[Impact of positive surgical margins on prostate cancer prognosis]

OBJECTIVE

To examine the impact of positive surgical margins (PSM) after radical prostatectomy (RP) for prostate cancer on oncological results.

PATIENTS AND METHODS

We performed a study where all patients who underwent radical prostatectomy between January 2004 and December 2018 for prostate cancer were included. The preoperative, postoperative data and the carcinological results collected were analyzed. Data were analysed using Kaplan-Meier survival analysis and proportional hazards models.

RESULTS

A total of 319 patients with a median age of 65 years (IQR : 62-69) were included. The median follow-up was 43.6 months (IQR: 19.4-79.3). The overall rate of PSM was 33.5%. PSM was associated with biochemical recurrence (P<0.001). Overall mortality was not associated with positive margins. A clinical stage> T1c was an independent predictor of PSM on multivariate analysis (P=0.01).

CONCLUSION

PSM would increase the risk of biochemical recurrence with no impact on survival. Clinical stage>T1c was an adverse predictor for PSM.

LEVEL OF EVIDENCE

3.

[Impact of antiplatelet and anticoagulant treatments on bleeding complications in patients treated with HoLEP]

INTRODUCTION

We aimed to assess the impact of antiplatelet and anticoagulation therapy for patients undergoing HoLEP.

METHODS

We performed a study during the learning curve on a consecutive series of patients who underwent HoLEP surgery from 2015 to 2018. The patients were divided into 3 groups: a control group, patients with antiplatelet therapy and patients with anticoagulation therapy.

RESULTS

A total of 223 patients underwent HoLEP surgery during this period: 124 in the control group, 63 in the antiplatelet group and 36 in the anticoagulant group. In the anticoagulant group, we observe significant differences with the control group for the catheterization time (2.05 days vs 5.17 days; P<0.001), the hospital length of stay (1.5 nights vs 4.49 nights; P<0.001) and complications (8.9% vs 58%; P<0.001). No difference between the control and antiplatelet groups in terms of catheterization time, hospital length of stay and complications (2.05 days vs 2.68 days; 1.5 nights vs 1.6 nights) but variation in terms of complications and bleeding complications (8.9% vs 21%; P<0,001; 8.1% vs 19%; P<0,001) CONCLUSION: Our study shows that HoLEP is therefore associated with a higher risk of bleeding for patients treated with anticoagulation therapy. Complications increase morbidity with longer catheterization time, hospitalization times and higher transfusion's rates, revision surgery and readmission.

LEVEL OF EVIDENCE

3.

[Result of treatment of urinary lithiasis for professional aptitude]

INTRODUCTION

Military people are inapt for presence of urinary stones. In this specific population, the treatment of stones is even more aggressive than for the general population without recommendation. The final decision about aptitude is the responsibility of the military doctor. Whereas, ureteroscopy has its place there and must done by any urologist.

METHODS

The purpose of this study was to estimate the results of treatments by ureteroscopy in this population. Success was defined by the complete absence of fragment visualized in the imaging of control operating comment and so the end of the inaptitude time.

RESULTS

Between 2009 and 2016, forty-two were treated for ureteral or renal calculi. The population comprises of 93% men, 35 years old on average. The stones were mainly multiple (more 2) and the medium size is 5mm; sixteen (42.9%) was at the left and eight (19%) was bilateral. In 78.8% (78) of the cases there was a stone in renal position whose 50% (39) still at the lower calyx. In total, 5% of the patients were stone-free in 2 sessions on average. The average deadline of inaptitude of the initial consultation in the resumption of work was of 6 months. In 4% of the cases there was a complication operating rank 4.

CONCLUSION

This study confirms the feasibility, the weak harmlessness of ureteroscopy and the lesser deadline of inaptitude. Every urologist can treat this specific population. The patient must be informed and accept the treatment because of excluding referential.

LEVEL OF EVIDENCE

4.

[Oncological results of active surveillance in prostate cancer: A retrospective multicentric cohort]

PURPOSE

To report oncological outcomes of patients with prostate cancer undergoing active surveillance according to SURACAP criteria.

METHODS

This multicentric study included patients who were initially treated with active surveillance for localized prostate cancer according to the SURACAP criteria. The duration of active surveillance as well as the causes of discontinuing the protocol and the definitive pathological results of patients who further underwent radical prostatectomy were retrospectively evaluated. The predictors of discontinuing active surveillance were assessed using a univariable Cox Model. In addition, the predictive value of initial MRI was assessed for patients who performed such imagery.

