Appropriateness criteria for surgery improve clinical outcomes in patients with low back pain and/or sciatica.

STUDY DESIGN: Prospective, controlled, observational outcome study using clinical, radiographic, and patient/physician-based questionnaire data, with patient outcomes at 12 months follow-up. OBJECTIVE: To validate appropriateness criteria for low back surgery. SUMMARY OF BACKGROUND DATA: Most surgical treatment failures are attributed to poor patient selection, but no widely accepted consensus exists on detailed indications for appropriate surgery. METHODS: Appropriateness criteria for low back surgery have been developed by a multispecialty panel using the RAND appropriateness method. Based on panel criteria, a prospective study compared outcomes of patients appropriately and inappropriately treated at a single institution with 12 months follow-up assessment. Included were patients with low back pain and/or sciatica referred to the neurosurgical department. Information about symptoms, neurologic signs, the health-related quality of life (SF-36), disability status (Roland-Morris), and pain intensity (VAS) was assessed at baseline, at 6 months, and at 12 months follow-up. The appropriateness criteria were administered prospectively to each clinical situation and outside of the clinical setting, with the surgeon and patients blinded to the results of the panel decision. The patients were further stratified into 2 groups: appropriate treatment group (ATG) and inappropriate treatment group (ITG). RESULTS: Overall, 398 patients completed all forms at 12 months. Treatment was considered appropriate for 365 participants and inappropriate for 33 participants. The mean improvement in the SF-36 physical component score at 12 months was significantly higher in the ATG (mean: 12.3 points) than in the ITG (mean: 6.8 points) (P = 0.01), as well as the mean improvement in the SF-36 mental component score (ATG mean: 5.0 points; ITG mean: -0.5 points) (P = 0.02). Improvement was also significantly higher in the ATG for the mean VAS back pain (ATG mean: 2.3 points; ITG mean: 0.8 points; P = 0.02) and Roland-Morris disability score (ATG mean: 7.7 points; ITG mean: 4.2 points; P = 0.004). The ATG also had a higher improvement in mean VAS for sciatica (4.0 points) than the ITG (2.8 points), but the difference was not significant (P = 0.08). The SF-36 General Health score declined in both groups after 12 months, however, the decline was worse in the ITG (mean decline: 8.2 points) than in the ATG (mean decline: 1.2 points) (P = 0.04). Overall, in comparison to ITG patients, ATG patients had significantly higher improvement at 12 months, both statistically and clinically. CONCLUSION: In comparison to previously reported literature, our study is the first to assess the utility of appropriateness criteria for low back surgery at 1-year follow-up with multiple outcome dimensions. Our results confirm the hypothesis that application of appropriateness criteria can significantly improve patient outcomes.

Sonication of removed breast implants for improved detection of subclinical infection.

BACKGROUND: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. METHODS: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. RESULTS: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49 years (range, 31-76 years). The mean implant indwelling time was 10.4 years (range, 3 months to 30 years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n = 12), submuscularly (n = 6), and subcutaneously (n = 4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). CONCLUSIONS: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosis.

