[Laparoscopy in the management of endometrial cancer]

Recent advance in laparoscopy have changed the surgical approach of endometrial cancer patients. The Swissendos Center, Fribourg, in collaboration with AGO (Groupe de travail pour la gynécologie oncologique) and AGE (groupe de travail pour la gynécologie endoscopique) have established a consensus based on the available evidence for the use of laparoscopy in the management of patients with endometrial cancer The main objective was to define Swiss clinical practice guidelines appropriate to the country and consistent with the needs of the physicians.

Hypothermia in VGKC antibody-associated limbic encephalitis

Voltage-gated potassium channel antibody (VGKC-Ab)-associated limbic encephalitis (LE) is a recently described syndrome that broadens the spectrum of immunotherapy-responsive central nervous system disorders. Limbic encephalitis is typically characterised by a sub-acute onset of disorientation, amnesia and seizures, but the clinical spectrum is not yet fully defined and the syndrome could be under-diagnosed. We here describe the clinical profile of four patients with VGKC-Ab-associated LE who had intermittent, episodic hypothermia. One of the patients also described a prodrome of severe neuropathic pain preceding the development of limbic symptoms. Both of these novel symptoms responded well to immunosuppressive therapy, with concurrent amelioration of amnesia/seizures.

Epidemiological studies of leukaemia in children and young adults around nuclear facilities: a critical review

The existence of an increased risk of childhood leukaemia near nuclear installations is a recurrent issue. A review of the related epidemiological literature is presented here. Results for 198 nuclear sites throughout 10 countries were included in the review. In addition to local studies, 25 multi-site studies have been published for eight countries. A large variability was noticed in the quality of the data as well as in the definition of the study population and in the methods of analysis. Many studies present important limits that make the results difficult to interpret. The review confirms that some clusters of childhood leukaemia cases exist locally. However, results based on multi-site studies around nuclear installations do not indicate an increased risk globally. Many studies were launched to investigate possible origins of the observed clusters around specific sites, but up to now, none of the proposed hypotheses have explained them.

Colocutaneous fistula complicating therapeutic mesenteric embolisation

Percutaneous embolotherapy has now assumed an important role in the management of massive colonic haemorrhage. However, this therapeutic option is associated with a significant risk of irreversible segmental colonic ischaemia. We present a case where distal segmental ischaemia led to a colocutaneous fistula, a complication not reported so far in the literature.

Totally extra-peritoneal repair of inguinal hernia by a glove-balloon: Technical innovation

Totally extra-peritoneal (TEP) laparoscopic repair of an inguinalhernia involves the creation of an extra-peritoneal space by blunt dissection or the use of commercial balloons. This new technique demonstrates the use of a device to create this extra-peritoneal space, without the need for any commercial balloons. The extra-peritoneal space was created using a glove-balloon. A total of 107 consecutive TEP repairs were carried out using the glove-balloon technique, these included ten bilateral and 17 recurrent inguinal hernias. This method is simple, cost-effective and easy to teach.

CMV colitis presenting as acute abdomen requires early diagnosis and treatment to avoid mortality

OBJECTIVE

Acute CMV-colitis is an unusual cause of emergency colectomy in a general surgical department. The aim of this article is to report our experience on CMV colitis as a cause of acute abdomen.

METHODS

Five patients were referred to general surgery during a three-year period with acute abdomen due to gastrointestinal CMV disease. All patients underwent serology for CMV except case 5. In all patients a gastroscopy or colonoscopy or both, based on individual clinical symptoms, was performed. Abdominal CT scan was requested in patients 1 and 2. Antiviral therapy was instituted in all patients. One patient (case 5) underwent surgery without prior diagnosis of CMV.

RESULTS

There were four men and a woman with a median age of 56 years. Abdominal CT revealed perforation in one patient, later confirmed at laparotomy. Four patients had a positive CMV diagnosis either on serology or tissue biopsy or both. Three patients were treated surgically of whom two died of multiorgan failure.

CONCLUSIONS

CMV may behave in the intestine as a non-pathogenic bystander. However, any condition that compromises the immune status may be sufficient to trigger its virulence. Severe colitis commits clinicians to start or increase immunosuppression regimens, whereas in gastrointestinal CMV disease such an approach inevitably aggravates the clinical picture. Tissue biopsy remains the gold standard test in CMV colitis. However, a positive diagnosis by 'any means' should prompt early antiviral treatment. Surgery should be limited to acute complications of CMV colitis and to unresponsive disease.

New insight into solvent-related end-stage renal disease: occupations, products and types of solvents at risk

OBJECTIVES

It has been shown that all-solvent exposure is associated with the progression of primary glomerulonephritis to end-stage renal disease (ESRD), but little is known about the type of solvents that are high risk. The aim of this study was to investigate the role of solvents by occupation, product and type.