RESULTS

Between 2007 and 2013, 80 patients were included, with a median age of 64 years [47-74]. Median follow-up was 52.9 months [24-108]. At 5 years follow-up, 43.4% patients were still under surveillance. Among patients that underwent surgery, 17.8% had an extra-capsular extension. The risk of discontinuing was not significantly greater for patients with tumor size of 2 or 3mm versus 1mm (HR=0.9 [0.46-1.75], P=0.763), 2 positives cores versus 1 (HR=0.98 [0.48-2.02], P=0.967), T2a vs. T1c stage (HR=2.18 [0.77-6.18], P=0.133), increased PSA level (HR=1 [0.96-1.15], P=0.975) or the patient's age (HR=1 [0.93-1.16], P=0.966). Among the 50 patients who performed initial MRI, the results of such imagery was not significantly associated to the risk of discontinuing active surveillance MRI (HR=1.49 [0.63-3.52], P=0.36).

CONCLUSION

Although this study reveals a high rate of release from active surveillance at 5 years, the rate of extra-capsular tumors reported in the group of patients that underwent surgery is among the lowest in literature.

LEVEL OF EVIDENCE

4.

Influence of barley malting operating parameters on T-2 and HT-2 toxinogenesis of Fusarium langsethiae, a worrying contaminant of malting barley in Europe

The fungus Fusarium langsethiae, exclusively described in Europe at present, seems to have taken the place of other Fusarium species in barley fields over the last 5 years. It has proved to be a highly toxic type-A trichothecene producer (T-2 and HT-2 toxins). The aim of this work was to study the ecotoxinogenesis of this fungus the better to identify and manage the health risk it may pose during the beer manufacturing process. The influence of temperature and water activity on its growth rate and production of toxins are particularly assessed from a macroscopic point of view. Different cultures were grown on sterilized rehydrated barley with a water activity between 0.630 and 0.997 and a temperature ranging from 5 to 35 degrees C. Biomass specific to F. langsethiae and T-2 and HT-2 toxins were quantified by real-time polymerase chain reaction and liquid chromatography-mass spectrometry, respectively. It appears that the optimal temperature and water activity for F. langsethiae toxinogenesis are 28 degrees C and 0.997. This fungus was able to produce 2.22 g kg(-1) of these toxins in 16 days on barley in optimal production conditions. The malting process seems to be a critical step because, in its temperature range, specific production was six times higher than under optimal temperatures for fungus growth. In the short-term, this work will help redefine the process conditions for malting. In the medium-term, the results will contribute to the development of a molecular tool to diagnose the presence of this contaminant and the detection of the toxins in barley, from fields to the end product.

[Necrosis of the glans penis: a complication of an injection of buprenorphin in a opioid abuser]

Necrosis of the penis glans is commonly described after circumcision or strangulation. We report the case of a patient, opioid abuser, who presented an isolated glans necrosis after an injection of buprenorphin. The buprenorphin (Subutex) is a sublingual partial mu-opioid agonist used for the treatment of heroin dependance. Its intravenous or subcutaneous abuse is associated with local infection. The patient require a surgical intervention. After the failure of a mucosal graft, a soft skin graft was done.

Partial Sensory and Motor Deficit of Ipsilateral Lower Limb After Continuous Interscalene Brachial Plexus Block

We describe a partial sensory and motor block of the ipsilateral lower limb after interscalene infusion. After and injection of 20 mL of ropivacaine through the needle, the catheter was advanced 5 cm, and an infusion of ropivacaine 0.2% 5 mL/h commenced. Six hours later, the patient reported a left sensory and motor hemisyndrome, which resolved after the infusion was discontinued. Cervical computed tomography showed the tip of the catheter close to the intervertebral foramen at the C7-T1 level and several intravertebral paramedullar air bubbles. We conclude that the neurological symptoms were caused by an injection of local anesthetic via an interscalene catheter placed in proximity to the epidural space. To avoid this complication, we recommend advancing the catheter no more than 2-3 cm and performing frequent neurological evaluation of patients.

A new test of random walks in heterogeneous environments

Environmental heterogeneities can change animal movement in two different manners. First, they can modify movement characteristics (move lengths or turning angles), in which case the movement remains of the diffusive kind. Second, they can bias displacement towards a particular direction in which case it becomes non-diffusive. We propose in this paper a simple method that only requires computing the mean length of a sample of trajectories in some bounded area to distinguish between these two kinds of movement. We show through simulations that the method allows to detect the presence of heterogeneities that orient animal movement. We apply it to experimental trajectories of Messor sancta ants engaged in corpse aggregation to show that their displacement is oriented at the contact of the formed corpse piles and that their trajectories become non-diffusive.

Posterior labat vs. lateral popliteal sciatic block: posterior sciatic block has quicker onset and shorter duration of anaesthesia

BACKGROUND

During foot and ankle surgery, a combination of a sciatic and femoral nerve block is a well-recognized technique for providing anaesthesia and post-operative analgesia. Our hypothesis is that the posterior gluteal sciatic block (PSB) is more efficient than the lateral popliteal sciatic block (LPSB), and this study compared the anaesthetic characteristics between these two techniques performed for elective ankle and foot surgery.

