Survie à long terme des cancers colorectaux métastatiques sous chimiothérapie par 5-fluoro-uracile

PURPOSE

Median survival in advanced colorectal cancer patients treated with 5-fluoro-uracil (5FU) and leucovorin (LV) is between 12 and 18 months. The aim of this study was to evaluate long term survival in this disease.

METHODS

We report here, retrospectively, the survival of 445 patients who entered in first-line prospective studies with LV-5FU-based regimen chemotherapy, between 1985 and 1995.

RESULTS

Median survival was 18 months. The 3, 5 and 10 year survival were respectively 17.9%, 4.5% and 2.4%. Seventy-five patients survived more than 3 years, among them, 10 achieved a complete and 34 a partial response, 12 had curative liver or lung surgery. Fifteen patients lived more than 5 years, 2 achieved a complete and 7 a partial response. Seven had curative surgery. Eleven patients were still alive in 2002, among them 7 in complete remission at 5 years, including 3 who did not have surgery.

CONCLUSION

This study shows that some patients with metastatic colorectal cancer can achieve long survival, especially when secondary curative surgery can be performed. However, 1% of the patients can be cured with LV-5FU chemotherapy alone. These results will be probably improve with the use of the new drugs: oxaliplatin and irinotecan.

Vibration induced nystagmus in normal subjects and in patients with dizziness. A videonystagmography study

OBJECTIVE

To analyze the incidence and characteristics of vibration-induced nystagmus in normal subjects and in patients with vertigo.

STUDY DESIGN AND SETTING

This is a prospective analysis of the effect of vibration on several points of the skull in 38 normal subjects, 10 patients who had undergone labyrinthectomy and 125 consecutive patients with dizziness referred to a tertiary care center. Nystagmus was documented and its corresponding slow phase velocity measured with a videonystagmography system.

RESULTS

In 81.6% of normal subjects and 80.8% of all patients, nystagmus could be provoked by stimulation of at least one of the points on the skull to which the vibrator was applied. In normals, however, no subject had nystagmus greater than 2.8 degrees s-1 whereas 35.2% of patients did.

CONCLUSION/SIGNIFICANCE

The value of the slow-phase velocity of vibration-induced nystagmus can be used to identify a sizeable proportion of patients with a vestibular disorders. Vibration-induced nystagmus is a frequent sign in patients with dizziness and can provide complimentary information about vestibular system function.

The auditory C-process of spectral profile analysis

OBJECTIVES

We here review the findings of several experiments, aimed at clarifying the functional role of the human auditory cortex in the processing of complex sound mixtures.

METHODS

Long-latency auditory evoked potentials were recorded to abrupt changes in the pitch or timbre of continuous complex tones (synthesized musical instrument sounds). Changes were made at intervals of 0.5-4.5 s while the subjects read a magazine.

RESULTS

The main response was a P1/N1/P2 complex which was maximal at the vertex and symmetrically distributed, consistent with origin in the supratemporal cortices of both hemispheres. To distinguish them from the conventional responses to brief pure tones, the potentials were named CP1 (c. 55 ms), CN1 (90 ms) and CP2 (165 ms). Responses to changes of pitch, where all the spectral components changed frequency, and to changes of timbre, where the frequencies remained the same but their energy levels changed, were very similar to one another. The response amplitudes were little affected by the magnitude of frequency changes in the range 6-100%, but were strongly influenced by the rate at which changes occurred (requiring at least 4 s for full recovery) and by the breadth of the changing frequency spectrum (the upper partials of the tone in sum contributing more than the fundamental). When the C-potentials were made refractory by a high rate of pitch changes (16/s) within a narrow frequency range, responses could still be elicited by infrequently interspersed changes of timbre. When the tones were split into their high and low partials, the responses to change in the two frequency bands combined roughly algebraically.

CONCLUSIONS

The responses appear to represent a cortical process concerned with analysing the distribution of sound energy across the frequency spectrum ('spectral profile analysis'). This may be an important stage in the analysis of complex sound mixtures and in the perception of sound quality.

