Spontaneous breathing trial with pressure support on positive end-expiratory pressure and extensive use of non-invasive ventilation versus T-piece in difficult-to-wean patients from mechanical ventilation: a randomized controlled trial

BACKGROUND

The aim of this study is to assess whether a strategy combining spontaneous breathing trial (SBT) with both pressure support (PS) and positive end-expiratory pressure (PEEP) and extended use of post-extubation non-invasive ventilation (NIV) (extensively-assisted weaning) would shorten the time until successful extubation as compared with SBT with T-piece (TP) and post-extubation NIV performed in selected patients as advocated by guidelines (standard weaning), in difficult-to-wean patients from mechanical ventilation.

METHODS

The study is a single-center prospective open label, randomized controlled superiority trial with two parallel groups and balanced randomization with a 1:1 ratio. Eligible patients were intubated patients mechanically ventilated for more than 24 h who failed their first SBT using TP. In the extensively-assisted weaning group, SBT was performed with PS (7 cmH2O) and PEEP (5 cmH2O). In case of SBT success, an additional SBT with TP was performed. Failure of this SBT-TP was an additional criterion for post-extubation NIV in this group in addition to other recommended criteria. In the standard weaning group, SBT was performed with TP, and NIV was performed according to international guidelines. The primary outcome criterion was the time between inclusion and successful extubation evaluated with a Cox model with adjustment on randomization strata.

RESULTS

From May 2019 to March 2023, 98 patients were included and randomized in the study (49 in each group). Four patients were excluded from the intention-to-treat population (2 in both groups); therefore, 47 patients were analyzed in each group. The extensively-assisted weaning group had a higher median age (68 [58-73] vs. 62 [55-71] yrs.) and similar sex ratio (62% male vs. 57%). Time until successful extubation was not significantly different between extensively-assisted and standard weaning groups (median, 172 [50-436] vs. 95 [47-232] hours, Cox hazard ratio for successful extubation, 0.88 [95% confidence interval: 0.55-1.42] using the standard weaning group as a reference; p = 0.60). All secondary outcomes were not significantly different between groups.

CONCLUSION

An extensively-assisted weaning strategy did not lead to a shorter time to successful extubation than a standard weaning strategy. Trial registration The trial was registered on ClinicalTrials.gov (NCT03861117), on March 1, 2019, before the inclusion of the first patient. https://clinicaltrials.gov/study/NCT03861117 .

Pharmacokinetics, efficacy and tolerance of cefoxitin in the treatment of cefoxitin-susceptible extended-spectrum beta-lactamase producing Enterobacterales infections in critically ill patients: a retrospective single-center study

BACKGROUND

Cefoxitin is active against some extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE), but has not been evaluated so far in the intensive care unit (ICU) settings. Data upon its pharmacokinetics (PK), tolerance and efficacy in critical conditions are scanty. We performed a retrospective single-center study in a university hospital medical ICU, in subjects presenting with cefoxitin-susceptible ESBL-PE infection and treated with cefoxitin. The primary aim was to determine cefoxitin PK. Secondary endpoints were efficacy, tolerance, and emergence of cephamycin-resistance.

RESULTS

Forty-one patients were included in this study, mainly with ESBL-PE pneumonia (35 patients, 85%). Cefoxitin was administered during a median [interquartile range (IQR)] duration of 5 [4-7] days. Cefoxitin serum concentrations strongly depended on renal function. Target serum concentration (> 5 × minimum inhibitory concentration (MIC) 24 h after cefoxitin onset was obtained in 34 patients (83%), using a median [IQR] daily dose of 6 [6-6] g with continuous administration. The standard dosage of 6 g/24 h was not sufficient to achieve the PK/PD target serum concentration for MIC up to 4-8 mg/L, except in patients with severe renal impairment and those treated with renal replacement therapy. Treatment failure occurred in 26 cases (63%), among whom 12 patients (29%) died, 13 patients (32%) were switched to alternative antibiotic therapy and 11 patients (27%) presented with relapse of infection with the same ESBL-PE. Serious adverse events attributed to cefoxitin occurred in 7 patients (17%). Acquisition of cephamycin-resistance with the same Enterobacterales was identified in 13 patients (32%), and was associated with underdosage.

CONCLUSION

Continuous administration of large doses of cefoxitin appears necessary to achieve the PK/PD target in patients with normal renal function. Renal status, MIC determination and therapeutic drug monitoring may be useful for treatment individualization in this setting. The treatment failure rate was 63%. The cefoxitin safety profile was favorable, but we observed a high rate of cephamycin-resistance emergence.