METHODS

This retrospective database analysis reviewed the onset, duration of action, success rate and complications among 287 patients who were operated upon using sciatic block. PSB was performed in 149 patients and LPSB in 138 patients, all with the use of 30 ml of 5 mg/ml ropivacaine (150 mg).

RESULTS

In the PSB group, the time to perform the block was shorter than in the LPSB group (2.5 +/- 1 vs. 4.5 +/- 4 min, P < 0.001), as was the time to complete sensory block (13 +/- 13 vs. 23 +/- 26 min, respectively; P < 0.001). However, the duration of sensory block was longer in the LPSB group (1130 +/- 470 vs. 960 +/- 310 min, respectively; P < 0.006).

CONCLUSION

PSB is easier to perform, and has a quicker onset of sensory blockade whereas LPSB has a longer duration of analgesia.

Pyélonéphrite emphysémateuse : diagnostic et traitement

Emphysematous pyelonephritis is a necrotizing kidney infection characterized by the presence of gas in renal parenchyma, collecting system or perinephric tissue. This rare affection occurs almost exclusively in patients with diabetes mellitus and is due to non-anaerobic gas-producing bacteria. This life-threatening condition leads to septic shock and multiple organ failure. Diagnosis is suspected when a pyelonephritis does not respond to correct treatment, especially with altered vital signs or a diabetic patient. Computed tomography scan permits visualization of the gas and a radiologic classification with a prognostic value. Current treatment modalities are based upon repeated clinical and scanographic evaluations. In addition to systematic antibiotic therapy, percutaneous drainage is probably the first therapeutic stage in the majority of cases, but should not delay emergent rescue nephrectomy if necessary.

[Stones and foreign bodies of the urethra]

Foreign bodies in the bladder and urethra have been already largely described either by their nature itself as well as by the circumstances of their introduction. If their presence often reveals dubious psychiatric behaviours, one must also evoke possible accidental introductions during transvesical surgery or migration from spaces adjacent to the bladder. The treatment of those foreign bodies can be sorted out through endoscopy or surgical approach.

Epinephrine and clonidine do not improve intrathecal sufentanil analgesia after total hip replacement

BACKGROUND

We compared analgesia after intrathecal sufentanil alone, sufentanil with epinephrine 200 microg and sufentanil with clonidine 30 microg in patients after total hip replacement, the endpoints being onset and duration of action.

METHODS

We performed a randomized double-blind study of 45 patients for elective total hip arthroplasty using continuous spinal anaesthesia. As soon as a pain score higher than 3 on a 10 cm visual analogue scale was reported, sufentanil 7.5 microg alone, sufentanil 7.5 microg + epinephrine 200 microg or sufentanil 7.5 microg + clonidine 30 micro g in 2 ml normal saline was given intrathecally. Pain scores, rescue analgesia (diclofenac and morphine) and adverse effects (respiratory depression, postoperative nausea and vomiting, itching) were observed for 24 h after surgery.

RESULTS

Time to a pain score of <3 [6 (SD 1) vs 6 (1) vs 5 (1) min], time to the lowest pain score [7 (2) vs 8 (2) vs 8 (2) min] and time to the first dose of systemic analgesic for a pain score >3 [281 (36) vs 288 (23) vs 305 (30) min] were similar in all three groups. Adverse effects and analgesic requirements during the first 24 h were also similar.

CONCLUSION

After total hip replacement, all three analgesic regimens gave good analgesia with comparable onset and duration of action, and minor adverse effects.

GATA-3 has dual regulatory functions in human interleukin-5 transcription

Interleukin-5 (IL-5) is a T-cell cytokine involved in Type 2 diseases and is commonly described as being coordinately regulated with other Type 2 cytokines, such as IL-4 and IL-13. Considering the unique control of eosinophilia by IL-5, such coordinate regulation would be surprising. In fact, the biological specificity of eosinophilia and its control by IL-5 suggests a unique and independent control of IL-5 regulation. In this report we show the binding of GATA-3 to three sites in the human IL-5 promoter in the human T-cell line PER117. The previously identified -70 site and another site at position -152 are shown to positively regulate IL-5 transcription. More importantly, the site located at -400 acts as a powerful repressor of IL-5 transcription with mutagenesis of this site allowing a high level expression of IL-5 without the activation of other factors normally required for IL-5 expression. Whereas GATA-3 has been proposed to be involved in the regulation of the IL-4/IL-5/IL-13 locus, we show here that it has another function in controlling IL-5 transcription that supports the observed unique biological function of this cytokine.

Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block

We tested the effect of epinephrine added to 20 mL ropivacaine 0.5% and 0.2% on postoperative analgesia via a femoral catheter after total knee replacement. Forty-one patients undergoing total knee replacement under combined peripheral block/general anesthesia were randomly allocated to two groups. After insertion of a femoral catheter, 21 patients in the Ropivacaine-Epinephrine (ROPI-EPI) group received 20 mL ropivacaine 0.5% plus epinephrine 1:200,000, whereas 20 patients in the Ropivacaine group (ROPI) received 20 mL plain ropivacaine 0.5%. Thereafter, a sciatic block with 30 mL bupivacaine 0.5% plus epinephrine 1:200,000 was performed in all patients, followed by general anesthesia. After surgery, patient-controlled analgesia (PCA) with ropivacaine 0.2% plus epinephrine 1:200,000 for Group ROPI-EPI and plain ropivacaine 0.2% for Group ROPI was available via the femoral catheter (200 mL ropivacaine 0.2% +/- epinephrine, bolus 20 mL, lockout 120 min). The patients were instructed to use PCA when the knee pain score was >3 cm. The interval between the initial ropivacaine injection and the first PCA injection determined the duration of 20 mL ropivacaine 0.5% +/- epinephrine, whereas the interval between the first and second PCA injection determined the duration of 20 mL ropivacaine 0.2% +/- epinephrine. The average duration of ropivacaine 0.5% was 657 +/- 345 min for the ROPI-EPI group and 718 +/- 423 min for the ROPI group (NS), whereas for ropivacaine 0.2%, the average duration was 409 +/- 245 min for the ROPI-EPI group and 419 +/- 339 min for the ROPI group (not significant). We conclude that epinephrine does not influence the duration of analgesia of the ropivacaine concentrations investigated.

IMPLICATIONS

We evaluated the effect of epinephrine on the duration of analgesia of 20 mL ropivacaine 0.5% or 0.2% injected in femoral three-in-one block for pain relief after total knee replacement. Our results show that epinephrine does not alter the duration of analgesia of the two solutions investigated.

[Dedifferentiation of mature teratomas secondary to testicular cancer: report of 2 cases]

The authors report two cases of adenocarcinomatous dedifferentiation of a recurrent mature teratoma arising 3 and 20 years after the initial resection. This is a rare event, occurring after macroscopically or microscopically incomplete resection of a mature teratoma. The nature of this recurrence was difficult to determine prior to histological examination. However, PET scan suggests the diagnosis of malignant teratoma in the presence of increased uptake by the lesion. These tumours have a poor prognosis. Treatment consists of complete resection of the tumour mass. The possibility of long-term malignant dedifferentiation of a teratoma therefore requires prolonged and regular life-long surveillance of patients presenting a mature teratoma after chemotherapy for non-seminomatous germ cell tumour of the testis.

[Progression of stage I non-seminomatous germ cell tumors during surveillance. Role of positron emission tomography]

Surveillance is one of the options proposed in the management of stage 1 non-seminomatous germ cell tumours when there is only a low risk of progression. No consensus has yet been reached concerning the modalities of this surveillance and several protocols are available, including the CCAFU protocol. The presence of recurrences in this population at low risk of progression, estimated to be 5%, accounts for the continuing research for more precise predictive factors of occult metastases. Although several studies appear to indicate a useful predictive value for some of these factors, their application in clinical practice still appears to be difficult. PET metabolic imaging (positron emission tomography) could constitute a new approach to staging of these tumours, allowing the detection of tumour sites by an increase of carbohydrate metabolism of malignant cells. However, no study is yet available to define the real place of this technique.

Skin tensile strength modulation by compressive garments in burn patients. A pilot study

Compression therapy is frequently used to prevent hypertrophy of post-burn scars. This pilot study was performed in 6 patients to assess non-invasive changes induced in the tensile strength of the skin before any clinical improvement can be perceived. Assessments were performed using a computerized suction device delivering three 5 s cycles of 500 mbar depression. Measurements were made at one-month intervals for three months after initiating the garment compression therapy. Comparisons were made between the intact skin, the ungrafted and grafted post-burn scars and the graft donor sites. Data show that garment compression therapy alters the tensile strength in the skin of all test sites. The most reliable variations consist of an increase in both the extensibility and elasticity of the tissues submitted to traction.

