Evidence of Electron Heating by Alpha Particles in JET Deuterium-Tritium Plasmas.

The fusion-born alpha particle heating in magnetically confined fusion machines is a high priority subject for studies. The self-heating of thermonuclear fusion plasma by alpha particles was observed in recent deuterium-tritium (D-T) experiments on the joint European torus. This observation was possible by conducting so-called "afterglow" experiments where transient high fusion yield was achieved with neutral beam injection as the only external heating source, and then termination of the heating at peak performance. This allowed the first direct evidence for electron heating of plasmas by fusion-born alphas to be obtained. Interpretive transport modeling of the relevant D-T and reference deuterium discharges is consistent with the alpha particle heating observation.

[Design, implementation and evaluation of an educational approach for patients with PICC line and midline]. / Conception, réalisation et évaluation d'une démarche éducative auprès des patients porteurs de PICC line et midline.

OBJECTIVES: Design the competency framework and an interview guide for patients with PICC line or midline. Develop a patient satisfaction evaluation questionnaire. METHODS: A multidisciplinary team has developed a reference system for the skills of patients with PICC line or midline. The skills are classified in three categories: knowledge, know-how and attitudes. An interview guide was written in order to transmit the priority skills, determined beforehand, to the patient. A second multidisciplinary team designed a questionnaire to evaluate patient satisfaction. RESULTS: The competency framework includes nine competencies: four, knowledge-based; three, know-how-based and two, attitude-based. Among these competencies, five were considered to be priorities. The interview guide is a tool that allows care professionals to transmit the priority skills to patients. The satisfaction questionnaire explores the information received by the patient, the passage through the interventional technical platform, the end of the management before the return home, and the overall satisfaction of the patients with the course of the device placement. Over a 6-month period, 276 patients responded with a high satisfaction rate. CONCLUSIONS: The PICC line or midline patient's competency framework has made it possible to list all the skills that patients should acquire. The interview guide serves as a support for the care teams in the patient education process. This work could be used by other establishments to develop the educational process around these vascular access devices.

Spatial calibration and synthetic diagnostic of a multi-energy hard x-ray camera at WEST tokamak.

WEST (tungsten environment in steady-state tokamak) is starting operation for the first time with a water-cooled full tungsten divertor, enabling long pulse operation. Heating is provided by radiofrequency systems, including lower hybrid current drive (LHCD). In this context, a compact multi-energy hard x-ray camera has been installed for energy and space-resolved measurements of the electron temperature, the fast electron tail density produced by LHCD and runaway electrons, and the beam-target emission of tungsten at the target due to fast electron losses interacting with the divertor plates. The diagnostic is a pinhole camera based on a 2D pixel array detector (Pilatus 3 CdTe CMOS Hybrid-Pixel detector produced by DECTRIS). The novelty of this diagnostic technique is the detector's capability of adjusting the threshold energy at pixel level. This innovation provides great flexibility in the energy configuration, allowing simultaneous space and energy-resolved x-ray measurements. This contribution details two important steps in the preparation of the diagnostic operation. First, the in-vessel spatial calibration that was carried out with a radioactive source. Second, the synthetic diagnostic is obtained by the suite of codes ALOHA/C3PO/LUKE/R5-X2, which simulates LH wave propagation and absorption, as well as the fast electron bremsstrahlung production.

[Cardiogenic shock : etiology and management]. / Choc cardiogénique : étiologie et prise en charge.

Cardiogenic shock is one of the four types of circulatory shock (cardiogenic, distributive, hypovolemic and obstructive). It is a serious complication associated with a hypoperfusion state of terminal organs and possible multivisceral failures, with a high mortality rate of nearly 50 %. It is secondary to an acute myocardial infarction in 8 out of 10 cases but only complicates it in 5 to 10 %. It is more frequently encountered in pluri-troncular coronary diseases. Coronary revascularization and supportive care are the main treatments.

Le choc cardiogénique fait partie des quatre types de choc circulatoire (cardiogénique, distributif, hypovolémique et obstructif). Il s'agit d'une complication grave, associée à un état d'hypoperfusion d'organes terminaux et de possibles défaillances multiviscérales, avec une mortalité élevée de près de 50 %. Le choc cardiogénique est secondaire à un infarctus aigu du myocarde dans 8 cas sur 10 cas, mais ne le complique que dans 5 à 10 % des cas. Il est plus fréquemment rencontré lors d'atteintes coronariennes pluri-tronculaires. La revascularisation coronaire et le traitement supportif constituent les principaux traitements.

