Albumin-impregnated polyester vascular prosthesis for abdominal aortic surgery: an improvement?

AIM

To compare the peroperative blood loss and the postoperative systemic inflammatory reaction in patients receiving either a Vasculour II Albumin pre-impregnated prosthesis (VA group, n = 32) or a preclotted Vasculour II prosthesis (V group, n = 33) for elective surgery of the abdominal aorta.

SETTING

University Hospital.

DESIGN

Prospective, randomised study.

METHODS

Peroperative blood loss was measured over two different periods: Phase I from the beginning of the operation to the completion of the proximal anastomosis, when blood loss cannot be related to the model of prosthesis implanted and phase II after the completion of the proximal anastomosis to the end of the operation. Postoperative blood loss was evaluated by the determination of the retroperitoneal drainage volume over a period of 2 days immediately following the operation. The presence of periprosthetic fluid was measured with echography at days 4, 9, 30 and 60. The postoperative systemic inflammatory reaction was evaluated by measuring the sedimentation rate and the C reactive protein levels daily from day 1 to day 9, and at days 14, 21, 28, 45, and 60, and by measuring the body temperature daily from day 1 to day 9.

RESULTS

No significant differences of peroperative blood loss were observed. The same proportion of patients (35%) in both groups received homologous transfusion. The mean number of units of homologous blood transfused per patient was respectively 0.77 and 0.91 for the VA and the V group. The retroperitoneal drainage volume and the percentage of patients with periprosthetic fluid did not differ significantly. No significant differences in systemic postoperative inflammatory reaction were observed.

CONCLUSION

There were no benefits in using albumin-impregnated prosthesis as opposed to preclotted prosthesis in terms of peroperative and postoperative blood loss, or by looking at the incidence of homologous blood transfusion. However, the glutaraldehyde cross-linked albumin did not induce any systemic inflammatory reaction.

Cdc48p interacts with Ufd3p, a WD repeat protein required for ubiquitin-mediated proteolysis in Saccharomyces cerevisiae

A library of random 10 residue peptides fused to the N-terminus of a reporter protein was screened in the yeast Saccharomyces cerevisiae for sequences that can target the reporter for degradation by the N-end rule pathway, a ubiquitin (Ub)-dependent proteolytic system that recognizes potential substrates through binding to their destabilizing N-terminal residues. One of the N-terminal sequences identified by this screen was used in a second screen for mutants incapable of degrading the corresponding reporter fusion. A mutant thus identified had an abnormally low content of free Ub. This mutant was found to be allelic to a previously isolated mutant in a Ub-dependent proteolytic system distinct from the N-end rule pathway. We isolated the gene involved, termed UFD3, which encodes an 80 kDa protein containing tandem repeats of a motif that is present in many eukaryotic proteins and called the WD repeat. Both co-immunoprecipitation and two-hybrid assays demonstrated that Ufd3p is an in vivo ligand of Cdc48p, an essential ATPase required for the cell cycle progression and the fusion of endoplasmic reticulum membranes. Further, we showed that, similarly to Ufd3p, Cdc48p is also required for the Ub-dependent proteolysis of test substrates. The discovery of the Ufd3p--Cdc48p complex and the finding that this complex is a part of the Ub system open up a new direction for studies of the function of Ub in the cell cycle and membrane dynamics.

Does haloperidol block methylphenidate? Motivation or attention?

The effect of methylphenidate preceded by a moderate dose of haloperidol on reaction times over the duration of a continuous performance test (CPT), was investigated in ten male children, with a DSM-III diagnosis of attention deficit disorder with hyperactivity disorder (ADDH). Using a within-subject double-blind design, the effects of methylphenidate preceded by haloperidol on reaction time during the first and second blocks of CPT test were compared. Methylphenidate maintained a significantly improved reaction time in the second block of the CPT test. When methylphenidate, preceded by placebo, was preceded by haloperidol this effect was not observed, suggesting opposing effects on attentional systems by methylphenidate versus haloperidol. The study is the first to examine the "blocking" effect of haloperidol over the course of a CPT. The results suggest that dopamine systems are involved in the maintenance of the CPT response, and support an "incentive motivation" theory of sustained attention.

