A Bayesian network meta-analysis of 14 molecules inhibiting UV daylight-induced pigmentation

INTRODUCTION

Hyperpigmentation disorders are very frequent, affect the quality of life and may become a psychological burden for afflicted patients. Many anti-pigmenting or depigmenting agents are available with various efficacy and almost no comparative data. 2-mercaptonicotinoyl glycine (2-MNG) was recently proposed as a viable candidate showing safe and effective results on hyperpigmentation control in vitro and in vivo.

OBJECTIVES

A Bayesian network meta-analysis (BNMA) was conducted to map and rank the anti-pigmenting and depigmenting efficacy of 2-MNG 0.5% on UV daylight (UVDL)-induced pigmentation together with 13 other reference molecules. A comparison in the kinetics of 2-MNG 0.5% was also performed.

METHODOLOGY

Fourteen studies were conducted, for each, on 15-30 women of skin phototype III in Shanghai, China and Paris, France. The products were applied on mini zone, in randomized and blinded protocol, on the back, 5 days a week during 6 weeks, at a dose of 4 mg/cm2 . During the second week, volunteers were exposed under to varying minimum erythemal dose of UVDL during 4 consecutive days-adapted to obtain a similar induction of skin pigmentation regardless of the population. Assessments were performed instrumentally using Chromameter®. Ascorbic acid 7% was used as a positive control for all experiments. A Bayesian network meta-analysis was then established to map and follow the kinetics of 2-MNG 0.5% performance with 13 reference molecules (glutathione 2%, kojic acid 1%, hydroquinone 4%, ascorbyl glucoside 2%, niacinamide 4%, etc.).

RESULTS

2-MNG 0.5% dominated the ranking at all time points with a significant high probability of strong efficacy against UVDL-induced pigmentation. Ascorbic acid 7% ranks second after 4 days of irradiations (D12 ) whereas hydroquinone 4% ranks second 1 month after irradiations (D40 ). In the kinetics, 2-MNG at 0.5% was effective as from the end of irradiations (D12 ) to the study endpoint (D40 ). This suggested an immediate and persistent efficacy across all timepoints evaluated.

CONCLUSION

The BNMA revealed a rapid and lasting efficacy of 2-MNG 0.5% on the anti-pigmenting and depigmenting phases of the clinical protocol. 2-MNG 0.5% ranked first, with immediate and lasting effect compared to 13 other references. This study is the first allowing comparison between reference anti-pigmenting and depigmenting agents and will help clinicians for proposing the most effective approach for their patients.

Impact on facial skin aging signs of a 1-year standardized photoprotection over a classical skin care routine in skin phototypes II-VI individuals: A prospective randomized trial

BACKGROUND

Data reflecting the impact of photoprotection on cutaneous aging are scarce and mostly limited to fair skin.

OBJECTIVE

To assess the effectiveness of a photoprotective product in counteracting the photoaging process in different skin phototypes over 1 year compared against a classical routine.

MATERIALS AND METHODS

Two hundred and ninety Brazilian women aged 30-65 years, with skin phototype II-VI were equally randomized in two groups. Group 1 kept on their routine whereas Group 2 applied, twice daily, a photoprotective product (SPF 60, PPD = 24.1) replacing the one they routinely used. Volunteers reported the duration of their daily sun-exposure. Standardized photographs taken at D0 and D365 were analysed by 15 dermatologists to assess eight wrinkles and pigmentation signs.

RESULTS

A global increase in severity was reported which was significant for Group 1. This increase was lower in Group 2 where only half the signs showed significant worsening. In Group 2 versus Group 1, the increase in forehead wrinkles, marionette lines, wrinkles created by ptosis and size of dark spot was significantly (p < 0.05) decreased by 30%-50%.

CONCLUSION

Daily application of a high photoprotective product significantly decreases the progression of skin aging signs after 1 year in skin phototypes II-VI.

Evaluation of adapted dermocosmetic regimens for perimenopausal and menopausal women using an artificial intelligence-based algorithm and quality of life questionnaires: An open observational study

BACKGROUND

The decline in estrogen levels from several years before (perimenopause) and during menopause has various negative effects, including skin specific issues, which often receive less attention than other menopausal symptoms despite having a significant negative effect on quality of life (QoL). The objective of this study was to evaluate the effectiveness of anti-aging dermocosmetic products designed for women during the perimenopause and menopause.

MATERIALS AND METHODS

An open study of 101 perimenopausal women (no menstruation for 4-12 months or irregular menstruation for <5 years) and 101 menopausal women (no menstruation for >12 months), not taking hormone replacement therapy, was conducted. Adapted dermocosmetic regimens, specific to each group (day cream, night cream and serum), were applied for 56 days. Assessments included automatic artificial intelligence diagnostics of eight clinical facial signs, hydration and transepidermal water loss (TEWL), and a menopause skin QoL questionnaire.

RESULTS

Mean age was 50 ± 3.9 years (range 41-57) and 59 ± 3.8 years (range 50-66) for the perimenopause and menopause groups, respectively. Significant improvements in wrinkles and vascular signs, increases in hydration, decreases in TEWL, and a positive impact on QoL were observed after 56 days of application of the respective dermocosmetic regimens for both the perimenopause and menopause groups.

CONCLUSION

The anti-aging skin care products designed specifically for perimenopausal and menopausal women increased skin hydration and improved wrinkles with a positive impact on QoL.

Objective and automatic grading system of facial signs from smartphones' pictures in South African men: Validation versus dermatologists and characterization of changes with age

OBJECTIVE

To evaluate the capacity of the automatic detection system to accurately grade, from selfie pictures, the severity of eight facial signs in South African men.

METHODS

Selfie pictures (obtained from frontal and back cameras) of 281 South African men differently aged (20-70 years) were obtained and analyzed by an automatic artificial intelligence (AI)-based automatic grading system. Data were compared with the clinical gradings made by experts and dermatologists.

RESULTS

In all facial signs, both series of gradings were found highly correlated with, however, different coefficients (0.59-0.95), those of marionette lines and cheek pores being of lower values. No differences were observed between data obtained by frontal and back cameras. With age, in most cases, gradings show up to the 50-59 year age-class, linear-like changes. When compared to men of other ancestries, South African men present lower wrinkles/texture, pigmentation, and ptosis/sagging scores till 50-59 years, albeit not much different in the cheek pores sign. The early onset (mean age) of visibility of wrinkles/texture for South African men were (i.e., reaching grade >1) 39 and 45 years for ptosis/sagging.

