Le chordome de la colonne cervicale

Résumé Observation d'une femme de 37 ans, qui présente un volumineux chordome des vertèbres C. 4 et C. 5, évoluant depuis 3 ans.Du point de vue radiologique, il faut noter l'intégrité relative des corps vertébraux par rapport à la destruction massive des masses latérales d'un côté. L'angiographie vertébrale met en évidence un foyer de vascularisation pathologique non spécifique. L'importance du développement de la tumeur dans les tissus mous du cou et de la nuque, bien visible entre autres sur les clichés standards par le refoulement de la trachée, nous parait être un argument valable en faveur du chordome dans le diagnostic différentiel d'avec les autres tumeurs malignes des vertèbres.La radiosensibilité de la tumeur fut indiscutable dans notre cas. Il y a grand intérêt à profiter de la fonte de la masse tumorale par les radiations à hautes doses pour entreprendre ensuite l'exérèse chirurgicale aussi complète que possible.

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Summary The case is recorded of a female, aged 37, who presented with a massive Chordoma of C4 and C5 which had developed over three years.From the radiological point of view it should be noted that there was relative preservation of the vertebral bodies in association with extensive destruction of the lateral masses on one side. Vertebral angiography showed an area of non-specific pathological circulation. The significance of tumour growth in the soft tissues of the neck, which was well shown on the standard projections by compression of the trachea, seems to us to be a valid argument for including chordoma in the differential diagnosis of other malignent tumours of the vertebrae.In our case the tumour was undoubtedly radiosensitive. The melting away of the tumour mass by radiation therapy in high dosage is of considerable interest to the subsequent undertaking of surgical extirpation as completely as possible.

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Zusammenfassung Kasuistische Beschreibung einer 37jährigen Frau mit einem umfangreichen Chordom der Wirbel C 4 und C 5, das sich innerhalb von drei Jahren entwickelt hat. In radiologischer Hinsicht ist die relative Intaktheit der Wirbelkörper im Vergleich zur erheblichen Zerstörung der Massae laterales einer Seite zu erwähnen. Die Vertebralis-Angiographie läßt einen Herd mit unspezifischer pathologischer Vaskularisation erkennen. Die Entwicklung des Tumors in den Weichteilen des Halses und Nackens, die übrigens auf den Übersichtsaufnahmen durch die Verlagerung der Trachea gut erkennbar ist, scheint uns in differentialdiagnostischer Hinsicht ein wertvoller Hinweis auf ein Chordom zu sein und ermöglicht die Abgrenzung von anderen malignen Wirbeltumoren.In unserem Fall war der Tumor eindeutig radiosensibel. Es scheint nützlich zu sein, zunächst die Tumormassen durch hochdosierte Bestrahlung zu verkleinern und dann eine möglichst radikale chirurgische Entfernung anzuschließen.

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Resumen Observación de un caso de una mujer de 37 años, que presenta un cordoma voluminoso de las vertebras C 4 y C 5, con una evolución de 3 años.Desde el punto de vista radiológico hay que destacar la integridad relativa de los cuerpos vertebrales en relación con la destrucción masiva de las masas laterales de un lado. La angiografía vertebral puso de manifiesto un foco de vascularización patológica y no específica. La importancia del crecimiento del tumor en las partes blandas del cuello y de la nuca, que son visibles en las places por el gran rechazamiento de la traquea, nos parecen un argumento de peso en favor de un cordoma, en diagnóstico diferencial con otros tumores malignos vertebrales.En nuestro caso la radiosensibilidad del tumor fué indiscutible. Tiene un gran interés la disminución de la masa tumoral por la radiación a dosis elevada para completar el tratamiento con una exéresis lo más completa posible.

     

Review on pharmacological pain management in trauma patients in (pre‐hospital) emergency medicine in the Netherlands

Pain is one of the main complaints of trauma patients in (pre‐hospital) emergency medicine. Significant deficiencies in pain management in emergency medicine have been identified. No evidence‐based protocols or guidelines have been developed so far, addressing effectiveness and safety issues, taking the specific circumstances of pain management of trauma patients in the chain of emergency care into account. The aim of this systematic review was to identify effective and safe initial pharmacological pain interventions, available in the Netherlands, for trauma patients with acute pain in the chain of emergency care. Up to December 2011, a systematic search strategy was performed with MeSH terms and free text words, using the bibliographic databases CINAHL, PubMed and Embase. Methodological quality of the articles was assessed using standardized evaluation forms. Of a total of 2328 studies, 25 relevant studies were identified. Paracetamol (both orally and intravenously) and intravenous opioids (morphine and fentanyl) proved to be effective. Non‐steroidal anti‐inflammatory drugs (NSAIDs) showed mixed results and are not recommended for use in pre‐hospital ambulance or (helicopter) emergency medical services [(H)EMS]. These results could be used for the development of recommendations on evidence‐based pharmacological pain management and an algorithm to support the provision of adequate (pre‐hospital) pain management. Future studies should address analgesic effectiveness and safety of various drugs in (pre‐hospital) emergency care. Furthermore, potential innovative routes of administration (e.g., intranasal opioids in adults) need further exploration.     