Twin sibling differences in parental reports of ADHD, speech, reading and behaviour problems

Differences between twins and siblings in behaviour problems were investigated in a non-selected sample of 1938 families with children aged 4-12 years. Families were sent a questionnaire based on DSM-III-R criteria for Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Conduct Disorder (CD) and Separation Anxiety (SA), which was validated by formal clinical interview. The questionnaire also included measures of speech and reading problems. There were significant differences between twins and siblings for ADHD symptoms, but not for symptoms of ODD, CD or SA. Twins and siblings differed significantly for gestational age, birth weight, speech and reading problems. While there was little evidence for birth weight or gestational age contributing to the difference in ADHD symptoms, there was a strong association between ADHD symptoms and speech and reading problems.

Combined pharmacotherapy or polypharmacy?

A case of possible 'serotonin syndrome' is reported. The use of combinations of psychotropic medications to treat children with severe behaviour disorders is an increasing trend among paediatricians and child psychiatrists. Some hazards as well as possible advantages are discussed.

Atrial natriuretic factor secretion: a role for atrial systolic ejection force?

The increase in plasma concentration of atrial natriuretic factor in heart transplant patients has not been fully elucidated. Besides an eventual pressure or volume overload leading to passive atrial distension, the atrial tension developed during atrial systole, or atrial ejection force, which may be increased by the transplantation procedure, is an important determinant of atrial natriuretic factor release. We therefore determined the plasma concentration of atrial natriuretic factor and the maximal atrial ejection force in 15 heart transplant patients and 8 controls, matched for age and body mass. Atrial ejection force, as defined as the force exerted by the left atrium to accelerate blood into the left ventricle during atrial systole, was obtained using combined two-dimensional imaging and doppler echocardiography. Serum creatinin concentrations, heart rate [91.9 (SD 13.2) vs 71.8 (SD 10.9) beats.min-1], mean arterial blood pressure [103.9 (SD 9.8) vs 87.4 (SD 5.8) mmHg, 13.85 (SD 1.31) vs 11.65 (SD 0.77) kPa], left ventricular posterior wall thickness and interventricular septum thickness were higher in heart transplant patients compared to controls. Plasma concentration of atrial natriuretic factor was also elevated in heart transplant patients [63.9 (SD 18.1) vs 34.0 (SD 3.2) pg.ml-1; P < 0.001]. In contrast, although the left atrial area was greater in heart transplant patients [28.2 (SD 4.8) vs 15.8 (SD 2.5) cm2; P < 0.001], mitral area, transmitral Doppler A-wave maximal velocity and atrial ejection force were similar in transplant and in control patients [7.7 (SD 3.5) vs 8.9 (SD 2.8) kdyn, 77 (SD 35) vs 89 (SD 28)mN]. No significant correlation was observed between concentration of atrial natriuretic factor and atrial ejection force, either in heart transplant patients or in controls. Thus, the elevated plasma concentration of atrial natriuretic factor observed in these heart transplant patients was multifactorial in origin, and was considered to depend upon an hypersecretion rather than upon a decreased clearance rate. Moreover, it is suggested that the atrial ejection force was unlikely to have participated in this enhanced release of atrial natriuretic factor.

A population genetic analysis of chloroplast DNA in Phacelia

Hierarchical sampling from populations, incipient and recognized varieties within Phacelia dubia and P. maculata has revealed high levels of intraspecific polymorphism in chloroplast DNA. Much of the variation is partitioned between populations as evidenced by population-specific variants at fixation in all three populations of P. dubia var. interior and in both populations of P. maculata. Nine of 16 populations were polymorphic for cpDNA haplotypes. A total of 16 haplotypes was found in a sample of 106 individuals; the most common occurred in eight of the 16 populations and in 31 per cent of the individuals in the entire sample. A phylogenetic analysis revealed four basic plastome types. The two major groups of plastomes were separated by four independent base-pair mutations which suggests an ancient split in the evolution of plastid genomes. Representatives from each major plastome division were found in each of five populations spanning two allopatric varieties of P. dubia. The geographical distribution of haplotypes and lack of evidence for recent admixture argue against migration as a source of the polymorphism. It is more likely that the current taxonomic varieties are descendants of a polymorphic common ancestor.

