[The French mesothelioma network from 1998 to 2013]. / Mésothéliome: les dispositifs en place en France « le réseau mésothéliome ¼ 1998-2013.

Mesothelioma is a rare disease less than 0.3% of cancers in France, very aggressive and resistant to the majority of conventional therapies. Asbestos exposure is nearly the only recognized cause of mesothelioma in men observed in 80% of case. In 1990, the projections based on mortality predicted a raise of incidence in mesothelioma for the next three decades. Nowadays, the diagnosis of this cancer is based on pathology, but the histological presentation frequently heterogeneous, is responsible for numerous pitfalls and major problems of early detection toward effective therapy. Facing such a diagnostic, epidemiological and medico-legal context, a national and international multidisciplinary network has been progressively set up in order to answer to epidemiological survey, translational or academic research questions. Moreover, in response to the action of the French Cancer Program (action 23.1) a network of pathologists was organized for expert pathological second opinion using a standardized procedure of certification for mesothelioma diagnosis. We describe the network organization and show the results during this last 15years period of time from 1998-2013. These results show the major impact on patient's management, and confirm the interest of this second opinion to provide accuracy of epidemiological data, quality of medico-legal acknowledgement and accuracy of clinical diagnostic for the benefit of patients. We also show the impact of these collaborative efforts for creating a high quality clinicobiological, epidemiological and therapeutic data collection for improvement of the knowledge of this dramatic disease.

Occupational and non-occupational attributable risk of asbestos exposure for malignant pleural mesothelioma.

OBJECTIVES: To estimate the proportion of pleural mesothelioma cases that can be attributed to asbestos exposure in France including non-occupational exposure. METHODS: A population-based case-control study including 437 incident cases and 874 controls was conducted from 1998 to 2002. Occupational and non-occupational asbestos exposure was assessed retrospectively by two expert hygienists. ORs of pleural mesothelioma for asbestos-exposed subjects compared to non-exposed subjects, and population-attributable risk (ARp) of asbestos exposure were estimated using a conditional logistic regression. RESULTS: A clear dose-response relationship was observed between occupational asbestos exposure and pleural mesothelioma (OR=4.0 (99% CI 1.9 to 8.3) for men exposed at less than 0.1 f/mL-year vs. 67.0 (99% CI 25.6 to 175.1) for men exposed at more than 10 f/mL-year). The occupational asbestos ARp was 83.1% (99% CI 74.5% to 91.7%) for men and 41.7% (99% CI 25.3% to 58.0%) for women. A higher risk of pleural mesothelioma was observed in subjects non-occupationally exposed to asbestos compared to those never exposed. The non-occupational asbestos ARp for these subjects was 20.0% (99% CI -33.5% to 73.5%) in men and 38.7% (99% CI 8.4% to 69.0%) in women. When considering all kinds of asbestos exposure, ARp was 87.3% (99% CI 78.9% to 95.7%) for men and 64.8% (99% CI 45.4% to 84.3%) for women. CONCLUSIONS: Our study suggests that the overall ARp in women is largely driven by non-occupational asbestos exposure arguing for the strong impact of such exposure in pleural mesothelioma occurrence. Considering the difficulty in assessing domestic or environmental asbestos exposure, this could explain the observed difference in ARp between men and women.

[The determinants of under-reporting occupational diseases. The case of mesothelioma]. / Les déterminants de la sous-déclaration des maladies professionnelles. Le cas du mésothéliome.

BACKGROUND: Despite widespread press coverage of the harm caused by the asbestos, 40% of mesothelioma patients still do not file claims for compensation as an occupational disease. We aimed at studying elements that influence the administrative procedure of compensation, in particular social classes and instruction level. METHODS: This was a statistical analysis of data from the French national survey program of mesothelioma designed to understand social determinants of reporting occupational illness. Data from a give administrative district were then submitted to a qualitative study using in-depth interviews of patients with suspected mesothelioma. Discourse analysis was then applied to the corpus of information collected. Content analysis grouped the data into themes. RESULTS: The statistical analyses tended to show that the higher the educational level, the less often patients filed claims for their occupational disease. Manual workers asked for compensation for their disease more often than executives. The interviews conducted with suspected mesothelioma patients suggest several factors explaining these findings. The process of reporting an occupational disease is often initiated by the primary care physician who informs the patient about the possible link with a previous occupation, explains the procedure and motivate the patient whose main preoccupation is to fight against the illness, and less so to become recognized as a victim. In this context, the physician plays a fundamental role, independently of the patient's social status. CONCLUSION: Those results throw new light on the complexity of the administrative procedure for reporting occupational diseases in France and highlights possible causes of underdeclaration reporting. Physician awarness of these causes might improve identification of links between occupation and disease and the transmission of adapted information to all concerned patients in order to fight more effectively against the disparities resulting from underreporting.

