[Sentinel node biopsy in T2 breast cancers larger than 3 cm and clinically negative axilla compared with the T1-T2 <3 cm standard indication]

OBJECTIVE

To present our experience in the application of sentinel node (SN) biopsy in patients with breast cancer T > 3 cm without clinical evidence of axillary metastasis.

MATERIAL AND METHOD

Retrospective study of 393 cases in the period 2001--2006, divided into group (A) 47 patients with 3-5 cm T2N0 tumours and group (B) 346 patients T < 3 cm, N0. We employed the combined technique with 99mTc-colloidal rhenium sulphide and isosulfan blue dye. Preoperative lymphoscintigraphy was performed and the SN was located intraoperatively with a gamma ray detection probe and the blue dye. Axillary lymph node dissection was completed only when the SN was positive for metastasis in the histopathology analysis or not located.

RESULTS

The SN detection rate for T2 > 3 cm was 94 % in the scintigraphy and 96 % with the probe, with no statistically significant differences between T < 3 cm (97 % and 98 %). In T2 > 3 cm, the final staging was 45 % pN0, 8 % pN1mi, 34 % pN1a, 11 % pN2a and 2 % pN3a. We found statistically significant differences (p < 0.05) when compared with palpable T < 3 cm and non-palpable cancer (62 % pN0 and 74 % pN0, respectively). In the follow-up of T2 > 3 cm (median 42.88 months) we did not find any axillary relapse which could be considered a false negative of the technique.

CONCLUSION

The detection of sentinel lymph nodes is feasible and safe in tumours larger than 3cm with clinically negative axilla. Axillary lymph node dissection can be avoided in 45 % of these patients and therefore, we consider that they should be included as a general indication in breast cancer SN detection.

[Myasthenia gravis and oropharyngeal disorders: two cases reports]

OBJECTIVE

Description of two atypical clinical cases of myasthenia gravis with pharyngeal dysphagia.

CASES REPORTS

A retrospective study from two cases report of myasthenia gravis with pharyngeal dysphagia.

CONCLUSION

The decrease of the laryngeal ascent and the desynchronization of the upper oesophageal sphincter opening appears as the main physiopathological mechanisms. The aspirations are frequent. In front of pharyngeal dysphagia, myasthenia have to be evocated. The alteration of the pharyngeal swallowing can be inaugural in this disease. The cholinesterase inhibitors can help for the diagnostic.

[Patient preference survey on the lack of taste and odor of Nasonex nasal spray. Which impact on compliance to treatment?]

In order to assess the acceptability of a new scent-free formulation of mometasone furoate (Nasonex) among allergic rhinitis patients, who already have been treated by the scented formulation of Nasonex, a phone survey was performed with a sample of 216 patients recruited by Nasonex GP's prescribers and pharmacists. The aim of this survey is to assess the diagnosis modalities, the allergic rhinitis characteristics and associated symptoms in one hand and in the other hand, the main reasons which led them to prefer a new scent-free formulation, in comparison with the only commercialized scented mometasone furoate (Nasonex) at the time when this survey was conducted. The impact of unscented Nasonex on patient's compliance to treatment was also assessed. This survey confirms that the GP is the key actor who usually establish the allergy diagnosis and the interrogatory is the principle method used. The prick test was more often and significantly used in 35% of the perennial rhinitis instead of 19% in seasonal allergic rhinitis (p < or = 0.05). When the diagnosis of allergy was established by an allergologist, 89% of them used a prick test. In this survey, asthma was associated in 24% of the patients, particularly in who suffering from perennial allergic rhinitis. 85% of patients rate their smell as globally good. 75% of the treated patients were interested by the new unscented formulation of Nasonex, regardless of the type of their rhinitis, seasonal or perennial. About 60% of patients stated that the lack of odor will led them to be more compliant to their treatment.

[Correlation between laryngoscopic examination and the gastroesophagial reflux in dysphonic patient]

OBJECTIVES

The gastro-esophageal reflux disease is responsible of oto-rhino-laryngological symptoms included dysphonia. We studied the relationship between reflux disease and dysphonia. The research for the prevalence of reflux disease, in a dysphonic population, has been performed by a clinical and laryngoscopic survey.

METHODS

175 patients were included prospectively. Each patient replies to the questionnaire and see the physician to do a laryngoscopic examination during the same time. A physician jury sees all videos to determine gastro-oesophagial reflux disease laryngoscopic signs.

RESULTS

Statistically significant correlations were found for vocal oedema and posterior hypertrophia in relation with reflux.

CONCLUSION

We have pointed out that laryngoscopy is not an adequate diagnosis tool, because it is operator dependant. Nevertheless the diagnosis of gastro-esophageal reflux disease, regarding the vocal symptoms, is proposed when associated with clinic reflux signs (pyrosis).

[Major orbital complications of acute maxillary sinusitis of dental aetiology]

OBJECTIVES

To demonstrate the importance of searching for a dental aetiology when confronted with an orbital cellulitis secondary to an acute unilateral maxillary sinusitis and to diagnose and treat as soon as possible in order to avoid visual sequelae.

CASE REPORT

Two cases are presented. The first case of a 35 year-old man who was diagnosed and treated late, for an orbital abscess secondary to a sinusitis of dental origin. The patient presented with visual signs such as diplopia and impaired occulomotoricity. The clinical diagnosis was concluded by an emergency sinus CT scan. Treatment consisted of an urgent surgical drainage associated to broad spectrum antibiotics with a high spectrum against Gram +cocci and anaerobes. Dispite this treatment regimen and two subsequent surgeries, the evolution was pejorative ending in a unilateral blindness. The second case is of a 45 year-old immunodeficient woman, presenting with the same pathology but without visual signs and whose evolution was satisfactory after adapted surgical and medical treatments. DISSCUSSION: The presence of visual and ocular signs warn on the gravity of the infection and indicate the need for urgent surgery. Sinus CT scan is essential to highlight the association between the orbit and the causal dental infection. For that, it must include the alveolar processes of the maxilla to show the dental lesion which is usually missed clinically. Functional endoscopic sinus surgery achieves two goals here; one diagnostic by the direct exploration of the nasal sinus cavities and the other therapeutic by the possible drainage all the paranasal sinuses.

[Endonasal endoscopic approach in the treatment of sino-nasal inverted papillomas]

INTRODUCTION

Sino-nasal inverted papilloma is a rare benign tumor of the nasal fossa and the paranasal sinuses for which the successful surgical treatment by an endonasal approach has been corroborated in the literature. Nevertheless, the authors aim in this study to evaluate the advantages and the limits of this approach, to analyse its failures and its recurrences, and to define the indications for using it with the external or dissimulated approach.

MATERIAL AND METHODS

42 patients presenting with a sino-nasal inverted papilloma and treated surgically over a ten year period were included in this retrospective study. The operative technique was chosen as a function of the endonasal and radiological examination results (CT scan and MRI). Follow-up was over one year for all patients.

RESULTS

Twenty eight patients were operated exclusively through an endoscopic endonasal approach. Fourteen patients were operated using a combined approach, associating either a vestibular (9 cases), a paralateral nasal (3 cases) or a fronto-orbital (2 cases) approach with endonsal endoscopy. In two cases, an associated squamous cell carcinoma was found. We observed a recurrence in 9.5% of the all cases and in 14.2% of the patients treated using a combined approach.

CONCLUSIONS

Endoscopic endonasal surgery is a validated surgical approach for the treatment of sino-nasal inverted papilloma in that total tumor removal is possible. This approach is particularly indicated in medially-situated papillomas without frontal or maxillary extension. In all other cases, associating an external or dissimulated approach is usually necessary.

Information and topology in attractor neural networks

A wide range of networks, including those with small-world topology, can be modeled by the connectivity ratio and randomness of the links. Both learning and attractor abilities of a neural network can be measured by the mutual information (MI) as a function of the load and the overlap between patterns and retrieval states. In this letter, we use MI to search for the optimal topology with regard to the storage and attractor properties of the network in an Amari-Hopfield model. We find that while an optimal storage implies an extremely diluted topology, a large basin of attraction leads to moderate levels of connectivity. This optimal topology is related to the clustering and path length of the network. We also build a diagram for the dynamical phases with random or local initial overlap and show that very diluted networks lose their attractor ability.

