Steroids in cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction that may contribute to postoperative complications. Preventing this reaction with steroids may improve outcomes. We performed a systematic review to evaluate the impact of prophylactic steroids on clinical outcomes in patients undergoing on-pump cardiac surgery. METHODS: We searched MEDLINE, EMBASE, and Cochrane CENTRAL for randomised controlled trials (RCTs) comparing perioperative corticosteroid administration with a control group in adults undergoing CPB. Outcomes of interest included mortality, myocardial infarction, and new onset atrial fibrillation. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Fifty-six RCTs published between 1977 and 2015 were included in this meta-analysis. Mortality was not significantly different between groups [3.0% (215/7258 patients) in the steroid group and 3.5% (252/7202 patients) in the placebo group; relative risk (RR), 0.85; 95% confidence interval (CI), 0.71-1.01; P=0.07; I2 = 0%]. Myocardial injury was more frequent in the steroid group [8.0% (560/6989 patients), compared with 6.9% (476/6929 patients); RR, 1.17, 95% CI, 1.04-1.31; P=0.008; I2=0%]. New onset atrial fibrillation was lower in the steroid group [25.7% (1792/6984 patients) compared with 28.3% (1969/6964 patients), RR, 0.91, 95% CI, 0.86-0.96, P=0.0005, I2=43%]; this beneficial effect was limited to small trials (P for interaction <0.00001). CONCLUSIONS: After randomising 16 013 patients, steroid administration at the time of cardiac surgery had an unclear impact on mortality, increased the risk of myocardial injury, and the impact on atrial fibrillation should be viewed with caution given that large trials showed no effect.

A novel lipase with dual localisation in Trypanosoma brucei.

Phospholipases are esterases involved in lipid catabolism. In pathogenic micro-organisms (bacteria, fungi, parasites) they often play a critical role in virulence and pathogenicity. A few phospholipases (PL) have been characterised so far at the gene and protein level in unicellular parasites including African trypanosomes (AT). They could play a role in different processes such as host-pathogen interaction, antigenic variation, intermediary metabolism. By mining the genome database of AT we found putative new phospholipase candidate genes and here we provided biochemical evidence that one of these has lipolytic activity. This protein has a unique non-canonical glycosome targeting signal responsible for its dual localisation in the cytosol and the peroxisomes-related organelles named glycosomes. We also show that this new phospholipase is excreted by these pathogens and that antibodies directed against this protein are generated during an experimental infection with T. brucei gambiense, a subspecies responsible for infection in humans. This feature makes this protein a possible tool for diagnosis.

[Proposal of a rating scale of posture for simple dysfunctional dysphonia: "S-TRAV"]. / Proposition d'une échelle d'évaluation de la posture pour les dysphonies dysfonctionnelles simples: "S-TRAV".

OBJECTIVE: This work aims to create a scale to evaluate posture, quick and easy to perform during the assessment of voice in patients with simple dysfunctional dysphonia. MATERIAL AND METHOD: The "S-TRAV" scale was evaluated on 60 subjects with dysphonia and 60 control subjects. It assesses "the overall severity" of the alteration of posture, the "Tension", the "Breathing", the "Ground anchoring" and the "Verticality" both quantitatively (score 0-3) and qualitatively. The patient also assesses his voice disorder and his posture. Postural observation was carried out in five conditions: at rest, conversational voice, reading, projected voice and singing voice. The comparison between the dysphonic subjects and control subjects was used to assess the sensitivity of this tool. Two reviewers rated the scale to determine its reproducibility. RESULTS: The scale is sensible for the majority of criteria with a significance coefficient less than 0.05. The most discriminate criteria relate to the cervical spine, the overall score of postural severity assessed by the therapist and verticality. All criteria have a low level of variability between the reviewers under all conditions. Most criteria are correlated with the criterion "Overall Severity" of postural alterations under all conditions. Non-sensible criteria were eliminated from the final scale). CONCLUSION: This tool is sensitive, reproducible and relevant in assessing the severity of postural alterations and their location. Further studies will validate the scale on a consistent population.

TP53 mutations predict disease control in metastatic colorectal cancer treated with cetuximab-based chemotherapy.

