[Dermatofibrosarcoma protuberans: Surgical margins using Slow-Mohs micrographic surgery. A clinical retrospective study about 20 cases]. / Marges d'exérèse des dermatofibrosarcomes cervico-faciaux par technique de Slow-Mohs : étude clinique rétrospective sur 20 cas.

OBJECTIVES: The main objective of this study is to determine the necessary surgical margins to obtain a complete R0 resection for head and neck dermatofibrosarcoma protuberans (DFSP) using Slow-Mohs micrographic surgery. The secondary objective is to study the recurrence rate of these tumors. PATIENTS AND METHODS: Slow-Mohs micrographic surgery was used for patients included between 2005 and 2015 at Bordeaux universitary hospital. For each patient the age, the sex and death occurrence, the initial surgical margins, the surgical margins for complete R0 resection, the occurrence of local or general recurrence during follow-up were reported. Surgery was realized under local anesthesia. The closure of the tumor site was realized secondarily using a skin graft or local flap. RESULTS: Twenty patients were included in the study. Initial surgical margins were 10mm (9 patients) or 15mm (11 patients). Complete resection was obtained from the first surgery for fifteen patients (75%). The average surgical margin for a complete R0 resection was 15,25±5,7mm (10-25). None of the patients presented recurrences during the entire follow-up (38 months) CONCLUSION: A complete R0 resection of head and neck DFSP is obtained from the first surgery in 75% of the cases, with minimum surgical margins (12,75±2,55mm) using the Slow-Mohs micrographic surgery. This allows a reduction of surgical margins and local recurrences. This technique provides a preservation of soft-tissues, which plays a key role for head and neck surgery.

[Prisma France: implementation program of an innovation in health and services system for disabled people. Adaptation of a case-management based integration model]. / Prisma France: programme d'implantation d'une innovation dans un système de soins et de services aux personnes en perte d'autonomie. Adaptation d'un modèle d'intégration basé sur la gestion de cas.

BACKGROUND: The French health and services system to maintain at home is characterized by its fragmentation, whereas the need of the people for intervention is generally total. This fragmentation have consequences: delay in services delivery, inadequate transmission of information, redundant evaluation, service conditioned by the entrance point solicited rather than by the need of the person and inappropriate use of expensive resources by ignorance or difficulty of access to the less expensive resources. PRESENTATION OF THE INNOVATION: The purpose of integration is to improve continuity of interventions for people in loss of autonomy. It consists in setting up a whole of organisational, managerial and clinical common tools. Organisational model "Projet et Recherches sur l'Intégration des Services pour le Maintien de l'Autonomie" (Prisma) tested in Quebec showed a strong impact on the prevention of the loss of autonomy in term of public health on a population level. This model rests on six principal elements: partnership, single entry point, case-management, a multidimensional standardized tool for evaluation, an individualized services plan and a system for information transmission. CONTEXTUAL ANALYSIS: Thus, it was decided to try to implement in France this organisational model. The project is entitled Prisma France and is presented here. The analysis of the context of implementation of the innovation which represents integration in the field of health and services for frail older reveals obstacles (in particular because of diversity of professional concerned and a presentiment of complexity of the implementation of the model) and favourable conditions (in particular the great tension towards change in this field). CONCLUSION: The current conditions in France appear mainly favourable to the implementation of integration. The establishment of Prisma model in France requires a partnership work of definition of a common language as well on the diagnoses as on the solutions. The strategic and operational dialogue is thus a key element of the construction of integration. This stage currently occurs in parallel in three areas contrasted in France. The results of associated qualitative research should make it possible to define the factors fostering or hindering the realization of integration according to each site (analyzes contrasted) and in all the sites (related to the particular context of care and French services as a whole).

Anatomical landmarks for maxillary nerve block in the pterygopalatine fossa: A radiological study.

