sustainable work resumption, pain severity, disability, and quality of life. The primary hypothesis is that (generalization of) fear of movement-related pain and avoidance behavior will negatively affect sustainable work resumption after back surgery. Second, we hypothesize that (generalization of) fear of movement-related pain and avoidance behavior, negative expectancies towards recovery and work resumption, longer pain duration, and more severe pain before the surgery will negatively affect work resumption, pain severity, disability, and quality of life after back surgery. In contrast, optimism and positive expectancies towards recovery and work resumption are expected to predict more favorable work resumption, better quality of life, and lower levels of pain severity and disability after back surgery.

Discussion

With the results of this research, we hope to contribute to the development of strategies for early identification of risk factors and appropriate guidance and interventions before and after back surgery.

Trial registration The study was preregistered on ClinicalTrials.gov: NCT04747860 on February 9, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00736-5.

Evidence in peroneal nerve entrapment: A scoping review

BACKGROUND AND PURPOSE

Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established.

METHODS

We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome.

RESULTS

Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%-≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%-100% after conservative treatment and 40%-100% after neurolysis. No study compared both treatments.

CONCLUSIONS

Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.

Transient hemiparesis caused by spontaneous cervical epidural hematoma

Spontaneous cervical epidural hematoma (SCEH) is rare and can result in various clinical phenotypes. Transient focal neurological symptoms, which have not yet been reported on, can result in overlooking this differential diagnosis in patients presenting with passing neurological deficits and assuming the diagnosis of a transient ischemic attack. Therefore, a thorough documentation of patient history is of importance, since this can reveal symptoms suggestive of a different etiology. Here, we present a case of a 66-year-old female who was admitted with a hemiparesis without cortical or cranial neurological abnormalities. When asked for preceding symptoms like headache or neck ache she mentioned interscapular pain. Imaging of the cervical spine showed an epidural hematoma. Symptoms resolved spontaneously over 24 h without surgical intervention. Our case illustrates the variation in the clinical presentation of SCEH which can result in transient symptoms, even without surgical intervention. Therefore, in patients with transient focal neurological deficits this diagnosis should be included in the differential, particularly when cortical and cranial signs are lacking.

In vivo bioluminescence imaging in an experimental mouse model for dendritic cell based immunotherapy against malignant glioma

The value of bioluminescence imaging (BLI) for experimental cancer models has become firmly established. We applied BLI to the GL261 glioma model in the context of dendritic cell (DC) immunotherapy. Initial validation revealed robust linear correlations between in vivo, ex vivo and in vitro luciferase activity measurements. Ex vivo BLI demonstrated midline crossing and leakage of tumor cells. Orthotopically challenged mice followed with BLI showed an initial adaptation phase, after which imaging data correlated linearly with stereologically determined tumor dimensions. Transition from healthy to moribund state corresponded with an increasing in vivo flux but the onset of neurological deficit was clearly delayed compared to the onset of in vivo flux increase. BLI was implemented in prophylactic immunotherapy and imaging data were prognostic for therapy outcome. Three distinct response patterns were detected. Our data underscore the feasibility of in vivo BLI in an experimental immunotherapeutic setting in the GL261 glioma model.

Etanercept in the treatment of active refractory Crohn's disease: a single-center pilot trial

OBJECTIVES

Etanercept, an injectable tumor necrosis factor (TNF) receptor fusion protein, binds and inactivates human TNF and is used in active rheumatoid arthritis. Blocking TNF with monoclonal antibodies has also been beneficial in Crohn's disease. We attempted to determine the efficacy and safety of etanercept for induction of clinical, endoscopic, and histological improvement in patients with moderate to severe Crohn's disease despite standard treatment.

METHODS

Ten patients with active Crohn's disease were treated with etanercept (25 mg s.c.) twice per week for 12 wk. Background therapy was kept stable during the trial. Crohn's disease activity index (CDAI), Inflammatory Bowel Disease Questionnaire, and C-reactive protein levels were measured at weeks 0, 2, 4, 8, and 12. Colonoscopies were performed before and after therapy in responders; endoscopic biopsies were scored for inflammation.

RESULTS

At week 2 after the start, a clinical response (deltaCDAI > or = 70) was observed in 6/10 patients (median = 305 [294-418] to 166 [107-392]), with reduction in serum C-reactive protein levels (median = 17.2 [6.8-67.2] to 9.1 [0.9-17.2] mg/dl). Colonoscopies showed a reduction in inflammatory lesions in the four patients who attained remission (CDAI < 150), whereas the inflammatory score of the biopsies did not decrease significantly. No moderate or severe adverse events were observed.