Necrotizing external otitis: analysis of relapse risk factors in 66 patients managed during a 12 year period

BACKGROUND

Necrotizing external otitis (NEO) is a severe infection of the skull base that occurs generally in the elderly and/or in diabetic recipients. There are few data in the literature about the therapeutic management of this complex bone infection.

OBJECTIVES

To analyse relapses after NEO treatment completion, and to describe the clinical features of NEO.

METHODS

We performed a retrospective cohort study in the Lyon regional reference centre for the management of complex bone and joint infections. Consecutive cases of NEO from 1 January 2006 to 31 December 2018 were included. The primary outcome was the relapse of NEO. Variables were analysed using Cox regression survival analysis with adjusted hazard ratio (aHR) and Kaplan-Meier curve.

RESULTS

Sixty-six patients were included. Median age was 75 (IQR 69-81) years and 46 (70%) patients were diabetic. Eleven patients (17%) had temporomandibular arthritis, 10 (15%) cranial nerve paralysis, 2 (3%) cerebral thrombophlebitis, and 2 (3%) contiguous abscess. Microbiological documentation was obtained in 56 patients and revealed Pseudomonas aeruginosa in 44/56 patients (79%). Nine (14%) cases had no microbiological documentation. Antibiotic therapy was dual for 63 (95%) patients. During a median follow-up of 27 (IQR 12-40) months, 16 out of 63 (25%) patients experienced a relapse. Fungal infection was significantly associated with relapse [aHR 4.1 (95% CI 1.1-15); P = 0.03].

CONCLUSIONS

NEO is a severe bone infection, mainly (but not exclusively) caused by P. aeruginosa, which occurs in elderly and diabetic recipients. Fungal infections at baseline significantly impact the outcome.

Coxiella burnetti prosthetic joint infection in an immunocompromised woman: iterative surgeries, prolonged ofloxacin-rifampin treatment and complex reconstruction were needed for the cure

Background

Q fever is a zoonotic disease caused by the bacterium Coxiella burnetii, a strictly intracellular pathogen that can cause acute and chronic infection. Chronic Q fever can occur in immunocompetent as well as in immuno-compromised hosts, as a persistent localized infection. The main localizations are endocardial, vascular and, less frequently, osteoarticular. The most frequent osteoarticular form is spondyliscitis. Recommended treatment is combined doxycycline and hydroxychloroquine for 18 months, with cotrimoxazole as another option. Coxiella burnetti infection has been implicated in rare cases of prosthetic joint infection (PJI), and the medical and surgical management and outcome in such cases have been little reported.

Case presentation

We report an unusual case of chronic Q fever involving a hip arthroplasty in an immunocompromised woman treated with tumor necrosis factor (TNF)-α blockers for rheumatoid arthritis. Numerous surgical procedures (explantation, “second look”, femoral resection and revision by megaprosthesis), modification of the immunosuppressant therapy and switch from doxycycline-hydroxychloroquine to prolonged ofloxacin-rifampin combination therapy were needed to achieve reconstruction and treat the PJI, with a follow-up of 7 years.

Conclusions

Coxiella burnetti PJI is a complex infection that requires dedicated management in an experienced reference center. Combined use of ofloxacin-rifampin can be effective.

Short- and long-term prognosis of acute critically ill patients with systemic rheumatic diseases: A retrospective multicentre study

Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.

Prevalence and risk factors of hemodynamic instability associated with preload-dependence during continuous renal replacement therapy in a prospective observational cohort of critically ill patients

Background

Hemodynamic instability is a frequent complication of continuous renal replacement therapy (CRRT). Postural tests (i.e., passive leg raising in the supine position or Trendelenburg maneuver in the prone position) combined with measurement of cardiac output are highly reliable to identify preload-dependence and may provide new insights into the mechanisms involved in hemodynamic instability related to CRRT (HIRRT). We aimed to assess the prevalence and risk factors of HIRRT associated with preload-dependence in ICU patients.

We conducted a single-center prospective observational cohort study in ICU patients with acute kidney injury KDIGO 3, started on CRRT in the last 24 h, and monitored with a PiCCO® device. The primary endpoint was the rate of HIRRT episodes associated with preload-dependence during the first 7 days after inclusion. HIRRT was defined as the occurrence of a mean arterial pressure below 65 mmHg requiring therapeutic intervention. Preload-dependence was assessed by postural tests every 4 h, and during each HIRRT episode. Data are expressed in median [1st quartile–3rd quartile], unless stated otherwise.

