Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues.

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

Characteristics of a molybdenum X-pinch X-ray source as a probe source for X-ray diffraction studies.

X-ray emission from a molybdenum X-pinch has been investigated as a potential probe for the high pressure states made in dynamic compression experiments. Studies were performed on a novel 300 kA, 400 ns generator which coupled the load directly to a low inductance capacitor and switch combination. The X-pinch load consisted of 4 crossed molybdenum wires of 13 µm diameter, crossed at an angle of 62°. The load height was 10 mm. An initial x-ray burst generated at the wire crossing point, radiated in the soft x-ray range (hυ < 10 keV). This was followed, 2-5 ns later, by at least one harder x-ray burst (hυ > 10 keV) whose power ranged from 1 to 7 MW. Time integrated spectral measurements showed that the harder bursts were dominated by K-alpha emission; though, a lower level, wide band continuum up to at least 30 keV was also present. Initial tests demonstrated that the source was capable of driving Laue diffraction experiments, probing uncompressed samples of LiF and aluminium.

Treatment of carcinoma of the penis by iridium 192 wire implant.

Since 1971, a group of 22 adult patients with squamous cell carcinoma of the penis have been treated by iridium 192 wires implant. There were 6 T1 tumors, 14 T2 tumors and 2 T3; only one patient (T3) presented with local failure after implant. Local necrosis occurred in 2 patients without local tumoral recurrence, but was sufficient enough to warrant amputation. Thus 19/22 (86%) patients were locally cured with penile conservation. In these patients the most frequent post-therapeutic complication is chronic urethral stenosis (9/19 patients, 47%) requiring repeated instrumental dilations. Four patients presented with initial inguinal metastatic nodes; only one was cured by radiosurgical treatment. Among patients without metastatic nodes at the time of diagnosis, none had delayed metastatic nodes. Three patients died of nodal evolution, 5 patients died of intercurrent disease without evidence of disease and 14 are now alive and NED. It appears that iridium 192 wires implant is the most effective conservative treatment of invasive squamous cell carcinoma of the penis; however, these results confirm that no particular treatment is required for inguinal nodal areas for patients who initially present with no disease.

Results of the treatment of 165 lid carcinomas by iridium wire implant.

A group of 160 adult patients with epithelial tumors of the lid and/or canthi treated by iridium 192 wire implant are presented. There were 165 epithelial tumors, most of them were basocellular type (85%). In all cases, a nonradioactive procedure was used with disposable angiocatheters before introducing active wires. Respectively, 111/114 (97.4%) of "new" lesions and 48/51 (94%) of previously treated tumors were definitively cured by iridium wire implant. Among the 6 local recurrences, 4 were salvaged by a second iridium implant, and the two others by extensive surgery. Local side effects were present in 30 patients (18%): impairment of the eyelid aperture 9, stenosis of lacrymal ducts 7, eversion of the lid 7, lack of substance 7. These postherapeutic complications were significantly more frequent in treating recurrent lesions (15/48, 31.2%) than in previously untreated tumors (15/112, 13.4%). No visual complication was observed even in the early patients of this series.

Radiotherapy alone in carcinoma of the intact uterine cervix according to G. H. Fletcher guidelines: a French cooperative study of 1383 cases.

A French Cooperative study of 1383 cases with invasive carcinoma of the intact uterine cervix treated with radiation therapy alone, using the guidelines provided by G. H. Fletcher led to the following conclusions: The techniques of treatment were easily reproducible in 9 French centers, working in a prospective cooperative study; Results similar to those of the original study were achieved in Stages I and IIA (MDAH substaging) with a locoregional failure rate of 7%; In Stage IIB, the locoregional failure rate of 16% is also comparable in both studies; Locoregional failures in Stage III are slightly lower than those reported in Houston, probably reflecting differences in patient's prognostic factors in France and Texas; The 5-year survival rate obtained in advanced Stages (UICC FIGO staging) are among the highest in the literature (76% in Stage IIb, 62% in Stage IIIa and 50% in Stage IIIb); The rate of severe complications remains acceptable and decreased throughout the study thanks to a better use of computer dosimetry.

Results of radiotherapy alone in 581 patients with Stage II carcinoma of the uterine cervix.