[Acute right heart failure]. / L'insuffisance cardiaque droite aiguë.

Even though, it has long been considered as a passive channel allowing communication between the systemic and pulmonary circulations, it is now clearly established that the right ventricle plays an essential role in cardio-pulmonary couple physiology. Its failure results in a clinical presentation that reflects the systemic congestion and reduced cardiac output. It is the consequence of two pathological situations frequently encountered in intensive care including pulmonary vascular resistance increase and right ventricle contraction alteration. Mechanical ventilation, certain drugs and volume overload can also participate. The management of the acute right heart failure is based on the combination of supportive treatment and causal treatment, specific to the etiology. Supportive therapy aims to optimize filling pressures, reduce afterload and support cardiac contractibility. With the growing number of therapeutic options used according to co-morbidities, decision-making by a multidisciplinary heart team seems essential.

Même s'il a été longtemps considéré comme un conduit passif permettant la communication entre les circulations systémique et pulmonaire, il est maintenant clairement établi que le ventricule droit joue un rôle essentiel dans la physiologie du couple cardio-pulmonaire. Sa défaillance est à l'origine d'un tableau clinique secondaire à la congestion systémique et à la réduction du débit cardiaque. Elle est la conséquence de deux situations pathologiques fréquemment rencontrées incluant l'augmentation des résistances vasculaires pulmonaires et l'altération de la contraction du ventricule droit. La ventilation mécanique, certains médicaments et la surcharge volémique peuvent également y participer. La prise en charge de l'insuffisance cardiaque aiguë repose sur l'association d'un traitement supportif et d'un traitement causal, spécifique à l'étiologie. Le traitement supportif vise à optimaliser les pressions de remplissage, réduire la postcharge et soutenir la contractilité myocardique. Avec le nombre croissant d'options thérapeutiques utilisées en fonction des comorbidités, la prise de décision par une équipe cardiologique multidisciplinaire est indispensable.

Compliance with antibiotic prophylaxis guidelines in surgery: Results of a targeted audit in a large-scale region-based French hospital network.

INTRODUCTION: While regional monitoring of antibiotic use has decreased since 2011 by 3.2%, in some healthcare facilities a significant increase (+43%) has occurred. The purpose of this study was to assess regional antibiotic prophylaxis (ABP) compliance with national guidelines. MATERIAL AND METHODS: In 2015, 26 healthcare facilities, both public and private, were requested to audit five items: utilization of antibiotic prophylaxis, the antimicrobial agent (the molecule) administered, time between injection and incision, initial dose, number of intraoperative and postoperative additional doses. Seven surgical procedures were selected for assessment: appendicectomy (APP), cataract (CAT), cesarean section (CES), colorectal cancer surgery (CCR), hysterectomy (HYS), total hip arthroplasty (THA) and transurethral resection of the prostate (TURP). A statistical analysis of the 2303 records included was carried out. RESULTS: The general rate of antibiotic prophylaxis compliance was 64%. The antimicrobial agent used and initial dose were in compliance with the guidelines for 93% and 97.4% of cases respectively, and administration of antibiotic prophylaxis was achieved 60minutes before incision in 77.6% of the records included. Regarding gastrointestinal surgery, amoxicillin/clavulanic acid was used in 32% of patients. In 26% of appendectomy files, administration occurred after incision, and one out of two files showed non-complaint perioperative and postoperative consumption. CONCLUSION: Compliance with nationwide ABP guidelines is in need of pronounced improvement, especially with regard to time interval between injection and incision and the molecule prescribed. An action plan based on specific recommendations addressed to each establishment and an updated regionwide ABP protocol are aimed at achieving better and reduced consumption of antimicrobial agents.

[Recommendations for a gradual and controlled resumption of electroconvulsive therapy in France during the period of lifting of the containment and of the COVID-19 pandemic linked to SARS-CoV-2]. / Recommandations pour une reprise progressive et contrôlée de l'électroconvulsivothérapie en France en période de levée du confinement et de pandémie COVID-19 liée au SARS-CoV-2.

