CD4 cell count at initiation of ART, long-term likelihood of achieving CD4 >750 cells/mm3 and mortality risk

OBJECTIVES

We sought to evaluate associations between CD4 at ART initiation (AI), achieving CD4 >750 cells/mm(3) (CD4 >750), long-term immunological recovery and survival.

METHODS

This was a prospective observational cohort study. We analysed data from ART-naive patients seen in 1996-2012 and followed ≥3 years after AI. We used Kaplan-Meier (KM) methods and log-rank tests to compare time to achieving CD4 >750 by CD4 at AI (CD4-AI); and Cox regression models and generalized estimating equations to identify factors associated with achieving CD4 >750 and mortality risk.

RESULTS

Of 1327 patients, followed for a median of 7.9 years, >85% received ART for ≥75% of follow-up time; 64 died. KM estimates evaluating likelihood of CD4 >750 during 5 years of follow-up, stratified by CD4-AI <50, 50-199, 200-349, 350-499 and 500-750, were 20%, 25%, 56%, 80% and 87%, respectively (log-rank P < 0.001). In adjusted models, CD4-AI ≥200 (versus CD4-AI <200) was associated with achievement of CD4 >750 [adjusted HR (aHR) = 4.77]. Blacks were less likely than whites to achieve CD4 >750 (33% versus 49%, aHR = 0.77). Mortality rates decreased with increasing CD4-AI (P = 0.004 across CD4 strata for AIDS causes and P = 0.009 for non-AIDS death causes). Among decedents with CD4-AI ≥50, 56% of deaths were due to non-AIDS causes.

CONCLUSIONS

Higher CD4-AI resulted in greater long-term CD4 gains, likelihood of achieving CD4 >750, longer survival and decreased mortality regardless of cause. Over 80% of persons with CD4-AI ≥350 achieved CD4 >750 by 4 years while 75% of persons with CD4-AI <200 did not. These data confirm the hazards of delayed AI and support early AI.

Performance of ACMG-AMP Variant-Interpretation Guidelines among Nine Laboratories in the Clinical Sequencing Exploratory Research Consortium

Evaluating the pathogenicity of a variant is challenging given the plethora of types of genetic evidence that laboratories consider. Deciding how to weigh each type of evidence is difficult, and standards have been needed. In 2015, the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology (AMP) published guidelines for the assessment of variants in genes associated with Mendelian diseases. Nine molecular diagnostic laboratories involved in the Clinical Sequencing Exploratory Research (CSER) consortium piloted these guidelines on 99 variants spanning all categories (pathogenic, likely pathogenic, uncertain significance, likely benign, and benign). Nine variants were distributed to all laboratories, and the remaining 90 were evaluated by three laboratories. The laboratories classified each variant by using both the laboratory's own method and the ACMG-AMP criteria. The agreement between the two methods used within laboratories was high (K-alpha = 0.91) with 79% concordance. However, there was only 34% concordance for either classification system across laboratories. After consensus discussions and detailed review of the ACMG-AMP criteria, concordance increased to 71%. Causes of initial discordance in ACMG-AMP classifications were identified, and recommendations on clarification and increased specification of the ACMG-AMP criteria were made. In summary, although an initial pilot of the ACMG-AMP guidelines did not lead to increased concordance in variant interpretation, comparing variant interpretations to identify differences and having a common framework to facilitate resolution of those differences were beneficial for improving agreement, allowing iterative movement toward increased reporting consistency for variants in genes associated with monogenic disease.

A retrospective review in the management of T3 laryngeal squamous cell carcinoma: an expanding indication for transoral laser microsurgery

BACKGROUND

The purpose of this study was to evaluate the functional and oncological outcomes of patients treated for T3 laryngeal squamous cell carcinoma. Specifically comparing transoral laser microsurgery and radiotherapy/chemoradiotherapy treatment modalities.

METHOD

A retrospective review of patients treated for T3 laryngeal SCC between 2002 and 2010 was undertaken.

RESULTS

Forty-nine patients were included. 15 cases were glottic, (9 treated with TLM, 6 with RT/CRT), 33 supraglottic (6 treated with TLM, 27 with RT/CRT) and 1 subglottic subsite (treated with RT/CRT). There was no statistical difference between treatment groups for 24 month locoregional control (72.3 %), overall survival (glottis 86.7 %, supraglottic 70.4 %) and disease specific survival (glottic 93.3 % and supraglottic 74.1 %). Overall laryngeal preservation (84.9 %) was also similar in both groups.

CONCLUSION

Our institution is expanding the application of TLM to selected patients with T3 laryngeal carcinoma. Oncological outcomes have not been jeopardized by this approach and the treatment is well tolerated by patients with few complications.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis

BACKGROUND

In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps.

