Estimation of Excess Deaths in Turin from COVID-19 and other causes, October to November 2020

Introduction

Understanding the effect of COVID-19 on mortality during this emergency and evaluating unexplained increases in deaths due to nonspecific outcomes can provide a more complete picture of this period and give better instrument to deal with the pandemy in the future.

Objective

The aim is to evaluate in the city of Turin the excess in the number of deaths from October to November 2020.

Methods

The number of excess deaths was defined as the difference between the deaths observed in the pandemic period of 2020 and the deaths expected for the years 2014-2019.

Results

There were approximately 2047 total all causes deaths in Turin October 1 to November 30 2020, representing 630 more deaths than would typically be expected at that time of year. This excess was higher between men than in women. The number of excess all cause death was higher in 80 years old, less evident between 60-79 years old and very few between under 60 years old. Regarding the place of death, the number of excess all cause death was higher in hospital or in some health institutions for old people. Regarding the causes of deaths the explanation of these excess of deaths was COVID-19 infection only for a part of deaths and there are some excess of deaths not caused by COVID-19. The cause of excess of death not COVID-19 seems to be due to cardiovascular diseases, respiratory diseases, psychiatric disorders, neurological diseases, diabetes or nephrological diseases and to other undefinited causes.

Conclusions

The results showed during pandemic an increase of mortality respect to the expected mortality. Only a part of this excess deaths is due to COVID-19 but there is a relevant percentage of excess of deaths apparentely not due to COVID-19 but probably due to other causes. A better knowledge of these phenomena could help to improve any gaps in territorial assistance and provide indications for the future management of the pandemic in Europe.

Key messages

Increase of mortality in pandemic respect to the expected mortality. There is an excess of deaths apparentely not due to COVID-19.

Mature tertiary lymphoid structures predict immune checkpoint inhibitor efficacy in solid tumors independently of PD-L1 expression

Only a minority of patients derive long-term clinical benefit from anti-PD1/PD-L1 monoclonal antibodies. The presence of tertiary lymphoid structures (TLS) has been associated with improved survival in several tumor types. Here, using a large-scale retrospective analysis of three independent cohorts of cancer patients treated with anti-PD1/PD-L1 antibodies, we showed that the presence of mature TLS was associated with improved objective response rate, progression-free survival, and overall survival independently of PD-L1 expression status and CD8+ T-cell density. These results pave the way for using TLS detection to select patients who are more likely to benefit from immune checkpoint blockade.

Spinal cord injury: A multisystem physiological impairment/dysfunction

Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.

Granulosa cells provide elimination of apoptotic oocytes through unconventional autophagy-assisted phagocytosis

STUDY QUESTION

Do human granulosa cells (GCs) ingest and destroy apoptotic oocytes?

SUMMARY ANSWER

Somatic GCs ingest and destroy apoptotic oocytes and other apoptotic substrates through unconventional autophagy-assisted phagocytosis.

WHAT IS KNOWN ALREADY

Most (99%) ovarian germ cells undergo apoptosis through follicular atresia. The mode of cleaning of atretic follicles from the ovary is unclear. Ovarian GCs share striking similarities with testicular Sertoli cells with respect to their origin and function. Somatic Sertoli cells are responsible for the elimination of apoptotic spermatogenic cells through unconventional autophagy-assisted phagocytosis.

STUDY DESIGN, SIZE, DURATION

Human GCs were tested for the ability to ingest and destroy the apoptotic oocytes and other apoptotic substrates. A systemic study of the main phagocytosis steps has been performed at different time points after loading of apoptotic substrates into the GC.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Primary cultures of GC retrieved following controlled ovarian stimulation of five women for IVF/ICSI and a human granulosa KGN cell line were incubated with different apoptotic substrates: oocytes which underwent spontaneous apoptosis during the cultivation of immature germ cells for IVF/ICSI; apoptotic KGN cells; and apoptotic membranes from rat retinas. Cultured GC were analyzed for the presence of specific molecular markers characteristic of different steps of phagocytic and autophagy machineries by immunocytochemistry, confocal microscopy, transmission electron microscopy and western blotting, before and after loading with apoptotic substrates.