The COVID-19 pandemic has had major consequences for the organization of care. In France and around the world, centers practicing electroconvulsive therapy (ECT) have seen their activity decrease, or even stop for many reasons. In this context, maintaining or resuming this essential therapeutic activity for many patients suffering from psychiatric disorders requires material, human and logistical adaptations that should be supervised. The objective of this collective and national work is to offer simple recommendations that can be applied immediately by any healthcare establishment, public or private, practicing ECT. They are the result of feedback from multiprofessional and inter-establishment experiences. Declined in three stages, these recommendations are accompanied by a practical sheet which describes in detail the necessary conditions and prerequisites for any resumption of ECT activity.

A 1-year survey of catheter-related infections in a pediatric university hospital: A prospective study.

BACKGROUND: Central venous catheters (CVCs) provide a great comfort for hospitalized children. However, CVCs increase the risk of severe infection. As there are few data regarding pediatric epidemiology of catheter-related infections (CRIs), the main objective of this study was to measure the incidence rate of CRIs in our pediatric university hospital. We also sought to characterize the CRIs and to identify risk factors. MATERIALS AND METHODS: We conducted an epidemiological prospective monocentric study including all CVCs, except Port-a-Caths and arterial catheters, inserted in children from birth to 18 years of age between April 2015 and March 2016 in the pediatric University Hospital of Nantes. Our main focus was the incidence rate of CRIs, defined according to French guidelines, while distinguishing between bloodstream infections (CRBIs) and non-bloodstream infections (CRIWBs). The incidence rate was also described for each pediatric ward. We analyzed the association between infection and potential risk factors using univariate and multivariate analysis by Cox regression. RESULTS: We included 793 CVCs with 60 CRBIs and four CRIWBs. The incidence rate was 4.6/1000 catheter-days, with the highest incidence rate occurring in the neonatal intensive care unit (13.7/1000 catheter-days). Coagulase-negative staphylococci were responsible for 77.5% of the CRIs. Factors independently associated with a higher risk of infection in neonates were invasive ventilation and low gestational age. CONCLUSIONS: The incidence of CRIs in children hospitalized in our institution appears to be higher than the typical rate of CRIs reported in the literature. This was particularly true for neonates. These results should lead us to reinforce preventive measures and antibiotic stewardship but they also raise the difficulty of diagnosing with certainty CRIs in neonates.

WITHDRAWN: A single center experience in resectable pancreatic ductal adenocarcinoma : the limitations of the surgery-first approach. Critical review of the literature and proposals for practice update.

The article has been withdrawn at the request of the authors and editor because of incorrect authorship, which is considered a form of unethical publication. The Publisher apologizes for any inconvenience this may cause.

Cefazolin tissue concentrations with a prophylactic dose administered before sleeve gastrectomy in obese patients: a single centre study in 116 patients.

BACKGROUND: In obese patients undergoing sleeve gastrectomy, the blood and fatty-tissue concentrations of cefazolin required for adequate antibiotic prophylaxis are uncertain. METHODS: This was a single centre prospective study in obese (Group A: 40≤ BMI ≤50 kg m-2) and severely obese (Group B: 50< BMI ≤65 kg m-2) patients undergoing bariatric surgery. Blood and fatty-tissue samples were collected after a cefazolin 4 g i.v. injection. The primary aim was to compare cefazolin concentrations in subcutaneous fatty tissue with a targeted tissue concentration of 4 µg g-1 according to Staphylococcus aureus resistance breakpoint. RESULTS: One hundred and sixteen patients were included: 79 in Group A and 37 in Group B. At the beginning of the surgery, cefazolin concentration in subcutaneous fatty tissue was 12.2 (5.4) µg g-1 in Group A and 12 (6.1) µg g-1 in Group B (P=0.7). At the end, cefazolin concentrations in subcutaneous fatty tissue were 9.0 (4.9) and 7.8 (4.2) µg g-1 in Groups A and B, respectively (P=0.2). The plasma concentration of free cefazolin during surgery was higher in Group A than in Group B (P<0.0001). Fatty-tissue concentrations of 95% and 83% patients in Groups A and B, respectively, were above S. aureus resistance breakpoint. CONCLUSIONS: After a 4 g dose, the concentrations of cefazolin in fatty tissue were above the 4 µg g-1 tissue concentration target, providing adequate antibiotic tissue concentrations during bariatric surgery. As cefazolin concentration in fatty tissue is a surrogate endpoint, the results should be considered in conjunction with the results on free cefazolin concentrations in subcutaneous tissue. CLINICAL TRIAL REGISTRATION: NCT01537380.

