Cost of SARS-CoV-2 self-test distribution programmes by different modalities: a micro-costing study in five countries (Brazil, Georgia, Malaysia, Ethiopia and the Philippines)

OBJECTIVE

Diagnostic testing is an important tool to combat the COVID-19 pandemic, yet access to and uptake of testing vary widely 3 years into the pandemic. The WHO recommends the use of COVID-19 self-testing as an option to help expand testing access. We aimed to calculate the cost of providing COVID-19 self-testing across countries and distribution modalities.

DESIGN

We estimated economic costs from the provider perspective to calculate the total cost and the cost per self-test kit distributed for three scenarios that differed by costing period (pilot, annual), the number of tests distributed (actual, planned, scaled assuming an epidemic peak) and self-test kit costs (pilot purchase price, 50% reduction).

SETTING

We used data collected between August and December 2022 in Brazil, Georgia, Malaysia, Ethiopia and the Philippines from pilot implementation studies designed to provide COVID-19 self-tests in a variety of settings-namely, workplace and healthcare facilities.

RESULTS

Across all five countries, 173 000 kits were distributed during pilot implementation with the cost/test distributed ranging from $2.44 to $12.78. The cost/self-test kit distributed was lowest in the scenario that assumed implementation over a longer period (year), with higher test demand (peak) and a test kit price reduction of 50% ($1.04-3.07). Across all countries and scenarios, test procurement occupied the greatest proportion of costs: 58-87% for countries with off-site self-testing (outside the workplace, for example, home) and 15-50% for countries with on-site self-testing (at the workplace). Staffing was the next key cost driver, particularly for distribution modalities that had on-site self-testing (29-35%) versus off-site self-testing (7-27%).

CONCLUSIONS

Our results indicate that it is likely to cost between $2.44 and $12.78 per test to distribute COVID-19 self-tests across common settings in five heterogeneous countries. Cost-effectiveness analyses using these results will allow policymakers to make informed decisions on optimally scaling up COVID-19 self-test distribution programmes across diverse settings and evolving needs.

Cost-effectiveness of intervention combinations towards the elimination of vertical transmission of HIV in limited-resource settings: a mathematical modelling study

BACKGROUND

Since 2000, there has been a substantial global reduction in the vertical transmission of HIV. Despite effective interventions, gaps still remain in progress towards elimination in many low-income and middle-income countries. We developed a mathematical model to determine the most cost-effective combinations of interventions to prevent vertical transmission.

METHODS

We developed a 12-month Markov model to follow a cohort of women of childbearing age (aged 15-49 years) in Zambia (n=1 107 255) who were either pregnant, in delivery, or breastfeeding; the population included in the model reflects the estimated number of pregnant women in Zambia from the 2018 Zambia Demographic and Health Survey. The model incorporated nine interventions: infant prophylaxis; three different HIV retesting schedule options; oral pre-exposure prophylaxis; maternal peer-support groups; regimen shift; tracing of loss to follow-up; and point-of-care viral load testing. We analysed incident HIV infections among mothers and infants, intervention costs, and evaluated 190 scenarios of different combinations of inventions to calculate the incremental cost-effectiveness ratios (ICERs) over 1 year.

FINDINGS

Three interventions with the greatest reduction in vertical transmission, individually, were support groups for 80% of those in need (35% reduction in infant infections), HIV retesting schedules (6·5% reduction), and infant prophylaxis (4·5% reduction). Of all 190 scenarios evaluated, eight were on the cost-effectiveness frontier (ie, were considered to be cost-effective); all eight included increasing infant prophylaxis, regimen shift, and use of support groups. Excluding the highest-cost scenarios, for a 1-22% increase in total budget, 23-43% of infant infections could be prevented, producing ICERs between US$244 and $16 242.

INTERPRETATION

Using the interventions modelled, it is possible to reduce vertical transmission and to cost-effectively prevent up to 1734 infant HIV infections (43% reduction) in Zambia over a period of 1 year. To optimise their effect, these interventions must be scaled with fidelity. Future work is needed to incorporate evidence on additional innovative interventions and HIV risk factors, and to apply the model to other country contexts to support targeted implementation and resource use.

FUNDING

The ELMA Foundation.

Impact and cost-effectiveness of SARS-CoV-2 self-testing strategies in schools: a multicountry modelling analysis

OBJECTIVES

To determine the most epidemiologically effective and cost-effective school-based SARS-CoV-2 antigen-detection rapid diagnostic test (Ag-RDT) self-testing strategies among teachers and students.

DESIGN

Mathematical modelling and economic evaluation.

SETTING AND PARTICIPANTS

Simulated school and community populations were parameterised to Brazil, Georgia and Zambia, with SARS-CoV-2 self-testing strategies targeted to teachers and students in primary and secondary schools under varying epidemic conditions.

INTERVENTIONS

SARS-CoV-2 Ag-RDT self-testing strategies for only teachers or teachers and students-only symptomatically or symptomatically and asymptomatically at 5%, 10%, 40% or 100% of schools at varying frequencies.

OUTCOME MEASURES

Outcomes were assessed in terms of total infections and symptomatic days among teachers and students, as well as total infections and deaths within the community under the intervention compared with baseline. The incremental cost-effectiveness ratios (ICERs) were calculated for infections prevented among teachers and students.

RESULTS

With respect to both the reduction in infections and total cost, symptomatic testing of all teachers and students appears to be the most cost-effective strategy. Symptomatic testing can prevent up to 69·3%, 64·5% and 75·5% of school infections in Brazil, Georgia and Zambia, respectively, depending on the epidemic conditions, with additional reductions in community infections. ICERs for symptomatic testing range from US$2 to US$19 per additional school infection averted as compared with symptomatic testing of teachers alone.