[Results of surgical treatment of acute traumatic aortic rupture]

Between 1967 and 1994 48 patients have been treated at our institution for acute rupture. Two patients died before operation, in two cases the operative attempt had to be abandoned with irreversible cardiopulmonary arrest, and in 44 patients surgical correction could be performed, The rupture was complete in 14 cases and incomplete in 30. In 25 patients surgery consisted of direct suture, in one patient an aortoplasty was performed, and in 18 patients a dacron tube interposition was necessary. In 7 cases the clamp and repair technique was applied, and in 37 cases extracorporeal circulation was installed. The hospital mortality amounted to 18% and was mainly contributable to the concomitant injuries. Two patients presented with paraplegia at admission, both died; postoperative paraplegia occurred in two instances, once after 48 hours. The late results were in the majority of the cases influenced by orthopedic or neurological sequelae, only one patient had to be reoperated for a false aneurysm. Our results and the review of the literature lead to the following conclusions: In spite of an optimized emergency care system, many patients with aortic rupture die before any surgical intervention. The installation of extracorporeal circulation can decrease the incidence of postoperative paraplegia; in our experience the administration of heparin does not increase the risk of bleeding from concomitant injuries. Direct suture represents the correction of choice. The long-term results are excellent.

Contact allergy to topical corticosteroids and systemic contact dermatitis from prednisolone with tolerance of triamcinolone

We report the case of a 27-year-old female who had an allergic contact dermatitis to topical corticosteroids belonging to the corticosteroid groups A and D. Upon oral treatment with prednisolone a disseminated exanthema began within 24 h. Patch tests revealed sensitization to corticosteroids of group A, C and D, including prednisolone-21-acetate and betamethasone valerate, but not of group B corticosteroids such as triamcinolone. After intradermal testing of corticosteroids the exanthema flared again and the patient was treated with oral triamcinolone, with rapid improvement of her symptoms. A literature review revealed that exanthematous reactions after systemic treatment with corticosteroids have been rarely reported. Since corticosteroids are essential emergency drugs, a safe corticosteroid should be identified for such patients. Patch and intradermal tests may be used for that purpose.

Neurometrics, dynamic brain imaging and attention deficit hyperactivity disorder

OBJECTIVE

The literature on the development of frequency analysis of the electroencephalogram (neurometrics) and functional dynamic brain imaging techniques is reviewed. Clinical applications in the diagnosis and treatment of learning disorders of childhood are discussed.

CONCLUSIONS

While questions remain about the sensitivity and specificity of the neurometric method in diagnosing attention deficit hyperactivity disorder (ADHD), if the technique proved predictive of medication response, its importance would be established. However, evoked-potential studies, cerebral blood flow and cerebral glucose metabolic studies promise a better understanding of underlying psychological processes in ADHD.

Spontaneous esophageal perforation presenting with right-sided pleural effusion

Boerhaave's Syndrome (spontaneous esophageal perforation) is an uncommon clinical entity that frequently presents with an antecedent history of marked vomiting followed by chest or abdominal pain. Misdiagnosis is the most important contributing factor in the continuing high morbidity and mortality of this disease. We report an atypical presentation of Boerhaave's Syndrome in an elderly female who presented to the Emergency Department with dyspnea, right sided chest pain, right pleural effusion, and hypovolemic shock without an identifiable antecedent event. A chest radiograph revealed massive right hydropneumothorax. After placement of a chest tube, the patient was admitted to the intensive care unit. Only 36 hours after admission did the diagnosis of Boerhaave's Syndrome become evident. She underwent operative repair and, after a prolonged stay, was discharged in relatively good condition 3 months after her admission. The absence of vomiting prior to presentation and the right sided effusion are the distinguishing features of this particular case.

