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Objectives The increasing frequency of skin tumors and longer life expectancy of the general population are likely to increase the frequency of dermatological surgery among elderly patients. The purpose of this study is to assess the rate of postoperative complications related to dermatological surgery in elderly patients and highlight the factors associated with these complications. Methods We conducted a retrospective monocentric study of patients aged > 75 years who presented at our multidisciplinary consultation specialized for skin tumors from January 2008 to December 2010. The clinical characteristics, demographic information, and cancer history of these patients were analyzed. Postoperative complications (dehiscence, infection, hematomas, and other sequelae) were identified to establish the postoperative complication rate and determine risk factors. Results We included 241 patients. Basal cell carcinoma, squamous cell carcinoma, and melanoma accounted for 46%, 25%, and 28% of tumors, respectively. Skin carcinomas were mainly located on the face (93% of basal cell carcinomas and 72% of squamous cell carcinomas), and melanomas were mainly located on the limbs (50%). The average number of comorbidities was 3.0 ± 1.5. The average postoperative complication rate was 20%. Multivariate analysis identified three independent risk factors: male gender (p < 0.033), histological type (squamous cell carcinoma and melanoma) (p < 0.008), and insufficient surgical resection (p < 0.004). Conclusion This study highlighted a high rate of postoperative complications in this elderly population. Three significant postoperative risk factors were identified. They may be used to assess a patient's operational risk as well as geriatric assessment tools. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to determine whether type II endoleak (T2E) after endovascular repair of abdominal aorta (EVAR) is a benign condition (ie, not associated with growth, reintervention, rupture, or death). Methods: Data from patients who underwent EVAR for atherosclerotic infrarenal aortic aneurysms between June 1995 and May 2010 in the Vascular Surgery Department of Henri Mondor Hospital were prospectively collected. Data from patients presenting with at least one T2E on computed tomography scan during their follow-up were compared with those with no T2E. Three subcategories of T2E were studied according to time of occurrence (early or late), persistence (persistent or transient), and recurrence (recurrent or not recurrent). Results: Seven hundred patients were included with follow-up ranging from 1 month to 15 years (median, 31.3 months; range, 12.4-61.4); 201 (28.9%) had at least one T2E. Patients with T2Es were significantly older (P < .001), female (P = .015), had larger aneurysms (P = .019), and patent lumbar arteries (P = .003). Patients without T2Es had a higher incidence of current smoking (P < .001) and chronic obstructive pulmonary disease (P < .005). Multivariate analysis showed risk of T2E was increased in older patients (odds ratio [OR], 1.04; confidence interval [CI], 95% 1.02-1.06; P < .001) and in those with patent lumbar arteries (OR, 1.70; CI, 95% 1.16-2.50; P = .007), and was reduced in active smokers (OR, 0.16 CI, 95% 0.04-0.71; P = .015) or patients with coronary artery disease (OR, 0.65; CI, 95% 0.45-0.92; P = .016). Patients with T2Es had more complications (death, rupture, reintervention, or conversion) (P < .001) and greater aneurysm sac enlargement (>5 mm upon follow-up) (P < .001). Multivariate analysis showed T2E was a risk factor for aneurysm diameter growth >5 mm; this risk was increased if T2E persisted more than 6 months (hazard ratio [HR], 3.16; CI, 95% 2.55-6.03; P < .001), was recurrent (HR, 1.88; CI, 95% 1.18-3.01; P = .008), or associated with a type I or III endoleak (HR, 1.96; CI, 95% 1.41-2.73; P < .001). Recurrent T2E was associated with a higher rate of reintervention (P = .04) and conversion to open surgery (P = .028). Conclusions: Not all T2Es are benign. Recurrent as well as persistent T2Es are prone to life-threatening complications. [Copyright &y& Elsevier]