CONCLUSIONS

Symptomatic testing of teachers and students has the potential to cost-effectively reduce a substantial number of school and community infections.

Progressive transformation of the HIV-1 reservoir cell profile over two decades of antiviral therapy

HIV-1 establishes a life-long reservoir of virally infected cells which cannot be eliminated by antiretroviral therapy (ART). Here, we demonstrate a markedly altered viral reservoir profile of long-term ART-treated individuals, characterized by large clones of intact proviruses preferentially integrated in heterochromatin locations, most prominently in centromeric satellite/micro-satellite DNA. Longitudinal evaluations suggested that this specific reservoir configuration results from selection processes that promote the persistence of intact proviruses in repressive chromatin positions, while proviruses in permissive chromosomal locations are more likely to be eliminated. A bias toward chromosomal integration sites in heterochromatin locations was also observed for intact proviruses in study participants who maintained viral control after discontinuation of antiretroviral therapy. Together, these results raise the possibility that antiviral selection mechanisms during long-term ART may induce an HIV-1 reservoir structure with features of deep latency and, possibly, more limited abilities to drive rebound viremia upon treatment interruptions.

Optimal use of COVID-19 Ag-RDT screening at border crossings to prevent community transmission: A modeling analysis

Countries around the world have implemented restrictions on mobility, especially cross-border travel to reduce or prevent SARS-CoV-2 community transmission. Rapid antigen testing (Ag-RDT), with on-site administration and rapid turnaround time may provide a valuable screening measure to ease cross-border travel while minimizing risk of local transmission. To maximize impact, we developed an optimal Ag-RDT screening algorithm for cross-border entry. Using a previously developed mathematical model, we determined the daily number of imported COVID-19 cases that would generate no more than a relative 1% increase in cases over one month for different effective reproductive numbers (Rt) and COVID-19 prevalence within the recipient country. We then developed an algorithm-for differing levels of Rt, arrivals per day, mode of travel, and SARS-CoV-2 prevalence amongst travelers-to determine the minimum proportion of people that would need Ag-RDT testing at border crossings to ensure no greater than the relative 1% community spread increase. When daily international arrivals and/or COVID-19 prevalence amongst arrivals increases, the proportion of arrivals required to test using Ag-RDT increases. At very high numbers of international arrivals/COVID-19 prevalence, Ag-RDT testing is not sufficient to prevent increased community spread, especially when recipient country prevalence and Rt are low. In these cases, Ag-RDT screening would need to be supplemented with other measures to prevent an increase in community transmission. An efficient Ag-RDT algorithm for SARS-CoV-2 testing depends strongly on the epidemic status within the recipient country, volume of travel, proportion of land and air arrivals, test sensitivity, and COVID-19 prevalence among travelers.

Signatures of immune selection in intact and defective proviruses distinguish HIV-1 elite controllers

[Figure: see text].

Distinct viral reservoirs in individuals with spontaneous control of HIV-1

Sustained, drug-free control of HIV-1 replication is naturally achieved in less than 0.5% of infected individuals (here termed 'elite controllers'), despite the presence of a replication-competent viral reservoir1. Inducing such an ability to spontaneously maintain undetectable plasma viraemia is a major objective of HIV-1 cure research, but the characteristics of proviral reservoirs in elite controllers remain to be determined. Here, using next-generation sequencing of near-full-length single HIV-1 genomes and corresponding chromosomal integration sites, we show that the proviral reservoirs of elite controllers frequently consist of oligoclonal to near-monoclonal clusters of intact proviral sequences. In contrast to individuals treated with long-term antiretroviral therapy, intact proviral sequences from elite controllers were integrated at highly distinct sites in the human genome and were preferentially located in centromeric satellite DNA or in Krüppel-associated box domain-containing zinc finger genes on chromosome 19, both of which are associated with heterochromatin features. Moreover, the integration sites of intact proviral sequences from elite controllers showed an increased distance to transcriptional start sites and accessible chromatin of the host genome and were enriched in repressive chromatin marks. These data suggest that a distinct configuration of the proviral reservoir represents a structural correlate of natural viral control, and that the quality, rather than the quantity, of viral reservoirs can be an important distinguishing feature for a functional cure of HIV-1 infection. Moreover, in one elite controller, we were unable to detect intact proviral sequences despite analysing more than 1.5 billion peripheral blood mononuclear cells, which raises the possibility that a sterilizing cure of HIV-1 infection, which has previously been observed only following allogeneic haematopoietic stem cell transplantation2,3, may be feasible in rare instances.

HIV-1 DNA sequence diversity and evolution during acute subtype C infection

Little is known about the genotypic make-up of HIV-1 DNA genomes during the earliest stages of HIV-1 infection. Here, we use near-full-length, single genome next-generation sequencing to longitudinally genotype and quantify subtype C HIV-1 DNA in four women identified during acute HIV-1 infection in Durban, South Africa, through twice-weekly screening of high-risk participants. In contrast to chronically HIV-1-infected patients, we found that at the earliest phases of infection in these four participants, the majority of viral DNA genomes are intact, lack APOBEC-3G/F-associated hypermutations, have limited genome truncations, and over one year show little indication of cytotoxic T cell-driven immune selections. Viral sequence divergence during acute infection is predominantly fueled by single-base substitutions and is limited by treatment initiation during the earliest stages of disease. Our observations provide rare longitudinal insights of HIV-1 DNA sequence profiles during the first year of infection to inform future HIV cure research.

