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Résumé La procédure ganglion sentinelle (GS) est la technique recommandée pour l’exploration chirurgicale axillaire dans le cancer du sein localisé sans atteinte clinique ou radiologique ganglionnaire axillaire. Cette technique chirurgicale est fondée sur une double détection isotopique et colorimétrique. Bien qu’elle permette une réduction significative de la morbidité axillaire par rapport au curage axillaire (CA), cette procédure induit un certain nombre de contraintes organisationnelles, notamment pour l’injection radio-isotopique. C’est en particulier pour ces raisons que d’autres méthodes d’identification des GS sont apparues depuis quelques années dont certaines semblent prometteuses (détection par la fluorescence et fer magnétique). L’objectif de cet article a été d’effectuer une synthèse sur la méthode de détection de référence (radio-isotopique) des GS et d’analyser la littérature récente portant sur les nouvelles méthodes de détection. The sentinel node procedure (GS) is the recommended technique for axillary surgical exploration in localized breast cancer with no clinical or radiological lymph node involvement. This surgical technique is based on a dual isotope and colorimetric detection. Although it allows a significant reduction in morbidity compared to axillary dissection (CA), this procedure induces a number of organizational constraints, in particular for the radioisotope injection. Specially for this reason, other GS methods have emerged in recent years, some of which appear promising (detection by fluorescence and magnetic iron). The objective of this paper was to carry out a synthesis of the reference method of detection (radioisotope) GS and analyze the recent literature on new detection methods. [ABSTRACT FROM AUTHOR]

Introduction Ni une sérologie positive dans le LCR, ni une pléiocytose méningée, ne permettent d’affirmer l’existence d’une neuroborréliose. La PCR pour Borrelia sur le LCR est également trop peu sensible pour être utile en pratique quotidienne. La détermination de cet index AI a par conséquent suscité beaucoup d’espoir en termes d’efficacité dans la démarche diagnostique d’une infection du système nerveux central par Borrelia. Patients et méthodes L’analyse du LCR (protéinorachie, cellularité, analyse immunitaire fine, sérologie de Lyme par Elisa et Western blot, mesure de l’index AI) a concerné 172 patients tous suspects de neuroborréliose entre janvier 2008 et décembre 2012 et pris en charge dans deux services d’un même hôpital (médecine interne et neurologie). Cette analyse ne concernait que des patients, à l’exception d’un seul, dont les sérologies de Lyme étaient positives dans le sang par technique Elisa et Western blot, mais dont les symptômes étaient très variés depuis des céphalées ou des cervicalgies inexpliquées, jusqu’à des tableaux neurologiques objectifs comme par exemple une atteinte polynévritique ou une atteinte d’un nerf crânien. Résultats Trente-cinq patients sur les 172 présentaient un index AI positif (supérieur à 2) avec pour 22 d’entre eux également une réaction cellulaire à prédominance lymphocytaire. Tous ces patients, sauf un, ont été traités par une antibiothérapie efficace sur Borrelia. Douze patients présentaient un index AI douteux (entre 1,5 et 1,9) dont 8 seulement ont été traités. Parmi les 124 patients dont l’index AI était négatif (inférieur à 1,5), 64 ont néanmoins été traités par une antibiothérapie et sur ces derniers, 21 ont été améliorés sur un plan subjectif (effet placebo ?). Discussion La spécificité de l’index AI a été de 92 % dans notre travail, comparable aux chiffres de la littérature, alors que la sensibilité n’a été que de 46,8 % probablement du fait d’inclusions cliniques très larges. Le choix de l’utilisation ou non d’un antibiotique (ceftriaxone dans 93,4 % des cas) a été laissé à l’initiative du praticien qui était en charge du patient. Le taux très élevé et probablement excessif de patients traités malgré un index AI négatif est lié à une proportion importante de malades n’ayant jamais bénéficié d’une antibiothérapie spécifique auparavant. Conclusion Un index AI positif ou douteux doit selon les auteurs conduire à une antibiothérapie ciblée (doxycycline ou ceftriaxone) car correspond le plus souvent à une infection du système nerveux central par Borrelia. Un index AI négatif rend le diagnostic de neuroborréliose très improbable, sans pour autant interdire l’utilisation d’une antibiothérapie surtout pour les patients n’ayant jamais été traités auparavant. [ABSTRACT FROM AUTHOR]

Children with neurologic impairment may not be able to feed safely or sufficiently by mouth to maintain an adequate nutritional state. Gastrostomy tube (G-tube) feeding is an important, often essential, intervention in such situations. However, many parents and families struggle with the decision to proceed with G-tube feeding. This practice point reviews common reasons for decisional conflict in parents and explores key aspects of life with G-tube feeding. A framework for shared decision-making and the International Classification of Functioning, Disability and Health (ICF) approach are highlighted. Practical recommendations for clinicians on engaging with families for decision-making around this life-changing intervention are provided.