[Current management of acute pediatric rhinosinusitis in France]

Un groupe de médecins généralistes et multidisciplinaire de spécialistes contribue à définir les différentes formes de sinusites ou rhinosinusites aiguës de l'enfant à partir des principaux symptômes et signes cliniques. Le rôle des pathologies associées telles que l'allergie, les troubles immunitaires est envisagé. L'incidence, la présentation clinique et la prise en charge des complications sont présentées. Les indications des examens radiologiques et biologiques sont analysées. La prise en charge médicale en particulier, la place et le type des antibiotiques sont discutés. Des propositions de prise en charge selon des situations cliniques rencontrées en pratique sont présentées.

[Prospective evaluation of the method of measurement of the peak nasal inspiratory flow (PNIF) in allergic rhinitis. Observational study "Pratic in ORL"]

OBJECTIVES

To establish the ENT specialists's interest for the nasal obstruction measurement by the Peak Nasal Inspiratory Flow (PNIF) for the primary care medical management of patients with allergic rhinitis.

MATERIAL AND METHODS

A nation wide mail survey was conducted on the whole set of 2,800 French ENT specialists. Physicians had to use the PNIF in 4-consecutive patients with allergic rhinitis and assess through a questionnaire their interest for this tool.

RESULTS

About 8% of all ENTs (n = 228) responded. 65.3% of them had used the PNIF with their 4 patients, 29.7% used it in only 1 to 3 of their patients, and 5% did not use it at all. The PNIF was mainly used in moderate to severe rhinitis (94%) in contrast with mild rhinitis (32%) and in persistent rhinitis (94.2%) compared to intermittent rhinitis (54.8%). The primary motivation to use the PNIF on a systematic basis was to quantitatively assess nasal obstruction and to obtain an objective measurement of nasal obstruction. Conversely, the reasons for not using the PNIF were the needless of an objective measurement of nasal obstruction, the drawback of the PNIF in the patient physician relationship and lack of patient's acceptance of the device. Most physicians considered training for a correct usage of the PNIF was easy. Finally, about 2 thirds of the sample gave a positive rating on the usefulness of the PNIF for their patients.

CONCLUSION

This study demonstrates the interest of the practitioners to dispose of a simple and reliable tool for the follow up of nasal obstruction in allergic rhinitis.

Site fidelity, migratory behaviour, and spatial organization of female isards (Rupicapra pyrenaica) in the Pyrenees National Park, France

We studied from 1993 to 2002 the spatial organization of visually marked females in an isard ( Rupicapra pyrenaica Bonaparte, 1845) population in the Pyrenees National Park. In winter, all individuals were concentrated within the same 3.7 km2 refuge area. In summer, two patterns of space use were recorded: sedentary females (n = 33; 52.2%) remained within the refuge area, whereas migrating females (n = 29; 46.8%) summered outside the refuge area, at a horizontal distance of 1.4–9.2 km and 300–800 m higher in elevation than their winter ranges. Females were faithful to their seasonal ranges. The population was organized in well-defined spatial units in summer. This organization was roughly preserved in winter, despite the spatial concentration of the individuals by this season. The resulting spatial clustering might reduce spatial competition and pathogenic contamination between groups, allowing the maintenance of high population density. The appearance of a migratory pattern occurred probably as a result of the protected status of the species, which allowed the population to increase. Some individuals dispersed as a result of the population density increase. The two recorded patterns of space use likely arose from spatial attachment and social affinity that developed in the first years of a female’s life, and could explain the coexistence of the two spatial patterns.