Abstract: Background: Rapalogs are emerging as promising targeted anticancer drugs. Activation of the PI3K/Akt/mTOR pathway has been observed in 15–50% of hepatocellular carcinomas. Methods: In this phase II study, patients with advanced hepatocellular carcinoma and underlying cirrhosis received sirolimus (20mg/week for 1 month then 30mg/week). Tumour response was assessed every 8 weeks. The primary endpoint was the objective tumour response rate according to the Response Evaluation Criteria in Solid Tumours criteria. Secondary endpoints included the objective response according to the modified Response Evaluation Criteria in Solid Tumours criteria, safety, and pharmacokinetic parameters. Results: Twenty-five patients received sirolimus for a median of 20.6 weeks. Two patients had an objective response (8%, 95CI: 0.98–26.03), including one complete response, and 8 patients had stable disease. There were 2 cases of grade 5 toxicity (infections) and 5 cases of grade 3 toxicity. The main grade 1/2 toxicity was mild transient fatigue (76%). Median time to radiological progression and overall survival were 15.3 weeks (range: 8.2–173.9) and 26.4 weeks (range: 8.2–173.9) respectively. Use of the modified Response Evaluation Criteria in Solid Tumours criteria did not identify any further responders. Conclusion: These data suggest that first-line sirolimus shows antitumoural efficacy in advanced hepatocellular carcinoma. Larger trials with Child A patients are needed. [Copyright &y& Elsevier]

Abstract: Site selection is a fundamental step, which can condition the success of a CO2 geological storage. A CO2 storage has to gather several targets, which can be expressed through a list of criteria. In the proposed site selection methodology, these criteria can be classified into “killer criteria” and “site-qualification criteria”, whose combinations allow identifying potential sites and the most appropriate one(s). This multicriteria methodology is applied on the PICOREF study area, located in the Paris Basin, on which potential site(s) in deep saline aquifers are investigated. [Copyright &y& Elsevier]

Introduction: We hypothesized that the coverage of the hypogastric artery with a stent-graft causes an occlusion of the artery in its proximal segment, allowing collateral network formation in distal segments of the artery. In contrast, hypogastric embolisation may cause the formation of microthrombi that tend to disseminate leading to embolic occlusion of secondary branches and collaterals. This phenomenon worsens pelvic ischemia. To answer this question we compared two groups of patients with aortoiliac aneurysms treated with or without coil embolization to assess 1) The occurrence and evolution of buttock ischemia and 2) the effect on endoleak. Materials/Methods: Between October 1995 and January 2007, 147 out of 598 EVAR patients (24.6%) required occlusion of one or both hypogastric arteries. 101 were available for over one year of follow-up. Group A included 76 patients (75%) who underwent coil embolization before EVAR and group B 25 patients (25%) who had their hypogastric artery covered by the sole limb of the stent. Patient demographics, aneurysm characteristics, operative details, immediate and long term clinical outcomes, and CT-scan evaluation were stored prospectively in a specific data base and analyzed retrospectively. Results: They were 96 males (95%). Mean age was 72.1±9.5 years. One month postoperatively, 51 patients (50.0%) suffered from buttock claudication. After six months, 34 patients were still disabled (34%), 32 in Group A (42%) and 2 in Group B (8%) (p =0.001). Post-operative sexual dysfunction occurred in 19 (19.6%) without statistical difference between the two groups. Type 2 endoleaks occurred in 12 patients (16.0%) in group A and 4 patients (16.0%) in group B (p =1). Endoleak from the hypogastric artery occurred in one patient in each group. Univariate analysis showed that predictive factors of long term (over six months) buttock claudication were embolization (p <0.001), younger age (p <0.03), coronary disease (p =0.06) and left ventricular dysfunction (p <0.01). The logistic regression analysis showed that buttock claudication was independently associated with embolization OR=9.1[95%CI=1.9-44] and left ventricular dysfunction OR=4.1[95%CI=1.3-12.7]. Conclusions: Coil embolization of hypogastric artery during EVAR is not an innocuous procedure and may not reduce the rate of type II endoleak. [Copyright &y& Elsevier]

