Hypoxia as a potential inducer of immune tolerance, tumor plasticity and a driver of tumor mutational burden: Impact on cancer immunotherapy.

In cancer patients, immune cells are often functionally compromised due to the immunosuppressive features of the tumor microenvironment (TME) which contribute to the failures in cancer therapies. Clinical and experimental evidence indicates that developing tumors adapt to the immunological environment and create a local microenvironment that impairs immune function by inducing immune tolerance and invasion. In this context, microenvironmental hypoxia, which is an established hallmark of solid tumors, significantly contributes to tumor aggressiveness and therapy resistance through the induction of tumor plasticity/heterogeneity and, more importantly, through the differentiation and expansion of immune-suppressive stromal cells. We and others have provided evidence indicating that hypoxia also drives genomic instability in cancer cells and interferes with DNA damage response and repair suggesting that hypoxia could be a potential driver of tumor mutational burden. Here, we reviewed the current knowledge on how hypoxic stress in the TME impacts tumor angiogenesis, heterogeneity, plasticity, and immune resistance, with a special interest in tumor immunogenicity and hypoxia targeting. An integrated understanding of the complexity of the effect of hypoxia on the immune and microenvironmental components could lead to the identification of better adapted and more effective combinational strategies in cancer immunotherapy. Clearly, the discovery and validation of therapeutic targets derived from the hypoxic tumor microenvironment is of major importance and the identification of critical hypoxia-associated pathways could generate targets that are undeniably attractive for combined cancer immunotherapy approaches.

PEC-PRO: A new prognostic score from a series of 87 patients with localized perivascular epithelioid cell neoplasms (PEComas) treated with curative intent.

BACKGROUND: Perivascular epithelioid cell neoplasms (PEComas) encompass a heterogeneous family of mesenchymal tumors. Previously described clinicopathologic features aimed at distinguishing benign from malignant variants but lacked prognostic value. METHODS: This retrospective analysis examined clinicopathologic data from patients who had localized PEComa across French Sarcoma Network centers. The authors analyzed 12 clinicopathologic features in a Cox proportional hazard framework to derive a multivariate prognostic risk model for event-free survival (EFS). They built the PEComa prognostic score (PEC-PRO), in which scores ranged from 0 to 5, based on the coefficients of the multivariate model. Three groups were identified: low risk (score = 0), intermediate risk (score = 1), and high risk (score ≥ 2). RESULTS: Analyzing 87 patients who had a median 46-month follow-up (interquartile range, 20-74 months), the median EFS was 96.5 months (95% confidence interval [CI], 47.1 months to not applicable), with 2-year and 5-year EFS rates of 64.7% and 58%, respectively. The median overall survival was unreached, with 2-year and 5-year overall survival rates of 82.3% and 69.3%, respectively. The simplified Folpe classification did not correlate with EFS. Multivariate analysis identified three factors affecting EFS: positive surgical margins (hazard ratio [HR], 5.17; 95% CI, 1.65-16.24; p = .008), necrosis (HR, 3.94; 95% CI, 1.16-13.43; p = .030), and male sex (HR, 3.13; 95% CI, 1.19-8.27; p = 0.023). Four variables were retained in the prognostic model. Patients with low-risk PEC-PRO scores had a 2-year EFS rate of 93.7% (95% CI, 83.8%-100.0%), those with intermediate-risk PEC-PRO scores had a 2-year EFS rate of 67.4% (95% CI, 53.9%-80.9%), and those with high-risk PEC-PRO scores had a 2-year EFS rate of 2.3% (95% CI, 0.0%-18.3%). CONCLUSIONS: The PEC-PRO score reliably predicts the risk of postoperative recurrence in patients with localized PEComa. It has the potential to improve follow-up strategies but requires validation in a prospective trial.

Bridge plating with decortication, autologous bone graft, and tight closure: a "stepwise surgical diamond concept" for treatment of nonunion in a series of fifty five patients.