[Surgical treatment of priapism: experience of 56 cases in an African setting]

Since priapism is uncommon, treatment is controversial and difficult. In this article we describe a practical, well-documented approach for management of priapism in countries with a high incidence of sickle cell disease. This approach is based on our experience including a total of 56 black patients (49 adults and 7 children) as well as on the results reported in the literature. The patients in our series were examined and treated by the same physician over an 18 year period in various African countries, i.e., Burkina (n = 8), Chad (n = 12), Gabon (n = 19), and Niger (n = 17). Etiologies and pathophysiology are reviewed. In all cases, surgical treatment involved diversion from corpora cavernosa. In the 51 cases with follow-up periods of 3 months or longer, results were considered as excellent in 17 cases (33 p. 100), partial in 5 (9.8 p. 100), and unsuccessful in 29 (56.8). Since 1984, needle drainage with a unilateral transglandular cavernosal-spongiosum shunt based on the technique described by Al Ghorab's has led to better results with immediate detumescence in 80 p. 100 of cases and a long-term success rate of 52 p. 100 (13/25 cases with sufficient follow-up). Except in cases involving sickle cell anemia in which concomitant medical treatment of priapism can be useful, immediate surgical treatment is the only technique effective in avoiding secondary impotence, which was common in our series (58.6). Our p. 100 needle drainage technique appears to be the method of choice for simplified achievement of a unilateral transglandular cavernosal-spongiosum shunt.

Onset and offset of intrathecal morphine versus nalbuphine for postoperative pain relief after total hip replacement

BACKGROUND

We designed this study to compare the postoperative analgesic effects of intrathecal morphine and nalbuphine, the endpoints being onset and offset of action.

METHODS

Geriatric patients scheduled for elective total hip replacement under continuous spinal anaesthesia were randomized to two double-blinded groups in the recovery room as soon as they experienced a pain score higher than 3 cm on the visual analogue scale (VAS, 0-10 cm). Either 160 microg morphine or 400 microg nalbuphine in 4 ml normal saline were administered intrathecally. Pain scores on VAS, rescue analgesia (diclofenac and morphine, not allowed during the first 60 min), and the adverse effects (respiratory depression, postoperative nausea and vomiting, itching) were recorded for 24 h after surgery.

RESULTS

The study was stopped after inclusion of 2 x 12 patients due to slow onset of analgesia in the morphine patients. In the nalbuphine group, when compared to the morphine group, the time to a pain score <3 cm (8+/-6 vs. 31+/-32 min, P<0.001), the time to the lowest pain score (18+/-11 vs. 66+/-75 min, P<0.001) and the time to the first systemic analgesic intervention for a pain score >3 cm (218+/-256 vs. 1076+/-440 min, P<0.05) were significantly shorter. The analgesic requirements during the first 24 h were significantly lower in the morphine group (P<0.001).

CONCLUSION

We conclude that after total hip replacement, administration of intrathecal nalbuphine resulted in a significantly faster onset of pain relief and shorter duration of analgesia than intrathecal morphine.

Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty

BACKGROUND

The usefulness of peripheral nerve blockade in the anesthetic management of hip surgery has not been clearly established. Because sensory afferents from the hip include several branches of the lumbar plexus, the authors hypothesized that a lumbar plexus block could reduce pain from a major hip procedure.

METHODS

In a double-blind prospective trial, 60 patients undergoing total hip arthroplasty were randomized to receive general anesthesia with (plexus group, n = 30) or without (control group, n = 30) a posterior lumbar plexus block. The block was performed after induction using a nerve stimulator, and 0.4 ml/kg bupivacaine, 0.5%, with epinephrine was injected. General anesthesia was standardized, and supplemental fentanyl was administered per hemodynamic guidelines. Postoperative pain and patient-controlled intravenous morphine use were serially assessed for 48 h.

RESULTS

The proportion of patients receiving supplemental fentanyl intraoperatively was more than 3 times greater in the control group (20 of 30 vs. 6 of 29, P = 0.001). In the postanesthesia care unit, a greater than fourfold reduction in pain scores was observed in the plexus group (visual analogue scale [VAS] pain score at arrival 1.3 +/- 2 vs. 5.6 +/- 3, P < 0.001), and "rescue" morphine boluses (administered if VAS > 3) were administered 10 times less frequently (in 2 of 28 vs. in 22 of 29 patients, P < 0.0001). Pain scores and morphine consumption remained significantly lower in the plexus group until 6 h after randomization (VAS at 6 h, 1.4 +/- 1.3 vs. 2.4 +/- 1.4, P = 0.007; cumulative morphine at 6 h, 5.6 +/- 4.7 vs. 12.6 +/- 7.5 mg, P < 0.0001). Operative and postoperative (48 h) blood loss was modestly decreased in the treated group. Epidural-like distribution of anesthesia occurred in 3 of 28 plexus group patients, but no other side-effects were noted.

CONCLUSIONS

Posterior lumbar plexus block provides effective analgesia for total hip arthroplasty, reducing intra- and postoperative opioid requirements. Moreover, blood loss during and after the procedure is diminished. Epidural anesthetic distribution should be anticipated in a minority of cases.

