Reconstruction of a neurocutaneous defect of the proximal phalanx with a heterodigital arterialised nerve pedicle flap

BackgroundComplex digital injuries involving soft-tissue loss and digital nerve defect pose a challenging problem for hand surgeons. The purpose of this study was to evaluate the efficacy of transferring the heterodigital arterialised nerve pedicle flap for reconstructing the digital neurocutaneous defects and to compare the results with those of transferring the cross-finger flap and secondary nerve grafting.MethodsFrom March 2008 to September 2011, the nerve pedicle flap was used in 12 patients who had a combination of soft-tissue and digital nerve defects. The injured fingers included four index, four long, three ring and one little finger. The mean size of the soft-tissue losses was 2.4 × 1.9 cm (range, 2.3 × 1.3 to 3.2 × 2.0 cm). The mean flap size was 2.6 × 2.1 cm (range, 2.5 × 1.5 to 3.4 × 2.2 cm). The length of the nerve defects ranged from 1.5 to 3.8 cm (mean, 2.8 cm). The nerve defect was reconstructed with transfer of the digital nerve dorsal branch. For comparison, we collected a series of 24 patients with similar defects treated with the cross-finger flap and secondary free nerve grafting.ResultsSignificant differences were found between the two groups in static two-point discrimination (p < .01) and pain (p = .03) in the reconstructed finger. In comparison, the study group presented better discriminatory sensation on the finger pulp and lower incidence of pain sensibility in the injured finger. There was no significant difference in cold intolerance and Semmes–Weinstein monofilament. In the study group, the total active motion of the donor fingers was similar to that of the opposite hands.ConclusionsThe heterodigital arterialised nerve pedicle flap is useful and reliable for reconstructing the neurocutaneous defects in the proximal phalanx. Comparable sensory recovery and lower pain incidence can be achieved using our nerve pedicle flap instead of conventional nerve grafting.Type of study/level of evidenceTherapeutic II.     

Bilaterally innervated dorsal digital flap for sensory reconstruction of digits

BackgroundProviding sensory coverage in digits continues to be a challenging problem. This study reports the sensory reconstruction of digits with bilaterally innervated dorsal digital flaps and compares the results between dual- and single-innervated flaps.MethodsOver 7 years, a retrospective study was conducted with 73 patients who had soft-tissue defect of the digit treated with the bilaterally innervated dorsal digital flap. There were 73 soft-tissue defects in 73 digits. The size of the defects ranged from 1.8 to 2.7 cm in length (mean, 2.2 cm) and from 1.6 to 2.2 cm in width (mean, 1.9 cm). The bilateral dorsal branches of the digital nerves were attached with the flap for the sensory reconstruction of digits. Reconstructive techniques included the cross-finger flap in 35 cases, the dorsal digital island flap in 24 cases, and the dorsal digital free flap in 14 cases. To objectively evaluate the efficacy of the bilaterally innervated flaps, we selected a comparison group that included 42 patients treated with the single-innervated flap.ResultsA significant difference was found between the dual- and single-innervated flaps in two-point discrimination, pain, Tinel's sign, and patient satisfaction results. By comparison, the dual-innervated flap presented better discriminatory sensation on the flap, lower incidence of pain and Tinel's sign, and a larger degree of satisfaction than the single-innervated flap. Of the dual-innervated flap group, the mean joint motion of the donor finger was similar to that of the opposite side.ConclusionsThe bilaterally innervated dorsal digital flap is a reliable alternative for the sensory reconstruction of digits. Performing double neurorrhaphies can improve flap sensation and reduce digital neuroma incidence when reconstructing a soft-tissue defect associated with both transected digital nerves.     

