Early continuous glucose monitoring for predicting remission of type 2 diabetes 1 year after bariatric surgery

BACKGROUND

Bariatric surgery in obese subjects can result in remission of type 2 diabetes (T2D) at a distant time post-surgery. The aim of our observational prospective single-centre study was to examine glycaemic patterns in adult T2D candidates for bariatric surgery using a continuous glucose monitoring (CGM) sensor for 14 days after surgery to search for indicators predictive of T2D remission 1 year later.

METHODS

Patients underwent CGM preoperatively and for 14 days postoperatively. Thereafter, body weight and glycated haemoglobin (HbA1c) levels were monitored at 3, 6 and 12 months after surgery.

RESULTS

A total of 31 patients (mean age 47±2 years) were analyzed. After surgery, mean interstitial glucose levels fell rapidly from 157±31mg/dL preoperatively to 109±35mg/dL postoperatively (P<0.001), reaching nadir levels from day 3 after surgery. Successful bariatric surgery (loss of excess weight ≥50%) was observed in 28 (90%) patients, and diabetes remission (HbA1c≤6% with no antidiabetic treatment) 1 year after surgery was noted in 21 (68%) patients. CGM for 14 days post-surgery allowed prediction of diabetes remission 1 year after surgery: time spent above range <14% and standard deviation (SD) of glucose levels <33mg/dL were both strong predictors of T2D remission. Indeed, the association of these two criteria predicted diabetes remission with a 100% positive predictive value, 81% sensitivity and 100% specificity and, when combined with the advanced Diabetes Remission (Ad-DiaRem) score, further increased predictive accuracy.

CONCLUSION

The use of 14-day postoperative CGM recordings together with presurgical clinical scores can help to predict diabetes remission 1 year after bariatric surgery.

Bariatric revisional surgery: What are the challenges for the patient and the practitioner?

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

Effect of intra-operative intravenous lidocaine on opioid consumption after bariatric surgery: a prospective, randomised, blinded, placebo-controlled study

Peri-operative lidocaine infusion warrants investigation in bariatric surgery because obese patients present different physiological and pharmacological risks. This single-centre, prospective, randomised double-blind placebo-controlled study enrolled obese patients scheduled for laparoscopic bariatric surgery using an enhanced recovery protocol. Patients received either lidocaine (bolus of 1.5 mg.kg^-1 , then a continuous infusion of 2 mg.kg^-1 .h^-1 until the end of the surgery, then 1 mg.kg^-1 .h^-1 for 1 h in the recovery area) or identical volumes and rates of 0.9% saline. The primary outcome was the consumption of the equivalent of oxycodone consumption over the first 3 postoperative days. Secondary outcomes were: postoperative pain; incidence of nausea and vomiting; bowel function recovery; and lengths of stay in the recovery area and in hospital. Plasma concentrations of lidocaine were measured. On the 178 patients recruited, data were analysed from 176. The median (IQR [range]) equivalent intravenous oxycodone consumption was 3.3 mg (0.0-6.0 [0.0-14.5]) and 5.0 mg (3.3-7.0 [3.3-20.0]) in the lidocaine and saline groups, respectively (difference between medians (95%CI): 1.7 (0.6-3.4) mg; p = 0.004). Length of stay in the recovery area, postoperative pain, nausea and vomiting, day of recovery of bowel function, and length of stay in hospital were not different between groups. Mean (SD) lidocaine plasma concentrations were 2.44 (0.70) µg.ml^-1 and 1.77 (0.51) µg.ml^-1 at the end of surgery and 1 hour after the end of infusion, respectively. Lidocaine infusion during bariatric surgery resulted in a clinically non-relevant difference in postoperative oxycodone consumption.

Comparison of the Pharmacokinetic Profiles of Three Low Molecular Mass Heparins – Dalteparin, Enoxaparin and Nadroparin – Administered Subcutaneously in Healthy Volunteers (Doses for Prevention of Thromboembolism)

The present trial was designed to comparatively investigate the pharmacokinetic profile and evaluate the apparent bioavailability pattern of three already marketed low molecular mass heparins (LMMHs): dalteparin (Fragmin®), nadroparin (Fraxiparin®), and enoxaparin (Love- nox®) given by subcutaneous route. The study was carried out in 20 healthy young volunteers given, according to a cross over design, a single subcutaneous injection of the doses recommended for the prophylaxis of deep vein thrombosis (commercial preparations, prefilled syringes): dalteparin 2,500 IU (= 2,500 IU anti-Xa), nadroparin 7,500 ICU (= 3,075 IU anti-Xa), enoxaparin 20 mg (= 2,000 IU anti-Xa) and enoxaparin 40 mg (= 4,000 IU anti-Xa). Of the markers used, activated partial thromboplastin time (APTT), thrombin clotting time (TCT), Heptest®, anti-thrombin (aIIa) activity and anti-Xa (aXa) activity, the most pertinent parameter (from a biodynamic viewpoint) is plasma aXa activity. We demonstrated that dalteparin, nadroparin and enoxaparin exhibit statistically significantly different pharmacokinetic and overall disposition patterns. Normalized to the same injected dose (1,000 IU aXa), the relative actual amount of plasma anti-Xa activity generated by enoxaparin is 1.48 times greater (p < 0.001) than that of nadroparin and 2.28 times greater (p < 0.001) than that of dalteparin while the plasma amount induced by nadroparin is 1.54 times greater (p < 0.001) than that of dalteparin. The apparent total body clearance of enoxaparin doses (CL/F = 16.7 ± 5.5 and 13.8 ± 3.2 ml/min) is significantly smaller than those of nadroparin (CL/F = 21.4 ± 7.0 ml/min ; p < 0.01) and dalteparin (CL/F = 33.3 ±11.8 ml/min ; p < 0.001) while dalteparin apparent clearance is about 1.5-fold greater (p < 0.001) than that of nadroparin. These LMMHs also differ by their renal excretion pattern : more fragments exhibiting an anti-Xa activity are recovered in urine following enoxaparin doses (6.4 and 8.7 % of the dose, respectively) than following nadroparin (3.9 %) and dalteparin (3.4 %) injection. These differences in the disposition profiles explain why the apparent elimination half life t1/2 values of the LMMHs compared here are different: dalteparin: 2.8 h; nadroparin: 3.7 h; and enoxaparin: 4.1 h. Whether or not these differences may contribute to explain the different safety/efficacy balance of each of these antithrombotic medications remains to be discussed and needs further studies.

