[Cirrhosis and coagulation : implications for clinical practice]. / Cirrhose et coagulation : implications pour la pratique clinique.

Coagulation disorders related to abnormalities in hepatic synthesis are well known as prognostic factors in hepatic cirrhosis. The risk of bleeding, mainly linked to portal hypertension, must be weighed against the risk of thrombosis, the most frequent manifestation of which is portal venous thrombosis. Conventional laboratory tests are not a reliable reflection of this delicate balance. The use of prophylactic anticoagulation in hospitalized patients with decompensated hepatic cirrhosis or therapeutic anticoagulation in venous thrombosis is recommended in most cases, in the absence of contraindications.

Les troubles de la coagulation liés aux anomalies de la synthèse hépatique sont bien connus comme facteurs pronostiques de la cirrhose hépatique. Le risque hémorragique, principalement lié à l'hypertension portale, est à mettre en balance avec le risque thrombotique, dont la manifestation la plus fréquente est la thrombose veineuse porte. Les tests de laboratoire classiques ne sont pas un reflet fiable de cet équilibre fragile. L'utilisation d'une anticoagulation prophylactique chez les patients hospitalisés avec cirrhose hépatique décompensée ou d'une anticoagulation thérapeutique en cas de thrombose veineuse est recommandée dans la plupart des cas, en l'absence de contre-indications.

Trends of incidence and survival of patients with chronic myelomonocytic leukemia between 1999 and 2014: A comparison between Swiss and American population-based cancer registries.

BACKGROUND: Chronic myelomonocytic leukemia (CMML) is a rare hematopoietic malignancy. Treatment with hypomethylating agents (HMA) was introduced between 2004 and 2006 but its impact on population-based survival remains controversial. The aim of this study was to investigate epidemiological characteristics and survival before and after introduction of HMA treatment. METHODS: We performed a population-based analysis of CMML cases reported to the Cantonal Cancer Registries in Switzerland (SWISS) and the Surveillance, Epidemiology, and End Results (SEER) Program from the United States for 1999-2006 (before HMA) and 2007-2014 (after HMA). Time trends were compared for these two time periods. RESULTS: 423 and 4144 new CMML cases were reported to the SWISS and SEER registries, respectively. We observed an increasing proportion of older patients ≥75 years in the SWISS (50.3%-62.3%) compared to a decreasing one in the SEER population (59.1%-55.1%). Age standardized incidence-rates were similar and remained stable in both countries (0.32-0.38 per 100'000 py). Relative survival (RS) improved significantly in the SEER (3 years 27%-37%; 5 years 19%-23%; p < 0.001 for both) but remained stable in the SWISS population (3 years 48% to 40%; 5 years 34% to 26%; n.s. for both). CONCLUSIONS: With the exception of opposing age-trends, epidemiologic characteristics are similar in both countries and comparable to other population-based registries. RS remains poor and different time trends of population-based survival cannot be faithfully explained by HMA but most likely by changes in diagnostic accuracy within prognostically distinct age-groups.

Diagnosis and management of idiopathic facial palsy in children.

Idiopathic or Bell's palsy is an acute peripheral-nerve palsy involving the facial nerve. The disorder is quite infrequent under the age of 10 years. The proposed etiologies of Bell's palsy include ischemic neuropathy and vascular diseases. This case series presents five children with Bell's palsy. The epidemiologic, diagnostic and therapeutic measures were summarized. The evolution regarding especially the facial motricity was detailed. The results about the role of some thrombophilic polymorphisms suggest a probable involvement of factor V haplotype, MTHFR and factor XIII in the etiology of Bell's palsy in five Tunisian children.

Acute acoustic trauma: how to manage and how to prevent?

