Diagnostic accuracy of a simple qualitative ultrasound assessment for the diagnosis of high-risk gastric contents in the parturient. A prospective observational cohort study

STUDY OBJECTIVE

Interpretation of gastric ultrasound relies on the use of a clinical algorithm that combines qualitative analysis of the gastric antrum contents with the calculation of the volume of fluid contents. This reference method may be difficult to apply in the parturient. We therefore aimed to assess the diagnostic accuracy of a simple qualitative assessment in the supine position for the diagnosis of high-risk gastric contents in the parturient. We also assessed the diagnostic accuracy of a composite scale and another clinical algorithm based on a mathematical model different to that used in the reference method.

DESIGN

Prospective observational cohort study.

SETTING

University hospital, Lyon, France.

PATIENTS

Adult women admitted to the delivery room.

INTERVENTIONS

Qualitative and quantitative gastric ultrasound examination within the first hour following admission.

MEASUREMENTS

With respect to the reference method, the diagnostic accuracy of a simple qualitative assessment for the diagnosis of high-risk gastric contents was assessed. The diagnostic accuracy of a composite scale and another clinical algorithm, and the agreement between each approach were also assessed.

MAIN RESULTS

A total of 235 parturients were included and analyzed. The simple qualitative assessment led to conclusive ultrasound assessment in 233 (99%) women, while the reference method led to conclusive assessment in 213 (91%) women (P < 0.05). The sensitivity and the specificity of the simple qualitative assessment were 97% (95%CI: 93 to 99%) and 96% (95%CI: 90 to 99%), respectively. These were not significantly different from those of the composite scale and the clinical algorithm. The four approaches showed almost perfect agreement with each other.

CONCLUSIONS

These results suggest that simple qualitative assessment may be useful in clinical practice to help the anesthesiologist in the assessment of gastric contents status and risk of aspiration.

Prevalence and factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth: a prospective multicentre cohort study

BACKGROUND

This multicentre prospective observational study sought to determine the prevalence and the factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth, and to identify the clinical situations in which ultrasound assessment of gastric contents would be most helpful (i.e. when the prevalence of high-risk gastric contents is close to 50%).

METHODS

Ultrasound assessments of gastric contents were performed within the first hour after admission to the maternity unit. The prevalence of high-risk gastric contents was calculated and variables associated with high-risk gastric contents were identified using logistic regression analyses.

RESULTS

A total of 1003 parturients were analysed. The prevalence of high-risk gastric contents was 70% (379/544; 95% confidence interval: 66-74%) in women admitted in spontaneous labour and 65% (646/1003; 95% confidence interval: 61-67%) in the whole cohort. Lower gestational age, increased fasting duration for solids, and elective Caesarean delivery were independently associated with reduced likelihood of high-risk gastric contents. In women admitted in spontaneous labour and in the whole cohort, the prevalence of high-risk gastric contents ranged from 85% to 86% for fasting duration for solids <6 h, 63%-68% for fasting 6-8 h, 54%-55% for fasting 8-12 h, and 47%-51% for fasting ≥12 h.

CONCLUSIONS

Around two-thirds of parturients had high-risk gastric contents within the first hour after admission to the maternity unit. Our results suggest that gastric emptying for solids continues in labouring women, and that gastric ultrasound would be most helpful when fasting duration is ≥8 h.

SimPhy: a simulation game to lessen the impact of phytosanitaries on health and the environment--the case of Merja Zerga in Morocco

Diffuse phytosanitary pollution is a complex phenomenon to manage. Reducing this type of pollution is one of today's key socio-economic and environmental challenges. At the regional level, few approaches enable the actors concerned to implement agricultural management strategies to reduce the use and impact of phytosanitary products. Our research problem focused on the consequences of intensive agriculture and, in particular, how to evaluate the impact of phytosanitary products on human health and the environment. In this article, we present the SimPhy simulation game which places the actors from a given region directly into a situation in which they manage farms whilst under pressure to reduce phytosanitaries (quantity and toxicity). The application focused on the Merja Zerga catchment area in Morocco. The region is dominated by intensive agriculture which is located upstream from a Ramsar-classified wetland area. The SimPhy simulation game is based on a decision support system-type tool. It allows us to anticipate the impact of regulations on farming systems. It also enables us to analyse the consequences of the actors' strategies on farm economies, human health and the quality of ecosystems. Initial results from the SimPhy simulation game enabled the technicians from Agricultural Development Center (CDA) themselves to learn about managing agricultural production systems in a dynamic and interactive fashion. With the simulation game, it was possible to learn about the farmer's ability to adapt to new regulatory constraints, and the involved consequences for toxicity risks for human health and the environment.

