Short stay laparoscopic hysterectomy: An evaluation of feasibility and patient satisfaction.

BACKGROUND: Short-stay total laparoscopic hysterectomy (TLH) could lead to reduced hospital costs and decrease complications associated with hospitalisation such as hospital acquired-infection and venous thromboembolism. OBJECTIVE: To evaluate the feasibility, safety and patient satisfaction of a novel short 'less than 23-hour' stay TLH protocol. MATERIAL AND METHODS: Prospective cohort study, at Birmingham Women's Hospital, United Kingdom including eligible women undergoing TLH for benign indications or early stage cervical/endometrial cancer. MAIN OUTCOME MEASURES: Feasibility of discharge within 23-hours following TLH. Surgical complications and readmission rates were collected within 30-days of hysterectomy and patient's satisfaction was assessed at 6-weeks. RESULTS: Of the 128 eligible women, 104/128 women (81%) were discharged within 23-hours of admission, of which 62/104 or 60% (48.4% of the whole cohort) were discharged on the same day. Adenomyosis/fibroids, and previous caesarean sections were associated with a greater likelihood of stay beyond 23-hours (P<0.05). The overall complications rate was 13/128 (10%) with two grade-3 Clavien-Dindo intraoperative complications; one serosal bowel injury oversewn and one ureteric injury requiring reimplantation. The readmissions rate was 5/128 (4%). 94% of patients were 'happy' or 'very happy' with the pathway, although satisfaction was higher in short-stay patients (RR 1.2; 95% CI 0.95-1.94). CONCLUSION: Hospital discharge within 23-hours of TLH appears to be safe, feasible and acceptable to patients where a standardised, multidisciplinary care protocol is used. WHAT IS NEW?: Our study is the first prospective case series in the UK reporting the safety and acceptability for performing laparoscopic hysterectomy as a 23-hour day case procedure.

[Specific tongue involvement revealing sarcoidosis]. / Atteinte linguale spécifique révélatrice d'une sarcoïdose.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease of unknown aetiology. Tongue involvement is extremely rare. Herein we report a new case. PATIENTS AND METHODS: A 65-year-old woman presented with a 6-month history of painless multiple nodules on the tongue. The patient also complained of xerostomia. Besides nodules on the tongue, physical examination revealed erythematous nodules on the dorsum of the hands and feet. A diagnosis of sarcoidosis with tongue, cutaneous and salivary gland involvement was made on the basis of these findings and further investigations performed. The patient's condition showed improvement with partial regression of tongue lesions after oral steroid therapy. DISCUSSION: Tongue involvement in sarcoidosis is exceedingly rare. It may be isolated or part of a generalized multisystem sarcoidosis. Nodules, indurations and swelling are the most common clinical manifestations. Management of tongue sarcoidosis is not consensual. Oral corticosteroids appear to be the most effective therapy. CONCLUSION: Sarcoidosis of the tongue should be considered when chronic unexplained nodules are noted. Diagnosis can easily be confirmed by a histological examination of mucosal biopsy.

New nomogram for safe laparoscopic entry to reduce vascular injury.

A nomogram is developed to determine the length of Veress needle that could be safely inserted to achieve pneumoperitoneum to reduce the risk of vascular injury during laparoscopic entry. Axial images of magnetic resonance imaging (MRI) were used to measure the vertical distance between umbilicus and retroperitoneal vessels (STR). This distance was correlated with body mass index and a nomogram was developed to exactly measure the safe distance for the length of Veress needle insertion. The fitted equation was STR (skin to rectus sheath) = 31.6 + 3.952 × BMI with adjusted R(2) = 94.5%. The abdominal cavity depth showed a correlation with adjusted R(2) = 84.2%. This showed a significant relation between body mass index and prediction of cavity depth. Using the mean regression line for STP (skin to peritoneum), a safe insertion distance was identified and a nomogram developed which can be used to objectively predict the depth of the peritoneal cavity.