INTRODUCTION: The consequence of an exposure to intense sounds can be a temporary or permanent hearing loss and even with a rapid therapeutic management, severe sensorineural sequelae may persist. METHODS: the authors report a retrospective study about 64 patients followed for an acute acoustic trauma during a period of 8 years (2006 to 2013). For all the cases, a clinical examination associated to a pure-tone audiometry was conducted. Hearing levels were measured at the frequencies 500, 1000, 2000 and 3000 Hertz. Auditory evoked potentials were performed in 17 cases. The therapeutic and evolutive data were detailed and discussed. RESULTS: All our patients were male with a mean age of 34 years. The cause of acoustic trauma was a firing of a gun near the ear in 48 cases, an explosion near the ear in 5 cases and a sudden exposure to loud noises near military planes in 11 cases. Clinical complaints were acute hearing loss with tinnitus. Audiometric exams found a sensorineural hearing loss with a hearing level average of 38 decibels (dB) +/- 14 SD. The therapy consisted of systemic cortisteroids associated in all the cases to peripheral vasodilators.  It was given intravenously during 10 days and then orally with vasodilators during one to 3 months. Hyperbaric oxygenotherapy have been administrated for 25 patients. The follow-up consisted of questioning about symptoms, clinical examination and pure-tone audiometry. A good evolution was noted in 52 cases (81%) and the mean of hearing level after therapy was: 24 dB +/- 12 dB. Despite a prolonged therapy with vaso-active drugs, tinnitus persisted in 36 cases. CONCLUSION: Controlling noise and its harmful effects through technical devices and safety professionals programs are the best way to reduce the frequency and the sensorineural sequelae due to acute acoustic trauma.

Management of combat-related facial injuries.

INTRODUCTION: Combat-related facial injuries involve various lesions of the mouth, the eye sockets and the facial bones. The goal of this study is to precise the particularities of these affections and their therapeutic management. METHODS: A retrospective study was performed about 56 cases of combat-related facial injuries over a period of 5 years (2010 - 2014). RESULTS: Our study included 56 male patients with an average age of 29 years (20-37). The trauma occurred during a real security intervention in all the cases. It was isolated in 18 cases and associated to other lesions in 38 cases. Clinical examination revealed facial edema (57%), facial cuts and lacerations (74%), broken teeth (14%), nasal deformation (26%), skin defect (16%) and periorbital ecchymosis (32%). The diagnosis retained after clinical examination and imaging exams were:  fractures of the mandible (34 cases), of the eye sockets (18 cases), of the nasal bones (15 cases), parotid gland injury (5 cases) and facial arterial injuries in (24 cases). The treatment was surgical in all the cases: stabilization of fractured segments (43 cases), suture of facial and vascular lacerations (51 cases), reduction of nasal fractures (15 cases), and reposition of teeth dislocations (35 cases). The evolution was good in 34 cases. The functional sequelae noted were ophthalmic (7 cases), dental abnormal occlusions (11 cases), residual trismus (4 cases) and facial palsy in 2 cases. CONCLUSION: Combat related facial injuries must be diagnosed and treated early to prevent the functional and, sometimes, life-threatening damages dues to those lesions.

Is there a real benefit of hyperbaric oxygenotherapy in the treatment of necrotizing otitis externa?

