Outcomes of hamstring graft with preserved tibial insertion for ACL reconstruction: systematic review and meta-analysis.

PURPOSE: Evaluate the outcomes of ACL (Anterior Cruciate Ligament) reconstruction techniques that use a hamstring graft with a preserved tibial insertion and compare them to standard techniques. METHODS: A systematic literature review and meta-analysis was done of the PubMed, MEDLINE, Cochrane and Ovid databases to identify published clinical studies on ACL reconstruction in which a non-detached hamstring tendon (NDHT) was used as a graft and to compare them to studies in which a detached hamstring tendon (DHT) or other techniques were used. The eligible studies were analyzed for the knee laxity, Lachman test, pivot shift test, joint range of motion, anterior drawer, pain, re-tear, revision surgery, Lysholm score, Tegner score, ACL-RSI scale, KOOS, IKDC, SNQ and Howell scale. RESULTS: Twelve articles in which NDHT was used for ACL reconstruction were analyzed. There was no significant difference between NDHT and DHT in the Lachman > 1 (p = .07), pivot shift test > 1 (p = .40), re-tears (p = .62), pain (p = .85) and the Tegner score (p = .95). However, the outcomes were somewhat better with the NDHT technique for the Lachman (RR = 0.30; 95% CI 0.08-1.12), pivot shift test (RR = 0.50; 95% CI 0.10-2.49) and re-tears (RR = 0.66; 95% CI 0.13-3.42). The other criteria were not included in the meta-analysis because of lack of data or because specific outcome scores were used in each article. CONCLUSION: NDHT techniques provide similar results to DHT for ACL reconstruction and tend to produce better stability and a lower re-tear rate.

A quadruple peripheral nerve block outside the OR for anterior cruciate ligament reconstruction reduces the OR occupancy time.

PURPOSE: The use of regional anesthesia (RA) for anterior cruciate ligament (ACL) reconstruction reduces morphine consumption, the time spent in the post-anesthesia care unit (PACU) and the hospital readmission rate. However, RA failures due to delays in the induction of anesthesia and its unpredictable success rate (Cuvillon et al. Ann Fr Anesth 29:710-715, 2010; Jankowski et al. Anesth Analg 10.1213/01.ANE.0000081798.89853.E7) can lead to disorganization of the operating room (OR) schedule. The hypothesis is that performing RA outside the OR will significantly reduce the OR occupancy time relative to using general anesthesia (GA). The primary objective was to compare the OR occupancy time between RA and GA when performing ACL reconstruction. METHODS: This was a retrospective, single-center study of data collected prospectively from consecutive patients operated by a single surgeon between January 2019 and December 2020. The patients undergoing ACL reconstruction were divided into two groups based on the type of anesthesia they received (GA, RA). RA consisted of a quadruple peripheral nerve block (femoral, sciatic, obturator and lateral femoral cutaneous nerves). The durations of the perioperative stages of the patient's journey in the OR suite were compared between these two groups. RESULTS: The analysis involved 469 ACL reconstructions: 356 GA and 113 RA. The two groups were comparable in age, gender and ASA score (American Society of Anesthesiologists). The OR occupancy time for ACL reconstruction with RA was reduced by a mean of 13 min (70 ± 12 SD vs. 83 ± 14 SD; P < 0.0001) and the PACU time by 41 min relative to GA (P < 0.0001). The entry-incision time was reduced by an average of 8 min and the end-exit time by 3 min (P < 0.0001). The care time in the PACU was reduced from 84 ± 35 to 46 ± 26 min (P < 0.0001). However, performing anesthesia outside the OR (i.e., in a RA block room) did not reduce the turnover time (n.s). CONCLUSION: Performing RA outside the OR reduced the OR occupancy time by nearly 20% relative to using GA for ACL reconstructions. LEVEL OF EVIDENCE: Level IV.

Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes.

