Laparoscopic management of adnexal masses: a gold standard?

PURPOSE OF REVIEW: To review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard. RECENT FINDINGS: Cyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure. SUMMARY: The laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.     

Etiologic diagnosis of 204 pericardial effusions

The etiologic evaluation of pericardial effusion is frequently unsuccessful when noninvasive methods are used. To determine the cause of the current episode, all patients with echographically identified pericardial effusion from May 1998 to December 2002 underwent noninvasive diagnostic testing of blood, throat, and stool samples. Patients with postpericardiotomy syndrome were excluded. To analyze the value of our tests, we tested randomly selected blood donors as negative controls. Among 204 included patients, 107 (52.4%) had a final etiologic diagnosis: the etiology of 52 was highly suspected at first examination and later confirmed (thyroid deficiency, 5 cases; systemic lupus erythematous, 7; rheumatoid arthritis, 7; scleroderma, 3; cancer, 25; and renal insufficiency, 5). A definite etiologic diagnosis was made in 11 patients from pericardial fluid analysis (cancer, 5 cases; tuberculosis, 3; Streptococcus pneumoniae, Citrobacter freundii, and Actinomyces, 1 case each). Among 141 patients considered to have idiopathic pericarditis, 44 (32.1%) gained an etiologic diagnosis by our systematic testing strategy. This included serologic evaluation of serum (Coxiella burnetii, 10 cases; Bartonella quintana, 1; Legionella pneumophila, 1; Mycoplasma pneumoniae, 4; influenza virus, 1), viral culture of throat swabs (enterovirus, 8 cases; and adenovirus, 1), high-level antinuclear antibodies (>1/400, 3 cases), and thyroid-stimulating hormone (15 abnormal results). Antibodies to Toxoplasma and cytomegalovirus, enterovirus recovered from rectal swabs, and low-level antinuclear antibodies were seen with equal frequency in patients and controls.Using our evaluation strategy, the number of pericardial effusions classified as idiopathic was less than in other series. Systematic testing for Q fever, Mycoplasma pneumoniae, thyroid abnormalities, and antinuclear antibodies, accompanied by viral throat cultures, frequently enabled us to diagnose diseases not initially suspected in patients with pericardial effusion.     

"Grape Cluster" Aneurysm of the Right Subclavian Artery: An Unusual Manifestation of Fibromuscular Dysplasia

Aneurysmal lesions affecting the intrathoracic portion of the subclavian artery are rare. We present a patient who had a right hemispheric stroke and transient ischemic attacks caused by a complex right subclavian artery aneurysm with unusual morphological features. Successful surgical repair of this lesion is described along with pathological studies demonstrating fibromuscular dysplasia. The occurrence of such lesions and their management is reviewed.     

Chemosensitization by a non-apoptogenic heat shock protein 70-binding apoptosis-inducing factor mutant

Heat shock protein 70 (HSP70) inhibits apoptosis and thereby increases the survival of cells exposed to a wide range of lethal stimuli. HSP70 has also been shown to increase the tumorigenicity of cancer cells in rodent models. The protective function of this chaperone involves interaction and neutralization of the caspase activator apoptotic protease activation factor-1 and the mitochondrial flavoprotein apoptosis-inducing factor (AIF). In this work, we determined by deletional mutagenesis that a domain of AIF comprised between amino acids 150 and 228 is engaged in a molecular interaction with the substrate-binding domain of HSP70. Computer calculations favored this conclusion. On the basis of this information, we constructed an AIF-derived protein, which is cytosolic, noncytotoxic, yet maintains its capacity to interact with HSP70. This protein, designated ADD70, sensitized different human cancer cells to apoptosis induced by a variety of death stimuli by its capacity to interact with HSP70 and therefore to sequester HSP70. Thus, its chemosensitizing effect was lost in cells in which inducible HSP70 genes had been deleted. These data delineate a novel strategy for the selective neutralization of HSP70.     

Mitochondrial uncoupling protein-2 protects the immature brain from excitotoxic neuronal death

Excitotoxic cell death is the fundamental process responsible for many human neurodegenerative disorders, yet the basic mechanisms involved are not fully understood. Here, we exploited the fact that the immature brain is remarkably resistant to seizure-induced excitotoxic cell death and examined the underlying protective mechanisms. We found that, unlike in the adult, seizures do not increase the formation of reactive oxygen species or result in mitochondrial dysfunction in neonatal brain, because of high levels of the mitochondrial uncoupling protein (UCP2). UCP2 expression and function were basally increased in neonatal brain by the fat-rich diet of maternal milk, and substituting a low-fat diet reduced UCP2, restored mitochondrial coupling, and permitted seizure-induced neuronal injury. Thus, modulation of UCP2 expression and function by dietary fat protects neonatal neurons from excitotoxicity by preventing mitochondrial dysfunction. This mechanism offers novel neuroprotective strategies for individuals, greater than 1% of the world's population, who are affected by seizures.     

Prenatal discovery of an omphalocele associated with an inner umbilical cord Meckel's diverticulum.