The sentinel node procedure (GS) is the recommended technique for axillary surgical exploration in localized breast cancer with no clinical or radiological lymph node involvement. This surgical technique is based on a dual isotope and colorimetric detection. Although it allows a significant reduction in morbidity compared to axillary dissection (CA), this procedure induces a number of organizational constraints, in particular for the radioisotope injection. Specially for this reason, other GS methods have emerged in recent years, some of which appear promising (detection by fluorescence and magnetic iron). The objective of this paper was to carry out a synthesis of the reference method of detection (radioisotope) GS and analyze the recent literature on new detection methods., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Pneumonia can be complicated by an empyema, progressing from an exudative effusion, to a fibrinopurulent stage with loculations, and then organized with a thick fibrinous peel. The predominant causative organisms are Streptococcus pneumoniae, Staphyloccocus aureus (including methicillin-resistant S aureus) and Streptococcus pyogenes. Recently, an increased incidence of paediatric complicated pneumonia has been reported. For diagnostic imaging, a chest radiograph followed by a chest ultrasound is preferred. Computed tomography chest scans, with associated radiation, should not be routinely used. Antibiotic coverage should treat the most common causative organisms. Additional invasive or surgical management is recommended to reduce the duration of illness in cases not promptly responding to antibiotics or with significant respiratory compromise. Choice of management should be guided by best evidence and local expertise. Video-assisted thorascopic surgery or insertion of a small-bore percutaneous chest tube with instillation of fibrinolytics are the best current options.

Objective: An observation of a difficult-to-diagnose complication of the cochlear implant: recurring cutaneous extrusion of a cochlear implant is reported., Patients and Methods: The history of an adult patient with total deafness is reported. She received an implant in her right ear in 1988, which was then explanted because of absence of hearing results. She received a second implant in her left ear in 2002, which was then explanted in 2007 because of cutaneous extrusion. In 2008, a second implant of a different brand was placed in her left ear, with the central part placed away from the first site, but extrusion recurred. A new attempt to encapsulate the central part with a hydroxyapatite box also ended in extrusion and was explanted in 2008., Results: Various diagnoses to explain these cutaneous problems were suggested during this clinical progression: infection, allergy, and a reaction to a foreign body. No hypothesis could be clearly ruled out., Conclusion: Cutaneous complications after cochlear implant are exceptional. As soon as cutaneous disorders appear, a rigorous diagnostic process must be followed so that the patient can be recommended a long-lasting solution to restore quality hearing.

Hypertension in subjects on long term dialysis is frequent. Its origins are found in extracellular volume overload, which is complicated by increased peripheral arterial resistance. The latter is affected by many systems, including that of renin-angiotensin, endothelin, nitric oxide, the sympathetic nervous system, and others. The interaction between these factors may explain why the control of hypertension in dialysis patients requires ongoing attention to the many aspects of good dialysis.

Objectives: The management of patients with presumed cerebral venous thrombosis has been recently modified by magnetic resonance imaging and evidence that the early use of heparin decreases mortality and morbidity. Long term outcome of patients with cerebral venous thrombosis (CVT) has rarely been described. We present the results of a follow-up study., Methods: Twenty patients admitted between 1987 and 1999 for CVT were retrospectively studied. Outcome and follow-up were obtained from direct observation or telephone interviews., Results: There were 16 women and 4 men aged a mean of 39 years (range: 19 to 72). The population was followed-up for a mean of 34 months (range: 12-96). All the patients were initially treated with full-dose heparin. Thirteen of the 20 patients (65%) exhibited no after effects. Seven patients (35%) remained neurologically impaired. The outcome of clinical forms with intracranial hypertension appeared better, but the existence of an initial neurological deficit is of poor prognosis. The small cohort in our series did not permit us to identify other poor prognostic factors. One patient (5%) exhibited subsequent epilepsy. Only one patient (5%) suffered for a second CVT. One patient died from an ovarian neoplasm. No systemic venous thromboembolic relapse was reported. Three patients had non complicated pregnancies., Conclusion: Recurrent CVT and systemic venous thrombo-embolic episodes are rare although heparin treatment was suspended early in more than half of the patients. This would question the indication of long-term antivitamin K, which is clearly indicated in auto-immune diseases but is debatable in cases of thrombophilia.

