Retreatment of previously treated intracranial aneurysm: Procedural complications and risk factors for complications

OBJECTIVE

Intracranial aneurysm (IA) is a frequent vascular malformation that can be managed by endovascular treatment (EVT) or microsurgery. A previously treated IA can recanalize, which may require further treatment. The aim of our study was to evaluate procedural complications related to IA retreatment and their risk factors.

METHODS

All patients retreated for IA between 2007 and 2017 in 4 hospitals were included. We retrospectively reviewed the frequency of procedural complications of IA retreatment, defined as death or≥1-point increase in modified Rankin score 24h after the procedure. We then screened for risk factors of procedural complications by comparing the characteristics of patients with and without complications.

RESULTS

During the inclusion period, 4,997 IAs were treated in our 4 institutions. Of these, 237 (4.7%) were retreated. 29 (12.2%) had≥1 procedural complication. However, severe complications, defined as death or dependency at 1 month, occurred only in 3 patients (1.3%). The only risk factor for complications was microsurgical clipping as retreatment.

CONCLUSIONS

Procedural complications during IA retreatment were frequent but, in most cases, retreatment did not lead to death or severe disability. The only risk factor for complications of IA retreatment was clipping as retreatment. However, the design of the study did not allow any conclusion to be drawn as to the optimal means of aneurysm retreatment, and further studies are needed.

Effects of antimicrobial exposure on the antimicrobial resistance of Escherichia coli in the digestive flora of dairy calves

Veal calves are often identified as reservoirs for antimicrobial resistant Escherichia coli (E. coli). This production is closely linked with dairy production, as young calves - mostly males - are collected from dairy farms to enter the fattening process. The aim of this prospective study was to explore the factors on dairy farms that favour the selection of antimicrobial resistance (AMR) in the digestive E. coli strains of young calves and to assess whether the resistance levels and selection pressure were the same for males and females. The exposure of calves to antimicrobials was investigated through three factors: antimicrobial treatment of calves; feeding of calves with milk from cows treated with antimicrobials; and the consumption of colostrum from cows treated with antimicrobials at dry-off. The study design involved 100 dairy farms. A calf of each sex was selected from birth on each farm. Information on the calves' exposure to antimicrobials was collected daily and calves were sampled (rectal swab) two weeks after birth, then seven weeks after birth for females only. Laboratory analyses included culture on two distinct media: a non-selective medium (identifying dominant flora) and a medium containing ceftiofur to select the extended-spectrum beta-lactamase (ESBL) phenotype. Susceptibility testing was performed on an E. coli strain from each medium. Generalised linear models were used to assess associations between the resistance of E. coli strains and antimicrobial exposure. A set of 280 swabs from healthy calves were analysed. In dominant flora, high levels of resistance (>60 %) were identified for streptomycin, tetracycline and amoxicillin but AMR levels were low (3 %) for critically important antimicrobials (3^rd- and 4^th-generation cephalosporins and fluoroquinolones). For females staying in dairy farms, a marked decrease in resistance was observed for almost all antimicrobials between the age of 15 days and 7 weeks. A selective medium revealed an ESBL phenotype for 20.7 % of the calves. Whether for AMR or antimicrobial exposure, no significant difference was found between male and female calves. The antimicrobial treatment of calves was associated with an increased resistance of E. coli from dominant flora for amoxicillin (OR = 2.9), gentamicin (OR = 4.6), florfenicol (OR = 5.0) and trimethoprim-sulfonamide (OR = 5.6). The consumption by calves of milk from cows treated with antimicrobials was also associated with an increased resistance to amoxicillin (OR = 2.6), gentamicin (OR = 4.0), tetracycline (2.6) and trimethoprim-sulfonamide (OR = 2.2). In contrast, the models did not reveal any association between AMR and consumption of colostrum from cows treated with antimicrobials at dry-off.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BACKGROUND

Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment.

METHODS

This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge.

RESULTS

The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi² test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment.

CONCLUSION

Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Antimicrobial resistance in bacteria isolated from diseased horses in France

BACKGROUND

Horses are one of the potential reservoirs of antimicrobial resistance (AMR) determinants that could be transferred to human subjects.

OBJECTIVE

To describe the AMR patterns of major bacteria isolated from diseased horses in France.

STUDY DESIGN

Retrospective observational study.

METHODS

Data collected between 2012 and 2016 by RESAPATH, the French national surveillance network for AMR, were analysed. Only antimicrobials relevant in veterinary and human medicine for the isolated bacteria were considered. Mono- and multidrug resistance were calculated. The resistance proportions of major equine diseases were assessed and compared. Where data permitted, resistance trends were investigated using nonlinear analysis (generalised additive models).

RESULTS

A total of 12,695 antibiograms were analysed. The five most frequently isolated bacteria were Streptococcus spp., Escherichia coli, Pseudomonas spp., Staphylococcus aureus, Pantoea spp. and Klebsiella spp. The highest proportions of resistance to gentamicin were found for S. aureus (22.1%) and Pseudomonas spp. (26.9%). Klebsiella spp. and E. coli had the highest proportions of resistance to trimethoprim-sulfamethoxazole (15.5 and 26.2%, respectively). Proportions of resistance to tetracycline were among the highest for all the bacteria considered. Resistance to third-generation cephalosporins was below 10% for all Enterobacteriaceae. The highest proportions of multidrug resistance (22.5%) were found among S. aureus isolates, which is worrying given their zoonotic potential. From 2012 to 2016, resistance proportions decreased in Pseudomonas spp. isolates, but remained the same for S. aureus. For Streptococcus spp. and E. coli, resistance proportions to trimethoprim-sulfamethoxazole increased.

