Implementation of a systematic comprehensive geriatric assessment for elderly patients suspected of pulmonary hypertension.

BACKGROUND: The phenotype of patients seen for a suspicion of pulmonary hypertension has changed, with an increasing age and frequency of comorbidities. Selection of elderly patients, in whom a classical work-up is mandatory, is challenging. Comprehensive geriatric assessment (CGA) has modified the management of elderly patients with cancer. Pulmonary hypertension (PH) shares with cancer a functional impact and may evolve rapidly, depending on the group of PH. We assessed the impact of a systematic CGA in patients over 70 years old referred for a suspicion of PH. METHODS: A standardised CGA was performed on every patient older than 70 years old, referred for a PH suspicion, before considering invasive tests for diagnosis and treatment, between July 2014 and May 2019. Our primary aim was to describe the impact of CGA on the decision to stop or pursue the recommended diagnostic work-up for PH. RESULTS: Among the thirty-one patients evaluated [mean age 81,5 (72-91) years], a negative CGA leads to stop the diagnostic work-up in eleven patients. Among the nineteen remaining patients, sixteen had confirmed PH, with half being chronic thromboembolic pulmonary hypertension. CONCLUSIONS: Our study indicates that comprehensive geriatric assessment could be an excellent first screen for elderly patients referred for a PH suspicion. Involving a geriatric physician stopped the investigations in one third of patients. In patients with a favourable CGA, PH was confirmed in most of the cases, with chronic thromboembolic pulmonary hypertension being the first cause of PH.

Chronic thromboembolic pulmonary hypertension suspicion after pulmonary embolism in cancer patients.

INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe condition which should be screened in patient with persistent dyspnea after pulmonary embolism (PE). After PE, CTEPH incidence was estimated between 0.1 and 9.1% in overall patients. Although cancer is associated with an increased risk of CTEPH, CTEPH incidence is still unknown in cancer patients with PE. We aimed to estimate the frequency CTEPH-likely patients after PE, in cancer patients. MATERIALS: We individualized cancer patients of a monocentric prospective registry including consecutive patients with symptomatic PE. The primary outcome was the frequency of "CTEPH-likely" patients defined by the European Respiratory Society (ERS) guidelines (an accelerated tricuspid regurgitation more than 2.8m/s and at least 1-2 segmental or larger-sized defects, after more than 3 months of therapeutic anticoagulation). RESULTS: We included 129 cancer patients with PE. Colorectal cancer (19%), breast cancer (17%) and prostate cancer (15%) were the most frequent cancers. PE occurred after surgery or medical immobilization in 17% of patients, while 26% of patients had history of venous thromboembolism. During the follow-up, 2 patients (1.5%) had a clinical suspicion of CTEPH and only 1 patient with ovarian cancer (0.75% 95%CI [0.0%-2.2%]) was classified as "CTEPH-likely", 6 months after PE. CONCLUSION: The frequency of screening for CTEPH seems negligible in PE patients with cancer. Concomitant cancer may affect the clinical suspicion of CTEPH.

[Management of cervical cellulitis with and without mediastinal extension: report of 17 cases]. / Prise en charge des cellulites cervicales avec on sans extension médiastinale: à propos de 17 cas.

OBJECTIVES: Cervical cellulitis is infrequent but serious. The aim of our study was to describe the way we care and to identify certain factors that promote the development of such a condition. PATIENTS AND METHODS: We conducted a retrospective study covering the period 2004 to 2009 and included patients with cervical cellulitis with or without mediastinal extension surgically supported by ENT department of the University Hospital of Dijon. Data were collected clinical, radiological, treatment, type of surgery and complications. RESULTS: Seventeen patients met our inclusion criteria, four of which had a form associated with mediastinitis. Eight patients had taken NSAIDs and/or corticosteroids and fifteen patients antibiotics before their hospitalization. All have benefited from surgery with an average of 1.35 interventions (range 1 to 3) and support postoperative resuscitation. In both cases the outcome was unfavourable. CONCLUSION: The use of NSAIDs and/or corticosteroids was a factor in promoting this type of infection. In the context of surgical treatment, it does not seem necessary to surgically reoperate systematically.

[Acute group A beta-hemolytic streptococcus membranous laryngotracheobronchitis in an adult]. / Laryngotrachéobronchite aiguë membraneuse à streptocoque bêta-hémolytique du groupe A de l'adulte.