Results

42 patients (62% male, age 69 [59–77] year, SAPS-2 65 [49–76]) were included 6 [1–16] h after CRRT initiation and studied continuously for 121 [60–147] h. A median of 5 [3–8] HIRRT episodes occurred per patient, for a pooled total of 243 episodes. 131 episodes (54% [CI_95% 48–60%]) were associated with preload-dependence, 108 (44%, [CI_95% 38–51%]) without preload-dependence, and 4 were unclassified. Multivariate analysis (using variables collected prior to HIRRT) identified the following variables as risk factors for the occurrence of HIRRT associated with preload-dependence: preload-dependence before HIRRT [odds ratio (OR) = 3.82, p < 0.001], delay since last HIRRT episode > 8 h (OR = 0.56, p < 0.05), lactate (OR = 1.21 per 1-mmol L⁻¹ increase, p < 0.05), cardiac index (OR = 0.47 per 1-L min⁻¹ m⁻² increase, p < 0.001) and SOFA at ICU admission (OR = 0.91 per 1-point increase, p < 0.001). None of the CRRT settings was identified as risk factor for HIRRT.

Conclusions

In this single-center study, HIRRT associated with preload-dependence was slightly more frequent than HIRRT without preload-dependence in ICU patients undergoing CRRT. Testing for preload-dependence could help avoiding unnecessary decrease of fluid removal in preload-independent HIRRT during CRRT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00883-9.

Ventilation Management and Outcomes for Subjects With Neuromuscular Disorders Admitted to ICUs With Acute Respiratory Failure

BACKGROUND

Patients with neuromuscular disorders (NMD) share the risk of acute respiratory failure (ARF) leading to ICU admissions. Noninvasive ventilation (NIV) is often proposed as an alternative to invasive ventilation. This study describes clinical features, ventilation management, and outcomes of subjects with NMD admitted to ICU and managed for ARF.

METHODS

We performed a multicenter retrospective study in 7 adult ICUs in the Auvergne-Rhone-Alpes area in France involving subjects with NMD admitted to the ICU for ARF. The primary end point was ICU mortality. Secondary end points were NIV failure, weaning from invasive ventilation, and long-term mortality. We hypothesized a poorer outcome in the case of bulbar musculature involvement.

RESULTS

A total of 242 subjects were included; 142 subjects had nonhereditary NMD (58.7%), and 100 had hereditary NMD (41.3%). Eleven subjects had home ventilation through a tracheostomy. While 112 were intubated at admission, 119 initially underwent NIV. NIV was successful in avoiding orotracheal intubation in 78 subjects (65.5%). ICU mortality was 13.6%. Factors associated with ICU mortality were nonhereditary NMD and requirement for invasive ventilation. The involvement of bulbar musculature in ARF and hereditary NMD were associated with NIV failure. After a median follow-up of 1.2 y, 53 of 209 subjects had died.

CONCLUSIONS

The ICU mortality of NMD subjects with ARF was low, with no impact of bulbar muscles involvement. NIV was proposed for approximately half of the subjects, and it was more effective when ARF was not attributed to bulbar musculature involvement. The long-term outcome was good.

[Cytomegalovirus infection in systemic lupus erythematosus patients. A series of 12 case reports and literature review]

INTRODUCTION

Patients with systemic lupus erythematosus (SLE) are at risk of cytomegalovirus (CMV) infection, due to the disease itself or to drug-induced immunosuppression. Also, active CMV infection may trigger or worsen SLE flare-up.

METHODS

In this retrospective single-centre cohort study, we reported all adult inpatients with a diagnosis of SLE, presenting with active and confirmed CMV infection. The goal was to describe their characteristics and outcomes (evolution of CMV infection, secondary infections and SLE flare-up), and to review the existing literature.

RESULTS

We identified 400 patients with confirmed SLE, including 12 who presented with active CMV infection. Severe CMV manifestations were present in 7 patients treated with immunosuppressive regimen out of 10, and in one patient out of two without immunosuppressive therapy. Six patients developed other infections, and 3 showed characterised SLE flare-up over the 3-month follow-up. All patients were alive at end of follow-up.

DISCUSSION

Among patients with SLE, CMV infection affected more frequently those treated with immunosuppressive drugs, but treatment-free patients were sometimes severely affected. CMV infection was associated with an increased incidence of SLE flare-up and infectious complications. Our results suggest that early anti-viral chemotherapy may be beneficial in these patients.

Simultaneous Presentation of Parvovirus B19 Infection and Systemic Lupus Erythematosus in a Patient: Description and Review of the Literature

We present the case of a 25-year-old woman without medical history, presenting with acute respiratory failure needing mechanical ventilation. Aetiologic screening showed PVB19 primary infection and concomitant SLE flare-up. We discuss the causative interactions between PVB19 and SLE in the pathogenesis of the disease. Difficulty diagnosing inaugural SLE flare-up concomitant with PVB19 infection can lead to delayed diagnosis and treatment. Inversely, overtreating a SLE-mimicking PVB19 infection with immunosuppressive agents can be highly detrimental.

