Therapeutic Abstention Research Articles

Treatment of humerus diaphyseal fractures using Hackethal's retrograde centro-medullary bundle nailing: about 54 cases

Les auteurs rapportent 54 cas de fracture de la diaphyse humérale traités par embrochage de Hackethal. 3 cas avec paralysie du nerf radial ont été observé dont l'abstention thérapeutique en urgence a été l'attitude avec surveillance et qui ont abouti à une récupération. La technique de l'embrochage est relativement facile mais nécessite une technique rigoureuse et une bonne expérience de l'opérateur. Un taux de 7,84 % de pseudarthrose était observé. L'embrochage d'Hackethal peut être considérer comme un traitement orthopédique amélioré avec un coût modeste et une innocuité importante.

Legg-Calvé-Perthes disease.

Current knowledge of the causes and risk factors of Legg-Calvé-Perthesdisease (LCPD) does not allow effective preventive strategies. The outcome in adulthood is usually good. Hip osteoarthritis rarely develops before 50 years of age. The risk of osteoarthrosis depends chiefly on the final degree of joint incongruence. Age at onset and the lateral pillar classification are the two main outcome predictors and serve to guide the surgical indications based on the studies by Herring's group. Non-operative treatment is not effective. In contrast, femoral varus osteotomy and Salter's innominate osteotomy provide good outcomes. In severe forms, however, combining these two techniques or performing a triple pelvic osteotomy seem preferable. Surgery is now performed considerably less often than in the past, as it is effective only in patients with lateral pillar group B or B/C disease with onset after eight years of age. In other situations, therapeutic abstention is recommended.

Lipœdème du cuir chevelu

Lipedematous scalp, with or without alopecia, is a poorly known and rarely reported entity. It was first described in 1935 by Cornbleet. It involves increased thickness of the subcutaneous tissue of the scalp, responsible for an overall thickening of the scalp, which may be associated with alopecia, pruritus or painful sensations. Currently, fewer than 50 cases of lipedematous scalp, both with and without alopecia, have been reported in the literature. Herein we present the case of a 36-year-old woman from the Ivory Coast, who presented scalp pain associated with infiltration of the entire subcutaneous tissue of the scalp seen clinically and confirmed at MRI. Histology added nothing. We diagnosed a new case of lipedematous scalp in an African woman. No cause was found. Therapeutic abstention appears the best management strategy.

Relapsing polychondritis: What's new in 2017?

Relapsing polychondritis (RP) is a rare condition characterized by recurrent inflammation of cartilaginous tissue and systemic manifestations. Data on pathophysiology are scarce and suggest an autoimmune mechanism. Recently, the possibility of dividing patients with RP into three distinct clinical phenotypes has been suggested: the hematological form representing less than 10% of patients, essentially older men with associated myelodysplasia and poor prognosis, the respiratory form representing about 25% of patients with predominant tracheobronchial involvement, and the mild and most frequent form, representing 65% of patients, with a good prognosis. Recent data on survival shows an improvement of overall prognosis compared to historical series. Reported poor prognosis factors are male gender, associated haemopathies and cardiac involvement. Few recent series suggest an interest for positron emission tomography for the diagnosis and the follow-up of treatment. Due to the lack of randomized therapeutic trial, treatment remains empirical and is mainly based on oral corticosteroids sometimes associated with immunosuppressive agents. The use of biologic agents has recently been reported in small retrospective series with different outcome. Finally, some selected patients with mild and occasional peripheral chondritis might justify a treatment with colchicine or a therapeutic abstention with occasional short-term corticosteroids therapy.

Embolisation of pulmonary radio frequency pathway – a randomised trial

Purpose: Pneumothorax is the most common complication following a pulmonary percutaneous radiofrequency ablation (RFA), and thoracic drainages are the most frequent causes of an extended hospital stay. Our main objective was to show that the use of gelatin torpedoes may significantly decrease the number of chest tube placement.Materials and methods: Seventy-three patients were prospectively included in this study and then randomised into two groups: 34 with embolisation and without 39 without embolisation. Each group was comparable for different pneumothorax risk factors.Results: There were 16 (47%) pneumothorax in Group A (“with embolisation”), which was significantly lower (p < .0001) than the 35 pneumothorax (90%) in Group B (“without embolisation”). The pneumothorax volume (p = .02) was significantly lower in Group A (22.7% average, standard deviation 15.6%) than in Group B (average 34.1%, standard deviation 17.1%). The number of drainages was significantly smaller in those with embolisation (3 drainages or 8%) than those without embolisation (25 drainages or 64%) (p < .001).Conclusion: When using absorbable gelatin torpedoes, pulmonary RFA pathways embolisation significantly decreased the number of pneumothorax and thoracic drainages to the advantage of therapeutic abstention and exsufflation, non-invasive and functional operational techniques.

