Practicability of a locking plate for difficult pathologies of the scaphoid.

INTRODUCTION: Headless compressions screws are the most implanted devices for scaphoid fractures and nonunions. For cases when screw osteosynthesis is not possible, a special locking plate for scaphoid reconstruction has been developed. The purpose of this study was to evaluate the safety and practicability of this device for difficult scaphoid pathologies. MATERIALS AND METHODS: Between March 2010 and December 2014, 20 patients (age range 16-59 years) were treated with scaphoid locking plate osteosynthesis. In 17 cases it was due to scaphoid nonunion or delayed union and in three cases to treat a complex multi-fragmentary fracture of the scaphoid. Most of the initial fractures were located either in the proximal third (n = 9) or the middle third (n = 8) of the scaphoid. RESULTS: Mean follow-up was 14.6 ± 8.9 months (range 2-30 months). All three scaphoid fractures (100%) showed bony healing in the CT scan after 2.7 ± 0.6 months. 15 of 17 (88.2%) patients with scaphoid nonunion demonstrated bony healing in the latest CT scan at an average of 6.2 ± 8.1 months (range 2-11 months) after scaphoid reconstruction. Range of motion (extension/flexion) was 104° ± 18.4° (range 80°-150°) and about one third less than the unaffected side. The average grip strength averaged 38.2 kg on the operated side and 44.1 kg on the unaffected side after surgery. 13 plates (65%) had to be removed due to impaction of the plate or protrusion of the screws. CONCLUSIONS: This new locking device for scaphoid reconstruction seems to be a safe, useful and reliable tool in the treatment of difficult nonunions or multi-fragmentary scaphoid fractures. The practicability is convincing and satisfying fusion rates can be accomplished. However, most patients require hardware removal. We recommend using this plate as a rescue option when a stable osteosynthesis is necessary for the healing process and screw fixation has already failed or is not possible.

Development of an Epstein-Barr virus-associated lymphoproliferative disorder in a patient treated with azacitidine for chronic myelomonocytic leukaemia.

Some chemotherapeutic agents can cause iatrogenic lymphoproliferative disorders. In analogy to what has been observed with other nucleoside analogues such as cladribine and fludarabine, we document the first case of an Epstein-Barr virus-positive, iatrogenic immunodeficiency-associated, lymphoproliferative disease, formally resembling polymorphic post-transplant lymphoproliferative disease in a patient treated with azacitidine (Vidaza) for chronic myelomonocytic leukaemia (CMML). A 78-year-old female patient was diagnosed with CMML in January 2012, and treatment with azacitidine was initiated, which lasted for five cycles from February until June 2012. The patient was hospitalized in June 2012 under the suspicion of pneumonia. Transformation of the CMML was suspected at that time too. During hospitalization, a generalized enlargement of the lymph nodes and the spleen was noticed. The patient rapidly deteriorated and finally died of respiratory insufficiency. At autopsy, an Epstein-Barr virus-associated lymphoproliferative disorder, resembling polymorphic post-transplant lymphoproliferative disease with involvement of the lymph nodes, the spleen and the lung and causing necrotizing pneumonia, was diagnosed. Diagnostic criteria for diffuse large B-cell lymphoma or infectious mononucleosis-like lymphoproliferative disease were not met. This is the first documented case of an azacitidine-associated lymphoproliferative disease, raising awareness for possible not yet known side effects of this drug, which should be kept in mind by oncologists and pathologists.

Comparison of seven serum thyroglobulin assays in the follow-up of papillary and follicular thyroid cancer patients.