Many coagulation disorders have been associated with cerebral venous thrombosis. These disorders may be primary like protein C and S deficiency, antithrombine III deficiency and activated protein C resistance. Antiphospholipid antibodies represent an acquired disorders of coagulation. A prothrombotic state induced by more common factor including oral contraceptive, pregnancy and puerperium increases the venous thrombosis risk.

Background: Fabry disease is a lysosomal disease resulting from deficient alpha galactosidase A activity. The enzyme's gene is situated on Xq22-1. Cardiac and cerebrovascular complications are usually observed late in the disease course., Case Report: A 54-year-old patient was admitted for ischemic stroke subsequent to thrombosis of the right sylvian artery. The only significant event in the patient's history was hypertrophic cardiomyopathy that had progressed for 9 years. Search for an etiology identified alpha galacosidase A deficiency. Gene sequencing identified a new mutation., Discussion: Two clinical forms of Fabry disease are described. The classical form has an early onset and is associated with systemic manifestations. The less common atypical form is associated with late-onset cardiomyopathy with no other systemic manifestations. Several mutations of the alpha galactosidase A gene have been recognized but to date no correlation has been established between the genotype and the phenotype. Our patient had an "intermediary" form of the disease associating a late onset, predominant cardiac manifestations, and limited systemic manifestations. The mutation observed in this case has not been described previously. Its relationship with the observed clinical phenotype remains to be demonstrated.

Inherited deficiency of lysosomal hydrolase often displays different clinical features. However, a greatly reduced enzyme activity may be observed in healthy individuals. This pseudo-deficiency concerns at least nine lysosomal hydrolases. When a deficiency has been proved, the presence of mutations known to cause pseudodeficiencies must be searched, above all in Tay-Sachs disease and metachromatic leukodystrophy.

Ciguatera is the most frequently observed form of tropical fish poisoning. It appears as a syndrome associating general signs, gastrointestinal, cardiac and neurological problems. Peripheral and central nervous system signs may be observed. We report a case of a 60-year-old man who developed Ciguatera poisoning with diarrhea, facial paresthesia, myalgia, cramps and weakness. Physical examination revealed a motor distal deficit of the four limbs, myokymia and ataxia. EMG testing was in favor of an axonal neuropathy. Neurologic symptoms persisted for two months. This case illustrates a new pathophysiological mechanism of neuropathy: "axonal channelopathy. Abnormalities of peripheral nerve sodium and potassium channels result in clinical and electrophysiological manifestations unrelated to axonal degeneration or demyelinization. The ciguatoxin mainly acts on sodium channels. Prolonged sodium channel activation results in repetitive axon firing. Recently ciguatoxin was recently demonstrated to have a novel action, blocking the sodium channel leading to slowed nerve conduction and decreased motor and sensory action potential amplitudes.

Background: Eales disease is a condition associating recurrent vitreous and retinal hemorrhage related to retinal periphlebitis. This ophthalmological disease is sometimes associated with central nervous system manifestations., Case Report: Two patients with Eales disease of the retina developed a progressively worsening neurological deficit several years later., Discussion: Evidence of multifocal anomalies of the white matter initially suggested a possible association of Earles disease with multiple sclerosis. Pathology findings enable formal differentiation of these two entities. Earles disease with neurological manifestations remains an uncommon condition and constitutes a differential diagnosis of multiple sclerosis.

It has been known for 300 years that normal life is possible with a single kidney. Removal of both kidneys, however, leads to death within several days. Between these extremes is found the quantity of kidney sufficient for life. It was in 1888 that Theodore Tuffier was the first to address this question. A few years later, Carnot did his studies on growth factors that could influence kidney growth. This subject has not lost its interest. Today, the problem of progressive renal failure is studied by many investigators, from clinicians to basic scientists, specialists in cytokines and molecular biology. This article will define the origins of those efforts, an adventure which is ongoing today.