CONCLUSIONS

Etanercept may be effective in Crohn's disease refractory to standard therapy.

Prevention of experimental autoimmune encephalomyelitis in the common marmoset (Callithrix jacchus) using a chimeric antagonist monoclonal antibody against human CD40 is associated with altered B cell responses

Inhibition of CD40-CD40 ligand interaction is a potentially effective approach for treatment of autoimmune diseases, such as multiple sclerosis. We have investigated this concept with a chimeric antagonist anti-human CD40 mAb (ch5D12) in the marmoset monkey experimental autoimmune encephalomyelitis (EAE) model. Marmosets were immunized with recombinant human myelin oligodendrocyte glycoprotein (rMOG) and treated from the day before immunization (day -1) until day 50 with either ch5D12 (5 mg/kg every 2-4 days) or placebo. On day 41 after the induction of EAE, four of four placebo-treated monkeys had developed severe clinical EAE, whereas all animals from the ch5D12-treated group were completely free of disease symptoms. High serum levels of ch5D12 associated with complete coating of CD40 on circulating B cells were found. At necropsy placebo- and ch5D12-treated animals showed similar MOG-specific lymphoproliferative responses in vitro, but ch5D12 treatment resulted in strongly reduced anti-MOG IgM Ab responses and delayed anti-MOG IgG responses. Most importantly, treatment with ch5D12 prevented intramolecular spreading of epitope recognition. Postmortem magnetic resonance imaging and immunohistologic analysis of the CNS showed a markedly reduced lesion load after ch5D12 treatment. In conclusion, the strong reduction of clinical, pathological, and radiological aspects of EAE by ch5D12 treatment in this preclinical model points to a therapeutic potential of this engineered antagonist anti-CD40 mAb for multiple sclerosis.

Infliximab induces potent anti-inflammatory and local immunomodulatory activity but no systemic immune suppression in patients with Crohn's disease

BACKGROUND

Anti-TNFalpha therapy with infliximab is effective for Crohn's disease. Infliximab neutralizes the biological activities of TNFalpha, a cytokine involved in host-defence against certain infections.

AIM

To evaluate the effects of infliximab on the gut and peripheral immune system functions.

METHODS

Biopsies and blood samples from three clinical trials of infliximab in Crohn's disease were analysed. Pharmacokinetics, changes in leucocyte counts and T cell subsets, T cell function, and cytokine profiles of lamina propria mononuclear cells (LPMC) and peripheral blood mononuclear cells (PBMC) were analysed.

RESULTS

Infliximab has a serum half-life of 9.5 days and is still detectable in serum 8 weeks after infusion. Leucocyte counts showed consistent changes from baseline toward normal values after therapy. Monocytes and lymphocytes were modestly increased, while neutrophils were decreased 4 weeks after treatment. Lymphocyte subsets and T cell proliferative responses were not altered after therapy. The proportion of PBMCs capable of producing IFNgamma and TNFalpha did not change, while Th1 cytokine production by stimulated LPMC was decreased after infliximab therapy.

CONCLUSION

The clinical efficacy of infliximab is based on local anti-inflammatory and immunomodulatory effects in the bowel mucosa, without generalized suppression of systemic immune functions in Crohn's disease patients.

Regulation of the IL-10 production by human T cells

Interleukin (IL)-10, an immunomodulatory cytokine predominantly produced by monocytes/macrophages and T cells, inhibits several functions of dendritic cells (DC), monocytes and T cells including their cytokine production, but it stimulates B cell immunoglobulin (Ig) production and cytotoxic T lymphocyte (CTL) generation. A precise knowledge of the mechanisms that control the IL-10 production is therefore highly important for understanding the immunoregulation. The IL-10 production was studied in cultures of freshly isolated human T cells. A rise in intracellular calcium as well as the common gamma-chain containing cytokine receptor triggering or CD28 triggering were found to be important signals for IL-10 induction. CD80, CD58, rIL-12 and rIFN-alpha all had efficacious and independent costimulatory activities on the IL-10 production, while PGE2 was inhibitory. Dependence on autocrine IL-2 signalling was shown by the effects of anti-IL-2 and anti-IL-2R monoclonal antibodies (MoAb), but the IL-10 production proceeded partly IL-2-independent when CD80 provided costimulation. Sensitivity to inhibition by CsA was not removed by CD80 or CD58 costimulation and/or by addition of rIL-12 or rIFN-alpha, pointing to the absolute requirement for calcineurin activity. These data reveal important differences in the regulatory pathways between IL-10 (a cytokine-inhibitory interleukin) and IL-2 (a cytokine-inducing interleukin), which can potentially be exploited therapeutically. The fact that CsA blocks the production of IL-10, which itself has important immunosuppressive properties, should be taken into account in defining immunosuppressive treatment schedules which include the use of CsA.