BACKGROUND: Serum thyroglobulin (Tg) is the marker of differentiated thyroid cancer after initial treatment and TSH stimulation increases its sensitivity for the diagnosis of recurrent disease. AIM: The goal of the study is to compare the diagnostic values of seven methods for serum Tg measurement for detecting recurrent disease both during L-T4 treatment and after TSH stimulation. METHODS: Thyroid cancer patients who had no evidence of persistent disease after initial treatment (total thyroidectomy and radioiodine ablation) were studied at 3 months on L-T4 treatment (Tg1) and then at 9-12 months after withdrawal or recombinant human TSH stimulation (Tg2). Sera with anti-Tg antibodies or with an abnormal recovery test result were excluded from Tg analysis with the corresponding assay. The results of serum Tg determination were compared to the clinical status of the patient at the end of follow-up. RESULTS: Thirty recurrences were detected among 944 patients. A control 131I total body scan had a low sensitivity, a low specificity, and a low clinical impact. Assuming a common cutoff for all Tg assays at 0.9 ng/ml, sensitivity ranged from 19-40% and 68-76% and specificity ranged from 92-97% and 81-91% for Tg 1 and Tg2, respectively. Using assays with a functional sensitivity at 0.2-0.3 ng/ml, sensitivity was 54-63% and specificity was 89% for Tg1. Using the two methods with a lowest functional sensitivity at 0.02 and 0.11 ng/ml resulted in a higher sensitivity for Tg1 (81% and 78%), but at the expense of a loss of specificity (42% and 63%); finally, for these two methods, using an optimized functional sensitivity according to receiver operating characteristic curves at 0.22 and 0.27 ng/ml resulted in a sensitivity at 65% and specificity at 85-87% for Tg1. CONCLUSION: Using an assay with a lower functional sensitivity may give an earlier indication of the presence of Tg in the serum on L-T4 treatment and may be used to study the trend in serum Tg without performing any TSH stimulation. Serum Tg determination obtained after TSH stimulation still permits a more reliable assessment of cure and patient's reassurance.

Modulation of IL-8, IL-1 beta, and G-CSF secretion by all-trans retinoic acid in acute promyelocytic leukemia.

Acute promyelocytic leukemia (APL) is a homogeneous subgroup of acute myeloid leukemias (AML) characterized by the presence of the t(15;17) translocation and the resulting PML/RAR alpha fusion proteins. To date APL is the only AML which is sufficiently sensitive to all-trans retinoic acid (ATRA) differentiating effect. We have recently reported that APL express and secrete hematopoietic growth factors (HGF) such as IL-1 beta, TNF alpha, and IL-6. In vivo ATRA alone allows achievement of complete remission in APL patients. One of ATRA therapy's drawbacks is the increase of peripheral blast cells often associated with the ATRA leukocyte activation syndrome. To determine if this specific side-effect was linked to an increase of HGF release by APL cells, we studied the modulation of cytokine production by APL cells, we studied the modulation of cytokine production by APL samples (n = 12) before and after incubation with ATRA. ATRA failed to modulate TNF alpha, IL-6 or GM-CSF secretion levels; however, IL-8 levels decreased in 11 cases, and in four cases up-regulation of IL-1 beta and G-CSF protein expression was observed. These modulations were found to be linked to ATRA sensitivity as ATRA failed to modulate cytokine production in non-APL cells (n = 8). Interestingly, the increase of IL-1 beta and G-CSF production in the presence of ATRA was highly correlated to an increase in APL cell count in vitro and in vivo hyperleukocytosis, resulting in fatal outcome. IL-1 beta, TNF alpha, IL-6, and IL-8 are known to be implicated in leukocyte activation. The results of this study suggest that ATRA-induced hyperleukocytosis and ATRA leukocyte activation syndrome in APL may be inherent to the secretion of specific hematopoietic growth factors by the APL cells.

Induction of high-affinity GM-CSF receptors during all-trans retinoic acid treatment of acute promyelocytic leukemia.

Differentiation of normal myeloid cells is accompanied by the increase of high-affinity GM-CSF receptors necessary for progenitor proliferation/differentiation and mature neutrophil function. All-trans retinoic acid (ATRA) induces terminal differentiation of acute promyelocytic leukemia cells (AML3 subtype). We report in this study that AML3 cells, like other AML subtypes, harbor high-affinity GM-CSF R (n = 138.3 +/- 69.3 sites/cell, Kd = 76.9 +/- 68.8 pM). In all cases, incubation with ATRA induces either an increase in the number of affinity of GM-CSF R (n = 212.7 +/- 116.2 sites/cell, Kd = 43.2 +/- 22.5 pM). The data presented show that modulation of GM-CSF receptors cells is correlated to the degree of ATRA-induced granulocytic differentiation but not to increased cell growth.

Percentage of free serum prostate-specific antigen: a new tool in the early diagnosis of prostatic cancer.