From January 1976 to December 1978, 581 previously untreated patients with Stage II carcinoma of the uterine cervix were treated by radiotherapy alone in nine departments of radiotherapy in France. This retrospective analysis was undertaken in an attempt to evaluate the therapeutic results and prognostically significant factors. The initial clinical staging and the therapeutic guidelines were as outlined at the U.T. M. D. Anderson Hospital in Houston; all our patients were treated by standardized protocols combining external beam irradiation and intracavitary irradiation with cesium sources. The overall locoregional control rate was 83.2%, with total disease control of 74.5%. Uncorrected actuarial survival rates are 76% at 3 years and 68% at 5 years. The incidence of severe posttherapeutic complications is 7.2%. Clinical substaging, patient's age at the time of the diagnosis, lymphangiogram findings, and tolerance to external irradiation were all found to have prognostic significance. According to those findings, the possibilities of improving the results are discussed.

Systemic vasomotor interaction between nicardipine and hypocapnic alkalosis in man.

The effects of hypocapnic alkalosis on the vasodilating action of nicardipine were studied in 6 patients after cerebral arterial aneurysm surgery. Each patient served as his/her own control during the 6 steps of the study. T0: baseline; T1: hypocapnic alkalosis alone (PaCO2: 3.5 kPa); T2: hypocapnic alkalosis and bolus injection of nicardipine (30 micrograms.kg-1 i.v.); T3: hypocapnic alkalosis and continuous 60 min infusion of nicardipine (0.5 microgram.kg-1.min-1), T4: determination of the infusion rate required to neutralize the effect of hypocapnic alkalosis; T5: same continuous dose of nicardipine as in T4 but reversal of hypocapnic alkalosis. Hypocapnic alkalosis alone caused a significant increase in the systemic vascular resistance index by 20% (T1). The bolus injection of nicardipine reversed this first effect (T2). The continuous infusion of nicardipine in T3 was insufficient to cancel the haemodynamic effect of hypocapnic alkalosis. During T4 the plasma levels required to neutralize completely the effect of hypocapnic alkalosis were twice those at T3. Normalization of the PaCO2 in step T5 induced a significant fall in the systemic vascular resistance index by 27.5% as compared with T0. In this study hypocapnic alkalosis modified the relationship between plasma levels of nicardipine and its expected vasoactive effects. This interaction was reversible.

Nosocomial pneumonia in mechanically ventilated patients, a prospective randomised evaluation of the Stericath closed suctioning system.

OBJECTIVE: To compare the ventilator-associated pneumonia (VAP) incidence rates in mechanically ventilated patients according to the type of endotracheal suctioning (closed versus open). SETTING: The Neurosurgery Intensive Care Unit of the Grenoble University Hospital, France. DESIGN: A prospective randomised study performed after a 6-month period of nursing personnel training. PATIENTS: One hundred four consecutive patients needing mechanical ventilation for more than 48 h were randomised into two groups. To be eligible, patients had to have no active infection or respiratory affection in their passes. In the Stericath group (S+, n = 54), patients were not disconnected from the ventilator during suctioning. The others were routinely managed (S-, n = 50). In both groups patterns of frequency and duration of suctioning were performed according to a standardised protocol. MEASUREMENTS: The non-adjusted incidence rate of VAP was lower for S+ than for S- (7.32 versus 15.89 per 1000 patient-days, p = 0.07). Multivariate analysis performed using the Cox model showed an adjusted risk of VAP 3.5 times higher in S- (95% CI: 11.00-12.33). The risk being 4.3 higher in patients receiving gastric acid secretion inhibitors (1.08-16.82). In non-censored cases (n = 76) length of ICU stay increased by an average of 16.8 days when VAP was present (p = 0.0008). No adverse effect due to Stericath use was noted and volume of tracheal aspirate was similar between groups (p = 0.178). CONCLUSION: The use of Stericath reduced the incidence rate of VAP without demonstrating any adverse effect.

Severe head injuries: an outcome prediction and survival analysis.

OBJECTIVE: To identify the predictors determined early after admission and associated with unfavorable outcome or early (within 48 h) death after severe head injury. DESIGN: Prospective cohort study. SETTING: A neurosurgical intensive care unit in a university hospital. PATIENTS: 198 consecutive comatose patients hospitalized from 1989 to 1992. RESULTS: Logistic regression showed that a combination of age, best motor response score from the Glasgow Coma Scale, and hypoxia provided a good prediction model of unfavorable outcome (sensitivity = 0.93). The length of participation of survivors was 6 to 61 months (median 27.1). The Cox model demonstrated age, motor score less than 3, mydriasis, and hypoxia as poor prognosis factors. CONCLUSIONS: Clinicians can determine the odds of a good outcome from the combination of three easily measurable factors using a simple diagram constructed from logistic regression. Survival analysis showed that motor score adjusted values greater than 3 had the same prognosis.

Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey.

OBJECTIVE: To observe the nosocomial infection (NI) distribution in ventilated patients of a single intensive care unit (ICU) according to the kind of control of the upper airways: noninvasive positive pressure ventilation (NPPV) versus endotracheal intubation (ETI). SETTING: ICU of a general hospital. DESIGN: Prospective clinical and epidemiologic survey. PATIENTS: In the period December 1994-March 1997, 761 patients were included who needed mechanical ventilation for more than 48 h: 129 were ventilated by NPPV (NPPV group), 607 were intubated (ETI group) and 25 required intubation after a period of NPPV (NPPV-ETI group). MEASUREMENTS AND RESULTS: The data used were prospectively collected according to the NI epidemiologic surveillance protocol of "C. CLIN Sud Est, Réa Sud Est", France. NI included a ventilator-associated pneumonia (VAP), catheter-related infection, urinary tract infection and bacteremia. Occurrence of NI was estimated by the density of incidence. Covariate-adjusted NI and VAP risk factors were assessed by the Cox model. The incidence density of total NI was lower for NPPV than for ETI (14.2 versus 30.3 per 1000 patient-days, p < 0.01). The Cox model showed that the use of noninvasive ventilation, adjusted to the severity of illness (SAPS II), reduced not only the VAP risk (hazard ratio (HR) = 4.07) but also the NI risk (HR = 1.95). CONCLUSION: The use of NPPV reduces the risk of VAP and NI, compared to ETI, irrespective of the severity of the patient's illness.

Pharmacokinetics of teniposide (VM 26) after IV administration in serum and malignant ascites of patients with ovarian carcinoma.

Nine patients with ovarian carcinoma and malignant ascites treated with IV teniposide chemotherapy (30 mg/m2/30 min) entered this study. Plasma and peritoneal fluid levels were measured by an HPLC method with electrochemical detection. Plasma decay kinetics followed a triexponential function. A high variability of drug diffusion in ascites was noticed. Peak concentrations in ascites ranged from 1.6% to 20.5% of serum peak concentration. The concentration in peritoneal fluid reached a maximum level 6 h after the infusion ended. Teniposide was less slowly eliminated from ascites than from serum. The exposure of the inflammatory peritoneal fluid to the drug expressed by area under the concentration-time curve (AUC) was also subject to significant interindividual variation, ranging from 223 to 2332 micrograms/ml X min. However, the peritoneal AUC was correlated with serum AUC and with the systemic clearance of the drug. A significant relationship between gamma glutamyltranspeptidase and both systemic clearance and either the serum or the peritoneal AUC was found, suggesting that liver plays a role in drug disposition.

Regulation of p42/p44 mitogen-activated protein kinase by the human adenosine A3 receptor in transfected CHO cells.

In this study we have investigated whether the human adenosine A3 receptor activates p42/p44 mitogen-activated protein kinase (MAPK) in transfected Chinese hamster ovary (CHO) cells (designated CHO-A3). The high affinity adenosine A3 receptor agonist IB-MECA (1-deoxy-1-[6-[[(3-iodophenyl)methyl]amino]-9H-purin-9-yl]-N-methyl-beta-D-ribofuranuronamide) stimulated time (peak activation occurring after 5 min) and concentration-dependent (pEC50=9.0+/-0.2) increases in p42/p44 MAPK in CHO-A3 cells. Adenosine A3 receptor-mediated increases in p42/p44 MAPK were sensitive to pertussis toxin and the MAPK kinase 1 inhibitor PD 98059 (2'-amino-3'-methoxyflavone). The broad range protein tyrosine kinase inhibitor genistein and the phosphatidylinositol 3-kinase inhibitors wortmannin and LY 294002 (2-(4-morpholinyl)-8-phenyl-4H-1-benzopyran-4-one) also blocked adenosine A3 receptor stimulation of p42/p44 MAPK. In contrast, inhibition of protein kinase C had no significant effect on adenosine A3 receptor-induced p42/p44 MAPK activation. IB-MECA (pEC50=10.1+/-0.2) also increased the expression of luciferase in CHO-A3 cells transiently transfected with a luciferase reporter gene containing the c-fos promoter. Furthermore, IB-MECA-induced increases in luciferase gene expression were sensitive to pertussis toxin, PD 98059, genistein, wortmannin and LY 294002. In conclusion, we have shown that the human adenosine A3 receptor stimulates p42/p44 MAPK and c-fos-mediated luciferase gene expression in transfected CHO cells.

Inhibition of NF-kappaB-mediated gene transcription by the human A2B adenosine receptor in Chinese hamster ovary cells.

NF-kappaB is a transcription factor that plays a vital role in regulating inducible gene expression in immune and inflammatory responses. In view of the well documented effects of adenosine on immune and inflammatory responses, we have explored whether adenosine A1, A2B and A3 receptors regulate NF-kappaB activity in transfected Chinese hamster ovary (CHO) cells using a luciferase reporter gene construct. No increases in NF-kappaB activity were observed in CHO-A1, -A2B and -A3 cells stimulated with the non-selective adenosine receptor agonist 5'-N-ethylcarboxamidoadenosine. Elevating intracellular cyclic AMP (cAMP) levels using forskolin (direct activator of adenylyl cyclase) and rolipram (type IV, cAMP-specific phosphodiesterase inhibitor), inhibited NF-kappaB activity in CHO cells. Adenosine A2B receptor stimulation also inhibited NF-kappaB activity, whereas adenosine A1 and A3 receptor activation had no effect. These data reflect the known coupling of adenosine A2B receptors to increases in cAMP. In conclusion, adenosine A1, A2B and A3 receptors do not directly activate NF-kappaB in CHO cells. However, adenosine A2B receptor activation significantly inhibited NF-kappaB activity. Inhibition of NF-kappaB activity by the adenosine A2B receptor may contribute to the anti-inflammatory effects of adenosine.

[Radiation therapy for stage IV carcinoma of the cervix (author's transl)]. / Traitement par agents physiques des cancers du col utérin stage IVa.

Fifty four cases of stage IVa carcinoma of the cervix and treated with radiotherapy were collected between 1971 and 1977. Overall actuarial survival was 16 per cent at 3 years and almost all the deaths occurred before that time. Amongst the factors studied, the initial size of the pelvis tumour and lumbo-aortic lymphography findings were the determing factors in the prognosis. To a lesser extent, the age of the patient, tumour differentiation and the amount of irradiation modified the prognosis. It was thus possible to define, within the stage IVa category, several prognostic groups, the determination of which has therapeutic consequences.

[Influence of the diagnosis of Hodgkin's disease on the quality of life of cured patients]. / Poids du diagnostic de maladie de Hodgkin sur la qualité de la vie des sujets qui en sont guéris.

Authors present results of an inquiry dealing with familial and socio-professional reinsertion of 130 patients who have been treated for Hodgkin disease. On a family point of view, after treatment, the rate of single people is higher than in general population. Even though one can observe marriages, and feminine sterility is rare, the number of children by married couple remains low. There is no change in rate of house moving. Most of cured patients return to work. This fact is related to duration of treatment, but variations depend essentially of familial situation, kind to work and quality of previous social insurance. For two groups of people risk of unemployement is higher: agricultural labourers who are often dismissed and contractual civil servants who meet with difficulties to be established. Definitive invalidity is rarely conceded by wearied social organisms. Finally cured patients appear most of the time comparable with healthy population. However they meet with important difficulties to get a loan or to contract a life insurance. Premiums are frequently raised and policies restricted. Difficulties are not related to organic sequelae. Cured patients still remain suspicious for their entourage and employer, that bring them about to hide the pathologic episode.

[Evaluation of the results of radiotherapy in 14 cases of malignant thymoma. Therapeutic prospects]. / Evaluation des résultats de la radiothérapie dans 14 cas de thymomes malins. Prospective thérapeutique

The authors present a critical review of 14 cases of malignant thymomas. They point out that the development of the tumours is similar to Hodgkin disease's (13 relapses in contiguous areas), that surgery is never sufficient for cure and that radiosensitivity is high (in 8 patients radiotherapy alone results in a total and early regression of the tumour). Therefore the authors propose a complementary post-operative treatment by limited irradiation and MOPP type polychemotherapy. This temporary choice of treatment can be reevaluated after further case studies. To facilitate this they wish that a cooperative project could gather the rare and dispersed observations of different centers.