Comparative study of two cytofluorometric methods of analysis

Cytofluorometry of lymphocytes is an important technique in experimental biology and clinical medicine. One source of variability in the results with this technique stems from the difficulty of delineating cell subpopulations on a visual basis. We have evaluated the performance of a novel software method (Attractor), which introduces cluster analysis for the more precise definition of cell populations. Using 115 blood samples from patients with various immunological diseases, we compared the results obtained for 19 lymphocyte cell populations employing either the Attractor program or a conventional program (Cellquest). The analysis focused on inter-observer and inter-method variability and comparability. Inter-observer variability was significantly lower with the Attractor software, particularly when quantifying small cell populations such as activated subsets. The results obtained with both methods showed high correlation coefficients except for some cell populations that were either very small or which had to be calculated from the sum of other counts. The performance of the novel flow cytometric software is similar to software programs currently in use, but it offers an advantage for the definition of small and/or activated lymphocyte subpopulations. Moreover, the consistency of the measurements is better. A major disadvantage for statistical analysis, however, is that the Attractor program has not been adapted for non-parametric data.

Western lifestyle, local defenses and the rising incidence of allergic rhinitis

Allergy was probably rare at the beginning of this century, but its prevalence in developed countries has now risen to true epidemic proportions. There has been about a doubling of children with allergic rhinitis in the past twenty years. This increase can only be due to a factor in the environment, and the identification of these factors should be a research priority in order to reverse the trend and to make atopy a preventable disease. Air pollution is unlikely to be a major contributor, while more attention is turning towards the influence of living conditions, hygiene, family size, vaccinations, infections and use of antibiotics. An explanation in immunologic terms is found in the need for external input in the maturation of our immune system, especially the need for local triggering in the respiratory and alimentary tract. This seems to be required to reverse the dominance of allergy-promoting Th2 cytokine patterns at birth into a balanced equilibrium between Th1 and Th2 cell responses upon antigenic triggering. On the basis of these epidemiologic and immunologic data, guidelines are emerging for allergy prevention.

Preserving soil quality under irrigation in the Senegal River Valley

Soil quality under irrigation in the Senegal River Valley may become affected by salinization (Delta) and alkalinization (Middle Valley) processes. The salinity status of 158 irrigated rice fields in the Delta was measured with an electromagnetic conductivity meter. Double-cropped fields (two rice crops per year on the same field) were least saline (average horizontal reading: 0.6 dS/m), followed by single-cropped drained fields (1.6 dS/m), single-cropped non-drained fields (2.5 dS/m), non-cropped sites outside irrigation schemes (4.7 dS/m) and abandoned fields (5.7 dS/m). Results illustrated that when cultivating rice in the delta, the ponded water on the soil surface blocks capillary rise of salt from the water table. In the valley, the difference in the total amount of carbonates in 1:50 soil extracts between cultivated and non-cultivated sites was used as an indicator for alkalinization risk in 27 irrigation schemes. Highest rates of carbonate accumulation (0.65 meq HCO3-/(kg soil) per cropping season) and, therefore, greatest soil degradation risk were observed in schemes without drainage, compared to 0.10 meq HCO3-/(kg soil) per cropping season in schemes with good irrigation and drainage facilities. Plot and scheme level recommendations that may preserve soil quality under irrigation are presented.

Toxic shock syndrome without rash in a young child: link with syndrome of hemorrhagic shock and encephalopathy?

