La ions in precipitated hydroxyapatites

Hydroxyapatites were synthesized by precipitation from an aqueous solution with La3+ (0-0.75%) and with carbonate (0-6.1%) at controlled pH 7.0. Uptake of La3+ was 90-95% complete. Relatively low Ca/P (1.54-1.63) ratios were attributed to nonstoichiometry. Carbonate in samples was identified by IR spectroscopy as B-type carbonate. Lattice parameters of the hexagonal apatite structure were not affected by the La3+ content. Noncarbonated samples heated to 800 degrees C transform partially to beta-Ca3(PO4)2. Thermogravimetric analysis showed release of 0.4 mol adsorbed and 1 mol crystalline water up to 400 degrees C and decomposition of carbonate up to 900 degrees C in the samples. Luminescence data obtained for Gd-containing hydroxyapatites prove that Gd3+ ions are not incorporated in the precipitated hydroxyapatite. These findings suggest that, in the La-containing samples, La3+ is surface absorbed and not incorporated in hydroxyapatite.

Early metabolic acidosis and coma after acetaminophen ingestion

Metabolic acidosis and coma may develop in patients who experience severe hepatic injury after acetaminophen poisoning. The onset of acidosis and coma soon after acetaminophen overdose, but preceding manifest hepatic injury, contrasts with the typical course of poisoning. This pattern has been reported in a limited number of cases. Coingestions and the rare occurrence of these findings after an overdose have engendered controversy as to whether acetaminophen alone is the cause of early coma and acidosis. We describe 4 separate overdoses among 3 patients who arrived at the emergency department comatose with a metabolic acidosis soon after ingesting large amounts of acetaminophen without evidence of toxic liver injury. Our cases support the view that early metabolic acidosis with coma does indeed occur after acetaminophen poisoning, independent of hepatic failure or its complications.

[Laparoscopic splenorraphy using a resorbable prosthesis in splenic injuries. Apropos of 5 cases]

STUDY AIM

The aim of this retrospective study is to report five cases of laparoscopic splenorraphy with an absorbable perisplenic mesh for splenic injury.

PATIENTS AND METHOD

From January 1996 to February 1998, three men and two women (mean age: 52 years) were included in this study. The splenic lesions were due to either a fall (n = 3), a traffic accident (n = 1), or pleural paracenthesis in a patient with mediastinitis after valvular replacement. Splenic injury was recognized by ultrasonography. The patients were operated as either emergency cases (n = 2), or within 24 hours (n = 3). The procedure included evacuation of the hemoperitineum, total liberation of the spleen, and splenic hemostasis with a perisplenic mesh which was used in open surgery. The mesh placed behind the spleen, covering its superior and inferior poles, was unrolled forwards and burses progressively tightened.

RESULTS

There was no conversion, no mortality, no morbidity. In the four injured patients, the mean duration of surgery was 120 minutes (70-180), without any blood transfusion, and the patients were discharged on d4 or 5. The fifth patient, after valvular replacement, was operated on with anticoagulation. The mean duration of surgery was 270 minutes. Four blood units were necessary. He was discharged at d26.

CONCLUSION

This technique combines the advantages of the perisplenic mesh which is efficient and safe, with the advantages of laparoscopic surgery which simplifies the postoperative course. It can only be used in case of isolated splenic injury in patients with stable hemodynamic condition.

Acute hepatitis after riluzole administration

Riluzole is a new drug representing the first active treatment for amyotrophic lateral sclerosis. We report the cases of two patients who developed acute hepatitis after taking riluzole at the recommended dose (100 mg daily) for 7 and 4 weeks, respectively. In both cases, liver histology showed hepatocellular damage with inflammatory infiltration and microvesicular steatosis without fibrosis. Liver enzymes returned to normal 4 and 8 weeks, respectively, after riluzole withdrawal. In one case, the readministration of riluzole was followed by the relapse of hepatitis. These two observations strongly suggest that riluzole can induce acute hepatitis with associated hepatocellular damage and microvesicular steatosis. They also suggest that liver enzymes should be monitored during treatment with riluzole.

[Severe digestive complications after heart surgery using extracorporeal circulation]

PURPOSE

To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC).

METHODS

Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997.

RESULTS

Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9).

CONCLUSION

Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.

Staphylococcus aureus nasal carriage in 104 cirrhotic and control patients. A prospective study

BACKGROUND/AIMS

Bacterial infections, specially Staphylococcus aureus (S. aureus) septicemia, remain a leading cause of death following liver transplantation. It has been demonstrated that nasal carriage of S. aureus is associated with invasive infections in patients undergoing hemodialysis and could be decreased by use of antibiotic nasal ointment. However, in cirrhotic patients, the frequency of nasal carriage is unknown. The aims of this study were to determine the prevalence of S. aureus nasal carriage in cirrhotic patients and to assess nosocomial contamination.

