How Much Does the US Public Value Equity in Health? A Systematic Review.

OBJECTIVES: This systematic review aims to summarize and qualitatively assess published evaluations on the US public's preferences for health equity and their willingness to trade-off efficiency for equity. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, we searched MEDLINE and Embase for relevant peer-reviewed publications on this topic before February 2021. We included English-language articles that solicited US preferences regarding efficiency-equity trade-offs and prioritizing healthcare resources based on socioeconomic status, race, disability, or burden of disease. Quantitative and qualitative data captured were decided a priori and iteratively adapted as themes emerged. RESULTS: Fourteen studies were found over a 25-year span. Only 4 focused on resource allocation across social groups. Three distinct notions of fairness were studied: equal distribution of resources, priority to the worse-off, and equal health achieved. We found modest support for equal distribution of resources and willingness to sacrifice efficiency for equity in the United States. Prioritizing the underserved was relatively less studied and received less support and was more preferred when resources were scarce, when allocating resources between social groups, or when participants were informed about the fundamental origins of health inequities. Equal health was the least studied, but received nontrivial support. CONCLUSIONS: The existing literature evaluating the US public's understanding and preferences toward equity was severely limited by the lack of rigorous quantitative studies and heterogeneous attribute selection and fairness definitions. High-quality studies that clearly define fairness, focus on social groups, and apply rigorous methods to quantify equity preferences are needed to integrate the public's value on equity into healthcare decisions.

Évolution catastrophique d'une électrisation des deux membres supérieurs: désarticulation bilaté-rale des épaules.

The importance of tissue damage secondary to high voltage electrical injury to the limbs often makes the management of this kind of burn very difficult. Repair interventions are sometimes ineffective and amputations are then unavoidable. We report the case of a young patient suffering electrical injury to both upper limbs caused by a high voltage current, whose evolution was dramatically marked by bilateral disarticulation of both shoulders.

Worse histological grade of proximal colorectal tumors and its relation with stage.

PURPOSE: Accumulated data seem to support the concept that proximal and distal colorectal cancers (CRC) should be considered as different disease entities. We investigated a particular aspect of this assumption by examining variation of stage and grade distribution according to tumor site in a Greek patients' group. METHODS: A total of 200 cases having had undergone surgery for primary CRC was retrospectively analysed. Fifty-seven proximal tumors were compared to 143 distal lesions regarding tumor stage (TNM I-IV) and grade of differentiation (well, moderate and poor). Grade distribution by site was also examined within each particular stage and within additional stage categories (I-II, III-IV, I-III, II-IV, II-III). RESULTS: There was an almost significant trend of distal tumors for earlier stage (I) presentation (p=0.055), whereas proximal cancers were more frequently diagnosed with stages II-III (p=0.08). Poorly differentiated lesions displayed a strong predilection for proximal site (p=0.002), while tumors with moderate differentiation were preferentially found distally (p=0.001). Such segmental differences in grade distribution were also ascertained within most particular stages and all additional stage subsets (especially the last three). Moreover, both the proximal and the poorly differentiated lesions showed a parallel decrease in their incidence during the study period. CONCLUSION: The consistently recorded worse histological pattern of proximal tumors implies a different biological behavior of these lesions possibly due to distinct tumorigenic pathways involved in their development, whereas their tendency for late stage presentation demands further investigation before considered supportive to this concept.

Site impact on colorectal cancer biological behavior in terms of clinicopathological and molecular features.

PURPOSE: We investigated the biological behavior of proximal and distal colorectal adenocarcinomas (CRC), intending to determine specific segmental differences, possibly arising from the distinct genetic pathways involved in their development. METHODS: Thirty-six proximal and 83 distal cancers were comparatively and retrospectively analyzed, regarding tumor stage, grade and Ki-67, p53 and Bcl-2 immunohistochemical expression. RESULTS: Proximal tumors were more likely to be poorly differentiated (p=0.005) and to exhibit low Ki-67 and p53 expression (<20% and ≤ 30% stained nuclei respectively; p=0.026 and 0.0014, respectively). Distal lesions were more likely to be moderately differentiated (p=0.001), to display moderate Ki-67 expression (20-50% stained nuclei, p= 0.013) and p53 staining higher than 30% stained nuclei (p= 0.0014). Such segmental variations regarding mainly p53 and to a lesser extent Ki-67 were seen within most of the specific sub-groups of patients (stratified by stage, grade, gender and age). An association between Bcl-2 expression and distal site was also observed among females (p=0.008). CONCLUSION: Proximal and distal cancers displayed different clinicopathological and molecular patterns, reinforcing the proposal that they are genetically and biologically different entities. Potential clinical applications of these findings should be investigated.

