Crenobalneotherapy for low back pain: systematic review of clinical trials.

Crenobalneotherapy is a treatment commonly used in Europe and Middle East. It uses mineral water sometimes combined with different hydrotherapy techniques. Most patients treated in spa centers suffer from low back pain. The purpose of this work is to identify clinical trials on crenobalneotherapy for low back pain. Publication research was performed on Medline, Cochrane, and PEDRO databases. Clinical trials were analyzed for internal validity, external validity, quality of statistical analysis, and quality of collection of adverse events. We present the best level of evidence. Bibliographic research identified 21 clinical trials and the coauthors added 5 references. The 26 trials represent 2695 patients. Some have good methodological quality and allow considering crenobalneotherapy as a potential treatment for low back pain, even if the role of mineral water remains uncertain. The methodological quality of therapeutic trials should be improved. These trials should be analyzed in the future guidelines on low back pain.

[Increase rate of ambulatory and management of the care path in breast cancer surgery]. / Augmentation du taux de prise en charge ambulatoire et organisation du parcours de soins en chirurgie sénologique.

OBJECTIVE: To describe practices and impact of ambulatory surgery rate, patient satisfaction after Nursing Support and Post Ambulatory Follow-up Device at Home at the Henri Becquerel Center (DIASPAD CHB) has been set up during surgical management in breast cancer. METHOD: This is a prospective monocentric observational study carried out between January 2017 and December 2018. Patients eligible for the study should undergone breast cancer surgery without reconstruction. Outpatient care was possible if patients met medical, surgical, psychosocial and environmental criteria according to the characteristics of the foreseeable operating suites. We evaluated the progression of the ambulatory hospitalization rate since the DIASPAD CHB beginning and compared the use of this device in conventional and ambulatory hospitalization. RESULTS: Since January 2017, 1312 patients undergone breast cancer surgery without reconstruction. After DIASPAD CHB implementation, ambulatory surgery rate increased from 46 % to 81.7 % for patients operated for breast cancer. The satisfaction rate of patients and nurses was 99 %. CONCLUSION: DIASPAD CHB enabled ambulatory care to take a important share in surgical care in breast cancer by ensuring collaboration between healthcare professionals, anticipation, programming and coordination of care.

[Limitations of breast reconstruction using exclusive lipofilling: A retrospective study over 10 years]. / Limites de la reconstruction mammaire par lipofilling exclusif : étude rétrospective sur 10 ans.

OBJECTIVES: The primary objective was to assess the failure rate of exclusive lipofilling breast reconstruction. The secondary objectives were the identification of failure predictive factors of exclusive lipofilling breast reconstruction and the early complications. METHODS: We performed a retrospective study in Normandy analysing cases of secondary breast reconstruction by exclusive lipofilling after radical mastectomy, from January 2006 to December 2016. We compared a group of patients who completed exclusive lipofilling breast reconstruction (n=22) with a group of patients who underwent other techniques of breast reconstruction (n=16). RESULTS: The failure rate of breast reconstruction by exclusive lipofilling was 32.6%. Need of adjuvant chemotherapy treatment was associated with a higher failure rate than exclusive lipofilling breast reconstruction (81.2% vs. 45.5%, P<0.05). The age of patients was significantly higher in case of reconstruction failure (45.2 vs. 50.9 years mean age, P<0.05). Need of adjuvant radiotherapy treatment was not associated with a higher failure rate than exclusive lipofilling breast reconstruction. The main complications were cutaneous burn due to cannula and haematoma at the donor site (11/22) and breast haematoma (11/22). CONCLUSIONS: Informing patients of the risk of breast reconstruction failure due to the high adipocytes resorption, is necessary when patients are undergoing exclusive lipofilling breast reconstruction. A prospective study with greater workforce is needed to shore these results and assess postoperative complications.

Inhibition of P-glycoprotein functionality by vandetanib may reverse cancer cell resistance to doxorubicin.

