Hopital Charles Nicolle

Tunis, Tunisia

Hopital Charles Nicolle

Tunis, Tunisia
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Bourre B.,Hopital Charles Nicolle | Zephir H.,University of Lille Nord de France | Papeix C.,Hopital Pitie Salpetriere | Brassat D.,Hopital Purpan | And 7 more authors.
Neurology | Year: 2012

Objective: The purpose of our study was to assess the influence of pregnancy on the course of neuromyelitis optica (NMO) and the impact of epidural analgesia and breastfeeding on its activity in the postpartum period. Methods: We performed a retrospective study of patients with NMO diagnosed according to Wingerchuk criteria. We noted the number of relapses during the year before pregnancy (BP), during pregnancy (first trimester, second trimester, third trimester), and the year after (Y+1: first trimester, second trimester [PP2], and third and fourth trimesters postpartum). Epidural analgesia and breastfeeding were recorded. Disability was evaluated with the Kurtzke Expanded Disability Status Scale (EDSS). The annualized relapse rate (ARR) was calculated. Results: We identified 124 patients (85 female) in the French NOMADMUS cohort on November 1, 2010. A total of 20 women (including 25 pregnancies) were informative with complete files. Comparisons between the ARR of each period and BP (1.0 ± 0.09) only showed an increased tendency for PP2 (0.8 ± 0.06, p = 0.07). Epidural analgesia and breastfeeding had no influence on the course of NMO. The EDSS score increased from 1.5±1.7 BP to 2.6±1.9 Y+1 (p=0.027). Conclusion: This study shows that pregnancy influences the activity of NMO, a finding that justifies close medical monitoring. We found no evidence to suggest that either epidural analgesia or breastfeeding has an aggravating effect on NMO. Copyright © 2012 by AAN Enterprises, Inc.

Schwarz L.,Hopital Charles Nicolle | Votanopoulos K.,Wake forest University | Morris D.,St George Hospital | Yonemura Y.,Kusatsu General Hospital | And 5 more authors.
Annals of Surgery | Year: 2016

Objective: To report the morbidity and risk factors for overall complications and for pancreatic fistula (PF) after distal pancreatic resection (DP) during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Summary Background Data: The safety of DP in patients with peritoneal surface malignancies treated by CRS and HIPEC has been debated. The risk of PF and its impact on surgical outcomes are not well defined. Methods: Between 2001 and 2012, 118 patients with peritoneal surface malignancy undergoing CRS/HIPEC required DP at 7 oncological surgical centers. The incidence, clinical impact, and risk factors of PF were analyzed. Results: The indications for DP were tumoral invasion of the pancreatic gland with (n=24; 20%) or without splenic extension (n=76; 64%), invasion of the pancreatic capsule (n=10; 9%), or iatrogenic lesions during CRS (n=8; 7%). The rate of 90 days postoperative mortality was 7.6%, and the rate of severe morbidity (Clavien-Dindo-III) was 44%. Pancreatic fistula was observed in 39 cases (33%), with the majority grade B (48.7%) or C (28.2%). In multivariate analysis, the risk factors for PF were a peritoneal cancer index more than 20 (risk ratio: 3.01; P=0.022) and an operative time more than 550 min (risk ratio: 2.74; P=0.038). The occurrence of PF was not associated with a higher risk of 90-day mortality (5.1% vs 8.8%, not significant). Conclusions: With regard to reported morbi-mortality rates, DP associated with CRS/HIPEC may be a reasonable procedure in highly selected patients when done in high-volume centers. Therefore, distal pancreatic involvement should not be considered as a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface disease. © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Cosnes J.,University Pierre and Marie Curie | Bourrier A.,University Pierre and Marie Curie | Laharie D.,Hopital Haut Leveque | Nahon S.,Groupe Hospitalier Intercommunal le Raincy Montfermeil | And 11 more authors.
Gastroenterology | Year: 2013

Background & Aims Immunomodulator therapy is effective for patients with Crohn's disease (CD) but has not been shown to affect disease progression, presumably because it is given too late after diagnosis. We compared the efficacy of early treatment (within 6 months after diagnosis) with azathioprine versus conventional management of patients at high risk for disabling disease. Methods We performed an open-label trial of adults with a diagnosis of CD for less than 6 months who were at risk for disabling disease. From July 2005 to November 2010, patients at 24 French centers were randomly assigned to treatment with azathioprine (2.5 mg â̂™ kg-1 â̂™ day-1, n = 65) or conventional management (azathioprine only in cases of corticosteroid dependency, chronic active disease with frequent flares, poor response to corticosteroids, or development of severe perianal disease) (n = 67). The primary end point was the proportion of trimesters spent in corticosteroid-free and anti-tumor necrosis factor (TNF) - free remission during the first 3 years after inclusion. Results During the 3-year follow-up period, 16 patients in the azathioprine group were switched to mercaptopurine or methotrexate therapy because of intolerance or poor efficacy. Forty-one patients in the conventional management group required immunosuppressant therapy (61%; median time to first prescription, 11 months). In the azathioprine group, a median 67% of trimesters were spent in remission (interquartile range, 11%-85%) compared with 56% in the conventional management group (interquartile range, 29%-73%) (P =.69). Among secondary outcomes, a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery than in the conventional management group (96% ± 3% and 82% ± 6% at month 36, respectively; P =.036). The cumulative proportion of patients free of intestinal surgery and anti-TNF therapy did not differ between groups. Conclusions Based on results from a clinical trial, administration of azathioprine within 6 months of diagnosis of CD was no more effective than conventional management in increasing time of clinical remission. Clinicaltrials.gov, Number NCT00546546. © 2013 by the AGA Institute.

