Synchronous versus metachronous brain metastasis from testicular germ cell tumors (TGCT): an analysis from the Spanish Germ Cell Cancer Group data base

BACKGROUND: Brain metastases of testicular germ cell tumor (TGCT) are a rare event. Prognostic is poor and there is not much evidence on optimal management of these patients. PATIENTS AND METHODS: A review of case records of germ cell tumor patients within the Spanish Germ Cell Cancer Group data base from 1994 to 2012 was conducted. RESULTS: Thirty-three out of 6,200 cases (0.5 %). Nineteen patients (57 %) group 1: synchronous, 13 (40 %) group 2: metachronous and only one developed brain metastasis during cisplatin-based chemotherapy (excluded from the analysis). Median serum BHCG levels at initial diagnosis was higher in group 1, whereas elevated AFP serum levels were more common in group 2. Histology in the primary tumor: chorionic carcinoma for group 1 versus embryonal carcinoma for group 2. Mainly solitary brain metastasis in group 2 (54 versus 21 %, respectively). The median overall survival from the diagnosis of central nervous system involvement was 16 months for group 1 (CI 95 % 13.9-18) and 23 months (95 % CI 0-165) for group 2 (log rank p = 0.84). Long-term survivors were practically identical in the two groups (38.9 % group 1 versus 38.5 % group 2). Regardless of the timing of brain metastasis, those patients that achieved complete response to the treatment had better survival (log rank p 0.003). CONCLUSION: Although some distinctive clinical characteristics have been found between patients with synchronous versus metachronous brain metastasis from TGCT, the timing of brain metastasis did not seem to have prognostic influence, but due to the retrospective nature of the analysis and the results should be interpreted with caution (AU)

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Synchronous versus metachronous brain metastasis from testicular germ cell tumors (TGCT): an analysis from the Spanish Germ Cell Cancer Group data base.

BACKGROUND: Brain metastases of testicular germ cell tumor (TGCT) are a rare event. Prognostic is poor and there is not much evidence on optimal management of these patients. PATIENTS AND METHODS: A review of case records of germ cell tumor patients within the Spanish Germ Cell Cancer Group data base from 1994 to 2012 was conducted. RESULTS: Thirty-three out of 6,200 cases (0.5 %). Nineteen patients (57 %) group 1: synchronous, 13 (40 %) group 2: metachronous and only one developed brain metastasis during cisplatin-based chemotherapy (excluded from the analysis). Median serum BHCG levels at initial diagnosis was higher in group 1, whereas elevated AFP serum levels were more common in group 2. Histology in the primary tumor: chorionic carcinoma for group 1 versus embryonal carcinoma for group 2. Mainly solitary brain metastasis in group 2 (54 versus 21 %, respectively). The median overall survival from the diagnosis of central nervous system involvement was 16 months for group 1 (CI 95 % 13.9-18) and 23 months (95 % CI 0-165) for group 2 (log rank p = 0.84). Long-term survivors were practically identical in the two groups (38.9 % group 1 versus 38.5 % group 2). Regardless of the timing of brain metastasis, those patients that achieved complete response to the treatment had better survival (log rank p 0.003). CONCLUSION: Although some distinctive clinical characteristics have been found between patients with synchronous versus metachronous brain metastasis from TGCT, the timing of brain metastasis did not seem to have prognostic influence, but due to the retrospective nature of the analysis and the results should be interpreted with caution.

[Complication and prevention of upper limb joints arthroscopy.] / Complication et prévention de l'arthroscopie du membre supérieur.

Arthroscopy for upper limb joints disorders has been used increasingly over the past two decades, and is often considered by population as minor surgery. It would be a mistake to mask potential complications, even if they are less important than equivalent conventional technique. Complications depend on the joint, and despite the relative lack of experience for wrist and small joints, elbow arthroscopy seems to be the arthroscopic technique with most important complication rate. However, most of these complications remain minor and curable. Teaching of anatomy and arthroscopic techniques, respect of elementary prudence rules, should allow to control the risk and the learnig curve. Clear and honest information about potential complications provided to patient is certainly the best way to reduce consequences of these complications.

[Complication and prevention of upper limb joints arthroscopy]. / Complication et prevention de l'arthroscopie du membre supérieur.

