[Regionalization of very preterm birth care sites in Ile-de France in 1998]

The objective of this article is to describe the conditions under which very premature babies were born in the Paris region between June 1 and December 31, 1998, that is to say those born prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams. The study looked at all pre-term births, including medical terminations of pregnancy (TOP), occurring in one of the 135 maternity units in the Paris region. Between June 1 and December 31, 1998, 1337 mothers gave birth to babies prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams in 84 maternity units in the Paris region, 263 of which had a medical termination of pregnancy (20%). These mothers were older than average for the region (25% were 35 years old or older); 4.3% of them do not have social insurance coverage. The remaining 1074 mothers (excluding TOP) gave birth to 1290 children, of which 202 were stillbirths, 46 died in the labor ward and 1042 were admitted to a neo-natal unit. Of the same group of 1074 mothers, 195 (18%) had a multiple pregnancy--175 twins, 19 triplets, and 1 quadruplet 60% of them (599 women) who had very premature or low birth weight babies (excluding TOPs) delivered them in a tertiary perinatal centre (TPC). This proportion varies according to two variables: 1) the community in which the family lives (40% in the Seine-et-Marne department, the eastern region of Paris and a district without TPCs, to 70% in the Hauts-de-Seine, a northern district), and 2) whether the pregnancy is single (58.8%), twin (72.6%) or triple (84.2%). In utero transfer accounts for 62.7% of the mothers who delivered in TPC, who were transferred prior to delivery. This type of study is useful for measuring the implementation of the regionalisation high-risk perinatal care and access to adequate services. It clearly demonstrates that inequities in access to care exist for women by district of residence.

Migraine and the risk of cervical artery dissection: a case-control study

The association between migraine and cervical artery dissection (CAD) was explored in a hospital-based case-control study. Migraine was present in 49.1% (23/47) of patients with CAD and in 21% (11/52) of patients hospitalized for a cerebral ischemic event not related to a CAD (adjusted odds ratio = 3.6; 1.5 to 8.6, p = 0.005). This result supports the hypothesis that an underlying arterial wall disease could be a predisposing condition for migraine.

Characterization and regulation of a CHO cell line stably expressing human serotonin N-acetyltransferase (EC 2.3.1.87)

Current melatonin research is essentially based on the finding of new molecular tools, including synthetic or natural agonists and antagonists for the melatonin receptors and synthetic inhibitors of the enzymes involved in its biosynthesis. Indeed, the use of these compounds will improve our understanding of some of the numerous mechanisms of action of melatonin. The present report deals with the establishment and description of a new cell line expressing in a stable manner human arylalkylamine-N-acetyltransferase (AANAT, E.C.2.3.1.87). This new cellular system permits one to check the capacity of newly discovered inhibitors to penetrate the cell and reach their target. Some emphasis is put on inhibitors of the bromoacetyltryptamine family since these precursor compounds form in situ bisubstrate inhibitors with strong affinity for the human enzyme. AANAT is known to undergo complex and rapid regulation by a subtle balance between extremely fast catabolism and protection against it, both due to serine phosphorylation. In the present report, this phosphorylation is shown to occur in vitro after incubation with several kinases (rho-kinase, chk-1, protein kinase A) but not with protein kinase C. Phosphorylation enhances the specific activity of the enzyme by a factor of two to five. This phosphorylation is also shown to occur after treatment of the cell with compounds such as forskolin and rolipram that enhance or protect the intracellular pool of cAMP or the cell-permeable cAMP analogue, dioctanoyl-cAMP. The specificity of the cellular model was assessed using a series of substrates and inhibitors of AANAT already described in the literature, and the characteristics of this cellular system are shown to correspond with those reported for the purified enzyme. This cell line was used to screen libraries of compounds in a living system and led to the discovery of several potent specific and non-toxic AANAT inhibitors.

[Marfan syndrome and pregnancy. Apropos of 4 cases]

OBJECTIVES

To create a follow-up protocol for pregnant patients with Marfan syndrome.

PATIENTS AND METHODS

We retrospectively reviewed the charts of patients who delivered in the Jeanne de Flandre University Hospital between June 1996 and June 1999. Four pregnant patients with Marfan syndrome were identified.

RESULTS

Three of these patients had Bentall procedure. One of them had vaginal delivery and the two others underwent cesarean section. One of these two patients developed aortic valve thrombus at 14 weeks of amenorrhea. The fourth patient did not have surgery and had two vaginal deliveries.