MAIN LIMITATIONS

Since antibiograms are not systematic analyses, any selection bias could impact the results.

CONCLUSIONS

Such studies are essential to estimate the magnitude of the potential threat of AMR to public health, to design efficient control strategies and to measure their effectiveness. These findings may also guide the initial empirical treatment of horse diseases.

Long term surgical results of 154 petroclival meningiomas: A retrospective multicenter study

BACKGROUND

Outcomes of petroclival meningiomas (PCM) (morbidity, permanent cranial nerves deficit, tumor removal and recurrence) are inconsistent in the literature, making it a challenge to predict surgical morbidity.

METHODS

A multicenter study of patients with PCMs larger than 2.5cm between 1984 and 2017 was conducted. The authors retrospectively reviewed the patients' medical records, imaging studies and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, recurrence rates and predictive factors.

RESULTS

There were 154 patients. The follow-up was 76.8 months on average (range 8-380 months). Gross total resection (GTR) was achieved in 40 (26.0%) patients, subtotal resection (STR) in 101 (65.6%), and partial resection in 13 (8.3%). Six (2.6%) perioperative deaths occurred. The 5-year, 10-year and 15-year progression-free survival (PFS) of GTR and STR with radiation therapy (RT) was similar (100%, 90% and 75%). PFS of STR without adjuvant radiation was associated with progression in 71%, 51% and 31%, respectively. Anterior petrosectomy and combined petrosectomy were associated with higher postoperative CN V and CN VI deficits compared to the retrosigmoid approach. The latter had a significantly higher risk of CN VII, CN VIII and LCN deficit. Temporal lobe dysfunction (seizure and aphasia) were significantly associated with the anterior petrosectomy approach.

CONCLUSIONS

Our study shows that optimal subtotal resection of PCMs associated with postoperative RT or stereotactic radiosurgery results in long-term tumor control to equivalent radical surgery. Case selection and appropriate intraoperative judgement are required to reduce the morbidity.

Contagious agalactia monitoring in caprine herds through regular bulk tank milk sampling

Surveillance and control of Mycoplasma spp. responsible for contagious agalactia (CA) in caprine herds are important challenges in countries with a large small-ruminant dairy industry. In the absence of any clinical signs, being able to determine the potential circulation of mycoplasmas within a herd could help to prevent biosecurity issues during animal exchanges between farms and improve health management practices. The objective of this study was to determine whether regular sampling of bulk tank milk was suitable for such surveillance. Twenty farms were sampled once a month for 2 yr and CA-responsible mycoplasmas were detected by real-time PCR on DNA extracted from milk, using 3 different DNA extraction methods. The pattern of mycoplasma excretion in bulk tank milk was assessed over time and several herd characteristics were recorded together with any event occurring within the herds. In general, the results obtained with the different detection methods were comparable and mainly agreed with the culture results. Several patterns of excretion were observed but were not related to herd characteristics (size, breed, and so on). Recurrence of the same (sub)species and same pulsed-field gel electrophoresis subtype during the 2-yr period is indicative of the considerable persistence of mycoplasmas. This persistence was associated with intermittent excretion. In conclusion, bulk tank milk sampling could be valuable for controlling CA in caprine herds provided it is repeated several times, yet to be defined, per year and analyzed using an appropriate methodology and the right cut-off for interpretation.

Quantitative and qualitative analysis of antimicrobial usage in white veal calves in France

The development of antimicrobial resistance has made it necessary to measure antimicrobial usage in animal production sectors. France is a major European producer of white veal calves, but few data were previously available for that sector, even though these young animals are particularly susceptible to infection and considered as a reservoir of antimicrobial resistance. A cross-sectional study was conducted on 186 batches of French calves to estimate the exposure of white veal calves to antimicrobials and identify the potential risk factors related to antimicrobial usage. An indicator of calf exposure was calculated as a count of the number of antimicrobial treatments per calf. The indicator was based on veterinary prescriptions (products, quantity dispensed and dosage prescribed) and the estimated weight of calves at treatment, using the dates of treatment collected from farm registers. The study showed that calves were exposed to an average of 8.55 antimicrobial treatments (SD: 2.21, range: 2.75-15.86) over the five to six months of the fattening process. Group treatments were predominant (95.8%) and administered by the oral route. The "starting treatments", given during the first two weeks of the fattening period, were administered systematically (to all the calves in all the farms) and accounted for a third of all treatments. Tetracyclines, polypeptides and macrolides were the most widely used antimicrobials, with respectively 4.32, 1.59 and 1.01 treatments per calf. Only rare uses of 3rd and 4th generation cephalosporins and fluoroquinolones, considered as critically important in human medicine, were reported. Despite low variability of exposure between farms, a linear mixed-effects model highlighted a higher variability between farmers (ICC=0.14) or veterinarians (ICC=0.12), than between integrators (ICC=0.06). The number of calves per pen, introduced as a fixed effect in the model, was also significant: calves housed in pens of 6-10 and fed in buckets had on average 2.55 more antimicrobial treatments per calf than calves housed in pairs with the same feeding system. The model also highlighted an increase of 1.48 treatments per calf for farms with more than five percent of mortality, versus those with two percent or less. The present study showed that antimicrobial treatments are numerous in veal calf fattening farms, particularly at the arrival of the animals. Taking into account the development of resistance to antimicrobials, the necessity and the effectiveness of some of these treatments should be re-evaluated.

