Postoperative empyema following chronic subdural hematoma surgery: Clinically based medicine.

INTRODUCTION: Subdural empyema (SDE) is a rare complication of chronic subdural hematoma (CSDH) surgery. We introduced antibiotic prophylaxis (AP) for this procedure in 2014 following a morbidity-mortality conference (MMC) in our department. We report the results of retrospective data analysis to assess the effect of systematic AP and to identify risk factors for SDE. MATERIAL AND METHODS: Two hundred eight patients were recruited between January 2013 and December 2015; 5 were excluded for incomplete data: 107 without and 96 with AP (n=203). SDE was confirmed by clinical examination, imaging and bacteriological analysis. Comparisons between AP-(no cefuroxime) and AP+ (cefuroxime) groups were made with Chi2 test and Student's t-test. RESULTS: One empyema was found in each group, indicating that AP had no effect (P=1). The only criterion associated with SDE for these two patients was a greater number of reoperations for CSDH recurrence (P=0.013). DISCUSSION: The incidence of postoperative empyema was 1%, similar to the range of 0.2%-2.1% reported in the literature. This rare incidence explains why we found no significant effect of AP. The medical decision taken at the MMC did not help to reduce the rate of postoperative SDE. MMCs can help to define factors associated with adverse surgical events and identify opportunities for improvement. CONCLUSION: AP, introduced after an MMC, did not impact SDE rates. In practice, AP should be required only in case of reoperation for CSDH recurrence. However, we still continue to use AP following the MMC considering different parameters discussed in the manuscript.

[Biceps crural myositis after an insect bite]. / Myosite du biceps crural après piqûre d'insecte.

INTRODUCTION: It can be difficult to diagnose focal muscular disease. We report a case of crural biceps focal myositis after an insect bite. DISCUSSION: We then discuss diagnostics of one or a small number of muscle injury. Focal inflammatory myositis has been described. We emphasize the role of pathology. In our case, pathological examination rules out inflammatory or tumoral disease and access likely toxical etiology. Muscle injury can appear, most frequently around the bite of venomous animal. CONCLUSION: Hymenopters are often responsible for such stings in France. Venoms are toxic for muscle cells membrane.

Prednisolone concentrations in cerebrospinal fluid after oral prednisone. Preliminary data.

Penetration of prednisolone across the blood-brain barrier was studied in 17 patients (ten women and seven men) with a mean age of 64 +/- 17 years admitted for nerve root pain warranting a lumbar puncture. One blood sample and one cerebrospinal fluid sample were obtained concomitantly from each patient, two hours (n = 7), four hours (n = 5) or six hours (n = 5) after an oral dose of 40 mg of prednisone. Prednisolone was assayed in all samples using high performance liquid chromatography and its binding to plasma proteins was determined using ultrafiltration. Total plasma prednisolone levels declined over time from 597 +/- 174 ng/ml two hours post-dose to 422 +/- 106 ng/ml four hours post-dose and 250 +/- 85 ng/ml six hours post-dose. Plasma levels of free prednisolone were 95 +/- 21 ng/ml, 59 +/- 17 ng/ml, and 18 +/- 14 ng/ml, respectively, at the same time points. Prednisolone was detectable in all cerebrospinal fluid samples, in levels of 14 +/- 2 ng/ml after two hours, 29 +/- 9 ng/ml after four hours and 17 +/- 7 ng/ml after six hours. These data demonstrate that equilibration of plasma and cerebrospinal fluid levels is achieved after six hours.

Systematic detection of mycoplasmas by culture and polymerase chain reaction (PCR) procedures in 209 synovial fluid samples.

The objective was to investigate the presence of mycoplasmas in rheumatoid arthritis (RA) and other chronic arthritides. Samples of synovial fluid (SF) were systematically collected from all patients presenting with an articular effusion. Each sample was divided into three parts. The first was kept for cytological count and culture on standard media for pyogens and mycobacteria, the second was cultivated on specific media for mycoplasmas and the third frozen for subsequent study by polymerase chain reaction (PCR). A total of 209 samples were studied. Half of the patients had inflammatory rheumatic diseases: RA (27), spondyloarthropathy (28), connective tissue disease (5), unclassified arthritis (45). The remaining suffered from other conditions, including osteoarthritis (60), gouty arthritis (19), haemarthrosis (5), post-traumatic effusion (2). Eight samples were positive by culture, two for Mycoplasma hominis; three for M. fermentans, one for M. salivarium, one for M. orale and one for Ureaplasma urealyticum. All the patients concerned had an inflammatory rheumatic disease: five had RA, one had psoriatic arthritis and two had unclassified arthritis. These results were confirmed by PCR in two cases (one M. fermentans, one U. urealyticum). The lack of sensitivity of the conventional PCR assay on SF is discussed. Mycoplasmas were mainly detected in SF of RA patients. These results raise the question of the possible role of mycoplasmas in the triggering and maintenance of inflammatory rheumatic diseases, especially RA.