[Baker Rosenbach erysipeloid appearing as a granulomatous cheilitis]. / Erysipéloïde de Baker-Rosenbach prenant l'aspect d'une chéilite granulomateuse.

BACKGROUND: Baker-Rosenbach's erysipeloid is a skin infection caused by Erysipelothrix rhusiopathiae. It occurs essentially in humans exposed to animals colonized with this germ such as swine. The typical skin lesion, an erythematous macule generally localized to inoculation site, frequently in the extremities, quickly resolves spontaneously. The lips are an atypical site of this infection. We describe a case of chronic granulomatosis cheilitis in a farmer caused by E. rhusiopathiae. CASE REPORT: A 40-year-old farmer, a wild-boar hunter and chronic smoker with no history of tuberculosis, injury or insect bites, presented at our dermatology unit with ulcerative macrocheilitis of the lower lip ongoing for 1 year. Its surface was purulent. A biopsy specimen showed non-caseating epithelioid granulomas. Laboratory and radiological screening for tuberculosis, sarcoidosis and Crohn's disease, and parasitological examination for Leishmaniasis proved negative. Bacteriological examination identified E. rhusiopathiae and labial Baker-Rosenbach's erysipeloid was diagnosed. The lesion healed after 15 days of treatment with parenteral penicillin G (12m IU/d), totally disappearing after 3 months. DISCUSSION: Swine erysipelas usually occurs in man as Baker-Rosenbach's erysipeloid. This localized form of infection with E. rhusiopathiae is the most frequent and the lesion typically observed is a violaceous plaque, less inflammatory with induration; spontaneous regression occurs after a mean 3 months. To our knowledge, this case is the first report of ulceration associated with macrocheilitis. Histologically, the granuloma directed our investigation towards the principal aetiologies of granulomatosis cheilitis, such as tuberculosis considering the epidemiological context, sarcoidosis or Crohn's disease. The diagnosis of erysipeloid was supported by epidemiological evidence (occupational exposure), isolation of the germ at the lesion and its regression on treatment with penicillin G. CONCLUSION: Diagnosis of E. rhusiopathiae infection was confirmed by bacteriology. However, the hypothesis concerning the pathogenesis of its chronic course in our patient remains a subject of discussion.

Results of a public awareness campaign in Morocco regarding the sun's deleterious effects.

OBJECTIVE: To investigate knowledge of the various sun radiation-related risks and awareness of photoprotection measures using a sample of the Moroccan population. METHODS: An investigation of prevalence, which was administered while a public awareness campaign on the sun's harmful effects, organized by the department of dermatology of Ibn Sina's hospital in Rabat, was running. The collection of the data was made on the basis of a questionnaire that was filled by the team of the doctors of the department. The logistic regression allowed to identify the explanatory factors for the prevalent knowledge and behaviours related to the subject in hand. RESULTS: Four hundred eleven subjects were included in the survey. The subjects' average age was 40 +/- 10 years. Eighty-four per cent were female. The analysis of the total score of knowledge related to the sunrays' deleterious effects demonstrated low levels of knowledge among 160 participants (38.9%). Females were clearly more knowledgeable than the opposite sex (P = 0.003) and also those having a higher educational level (P = 0.006) scored high. The use of sunscreens was recognized by 52.8% of the patients and was associated with female gender and higher educational level. CONCLUSION: Our study reports the results of the first public awareness campaign on the sun's deleterious effects on the Moroccan population, inclusive and relevant to all ages. Awareness of the sun's radiation-related risks in a country as sunny as ours is low, whereas different measures of photoprotection are rather well known. Messages adapted to the characteristics of our population are a necessity.

Oto-Rhino-Laryngology (ORL) tumor presentation in a case of systemic AA amyloidosis.