OBJECTIVE: To describe the first case of a group A beta-hemolytic streptococcus laryngotracheobronchitis as well as the other possible etiologies in a case of acute dyspnea. METHODS: We report the case of a 46-year-old woman with a doubtful vaccination status who presented clinical features of croup (laryngotracheobronchitis). She developed respiratory distress and required endotracheal intubation. RESULTS: The endoscopy demonstrated a great deal of crust and pseudomembrane detachment. Bacterial culture grew group A beta-hemolytic streptococcus. Progression was good with antibiotics and corticosteroid treatment. CONCLUSION: Bacterial acute pseudomembranous croup (laryngotracheobronchitis) is rare. We must search for the most frequent diagnoses such as diphtheria and epiglottitis. This is the first case to be reported in the literature.

[Zenker's diverticulum: technique and results of endoscopic treatment with Endo-GIA 30 stapler]. / Diverticule de Zenker : technique et résultats du traitement endoscopique a la pince GIA 30.

OBJECTIVES: The purpose of this project was to analyze the endoscopic management of Zenker diverticulum using an Endo-GIA stapler inserted transorally to perform an oesophageal diverticulostomia. PATIENTS AND METHODS: Between January 97 and December 2006, 30 consecutively treated symptomatic patients (13 men; median age 67 years; range 45-91) with Zenker's diverticulum were enrolled into this retrospective study. Ninety six percent complained about dysphagia with slimming in 33%. The diagnosis of Zenker's diverticulum is based on anamnesis and radiological examinations with applied contrast medium of the upper digestive tract. RESULTS: Twenty-six patients had the endoscopic approach. A patient profited in same time from a resection by external cervical approach following a tearing of the mucous membrane after installation from staled diverticulotomy. Finally 3 patients failed endoscopic exposure. On the 26 patients operated by strict endoscopic treatment, the average duration of intervention was 29 minutes. Overall, an onset of liquid intake on 2.3 postoperative days and the average length of stay was 6 days. Mean follow-up was 40 months. A recurrency was noted in the 2 cases, one was reoperated with the same technique. CONCLUSION: This endoscopic technique using an Endo-Gia stapler is an efficient, safe and minimally invasive method for the treatment of Zenker's diverticulum. With a low rate of morbidity, it is a good technique especially for patients with impaired of health or associated diseases.

[Upper airway obstruction by retropharyngeal haematoma: a complication of central venous catheter insertion attempt]. / Hématome rétropharyngé asphyxiant après tentative de pose d'une voie veineuse jugulaire interne.

Retropharyngeal haematomas are a rare complication of central venous catheters insertion. A case of a retropharyngeal haematoma in a patient treated by acetylsalicylic acid is reported. This case emphasized the difficulty in diagnosis. Close airway surveillance must be done and can lead to surgery in case of airway obstruction.

[Frontal sinus pathology and epilepsy]. / Epilepsie et pathologie du sinus frontal.

OBJECTIVES: Because of its location and the fragility of its physiology, the frontal sinus is the first of the facial sinuses to cause complications. In this context, orbital sepsis, cranial vault osteitis, meningitis, cerebral abscess, longitudinal sinus thrombophlebitis can occur. A more uncommon consequence of frontal sinusitis is isolated epilepsy. METHODS: We report two cases of patients admitted in our department after a generalised epilepsy seizure with, on the CT-scan, an opacity of the frontal sinus with a posterior wall lysis. RESULTS: We operated on quickly both patients after the seizure via an eyebrow approach. The first one had a purulent collection of the frontal sinus, the second an infected cholesteatoma. Both had a stenosis of the nasofrontal canal and a lysis of the sinus posterior wall with a bare dura mater. The surgical treatment consisted in the cleaning of the sinus associated with an antibiotic treatment in one case and the cholesteatoma matrix removal in the other. The nasofrontal canal was calibrated for respectively four and two months. An antiepileptic treatment was administered for one year. Four years later the nasofrontal canal is pervious and the frontal sinus sound in both patients. CONCLUSION: An epilepsy seizure can follow a frontal sinusitis. It does not convey the existence of an endocranial complication but requires researching it. The posterior wall lysis of the sinus with a bare dura mater is sufficient to lead to a seizure in case of sinus infection.

[Intratumoral chemotherapy: experimental data and applications to head and neck tumors]. / La chimiothérapie intratumorale: aspects expérimentaux et applications aux tumeurs de la tête et du cou.

