Cytotoxic T-cell and NK-cell Lymphomas: Current Questions and Controversies.

The cytotoxic T-cell and natural killer (NK)-cell lymphomas and related disorders are important but relatively rare lymphoid neoplasms that frequently are a challenge for practicing pathologists. This selective review, based on a meeting of the International Lymphoma Study Group, briefly reviews T-cell and NK-cell development and addresses questions related to the importance of precise cell lineage (αβ-type T cell, γδ T cell, or NK cell), the implications of Epstein-Barr virus infection, the significance of anatomic location including nodal disease, and the question of further categorization of enteropathy-associated T-cell lymphomas. Finally, developments subsequent to the 2008 World Health Organization Classification, including the recognition of indolent NK-cell and T-cell disorders of the gastrointestinal tract are presented.

Intravitreal ranibizumab for AMD : the individual rhythm of OCT guided retreatment intervals

Purpose: We intended to determine whether the need for retreatmentwith intravitreal ranibizumab follows an individual rhythm in patientswith exudative AMD. Setting: Prospective mono-centre cohort study.Methods: Prospective study. 48 patients with exudative AMD. 3 loadingdoses of ranibizumab, followed by a 12 months PRN regimen guided byearly exudative signs on SD-OCT. An intensified follow-up allowed todetect recurrences early.Results:Mean VA improved by 6.4 letters at month 3 and by 13.1 letters atmonth 12, with a mean of 8.0 injections (range 0-12) during the maintenancephase. The intra-individual variance of the intervals was relativelysmall and ranged within 20% of themean interval in 91% of patients.Thefirst interval was within 1 week of the mean interval in 84% of patients.The retreatment criteria were stable in 89% of patients.Conclusion: The relative stability of the intra-individual intervalsmay allowsimplifying the care for AMDpatients.Theremay be a predictive role for thefirst interval after the loading phase. The functional results of this PRNregimenwith early retreatmentwere excellent. Financial disclosure:None.

ESPEN Guidelines on Enteral Nutrition: Intensive care.

Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.

Improvement of rehabilitation possibilities with the MotionMaker (TM)

"MotionMaker (TM)" is a stationary programmable test and training system for the lower limbs developed at the 'Ecole Polytechnique Federale de Lausanne' with the 'Fondation Suisse pour les Cybertheses'.. The system is composed of two robotic orthoses comprising motors and sensors, and a control unit managing the trans-cutaneous electrical muscle stimulation with real-time regulation. The control of the Functional Electrical Stimulation (FES) induced muscle force necessary to mimic natural exercise is ensured by the control unit which receives a continuous input from the position and force sensors mounted on the robot. First results with control subjects showed the feasibility of creating movements by such closed-loop controlled FES induced muscle contractions. To make exercising with the MotionMaker (TM) safe for clinical trials with Spinal Cord Injured (SCI) volunteers, several original safety features have been introduced. The MotionMaker (TM) is able to identify and manage the occurrence of spasms. Fatigue can also be detected and overfatigue during exercise prevented.

Cellules gliales et douleur chronique: du laboratoire a l'espoir clinique [Glial cells and chronic pain: from the laboratory to clinical hope].

Despite their high prevalence, associated disability and seemingly rich pharmacopeia, the various forms of chronic pain remain frequently intractable. The past decade witnessed the rise of a concept stating that non-neuronal cells of the central nervous system, astrocytes and microglia, are crucial elements in pathological pain. This review gathers and summarizes the experimental data underpinning this theory in animal models and addresses their pertinence in humans. The potential opportunities and constraints of glial inhibition are exposed and compared to more moderate strategies of selective modulation. This therapeutic hope is particularly highlighted in our discussion of the first completed clinical trials employing glial inhibitors in the treatment of chronic pain.

Quelle perception ont les médecins de famille en Suisse de leur rôle dans la prévention et la promotion de la santé? : comprendre les barrières à l'implémentation