Prostate-specific antigen (PSA) is a protease able to bind to serum antiproteases as alpha 1 antichymotrypsin (ACT). Free PSA (FPSA) corresponds to the fraction of total PSA (TPSA) which is unbound to ACT. Specific detection of the FPSA seems to be a valuable tool in the distinction between prostatic cancer (PCa) and benign prostatic hyperplasia (BPH). Our aim was to evaluate retrospectively the FPSA/TPSA ratio in comparison to TPSA or FPSA determination, using two new immunoradiometric assays (PSA-RIACT and FPSA-RIACT, CIS bio international, Gif Sur Yvette, France) in the early diagnosis of PCa. 256 men, with TPSA levels between 0.7 and 44.7 ng/ml (median age = 69 years), including 164 sera obtained from patients with BPH and 92 sera from patients with untreated PCa were assayed. All diagnoses were histologically confirmed and patients tested before any adjuvant treatment. The evaluation of the median FPSA/TPSA ratio in the two groups showed significantly different values (BPH group: 24.2%, PCa group: 12.1%, P < 0.0001). By R.O.C. (Receiver-Operating-Characteristics) analysis, we show that the FPSA/TPSA ratio is the method of choice for discriminating BPH and PCa, since the area under curve is the greatest for the FPSA/TPSA ratio curve, as compared to the TPSA or FPSA curves (P < 0.0001). The best accuracy (number of true positive + true negative/total = 82.4%) was obtained with a FPSA/TPSA ratio < or = 15% with high odds ratio (20.5; confidence interval (CI): 11.2; 37.7). Of interest, similar results were also confirmed even in the subpopulation with serum TPSA levels between 2.5 and 10 ng/ml (161 patients including 99 BPH and 62 PCa). We thus confirm that combined serum measurement of FPSA and TPSA is of particular interest in the early diagnosis of PCa for patients with non-suspicious digital rectal examination and a TPSA value between 2.5 and 10 ng/ml. In those patients, biopsy should be reserved to the cases with FPSA/TPSA below 15%, which allows significant odds ratio (12.8; CI: 5.2; 31.4). Otherwise, to avoid the risk of missing any PCa, usual follow-up with combined TPSA and FPSA determination would be required with the same criteria of biopsy (i.e. FPSA/TPSA ratio < or = 15% when TPSA value is between 2.5 and 10 ng/ml; or TPSA > 10 ng/ml).

Non-treatment of screened children with intermediate blood lead levels.

An aggressive screening and follow-up program for children at risk for lead poisoning was conducted by a nurse practitioner in a small family practice unit. Subsequent venous blood lead determinations untreated cases show the natural fall in lead level over 12 to 18 months. Many of these children would have been chelated by others, yet individualized, specific, personalized care by a nurse practitioner permitted monitoring without treatment even in persistently leaded environments. No chelation therapy was necessary until the third summer, when coincident with a long, hot, dry season, the city's abatement system because nonfunctional. Non-treatment requires close follow-up, a relatively small population, and cooperation from the city.

From guidelines to hospital practice: reducing inappropriate ordering of thyroid hormone and antibody tests.

OBJECTIVE: Because of major technical improvements and conscious care about cost effectiveness, limiting the inadequate use of thyroid biological tests appears to be a major issue. DESIGN: To (i) estimate the ordering prevalence of each thyroid test, (ii) assess the prevalence of relevant thyroid tests, and (iii) evaluate the impact of expressing justification for tests during a 2-month intervention period on these prevalences. METHODS: During a prospective 2-month survey (June-July 1997), all the request forms were divided into four groups of prescription: (1) investigation of thyroid function, (2) taking drugs affecting the thyroid, (3) monitoring of nodule and cancer, and (4) investigation of thyroid autoimmunity. Their appropriateness was thus determined according to consensus in our hospital and previously published recommendations. Results were compared with those of retrospective similar 2-month periods in 1996 and 1998. Combinations of thyroid function tests and thyroid antibodies were analyzed during the 1996, 1997 and 1998 periods. RESULTS: The overall estimated rate of appropriate ordering between 1996 and 1997 increased from 42.5% to 72.4% (P<10(-4)), with a significant improvement in each group of main diagnosis referral, except in group 3 where suitability was always over 85%. However, in group 4, appropriateness remained low (36%). Combinations of thyroid tests revealed an increase in single TSH order forms and single autoantibodies to thyroperoxidase (TPOAb) ones, while TSH+free thyroxine+free tri-iodothyronine and TPOAb+ autoantibodies to thyroglobulin ones decreased significantly. Interestingly, all these changes were maintained 1 year later (June-July 1998) even though physicians were not aware of this new study. CONCLUSIONS: Persistent change in medical practice was thus assessed.