Diversity and variation in antimicrobial susceptibility patterns over time in Mycoplasma agalactiae isolates collected from sheep and goats in France

AIMS

Mycoplasma agalactiae is responsible for Contagious Agalactia, a severe syndrome affecting small ruminants worldwide and resulting in significant economic losses in countries with an important dairy industry. The aim of this study was to examine the antimicrobial susceptibility patterns of M. agalactiae isolates in France, their evolution over the last 25 years and their relationships with the genetic diversity of isolates and their origin (geographical and animal host).

METHODS AND RESULTS

Susceptibility patterns were determined by measuring minimal inhibitory concentrations (MICs) of several antimicrobials used against mycoplasmas. Caprine M. agalactiae strains showed increased MICs over time for most of the antimicrobials tested, except fluoroquinolones. This susceptibility loss was homogeneous despite the considerable genetic and geographical heterogeneity of the isolates. In contrast, all the ovine isolates originating from a single clone and the same region showed increased MICs only to some macrolides.

CONCLUSIONS

MICs have evolved differently depending on the origin of the isolates but the overall loss in susceptibility has remained far more moderate than that of Mycoplasma bovis, a cattle pathogen closely related to M. agalactiae.

SIGNIFICANCE AND IMPACT OF THE STUDY

Several hypotheses are proposed to explain the differences in susceptibility patterns, such as local, specific, nonmycoplasma-targeting antibiotic treatments and the genetic background of isolates in connection with their animal host.

Syndromic surveillance of abortions in beef cattle based on the prospective analysis of spatio-temporal variations of calvings

Our objective was to study the ability of a syndromic surveillance system to identify spatio-temporal clusters of drops in the number of calvings among beef cows during the Bluetongue epizootic of 2007 and 2008, based on calving seasons. France was partitioned into 300 iso-populated units, i.e. units with quite the same number of beef cattle. Only 1% of clusters were unlikely to be related to Bluetongue. Clusters were detected during the calving season of primary infection by Bluetongue in 28% (n = 23) of the units first infected in 2007, and in 87% (n = 184) of the units first infected in 2008. In units in which a first cluster was detected over their calving season of primary infection, Bluetongue was detected more rapidly after the start of the calving season and its prevalence was higher than in other units. We believe that this type of syndromic surveillance system could improve the surveillance of abortive events in French cattle. Besides, our approach should be used to develop syndromic surveillance systems for other diseases and purposes, and in other settings, to avoid "false" alarms due to isolated events and homogenize the ability to detect abnormal variations of indicator amongst iso-populated units.

A rare case study of a retropharyngeal neurofibroma and a brief literature review

INTRODUCTION

Space occupying lesions in the retropharyngeal space are rare.

CASE REPORT

Here, we present a rare case of a retropharyngeal neurofibroma treated surgically through an open cervical approach without any complication.

DISCUSSION

Neurofibromas are benign, slowly growing neoplasms that could be associated or not with neurofibromatosis. They are derived from peripheral nerves. Diagnostic work-up should include CT-scan and MRI as well as a biopsy to confirm the diagnosis. Treatment of localized and diffuse neurofibromas is often surgical resection, which may require sacrifice of the nerve. Malignant transformation of these lesions, without association to NF-1, is rare and exceptionally documented in the literature.

CONCLUSION

We presented a rare case of solitary neurofibroma of the retropharyngeal space. Complete resection of the lesion was performed without any complication. We also presented a brief review of the literature about neurofibromas.

Prone position affects stroke volume variation performance in predicting fluid responsiveness in neurosurgical patients

BACKGROUND

Stroke volume variation (SVV) during mechanical ventilation predicts preload responsiveness. We hypothesized that the prone position would alter the performance of this dynamic indicator.

METHODS

Two parallel groups of ventilated neurosurgical patients with low tidal volume (6-8 ml.kg-1) were studied before surgical incision. SVV was measured at T0, T15 and T30 min during a fluid volume expansion (250 mL hetastarch 6% over 30 min) with patients in either the supine (N.=29; Supine group) or prone position (N.=23; Prone group). Fluid responsiveness was defined as an increase in the stroke volume index (SVI) of ≥20% at T30. Receiver-operating characteristics (ROC) curves were generated for SVV.

RESULTS

Prone positioning significantly increased SVV. Volume expansion in the Prone group increased SVI but led to a decline in SVV from 16% (12-22; median, 25-75th percentile) at T0 to 9% (8-13%) at T30. These effects on SVI and SVV were more pronounced compared to those obtained in the Supine group (P ≤0.05). Fluid responsiveness was predicted by SVV >12% at T0 (sensitivity 88%, specificity 62%) in the Supine group. In the Prone group, the area under the ROC curve of SVV (0.53; 95% confidence interval 0.27-0.79) did not allow the determination of a threshold SVV value.

CONCLUSION

In ventilated patients with low tidal volume, a prone position may have a direct effect on the heart that alters the performance of SVV in predicting fluid responsiveness. External factor such as prone position renders difficult the interpretation of SVV as a dynamic indicator of cardiac preload.

Trauma network for severely injured patients

Survival after severe trauma may depend on a structured chain of care from the management at the scene of trauma to hospital care and rehabilitation. In the USA, the trauma system is organized according to a pre-hospital triage by paramedics to facilitate the admission of patients to tertiary trauma centres. In France, trauma patients are transported to the most suitable facility, according to the on-scene triage by an emergency physician. Because French hospital's resources become scarce and expensive, the access to all techniques of resuscitation after severe trauma is restricted to tertiary trauma centres, at the expense of prolonged duration of transfer to these centres with a possible impact on mortality. The Northern French Alps Emergency Network created a regional trauma network system in 2008. This organization was based upon the interplay between the resources of each hospital participating to the network and the categorization of trauma severity at the scene. A regional registry allows the assessment of trauma system, which has included 3,690 severe trauma patients within the past 3 years. Bystanders, medical call dispatch centres, and interdisciplinary trauma team should form a structured and continuous chain of care to allocate each severe trauma patient to the best place of treatment.

