[Ambulatory minimally invasive hysterectomy: Limiting factors related to health professionals]. / Prise en charge ambulatoire de l'hystérectomie par voie mini-invasive : analyse des causes de résistances liées aux professionnels de santé.

OBJECTIVES: The feasibility of minimally invasive hysterectomy for ambulatory benign pathology has been demonstrated in many international studies. France has a considerable delay of multifactorial origin in this field. The objective of this study is to identify the limiting factors related to health professionals to the realization of minimally invasive ambulatory hysterectomy and to determine possible strategies to increase its rate. METHODS: This is a cross-sectional survey conducted over 2 months using a self-administered questionnaire sent by email to 180 gynecological surgeons in 2 French regions (Grand Est and Bourgogne-Franche Comté). RESULTS: A total of 22% of health professionals responded to the survey. The vast majority of practitioners (60%) said they did not carry out ambulatory care by habit. The apprehension of the reaction of the patients (47.5%), the fear of delayed diagnosis of complications (12.5%), the management of pain in the postoperative period (42.5%) also participated in brake of the promotion of ambulatory care. DISCUSSION: Improvement of the organisation of city and hospital management allowing a better continuity of care (70%), the economic valuation (37.5%) and the increase in the hourly amplitude of the ambulatory surgery unit (5%) would improve the rate of ambulatory care of minimally invasive hysterectomies, according to the gynecologist surgeons surveyed. In addition, a prospective study evaluating the quality of life of patients after ambulatory care of minimally invasive hysterectomy would allow better adherence of health professionals and patients to the ambulatory care project in 70% of cases. CONCLUSION: The change of mentality of health professionals remains a priority for the promotion of ambulatory surgery in gynecology. Information and communication are therefore essential to the expansion of the ambulatory.

Butterfly-cartilage tympanoplasty in children: A 28-case series and literature review.

OBJECTIVE: This study presents results for a pediatric series of tympanoplasty using the butterfly-cartilage technique, with comparison to literature reports. METHODS: A retrospective study included patients aged between 2 and 12 years receiving tympanoplasty performed by a single senior surgeon in our department between 2003 and 2012, for whom pre- and postoperative tympanum imaging was complete. Results were analyzed at a minimum 10 months' follow-up in terms of graft healing and auditory data, with pre- and postoperative audiograms and calculation of mean hearing loss. RESULTS: Twenty-eight tympanoplasties were performed in 27 children: 16 males, 11 females; in 1 case, perforation was bilateral. Perforation location was inferior or antero-inferior in 14 cases (50%), antero-superior in 9 (32.1%) and anterior in 5 (17.9%). Perforation size on otoscopy ranged from 11.1% to 36.4% of tympanum area (mean, 26.3%). Mean follow-up was 25 months. Closure of the perforation was achieved in 87.7% of cases. Mean hearing loss was 20.2dB (range, 10-31.25dB) preoperatively and 14dB (range, 5-31.25dB) postoperatively. DISCUSSION: We analyze our results and compare them with the international literature to refine indications for this technique of tympanic repair. CONCLUSION: Tympanoplasty using the butterfly-cartilage technique was reliable and easy to perform. It should be included in the therapeutic armamentarium for moderate non-marginal tympanic perforation. In the present series, the technique was reserved to perforations involving less than 40% of tympanum area.

Virtual planning and guided surgery in fibular free-flap mandibular reconstruction: A 29-case series.

