Presentation and management of mycotic pseudoaneurysm after kidney transplantation.

Pseudoaneurysms (PAs) developing at the site of vascular anastomosis after organ transplantation are a rare but serious complication. We report a series of 3 cases of PA observed in a single center over a period of 18 years. The mode of presentation was acute bleeding in 2 cases. In the third patient, who underwent combined kidney and pancreas transplantation, the PA on the renal graft was discovered by chance. Graft removal associated with iliac artery ligation and extra-anatomic femoro-femoral bypass represents the standard treatment. However, interposition of a venous homograft may allow preservation of inferior limb perfusion and possibly graft salvage.

Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring.

Intraoperative nerve monitoring (IONM) aimed at reducing the injuries of recurrent laryngeal nerve during thyroidectomy is controversial. We conducted a meta-analysis to assess the incidence of nerve injuries with or without IONM. Studies published from January 1994 to February 2012 in English language on humans were identified. Heterogeneity of studies was checked by the Higgins test. Summary estimates of predictive values of injury were made using the Mantel-Haenszel test based on the fixed-effects model. Publication bias was assessed by a funnel plot and Egger's method. Eight articles were selected accounting a total of 5257 nerves at risk. IONM revealed a significant impact in preventing transient injuries (positive predictive value = 5% [95% CI: 2-8], negative = 96% [95% CI: 91-100], relative risk = 0.73 [95% CI: 0.54-0.98], p = 0.035), whereas they failed to demonstrate effect on permanent injuries (positive predictive value = 2% [95% CI: 0.6-3.8], negative 99% [95% CI: 97-100], relative risk = 0.73 [95% CI: 0.44-1.23], p = 0.235). This meta-analysis demonstrated the merit of IONM in preventing transient injury during thyroidectomy. No advantage was found in permanent injuries.

Does erythropoietin always win?

The synthesis of recombinant human erythropoietin has marked a turning point in the treatment of anaemia secondary to chronic kidney disease. However, the potentially fatal cardio- and cerebrovascular complications of the intake of high-doses of ESAs (erythropoiesis-stimulating agents), such as those observed in athletes who resort to doping, reason out the ever-prevalent debate concerning the balance between the risks and benefits of ESA administration for therapeutic purposes. Hence, there is still a discussion as to what values haemoglobin should ideally be maintained at. Additional concerns arise in cancer patients due to the ability of erythropoietin to act as an angiogenic and, in general, as a cell growth factor, because this might favour the progression of neoplastic disease. We summarized the prominent points of the latest guidelines on the management of anaemia in nephropathic patients, also identifying the possible risks that may result from the tendency to aim at too low haemoglobin levels.

Comparison between single incision and conventional laparoscopic cholecystectomy for uncomplicated cholelithiasis.

AIM: To compare surgical outcomes of patients presenting with uncomplicated cholelithiasis and operated by single incision (SILC) or by conventional laparoscopic cholecystectomy (CLC). METHODS: The series concerned 58 consecutive patients operated between October 2008 and October 2009. There were 11 men and 47 women with a mean age of 47 years and a BMI of 29. Six patients had a past surgical history with a midline incision. The main parameters analysed were duration of operation, morbidity, postoperative pain, return to normal activities and aesthetic result. One month and one year after surgery, the cosmetic result was assessed on a visual analogue scale (VAS), a score between 9 and 10 was considered as an excellent cosmetic result. RESULTS: A SILC was performed in 26 and a CLC in 32 patients. Patients in the SILC group were characterised by a lower BMI : 25 versus 32 (p <0.001) and by the absence of previous midline incision: 0/26 (0%) versus 6/32 (19%) (p <0.028). Outcomes were similar between groups except the aesthetic result. Multivariate statistical analysis revealed that the percentage of excellent cosmetic result was higher in SILC than in CLC group : respectively 73% (19/26) vs. 28% (9/32) one month postoperatively (OR : 5.3, 95% CI: 1-23, p <0.03) and 92% (22/24) versus 55% (17/31) one year postoperatively (OR : 6.9, 95% CI : 1-46, p < 0.04). CONCLUSIONS: Our study demonstrates that SILC is a feasible and safe procedure in a selected population. Compared to CLC, the only obvious benefit is a better cosmetic result that is still observed one year after surgery.