MAIN RESULTS AND THE ROLE OF CHANCE

Incubation of human GC with apoptotic substrates resulted in their translocation in cell cytoplasm, concomitant with activation of the phagocytosis receptor c-mer proto-oncogene tyrosine kinase MERTK (P < 0.001), clumping of motor molecule myosin II, recruitment of autophagy proteins: autophagy-related protein 5 (ATG5), autophagy-related protein 6 (Beclin1) and the rise of a membrane form of microtubule-associated protein 1 light chain 3 (LC3-II) protein. Ingestion of apoptotic substrates was accompanied by increased expression of the lysosomal protease Cathepsin D (P < 0.001), and a rise of lysosomes in the GCs, as assessed by different techniques. The level of autophagy adaptor, sequestosome 1/p62 (p62) protein remained unchanged.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

The number of patients described here is limited. Also the dependence of phagocytosis on reproductive hormone status of patients should be analyzed.

WIDER IMPLICATIONS OF THE FINDINGS

Removal of apoptotic oocytes by surrounding GC seems likely to be a physiological mechanism involved in follicular atresia. Proper functioning of this mechanism may be a new strategy for the treatment of ovarian dysfunctions associated with an imbalance in content of germ cells in the ovaries, such as premature ovarian failure and polycystic ovary syndrome.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by Rennes Metropole (AIS 2015) and Agence de BioMédecine. This work was supported by funding from Université de Rennes1, Institut National de la Santé et de la Recherche Médicale (INSERM) and CHU de Rennes. A.B. is funded in part by the program Actions Concertées Interpasteuriennes (ACIP) and a research grant from the European Society of Pediatric Endocrinology. This work is supported by the Agence Nationale de la Recherche Grants ANR-17-CE14-0038 and ANR-10-LABX-73. The authors declare no competing interests.

Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

P1255Comparative safety and effectiveness of standard doses of apixaban versus dabigatran, rivaroxaban, and VKAs in non-valvular atrial fibrillation patients in France: the NAXOS study

Background

Real-world data comparing all available oral anticoagulants (OAC) on a nationwide scale (i.e. in France: apixaban, rivaroxaban, dabigatran and vitamin K antagonists – VKAs) are lacking. In everyday practice, oral anticoagulants are often underdosed, which may render comparisons between agents difficult.

Purpose and methods

NAXOS is a French real-world study comparing the safety (major bleeding), effectiveness (stroke, systemic thromboembolic events (STE)) and all-cause mortality for apixaban, dabigatran, rivaroxaban, and VKAs, in adult patients with non-valvular atrial fibrillation (NVAF) initiating a given OAC between 2014 and 2016. The French national health insurance data (SNIIRAM) were used. Analyses were performed with adjustment on propensity scores. To avoid bias potentially related to underdosing, the present analysis included only patients receiving standard doses of apixaban (5mg bid), rivaroxaban (20mg od), and dabigatran (150 mg bid), or VKAs. Only OAC naïve patients were included.

Results

In the OAC-naive cohorts treated with apixaban, rivaroxaban, and dabigatran, 54,575 (62.3%), 65,208 (65.2%), and 9,000 (42.4%), respectively, had the standard dose at the index dispensation, and 112,628 patients received VKAs. After adjustment on propensity scores, apixaban 5 mg was associated with a lower risk of major bleeding, compared to VKAs (Hazard Ratio: 0.47; 95% CI: 0.43–0.51) and rivaroxaban 20mg (HR: 0.64; 0.59–0.71), but not to dabigatran 150 mg (HR: 0.97; 0.79–1.18). Apixaban was associated with a lower risk of stroke and STE, compared to VKAs (HR: 0.62; 0.56–0.69) but not to rivaroxaban (HR: 1.03; 0.92–1.16), and dabigatran (HR: 0.96; 0.76–1.21). Apixaban showed a lower risk of all-cause mortality compared to VKAs (HR: 0.44; 0.41–0.47) and rivaroxaban (HR: 0.87; 0.81–0.94) but not to dabigatran (HR: 1.10; 0.92–1.32).

Figure 1. Forest plot presenting the results of the standard dose analysis (PS adjusted).

Conclusions

The NAXOS population-based country-wide observational study shows that 42% to 65% of patients were treated with standard doses of OACs. Analyses of standard doses confirmed the superiority of apixaban compared with VKAs for the three studied outcomes and suggests better safety profile of apixaban compared to rivaroxaban but similar to dabigatran.

Acknowledgement/Funding

The Alliance Bristol-Myers Squibb/Pfizer

[Bladder cancer in neurogenic patients: A retrospective study of management and follow-up]

INTRODUCTION

The prevalence of bladder cancer (BC) in neurological patients seems to be similar to that of the general population. However, they are more aggressive with a higher rate of muscle-invasive forms and squamous cells carcinomas. The aim of the current study was to report etiologies, management and outcomes of BC in neurological population.