Sleep apnea syndrome (SAS) in children has been identified only recently. Its incidence is unknown but seems to be rising. The cause is usually an obstruction (enlarged tonsils) that alters the fragile physiologic mechanisms responsible for maintaining the upper airways open when the child is sleeping. Diagnosis of SAS rests on clinical findings. The parents should be questioned as to the frequency over time of the various symptoms, of which most occur during the night: snoring, difficult breathing, respiratory pauses. Sleep polygraphy studies are indicated only in specific situations. The main cause is enlargement of the adenoids and tonsils. Cardiovascular complications may develop; weight gain and statural growth, psychomotor development and development of the face may be altered. Chronic snoring without apneas should be considered as a form of SAS. Treatment rests mainly on surgery (removal of the adenoids and tonsils).

An open operative technique was used in 36 (38%) of 95 patients with chronic cholesteatomatous otitis followed up by the same surgeon between 1986 and 1990. Although a good anatomical result was obtained in 88% of cases the functional result was less evident, since 57% of patients were left with a liminal tonal loss of less than 30 décibels. The reasons for using an open technique are analyzed, but in only 5% of cases could the possibility of using a closed technique be envisaged, making the classical discussion between open and closed methods of treatments of only academic interest. Petromastoidian evidement with reorganization of the cavity is considered to be effective therapy for cholesteatoma, but indications and technical procedures must be adhered to strictly.

43 children with a clinical suspicion of obstructive sleep apnea-hypopnea were studied. All children underwent clinical examination and a standardised questionnaire was completed by their parents in order to investigate the principal nocturnal and diurnal symptoms present. A sleep study was performed. In addition to methods designed to identify the stage of sleep (EEG, EOG, EMG), this included recording of nasal and buccal airflow, thoracic and abdominal respiratory movements and blood gas analysis. 38 children has recordings during their afternoon nap, and 4 children during the night. Tonsillar hypertrophy was the principal etiology responsible for nocturnal respiratory disorders (33 cases). In addition, other etiologies were demonstrated: Pierre Robin syndrome, cranio-facial stenosis, laryngomalacia, Prader-Willi syndrome and Arnold Chiari malformation. Surgery was performed in 31 children: 22 tonsillectomies with or without adenoidectomy, 4 uvulo-palato-pharyngoplasties with tonsillectomy, 3 epiglottoplasties and 2 staphylorrhaphies. Long-term results were studied clinically and in 11 cases by polysomnographic recording.

The Girdlestone procedure was performed in 36 cases of septic arthritis of the hip, most of which arose following operation. In 21 instances, the greater trochanter was inserted into the acetabulum and the hips were fixed by external fixators. In 15 instances a standard operation was performed followed by traction. The results were better after simple procedures; there was less pain and more mobility but the hip was more unstable. It is concluded that the simple procedure is preferable especially when it is planned to perform a further arthroplasty later.

The activity of the enzyme leucine aminopeptidase (LAmP) in serum was examined in 305 pregnant women (174 women with normal pregnancy, and 131 women with disturbed pregnancy). The activity of this enzyme increases during the normal development of pregnancy. In disturbed pregnancies, the LAmP activity is lower as compared to normal pregnancies. A peculiar case: toxemia of pregnancy, where the activity of the enzyme is considerably increased. This fact may be compared with the increase of LAmP activity in cases of liver damage. The LAmP activity test in pregnancy is reliable and can be performed practically in every laboratory, thus deserving its place among the many tests meant to assess the normal function of the foeto-placental unit. This test may also help in the diagnostic of some specific pregnancies such as twin pregnancy, hydatidiform mole and extra-uterine pregnancy.

After a preliminary report on 20 cases, we have used extra-amniotic perfusion of isotonic saline, in association or not with syntocinon, for performing:--56 2nd trimester therapeutic abortions,--16 labor inductions in interrupted 2nd and 3rd trimester pregnancies, with macerated fetus (missed abortion and missed labor). This method, relatively simple, permits the discharge of the conceptus within a reasonable time. Our experience allowed us to draw the indications of choice in the use of this method, which are the following: 1. When the amniotic puncture may be difficult (at the beginning of the 4th month or if the age of pregnancy is uncertain). 2. When there is an increased risk of hemorrhage with coagulation disorder macerated fetus or some systemic diseases). 3. When there are counter-indications for the use of hypertonic saline solution or prostaglandins (some renal, cardiac or respiratory diseases). 4. When one needs a fetus in a relatively good state for embryologic, histologic or genetic studies, which are important in case of abortion for rubella or chromosomic anomaly. In view of the innocuousness of this method, its use for labor induction in evolutive pregnancies is suggested.