In vitrorearingOestrus caucasicusthird-instar larvae and pupae (Diptera: Oestridae) from naturally-infested Iberian ibex,Capra pyrenaica(Artiodactyla: Bovidae)

Third-instar Oestrus caucasicus larvae (n = 236) obtained from Iberian ibex, Copra pyrenaica, were reared in a laboratory to obtain adult flies. They were maintained at a temperature of 21.9 +/- 2.7 degrees C and a relative humidity of 38.9 +/- 8.0 %. In all, 78 imagos emerged (33.1 %), with a sex-ratio at emergence not differing significantly from 1:1; 25 larvae did not complete pupariation. A total of 14 adult flies (17.9 % of the adults obtained) showed malformations, mainly in their wings. The pupariation period lasted around 30 hours and the pupal stage lasted on average 29.8 +/- 6.8 days. The success of pupation in both sexes was mainly determined by the weight of the larvae. Sexual dimorphism, with higher weights in females, was evident in third-instar arvae, pupae and adults. The mean longevity of adult flies was 224.8 +/- 91.4 hours and males generally survived for onger than the females.

Proposal for relative units of value (RUV) for use in allergy examinations

Health resources are limited and consequently real cost generators must be identified to optimize resources. In the present article, we describe the structure of the Homogeneous Functional Groups (HFG) for Diagnostic Techniques in the Allergy Department of the Virgen de la Arrixaca University Hospital in Murcia (Spain) and the healthcare products generated. Based on the 2005 budget, variable costing was used to calculate the costs of the healthcare products generated (skin tests, investigation of drug allergies, etc.) by one of the three HFG (the HFG for complementary investigations). On the basis of these costs, and taking as the unit the cost of one skin prick test, we assigned relative units of value (RUV) to each of the products in our services portfolio. The following conclusions can be drawn: 1) the current system of variable costing provides information, which should be useful to health professionals; 2) the real cost generators in the microcosm of daily clinical practice should be identified to allow resource reallocation; 3) the costing system used enables modifications to be made that allow decision making on optimal use of the budget; 4) to take the decisions required to optimize resources, clinical management and complementary tests should go hand-in-hand.

Neuregulin (NRG) expression modulates clinical response to trastuzumab in patients with metastatic breast cancer (MBC)

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Background: ErbB2 overexpression is the major determinant of response to trastuzumab (Herceptin, H). Recently, some authors have reported the potential role of the expression of NRG on ErbB2 activation in breast cancer cells, and its consequences in response to treatment with H. In the present study we analyze the relationship between response to H and expression of ErbB2 and NRG in patients (pt) with MBC. Methods: Data and frozen tissue samples from 30 consecutive pt with MBC and positive ErbB2 at diagnosis [Immunohistochemistry (IHC)] were collected. All pt were treated with an Herceptin-based regimen. Central Pathologic review of ErbB2 expression was performed in all samples (Herceptest and FISH). NRG expression was studied by IHC on paraffin embedded material and by Western blotting on frozen tissue using an antibody raised against the intracellular domain of NRG. NRG expression by IHC was evaluated using a semiquantitative scoring system that assesses both extension and intensity of cytoplasmic staining. Correlation between ErbB2 and NRG expression and its influence in response to H was analyzed. Characteristics of pt: Median Age: 54; Median mts sites: 2; Treatment: H alone:1 pt; H+Taxol:15 pt; H+Taxol+Carbo: 4 pt; H+Taxol+Lip.Doxorub:2 pt, H+Vinorelbine:7 pt; H+CDDP:1 pt. Results: ORR: 76% (CR:23%, PR:53%). Median TTP: 7.8 m. After central Pathologic review, a total of 20 tumors showed ErbB2 amplification by FISH and 19 of them were Herceptest 3+. A positive correlation was observed between ErbB2 amplification and NRG expression. All complete responses (n=7) were seen in pt with ErbB2 amplification. Interestingly, in the group of tumors without ErbB2 amplification (n=10), 7 had high NRG expression levels, as assessed by IHC. Six out of these 7 tumors having high levels of NRG expression, exhibited partial responses. NRG expression, in turn, did not have impact on response among ErbB2 amplified tumors. Conclusions: These preliminary results suggest that responses to H regimens in pt with MBC can be seen in pt lacking ErbB2 amplification in presence of high levels of expression of transmembrane ligand NRG. This suggests that the group of pt that may benefit from treatment with H could be broader than currently established. A confirmatory study is ongoing in a larger series.