Ducreux M.,CNRS Gustave Roussy Institute | Ducreux M.,University Paris - Sud | Malka D.,CNRS Gustave Roussy Institute | Mendiboure J.,CNRS Gustave Roussy Institute | And 16 more authors.
The Lancet Oncology | Year: 2011

Background: The optimum use of cytotoxic drugs for advanced colorectal cancer has not been defined. Our aim was to investigate whether combination treatment is better than the sequential administration of the same drugs in patients with advanced colorectal cancer. Methods: In this open-label, randomised, phase 3 trial, we randomly assigned patients (1:1 ratio) with advanced, measurable, non-resectable colorectal cancer and WHO performance status 0-2 to receive either first-line treatment with bolus (400 mg/m 2) and infusional (2400 mg/m 2) fluorouracil plus leucovorin (400 mg/m 2) (simplified LV5FU2 regimen), second-line LV5FU2 plus oxaliplatin (100 mg/m 2) (FOLFOX6), and third-line LV5FU2 plus irinotecan (180 mg/m 2) (FOLFIRI) or first-line FOLFOX6 and second-line FOLFIRI. Chemotherapy was administered every 2 weeks. Randomisation was done centrally using minimisation (minimisation factors were WHO performance status, previous adjuvant chemotherapy, number of disease sites, and centre). The primary endpoint was progression-free survival after two lines of treatment. Analyses were by intention-to-treat. This trial is registered at ClinicalTrials.gov, NCT00126256. Findings: 205 patients were randomly assigned to the sequential group and 205 to the combination group. 161 (79%) patients in the sequential group and 161 (79%) in the combination group died during the study. Median progression-free survival after two lines was 10·5 months (95% CI 9·6-11·5) in the sequential group and 10·3 months (9·0-11·9) in the combination group (hazard ratio 0·95, 95% CI 0·77-1·16; p=0·61). All six deaths caused by toxic effects of treatment occurred in the combination group. During first-line chemotherapy, significantly fewer severe (grade 3-4) haematological adverse events (12 events in 203 patients in sequential group vs 83 events in 203 patients in combination group; p<0·0001) and non-haematological adverse events (26 events vs 186 events; p<0·0001) occurred in the sequential group than in the combination group. Interpretation: Upfront combination chemotherapy is more toxic and is not more effective than the sequential use of the same cytotoxic drugs in patients with advanced, non-resectable colorectal cancer. Funding: Sanofi-Aventis France. © 2011 Elsevier Ltd.

Kirsch M.,Institute Of Cardiologie | Mazzucotelli J.-P.,Nouvel Hopital Civil | Roussel J.-C.,Institute du Thorax | Bouchot O.,Hopital du Bocage | And 4 more authors.
Journal of Heart and Lung Transplantation | Year: 2012

Background: Biventricular support can be achieved using paracorporeal biventricular assist devices (BiVADs), the total artificial heart (TAH), and implantable VADs. This study evaluated the influence of the device on patient survival. Methods: Data from 383 patients (321 men [84%]) undergoing primary, planned biventricular support using durable devices between 2000 and 2010 were extracted from the French multicentric Groupe de Réflexion sur l'Assistance Mécanique (GRAM) registry. Mean age was 41.6 ± 14.0 years. Patients were classified as group 1, 255 (67%) with paracorporeal BiVADs; group 2, 90 (24%) with TAH; and group 3, 38 (10%) with implantable BiVADs. Results: Mean patient support duration was 82.8 ± 107.4 days and similar among groups (p = 0.53). Bridging to transplantation was successful in 211 patients (55%) and to recovery in 23 (6%). Mortality on device was similar among groups (p = 0.16). TAH patients had a significantly lower stroke rate (p < 0.0001). Actuarial estimates for survival while on support were 75.2% ± 2.3%, 64.4% ± 2.7%, 61.1% ± 2.8%, and 56.8% ± 3.1% at 30, 60, 90, and 180 days, respectively, and were similar among groups. However, TAH patients undergoing prolonged support (<90 days) showed a trend toward improved survival (p = 0.08). Actuarial post-transplant survival estimates were, respectively, 81.7 ± 2.7, 75.3 ± 3.0, 73.0 ± 3.0, and 64.7 ± 3.7 at 1 month and 1, 3, and 5 years and were similar among groups (p = 0.84). Conclusion: Survival while on support and after heart transplantation did not differ significantly in patients supported with paracorporeal BiVADs, implantable BiVADs, or the TAH. Patients undergoing prolonged support (>90 days) tended to have improved survival when supported with TAH compared with BiVADs, which may be related to a lower incidence of neurologic events. © 2012 International Society for Heart and Lung Transplantation. All rights reserved.

