Gastrointestinal tract involvement in hepatocellular carcinoma: two cases illustrating duodenal and oesophageal invasion.

We present here two hepatocellular carcinoma (HCC) patients with gastrointestinal tract involvement (GITI). Hemorrhage due to duodenal involvement was the inaugural event of the HCC for the first patient. Dysphagia due to HCC recurrence in the oesophagus four years after left hepatectomy was the call symptom for the second. As incidence of HCC increases, and overall survival improves, incidence of GITI in HCC patients is expected to increase.

Is early enteral nutrition dangerous in acute non surgical complicated diverticulitis? About 25 patients fed with oral fiber free energetic liquid diet.

BACKGROUND AND STUDY AIMS: Complicated Acute Colonic Diverticulitis (ACD) is usually treated by parenteral way thus keeping the bowel at rest. To date there are no clear recommendations regarding the route of nutrition administration. We study the safety of early feeding by oral energetic fiber-free liquid diet in non-surgical complicated ACD patients. PATIENTS AND METHODS: From February 2008 to October 2011, 25 patients were admitted with complicated ACD and took part in this prospective study. Surgical and medical assessments were performed at admission. Initial treatment was given with perfusion, intravenous antibiotics and hydric diet. Within 72 hours of admission, antibiotic therapy was switched to oral administration for 5 up to 15 days depending on the progression of the disease. At the same time the patient received oral liquid fiber-free feeding. Solid but fiber-free diet was introduced 24h hours before discharge. RESULTS: 25 cases of ACD were complicated with covered perforation and/or abscess. Mean hospitalisation time was 10A.4 days. 23 cases had good recovery and discharged, while 1 case progressed to colonic stenosis during hospitalisation, requiring a sigmoidectomy with a one-time anastomosis with good recovery. One patient relapsed his abscess during hospitalisation despite CT guided drainage and required sigmoidectomy with transient ileostomy. The mean daily treatment and nutrition cost for the non-surgical 23 patients was 30 euros. CONCLUSIONS: Early enteral nutrition in complicated ACD is feasible, not harmful, and reduce both, mean hospitalization time and treatment cost. Further studies comparing enteral with parenteral nutrition are necessary to confirm our hypothesis.

Congenital transverse deficiencies: bilateral presentation of the foot.

Congenital transverse deficiency is a rare structural anomaly, primarily occurring in utero. Even though it is rare, congenital transverse deficiency is seen in the private practice setting, and many physicians may be unprepared to make the diagnosis or offer treatment. Furthermore, congenital transverse deficiencies, particularly of the lower extremity, are given little attention in literature. This article briefly highlights congenital transverse deficiencies and discusses the differences and similarities between true Ainhum and congenital transverse deficiency. It provides a case presentation in the hope of helping readers understand, identify, and treat patients who have such afflictions.

Asthma, sedation, and the podiatric patient.

Propofol is a common drug used for anesthetic induction of patients undergoing surgery. This popular drug has been around for many years and has been subjected to changes in formulation from its original patented formula. Once touted as safe, the newer propofol may possess hidden dangers, particularly for individuals suffering with hyperreactive airway disease.

Fractures of the forefoot.

Fractures of the forefoot are common injuries of various causes. Although not crippling, forefoot fractures can be debilitating if they go undiagnosed or are mistreated. Whenever patients complain of foot pain with ambulation or difficulty ambulating, radiographs should be taken as part of a standard routine to assess for bony pathology. This article discusses the classification and treatment of metatarsal fractures, digital and sesamoid fractures, and open fractures about the forefoot.

Ankle fractures.

Although ankle injuries are common, it is imperative for the treating physician to be able to identify the mechanism of injury and accurately restore the normal anatomy of the ankle joint. Attention must be given to restoring the normal alignment and length of the fibula because of its dominant role in controlling talar stability. The medial ankle must not be overlooked, with the role of the deltoid taken into consideration. With a thorough understanding of the anatomy, biomechanics, mechanism of injury, and fixation techniques, repair of the damaged ankle joint can lead to rewarding outcomes for the patient and physician.

Inter-rater agreement of two functional independence scales: the Functional Independence Measure (FIM) and a subjective uniform continuous scale.

