[Rheological parameters in hemorrhoid pathology]

The authors studied erythrocyte aggregation in 62 patients suffering from hemorrhoidal disease, distributed on the basis of proctoscopy findings between three groups (recent uncomplicated congestive attack, recent thrombosed hemorrhoid, stage IIb or III chronic prolapse). This hemorheological parameter is a sensitive marker of circulatory stasis. Values measured were compared with those obtained in 21 healthy subjects. Erythrocyte aggregation index was significantly higher in patients than in controls (31.6 +/- 6.8 versus 27.7 +/- 4.4) (p < 0.05). This difference was due essentially to increased values in patients with acute hemorrhoid problems. A parallel increase in blood fibrinogen was found in these same patients. Hemorheological changes could predispose to worsening of venous stasis in the hemorrhoidal circulation and participate in the onset or spread of thrombotic processes.

[Hydatid cyst of the interventricular septum. Apropos of a case]

A cardiac tumour of the interventricular septum was detected in a young woman presenting with an ejectional systolic murmur. Surgical ablation was carried out before a precise diagnosis was made. Histopathological analysis of the surgical specimen confirmed a hydatid cyst. The main complication was complete atrioventricular block. This case underlines the difficulty of making the diagnosis of intracardiac hydatid disease in a non-specific context, because of the long period of clinical latency, despite the considerable aid of echocardiography and other medical imaging techniques (CT scan and magnetic resonance imaging.

Ganciclovir ophthalmic gel in herpes simplex virus rabbit keratitis: intraocular penetration and efficacy

A chronic administration of three ganciclovir gels (0.2%, 0.05%, 0.0125%) was compared with a placebo gel and a 3% acyclovir ophthalmic ointment in the treatment of HSV-1 rabbit keratitis. All the ganciclovir gels showed a clinical efficacy: a significant reduction of the corneal ulcer area, clouding and vascularization (p < 0.05) and a fast inhibition of HSV isolates into tear film with the 0.2% and 0.05% ganciclovir gels. However the efficacy was slower than using acyclovir ointment. No significant difference could be shown between the 0.2% and 0.05% ganciclovir gels or the 0.05% ganciclovir gel and the acyclovir treatment on viral isolation, when it was performed on pooled samples. The distribution of ganciclovir and acyclovir into the rabbit eyes (HPLC methods), were similar but markedly higher in solid tissues than ocular fluids. It might explain the recovery from tissue damages. The mean corneal ganciclovir concentrations were largely higher than ED 50 of ganciclovir for HSV-1. No toxicity was expected, due to very limited systemic availability. This study suggests a comparable activity on HSV-1 superficial keratitis between 0.05%, 0.2% ganciclovir gels and 3% acyclovir ointment. Higher concentration of ganciclovir gels are probably necessary in order to treat the HSV-1 kerato-uveitis.

Cross-resistances to antiviral drugs of IUdR-resistant HSV1 in rabbit keratitis and in vitro

The emergence of cross-resistance to various antiviral drugs was investigated both in vivo and in vitro for herpes simplex virus type 1 (HSV1) resistant to idoxuridine (IUdR 0.24%) obtained by seven successive passages (from P0 to P7) in rabbit keratitis treated by IUdR. The viral population obtained at the seventh IUdR passage (P7) showed an activity of the thymidine kinase (TK) reduced to 5.6% of the parental strain (PO); moreover, most of the clones of P7 showed an altered TK phenotype determined by the [125I]iododeoxycytidine (IDC) procedure. In rabbit keratitis, IUdR-resistant viral population P7 showed cross-resistance to bromovinyl desoxyuridine (BVDU) (0.5%) and to acyclovir (ACV) (3%). Under trifluorothymidine (1%) treatment, P7 showed an intermediate sensitivity. HSV1 at P7 remained sensitive to adenine arabinoside (Ara A) (3%) and to dihydroxy-propoxymethylguanine used at high concentration (3%). The in vitro sensitivity determination to various antiviral drugs was investigated by dye-uptake assay for the initial viral population PO and for HSV1 collected under IUdR treatment at the third (P3) and the seventh (P7) passages. Cross-resistance to TK-dependent drugs, such as IDC, BVDU, and ACV were found at P7. P7 remained sensitive to Ara A and to phosphonoformic acids antiviral drugs known not to be dependent on viral TK.