Transpulmonary pressures in obese and non-obese COVID-19 ARDS

BACKGROUND

Data on respiratory mechanics of COVID-19 ARDS patients are scarce. Respiratory mechanics and response to positive expiratory pressure (PEEP) may be different in obese and non-obese patients.

METHODS

We investigated esophageal pressure allowing determination of transpulmonary pressures (PL ) and elastances (EL) during a decremental PEEP trial from 20 to 6 cm H₂O in a cohort of COVID-19 ARDS patients.

RESULTS

Fifteen patients were investigated, 8 obese and 7 non-obese patients. PEEP ≥ 16 cm H₂O for obese patients and PEEP ≥10 cm H₂O for non-obese patients were necessary to obtain positive expiratory P_L. Change of PEEP did not alter significantly ΔP_L or elastances in obese patients. However, in non-obese patients lung EL  and ΔP_L increased significantly with PEEP increase. Chest wall EL was not affected by PEEP variations in both groups.

Quantitative-analysis of computed tomography in COVID-19 and non COVID-19 ARDS patients: A case-control study

PURPOSE

The aim of this study was to assess whether the computed tomography (CT) features of COVID-19 (COVID+) ARDS differ from those of non-COVID-19 (COVID-) ARDS patients.

MATERIALS AND METHODS

The study is a single-center prospective observational study performed on adults with ARDS onset ≤72 h and a PaO₂/FiO₂ ≤ 200 mmHg. CT scans were acquired at PEEP set using a PEEP-FiO₂ table with VT adjusted to 6 ml/kg predicted body weight.

RESULTS

22 patients were included, of whom 13 presented with COVID-19 ARDS. Lung weight was significantly higher in COVID- patients, but all COVID+ patients presented supranormal lung weight values. Noninflated lung tissue was significantly higher in COVID- patients (36 ± 14% vs. 26 ± 15% of total lung weight at end-expiration, p < 0.01). Tidal recruitment was significantly higher in COVID- patients (20 ± 12 vs. 9 ± 11% of VT, p < 0.05). Lung density histograms of 5 COVID+ patients with high elastance (type H) were similar to those of COVID- patients, while those of the 8 COVID+ patients with normal elastance (type L) displayed higher aerated lung fraction.

Minimally invasive management of Bartholin gland abscesses (with demonstrative video)

Bartholin gland abscesses are common problems in women and their management represents a mainstay of gynecology. Various treatment methods have been described. We present a technique performed under local anesthesia, without hospitalization or postoperative care. As part of a minimally invasive approach, this procedure promotes therapeutic de-escalation, has high patient acceptance, improves clinical outcomes and reduces costs. The procedure is highlighted through an instructive video article which standardizes the essential steps, to make the technique ergonomics and easy to perform (step-by-step explanation).

Mechanisms underlying vasorelaxation induced in the porcine coronary arteries by Thymus linearis, Benth

ETHNOPHARMACOLOGICAL RELEVANCE

Thymus linearis, Benth indigenous to Pakistan has been traditionally used for the treatment of various diseases including hypertension.

AIM OF THE STUDY

Present study aims to investigate vasorelaxant effect of Thymus linearis and its underlying vasorelaxation mechanisms in porcine coronary artery rings.

MATERIALS AND METHODS

Aqueous-methanolic extract of aerial parts of Thymus linearis was prepared by maceration process and then bio-guided fractionation was carried out using different solvents. The effects of extract and subsequent fractions were assessed on coronary artery rings with intact and denuded endothelium. The mechanisms of vasorelaxant effect were investigated using different pharmacological tools. The in-vitro inhibitory effects of the test fractions were also assessed on purified phophodiestrases using radioenzymatic assay. Phytochemical studies were carried out using GCMS.

RESULTS

The aqueous-methanolic extract elicited similar relaxations in coronary artery rings with and without endothelium in dose dependent fashion and removal of endothelium did not alter this response. Further, n-butanolic fraction of Thymus liniaris (TLB) was found to be the most potent among other derived fractions. TLB did not alter the relaxation produced by endothelium dependent vasodilators in rings with intact endothelium. However, TLB significantly potentiated the relaxation elicited by cyclic AMP and cyclic GMP elevating drugs but not those to soluble guanylyl cyclase activators (YC-1 and BAY 41-2272) and K⁺ channel openers (levcromakalim and 1-EBIO). Pretreatment with TLB inhibited in a concentration-dependent manner contractions to KCl, CaCl₂ and U46619 in coronary artery rings without endothelium. Further, TLB was found to non-selectively inhibit the PDE activity in concentration manner.