A comparison of intrathecal analgesia with fentanyl or sufentanil after total hip replacement

We designed this study to compare the postoperative analgesic effects of intrathecal fentanyl and sufentanil, the end points being onset, quality, and duration of action. A total of 42 geriatric patients, scheduled for elective total hip replacement under continuous spinal anesthesia, were randomized in two double-blinded groups as soon as they experienced a pain score higher than 3 of 10 on the visual analog scale in the recovery room. Either 7.5 microg sufentanil or 40 microg fentanyl in 2 mL normal saline were intrathecally administered. Pain scores, rescue analgesia (ketorolac and morphine), and adverse effects (respiratory depression, postoperative nausea and vomiting, and itching) were recorded for 24 h after surgery. In both groups, comparing sufentanil to fentanyl, the time to a pain score <3 (9 +/- 9 vs 11 +/- 8 min), the time to the lowest pain score (18 +/- 6 vs 20 +/- 15 min), and the time to the first systemic analgesic intervention for a pain score >3 (241 +/- 102 vs 214 +/- 120 min) were comparable as were the analgesic requirements during the first 24 h. We conclude that, after total hip replacement, both lipid soluble opioids produce excellent analgesia with comparable onset, duration of action, and low incidence of minor adverse effects.

IMPLICATIONS

We compared the postoperative analgesic properties of 40 microg intrathecal fentanyl and 7.5 microg sufentanil after total hip replacement. Both opioids provided satisfactory analgesia, with comparable onset (11 +/- 8 vs 9 +/- 9 min) and duration of action (214 +/- 120 vs 241 +/- 102 min), as well as low incidence of minor side effects.

[Current chemotherapy of locally advanced or metastatic bladder tumors]

Standard chemotherapy of transitional cell carcinoma of the bladder is actually the combination of cisplatine, methothrexate, vinblastine and doxorubicine (MVAC). Although a high response rate, long term survival are rarely observed. More effective agents without toxicity are necessary. Several agents have demonstrated activity alone or in combinations. Combinations regimens use, paclitaxel, gemcitabine and Gallium nitrate, who prove activity alone or in combination with cisplatine or carboplatine, with a response rate of 40 to 70% in patient with visceral localisations. The optimal regimen is not yet determined.

Nuclear factor of activated T cells and YY1 combine to repress IL-5 expression in a human T-cell line

BACKGROUND

IL-5 is an inducible T-cell cytokine with the unique ability to induce eosinophilia without increases in other cell compartments. Regulation of IL-5 expression is controlled primarily at the level of transcription. The role of eosinophilia in allergic disorders indicates IL-5 as a target for therapy.

OBJECTIVE

This report aims to increase our understanding of IL-5 gene regulation by identifying distal control elements in the human (h) IL-5 promoter, determining the transcription factors that bind these elements and elucidating their role in control of hIL-5 gene expression.

METHODS

Methods used in this study include deoxyribonuclease I footprint analysis, electrophoretic mobility shift assay, and functional analysis by transfection of PER-117 cells with site-directed mutants of the hIL-5 promoter.

RESULTS

We have identified a protected region in the distal hIL-5 promoter that has sequence homology to the previously identified negative regulatory element within BR3. This protected region has not been previously reported and is shown to contain overlapping binding sites for YY1 and nuclear factor of activated cells. The binding sites exist between positions -447 and -459, and this sequence was named hPRE2-IL5. Substitution mutations that abolish binding of these proteins to hPRE2-IL5 result in a 2- to 3-fold increase in hIL-5 promoter activity in activated human T cells.

CONCLUSION

We report the novel combination of YY1 and nuclear factor of activated T cells transcription factors binding to a distal hIL-5 promoter element where both factors are involved in down-regulation of hIL-5 gene expression in human T cell.

The conservative management of corynebacterium group D2 encrusted pyelitis

OBJECTIVE

To evaluate the conservative management of encrusted pyelitis (EP), an infectious disease caused by urea-splitting micro-organisms (Corynebacterium group D2 being the most common), and characterized by stone encrustation of the collecting system.

PATIENTS AND METHODS

Four patients (aged 17-62 years) with EP caused by Corynebacterium group D2 were treated conservatively with intravenous vancomycin and percutaneous acidification of the renal collecting system. Percutaneous nephrostomy tubes were placed to allow irrigation with Thomas' acid solution, the outflow being ensured by ureteric catheters. Patients were monitored and the results of and tolerance to treatment evaluated clinically, by biological assays, and by imaging techniques (ultrasonography, computed tomography and pyelography).

