Bénéfice risque de la prescription forte dose de lysodren dans la prise en charge de 22 patients opérés d'un corticosurrénalome

INTRODUCTION : Le ratio bénéfice-risque de la stratégie du Lysodren forte dose dans la prise en charge des corticosurrénalomes est à ce jour inconnue. Le rationnel de cette stratégie est basé sur le retard à l'équilibre thérapeutique observé avec la stratégie traditionnelle dans une pathologie caractérisée par son mauvais pronostic. METHODES ET OBJECTIFS : Vingt deux patients consécutifs, suivis à l'Institut Gustave Roussy, entrés pour corticosurrénalome, ont été traités par Lysodren à visée adjuvante (59 %) ou palliative (41 %). Ils ont reçu le Lysodren selon une stratégie forte dose, consistant à débuter par 2-3g/jour puis à augmenter rapidement la posologie jusqu'à la dose maximale tolérée sur le plan digestif (6-9g/jour) en moins de 15 jours. Les objectifs de l'étude ont été d'évaluer le bénéfice de cette stratégie sur le délai d'obtention d'une mitotanémie > 14 mg/l et de déterminer l'impact sur la tolérance clinique et biiologique dans les 3 premiers mois de traitement. La mitotanémie a été dosée mensuellement pendant 3 mois par chromatographie liquide à haute performance. Les patients ont été surveillés jusquà rechute ou progression. RESULTATS : La dose médiane de Lysodren absorbée a été de 6 g/jour pendant les quinze premiers jours de traitement (extrêmes, 4-9g/jour). Une mitotanémie > 14 mg/l a été observée dès le premier mois de traitement pour 27 % des patients, qui ont maintenu une mitotanémie efficace à 3 mois. Parmi les patients qui ont atteint une mitotanémie thérapeutique, le temps médian nécessaire a été de 2 mois (extrêmes, 1-27 mois). Nous n'avons pas mis en évidence de corrélation entre la dose cumulée de Lysodren et la mitotanémie.Une toxicité grade 3-4 a été retrouvée chez 14 % des patients. Aucun patient n'a arrêté définitivement le traitement pour toxicité mais 50 % des patients ont interrompu au moins une fois le traitement pour toxicité. CONCLUSION : La stratégie forte dose apporte un bénéfice sur le délai d'efficacité du Lysodren avec une toxicité acceptable, qui n'est pas plus importante que dans la stratégie faible dose. La variabilité individuelle reste majeure.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

LES ANIMAUX ET LEUR SYMBOLIQUE DANS LE FOLKLORE DE LA CHINE ANCIENNE, UN HERITAGE CULTUREL

L'objectif de cette étude est d'aborder la culture chinoise sous l'un de ses aspects, afin de souligner l'importance de l'influence animale sur la Chine depuis les temps archaïques jusqu'à aujourd'hui. Pour cela, l'auteur pose dans la première partie les bases du mode de pensée en Chine, en présentant la géographie puis l'Histoire chinoises, et en indiquant de quelle manière s'y est construite la symbolique animalière. Puis dans la seconde partie l'auteur expose le folklore chinois primitif, et l'impact que les animaux ont eu sur ce dernier. Enfin, dans la troisième partie, l'auteur dévoile l'héritage qu'a rec u la Chine contemporaine de ses coutumes primitives, spécialement à travers l'astrologie, les arts martiaux, les spectacles et les rébus chinois. Cette étude montre ainsi que, notamment par le truchement du taoïsme, les animaux et leur symbolique ont eu une influence majeure non seulement sur la Chine, mais aujourd'hui également sur le monde occidental.MAISONS-ALFORT-Ecole Vétérin (940462302) / SudocSudocFranceF

Normotensive Incidentally Discovered Pheochromocytomas Display Specific Biochemical, Cellular, and Molecular Characteristics

International audienceDesign: This was a retrospective cohort recruited from 2001 to 2011 in 2 tertiary care medical departments.Patients and Methods: Clinical, biological, and radiological investigations performed in 96 consecutive patients with sporadic unilateral pheochromocytomas were examined; 47 patients had overt pheochromocytomas responsible for hypertension. Among the patients with incidental pheochromocytomas, 28 had hypertension and 21 were normotensive (NIPs). A total of 62 tumors were examined to determine the Pheochromocytoma of the Adrenal Gland Scale Score, and 29 were studied for the expression of 16 genes involved in chromaffin cell function.Context: A number of incidentally discovered pheochromocytomas are not associated with hypertension. The characteristics of normotensive incidentally discovered pheochromocytomas (NIPs) are poory known.Objective: The purpose of this work was to assess the clinical, hormonal, histological, and molecular features of NIPs.Results: Tumor size and metaiodobenzylguanidine (MIBG) scintigraphy results were similar for hypertensive pheochromocytomas (HPs) and NIPs. Patients with NIPs displayed reduced summed levels of urinary catecholamines and metanephrines and, more specifically, reduced levels of adrenaline and metadrenaline compared with those of patients with HPs (P < .001). Urinary metanephrines had 98% diagnostic sensitivity in patients with HPs and only 75% in patients with NIPs (P < .01). Tumor diameter positively correlated with the total amount of urinary concentrations of metanephrines in patients with HPs (P < .001) but not in patients with NIPs. NIPs displayed global decreased chromaffin gene expression (reaching significance for 5 of them) and 2 corresponding proteins (phenylethanolamine N-methyltransferase and secretogranin II) and a significant increase in the cellularity, mitotic activity, and presence of atypical mitosis (P < .05).Conclusions: NIPs differ from pheochromocytomas responsible for hypertension and display features of altered chromaffin differentiation. These tumors may be misdiagnosed with the use of the usual biological diagnostic tools

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort.

Objective:To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).Background:AL after RC resection often results in a permanent stoma.Methods:This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.Results:This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).Conclusions:The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies