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Traitement du PTI et de l’AHAI au cours du DICV : revue systématique de la littérature
Full text linkINTRODUCTION: Ten to 15% of common variable immunodeficiencies (CVID) develop auto-immune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Treatment is based on immunosuppressants, which produce blocking effects in the CVID. Our objective was to assess their risk-benefit ratio in these immunocompromised patients.
METHODS: We identified 17 articles detailing the treatment of AIHA and/or ITP in patients suffering from CVID through a systematic review of the MEDLINE database.
RESULTS: The increased infectious risk with corticosteroids does not call into question their place in the first line of treatment of ITP and AIHA in CVID. High-doses immunoglobulin therapy remain reserved for ITP with a high risk of bleeding. In second-line treatment, rituximab appears to be effective, with a lower infectious risk than the splenectomy. Immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclophosphamide, vincristine, ciclosporine) are moderately effective and often lead to severe infections, meaning that their use is justified only in resistant cases and steroid-sparing. Dapsone, danazol and anti-D immunoglobulins have an unfavorable risk-benefit ratio. The place of TPO receptor agonists is still to be defined. The establishment of immunoglobulin replacement in the place of immunosuppressants (except for short-term corticotherapy) or splenectomy appears to be essential to limit the risk of infections, including in the absence of previous infections.
CONCLUSION: The presence of CVID does not mean that it is necessary to give up on corticosteroids as a first-line treatment and rituximab as a second-line treatment for AIHA and ITP, but it should be in addition to immunoglobulin replacement. A splenectomy should be reserved as a third-line treatment
Long term surgical results of 154 petroclival meningiomas: A retrospective multicenter study
Full text linkBACKGROUND: 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\u27 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
Toward the development of 3-dimensional virtual-reality video tutorials in the French neurosurgical residency program
Full text linkBACKGROUND: The present study developed 3D video tutorials with commentaries, using virtual-reality headsets (VRH). VRHs allow 3D visualization of complex anatomy from the surgeon\u27s point of view. Students can view the surgery repeatedly without missing the essential steps, simultaneously receiving advice from a group of experts in the field.
METHODS: A single-center prospective study assessed surgical teaching using 3D video tutorials designed for French neurosurgery and ENT residents participating in the neuro-otology lateral skull-base workshop of the French College of Neurosurgery. At the end of the session, students filled out an evaluation form with 5-point Likert scale to assess the teaching and the positive and negative points of this teaching tool.
RESULTS: 22 residents in neurosurgery (n=17, 81.0%) and ENT (n=5) were included. 18 felt that the 3D video enhanced their understanding of the surgical approach (81.8 %). 15 (68.2%) thought the video provided good 3D visualization of anatomical structures and 20 that it enabled better understanding of anatomical relationships (90.9%). Most students had positive feelings about ease of use and their experience of the 3D video tutorial (n=14, 63.6%). 20 (90.9%) enjoyed using the video. 12 (54.5%) considered that the cadaver dissection workshop was more instructive.
CONCLUSIONS: 3D video via a virtual reality headset is an innovative teaching tool, approved by the students themselves. A future study should evaluate its long-term contribution, so as to determine its role in specialized neurosurgery and ENT diploma courses
Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities
Full text linkPediatric arterial ischemic stroke (AIS) is a severe condition, with long-lasting devastating consequences on motor and cognitive abilities, academic and social inclusion, and global life projects. Awareness about initial symptoms, implementation of pediatric stroke code protocols using MRI first and only and adapted management in the acute phase, individually tailored recanalization treatment strategies, and multidisciplinary rehabilitation programs with specific goal-centered actions are the key elements to improve pediatric AIS management and outcomes. The main cause of pediatric AIS is focal cerebral arteriopathy, a condition with unilateral focal stenosis and time-limited course requiring specific management. Sickle cell disease and moyamoya angiopathy patients need adapted screening and therapeutics
Natura in fabula. Topiques romanesques de l’environnement
Full text linkThe papers brought together in Natura in Fabula focus on nature and environment-related issues in the novel, addressing them from the perspective of topics through the identification of recurrent narrative patterns. Nature often functions as a setting with its scenographies and topographies, but it may also embody an entity which man, more than the novel’s characters, is to cope with.
