Habitual snoring as a risk factor for brain infarction

The association of habitual snoring with cerebral ischaemia was studied, in a case control-study, in 133 patients aged 45-75 years (103 men and 30 women) and 133 controls matched for sex and age. Ischaemic stroke was confirmed by brain computed tomography or magnetic resonance imaging. History of risk factors, especially of snoring and sleeping habits was recorded with structured questionnaire during interview. Prevalence of habitual snoring significantly differs between patients with stroke and controls: 31/133 (23.3%) vs 11/133 (8.3%) (Odds ratio 3.4, 95% confidence interval 1.5 to 7.6, p < 0.001). Even after adjusting for matching variables and confounding risk factors (arterial hypertension, cardiac arrhythmia, and obesity), habitual snoring carries a significant risk factor for stroke (odds ratio: 2.9, 95% confidence interval 1.3 to 6.8 (p = 0.01)). The risk of ischaemic stroke was higher among older male patients with arterial hypertension who always snored. Habitual snoring was not significantly linked with sleep-related stroke nor with the pathophysiology of strokes. Inquiring about habitual snoring should become a routine practice, especially among older male patients with arterial hypertension, and specific preventive measures should be instituted at an earlier stage.

Changes of cerebral biopterin and biogenic amine metabolism in leukemic children receiving 5 g/m2 intravenous methotrexate

Acute or subacute neurologic disorders can be observed in patients receiving high-dose methotrexate therapy for lymphoblastic leukemia or malignant tumor. Impairment of biopterin metabolism leading to decreased availability of monoamine neurotransmitters has been suggested to explain methotrexate neurotoxicity. To investigate such a mechanism, we have measured prospectively by HPLC the concentrations of total biopterin, homovanillic acid, and 5-hydroxyindolacetic acid in cerebrospinal fluid of 57 children with acute lymphoblastic leukemia. A sequential analysis of cerebrospinal fluid was performed for each patient: cerebrospinal fluid samples were obtained before therapy and after each of the four high-dose methotrexate infusions during the CNS prophylaxis phase. A significant increase of total biopterin concentrations in cerebrospinal fluid was observed after high-dose methotrexate therapy compared with the pretreatment values. No cumulative effect was noted. In contrast, no significant variation of the homovanillic acid and 5-hydroxyindolacetic acid levels was observed in cerebrospinal fluid. However, individual analysis revealed a transient decrease of homovanillic acid and 5-hydroxyindolacetic acid concentrations in cerebrospinal fluid of six children. The increase of total biopterin mimicking that observed in inherited dihydropteridine reductase deficiencies suggests that methotrexate inhibits the regenerating system of biopterin in the brain of patients undergoing high-dose methotrexate therapy.

[Simplified vesico-urethral anastomosis after radical retropubic prostatectomy for cancer. A preliminary comparative study]

The authors have done a prospective non randomized study to compare two methods of radical retropubic prostatectomy, without bladder neck preservation (Group 1 = 30 patients) or with bladder neck preservation (Group 2 = 15 patients). Anastomosis was simplified for the 15 patients with bladder neck preservation according to the Vest suture procedure. A comparative urodynamical study was performed with each group. Selection for one or the other technique was made by the personal choice or every surgeon. Results were similar for pre operative clinical staging, Gleason score with both groups. There was no significant difference in survival, progression of the disease and three month PSA level as those of the last follow-up visit (18-96 months). There was no difference between the 2 groups regarding operative time, blood loss, urethral catheterization time, drainage output and mean hospitalisation time. The only significant difference was the number of post operative transfused blood units in the Vest suture group (p < 0.001). There were no positive margin on the preserved bladder neck in group 2, even if there was finally an understaging or another apical positive margins. Complications were not significantly different in the two groups with 10 bladder neck strictures in the group 1 (33%) and only 2 in the group 2 (14.2%) (NS). Complete continence rate was 73.3% and 64.2% respectively (NS). Bladder neck incision was never followed by incontinence. On urodynamical study, 9 cases in each group were compared and both were similar but there was a tendency to a higher urethral pressure in group 2. Comments pointed out that bladder neck preservation and simplified Vest traction suture did not give more post operative nor carcinological complications than classical technique with direct separate stitches sutures. Disease progression, continence and bladder neck stricture rates were compared to literature. The urodynamical results were the same as those observed by others studies.