INTRODUCTION: Virtual planning and guided surgery (VPGS) has been recently developed for mandibular reconstruction, but benefit remains to be assessed. The aim of this study was to analyze the impact of VPGS on operative time and postoperative course. MATERIAL AND METHODS: All patients who underwent fibula free-flap mandibular reconstruction between 2013 and 2014 in our institution were included in a retrospective study. Operative times and postoperative course were compared between patients who underwent conventional surgery in 2013 and those who underwent VPGS in 2014. RESULTS: A total of 29 patients were included: 11 in 2013 and 18 in 2014. Taking all types of mandibular defect together, ischemia time was significantly decreased by VPGS (75min, vs 150min for conventional surgery; P<0.001), whereas overall operative time was not significantly reduced (481 and 516min, respectively; P=0.4). VPGS had no impact on postoperative course: local or general complications, time to decannulation and nasogastric tube removal, or length of stay. CONCLUSION: VPGS significantly reduced fibula free-flap ischemia time. Long-term functional and esthetic benefit remains to be evaluated.

Prognostic impact of tumour multifocality in thyroid papillary microcarcinoma based on a series of 160 cases.

OBJECTIVE: The objective of this study was to evaluate the prognostic impact of tumour multifocality in papillary thyroid microcarcinoma (PTMC). METHODS: All patients who underwent total thyroidectomy and central neck dissection for PTMC in our institution between 1990 and 2007 were included in this retrospective study. Statistical correlations between tumour multifocality and various clinical or pathological prognostic parameters were assessed by univariate and multivariate analyses. RESULTS: A total of 160 patients (133 women and 27 men; mean age: 47.8±13.7 years) were included in this study. Tumour multifocality was demonstrated in 59 (37%) patients. Central neck metastatic lymph node involvement was identified in 46 (28%) patients. No statistical correlation was demonstrated between tumour multifocality and the following factors: age, gender, tumour size, extension beyond the thyroid, metastatic central neck lymph node involvement and risk of recurrence. A tumour diameter greater than 5mm was associated with a higher risk of recurrence (P=0.008). CONCLUSION: Tumour multifocality does not appear to have a prognostic impact in PTMC.

Cervical sympathetic chain schwannoma.

INTRODUCTION: Cervical schwannoma is a benign peripheral nerve tumor specifically developing from Schwann cells. Cervical sympathetic chain schwannoma is rare. Following a case report, the authors describe its specific radiological and histological characteristics. Treatment is surgical. CLINICAL CASE: A 56-year-old woman consulted for an isolated left lateral cervical mass of several years' standing, but with recently associated pharyngeal discomfort. Cervical CT revealed a vascularized retrostyloid mass with venous-time enhancement, inducing anterior displacement of the jugulo-carotid axis. The tumor could not be identified on fine-needle aspiration cytology, and surgical resection was performed by cervicotomy. Surgical exploration found a tumor developing from the cervical sympathetic nerve, posterior to the jugular vein and carotid sheath. Histopathologic examination diagnosed schwannoma. Postoperative outcome featured Horner's syndrome. CONCLUSION: Cervical sympathetic chain schwannoma is a rare benign tumor, to be suspected in the presence of an isolated lateral cervical mass. Preoperative CT is mandatory to guide diagnosis; treatment is surgical, to confirm histologic diagnosis. Postoperative Horner's syndrome often confirms cervical sympathetic chain involvement.

Laryngeal chondrosarcoma: report of two cases.

OBJECTIVE: The present study describes the clinical, radiological and histological features of laryngeal chondrosarcoma, on the basis of two clinical cases, and discusses management. CASE STUDIES: Two male patients, aged 63 and 51 years, presented with low-grade chondrosarcoma revealed respectively by a mass in the lateral neck and by laryngeal dyspnea. CT showed a tumoral process with calcification, developed from the thyroid and cricoid cartilage, respectively. The first patient underwent partial and the second total laryngectomy. DISCUSSION: Chondrosarcoma is diagnosed on the basis of combined clinical, radiological and histological signs. Differential diagnosis with chondroma may be difficult, especially in grade-1 chondrosarcoma. CONCLUSION: Laryngeal chondrosarcoma is a rare tumor. Management is basically surgical. Prognosis is generally good, depending essentially on histologic grade.

Head and neck free-flap reconstruction in the elderly.