INTRODUCTION: Necrotizing otitis externa remains a severe and sometimes life-threatening disease in diabetic patient. Many therapeutic approaches have been described but what about the real benefit of hyperbaric oxygenotherapy in the management of this disease? METHODS: The authors reported a retrospective study about 42 patients treated for necrotizing external otitis over a period of 9 years (2006 to 2014). The patients were treated either by only antibiotherapy (23 cases) or with both antibiotherapy and hyperbaric oxygenotherapy (19 cases). The evolution under treatment was appreciated in the two groups through clinical, biological and radiological parameters. RESULTS: The study included 42 diabetic patients with a mean age of 67 years (50 to 84 years). The sex-ratio M/F was 0.82. The diagnosis of necrotizing otitis externa was assessed through clinical and bacteriologic criteria in diabetic patients. A temporal bone CT-scan and a technetium scintigraphy were performed in order to precise the topography of the disease and the level of bone lysis. Antibiotherapy was prescribed intravenously and then orally for a mean period of 8 weeks (5 to 15 weeks). Hyperbaric oxygenotherapy was given for 19 patients (average: 20 sessions). The recovery was affirmed on clinical, biological and radiological features. Otalgia disappeared at the 11th day of treatment without HOT and at the 5th day with HOT. Otorrhea disappeared at the 6th day of treatment by HOT and at the 13th day without HOT. The recovery or the regression of facial palsy occurred in 75% of the cases when HOT was given. The total recovery from the disease was diagnosed in 36 patients (86%). The rate of recovery was 100% in the group treated by HOT and 74% in the group treated by only antibiotics. The recurrence of the disease was noted in 6 patients that haven't benefited from HOT. The end of the oral therapy was guided by the results of the Gallium bone scintigraphy. CONCLUSION: Hyperbaric oxygenotherapy must be associated in the treatment of necrotizing otitis externa. The results of our study suggest a real benefit of this therapy regarding clinical, biological and radiological parameters of this severe affection.

[Performances of imaging investigations and scintigraphy for pre operative hyperparathyroidism]. / Résultats et limites de l'exploration radiologique et isotopique préopératoire de l'hyperparathyroïdie.

BACKGROUND: Hyperparathyroidism is a frequent affection. Therapeutic management is based on surgical removal of pathological glands. Therapeutic results are ameliorated thanks to preoperative imaging approach. AIM: To evaluate performances of different imaging investigations and scintigraphy for preoperative parathyroid localization. METHODS: Retrospective study about 26 patients with confirmed hyperparathyroidism. RESULTS: After radio-surgical and histological correlation, scintigraphy showed the best rate of sensitivity (92.3%), compared to other morphologic imaging (ultrasonography: 66.6%, CT-scan: 33.3% and MRI: 66.6%). The specificity was the same (100 %). No difference was obseved for both scintigraphic modalities. CONCLUSION: Our results compared to the literature showed that scintigraphy is the most satisfying for preoperative localization of abnormal parathyroid glands in hyperparathyroïdism.

[Clinical and phmetric evaluation of gastro-esophageal reflux impact on upper airways in adult]. / Evalution clinique et phmétrique de l'impact du reflux gastro-oesophagien sur les voies aérodigestive supérieures chez l'adulte.

BACKGROUND: Gastroesophageal reflux is a frequent and benign affection. It represents an etiopathological entity in otorhinolaryngology; that may occasion a large variety of ENT manifestations. AIM: To evaluate clinical and pHmetric impact of gastro esophageal reflux on upper airways in adult. METHODS: Prospective study about 95 cases diagnosed and treated at the ENT department of military hospital of Tunis. Clinical features, pH metric profiles and therapeutic approach are reported and compared to the literature. RESULTS: The mean age was 37 years old. Sex ratio was 1.16. Pharyngolaryngeal symptoms dominated ENT manifestations (41 cases). Laryngeal dyspnea, cough and dysphonia were predictive of danger. Positive pH metric rate collated to posterior laryngitis and pharyngitis were respectively 81.2% and 79.1%. Posterior laryngitis, dental erosion and chronic sinusitis, seem to have pejorative significance. CONCLUSION: Otorhinolaryngologist must think about asymptomatic reflux every time when chronic or recurrent ENT affection remain unexplained after complete clinical investigations. PH monitoring confirms gastroesophageal reflux disease.

[Preoperative CT Scan in middle ear cholesteatoma]. / Apport de la tomodensitométrie dans le bilan pré opératoire de l'otite moyenne chronique cholestéatomateuse. A propos de 60 cas.

