Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

AIM: To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS). MATERIALS AND METHODS: Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan-Meier were performed. RESULTS: Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness (p<0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR=5.6, p<0.001), positive SN (RR=5.0, p<0.001) and male sex (RR=2.9, p=0.001). The presence of a metastatic SN (RR=8.4, p<0.001), male sex (RR=6.1, p<0.001), Breslow thickness (RR=3.2, p=0.013) and ulceration (RR=2.6, p=0.015) were significantly associated with a poorer DSS. CONCLUSION: SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure

Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

Résumé Etude de la valeur pronostique de la biopsie du ganglion sentinelle dans une étude prospective monocentrique de 327 patients atteints de mélanome malin But II s'agit de confirmer la validité de la biopsie du ganglion sentinelle, d'en définir la morbidité, d'investiguer les facteurs prédictifs pour le statut du ganglion sentinelle ainsi que de déterminer les facteurs pronostiques pour la survie sans récidive et la survie spécifique liée à la maladie. Matériel et méthode D'octobre 1997 à décembre 2004, 327 patients consécutifs présentant un mélanome cutané primaire des membres, du tronc et de la tête, sans adénopathie clinique ni métastase à distance ont été inclus. La biopsie du ganglion sentinelle a été réalisée selon la triple technique (lymphoscintigraphie, colorant bleu vital et sonde de détection gamma). Les paramètres et la survie ont été évalués par différentes analyses de régression logistique multiple selon Cox et la survie évaluée selon Kaplan Meier. Résultats Vingt-trois pour cent des patients présentaient au moins un ganglion sentinelle métastatique, ce qui était associé de façon significative à l'épaisseur selon Breslow (p<0.001). Le taux de succès de la biopsie du ganglion sentinelle était de 99.1% et sa morbidité de 7.6%. Avec une durée médiane de suivi de 33 mois, la survie sans récidive à 5 ans était de 43% pour les patients avec un ganglion sentinelle positif et de 83.5% pour ceux avec un ganglion sentinelle négatif. La survie spécifique liée à la maladie à 5 ans était de 49% pour les patients avec un ganglion sentinelle positif et de 87.4% pour ceux avec un ganglion sentinelle négatif. Le taux de faux négatif de la biopsie du ganglion sentinelle était de 8.6%. L'analyse multivariée a démontré que la survie sans récidive était significativement péjorée par :l'épaisseur selon Breslow (RR=5.6, p<0.001), un ganglion sentinelle positif (RR=5.0, p<0.001), et le sexe masculin (RR=2.9, p=0.001). La survie spécifique liée à la maladie était significativement diminuée par : un ganglion sentinelle métastatique (RR=8.4, p<O.OOI), le sexe masculin (RR=6.1, p<0.001), l'épaisseur selon Breslow (RR=3.2, p=0.013), et la présence d'une ulcération (RR=2.6, p=0.015). Conclusion La biopsie du ganglion sentinelle est une procédure fiable avec une haute sensibilité (91.4%) et une faible morbidité (7.6%). L'épaisseur selon Breslow était le seul facteur prédictif significatif pour le statut du ganglion sentinelle. La survie sans récidive était péjorée selon un ordre décroissant par :l'épaisseur selon Breslow, un ganglion sentinelle métastatique, et le sexe masculin. De façon similaire la survie spécifique liée à la maladie était péjorée par : un ganglion sentinelle métastatique, le sexe masculin, l'épaisseur selon Breslow, et une ulcération. Ces données renforcent le statut du ganglion sentinelle en tant que puissant moyen pour évaluer le stade tumoral ainsi que le pronostic.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Predicting the impacts of climate change on genetic diversity in an endangered lizard species.

Many endangered species persist as a series of isolated populations, with some populations more genetically diverse than others. If climate change disproportionately threatens the most diverse populations, the species' ability to adapt (and hence its long-term viability) may be affected more severely than would be apparent by its numerical reduction. In the present study, we combine genetic data with modelling of species distributions under climate change to document this situation in an endangered lizard (Eulamprus leuraensis) from montane southeastern Australia. The species is known from only about 40 isolated swamps. Genetic diversity of lizard populations is greater in some sites than others, presumably reflecting consistently high habitat suitability over evolutionary time. Species distribution modelling suggests that the most genetically diverse populations are the ones most at risk from climate change, so that global warming will erode the species' genetic variability faster than it curtails the species' geographic distribution.

An objective anisotropic elastic plastic model and Algorithm applicable to bone mechanics

The implicit projection algorithm of isotropic plasticity is extended to an objective anisotropic elastic perfectly plastic model. The recursion formula developed to project the trial stress on the yield surface, is applicable to any non linear elastic law and any plastic yield function.A curvilinear transverse isotropic model based on a quadratic elastic potential and on Hill's quadratic yield criterion is then developed and implemented in a computer program for bone mechanics perspectives. The paper concludes with a numerical study of a schematic bone-prosthesis system to illustrate the potential of the model.