OBJECTIVE: Intratumoral chemotherapy consists in the direct intratumoral injection of the anticancer drugs. Despite its simple and logical principle it remains relatively little used. MATERIAL AND METHODS: This work reviews and analyses the national and international literature about experimental and clinical studies of intratumoral chemotherapy. RESULTS: Numerous experimental studies validated its theoretical advantages compared with the intravenous one: drug intratumoral concentration increase, antitumoral activity improvement and systemic toxicity decrease. But they also underlined its limits: the high clearance and the non-homogeneous drug diffusion. Research works led to the improvement of the results and performed clinical trials with slow release devices (microspheres, collagen matrix with or without vasoconstrictive agent), anticancer drug in an aqueous solution with a vasoconstrictive agent, intratumoral injection in association with electrochemotherapy or radiotherapy. These trials showed the feasibility of this technique with, in recurrent tumors, response rate between 27 and 50% and an increase in quality of life. The more frequent adverse effects were pain in 24 to 80% of cases, ulceration, necrosis and oedema of the treated locations in 53 to 87,4% of cases and during the use of vasoconstrictive agents systemic effects like arterial hypertension and extrasystoles. CONCLUSIONS: Intratumoral chemotherapy is an effective therapeutic even when used after the classical treatments. Improvements are necessary to define the best drugs, injection technique, treatment periodicity and indications. Intratumoral chemotherapy deserves better interest at the moment where drugs and antibodies limit their action to the cancer cells preserving the healthy ones.

[Nasopharyngeal tonsillolith: a report of 31 cases]. / Les tonsillolithes nasopharyngés au scanner: à propos de 31 cas.

OBJECTIVE: Nasopharyngeal tonsilloliths are less well known to radiologists than palatine tonsil lithiases. The possibility of routinely available fine slices during CT scans of the head and neck prompted a retrospective study on the causes and radiological signs and patterns of nasopharyngeal tonsilloliths. MATERIAL AND METHODS: A total of 515 CT scans were retrospectively re-examined looking for calcifications of the posterior wall of the nasopharynx. One patient with this type of calcification underwent a cerebral MRI as part of the etiological workup of his faintness, which also provided a study of the nasopharyngeal wall. The size, density, and position of these calcium concretions were analyzed with CT in all cases. RESULTS: In 31 patients (18 men, 13 women), we discovered one or several calcifications in the pharyngeal mucous area, between 2 and 5.5 mm in size, with a median density of 202 HU. In two cases, we observed that these calcifications adhered to an adenoid cyst, whereas in three cases, the patients had both palatine tonsil and nasopharyngeal calcifications. None of the 31 patients had previously had an adenoidectomy. Sagittal CT and MRI images clearly localized all these calcifications before the pharyngobasilar fascia. DISCUSSION: The position of these nasopharyngeal calcifications in front of the pharyngobasilar fascia means that a calcified vestige of the notochord can be ruled out. Moreover, the simultaneous presence of nasopharyngeal tonsil and palatine tonsil calcifications in three patients is an additional argument for considering these calcifications of the posterior wall of the nasopharynx as tonsilloliths, all of which, representing 6% of the CTs in our series, were asymptomatic. CONCLUSION: The nasopharyngeal tonsilloliths are stones less than 1 cm in size lodged in the pharyngeal tonsils that are frequently detected on CT when there are no clinical symptoms.

[Pharyngeal stenosis: treatment by resection-end to end anastomosis]. / Sténose pharyngée: traitement par résection-anastomose.

OBJECTIVES: Pharyngeal stenosis occurs frequently after laryngectomy or total laryngectomy extended to the pharynx. Oral feeding might become impossible or is limited to liquids. In such cases, dilations can be performed, but surgery becomes necessary when they are unsuccessful. The objective of this report is to show that pharyngeal resection anastomosis is one of the existing techniques which can be helpful in such cases. METHODS: A 67-year-old woman had been operated on a laryngeal cancer 18 years earlier when she presented with a 2 cm height pharyngeal stenosis responsible for a chronical dysphagia to solids. The multiple dilations performed were unsuccessful and she underwent a pharyngeal resection and end to end anastomosis by lateral cervicotomy. RESULTS: The outcome was uneventful. Normal pharyngeal permeability and swallowing were restored and are still maintained with a 18 months follow-up. CONCLUSION: Rehabilitation technics using flaps--pectoralis myocutaneous, lingual, platysma or jejunum flaps--is not always mandatory in patients presenting with pharyngeal stenosis. A pharyngeal resection end to end stenosis, pharynx anastomosis can also be successfully performed in stenosis of limited height.

[Labyrinthine fistulae and cholesteatoma]. / Les fistules labyrinthiques d'origine cholestéatomateuse.