CONCLUSION

n-Butanolic fraction of Thymus linearis possesses endothelium independent vasorelaxant effects in coronary artery by direct acting on the smooth muscles. These effects involve the elevation of the cyclic AMP and cyclic GMP possibly through the inhibition of various PDEs. GCMS analysis revel presence of thymole and carvacrol as major constituents. Furthermore, these investigations also support the folklore use of Thymus linearis in hypertension.

[What haemostatic technique should we use for opportunistic salpingectomy during benign laparoscopic hysterectomy?]

OBJECTIVE

To compare ovarian function before and after laparoscopic hysterectomy with bilateral salpingectomy for benign lesions with two different systems of haemostasis.

METHODS

In this prospective randomized study comparing two types of energy used for coagulation in bilateral salpingectomy (group A: bipolar electric energy, versus group B: ultrasonic advanced energy [Harmonic^®]), forty consecutive non-menopausal patients undergoing laparoscopic hysterectomy for benign lesions were included. Values of anti-Müllerian hormone (AMH), LH and FSH, antral follicle count (AFC) and ovarian vascularization on bilateral Doppler ultrasound, quality of life (questionnaire) were assessed preoperatively and at 1 and 3 months postoperatively.

RESULTS

Preliminary analysis showed shorter salpingectomy operating time (P<0.0001) and less bleeding (P<0.005) in group B. In group A, there was no statistical difference except a decrease in AFC at 1 and 3 months on the right ovary (P=0.04). In group B, AMH levels were significantly lower postoperatively at 3 months and LH levels were increased at 3 months (respectively P=0.02 et P=0.04). There was no statistical difference in the ultrasonographic data. Quality of life did not significantly differ in both groups.

CONCLUSION

Preliminary findings showed reduced AMH levels at 3months postoperatively in ultrasonic energy group whereas there was no significative menopausal symptoms. It seems important to continue this study in order to know the real effects of both energy systems on the ovarian function.

[Lucy's cancer(s): A prehistorical origin?]

OBJECTIVES

The recent discovery of the earliest hominin cancer, a 1.7-million-year-old osteosarcoma from South Africa has raised the question of the origin of cancer and its determinants. We aimed to determine whether malignant and benign tumors exist in the past societies.

METHODS

A review of literature using Medline database and Google about benign and malignant tumors in prehistory and antiquity. Only cases with morphological and paraclinical analysis were included. The following keywords were used: cancer; paleopathology; malignant neoplasia; benign tumor; leiomyoma; myoma; breast cancer; mummies; soft tissue tumor; Antiquity.

RESULTS

Thirty-five articles were found in wich there were 34 malignant tumors, 10 benign tumors and 11 gynecological benign tumors.

CONCLUSIONS

The fact that there were some malignant tumors, even few tumors and probably underdiagnosed, in the past may be evidence that cancer is not only a disease of the modern world. Cancer may be indeed a moving target: we have likely predisposing genes to cancer inherited from our ancestors. The malignant disease could therefore appear because of our modern lifestyle (carcinogens and risk factors related to the modern industrial society).

Endothelium-independent vasorelaxant effect of a Berberis orthobotrys root extract via inhibition of phosphodiesterases in the porcine coronary artery

BACKGROUND

Berberis orthobotrys Bien ex Aitch. (Berberidaceae) is a plant indigenous of Pakistan that is locally used for the treatment of hypertension.

HYPOTHESIS

This study evaluated the vasoactive properties of a Berberis orthobotrys root extract and its fractions, and investigated the role of the endothelium and the underlying mechanism.

STUDY DESIGN

An aqueous methanolic extract of Berberis orthobotrys roots was prepared and submitted to a multi-step liquid-liquid fractionation with solvents of increasing polarity. Vascular reactivity of the different fractions was assessed using porcine coronary artery rings either with or without endothelium, and in the presence or absence of specific pharmacological tools. The ability of Berberis orthobotrys extracts to affect phosphodiesterase (PDE) activity was evaluated using a radioenzymatic method and purified phosphodiesterases.

RESULTS

The aqueous methanol extract induced similar relaxations in coronary artery rings with and without endothelium, and, amongst the three derived preparations, the butanol fraction (BFBO) was slightly but significantly more effective than the ethyl acetate fraction and the aqueous residue in rings without endothelium. Analysis of the butanol fraction (BFBO) by LC-ELSD-MS indicated the presence of four major isoquinoline alkaloids including berberine. BFBO significantly potentiated the relaxations induced by cyclic GMP- and cyclic AMP-dependent relaxing agonists, and inhibited contractions to KCl, CaCl2, and U46619 in endothelium denuded rings. In contrast, BFBO did not affect relaxations to endothelium-dependent vasodilators. BFBO concentration-dependently inhibited the cyclic GMP-hydrolyzing activity of basal PDE1, calmodulin-activated PDE1 and PDE5, and of cyclic AMP-hydrolyzing activity of PDE3 and PDE4 with IC50 values ranging from 40 to 130µg/ml.

CONCLUSION

The butanol fraction of the aqueous methanol extract of Berberis orthobotrys roots induced pronounced endothelium-independent relaxations and inhibited contractile responses by acting directly at the vascular smooth muscle in the coronary artery. Moreover, BFBO potentiated relaxations induced by both cyclic GMP- and cyclic AMP-dependent vasodilators most likely due to its ability to inhibit several vascular PDEs, and in particular PDE4 and PDE5.

[Current surgical practice of prophylactic and opportunistic salpingectomy in France]

OBJECTIVES

Since the recent evidence of a tubal origin of most ovarian cancers, opportunistic salpingectomy could be discussed as a prophylactic strategy in the general population and with hereditary predisposition. We aimed to survey French gynecological surgeons about their current surgical practice of prophylactic salpingectomy.

METHODS

An anonymous online survey was sent to French obstetrician-gynaecologists and gynecological surgeons. There were 13 questions about their current clinical practice and techniques of salpingectomy during a benign hysterectomy or as a tubal sterilization method, salpingectomy versus salpingo-oophorectomy in the population with genetic risk, salpingectomy in relationship with endometriosis and questions including histopathological considerations.

RESULTS

Among the 569 respondents, opportunistic salpingectomy was always performed between 42.48% and 43.44% during laparoscopic, laparoscopic-assisted vaginal or laparotomic hysterectomy and only 12.26% in case of vaginal route. In the genetic population, salpingo-oophorectomy was mainly performed. Tubal sterilization was often practiced by the hysteroscopic route. More than 90% of respondents didn't perform salpingectomy in case of endometriosis. There was not any specific tubal histopathological protocol in 71.54% of cases.

CONCLUSIONS

Salpingectomy may be a preventing strategy in the low- and high-risk population. The survey's responses show that salpingectomy seems to be a current practice during benign hysterectomy for more than 40% doctors. However, there is not any change with no more salpingectomy in the population with genetic risk, or in case of endometriosis or tubal sterilization.

[Is endometriosis a precancerous lesion? Perspectives and clinical implications]

Epidemiological studies have shown a relationship between endometriosis and clear cell/endometrioid ovarian cancers (named "Endometriosis Associated Ovarian Cancer" or EAOC). The recent discovery of signaling pathways (especially the SWI/SNF and PI3K/AKT/mTOR pathways) that linked endometriosis and EAOC could lead to the development of specific biomarkers as ARID1A to screen benign to premalignant endometriosis and to new targeted treatment. Moreover, the better understanding of the pathogenesis of the epithelial ovarian cancer arising from the Fallopian tube could allow new early prevention strategies that will be described in this review.

Antimony to Cure Visceral Leishmaniasis Unresponsive to Liposomal Amphotericin B

We report on 4 patients (1 immunocompetent, 3 immunosuppressed) in whom visceral leishmaniasis had become unresponsive to (or had relapsed after) treatment with appropriate doses of liposomal amphotericin B. Under close follow-up, full courses of pentavalent antimony were administered without life-threatening adverse events and resulted in rapid and sustained clinical and parasitological cure.

Visceral leishmaniasis causes fever, enlargement of internal organs like the liver and the spleen, and leads to death if no treatment is given. It is caused by a microbe called Leishmania and affects children and adults in warm and temperate regions of the world. Antimony in different forms has been used to treat Visceral Leishmaniasis for almost one century and is still in use in several countries despite the fact that it sometimes displays toxic effects, especially in patients with underlying health problems. Because it is better tolerated and at least as effective as antimony, liposomal amphotericin B is now used as the first treatment for Visceral Leishmaniasis in Southern Europe. We observed that a small proportion of patients—especially those with an impaired immune system—do not cure even after several courses of liposomal amphotericin B. In 4 such patients with “unresponsiveness” to liposomal amphotericin B, antimony provided a sustained cure without major side effects. We conclude that when multiple failures or relapses occur after treatment with liposomal amphotericin B, antimony is a reasonable, potentially life-saving treatment option. These observations also suggest that “unresponsiveness” to amphotericin B results from unusual resistance mechanisms.

