Long-term results of the GIMEMA VEL-03-096 trial in MM patients receiving VTD consolidation after ASCT: MRD kinetics' impact on survival.

Polymerase chain reaction (PCR)-based minimal residual disease (MRD) analysis is a useful prognostic tool in multiple myeloma (MM), although its long-term impact still needs to be addressed. This report presents the updated results of the GIMEMA-VEL-03-096 trial. Thirty-nine MM patients receiving bortezomib-thalidomide-dexamethasone after autologous transplantation were monitored for MRD by both nested and real-time quantitative-PCR until relapse. Our data confirm the strong impact of MRD on survival: overall survival was 72% at 8 years median follow-up for patients in major MRD response versus 48% for those experiencing MRD persistence (P=0.041). In addition, MRD kinetics resulted predictive for relapse: indeed median remission duration was not reached for patients in major MRD response, 38 months for those experiencing MRD reappearance and 9 months for patients with MRD persistence (P<0.001). Moreover: (1) 26 patients achieving major MRD response (67%) benefit of excellent disease control (median TNT: 42 months); (2) MRD reappearance heralds relapse, with a TNT comparable to that of MRD persistence (9 versus 10 months, P=0.706); (3) the median lag between MRD reappearance and need for salvage treatment is 9 months. These results suggest the usefulness of a long-term MRD monitoring in MM patients and the need for maintenance or pre-emptive treatments ensuring durable responses.

Ruptured anterior talofibular ligament: a simplified procedure for late repair.

The author has described a simplified procedure for late repair of a ruptured anterior talofibular ligament. This procedure has been utilized in 14 patients (20 feet) and all results have been good. Complications have included 1) restriction of motion (inversion) at the ankle joint (two cases, probably resulting from overly short grafts); 2) chronic edema, exceeding 4 months (three cases, probably resulting from poor subcutaneous closure of tissue planes); and 3) failure to correct presenting complaint (one case, most likely resulting from spontaneous rupture of graft). The remaining 14 feet have all functioned well with proper biomechanical control from the shortest follow-up of 11 months through the longest follow-up of 3 years.

Podiatric manifestations in patients with acute and chronic neurologic disorders.

It is impossible to delineate, in the short space provided, the entire spectra of possible and potential podiatric manifestations of acute and chronic neurologic disease. An attempt has been made to delineate the neuroanatomic, neurophysiologic, etiologic, and diagnostic procedural knowledge required to fully comprehend, evaluate, and manage neurologic complaints in presenting patients. By following a specific outline for evaluation, a functional and meaningful differential diagnosis can be formulated. By properly employing the ancillary procedures discussed, a correct diagnosis will be attained. Concurrently, at this point in evaluation, a grasp of the location and gravity of the discovered lesion will allow us to intelligently treat or refer the patient for proper management. Since the vast majority of neurologic manifestations involve and cross-effect several bodily systems, not all neurologic diagnoses are or will be easy. Only through a constant awareness of the mechanisms, symptomatology, clinical findings, and a careful, precise, and thorough neurologic evaluation and test selection will these patients be helped.

Infections in minimal incision surgery.

We have attempted to delineate a logical and rational approach to the recognition and management of postoperative infections. The reader is urged to use the tenets presented strictly as guidelines. Each and every treatment regimen must be tailored to the individual case. The priorities of early detection and treatment as well as the routine ordering of Gram stain and culture and sensitivity studies must never be ignored. The best prevention of bone infection is high serum levels of antibiotic in the early stages of management. Also, medications should have a high osseous perfusion rate. Among these are the cephalosporins, oxacillins, cloxacillins, and penicillins. After making a definitive diagnosis of osteomyelitis, radiographic evidence may be anticipated from 21 days after the start of infection. Bone scans will demonstrate this condition much sooner and allow for earlier treatment. There are two basic requirements for effective antibiotic therapy. The antibiotic chosen must be capable of inhibiting the growth of the agent or agents causing the infection (this requires an identification of the infecting bacteria and the selection of an antibiotic effective against that organism). Secondly, a therapeutically effective concentration of the antibiotic must reach the infected tissues for a sufficient period of time to allow the antimicrobial activity of the compound to be effective. This requires a blood supply capable of delivering the antibiotic in the blood to the affected tissues. Furthermore, the physiologic state of the patient, the nutritional status, and the immunosuppressive systems should be supported by the means necessary to initiate host reactions against the invading organism. Three last principles may be added to this antibiotic prescribing regimen. (1) When using broad-spectrum antibiotics, be constantly aware of the likelihood of superinfection. This is the overgrowth of bacterial organisms present on the skin as normal flora that multiply rapidly when the surrounding flora is destroyed by the broad-spectrum antibiotic. (2) Ancillary measures including heat, elevation, and immobilization should be employed when conditions permit. (3) Always check for allergy before prescribing an antibiotic. There are no certainties in the treatment of infections; the regimens may change daily as newer and more effective medications are marketed. Nonetheless, the principles remain unchanged. Clinical disease results only when the invading agent evokes anatomic and functional damage in the course of obtaining the necessary requirements for survival.(ABSTRACT TRUNCATED AT 400 WORDS)