[Autologous fascia pubovaginal slings in women with stress urinary incontinence at high risk of mesh/device-related complications]. / Bandelette aponévrotique pubovaginale pour incontinence urinaire d'effort chez les femmes à risque de complications prothétiques.

INTRODUCTION: Very popular in many parts of the world, autologous fascial pubovaginal sling (AFPVS) remains marginally used in France. However, it may be of particular interest in patients carrying a high risk of mesh-related or device-related related complications. The aim of the present series was to report the outcomes of AFPVS in this high-risk population. MATERIAL AND METHODS: The charts of all female patients who underwent a fascial sling for SUI at a single academic center between April 2019 and May 2021 were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI. Success was defined as complete resolution of SUI at 3 months. RESULTS: Sixteen patients were included in this study: 13 rectus fascia slings and 3 fascia lata slings. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). Two patients had major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%). Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%). CONCLUSION: The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes. LEVEL OF PROOF: 4.

Evaluation of arthroscopic skills with a virtual reality simulator in first-year orthopaedic residents.

PURPOSE: This study of residents' initial performance was performed to determine which factors predisposed residents for success in demonstrating the best arthroscopic skills. METHODS: Each orthopaedic first-year resident was officially invited to take part in a one hour evaluation on a VirtaMed™ ArthroS™ simulator. On the FAST module, the Periscoping exercise was chosen to test for use of angled optics. The Shoulder Module was chosen to test their ability to extract intra-articular foreign bodies using the Catch the Stars exercise. The variables such as time, camera alignment, camera path length, and grasper path length were analysed. Residents completed a questionnaire prior to the evaluation. Their results were analysed according to gender, orientation assessment, and surgical history. RESULTS: A total of 34 women and 82 men were included in the study. In the Periscoping exercise, a significant difference between women and men in the time variables was noticed (275 ± 82 and 195 ± 71; p < 0.00001) and camera path length (207 ± 60 and 170 ± 66; p = 0.00094). For the Catch the Stars exercise, there was a significant difference between women and men for the time values (249 ± 114 and 201 ± 99; p = 0.01246) and grasper path length (290 ± 130 and 229 ± 108; p = 0.00493). After multivariate analysis, no influence of self-assessed spatial perception (p=0.1), number of arthroscopic procedures (p=0.39), or laparoscopic procedures (p=0.43) to which they had already assisted was found. CONCLUSIONS: This study shows a significant difference in skills regarding spatial recognition and triangulation related to gender at the beginning of specialization training. It also demonstrates that male medical students are more attracted by surgical departments during their medical training.

Are ligament-tensioning devices interchangeable? A study of femoral rotation.

BACKGROUND: During total knee arthroplasty (TKA), femoral rotation can be adjusted either in relation to bony landmarks or by tensioning the ligaments with the knee in 90° of flexion. The primary objective of this study was to compare femoral rotations achieved using various ligament-tensioning devices. The secondary objective was to compare these femoral rotations to that indicated by the transepicondylar axis (TEA). MATERIAL AND METHODS: We performed 13 posterior-stabilised TKA procedures using HiFit (Ceraver(®)) on cadaver knees. Before performing the posterior condyle cut, we used an original method to measure the femoral rotation induced by five different ligament-tensioning devices (2 with a ratchet mechanism, 1 with screws, 1 force-sensing device, and 1 with spacer blocks) and the central tibio-femoral distance (CTFD). RESULTS: Both ratchet tensioners provided significantly greater mean external rotation values (P=0.002), of 4.94° and 4.46°, respectively, compared to the force-sensing and spacer tensioners. Significant differences were found across devices for CTFD, with a mean difference of about 2mm between the ratchet and screw tensioners versus the force-sensing and spacer tensioners. The mean differences in rotations obtained using the tensioners versus the TEA were close to 0° but with standard deviations greater than 4°. CONCLUSION: Femoral rotation was dependent on the distraction force applied to the joint. Tensioners that did not measure the distraction force were associated with greater distraction force and external rotation values. The TEA criterion did not reliably indicate good ligament balance. LEVEL OF EVIDENCE: Experimental study.

Predictors of failure for prosthetic joint infections treated with debridement.