P-glycoprotein belongs to the ATP binding cassette transporters, responsible for the multidrug resistance of cancer cells. These transporters efflux hydrophobic drugs outside cells and decrease their therapeutic efficacy. The aim of this study was to investigate the effect of vandetanib, an oral tyrosine kinase inhibitor of EGFR, VEGFR 2 and RET kinases, on the functionality of P-gp after a 24h-treatment at therapeutic concentration (2µM), and its ability to increase the cytotoxicity of chemotherapeutic agents in multidrug resistance cancer cells. In this study we found that IGROV1-DXR and IGROV1-CDDP cells were resistant to doxorubicin and cisplatin respectively, compare to parental cell line IGROV1. The parental sensitive and the two resistant cell lines similarly expressed MRP1 and did not express BCRP. Moreover, in contrast to the IGROV1 and IGROV1-CDDP cells, IGROV1-DXR cell line overexpressed P-gp. Functional activity studies demonstrated that MRP1 was not functional and the MDR phenotype in IGROV1-DXR cells was linked to P-gp functionality. Results also showed that vandetanib reversed resistance to doxorubicin in IGROV1-DXR cells, but not to cisplatin in IGROV1-CDDP cells. After 24h of treatment, vandetanib increased the accumulation of rhodamine 123 and calcein AM, demonstrating a functional inhibition of the transporter. In IGROV1-DXR cell line, vandetanib reverse resistance to doxorubicin by inhibiting the functionality of P-gp. In conclusion, vandetanib should be an option for drug combination in patients already developing a P-gp mediated multidrug resistance.

[Bilateral simultaneous central retinal artery occlusion revealing giant cell arteritis]. / Occlusion bilaterale et simultanee de l'artere centrale de la retine revelatrice d'une maladie de Horton.

AIM: To point out the importance of the early diagnosis of giant cell arteritis (GCA) (Horton's disease). MATERIALS AND METHODS: a case report of a sudden bilateral blindness that had revealed GCA. CASE REPORT: A 68-year old female patient with a history of elevated blood pressure and diabetes mellitus type 2, was examined in emergency for a right painful headache developed one week previously. In ophthalmological examination, her BCVA was 0.9 and P2 in both eyes. Diagnosis of Horton's disease was not initially done in spite of elevated erythrocytes sedimentation rate (ESR) at 30 mm, protein C reactive (CRP) at 19 mg/l. The patient consulted seven weeks later in emergency for a sudden bilateral blindness associated with severe headache, recent asthenia, and limping of the lower jaw. At that time, visual acuity was reduced to light perception in both eyes whereas ophthalmoscopy revealed a bilateral central retinal artery occlusion (CRAO). ESR was 74 mm and CRP 233 mg/I. Temporal artery biopsy confirmed the diagnosis of GCA. The patient was treated with systemic steroids without visual recovery. CONCLUSION: This case outlines the importance of the early diagnosis of GCA in order to make possible to start treatment before the occurrence of irreversible complications.

[Contributions of the ex vivo human perfused placenta in the study of placental transfer of drugs]. / Apports de la perfusion ex vivo du cotylédon humain dans l'étude du passage placentaire des médicaments.

Perfused human placental lobule was developed during the 1970s. Only this model respects the anatomical features of the human placenta. This approach allows different technical conditions (concentrations of drugs…) without ethical problems. Limitations of this ex vivo model are detailed in this review, also its recent contributions in better understanding of placental passage of drugs.

Comparative effects of drugs on P-glycoprotein expression and activity using rat and human trophoblast models.