MATERIAL AND METHOD

Were enrolled all neurological patients with a BC diagnosed between 2004 and 2017. The following data were retrospectively reported: age, gender, duration of the disease, mode of discovery, histological type, treatment and outcomes.

RESULTS

In total, 27 patients were included: 11 spinal cord injuries, 7 Parkinson's disease, 5 multiple sclerosis, 3 head trauma, 3 brain strokes, 2 cerebral palsies and 1 spina bifida. The histological subtypes were as follows: 22 transitional cells carcinomas, 4 squamous cell carcinomas (SCC), one mucinous adenocarcinoma, one sarcomatoid and one neuroendocrine with 19 high-grade tumors and 15 muscle-invasive bladder cancer. Seven patients (26%) were diagnosed before 15 years history of neurogenic bladder. The mean follow-up was 14 months (1-210 months). Eight deaths were observed, with 5 related to bladder cancer. In our study, smoking habits, voiding mode, lithiasis or infection histories were not related with a more aggressive pattern, such as SCC.

CONCLUSION

The high rate of muscle-invasive bladder cancer and aggressive patterns justify neuro-urological follow-up, even before 15 years of neurogenic bladder.

LEVEL OF EVIDENCE

4.

Marker of coxsackievirus-B4 infection in saliva of patients with type 1 diabetes

BACKGROUND

Coxsackieviruses B (CV-B) are enteroviruses that have been reported to play a role in the pathogenesis of type 1 diabetes. Enteroviral RNA was detected in the gut mucosa of patients. The mucosal immunity is an interconnected network; therefore, the response to enteroviruses possibly present in the gastrointestinal mucosa can be reflected by specific antibodies in the saliva. In the present study, the anti-CV-B neutralizing activity of saliva samples from patients with type 1 diabetes was investigated.

METHODS

Saliva samples were collected from patients and controls of 3 countries, and plasma was obtained from some of them. The anti-CV-B activity of clinical samples was determined by neutralization of the cytopathic effect induced by challenging viruses in vitro and expressed as titre value.

RESULTS

Overall prevalence and levels of anti-CV-B4 activity of saliva were higher in patients (n = 181) than in controls (n = 135; P = .0002; titre values ≥ 16: odds ratio = 4.22 95% CI: 1.90-9.38 P = .0002). It has been shown that IgA1 played a role in this activity. There was no correlation between the saliva and the plasma anti-CV-B4 neutralizing activity. The neutralizing activity of saliva against CV-B1, CV-B2, CV-B3, and CV-B5 existed rarely, if at all. Increased levels of anti-CV-B4 activity were observed all along a 4 year follow-up period in patients but not in matched controls (P = .01).

CONCLUSION

There is an anti-CV-B4 activity in saliva of patients with type 1 diabetes that may be a useful marker to study the role of CV-B in the pathogenesis of the disease.

Gold-iron oxide dimers for magnetic hyperthermia: the key role of chloride ions in the synthesis to boost the heating efficiency

With the aim of producing Au-Fe x O y dimers with outstanding heating performances under magnetic hyperthermia conditions applicable to human patients, here we report two synthesis routes, a two-pot and a one-pot method. The addition of chloride ions and the absence of 1,2-hexadecanediol (HDDOL), a commonly used chemical in this synthesis, are the key factors that enable us to produce dimers at low temperature with crystalline iron oxide domains in the size range between 18-39 nm that is ideal for magnetic hyperthermia. In the case of two-pot synthesis, in which no chloride ions are initially present in the reaction pot, dimers are obtained only at 300 °C. In order to lower the reaction temperature to 200 °C and to tune the size of the iron oxide domain, the addition of chloride ions becomes the crucial parameter. In the one-pot method, the presence of chloride ions from the start of the synthesis (as counter ions of the gold salt precursor) enables a prompt formation of dimers directly at 200 °C. In this case, the reaction time is the main parameter used to tune the iron oxide size. A record value of specific absorption rates (SARs) up to 1300 W gFe-1 at 330 kHz and 24 kA m-1 was measured for dimers with an iron oxide domain of 24 nm in size.

