[Hydatid pulmonary embolism. Two case reports]

Hydatid pulmonary embolism is an uncommon condition resulting from the rupture of a hydatid heart cyst or the opening of a visceral hydatid cyst (often in the liver) into the venous circulation. We report two cases of hydatid pulmonary embolism following rupture of a hydatic cyst in the right ventricle. One case progressed to chronic cor pulmonale. We examine the pathophysiological mechanisms as well as the clinical, therapeutic and evolutive aspects.

[Peripheral infected aneurysm: report of 15 cases]

In this retrospective study we report 15 cases of peripheral infected aneurysms. The sex ratio was 13/2 and the mean age was 23 years. Patients presented with infection syndrome in 9 cases, vascular mass in 11 cases and limb ischemia in 2 instances. Arterial lesion was documented and confirmed by echography, tomodensitometry and angiography. The infection was recognised by different criteria the main one being micro-organism isolation. In 10 cases aneurysm was secondary to bacterial endocarditis, in 4 it was primary and in one case it was related to arterial catheter procedure. Treatment is based on antibiotics and surgical management by removing of infected aneurysm and arterial restoration whenever possible. Arterial flowerest re-establishment was done in 10 patients among whom 6 by anatomic procedures 4 by extra-anatomic ones. Hospital mortality rate was 13% (2/15), all deaths occurred after cardiac surgery for endocarditis. Two patients were readmitted for adjacent spine infection, one month and one and a half respectively after surgery. One young patient required late surgery (aorto-bifémoral bypass) 24 months after initial treatment and one patient died by intra-duodenal rupture of recurrent false aneurysm. Analysis of our results and literature review allow discussion of clinical, physiopathological and specially therapeutic aspects of infected aneurysm.

Cartilage protection by nitric oxide synthase inhibitors after intraarticular injection of interleukin-1beta in rats

OBJECTIVE

To evaluate the effect of nitric oxide synthase (NOS) inhibitors on proteoglycan synthesis following intraarticular administration of interleukin-1beta (IL-1beta) in rats.

METHODS

Recombinant human IL-1beta and NOS inhibitors with different selectivity for inducible NOS (N-monomethyl-L-arginine [L-NMA], N-iminoethyl-L-ornithine [L-NIO], and S-methylisothiourea [SMT]) were simultaneously administered in rats by a single intraarticular injection in each knee. L-NMA was also infused for 72 hours using an Alzet mini osmotic pump implanted into the peritoneal cavity 24 hours before IL-1beta challenge. NO production was determined as nitrate and nitrite, either in synovial fluid or ex vivo in supernatants of synovium and patellae. Proteoglycan synthesis was measured by ex vivo incorporation of 35SO4(2-) into patellar cartilage.

RESULTS

IL-1beta induced a time-dependent increase in NO production in synovial fluid. Synovium and patellae released large amounts of nitrate and nitrite under ex vivo conditions, indicating that both tissues are effective sources of NO within the joint. This production of NO was accompanied by a delayed inhibition of proteoglycan synthesis. The intraarticular administration of L-NMA and L-NIO reduced NO release in synovial fluid and resulted in a partial recovery of proteoglycan synthesis. Under our experimental conditions, SMT failed to reduce NO synthesis and to restore proteoglycan synthesis. The protection of cartilage was improved by the systemic and sustained delivery of L-NMA. However, the complete inhibition of NO production in synovial fluid was not sufficient to fully restore cartilage anabolism.

CONCLUSION

Our findings show that in rats: 1) NO may be an early mediator of the effect of IL-1beta on cartilage, 2) NO inhibition may have therapeutic relevance, although it is not sufficient to fully reverse the deleterious effects of IL-1beta, 3) among NOS inhibitors tested, only amino acid derivatives are effective, 4) protection can be achieved by local administration of NOS inhibitors, and 5) systemic and sustained delivery of the NOS inhibitor with the highest efficacy after intraarticular injection provides the most benefit.