Labyrinthine fistula is a potentially serious complication of cholesteatoma. During or after surgery, cholesteatoma can induce partial or total destruction of cochleovestibular functions. We operated 38 patients from 1983 to 1996. The site of the fistula was the external semi-circular canal in 90% of the cases. The facial nerve canal was eroded in 66% of the cases. We performed 11 CT scans; only 7 evidenced the fistula. We removed the matrix of the cholesteatoma during the initial surgery in 35 cases and in 3 left the fistula in situ for subsequent excision at a second operation. Postoperative hearing loss compared with the preoperative situation was observed in 66% of the patients. Deafness was observed in 4 ears (11%). Hearing improved after surgery in 23% of the patients. We consider that a closed technique with immediate removal of the cholesteatoma matrix is indicated for most fistulae but that second-intention resection (combined approach tympanoplasty) is the better choice when the fistula is wide and the ear is infected. In some cases (old patient, one functional ear, better ear) an open technique may be preferred without risk for the cochleovestibular functions.

Pre-clinical study of the epinephrine-cisplatin association for the treatment of intraperitoneal carcinomatosis.

We have previously shown that intraperitoneal (i.p.) epinephrine enhances tumour penetration and anti-cancer activity of i.p.-administered cisplatin in rats with peritoneal carcinomatosis. Here, we show a direct correlation between the i.p. epinephrine concentration and cisplatin accumulation in rat peritoneal tumour nodules up to a concentration of 5 mg/l. This concentration leads to a maximal 3.7-fold increase of tumour platinum content and a maximal vasoconstriction of the peritoneal and tumour superficial microcirculation when registered by a laser doppler probe. Further, epinephrine half-life was 20.8+/-3.6 min in the peritoneal cavity of two laparotomized pigs. In these animals, epinephrine plasma concentration, heart rate and systolic blood pressure were dependent on the intraperitoneal dose of epinephrine, and life-threatening signs were not observed in either animal. In conclusion, a 5 mg/l concentration of epinephrine could be safely maintained in peritoneal fluid by regular replacement. This concentration is sufficient to maintain a constant vasoconstriction of the peritoneal and tumoral microvascular bed, and enhance the slow diffusion of cisplatin into peritoneal tumour nodules in the course of per-operative intraperitoneal chemotherapy.

[Mastoid cortical bone grafts in ossiculoplasty]. / L'os cortical mastoïdien dans les ossiculoplasties.

Ossicular homografts have been left for safety reasons with regard to viral transmission diseases. Several means are usable to reconstruct ossicular chain: synthetic prosthesis and autologous bone. On grounds of disponibility, biocompatibility, cost and use easiness we have been using mastoid cortical bone since 1995. We have studied hearing results and tolerance of 45 ossiculoplasties performed with cortical bone. Two years after, we have been obtaining as good or even better functional results with cortical bone graft than with auto or homologous ossicular bones (air bone gap inferior or equal to 20 DB in 89 % of the cases) and no extrusion. Thus, cortical bone seems to be, the better material when autologous ossicular bones are not available.

[Intraperitoneal cisplatin plus epinephrine and surgical debulking for the treatment of advanced peritoneal carcinomatosis in the rat]. / Optimisation du traitement des carcinoses péritonéales évoluées par la réduction tumorale chirurgicale et l'association cisplatine-adrénaline chez le rat.

OBJECTIVE: To evaluate and compare the effects of cytoreductive surgery with intraperitoneal cisplatin and epinephrine on peritoneal carcinomatosis in the rat. MATERIAL AND METHODS: Twenty-day old peritoneal carcinomatosis was obtained after intraperitoneal injection of 1 x 10(6) DHD/K12/PROb cells into BDIX rats. The surgical treatment included electric fulguration of the peritoneal tumors with spleen and omentum removal while intraperitoneal chemotherapy included platinum (3 mg/kg) associated with epinephrine (2 mg/kg). RESULTS: Surgery did not increase rat survival unlike cisplatin or cisplatin/epinephrine chemotherapy. Intraperitoneal chemotherapy alone with cisplatin +/- epinephrine increased survival but did not provide cure. Surgery followed by intraperitoneal cisplatin and epinephrine cured four out of five twenty-day old peritoneal carcinomatosis. CONCLUSION: Surgery combined with intraperitoneal cisplatin and epinephrine could be an efficient treatment for peritoneal carcinomatosis in man.

[The effect of intra-abdominal temperature on the tissue and tumor diffusion of intraperitoneal cisplatin in a model of peritoneal carcinomatosis in rats]. / Effets de la température intra-abdominale sur la diffusion tissulaire et tumorale du cisplatine intrapéritonéal dans un modèle de carcinose péritonéale chez le rat.