Sensory reconstruction in different regions of the digits: A review of 151 cases

BackgroundSoft tissue defects of the digits are very common in hand trauma and can result in functional disability. The purpose of the study is to introduce the use of several modified and traditional sensate flaps to reconstruct different regions of the digits and to evaluate the efficacy of these techniques.MethodsA retrospective study was conducted with 151 patients who had soft tissue defects of the digits treated with the sensate flaps from February 2005 to March 2014. Based on different regions of the soft tissue defects, the patients in the study were divided into four groups [1]: thumb group treated with the dual-innervated and traditional kite flaps [2]; distal finger group treated with the single- and dual-innervated dorsal digital flaps [3]; proximal finger group treated with the heterodigital neurocutaneous island flap; and [4] awkward region group treated with the Litter flap. The main outcomes were static 2PD and Semmes-Weinstein monofilament scores of the flap, pain and patient satisfaction.ResultsSignificant difference was found between dual-innervated and traditional kite flaps, and between single- and dual-innervated dorsal digital flaps in static 2PD, pain and patient satisfaction (P < 0.05). Double nerve repairs presented better discriminatory sensation on the flap, lower incidence of pain in the injured digit and larger satisfaction degree than single nerve repair.ConclusionsCompared to single-innervated flap, dual-innervated flap exhibited better sensory recovery and lower pain incidence. Being an additional treatment option, Littler flap may be better choice for sensory coverage in some specific situations including border injuries.     

Repair of multiple finger defects using the dorsal homodigital island flaps

Background

Providing soft-tissue coverage for multiple finger defects remains a challenge for the hand surgeons. This article reports reconstruction of multiple digital defects using the dorsal homodigital island flaps based on the dorsal branch of the digital artery.

Methods

Over 3 years, a retrospective study was conducted with 12 patients who had multiple finger defects treated with the dorsal homodigital island flaps. Our series included nine male and three female patients. There were 30 soft-tissue defects in 30 fingers. The injured fingers included seven index, nine long, nine ring and five little fingers. The average size of soft-tissue defects and flaps was 2.4 ± 0.4 cm × 1.7 ± 0.2 cm and 2.6 ± 0.4 cm × 1.9 ± 0.2 cm, and the mean pedicle length was 1.1 ± 0.2 cm.

Results

Full flap survival was achieved in 26 fingers. Partial distal flap necrosis was noted in four fingers, which healed without surgical intervention. At a median of 20 (range, 19–23) months’ follow-up, the static two-point discrimination on the flap averaged 9.1 ± 1.6 mm, and the median (range) Semmes–Weinstein monofilament score was 3.84 (3.84–4.17). The donor-site morbidity was accepted. According to the Michigan Hand Outcomes Questionnaire, seven patients were strongly satisfied and five were satisfied with functional recovery of the reconstructed fingers.

Conclusions

The dorsal homodigital island flap, based on the dorsal branch of the digital artery, is less invasive, versatile and technically easy for simultaneous coverage of small-to-moderate defects in multiple fingers.     

Cemented K-wire fixation for the treatment of shaft fractures of middle phalanges

BackgroundThe objective of this report is to introduce an external-fixation technique using the combination of K-wires and cement.MethodsFrom February 2009 to January 2015, 51 patients with shaft fractures of middle phalanges were treated with cemented K-wire fixation. The mean age of patients at surgery was 41 years. The mean time interval from injury to operation was 6 ± 5.78 days. Injured digits included index (n = 18), long (n = 15), ring (n = 7), and little (n = 11) fingers. Types of fractures were transversal (n = 32), short oblique or spiral (n = 5), and comminuted (n = 14) fractures. Active range of motion of the fingers was measured. Total active motion was scored based on the American Society for Surgery of the Hand. All measurements were compared with those on the opposite fingers. Patients also reported on their satisfaction using the 100-mm visual analogue scale.ResultsAt the final follow-ups of 2 years, range of motion of metacarpophalangeal joint, proximal phalangeal joint, and distal interphalangeal joint reached 97% ± 2.88, 93% ± 6.65, and 96% ± 3.22 of the opposite fingers, respectively. Based on Total active motion scoring system, we obtained 36 excellent and 15 good results. Based on VAS, patient satisfaction was 96 ± 3.44.ConclusionsThe cemented K-wire fixation is a reliable technique for the treatment of shaft fractures of middle phalanges. The technique is a minimally invasive procedure with minimal complications.Level of evidenceTherapeutic study, Level IVa.     