Guiding the non-bariatric surgeon through complications of bariatric surgery

Complications in bariatric surgery are varied; they are severe at times but infrequent. They may be surgical or non-surgical, and may occur early or late. The goal of this systematic review is to inform and help the attending physician, the emergency physician and the non-bariatric surgeon who may be called upon to manage surgical complications that arise after adjustable gastric band (AGB), sleeve gastrectomy (SG), or gastric bypass (GBP). Data from evidence-based medicine were extracted from the literature by a review of the Medline database and also of the most recent recommendations of the learned societies implicated. The main complications were classified for each intervention, and a distinction was made between early and late complications. Early complications after AGB include prosthetic slippage or perforation; SG can be complicated early by staple line leak or fistula, and BPG by fistula, stenosis and postoperative hemorrhage. Delayed complications of AGB include intragastric migration of the prosthesis, late prosthetic slippage and infection, while SG can be complicated by gastro-esophageal reflux, and BPG by anastomotic ulcer and internal hernia. The analysis of available data allowed us to develop decisional algorithms for the management of each of these complications.

Stenosis without stricture after sleeve gastrectomy

Sleeve gastrectomy (SG) is an increasingly popular restrictive bariatric procedure as attested by the 5,302 procedures performed in 2009, increasing worldwide to 13,557 in 2011 and to 24,190 in 2013. Among the early complications, gastric stricture is well described with a prevalence between 0.7 and 4.0% (Dhahri et al., 2010). The patient reported here had functional stenosis without any underlying anatomic stricture. This complication is rare and is the consequence of spiral stapling resulting in a gastric tube that is twisted from the start (Iannelli et al., 2014). Twisted sleeve gastrectomy resulting from spiral stapling exposes the patient to the risk of recurrent dysphagia, which has the appearance of stenosis on upper GI series but not on fibroscopy. Conversion to RY-GBP is one solution. At six months follow-up after conversion, our patient is symptom-free, with quality of life was rated excellent (a score greater than 9 on the BAROS questionnaire).

First evidence of the presence of genomic islands in Escherichia coli P4, a mammary pathogen frequently used to induce experimental mastitis

Mastitis pathogens belonging to Escherichia coli species are often considered as environmental opportunistic pathogens that invade the udder and are rapidly killed by the immune system of cows. However, several studies have reported that some of these strains are able to persist in the udder for prolonged periods or to adhere and invade mammary epithelial cells, suggesting that they might possess some specific properties or genes that could be involved in their capacity to provoke mastitis. The aim of this work was to search for such specific genes in the E. coli strain P4, which was isolated from a case of severe mastitis and is often used to induce experimental mastitis. We established that this strain belongs to phylogenetic group A of the E. coli species, and that its core genome is very similar to that of the commensal nonpathogenic strain E. coli K-12 MG1655. Seventeen transfer RNA loci, known to be frequently associated with genomic islands, were screened and an altered structure was detected for 7 of them. The partial characterization of 5 of these loci (asnT, leuX, pheV, serU, and thrW) and the complete characterization of 1 (argW) revealed the presence of genomic islands that differ from those already described in pathogenic or nonpathogenic E. coli strains.

Short Communication: Study of Mammary Epithelial Role in Polycyclic Aromatic Hydrocarbons Transfer to Milk

Food would appear to be one of the main routes for animal and human contamination with polycyclic aromatic hydrocarbons (PAH). Many studies have shown the presence of PAH in milk and dairy products, suggesting that these foods can represent a part of this contamination. Our work aimed at defining, in vitro, the mammary barrier role in PAH transfer to milk. MAC T cells were cultivated on permeable filters to measure transepithelial permeability of 14C labeled benzo[a]pyrene (BaP), pyrene (Pyr), and phenanthrene (Phen), which differed in their physicochemical properties. The results showed that only 2 molecules, Phen and Pyr, were able to cross mammary cell layers. Phenanthrene radioactivity appeared more quickly in apical media, and its level after a 6-h exposure was 1.3 times higher than for Pyr and 7.7 times higher than for BaP. These findings suggested that mammary epithelium could play a key role in the selective transfer of PAH from food to milk.