OBJECTIVE: To evaluate the effects of hyperthermia and hypothermia on the peritoneal and on tumor penetration by intraperitoneal cisplatin. MATERIAL AND METHODS: Twenty day old peritoneal carcinomatosis was obtained after intraperitoneal injection of 1 x 10(6) DHD/K12/PROb cells into BD IX rats. Animals were treated by intraperitoneal infusion of cisplatin (25 micrograms/mL) using hyperthermic (16.6 degrees C), normothermic (37.6 degrees C) or hyperthermic (41.8 degrees C) intraperitoneal chemotherapy. RESULTS: Hyperthermia increased cisplatin concentration in tumoral and diaphragmatic tissues compared to normothermic treatment, while renal concentrations were lower. Hypothermia produced lower cisplatin concentrations in both cancer and peritoneal tissues compared to normothermic treatment. CONCLUSION: These experiments confirmed the pharmacological advantage produced by hyperthermia in cisplatin intraperitoneal chemotherapy.

Epinephrine enhances penetration and anti-cancer activity of local cisplatin on rat sub-cutaneous and peritoneal tumors.

Despite the theoretical advantages of a high local concentration of anti-cancer drugs, local chemotherapy often fails to produce complete and lasting responses in experimental and human solid tumors. Experiments using Patent Blue dye showed that fluids diffused poorly into tumor mass when injected inside or around s.c. rat tumors in rats. In the same way, Patent Blue dye distributed poorly from the peritoneal cavity into the tumor nodules of rats with peritoneal carcinomatosis. The potent vasoconstrictor, epinephrine (1 mg/kg of body weight) was shown to facilitate the penetration of Patent Blue dye into s.c. and peritoneal rat tumors. Platinum concentration evaluated by micro-PIXE in s.c. DHD/K12/ PROb colon tumors or by atomic absorption spectrometry in DHD/K12/PROb peritoneal tumors was 4- to 12-fold higher when epinephrine was added to local cisplatin. Peri-tumoral or intra-tumoral injection of cisplatin (2 mg/kg) alone does not cure s.c. DHD/K12/PROb colon tumors or GV1A1 glioma tumors in BD IX rats. By contrast, a complete and lasting cure of s.c. tumors was achieved regularly and without skin necrosis when epinephrine was added to intra-tumoral or peri-tumoral cisplatin. Rats with peritoneal-tumor nodules 1 to 2 mm in diameter, and insensitive to i.p. cisplatin alone, were cured when the anti-cancer drug was combined with epinephrine. These experimental results could justify clinical trials using a combination of cisplatin and epinephrine in the treatment of locally growing solid tumors.

[Intratumoral chemotherapy in an experimental animal model: another therapeutic possibility in cancerology]. / La chimiothérapie intratumorale dans un modèle expérimental animal: une autre possibilité thérapeutique en cancérologie.

OBJECTIVE: Assess the efficacy of intratumoral chemotherapy in a colonic tumor model implanted subcutaneously in the BD IX rat. METHOD: In order to determine their antitumoral effect, 5 anticancer drugs were administered via intravenous and direct intratumoral routes 2 or 10 days after subcutaneous inoculation of tumoral cells. Intratumoral diffusion was evaluated using Patent blue injected directly into the tumoral tissue. Cisplatinum was administered via intratumoral, intravenous and intra-arterial routes to determine the intratumoral and intrarenal concentrations achieved with each of these administration routes. Cisplatinum was also administered via intravenous and intratumoral infusion for 30 minutes to determine the antitumoral effect of each of these routes. RESULTS: Mitomycin and cisplatinum inhibited growth of tumors which had not yet become established and caused advanced stage tumors to regress. For early stage tumors, the intratumoral route was always more effective than the intravenous route. Patent blue diffusion demonstrated a nonhomogeneous intratumoral distribution. Compared with intravenous or intra-arterial infusion, intratumoral infusion gave much higher concentrations of cisplatinum within the tumors and reduced systemic diffusion. At 7 weeks, the antitumoral effect was equivalent for the 2 administration routes while at 13 weeks, the intratumoral treatment was more effective than the intravenous treatment. CONCLUSION: These findings in an experimental animal model demonstrate that intratumoral chemotherapy is more effective than intravenous chemotherapy. It is however still impossible to consistently cure tumors induced in animals.

[A difficult diagnosis of a congenital minor ear anomalie]. / Un cas trompeur d'aplasie mineure de l'oreille.

We report an unusual congenital middle ear anomalie with an inflammatory tympanic membrane, a total opacity of the middle ear on the CT scan and a tumor in the mesotympanum.