[Cavopulmonary shunts: apropos of 40 observations]

Fourty patients with univentricular heart, underwent a cavopulmonary shunt procedure. The majority have an excellent hemodynamic status with ventricular end diastolic pressure > 12 mmHg and a mean pulmonary artery pressure > 15 mmHg. However, 11 patients have ventricular dysfunction, 9 have an incompetent systemic atrio-ventricular valve and 6 have mean pulmonary artery pressure > 15 mmHg. The pulmonary arteries were of a good size in all cases with a Nakata index > 100 mm2/m2. Cavopulmonary connections are satisfactory palliative procedures in the treatment of univentricular cardiac disease.

[Mediastinitis caused by Klebsiella pneumoniae with a pharyngeal portal]

We report a case of Klebsiella pneumoniae medisatinitis secondary to a retrophyarygeal abscess in a 40-year-old patient. The patient was treated with antibiotics and pleural drainage. Surgery was not necessary and the clinical course was favorable. We recall the pathophysiological and clinical aspects of this now uncommon condition and discuss the prognosis and therapeutic options.

Evidence for neurogenic transmission inducing degenerative cartilage damage distant from local inflammation

OBJECTIVE

To investigate involvement of the nervous system in ipsilateral and contralateral joint inflammation.

METHODS

Freund's complete adjuvant (CFA; 1 mg or 1 microg) was injected unilaterally and the messages (a) from the hind paw to the ipsilateral and contralateral knees and (b) from one knee to the contralateral knee were analyzed. The degenerative impact of the local injury on distant cartilage was assessed using patellar proteoglycan synthesis as an indicator. Neurogenic mechanisms were blocked either by spinal cord compression or by injection of neurokinin 1 (NK-1) antagonist, or they were mimicked by intraarticular injection of substance P. The data were compared with those gathered in a model of systemic inflammation, characterized by fever and serum interleukin-6 production.

RESULTS

After unilateral subcutaneous injection of CFA, proteoglycan anabolism decreased bilaterally. Spinal cord compression and administration of the NK-1 antagonist inhibited the response in the contralateral limb. Following 1 mg CFA subcutaneous injection, the ipsilateral response implicated both neurogenic and systemic mechanisms, whereas the nervous system alone was implicated after 1 microg subcutaneous CFA injection. The 1 microg CFA intraarticular injection induced a degenerative contralateral signal, which was abolished by spinal cord compression and by pretreatment with the NK-1 antagonist. Intraarticular injection of 1 microg CFA also induced an ipsilateral increase of anabolism, which was enhanced by spinal cord compression. Similar results were obtained after intraarticular injections of substance P. These effects were not reproduced with turpentine treatment, a systemic model, in which spinal cord compression had no effect.

CONCLUSION

A unilateral inflammation can induce, by neurogenic mechanisms, distal bilateral degeneration of articular cartilage, implicating involvement of neuropeptides.

Segmental bronchial atresia--a case report and a literature review

Bronchial atresia is a short and juxtahilar bronchus interruption. This uncommon malformation leads to an obstructive and systematized emphysema, often associated with mucoid impaction. The authors report the case of a 5-year-old boy and review the literature in order to recall the radiologic features of this affection, which are characterized by an obstructive segmental or lobar emphysema often located in the upper lobe. The modern imaging means are not necessary for diagnosis. Bronchography confirms the atresia. Neonatal bronchial atresia appears as an opaque segment or lobe with retention of the alveolar liquid.

Identification of the uridine diphosphate glucuronosyltransferase isoform UGT1A6 in rat brain and in primary cultures of neurons and astrocytes

The expression of a phenol uridine diphosphate glucuronosyltransferase (UGT) was investigated in rat brain homogenate and in primary cultures of astrocytes and neurons, by means of model substrates (1-naphthol and 4-methylumbelliferone) assays, Western blot analysis and reverse transcription-polymerase chain reaction (RT-PCR) experiments. Glucuronidation of these substances occurred in cerebral cell or brain homogenates, although to different extents. The specific activity was the highest in astrocytes, with values more than 10- and 100-fold those found in neurons or total brain, respectively. Using antibodies able to recognize several rat liver UGT isoforms, only one protein with an apparent molecular mass of 54 kDa was detected in astrocyte and neuron homogenates and brain microsomes. RT-PCR experiments run with primers specifically designed for the rat liver UGT1A6 revealed amplificons of the expected sizes in accordance with the presence of UGT1A6 mRNA. The nucleotide sequence of the 330-base pair product was 100% homologous to that of exon 1 of rat liver isoform UGT1A6. In conclusion, this work allowed us to identify for the first time a constitutive cerebral UGT isoform identical to rat liver UGT1A6, which glucuronidates planar phenolic substances in cultured astrocytes, neurons, and the entire brain.

Cyclo-oxygenase isoenzymes. How recent findings affect thinking about nonsteroidal anti-inflammatory drugs

The discovery of at least 2 cyclo-oxygenase (COX) isoenzymes, referred to as COX-1 and COX-2, has updated our knowledge of nonsteroidal anti-inflammatory drugs (NSAIDs). This has lead investigators to reconsider what can be awaited from this class of drugs. The 2 COX isoenzymes share structural and enzymatic similarities, but are specifically regulated at the molecular level and may be distinguished apart in their functions, although some physiological overlap between them does occur. The major goal in developing selective COX inhibitors is to improve NSAID tolerability. Classic NSAIDs preferentially inhibit COX-1 in vitro, but it appears hazardous to judge their gastrointestinal (GI) safety profile from these data. New compounds with a high selectivity for COX-2, especially those that are non-acidic, may be better tolerated in the GI tract. While these compounds also might have a potential use in various diseases such as colorectal cancer and neurodegenerative diseases of the Alzheimer type, the possible appearance of adverse effects, perhaps renally-related, must be taken into consideration. Finally, well-designed large clinical trials are required to adequately estimate both the promising therapeutic advantages that may be offered by highly selective NSAIDs, and the potential drawbacks that may be inherent with prolonged COX-2 inhibition.

Expression and inducibility of UDP-glucuronosyltransferases 1-naphthol in human cultured hepatocytes and hepatocarcinoma cell lines

The UDP-glucuronosyltransferase (UGTs) isoforms involved in the conjugation of 1-naphthol were characterized in human cultured hepatocytes and in two human hepatocarcinoma cell lines, KYN-2 and Mz-Hep-1 in terms of expression, kinetics and induction by drugs. Their properties were compared to those of UGT1*6 stably expressed in the V79 cell line (V79UGT1*6), which glucuronidates 1-naphthol preferentially. The determination of kinetic constants for glucuronidation of 1-naphthol revealed a two-site model in human hepatocytes, but a one-site model in the two hepatocarcinoma cell lines. Southern blot analysis of RT-PCR products, showed that the UGT1*6 mRNA was expressed in KYN-2, but not in Mz-Hep-1 cells. However, a mRNA encoding a UGT different from UGT1*6 was expressed in Mz-Hep-1 cells. The two inducers, beta-naphthoflavone and rifampicin exerted a differential effect, depending on the cell lines considered. Altogether, the results suggest that, in hepatocytes, two UGT isoforms, which glucuronidate 1-naphthol are expressed and are differentialy regulated by inducers. Both KYN-2 and Mz-Hep-1 cells express one of the two different UGT isoforms found in hepatocytes. The UGT isoform present in KYN-2 cells corresponds to UGT1*6, whereas in Mz-Hep-1 cells the UGT isoform present was different from UGT1*6 and UGT1*7.

Inducibility of ethoxyresorufin deethylase and UDP-glucuronosyltransferase activities in two human hepatocarcinoma cell lines KYN-2 and Mz-Hep-1

