Red cell transfusion in outpatients with myelodysplastic syndromes: a feasibility and exploratory randomised trial

Optimal red cell transfusion support in myelodysplastic syndromes (MDS) has not been tested and established. The aim of this study was to demonstrate feasibility of recruitment and follow-up in an outpatient setting with an exploratory assessment of quality of life (QoL) outcomes (EORTC QLQ-C30 and EQ-5D-5L). We randomised MDS patients to standardised transfusion algorithms comparing current restrictive transfusion thresholds (80 g/l, to maintain haemoglobin 85-100 g/l) with liberal thresholds (105 g/l, maintaining 110-125 g/l). The primary outcomes were measures of compliance to transfusion thresholds. Altogether 38 patients were randomised (n = 20 restrictive; n = 18 liberal) from 12 participating sites in UK, Australia and New Zealand. The compliance proportion for the intention-to-treat population was 86% (95% confidence interval 75-94%) and 99% (95-100%) for restrictive and liberal arms respectively. Mean pre-transfusion haemoglobin concentrations for restrictive and liberal arms were 80 g/l (SD6) and 97 g/l (SD7). The total number of red cell units transfused on study was 82 in the restrictive and 192 in the liberal arm. In an exploratory analysis, the five main QoL domains were improved for participants in the liberal compared to restrictive arm. Our findings support the feasibility and need for a definitive trial to evaluate the effect of different red cell transfusion thresholds on patient-centred outcomes.

The role of immunohistochemical tests in multimodal treatment of the aggressive forms of breast cancer

Aggressive breast cancer is an invasive form with a differentiation degree G3/G4, the absence of estrogen receptor and progesterone and the absence or presence of the gene HER 2(+ or 3+). The immunohistochemical tests have an important role in establishing the diagnosis and the therapy.

MATERIAL AND METHOD

It was shown that the aggressive breast cancers, 97 out of 316 cases were operated in the period October 2011 - February 2014. The criteria of inclusion/ exclusion in the study groups and the treatment schemes were exposed.

RESULTS

For the study group (group A=43/ group B=45/ group C=9 cases), the distribution according to the age group and immunohistochemical classification, were shown and, histologically, the type of surgical intervention, postoperative staging, postoperative complications were highlighted.

CONCLUSIONS

The treatment of the aggressive forms of breast cancer, neoadjuvant and adjuvant can both be set only by IHC tests.

Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI)

INTRODUCTION

Surgical management of intussusception is required for cases where enema reduction fails. Some articles report an advantage of the laparoscopic over the open approach, but complications such as serosal tearing and frank perforation have been described. We aim to determine the best indication of laparoscopy in the decisional management tree of intussusception.

PATIENT AND METHOD

This is a retrospective chart review of all children with intussusception who failed hydrostatic enema reduction and who underwent immediate laparoscopic management. Cases were compiled from 7 pediatric surgical centers (French Study Group of Pediatric Laparoscopy) between 1992 and 2005. Data collected included age, duration of symptoms, findings on initial assessment, level of intussusceptum after attempted hydrostatic enema reduction, type of laparoscopic approach, operative time, conversion to open surgery, etiology, and postoperative complications. Two groups were analyzed-conversion to open surgery or not.

RESULTS

Sixty-nine patients (48 males and 21 females) were reviewed. In total, 22 patients required a conversion to open surgery (31.9%). Eleven of these were converted because of failure of laparoscopic reduction. The risk for conversion to open surgery is directly linked to the length of time between onset of symptoms and diagnosis (1.6 vs 3.1 days for conversion group, P = .048), the presence of signs of peritonitis on the initial clinical assessment (10.6% vs 41% in conversion group, P = .003), and the presence or absence of a pathologic lead point (17% vs 50% in conversion group, P = .004).

CONCLUSION

The child seen early after the onset of symptoms (<1.5 days) with no signs of peritonitis is the best candidate for a laparoscopic approach in management of intussusception requiring surgery. Particular attention must be paid to not miss a pathologic lead point, especially as most tactile cues are lost.

