Severe blunt trauma of the liver: study of mortality factors

One hundred three victims of blunt trauma of the liver with serious hepatic lesions (classes III through V of Moore's classification) were seen over a period of 18 years, the total duration of this retrospective study being divided in two: 1973-1981 and 1982-1990. During the first period, indications for hepatic resection were extensive (56% of all surgical procedures), and overall perioperative mortality was 24%. Preference was shown for conservative treatment during the second period (71% of patients) and there was an increase in perioperative mortality to 34%. This increase was not attributable to the decrease in the number of excisions but rather to an increase in the severity of hepatic lesions between the two periods (the rate of class V lesions rising from 17% to 26% of cases) and the rate of multiple trauma (rising from 41% to 95%), with mortality linked to the presence of extra-abdominal lesions rising from 20% to 50% of all deaths. These results may bring into question the validity of conservative treatment for liver trauma at the present time.

Lipogenic enzyme and apoprotein messenger RNAs in long-term primary culture of chicken hepatocytes

Hepatocytes isolated from 9-week-old chickens were cultured in a serum-free, hormonally defined medium. Relative amounts of mRNAs coding for lipogenic enzymes (acetyl-CoA carboxylase, fatty acid synthase, delta 9 desaturase, malic enzyme) and apoproteins (apoprotein A1 and apoprotein B) were determined until the 12th day. beta-actin and albumin mRNA, as well as albumin secretion, were also assessed. Cellular metabolic activity appeared to be very low for the first days of culture, but increased after the 7th day. All the mRNAs studied, except for that of malic enzyme, were present from this time throughout the culture lifespan. The biological significance of the observed results and the relevance of this chicken hepatocyte culture system for long-term metabolic and genetic studies are discussed.

[Pancreatic endocrine tumor with metastases and increase of alpha-fetoprotein. A case report]

The authors report the case of a 48 years old man presenting a pancreatic islet cell carcinoma (gastrinoma) with liver, nodes and peritoneal metastases, associated with an elevated alpha-fetoprotein (AFP) concentration. Incomplete remission was first obtained with a chemotherapy using Streptozotocin combined with 5-Fluorouracil, in association with a Somatostatin analogue (SMS 201-995). But when relapses occur, another chemotherapy was not so effective. Serum gastrin and AFP levels had the same evolution and appear to have the same interest to follow the course of the disease.

Identifying genes involved in the variability of genetic fatness in the growing chicken

A precise knowledge of the genome involved in the expression of a quantitative trait could provide a useful tool in breeding programs; molecular genetic methods are capable of yielding this kind of information. An experimental procedure is presented here for identifying genes whose expression is related to weight variability of abdominal adipose tissue in the growing chicken. Quantitative traits are the result of metabolic pathways exhibiting some major regulation stages that are controlled genetically. These steps involve genes that may act as "major genes". With regard to chicken fat metabolism, most fatty acids are synthesized in the liver and incorporated into very low density lipoprotein (VLDL) particles before their secretion into the plasma. Accordingly, the present study focused on the expression of liver genes. The mRNA of lipogenic enzymes (acetyl-coenzyme-A carboxylase, fatty acid synthase, malic enzyme, and delta 9-desaturase) were analyzed. Also studied were apoprotein (apo)A1, apoVLDL-II, and apoB mRNA from 9-wk-old male chickens from two lines selected for high and low abdominal fat pads. Significant differences for apoA1 mRNA levels occurred between fat and lean birds. Moreover, the total quantity of mRNA provided an accurate estimation of the abdominal fat pad (r = .74 with P < .05).

[Long-term effects of splenectomy for immune thrombopenic purpura related to human immunodeficiency virus. A retrospective study from 2 groups, with and without splenectomy]

In order to evaluate the long-term effects of splenectomy in patients with human immunodeficiency virus-related immune thrombocytopenic purpura (ITP), we studied retrospectively two populations of patients: 21 had undergone splenectomy and 18 had not. At the time of diagnosis the first population had on average lower platelet counts than the second one. After a mean follow-up of 47 +/- 9 months the situation has been reversed: the population that underwent splenectomy had significantly higher platelet counts than that without splenectomy (190.600 +/- 55.300/mm3 versus 91.500 +/- 55.300/mm3, P less than 0.001). Moreover 76 percent of the patients with splenectomy versus 50 percent in the population without splenectomy were in complete remission of ITP at the last follow-up. It therefore seems that splenectomy had a statistically positive effect on platelet counts without worsening the immune status. Indeed, the clinical course towards AIDS was the same in both populations (35 percent in patients with splenectomy and 22 percent without, P = NS). Following splenectomy, the total blood lymphocytes count was increased, especially the CD8 population, while the CD4 count remains unchanged; these findings seem to be a common feature after splenectomy.