Analysis of 7 immunohistochemical markers in male germ cell tumors demonstrates the prognostic significance of p53 and MIB-1.

BACKGROUND: Various prognostic factors have been investigated in order to predict the minority of male germ cell tumor (GCT) patients who will develop resistant disease. However, no prognostic system has been proven accurate. MATERIALS AND METHODS: Paraffin-embedded tissue specimens, obtained from primary lesions during the initial diagnosis of 83 advanced chemotherapy-treated GCT male patients, were stained for 7 immunohistochemical markers: p53, bax, bcl-2, MIB-1, topoisomerase IIa, c-kit and COX-2. The percentage of positive cells for each marker was measured for each patient. Cox regression was used for the prognostic factor analysis. RESULTS: All patients were followed for a median of 4 years. Nineteen patients had seminoma and 64 non-seminomatous GCT. In univariate analysis, only p53 (hazard ratio (HR) = 4.01, 95% confidence interval (CI) = 1.25-12.84, p = 0.019) and MIB-1 (HR = 3.16, 95% CI = 1.06-9.45, p = 0.039) were found to be prognostic for disease-specific survival. The best prognostic cut-off values of p53 and MIB-1 were 10% and 30% respectively. In multivariate analysis, these two markers obtained independent significance only when considered in combination (HR = 6.63, 95% CI = 1.40-31.41, p = 0.017, for patients with one or both markers above their cut-off), while the International Germ Cell Consensus Cancer Group (IGCCCG) risk was the most significant (HR = 7.99, 95% CI = 1.96-32.52, p = 0.004, for the high-risk group). However, the expression of these markers seemed to be significantly correlated with known prognostic factors. Nevertheless, we identified 34 patients of low IGCCCG risk expressing both markers below their cut-off with excellent survival. CONCLUSION: Among 7 immunohistochemical markers, p53 and MIB-1 demonstrated prognostic significance. Their combination may contribute to improvement of the accuracy of the currently approved prognostic system (IGCCCG).

Reevaluating pancreatic duct ligation in Whipple procedure.

In an effort to avoid the morbidity and mortality related to pancreaticojejunal anastomosis after pancreaticoduodenectomy (PPD), we report on the treatment of the pancreatic stump by pancreatic duct ligation (PDL) following Whipple procedure. We studied a series of 9 consecutive unselected patients (8 with pancreatic cancer and 1 with chronic pancreatitis). Of those, pancreatic fistula occurred in 4 patients and persisted for 14 to 58 days (mean 35.4 days). Two patients died within 30 days after surgery from causes not related to PDL. None of our patients developed diabetes mellitus following PDL surgery, nor any of the other frequently mentioned postoperative complications such as acute pancreatitis or pancreatic insufficiency. In conclusion, PDL may occasionally lead to a controlled pancreaticocutaneous fistula with fading inactive contents over time not causing further metabolic complications but is a safe, simple and fast alternative to pancreaticojejunostomy.

Kit expression in male germ cell tumors.