OBJECTIVE: Prosthetic joint infections (PJI) may be cured in selected patients with debridement and prosthesis retention. We aimed to identify predictors of failure to better target patients most likely to benefit from this conservative strategy. METHODS: Observational study of patients presenting with PJI initially treated at our hospital with debridement between 2008 and 2011, with>6 months of post-treatment follow-up. RESULTS: Sixty consecutive patients presenting with PJI (hip, n=34; knee, n=26) fulfilled the inclusion criteria. Failures (n=20, 33%), predefined as persistence of PJI signs or relapses, were managed with additional surgery (n=17) and/or lifelong suppressive antibiotic treatment (n=6). Variables independently associated with failure: previous surgery on the prosthetic joint (OR: 6.3 [1.8-22.3]), Staphylococcus aureus PJI (OR: 9.4 [1.6-53.9]), post-debridement antibiotic treatment for <3 months (OR: 20.0 [2.2-200]). CONCLUSION: Previous surgery, S. aureus PJI, and short duration antibiotic treatment are associated with an increased risk of failure after debridement.

[Metastasizing primary duodenal cancer. Extended remission in a patient following chemotherapy]. / Metastasierendes primäres Duodenalkarzinom. Anhaltende Remission bei einem Patienten nach Chemotherapie.

Extended, especially metastatic primary duodenal cancer is thought to be of extraordinary bad prognosis, and is hardly to be influenced by chemotherapy. In the meantime we were able to achieve a 20-month lasting remission in a patient with metastatic duodenal cancer treated with the FAM-regime.

[Clinical and prognostic relevance of the Kiel classification of non-Hodgkin lymphomas]. / Klinische und prognostische Relevanz der Kiel-Klassifikation der Non-Hodgkin-Lymphome.

The Kiel classification provides a new subdivision of non-Hodgkin lymphomas into distinct entities showing different clinical and prognostic properties. In comparison with earlier classifications this system defines additional types of lymphoma (e.g. CC lymphoma, LP immunocytoma) (for abbreviations see text) which are to be considered separate entities also from a clinical point of view. By data derived from a multicenter prospective observation study (1,127 patients recruited from 1975 to 1980, follow-up until 1985) a precise definition of the clinical features of each lymphoma entity (e.g. frequency, age and sex distribution, patterns of initial involvement and spread of disease) was possible. In addition, the effect of radio- and/or chemotherapeutic measures was evaluated. Strictly localized disease (stage I/IE according to the Ann Arbor classification) occurred in 1.5 to 8% of patients with NHL of low-grade malignancy (comprising 69.4% of cases studied) and in 8 to 17% of patients with high-grade malignant NHL (comprising 30.2% of cases studied). Loco-regional irradiation alone was able to induce complete remission in 86 to 89% (CB and IB lymphomas) and in 100% (LP immunocytoma, CB-CC and CC lymphomas), respectively, of stage I/IE patients. Only CC and IB lymphomas showed a relevant risk of relapse (40% and 50%, respectively). Total lymphoid irradiation as able to induce stable complete remissions in about 50% of patients with stage III of CB-CC lymphoma. Probabilities of survival of patients with initial stages III and IV treated by several types of chemotherapy reflect different prognostic features of individual lymphoma entities.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and prognostic relevance of the Kiel classification of non-Hodgkin lymphomas results of a prospective multicenter study by the Kiel Lymphoma Study Group.

Clinical and prognostic relevance of the Kiel classification of non-Hodgkin lymphomas (NHL) was investigated in 1127 patients entering a prospective multicenter observation study. Survival of the 782 (69.4 per cent) patients with low-grade malignant NHL (lymphocytic lymphomas, predominantly B-CLL, LP immunocytoma, centrocytic lymphoma, centroblastic-centrocytic lymphoma) exceeded that of the 341 patients (30.2 per cent) with high-grade malignant NHL (centroblastic, immunoblastic, lymphoblastic lymphomas). Prognosis was best in centroblastic-centrocytic lymphoma and in B-CLL and least favorable in immunoblastic and lymphoblastic lymphomas. Survival of LP immunocytoma and centrocytic lymphoma patients was intermediate after 2 to 2.5 years of follow-up. Corresponding to histopathology, pattern of survival curves of low-grade malignant NHL (slow decline, no plateauing) differed from that of high-grade malignant NHL (rapid decline, subsequent plateauing). Prognosis of B-CLL was superior to that of LP immunocytoma. Stages I and II were more frequent in centroblastic-centrocytic lymphoma (21 per cent) than in LP immunocytoma (2.5 per cent) and centrocytic lymphoma (11 per cent). Ability of radiotherapy to induce stable complete remissions in stage III of centroblastic-centrocytic lymphoma indicates prolonged restriction of lymphoma to the lymphatic system. In immunoblastic and centroblastic lymphomas, stages I and II were diagnosed in 34 and 38 per cent of cases, respectively, but only in stage I/IE of centroblastic lymphoma prolonged remissions were achieved by radiotherapy. In advanced high-grade malignant NHL marked improvement of prognosis was solely possible by induction of complete remissions whereas in corresponding low-grade malignant lymphomas also partial remissions were prognostically relevant.