[Trap in severe trauma: the rotary atlantoaxial dislocation]

We reported the case of asymptomatic traumatic atlantoaxial dislocation in a 14-year-old woman. Clinical diagnosis of this uncommon dislocation is difficult and often made late. The early diagnosis by CT scan is necessary to avoid secondary aggravation. Integrity of the transverse ligament of the atlas is a determining factor for atlantoaxial stability and allows orthopaedic treatment after reduction using moderate traction on the head.

A simplified method of performance indicators development for epidemiological surveillance networks--application to the RESAPATH surveillance network

BACKGROUND

Develop and calculate performance indicators allows to continuously follow the operation of an epidemiological surveillance network. This is an internal evaluation method, implemented by the coordinators in collaboration with all the actors of the network. Its purpose is to detect weak points in order to optimize management. A method for the development of performance indicators of epidemiological surveillance networks was developed in 2004 and was applied to several networks. Its implementation requires a thorough description of the network environment and all its activities to define priority indicators. Since this method is considered to be complex, our objective consisted in developing a simplified approach and applying it to an epidemiological surveillance network.

METHODS

We applied the initial method to a theoretical network model to obtain a list of generic indicators that can be adapted to any surveillance network.

RESULTS

We obtained a list of 25 generic performance indicators, intended to be reformulated and described according to the specificities of each network. It was used to develop performance indicators for RESAPATH, an epidemiological surveillance network of antimicrobial resistance in pathogenic bacteria of animal origin in France.

CONCLUSION

This application allowed us to validate the simplified method, its value in terms of practical implementation, and its level of user acceptance. Its ease of use and speed of application compared to the initial method argue in favor of its use on broader scale.

[Orbital tumors. Neurosurgical activity]

In this chapter, we report the results of orbital tumor management in a few neurosurgical departments and compare it to a Paris neurosurgical department that has developed a close relation with an ophthalmological department. These departments' activity is quite low, treating mainly sphenoorbital meningiomas. Other tumor groups are unequally and sporadically managed.

PET-CT as an effective imaging modality in the staging and follow-up of post-transplant lymphoproliferative disorder following solid organ transplantation

INTRODUCTION

To establish the role of positron-emission tomography (PET)-computed tomography (CT) in post-transplant lymphoproliferative disorder (PTLD) patients, compared to conventional imaging (ultrasonography/CT/magnetic resonance imaging) in relation to its accuracy, sensitivity and specificity.

METHODS

30 patients (26 males and 4 females), with a median age of 49.5 (range 18-74) years, were retrospectively evaluated. In 29 cases, the diagnosis was confirmed by histopathology. Malignant lymphoma was detected in 20 cases, polymorphic lymphoproliferative disorder in six cases, multiple myeloma in two cases and Hodgkin's disease in one case. A total of 49 PET-CTs (13 studies for staging at diagnosis and 36 studies at follow-up as assessment post-therapy) were compared to conventional imaging. Imaging results in accordance with disease status were assessed at a median follow-up of 17.8 (range 1.5-42.2) months post-PET-CT.

RESULTS

In 41 of 49 examinations performed for staging and on follow-up, PET-CT and conventional imaging findings were concordant. Compared to conventional imaging, PET-CT showed comparable sensitivity (75 percent vs. 83 percent), similar specificity (100 percent in both modalities) and comparable accuracy (77 percent vs. 85 percent) during staging at diagnosis. PET-CT was found to be superior to conventional imaging modalities at follow-up, with greater sensitivity (100 percent vs. 81 percent), specificity (80 percent vs. 100 percent) and accuracy (97 percent vs. 83 percent).

CONCLUSION

PET-CT is an accurate diagnostic tool for staging and for the follow-up of PTLD patients. It represents a good alternative imaging method to avoid contrast-related nephrotoxicity in patients who often develop impaired renal function secondary to chronic immunosuppressive therapy. However, further studies are recommended before considering PET-CT as a routine diagnostic tool in PTLD.

Reported prevalence and co-morbidity of asthma, chronic bronchitis and emphysema: a pan-European estimation

OBJECTIVE

Comparable population-based data exist at the European level for asthma but not for chronic obstructive pulmonary disease. Data from the World Health Organization's Large Analysis and Review of European Housing and Health Status Study conducted in random samples from eight European cities were used 1) to describe the prevalence of chronic bronchitis and emphysema (CBE) and asthma according to socio-demography, addictions, physical activities and body mass index; and 2) to identify the co-morbidities of these respiratory diseases.

DESIGN

A total of 6915 adults filled out a standardised questionnaire on health outcomes, including major respiratory diseases and individual characteristics.

RESULTS

Data showed that in the year preceding the survey, 3.3% of individuals had been diagnosed or treated for asthma and 6.2% for CBE. One per cent suffered simultaneously from both. Large variations were observed between cities. Physical activities and never smoking were inversely associated with CBE, independently of socio-cultural differences between the eight cities. Furthermore, both asthma and CBE were significantly related to several non-respiratory diseases, after adjustment for potential confounders.

CONCLUSION

Population-based data from eight European cities show that there is a link between chronic respiratory diseases and various non-respiratory co-morbidities that needs further investigation.

