Polypoid endometriosis of the Douglas pouch

Polypoid endometriosis is a rare form of endometriosis that corresponds to a benign variant but which systematically mimics malignant tumors. Magnetic resonance imaging (MRI) is the preferred imaging modality for these lesions. We present herein a case of a 43-year-old female with recent pelvic pain and longstanding dyspareunia related to polypoid endometriosis of the Douglas pouch. MRI found an infiltrative lesion 6 cm in diameter with intermediate signal on T2-weighted imaging, cystic hemorrhagic spots, and fibrous surrounding rim of nodular portion. There was no functional sign of malignancy (no diffusion restriction, pronounced tumor enhancement, or metastasis). The patient underwent total abdominal radical colpohysterectomy with bilateral salpingectomy and ovarian transposition was performed. Histopathological examination found a multinodular endometrial-type polypoid mass arising from the serosa of the cervix, with cystic area and fibrous surrounding tissue. In the case presented, MRI findings were useful for preoperative diagnosis that altered patient management by supporting a complete but reasonable surgical resection that yielded relief of symptoms.

Awe and the Experience of the Sublime: A Complex Relationship

Awe seems to be a complex emotion or emotional construct characterized by a mix of positive (contentment, happiness), and negative affective components (fear and a sense of being smaller, humbler or insignificant). It is striking that the elicitors of awe correspond closely to what philosophical aesthetics, and especially Burke and Kant, have called “the sublime.” As a matter of fact, awe is almost absent from the philosophical agenda, while there are very few studies on the experience of the sublime as such in the psychological literature. The aim of this paper is to throw light on the complex relationship between awe (as understood by psychologists) and the experience of the sublime (as discussed by philosophers). We distinguish seven ways of conceiving this relationship and highlight those that seem more promising to us. Once we have a clearer picture of how awe and the experience of the sublime are related, we can use it to enhance collaboration between these domains. We would be able to use empirical results about awe in a philosophical analysis of the experience of the sublime, which in turn can help us to design novel experimental hypotheses about the contexts in which we experience awe.

Social Influence on Metacognitive Evaluations: The Power of Nonverbal Cues

Metacognitive evaluations refer to the processes by which people assess their own cognitive operations with respect to their current goal. Little is known about whether this process is susceptible to social influence. Here we investigate whether nonverbal social signals spontaneously influence metacognitive evaluations. Participants performed a two-alternative forced-choice task, which was followed by a face randomly gazing towards or away from the response chosen by the participant. Participants then provided a metacognitive evaluation of their response by rating their confidence in their answer. In Experiment 1, the participants were told that the gaze direction was irrelevant to the task purpose and were advised to ignore it. The results revealed an effect of implicit social information on confidence ratings even though the gaze direction was random and therefore unreliable for task purposes. In addition, nonsocial cues (car) did not elicit this effect. In Experiment 2, the participants were led to believe that cue direction (face or car) reflected a previous participant's response to the same question—that is, the social information provided by the cue was made explicit, yet still objectively unreliable for the task. The results showed a similar social influence on confidence ratings, observed with both cues (car and face) but with an increased magnitude relative to Experiment 1. We additionally showed in Experiment 2 that social information impaired metacognitive accuracy. Together our results strongly suggest an involuntary susceptibility of metacognitive evaluations to nonverbal social information, even when it is implicit (Experiment 1) and unreliable (Experiments 1 and 2).

Influence of fixation with two vs. three screws on union of arthroscopic tibio-talar arthrodesis: Comparative radiographic study of 111 cases

BACKGROUND

Ankle arthrodesis is a treatment of choice for advanced tibio-talar disease unresponsive to conservative treatment. Using arthroscopy to perform this procedure minimises soft-tissue trauma while providing similar outcomes to those of open surgery. Union rates have ranged across studies from 85% to 100%. The objective of this study was to assess the potential influence on union of the number of screws used for arthrodesis fixation.

HYPOTHESIS

The working hypothesis was that using three screws for arthrodesis produced a higher union rate than did using only two screws.

MATERIAL AND METHODS

This single-centre retrospective comparative study included 111 cases of arthroscopic ankle arthrodesis (in 108 patients) carried out between February 1994 and October 2012. The number of screws was two in 75 cases and three in 36 cases. Union was assessed on radiographs taken 2, 6, and 12months postoperatively.

RESULTS

Mean age at surgery was 55.8years. After 12months, union was achieved in 87.4% cases overall. The non-union rate was 16% with two screws and 5.6% with three screws. Three-screw fixation was associated with a significantly higher rate of union of the medial gutter after 6months and of the lateral gutter after 12months.