PURPOSE: Despite encouraging clinical, biomechanical and histological results, ACL reconstruction using the ITB was slowly abandoned. The hypothesis was that the current literature supports the use of ITB as the graft of choice for ACL reconstruction because of its good outcomes. METHODS: A systematic search of the literature was performed in the PubMed, MEDLINE, Cochrane, and Ovid databases to identify published clinical studies relevant to ACL reconstruction with ITB autograft and studies comparing ITB autograft with bone-patellar tendon-bone (BPTB) and hamstring (HT) autografts (none were found). The results of the eligible studies were analyzed in terms of graft failure, instrumented knee laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, Tegner activity score, return to sports rate, return to sports at pre-injury level and complications. RESULTS: Nineteen clinical studies including 1,210 patients with ACL reconstruction met the inclusion criteria. Graft failure occurred after ITB autograft in 4.2% of patients. Postoperative mean side-to-side laxity was 1.41 mm with 21% of patients having greater than 3 mm side-to-side difference. Lachman test and pivot-shift test were negative (grade 0) in 57% and 85%, respectively, and were grade 0 or 1 in 95% and 97%, respectively. Functional outcomes were satisfactory in 84% of patients with good to excellent results (Lysholm score > 84). Mean postoperative Lysholm score was 93.3 and 84% of patients had an objective IKDC grade of A or B. Mean postoperative Tegner score was 6.8. The return to sports rate was 89% and 61% of patients returned to their pre-injury level. A comparison of 89 ITB versus 80 BPTB autografts revealed no significant differences in graft failure (n.s.), instrumented mean side-to-side knee laxity difference (n.s.) or Tegner score (n.s.). CONCLUSION: The graft survival rate and clinical and functional outcomes for ITB autograft are satisfactory. By allowing ACL reconstruction and lateral tenodesis to be done with a single, continuous, pedicled graft through an outside-in femoral tunnel, this technique may become the preferred alternative for primary or secondary ACL surgery. LEVEL OF EVIDENCE: Level IV.

Femoral and tibial bone bruise volume is not correlated with ALL injury or rotational instability in patients with ACL-deficient knee.

PURPOSE: Some researchers have suggested that bone bruises are evidence of rotational instability. The hypothesis was that the extent of lateral bone edema is correlated with the presence of an anterolateral ligament (ALL) injury. The main objective was to determine whether there was a correlation between the presence of an ALL injury the extent of bone bruises. METHODS: A prospective diagnostic study enrolled all the patients who suffered an acute anterior cruciate ligament (ACL) who were operated on within 8 weeks. The extent of bone bruising according to the ICRS classification was measured on preoperative MRIs by two independent blinded raters twice with an interval of 4 weeks. Dynamic ultrasonography (US) to look for ALL injury and the pivot shift test were performed before the ACL surgery. The correlation between ALL injury and bone bruises, and the correlation between an ALL injury and a high-grade pivot shift test were determined. RESULTS: Sixty-one patients were included; 52% of patients had an ALL injury on US. The extent of lateral bone bruise was not related to the presence of an ALL injury, nor related to the presence of a high-grade pivot shift. A grade 2 or 3 pivot shift was significantly correlated with an ALL injury (p < 0.0001). Inter- and intra-rater reliability for the bone bruise rating was excellent. CONCLUSION: The extent of lateral bone bruise is not correlated with ALL injury or a high-grade pivot shift; thus, it is not correlated with rotational instability of the knee. LEVEL OF EVIDENCE: II.

Simple Knee Value: a simple evaluation correlated to existing knee PROMs.

PURPOSE: The Simple Knee Value (SKV) is an outcome score in which patients are asked to grade their knee function as a percentage of that of a normal knee. The primary aim of this study was to validate the SKV by measuring its correlation with existing knee-related PROMs. METHODS: This was a prospective study conducted at a teaching hospital to assess the SKV's validity. The study enrolled 47 young patients (16-54 years old), 49 older patients (≥ 55 years) and 30 healthy controls. A paper questionnaire consisting of the Lysholm, IKDC, KOOS, WOMAC and SKV was given to subjects three times (enrolment, 1-month preoperative visit and 6 months postoperative visit). The criterion validity of the SKV was determined by correlating it to existing knee PROMs using the Spearman correlation coefficient (S). SKV test-retest reliability was assessed by the intraclass correlation coefficient (ICC) between two time points (initial consultation at enrolment and preoperative visit, reflecting the same clinical condition). Responsiveness to change was determined by comparing the SKV scores before and after surgery (enrolment consultation and 6 months postoperative). Discriminative ability was determined by comparing the SKV distribution in patients and controls. RESULTS: There was a strong and significant correlation between the SKV and the gold standard Lysholm, IKDC, KOOS and WOMAC in the younger patients and the older patients (p < 0.0001). The reliability between the SKV at the initial consultation and before surgery was excellent (ICC 0.862, 95% CI 0.765; 0.921) in the younger patients, and moderate (ICC 0.506, 95% CI 0.265; 0.688) in the older patients. The SKV was responsive to change in both patient groups (p < 0.0001 for the SKV before versus 6 months after surgery). Like the other knee-specific PROMs (p < 0.0001), the SKV was able to distinguish between patients and controls (p < 0.0001). CONCLUSIONS: The SKV is valid as it is significantly correlated to existing knee PROMs. It is also reliable, responsive to change and discriminating. Its simplicity gives it many advantages and it can be used by physicians in their daily practice. LEVEL OF EVIDENCE: Level II.