Bimodal magmatism as a consequence of the post-collisional readjustment of the thickened Variscan continental lithosphere (Aiguilles Rouges - Mont Blanc Massifs, Western Alps)

High Precision U-Pb zircon and monazite dating in the Aiguilles Rouges-Mont Blanc area allowed discrimination of three short-lived bimodal magmatic pulses: the early 332 Ma Mg-K Pormenaz monzonite and associated 331 Ma peraluminous Montees Pelissier monzogranite; the 307 Ma cordierite-bearing peraluminous Vallorcine and Fully intrusions; and the 303 Fe-K Mont Blanc syenogranite. All intruded syntectonically along major-scale transcurrent faults at a time when the substratum was experiencing tectonic exhumation, active erosion recorded in detrital basins and isothermal decompression melting dated at 327-320 Ma. Mantle activity and magma mixing are evidenced in all plutons by coeval mafic enclaves, stocks and synplutonic dykes. Both crustal and mantle sources evolve through time, pointing to an increasingly warm continental crust and juvenile asthenospheric mantle sources. This overall tectono-magmatic evolution is interpreted in a scenario of post-collisional restoration to normal size of a thickened continental lithosphere. The latter re-equilibrates through delamination and/or erosion of its mantle root and tectonic exhumation/erosion in an overall extensional regime. Extension is related to either gravitational collapse or back-are extension of a distant subduction zone.

Severe traumatic brain injury in Switzerland - feasibility and first results of a cohort study.

BACKGROUND: We aimed to study the incidence and outcome of severe traumatic brain injury (TBI) in Switzerland and to test the feasibility of a large cohort study with case identification in the first 24 hours and 6-month follow-up. METHODS: From January to June 2005, we consecutively enrolled and followed up all persons with severe TBI (Abbreviated Injury Score of the head region >3 and Glasgow Coma Scale <9) in the catchment areas of 3 Swiss medical centres with neurosurgical facilities. The primary outcome was the Extended Glasgow Outcome Scale (GOSE) after 6 months. Secondary outcomes included survival, Functional Independence Mea - sure (FIM), and health-related quality of life (SF-12) at defined time-points up to 6 months after injury. RESULTS: We recruited 101 participants from a source population of about 2.47 million (ie, about 33% of Swiss population). The incidence of severe TBI was 8.2 per 100,000 person-years. The overall case fatality was 70%: 41 of 101 persons (41%) died at the scene of the accident. 23 of 60 hospitalised participants (38%) died within 48 hours, and 31 (53%) within 6 months. In all hospitalised patients, the median GOSE was 1 (range 1-8) after 6 months, and was 6 (2-8) in 6-month survivors. The median total FIM score was 125 (range 18-126); median-SF-12 component mea - sures were 44 (25-55) for the physical scale and 52 (32-65) for the mental scale. CONCLUSIONS: Severe TBI was associated with high case fatality and considerable morbidity in survivors. We demonstrated the feasibility of a multicentre cohort study in Switzerland with the aim of identifying modifiable determinants of outcome and improving current trauma care.

The role of basalt replenishment in the generation of basaltic andesites of the ongoing activity at Arenal volcano, Costa Rica: evidence from clinopyroxene and spinel

The bulk composition of magma erupted from Volcan Arenal has remained nearly constant (SiO2 = 53.6-54.9 wt%; MgO = 5.0-4.5 wt%) during almost 30 years of continuous activity (1969-1996). None the less, clinopyroxene (cpx) phenocrysts and their spinel inclusions record a much more complex open-system evolution in which steady-state production of the erupted basaltic andesitic magma is linked to episodic injections of basalt into Arenal's magma conduit/reservoir system. High-resolution major element zoning profiles (electron microprobe) on a large number of phenocrysts (>14,000 analyses), tied to back-scattered electron (BSE) images, have been used to assess the compositional characteristics of the magmatic end members as well as the timing and dynamics of magma replenishment events. No two cpx phenocrysts have exactly the same zoning profile. The vast majority of our analyses record the crystallization of cpx (Cr2O3 < 0.12 wt%; Mg# = 65-79; Al/Ti = 2-7) from a liquid comparable to or more evolved than erupted magma compositions. However, half of all cpx grains are cored by high-Cr cpx (Cr2O3 = 0.2-0.72 wt%) or contain similar basaltic compositions as abrupt growth bands in phenocrysts with and without high-Cr cores; phenocrysts with high-Cr cpx occur throughout the ongoing activity. In a few cases, high-Cr cpx occurs very near the outer margin of the grain without an apparent growth hiatus, particularly in 1968/69 and 1992/93. The main conclusions are: (1) all basaltic andesitic lavas erupted at Arenal during the ongoing activity that began in July, 1968, are the products of magma mixing, (2) clinopyroxenes record multiple replenishment events of basaltic magma in contrast to the near constancy of erupted bulk compositions, (3) some phenocrysts preserve records of multiple interactions with basaltic magmas requiring magmatic processes to operate on time-scales shorter than residence times of some phenocrysts, (4) multiple occurrences of clinopyroxene with high-Cr rims suggest that basalt replenishment events have occurred with sub-decadal frequency and may predate eruption by months or less. From this we infer that Arenal volcano is underlain by a continuously active, small-volume magmatic reservoir maintained in quasi-steady state by basalt recharge over several decades. The monotony of erupting Arenal magmas implies that fractionation, recharge, ascent, and eruption are well balanced in order for magmas to be essentially uniform while containing phenocrysts with vastly different growth histories at the time of eruption.

