COgnitive enhancement and consumption of psychoactive Substances among Youth Students (COSYS): a cross-sectional study in France.

OBJECTIVES: This descriptive and analytical study investigated the consumption rates of psychoactive substances among individuals aged 18-25 years in France. More specifically, it enabled assessment of the extent of the neuroenhancement (NE) phenomenon among students in France (including study of the misuse of psychostimulant medicines). STUDY DESIGN: COgnitive enhancement and consumption of psychoactive Substances among Youth Students (COSYS) is a cross-sectional survey of students in France. METHODS: Between January and June 2017, a questionnaire was mailed to students. All questionnaires were completed anonymously and included questions regarding the use of all kind of psychoactive substances, motivations for use and socio-economic situations. Statistics for all variables and the results of a multiple correspondence analysis (MCA) are presented. RESULTS: This study recorded 46,203 respondents, mostly in universities (>60%), mostly women (63.4%), with an average age of 21.4 years. In terms of substance use, medications were cited in the third position after alcohol and tobacco by women (22.48%) and in the fourth position after alcohol, tobacco and cannabis by men (15.14%). Among medications, opiates were the most frequently used, followed by benzodiazepines. Students who declared a non-medical use (NMU) of drugs obtained these through various ways (e.g. family medicine cabinet, a friend, a dealer or via the Internet), or by increasing their recommended doses (e.g. codeine). In total, 18.6% of students consumed psychoactive substances for 'stress management' and 14.1% for 'sleep management'. Results indicated that NE in students is a problem, with 18.6% of students in the COSYS survey confirming the use of psychoactive substances for this reason. There was a very low prevalence for psychostimulant medications (0.57% of men), mostly NMU (67%). MCA yielded three different profiles (doping candidate, experimenter and psychiatric profile) of psychostimulant users, which complicates the implementation of prevention programmes. CONCLUSIONS: It is evident that NMU and 'conventional' use of medications are highly prevalent in French students, especially females. NMU is associated with substance use disorders, psychopathology and suicidality. Social norms and social media increase NMU of psychoactive substances, but also provide a potential platform for anti-NMU campaigns. CLINICAL TRIAL REGISTRATION NUMBER: NCT02954679.

Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort.

BACKGROUND AND AIMS: Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. METHODS: From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. RESULTS: Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ±â€…20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159]. CONCLUSIONS: Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

Use of a navigation system in endonasal surgery: Impact on surgical strategy and surgeon satisfaction. A prospective multicenter study.

OBJECTIVES: Surgical navigation systems (SNS) are now widely used in endoscopic endonasal surgery. Benefit, however, has not been fully studied. The objective of this study was to evaluate the impact of an SNS in terms of performance of the surgical procedure and of surgeon satisfaction, in a prospective multicenter study. MATERIALS AND METHODS: A multicenter prospective study included patients undergoing endoscopic endonasal surgery using the electromagnetic DigiPointeur® (DGP) SNS in 16 French hospitals. An observation form, completed by the surgeon immediately at end of procedure, included type of procedure, and any changes in strategy or extent of surgery related to use of the SNS. Surgeon satisfaction was rated on an analog scale, with self-assessment of stress experienced during the procedure. RESULTS: The study included 311 patients operated on by 36 surgeons in 16 French hospitals. Ethmoidectomy was the most frequent procedure (90%); tumor resection was performed in 5.1% of cases. The SNS enabled more extensive surgery in 81% of cases, in particular by identifying and opening additional cells (57% of cases). Mean satisfaction was 8.6/10; surgeons reported decreased surgical stress thanks to the SNS in 95% of cases. CONCLUSION: In this observational study, the use of an SNS increased the extent of surgery in 81% of cases, and had a positive impact on the stress perceived by the surgeon in 95% of cases.