[Thyroid trabecular carcinoma. A clinicopathological entity of poor prognosis? (author's transl)]. / L'epithélioma trabéculaire du corps thyroïde. Une entité anatomoclinique à pronostic défavorable?

The records of 32 patients with trabecular carcinomas of the thyroid gland were critically reviewed from a previously published serie of 138 thyroid cancers referred to the Centre Claudius Regaud, between 1952 and 1973. On the basis of clinico-pathological considerations, it seems possible to divide trabecular carcinomas into two groups. Pure trabecular carcinomas (moderately differenciated follicular carcinomas--WOH) which have a poor prognosis (5 years actuarial survival: 13%) related to high rate of local recurrences, fast metastatic spread to the lung, bad response to suppressive hormonotherapy and lack of 131 iode uptake by malignant tissue. Mixed trabeculo-vesicular carcinomas which have in comparison a fairly good prognosis (5 years actuarial survival: 63%) in keeping with a lower tendency to local recurrences and a useful concentration of radioactive iodine by metastases (most of them located in the skeleton) although dependent on the pourcentage of vesicles in the tumor process. Among differentiated thyroid carcinomas, distinction between pure trabecular and mixed trabeculo-vesicular carcinomas with quantitative determination of vesicules seems of great interest in relation to the therapeutic approach.

[Dysgerminoma of the ovary: a study of 13 cases (author's transl)]. / Séminomes purs de l'ovaire. Etude clinique et thérapeutique. A propos de 13 cas vus au Centre Claudius Regaud.

Thirteen cases of primary ovarian seminoma have been referred to the Claudius Regaud Cancer Center during the last 2 decades, patients' ages ranging form 10 to 41 years with a peak in the 20's. Two patients were treated by surgery as definitive therapy, the others underwent combined radiation therapy (dose range 25 to 45 Gy) following surgical excision. The 2 patients treated by surgery alone had pelvic recurrences, whereas only 2 local failures appeared in the group treated by surgery and radiotherapy. Ten patients are asymptomatic and clinically free of disease after a mean follow-up of 3.5 years, the mean survival time of the series being 6 years. Because of the generally improved prognosis, surgical oophoropexy is recommended before radiotherapy.

[Cancer of the rectum: preoperative radiotherapy (344 cases)]. / Cancers du rectum: radiothérapie pré-opératoire (344 cas).

Radiation therapy prescribed as an adjuvant to surgery is an effective treatment of many cancers but has not been universally accepted for treatment of rectal cancer. Since 1969, preoperative radiation therapy of rectal carcinoma has been proposed in a curative intent, both at Centre Paul Lamarque in Montpellier and at Centre Claudius Regaud in Toulouse, France. Megavoltage radiotherapy was used in all patients and doses ranges from 35 to 40 Gy during 2.5 to 3 weeks. Among the 344 patients treated between 1969 and 1981, the ratio of abdominoperineal excision to anterior resection was 239/105, the percentage of pelvic recurrence was 7,8 per cent, and the 5-year survival rate, including postoperative mortality (5.2%) was 78 per cent in the Centre Claudius Regaud series and 64 per cent in the Centre Paul Lamarque series. The 10-year survival rate was 50 per cent. There was no evidence of an increased morbidity following irradiation. Pathologic staging showed no residual tumour in the excised specimen in 5.2 per cent of the cases. The number of Dukes'C cases was smaller than according to the clinical pre-treatment assessment of the tumours (16%). Ultrasonography of the liver and plasmatic CEA determination avoid irradiation of metastatic patients. Further development of this curative approach should include a postoperative boost of 25 Gy for patients who are at high risk for local failure in the pelvis, and an adjuvant chemotherapy for Dukes'C patients.

Comparison of nicardipine and sodium nitroprusside in the treatment of hypertension after coronary bypass surgery (a pilot study).

Sodium nitroprusside is widely used in the treatment of hypertension after coronary artery bypass surgery despite its toxicity and its deleterious effect on the coronary circulation. The aim of this study was to compare the safety and effectiveness of nicardipine with sodium nitroprusside in a randomized study. Nicardipine and sodium nitroprusside are effective for controlling hypertension after coronary artery surgery. Oxygen myocardial balance was more often improved by nicardipine than by sodium nitroprusside. Hemodynamic stability was better with nicardipine which was also devoid of toxicity and might therefore have advantages over sodium nitroprusside in the management of hypertension after coronary artery surgery.