PHENOPSIS DB: an information system for Arabidopsis thaliana phenotypic data in an environmental context

BACKGROUND

Renewed interest in plant×environment interactions has risen in the post-genomic era. In this context, high-throughput phenotyping platforms have been developed to create reproducible environmental scenarios in which the phenotypic responses of multiple genotypes can be analysed in a reproducible way. These platforms benefit hugely from the development of suitable databases for storage, sharing and analysis of the large amount of data collected. In the model plant Arabidopsis thaliana, most databases available to the scientific community contain data related to genetic and molecular biology and are characterised by an inadequacy in the description of plant developmental stages and experimental metadata such as environmental conditions. Our goal was to develop a comprehensive information system for sharing of the data collected in PHENOPSIS, an automated platform for Arabidopsis thaliana phenotyping, with the scientific community.

DESCRIPTION

PHENOPSIS DB is a publicly available (URL: http://bioweb.supagro.inra.fr/phenopsis/) information system developed for storage, browsing and sharing of online data generated by the PHENOPSIS platform and offline data collected by experimenters and experimental metadata. It provides modules coupled to a Web interface for (i) the visualisation of environmental data of an experiment, (ii) the visualisation and statistical analysis of phenotypic data, and (iii) the analysis of Arabidopsis thaliana plant images.

CONCLUSIONS

Firstly, data stored in the PHENOPSIS DB are of interest to the Arabidopsis thaliana community, particularly in allowing phenotypic meta-analyses directly linked to environmental conditions on which publications are still scarce. Secondly, data or image analysis modules can be downloaded from the Web interface for direct usage or as the basis for modifications according to new requirements. Finally, the structure of PHENOPSIS DB provides a useful template for the development of other similar databases related to genotype×environment interactions.

Probing the reproducibility of leaf growth and molecular phenotypes: a comparison of three Arabidopsis accessions cultivated in ten laboratories

A major goal of the life sciences is to understand how molecular processes control phenotypes. Because understanding biological systems relies on the work of multiple laboratories, biologists implicitly assume that organisms with the same genotype will display similar phenotypes when grown in comparable conditions. We investigated to what extent this holds true for leaf growth variables and metabolite and transcriptome profiles of three Arabidopsis (Arabidopsis thaliana) genotypes grown in 10 laboratories using a standardized and detailed protocol. A core group of four laboratories generated similar leaf growth phenotypes, demonstrating that standardization is possible. But some laboratories presented significant differences in some leaf growth variables, sometimes changing the genotype ranking. Metabolite profiles derived from the same leaf displayed a strong genotype x environment (laboratory) component. Genotypes could be separated on the basis of their metabolic signature, but only when the analysis was limited to samples derived from one laboratory. Transcriptome data revealed considerable plant-to-plant variation, but the standardization ensured that interlaboratory variation was not considerably larger than intralaboratory variation. The different impacts of the standardization on phenotypes and molecular profiles could result from differences of temporal scale between processes involved at these organizational levels. Our findings underscore the challenge of describing, monitoring, and precisely controlling environmental conditions but also demonstrate that dedicated efforts can result in reproducible data across multiple laboratories. Finally, our comparative analysis revealed that small variations in growing conditions (light quality principally) and handling of plants can account for significant differences in phenotypes and molecular profiles obtained in independent laboratories.