The role of general practitioners in diagnosis of cutaneous melanoma: a population-based study in France.

BACKGROUND: Little data are available concerning the role of general practitioners (GPs) in the diagnosis of melanoma. OBJECTIVES: To evaluate the actual role of GPs in a population-based study covering five regions of France and 8·2 million inhabitants. MATERIALS AND METHODS: A survey of cancer registries and pathology laboratories, and questionnaires to practitioners were used to identify incident melanomas in 2008, and evaluate characteristics of patients (age, sex, area of residence, social isolation), tumours (Breslow, ulceration, location, histological type), and GPs (training, conditions of practice), and their influence on patterns of diagnosis and Breslow thickness. RESULTS: Among 898 melanomas, 376 (42%) were first diagnosed in a general practice setting (GP group). Breslow thickness was much higher in the GP group than in other melanomas (median: 0·95 vs. 0·61 mm, P < 0·0001). Multivariate analysis identified an older age, lower limb location, nodular subtype and Breslow thickness as factors associated with the GP group. Within this group, 52·5% of melanomas were detected by patients (median Breslow thickness: 1·30 mm) and 47·5% by GPs (median Breslow thickness: 0·80 mm, P = 0·0009), including 8% during a systematic full-body skin examination. Previous GP training on melanoma was associated with active detection by GPs. Male sex and social isolation of patients were associated with thicker melanomas, whereas active detection by GPs was associated with thinner CMs. CONCLUSIONS: GPs play a key role in melanoma diagnosis in France, but still frequently detect thick tumours. Increasing awareness and training of GPs and focusing attention on male and/or socially isolated patients should help to improve early detection of melanoma.

A new therapy for kidney injury: regeneration.

Because of progressive population ageing and epidemic diffusion of type 2 diabetes mellitus in industrialized Countries, we are attending a growing incidence of end stage renal disease. This phenomenon has induced researchers to study potential alternative methods of renal function replacement. Actually, only dialytic methodics and renal transplant make possible survival of patients with terminal uremia, but both these therapeutic approaches show important limitations. The ideal solution would be represented by the possibility to "regenerate" the injured organ. This is the purpose of Regenerative Nephrology, a new medical domain which tries to develop new therapies through stimulation and induction in humans of regenerative processes already observed in other species, like reptiles and fishes. Such an ambitious and fascinating purpose requires a deep knowledge of the intricate networks which regulate the production of the hormones and mediators involved in the tissue regenerative processes. In this field the kidney embryonic development phases can represent a fundamental study model to acquire information about the reparative mechanisms of the structure and function of this excretory organ.

[Prostate cancer management and factors associated with radical prostatectomy in France in 2001]. / Le cancer de la prostate en France en 2001: état des pratiques et facteurs associés à la réalisation d'une prostatectomie totale.

INTRODUCTION: Prostate cancer was the most common cancer in men in France in 2005, and the second cause of male death from cancer. In this study, we analyzed clinical characteristics of patients with prostate cancer diagnosed in France in 2001 with a focus on therapeutic management of localized prostate cancers. PATIENTS AND METHODS: A total of 2181 cases of prostate cancer diagnosed in 2001 from 11 French counties covered by a cancer registry were analyzed. A descriptive study of the clinical characteristics of patients was performed. Parameters studied included age, county, TNM stage, PSA value, Gleason score, D'Amico prognostic group, Charlson's comorbidity index and initial treatment modalities. For localized cancers, multivariate logistic regression analysis identified factors associated with radical prostatectomy. RESULTS: The proportion of localized prostate cancer (T1 or T2) was 86.6 %. The use of invasive curative treatment (radical prostatectomy and radiotherapy) was 58.4 % for localized cancers. Significant differences in therapeutic management were found between counties. Radical prostatectomy was associated with age at diagnosis, D'Amico prognostic group and the presence of comorbidities. CONCLUSIONS: Most of prostate cancers diagnosed in France in 2001 were clinically localized and were treated by invasive therapy. The consequences of these practices remain to be determined given the limited evolution of many prostate cancers and the frequency of adverse events related to invasive treatments.