Diffraction efficiency of reflection gratings with a parabolic section profile

Diffraction properties of reflection gratings with a parabolic groove profile are analyzed. It is shown that these structures produce a large number of diffracted waves with similar intensities. Theoretical and experimental results at the wavelength of 780 nm are shown. These gratings are made from holographic diffraction gratings recorded in a photoresist.

[The Pharmacia CAP system as a new measure of specific IgE. Application in the diagnosis of hypersensitivity to the venom of the Vespula wasp]

Every improvement can make the measurement of specific IgE more effective. This is the case with the CAP system, a new solid phase technique which uses an Immunocap made from hydrophilic polymer, encased in a capsule, for the fixation of anti-IgE or allergen. The Immunocap fixes 3 times more protein than paper discs. Another improvement is that of calibration of the CAP System by the WHO standard for IgE, with the results expressed in KUI/I: 0.35 to 100 KUI/I for specific IgE and 2 to 2,000 KUI/I for total IgE. The study was of patients who had an anaphylactic or systemic reaction after wasp stings. The subjects were divided into two groups A and B and compared with a reference Groupe C. The study also included subjects who were sensitive to mites, grass pollens and egg. Finally, the technique itself was submitted to a reproducibility test. The results confirm that the sensitivity and specificity of the test were both equal to unity. The CAP System therefore offers the possibility of detecting the lowest amounts of IgE.

ApoVLDLII gene transcription in immature cockerels without estradiol stimulation

1. Previous studies have led to the conclusion that the gene encoding the apo very low density lipoprotein II (ApoVLDLII) is under full estrogen control. However, by using a sensitive hybridization technique we found a weak expression of this gene in some males in the absence of hormone. 2. As the vitellogenin II gene, which is also estrogen dependent, remains inactive in these animals it is likely that they carry a deregulated allele of the ApoVLDLII gene. 3. The highest level of ApoVLDLII mRNA is found in genetically fat males suggesting a possible involvement of the ApoVLDLII gene in fatness determinism.

[Splenectomy can cure thrombocytopenia of systemic lupus erythematosus]

Between 1976 and 1988, 7 patients with systemic lupus erythematosus (SLE) underwent splenectomy for severe peripheral thrombocytopenia (platelet count below 30,000/mm3) which had resisted corticosteroid therapy (n = 7), high-dose immunoglobulins (n = 4), vincristine (n = 2), danazol (n = 1), cyclophosphamide and plasma exchanges (n = 1). No infective or non-infective complication of splenectomy was observed. One patient died of intracerebral haemorrhage 3 years later, after several recurrences of thrombocytopenia. The 6 survivors have normal platelet counts (more than 150,000/mm3) after splenectomy, over a mean follow-up period of 80 months. Two of these 6 patients never had recurrent thrombocytopenia and have not received any treatment for 17 to 102 months. Four patients are still under prednisone in doses lower than 30 mg/day. Among these, 2 had recurrent thrombocytopenia 2 and 60 months respectively after splenectomy and responded favourably to another course of corticosteroids associated, in one case, with cyclophosphamide. Thus, splenectomy is an effective treatment of the thrombocytopenia associated with SLE. However, the possibility of early or late recurrences makes it necessary to reserve splenectomy to those cases where medical treatment has failed or is contra-indicated.

Iron chelators: in vitro inhibitory effect on the liver stage of rodent and human malaria

The activity of desferrioxamine (Desferal) and desferrithiocin (a newly developed oral iron chelator) was evaluated against the liver stage of Plasmodium yoelii and P. falciparum in the rodent and the human hepatocyte in vitro culture system. The two iron chelators were found to inhibit the liver schizogony of both the rodent and the human Plasmodium species at concentrations achievable in vivo. P. falciparum proved to be more sensitive (ic 95% below 20 micromol/l than P. yoelii (ic 95% 50-100 micromol/l). As assessed by electron microscopy, drug administration was associated with focal clarification of the cytoplasm thought to be reversible. As desferrioxamine and desferrithiocin are known to be equally active on the blood stage of rodent and human plasmodia, iron chelators are deserving of further investigation as potential alternative candidates to existing drugs for radical cure of malaria.

Plasmodium ovale: in vitro development of hepatic stages

Primary cultures of human hepatocytes, a culture-derived clone from the human hepatoma Hep G2 line, and cultured rat hepatocytes were inoculated in vitro with Plasmodium ovale sporozoites extracted from Anopheles stephensi, An. gambiae, and An. dirus mosquitoes. Penetration and differentiation of P. ovale sporozoites into trophozoite stage parasites occurred in all three cell types, but with a lower transformation rate in the Hep G2 cell line than in the primary cultured hepatocytes. Further maturation was obtained only in the human hepatocytes, in which the parasites were uninucleate until the third day after infection, before development to 60 micron in length by the eighth day. Additionally, this culture system was used to assess the ability of an anti-P. ovale sporozoite monoclonal antibody to inhibit penetration of sporozoites into hepatocytes and to detect sporozoite determinants in the maturing liver stage parasites.

