889 A Window to Individual Surgical Training Plans

Introduction

A recent publication in the Plastic and Reconstructive Surgery journal (Rohrich et al., 2020) has attracted controversy for its generalised approach to “millennial” plastic surgeons. We suggest that surgeons in training, trainers and colleagues need to adjust their focus from the group to the individual in order to maximise clinical performance, quality of working life and quality of care delivered to patients.

Method

We outline a simple model, adapted from the Johari window tool, with the aim of delivering a job and training plan with which all parties are content. It considers individual ability to process scenarios and perform tasks (bandwidth), and the resources available to the individual trainee, to assess each aspect of the role.

Results

No two clinicians have the same strengths and weaknesses, and no two posts are identical. The Johari-like matrix allows trainers and trainees to identify which activities are firmly within the bandwidth and resources of the trainee, those which are clearly not, and those which may cause some concern and require further discussion or modification.

Conclusions

In this model, we suggest a framework which may help surgeons in training and trainers alike and provide a means of recording this longitudinally as individuals or roles evolve.

Investigation of Localized Skin Temperature Distribution Across the Transtibial Residual Limb

BACKGROUND

Interventions to resolve thermal discomfort as a common complaint in amputees are usually chosen based on the residual limb skin temperature while wearing prosthesis; whereas, less attention has been paid to residual limb skin temperature while outside of the prosthesis. The objective of this study was to explore the localized and regional skin temperature over the transtibial residual limb (TRL) while outside of the prosthesis.

METHODOLOGY

Eight unilateral transtibial adults with traumatic amputation were enrolled in this cross-sectional study. Participants sat to remove their prostheses and rested for 30 minutes. Twelve sites were marked circumferentially in four columns (anterolateral, anteromedial, posteromedial, and posterolateral) and longitudinally in three rows (proximal, middle, and distal) over the residual limb and used for attachment of analog thermistors. Skin temperature was recorded and compared for 11 minutes. Furthermore, the relationship of skin temperature with participants' demographic and clinical characteristics was explored.

FINDINGS

The whole temperature of the TRL was 27.73 (SD=0.83)°C. There was a significant difference in skin temperature between anterior and posterior columns. Likewise, the distal row was significantly different from the proximal and middle rows. The mean temperature at the middle and distal zones of the anteromedial column had the highest and lowest skin temperatures (29.8 and 26.3°C, p<0.05), respectively. The mean temperature of the whole TRL had no significant relationships (p>0.05) with participants' demographic and clinical characteristics.

CONCLUSIONS

An unequal distribution of temperature over the TRL was found with significantly higher and lower temperatures at its anterior column and distal row, respectively. This temperature pattern should be considered for thermoregulation strategies. Further investigation of the residual limb temperature with and without prosthesis, while considering muscles thickness and blood perfusion rate is warranted.

Free Fluid Accumulation following Blunt Abdominal Trauma: Potential for Expansion of the Fast Protocol

Objective

To determine sites of free intra-peritoneal fluid collection following blunt abdominal trauma, with a view to refinement of the Focused Assessment by Sonography for Trauma (FAST) protocol.

Methods

This was a retrospective observational study of CT scans of subjects who had suffered blunt abdominal trauma and had free intra-peritoneal fluid detected on CT scan within 24 hours. The depth from the skin and amount of fluid at 14 abdominal sites were determined.

Results

CT scans of 105 patients were examined: 68 (64.8%) were male, mean age 36.7±18.4 years, mean injury severity score 25.4±11.6. Fluid collected most commonly at three sites: right mid-axillary line at the level of the xiphisternum (52 patients, 49.5%), lateral margin of the right rectus muscle at the level of the anterior superior iliac spine (49 patients, 46.7%) and right mid-axillary line at the level of the umbilicus (40 patients, 38.1%). Mean depth of fluid at these sites were 3.6, 3.6 and 4.2 cm, respectively.

Conclusions

Free fluid collects commonly in the area of the right iliac fossa following blunt abdominal trauma. The inclusion of this site in the FAST protocol may increase the ultrasonographic detection of free fluid in the acute trauma setting.

Mechanism of Injury and Clinical Variables in Thoracic Spine Fracture: A Case Control Study

Objective

To determine the mechanisms of injury and clinical findings significantly associated with traumatic thoracic spine (T-spine) fractures.

Methods

This was a case-control study in a tertiary adult trauma centre. Cases were patients admitted with traumatic T-spine fractures between January 1999 and August 2007, inclusive. Each case had two controls matched for gender, age and injury severity. Data were collected from patient medical records and the trauma service database. Factors potentially associated with T-spine fracture were derived from the literature, expert consensus and univariate analysis. Multivariate logistic regression was employed to determine factors significantly associated with T-spine fracture.

Results

Two hundred and sixty one cases and 512 controls were enrolled. Univariate analysis showed the mechanisms of fall from a height ≥2 meters (m) and motorbike accident ≥60 kilometers per hour were significantly associated with T-spine fracture (p<0.001). The clinical findings of thoracic back pain, tenderness, intoxication, step deformity and abnormal neurological symptoms were also significantly associated with T-spine fracture (p<0.05). Multivariate analysis indicated that falls from a height of ≥2 m and thoracic back pain were significantly and positively associated with T-spine fracture (p<0.001). However, intoxication was negatively associated with T-spine fracture.