PURPOSE: This study was conducted to assess a stepwise surgical procedure applied to treat a continuous series of patients with aseptic atrophic nonunion of long bones. METHODS: A retrospective review was performed of the medical files of patients treated by the senior author between January 2014 and January 2021 for aseptic atrophic nonunion of long bones using a standard stepwise surgical procedure consisting of four successive surgical steps: bridge locked plating, aggressive osteoperiosteal decortication, copious autologous iliac bone grafting, and tight closure without drainage. Patients were clinically and radiographically evaluated until bone healing, then at final follow-up for the purpose of the study. The primary objective of the study was to assess completion of bone healing; secondary objectives were the time required reaching bone union, the occurrence of complications at the iliac bone graft donor site, and the achievement of bone consolidation after a second attempt of treatment when indicated following failure of the index procedure. RESULTS: There were a total of 55 patients. One patient died from myocardial infarction before reaching bone healing and another one lost from early follow-up. There were remaining 53 patients with 37 years of mean age. The affected bone was the clavicle in five patients, humerus in 14, ulna in four, radius in one, femur in 13, and tibia in 16. The mean follow-up period was 3.4 years. A total of 52 patients (98.1%) achieved bone healing at a mean of 14.8 weeks from the index procedure. The only patient who did not reach bone healing after the index procedure was successfully revised using decortication-bone graft and new fixation with intra-medullary femoral nailing. Four patients (7.5%) developed local complications at the site of iliac bone harvesting. CONCLUSION: Our stepwise surgical procedure was very effective treating aseptic atrophic nonunion of long bones. However, as this study is a retrospective review of a limited series of one surgeon's experience, prospective comparative studies with large number of patients are suitable to define the advantages and indications of the procedure herein described.

The instep flap for anterior ankle coverage with bone and hardware exposure.

PURPOSE: The instep medial plantar flap is a well-known flap based on the medial plantar artery of the foot and usually used for coverage of soft tissue defects of the heel area. It has seldom been reported for coverage of anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures. The primary purpose of this study is to evaluate the feasibility and viability of this flap as well as its reliability saving the internal fixation devices and efficiency protecting bone healing; the secondary purpose is to assess the condition of the flap and its cosmetic appearance, as well as occurrence of complications related to its harvesting. MATERIAL AND METHODS: This is a retrospective review of medical records of patients operated from December 2015 to December 2020 with application of an instep flap for coverage of the anterior ankle area with exposure of the bone and metallic hardware secondary to open reduction and internal fixation of distal tibial fractures. All patients were reviewed for the purpose of this study; they were assessed for the viability and functional and sensory condition of the flap, signs of local infection, as well as for residual pain and sensory impairment of the toes; subjective cosmetic appearance of the flap was also judged. RESULTS: There were four patients with 32 years mean age and 35 months mean follow-up. The mean flap size was 7.75 cm × 5.75 cm. At final follow-up, all fractures were completely consolidated, and all flaps were living, stable, and sensitive. No distal sensation disturbance was noticed, and none of the patients had pain or annoyance caused by the flap or presented signs of infection. Only one patient expressed mild aesthetic complain. CONCLUSION: The fascio-cutaneous instep medial plantar flap is a reliable solution to cover the anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures, especially for defects measuring up to 9 cm × 6 cm. This flap is technically valid and reproducible; it offers good quality of soft tissue coverage with satisfactory cosmetic appearance and minimal morbidity.

Integrating tumor hypoxic stress in novel and more adaptable strategies for cancer immunotherapy.

Immunotherapy is poised to become an increasingly utilized therapy in the treatment of cancer. However, several abnormalities in the tumor microenvironment (TME) that can thwart the efficacy of immunotherapies have been established. Microenvironmental hypoxia is a determining factor in shaping aggressiveness, metastatic potential and treatment resistance of solid tumors. The characterization of this phenomenon could prove beneficial for determining a patient's treatment path and for the introduction of novel targetable factors that can enhance therapeutic outcome. Indeed, the ablation of hypoxia has the potential to sensitize tumors to immunotherapy by metabolically remodeling their microenvironment. In this review, we discuss the intrinsic contributions of hypoxia to cellular plasticity, heterogeneity, stemness and genetic instability in the context of immune escape. In addition, we will shed light on how managing hypoxia can ameliorate response to immunotherapy and how integrating hypoxia gene signatures could play a role in this pursuit.