A population-based study of adjuvant chemotherapy for stage-II and -III colon cancers.

BACKGROUND: Although clinical trials have demonstrated that adjuvant chemotherapy improves survival for stage-III colon cancer, the benefits remain controversial for stage-II lesions. The objective of the present study was to determine the extent to which adjuvant chemotherapy is used for patients with stage-II and -III colon cancers. METHODS: The study population comprised 1074 patients with stage-II and -III colon cancers diagnosed in 2000 in 12 French administrative districts and recorded in population-based cancer registries. Data were collected using a standardized procedure. RESULTS: Overall, 20.4% of patients with stage II and 61.9% with stage III received adjuvant chemotherapy. Age at diagnosis was the strongest determinant of chemotherapy. Among stage-II patients, those receiving chemotherapy decreased from 57.6% in patients aged or=85. The corresponding percentages with stage III were 93.6% and 1.4%. In multivariate analyses, other factors found to be independently and significantly associated with administration of adjuvant chemotherapy for stage II were extension of the cancer (stage IIA vs. stage IIB), clinical presentation (obstruction or perforation vs. uncomplicated cancer) and discussion of the case at a multidisciplinary case-review meeting. For stage III, apart from age, discussion of the case at a multidisciplinary meeting was the only factor independently associated with administration of chemotherapy. CONCLUSION: Adjuvant chemotherapy for stage-III colon cancer is used extensively for patients under 75 years of age. However, many elderly patients do not receive such treatment. On the other hand, a substantial percentage of stage-II colon cancer patients receive adjuvant chemotherapy despite its uncertain benefits.

[Current management and prognosis of intrahepatic cholangiocarcinoma in France]. / Prise en charge et pronostic du cholangiocarcinome intrahépatique en France.

INTRODUCTION: Intrahepatic cholangiocarcinoma (ICC) is a rare tumor with a poor prognosis. The aim of this study was to evaluate current management and prognosis of ICC in nine French administrative areas, which are covered by population-based cancer registries. METHODS: Between 1997 and 1998, 1100 cases of primary liver cancer were observed in nine French departments: 68 were ICC. Clinicopathological characteristics and applied treatments were recorded and a comparative analysis and a 5-year survival study were performed. RESULTS: In most cases (85%), the presence of symptoms was the principal mode of discovery. Histological confirmation revealed ICC in two thirds of cases. The remaining liver was normal in 72% of cases (patients with cirrhosis: 12%). The mean size of tumours was 6 cm. Metastases were present in one out of four cases. Surgical management, chemotherapy and radiotherapy were performed in 40%, 20% and 11.5% of patients, respectively. Hepatic surgical resection was correlated with age and bilirubin level. One third of the patients were treated for symptoms. Five-year survival rate was 7.4% and median survival was 7 months. Patients with hepatic surgical resection had 5-year survival rate of 24.5%. CONCLUSION: At present, complete resection is the only therapy offering possible long-term survival in this entity. New adjuvant chemotherapy after surgery must be offered to these patients.

The erythropoietin and regenerative medicine: a lesson from fish.

BACKGROUND: Erythropoietin (EPO), the main haematopoietic growth factor for the proliferation and differentiation of erythroid progenitor cells, is also known for its angiogenic and regenerative properties. MATERIALS AND METHODS: In this study, we aimed to test the regenerative effects of EPO administration in an experimental model of Sea bass (Dicentrarchus labrax) subjected to amputation of the caudal fin. RESULTS: Erythropoietin-treated fishes (3000 UI of human recombinant EPO-alpha immediately after cutting and after 15 days) showed an increased growth rate of their fins compared with those untreated (anova variance: P: 0.01 vs. P: 0.04). By analysing fin length at established times (15 and 30 days after cut), EPO-treated fishes always showed an increased length compared with untreated ones (T-15: 1.1 +/- 0.2 vs. 0.7 +/- 0.2 cm, P: 0.03; T-30: 1.9 +/- 0.3 vs. 1.2 +/- 0.2 cm, P: 0.01). Moreover, exogenous EPO administration induced an enormous increase in EPO-blood levels at each observation time (T-15: 2240 +/- 210 vs. 16.7 +/- 1.8 mU mL(-1), P < 0.001; T-30: 2340 +/- 190 vs. 17.1 +/- 1.9 mU mL(-1), P < 0.001), whereas these levels remained quite unmodified in untreated fishes. Immunochemical analyses performed by confocal laser scanning microscopic observations showed an increased expression of EPO-receptors and PECAM-1 (an endothelial surface marker of vessels sprout) in the regenerating tissue, whereas no signs of inflammation or fibrosis were recognisable. CONCLUSIONS: All these findings confirm EPO as a new factor involved in regenerative processes, also suggesting a potential, future utility for new therapeutical applications in the field of human regenerative medicine.

Cancer incidence and mortality in France over the period 1980-2005.

BACKGROUND: The objective of this study was to provide updated estimates of national trends in cancer incidence and mortality for France for 1980-2005. METHODS: Twenty-five cancer sites were analysed. Incidence data over the 1975-2003 period were collected from 17 registries working at the department level, covering 16% of the French population. Mortality data for 1975-2004 were provided by the Inserm. National incidence estimates were based on the use of mortality as a correlate of incidence, mortality being available at both department and national levels. Observed incidence and mortality data were modelled using an age-cohort approach, including an interaction term. Short-term predictions from that model gave estimates of new cancer cases and cancer deaths in 2005 for France. RESULTS: The number of new cancer cases in 2005 was approximately 320,000. This corresponds to an 89% increase since 1980. Demographic changes were responsible for almost half of that increase. The remainder was largely explained by increases in prostate cancer incidence in men and breast cancer incidence in women. The relative increase in the world age-standardised incidence rate was 39%. The number of deaths from cancer increased from 130,000 to 146,000. This 13% increase was much lower than anticipated on the basis of demographic changes (37%). The relative decrease in the age-standardised mortality rate was 22%. This decrease was steeper over the 2000-2005 period in both men and women. Alcohol-related cancer incidence and mortality continued to decrease in men. The increasing trend of lung cancer incidence and mortality among women continued; this cancer was the second cause of cancer death among women. Breast cancer incidence increased regularly, whereas mortality has decreased slowly since the end of the 1990s. CONCLUSION: This study confirmed the divergence of cancer incidence and mortality trends in France over the 1980-2005 period. This divergence can be explained by the combined effects of a decrease in the incidence of the most aggressive cancers and an increase in the incidence of less aggressive cancers, partly due to changes in medical practices leading to earlier diagnoses.

[Ovarian cancer: incidence and mortality in France]. / Les cancers de l'ovaire: incidence et mortalité en France.