METHODS

Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution.

RESULTS

Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group.

CONCLUSIONS

We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.

Illustrative case studies in the return of exome and genome sequencing results

Whole genome and exome sequencing tests are increasingly being ordered in clinical practice, creating a need for research exploring the return of results from these tests. A goal of the Clinical Sequencing and Exploratory Research (CSER) consortium is to gain experience with this process to develop best practice recommendations for offering exome and genome testing and returning results. Genetic counselors in the CSER consortium have an integral role in the return of results from these genomic sequencing tests and have gained valuable insight. We present seven emerging themes related to return of exome and genome sequencing results accompanied by case descriptions illustrating important lessons learned, counseling challenges specific to these tests and considerations for future research and practice.

Actionable exomic incidental findings in 6503 participants: challenges of variant classification

Recommendations for laboratories to report incidental findings from genomic tests have stimulated interest in such results. In order to investigate the criteria and processes for assigning the pathogenicity of specific variants and to estimate the frequency of such incidental findings in patients of European and African ancestry, we classified potentially actionable pathogenic single-nucleotide variants (SNVs) in all 4300 European- and 2203 African-ancestry participants sequenced by the NHLBI Exome Sequencing Project (ESP). We considered 112 gene-disease pairs selected by an expert panel as associated with medically actionable genetic disorders that may be undiagnosed in adults. The resulting classifications were compared to classifications from other clinical and research genetic testing laboratories, as well as with in silico pathogenicity scores. Among European-ancestry participants, 30 of 4300 (0.7%) had a pathogenic SNV and six (0.1%) had a disruptive variant that was expected to be pathogenic, whereas 52 (1.2%) had likely pathogenic SNVs. For African-ancestry participants, six of 2203 (0.3%) had a pathogenic SNV and six (0.3%) had an expected pathogenic disruptive variant, whereas 13 (0.6%) had likely pathogenic SNVs. Genomic Evolutionary Rate Profiling mammalian conservation score and the Combined Annotation Dependent Depletion summary score of conservation, substitution, regulation, and other evidence were compared across pathogenicity assignments and appear to have utility in variant classification. This work provides a refined estimate of the burden of adult onset, medically actionable incidental findings expected from exome sequencing, highlights challenges in variant classification, and demonstrates the need for a better curated variant interpretation knowledge base.

[The effect of platelet-rich plasma on graft healing in reconstruction of the anterior cruciate ligament of the knee joint: prospective study]

PURPOSE OF THE STUDY Growth factors produced by platelets enhance tissue healing. The aim of this study was to confirm or disprove the hypothesis that, in anterior cruciate ligament (ACL) reconstruction, the application of platelet-rich plasma (PRP) into the tibial and femoral tunnels and in the graft enhances graft maturation and graft-bone interface healing and thus improves knee function at 3 and 12 months post-operatively in comparison with the control group. MATERIAL AND METHODS A total of 40 patient had the surgery; 20 underwent single-bundle hamstring reconstruction with PRP application (PRP group) and 20 had the same surgery without PRP addition (control group). A 5 ml amount of PRP was obtained from the patient's peripheral blood. A graft inserted in the bone tunnels was fixed with interference screws and, after intra-articular fluid aspiration, 1 ml of PRP was injected into each tunnel and 3 ml were evenly applied to the intra-articular portion of the graft. The patients were examined by MRI at 3 and 12 months after surgery. The subsidence of swelling in the tunnelsurrounding tissues was taken as a sign of graft-bone interface healing, and increased signal intensity of the graft was considered as a result of its ligamentisation. The knee functional status was evaluated at 3 and 12 post-operative months, using the scoring systems (Cincinnati score, IKDC score). RESULTS Bone swelling was found at 3 post-operative months in 18 of 20 patients in both the PRP and the control group. Graft signal intensity was increased in most patients (19 of the PRP group; 18 control patients; p = 0.949). The Cincinnati score at 3 months had an average value of 72.7 (34-100; SO, 18.7) in the PRP group and 73.4 (42-99; SO, 16.3) in the control group (p = 0.793). The functional score after 12 months improved to 97.5 (75-100; SO, 12.8) in the PRP group and to 95.1 (66-100; SO, 13.1) in the control group; there was no significant difference between the groups (p = 0.885) at either 3 or 12 months. The IKDC score showed similar results. At 12 months bone swelling was recorded in seven out of 20 patients in the PRP group and in nine patients in the control group (p = 0.751). Graft signal intensity was increased in three and four patients of the PRP and control groups, respectively (p = 0.681). There was a statistical difference between the findings at 3 and 12 months within each group, but no difference between the groups. DISCUSSION In ACL reconstruction, the process of tendon graft-to-bone healing has several stages involving inflammation, cell proliferation and graft ligamentisation. At each stage, an important role is played by growth factors produced by thrombocytes, and therefore their potential use in the treatment of injuries to ligaments and tendons has recently come into focus. A number of experimental studies dealing with the effect of platelet-rich plasma on soft tissue healing has been published. Therefore, the method of using PRP to enhance graft healing in ACL reconstruction in humans is still being studied. CONSLUSIONS The use of PRP in ACL reconstruction does not accelerate graft remodelling and bone ingrowth into the tendon. The function scoring results showed a statistically significant improvement in knee function between 3 and 12 months of followup within each group studied but revealed no difference between the groups. The hypothesis postulated above was disproved. Key words: anterior cruciate ligament, platelet-rich plasma, anatomic single-bundle reconstruction.