The needs and clinical decisions of care centres are related to patients' ability to carry out daily living activities. Most of the functional scales are not easy to use. This study examined the inter-rater agreement of the Functional Independence Measure (FIM) and a subjective uniform continuous scale (UCS) (the rating varied between 0 = complete dependence and 9 = complete independence) between 'educators', physiotherapists and occupational therapists. Two hundred and fifty-four patients aged below 20 in a rehabilitation centre were rated by professionals who were most familiar with them. For the two scales, inter-rater agreement was very good for all activities except for locomotion outside the centre for the UCS. The rating differences were slightly smaller for the FIM than for the UCS. Physiotherapists rated similarly to occupational therapists. The educators rated slightly though significantly lower than the other raters. The differences could be explained by their professional activities.

Self-monitoring of blood glucose and insulin dose alteration in type 1 diabetes mellitus.

The purpose of this study was to evaluate the relationship between proper use of self-monitoring of blood glucose (SMBG) including knowledge and application of specific algorithms and metabolic control in a group of randomly selected insulin-dependent diabetic patients. We studied 80 patients responding to the following criteria: intensive conventional insulin therapy and SMBG for at least 6 months using a reflectance meter, and previous 5-day hospital education period. The practical knowledge of the guidelines was evaluated by a questionnaire simulating 8 metabolic situations. A computer analysis of the SMBG data for the 3 months preceding the study allowed us to evaluate patient compliance with SMBG (number of blood glucose determinations) and patients' application of the guidelines (percentage of insulin doses modified according to the guidelines). Fifty-nine patients (79%) were compliant with SMBG and had better metabolic control than the non-compliers (HbA1c: 6.7 +/- 1.1% vs. 7.5 +/- 1.9, P < 0.05). Twenty-eight out of the 59 compliant subjects had good knowledge of the guidelines but without patent improvement of glycemic control. Seventeen of these 28 correctly used the algorithms to modify insulin dosage; their HbA1c levels were lower than those of the 11 patients who did not use the algorithms (6.1 +/- 0.9 vs. 7.1 +/- 0.9%, P < 0.05). The percentage of insulin dose modification consistent with the guidelines and the level of HbA1c was negatively correlated in the good-knowledge group. The conclusion is that good metabolic control is linked not only with the degree of knowledge but also with the application of this knowledge.

Mortality in retired coke oven plant workers.

A previous study on 536 retired coke oven plant workers in Lorraine Collieries (France) reported an excess of deaths from lung cancer (standardised mortality ratio (SMR) = 251) compared with the French male population. Occupational exposures during working life were retraced for each subject, but the number of deaths during the observation period (1963-82) was small, and smoking habits were known only for dead subjects. In 1988, the cohort was re-examined (182 deaths occurred between 1963 and 1987) and smoking habits were determined for all the subjects. This study confirmed the excess of lung cancer (SMR = 238, p < 0.001). It showed an excess of mortality from all causes (SMR = 141, p < 0.001), overall cancers (SMR = 133, p < 0.05), and cardiovascular diseases (SMR = 133, p < 0.05). A significant excess of deaths was found for subjects who worked near the ovens for all causes (145, p < 0.01), lung cancer (SMR = 252, p < 0.01), colon cancer (SMR = 381, p < 0.05), and cardiovascular diseases (SMR = 155, p < 0.05). A significant excess mortality was also found from all causes (176, p < 0.05) and stomach cancer (SMR = 538, p < 0.01) in subjects who worked in byproducts, from lung cancer (SMR = 433, p < 0.001) in those in the workshops, and from cirrhosis of the liver and alcoholism (SMR = 360, p < 0.01) in those underground; but, due to small numbers, these figures were not robust. An excess of mortality from all causes (SMR = 163, p<001), lung cancer (SMR = 228, p<0.05) and cardiovascular diseases (SMR = 179, p<0.01) was shown also for non-exposed or slightly exposed subjects. The fact that, on the whole, mortality of various exposed groups was similar to that of non-exposed or slightly exposed workers may be explained in part by the selection at hiring and the healthy worker effect. As an increased risk of lung cancer was noted among subjects who worked in the old generations of plant compared with the other workers (although the relative risk was not significant) it is concluded that the role of occupational hazards could not be excluded.

Lung function in retired coke oven plant workers.

