[Fatal nutrient deficiencies after gastric bypass]

INTRODUCTION

Bariatric surgery is a very effective treatment for obesity. After gastric bypass, micronutrient deficiencies frequently occur which can have dramatic consequences.

CASE REPORT

We report the case of a 55-year-old woman who was admitted for psychomotor retardation, bilateral leg pitting edema and psoriasis-like rash that had been ongoing for 3 months. Pancytopenia, encephalopathy and heart failure rapidly occurred leading to multiorgan dysfunction syndrome and death. We retrospectively identified severe selenium deficiency with possible secondary cardiomyopathy, niacin deficiency resulting in pellagrous encephalopathy with skin lesions and gelatinous transformation of bone marrow.

CONCLUSION

Micronutrient deficiency should systematically be assessed when new symptoms occur in a patient with a history of bariatric surgery. Selenium deficiency should be considered in the presence of any heart failure in this context.

Infection after transurethral resection of the prostate: variation among centers and correlation with a long-lasting surgical procedure. Association pour la Recherche en Anesthésie-Réanimation

OBJECTIVES

The purpose of this study was to analyze the risk factors of postoperative infection following transurethral resection of the prostate (TURP).

METHODS

857 consecutive patients scheduled for TURP were included in a French multicenter prospective study (12 surgical centers). For each patient, data were collected and analyzed as risk factors of postoperative infection. Statistical analysis used the chi 2 test or Student's test for univariate analysis, then stepwise logistic regression for multivariate analysis.

RESULTS

The incidence of post-TURP infection was 21.6%: urinary tract infection (19.3%) and bacteremia and/or septic shock (2.3%). Multivariate analysis documented three independent risk factors of postoperative infection: preoperative bacteriuria (p < 0.003), duration of surgical procedure > 70 min (p < 0.01) and the surgical center (p < 0.00001).

CONCLUSION

The duration of the surgical procedure is an important postoperative risk factor of infection and there is a major difference between centers in terms of postoperative risk of infection. Further studies are needed to explain this last phenomenon.

[Brain death and organ procurement: a specific context]

Brain death is defined as an irreversible damage to the brain stem associated with lesions of the hemispheres. It determines the irremediable destruction of the whole body which occurs within a short delay. Brain death diagnosis is identified from a series of neurological criteria, i.e.: the loss of consciousness, the disappearance of brainstem reflexes, the lack of spontaneous breathing movements. Legal considerations in use in France imply that brain death must be confirmed by two isoelectric encephalographs or by the absence of cerebral perfusion on cerebral arteriography. The diagnosis must be established by two practitioners who are not involved in transplantation activity. Prexisting cardiac activity and organ perfusion allow indeed organs and tissue procurement for transplantation. Organ procurement is supported by intensive care of the brain dead patient aiming to correct hemodynamic, ventilatory and metabolic disorders related to brain death. Organ donation implies that one would know the patient's will which would have been clearly expressed during his lifetime. Organ harvesting is organized according to guidelines for local practice and regional and national allocation. In consideration of transplantation requirements there is a persisting organ shortage for several years. Efforts must be directed toward an improvement in brain dead patients identification and management.

AIDS in a medical intensive care unit: immediate prognosis and long-term survival

OBJECTIVE

To help physicians decide whether to admit patients with acquired immunodeficiency syndrome (AIDS) to the medical intensive care unit (MICU).

DESIGN

Case series study of AIDS patients admitted to the MICU between October 1990 and October 1992 and followed up until April 1993 (median follow-up, 1 year).

SETTING

The MICU in a 970-bed teaching hospital in Paris, France.

PATIENTS

A total of 120 consecutive AIDS patients with acute respiratory failure (50%), central nervous system dysfunction (22.5%), pneumothorax (12.5%), shock (10.8%), or miscellaneous conditions (4.2%). A total of 86 patients were discharged alive from the MICU.

MAIN OUTCOME MEASURES

Predictive factors for mortality during and after MICU stay.

RESULTS

Multivariate analysis identified 3 factors predicting poor MICU outcome: Simplified Acute Physiology Score I (SAPS I) above 10 (relative risk [RR], 6.1; 95% confidence interval [CI], 1.5-26.6), time between AIDS diagnosis and MICU admission more than 1 year(RR, 6.0; 95% CI, 2.1-17.5), serum albumin level less than 30 g/L (RR, 4.9; 95% CI, 1.3-18.2). The CD4 cell count, beta2-microglobulinemia, and previous opportunistic infections had no influence on MICU mortality. After MICU discharge, survival rates were 86% at 1 week, 82% at 1 month, 53% at 6 months, and 39% at 1 year. The Karnofsky scale score and the number of previous opportunistic infections were simultaneously associated with post-MICU outcome. Predictive factors for MICU survival did not influence post-MICU survival.