Unusual Keloid Formation at the Mammostat Location Following Breast Reduction

We report the case of a patient who developed keloid scarring associated with Mammostat-induced skin trauma during reduction mammoplasty. A 32-year-old patient consulted for breast hypertrophy and developed from the fourth postoperative month significant keloid scars on skin shears caused by dermal stretching techniques used during de-epithelialization. The Mammostat-related scars were keloid, while those found on old skin incisions were only enlarged and slightly hypertrophic. We followed up this patient for 7 years. During this time, she received the following local treatments: scar kneading, silicone dressings, intralesional injections of corticosteroids, and potent dermocorticosteroids. After balancing the benefit/risk ratio of a possible revision surgery for resection and plasty of her keloid scars, we opted for therapeutic abstention. In patients at high risk of keloids, we recommend a soft de-epithelialization causing no skin shear, performed by manual tensioning of the dermis.

Abstention or intervention for isolated hypotension in the first 3 days of life in extremely preterm infants: association with short-term outcomes in the EPIPAGE 2 cohort study

ObjectiveTo compare outcomes at hospital discharge for preterm infants born before 29 weeks of gestation who had at least one episode of isolated hypotension during their first 72 hours of...

Pancreas Cancer: Epidemiological, Clinical, Morphological Aspects, and Therapeutic Modalities: Result of a Moroccan University Centre

Introduction: Cancer of the pancreas is one of the most aggressive solid tumors often discovered at a locally advanced or metastatic. Adenocarcinoma is the most common histological type. The aim of our study was to analyze the profile of pancreatic cancer by the various imaging techniques. Materials and methods: Descriptive retrospective study over a period of 7 years including all patients who were followed for pancreatic cancer. The epidemiological data, clinical, morphological and treatment were collected, all the patients were hospitalized. The therapeutic decision was taken after a multidisciplinary meeting between the different specialists in the Department of Gastroenterology and liver diseases, medicine C, ibn sina hospital, Rabat, Morocco. Results: Over a period of 7 years, 67 patients were collected. These 37 men and 30 women with a sex ratio of 1.23. The average age was 60 years (26-93 ans). 37% of patient’s had a history of diabetes. Clinically 43% of patients had cholestatic jaundice, 28% had abdominal pain. Clinical examination revealed an abdominal mass in 23% of cases. Abdominal ultrasound showed dilatation of the biliary tract in 67% of cases, the abdominal scanner allowed the diagnosis of pancreatic cancer in 88% of cases. The tumor site was cephalic in 67% of cases, corporeal in 7% of cases and caudal in 25% of cases. Magnetic resonance imaging (MRI) was reported in 11% of patients for suspected intra-ductal papillary mucinous neoplasms (IPMNs) or as a complement to the diagnosis. Echoendoscopy was performed in 11% of the patients as part of the locoregional extension. The average size of the tumor was 48 mm. CA19-9 was only dosed in 26 patients. It was positively positive in 65% of patients and normal in 35% of patients. Histologically, 83% had adenocarcinoma, 3% had lymphoma, 3% had neuroendocrine tumors, and 5% had degenerated IPMNs. Cancer was resectable in 9 patients (13%). The main operative contraindications were vascular and lymph node invasion in 6 patients (8%) and pulmonary or peritoneal liver metastases in 53 patients (80%). For patients with non-resectable cancer, palliative treatment was indicated either by surgical biliary drainage in 4% patients or by endoscopic insertion of biliary prosthesis in 14% of cases or by external biliary drainage in 4% of cases. Chemotherapy was indicated in 78% of patients. Therapeutic abstention was indicated in 10 patients. Conclusion: In our study 82% of pancreatic cancers were diagnosed in the metastatic stage and 10% in locally advanced stage. The only curative treatment currently exists is surgery that has been achieved only in 8% of our patients.

