[Sequential orthotopic liver transplantation--domino transplantation]

Familial amyloid polyneuropathy (FAP) is a rare indication for liver transplantation. The excised liver of the FAP patient can be transplanted into a selected patient. In the following report, sequential liver transplantation is described where a 34-year-old female FAP patient received a cadaver donor liver. The excised native liver was transplanted to a 60-year-old male patient suffering from hepatocellular carcinoma in cirrhosis due to hepatitis C.

A new out-patient care facility for HIV-infected destitute populations in Paris, France

In France, the entire population theoretically has access to health coverage, but in fact a section of the poorest population does not. Institutions have therefore been set up to provide medical care for the destitute. The objectives of this study were to describe the social characteristics of the HIV-positive destitute population attending an out-patient clinic providing free health care for the destitute in a Paris University Hospital, to compare their clinical-epidemiological characteristics with those of non-destitute HIV-positive patients, and to evaluate the quality of their care. We performed a historical prospective study wherein a cohort of 115 HIV-positive destitute patients (defined as having no health coverage at their first consultation) was compared with a control cohort of 183 HIV-positive non-destitute patients attending the same clinic. Ninety-five per cent of the destitute patients had no stable employment, 32% had no source of income, 75% had no permanent residence and 27% were i.v. drug abusers. Fifty-nine per cent were foreigners, most of whom had legal residence papers and had been in France for more than 3 years. When comparing the control and the destitute groups, the latter had a three times greater risk of developing tuberculosis (RH = 3.2, CI 95% = [1.1-9.4]). Medical compliance, access to antiretroviral treatment and hospitalization were identical in both groups. No difference was observed in terms of occurrence of a new AIDS-related disease during follow-up when full-blown AIDS before entry, CD4 count at entry and transmission group were taken into account in multivariate analysis. From the moment that destitute patients attended this adapted medico-social facility, their access to care was the same as, if not better than, that of the other patients. The development of out-patient medico-social facilities for HIV-positive destitute patients must be a public health priority even for those countries theoretically providing generalized health coverage.

Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients

OBJECTIVE

To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals.

METHODS

All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied.

RESULTS

The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)).

CONCLUSION

The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.

[Tuberculous meningitis: clinical, biological and x-ray computed tomographic comparison between patients with or without HIV infection]

OBJECTIVES

Determine possible differences in clinical manifestations, laboratory findings and neuroimaging results in tuberculous meningitis patients with and without HIV infection.

PATIENTS AND METHODS

We retrospectively reviewed data of 38 patients with positive cerebrospinal fluid cultures for Mycobacterium tuberculosis who were hospitalized in 3 university hospitals in Paris over the last 11 years.

RESULTS

There were 24 HIV-infected patients and 14 without HIV infection. Mean CD4 lymphocyte count was 103 +/- 180/mm3 in the HIV group. Age (median age = 33 years for the HIV group vs. 53 for the non-HIV group), sex ratio (3 vs. 0.75), and prior history of tuberculosis (46% vs. 43%) were similar in both groups. Clinical presentation was similar for headache (83% in HIV group vs. 50% in non-HIV group; p = 0.02) and confusion (54% vs. 93% in non-HIV group p = 0.05). Serum natremia (mmol/l) (131 +/- 5 vs. 125 +/- 8; p = 0.024), white blood cell count (x 10(9)/l) (5.8 +/- 4.7 vs. 10.7 +/- 1.7; p = 0.37) and erythrocyte sedementation rate (mm/h) (68 +/- 34 vs. 31 +/- 35; p = 0.003) were significantly different in the 2 groups. Median cerebrospinal fluid findings were similar in the 2 groups: leukocytes (x 10(6)/l) (375 +/- 860 vs 218 +/- 250), glucose (mmol/l) (2.3 +/- 0.9 vs 2.7 +/- 1.9) and protein (g/l) (3.8 +/- 7.1 vs. 2.6 +/- 1.6). CT-scans of the brain were similar in the 2 groups. Mortality during hospitalization was similar (42% vs 36%; NS).

CONCLUSION

HIV infection appears to have little impact on the presentation of tuberculous meningitis.

CD4+ T-lymphocyte counts in HIV infection: are European standards applicable to African patients?