Evolution of pleural cancers and malignant pleural mesothelioma incidence in France between 1980 and 2005.

The evolution of pleural cancers and malignant pleural mesothelioma incidence in France between 1980 and 2005 was analysed using data derived from the French network of cancer registries (FRANCIM) and the French National Mesothelioma Surveillance Program (PNSM). Mesothelioma proportions in pleural cancers were calculated by diagnosis year in the 1980-2000 period. Our results suggest that the incidences of pleural cancer and mesothelioma levelled off in French men since 2000 and continued to increase in French women. A decrease of the annual pleural cancer incidence average in men was noticed (-3.4% of annual rate of change) between 2000 and 2005. The proportion of pleural cancers that were mesothelioma was unchanged between 1980 and 2003 with an average of 86%. The age standardised incidence rate of pleural mesothelioma remained relatively stable between 1998 and 2005 with a slight falling trend. For women, the age standardised incidence rate of pleural cancers and mesothelioma increased during the period 1998-2005. Additionally, the proportion of pleural cancers that were mesothelioma increased during the same period of time. Finally, the increased trend observed in the incidence of pleural mesothelioma and cancers in women is credibly due to their under diagnosis in the 1980-1997 period. The comparison between the French incidence and the American and British ones shows that the decreasing trend in incidence of mesothelioma and pleural cancers in French men since 2000 is potentially associated with a lower amphibole consumption and by the implementation of safety regulations at work from 1977.

[Subjective function scores for the musculoskeletal system of uninjured high-level competitive pole vaulters in recreational, training and competition periods]. / Subjektive Funktionsscores des Bewegungsapparates in Ruhe-, Trainings- und Wettkampfphase bei unverletzten Kaderathleten im Stabhochsprung.

STUDY AIM: The aim of the present study was to evaluate the use of commonly used subjective, clinical scores to describe the health status of high-level competitive athletes in different phases of one training year. METHOD: 32 high-level pole vaulters (17 males and 15 females) were followed with support of "Deutscher Leichtathletik Verband" and "Leichtathletik Verband Nordrhein" for the period of a whole competition year. We used the Tegner activity scale (TAS), the Lysholm score and WOMAC (Western Ontario and McMaster Universities Osteo-arthritis Index) during recreational, training and competition periods. The score results for the athletes in the recreational phase were compared to the results of a control group. Also, the score results for the athletes in the different periods of the training year were statistically evaluated. RESULTS: The statistical comparison of the score values of the control group with those of the athletes in the recreational phase showed no significant differences. Therefore, high-level athletes in pole vault have no subjective physical limitations compared to a control group. In the competition period, the athletes rated themselves lower in the TAS and in the WOMAC index than in the recreational and training phase. The Lysholm score did not show any significant change of subjective physical status in the competition period compared to recreation and training. CONCLUSION: The subjective clinical scores used in this study do not show any changes in the health status of high-level competitive athletes in the course of one training year. If subjective scores are to be used to monitor the health status of high-level athletes, the Tegner scale, as well as the Lysholm and WOMAC scores are most likely not sensitive enough to measure possible over-use or repetitive stress problems.

[Influence of the riding discipline and riding intensity on the incidence of back pain in competitive horseback riders]. / Einfluss der Reitdisziplin und -intensität auf die Inzidenz von Rückenschmerzen bei Reitsportlern.