[Lymphocytic interstitial pneumopathy in AIDS-related complex. Presence of the LAV virus in the bronchoalveolar lavage fluid]

A new case of lymphocytic interstitial pneumonitis developed in the course of a persistent generalized lymphadenopathy syndrome is reported. The patient was a 30-year old Haitian woman with only her ethnic risk factor. Broncho-alveolar lavage showed high cellularity with mostly major lymphocytosis (76%) and a fall of the OK T4/OK T8 ratio to 0.23. The LAV was isolated from the lavage fluid lymphocytes on the same day and within the same culture time as from blood, using lymphocyte culture and measurement of reverse transcriptase activity in the supernatant fluid of cell cultures. This, together with the strongly positive (1/80) LAV serology in fluid as compared with blood (1/640), suggested that the LAV virus was directly or indirectly involved in the pneumonitis, being responsible for lymphocyte proliferation as it is in lymph nodes. No superinfection with a bacterial, fungal or other than LAV viral agent was found in blood or in lavage fluid. Lymphocytic interstitial pneumonitis is uncommon in AIDS or ARC (13 cases reported), but its incidence no doubt is underestimated, as it may be latent. It certainly accounts for the high lymphocyte count observed in broncho-alveolar lavage fluid in the absence of superinfection and, most probably, for many cases of so-called "non-specific pneumonia". In 1986, patients with apparently primary lymphocytic interstitial pneumonitis should be investigated for AIDS or ARC.

[Post-stress nonlithiasic acute cholecystitis. Contribution of ultrasonics to the diagnosis and treatment in 50 cases]

Fifty cases of post-stress acute acalculous cholecystitis were observed during the past 9 years, mainly after major surgery or trauma. The apparently increasing incidence over the last 4 years (42 cases) could probably be explained by a better diagnostic approach of this condition by routine use of ultrasonography. No specific etiological factor could be found; however total parenteral nutrition and/or sepsis and/or use of narcotics could possibly play a role in the appearance of this complication. Although diagnosis can occasionally be suspected in the basis of abdominal and infectious signs, diagnosis was made primarily on the following ultrasonographic signs: enlarged gallbladder with thickened wall, sludge, and occasionally a double-wall aspect and a pericholecystic collection. In this series, most of the patients were treated by cholecystectomy, but a new therapeutic approach was used in 10 cases: percutaneous transhepatic drainage under sonographic control. Outcome is still poor, with a 50 p. 100 mortality rate.

[Digestive manifestations of periarteritis nodosa in a series of 120 cases]

In a series of 120 patients with periarteritis nodosa (PAN), 50 had gastrointestinal manifestations; 34 had transient abdominal pain which regressed spontaneously or in response to corticosteroid therapy and required no further investigation. Thirty one more serious episodes occurred in the remaining 26 patients. Eight of these were in fact the initial signs of PAN and 13 required laparotomy. There were 20 episodes of abdominal pain (peritonitis: 9, pancreatitis: 4, acute cholecystitis: 2, duodenal ulcer: 3, intestinal infarction: 1, unexplained pain without diagnosis at laparotomy: 1) and 11 of gastrointestinal hemorrhage (melaena or hematemesis: 4; hematochezia: 5). Clinical and biological features of patients with and without gastrointestinal manifestation were not significantly different except for cardiac involvement which was significantly more frequent (p less than 0.05) in the second group. Corrected survival rates were significantly lower (p less than 0.05) in patients with gastrointestinal manifestations. These results show that, in patients with PAN, digestive manifestations, particularly perforations, carried a poor prognosis. Nevertheless exploratory laparotomy and surgery unrelated to PAN (eg appendicectomy) were well tolerated.

[Percutaneous cholecystostomy in so-called post-stress acute cholecystitis]

During the last 8 years 51 cases of acute post-traumatic or post-operative cholecystitis were observed in our intensive care unit. Twelve patients benefited from ultrasonically guided percutaneous cholecystostomy under television control. Diagnosis was made by ultrasonic examination and was based on the finding of an enlarged and tender gallbladder with an abnormally thick wall, sometimes with a double wall, and on the presence of sludge. Immediate cholangiography revealed spontaneous perforation in 4 patients who were operated upon at once. The other patients were treated by percutaneous cholecystostomy only with apparent success. The frequency, physiopathology, diagnosis and treatment of acute post-aggressive cholecystitis are discussed, with special reference to this new therapeutic approach.