Combined genetic and modeling approaches reveal that epidermal cell area and number in leaves are controlled by leaf and plant developmental processes in Arabidopsis

Both leaf production and leaf expansion are tightly linked to cell expansion and cell division, but the functional relationships between all these variables are not clearly established. To get insight into these relationships, a quantitative genetic analysis was performed in 118 recombinant inbred lines derived from a cross between the Landsberg erecta and Antwerp accessions and was combined with a structural equation modeling approach. Main effects and epistatic interactions at the quantitative trait locus (QTL) level were detected for rosette area, rosette leaf number, leaf 6 area, epidermal cell area and number. A QTL at ERECTA marker (ER) controlled cell expansion and cell division, in interaction with two other QTLs at SNP295 and SNP21 markers. Moreover, both the screening for marker association involved in the variation of the relationships between leaf growth variables and the test of alternative functional models by structural equation modeling revealed that the allelic value at ER controlled epidermal cell area and epidermal cell number in a leaf. These effects are driven both by a whole plant mechanism associated with leaf production and by a single leaf mechanism associated with leaf expansion. The complex effects of the QTL at ER were validated in selected heterogeneous inbred families. The ERECTA gene, which is mutated in the Landsberg erecta parental line, was found to be a putative candidate responsible for these mapped effects by phenotyping mutants of this gene at the cellular level. Together, these results give insight into the complex determination of leaf epidermal cell number and area.

A Study of the Knowledge, Attitudes, and Behaviors of French Dairy Farmers Toward the Farm Register

Health organizations worldwide have advocated that treatment records be required to show that antibiotics are used prudently by veterinarians and farmers alike. In 2000, the French government passed legislation making a farm register mandatory for all farms that raise animals for food production. The farm register is a comprehensive record designed to track all animal movements, treatments, and veterinary interventions on the farm. We conducted a survey to assess the knowledge, attitudes, and behaviors of dairy farmers toward the farm register, with particular emphasis on recording of antibiotic treatments. The 43 farmers interviewed belonged to veterinary health cooperatives. All farmers correctly named an antibiotic or antibiotic preparation, yet only 2 recognized the 5 components of the farm register. Farmer attitudes toward the register were globally positive, even though they named a wide variety of constraints. Nevertheless, 72% of farmers interviewed had a permanent health record, and approximately half had recorded either the last treatment (irrespective of drug class) or the last intramammary tube administered. Results were discussed in the light of health behavior change models that are applied in human medicine. We suggest that programs that seek compliance with the farm register should focus on educational interventions and bonus incentives.

Reduction of fat accumulation and lipid disorders by individualized light aerobic training in human immunodeficiency virus infected patients with lipodystrophy and/or dyslipidemia

BACKGROUND

The management of abdominal fat accumulation and metabolic disorders in HIV1-infected patients, by an aerobic training program, is considered.

METHODS

Seventeen lipodystrophic and 2 dyslipidemic (without body modification) adults were studied before and after 4 months of training. The training load was individualized on a ventilatory threshold basis, determined during a maximal exercise test on cycle ergometer. Total (TAT), Visceral (VAT) and Subcutaneous Adipose Tissue (SAT) were assessed by CT-scan. Total (TC) and High Density Lipoprotein (HDL-C) Cholesterol, Triglycerides (TG), lactate (La), insulin and glucose were measured after a 12-hour-overnight fast. LDL, TC/HDL, TG/HDL, HOMA-insulin resistance index and coronary heart disease (CHD) relative risk (RR(CHD)) were calculated.

RESULTS

Besides a significant improvement of aerobic fitness, trained patients exhibited a reduction in TAT (-12.8%, p < 0.001), specially at the visceral level (- 12%, p < 0.01) and in TC, TG and La (- 23%, - 43% and - 19% respectively, p < 0.01). HDL-C was increased (+ 6%, p < 0.01). All these effects were above changes that could be expected by a possible regression to the mean artefact. Both TC/HDL and TG/HDL were reduced (p < 0.01) and the estimated RR(CHD) decreased by approximately 13% (p < 0.01). No significant training effect was observed on the 9 available HOMAs. Significant correlations were found between changes in blood lipid values and baseline measures (r range - 0.55 to - 0.79, p < 0.05), indicating a larger improvement when baseline lipid parameters were higher.

CONCLUSION

Aerobic training reduced visceral fat, lipid disorders, basal blood lactate and CHD markers in HIV patients. Training effects were particularly important for patients with marked dyslipidemia.

