RESUMO
The management of melanoma is a typical example of a pluridisciplinary approach, in order to provide the patient with a rapid and adequate treatment plan after the initial diagnosis. Both in the domains of dermatology, pathology and oncology, enormous progress has been made. Recent advances permit a rapid access to diagnostic techniques using teledermoscopy, an improved diagnostic accuracy using dermoscopy, pre-interventional high-frequency ultrasound and optical coherence tomography, a determination of risk factors using immunohistochemistry and genetic analyses on the pathology samples. Furthermore, the development of immunotherapies, in particular the anti-PD1 antibodies, and the directed therapies, therapies permitting an increased number of patients to experience an increased survival with an acceptable tolerance profile in the event of metastatic lesions. This article describes the patient's care pathway, from the initial diagnosis, staging, to an eventual treatment and follow-up.
Le traitement du mélanome est un exemple type de collaboration multidisciplinaire, afin de pouvoir garantir au patient une prise en charge rapide dès le moment de la détection de la lésion. Tant au niveau dermatologique, anatomopathologique et oncologique, d'énormes progrès ont eu lieu ces dernières années. Ils permettent un accès au diagnostic de plus en rapide par la télédermoscopie, une précision diagnostique accrue par la dermoscopie, l'ultrason à haute fréquence et la tomographie par cohérence optique, une détermination des facteurs de risque immunohistochimiques et génétiques sur les analyses anatomo-pathologiques ainsi que le recours à des immunothérapies, notamment les anti-PD1, et à des traitements ciblés. Ces nouveaux traitements permettent souvent une plus longue survie du patient, avec un profil de tolérance acceptable en cas de lésions métastatiques. Cet article reprend le trajet de soins du patient, du diagnostic initial et du staging au traitement éventuel avec son suivi.
Assuntos
Melanoma , Neoplasias Cutâneas , Dermoscopia , Humanos , Imuno-Histoquímica , Imunoterapia , Melanoma/diagnóstico , Melanoma/terapia , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/terapiaRESUMO
The treatment of locally advanced or metastatic cutaneous squamous cell carcinoma (cSCC) essentially relies on surgery and eventually radiotherapy of the treated site and afferent lymph nodes. Unfortunately, some cases are no candidates for surgery or radiotherapy and a systemic treatment may be indicated. Chemotherapies are only partially efficacious and associated with potential toxicities. A recent study evaluating the efficacy and tolerance of cemiplimab, a PD1 antagonist for locally advanced and metastatic cSCC demonstrated an objective response rate of 49 % and 47 % for locally advanced and metastatic cSCC, while maintaining a response of at least 6 months of 63 % and 60 %, respectively. We present a clinical case of a patient with a locally advanced cSCC of the forehead with bone resorption and cervical lymphadenopathies. After failure of multiple surgical interventions and radiotherapies, he responded partially to cemiplimab immunotherapy with a good safety profile.
Le traitement du carcinome spinocellulaire cutané (cSCC) localement avancé et/ou métastatique repose essentiellement sur la chirurgie et, éventuellement, sur une radiothérapie de la zone chirurgicale et de l'aire ganglionnaire afférente. Malheureusement, certains cas ne sont plus opérables ou accessibles à la radiothérapie et un traitement systémique est alors indiqué. Les chimiothérapies sont peu efficaces et potentiellement toxiques. Une étude récente évaluant l'efficacité et la tolérance du cémiplimab, un antagoniste PD1, dans les cSCC localement avancés et métastatiques, démontre une réponse objective confirmée de 49 % et de 47 %, respectivement, avec un maintien de la réponse d'au moins 6 mois de 63 % et de 60 %, respectivement. Nous présentons le cas d'un patient avec un cSCC localement avancé au niveau du front, avec effraction osseuse et adénopathies cervicales, ayant eu de multiples chirurgies et radiothérapies. Il a présenté une réponse partielle au cémiplimab avec un profil de tolérance satisfaisant.
