Subarachnoid-pleural fistula: To drain or not to drain.

Subarachnoid-pleural fistula (SPF) is a rare complication of spine surgery with a transthoracic approach. The outcome of such an injury is affected by not only the pulmonary status due to the pleural effusion but also the neurological one, secondary to the intracranial hypotension. After reviewing the few published cases of SPF, the journey to diagnosis seams heterogenous and the management plan non-uniform. We report the case of a 48-year old women who underwent a right transthoracic discectomy that was complicated by an SPF. The diagnosis, although suspected perioperatively, was established with the gathering of an abundant post-operative pleural effusion, a subdural hematoma on head Computerized Tomography after drainage and Cerebro-Spinal Fluid markers present in the pleural fluid. The defect was effectively corrected with a radiological procedure. We compare our clinical and paraclinical findings and management plans to those reported in the few other published cases of SPF.

Osteonecrosis of the jaw induced by arsenic trioxide therapy in a leukemia patient: A rare case report and literature review.

A patient suffering from acute promyelocytic leukemia (APL) was referred to the dental department before introduction of chemotherapy by all-trans retinoic acid and arsenic trioxide (ATO). A panoramic radiography showed his third upper maxillary left tooth included into the maxillary bone. The patient presented with a febrile episode. Consequently, the infectious gateway was researched. A left maxillary sinus migration of his third upper left tooth together with a bony sequestrum has been observed on a CT-scan. A surgery was then performed to remove the bony sequestrum and the tooth. The first hypothesis of tooth migration could be that the patient had an infection prior to introduction of chemotherapy. However, neither clinical or radiographic signs were observed during the initial check-up. The second hypothesis is that ATO caused osteonecrosis of the jaw (ONJ) induced the formation of a bony sequestrum associated to the tooth migration into the sinus. ONJ could be a potential adverse of ATO chemotherapy.

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective.

BACKGROUND: The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway. OBJECTIVE: To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period. METHODS: A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05. RESULTS: 86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge. DISCUSSION: Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

Challenging the dogma of traumatic cardiac arrest management: a military perspective.

Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.

A double amino-acid change in the HLA-A peptide-binding groove is associated with response to psychotropic treatment in patients with schizophrenia.

The choice of an efficient psychotropic treatment for patients with schizophrenia is a key issue to improve prognosis and quality of life and to decrease the related burden and costs. As for other complex disorders, response to drugs in schizophrenia is highly heterogeneous and the underlying molecular mechanisms of this diversity are still poorly understood. In a carefully followed-up cohort of schizophrenic patients prospectively treated with risperidone or olanzapine, we used a specially designed single-nucleotide polymorphism (SNP) array to perform a large-scale genomic analysis and identify genetic variants associated with response to psychotropic drugs. We found significant associations between response to treatment defined by the reduction in psychotic symptomatology 42 days after the beginning of treatment and SNPs located in the chromosome 6, which houses the human leukocyte antigen (HLA). After imputation of the conventional HLA class I and class II alleles, as well as the amino-acid variants, we observed a striking association between a better response to treatment and a double amino-acid variant at positions 62 and 66 of the peptide-binding groove of the HLA-A molecule. These results support the current notion that schizophrenia may have immune-inflammatory underpinnings and may contribute to pave the way for personalized treatments in schizophrenia.

High mobility group box 1 protein (HMGB-1): a pathogenic role in preeclampsia?

We evaluated whether preeclampsia is associated with elevated circulating levels of High mobility group box 1 protein (HMGB-1), a nuclear protein with proinflammatory effects when released extracellularly. We enrolled 48 women, 32 in third trimester pregnancy (16 with, 16 without preeclampsia), and 16 healthy non pregnant. In the peripheral blood of pregnant women, HMGB-1 concentration was assessed serially, before and after delivery. With or without preeclampsia, third trimester pregnancy was associated with elevated levels of HMGB-1. This elevation is exaggerated in preeclampsia. The source of HMGB-1 observed in these conditions is likely to involve tissues other than the placenta itself.

Residential exposure to radiofrequency fields from mobile phone base stations, and broadcast transmitters: a population-based survey with personal meter.