CONCLUSION

This study completes and enlarges the previous works conducted on men of other ancestries by showing some South African specificities and slight differences with men of comparable phototypes (Afro American).

Analysis of images supplied by Skincam® can record the changes of some scar features that occur over time. Comparisons with the assessments of dermatologist and patients' perception

OBJECTIVE

The objective of the study was to assess in vivo the validity of a new imaging device in quantifying the scarring process over time and to compare its data with the expertise of dermatologist and patients' self-appraisals.

MATERIALS AND METHODS

A total of 37 Korean women, aged 20-50 year, with closed scars of different types, were enrolled after a dermatological evaluation. All subjects applied daily a hydrating cream on their scars for 2 months. Images of scars at different times (Day 0, Day 28, and Day 56) were taken and further analyzed, yielding various parameters such as color, luminance, size, volume, and depth of each scar. A dermatologist visually graded, at each time point, the clinical aspect of the scar, and patients were asked to answer to some questions dealing with their self-examination of their scar.

RESULTS

The changes in some scar features that occurred during the application period were quantified and statistically differed from the D₀ baseline value. Scars became of reduced size, lighter (Increased luminance), less red, less deep, and less voluminous. Some of these parameters (volume, lightness, smoothness, texture regularity) were statistically different at D₂₈ whereas some others (area, depth, redness) showed significant changes at D₅₆ . Dermatologist expertise and patients' assessments were in high agreement.

CONCLUSION

This methodological approach that uses a dedicated camera associated with image analysis, despite some inherent limits (size of the scar), appears as a valuable aid to surgeons in the management of scars, in the follow-up of a given procedure or treatment. Beyond scar management, this approach may be extended to other skin disorders such as acne.

Accuracy and clinical relevance of an automated, algorithm-based analysis of facial signs from selfie images of women in the United States of various ages, ancestries and phototypes: A cross-sectional observational study

BACKGROUND

Real-life validation is necessary to ensure our artificial intelligence (AI) skin diagnostic tool is inclusive across a diverse and representative US population of various ages, ancestries and skin phototypes.

OBJECTIVES

To explore the relevance and accuracy of an automated, algorithm-based analysis of facial signs in representative women of different ancestries, ages and phototypes, living in the same country.

METHODS

In a cross-sectional study of selfie images of 1041 US women, algorithm-based analyses of seven facial signs were automatically graded by an AI-based algorithm and by 50 US dermatologists of various profiles (age, gender, ancestry, geographical location). For automated analysis and dermatologist assessment, the same referential skin atlas was used to standardize the grading scales. The average values and their variability were compared with respect to age, ancestry and phototype.

RESULTS

For five signs, the grading obtained by the automated system were strongly correlated with dermatologists' assessments (r ≥ 0.75); cheek skin pores were moderately correlated (r = 0.63) and pigmentation signs, especially for the darkest skin tones, were weakly correlated (r = 0.40) to the dermatologist assessments. Age and ancestry had no effect on the correlations. In many cases, the automated system performed better than the dermatologist-assessed clinical grading due to 0.3-0.5 grading unit differences among the dermatologist panel that were not related to any individual characteristic (e.g. gender, age, ancestry, location). The use of phototypes, as discontinuous categorical variables, is likely a limiting factor in the assessments of grading, whether obtained by automated analysis or clinical assessment of the images.

CONCLUSIONS

The AI-based automatic procedure is accurate and clinically relevant for analysing facial signs in a diverse and inclusive population of US women, as confirmed by a diverse panel of dermatologists, although skin tone requires further improvement.

Structural and Functional age-related changes in some facial signs of Chinese men. A Pilot study

OBJECTIVE

To associate, on the same Chinese male subjects, changes in facial aging signs with some biomechanical skin properties.

METHODS

The severities of 20 facial aging signs of 219 differently aged Chinese men (20-65y) were graded in blind by trained experts through standardized photographs, using a referential skin Atlas dedicated to Asian men. On each subject, the mechanical properties were assessed on the cheek area (left or right at random) by the validated suction technique Cutometer®. Finally, the skin color parameters were assessed on images from VISIA-CR device.

RESULTS

Clinically speaking, the severity of almost all facial aging signs increases from 30y to 65y, in a linear like progression, whereas the 20-30y shows weak increases. Skin color shows slight but progressive decreases in Luminance and ITA, whereas the yellow and red components slightly increased between 40y and 65y. At the exception of skin firmness, the skin mechanical properties show a clear decline during the 30-50y period and plateau beyond.

CONCLUSION

The present study suggests that the 20-30y period, albeit more clinically "silent" than the other periods of age, seems to be an age-range during which early alterations of some dermal elements' onset. Deeper in vivo investigating techniques (Echography, Multiphotonic microscopy) are needed to confirm such hypothesis.

Objective and automatic grading system of facial signs from selfie pictures of South African women: Characterization of changes with age and sun‐exposures

OBJECTIVE

To evaluate the capacity of the automatic detection system to accurately grade, from smartphones' selfie pictures, the severity of fifteen facial signs in South African women and their changes related to age and sun-exposure habits.

METHODS

A two-steps approach was conducted based on self-taken selfie images. At first, to assess on 306 South African women (20-69 years) enrolled in Pretoria area (25.74°S, 28.22°E), age changes on fifteen facial signs measured by an artificial intelligence (AI)-based automatic grading system previously validated by experts/dermatologists. Second, as these South African panelists were recruited according to their usual behavior toward sun-exposure, that is, nonsun-phobic (NSP, N = 151) and sun-phobic (SP, N = 155) and through their regular and early use of a photo-protective product, to characterize the facial photo-damages.

RESULTS

(1) The automatic scores showed significant changes with age, by decade, of sagging and wrinkles/texture (p < 0.05) after 20 and 30 years, respectively. Pigmentation cluster scores presented no significant changes with age whereas cheek skin pores enlarged at a low extent with two plateaus at thirties and fifties. (2) After 60 years, a significantly increased severity of wrinkles/texture and sagging was observed in NSP versus SP women (p < 0.05). A trend of an increased pigmentation of the eye contour (p = 0.06) was observed after 50 years.