Assuntos
Anticorpos Monoclonais , Carcinoma de Células Escamosas , Neoplasias Cutâneas , Anticorpos Monoclonais/uso terapêutico , Anticorpos Monoclonais Humanizados , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/patologia , Humanos , Masculino , Neoplasias Cutâneas/tratamento farmacológico , Neoplasias Cutâneas/patologiaRESUMO
In Belgium, epidemiological data are rare, and most often extrapolated, for burn injuries, especially in the pediatrician population. The purpose of this study was to obtain data for the pediatrician population in Liege. It retrospectively analyzed burns in the pediatrician population treated in the Burn Center Liege, during five years. Overall 844 patients (379 girls, 465 boys) were included for the first part of this study (burns localization and etiology, sex ratio, age), with a mean age of 4.2 years old. Over this five years period, the number of pediatrician patients admitted increased by 47 %. The most frequent burn site was the hand (32.8 %) and the burn cause was scalds (49.4 %). For the second part of the study (hospitalisation and treatment duration, hypertrophic scars), 712 patients were included (321 girls and 391 boys). Hypertrophic scars were found in 9.27 %. Our results show that burn injury is more often found in boys, and this injury occurs mostly in children under 5 years of age.
Les données épidémiologiques pour les traumatismes par brûlures en Belgique sont rares, et issues d'extrapolations, particulièrement pour la population pédiatrique. Cette étude a pour but d'obtenir des chiffres propres à la population pédiatrique liégeoise. Il s'agit d'une étude rétrospective des brûlures dans la population pédiatrique prise en charge par le Centre des Brûlés de Liège sur une période de 5 ans. Dans la première partie de l'étude (localisation et nature des brûlures, sex ratio et âge moyen), 844 patients (379 filles et 465 garçons) ont été inclus avec un âge moyen de 4,2 ans. Au fil des années, le nombre de contacts pédiatriques a augmenté de 47 %. Le site de brûlure le plus fréquemment constaté est la main (32,8 %) et la cause principale de brûlure est le contact avec des liquides chauds (49,4 %). Dans la seconde partie (durée de pansement, d'hospitalisation et apparition de cicatrice hypertrophique), 712 patients ont été pris en compte (321 filles et 391 garçons). Une cicatrice hypertrophique a été observée chez 9,3 % des patients. Nos résultats montrent que les garçons sont plus souvent victimes de ce type de traumatisme et que ce dernier survient principalement chez l'enfant de moins de 5 ans.
Assuntos
Queimaduras/epidemiologia , Distribuição por Idade , Bélgica/epidemiologia , Unidades de Queimados , Criança , Pré-Escolar , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Distribuição por SexoRESUMO
Distal lower leg soft tissue defect is frequently a challenge to repair, particularly on the tibial crest. The coverage of this kind of lesion has some limitations because of regional minimal blood supply and paucity of local soft-tissue flaps. The perforator pedicled propeller (PPP) method tries to find a new place in lower leg reconstruction in bringing similar tissues at the recipient site and avoiding long and difficult free flap transfer or muscular sacrifice. The authors report on the use of PPP method for a tibial crest exposure after trauma and for a soft tissue defect with osteomyelitis on the tibial crest.
Assuntos
Traumatismos da Perna/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos/irrigação sanguínea , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
We report the first density functional study of water catalytic effect in the double proton transfer (DPT) taking place in the adenine-thymine (AT) base pair. To gain more insight regarding the accuracy of several theoretical methods, the ability of various functionals and models for describing the geometry of this system has first been checked. According to our results, BP86/6-311++G(d,p) is the best option for describing the solvation effects in AT when applied to a two-water-molecule-featuring model. The two possible mechanisms for DPT in solution are explored: in the first one, water molecules only remain passive elements, whereas in the second one they are directly included in the reaction path. For the noncatalyzed mechanism, the stable structures constitute the canonical form of the base pair and the first proton transfer product. Nevertheless, by involving the two water molecules in the reaction, we found three stable species: canonical base pair, first proton transfer product, and double proton transfer product. Although the thermodynamic analysis confirms that AT does not contribute to spontaneous mutation through proton transfer catalyzed by surrounding water, our results suggest that microhydration may play a crucial role for DPT reaction in others DNA or RNA basis pair.
Assuntos
Adenina/química , Pareamento de Bases , Prótons , Timina/química , Água/química , DNA/química , Gases/química , Modelos Moleculares , Conformação Molecular , Teoria Quântica , Solventes/químicaRESUMO
Accurate calculations of the double proton transfer (DPT) in the adenine-thymine base pair (AT) were presented in a previous work [J. Phys. Chem. A 2009, 113, 7892.] where we demonstrated that the mechanism of the reaction in solution is strongly affected by surrounding water. Here we extend our methodology to the guanine-cytosine base pair (GC), for which it turns out that the proton transfer in the gas phase is a synchronous concerted mechanism. The O(G)-H-N(C) hydrogen bond strength emerges as the key parameter in this process, to the extent that complete transfer takes place by means of this hydrogen bond. Since the main effect of the molecular environment is precisely to weaken this bond, the direct proton transfer is not possible in solution, and thus the tautomeric equilibrium must be assisted by surrounding water molecules in an asynchronous concerted mechanism. This result demonstrates that water plays a crucial role in proton reactions. It does not act as a passive element but actually catalyzes the DPT.