Objective: To review, in the era of endovascular abdominal aortic repair (EVAR), the clinical spectrum of colonic ischemia (CI) following abdominal aortic aneurysm (AAA) repair and to assess the rate, overall mortality, and associated factors of occurrence. Methods: Between 1995 and 2005, 1174 patients with infrarenal AAA were treated either by open surgery (n = 682) or by EVAR (n = 492). Preoperative risk factors, clinical presentation, intraoperative data, and early postoperative outcomes were prospectively assessed. Overt colonic ischemia as proven by colonoscopy and/or by operation was considered as a validating event and was correlated to collected variables. Results: CI occurred in 34 patients (2.9%). Eighteen out of 34 (53%) patients died within 1 month. At 2 years, the survival rate was 35% in the CI group vs 86% in the non-CI group. Associated factors of occurrence of CI were: type of operation (open group = 27/682 [4%] vs EVAR = 7/492 [1.4%] [P = .01]), aneurysm rupture (11/88 [12.5%] vs 23/1086 [2.1%], P < .001), preoperative renal insufficiency (4/30 [13.3%] vs 29/1133 [3.1%], P = .01), preoperative respiratory insufficiency (8/157 [7%] vs 23/1005 [2%], P = .01), duration of operation (<2 hours [518] = 1.7%, between 2 to 4 hours [558] 2.9%, more than 4 hours [66] 13.6%, P = .001). Mean blood loss was greater in patients with CI (CI = 2000 ml [650-3350] than in those without CI = 1000 ml [500-1800] P = .008). Logistic regression analysis showed that rupture (OR 6.03 [interval of confidence (IC) 95% 2.68-13.5] P = .0001), duration of operation (OR 5.73 [IC 95% 2.06-15.9] P = .001) and creatinin > 200 mol/l (OR 4.67 [IC 95% 1.39-15.7] P = .028) were independent factors of CI. The mortality due to colonic ischemia was not statistically different between open surgery 14/27 (52%) and EVAR 4/7 (57%). Conclusion: CI remains a serious complication following AAA repair. In the univariate analysis, EVAR was associated with a lower rate of colonic ischemia. However, the logistic regression analysis showed that only rupture, long duration of operation, and prior renal disease were independently associated with CI. Within the two treatment modalities, the mortality rate remained identical. [Copyright &y& Elsevier]

Background & Aims: Steatosis is highly prevalent in patients with chronic hepatitis C (CHC) and has been reported to increase fibrosis and reduce the rate of viral eradication. Two recent studies indicate that endocannabinoids promote experimental steatosis via activation of hepatic CB1 receptors. We therefore investigated the impact of cannabis smoking on steatosis severity during CHC. Methods: A total of 315 consecutive patients with untreated CHC undergoing liver biopsy were included. Detailed histories of recent cannabis, alcohol, and tobacco use were recorded. Steatosis, activity, and fibrosis stage were assessed by 2 pathologists according to METAVIR. Marked steatosis was defined as ≥30%. Patients were categorized as cannabis nonusers (63.5%), occasional cannabis smokers (12.4%), or daily cannabis smokers (24.1%). Results: Multivariate analysis identified 6 predictors of marked steatosis: daily cannabis use (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.01–4.5]), activity grade ≥A2 (OR, 2.1; 95% CI, 1.0–4.3), genotype 3 (OR, 5.4; 95% CI, 2.6–11.3), hyperglycemia or diabetes (OR, 5.1; 95% CI, 1.8–15.0), body mass index >27 kg/m2 (OR, 2.1; 95% CI, 1.0–4.3), and serum HCV RNA load (OR, 1.7; 95% CI, 1.0–2.9). Upon adjustment of HCV genotype (3 vs non-3) or alcohol intake (<30 g/day vs ≥30 g/day), marked steatosis was more frequent in daily cannabis users compared with occasional users and nonusers (P = .03 and P = .008, respectively). Conclusions: Our results identify daily cannabis smoking as a novel independent predictor of steatosis severity during CHC and strongly argue for a steatogenic role of the cannabinoid system. Cannabis use should be discouraged in patients with CHC. [Copyright &y& Elsevier]