The adjunct use of lateral hinged external fixator in the treatment of traumatic destabilizing elbow injuries.

PURPOSE: The purpose of this study is to evaluate the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries. METHODS: A retrospective review was performed on the medical records of patients in whom a lateral monolateral elbow hinged external fixator was applied by the senior author. The indication to apply the fixator corresponded to a variety of acute injury patterns ranging from simple elbow trauma or dislocation to complex fracture-dislocation, and the decision was based on either the presence of recurrent or persistent instability in any direction and/or to secure a vulnerable or weak bony fixation or soft tissue repair as intra-operatively judged by the surgeon. The fixator was inserted in the same setting after the repair of the associated ligamentous and/or bony structures. Patients operated after one month of the trauma and those presented with open elbow injury or associated humeral or ulnar shaft fracture were excluded. Rehabilitation was immediately started and the fixator removed at six to eight weeks with elbow testing and gentle manipulation under general anaesthesia, and resuming of rehabilitation after removal. Clinical assessment was performed for all patients according to the Mayo Elbow Performance Score (MEPS) with evaluation of range of motion at regular intervals till the end of the post-operative first year, then at final follow-up for the purpose of the study with radiographic assessment for evaluation of elbow reduction and concentricity. RESULTS: There were 13 patients with a mean age of 42 years. Two patients had instability secondary to LCL rupture; one patient had redislocation because of associated coronoid process fracture; one patient had radial head fracture with rupture of both collateral ligaments; five patients had terrible triad injury with variable association of collateral ligaments lesions; and four patients had posterior Monteggia fracture-dislocation. The mean MEPS was 90 at a mean follow-up of seven years with six excellent, six good, and one fair result. All patients had a concentrically reduced and stable elbow as assessed clinically and radiologically with a mean functional arc of motion of 132° for extension-flexion and 178° for pronation-supination. CONCLUSION: The hinged elbow external fixator represents a valuable adjunct in the therapeutic arsenal for the treatment of unstable elbows after bony and soft tissue repair. It provides satisfactory results in terms of stability and function and should be available in the operating room when a surgeon treats a complex elbow dislocation or fracture-dislocation.

Minimally invasive percutaneous plate osteosynthesis for treatment of proximal humeral shaft fractures.

PURPOSE: The objective of this study was to evaluate the feasibility and safety of a minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure for proximal humeral shaft fractures using lateral minimal proximal and distal approaches and lateral bridge plating with primary radial nerve control, and to assess its clinical and radiographic outcomes. METHODS: A retrospective review was done for the medical records of adult patients admitted for fracture of the proximal humeral shaft without associated injury to the ipsilateral upper limb and who consented to undergo a novel MIPPO technique herein reported. Patients were reviewed at regular follow-up periods and assessed at a final follow-up for evaluation of Constant, normalized Constant, and QuickDASH scores. RESULTS: There were 21 adult patients with mean age of 56 years. Three patients were lost from early follow-up; one of them had post-operative radial nerve paralysis. Eighteen patients were reviewed for the purpose of this study at a mean of 20 months of final follow-up; among them, one patient developed post-operative radial nerve paralysis with complete recovery after three months. Bone healing was achieved without any malalignment in 17 patients at a mean of 15 weeks, and one patient developed nonunion. At final assessment (mean, 20 months), the mean values of Constant, normalized Constant, and QuickDASH scores were 84 (range, 59 to 100), 95 (range, 73 to 100), and 5 (range, 0 to 18.2) respectively. CONCLUSION: Compared to pre-reported methods of MIPPO, this technique of lateral proximal and distal mini-approaches with lateral bridge plating after primary control of the radial nerve seems safe and feasible for proximal humeral shaft fractures. It gives good clinical and radiographic results with excellent restoration of upper limb function, very low incidence of post-operative radial nerve injury, and high rate of bone union in good alignment.

