[Determinants of group B streptococcus maternal colonization and factors related to its vertical perinatal transmission: case-control study]. / Déterminants de la colonisation maternelle à streptocoque B et facteurs associés à sa transmission verticale périnatale: étude cas-témoins.

OBJECTIVES: To investigate the determinants of Group B streptococcus (GBS) maternal colonization, as well as factors associated with its vertical transmission. PATIENTS AND METHODS: Case-control study on all singletons pregnancies delivered beyond at least 24 weeks of amenorrhoea in Southern Reunion maternities for which GBS screening was known. Multiple logistic regression analysis using 2004-2007 dataset of South Reunion birth registers. RESULTS: Out of 17,430 women delivered between 1st January 2004 and 31st December 2007, 2911 (16.7%) carried GBS. In a model adjusted on antenatal care, risk groups for GBS carriage were the women indigenous from another island of the Indian Ocean than Reunion (OR: 1.29, CI95%: 1.05-1.57) and obese women (body mass index ≥ 30, OR: 1.19, CI95%: 1.03-1.18). Protective factors included birthplace in mainland France (OR: 0.82, CI95%: 0.69-0.97) and underweight (OR: 0.81; CI95%: 0.69-0. 95). In a model controlling for a composite obstetrical variable delineating the protective roles of C-section and antibioprophylaxis as well as the putative role of meconium-stained fluids (thin, thick or fetid), all previously found in our setting, three key factors were independently associated with GBS vertical mother-to-child transmission: obesity (OR: 1.48, CI95%: 1.05-2.09), fetal tachycardia (OR: 4.92, CI95%: 2.79-8.68) and late preterm birth (35 to 36 wks, OR: 2.14, CI95%: 1.32-3.45). CONCLUSION: These findings strengthen the putative roles of corpulence and ethnicity in GBS acquisition previously found in the United States, while confirming an authentic role of obesity in its vertical transmission, independently of other classical cofactors lighted by our study.

[Nipple sparing mastectomy: an update]. / Mastectomie totale avec conservation de la plaque aréolo-mammelonnaire: état des lieux.

In order to decrease the psychological impact and the mutilating feeling of surgical treatments of the breast cancer when the mastectomy is indicated, authors described and propose the nipple sparing mastectomy (NSM). The only opposable criticism would be the increase of recurrence rate. The study of the recent literature allows us to make a inventory of fixtures concerning this evolution of the surgical practices whether on a technical, oncological, plastic or psychological plan. This technique is not validated in France and adjuvent therapies as the radiotherapy of the nipple are not validated yet. It seems that the NSM is a safe practice from the carcinologic point of view, while having a positive psychological impact in terms of disease and treatment acceptance. The technique seems possible after an information and selection of the patients and with a respect for technical rules (frozen section, peroperative evaluation of the nipple vitality).

Efficacy of a toxicity-adjusted topotecan therapy in recurrent small cell lung cancer.

The present prospective multicentre trial investigated whether topotecan, given at a starting dose of 1.25 mg.m(-2) with individual dose adjustment, can improve safety in patients with relapsed/refractory small cell lung cancer without loss of efficacy. Patients received topotecan intravenously on days 1-5, every 21 days, for up to six courses. In the absence of relevant haematotoxicities, topotecan was increased to 1.5 mg.m(-2) and reduced to 1.0 mg.m(-2) in case of severe haematotoxicities. Of 170 recruited patients, 73.2% had stage IV disease and 63.4% had platinum-containing pre-treatment. Patients received a total of 521 courses. In 72.6% of those courses, the dose remained at 1.25 mg.m(-2); in 9.1% it was reduced and in 18.3% it increased. Overall response rate was 14.1% including one complete response; 28.8% had stable disease. Median duration of response was 13.6 weeks and median survival was 23.4 weeks. Clinical benefit was obvious for sensitive as well as for refractory patients. Haematotoxicity of grade 3 or 4 was clearly lower compared with the standard dose of 1.5 mg.m(-2). In conclusion, topotecan at a dose of 1.25 mg.m(-2) appears to be as effective as the dose of 1.5 mg.m(-2), but with reduced toxicity. Since patients with recurrent small cell lung cancer have a poor prognosis, they benefit especially from good tolerability.

