ECP versus ruxolitinib in steroid-refractory chronic GVHD - a retrospective study by the EBMT transplant complications working party

Ruxolitinib has become the new standard of care for steroid-refractory and steroid-dependent chronic GVHD (SR-cGVHD). Our aim was to collect comparative data between ruxolitinib and extracorporeal photophoresis (ECP). We asked EBMT centers if they were willing to provide detailed information on GVHD grading, -therapy, -dosing, -response and complications for each included patient. 31 centers responded positively and we included all patients between 1/2017-7/2019 treated with ECP or ruxolitinib for moderate or severe SR-cGVHD. We identified 84 and 57 patients with ECP and ruxolitinib, respectively. We performed multivariate analyses adjusted on grading and type of SR-cGVHD (steroid dependent vs. refractory vs. intolerant to steroids). At day+180 after initiation of treatment for SR-cGVHD the odds ratio in the ruxolitinib group to achieve overall response vs. the ECP group was 1.35 (95% CI = [0.64; 2.91], p = 0.43). In line, we detected no statistically significant differences in overall survival, progression-free survival, non-relapse mortality and relapse incidence. The clinical significance is limited by the retrospective study design and the current data can't replace prospective studies on ECP in SR-cGVHD. However, the present results contribute to the accumulating evidence on ECP as an effective treatment option in SR-cGVHD.

ECP versus ruxolitinib in steroid-refractory acute GVHD - a retrospective study by the EBMT transplant complications working party

Introduction

Extracorporal Photophoresis (ECP) is in clinical use for steroid-refractory and steroid-dependent acute GVHD (SR-aGVHD). Based on recent Phase-III study results, ruxolitinib has become the new standard of care for SR-aGVHD. Our aim was to collect comparative data between ruxolitinib and ECP in SR-aGVHD in order to improve the evidence base for clinical decision making.

Methods

We asked EBMT centers if they were willing to participate in this study by completing a data form (Med-C) with detailed information on GVHD grading, -therapy, -dosing, -response and complications for each included patient.

Results

31 centers responded positively (14%) and we included all patients receiving alloSCT between 1/2017-7/2019 and treated with ECP or ruxolitinib for SR-aGVHD grades II-IV from these centers. We identified 53 and 40 patients with grades II-IV SR-aGVHD who were treated with ECP and ruxolitinib, respectively. We performed multivariate analyses adjusted on grading and type of SR-aGVHD (steroid dependent vs. refractory). At day+90 after initiation of treatment for SR-aGVHD we found no statistically significant differences in overall response. The odds ratio in the ruxolitinib group to achieve overall response vs. the ECP group was 1.13 (95% CI = [0.41; 3.22], p = 0.81). In line, we detected no statistically significant differences in overall survival, progression-free survival, non-relapse mortality and relapse incidence.

Discussion

The clinical significance is limited by the retrospective study design and the current data can't replace prospective studies on ECP in SR-aGVHD. However, the present results contribute to the accumulating evidence on ECP as an effective treatment option in SR-aGVHD.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Acute abdominal pain due to internal herniation of the sigmoid colon, fallopian tube and left ovary, a rare presentation of Allen Masters syndrome

In 1955, Allen and Masters describe a painful syndrome which associates traumatic delivery to laceration found on the posterior leaf of the broad ligament. Herniation through this defect is a rare entity, accounted for about 4-7% of all internal hernias. Normally, it involves the small bowel. The authors present the case of a multiparous woman admitted at emergency for constipation and abdominal pain. The CT scan showed an extremely rare case of internal hernia of the sigmoid colon, fallopian tube and left ovary through a large defect of the broad ligament. The patient underwent a full laparoscopic surgery that allowed the reduction of the hernia and the suture of the defect with very good outcome.

[Pleuroperitoneal communication: pleural effusion subsequent to the initiation of peritoneal dialysis, about a case]

We report the case of a patient with pleural effusion occurring after initiation of a peritoneal dialysis. This phenomenon is favoured by the existence of a pleuroperitoneal communication. The latter is described at the origin of other diseases like catamenial pneumothorax and pleural effusion in connection with cirrhotic ascites. We describe this rare complication of peritoneal dialysis in order to draw attention of nephrologists, pulmonologists and surgeons.