Évaluation de l'information sur Internet destinée aux patients francophones en neuro-oncologie

OBJECTIVE

Internet has become the first place where patients go to when seeking information about their disease. Little is known about the type and the quality of the medical information available on French-speaking websites, especially in the field of neuro-oncology. The purpose of this study was to evaluate the quality of these sites.

MATERIALS AND METHODS

We entered six key words "glioblastome", "méningiome", "métastase cérébrale", "neurinome de l'acoustique", "adénome à prolactine" and "lymphome primitif cérébral" into 2 different search engines and, for each key word, the first fifty websites were reviewed using the tool "DISCERN", and with the help of two neuro-oncologists, we rated their content in terms of quality and comprehension.

RESULTS

On 612 websites only 110 (18%) contained information that proved to be somewhat useful to patients. The average score for quality was 32, which is considered to be <<poor>>. According to our scoring system, 1.8% of websites were found to be "excellent", 11.8% "good", 24.5% "fairly good", 15.4% "average", 32.7% "poor" and 13.6% "very poor". Just over 50% of the websites were found to be clear. The study also showed that the order in which these websites were ranked in the search engine, their affiliation, their target or who financed them had little impact on quality. The websites were more likely to be of high quality if they were managed by doctors and had bibliographical references as well as a date indicating a recent website's update.

DISCUSSION AND CONCLUSION

This study shows that the search for medical information on the Internet is time consuming and often disappointing: very few websites provide information that is both clear and exhaustive. However, we also found that very few websites contained information that was seriously inaccurate. Given the growing popularity of the Internet, patients could certainly benefit from a high quality French speaking website that would specialize in cerebral tumors, as well as from a neuro-oncological portal that would take them to selected websites as it would save time and would be a guarantee for quality.

Traitement par cœlioscopie des hernies inguinales de l'enfant: 212 patients

OBJECTIVES

Laparoscopic treatment of inguinal hernias in children remains controversial. The inguinal approach is the only recommended procedure nowadays. The aim of our series was to precise the results of this technique and its advantages.

POPULATION AND METHODS

We report our preliminary experience in laparoscopy for inguinal hernias in 212 children.

RESULTS

Laparoscopy allowed us to discover 26 controlateral hernias not previously diagnosed, 3 direct hernias with 1 of them associated with a patent process vaginalis, 2 femoral hernias associated with a patent process vaginalis, 1 double pouch hernia and 1 volvulus of a cyst developed from a patent process vaginalis. In case of recurrence after an inguinal approach, laparoscopy seemed to be helpful to evaluate the anatomical lesion. We observed only 1 recurrence.

DISCUSSION

Indications for laparoscopy in case of inguinal hernia in children are reviewed and discussed in the literature. Laparoscopic diagnosis for a precise diagnosis is no more discussed. Various techniques were proposed in case of laparoscopic treatment of inguinal hernias in children: most of surgeons realized only a suture of the sac. We prefer to dissect all the sac in order to avoid any recurrence. Advantages of laparoscopic approach become more obvious after the age of 2 years when the opening of the parietal wall is required in case of an inguinal approach and when local anaesthesia is no more recommended. The opportunity to diagnose a bilateral hernia when non diagnosed before surgery or to discover a femoral or a direct hernia, or in case of recurrence after an inguinal approach, the atraumatic dissection of the vas and spermatic vessels at the level of the internal inguinal ring, are the main advantages for laparoscopy.