Mismatch negativity to single and multiple pitch-deviant tones in regular and pseudo-random complex tone sequences

OBJECTIVES

To determine whether the process responsible for the mismatch negativity (MMN) might be involved in the analysis of temporal sound patterns for information.

METHODS

Synthesized musical instrument tones of 'clarinet' timbre were delivered in a continuous sequence at 16 tones/s, such that there was virtually no N1 potential to each individual tone. The standard sequence comprised 4 or 5 adjacent notes of the diatonic scale, presented either as a regularly repeated, rising pattern or pseudo-randomly. The deviant stimuli were 1-5 consecutive tones of higher pitch than the standards.

RESULTS

A MMN was evoked by a single deviant tone, 1 or 5 semitones above the pitch range of the standards. The response to the 5-semitone deviant was significantly larger (mean of 7.3 microV) when the standard pattern was regular as compared with pseudo-random. The MMN latency, on the other hand, was only influenced by the magnitude of pitch deviation. A second MMN was evoked by a second deviant tone, immediately (SOA 62.5 ms) following the first. Further consecutive MMNs were not consistently evoked.

CONCLUSIONS

The large amplitude of these MMNs can be attributed to the use of complex tones, continuous presentation and a rapid rate of pitch changes, such that no waveform subtraction was required. Over and above the probability with which each individual tone occurs in the standard sequence, the mismatch process is influenced by its temporal structure, i.e. can be regarded as a temporal pattern analyzer. Contrary to the findings of some other groups, we found that two consecutive deviants can evoke an MMN, even at high rates of presentation such that both occur within the postulated 'temporal window of integration' of ca. 170 ms. These findings suggest that the mismatch process might be involved in the extraction of sequential information from repetitive and non-repetitive sound patterns.

Factor analysis and correlation between Dizziness Handicap Inventory and Dizziness Characteristics and Impact on Quality of Life scales

In order to assess the different dimensions of disability and handicap analyzed in the Dizziness Handicap Inventory (DHI) and Dizziness Characteristics and Impact on Quality of Life (UCLA-DQ) questionnaires a factor analysis study was done. The instruments used were the corresponding transculturally adapted versions of the originals into Spanish. The study included 337 patients with dizziness, independent of location and etiology, who were able to respond to all the items in the questionnaires given before vestibular testing. Factor analysis was used to determine the structure of both scales; a principal components analysis with orthogonal rotation (Varimax) was conducted on data collected from the patients. A three-factor solution was obtained in the DHI and a two-factor solution for the UCLA-DQ. The factors obtained from the DHI were related to vestibular handicap, vestibular disability and visuo-vestibular disability; the factors from the UCLA-DQ were related to frequency and severity of dizziness. There was no coincidence between the items in each of the factor obtained in the DHI questionnaire and the items in the subscales provided in the original version. The main relation between factors was found between vestibular handicap and frequency. The DHI and UCLA-DQ questionnaires are multidimensional questionnaires for the assessment of the impact of dizziness and provide a model for vestibular disability and handicap.

Can laparoscopy reduce hospital stay in the treatment of Crohn's disease?

PURPOSE

The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery.

METHODS

Among 51 consecutive patients with inflammatory bowel disease (1996-2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures).

RESULTS

There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes) vs. the open group (244.7 minutes) (P < 0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutes vs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic group vs. the open group in terms of passage of flatus (3.7 vs. 4.7 days) (P < 0.05) and resumption of oral intake (4.2 vs. 6.3 day) (P < 0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent) vs. the open group (18.5 percent) (P < 0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days) vs. the open group (13.2 days) (P < 0.01); and the cost of hospital admission was significantly lower in the laparoscopic group ($6106, United States dollars) vs. the open group ($9829, United States dollars) (P < 0.05).

CONCLUSION

There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohn's disease is safe, and it is potentially more cost-effective than traditional open surgery.

