[Clinical practice guidelines: 2004 Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach--radiotherapy]

CONTEXT

"The Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

OBJECTIVES

To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement.

RESULTS

Adjuvant radiation therapy alone is not a standard treatment for patients with stomach adenocarcinoma. Adjuvant concomitant chemoradiotherapy is not a standard treatment for patients with stage II or III stomach adenocarcinoma R0, with Dl or D2 lymphadenectomy who have undergone surgery. Following surgical resection, adjuvant concomitant chemoradiotherapy should be proposed to patients without denutrition with a lymphadenectomy < Dl (fewer than 15 lymph nodes examined) and those with T3 and/or N+ tumours following the protocol used in the MacDonald trials (SWOG-9008) (Level of evidence B1). Adjuvant concomitant chemoradiotherapy can be administered to patients without denutrition with DI or D2 lymphadenectomy and with involvement of regional lymph nodes (N2 or N3).

Impact des facteurs de fragilité sur le devenir des sujets âgés de 75 ans et plus opérés d'une prothèse de hanche

OBJECTIVE

Hip pathology of hip requiring a surgical assumption of responsibility (coxarthrose invalidating, hip fracture) is increasing, and after the year 2025, the number of interventions will double. In parallel, the number of elderly people (older than 75 years) with malnutrition associated with cognitive impairment and reduced autonomy is on the increase. So the concept of frail elderly identified by specific criteria allows for better defining the health needs of heterogeneous elderly people. The objective of this study was to determine the influence of frailty factors on autonomy and clinical outcome after intervention for prosthesis of the hip.

METHODOLOGY

This prospective work, completed over 8 months, included 55 patients with total or intermediate prostheses of hip, whatever the cause, recruited from rehabilitation wards. Results from a pre-established questionnaire defined the personal status and social framework of these patients. A medical examination evaluated cognitive function Mini Mental State (MMS), nutritional state (IMC) and the level of autonomy immediately after surgery (the first 2 weeks) by the measurement of functional independence (MIF). The second MIF was carried out by the same operator at the end of the assumption of responsibility by the institution.

RESULTS

Three factors of frailty influenced progress at the time of reacquisition of autonomy: cognitive impairment (P < 0001; 1 patient out of 2 [50%] had an MMS score < 22); reduced nutrition? (P < 0.0026; [29% had a BMI score < 20 or a perimeter of the calf < 30 cm]; and accommodations before the intervention (P < 0.028; [15% lived in an institution]).

CONCLUSION

Nutritional state, cognitive level and social activity must be evaluated regularly in elderly subjects with hip prosthesis to evaluate optimal load and adaptation.

Tuberculose péritonéale de l'enfant : à propos de deux cas

Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss.

CASES REPORT

We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically.

CONCLUSION

Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.

[A rare cause of intestinal obstruction after laparoscopic colectomy]

Described here is a case of obstruction of the ileal loop caused by a volvulus forming on an internal hernia through the mesenteric opening following left laparoscopic-assisted hemicolectomy. The clinical radiologic, pathogenic and therapeutic aspects are described with review of the literature.

[Unusual cause of myocardial infarction]

The authors report the case of a woman with an acute myocardial infarction in whom coronary angiography performed a few hours earlier was completely normal. Transoesophageal echocardiography showed two thrombi in the left atrial appendage confirming the thromboembolic mechanism of this infarct.

L’estomac pastèque : une cause rare d’anémie ferriprive, de traitement chirurgical ; un nouveau cas et revue de la littérature

The authors report a new case of water-melon stomach, without portal hypertension, and responsible for a iron deficiency anemia cured by antrectomy. Water-melon stomach is a particular form of gastric antral vascular ectasia, characterized by a specific and striking endoscopic aspect. The diagnostic, histologic, pathogenic and therapeutic aspects are reviewed.

[Meningitis and osteitis caused by Pasteurella multocida in a three-month-old infant]

Pasteurella multocida is usually responsible for local infections occurring after animal bites. It can also be responsible for meningitis in infants. A three-month old infant was admitted to hospital with a diagnosis of bacterial meningitis and hip osteitis. Cultures of cerebrospinal fluid, blood and joint liquid were positive to Pasteurella multocida. Licking from the family dog was the transmission mode in this case. Despite initial neurological complications, clinical evolution was favourable after three weeks of intravenous antibiotic therapy followed by an oral administration for three months. Pasteurella multocida meningitis is rare in infants. It can be associated with arthritis, osteitis and septicaemia. Besides animal bites, licking is also a mode of contamination.