DISCUSSION

According to our results and after reviewing literature pregnant patients with Marfan syndrome were divided into two groups. The 1st group was comprised of patients who underwent Bentall procedure. The 2nd one was comprised of patients who did not undergo any surgical procedure. The possibility of vaginal delivery for patients who underwent Bentall procedure (one case) and the interest of Propanolol and anticoagulant treatment are emphasized.

CONCLUSION

The multivariant approach of pregnant patients with Marfan syndrome is stressed out with special reference to the potential complications of this syndrome such as aortic dissection and to the problems related to the anticoagulant treatment.

[Four-bone fusion of the wrist: review of 17 cases at an average 3.4 years follow-up]

PURPOSE OF THE STUDY

We reviewed retrospectively outcome after intracarpal arthrodesis for advanced-stage osteoarthritis of the wrist.

MATERIAL AND METHODS

Among the 20 patients who underwent a four-bone fusion between 1989 and 1998 in our unit, 17 were available for analysis. Mean age of the study population was 41.5 years. These young patients had an occupational activity and 80% of them were manual laborers. Preoperatively, pain was the main complaint; 95% of the patients considered pain to be invalidating. Grip force was 48.5% compared to the healthy side. Joint amplitudes were limited in all patients: flexion-extension 85 degrees, radio-ulnar inclination 22.5 degrees with 12.5 degrees for the ulnar side. Mean loss of motion compared with the healthy side was 32.5% for flexion-extension, and 44% for radio-ulnar inclination. The preoperartive radiograph showed degenerated capito-lunate joints in 63% of the cases, degenerative scapho-capital joints in 58% and total loss of the radio-scaphoid joint space in 100%. Degeneration was considered to be global in 58% of the wrists.

RESULTS

Mean follow-up for the 17 wrists studied was 3.4 years (range 1-10). At last follow-up, 41% of the wrists were pain free, 24% were painful occasionally, and 35% were bothersome for heavy work. The patients did not express any difficulties in daily activities. Grip force was only slightly improved with a 7.5% gain over the preoperative value. Joint motion at last follow-up was, on the average, 70 degrees flexion-extension (40 degrees flexion and 30 degrees extension) and 35 degrees radio-ulnar inclination (17.5 degrees ulnar). Eleven patients (65%) had resumed their occupational activities at the same level two months after surgery. Outcome was deemed satisfactory by 65% of the patients, fair by 17.5%, and poor by 17.5% (3 patients). Radiological fusion was achieved in 16 wrists at a mean 4.5 weeks. Mean carpal height was 0.42 compared with 0.52 for the healthy side and 0.47 preoperatively. There was no significant relationship between carpal height and poor outcome.

DISCUSSION

Data in the literature are in agreement with the good results obtained for pain and activity level despite the inconstant effect on grip force and joint amplitude.

CONCLUSION

Four-bone fusion is an effective treatment for patients with advanced-stage osteoarthritis of the wrist where the level of degeneration rules out resection. The consequences of total wrist arthroplasty are much more invalidating.

The 5A6A polymorphism in the promoter of the stromelysin-1 (MMP3) gene as a risk factor for restenosis

AIMS

Intracoronary ultrasound studies in humans show that chronic remodelling rather than neointimal hyperplasia is the mechanism of restenosis. Stent implantation limits this remodelling process and significantly reduces restenosis. MMP3 (Stromelysin-1), a member of the matrix metalloproteinase family may play a role in this remodelling. We used a functional polymorphism (with alleles designated 5A or 6A) in the promoter of the MMP3 gene to examine the possible role of MMP3 in restenosis.

METHODS AND RESULTS

Genotypes were determined in a series of consecutive patients who underwent conventional balloon coronary angioplasty without stenting (n=287) or who also had successful implantation of a Palmaz-Schatz stent (stent) (n=198). For all patients restenosis was estimated at 6 months using quantitative computer-assisted angiography. The minimal luminal diameters before and after the procedures did not differ significantly between genotypes. At follow-up in the patients without stent, those with the 6A6A genotype had an increased degree of restenosis after coronary angioplasty compared to those with one or more 5A alleles, with a greater diameter stenosis (52+/-21% vs 45+/-19%, P=0.012), and a greater late loss (0.58+/-0.59 mm vs 0.38+/-0.59 mm, P=0.038). By contrast, in the stented patients MMP3 genotype was not associated with any angiographically determined measure of vessel dimensions.

CONCLUSIONS

These data imply the involvement of MMP3 in chronic remodelling after conventional balloon angioplasty, and suggest that the 6A6A MMP3 genotype is a genetic susceptibility factor for restenosis after angioplasty without stenting.