Antibiothérapie péri-opératoire et greffe de peau: état des lieux sur les prescriptions dans les centres français de traitement de la brûlure, vers une harmonisation des pratiques?

Most hospitals use protocols for surgical antibioprophylaxis (ABP). Despite SFB's 2009 recommendations promoting ABP in burn patients and stating the molecules to be used, wide variations exist within hospitals and among French hospitals, in cases of skin grafting and use of dermal substitutes. We contacted surgeons in 12 French Burn Centres (BCs) via email and questioned them about ABP in cases of skin grafting (thin and total) as well as in the use of dermal substitutes, in acute and sequelae settings. Eight BCs answered. In the acute phase, 3 BCs (37.5%) always use ABP in skin grafts, 2 (25%) use ABP on suspicion of wound infection and 3 (37.5%) never use ABP. When installing skin substitute, 5 BCs (62.5%) use ABP, one (12.5%) does so if the wound is suspected of being infected and 2 (25%) never use ABP. For sequelae, 5 BCs (62.5%) use ABP whatever the surgery, while 3 (37.5%) never use it. Infection onset after skin graft or use of dermal substitute is frequent. Our study shows wide variations in the use of ABP in these surgeries. A multi-centre evaluation of the implementation of SFB's 2009 recommendations and their role in preventing postoperative infections after skin grafting and skin substitute use, both in acute and sequelae phases, could help harmonize practices in BCs.

PCA3 como biomarcador de segunda línea en un programa de screening oportunista prospectivo, aleatorizado y controlado / PCA3 as a second-line biomarker in a prospective controlled randomized opportunistic prostate cancer screening programme

Objetivos: Determinar el comportamiento del PCA3 como un marcador de segunda línea en un programa de cribado oportunista de cáncer de próstata (CaP) y su comparación con la calculadora de riesgo 3 del cribado aleatorizado europeo en cáncer de próstata (ERSPC RC-3). Material y métodos: En total de 5.199 hombres de 40-75 años se hicieron la prueba del antígeno prostático específico (PSA) y un tacto rectal (TR). Aquellos con TR normal y PSA ≥ 3ng/ml se realizaron un PCA3. Todos los hombres con PCA3 ≥ 35 se hicieron biopsia inicial (BxI) -12 cilindros-. Aquellos con PCA3 < 35 se aleatorizaron 1:1 a BxI u observación. Los resultados se comparan con los obtenidos con la aplicación de la calculadora ERSPC RC-3. Resultados: PCA3 se testó en 838 hombres (16,1%). En los grupos PCA3(+) y PCA3(-), las tasas de detección global de CaP fueron del 40,9 y del 14,7% a una mediana de seguimiento de 21,7 meses (p < 0,001. En el grupo PCA3(+) (n = 301, 35,9%), se identificó CaP en 115 hombres en BxI (38,2%). En el brazo aleatorizado, 256 se hicieron BxI y se objetivó CaP en 46 (18,0%) (p < 0,001). La potencial tasa de ahorro de biopsias siguiendo el corte PCA3 = 35 hubiera sido de 64,1% frente a la de 76,6% si hubiéramos usado ERSPC RC-3. Sin embargo, la tasa estimada de falsos negativos de CaP de alto grado (CaPAG = Gleason ≥ 7) se hubiera reducido un 37,1% (de 89 a 56 pacientes) al usar el PCA3. Si hubiéramos usado el corte 35 de PCA3 para no realizar BxI, hubiésemos dejado de diagnosticar un 14,7% de CaP y un 9,1% de CaP clínicamente significativo, a un seguimiento medio aproximado de 2 años. Conclusiones: Cuando se usa PCA3-35 como biomarcador de segunda línea en hombres con PSA ≥ 3ng/ml y TR normal, se puede obviar la BxI un 12,5% menos que usando la ERSPC RC-3, pero reduciendo los falsos negativos un 36,2%. A un seguimiento de 21,7 meses, este protocolo dual no hubiera detectado un 9,1% de CaP clínicamente significativo, por lo que el seguimiento con estrictos criterios de biopsia basados en PSA y TR es obligatorio en casos con PCA3 < 35