Introduction: The importance of health promotion and prevention and the potential of general practitioners (GPs) to conduct individual prevention procedures have been demonstrated in several studies. Clinical recommendations for screening and prevention activities, an important condition for success, are published regularly, but their implementation into daily practice does not necessarily follow. Information is lacking about the actual conditions of how prevention is carried out on a daily basis by Swiss GPs, about their perceptions and needs, their attitudes and the present barriers they face. Such information is essential for the development of new tools and programs targeting better implementation of clinical recommendations for prevention in primary care in Switzerland. Objectives: The objectives of the study were to analyze how Swiss GPs perceive their role in prevention by obtaining information regarding the following issues: What do disease prevention and health promotion mean to them? What are the current incentives and barriers they face? What are their ideas and suggestions to deal with these barriers? What are their needs and expectations regarding prevention guidelines and tools? Methods: We conducted a qualitative research project using focus groups to examine the questions mentioned above. A total of 13 focus groups took place including GPs from eight cantons: five groups in German- speaking Switzerland and eight in French- speaking Switzerland. Each group was composed of 4-11 GPs, making in total 102 participants, who were paid expenses to cover their participation. The sessions were audio-recorded and transcribed verbatim. Data analysis: Content analysis of the transcriptions began by classifying the data according to a typology, the first level of which was developed in line with the structure of the interview guide. This typology was extended by successively regrouping similar statements. Synopsis and interpretation was then performed on each category thus obtained. This research report is based on the results from the French-speaking cantons. Results: Physicians perceive a change in their role as a consequence of changes in society and the health system. They emphasize the importance of a personalized and long lasting relationship between the family doctor and his/her patient; a privileged position allowing them to perform individualized prevention activities, considered to be more effective, as they are appropriate to the specific situation and needs of the patient. They point out their need for training and for better information concerning prevention and health promotion interventions, and stress difficulties arising from the lack of a clear political signal conferring them with a mandate for prevention. -- INTRODUCTION L'importance de la prévention et de la promotion de la santé et le potentiel des médecins de famillea à mettre en oeuvre des mesures individuelles de prévention, de dépistage et de conseils, a été démontrée dans plusieurs études. Régulièrement durant les dernières années, de nombreuses associations médicales ont publié des recommandations cliniques concernant les activités de dépistage et de prévention qui sont une condition essentielle pour le succès, mais ne sont pas forcément appliquées de manière systématique dans la pratique médicale quotidienne. Des contraintes spécifiques contribuent à l'écart entre le désir des médecins de pratiquer une médecine préventive et la réalité d'un cabinet médical. Nous n'avons que peu de données sur les conditions actuelles dans lesquelles la prévention et la promotion de la santé sont réalisées par les médecins de famille suisses dans leur travail quotidien. Des informations précises et représentatives sur leurs perceptions et leurs besoins, leurs attitudes et les contraintes auxquelles ils sont confrontés manquent. Or ces données sont essentielles dans le développement de nouveaux outils et programmes visant une meilleure implémentation des recommandations cliniques dans le domaine de la prévention et la promotion de la santé dans la médecine de famille en Suisse. OBJECTIFS Le développement de concepts pour une prévention systématique ainsi que d'outils adéquats, tout comme l'amélioration des conditions qui permettent une implémentation à grande échelle, implique, avant tout, l'analyse de la perception que les médecins de famille suisses ont de leur rôle dans la prévention. Par conséquent, cette étude a eu pour objectif d'obtenir des informations concernant les questions suivantes : ? Que signifient la prévention et la promotion de la santé pour les médecins de famille suisses ? ? Quelles sont leurs incitations et les barrières rencontrées ? ? Quelles sont leurs idées et leurs suggestions pour faire face à ces contraintes ? ? Quels sont leurs besoins et leurs attentes concernant les outils pour la prévention ? METHODES Nous avons mené un projet de recherche qualitative en utilisant la technique des focus groups pour examiner les questions mentionnées ci-dessus. Une telle technique de collecte de données est particulièrement adaptée à un domaine où l'on connaît mal les perceptions des parties prenantes. Nous avons mené 13 focus groups au total, comprenant des médecins issus de huit cantons: cinq groupes ont eu lieu en Suisse alémanique et huit groupes en Suisse romande. Chaque groupe était composé de 4 à 11 médecins de famille, avec au total 102 participants qui ont été défrayés pour leur participation. Les séances ont été audio-enregistrées et transcrites. ANALYSE DES DONNEES L'analyse du contenu des transcriptions a commencé par la classification des données selon une typologie dont le premier niveau a été développé à partir de la structure de la grille d'entretiens. Cette typologie a été affinée et élargie en regroupant successivement des propos similaires. Une synthèse a été effectuée pour chaque catégorie. Ce rapport est basé sur les résultats de l'analyse des données des cantons francophones. RESULTATS Les médecins perçoivent un changement de leur rôle dans une société et dans un système de santé qui évoluent. Ils soulignent l'importance de la relation personnalisée et durable du médecin de famille avec son patient, atout précieux, qui leur permet de réaliser des activités de prévention individualisées et adaptées à la situation et aux besoins du patient, considérées plus efficaces. Afin de surmonter leur doutes et découragement par rapport aux interventions de prévention, ils pointent la nécessité d'une formation aux nouvelles connaissances en prévention et promotion de la santé et d'une meilleure information aux médecins quant à leur efficacité et importance. Ils montrent le besoin d'un signal clair des politiques par rapport à l'attribution de ce mandat aux médecins de famille et de leur reconnaissance en tant qu'acteur de prévention dans le système de santé.