[Long term survival with the Bentall button operation in 150 patients]. / Suivi à long terme de l'opération de Bentall avec collerettes sur 150 patients.

Between May 1980 and May 2000, 150 patients (123 males and 27 females) underwent surgery with the same surgeon for ascending aortic replacement with a valvular conduit and coronary reimplantation with the aid of a collar of aortic wall (button technique). The average age was 50 +/- 16 years. Within this population, 114 patients had isolated annulo-ectasial disease, 36 had Marfan syndrome and 20 had dissection (5 acute and 15 chronic). A carbon fibre valve with 2 leaflets was implanted in 124 patients, a mono-leaflet valve in 20 and 6 others required a heterograft due to their age or a contra-indication to anticoagulation. The associated procedures were: 12 arch replacements, 5 myocardial revascularisations, 4 mitral replacements, 1 tricuspid plasty, 1 inter-atrial communication closure. In 30 patients (20%) there was a cardiovascular surgical re-intervention. The operative and first month mortality amounted to one sudden death on the 19th day, ie 0.6%. Three patients were lost to follow up. The average survival was 7.87 +/- 5.37 years (minimum 1, maximum 20 years). The actuarial survival was 85% at 10 years and 60% at 20 years. These figures are much higher than those reported in our previous statistics from 1994 when the percentage of survivors at 12 years was only 61%. In the group of patients undergoing surgery before 60 years of age, the survival at 14 years was 94% and 81% at 20 years. Only four late re-interventions were attributable to the Bentall procedure, of which 2 were left coronary ostium stenoses. The rate of thrombosis and embolism was 0.42 per 100 patient-years and the rate of haemorrhagic accidents was identical, including minor accidents. This considerable improvement in long-term prognosis is explicable by the adoption of a single operative technique, considered to be the best, with the best myocardial protection thanks to coronary retro-perfusion and cold or hot cardioplegia, and also without doubt with the best medical survival.

[Coronary surgery of the beating heart. First year of experience in a series of 317 non-selected coronary patients]. / Chirurgie coronaire à coeur battant. Première année d'expérience sur une série de 317 patients coronariens non sélectionnés.

From May 1999 to May 2000, 317 unselected patients, representing 92.7% of all coronary artery surgery procedures, underwent open heart surgery of the beating heart by median sternotomy with the aid of a cardiac stabilising device. The main preoperative characteristics were: mean age = 66.1 years; men = 78.9%; left main stem disease = 31.8%; mean left ventricular ejection fraction = 54.1%; mean Parsonnet index = 16.9. These 317 patients were compared with a group of 303 patients who underwent coronary bypass surgery the year before by the same surgical team with cardiopulmonary bypass (CPB) and cardiac standstill. Seven hundred and eighty-six distal anastomoses were carried out in the beating heart group (2.48 grafts per patient) compared with 2.91 in the CPB group: p < 0.001). There were 10.1% single bypass, 37.5% double bypass, 47.3% triple bypass and 5% quadruple bypass procedures. A cardiopulmonary bypass was required in 13 patients (4.1%). The mortality at 30 days was 3.1% versus 4.6% in the CPB group (p = NS). The need for blood transfusion was reduced by nearly 40% in the beating heart group (23.7% versus 39.9%, p < 0.001). The incidence of cerebrovascular complications was reduced from 3% in the CPB group to 0.6% in the beating heart group (p = 0.06). The peak postoperative troponine I levels were much lower in the beating heart group (2.5 versus 6.4 ng/ml, p < 0.001). The authors conclude that surgery on the beating heart is feasible in most patients. Compared with conventional surgery under CPB, there seems to be less requirement for blood transfusion and a tendency to reduce the cerebral risk. Nevertheless, a large prospective randomised trial is required to validate the potential advantages and limitations of this technique with respect to conventional surgery and to determine the optimal indications of surgery on the beating heart.