Positive change in hand care habits using therapeutic patient education in chronic hand eczema.

BACKGROUND: Chronic hand eczema (CHE) is a major burden for patients. Maintenance treatment involves prevention measures limiting detrimental behaviour and aggravating factors. OBJECTIVE: To evaluate the effect of a standardised care program including therapeutic patient education (TPE) on hand care behaviours, clinical severity, quality of life, and work productivity. METHODS: A single-centre study was conducted prospectively. Together with the prescription of a topical steroid, patients participated in individual TPE sessions. Evaluations were performed initially and repeated three months after the therapeutic intervention. They included a structured analysis of hand care behaviours, the assessment of the mTLSS (modified Total Lesion Symptom Score), DLQI (Dermatology Life Quality Index), and WPAI (Work Productivity and Activity Impairment). RESULTS: Seventy-one patients were included (30 men, 42.3%). Three months after completion of the standardised care program, hand care behaviours such as hand washing and rinsing, hand drying, wearing protective gloves, using moisturizing creams, and following specific treatments and recommendations for CHE improved significantly in the 58 patients who completed the study and were associated with a significant improvement in the mTLSS, DLQI, and WPAI scores. CONCLUSIONS: TPE helps patients change their hand care behaviours and adopt skin protection measures, and may improve CHE severity, quality of life, and work productivity.

Lower donor-site morbidity using QT autografts for ACL reconstruction.

PURPOSE: Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. METHODS: Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS. RESULTS: Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). CONCLUSION: Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. LEVEL OF EVIDENCE: III.

Are social inequalities in acute myeloid leukemia survival explained by differences in treatment utilization? Results from a French longitudinal observational study among older patients.

BACKGROUND: Evidences support social inequalities in cancer survival. Studies on hematological malignancies, and more specifically Acute Myeloid Leukemia (AML), are sparser. Our study assessed: 1/ the influence of patients' socioeconomic position on survival, 2/ the role of treatment in this relationship, and 3/ the influence of patients' socioeconomic position on treatment utilization. METHODS: This prospective multicenter study includes all patients aged 60 and older, newly diagnosed with AML, excluding promyelocytic subtypes, between 1st January 2009 to 31st December 2014 in the South-West of France. Data came from medical files. Patients' socioeconomic position was measured by an ecological deprivation index, the European Deprivation Index. We studied first, patients' socioeconomic position influence on overall survival (n = 592), second, on the use of intensive chemotherapy (n = 592), and third, on the use of low intensive treatment versus best supportive care among patients judged unfit for intensive chemotherapy (n = 405). RESULTS: We found an influence of patients' socioeconomic position on survival (highest versus lowest position HRQ5: 1.39 [1.05;1.87] that was downsized to become no more significant after adjustment for AML ontogeny (HRQ5: 1.31[0.97;1.76] and cytogenetic prognosis HRQ5: 1.30[0.97;1.75]). The treatment was strongly associated with survival. A lower proportion of intensive chemotherapy was observed among patients with lowest socioeconomic position (ORQ5: 0.41[0.19;0.90]) which did not persist after adjustment for AML ontogeny (ORQ5: 0.59[0.25;1.40]). No such influence of patients' socioeconomic position was found on the treatment allocation among patients judged unfit for intensive chemotherapy. CONCLUSIONS: Finally, these results suggest an indirect influence of patients' socioeconomic position on survival through AML initial presentation.

Ferritin heavy/light chain (FTH1/FTL) expression, serum ferritin levels, and their functional as well as prognostic roles in acute myeloid leukemia.