Spatial modelling of biodiversity at the community level

1. Statistical modelling is often used to relate sparse biological survey data to remotely derived environmental predictors, thereby providing a basis for predictively mapping biodiversity across an entire region of interest. The most popular strategy for such modelling has been to model distributions of individual species one at a time. Spatial modelling of biodiversity at the community level may, however, confer significant benefits for applications involving very large numbers of species, particularly if many of these species are recorded infrequently. 2. Community-level modelling combines data from multiple species and produces information on spatial pattern in the distribution of biodiversity at a collective community level instead of, or in addition to, the level of individual species. Spatial outputs from community-level modelling include predictive mapping of community types (groups of locations with similar species composition), species groups (groups of species with similar distributions), axes or gradients of compositional variation, levels of compositional dissimilarity between pairs of locations, and various macro-ecological properties (e.g. species richness). 3. Three broad modelling strategies can be used to generate these outputs: (i) 'assemble first, predict later', in which biological survey data are first classified, ordinated or aggregated to produce community-level entities or attributes that are then modelled in relation to environmental predictors; (ii) 'predict first, assemble later', in which individual species are modelled one at a time as a function of environmental variables, to produce a stack of species distribution maps that is then subjected to classification, ordination or aggregation; and (iii) 'assemble and predict together', in which all species are modelled simultaneously, within a single integrated modelling process. These strategies each have particular strengths and weaknesses, depending on the intended purpose of modelling and the type, quality and quantity of data involved. 4. Synthesis and applications. The potential benefits of modelling large multispecies data sets using community-level, as opposed to species-level, approaches include faster processing, increased power to detect shared patterns of environmental response across rarely recorded species, and enhanced capacity to synthesize complex data into a form more readily interpretable by scientists and decision-makers. Community-level modelling therefore deserves to be considered more often, and more widely, as a potential alternative or supplement to modelling individual species.

Quelle assistance psychologique pour les couples requérant une aide médicale à la procréation [Which psychological support for couples seeking medical assistance for procreation?]

OBJECTIVES: The objective of our qualitative study was to define modalities of psychological support to be offered to couples seeking medically assisted procreation. MATERIAL AND METHODS: Forty couples participated in a semi-structured videotaped interview, which touched on themes such as personal and family histories, the couple's relationship, etc. We focused on the "narrative mobility", that is the way in which the couples transmit their personal and family history during the interview and the interviewer's impression that he may or may not share this with the couples. RESULTS: Observed differences in narrative mobility led us to distinguish three groups of couples and to propose various types of psychological support. DISCUSSION AND CONCLUSION: This exploratory study, with its interest for the narrative mobility, concerns the couples' capacity to stand back from their own story as responsible interlocutors. We made the hypothesis that this capacity is linked to their capacity to handle their emotional stress, to act as partners to the medical team and to prepare themselves for their future parenthood.

Characterization of pip5k3 fleck corneal dystrophy-linked gene in zebrafish.

PIKfyve is a kinase encoded by pip5k3 involved in phosphatidylinositols (PdtIns) pathways. These lipids building cell membranes have structural functions and are involved in complex intracellular regulations. Mutations in human PIP5K3 are associated with François-Neetens mouchetée fleck corneal dystrophy [Li, S., Tiab, L., Jiao, X., Munier, F.L., Zografos, L., Frueh, B.E., Sergeev, Y., Smith, J., Rubin, B., Meallet, M.A., Forster, R.K., Hejtmancik, J.F., Schorderet, D.F., 2005. Mutations in PIP5K3 are associated with François-Neetens mouchetee fleck corneal dystrophy. Am. J. Hum. Genet. 77, 54-63]. We cloned the zebrafish pip5k3 and report its molecular characterization and expression pattern in adult fish as well as during development. The zebrafish PIKfyve was 70% similar to the human homologue. The gene encompassed 42 exons and presented four alternatively spliced variants. It had a widespread expression in the adult organs and was localized in specific cell types in the eye as the cornea, lens, ganglion cell layer, inner nuclear layer and outer limiting membrane. Pip5k3 transcripts were detected in early cleavage stage embryos. Then it was uniformly expressed at 10 somites, 18 somites and 24 hpf. Its expression was then restricted to the head region at 48 hpf, 72 hpf and 5 dpf and partial expression was found in somites at 72 hpf and 5 dpf. In situ on eye sections at 3 dpf showed a staining mainly in lens, outer limiting membrane, inner nuclear layer and ganglion cell layer. A similar expression pattern was found in the eye at 5 dpf. A temporal regulation of the spliced variants was observed at 1, 3 and 5 dpf and they were also found in the adult eye.

