Douleur postopératoire après hystérectomie par voie vaginale selon la méthode d'hémostase utilisée: thermofusion ou suture aux fils

OBJECTIVES

The purpose of the study was to compare the postoperative pain of patients who had a hysterectomy through vaginal route according to the process of binding: wire or electrosurgical bipolar vessel sealing.

PATIENTS AND METHODS

Retrospective study carried out in the 60 last patients who underwent a hysterectomy by vaginal route for a benign pathology in the gynaecological service of surgery of the CHI Poissy-Saint-Germain-en-Laye until March 2006. Among these patients, 32 had profited from a binding by wire and 28 of the electrosurgical bipolar vessel sealing. The studied criteria were the post-operative pain, total morphine consumption and the durations of the analgesic treatment, the hospitalisation and intervention time.

RESULTS

The postoperative pain in the first 24 hours was twice lower using thermofusion; it was valid in immediate post-operative period and after 24 hours. In addition, total morphine consumption was also significantly lower using thermofusion.

DISCUSSION AND CONCLUSION

This pilot study shows that the electrosurgical bipolar vessel sealing allows a reduction in the pain into the immediate postoperative period. Other prospective and randomised studies would allow it and conclude on the duration of hospitalisation, the quality of life from the patients and the cost in terms of public health.

[218 tooth extraction in patients taking platelet aggregation inhibitors]

INTRODUCTION

The aim of this survey was to show that tooth extraction could be performed in patients taking antiplatelet agents. The main indication of antiplatelet agents is to reduce the thrombotic disease.

MATERIAL AND METHOD

The authors made a descriptive and retrospective analysis of 52 patients taking antiplatelet agents in their department between February 2003 and January 2005. Two hundred and eighteen tooth extractions were performed. For each extraction, a protocol of local hemostasis (filling, suture, compression) was applied.

RESULTS

Three hemorrhagic sockets were reported out of 218 extractions performed without stopping the antiplatelet agent treatment (1.3%). One patient presented with persistent bleeding out of 52 cases (1.9%). No hemostasis had been performed on this patient; a local hemostasis was performed during surgical revision, which stopped the persistent bleeding.

DISCUSSION

These results show that the hemorrhagic risk can be controlled by a local hemostasis protocol.

Prise en charge conservatrice d'un placenta percreta. Apport des nouvelles techniques d'imagerie

The placenta percreta is a rare form of anomaly of placental insertion threatening the maternal and foetal lives. The incidence of abnormal placental adhesion is correlated to frequency of caesarean sections and advanced maternal age. Patients who are at high risk should be identified during pregnancy by ultrasound examination with Color Doppler looking for characteristic features. The practice of MRI in case of echographic suspicion may be useful, particularly in posterior placentas. A late diagnosis, in an emergency context, leads generally to hysterectomy and even to partial resection of neighbour organs. Thus, we report the case of a conservative management associating uterine embolisation following an elective caesarean delivery at 36 weeks gestation. In postpartum, the placental involution was followed clinically and by imagery. In our case, a total abdominal hysterectomy was performed on the fifth postoperative week because of a severe antibiotics resistant infection. No blood transfusion was required and the postoperative period was uneventful. This clinical case aims to show, through an analysis of the recent data of the literature, the interest of modern imagery to select patients with suspected placenta percreta that would be suitable candidates for conservative management.

[Proposition of a simplified investigation model for adverse outcomes in obstetrics and gynaecology]

Investigation of adverse outcomes in obstetrics and gynaecology requires a systematic and systemically oriented approach. The main objective of these assessments is to decrease their incidence. Lethal complications in obstetrics and gynaecological surgery have become so rare in developed countries that we have to grapple mainly with severe morbidities. A model for such investigation is presented, based on answers to 3 questions: What? How? and Why? These questions correspond to 3 components of quality assurance: Outcome, Process, and Structure, respectively. Aspects of Reason's model of accidents are also included, in the form of "active failures" and "latent conditions." The latter are divided into basic contributory factors, 4 of which are derived from a model of human factors influencing behaviour in anaesthesia or flight-crew environments. To illustrate its basic nature, the model is applied to anonymized cases of surgical complications. Application of the model to the reactive investigation of close calls is discussed, as is application to the proactive interrogation of the care system for the presence and nature of hazards that pose threats to safety.