OBJECTIVES: We previously reported the prognostic value of serum ferritin in younger patients with intermediate-risk acute myeloid leukemia (AML). The aims of this study were to confirm this finding in a larger cohort regardless of age and prognostic subgroups, to explore the expression and functional role of ferritin in AML cells as well as the regulation of serum ferritin levels in AML patients. PATIENTS/MATERIALS/METHODS: Serum ferritin levels at diagnosis were collected in a cohort of 525 patients treated by intensive chemotherapy. In silico, in vitro, and in vivo analyses were conducted to assess the pattern of expression and functional role of FTH1 and FTL in AML. RESULTS: We confirmed the independent prognostic value of serum ferritin. In transcriptomic databases, FTH1 and FTL were overexpressed in AML and leukemic stem cells compared to normal hematopoietic stem cells. The gene signature designed from AML patients overexpressing FTH1 revealed a significant enrichment in genes of the immune and inflammatory response including Nf-KB pathway, oxidative stress, or iron pathways. This gene signature was enriched in cytarabine-resistant AML cells in a patient-derived xenograft model. FTH1 protein was also overexpressed in patient's samples and correlated with the in vitro cytotoxic activity of cytarabine. Lastly, we demonstrated that chemotherapy induced an inflammatory response including a significant increase in serum ferritin levels between day 1 and 8 of induction chemotherapy that was blocked by dexamethasone. CONCLUSION: Ferritin is deregulated in most AML patients likely through inflammation, associated with chemoresistance, and could represent a new therapeutic target.

Delayed reconstruction and high BMI z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury.

PURPOSE: The purpose of this study was to identify epidemiologic risk factors for secondary meniscal tears in paediatric and adolescent patients who sustain an anterior cruciate ligament (ACL) tear. The hypothesis was that delayed reconstruction and elevated BMI z score, increase the risk for secondary meniscal tears. METHODS: A prospective, descriptive and analytical study of consecutively accrued children and adolescents with an ACL tear was performed. One hundred and sixty subjects (114 males and 46 females) were identified between 2006 and 2015 at one institution. The age range was between 7 and 19 years. Fifteen parameters were recorded and analysed: age at initial trauma, initial trauma circumstance, sex, BMI z score, affected side, type of sport, Tegner score, athletic level, time to MRI, time to first referral, time to surgery, age at surgery, attempted non-operative treatment, operative report and associated meniscal tear. These meniscal lesions could be diagnosed by an MRI and / or during surgery. RESULTS: Out of the 160 cases, 143 were treated surgically and 17 cases non-operatively. Median corrected BMI z score was 0.5 (range - 1.8 to 4.7). 41.9% had one or more meniscal lesions. 55 patients were initially treated non-operatively, of which 39 patients were secondarily operated. There was a positive relationship between meniscal lesion and: BMI z score (p = 0.0364), attempted non-operative treatment (p = 0.001) and time to surgery (p = 0.002). The median time to ACL reconstruction was 229 days for patients with secondary meniscal lesions. CONCLUSIONS: Patients with ACL tears treated non-operatively developed secondary meniscal lesions requiring delayed surgical management. There was a positive correlation between BMI z score and secondary meniscal lesions. Thus, early ACL reconstruction is advocated in young athletes. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Determination of normal KOOS and WOMAC values in a healthy population.

PURPOSE: The KOOS questionnaire is used to assess the symptoms and function of patients with traumatic or degenerative knee pathology. The WOMAC score has been validated mainly in the context of knee osteoarthritis. The distribution of these scores in a non-diseased population is not known. The hypothesis was that KOOS and WOMAC scores were influenced by patients' age, sex, and BMI. The primary objective of this study was to describe, for the first time, the distribution of KOOS and WOMAC scores in a healthy population based on age, sex, and BMI. METHODS: This was a pilot (innovative), cross-sectional, international, multicenter, descriptive study. Persons accompanying patients to our clinic were invited to participate in this study by filling out the KOOS questionnaire. These data were also used to calculate the WOMAC score. The study was designed according to guidelines on pilot studies and planned to enroll a minimum of 30 subjects in each age, gender, and BMI group. Expected KOOS and WOMAC scores by age, gender, and BMI were determined using a linear regression model. RESULTS: Seven hundred and fourteen subjects were included: 305 men (42.7%) and 409 women (57.3%). For the KOOS score, as age increases, there was a decrease in the "ADL" (p = 0.0001) and "sport" (p = 0.0001) items and an increase in the "symptoms" (p = 0.0025) and "QOL" items (p = 0.0001). Women had lower scores (p < 0.05) than men on all the KOOS items, except "QOL". For the WOMAC, the "pain", "stiffness", and "function" items varied significantly based on age (p = 0.0203) and sex (p = 0.0121). The "stiffness" item varied significantly based on age (p = 0.0005) and sex (p = 0.0477). The "function" item varied significantly based on age (p = 0.0001) and sex (p = 0.0256). The expected value for the KOOS and WOMAC scores in a healthy population without any knee ailments were determined. CONCLUSIONS: The KOOS and WOMAC scores vary significantly based on age, sex, and BMI in a healthy population. This study also provides KOOS and WOMAC values in a population without any knee issue. These scores can be used, in a daily practice, as a reference to assess functional outcomes after a surgical procedure. LEVEL OF EVIDENCE: IV.