Prospective, multicentric, comparative study between sleeve gastrectomy and Roux-en-Y gastric bypass, 277 patients, 3 years follow-up.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en Y gastric bypass (LRYGB) are commonly performed, but few studies have shown superiority of one strategy over the other. OBJECTIVE: Simultaneously compare LSG and LRYGB in terms of weight loss and morbimortality over a 36-month follow-up period. SETTING: University hospital and bariatric surgery centers, France. METHODS: Prospective, comparative study between LSG and RYGBP. The primary endpoint of this study was a joint hypothesis during the 36-month follow-up: the first primary outcome pertained to the frequency of patients with an excess weight loss (EWL) greater than 50% (% EWL>50%) after LSG or RYGB; the second primary outcome was defined as a composite endpoint of at least one major complication. Secondary objectives were regression of comorbidities and improvement in quality of life. RESULTS: Two hundred and seventy-seven patients were included (91 RYGBP, 186 LSG). The mean age was 41.1±11.1 years, and average preoperative body mass index of 45.3±5.5kg/m2. After 36months, the %EWL>50% was not inferior in the case of LSG (82.2%) relative to LRYGB (82.1%); while major complications rates were significantly higher in LRYGB (15.4%) vs. LSG (5.4%, P=0.005). After 36months, all secondary objectives were comparable between groups while only gastroesophageal reflux disease (GERD) increased in LSG group and decreased in LRYGB group. CONCLUSIONS: LSG was found non-inferior to LRYGB with respect to weight loss and was associated with lower risk of major complications during a 3-year follow-up. But GERD increased in LSG group and decreased in LRYGB group.

Angiotensin II receptor blockers, steroids and radiotherapy in glioblastoma-a randomised multicentre trial (ASTER trial). An ANOCEF study.

BACKGROUND: Glioblastomas (GBMs) induce a peritumoural vasogenic oedema impairing functional status and quality of life. Steroids reduce brain tumour-related oedema but are associated with numerous side-effects. It was reported in a retrospective series that angiotensin receptor blockers might be associated with reduced peritumoural oedema. The ASTER study is a randomised, placebo-controlled trial to assess whether or not the addition of Losartan to standard of care (SOC) can reduce steroid requirement during radiotherapy (RT) in patients with newly diagnosed GBM. PATIENTS AND METHODS: Patients with a histologically confirmed GBM after biopsy or partial surgical resection were randomised between Losartan or placebo in addition to SOC with RT and temozolomide (TMZ). The primary objective was to investigate the steroid dosage required to control brain oedema on the last day of RT in each arm. The secondary outcomes were steroids dosage 1 month after the end of RT, assessment of cerebral oedema on magnetic resonance imaging, tolerance and survival. RESULTS: Seventy-five patients were randomly assigned to receive Losartan (37 patients) or placebo (38 patients). No difference in the steroid dosage required to control brain oedema on the last day of RT, or one month after completion of RT, was seen between both arms. The incidence of adverse events was similar in both arms. Median overall survival was similar in both arms. CONCLUSIONS: Losartan, although well tolerated, does not reduce the steroid requirement in newly diagnosed GBM patients treated with concomitant RT and TMZ. Trial registration number NCT01805453 with ClinicalTrials.gov.

Early screening for gestational diabetes mellitus is not associated with improved pregnancy outcomes: an observational study including 9795 women.