METHODS

One hundred and four patients were included in a prospective study, 52 cirrhotic and 52 control (hospitalized patients without cirrhosis or disease which might increase the rate of nasal carriage of S. aureus). On admission and after a few days of hospitalization, nasal specimens from each anterior naris were obtained for culture. S. aureus was identified by the gram strain, positive catalase and coagulase reactions; antibiotic susceptibility was determined using a disk-diffusion test.

RESULTS

Both groups were similar with regard to age and sex. The prevalence of nasal colonization on hospital admission was 56% in cirrhotic patients and 13% in control patients (p = 0.001). After an average of 4 days, 42% of cirrhotics and 8% of control patients were colonized (p = 0.001), without any nosocomial contamination. Three strains out of 29 were oxacillin-resistant in cirrhotic patients, and none in controls (p>0.05). There was no statistical difference in carriage rate according to sex, age, cause of cirrhosis and Child-Pugh score. Previous hospitalization (OR, 6.3; 95% CI, 2.3 to 19.9; p = 0.0006) and cirrhosis (OR, 4.4; 95% CI, 1.5 to 13.4; p = 0.0048) were independent predictors of colonization.

CONCLUSION

Cirrhotic patients had a higher S. aureus nasal carriage rate than control subjects. Previous hospitalization and cirrhosis diagnosis were correlated to nasal colonization. Further studies are necessary to determine if nasal decontamination could reduce S. aureus infections after liver transplantation.

[Radiofrequency ablation in auricular flutter. Predictive factors of primary success and medium term results]

Ninety-one consecutive patients underwent radiofrequency ablation of chronic or paroxysmal atrial flutter. The average age of the patients was 66. There was a previous history of atrial fibrillation in 38% of cases and of cardiac surgery in 14.3% of cases. The primary success rate was 79% (92% in cases of common flutter). The predictive factors of success were the type of flutter (p < 0.001), left ventricular (p < 0.01) and left atrial dimensions (p < 0.01) at echocardiography. The length of the cavo-tricuspid isthmus measured by echocardiography had no influence on the initial result but, in primary success, did affect the parameters of the procedure (duration and number of applications of radiofrequency energy). After an average of 11 +/- 2 months, sinus rhythm was maintained in 67% of patients. There were recurrences of flutter in 27.5% of cases and of atrial fibrillation in 5.5% of cases: 85% of these episodes occurred during the first six months after ablation. A second procedure was carried out in 12 patients for recurrence of flutter (92% primary success rate). After an average follow-up of 8.4 months, 4 patients had a recurrence and required a third procedure (100% success rate). In cases of failure of ablation, the rhythm was converted by a shock or atrial pacing: 47.3% of these patients remained in sinus rhythm with antiarrhythmic therapy with a 12 month follow-up. Radiofrequency ablation of atrial flutter is, therefore, a safe method, the difficulty of which is mainly related to anatomical factors: the medium-term results are better than those of other therapeutic methods.

Management of intraductal papillary mucinous tumours of the pancreas

OBJECTIVE

To focus attention on the management and outcome of patients with intraductal papillary mucinous tumours of the pancreas.

DESIGN

Retrospective study and analysis of published reports.

SETTING

University hospital, France.

SUBJECTS

111 patients (101 published cases and our own 10 cases) divided in two groups: the first including malignant tumours (n = 46), and the second group benign or in situ tumours (n = 61). In 4 patients the type of tumour was not known.

MAIN OUTCOME MEASURE

Resectability, mortality and recurrence.

RESULTS

More men had benign or in situ tumours [48/61 (79%) compared with 28/46 (61%), p = 0.054]. Pancreatitis was more common among benign than malignant tumours [34/61 (58%) compared with 21/46 (46%), p = 0.33]. In group I, 39 patients had diabetes. A total of 107 patients were operated on: pancreaticoduodenectomy (n = 54, 50%), distal pancreatectomy (n = 25, 23%), total pancreatectomy (n = 4,4%), bypass (n = 2,2%). The type of resection was not mentioned in 22 records (21%). Four patients were not operated on because of their poor general condition. The resectability rate was 98% (105/107). Eleven patients had died at the time of publication. Hospital mortality rate was 3% (n = 3), mainly because 2 of the 4 who had total pancreatectomy died. With a median follow-up of 37 months, recurrence was 5% (n = 5).

CONCLUSION

Intraductal papillary mucinous tumours of the pancreas are well known distinctive pancreatic tumours that are usually intraductal but may develop into invasive carcinoma. They should be resected, and have a good prognosis and low recurrence rate.

New iridoids from the medicinal plant Barleria prionitis with potent activity against respiratory syncytial virus

Two new iridoid glycosides (1 and 2), together with the known compounds barlerin (3) and verbascoside (4), were isolated from Barleria prionitis. The new iridoid glycosides were determined to be 6-O-trans-p-coumaroyl-8-O-acetylshanzhiside methyl ester (1) and its cis isomer (2) by using spectroscopic, especially 2D NMR, data. A 3:1 mixture of 1 and 2 was shown to have potent in vitro activity against respiratory syncytial virus (EC50 2.46 microgram/mL, IC50 42.2 microgram/mL).

Doppler study of mesenteric, hepatic, and portal circulation in alcoholic cirrhosis: relationship between quantitative Doppler measurements and the severity of portal hypertension and hepatic failure

To determine the relationship between quantitative Doppler parameters of portal, hepatic, and splanchnic circulation and hepatic venous pressure gradient (HVPG), variceal size, and Child-Pugh class in patients with alcoholic cirrhosis, we studied forty patients with proved alcoholic cirrhosis who underwent Doppler ultrasonography, hepatic vein catheterization, and esophagoscopy. The following Doppler parameters were recorded: time-averaged mean blood velocity, volume flow of the main portal vein flow, and resistance index (RI) of the hepatic and of the superior mesenteric artery. Doppler findings were compared with HVPG, presence and size of esophageal varices, and Child-Pugh class. There was a significant inverse correlation between portal velocity and HVPG (r = -.69), as well as between portal vein flow and HVPG (r = -.58). No correlation was found between RI in the hepatic artery or superior mesenteric artery and HVPG. No correlation was found between portal vein measurements and presence and size of varices. Severe liver failure was associated with lower portal velocity and flow. In patients with alcoholic cirrhosis, only portal vein blood velocity and flow, but neither hepatic nor mesenteric artery RI, are correlated to the severity of portal hypertension and to the severity of liver failure.

[Economic impact of a prescription protocol in an intensive care unit]

OBJECTIVE

To assess the economic impact of a prescribing protocol for i.v. fluid therapy and artificial nutrition.

STUDY DESIGN

Comparative study, before and during use of the protocol.

PATIENTS

The study included 555 ICU patients allocated into two groups, before and after starting with the protocol. The groups were comparable for number, pathologies, age, severity score, duration of ICU stay, incidence of nosocomial infections, mortality rate.

METHOD

In February 1995, a written literature-based prescribing protocol for fluid therapy (hydroxyethylstarch and albumin), and artificial nutrition (enteral nutrition as first-line therapy) was devised. A cost analysis was made for two 6-month periods: before (August 1994 to January 1995) and after start of protocol (February to July 1995).

RESULTS

The prescription of albumin and hydroxyethylstarch decreased (by 33 and 58% respectively), whereas administration of Ringer lactate and gelatine solutes increased simultaneously. This induced a cost saving of 15,000 FF (a 20% decrease in cost). The reduction of parenteral nutrition in favour of early enteral nutrition induced a cost saving of 56,000 FF (31% decrease in cost).

CONCLUSION

Our prescribing protocol generated a cost saving of 9% of the pharmaceutical budget and decreased the cost-benefit ratio of our ICU.

Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial

BACKGROUND/AIMS

Norfloxacin is useful to prevent infections in hospitalized cirrhotic patients with low ascitic fluid protein concentrations. It is also effective in preventing the recurrence of spontaneous bacterial peritonitis. The aim of our study was to determine the efficacy of norfloxacin in the primary prophylaxis of gram-negative bacilli infections in cirrhotic patients with low ascitic fluid protein levels (<15 g/l).

METHODS

One hundred and seven patients were randomized to receive norfloxacin (400 mg/day; n=53) or placebo (n=54) for 6 months. The patients had no history of infection since cirrhosis diagnosis and no active infection.

RESULTS

The probability of gram-negative infection was significantly lower among patients treated with norfloxacin than among those treated with placebo. Six gram-negative bacilli infections occurred in the placebo group and none in the treatment group. Severe infections (spontaneous bacterial peritonitis, neutrocytic ascites and bacteremia) developed in nine patients in the placebo group (17%) and in one patient in the norfloxacin group (2%; p<0.03). There was no between-group difference in the overall rate of infection or in survival. In ten patients from the norfloxacin group, gram-negative bacilli not present in baseline stool cultures were transiently isolated in follow-up cultures.

CONCLUSIONS

These data show that primary prophylaxis with norfloxacin for 6 months is effective in the prevention of infections caused by gram-negative bacilli in cirrhotic patients with low ascitic fluid total protein levels.