Conclusions

Patients with T-spine injury are significantly more likely to have fallen from a height ≥2 m or to have had thoracic back pain but less likely to be intoxicated. These findings should be validated prospectively prior to development of clinical guidelines for the identification of patients who may benefit from CT screening of the thoracic spine.

African horse sickness: The potential for an outbreak in disease-free regions and current disease control and elimination techniques

African horse sickness (AHS) is an arboviral disease of equids transmitted by Culicoides biting midges. The virus is endemic in parts of sub-Saharan Africa and official AHS disease-free status can be obtained from the World Organization for Animal Health on fulfilment of a number of criteria. AHS is associated with case fatality rates of up to 95%, making an outbreak among naïve horses both a welfare and economic disaster. The worldwide distributions of similar vector-borne diseases (particularly bluetongue disease of ruminants) are changing rapidly, probably due to a combination of globalisation and climate change. There is extensive evidence that the requisite conditions for an AHS epizootic currently exist in disease-free countries. In particular, although the stringent regulations enforced upon competition horses make them extremely unlikely to redistribute the virus, there are great concerns over the effects of illegal equid movement. An outbreak of AHS in a disease free region would have catastrophic effects on equine welfare and industry, particularly for international events such as the Olympic Games. While many regions have contingency plans in place to manage an outbreak of AHS, further research is urgently required if the equine industry is to avoid or effectively contain an AHS epizootic in disease-free regions. This review describes the key aspects of AHS as a global issue and discusses the evidence supporting concerns that an epizootic may occur in AHS free countries, the planned government responses, and the roles and responsibilities of equine veterinarians.

From guidelines to standards of care for open tibial fractures

INTRODUCTION

The standards for the management of open fractures of the lower limb published by the British Association of Plastic, Reconstructive and Aesthetic surgeons (BAPRAS) and British Orthopaedic Association (BOA) were introduced to improve the treatment received by patients after open injury to the lower limb. These Standards were released after BAPRAS/BOA published Guidelines for the management of open tibial fractures.

METHODS

We wished to determine the impact of these Standards upon the surgical management of open tibial fractures by comparing patients admitted to an orthoplastic centre in the 45 months concluding December 2009 (the Guidelines era) with those admitted during 2011 (the Standards era). Surgical procedures required during the first 30 days and 12 months after injury were determined. Cases were divided into 'directly admitted patients' (DAP) and 'transferred patients' (TP). Standards-era patients were divided further into those who had surgery exclusively at the orthoplastic centre (orthoplastic patients (OPP)) and those transferred after surgery (TASP).

RESULTS

The number of TP trebled in frequency in the Standards era, 25% of whom were transferred before surgery. Significantly fewer surgical procedures were required for DAP and OPP groups compared with TP (and TASP) groups in both eras (Mann-Whitney U-test, p=0.05). DAP and OPP groups during the Standards era underwent the fewest procedures, with the vast majority of cases treated with two or fewer procedures in the first 12 months (88% and 80%, respectively, compared with 61% in the Guidelines era). In the Guidelines era, 44% of TP cases and in the Standards era 39% of TP and 29% of TASP groups underwent two or fewer procedures. Approximately two-thirds of open tibial fractures managed in our orthoplastic centre were patients transferred after surgery. The greatest impact of the Standards was evident for those who underwent surgery exclusively in the orthoplastic centre, reflecting a more deliberate combined strategy.

CONCLUSION

These findings vindicate the Standards as well as mandating reorganisation and resourcing of orthoplastic services to ensure immediate transfer and early combined surgery. By increasing the capacity to deal with time-dependent initial surgery, the surgical burden that the patient must endure, and which the service must provide, are reduced.

Influence of disease process and duration on acute phase proteins in serum and peritoneal fluid of horses with colic

Background

The acute phase proteins (APP) serum amyloid A (SAA), haptoglobin, and fibrinogen are valuable blood biomarkers in equine inflammatory diseases, but knowledge of factors influencing their concentrations in blood and peritoneal fluid (PF) of horses with colic is needed.

Objectives

The objective of this study was to investigate the influence of demographics (age, sex, breed), disease process (simple obstruction, strangulating obstruction, inflammatory), disease location, disease duration, hypovolemia, and admission hospital on concentrations of APP, lactate and white blood cell counts (WBC) in horses with colic admitted to 2 referral hospitals.

Animals

The study included 367 horses with colic admitted at 2 referral hospitals.

Methods

Prospective multicenter observational study of clinical data, as well as blood and PF biomarkers. Associations between biomarker concentrations and clinical variables were analyzed using multivariate linear regression analysis.

Results

Increasing pre‐admission duration of colic was associated with increased concentrations of APP in blood and PF. Blood concentrations of SAA and fibrinogen were associated with disease process (inflammatory, strangulations, simple obstructions) in more colic duration groups (5–12 and >24 hours) than any of the other biomarkers. No relevant associations between demographic factors, hospital, or hydration status and the measured biomarkers were found.

