[Profile and immune environment of upper tract urothelial carcinoma]

INTRODUCTION AND OBJECTIVES

Upper Tract Urothelial Carcinoma (UTUC) are tumors that share similarities with bladder tumors. Immunotherapy is already used for bladder locations and appears to have interest for UTUC. In order to rationalize the immunotherapy development pipeline it seemed necessary to describe the immune infiltrate of a cohort of UTUC treated with nephroureterectomy and to determine the expression of a panel of immune checkpoints and co-stimulatory molecules on tumor cells as well as on infiltrating and circulating lymphocytes.

MATERIALS AND METHODS

This is a monocentric, prospective and exploratory work. Patients treated with total nephroureterectomy or segmental ureterectomy for presumably infiltrative (≥ T1) UTUC managed at the Saint-Louis Hospital were included from January 2019 to July 2020. A set of markers and immune checkpoints were studied by flow fluorocytometry on circulating lymphocytes (PBMCs) and tumor-infiltrating lymphocytes (TILs). Some markers were also studied by immunohistochemistry on tumor sample.

RESULTS

In total, 14 patients were included and 13 patients could be analyzed. 1 patient had no residual tumor. 5 tumors out of the 12 (41.7%) showed a lymphocytic inflammatory infiltrate. PD1 was the most represented checkpoint with a median expression rate of 41.4% on CD4+ TILs and 3.89% on circulating CD4+ T cells. This rate was 62.4% and 7.45% respectively on CD8+ T cells. TIGIT was the second most represented marker with a median expression rate on tumor-infiltrating CD4+ T cells of 25% and 2.9% on circulating CD4+ T cells. The median expression level of TIGIT on tumor-infiltrating CD8+ T cells was 23.3% and 3.2% on circulating CD8+ T cells. ICOS was highly expressed on CD4+ TILS with a median of 33.9% in contrast to CD8+ TILS (median: 6.67%). Variable expression of other checkpoints (ILT2, TIM3, LAG3 and OX40) was found without clear trend.

CONCLUSION

This exploratory work highlighted that PD1 was the most represented checkpoint. TIGIT was the second most represented checkpoint while ICOS, TIM3 and LAG3 were 3 other checkpoints whose expression was found to be less important. ILT2 and OX40 appeared to be weakly expressed.

LEVEL OF EVIDENCE

II.

[Preoperative chemotherapy for patients with upper tract urothelial carcinoma: Impact on renal function]

PURPOSE

Upper tract urothelial carcinoma (UTUC) are rare tumors with a poor prognosis. The standard treatment for localized disease is based on total nephroureterectomy (NUT) followed by platinum-based adjuvant chemotherapy for eligible patients at risk of recurrence. However, many patients have renal failure after surgery preventing chemotherapy. Thus, the place of preoperative chemotherapy (POC) is questioned with little information available about renal toxicity and efficacity.

METHODS

A single center retrospective study was performed on patients with UTUC who received POC.

RESULTS

In all, 24 patients with localized UTUC were treated with POC between 2013 and 2022. Twenty-one (91%) had secondarily NUT. In this cohort, POC did not result in degradation of median renal function (pre-POC median GFR: 70mL/min, post-POC median GFR: 77mL/min, P=0.79), unlike NUT (post-NUT median GFR: 51.5mL/min, P<0.001). In addition, the rate of complete pathological response to pathological examination was 29%. After a median follow-up of 27.4 months, the overall survival rate was 74% and the recurrence-free survival rate was 46%.

CONCLUSION

POC for UTUC shows a very reassuring renal toxicity profile and encouraging histological results. These data encourage prospective studies assessing its place for UTUC management.

LEVEL OF EVIDENCE: 3

[Monochorionic biamniotic twin pregnancies outcomes in Reunion Island with indication of in utero transfert]

OBJECTIVE

Complicated monochorionic biamniotic (MCBA) twin pregnancies may require treatment with fetoscopic laser photocoagulation, in case of Twin Oligo-Polyhydramnios Sequence or need of a selective termination of pregnancy. Patients requiring these treatments would need medical transfer to Metropolitan France because these are unavailable in Réunion Island. We evaluated the outcomes of MCBA pregnancies in Reunion Island with indications for fetoscopy, with a view to discussing the interest of training doctors on the Reunion Island, to practice fetoscopy on site.

MATERIALS AND METHODS

Retrospective hospital study running from 2015 to 2018. We included all MCBA pregnancies between 15 and 25 weeks of gestation, with indications for in utero transfer. Our objective was to examine whether and why they were transferred and pregnancy outcomes.

RESULTS

Of the 23 patients, 17 (73.9%) benefited from sanitary transfers. The survival rate of the fetuses in 15 pregnancies with Twin Oligo-Polyhydramnios Sequence (TOPS) was 73.3% for one twin and 53.3% for both twins. For the eight cases of Selective Termination of the pregnancy (ST), the survival rate of the twin was better with a transfer (n=5/6, 83.3%) than without a transfer (n=1/2 or 50%). The rate of premature rupture of the membranes after sanitary transfer among patients with TOPS was 63.6%.

CONCLUSION

The sanitary transfer allows the management in expert center of complicated MCBA twin pregnancies, but is not always feasible and is accompanied by a high rate of premature ruptures of membranes.