An unusual cause of cardiothyreosis

Severe hyperthyroidism can cause cardiac complications, such as severe rhythm disturbances, heart failure and angina. Gestational trophoblastic disease (GTD) is a rare complication of pregnancy, ranging from benign hydatidiform mole to malignant form. Clinical hyperthyroidism may occur in GTD, as human chorionic gonadotropin (hCG) secreted by molar tissue is structurally similar to thyroid-stimulating hormone. Cardiothyreosis in this context is exceptional. We report the case of a nulligravida 42-year-old woman without thyroid or cardiac history who presented to the emergency department for dyspnoea. Examinations revealed an acute pulmonary oedema and sinus tachycardia. Serum hCG concentration was abnormally high (762 878 UI/l, N < 5). CT scan showed a voluminous uterine mass and eliminated pulmonary embolism. Cardiac output was increased in echocardiography. Complementary blood tests showed a peripheral hyperthyroidism. GTD was evoked in the context of uterine mass and high hCG concentration, which was responsible for inducing clinical hyperthyroidism and cardiothyreosis. A total hysterectomy was performed and histopathological examinations concluded to a non-invasive complete hydatidiform mole (begnin form). hCG fell to normal within 12 weeks, cardiac and thyroid functions normalized after mole evacuation.

[Surgery alone or in association with preoperative uterovaginal brachytherapy for stage IB1 cervical cancer: Toxicities profiles]

OBJECTIVE

To assess toxicity profile in two stage-IB1 cervical cancer treatment strategies: surgery with and without preoperative uterovaginal pulsed dose-rate brachytherapy.

METHODS

A retrospective study included 45 patients presenting stage-IB1 cervical cancer without pelvic lymph-node invasion, between 2009 and 2011: 25 treated by colpohysterectomy alone (group A) and 20 with preoperative uterovaginal pulsed dose-rate brachytherapy (group B). The median follow-up was 45 and 39 months (group A and B).

RESULTS

Groups were comparable for age (median, 46.9 vs 47.6 years), histologic type (52% vs 65% squamous cell carcinoma) and tumor size (68% vs 60%, <2cm). In postoperative year 1, rates of urinary, digestive and gynaecological disorder were 39.1%, 8.7% and 15% respectively in group A versus 36.8%, 5.3% and 31.6% in group B and in year 2, 5.9%, 8.4% and 15% versus 5.6%, 5.1% and 27.8%.

DISCUSSION AND CONCLUSION

The present study comparing two stage-IB1 cervical cancer treatment strategies found no significant difference in early or late complications. In 2 months, there was greater grade-3 urinary toxicity (21.1%) and sexual disorder (15.8%) with preoperative brachytherapy but no significant difference. Exclusive surgery is probably preferable for the patient's quality of life.

An intracellular wave of cytochrome c propagates and precedes Bax redistribution during apoptosis

Bax is considered to be pivotal in inducing cytochrome c release (CCR) from mitochondria during apoptosis. Indeed, Bax redistributes to the mitochondrial outer membrane (MOM) upon activation and forms homo-multimers that are capable of permeabilizing the MOM. Our attempts to image this sequence of events in single live cells resulted in unexpected observations. Bax redistribution exhibited two distinct components: an early minor redistribution that was silent in terms of homo-multimerization and a major late redistribution that was synchronous with the formation of Bax multimers, but that proceeded belatedly, i.e. only after caspase 3/7 (C3/7) had already been activated. Intriguingly, neither of these two components of redistribution correlated with CCR, which turned out to be spatially organized, propagating as a traveling wave at constant velocity. Strikingly, propagation of the CCR wave (1) preceded signs of in situ Bax conformational activation; (2) appeared to be independent of autocatalytic loops involving a positive feedback of either C3/7, Ca(2+) mobilization or mitochondrial permeability transition; and (3) was triggered by diffuse stimulation with the synthetic Bak activator BH3I-1 but then proceeded independently of Bak activation. Thus, the CCR wave not only questions the exact role of Bax redistribution in cell death, but also indicates the existence of yet unidentified positive-feedback loops that ensure a spatiotemporal control of apoptosis at the subcellular scale.

Suspension du fond du vagin par bandelette transobturatrice postérieure

OBJECTIVE

A study on the feasibility and safety of a new surgical procedure of vaginal vault suspension using a polypropylene mesh placed in the uterovaginal septum by a posterior transobturator approach.

PATIENTS AND METHODS

Longitudinal study from March 2002 to January 2006 of patients treated by this new surgical procedure. Postoperative visits, including an interview and a physical examination were made at two, six and 12 months and annually thereafter. The minimal required follow-up time was 12 months up to January 2007.

RESULTS

Seventy-eight patients were included. Three cases of intraoperative bleeding occurred. In these cases no transfusion was required and no complications were observed later on. The mean hospital stay was five days (range 3-9). The mean follow-up time was 20.36 months (range 12-48). Six recurrences were observed in the medial compartment (8%) and two anterior recurrences (2%). There was no recurrence in the posterior compartment. New-onset moderate dyspareunia was noted in 13% of the cases and a severe in two cases. No erosion occurred.