Conclusions and Clinical Importance

In horses with colic, concentrations of APP are associated mainly with disease process and duration of colic and may thus be used for assessment of disease independently of demographic or geographic factors. Serum amyloid A may be a diagnostic marker for use in colic differential diagnosis, but further evaluation is needed.

Multicolumn spinal cord stimulation for significant low back pain in failed back surgery syndrome: design of a national, multicentre, randomized, controlled health economics trial (ESTIMET Study)

BACKGROUND

Many studies have demonstrated the efficacy of spinal cord stimulation (SCS) for chronic neuropathic radicular pain over recent decades, but despite global favourable outcomes in failed back surgery syndrome (FBSS) with leg pain, the back pain component remains poorly controlled by neurostimulation. Technological and scientific progress has led to the development of new SCS leads, comprising a multicolumn design and a greater number of contacts. The efficacy of multicolumn SCS lead configurations for the treatment of the back pain component of FBSS has recently been suggested by pilot studies. However, a randomized controlled trial must be conducted to confirm the efficacy of new generation multicolumn SCS. Évaluation médico-économique de la STImulation MEdullaire mulTi-colonnes (ESTIMET) is a multicentre, randomized study designed to compare the clinical efficacy and health economics aspects of mono- vs. multicolumn SCS lead programming in FBSS patients with radicular pain and significant back pain.

MATERIALS AND METHODS

FBSS patients with a radicular pain VAS score≥50mm, associated with a significant back pain component were recruited in 14 centres in France and implanted with multicolumn SCS. Before the lead implantation procedure, they were 1:1 randomized to monocolumn SCS (group 1) or multicolumn SCS (group 2). Programming was performed using only one column for group 1 and full use of the 3 columns for group 2. Outcome assessment was performed at baseline (pre-implantation), and 1, 3, 6 and 12months post-implantation. The primary outcome measure was a reduction of the severity of low back pain (bVAS reduction≥50%) at the 6-month visit. Additional outcome measures were changes in global pain, leg pain, paraesthesia coverage mapping, functional capacities, quality of life, neuropsychological aspects, patient satisfaction and healthcare resource consumption.

TRIAL STATUS

Trial recruitment started in May 2012. As of September 2013, all 14 study centres have been initiated and 112/115 patients have been enrolled. Preliminary results are expected to be published in 2015.

TRIAL REGISTRATION

Clinical trial registration information-URL: www.clinicaltrials.gov. Unique identifier NCT01628237.

Presence of digital dermatitis treponemes on cattle and sheep hoof trimming equipment

Digital dermatitis (DD) is an infectious foot disease causing severe lameness in dairy cattle (worldwide) and sheep (UK). This study investigated whether DD Treponema phylogroups can be present on equipment used to trim ruminant hooves and, therefore, consider this trimming equipment as a possible vector for the transmission of DD. Equipment was tested after being used to trim DD symptomatic and asymptomatic cattle and sheep hooves, and subsequently after disinfection of equipment. After trimming, 'Treponema medium/Treponema vincentii-like', 'Treponema phagedenis-like' and 'Treponema denticola/T putidum-like' DD spirochaetes, were shown to be present on 23/37 (62%), 21/37 (57%) and 20/37 (54%) of knives, respectively. After disinfection, detection rates for the DD treponemes were 9/37 (24%), 6/37 (16%) and 3/37 (8%), respectively. Following culture of a swab, an isolate belonging to the T phagedenis-like spirochaetes was identified from a knife sample after trimming a DD positive cow. No isolates were obtained from knife samples after disinfection. This new data has, for the first time, identified treponemes in the farm environment, and highlighted disinfection of hoof trimming equipment between animals and between farms, as a logical precaution to limit the spread of DD.

Critical role of Nox4-based NADPH oxidase in glucose-induced oxidative stress in the kidney: implications in type 2 diabetic nephropathy

Molecular mechanisms underlying renal complications of diabetes remain unclear. We tested whether renal NADPH oxidase (Nox) 4 contributes to increased reactive oxygen species (ROS) generation and hyperactivation of redox-sensitive signaling pathways in diabetic nephropathy. Diabetic mice ( db/ db) (20 wk) and cultured mouse proximal tubule (MPT) cells exposed to high glucose (25 mmol/l, d-glucose) were studied. Expression (gene and protein) of Nox4, p22phox, and p47phox, but not Nox1 or Nox2, was increased in kidney cortex, but not medulla, from db/ db vs. control mice ( db/ m) ( P < 0.05). ROS generation, p38 mitogen-activated protein (MAP) kinase phosphorylation, and content of fibronectin and transforming growth factor (TGF)-β1/2 were increased in db/ db vs. db/ m ( P < 0.01). High glucose increased expression of Nox4, but not other Noxes vs. normal glucose ( P < 0.05). This was associated with increased NADPH oxidase activation and enhanced ROS production. Nox4 downregulation by small-interfering RNA and inhibition of Nox4 activity by GK-136901 (Nox1/4 inhibitor) attenuated d-glucose-induced NADPH oxidase-derived ROS generation. High d-glucose, but not l-glucose, stimulated phosphorylation of p38MAP kinase and increased expression of TGF-β1/2 and fibronectin, effects that were inhibited by SB-203580 (p38MAP kinase inhibitor). GK-136901 inhibited d-glucose-induced actions. Our data indicate that, in diabetic conditions: 1) renal Nox4 is upregulated in a cortex-specific manner, 2) MPT cells possess functionally active Nox4-based NADPH, 3) Nox4 is a major source of renal ROS, and 4) activation of profibrotic processes is mediated via Nox4-sensitive, p38MAP kinase-dependent pathways. These findings implicate Nox4-based NADPH oxidase in molecular mechanisms underlying fibrosis in type 2 diabetic nephropathy.