OBJECTIVE: To evaluate the reliability of free-flap head and neck reconstruction in the elderly. MATERIAL AND METHODS: All patients who underwent free-flap head and neck reconstruction in our institution between 2000 and 2010 were included in this retrospective study. In all, 418 patients (301 men and 117 women) were enrolled, including 95 patients aged 70 years or older (mean age=60.2±11.6 years). The impact of age on free-flap failure and local and general complication rates was assessed on univariate and multivariate analysis. RESULTS: Advanced age had no impact on free-flap failure and local complications rate but was correlated with a higher risk of general complications (multivariate analysis: P=0.007). A high level of comorbidity also had a significant impact on the general complications rate (multivariate analysis: P=0.001). Patients who underwent circular total pharyngolaryngectomy showed elevated risk of free-flap failure (P=0.005) and local complications (P=0.001) on multivariate analysis. CONCLUSION: Free-flap reconstruction of the head and neck is safe and reliable in the elderly. Nevertheless, meticulous patient selection, mainly based on the level of comorbidity, is necessary.

Pharmacokinetics and tolerability of intranasal diazepam and midazolam in healthy adult volunteers.

OBJECTIVE: The purpose of this pilot study was to determine the pharmacokinetics and tolerability of an investigational diazepam (DZP) formulation and a parenteral midazolam (MDZ) formulation following intranasal (i.n.) administration for the efficient treatment of seizure emergencies. METHODS: Each subject received 5 mg of DZP and MDZ via both i.n. and intravenous routes in a four-way, randomized crossover trial. Blood samples were collected over 48 h. DZP and MDZ concentrations were measured using HPLC. Using analog scales, subjects rated tolerability (0 = no change from normal; 10 = maximum intolerability) and pain (0 = no pain; 4 = extreme pain) prior to and 0, 5, 15, 60 min, and 8 h after administration. RESULTS: The C(max) and T(max) values for i.n. DZP and MDZ were 179.2 ng/ml and 28.8 min vs 62.8 ng/ml and 21.6 min, respectively. Immediately following i.n. administration, subjects reported tolerability scores of 6.75 and 6.0, and identical pain scores, 3.2, for DZP and MDZ, respectively. CONCLUSION: Both formulations were rapidly absorbed following i.n. administration with transient discomfort. DZP had a longer half-life, which may result in an extended duration of action. Further studies in large patient populations to evaluate the safety after long term use, efficacy and pharmacokinetics of i.n. DZP are warranted.

Benzodiazepines in epilepsy: pharmacology and pharmacokinetics.

Benzodiazepines (BZDs) remain important agents in the management of epilepsy. They are drugs of first choice for status epilepticus and seizures associated with post-anoxic insult and are also frequently used in the treatment of febrile, acute repetitive and alcohol withdrawal seizures. Clinical advantages of these drugs include rapid onset of action, high efficacy rates and minimal toxicity. Benzodiazepines are used in a variety of clinical situations because they have a broad spectrum of clinical activity and can be administered via several routes. Potential shortcomings of BZDs include tolerance, withdrawal symptoms, adverse events, such as cognitive impairment and sedation, and drug interactions. Benzodiazepines differ in their pharmacologic effects and pharmacokinetic profiles, which dictate how the drugs are used. Among the approximately 35 BZDs available, a select few are used for the management of seizures and epilepsy: clobazam, clonazepam, clorazepate, diazepam, lorazepam and midazolam. Among these BZDs, clorazepate has a unique profile that includes a long half-life of its active metabolite and slow onset of tolerance. Additionally, the pharmacokinetic characteristics of clorazepate (particularly the sustained-release formulation) could theoretically help minimize adverse events. However, larger, controlled studies of clorazepate are needed to further examine its role in the treatment of patients with epilepsy.

Treatment of Q fever endocarditis: comparison of 2 regimens containing doxycycline and ofloxacin or hydroxychloroquine.