The antenatal discovery of Meckel's diverticulum is a rare occurrence; the localization of both Meckel's diverticulum and omphalocele in the umbilical cord has never been described. We present herein a prenatal case of an omphalocele associated with inner umbilical cord dilated Meckel's diverticulum. An umbilical cord cyst was suspected with the cystic image seen during the first trimester exam, and sonography was repeated every month. Several possible diagnoses were discussed including umbilical cord cyst, omphalocele and umbilical cord hernia due to the changing sonographic images during pregnancy. Childbirth had to be arranged at a specialized center. After birth, clamping of the umbilical cord away from the base prevented iatrogenic atresia of the ileum. Surgical treatment had to be arranged during the first days of life.     

Dopaminergic system genes in ADHD: toward a biological hypothesis.

Converging evidence has implicated abnormalities of dopamine neurotransmission to the pathology of attention deficit hyperactivity disorder (ADHD). Several genetic association studies have been published, but so far, no DNA variants have been unequivocally demonstrated as contributing to ADHD susceptibility. Four dopamine related gene loci have been implicated, however: DAT 1, DRD 4, DBH, and DRD 5. Each of these may influence the liability of ADHD to a small degree. Notably, all are involved in signal transduction at the neuronal synapse. In this article, we investigate as candidate genes for ADHD, DNA polymorphisms at dopamine receptors, the dopamine transporter, and genes known to be involved in dopamine synthesis and metabolism. In a recent article, we confirmed the previously reported association of DAT 1 (480 bp allele) with ADHD and identified polymorphisms at two additional loci showing preferential transmission to ADHD children of alleles at DRD 5 (148 bp allele) and at DBH (allele 2, Taq I polymorphism). Increased transmission of the 4 bp deletion in the untranslated exon 1 of the DOPA decarboxylase gene was also observed but was of marginal significance. Nonsignificant trends of association were found for TH (allele 2) and DRD2 (Ser-311). No preferential transmission of alleles to ADHD children was observed for polymorphisms at DRD 1, DRD 2 (Taq I), DRD 3, DRD 4, and COMT. Analyzing the data by sex of transmitting parent showed significant preferential paternal transmission of alleles at TH (allele 2) and a nonsignificant trend for paternal transmission for DRD 2 (Ser-311). We attempt to put these findings together with what is known of the function of the particular proteins, and suggest working hypotheses.     

Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis

Aim: Stigma is pervasive among families of individuals with psychotic disorders and includes both general and ‘associative’ stigma – that is, the process by which a person is stigmatized by virtue of association with another stigmatized individual. These forms of stigma may present a barrier to help seeking. However, little is known about stigma in the early stages of evolving psychotic disorder. Methods: Family members of 11 individuals at clinical high risk and of nine patients with recent‐onset psychosis were evaluated for generalized and associative stigma using the Opinions about Mental Illness (modified) and the Family Experiences Interview Schedule. Results: In this small study, the level of stigma was low, as families endorsed many supportive statements, forexample, patients should be encouraged to vote, patients want to work, mental illness should be protected legally as a disability and parity should exist in insurance coverage. Families also endorsed that both talking and a belief in God and prayer can help someone get better. Only ethnic minority families of individuals with recent‐onset psychosis endorsed a sense of shame and need to conceal the patient's illness. Conclusions: This preliminary study suggests that family stigma is low in the early stages of psychotic disorder, a finding that requires further investigation in a larger and more representative sample. This may be an opportune time to engage young people and families, so as to reduce duration of untreated illness. Ethnic differences in stigma, if replicated, highlight the need for cultural sensitivity in engaging individuals and their families in treatment.     

Person-centredness: conceptual and historical perspectives

PURPOSE: The definition and aims of rehabilitation are both topics of frequent debate. Recently several authors have suggested defining rehabilitation and its goals in terms of 'person-centredness'. However such attempts to define rehabilitation in this way have not occurred without running into their own difficulties and criticisms. Consequently, one may question whether person-centredness is a good candidate to characterize and define rehabilitation. The purpose of this article is to reflect upon the historical background and conceptual underpinnings of this term and their relevance for understanding contemporary person-centred rehabilitation. METHOD: We conducted a conceptual and historical analysis of the notion of person-centredness in relation to rehabilitation. We ask first whether person-centredness has a consistent and fixed definition and meaning? Secondly, where does person-centredness come from, what is its conceptual history and does an historical approach enable us to identify a unique source for person-centredness? RESULTS: In the context of rehabilitation, we have identified four main understandings or interpretations of the term person-centredness, each of which denotes several ideas that can be, in turn, interpreted in quite different ways. Thus the concept of person-centredness in rehabilitation has multiple meanings. The conceptual history indicates that person-centredness has diverse meanings and that it has been used in a variety of contexts somewhat unrelated to disability and rehabilitation. Moreover, there does not seem to be any strict relationship between person-centredness as it is used in the context of rehabilitation and these prior uses and meanings. CONCLUSION: Person-centredness has an ancient pedigree, but its application in the field of rehabilitation raises both practical and theoretical difficulties. It may be that rehabilitation might get a better sense of what it should be and should do by focusing less on the rhetoric of person-centredness and by putting more emphasis on the investigation and operationalization of its key conceptual components.