OBJECTIVES: To describe the ovarian cancer incidence and mortality trends in France from 1980 to 2000. MATERIALS AND METHODS: Incidence data were obtained from 9 French departments covered by cancer registries which systematically record all cancers, of which those of the ovary. Mortality data has been provided by INSERM bureau in charge of the analysis of death certificates. RESULTS: With 4500 incident cases and 3500 deaths for the year 2000 in France, ovarian cancer still shows a poor prognosis. Age adjusted incidence and mortality rates are almost stable over the study period at an annual rate of 9 by 100000 for incidence and 5.5 by 100000 for mortality. However the risk of developing this cancer and the risk of dying from it, steadily decreased for the cohort born in 1930 to 1950, and the beginning of this reduction corresponds exactly to the beginning of oral contraception. We present comparisons between departments and analyze the border-line tumors in parallel with invasive cancers. CONCLUSION: The cancer of the ovary represents only a small part of female cancers (3.8%) in France and its incidence is stable over time, but its prognosis is very bad.

Social and geographic disparities in access to reference care site for patients with colorectal cancer in France.

The aim of this study was to investigate the relationship between social and geographic characteristics and the type of care centre for initial colorectal surgery in France. Patients living far from a reference cancer site were less frequently treated in a reference cancer site than those who were living near a reference cancer site OR(a)=(0.50 (0.33-0.76)). As for topography and emergency presentation, place of residence (urban/rural), occupation and marital status were not associated with the type of the care centre. Improvements in diagnosis and treatment and of clinical practice guidelines are therefore crucial to ensure equality in health care in France.

Medical and non-medical determinants of prostate cancer management: a population-based study.

Non-medical factors influencing treatment choices in prostate cancer are not well understood. We carried out a population-based study to obtain information on the management of prostate cancer patients. Our study population consisted of 1000 men diagnosed during 1995 from five French cancer registries. We looked at the main treatments performed in the year following diagnosis. Multivariate analysis was used to describe the determinants of the various treatment choices, simultaneously taking into account medical and non-medical factors. The probability of treatment by radical prostatectomy (RP) was 3 times higher in the Tarn area, whereas in the Calvados area the probability of treatment by radiotherapy was almost 6 times higher. The private sector favoured radical prostatectomy and hormonal therapy. In France, as in other developed countries, the initial treatment of prostate cancer varies greatly according to non-medical factors. This type of investigation, if carried out regularly, would make it possible to evaluate changes in practice patterns.

Cancer incidence and mortality in France over the period 1978-2000.

BACKGROUND: Monitoring cancer incidence and mortality time trends is essential for cancer research and health-care planning. French cancer registries do not cover the entire population and do not provide a representative sample of the national population. Our study aimed at estimating national cancer incidence and mortality trends over the longest period available. METHODS: Incidence and mortality data were collected over the period 1978-1997. Twenty-seven cancer sites were selected and age, sex and site specific incidence and mortality rates were estimated for each year from 1978 up to 2000. Observed incidence and mortality data in the population covered by cancer registries were modelled using age-cohort methods. An estimation of the incidence/mortality ratio was obtained from these models and applied to the mortality rates predicted from an age-cohort model for the entire French population. The person-years of observation were calculated cohort-wise from census data provided by the national institute of statistics RESULTS: Cancer incidence increased by 63% throughout the study period, from 170,000 new cases in 1980 to 278,000 in 2000. This evolution was due to demographic changes but also to an increase in the risk of cancer which was estimated to more than 35% during the same period. In men, this change is largely explain by the increase of prostate cancer incidence. Among women, the increase was dominated by the continuing increase in breast cancer incidence. Large increases were also seen for non-Hodgkin lymphoma, melanoma, and thyroid cancer in both genders and for lung cancer in women. Cancer mortality increased by 20% from 125,000 deaths in 1980 to 150,000 in 2000. This increase is less than that predicted from changes in demographic factors and corresponds in fact to a decrease in the risk of death estimated to about 8%, slightly greater for women than for men. This decrease is associated with a decreasing incidence for stomach cancers for both sexes, alcohol-related cancer for men and cervical cancer for women. Colo-rectal cancer decreasing mortality contributes to this improvement despite an incidence increase. CONCLUSION: Between 1980 and 2000, the study showed a large change in the cancer burden both quantitatively and qualitatively. Decrease in exposure, earlier diagnosis and therapeutic improvement explained part of this change, but overall the distribution of cancer cases shifted toward a distribution including less aggressive cancers. A striking divergence between incidence and mortality trends is observed for a great number of cancers. Prostate cancer shares with breast cancer the same pattern of a severe increasing incidence and a stable mortality. This points to important changes in medical practice and needs further analysis. The trend of lung cancer mortality among women should be emphasised since the situation will inevitably worsen in the coming years. It is already the third cause of cancer death among women.