Oral acyclovir for herpes zoster ophthalmicus

BACKGROUND

Reports on the natural history of herpes zoster ophthalmicus stress its high morbidity related to vicious scars on eyelids, ocular complications, and post-herpetic neuralgia. Early treatment with oral acyclovir is effective, but the optimal duration of treatment has not been defined.

METHODS

The authors performed a bicentric, prospective, randomized, double-masked study of 86 patients with acute herpes zoster ophthalmicus, within 72 hours of skin eruption, who received oral acyclovir (800 mg 5 times daily), either for 7 days (plus 7 days oral placebo) or for 14 days. All patients concomitantly received ophthalmic 3% acyclovir ointment; follow-up was at least 6 months.

RESULTS

Statistical analyses of subjective symptoms, skin lesions, and ocular complications showed no significant differences between the groups, suggesting that a 7-day course of treatment was sufficient. Drug tolerance was good. Pooled data from both groups corroborated earlier reports that prompt treatment with oral acyclovir reduces the severity of the skin eruption, the incidence and severity of late ocular manifestations, and the intensity of postherpetic neuralgia. At 6 months, late ocular inflammatory complications were seen in 29.1% of our 86 patients, versus 50% to 71% of untreated patients described by others. Only 13% of our patients experienced post-herpetic neuralgia, which in no case required the use of analgesics.

CONCLUSION

The authors believe it is not useful to prolong treatment with 800 mg of oral acyclovir 5 times daily for more than 7 days in herpes zoster ophthalmicus. This study confirms the efficacy of oral acyclovir not only against skin lesions and ocular complications, but also against postherpetic neuralgia in herpes zoster ophthalmicus.

Anorectal lesions in human immunodeficiency virus-infected patients

In a prospective study, we analysed the anorectal lesions observed in 148 human immunodeficiency virus-infected patients and compared the data with those reported in the literature. The majority of the patients (97.3%) were homosexual or bisexual men. The mean age of the population was 34.2 years. A history of previous sexually transmitted diseases was found in 79.7% of the male patients. The stage of HIV-related disease, according to the Centers for Disease Control classification, could be determined in 141 patients: 54.6% were stage II, 3.5% stage III and 41.8% stage IV. Anal condylomata were the most frequent manifestation, affecting 29.7% of the patients, 7.1% of whom showed moderate to severe dysplasia. The types were mainly 6, 11, 16 and 18, but types 31, 35 and 39 were also observed. Ulcerations were the most frequent non-condylomatous lesions, occurring in 41 patients; most (60%) were due to herpes viruses, and a large minority (21%) to cytomegalovirus. The etiology could not be determined in five cases. Anal sepsis was present in 11.4%, haemorrhoidal disease in 16.8% and fissures in 6%. Six patients developed Kaposi's sarcoma and seven, non-Hodgkin's lymphoma. No anal cancers were observed. Finally, wound healing was slowed in the patients operated on for haemorrhoids, fissures and suppuration. No statistical analysis could be performed because of the small number of patients.

[Osteocalcin in chronic alcoholism]

In order to investigate the mechanism by which the inorganic content of the bone is reduced in chronic alcoholism, the authors assayed osteocalcin in 60 chronic alcoholics. The level was significantly lower than in control subjects. There was no significant difference between levels in cirrhotics and in non-cirrhotic alcoholics. There was a negative correlation between osteocalcin and gamma GT levels. There was no correlation between osteocalcin and blood calcium, blood phosphorus, ALAT, ASAT, alkaline phosphatase, 5'-nucleotidase, albumin or bilirubin levels, or with the prothrombin time. These results suggest a direct impact of alcohol on the osteoblast.

Kaposi's sarcoma of the colon in a young HIV-negative woman with Crohn's disease

We report a case of isolated colonic Kaposi's sarcoma in a 36-year-old HIV-negative woman with refractory Crohn's disease of the colon and perineum following 11 months' treatment with azathioprine. The clinical features of this case are quite different from those classically described in Kaposi's sarcoma. Among the known risk factors, iatrogenic immunosuppression would appear to be the most probable.