Randomised trial of prevention of biliary stent occlusion by ursodeoxycholic acid plus norfloxacin

Biliary stents are liable to clog. We investigated whether a choleretic plus an antibiotic could delay clogging. 20 consecutive patients with a malignant biliary stricture were randomised after endoscopic insertion of a polyethylene stent to receive ursodeoxycholic acid plus norfloxacin (13-15 mg/kg and 400 mg, daily) or conservative treatment. The drug combination was associated with: a longer median patency of first (49 vs 6 weeks) and all stents (38 vs 7 weeks); a prolonged median survival (67 vs 18 weeks); and a shorter mean hospital stay (0.2 vs 1.0 days per week of survival). Thus ursodeoxycholic acid plus norfloxacin may prevent stent clogging.

Serum antibody response to the superficial and released components of Helicobacter pylori

Superficial and released components were extracted from six selected Helicobacter pylori strains. The protein and antigenic profiles of these extracts were representative of the profiles found most frequently among the clinical strains and included major peptidic fractions at 19, 23.5, 57, 68, 76, 118, and 132 kDa and major antigens at 68, 57, and 23.5 kDa. Immuno-cross-reactions were seen with a hyperimmune rabbit serum to Campylobacter fetus but not with sera to Campylobacter jejuni or Salmonella spp. An antigenic preparation was obtained by pooling equivalent quantities of each extract, and the antigenic preparation was used to study the antibody responses of sera from 65 French patients and 127 Tunisian patients. By enzyme-linked immunosorbent assay, we observed that the sera from French and Tunisian patients clustered into two populations, defined as antibody positive (72 patients) and antibody negative (120 patients). The antibody-positive patients were more frequently infected with H. pylori (P < 0.01) and were more frequently affected with gastritis (P = 0.05). However, no correlation between antibody levels and clinical signs of dyspepsia was noticed. The proportions of antibody-positive patients were similar in France and Tunisia. Antibody-positive and antibody-negative sera were studied by western blot (immunoblot) analysis. The antibody-positive sera revealed an average of 7.7 antigenic bands, whereas the antibody-negative sera revealed an average of 2.4 antigenic bands (P < 0.01). The antigens between 15 and 40 kDa and greater than 66 kDa were specifically recognized by the antibody-positive sera, although in this molecular size range the antibody profiles of these sera exhibited a fairly high degree of diversity. We conclude that the superficial and released components from H. pylori contain a variety of bacterial immunogens and may be useful in antigenic preparations for the serodiagnosis of H. pylori infections. Moreover, a group of antigens in combination appears to be useful for discriminating antibody-positive and antibody-negative patients.

[Analysis of the monthly incidence of cutaneous leishmaniasis in Ceará (Brazil) between 1986 and 1990]

To determine the value of an epidemiological surveillance system, we evaluated the incidence rate and trends of American Cutaneous Leishmaniasis (ACL) in three health districts of Ceara state, Brazil. We used a retrospective time series analysis of ACL notifications in Ceara state between 1986 and 1990. The trend of this endemic/epidemic disease was analysed by using three types of modeling on the moving average graph: a linear, linear periodic and non linear periodic model. The study samples consisted of the 14,615 cases of ACL notified in Ceara state between 1986 and 1990. Males accounted for 54% of cases. Age was between 1 month and 19 years in 42% of cases. Most cases (81%) were diagnosed on clinical grounds only. After calculation of the moving average and application of a linear regression model to these means, the trend analysis revealed that 1) there was a significant trend towards an increase in two of the three health districts, with correlation coefficients of 0.31 and 0.49 (Student's t test = 2.24 and 3.88) and a significant trend towards a decrease in the remaining district (correlation coefficient = 0.51, t = 4.1). The linear periodic model showed a cyclic representation with a 36-month period and a base of 241. The non linear periodic model showed a cycle of 32 months and a base of 241, and was a better representation of the disease variations. Despite the limited study period, it appears that the 32-month cycle could be attributed to meteorological conditions. Field studies are underway to determine the precise causes of this periodicity.