Brain Metastases and Place of Antiangiogenic Therapies in Alveolar Soft Part Sarcoma: A Retrospective Analysis of the French Sarcoma Group.

BACKGROUND: Alveolar soft part sarcoma (ASPS) is a rare sarcoma characterized by a slow evolution, brain metastasis (BM), and resistance to doxorubicin. Antiangiogenic therapies (AAT) have shown clinical activity, but little is known about the optimal therapeutic strategy, specifically considering BM. SUBJECTS, MATERIALS, AND METHODS: We performed a retrospective analysis of all patients with ASPS treated in three referral centers of the French Sarcoma Group. We aimed to describe factors associated with overall survival (OS) and the impact of BM on outcome of patients treated by AAT. RESULTS: We identified 75 patients between 1971 and 2012 (median age = 23, range: 5-96 years). Median follow-up was 74 months. Patients with localized (n = 44, 59%) and metastatic (n = 31, 41%) diseases had a 10-year OS of 69% and 25%, respectively. Only surgical incomplete resection was associated with shorter OS in localized disease (hazard ratio [HR] = 5.2, 95% confidence interval [CI] 1.2-22.4, p = .02). Fifty-two (69%) patients developed lung metastasis (LM; baseline: n = 31, [41%]; de novo: n = 21, [28%]). Thirteen patients developed BM, all occurring after LM. Tumor size ≥5 cm was associated with poorer BM-free survival (HR = 8.4, 95% CI 2.1-33.9, p = .002). Median OS post-BM was 17 months (95% CI 15 to not assessable). Overall, 12 patients were treated with AAT (sunitinib n = 10): 5 patients had BM and achieved poor outcomes compared with patients without, with median progression-free-survivals of 2 versus 11 months, respectively. CONCLUSION: Baseline larger tumors were associated with increased risk of brain metastasis in patients with ASPS. Patients with BM seem to have little benefit from AAT, suggesting the need to develop antineoplastic agents with high central nervous system penetrance in this setting. IMPLICATIONS FOR PRACTICE: Alveolar soft part sarcoma (ASPS) is an extremely rare subtype of sarcoma that is particularly resistant to conventional therapies. Antiangiogenic therapies (AAT) have shown promising results. However, patients with ASPS still die of tumor evolution. This study highlights the prognostic shift induced by brain metastasis (BM), identifying this event as a major contributor to the death of patients with ASPS, and observes a striking lack of effectiveness of AAT in patients who had previously developed BM. This observation is of interest for the therapeutic development in ASPS, highlighting the need to develop strategies dedicated to BM, such as radiosurgery or high-central nervous system penetrance tyrosine kinase inhibitors.

FARES method for reduction without medication of first episode of traumatic anterior shoulder dislocation.

PURPOSE: The aim of this study is to demonstrate the efficiency of (FARES) method for reduction of first-episode anterior shoulder dislocation, as well as its safety, reliability, and quick easy reproducibility by inexperienced physicians without any use of medications. METHODS: This was a prospective study of 28 patients with first episode of anterior shoulder dislocation that underwent closed reduction using FARES method by junior orthopaedic residents without use of any analgesic, muscle relaxant, or anesthesia. Only two attempts of reduction were allowed for each patient. The time needed for reduction was recorded, and the patients were asked to grade their pain according to a visual analog scale from 0 to 10. RESULTS: Reduction was achieved after one attempt in 21 patients (75%) and after two attempts in three additional patients (total 85.7%). The mean time needed for reduction was 62.66 seconds, and the mean visual analog scale for pain evaluation was 5.29. CONCLUSION: FARES method is a fast, reliable, and safe method for reduction of a first episode of anterior shoulder dislocation and can be easily performed by inexperienced physicians and junior residents.

Transfracture medial transposition of the radial nerve associated with plate fixation of the humerus.