Urachal carcinoma: a large retrospective multicentric study from the French Genito-Urinary Tumor Group

Introduction

Urachal cancer (UrC) is a rare, non-urothelial malignancy. Its natural history and management are poorly understood. Although localized to the bladder dome, the most common histological subtype of UrC is adenocarcinoma. UrC develops from an embryonic remnant, and is frequently diagnosed in advanced stage with poor prognosis. The treatment is not standardized, and based only on case reports and small series. This large retrospective multicentric study was conducted by the French Genito-Urinary Tumor Group to gain a better understanding of UrC.

Material and Methods

data has been collected retrospectively on 97 patients treated at 22 French Cancer Centers between 1996 and 2020.

Results

The median follow-up was 59 months (range 44-96). The median age at diagnosis was 53 years (range 20-86), 45% were females and 23% had tobacco exposure. For patients with localized disease (Mayo I-II, n=46) and with lymph-node invasion (Mayo III, n=13) median progression-free-survival (mPFS) was 31 months (95% CI: 20-67) and 7 months (95% CI: 6-not reached (NR)), and median overall survival (mOS) was 73 months (95% CI: 57-NR) and 22 months (95% CI: 21-NR) respectively. For 45 patients with Mayo I-III had secondary metastatic progression, and 20 patients were metastatic at diagnosis. Metastatic localization was peritoneal for 54% of patients. Most patients with localized tumor were treated with partial cystectomy, with mPFS of 20 months (95% CI: 14-49), and only 12 patients received adjuvant therapy. Metastatic patients (Mayo IV) had a mOS of 23 months (95% CI: 19-33) and 69% received a platin-fluorouracil combination treatment.

Conclusion

UrC is a rare tumor of the bladder where patients are younger with a higher number of females, and a lower tobacco exposure than in standard urothelial carcinoma. For localized tumor, partial cystectomy is recommended. The mOS and mPFS were low, notably for patients with lymph node invasion. For metastatic patients the prognosis is poor and standard therapy is not well-defined. Further clinical and biological knowledge are needed.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Safety of systemic anti-cancer treatment in oncology patients with non-severe COVID-19: a cohort study

Background

The viral pandemic coronavirus disease 2019 (COVID-19) has disrupted cancer patient management around the world. Most reported data relate to incidence, risk factors, and outcome of severe COVID-19. The safety of systemic anti-cancer therapy in oncology patients with non-severe COVID-19 is an important matter in daily practice.

Methods

ONCOSARS-1 was a single-center, academic observational study. Adult patients with solid tumors treated in the oncology day unit with systemic anti-cancer therapy during the initial phase of the COVID-19 pandemic in Belgium were prospectively included. All patients (n = 363) underwent severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) serological testing after the first peak of the pandemic in Belgium. Additionally, 141 of these patients also had a SARS-CoV-2 RT-PCR test during the pandemic. The main objective was to retrospectively determine the safety of systemic cancer treatment, measured by the rate of adverse events according to the Common Terminology Criteria for Adverse Events, in SARS-CoV-2-positive patients compared with SARS-CoV-2-negative patients.

Results

Twenty-two (6%) of the 363 eligible patients were positive for SARS-CoV-2 by RT-PCR and/or serology. Of these, three required transient oxygen supplementation, but none required admission to the intensive care unit. Hematotoxicity was the only adverse event more frequently observed in SARS-CoV-2 -positive patients than in SARS-CoV-2-negative patients: 73% vs 35% (P < 0.001). This association remained significant (odds ratio (OR) 4.1, P = 0.009) even after adjusting for performance status and type of systemic treatment. Hematological adverse events led to more treatment delays for the SARS-CoV-2-positive group: 55% vs 20% (P < 0.001). Median duration of treatment interruption was similar between the two groups: 14 and 11 days, respectively. Febrile neutropenia, infections unrelated to COVID-19, and bleeding events occurred at a low rate in the SARS-CoV-2-positive patients.

Conclusion

Systemic anti-cancer therapy appeared safe in ambulatory oncology patients treated during the COVID-19 pandemic. There were, however, more treatment delays in the SARS-CoV-2-positive population, mainly due to a higher rate of hematological adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08349-8.

Cytometry-based analysis of HLA-G functions according to ILT2 expression

HLA-G was described as a molecule inhibiting NK and T cells functions through its receptor, ILT2. However, most functional studies of HLA-G were so far performed on heterogeneous immune populations and regardless of ILT2 expression. This may lead to an underestimation of the effect of HLA-G. Thus, considering the immune subpopulations sensitive to HLA-G remained an important issue in the field. Here we present a new cytometry assay to evaluate HLA-G effects on both NK and CD8⁺ T cell cytotoxic functions. Using flow cytometry allows for the comparison of HLA-G function on multiple subsets and multiple functions in the same time. In particular, we sharpen the analysis by specifically studying the immune subpopulations expressing HLA-G receptor ILT2. We focused our work on: IFN-gamma production and cytotoxicity (CD107a expression) by CD8⁺ T cells and NK cells expressing or not ILT2. We compared the expression of these markers in presence of target cells, expressing or not HLA-G1, and added a blocking antibody to reverse HLA-G inhibition. This new method allows for the discrimination of cell subsets responding and non-responding to HLA-G1 in one tube. We confirm that HLA-G-specifically inhibits the ILT2⁺ CD8⁺ T cell and ILT2⁺ NK cell subsets but not ILT2-negative ones. By blocking HLA-G/ILT2 interaction using an anti-ILT2 antibody we restored the cytotoxicity level, corroborating the specific inhibition of HLA-G1. We believe that our methodology enables to investigate HLA-G immune functions easily and finely towards other immune cell lineages or expressing other receptors, and might be applied in several pathological contexts, such as cancer and transplantation.