Auditory brain-stem responses (ABRs) in sleep respiratory disorders

Neurophysiological repercussions of sleep respiratory disorders (SRDs) are still unclear. It has been shown that SRDs induce disturbance on auditory event-related potentials with a delayed latency of the cognitive P300 potentials. Since the Auditory Brainstem Responses (ABRs) explore the auditory brainstem structures and are independent on cognition, we evaluated the neurological impact of SDRs on central nervous system by ABRs in these patients. Four groups of patients were studied: snorers (S, 17 subjects), sleep apnoea syndrome (SAS, 48 subjects), apnoeic patients with respiratory insufficiency (SAI, 17 patients) and patients with respiratory insufficiency alone (RI, 12 subjects). A standard polysomnographic study was done in each patient with further quantitative analysis of sleep, respiratory events, and oxygen arterial saturation. ABRs were recorded before the study night and interpeak latencies (IPLs) between waves I, III and V were measured. Results were expressed as the mean of each group for all the different parameters. ABR IPL latencies (IPLI-III, IPLIII-V, IPLI-V) of the four groups were within the normal range. However, comparing groups between themselves, there were significant differences (ANOVA) between groups. Longer IPLIII-V and IPLI-V (which explored the central conduction time) were observed in group SAI compared to group SAS. No evidence on the origin of this elongation was found; the level of hypoxia, in particular, was not related to IPL values. These results show that SAS alone do not affect lower brainstem auditory function, in contrast to the association of SAS and RI.

Predictive factors of long-term compliance with nasal continuous positive airway pressure treatment in sleep apnea syndrome

The long-term acceptability of treatment with nasal continuous positive airway pressure (CPAP) was studied prospectively in 44 patients with obstructive sleep apnea syndrome. At 14 months on the average after starting treatment with CPAP, 30 patients (68 percent) were found to be compliant (characterized by use of the apparatus every night throughout the night, for more than 5 h per night). The daily use of nasal CPAP was significantly correlated to the initial apnea/hypopnea index (p = 0.013; r = 0.37), as well as to the percentage of light sleep (p = 0.045; r = 0.30) and slow-wave sleep (p = 0.037; r = -0.31) during the initial polygraphic recording. We found a strong correlation between the daily use of nasal CPAP and the difference in the apnea/hypopnea index (p = 0.025; r = -0.34), the difference in mean oxygen saturation during sleep (p = 0.013; r = 0.38), and the difference in hypersomnia scores (p = 0.006; r = -0.40) obtained before and after treatment by nasal CPAP. Thus, patients used CPAP much more if they had an initial significant clinical handicap and if they were aware of the beneficial effects of CPAP. Under these conditions, patients tended to use the apparatus for the optimal length of time, regardless of the side effects linked to the treatment. This ensured efficacy and the maintenance of good compliance. This study confirms the importance of supervision of the time counter, as well as regular encouragement of patients to use the treatment as long as possible each night, in order to extract a maximum benefit from treatment by nasal CPAP.

Is ursodeoxycholic acid an effective therapy for total parenteral nutrition-related liver disease?

Cholestasis is the predominant complication in patients with total parenteral nutrition-related liver disease. Ursodeoxycholic acid has been reported to be beneficial for patients with various chronic cholestatic liver diseases. The aim of this prospective study was to determine the effects of short-term administration of ursodeoxycholic acid in nine patients (mean age 54 years) treated with home total parenteral nutrition (31 +/- 2 (mean +/- SEM) kcal/kg per day) for 13.9 +/- 5.2 months for short bowel syndrome; all presented biological evidence of hepatic cholestasis (mean alkaline phosphatase activity 5.2 times the upper limit of the normal) which appeared during nutrition; there was no cause of hepatic dysfunction other than total parenteral nutrition. Patients received 11.2 +/- 0.8 mg/kg per day of ursodeoxycholic acid orally for 1 (n = 9) or 2 (n = 5) 2-month periods, each of which was followed by a 2-month wash-out period. Liver function tests were performed before and at the end of each period. Compared with non-treatment periods, the two periods of ursodeoxycholic acid administration induced a significant reduction in gamma-glutamyl transpeptidase (27.1% and 20.4% respectively; p = 0.001) and alanine aminotransferase serum activities (7.0% and 34.8% respectively; p = 0.01) from baseline values. Alkaline phosphatase activity (p = 0.09), aspartate aminotransferase (p = 0.11) and bilirubin (p = 0.75) serum activities underwent no significant change during the study. These preliminary results strongly suggest that short-term ursodeoxycholic acid administration leads to biochemical improvement in liver function tests in patients with total parenteral nutrition-related liver disease.