A 64-year-old male with no underlying disease presented with the development of multiple skin nodules, loss of sensation in the extremities, hoarseness, macroglossia, and pain in the oral cavity. Direct laryngoscopy showed nodules involving the oral cavity, oropharynx, supraglottic region, and vocal cords. Biopsy from skin nodules showed amyloid deposits staining with Congo red. Immunohistochemical staining was used for AA protein and was positive. Biopsy from the oral floor was also positive for amyloid. Oto-Rhino-Laryngology (ORL) involvement has been reported in approximately 40 percent of AL amyloidosis patients, but does not appear to be frequent in AA amyloidosis. Cutaneous manifestations in AA amyloidosis are rare, although cases with lesions presenting as purpura are reported occasionally; we are not aware of other cases of ORL nodular involvement in systemic AA.

[Juvenile dermatomyositis: 4 case studies]. / La dermatomyosite juvénile: à propos de 4 cas.

Juvenile dermatomyositis is a rare disease. The estimated incidence is 2 to 3 cases per million population. Before the use of corticosteroids, prognosis was poor for most patients. Today, despite a better prognosis, the side effects of long-term treatment still burden the outcome of the disease. The diagnosis of this entity is difficult and often delayed due to its rarity. It has been shown that the delay in diagnosis and care is a major factor for poor prognosis. Cutaneous findings are often inaugural, allowing early diagnosis. This study's aim was to share our 10-year experience with juvenile dermatomyositis.

[Oral verrucous carcinoma and human papillomavirus infection]. / Carcinome verruqueux buccal et infection à papillomavirus.

BACKGROUND: Verrucous carcinoma of the oral cavity is a clinical variant of squamous cell carcinoma. Infection with human papillomavirus (HPV) seems to be a significant risk factor in carcinogenesis, as illustrated in our case report. PATIENTS AND METHODS: A 72 year-old woman with a history of actinic cheilitis consulted for a bulky tumour of the lips and palate. Clinical examination revealed a highly infiltrated labial tumour vegetating and budding, with a thick edge. A bulky tumour and firm masses were seen on the hard and soft palates. Biopsy samples from both sites indicated well-differentiated veruccous epidermoid carcinoma with chorionic infiltration. The immunohistochemical study showed intestinal tumour containing HPV-16 virus. The central facial scan showed involvement of the nasal fossae, soft palate and lips with lysis of the upper maxilla arcade and the osseous palate. The patient died a few days before the start of preoperative chemotherapy following severe deterioration of her general state. DISCUSSION: Verrucous carcinoma is an authentic well-differentiated low-grade cancer. It appears as a wart-like exophytic lesion and progresses over several years. Diagnosis is based on histological examination. Management and treatment are not codified but surgery remains the treatment of choice and relapse is common in the case of locoregional involvement.

[Pseudoainhum and peripheral neuropathy]. / Pseudo-aïnhum et neuropathie axonale.

BACKGROUND: Pseudoainhum is a rare disease characterised by gradual fibrous constriction of the fingers and/or toes eventually resulting in their amputation. In this article, we report the first case seen in Morocco, highly unusual in terms of its severity. CASE REPORT: A 46-year-old woman with no toxic habits was hospitalised for spontaneous amputation of the fingers and toes. This condition began when the patient was 12 years old with the appearance of a circular constriction band at the base of the fifth toe, eventually resulting in its loss. The patient gradually lost all her other toes and fingers except for the first joint of her left index finger. There was no family history of any similar condition. Clinical examination also revealed perforating plantar disease in two of the stumps and peripheral neuropathy in all four limbs, comprising predominantly axonal disease responsive to electromyogram. Amputation of the index finger was completed and histological examination of the removed section showed nothing unusual, with no signs of diabetes. DISCUSSION: The peculiarity of our case resides in the exceptional severity of these amputations and their association with isolated polyneuropathy. Pseudoainhum has been described chiefly in patients with congenital keratoderma, certain systemic diseases, diabetes and alcohol dependence. A number of etiopathogenic hypotheses have been suggested: traumatic, infectious, vascular, neurological and genetic processes.