Awake C1-2 laminectomy, instrumentation, and fusion: case report

Surgery of the cervical spine under conscious sedation has been rarely reported in the literature. The main indications are the lack of neurophysiological monitoring and surgery in patients with high cardiovascular risk. To date, no reports of awake C1-2 instrumentation have been published in the English-language literature. The authors present the case of a 76-year-old patient with multiple myeloma and severe cardiomyopathy associated with primary amyloidosis who experienced severe myelopathy from a C2 pseudotumor associated with an odontoid fracture. Due to his high cardiovascular risk, the patient underwent C1 decompression and C1-2 instrumentation and fusion via an awake technique. To accomplish this task, the authors performed multilayered muscular infiltration of local anesthetics and avoided manipulating the C2 root by anchoring C1 with a rod-claw system. The procedure did not last longer than that of general anesthetic approaches, and no complaints were reported by the patient during surgery, which he described as an overall "good experience." The patient was discharged on the 7th postoperative day and resumed his previous work 3 months later. Performing surgery under local anesthesia and conscious sedation reduces the risk of perioperative cardiovascular and respiratory complications in these high-risk patients by avoiding the use of drugs with cardiodepressant effects and endotracheal intubation.

[Impact of neoadjuvant chemotherapy on the peri-operative morbidity of radical cystectomy for muscle invasive bladder cancer]

INTRODUCTION

Platinum-based neoadjvant chemotherapy (NAC) before radical cystectomy (RC) is the gold standard in the treatment of muscle invasive bladder cancer (MIBC). We aimed to compare the peri-operative morbidity in patients treated by NAC then RC and patients having RC alone.

METHODS

Between 1st January 2008 and 31st December 2015, we retrospectively included consecutive patients undergoing RC for MIBC in 2centers. We collected clinical, pathological and peri-operative data (30day post operative complications according to the Clavien-Dindo score, delayed complications, pathological results). Patients treated by NAC (NAC-RC group) before RC were compared to patients performing RC alone. The NAC-RC group received 1 to 6cycle of high-dose MVAC, MVAC or gemcitabine-cisplatine chemotherapy. Logistic regression identified independant factors of peri-operative complications.

RESULTS

We included 199 patients: 48in the NAC-RC group and 151in the RC group. Complications rate was 73.9% in the NAC-RC group versus 73.8% in the RC group (P=1.0). In multivariate analyses, only the Charlson score was associated with an increased risk of peri-operative complications (P=0.05). PT0 tumour rate was significantly higher in the NAC-CR group (50% vs 7%, P<0.001).

CONCLUSION

NAC does not increase the peri-operative morbidity of the RC. Patients' pre operative comorbidities is the main risk factor for peri-operative complications.

Why should the anesthesiologist evaluate nutritional status?

BACKGROUND

The anesthesiologist's involvement in perioperative medicine has significantly changed. In order to identify patients at risks of perioperative complications, the anesthesiologist has to consider, amongst others, screening and management of undernutrition. For this purpose knowledge of prevalence and risk factors, along with screening tools and guidelines for an adapted nutritional management and outcomes of renutrition are mandatory. The present review intends to provide these tools to the Anesthesiologists.

METHOD

We conduct a literature review in Pubmed, Direct Science and Cochrane Library without limit of time related to undernutrition in the perioperative period.

RESULTS

Undernutrition is common in surgical patients. Undernutrition is associated with an increase of morbidity, mortality, length of hospital stay and costs. Undernutrition could probably be detected during the anesthetic consultation with simple and rapid tests, such as SNAQ, MST, MUST and NRS-2002. Nevertheless, further studies are needed to validate such tests in surgical patients. Waiting for these results, we prefer MUST. The implementation of nutritional support recommendations would reduce postoperative complications.

CONCLUSION

The anesthesiologist could play an important role in undernutrition screening and its management in order to reduce perioperative morbidity.

[Ultrasound appearance of the area of uterine closure in asymptomatic patients at 48 hours of uneventful cesarean section]

OBJECTIVE

It seeks to assess the appearance of the hysterorrhaphy area and seeks hematoma in asymptomatic patients at 48hours of their cesarean.

METHOD

It is common to see, ultrasound or CT scan, collection of images next to the hysterorrhaphy area in symptomatic patients after cesarean. Their interpretation remains difficult which led us to propose a prospective study looking for an evocative image collection or hematoma in asymptomatic patients at 48hours of their cesarean. It was directed suprapubic and transvaginal pelvic ultrasound with study area hysterorrhaphy and inter-uterine bladder space.

RESULTS

The suprapubic ultrasound examination was performed in 31 asymptomatic patients after collecting their written consent. Twenty-eight patients also received an endovaginal examination. The studied area was easily identified by visualizing the path of hysterotomy and hyperechoic aspect of the hysterorrhaphy. In 28 cases there were no abnormal image in front of the hysterorrhaphy area. In 3 cases, an evocative image of a haematic collection was displayed and measured a maximum of only 49mm long axis with a weak Doppler signal. The exam was very well tolerated by patients, especially by transvaginal route. Also the duration of ultrasound never exceeded 58seconds and remained fastest vaginally.