AIMS: In addition to screening for hyperglycaemia during pregnancy after 24 weeks of gestation (WG), the current guidelines also suggest screening in early pregnancy and referring women with early gestational diabetes mellitus (eGDM) or overt diabetes (OD) for immediate care. Our aim was to evaluate this strategy. METHODS: This study evaluated, at our hospital (2012-2016), whether the incidence of a predefined composite outcome (preeclampsia, large-for-gestational-age infant, shoulder dystocia) and secondary outcomes was different when women were screened only after 22WG ('late screening only') or before 22WG and treated for eGDM or OD if present, with repeat screening after 22WG if absent ('early ± late screening'). RESULTS: Early ± late screening (n = 4605, 47.0%) increased between 2012 and 2016 (P < 0.0001) and was associated with more risk factors for GDM than late screening only. Glycaemic status differed in both groups (early ± late screening: eGDM 10.3%, GDM 12.1%, OD 0.9% vs. late screening only: GDM 16.8%, OD 1.2%; P < 0.001), with a higher rate of insulin therapy (8.9% vs. 6.0%; P < 0.001) and less gestational weight gain (11.1 ± 5.4 kg vs. 11.4 ± 5.5 kg; P = 0.013) in the early ± late screening group. Rates of those meeting the composite criterion were similar in both groups [11.6% vs. 12.0%, respectively; odds ratio (OR): 1.040, 95% confidence interval (CI): 0.920-1.176; P = 0.53] and remained comparable after adjusting for Propensity Scores (OR: 1.046, 95% CI: 0.924-1.185; P = 0.4790). Rates for secondary outcomes were also similar in both groups. CONCLUSION: While a strategy including early measurement of fasting plasma glucose during pregnancy increases the incidence and care of hyperglycaemia during pregnancy, it may not significantly improve pregnancy outcomes.

Outcomes of endoscopic ethmoidectomy performed on a day-case basis: a prospective bi-centric study.

Evaluation of endoscopic ethmoidectomy performed as a day-case in terms of security, quality, and satisfaction of the patient. This prospective observatory bi-centric study over 1 year included 74 patients undergoing an ethmoidectomy respecting the eligibility criteria of ambulatory care. We recorded patients' demographic data, operative details, satisfaction, postoperative course, and follow-up results. Nasal symptoms were evaluated by SNOT-22 on preoperative appointment and postoperatively at D30. No non-absorbable nasal packing was used, eventually in the case of preoperative-bleeding absorbable gelatine packing. The postoperative follow-up took place at D1 by phone call and at D10 and D30 to assess complications, Visual Analogue Scale, and state of ethmoidal corridors by endoscopic exam. Patients benefited of bilateral ethmoidectomy in 82.4 % cases associated with septoplasty in 42 %. The majority (95 %) was discharged on the same day. Only one patient had bleeding at D0 and was kept in standard hospitalization, such as three other patients for medical or organizational reasons not related to surgery. At D1, 23 % described postoperative light bleeding but needed no revisit and pain was estimated at 1.3 (VAS). No readmission was observed, and no major complication was noted. SNOT-22 decreased successfully by 56 %, statistically related to postoperative treatment of corticosteroids and in the case of Samter triad. 97 % of patients were satisfied of the ambulatory care. These results suggest that within an experienced and dedicated day-case medical and paramedical team, ethmoidectomy can be safely performed on a day-case basis with high quality of taking care and satisfaction of patients.

[PSA testing, biopsy and cancer and benign prostate hyperplasia in France]. / Dosage du PSA, biopsie, cancer et hypertrophie bénigne de la prostate en France.

INTRODUCTION: Prostate-specific antigen (PSA) testing is high in France. The aim of this study was to estimate their frequency and those of biopsy and newly diagnosed cancer (PCa) according to the presence or absence of treated benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: This study concerned men 40 years and older covered by the main French national health insurance scheme (73 % of all men of this age). Data were collected from the national health insurance information system (SNIIRAM). This database comprehensively records all of the outpatient prescriptions and healthcare services reimbursed. This information are linked to data collected during hospitalisations. RESULTS: The frequency of men without diagnosed PCa (10.9 millions) with at least one PSA test was very high in 2011 (men aged 40 years and older: 30 %, 70-74 years: 56 %, 85 years and older: 33 % and without HBP: 25 %, 41 % and 19 %). Men with treated BPH totalized 9 % of the study population, but 18 % of the men with at least one PSA test, 44 % of those with at least one prostate biopsy and 40 % of those with newly managed PCa. Over a 3-year period, excluding men with PCa, 88 % of men with BPH had at least one PSA test and 52 % had three or more PSA tests versus 52 % and 15 % for men without BPH. One year after PSA testing, men of 55-69 years with BPH more frequently underwent prostate biopsy than those without BPH (5.4 % vs 1.8 %) and presented PCa (1.9 % vs 0.9 %). CONCLUSIONS: PSA testing frequencies in France are very high even after exclusion of men with BPH, who can be a group with more frequent managed PCa. LEVEL OF EVIDENCE: 4.