Abrupt regression of a meningioma after discontinuation of cyproterone treatment

The multiplicity of meningiomas or abrupt lesion growth in patients treated with cyproterone acetate suggests that this progestative treatment may promote lesion growth. We report the rapid regression of an incidental meningioma after discontinuation of a 10-year cyproterone acetate treatment. This unique observation suggests that conservative management of meningiomas may be the best option among users of high doses of cyproterone acetate, given that spontaneous regression may occur after hormonal treatment discontinuation.

Endovascular coil transfixing a cranial nerve five years after embolisation

After endovascular coiling, several authors have reported refilling of the aneurysm, appearance of a mass effect, coils protruding into the parent artery, migration of coils into parent artery or through aneurysm wall, and compression of the parent artery by coil impaction. This is the first report of an endovascular coil transfixing a cranial nerve. We present a 59 year old man who presented with a symptomatic bilobulated aneurysm of the right internal carotid artery. The aneurysm was embolised by endovascular coiling. Angiographic follow up showed occlusion of the aneurysm. Five years later, the patient complained of progressive diplopia with ptosis. Follow-up angiography showed renewed filling of the aneurysm at its neck. The aneurysm was clipped surgically. At operation, a coil mass effect was noted and one coil penetrated the fibres of the right oculomotor nerve.

Cavernomes du tronc cérébral: l'expérience chirurgicale du centre hospitalier Sainte-Anne

BACKGROUND AND PURPOSE

No standard treatment for brainstem cavernoma has been established because of the lack of sufficient data about the natural history of these lesions in a highly functional location with potential difficult surgical accessibility.

METHODS

We present a series of 82 brainstem cavernomas managed at the Sainte-Anne Hospital. Surgery was undertaken for 25 with stereotactic biopsy for 9 and direct surgery for 19 (3 after biopsy).

RESULTS

Surgical outcome was good or fair for 17 patients. Two patients worsened and one died. Biopsy results were disappointing with high morbidity (4 patients with 2 permanent deficits). Histological diagnostic was possible for all biopsies.

CONCLUSION

In light of these results, an active surgical attitude could be proposed for cavernomas in an accessible locations which have produced at least one previous hemorrhage. Stereotactic biopsies for suspect brainstem cavernoma must be avoided.

Angiogenic gene therapy in patients with nonrevascularizable ischemic heart disease: a phase 2 randomized, controlled trial of AdVEGF121 (AdVEGF121) versus maximum medical treatment

The demonstration that angiogenic growth factors can stimulate new blood vessel growth and restore perfusion in animal models of myocardial ischemia has led to the development of strategies designed for the local production of angiogenic growth factors in patients who are not candidates for conventional revascularization. The results of recent clinical trials of proangiogenesis gene therapy have been disappointing; however, significant limitations in experimental design, in particular in gene transfer strategies, preclude drawing definitive conclusions. In the REVASC study cardiac gene transfer was optimized by direct intramyocardial delivery of a replication-deficient adenovirus-containing vascular endothelial growth factor (AdVEGF121, 4 x 10(10) particle units (p.u.)). Sixty-seven patients with severe angina due to coronary artery disease and no conventional options for revascularization were randomized to AdVEGF121 gene transfer via mini-thoracotomy or continuation of maximal medical treatment. Exercise time to 1 mm ST-segment depression, the predefined primary end-point analysis, was significantly increased in the AdVEGF121 group compared to control at 26 weeks (P=0.026), but not at 12 weeks. As well, total exercise duration and time to moderate angina at weeks 12 and 26, and in angina symptoms as measured by the Canadian Cardiovascular Society Angina Class and Seattle Angina Questionnaire were all improved by VEGF gene transfer (all P-values at 12 and 26 weeks < or =0.001). However, if anything the results of nuclear perfusion imaging favored the control group, although the AdVEGF121 group achieved higher workloads. Overall there was no significant difference in adverse events between the two groups, despite the fact that procedure-related events were seen only in the thoracotomy group. Therefore, administration of AdVEGF121 by direct intramyocardial injections resulted in objective improvement in exercise-induced ischemia in patients with refractory ischemic heart disease.