Intradiscal electrothermal treatment for chronic discogenic low back pain: a prospective outcome study with minimum 1-year follow-up.

STUDY DESIGN: Prospective case series. OBJECTIVE: To determine the outcome of patients with chronic low back pain whose symptoms did not improve with aggressive nonoperative care and who chose (intradiscal electrothermal anuloplasty) IDET as an alternative to chronic pain management or interbody fusion surgery. SUMMARY OF BACKGROUND DATA: Patients with unremitting chronic discogenic low back pain are faced with the choice of long-term pain management or fusion surgery. Intradiscal electrothermal anuloplasty (IDET) was developed as an alternative minimally invasive treatment. MATERIALS AND METHODS: Sixty-two patients from the author's practice who had chronic low back pain unresponsive to nonoperative care, no evidence of compressive radiculopathy, and concordant pain reproduction at one or more disc levels on provocative discography were enrolled in the study. Visual analog scale (VAS) pain scores and Short Form (SF)-36 Health Status Questionnaire Physical Function subscale and SF-36 Bodily Pain subscale scores were assessed at baseline and at least 1 year later. RESULTS: Mean follow-up was 16 months, and mean preoperative duration of symptoms was 60 months. Baseline and follow-up outcome measures demonstrated a mean change in VAS score of 3.0 (P < 0.001), mean change in SF-36 physical function of 20 (P < 0.001), and mean change in SF-36 bodily pain of 17 (P < 0.001). Symptoms improved in 44 (71%) of 62 of the study group on the SF-36 physical function subscale, in 46 (74%) of 62 on the SF-36 Bodily Pain subscale, and in 44 (71%) of 62 on the VAS scores. Twelve (19%) of 62 of the patients did not show improvement on any scale. CONCLUSION: A cohort of patients with chronic unremitting low back pain of discogenic origin whose symptoms had failed to improve with aggressive nonoperative care demonstrated a statistically significant and clinically meaningful improvement on the SF-36 and the VAS scores at a minimum follow-up of 1 year after IDET. The positive results should be validated with placebo-controlled randomized trials and studies that compare IDET with alternative treatments.-

Immunoadsorption onto protein A induces remission in severe systemic lupus erythematosus.

BACKGROUND: Reduction of pathological autoantibodies and circulating immune complexes can be useful in the treatment of autoimmune disease. Plasmapheresis has been shown to reduce autoantibody levels in systemic lupus erythematosus (SLE), but its effect on patients' outcome was not better compared with conventional immunosuppression in the past. AIM OF THE STUDY: Immunoadsorption as a selective extracorporeal immunoglobulin elimination technique was evaluated as rescue therapy in patients suffering from SLE. METHODS: Eight patients with severe, therapy-resistant SLE underwent immunoadsorption onto protein A sepharose without concomitant immunosuppressants. RESULTS: Remission of the disease was achieved in seven patients. Therapy had to be stopped in one patient because of side-effects. The best results were obtained when immunoadsorption was carried out daily, without supplementary intravenous immunoglobulin therapy. Oral cyclophosphamide for 3-6 months during follow-up was used to suppress relapse. Autoantibodies and circulating immune complexes were effectively eliminated regardless of their IgG subclass. CONCLUSION: Immunoadsorption onto protein A might be used as an extracorporeal treatment option in SLE when other therapies are ineffective.

Management of chronic discogenic low back pain with a thermal intradiscal catheter. A preliminary report.