Dysplasie osseuse floride : gestion d’un cas symptomatique

Florid osseous dysplasia is a rare and benign fibro-osseous pathology, in which bone is replaced by fibrous tissue and metaplastic bone. It can remain asymptomatic for a long time and is most often discovered incidentally during a radiological examination. Sometimes, patients are seen because of an infectious complication. An edentulous 62 years-old woman was referred for a painful mandibular swelling preventing insertion of her removable denture. Clinical examination showed a chin swelling, a deformation of mandibular bone tables of approximately four centimeters in diameter, an intra-oral fistula and a suppuration. Radiological examination showed a mixed bone lesion blowing up the buccal and lingual cortical plates and a bone sequestrum. Blood test was normal and there were no other skeletal abnormalities. The diagnosis of florid osseous bone dysplasia was made thanks to the confrontation of the clinical, radiological and histological examinations. Excision of the bone sequestrum associated to remodeling osteoplasty was performed under general anesthesia. The removable denture was rebased to drivehealing. Surgical management of osseous bone dysplasia is legitimate only in the presence of complications not responding to medical treatment. In all other cases, therapeutic abstention and long term supervision are essential.

Histiocytose sinusale de Rosai–Dorfman

Rosai-Dorfman sinusal histiocytosis is a benign histiocytic disorder presenting as large lymphadenopathies, mostly in the cervical area. Visceral involvement is not unusual. The diagnosis is based on histologic findings, showing intrasinusoidal histiocytic infiltration with pathognomonic emperipolesis features. Histiocytes display a normal activated phenotype. It probably represents a heterogeneous group of diseases with some common histopathologic findings. An association with immunologic abnormalities or auto-immune diseases, mostly auto-immunes cytopenias is possible. This is a criterion of poor prognosis. The evolution can sometimes be spontaneously favorable. Nonetheless, there is a risk of compression, due to the huge volume of tumoral masses, especially in case of orbital or epidural involvement. Therapeutic abstention is usually justified. Treatments are discussed in threatening forms, evolving forms or in case of poor prognosis factors. Treatment, when indicated, is not codified. Surgery, corticosteroids, immunosuppressive agents and/or alpha interferon can be used.

Traiter ou ne pas traiter les bactériuries asymptomatiques avant bolus de méthylprednisolone ?

The prescription of methylprednisolone for multiple sclerosis acute relapse involves sterilization of urine. An observational study was conducted to clarify the benefit of antibiotic prophylaxis in case of asymptomatic bacteriuria found before methylprednisolone. Ninety-seven patients were included; 32patients had asymptomatic bacteriuria. Seventeen patients were treated and 15 were not. The number of urinary tract infections in the month following the methylprednisolone was the same in the two groups. The results seem in favor of a therapeutic abstention. A larger study will be performed to confirm these results and determine appropriate recommendations.

Hémangiomes infantiles : quand explorer et actualités thérapeutiques

Infantile haemangioma (IH) is the most frequent benign tumour seen in children. In most cases, diagnosis is made chiefly on clinical grounds, and because the condition tends to subside naturally within several years and without any major sequelae, therapeutic abstention is the rule. However, a number of additional investigations may be necessary: where the clinical picture is atypical or potentially confusing, where the condition may affect adjacent or remote structures, in screening for associated anomalies in certain syndromal forms which practitioners must be able to recognise. Such investigations facilitate therapeutic indications for forms of haemangioma likely to lead to complications. The most important recent therapeutic development has been the discovery of the spectacular efficacy of beta-blockers (propranolol) upon the development kinetics of infantile haemangioma, greatly transforming the prognosis for these haemangiomas at risk.