Bergeron A.,University Paris Diderot | Chevret S.,University Paris Diderot | Chagnon K.,University Paris Diderot | Chagnon K.,University of Montréal | And 13 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2015

Rationale: Systemic steroids are the standard treatment for bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic stem cell transplantation (HSCT) despite their poor efficacy and disabling side effects. Objectives: To evaluate the effectiveness and tolerance of budesonide/ formoterol as an alternative treatment for BOS after HSCT. Methods: In this randomized, double-blind, placebo-controlled study, we randomly assigned 32 HSCT recipients with mild/severe BOS to receive budesonide/formoterol or placebo for 6 months. The primary outcome was the change in the FEV1 after 1 month of treatment (M1) compared with the baseline value. Patients were unblinded at M1 if there was no improvement in the FEV1. Those who had initially received placebo were switched to budesonide/ formoterol. Intention-to-treat analysis was performed to assess the primary outcome. Additional analyses took scheduled treatment contamination into account. Measurements and Main Results: At M1, the median FEV1 increased by 260 ml in the budesonide/formoterol arm compared with 5 ml in the placebo arm (P = 0.012). The median increases in the FEV1 at M1 relative to the baseline value for the treated and placebo groups were 13 and 0%, respectively (P = 0.019). Twenty-five patients received budesonide/formoterol during the study. The median difference in the FEV1 between the baseline and after 1 month of treatment for these patients was 1240 ml (P = 0.0001). The effect of budesonide/formoterol on the FEV1 was maintained in the 13 patients who completed 6 months of treatment. Conclusions: Budesonide/formoterol administration led to a significant improvement in the FEV1 in patients with mild/severe BOS after allogeneic HSCT. Copyright © 2015 by the American Thoracic Society.

Post-traumatic peri-lymphatic fistulas have been described following ear and temporal bone injury, particularly in the setting of temporal bone fractures. The symptoms and signs of perilymphatic fistulae (PLF) are very varied and frequently misleading. The diagnosis can be suspected on the bases of the clinical and the audiometrial findings. Indications for exploratory surgery in cases of trauma are vague and not well described. Aim: To assess the principal clinical and radiologic signs of PLF. Study of 13 patients with different symptoms of posttraumatic peri-lymphatic fistulae. Ten patients had vertigo, and 2 presented otoliquorreha. Two patients had tympanic perforation. Nine patients presented neurosensorinal hearing loss and 5 were completely deaf. A CT Scann was realized in 12 cases and showed the fracture in 10 cases (91%) with a pneumolabyrinth in 4 cases. Medical and postural treatment was indicated for all the patients then a surgery was indicated in all of them in an average wait of 4 months realizing an ear exclusion in one case and a filling-up for 12 patients. Vertigo improved in 10 cases and the hearing loss in 2 cases. The diagnostic of perilymphatic fistulae is not easy. The trauma and the clinical signs can help but the confirmation is surgical. The indication of surgery and its timing are still discussed.

While aortic valve replacement gives excellent short-term and long-term results and is now the " gold standard " treatment for the vast majority of patients with degenerative aortic stenosis, implantation by cardiac catheterization represents a source of hope for thousands of patients who previously had no effective treatment option.

Kourda N.,Hopital Charles Nicolle
Médecine tropicale : revue du Corps de santé colonial | Year: 2010

Disseminated histoplasmosis is a fungal infection caused by Histoplasma capsulatum. It often involves immunodeficient patients and can occur in two forms, i.e., the large- and small-celled variants. The purpose of this report is to describe a case of disseminated histoplasmosis with cutaneous and digestive involvement observed four years after kidney transplantation in a man from Senegal. The patient developed severe sepsis secondary to colonic perforation. Outcome was fatal due to delayed diagnosis and extent of disease.

Obesity is a state of chronic low-grade inflammation that predisposes people to several diseases and that is increasingly prevalent. Rheumatoid arthritis (RA) is marked by the presence of proinflammatory cytokines and, in general, the presence of high levels of inflammatory markers is associated with a severe disease course and joint damage. To assess the impact of obesity on disease activity, quality of life and articular damage in patients with established RA. Between July 2009 to December 2009, 119 RA patients were included and divided in two groups according to the body mass index (obeses and controls). RA activity was assessed by the Disease Activity Score (DAS) 28, quality of life by the Health Assessment Questionnaire (HAQ) and radiographic joint damage by the modified Sharp score. Obesity was not correlated with worsen RA activity (p=0.71) nor quality of life impairment (p=0.51). The obese group had a lower modified Sharp score than the control group (64.97versus113.64; p < 0.032) and this association remained significant after adjustment for age, sex, disease activity, extraarticular manifestations, comorbidities, presence of rheumatoid factor, and disease duration. Obesity does not have an impact on disease activity nor changes in quality of life, but it has a protective effect on the amount of joint destruction in established rheumatoid arthritis.

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