Influence of canal paresis and compensation on gain and time constant of nystagmus slow-phase velocity to yaw-axis rotation

In order to assess the influence of canal paresis and compensation on the yaw-axis rotatory chair test parameters gain and time constant, a study was conducted in 435 patients diagnosed with unilateral peripheral vestibulopathy. Patients were grouped according to the amount of canal paresis found in the caloric test and by the result of a bedside examination of the vestibulo-ocular reflex (VOR). The time constant of the VOR diminishes as canal paresis increases and, when using a high-velocity sinusoidal test, there is a similar reduction in gain. Mean time constant was reduced when rotations were to the side of the lesion (ipsilesional) and to the normal (contralesional) and differences between both rotations were found for 21-80%, canal paresis. Ipsilesional gain was significantly less than contralesional gain, which had a normal result independent of the amount of canal paresis; differences between them were significant when canal paresis was > 41%. Spontaneous nystagmus significantly influenced the appearance of asymmetries in gain and time constant in the tests performed while, with high-velocity sinusoidal rotation, gain was found to be significantly different for ipsilesional and contralesional rotations in non-acute symptomatic patients.

Cancer metastatic to the orbit: the 2000 Robert M. Curts Lecture

PURPOSE

To report the demographics and clinical features of a large series of patients with orbital metastasis.

METHODS

Retrospective chart review on 100 consecutive patients and a literature review on orbital metastasis.

RESULTS

Of 100 patients, the primary tumor site was breast in 53 (53%), prostate gland in 12 (12%), lung in 8 (8%), skin (melanoma) in 6 (6%), kidney in 5 (5%), gastrointestinal tract in 5 (5%), choroid (melanoma) in 2 (2%), parotid gland in 1 (1%), and adrenal gland (neuroblastoma) in 1 (1%). Of patients in whom a detailed history was available, there was no history of cancer at the time of presentation in 19%. In 10%, the primary tumor remained undetected despite systemic evaluation. There were 36 male patients and 64 female patients whose mean age at diagnosis was 62 years (median 60 years, range 5 to 91 years). Both the right and left orbits were affected equally, and 4 cases (4%) were bilateral. The most frequent clinical findings were limited ocular motility (54%), proptosis (50%), and palpable mass (43%). The diagnoses were established by history, systemic survey, imaging studies, and biopsy. Treatment included chemotherapy, hormone therapy, irradiation, surgical excision, or observation, depending on clinical circumstances. Among patients with sufficient follow-up, 95% died of metastasis, with overall mean survival of 15 months (median 15 months; range 3 to 96 months) after orbital diagnosis.

CONCLUSIONS

The most common primary cancers that metastasize to the orbit are breast, prostate gland, and lung cancer. In 19%, there is no history of cancer when the patient presents with ophthalmic symptoms and in 10% the primary site remains obscure despite systemic evaluation. The systemic prognosis is generally poor.

The auditory ‘C-process’: analyzing the spectral envelope of complex sounds

OBJECTIVE

To examine the hypothesis that auditory evoked potentials (AEPs) to pitch and timbre change of complex harmonic tones reflect a process of spectral envelope analysis.

METHODS

AEPs were recorded to: (1) continuous tones of 'clarinet' timbre whose pitch abruptly rose or fell by 1 or 7 semitones every 0.5 or 1.5 s; (2) a cycle of 6 pitches changing every 0.5 s; (3) tones of constant pitch whose timbre (spectral envelope shape) changed periodically; (4) pitch change of high- and low-pass filtered 'clarinet' tones.

RESULTS

The amplitudes of the 'change-N1' (CN1) potential peaking at ca. 90 ms and the following CP2 were influenced to a far greater degree by the time interval between changes, than by the magnitude of the change or by the time interval between occurrences of the same pitch. Amplitudes were also strongly dependent on the number of partials present, irrespective of whether they were increasing or decreasing in energy. The algebraic sum of the responses to pitch change of high- and low-pass filtered tones closely approximated the response to the unfiltered tone.

CONCLUSION

The rate-sensitivity of the responses cannot be explained by the refractoriness of frequency-specific 'feature detector' neurones, but rather of a process (termed 'C-process') which analyzes amplitude modulations across the spectral envelope, the contribution of different frequency bands combining linearly in the scalp-recorded activity. On-going computation of the spectral envelope shape may be an important factor in maintaining the perceptual constancy of timbre.