Proteolysis in milk during experimental Escherichia coli mastitis

This work consisted of the intramammary infections (IMI) of 8 heifers by high doses of Escherichia coli to study both the proteolytic activity in milk and the resulting peptides. Therefore, a milking kinetic has been followed, and several parameters have been studied, such as proteose peptones (PP) fraction (quantitative and qualitative changes), plasmin activity (PA), milk somatic cell count (SCC), and bacterial count. A qualitative study of milk proteins and PP was performed by sodium dodecyl sulfate-PAGE, and the peptides recovered in PP during the acute phase of inflammation were amino-terminal micro-sequenced. A BSA increase in milk over time supported the hypothesis of an increase in the permeability of the epithelial barrier. A significant increase in PP content, considered to be an indicator of proteolysis, was observed from postinfusion hours (PIH) 12 to 48. Both the E. coli bacterial count and the SCC increased from PIH 3 to 216. Plasmin activity was increased noticeably from PIH 15 to 24. The respective increases in SCC, bacterial count, and PA suggest their involvement in a global mechanism responsible for the increase in proteolysis in milk after E. coli challenge. Somatic cell count and E. coli may be involved from PIH 3 to 216, and PA involvement might be highlighted during the maximum proteolysis, from PIH 15 to 24. A qualitative study of PP fraction by electrophoresis revealed the apparition of 5 peptide bands: P1 and P2 previously recovered during the lipopolysaccharide challenge, and E1 (27.0 kDa), E2 (15.5 kDa), and E3 (9.0 kDa) were specific to E. coli challenge; E1, E2, and E3 contained casein fragments. The roles played by leukocytes and E. coli are discussed.

Isolation and Characterization of Copolymers of β-Lactoglobulin, α-Lactalbumin, κ-Casein, and αs1-Casein Generated by Pressurization and Thermal Treatment of Raw Milk

Raw skim milk was submitted to high pressure (300 to 600 MPa) and temperature (4 to 70 degrees C) treatments for 2 or 5 min. The combined effects of pressure and temperature on milk proteins induced structural changes and polymer and copolymer formation characterized by anion-exchange and size-exclusion fast protein liquid chromatography and electrophoretic techniques. Approximately half of the beta-lactoglobulin formed polymers, and the other half formed large copolymers, mainly with kappa-casein, alpha-lactalbumin via intermolecular disulfide bond exchange, and alpha(s1)-casein via physicochemical interactions, in proportions of 1.0:0.7:0.3:0.1, respectively. Minor whey proteins (serum albumin, immunoglobulins, and lactoferrin) also participated in the formation of the copolymers but to a lesser extent. Two populations of the copolymers were found with apparent molecular masses ranging from 440 to 2000 kDa for the first and more than 2000 kDa for the second. On the contrary, for heated milks the aggregation kinetics obtained by combination of high pressure and thermal treatment were very fast, as no intermediates such as dimers and small size oligomers were observed after pressurization, whatever the temperature studied. Lactosylation of proteins as well as proteolysis were very limited. A beta-casein amino-terminal peptide of 22 kDa was specifically recovered in milk samples treated under the more drastic conditions (500 MPa/55 degrees C per 5 min and 600 MPa/70 degrees C per 5 min) and might have been generated by neutral proteases such as elastase released from somatic cells present in milk. No casein was released from the micelle whatever the combination of high pressure and temperature studied.

Thoracoscopic plication of the diaphragm for postoperative phrenic paralysis: a report of two cases

Unilateral phrenic nerve paralysis after cardiothoracic surgery is not uncommon. When symptomatic, it can require surgical treatment. Plication of the diaphragm through a thoracotomy is known to provide excellent long-term results. Plication is now being performed via video-assisted thoracoscopic surgery (VATS). We report the cases of two patients with postoperative left phrenic nerve paralysis who underwent plication of the diaphragm using VATS and achieved total relief of all symptoms.

Contamination of pastures by polycyclic aromatic hydrocarbons (PAHs) in the vicinity of a highway

To assess PAH contamination pastures, grass and soil samples have been collected from 10 m (d1), 50 m (d2), and 150 m (d3) perpendicular to a French highway (70,000 vehicles per day) and at a control site in a rural area away from nearby contaminating sources. Total PAH concentration ranges from 767 ng/g dry weight to 3989 ng/g dry weight, according to the matrix and the distance from the highway. Distance is not a significant factor for PAH deposition on grass, while in soil it has an effect between d1 and d2 or d3. The total PAH concentration in highway samples is 8 times higher than in control site samples for grass and 7 to 4 times higher for soil. Fluoranthene, pyrene, and phenanthrene are the major PAHs in grass samples at the control site and the highway, but the concentrations are about 5 times higher near the highway. In soil samples collected near the highway, the values of concentrations between all compounds are not statistically different. PAH deposition on grass is linked to the physicochemical properties of the compounds, which lead to a specific distribution of each molecule (according to their volatility and the number of aromatic rings) while no specific behavior is revealed in soil.

Characterization and proteolytic origins of specific peptides appearing during lipopolysaccharide experimental mastitis

Based on the compositional change of the proteose peptone fraction, proteolysis was studied over time following lipopolysaccharide-induced experimental mastitis. Electrophoresis of the proteose peptone fraction revealed many degradation products. Five peptides were identified by amino-terminal sequencing as internal fragments of beta-, kappa-, alpha(s1)-, and alpha(s2)-casein that were generated by somatic cell proteases. Although kappa-casein is considered particularly resistant to endogenous proteolysis, a kappa-casein peptide was electrophoretically isolated in association with a beta-casein fragment. The in vitro kinetic studies of caseinate hydrolysis by elastase, one of the main polymorphonuclear neutrophil (PMN) proteases, suggested that the beta-casein peptide might be generated by elastase. In addition, elastase activity in milk PMN was higher during the inflammation of the mammary gland than prior to infusion.