How do natural topoi work in writing, owing to their malleability or reversibility in a literary text? To what extent do historic turning points impact these topoi, encouraging new ones to emerge? And what kinds of “eco-logics” do they help elaborate regarding man’s relation with nature in works of fiction
Stagnation-aware breakout tabu search for the minimum conductance graph partitioning problem
Full text linkThe minimum conductance graph partitioning problem (MC-GPP) is to partition the vertex set of a graph into two disjoint subsets while minimizing the ratio between the number of the edges crossing the two subsets and the smallest volume of the two subsets, the volume of a vertex set being the sum of degrees of its vertices. MC-GPP has a variety of relevant applications, and however, is known to be NP-hard. In this work, we present a novel metaheuristic algorithm called “stagnation-aware breakout tabu search” for approximating MC-GPP. The algorithm combines a dedicated tabu search procedure to discover high-quality solutions and a self-adaptive perturbation procedure to overcome hard-to-escape local optimum traps. We perform extensive evaluations of the algorithm on five datasets of 110 benchmark instances in the literature. The key components of the proposed algorithm are analyzed to illustrate their influences on the performance of the algorithm
Maxillary sinus floor elevation using Beta-Tricalcium-Phosphate (beta-TCP) or natural bone: same inflammatory response
Full text linkSinus elevation is a common procedure to increase bone volume in the atrophic maxilla to allow placement of dental implants. Autogenous bone is the gold standard but is limited in quantity and causes morbidity at the donor site. β-TCP is a synthetic biomaterial commonly used in that purpose. It appears to induce a poor inflammatory response. This study aimed to evaluate the degree of edema of the sinus mucosa after sinus lift surgery according to the type of biomaterial. Forty sinuses (20 patients) were included retrospectively and divided into 2 groups according to the biomaterial that was used: synthetic biomaterial (BTCP group), natural bone (BONE group). A control group (CTRL group) was constituted by the non-grafted maxillary sinuses. Twelve measurements per sinus were realized on pre- and post-operative computed tomography and averaged to provide the sinus membrane thickness value (SM.Th). SM.Th was thicker post-operatively in the BTCP and BONE groups in comparison with the CTRL group and in comparison with pre-operative measurements. No difference was found post operatively between the BTCP and BONE groups. We found that a synthetic biomaterial (β-TCP) induced the same degree of edema, and thus of inflammation, as natural bone. It constitutes therefore an interesting alternative to autogenous bone for maxillary sinus lifts
Effort-reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort
Full text linkOBJECTIVES: To examine the association between effort-reward imbalance and incident long-term benzodiazepine use (LTBU).
METHODS: We included 31 077 employed participants enrolled in the French population-based CONSTANCES cohort between 2012 and 2014 who had not undergone LTBU in the 2 years before enrolment. LTBU was examined using drug reimbursement administrative databases. The effort-reward imbalance was calculated in quartiles. We computed ORs (95% CIs) for LTBU according to effort-reward imbalance over a 2-year follow-up period. We adjusted for age, gender, education, occupational grade, income, marital status, tobacco smoking, risk of alcohol use disorder, depressive symptoms and self-rated health.
RESULTS: Over the 2-year follow-up, 294 (0.9%) participants experienced incident LTBU. In the univariable analysis, effort-reward imbalance was associated with subsequent LTBU with ORs of 1.79 (95% CI 1.23 to 2.62) and 2.73 (95% CI 1.89 to 3.95) for the third and fourth quartiles, respectively, compared with the first quartile. There was no interaction between effort-reward imbalance and any of the considered variables other than tobacco smoking (p=0.033). The association remained significant in both smokers and non-smokers, with higher odds for smokers (p=0.031). In the fully adjusted model, the association remained significant for the third and fourth quartiles, with ORs of 1.74 (95% CI 1.17 to 2.57) and 2.18 (95% CI 1.50 to 3.16), respectively. These associations were dose dependent (p for trend <0.001).
CONCLUSIONS: Effort-reward imbalance was linked with incident LTBU over a 2-year follow-up period after adjustment for sociodemographic and health-related factors. Thus, screening and prevention of the risk of LTBU should be systematised among individuals experiencing effort-reward imbalance, with special attention paid to smokers
Emergency Surgery for Obstructive Colon Cancer in Elderly Patients: Results of a Multicentric Cohort of the French National Surgical Association
Full text linkBACKGROUND: Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited.
OBJECTIVE: The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer.
DESIGN: This was a multicenter, retrospective cohort study.
SETTINGS: Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging.
PATIENTS: Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years.
MAIN OUTCOME MEASURES: Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population.
INTERVENTIONS: A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure.
RESULTS: A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75-84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09).
LIMITATIONS: It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration.
CONCLUSIONS: Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964