Primitive pulmonary "malignant epithelioid hemangioendothelioma" versus epithelioid angiosarcoma. A case report and review of the literature

We describe the case of a 56-year-old man presenting a primary pulmonary epithelioid angiosarcoma versus malignant epithelioid hemangioendothelioma still alive, without recurrence at nearly two years after the beginning of the symptoms. The primary pulmonary angiosarcoma is extremely rare, being reported only in a handful of cases. Metastatic involvement of the lung (90%) is far more common than primary pulmonary involvement (10%). Various predisposing condition for the development of angiosarcoma have been described. Early diagnosis is not common, because of the rarity of angiosarcoma in the lung and consequent low index of suspicion. Due to the paucity of cases, there are no defined treatment regimens for this entity. However, there is a tendency for surgical intervention in all reported cases.

Ruptured aneurysm of the popliteal artery. Is the diagnosis still difficult?

The aneurysm of the popliteal artery is the most commonly treated non-aortoiliac aneurysm, accounting for more than 70% of all peripheral aneurysms. The rupture of a popliteal aneurysm is rare and it is often misdiagnosed. In the case of a 46-year old female patient here reported, the patient was referred to our department with the diagnosis of ruptured aneurysm of the right popliteal artery with formation of a large pseudo-aneurysm. We operated the patient on a semi-urgent basis and performed a replacement of the popliteal artery by a saphenous vein graft. Three months after the operation, the patient was free of symptoms. This article's aim was to emphasize on how the pitfalls during clinical examination, as well as the problems of imaging interpretation, can make the diagnosis of ruptured popliteal aneurysm still difficult.

[Iliac arteriovenous fistula as a complication of lumbar disc surgery]

A 56-year-old man suffering from moderate dyspnea was hospitalised in the unit of surgery. Fifteen days before, he was subjected to a discectomy at L4-L5. The clinical examination demonstrated sinus tachycardia and hepatomegalia. An abdominal CT revealed an arteriovenous fistula between the right common iliac artery and vein that was subsequently confirmed by angiography. The patient underwent an endovascular stent-graft which was positioned at the level of the right common iliac artery related to the fistula. This treatment had an immediate successful effect leading the cardiac rhythm to be back to normal and the fistula to dry up.

Endovascular treatment of axillary artery dissection following anterior shoulder dislocation

Injury to the axillary artery is a rare complication of anterior shoulder dislocation. Open surgical repair is technically demanding because of the anatomical position of the vessel and the propensity for concomitant injuries. Standard surgical exposure techniques involve extensive dissection, including a combination of supraclavicular or infraclavicular incision, median sternotomy, and thoracotomy causing significant morbidity and mortality rates. Endovascular techniques may offer an alternative to these surgically demanding procedures. We present a patient with a traumatic dissection of the axillary artery following anterior shoulder dislocation who was successfully managed with an endovascular stent.

Totally retroperitoneal laparoscopic aortobifemoral bypass

The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves-Marie Dion, laparoscopy has been accepted by several authors as a possible minimally invasive alternative for aorto-iliac occlusive disease. The transperitoneal left retrocolic and retrorenal ways are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. We report here a totally laparoscopic retroperitoneal approach to performing aortobifemoral bypass. This approach was proposed to a 51-year-old man with aorto-iliac occlusive disease. There was no indication for endovascular revascularization. The patient suffered from 10 metres of bilateral intermittent claudication and lower limb ulcers. During the surgical procedure our patient was placed in a 30-degree right lateral decubitus position. The optical system was first placed in an intra-abdominal position to check the positioning of the trocars in the left retroperitoneal space. The dissection of the retroperitoneal space was performed by CO2 insufflation and by blunt dissection using laparoscopic forceps. The infrarenal aorta was exposed and clamped by laparoscopic clamps. A bifurcated graft was sutured on the left-hand side of the aorta by a running suture. Both prosthetic limbs were tunnelized retroperitoneally to the groin under optical control. The femoral anastomoses were performed by classic open surgery.

Surgical management of acute perforation of peptic ulcers. A single centre experience

INTRODUCTION

Acute perforation may occur in gastric and duodenal ulcers. During the past decade, the need for elective operation for peptic ulceration has decreased as medical treatment has improved. However, emergency operations for acute complications such as perforation or bleeding remain constant. Actually, the treatment of choice is simple suture-closure, with or without omentoplasty, and peritoneal lavage or even omentoplasty alone, associated with a high intravenous dose of inhibitors of the proton pump and Helicobacter pylori eradication, if needed.

PATIENTS AND METHOD

The standard treatment in our team is to perform a peritoneal lavage and drainage and a simple closure of the ulcer with an omentoplasty. A first retrospective analysis was made on data collected from 1996 to 2001 and we completed a prospective study from 2001 to 2003 to compare our results with our old data and with data collected from other teams.