[Adult supratentorial oligodendrogliomas. Surgical treatment: indications and techniques]

Surgical resection is the first step in the treatment of adult supratentorial oligodendrogliomas (OLG). However, the role of resection on prognosis, the most appropriate time for surgery along the natural history of those tumors, and the best operative strategy remain debated. Survival curves after resection vary greatly among reported series, in particular as a result of a persisting confusion in identification and classification of cerebral OLG. Surgical or stereotactic biopsy is the first surgical procedure which enables confirmation of the diagnosis suggested on imaging, assessment of extension of tumor cell infiltration beyond abnormalities limit described an imaging, and currently available molecular biology studies. Biopsies may be the only surgical procedure in patients having a deep-seated tumor with minimal mass effect, or prior to a surgical resection or a "wait and watch" strategy. Surgical resection is indicated for the other patients. However, it has not been demonstrated that time for resection has an influence on survival, excepted in patients with rapidly growing tumors, with mass effect causing increased intracranial pressure. A wait and watch strategy is therefore warranted in patients with a tumor aspect suggestive of a grade A OLG; surgical resection may be indicated later. There is a current trend for maximal safe resection, preserving functional cerebral areas, since truly complete resection of the tumor including infiltration is exceptional. However, from the contradictory results reported to date, one cannot ascertain whether large or complete resection based on imaging is associated with significantly longer survival. Neuronavigation guidance, intraoperative imaging, and cortical stimulation techniques are helpful neurosurgical techniques enabling maximal safe resection with preservation of functional areas.

[Results of the Sainte-Anne - Lyons series of 318 oligodendroglioma in adults]

INTRODUCTION

Incidence of cerebral oligodendrogliomas is increasing because of better recognition made possible by improved classifications. We studied a homogeneous series using the Sainte-Anne grading scale in order to better understanding the history of these tumors with or without treatment and to assess prognosis and associated factors.

PATIENTS AND METHODS

A retrospective series of 318 adult patients with oligodendroglioma (OLG) treated at Hôpital Sainte-Anne, Paris (SA) and Hôpital Neurologique, Lyons (L) between 1984 and 2003 was analyzed: 182 grade A OLG (SA + L), 136 grade B among which a homogenous series of 98 (SA) were included. For grade A: age at diagnosis ranged from 21 to 70 (mean: 41), sex ratio was 1.28. For grade B: age at diagnosis ranged from 12 to 75 (mean: 45.5), sex-ratio was 1.58. The main first symptoms were: epilepsy (A: 91.5%; B: 76%), intracranial hypertension (A: 7.9%; B: 14.6%), neurological deficit (A: 5.1%; B: 17.7%). The most frequent locations were: frontal, insular and central for both A and B. Mean size was 55 mm for grade A, 62 mm for B. Calcifications were found in 20% of A, 48.5% of B. No tumor was enhanced on imaging (CT/MRI) in grade A, all but 7 in grade B. All patients underwent surgery either for biopsy (A: 47.2%; B: 53%), or removal which was partial (A: 26.4% vs B: 19.4%) or extended (A: 36.3% vs B: 37.8%). Fifty-six patients underwent 2 procedures and 12 three procedures. Radiotherapy was performed in 76.9% of grade A, and 91% of B patients, in the immediate postoperative period for 71% A and 82.7% B. Chemotherapy was delivered for 36% of grade A (in the event of transformation to grade B or failure of radiotherapy) and 67.5% of B patients. Among grade A tumors, 38% transformed into grade B within a mean delay of 51 months with a mean follow-up of 78 months.

RESULTS

Median survival was 136 months for grade A and 52 for grade B. Survival at 5, 10 and 15 was 75.5%, 51% and 22.4% for grade A vs 45.2%, 31.3% and 0% for grade B respectively. In univariate and multivariate analysis, grade A survival was associated with age at diagnosis, tumor size, large removal and response to radiotherapy. Grade B survival was associated with age at diagnosis, wide removal and sharply defined limits of the tumor on imaging.

CONCLUSIONS

Analysis of both published data and this series underlines many prognostic parameters. It shows that OLG are heterogeneous tumors even in each grade (A and B). Treatment should consequently progress towards more targeted procedures for patients mainly with postoperative radiotherapy and chemotherapy.

Suprasellar paraganglioma: a case report and review of the literature

Paragangliomas arising in the suprasellar region are extremely rare. We report a case of suprasellar paraganglioma in a 47-year-old man who presented with amnesia and impaired visual acuity without any endocrine dysfunction. Magnetic resonance imaging (MRI) showed a large enhancing tumour in the suprasellar area. Following subtotal surgical excision, the diagnosis of paraganglioma was confirmed by pathology. In this case report we describe the MRI pattern of suprasellar paraganglioma and review the literature of this uncommon lesion.

[Adenocarcinomas of the ethmoid sinuses. Epidemiological data]

OBJECTIVE

The relationship between adenocarcinomas of the ethmoid (ADKE) and wood-dust exposure has been well established. Sino-nasal cancer in wood-workers has been added to the list of occupational disorders in France, as prescribed disease number 47-Bq.