Management and Outcomes of Nodular Lymphocyte Predominant Hodgkin Lymphoma: A Retrospective Study By the Lymphoma Study Association

IntroductionNodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is a rare entity with distinct clinico-pathological features accounting for 5% of all Hodgkin lymphomas. Its optimal management is still debated, including the place of therapeutic abstention, and the role of rituximab. With the aim to report the management of the disease in a large series of patients (pts), we performed a retrospective study describing the characteristics of NLPHL at diagnosis, the therapeutic strategies, outcomes and the risk of late complications, including secondary malignancies.MethodsWe retrospectively analyzed adult pts with NLPHL treated in the Lymphoma Study Association (LYSA) centers between 1974 and 2012. Survival analysis were made according to the log-rank regression model. We also performed a competing risk analysis in order to better assess the risks of death, progression and secondary malignancies.Results314 pts, out of a total of 366 were retained for further analysis. Median age at diagnosis was 38 years. Most pts (82.5%) presented with localized, Ann Arbor stage I-II disease. Watchful waiting (WW) was the most frequent attitude at diagnosis, and concerned 114 pts (36%), mainly with localized disease (104 pts). 200 pts received a treatment, which comprised chemotherapy +/- rituximab for 68 pts (34% of pts with treatment), radiotherapy for 63 pts (31.5%), combined modality treatment (CMT, chemotherapy +/- rituximab followed by radiotherapy) for 40 pts (20%), and rituximab alone for 28 pts (14%). Among 155 pts with localized disease who received initial treatment, radiotherapy alone was delivered to 62 pts (42 with stage I, 20 with stage II disease), mainly on the cervical, supra-clavicular or axillar areas. The radiotherapy fields included the mediastinum in 7 localized pts treated by CMT. Among 55 pts with disseminated disease receiving initial treatment, chemotherapy +/- rituximab was administered to 32 pts. Most of them received anthracycline-based chemotherapy, and ABVD-derived chemotherapies were the preferred regimens with 19 pts; 8 pts received CHOP-like regimens.With a median follow-up of 55.8 months, 112 pts relapsed or progressed. Among them, 37 pts (33%) received chemotherapy +/- rituximab, 27 pts (24%) radiotherapy alone, 19 pts (17%) rituximab alone, 7 pts (6%) CMT, and 2 pts rituximab + radiotherapy. WW concerned 19 pts (17%) at first relapse/progression.The overall response rate (ORR) for the whole population was 83%, with 200 pts (79%) reaching CR or CRu, 3 months after diagnosis. The CR/CRu rate according to the different treatment modalities were 95% for radiotherapy alone, 89% for rituximab alone, 87% for chemotherapy +/- rituximab and 91% for CMT, respectively. In localized disease, 40 pts had persistent CR/CRu after radiotherapy alone. In disseminated disease, 45 pts who attained CR/CRu after chemotherapy +/- rituximab did not subsequently relapse.The median PFS for the whole population was 112.1 months. There was no impact of Ann Arbor stage on PFS, but the attitude at diagnosis had a powerful impact. Compared to WW, the risk of progression was significantly reduced for pts treated by radiotherapy alone (Hazard ratio: 0.345 [95% CI: 0.196; 0.610], p = 0.0002), chemotherapy +/- rituximab (HR: 0.476 [0.266; 0.855], p = 0.0129), or CMT (HR: 0.292 [0.148; 0.577], p = 0.0004), but not with rituximab alone. The risk reduction remained significant for pts who had complete surgical resection of the initial lesions and received any additional treatment vspts who were just watched after surgery (HR: 0.344 [0.122; 0.974], p = 0.0444).The estimated OS at 72 months is 96.9%. OS was not different according to the attitude at diagnosis, including WW. 10 pts died, 1 due to lymphoma progression, 5 of secondary malignancies and the remaining 4 of accident or unknown causes.The competing risk analysis model confirmed that the risk of relapse/progression was significantly reduced with radiotherapy in stage I-II pts (HR : 0.474 [0.277; 0.812]), and with a treatment combining chemotherapy +/- rituximab +/- radiotherapy in the whole population (HR: 0.388 [0.234; 0.643]).ConclusionOur study supports the use of radiotherapy in localized disease, and of treatments combining chemotherapy +/- rituximab +/- radiotherapy, to improve disease control in adult patients with NLPHL. DisclosuresNo relevant conflicts of interest to declare.