Two human hepatoma cell lines, KYN-2 and Mz-Hep-1 were characterized in terms of glucuronidation capacity and inducibility of cytochrome P4501A1/1A2 and several UDP-glucuronosyltransferases (UGTs). Cytochrome P4501A1/1A2 activity was measured using 7-ethoxyresorufin and that of UGTs with 16 different substrates. The effects of dimethyl sulfoxide (DMSO), 3-naphthoflavone, alpha-naphthoflavone, and rifampicin on these drug-metabolizing enzyme activities were studied. DMSO treatment increased in a dose-dependent manner the ethoxyresorufin O-deethylase (EROD) activity in KYN-2 cells, while an opposite effect was observed in Mz-Hep-1 cells. In KYN-2 cells, EROD was more responsive toward beta-naphthoflavone treatment in combination with DMSO. This activity was enhanced in Mz-Hep-1 cells more than 83 times by beta-naphthoflavone. The enhancement of EROD activity by DMSO and beta-naphthoflavone treatments of KYN-2 cells was abolished by alpha-naphthoflavone treatment. In Mz-Hep-1, only the inducing effect of beta-naphthoflavone was abolished by alpha-naphthoflavone treatment. Rifampicin treatment of KYN-2 cells reversed both the DMSO and beta-naphthoflavone effects on the EROD activity. Glucuronidation of steroids, bile acids, fatty acids and drugs was effective in KYN-2 and Mz-Hep-1 cells. Both 1-naphthol glucuronidation and the level of UGT1*6 protein detected by immunoblot and supporting this activity were lowered by DMSO treatment and increased by beta-naphthoflavone treatment in KYN-2 cells. In Mz-Hep-1 cells, DMSO and beta-naphthoflavone had no effect on 1-naphthol glucuronidation activity. DMSO, beta-naphthoflavone and rifampicin also affected the glucuronidation of various substrates supported by different UGT isoforms. These results indicate that KYN-2 and Mz-Hep-1 cells can be used as new in vitro models for the studies of drug metabolism and the regulation of the corresponding enzymes.

Glucuronidation in the Caco-2 human intestinal cell line: induction of UDP-glucuronosyltransferase 1*6

The ability of the differentiated human intestinal cell line, Caco-2, to glucuronidate various endobiotic and xenobiotic molecules was investigated. Glucuronidation of hydroxylated or carboxylic acid compounds such as 1-naphthol, thymol, androsterone, estriol, hyodeoxycholic acid, lithocholic acid, chloramphenicol, paracetamol and morphine could be determined in microsomal fractions of Caco-2 cells. The activity toward 1-naphthol was the highest glucuronidation activity measured in Caco-2 cells. This activity was specifically increased four-fold upon addition of beta-naphthoflavone into culture medium but not by rifampicine or clofibrate and was related to a biosynthesis of UDP-glucuronosyltransferase 1*6 (UGT1*6). alpha-Naphthoflavone did not affect the inducing property of beta-naphthoflavone. 7-Ethoxyresorufin-O-dealkylation activity, supported by cytochrome P4501A1, was induced more than 1000-times in Caco-2 cells by beta-naphthoflavone treatment, and this effect was partially abolished by alpha-naphthoflavone treatment. The results suggest that several isoforms, including UGT1*6, are expressed in Caco-2 cells.

Human cell lines in pharmacotoxicology. An introduction to a panel discussion

Various types of cells lines are used in pharmacotoxicology. Established cell lines are easily available, with few ethical restrictions. Some specific properties are preserved, although they have kept the phenotype of the original tissue, which is frequently a tumor phenotype. They are usually more resistant to toxic compounds than freshly isolated cells. Some drug-metabolizing enzymes are expressed and regulated in these cells. Immortalized cell lines are also of interest in toxicology. They are mainly examined for their potential in mutagenicity testing. These cells and numerous others of animal or human origin can be transfected with cDNA coding for human enzymes. They are used for determination of the individual enzyme involved in a particular metabolic pathway, or, when multiple transfections are successfully achieved, for mutagenicity testing. Regulation studies are also possible in such cells after transfection of DNA elements regulating gene transcription.

Aortic valve replacement in children under 16 years of age with congenital or rheumatic valvular disease. A study of 64 cases

Sixty-four children have had a single aortic valve replacement under 16 years of age, 50 for rheumatic disease (47) or bacterial endocarditis (3) (group I) and 14 for a congenital aortic valve lesion (group II), 38 were disk prostheses and 26 were ball prostheses. Associated procedures had to be performed 31 times, with widening of a small aortic annulus by a patch in 7 patients. The early mortality was 12.5%. Of 56 survivors, 55 were followed postoperatively for a mean period of 7 years (group I: 44, group II: 11). Forty of the 55 patients were anticoagulated (correctly maintained in only 24 patients), 15 were not anticoagulated. A high rate of late complications was observed. Thrombo-embolic accidents in 5 patients with inefficient anticoagulant treatment, 2 haemorrhagic episodes, 7 prosthetic leaks; specific problems related to this group of young patients were: recurrence of rheumatic fever with increasing severity of mitral valve disease requiring mitral valve replacement in 5 patients and outgrowth of the prosthesis, which affected 7 patients; this complication is the result of either fibrous deposit around the valve annulus or such a small annulus that the surgeon could only implant a small prosthesis. Ten patients required 11 reoperations for various reasons. The main reason for reoperation was mitral valve replacement for worsening of mitral valve disease caused by recurrence of rheumatic fever. A high late mortality 10/55 (18%) was noted. The main cause of death was a perivalvular leak (5); 1 late death was caused by a stenotic number 17 Björk-Shiley valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Hydatid cyst of the heart and pericardium