AIM: To compare preoperative CT scan finding and per-operative lesions in patients operated for middle ear cholesteatoma, METHODS: A retrospective study including 60 patients with cholesteatoma otitis diagnosed and treated within a period of 5 years, from 2001 to 2005, at ENT department of Military Hospital of Tunis. All patients had computed tomography of the middle and inner ear. High resolution CT scan imaging was performed using millimetric incidences (3 to 5 millimetres). All patients had surgical removal of their cholesteatoma using down wall technic. We evaluated sensitivity, specificity and predictive value of CT-scan comparing otitic damages and CT finding, in order to examine the real contribution of computed tomography in cholesteatoma otitis. RESULTS: CT scan analysis of middle ear bone structures shows satisfaction (with 83% of sensibility). The rate of sensibility decrease (63%) for the tympanic raff. Predictive value of CT scan for the diagnosis of cholesteatoma was low. However, we have noticed an excellent sensibility in the analysis of ossicular damages (90%). Comparative frontal incidence seems to be less sensible for the detection of facial nerve lesions (42%). But when evident on CT scan findings, lesions of facial nerve were usually observed preoperatively (spécificity 78%). Predictive value of computed tomography for the diagnosis of perilymphatic fistulae (FL) was low. In fact, CT scan imaging have showed FL only for four patients among eight. Best results can be obtained if using inframillimetric incidences with performed high resolution computed tomography. CONCLUSION: Preoperative computed tomography is necessary for the diagnosis and the evaluation of chronic middle ear cholesteatoma in order to show extending lesion and to detect complications. This CT analysis and surgical correlation have showed that sensibility, specificity and predictive value of CT-scan depend on the anatomic structure implicated in cholesteatoma damages.

[Management of thyroid microcarcinoma. Report of 13 cases]. / Prise en charge des microcarcinomes de la glande thyroïde: a propos de 13 cas.

BACKGROUND: Thyroid microcarcinoma is defined as a tumour of one centimeter or less in its greater diameter. Prognoses and therapeutic modalities remain controversial therapeutic guidelines for surgical treatment. AIM: To analyse the anatomical and clinical characteristics and discuss the modalities of care and therapeutic indications of these microcarcinoma. METHODS: We report a retrospective study concerning 13 cases of thyroid microcarcinoma, diagnosted and treated at the ENT department of Military Hospital of Tunis from 1998 to 2007. RESULTS: The mean age was 41 years and sex-ratio was 0.18. Clinical investigation by cervical ultrasonography found an isolated nodule in 30.7% and a multinodal goiter in 69.2%. Lymph node metastasis was precessiving in two cases. Five patients underwent loboisthmectomy and higt patients had a total thyroidectomy. Surgical lymph node removal was practiced for both cases with preceding cervical node involvement. Iodine 131 ablation was necessary every time when total thyroidectomy was practiced. A six years mean follow-up revealed no recurrence or death. CONCLUSION: Thyroid microcarcinoma is favorable long-term prognosis. Therapeutic modalities are closely depending on risk factors such as histology type, tumor size, lymph node involvement and extra thyroid extension.

[Scintigraphic preoperative localization of abnormal parathyroid gland]. / Place de la scintigraphie dans la détection préopératoire des glandes parathyroïdes pathologiques.

UNLABELLED: THE AIM of this study is to evaluate the accuracy of scintigraphic preoperative localization of abnormal parathyroid gland. METHODS: 25 patients with confirmed hyperparathyroidism undergone scintigraphic and ultrasound localization prior to surgery. Paratthyroid scintigraphy was done with thallium - techetium substraction and technetium-tetrofosmin dual phase techniques. RESULTS: scintigraphic sensitivity and specificity was 83% and 100%. In primary hyperparathyroidism the sensitivity was 91% vs 75% in secondary one. Multinodular goiter affected sensitivity (72%). Ultrasound had an overall sensitivity of 66 % and a specificity of 100%. CONCLUSION: parathyroid scintigraphy is non invasive, accurate and costeffective in localizing abnormal parathyroid gland especialy adenoma.