CONCLUSION

This work illustrates specific impacts of aging and sun-exposures on facial signs of South African women, when compared to previous experiments conducted in Europe or East Asia. Results significantly confirm the importance of sun-avoidance coupled with photo-protective measures to avoid long-term skin damages. In inclusive epidemiological studies that aim at investigating large human panels in very different contexts, the AI-based system offers a fast, affordable and confidential approach in the detection and quantification of facial signs and their dependency with ages, environments, and lifestyles.

Skin moisture assessment using Hydration Sensor Patches coupled with smartphones via Near Field Communication (NFC). A pilot study with the first generation of patches that allow self-recordings of skin hydration

OBJECTIVES

To evaluate the potency of a new skin hydration sensor patch in the fast self-recording of skin hydration.

MATERIAL AND METHODS

The Skin Hydration Sensor Patch (SHSP) turns the user's smartphone into a wireless skin moisture measuring device. The SHSP combines a capacitive measurement unit and Near Field Communication technology (NFC) for transmitting data and energy. The probe is fixed onto the back of the smartphone and pressed to the skin for a few seconds where the application immediately calculates the capacitance value. Once recorded, the probe is then immediately taken off from the skin. In a first study, this system was compared to the Corneometer^® technique, in vivo, on various skin sites of 23 healthy French women. In a second study, 20 women with moderate dry skin on face and forearm self-recorded, through the SHSP the changes in skin hydration induced by a Xanthan gel containing 3% (w/w) of Glycerol, along 24 hours. A questionnaire based on 5 types of questions was established to be filled by subjects about their perception of the use of this new system.

RESULTS

In the first study, the values recorded by the SHSP were found highly correlated with those provided by the Corneometer^® . The second study allowed to observe significant differences in skin hydration of both sites at all times, as compared to values obtained before the application of the gel. Differences between both sites were observed, the face being less hydrated than forearm. From a practical aspect, the self-recordings on the face show a higher variability (approx. 10% than those of the forearm). The questionnaire led to positive answers on almost all points.

CONCLUSION

This SHSP appears as a promising approach in the field of connected skin-related devices. As such, it opens or enlarges a new paradigm in the relationships between a consumer and a cosmetic product.

Developing an Artificial Intelligence (A.I)-based descriptor of facial appearance that fits with the assessments of makeup experts

OBJECTIVE

To develop an A.I-based automatic descriptor that detects and grades, from selfie pictures, 23 facial signs, hairs included, as a help to making-up procedures.

MATERIAL AND METHODS

The selfie images taken in very different conditions by 3326 women and men were used to create (90% of dataset) and validate (10% of dataset) a new algorithm architecture to appraise and grade 23 different facial signs such as lips, nose, eye color, eyebrows, eyelashes, and hair color as defined by makeup artists. Each selfie image was annotated by 12 experts and defined references to train Artificial Intelligence (A.I)-based algorithm.

RESULTS

As some the 23 signs present a continuous or discontinuous feature, these were analyzed by two different statistical approaches. The results provided by the automatic descriptor system were not only in good agreement with the expert's assessments but were even found of a better precision and reproducibility. This automatic descriptor system has proven a good and robust accuracy despite the very variable conditions in the acquisition of selfie pictures.

CONCLUSION

Such automatic descriptor system seems providing a valuable help in making-up procedures and may extend to other activities such as Skincare or Haircare. As such it should allow large investigations to better evaluate the consumers' needs of esthetical improvements.

Comparing the self-perceived effects of a facial anti-aging product to those automatically detected from selfie images of Chinese women of different ages and cities

OBJECTIVE

To assess the agreement, after 1-month application of a popular and efficient anti-aging product, between self-perceived facial signs of aging and those detected and graded by an automatic A.I-based system, using smartphones' selfie images.

MATERIAL AND METHODS

Of 1065 Chinese women, aged 18-60 years, from eight different Chinese cities were recruited. They were asked to apply daily, for 1 month, a referential anti-aging product onto their whole face. Selfie images were taken by all subjects at D₀ and D₂₈ and sent to our facilities for being analyzed through 10 different facial signs. At D₂₈ , all subjects were asked to fill a questionnaire on the status of their faces, through six general statements.

RESULTS

A global agreement between both approaches is reached, particularly among women older than 40 years where the severity of facial signs is already more pronounced or among younger women who present at least facial signs scored above one grading units. This limit becomes, therefore, a prerequisite in the recruitment of Chinese subjects in the case of anti-aging applied studies and possible automatically based on automatic grading system. When respecting such conditions, the positive effects of the product on most facial signs can be demonstrated after 28 days of successive applications.

CONCLUSION

Such methodological approach paves the road in fulfilling the need of consumers of a better transparency in the claims of an anti-aging product.

Changes in facial signs due to age and their respective weights on the perception of age and skin plumpness among differently aged Korean women

OBJECTIVE

To determine the respective weights of certain facial signs on the assessment of perceived age and plumpness on Korean women of different ages.

MATERIAL AND METHODS

Photographs were taken of the faces of 112 Korean women of different ages (18-80 years) under standardized conditions. These photographs allowed to focus and define 19 facial signs, which were then graded by 15 experts and dermatologists, using standardized scales provided by a reference Skin Aging Atlas. The facial signs were dispatched into 5 clusters, namely Wrinkles/Texture, Ptosis/Sagging, Pigmentation disorders, Vascular disorders, and Cheek skin pores. A naïve panel, composed of 92 Korean women, of similar age range were asked, when viewing full-face photographs, to: (a) attribute on a 0-10 scale their perception of the skin plumpness (ie supple/hydrated/nourished) and (b) estimate the age of the subject.

RESULTS

With the exception of Vascular disorders, the severity of all 4 clusters increased with age, although at different rates. The Wrinkles/Texture or Ptosis/Sagging showed a rather regular progression. Although perceived ages and real ages were found highly correlated, half of the subjects were judged older by 2-12 years. The facial signs/clusters were significantly correlated with perceived age, with the exceptions of vascular disorders, size of pigmentary spots and cheek skin pores. The weights in perceived ages of Wrinkles/Texture and Ptosis/Sagging represent 37% each and Pigmentation disorders at 26%. Skin plumpness was logically found significantly anti-correlated with perceived age. If, surprisingly, Vascular disorders were found not impacting the plumpness aspect, Cheek skin pores presented a clear influence.