Clinical impact of cachexia on survival and outcome of cancer patients

Approximately one half of all cancer patients experience a complex metabolic status involving progressive exhaustion of adipose and skeletal muscle tissue. This condition, known as cachexia, is responsible for more than 20% of the overall deaths in cancer patients. Although its main mechanisms remain unknown, several hypotheses have been proposed. One of the pathogenic mechanisms involves leptin and hypothalamic neuropeptide-containing pathways. Orexigenic and anorexigenic neuropeptides are down-regulated respectively upregulated as a result of cancer. Other pathogenic theories consider tumour derived factors, such as LMF (Lipid Mobilising Factor) and PIF (Proteolysis-inducing Factor), to be responsible for the weight losing pattern of cancer patients via activation of various catabolic pathways (e.g. ubiquitin-proteasome proteolytic-pathway, etc.). Despite the controversial discussion of cachexia-inducing mechanisms it is clear that proinflammatory cytokines, such as TNFalpha, IFNgamma, IL-1, IL-6 and IL-8, are linked to all pathways that induce cachexia. Although only limited treatment exists for patients with cancer cachexia, recent studies with eicosapaentanoic acid showed promising effects in reversing weight losing pattern of cachectic patients. Cytokine targeted monoclonal antibodies, cytokine traps and genetic therapies are also evaluated for future therapeutic strategies.

[Analysis of 3100 laparoscopic cholecystectomies]

AIM

To evaluate the results of laparoscopic cholecystectomy (LC) in the 8 years period.

PATIENTS AND METHODS

First LC in Coltea Hospital was performed in September 1993 and introduced for treatment of patients with gallbladder disease. From September 1993 to February 2001 LC was performed in 3100 patients. Mean age 51.2 years (ranged from 8 to 87 years) among 2512 women and 588 men. 232 (7.48%) of the cases were patients with acute cholecystitis. Intraoperative cholangiography was performed in 112 cases (3.6%).

RESULTS

Conversion to open cholecystectomy (OC) was necessary in 111 patients (3.58%). Operative complications occurred in 16 (0.5%) patients: CBD lesions in 4 (0.12%) patients, bleeding from cystic artery--12 (0.38%) patients. In one patient CBD injuries was recognized at the time of operation and after conversion to OC primary ductal repair was performed. Postoperative complications occurred in 44 (1.41%) patients: a) local infection--in 15 (0.48%) patients (subhepatic abcess-3, wound infection-9. b) bile leakage--in 21 (0.67%) patients. c) haemoperitoneum because of the bleeding: from the abdominal wall at the trocar insertion site--in 2 patients, from a. cystica-one patient. d) obstructive jaundice due to stone in CBD--in 5 patients (endoscopic papillosphincterotomy and stone extraction was performed). There 21 reoperations due to complications: 13 laparatomies and 8 relaparascopies. Two patients (52 and 64 years old) died after LC-mortality 0.06 per cent. Mean hospitalisation day was 3.8.

CONCLUSIONS

To prevent iatrogenic CBD injuries correct preparation with a clear identification of the anatomic structures is essential. Relaparascopy and endoscopic retrograde cholangyopancreatography can be successfully used in the treatment of complications after LC.

[The place of laparoscopy in assessing and treating a pain syndrome of the right iliac fossa]

The study is considering a trial of 87 patients (61 women 17 and 76 years old) admitted in our clinic between 1995-1996. The preoperative diagnosis was coincident with the laparoscopic one in 10 cases the laparoscopic one in 10 cases the laparoscopy completed the diagnosis and in 12 cases it showed out other organ's disease, evicting useless operations. In the 87 patients we performed: 53 appendectomies, 20 oophorectomies, 15 partial oophorectomies, 9 right adnexectomies, 2 adhesiolysis, 2 lymph node biopsies, 1 epiploic fringe excision for necrosis, 1 appendicular stump removal. The evolution was favourable in all patients, the mean postoperative hospitalization was 48 hours.

[Left lumbar sympathectomy via the retro-pneumoscopic approach. The technical considerations]

Retropneumoscopic lumbar sympathectomy is performed with an increasing frequency as a treatment of chronic obstructive arteriopathies; though the method has limited indications. We present the operative technique as it was performed în the Colţea Surgical Department in 2 patients. We highlights on difficulties advantages and disadvantages of the method.