Apocrypha Hiberniae. I. Evangelia infantiae

In 1927 M. R. James published Latin Infancy Gospels, identified by him in two related but not identical manuscripts (one the British Library Arundel 404; the other from Hereford), together with a parallel text from the Irish manuscript known as the Leabhar Breac. Later researches brought to light more manuscripts of this Latin work, and also of the Irish text. James recognized that his apocryphal Latin Infancy text was compiled from a combination of the Protevangelium of James and a hitherto unknown text which he named "The Source". Recent research has identified a full Latin translation of the Protevangelium of James. A hitherto unrecognized Irish Infancy Narrative has also been identified in the Dublin manuscript known as the Liber Flavus Fergusiorum. A deep study of this related tradition was called for. This has been carried out over the past ten years by an Irish team in conjunction with Professor Daniel Kaestli and AELAC. The fruits of this labour are published in these two volumes. Volume 13 has a general introduction with a historical sketch of New Testament apocrypha in Ireland and a history of research on the subject. This is followed by a comparison of the Infancy Narratives in the Leabhar Breac and the Liber Flavus Fergusiorum. There are special introductions to these Infancy texts, followed by critical editions of the Irish texts, accompanied by English translations and rich annotation. Next there is similar treatment of the Irish versified Narrative (from ca. 700) of the Childhood Deeds of Jesus (commonly known as the Infancy Narrative (or Gospel) of Thomas. There is then (in volume 14, but with continuous pagination) the edition and translation of an Irish thirteenth-century poem with elements from Infancy Narratives, and both Latin and Irish texts on the wonders at Christ's birth, accompanied by translations and notes. The edition of the Irish material is followed by a critical edition of the full Arundel and Hereford forms of the Infancy Narrative (here referred to as the "J Compilation"), together with a detailed study of all the questions relating to this work. The volume concludes with a critical edition (by Rita Beyers) of the Latin text of the Protevangelium of James, accompanied by a detailed study of the work.. The work contains a detailed study of the Latin translations of the Protevangelium of James and the transmission of this work in the West. The "J Compilation" (a combination of the Protevangelium and texts of Pseudo-Matthew) can be traced back in manuscript transmission to ca. 800,and must have originated some time earlier. Behind it stands an earlier "I ("I" for Irish) Compilation" without influence from Pseudo-Matthew, the form found in the Irish witnesses. It is argued that M. R. James's "Source" may be of Judaeo-Christian origin and may really be the Gospel of the Nazoreans. Among the indexes there is a list of all the Irish words found in the texts. This edition of the Irish and related Latin texts is a major contribution to the study of the apocryphal Infancy Narratives. It should also be of particular interest to Celtic scholars, to students of Irish ecclesiastical learning, and in general to all medievalists.

Individual versus standard quality of life assessment in a phase II clinical trial in mesothelioma patients: feasibility and responsiveness to clinical changes.

BACKGROUND: In patients with malignant pleural mesothelioma undergoing a multimodality therapy, treatment toxicity may outweigh the benefit of progression-free survival. The subjective experience across different treatment phases is an important clinical outcome. This study compares a standard with an individual quality of life (QoL) measure used in a multi-center phase II trial. PATIENTS AND METHODS: Sixty-one patients with stage I-III technically operable pleural mesothelioma were treated with preoperative chemotherapy, followed by pleuropneumonectomy and subsequent radiotherapy. QoL was assessed at baseline, at day 1 of cycle 3, and 1, 3 and 6 months post-surgery by using the Rotterdam Symptom Checklist (RSCL) and the Schedule for the Evaluation of Quality of Life-Direct Weighting (SEIQoL-DW), a measure that is based on five individually nominated and weighted QoL-domains. RESULTS: Completion rates were 98% (RSCL) and 92% (SEIQoL) at baseline and 98%/89% at cycle 3, respectively. Of the operated patients (N=45) RSCL and SEIQoL were available from 86%/72%, 93%/74%, and 94%/76% at months 1, 3, and 6 post-surgery. Average assessment time for the SEIQoL was 24min compared to 8min needed for the RSCL. Median changes from baseline indicate that both RSCL QoL overall score and SEIQoL index remained stable during chemotherapy with a clinically significant deterioration (change>or=8 points) 1 month after surgery (median change of -66 and -14 for RSCL and SEIQoL, respectively). RSCL QoL overall scores improved thereafter, but remained beneath baseline level until 6 months after surgery. SEIQoL scores improved to baseline-level at month 3 after surgery, but worsened again at month 6. RSCL QoL overall score and SEIQoL index were moderately correlated at baseline (r=.30; p<or=.05) and at 6-month follow-up (r=.42; p<or=.05) but not at the other time points. CONCLUSION: The SEIQoL assessment seems to be feasible within a phase II clinical trial, but may require more effort from staff. More distinctive QoL changes in accordance with clinical changes were measured with the RSCL. Our findings suggest that the two measures are not interchangeable: the RSCL is to favor when mainly information related to the course of disease- and treatment is of interest.

The Irish Infancy Narratives and their Relationship with Latin Sources

(Résumé de l'ouvrage) In 1927 M. R. James published Latin Infancy Gospels, identified by him in two related but not identical manuscripts (one the British Library Arundel 404; the other from Hereford), together with a parallel text from the Irish manuscript known as the Leabhar Breac. Later researches brought to light more manuscripts of this Latin work, and also of the Irish text. James recognized that his apocryphal Latin Infancy text was compiled from a combination of the Protevangelium of James and a hitherto unknown text which he named "The Source". Recent research has identified a full Latin translation of the Protevangelium of James. A hitherto unrecognized Irish Infancy Narrative has also been identified in the Dublin manuscript known as the Liber Flavus Fergusiorum. A deep study of this related tradition was called for. This has been carried out over the past ten years by an Irish team in conjunction with Professor Daniel Kaestli and AELAC. The fruits of this labour are published in these two volumes. Volume 13 has a general introduction with a historical sketch of New Testament apocrypha in Ireland and a history of research on the subject. This is followed by a comparison of the Infancy Narratives in the Leabhar Breac and the Liber Flavus Fergusiorum. There are special introductions to these Infancy texts, followed by critical editions of the Irish texts, accompanied by English translations and rich annotation. Next there is similar treatment of the Irish versified Narrative (from ca. 700) of the Childhood Deeds of Jesus (commonly known as the Infancy Narrative (or Gospel) of Thomas. There is then (in volume 14, but with continuous pagination) the edition and translation of an Irish thirteenth-century poem with elements from Infancy Narratives, and both Latin and Irish texts on the wonders at Christ's birth, accompanied by translations and notes. The edition of the Irish material is followed by a critical edition of the full Arundel and Hereford forms of the Infancy Narrative (here referred to as the "J Compilation"), together with a detailed study of all the questions relating to this work. The volume concludes with a critical edition (by Rita Beyers) of the Latin text of the Protevangelium of James, accompanied by a detailed study of the work.. The work contains a detailed study of the Latin translations of the Protevangelium of James and the transmission of this work in the West. The "J Compilation" (a combination of the Protevangelium and texts of Pseudo-Matthew) can be traced back in manuscript transmission to ca. 800,and must have originated some time earlier. Behind it stands an earlier "I ("I" for Irish) Compilation" without influence from Pseudo-Matthew, the form found in the Irish witnesses. It is argued that M. R. James's "Source" may be of Judaeo-Christian origin and may really be the Gospel of the Nazoreans. Among the indexes there is a list of all the Irish words found in the texts. This edition of the Irish and related Latin texts is a major contribution to the study of the apocryphal Infancy Narratives. It should also be of particular interest to Celtic scholars, to students of Irish ecclesiastical learning, and in general to all medievalists.