A comparison of flap reconstruction vs the laying open technique or excision and direct suture for pilonidal sinus disease: A meta-analysis of randomised studies.

Many treatments have been described for pilonidal disease, but recurrence cannot be completely eliminated. The aim of this study was to perform a meta-analysis of randomised, controlled trials comparing flap repair vs the laying open technique and/or excision and direct closure techniques in the treatment of chronic pilonidal sinus disease. The primary outcome measure was the recurrence rate. Secondary outcomes were complete wound-healing time, duration of the incapacity to work, quality of life and patient satisfaction, postoperative pain, wound infection, bleeding or haematoma, skin wound complications, and duration of hospital stay. Seventeen studies were included. The meta-analysis demonstrated a lower risk of recurrence, a shorter duration of incapacity to work, a lower risk of wound infections, a lower risk of skin wound complications, and a shorter duration of hospitalisation in favour of flap vs direct closure. A shorter time to complete wound healing and a shorter duration of incapacity to work for flap vs the laying open technique were observed. Superiority of flap repair vs direct closure in pilonidal sinus treatment was demonstrated in this meta-analysis. These results suggest avoiding primary direct closure in clinical practice. Compared with the laying open technique, flaps result in faster healing and a shorter time to return to activities.

Grazoprevir plus elbasvir in HCV genotype-1 or -4 infected patients with stage 4/5 severe chronic kidney disease is safe and effective.

Patients with advanced chronic kidney disease who receive direct-acting antiviral drugs require special consideration regarding comorbid conditions. Here we assessed the efficacy and safety of grazoprevir plus elbasvir in 93 patients infected with HCV genotype 1 or 4 and with advanced chronic kidney disease in a non-randomized, multicenter, nationwide observational survey. Twenty patients with HCV genotype 1a, 51 patients with 1b, four unclassified genotype 1, 17 with genotype 4 and one with genotype 6 received grazoprevir plus elbasvir (100/50 mg) once daily. All patients had severe chronic kidney disease with 70 patients stage G5, including patients on hemodialysis (74.2%), and 23 were stage G4 chronic kidney disease. Severe liver disease (Metavir F3/F4) was found in 33 patients. A sustained virologic response 12 weeks after the end of therapy was achieved in 87 of 90 patients. Two patients had a virologic breakthrough and one had a relapse after treatment withdrawal. Most patients received many concomitant medications (mean 7.7) related to comorbid conditions. Serious adverse events occurred in six patients, including three deaths while on grazoprevir plus elbasvir, not related to this therapy. Thus, once-daily grazoprevir plus elbasvir was highly effective with a low rate of adverse events in this advanced chronic kidney disease difficult-to-treat population with an HCV genotype 1 or 4 infection.

Dexamethasone in hyperleukocytic acute myeloid leukemia.

Patients with acute myeloid leukemia and a high white blood cell count are at increased risk of early death and relapse. Because mediators of inflammation contribute to leukostasis and chemoresistance, dexamethasone added to chemotherapy could improve outcomes. This retrospective study evaluated the impact of adding or not adding dexamethasone to chemotherapy in a cohort of 160 patients with at least 50×109 white blood cells. In silico studies, primary samples, leukemic cell lines, and xenograft mouse models were used to explore the antileukemic activity of dexamethasone. There was no difference with respect to induction death rate, response, and infections between the 60 patients in the dexamethasone group and the 100 patients in the no dexamethasone group. Multivariate analysis showed that dexamethasone was significantly associated with improved relapse incidence (adjusted sub-HR: 0.30; 95% CI: 0.14-0.62; P=0.001), disease-free survival (adjusted HR: 0.50; 95% CI: 0.29-0.84; P=0.010), event-free survival (adjusted HR: 0.35; 95% CI: 0.21-0.58; P<0.001), and overall survival (adjusted HR: 0.41; 95% CI: 0.22-0.79; P=0.007). In a co-culture system, dexamethasone reduced the frequency of leukemic long-term culture initiating cells by 38% and enhanced the cytotoxicity of doxorubicin and cytarabine. In a patient-derived xenograft model treated with cytarabine, chemoresistant cells were enriched in genes of the inflammatory response modulated by dexamethasone. Dexamethasone also demonstrated antileukemic activity in NPM1-mutated samples. Dexamethasone may improve the outcome of acute myeloid leukemia patients receiving intensive chemotherapy. This effect could be due to the modulation of inflammatory chemoresistance pathways and to a specific activity in acute myeloid leukemia with NPM1 mutation.