CONCLUSION

Within facial clinical clusters, Wrinkles/Texture, Ptosis/Sagging, and Pigmentation disorders are major factors in the assessment of perceived age in Korean women. The perception of a decreased skin plumpness is significantly associated with increased perceived age.

Can the presence of an infection be predicted before a revision total hip arthroplasty? Preliminary study to establish an infection score

INTRODUCTION

The diagnosis of periprosthetic joint infection can be challenging, in part because there is no universal diagnostic test. Current recommendations include several diagnostic criteria, and are mainly based on the results of deep microbiological samples; however, these only provide a diagnosis after surgery. A predictive infection score would improve the management of revision arthroplasty cases. The purpose of this study was to define a composite infection score using standard clinical, radiological and laboratory data that can be used to predict whether an infection is present before a total hip arthroplasty (THA) revision procedure.

HYPOTHESIS

The infection score will make it possible to differentiate correctly between infected and non-infected patients in 75% of cases.

MATERIAL AND METHODS

One hundred and four records from patients who underwent THA revision for any reason were analysed retrospectively: 43 with infection and 61 without infection. There were 54 men and 50 women with an average age of 70±12 years (range 30-90). A univariate analysis was performed to look for individual discriminating factors between the data in the medical records of infected and non-infected patients. A multivariate analysis subsequently integrated these factors together. A composite score was defined and its diagnostic effectiveness was evaluated as the percentage of correctly classified records, along with its sensitivity and specificity.

RESULTS

The score consisted of the following individually weighed factors: body mass index, presence of diabetes, mechanical complication, wound healing disturbance and fever. This composite infection score was able to distinguish correctly between the infected patients (positive score) and non-infected patients (negative score) in 78% of cases; the sensitivity was 57% and the specificity 93%.

DISCUSSION

Once this score is evaluated prospectively, it could be an important tool for defining the medical - surgical strategy during THA revision, no matter the reason for revision.

LEVEL OF EVIDENCE

Level IV - retrospective study.

Effect of hydroxyapatite coating on the radio-clinical results of a grit-blasted titanium alloy femoral taper. A case-control study of 198 cementless primary total hip arthroplasty with the Alloclassic™ system

BACKGROUND

The effect of hydroxyapatite (HA) coating on the fixation of a cementless femoral stem is discussed, in particular in cases of primary fixation with geometrically stable components. Therefore, we performed a comparative retrospective study of a series of Alloclassic-SL™ stems to: 1) present the long-term results and 2) evaluate the contribution, if any, of proximal HA coating.

HYPOTHESES

Long-term cementless press-fit ("flat wedge-shaped") fixation is reliable and HA coating only improves the radiological results of the proximal bone-prosthesis interface.

MATERIALS AND METHODS

One hundred and ninety-eight Alloclassic total hip arthroplasties were performed in 179 patients, mean age 66 years old (22-85), including 105 with proximal HA coating and 93 with the original grit-blast coating. One hundred and ninety-three hips were analyzed after a mean follow-up of 9.8 years (1-24 years).

RESULTS

Results were excellent or good in 184 hips (95%) with no significant difference between the 2 groups (Merle d'Aubigné≥16 for 89/92 (98%) without HA compared to 95/101 (94%) with HA P=0.59). Radiographic signs of stable osseointegration were observed in 173 hips (90% of the cases). HA coating significantly improved the radiographic results of the proximal bone-implant interface: (42/92 (46%) of the stems without HA had proximal radiolucencies in zones 1 and 7 compared to 4/101 (4%) with HA (P=0.0001)). Polyethylene wear>0.1 mm/year was observed in 6 hips (3%) including 1/101 (1%) in the group with HA versus 5/92 (5.4%) without HA (P=0.17). One intra-operative femoral fracture occurred and there were 9 dislocations in the first 3 postoperative months (4.5%). The main cause of revision surgery was recurrent dislocation (11/17 cases). The "revision per-100 observed-femoral component years" was 0.10 in both groups and survival for aseptic loosening of the stem was 100% (95% CI=73.2% to 100%) at 20 years.

CONCLUSION

This study shows that secondary fixation by osseointegration of a straight standard grit-blasted titanium alloy non-anatomical implant is reliable. Possible proximal fibrous encapsulation, which is reduced by HA coating, but especially conventional polyethylene wear, were the main limitations of this system.

LEVEL OF EVIDENCE

III retrospective case-control study.

Revision of primary total hip arthroplasty for peri-prosthetic fracture: A prospective epidemiological study of 249 consecutive cases in France

BACKGROUND

Revision total hip arthroplasty (reTHA) for peri-prosthetic fracture (PPF) is increasingly performed but still ranks fourth among reasons for reTHA in registries. In France, no specific registry is available and the frequency of PPF among reasons for THA revision is therefore unknown. Here, our objectives were to determine the relative frequency of PPF as a reason for reTHA, to identify patient-related and primary-THA-related factors associated with reTHA for PPF, to describe reTHA modalities for PPF, and to determine the morbidity and mortality associated with reTHA for PPF.

HYPOTHESIS

PPF is the second most common reason for reTHA, after loosening.

METHODS

Consecutive reTHA procedures performed in 30 French centres over a 2-year period were collected prospectively. Repeat revisions and revisions of hemi-arthroplasties were excluded. The epidemiological, clinical, and surgical data needed to answer the questions of the study were collected.

RESULTS

PPF was the second leading reason for reTHA (249/2107, 11.8%). Vancouver type B2 fractures were the most common (n=127 [51.5%]). Compared to patients who underwent reTHA for reasons other than PPF, those with reTHA for PPF were older at primary THA (67.9 years versus 57.7 years) and more often had intra-operative complications (16.9% versus 11.6%); furthermore, the primary THA was more often cementless (62.7% versus 42.7%) with a dual-mobility cup (20.6% versus 11.1%). At reTHA, the patients with PPF were older (77.6 years versus 69.2 years), had worst medical condition (mean ASA score, 2.4 versus 2.1) and less physically active (mean Devane score, 2.1 versus 2.4). The patients with reTHA for PPF had a shorter time to revision (9.8 years versus 11.4 years), a longer operative time (144 minutes versus 128 minutes), and more frequent use of the posterior approach (77% versus 67%) with a cementless dual-mobility cup (78% versus 60%) and a cementless revision femoral stem (72% versus 50%). Morbidity and mortality rates were high (5.9% operative complication rate and 12% of surgical complications with 4.8% mortality within the first 3 months) however, these results were similar to those in the rest of the cohort.

