Léiomyosarcome gastrique simulant une tumeur du hile splénique: à propos d’un cas

Depuis la découverte de leur phénotype particulier, les tumeurs stromales gastro-intestinales représentent les tumeurs mésenchymateuses les plus fréquentes du tractus digestif et ne sont plus confondues avec les vrais léiomyosarcomes gastriques devenant ainsi exceptionnellement rencontrés dans la pratique médicale. Nous rapportons le cas d'une jeune femme de 32 ans admise pour une masse douloureuse de l'hypochondre gauche  et chez qui le bilan radiologique objectivait une volumineuse tumeur occupant le hile splénique. Une résection monobloc emportant la masse, la rate, le grand épiploon et une collerette de la paroi gastrique a été effectuée et l'examen histologique a confirmé le diagnostic d'un léiomyosarcome gastrique. Il est extrêmement  important de différencier les autres tumeurs mésenchymateuses du tractus digestif des léiomyosarcomes gastriques dont l'exérèse chirurgicale complète reste, jusqu'à présent, le seul traitement à visée curative.Key words: Léiomyosarcome, estomac, masse abdominal

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Stability and dynamic behaviour of steel structures with non-linear restraints

This study was undertaken to investigate the effects of imperfections in the initial geometry of bracing members on the stability of the structural frameworks. The general non-linear behaviour of frameworks, consisting of single columns, or multistorey frames stiffened by curved bracings, were studied under the effects of combined vertical and horizontal load systems. The study was divided into two main parts. In part one, the study examined the structural frameworks in the following situations: i) Influence of initial bowing on the behaviour of individual members subjected to axial or eccentric forces. ii) General static behaviour of a single column restrained by curved member or members. iii) General static behaviour and instability of multistorey frameworks with non-linear cross bracings. It has been the goal of the thesis to reinforce the theory put forward to explain the particular type of instability encountered, therefore a critical state, or transient instability region, has been investigated. The characteristics of individual curved members were determined using the theory of large deformations. The general behaviour and the stability of frameworks restrained by imperfect bracing systems were studied using tangent slope and influence coefficient techniques. The results of this study have shown that the initial imperfections of bracings are very important and have major effects on the overall behaviour of the braced frame structures. The particular type of instability encountered, i. e. the critical state or the transient instability region, may be considerably influenced by the initial geometric imperfections of bracings and the relative magnitude of the ratio between vertical and horizontal applied loads on the frameworks. The critical loads have been presented in a series of curves and tables. In part two of the study, the dynamic behaviour at the critical state, i. e. in the region of transient instability, has been investigated. Numerical methods for the dynamic analysis of structural frameworks have been discussed. A new procedure of numerical differentiation has been presented and its advantage over existing procedures has been shown. The method is convenient for use with a digital computer and can also be used for solving simple problems with a calculator. In general the results of parameters studied were presented in a series of curves and tables to enable the stability and dynamic actions to be readily determined for a wide range of structural configurations. Finally, a test programme was carried out to investigate experimentally the non-linear behaviour of frameworks restrained by these imperfect bracings. Three separate models were used in the experimental programme. The experimental results were used to verify the general accuracy of the theoretical methods of analyses. In general the theoretical results and the experimental ones were in very close agreement.This study was undertaken to investigate the effects of imperfections in the initial geometry of bracing members on the stability of the structural frameworks. The general non-linear behaviour of frameworks, consisting of single columns, or multistorey frames stiffened by curved bracings, were studied under the effects of combined vertical and horizontal load systems. The study was divided into two main parts. In part one, the study examined the structural frameworks in the following situations: i) Influence of initial bowing on the behaviour of individual members subjected to axial or eccentric forces. ii) General static behaviour of a single column restrained by curved member or members. iii) General static behaviour and instability of multistorey frameworks with non-linear cross bracings. It has been the goal of the thesis to reinforce the theory put forward to explain the particular type of instability encountered, therefore a critical state, or transient instability region, has been investigated. The characteristics of individual curved members were determined using the theory of large deformations. The general behaviour and the stability of frameworks restrained by imperfect bracing systems were studied using tangent slope and influence coefficient techniques. The results of this study have shown that the initial imperfections of bracings are very important and have major effects on the overall behaviour of the braced frame structures. The particular type of instability encountered, i. e. the critical state or the transient instability region, may be considerably influenced by the initial geometric imperfections of bracings and the relative magnitude of the ratio between vertical and horizontal applied loads on the frameworks. The critical loads have been presented in a series of curves and tables. In part two of the study, the dynamic behaviour at the critical state, i. e. in the region of transient instability, has been investigated. Numerical methods for the dynamic analysis of structural frameworks have been discussed. A new procedure of numerical differentiation has been presented and its advantage over existing procedures has been shown. The method is convenient for use with a digital computer and can also be used for solving simple problems with a calculator. In general the results of parameters studied were presented in a series of curves and tables to enable the stability and dynamic actions to be readily determined for a wide range of structural configurations. Finally, a test programme was carried out to investigate experimentally the non-linear behaviour of frameworks restrained by these imperfect bracings. Three separate models were used in the experimental programme. The experimental results were used to verify the general accuracy of the theoretical methods of analyses. In general the theoretical results and the experimental ones were in very close agreement

Evaluation of aortic valve in valve sparing root replacement: Reimplantation versus noncoronary sinus replacement

Background: Valve sparing aortic root replacement (VSRR) had been popularized in the last decades because preservation of the native valve allows for better hemodynamics, better left ventricular performance, lesser risk of endocarditis and avoidance of lifelong anticoagulation. Two basic types of VSRR techniques are used: reimplantation of the aortic valve (Tirone David) and remodeling of the aortic root(Yacoub). We compared the David reimplantation technique versus one or two sinus replacement in repair of aortic root aneurysm or dissection associated with aortic regurge. Patients & Methods: Fifty patients were divided into two groups: Group I (25 patients) undergone David reimplantation technique, Group II (25 patients) undergone supracoronary with one or two sinus replacement. Results: There were two deaths (8%) within 30 days in each group. Postoperative significant regurge in Group I occurred in 1 case (4.3%) and in 2 cases (8.6%) in Group II with no significant difference. Cross clamp time was significantly shorter in Group II; 137 ± 37.0 min versus 177 ± 33.0 min in Group I. Significant bleeding occurred in 7 cases (28%) in Group I which was significantly higher than Group II; 1 case (4%). Conclusion: Replacement of one or two sinuses is not inferior to reimplantation technique regarding early survival and correction of aortic regurge. Noncoronary sinus replacement provided better results than reimplantation technique regarding postoperative bleeding and cross clamp time

Scroto-perineal hidradenitis suppurativa complicated by giant scrotal elephantiasis

Scrotal elephantiasis has been a recognized complication of inguinal node irradiation, filarial infection, tumor involvement and surgical lymphatic destruction, but has rarely been reported in association with hidradenitis suppurativa (HS). HS, also known as acne inversa, is a chronic and often debilitating disease primarily affecting the axillae, inframammary regions and perineum. The location of the lesions may lead to social embarrassment and failure to seek medical treatment. Scroto-preineal HS complicated by scrotal elephantiasis is a distressing disease. Excisional surgery with reconstruction is the recommended treatment with a high likelihood of good outcome. We present a 38-year-old male patient with long-standing scroto-perineal HS complicated by giant scrotal elephantiasis