Arthroscopy for upper limb joints disorders has been used increasingly over the past two decades, and is often considered by population as minor surgery. It would be a mistake to mask potential complications, even if they are less important than equivalent conventional technique. Complications depend on the joint, and despite the relative lack of experience for wrist and small joints, elbow arthroscopy seems to be the arthroscopic technique with most important complication rate. However, most of these complications remain minor and curable. Teaching of anatomy and arthroscopic techniques, respect of elementary prudence rules, should allow to control the risk and the learnig curve. Clear and honest information about potential complications provided to patient is certainly the best way to reduce consequences of these complications.

[Endoscopic aponeurotomy for chronic exertional compartmental syndrome of the forearm: report of 41 cases]. / L'aponévrotomie endoscopique dans les syndromes de loges chroniques d'effort à l'avant-bras: à propos de 41 cas.

INTRODUCTION: Chronic exertional compartment syndrome of the forearm is probably underdiagnosed as a cause of forearm pain in the sportsman. Its pathological basis is a critical elevation of extracellular pressure. The clinical diagnosis is confirmed by measurements of intracompartmental pressures. We described a reliable original method of endoscopically assisted superficial fasciotomy for treating chronic exertional compartment syndrome of the forearm. The goal of the study is the physiological and clinical validation of this technique. STUDY DESIGN: Retrospective cohort study after the anatomical assessment of the feasibility of our endoscopically assisted fasciotomy. METHODS: Review of 41 forearm decompressions in 25 patients (23 sportsmen and 2 musicians). Follow-up of 6 months to 9 years. RESULTS: Eighty-eight percent reported an excellent or good outcome with significant reduction of pain during exercise. Three patients noted the return of their compartment syndrome and this was confirmed by new measurements of intramuscular pressure. Two of them underwent fasciectomy with excision of a hypertrophic scar of the superficial aponevrosis to good effect. COMPLICATIONS: Two hematomas and 2 lateral epicondylitis with no adverse effect on the final result. DISCUSSION: Endoscopically assisted fasciotomy is a reliable technique for reducing pain in chronic compartment exertional syndromes. It allows the large majority of patients to return to sports. It is our first choice indication in young sportsmen for syndromes of the forearm (anterior and/or posterior compartment). The limit of the technique is the current knowledge of collagenic tissues pathology as a cause of recurrence with hypertrophic aponevrotic scars.

[Anatomical study of the pre-retinacular fat pad of the wrist: application to a new surgical approach to the carpal tunnel]. / Etude anatomique du coussin graisseux sus-rétinaculaire: application à l'abord chirurgical du canal carpien.

INTRODUCTION: Decompression of the median nerve in the carpal tunnel by section of the flexor retinaculum is the generally accepted treatment for carpal tunnel syndrome and is usually effective in relieving the symptoms. Following postoperative observations we proposed the hypothesis that incisional pain following open carpal tunnel release could be partly explained by injury to the fat pad situated between the palmar carpal ligament and the flexor retinaculum. METHOD: We performed an anatomical study on 20 fresh adult latex injected upper limbs. RESULTS: The sus-retinacularis fat pad is a real anatomical structure, clearly delineated and located inside a defined fibrous space with its own innervation from the ulnar nerve. It lies in the path of the normal carpal tunnel approach. DISCUSSION: Although most postoperative scar tenderness is attributed to neuroma formation because of injury to transverse branches of the palmar cutaneous nerves, we nevertheless consider that injury to the preretinacular fat pad also plays a part. We propose a modified approach to the carpal tunnel. This is a safe and simple method which respects the integrity of the sus-retinacularis fat pad so as to minimise the extent of scar tenderness.

Intramedullary fixation by resorbable rods in a comminuted phalangeal fracture model. A biomechanical study.

The mechanical rigidity of three different methods of resorbable intramedullary fixation (bone peg, and polyglycolide rods with and without interlocking) was assessed in a comminuted phalangeal fracture model and the results compared with two commonly used internal fixation devices (lateral plate, crossed K-wires) in a cadaver model. Each fixation technique was tested for its biomechanical strength in apex palmar bending, compression and torsion. Failure testing for the three resorbable methods was also done. The results showed that lateral plating provided the best rigidity in apex palmar bending and torsion, followed by intramedullary bone peg fixation. All resorbable intramedullary fixations had rigidity that was at least the same as crossed K-wires. For the torque test, polyglycolide rods with interlocking provided better rigidity than without interlocking. There was no significant difference between the different methods in the compression test, except that the intramedullary bone peg was significantly stiffer than K-wires.