[Use of prosthetic materials in reconstructive pelvic floor surgery. An evidence-based analysis]

Many surgical procedures for the repair of pelvic organ prolapse are used nowadays. Reconstructive pelvic surgery continues to evolve while surgeons continue to search the definitive surgical cure and have to choose the most appropriate procedures for their patients. Concerning the vaginal approach procedures, there is an increasing interest in the use of synthetic meshes which are at present widely used for surgical repair of pelvic organ prolapse. Prosthetic repair seems to be more reliable, especially when native tissues are of poor quality. The use of synthetic meshes may also simplify surgical procedures and reduce operative duration and morbidity. Material must be inert, permanent and resistant to infection. Based on authors' and other researchers' published experimental and clinical experience, polypropylene is assumed to be the most appropriate material for the vaginal repair of pelvic organ prolapse. However, since no standardized outcome measure is available, it is difficult to compare the results of surgical procedures. Only in recent studies, the subjective cure rates (patient satisfaction and outcome) have been assessed as well as the objective cure rates determined by the investigators. The subjective cure rate is probably more influenced by the functional outcome and sexual activity than by the anatomical result. Continuous evaluation is necessary to study replacement synthetic materials which should improve the rate of prolapse recurrence and reduce the risk of complications. Randomized controlled trials are required to determine which surgical procedures and type of prosthesis are most suitable. This review evaluates the properties of prosthetic materials, their complications and the most common procedures involved in the use of meshes for pelvic reconstructive surgery.

Elevated plasma homocysteine in acute stroke was not associated with severity and outcome: stronger association with small artery disease

Homocysteine increases in the acute phase of ischaemic stroke and from the acute to the convalescent phase, suggesting that hyper-homocysteinaemia may be a consequence rather than a causal factor. Therefore we measured homocysteine plasma levels in stroke patients in order to investigate possible correlations of homocysteine with stroke severity and clinical outcome. Further we looked for eventual differences in stroke subtypes. We prospectively studied plasma homocysteine levels in acute stroke patients admitted to the stroke unit of our department. Seven hundred and seventy-five ischaemic stroke patients, 39 cerebral haemorrhages and 421 healthy control subjects have been enrolled. Stroke severity and clinical outcome were measured with the Scandinavian Stroke Scale, the Rankin Scale and the Barthel Index. Stroke severity by linear stepwise regression analysis was not an independent determinant of plasma homocysteine levels. Homocysteine was not correlated with outcome measured by the Barthel Index. Mean plasma homocysteine of both ischaemic and haemorrhagic stroke was significantly higher than controls (p<0.05). Homocysteine had an adjusted odds ratios (OR) of 4.2 (95% CI 2.77-6.54) for ischaemic stroke and of 3.69 (95% CI 1.90-7.17) for haemorrhagic stroke. Compared with the lowest quartile, the upper quartile was associated with an adjusted OR of ischaemic stroke due to small artery disease of 17.4 (95% CI 6.8-44.3). Homocysteine in the acute phase of stroke was not associated with stroke severity or outcome. Elevated plasma homocysteine in the acute phase of stroke was associated with both ischaemic and haemorrhagic stroke. Higher levels are associated with higher risk of small artery disease subtype of stroke.

[Cystocele repair by vaginal approach with a tension-free transversal polypropylene mesh. Technique and results]

OBJECTIVE

To evaluate mid term results, tolerance and efficiency of interposition of a tension-free polypropylene monofilament mesh by vaginal approach for the repair of cystoceles.

PATIENTS AND METHODS

Fourty consecutive women underwent this new procedure between March 2001 and September 2002. After complete dissection of the cystocele, the polypropylene mesh (Gynemesh), Gynecare, Ethicon, Johnson & Johnson, France), proper cut-out was positioned under the bladder without any fixation. The lateral extensions of the mesh where introduced in the para-vesical spaces in contact with the arcus tendinus fascia pelvis.