INTRODUCTION: The aim of this study was to describe the anatomical landmarks for maxillary nerve block in the pterygopalatine fossa. The risk of injury to the skull base and maxillary artery was assessed. METHODS: This retrospective study was based on the analysis of 61 consecutive computed tomography angiographies obtained from patients suffering from different pathologies. Anatomical relationships between optic canal (OC), foramen rotundum (FR), inferior orbital fissure (IOF) and puncture point (PP) were assessed. A "maxillary section" was virtually carried out on the CTs, following a plane passing through PP, IOF and FR in order to mimic the anaesthesia needle route. RESULTS: No gender difference was observed except for the PP-OC distance that was longer in men. The mean PP-IOF distance was of 31.9 (± 0.7mm). PP-OC (43.9±0.5) and PP-FR (44.2±0.7) distances increased significantly with the patients height (PP-FR=17.25+0.16×height (cm); PP-OC=20.54+0.13×height (cm)). The route to the skull base was curved, with an angle of 168±1.6° at the FR level. The angle to reach the OC was greater than 7°. DISCUSSION: With a 35-mm needle length, the probability to reach the IOF was high (79%), while the risk to injure the skull base (2%) and the optical nerve (0%) was low. Artery injuries were only found in 13% of cases. Therefore, a 35-mm needle length allows for the best efficacy/risk ratio in maxillary nerve block.

The pharmacokinetics and metabolic disposition of tacrolimus: a comparison across ethnic groups.

OBJECTIVE: Our objective was to compare the intravenous and oral pharmacokinetics of tacrolimus among subjects of three different ethnic backgrounds, African American, white, and Latin American. METHODS: Ten African American, 12 white, and 12 Latin American subjects received intravenous and oral tacrolimus in an open-label, two-period, parallel group study. All of the subjects received intravenous tacrolimus (0.015 mg/kg) as a constant infusion over 4 hours and oral tacrolimus capsules (5 mg) as single doses in randomized order. Concentrations of tacrolimus and its metabolites were measured in whole blood with the use of a validated HPLC-mass spectrometry assay. RESULTS: There were no significant differences in pharmacokinetic parameters among the three study groups after intravenous administration of the drugs. After oral administration, the tacrolimus maximum concentration was significantly lower (P < .01) in the African American subjects (20.8 microg/L) than in the white subjects (37.8 microg/L) and Latin American subjects (33.0 microg/L). Absolute bioavailability was significantly lower (P = .01) in the African American subjects (11.9%) and in the Latin American subjects (14.4%) than in the white subjects (18.8%). After the oral dose, the area under the plasma concentration-time curve was lower in the African American subjects (179 microg/L x h, geometric mean) than in the white (293 microg/L x h) and Latin American subjects (239 microg/L x h, differences not statistically significant). Maximum concentration (P < .02) and area under the plasma concentration-time curve (not statistically significant) of the main tacrolimus metabolite 13-O-desmethyl tacrolimus was lower in the African American subjects than in the white and Latin American subjects. CONCLUSIONS: Significant differences in tacrolimus pharmacokinetics exist among the three different ethnic groups. Our results indicate that this may result from differences in intestinal CYP3A or P-glycoprotein activities.

Erectile dysfunction.

A better understanding of penile physiology and pathophysiology has revolutionized the diagnosis and treatment of erectile dysfunction in the past decade. This article summarizes the current knowledge and presents a patient's goal-directed approach to the evaluation and treatment of erectile dysfunction.

Improved neonatal survival following multiple doses of bovine surfactant in very premature neonates at risk for respiratory distress syndrome.

To determine whether multiple doses of bovine surfactant would improve neonatal mortality in very premature neonates, we conducted two multicenter controlled trials under identical protocols; the results were combined for analysis. Four hundred and thirty neonates born between 23 and 29 weeks gestation and weighing 600 to 1250 g at birth were assigned randomly at birth to receive either 100 mg of phospholipids/kg of Survanta, a modified bovine surfactant (n = 210), or a sham air placebo (n = 220) within 15 minutes of birth. Neonates who developed respiratory distress syndrome and required mechanical ventilation with at least 30% oxygen could be given up to three more doses in the first 48 hours after birth. Dosing was performed by investigators not involved in the clinical care of the neonates; nursery staff were kept blinded as to the treatment assignment. Cause of death was determined by a panel of three independent, board-certified neonatologists after blindly reviewing case report forms and autopsy reports. Fewer Survanta-treated neonates died of any cause (11.4% vs 18.8%, P = .031), died of respiratory distress syndrome (1.9% vs 15.6%, P less than .001), and either died or developed bronchopulmonary dysplasia due to respiratory distress syndrome (39.5% vs 49.1%, P = .044). The incidence of respiratory distress syndrome was also lower in Survanta-treated neonates (28.0% vs 56.9%, P less than .001), and the Survanta-treated neonates' oxygenation and ventilatory status were improved significantly at 72 hours. Survanta-treated neonates were also at lowered risk of developing pulmonary interstitial emphysema (23.3% vs 36.9%, P = .002) and other forms of pulmonary air leaks (9.6% vs 20.8%, P .002).(ABSTRACT TRUNCATED AT 250 WORDS)

Demonstration of in vivo bioequivalence of a generic albuterol metered-dose inhaler to Ventolin.

