[Alcoholic hepatitis]. / L'hépatite alcoolique aiguë.

Alcoholic hepatitis is a syndrome defined primarily by the clinical onset of jaundice in patients with a concomitant heavy consumption of alcoholic beverages. This pathology is managed by alcohol withdrawal with a 30-day survival rate of 90 %. For patients with severe alcoholic hepatitis, with a Maddrey score greater than 32 (taking into account bilirubin and prothrombin time), treatment with corticosteroids is discussed provided that a possible infection can be sufficiently excluded or adequately managed. The administration of corticosteroids is continued for 28 days if the Lille score, calculated after 7 days of treatment, is favourable (inferior to 0.45), leading to a survival rate of 80-90 %. However, if the Lille score is unfavourable (superior to 0.45), the prognosis is bad, with a survival of only 25-30 % at 6 months. Special attention needs to be paid to assure a sufficient caloric intake during the treatment period for a successful management. Liver transplantation, previously prohibited for this indication, can be discussed under certain circumstances. However, the success of treatment is contingent upon the alcohol withdrawal. Innovative drugs are currently under investigation to improve the prognosis of this condition.

: L'hépatite alcoolique aiguë (HAA) se définit selon des paramètres essentiellement cliniques (ictère d'apparition récente chez un patient avec une consommation abusive d'alcool). L'HAA peu sévère est prise en charge par un sevrage éthylique, avec un espoir de survie de 90 % à un mois. Pour les patients atteints d'HAA sévère (évaluée par le score de Maddrey sup�rieur a 32, tenant compte de la bilirubine et du temps de prothrombine), un traitement par corticoïdes se discute, pour autant qu'une éventuelle infection ait pu être exclue ou jugulée. Le traitement par corticoïdes est poursuivi 28 jours si le score de Lille, calculé après 7 jours de corticoïdes, est favorable (inf�rieur a 0,45), avec un espoir de survie de 80-90 %. Par contre, si le score de Lille est défavorable (sup�rieur a 0,45), le pronostic est nettement plus péjoratif avec une survie de 25-30 % à 6 mois. Dans la prise en charge, on apportera une attention toute particulière à la nutrition avec un apport calorique suffisant. La transplantation hépatique, autrefois non autorisée dans cette indication, peut actuellement être discutée dans certaines circonstances particulières. La clé de la réussite résidera, de toute façon, dans le sevrage. Des médicaments novateurs sont actuellement en cours d'étude pour améliorer le pronostic de cette affection.

[Considerations on liver transplantation in the alcoholic patients]. / Problématique de la transplantation hépatique chez le patient alcoolique.

In Belgium as in many other countries, alcohol is one of the leading causes of adult liver transplantation. Liver transplantation for terminal liver failure due to excessive alcohol intake raises clear ethical issues concerning the use of grafts to save patients suffering from a self-inflecting affection. Alcoholic liver disease is one of the best indications for liver transplantation, with excellent results in terms of length of survival and post transplantation quality of life, if this transplantation is proposed by a multidisciplinary team in a patient able to and helped by a supporting family and social environment.

En Belgique, comme dans beaucoup d'autres pays, la maladie alcoolique constitue une des causes les plus fréquentes menant à la transplantation hépatique chez l'adulte. Or la transplantation hépatique chez des patients alcooliques pose de claires questions éthiques concernant l'utilisation de greffons pour soigner des patients souffrant d'une maladie trop souvent considérée comme étant auto-infligée. La maladie alcoolique du foie est une des meilleures indications de greffe hépatique, avec d'excellents résultats en termes de durée de survie et de qualité de vie après transplantation. Le pré-requis est que cette transplantation soit proposée par une équipe multidisciplinaire, chez un patient capable de se prendre en charge et soutenu par un environnement familial et social favorable.

Evaluation of mastectomy with immediate autologous latissimus dorsi breast reconstruction following neoadjuvant chemotherapy and radiation therapy: A single institution study of 111 cases of invasive breast carcinoma.