Spatial and Temporal Patterns of Herd Somatic Cell Score in France

Spatial and temporal patterns of annual milk somatic cell score (ASCS) were explored in French dairy herds between 1996 and 2000 to detect regional singularities for risk of mastitis. A new cluster detection method was used, which was adapted to continuous variables and which allowed ASCS variation factors to be taken into account. The statistical unit was the herd-year. A linear regression model for each year allowed adjustment for breed, mean parity, number of calvings for each season, herd size, and farm altitude. Cluster detection was performed on raw data and on residuals of the model through a method based on the Hellinger distance between spatial distributions. The Hellinger distance between farm distributions was computed at different levels of ASCS (or residuals). Temporal ASCS patterns were explored using a computation of correlations and comparisons between spatial structures of the different years. The general ASCS trend over the study period was a decrease. The global Hellinger distance, which was higher than what could have been randomly expected for each of the 5 yr, indicated a significant spatial cluster formation. Cluster mapping over the 5 yr identified several areas, which sometimes differed between detection using raw data and that using ASCS residuals. Temporal correlations between ASCS residuals for each year were positive and decreasing, and 1996 and 2000 appeared spatially different from the other years. The more affected areas were regions that were not specialized in dairy production. During the study period, 2 progressive movements were detected, corresponding to a disappearance of clusters in the northwest and an increase of clusters in the southwest. Cluster detection could aid in the identification of new risk factors that are relevant at different spatial scales, and could help local organizations to supervise the risk of mastitis, and improve udder health management.

[French neurosurgical practice in Neuro-Oncology (national survey--part I)]

OBJECTIVE

The aim of this work is to summarize the elements of the "Cancer Plan" applicable to neurosurgical practice, and to give the results of a national inquiry concerning the daily practice of Neuro-Oncology from the neurosurgical point of view.

METHOD

The Neuro-Oncology Group of the French Society of Neurosurgery has submitted a questionnaire to every department of Neurosurgery in France.

RESULTS

The response rate of the public centers was 96.5%. Moreover, responses were available from 7 private centers. The results are detailed in the text.

CONCLUSION

This national survey highlights the interest and implication of French neurosurgeons in the field of Neuro-Oncology. But also, to be in accordance with the guidelines for good clinical practice, the importance of developing official neuro-oncological networks in order to offer the best access to clinical and fundamental data and hence optimise patient's care. The publication of the "Cancer Plan", the creation of a National Neuro-Oncology Group, and the results of this survey (actual multidisciplinary approach, better information and transparency, individualized care of the patients), are in the line with updating our daily practice, even though discrepancies remain among centers. French neurosurgeons must continue along the same path, but at the same time there is a need for additional help to definitely reach a truly, and homogeneous, optimized care of neuro-oncological patients.

La prothèse cervicale de bryan® dans le traitement des affections cervicales dégénératives

PURPOSE

After an anterior cervical discectomy, immobility at the fused level may increase stress on adjacent disc spaces and causes disc degeneration in 92% of the cases with clinical manifestations in 25.6% of the patients within 10 years. The cervical disk prosthesis may help to prevent this problem. The Bryan prosthesis (Medtronic Sofamor Danek) is currently available in France after a European pilot study.

METHODS

Since January 2002, 8 patients (9 implants) (mean age: 35 years) were operated on with a prosthesis implantation for disc degeneration after an adjacent previous interbody fusion in 2 patients and for disc herniation or spondylosis in 6 patients. The prosthesis were implanted at the C4-C5 level (one patient), C5-C6 (four patients), and C6-C7 (four patients). Post-operative radiological evaluations with dynamic X-rays and clinical status (Odom questionnaire) were analyzed.

RESULTS

Surgical procedures, which were longer than the classical technique, were uneventful. Radicular pain resolved after surgery with excellent results with the Odom's score. With a mean follow-up of 12 months, the prosthesis mobility was 8.9 degrees . But one fusion of an implant was encountered 6 months after implantation.

CONCLUSIONS

The general follow-up for the Bryan(R) cervical disc prosthesis implantation is still too short (2 years) for a definitive evaluation. If clinical results on pain are as good as expected, long-term mobility of the prosthesis has to be checked, as it is the main advantage over classical anterior cervical discectomy with fusion. Patient selection has to be considered.

Lymphatic mapping in early stage breast cancer: comparison between periareolar and subdermal injection

The combination of preoperative lymphatic mapping with intra-operative probe detection is becoming the standard procedure for identifying tumour lymphatic spread at the time of initial treatment in breast cancer. There are a number of identification techniques for sentinel lymph nodes, but the concordance of the results of a sentinel lymph node biopsy with axillary lymph node dissection did not vary significantly among them. Periareolar (p.a.) injection of tracer is a new procedure specifically studied to overcome some limitations of other techniques; in two groups of patients with early breast cancer we compared the periareolar with the subdermal technique. One hundred and fifty biopsy proven breast cancer patients were consecutively enrolled in this study. This population was divided into two groups: (1) group A, including 100 cancers; lymphatic mapping was performed by s.d. injection of both blue dye and radiotracer; and (2) group B, including 50 cancers; lymphatic mapping was performed with a combination of blue dye injected p.a. and radiotracer injected s.d. For group A, with both techniques we identified one or more SLNs in 100/100 tumours; blue dye detected the SLNs in 99/100 cancers (99%), lymphoscintigraphy in 93/100 cancers (93%). The concordance rate was 92%. For group B, with both techniques we identified one or more SLNs in 49/50 cancers (98%); blue dye detected the SLNs in 48/50, lymphoscintigraphy in 46/50 cancers (92%). The concordance rate was 92%. In the present study p.a. and s.d. injection of blue dye give similar and comparable results. The periareolar technique is simpler and has several advantages over the subdermal technique.