RESULTS

Before surgery all patients had cystocele of more or equal than grade II according to the POP-Q classification. Eight had grade II cystocele (20%) and 32 had grade III cystocele (80%). Thirty women had associated posterior or median prolapse (82.5%). Thirty women had urinary incontinence (75%). Mean age was 63.9 years (51-78). The procedure was performed without any difficulty in all cases. Duration of a cystocele cure procedure was 20 min +/- 2.2 (16-24). Mean follow-up is 16.4 months +/- 4.7 (12-24). The early complication rate was 7.5% (two vaginal erosions and one complete exposition of the mesh which requires secondary ablation). There was no mesh infection. The success rate was 95%. The satisfaction index overpasses 80% in 95% of our patients 6 months after the cystocele repair.

DISCUSSION AND CONCLUSIONS

The interposition of a sub-vesical transversal tension-free polypropylene mesh by the vaginal route seems to be an excellent procedure in the definitive surgical treatment of grades II and III anterior vaginal wall prolapse. This new procedure is simple, mini-invasive, reproducible and efficient with low morbidity and good tolerance.

[Ovarian choriocarcinoma: about one case]

We report the case of a woman, 43 years old, presenting with an ovarian choriocarcinoma. This patient, addressed for a right-side suspicious pelvic mass, had an exploratory laparotomy. Frozen section found an ovarian cancer. The patient had total hysterectomy, left annexectomy and a complete staging surgery. Histology concluded to an ovarian gestational choriocarcinoma. It is a rare germinal tumour, the treatment of which was medical, with radical exeresis and complete staging surgery associated with polychemotherapy.

Enuresis, sleep and desmopressin treatment

AIM

To detect effects of desmopressin on sleep in enuretic children and to look for polysomnographical differences between responders and non-responders to desmopressin treatment.

METHODS

Twenty-one children with primary nocturnal enuresis were examined polysomnographically before treatment. All but one of the children then received treatment with desmopressin in standard dosage, and the response was documented. Seven of the children underwent a second polysomnographic registration while on treatment.

RESULTS

The time interval (+/- 1 SD) between sleep onset and the enuretic episode was 92 +/- 67 min without medication and 372 +/- 157 min when desmopressin was given (p = 0.003). Standard polysomnographic variables were not affected by the drug. Ten children were desmopressin responders and 10 were non-responders. The total sleep time was 455 +/- 56 min in the former and 408 +/- 31 min in the latter group (p = 0.04). The responders spent 27.4 +/- 5.5% of their total sleep time in rapid eye movement sleep, compared with 18.2 +/- 6.5% in the non-responder group (p = 0.004).

CONCLUSION

Desmopressin has no major effects on sleep as such but does delay bladder emptying. Enuretic children responding to desmopressin treatment have more rapid eye movement sleep than therapy-resistant children.

Use of recombinant factor VIIa to treat persistent bleeding following dental extractions in two cirrhotic patients

BACKGROUND AND OBJECTIVES

A single dose of recombinant factor VIIa (rFVIIa) has been shown to be effective and safe in correcting the prothrombin time (PT) in cirrhotic patients, but no clinical data exists demonstrating its efficacy in arresting active bleeding.

MATERIALS AND METHODS

rFVIIa was used in two cirrhotic patients for persistent bleeding following dental extractions despite repeated treatment at the wound site and, in one case, repeated administrations of fresh-frozen plasma (FFP).

RESULTS

Bleeding stopped promptly in both patients after administration of rFVIIa. However, bleeding recurred in the patient who had not received concomitant treatment at the extraction sites. No recurrence of bleeding was observed in the second patient, who underwent local treatment 15 min after rFVIIa.

CONCLUSIONS

Recombinant factor VIIa arrested bleeding after dental extractions in two cirrhotic patients who had been unsuccessfully treated with FFP. However, additional local treatment is needed to limit the risk of recurrence as a result of the short half-life of rFVIIa.

Screening for mental illness in a Veterans Affairs women's health clinic

This study examined the prevalence of self-reported mental illness and related impairment in social and occupational functioning among 209 female veterans enrolled in a primary care clinic. Ninety-four (45 percent) of the women screened positive for at least one psychiatric disorder, 46 (22 percent) for two or more coexisting psychiatric disorders, and 40 (19 percent) for only subthreshold disorders. The degree of self-reported impairment in social and occupational functioning was strongly related to the number of psychiatric diagnoses. Women who were under the age of 50 and those who had a service-connected disability were more likely to screen positive for a mental disorder.