Sonolysis of metal beta-diketonates in alkanes

The kinetics of metal beta-diketonates sonolysis was studied in hexadecane solutions using a UV/VIS spectrophotometric technique. The following complexes were prepared and studied: Cu(HFAA)(2), Cu(DPM)(2), Fe(ACAC)(3), Ni(DPM)(2), Er(DPM)(3), Nd(DPM)(3), Th(DPM)(4), UO(2)(BTFA)(2).TOPO, and Np(HFAA)(4), where HHFAA is hexafluoroacetylacetone, HDPM is dipivaloylmethane, HACAC is acetylacetone, HBTFA is benzoyltrifluoroacetone, and TOPO is trioctylphosphine oxide. Sonolysis was performed under the following conditions: ultrasonic frequency 22 kHz, intensity of ultrasound 3-5 Wcm(-2), temperature 70-92 degrees C, Ar atmosphere. The kinetic behavior of the studied complexes are interpreted using a two-site model of the sonochemical processes. In the case of metal beta-diketonates with high vapor pressure the sonochemical reactions tend to occur in the gaseous phase of the cavitating bubbles. The sonolysis of less volatile complexes first occur in the liquid reaction zone surrounding the bubbles. Sonication of the studied complexes results in the formation of X-ray amorphous products consisted of a mixture of metal beta-diketonates partial degradation products. Heating of as-prepared sonication products in air yields nanocrystalline oxides of corresponding metals.

Anaplastic lymphoma kinase (ALK) protein expressing lymphoma after liver transplantation: case report and literature review

Most post transplantation lymphoproliferative disorders (PTLDs) are Epstein-Barr virus (EBV) associated B cell proliferations. We report a case of aggressive anaplastic large cell lymphoma expressing the anaplastic lymphoma kinase (ALK) protein in a 58 year old man who had previously undergone liver transplantation. A definite diagnosis was not possible on histopathological examination. Immunostaining clearly showed a predominant population of small irregular lymphocytes, admixed with large cells strongly positive for CD30, epithelial membrane antigen, and the ALK protein. Neoplastic cells were of the T/cytotoxic phenotype. In situ hybridisation with EBV encoded early RNA probes showed only a few scattered positive non-neoplastic small lymphocytes. Polymerase chain reaction analysis of immunoglobulin and T cell receptor rearrangements was negative. The NPM-ALK fusion transcript associated with the t(2;5) translocation was detected by reverse transcription polymerase chain reaction. A review of the literature revealed 76 cases of T cell PTLD, showing a broad spectrum of morphological features and clinical behaviour. Most of these cases were EBV negative (61 of 76) and occurred after renal transplantation (48 of 76). To our knowledge, this is the first case of ALK positive lymphoma occurring in the setting of organ transplantation. This observation stresses the need for accurate immunostaining for diagnosing this rare, apparently aggressive, lymphoma in immunosuppressed patients.

[Effectiveness of falls prevention strategies for elderly subjects who live in the community with performance assessment of physical activities (before-after)]

OBJECTIVES

The development of falls prevention strategies is an essential health concern in elderly people. However, a global consensus does not exist for elderly subjects who live independently in the community. The aim of the study was to evaluate the benefit of an exercises program.

MATERIALS AND METHODS

A control group (153 subjects) and an "Intervention" group (150 subjects) were tested before and after a 1-year prospective study. The "Intervention" group performed ten training sessions of physical activity, based on balance, muscular activity and coordination. We compared the incidence of falls, and the performances in several tests between the two groups.

RESULTS

The clinical features were similar between the two groups: mean age 71 years, 83% of females, subjects who were independent for activities of daily living. However, all subjects presented risk for factors for falls: 38% were not able to maintain the unipodal position more than five seconds, 29% had already fallen during the previous year. For the "Intervention" group, the comparison of the performances before and after the physical activity program showed significant increases (p < 0.001) for all the tests, and specifically for the unipodal position and for the exercises performed with eyes closed. After one year follow-up, the incidence rate of falls was lower in the "Intervention" group compared with the control group, but the difference was not significant (p = 0.32). However, falls occurred significantly latter in the "Intervention" group (p = 0.02).

CONCLUSION

Ten training sessions of physical activity allowed to improve the performance of elderly people in several tests. This result suggests that a fall prevention program based on collective and regular exercises, may be efficient for elderly subjects who still have an active and independent way of live.