All trans retinoic acid abrogates spontaneous monocytic growth in juvenile chronic myelomonocytic leukaemia.

INTRODUCTION: All trans retinoic acid, the active metabolite of vitamin A, exerts profound effects on cell differentiation. On normal myeloid progenitors, retinoids switch the differentiation program of granulo-macrophagic progenitors towards the granulocytic lineage and consequently reduce CFU-M colony formation. Bone marrow and peripheral blood mononuclear cells from children with Juvenile Chronic Myelomonocytic Leukaemia show typical spontaneous monocytic growth. We questioned whether in this disease, retinoids could switch myelomonocytic growth and inhibit the abnormal CFU-M colony proliferation. METHODS: Ten JCML samples were studied in the presence of ATRA in methyl cellulose colony assay, before (CFU-C) or after (pre-CFU) liquid suspension culture. RESULTS: In vitro characteristics of JCML such as spontaneous monocytic growth in the absence of growth factor was noted in all patients. In the presence of leucocyte-conditioned medium, nine samples showed only CFU-M growth and one sample CFU-GM growth. Incubation with ATRA inhibited CFU-M colony formation in nine cases. Enhancement of granulocytic differentiation (CFU-G) was noted in nine cases. ATRA also inhibited CD34+ JCML monocytic growth and GM-CSF hypersensitivity. CONCLUSION: These data suggest that, in JCML progenitors, retinoid pathways are functional and inhibition of immature monocytic progenitors cells may be achieved with retinoids, without impeding granulocytic cell growth.

Evaluation of total PSA assay on vitros ECi and correlation with Kryptor-PSA assay.

BACKGROUND: An increasing number of multiparametric immuno-analysers for PSA assays are available. As different immuno-assays may vary in their analytical quality and their accuracy for the follow-up of patients, expertise is necessary for each new assay. METHODS: The PSA assay on the Vitros-ECi analyser has been evaluated and compared with the PSA assay from the Kryptor analyser. RESULTS: Variation coefficients were 0.91 to 1.98% for within-run assays, and 4.2% to 5.4% for interassay (PSA levels = 0.8 microgram/L to 33.6 micrograms/L). Dilution tests showed 93 to 136% recovery until 70 micrograms/L PSA. Functional sensitivity was estimated at 0.03 microgram/L. Equimolarity of the test was confirmed. Correlation of PSA levels measured with Vitros-ECi and Kryptor analysers displayed a correlation coefficient r2 of 0.9716. The half-lives and doubling times of PSA were similar using both methods. CONCLUSION: Vitros-ECi PSA assay meets the major criteria for the management of prostate cancer patients.

[Chondromalacia patellae--arthrographic observations on the genesis and diagnosis of cartilaginous damage (author's transl)]. / Die Chondromalacia patellae--Arthrographische Beobachtungen zur Genese und Diagnose.

Thanks to recent advances in arthrography, diagnosis of cartilaginous lesions has increasingly become a task of the radiologist. An accurate assessment of the cartilage of the femoropatellar joint can be established via double-contrast technique and so-called "défilé" projections, whereas the axial projection of the patella without contrast medium shows only secondary arthrotic changes of bone and is unsuitable for demonstrating early cartilaginous damage. The classification of dysplastic patellae into different types according to Wiberg and Baumgartl yields a statistical correlation with the frequency of chondromalacia, but does not give any conclusive evidence in individual cases. A special influence on joint mechanics and the development of chondromalacia patellae is exercised by a cartilaginous ridge of the medial patellar facette.

[Current data on GM-CSF (Granulocyte-Macrophage Colony Stimulating Factor) in acute myeloid leukemia]. / Données actuelles sur les récepteurs du GM-CSF (Granulocyte-Macrophage Colony Stimulating Factor) dans les leucémies aiguës myéloïdes.

GM-CSF (Granulocyte-Macrophage Colony Stimulating Factor) activates neutrophil, eosinophil, granular, and macrophage precursors through binding to specific receptors. GM-CSF receptor is a member of the "cytokine receptor superfamily", which displays a particular transmembrane structure. It is expressed in small amounts on normal mature blood or medullary cells, with a high affinity. On acute myeloid leukemia blasts (18 patients), our results agree with the review of the literature: GM-CSF receptors are in small amounts, of two types (high and low affinity), with no relation to the FAB classification of leukemias.