Mechanisms involved in milk endogenous proteolysis induced by a lipopolysaccharide experimental mastitis

Experimental mastitis has been induced by the lipopolysaccharide (LPS) of Escherichia coli on six dairy cows in order to study the mechanisms involved in milk endogenous proteolysis during the inflammatory process. Variations in somatic cell count (SCC), plasmin activity, and total casein (CN) content were measured, and proteose-peptone content and the percentage of pH 4.6 insoluble peptides including gamma-CN have been considered as indicators of endogenous proteolysis. Furthermore, polymorphonuclear neutrophils (PMN) maturity has been evaluated by optical microscopy, and proteolysis by PMN proteinases has been studied at neutral and acidic pH in order to establish a link between caseinolysis, proteinase class, and PMN maturation. Two peaks of proteose-peptones content have been noticed for the six cows. First peak could be explained by both plasmin activity and SCC, while second peak was concomitant with a low plasmin activity but a SCC remaining high. The second peak of proteose-peptones content confirmed the role of cellular proteases in milk caseinolysis. Casein breakdown by cellular proteases was confirmed by SDS-PAGE electrophoresis, and a link between neutral proteinases activity and immature PMN recruitment was shown. Acidic proteinases activity was effective with mature PMN and during the recovery phase.

Enzymatic activities of bovine peripheral blood leukocytes and milk polymorphonuclear neutrophils during intramammary inflammation caused by lipopolysaccharide

Leukocytes are recruited from peripheral blood into milk as part of the inflammatory response to mastitis. However, excessive accumulation of inflammatory cells alters the quality of milk and the proteases produced by polymorphonuclear neutrophils (PMNs) and macrophages may lead to mammary tissue damage. To investigate PMN recruitment and the kinetics of their intracytoplasmic enzymes in inflammation, we generated mastitis in six cows by intramammary infusion of lipopolysaccharide (LPS). Clinical signs of acute mastitis were observed in all of the cows, and normal status was resumed by 316 h. Intracytoplasmic elastase, collagenase, and cathepsin activities were measured within live cells by flow cytometry in peripheral blood leukocytes and milk PMNs before and during the inflammatory process (at 10 time points between 4 and 316 h). The proportion of immature PMNs was appreciated by CD33 surface labeling measured in flow cytometry. Leukopenia was observed in the peripheral blood 4 h postinfusion, concomitant to an increase in somatic cell counts in milk. CD33(+) PMNs were preferentially recruited from the peripheral blood to milk. Enzymatic activities were detected in PMNs, lymphocytes, and monocytes at levels depending on the cell type, sample nature, and time of collection. Milk PMNs had lower enzymatic activities than peripheral blood PMNs. This study showed that milk PMNs recruited during LPS-induced experimental mastitis have an immature phenotype and significantly lower enzymatic activities than peripheral blood PMNs. This suggests that CD33, an adhesion molecule, may be involved in the egress from blood to milk and that the enzymatic contents of PMNs are partly used during this process.

[Statistical analysis in the evaluation of controlled diffusion of iodine in the water in developing countries]

This report describes the methodology and findings of a novel statistical technique for evaluation of the efficacy of the Rhodifuse Iode system in prevention of endemic goiter in Mali. The system involves continuous release of iodine in ground water used for drinking. Study was carried out in four villages for one year. The iodine release system was used in three villages. The fourth village served as the control. The incidence of goiter graded using the criteria of the WHO was assessed in each village according to sex. Statistical analysis consisted of correlating goiter grade with four predictors, i.e., village, sex, iodine release, and time. Since goiter grade is a dependent variable, its law of probability was modeled in function of the predictors. The Cat Mot procedure included in the SAS software package allowed both definition of the law of probability of grade of goiter and its transformation in function of predictor. The generalized linear model was obtained by either the generalized least square method or greatest likelihood method. The Proc Catmod procedure was then used to generalize analysis of variance in case of a nominal or ordinal, binary or polytomic response. The results of this novel statistical technique suggested that the Rhodifuse Iode system was effective.

[Use of the vacuum-assisted closure system for the treatment of perineal gangrene involving the abdominal wall]

The vacuum-assisted closure (VAC) system is used for the treatment of complicated wounds and large tissular dehiscences. The study aim was to report a case of perineal gangrene extended to the abdominal wall in a 53-year old woman. After several extensive surgical debridments, using of the VAC was followed by a good and rapid healing of the wound.