INTRODUCTION: The connection between morphologic changes of the spine and the intensity of training has been assessed for a number of sport activities. The influence of horseback riding on the spine has only rarely been evaluated. The aim of our study was to evaluate to what degree horseback riders suffer from back pain and whether there is an association between this parameter and the category i. e. the intensity of horseback riding. Furthermore we wanted to judge whether riding may have a positive effect on pre-existent back pain. METHODS: 508 horseback riders (63.2 % females; 36.8 % males) competing in either dressage, showjumping or vaulting were interviewed using a questionnaire. Apart from biometric data, the intensity with which riding was performed and the localisation and intensity (VAS) of back pain was assessed. Furthermore, in the case of existing back pain, riders were asked whether different riding disciplines and paces changed the intensity of pain. RESULTS: 300 dressage riders (59.1 %), 188 showjumpers (37.0 %) and 20 vaulters (3.9 %) with an average age of 33.5 Jahre (12 - 77 years) were questioned. The incidence of back pain was 72.5 %. A significant correlation between back pain and riding discipline respectively gender or riding level could not be found. Discrepancies in VAS-score for dressage riders (3.95 +/- 0.13), show jumpers (4.10 +/- 0.16) and vaulters (3.76 +/- 0.5) were marginal and not significant (p > 0.05). Overall 58.7 % resp. 15.2 % reported to have pain in the lumbar i.e cervical spine. Despite the fact that a large fraction of dressage riders claimed to have problems in these spine areas with 57.7 % resp. 68.8 %, this finding was not significant compared to the other riding disciplines. While 61.6 % of dressage riders reported an improvement of their back pain when riding, this was only the case in 40.9 % of show jumpers. CONCLUSION: Compared to the general population, a high incidence of back pain is found among riders. A significant correlation between the intensity of riding or the riding discipline and frequency or severity of back pain could not be found. For riders with pre-existent back pain the pace "walk" seems to have a positive influence on pain intensity.

[Comparison of the French DRG based information system (PMSI) with the National Mesothelioma Surveillance Program database]. / Confrontation des données du Programme national de surveillance du mésothéliome (PNSM) et du Programme de médicalisation du système d'information (PMSI).

BACKGROUND: One of the main purposes of the French National Mesothelioma Surveillance Program is to estimate and follow the national incidence of pleural mesothelioma. We wanted to study the contribution of the French hospital national database as a valid source of mesothelioma incident cases. METHODS: From the 1998 and 1999 hospital national database, medical records with a diagnosis code of mesothelioma or pleural cancer where selected among patients who resided in one of the 17 administrative divisions covered by the National Mesothelioma Surveillance Program in 1998. From these records, 506 patients in 1998 and 474 patients in 1999 where identified and matched with the National Mesothelioma Surveillance Program cases over the same period using indirect criteria of identification (sex, age, place of residence). Medical records of cases unknown by the National Mesothelioma Surveillance Program where consulted in one of the administrative divisions. RESULTS: Only two-thirds of the registered cases of the National Mesothelioma Surveillance Program could be matched with a patient identified in the hospital national database with a diagnosis of mesothelioma registered during the same year. Consultation of the medical records showed that 1) certified cases registered in the National Mesothelioma Surveillance Program where often (83%) found in the hospital national database with a code of mesothelioma but 10 to 15% of the patients with a code of mesothelioma in the national hospital databases had a different diagnosis according to their medical records; 2) 65% of the patients with a code of mesothelioma in the national hospital databases that where unknown from the National Mesothelioma Surveillance Program in 1998 and 55% in 1999 where prevalent cases; 3) 3 suspected cases had not been reported to the National Mesothelioma Surveillance Program. CONCLUSION: Because of lack of diagnosis certification, mistakes in encoding diagnosis and the fact that incident and prevalent cases cannot be distinguished in the hospital national database make it impossible to estimate the mesothelioma incidence solely from this source of data. However, the hospital claim databases constitute a complementary source of information for the active search of incident cases performed by the National Mesothelioma Surveillance Program.

The French National Mesothelioma Surveillance Program.