Formal strategy in public hospitals

This paper suggests that the difficulties associated with the application of formal strategic planning in public professional service organizations may have been underestimated in much of the literature. A survey of written strategic plans produced by Canadian hospitals showed that these plans were often heavily oriented towards expansion, ambiguous and rather loosely integrated, leading to questions concerning their realism and utility as a basis for strategic decisions. This phenomenon seems symptomatic of the complex (and often highly political) decision making environment faced by hospital administrators (and by managers of other professional service organizations such as universities and social service agencies). It is concluded that the benefits of formal planning may be different and less tangible for these organizations than for private business.

Emergence of cross-resistant herpes simplex virus following topical drug therapy in rabbit keratitis

The acquisition of drug resistance in vivo was investigated by 7 serial passages (from P0 to P7) of herpes simplex virus (HSV-1) in rabbit cornea treated with either IUdR (idoxuridine), IDC (idoxycytidine), ACV (acyclovir), TFT (trifluridine), or Ara A (adenine arabinoside). Therapeutic failure was acquired gradually: at P3 for IUdR, at P4 for ACV and at P5 for TFT. At P7, viral thymidine kinase (TK) activity was reduced to 5.6% of the parental strain for IUdR, to 7.5% for ACV and to 4.6% for TFT treatment. No signs of clinical unresponsiveness occurred with IDC or Ara A. The in vitro determination of antiviral drug sensitivity performed by the dye-uptake assay on HSV isolates at each passage showed a correlation between the increase in the 50% effective dose (ED50) and the increase of ulcer area grade at each passage under antiviral drug (p less than 0.1). Both IUdR- and TFT-resistant HSV1 developed cross-resistances to TK dependent drugs. However ACV-resistant HSV1 did not show cross-resistance to other antiviral TK dependent drugs. The acquisition of the cross-resistances is discussed, and the practical implications in case of therapeutic failures are suggested.

Rectal stenosis due to Veganine suppositories

A new case of rectal stenosis due to the chronic use of suppositories of associated analgesic drugs is reported. Surgical treatment was conservative. This observation outlines the dramatic consequences of chronic self-treatment and the difficulties of ensuring long-term withdrawal.

Anal ulcerations due to cytomegalovirus in patients with AIDS. Report of six cases

Lesions due to cytomegalovirus (CMV) are frequent in the immunocompromised patient. This is particularly the case in patients with AIDS, where the colon and rectum are the regions most often involved. The authors report six cases of anal ulcerations due to CMV in patients with AIDS. These lesions, confirmed histologically, were either isolated or associated with other localizations. Treatment is based on specific antiviral agents but resistance and recurrence can occur. The current report underlines the importance of histologic examination of anal lesions in HIV-infected subjects.

[Idiopathic portal hypertension associated with connective tissue disease similar to systemic lupus erythematosus]

A case of idiopathic portal hypertension associated with connective disease resembling systemic lupus erythematosus is described. The patient was a 50-year-old woman with splenomegaly, ascites, esophageal varices, and pancytopenia, but without extrahepatic portal obstruction or cirrhosis of the liver. Electron microscopy of the liver showed perisinusoidal fibrosis. High titers of autoantibodies against proliferating cell nuclear antigen (PCNA) were found in the sera as well as in ascites; anti-DNA antibodies appeared after anti-PCNA antibodies and remained thereafter at a moderate titer. The possibility of an immunological process in the pathogenesis of idiopathic portal hypertension is discussed.

Hemorrhoidectomy: Hospital Leopold Bellan procedure

The authors describe their hemorrhoidectomy technique, a modification of Milligan-Morgan. It differs by the association of a posterior anoplasty (with internal sphincterotomy in the case of a fissure or sphincter hypertonia) and of a sub-mucocutaneous dissection of the security bridges. They report on their experience with 410 operations carried out during the year 1985. Immediate complications are mainly hemorrhage (2.68%) and urinary problems (9%). Average cicatrization time is about six weeks. At one year, there were no relapses nor fissures. A moderate stenosis was observed in 1.45% of the cases, and a hypocontinence to flatus in 2.3%. Use of a CO2 laser does not result in any modification of these results.