CONCLUSION

The MICU mortality was related to immediate severity (assessed within 48 hours of admission) and the time between AIDS diagnosis and MICU admission. Long-term survival after MICU discharge depended only on the severity of AIDS. We conclude that AIDS patients should be admitted to the MICU on the same basis as other patients.

Use of normal C57BL/6 mice with established Mycobacterium avium infections as an alternative model for evaluation of antibiotic activity

Several murine models have been used to evaluate the activities of antimicrobial agents against Mycobacterium avium infection. The main model used is the beige mouse model, but beige mice are expensive and not easily available. Thus, we developed a model of infection in wild C57BL/6 mice. The drugs that exhibited some activity in a previous model of early infection were evaluated in a new model of established infection. Sparfloxacin (50 mg/kg of body weight), ethambutol (50 mg/kg), minocycline (25 mg/kg), and the inhibitor of the cortisol receptors RU-40555 (100 mg/kg) were compared with clarithromycin (50 mg/kg). Treatments were started 5 weeks after the inoculation and were continued for 21 days. Sparfloxacin and RU-40555, which exhibited a moderate activity in the model of early infection, were not effective in this model of established infection. Clarithromycin and combinations with clarithromycin kept their activities against M. avium infection, both in the spleen and in lungs. The present model of established infection of normal C57BL/6 mice is more relevant than the model of early infection for a stringent evaluation of drugs.

Generalized air cysts complicated by fatal bilateral pneumothoraces in a patient with AIDS-related Pneumocystis carinii pneumonia

We describe a case of air cyst lesions in an AIDS patient suffering from Pneumocystis carinii pneumonia. This case is unique because these lesions were generalized to both lungs and initially well tolerated. Pathologic examination revealed extensive tissue invasion by P carinii. The prognosis was complicated by bilateral pneumothoraces. Surgical right pleurodesis allowed lung re-expansion but did not prevent recurrence of fatal contralateral pneumothorax.

Chloroquine does not enhance the activity of clarithromycin against multiplication of Mycobacterium avium within human macrophages

SETTING

Chloroquine, an alkalinizing lysosomotropic agent, enhances the intracellular activity of antibiotics against Mycobacterium tuberculosis or Coxiella burnetii.

OBJECTIVE

To determine if chloroquine modifies the activity of clarithromycin, less effective at acidic pH, against intracellular Mycobacterium avium.

DESIGN

The activity of clarithromycin (4 micrograms/ml) against the MO-1 strain of M. avium was evaluated within human macrophages in presence of chloroquine (5 micrograms/ml). The minimal inhibitory concentration of clarithromycin for the strain was 2 micrograms/ml.

RESULTS

While clarithromycin alone did decrease the intracellular infection at day 7 of culture (P < 0.01), chloroquine alone did not impede the intracellular growth of M. avium, and did not enhance the activity of clarithromycin.

CONCLUSION

Chloroquine should not improve clarithromycin treatment against M. avium infection.

Clarithromycin, minocycline, and rifabutin treatments before and after infection of C57BL/6 mice with Mycobacterium avium

C57BL/6 mice were pretreated with rifabutin or clarithromycin alone or combined with minocycline 3 days before intravenous challenge (day 0) with Mycobacterium avium. Treatment was continued until sacrifice at days 1, 8, 15, and 21. Rifabutin or clarithromycin decreased the level of infection in both the lungs and the spleen. Rifabutin was as effective as clarithromycin in the lungs but was less [corrected] effective in the spleen. The clarithromycin-minocycline combination was as effective as clarithromycin alone.

Efficacy of granulocyte colony-stimulating factor and RU-40555 in combination with clarithromycin against Mycobacterium avium complex infection in C57BL/6 mice

We compared the activities of two different biological-response modifiers with that of clarithromycin against Mycobacterium avium complex infection in C57BL/6 mice. Mice were pretreated daily with clarithromycin (50 mg/kg of body weight subcutaneously [s.c.]), RU-40555 (100 mg/kg s.c.), or granulocyte colony-stimulating factor (G-CSF) at low dose (15 micrograms/kg intraperitoneally [i.p.]) or high dose (300 micrograms/kg i.p.) 3 days before intravenous challenge with 2.5 x 10(7) CFU of the MO-1 strain of M. avium complex. Mice were treated daily until sacrifice at day 1, 8, 15, or 21 after challenge, and the numbers of CFU were measured per gram of tissue in lung and spleen. Compared at day 21 with control treatment, clarithromycin significantly decreased the level of infection in spleen (P < 0.0001) and lungs (P < 0.0001). Compared with control treatment, G-CSF at low dose had no activity, but G-CSF in combination with clarithromycin was more effective than clarithromycin alone in spleen (P < 0.05) and lungs (P < 0.015). The high dose of G-CSF was as effective as the low dose. RU-40555 alone had no beneficial activity. The RU-40555-clarithromycin combination was more effective than control treatment in spleen (P = 0.0001) and lungs (P < 0.0005) and more effective than clarithromycin alone in spleen (P < 0.009) but not in lungs. Thus, our experiments suggest that clarithromycin alone or in combination with G-CSF should be further evaluated for the prophylaxis of M. avium complex infection.