STUDY OBJECTIVE: To use histamine bronchoprovocation and bioassay statistical procedures to evaluate the in vivo bioequivalence of a generic albuterol metered-dose inhaler (MDI). DESIGN: A randomized, double-blind, balanced, crossover design was used to determine the potency of each generic albuterol MDI actuation relative to Ventolin (Glaxo Wellcome; Research Triangle Park, NC) administration. One treatment was administered on each of 4 study days. A histamine bronchoprovocation procedure was initiated 1.25 h before and 15 min after administration of the study treatment. PATIENTS: Twenty-four nonsmoking subjects with mild-to-moderate asthma were studied (18 to 65 years of age; FEV(1), > 60% of predicted; and provocative concentration of histamine causing a 20% fall in FEV(1) [PC(20)], < or = 8 mg/mL at screening). INTERVENTIONS: One and four actuations (90 and 360 microg, respectively) of the generic MDI and of Ventolin MDI. Placebo inhalers were used to maintain blinding of inhaler and doses. MEASUREMENTS AND RESULTS: The primary outcome variable was histamine PC(20) measured after study treatment administration. A significant dose-effect relationship was present (p < 0.0001). Deviation from parallelism of the generic and Ventolin dose-response curves (p = 0.95) and differences in overall mean response between the two formulations (p = 0.68) were not significant. Using Finney 2 x 2 bioassay statistical procedures, we estimated that one actuation of the generic albuterol MDI was equivalent to 1.01 puffs of Ventolin (90% confidence interval, 0.69 to 1.50). CONCLUSION: The generic albuterol MDI delivers a quantity of albuterol to the beta(2)-receptor site in the lung that is the bioequivalent to Ventolin. Further, this study reinforces the validity of this statistical methodology for determining in vivo bioequivalence.

Time course of the medial olivocochlear efferent effect on otoacoustic emissions in humans.

The time course of the medial olivocochlear efferent system has been studied in humans, using the suppressive effect of a contralateral broad-band noise (CBBN) on 2f1-f2 distortion product otoacoustic emissions (DPOAE) amplitude. DPOAE were recorded with F2 at 1.5 kHz, with a temporal resolution of 2.6 s, in the presence and absence of a 40 dB SL continuous CBBN, whose duration ranged between 30 s and 20 min. The CBBN suppressive effect on DPOAE amplitude was greatest from the first 2.6 s, and was sustained for 20 min. At the CBBN offset, when the CBBN duration was > or = 2 min, DPOAE amplitude continued to increase for > 1 min, showing an efferent effect outlasting CBBN stimulation.

Pathophysiology of erectile dysfunction.

During the past decade, our knowledge of the hemodynamics, functional anatomy, neurophysiology, and neuropharmacology of erectile function has evolved substantially. The change of smooth muscle tone has emerged as a key factor in erection and detumescence. However, future studies are needed to elucidate the cellular and molecular basis of erectile physiology. With insight into normal physiology we will understand the pathologic process and be able to treat it.

Effect of simulated birth trauma on the urinary continence mechanism in the rat.