Terlipressin plus transdermal nitroglycerin vs. octreotide in the control of acute bleeding from esophageal varices: a multicenter randomized trial

We undertook a multicenter randomized trial to compare the efficacy of terlipressin combined with transdermal nitroglycerin and that of octreotide in the emergency control of acute variceal hemorrhage in cirrhosis. Over 16 mo, 87 patients with endoscopically proved active bleeding from esophageal or cardiac varices were enrolled in five centers in France and randomly assigned to receive intravenous terlipressin (2 mg and then 1 mg/4 hr over 24 hr) and transdermal nitroglycerin (10 mg/12 hr over 24 hr) (group 1) or octreotide (continuous intravenous infusion of 25 micrograms/hr over 12 hr and then 100 micrograms at hr 12 and hr 18 subcutaneously) (group 2). Initial control of bleeding was assessed at the end of 12 hr of treatment on the basis of stability of blood pressure and hematocrit level with no further transfusion requirements. At 12 hr, bleeding was controlled in 59% (24 of 41) in group 1 and 78% (36/46) of group 2 patients (Fisher's exact test, p = 0.064). Mean transfusion requirements over this 12-hr period were significantly greater in group 1 (three blood units; range = 0 to 13) than in group 2 (one blood unit; range = 0 to 5) (p = 0.002). After the first 12 hr, 20% of patients (5 of 24) had repeat bleeding in group 1 compared with 27% (10 of 36) in group 2. During the first 48-hr period, five patients (12%) died in group 1, compared with 3 (6%) in group 2. Few side effects were noted in either group. However, in group 1 two patients experienced severe bradycardia; it resulted in death in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Endothelin modulates dihydropyridine receptor decreased binding in hippocampal slices from normotensive and spontaneously hypertensive rats

Previous studies in rats have demonstrated both the link between voltage-operated calcium channels and endothelin and their cerebral involvement in the pathophysiology of spontaneous hypertension. In the present study, the interaction of endothelin with specific dihydropyridine (DHP) binding sites was investigated using the brain slices model. In rat hippocampal slices, pre-incubation with Bay K 8644 decreased [3H] (+) PN 200-110 binding. There was no difference in agonist-induced decrease of DHP binding in normotensive and spontaneously hypertensive (SH) rats. The effect of Bay K 8644 was partially inhibited by endothelin but not by angiotensin in both normotensive and hypertensive rats. These data compared to those of other studies suggest that DHP binding sites which are regulated by endothelin are post-synaptic. We conclude that brain slices provide a good in vitro model to study DHP receptor regulation and to explore endothelin interactions with DHP-sensitive Ca2+ channels.

Event-related auditory evoked potentials and multiple sclerosis

Long latency event-related auditory evoked potentials, particularly the P300 wave, constitute an objective electrophysiological index of cognitive function. For this reason, these potentials have been studied in a series of 101 patients with multiple sclerosis (MS), classified according to McAlpine's criteria into definite, probable and possible cases. The patients were also classified as depressed or non-depressed according to the DSM-III and Research Diagnostic Criteria. They were also subjected to a battery of psychometric tests. In the patient population the N200 and P300 latencies were increased, as were the P200 latencies, when compared with a control population. This electrophysiological pattern had previously been observed in other conditions characterised by subcortical lesions. Partial correlations (at constant disease duration) between the disability score and the cognitive deficit were found to be significant. Patients with an increased P300 latency had a greater disability and the P300 latency was significantly correlated with the duration of the illness. The N200 and P300 latencies were increased in depressed MS subjects, but this increase did not reach the level of significance. Depression was more frequent in the more severely handicapped patients. This suggests that the origin of the depression seen in multiple sclerosis is only partly organic, and that it is one of the factors contributing to the subcortical cognitive deficit in multiple sclerosis. Progressive forms of the disease exhibited the most profound cognitive deficit, and the most marked increase in P300 latency.