CONCLUSION

This preliminary work to a prospective double cohort (symptomatic patients and asymptomatic patients) has clarified the technique to use and focus in the search for a collection next to the hysterorrhaphy area. Ultrasound examination postoperatively, especially vaginally, is very fast, well tolerated with satisfactory image quality. Finally in this cohort of asymptomatic patients, it was very unusual for a collection, confirming the credit to be given to this type of image in case of symptoms after cesarean.

[Minimally invasive osteosynthesis. : even in talus fractures?]

OBJECTIVE

Minimally invasive osteosynthesis of talar fractures.

INDICATIONS

Minimally displaced fractures of the lateral process of the talus and talar neck fractures type 1 according to Hawkins classification.

CONTRAINDICATIONS

Dislocated peripheral fractures. Displaced fractures of the talar neck or body.

SURGICAL TECHNIQUE

For factures of the lateral process of the talus: short incision of skin over the lateral process of the talus. Gentle preparation and contact with the bone with scissors. Fragment reposition using a dentist's hook and Kirschner wire in a joy-stick technique under C-arm imaging. Stabilization with a miniscrew. For talar neck fracture Hawkins type 1: short incision of skin ventromedially and ventrolaterally. Blunt preparation of soft tissue and safe bone contact. Introduction of one small-fragment corticalis screw both medially and laterally under C-arm imaging. As an alternative, cannulated screws can also be used.

POSTOPERATIVE MANAGEMENT

For fractures of the lateral process of the talus: postoperative protection in an ankle splint (air cast, gel cast) for 4 weeks. During this time moderate weight bearing is possible. For talar neck fractures Hawkins type 1: physiotherapy and only floor contact for 6 weeks.

RESULTS

From January 1996 to December 2002, 44 talar fractures were operatively treated in our department. Six patients had talar neck fractures type 1 according the Hawkins classification and 3 patients showed fractures of the lateral process of the talus. From those injuries, 3 Hawkins type 1 fractures and 2 fractures of the lateral process were stabilized using minimally invasive osteosynthesis. The clinical outcomes were assessed using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society. Both groups reached good cosmetic and functional results. We did not observe any avascular talar necrosis or nonunions in the two groups.

[Physical restraint and procedure]

The widespread practice of physical restraint of the elderly has used in most case in order to protect elders against injuries after falls or to manage behaviour agitation during delirium for example. However, "protect" isn't correct because of the adverse effects have been reported as falls increase, pressures sores, depression, aggression and death. In fact, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current medico-legal knowledge regarding physical restraint use in this frail population and suggests some considerations about ethical practice and procedure evaluation.

[Soft tissue protective and minimally invasive osteosynthesis for metacarpal fractures II-V]

OBJECTIVES

Soft tissue protection, closed reduction or short open reconstruction of length, rotation and articulation of metacarpals. Aftercare: early active exercises protected by additive orthesis.

INDICATIONS

Closed or grade 1 open fractures with significant dislocation, deviation of rotation or loss of length. Fractures of the metacarpal, metaphyseal and extensive oblique or spiral fractures. Intra-articular fractures of the distal metacarpal that can be reduced without a step in articular surface. Proximal partial articular fractures that can be reduced without a step in articular surface in the mini-open technique.

CONTRAINDICATIONS

Grade 2 and 3 open fractures, extensive bending fractures in the middle third and absence of the palmar bony restraint. Multifragmentary proximal and distal metaphyseal fractures that cannot be reduced by closed methods. Intra-articular fractures that cannot be reduced without a step in articular surface.

SURGICAL TECHNIQUE

Intramedullary antegrade or percutaneous K-wires or mini-open repair screw/K-wire osteosynthesis.

POSTOPERATIVE MANAGEMENT

Two or three finger forearm cast for about 3-4 days, subsequent metacarpal orthesis, an integrated hard cast Longuette (Combicast) SoftCast™ is preferred beginning with active and passive exercises of the fingers.

RESULTS

In this retrospective study we analyzed metacarpal (MC) fractures that were treated with minimally invasive osteosynthesis during the period 2009-2010 and 65 patients (mean age 34.8 years, female/male 13/52) with 75 metacarpal fractures were enrolled. Fractures affected MC-2 (n=9), MC-3 (n=5), MC-4 (n=15) and MC-5 (n=46). Removal of implant was performed after 6-12 weeks in 44 patients. All fractures except one showed bony healing in x-ray. At 2-months follow-up 61 patients could be evaluated and at 27-months (15-37) follow-up 34 patients could be evaluated according to the DASH score. Median DASH score results were 16 points (SD 49, n = 61) after 2 months and median DASH score results were 5 points (SD 23, n = 34) after 27 months (15-37). Range of motion was limited in 6 patients after 8 weeks (range 6-12 weeks) with a deficit in flexion of finger to distal palmar crease of 1.0 cm (range 0.5-1.5 cm), 2 patients showed a deficit in finger extension of 10° in the metacarpophalangeal joint. One patient showed restricted finger extension of 15° in the proximal phalangeal joint after tendon rupture and tendon reconstruction. Complications were observed, such as circumscribed redness in two patients at the entry point of k-wires which was managed by early removal of the implant. Perforation of the k-wire occurred in one patient with subcapital and diaphyseal fracture and was managed by plate osteosynthesis. One diaphyseal transverse refracture healed after plate osteosynthesis, three circumscribed cases of paresthesia occurred, one at the entry point of the K-wires and two at the level of fracture.