RESULTS

The mean age and the mean ASA score were similar in the two groups. For the majority of the patients, the diagnosis was made from symptoms and the presence of free abdominal air. The delay between arrival in the emergency room and the operating room was significantly shorter in the second group, but operating time was longer in this group. Morbidity was more frequent in the first group but mortality remained quite similar. Our results indicate that in a trained team the morbidity has decreased as the delay in surgery decreased and that the rate of diagnosis on plain abdominal film has increased. Laparoscopic suture of a perforated peptic ulcer is as safe as the open procedure but allows the surgeon to search for another cause of free air and offers the possibility, if conversion is needed, to perform a shorter laparotomy.

Manubriosternal disjunction a new approach for surgical repair

We report a case of manubriosternal disjunction and review the literature. We describe a new approach for surgical repair with direct suture with PDS ropes.

Immediate implant placement using injectable calcium phosphate hydraulic cement in dogs

Techniques allowing implant placement in extraction sockets require either high diameter implants in surgically enlarged sockets or grafting and/or regenerative procedures around implants after their primary surgical stabilization. This study aimed to evaluate the ability of calcium phosphate hydraulic cement (CPHC) to immobilize commercially available titanium implants in extraction sockets. CPHC was used in seven fresh dog extraction sockets in conjunction with ITI TPS implants. Three extraction sockets without CPHC were used as controls. Initial implant stability was measured after 10 min hardening with periostest. The dogs were sacrificed after 9 months. Non-decalcified specimens were prepared for histologic and histomor-phometric examination. The surface percentage of implant-to-mineralized bone contact and bone density was calculated for each specimen. The periotest values were significantly different for implants stabilized with CPHC than for the controls, and simi-lar to values reported for osteointegrated implants. New alveolar bone was formed in intimate contact with titanium. In two cases, non-resorbed CPHC residues were observed closely bound to the implant. This study clearly demonstrates that CPHC cement is suitable for immediate implant immobilization in extraction sockets.

Injectable calcium phosphate hydraulic cement (CPHC) used for periodontal tissue regeneration: A study of a dog model

Injectable calcium phosphate hydraulic cement (CPHC) is a new bone substitute family. This study aimed to evaluate the use of CPHC in surgical periodontitis-simulating defects in a dog model. CPHC was obtained by adding powder mixtures of different calcium phosphates with different solubility. Alveolar bone was removed by drilling over the mesial and distal roots of the 2nd mandibular premolar in six dogs. The defects were randomly selected, three were untreated and six treated. The defects had a depth of 6 mm and a width of 3 mm. The animals were sacrificed after 9 months and samples prepared, with no decalcification, for histological evaluation. Seventy-nine percent of the root was covered by bone in the experimental defects, compared to 41% of the root for the control defects. Bone height was significantly higher for the experimental defects (4.9 +/- 0.9 mm) than for the control defects (1.4 +/- 0.5 mm). After 9 months, 97 +/- 6% of the CPHC was degradated and replaced by bone. This study proves the interest of this cement because of the particularly high level of periodontal bone regeneration. The ability of the cement to be easily injected and shaped in bone defects and the immediate immobilization of the teeth after hardening is notable. (Journal of Applied Biomaterials & Biomechanics 2003; 1: 186-93).

Bone colonization of beta-TCP granules incorporated in brushite cements

Injectable calcium phosphate hydraulic cements are known to have a high clinical potential in bone reconstruction for mini-invasive orthopaedic surgery, interventional radiology, and rheumatology. Previous in vivo experiments in rabbit have shown that the presence of beta-TCP granules in injectable bone cement help maintain the transient biomechanical function of the implanted bone and promote the formation of good-quality new bone. Histomorphometric analysis of two brushite hydraulic cement (BHC) mixtures selected from previous results (referred to in this work as BHC-A and BHC-B) was performed at three postoperative delays (0, 12, and 24 weeks): histomorphometric analysis of bone colonization within beta-TCP shows that, just before implantation, the beta-TCP granule area is significantly higher in BHC-B; the residual granule area decreases steadily over time in BHC-A, whereas it goes through a maximum of 30% at 12 weeks in BHC-B; the residual granule porosity increases steadily up to 35% in BHC-A, whereas it goes through a maximum of 35% at 12 weeks and decreases somewhat until 24 weeks in BHC-B. New bone formation within granules appears higher in BHC-A (58% Area) compared to BHC-B (38% area) at 12 weeks. At 24 weeks bone colonization levels off in both cements at about 50% area. Irrespective of the cement matrix composition, beta-TCP granules contribute actively to the conduction of new bone formation.