Evaluation of cardiac troponin I stability in blood sample using the AccuTnI+3 assay

OBJECTIVE

Troponins are considered as the biomarkers of choice to highlight cardiac injury in emergency departments, but are also valuable to detect cardiac injury in a non-emergency setting. In this latter case, transport of blood samples to laboratories often exceeds the manufacturer's recommendations (<2 h between vein puncture and analysis for the Beckman Coulter AccuTnI+3 assay). We aim to evaluate in vitro the stability of troponin Ic (cTnI) at two intervals (<2 h and at 4 h) over a wide range of concentrations using the Beckman Coulter AccuTnI+3 assay.

PATIENTS AND METHODS

For each of the 95 patients included in this study, we analyzed the first blood sample with a time of transport <2 h, and the second sample after 4 h from vein puncture. We then calculated the correlation between the two periods of analysis and evaluated the bias by a Bland-Altman test.

RESULTS

Taking into account of our analytical reproducibility, we did not observe any significant differences in cTnI values between <2 h and 4 h.

CONCLUSIONS

The time between vein puncture and analysis of cTnI can be extended to 4 h.

Measurement of the quality factor of a new low-frequency differential accelerometer for testing the equivalence principle

A cryogenic differential accelerometer has been developed to test the weak equivalence principle to a few parts in 10(15) within the framework of the general relativity accuracy test in an Einstein elevator experiment. The prototype sensor was designed to identify, address, and solve the major issues associated with various aspects of the experiment. This paper illustrates the measurements conducted on this prototype sensor to attain a high quality factor (Q ∼ 10(5)) at low frequencies (<20 Hz). Such a value is necessary for reducing the Brownian noise to match the target acceleration noise of 10(-14) g/√Hz, hence providing the desired experimental accuracy.

The Tammar Wallaby and Fur Seal: Models to Examine Local Control of Lactation

Mammary development and function are regulated by systemic endocrine factors and by autocrine mechanisms intrinsic to the mammary gland, both of which act concurrently. The composition of milk includes nutritional and developmental factors that are crucial to the development of the suckled young, but it is becoming increasingly apparent that milk also has a role in regulating mammary function. This review examines the option of exploiting the comparative biology of species with extreme adaptation to lactation to examine regulatory mechanisms that are present but not readily apparent in other laboratory and livestock species. The tammar wallaby has adopted a reproductive strategy that includes a short gestation (26 d), birth of an immature young, and a relatively long lactation (300 d). The composition of milk changes progressively during the lactation cycle, and this is controlled by the mother and not the sucking pattern of the young. Furthermore, the tammar can practice concurrent asynchronous lactation; the mother provides a concentrated milk high in protein and fat for an older animal that is out of the pouch and a dilute milk low in fat and protein but high in carbohydrates from an adjacent mammary gland for a newborn pouch young. This phenomenon suggests that the mammary gland is controlled locally. The second study species, the Cape fur seal, has a lactation characterized by a repeated cycle of long at-sea foraging trips (up to 28 d) alternating with short suckling periods of 2 to 3 d ashore. Lactation almost ceases while the seal is off shore, but the mammary gland does not progress to apoptosis and involution, most likely because of local control of the mammary gland. Our studies have exploited the comparative biology of these models to investigate how mammary function is regulated by endocrine factors, and particularly by milk. This review reports 3 major findings using these model animals. First, the mammary epithelial cell has an extraordinary intrinsic capacity for survival in our culture model, and the path to either function or death by apoptosis is actively driven. The second outcome is that the route to apoptosis is most likely regulated by specific milk factors. Finally, whey acidic protein, a major milk protein in some species, may play a role in normal mammary development, but that role in vivo may be limited to marsupials. Evolutionary pressure has led to changes in the structure of the protein with an accompanying change in function. Therefore, we propose that a loss of function of this protein in eutherians may relate to a reproductive strategy that is less dependent on lactation.

Characterization of two whey protein genes in the Australian dasyurid marsupial, the stripe-faced dunnart (Sminthopsis macroura)

We report the first isolation and sequencing of genomic BAC clones containing the marsupial milk protein genes Whey Acidic Protein (WAP) and Early Lactation Protein (ELP). The stripe-faced dunnart WAPgene sequence contained five exons, the middle three of which code for the WAPmotifs and four disulphide core domains which characterize WAP. The dunnart ELPgene sequence contained three exons encoding a protein with a Kunitz motif common to serine protease inhibitors. Fluorescence in situ hybridization located the WAPgene to chromosome 1p in the stripe-faced dunnart, and the ELPgene to 2q. Northern blot analysis of lactating mammary tissue of the closely related fat-tailed dunnart has shown asynchronous expression of these milk protein genes. ELPwas expressed at only the earlier phase of lactation and WAPonly at the later phase of lactation, in contrast to beta-lactoglobulin (BLG) and alpha-lactalbumin (ALA) genes, which were expressed in both phases of lactation. This asynchronous expression during the lactation cycle in the fat-tailed dunnart is similar to other marsupials and it probably represents a pattern that is ancestral to Australian marsupials.