[Cystadenoma and cystadenocarcinoma of the pancreas. Apropos of 7 new cases]

Cystadenomas and cystadenocarcinomas of the pancreas are tumours which remain poorly known because of their relative rarity. They are seen essentially in women aged between 40 and 60 and involve the left half of the pancreas more often than the right. The symptomatology remains latent for a fairly long time, which explains the fact that they are most often discovered only at the stage of a palpable tumour. Recent methods of investigation--echotomography and computed tomography--are of very great value in preoperative diagnosis. It is extremely important to draw the distinction within the group of benign cystadenomas between microcystic forms and macrocystic forms or mucinous cystadenomas, the latter having a definite potential for malignant change, possibly explaining the link with certain cystadenocarcinomas. As a result, excision surgery is always preferable, when possible, to bypass surgery, at least in caudal or corporeo-caudal lesions, since excision surgery is usually easy. For cephalic lesions, if excision surgery seems difficult, it may be conceivable, using modern techniques of investigation, to adopt a conservative attitude when there are no features suggestive of potential malignant change.

[Intra-arterial chemotherapy for hepatic metastases. Experience of the Pitié-Salpêtrière Hospital Group]

Intra-arterial chemotherapy of hepatic metastases is theoretically interesting because of the essentially arterial blood supply of these metastases in contrast with the healthy tissue and because of the theoretical pharmacokinetic advantage for certain drugs, depending on their quotient of hepatic extraction and the wole body clearance. We have treated 43 patients with this technique. The primary cancer was a cancer of the colon in 10 patients, a breast cancer in 16 patients, a melanoma in 7 patients and cancers of other sites in 10 patients. The chemotherapy was initially administered by selective catheterisation of the hepatic artery via an axillary approach and usually consisted of a bolus injection of adriamycin 40 mg/m2 and mitomycin 10 mg/m2 and an infusion of 5 FU 1 g/m2 for 24 to 72 hours. In 15 patients, we surgically implanted a subcutaneous reservoir and catheter. To date, we have performed 114 arterial injections via the catheter and 60 injections into sub-cutaneous reservoirs. We have observed few complications, apart from thrombosis of the axillary artery (3 cases) and of the hepatic artery (5 cases). We have obtained 4 complete responses, 16 partial responses, 8 stabilisations, 10 failures and, unfortunately, 5 patients died rapidly after a single course of chemotherapy and could not be evaluated. The response rate was particularly high for the breast cancers (about 60 percent) and the cancers of the colon (more than 50 percent). We have also observed 3 complete responses in patients treated by intravenous chemotherapy with the same protocol.

[Hepatic metastases. Value of chemotherapy by the intra-arterial route]

Forty-three patients with metastatic liver cancer were treated with multiple chemotherapy by the intra-arterial route. Metastases originated from primary cancer of the breast (16) or colon (10), melanoma (7) and miscellaneous tumours (10). In 35 patients chemotherapy was administered by selective catheterization of the hepatic artery via the axillary artery; it usually (31 cases) consisted of doxorubicin (60 mg/m2) and mitomycin (10 mg/m2) injections, and continuous infusion of 5-fluorouracil (1 g/24 or 72 hours). In 14 patients (10 responders to the above method and 4 new cases), a catheter with subcutaneous chamber was implanted surgically so that chemotherapy could be continued through the chamber. Blood toxicity was usually moderate. The main complication of injections through the catheter (114) or through the chamber (60) was thrombosis. However, except for 1 lethal cerebral thrombosis, the others (axillary artery 3, hepatic artery 5) were unattended by functional symptoms. Transient biochemical signs of hepatic cytolysis were frequent after each course. Hepatic insufficiency was severely aggravated in 2 cases. Painful digestive disorders were relieved by symptomatic treatments. Four complete responses, 16 partial responses, 8 stabilizations and 10 failures were observed; 5 patients died soon after one single course of intra-arterial therapy. The high response rates (greater than 50%) in metastases from cancer of the breast and colon, and chiefly the 3 complete responses obtained in patients with mammary carcinoma were most encouraging, bearing in mind that one of these 3 patients had not responded to intravenous chemotherapy.

[Fatal polyarteritis nodosa following Graves' disease (author's transl)]

Polyarteritis nodosa (PAN), with a fatal outcome, developed during the course of a therapeutically controlled Graves'disease. A review of the published literature confirms that two mechanisms may be involved in the onset of PAN in hyperthyroid patients: an immune response, which is probable in the case reported, or a toxic effect related to the treatment of the hyperthyroidism. This case also emphasizes the therapeutical difficulties encountered, in spite of the corticoid and cyclophosphamide associated treatment with plasmapheresis.