BACKGROUND: Q fever endocarditis, caused by Coxiella burnetii, is fatal in 25% to 60% of patients. Currently, treatment with a long-term tetracycline and quinolone regimen for at least 4 years is recommended, although relapses are frequent. METHODS: Between January 1987 and December 1997, the reference treatment of Q fever endocarditis was compared with one of doxycycline and hydroxychloroquine sulfate. Patients were treated by conventional therapy until May 1991 and then by the new regimen. Microimmunofluorescence was used for antibody-level determination for diagnosis and follow-up. RESULTS: Thirty-five patients were included in the study, 26 males and 9 females. Of 14 patients treated with a doxycycline and quinolone combination, 1 died, 7 relapsed (3 were re-treated and 4 switched to the new regimen), 1 is still being treated, and 5 were considered cured using this regimen only. The mean duration of therapy for cure in this group was 55 months (median, 60 months). Twenty-one patients received the doxycycline and hydroxychloroquine regimen: 1 patient died of a surgical complication, 2 are still being treated, 17 were cured, and 1 is currently being evaluated. Two patients treated for 12 months but none of the patients treated for longer than 18 months relapsed. The mean duration of treatment in this group was 31 months (median, 26 months). No significant differences were observed between the 2 regimens in terms of death, valve surgery, or tolerance. The mortality rate for both regimens in this study was 5%. CONCLUSION: Prescription of the doxycycline and hydroxychloroquine combination for at least 18 months allows shortening of the duration of therapy and reduction in the number of relapses.

Expression of novel alternatively spliced isoforms of the oct-1 transcription factor.

Analysis of the alternatively spliced isoforms of the human and mouse oct-1 genes, combined with their exon-intron structure, show a high level of evolutionary conservation between these two species. The differential expression of several oct-1 isoforms was examined by reverse transcription-polymerase chain reaction performed on the 3' region of the murine oct-1 cDNA. Variations in the relative levels and patterns of expression of the isoforms were found among different tissues. Three novel isoforms originating from the 3'-distal region of oct-1, were isolated and sequenced: Two were derived from testis, and one from myeloma cells. Splicing out of different exons as revealed in the structure of these isoforms results in reading frameshifts that presumably lead to the expression of shortened Oct-1 proteins, with distinct C-terminal tails. Altogether, six out of the eight known murine oct-1 isoforms may have distinct C-termini, implying that these multiple tails have different functional roles in cellular differentiation and physiology.

Neurologic onset of Behçet's disease: a diagnostic enigma in childhood.

Neuro-Behçet's disease, which is uncommonly reported in childhood, encompasses a wide variety of clinical features since any part of the neuraxis may be involved. It carries a serious prognosis and represents a leading cause of death or severe disability. Neuro-Behçet's disease may occur in 5% to 50% of adults with Behçet's disease and is usually subsequent to other systemic manifestations. In this report, we express the possibility of a primary neurologic presentation of Behçet's disease in childhood with pseudotumor cerebri and meningoencephalitis as exclusive initial features. We focus on diagnostic problems when major features of Behçet's disease are missing at the outset. We emphasize the high sensitivity of magnetic resonance imaging to make the diagnosis of cerebral vasculitis or thrombosis with a good reliability to clinical features.

[Occlusion of the central retinal vein after vaccination against viral hepatitis B with recombinant vaccines. 4 cases]. / Occlusion de la veine centrale de la rétine après vaccination contre l'hépatite virale B par vaccin recombinant. Quatre observations.

OBJECTIVES: Hepatitis B vaccination has been proven to be effective and well-tolerated. Certain neurological, ocular or systemic complications have, however, been reported to be induced by the vaccine. Clinicians should be aware of exceptional ocular complications. CLINICAL REPORT: Four patients under 50 years of age developed occlusion of the central vein of the retina after vaccination with recombinant hepatitis B vaccine. None of the classical causes of occlusion of the central vein of the retina could be evidenced. DISCUSSION: Several pathophysiological hypotheses have been proposed to explain these ocular manifestations after vaccination: role of immunocomplexes, antigenic cross-reactions, role of immediate hypersensitivity, simulation of a pathogenic lymphocyte repertoire. None of these hypotheses is entirely satisfactory. It is important however to emphasize the need for a complete general evaluation, including an ophthalmological examination in the presence of unexplained ocular manifestations following hepatitis B vaccination.