[Medullary extradural hematoma revealing a coarctation of the aorta]

The authors report a spontaneous, unusual complication of coarctation of the aorta. An 11 year old child was admitted for investigation of chest pain. Cardiovascular examination revealed typical clinical signs of coarctation of the aorta. Neurological examination found neck stiffness without headache or deficit. The presumptive diagnosis of dissection of the aorta was infirmed by echocardiography and MRI. The latter investigation, with views of the spinal cord, revealed a compressive medullary extradural haematoma. Antihypertensive therapy and corticosteroids with strict bed rest resulted in complete regression of the haematoma and the coarctation was operated 6 months later. Medullary complications of coarctation of the aorta are usually postoperative. Spontaneous complications are exceedingly rare but very serious: medullary compression by the dilated anterior spinal artery or rupture of an aneurysmal collateral vessel. In this case, magnetic resonance imaging led to diagnosis and effective early treatment of this complication before the patient developed a neurological deficit and the coarctation was treated surgically thereafter.

Mechanical thrombectomy in patients with deep venous thrombosis

PURPOSE

To report our experience with mechanical thrombectomy in proximal deep vein thrombosis (DVT).

METHODS

Eighteen patients with a mean (+/- SD) age of 37.6 +/- 16.1 years who presented with DVT in the iliac and femoral vein (n = 3), inferior vena cava (n = 5), or inferior vena cava and iliac vein (n = 10), were treated with the Amplatz Thrombectomy Device after insertion of a temporary caval filter.

RESULTS

Successful recanalization was achieved in 15 of 18 patients (83%). Overall, the percentage of thrombus removed was 66 +/- 29%: 73 +/- 30% at caval level and 55 +/- 36% at iliofemoral level. Complementary interventions (seven patients) were balloon angioplasty (n = 2), angioplasty and stenting (n = 2), thrombo-aspiration alone (n = 1), thrombo-aspiration, balloon angioplasty, and permanent filter (n = 1), and permanent filter alone (n = 1). There was one in-hospital death. Follow-up was obtained at a mean of 29.6 months; three patients had died (two cancers, one myocardial infarction); 10 had no or minimal sequelae; one had post-phlebitic limb.

CONCLUSION

Mechanical thrombectomy is a potential therapeutic option in patients presenting with proximal DVT.

Prenatal diagnosis of solid placental masses: the value of color flow imaging

OBJECTIVES

To determine the value of color flow imaging in the prenatal differentiation of solid placental masses protruding from the fetal surface of the placenta.

METHODS

Seven pregnancies in which a large solid mass was seen on the fetal surface of the placenta were prospectively studied. Color flow imaging was used to identify vessels within the mass and the prenatal ultrasound finding correlated with placental pathology.

RESULTS

Postpartum examination of the placenta revealed four cases of chorioangioma, two cases of subchorionic thrombohematoma and one case of subamniotic hematoma. Prenatal ultrasound using color flow imaging correctly identified all cases of placental chorioangioma by the demonstration of blood flow within the mass. Conversely, absence of blood flow signals was invariably documented in both cases of subchorionic thrombohematoma and in the single case of subamniotic hematoma. Among the four cases of chorioangioma, two developed complications requiring delivery. No complications were noted in cases of avascular placental masses in this series.

CONCLUSIONS

Color Doppler ultrasound plays an important role in the prenatal evaluation of solid placental masses. This technique allows the identification of those cases at increased risk of pregnancy complications which need close monitoring throughout gestation.

A functional assay in Escherichia coli to detect non-assisted interaction between galactose repressor dimers

Among the Escherichia coli operons repressed from multiple sites on DNA, the galactose operon is unique: its repression requires an auxiliary protein, HU, to assist cooperative repressor binding to two distant DNA sites. Here we show that GalR can still mediate repression from distant sites in an artificial and simplified regulatory region which totally disturbs the organisation of the natural interactions. This simple and unexpected cooperation of a protein incapable of self-association in solution might be involved in regulation of the gal operon. Furthermore, the assay may be generalised to detection of rather weak cooperative interactions between DNA-bound proteins.

[Pituitary gland MRI and Cushing disease: report of 14 operated patients]

PURPOSE

Evaluate the MR sensibility for detection and localisation of ACTH-secreting microadenomas of the pituitary gland.