OBJECTIVES: Both the public perceptions, and most published epidemiologic studies, rely on the assumption that the distance of a particular residence from a base station or a broadcast transmitter is an appropriate surrogate for exposure to radiofrequency fields, although complex propagation characteristics affect the beams from antennas. The main goal of this study was to characterise the distribution of residential exposure from antennas using personal exposure meters. METHODS: A total of 200 randomly selected people were enrolled. Each participant was supplied with a personal exposure meter for 24 h measurements, and kept a time-location-activity diary. Two exposure metrics for each radiofrequency were then calculated: the proportion of measurements above the detection limit (0.05 V/m), and the maximum electric field strength. Residential address was geocoded, and distance from each antenna was calculated. RESULTS: Much of the time, the recorded field strength was below the detection level (0.05 V/m), the FM band standing apart with a proportion above the detection threshold of 12.3%. The maximum electric field strength was always lower than 1.5 V/m. Exposure to GSM and DCS waves peaked around 280 m and 1000 m from the antennas. A downward trend was found within a 10 km range for FM. Conversely, UMTS, TV 3, and TV 4&5 signals did not vary with distance. CONCLUSIONS: Despite numerous limiting factors entailing a high variability in radiofrequency exposure assessment, but owing to a sound statistical technique, we found that exposures from GSM and DCS base stations increase with distance in the near source zone, to a maximum where the main beam intersects the ground. We believe these results will contribute to the ongoing public debate over the location of base stations and their associated emissions.

The experience of Teesside helicopter emergency services: doctors do not prolong prehospital on-scene times.

BACKGROUND: The benefits of helicopter emergency medical services (HEMSs) attending the severely injured have been documented in the past. The benefits of doctors attending HEMS casualties have been demonstrated in particular in inner-urban and metropolitan areas. However, for UK regions with potentially less major trauma, concerns have been raised by ambulance services that a willingness of doctors to "stay and play" may lead to unnecessary delays on-scene without any additional benefit to the patient. AIMS: To identify factors that do prolong on-scene time, establish whether doctors "stay and play" on-scene compared with paramedics and document how often advanced medical skills may have to be used by HEMS doctors working outside the London HEMS environment. METHODS: Patient report form data were studied with regard to the number of and mean on-scene times of missions flown to (A) road-traffic collisions (RTCs), (B) other trauma calls (OTCs) and (C) medical emergencies. Trauma missions (categories A and B) were further subcategorised with regard to associated patient entrapment. Any advanced medical interventions (AMIs) performed by HEMS doctors were recorded and categorised. Finally, we looked at the difference in on-scene times for physician-paramedic partnerships (PPPs) and conventional paramedic crews (CPCs) for the above categories and subcategories. RESULTS: A total of 203 patient report forms were identified and examined. In all, 44.3% of missions were flown to RTCs with a further 44.3% for OTCs and 11.4% to medical emergencies. AMIs were performed by HEMS doctors in 34.1% of PPP missions, with a prehospital rapid sequence induction rate of 3.8%. Overall mean on-scene time was 25 min, with no difference for PPP and CPC missions. The mean on-scene time was prolonged by 6 min for RTCs (p = 0.006) and by 23 min for patient entrapment (p<0.001). No significant differences were found for the comparison between PPPs and CPCs in any of the subgroups A-C. However, there seemed to be a trend towards reduced on-scene times of PPPs for medical emergencies and patient entrapments. DISCUSSION: This study did not show any significant prolongation of mean on-scene times for PPP missions either overall or for any of the subgroups A-C. The fact that AMIs were performed in a large number of missions attended by HEMS doctors seems to further justify their current role in providing improved care at the roadside without leading to any delays in transfer to definitive care.

Immunological and biochemical responses in Mya arenaria (Mollusca Bivalvia) exposed in vivo to estradiol-17beta.

Soft-shell clams Mya arenaria were injected with 10, 20 or 40 nmol of estradiol 17beta (E2). We observed a significant inhibiting effect of E2 on phagocytic activity of hemocytes from clams exposed to 10 and 20 nmol. A dose-response increase of the glycogen phosphorylase in the gonad tended to show a remobilisation of glycogen reserves involved in vitellogenesis although the exposure time must have been too short to observe a decrease in glycogen reserves or an increase in RNA concentration. Both results corroborate those of other studies about estrogen involvement in controlling immune capacity and energy metabolism related to vitellogenesis in bivalves. We can assume that immune parameters should now be taken into consideration in assessing endocrine disruption in bivalves. Nevertheless further studies are needed to understand the controlling pathways of E2 with a special regard on its interactions with other effectors involved in bivalve immunity and reproduction as well.

Estradiol-17beta and testosterone concentrations in male and female Mya arenaria (Mollusca bivalvia) during the reproductive cycle.

Perturbation of the reproductive cycle as well as vitellin-like protein synthesis have already been reported in Mya arenaria sampled in contaminated areas of the St. Lawrence maritime estuary (Québec, Canada). To assess the potential role of endocrine disruptors in modulating the reproductive cycle in clams, the role of sex steroids has to be clarified. We determined the levels of estradiol-17beta and testosterone during the reproductive cycle in female and male M. arenaria. Both steroids were measured by ELISA in the gonads and no differences in steroid profiles appeared between sexes. Estrogen levels varied between 150 and 400 pg g(-1) wet weight over gametogenesis and were near 10 times higher than testosterone levels. Results showed transient increases of both steroids at the onset of vitellogenesis in females and during the spawning stage in both sexes. These findings indicate that these hormones could have a role as endogenous modulators of gametogenesis. Further studies are, however, needed to describe the pathway of steroid synthesis in clam gonad and elucidate steroid involvement in controlling gametogenesis and as well as their relationship with neurohormones since these latter are required to promote sexual maturation.