Algorithm for a DNA-cytophotometric diagnosis and grading of malignancy.

An algorithm for processing data on nuclear DNA content obtained cytophotometrically was developed (1) to obtain an objective discrimination between benign and malignant lesions in conventional cytologic smears secondarily stained according to Feulgen and (2) to obtain an objective degree of tumor malignancy on a continuous scale of malignancy grades. Investigations in 258 malignant tumors (95 malignant lymphomas, 52 uterine cervix carcinomas, 28 prostate carcinomas, 18 breast carcinomas, 45 malignant bone tumors and 19 larynx carcinomas) and in 74 benign lesions in these organs yielded a diagnostic accuracy of no false-positive, no false-negative and 21% suspicious diagnoses. The probability that "suspicious" cases were malignant was 81%. The overall diagnostic accuracy for non-negative cases thus amounted to 100%. Results in 95 patients with different malignant lymphomas and in 16 patients with squamous-cell carcinoma of the larynx demonstrated the prognostic validity of the DNA-grading system.

Studies on various parameters influencing leukemic cell destruction by alkyl-lysophospholipids.

Critical parameters of alkyl-lysophospholipid (ALP) induced destruction of freshly isolated human leukemic cells have been evaluated. The destructive activity of ALP is shown to be competitively inhibited by metabolizable lysophospholipids added to the cultures. It has also been found that destruction depends on the amount of serum present. Temperature and Ph strongly influence the cytotoxic activity of ALP. A slight decrease in temperature causes a reduction in cell death, whereas a temperature increase results in a marked potentiation. At low pH ALP cytotoxicity is inhibited. Incubation of cells with combinations of ALP and other cytotoxic drugs revealed a striking cytotoxic synergism with vinca-alkaloids, whereas corticosteroids retarded ALP induced cell destruction.

Lymphoplasmacytic/lymphoplasmacytoid lymphoma: a clinical entity distinct from chronic lymphocytic leukaemia?

Clinical data of 116 patients with chronic lymphocytic leukaemia (CLL) and of 114 patients with lymphoplasmacytic/lymphoplasmacytoid lymphoma (synonym: LP immunocytoma, IC) as diagnosed according to the Kiel classification were compared. This interim evaluation of a prospective multicenter study of the Kiel Lymphoma Study Group characterizes IC the less favorable lymphoma entity as evidenced by a more rapid lymph node enlargement, by a higher incidence of constitutional symptoms and of marked anaemia, and by a higher percentage of patients requiring early treatment. In addition, in IC autoimmune haemolytic anaemia was detected in 11.2% of investigated patients as compared to none of the patients with CLL, and monoclonal gammopathy was disclosed in 34.2% of investigated patients as compared to only three patients with CLL who could be, however, unrecognized cases of IC. Actuarial survival data after a follow-up period of 40 months are in favor of an overall better prognosis of patients with CLL than of patients with IC.

Germinal center cell lymphomas: prognostic significance of their histopathological differentiation.

Clinical data of 48 patients with centrocytic, 83 patients with centroblastic/centrocytic and 64 patients with centroblastic lymphoma who had entered a prospective multicenter study of the Kiel Lymphoma Study Group since October 1975 were compared. Advanced (stage IV) disease at time of diagnosis, predominantly due to bone marrow infiltration, was most frequent in centrocytic (69% of patients) and in centroblastic/centrocytic (51% of patients) lymphomas as compared to only 28% of patients with centroblastic lymphoma. High survival probability of patients with localized centrocytic and centroblastic/centrocytic lymphomas after radiotherapy, contrasting with a worse prognosis of corresponding patients with centroblastic lymphoma, is compatible with the classification of these lymphoma entities as neoplasias of low-grade malignancy. However, as shown by this prospective and previous retrospective trials overall survival probability of patients with advanced centrocytic lymphoma was inferior to that observed in corresponding patients with centroblastic/centrocytic lymphoma. These findings suggest the possibility that patients with advanced centrocytic lymphoma occupy an intermediate position between typical low-grade and typical high-grade malignant non-Hodgkin lymphomas.