OBJECTIVES: The French National Mesothelioma Surveillance Program (NMSP) was established in 1998 by the National Institute for Health Surveillance (InVS). Its objectives are to estimate the trends in mesothelioma incidence and the proportion attributable to occupational asbestos exposure, to help improve its pathology diagnosis, to assess its compensation as an occupational disease, and to contribute to research. METHODS: The NMSP records incident pleural tumours in 21 French districts that cover a population of approximately 16 million people (a quarter of the French population). A standardised procedure of pathological and clinical diagnosis ascertainment is used. Lifetime exposure to asbestos and to other factors (man made mineral fibres, ionising radiation, SV40 virus) is reconstructed, and a case-control study was also conducted. The proportion of mesothelioma compensated as an occupational disease was assessed. RESULTS: Depending on the hypothesis, the estimated number of incident cases in 1998 ranged from 660 to 761 (women: 127 to 146; men: 533 to 615). Among men, the industries with the highest risks of mesothelioma are construction and ship repair, asbestos industry, and manufacture of metal construction materials; the occupations at highest risk are plumbers, pipe-fitters, and sheet-metal workers. The attributable risk fraction for occupational asbestos exposure in men was 83.2% (95% CI 76.8 to 89.6). The initial pathologist's diagnosis was confirmed in 67% of cases, ruled out in 13%, and left uncertain in the others; for half of the latter, the clinical findings supported a mesothelioma diagnosis. In all, 62% applied for designation of an occupational disease, and 91% of these were receiving workers' compensation. CONCLUSIONS: The NMSP is a large scale epidemiological surveillance system with several original aspects, providing important information to improve the knowledge of malignant pleural mesothelioma, such as monitoring the evolution of its incidence, of high risk occupations and economic sectors, and improving pathology techniques.

[Long-term results (5 - 13 years) after surgical local repair and deltoid muscle flap for massive rotator cuff tears]. / Langzeitergebnisse (5 - 13 Jahre) nach lokaler Rekonstruktion und Deltoideuslappenplastiken bei massiven Rotatorenmanschettendefekten.

AIM: The functional long-term results of reconstructions of massive rotator cuff tears (Bateman IV) were evaluated and analyzed. METHODS: 38 patients (6 female/32 male) had a clinical and sonographical assessment and an evaluation of the Constant score after a follow-up of 81 (60 - 160) months. Operative procedures were direct transosseous refixation in 16, local tendon shifts in 17 and deltoid flaps in 5 patients. RESULTS: The average age and sex related Constant score was 77 %. The 5 patients with the deltoid flap achieved a Constant score of 60 %, all had a sonographically detected re-tear and 4 of them rated their result as only moderate. 25/33 patients with reconstruction (76 %) rated their result as good or excellent, 5 (15 %) as satisfactory, 1 (3 %) as moderate and 2 (6 %) as poor. 12 (36 %) of the 33 patients met the sonographic criteria of a re-tear. These patients had a Constant score of 71 %, whereas 21 (64 %) patients with intact reconstruction achieved a score of 85 %. CONCLUSION: The reconstruction of massive rotator cuff tears achieves good clinical long-term results if the tendons remain intact. But even with a recurrent defect, the results have been better than in patients treated with a deltoid flap. In massive rotator cuff tears a thorough selection of the operative procedure regarding atrophy and fatty infiltration of the rotator cuff muscles as well as the tendon retraction and quality is mandatory.

[Ultrasonographic evaluation of the rotator cuff after shoulder arthroplasty]. / Sonographie der Rotatorenmanschette nach Schulter-Endoprothese.

AIM: Ultrasonography of the rotator cuff tendons is a standard imaging technique. Although increasing numbers of shoulder arthroplasty are performed, there is no available data concerning the use of ultrasound after shoulder replacement. Our experimental study was performed to analyse the value of ultrasonography after shoulder arthroplasty a) in an ex-vivo-setting and b) in a retrospective analysis of our patients after shoulder hemiprothesis. METHOD: After defrosting, anatomic modular humeral head replacement was performed in four fresh-frozen specimens with intact rotator cuffs. The supraspinatus and subscapularis tendons of each specimen were either detached to simulate a cuff defect or reattached anatomically (four times per specimen). Two experienced examiners then performed ultrasonography to evaluate the two tendons to be either intact or deficient. In a retrospective study, 22 patients with 25 hemiprotheses of the shoulder underwent clinical and sonographic examination. For documentation of the clinical findings, the Constant score was used. RESULTS: In the cadaver study, the reliability of the method was slightly higher for the subscapularis tendon (13 correct, 3 false results) than for the supraspinatus tendon (12 correct, 4 false results). In our patients, rotator cuff defects and effusions around the biceps tendon and in the subdeltoid bursa could be detected. Normal sonograms correlated with good clinical results. CONCLUSION: In the cadaver study, we found a good reproducibility of in-vivo conditions. We believe that ultrasonography is beneficial in follow-up evaluation after shoulder arthroplasty.