Ultrasonographic Evaluation of Anterolateral Ligament Injuries: Correlation With Magnetic Resonance Imaging and Pivot-Shift Testing.

PURPOSE: (1) To compare the diagnostic ability of ultrasonography (US) and magnetic resonance imaging (MRI) to detect anterolateral ligament (ALL) injuries in anterior cruciate ligament (ACL)-deficient patients, and (2) to evaluate the correlation between ALL injury status (as determined by US and MRI) and the knee's rotational stability. METHODS: Thirty patients with an isolated ACL injury were included prospectively over a 3-month period. The condition of the ALL was evaluated by 2 experienced radiologists using both US and MRI. Rotational stability was evaluated by 2 surgeons with the pivot-shift test with patients under general anesthesia. It was classified as either negative (grades 0 and I) or positive (grades II and III). The radiologists were blinded to the knee's rotational stability, and the surgeons were blinded to the ALL's status based on the US images. The correlation between the ALL's injury status (US and MRI) and the pivot shift was determined with the Pearson χ2 test. To evaluate the reproducibility of the results, the agreement between observers was determined with the Cohen κ coefficient. RESULTS: On US, the ALL was identified and visible over its entire length in 100% of patients (30 of 30, κ = 1). The ALL was injured in 63% of patients (19 of 30, κ = 0.93). On MRI, the ALL was identified in 96% of patients (29 of 30, κ = 0.91). The ALL appeared injured in 53% of cases (16 of 30, κ = 0.93). An ALL that appeared injured on US was more often associated with a positive pivot shift than was an uninjured ALL (75% vs 39%, χ2 = 13.7, P < .05). The interobserver agreement was high for both US (κ = 0.91-1) and MRI (κ = 0.76-1). CONCLUSIONS: US is a reproducible examination for the diagnosis of ALL injury. An ALL injury is most often associated with a high pivot-shift grade. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Impact of obesity in favorable-risk AML patients receiving intensive chemotherapy.

We assessed the influence of obesity on the characteristics and prognosis of acute myeloid leukemia (AML). Indeed, safety of intensive chemotherapy and outcome of obese AML patients in a real-life setting are poorly described, and chemotherapy dosing remains challenging. We included 619 consecutive genetically-defined cases of AML treated with intensive chemotherapy between 2004 and 2012. In this cohort, 93 patients (15%) were classified in the obese category according to WHO classification; 59% of them received capped doses of chemotherapy because of a body surface area above 2 m(2) . Obese patients were older and presented more often with cardiovascular comorbidities. Although obese patients had more frequently de novo AML, main characteristics of AML including white blood cell count, karyotype and mutations were well-balanced between obese and non-obese patients. After induction chemotherapy, early death and complete remission rates were similar. Overall (OS), event-free (EFS) and disease-free (DFS) survival were not significantly different compared to non-obese patients. However, in the European LeukemiaNet (ELN) favorable subgroup, obese patients had lower median OS, EFS and DFS than non-obese patients (18.4, 16.8 and 17.2 vs. 43.6, 31.8 and 29.7 months, respectively) and obesity showed a significant impact on OS (OR 2.54; P = 0.02) in multivariate models. Although we did not find any significant impact of obesity on outcome in the whole series, this study suggests that special efforts for chemotherapy dose optimization are needed in the ELN favorable subgroup since dose capping may be deleterious.

Surgical Treatment of Facial Basal Cell Carcinoma: Patient-Based Assessment of Clinical Outcome in a Prospective Cohort Study.