[Long-term results of the treatment of eventrations by intraperitoneal non-absorbable prosthesis (149 patients)]

The authors report a series of 149 cases of incisional hernia, operated between 1983 and 1993, by insertion of a non-absorbable prosthetic mesh within the intraperitoneal cavity. This series consisted of 93 women and 56 men, with a mean age 57 years. One third of repairs were performed because of primary treatment failure. One or more operative risk factors were present in 127 patients. A non-absorbable intraperitoneal prosthetic mesh was inserted with tension to allow good musculo-aponeurotic repair. Postoperative mortality was 0.6%. All but 13 of the patients, were reviewed with a mean follow-up of 83 months. Twenty eight patients (20%) developed recurrence. In 8 cases, the cause of recurrence was failure of prosthetic mesh insertion because of excessive tension. Three patients (1.7%) developed a fistula in contact with the prosthetic mesh, that had to be removed. A small bowel fistula was observed in 2 cases after an intraoperative wound in 1 case, and a colonic fistula in 1 case. The results of incisional hernia repair with nonabsorbable intraperitoneal prosthetic mesh can be compared with these of other techniques using prosthetic materials. This technique does not require dissection of the intermediate planes and avoids undermining which causes substantial bleeding. The risk of sepsis is also decreased by deep placement of the prosthesis. The exceptional cases of fistula or the possibility of migration of the prosthesis are not exclusively observed with this technique, but must clearly encourage a very strict aseptic technique, with placement of omentum between the prosthetic mesh and the viscera.

[Laparoscopic treatment of common bile duct lithiasis. Study of 56 cases]

AIM OF THE STUDY

The aim of this retrospective study was to report the results of the laparoscopic management of common bile duct stones in an unicentric series of 56 patients.

PATIENTS AND METHOD

From January 1993 to April 1998, 56 patients, 38 women, 18 men (mean age: 59.2 years), underwent a common bile duct exploration for lithiasis through a laparoscopic approach. The patients were hospitalised for angiocholitis (n = 13), cholecystitis (n = 11), biliary pain (n = 29, nine with jaundice), pancreatitis (n = 3), abnormality of hepatic profile (n = 1). All the patients underwent an intraoperative cholangiography. Removal of the stones was tried in 50 cases through a choledochotomy, in four through the cystic duct, using Mirrizi forceps, or Dormia and Fogarty catheters in case of failure. External biliary drainage and postoperative cholangiography were done systematically. The average diameter of the common bile duct was 10.5 mm (6-20 mm).

RESULTS

In 41 patients, removal of the stones was laparoscopically successful. In 11 patients, a conversion into laparotomy was necessary for several reasons. In three patients with common bile duct of small diameter, the stones were abandoned for a further endoscopic sphincterotomy. There was no mortality and the morbidity rate was 7%. The mean postoperative hospital stay was 8.6 days (4-20) for all the series and 7.8 days in case of successful laparoscopic management.

CONCLUSION

In 73% of the patients, the treatment of the common bile duct lithiasis could be achieved laparoscopically, but conventional approach and endoscopic sphincterotomy are still useful in case of failure of the laparoscopic management.

[Medico-economic evaluation of treatment of inguinal hernia: Shouldice vs. laparoscopy]

Between May 1994 and September 1995, 64 men were included in a randomized prospective study comparing conventional Shouldice repair (S group) and transperitoneal laparoscopic repair with polypropylene mesh (L group). Cost evaluation was divided into distinct parts: drugs, non usable surgical materials, medico-technical procedures food and employees costs. In group S, mean operating time was 56', total cost was 3,922 FF in the case of unilateral hernia and 4,808 FF and respectively 77' in the case of bilateral hernia. In group L, mean operative time was 89', total cost 8,949 FF (disposable trocars) and 7,136 FF (non-disposable trocars) in the case of unilateral hernia and 116', 9,570 FF and 7,763 FF in case of bilateral hernia. Postoperative stay was 4.2 days in group S and 4 days in group L. Return to work was 28.6 days in group L and 35.5 days in group S (ns). In conclusion laparoscopic hernia repair does not decrease post operative pain, hospital stay and return to work, but is twice as expensive.

Use of the repeated cross-over design in assessing bioequivalence: (within and between subjects variability - Schuirmann Confidence Intervals estimation)

In 1992, the Division of Bioequivalence in the Office of Generic Drugs published a guide to Statistical procedures for bioequivalence studies using a standard two-treatments cross-over design (1). This paper describes the application of the guidelines to a practical protocol and the recent Proc MIXED (SAS) will be shown to be much more convenient than the traditional Proc GLM for theoretical and practical reasons (correct estimation of residuals, analysis of the within-subjects variation, direct calculation of the Schuirmann 90% Confidence Intervals). This new procedure was applied to a study protocol on riluzole (Rilutek) including a replicate design with the within-subject and between-subject variances being estimated on Cmax and AUC biopharmaceutic parameters.

[Contribution of laparoscopy in the management of abdominal stab wounds]

Laparotomy is useless in 5 to 39% of patients suffering from penetrating abdominal trauma. The objective of this study is to try to determine the value of laparoscopy in the management of such patients. Thirteen patients underwent laparoscopy for abdominal wound. 11 of these patients had a penetrating abdominal trauma and only 4 of them suffered from lesions requiring surgical treatment (2 intestinal wounds, 1 gastric wound and 1 coeliac artery disruption). No treatment was required in 30 cases (1 wound of intestinal serosa and 2 superficial hepatic wounds). In the last 6 cases no intra-abdominal wound was found. There was no mortality or morbidity. No lesions were missed at laparoscopy. Laparoscopy avoided useless laparotomy in 9 out of 13 patients. This suggests that laparoscopy is a reliable method in the management of patients suffering from abdominal wounds, allowing a very sensitive and specific diagnosis of penetration and visceral injuries. In some cases, is allows laparoscopic treatment of the visceral injury.