Nævi orbitaires congénitaux : principes de prise en charge thérapeutique à propos de 51 cas

The incidence of congenital nevi is one over 20,000 newborns per year, 14 % of them are located in the head and neck area. Nevi of the orbital region are particularly difficult to handle on the aesthetic and functional side. The objectives of this study were to conduct an analysis of different clinical presentations of congenital nevi of the eyelid orbital region in children to establish a treatment algorithm. We realised a bi-centric retrospective study including 51 children with orbito-palpebral congenital nevi. We analysed the different clinical presentations, their treatments and their results. Nineteen underwent direct suture excision; three a total skin graft; 15 a combination of treatments, among them four underwent tissular expansion and 14 patients were not operated and clinically followed-up. The average follow-up time was 6.6 years. In 33 cases residual nevic area was still present. The postoperative sequelae were: dyschromia (n=17), anatomical deformation of the eye (n=10), nevi outbreaks (n=8), internal canthus deformation (n=5) and ectropion (n=1). The results of our study show that therapeutic abstention is preferred when the aesthetic wrong is accepted by the patient and when there is not a higher risk of malignant degeneration. In order to minimise the risk of postoperative sequelae, we propose a therapeutic algorithm for the management of congenital orbital nevi.

PO-0165 Predictors Of Chronic Primary Immune Thrombocytopenia

Background and aims The primary immune thrombocytopenia (ITP) in children has a favourable evolution in most of cases. Chronic ITP has been noted in 14–30% of the cases. This study reviewed the pattern of presentation and response to therapy in patients with ITP, in order to identify risk factors for chronic disease. Methods We conducted a retrospective study of all cases of ITP in paediatrics and haematological departments of Hedi Chaker University Hospital in Sfax, during a period of 15 years (1995 to 2009). Predictors of chronicity were investigated using Fisher’s test with a significance if p Results 140 cases of ITP were collected including 75 girls (54%) and 65 boys (46%). The average age was 6 years 7 months (3 months to 15 years). The diffuse mucocutaneous purpura was constant and mucosal haemorrhages were present in one third of cases. The mean platelet count was 25000/mm 3 (1000/mm 3 to 50000/mm 3 ). Therapeutic abstention was the rule in 19 cases (14%), 111 children received corticosteroids (79%) and 10 children received immunoglobulins associated with corticosteroids (7%). Fifteen patients were lost of follow up and evolution has identified two groups: acute ITP in 95 cases (67%), and chronic ITP in 30 cases (21%). The parameters that were found as predictors of chronicity were female sex and age. Conclusions Acute ITP is the most common. Chronic forms are found in one fifth of cases. The determination of risk factors for chronicity can make an early prognosis.

Priapisme sous antipsychotiques et défis de prise en charge : à propos d’un cas

Priapism is a persistent, and often painful, penile erection, lasting more than 3 hours, not usually associated with sexual stimuli. It is a urological emergency that can cause serious complications. Drugs are responsible of the onset of 25 to 40% of cases of priapism. Several classes of medication are involved: antidepressants, antihypertensives, anticoagulants, alpha-blockers and some psychoactive substances (alcohol, cocaine, cannabis...). However, about 50% of drug related priapism is due to antipsychotics (AP). Clinicians should be aware of this rare side effect because of the severity of its complications and the difficulty of its management, especially in non-stabilized psychotic patients. We report a case of a 22-year-old male Moroccan patient, diagnosed with schizophrenia, who had been admitted for the first time to a psychiatric hospital for management of a psychotic episode. First, he received 15 mg per day of haloperidol, and seven days later he developed priapism. The patient was immediately referred for urological care. Aspiration and irrigation of the corpora cavernosa was proposed, but could not be performed because of patient refusal, and the erection resolved spontaneously after 10 hours. Haloperidol was stopped, and four days later the patient was switched to 10mg per day of olanzapine. After 10 days of treatment, he developed a second episode of priapism, and olanzapine was also stopped. A cavernosal aspiration-irrigation was performed in emergency; which resulted in the partial detumescence of the penis. Two days later, and despite therapeutic abstention, the patient presented another episode of priapism. The indication of a revascularization of the corpora cavernosa was proposed, but again the patient refused the surgery. Finally, the patient was administered 400mg/day of amisulpride, with a favorable outcome. Priapism disappeared after a month with the installation of fibrosis and partial loss of erectile function. The precise mechanisms of the role of AP in the occurrence of priapism are not all known and a multifactor etiology seems the most likely. Neuromuscular hypothesis is the most mentioned, involving the blocking action of alpha1-adrenergic receptors of the corpora cavernosa for which most of AP have an affinity. The occurrence of priapism in a psychotic patient, especially during periods of decompensation, raises a number of challenges for the medical staff. First, the non-recognition by the patient of this side effect, and its potentially severe consequences. Second, the absence of link between dose and duration of AP treatment on one side, and the onset of priapism on the other, which makes it hard to predict. The third challenge is the choice and initiation of another AP. The literature reveals many cases of priapism in both conventional and atypical AP, the presence of a predisposition to this type of incident has been reported. However, few authors have focused on alternatives to provide for these patients. Amisulpride is currently the only molecule that does not have alpha-adrenergic affinity and is therefore preferred in these cases. Priapism is a rare but serious adverse event of AP medication. Informing patient about the risk of priapism would help to report it early and prevent erectile dysfunction. Switching to another AP with less alpha1-blocking properties is generally recommended.