[Tendinitis of the long head of biceps tendon associated with lesions of the "biceps reflection pulley"]. / Die Tendinitis der langen Bizepssehne bei Läsion des "Biceps reflection pulley"

UNLABELLED: In some patients with persistent pain around the Long Head of Biceps Tendon (LHB), lesions of the "biceps reflection pulley", associated with biceps tendinitis, can be found. The aim of this study is to describe the anatomy of the reflection pulley and the arthroscopic appearance of the pulley lesion. Therapeutic options will be discussed. METHOD: The results of a former histo-anatomic study done by the authors in 13 cadaver shoulders are compared with the intra-operative findings in patients with persistent tendinitis of the LHB together with a lesion of the reflection pulley and signs of LHB instability. Intra-operative findings from patients with either posttraumatic anterior instability or calcific tendinitis served as control. RESULTS: The superior glenohumeral ligament (SGHL) together with the coraco-humeral ligament (CHL) and fibers from the subscapularis and supraspinatus tendons form a stabilizing reflection pulley for the LHB in the rotator cuff interval. Arthroscopy shows an association between a lesion of this pulley and persistent LHB-tendinitis. Pulley lesions can occur as isolated ligamentous pathology or together with a partial detachment of rotator cuff tendons. CONCLUSION: In patients with therapy-resistant pain around the LHB, lesions of the reflection pulley need to be excluded beside more common causes of biceps problems. Arthroscopy is a reliable tool to assess these lesions. Therapy should address the definite pathology.

[Self-training versus conventional physiotherapy in subacromial impingement syndrome]. / Zentrierende Kräftigungstherapie beim einfachen subakromialen Schmerzsyndrom: Eigentraining versus Krankengymnastik.

AIM: This prospective, randomized study was aimed to compare the effect of a standardized self-training versus standard physiotherapist-supervised exercises in the non-operative treatment of shoulder impingement syndrome types Neer I and II. METHOD: 40 patients with subacromial impingement I/II were randomized to two groups. Group 1 performed a mostly isometric self-training after instruction by a physiotherapist, group 2 received prescriptions for physiotherapy and "strengthening exercises for the rotator cuff". Follow up was performed after 6 and 12 weeks with the use of the constant score (unpondered). Patient satisfaction with the treatment was controlled by VAS (1 - 6). RESULT: After 12 weeks, patients of group 1 had performed the exercises 5 x/week for 15 minutes. Patients of group 2 had received 30 sessions in average. Patients of group 1 improved from a mean of 59 points (39.5 - 86) to a mean of 68 points (37 - 88) after 6 and 75 points (65 - 90) after 12 weeks. Patients of group 2 improved from 60.5 points (41 - 83) to 67 points (39.5 - 92) and 72 points (43 - 93), respectively. Patient satisfaction was higher in the self-training group (1.9 : 2.8). CONCLUSION: Strengthening of the centering muscles around the humeral head leads to good results in the non-operative treatment of subacromial impingement. Self-training after instruction showed no difference to physiotherapist-supervised exercises in the non-operative treatment of subacromial impingement.

[Kapandji intramedullary wire osteosynthesis in proximal humeral fractures]. / Die intramedulläre Drahtosteosynthese nach Kapandji bei der proximalen Humerusfraktur.