[Radiological consequences of lumbar disk surgery. Evaluation by MRI after 3 months]

Radiologic effects of the surgery for lumbar disc herniation: a study with MRI at the end of the third post-operative month. The results of patients operated for lumbar disc herniation are good in 83%, fair in 10% and poor in 7. The poor results are considered to be the consequence of post operative fibrosis. A prospective study in 67 patients has been performed to study the post operative appearance of the operated lumbar spine, three months after surgery. 45 days after surgery the recovery of patients was assessed by the score of Staufer and Coventry and patients were entered in the study independently of their clinical state. The MRI was performed at the end of the third month postoperatively and patient recovery assessed according to the score of Senegas and Lavignolle. All the clinical and radiologic data were statistically analysed... the chi-square test, a p. value less than 0.05 was considered statistically non significant. The correlation between the clinical recovery and the MRI was realized.

A comparative study of enzymuria, in the rat, of the drug combinations amikacin/vancomycin and amikacin/teicoplanin

The aim of this study was to compare nephrotoxicity of the combinations amikacin/vancomycin and amikacin/teicoplanin. Eighteen male Wistar rats were divided into 3 groups of 6 animals each. The first group received 50 mg.kg-1 of amikacin (i.m. route) and 100 mg.kg-1 of vancomycin (i.p. route). The second group received 50 mg.kg-1 of amikacin (i.m. route) and 40 mg.kg-1 of teicoplanin (i.p. route). The third group received an isotonic solution of sodium chloride. The antibiotics were injected for a period of 6 days. Urine samples of animals were taken 24 h before the beginning of the experiment, then every day, throughout the duration of the treatment (6 days), continuing for an additional 3 days following completion of the administration of the drugs. There were no significant modifications in the urinary excretions of alanine aminopeptidase and the creatinine between the 3 groups; but in the group receiving amikacin/teicoplanin, we observed between days 3 and 8 an increase in the excretion of N-acetyl-beta-D- glucosaminidase when compared to the group receiving amikacin/vancomycin (p < or = 0.05) and to the control group (p < or = 0.01).

Long-term outcome of severe radiation enteritis treated by total parenteral nutrition

The outcome of 31 patients with severe radiation enteritis treated by total parenteral nutrition (TPN) was analyzed. Before initiation of parenteral nutrition, 18 of the patients had not had abdominal surgery, while 13 had either a resection or an intestinal bypass for radiation enteritis. Median follow-up was 2 1/2 years (range: 1 month to 12 years) from the time of initiation of parenteral nutrition. Surgery was required in 15 cases because parenteral alimentation could not be continued. Only eight of these 15 were able to resume a normal oral intake. Total parenteral nutrition allowed oral feeding to be resumed in 11 (36%) after a median follow-up of 40 months (range: 6-142 months). In general, total parenteral nutrition was well tolerated and was associated with low morbidity. Eighteen patients died, 13 of complications due to radiation therapy, four of cancer recurrence, and one of an unrelated cause. Survival probability was 58% at one year and 36% at five years. When possible, prognostic factors present either before or at initiation of total parenteral nutrition were analyzed. Age, predisposing vascular factors (hypertension, diabetes mellitus, or vascular disease), and enteric fistula and/or perforation were found to have prognostic value. The probability of clinical radiation enteritis recurrence was 34% at one year and 47% at two years. A clinical recurrence of symptoms was more frequent but not significantly so after parenteral nutrition as compared to surgical therapy of radiation enteritis. Although TPN corrected denutrition and allowed deferred surgery in some patients, severe radiation enteritis remains a poorly predictable progressive disease with numerous relapses.

Wave III of brain-stem auditory evoked potentials analysed both with 3-channel Lissajous' trajectory and dipole localization method

Wave III of the BAEP was analysed both with 3-channel Lissajous' trajectory (3-CLT) and a dipole localization method. The experiments were performed on 5 normally hearing subjects. The dipole analysis used an iterative algorithm assuming a spherical head model and homogeneous media. 3-CLT planar analysis was performed with a laboratory system. The parameters of plane C (azimuth and elevation) corresponding to wave III and those of the equivalent dipole showed a similar orientation of the plane and the dipole. This result is in agreement with previous investigations and confirms the interest of 3-CLT in far-field analysis and, at the same time, validates the dipole localization model used in this study, at least for BAEP analysis.