PATIENTS AND METHODS

Our data set consisted of 207 cases with sino-nasal cancer (from January 1985 to January 2001). Among these cases, 67.1% were adenocarcinoma. A wood dust exposure has been reported in 96.4% cases. The mean duration of wood dust exposure was 30 years. The mean latency between the end of the exposure and the diagnostic was 10.6 years.

RESULTS

Our epidemiological data confirmed those from the biomedical literature. The occupations at greatest risk are furniture workers, sawmill workers, carpentry workers, and other wood product workers. Two components of exposure - duration and average level - contributed independently to the overall elevated risk. The risk is greater among men who were employed in jobs with the highest wood dust exposure and increases with the duration of exposure.

CONCLUSIONS

The preinvasive stages of ADKE (mucostasis/cuboïd metaplasia/dysplasia) are still an unverified hypothesis. ADKE were observed in workers who use "hard" woods. The chemical nature of the carcinogenic factor(s) in wood dust is not known. The factors responsible for induction of ADKE in hard wood-workers probably exist in the wood-dust itself. Tannins were suggested as possible contributing agents to induction of ADKE. In addition to wood dust, exposures may include formaldehyde. Given these facts, it should be possible to define preventive measures, so that incidence of ADKE in professional wood and leather workers should decrease.

[The endonasal approach to pituitary adenomas: experience in 105 procedures]

OBJECTIVE

The endonasal approach to the sella turcica is supposed to simplify surgical techniques and reduce the risk and sequelae linked to removal of pituitary adenomas. We report our experience with 105 procedures using this approach.

METHOD

The series included 45 men and 60 women, aged 17 to 83 years. Their intrasellar lesions were: 43 non-functional adnomas, 37 prolactinomas, 7 GH- adenomas, 9 corticotrop adenomas, 9 miscellaneous lesions (abscess, Rathke cleft cysts, empty sella). Mean duration of the procedures was 50 minutes. Mean hospital stay was 4 days.

RESULTS

There were no deaths. Morbidity included: 1 (0.95%) rhinorrhea associated with meningitis which cured without sequelae, 11 (10.5%) transient diabetes insipidus lasting no longer than 48 hours, 2 cases of permanent diabetes insipidus (1 non-functional macroadenoma, 1 pituitary abscess), 1 transient hyposmia (3 months), 2 transient nasal obstructions. There were no cases of septal perforation, nasal deformation, partial or complete mucosal anesthesia, nasal pain, dental pain, or epistaxis.

CONCLUSION

This surgical approach is easier to perform and causes less rhinological sequelae than the sublabial transsphenoidal approach. It allows an as effective tumor removal than the latter. Hospitalization stay is significantly shortened.

[The role of surgery in the treatment of prolactinomas]

TECHNIQUE

Almost all prolactinomas are operated through a transsphenoidal route, even in case of significant suprasellar extension or intracavernous invasion. Since 1996, we use the only endonasal route which is easier, quicker, less haemorrhagic and less aggressive than the sublabial one. If the removal of a large macroadenoma cannot be completed (50-70% of cases), a second procedure, usually transsphenoidal, is performed a few weeks later.

INDICATIONS

Microprolactinomas: usually surgery is proposed as soon as medical treatment is not well tolerated or if the patient wishes to be pregnant. Macroprolactinomas: bromocriptine or quinagolide are sometimes prescribed in a first stage. Surgery beeing indicated in case of inefficacy or intolerance of the medical treatment, or in emergency due to an acute visual pathways compression (tumoral necrosis). Giant adenomas (= 30-40 mm): usually dopaminergic agonists allow a tumoral volume reduction and assure a limitation of visual risks due to rapid decompression of visual pathways. Exceptionally, medical treatment leads to a complete regression of the adenoma.

RESULTS

Morbidity of transsphenoidal procedures: insipidus diabetes: transient 5-15%, definitive: 1-2%; septal perforation: 3-5%; rhinorrhea: 5%; visual aggravation: 2%. The most frequent complaint for patients operated through sublabial route is gum and dental pain, non-existent with endonasal procedures. Operative mortality: 0-1.7% (0% in our series). In men, normalization of prolactinemia is linked to the tumoral volume: 90-100% in case of microprolactinoma, 30-35% for enclosed macroprolactinomas, 0-5% for invasive macroprolactinomas. Conventional, conformational or stereotactic radiotherapy can be useful in case of contraindication to surgery and failure of medical treatment.

Magnetic resonance imaging of the wrist ligaments

The advent of small arthroscopes has enabled the hand surgeon to visualize the ligaments of the wrist directly with resultant increased accuracy in diagnosing and treating pathology. Orthopaedists are now demanding a preoperative assessment and this, in turn, has necessitated that radiologists have a comprehensive understanding of wrist anatomy. High resolution MR imaging can identify the wrist ligaments reliably and provide information concerning their integrity. Interpretation is not straightforward; there is considerable anatomic variation, and there are perforations, defects and degenerative tears that can be troublesome in diagnosing injury. However, with experience and attention to anatomic detail, the radiologist can provide useful information regarding structural abnormalities. When injured, the ligaments of the wrist behave as other joint ligaments do. Findings following injury include discontinuity of normal striated bands, incomplete disruption, irregularities and alteration in normal signal. Fluid pooling around a ligament and concomitant bone injury are other clues to injury. The identification of such structural abnormalities may help to explain altered biomechanics and improve the management of patients following wrist injury.