Long-term safety and efficacy of nevirapine tolerance induction

BACKGROUND

The most frequent side-effects due to nevirapine (Viramune), the first non-nucleoside HIV reverse transcriptase inhibitor introduced for clinical use, are cutaneous hypersensitivity reactions. In non-serious cases, tolerance induction can be proposed.

OBJECTIVE

Describe the long-term safety and efficacy of tolerance induction to nevirapine.

METHODS

Six HIV-infected patients started a tolerance 1 to 2 months after an episode of nevirapine hypersensitivity. Increasing doses of nevirapine (2.5, 10, 25, 100, 250 and 750 microg and 2.5, 5, 10, 25, 50 and 100 mg) were given orally at half-hour intervals under strict medical surveillance and patients were followed up regularly.

RESULTS

All but two of the patients tolerated this induction well. One had a mild and transient reaction on day 1; nevirapine was not stopped. One had a moderate to severe reaction one month later; nevirapine was stopped and he recovered fully. All other patients have been taking nevirapine for more than 3 months without any adverse reaction.

CONCLUSION

Therefore, when no alternatives are available in severely ill and hypersensitive HIV-infected patients, tolerance induction is a possible therapeutic option.

[Pneumothorax in distomatosis]

INTRODUCTION

Distomatosis is a parasite infection following ingestion of food contaminated by Fasciola hépatica, the tropism of which is essentially hepatic. The mechanism of this exceptional complication is discussed in two cases of pneumothorax.

OBSERVATIONS

Two 35 and 60 year-old patients presenting spontaneous pneumothorax during distomatosis, the first revealing the disease, the second suggesting the evolution of a severe form of the disease. The surgical biopsy in the first patient revealed a granulomatous pleuro-pneumopathy rich in giant cells.

DISCUSSION

Pulmonary manifestations of distomatosis are frequent during the invasive phase. Their immunoallergic origin can be questioned and emphasis should be placed on lesions secondary to aberrant parasite migrations.

Syndrome of body fat redistribution in HIV-1-infected patients: relationships to cortisol and catecholamines

OBJECTIVE

Alterations of body fat distribution have been recently reported in HIV-infected patients. We aimed to investigate whether the hormones modulating adipose tissue metabolism could be implicated.

SUBJECTS

We investigated twenty-eight HIV-infected patients who had developed abdominal fat, combined with peripheral lipodystrophy in 25 cases and 'buffalo hump' in 2 cases, but who had otherwise improved on antiretroviral therapies. Twelve patients with no change in body fat, matched for age, disease control and treatment, were studied as controls.

MEASUREMENTS

Body composition was assessed by bioelectrical impedance analysis. Subcutaneous (SAT) and visceral (VAT) compartments of total abdominal adipose tissue (TAT) were measured by computed tomography. Resting metabolic rate (RMR) was assessed by indirect calorimetry. Endocrine investigations included plasma thyroid hormones, cortisol, testosterone, oestradiol and 24-hour urinary free cortisol (UFC) and catecholamines.

RESULTS

Despite similar body mass index, the patients with body fat alterations showed significantly larger VAT and higher VAT:TAT ratio than controls (P = 0.002 and 0.0001, respectively). In these patients, RMR was significantly higher than estimated according to the Harris-Benedict formula (+ 19.7 +/- 11.6 %, P = 0.0001) and correlated with VAT (r = 0.58, P = 0.003) and 24-hour urinary output of catecholamines (r = 0.67, P = 0.002), that was significantly increased in comparison with controls (1737 +/- 1228 vs 476 +/- 292 nmol, P = 0.013). We also found a significant correlation between VAT and UFC (r = 0.41, P = 0.042) that was absent in controls, although levels of UFC were similar in the two groups.

CONCLUSIONS

Our data suggest that body fat redistribution may involve cortisol and catecholamine actions. While high release of catecholamines may enhance RMR through increased lipolysis, cortisol may promote central fat storage. These effects might be related both to persistent hormonal responses to stress becoming inappropriate while disease control improved and to an increased sensitivity of visceral adipose tissue to cortisol in affected patients.