The drug efflux transporter P-glycoprotein (P-gp) is an active component of the placental barrier which protects the fetus against maternal xenobiotics. The goal of the study was to compare species difference between human and rat in terms of susceptibility to drugs at the level of the placental barrier using in vitro models in order to improve translation from rat to human. Effects of selected drugs (Aspirin, Methadone, a Cardiovascular Proprietary Compound, Thalidomide) on cytotoxicity and P-gp expression and activity were compared using human and rat trophoblast cultures. No direct cytotoxicity of drugs on trophoblasts was noted in both invitro models, but for Thalidomide a proliferative effect on human trophoblast primocultures was observed. All tested drugs induced changes towards P-gp; for each drug the same profile was noted in both human and rat trophoblast models except for Thalidomide. Observation of this similar response between these two in vitro trophoblast models is promising for assessment between P-gp expression and activity of drugs towards placental function.

Development and characterisation of a new model of rat trophoblasts.

The placenta plays a key role during pregnancy. In vitro models have proven to assess the role of placental transporters in the exchange of nutrients, waste products and the distribution of drugs between the maternal and fetal compartments. Therefore, a primoculture of Wistar rat trophoblasts from the labyrinth zone was developed and characterised. Expression of placental transporters including P-glycoprotein (P-gp) and bcrp was evaluated by western blot and their activity using different inhibitors. A time-dependent increase in P-gp expression was noted from primocultures Day 2 to Day 4 followed by a plateau thereafter, whereas bcrp expression was stable throughout the culture period. P-gp and bcrp expression was maintained after seven passages in primocultures and in cryopreserved trophoblasts (up to 3 freezings and 10 passages). Activity of efflux transporters was confirmed in both placental primocultures and cryopreserved trophoblasts by an approximately 60% inhibition with cyclosporin A and valspodar for P-gp and 55% with elacridar for bcrp. In sum, this new in vitro model seems promising for a better understanding of the role of P-gp and bcrp in the toxicity of drugs during pregnancy and could be considered as an additional step towards the minimization of animal testing during drug development.

[Anterior chamber migration of Supramid tube from short Krupin valves after more than 13 years of implantation. Two case reports]. / Luxation intracamérulaire du tube en Supramid de valves de Krupin courtes plus de 13 ans après leur implantation. A propos de deux cas.

INTRODUCTION: In 2004, the authors had to remove two short Krupin valves because the Supramid tube of these valves implanted 13 years previously had migrated into the anterior chamber. CASE REPORT: The first case was treated in April 2004, the second in November 2004. These valves had been implanted in January 1991 and August 1983 respectively; both because of insufficient, intense general and local medical treatments for vascular glaucoma: post-traumatic for one and neovascular glaucoma after central retinal vein occlusion for the other. RESULTS: In 2004 in each case, the authors performed the extraction, with Healon, of the Supramid tube that had migrated into the anterior chamber and the dissection of the previous scleral flap, which allowed them to uncover and extract the Silastic scleral tube whose split distal end continued to allow seepage of aqueous humour. The two lateral Supramid arms used to stitch the valve were also removed. The two valves were replaced with a Molteno glaucoma drainage implant. Follow-up was simple. DISCUSSION: Since February 1981, several Krupin valves, first short, then long, were placed in the Ophthalmic Ward of the Villeneuve St Georges Hospital in France. The authors discuss their structure and evolution. The design of these valves, at first made of two different materials (an intracameral Supramid tube followed by a intrascleral Silastic tube) evolved toward a draining tube made from the same material for its entire length, preventing the disconnection of the two tubes. A literature review retraces the history of the device and the modifications over time. CONCLUSION: These old Krupin valves have stabilized the IOP for several years in numerous glaucoma patients who did not respond to intense medical treatments. Their dual-material concept was redesigned in favor of a single tube that could no longer become a mobile intraocular foreign body.

[Recurrent acute Enterococcal faecalis endophthalmitis following cataract surgery: a case report with a favorable outcome]. / Endophtalmie aiguë récurrente à Enterococcus faecalis après chirurgie de la cataracte: un cas à évolution favorable.