DISCUSSION AND CONCLUSION

PPF is the second most common reason for reTHA, a result that is at variance with data in national registries.

LEVEL OF EVIDENCE

Level IV, prospective observational cohort study.

Characteristics and costs of carbapenemase-producing enterobacteria carriers (2012/2013)

OBJECTIVES

We had for aim to determine the characteristics of carbapenemase-producing enterobacteria (CPE) carriers and to assess the economic impact of isolation measures leading to loss of activity (closed beds, prolonged hospital stays) and additional personnel hours.

PATIENTS AND METHODS

We conducted a retrospective study for 2years (2012/2013), in a French general hospital, focusing on CPE carriers with clinical case description. The costs were estimated by comparing the activity of concerned units (excluding the ICU) during periods with CPE carriers or contacts, during the same periods of the year (n-1), plus additional hours and rectal swabs.

RESULTS

Sixteen EPC carriers were identified: 10 men and 6 women, 65±10years of age. Seven patients acquired EPC in hospital during 2 outbreaks in 2012. Four patients presented with an infection (peritonitis, catheter infection, and 2 cases of obstructive pyelonephritis) with a favorable outcome. The median length of stay was 21days [4,150]. Six patients died, 1 death was indirectly due to CPE because of inappropriate empiric antibiotic therapy. A decrease in activity was observed compared to the previous year with an estimated 547,303€ loss. The 1779 additional hours cost 63,870€, and 716 screening samples cost 30,931€. The total additional cost was estimated at 642,104€ for the institution.

CONCLUSIONS

Specialized teams for CPE carriers and isolation of contact patients, required to avoid/control epidemics, have an important additional cost. An appreciation of their support is needed, as well as participation of rehabilitation units.

Infection as a cause of primary total hip arthroplasty revision and its predictive factors

INTRODUCTION

Infection is a serious complication of total hip arthroplasty (THA) and is one of the most frequent causes of failure. The goal of this study was to evaluate the importance of infection among the different causes of revision THA and identify any risk factors specifically associated with this cause of revision.

MATERIALS AND METHODS

All patients who underwent a first revision of THA were included in a prospective multicenter study. Postoperative clinical and radiological evaluation and follow-up of morbidity and mortality were performed at 3 months.

RESULTS

Two hundred forty out of 2107 revisions (11.4%) were performed for infected THA, which was the third cause after aseptic loosening (42.3%) and peri-prosthetic fractures (11.8%). These patients had a higher BMI associated with co-morbidities and lower clinical scores than patients with other causes of revision. One-stage revision was performed in most cases (66%) with replacement of the complete implant in 86% of cases, resulting in longer surgery compared to that for other causes. Male gender (OR 2.3), avascular necrosis (OR 2.4), arthroplasties with dual mobility cups (OR 2.5) and a Rottinger anterolateral approach (OR 3.4) were all associated with an increased risk of infection.

DISCUSSION

Some of these risk factors are not or have rarely been reported in the literature. They should be taken into consideration to help in the prevention and continuing battle against THA infection.

LEVEL OF EVIDENCE

Level IV, prospective cohort study.

Metal-on-metal bearings total hip arthroplasty: the cobalt and chromium ions release concern

With certain concerns recently reported on metal-on-metal bearing couples in total hip arthroplasty, this study's objective is to review the current knowledge concerning release of metal ions and its potential consequences. Each metal-on-metal implant presents different tribological properties. The analytical techniques for metals are accurate and the Co ion rates seem acceptable up to 2 μg/L. A delayed type IV hypersensitivity reaction (atypical lymphocytic vasculitis-associated lesion [ALVAL]) may be the source of arthroplasty failure. Idiosyncratic, it remains unpredictable even using cutaneous tests and apparently is rare (0.3%). Today, there are no scientific or epidemiologic data supporting a risk of carcinogenesis or teratogenesis related to the use of a metal-on-metal bearings couple. Solid pseudotumors nearly exclusively are observed with resurfacing procedures, carrying a high annual revision rate in women under 40 years of age, occurring particularly in cases of acetabular malposition and with use of cast molded Cr-Co alloys. Osteolysis manifests through complete and progressive radiolucent lines or through cavitary lesions stemming from ALVAL-type alterations or impingement problems or implant incompatibility. The formation of wear debris exceeding the biological tolerance is possible with implant malposition, subluxation, and jamming of the femoral head in cases of cup deformity. Moreover, each implant presents different metal ion production; assessment of their performance and safety is required before their clinical use. With the knowledge available today, metal-on-metal bearing couples are contraindicated in cases of metal allergies or end stage renal dysfunction and small size resurfacing should cautiously be used.

[Suitability of red blood cell transfusion: a multicenter study]

The purpose of this retrospective observational multicenter study was to assess appropriateness of red blood cell (RBC) transfusion, according to the French national guidelines (Agence française de sécurité sanitaire des produits de santé) published in 2002. Six hundred and thirty-nine RBC transfusions from nine institutions have been randomly selected and analysed. The data collected are issued from different specialities. Patients' characteristics, occurrences of transfusion, admission, pre-transfusion, post-transfusion and discharge haemoglobin concentrations have been collected. Two physicians (who are in charge) must evaluate the appropriateness of pre-transfusion, discharged haemoglobin concentrations, quantity and quality of transfused RBC. The mean pre-transfusion haemoglobin concentration was 7.89 ± 1.24, the median number of transfused RBC was two (extremes: 1-16), the mean discharge haemoglobin concentration was 10.14 ± 1.30 (-5 days after the end of transfusion). The pre-transfusion and discharge haemoglobin concentrations were higher if the patient presented a co-morbidity factor. Ninety-three percent of pre-transfusion and 79% of discharge haemoglobin concentrations are in accordance with the guidelines. According to the physicians, the RBC transfusions are too "precocious" when pre-transfusion haemoglobin concentration is above nine and the anaemia is asymptomatic. 50% of RBC transfusion with discharge haemoglobin concentration above 10 is not excessive. In case of acute anaemia, the pre-transfusion and discharge haemoglobin concentrations are higher and RBC transfusion excessive. In this study, the trigger haemoglobin concentration is "restrictive", but the target haemoglobin concentration is "liberal" with a high-discharge haemoglobin concentration. Inappropriate RBC transfusions are mainly due to over-transfusion.