Treatment of acute neonatal vascular injuries--the utility of multiple interventions

BACKGROUND/PURPOSE

Vascular injuries in neonates are a rare complication of the varied invasive procedures performed in these small children. Unfortunately there remains a reluctance to repair these injuries early, often because of the relative small size of the affected vessels and the nature of the patient's underlying medical condition. The authors report a consecutive series of patients treated for arterial and venous injuries early in their course using a variety of microsurgical techniques.

METHODS

A retrospective chart review was performed of consecutive patients (n = 7) treated over a 2-year period. All had injury as a result of invasive procedures performed in the neonatal period. Both arterial and venous injuries that required some form of intervention were included.

RESULTS

Five arterial and two venous injuries were identified. Surgical thrombectomy and microvascular repair was required in two patients. Primary healing occurred despite prolonged (>13 hours) warm ischemia time. Pseudoaneurysms of the brachial artery and radial artery were controlled with surgical ligation, and one patient required bilateral fasciotomies for compartment syndromes related to severe spasm of the common femoral arteries. Phlegmasia cerulea dolens of the lower extremity (n = 2) was treated with leech therapy. All patients healed without tissue loss or functional deficit.

CONCLUSIONS

A variety of microvascular interventions have application to the treatment of acute vascular injuries in neonates. Early, aggressive use of these techniques can provide effective therapy for these potentially devastating injuries and allow for complete limb recovery without tissue loss.

Thoracoscopic approach to posterior mediastinal neurogenic tumors in the adult

Although neurogenic tumors are the most frequent posterior mediastinal tumors, few reports exist on thoracoscopic resection, and methods are not yet standardized. Two cases of thoracoscopic resection of benign posterior mediastinal schwannomas are presented. We believe that in carefully selected patients, thoracoscopic resection can be performed easily and with minimal morbidity.

Six-hour trimethoprim-sulfamethoxazole-graded challenge in HIV-infected patients

BACKGROUND

Hypersensitivity reactions to trimethoprim-sulfamethoxazole (TMP-SMX) are very common in HIV-infected patients, leading to drug discontinuation. However, it is the drug of choice as prophylaxis for Pneumocystis carinii pneumonia.

OBJECTIVES

We sought to determine the safety and long-term efficacy of a 6-hour TMP-SMX-graded challenge in a group of hypersensitive HIV-infected patients.

METHODS

Forty-four consecutive HIV-infected patients with documented TMP-SMX hypersensitivity were seen in our outpatient allergy department. They ingested 12 doses of increasing amounts of TMP-SMX at half-hour intervals. Thereafter, they took 80/400 mg TMP-SMX daily and were advised to "treat through" every nonbullous cutaneous adverse reaction.

RESULTS

All 44 patients tolerated the procedure without any adverse reactions during the day of challenge. Eleven of the 44 patients experienced mild hypersensitivity reactions on days 1 to 2 (8 patients) and 8 to 10 (3 patients), consisting mainly on a 1-day pruritic maculopapular eruption. Two patients stopped TMP-SMX at day 1, and 2 stopped it at days 10 and 15, giving an overall success rate at 1 month of 91% (40 of 44). Two were successfully rechallenged late. After a median follow-up of 10 months, 42 patients were taking TMP-SMX without any adverse reaction, giving an overall success rate of 95%.

CONCLUSIONS

A 6-hour graded challenge with cautious "treating through" of mild reactions enables more patients to take TMP-SMX and is safe and effective.

Is there a relationship between psychological well-being and patient-carers consensus? A clinical pilot study

Does communication with terminal cancer patients about their disease influence their psychological well-being? The degree of patient-carer consensus about the disease was compared to psychological well-being related to acceptance of the disease, emotional state, and hope. These were evaluated and scored from 6 (good) to 0 (poor) through a semi-structured interview of 10 open-ended questions. Nineteen palliative care patients were studied, 18 of whom were suffering from advanced cancer. Overall, 57 interviews were conducted with the patients, staff nurses, and medical doctors. The answers of the carers (staff nurses and doctors) were compared to the patients' answers to determine the degree of consensus in terms of communication about disease, aim of treatment, and ultimate objective of hospitalization. The consensus between patients and carers was scored from 6 (satisfactory) to 0 (unsatisfactory). A significant positive correlation between the scores of consensus and those of psychological well-being (r = 0.90, p < 0.001) was found. These results suggest that good and truthful communication may improve patients' psychological well-being.