INTRODUCTION: Enterococcal faecalis endophthalmitis is an acute type of endophthalmitis that is exceptional because it is rare, can be recurrent, and has a poor functional prognosis. OBSERVATION: We report a case of recurrent Enterococcus faecalis endophthalmitis after cataract surgery on a 76-year-old woman. After four acute infectious episodes over a few months, this patient recovered without ablation of the IOL. After the classic intravitreous and general antibiotic injections, the treatment required posterior vitrectomy with posterior capsulorrhexis. Only this surgery enabled the cleansing of the vitreous cavity by removing the germs present in the intravitreous abscesses. Despite the responsible germ's virulence, the visual recovery at 7/10 P2 remained stable 2 years after these recurrent infectious episodes. DISCUSSION: As far as we know, this is the only published case of Enterococcus faecalis endophthalmitis that was cured without ablation of the IOL. A review of the literature shows the rarity of acute Enterococcus faecalis endophthalmitis, characterized by recurrences and a poor visual prognosis. The microbiologic and therapeutic particularities of Enterococcus faecalis endophthalmitis are discussed with the objective of elaborating a therapeutic protocol combining antibiotic therapy, corticotherapy, vitrectomy, and posterior capsulorrhexis while leaving the IOL in place. CONCLUSION: Enterococcus faecalis endophthalmitis is an ophthalmologic emergency, which requires not only a rapid intervention, but also close follow-up to detect recurrences early and perform vitrectomy and posterior capsulorrhexis with as little delay as possible.

P-glycoprotein expression of the human placenta during pregnancy.

OBJECTIVE: To investigate whether the placental expression of P-glycoprotein shows a quantitative difference during pregnancy. STUDY DESIGN: Villous tissue was collected from chorionic villus samples (13-14 weeks of gestation; n = 3 and 20-25 weeks of gestation; n = 4) and from full-term placentas (38-41 weeks of gestation; n = 28). P-glycoprotein was detected by western blot analysis and quantified by densitometry. RESULTS: We showed for the first time a significant and progressive two-fold decrease in the mean expression of P-glycoprotein between early and late samples, with a major overlap of values. CONCLUSION: As P-glycoprotein appears to be involved in drug extrusion, these data suggest that the placenta's ability to protect the fetus from xenobiotics is greater in early pregnancy than at term.

Prenatal diagnosis of common aneuploidies using multiplex quantitative fluorescent polymerase chain reaction.

OBJECTIVE: Prenatal diagnosis of foetal trisomies is usually performed by cytogenetic analysis. This requires lengthy laboratory procedures and it is expensive. Here, we report a retrospective study of quantitative fluorescent polymerase chain reaction (QF-PCR) for prenatal detection of trisomies 13, 18 and 21. METHODS: QF-PCR was performed on a total of 447 amniotic fluids blindly analysed without any knowledge of the cytogenetic results and 43 samples with known karyotype. All samples were tested with at least 4 small tandem repeat markers specific for each chromosome 13, 18 or 21. RESULTS: QF-PCR results on amniotic fluid were consistent with conventional cytogenetic data. QF-PCR detected 5 cases of trisomy 21, 2 cases of trisomy 18, 1 case of trisomy 13 and 1 case with Klinefelter's syndrome. CONCLUSIONS: QF-PCR has proved to be very useful in clinical settings, since it allows the detection of major numerical disorders in a few hours after sampling and thus reduces parental anxiety.

Changes in type B natriuretic peptide (BNP) concentrations during cardiac valve replacement.

OBJECTIVE: The aim of our study was to investigate the ability of BNP levels to reveal the immediate post-surgery cardiac function improvement. We measured the perioperative variations in BNP concentrations in patients scheduled for cardiac surgery with cardiopulmonary bypass (CPB), chronic mitral regurgitation, valvular aortic stenosis, or myocardial ischaemia. METHODS: Three groups were included: patients with coronary artery bypass graft (CABG, group I, n = 14), aortic (AVR, group II, n = 14) or mitral (MVR, group III, n = 7) valve replacement. BNP assay was performed at the induction of anesthesia, immediately after the CPB, at the arrival in the intensive care unit, 4 h, 8 h and 12 h after the arrival in ICU. RESULTS AND CONCLUSION: The occurring variation in BNP levels after the operation is an increase whatever the corrective surgery, underlying the relative lack of specificity of BNP with regard to the cardiac pathology. Besides iatrogenic cardioplegia one can supposes that cardiac surgery involves other major stimuli such as anesthesia, sternotomia, hemodynamics, post-operative that could influence in a non specific way BNP levels.