VUMeF: extending the French involvement in the UMLS Metathesaurus.

A considerable number of robust vocabularies and thesauri have been developed for the healthcare and biomedical domain. No single vocabulary, however; provides complete coverage of the information needs from a public health perspective. The results of an investigation of vocabulary sources for the development of a comprehensive controlled vocabulary for the public health domain at the Centers for Disease Control and Prevention (CDC) is presented.

Incidence of thyroid cancer in adults recorded by French cancer registries (1978-1997).

This article analyses time trends and geographical variations of thyroid cancer by histological type. Incidence data were provided by 8 French cancer registries over the period 1978-1997, with 3853 adult cases reported. To assess the effects of age, period, cohort and area on incidence, log-linear Poisson regression models were used. Thyroid cancer increased exponentially from the cohort born in 1925. This increase was essentially due to papillary cancer, which increased by 6.2% per year in men and 8.1% per year in women over the entire period (1978-1997). In women, the recent trends were significantly different between the studied geographical areas. The analysis shows that the increase in thyroid cancer, essentially of the papillary type, is not recent. It may be attributed to a possible screening effect or to an increase in the number of "incidentally" discovered cases linked to the use of modern diagnostic tools.

[Estimate of regional prevalence of colorectal cancer in France]. / Estimation de la prévalence régionale des tumeurs colorectales en France.

BACKGROUND: Colorectal cancer prevalence is an important determinant of the health demand that completes information provided by cancer incidence. Current estimations established from data for the years 1985 and 1995 can be used to establish a precise description of changing healthcare needs for colorectal cancer. METHOD: Prevalence estimates method were based on incidence data computed on the regional scale by the FRANCIM network and mortality data provided by INSERM. We used the relationship that exists between the net risk of cancer, the net risk of dying of the given cancer and the age-specific prevalence of cancer. RESULTS: In 1995, the prevalence of patients who had a diagnosis of colorectal cancer amounted to 200 000 persons. The estimated number of prevalent cases was never lower than 3500 in any region and in 7 regions this number was higher than 10 000. From 1985 to 1995, there has been an increase of 35% in the prevalence rates. CONCLUSION: The evaluation of the number of persons who have had a diagnosis of colorectal cancer provides knowledge for health care planning. Such information on the regional scale is very useful for the health organisation (SROS). This geographical level induces difficulties not encountered at the national level.

[Lip, oral cavity and pharynx cancers in France: incidence, mortality and trends (period 1975-1995)]. / Les cancers de la lèvre, de la cavité buccale et du pharynx en France: incidence, mortalité et tendance (période 1975-1995).

With 10,882 estimated new cases in 1995 in France, lip, oral cavity and pharynx tumours rank 4th, representing 8.1% of all cancers in men. They are less frequent in women, with a sex ratio of 7. Based on the French cancer registries data which cover 13% of the metropolitan territory in 2000, both incidence and mortality increased until early 1980s to decrease thereafter. The main hypothesis proposed to explain the French leadership world-wide for these tumours deals with alcohol and tobacco consumption. Important differences observed between several areas within Europe, for some subsites, in connection with age or sex, are pointing toward the need of new studies about environment and/or genetics. Until now, comparisons between countries were made at the level of lip, oral cavity and pharynx category as a whole or by large subgroups. In this work we attempt to establish more accurate statistics, in order to comply with the situation of this cancer in France. Present results should encourage the scientific community to conduct site specific epidemiological studies.