METHODS

Using a retrospective cohort design, the authors studied 269 patients with non-end-stage and biopsy-proven primary glomerulonephritis diagnosed between 1994 and 2001 in Paris and its suburbs. Two industrial hygienists evaluated patients' exposures from lifetime occupational histories collected by interview from 2002-4, and using a list of the 30 most common solvents. The studied outcome was ESRD, defined as glomerular filtration rate <15 ml/mn/1.73 m(2) or dialysis. It was recorded during a mean follow-up of five years. Cox models were used to estimate adjusted hazard ratios (HR) of ESRD related to exposures.

RESULTS

Eighteen per cent of the patients had ever been exposed to solvents. Those with the highest risk of progression to ESRD were exposed machinery fitters and machine assemblers (HR 4.7, 95% CI 1.2 to 17.4) and plumbers/welders (HR 4.2, 95% CI 1.3 to 13.6), as compared to never exposed patients, as well as those who ever handled printing inks and petroleum products (HR 12.6 (95% CI 1.7 to 94.9) and 3.2 (95% CI 1.4 to 7.2), respectively). Among solvents, the highest risks were found for: toluene/xylene (HR 5.1, 95% CI 1.8 to 14.8), gasoline, fuel and gas-oil (HR 8.6, 95% CI 2.7 to 27.4), and ketones (HR 13.3, 95% CI 1.4 to 123.5).

CONCLUSION

This study highlights the potential nephrotoxicity of several solvents. Intervention to promote screening for proteinuria in exposed workers may prevent the progression of glomerulonephritis to ESRD.

[Placenta praevia totalis et increta. Cause of life-threatening haemorrhaging during a caesarean section]

Placenta increta is a rare but potentially life-threatening risk constellation after a previous caesarean section. We present the case of a 29-year-old gravida 2 para 1 patient, who developed dramatic haemorrhaging caused by this abnormal placentation, which could only be resolved by a postpartal hysterectomy. This demonstrates that in the case of a combination of the two most common predisposing factors, repeat caesarean section and placenta praevia, the possibility of a placenta increta should be considered and suitable precautions should be taken.

Evidenzbasierte Medizin

Founded on evidence based medicine (EBM), medical decisions should involve the best possible external scientific evidence as well as the expertise of the individual physician, while taking into consideration the subjective perspective of the patient. The Institute for Quality and Cost Effectiveness (Institut für Qualität und Wirtschaftlichkeit, IQWIG), which is financed through membership contributions to the statutory health insurance, deviates drastically in its evaluations for innovative medications from this concept. All publications on a medication are reduced to only a few "relevant" studies so that the statistics from the resulting meta-analysis are invalid. The resulting method dependent lack of statistical significance is considered by IQWIG authors to show the non-superiority of the test products, which are then speculatively discredited in terms of their safety. The "recommendations" of the IQWIG are accepted uncritically by the cost carriers. The aim of this article is to evaluate IQWIG-EBM in comparison with international standards on the basis of published IQWIG reports on metabolically active medications. The example of the reports on statins, short-term insulin analogues and inhaled insulin shows a methodology which suggests the misuse of study results and can best be characterized by the term "evidently biased medicine."

Frequent alteration of DNA damage signalling and repair pathways in human colorectal cancers with microsatellite instability

Accumulation of frameshift mutations at genes containing coding mononucleotide repeats is thought to be the major molecular mechanism by which mismatch repair-deficient cells accumulate functional alterations. These mutations resulting from microsatellite instability (MSI) can affect genes involved in pathways with a putative oncogenic role, but may also arise in genes without any expected role in MSI carcinogenesis because of the high mutation background of these tumours. We here screened 39 MSI colorectal tumours for the presence of mutations in 25 genes involved in DNA damage signalling and repair pathways. Using a maximum likelihood statistical method, these genes were divided into two different groups that differed significantly in their mutation frequencies, and likely represent mutations that do or do not provide selective pressure during MSI tumour progression. Interestingly, the so-called real-target mutational events were found to be distributed among genes involved in different functional pathways of the DNA metabolism, for example, DNA damage signalling (DNA-PKcs, ATR), double-strand break (DSB) repair (DNA-PKcs, RAD50), mismatch repair (MSH3, MSH6, MBD4) and replication (POLD3). In particular, mutations in MRE11 and/or RAD50 were observed in the vast majority of the tumours and resulted in the concomitant loss of immunohistochemical expression of both proteins. These data might explain why MSI colorectal cancers (CRC) behave differently in response to a wide variety of chemotherapeutic agents, notably those targeting DNA. More generally, they give further insights into how MSI leads to functional changes with synergistic effects in oncogenic pathways.