Ultrastructural characterization of the early changes in intercellular junctions in response to cadmium (Cd2+) exposure in LLC-PK1 cells

Previous studies have shown that Cd2+ can disrupt the Ca2+-dependent junctions between LLC-PK1 cells. The objective of the present studies was to further characterize the early junctional effects of Cd2+ in LLC-PK1 cells and to identify the initial site of injury. LLC-PK1 cells were grown on permeable membrane supports and were exposed to 10 microM Cd2+ from the basolateral compartment. The integrity of cell junctions was assessed by light and electron microscopy and by measuring the transepithelial electrical resistance. After as little as 15 min of Cd2+ exposure, there was an increase in the amount of light transmitted between the cells. The transepithelial resistance began to decline by 30 min and continued to fall until reaching zero after about 6 hr. Ultrastructural analysis showed that the initial disruption of cell-cell junctions coincided with a decrease in the density of intracellular plaques associated with the adhering junctions (zonulae adherens). This effect increased with time and paralleled an increase in the space between cells and a change in the shape of the cells from squamous to rounded. Sectioning the cells horizontally, in a plane parallel to the membrane support, allowed us to see large areas of zonulae adherens. Cd2+ caused the formation of gaps within the zonulae which increased with time of exposure. No significant changes in most occluding junctions (zonulae occludens) were seen until 6-8 hr after Cd2+ exposure. These results indicate that the adhering junctions and associated cytoplasmic components are primary sites of early Cd2+ injury in LLC-PK1 cells and they suggest that these effects may result from the interaction of Cd2+ with target sites associated with the basolateral cell surface.

[A comparative study of the laparoscopic and classic treatments of inguinal hernias]

AIM

of this study is to compare two similar groups presenting inguinal herniae, one group having laparoscopic herniography and the other having a Bassini or Fruchaud repair.

METHOD

Since September 1994, in our department, patients presenting with symptoms of unilateral or bilateral inguinal herniae to our practice were offered the transperitoneal or preperitoneal approach as an alternative of open surgical repair. We considered the first 50 patients operated by laparoscopic technic (35 M and 15 F), age between 22-72 years (group A), and similar group operated by Bassini or Fruchaud technic (group B). All the patients had general anesthesia and perioperative antibiotics. In the group A we used Prolene, Mercilene or Plastex mesh. The following parameters were assessed: 1) operative time from incision to closure: 2) amount and type of analgesia required postoperatively; 3) morbidity related to the procedure; 4) interval before returning to full activity; 5) early recurrence rate; 6) hospital cost.

RESULTS

The mean operative time for unilateral herniae in group A was 70 +/- 10 minutes versus 40 +/- 12 minutes in group B. Group A required to return to work was significantly shorter for the patients in group A (7 +/- 3 days) compared with group B patients (25 +/- 10 days). Although no recurrent herniae have yet been found in patients from either group; follow-up was only 2-18 months in the two groups. The cost of hospital care of group A patients exceeded that of group B by approximately 1.7 more.

IN CONCLUSION

was consider that although is more expensive, the laparoscopic procedure in treatment of inguinal herniae, has more benefits for the patients.

[A case of abdominal pregnancy--a case report]

Rare anatomical variety, the ectopic abdominal gestation involve a high maternal and foetal risk. On report an abdominal gestation in the 2nd quarter of evolution at a 42 yrs. age of a female with multiple uterine leiomyomas, the diagnosis being establish by ultrasonography. The attitude in the same cases is decided by the foetal viability: if the foetus is in a life, the pregnant women is hospitalised and followed each day; if the foetus is dead, there are indication of surgery, the major problem being represented by the total or partial removed of the placenta.

Collagen transformation in abdominal skin of rabbit under continuous wave CO2 laser irradiation: a transmission electron microscopy study

Irradiation of abdominal skin of the rabbit with a continuous-wave CO2 laser beam disrupted the collagen fibril into a spiral-like arrangement of thin filaments. An altered collagen fibril resulted with the potential for interactions between the fibrils. On cross section, the altered fibril shows a central core and an irregular limit which seems to interconnect the fibrils. This structure was found in a thin layer in the zone with altered collagen, at the boundary of the tissue apparently unaffected by the irradiation.