Between 1977 and 1988, six young patients (average 22 years) underwent surgery for cardiac echinococcosis. Three had a single cyst and the others had multiple cysts which ruptured into the pericardium. The diagnosis was always confirmed by cross-sectional echocardiography and cardiac angiography. Surgery was always performed through median sternotomy using cardiopulmonary bypass. Morbidity and mortality were nil and late results were satisfactory.

Closed mitral valvotomy in pregnancy--a study of seven cases

Between 1977 and 1987, seven pregnant women (mean age 28 years) had closed mitral valvotomy through a left lateral thoracotomy during their first (3 cases), second (2 cases) or third (2 cases) trimester. Surgery was necessary either because of acute heart failure with pulmonary edema not responding to medical treatment (4 cases) or to prevent the complications of severe mitral stenosis affecting either the mother or the fetus in three patients with desired pregnancies. There were neither maternal nor fetal deaths. The only complication was bleeding from a low insertion of the placenta identified in the early postoperative period in one patient that required a caesarean section, which produced a normal baby. Six pregnancies continued until term with uneventful delivery and produced normal children. We conclude that closed mitral valvotomy is a simple and a low risk procedure in pregnant women. It prevents complications of severe mitral stenosis occurring in either the mother or the fetus during pregnancy and delivery.

[Postoperative analgesia after cesarean section: sublingual buprenorphine versus subcutaneous morphine]

This study aimed to compare the efficacy and side-effects of sublingual buprenorphine, a synthetic opioid agonist antagonist, with those of subcutaneous morphine. Fifty ASA class 1 patients were included in the study after having given their informed consent. Caesarean section was carried out under epidural block with 0.5% bupivacaine; no opioids were used during the procedure. The first dose of opioid was given 2 h after the first dose of bupivacaine. Patients were randomly given either 10 mg morphine (n = 25) or 0.4 mg buprenorphine (n = 25), followed by the same dose every 6 h for 36 h. When analgesia was insufficient, tablets containing dextropropoxyphene and paracetamol were given. No attempt was made to blind the study to the patient, but the investigator assessing pain was unaware of the drug given to the patient. Pain intensity was assessed before, and 2 h after each dose of opioid with a 100 mm visual scale, as well as systolic, diastolic and mean arterial blood pressures, heart and breathing rates, and SpO2. Side-effects (pruritus, nausea, vomiting, drowsiness) were also noted. In 2 patients in each group, the protocol was stopped before the 36th h, but after the fourth dose, either because of side-effects, or at the patient's request. Results were similar in both groups of patients, whether for degree of pain relief, or physiological effects. There was no clinically detectable respiratory depression. Duration and intensity of episodes of arterial oxygen desaturation, and the incidence of nausea, were similar in the 2 groups; pruritus was more common in the morphine group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tolerance of amoxicillin-clavulanic acid combination in the child]

Forty children all aged over 2 years and eutrophic were treated with the combination amoxycillin and clavulanic acid for various infections (twenty-three with meningitis, eleven with bronchial pneumonia, three with typhoid fever, two with lower urinary tract infections and one with ear infection of moderate severity). Nine of these patients had sickness during treatment which was mild and transient in the majority of cases and caused treatment to be stopped in only one case (2.5%). This low level of gastric tolerance should not concern the paediatrician faced with an infection due to (or most likely to be) a beta-lactamase producing micro-organism.