Laparoscopic anatomical hepatic resection. Report of four left lobectomies for solid tumors

Four patients underwent a laparoscopic left hepatic resection for solid tumor, two for metastasis from colonic cancer, and two for focal nodular hyperplasia (final diagnosis). The procedure was performed according to the rules of conventional hepatic surgery and cancer surgery. No blood transfusion was necessary. No surgical complication occurred. In malignant disease, laparoscopy allows a good staging and the performance of a real no-touch technique; the specimen is removed in a plastic bag without contact to the abdominal wall. In symptomatic benign disease the esthetic benefit of the laparoscopic approach is real. In asymptomatic benign disease, laparoscopy could allow large biopsies in the case of uncertain diagnosis or dangerous resection. It allows safe resections in the case of small, well-located tumors. This approach requires sophisticated material and extensive experience in both laparoscopy and hepatobiliary surgery.

Single- and multiple-dose pharmacokinetics of riluzole in white subjects

Riluzole is a novel neuroprotective agent that has been developed for the treatment of amyotrophic lateral sclerosis. A series of studies was undertaken to establish its pharmacokinetics on single- and multiple-dose administration in young white male volunteers. The mean absolute oral bioavailability of riluzole (50-mg tablet) was approximately 60%. Maximum plasma concentration (Cmax) and area under the concentration-time curve (AUC) values were linearly related to dose for the range studied. Cmax occurred at 1.0 hour to 1.5 hours after administration. Plasma elimination half-life appeared to be independent of dose. After repeated administration of 100 mg riluzole for 10 days, some intraindividual variability in bioavailability was seen. A high-fat meal significantly reduced the rate (tmax = 2 hours compared with 0.8 hours; Cmax = 216 ng.mL-1 compared to 387 ng.mL-1) and extent of absorption (AUC = 1,047 ng.hr.mL-1 versus 1,269 ng.hr.mL-1). With multiple-dose administration, riluzole showed dose-related absorption, although the terminal plasma half-life was prolonged slightly. Steady-state plasma concentrations were achieved within 5 days. Steady-state trough plasma concentrations were significantly higher with a 75-mg dose twice daily than with a 50-mg dose three times daily, although AUC values did not differ.

[Geotropic reaction of different types of roots in Hevea brasiliensis]

To describe the different types of geotropic reactions of hevea (Hevea brasiliensis), young seedlings were cultivated in root observation boxes and submitted to a double gravistimulation (90 degrees rotation of the minirhizotrons in the vertical plane). It was demonstrated that the taproot is a strongly orthogeotropic organ since it resumed rapidly its prestimulation vertical position. Morphological and morphogenetic modifications were associated with the geotropic response: reduced speed of growth coupled with a reduction of the apical diameter as well as an alteration of ramification density in the curving zone and the following one. Early secondary roots showed a somewhat reduced orthogeotropism that was weaker as the growth direction before gravistimulation was more distant from the vertical. Secondary roots of the acropetal sequence were semiplagiotropic, that is only those roots oriented upward after the gravistimulation resumed, more or less, the original direction. Tertiary roots didn't respond to the gravistimulation and therefore were ageotropic. Complementary observations conducted in large laboratory rhizotrons showed that late forming secondary roots were plagiotropic in their younger stages, thereafter loosing most of their sensitivity to gravity. Quaternary roots were ageotropic. On the basis of these data, a geotropic gradient was defined within the hevea root system, where the strongly responding taproot and late secondary roots are opposed to the weakly or nonresponding tertiary and quaternary roots. Functional significations of the differential geotropic reactions in different hevea root types are discussed.

Proteolysis in samples of quarter milk with varying somatic cell counts. 2. Component PP3 and beta-casein-1P (f29-105 and f29-107) of the proteose-peptone fraction

The proteose-peptone fraction was studied to measure proteolysis in 86 samples of quarter milk from 31 cows with subclinical mastitis. The relative content of component PP3 decreased significantly in the total of proteose-peptone as plasmin activity increased, but the content of this component in milk was not correctly correlated with the plasmin activity (r = .52). Electrophoresis, amino acid composition, and sequence analysis showed that the component beta-CN-1P (f29-105/7) of the proteose-peptone fraction was a terminal product of plasmin-like activity and was located correctly electrophoretically. Correlation factors between the plasmin activity and content in milk of component beta-CN-1P (f29-105/7) was very high (r = .87). This component could be used as indicator of the endogenous proteolysis in milk from cows with subclinical mastitis.

Proteolysis in samples of quarter milk with varying somatic cell counts. 1. Comparison of some indicators of endogenous proteolysis in milk

Eighty-six samples of quarter milk from 31 cows, the mean SCC of which exceeded 400,000 cells/ml, were analyzed for SCC, chloride content, pH, clotting time, total N, soluble N, casein N, proteose-peptone content, plasmin activity, and amount of free NH2 groups, parameters that are related to the udder health condition and to the deterioration of the protein quality. Analysis of the milk from each quarter separately improved the correlations considerably compared with analyses of samples from all 4 quarters mixed together. Measurement of free NH2 groups, using the 2, 4, 6-trinitrobenzene sulfonic acid, was not appropriate for estimating the extent of protein deterioration in milk samples with different SCC. Unlike SCC, the proteolysis index, plasmin activity, and the proteose-peptone content were highly correlated themselves and with most of the parameters related to proteolysis in milk. Proteolysis occurred in milk samples with SCC as low as 250,000 cells/ml. The quality of milk protein decreased unavoidably during lactation, regardless of SCC.