[Severity of aortic ring abscess complicated by cardiac conduction abnormalities]

OBJECTIVE

To determine clinical features, management and prognosis of cardiac conduction abnormalities (CCA) complicating abscessed endocarditis.

METHODS

We have analysed clinical, microbiologic and echocardiographic datas, therapies and outcome of cardiac abscesses complicated by CCA in patient hospitalized between 1995 and 2001 in our centre.

RESULTS

Above 35 cardiac abscesses, six men (mean age 62 years) had CCA complicating six aortic ring abscesses (4 on native valve and 2 on prosthetic valve) with four cases of interventricular septal involvement and fistulization. Severe heart failure is present four times, a septic cerebral embolization twice. Streptococcus and Staphylococcus prevail. Complete atrioventricular block (AVB) reveals endocarditis twice and complicates the evolution three times. Trifascicular block (first degree AVB, left anterior fascicular block and complete right bundle branch block) revealed recurrence of endocarditis. Two patients were treated medically: one died quickly (complete AVB pre-mortem), and the other one had favourable issue (paroxystic complete AVB). Four patients had surgery with temporary pacemaker in three cases (one died) then definitive pacemaker in two cases. At 26.5 month (7-50), the four survivors had no recurrence of endocarditis.

CONCLUSION

Severe CCA are classical in aortic ring abscessed endocarditis and associated with increased mortality. Immediate transfert in a dentre with cardiac surgery is necessary. Definitive cardiac pacing can be performed early without leads infection.

The Paget-Schroetter syndrome

Primary axillo-subclavian venous thrombosis is pathology of the young working man. It affects above all the main upper limb and arises during a physical activity of the shoulder. Its aetiology is complex and multifactorial. It is most often the consequence of a chronic compression of the subclavian vein at the level of the thoracic outlet. Clinical presentation can be confirmed with a duplex scan investigation.Early diagnosis offers the opportunity for rapid venous recanalisation with an anticoagulation treatment. A fibrinolytic therapy can be started in the same session of the phlebography. In case of success, a dynamic phlebography is performed to confirm the existence of a venous thoracic outlet syndrome. Even if indications for surgical management of primary subclavian vein thrombosis are still controversial, it is actually clear that this multidisciplinary management of these patients has to be as early as possible. Decompression of the thoracic outlet can be performed secondarily using various techniques including first-rib resection. Should this approach fail to re-establish patency, leaving some residual disabling of the arm, axillo-subclavian vein revascularization can provide good mid-term results.

[Outcome of 30 congenital atrio-ventricular blocks]

Congenital isolated atrio-ventricular block (CAVB) is a rare pathology, and its management is still rather poorly described through international literature. Within the service of pediatric cardiology leaded by Pr Choussat and Dr Jimenez (Cardiologic Hospital Haut-Lévêque of Bordeaux), we collected from 1980 to 2003, 30 isolated congenital CAVB, constituting the purpose of this retrospective study. Average follow-up is 14 +/- 8.8 years. None death occurred. CAVB are discovered at an average age of 4.8 years old; 6 cases were diagnosed in utero, half of them were associated with maternal lupus. Twenty patients on 30 were fitted with stimulator at an average age of 8.7 +/- 6.9 years old, due to symptoms or bradycardy. Epicardic fitting in VVI mode represents 65% of first approaches, it is followed by endocavitary way for 81% of cases. Cardiac stimulation does not prevent from dilated cardiomyopathy. Among 30 patients 10 were not fitted with stimulator, half of them presents chronotrop insufficiency during effort. As a conclusion, our patients show a good long-term vital prognosis; although CAVB discovered in utero lead to worse prognosis for children.

Endofibrosis of the iliac arteries: an underestimated problem

Arterial endofibrosis is a recently discovered artery disease that is specific to endurance athletes. Cycling is the sport that has shown the greatest number of cases. The endofibrosis is located most frequently in the external iliac artery, but other locations must also be sought. Thigh pain during supramaximal exercise and patient questioning provide strong indications. The diagnosis is confirmed when there is concordance of exercise-induced symptoms, a positive exercise test result and discrete arteriographic characteristics. Treatment is based on folate supplements and standardised surgery carried out by an experienced surgical team.

[A strange case of phlebitis]

Report of a rare case concerning an elderly man (81 years) suffering from a leiomyosarcoma of the leg already metastasized to the lungs, discovered in connection with a suspected thrombophlebitis. This sarcoma developed from the smooth muscle of a leg vessel, probably a vein. Leiomyosarcoma is a malignant mesenchymal tumor of specialized connective tissue, with a strong potential for local proliferation and metastatic spread. It usually involves the uterine muscle or the wall of the digestive tract, as well as the large vessels of the abdomen and thorax, the prostate very seldom, and only exceptionally a peripheral vein as in this case. The diagnosis suggested by imaging techniques (in particular MRI) is first and foremost immunohistochemical. The treatment is surgical when possible, associated with radiotherapy and chemotherapy as appropriate. The prognosis is especially poor when the diagnosis is made at the metastatic stage.

Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results

OBJECTIVE

Repair of post infarction ventricular septal defect (VSD) is still a challenging procedure with a high risk of recurrence of the VSD and subsequent mortality. The aim of this retrospective study was to assess if technical change in the surgical procedure was followed by an improvement in recurrence of the VSD and operative results.

METHOD

This retrospective study from 1971 to 2001 included 85 patients operated on early (<15 days) after the occurrence of a post infarction VSD. Double patch technique was introduced in 1986. A total of 44 variables were studied by a uni- and multivariate analysis.