Endoscopic epiglottopexy using Lichtenberger's needle carrier to avoid breakdown of repair.

Severe type III laryngomalacia LM is represented by a retroflexed epiglottis that touches the posterior pharyngeal wall and obstructs the laryngeal inlet. Endoscopic epiglottopexy is advised in such cases wherein pexy sutures are passed between the epiglottis and base of tongue. Using conventional needle carriers, it is difficult to pass such sutures that go deep enough into the tongue base. Such a pexy is prone to a break down. We describe a novel technique of placing these glossoepiglottic sutures using the Lichtenberger's needle carrier. We used this technique in three patients with excellent results and report no complications. We propose to use this technique in cases of epiglottic prolapse seen in severe LM and certain hypotonic conditions.

Les neurosciences au Tribunal : de la responsabilité à la dangerosité, enjeux éthiques soulevés par la nouvelle loi française

AIM: In the past few years, spectacular progress in neuroscience has led to the emergence of a new interdisciplinary field, the so-called "neurolaw" whose goal is to explore the effects of neuroscientific discoveries on legal proceedings and legal rules and standards. In the United States, a number of neuroscientific researches are designed specifically to explore legally relevant topics and a case-law has already been developed. In Europe, neuroscientific evidence is increasingly being used in criminal courtrooms, as part of psychiatric testimony, nourishing the debate about the legal implications of brain research in psychiatric-legal settings. Though largely debated, up to now the use of neuroscience in legal contexts had not specifically been regulated by any legislation. In 2011, with the new bioethics law, France has become the first country to admit by law the use of brain imaging in judicial expertise. According to the new law, brain imaging techniques can be used only for medical purposes, or scientific research, or in the context of judicial expertise. This study aims to give an overview of the current state of the neurolaw in the US and Europe, and to investigate the ethical issues raised by this new law and its potential impact on the rights and civil liberties of the offenders. METHOD: An overview of the emergence and development of "neurolaw" in the United States and Europe is given. Then, the new French law is examined in the light of the relevant debates in the French parliament. Consequently, we outline the current tendencies in Neurolaw literature to focus on assessments of responsibility, rather than dangerousness. This tendency is analysed notably in relation to the legal context relevant to criminal policies in France, where recent changes in the legislation and practice of forensic psychiatry show that dangerousness assessments have become paramount in the process of judicial decision. Finally, the potential interpretations of neuroscientific data introduced into psychiatric testimonies by judges are explored. RESULTS: The examination of parliamentary debates showed that the new French law allowing neuroimaging techniques in judicial expertise was introduced in the aim to provide a legal framework that would protect the subject against potential misuses of neuroscience. The underlying fear above all, was that this technology be used as a lie detector, or as a means to predict the subject's behaviour. However, the possibility of such misuse remains open. Contrary to the legislator's wish, the defendant is not fully guaranteed against uses of neuroimaging techniques in criminal courts that would go against their interests and rights. In fact, the examination of the recently adopted legislation in France shows that assessments of dangerousness and of risk of recidivism have become central elements of the criminal policy, which makes it possible, if not likely that neuroimaging techniques be used for the evaluation of the dangerousness of the defendant. This could entail risks for the latter, as judges could perceive neuroscientific data as hard evidence, more scientific and reliable than the soft data of traditional psychiatry. If such neuroscientific data are interpreted as signs of potential dangerousness of a subject rather than as signs of criminal responsibility, defendants may become subjected to longer penalties or measures aiming to ensure public safety in the detriment of their freedom. CONCLUSION: In the current context of accentuated societal need for security, the judge and the expert-psychiatrist are increasingly asked to evaluate the dangerousness of a subject, regardless of their responsibility. Influenced by this policy model, the judge might tend to use neuroscientific data introduced by an expert as signs of dangerousness. Such uses, especially when they subjugate an individual's interest to those of society, might entail serious threats to an individual's freedom and civil liberties.

Cost-minimization analysis of three decision strategies for cardiac revascularization : results of the "suspected CAD"cohort of the european cardiovascular magnetic resonance registry.

BACKGROUND: Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry. METHODS: In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50 % stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50 % stenoses. To calculate the proportion of patients with ≥50 % stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems. RESULTS: Revascularizations were performed in 6.2 %, 4.5 %, and 12.9 % of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3 %, 1.1 %, and 1.5 %, respectively. The CMR + CXA-strategy reduced costs by 14 %, 34 %, 27 %, and 24 % in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59 %, 52 %, 61 % and 71 %, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3 %), intermediate in the US and Swiss (11.6 % and 12.8 %, respectively), and remained substantial in the UK (18.9 %) systems. Sensitivity analyses proved the robustness of results. CONCLUSIONS: A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.