281. The role of insulin in milk protein synthesis

The mammary explant culture model has been frequently used to mimic lactation and to examine the endocrine control of milk protein gene expression. Studies in the mouse show the expression of the milk protein genes in explants requires insulin in the presence of prolactin and cortisol. The role of insulin in milk protein synthesis in the dairy cow is not as clear. The bovine mammary explant culture model has been utilised to show that insulin is essential for alpha-s1-casein gene expression and the synthesis of the casein proteins. In addition, mouse culture experiments were undertaken to provide an insight into the underlying molecular mechanisms of insulin action in hte mammary gland. A global analysis of the genes induced in the cultured explants was done using Affymetrix microarray and showed 132 genes, including the major milk protein genes, required the complement of insulin, cortisol and prolactin for maximal expression. Twenty-seven genes showed a 3-fold change in gene expression in response to insulin. The function of these genes can be largely categorised into maintenance of cell integrity, signal transduction, transport mechanisms, cellular metabolism and a direct effect on gene transcription in the nucleus. The requirement for insulin in milk protein synthesis is highlighted by its role in inducing the STAT5 gene, known to be a key transcription factor for the milk protein genes. Interestingly, dairy cows of high genetic merit have unusually low serum concentrations of insulin. This has occured in association with a high selection pressure for milk volume that has altered the regulation of blood glucose homeostasis. Our study indicates that this intensity of selection for high milk volume could be compromising the dairy cow’s potential for milk protein production: Has selecting for milk volume in many populations of dairy cows been achieved by lowering circulating insulin levels with consequent effects on the efficiency for milk protein yield as well as compromised reproductive performance.

Sequencing and mapping hemoglobin gene clusters in the Australian model dasyurid marsupial Sminthopsis macroura

Comparing globin genes and their flanking sequences across many species has allowed globin gene evolution to be reconstructed in great detail. Marsupial globin sequences have proved to be of exceptional significance. A previous finding of a beta(beta)-like omega(omega) gene in the alpha(alpha) cluster in the tammar wallaby suggested that the alpha and beta cluster evolved via genome duplication and loss rather than tandem duplication. To confirm and extend this important finding we isolated and sequenced BACs containing the alpha and beta loci from the distantly related Australian marsupial Sminthopsis macroura. We report that the alpha gene lies in the same BAC as the beta-like omega gene, implying that the alpha-omega juxtaposition is likely to be conserved in all marsupials. The LUC7L gene was found 3' of the S. macroura alpha locus, a gene order shared with humans but not mouse, chicken or fugu. Sequencing a BAC contig that contained the S. macroura beta globin and epsilon globin loci showed that the globin cluster is flanked by olfactory genes, demonstrating a gene arrangement conserved for over 180 MY. Analysis of the region 5' to the S. macroura epsilon (epsilon) globin gene revealed a region similar to the eutherian LCR, containing sequences and potential transcription factor binding sites with homology to eutherian hypersensitive sites 1 to 5. FISH mapping of BACs containing S. macroura alpha and beta globin genes located the beta globin cluster on chromosome 3q and the alpha locus close to the centromere on 1q, resolving contradictory map locations obtained by previous radioactive in situ hybridization.

Bone morphing: 3D morphological data for total knee arthroplasty

OBJECTIVE

The clinical outcome of a total knee arthroplasty (TKA) is mainly determined by the accuracy of the surgical procedure itself. To improve the final result, one must take into account (a) the alignment of the prosthesis with respect to the mechanical axis, and (b) the balance of the soft tissues. Therefore, morphologic data (such as the shape of the epiphysis) and geometric data are essential. We present a new method for performing TKA based on morphologic and geometric data without preoperative images.

MATERIALS AND METHODS

The global method is based on the digitization of points with an optical 3D localizer. For the morphologic acquisitions, we use a method based on the registration of sparse point data with a 3D statistical deformable model. To build the mechanical axis, we use a kinematics method for the hip center and digitization of anatomical landmarks for the ankle centers. The knee center is not determined by digitization or kinematics of the knee, as this would not be accurate. The surgical planning relies totally on the soft-tissue balance, which is the key issue for a good kinematics result.