STUDY DESIGN: A prospective nonrandomized clinical trial. OBJECTIVE: To determine the outcome in a group of patients with chronic, function-limiting low back pain who met the criteria for interbody fusion surgery, but were instead treated with an intradiscal thermal catheter (SpineCath, Oratec Interventions, Inc., Menlo Park, CA). SUMMARY OF BACKGROUND DATA: This study represents the first reported trial of treatment for chronic discogenic low back pain with a novel thermal intradiscal catheter. METHODS: The authors evaluated 25 consecutive patients. The minimum duration of nonoperative care with the authors was 6 months. The visual analog pain scores, sitting tolerance times, and SF-36 summary scores were tabulated. RESULTS: The mean follow-up period was 7 months, and the mean duration of symptoms 58.5 months. Of the 25 patients, 20 (80%) reported a reduction of at least 2 points in visual analog pain scores, and 18 (72%) reported an improvement in sitting tolerance as well as reduction or discontinuance of analgesic medication. Visual analog pain scores improved by a mean reduction of 3.74, a 51% change (P = 0.0001). On the SF-36 physical function subscale, 72% of the patients improved by a mean increase of 15 points (P = 0.001), a mean change of 38%, and by a mean increase of 14 points on the bodily pain subscale (P = 0.004), a mean change of 48%. CONCLUSIONS: A statistically significant improvement in functional outcome was obtained in patients with chronic discogenic low back pain treated thermally by the SpineCath.

Synovial Epstein-Barr virus infection increases the risk of rheumatoid arthritis in individuals with the shared HLA-DR4 epitope.

OBJECTIVE: To investigate the presence of the Epstein-Barr virus (EBV) in rheumatoid arthritis (RA) synovium and its correlation with the HLA genotype in an attempt to elucidate the role of EBV in the pathogenesis of RA. METHODS: EBV DNA/RNA was investigated by polymerase chain reaction (PCR) analysis of synovial tissue from 84 patients with RA and from 81 patients with non-RA arthritis (controls) and was correlated with the patients' HLA genotype. RESULTS: EBV DNA and EBV-encoded RNA 1 transcripts were significantly more frequently present in synovial tissue from the RA patients (29 of 84) than in that from the non-RA patient controls (8 of 81). EBV DNA-positive individuals had a 5.47 times higher risk of presenting with RA than did EBV DNA-negative individuals. In HLA-DRB1*0401,0404,0405,0408-positive or shared epitope-positive patients, the risk was further increased (odds ratio for EBV and HLA-DR4 approximately 41, for EBV and the shared epitope approximately 15) compared with those who lacked both EBV DNA and RA-linked HLA genotypes. CONCLUSION: EBV seems to function as an environmental risk factor for RA, particularly in patients with the RA-linked HLA-DRB1 alleles.

[Postoperative infections after heart surgery under extracorporeal circulation]. / Infections postopératoires après chirurgie cardiaque sous circulation extracorporelle.

Postoperative infection is still an important cause of mortality and morbidity after cardiac surgery. The aim of this study was to assess its incidence and causes in order to optimise treatment. Between January 1996 and December 1997, 1,000 consecutive patients (253 women and 747 men) were operated for cardiac aortic pathology under cardiopulmonary bypass. The mean age was 66 +/- 11 years. The initial pathology was coronary artery disease (N = 663), valvular heart disease (N = 193), an association of the two (N = 94), thoracic aortic pathology (N = 38) or other pathologies (N = 12). The global postoperative infection rate was 4.9% (N = 49). The incidence of sternal and/or mediastinal infections was 0.7%, of bronchopneumonia 0.9%, urinary infection 2.1%, and septicaemia 1.7%. Nine patients died of the consequences of an infection. The hospital stay was significantly longer in infected patients, irrespective of the site of infection. Statistical analysis of the whole population did not show any predictive factor related to the preoperative clinical status of the patients. The only predictive factor demonstrated was the day on which surgery was performed: the infection rate in patients operated during the first 4 days of the week was 2.2% compared with 7.3% for the patients operated during the last 3 days (p = 0.004, odds ratio (OR) = 3.57). In those patients who had an urinary infection, the two identified risk factors were the female gender (p = 0.006, OR = 3.34) and an operation performed at the end of the week (p = 0.017, OR = 3.77). In patients with sternal and medistinal infections, the only identified predictive factor was combined coronary artery and valvular surgery (p = 0.009, OR = 7.43). With respect to pulmonary infections, the only predictive factor was recent preoperative myocardial infarction (< 1 month) (p = 0.004, OR = 7.5). Finally, no predictive risk factors were identified in those patients who developed septicaemia. In conclusion, this study showed that postoperative infection remains a serious complication of cardiac surgery. The prevention of these complications should be a priority for quality health care.