Illustrative case studies in the return of exome and genome sequencing results

Whole genome and exome sequencing tests are increasingly being ordered in clinical practice, creating a need for research exploring the return of results from these tests. A goal of the Clinical Sequencing and Exploratory Research (CSER) consortium is to gain experience with this process to develop best practice recommendations for offering exome and genome testing and returning results. Genetic counselors in the CSER consortium have an integral role in the return of results from these genomic sequencing tests and have gained valuable insight. We present seven emerging themes related to return of exome and genome sequencing results accompanied by case descriptions illustrating important lessons learned, counseling challenges specific to these tests and considerations for future research and practice.

[The effect of central anatomical single-bundle versus anatomical double-bundle reconstruction of the anterior cruciate ligament on knee stability. a clinical study]

PURPOSE OF THE STUDY A comparison of the efficacy of central anatomical single-bundle (CASB) reconstruction with that of double-bundle (DB) repair of the anterior cruciate ligament (ACL) in relation to knee stability in anteroposterior translation (APT), internal rotation (IR) and external rotation (ER) of the joint. MATERIAL AND METHODS A total of 40 patients were evaluated; 20 had ACL reconstruction by the CASB technique using hamstrings and 20 underwent DB repair surgery. The average age was 31.3 years, and the group included 22 men and 18 women with 19 right and 21 left knees. The KT-1000 test was used to assess the amount of APT in the knee and rotational deviations were measured by the Rolimeter. In the DB patients, measurements were performed before surgery (on joints with ACL injury), then after reconstruction of the anteromedial (AM) or the posterolateral (PL) bundle and subsequently after repair of both ACL bundles. The CASB patients were assessed before and after graft insertion. RESULTS The average APT value was 18.5 mm for the pre-operative knees and it fell to 8.9 mm after AM bundle reconstruction. However, when the PL bundle was inserted in the first place, the average APT value was 13.1 mm only. The average values recorded after the DB and CASB reconstructions were 6.1 mm and 9.1 mm, respectively. The average IR range of motion in the pre-operative joints was 18.6 degrees. After AM bundle reconstruction it was 13.9 degrees and after PL bundle repair it was 15.3 degrees. In DB reconstruction the average IR value achieved 10.4 degrees, and in CASB repair surgery it was 13.7 degrees. The average ER range of motion in the pre-operative joints was 17.8 degrees. After AM bundle reconstruction it was 14.5 degrees and after PL bundle repair it was 14.9 degrees. In DB reconstruction the average ER value achieved 11.4 degrees, and in CASB repair surgery it was 14.5 degrees. DISCUSSION Rotational stability of the knee after ACL reconstruction is one of the most important factors in restoring physiological kinematics of the joint after ACL injury. Since there are not many studies comparing knee rotational stability after CASB with that after DB reconstructions, the results presented here may contribute to selecting the optimal method of ACL reconstruction. CONCLUSIONS The results show that, in ACL reconstruction, the DB technique provides better stability to the knee, in both APT and rotation, than the CASB method. The latter has the same effect on knee stability as the presence of the AM bundle alone. When the PL bundle is added, knee stability, in both APT and internal/external rotation, is increased in comparison with central single-bundle ACL repair. Key words:anterior cruciate ligament, navigation, central anatomical single-bundle reconstruction, double-bundle reconstruction.

[Tangent sign - a reliable predictor of risk for tendon re-rupture in rotator cuff repair]

PURPOSE OF THE STUDY

Repair techniques for rotator cuff injury are currently well advanced. However, the risk of re-rupture, particularly when severe damage to the tendons has been repaired, is still high. The causes of failure can be due to the extent of injury, a repair done on a highly degenerated tendon with diminished viability or ischaemic damage to the tendon tissue resulting from suture material. The aim of the study was to ascertain the reliability of the tangent sign, a commonly used indicator of the degree of suprasupinatus muscle atrophy, in the prediction of risk for tendon re-rupture in the post-operative period.