RESULTS

No kidneys were lost and in all patients with initial renal failure, creatinine levels recovered to previous values. The adverse effects were moderate, consisting of flank pain or discomfort, and low-grade fever. Three patients developed asymptomatic fungal urinary tract infections requiring antifungal agents. The encrustations were treated effectively and almost disappeared in two patients, while the other two had no residual calcification. One transplanted-kidney recipient developed a ureteric stricture requiring surgical repair. Within a mean follow-up of 16 months, there was no recurrence of EP and the residual encrustation remained small.

CONCLUSION

The conservative treatment of EP can avoid surgery in many cases, although there are some adverse effects of irrigation. The long-term follow-up and prevention of recurrent EP are nevertheless required.

Binding of YY1 and Oct1 to a novel element that downregulates expression of IL-5 in human T cells

BACKGROUND

IL-5 controls development of eosinophilia and has been shown to be involved in the pathogenesis of allergic diseases. In both atopic and nonatopic asthma, elevated IL-5 has been detected in peripheral blood and the airways. IL-5 is produced mainly by activated T cells, and its expression is regulated at the transcriptional level.

OBJECTIVE

This study focuses on the functional analysis of the human IL-5 (hIL-5) promoter and characterization of cis -regulatory elements and transcription factors involved in the suppression of IL-5 transcription in T cells.

METHODS

Methods used in this study include DNase I footprint assays, electrophoretic mobility shift assays, and functional analysis by mammalian cell transfection involving deletion analysis and site-directed mutagenesis.

RESULTS

We identified 5 protein binding regions (BRs) located within the proximal hIL-5 promoter. Functional analysis indicates that the BRs are involved in control of hIL-5 promoter activity. Two of these regions, BR3 and BR4 located at positions -102 to -73, have not previously been described as regulators of IL-5 expression in T cells. We show that the BR3 sequence contains a novel negative regulatory element located at positions -90 to -79 of the hIL-5 promoter, which binds Oct1, octamer-like, and YY1 nuclear factors. Substitution mutations, which abolished binding of these proteins to the BR3 sequence, significantly increased hIL-5 promoter activity in activated T cells.

CONCLUSION

We suggest that Oct1, YY1, and octamer-like factors binding to the -90/-79 sequence within the proximal IL-5 promoter are involved in suppression of IL-5 transcription in T cells.

[Value of detection of carcinoma in situ in conservative surgery of germ cell tumors of the testis]

OBJECTIVE

It is currently proposed to perform tumour enucleation in mono-orchid patients presenting with a small germ cell tumour, in order to preserve physiological endocrine function. However, this conservative surgery must be accompanied by treatment of any carcinoma in situ lesions present in the remaining testicular parenchyma.

MATERIAL AND METHODS

The presence of carcinoma in situ was investigated in 35 patients with germ cell tumour of the testis on samples obtained from the presumably healthy pulp of the orchidectomy specimen, adjacent to and away from the tumour. Samples away from the tumour were performed according to principle of surgical testicular biopsy. Histological examination also concerned the tissue situated in contact with the tumour.

RESULTS

25 patients (74.22%) presented intratubular germ cell dysplasia in the testicular parenchyma presumed to be healthy. These lesions were always concomitantly observed on samples performed adjacent to and away from the tumour. It was observed more frequently in seminomas, but was also observed in other histological forms.

CONCLUSION

Because of the diffuse nature of carcinoma in situ in germ cell tumours of the testis, pulp samples adjacent to the tumour are sufficient to ensure the diagnosis during conservative surgery. Carcinoma in situ is currently treated by local radiotherapy.

[Benign neurogenic tumors of the lumbar plexus. Role of the enucleation procedure]

Benign neurogenic tumours originating from lumbar plexus or roots are rare. Two cases are reported. Resection, often possible with another localisation, may result in neurological deficit in these cases. Enucleation, the best choice, is not always feasible. Hollowing-out is therefore a procedure worth understanding.

U3 snoRNA genes with and without intron in the Kluyveromyces genus: yeasts can accommodate great variations of the U3 snoRNA 3'-terminal domain

The U3 snoRNA coding sequences from the genomic DNAs of Kluyveromyces delphensis and four variants of the Kluyveromyces marxianus species were cloned by PCR amplification. Nucleotide sequence analysis of the amplification products revealed a unique U3 snoRNA gene sequence in all the strains studied, except for K. marxianus var. fragilis. The K. marxianus U3 genes were intronless, whereas an intron similar to those of the Saccharomyces cerevisiae U3 genes was found in K. delphensis. Hence, U3 genes with and without intron are found in yeasts of the Saccharomycetoideae subfamily. The secondary structure of the K. delphensis pre-U3 snoRNA and of the K. marxianus mature snoRNAs were studied experimentally. They revealed a strong conservation in yeasts of (1) the architecture of U3 snoRNA introns, (2) the 5'-terminal domain of the mature snoRNA, and (3) the protein-anchoring regions of the U3 snoRNA 3' domain. In contrast, stem-loop structures 2, 3, and 4 of the 3' domain showed great variations in size, sequence, and structure. Using a genetic test, we show that, in spite of these variations, the Kluyveromyces U3 snoRNAs are functional in S. cerevisiae. We also show that S. cerevisiae U3A snoRNAs lacking the stem-loop structure 2 or 4 are functional. Hence, U3 snoRNA function can accommodate great variations of the RNA 3'-terminal domain.