Crystal structure of rat GTP cyclohydrolase I feedback regulatory protein, GFRP

Tetrahydrobiopterin, the cofactor required for hydroxylation of aromatic amino acids regulates its own synthesis in mammals through feedback inhibition of GTP cyclohydrolase I. This mechanism is mediated by a regulatory subunit called GTP cyclohydrolase I feedback regulatory protein (GFRP). The 2.6 A resolution crystal structure of rat GFRP shows that the protein forms a pentamer. This indicates a model for the interaction of mammalian GTP cyclohydrolase I with its regulator, GFRP. Kinetic investigations of human GTP cyclohydrolase I in complex with rat and human GFRP showed similar regulatory effects of both GFRP proteins.

Investigations of the mechanism of membrane activity of selected triterpenoid saponins

The experiments with different triterpenoid saponins showed a significant difference in the microphysiometric activity between acylated and non-acylated compounds. Only acylated saponins in low concentrations were able to activate the metabolism of endothelial cells after short-time incubation in a transient manner lasting approximately 2 hours. The strongest effect was produced by virgaureasaponin b, an incubation with 4 microg/ml over 6 min induced a stimulation of the metabolic activity of 190% maximum after 30 min. This treatment did not induce non-reversible toxic effects, and could be repeated in the same way after a recovery period. The saponins without acylation in the glycosidic part did not induce metabolic stimulation, even in concentrations higher than observed for the acylated compounds. The current interpretation of the results is connected with the suggestion that especially acylated saponins are able to integrate into the cellular membrane transiently. This integration might induce pore-like structures which change the membrane permeability associated with alterations in the ionic homeostasis between intracellular and extracellular compartments.

Zinc plays a key role in human and bacterial GTP cyclohydrolase I

The crystal structure of recombinant human GTP cyclohydrolase I was solved by Patterson search methods by using the coordinates of the Escherichia coli enzyme as a model. The human as well as bacterial enzyme were shown to contain an essential zinc ion coordinated to a His side chain and two thiol groups in each active site of the homodecameric enzymes that had escaped detection during earlier studies of the E. coli enzyme. The zinc ion is proposed to generate a hydroxyl nucleophile for attack of imidazole ring carbon atom eight of the substrate, GTP. It may also be involved in the hydrolytic release of formate from the intermediate, 2-amino-5-formylamino-6-ribosylamino-4(3H)-pyrimidinone 5'-triphosphate, and in the consecutive Amadori rearrangement of the ribosyl moiety.

Apolipoprotein E polymorphism is not associated with longevity or disability in a sample of Italian octo- and nonagenarians

BACKGROUND

Apolipoprotein E (apo E) is a protein associated with plasma lipoproteins. Apo E polymorphism has been related to significant modifications of lipoprotein profile, as well as to the incidence of different pathologies including cardiovascular disease, Alzheimer's disease, and vascular dementia. Furthermore, it was proposed that apo E polymorphism might be involved in the aging selection process.

OBJECTIVE

The purposes of the present study were the following: (1) to evaluate apo E polymorphism in 'successful' and 'unsuccessful' aging, defined as the absence or presence of disability and severe chronic diseases (mainly cardiovascular disease and dementia), respectively; (2) to evaluate the impact of apo E polymorphism on plasma lipids in very old individuals free of or affected by disability.

METHODS

253 Italian subjects including 100 free-living healthy octo- and nonagenarians, 62 disabled octo- and nonagenarians, and 91 healthy adult controls, all matched for origin were studied. Apo E phenotypes were determined by PhastSystem (Pharmacia). Lipoprotein parameters (total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, lipoprotein (a), and apoprotein A-I and B) were measured by standardized methods. ADL were evaluated by the Katz index.