Mycoplasmas and arthritides.

Rheumatoid arthritis and other autoimmune diseases might be triggered by infectious agents. We have reviewed the evidence suggesting that mycoplasmas may play a role in the genesis of arthritis. Mycoplasmas are a common cause of spontaneous arthritis in many animal species. Numerous experimental models of mycoplasma-induced arthritis have been developed, some with mycoplasmas known to cause disease in humans. Mycoplasmas entertain complex relationships with the immune system of their hosts and frequently induce autoimmune events such as rheumatoid factor production. However, the potential role of mycoplasmas in human joint disease remains unknown. Mycoplasmas can be responsible for septic arthritis in patients with immune deficiencies, especially hypogammaglobulinemia. Whether mycoplasmas can incite or perpetuate inflammatory joint diseases such as rheumatoid arthritis remains controversial. Advances in molecular biology techniques for detecting infectious agents can be expected to settle this issue in the near future.

Chronic immunity-driven polyarthritis in hairy cell leukemia. Report of a case and review of the literature.

Hairy cell leukemia can be responsible for polyarthritis due either to leukemic infiltration or to immunity-drive inflammation. The second variant can antedate or post-date the clinical onset of leukemic symptoms and usually presents as rheumatoid arthritis, more rarely as lupus or scleroderma. The presence of hairy cells in the joint fluid does not rule out autoimmune polyarthritis. The main differential diagnoses are Felty's syndrome and large granular lymphocyte leukemia. We report a case of hairy cell leukemia with seropositive rheumatoid arthritis.

Remitting seronegative symmetrical synovitis with pitting oedema: disease or syndrome?

OBJECTIVE: To evaluate the outcome of patients with remitting seronegative symmetrical synovitis with pitting oedema (RS3PE). METHODS: In a retrospective chart review study, we identified all the patients presenting with polyarthritis and pitting oedema in the past 20 years. We tried to recall the 24 patients with characteristics of RS3PE according to McCarty et al. Two patients had died and four could not be traced. Five could not be seen after the initial period of follow up; relevant data were obtained from their practitioner. For the remaining 13 patients, clinical, radiological, and biological evaluation was performed in our department, with the last assessment in 1993. RESULTS: The follow up period was from one to 18 years (mean 4.6 (SD 4.5) years). Eleven patients developed one or several recurrences of articular manifestations consisting of mild oligoarthritis (n = 8), definite spondyloarthropathy (n = 2), and rheumatoid arthritis (n = 1). The delay of the first recurrence was 18 months to 12 years after the first attack. Thirteen patients had no recurrence, but three of them developed remarkable features: rheumatoid factor, antinuclear antibodies (1/2000), Sjögren's syndrome. HLA B typing was performed in nine patients and revealed B7 (n = 2), B27 (n = 2) and B22 (n = 2). Isolated HLA B27 typing was performed in two other patients and was positive in one. CONCLUSION: The long term outcome of RS3PE can lead to different rheumatic diseases. RS3PE appears to be a syndrome related to the elderly onset of the rheumatic diseases, including spondyloarthropathy and rheumatoid arthritis, rather than a specific entity.

[Comparative study of adriamycin, epirubicin and mitoxantrone in cancer of the breast. Review of the literature]. / Etude comparative de l'adriamycine, l'épirubicine et la mitoxantrone dans le cancer du sein. Revue de la littérature.

An overview of all published randomized trials which compared mitoxantrone or epirubicine to adriamycin was performed to analyse tolerance, toxicity and efficacy of these drugs, related to adriamycin. Mitoxantrone confirms its better tolerance: nausea and vomiting are less frequent (P < 10(-9)) and alopecia less intensive (P < 10(-9)). There is a significant decrease in cardiotoxicity occurrence with mitoxantrone (P < 0.01) but a significantly higher degree of leucopenia (P < 10(-4)). As far a response rate is concerned, mitoxantrone is somewhat less effective than adriamycin (P < 0.001). As compared to adriamycin, epirubicine does not reduce side effects incidence, nevertheless, their intensity is less important: nausea and vomiting (P < 0.04) and alopecia (P < 0.01). Leucopenia is less frequent following epirubicine administration as compared to adriamycin, documented course by course (P < 0.01) or on the overall treatment (P < 0.01). Epirubicine is noted to be less cardiotoxic than adriamycin (P = 0.001) with a decreased incidence of heart failures (P < 0.05). No difference can be observed in response rate between these two treatments, for objective as well as for complete responses.