DISCUSSION

Our findings support the use of three screws for fixation of arthroscopic tibio-talar arthrodesis. Adding a third screw seems associated with a lower risk of non-union and a shorter time to union. These effects can be ascribed to greater stability of the construct.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Two-stage total hip arthroplasty for complex pelvic abnormalities: Example of hip arthrodesis conversion with concomitant treatment of pelvic and acetabular non-union

Hip prosthesis implantation requires a stable pelvic foundation, which may be lacking in patients with complex pelvic abnormalities (e.g., arthrodesis conversion, tumour excision, or revision with large bony defects). Many reconstructive options exist for these situations, but their outcomes vary with the initial amount of bone loss and with the technique used. We describe a two-stage arthroplasty technique (acetabular cup first, then femoral stem) and report its use in a case of arthrodesis conversion with concomitant treatment of pelvic and acetabular non-union. Clinical and radiological outcomes after 5 years are reported. This procedure can be adapted to the most complex cases of pelvic reconstruction.

Source unreliability decreases but does not cancel the impact of social information on metacognitive evaluations

Through metacognitive evaluations, individuals assess their own cognitive operations with respect to their current goals. We have previously shown that non-verbal social cues spontaneously influence these evaluations, even when the cues are unreliable. Here, we explore whether a belief about the reliability of the source can modulate this form of social impact. Participants performed a two-alternative forced choice task that varied in difficulty. The task was followed by a video of a person who was presented as being either competent or incompetent at performing the task. That person provided random feedback to the participant through facial expressions indicating agreement, disagreement or uncertainty. Participants then provided a metacognitive evaluation by rating their confidence in their answer. Results revealed that participants’ confidence was higher following agreements. Interestingly, this effect was merely reduced but not canceled for the incompetent individual, even though participants were able to perceive the individual’s incompetence. Moreover, perceived agreement induced zygomaticus activity, but only when the feedback was provided for difficult trials by the competent individual. This last result strongly suggests that people implicitly appraise the relevance of social feedback with respect to their current goal. Together, our findings suggest that people always integrate social agreement into their metacognitive evaluations, even when epistemic vigilance mechanisms alert them to the risk of being misinformed.

Is rotator cuff repair appropriate in patients older than 60 years of age? prospective, randomised trial in 103 patients with a mean four-year follow-up

BACKGROUND

The objective of this randomised trial was to compare surgical rotator cuff repair to simple decompression by acromioplasty and biceps tenotomy in patients older than 60 years of age with a mean follow-up of 4 years.

HYPOTHESIS

Tendon repair produces better functional outcomes than simple decompression and prevents progression towards cuff tear arthropathy in the longer term.

PATIENTS AND METHOD

Of 130 initially included patients older than 60 years of age and having rotator cuff tears deemed amenable to surgical repair, 103 (79%) were evaluated after a mean of 4 years. These patients had been randomly allocated to acromioplasty and tenotomy (AT group, n=49) or to acromioplasty, tenotomy, and tendon suture (CR group, n=54). The tear was distal in 41 patients, intermediate in 40, and retracted in 22. At last follow-up, the evaluation included the clinical Constant's Score, radiographs and, in the CR group, ultrasonography.

RESULTS

The complication rate was 4%. The mean Constant Score was 44 preoperatively; values after 4 years were 76 overall (P=0.01), 78 in the CR group, and 73 in the AT group (P=0.01). The tendon-healing rate as assessed using ultrasonography was 63%. The Constant Score was significantly better when tendon healing was achieved (82/73, P<0.001). In the AT group, the acromio-humeral distance was significantly shorter (6.9 mm/7.8mm, P=0.03) and eccentric humeral head position was more common (44%/26%, P=0.01).

DISCUSSION

Arthroscopic rotator cuff repair provides better functional outcomes than does simple decompression in patients older than 60 years and prevents cuff tear arthropathy with eccentric humeral head position in the medium term. Tendon healing is the main determinant of outcomes after rotator cuff repair.

LEVEL OF EVIDENCE

II, randomised trial.

Group B streptococci in milk and late neonatal infections: an analysis of cases in the literature

BACKGROUND

The source for late-onset neonatal infections (LONI) due to group B Streptococcus (GBS) has not been fully explored. We reviewed GBS LONI cases associated with contaminated breast milk to determine whether breast milk was a possible route for neonatal infection.

DATA SOURCES

A PubMed search from January 1977 to March 2013 was performed with MeSH words "Streptococcus agalactiae", "group B Streptococcus", "infection", "milk", "human", "late-onset infection" and/or "neonate"; relevant cross references were also reviewed.

RESULTS

Forty-eight documented cases of GBS LONI matched our search criteria and were retrieved from the literature. When performed, molecular typing identified clonal isolates in the neonate and milk samples taken after LONI in all cases, with the hypervirulent sequence type 17 (ST-17) clone identified in two of these cases. Caesarean delivery combined with the absence of GBS recovery from maternal samples other than milk was noted for four cases. The rate of recurrent infections was high (35%) and, together with the data reviewed, points to a potential role of breast milk in GBS LONI.

CONCLUSIONS

The cases reviewed here, together with the evidence of breast milk transmission for other pathogens, suggest that breast milk, which would account for repeated GBS transmission to the neonate, may favour gut translocation and subsequent LONI. Further investigations are nevertheless needed to study the relative importance of this contamination route compared with persistent postnatal gut colonisation and the dynamics of milk and neonatal gut colonisation.