Clusters of autochthonous hepatitis A cases in a low endemicity area.

At the University Hospital of Besançon (département of Doubs, France), an unusually high number of patients were hospitalized for hepatitis A during the 1999-2000 period, some of whom had not travelled abroad. This prompted us to conduct an investigation on a population basis and search for clusters of cases possibly related to local sources of contamination. Accordingly, case definition was restricted to autochthonous cases. During the 1999-2002 period, 45 autochthonous cases were classified as possibly originating from local environmental sources. A space-time scan statistic detected one most likely cluster (standardized incidence ratio 20.63, 95% confidence interval 10.6-37.1), consisting of 11 persons (of whom five children had attended the same swimming pool). It remained significant in a sensitivity analysis, strongly supporting the hypothesis of an environmental source of contamination. This study reveals the necessity of regular surveillance for hepatitis A and raises the issue of virological surveys of pool waters.

Sex alteration in soft-shell clams (Mya arenaria) in an intertidal zone of the Saint Lawrence river (Quebec, Canada).

The purpose of this study was to verify whether any changes in sex ratio might occur in soft-shell clams (Mya arenaria) located in an intertidal harbor zone located at the mouth of the Saguenay Fjord in the Saint Lawrence estuary (Baie Sainte-Catherine (BSC), Québec, Canada) likely to be contaminated by organotin compounds. Bivalves were harvested at the BSC harbor site and from two reference sites. Condition index (weight to length ratio), gonado-somatic index, sex ratio, vitellin-like proteins, organotin concentrations in gonad tissue, maturation stages of the gonads, the number of estradiol-17beta binding sites and the capacity of female gonad extracts to produce estradiol-17beta were determined in collected animals. Results showed that sex ratio in clams was significantly skewed toward males. Moreover, the condition and gonad-somatic indices, vitellin-like proteins in female gonads and the capacity of female gonads to produce estradiol-17beta were significantly reduced at the harbor site with respect to the reference sites. Maturation status of male gonads was clearly delayed at the harbor site. Additionally, gonad tissue contained tributyltin (TBT) at an average level of 109+/-18 ngSn/gdry wt. at the harbor site while organotins were not detected from the reference sites. Finally, female gonads had a higher number of unoccupied estradiol binding sites at the harbor site indicating low levels of this steroid in this tissue. Overall, this paper is first to report that clams collected in the vicinity of a TBT contaminated harbor are subject to masculinizing effects which seems to be consistent with biological effects that organotins are known to exert toward some other marine invertebrates.

Delayed gametogenesis of Mya arenaria in the Saguenay fjord (Canada): a consequence of endocrine disruptors?

The Saguenay fjord located in Canada on the north coast of the Saint-Lawrence Estuary, is well known for its multiple contaminations following a linear distribution upstream to downstream. Mya arenaria is well established in the fjord and potentially exposed to persistent sediment contamination as an endobenthic bivalve. From May to October 1997, clams energy storage and utilization in the gonad was shown to be closely linked with reproduction. Wherever the sampling site location in the fjord, a seasonal pattern is evident for lipid and glycogen levels in the gonad, this, reflecting the vitellogenic process. Nevertheless, in comparison with energy status and gametogenesis of clams collected on the north coast of the Saint-Lawrence Estuary, clams located in the fjord have to face limited nutritive conditions resulting in a single and shorter reproductive period. Although environmental factors could explain differences in physiological condition and reproductive status observed between clams from the fjord and the estuary, our results can discriminate clams from the upper part of the fjord, according to a delayed gametogenesis, concomitant with significant higher gonad glycogen concentrations observed in June 1996 and 1997. A persistent dysfunction of a vitellogenic process is suspected to be due to the exposure to anti-estrogenic contaminants.

Alteration of the biochemical properties of female gonads and vitellins in the clam Mya arenaria at contaminated sites in the Saguenay Fjord.