PURPOSE: The aim of this study was to illustrate safety, feasibility and advantages of transfracture medial transposition of the radial nerve during the lateral approach and lateral plating of humeral fractures located in the mid and distal shaft. METHODS: This was a retrospective review and analysis of medical records and radiographs of 19 patients who underwent a transfracture medial transposition of the radial nerve. Fifteen patients were treated for fresh fracture and four for nonunion. All patients were followed up clinically and radiographically for a minimum of 12 months. RESULTS: Pre-operative radial nerve paralysis was present in four patients in the fresh fractures group; post-operative paralysis occurred in two. All patients completely recovered a few months after the index procedure. Except for two, all patients achieved bone healing. One patient from the fresh-fracture group developed nonunion, and one from the nonunion group experienced persistent nonunion; both underwent successful revision surgeries. In addition, four patients with a fresh fracture underwent revision surgery for hardware removal. All but two patients showed no restricted elbow or shoulder joint motion compared with the opposite side. CONCLUSION: Transfracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures is a safe, harmless and feasible procedure when applied for fractures of the middle and distal humeral shaft; it removes the nerve from the surgical field during fracture manipulation and fixation, with a gain in length of the nerve by transforming its course from spiral to straight. Following radial nerve transposition across the fracture, a repeat surgical approach to the humerus for hardware removal or treatment of nonunion transforms the procedure into a simple one; the skin incision is carried straight down to the bone without the need to identify or dissect the nerve that was previously transposed to the medial compartment of the arm.

Unraveling Myelodysplastic Syndromes: Current Knowledge and Future Directions.

Myelodysplastic syndromes (MDS) affect more than 30,000 patients in the USA per year, most of whom are elderly, and these diseases are associated with dismal prognoses. The main features of MDS are ineffective hematopoiesis and aberrant myeloid differentiation. Furthermore, MDS are heterogeneous, both clinically and molecularly. This heterogeneity and the frequent occurrence of age-related comorbidities make the management of these diseases challenging. In fact, there have been no new drug approvals for MDS in the USA in the last 9 years, and few currently available investigational drugs are likely to be approved in the near future. Novel targeted treatment based on better understanding of the pathogenesis of MDS is needed to maximize patient outcomes. Here, we discuss new insights into diagnostic accuracy, prognostic assessment, pathogenic mechanisms, and effective treatments for MDS.

GUIDING PRINCIPLES AND PEARLS IN A STEPWISE SURGICAL TECHNIQUE OF REVISION TOTAL KNEE ARTHROPLASTY.

The authors aim at reviewing the guiding principles in revision total knee arthroplasty according to a stepwise procedure. Strict preoperative planning is of paramount importance for this surgery. Thorough clinical history and physical exam, the assessment of limb deformity and knee range of motion as well as knee stability in flexion, extension and mid-flexion are crucial. Blood exam, standardized radiographic views, and CT scan are powerful tools for etiologic diagnosis of total knee arthroplasty failure. Templating is unique and mandatory to provide the surgeon with the critical data concerning the valgus position of the femoral component, the AP size of the femoral component, and the optimal position of the joint line; these three parameters are determinant for the final clinical outcome. A stepwise surgical technique with close adherence to the guiding principles of revision knee arthroplasty should be adopted from skin incision to closure. Femoral and tibia components with modular stem are ideally set at their optimal position as predetermined by templating. Any residual implant-bone gap is filled with metallic augment or bone graft. Finally, repositioning of the patella on a symmetrical bone cut presents a great value for a successful procedure.

KAPANDJI TECHNIQUE AS AMINIMALLY INVASIVE PROCEDURE FOR SELECTED PATIENTS WITH TWO- AND THREE-PART FRACTURES OF THE PROXIMAL HUMERUS.