Recent studies have suggested that activation of the EGFR pathway leads to malignant transformation only if the p53 protein is inactivated. Therefore, we evaluated the impact of TP53 mutations on cetuximab-based chemotherapy (CT) sensitivity in combination with KRAS mutations that have been associated with cetuximab resistance. KRAS and TP53 status were assessed in tumours from 64 metastatic colorectal cancer patients treated with cetuximab-based CT and correlated to clinical response using the Fisher's exact test. Times to progression (TTPs) according to gene status were calculated using the Kaplan-Meier method and compared with log-rank test. TP53 mutations were found in 41 patients and were significantly associated with controlled disease (CD), as defined as complete response, partial response or stable disease (P=0.037) and higher TTP (20 vs 12 weeks, P=0.004). Remarkably, in the subgroup of 46 patients without KRAS mutation, but not in patients with KRAS mutation, TP53 mutations were also associated with CD (P=0.008) and higher TTP (24 vs 12 weeks, P=0.0007). This study suggests that TP53 mutations are predictive of cetuximab sensitivity, particularly in patients without KRAS mutation, and that TP53 genotyping could have a clinical interest to select patients who should benefit from cetuximab-based CT.

Cardiac surgery in patients with haemophilia B: a case report and review of the literature.

Cardiac surgery for coronary heart disease, and for calcific and degenerative valvular heart disease, will likely become more frequent with an ageing haemophilia population. Our report describes the successful management of an individual with mild haemophilia B undergoing elective aortic valve replacement using a continuous infusion of recombinant factor IX. Emphasis is placed on the multidisciplinary coordination of care required across three hospital sites to ensure an uncomplicated peri- and postoperative course. We also provide a review of the current literature on cardiac surgery in patients with haemophilia B.

Incidental findings in CT imaging of coronary artery bypass grafts: results from a Canadian multicenter prospective cohort.

OBJECTIVE: To assess the prevalence and clinical significance of incidental findings identified during computed tomography imaging of coronary artery bypass grafts. RESULTS: This prospective study includes 144 patients undergoing coronary graft patency assessment using computed tomography. Incidental findings were classified as significant if they were considered to need an immediate action or treatment, short-term work-up or follow-up, or minor. A total of 211 incidental findings were present in 109 (75.7%) patients. Seventy-one incidental findings (33.6%) were cardiac and 140 (66.4%) were extracardiac. Most common cardiac incidental findings were atrial dilatation [39 patients, 48 incidental findings (67.6%)] and aortic valve calcifications (7 patients, 9.9%). Among the 140 extracardiac incidental findings, the most common were lung nodules (51 patients, 54 nodules, 38.6%), and emphysema (21 patients, 15%). Thirty-six (25.7%) extracardiac incidental findings were significant and notably, 23 (63.9%) were lung nodules. Follow-up was recommended in 37 cases, among which all patients with significant lung nodules (23 patients, 62.2%). In conclusion, most common computed tomography incidental findings in patients with coronary grafts were lung nodules and emphysema.

[Tumour sequencing: Evolutions and revolutions]. / Séquençage des tumeurs : évolutions et révolutions.

For some years now, we have entered the genomic age of tumour genotyping from a medical point of view. Technological breakthroughs in both biology and information science now allow a genomic analysis of cancers in everyday medical practice with, in some case, a major impact on patient care not only for the choice of therapy (i.e. EGFR mutations in lung adenocarcinoma), but also for diagnosis and monitoring of the disease. Tumour genotyping is performed from formalin-fixed paraffin-embedded tissues used for diagnosis of cancer. However, new approaches have emerged, with for example the more and more spread use of "liquid biopsies". Genotyping of a gene panel implicated in carcinogenesis is now routinely performed in some cancer types, with the help of high-throughput sequencers, and it is likely that improvement of these machines will make tumour genotyping easier and more accessible in the near future. Nevertheless, the current challenge is not anymore detection of molecular alterations, but their relevant interpretation, so as to be the most useful in patient care.

The Canadian off-pump coronary artery bypass graft registry: a one-year prospective comparison with on-pump coronary artery bypass grafting.