PURPOSE: The aim of the study was to evaluate morbidity and patient satisfaction following surgically treated skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) following mastectomy with neoadjuvant chemotherapy (NACT), and preoperative radiotherapy (RT), for operable invasive breast cancer. PATIENTS AND METHODS: This retrospective single-institution study included 111 patients who underwent a mastectomy with IBR after RT and/or NACT for invasive breast carcinoma at the Institut de Cancérologie de l'Ouest Paul Papin from January 1997 to January 2012. Only patients with breast reconstruction by autologous latissimus dorsi flap with (LDI) or without (ALD) implant were considered. The primary endpoints were the delay in therapeutic sequence, post-operative complication rate, surgical revision rate, time of hospitalization and the anonymous analysis of the patient satisfaction survey. RESULTS: 111 patients underwent mastectomy after RT. The median age was 48 years old and the median body mass index (BMI) was 23.6. SSM were performed in 94.5% of cases. The median interval between the end of chemotherapy (CT) and the beginning of RT was 30 days while the median interval between the end of RT and surgery was 41 days. The rate of primary complications was 66.6% including seroma secretion (reduced to 10.8% when seroma secretion was excluded). The necrosis rate was 5.4%. The average patient satisfaction score for the reconstruction was 17 out of 20. Five-year disease-free and overall survival rates were 93.2% and 98.3% respectively with a median follow-up of 31.6 months. There was only one case of local relapse diagnosed after seven years of follow-up. CONCLUSION: This study shows that our therapeutic sequence does not appear to increase IBR morbidity and remains within the acceptable safety margins of oncological treatment. It also gives a high quality aesthetic result that helps to maintain patient self-esteem.

[Male breast cancer: prognostic factors, diagnosis and treatment: a multi-institutional survey of 95 cases]. / Le cancer du sein chez l'homme: approche épidémiologique, diagnostique, et thérapeutique: étude multicentrique rétrospective à propos de 95 cas.

OBJECTIVES: The optimal treatment for male breast cancer is not known because male breast cancer is a rare disease. It represents as little as 0.6% of all breast cancers and less than 1% of human cancers. The aim was to analyze the clinical, histological and therapeutic characteristics of 95 men cared for breast cancer between 2000 and 2010 in four hospitals, and determine predictors of poor prognosis to improve care of male breast cancer. METHODS: This study is a multi-institutional survey, retrospective, involving four French institutions: Cancer Institute of the West (ICO), Reunion Island South hospital group, the hospital group of Dax, and the Bergonié Institute. All carcinomas in situ or invasive breast occurred in male patients were included. An analysis of clinical, histological and therapeutic features was performed. Statistical analysis of our study focused on the overall survival of patients and specific method of Kaplan-Meier, enabling search for predictors of poor prognosis. RESULTS: The mean age was 65 years. Thirty-seven percent of patients were overweight or obese. It was in 88% of cases of palpable tumor whose average size was 26.29mm. Ninety patients, none had a lesion palpable T0, 44% T1 tumors, 38% T2 tumors, 3% had a T3 tumors, and finally 10% T4 tumors. The histological type was the most common invasive ductal carcinoma (87%). He found a similar proportion of patients with or without lymph node involvement. N+ patients, capsular rupture was observed in 29% of cases. Receptor positivity was found, estrogen in 95% of cases and progesterone in 83% of cases. Additional irradiation was performed in 75% of patients and chemotherapy in 37% of patients. Overall survival was 79.2% at five years and 70.8% at ten years. Age, tumor size and histological capsular rupture are factors that significantly influence the overall survival and specific. CONCLUSION: Male breast cancer is a different pathology of breast cancer in women. The majority of recommendations suggest treating men who are diagnosed with breast cancer, using the guidelines applied to postmenopausal women treatments. There is no study based on male population that has evaluated these treatment modalities in terms of impact on survival. The diagnosis is usually made at later stages, and tumor size is often greater. Histological characteristics also differ. However, the treatment is almost identical.

[Prophylactic surgery in patients mutated BRCA or high risk: retrospective study of 61 patients in the ICO]. / La chirurgie prophylactique chez les patientes mutées BRCA ou à haut risque: étude rétrospective de 61 patientes de l'ICO.