Latin Infancy Gospels: The J Compilation. Introduction and Edition

(Résumé de l'ouvrage) In 1927 M. R. James published Latin Infancy Gospels, identified by him in two related but not identical manuscripts (one the British Library Arundel 404; the other from Hereford), together with a parallel text from the Irish manuscript known as the Leabhar Breac. Later researches brought to light more manuscripts of this Latin work, and also of the Irish text. James recognized that his apocryphal Latin Infancy text was compiled from a combination of the Protevangelium of James and a hitherto unknown text which he named "The Source". Recent research has identified a full Latin translation of the Protevangelium of James. A hitherto unrecognized Irish Infancy Narrative has also been identified in the Dublin manuscript known as the Liber Flavus Fergusiorum. A deep study of this related tradition was called for. This has been carried out over the past ten years by an Irish team in conjunction with Professor Daniel Kaestli and AELAC. The fruits of this labour are published in these two volumes. Volume 13 has a general introduction with a historical sketch of New Testament apocrypha in Ireland and a history of research on the subject. This is followed by a comparison of the Infancy Narratives in the Leabhar Breac and the Liber Flavus Fergusiorum. There are special introductions to these Infancy texts, followed by critical editions of the Irish texts, accompanied by English translations and rich annotation. Next there is similar treatment of the Irish versified Narrative (from ca. 700) of the Childhood Deeds of Jesus (commonly known as the Infancy Narrative (or Gospel) of Thomas. There is then (in volume 14, but with continuous pagination) the edition and translation of an Irish thirteenth-century poem with elements from Infancy Narratives, and both Latin and Irish texts on the wonders at Christ's birth, accompanied by translations and notes. The edition of the Irish material is followed by a critical edition of the full Arundel and Hereford forms of the Infancy Narrative (here referred to as the "J Compilation"), together with a detailed study of all the questions relating to this work. The volume concludes with a critical edition (by Rita Beyers) of the Latin text of the Protevangelium of James, accompanied by a detailed study of the work.. The work contains a detailed study of the Latin translations of the Protevangelium of James and the transmission of this work in the West. The "J Compilation" (a combination of the Protevangelium and texts of Pseudo-Matthew) can be traced back in manuscript transmission to ca. 800,and must have originated some time earlier. Behind it stands an earlier "I ("I" for Irish) Compilation" without influence from Pseudo-Matthew, the form found in the Irish witnesses. It is argued that M. R. James's "Source" may be of Judaeo-Christian origin and may really be the Gospel of the Nazoreans. Among the indexes there is a list of all the Irish words found in the texts. This edition of the Irish and related Latin texts is a major contribution to the study of the apocryphal Infancy Narratives. It should also be of particular interest to Celtic scholars, to students of Irish ecclesiastical learning, and in general to all medievalists.

Cerebellar transcranial direct current stimulation modulates verbal working memory.

BACKGROUND: Neuroimaging studies show cerebellar activations in a wide range of cognitive tasks and patients with cerebellar lesions often present cognitive deficits suggesting a cerebellar role in higher-order cognition. OBJECTIVE: We used cathodal transcranial direct current stimulation (tDCS), known to inhibit neuronal excitability, over the cerebellum to investigate if cathodal tDCS impairs verbal working memory, an important higher-order cognitive faculty. METHOD: We tested verbal working memory as measured by forward and backward digit spans in 40 healthy young participants before and after applying cathodal tDCS (2 mA, stimulation duration 25 min) to the right cerebellum using a randomized, sham-controlled, double-blind, cross-over design. In addition, we tested the effect of cerebellar tDCS on word reading, finger tapping and a visually cued sensorimotor task. RESULTS: In line with lower digit spans in patients with cerebellar lesions, cerebellar tDCS reduced forward digit spans and blocked the practice dependent increase in backward digit spans. No effects of tDCS on word reading, finger tapping or the visually cued sensorimotor task were found. CONCLUSION: Our results support the view that the cerebellum contributes to verbal working memory as measured by forward and backward digit spans. Moreover, the induction of reversible "virtual cerebellar lesions" in healthy individuals by means of tDCS may improve our understanding of the mechanistic basis of verbal working memory deficits in patients with cerebellar lesions.

Basal and antigen-induced exposure of the proline-rich sequence in CD3ε.