Assuntos
Pareamento de Bases , Citosina/química , DNA/química , Guanina/química , Mutação , Prótons , Água/química , DNA/genética , Transferência de Energia , Ligação de Hidrogênio , Modelos Químicos , Modelos Moleculares , Estrutura Molecular , Transição de FaseRESUMO
In accordance with the principle of personal autonomy, expert consensus statements on amyotrophic lateral sclerosis (ALS) recommend early engagement with terminal-phase patients on the type of symptomatic treatment to be administered in the event of respiratory failure, since decompensation progresses too rapidly to allow time for a discussion. The French Parliamentary Act on Patients' Rights and End-of-Life Care (dated 22 April 2005) grants individuals the right to refuse unreasonable treatment and obliges physicians to take account of any prior instructions given by a person before he/she became incapable of communicating. The provision of prior instructions is a very reassuring situation for the physician: the autonomous patient indicates his or her choice of end-of-life care. However, there are two pitfalls which must be avoided: (i) holding a discussion for the sole purpose of obtaining prior instructions and (ii) not acknowledging the patient's vulnerability. The present study dealt with 35 ALS patients for whom the question of either intensive care or palliative end-of-life care remained open. Even though the great majority of these individuals were keen to know their exact state of health, 48% refused to consider this circumstance and only 20% expressed prior instructions. These results prompted us to question the ethical dimension of the concept of autonomy beyond its founding formulation: can one envisage an incapacity to confront oneself with the existential question of possible death? In 80% of cases, the physician will have to take a care decision in the absence of any prior instructions from the patient. This amounts to more than respecting a person's autonomy and involves exercising medical responsibility.
Assuntos
Doença dos Neurônios Motores/terapia , Autonomia Pessoal , Assistência Terminal/legislação & jurisprudência , Morte Súbita Cardíaca , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Suicídio , Traqueotomia , Ventiladores MecânicosRESUMO
Retroperitoneal fibrosis is characterized by the presence of a retroperitoneal tissue, consisting of chronic inflammation and marked fibrosis, which entraps the retroperitoneal organs. In two-thirds of cases, the retroperitoneal fibrosis is idiopathic. The pathogenic mechanism is not clearly identified. We report a case of idiopathic retroperitoneal fibrosis associated with type 1 diabetes mellitus. A 61-year-old woman with C peptide negative insulindependent diabetes developed retroperitoneal fibrosis revealed by bilateral hydronephrosis. Anti-GAD 65 antibodies were positive. There were no signs of autoimmune pancreatitis: no steatorrhea, normal IgG4 isotype levels, and absence of pancreas morphological abnormalities.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Fibrose Retroperitoneal/complicações , Anti-Inflamatórios/uso terapêutico , Peptídeo C/sangue , Diabetes Mellitus Tipo 1/diagnóstico por imagem , Diabetes Mellitus Tipo 1/patologia , Feminino , Glutamato Descarboxilase/imunologia , Glutamato Descarboxilase/metabolismo , Humanos , Hidronefrose/complicações , Hidronefrose/patologia , Pessoa de Meia-Idade , Fibrose Retroperitoneal/diagnóstico por imagem , Fibrose Retroperitoneal/patologia , Espaço Retroperitoneal/diagnóstico por imagem , Espaço Retroperitoneal/patologia , Esteroides/uso terapêutico , Tomografia Computadorizada por Raios X , Ureter/patologiaRESUMO
Solitary lipoma is the most frequent soft tissue tumor, often appearing between 40 and 60 years of age. It is described as "giant" beyond 1 kg of weight and 10 cm of diameter. Its volume is the source of a good many problems in social life (camouflage, difficulties to dress) and causes multiple health problems such as pain, difficulties to sleep, compressions of nerves or vital structures, infections, etc. The diagnosis is primarily clinical. However, it is necessary to systematically exclude a malignant process. Surgical biopsy is recommended if the diagnosis cannot be asserted by the clinic or an imagery. The therapeutic attitude is abstention in case of small volume without functional impairment. Otherwise, total surgical excision is indicated with pathological analysis. We describe the clinical history of a patient suffering from a giant dorsal lipoma.