The "Skull Flap" a new conceived device for decompressive craniectomy/cranioplasty: Feasibility study on cadaver specimen.

BACKGROUND: Decompressive craniectomy (DC) is a procedure that is currently performed with increasing frequency. The reason is that its indications have become much broader. This procedure may be associated with the relevant morbidity in the postoperative stage due to the creation of a large bone defect. On the other hand, cranioplasty is associated too with some of the common complications related to any reconstructive head surgery. The authors present a newly developed device: The "Skull Flap" (SF). This new device allows the surgeon to complete a DC, yet providing at the same time a cranial reconstruction that will not require the patient to undergo a second reconstructive procedure. MATERIALS AND METHODS: Different size and location craniectomies were carried out on four human cadaveric heads; the bone flaps were then repositioned in a more elevated position with respect to the skull edges. The flaps were placed at a distance of 12 and 15 mm from the skull edges using the SF system. Crash tests were conducted on each flap while in open and closed positions to assess its reliability and efficacy. RESULTS: SF was shown to be a strong fixation device that allows satisfactory brain decompression by keeping the original bone flap away from the swollen brain; at the same time, in a later stage, it allows cranial reconstruction in a simple way. CONCLUSION: The SF device was shown to be very easy to use, adaptable, and practical to apply; thus, allowing both satisfactory brain decompression as well as bone flap repositioning at a later time after the brain swelling has subsided.

Optimal time for catheterization in NSTE-ACS patients with impaired renal function: insights from the ABOARD Study.

BACKGROUND: To assess the impact of impaired renal function (IRF) and timing of catheterization (immediate versus delayed intervention) on outcomes in intermediate/high risk NSTE-ACS patients. METHODS: We performed a post-hoc analysis of the randomized ABOARD population to compare 1) patients with vs. without IRF and 2) the two intervention strategies in patients with IRF. A creatinine clearance <60 mL/min defined IRF. The primary endpoint was the in-hospital peak troponin I value; the secondary endpoints were a) the composite of death, myocardial infarction, urgent revascularization or recurrent ischemia (death/MI/UR/RI) and b) STEEPLE major bleeding (MB) at 1-month follow-up. RESULTS: Among the 345 patients, 75 (21.7%) had IRF. Patients with IRF were older, had more comorbidities and were at higher cardiovascular risk. Radial catheterization was predominant (84%). Among IRF patients, 37 (49%) and 38 (51%) patients were randomized to an immediate and delayed strategy, respectively. The primary and secondary endpoints rates were not different for the two comparisons. IRF was associated with more death (5.3% vs. 1.1%, p=0.043) and non-CABG MB (9.3% vs. 2.2%, p=0.001). In patients with IRF, a delayed strategy was associated with more recurrent ischemia (28.9% vs. 8.1%, p=0.021). Absence of clopidogrel pretreatment, insulin therapy and left main culprit lesion were independently associated with death/MI/UR/RI, while age and CABG surgery were related with MB. CONCLUSION: IRF is associated with worse outcomes in NSTE-ACS patients. The primary results of the ABOARD study apply also to patients with IRF in which the timing of catheterization does not impact hard outcomes.

[The impact of early cranioplasty on cerebral blood flow and its correlation with neurological and cognitive outcome. Prospective multi-centre study on 24 patients]. / Impact de la cranioplastie sur l'hémodynamique cérébrale comme facteur pronostic de l'amélioration clinique chez les patients craniectomisés pour traumatisme crânien grave.