The CD3ε cytoplasmic tail contains a conserved proline-rich sequence (PRS) that influences TCR-CD3 expression and signaling. Although the PRS can bind the SH3.1 domain of the cytosolic adapter Nck, whether the PRS is constitutively available for Nck binding or instead represents a cryptic motif that is exposed via conformational change upon TCR-CD3 engagement (CD3Δc) is currently unresolved. Furthermore, the extent to which a cis-acting CD3ε basic amino acid-rich stretch (BRS), with its unique phosphoinositide-binding capability, might impact PRS accessibility is not clear. In this study, we found that freshly harvested primary thymocytes expressed low to moderate basal levels of Nck-accessible PRS ("open-CD3"), although most TCR-CD3 complexes were inaccessible to Nck ("closed-CD3"). Ag presentation in vivo induced open-CD3, accounting for half of the basal level found in thymocytes from MHC(+) mice. Additional stimulation with either anti-CD3 Abs or peptide-MHC ligands further elevated open-CD3 above basal levels, consistent with a model wherein antigenic engagement induces maximum PRS exposure. We also found that the open-CD3 conformation induced by APCs outlasted the time of ligand occupancy, marking receptors that had been engaged. Finally, CD3ε BRS-phosphoinositide interactions played no role in either adoption of the initial closed-CD3 conformation or induction of open-CD3 by Ab stimulation. Thus, a basal level of open-CD3 is succeeded by a higher, induced level upon TCR-CD3 engagement, involving CD3Δc and prolonged accessibility of the CD3ε PRS to Nck.

La visite médicale en pratique hospitalière: entre soins et apprentissage [Conducting ward rounds: a balance between care and teaching].

Every day, hospital doctors spend time at conducting ward rounds. Rounds are a core clinical activity during which doctors interact with patients, synthetise a whole set of informations and make many decisions. In addition, rounds can become a crucial teaching moment, when a trainee gets supervised by an attending physician. However, litterature on the topic of rounds is scarce. This paper summarizes the results of the few key studies focusing on ward rounds. The results are presented in four sections, each one being dedicated to one of the round stakeholders: the trainee or resident, the trainer, the patient and the nurse. An emphasis is put on ward rounds involving both a trainee and a trainer, since such rounds always mean striking a balance between care and teaching.

Closure of large intrathoracic airway defects using extrathoracic muscle flaps.

BACKGROUND: Prospective assessment of pedicled extrathoracic muscle flaps for the closure of large intrathoracic airway defects after noncircumferential resection in situations where an end-to-end reconstruction seemed risky (defects of > 4-cm length, desmoplastic reactions after previous infection or radiochemotherapy). METHODS: From 1996 to 2001, 13 intrathoracic muscle transpositions (6 latissimus dorsi and 7 serratus anterior muscle flaps) were performed to close defects of the intrathoracic airways after noncircumferential resection for tumor (n = 5), large tracheoesophageal fistula (n = 2), delayed tracheal injury (n = 1) and bronchopleural fistula (n = 5). In 2 patients, the extent of the tracheal defect required reinforcement of the reconstruction by use of a rib segment embedded into the muscle flap followed by temporary tracheal stenting. Patient follow-up was by clinical examination bronchoscopy and biopsy, pulmonary function tests, and dynamic virtual bronchoscopy by computed tomographic (CT) scan during inspiration and expiration. RESULTS: The airway defects ranged from 2 x 1 cm to 8 x 4 cm and involved up to 50% of the airway circumference. They were all successfully closed using muscle flaps with no mortality and all patients were extubated within 24 hours. Bronchoscopy revealed epithelialization of the reconstructions without dehiscence, stenosis, or recurrence of fistulas. The flow-volume loop was preserved in all patients and dynamic virtual bronchoscopy revealed no significant difference in the endoluminal cross surface areas of the airway between inspiration and expiration above (45 +/- 21 mm(2)), at the site (76 +/- 23 mm(2)) and below the reconstruction (65 +/- 40 mm(2)). CONCLUSIONS: Intrathoracic airway defects of up to 50% of the circumference may be repaired using extrathoracic muscle flaps when an end-to-end reconstruction is not feasible.