Prenatal management of congenital infantile fibrosarcoma: unexpected outcome

We report the case of a large leg tumor in a fetus at 36 weeks of gestation. The tumor's location, ultrasound characteristics and magnetic resonance imaging (MRI) findings enabled a prenatal diagnosis of congenital fibrosarcoma and allowed us to establish the prognosis. After multidisciplinary discussion, it was decided that the pregnancy should continue to 38 weeks, with surgery or neo-adjuvant chemotherapy scheduled after delivery. Unfortunately, the tumor unexpectedly burst in utero and the newborn died of the consequences of hemorrhagic shock, despite rapid amputation. Histological examination confirmed the nature of the tumor. The prognosis of congenital fibrosarcoma is generally good when there are no metastases. MRI is key to establishing a prenatal diagnosis. However, rupture of the tumor can result in fatal hemorrhaging and the pregnancy should be monitored closely before scheduled delivery.

[How to improve the continuity of pharmacotherapy at hospital admission and discharge]

The continuity of pharmacotherapy is of vital importance when patients move from one health care setting to another. Unfortunately, this continuity is not always guaranteed. The aim of this study is to propose solutions to enhance the continuity of pharmacotherapy at hospital admission and discharge. The study consists of a systematic review of the international literature and an analysis of seamless care initiatives in seven selected countries; a summary of Belgian data on problems as well as solutions with regard to continuity of care; a quantification of the extent of medication changes as a result of a hospital stay in Belgium; and a qualitative analysis of the perception of Belgian health care professionals (HCPs) on approaches to improve seamless care. The literature review yielded 15 papers of sufficient quality. However, this review did not generate definitive conclusions on the clinical impact and the cost-effectiveness of interventions aiming to enhance the continuity of pharmacotherapy. The most important initiatives that have been put in practice in foreign countries include the development and implementation of guidelines for HCPs; national information campaigns; education of HCPs; and the development of information technologies as to share patient and prescription data between settings of care. For Belgium, 66 seamless care initiatives were identified. The high number and variety of projects show the interest for this topic as well as the involvement of various HCPs from diverse settings in the development of solutions. Based on this research, and the solutions discussed in the focus groups, the following elements are proposed to enhance the continuity of pharmacotherapy: a national guideline governing the continuity of pharmacotherapy; a national campaign to sensitize HCPs and patients in this area; the availability of a comprehensive and up to date medication list for each patient; and electronic healthcare infrastructure that facilitates sharing of information.

Knee motion analysis of the non-loaded and loaded knee: a re-look at rolling and sliding

Many studies of knee motion have been reported in the literature over more than 100 years. Of particular interest to the analysis presented here is the work of the Freeman group, who elegantly measured tibio-femoral kinematics in studies made on cadavers and the knees of living individuals using MRI, anatomical dissection and RSA. We examined and re-evaluated the data collected by Freeman's group and suggest that their conclusion should be considered to be incorrect, since their methods of evaluation were oversimplified from the mathematical and physical perspectives. By applying appropriate methods, however, it is possible to show that the same data yield important insights into physiological knee kinematics and reveal that the rolling-sliding relationship depends on the degree of flexion and on joint load in the medial and lateral compartment, as well. In the initial range of flexion, a considerable amount of rolling was found to occur. Based on this analysis, it is possible to gain useful insights of value for the design of total knee replacements.

Mechanisms of circumduction and axial rotation of the carpometacarpal joint of the thumb

Osteoarthritis of the carpometacarpal joint of the thumb (CMCJ) is a frequent clinical problem. The aim of the study was to discuss the mechanisms of circumduction and axial rotation of the CMCJ considering geometrical properties of the articulating surfaces and the configuration of the muscle system acting over the CMCJ. 28 CMCJ from 7 female and 7 male corpses (age: 81 yrs (median), 53-91 yrs (interval), which did not show any sign of arthrosis, were investigated. Contours in flexion/extension: in saddle point O, the contour of the proximal surface is stronger curved. For 23 of the 28 joints the contours showed an eye-catching difference. Contours in ab-/adduction: all 28 joints showed the respective incongruity. Straight lines and their included angles: in both articulating surfaces, the angles between the straight lines through the saddle point showed values which were close to 90 degrees. Out of neutral position a small axial rotation (maximal range: 3.5 degrees) is possible without that the contact at the saddle points is changed. But, when one of the straight lines of the proximal surface meets a respective straight line of the distal surface, the contact "point" is enlarged to a contact "line". When the axial rotation is further increased, the contact "line" splits into two contacts "points", which are located at outer areas of the articulating surfaces.

How do spinal segments move?

PURPOSE

To study and clarify the kinematics of spinal segments following cyclic torques causing axial rotation (T(z) (t)), lateral-flexion (T(x) (t)), flexion/extension (T(y) (t)).

METHODS

A 6D--Measurement of location, alignment, and migration of the instantaneous helical axis (IHA) as a function of rotational angle in cervical, thoracic, and lumbar segments subjected to axially directed preloads.