BACKGROUND: Genetic predisposition is involved in only 10% of patients with breast cancer. This study was to evaluate the impact of prophylactic surgery. PATIENTS AND METHODS: This is a retrospective study of 61 patients who received prophylactic breast surgery. Data collection was carried out through the computer file of the ICO. The inclusion criteria were: patients who benefited from a bilateral prophylactic mastectomy. There were no exclusion criteria. Patients received a satisfaction questionnaire to complete. RESULTS: Our study included 61 patients, 67% had a history of breast cancer. Bilateral prophylactic surgery was performed in 40 patients. It was made an average of two interventions, 44.3% of them presented postoperative complications, 18% recovery. Forty-three patients were satisfied with the medical information before surgery. The end result matched the expectations of 54.4% and 67.4% of patients would be ready to start. It was found pain associated with breast surgery in 56.5% of patients and almost half reported a change in their sexual life. DISCUSSION AND CONCLUSION: Prophylactic mastectomy is the most effective technique to prevent the risk of breast cancer. The consequences of such an action are important. It is necessary to better select patients who would benefit most from this type of surgery.

[Perinatal outcome of monochorionic and dichorionic twin gestations: a study of 775 pregnancies at Reunion Island]. / Morbidité et mortalité périnatale des jumeaux et influence de la chorionicité: expérience de 10ans dans le Sud-Réunion. Étude de 775 grossesses.

OBJECTIVES: To compare the perinatal mortality and morbidity of infants born from monochorionic versus dichorionic twin pregnancies (TP). PATIENTS AND METHODS: Retrospective, comparative study of monochorionic and dichorionic TP over 10 years in the south of Reunion Island. Information regarding demographic, gestational and perinatal variables of mothers and infants was collected from the hospital perinatal database. RESULTS: Six hundred and twenty dichorionic and 155 monochorionic TP were analyzed. In case of monochorionic TP, mothers had higher rates of pregnancy-related hypertension (OR=1.82, 95%CI=[1.02-3.29] ; P=0.03) and hospitalization (OR=1.48, 95%CI=[1.02-2.16]; P=0.03). Newborns from monochorionic TP had higher morbidity for : very preterm birth (birth before 33 weeks gestation) (OR=1.65, 95%CI=[1.02-2.66]; P=0.02), very low birth weight (birth weight<1500g) (OR=1.73, 95%CI=[1.57-3.13]; P<0.001), Apgar<7 at 1 minute (OR=1.76, 95%CI=[1.18-2.61]; P<0.01) and hospitalization (OR=2.08, 95%CI=[1.58-2.73]; P<0.001). Perinatal mortality was also significantly higher (OR=2.47, 95%CI=[1.54-3.94]; P<0.001), as well intrauterine fetal death (OR=3.96, 95%CI=[1.95-8.05]; P<0.001) CONCLUSION: This study confirms that few differences exist among dichorionic and monochorionic TP with regard to maternal morbidity, while neonatal morbidity and mortality are higher in twins born from monochorionic pregnancies.

[Quality of life after lipomodelling: retrospective study of 42 patients]. / Qualité de vie après lipomodelage: étude rétrospective à propos de 42 patientes.

OBJECTIVES: Study of the quality of life of 42 patients who underwent a lipofilling in our institution between 2009 and 2010. PATIENTS AND METHOD: Analysis of cosmetic outcomes, side effects, emotional life and preoperative information received by a cohort of 42 patients contacted by anonymous questionnaires. Comparisons between patients with a single prothesis, latissimus dorsi flap with prothesis, autologous latissimus dorsi flap and rectus abdominal flap. RESULTS: The response rate was 56% (42 patients). The average volume of fat injected was 80mL. The aspect of the reconstructed breast and the harmony between two breasts were better after lipofilling (P=0.0001, P=0.0005). The evolution of the aesthetic result is satisfying for 64.1% of the patients. In 29% of cases, patients noticed adhesions at the injection site. Apprehension to touch the reconstructed breast and to wear a swimsuit decreases after lipofilling (P=0.0345;P=0.0284). All patients declared to be satisfied with the presurgery information. Half of the patients declare that the final result corresponds to their wishes. DISCUSSION: The side effects of lipofilling were studied from an oncological point of view. Less publications describe the patients quality of life after lipofilling. This surgery improves the breast reconstruction results and helps patients in a social, affective and aesthetic way. Overall, lipofilling improves more consistency in patients reconstructed by single prothesis and improves more appearance in patients reconstructed by single flap. CONCLUSION: Lipofilling improves significantly patients' quality of life. A clinical research protocol (GRATSEC) is currently underway to extend its indications. The lipofilling should not replace a bad indication of breast reconstruction.

Individual risk factors for Post-weaning Multisystemic Wasting Syndrome (PMWS) in pigs: a hierarchical Bayesian survival analysis.