For operative treatment of proximal humeral fractures minimal invasive techniques reduce the risk of iatrogenic damage of blood supply and periarticular scarring. Reported preliminary results are encouraging. We present our experience achieved with an intramedullary wire fixation adapted from a report of Kapandji in 1989. Between 3/95 and 6/00 29 patients were treated with this technique at our institution. All received early functional treatment. 14 patients (average mean age 56 years at time of trauma) who had a minimum follow up of 24 months (mean 36.4 months) and therefore allowed a preliminary conclusion regarding avascular head necrosis (AVN) were reexamined by use of the Constant Score and x-ray. We examined three unstable 2-part, four 3-part and seven 4-part fractures (5 of them valgus-impacted). The mean Constant Score at follow up was 70 points (31-86 points). We saw one total collapse of the humeral head because of AVN. In one patient the distal end of the wires led to a skin irritation and had to be shortened. We observed no secondary fragment displacement or non-unions. In our hands, this technique offers good results, even in valgus-impacted 4-part fractures of the elderly and allows internal fixation in little displaced but unstable fractures with the benefit of early functional treatment instead of longer immobilization. Based on the experience with intramedullary wiring the previously performed technique using threading wires was abandoned and the indication for primary arthroplasty considerably influenced.

Secondary intra-articular dislocation of a broken bioabsorbable interference screw after anterior cruciate ligament reconstruction.

We report a case of intra-articular migration of the proximal part of a broken polylactic acid screw from the tibial site of anterior cruciate ligament-reconstruction with quadrupled semi-tendinosus tendon. Five months after initially successful ACL surgery the patient felt a sudden locking of the knee without another injury. MRI showed intra-articular migration of one-half of the polylactic acid screw, and standard radiographs a widening of the proximal tibial tunnel. At revision arthroscopy the broken part was easily removed. The patient had full recovery. This case demonstrates the problem of "bioscrew" breakage in ACL surgery.

The intra- and inter-observer reliability of the Samilson and Prieto grading system of glenohumeral arthropathy.

Severity of glenohumeral arthropathy following shoulder instability is often graded radiologically on the basis of osteophyte size according to Samilson and Prieto. Intra- and inter-observer reliability of this popular grading system was determined using standard radiographs of 20 arthritic cadaveric humeri. Using two observers on two occasions, reliability of the grading system using the antero-posterior radiograph varied between fair and poor (kappa coefficients 0.07-0.33). This study shows that the Samilson and Prieto grading of glenohumeral arthropathy is unreliable and, in clinical use, when magnification and rotation is less easy to control, it is likely to be even more so. Another validated classification system must therefore be found.

Estimation of the past and future burden of mortality from mesothelioma in France.

OBJECTIVES: Firstly to evaluate future mortality from mesothelioma in France with an age-period-cohort approach and evaluate different hypotheses on risk of mesothelioma for the most recent birth cohort. Secondly to compare the results with a British and an American study. Thirdly to study if any trends were detectable on data for women which would be consistent with the consequences of increasing environmental exposure to asbestos. METHODS: Estimates of mortality from mesothelioma among men and women in France from 1950 to 1995 were based on the analysis of the pleural cancer mortality data coded 163 in the ninth revision of the international classification of diseases (ICD-9). Correction factors were used to derive the mortality from mesothelioma from these data, based on two regional registries. The analysis of the past mortality data has been performed by an age-cohort model (with a maximum likelihood technique). Predictions of deaths from mesothelioma over the next 50 years were based on four different assumptions on the risk of death from mesothelioma in future birth cohorts. RESULTS: The predicted lifetime probability of dying from mesothelioma increases until the last birth cohort 1964-8 among men whereas it decreases strongly from the 1954-8 birth cohort among women. The projected numbers of deaths from mesothelioma in France until 2020 are similar, whichever hypothesis is considered: around 20,000 deaths from mesothelioma might occur among men and 2900 among women from 1996 to 2020. CONCLUSIONS: French data show an increasing lifetime probability of death from mesothelioma in the more recent male cohorts. Although the mortality burden can be predicted until 2020, and is intermediate between the United Kingdom and United States estimates, there is still high uncertainty on the figures after 2020. No increase is found in women, and this does not support the hypothesis that current environmental exposure to asbestos could be associated with a detectable risk of death. Specific surveillance should be set up to monitor future trends or their absence.