Objectives: PCA3 performance as a single second line biomarker is compared to the European Randomised Study of Screening for Prostate Cancer risk calculator model 3 (ERSPC RC-3) in an opportunistic screening in prostate cancer (PCa). Material and methods: 5,199 men, aged 40-75y, underwent prostate-specific antigen (PSA) screening and digital rectal examination (DRE). Men with a normal DRE and PSA ≥3ng/ml had a PCA3 test done. All men with PCA3 ≥ 35 underwent an initial biopsy (IBx) -12 cores-. Men with PCA3 < 35 were randomized 1:1 to either IBx or observation. We compared them to those obtained with ERSPC RC-3. Results: PCA3 test was performed on 838 men (16.1%). In PCA3(+) and PCA3(-) groups, global PCa detection rates were 40.9% and 14.7% with a median follow-up (FU) of 21.7 months (P <.001). In the PCA3(+) arm (n = 301, 35.9%), PCa was identified in 115 men at IBx (38.2%). In the randomized arm, 256 underwent IBx and PCa was found in 46 (18.0%) (P < .001). The biopsy-sparing potential would have been 64.1% as opposed to 76.6% if we had used ERSPC RC-3. However, the estimated false negative cases for HGPCa would have been reduced by 37.1% (89 to 56 patients). Moreover, if we had applied PCA3-35 to avoid IBx, 14.7% PCa and 9.1% of clinical significant PCa patients would not have been diagnosed during this FU. Conclusions: When PCA3-35 is used as a second-line biomarker when PSA ≥ 3ng/ml and DRE is normal, IBx could be avoided in 12.5% less than if ERSPC RC-3 is used and would reduce the false negative cases by 36.2%. At a FU of 21.7 months, this dual protocol would miss 9.1% of clinically significant PCa, so strict FU is mandatory with established biopsy criteria based on PSA and DRE in cases with PCA3 < 35

PCA3 as a second-line biomarker in a prospective controlled randomized opportunistic prostate cancer screening programme. / PCA3 como biomarcador de segunda línea en un programa de screening oportunista prospectivo, aleatorizado y controlado.

OBJECTIVES: PCA3 performance as a single second line biomarker is compared to the European Randomised Study of Screening for Prostate Cancer risk calculator model 3 (ERSPC RC-3) in an opportunistic screening in prostate cancer (PCa). MATERIAL AND METHODS: 5,199 men, aged 40-75y, underwent prostate-specific antigen (PSA) screening and digital rectal examination (DRE). Men with a normal DRE and PSA ≥3ng/ml had a PCA3 test done. All men with PCA3 ≥35 underwent an initial biopsy (IBx) -12 cores-. Men with PCA3 <35 were randomized 1:1 to either IBx or observation. We compared them to those obtained with ERSPC RC-3. RESULTS: PCA3 test was performed on 838 men (16.1%). In PCA3(+) and PCA3(-) groups, global PCa detection rates were 40.9% and 14.7% with a median follow-up (FU) of 21.7 months (P<.001). In the PCA3(+) arm (n=301, 35.9%), PCa was identified in 115 men at IBx (38.2%). In the randomized arm, 256 underwent IBx and PCa was found in 46 (18.0%) (P<.001). The biopsy-sparing potential would have been 64.1% as opposed to 76.6% if we had used ERSPC RC-3. However, the estimated false negative cases for HGPCa would have been reduced by 37.1% (89 to 56 patients). Moreover, if we had applied PCA3-35 to avoid IBx, 14.7% PCa and 9.1% of clinical significant PCa patients would not have been diagnosed during this FU. CONCLUSIONS: When PCA3-35 is used as a second-line biomarker when PSA ≥3ng/ml and DRE is normal, IBx could be avoided in 12.5% less than if ERSPC RC-3 is used and would reduce the false negative cases by 36.2%. At a FU of 21.7 months, this dual protocol would miss 9.1% of clinically significant PCa, so strict FU is mandatory with established biopsy criteria based on PSA and DRE in cases with PCA3 <35.