Current algorithms for decision making in proximal humerus fractures consider the fracture pattern along with the patient characteristics and surgeon's experience. Minimally invasive techniques for reduction and internal fixation of many types of these fractures have recently been widely promoted, especially with the use of the newly developed locking plate systems. Intramedullary flexible nailing is one of the oldest techniques using minimally invasive reduction and fixation of proximal humerus fractures. Kapandji technique uses the "Deltoid V" landmark as entry point for intramedullary insertion of the flexible nails into the humeral head. The authors report their experience with this procedure in twenty-six, relatively young patients with good bone quality, presenting with displaced 2- or 3-part extra-articular fracture of the proximal humerus, treated with percutaneous reduction and intramedullary flexible nailing as described by Kapandji. Nineteen medical records were available for this retrospective review, with 9 to 12 months follow-up. There were 15 excellent and 1 good results when patients were assessed for pain, function and range of motion of the shoulder. The authors submit that Kapandji technique is a valuable procedure for management of extra-articular displaced 2- and 3- part proximal humerus fractures in young patients with good bone quality.

Quanta of geometry: noncommutative aspects.

In the construction of spectral manifolds in noncommutative geometry, a higher degree Heisenberg commutation relation involving the Dirac operator and the Feynman slash of real scalar fields naturally appears and implies, by equality with the index formula, the quantization of the volume. We first show that this condition implies that the manifold decomposes into disconnected spheres, which will represent quanta of geometry. We then refine the condition by involving the real structure and two types of geometric quanta, and show that connected spin manifolds with large quantized volume are then obtained as solutions. The two algebras M_{2}(H) and M_{4}(C) are obtained, which are the exact constituents of the standard model. Using the two maps from M_{4} to S^{4} the four-manifold is built out of a very large number of the two kinds of spheres of Planckian volume. We give several physical applications of this scheme such as quantization of the cosmological constant, mimetic dark matter, and area quantization of black holes.

Invasive aspergillosis in neutropenic patients during hospital renovation: effectiveness of mechanical preventive measures in a prospective cohort of 438 patients.

BACKGROUND: Aspergillus species are the main cause of invasive fungal disease for patients with severe and prolonged neutropenia. Building or renovation works have been shown as one of the major causes of outbreaks of aspergillosis. OBJECTIVES: This study aimed to assess the effectiveness of introduction and adaptation by air sampling of mechanical preventive measures on the incidence of invasive pulmonary aspergillosis in neutropenic patients during hospital renovation. PATIENTS: All of the patients admitted for prolonged and severe neutropenia during a renovation period from 2003 to 2008 were prospectively enrolled. Invasive pulmonary aspergillosis (IPA) cases were classified as possible, probable, and proven, according to the 2008 European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group criteria. The effectiveness of preventive measures was determined by air sampling. RESULTS: We recorded 705 hospitalizations for neutropenia concerning 438 patients. The majority of hospitalized neutropenic patients was treated for acute leukemia (38.3 %), followed by patients suffering from non-Hodgkin and Hodgkin lymphomas (33 %). The total cumulative incidence of probable and proven IPA was 4.1 %. Risk factors for developing IPA were underlying disease, treatment course at the time of hospitalization, and the mean duration of hospitalization and of neutropenia. CONCLUSIONS: In this prospective study, the incidence of invasive pulmonary aspergillosis did not increase in neutropenic patients during a renovation period because of efficient mechanical preventive measures systematically adjusted using the results of air sampling.

Shortening of the distal ulna to correct ulnar variance in osteoporotic wrist fractures treated with intra-focal pining.

The aim of this study is to correct the ulnar variance in severe osteoporotic wrist fracture treated with intra-focal pining of the distal radius, with shortening osteotomy of the distal ulna. Thirteen patients, 12 females and one male, 61-83 years old, 6-year follow-up, were treated by intra-focal pining (kapandji). When preoperatively the ulnar variance did not return to a normal value comparing to the opposite wrist, a shortening osteotomy of the ulna was performed in one stage, 4 cm proximal to the ulnar head. The fractures healed 6-8 weeks with stability and normal motion: flexion 70°, extension 60° and pronation/supination 140°. There was no pain upon palpation of distal ulna and no sign of radial impingement. Concerning the ulnar variance and starting with nine neutral values at the normal wrist, we obtained eight negative and one neutral ulnar variance after surgery. In four cases of negative variance at normal wrist, we obtained four negative ulnar variances after surgery and two cases of ulnar non-union. In cases of dorsal comminution in wrist fracture with severe osteoporosis, intra-focal pining technique is able to restore all the radiological parameters, but it could not correct the inversion of ulnar variance relative to shortening of the radius. Avoiding secondary interventions, acute shortening osteotomy of the ulna performed is a procedure which allows restoring the ulnar variance without affecting carpal stability and the mobility.