Lung function was studied in 354 coke oven plant workers in the Lorraine collieries (Houillères du Bassin de Lorraine, France) who retired between 1963 and 1982 and were still alive on 1 January 1988. A spirometric examination was performed on 68.4% of them in the occupational health service. Occupational exposure to respiratory hazards throughout their career was retraced for each subject. No adverse effect of occupational exposure on ventilatory function was found. Ventilatory function was, however negatively linked with smoking and with the presence of a respiratory symptom or discrete abnormalities visible on pulmonary x ray films. The functional values were mostly slightly lower than predicted values and the most reduced index was the mean expiratory flow, FEF25-75%. The decrease in forced expiratory volume in one second (FEV1) was often parallel to that in forced vital capacity (FVC), but it was more pronounced for subjects who had worked underground, for smokers of more than 30 pack-years, and for subjects having a respiratory symptom. Pulmonary function indices were probably overestimated because of the exclusion of deceased subjects and the bias of the participants.

Morbidity in retired coke oven plant workers.

The effect of past occupational exposure on morbidity was studied in 354 coke oven workers in Lorraine Collieries (France) who retired between 1963 and 1982, and were still alive in 1988; 96% of them participated in this study. Occupational exposure to respiratory hazards during the working life was retraced for each subject. No significant association between the occupational exposure and the frequency of ischemic cardiopathies, arterial hypertension, gastro-duodenal ulcers, and respiratory symptoms was revealed. However, subjects who had worked on the Ovens, in the Workshops, and in the Byproducts showed a prevalence of arterial hypertension significantly higher than the non- or slightly exposed subjects. The healthy worker effect phenomenon, the exclusion of deceased subjects, and the small size of this retiree population may conceal possible differences between exposure groups.

Prospective mortality study among iron miners.

A prospective mortality study was conducted over a period of 5 years on a group of 13,801 iron miners, who were alive on January 1, 1982. During this 5-year period, 1813 deaths were registered. For 1222 (67.4%), the cause of death and work history are known. For 135 (7.4%), the cause of death is known, but not the work history. For 455 (25.1%), the cause of death is unknown. Proportional mortality ratio (PMR) is significantly higher than 1 for lung cancer (PMR = 2.51, p less than 0.001) and for stomach cancer (PMR = 2.31, p less than 0.001). The results are discussed in regard to occupational risks that result in these two kinds of increased mortality rates, and the hypothesis of redox activity on the surface of dust particles is advanced as a common denominator.

Radio-functional analysis of the cervical spine using the Arlen method. Part Three: Post-traumatic syndromes. A statistical analysis of 480 subjects.

The purpose of this study was to determine the differences in patterns of cervical mobility diagrams obtained by the Arlen method in a control population of 240 subjects and in a group of 240 patients who had previously sustained an indirect cervical trauma. The characteristics of antero-posterior mobility of the cervical spine in the control population and their variations due to age and sex are summarized. A statistical study is devoted to the amplitudes of the different vertebral segments during flexion and extension. The authors have tried to elucidate the functional features of the injured spine in its totality and at different levels in both flexion and extension. The two groups were compared in an analysis of spinal dysfunctions (hypomobility, loss of mobility, paradoxical mobility).

Radio-functional analysis of the cervical spine using the Arlen method. A study of 699 subjects. Part One: Methodology.

The authors describe successively the radiological technique and measurement method of Arlen's radio-functional analysis of the cervical spine, the characteristics of antero-posterior cervical spine mobility in a control population and the variations observed in these characteristics according to age and sex. A few typical diagrams of radio-functional analysis obtained in various types of pathology are offered as examples. The ease with the Arlen method can be used in routine practice; its diagnostic and prognostic value and its role in the follow-up of patients with cervical diseases or injuries are emphasized.

Radio-functional analysis of the cervical spine using the Arlen method. A study of 699 subjects. Part Two: Paradoxical tilting of the atlas.

The authors describe a peculiar movement of the first cervical vertebra: the so-called paradoxical tilting of the atlas, which consists of extension in relation to McGregor's line during flexion of the cervical spine. This physiological phenomenon has already been reported by several authors. The purpose of this study was to determine the mean amplitude and frequency of paradoxical tilting of the atlas in subjects with no known cervical pathology and to evaluate some of the factors that may influence it. The younger the subject the more frequent and more ample this paradoxical tilting: it occurs very often before the age of 40 years and is present in more than 93% of subjects under 20. Its amplitude diminishes with age, until it is replaced by mobility in flexion.

[Endoscopic sclerotherapy versus propranolol after hemorrhage caused by rupture of esophageal varices in patients with cirrhosis. Results of a 4-year randomized study]. / Sclérothérapie endoscopique contre propranolol après hémorragie par rupture de varices oesophagiennes chez le cirrhotique. Résultats à 4 ans d'une étude randomisée.