Synthesis and biodistribution of new oxo and nitrido 99mTc complexes with asymmetrical potentially dianionic or trianionic tetradentate SNNO ligands derived from methyl-2-aminocyclopentene-1-dithiocarboxylic acid

In this work, 10 new asymmetrical tetradentate SNNO ligands were prepared by reaction of the amine function of methyl 2-[(beta-aminoethyl)amino]cyclopentene-1-dithiocarboxylate with various bifunctional substituents bearing hydroxyl/ketone and hydroxyl/aldehyde functional groups and with diethyl oxalate. 99mTc labeling efficiency was optimized by adjusting temperature and pH conditions. Seven nitrido and two oxo 99mTc complexes were isolated. Six of them proved to be stable near physiological conditions. Biodistribution studies in the rat showed a significant heart uptake for four of them and strong kidney and liver uptake for the other two.

Organ donation in the UK: a survey by a British Transplantation Society working party

BACKGROUND

During the past few years the number of organ donors in the UK has declined after a slow but steady increase during the 1980s. Concern about the decline led to a survey by the British Transplantation Society. The report of this survey highlighted a number of reasons for the decline and this manuscript presents and discuss the main items in the report.

METHODS

Comprehensive information relating to organ donation was obtained by a combination of structured interviews during visits to intensive care units (ICUs) and neurosurgical units, the use of detailed questionnaires sent to all UK ICUs, and from the register held by the United Kingdom Transplant Support Service Authority.

RESULTS

The information obtained highlighted a number of reasons for the decline in organ donor numbers and these are presented and discussed. The pool of potential donors is shrinking as death rates from road traffic accidents and intracranial haemorrhage decrease. Also the increasing use of modern imaging techniques has improved predictive ability in patients with severe brain damage with the result that more patients whose prognosis is assessed as hopeless are not treated by ventilation. Inadequacies both in intensive care unit bed provision and the resourcing of the transplant co-ordinator service were also thought to be important.

CONCLUSIONS

Eight recommendations have been made, covering ICU bed provision, neurosurgical provision, transplant surgical staffing, the transplant co-ordinator network, reimbursement to donor units, asystolic donation, live donor transplantation, and interventional ventilation.

Technetium labeling of bi, tri and tetradentate ligands derived from 2-aminocyclopentene-1-dithiocarboxylic acid: characterization and biodistribution of their oxo and nitrido 99mtechnetium complexes

We have synthesized and characterized seven ligands derived from 2-aminocyclopentene-1-dithiocarboxylic acid with different donor sets (SN2-, SNO2-, SNN2-, SNNO3- and SNNN3-) and different substituents on the sulfur moieties-SR (with R = H, CH3 or C2H5O(CH3)CH). With five of these ligands technetium nitrido complexes have been obtained with high yields (over 95%) using rather harsh conditions (pH = 1, temperature > or = 80 degrees C), whereas for technetium oxo complexes similar high yields were only obtained with two ligands but with mild conditions (pH = 7-8, temperature approximately equal to 50 degrees C). Changing an OH group for an NH2 has a drastic effect upon labeling yields. The possibility of complexing ligands as either oxo (TcO)3+ or nitrido (TcN)2+ derivatives increases the number of available labeled agents with different overall change and consequently with different biological behavior.

Colonic transit in soccer players

To evaluate the effects of exercise on colonic function, we measured total and segmental transit times in 11 male soccer players and nine male radiology student technicians. Diet was kept constant in all subjects, who maintained their normal activities. For the soccer players, normal activities included 15 h of training and one match each week. Transit times were measured with radioopaque markers, using the multiple-ingestion, single-radiograph technique. No overall difference in large bowel transit was observed between the two groups. Right colon transit was considerably slower in the soccer players, whereas left colon and rectal transit were slightly accelerated. We conclude that an intensive sport activity only modifies regional differences in large bowel function. This may be of importance in extreme conditions, such as those experienced by marathon runners. Data should be obtained before prescribing exercise to treat constipation.