[Mitral valvuloplasty for asymptomatic or pauci-symptomatic mitral insufficiency]. / Valvuloplastie mitrale pour insuffisance mitrale asymptomatique ou paucisymptomatique.

The aim of this study was to assess the results of mitral valvuloplasty for chronic asymptomatic or paucisymptomatic mitral regurgitation. Of 584 patients operated for chronic mitral regurgitation between January 1989 and December 1994, 175 were in NYHA Classes I and II and made up the study population. All had chronic grade 3 or 4/4 mitral regurgitation suitable for mitral valvuloplasty. The average follow-up was 34.3 months. Mitral valvuloplasty was performed in 174 patients, the other patient requiring mitral valve replacement. Three patients died (1.7%) and the actuarial 5 year survival was 98.2 +/- 1.0%. The probability of absence of reoperation and absence of thrombo-embolic complications at 5 years were 97 +/- 0.8% and 96.3 +/- 1.7% respectively. The residual regurgitation at Doppler echocardiography was minimal or absent in 94% of patients at the last follow-up control. The mean end-systolic and end-diastolic left ventricular dimensions decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm before surgery to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001) at the last control. The authors conclude that conservative mitral valve surgery for NYHA Classes I and II patients with chronic mitral regurgitation is feasible with a low risk and is associated with a significant reduction in ventricular volumes and stability of valvular continence at medium-term. When performed by teams trained in techniques of mitral valvuloplasty, these results suggest that surgery should be performed early.

Expression of cyclooxygenase 1 and cyclooxygenase 2 in human synovial tissue: differential elevation of cyclooxygenase 2 in inflammatory joint diseases.

OBJECTIVE: To compare the expression of the cyclooxygenase (COX) isoforms, COX-1 and COX-2, in synovial tissue samples between patients with inflammatory arthritis (i.e., rheumatoid arthritis [RA], ankylosing spondylitis [AS], or psoriatic arthritis [PsA]) and patients with osteoarthritis (OA). METHODS: Paraffin-embedded sections of synovial tissue from patients with OA (n = 18), RA (n = 35), AS (n = 9), and PsA (n = 16) were immunostained for COX-1 and COX-2. Staining intensity was quantified videodensitometrically from specific synovial cell areas. In addition, samples of OA and RA synovial tissue were analyzed for levels of COX-1 and COX-2 messenger RNA (mRNA) using reverse transcriptase-polymerase chain reaction. RESULTS: Strong COX-2 immunostaining was observed in synovial blood vessel endothelium, synovial lining cells, chondrocytes, and subsynovial fibroblast-like cells in patients with inflammatory arthritides. In the blood vessels, the mean (+/-SD) optical density (MOD) of staining was elevated, especially in AS samples (2.73 +/- 0.63), but also in PsA (1.99 +/- 0.66) and RA samples (1.54 +/- 0.73), in comparison with OA synovial tissue (0.84 +/- 0.30; P < 0.01 versus other groups). COX-1 staining was almost exclusively localized in synovial lining cells, with no significant differences in the MOD between the diseases. COX-2 mRNA expression was higher in RA than in OA samples (P < 0.05). CONCLUSION: The expression of COX-2, but not the expression of COX-1, was found to be elevated in a disease-related pattern in the synovial tissue from patients with RA, AS, or PsA in comparison with OA samples, and was especially high in AS synovial tissue. These results may improve our understanding of the pathogenesis of different arthritic diseases, and may have implications for the use of selective COX-2 inhibitors in the treatment of inflammatory joint symptoms.

[Initial results of mitral valvuloplasty using the Physio-Carpentier-Edwards ring]. / Résultats préliminaires de la plastie mitrale avec l'anneau physio-carpentier-edwards.