[Mydriatic eye drops for children: Analysis of use]. / Collyres mydriatiques en pédiatrie : analyse des pratiques d'utilisation.

Mydriatic eye drops are indicated for ophthalmologic exams (fundus and cycloplegic effect for refraction diagnosis). Their use must be optimal to avoid adverse reactions. This is even more important in pediatrics, because few clinical studies were conducted in this population during drug development. We reviewed the use of mydriatic eye drops, gathering information from the Summary of Product Characteristics (SPC) from the Theriaque® database (CNHIM) and the manufacturers' information, in terms of dose, concentration and volume administered, age limit indications, recommendations for administration, and our local practice. This tool is useful in our hospital for physicians, pharmacists, and nurses but could be also useful for all healthcare providers using mydriatic eye drops for children.

Effect of age and carcass weight on quality traits of m. rectus abdominis from Charolais heifers.

In practice cattle may be slaughtered at different combinations of age and weight. As each of these factors could affect meat quality traits, the present work aimed to identify which combination can be expected to increase overall meat quality of m. rectus abdominis of Charolais heifers. Totally, 40 heifers were slaughtered either at 26±1 or at 36±1 months of age. Young heifers were sampled at two different carcass weights (349±12 and 394±8 kg). Old heifers were also sampled at two different carcass weights (397±6 and 451±9 kg). The m. rectus abdominis was excised 24 h postmortem to determine metabolic enzyme activities, myosin heavy-chain isoform proportions, lipid contents, collagen content and collagen solubility. Shear force measurements were evaluated on raw and broiled meat after 14 days of ageing. Meat quality traits scored between 0 and 10 by sensory analysis. Increasing slaughter age from 26 to 36 months had no impact on either raw/broiled shear force (0.31⩽P⩽0.47) and/or meat quality traits (0.62⩽P⩽0.91) or on physicochemical properties of heifer's meat samples. Increasing carcass weight for a similar slaughter age of 26 months had also impact neither on meat quality traits (0.52⩽P⩽0.91) nor on muscular properties. On the contrary, increasing carcass weight for a similar slaughter age of 36 months had induced a decrease of muscular shear force (raw muscle; P=0.009) and a concomitant decrease of total collagen content (P=0.03). Nevertheless, no significant impact on meat quality traits was revealed by the sensorial panel (0.13⩽P⩽0.49). Metabolic enzyme activities (0.13⩽P⩽0.86) and myosin heavy-chain proportions (0.13⩽P⩽0.96) were not significantly impacted by slaughter age and carcass weight. Thus, the impact of increasing carcass weight and/or slaughter age in young Charolais heifers has a limited impact on meat quality traits and associated muscular characteristics. Modulating heifer's cycles (age and/or carcass weight in the studied range) appears to be a way to answer to the numerous marketing chains, without penalising meat quality traits.

A single center experience in resectable pancreatic ductal adenocarcinoma : the limitations of the surgery-first approach. Critical review of the literature and proposals for practice update.