Plasmocytomes cutanés primitifs multiples

Primary cutaneous plasmacytoma is a rare form of cutaneous B-cell lymphoma. A 51 year-old male with an unremarkable history gradually presented erythematous papulonodular lesions that had appeared gradually over the whole body throughout a two-year period and showing histologic and immunohistochemical features of cutaneous plasmacytoma. Staging investigations confirmed the primary character of the disease, and because of this and the absence of functional impairment, we opted for therapeutic abstention. No progression was noted after 4 years of regular monitoring. Primary cutaneous plasmacytoma (PCP) is characterized by clonal proliferation of plasma cells in skin. Multiple PCPs are extremely rare and to date have been treated in most cases by chemotherapy, either with or without radiotherapy. The prognosis is poor, with 2-year survival of only 25%. The present case is original, being the only one to our knowledge in which therapeutic abstention was followed by a lack of progression after 4 years of regular follow-up. Consequently, certain indolent forms of PCP do not warrant automatic institution of chemotherapy.

CT and MR imaging of retroperitoneal schwannoma

The purpose of this presentation is to allow the radiologist to discuss the diagnosis of retroperitoneal schwannoma, involving mostly a fortuitous discovery and a misleading clinical presentation. We present 4 cases of retroperitoneal schwannoma, two having benefited from a surgery and two others of a therapeutic abstention. The retropritoneal localization and the imaging are good indicator elements of this pathology. The constant improvement of the CT and MR imaging allows a better approach of this entity also by specifying its localization and its anatomical relationships to guide the therapeutic attitude which must be remain mutidisciplinary.

CONTROVERSIES IN ENDOCRINOLOGY: On the need for universal thyroid screening in pregnant women

There is a well-known controversy among scientific societies regarding the recommendation to screen for thyroid dysfunction (TD) during pregnancy. Although several studies have shown an association between maternal subclinical hypothyroidism and/or hypothyroxinemia with obstetric problems and/or neurocognitive impairment in the offspring, there is only limited evidence on the possible positive effects of thyroxine (T4) treatment in such cases. Despite the scarcity of this evidence, there is a widespread agreement among clinicians on the need for treatment of clinical hypothyroidism during pregnancy and the risks that could arise due to therapeutic abstention. As maternal TD is a quite prevalent condition, easily diagnosed and for which an effective and safe treatment is available, some scientific societies have proposed to assess thyroid function during the first trimester of pregnancy and ideally before week 10 of gestational age. Given the physiologic changes of thyroid function during pregnancy, hormone assessment should be performed using trimester-specific reference values ideally based on locally generated data as geographic variations have been detected. Screening of TD should be based on an initial determination of TSH performed early during the first trimester and only if abnormal should it be followed by either a free or total T4 measurement. Furthermore, adequate iodine supplementation during pregnancy is critical and if feasible it should be initiated before the woman attempts to conceive.

A giant right coronary artery related to a small fistula to the coronary sinus

Coronary artery fistulas to the coronary sinus are very rare coronary anomalies most often resulting in extreme dilatation of the donor coronary artery and the receiving vessel. However, despite common impressive appearance, their clinical and functional impact may be extremely various from asymptomatic and benign cases to disabling and life threatening situations. To adequately stratify the inherent risks and to plan the most appropriate therapeutic strategy, an overall investigation is necessary. We herein report the case of a 56year-old woman with a giant right coronary artery related to a small and restrictive fistula to the coronary sinus that was extensively investigated by multi-imaging strategy before decision of a therapeutic abstention and long-term follow-up.