RESULTS

We have used this system for 6 months in a randomized clinical trial involving 35 patients to date. For the first 11 patients that could be measured in the navigation group, the postoperative frontal alignment was within the range of 180 +/- 3 degrees. Fluoroscopic assessment of the soft-tissue balancing will be performed at the conclusion of an extended 2-year study to evaluate the results from a functional point of view.

CONCLUSION

Bone Morphing is an accurate, fast, and user-friendly method that can provide morphologic as well as geometric data. We have introduced the important notion of soft-tissue balancing into the intraoperative planning step to optimize the kinematics as well as the anatomy. Therefore, this method should be considered as an alternative to the CT-based method.

[Long gamma nail for the treatment of subtrochanteric fracture of the femur]

PURPOSE OF THE STUDY

The standard gamma nail is commonly used for the treatment of trochanteric fractures but cannot be used if the fracture lies at the level of the distal locking. Theoretically, the long gamma nail would overcome this inconvenience and could be used for all cases of subtrochanteric and trochanteric-shaft fractures.

MATERIAL AND METHODS

Clinical and radiological charts were established in 1990 for a multicentric study. The radiology work-up included an AP view of the pelvis and an oblique lateral view of the hip. Two classifications were used: Seinsheimer and Muller as modified by Nazarian. Three stages of fracture reduction were recorded: 1=anatomic reduction, 2=acceptable reduction, 3=poor reduction. From January 1995 to December 1999, 46 patients were treated with the long gamma nail. Twenty-four cases were excluded for various reasons (from which 3 early death). 22 remaining patients were followed for more than six months. Mean age was 68 years (range 42-96); there were six women and 16 men. Ten patients were traffic or work accident victims and 12 had had a home accident.

RESULTS

Mean duration of surgery was 70 minutes. Three patients required revision surgery within a week of the initial osteosynthesis. Mean hemoglobin level before surgery was 12.9 g/dl; 8.9 g/dl during the first postoperative week. Mean hospital stay was 14 days. Weight-bearing with support was possible early after surgery in 16 patients who walked with crutches or a walker. Mean delay to weight-bearing was 11 days. At three months, all patients were using an aid for walking; at six months, four patients used a walker. Bone healing was achieved on the average at the twelfth week. Radiological reduction was anatomic in four, acceptable in three and poor in 15.

DISCUSSION

We advocate the AO classification as it allows a structured analysis of all fractures within a unique system. We compared our results with nine series reported in the literature using other therapeutic methods (screw-plate, nail-plate, Ender nail). The operative time for the long gamma nail (70 min) was comparable with that for other surgical techniques. Treatment with the long gamma nail favors bone healing and limits the risk of infection. Radiological results in our series were poor, but there were no cases with nonunion and the morbidity was low.

Pedicle island flaps of latissimus dorsi. Applications in surgical repair of ruptures of the rotator cuff

There are considerable problems in repair of major ruptures of the rotator cuff tendons particularly those of the supra and infraspinatus mm. The Gerber technique only transfers the tendinous insertion of the latissimus dorsi onto the greater tuberosity in massive cuff ruptures. We have extended this approach. In 12 shoulders, we studied the feasibility of a latissimus dorsi transfer harvested to fit and bearing muscle and tendon detached at its two extremities and transposed as a neurovascular island. The muscular part is transferred to the infra or supraspinous fossae and the tendon to the greater tuberosity with the aim of reactivating the infra and supraspinatus muscles. The lateral bundle of the latissimus dorsi is always transferable on its neurovascular pedicle into the infraspinous fossa, even into the supraspinous fossa, or into both if transfer is used as a bilobed flap. This anatomical work allowed a parallel study of the different possibilities of transposing the neurovascular pedicle, which might limit the technique, and also to determine the most appropriate surgical approach.

The use of MR images to evaluate the risks associated with proximal locking of intramedullary tibial nails

Vascular complications associated with locked intramedullary tibial nailing are infrequent but always serious, with a secondary amputation rate of 30%. These complications, based on an MR study of the anatomic relationships between the interlocking screws and the neurovascular or articular structures at the proximal end of the tibia, have been analysed. Two types of nails were used: one with anterior-posterior locking and a specially designed prototype with oblique locking. In particular this study emphasised the anatomic risk of injury to the popliteal structures when using anterior-posterior locking, as well as to the anterior tibial vessels and proximal tibiofibular joint when using oblique locking. As no locking method appears to be better than any other, the best is that associated with the lowest morbidity. Consequently, the use of frontal instead of anterior-posterior locking is recommended; the use of oblique locking, which this study has shown carries a much higher risk of complications, is strongly advised against.