OBJECTIVE: KIT functions as the receptor for stem cell factor (SCF) and this interaction is essential for regulation of proliferation and survival, particularly for germ cells since it regulates oogenesis, folliculogenesis and spermatogenesis. Up-regulation of KIT signalling has been associated with oncogenic transformation in cells expressing the molecule. Our objective was to investigate the expression of KIT in germ cell tumor patients and correlate it with the patients' clinical characteristics. PATIENTS AND METHODS: One hundred and seventy-three archival blocks of formalin fixed, paraffin-embedded tumor samples from histologically confirmed germ cell tumor (GCT) patients were included in the study. Immunohistochemical staining for KIT was performed and the percentage of positive cells was calculated by an independent pathologist. KIT expression was considered as positive if > 10% of tumor cells displayed membranous or cytoplasmic staining. RESULTS: Sixty-one patients with seminomatous (49 pure, 11 anaplastic, 1 spermocytic) and 112 with non-seminomatous GCTs (36 malignant teratoma undifferentiated (MTU), 15 malignant teratoma trophoblastic (MTT), 20 malignant teratoma intermediate (MTI), 35 malignant teratoma combined (MTC) and six others) were identified. Among pure seminoma patients, 38 (77.5%) revealed a positive staining for KIT, while only two out of eleven (18.2%) anaplastic seminoma patients were identified as positive. This difference was statistically significant (p < 0.001). Among 35 patients with an MTC, 48.6% had a positive KIT staining while only two of the remaining patients with a non-seminomatous GCT had a positive staining. Although KIT was strongly correlated with seminomatous histology (p < 0.001), it failed to correlate with stage (p = 0.19) or treatment response (p = 0.11) in these patients. Overall, four (one seminoma, three MTC) out of 22 chemoresistant patients showed a positive staining for KIT. CONCLUSION: KIT is expressed in the majority of seminomas and in seminomatous components of the combined tumors, but only in a minority of anaplastic seminomas and rarely in non-seminomatous GCTs. The recent development of tyrosine kinase inhibitors may offer a possibility of cure in chemoresistant patients overexpressing KIT.

[Intramural pseudodiverticulosis of the esophagus. A case report and review of the literature]. / La pseudodiverticulose oesophagienne intramurale. A propos d'un cas avec revue de la littérature.

Oesophageal intramural pseudodiverticulosis is a very rare cause of dysphasia. This work reports the observation of a 42 year-man who presented with dysphasia; Diagnosis was established by baryum meal. The patient underwent an oesophagectomy because of failure of endoscopic dilatation. Pathologic examination revealed characteristic lesions of esophageal pseudodiverticulosis, with fissures between the lumen and sero-mucosal glands located in the oesophageal wall and containing Candida spores. By means of a review of the relevant literature, etiopathogenesis, diagnosis and treatment of oesophageal intramural pseudodiverticulosis are discussed.

[Retro-cost-xyphoid hernia and common mesentery: a case diagnosed in an adult]. / Hernie rétro-costo-xyphoïdienne et mésentère commun: un cas diagnostiqué chez l'adulte.

Authors analysed Morgagni's hernia pathogenesis through a new case associated to a common mesentery position and revealed by respiratory distress after delivery.

[Primary linitis plastica of the rectum]. / La linite plastique primitive du rectum.

One case of primary linitis plastica of the rectum is presented, it is a rare entity presentation in younger patients. The diagnosis was made by excluding the stomach as a primary source by peroperative palpation and fibroscopy examination. Because of potential for local invasion and infiltration, linitis is often detected only at the equivalent of stage C (Astler-Cller). The prognosis is poor, the mean survival time is about 9 months.

[Cicatrix endometriosis of the abdominal wall]. / L'endométriose cicatricielle de la paroi abdominale.

Endometriosis is a rare entity, related after operation on the uterus or uterine tubes or a laparotomy procedures or other extrapelvic procedures, when seeding of endometrial fragments were shed into the peritoneal cavity. We report the case of a menopaused woman with a subcutaneous incisional scar mass that appeared 22 years after a caesarean section. The diagnosis was made by histological examination.

[Stromal tumor of the stomach with exo-gastric growth]. / Les tumeurs stromales du tube digestif. Réflexions à propos d'un cas à développement exo-gastrique.

A 60 year-old male patient presented with a giant stromal tumor of the stomach that showed predominant extragastric growth. Surgery consisted of total tumor resection with partial gastrectomy. The stromal origin of the tumor was established by immunohistochemistry. In spite of its large size and the presence of necrotic foci, the tumor was considered to be of low grade in view of the low mitosis index. The patient was maintained on careful surveillance. The histological features which characterize these tumors and their implications for prognosis and therapy are briefly discussed.

p53 protein accumulation and colonic adenoma recurrence.