Assuntos
Dorso/patologia , Dorso/cirurgia , Lipoma/patologia , Adulto , Biópsia , Diagnóstico Diferencial , Feminino , Humanos , Lipoma/complicações , Lipoma/cirurgia , Qualidade de Vida , Escápula/patologia , Resultado do TratamentoRESUMO
INTRODUCTION: Groin lymphatic fistulas are a troublesome finding after limb revascularization surgery. Its management represents a difficult task for the clinician. REPORT: We report our experience in the treatment of such a condition with negative-pressure wound therapy (NPWT) in a 70-year-old man which benefited from extra-anatomic prosthetic axillofemoral bypass. After a week of treatment, the fistula dried up and closure was obtained with simple suture under local anaesthesia. Follow-up at 9 months showed stable coverage without any sign of leakage. DISCUSSION: This study depicts NPWT as an effective non-invasive treatment in the management of groin lymphocutaneous fistula.
Assuntos
Fístula Cutânea/terapia , Fístula/terapia , Virilha , Doenças Linfáticas/terapia , Tratamento de Ferimentos com Pressão Negativa , Idoso , Implante de Prótese Vascular/efeitos adversos , Artéria Femoral/cirurgia , Humanos , MasculinoRESUMO
On the occasion of the twentieth anniversary of the 'Belgian Association of Burn Injuries' an inventory was made of all surgical techniques used in the five largest Belgian burn centres in order to draw up a consensus document. A questionnaire covering the whole treatment of severely burned patients was sent to the surgeons of each burn unit, ranging from emergency treatment, through diagnostic techniques, burn surgery and post-healing treatment (scars, contractures). During the past decade, several (often expensive) new techniques have been commercialised, resulting in a wide variety of treatment modalities in the different centres. For the majority of bums, however, a similar protocol is followed: the superficial burns are treated conservatively and the deep burns surgically. Nevertheless, burns of indeterminate depth are susceptible to variations in their treatment. There are also different therapeutic options for the deepest burns, from the use of donor skin to dermal substitutes as well as cultured keratinocytes. The writing of this consensus required intense communication on the different therapeutic modalities, as well as an increased exchange of experiences, which could lead to an improvement in the quality of burn treatment in Belgium.
Assuntos
Queimaduras/cirurgia , Bandagens , Bélgica , Queimaduras por Corrente Elétrica/cirurgia , Desbridamento , Serviços Médicos de Emergência , Pesquisas sobre Atenção à Saúde , Humanos , Queratinócitos/transplante , Retalhos Cirúrgicos , CicatrizaçãoRESUMO
We present the case of a patient with a circumferential venous ulcer at the level of the calf. She is hospitalized for surgical treatment by continuous aspiration dressing and coverage with skin graft. This patient presents a history of chronic pain, on which classical medications have few effects and are accompanied by side effects. After discussion with the patient, a double continuous peripheral nervous block (femoral and sciatic nerve) is set up to improve the tolerance to wound dressing. This technique presents favorable antalgic results. The indications and the different techniques of block performance (by electrostimulation or echo-guided) are described. The infectious risks related to the presence of catheter near cutaneous wounds are clarified according to recent data of literature. The relevance of these techniques in correlation with the development of chronic pain and on the trophicity of the wounds are also discussed.
Assuntos
Bandagens , Bloqueio Nervoso , Dor/prevenção & controle , Úlcera Varicosa/terapia , Idoso , Feminino , Humanos , Dor/etiologia , Higiene da PeleRESUMO
Spiropyrans undergo Cspiro-O bond breaking to their ring-open protonated E-merocyanine form upon protonation and irradiation via an intermediate protonated Z-merocyanine isomer. We show that the extent of acid-induced ring opening is controlled by matching both the concentration and strength of the acid used and with strong acids full ring opening to the Z-merocyanine isomer occurs spontaneously allowing its characterization by 1H NMR spectroscopy as well as UV/vis spectroscopy, and reversible switching between Z/ E-isomerization by irradiation with UV and visible light. Under sufficiently acidic conditions, both E- and Z-isomers are thermally stable. Judicious choice of acid such that its p Ka lies between that of the E- and Z-merocyanine forms enables thermally stable switching between spiropyran and E-merocyanine forms and hence pH gating between thermally irreversible and reversible photochromic switching.