[Course of headaches associated with cAVMs after radiosurgery]

The purpose of this study is to evaluate the response of headaches associated with cerebral arteriovenous malformations following radiosurgery and determine the factors that are associated with a positive outcome. From our series of 700 patients whose cAVM was treated by radiosurgery, this study includes 109 patients (48 males, 61 females) with a mean age of 32 when radiosurgery was performed. Headaches resolved in 37 patients (53.7%), decreased in 14 patients (20.3%), persisted in 16 patients (23.2%), and even increased in frequency in 2 (2.9%). Headaches disappeared 2 years following radiosurgery in the majority of patients (31 out of 37: 83.3%). The disappearance rate of headaches was better when it was the only sign of the malformation (64%) or preceded an epileptic seizure (60%) with respect to the case when it preceded cerebral hemorrhage (34.8%). Headaches having the best response were those with 1 to 2 episodes per month (64.9%) and whose episode duration was less than 3 hours (67.6%). Unilateral headaches accounted for 86.5% of resolved headaches whereas bilateral headaches were only 8.1% and even less were the diffuse ones (5.4%). The best evolution was obtained for those associated with a parietal location of the cerebral arteriovenous malformation, followed by rolandic (respectively 55.5% and 50%). Occipital malformation was associated with headache disappearance in 38.1% and temporal with 34.3%, whereas frontal location was associated with headache disappearance in only 25% of the cases. Headache disappearance was often correlated with cerebral arteriovenous malformation outcome after radiosurgery (64.9% of disappearance in case of complete obliteration). However, in 24.8%, headaches disappeared prior to the malformation obliteration and were associated with a decrease of the flow, of the nidus volume or with the nidus disappearance with the persistence of a precocious venous drainage. Headaches disappeared in spite of the malformation persistence in 5.4% of the cases. We found de novo headaches in one patient one year following RS. Another patient presented an episode of headache 12 hours following RS. The course of headaches associated with cerebral arteriovenous malformations after radiosurgery is positive in the majority of cases and correlated to the malformation outcome. This correlation suggests a link between cerebral arteriovenous malformations and headaches and the equal benefit of radiosurgery on both of them.

[Surgical removal of radio-induced lesions after radiosurgery of cerebral arteriovenous malformations]

Radioinduced lesions after radiosurgery of cerebral arteriovenous malformations may be associated with an increased signal on T2-weighted and gadolinium enhancement on T1-weighted MR images. They do not have necessarily a poor prognosis. These lesions are mostly asymptomatic. But in a few cases they can be associated with severe clinical symptoms which can become corticodependant or corticoresistant. We present the 5 cases of such cerebral arteriovenous malformations treated by radiosurgery, out of our series of 705 patients. The removal was easier than that of untreated cerebral arteriovenous malformations, and led to a complete recovery of symptoms and progressive decrease of imaging abnormalities. Such surgery should be proposed in case of symptomatic radioinduced lesions which fail to respond to steroids.

[Evolution of epileptic seizures associated with cerebral arteriovenous malformations after radiosurgery]

The goal of this study is to evaluate the response of epileptic seizures associated with cerebral arteriovenous malformations following radiosurgery and determine the factors associated with a positive outcome. The series included 210 patients (123 men, 87 women) with a mean age of 33. One hundred seventy three patients out of 210 were controlled after radiosurgery. Seizures completely disappeared in 58% of cases and decreased in 18%. Anti-epileptic treatment was stopped in 44%. Sex and age upon seizure appearance were not found as determining factors in patients whose seizures disappeared after radiosurgery. Generalized seizures disappeared following radiosurgery in 90.7%, partial secondary generalized seizures in 53.5%, and partial seizures in only 39.6%. Frontal or temporal malformations are associated with a better response after radiosurgery than sylvian or rolandic location. Seizure disappearance was maximal in case of isolated seizure prior to the radiosurgery (84.4%), was reduced to 61.2% when seizures were limited to 2 to 20, and disappeared in 21.4% in severe seizures. Epilepsy present less than 3 years prior to radiosurgery disappeared in 71.9%; was reduced to 45% when the delay was over 3 years. Seizures disappeared in 64.4% when the malformation was obliterated, they were reduced to 46.9% when malformations persisted. The persistence of severe seizures following radiosurgery was linked to persistence of the malformation. On the other hand early seizures occurred in 3.3% during the first 48 hours following radiosurgery; they disappeared in 72.2% after that period. De novo seizures also occurred in 1.7% and disappeared in all these cases. In conclusion, seizures associated with cerebral arteriovenous malformations respond well to radiosurgery; the malformation obliteration evokes its association with the seizure; the seizure disappearance in spite of persistence of the malformation evokes the positive effect of radiotherapy on epileptic seizures.