Long-term sensation in the medial plantar flap: A two-centre study

BackgroundReconstruction in the foot and ankle region is challenging. This study aimed to quantify objective sensation return when a sensate medial plantar flap is used for like-for-like reconstruction of foot and ankle defects.MethodsTwo-point discrimination (2PD) was assessed in flap and normal tissue at a minimum of 1 year post-operatively. A paired T-test assessed for significance.Results8 patients were included. Mean 2PD in normal tissue and flap was 29 mm (SD: 11.9) and 33 mm (SD: 9.97) respectively with no statistically significant difference between the two (two-tailed p-value: 0.1898). Mean age was 53.2 years (range: 15–84). There was no statistically significant correlation between age and 2PD in flap tissue (r = 0.6, p = 0.15).ConclusionsThis is the largest case series of its kind. Our results suggest that sensation in medial plantar flaps can return to near normal and demonstrate the important role the medial plantar flap plays in soft tissue reconstruction in this region.     

When does intraoperative 3D-imaging play a role in transpedicular C2 screw placement?

IntroductionThe stabilization of an atlantoaxial (C1-C2) instability is demanding due to a complex atlantoaxial anatomy with proximity to the spinal cord, a variable run of the vertebral artery (VA) and narrow C2 pedicles. We perfomed the Goel & Harms fusion in combination with an intraoperative 3D imaging to ensure correct screw placement in the C2 pedicle. We hypothesized, that narrow C2 pedicles lead to a higher malposition rate of screws by perforation of the pedicle wall. The purpose of this study was to describe a certain pedicle size, under which the perforation rate rises.Patients and methodsIn this retrospective study, all patients (n = 30) were operated in the Goel & Harms technique. The isthmus height and pedicle diameter of C2 were measured. The achieved screw position in C2 was evaluated according to Gertzbein & Robbin classification (GRGr).ResultsA statistically significant correlation was found between the pedicles size (isthmus height/pedicle diameter) and the achieved GRGr for the right (p = 0.002/p = 0.03) and left side (p = 0.018/p = 0.008). The ROC analysis yielded a Cut Off value for the pedicle size to distinguish between an intact or perforated pedicle wall (GRGr 1 or ≥2). The Cut-Off value was identified for the isthmus height (right 6.1 mm, left 5.4 mm) and for the pedicle diameter (6.6 mm both sides).ConclusionThe hypothesis, that narrow pedicles lead to a higher perforation rate of the pedicle wall, can be accepted. Pedicles of <6.6 mm turned out to be a risk factor for a perforation of the pedicle wall (GRGr 2 or higher). Intraoperative 3D imaging is a feasible tool to confirm optimal screw position, which becomes even more important in cases with thin pedicles. The rising risk of VA injury in these cases support the additional use of navigation.     

Reconstruction of a soft tissue defect in the finger using the heterodigital neurocutaneous island flap

Background

This article describes reconstruction of a soft tissue defect in the finger using the heterodigital neurocutaneous island flap and reports the results of the use of the flap.

Methods

From February of 2008 to March of 2011, the neurocutaneous island flap was used in 12 patients with soft tissue defects in the middle phalanx or the proximal interphalangeal joint, or both. The injured fingers included 4 index, 3 middle, 3 ring and 2 little fingers. The donor fingers included 7 middle fingers and 5 ring fingers. The mean size of soft tissue defects and the flaps was 2.4 cm × 1.8 cm and 2.7 cm × 2.0 cm, respectively. The mean pedicle length was 2.8 cm.

Results

Full flap survival was achieved in 11 cases. Partial distal flap necrosis was noted in one case, which healed without surgical intervention. At a mean follow-up of 22 months, the mean static 2-point discrimination and Semmes-Weinstein monofilament scores on the flap were 8.3 mm and 3.94, respectively. Based on the modified American Society for Surgery of the Hand guidelines for stratification of 2-point discrimination, 10 (83%) of 12 flaps achieved good results. According to the Michigan Hand Outcomes Questionnaire, 5 patients were strongly satisfied and 7 were satisfied with functional recovery of the reconstructed finger.

Conclusions

The neurocutaneous island flap of the dorsal branch of the digital nerve is useful, reliable, and technically easy for reconstructing a defect in the adjacent fingers, especially when sensory reconstruction is needed.     