CD4+ lymphocyte count (CD4+ LC) is a widely used marker of Human Immunodeficiency Virus (HIV) immune impairment. Physiological lymphocytosis is frequently encountered in Africans. Therefore, we tried to determine if given CD4+ LC levels are of similar significance in European versus African HIV-infected individuals. Lymphocyte phenotyping of 750 HIV-infected adults was retrospectively analyzed. Three hundred and seventy patients were consecutively selected in Paris, France; 185 in Abidjan, Côte d'Ivoire; and 195 in Bobo-Dioulasso, Burkina Faso. In the three settings, lymphocyte phenotyping was performed by flow cytometry using similar protocols. Data from Abidjan and Bobo-Dioulasso were combined on the basis of geographic proximity and contrasted with those from Paris. Geometric mean levels of Total Lymphocyte Count (TLC), CD4+ LC, CD8+ lymphocyte count (CD8+ LC), and CD4:CD8 ratio, adjusted for percentage of CD4+ T-cells (%CD4+), were compared between Africans and Europeans. For a given %CD4+, TLC and CD4+ LC but not CD8+ LC tended to be about one third higher in West African than in French adults (p < 0.0001). Approximate equivalencies of absolute CD4+ counts in French and West African HIV-infected adults suggest that where thresholds of 200 and 500 CD4+ cells/microliter are applied in Europe, it might be appropriate to apply a threshold of approximately 250 and 700 CD4+ cells/microliter in West Africa, respectively. Establishing indicators of progression of HIV infection with locally appropriate thresholds may represent important steps toward improvement of HIV disease management in Africa.

The course of shipped livers used as full size, reduced or split grafts

A total of 110 transplants, 66 in adults (8 retransplants) and 30 in children (6 retransplants) were analysed according to the origin of the graft (shipped n = 39-non-shipped i.e. self procured n = 71) and the way they were transplanted (as full size grafts (FS) n = 82, reduced size grafts (RED) n = 23 or split grafts (SG) n = 5). Twenty-nine transplants were performed for urgent and 81 for elective indications. There was a statistically higher incidence of 2 or more risk factors in the donors that were selfprocured (non shipped) than in donors from shipped livers (p = 0.025). The overall 3 months graft survival was 79.5% for shipped livers versus 69% for non-shipped livers and patients survival was 89.2% versus 79.0% respectively after 3 months and 82.9% versus 74.4% after 40 months. From these results that were analysed with risk factors of the donors, cold ischaemia time and liver function tests in recipients, transplanted for acute and elective indications, it is concluded that shipping of grafts is a practical and safe procedure even if size reduction or the use of SG is intended.

Limited intentional normovolemic hemodilution: ST-segment changes and use of homologous blood products in patients with left main coronary artery stenosis

OBJECTIVE

To assess and compare the effects of limited intentional normovolemic hemodilution (LINH) on ST-segment changes and to evaluate the need for homologous blood products.

DESIGN

Prospective, randomized study.

SETTING

University hospital.

PARTICIPANTS

Seventy-one patients with left main stenosis scheduled for semi-urgent coronary artery bypass grafting.

INTERVENTIONS

Patients in group A (n = 39) underwent LINH during the prebypass period until a hematocrit of 34% was obtained. Simultaneously, succinyl-linked gelatin was infused. In group B (n = 32), no hemodilution was performed. Mean arterial pressure and central venous pressure were kept as constant as possible. During the postbypass period, autologous blood was retransfused. The need for homologous blood products was noted intraoperatively and postoperatively.

MEASUREMENTS AND MAIN RESULTS

ST-segment analysis of lead II and chest lead was continuously performed in all patients. An ST-segment change was defined as a decrease from baseline of 1.0 mm (-0.1 mV). The appearance and degree of ST-segment depression were comparable in both groups (group A: 7 patients -0.1 mV, 1 patient -0.2 mV; group B: 5 patients -0.1 mV; 3 patients -0.2 mV). In group A, ST-segment depression occurred during and after the blood exchange. However, the mean duration of the ST-segment depression (group A: 33 +/- 18 minutes; group B: 20 +/- 10 minutes) was comparable between groups. In group A, a mean of 750 mL +/- 245 mL of blood was obtained. Total blood loss was significantly higher in group B (p < 0.052); 25 patients in group A (64%) and 12 patients in group B (38%) did not require homologous blood products (p < 0.03). Intraoperatively, only the need for packed red cells was greater in group B (p < 0.04). Postoperatively, the use of homologous blood products is higher than intraoperatively (p < 0.02).

CONCLUSIONS

LINH performed in patients with left main stenosis, scheduled for semi-urgent coronary bypass, is not associated with increases in frequency, degree, or duration of ST-segment changes. This procedure allowed a reduction in the number of patients who received homologous blood products.

Operative closure of patent ductus arteriosus in the neonatal intensive care unit

Preterm infants undergoing surgical closure of patent ductus arteriosus are usually critically ill and are suffering from many concomitant diseases. The high risk of increased morbidity in transferring them from the neonatal intensive care unit (NICU) to a distant operating room is generally recognized. For this reason we report our experience in 33 premature infants with patent ductus arteriosus who have been operated in the NICU over a six-year period. There were no operative or immediate postoperative deaths and the 30 days hospital mortality was 6%. Based upon these findings we can confirm that operative closure of PDA can be performed safely in the NICU.