[Pellet guns: a persistent threat to eyes]. / Armes à grenailles: une menace oculaire qui persiste.

Following a recent case of bilateral perforating ocular trauma by multiple pellets, the authors reviewed pellet traumatisms treated in the Emergency Department and operated on in the Ophthalmology Department of the Villeneuve-St-Georges Hospital over the past 15 years. At close range, pellet weapon shootings can generate lid, conjunctiva, and powder cornea tattoos; in these cases, the lesions are often unilateral. Shooting at longer range does not result in corneodermic tattoos, but because pellets scatter, binocular lesions frequently occur. The different lesions caused by these nonmagnetic foreign bodies are often very serious. An early, even very early, traumatic cataract is sometimes very difficult to treat in these polytraumatized eyes. The visual prognosis is more reserved, as the impact zones often involve the posterior pole and the macular area. The best recovered visual acuity is 30-35/20, with visual field alterations, but the injury to the eyeball by multiple pellets can generate globe atrophy. The authors stress the gravity of these ocular traumas, fortunately rarer but not completely eradicated since the law of May 6, 1995, which restricted the possession of these pellet guns.

[Air bags and eye injuries: chemical burns and major traumatic ocular lesions--a case study]. / Air bags--sécurité vitale et risques oculaires: brûlures alcalines et lésions traumatiques profondes. A propos d'un cas.

The authors report a case of bilateral eye lesions with extended visual sequelae after the inflation of a driver's airbag during a head-on collision. The superficial facial lesions were accompanied by bilateral eye lesions, reaching both the anterior and posterior segments. Bilateral periorbital palpebral hematomas; voluminous bipalpebral edema combined with severe -conjunctival edema, corneal erosions, and edema; bilateral hyphema; pupillary changes with multiple iris sphincter breaks and weak pupillary light reflex only on the right eye; retrocession of the iridocorneal angle; and on fundus examination both retinas had posterior and peripheral hemorrhages and Berlin retinal edema. Five years after the trauma and 4 years after posttraumatic surgery for cataract that had progressively appeared on the left eye, the visual acuity is 25/20 in both eyes notwithstanding a small paracentral scotoma related to a break in the Bruch membrane. A review of the literature shows several types of ophthalmological lesions related to the airbag mechanism, which after combustion of an alkaline powder inflates at a very high speed, resulting in a risk of corneal-conjunctive-palpebral alkaline burns added to an eye contusion, which may be responsible for severe lesions. The American studies distinguish three factors affecting the seriousness of these airbag accidents: (a) wearing glasses, (b) position and size of the driver, and (c) inflation force of the airbag. Wearing a seatbelt is mandatory to minimize the violence of the oculofacial impact. After facial trauma from an airbag, an ophthalmological examination is necessary to assess of the chemical burns of the tissues exposed to the alkaline powder and possible major ocular lesions.

Hyperechogenic fetal bowel: a large French collaborative study of 682 cases.