[Cerebral arteriovenous malformations treated by radiosurgery: a series of 705 cases]

BACKGROUND AND PURPOSE

After a review of the main radiosurgical published series, to evaluate our own series of 705 patients with cerebral arteriovenous malformations treated by radiosurgery alone or in combination with embolization or surgery.

PATIENTS

and method. From January 1984 to December 1998, 705 patients were treated by a multidisciplinary team including neurosurgeons, neuroradiologists, radiophysicians and radiotherapists. Age of revelation of the cerebral arteriovenous malformations ranged between birth to 73 years (mean 27, median 25). Age at time of radiosurgery ranged between 7 and 75 years (mean 33, median 31). There were 410 males for 295 females (sex- ratio 1.4). Symptoms of revelation were hemorrhage for 59%, seizures for 23%, headaches for 14% and progressive deficits for 4%. Discovery of cerebral arteriovenous malformation was fortuitous in 4% of cases. Repartition following Spetzler's grading was 12% in grade I, 36% in grade II, 40% in grade III, 12% in grade IV and 0% in grade V. Maximal size ranged between 4 and 60 mm (mean 23, median 20). Volume ranged between 0.2 and 24.3 cc (mean 3.8, median 2.8). Majority of cerebral arteriovenous malformations were large size (42% with size higher than 25 mm) and large volume (54% higher than 10 cc. 54% of patients had treatment prior radiosurgery: 38% had embolization, 10% were operated, 4% were treated by radiosurgery (reirradiation) and 3% were operated and embolized.

RESULTS

Overall complete obliteration rate was 55%. The obliteration rate was correlated with size (77% for cAVMs lower than 15 mm, 62% for cerebral arteriovenous malformations between 15 and 25 mm, and 44% for cerebral arteriovenous malformations higher than 25 mm), with volume (94% for cerebral arteriovenous malformations lower than 1 cc, 64% between 1 and 4 cc, 48% between 4 and 10 cc, and 62% for cerebral arteriovenous malformations higher than 10 cc), dose at reference isodose, minimal dose, morphological parameters (presence of dural components, arteriolovenous fistula, plexiform angioarchitecture, arterial steal, arterial recruitment, deep exclusive drainage, venous plicature, venous confluence, venous ectasia, venous reflux), sectional topography and good recovery of the target. Embolization was a confusion factor not associated with obliteration rate. After multivariate analysis, only Dmin and complete coverage of the cerebral arteriovenous malformations were correlated with obliteration rate. Delay of obliteration was significantly correlated after multivariate analysis with Dmin, complete coverage, arteriolovenulary angioarchitecture (positive correlation) and venous ectasia (negative correlation).

CONCLUSION

Overall complete obliteration rate is unreliable data to assess efficacy of radiosurgical method in the tretment of cerebral arteriovenous malformations. The obliteration rate must be interpretated after stratification on several morphological and dosimetric parameters.

Quality of care-risk adjustment outcomes model: testing the effects of a community-based educational self-management program for children with asthma

This article describes the design of an outcomes model incorporating adjustment for patients' risks for various outcomes of care. A community-based educational self-management program for children with asthma is proposed for testing the model. Measures of model components: clinical factors; nonclinical factors; psychological, cognitive, and psychosocial functioning; and patient and client satisfaction are described. Testing this model has implications for guiding the development of individualized culturally sensitive nursing interventions for children with asthma and their parents.

Subcranial fronto-orbito-nasal approach for ethmoidal cancers surgical techniques and results

BACKGROUND

The authors report their experience with the subfronto-orbito-nasal approach (SFON) for the treatment of 30 patients suffering from ethmoidal cancers over the past 3 years. The advantages and pitfalls of this technique are described and compared with other classic approaches.

METHODS

Among 156 patients suffering from ethmoidal cancers and treated between January 1984 and January 1998, 30 patients were operated on using the SFON approach during the past 3 years. There were 27 males and 3 females, ranging in age from 15 to 77 years. Histologic composition of the lesions was as follows: 15 adenocarcinomas, 6 esthesioneuroblastomas, 3 melanomas, 2 epidermoid carcinomas, 1 nondifferentiated carcinoma, 1 neuroendocrine carcinoma, 1 villous carcinoma, and 1 cystic adenoid carcinoma (cylindroma). According to the authors' classification, 7% were T1, 6% T2, 22% T3, 38.5% T4a, and 26.5% T4b. All patients were operated on through a SFON approach, followed by removal of the tumor and reconstruction of the skull base with a pericranial flap.

RESULTS

Since the mean follow-up was of short duration (12 months, ranging from 3 to 29 months), significant carcinologic results could not be obtained. However, a detailed analysis of the surgical procedure was performed. No patient died or had major complications related to the SFON approach. One cerebrospinal fluid (CSF) fistula and four oculomotricity dysfunctions were observed. Definitive anosmia was reported in all cases.

CONCLUSION

The advantages of the procedure include a wide exposure of the anterior skull base through a limited approach, the possibility of modifying the approach according to the size and location of the lesion, total resection of tumors, simplified skull base reconstruction technique, and reduction of postoperative confusion and hospital stay.