Comparison of the pharmacokinetic profiles of three low molecular mass heparins--dalteparin, enoxaparin and nadroparin--administered subcutaneously in healthy volunteers (doses for prevention of thromboembolism)

The present trial was designed to comparatively investigate the pharmacokinetic profile and evaluate the apparent bioavailability pattern of three already marketed low molecular mass heparins (LMMHs): dalteparin (Fragmin), nadroparin (Fraxiparin), and enoxaparin (Lovenox) given by subcutaneous route. The study was carried out in 20 healthy young volunteers given, according to a cross over design, a single subcutaneous injection of the doses recommended for the prophylaxis of deep vein thrombosis (commercial preparations, prefilled syringes): dalteparin 2,500 IU (= 2,500 IU anti-Xa), nadroparin 7,500 ICU (= 3,075 IU anti-Xa), enoxaparin 20 mg (= 2,000 IU anti-Xa) and enoxaparin 40 mg (= 4,000 IU anti-Xa). Of the markers used, activated partial thromboplastin time (APTT), thrombin clotting time (TCT), Heptest, anti-thrombin (aIIa) activity and anti-Xa (aXa) activity, the most pertinent parameter (from a biodynamic viewpoint) is plasma aXa activity. We demonstrated that dalteparin, nadroparin and enoxaparin exhibit statistically significantly different pharmacokinetic and overall disposition patterns. Normalized to the same injected dose (1,000 IU aXa), the relative actual amount of plasma anti-Xa activity generated by enoxaparin is 1.48 times greater (p < 0.001) than that of nadroparin and 2.28 times greater (p < 0.001) than that of dalteparin while the plasma amount induced by nadroparin is 1.54 times greater (p < 0.001) than that of dalteparin. The apparent total body clearance of enoxaparin doses (CL/F = 16.7 +/- 5.5 and 13.8 +/- 3.2 ml/min) is significantly smaller than those of nadroparin (CL/F = 21.4 +/- 7.0 ml/min; p < 0.01) and dalteparin (CL/F = 33.3 +/- 11.8 ml/min; p < 0.001) while dalteparin apparent clearance is about 1.5-fold greater (p < 0.001) than that of nadroparin. These LMMHs also differ by their renal excretion pattern: more fragments exhibiting an anti-Xa activity are recovered in urine following enoxaparin doses (6.4 and 8.7% of the dose, respectively) than following nadroparin (3.9%) and dalteparin (3.4%) injection. These differences in the disposition profiles explain why the apparent elimination half life t1/2 values of the LMMHs compared here are different: dalteparin: 2.8 h; nadroparin: 3.7 h; and enoxaparin: 4.1 h. Whether or not these differences may contribute to explain the different safety/efficacy balance of each of these antithrombotic medications remains to be discussed and needs further studies.

Pharmacokinetics of sparfloxacin in humans after single oral administration at doses of 200, 400, 600, and 800 mg

The pharmacokinetics of sparfloxacin at oral doses of 200, 400, 600, and 800 mg were studied in 12 healthy volunteers in a randomized double-blind crossover study. Each dose administration was separated by a 1-week washout period. Plasma and urine samples were collected up to 120 hours postdosing, for determination of free and total (free plus glucurono-conjugated) sparfloxacin levels by high-performance liquid chromatography assay and ultraviolet detection. Mean Cmax values ranged from 705 +/- 158 to 1966 +/- 620 ng/mL for the 200 to 800 mg doses, at median tmax ranging from 4 to 5 hours. A slight decrease of sparfloxacin bioavailability with increasing dose was observed because AUC was 87% to 88% of the expected area when the dose was doubled. The elimination half-life values were constant over the dose range (with values ranging from 18 to 21 hours) as well as the renal clearance. The metabolic ratio conjugated/free drug was not modified by increasing dose.

Pharmacokinetics and suction blister fluid penetration of a semisynthetic injectable streptogramin RP 59500 (RP 57669/ RP 54476)

RP 59500 is a new semisynthetic injectable streptogramin with excellent activity against most gram-positive bacteria. In order to assess its potential for the treatment of tissue infections, the pharmacokinetics and penetration into suction blister fluid were studied in a pilot phase I study in six male volunteers following a single infusion of 12 mg/kg over 1 h. Plasma and suction blister fluid concentrations were determined by microbiological assay. The mean peak concentration in plasma was 8.65 mg/l at the end of infusion. The mean plasma elimination half-life was 1.48 h. The mean peak concentration in interstitial fluid was 2.41 mg/l and was reached after 1 h in two volunteers and after 2 h in the other four. The mean percentage penetration for the interval 0-6 h was 82.5%. RP 59500 was still detectable in interstitial fluid at 6 h at a mean concentration of 0.92 +/- 0.25 mg/l. The data of this pilot study demonstrate good penetration of RP 59500 into non-inflammatory interstitial fluid.

[Celioscopic treatment of perforations of duodenal ulcers. 6 cases]

Traditionally, perforations of duodenal ulcers are managed by suturing followed by peritoneal lavage and the underlying cause is addressed secondarily. Laparoscopy provides a means of meeting the different therapeutic needs. From May to October 1993, we treated 6 consecutive perforations of duodenal ulcers laparoscopically. In 5 cases, the perforation was the first manifestation of acute duodenal ulceration and the other case was chronic. The laparoscopic operation included peritoneal lavage and simple suture of the ulcer. The immediate post-operative period was uneventful. With a current follow-up of 3.6 months, 5 patients are asymptomatic and ulcer cicatrization has been confirmed by fibroscopy. In the sixth case with a past history of chronic duodenal ulcer, re-operation was required after a delay of 2 months for acido-fundic vagotomy (performed laparoscopically). The local presentation was satisfactory in this patient. Extensive peritoneal lavage, which can be performed with laparoscopy together with suture when the ulcer is recent, allows managing such patients according to Taylor's method. The usefulness of vagotomy can then be addressed and performed later laparoscopically after the initial lavage. This new approach offers a means of complete cure and has all the advantages of the classical technique.