[Patients with systemic disease admitted to intensive care units: course and prognostic factors]

Based on our experience, hospitalization in intensive care units of patients with systemic diseases occurs several years after diagnosis. Though mortality ranges from 30 to 45%, it is not statistically different from that in unselected patients. Outcome is clearly related to controllable infectious complications. Three other prognosis factors are the gravity of the patient's status at admission (APACHE or IGS scores), corticosteroid therapy and prior health status. Long-term prognosis for patients discharged from intensive care is good with a 30% mortality at 5 years despite the irreversible nature of their disease.

Evaluation of the anticoagulant properties of aprotinin in vitro

The interaction of aprotinin with normal coagulation was studied in blood samples obtained from 10 healthy subjects. Each sample was simultaneously tested in four different preparations: NaCl-treated blood: 0.03 mL 0.9% NaCl in 0.33 mL blood; aprotinin treated blood: 0.33 mL blood+aprotinin in 0.03 mL in aliquots to obtain a final blood concentration of respectively 50 KIU mL-1; 100 KIU mL-1 and 200 KIU mL-1. The coagulation process was analysed by thromboelastography. R-time, reflecting intrinsic coagulation, increased in a dose dependent manner between NaCl-treated and aprotinin-treated blood. These findings suggest a dose dependent impairment of intrinsic coagulation by aprotinin.

[Pulmonary toxoplasmosis in patients with human immunodeficiency virus infection. 21 cases]

OBJECTIVES

Assess expression of pulmonary toxoplasmosis, the second most frequent localization after brain, in patients infected with the human immunodeficiency virus (HIV).

METHODS

Twenty-one HIV-infected patients (18M, 3F) were admitted for pulmonary toxoplasmosis between September 1987 and February 1995. Mode of HIV transmission was unprotected homosexual sexual activity (n = 16), intravenous drug abuse (n = 3) and transfusion (n = 2).

RESULTS

Isolated pulmonary toxoplasmosis was found in 11 patients. In 10 patients pulmonary toxoplasmosis was associated with cerebral (n = 4), bone marrow (n = 2), ocular (n = 1) and multifocal (n = 3) localizations. Seven patients were admitted for acute pulmonary distress. Fever (reported for 20 patients) and nonproductive cough (reported for 16 patients) were the most common clinical symptoms. Chest roentgenogram revealed bilateral pulmonary infiltrates in 16 (76%) patients. Mean absolute CD4 count was 25 +/- 57 (range 0-110). Serologic evidence of past infection was observed in 18 patients. Serology tests were not done for two patients and negative for one. Two patients presented co-infection with Pneumocystis carinii. Fourteen patients had elevated serum lactic dehydrogenase (LDH) concentration. Among those, 4 patients whose LDH concentration was elevated more than ten fold died of respiratory distress. Patients received pyrimethamine and sulfadiazine (n = 13) or clindamycin (n = 8). Seven patients died during the first month after diagnosis was made. For the other patients, mean survival was 8 months. No relapse of toxoplasmosis was observed. All the patients took a secondary prophylaxis.

CONCLUSION

No difference between patient with isolated pulmonary toxoplasmosis and patients with associated extra-pulmonary localization was noted for clinical, biological, radiological presentations and outcome.

Rapidly progressive pulmonary artery hypertension and end-stage liver disease

Pulmonary hypertension is a recognized but unusual complication of liver disease. It can complicate the perioperative course of liver transplantation. Mild to moderate pulmonary hypertension is generally well tolerated during the procedure and does not appear to contribute to mortality. Since the pulmonary vascular disease may progress rapidly, it may have advanced to the point of irreversibility at the time of surgery. So, patients with known moderate pulmonary hypertension should have pulmonary arterial catheterisation immediately prior to transplantation. If pulmonary artery hypertension has become severe, then a preoperative trial of vasodilators is warranted. If this fails, the procedure should be cancelled. We present a patient with alcoholic liver cirrhosis in whom a rapidly progressive pulmonary hypertension made liver transplantation impossible.

[Corynebacterium diphtheriae endocarditis complicated by septic arthritis and cerebral abscess]

The authors report a rare case of the mitis type Corynebacterium diphteriae endocarditis on a prosthetic valve complicated by septic arthritis and cerebral abscess. The authors underline the importance of regular transoesophageal echocardiographic control and underline the diagnostic value of ultrafast computed tomography for the diagnosis of aortic annular and interventricular septal abscesses in patients with mechanical prosthetic valves.

Monostotic Paget's disease involving the calcaneus. Diagnostic and therapeutic problems. Two case-reports

The authors report the cases of two patients who had chronic incapacitating heel pain unresponsive to standard therapy. They were both found to have Paget's disease of the calcaneus. The diagnosis was difficult because the typical roentgenological changes required time to develop and because no other sites were involved. Local corticosteroid injections, elimination of weight-bearing, and standard analgesic therapy were ineffective. Bisphosphonate therapy (pamidronate) given as intravenous infusions ensured prompt lasting pain relief, making ambulation possible.