Reconstruction of two fingertip amputations using a double thenar flap and comparison of outcomes of surgery using a single thenar flap

BackgroundAlthough thenar flap for single fingertip amputation is a common and popular surgical technique, double thenar flap technique for patients with two fingertip amputations has rarely been reported in the literature. The purpose of this case-control study was to introduce the double thenar technique and compare the clinical outcomes between single thenar flap and double thenar flap surgical treatments.MethodsFrom January 2005 to December 2014, 92 patients with single fingertip amputations were treated with thenar flap (Group I) and 28 patients with two fingertip amputations were treated with double thenar flap (Group II). These 120 patients were followed-up for a minimum of 12 months postoperatively. At the latest follow-up, the two groups were assessed for pain, cold intolerance in the reconstructed finger, functional outcomes by Chen’s criteria, and subjective patient satisfaction.ResultsAt the final follow-up, all flaps in both groups had survived. No flap failure occurred. There was no significant difference in cold intolerance (p = 0.783), donor site pain (p = 0.728), fingertip pain (p = 1.000), or paresthesia (p = 0.514) between the two groups. A total of 100 (83.3%) patients were completely or fairly satisfied. There was no significant difference in satisfaction between the two groups (p = 0.801). According to the Chen criteria, 102 (85%) patients had excellent or good results.ConclusionThis study demonstrated that the double thenar flap technique used for patients with two fingertip amputations produced complete survival with functional outcomes comparable to those of the single thenar flap technique at the last follow-up.     

Matrix-associated stem cell transplantation (MAST) in chondral defects of foot and ankle is effective

BackgroundThe aim of the study was to assess the feasibility and clinical results of matrix-associated stem cell transplantation (MAST) and 2-year-follow-up in chondral defects of foot and ankle.MethodsIn a prospective, consecutive, non-controlled clinical follow-up study, all patients with chondral defects, that were treated with MAST from April 1st to November 30th, 2009 were analyzed. The size and location of the chondral defects, method-associated problems and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were registered and analyzed.ResultsTwenty-six chondral defects in 25 patients were included in the study. The mean age of the patients was 33 years (range, 16–48 years), 18 (72%) were male. The VAS FA before surgery was 49.2 on average (range, 24.3–68.4). The defects were located as follows: medial talar shoulder, n = 9; lateral talar shoulder, n = 13 (medial and lateral talar shoulder, n = 1); distal tibia, n = 1; posterior calcaneal facet, n = 1; head of 1st metatarsal, n = 2. The defect size was 1.1 cm² on average (range, .5–6 cm²). All patients completed 2-year-followup. No complications or consecutive surgeries were registered. The mean VAS FA at follow-up was 94.5 (range, 73.4–100; t-test, p < .01).ConclusionsMAST led to good clinical scores. No complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects. The main advantage of MAST in comparison with ACI and MACI is the single procedure methodology. The advantage in comparison with AMIC is the potential higher concentration of stem cells.     

Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience

PurposeThe management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases.MethodsAll pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU).Resultsn = 27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n = 8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n = 7 had headache, n = 4 had ataxia, and n = 2 had impaired level of consciousness. In the unruptured group N (n = 19), n = 7 patients had headache, n = 6 patients had focal neurological deficit, n = 4 patients had tinnitus, n = 3 (had ataxia, and one presented with seizure. n = 24 patients were treated by endovascular therapy (EVT), n = 2 patients were treated by microsurgery (MS) and n = 1 patient was managed with a combined approach. Re-treatment was necessary in n = 6 patients. n = 24 patients showed total exclusion at last FU. n = 2 patients died during the first 30 days; n = 1 patient died during FU.ConclusionsWhile EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.     

CT-guided biopsy of lung nodules with pleural contact: Comparison of two puncture routes