Vitellins (Vn) are the major egg yolk proteins that constitute an important energy reserve for mollusc embryos. The purpose of the present study was to examine whether the relative levels of sugars, lipids, phosphates, and labile IIb metals and calcium normally associated with Vn would differ in clam populations living at contaminated sites. Softshell clams (Mya arenaria) were collected at three sites in the area of the Saguenay Fjord: a marina, a municipal sewer outfall zone, and a reference site. The condition factor (weight:length ratio), metallothionein-like proteins, cytochrome P450 1A1 activity and DNA damage were all determined in the clam's digestive gland. Levels of total sugars, lipids, alkali-labile phosphates, proteins, and labile zinc and calcium were determined in female gonad homogenates and in purified Vn. The results show that clam gonads at the contaminated site by a marina displayed a lower index of gonad activity than the reference site. In addition, the condition factor was significantly lower at the marina site as compared to the reference site, with a concomitant increase in DNA damage and metallothionein (MT) induction. In fact, the condition factor was significantly correlated with DNA damage (R = -0.413, P = 0.045) and MT levels (R = -0.622, P = 0.03). Homogenates of female gonads were found to contain higher levels of labile IIb metals and calcium, with lower lipid content at the marina site compared to the reference site, and much higher levels of alkali-labile phosphates (ALP) and calcium at the municipal outfall site. Vn from the marina site were significantly higher in labile IIb metals but lipid content appeared to be somewhat lower than at the reference site. Vn from the municipal site were found to be highly phosphorylated, with higher levels of lipids and calcium. These results suggest that the chemical composition of the gonads and Vn are altered in contaminated sites.

[Socioeconomic aspects in the therapy of peritonsillar absscess]. / Aspects socio-économiques dans la prise en charge de l'abcès péritonsillaire.

OBJECTIVE: To determine which treatment for quinsy is the most cost-effective option. MATERIAL AND METHOD: 277 quinsies were diagnosed in 262 patients in our institution between 1.1.1991 and 31.12.1998. Median age was 29 years (1-89 years), and sex ratio was 3 males:2 females. 82 quinsy tonsillectomies (AC), 91 drainages with interval tonsillectomy (DAF) and 104 drainages of the abscess without tonsillectomy (D) were carried out. RESULTS: Median hospital stay was 3 (1-7) days for quinsy tonsillectomy, and 10 (4-18) days for drainages with interval tonsillectomy (hospital stay after drainage added to hospital stay after tonsillectomy). If interval tonsillectomy is performed as an outpatient procedure, median hospital stay decreases to 5 (2-8) days. For patients who refused tonsillectomy, median hospital stay was 3 (0-14) days. Median disability after treatment was 15 (7-30) days for quinsy tonsillectomy. For drainages with interval tonsillectomy (disability succeeding the drainage added to that following interval tonsillectomy), the median is 20 (15-52) days. For patients who refused tonsillectomy it is 6 (0-15) days. In the AC group we counted 9 late haemorrhages (11%). In the DAF group 14 patients (15%) presented a late haemorrhage; 6 patients (6%) presented a postoperative superinfection of the tonsillar fossae. DISCUSSION: On the basis of the tariffs of our institution (CHUV), and of statistical data obtained from the National Institute for Social Insurance (SUVA) with regard to the economic impact of each day of disability, the cost of the various treatment options is presented. CONCLUSION: It results from our study that in the absence of a significant difference in the rate of complications, and even considering the possibility of carrying out interval amygdalectomy on an outpatient basis, the most cost-effective treatment of peritonsillar abscess is quinsy tonsillectomy.

Quantification of bias related to the extraction of DNA directly from soils.

In recent years, several protocols based on the extraction of nucleic acids directly from the soil matrix after lysis treatment have been developed for the detection of microorganisms in soil. Extraction efficiency has often been evaluated based on the recovery of a specific gene sequence from an organism inoculated into the soil. The aim of the present investigation was to improve the extraction, purification, and quantification of DNA derived from as large a portion of the soil microbial community as possible, with special emphasis placed on obtaining DNA from gram-positive bacteria, which form structures that are difficult to disrupt. Furthermore, we wanted to identify and minimize the biases related to each step in the procedure. Six soils, covering a range of pHs, clay contents, and organic matter contents, were studied. Lysis was carried out by soil grinding, sonication, thermal shocks, and chemical treatments. DNA was extracted from the indigenous microflora as well as from inoculated bacterial cells, spores, and hyphae, and the quality and quantity of the DNA were determined by gel electrophoresis and dot blot hybridization. Lysis efficiency was also estimated by microscopy and viable cell counts. Grinding increased the extracellular DNA yield compared with the yield obtained without any lysis treatment, but none of the subsequent treatments clearly increased the DNA yield. Phage lambda DNA was inoculated into the soils to mimic the fate of extracellular DNA. No more than 6% of this DNA could be recovered from the different soils. The clay content strongly influenced the recovery of DNA. The adsorption of DNA to clay particles decreased when the soil was pretreated with RNA in order to saturate the adsorption sites. We also investigated different purification techniques and optimized the PCR methods in order to develop a protocol based on hybridization of the PCR products and quantification by phosphorimaging.