Comparative anatomical study of division of the ileocolic pedicle or the superior mesenteric pedicle for mesenteric lengthening

BACKGROUND

Lengthening of the mesentery by vascular division may be necessary to perform an ileal pouch-anal anastomosis without tension. The aim of this study was to compare, in fresh cadavers, the increase in mesentery length after division of the ileocolic pedicle (ICP) and the superior mesenteric pedicle (SMP).

METHODS

Total colectomy was performed in 12 fresh cadavers, which were then randomly divided into two groups. Pouch-anal anastomosis was performed with division of the ICP in one group of six cadavers and with division of the SMP in the other. The ileum was measured and the increase in length was recorded and compared statistically.

RESULTS

The mean(s.d.) increase in length was 3.0(0.8) cm after ICP division and 6.5(1.1) cm after SMP division (P < 0.001). The distance between the end of the ileum and the point giving the greatest length was 25.5(5.0) cm in the ICP group and 46.8(4.2) cm in SMP group (P < 0.001).

CONCLUSION

In fresh cadavers, the increase in mesenteric length was greater after SMP division than after ICP division, but if pouch-anal anastomosis is performed a short segment of small bowel must be removed.

Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation

OBJECTIVES

To assess the relationship between the time period before hyperbaric oxygenation therapy (HBO) and clinical outcome in patients with iatrogenic cerebral air embolism.

DESIGN AND SETTING

Retrospective study in a hyperbaric chamber and medical intensive care unit of a university hospital.

PATIENTS

All patients with air embolism from 1980 to 1999.

INTERVENTIONS

We retrieved the cases of 86 patients who benefited from an identical HBO and analyzed the relationship between the time period before HBO and clinical outcome.

RESULTS

Patients treated with HBO less than 6 h had a better outcome than those treated later. In patients treated within this delay the cause was venous air embolism in 84% and arterial air embolism in only 16% of cases. After this delay the cause was venous air embolism (53%) and arterial air embolism (47%). Patients with venous air embolism and recovery had a shorter delay than patients with sequelae or death (2 h 15 min vs. 4 h). Patients with venous air embolism treated less than 6 h had a better outcome than those treated later. In patients with arterial air embolism the time period before HBO was longer than in venous air embolism (8 h vs. 3 h) and the outcome worse (recovery in 35% vs. 67%). In patients with arterial air embolism no difference in the time period was found between patients with recovery and sequelae or death.

CONCLUSIONS

We stress the beneficial effect of an early HBO in air embolism, the importance of an increased awareness of physicians concerned with this severe complication, and the need to develop techniques to detect air emboli in the cerebral circulation.

Single-lead VDD-pacing system incorporating high impedance stimulation: a multicentre study

AIM

The purpose of this study was to evaluate the performance of a new VDD pacing system incorporating a high impedance, single-pass VDD lead. The new lead is a bipolar, steroid-eluting, high impedance lead with a full-ring atrial dipole.

METHODS AND RESULTS

The system was implanted in 46 patients with high degree atrioventricular (AV) block. Patients were followed at pre-discharge, 6 weeks, and 3 months. The mean measured P-wave amplitude was stable, with values between 1.18 and 1.43 mV. Atrial sensing was reliable during short-term evaluation at rest and in the sitting position, with AV-synchronous stimulation between 98.79 +/- 6.90% and 99.73 +/- 1.47%. Holter recordings after 6 weeks demonstrated AV-synchronous stimulation in 99.57 1.03% of all P-waves. Lead impedance was stable during follow-up, with mean values between 1000 and 1167 Q. Mean ventricular pacing thresholds (at 0.5 ms) were 0.47 V at implant, 0.49 V at pre-discharge, 0.74 V at 6 weeks, and 0.72 V at 3 months. R-wave amplitude remained stable between 14.9 and 16.7 mV during follow-up.

CONCLUSION

This new single-pass VDD lead system provided reliable atrial sensing and stable high impedance stimulation during a 3-month follow-up period.

A national study of medical care expenditures for respiratory conditions

This study was undertaken to estimate the magnitude of medical care expenditures among persons with respiratory conditions in the USA in 1996, and the increment in expenditures attributable to these conditions. The study data were derived from the 1996 Medical Expenditure Panel Survey, a national sample of 21,571 persons. Of the 21,571, 1,027 reported one or more respiratory condition. After weighting, the individuals may represent about 12.1 million persons in the USA. All medical care expenditures of these individuals were tabulated, stratified by comorbidity status, and then compared to those among persons with nonrespiratory conditions or with no conditions. Regression techniques were then used to estimate the increment of healthcare expenditures attributable to the respiratory conditions. From a national total of $45.3 billion, medical care expenditures averaged $3,753 among persons with respiratory conditions. Hospital stays comprised the largest component (45%). The per capita increment in total expenditures attributable to respiratory conditions ranged from $1,003-2,588, from a national total ranging from $12.1-31.3 billion. The total medical care expenditure of persons with respiratory conditions was estimated to be $45.3 billion, of which $12.1-31.3 billion represents an increment in expenditures associated with the conditions themselves.