RESULTS

Hospital death occurred in 36 patients. Significant factors for hospital mortality included: preoperative and evolution of the clinical status, right ventricular function and type of repair (one or two patches). Moreover, no recurrence was observed in patients repaired with the double patch technique (P=0.09). None of the studied variables were significant for long term survival. Concomitant CABG was not associated with higher hospital mortality and long-term survival rate was similar in patients with or without concomitant CABG.

CONCLUSION

The use of the double patch technique and glue by avoiding recurrence of the VSD played a role in the reduction of the hospital mortality. This technique has to be recommended in the early repair of post infarction VSD. Concomitant CABG can be done safely to control the added risk of an associated coronary artery lesion.

Spontaneous dissection of the celiac artery

Spontaneous dissection of the celiac artery (CA) is uncommon, considering the number of isolated lesions without associated aortic dissection and exclusive of abdominal trauma. We have treated five cases of isolated spontaneous dissection of the CA or its branches. There were three men and two women with a mean age of 54 years. The presenting manifestation was acute epigastralgia in three cases and chronic abdominal pain in one. In the remaining case, dissecting CA was a coincidental finding. All patients underwent abdominal Doppler ultrasound and CT scan imaging, which demonstrated aneurysm in three cases and dissection in two. Work-up also included arteriography in three cases and magnetic resonance (MR) angiography in one. Management consisted of emergency surgical repair in three cases and close surveillance in two. The repair procedure was resection-anastomosis in one case and prosthetic bypass to the hepatic artery in two cases. Postoperative recovery was uneventful in all three cases and patients were symptom-free at 6, 8, and 18 months. Both patients under surveillance were symptom-free at 1 and 2 years. Because of the risk of ischemic and hemorrhagic complications, surgery should be considered for any patient with CA dissection. However, some patients with uncomplicated asymptomatic lesions may be eligible for medical treatment with regular surveillance.

Structure of mouse L-chain ferritin at 1.6 A resolution

Cubic F432 crystals of recombinant mouse L-chain apoferritin were obtained by the hanging-drop technique with ammonium sulfate and cadmium sulfate as precipitants. The structure was refined to 2.1 and 1.6 A resolution from data obtained at room temperature and under cryogenic conditions, respectively. The structure of an eight-amino-acid loop insertion in the mouse sequence is found to be highly disordered both at room temperature and at low temperature.

Pressure measurements at rest and after heavy exercise to detect moderate arterial lesions in athletes

PURPOSE

This study defined how ankle arterial blood pressure measurements should be analyzed for the detection of moderate arterial disease (asymptomatic while walking). We used external iliac artery endofibrosis as a unique model of an isolated moderate arterial lesion, the role of which in exercise-related pain can be surgically proven.

METHODS

Patients who were ambulatory in our institutional referral center were studied. Brachial pressures, ankle pressures, and heart rate were measured simultaneously on all four limbs at rest and after maximal exercise in 108 healthy athletes and 78 patients (among 89 athletes referred for suspicion of endofibrosis) with confirmed or excluded external iliac endofibrosis. For these 78 patients, we calculated systolic ankle pressure change, ankle/brachial index, and deviation from the ankle/brachial index to heart rate regression line (DAHR) that was defined in the 108 healthy athletes.

RESULTS

In patients with endofibrosis, ankle/brachial index and ankle pressure were normal at rest. One minute after exercise, areas (mean +/- SE of area) under the receiver operating characteristics curve for the diagnosis of endofibrosis were 0.91 +/- 0.02, 0.91 +/- 0.03, 0.95 +/- 0.02, and 0.96 +/- 0.02 for ankle pressure, pressure change, ankle/brachial index, and DAHR, respectively. For all criteria, area decreased with time in the recovery period.

CONCLUSION

After heavy-load exercise, the ankle/brachial index at minute 1 should be used rather than the systolic ankle pressure value or ankle pressure change as a means of improving the efficacy of the detection of endofibrosis in athletes. A 0.66 value of the index at minute 1 after maximal exercise seems an optimal cutoff point for clinical use, providing a 90% sensitivity rate and 87% specificity rate in the diagnosis of moderate arterial lesions. At rest and after 1 minute of recovery, the ankle/brachial index to heart rate relationship should be considered to be an efficient tool for analyzing the results of pressures measurements and improving detection efficiency.

Long-term results of venous revascularization for Paget-Schroetter syndrome in athletes

The indications for surgical management of primary subclavian vein thrombosis are not agreed upon. This report describes our experience in the treatment of exertional thrombosis causing Paget-Schroetter syndrome in 10 athletes between 18 and 45 years of age. In seven patients urokinase was injected and this resulted in complete revascularization in three cases (42.9%). The remaining three patients were treated by anticoagulation using heparin with adjuvant Coumadin after resolution of thrombosis. Duplex ultrasonography and dynamic phlebography were performed to assess the results of drug treatment. Decompression of the thoracic outlet was performed secondarily using various techniques, including first-rib resection in 10 cases, scalenectomy in 9, and resection of a clavicular callus in 1 case. In six patients, persistent debilitating venous stasis required revascularization by axillojugular bypass in three cases, thrombectomy in two, and axillojugular anastomosis in one case. All patients were reexamined. Mean follow-up was 45 months. Symptomatic relief and vein patency was achieved in all cases. All patients were able to resume sports activity. In agreement with previous studies, our findings confirm the efficacy of immediate anticoagulation, thrombolysis, and complete decompression of the thoracic outlet. Should this approach fail to reestablish patency, axillosubclavian vein revascularization can provide good mid-term results.