[Staphylococcus aureus meningitis with intermediate sensitivity to glycopeptides. Therapeutic indications]

INTRODUCTION

Since 1997, several observations of glycopeptide intermediate Staphylococcus aureus (GISA) infections have been described. We report the case of meningitis.

OBSERVATION

A 46 year-old man was treated surgically on several occasions for a meningioma of the back cranial fossa. Intracranial hypertension required the placing of a cerebrospinal leading-catheter. He developed a GISA meningitis. Antibiotics and removal of the catheter cured the infection.

DISCUSSION

To our knowledge, this is the first observation of GISA meningitis. Such infections are rare and are probably underestimated due to the lack of standardized detection methods. They occur in fragile, surgical, immunodeficient patients, often living with prostheses. Prior treatment with vancomycine is often reported. The emergence of these infections is a serious therapeutic problem, since vancomycine is a major antibiotic used in the treatment of meticillin-resistant S. aureus (MRSA) infections.

Chordoid glioma of the third ventricle: CT and MRI, including perfusion data

Chordoid glioma is a homogeneous tumour involving the third ventricular region of middle-aged women, containing a small central cyst or necrosis. Histologically the tumour has a chordoid appearance. We report a new case with a haemodynamic imaging approach which indicates tumour angiogenesis at the capillary level.

New HLA-A*11 allele, A*1112, identified by sequence-based typing

In this report, we describe the identification of HLA-A*1112, a novel HLA-A*11 allele found in two Italian families. The new allele was detected during routine HLA typing by a polymerase chain reaction sequence-specific primer and was confirmed by high-resolution sequencing-based typing. The nucleotide sequences of HLA-A*1112 exons 2 and 3 are identical to HLA-A*11011 except for a single nucleotide substitution in codon 90 (GAC-->GCC).

[Role of perioperative biological tests during the performance and follow-up of corticotroph adenoma exeresis]

ACTH assay in cavernous sinus samples during resection of pituitary adrenocorticotroph adenomas is a simple and safe technique providing an intraoperative assessment of adrenocorticotroph hormone gradients. Bilateral puncture of the cavernous sinus can be achieved vial the standard transsphenoidal approach to the sella turcica. ACTH is determined with IRMA at 37;C with an incubation time of less than one hour. Among 71 cases in our experience, the ACTH gradient accurately predicted the position of the adenoma in 93% of the cases. This rate is higher than the 61% accuracy reported for inferior petrosal sinus sampling. The technique reported is more precise than MRI which correctly identifies adenomas in only 50% of the cases. The remaining cases are either false positives or false negatives. We report an 82% cure rate either via direct resection of the microadenoma or via partial hypophysectomy guided by the ACTH gradient. In our series, 20 cases of Cushing's disease had a normal MRI and no surgically identifiable adenoma. In 10 of these cases however, cure was achieved by performing ACTH gradient guided partial hypophysectomy. This method produces no morbidity and is most helpful for the neurosurgeon allowing confirmation of the position of an MRI-visible adenoma or an adenoma identified intraoperatively. It does not however replace neurosurgical experience which remains the most important predictive factor for outcome in surgical treatment of Cushing's disease.

Disparities in hormone replacement therapy use by socioeconomic status in a primary care population

The use of hormone replacement therapy (HRT) is a controversial decision for many women, yet few studies have evaluated the socio-demographic, psychological, and behavioral correlates of HRT use. This cross-sectional, mailed survey evaluated the associations of socioeconomic status, preventive health behaviors, knowledge and perceptions about HRT-related risks and benefits with HRT use among 428 women 50-70 years old in Vermont. The overall prevalence of HRT use was 40%. Women of moderate to high income were three times more likely than those of low income to use HRT. HRT use was significantly higher among women whose physician had encouraged use (58%) than among those who received ambivalent recommendations from their physicians (20%). Hysterectomy, higher income, younger age, regular adherence to cervical cancer screening, and recommendation by a provider were significantly associated with HRT use in multivariate analyses. There were no differences in HRT use according to level of concern about heart disease, osteoporosis, or breast cancer. A recommendation by a health care provider is a powerful predictor of HRT use, but disparities in use exist by socioeconomic status. Future research should examine why lower income women are less likely to use HRT and whether the discrepancy is due to inconsistent recommendations by health care providers.

Management of craniocervical junction dislocation

The discovery of a craniocervical junction malformation requires management in three steps: (1) The patterns must be recognized using tomographic measurements (Chamberlain's line, Wackenheim's line). Dynamic flexion-extension studies are necessary to assess stability or instability. Stable patterns range from platybasia to basilar invagination, with gradual deformation, and are frequently associated with Chiari malformation. Unstable patterns characterized by odontoid instability are the equivalent of an odontoid fracture. The origin is malformative (hypoplasia, aplasia of the dens, os odontoidum), but the last may be difficult to distinguish from an old odontoid fracture. They are found in many syndromes (Down, Morquio, etc.). Unstable atlantoaxial patterns with atlas assimilation are hardly reducible; they evolve toward progressive instability. (2) The neurological consequences must be defined from the clinical features of the spinal cord and the cranial nerves. Both static and dynamic MRI scans must be performed; in this way identification of the neural abnormalities (hydromyelia, Chiari, etc.) and of the osseous compression is possible. (3) The most appropriate operative procedure must be selected: stable platybasia with a nervous compression by Chiari is cured only by posterior decompression; odontoid instability is cured by reduction and posterior fixation, using hooks and autologous bone grafts on the posterior arches of C-1 and C-2. Sometimes a transarticular screw fixation of C1-2 is necessary if there is a defect on the C-1 posterior arch. Craniocervical dislocations with assimilation of the atlas require posterior occipito-vertebral bony fixation with grafts and external halo immobilization or internal fixation with hooks or screws, with anterior transoral decompression in a second step.

