Symptomatic lower-limb giant-cell arteritis: Characteristics, management and long-term outcome

OBJECTIVE

To describe characteristics and long-term outcomes of the rare symptomatic lower-limb giant-cell arteritis (LL-GCA).

METHODS

Retrospective analysis of 8 patients (6 women; mean±SD age, 63.6±10.9 years; follow-up, 137.3±57.3 months).

RESULTS

Four patients satisfied≥3 American College of Rheumatology (ACR) GCA-classification criteria; 4 had<3 criteria and histological LL-GCA proof or associated typical upper-limb involvement. Patients had 2.1±1.1 vascular risk factors. Bilateral and rapidly progressive arterial claudication was the first LL sign; 2 had rest ischemia. Imaging-visualized most-to-least frequent inflammatory lesion localizations were: superficial femoral, popliteal, tibiofibular trunk, posterior tibial arteries. All received corticosteroids for 132±76.2 months; 2 required immunosuppressive agent adjunction. Only 3 required 1-6 revascularizations: twice during the first month post-diagnosis and twice later. Thromboendarterectomy and endovascular procedures did not work while bypasses were successful. LL-claudication regressed for 7 (10.5±12.1 months) and disappeared for 5 (16.8±9.8 months). Three patients stopped corticosteroids (26-90 months), 1 restarted 45 months later. Every patient relapsed once (23.9±26.7 months, mean corticosteroid dose: 0.28±0.30mg/kg/day). LL-GCA caused only 1 of the 4 deaths.

CONCLUSION

Symptomatic LL-GCA attributable long-term mortality seems to be low despite frequent relapses and corticosteroid-dependence.

[Partial delegation to radiation therapists of the control by cone beam CT of prostate positioning]

PURPOSE

Intensity modulated radiotherapy for prostate cancer involves daily monitoring of the positioning of the prostate, possible with cone beam CT (CBCT). It allows increased accuracy compared to readjustments but induces an increase in the time dedicated to these medical checks. The aim of the study was to evaluate the possibility of delegation of this task to the radiation therapists by comparing their readjustments to the doctors.

PATIENTS AND METHODS

Five consecutive patients treated with radiation for prostate cancer (76Gy) were analysed. All had a daily CBCT for position control. The movements of the prostate relative to the bony part, the positional variations of the prostate measured by the radiation therapists and the doctors and medical time required to analyse imagery (filling of the rectum and bladder and perform a recalibration) were measured.

RESULTS

One hundred seventy-six CBCT were analysed or 980 steps in the three axes. The movements of the prostate relative to bony part were respectively at least 5mm in 19%, 7% and 3% in the anterior-posterior, upper-lower and right-left axes. Changes readjustments between radiation therapists and doctors were in 95% of cases at the most 4mm in the anterior-posterior and upper-lower axis, and 3mm in the left-right axis. The time for medical use of the CBCT averaged 8min 40 [4 to 22min].

CONCLUSION

The daily readjustment on the prostate using CBCT may be delegated to radiation therapists with acceptable concordance of less than 4mm for 95% of measurements. An initial and ongoing training will ensure treatment safety.

Adenomatous hyperplasia of the mucous glands in captive Archey's frogs (Leiopelma archeyi)

AIMS

To describe the gross and light microscopic characteristics of skin lesions observed on the ventral skin of captive Archey's frogs (Leiopelma archeyi) between 2000 and 2012, and to investigate their occurrence, possible aetiology and association with survival.

METHODS

Postmortem skin samples were obtained for histological evaluation from 37 frogs, with and without skin lesions, that died while in captivity at Auckland Zoo between 2000 and 2012. Four frogs with skin lesions were biopsied under general anaesthesia and samples used for both light and transmission electron microscopy. The records of 94 frogs held at the University of Otago and Auckland Zoo between 2000-2012 were reviewed, which included some frogs recently collected from the wild. Information about the occurrence of skin lesions, and mortality associated with skin lesions was collated.

RESULTS

Grossly the skin lesions varied in appearance; most were circular, pale grey papules, which measured from <0.5-1.5 mm in diameter with no umbilication. The overlying epidermis was not fragile and there was no associated inflammation. Contents often appeared clear or semi-transparent. Lesions were located predominantly on ventral surfaces including trunk, thighs, lower legs and forearms, and gular region, but not on digits. The number ranged from single to multiple, often confluent lesions covering the entire ventral surface of the frog. Histologically the lesions consisted of enlarged proliferating mucous glands that expanded the dermis and elevated the epidermis. They were semi-organised, solid or occasionally cavitated acinar structures with central lumina which sometimes contained mucus. Nuclei showed moderate anisokaryosis and mitotic figures were uncommon. Transmission electron microscopy did not show any infectious agents. Between 2000 and 2012, skin lesions were recorded in 35/94 (37%) frogs. The size and location of skin lesions varied over time, with some resolving and sometimes reappearing. Skin lesions were not associated with an increased risk of death.

CONCLUSIONS

The skin lesions had the gross and microscopic characteristics of adenomatous hyperplasia of the dermal mucous glands.