PurposeThe purpose of this study was to retrospectively compare two puncture routes (transpleural vs. transpulmonary) for computed tomography (CT) fluoroscopy-guided cutting needle biopsy of lung nodules with pleural contact.Patients and methodsA total of 102 patients (72 men; mean age, 71.1 ± 9.5 [SD] years) were included and 102 biopsies of 102 lung nodules (mean size, 16.7 ± 5.9 [SD] mm; range, 6.0–29.4 mm; mean length of pleural contact, 10.1 ± 4.2 [SD] mm; range, 2.8–19.6 mm) were analyzed. All procedures were classified as biopsies via the direct transpleural route or the transpulmonary route. The patient-, lesion-, and biopsy-related variables, diagnostic yields, and incidence of complications were compared between the two routes.ResultsBiopsy was performed via the direct transpleural route (n = 59; 57.8%) and transpulmonary route (n = 43; 42.2%). In the transpulmonary route group, the mean distance of the intrapulmonary pathway was 17.7 ± 9.4 [SD] mm (range: 4.1–47.6 mm; P < 0.001) and the introducer needle trajectory angle of < 45° was significantly observed (8.5% [5/59] vs. 60.5% [26/43]; P < 0.001). There was no significant difference in diagnostic accuracy between the direct transpleural and transpulmonary routes (93.2% [55/59] vs. 90.7% [39/43]; P = 0.718). The frequencies of all complications (64.4% [38/59] vs. 97.7% [42/43]; P < 0.001), pneumothorax (33.9% [20/59] vs. 65.1% [28/43]; P = 0.003), pneumothorax with chest tube placement (3.4% [2/59] vs. 18.6% [8/43]; P = 0.016), and pulmonary hemorrhage (47.5% [28/59] vs. 76.7% [33/43]; P = 0.004) were significantly lower in the direct transpleural group.ConclusionDirect transpleural route is recommended for CT fluoroscopy-guided biopsy of lung nodules with pleural contact because it is safer and yields similar diagnostic accuracy than transpulmonary route.     

Minimally invasive radiologic techniques in the treatment of uretero-enteric fistulas

ObjectivesThe goal of this study was to assess the efficacy of minimally invasive interventional radiologic (IR) techniques in the management of uretero-enteric fistulae in comparison to established surgical modalities.Materials and methodsTwenty-five patients (16 men, 9 women) with a mean age of 47 (range: 19–77 years) with uretero-enteric fistulae were treated with percutaneous nephrostomy, double “J” stent, radiologic uretero-neocystostomy, and radiologic uretero-pyelocalicostomy. All patients had a single fistula each. Uretero-enteric fistulas were due to direct or iatrogenic trauma in 14 patients (uretero-ileal fistulas, n = 6; uretero-colonic fistulas, n = 4; uretero-duodenal fistulas, n = 2; uretero-pancreatic fistula, n = 1; uretero-fallopian tube, n = 1), complications of pelvic neoplasms in 4 patients (uretero-sigmoid fistulas, n = 4), inflammatory disease in 4 patients (uretero-ileal fistulas, n = 2; uretero-sigmoid fistulas, n = 2), and avascular necrosis of renal transplants in 3 patients (uretero-sigmoid fistulas, n = 3).ResultsDrainage by percutaneous nephrostomy and double “J” stent resulted in closure of 8 uretero-enteric fistulae over 7–16 weeks. Four uretero-enteric fistulae obliterated after re-routing urine flow using 3 radiologic uretero-neocystostomies and one IR pyelocalicostomy. In other patients, flow through the fistulae was substantially decreased by five double “J” stents and 3 percutaneous nephrostomies. The duration of inpatient hospitalization was significantly less for patients managed successfully by IR procedures than those treated by surgical modalities, 5.07 versus 10.5 days mean (P < 0.05).ConclusionsIR procedures provided definitive treatment in 48% of uretero-enteric fistulae at significantly reduced inpatient hospitalization and cost. As palliative treatment, it improved the quality of life.     

Day case endourology in surgical outpatient clinic at Ibadan: A 5 year review

ObjectiveTo review our day case endourological practice over a five-year period.Subjects and methodsData was obtained from the endourology day case register and these were analysed using simple statistical methods. Caudal anaesthesia and intravenous sedatives were used for the procedures.ResultsA total of 559 patients underwent endoscopic procedures as day cases. Their ages ranged from 10 to 88 years, with a male to female ratio of 4 to 1. Four hundred and thirty eight (78.4%) were diagnostic and 121 (21.6%) were therapeutic. The main diagnostic procedures were urethrocystoscopy (n = 222), and cystoscopy alone (n = 116), cystoscopy and biopsy (n = 46) while the therapeutic procedures were direct visual internal urethrotomy (n = 86), endoscopic cystolitholapaxy (n = 10), and rigid retrograde endoscopic realignment (n = 7) for posterior urethral injury. The main anaesthesia was caudal block in 472 patients and topical 2% xylocaine jelly with sedation in 86 patients.ConclusionsThere is a steady increase in therapeutic day case endourology. Caudal anaesthesia provides effective pain free procedure to the patient. Surgical trainees can benefit by learning the technique of caudal block anaesthesia.     