[Hepatic artery aneurysms]

AIM OF THE STUDY

The aim of this retrospective study was to report a series of nine aneurysms of the hepatic arteries, including real aneurysms (n = 4), pseudoaneurysms (n = 3) and false aneurysms (n = 2) observed from 1987 to 1999.

PATIENTS

There were 7 men and 2 women (mean age: 58 years). In 3 cases, the aneurysm was asymptomatic and detected by sonography; in 4 cases it was revealed by rupture with a severe hemorrhage and in 2 cases by cholestasis. The aneurysm was located on right (n = 3), proper and common (n = 3), proper (n = 2), and common (n = 1) hepatic arteries. The aneurysm was associated with hepatocellular carcinoma (n = 1), carcinoma of the head of the pancreas (n = 1) and liver metastases (n = 1).

METHODS AND RESULTS

Eight patients were operated and one of them was operated three times. Hepatic arterial blood supply was restored in 6 patients with simple suture (n = 1), Goretex graft (n = 2), allograft (n = 2) and autologous vein (n = 1), with one failure which required liver retransplantation. Only one of the three attempts of embolization was successful. One patient with surgical contraindications died from hemobilia after embolization failure. During follow-up, there was one thrombosis of the common hepatic artery which had been excluded and two late deaths: one from rupture of a false aneurysm after bypass with an allograft and one by terminal progression of the cancer. The other 6 patients were alive at the time of this study.

CONCLUSION

Clinical characteristics and therapeutic indications of hepatic arterial aneurysm are variable. Management is usually surgical, while embolization is reserved for special circumstances. Restoration of the hepatic arterial blood supply is necessary in aneurysms located on the proper hepatic artery.

[Tachycardia-induced cardiomyopathy, unusual and reversible cause of left ventricular dysfunction: report of 9 cases]

In this study, 9 cases of tachycardia-induced cardiomyopathy have been reported, with a 7-year follow-up period. The patient population consisted of 5 males and 4 females with a mean age of 41 +/- 18 years (range: 10-70 years). It was difficult to determine the onset of the arrhythmia, due to its frequently asymptomatic course until such time as cardiac insufficiency became apparent (this was the case in 7 patients, while 2 subjects had palpitations). Four cases of AV intranodal reentry tachycardia (3 with an accessory pathway), 2 cases of atrial fibrillation, 1 case of auricular flutter, 1 case of atrial tachycardia and 1 case of ventricular tachycardia were observed. Disappearance of the symptomatology following restoration of sinus rhythm was accompanied by echocardiographically-determined normalization of systolic function on average 5 +/- 4 months post-arrhythmia (range: 1-12 months). Left-ventricular end-diastolic volumes decreased from 60 +/- 5 mm to 51 +/- 4 mm (P < 0.01), and end-systolic volumes from 50 +/- 7 mm to 35 +/- 4 mm (P < 0.001), while the left ventricular shortening fraction increased from 17 +/- 5% to 33 +/- 4% (P < 0.0001). In the differential diagnosis for primary dilated cardiomyopathy, tachycardia-induced cardiomyopathy appears very similar to the former, and only an adequate period of follow-up after the restoration of sinus rhythm can confirm the diagnosis.

[Total hip arthroplasty. Risk factors and prevention of iatrogenic vascular complications]

Vascular injuries during orthopaedic hip surgery are rare. However, they must always be feared because they threaten life and limb. We present 11 vascular injuries observed over a 12-year period. Seven women and 4 men, treated by elective surgery, presented 14 vascular injuries (6 arterial, 5 venous and 3 prosthetic vascular graft). Four injuries occurred during revision procedures. They were all operated as an emergency for ischaemic syndrome (6 cases) and/or haemorrhage (7 cases). Four patients (37%) died and 4 developed sequelae, various directly attributable to the vascular injury. In the light of these cases, we tried to determine the various mechanisms of the injury and the orthopedic and vascular risk factors. Preoperative detection and well defined therapeutic rules are very important for the prevention of these severe vascular accidents.

[Cardiac myxoma in patients over 75 years of age. Report of 19 cases]

Left atrial myxoma is considered to be exceptionally rare in the elderly. The authors observed and reported on 19 cases occurring in patients over 75 years of age out of a series of 100 myxomas diagnosed between 1962 and 1997, in 12 women and 7 men (mean age: 80 years, range 75 to 89 years). In 3 cases, the myxomas were chance findings at echocardiography but the 16 symptomatic patients (85%) had left ventricular failure (47%), positional symptoms (25%), pyrexia and poor general health (17%) or systemic embolism (17%). The location of the myxoma was the left atrium in all cases, with mitral valve obstruction in 13 of the 19 cases. Eighteen tumours were attached to the interatrial septum and one to the atrial surface of the anterior mitral leaflet. Calcifications were observed in 5 patients. Surgical ablation of the tumour was performed in 15 of the 19 patients. The post-operative course was usually uncomplicated: one patient died of a cerebral haemorrhage. Four patients did not undergo surgery because of patient refusal in 3 cases and major associated morbidity in the other case. These cases were included in the study because the tumours had all the characteristics of myxomas. Though the discovery of a myxoma remains a classical surgical emergency, the presence of quiescent, non-obstructive, well circumscribed and calcified myxomas with a low risk of obstruction and of embolism in elderly high risk patients may be exceptions to this traditional dogma.