Probing magnetic properties of the reduced [2Fe-2S] cluster of the ferredoxin from Arthrospira platensis by 1H ENDOR spectroscopy

The 1H electron nuclear double resonance (ENDOR) spectra in frozen solutions of the reduced [2Fe-2S] cluster in ferredoxin from Arthrospira (Spirulina) platensis have been measured at low temperatures (5-20 K) and simulated using orientational selection methods. The analysis confirmed the existence of a single paramagnetic species with iron valence states II and III connected uniquely to the cluster irons. The experimental ENDOR spectra were fitted to a model including the spin distribution on the centre, the orientation of the g-matrix, and the isotropic and anisotropic hyperfine couplings of the nearest protons in the crystallographically determined structure. In order to partially simulate ENDOR line shapes, a statistical distribution of the corresponding torsion angles between the Fe(III) centre and one of the beta-CH2 protons was introduced. From the analysis, four of the larger hyperfine couplings found were assigned to the cysteine beta-protons near the Fe(III) ion of the cluster, with isotropic hyperfine couplings ranging from 1.6 to 4.1 MHz. The spin distribution on the two iron ions was estimated to be +1.85 for the Fe(III) ion and -0.9 for the Fe(II) ion. The Fe(III) ion was identified as being coordinated to the cysteine ligands Cys49 and Cys79, confirming previous NMR results. The direction of the g-tensor with respect to the cluster was deduced. The g1-g2 plane is parallel to the planes through each iron and its adjacent cysteine sulfurs; the g2-g3 plane is nearly perpendicular to the latter planes and deviates by 25 degrees from the FeSSFe plane. The g1 direction is dominated by the bonding geometry of Fe(II) and does not align with the Fe(II)-Fe(III) vector.

Analysis of the turin umbilical cord blood bank registry

BACKGROUND

The polymorphic nature of the HLA system reduces a patient's probability of finding an HLA-compatible unrelated bone marrow (BM) donor, even though more than 6 million individuals are enrolled in international registries. Recently, umbilical cord blood (UCB) has been successfully employed as a source of HPCs. The use of such cells reduces the risk of GVHD and allows transplants with one or two HLA mismatches. UCB represents an expensive resource: therefore, it is necessary to carefully manage the UCB unit inventory.

STUDY DESIGN AND METHODS

The current study analyzed the genetic heterogeneity of HLA-A, -B, and -DR gene frequencies between pools of UCB and unrelated-donor BM in the Piedmont (an administrative region of Italy). An Italian hematology patient's probability of finding complete or partial matches as a function of donor pool size was determined by considering subsamples randomly selected from the local unrelated BM donors.

RESULTS

The HLA gene frequencies in UCB and unrelated-donor BM pools were not significantly different. The search simulation, based on actual HLA phenotypes, showed that the percentage of Italian patients matched with an HPC unit increases remarkably if 1 or 2 mismatches are accepted, reaching a proportion of 90 percent with an inventory of only about 500 units, while the increment is not so remarkable if the number of UCB units is greater.

CONCLUSION

To optimize economic resources and to be internationally competitive, UCB banks should aim to increase the genetic heterogeneity of their units rather than increasing the UCB inventory, acquire efficient quality control systems, and acquire and preserve UCB units with a greater number of nucleated cells.

AUUUA sequences compromise human insulin-like growth factor binding protein-1 mRNA stability

The instability of IGFBP-1 mRNA appears to play a role in regulating the expression of the IGFBP-1 gene, the 3' region of which contains five ATTTA sequences. We have studied the implication of these sequences for IGFBP-1 mRNA destabilization. Six plasmids were constructed, containing increasingly shorter lengths of IGFBP-1 cDNA, each with a successive ATTTA sequence deleted from the 3' end. These were stably transfected into two non-IGFBP-1-expressing (cervical carcinoma and neuroblastoma) cell lines. Kinetics studies following inhibition of transcription showed that (1) the half-life of the full-length messenger was 2.80 +/- 0.32 h; (2) deletion of each successive sequence (particularly the second and the fourth) yielded a transcript of increasing stability; and (3) the half-life of the AUUUA-free mRNA was 26.65 +/- 1.65 h. Although the primary source of IGFBP-1 is the liver, our results demonstrate that destabilization of its mRNA is not liver-specific. The ATTTA consensus sequences in the 3' untranslated region of the IGFBP-1 gene therefore provide a posttranscriptional regulation pathway that, combined with transcriptional regulation, may account for the variations in IGFBP-1 expression with developmental stage, nutritional status, and hormonal environment.

[Unusual approaches to hypophyseal adenomas]

For pituitary adenomas surgery, rhinoseptal transsphenoidal approach is used in 98 to 99% of the cases. Although this approach is fitting for microadenomas and the majority of macroadenomas, some of them develop extensions in the nasal fossas, the posterior cranial fossa, the suprasellar region, or into the cavernous sinus and will require other approaches. For the superior routes, the frontopterional approach gives good control of the suprasellar region, the anterior and middle base of the skull. The tumor dissection is performed inside the concavity of the chiasm and between the internal carotid artery and the optic nerve (optico-carotid approach). The frontopterional approach is used for superolateral extensions, especially in the lateral fissure. The bifrontal basal inter hemispheric approach, through a medial frontal bone flap tangential to the base, gives a good route to the suprasellar region and behind the dorsum, and also for tumors extended in the third ventricle in case of prefixed chiasm. For the inferior routes, the participation of ENT or craniofacial surgeons is a great help. The transfacial or transethmoidal approach performs a hollowing of the nasal fossas and gives a large interorbital tunnel adapted for tumors extended in the rhinopharynx and the ethmoid. The Le Fort I maxillary osteotomy offers also a large approach for adenomas extending in the rhinopharynx. The transcavernous approach from Dolenc, for adenomas progressing in the cavernous sinus requires a long and difficult procedure. The progression of some adenomas in many directions may require a combined approach in one or two procedures.