[Immunotherapy of severe infectious states]

Although symptomatic treatments have been optimized, mortality in severe infectious conditions still exceeds 50% in many instances. Excessive activation of inflammation mediators, the endogenous relay of the initial stimulus, may account for the secondary occurrence of polyvisceral failure. This "internal" conception of severe infectious conditions opens new therapeutic possibilities including the modulation of the host's response. However, this new treatment of severe septic conditions, which complements antibiotic therapy and symptomatic measures, encounters several difficulties: a) proinflammatory mediators also have beneficial effects; b) as the mediator cascade is activated within a few hours, ordering immunity-modulating treatments early appears to be a logical step; c) monoclonal antibodies and recombining molecules are very expensive. Costs may be further increased by the probable need to use "cocktails" of antiinflammatory molecules. All these reservations show how technically blameless future clinical trials have to be. Cost efficiency and cost/benefit studies are also required. We may wonder whether society will make the financial choice to use these new treatments.

Ventilatory effects of medical antishock trousers in healthy volunteers

The ventilatory effects of medical antishock trousers (MAST) were investigated using 10 healthy volunteers. Use of the MAST (60-80 mm Hg) decreased forced expiratory volume (-8% +/- 4%, p less than 0.01), vital capacity (-8% +/- 5%, p less than 0.01), and functional residual capacity (-12% +/- 6%, p less than 0.01) and induced a significant decrease in tidal volume (-30% +/- 17%, p less than 0.05), but minute ventilation was unmodified because of a concomitant increase in respiratory rate (+17% +/- 8%, p less than 0.001). The MAST modified the breathing pattern: the abdominal contribution to ventilation was markedly decreased (-57% +/- 22%, p less than 0.001), suggesting a decrease in the diaphragmatic contribution to ventilation. The MAST increased both the end-expiratory (+131% +/- 115%, p less than 0.01) and inspiratory variation (delta Pgas: +42% +/- 40%, p less than 0.05) of gastric pressure, whereas the end-expiratory and inspiratory variation of esophageal pressure remained unchanged. Because of a higher delta Pgas, the dynamic compliance of the abdominal compartment markedly fell (-77% +/- 10%, p less than 0.001). Transdiaphragmatic pressure (Pdi: +28% +/- 30%, p less than 0.05) significantly increased and the pressure-time index of the diaphragm significantly increased (+32% +/- 32%, p less than 0.05) after inflation of the MAST, suggesting an increase in the diaphragmatic cost of breathing. Inspiratory activity of the parasternal intercostal muscles significantly increased after the MAST was inflated. Computerized tomography showed that the MAST induced a cephalad shift of the diaphragm, which reduced pulmonary height.(ABSTRACT TRUNCATED AT 250 WORDS)

[Proteinuria after infusion of gelatin. Comparison of Plasmion and Haemaccel]

Modified gelatin are said without deleterious effect on kidney, an important proteinuria as been seen however in surgical patients after gelatin perfusion. A study in 15 patients scheduled for abdominal surgery compared the renal effects of two modified gelatin: Plasmion (gr P) and Haemaccel (gr H) administered in a similar manner. In the two groups proteinuria appears as soon as perfusion begins with at the third hour a peak which may be as high as 6 g/l. In the same time low molecular weight proteinuria (less than 30 kdalton) appears. The beta 2 microglobulinuria (beta 2m) is significatively enhanced (p less than 0,001). Albuminuria is also enhanced but without statistic signification. Comparison between the two groups reveals that in gr P proteinuria is of the same importance, but delayed, with a significatively smaller elimination of beta 2m (1,8 mg/mmol creatininuria versus 8,6,p less than 0,001). Enzymuria increases in a variable fashion. Proteinuria is probably due to tubular reabsorption inhibition of filtered protein induced by gelatin, particularly by amino acids arginine and lysin which become free after gelatin hydrolysis. If this phenomenon is pathologic or not is unclear and gelatin cannot be said absolutely innocuous. However this phenomenon must be known when proteinuria specially beta 2m is to be interpreted.