RESULTS

IHA retained an almost constant alignment, but migrated along distinct centrodes. THORACIC SEGMENTS: IHA was almost parallel to T(z) (t), T(x) (t), or T(y) (t), stationary for T(x) (t) or T(y) (t), and migrating for T(z) (t) along dorsally opened bows. IHA locations hardly depended on the position or size of axial preload. LUMBAR SEGMENTS: IHA was also almost parallel to T(z) (t), T(x) (t), or T(y) (t). In axial rotation IHA-migration along wide, ventrally or dorsally bent bows depending on segmental flexional/extensional status. Distances covered: 20-60mm. In lateral-flexion: IHA-migration to the left/right joint and vice versa. In flexion/extension IHA-migration from the facets to the centre of the disc. CERVICAL SEGMENTS: In flexion/flexion IHA was almost stationary for and parallel to T(y) (t). In axial rotation or lateral-flexion IHA intersected T(z) (t)/T(x) (t) under approximately -30 degrees /+30 degrees.

CONCLUSIONS

Generally joints alternate in guidance. Lumbar segments: in axial rotation and lateral-flexion parametrical control of IHA-position and IHA-migration by axial preload position. Cervical segments: kinematical coupling between axial rotation and lateral-flexion. The IHA-migration guided by the joints should be taken into account in the design of non-fusion implants. FE-calculations of spinal mechanics and kinematics should be based on detailed data of curvature morphology of the articulating surfaces of the joint facets.

Physiological functions of the human finger

Using morphological data describing the physiological curvature morphology of the corresponding articulating surfaces in each finger joint, it is shown that a) the flexion of each finger joint is described by two angles of flexion; b) in each finger joint, a "pump mechanism" for synovial fluid is present whose function is to lubricate and nourish the joint cartilage and c) finger posture has six kinematic degrees of freedom (DOF). Since six muscle forces control finger posture, the relationship between the muscle forces and finger posture is unambiguously described. The states of flexion of the interphalangeal joints restrict possible flexions in the metacarpophalangeal joint. Since the muscle forces act simultaneously on all three finger joints, the interdependence of the flexional states in the three finger joints can be attributed to the alignment of the lines of force and their sites of insertion, as a function of the corresponding flexion in the joints.

Mandible, maxilla and cervical spine--a functional unit?

The motion patterns of mandibular points were recorded in vivo in closed, free movements of the mandible parallel to the sagittal-vertical plane. The points ran along loops which were valued by their area and length. All points whose loops included the same area under regarding the sense of circulation formed a straight line. Lines belonging to different areas were parallel. When the absolute areas of the oops were plotted for particular points a hollow depression with two minima resulted. The point that showed the lowest minimum in the depression corresponded to the position of the neuromuscular mandibular axis of rotation. The points running along equal loop lengths formed elliptical lines with a minimum below the condyle. The lines of constant loop area and loop length were overlaid with lateral radiographs, to match the patterns of motion with anatomical structures. The mandibular axis of rotation lay mostly cranial anterior of the condyle whereas the point with the shortest path lay mainly below this axis point, inside the bony structures. The row of teeth in the maxilla was found to be located below the line of minimal loop lengths. The cervical spine was arranged along the depression of the minimal absolute areas.

A novel total knee replacement by rolling articulating surfaces. In vivo functional measurements and tests

The purposes of the paper were as follows: to show the fundamental functional differences between the natural knee and common total knee replacements (TKR), to describe the ideas on how main properties of the natural knee can be adopted by a novel TKR and to present some main biomechanical functions of this TKR. By analyzing the morphology of the articulating surfaces and the kinematics of the natural knee the design of the novel TKR was developed. The use was made of the test procedures established in vitro and of lateral X-ray photographs as well as fluoroscopy in vivo. The function of the novel TKR is comparable to that of the natural knee joint in terms of kinematics (roll/slide behaviour), loads of the articulating surfaces (diminished shear loads), stability and leeway under external impacts, reduction of the load in the patellofemoral joint, and ligament balancing.

[Free scapular or parascapular flaps for soft tissue damage accompanying talus or calcaneus fractures]

BASIS

Fractures of the talus or calcaneus with accompanying soft tissue damage require precisely planned treatment to prevent infection of the wound over time, especially in severely injured patients.

MATERIAL AND METHODS

Seven patients with fractures of the talus or calcaneus and accompanying 2nd and 3rd degree open or 3rd degree closed soft tissue injuries were followed up retrospectively. These patients were operated on between January 1999 and January 2006 with free fasciocutaneous scapular or parascapular flaps. The average age was 34 (range 16-54). Follow-up was at 6-36 months.

RESULTS

Osteosynthesis was primarily in six cases, post-primarily in one, and in four cases exterior fixation was used additively. Temporary vacuum therapy was performed for a mean of 28 days (6-42). Parascapular, scapular, and Latissimus dorsi flap coverage was performed six, one, and one times, respectively. Six flaps healed without complication. One necrosis of a parascapular flap occurred and made a Latissimus dorsi flap necessary. In one case of donor-site wound dehiscense, a local rotation flap became necessary. There was no joint infection or osteomyelitis. Bony consolidation was achieved within all fractures.

CONCLUSION

Traumatic soft tissue damage must be taken into account when primary or secondary internal fixation is performed and should influence the choice of implant. Free fasciocutaneous parascapular or scapular flaps are a powerful tool for preventing infection if local flaps are not sufficient to achieve stable soft tissue coverage.