Assessment of Passive Intestinal Permeability Using an Artificial Membrane Insert System

Despite reasonable predictive power of current cell-based and cell-free absorption models for the assessment of intestinal drug permeability, high costs and lengthy preparation steps hamper their use. The use of a simple artificial membrane (without any lipids present) as intestinal barrier substitute would overcome these hurdles. In the present study, a set of 14 poorly water-soluble drugs, dissolved in 2 different media (fasted state simulated/human intestinal fluids [FaSSIF/FaHIF]), were applied to the donor compartment of an artificial membrane insert system (AMI-system) containing a regenerated cellulose membrane. Furthermore, to investigate the predictive capacity of the AMI-system as substitute for the well-established Caco-2 system to assess intestinal permeability, the same set of 14 drugs dissolved in FaHIF were applied to the donor compartment of a Caco-2 system. For 14 drugs, covering a broad range of physicochemical parameters, a reasonable correlation between both absorption systems was observed, characterized by a Pearson correlation coefficient r of 0.95 (FaHIF). Using the AMI-system, an excellent predictive capacity of FaSSIF as surrogate medium for FaHIF was demonstrated (r = 0.96). Based on the acquired data, the AMI-system appears to be a time- and cost-effective tool for the early-stage estimation of passive intestinal permeability for poorly water-soluble drugs.     

The transition from patient to mental health peer worker: A grounded theory approach

Peer workers are increasingly being engaged in contemporary mental healthcare. To become a peer worker, patients must evolve from having a patient identity to a peer worker identity. This study aims to understand how mental health peer workers experience their transition and how it affects their view of themselves and their direct working context. A grounded theory approach was used. Seventeen mental health peer workers in Belgium were recruited through theoretical sampling. Semi‐structured interviews were conducted and analysed according to the constant comparative method. The results indicate that novice peer workers experience peer work as an opportunity to liberate themselves from the process of mental suffering and realise an acceptable form of personal self‐maintenance. As peer workers become more experienced, they are confronted with external factors that influence their self‐maintenance and personal development. Experiencing clarity in their duties and responsibilities, equality, and transparency in the workplace reinforce their experience of self‐maintenance and positively influence their self‐development. Experiencing a lack of clarity in their duties and responsibilities, inequality, and lack of openness discourage peer workers’ self‐development process. These experiences challenge their personal motivations to become peer workers, which are usually linked to building a meaningful life for themselves. The insights can encourage organisations to build up a supportive environment collaboratively with peer workers and ensure that peer workers can exert their authentically unique role in mental healthcare.     

Pitfalls of digital angiography in the diagnosis of right aortic arch

The authors describe the difficulties using intravenous digital subtraction angiography, in diagnosing on a left anterior oblique view a right aortic arch with aberrant left subclavian artery and left descending aorta. The proximal topography of the left common carotid artery ostium is a useful sign in the diagnosis of this kind of abnormality.     

Rapid reductions and millennial-scale variability in Nordic Seas sea ice cover during abrupt glacial climate changes

Constraining the past sea ice variability in the Nordic Seas is critical for a comprehensive understanding of the abrupt Dansgaard-Oeschger (D-O) climate changes during the last glacial. Here we present unprecedentedly detailed sea ice proxy evidence from two Norwegian Sea sediment cores and an East Greenland ice core to resolve and constrain sea ice variations during four D-O events between 32 and 41 ka. Our independent sea ice records consistently reveal a millennial-scale variability and threshold response between an extensive seasonal sea ice cover in the Nordic Seas during cold stadials and reduced seasonal sea ice conditions during warmer interstadials. They document substantial and rapid sea ice reductions that may have happened within 250 y or less, concomitant with reinvigoration of deep convection in the Nordic Seas and the abrupt warming transitions in Greenland. Our empirical evidence thus underpins the cardinal role of rapid sea ice decline and related feedbacks to trigger abrupt and large-amplitude climate change of the glacial D-O events.