[Third degree atrio-ventricular block induced by interferon alpha. Report of a case]

Iatrogenic third degree atrioventricular block due to alpha interferon is rare. The authors present a case which occurred with low dosage, regressed when treatment was withdrawn and reappeared when treatment was reintroduced. The physiopathological mechanism of disease of the conduction pathways and its general cardiotoxicity is not yet understood. The secondary effects of this increasingly widely used anti-tumoral and anti-infectious drug should be recognised in order to prevent them. Initial cardiological investigation and follow-up are indicated to ensure this prevention.

[Congenital left ventricular aneurysms and diverticula. Two case reports]

The authors report the cases of two young adults (25 and 27 years) presenting with congenital left ventricular aneurysm or diverticulum with healthy coronary arteries. This saccular evagination of the ventricular wall is rare. The authors describe a classification distinguishing muscular (contractile) diverticula, composed of the three cardiac tunics, fibrous diverticula and finally aneurysms with a dyskinetic wall. Although the limits of this classification are sometimes poorly defined, it presents a prognostic value, because it appears logical to propose nonsurgical management in the context of muscular diverticula and it seems legitimate to operate on fibrous diverticula and aneurysms due to the risks of rupture, extension, thrombosis or arrhythmia.

External iliac artery endofibrosis: a 40-year course

External iliac artery endofibrosis is a rare disease affecting mainly highly trained cyclists. As the disease has only recently been described, the long term spontaneous evolution of external iliac artery endofibrosis is not known. We report a suspected case of forty-year spontaneous evolution of endofibrosis in a former competition cyclist. The results of this isolated original report suggest, as we intuitively presumed, that the lesions may stabilise when intensive training is stopped. Therefore, when no symptoms are noted on usual daily activity or submaximal exercise, surgery should not be performed. Surgery should only be considered, at the request of the subjects to allow them to continue competing.

External iliac artery endofibrosis in athletes

Atherosclerosis and inflammatory arterial diseases are rare in young people. Since the early 1980s, an increasing incidence of iliac arterial stenosis in competition cyclists has been reported. Histological findings in these individuals are specific, with fibrosis of the intimal wall on histology and no atherosclerotic or inflammatory lesions. Clinical consequences of this arterial endofibrosis are usually described as an exercise-related subjective sensation of swollen thigh in one or both (15%) legs, with normal clinical and Doppler investigations at rest. Following maximal exercise, ankle-to-brachial systolic pressure index is lower than 0.5 in 85% of individuals with disease and is used as a key argument for diagnosis before deciding upon arteriography. Surgery (recalibrated saphenous grafts or angioplasty-endofibrosectomy) seems to be efficient to allow an early return to competition, but its long term results are still to be evaluated. The physiopathology of this disease and its possible relationship with atherosclerosis are unknown.

Lower extremity arterial disease in sports

The recent description of exercise-induced intimal fibrosis affecting mainly the iliac artery (and therefore usually described as external iliac artery endofibrosis) has dramatically changed the diagnostic approach of unexplained recurrent lower limb exercise pain, especially in cyclists. Because arterial disease is often associated with the aftereffect of various concomitant musculotendinous lesions, several months may pass before an arterial origin is suspected. The arterial origin of the pain must not be eliminated on normal ankle-to-arm index or normal Doppler velocity profiles at rest. Ultrasound examinations taken at rest may show the lesions in 80% of endofibrotic patients and allow for the diagnosis of popliteal entrapment syndrome during dorsiflexion of the foot. However, the hemodynamic consequences of a stenosis on the aortoiliofemoral axis can only be proved by measurement of the ankle-to-arm index after exercise. A cutoff of this index <0.5 provides an 85% sensitivity in the detection of endofibrosis. Invasive investigations (arteriography or angioscopy) will confirm the diagnosis before surgery is discussed. Although long-term results in endofibrosis are unknown, most of the surgically treated patients return to competition.

Eversion endarterectomy of the internal carotid artery: midterm results of a new technique

A new eversion endarterectomy technique was used in 65 internal carotid artery reconstructions in 56 patients. The original features of the technique include a complete oblique transection of the internal carotid artery distal to the lesion and eversion endarterectomy through a longitudinal incision of the common carotid and external carotid arteries. The mean age of the patients was 68.2 +/- 7.8 years. Seventy-three percent of the patients had hypertension and 45.5% had coronary heart disease. Fifty-four percent experienced neurologic symptoms (transient in 36%, reversible in 6%, and permanent in 11%). Operations were performed under general anesthesia. An indwelling shunt was inserted whenever routine stump pressure was < 50 mmHg. There were no neurologic complications but one patient died of a compression hematoma of the neck, for a combined mortality and morbidity rate of 1.5%. Arteriograms were obtained from all patients on day 5 and showed complete restoration of normal anatomy in all cases and thrombosis of the external carotid artery in one. During a mean follow-up of 27 +/- 4.7 months no strokes were observed. Follow-up duplex scans showed no hemodynamically significant restenoses. Eversion endarterectomy is a reliable alternative to other reconstruction procedures of the internal carotid artery.

[What attitude should be adopted in congenital heart disease in adults?]

Two types of congenital heart disease are observed in adults: those discovered during childhood which may or may not have been operated, depending on their degree of severity and the surgical possibilities; those discovered during adulthood, which represent approximately 500 new cases per year and which raise particular problems: the extensive assessment which must be performed, the therapeutic solution adapted to particular situations, contraception, pregnancy, prophylaxis of endocarditis, sports or work. It is often difficult to decide to operate. Interventional catheterization represents an elegant solution in congenital heart disease in adults.