[Bilateral bipartite carpal scaphoid bone: a congenital disease or unrecognized pseudarthrosis? Discussion a propos of a clinical case]

PURPOSE OF THE STUDY

Bipartite scaphoid has long been debated, and is of traumatic origin for some authors or congenital for others. The aim of the study is to distinguish clinical and radiographic criteria for the diagnosis of congenital bipartite scaphoid.

MATERIAL AND METHOD

A case of bilateral bipartite scaphoid is presented. To distinguish pseudarthrosis from congenital bipartite scaphoid we used, the revised carpal height ratio of Nattrass, the CT, and magnetic resonance imaging.

RESULTS

These examinations showed no collapse and they revealed evidence of articular cartilage around the fragments with the same thickness in all the carpus.

CONCLUSION

We believe that congenital origin is more probable but we recommend to follow the patient, with yearly standard wrist radiograph and use, the revised carpal height ratio of Nattrass to research a carpal shift or collapse.

New susceptibility locus for rheumatoid arthritis suggested by a genome-wide linkage study

Rheumatoid arthritis (RA), the most common autoimmune disease, is associated in families with other autoimmune diseases, including insulin-dependent diabetes mellitus (IDDM). Its genetic component has been suggested by familial aggregation (lambdas = 5), twin studies, and segregation analysis. HLA, which is the only susceptibility locus known, has been estimated to account for one-third of this component. The aim of this paper was to identify new RA loci. A genome scan was performed with 114 European Caucasian RA sib pairs from 97 nuclear families. Linkage was significant only for HLA (P < 2.5.10(-5)) and nominal for 19 markers in 14 other regions (P < 0.05). Four of the loci implicated in IDDM potentially overlap with these regions: the putative IDDM6, IDDM9, IDDM13, and DXS998 loci. The first two of these candidate regions, defined in the RA genome scan by the markers D18S68-D18S61-D18S469 (18q22-23) and D3S1267 (3q13), respectively, were studied in 194 additional RA sib pairs from 164 nuclear families. Support for linkage to chromosome 3 only was extended significantly (P = 0.002). The analysis of all 261 families provided a linkage evidence of P = 0. 001 and suggested an interaction between this putative RA locus and HLA. This locus could account for 16% of the genetic component of RA. Candidate genes include those coding for CD80 and CD86, molecules involved in antigen-specific T cell recognition. In conclusion, this first genome scan in RA Caucasian families revealed 14 candidate regions, one of which was supported further by the study of a second set of families.

[Surgical treatment of freshly closed articular fractures of proximal interphalangeal joints]

Eleven fractures of the base of P2 and 8 fractures of the head of P1 were treated surgically. We review the results after a mean follow-up of 4 years 5 months. Due to their complexity is no real consensus on the treatment of P2 and various treatments were used. This series demonstrated two points: first the was no correlation between the degree of patient satisfaction and the section of digital immobilization; second, residual subluxation and/or arthrosic remodeling was frequent but was not incompatible with a good objective and subjective outcome.

[Use of muscular flaps for the treatment of open fractures of limbs. Apropos of 42 cases]

PURPOSE OF THE STUDY

Since 1988, skin defect associated with upper (6 cases) or lower (34 cases) limb fractures were treated in our Orthopaedic Department with regional or free muscular flaps. The aim of this study was to demonstrate that muscular flaps represent a treatment of choice for infection prevention and consolidation.

MATERIAL AND METHODS

42 patients have been treated: 29 Cauchoix III or IV, 12 secondary exposed fractures, 1 amputation. A total of 42 flaps, including 28 regional flaps and 14 microvascular free-tissue transfers were performed. A first stage included thorough debridement, fixation with external fixator in 85 per cent, and revascularization (4 cases). A second look was necessary in all but 3 cases: flap coverage was performed at this stage. A bone graft was proposed in 17 cases after a mean time of 3 months and 20 days.