Risk factors for Post-weaning Multisystemic Wasting Syndrome (PMWS) at the pig level were identified using data from a longitudinal study in seven PMWS-affected farms in France. In each farm, a representative sample of 120 pigs (180 in one farm) was randomly selected after farrowing and followed from birth to slaughter. Individual information included serological status for Porcine Circovirus type 2 (PCV-2), Porcine Reproductive and Respiratory Syndrome (PRRS) virus, and Porcine Parvovirus (PPV), individual weight, rearing conditions, and clinical observations recorded at 7, 13, 16 and 21 weeks of age and at slaughter. Two different Bayesian frailty models were used to identify variables related to time-to-PMWS: (i) a logistic-survival model and (ii) an accelerated failure time model (different survival time distributions) both with two levels of clustering (litter and farm). Similar results in terms of variables related to time-to-PMWS were obtained with both models. However, information provided by the different approaches were complementary. Piglets were more likely to exhibit PMWS after early infection by PCV-2 (i.e. before 7 weeks old) and if they were weaned early (before 21 days). Piglets born to PCV-2 seronegative sows and/or to sows with neck injuries due to poorly performed injections were also more at risk. With the accelerated failure time model, time ratios were obtained giving an estimation of the expected survival time (increased or decreased) after exposure to the factor. The logistic-survival model showed that the majority of the risk factors were mostly related to the odds of PMWS whereas the PCV-2 passive immunity derived from the dam also tended to postpone PMWS appearance later.

Vaccination of porcine circovirus type 2 (PCV2)-infected sows against porcine Parvovirus (PPV) and Erysipelas: effect on post-weaning multisystemic wasting syndrome (PMWS) and on PCV2 genome load in the offspring.

The effect of different Parvovirus+Erysipelas vaccination schemes in PCV2-infected sows on PMWS outcome in the offspring was investigated under experimental conditions. Six PCV2-free sows were first infected oro-nasally with PCV2 two months before insemination (D0; "Day 0") and then by the intra-uterine route at insemination (D62). On D21 and D42, vaccinated sows received either the two commercial monovalent vaccines, A1(PPV) and A2(Erysipelas), or the bivalent vaccine B (PPV+Erysipelas). In addition, three SPF sows (foster-sows) were synchronized for farrowing dates to enable them to foster piglets born to infected sows and removed at birth before colostrum intake. A significantly higher proportion of mummified fetuses was obtained from PCV2-infected non-vaccinated sows than from vaccinated sows. Acute myocarditis lesions were found in their piglets, together with a high PCV2 genome load. The latter was significantly higher than in those born to PCV2-infected vaccinated sows. Sentinel PCV2-negative piglets, born to SPF foster-sows, seroconverted at almost the same time as piglets without PCV2 passive immunity and born to infected sows. Sixteen of the 84 liveborn piglets born to infected sows and foster-sows were affected by a syndrome possibly related to PMWS, as judged by clinical signs and histological lesions. Most were born to PCV2-infected non-vaccinated sows and 12/16 did not receive PCV2 passive immunity. The probability of PCV2 infection and the number of PCV2 genome copies per gram of tissue were significantly increased in piglets that did not receive PCV2 passive immunity.

Risk factors for porcine post-weaning multisystemic wasting syndrome (PMWS) in 149 French farrow-to-finish herds.

A cross-sectional study involving 149 farms was carried out in France in 2000 and 2001 to assess the risk factors for post-weaning multisystemic wasting syndrome (PMWS). The farms were divided into three groups according to their current or past PMWS status: CASES (current and typical PMWS), CONTROLS#1 (PMWS-free farms), and CONTROLS#2 (farms which have recovered from PMWS). Two different comparisons were tested: CASES versus CONTROLS#1 and CASES versus CONTROLS#2. In the first comparison, the odds of PMWS were increased when fattening pigs tested positive for parvovirus (PPv) and porcine reproductive and respiratory syndrome (PRRS) virus (OR=4.4 and 6.5, respectively), when separate vaccines for parvovirus and Erysipela for the gilts versus associated vaccines were used (OR=2.5), and when on-farm semen collection was used versus all the semen purchased from an insemination centre (OR=4.6). Large pens in weaning facilities increased the odds of PMWS (OR=4.1); whereas long empty periods in weaning and farrowing facilities versus shorter (OR=0.2), regular treatment against external parasites (OR=0.1), and housing the sows in collective pens during pregnancy versus individual pens (OR=0.3) all decreased the odds of PMWS. The same kinds of risk factors were found with the second comparison with, in addition, a common pit for several adjacent fattening rooms versus separate pits (OR=6.7) and a high level of cross-fostering (OR=5.1). On the other hand, when farms had a self-replacement scheme for the gilts (OR=0.1), and when vaccination of the sows against E. coli was in place (OR=0.2), the odds of PMWS were decreased.