BACKGROUND: The authors sought to examine in-hospital and one-year outcomes of off-pump coronary artery bypass grafting (CABG) and to determine the subgroups of patients most likely to benefit from the off-pump procedure in a regular surgical practice. METHODS: From March 2001 to December 2002, 1657 consecutive patients were treated with off-pump CABG and 1693 consecutive patients were treated with on-pump CABG. Propensity score modelling was performed to control for treatment and selection bias. A propensity-matched analysis was performed to identify factors associated with survival benefit from the off-pump procedure. RESULTS: The mortality was similar postoperatively and at one year after surgery. The rate of stroke was decreased in the off-pump group postoperatively (OR=0.49, 95% CI 0.23 to 1.06) and significantly at one year after surgery (OR=0.49, 95% CI 0.27 to 0.90). A significant reduction in acute renal dialysis and a significant increase in myocardial infarction rates were seen in off-pump patients during the initial hospitalization but these differences disappeared during the follow-up period. The number of grafts completed was significantly lower in off-pump CABG than in on-pump CABG (2.62+/-1.00 versus 3.36+/-0.92, respectively; P<0.001). Hospital length of stay and the percentage of patients who required mechanical ventilation were significantly lower in the off-pump group than in the on-pump group. At one year after surgery, the adjusted rate of coronary angiogram and revascularization was similar between the two groups, and the adjusted rate of self-reported angina and memory status was significantly better in the off-pump CABG group. Almost all subgroups of patients had a neutral effect or a survival benefit with the off-pump technique. CONCLUSIONS: The results from a Canada-wide multicentre registry showed the safety and effectiveness of off-pump CABG in most subgroups of patients in a regular surgical practice.

Influence of the natural growth environment on the sensitivity of phototrophic biofilm to herbicide.

Ecotoxicological experiments were performed in laboratory-scale microcosms to investigate community-level structural responses of river phototrophic biofilms from different environments to herbicide exposure. Biofilms were initially cultivated on artificial supports placed in situ for 4 weeks at two sites, site M, located in an agricultural watershed basin and site S, located in a forested watershed basin. The biofilms were subsequently transferred to microcosms and, after an acclimatisation phase of 7 days were exposed to alachlor at 10 and 30 µg L(-1) for 23 days. Alachlor effects were assessed by a combination of structural parameters, including biomass (ash-free dry mass and chlorophyll a), molecular fingerprinting of the bacterial community (polymerase chain reaction (PCR)-denaturing gradient gel electrophoresis (DGGE)) and diatom species composition. Alachlor impacted the chlorophyll a and ash-free dry mass levels of phototrophic biofilms previously cultivated at site S. The structural responses of bacterial and diatom communities were difficult to distinguish from changes linked to the microcosm incubation period. Phototrophic biofilms from site S exposed at 30 µg L(-1) alachlor were characterised by an increase of Achnanthidium minutissimum (K-z.) Czarnecki abundance, as well as a higher proportion of abnormal frustules. Thus, phototrophic biofilms with different histories, exhibited different responses to alachlor exposure demonstrating the importance of growth environment. These observations also confirm the problem of distinguishing changes induced by the stress of pesticide toxicity from temporal evolution of the community in the microcosm.

Community structure and nutrient level control the tolerance of autotrophic biofilm to silver contamination.

Autotrophic biofilms are complex and fundamental biological compartments of many aquatic ecosystems. Since microbial species differ in their sensitivity to stressors, biofilms have long been proposed for assessing the quality of aquatic ecosystems. Among the many stressors impacting aquatic ecosystems, eutrophication and metal pollution are certainly the most common. Despite that these stressors often occur together, their effects on biofilms have been far much studied separately than interactively. In this study, we evaluated the interactive effects of silver (Ag), a reemerging contaminant, and phosphorus (P), a nutrient often associated with freshwater eutrophication, on the structure and functioning of two types of autotrophic biofilms, one dominated by diatoms and another one dominated by cyanobacteria. We hypothesized that P would alleviate the toxic effects of Ag, either directly, through the contribution of P in metal detoxification processes, or indirectly, through P-mediated shifts in biofilm community compositions and associated divergences in metal tolerance. Results showed that Ag impacted biofilm community structure and functioning but only at unrealistic concentrations (50 µg/L). P availability led to significant shifts in biofilm community composition, these changes being more pronounced in diatom- than those in cyanobacteria-dominated biofilm. In addition, P tended to reduce the impact of Ag but only for the cyanobacteria-dominated biofilm. More generally, our results highlight the preponderant role of the initial community structure and nutrient level on biofilm response to metallic pollutants.

Intimal hyperplasia and thrombosis of the visceral arteries in a young woman: possible relation with oral contraceptives and smoking.

This is a report of a 26-year-old woman who died of a massive intestinal infarction caused by occlusion of the celiac axis and the superior and inferior mesenteric arteries. Autopsy showed intimal hyperplasia and an overlying thrombus that obstructed the lumen of the vessel. As shown by Irey et al., exogenous or endogenous female reproductive steroids can act on the vascular system as a target organ and induce intimal hyperplasia and thrombus formation. The effects of contraceptive estrogens and progestogens are discussed, but the catalytic effect of heavy cigarette smoking appears to be the factor that induces, in predisposed women with hyperplasia, thrombosis of visceral arteries. In this case report we want to emphasize that the association between smoking and oral contraceptives can cause cardiovascular disease in young women. Failure to recognize this fact could result in delayed diagnosis and worsen the prognosis.