[Efficacy of intravenous sotalol in the treatment of supraventricular tachycardia]

20 patients with supraventricular tachycardia, received one to three intravenous injections of 0.5 mg/kg of sotalol. This group included 8 atrial fibrillations, 5 atrial flutters, 2 systolic tachycardias and 5 junctional tachycardias. Return to a normal sinus rhythm is obtained in 2 of the 8 patients with atrial fibrillation while a decreased heart rate under 100 per minute is noted in 3 of them. Among the 5 patients with atrial flutter, only one returned to a normal sinus rhythm and in 2 the tachycardia decreased. In the 2 patients with systolic tachycardia, the heart rate decreased without return to a normal sinus rhythm while the heart rate decreased in all 5 cases of junctional tachycardia. A left ventricular failure with hypotension, a bradycardia at 30/min. and a transient left bundle branch block were observed during treatment. The bundle branch block is explained by an increased ventricular effective, refractory period induced by this beta-blocker. Intravenous sotalol appears as an interesting alternative in the treatment of supraventricular tachycardias with an efficacy of about 70 p. cent; it is well tolerated if the contraindications of the beta-blockers are respected.

[Pharmacokinetics of netilmicin in cirrhotic patients with or without ascites]

The pharmacokinetics of netilmicin after intramuscular injection (2 mg/kg) was investigated comparatively in cirrhotic patients with or without ascites, and in healthy subjects. In patients with ascites, the same pharmacokinetic parameters were measured after the ascites had been cured. Twenty-four hours after intramuscular injection, the residual levels in cirrhotic patients were moderately higher than in controls, showing that liver failure or ascites did not significantly modify the pharmacokinetics of netilmicin. Serum concentrations were bactericidal. The ascitic fluid level was lower than the therapeutic range, but it was sustained for nearly 24 hours after intraperitoneal injection (2 mg/kg). These results indicate that netilmicin may be administered to cirrhotic patients without peritoneal infection using the same regimen as in healthy subjects. The peritoneal route may be preferable in case of peritoneal infection.

[Rupture of the left ventricle into the free pericardium in the early stage of a myocardial infarction. Diagnosis using echocardiography and surgical treatment]

A case of subacute left ventricular rupture on the 4th day of an inaugural antero-septal infarction in a 63-year old woman is reported. The diagnosis, suggested by cardiovascular collapse with acute tamponade, was confirmed by echocardiography. Haemodynamic stability was maintained by needle aspiration followed by pericardial drainage, and right heart catheterization long enough for the patient to be transported to a Cardiovascular Surgery unit where surgical repair was successfully performed 9 hours after the rupture. The elements for a positive diagnosis, the value of echocardiography, the various surgical procedures and the favourable long-term prognosis in patients operated upon are discussed.

HSV1 strain sensitivity in experimental rabbit keratitis: evolution under repeated topical IDU administrations

The effects of repeated topical idoxuridine (IDU) administration of HSV1 strain sensitivity were investigated during 6 serial passages (P1 to P6) in the rabbit. By comparison to placebo treated rabbits, a delay in ulcer cicatrization appeared at P2 and clinical resistance was completed at P3. Clinical cross resistance to acyclovir (ACV) was also tested and demonstrated at P7. In vitro, a plaque reduction test on Vero cells using directly the tear film HSV populations allowed the prediction of the resistance by an early rise in the effective dose 90% (ED 90) value anticipating that in ED 50%. An ED 50 determination by dye-uptake assay on P6 HSV isolate demonstrated a cross resistance to viral thymidine kinase (TK) dependent drugs without any change in Ara-A and PFA sensitivity, according to a 23% TK activity at P6. At the last passage the HSV drug resistant population had an unrestricted corneal pathogenicity. A return to IDU and ACV in vitro sensitivity was demonstrated in group control animals at P2 but not at P4 or P6.

[Plasma levels of clomipramine and declomipramine in patients with depression: a study of its correlation with therapeutic efficacy]

Twenty four in-patients with an endogenous or non endogenous depressive syndrome (9 and 15, respectively) were treated in hospital for 21 days with various dosages regimens of clomipramine. Plasma concentrations of clomipramine and demethylclomipramine were determined once a week in blood samples. Therapeutic effects were assessed with Hamilton Rating Scale. At day 21, optimal therapeutic effect was observed when the sum of clomipramine and demethylclomipramine plasma levels was situated between 200-400 ng/ml.