Introduction: We reviewed our experience with limb occlusion after EVAR in order (1) to assess the clinical pattern and treatment options (2) to assess outcomes and (3) to identify predictive factors of occurrence. Materials and method: Between 1995 and 2005, 460 AAA patients were electively treated with a variety of commercially available stent grafts. There were 369 bifurcated and 91 aortouniiliac grafts (829 limbs). Follow-up included physical examination, plain X-ray, Duplex ultrasonography, and spiral computed tomographic scans at 1, 6, 12 months and annually thereafter. All pertinent data were collected prospectively and analysed retrospectively. The follow-up period ranged from Day 0 to 104 months, with a median follow-up of 23.4 months. Results: 36 limbs in 33 patients (7.2%) occluded between Day 0 and 71 months (average: 9.5 months) after EVAR. Presentation was acute ischemia in 11 cases, rest pain in 9, claudication in ten. Four occlusions remained asymptomatic and two occurred intraoperatively. Treatment was femoro-femoral cross-over graft in 19 cases, axillo-femoral bypass in three, thrombectomy and stent in three, thrombolysis and stent in nine, and conservative in two. One patient (3%) died of multiple organ failure after thrombolysis. There was no amputation. Reocclusions occurred in two patients (6.1%). Multivariate logistic regression showed that kinking (odds ratio [OR] 11.9; confidence interval [CI] 3.39–42.1; p =0.0001), first graft generation (OR 2.87; CI 1.25–6.62; p =0.017) and younger age (OR 1.05; CI 1.00–1.09; p =0.034) were independently related to the occurrence of graft limb occlusion. Conclusion: Acute graft limb occlusion is not rare after EVAR. The frequency of limb occlusion has declined with current stent grafts generation. Although surgery and endovascular treatments are efficient and safe, development of a graft limb kink should lead to aggressive pre-emptive treatment to prevent occlusion. [Copyright &y& Elsevier]

Objective: To determine the impact on late postoperative renal function of suprarenal and infrarenal fixation of endografts used to treat infrarenal abdominal aortic aneurysm (AAA). Methods: Retrospective analysis of 277 patients treated from 2000 to 2003 with three different endografts at two clinical centers. Five patients on dialysis for preoperative chronic renal failure were excluded. Group IF of 135 patients treated with an infrarenal device (Medtronic AneuRx) was compared with group SF of 137 patients treated with a suprarenal device (106 Cook Zenith and 31 Medtronic Talent). Renal function was evaluated by calculating preoperative and latest postoperative creatinine clearance (CrCl) using the Cockcroft formula. Patients who developed a >20% decrease in CrCl were considered to have significantly impaired renal function. Results: There were no significant differences in patient age, sex, aneurysm size, preoperative risk factors, dose of intra- and postoperative contrast, or baseline CrCl (IF: 69.3 mL/min, SF: 71.7 mL/min, P = .4). Follow-up time of 12.2 months was the same in both groups. CrCl decreased significantly during the follow-up period in both groups (IF: 69.3 mL/min to 61.7 mL/min, P < .01; SF: 71.7 mL/min to 64.9 mL/min, P < .03). Postoperative CrCl (IF: 61.7 mL/min, SF: 64.9 mL/min, P = .3), and the rate of CrCl decrease during the follow-up period (IF: −10.9%, SF: −9.5%, P = .2) was not different between the two groups. The number of patients with a >20% decrease in CrCl was not different between the two groups (IF: n = 35 [25.9%], SF: n = 41 [29.9%], P = .46). However, the magnitude of decrease in CrCl in patients with renal impairment was greater in patients treated with suprarenal fixation endografts (SF: −39%) compared with those treated with infrarenal endografts (IF: −31%, P = .005). This greater degree of renal impairment was not due to identifiable differences in preoperative risk factors, age, or baseline CrCl. No patients in these series required dialysis. Conclusions: Regardless the type of endograft used, there is a 10% decrease in CrCl in the first year after endovascular aneurysm repair. Suprarenal fixation does not seem to increase the likelihood of postoperative renal impairment. Decline in renal function over time after endovascular aortic repair is probably due to multiple factors, and measures known to be effective in protecting kidneys should be considered for these patients. Long-term follow-up with measurement of CrCl, along with renal imaging and regular blood pressure measurements, should be performed to detect possible late renal dysfunction. Prospective studies comparing suprarenal versus infrarenal fixation are needed to confirm those results. [Copyright &y& Elsevier]

Rationale and objectives: Most methods used in functional MRI (fMRI) brain mapping require restrictive assumptions about the shape and timing of the fMRI signal in activated voxels. Consequently, fMRI data may be partially and misleadingly characterized, leading to suboptimal or invalid inference. To limit these assumptions and to capture the broad range of possible activation patterns, a novel statistical fMRI brain mapping method is proposed. It relies on hidden semi-Markov event sequence models (HSMESMs), a special class of hidden Markov models (HMMs) dedicated to the modeling and analysis of event-based random processes. Materials and methods: Activation detection is formulated in terms of time coupling between (1) the observed sequence of hemodynamic response onset (HRO) events detected in the voxel’s fMRI signal and (2) the “hidden” sequence of task-induced neural activation onset (NAO) events underlying the HROs. Both event sequences are modeled within a single HSMESM. The resulting brain activation model is trained to automatically detect neural activity embedded in the input fMRI data set under analysis. The data sets considered in this article are threefold: synthetic epoch-related, real epoch-related (auditory lexical processing task), and real event-related (oddball detection task) fMRI data sets. Results: Synthetic data: Activation detection results demonstrate the superiority of the HSMESM mapping method with respect to a standard implementation of the statistical parametric mapping (SPM) approach. They are also very close, sometimes equivalent, to those obtained with an “ideal” implementation of SPM in which the activation patterns synthesized are reused for analysis. The HSMESM method appears clearly insensitive to timing variations of the hemodynamic response and exhibits low sensitivity to fluctuations of its shape (unsustained activation during task). Real epoch-related data: HSMESM activation detection results compete with those obtained with SPM, without requiring any prior definition of the expected activation patterns thanks to the unsupervised character of the HSMESM mapping approach. Along with activation maps, the method offers a wide range of additional fMRI analysis functionalities, including activation lag mapping, activation mode visualization, and hemodynamic response function analysis. Real event-related data: Activation detection results confirm and validate the overall strategy that consists in focusing the analysis on the transients, time-localized events that are the HROs. Conclusion: All the experiments performed on synthetic and real fMRI data demonstrate the relevance of HSMESMs in fMRI brain mapping. In particular, the statistical character of these models, along with their learning and generalizing abilities are of particular interest when dealing with strong variabilities of the active fMRI signal across time, space, experiments, and subjects. [Copyright &y& Elsevier]