Survival analysis of an asymmetric primary total knee replacement: a European multicenter prospective study

PURPOSE OF THE STUDY

This multicenter prospective study objective is to provide midterm results and 10-year survival analysis of the original Natural Knee-I System™ as experienced by a group of surgeons performing, within various settings, primary total knee replacement (TKR) in the general population.

HYPOTHESIS

The midterm experience with this TKR system in the hands of independent surgical teams can duplicate the satisfaction level that was already published by the designer's group itself.

MATERIAL AND METHOD

Two hundred and sixty-three primary TKR were performed by seven surgical teams (37 surgeons) and prospectively evaluated in four European countries. Mean age of the 263 patients (sex ratio, 2.7 females/1 male) was 69 years (range, 35-92) and diagnosis was primary osteoarthritis in 85%. For the 247 TKR with complete operative data, the approach was subvastus in 59%, posterior cruciate ligament was spared in 78%, patella was resurfaced in 56%, and 79% of reconstructions were totally cement-free. Fixation mode was only depending on the surgeon's choice.

RESULTS

At 76 months average follow-up (range 24-190 months), modified Hospital for Special Surgery knee mean score improved from 48 points preoperatively to 83 points. Four reoperations and five revision procedures were required for eight knees. Over the 14-year survey period, the overall revision rate burden was 2% and revision rate per 100 observed component/year, 0.32. At 10 years, survivorship (with revision for aseptic loosening as its end-point [two fully cementless knees]) was 98.6%.

DISCUSSION

Both this multicenter study and data drawn from national registers provided outcomes with equivalent level of satisfaction at equivalent follow-up to those reported by the NK-I prosthesis designer. There was no significant difference between revision rates of cemented, hybrid or cementless reconstructions.

CONCLUSION

In non-designer orthopaedists' hands, the Natural Knee-I System™, either with cemented or cementless fixation, provided satisfying midterm results as normally expected in primary TKR with such a modern modular prosthesis.

LEVEL OF EVIDENCE

Level IV. Prospective study.

Near-miss event assessment in orthopedic surgery: Antimicrobial prophylaxis noncompliance

INTRODUCTION

Antimicrobial prophylaxis is one of the main safety measures to be enforced when implanting any medical device; surveys of practice, however, have found poor compliance.

MATERIAL AND METHODS

This study is based on analysis of 153 dedicated in-depth analysis forms sent to orthopedic surgeons who had reported an antimicrobial prophylaxis-related near-miss event (NME) during the year 2008 as part of their certification report to the official organization, Orthorisq (orthopaedic Patient safety risk management agency).

RESULTS

Antimicrobial prophylaxis guidelines exist in 95% of French centers, but in 14% are not available in the right place. 88% of orthopedic surgeons consider them well-adapted to their practice. Most declarations follow fortuitous discovery by the surgeon of an immediate peri-operative malfunction. Human causes were found in 92% of declarations, general organizational causes in 50% and material causes in 28%. Regarding corrective action, 65% of respondents reported implementing a second-order procedure, and only 20% were able to resume truly regular antimicrobial prophylaxis.

CONCLUSION

The main reason for poor or non-performance of antimicrobial prophylaxis was "omission by negligence or oversight", reported in 56% of declarations. Proposals for improvement were: revised antimicrobial prophylaxis guidelines specifying "who does what"; guideline awareness checks on new, temporary and locum-tenens staff; patient involvement in personal data collection; and implementation of a check-list in line with WHO and French Health Authority recommendations. These improvement proposals were taken on board in the antimicrobial prophylaxis consensus update currently being drawn up by the French Society for Anesthesia and Intensive Care.

LEVEL OF EVIDENCE

Level IV, Decision Analyses Study.

Composite renal cell carcinoma with clear cell renal cell carcinomatous and carcinoid tumoral elements: a first case report

Renal endocrine tumours are extremely rare, and carcinoid tumoral elements in renal cell carcinoma have never been reported. This is the first report of a composite renal cell carcinoma containing a clear cell renal cell carcinoma associated with carcinoid tumoral elements, in a patient with synchronous metastatic disease. In the absence of specific radiological and clinical manifestations, typical morphological features as well as an immunostaining profile of neuroendocrine differentiation were identified by microscopy. Secondary nodal and liver localisations were characterised by carcinoid elements only. Despite antiangiogenic therapy, liver metastasis progressed, suggesting that adjuvant therapy cannot be based on the presence of the clear cell renal cell carcinoma component. In this context, extensive tissue sampling is recommended to reveal the endocrine component that is the most aggressive element of such a composite carcinoma.

Cross-cultural adaptations of the Oxford-12 HIP score to the French speaking population

BACKGROUND

An objective measurement of surgical procedures outcomes is inherent to professional practices quality control; this especially applies in orthopaedics to joint replacement outcomes. A self-administered questionnaire offers an attractive alternative to surgeon's judgement but is infrequently used in France for these purposes. The British questionnaire, the 12-item Oxford Hip Score (OHS) was selected for this study because of its ease of use.

HYPOTHESIS

The objective of this study was to validate the French translation of the self-assessment 12-item Oxford Hip Score and compare its results with those of the reference functional scores: the Harris Hip Score (HHS) and the Postel-Merle d'Aubigné (PMA) score.

MATERIALS AND METHODS

Based on a clinical series of 242 patients who were candidates for total hip arthroplasty, the French translation of this questionnaire was validated. Its coherence was also validated by comparing the preoperative data with the data obtained from the two other reference clinical scores.

RESULTS

The translation was validated using the forward-backward translation procedure from French to English, with correction of all differences or mistranslations after systematized comparison with the original questionnaire in English. The mean overall OHS score was 43.8 points (range, 22-60 points) with similarly good distribution of the overall value of the three scores compared. The correlation was excellent between the OHS and the HHS, but an identical correlation between the OHS and the PMA was only obtained for the association of the pain and function parameters, after excluding the mobility criterion, relatively over-represented in the PMA score.