Prognostic impact of fat tissue loss and cachexia assessed by computed tomography scan in elderly patients with diffuse large B-cell lymphoma treated with immunochemotherapy.

OBJECTIVES: Approximately 30% of DLBCL patients are older than 70 yr. This study evaluated the prognostic impact of a cachexia score (CS) including fat tissue loss (adipopenia) and sarcopenia as assessed by computed tomography (CT scan) in elderly DLBCL patients treated with chemotherapy and rituximab (R). METHODS: This retrospective analysis included 80 DLBCL patients older than 70 yr treated with R-CHOP or R-miniCHOP. Skeletal muscle (SM) and visceral (V) and subcutaneous (S) adipose (A) tissues were measured by analysing CT images at the third lumbar (L3) level. RESULTS: The median age of the patients was 78 yr. Forty-four and 46 patients were considered sarcopenic and adipopenic, respectively. The median progression-free survival (PFS) was 13.6 months in the adipopenic group and 49.4 months in the non-adipopenic group [hazard ratio (HR) = 2.27; 95% confidence interval (CI): 1.3-4; P = 0.0042]. The median overall survival (OS) was 25.7 months in the adipopenic group and 57.1 months in the non-adipopenic group (HR = 1.93; 95% CI: 1.05-3.55; P = 0.0342). A two-point CS including adipopenia and sarcopenia was created and defined two distinct risk groups with differences in outcomes that were highly significant. The CS was predictive of the prognosis in a multivariate analysis including body mass index (BMI) (< or ≥ 25 kg/m(2) ), age (< or ≥ 80 yr), international prognostic index (IPI) and albuminaemia (HR = 3.67; 95% CI = 1.93-6.97; P < 0.0001). CONCLUSION: A CS including sarcopenia and adipopenia, assessed by a single CT scan slice, predicts outcome independent of BMI and the IPI.

Trans-fracture transposition of the radial nerve during the open approach of humeral shaft fractures.

The radial nerve constitutes a major problem in humeral shaft fractures; it may be injured immediately or during closed reduction or open reduction and internal fixation with plate and screws. After fixation, the nerve always runs directly over the plate without any interposed structure. If a revision surgery is indicated, the nerve is at high risk as it is usually difficult to dissect from surrounding fibrotic scar tissue or callus formation. To avoid these complications, some authors reported transposition of the radial nerve through the fracture line. We present herein the surgical technique of the trans-fracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures, along with our preliminary results in 6 cases and a review of the literature.

Airborne transmission of SARS-Cov2: What consequences for digestive endoscopy?

The SARS-Cov-2 disease disrupted essential hospital procedures, such as gastrointestinal (GI) endoscopy, due to concerns about air transmission and the risk of exposing health care workers. With the spread of the pandemic, air transmission was considered as the main source of SARS-Cov2 transmission. This raised the problem of transmission by aerosolization of viral particles in operating rooms as well as endoscopy units. This is in line with the known airborne transmission of many other respiratory viruses. The risk of SARS-Cov-2 transmission during GI endoscopy was initially reduced by controlled measures, involving personal protections (mask…), restricted access to endoscopy rooms, and detection of infected patients. Gastrointestinal endoscopy generates aerosols, which may carry viruses. In addition, the endoscopy system may facilitate the diffusion of virus particles or fomites considering the forced-air cooling system used to maintain a stable temperature inside the box (25°C). The volume of air that goes through the light source box is high (240-300 m3 for a 1-h period). Moreover, the light system contains an air pump to inflate air inside the gut lumen. In order to isolate people from hazard, different levels of protection and solutions to avoid airborne transmission of microorganisms should be proposed, such as the reinforcement of personal protective equipment, the change in the way people work and engineering control of the risk.