Breast cancer in women under 40 years of age: A series of 57 cases from Northern Ireland

BackgroundThere are few studies examining breast cancer in women under the age of 40 years, particularly in western European populations. Such tumours are reported to be more aggressive, possibly due to a different pathophysiology compared to older patients.MethodsWe performed a retrospective review of all women less than 40 years of age, diagnosed or treated with breast cancer, from June 2001 to June 2007 to assess pathophysiological factors that may influence clinical outcome and prognosis including patient demographics, clinical presentation, pre-operative investigations, surgical and pathological findings, treatment and outcome.ResultsFifty-eight women (mean age 34.9 years, range 27–39 years) were identified. One patient was excluded due to incomplete data; 98.2% (n = 56) patients presented directly to our symptomatic clinic; 89.5% (n = 51) patients had a palpable lump; 71.9% (n = 41) patients had no family history. Mammography was less sensitive than ultrasound (64.3% vs. 82.4%) while fine needle aspiration cytology was 92.5% sensitive for malignancy. Twenty-nine (50.9%) patients underwent breast-conserving surgery (BCS) of which 7 proceeded subsequently to completion mastectomy due to involved margins. Twenty-six (45.6%) patients required total mastectomy primarily while 2 (3.5%) patients were treated palliatively due to metastatic disease. The mean tumour size (nearest resection margin) was 2.13 cm (2.58 mm) for BCS and 3.95 cm (6.38 mm) for mastectomy. From a total of 55 primary resections, 85.5% (n = 47) of tumours were invasive ductal carcinoma; 57.4% (n = 31) and 40.7% (n = 22) were grade II and III tumours respectively. Lymphovascular invasion was identified in 50.9% (n = 28) while 40.0% (n = 22) were lymph node positive for metastatic disease. 76.8% (n = 43), 39.3% (n = 22) and 30.2% (n = 16) were oestrogen, progesterone and human epidermal growth factor receptor-2 positive respectively. The mean Nottingham prognostic index was 4.37 (range 2.2–8.4). Neo-adjuvant and adjuvant chemotherapy was administered to 9.3% (n = 5) and 80.0% (n = 44) of surgically treated patients respectively while 76.4% (n = 42) patients received adjuvant radiotherapy. 76.4% (n = 42) of patients were treated with tamoxifen. Four patients received Herceptin® therapy. Statistically significant univariate factors adversely associated with overall survival were time from referral to out-patient department attendance (p = 0.038), administration of neo-adjuvant treatment (p = 0.019), surgical intervention (p < 0.001), progesterone receptor positivity (p = 0.018) and tumour recurrence (p < 0.001). 86.0% (n = 49) patients were alive at mean follow-up of 52 months; 82.5% (n = 47) remain disease free.ConclusionOur study reports a low familial trait rate combined with a high proportion of hormonally active tumours less than grade III which suggests that breast cancer in this series of young women from Northern Ireland may be less aggressive and more hormonally responsive than anticipated.     

New biologics and targeted therapies in systemic lupus: From new molecular targets to new indications. A systematic review

