Controversies in ACL revision surgery: Italian expert group consensus and state of the art

Background Revision ACL reconstruction is a complex topic with many controversies and not-easy-to-make decisions. The authors' aim is to provide some feasible advice that can be applied in daily clinical practice with the goal of facilitating the decision-making process and improving the outcomes of patients subjected to revision ACL reconstruction. Methods A national survey with seven questions about the most controversial topics in revision ACL reconstruction was emailed to members of two societies: SIOT and SIAGASCOT. The participants' answers were collected, the most recent literature was analyzed, and a consensus was created by the authors, according to their long-term surgical experience. Conclusions The decision-making process in revision ACL reconstruction starts with a standardized imaging protocol (weight-bearing radiographs, CT scan, and MRI). One-stage surgery is indicated in almost all cases (exceptions are severe tunnel enlargement and infection), while the choice of graft depends on the previously used graft and the dimensions of the tunnels, with better clinical outcomes obtained for autografts. Additional procedures such as lateral extra-articular tenodesis in high-grade pivot-shift knees, biplanar HTO in the case of severe coronal malalignment, and meniscal suture improve the clinical outcome and should be considered case by case

The prognostic role of nephrectomy in patients (pts) with metastatic renal cell carcinoma (mRCC) treated with immunotherapy according to the novel prognostic Meet-URO score: Subanalysis of the Meet-URO 15 study

Background: Most of mRCC pts with favorable and intermediate prognosis, according to the IMDC classification, are offered a nephrectomy. However, in the immunotherapy era, the role of nephrectomy is still unclear. In the Meet-URO 15 study we reported the higher prognostic accuracy of the Meet-URO score compared to the IMDC score, by the addition of the neutrophil-to-lymphocyte ratio (NLR) and the presence of bone metastases to the IMDC score, identifying five categories with progressively worse prognosis. For this reason, we aimed to explore the prognostic impact of the previous nephrectomy (PN) on mRCC pts receiving immunotherapy and according to the Meet-URO score groups. Methods: The Meet-URO 15 study was a multicentric retrospective analysis on 571 pretreated mRCC pts receiving nivolumab. Univariable analysis of the correlation between PN and overall survival (OS) and multivariate analysis adjusted for IMDC score, therapy line, NLR and metastatic sites were performed. The interaction of PN with the Meet-URO prognostic groups was then evaluated. Results: 503/571 pts (88%) underwent PN. A reduced risk of death (HR = 0.44; 95% CI: 0.32-0.60; p< 0.001) and higher mOS and OS rate were observed in pts with PN than without (mOS: 36 vs 13 monhts; 1-year-OS 72% vs 52% and 2-year-OS 57% vs 24%, respectively). The reduced risk of death for pts who underwent PN was confirmed at the multivariate analysis (HR = 0.69; 95% CI: 0.49-0.97; p= 0.032). The percentage of pts receiving PN progressively reduced through the five Meet-URO prognostic groups (PN: group 1: 98%, group 2: 95%, group 3: 84%, group 4: 79%, group 5: 59%). No significant interaction was observed between the PN and Meet-URO score when all the five groups were considered (p= 0.17). A significant interaction was observed when the Meet-URO groups 1,2 and 3 were taken together (HR = 0.40; 95% CI: 0.25-0.63; p< 0.001), highlighting the significant protective role of the PN on OS for these three groups. For the Meet-URO groups 4 and 5, the interaction was indeed not significant (HR = 0.81; 95% CI: 0.51-1.30; p= 0.39). Conclusions: PN has a favourable prognostic impact on pretreated mRCC pts receiving immunotherapy. This benefit may be limited to mRCC pts with more favorable diseases as belonging to Meet-URO prognostic groups 1, 2 and 3. Further analysis of the type of PN (i.e., radical vs cytoreductive) is ongoing and confirmatory prospective evaluations are warranted

The prognostic value of the previous nephrectomy in pretreated metastatic renal cell carcinoma receiving immunotherapy: a sub-analysis of the Meet-URO 15 study

Nephrectomy is considered the backbone of managing patients with localized and selected metastatic renal cell carcinoma (mRCC). The prognostic role of nephrectomy has been widely investigated with cytokines and targeted therapy, but it is still unclear in the immunotherapy era

INfluenza Vaccine Indication During therapy with Immune checkpoint inhibitors: a transversal challenge. The INVIDIa study

Aim: Considering the unmet need for the counseling of cancer patients treated with immune checkpoint inhibitors (CKI) about influenza vaccination, an explorative study was planned to assess flu vaccine efficacy in this population. Methods: INVIDIa was a retrospective, multicenter study, enrolling consecutive advanced cancer outpatients receiving CKI during the influenza season 2016-2017. Results: Of 300 patients, 79 received flu vaccine. The incidence of influenza syndrome was 24.1% among vaccinated, versus 11.8% of controls; odds ratio: 2.4; 95% CI: 1.23-4.59; p = 0.009. The clinical ineffectiveness of vaccine was more pronounced among elderly: 37.8% among vaccinated patients, versus 6.1% of unvaccinated, odds ratio: 9.28; 95% CI: 2.77-31.14; p < 0.0001. Conclusion: Although influenza vaccine may be clinically ineffective in advanced cancer patients receiving CKI, it seems not to negatively impact the efficacy of anticancer therapy