Major depressive disorders in the general hospital: how to implement guidelines.

OBJECTIVE: An implementation study that evaluated the impact of previously adopted guidelines on the clinical practice of medical residents was conducted to improve the recognition and treatment of major depressive disorders (MDDs) in hospitalized patients with somatic diseases. METHODS: Guidelines were implemented in two wards (ENT and oncology) using intranet diffusion, interactive sessions with medical residents, and support material. Discharge letters of 337 and 325 patients, before and after the intervention, respectively, were checked for statement of diagnosis or treatment of MDDs and, in a post hoc analysis, for any mention about psychiatric management. RESULTS: No difference was found in the number of diagnosed or treated MDDs before and after the intervention. However, significantly more statements about psychological status (29/309 vs. 13/327) and its management (36/309 vs. 19/327) were observed after the intervention (P<.01). CONCLUSION: The intervention was not successful in improving the management of MDDs. However, a possible effect on general psychological aspects of medical diseases was observed.

Collaboration entre cliniciens et chercheurs autour de la «consultation systémique» : une situation de violence intrafamiliale

Cet article vise à illustrer la collaboration et l'enrichissement mutuel qu'apportent aux chercheurs et aux cliniciens l'utilisation de la «consultation systémique». Cette dernière, demandée soit spontanément par les parents, soit par le(s) thérapeute(s) qui suive(nt) la famille, a pour but l'évaluation des interactions familiales. Lors d'une première rencontre, les questions qui motivent les parents et/ou thérapeute(s) à consulter sont formulées et la famille est invitée à faire des jeux familiaux semi-standardisés qui sont filmés. Lors d'une deuxième rencontre réunissant les mêmes personnes, un visionnement d'extraits des films sert de base à une discussion ainsi qu'à l'élaboration de réponses aux questions posées, en partant des observations des chercheurs. Après une description de la consultation systémique standard (principes, objectifs, procédure et situations d'observation), une vignette clinique atypique, concernant des violences intrafamiliales, illustrera la variété et la richesse de ces consultations. Les observations micro et macro-analytiques des interactions données par les chercheurs, auxquelles s'ajoute la compréhension clinique des thérapeutes, montrent qu'une collaboration entre eux est fructueuse pour toutes les parties concernées.

Early diabetes and abnormal postnatal pancreatic islet development in mice lacking Glut-2.

Glut-2 is a low-affinity transporter present in the plasma membrane of pancreatic beta-cells, hepatocytes and intestine and kidney absorptive epithelial cells of mice. In beta-cells, Glut-2 has been proposed to be active in the control of glucose-stimulated insulin secretion (GSIS; ref. 2), and its expression is strongly reduced in glucose-unresponsive islets from different animal models of diabetes. However, recent investigations have yielded conflicting data on the possible role of Glut-2 in GSIS. Whereas some reports have supported a specific role for Glut-2 (refs 5,6), others have suggested that GSIS could proceed normally even in the presence of low or almost undetectable levels of this transporter. Here we show that homozygous, but not heterozygous, mice deficient in Glut-2 are hyperglycaemic and relatively hypo-insulinaemic and have elevated plasma levels of glucagon, free fatty acids and beta-hydroxybutyrate. In vivo, their glucose tolerance is abnormal. In vitro, beta-cells display loss of control of insulin gene expression by glucose and impaired GSIS with a loss of first phase but preserved second phase of secretion, while the secretory response to non-glucidic nutrients or to D-glyceraldehyde is normal. This is accompanied by alterations in the postnatal development of pancreatic islets, evidenced by an inversion of the alpha- to beta-cell ratio. Glut-2 is thus required to maintain normal glucose homeostasis and normal function and development of the endocrine pancreas. Its absence leads to symptoms characteristic of non-insulin-dependent diabetes mellitus.