Sea ice is a critical component of the global climate system as it affects Earth’s albedo, phytoplankton productivity, ocean-atmosphere heat and gas exchange, and ocean circulation (1). Rapid sea ice retreat, as observed in the modern Arctic Ocean, exerts important climate feedbacks that may lead to an accelerated climate warming at northern high latitudes (2). While many climate models have difficulties in reproducing the currently observed Arctic sea ice decline (3), the rates of ongoing atmospheric warming in some Arctic regions are already comparable with those of prominent abrupt climate changes that occurred during the last glacial period (4). The latter are referred to as Dansgaard–Oeschger (D-O) climate events and known from Greenland ice core records as abrupt shifts between cold Greenland stadials (GS) and warmer Greenland interstadials (GI) occurring repeatedly ∼10–110 ka (5, 6). The millennial-scale glacial climate variability was a global phenomenon with different characteristics in the northern and southern hemispheres, but the most striking feature of the D-O events is an extremely abrupt climate transition that includes an atmospheric warming of 5–16.5 °C over the Greenland ice sheet happening in just a few decades (7). Analogous to the modern and future sea ice retreat and resulting warming in the Arctic, the abrupt D-O climate transitions are widely believed to have been amplified by rapid sea ice retreat in the Nordic Seas (8–15).Today, the Nordic Seas are largely ice-free, and warm Atlantic surface waters flow into the Norwegian Sea as far north as Svalbard at ∼80°N (Fig. 1), where the Arctic sea ice cover is being eroded, in particular in the Barents Sea. The warm Atlantic surface waters release heat to the atmosphere as it flows northward, which is accompanied by convective intermediate and deep-water formation between Norway and Greenland, feeding the lower limb of the Atlantic Meridional Overturning Circulation (AMOC) (16). A portion of the Atlantic waters continues flowing into the stratified Arctic Ocean as subsurface waters (17). While the pattern of ocean circulation during GI was fairly comparable to that today, proxy data indicate that the glacial Nordic Seas exhibited a stable surface stratification during GS, similar to the modern Arctic Ocean (13, 18). The AMOC and associated northward surface heat transport into the Nordic Seas were weakened during GS, with most extreme weakening related to Heinrich events signified by massive iceberg discharges to the North Atlantic (19, 20). Intermediate and deep waters in the stadial Nordic Seas were 2–4 °C warmer as compared with GI or modern conditions, resulting from a stable halocline and reduced open-ocean convection (21, 22). Contemporaneously, an extended sea ice cover reaching at least as far south as the Greenland–Scotland Ridge at ∼60°N insulated the high-latitude atmosphere from the deep oceanic heat reservoir (23, 24). Model simulations support a subsurface warming scenario under extended sea ice during GS (22, 25, 26) and suggest that a rapid removal of the sea ice cover might have caused the abrupt and high-amplitude D-O climate warming (11, 12, 14, 15).Open in a separate windowFig. 1.Core sites and regional context of the study area. Yellow diamonds mark the core sites investigated in this study. The map shows the core-top P_BIP₂₅ distribution (42, 43, 63), illustrating the great potential of the biomarker approach for sea ice reconstruction. Orange, yellow, and green dots mark core-top sites north, east, and south of Greenland, respectively, data of which are investigated in this study. Small black dots indicate locations of published core-top data. Purple lines mark the modern sea ice extent during September (dashed) and March (solid), averaged between A.D. 1981 and 2010 (https://nsidc.org/; ref. 64). The thin blue line shows the P_BIP₂₅ = 0.2 isoline, representing best the modern winter/spring sea ice extent. Red arrows illustrate the warm and saline North Atlantic Current (NAC). The map was produced with Ocean Data View software (65).Although there is some evidence of millennial-scale sea ice fluctuations during the last glacial, the few available sea ice proxy records (23, 24, 27–31) are mostly restricted to the southern Norwegian Sea and the Arctic Ocean, often have a limited temporal resolution, and partly reflect opposing trends regarding stadial–interstadial sea ice changes depending on the proxies used. Here we present high-resolution sea ice biomarker records from two key sites that form a North–South transect within the Atlantic inflow region in the Norwegian Sea and are thus ideally suited to record spatiotemporal shifts in sea ice cover in both the entrance and the interior of the ocean basin, oceanic fronts, and Atlantic water inflow during the last glacial (Fig. 1). Furthermore, we combine these marine sea ice proxy records with an independent sea ice record based on bromine-enrichment (Br_enr) values from an East Greenland ice core, which significantly enhances the spatial coverage, the robustness of results, and temporal constraint of the sea ice reconstruction. We focus on five representative glacial D-O cycles between 32 and 41 ka, which comprise long- and short-lasting GI as well as several GS, one of which includes Heinrich Event 4. The application of the cryptotephra-based chronological constraints provides a level of robustness as to the timing, duration, and nature of the events unfolding during abrupt climate changes. Our study provides robust empirical evidence that resolves rapid and widespread sea ice retreat in the Nordic Seas and its role in initiating and amplifying the abrupt climate change of the glacial D-O events.