DISCUSSION AND CONCLUSION

Subjective questionnaires that contribute a personal appreciation of the results of arthroplasty by the patient can easily be applied on a large scale. This study made a translated and validated version of an internationally recognized, reliable self-assessment score available to French orthopaedic surgeons. The results obtained encourage us to use this questionnaire as a complement to the classical evaluation scores and methods.

Infliximab to etanercept switch in patients with spondyloarthropathies and psoriatic arthritis: preliminary data

OBJECTIVE

To report early experience of switching anti-tumor necrosis factor-a (TNF-alpha) therapy from infliximab to etanercept in patients with spondyloarthropathy (SpA) and psoriatic arthritis (PsA).

METHODS

Thirteen patients with various SpA (7 with ankylosing spondylitis and 6 with undifferentiated SpA) and 2 patients with PsA were receiving infliximab. Because they were experiencing inadequate response or adverse events, therapy was changed to etanercept. Patients were evaluated for response to the change in anti-TNF-alpha therapy at baseline, after 3 months, and then every 6 months.

RESULTS

During the mean 10-month followup after the change in therapy, 9 of 13 patients with SpA and both patients with PsA responded to etanercept and none experienced intolerance to this agent.

CONCLUSION

These data suggest that switching between anti-TNF-alpha drugs may be useful for patients with SpA who are unresponsive or intolerant to a first anti-TNF-alpha agent.

Mesenchymal stem cells rescue CD34+ cells from radiation-induced apoptosis and sustain hematopoietic reconstitution after coculture and cografting in lethally irradiated baboons: is autologous stem cell therapy in nuclear accident settings hype or reality?

Autologous stem cell therapy (ACT) has been proposed to prevent irradiated victims from bone marrow (BM) aplasia by grafting hematopoietic stem and progenitor cells (HSPCs) collected early after damage, provided that a functional graft of sufficient size could be produced ex vivo. To address this issue, we set up a baboon model of cell therapy in which autologous peripheral blood HSPCs collected before lethal total body irradiation were irradiated in vitro (2.5 Gy, D0 1 Gy) to mimic the cell damage, cultured in small numbers for a week in a serum-free medium in the presence of antiapoptotic cytokines and mesenchymal stem cells (MSCs) and then cografted. Our study shows that baboons cografted with expanded cells issued from 0.75 and 1 x 10(6)/kg irradiated CD34+ cells and MSCs (n=2) exhibited a stable long-term multilineage engraftment. Hematopoietic recovery became uncertain when reducing the CD34+ cell input (0.4 x 10(6)/kg CD34+ cells; n=3). However, platelet recovery was accelerated in all surviving cografted animals, when compared with baboons transplanted with unirradiated, unmanipulated CD34+ cells (0.5-1 x 10(6)/kg, n=4). Baboons grafted with MSCs alone (n=3) did not recover. In all cases, the nonhematopoietic toxicity remained huge. This baboon study suggests that ACT feasibility is limited.

Un couple de frottement métal-métal peut-il améliorer la longévité des prothèses totales de hanche ?

PURPOSE OF THE STUDY

In total hip arthroplasty (THA), inter-series comparative clinical results cannot be considered worthy before at least 10 years of average follow-up, as shown in the Swedish Arthroplasty Register experience (1978-1993). Last generation metal-on-metal bearings were introduced in France only nine years ago (1995). To date, using mid term information, data from the literature, and our experience, one could assume that this bearing material has the capacity to improve THA longevity. Three types of information were analyzed: 1) comparative radiographic and EBRA studies published on early migration (<2 years) of acetabular implants; 2) preliminary comparative data on wear and osteolysis at the 8-year maximum follow-up; 3) clinical data on dislocation frequency and in vitro and in vivo observations of bearing separation and sliding. Study no 1: primary stability of these metal-on-metal acetabular cups was better than for polyethylene (PE) cups or alumina liners; study no 2: no detectable wear and less osteolysis were observed to date with metal-on-metal bearings versus their alumina-on-PE counterparts. Study no 3: less dislocation and less head sliding were measured with the metal-on-metal versus alumina-on-PR bearings possibly due to the interfacial forces provided by lubricating fluid (suction fit).

CONCLUSION

According to current knowledge, this metal-on-metal bearing still represent, with alumina-on-alumina and highly crosslinked PE, a competitive and comprehensive option to improve THA longevity. The real pending problem concerns the frequency and above all the intensity of metal delayed hypersensitivity reaction and their potential effect on implant loosening.

Second generation anti-cyclic citrullinated peptide (anti-CCP2) antibodies can replace other anti-filaggrin antibodies and improve rheumatoid arthritis diagnosis

We compared the diagnostic performance of anti-cyclic citrullinated peptide antibodies detected with second-generation enzyme immunoassay (anti-CCP2) with that of IgM-rheumatoid factor (RF), anti-perinuclear factor (APF), and anti-keratin antibodies (AKA). The sensitivity of anti-CCP2 was better than that of APF and AKA: they were detected in 25% rheumatoid arthritis (RA) patients without detectable APF or AKA. Their specificity, evaluated in other inflammatory rheumatic disease, was similar to that of APF and AKA. Despite the lower specificity, IgM-RF in combination with anti-CCP2 is interesting, as they do not completely overlap. Anti-CCP2 antibody detection seems to be a good alternative to other anti-filaggrin antibodies in the diagnosis of RA.

Toxidermie lichénoïde à l’imatinib (Glivec®)

INTRODUCTION

Imatinib (Glivec) is a new therapeutic molecule used for the treatment of chronic myeloid leukemia. Cutaneous side effects with this treatment are common but lichenoid drug eruption is exceptional. We report the first case with profuse cutaneous lichen.

CASE REPORT

A 52 year-old woman presented with a 5-year history of chronic myeloid leukemia. The different chemotherapies had failed (persisting polyadenopathies and splenomegalia). She was treated with imatinib (400 mg/day). Two months after the beginning of this treatment a disseminated cutaneous eruption appeared on the trunk, legs, arms and face without mucosal involvement and composed of dark purple, prurigenous, papules suggestive of lichen planus. The cutaneous biopsy confirmed the diagnosis of lichen planus. Suspension of the drug led to the complete regression of the eruption, without any other local treatment, within 2 months. Reintroduction of the drug led to the recurrence of the lesions.