[Thromboembolic and hemorrhagic complications in valve prosthesis patients]

567 patients with valve prostheses who received anticoagulant therapy were followed up by Professor Ben-Ismail's department at the Ernest-Conseil Hospital, over a period of 2 to 160 months (mean: 53 months). 220 of them had a mitral prosthesis, 183 had an aortic prosthesis and 161 had a double (153) or triple (8) valvular replacement. 66 patients (11.6%) presented a total of 85 thrombo-embolic episodes, i.e. a global incidence of 4.6 emboli per 100 patient-years. Amongst the thrombo-embolic incidents, there were 26 cases of valvular thrombosis, 47 cases of cerebral vascular accident and 11 cases of peripheral vascular emboli. The course was fatal in 18 cases. These accidents mostly occurred in the cases with mitral or polyvalvular replacements. More than one half of these patients were pursuing a regular and effective treatment. 55 patients presented a total of 60 serious haemorrhagic accidents, of which 10 died. This study reveals that the incidence of thrombo-embolic accidents is much higher in patients with mitral or tricuspid valve replacements and when the anticoagulant treatment is irregular or capricious. However, an apparently well managed anticoagulant treatment does not prevent the development of thrombo-embolic accidents and carries a significant risk of haemorrhage.

Heart valve replacement with the Ionescu-Shiley pericardial xenograft

Between March, 1971, and September, 1975, glutaraldehyde-stabilized pericardial xenografts were used for single valve replacement in.212 patients (142 aortic, 67 mitral, and three tricuspid). The 195 operative survivors were observed for a total of 5,926 months over a period 6 to 61 months (mean 30). actuarial analysis of late results indicates an expected survival rate at 5 years of 92.3 per cent for patients with aortic and 91.1 per cent for patients with valve replacement. The rate of systemic embolism has been 0.62 episodes per 100 patient years for the aortic and 2.48 episodes per 100 patient years for the mitral group in the absence of anticoagulant treatment. All six emboli occurred early postoperatively, were trivial or mild, and left no sequelae. Symptomatically, 96.7 per cent of patients are now in Class I and 3.3 per cent in Class II (N.Y.H.A.). Maintenance of structural and functional integrity of the glutaraldehyde-stabilized pericardial zenograft was demonstrated by histologic and hemodynamic investigations. Catheterization showed substantial circulatory improvement in both patients with aortic and those with mitral replacement. The transaortic gradients were negligible (8 mm. Hg at rest and 17.5 mm. Hg during exercise). The available indicates that results of valve replacement withpericardial xenografts. Over this period of follow-up, compare very favorably with those obtained with other available prostheses and tissue valves.

[Study on a focus of ascaridiasis in a locality of Cap Bon (Tunisia)]

The study of ascaridiasis in a single locality of the Cap Bon region (Tunisia) where prevalence of this helminthiasis is much higher than anywhere else in the region, shows that 71,1% of the population is infected and all ages approximately in the same proportion. This high prevalence can be explained by a cumulative effect of two transmission factors: a particular construction of houses, which have a kind of reservoir for organic wastes in direct connection with the street, and the use of human excrements in agriculture. Mass chemotherapy every 3 months during several consecutive years is proposed.

Sequential hemodynamic studies following mitral fascia lata valve replacement

Sequential hemodynamic studies were performed at mean intervals of 6 and 38 months following mitral valve replacement in 10 patients who had angiographically competent fascia lata valves and in whom preoperative hemodynamic studies were available. The cardiac index did not change significantly during postoperative studies as compared with the preoperative values, and its response in relation to oxygen uptake during exercise remained impaired. The mean pulmonary wedge and pulmonary artery pressures showed significant reduction at the first and the second postoperative studies, both at rest and during exercise. Progressive reduction in the pulmonary vascular resistance occurred in patients with high initial values, although the group mean did not alter significantly. The mean diastolic gradient across the mitral fascial valves averaged 8.1 +/- 1.3 mm Hg at rest rising to 22.5 +/- 2.4 mm Hg during exercise (P less than 0.001), and the calculated mitral valve area was 1.9 +/- 0.22 cm2 at rest and 2.36 +/- 0.3 cm2 during exercise (P less than 0.02). This study indicates that the insertion of stented mitral fascia lata valves results in significant hemodynamic improvement, which is maintained at least for 3 years after surgery, in patients with competent valves. However, a degree of obstruction to the forward flow is apparent especially during exercise, despite the central flow design of the valve.