PIP: To further understand the pathophysiology of arterial diseases induced by oral contraceptives (OCs), a case report is presented of a young woman who died of extensive visceral artery thrombosis. The possible role of estrogens and progestogens and of cigarette smoking as the predisposing factors in this patient are discussed. A 26-year-old woman, who complained of progressive abdominal pain and whose past medical and surgical history was negative, was admitted to the general surgery service. She was the mother of 1 child and had had 2 previous spontaneous abortions. She had received ethinyl estradiol 35 mcg with norethindrone 500 mcg and 1000 mcg for 3 months, but because of a problem with breakthrough bleeding the medication was changed to mestranol 50 mcg with norethindrone 1000 mcg. She had been taking Ortho-Novum 1/50 for 2 1/2 years. She had smoked 25-35 cigarettes daily for about 10 years but denied use of alcohol or other drugs. She was not known to be diabetic, hypertensive, or dyslipidemic, and had no history of atherosclerosis in her family. For 7 months prior to her admission, the patient complained of abdominal pain, which progressively increased in intensity and duration, interrupted by periods of well-being. The patient reported 2 recent, isolated episodes of mild proctalgia but no tenesmus or melena. There had been no fever, but the patient had been anorexic for the past 2 weeks and reported losing 10 kg in the past month. She had no complaints apart from those related to the gastrointestinal system. At an emergency laparotomy, gangrenous acalculous cholecystitis and infarction of the terminal ileum were discovered. A cholecystectomy with resection of the terminal ileum and the right colon was performed. An end-to-end primary anastomosis was performed. On exploration of the superior mesenteric artery, a thrombus was discovered at its origin. As a transverse arteriotomy showed a good retrograde flow, a thrombectomy was performed. There appeared to be an unsatisfactory antegrade flow. The superior mesenteric artery then was transposed in an end-to-end fashion on the abdominal aorta. An immediate postoperative arteriogram showed thrombosis of the celiac axis at its origin. Revascularization failed to improve the condition of the intestine. The patient died. The intent of this case report is to emphasize that the association between smoking and oral contraceptives can cause cardiovascular disease in young women, and a failure to recognize this association can result in delayed diagnosis and worsen the prognosis.

Anterior and middle mediastinum paraganglioma: complete resection is the treatment of choice.

Paraganglioma of the mediastinum is described to be an indolent and slow-growing tumor. After a patient presented to our center, we reviewed the world literature to evaluate the prognosis of this tumor. This review showed that paragangliomas are locally invasive and have a high local recurrence rate (44/79 or 55.7%) with a true metastatic capacity (21/79 or 26.6%). The overall survival is 62.0% (49/79), but only 36.7% (29/79) of patients could be considered as free of disease, with survival time of 98.2 +/- 11.7 months (mean +/- standard error). The survival with a complete resection is 84.6% (125.7 +/- 18.7 months) versus 50.0% (71.5 +/- 13.8 months) for patients with a biopsy or a partial excision and adjuvant treatment (p < 0.01). We acknowledge the limitation of this retrospective study, but a prospective trial is not possible because of the rarity of the tumor. We want to emphasize that paraganglioma of the anterior and middle mediastinum is an aggressive tumor, and complete surgical resection, using cardiopulmonary bypass if necessary, is highly recommended.

Gastrointestinal function following esophagectomy for malignancy.

BACKGROUND: The frequency and causes of gastrointestinal complications following esophagectomy for malignancy are unknown. PATIENTS AND METHODS: We reviewed 295 esophagectomies performed for malignancy between January 1980 and September 1994 in order to determine the frequency and causes of early and late gastrointestinal complications. RESULTS: Compared to transhiatal and left thoracoabdominal esophagectomies, esophagectomies carried out through a right posterolateral thoracotomy with cervical esophagogastric anastomosis had a higher incidence of delayed gastric emptying (11%), pneumonia (26%), and hospital death (9%). The same operation had a higher incidence of gastroesophageal reflux (20%) and dysphagia requiring esophageal dilatation (53%). We found no independent effect of gastric drainage procedures, feeding jejunostomy, preoperative radiotherapy, pathology, or age on these outcomes. Women had no operative mortality, but a higher incidence of gastroesophageal reflux and diarrhea following esophagectomy. CONCLUSIONS: Surgical techniques aimed at improving gastric emptying following esophagectomy for cancer should improve operative morbidity and mortality.