A diffuse macular erythroderma and subsequent desquamation after 1 to 2 weeks are two of the five major diagnostic criteria of toxic shock syndrome (TSS). We present the case of a 15-month-old girl with TSS, but without erythroderma or desquamation. She was admitted with high fever, shock, and multiorgan involvement. Minimal or no cutaneous signs were present. Initially the diagnosis of the syndrome of hemorrhagic shock and encephalopathy was made. After 7 days, a TSS toxin 1-producing strain of Staphylococcus aureus was cultured from an inguinal lymph node, where inflammation had already been noticed on admission. Moreover, the girl had no antibodies against this toxin. The serum cytokine profile during the acute phase of her illness showed high levels of tumor necrosis factor-alpha, interleukin-6 and interferon-gamma, as is seen during activation of the immune system by TSS toxin 1. Other possible causes for the patient's illness were excluded. We conclude that the patient had TSS without rash. Without the evidence implicating a TSS toxin 1-producing strain of S. aureus as the cause of her disease, a diagnosis of syndrome of hemorrhagic shock and encephalopathy would have been made. It is possible that some cases of syndrome of hemorrhagic shock and encephalopathy represent a variant of TSS in small children.

Use of the methylxanthine derivative A802715 in transplantation immunology: I. Strong in vitro inhibitory effects on CD28-costimulated T cell activities

BACKGROUND

Recently, methylxanthines such as pentoxifylline (PTX) were shown to be immunosuppressive in vitro. Unfortunately, when used in transplant patients, PTX was poorly active as an immunosuppressant. Here we report that the new methylxanthine derivative A802715 not only is more active than PTX, it also suppresses the cyclosporine (CsA)-resistant "signal two"-dependent pathway of T cell proliferation, making it an interesting drug to associate with CsA.

METHODS

"Signal one"- and "signal two"-dependent T cell activation was investigated with purified human T cells stimulated with immobilized anti-CD3 or anti-CD28 monoclonal antibody (mAb) plus phorbol myristate acetate (PMA) or with a 3T6 mouse fibroblast cell line presenting anti-CD3 mAb on transfected human Fcgamma receptors II (FcgammaRII) in the presence or absence of transfected B7-1 (CD80) molecules.

RESULTS

A802715 was more immunosuppressive in the mixed lymphocyte reaction (MLR) than PTX. A802715 dose-dependently suppressed polyclonal signal one-dependent T cell activation induced by anti-CD3 mAb/PMA. In addition, A802715 also suppressed signal two-dependent T cell proliferation induced by anti-CD28 mAb/PMA. The expression of the interleukin-2 receptor on T cells stimulated by anti-CD3 mAb presented on 3T6/FcgammaRII cells was equally well suppressed by A802715 and PTX. In contrast, interleukin-2 receptor or CD40L (gp39) expression by T cells after stimulation with the same anti-CD3 mAb- 3T6/FcgammaRII cells, but coexpressing transfected B7-1, was only suppressed by A802715. The anticipated synergism between A802715 and CsA was confirmed in MLR assays. Moreover, generation of cytotoxic T lymphocytes during MLR with Epstein-Barr virus-transformed B cells, which strongly express B7-1 and B7-2, was also inhibited by A802715.

CONCLUSIONS

These in vitro data indicate that the A802715 (1) is a stronger immunosuppressant for T cells than PTX, (2) suppresses T cell activation pathways that are resistant to PTX or CsA, and (3) acts synergistically with CsA.

Cortisol-free transcortin: preparation and effect on mitogen-stimulated lymphocytes

Human cortisol-free transcortin was prepared from charcoal-treated serum. The major purification was achieved by affinity chromatography on an immunoadsorbent column of transcortin antibodies coupled to Sepharose 4B. A further purification on hydroxylapatite yielded pure transcortin with preserved steroid-binding activity. This preparation had no significant influence on the proliferation of human lymphocytes stimulated with phytohemagglutinin, nor did it increase the inhibition of lymphocyte proliferation by cortisol or dexamethasone.

Regulation of the immune response by prostaglandins

Of all the arachidonic acid metabolites, only prostaglandin E (PGE) has been shown to have a clear role in the regulation of cellular and humoral immune responses. In cellular immune responses such as T cell proliferation, lymphokine production, and cytotoxicity, PGE usually acts as a feedback inhibitor of the response. This is also true of macrophage and natural killer cytotoxicity. In some instances PGE is responsible for cellular activation rather than inhibition. This is clearest in the control of humoral immunity, where PGE production is a necessary component in the generation of some type of T suppressor cells. Disturbances in immune function found in several human conditions and diseases have been linked to changes in PGE mediated immunoregulation. Either increased production of PGE or increased sensitivity to PGE results in depressed cellular immunity. Conversely drugs which inhibit PGE production act as stimulants of cellular immune function in vitro and in vivo.