Antiviral phenylpropanoid glycosides from the medicinal plant Markhamia lutea

Three new phenylpropanoid glycosides, named luteoside A (3), luteoside B (4), and luteoside C (5), were isolated together with the known compounds verbascoside (1) and isoverbascoside (2) from the roots of the medicinal plant Markhamia lutea. The structures of the new compounds were determined to be 1-O-(3, 4-dihydroxyphenyl)ethyl beta-D-apiofuranosyl(1-->2)-alpha-l-rhamnopyranosyl(1-->3)-4-O- caffeo yl-6-acetyl-beta-d-glucopyranoside, 1-O-(3,4-dihydroxyphenyl)ethyl beta-d-apiofuranosyl(1-->2)-alpha-l-rhamnopyranosyl(1-->3)-6-O- caffeo yl-beta-d-glucopyranoside, and 1-O-(3,4-dihydroxyphenyl)ethyl beta-D-apiofuranosyl(1-->2)-alpha-l-rhamnopyranosyl(1-->3)-6-O- ferulo yl-beta-d-glucopyranoside, respectively, on the basis of chemical and spectroscopic data. All five phenylpropanoid glycosides exhibited potent in vitro activity against respiratory syncytial virus.

Response of cultured fetal and adult rat hepatocytes to growth factors and cyclosporine

Hepatocyte transplantation is a promising alternative to orthotopic liver transplantation in experimental animal models with genetic disorders of liver metabolism and liver failure. Fetal hepatocytes have several characteristics that make them potentially suitable as donor cells. In contrast to adult hepatocytes, fetal hepatocytes are thought to be highly proliferative, which may facilitate engraftment, expansion of transplanted cell population, and gene transfer requiring active DNA synthesis. The present study was undertaken to evaluate the proliferative capacity of fetal and adult rat hepatocytes under standardized culture conditions. Fetal (20 days of gestation) and adult hepatocytes were cultured in serum-free media at low densities and treated with growth factors. Proliferation was assessed by [3H]-thymidine incorporation and cell cycle analysis by flow cytometry. In nonstimulated cells, DNA synthesis at 4 h was about x100 higher and after 10 days in culture x20 higher in fetal compared to adult hepatocytes. When epidermal growth factor (EGF) was added, maximal DNA synthesis in fetal hepatocytes was seen at 48 h, whereas in adult hepatocytes at 72 h. For adult hepatocytes, the average increase compared to untreated cells was x13.8 with EGF, x18.5 with transforming growth factor alpha (TGF-alpha), and x7.6 with hepatocyte growth factor (HGF). For fetal hepatocytes, the increase was twofold with either EGF, TGF-alpha or HGF. EGF-, TGF-alpha- and HGF-dependent DNA synthesis was inhibited by transforming growth factor beta-1 (TGF-beta1) in both fetal and adult hepatocyte cultures; this antiproliferative effect was significantly stronger in adult hepatocyte cultures. With cyclosporine, EGF-, TGF-alpha- and HGF-dependent DNA synthesis in fetal hepatocyte cultures decreased by 36-46%, whereas in adult hepatocytes by 19-27 %. These results show that in contrast to adult hepatocytes, fetal hepatocytes have high spontaneous proliferative activity independently of growth factors and are relatively resistant to the inhibitory effect of TGF-beta1. It was also found that cyclosporine suppresses proliferation of cultured fetal hepatocytes.

[Importation of Plasmodium falciparum malaria, in Réunion Island, from 1993 to 1996: epidemiology and clinical aspects of severe forms]

Located in the Indian ocean, Reunion island, a French overseas territory, is free of malaria since the 1960's. As malaria is still highly endemic in the neighbouring countries, imported cases are averaging 130 to 150 cases per year. From 1993 to 1996, about 483 cases of imported malaria were admitted in Reunion. Five severe complicated Plasmodium falciparum malaria cases occurring in non-immune persons, required further treatment in the intensive care unit (age 40 +/- 8 years, duration: 14.8 +/- 7.4, SAPS: 21 +/- 10). Three patients died. As short-stay travellers, patients were contaminated in Madagascar (4) and in Malawi (1) and presented with an associated pathology: alcohol and tobacco abuses (2 cases), AIDS (1 case). In all cases, chemoprophylaxis was either inadequate (chloroquine alone, 3 cases) or absent (2 cases) and the diagnosis and the appropriate treatment were delayed. Moreover, patients were either self-treating themselves, or initially refused to be admitted. Parasitemia was very high. Two patients died within an hour following their admission before diagnosis could be made and quinine treatment be initiated (rupture of the spleen, multiple organ failure). One patient died at day 7 (acute respiratory distress syndrome, renal failure). Two survived under respiratory assistance and hemodialysis and presented the usual intensive care complications (respiratory nosocomial infection, acute cholecystitis). In Réunion island, imported P. falciparum still accounts for a high rate of morbidity and few fatalities, despite a sophisticated curative health system. Delay in diagnosis and institution of an appropriate treatment is frequent in non-immune persons who develop fever and non-specific symptoms. It markedly increases the risk of complications and death from falciparum malaria as well as morbidity cofactors. Emphasis must be placed on appropriate information of health personnel and travellers.