[Hemorrhagic surgery in two Jehova's witness children refusing programmed autotransfusion: a place for erythropoietin]. / Chirurgie hémorragique chez deux enfants de témoins de Jéhovah refusant l'autotransfusion programmée: place de l'érythropoïétine.

We report two cases of haemorrhagic surgery in a 6-year-old and 16-year-old girl, respectively, whose parents were Jehovah's witnesses and therefore opposed to preoperative blood donation, but accepting intraoperative blood salvage. Erythropoietin and intravenous iron were administered preoperatively to increase red cell mass. Intraoperative blood salvage, including normovolaemic haemodilution and intraoperative autologous transfusion, avoided homologous blood transfusion.

[Bronchial endoscopy under local anesthesia and pain in children. The value of a nitrous oxide-oxygen combination]. / Endoscopie bronchique sous anesthésie locale et douleur chez l'enfant. Intérêt du mélange protoxyde d'azote-oxygène.

To evaluate the efficacy of continuous administration of 50% nitrous oxide in oxygen for reducing pain during flexible fiberoptic bronchoscopy 32 children aged 3-60 months were randomly assigned to an experimental or a control group. Indications for endoscopy included persistent atelectasis (6), wheezing (10) cystic fibrosis (2) pneumonia (11) persistent cough (3). All patients received Midazolam (0.3 mg/kg) atropine (20 mcg/kg) intra rectaly 20 minutes before the procedure. The flexible fiberoptic bronchoscope (Olympus BF3C4) was inserted transnasally through a face mask. Topical anesthesia with 1% lidocaine hydrochloride (3 mg/kg) was applied to the nose, larynx, trachea and bronchial tree over 15 minutes through the suction chanel of the bronchoscope. All patients were monitored with a pulse oximeter and a cardiac monitor. The experimental group (n = 16) received 50% nitrous oxide in oxygen prior (3 minutes) and during flexible fiberoptic bronchoscopy, the control group (n = 16) received only oxygen. We measured pain of the children by a behavioral observation scale (Children's Hospital of Eastern Ontario Pain Scale: CHEOPS) at each phase of topical anesthesia during bronchoscopy in the two groups. At the end of bronchoscopy physician's satisfaction was scored by a visual analogue scale (VAS 0-100) in which 0 corresponded to absence of satisfaction. Nitrous oxide was associated with lesser pain scores than those with oxygen. Physician significantly preferred these procedure compared with oxygen. No complication occurred during procedure. Combined with local anesthesia midazolam and atropin the administration of 50% nitrous oxide in oxygen seems a better choice for flexible fiberoptic bronchoscopy in children and should be used routinely.

Pharmacokinetics of alfentanil in children undergoing surgery.

Alfentanil pharmacokinetics and protein binding were determined in 20 children aged 10 months-6.5 yr. The data were compared with those from 10 adult patients. Eighteen children received a single i.v. dose of alfentanil 20 micrograms kg-1. The apparent volume of distribution (V beta) did not differ between the two groups. The degree of plasma protein binding was also similar in children and adults with mean free fractions of 11.5 +/- 0.9% (+/- SD) and 11.8 +/- 3.9%, respectively. There were marked differences in the elimination half-life of alfentanil (63 +/- 24 min in children; 95 +/- 20 min in adults (P less than 0.001] and plasma clearance of alfentanil (11.1 +/- 3.9 ml min-1 kg-1 in children and 5.9 +/- 1.6 ml min-1 kg-1 in adults (P less than 0.001].

[Induced normovolemic hemodilution associated with autotransfusion in orthopedic surgery in children]. / Hémodilution normovolémique intentionnelle associée à l'autotransfusion en chirurgie orthopédique infantile.

One hundred provoked normovolemic hemodilutions, which were associated with autotransfusion, have been performed in ninety-three children during a period of sixteen months. This study shows a significant saving of homologous blood (thirteen children, only had to be transfused). The mean difference in the hemoglobin level before and after surgery was of 2.1 g/100 ml. This technic did not result in any complication.