Clinical and prognostic heterogeneity of non-Hodgkin lymphomas of high-grade malignancy.

Comparison of clinical data of 64 patients with centroblastic lymphoma, 55 patients with immunoblastic lymphoma and 31 patients with lymphoblastic lymphoma not only confirmed the original assumption of high-grade malignancy as proposed by the concept of the Kiel classification but also demonstrated distinct clinical differences, particularly between lymphoblastic lymphoma and the two other entities. Rapid lymph node enlargement as well as steep fall of survival curves within the first year after diagnosis were common characteristics. Bimodal age distribution, predominance of males and early generalization of disease were typical features of lymphoblastic lymphoma; elderly patients and patients with the unclassified subtypes of lymphoblastic lymphoma exhibited the worst prognosis. Whereas patients with centroblastic and immunoblastic lymphomas showed similar distribution of age, sex and initial stage of disease, patients with immunoblastic lymphoma presented more frequently with a reduced performance status and showed a poorer response to radio- and chemotherapy resulting in a worse prognosis discernible after the first year of follow-up. Generalization during course of the disease was significantly more frequent in immunoblastic than in centroblastic lymphoma.

Deep vein thrombosis treated with streptokinase or heparin. Follow-up of a randomized study.

Twenty-seven patients with deep vein thrombosis whose primary therapy was randomized between streptokinase and heparin were reevaluated clinically and by ascending venography after a mean period of 7 months. Normal venograms were found in 6 (40%) of the streptokinase-treated patients and in 1 patient (8%) who had heparin therapy. Segmental valve preservation was found in 1 patient from each group. All patients with complete or partial valve preservation became asymptomatic. Vein recanalization without preservation of valves occurred in 18 patients: 8 (54%) of those on streptokinase, and 10 (83%) of those on heparin. At the time of follow-up, 11 of these 18 patients, including 8 who had had prior thrombosis, reported peripheral edema; the postphlebitic syndrome developed in 1. Factors favoring a good outcome of acute venous thrombosis were (1) no prior thrombotic disease, (2) localized thrombosis, and (3) prompt streptokinase therapy.

Healing of deep venous thrombosis: venographic findings in a randomized study comparing streptokinase and heparin.

Sequential ascending venographic studies were used to assess the healing of deep venous thrombosis in 50 patients randomly assigned to streptokinase or heparin therapy. Various degrees of thrombolysis and/or recanalization were demonstrated by venograms performed on the fourth and tenth days of treatment. Late follow-up studies (mean, 7 months after treatment) showed three basic patterns of resolution: (1) return to normal, (2) complete recanalization, and (3) incomplete recanalization and/or collateralization. Loss of valves or their function was associated with recanalization. The character, speed, and outcome of healing reflected the nature and extent of thrombosis, prior thrombotic disease in the extremity, and the type and timing of treatment. Streptokinase was highly effective and preferable to heparin in patients with deep vein thrombosis when therapy was begun within 4 days of onset of symptoms. In later stages of acute or recurrent deep vein thrombosis, the effectiveness of both drugs was significantly reduced.

Deep vein thrombosis treated with streptokinase or heparin. A randomized study.

Randomly assigned streptokinase or heparin therapy was studied in 50 patients with deep vein thrombosis of less than 2 weeks' duration. Venography was performed prior to therapy, after 3 days, and after 10 days. Two radiologists who were unaware of the patient's therapy compiled a single average lytic score for each patient at each time interval. Lysis of venous thrombi was significantly greater with streptokinase than with heparin after 3 days, but not after 10 days of treatment. Lytic scores achieved with streptokinase were significantly better than those achieved with heparin therapy (P less than .01) in male patients who were symptomatic for 3 days or less. In females, regardless of the duration of symptoms, thrombolytic results obtained with streptokinase were not significantly different than results obtained with heparin.

Comparison of heparin and streptokinase in the treatment of venous thrombosis.

Heparin or streptokinase was administered in a prospective randomized fashion to 50 patients with phlebographically confirmed venous thrombosis of the extremities of 14 days or less duration. A total of 49 patients completed the investigative protocol with 26 receiving heparin and 23 receiving streptokinase. All patients were evaluated with sequential phlebograms. Complete thrombolysis with restoration of venous valve function occurred in one of 26 patients receiving heparin and in six of 23 patients receiving streptokinase. Fifty per cent of the patients treated with streptokinase with a total duration of symptoms of three days or less achieved complete lysis. The total incidence of therapeutic complications was similar in the two groups, but was more severe in the streptokinase treated patients.