Liver-specific expression of human insulin-like growth factor binding protein-1 in transgenic mice: repercussions on reproduction, ante- and perinatal mortality and postnatal growth

Study of the in vivo functions of the insulin-like growth factor binding proteins (IGFBPs) is complicated by their variety (six molecular species) and the differences in their expression related to tissue of origin and stage of development. To investigate the physiological role of IGFBP-1 in the bloodstream, we induced hepatic overexpression of IGFBP-1 in transgenic mice, placing human IGFBP-1 (hIGFBP-1) cDNA under the control of the alpha1-antitrypsin promoter so as to obtain liver-specific expression. Five transgenic founder mice were raised, only two of which (lines 124 and 149) produced transgenic offspring. Northern blotting revealed transgene expression exclusively in the liver during fetal life and unchanged through to adulthood, whereas expression of the endogenous gene was undetectable beyond 10-15 days postnatally. hIGFBP-1 was detected by western immunoblotting in the plasma of transgenic mice and IRMAs yielded mean concentrations of 2.41 +/- 0.33 ng/ml and 13.69 +/- 1.42 ng/ml in homozygous animals of lines 124 and 149, respectively. In the latter, IGFBP-1 levels were distinctly higher than in heterozygotes (2.99 +/- 0.39 ng/ml), P < 0.0001. These levels remained stable in each given animal and did not change with age. Plasma concentrations of IGF-I measured in line 149 exhibited the well-known profile of an increase from birth up to puberty. Values for heterozygotes were similar to those for wild-type mice, with adult levels (544 +/- 98 ng/ml) slightly below those of controls (630 +/- 56 ng/ml), P < 0.05. In homozygotes they were distinctly lower, with adult levels of 370 +/- 75 ng/ml, P = 0.001. In heterozygous and homozygous adults, there was a negative correlation between IGF-I and IGFBP-1 concentrations (r = 0.8, P < 0.0001), suggesting a link between transgene expression and IGF-I levels. Study of body weight gain in line 149 revealed growth retardation within the first weeks after birth, which was marked in homozygous males and females (P < 0.001) but also present in heterozygous males (P = 0.002), indicating some relationship with transgene expression. In addition, body weight in adult mice was negatively correlated to plasma concentrations of IGFBP-1 (r = 0.7, P < 0.0001). Reproductive function also appeared to be severely affected, especially in homozygous females: mating that failed to result in pregnancy in half of the homozygous females crossed with nontransgenic males, suggestive of impaired fertilization or implantation; interrupted or prolonged pregnancies with fetal and neonatal death. Litter size was reduced in transgenic females (by about half in homozygotes) and in nontransgenic females mated with homozygous males, resulting from pre- or neonatal mortality. Moreover, deaths occurred within the first 5 days of life, with an incidence of approximately 50% in the litters of homozygous females, 12-18% among heterozygotes mated with nontransgenic or heterozygous males, respectively, and 30% among those mated with homozygous males. These results, suggesting that fetal transgene expression largely accounted for ante- and perinatal mortality, were confirmed by the predominance of homozygotes among those that could be analyzed genetically. Similarly impaired reproductive function was seen in line 124, but to a lesser degree. Although the mechanisms responsible for these disorders remain to be determined, our results indicate that permanent and uncontrolled hepatic expression of IGFBP-1, even at low levels, affects fertility in females and both ante- and postnatal development.

Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders

Tremor was suppressed by test stimulation of the thalamic ventralis intermedius (VIM) nucleus at high frequency (130 Hz) during stereotaxy in nonanesthetized patients suffering from Parkinson's disease or essential tremor. Ventralis intermedius stimulation has since been used by the authors over the last 8 years as a treatment in 117 patients with movement disorders (80 cases of Parkinson's disease, 20 cases of essential tremor, and 17 cases of various dyskinesias and dystonias including four multiple sclerosis). Chronic electrodes were stereotactically implanted in the VIM and connected to a programmable stimulator. Results depend on the indication. In Parkinson's disease patients, tremor, but not bradykinesia and rigidity, was selectively suppressed for as long as 8 years. Administration of L-Dopa was decreased by more than 30% in 40 Parkinson's disease patients. In essential tremor patients, results were satisfactory but deteriorated with time in 18.5% of cases, mainly for patients who presented an action component of their but deteriorated with time in 18.5% of cases, mainly for patients who presented an action component of their tremor. In other types of dyskinesias (except multiple sclerosis), results were much less favorable. Fifty-nine patients underwent bilateral implantation and 14 other patients received implantation contralateral to a previous thalamotomy. Thirty-seven patients (31.6%) experienced minor side effects, which were always well tolerated and immediately reversible. Three secondary scalp infections led to temporary removal of the implanted material. There was no permanent morbidity. This tremor suppression effect could be due to the inhibition or jamming of a retroactive loop. Chronic VIM stimulation, which is reversible, adaptable, and well tolerated even by patients undergoing bilateral surgery (74 of 117 patients) and by elderly patients, should replace thalamotomy in the regular surgical treatment of parkinsonian and essential tremors.