Substantially elevated serum glutamate and CSF GOT-1 levels associated with cerebral ischemia and poor neurological outcomes in subarachnoid hemorrhage patients

Abstract Brain injury and cerebral vasospasm during the 14 days after the subarachnoid hemorrhage (SAH) are considered the leading causes of poor outcomes. The primary injury induces a cascade of events, including increased intracranial pressure, cerebral vasospasm and ischemia, glutamate excitotoxicity, and neuronal cell death. The objective of this study was to monitor the time course of glutamate, and associated enzymes, such as glutamate–oxaloacetate transaminase (GOT1), glutamate-pyruvate transaminase (GPT) in cerebrospinal fluid (CSF) and serum, shortly after SAH, and to assess their prognostic value. A total of 74 participants participated in this study: 45 participants with SAH and 29 controls. Serum and CSF were sampled up to 14 days after SAH. SAH participants' clinical and neurological status were assessed at hospitalization, at discharge from the hospital, and 3 months after SAH. Furthermore, a logistic regression analysis was carried out to evaluate the ability of GOT1 and glutamate levels to predict neurological outcomes. Our results demonstrated consistently elevated serum and CSF glutamate levels after SAH. Furthermore, serum glutamate level was significantly higher in patients with cerebral ischemia and poor neurological outcome. CSF GOT1 was significantly higher in patients with uncontrolled intracranial hypertension and cerebral ischemia post-SAH, and independently predicted poor neurological outcomes

Studio multicentrico sulla nuova normalità della spalla instabile operata. Valutazione clinica ed isocinetica

E opinione comune che la perdita di alcuni gradi di extrarotazione, dopo un intervento chirurgico di stabilizzazione in spalle con instabilità anteriore, sia il sacrificio indispensabile per ottenere una soddisfacente stabilità articolare (DePalma, 1950; Watson-Jones, 1955), E altresi diffusa l’idea che la riduzione post-chirurgica di alcuni gradi di extrarotazione sia generalmente ben tollerata o addirittura sconosciuta a coloro che non svolgono attività lavorative o sportive che richiedano un elevato impegno degli arti superiori (Hovelius et al., 1979). Studi retrospettivi (Hawkins e Angelo, 1990; Lusardi et al., 1993) hanno tuttavia dimostrato che una capsulorrafia serrata, responsabile, da una parte, di una soddisfacente stabilizzazione, ma dall'altra, di una riduzione dell’extrarotazione, causa alterazioni degenerative articolari a distanza. Ciononostante, ancora oggi vi sono pareri contrastanti sui gradi della riduzione dell'extrarotazione conseguente ad interventi chirurgici di stabilizzazione e sulla percentuale di pazienti che hanno tale limitazione articolare post-chirurgica. Moseley (1961) e Helium et al. (1973), ad esempio, ritengono che la capsulorrafia secondo la tecnica originate di Bankart comporti mediamente una perdita di 20° dell'extrarotazione; per Gill et al. (1997), invece, la riduzione media e di 12°. In tre studi retrospettivi, Werner e Reimers (1972), Rowe et al. (1978) e Hovelius et al. (1979) hanno osservato, rispettivamente, che il 4.7%, 25% e 69% dei pazienti sottoposti a stabilizzazione secondo Bankart conservano una motilità articolare completa. Altre incongruenze emergono dalle analisi condotte su pazienti sottoposti a tecniche chirurgiche a cielo aperto concettualmente diverse da quella di Bankart. In due studi retrospettivi, su pazienti sottoposti ad intervento di stabilizzazione secondo Putti-Platt, la perdita media dell'extrarotazione e stata di 17° (Leach et al., 1982) e 30° (Quigley e Freedman, 1974). Da altri studi e emerso che la riduzione dopo la tecnica di Magnuson-Stack e compresa tra 10° (Karadimas et a)., 1980) e 30° (Ahmadain, 1987), tra 12° (Carol et al,, 1985) e 20° (Hovelius et al., 1983) dopo la procedura di Bristow-Lalarjet, e tra 5° (Werner e Reimers, 1972) e 10° (Paavolainen et al., 1984) dopo Tintervento di Hybbinette. In molti degli studi retrospettivi, non e descritto il metodo utilizzato per la misurazione dell'extrarotazione residua, e, dei pazienti esaminati, viene usualmente indicato soltanto il sesso e I'eta media. Studi epidemiologici hanno invece dimostrato che il grado di motilità della spalla dipende anche da altre caratteristiche dell'esaminato quale: I'eta, razza, occupazione, stato culturale e sociale e posizione del soggetto durante la misurazione (Ahlberg et al., 1988; Gunal et al., 1996). Recentemente e stata rilevata anche una differenza significativa del’extrarotazione attiva tra i due lati che ha reso non perfettamente sovrapponibile la misurazione del gradi residui di un lato mediante il confronto con I'arto controlaterale (Gunal et al., 1996). Nel nostro studio abbiamo valutato clinicamente la funzionalità della spalla in gruppi di pazienti che per un'instabilità anteriore di spalla sono stati .sottoposti a diverse tecniche chirurgiche di stabilizzazione e abbiamo correlato la motilità della spalla alle caratteristiche anagrafiche del paziente, al suo stato sociale e culturale. Alcuni dei pazienti di ciascun gruppo sono stati sottoposti a valutazione della forza mediante dinamometro isocinetico mettendo a confronto i valori del lato operato con quelli del controlaterale