[Pruritus sine materia: a prospective study of 95 patients]. / Enquête étiologique d'un prurit sine materia: étude prospective d'une série de 95 patients.

PURPOSE: To describe the nature and the frequency of systemic diseases responsible for the pruritus sine materia. Value of this sign as a marker of malignancy. METHODS: Prospective study undertaken over five years (1996-2001). INCLUSION CRITERIA: generalized aspect of the pruritus and absence of specific primitive cutaneous lesions of an itching dermatosis. Parameters taken from the data of the anamnesis and the physical examination. Standard biologic and morphologic investigations were done. RESULTS: Ninety-five patients included (54 men, 41 women) of 55.5 years average age +/-18.1. In 24 patients, traditional hospitalisation with one average duration of eight days stay +/-3.15 was necessary. In 38 cases (40%), a systemic cause was found. The main conditions were: toxocariasis (8 cases), hematologic diseases (7 cases), chronic renal failure (6 cases), hypothyroidism (5 cases) and iron deficiency (5 cases). A neoplasm was found in eight cases (8,42%): seven hematologic malignancy (3 myeloma, 2 Hodgkin's diseases, 2 myeloproliferative syndromes) and one solid cancer (pulmonary adenocarcinoma). CONCLUSION: A systemic aetiology was observed in 38 cases (40%). The toxocariasis an underestimated disease comes at the first place. The pruritus sine materia can hide an hematologic malignancy.

Pharmacological treatment of hypertension in pregnancy.

The hypertensive disorders of pregnancy complicate 5-10% of pregnancies. Of these disorders 70% are pregnancy related (preeclampsia-eclampsia and gestation hypertension) and 30 % are a pre-existing hypertensive condition (chronic hypertension). These disorders are associated with maternal and fetal complications and have a substantial economic impact. This review examined the pharmacological treatment of the hypertensive disorders of pregnancy. There is a general consensus that anti-hypertensive should be given with severe hypertension and this should be in the hospital. The value of antihypertensive drugs in pregnant women with mild hypertension continues to be an area of debate that the evidence is too scanty to securely evaluate the clinical benefits of treating mild hypertension during pregnancy. The choice of the antihypertensive agents depends on individual clinician preference, the specified maternal and foetal benefits and the reproductive complications (teratogenisity, fetotoxicity and neonatal toxicity) of each particular agent. There are unequivocal evidences that Magnesium sulphate is superior to other agents in reducing recurrent eclamptic seizures. There is a strong recent evidence recommended that magnesium sulphate should be considered for women with pre-eclampsia for whom there is concern about the risk of eclampsia.

Reducing the dose of gonadotrophin-releasing hormone agonist on starting ovarian stimulation: effect on ovarian response and in-vitro fertilization outcome.

The aim of this study was to examine if lowering the dose of gonadotrophin-releasing hormone agonist (GnRHa) on starting ovarian stimulation could be beneficial in in-vitro fertilization (IVF) programmes. A total of 64 normally ovulating patients entering an IVF programme were randomized to receive GnRHa (nafarelin acetate/Synarel) as an intranasal spray commencing in the midluteal phase, either at a dosage of 200 microg three times daily until the day of human chorionic gonadotrophin (HCG) administration, or to be reduced to 200 microg twice daily as ovarian stimulation was initiated. Patients in both groups were below 35 years with a body mass index below 30. All patients received three ampoules of Metrodin HP per day. Blood samples were taken on the day of HCG administration to measure luteinizing hormone (LH), oestradiol, and progesterone. LH and oestradiol were found to be significantly higher in the lower Synarel dose group. Our results show that reducing the GnRHa dose during ovarian stimulation in IVF might be beneficial in terms of significantly more oocytes recovered, and significantly greater number of embryos available for transfer and freezing, with no incidence of premature luteinization.