OBJECTIVES: The prognostic value of p53 protein accumulation in colonic adenomas is still controversial. The aim of the present study was to determine whether the evaluation of p53 protein accumulation in newly diagnosed colonic adenomas could predict the development of metachronous adenomas. DESIGN/METHODS: Fifty-five patients who underwent prior endoscopic polypectomy for colonic adenomas were colonoscopically re-evaluated at 24-38 months after index colonoscopy. In cases with more than one adenoma, the one with the greatest diameter and the most serious histology was taken into account. p53 protein expression was immunohistochemically examined using specific monoclonal antibody. RESULTS: p53 protein was detected in 41.8% of the 55 index adenomas. Recurrent adenomas were present in 21 patients (38.2%). Metachronous adenomas were present in 56.5% of patients with p53-positive index adenomas and in 25% of those with p53-negative index adenomas (odds ratio 3.90, P = 0.018). Among patients with 1 or 2 index adenomas, metachronous adenomas were found in 50% of those with p53-positive index adenomas and in 22.6% of those with p53-negative index adenomas (odds ratio 3.43, P= 0.042). Multivariate stepwise logistic regression analysis revealed that number of index adenomas per patient (1 or 2 versus > 2) and p53 expression (positive versus negative) in index adenomas contain independent prognostic information for adenoma recurrence (chi2 = 8.2, P= 0.004 and chi2 = 4.08, P = 0.04 respectively). Patients aged < 60 years developed recurrent adenomas relatively more frequently if they had a p53-positive index adenoma (P= 0.068). In the subgroup of patients aged < 60 years with 1 or 2 index adenomas, the recurrence of adenomas was more frequent in those with a p53-positive index adenoma but the difference did not reach statistical significance (P= 0.13). CONCLUSIONS: Our data suggest that p53 expression in index adenomas is associated with recurrent colonic adenomas.

Proliferative patterns of rectal mucosa as predictors of advanced colonic neoplasms in routinely processed rectal biopsies.

OBJECTIVES: We sought to determine whether the evaluation of rectal cell proliferation in routinely processed rectal biopsies of apparently normal mucosa can predict the presence of advanced colonic neoplasms. METHODS: Fifty consecutive patients, who did not meet any of the following exclusion criteria, underwent total colonoscopy. Patients with nonadvanced adenomas, inflammatory bowel disease, hereditary predisposition to colonic cancer, or a history of colonic neoplasms were excluded. Patients with neoplasms in the distal 40 cm of the large bowel were also excluded. An adenoma was considered advanced if it had a diameter > 1 cm, or villous or severe dysplasia histology were present. In 26 of the 50 patients (Group A: 16 men, 10 women; mean age, 65 yr) advanced colonic neoplasms (advanced adenomas or cancer) were detected; in the remaining 24 (Group B: 13 men, 11 women; mean age, 66 yr) the large bowel was free of neoplasms. In all patients the proliferative patterns of apparently normal rectal mucosa were evaluated using the monoclonal antibody MIB-1 to assess the expression of Ki-67 antigen in routinely processed tissues. Proliferation index for the entire crypt, as well as proliferation indices for each of the five equal compartments, into which the crypt had been divided longitudinally, were calculated for each patient. RESULTS: The mean proliferation indices were similar between the two groups compared. The mean proliferation index for the upper crypt compartments (4 + 5) in the Group A patients was significantly higher than for those of the Group B patients (p < 0.01). Multivariate stepwise logistic regression analysis revealed that among gender, age, and proliferative parameters, the pattern of cell proliferation in the upper rectal crypt (4 + 5) compartment was the only predictor of advanced colonic neoplasms (beta = 11.01, p < 0.001). CONCLUSIONS: Our data suggest that the evaluation of the upward expansion of the rectal crypt proliferative zone in routinely processed rectal biopsies of apparently normal mucosa appears to predict the presence of advanced colonic neoplasms. These preliminary results should be confirmed in larger studies.

[Apropos of a case of gas gangrene of the abdominal wall after cholecystectomy]. / A propos d'une observation de gangrène gazeuse de la paroi abdominale après cholécystectomie.

The authors report a new case of gas gangrene following cholecystectomy with a fatal outcome. Mode of infection and principles of diagnosis and therapy are discussed together with a review of the literature.