[Isolated fractures of the zygomatic arch]

Out of 245 cases of zygomatic complex fractures which have been treated during 1978-1987, 20 were isolated zygomatic arch fractures. The analysis of the cases showed that the causing factors had been direct violence due to fight, sport and traffic accidents. It had been proved that these fractures are not very rare. Evaluation and treatment must be in time. Reduction of the fracture with the Ginestet hook and the Gillies method offer the most promising therapeutic results as it has been showed through this study.

[Sphincterotomy in the surgical treatment of abscesses of the anorectal region]

In 29 patients with abscesses of the anorectal region the wall of the purulent collection was sectioned not only toward the tegumental surface but also to the anal canal with partial sectioning of the sphincter in 9 of the cases with superficial abscesses, and complete sectioning of the sphincter in the remaining 20 patients that presented with ischio-rectal abscesses, and with deep posterior anal abscesses. No relapse was noted and in none of the cases did anal fistulae or anal incontinence develop. In contrast with the scars that develop following surgery for fistulae, the scars that develop after sectioning of the sphincter for anorectal abscesses are supple and do not lead to deformation of the sphincter.

[Treatment of duodenal stress ulcer by means of chemical sclerosis of the gastric mucosa induced with a 60 percent glucose solution (results after 1--5 years)]

Sclerosing of the gastric mucosa with a 60% fresh sterile solution of glucose was applied in 60 selected patients with chronic conflictual duodenal ulcers, hyperacidic gastritis by vagal neurogenic hyper-reactivity, associated with ischaemic gastropathy developed on an sympathico-adrenergic background. The immediate operatory results were good. The late results (between 1 and 5 years) were as follows: the clinical, radiological and metabolic results were good in 57 patients. Gastric chemical analysis, the values of the hourly basal output remained high in 16,6% of the patients, and those of acidity stimulated by histamine administration remained high in 13,3% of the patients. No peptic recidive was recorded. Unsatisfactory late results were noted in 3 patients (of which forced indication of the method in one patient and non-association of drainage in two patients).

Examination of human and animal leukemic cells by high contrast scanning electron microscopy

Investigation of human or animal (sheep and ox) leukemic cells by scanning electron microscopy enabled the identification and study of some ultrastructural details of the cell surface. A more detailed visualization by the high contrast technique of the same cell surface was obtained, in this work, for the first time in the biological field. This technique allows a better interpretation of any zone of the preparation examined, irrespective of the species from which the cells are collected.

[Treatment of duodenal ulcer with chemical sclerosis of the gastric mucosa. Preliminary results]

On the basis of experimental studies and of the results obtained, the authors have applied over the last two years, sclerosis of the gastric mucosa with fresh, sterile solution of hypertonic (66%) glucose in 25 patients with duodenal ulcers and cellular and vagal hyperacidity resistant to medical therapy. Mucosclerosis was associated with gastric drainage in 14 patients with duodenal ulcer complicated by stenosis or hemmorhage. Sclerosis of the gastric mucosa is a physiological intervention because it achieves the sclero-atrophy of the acid-secreting glands and vago-sympatic denervation in the gastric territory, while the storage function of the stomach is maintained. It was not followed by extra-gastric disturbances or antro-pyloric distonia. It is easy to perform from the technical viewpoint and has a high degree of fiability, providing constantly satisfactory clinical, functional and metabolic results. Chemical values of basal secretion have decreased in a constant manner but in 9 patients the values of induced acidity showed inconstant decreases. Gastro-antro-pyloro-duodenal transit was good and all operated patients have gained weight. No diarrhea, dumping or peptic recidives were noted.

[Complications of Crohn's disease (Clinical and anatomopathological observations on 13 cases)]

Malignization of Crohn disease remains the most severe complication, both due to its intrinsic gravity and to the major complications that it may induce such as: peritonitis--following suppurations and perforation of the involved intestinal segment; intestinal sub-occlusion or mechano-inflammatory occlusion, either tumoral or chronic leading to stenosis of the intestine; hemorrhage. Malignization of Crohn disease was found in 53,84% of the cases (7 out of a total of 13 cases, between 1968 and 1974). This allows to conclude that Crohn disease can be considered as a pre-cancerous disease.