Hyperechogenic fetal bowel is detected in 0.1-1.8% of pregnancies during the second or third trimester. This ultrasound sign is associated with cystic fibrosis or other conditions (e.g., chromosomal anomalies, viral infection) but no large-scale prospective studies have been conducted. This 1997-1998 multicenter study in 22 molecular biology laboratories identified 682 cases of hyperechogenic fetal bowel detected by routine ultrasound examination during the second (86%) or third trimester. The fetal bowel was considered hyperechogenic when its echogenicity was broadly similar to, or greater than, that of the surrounding bone. Karyotyping, screening for viral infection, and screening for cystic fibrosis mutations were performed in all cases. Pregnancy outcome and postnatal follow-up were obtained in 656 of the 682 cases (91%). In 447 cases (65.5%), a normal birth was observed. Multiple malformations were observed in 47 cases (6.9%), a significant chromosomal anomaly was noted in 24 (3.5%), cystic fibrosis in 20 (3%), and viral infection in 19 (2.8%). In utero unexplained fetal death occurred in 1.9% of cases, toxemia in 1.2%, IUGR in 4.1%, and premature birth in 6.2%. This study demonstrates that this ultrasound sign is potentially associated with medically significant outcomes. Having established that the bowel is hyperechogenic, recommended investigations should include a detailed scan with Doppler measurements, fetal karyotyping, cystic fibrosis screening, and infectious disease screening. After birth, newborns require pediatric examination because a surgical treatment may be necessary. This should be combined with clear counseling of the parents.

[Training for adult subclavian venous catheterization: use of real-time echography]. / Apprentissage du cathétérisme de la veine sous-clavière chez l'adulte: apport de l'assistance échographique en temps réel.

OBJECTIVE: To assess the training in adult subclavian venous catheterization of an inexperienced operator, with two different procedures: ultrasound guidance vs anatomic landmark technique. STUDY DESIGN: Prospective, comparative study. PATIENTS AND METHODS: After informed consent, 50 adults were divided in two groups, with an original method of inclusion, designed to assess the training of the operator, which alternated ultrasound guidance (n = 25) and Aubaniac's landmark technique (n = 25). RESULTS: All the catheterizations have been completed. The success rate at first attempt was higher in ultrasound group than in landmark group, without reaching significance (76 vs 56%). Two arterial punctures were reported in landmark group. With ultrasound guidance, there were 21 puncture sites at the external third and 4 at the medial third of the clavicle. Average access time (skin to vein) was 15 +/- 8 seconds in ultrasound group and 63 +/- 78 seconds in landmark group (p < 0.01), with a significant relation between access time and patient rank in landmark group (r2 = 0.42, p < 0.01). CONCLUSION: Ultrasound guidance makes the training in adult subclavian venous catheterization easier, and allows inexperimented operator to be rapidly efficient. The use of ultrasound would decrease the incidence of complications by a real time visualization of anatomical structures, and by a more external approach of the vein than in the Aubaniac's technique.

Platelet function point-of-care tests in post-bypass cardiac surgery: are they relevant?

BACKGROUND: Platelet dysfunction is an important cause of excessive bleeding after cardiac surgery. We assessed two platelet function point-of-care tests: the platelet function analyser (PFA-100) and the Hemostatus(TM) in patients with and without excessive bleeding after cardiac surgery with cardiopulmonary bypass. METHODS: Mediastinal chest tube drainage (MCTD) was measured for the first 6 h in the intensive care unit (ICU). Haematology and coagulation tests were done on arrival in the ICU, and when excessive bleeding occurred (MCTD >1 ml kg(-1) h(-1)) or after 3 h. RESULTS: Eighteen patients bled excessively and 27 had normal MCTD. Hemostatus measurements were prolonged in those with excessive bleeding compared with the normal group. The times for PFA-100 adenosine diphosphate (ADP) and epinephrine were 91 vs 71 s (P=0.004) and 155 vs 114 s (P=0.02) in the bleeding and normal group s, respectively. None of the Hemostatus or PFA-100 values correlated with total MCTD. Depending on the agonist used, maximum aggregation was 33-81% and 52-86% in bleeding and normal groups, respectively. Only poor correlations were found between PFA-100 epinephrine and maximum aggregation in response to ADP (r=-0.52, P=0.03) or to collagen (r=-0.48, P=0.04). CONCLUSION: Patients bleeding excessively in the ICU had abnormal measurements in point-of-care tests without a dramatic decrease in aggregation. Except for patients with increased risk of postbypass bleeding, point-of-care tests are not useful for routine use after cardiac surgery.