The continuous recording of blood pressure in patients undergoing carotid surgery under remifentanil versus sufentanil analgesia

We compared the hemodynamic stability during carotid endarterectomy of remifentanil with that of sufentanil anesthesia. Fifty-six patients were randomly assigned into Remifentanil (n = 27) or Sufentanil (n = 29) groups. In the Remifentanil group, IV propacetamol (2 g) and morphine (0.1 mg/kg) were infused 30 min before skin closure. In the Sufentanil group, patients received 2 g propacetamol. Beat-to-beat recordings of systolic arterial blood pressure (SBP) and heart rate (HR) were stored on a computer. The maximum and minimum values of BP and HR after induction, at intubation, during the surgical procedure, and after the operation and the coefficients of variation of SBP and HR were used as indices of hemodynamic stability. The coefficients of variation of SBP and HR were similar in both groups during and after surgery. However, at intubation, maximal SBP was higher in the Sufentanil group (P < 0.05). Decreased propofol doses and isoflurane end-tidal concentrations were used in the Remifentanil group. At recovery, a similar profile of SBP and HR was found in both groups. We conclude that intra- and posthemodynamic stability was similar with remifentanil or sufentanil in patients undergoing carotid endarterectomy. However, remifentanil was more effective for blunting the increase in SBP at intubation without increasing the blood pressure-decreasing effect of induction. Intraoperative remifentanil use was associated with a decreased amount of hypnotic drug administered.

IMPLICATIONS

Beat-to-beat recordings of heart rate and blood pressure in patients undergoing carotid surgery revealed that hemodynamic stability was similar with remifentanil or sufentanil anesthesia both during and after surgery. Remifentanil was more effective in limiting the increase in blood pressure associated with intubation without increasing the blood pressure-lowering effect of induction or the blood pressure response to recovery.

Cadmium inhibits epoxidation of diatoxanthin to diadinoxanthin in the xanthophyll cycle of the marine diatom Phaeodactylum tricornutum

Cd has pleiotropic effects on plant physiology and in particular on photosynthesis. It has not been established yet if Cd alters the functioning of the xanthophyll cycle. To answer this question, an exponentially growing culture of the marine diatom Phaeodactylum tricornutum was incubated with Cd (20 mg/l) for 24 h and irradiated with a light activating the xanthophyll cycle, which in diatoms, consists of the reversible deepoxidation of diadinoxanthin to diatoxanthin. The measurements show that the deepoxidation step is not influenced by Cd. In contrast, the Cd concentration used sharply inhibits the epoxidation of diatoxanthin to diadinoxanthin.

Acute coronary syndrome without ST elevation: implementation of new guidelines

Unstable angina and non-ST-segment-elevation myocardial infarction have in recent years been recognised as frequent and important clinical manifestations of coronary-artery disease. The European (ESC) and American (ACC/AHA) professional societies last year released guidelines on diagnosis, risk stratification, and treatment of these disorders. These guidelines summarise similarly the current evidence and translate them to clinical practice. Most important changes relate to the inclusion of troponins into the risk stratification algorithm, the addition of low-molecular-weight heparin and glycoprotein IIb/IIIa antagonists to medical treatment, and the role of invasive management for improved long-term outcome. Guidelines are constantly challenged by newly emerging study results. Recently, early invasive management and clopidogrel have been found to exert further benefit to this high-risk group of patients. Accordingly, the societies on both sides of the Atlantic will work together closely to update and implement these guidelines.

[Tibio-talar arthrodesis: long term influence on the foot]

PURPOSE OF THE STUDY

The aim of this study was to evaluate the long-term effect of tibiotalar arthrodesis on function, clinical and radiological tolerance, and subtalar joints.

MATERIAL AND METHODS

We reviewed 37 cases of tibiotalar arthrodesis in 27 young patients who were generally manual workers. Their mean age at surgery was 46 years and mean follow-up at review was 12.8 years (range 5-26 years). Functional outcome was assessed with the Duquennoy scale. We reviewed the anterioposterior and lateral weight-bearing views as well as the lateral view in dorsal and forced plantar flexion.

RESULTS

Mean functional outcome was good and very good in 66% of the cases, fair in 30% and poor in one case. Total pain relief had been achieved in 45% of the cases with a mean walking distance of 1500 m without crutches. Residual mobility at last follow-up was 13 degrees for the mediotarsal joint. This mobility allowed the arthrodesed foot to adapt to gait. Radiologically, fusion had been achieved in 83% of the cases within 3 months. The overall functional score fell off proportionally with the degree of arthrodesis valgus starting at 5 degrees. Likewise pes equinus > 10 degrees led to pain and reduced motion. The subtalar joints were affected in all cases, leading to poor adaptation of the foot on uneven ground. Grade 1 osteoarthritis affected the mediotarsal joint and was more marked in case of equine fixation.