CLINICAL RELEVANCE

The aetiology of this adenomatous hyperplasia is unknown, but factors associated with the captive environment are the most likely cause. This is the first description of adenomatous hyperplasia of the cutaneous mucous glands in amphibians.

Percutaneous absorption of chemicals: developing an understanding for the treatment of disease in frogs

The permeable nature of frog skin presents an alternative route for the delivery of therapeutic chemicals to treat disease in frogs. However, although therapeutic chemicals are often topically applied to the skin of frogs, their pharmacokinetics have rarely been reported. To provide evidence to guide both candidate drug and formulation selection, we highlight factors expected to influence percutaneous absorption through frog skin, including the anatomy and physiology of the skin and the physicochemical properties of applied therapeutic chemicals. Importantly, we also highlight the effects of the formulation on percutaneous absorption, especially the inclusion of potential penetration enhancers as excipients. Finally, we collate empirical data on the topical application of various therapeutic chemicals in postmetamorphic frogs and show that, in contrast to mammalian species, even large chemicals (i.e. >500 Da) and those with a wide range of log P values (-4 through +6) are likely to be absorbed percutaneously. Topical application in frogs thus promises a convenient and effective method for delivering systemic treatments of a diverse range of chemicals; however, further experimental quantification is required to ensure optimal outcomes.

Q fever outbreak among travelers to Germany associated with live cell therapy - United States and Canada, 2014: a co-publication

WHAT IS ALREADY KNOWN ON THIS TOPIC?

Q fever is a zoonotic disease caused by Coxiella burnetii and is usually transmitted through inhalation of air contaminated with animal excreta. The disease is considered to be underdiagnosed because symptoms are nonspecific and can vary from patient to patient, making diagnosis difficult.

WHAT IS ADDED BY THIS REPORT?

During September-October 2014, the New York State Department of Health identified Q fever in five patients with exposure to a treatment known as live cell therapy, an alternative medicine practice involving injections of fetal sheep cells, which is a type of xenotransplantation. Investigation revealed that a group of U.S. residents traveled to Germany twice a year to receive this treatment.

WHAT ARE THE IMPLICATIONS FOR PUBLIC HEALTH PRACTICE?

Clinicians should consider zoonotic diseases, such as Q fever, in patients whose history includes receipt of a treatment known as live cell therapy. International travel for xenotransplantation procedures can facilitate transmission of zoonotic disease.

[Consequences of increasing and ageing population of Basse-Normandie on gynecology and obstetrics activity]

INTRODUCTION

In Basse-Normandie, the population over 65 years old will expend more rapidly between 2007 and 2042 (+11.6%) than the rest of the French population (+9.2%). The same population of Basse-Normandie will get old in the 15 years to come. The impact of these demographic changes over the activity in the gynecology-obstetrics field is not clearly identified. Although we cannot predict the technical and scientific developments in the next 15 years, we are presenting a model allowing to hypothesize about changes of gynecology and obstetrics according to population's aging.

MATERIALS AND METHODS

We have established a projection model for the realizable surgical acts in obstetrics and gynecology in accordance with the aging of the population in Basse-Normandie. The study was realized based on the acts concerning the cesarean sections (C-section), tubal sterilization, hysteroscopy and hysterectomy as well as ovarectomy and breast surgery. For each activity branch, the codes of the Classification commune des actes médicaux (CCAM) were selected and then removed from the Programme médicalisé des systèmes d'information (PMSI) database. We have used and adapted the Omphale model of the National Statistics and Economical Studies Institute and we have applied it for the period of 2009-2025.

RESULTS

Our projection model has permeated to show a 5.5% regression of the C-section acts, a 2% incretion of the hysterectomies and hysteroscopies, 7.7% of ovarectomies as well as a 9.8% augmentation of the breast surgeries. However, we predict a 11.8% diminution of the sterilizations by tubal implants. Globally, the activity in obstetrics and gynecology will remain constant with an insignificant augmentation of 46 acts (0.01%).

CONCLUSION

In Basse-Normandie, the surgical activity in gynecology-obstetrics will moderately increase in the next 15 years. This constant activity signifies that there is no need to form more residents than the number of practitioner to retire. The interest of this model is that it is applicable at a national level and it permits to confront the demographic data and the projections of different activities.

[Gynaecology and obstetrics in Basse-Normandy: demographic perspectives in 15 years]

OBJECTIVES

The French population is growing and ageing. In this context, it is important to consider the future of gynecologists and obstetricians in Basse-Normandie. The aim of this study was to perform an overview of the demographics of practitioners and estimate the retirements. We also try to project the need of trainees for the next years.

MATERIALS AND METHODS

We conducted a demographic and workload survey among 142 practitioners and 35 trainees. We detailed retirements and arrivals of this population.

RESULTS

By 2025, nearly two-thirds of practitioners in 2012 will retire, including 100% of medical gynecologists. Otherwise, there will be a lack of 1 to 2 practitioners per year. We also noted the tendance of feminization (86%) and the wish of a multi-practice in public hospital (86%).

CONCLUSION

A reflection about the health planning will be necessary in order to answer the demographics difficulty in the region. We will have to take into account the future retirements and also the specific situations in each area.