RESUMO
A 51-year-old Caucasian woman developed severe drug-induced toxic epidermal necrolysis (TEN) due to allopurinol. The withdrawal of the culprit drug was unfortunately delayed, and dramatic retardation of reepithelialization was observed. At that stage of disease evolution, an inflammatory cell infiltrate was present in the dermis. Coverage of eroded lesions by frozen cultured keratinocyte allografts failed to hasten reepithelialization compared to ungrafted sites. This unusual protracted TEN evolution was followed by the development of extensive hypertrophic and keloid scars. Several biopsies were taken over 6 months. The histologic presentation of the grafted and ungrafted eroded scar tissues looked similar. Both the number and size of the Factor XIIIa-positive dermal dendrocytes, as well as the number of alpha-actin-positive myofibroblasts showed a marked increase between weeks 2 and 12 after grafting. They were reduced after 6 months when the scarring process was stabilized. alpha1 [IV] collagen was never expressed over the eroded scars. Similar to burn patients, delayed reepithelialization might be a risk factor for abnormal scarring in TEN. Cultured keratinocyte allograft apparently offered no improvement in reepithelialization and did not prevent abnormal scarring in this TEN patient.
Assuntos
Alopurinol/efeitos adversos , Antimetabólitos/efeitos adversos , Cicatriz Hipertrófica/patologia , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Transplante de Pele/métodos , Síndrome de Stevens-Johnson/patologia , Cicatriz Hipertrófica/induzido quimicamente , Feminino , Humanos , Queratinócitos/transplante , Lúpus Eritematoso Sistêmico/patologia , Pessoa de Meia-Idade , Transplante de Pele/patologia , Síndrome de Stevens-Johnson/etiologia , Transplante HomólogoRESUMO
The authors report their experience in the treatment of a posttraumatic enterocutaneous fistula with negative-pressure therapy. After sustaining an epigastric shot wound, a 33-year-old woman underwent three consecutive laparotomies, which eventually led to an open abdomen with the interposition of a surgical mesh. Enterocutaneous fistulae were subsequently documented and vacuum-assisted closure therapy was instituted along with total parenteral nutrition and systemic antibiotics. Development of a suitable granulation bed and closure of the fistulae were noted after two weeks of treatment and a split-thickness skin graft was applied to the wound. Follow-up at 8 months showed stable coverage and a return to normal enteral feeding.
Assuntos
Fístula Intestinal/cirurgia , Tratamento de Ferimentos com Pressão Negativa , Adulto , Feminino , Tecido de Granulação/patologia , Humanos , Nutrição Parenteral , Transplante de PeleRESUMO
Basal cell carcinomas (BCC) are the most common malignant neoplasms in humans. Clinical misdiagnoses are not uncommon. These cancers are classified according to their histological and clinical characteristics which exhibit distinct malignant behaviours. It is important to be aware of the different clinical presentations both for the accurate diagnosis and tumour management. We report the case of a 78-year-old man, who presented an unusual pedunculated and pigmented BCC. This combined aspect is rarely encountered.
Assuntos
Carcinoma Basocelular/patologia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias Cutâneas/patologia , Idoso , Humanos , MasculinoRESUMO
The synthesis of a series of (formazanate)boron difluorides and their 1-electron reduction products is described. The neutral compounds are fluorescent with large Stokes shifts. DFT calculations suggest that a large structural reorganization accompanies photoexictation and accounts for the large Stokes shift. Reduction of the neutral boron difluorides occurs at the ligand and generates the corresponding radical anions. These complexes are non-fluorescent, allowing switching of the emission by changing the ligand oxidation state.
RESUMO
An unprecedented strategy for preparing photoresponsive cellulose paper enabling the storage of short-lived optical data by covalent photopatterning is disclosed. An ab initio design hinting that the covalent grafting of coumarins on the paper could yield valuable photoresponsive units was first performed. Second, light sensitive paper that can be reversibly altered upon irradiation at a specific wavelength was prepared by covalent surface functionalization with coumarins. Third, the validity of this strategy is demonstrated using the photolithography of several gripping patterns such as a dynamic QR code.
RESUMO
In this paper it is argued that questions in perinatal medicine concerning treatment or non-treatment of severely handicapped children, after or before birth, cannot be answered solely by referring to the general aims and objectives of medical treatment and its specific deontology. Justifications of decisions about treatment and non-treatment need to be placed in a broader context of discussions about social justice and the social significance of medical practice as a whole.