Distal humerus fractures in patients over 65: complications

INTRODUCTION

Fractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study.

MATERIALS AND METHODS

Four hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up.

RESULTS

The rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments.

DISCUSSION

Complications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome.

Precise control of thermal conductivity at the nanoscale through individual phonon-scattering barriers

The ability to precisely control the thermal conductivity (kappa) of a material is fundamental in the development of on-chip heat management or energy conversion applications. Nanostructuring permits a marked reduction of kappa of single-crystalline materials, as recently demonstrated for silicon nanowires. However, silicon-based nanostructured materials with extremely low kappa are not limited to nanowires. By engineering a set of individual phonon-scattering nanodot barriers we have accurately tailored the thermal conductivity of a single-crystalline SiGe material in spatially defined regions as short as approximately 15 nm. Single-barrier thermal resistances between 2 and 4 x 10(-9) m(2) K W(-1) were attained, resulting in a room-temperature kappa down to about 0.9 W m(-1) K(-1), in multilayered structures with as little as five barriers. Such low thermal conductivity is compatible with a totally diffuse mismatch model for the barriers, and it is well below the amorphous limit. The results are in agreement with atomistic Green's function simulations.

Rapid quantitative procalcitonin measurement to diagnose nosocomial infections in newborn infants

BACKGROUND AND OBJECTIVE

Serum procalcitonin (PCT) monitoring may help clinicians to manage nosocomial infections in neonates. This study investigated the diagnostic value of a new, rapid method to measure PCT and sought to determine the best cut-off value.

METHODS

This monocentric, prospective study included all newborn infants with clinical suspicion of infection in a neonatal intensive care unit. Rapid, automated PCT measurements were performed on blood samples obtained for C-reactive protein (CRP) measurement. Negative and positive predictive values, sensitivity and specificity were calculated. Logistic regression analysis determined the best cut-off value to obtain a negative predictive value of PCT that was at least 15% above that of CRP.

RESULTS

Between June 2005 and May 2006, 73 newborn infants with a median (Q25-Q75) gestational age of 28 (26-30) weeks and a birth weight of 995 (720-1350) g were included. Thirty (41%) were infected. The best PCT cut-off value was 0.6 ng/ml, which provided a negative predictive value of 100%. The sensitivity, specificity and positive predictive value were 100%, 65%, and 67%, respectively, for PCT at the 0.6 ng/ml cut-off value.

CONCLUSION

Rapid measurement of PCT could help to rule out nosocomial infection in newborn infants hospitalised in intensive care units.

[Revelation of an acute lymphoblastic leukemia in the delivery room]

Acute leukemia is uncommon in neonates and has a much poorer prognosis than in older children. We report on a case of acute lymphoblastic leukemia observed in a neonate who had bleeding and hepatosplenomegaly at birth, which justified intensive care during the first postnatal week. Despite early appropriate treatment, the patient died at 7 months of age. We present here physical and laboratory findings, which indicate a grim prognosis. These criteria should be considered carefully in order to ensure a realistic information for the parents and appropriate decisions.

Hypertrophic cardiomyopathy: value of atrial programmed electrical stimulation in patients with or without syncope with special reference to the role of atrial arrhythmias

Hypertrophic cardiomyopathy may be associated with both supraventricular and ventricular arrhythmias, which may play a role in the genesis of syncope. The aim of this study was to assess the findings of electrophysiological study and programmed atrial and ventricular stimulation and their possible role in syncope. Programmed atrial and ventricular stimulation using up to two extrastimuli in right atrium and three in right ventricle at three cycle lengths (600, 400 ms and spontaneous) was systematically performed in 56 patients with hypertrophic cardiomyopathy. Thirty seven had unexplained dizzinesses or syncopes (group I) and 19 did not present loss of consciousness (group II). Patients with syncopes had a higher prevalence of induced sustained supraventricular tachyarrhythmia (73%) than those of group II (16%) (P<0.05). Inducible supraventricular tachycardia was the only finding in 16 patients with syncopes. During the follow-up (3 years+/-6 months), empirical antiarrhythmic therapy suppressed the symptoms, except in two patients who developed atrial fibrillation despite therapy. The high incidence of inducible atrial tachycardia of these patients was not correlated with particular Holter findings or echocardiographic data. However, their mean age was rather high (58+/-12 years). In conclusion, atrial tachyarrhythmias may play a role in syncopes of middle-aged patients with hypertrophic cardiomyopathy. Moreover programmed atrial stimulation is an useful means to identify this syncope mechanism.

[Migration and uneven aging in the regions of France]

Regional differences in the rate of demographic aging in France are examined. The author notes that "contrary to popular belief, of the two factors that contribute to aging, natural trends (births and deaths) still have the edge over the effect of population migrations across regions. The only exception to this is in the Paris area, due to the influence of Paris itself, where youthfulness caused by migrations is on a more or less equal footing with 'natural' aging. Conversely, migration contributes the most to the increase in the average age in the western French regions, with the joint effects of young people leaving and the over-60s returning." (SUMMARY IN ENG AND GER AND SPA)