RESULTS

Bony healing was found in 37 cases (86.5 per cent) with a mean delay of 7 months 20 days. 5 patients required another method of treatment because of flap necrosis or non-union, with an average time to bony healing of 13 months. 42 tissue transfers were performed with an overall success rate of 95.3 per cent (2 necrosis of latissimus dorsi flaps). 3 partial necrosis involved 2 regional and 1 free flap. One of them needed another treatment. No infection was encountered in 40 cases (95 per cent) even if most of the patients were treated after initial treatment elsewhere.

DISCUSSION

Experience with regional muscle transfer has advocated the gastrocnemius and proximal pedicle medial soleus as reliable and excellent choice for reconstruction of the proximal and middle third of the leg. Latissimus dorsi transfer, which can be used totally, partially, or as a "vascular graft flap" represent the treatment choice for extensive upper or lower limb exposed fracture especially for distal lower limb fracture (exposure of the tibia). Muscle flap coverage in the acute period (within 48 or 72 hours) remains for us the best treatment.

Osteoarthritis of the pisiform-triquetral compartment. A review of eight cases of an underrecognized entity

Seven patients (eight hands) with pain suggestive of the pisiform-triquetral compartment were studied to compare outcomes after surgical excision of the pisiform (four hands) and after conservative therapy (four hands). All patients were reevaluated by a rheumatologist who was not involved in their treatment. The efficacy of conservative therapy was mediocre in every case. Although it is reasonable to assume that the surgically-treated patients had more severe manifestations at baseline, all were free of symptoms at reevaluation, versus none of the conservatively-treated patients. After two years, excision of the pisiform yielded excellent results with no adverse effects on range of motion or grip strength. Despite the small size of our sample and the relatively low incidence of pisitriquetral osteoarthritis, our data suggest that surgery is preferable over conservative therapy in this condition.

A novel tandem repeat sequence located on human chromosome 4p: isolation and characterization

In an effort to analyze the genomic region of the distal half of human chromosome 4p, to where Huntington disease and other diseases have been mapped, we have isolated the cosmid clone (CRS447) that was likely to contain a region with specific repeat sequences. Clone CRS447 was subjected to detailed analysis, including chromosome mapping, restriction mapping, and DNA sequencing. Chromosome mapping by both a human-CHO hybrid cell panel and FISH revealed that CRS447 was predominantly located in the 4p15.1-15.3 region. CRS447 was shown to consist of tandem repeats of 4.7-kb units present on chromosome 4p. A single EcoRI unit was subcloned (pRS447), and the complete sequence was determined as 4752 nucleotides. When pRS447 was used as a probe, the number of copies of this repeat per haploid genome was estimated to be 50-70. Sequence analysis revealed that it contained two internal CA repeats and one putative ORF. Database search established that this sequence was unreported. However, two homologous STS markers were found in the database. We concluded that CRS447/pRS447 is a novel tandem repeat sequence that is mainly specific to human chromosome 4p.

Texas Res-X and rhodamine Red-X, new derivatives of sulforhodamine 101 and lissamine rhodamine B with improved labeling and fluorescence properties

Texas Red sulfonyl chloride (TR-SC) and Lissamine rhodamine B sulfonyl chloride (LRB-SC) are popular dyes often used to prepare red fluorescent conjugates that are useful second labels in combination with fluorescein. Unfortunately, being sulfonyl chloride derivatives, both are unstable to moisture during storage and prone to hydrolysis in the conjugation reaction. Their instability causes the percentage of reactive dye to vary from lot to lot and requires use of low temperatures and a relatively high pH to optimize conjugation efficiency. Succinimidyl esters of the aminohexanoic acid sulfonamides of both dyes have been prepared, which are designated Texas Red-X succinimidyl ester (TR-X-SE) and Rhodamine Red-X succinimidyl ester, respectively. Their spectral properties are similar to those of their sulfonyl chloride analogs; moreover, incorporation of the succinimidyl ester at the end of the aliphatic chain spacer facilitates conjugation, decreases precipitation of proteins during conjugation and storage, and usually increases the fluorescence yield of the conjugate. Comparison of the rate of hydrolysis of TR-SC with that of TR-X-SE shows that, while the former was completely hydrolyzed within 5 min by exposure to water, TR-X-SE retains most of its reactivity for more than an hour. The reactivity of both new derivatives is high between pH 7.5 and 8.5, allowing conjugation of proteins that do not tolerate the high pH required for reaction with sulfonyl chlorides. In addition, Texas Red maleimides and haloacetamides containing spacer groups were prepared for labeling sulfhydryl groups. A Texas Red-X derivative of phalloidin has also been prepared, and its use for labeling F-actin has been characterized.