Background & Aims: The aim of this study was to generate an improved prognostic model for predicting recurrence in liver transplant candidates with hepatocellular carcinoma (HCC). Methods: Predictors of recurrence were tested by a Cox model analysis in a training cohort of 537 patients transplanted for HCC. A prognostic score was developed and validated in a national cohort of 435 patients followed up prospectively. Results: α-Fetoprotein (AFP) independently predicted tumor recurrence and correlated with vascular invasion and differentiation. At a Cox score threshold of 0.7 (area under the receiver operating characteristic curve, 0.701; 95% confidence interval, 0.63–0.76; accuracy, 75.8%), a model combining log10 AFP, tumor size, and number was highly predictive of tumor recurrence and death. By using a simplified version of the model, with untransformed AFP values, a cut-off value of 2 was identified. In the validation cohort, a score greater than 2 predicted a marked increase in 5-year risk of recurrence (50.6% ± 10.2% vs 8.8% ± 1.7%; P < .001) and decreased survival (47.5% ± 8.1% vs 67.8% ± 3.4%; P = .002) as compared with others. Among patients exceeding Milan criteria, a score of 2 or lower identified a subgroup of patients with AFP levels less than 100 ng/mL with a low 5-year risk of recurrence (14.4% ± 5.3% vs 47.6% ± 11.1%; P = .006). Among patients within Milan criteria, a score greater than 2 identified a subgroup of patients with AFP levels greater than 1000 ng/mL at high risk of recurrence (37.1% ± 8.9% vs 13.3% ± 2.0%; P < .001). Net reclassification improvement showed that predictability of the AFP model was superior to Milan criteria. Conclusions: Prediction of tumor recurrence is improved significantly by a model that incorporates AFP. We propose the adoption of new selection criteria for HCC transplant candidates, taking into account AFP. [ABSTRACT FROM AUTHOR]

Frequency-domain analysis of heart rate variation has been suggested as an effective screening tool for sleep apnoea syndrome (SAS) in the general population. The aim of this study was to determine whether this method could be effective in patients with chronic congestive heart failure (CHF). 84 patients with stable CHF, left ventricular ejection fraction (LVEF) <45 %, and sinus rhythm were included prospectively. Patients underwent simultaneous polygraphy to measure apnoea/hypopnoea index (AHI) and ECG Holter monitoring to measure the power spectral density of the very low frequency component of the heart rate increment, expressed as the percentage of total power spectral density (% VLFI). VLFI could be determined in 54 patients (mean age 52.8+/-12.3 years and LVEF 33.5+/-9.8 %). SAS defined as AHI >=15•h-1 was diagnosed in 57.4 % of patients. % VLFI was not correlated with AHI (R=0.12). Receiver operating characteristic curves constructed using various AHI cut-offs (5 to 30.h-1) failed to identify a % VLFI cut-off associated with SAS. The 2.4 % VLFI cut-off recommended for the general population of patients with suspected SAS had low values for specificity (35 %), positive and negative predictive value (35 % and 54 % respectively). Heart rate increment analysis demonstrated several limitations in CHF. At this time, HRV methodology could not be proposed as the first step of SAS screening in CHF population. [Copyright &y& Elsevier]

White Leghorn chicks homozygous for B19 MHC haplotype were selected for 18 generations on tu- mor regression after inoculation in the wing web with an SR-D strain of Rous sarcoma virus (RSV) at 4 wk of age. Each chick was assigned a tumor profile index (TPI) based on age at death and size of the tumor. During 18 generations, 2,010 birds were divergently selected on TPI for either progression or regression of the tumor (P and R lines). A Brody growth curve was fitted for each bird. Brody function parameters included the asymptotic tumor volume (A), the factor for increased growth in progression phase (K1), the factor for decreased growth in regression phase (K2), age at maximum volume (Tmax), and maximum volume of the tumor (Vmax). Tumor growth curves were found to be different according to line, sex, and restriction fragment pattern Y complex Rfp-Y MHC haplotype (Yw*15, Yw*16, and Yw*17). Within the P line, birds from the Yw*16 haplotype reached Vmax at an earlier age than Yw*15 and Yw*17, but with a lower Vmax value. Within the R line, tumor growth curves of birds from Yw*16 and Yw*17 haplotypes were similar. Rank correlations between the different parameters and TPI were low (between -0.26 and 0.36). Heritability estimated by the sire component was high for Vmax (0.73). Heritabilities of Tmax and K2 were moderate (0.20 to 0.23 for Tmax and 0.18 to 0.21 for K2) allowing these traits to be used as selection criteria. Heritabilities of A and K1 were lower than 0.12. Modeling the growth curve should contribute to better distinction between progressors and regressors. [ABSTRACT FROM AUTHOR]