IntroductionDespite available therapies, persistently active and corticosteroid-dependent Systemic Lupus Erythematosus (SLE) represent a significant therapeutic challenge. The purpose of this systematic review was to provide an updated view of targeted therapies currently in clinical development in SLE, with a special focus on the most promising ones.MethodsWe performed a systematic review of targeted therapies in clinical development in SLE in clinicaltrials.gov (search date: 28th of August 2022). Targeted therapies (defined as drugs specifically designed to block certain molecules, receptors, or pathways involved in the development of SLE) were extracted. For each investigational drug, we considered only the study at the most advanced stage of clinical development.ResultsThe systematic review yielded a total of 92 targeted therapies (58 biological DMARDs [bDMARDs] and 34 targeted synthetic [ts]DMARDs) assessed in a total of 203 clinical trials. The candidate drugs reached phase I (n = 20), Ia/IIb (n = 6), phase II (n = 51), phase II/III (n = 1), phase III (n = 13) and phase IV (n = 1). These trials were reported as recruiting (n = 31), active but not recruiting (n = 8), not yet recruiting (n = 4), enrolling by invitation (n = 2), completed (n = 31), prematurely terminated (n = 12) and withdrawn in 1 (status unknown in 3). The main investigational drugs for SLE target inflammatory cytokines, chemokines or their receptors (n = 19), intracellular signaling pathways (n = 18), B cells (n = 14) or plasma cells (n = 7), T/B cells co-stimulation molecules (n = 10), complement molecules (n = 5), T lymphocytes (n = 2), plasmacytoid dendritic cells (n = 2), as well as various other immune targets (n = 15).ConclusionThe pipeline of investigational drugs in SLE is highly diversified and will hopefully enable more optimal Treat-To-Target with the goal of disease modification. Companion biomarkers will be needed to better characterized SLE heterogeneity and optimize treatment selection at the individual-patient level.     

Efeitos de dexmedetomidina em conjunto com o pré‐condicionamento isquêmico remoto em lesão de isquemia‐reperfusão renal em ratos

Background and objectivesThe aim of this study was to evaluate the effects of remote ischemic preconditioning by brief ischemia of unilateral hind limb when combined with dexmedetomidine on renal ischemia–reperfusion injury by histopathology and active caspase‐3 immunoreactivity in rats.Methods28 Wistar albino male rats were divided into 4 groups. Group I (Sham, n = 7): Laparotomy and renal pedicle dissection were performed at 65th minute of anesthesia and the rats were observed under anesthesia for 130 min. Group II (ischemia–reperfusion, n = 7): At 65th minute of anesthesia bilateral renal pedicles were clamped. After 60 min ischemia 24 h of reperfusion was performed. Group III (ischemia–reperfusion + dexmedetomidine, n = 7): At the fifth minute of reperfusion (100 μg/kg intra‐peritoneal) dexmedetomidine was administered with ischemia–reperfusion group. Reperfusion lasted 24 h. Group IV (ischemia–reperfusion + remote ischemic preconditioning + dexmedetomidine, n = 7): After laparotomy, three cycles of ischemic preconditioning (10 min ischemia and 10 min reperfusion) were applied to the left hind limb and after 5 min with group III.ResultsHistopathological injury scores and active caspase‐3 immunoreactivity were significantly lower in the Sham group compared to the other groups. Histopathological injury scores in groups III and IV were significantly lower than group II (p = 0.03 and p = 0.05). Active caspase‐3 immunoreactivity was significantly lower in the group IV than group II (p = 0.01) and there was no significant difference between group II and group III (p = 0.06).ConclusionsPharmacologic conditioning with dexmedetomidine and remote ischemic preconditioning when combined with dexmedetomidine significantly decreases renal ischemia–reperfusion injury histomorphologically. Combined use of two methods prevents apoptosis via active caspase‐3.     

Fibroadenoma: Can fine needle aspiration biopsy avoid short term follow-up?

ObjectiveTo confirm whether fine needle aspiration biopsy (FNAB) can avoid close monitoring, a source of worry for women patients with a suspected fibroadenoma found by ultrasound, and requiring their compliance.Patients and methodsOver 39 months, 427 nodules with a diagnosis of fibroadenoma were sampled in 372 patients using ultrasound-guided FNAB. The sonographic appearance of all the nodules suggested BI-RADS category 3 fibroadenomas. The mean size of the fibroadenomas was 9 mm. The mean duration of follow-up was 29.7 months.ResultsSeven nodules had atypical cytology: a microbiopsy and/or excision found a simple fibroadenoma (n = 3), mastitis (n = 1), a fibroadenoma associated with a papilloma (n = 1), fibrosis (n = 1) and normal tissue (n = 1). Seven other nodules were resected during treatment for synchronous cancer, and were diagnosed as fibroadenomas. Two hundred and seventy-six nodules were followed-up (121 patients were lost to follow-up [n = 132]) and the appearance of 263 nodules (95.29%) was stable. Seven nodules, which had increased in size, underwent another FNAB or microbiopsy or surgery. Five nodules were not found again. The borders of one nodule showed modifications.ConclusionThe use of fine needle aspiration biopsy, interpreted by an experienced cytologist, means that short term follow-up of fibroadenomas can be avoided.     