OBJECTIVES: To examine the effect of simulated birth injury in an animal model as part of a study on the pathogenesis of stress urinary incontinence (SUI) and the urinary continence mechanism. METHODS: A balloon was inflated in the vaginas of rats for 4 hours to simulate prolonged labor. The effect on the continence mechanism was assessed by functional, anatomic, biochemical, and histologic examinations. The functional test consisted of placing chili powder or a clipped whisker into the rat's nostrils to induce sneezing. Anatomic measurement of the genital hiatus was performed with a caliper. Serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) were measured to examine the value of muscle injury in predicting incontinence. c-Fos immunostaining in the spinal cord was used as a marker of nerve injury. These data were then correlated with histopathologic examination of the urethra and pelvic floor tissues. RESULTS: Four weeks after simulated birth injury, SUI was noted in 19 of 48 experimental rats. The genital hiatus was significantly wider in incontinent rats. The serum CPK and LDH levels were markedly elevated, but no difference was noted between the continent and incontinent rats. All experimental rats showed many c-Fos immunostaining neurons in the L6 to S1 spinal cord segments, but none was seen in control rats. Histologic study revealed a marked decrease of ganglion cells in the neural plexuses posterolateral to the vagina in experimental rats. After 4 weeks, muscle necrosis and degeneration, irregular shape and size of muscle fibers, and a change in the type I/II ratio were prominent features in the levator ani. In the urethra, we noted a significant decline in urethral wall musculature (both smooth and striated) in incontinent rats. CONCLUSIONS: In this novel rat model, simulated birth injury resulted in SUI in a portion of the animals. Pathologic changes in the urethra, pelvic ganglia, and levator muscles seem to be the contributing factors to SUI.

Is colchicine effective in Peyronie's disease? A pilot study.

OBJECTIVES: The treatment of Peyronie's disease with oral or topical agents has not been entirely satisfactory. In this pilot study, we hypothesized that colchicine, known to induce collagenase activity and decrease collagen synthesis, might be an ideal agent in the treatment of Peyronie's disease. METHODS: Colchicine was administered orally for 3 to 5 months to a group of 24 previously untreated patients with Peyronie's disease. RESULTS: Peyronie's plaque decreased or disappeared in 12 of the 24 patients, 7 of 9 patients with painful erections reported significant relief, and penile curvature was improved in 7 of 19 cases. Erectile status, narrowing of the penis, and accompanying Dupuytren's contracture did not change in any of the cases. CONCLUSIONS: Although this pilot study shows some promising results of the use of colchicine in the treatment of Peyronie's disease, the ultimate usefulness of this agent will be determined only by a prospective double-blind clinical study.

Increases in clitoral and vaginal blood flow following clitoral and pelvic plexus nerve stimulations in the female rat.

The objective of this present study is to establish a model in the rat for the study of female clitoral and vaginal vascular changes during sexual excitation. A laser Doppler was used to measure blood flow changes following clitoral and pelvic plexus nerve stimulations. Results show an increase in clitoral blood flow following clitoral nerve (df1 = 12, df2 = 108, F = 21.4, P < 0.001) and pelvic plexus nerve stimulations (n = 3). A vaginal blood flow increase is also observed following pelvic plexus nerve stimulations (df1 = 12, df2 = 108, F = 4.75, P < 0.001). The female rat can therefore be used as a model for the study of the physiology, pharmacology and sexual dysfunction relating to blood flow in clitoral and vaginal tissue.

Erectile dysfunction occurs following substantia nigra lesions in the rat.

Erectile function was assessed 6 weeks following uni- and bilateral injections of 6-hydroxydopamine in the substantia nigra nucleus of the brain. Behavioral apomorphine-induced penile erections were reduced (5/8) and increased (3/8) in uni- and bilateral lesioned animals. Intracavernous pressures, following electrical stimulation of the cavernous nerve, decreased in lesioned animals. Lesions of the substantia nigra were confirmed by histology. Concentration of dopamine and its metabolites were decreased in the striatum of substantia nigra lesioned rats. Lesions of the substantia nigra are therefore associated with erectile dysfunction in rats and may serve as a model to study erectile dysfunction in Parkinson's disease.

Intraperitoneal versus extraperitoneal insufflation of carbon dioxide as for laparoscopy.