MATERIAL AND METHODS

In 2011 the rotator cuff torn tendons were repaired by the method of double-row suture in 37 patients. The surgery was done by an open technique using the deltoid-splitting approach. A pre-operative magnetic resonance image (MRI) of the shoulder was obtained in all patients and each was assessed by a competent independent radiology specialist with a focus on the extent of a tendon lesion and the tangent sign. At 2-year follow-up, the results of repeated MRI were evaluated in view of the state of repaired tendons and, if a re-tear was found, its relation to the original suture and its extent in the sagittal plane were determined. The pre- and post-operative MRI findings were compared to find out how the presence or absence of a tangent sign before surgery relates to the incidence of supraspinatus tendon re-rupture at 2 years after surgery. The results were statistically analysed using Student's t-test and the Chi-square test.

RESULTS

Of the 37 shoulders, in the pre-operative period, a tangent sign was identified in 21 (56.8%). The average size of a rotator cuff tear was 29.3 mm for the whole group. For the shoulders with no tangent sign, the average value was 21.8 mm, for those with a tangent sign present, it was 39.6 mm. At 2-year follow-up, no tear was found in the patients in whom preoperative MRI showed no tangent sign while re-tears were recorded in 18 of 21 shoulders (85.7%) with a tangent sign present before surgery. On the average, the re-rupture had 40.8 mm in size and, in all cases, it occurred at the site of tendon re-insertion into the greater tubercle. These results were statistically significant (p < 0.01).

DISCUSSION

In repair of injury to the tendons of the rotator cuff muscles, emphasis is currently placed on a thorough pre-operative examination. MRI is an important part of the diagnostic procedure because it provides a detailed image of the muscle as a whole. Although great advances have recently been made in both the diagnostic and surgical techniques, the incidence of tendon re-rupture within a few years of the procedure is still high.

CONCLUSION

Our results show that the presence of a tangent sign detected by pre-operative MRI examination of the shoulder can be an important predictor of failure in rotator cuff repair and can also turn attention to the selection of an alternative technique to be used.

Treatment of extra-articular and simple articular distal radial fractures with intramedullary nail versus volar locking plate

The purpose of this prospective, randomized and blinded study was to compare the clinical outcomes of distal radial fractures treated with either an intramedullary nail or a volar locking plate. Sixty two patients were enrolled in the study and randomized to treatment with a MICRONAILTM (Group 1, 31 patients) or an adaptive plate (Group 2, 31 patients). Fracture types included were unstable extra-articular metaphyseal distal radial fractures and simple or multifragmentary sagittal articular distal radial fractures (AO classification types A2, A3, B1.1 and B1.2). All patients were evaluated at 6 weeks, 3 months and 12 months after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist scores. We concluded that treatment of this subset of distal radius fractures with minimally invasive intramedullary nailing gives better clinical outcomes at 6 weeks after surgery than treatment with a volar locking plate. By 3 and 12 months following surgery, there are no significant differences in outcome between the two treatment methods. Disadvantages of the MICRONAIL™ fixation system include risk of injury to the superficial branch of the radial nerve and a narrower spectrum of indications than volar locking plates.

[Hinged external fixation in orthopaedic and trauma surgery of the elbow]

PURPOSE OF THE STUDY

A hinged external fixator of the elbow provides stable fixation of the joint while maintaining the range of its motion. The aim of the study was to evaluate a group of patients in whom an external fixator was used to manage severe injuries to the elbow, namely, traumatic unstable dislocation, unstable fracture-dislocation, and elbow fractures not permitting management by primary osteosynthesis. This also involved assessment of early elbow mobilisation and a comparison of this group with a group of patients treated conservatively for less severe elbow injuries.

MATERIAL AND METHODS

A group of 25 patients were evaluated at a follow-up of 18 months. There were 10 women and 15 men; the average age was 48 years (range, 20 to 76). The external fixator was applied in 13 patients, of whom eight had unstable elbow dislocation, three had unstable fracture-dislocation and two suffered a comminuted supracondylar fracture of the distal humerus. The hinged fixator was removed at an average of 7.6 weeks (range, 3 to 9 weeks). In the group of 12 patients treated conservatively by plaster cast application and subsequent rehabilitation, five had elbow dislocation without ligament injury and seven had elbow dislocation with ulnar collateral ligament injury. None of them showed any instability. The patients were evaluated on the basis of clinical and radiological findings, with the Mayo elbow performance (MEP) score being used for clinical assessment.