Surgical management of posterior fossa medulloblastoma in children: The Lyon experience

IntroductionModern approach for the treatment of posterior fossa medulloblastomas remains a challenge for pediatric neurosurgeons and pediatric oncologists and requires a multidisciplinary approach to optimize survival and clinical results.Material and methodsWe report the surgical principles of the treatment of posterior fossa medulloblastomas in children and how to avoid technical mistakes especially in very young patients. We also report our experience in a series of 64 patients operated from a medulloblastoma between 2000 and 2018 in Lyon.ResultsAll patients had a craniospinal MRI. Eighty-one percent of the patients (n = 50) had strictly midline tumor while 19% (n = 14) had lateralized one. Eleven percent (n = 7) had metastasis at diagnosis on the initial MRI. Forty-one percent (n = 29) had an emergency ETV to treat hydrocephaly and the intracranial hypertension. All patient underwent a direct approach and a complete removal was achieved in 78% (n = 58) of the cases on the postoperative MRI realized within 48 h postsurgery. Histological findings revealed classical medulloblastoma in 73% (n = 46), desmoplastic medulloblastoma in 17% (n = 11) and anaplastic/large cell medulloblastoma in 10% (n = 7). Patients were classified as low risk in 7 cases, standard risk in 30 cases and high risk in 27 cases.Ninety-six percent (n = 61) of the patient received radiotherapy. Seventy-six percent (n = 48) received pre-irradiation or adjuvant chemotherapy. At last follow-up in December 2018, 65% (n = 41) of the patient were in complete remission, 12% (n = 8) were in relapse and 27% (n = 15) had died from their disease. The overall survival at five , ten and fifteen years for all the series was of 76%, 73% and 65.7% respectively.ConclusionsMedulloblastomas remain a chimiosensible and radiosensible disease and the complete surgical removal represents a favorable prognostic factor. The extension of surgery has also to be weighted in consideration of the new biomolecular and genetic knowledge that have to be integrated by surgeons to improve quality of life of patients.     

Introduction of the use of a pediatric PICC line in a French University Hospital: Review of the first 91 procedures

PurposeIn order to assess the establishment of a pediatric PICC line service in a University Hospital after the first 91 consecutive procedures.Materials/Patients and methodsRetrospective study over a period of 24 months. The criteria analysed were success or failure of the procedure, indication, age when inserted, type of PICC line, mean length of use and development of complications such as accidental removal, venous thrombosis or infection.ResultsNinety-one PICC lines were inserted in 74 patients between 4 months and 25 years old (sex-ratio: 1.1 girls/boys). The procedure was performed under general anaesthesia in four cases (4.4%) and under EMLA and MEOPA in 87 cases (95.6%). The insertion was ultrasound guided through the basilic (n = 63, 70%), humeral (n = 18, 20%) or cephalic (n = 9, 10%) veins in the non-dominant arm (L in 62 cases, R in 28 cases). The insertion success rate was 99% (n = 90). The main indications were starting antibiotic therapy (n = 47, 52%), chemotherapy (n = 34, 38%) and parenteral nutrition (n = 5, 5%). The devices used were single lumen 3F (n = 4, 4%), single lumen 4F (n = 31, 34%), double lumen 4F (n = 2, 2.2%), single lumen 5F (n = 12, 13%), and double lumen 5F (n = 41, 45%). The PICC line was used for an average period of 45 days (14 to 300 days). The complications found were accidental removal (n = 2, 2.2%), catheter fracture (n = 2; 2.2%), obstruction (n = 5, 5.5%), suspected infection (n = 1, 1.1%), and venous thrombosis and pulmonary embolism (n = 3, 3.3%). The overall complication rate was 14.4% (n = 13) including 4.4% serious complications (n = 4).ConclusionPICC lines are a future solution in pediatrics. This technique is reliable and has a similar complication rate to studies carried out in adults, most of which can be prevented by careful catheter maintenance and informing the care staff.