No significant financial relationships to disclose.

Comparison of two quantitative GC-MS methods for analysis of tomato aroma based on purge-and-trap and on solid-phase microextraction

Two analytical procedures, one based on purge-and-trap and the other on solid phase microextraction, both followed by GC-MS measurement using an ion-trap mass spectrometer in the electron impact mode, have been developed for determination and quantitation of up to 39 aroma compounds in fresh tomatoes. The method based on purge-and-trap for isolation of the volatile compounds uses Tenax as adsorbent and a hexane-diethyl ether mixture as solvent for elution. The method was validated for linearity, precision (better than 20% for most compounds), and limit of detection, which was approximately 1 ng g(-1). This method enabled identification of up to 30 compounds in real samples. Use of SPME was considered as an alternative, to simplify sample treatment while maintaining the information level for the samples (e.g. the number of compounds detected) and quality of quantitation. A procedure based on SPME using a Carboxen/polydimethylsiloxane fibre was developed and validated for determination of 29 aroma compounds; precision was better than 20% and limits of detection ranged from 4 to 30 ng g(-1).

Sex-Difference in The Ossification Rate of The Appendicular Skeleton in Capra pyrenaica Schinz, 1838, and Its Utility in The Sex Identification of Long Bones

The main goal of our work is to quantify differences in the rate of ossification in post-cranial Iberian ibex skeletons, related to sex. Another objective is to improve criteria for assessing the sex of post-cranial bones by combining the degree of ossification of the distal epiphysis and biometrical data. Forty Capra pyrenaica skeletons were examined in order to determine the degree of ossification by means of an Ossification Index. Our results evidence that sexual differences in the rate of ossification become visible at 6 months of age. On average, females complete their bone development 2 years before males do. Finally, by means of lineal classification functions which take into account both biometrical and anatomical criteria, we can achieve, in average, a 95.5% of correct sex discrimination within a sample consisting of ibex metacarpi and metatarsi from individuals aging from <1 to 12 years. Therefore, we conclude that the rhythm of ossification in the post-cranial skeleton of C. pyrenaica may be used as a criterion for assessing the sex of skeletal remains and could be applicable to other dimorphic ungulates. Nevertheless, the results obtained for specimens belonging to a particular population may have limited application to other populations with different medium sizes and living at particular densities within habitats with variable quality.

[Community-acquired acute maxillary sinusitis or rhinosinusitis in adults in France: current management]

Sinus infections, often viral, are a common reason for physician visits. The multiplicity of clinical presentations makes its diagnosis difficult. The problem is to recognize bacterial infection without additional testing, except in cases of treatment failures, complications or relapse. Patients with signs suggestive of rhinosinusitis fall into one of four basic clinical situations: common colds, 'doubtful' rhinosinusitis, apparent acute maxillary bacterial rhinosinusitis, and complications. Anterior rhinoscopy may help confirm diagnosis. Current bacterial epidemiology is based on the results of clinical studies, microbial ecology, and samples taken in cases of treatment failure. The two bacteria isolated most frequently are Streptococcus pneumoniae and Haemophilus influenzae, both of which pose resistance problems. Moraxella catarrhalis, Streptococcus pyogenes and Staphylococcus aureus are isolated less often. The dominant issue in management of acute rhinosinusitis is whether to use antibiotic or symptomatic treatment. For viral infections, antibiotic therapy is useless and highly inadvisable. For 'doubtful' infections, symptomatic treatment is likely to lead to recovery. The use of non-recommended antibiotics also increases the risk of selection of resistant bacteria. When bacterial rhinosinusitis is strongly suspected, recourse to antibiotic treatment is recommended in view of the benefits in this situation (AFSSAPS 2005). This treatment is probabilistic, should be decided at the end of the consultation, and follows the AFSSAPS guidelines.