[Experiences with a subcutaneous, fully resorbable bridge in construction a double loop ileo- and colostomy]. / Erfahrungen mit einem subcutanen, voll resorbierbaren Reiter bei der Anlage einer doppelläufigen Ileo- und Colostomie.

Our experience with the subcutaneous absorbable bridge for constructing a temporary loop ileostomy and loop colostomy is described. The use of this subcutaneous absorbable bridge in 15 patients - 6 with loop ileostomy and 9 with loop colostomy - was almost without complications. The absorbable bridge is a progress for maturation of the stoma and for immediate postoperative as prospective fitting of a watertight appliance. The actual trend substituting the temporary loop colostomy by the loop ileostomy may be advanced by the unlimited use of the subcutaneous absorbable bridge for constructing a temporary loop ileostomy.

[Problems of pelvic infection following rectopexy using synthetics and its treatment]. / Die Problematik der pelvinen Sepsis nach Rectopexie mittels Kunststoff und ihre Behandlung.

The complication of the infected Ivalon-sponge after rectopexy is described in five patients. In two patients the pelvic sepsis perforated spontaneously into the vagina and in another two patients the pelvic abscess perforated through the levator muscles into the ischio-rectal fossa formating a typical horse-shoe abscess in one case. The management of choice in cases of pelvic sepsis is the complete removal of the infected Ivalon-sponge. We personally prefer the laparotomy for the complete removal of the prosthesis and not the removal through the vagina or through the rectum.

[Intramedullary osteosynthesis of distal metacarpal fractures with curved wires]. / Die intramedulläre Osteosynthese distaler Metakarpalfrakturen mit gebogenen Drähten.

When intramedullary pinning is used to treat metacarpal fractures, as recently described by Förstner (1994) and Foucher (1995), the closed reduction technique developed by Jahss (1938) is applied in the same way as for conservative fracture treatment. It is not always possible to achieve complete anatomical reduction using this closed technique. The intramedullary pinning technique, that we have applied since 1989, involves a Kirschner wire which is bent at one end. Apart from reducing the fracture, the pre-set Kirschner wire serves as a butressing internal fixator. The elastic clamping of the wire acts as an internal wire spring splint, permitting early mobilisation. We have operated on 62 metacarpal fractures using the above-mentioned technique over a period of 6 years until 1995. Anatomic reduction was realized in 50 of 62 fractures. In the follow-up of 32 fractures, we noticed four complications: one infection, two paraesthesias, and one non-union.

[Screening for cancer of the prostate using prostate-specific antigen]. / Dépistage du cancer de la prostate par l'antigène spécifique de prostate.

Systematic screening for prostate cancer was carried out in 600 men over 50 years of age by the industrial medicine departments of four big companies in the Paris region. The exploratory methods included prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) assays, rectal palpation and two-dimensional transrectal ultrasonography. Biopsy of the prostate was performed either when the PSA level was above 5 ng/ml or when rectal palpation gave suspicious results, or when ultrasonography showed abnormal images. A total of 93 biopsies were performed, and 18 cases of cancer were detected. Eleven of these 18 patients underwent radical prostatectomy. The PSA assay, with an accepted limit of 5 ng/ml, detected 17 out of 18 cancers but was not very specific. The PAP assay had low sensitivity (only 5 positive results). Combined PAP assay and rectal palpation provided high sensitivity and good specificity. Transrectal ultrasonography was helpful only to determine the site of biopsy and the distribution of the lesions.

[Saphenous perforator flap]. / Der Saphenusperforatorlappen.

OBJECTIVE: Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery. INDICATIONS: Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated. CONTRAINDICATIONS: For patients, in whom a 1-2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised. SURGICAL TECHNIQUE: Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~ 10 cm (6-14 cm) proximal of the tip of the medial malleolus; base ~ 5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No "tunnelling "of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by "artificial skin". A gap in the bandage over the skin island allows for observation. POSTOPERATIVE MANAGEMENT: Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted. RESULTS: Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995-2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995-2006, 44/50 (88 %) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007-2011, 13/20 (65 %) flaps healed completely and 6/20 (30 %) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5 %).