DISCUSSION AND CONCLUSION

The analysis of our experience shows that vaginal vault suspension by posterior transobturator approach is a safe and simple procedure, and demonstrates its median efficacy. Further, this study should confirm these results over the long-term follow-up.

Collisionless heating in capacitive discharges enhanced by dual-frequency excitation

We discuss collisionless electron heating in capacitive discharges excited by a combination of two disparate frequencies. By developing an analytical model, we find, contrary to expectation, that the net heating in this case is much larger than the sum of the effects occurring when the two frequencies act separately. This prediction is substantiated by kinetic simulations, which are also in excellent general quantitative agreement with the model for discharge parameters that are typical of recent experiments.

Inductive heating and E to H transitions in capacitive discharges

Capacitive discharges have classically been modeled in the electrostatic approximation. However, electromagnetic effects become significant if the excitation wavelength lambda and the plasma skin depth delta are not infinite. An electromagnetic model valid in the entire range of lambda and delta of practical interest is solved. We find that the plasma may either be sustained by the usual capacitive (E) field or by an inductive (H) field, and that the discharge experiences E to H transitions as the voltage between the electrodes is raised.

Enhanced plasma transport due to neutral depletion

The dynamics of plasma and neutral gas in pressure balance are solved self-consistently to reveal the impact of neutral depletion. Analytical relations that determine the electron temperature, the rate of ionization, and the plasma density are derived. Because of the inherent coupling of ionization and transport, an increase of the energy invested in ionization can nonlinearly enhance the transport process. We show that such an enhancement of the plasma transport due to neutral depletion can result in an unexpected decrease of the plasma density when power is increased, despite the increase of the flux of generated plasma.

[Uterine and ovarian metastases 28 years after the discovery of breast cancer]

INTRODUCTION

Breast cancer seldom leads to uterine metastases, but more frequently spreads to the ovaries.

OBSERVATION

A 72 year-old woman treated 28 years earlier for a breast cancer (conservative treatment and ovarian castration through radiotherapy) presented with metrorrhagia. The hysteroscopy and uterine curettage were normal. Three months later she presented with bone pains and pain along the course of the femoral nerve. The clinical examination revealed the existence of left axillary and sub-clavicle adenopathies. A biopsy of the lymph nodes showed a lobular adenocarcinoma with positive hormonal receptors. The clinical and biological state of the patient improved under treatment with tamoxifen and aredia. Eight months later the patient complained of pelvic pains. The ultrasound examination showed a pelvic tumour situated at the fundus of an enlarged uterus, as well as peritoneal effusion. The patient underwent a total hysterectomy and multiple biopsies that revealed diffuse metastases of a lobular adenocarcinoma spreading to the neck and the body of the womb, the mesosalpinx, the left ovary and the epiploon. The patient died less than a year after the first symptoms had appeared.

DISCUSSION

Uterine metastases of extrapelvic origin are rare. Breast cancer is the first cause of this dissemination. It is generally invasive, lobular, and frequently spreads to the ovaries. In the case reported here, what is remarkable is the exceptionally long period between the discovery of a breast cancer and the apparition of metastases. Hence, in order to detect a primary or secondary ovarian or uterine cancer, it is important to emphasize the necessity of systematic pelvic examination in patients treated for breast cancer.

[Management of triplet and quadruplet pregnancies]

The management of multiple pregnancies is analyzed on the basis of the results in a series of 34 triple pregnancies and 5 quadruple pregnancies. Hypertension of pregnancy occurred in 6 of the patients, a threat of severe premature delivery in 15 patients. Severe cardiovascular complications, related to beta-mimetics, occurred in one case. Delivery was virtually always by Caesarian, with a mean gestational age of 31 weeks and 5 days for the triple pregnancies and 30 weeks and 5 days for the quadruple pregnancies. In 8.4% of cases, the offspring showed severely retarded intrauterine growth. The total mortality rate was 11.7% for the triple pregnancies and 15% for the quadruple pregnancies. Most deaths during the neo-natal period occurred in offspring from 4 pregnancies in which delivery occurred before 28 weeks of amenorrhea. After 28 weeks of amenorrhea, the adjusted total mortality was 4.2% for the triple pregnancies and no offspring of a quadruple pregnancy died. The prevention of the risk of threatened very early premature delivery led us to propose routine hospitalization after 26 weeks of amenorrhea, in order to improve the foetal prognosis in this age group. Carrying out a Caesarian later, after about 34 weeks of amenorrhea for the triple pregnancies and 32 weeks of amenorrhea for the quadruple pregnancies, made it possible to reduce the incidence of delayed intra-uterine growth and in utero foetal death and also made it possible to schedule the date of delivery. Good obstetric-pediatric coordination is also an essential factor in improving the prognosis for these high-risk pregnancies.