Mutation in the alpha-cardiac actin gene associated with apical hypertrophic cardiomyopathy, left ventricular non-compaction, and septal defects

AIMS

The E101K mutation in the alpha-cardiac actin gene (ACTC) has been associated with apical hypertrophic cardiomyopathy (HCM). As prominent trabeculations were described in some carriers, we screened for the E101K mutation in our index patients with HCM, dilated cardiomyopathy (DCM), or left ventricular non-compaction (LVNC).

METHODS AND RESULTS

Clinical, echocardiographic, and genetic screening by restriction fragment length polymorphism of the ACTC E101K mutation in 247 families with HCM, DCM, or LVNC. The mutation was found in five index patients (one with LVNC and four with HCM). Clinical and morphological data were obtained from 94 family members. Forty-six individuals had cardiomyopathy (43 with the mutation and three with no genetic study): 23 fulfilled criteria for LVNC, 22 were diagnosed as apical HCM, and one had been diagnosed as restrictive cardiomyopathy. There had been one heart transplant and one congestive heart failure death in patients with severe diastolic dysfunction, and five premature sudden deaths. The E101K mutation was not found in 48 unaffected relatives. Septal defects (eight atrial and one ventricular) were found in nine mutant carriers from four families, and were absent in relatives without the mutation (P = 0.003).

CONCLUSION

LVNC and HCM may appear as overlapping entities. The ACTC E101K mutation should be considered in the genetic diagnosis of LVNC, apical HCM, and septal defects.

Wie sind die klinischen Ergebnisse operativ behandelter Talusfrakturen?

Our study focuses to determine the medium range results of function and radiological findings of operatively treated fractures of the talus. Furthermore we had the intention to investigate risk-factors for posttraumatic arthrosis and necrosis of the talus.

MATERIAL AND METHODS

We included all 41 patients (w/m: 13/28) operated between 1995-2000 with talus neck, corpus or dislocated fracture of the talus edge (open/closed: 11/30). Fractures were classified according to Hawkins: type 1: 6 x, type II: 17 x, type III: 7 x, type IV: 3 x, 8 x dislocated peripheral fractures. 39 x screw osteosynthesis, 2 x K-wire fixation were done and 12 additive transfixation with fixateur externe. Score: AOFAS Ankle-Hindfoot-Scale, radiological assessment according to the Bargon score. 34 patients, mean age 35 years (12-60), were followed up clinically with an average of 4 years (24-72 months).

RESULTS

AOFAS Score: pain (40 points): diameter 31 [10-40]; function (50 points): diameter 39 [14-50]; alignement (10 points):diameter 7 [0-10]; degree of arthritis due to the Bargon scale: 0 degree: 5x,1 degree: 8x, 2 degrees: 7 x, 3 degrees: 7 x.

COMPLICATIONS

4 x necrosis of margin of the wound, 1 deep infection, 5 necrosis of the talus bone. The severity of the fracture was 1 x type II according to Hawkins 3 x type III and 1 x type IV. 3 of the 5 patients who developed a talus necrosis had 28 or 38 soft tissue damage. One patient had an imminent compartment syndrome. One patient who suffered a polytrauma was operated six days post injury. Second operation: 1 Syme amputation due to necrosis of the talus subsequent to an infection. 4 x arthrodesis of the upper ankle joint and 5 x arthrodesis of the subtalar joint due to posttraumatic arthritis.

CONCLUSION

Primary screw osteosynthesis is the treatment of choice depending on the lesions of the soft-tissue and accompanied injuries in combination with a fixateur externe. Nevertheless the primary osteosynthesis is not able to prevent necrosis of the talus completely, that occurs in a frequency of 15%. Risk factors for a posttraumatic arthritis in addition to the type of fracture and the result of reconstruction are an accompanied soft tissue defect and local capsule-band complex with necessary temporary transfixation. Early plastic reconstruction of defects can reduce the time of immobilisation and allows motion therapy. The functional results are positive compared with the radiological results that showed arthritis in 70%.

[Beta-myosin heavy-chain gene mutations in patients with hypertrophic cardiomyopathy]

INTRODUCTION AND OBJECTIVES

To determine the frequency of mutations in the beta-myosin heavy-chain gene (MYH7) in a cohort of patients with hypertrophic cardiomyopathy (HCM) and their families, and to investigate correlations between genotype and phenotype.

METHODS

Single-strand conformation polymorphism analysis and sequencing of fragments with abnormal MYH7 gene mobility were carried out in 128 consecutive index patients with HCM. The phenotypes of patients with and without mutations were compared and the phenotypes of identified families were recorded.

RESULTS

A total of 11 mutations were found in 13 families (10%); 7/11 had been previously described. The I736T mutation was found in three families and the A797T in two. One patient had two mutations (i.e., I736T and R787H). Mutations were more frequent in patients with a family history of sudden death (31%) and in those with severe hypertrophy (39% had a thickness > or = 30 mm). Mutations were found in 29 of 42 members of the 13 families, including six family members (20%) who were healthy carriers and aged < or = 36 years. Sudden death had occurred in eight members of four families: four in two families with the I736T mutation, one in a family with A797T, one in a family with R870H, and two in a family with A901P.

CONCLUSIONS

MYH7 mutations were present in 10% of our families. Mutations were more frequent in patients with a family history of sudden death and in those with severe hypertrophy. Most mutations had been described previously. Some appeared in several families. For some mutations, the correlation between genotype and phenotype was stable, while for others, there were marked differences between the phenotypes of the index patients and their relatives, suggesting the presence of additional genetic factors that have yet to be identified.