[A systematic radio-surgical combination in the treatment of sarcoma of soft tissues in adults. Results in 106 cases at the Centre François Baclesse]. / Association radio-chirurgicale systématique dans le traitement des sarcomes des tissus mous de l'adulte. Résultats dans 106 cas au Centre François Baclesse.

Based on a series of 143 cases of soft tissue sarcomas, including 106 cases treated curatively, the author stresses the importance of surgical resection with frozen section histological control, systematically combined with radiotherapy. Even when resection is complete, the frequency of loco-regional recurrences in all published series shows that neoplastic cells were already present around the resection site. Consequently, since 1972 at the Centre François Baclesse, whenever possible, surgery is preceded by concentrated regional irradiation (2 sessions of 6.50 Gy at 48 hour's interval) and postoperative complementary radiotherapy is always performed regardless of the quality of the resection 3 weeks after the preoperative irradiation. The dose is limited to a total of 50 Gy when the resection is complete and is increased to 60 to 70 Gy in the zones of doubtful or incomplete resection. This postoperative radiotherapy is associated with 5 injections of actinomycin D during the first sessions, but no adjuvant chemotherapy such as cyvadic is administered routinely. Under the conditions of treatment, the 5-year results obtained in 106 cases were as follows: local recurrences: 12.4%, metastases: 26%, survival rate: 76%. When the surgical resection was complete (62 cases), the 5-year local recurrence rate was 1.5% with 9% metastases and 92% survival. Metastases were related to factors of high malignancy which are beginning to be more clearly defined. These forms may benefit from intensive combination chemotherapy.

Local control and survival in soft tissue sarcomas of the limbs, trunk walls and head and neck: a study of 113 cases.

One hundred thirteen patients with soft tissue sarcomas of the limbs, trunk walls, and head and neck have been treated at the Centre François Baclesse since 1972. Of these, 89 histologically confirmed patients were treated with a multimodality treatment protocol. Treatment policy was designed to use each treatment method as efficiently, economically and conservatively as possible: preoperative irradiation at moderate dose to a large volume (6.5 Gy, 2 sessions, 48 hr interval); surgery 48 hr after the last preoperative irradiation; surgical excision was guided and verified intra operatively by the pathologist (with frozen sections); postoperative irradiation aimed at sterilizing all residual isolated and radiosensitive tumor cells, possibly scattered throughout the anatomical region. The total dose is brought to the equivalent of 50 Gy (preoperative dose included). This dose was increased to 60 or even 70 Gy to a restricted volume, when limb conservation was sought, but tumor foci too large for total resection without amputation; actinomycin was added to the first five postoperative irradiations. The results at 5 years were as follows: local recurrence rate, 13.6%; metastatic rate, 28%; survival rate, overall (113 patients,) 65.6%, curative series (89 patients), 75%. When the surgical excision of the primary tumor was histologically complete (54 patients) the local recurrence rate was 1.9%, the metastatic rate 11.6%, and the survival rate 89.6% at 5 years.

Autopsy findings in 111 cases of esophageal cancer.

Autopsy findings for 111 cases of esophageal cancer are presented. Residual tumor in the esophagus was present in 75% of the cases. Lymph node metastases were found in 74.5% and visceral metastases in 50% of the cases. Autopsy revealed a second primary tumor in 21% of the cases; 12% of these were oropharyngeal-laryngeal (OPL) carcinomas, and 9% were visceral carcinomas or malignant lymphomas. Nonmalignant disease found in association with esophageal cancer was dominated by conditions related to chronic alcoholism. Autopsy findings thus revealed that the patients bore not only esophageal lesions, but also patterns of other associated malignant and nonmalignant diseases which would seem to correspond to a complex pathologic state occurring in association with chronic alcoholism. The time between onset of symptoms and autopsy averaged 10.6 months and between first consultation and autopsy, 6.3 months. The brevity of survival from onset of symptoms would seem to confirm that by the time esophageal cancer manifests clinically, it is already at a stage of development beyond the scope of treatment.