Hydroxyapatite cement scaffolds with controlled macroporosity: fabrication protocol and mechanical properties

Precipitated hydroxyapatite cement scaffolds with macroporosity of controlled size and shape were successfully built using a solid freeform fabrication process. The negative macroporosity was designed using CAD software and built with an inkjet machine. A slip casting process using a plaster mold was used to precipitate the cement and manufacture samples for mechanical testing. The negative macroporosity was then extracted from the samples using a thermal process. Compression, tension and torsion tests were completed successfully on the precipitated hydroxyapatite cement samples in moist condition. Elastic and strength properties were measured for these three loading cases and compared to the plain hydroxyapatite cement properties reported in a previous study. Homogenization theory was applied to estimate the elastic properties of the manufactured scaffolds. A good correlation was obtained between the experimental data and the theory.

Effect of several additives and their admixtures on the physico-chemical properties of a calcium phosphate cement

Combinations of citrate (C6H5O(7)3-), pyrophosphate (P2O(7)4-) and sulfate (SO(4)2-) ions were used to modify the physico-chemical properties of a calcium phosphate cement (CPC) composed of beta-tricalcium phosphate (beta-TCP) and phosphoric acid (PA) solution. The results obtained with only one additive at a time are similar to those previously published. New facts are: the positive effect of C6H5O(7)3- ions on cement failure strain and their negative effect on cement pH. The position of the setting time maximum measured at an SO(4)2- concentration of 0.09 M was not displaced by the addition of C6H5O(7)3- and P2O(7)4- ions. However, the effect of SO(4)2- ions on the setting time was depressed by C6H5O(7)3- ions. Moreover, no increase in tensile strength was observed when increasing amounts of SO(4)2- were added into a C6H5O(7)3--containing cement. The latter results suggest a competitive effect of C6H5O(7)3- and SO(4)2- on setting time and tensile strength. Anhydrous dicalcium phosphate (DCP; CaHPO4) appeared in cement samples dried just after setting, but not in cement samples incubated for 24 h in deionized water before the drying step. It is believed that the setting reaction is stopped by the drying step, leaving a low internal pH in the sample, hence providing favorable conditions for the transformation of dicalcium phosphate dihydrate (DCPD) into DCP. Interestingly, even though C6H5O(7)3- ions dramatically lowered the equilibrium pH of the cement with 5 ml of deionized water, they still prevented the occurrence of the transformation of DCPD into DCP.

[Development of a model which makes it possible to test injectable bone substitutes and evaluation of a calcium phosphate cement]

New percutaneous filling techniques are beginning to be used in bone tumor pathology. The purpose of this study was to develop a reproducible model for testing new injectable bone substitutes. A closed cancellous bone defect was created in the distal femoral condyles of rabbit. Bone defect was filled by a percutaneous injection. Several situations were tested: spontaneous evolution of unfilled cavities, evolution of cavities filled either with a conventional orthopedic cement (PMMA), either with a mixed collagen-hydroxyapatite material, either with a biomaterial derived from the vegetal protein zein, either with a calcium phosphate cement brushite type. The new bone formation was quantified in the defect for each group in which several delays were tested. A bone defect of reproducible size was obtained consistently. A partial bone formation was observed in the unfilled group. The best bone formation rate was obtained in the phosphate cement group. This model showed the interest of injectable biomaterials and more precisely the interest of the phosphate calcium cements as brushite.

[Post-traumatic carotid-cavernous sinus fistula]

The authors report the case of a 51 year-old man who developed a carotid-cavernous sinus fistula after a blunt trauma. In view of an exophthalmia, an impressive chemosis, a pupillary dilatation due to parasympathetic paralysis and a bruit over the right orbit, a carotid-cavernous sinus fistula was diagnosed. The existence of the fistula was confirmed by a brain CT scan and a cerebral angiogram. Carotid-cavernous sinus fistulas are rare. They are spontaneous or posttraumatic. Cerebral angiography is the diagnostic procedure of choice. The authors review the signs and symptoms, diagnostic procedures, treatment, and prognosis of this complication.

Leiomyosarcoma of the mesocolon

Retroperitoneal sarcomas are rare tumours. Although exceptional in the mesocolon, they can yet be considered as a special kind of retroperitoneal tumours. Leiomyosarcoma represents from 25 to 30% in this location. Clinical features are rarely obvious because the symptomatology depends upon displaced or compressed adjacent organs. Most authors agree on using the CT-scanner or MRI as diagnostic tools. However, the diagnosis is made after a histologic examination permitting the establishment of its grade and margins. Only a surgical treatment can offer prolonged survival and this can be improved if there is a low histological grade and total excision. The mesocolic location facilitates a radical removal and may therefore offer a better long-term prognosis.