T1-weighted cine FLASH is superior to IR imaging of post-infarction myocardial viability at 4.7T

PURPOSE

Data are unavailable for rational selection of pulse sequences to assess postinfarction myocardial viability in rodents at high field strength. We implemented a widely used clinical inversion recovery (IR) sequence at 4.7T and compared the results to a heavily T1-weighted cine FLASH sequence (T1-CF) for assessment of infarction size.

MATERIALS AND METHODS

Eleven infarcted rats were examined within 24 h of infarction after injection of Gadophrin-3 contrast agent. Images were acquired using both pulse sequences and a standard cine (SC) sequence. Estimates of infarct size were compared to TTC. Global LV function was compared between the T1-CF and SC sequences.

RESULTS

SNR, relative SNR, and CNR for the infarcted and normal myocardium were significantly greater for the IR sequence. Infarction size was overestimated by both sequences, but correlated highly and showed very close agreement with TTC. Global function revealed no significant differences between T1-CF and SC.

CONCLUSION

Both IR and T1-CF produced reliable results for assessment of infarction size at 4.7T. While the IR sequence delivers better overall SNR and CNR, the T1-CF allows concomitant assessment of global cardiac function with a much shorter acquisition time.

[Preventive practice in general medicine in the Rhone-Alps region]

The Fifth Health Conference in the Rhone-Alps which took place in early 2001 provided the ideal opportunity and forum for holding a debate about prevention in ambulatory care. In order to provide arguments supporting a wider basis for reflection, the Regional Department of Social and Health Affairs in the Rhone-Alps initiated a study focusing on preventive practices of general practitioners in various areas such as vaccination follow-up procedures; care provided to the elderly; gynaecology, life styles and additions (alcohol, tobacco, and drugs). Utilising the network of the Association for the Development of Medical Information (A.D.I.M.), a representative sample of 80 general practitioners working in the Rhone-Alps region was constituted, which allowed for the inclusion of 3,658 patients from July to December 2000. Results show a distortion between objective preventive practices measured with different physicians' activity scores in the aforementioned areas and the estimated level of effectiveness determined from individual physician's statements. The subsequent calculation of these scores, based on a large sample of patients with similar characteristics to the general population, provide an objective reality from the care consumer's perspective: there is an overall lack of prevention on the part of physicians. The physicians themselves cite the lack of time; an inadequate system of payment and insufficient training as causes for this situation. The implementation of an economic incentive system could facilitate the development preventive practice in general medicine and ambulatory care.

Predictive factors for rapid loss on the mini-mental state examination in Alzheimer's disease

OBJECTIVES

To seek predictors of rapid loss of cognition and to evaluate their frequency in a prospective study of patients suffering from Alzheimer's disease (AD).

DESIGN

A one-year prospective study.

METHODS

312 AD patients from the memory clinic at Toulouse University Hospital, participants in the ELSA study, were enrolled. Rapid cognitive decline was defined as a 4-point or greater loss on the Mini-Mental State Examination (MMSE) in 6 months. Comprehensive geriatric and neuropsychological assessment was conducted at baseline, 6 months and one year.

RESULTS

Seventy-nine (24.8%) patients presented rapid cognitive loss over 6 months. The majority were stable at one year whereas 15 experienced continued rapid cognitive loss. Multivariate analysis showed that only the Mini Nutritional Assessment score (MNA) was correlated with rate of decline. Patients with rapid cognitive decline were also significantly more dependent at 6 months.

CONCLUSIONS

Our findings demonstrate that rapid cognitive loss is frequent in AD patients, probably indicating underlying frailty. Future studies should lead to a practical approach to detecting these frail patients and to increasing preventive interventions.

Factors affecting the concentrations of lead in British wheat and barley grain

The entry of Pb into the food chain is of concern as it can cause chronic health problems. The concentration of Pb was determined in cereal grain samples collected representatively from British Cereal Quality Surveys in 1982 and 1998 (n = 176, 250 and 233 for wheat collected in 1982 and 1998, and barley in 1998, respectively). In addition, paired soil and grain samples were collected from 377 sites harvested across Britain in 1998-2000. Wheat grain Pb ranged from below the analytical detection limit (0.02 mg kg(-1) dry weight, DW) to 1.63 mg kg(-1) DW, and barley grain Pb from <0.02 to 0.48 mg kg(-1) DW. The vast majority of samples (>99% for both wheat and barley, excluding Scottish barley samples collected in 2000) were well below the newly introduced EU limit for the maximum permissible concentration of Pb in cereals (0.2 mg kg(-1) fresh weight, equivalent to 0.235 mg kg(-1) DW). There was a significant reduction in wheat grain Pb in the 1998 survey compared with the 1982 survey. However, 40 barley samples collected from Scotland in 2000 in the paired soil and crop survey showed anomalously high concentrations of Pb, with 10 samples exceeding the EU limit. Washing experiments demonstrated that surface contamination, introduced during grain harvest and/or storage, was the main reason for the high concentrations in these samples. In the paired soil and crop surveys, there were no significant correlations between grain Pb concentrations with total soil Pb and other soil properties, indicating low bioavailability of Pb in the soils and limited uptake and transport of Pb to grain. The Pb in cereal grain is likely to originate mainly from atmospheric deposition and other routes of surface contamination during harvest and storage.