Between December 1982 and April 1987, we conducted a prospective randomized trial comparing the efficiency of endoscopic sclerotherapy with oral propranolol after variceal hemorrhage in cirrhosis. We present our results after a median follow-up of 3 years (range = 57-231 weeks). The sclerotherapy group (S) consisted of 28 patients and the propranolol group (P), 27 patients. The two groups were similar for age, sex, etiology and severity of liver disease, and severity of hemorrhage; the only difference concerned previous hemorrhages which were significantly more numerous in the S group. Sclerotherapy was performed with polidocanol 1 p. 100. A slow-release preparation of propranolol was used; the average daily dose was 160 mg. Eighteen patients in the S group had at least one hemorrhagic recurrence as opposed to 12 in the P group. This difference was not significant nor was the difference between actuarial curves of no-rebleeding (p = 0.30). No difference was noted concerning total deaths (15 in S versus 12 in P). Cumulative survival curves showed a non-significative difference (p = 0.99) percentages of survival in S and P groups were 75.0 p. 100 and 73.6 p. 100 at 1 year, 67.9 p. 100 and 64.6 p. 100 at 2 years, and 51.1 p. 100 and 52.7 p. 100 at 3 years respectively. Stratification according to Child's group, variceal size and history of variceal hemorrhage did not modify these results. However, male patients had less hemorrhagic recurrences with propranolol than after sclerotherapy. Length of hospitalization was not different in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Applications of a simple system of aid to medical decision-making with various patients in internal medicine: SELF]. / Applications d'un système simple d'aide à la décision médicale à différents sujets de médecine interne SELF.

Many medical decision helping systems are very complex and require expensive computers, which restricts their diffusion and limits their use to specialized people. The idea was to find a simplified system that any practitioner--even unaccustomed to microcomputing--would be able to use. Moreover, this system had to work on widely available and inexpensive microcomputers. SELF (system in fuzzy set) is this kind of system. It has been devised as a complete interactive system of medical decision help. It is entirely parameterized, allows any kind of application and works according to such rules as "if there is premise, then there is conclusion", tempered by a coefficient. The bases of knowledge are represented on a correspondence chart where columns materialize the premises (clinical signs, laboratory results, etc.) and horizontal lines all the diagnoses and therapeutic conclusions. The system includes proceedings that create, modify and update basic knowledge. It uses the fuzzy set rules to draw conclusions. SELF was first applied to the prescription of contraceptive methods, but it has now been tested in other specialties, such as gynaecology, pneumology, haematology and so forth. In every case, the reliability of the results obtained depends on the bases chosen by the creator himself. Owing to the general character of the system, one may regard it as being open to any user who would like to create his own applications.

Mortality due to respiratory cancers in the coke oven plants of the Lorraine coalmining industry (Houillères du Bassin de Lorraine).

The main activity of the Houillères du Bassin de Lorraine (Lorraine Collieries), employing 23,000 operatives and executives, is coalmining. The coke production is carried out by two coke oven plants with a workforce of respectively 747 and 552 workers. The coal coking process entails the emission of noxious products such as polycyclic aromatic hydrocarbons (PAH) from the ovens. The influence of occupational exposure on mortality due to respiratory cancers, and particularly to lung and upper respiratory and alimentary tracts cancer, was investigated among a cohort of 534 male workers from the two coke oven plants who had retired from work between 1963 and 1982. The job history of each subject has been precisely reconstructed by indicating the duration of exposure on the ovens, close to the ovens, and in maintenance occupations. The cohort mortality has been analysed according to the method of indirect standardisation with reference to the French male population and by a case-control study concerning the consumption of tobacco per cohort. The mortality due to lung cancer is 2.51 times higher than expected. This excess of mortality differs, but not significantly, between the two coke oven plants (standardised mortality ratio equals 3.05 and 1.75 respectively). It is not significantly higher among subjects exposed for more than five years, directly exposed on the ovens or working near the ovens or at maintenance occupations on the ovens (SMR = 2.78), than among those exposed for less than five years (SMR = 2.35) or those not exposed at all. Even taking into account the excess of mortality due to lung cancers in the Moselle district (1.6 time that of France), the excess of lung cancers does not seem to be explained by the regional factor, or by tobacco and alcohol consumption. Although no significant relation was offered between lung cancer and the duration of exposure to PAH, even when taking smoking habits into account, the carcinogenic role of occupational nuisances cannot be excluded.