[Anaphylaxis after rocuronium: advantage of blood tests for early diagnosis]

A 56-year-old patient was scheduled for coronary artery bypass surgery, because of a severe coronary artery disease. Soon after induction of anaesthesia, he rapidly developed a cardiovascular collapse with bronchospasm and rash. Specific immunoglobulin E and tryptase measurements supported the diagnosis of grade III anaphylactic shock due to rocuronium bromide. A few days later, a general anaesthesia was administered without muscle relaxant and was uneventful.

[Use of a polyethylene bag: a way to improve the thermal environment of the premature newborn at the delivery room]

BACKGROUND

Early interventions, such as occlusive wrapping of very low birth weight infants at delivery reduce postnatal temperature fall. This new intervention was implemented in our hospital on January 2000. The aim of this study was to investigate retrospectively the effect of polyethylene wrap, applied immediately at birth, on thermoregulation.

PATIENTS AND METHODS

Matched pair analysis was conducted for 60 infants delivered inborn at less than 33 weeks' gestation and 60 premature infants who were born during the second half of 1999 fulfilling the same criteria. The only difference in the management (medical and environmental) was wrapping with a polyethylene bag in the delivery room. Rectal temperature and other vital parameters were taken, after removal of wraps, on admission to NICU.

RESULTS

The perinatal characteristics of both groups were comparable. Use of wrapping resulted in a significantly higher admission rectal temperature (difference in means = 0.8 degree C, p < 0.0001), this difference was also significant in infants < 30 weeks. The incidence of hypothermia (< 35.5 degrees C) was less frequent in infants enclosed in plastic bags (8.3% vs 55%). No side effects (skin burns, infection or hyperthermia) were attributable to the intervention. The heart rate was higher in the wrapping group (163 +/- 16 vs 150 +/- 17 b/min, p < 0.01), as well as the capillary glycemia (62 +/- 26 vs 45 +/- 30 mg/dl, p < 0.01). There was no significant difference on arterial pressure.

CONCLUSION

Occlusive wrapping with a polyethylene bag at birth prevented low rectal temperature in premature infants in the immediate postnatal period. This method is easy, practical and effective, and does not interfere with current practice for resuscitation.

Laparoscopic repair of incisional hernia: a retrospective study of 159 patients

BACKGROUND

In this long-term retrospective study, a laparoscopic technique was used for incisional hernia repair.

METHODS

Over a 6-year period, we performed laparoscopic repairs with prosthetic mesh in 159 patients suffering from incisional hernia. Morbidity factors were noted and operative data were collected. In addition, early and long-term complications and recurrences were analyzed.

RESULTS

There were no deaths as a result of the procedure. In 21 patients (13.8%), the operation was converted to an open procedure. Small bowel perforation occurred in three patients (1.9%). Mean hospital stay was 3.5 days. Early complications occurred in 61 patients (44%). The mean follow-up time was 49 months. There were no infections of the prosthetic mesh. Residual abdominal pain was reported in 31 patients (26%). Bowel obstructions requiring resection were found in two patients (1%), and hernia recurrence was observed in 19 patients (15.7%).

CONCLUSIONS

Laparoscopic herniorraphy is a promising technique with all the advantages of minimal-invasive surgery. Nevertheless, close attention needs to be paid to the choice of the hernia and mesh size and to the fixing of the mesh.

[Diogenes syndrome in the elderly: clinical form of frontal dysfunction? Report of 4 cases]

PURPOSE

Diogenes syndrome is characterised by self-neglect and domestic squalor which leads to unhealthy living conditions. It seems that no single model satisfactorily explains the development of Diogenes syndrome.

METHODS

We report four cases of Diogenes syndrome discovered during a short-stay geriatric hospitalization. We were able to analyse them as regards social, physical, psychiatric and cognitive aspects.

RESULTS

The results showed absence of socioeconomic precariousness, psychiatric and physical pathologies which generate handicaps. A dementia characterised by a frontal dysfunction was constantly found.

CONCLUSION

Diogenes syndrome seems to be a particular behavioural demonstration of a frontal lobe dementia. It does not correspond to a lucid life choice, which must encourage a medico-social assumption.