BACKGROUND: There are limited data on the esthetic, functional, and morphological outcomes of surgical treatment of facial basal cell carcinoma (BCC). OBJECTIVE: The aim of our study was to assess the determinants of the evaluation of both the patients and the investigator of the esthetic, functional, and morphological impact of the surgical treatment of facial BCC. METHODS: A prospective observational study evaluated 111 patients treated surgically for facial BCCs (n = 135 BCCs), using the Patient and Observer Scar Assessment Scale (POSAS), a validated and reliable scale designed for the evaluation of all types of scars by professionals and patients. RESULTS: Scar assessment rated by the patients was very good. Skin aging was associated with a better surgical outcome as evaluated by POSAS (OR = 0.30, 95% CI: 0.09-0.98; p = 0.04). Conversely, histologically infiltrative or sclerosing BCC (OR = 2.33, 95% CI: 0.95-5.71; p = 0.06) was independently associated with poorer POSAS. In terms of the investigator's evaluation, aging signs (protective factor: OR = 0.17, 95% CI: 0.04-0.73; p = 0.01), location on the H-zone of the face (risk factor: OR = 2.95, 95% CI: 1.07-8.15; p = 0.03), and histologically infiltrative or sclerosing BCC (risk factor: OR = 2.89, 95% CI: 1.01-8.29; p = 0.04) were independently associated with POSAS. CONCLUSION: Esthetic, functional, and morphological outcomes of facial BCC surgery provide high patient satisfaction overall. Taking wider margins requires specific measures to improve the surgical outcome.

Time from diagnosis to intensive chemotherapy initiation does not adversely impact the outcome of patients with acute myeloid leukemia.

In acute myeloid leukemia (AML), new strategies assess the potential benefit of genetically targeted therapy at diagnosis. This implies waiting for laboratory tests and therefore a delay in initiation of chemotherapy. We studied the impact of time from diagnosis to treatment (TDT) on overall survival, early death, and response rate in a retrospective series of 599 newly diagnosed AML patients treated by induction chemotherapy between 2000 and 2009. The effect of TDT was assessed using multivariate analysis. TDT was analyzed as a continuous variable using a specific polynomial function to model the shape and form of the relationship. The median TDT was 8 days (interquartile range, 4-16) and was significantly longer in patients with a white blood cell count (WBC) <50 Giga per liter (G/L) (P < .0001) and in older patients (P = .0004). In multivariate analysis, TDT had no impact on overall survival (P = .4095) compared with age >60 years, secondary AML, WBC >50 G/L, European LeukemiaNet risk groups, and Eastern Cooperative Oncology Group performance status. Furthermore, TDT was not associated with response rate and early death. Thus, waiting a short period of time for laboratory tests to characterize leukemias better and design adapted therapeutic strategies at diagnosis seems possible.

Expired-air carbon monoxide as a predictor of 16-year risk of all-cause, cardiovascular and cancer mortality.

BACKGROUND: Measurement of expired-air carbon monoxide (EACO) is commonly used to ascertain non-smoking status, although it can also reflect exposures not related to smoking. Our aim was to assess 16-year mortality according to EACO measured at baseline, in a general population. METHODS: Our analysis was based on the Third French MONICA population survey (1994-1997). Causes of death were obtained 16 years after inclusion, and assessment of determinants of mortality was based on Cox modeling. RESULTS: EACO was measured in 2232 apparently healthy participants aged 35-64. During follow-up, 195 deaths occurred (19% were due to cardio-vascular (CV) causes and 49% to cancer). At baseline, the mean EACO was 11.8 (±7.4)ppm, 4.6 (±2.5)ppm, 4.3 (±2.2)ppm for current, former and never smokers, respectively (P<0.001). After adjustment for main mortality risk factors and smoking, the hazard ratio (HR) for total mortality was 1.03[95% confidence interval: 1.01-1.06] per 1-unit increase in EACO, and it was 1.04[1.01-1.07] for cancer mortality. Adjusted HR for CV mortality was 1.05[1.01-1.10] but did not remain significant after additional adjustment for smoking (0.98[0.91-1.04]). Interactions between EACO and smoking were not significant. CONCLUSIONS: In a general population, baseline EACO is an independent predictor of 16-year all-cause and cancer mortality, after adjustment for confounders including smoking. Given that the effect of EACO is similar among smokers and non-smokers, EACO is probably not solely related to smoking but could also be a marker of inhaled ambient carbon monoxide and/or endogenous production. Besides, smoking better predicts CV mortality than EACO.