RESULTS

The frequency of sigma2, sigma3, and sigma4 alleles was 0.062, 0.887, and 0.051 respectively in the entire sample; no differences in alleles distribution were found between the three groups. When the subjects were divided according to the E type (E2 type: E2/E2 and E2/E3; E3 type: E3/E3; E4 type: E3/E4 and E4/E4), no differences in lipoprotein parameters emerged, but a trend toward higher total and LDL-cholesterol from the E2 to the E4 type was observed. The sigma4 allele had a raising effect, while sigma2 had a lowering effect on total cholesterol levels, but these effects were much less profound in the disabled octo- and nonagenarians.

CONCLUSIONS

We conclude that (1) the frequency of the sigma4 allele is very low in this sample of subjects from central Italy; (2) no differences emerged in sigma4 distribution between healthy and disabled octo- and nonagenarians, and adult controls; the very low frequency of sigma4 allele might contribute to this finding; (3) our data do not support the hypothesis of a possible association between apo E polymorphism and longevity or disability in this population.

Body movement during sleep in subjects with long-standing bruxing behavior

PURPOSE

This study aimed to determine whether patients with long-standing nocturnal bruxing behavior present different body movement activity during sleep compared with healthy subjects.

MATERIALS AND METHODS

Eleven bruxers and 8 nonbruxers were studied in the sleep laboratory, and motor activity was detected with sensor pads placed under the mattress. Movements simultaneously recorded on videotapes were classified according to their duration and grouped in different types according to their characteristics.

RESULTS

Subjects with bruxism had significantly more movements during sleep compared with controls; the difference was especially obvious for movements of short duration (< 5 seconds). The differences became significant from the fourth hour of sleep. These short movements were twitches, jerks, or any sudden, brusque movements of the extremities, but without the periodicity encountered in, for example, periodic limb movements during sleep. No significant relationship was found between the occurrence of masseter activity and movements.

CONCLUSION

The findings suggest that subjects with nocturnal bruxism have movement disorders that are expressed not only as grinding or clenching of the teeth, but also as an increase of short-duration body movements during sleep. This reinforces the hypothesis of a central etiology common to both bruxism and short movements during sleep.

The crystal structure of dihydrofolate reductase from Thermotoga maritima: molecular features of thermostability

Two high-resolution structures have been obtained for dihydrofolate reductase from the hyperthermophilic bacterium Thermotoga maritima in its unliganded state, and in its ternary complex with the cofactor NADPH and the inhibitor, methotrexate. While the overall fold of the hyperthermophilic enzyme is closely similar to monomeric mesophilic dihydrofolate reductase molecules, its quaternary structure is exceptional, in that T. maritima dihydrofolate reductase forms a highly stable homodimer. Here, the molecular reasons for the high intrinsic stability of the enzyme are elaborated and put in context with the available data on the physical parameters governing the folding reaction. The molecule is extremely rigid, even with respect to structural changes during substrate binding and turnover. Subunit cooperativity can be excluded from structural and biochemical data. Major contributions to the high intrinsic stability of the enzyme result from the formation of the dimer. Within the monomer, only subtle stabilizing interactions are detectable, without clear evidence for any of the typical increments of thermal stabilization commonly reported for hyperthermophilic proteins. The docking of the subunits is optimized with respect to high packing density in the dimer interface, additional salt-bridges and beta-sheets. The enzyme does not show significant structural changes upon binding its coenzyme, NADPH, and the inhibitor, methotrexate. The active-site loop, which is known to play an important role in catalysis in mesophilic dihydrofolate reductase molecules, is rearranged, participating in the association of the subunits; it no longer participates in catalysis.

Cytotoxicity of triterpenoid saponins. Part 2: Relationships between the structures of glycosides of polygalacic acid and their activities against pathogenic Candida species

Glycosides of polygalacic acid (2 beta,3 beta,16 alpha,23-tetrahydroxy-olean-12-ene-28-oic acid) is isolated from the aerial parts of Solidago virgaurea L. subsp. virgaurea, Heteropappus altaicus (Willd.) Novopokr. and Heteropappus biennis (Ldb.) Tamamsch. or produced by degradation of these genuine saponins were tested against humanpathogenic strains of Candida albicans, C. glabrata, C. krusei and C. tropicalis using a micro-dilution assay. The antifungal action can be influenced the variation of the etherglycosidically bonded carbohydrate units at C-3 as well as of the acylglycosidically bonded oligosaccharide at C-28 of the aglycone.