DISCUSSION

Cutaneous reactions to imatinib are common and occur in 11 to 67 p. 100 of patients depending on the series. More severe cutaneous reactions have been described: exfoliating dermatites, generalized pustulosis, epidermal necrolysis. The aspect of profuse lichenoid eruption of the skin and the correlation with cutaneous lesions clinically and histologically evocative of lichen planus has not been described other than an isolated buccal involvement in a 72 year-old woman. In our patient, study of the imputability criteria is in favor of imatinib's responsibility.

[Six to ten year results of use of the alloclassic hip prosthesis--a multicentre survival analysis]

AIM

This prospective study describes This retrospective multicenter study was undertaken to calculate mid- and long-term survival rates of the cementless Zweymüller/Alloclassic total hip prosthesis.

MATERIAL AND METHODS

The rectangular titanium stem and threaded cup have been in use since 1986. The ball head is made of alumina ceramic, the inlay of UHMW polyethylene. Five hospitals in Austria, France and Germany cooperated in the follow-up of 848 patients operated between October 1986 and September 1990 (mean age 62.2 years, 62% women, 38% men, mean patient weight 73.8 kg, body mass index 26.8). 468 patients were followed clinically, 320 patients interviewed on the phone, 29 sent a letter. No information was available concerning the remaining 31 patients. Probabilities of implant survival were estimated with the Kaplan-Meier method.

RESULTS

98 patients (11.5%) had died at a median follow-up time of 81.1 months. The probability of survival at 81.1 months was 98.6% looking at stem and cup. There was no significant association of survival of the prosthesis and patient weight, gender or body mass index.

CONCLUSION

Our results are in accordance with previously published data of smaller series using the Zweymüller/Alloclassic( total hip. The survival rate of this cementless rectangular titanium prosthesis for the reported follow-up time compares favorably with contemporary cemented hip prostheses.

Osteopenia in patients infected by the human immunodeficiency virus. A case control study

Summary - In the last few years, the use of highly active antiretroviral therapy has radically modified the prognosis of human immunodeficiency virus (HIV) infection. Osteonecrosis and osteoporosis are among the bone complications recently described in HIV-infected patients. We report a preliminary study comparing 47 HIV-infected patients (31 men and 16 women) to 47 age- and sex-matched controls. Bone mineral density was lower in patients than in controls: in men, 0.919 +/- 0.120 g/cm2 vs. 1.010 +/- 0.139 g/cm2 (P = 0.01) at the total hip and 0.948 +/- 0.100 g/cm2 vs. 1.043 +/- 0.117 g/cm2 (P = 0.0008) at the lumbar spine; in women, 0.912 +/- 0.149 g/cm2 vs. 0.968 +/- 0.090 g/cm2 at the total hip (P = 0.17) and 0.989 +/- 0.152 g/cm2 vs. 1.080 +/- 0.097 g/cm2 (P = 0.01) at the lumbar spine. HIV-infected males were more likely to have osteopenia and osteoporosis, as compared to the male controls (19 vs. 14 and 4 vs. 1, respectively, P = 0.02). None of the women had osteoporosis; nine HIV-infected women and one female control had osteopenia (P = 0.003). No fractures were recorded. In this preliminary study, no evidence supporting a relationship between bone loss and protease inhibitor treatment was found.

[Straight femoral taper in cementless primary total hip replacement in less than 65 year-old patients: multicenter study of 115 consecutive implantations at mean 8,2 year follow-up]

PURPOSE OF THE STUDY

The Swedish Arthroplasty Registry experience with cemented primary total hip arthroplasty (THA) has pointed out age below 65 and high activity level as 2 major factors impairing THA long-term outcome. The aim of this study was to provide intermediate results of cementless femoral replacement in primary THA with use of the Alloclassic-SL grit-blasted titanium stem in "high risk" groups of patients.

MATERIAL AND METHODS

From June, 1988 to June, 1992, 127 cementless primary THA's were consecutively performed in<65 year old patients in 2 institutions. Acetabular components were all cementless (threaded cup in 74%) and bearing surfaces were all alumina-ceramic 28mm heads on polyethylene (PE). Five patients (6 hips) died and 6 other hips were lost to follow-up before the 5-year minimum follow-up. Thus, 115 hips in 106 patients could be fully reviewed after a 8.2 year average follow-up period (range, 5 to 12 years). Mean age at surgery of the 62 male and 44 female patients was 52 years (range, 27 to 65 years).

RESULTS

Of the index group (127 hips), intra-operative fracture of the greater trochanter and early dislocation were noted in 4.7% and 3.2% of hips, respectively. Of the study group (115 hips), clinical results according to the Merle d'Aubigné and Charnley rating system were graded excellent and good in 94% of hips and fair in 6% (7 hips), with no poor result. Radiologically, early subsidence of more than 2mm could be detected in 8 hips (7%). Calcar atrophy and spot welds were noted in 81% and 89% of hips, respectively. Proximal reactive and lucent lines and mild proximal stress shielding were observed in 10.5% and 4.3% of hips, respectively. Ten-year survivorship with stem revision for any reason as the end point was 99.2% (92.4-99.9) (1 stem exchanged and reoriented for immediate dislocation). One revision is pending for extensive femoral osteolysis due to polyethylene (PE) wear. There was no stem fracture and no ceramic head breakage thus far. Overall PE-wear rate ranging 1-2 mm was detected in 13 hips (9.6%) and femoral osteolysis in 4 hips (3.5%).

DISCUSSION

Mid-term results of this cementless straight taper at 10 year are at least equal to those of well performing cemented components, even in "high risk" groups of patients. Conversely, 28mm alumina-ceramic heads can reduce but not prevent the occurrence of PE-wear in such a healthy and active population.

CONCLUSION

Press-fitting but not filling the femoral canal with rough titanium straight tapers like the Alloclassic-SL femoral component represent a promising alternative to modern femoral cementing technique in primary THA. Improvement is expected through the use of more wear resistant bearing surfaces.