BACKGROUND AND STUDY AIMS: The current standard of care for resectable pancreatic ductal adenocarcinoma (PDAC) is surgery-first followed by adjuvant chemotherapy. We review our single center experience in a PDAC cohort managed by the surgery-first strategy. We then compare our data to those of Belgian and international literature. PATIENTS METHODS: We reviewed a series of 83 consecutive resectable patients with PDAC, treated by the surgery-first approach in a Belgian Academic Hospital between 2007 and 2013. The outcomes were assessed with univariate and multivariate Cox regression analysis. Kaplan-Meier curves were drawn according to patient groups. RESULTS: For the entire population, the median survival (MS) was 18.4 months; the 1-year relapse-free survival was 56%, and the 5-year overall survival (OS) was 13%. The size of the primary tumor larger than 3 cm (OS, HR = 1.76, p = 0.033) and vascular resection (DFS, HR = 2.1, p = 0.024) were the single independent prognostic factors in the multivariate analysis of this cohort. Only 69% of the patients received adjuvant chemotherapy, and more than 75% of them demonstrated no chance of survival beyond 3 years because they harbored poor prognostic factors, recognized only postoperatively. CONCLUSIONS: Our results and those published in the literature brought to light the limited perspectives of the surgery-first strategy in a population of apparently resectable pancreatic cancers. In comparison, data from reported neo-adjuvant series deserve our interest to bring this strategy upfront in selected patients in the context of close observational monitoring and randomized trials. The actual standard of care for resectable PDAC is surgery-first followed by adjuvant chemotherapy. The performance of this strategy relies on the dedicated imaging that does not accurately recognize the limits of the tumor and the high prevalence of adverse prognostic factors. Moreover, pancreatectomy remains associated with high postoperative complication rates and the poor completion of adjuvant therapy. This translates into poor long-term survival figures. In our series the MS was 18.4 months and 5-year OS was 13%. The disease-free survival (DFS) was 15.6 months, 1 and 3-year DFS were 56 and 26%, respectively. The variables that significantly correlated with OS in univariate analysis are tumor size and lymph node involvement. Regarding DFS, vascular resection was the only significant factor. In the multivariate analysis, the only significant factor related to OS remained the tumor size >3 cm in greatest diameter. Vascular resection remained significant for DFS. 31% of the patients did not receive any chemotherapy at all before the 6-month period following resection. The rates of complete resections compared favorably with those of a surgery-first strategy with no excess of operative mortality, complications and early relapse rates. The advantages of a chemotherapy-first approach, eventually combined with chemo-radiotherapy, are to offer higher combined therapy completion rates and improve the level of free resection margins, lymph node involvement and patient selection. The advent of safe, more potent chemotherapy combinations has the potential to further improve survival when administered upfront.

[RENDU-OSLER DISEASE: A RARE CAUSE OF AMMONIA ENCEPHALOPATHY]. / LA MALADIE DE RENDU-OSLER: une cause rare d'encéphalopathie ammoniacale.

Hereditary Hemorrhagic Telangiectasia (HHT) also known as Rendu-Osler disease is a group of related disorders inherited in an autosomal dominant fashion and characterized by the development of arteriovenous malformations (AVM) in the skin, mucous membranes, and/or internal organs such as the brain, lungs, and liver. The prevalence of liver involvement is clinically estimated between 8 and 31 percent. It can be revealed by the following clinical signs : ascites, edema of the lower extremities, abdominal pain, dyspnea, and, rarely, hepatic encephalopathy and gastrointestinal bleeding associated with portal hypertension. This case illustrates the highlight of liver damage revealed by an ammonia encephalopathy associated with iconographic anomalies on ultrasonography and magnetic resonance liver as part of Rendu-Osler disease.

[Evolution in the therapeutic strategy of localized resectable pancreatic ductal adenocarcinoma]. / Evolution dans la prise en charge de l'adénocarcinome du pancréas localisé estimé résécable.

Pancreatic ductal adenocarcinoma is characterized by a high rate of early metastatic relapse. Surgical resection is still recognized as the cornerstone upfront therapy. However, reported 5 years survival rates are inferior to 20-25% even when surgery is followed by chemotherapy. Margins involvement on the surgical specimen (50 to 85%) and lymph node involvement (around 70%) both strongly impact survival. Median survivals are close to those of locally advanced diseases treated by chemotherapy or chemoradiotherapy, 15 to 16 months. This review focuses on adverse prognostic factors, post-operative outcomes and their impact on multimodality therapy completion rates and survivals in patients undergoing upfront surgery. Current data and emerging results from neoadjuvant series could lead to a change in the therapeutic strategy.

Información obligatoria que debe conocer un paciente con cáncer de próstata candidato a vigilancia activa / Obligatory Information that a Patient Diagnosed of Prostate Cancer and Candidate for an Active Surveillance Protocol must know