Behaviour of Crohn's disease according to the Vienna classification: changing pattern over the course of the disease.

BACKGROUND: Crohn's disease is a heterogeneous disorder with both a genetic and environmental aetiology. Clinical classifications of the disease, such as the newly proposed Vienna classification, may help to define subgroups of patients suitable for studying the influence of specific genetic or environmental factors. AIM: To assess the stability over the course of the disease of its location and behaviour, as determined according to the Vienna classification. PATIENTS AND METHODS: The notes of 297 Crohn's disease patients regularly followed up at our institution were carefully reviewed retrospectively. The behaviour and location of the disease according to the Vienna classification were determined at diagnosis and after 1, 3, 5, 10, 15, 20, and 25 years of follow up. The proportions of the different behaviours and locations of the disease were calculated at these time points. A statistical analysis of the evolution of these characteristics over 10 years was performed on a subgroup of 125 patients with at least 10 years of follow up. The influence of age at diagnosis on location and behaviour of the disease was assessed as well as the influence of location on the behaviour of the disease. RESULTS: The location of the disease remained relatively stable over the course of the disease. Although the proportion of patients who had a change in disease location became statistically significant after five years (p=0.01), over 10 years only 15.9% of patients had a change in location (p<0.001). We observed a more rapid and prominent change in disease behaviour, which was already statistically significant after one year (p=0.04). Over 10 years, 45.9% of patients had a change in disease behaviour (p<0.0001). The most prominent change was from non-stricturing non-penetrating disease to either stricturing (27.1%; p<0.0001) or penetrating (29.4%; p<0.0001) disease. Age at diagnosis had no influence on either location or behaviour of disease. Ileal Crohn's disease was more often stricturing, and colonic or ileocolonic Crohn's disease was more often penetrating: this was already the case at diagnosis and became more prominent after 10 years (p<0.05). CONCLUSIONS: Location of Crohn's disease, as defined by the Vienna classification, is a relatively stable phenotype which seems suitable for phenotype-genotype analyses. Behaviour of Crohn's disease according to the Vienna classification varies dramatically over the course of the disease and cannot be used in phenotype-genotype analyses. The potential influence of genes on the behaviour of Crohn's disease should be studied in subgroups of patients defined by their disease behaviour after a fixed duration of disease.

Incidence of inflammatory bowel disease in the province of Liège (Belgium). La Société de Gastroentérologie Liègeoise.

UNLABELLED: Up to now, as there is no national registry of patients with inflammatory bowel disease (IBD) in Belgium, the study of IBD epidemiology in our country is only possible through institutional or regional series. Therefore we conducted a prospective epidemiologic study of IBD in the Province of Liège (1 million inhabitants). METHODS: 29 (out of 47) private and public gastroenterologists completed a standard questionnaire for each patient consulting for the first time with clinical symptoms compatible with IBD between 1/06/1993 and 31/05/1994. RESULTS: During that period 104 cases of IBD were recorded: 56 (54%) Crohn's disease (CD), 36 (35%) ulcerative colitis (UC) including 7 proctitis (19% of UC) and 12 (11%) unclassified colitis. The annual incidence was 5.5 per 100.000 for CD and 3.5 for UC. The sex ratio F/M was 1.7 for CD and 0.7 for UC. The median age at the time of diagnosis was 33.5 yrs for CD and 40 yrs for UC. The highest age specific incidence rate for CD and UC was between 20 and 29 yrs : 13.6 and 6.1, respectively. CONCLUSIONS: This first Belgian prospective study has shown an incidence rate for CD comparable with that seen in north European studies but lower than that seen for UC. These results were similar to those observed in the northern part of France. Belgium appears to be a privileged country to undertake a national register and to study epidemiological aspects of IBD.