[Retinal vascular closure using laser photocoagulation]. / Occlusion vasculaire rétinienne par photocoagulation laser.

The aim of this experimental work was to produce a vascular occlusion of the retina by laser photocoagulation. Three types of lasers were used: argon green (514 nm), yellow laser (574 nm) and double frequency Neodymium YAG (514 nm) (DF-Nd: YAG) (532 nm). Pigmented retinas from 18 rabbits were photocoagulated using the three mirror technique under general anaesthesia. A fluorescenin angiogram of the retina was done after the photocoagulation to verify vessel occlusion. The rabbits were sacrificed at one day, one week and three weeks after photocoagulation for histology examinations. In most cases, laser photocoagulation did not cause vessel constriction. The angiograms showed that flow was slower but not interrupted. Yellow and DF-Nd: YAG lasers were more effective in creating vascular occlusions. The three lasers caused similar histological lesions which varied only in their extension to the different layers of the retina. The endothelium was destroyed and red cells aggregated in the vessel lumen. These findings suggest that yellow and DF-Nd: YAG laser should be used in all situations requiring coagulation of a vessel in the retina.

[Ocular toxoplasmosis: value of immunoblotting for the determination of an intra-ocular synthesis of antibodies]. / Toxoplasmose oculaire: intérêt de l'immunoblot pour la mise en évidence d'une synthèse intra-oculaire d'anticorps.

The aim of this study was to demonstrate the intraocular synthesis of specific antibodies in case of Toxoplasma retinochoroiditis on the basis of immunoblot analysis. Vitreous or aqueous and serum were analyzed by immunoblot in four cases of toxoplasmic chorioretinitis. The same assays were performed on samples from 16 control subjects. Immunoblot analysis of serum and ocular fluid from patients with toxoplasmic chorioretinitis showed IgG and IgA specific antibodies. Recognition patterns were different and demonstrated neo-antibodies in ocular fluid. In control samples only IgG were found and the same patterns were observed in the two compartments. Immunoblot is a useful technique to demonstrate the local synthesis of antibodies in ocular toxoplasmosis by comparison of recognition patterns between serum and ocular fluids. Integration of immunoblot patterns allows quantification of antibodies specific for each Toxoplasma antigen in the two compartments.

Cloning, sequencing and expression of two isoforms of the murine oct-1 transcription factor.

Oct-1 is a ubiquitously expressed regulatory gene of the POU domain family. The Oct-1 protein binds to the octamer motif present in the control regions of a variety of genes such as the immunoglobulins, histone H2B and snRNAs. To learn about Oct-1 and its possible role in B-cell maturation, we have used oct-2 cDNA to screen a murine pre-B cell, cDNA library. Two cDNA clones were identical in their POU-homeo box DNA binding domain, but differed in their 3'-region. Whereas one clone (oct-1a) was very similar to its human oct-1 homologue, the other (oct-1b), contained an additional 72 bp sequence (designated E1) at the serine threonine rich coding region (position 1485 of the human oct-1), and a deletion of another 72 bp sequence (designated E2) downstream (position 1920). These changes preserve the protein reading frame. DNA blot analysis indicates that murine oct-1 is a single copy gene and that the two oct-1 isoforms oct-1 is expressed as a large approximately 10 kb transcript in all the cell are generated by alternative RNA splicing. RNA blots showed that oct-1 is expressed as a large approximately 10 kb transcript in all the cell lines tested. PCR analysis of the E1 and E2 72 bp regions, indicated the presence of a third isoform containing both E1 and E2 (Oct-1c). Oct-1a and Oct-1b were present in all cell types examined, but the level of expression was lower in liver and spleen as compared to testis, thymus and kidney. The ratio of Oct-1b to Oct-1a ranged between 0.2 to 0.5, for all tissues examined except for testis which expressed higher amounts of oct-1b and/or oct-1c. Our findings thus show that the pattern of expression of the oct-1 gene is more complex than hitherto thought.