INTRODUCTION: Cranioplasty after decompressive craniectomy in patients suffering from severe head injury often leads to a functional improvement although, to date, the pathophysiology of this phenomenon remains unclear. A few hypotheses have been proposed. The impact of cranioplasty on cerebral perfusion could be one explanation. We have evaluated the impact of cranioplasty on the functional status of patients undergoing decompressive craniectomy for severe head injury with its influence on cerebral perfusion. MATERIALS AND METHODS: Twenty-four patients undergoing craniectomy for severe head injury were included in this multi-centric and prospective study. All of them had a cranioplasty within 12 weeks following decompressive craniectomy. A clinical and radiological evaluation was performed prior to and after cranioplasty. Neurological and cognitive evaluation was performed with the Glasgow Outcome Score (GOS), the Frontal Assessment Battery (FAB) and the Mini Mental State Examination (MMSE). Radiological evaluation was performed by perfusion CT scan and transcranial Doppler. RESULTS: A statistically significant neurological and cognitive improvement was observed in 92% of patients at 6 months follow-up (F-U). Brain perfusion was improved at 6 weeks F-U, predominantly in the affected hemisphere. Systolic and diastolic blood velocity flow were improved in both middle cerebral arteries. CONCLUSION: Cranioplasty after decompressive craniectomy for patients suffering from severe head injury probably improves the functional outcome of these patients, thanks to a global improvement of cerebral perfusion.

[Early detection of COPD in primary care: which tools?]. / Sujets à risque de BPCO en médecine générale: comment favoriser la réalisation de spirométries et la détection précoce de l'obstruction bronchique?

INTRODUCTION: The early diagnosis of COPD in general practice is not satisfactory. OBJECTIVES: To evaluate the impact of different diagnostic tools (Piko-6, Software) in general practice (GP). METHODS: A multicentre, randomised, controlled study in GP assessing the effect of the tested strategies on the rate of referrals for spirometry and the rate of detection of airflow obstruction. RESULTS: One thousand one hundred and three patients (55 years old, 60% males, 31 years of smoking habits) were included by 248 GP. The rates of referal to a pneumologist were significantly higher in the Software (50% of patients), and Piko/Software (47%) groups than in the Control (22%) and Piko groups (28%). A high proportion (44%) of lung function tests recommended by the GP were not performed, often because of patient refusal. The confirmation rates were lower in the Software and Piko/Software groups (47% and 43%, respectively) compared with the Piko and Control groups (68% and 79%, respectively). Concordance between PFT and Piko-6 for the diagnosis of airflow obstruction was poor (about 50%). CONCLUSIONS: The use of software in association or not with the Piko-6 was useful for GPs to identify patients to refer for further lung function testing, but did not improve the confirmation of the obstructive syndrome, mainly due to reluctance of patients to go on to have further lung function tests. The use of a diagnostic tool (software and/or mini-spirometry) does however seem to improve early COPD detection.

[Hypertensive leg ulcers: epidemiological characteristics and prognostic factors for healing in a prospective cohort]. / Angiodermites nécrotiques : caractéristiques épidémiologiques et facteurs pronostiques de cicatrisation dans une cohorte prospective.