PATIENTS

and method. The MRI studies of the pituitary gland, performed before transsphenoidal surgical exploration, about 14 patients who present clinical and biological signs of Cushing disease, were reviewed retrospectively. We have always used unenhanced sagittal and coronal spin-echo T1 sequences, and coronal T1 after injection of gadolinium (1 Tesla).

RESULTS

The global sensibility for detection of an adenoma was 100% (84 to 92% when the lesional localisation was considered). The injection of gadolinium increased the sensibility of 38 to 42% according the readers. 7 to 14% of the lesions were isointense after injection. The estimation of lesional size after injection was the nearer to the surgical results. The indirect sign most frequently seen (35.7 to 64.3%) was focal bulging of the sellar diaphragm. The only differences between the different radiologists, statistically significant, concerned the lesional size before injection and location of the lesion in the sagittal plane.

CONCLUSION

This study confirmed the good sensibility of contrast-enhanced MRI in detection of ACTH-secreting microadenomas. The anatomo-radiological correlations are nevertheless incomplete.

Functional MRI in double cortex: functionality of heterotopia

A 12-year-old boy with epilepsy and subcortical laminar heterotopia (band heterotopia) underwent a functional MRI protocol to study voluntary motor activity in the hand. Finger tapping produced an activation of a contralateral limited and focused frontal cortical area both in the subcortical band heterotopia and the overlying cortex. Despite its epileptogenic activity, subcortical laminar heterotopia seems to be responsible for part of the functional activity of the brain. This has to be pointed out for epilepsy surgery resecting cortical dysplasia.

Proposed curriculum for an "observational" international emergency medicine fellowship program

This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

Experimental study following inactive implantation of an auditory brain stem implant in nonhuman primates

We report changes in the cochlear nuclei (CNs) after 3 months of bilateral auditory deafferentation and simultaneous unilateral implantation of a dummy auditory brain stem implant (ABI) in 6 nonhuman primates (Macaca fascicularis). These specimens were compared to CNs of 9 controls and 7 bilaterally deafferented animals without implantation. The ABI array consists of 3 platinum electrodes mounted on a silicone pad with the back side covered with Dacron. No migration of the ABI was observed. All deafferented animals showed astrocytic reorganization in the CNs. Histologic changes consisted of superficial reactions around the implant, with formation of fibrillar bundles of fusiform cells, and the presence of giant cells close to the Dacron. Other findings were related to surgical trauma. The dummy ABI did not itself provoke serious adverse reactions in the CNs. Our observations support the possibility of ABI reimplantation surgery.

Atlanto-occipital dislocation: an unusual lethal airbag injury

Airbag-induced injury fatality is increasing in frequency. We present the case of a 6-year-old passenger who sustained a fatal atlanto-occipital dislocation associated with airbag deployment in a low-speed motor vehicle crash. The current literature regarding airbag fatalities and methods to ameliorate airbag-induced injury are reviewed.

Spiral CT quantification of aorto-renal calcification and its use in the detection of atheromatous renal artery stenosis: A study in 42 patients

PURPOSE

To investigate whether a correlation exists between aortic and renal arterial calcifications detected with spiral CT and significant angiographic renal artery stenosis (RAS).

METHODS

Forty-two patients (mean age 67 years, range 37-84 years), of whom 24 were hypertensive, prospectively underwent abdominal helical CT and aortic and renal arteriography. The 3-mm thickness CT scans (pitch = 1) were reconstructed each millimeter. A manual outline of the renal artery including its ostial portion was produced. Calcific hyperdensities were defined as areas of density more than 130 HU. CT data were compared with the presence or absence of RAS on angiography (24 cases); hypertension and age were taken into account (Mann-Whitney U-test).

RESULTS

CT detection and quantification appeared to be reliable and reproducible. We did not find any correlation between aortic and renal arterial calcifications and RAS, even for the patients above 65 years, with or without hypertension. There was no correlation either between calcifications and hypertension in patients without RAS.

CONCLUSION

In this population, aortic and renal arterial calcifications have no predictive value for RAS.