Analysis of all stratum corneum lipids by automated multiple development high-performance thin-layer chromatography

An optimized gradient enabling the separation of all stratum corneum lipids by automated multiple development on HPTLC plates is presented. An initial isocratic step separates sebum lipids. This is followed by a 25-step development using a gradient with a polarity range of methanol-water to hexane. Application to in-vivo extracted and isolated stratum corneum lipids demonstrates the possible quantification of the lipid classes with a "one-experiment" separation.

[Surgical treatment of sclerotic arterial diseases of the lower limbs]

Among arterial reconstruction procedures, thromboendarterectomy has progressively left place to prosthetic grafts for aorto-iliac surgery. At infra-inguinal level, inversed or in situ venous grafts allow distal revascularisations down to the foot. Lumbar sympathectomy keeps some indications. Indications depend upon the level of arterial obstruction, the symptoms, and the operative risk of the patient. At aorto-iliac level surgery provides excellent results; indications for proximal surgery are large; operative risk is the main limiting factor. At infra-inguinal level surgery is well tolerated but permeability rates are not as good as with aorto-iliac surgery; distal surgery is appropriate only is case of critical ischaemia, when everything must be done for limb salvage.

Colectomy and ileorectal anastomosis in patients with Crohn's disease

Eighty-three patients underwent colectomy and ileorectal anastomosis for Crohn's disease of the large bowel. There were two postoperative deaths and seven anastomotic leaks. Fifty-two patients retained a functioning anastomosis with a mean follow-up of 8 years. Forty had an excellent or good functional result. The cumulative proportion of patients with a functioning ileorectal anastomosis was 77 and 63 per cent at 5 and 10 years respectively. Patients presenting with perforating Crohn's disease had a significantly increased risk of failure of the anastomosis. Perianal Crohn's disease following ileorectal anastomosis was significantly related to the need to defunction or excise the rectum.

[Ambulatory measurement of Korotkoff sounds timing (QKD interval) in a normal population]

Ambulatory monitoring of Korotkoff sounds appearance time (QKD interval) was performed during 24 hours in 131 normal subjects (85 males, 46 females, aged 14-78 years, mean 36 +/- 15 years) with a new device (Diasys 200RK, Novacor-France). This device allows simultaneous measurements of blood pressure, heart rate and QKD interval at programmed intervals, every 15 minutes in this study. For each patient we calculated the average 24th QKD interval, the QKD interval for a systolic BP of 100 mmHg and a heart rate of 60 bt/min (QKD: 100-60), and the slope (S) of the variations of the QKD interval against systolic BP and pulse pressure (PP). Results are presented for each 10 years age group (mean +/- SD).

[Arterial embolism caused by an intra-aortic thrombus or a patent foramen ovale? Diagnosis by transesophageal echocardiography]

This case report demonstrates the value of transoesophageal echocardiography (TOE) in comparison with transthoracic echocardiography as it allows a better view of the thoracic aorta, the auricles, the interauricular septum and the cardiac valves, especially in the intubated and ventilated patients. A 84-year-old woman was admitted to the ICU for hypoxia after carotid-subclavian bypass surgery for acute ischaemia of the left upper limb. The TOE showed a dilated right heart and a patent foramen ovale, compatible with pulmonary embolism as well as two thrombi in the aortic arch. The patient died on the 8th postoperative day from refractory hypoxia. the autopsy confirmed the pulmonary embolism and the intraaortic thrombi. It is concluded that TOE, readily feasible is indicated in case of hypoxia, shock and systemic embolism without cause immediately recognizable, especially in ventilated patients.

Echography of external iliac artery endofibrosis in cyclists

Forty-eight cyclists were studied for suspected external iliac artery endofibrosis with ultrasound B-mode imaging. In highly trained competition cyclists, symptoms of external iliac artery endofibrosis were characterized by lower limb claudication during maximal effort that was caused by fibrosis thickening of the intima of the external iliac arterial wall. Typical ultrasound imaging aspects consisted of parietal thickening, enhanced echogenicity of the arterial wall, straightness of the abnormal arterial segment, and mild narrowing of the arterial diameter of the proximal or medial segment of the diseased external iliac artery. Although ultrasound B-mode imaging study seems to be useful in the diagnosis of external iliac artery endofibrosis, results with this technique must be compared with results of clinical examination, physiologic tests, and arteriography.

In situ thrombolysis for late occlusion of suprafemoral prosthetic grafts

Low-dose urokinase was used to obtain in situ thrombolysis in the treatment of 20 late occlusions of suprafemoral prosthetic grafts in 19 patients. Aortofemoral or aortobifemoral bypasses with occlusion of one limb had been performed in nine patients, direct iliofemoral bypasses in six, crossover iliofemoral bypasses in two, and axillofemoral bypasses in three. Sixteen of the grafts were polytetrafluoroethylene and four were Dacron. Vascular surgery had been performed on an average of 3 years earlier. Thrombolysis was inhibited on an average of 3 days after onset of occlusion. The protocol called for penetration of the thrombus with a 5 F catheter inserted through a brachial (12 cases) or femoral (eight cases) route. After initial injection of 2500 units of urokinase a continuous infusion of urokinase was begun at a dose of 2500 units/hr and heparin at 100 units/kg/12 hr. Clinical, biochemical (fibrinogen and activated cephalin time every 6 hours), and arteriographic surveillance was carried out every 12 hours with progressive mobilization of the catheter until complete clearance of the artery. Clearance was achieved in all cases. Anteroposterior and occasionally lateral arteriograms with the hip joint in flexion were obtained. An organic cause amenable to treatment was found in 16 cases, including distal or proximal lesions (two and 10 cases, respectively) and elongation/kinking (four cases). Endoluminal angioplasty, stenting, or endarterectomy (six cases) and conventional procedures (10 cases) were also performed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Wounding of an iliac artery during celioscopy]