DISCUSSION

Our results are similar to those reported in the literature. We had 4 cases of nonunion in patients with risk factors previously discussed in the literature.

CONCLUSION

Arthrodesis remains a useful method for treating talocrural osteoarthritis, providing good long-term results. The position of the fixation should be 90 degrees in the sagittal plane and 0 degrees to 5 degrees valgus in the frontal plane.

[Time and narrative: the psychic character of history]

The thesis developed here is that of the "psychic character of history", following Simmel's terminology. Psychic character must not, however, be understood as a lack of objectivity. On the contrary, it is an instrument of investigation, which indicates the conditions of objectification in the human and social sciences. If the historian always reconstructs a past time, it is because the past form is the mode, specific to history, of distancing/objectification. Anthropology and sociology make use of other modes of distancing. The reconstruction that takes place during psychoanalysis is thus, on three points of comparison, clarified by the narrative process proper to history.

A novel realistic three-layer phantom for intravascular ultrasound imaging

Intravascular ultrasound (IVUS) is an imaging modality that experienced a tremendous development over the last 20 years. Phantoms for IVUS are rare and poorly documented. The aim of this paper is to propose an original IVUS phantom that has geometries and specular textures closer to those of coronary arteries than conventional tube-like phantoms. The proposed phantom has a three-layer aspect, reproducing the intima, media and adventitia that compose the arterial wall. It is made of an agar-based compound, with water, glycerol and cellulose particles. Fourteen phantoms were quantified using IVUS. Six phantoms were evaluated by both photomacroscopy and IVUS. There was an excellent correlation between phantom dimensions evaluated by photomacroscopy and the nominal values (mold dimensions). The IVUS quantification of the phantom was closely correlated to the measurements obtained by photomacroscopy. These results demonstrate that a multilayer phantom, with known and reproducible dimensions and with realistic geometric and echographic properties has been developed.

[Representative observations of therapies in arterial hypertension]

An enquiry was conducted by 125 general practitioners in 1998 concerning 1,204 hypertensive patients (55.5% women, 71% aged 60 or over, 54% with normalised blood pressures). At the first visit (inclusion) the most frequently described therapeutic classes were: diuretics (19%), betablockers (19%), ACE inhibitors (14%), angiotensin II inhibitors (7%). The use of fixed associations was uncommon except for that of ACE inhibitors with diuretics (10.5%). The incidence of normalisation of blood pressure was the same in all therapeutic classes, about 55%, comparable to reported data; however, 42% of non-normalised patients were on monotherapy. Only 7.4% of patients had their treatment changed at inclusion: 3.8% of normalised and 11.2% of non-normalised hypertensives. This low incidence of change of treatment is partially explained by the patients' own opinion about the treatment of their hypertension. In fact, the majority of therapeutic changes is observed when the patient and the doctor both concur. This data on the treatment of hypertension confirms the respective usage of the main therapeutic classes but the limited number of treatment changes at inclusion does not allow yet assessment of these new choices. One year follow-up of this cohort to the second phase of results should provide important information with respect to this point.

The oxygenation variations related to prone positioning during mechanical ventilation: a clinical comparison between ARDS and non-ARDS hypoxemic patients

OBJECTIVES

To compare, in clinical practice, the oxygenation variations related to prone positioning (PP) during mechanical ventilation in ARDS and non-ARDS hypoxemic patients.

DESIGN AND SETTING

Prospective observational study of data on consecutive patients treated with the same protocol in the intensive care unit (ICU) of a university hospital.

PATIENTS

From May 1996 to December 1998, 226 PP periods without adjunction of nitric oxide (NO) inhalation and/or almitrine bismesylate infusion, performed in 59 mechanically ventilated hypoxemic patients (arterial oxygen tension/fractional inspired oxygen (PaO2/FIO2) ratio <300 mmHg) with no evidence of left ventricular failure, were included in this study.

MEASUREMENTS

Arterial blood gas was measured before the PP, at 1 h from the beginning of the PP, at the end of the PP and 1 h after returning to the supine position.