Objetivos: Conocer la información necesaria para reproducir los resultados de la literatura en vigilancia activa (VA) en cáncer de próstata (CaP) en nuestro propio centro, de tal forma que dicha información sea objetiva y se le pueda dar al paciente de forma fehaciente. Contemplamos estudiar el porcentaje de pacientes candidatos a VA y que la escogen en nuestro ambiente, los datos de infraestadificación, infragradación y predicción de CaP insignificante, depurar el poder predictivo de distintas variables clínicas para mejorar nuestros criterios de selección y analizar los resultados de nuestros pacientes en VA. Material y métodos: Revisión retro y prospectiva de nuestras bases de datos. Se analiza un periodo de un año natural seleccionando posibles candidatos a VA. Análisis de nuestras prostatectomías radicales para conocer las tasas de infraestadificación, infragradación y tasa de CaP insignificante (criterios de Epstein). Análisis uni/multivariado de variables clínicas en pacientes con tumor insignificante en pieza de prostatectomía radical. Valoración prospectiva de supervivencia global y libre de tratamiento activo (SLTA) en pacientes en VA. Resultados: Entre octubre de 2010 y octubre de 2011, un 44,7% de los CaP cumplían criterios para ser incluidos en VA, y un 11,2% la escogieron. Nuestros porcentajes de infraestadificación, infragradación y tasa de CaP insignificante fueron 14%; 31,4%; y 55,7% respectivamente, pero solo 6 pacientes (6,97%) tuvieron CaP ≥ pT3a + Gleason ≥ 7 + volumen > 0,5 cc. En el estudio multivariado para predicción de tumor insignificante, la densidad de PSA y el número de cilindros afectos son factores independientes. Con un seguimiento medio de 36 ± 39 meses, de 232 incluidos en VA, 63 pacientes pasaron a tratamiento activo (27,1%), solo 13 por ansiedad sin progresión patológica. La mediana del tiempo de SLTA es de 72,7 meses (IC 95%: 30,9-114,4). La SLTA a los 24 meses es del 76,4% (69,7-83,1%) y a 48 meses es del 58,1% (48,8-67,4%). Solo 10 pacientes (4,3%) fallecieron, 9 por causa diferente al CaP. La supervivencia global estimada a 5 años es del 92,8% (IC 95%: 86,7-98,9%). Conclusiones: El conocimiento exacto de la casuística de cada centro debería ser obligatorio para informar a los pacientes verazmente de la rentabilidad de la biopsia y de si los porcentajes de infragradación, infraestadificación y de CaP insignificante se adecuan a los de la literatura. A 3 años reproducimos los resultados de las series más longevas de VA, por lo que el programa de VA puede seguir implementándose e incluyendo cada vez a más pacientes

Objectives To know the necessary information to reproduce the results found in the literature on active surveillance (AS) in prostate cancer (PCa) in our own center so that the information would be objective and correctly given to the patients. We have aimed to study the percentage of candidates for AS chosen in our setting, and the data on infrastaging, subgrading and prediction of insignificant PCa, debugging the predictive value of clinical variables to improve our selection criteria and finally to analyze the results of our patients enrolled in AS. Materials and methods: A retro- and prospective review of our data bases was performed. A one-year period was analyzed to know AS candidates. Analysis of our radical prostatectomy specimens for infrastaging, subgrading and prediction of insignificant PCa (Epstein's criteria) was made as well as a uni/multivariate analysis of clinical variables in patients with insignificant PCa in the specimen. A prospective validation was performed with overall survival and survival free of active treatment (SFAT) as endpoints in patients enrolled in AS. Results: Between October-2010/October-2011, 44.7% of our PCa were candidates for AS, but only 11.2% choose it. The percentages found for infrastaging, subgrading and prediction of insignificant PCa were 14%, 31.4% and 55.7%, respectively. However, only just 6 patients (6.97%) had ≥ pT3a + Gleason ≥7 + volume > 0.5 cc PCa. The multivariate analysis showed that PSA density and number of affected cores were independent predictors of insignificant PCa. With a mean follow-up of 36 ± 39 months, 63 out of 232 patients enrolled in AS went on to active treatment (27.1%), with only 13 due to anxiety without pathologic progression. Median time of SFAT was 72.7 months (CI 95% 30.9-114.4). SFAT at 24 months was 76.4% (69.7-83.1%) and at 48 months 58.1% (48.8-67.4%). Only 10 patients died (4.3%), 9 due to causes different of PCa. Estimated overall survival at 5 years was 92.8% (CI 95% 86.7-98.9%). Conclusions: It should be mandatory to have the exact knowledge of the local data of each Center in order to objectively inform patients about prostate biopsy efficiency, and if percentages of infrastaging, subgrading and prediction of insignificant PCa are in accordance with the literature. At 3 years, we reproduced the results of the longest series of AS, so we have ascertained that our AS protocol can be implemented with increasingly more patients