Vascular accidents during celioscopy are rare but potentially serious. Arterial injuries usually involve the aortic bifurcation and are generally recognized and treated as emergencies. In the present case, a transfixing wound of the right common iliac artery provoked by a trocar during gynecological celioscopy in a 36 year old woman was diagnosed secondarily, the posterior orifice being unrecognized during laparotomy to control hemorrhage. A false iliac artery aneurysm was detected 2 months later when she presented signs of a compressive retroperitoneal hematoma confirmed by arteriography and scan images. The common iliac artery was ligatured through a right retroperitoneal approach with extra-anatomical revascularization by a crossed iliofemoral venous shunt. The postoperative course was uncomplicated apart from a right cruralgia sequela. Immediate circumferential dissection for treatment of aortic bifurcation injuries is recommended, to avoid missing a transfixing wound, and to allow direct restoration usually by simple suture. In contrast, secondary treatment is complex, raises problems of arterial reconstruction, and cannot always prevent functional sequelae.

Transthoracic endoscopy for upper thoracic chemical sympathectomy

Beginning in April 1989, we have performed eight upper thoracic chemical sympathectomies by transthoracic endoscopy. The indications were occlusive arterial disease in four patients and Raynaud's syndrome and palmar hyperhidrosis in two patients each. Transthoracic endoscopy was performed under general anesthesia, through the third costal interspace on the anterior mid-clavicular line. Five ml of phenol were injected into the parietal pleura covering the three proximal thoracic ganglia. The duration of thoracic drainage was 24 hours. The postoperative course was uneventful except for one case of subcutaneous emphysema and transient Horner's syndrome in three instances. There were no initial failures. Because of its simplicity and the short hospitalization period, chemical sympathectomy by transthoracic endoscopy constitutes a valuable alternative to conventional surgery. This technique is, however, limited in the case of antecedent pleuropulmonary disorders.

[Angioscopy in peripheral vascular diseases]

Angioscopy is a useful investigation in patients referred for vascular surgery. The material has been improved over the last few years to make available angioscopes with external diameters ranging from 0.55 to 3.2 mm. The angioscopes are either rigid, composed of two groups of fibre optics (image and light transmission) or orientable and more complex. Both systems may carry operating channels. The angioscopy may be performed peroperatively or percutaneously. Other essential equipment includes catheter guides, balloon catheters, counterpulsation balloons or perfusion pumps. This investigation is used for diagnostic evaluation but when used peroperatively it may also help guide therapeutic intervention. Angioscopy is complementary to ultrasonic and radiological methods of vessel imaging.

[Mitral valve prolapse and angina with normal coronary arteries: research of a thrombogenic factor]

The potential thrombotic risk of mitral valve prolapse may, in certain circumstances, require preventive treatment. This study was aimed at determining whether the presence of angina in patients with mitral valve prolapse and healthy coronary vessels was accompanied by a high-risk thrombogenic profile. Forty two patients (19 women and 23 men) with anginal chest pain and angiographically normal coronary vessels were divided into two populations according to the presence (18 patients) or absence (24 patients) of mitral valve prolapse (MVP) shown by angiography. Before angiography, all patients underwent laboratory studies to detect any possible abnormality of plasma coagulation and of prothrombotic physiological fibrinolysis. Study of subgroups, according to sex and/or the presence of MVP, revealed no significant difference in the profile of laboratory parameters. Thus the presence of angiographic MVP in symptomatic patients free of atherosclerosis is not associated with the existence of any particular thrombotic profile and, theoretically, does not require preventive anti-thrombotic treatment.

[Efficacy of intra-arterial fibrinolysis in subacute atheromatous ischemia of the lower limbs]

The study of 44 patients treated with intra-arterial fibrinolysis is reported. All these patients had an impending subacute ischemia of the lower limbs, a major complication of atheromatous disease. The criteria for patient selection were clinical, hemodynamic and radiological. The procedure of the treatment associating Urokinase, Heparin and Naphthidrofluril are defined, as well as its follow-up. The results have been evaluated according to the clinical and radiological improvement. 2 patients died when the treatment ceased and 10 were amputated, ie 27% of failures. The fibrinolytic treatment allowed identifying the patients who might quickly receive an additional treatment. In our experience, this treatment seems to improve the prognosis of impending subacute ischemia.

[Pulmonary orifice stenosis: the medical solution. Apropos of 62 cases]

Sixty two patients with moderate or severe stenosis of the pulmonary orifice (SPO) underwent balloon catheter valvuloplasty. Thirty one were aged under 5 years. The mean right ventricle-pulmonary artery trunk (RV-PAT) gradient fell from 75 (+/- 26) to 23 (+/- 10) mmHg (p less than 0.001). All dilatations except one were effective with only a few incidents and no mortality. Six (+/- 2) months later, hemodynamic evaluation of 45 patients (70%) showed stability of the RV-PAT gradient at 26 (+/- 18) as compared with 23 (+/- 11) mmHg. Ten patients required a second dilatation because of a residual gradient of greater than 35 mmHg. The result was favourable in all ten cases, the RV-PAT gradient falling from 53 (+/- 17) to 13 (+/- 8) mmHg (p less than 0.001). This series confirmed the efficacy, reproducibility and safety of this technique which led to a lowering of ventriculo-pulmonary gradient, persistent at six months, to an infra-surgical level, at the price of pulmonary incompetence (27%) which was always well tolerated in the mid-term. This valvuloplasty may be suggested for all cases of SPO with a gradient of greater than 35 mmHg.