RESULTS

At a follow-up of 18 months, the patients with the external fixator showed the average range of motion at the elbow joint of 127° (105° to 140°), the MEP score of 92 points (75 to 100) and restriction of elbow extension by 8° (0° to 40°). In the conservatively treated patients, the range of motion was 133° (112° to 145°), the MEP score was 95 points (85 to 100) and extension restriction by 8° (0° to 22°). X-ray examination showed a congruent joint in both groups. The use of external fixator was associated with minor complications: transient radial nerve irritation in one case, and pin-tract infection in two cases (23%) which healed spontaneously after screw removal.

DISCUSSION

The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent consequence of severe elbow injury.

CONCLUSIONS

Elbow injuries differ from patient to patient and therefore the approach to their treatment has to be individual in every patient. A hinged external fixator provides stable fixation and allows for early movement of the elbow. Maintenance of the range of motion facilitated by the hinged fixator is not at the expense of joint stability or fracture non-union. Based on the results presented here, we recommend the use of external fixation in severe unstable elbow fractures and in fractures in which primary osteosynthesis cannot be used because of soft tissue injury.

[Computer-assisted kinematic 2D and 3D navigation in medial opening-wedge high-tibial valgus osteotomy]

PURPOSE OF THE STUDY

The aim of the study was to assess the accuracy of axis deformity correction achieved by high-tibial valgus osteotomy either without or with a computer-assisted kinematic navigation system, on the basis of comparing the planned and the achieved frontal axis of the leg. Comparisons of mechanical axis deviation were made using both pre- and post-operative measurements with the planning software and intra-operative measurements with the navigation system before and after osteotomy. In addition, the aim was to test the hypothesis that the use of 3D navigation, as compared with 2D navigation, would help reduce changes in the tibial plateau slope

MATERIAL AND METHODS

In the period 2008-2011, high-tibial osteotomy was performed in 68 patients. Twenty-one patients (group 1) underwent osteotomy without the use of navigation and 47 patients (group 2) had osteotomy with a computer-assisted navigation system (32 with 2D navigation and 15 with 3D navigation). Using the planning software, the mechanical leg axis before and after surgery and the anatomical dorsal proximal tibial angle in the sagittal plane were assessed. Medial openingwedge high-tibial valgus osteotomy was carried out in all patients. When using 2D navigation, the mechanical leg axis was measured intra-operatively before osteotomy and then after osteosynthesis which included a simulated axial load of the heel. When using 3D navigation, the procedure was identical and furthermore involved a measurement of the tibial plateau slope obtained with an additional probe in the proximal fragment. The results were characterised using descriptive statistics and their significance was evaluated using the Mann-Whitney U test and Wilcoxon's test, with the level of significance set at p < 0.05.

RESULTS

In group 1, osteotomy resulted in good correction of the mechanical axis in nine patients (43%), inadequate correction in nine (43%) and overcorrection and three (14%) patients. In group 2 with the use of navigation, accurate correction of the mechanical leg axis was achieved in 24 patients (51%), undercorrection was recorded in 21 (45%) and overcorrection in two (4%) patients. The difference in outcomes between the two groups was not statistically significant (p = 0.73). The average correction of the mechanical axis based on comparing measurements on pre- and post-operative radiographs was 9.1 degrees (range, 5-27 degrees); the average correction of the axis visualised intra-operatively was 8.7 degrees (range, 4-27 degrees). The difference was not significant (p = 0.1615) and confirmed our hypothesis that the accuracy of measuring the mechanical axis was not influenced by the method used. The average change in the dorsal slope of the tibial plateau following osteotomy without navigation was 0.9 degrees (range, -8.9 to 9.0 degrees) and that after osteotomy with intra-operative visualisation of the proximal tibial slope was 0.3 degrees (range, -4 to 4 degrees). This difference was not statistically significant (p = 0.813).

DISCUSSION

A good clinical outcome of high-tibial valgus osteotomy depends on achieving accurate correction of the mechanical leg axis with partial load transfer to the lateral compartment of the knee.

CONCLUSIONS

Although the number of cases with good correction was slightly higher in the patients undergoing osteotomy with navigation, the difference was not significant. Intra-operative visualisation of the mechanical axis proved sufficiently accurate on comparison with the pre-operative planning based on weight-bearing radiography of the leg. A simulated axial load of the heel included in the kinematic navigation system does not sufficiently correspond to normal weight-bearing and therefore an undercorrection of the deformity might occur. Using 3D navigation had no marked effect on a change in the slope of the tibial plateau.