The allergen of Ficus benjamina in house dust

Ficus benjamina, a member of the Moraceae family, is a tropical, non-flowering green plant which is widely used for ornamental purposes. It is an occupational allergen in plant keepers but sensitization is also increasingly found in non-occupationally exposed atopic and non-atopic patients. The allergen of Ficus benjamina is located in the plant sap, a so-called latex. By radioallergosorbent test-(RAST)-inhibition studies allergen could also be demonstrated in the dust collected from the leaf surface and in dust samples from the floor of rooms where the plant was placed. These findings could result in more extensive preventive measures in patients sensitized to Ficus benjamina. In addition there is some evidence that possibly a crossreactivity between latex of Ficus benjamina and latex from the rubber tree Hevea brasiliensis, a member of the Euphorbiaceae family, may exist.

Oral findings in elderly nursing home residents in selected countries: quality of and satisfaction with complete dentures

A total of 249 complete denture wearers were examined from a geriatric population of 610 patients in seven institutions in four different countries. The evaluation of denture quality was made by the patients' opinions and the examiners rankings with a questionnaire on interocclusal distance, occlusal function, extension, stability, comfort, and esthetics of the dentures. At each of the surveyed institutions, the patients consistently considered their dentures better than did the examiners and the maxillary dentures were rated better that the mandibular dentures by the clinicians and by the patients.

Neural networks and psychiatry: candidate applications in clinical decision making

Neural networks comprise a fundamentally new type of computer system inspired by the functioning of neurons in the brain. Such networks are good at solving problems that involve pattern recognition and categorisation. An important difference between a neural network and a traditional computer system is that in developing an application, a neural network is not programmed; instead, it is trained to solve a particular type of problem. This ability to learn to solve a problem makes neural networks adaptable to solving a wide variety of problems, some of which have proved intractable using a traditional computing approach. Neural networks are particularly suited to tasks involving the categorisation of patterns of information, such as is required in diagnosis and clinical decision making. In the last three years reports of applications involving neural networks have begun to appear in the medical literature, and these are described in this paper. However, a comprehensive search of the literature has shown that there have not as yet been reports of any applications in psychiatry. This paper discusses the nature of clinical decision making, outlines the sorts of problems in psychiatry which neural networks applications might be developed to address, and gives examples of candidate applications in clinical decision making.

[30 years' development of economic theories in confrontation with facts]

In 1969, R. Frish and J. Tinbergen received the first Nobel Price in Economics. 200 years after Quesnay's "economic tables", economics were at last considered as a science. During the last thirty years, economics haven't lost their scientific reputation, but, confronted with different situations in the world and in France, economics have been unable to bring appropriate solutions to every problem. Nowadays, economics are quite far from the promises born after the Second World War: indeed, until the 1974 world crisis, Keynes' theory (from a macro-economic point of view) and Walras' formalisation of the markets (from a micro-economic point of view) were sufficient to give satisfying representations of any economic reality and mechanism. Nevertheless, these theories were unable to deal with both growing unemployment and raising inflation in the late 70's and early 80's. Today, economics present a wide variety of efficient analysis of society. Game theory, behaviour theory or econometrics are new means used to found new kinds of reality representation. Therefore, if economics can no longer be considered as an exact science, it remains nevertheless scientific.

Medico-legal investigations of the Airbus, A320 crash upon Mount Ste-Odile, France

The authors present the medico-legal investigations and identification after the aircrash of the Airbus A320 upon the Mount Sainte-Odile (France). The identification team comprising investigators from the gendarmerie, forensic pathologists, odontologists, and scientists of the Institute from Legal Medecine rapidly retrieved and identified 85 of the 87 victims, with 17 being identified through DNA typing, three through fingerprints and the remaining through dental records and specific physical or X-ray findings. Full autopsies were performed on all fatalities to determine patterns of injury and cause of death. Results lead us to point out the importance of a multidisciplinary team of forensic practitioners especially trained for managing medico-legal investigation in mass disaster and the ability of DNA technology to solve complex identification problems.