Low density lipoprotein cholesterol, lipoprotein(a), and apo(a) isoforms in the elderly: relationship to fasting insulin. Associazione Medica Sabin

BACKGROUND AND AIM

Insulin resistance/hyperinsulinemia are often associated with aging and could play an important role in the development of glucose intolerance and dyslipidemia in the elderly. We investigated the relationship between plasma fasting insulin with total cholesterol (TC) and low density lipoprotein LDL cholesterol (LDL-C), triglycerides (TG), lipoprotein(a) [Lp(a)] levels apolipoprotein (a) [apo (a)] isoforms in 100 free-living "healthy" octo-nonagenarians.

METHODS AND RESULTS

Fasting insulin was positively correlated with TG, whereas a negative relation was found with TC and LDL-C (r = -0.29 and r = -0.28 respectively; p < 0.01), LDL-C/apo B, HDL-C and apo A-I levels. Fasting insulin was also inversely correlated with Lp(a) levels (r = -0.22; p < 0.03), whereas the latter were significantly related with TC and LDL-C (r = 0.30 and r = 0.31; p < 0.005), TG (r = 0.21; p < 0.05) and apo B (r = 0.26; p < 0.02). There was a negative relation between Lp(a) levels and apo(a) isoforms: the greater the apo(a) molecular weight, the lower the Lp(a) level (p < 0.0001). Fasting insulin increased with apo(a) size, though the difference in insulin levels among apo(a) isoforms was not significant (p = 0.4). Multiple regression analysis showed that fasting insulin was the best predictor of LDL-C (R2 = 0.14; p = 0.002) irrespective of age, gender, BMI, waist circumference and TG, while apo(a) isoform size, BMI and waist circumference were related with Lp(a) irrespective of TC and LDL-C, TG and apo B (R2 = 0.35 to 0.37; p < 0.0001).

CONCLUSIONS

These results suggest that fasting insulin levels significantly influence LDL-C metabolism in old age. Lp(a) levels seem to be very strongly related to genetic background, although an indirect relation with insulin through adiposity and/or other associated lipid abnormalities cannot be ruled out.

Characterization of a new form of inherited hypercholesterolemia: familial recessive hypercholesterolemia

We previously described a Sardinian family in which the probands had a severe form of hypercholesterolemia, suggestive of familial hypercholesterolemia (FH). However, low density lipoprotein (LDL) receptor activity in fibroblasts from these subjects and LDL binding ability were normal. The characteristics of the pedigree were consistent with an autosomal recessive trait. Sitosterolemia and pseudohomozygous hyperlipidemia were ruled out. A second Sardinian kindred with similar characteristics was identified. Probands showed severe hypercholesterolemia, whereas their parents and grandparents were normolipidemic. FH, familial defective apoprotein (apo) B, sitosterolemia, and cholesteryl ester storage disease were excluded by in vitro studies. We addressed the metabolic basis of this inherited disorder by studying the in vivo metabolism of LDL in 3 probands from these 2 families. 125I-LDL turnover studies disclosed a marked reduction in the fractional catabolic rate (0.19+/-0.01 versus 0.36+/-0.03 pools per day, respectively; P<0.001) and a significant increase in the production rate [20.7+/-4.4 versus 14. 0+/-2.4 mg. kg-1. d-1, respectively; P<0.01] of LDL apoB in the probands compared with normolipidemic controls. We then studied the in vivo biodistribution and tissue uptake of 99mtechnetium-labeled LDL in the probands and compared them with those in normal controls and 1 FH homozygote. The probands showed a significant reduction in hepatic LDL uptake, similar to that observed in the FH homozygote. A reduced uptake of LDL by the kidney and spleen was also observed in all patients. Our findings suggest that this recessive form of hypercholesterolemia is due to a marked reduction of in vivo LDL catabolism. This appears to be caused by a selective reduction in hepatic LDL uptake. We propose that in this new lipid disorder, a recessive defect causes a selective impairment of LDL receptor function in the liver.