Giant hydatid lung cysts in the Canadian northwest: outcome of conservative treatment in three children.

Hydatid lung disease due to Echinococcus granulosus in the Canadian northwest and Alaska is often asymptomatic and usually benign. We reviewed the course and outcome of three children with giant hydatid lung cyst seen over a 2-year period. All were North American Indian children aged 9 to 12 years who presented with cough, fever, and chest pain. One had a rash. There was a history of exposure to domestic dogs who had been fed moose entrails in each case. Chest x-rays showed solitary lung cysts with air-fluid levels, from 6 cm to 12 cm in diameter. Aspiration of each cyst demonstrated Echinococcus hooklets and protoscolices. Serology was unhelpful, being negative in two cases. Transient pneumonitis and pneumothorax were seen as complications of needle aspiration. Two cysts gradually resolved over the following 6 months. One child returned after 9 months with a lung abscess due to superimposed infection of the cyst remnant with Haemophilus influenzae, and eventually required lobectomy. The existence of an endemic benign variant of E granulosus in Canada is not widely known, and it is important to distinguish it from the more aggressive pastoral form of the disease seen in immigrants from sheep-rearing countries. The native Canadian disease usually resolves spontaneously, does not cause anaphylaxis, and does not implant daughter cysts if spilled. Surgical treatment should be avoided except for complications such as secondary bacterial infection.

[Perineal necrotizing cellulitis disclosing rectal adenocarcinoma]. / Cellulite nécrosante périnéale révélant un adénocarcinome rectal.

We report one case of rectal cancer disclosed by a perineal cellulitis in a diabetic woman. This infrequent association has a bad prognosis. Diagnosis is mainly clinical. Treatment is urgent with large spectrum antibiotic therapy, surgical debridement, colostomy and hyperbaric oxygen if available. Surgical treatment of the rectal cancer can be done immediately or delayed.

[Pudendal hernia of the labia]. / Hernie de la grande lèvre.

A case of hernia is reported with a brief review of perineal hernia.

[Acute severe colitis with recto-vaginal fistula during treatment with non-steroidal anti-inflammatory agents]. / Colite aiguë grave avec fistule recto-vaginale sous anti-inflammatoires non stéroïdiens.

INTRODUCTION: We report the case of severe colitis occurring during treatment with non-steroid anti-inflammatories (NSAI). OBSERVATION: A 57 year-old woman was hospitalized for lumbar pain that had not been relieved by AINS, tramadol and then morphine. The patient presented with septic shock and peritonitis by rectal perforation, followed by acute rectorrhagia. The endoscopic aspect evoked Crohn's disease with a recto-vaginal fistula. Progression was further complicated by two episodes of collapse because of acute rectorrhagia, requiring hemostasis colectomy and abdominal-perineal amputation. CONCLUSION: The diagnosis retained was AINS-induced colitis complicated by acute colectasia on a fecaloma with recto-vaginal fistula.

Cost implications of the use of basal insulin glargine in people with early dysglycemia: the ORIGIN trial.

AIMS: The cost implications of the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial were evaluated using a prespecified analysis plan. METHODS: Purchasing power parity-adjusted country-specific costs were applied to consumed healthcare resources by participants from each country. Subgroup analyses were conducted on subgroups based on baseline metabolic status and diabetes duration. RESULTS: The total undiscounted cost per participant in the insulin glargine arm was $13,491 ($13,080 to $14,254) versus $11,189 ($10,568 to $12,147) for standard care, an increase of $2303 ($1370 to $3235; p < 0.0001); the discounted increase was $2099 ($1276 to $2923; P < 0.0001). The greater number of mainly generic oral anti-diabetic agents in the standard group partially offset the higher cost of basal insulin glargine. As the trial progressed and the standard group required more anti-diabetic medications, the annual cost difference decreased, reaching $68 (-$160 to $295) in the last year. The subgroup whose baseline diabetes duration was ≥ 6 years achieved cost-savings during the trial. CONCLUSIONS: From a global perspective basal insulin glargine use in ORIGIN incurred greater costs than standard care using older generic drugs. Nevertheless, the cost difference fell with time such that the intervention was cost-neutral by the last year.