BACKGROUND: The data concerning changes in the characteristics of hypertensive leg ulcers (HLU) were taken from open studies in a small patient cohort. The aim of this study was to describe the epidemiological characteristics and to identify prognostic factors for healing in a prospective cohort of 59 patients presenting HLU. PATIENTS AND METHODS: The cohort comprised patients included in a randomized, double-blind, controlled study published elsewhere; the patients were receiving becaplermin gel (Regranex(®)) or Duoderm Hydrogel™ once daily for eight weeks for the most recent wound. Total follow-up was 12 weeks. RESULTS: The epidemiological analysis was performed for 59 consecutive patients randomized in 17 dermatology departments. Mean patient age was 74.5 ± 9 years and 61% were female. Mean wound duration was 11.1 ± 9 weeks and median wound area was 16 cm(2) (q1; q3: 8; 25.5). Among, 94.9% of patients had hypertension and 39.7% were diabetic. A homolateral peripheral pulse was present in 91.5% of patients. At the end of follow-up, complete wound healing was obtained in 30.5% of the patients. In univariate analysis, neither the foregoing criteria nor the treatment group were significantly associated with healing during the study. CONCLUSION: This study confirms female predominance, old age, prevalence of diabetes and delay in the diagnosis of HLU. The prognosis for healing does not appear to be dependent on wound duration, wound area or the presence of moderate peripheral arterial disease, doubtless because this condition progresses by episodes of flare-up and under specific conditions.

HCV genotype 3 is associated with a higher hepatocellular carcinoma incidence in patients with ongoing viral C cirrhosis.

Liver steatosis is a main histopathological feature of Hepatitis C (HCV) infection because of genotype 3. Steatosis and/or mechanisms underlying steatogenesis can contribute to hepatocarcinogenesis. The aim of this retrospective study was to assess the impact of infection with HCV genotype 3 on hepatocellular carcinoma (HCC) occurrence in patients with ongoing HCV cirrhosis. Three hundred and fifty-three consecutive patients (193 men, mean age 58 ± 13 years), with histologically proven HCV cirrhosis and persistent viral replication prospectively followed and screened for HCC between 1994 and 2007. Log-rank test and Cox model were used to compare the actuarial incidence of HCC between genotype subgroups. The patients infected with a genotype 3 (n = 25) as compared with those infected with other genotypes (n = 328) had a lower prothrombin activity [78 (interquartile range 60-85) vs 84 (71-195) %, P = 0.03] and higher rate of alcohol abuse (48%vs 29%, P = 0.046). During a median follow-up of 5.54 years [2.9-8.6], 11/25 patients (44%) and 87/328 patients (26%) with a genotype 3 and non-3 genotype, respectively, develop a HCC. HCC incidences were significantly different among the genotype subgroups (P = 0.001). The 5-year occurrence rate of HCC was 34% (95% CI, 1.3-6.3) and 17% (95% CI, 5.7-9.2) in genotype 3 and non-3 genotype groups, respectively (P = 0.002). In multivariate analysis, infection with a genotype 3 was independently associated with an increased risk of HCC occurrence [hazard ratio 3.54 (95% CI, 1.84-6.81), P = 0.0002], even after adjustment for prothrombin activity and alcohol abuse [3.58 (1.80-7.13); P = 0.003]. For patients with HCV cirrhosis and ongoing infection, infection with genotype 3 is independently associated with an increased risk of HCC development.

Genetic polymorphisms and the impact of a higher clopidogrel dose regimen on active metabolite exposure and antiplatelet response in healthy subjects.

A double-blind crossover study was conducted in four CYP2C19 genotype-defined metabolizer groups to assess whether increase in clopidogrel dosing can overcome reduced pharmacodynamic response in CYP2C19 poor metabolizers (PMs). Ten healthy subjects in each of four metabolizer groups were randomized to a clopidogrel regimen of a 300-mg loading dose (LD) and a 75-mg/day maintenance dose (MD) for 4 days followed by 600-mg LD and 150 mg/day MD, or vice versa. The exposure levels of clopidogrel's active metabolite H4 (clopi-H4) in PMs were 71% lower on the 75-mg/day regimen and 64% lower on the 150-mg/day regimen than the corresponding exposure levels in extensive metabolizers (EMs). In PMs, the maximal platelet aggregation (MPA) induced by adenosine diphosphate (ADP) 5 µmol/l was 10.5% lower on the 75-mg/day regimen and 7.9% lower on the 150-mg/day regimen than the corresponding values in EMs. PMs who were on the clopidogrel regimen of 600-mg LD/150 mg/day MD showed clopi-H4 exposure and MPA levels similar to those in EMs who were on the regimen of 300-mg LD/75 mg/day MD. In a pooled analysis evaluating CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP3A5, CYP2D6, ABCB1, and P2RY12 polymorphisms (N = 396 healthy subjects), only CYP2C19 had a significant impact on antiplatelet response. In healthy CYP2C19 PMs, a clopidogrel regimen of 600-mg LD/150 mg/day MD largely overcomes diminished clopi-H4 exposure and antiplatelet response, as assessed by MPA levels.

Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer.

AIM: Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR. METHOD: Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n = 27), asymptomatic 7% (n = 14)]. Possible risk factors for DS after AL were analysed. RESULTS: Management of AL consisted in no treatment (n = 14), medical treatment (n = 6), local drainage (n = 10) and abdominal reoperation (n = 11). After a median follow-up of 38 months, the overall rate of DS was 3% (n = 6): 0% for asymptomatic vs 22% after symptomatic AL (P = 0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P = 0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score > 2 and abdominal reoperation for AL. CONCLUSION: The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed.

Skull bone flap fixation - reliability and efficacy of a new grip-like titanium device (Skull Grip) versus traditional sutures: a clinical randomized trial.

BACKGROUND: After completing a craniotomy, it is important to replace the removed bone flap in its natural position in order to guarantee brain protection as well as improve cosmesis. A skull defect can expose the brain to accidental damage, and in cases of larger defects it may also cause the patients psychosocial problems. The ideal fixation device should provide reliable attachment of the flap to the skull and promote fast bony healing to avoid possible pseudo-arthrosis and/or osteolytic changes. MATERIALS AND METHODS: This is a pilot randomized clinical trial on a series of 16 patients undergoing different craniotomies for benign brain lesions in which the bone flaps were replaced using traditional sutures (Prolene 0.0) in 8 cases and with a new skull fixation device (Skull Grip) in the other 8 (randomly allocated). All patients underwent CT scans of the head with 3D reconstruction at day 1 and day 90 postoperatively to evaluate bone flap position and fusion. These scans were independently reviewed by a neuroradiologist. Cosmesis was also evaluated clinically by the surgeon and radiologically by the neuroradiologist in the 2 patient groups. RESULTS: The new "Skull Grip" device has shown stronger fixation qualities with optimal bone flap fusion and increased cosmetic healing features vs. traditional sutures. CONCLUSION: The "Skull Grip" has shown to be a reliable, effective and stronger bone flap fixation device when compared to traditional sutures.

Neurosurgery and elderly: analysis through the years.

The aging of the population in westernized countries constitutes an important issue for the health systems struggling with limited resources and increasing costs. Morbidity and mortality rates reported for neurosurgical procedures in the elderly vary widely. The lack of data on risk benefit ratios may result in challenging clinical decisions in this expanding group of patients. The aim of this paper is to analyze the elderly patients cohort undergoing neurosurgical procedures and any trend variations over time. The medical records of elderly patients (defined as an individual of 70 years of age and over) admitted to the Neurosurgical and Neuro-ICU Departments of a major University Hospital in Paris over a 25-year period were retrospectively reviewed. The analysis included: (1) number of admissions, (2) percentage of surgically treated patients, (3) type of procedures performed, (4) length of hospital stay, and (5) mortality. The analysis showed a progressive and significant increase in the proportion of elderly presenting for neurosurgical elective and/or emergency procedures over the last 25 years. The number of procedures on patients over 70 years of age increased significantly whereas the mortality dropped. Though the length of hospital stay was reduced, it remained significantly higher than the average stay. The types of procedures also changed over time with more craniotomies and endovascular procedures being performed. Age should not be considered as a contraindication for complex procedures in neurosurgery. However, downstream structures for postoperative elderly patients must be further developed to reduce the mean hospital stay in neurosurgical departments because this trend is likely to continue to grow.