Diffuse choroidal hemangioma: report of a clinicopathological study in a 4-year-old boy.

The authors examined the clinicopathologic features of a 4-year-old boy with a diffuse choroidal hemangioma, yet without any features of the Sturge-Weber syndrome. The tumor occurred as a grayish intraocular mass with an overlying retinal detachment and was highly reflective in the ultrasonic examination. After contrast, the CT scan revealed diffuse thickening of the ocular wall associated with an enhanced irregular orbital mass. The pathologic examination revealed a cavernous hemangioma involving the entire choroid with extrascleral extension. Diffuse choroidal hemangioma occurring in childhood and unrelated to the Sturge-Weber syndrome is a rare condition that should be included in the differential diagnosis of retinoblastoma.

Primary structure of dystrophin-related protein.

Dystrophin-related protein (DRP or 'utrophin') is localized in normal adult muscle primarily at the neuromuscular junction. In the absence of dystrophin in Duchenne muscular dystrophy (DMD) patients, DRP is also present in the sarcolemma. DRP is expressed in fetal and regenerating muscle and may play a similar role to dystrophin in early development, although it remains to be determined whether DRP can functionally replace dystrophin in adult tissue. Previously we described a 3.5-kilobase complementary DNA clone that exhibits 80 per cent homology to the C-terminal domain of dystrophin. This sequence identifies a 13-kilobase transcript that maps to human chromosome 6 (refs 2, 11). Antibodies raised against the gene product identify a polypeptide with a relative molecular mass of about 400K in all tissues examined. To investigate the relationship between DRP and dystrophin in more detail, we have cloned and sequenced the whole DRP cDNA. Homology between DRP and dystrophin extends over their entire length, suggesting that they derive from a common ancestral gene. Comparative analysis of primary sequences highlights regions of functional importance, including those that may mediate the localization of DRP and dystrophin in the muscle cell.

Molecular cloning of the bovine thymopoietin gene and its expression in different calf tissues: evidence for a predominant expression in thymocytes.

Thymopoietin (TP), a 49 amino acid peptide, is regarded as a thymic hormone, secreted specifically by some epithelial cells in the thymic stroma and exerting a multitude of effects on maturation and function of T lineage cells. As part of our study on the molecular biology of TP, we isolated cDNA clone coding for a bovine TP precursor and used it as a probe to analyze the presence of mRNA coding for TP in different tissues. The cDNA clone reported here is 1.1 kb long and contains an open reading frame (ORF) of 741 bp which corresponds to 247 amino acids. The 147 bp coding for the entire bovine TP are at the 5' end of the ORF. A DNA fragment coding for amino acids 1-42 of bovine TP was used as a probe to look for hybridizable RNA sequences, extracted from various calf tissues, by the S1 nuclease protection method. Our results indicate that the TP gene is expressed predominantly in lymphatic tissues. Lymphatic tissues with the highest levels observed were thymocytes and not thymic stroma. Lower, but still significant, amounts were present in tonsils, neck lymph nodes, and small intestine (probably because of its lymphatic part--the Peyer's patches), whereas cultured thymic stromal cells, spleen tissue and peripheral blood mononuclear cells displayed a low level of TP mRNA. The TP gene expression in all other (non-lymphatic) tissues tested, was weak, barely detectable or virtually absent. However, the cerebellum could be singled out with relatively strong expression of TP mRNA.(ABSTRACT TRUNCATED AT 250 WORDS)