The Physio-Carpentier-Edwards ring is a new prosthetic ring developed to allow mitral annuloplasty associating remodelling and flexibility of the native mitral annulus. The object of this study was to assess the feasibility and reliability of mitral valvuloplasty with the Physio ring. Between December 1992 and October 1995, 100 patients with an average age of 56.8 years suffering from mitral insufficiency underwent mitral valvuloplasty with a Physio ring. The mitral insufficiency was degenerative in 94% of cases. The degree of regurgitation was scored 3+ or 4/+4/+ in 94 patients. Mitral valve prolapse was observed in 83 patients. Mitral reconstruction was undertaken using Carpentier's techniques. One patient died in the immediate postoperative period. Two patients were reoperated for valve replacement because of systolic anterior motion (SAM). One patient had SAM which regressed with medical treatment. There were no deaths after the hospital period. There were no late reoperations of thrombo-embolic complications. The average follow-up period was 19 +/- 8 months; 77 patients were followed up for over 1 year and all underwent control Doppler echocardiography. Sixty-one patients had no residual mitral insufficiency: 15 patients had grade 1/4 regurgitation and one patient had grade 2/4 regurgitation. The average mitral valve surface area was 2.8 +/- 0.3 cm2. The average left ventricular end diastolic volume decreased from 186 +/- 59 cm3 before surgery to 129 +/- 37 cm3 at the last control (p < 0.001). The authors conclude that the Physio ring enables reliable and effective mitral valvuloplasty with excellent short term results. The benefits of the flexibility of the Physio ring remain to be evaluated by a randomised trial.

Evaluation of synovial cytokine patterns in rheumatoid arthritis and osteoarthritis by quantitative reverse transcription polymerase chain reaction.

To compare the cytokine profile with the degree and composition of cellular infiltration in rheumatoid arthritis (RA) and osteoarthritis (OA) synovium, synovial membranes from patients with RA (n = 14) and OA (n = 5) were examined, employing immunohistochemistry and competitive reverse-transcriptase polymerase chain reaction (RT-PCR), for interleukin (IL)-I beta, IL-2, IL-4, IL-5, IL-6, and IL-10, and tumour necrosis factor-alpha (TNF-alpha) gene expression. It was found that the strength of cytokine gene expression within the synovial membranes of patients with RA was not significantly correlated with the degree of synovial infiltration of T-cells, B-cells, or macrophages. No IL-2, IL-4, or IL-5 RNA was detected in the synovium of either RA or OA. Quantitative cytokine determination showed a similar pattern in RA and OA, although the two diseases differed in total synovial infiltration and the composition of infiltrating cellular elements. Thus the number of cell types known to produce certain cytokines does not appear to determine the strength of synovial cytokine expression measured by quantitative RT-PCR. Furthermore, the pattern of T-cell specific cytokines found in RA synovium does not accord with the concept of the TH0, TH1, and TH2.

Natural history and nonoperative treatment of lumbar disc herniation.

Lumbar disc herniation is a common condition with a favorable prognosis in the majority of circumstances. This article reviews the published scientific evidence regarding the impact of nonoperative care on this condition. The published studies are critiqued and evaluated on their relative strengths and weaknesses. The effect of time, medications, exercise, injection therapy, and manipulation are considered. The literature regarding the natural history process of disc resorption is reviewed, including time frames and the proposed underlying mechanisms that may enhance or impede this process. The effect of inflammation on treatment effectiveness and decision-making is evaluated. The possible impact of various types and locations of lumbar disc herniation, coexisting anatomic factors, lumbar disc herniation material type, lumbar disc herniation material chemical factors, clinical characteristics, and patient-related factors are discussed. Appropriate candidates for operative versus nonoperative care are discussed. Conclusions are drawn from this literature review that will help guide management decisions.

Consensus summary of the diagnosis and treatment of lumbar disc herniation.

Clinicians must not simply decide that a patient with symptoms and a positive diagnostic test has a reason for a specific treatment, and likewise clinicians must not decide that a patient with symptoms and a negative test does not have a clinically important problem. We must also consider the sensitivity, specificity and predictive value of the diagnostic test and the individual characteristics of the patient. Treatment outcome depends on many factors. Point of service decisions vs population based decisions are obviously different. Each patient presents to the treating practitioner on a given day, at a given time, and it is this picture upon which a plan of care is formulated.