Adsorption of Catalase on Hydroxyapatite

The adsorption of catalase on calcium hydroxyapatite is reported in this study. In all the solutions investigated, catalase adsorption takes place under conditions where the adsorbent and the adorbate are both negatively charged and is accompanied by the release of phosphate ions. This suggests that electrostatic attraction does not play a leading role in the adsorption process. However, electrostatic repulsion does play a role as evidenced by the influence of the solution composition on the maximum amount adsorbed. In fact, the amount adsorbed increases when the surface charge tends to be less negative (decrease of pH and phosphate concentration, presence of calcium) or when the electrical charges are screened as a result of the ionic strength increase. This was confirmed by the electrophoretic mobility which becomes more negative after protein adsorption. The rate of catalase adsorption is extremely low; the time required to reach a stationary concentration is 60 and 125 h in potassium nitrate and phosphate solution, respectively. The reversibility of catalase was examined with respect to changes in the bulk solution concentration. No significant desorption was obtained after several days of observation. The adsorption, desorption, and kinetic aspects have been discussed in relation to changes in the the protein structure upon interaction and to the microstructural characteristics of the mineral. Copyright 1998 Academic Press.

Löeffler endomyocarditis: a clinical presentation as right ventricular tumor

A four-year-old girl presented with an apical mass of the right ventricle, pulmonary embolism and hypereosinophilia, and was shown to be infected with Toxocara canis. Cardiac involvement was represented by endomyocardial fibrosis, mainly at the apex of the right ventricle, mural thrombi and tricuspid regurgitation. Hypereosinophilia appears to be the head point at the basis of multiple organ damage in Löeffler endomyocarditis. The disease mechanism proposed is the eosinophilic production of peroxidases, which are cytotoxic when released in large amounts into the blood flow. Treatment is based on etiologic and corticosteroid therapy (prednisolone 1-2 mg/kg/day); surgical therapy is indicated in the end stages of the pathologic process.

Composition effects on the pH of a hydraulic calcium phosphate cement

The pH of a hydraulic calcium phosphate cement (HCPC) made of monocalcium phosphate monohydrate (Ca(H2PO4)2.H2O; MCPM), beta-tricalcium phosphate (beta-(Ca3(PO4)2; beta-TCP) and water was measured as a function of reaction time and composition at room temperature. During setting, the cement pH varies from very acidic pH values, i.e., 2.5, to almost neutral pH values, i.e., 6. The cement pH profile significantly depends on the initial cement composition. However, all profiles are characterized by a sharp initial decrease of the pH due to the dissolution of MCPM crystals and the precipitation of dicalcium phosphate dihydrate (CaHPO4. 2H2O; DCPD) crystals. With an excess of MCPM, the final pH stays low, and its value can be predicted from the initial composition of the cement and solubility data. With an excess of beta-TCP, the end pH is close to 5, which is much lower than 5.9, the value predicted by calculation. Results suggest that the difference may be due to the presence of impurities in the cement. Replacing MCPM by phosphoric acid renders the cement paste very acidic for the initial 30 s, but then the pH profile follows that obtained with MCPM. Adding pyrophosphate ions into the cement paste postpones the position of the pH minimum. The delay, which is proportional to the concentration of pyrophosphate ions, is thought to be due to the inhibiting action of pyrophosphate ions on the precipitation of DCPD crystals.

[Transsexualism and legal proceedings]

One may not ignore the legal problem to which the transsexuals are exposed, once they have to search medical care. In Belgium, there does not exist any laws, which deal with the change of sex, although such laws would be very important for transsexual patients. On the other hand, change of the first name has been regulated by law. The actual knowledge of this problem is reviewed in this paper.

Calcium phosphate cements: study of the beta-tricalcium phosphate--monocalcium phosphate system

The possibility of making cements based on beta-tricalcium phosphate (beta-TCP), a promising bone graft material, was investigated. Upon admixture with water, beta-TCP/monocalcium phosphate monohydrate (MCPM) mixtures were found to set and harden like conventional hydraulic cements. Beta-TCP powders with larger particle size, obtained by sintering at higher temperatures, increased the ultimate strength of the cement. Results show that setting occurs after dissolution of MCPM, as a result of the precipitation of dicalcium phosphate dihydrate (DCPD) in the paste. The ultimate tensile strength of the hardened cement is proportional to the amount of DCPD formed. Upon ageing above 40 degrees C, DCPD transforms progressively into anhydrous dicalcium phosphate (DCP), thereby decreasing the strength. Ageing of the pastes in 100% r.h. results in a decay of the mechanical properties. This can be ascribed to an intergranular dissolution of the beta-TCP aggregates as a result of the pH lowering brought about by the MCPM to DCPD conversion.