Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery

BackgroundWhen feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection.MethodsA Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines.Results5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications.ConclusionAlthough 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.     

Anterolateral Ligament of the Knee: Diagnosis,Indications, Technique,Outcomes

In the context of anterior cruciate ligament reconstruction surgery, anterolateral ligament reconstruction is now recognized as a reliable option to control rotatory instability and should be considered in the knee surgeon's modern armamentarium. By highlighting its daily practical application, this infographic presents the indications for this specific additional lateral augmentation, the anatomic and biomechanical principles that underline its rationale, and the clinical outcomes from recent large series.In 2013, Claes et al. updated the anterolateral ligament (ALL) concept, and numerous subsequent studies detailed its precise anatomy. It is now accepted that the femoral insertion is located proximal and posterior to the epicondyle. The biomechanical behavior of the ALL during the knee flexion path has been reported to provide control of tibial internal rotation during the pivot shift and with increasing knee flexion angles (>35). Clinically, when a patient presents with an anterior cruciate ligament (ACL) injury, clinical examination (pivot shift test), radiography (Segond fracture), ultrasound, and 3-dimensional magnetic resonance imaging are useful to assess a combined ALL injury.The following indications for ALL reconstruction are now well established: ACL revision, high-grade pivot shift test, chronic ACL rupture, young patients, pivoting activities, and patients undergoing medial meniscus repair. It has been reported that anatomic and minimally invasive surgical techniques that control anterolateral rotatory instability can achieve successful outcomes without specific complications. Finally, the addition of ALL reconstruction does not delay postoperative rehabilitation, and no modification is required for an early rehabilitation protocol.     

Do patients with cystic fibrosis participating in clinical trials demonstrate placebo response? A meta-analysis

BackgroundPatients' and families' expectation that a cure for cystic fibrosis (CF) will be found is high. In other debilitating conditions, high expectation has been shown to drive a strong placebo response (PR). Therefore, our goal was to evaluate PR on objective continuous outcomes (FEV₁, BMI) and the CF Questionnaire Revised-Respiratory Domain (CFQR-RD) monitored during randomised clinical trials (RCTs) for CF.MethodsWe conducted a meta-analysis after a systematic review of the literature carried out to identify RCTs with FEV₁, CFQR-RD and BMI as outcome measures. The standardised mean difference (SMD) was calculated to estimate the PR. A meta-regression analysis was conducted to assess other contributing factors on PR such as study design, trial duration, patient age and disease severity.ResultsOut of 289 RCTs found in the search, we identified 61 articles (published from 1987 to 2017) with respectively 59, 17 and 9 reporting FEV₁, CFQR-RD and BMI at the start and at the end of the RCTs. No significant PR was found on FEV₁ or CFQR-RD. However, a small but significant PR was found on BMI SMD, 0.09 (95% CI (0.01; 0.17); p = 0.03).ConclusionThe PR seems higher when measuring BMI. However, it is not clear whether this improvement can be explained by a PR alone.