[Late diagnosis of the avulsion of the pyelo-ureteral junction treated by ureterocalicostomy]

The authors report an exceptional case of delayed diagnosis of avulsion of the ureteropelvic junction in a 27-year-old man. Organization of the urohaematoma prevented ureteropelvic anastomosis and the kidney could only be preserved by performing ureterocalicostomy. This technique, generally used for tuberculous retracted renal pelvis, or failure of pyelotomy or ureteropelvic junction repair in horseshoe kidneys or kidneys with retracted renal pelvis, allowed renal preservation in this case.

[Subperitoneal rupture of the bladder due to pelvic fractures. Apropos of 3 cases]

Three different approaches to the diagnostic and therapeutic management of bladder trauma were adopted in 3 patients. Haematuria was discovered on bladder catheterization. Emergency cystography remains the best diagnostic examination. CT has the same limitations as intravenous urography. There are two schools of thought concerning the treatment of the bladder lesion: surgical repair and healing by simple drainage. The indications depend on the size of the rupture and the severity of haematuria: intravesical clots and the need for continuous irrigation constitute contraindications to simple drainage. Emergency surgery must be combined with treatment of the bone lesions. Apart from external fixation, posterior osteosynthesis, when possible, is also indicated in unstable fractures.

Postoperative analgesia with "3-in-1" femoral nerve block after prosthetic hip surgery

PURPOSE

To evaluate the efficacy of a single shot "3-in-1" femoral nerve block for prosthetic hip surgery in association with general anaesthesia on post-operative analgesia.

METHODS

Forty patients, ASA 1 to 3, received sham block or "3-in-1" femoral nerve block, following Winnie's landmarks with a nerve stimulator, and 40 ml bupivacaine 0.5% with epinephrine were injected after induction of anaesthesia. Vecuronium, 0.1 mg.kg-1, was added after performing the block and anaesthesia was maintained with isoflurane, oxygen 40% and nitrous oxide 60%. Fentanyl, 1.5 microgram.kg-1, was administered before incision to all patients. Heart rate, blood pressure, fentanyl requirements and FETiso were measured throughout surgery. During the post-operative period, 75 mg diclofenac i.m. and/or 0.1 mg.kg-1 morphine s.c. were administered when pain score was > 3/10 and repeated when necessary. Pain scores at first analgesic intervention, at 24 hr and 48 hr as well as diclofenac and morphine requirements after surgery were recorded.

RESULTS

There was no difference in anaesthetic requirements during surgery. The time from performance of sham or "3-in-1" femoral nerve block to the first analgesic intervention (261 +/- 49 min versus 492 +/- 40 min, P < 0.05) and time from extubation to the first analgesic intervention (61 +/- 44 min vs 298 +/- 39 min, P < 0.05) were prolonged in the study group. However, pain scores and the analgesic requirements in the postoperative periods (24 and 48 hr) were similar.

CONCLUSION

There is a short-term benefit during the first few postoperative hours in using a single shot "3-in-1" femoral nerve block to complement general anaesthesia for elective hip surgery.

Glucose kinetics of the Virginia opossum: possible implications for predicting glucose turnover in mammals

Primed continuous infusions of 6-3H-glucose, respirometry and measurements of nitrogen excretion were carried out in adult Virginia opossums (Didelphis virginiana). Our goals were to determine resting glucose turnover rate, to establish the relative importance of this oxidative fuel in the energy budget of this species, to assess whether metabolic rate is a better predictor of glucose turnover rate than body mass and to demonstrate that glucose kinetics can be measured in the opossum for future use of this animal model in studies of mammalian glucoregulation. Results show that the resting glucose turnover rate of opossums averages 17.5 +/- 0.9 mumol/kg.min (n = 9), that 31% of total glucose flux is oxidized and that glucose oxidation represents 9% of their metabolic rate. An allometric equation predicting glucose turnover rate from body mass for placental mammals overestimates the measured turnover rate of this marsupial by 30%, suggesting that turnover rate is better predicted from metabolic rate than from body mass. Finally, this study demonstrates that the Virginia opossum is a convenient model to study glucose metabolism in vivo, and we propose that the very rapid aging characteristics of this species should be exploited to investigate the effects of aging on glucose homeostasis.