Results of heart-lung transplantation in children with cystic fibrosis

Children with cystic fibrosis represent the largest group referred for, and undergoing, heart-lung transplantation at our institute. Between June 1988 and July 1993, 76 patients were accepted for transplantation, of whom 25 were transplanted, while a further 36 died waiting. Those transplanted ranged from 5-18 years of age and included 13 males and 12 females. Organs were used from donors matched by ABO blood group, size and cytomegalovirus (CMV) status. Post-transplant maintenance immunosuppression comprised cyclosporin A, azathioprine and prednisolone. Anti-thymocyte globulin and high dose methylprednisolone were given peri-operatively and for acute rejection episodes. Actuarial survival was 67% at 1 year, 61% at 2 years and 54% at 3 years. Obliterative bronchiolitis (OB) has occurred in 13 patients (52%) and was the major cause of mortality and morbidity. In three patients, OB was associated with the development of tracheal anastomotic stenosis. Other complications included diabetes mellitus (n = 9), pancreatitis (n = 1) and hypertension (n = 8). Despite these problems, those surviving the first year post-transplant showed a mean FEV1 of 71% (compared to 29% pre-transplant) and enjoyed an overall improved quality of life.

Recurrent renal salt wasting in a child treated with carboplatin and etoposide

BACKGROUND

Nephrotoxicity of carboplatin is rare, especially in children with normal renal function. A 3-year-old boy had localized esthesioneuroblastoma and received 2 courses of carboplatin (200 mg/m2/day during a 1-hour infusion for 3 consecutive days) associated with etoposide (150 mg/m2/day after carboplatin). Because of a good tumor response, a second course was given 21 days later. Complete surgical excision and local irradiation were performed. However, the tumor recurred a few months later, and the patient subsequently died of the disease.

METHODS

Renal function initially was assessed by standard baseline chemistry and technetium-panetetic acid (Tc-DTPA) clearance. Follow-up included ionic controls and tubular exploration during the episodes of hyponatremia.

RESULTS

Hyponatremia occurred 4 days after completion of the first course and resolved after intravenous supplementation. It recurred 20 days after the second course despite salt and magnesium prehydration and posthydration and resolved 17 days later. No glomerular dysfunction was noticed. The association of urinary bicarbonate loss with elevated N-acetyl-beta-glucosaminidase suggested a proximal tubular damage.

CONCLUSIONS

Standard doses of carboplatin may lead to recurrent renal salt wasting in children with initially normal renal function.

Evaluation of a cardiopulmonary preservation method for heart-lung transplantation

This study was designed to examine whether concomitant administration of anti-free radicals with donorcore cooling on cardiopulmonary bypass (CPB) and hypothermic storage of the heart and lung, could provide successful extended cardiopulmonary preservation. Fourteen sheep heart-lung blocks harvested after core-cooling and cardioplegic arrest were preserved at 4 degrees C for 8.5 hr. Before and during CPB, the animals were perfused with Prostaglandin E1 (PGE1), superoxide dismutase (SOD), catalase (CAT) and deferoxamine (DEF). Cardioplegic arrest was induced with St. Thomas' Hospital solution (Plegisol) to which SOD, CAT and DEF had been added. The preservation solution consisted of Plegisol modified by the addition of K-lactobionate, raffinose, mannitol, SOD, CAT, DEF, a phosphate buffer and penicillin. Histological examination performed on 3 donor heart-lung blocks before and after CPB and cardioplegia, then immediately following cold storage, produced no clear evidence of structural damage in cardiac myocytes and lung parenchyma. Eleven donor organs were therefore transplanted in size-matched recipients with a total mean ischemic time of 12 hr. The combined administration of SOD, CAT, DEF, insulin and glucose during the initial period of reperfusion had no beneficial effect on cardiopulmonary performance. A progressive fall in Pa O2 and mean aortic pressure was observed post-operatively in the 7 animals that were weaned from CPB. Five of them died within 3 to 5 hr after CPB weaning, the remaining 2 animals died of cardiac arrest within the fourth hour. The results of this experiment seem to indicate that: 1. better organ function and improved survival could have been obtained if the duration of anti-radical treatment had been prolonged after reperfusion and, 2. physical manipulation of the donor grafts during harvesting and transplantation may have been partly responsible for the poor post-transplantation cardiopulmonary performance.