RESULTS

We analyzed 136 PP periods in 34 non-ARDS patients (60.2%) and 90 in 25 ARDS patients. The PP was repeated and the duration of the PP periods was: 10.6+/-0.22 h. The PP during the mechanical ventilation appeared to be safe and well tolerated. A PaO2/FIO2 ratio improvement at the end of the PP period, occurred for 196 periods (86.7%) with a mean PaO2/FIO2 ratio increase of +46.4+/-0.03% at the end of the PP periods compared to the baseline supine value. The PaO2/FIO2 ratio variations at 1 h after the start of the PP, at the end of the PP period and at 1 h after the return to supine were not different in ARDS or non-ARDS hypoxemic patients. The PaO2/FIO2 ratio improvement appeared to be more intense and more rapid in ARDS patients.

CONCLUSIONS

In about 90% of periods, PP improved the PaO2/FIO2 ratio in patients with ARDS as well as in hypoxemic patients with non-ARDS. Studies are necessary to determine the impact of PP on survival and the mechanical ventilation duration in ARDS or non-ARDS hypoxemic patients.

Cytotoxic activities of novel hexahydroindolizino[8,7-b]indole derivatives prepared by 1,3-dipolar cycloaddition reactions of 3,4-dihydro-beta-carboline ylides

A series of 1-cyano and 2-cyanohexahydroindolizino[8,7-b]indole derivatives was prepared by 1,3-dipolar cycloaddition of acrylonitrile with ylides derived from 3,4-dihydro-beta-carboline and its 6-methoxy, 6-benzyloxy, 9-methyl and 9-benzyl analogues. The products, together with their reduced 1- or 2-aminomethyl derivatives, were evaluated for cytotoxic activity in L1210 cancer cells. Compounds derived from 6-benzyloxy or 9-benzyl-3,4-dihydro-beta-carboline were found to be the most active, with IC(50)'s in the 2-50 microM range. Of these, two compounds, the 1- and 2-cyano 8-benzyloxyindolizino[8,7-b]indole derivatives 20a and 20c, respectively, were found by cytometric flux analysis to stop cancer cell growth at the G(2)M and 8N (>G(2)M) stage of the cell cycle. These two compounds also showed no loss of cytotoxic activity in K562R cancer cells resistant to doxorubicin.

Endovascular treatment of abdominal aortic aneurysms: is there a benefit regarding postoperative outcome?

BACKGROUND AND OBJECTIVE

The endovascular treatment of abdominal aortic aneurysms has raised great interest amongst vascular surgeons. The aim of this study was to compare the postoperative morbidity and mortality rates of endovascular treatment with those of open surgery, from the anaesthesiologist's standpoint.

METHODS

From January 1997 to June 2000, 425 consecutive patients with abdominal aortic aneurysms were referred for regular surgery. Thirty-nine patients who needed a visceral or renal artery revascularization, or a nephrectomy were excluded. The remaining 386 patients were studied in a prospective manner. Aneurysms were evaluated with spiral computerized tomography scanning and calibrated aortography. After informed consent, only those patients with a suitable vascular anatomy underwent endovascular treatment (n = 193). All other patients underwent open surgery and are considered as a control group (n = 193). Endovascular treatment was performed by a femoral or an iliac retroperitoneal route. All stent-grafts were made to measure using auto-expandable stainless-steel stents covered with a standard polyester prosthetic graft.

RESULTS

Six patients in the endovascular treatment group needed to be converted to the open surgical technique (during the same operation) because of rupture of the iliac bifurcation (1 patient), a large endoleak (2 patients), or technical problems (3 patients).

CONCLUSION

The amount of bleeding and the need for blood products were significantly lower in the endovascular treatment group. Despite the absence of significant differences regarding cardiac complications and mortality, there was a lesser incidence of pneumonia, acute respiratory and renal failure. Patients in the endovascular treatment group spent less time in the intensive care unit and in the Hospital.

An overview of the MAGE gene family with the identification of all human members of the family

The first human members of the MAGE gene family that have been described are expressed in tumor cells but silent in normal adult tissues except in the male germ line. Hence, they encode strictly tumor-specific antigens that represent attractive targets for cancer immunotherapy. However, other members of the family were recently found to be expressed in normal cells, indicating that the family is larger and more disparate than initially expected. We therefore performed a database screening to identify all of the recorded members of both classes of human MAGE genes. This report provides an overview of the MAGE family and proposes a general nomenclature for all of the MAGE genes identified thus far. We found that the MAGE-D genes were particularly well conserved between man and mouse, suggesting that they exert important functions. In addition, the genomic structure of the MAGE-D genes indicates that one of them corresponds to the founder member of the family, and that all of the other MAGE genes are retrogenes derived from that common ancestral gene. Intriguingly, the COOH-terminal domain of MAGE-D3 was found to be identical to trophinin, a previously described protein believed to be involved in embryo implantation.