In order to compare the effects of intraperitoneal and extraperitoneal insufflation of CO2, we obtained blood gas measurements and chest radiographs in dogs during insufflation into three sites: the peritoneal cavity alone, the retroperitoneal space with communication into the peritoneal cavity, and the retroperitoneal space alone. The blood pH fell a mean of 0.11 +/- 0.03 and the PaCO2 rose a mean of 16.0 +/- 3.7 mm Hg when insufflation included the peritoneal cavity, whereas when insufflation was limited to the retroperitoneum, the pH fell a mean of 0.05 +/- 0.03 and the PaCO2 rose a mean of 7.5 +/- 2.8 mm Hg. Extrapleural thoracic dissection of gas was noted in one animal after insufflation limited to the retroperitoneal space. These findings confirm that there is significant absorption of CO2 from the peritoneal cavity during laparoscopy with CO2 insufflation, whether the pneumoperitoneum is primary or occurs secondary to retroperitoneal insufflation. If the insufflated gas is limited to the retroperitoneal space, however, the absorption of CO2 appears to be reduced in this animal model. The risk of thoracic dissection of gas may be greater during extraperitoneal insufflation than during intraperitoneal insufflation.

Expression of airway secretory epithelial functions by lung carcinoma cells.

We examined 12 non-small cell lung carcinoma cell lines for expression of airway goblet, serous, and mucous cell characteristics. The cells expressed some ultrastructural traits of secretory epithelial cells but none contained secretory granules typical of the airway secretory cells. Using immunocytochemistry and cell-specific monoclonal antibodies, we identified heterogeneous expression of goblet, mucous, and serous cell markers among the cell lines. After metabolic radiolabeling, cells incorporated isotope into high molecular weight material. Incubation of pulse-radiolabeled cells with a number of known mucus secretogogues revealed that 5 of the 12 cell lines released radiolabeled material in response to the agonists. However, in each cell line only one of the receptor-activated pathways tested was intact. Although we did not identify a single cell line expressing a phenotype similar to normal airway secretory cells, particular functions retained by some of these cell lines may make them useful for specific studies of mucus production or secretion.

Bladder leiomyoma: report of two cases and literature review.

Mesenchymal tumors of the urinary bladder are rare and the majority of them are malignant. We report two cases of leiomyoma of the urinary bladder presenting with symptoms of bladder outlet obstruction. The first patient was managed with staged transurethral resections, and the second with holmium laser transurethral inoculation. The outcome was excellent in both cases. A review of the literature is also outlined.

Bellini duct carcinoma with ovarian metastasis.

We report a case of collecting duct carcinoma presenting as pyelonephritis with hypercalcemia and metastasis to the ovary. Case management and literature review being presented.

Postnatal development of penile NADPH diaphorase in male rats (Rattus norvegicus): an indicator of erectile function.

The aim of this study was to determine the contribution of nitric oxide (NO) to the development of penile erection in rats and was accomplished by evaluating the nicotinamide adenine dinucleotide phosphate diaphorase (NADPH) content of juvenile penile tissues. NADPH is an enzyme involved in the synthesis of NO, a mediator of smooth muscle relaxation in penile tissues. We euthanized 36 rats (age, 1 to 65 days) and obtained penile midshaft specimens for NADPH staining. The number of NADPH-positive granules in the corpus cavernosum and dorsal penile nerve increased significantly (P < 0.001) until animals were 50 days of age. Penile erections in young rats are known to occur around 30-40 days, and penile tissues showed a very significant (P < 0.001) increase of NADPH-positive granules in the corpus cavernosum and the dorsal penile nerve during this period. Therefore, NO seems important for the development of penile erection in juvenile rats.

[Comparison of prostatic electro-vaporization and transurethral resection in the treatment of benign prostatic hypertrophy]. / Comparaison de l'électrovaporisation et de la résection trans-urétrale de la prostate dans le traitement de l'hypertrophie bénigne de la prostate.

The objectives of this study was to compare electrovaporization (EVAP) of the prostate to transurethral resection of the prostate (TURP). A prospective evaluation of 60 patients treated for benign prostatic hypertrophy (BPH) was carried out between November 1994 and November 1996. Twenty five patients were treated with TURP and 35 patients with EVAP. All patients had a minimum 12 month follow-up. The results obtained were comparable in terms of surgical procedure time with a bloodless surgical field using EVAP. EVAP was advantageous in reducing the time with indwelling urinary catheter postoperatively and reducing hospital stay. At 12 month follow-up results of flow rates and symptom scores were similar for both TURP and EVAP. Reoperation rate for residual BPH in the EVAP group was higher than for TURP, suggesting that EVAP should probably be limited to smaller sized glands. This study suggests that EVAP is a viable alternative to TURP in selected patients. It requires no specialized equipment and may allow a reduction in catheterization and hospital stay.