Pharmacokinetics of sparfloxacin in patients with renal impairment

The pharmacokinetics of sparfloxacin were studied in 14 renal failure patients (group I, 7 with creatinine clearance of > 10 to 30 ml/min; and group II, 7 with creatinine clearance of < or = 10 ml/min) after a single oral dose of 400 mg. Plasma and urine samples were collected up to 144 h postdosing for determination of parent and total (parent-plus-glucuronide-conjugated) sparfloxacin levels, by high-pressure liquid chromatography assay and UV detection. The elimination of the drug in patients compared with that in healthy volunteers was markedly impaired. The mean elimination half-lives of sparfloxacin were 34.9 and 38.5 h in group I and group II, respectively, versus 19.1 h in healthy volunteers. Conjugated drug half-lives were 23.7, 35.0, and 15.3 h, respectively. The renal clearance of the drug was markedly reduced in the patients, with values of 6.8, 4.8, and 21.2 ml/min determined for group I, group II, and healthy subjects, respectively, for parent sparfloxacin and with values of 31.5, 14.0, and 327 ml/min for conjugated sparfloxacin. The nonrenal clearance of sparfloxacin was moderately, but not significantly, decreased in group II renal failure patients. No difference between the two groups of patients was detected in sparfloxacin levels in plasma. A significant relationship between pharmacokinetic parameters and creatinine clearance was observed only for renal clearance of parent or conjugated sparfloxacin.

[Pelvic lymphoceles after kidney transplantation. Intraperitoneal marsupialization by celioscopy]

OBJECTIVES

The appropriate treatment for symptomatic pelvic lymphoceles occurring after renal transplantation is still debated. External drainage exposes to risk of recurrence, infection or graft sclerosis and laparotomy has been required for intraperitoneal marsupialization in patients at risk. We report our experience with two cases treated by laparoscopic intraperitoneal marsupialization.

PATIENTS

From November 1986 to September 1992, 170 renal transplantations were performed at our University Hospital. Lymphoceles developed in 12 cases and percutaneous puncture and irrigation was performed in all, successfully in 10. Relapse occurred in 2 patients--one 50-year-old woman with chronic glomerulonephritis and one 41-year-old man on peritoneal dialysis for polycystic renal disease--recipients of cadaver kidneys.

SURGICAL TECHNIQUE

The laparoscopy was conducted under general anaesthesia. Four trocars were inserted, a 10 mm via the umbilicus for the optical system and three 5 mm trocars via the right and left flank and the left iliac fossa. A long puncture needle was used to drain the lymphocele and a localized collection and a large peritoneal window was created. The abdominal cavity was abundantly washed before withdrawing.

RESULTS

Operation time was 35 minutes and conversion to laparotomy was not required. The only complication was a haematoma at one insertion site. Patients were discharged on day 2 and on day 1 with an unchanged immunosuppressor regimen. At 10 months follow-up, the patients were symptom-free and echography was normal.

CONCLUSIONS

Surgical treatment of lymphoceles can be successfully performed by laparoscopy. The choice between conservative treatment and laparoscopic surgery remains to be determined.

Evaluation of Bayesian estimation in comparison to NONMEM for population pharmacokinetic data analysis: application to pefloxacin in intensive care unit patients

The pharmacokinetics of pefloxacin (PF) were investigated in a population of 74 intensive care unit patients receiving 400 mg bid as 1-hr infusion using (i) Bayesian estimation (BE) of individual patient parameters followed by multiple linear regression (MLR) analysis and (ii) NONMEM analysis. The data consisted of 3 to 9 PF plasma levels per patient measured over 1 to 3 dosage intervals (total 113) according to four different limited (suboptimal) sampling 3-point protocols. Twenty-nine covariates (including 15 comedications) were considered to explain the interpatient variability. Predicted PF CL for a patient with median covariates values was similar in both BE/MLR and NONMEM analysis (4.02 and 3.92 L/hr, respectively). Bilirubin level and age were identified as the major determinants of PF CL by both approaches with similar predicted magnitude of effects (about 40 and 30% decrease of median CL, respectively). Confounding effects were observed between creatinine clearance (26% decrease of PF CL in the BE/MLR model), simplified acute physiology score (a global score based on 14 biological and clinical variables) (18% decrease of median CL in the NONMEM model) and age (entered in both models) which were highly correlated in our data base. However, both models predicted similar PF CL for actual subpopulations by using actual covariate values. Finally, the NONMEM analysis allowed identification of an effect of weight on CL (decrease of CL for weight < 65 kg) whereas the BE/MLR analysis predicted an increase of CL in patients treated with phenobarbital. In conclusion, both approaches allowed identification of the major risk factors of PF pharmacokinetics in ICU patients. Their potential use at different stages of drug development is discussed.

[Complicated solitary biliary cysts]

With development of ultra sound, solitary hepatic cyst (SHC) appears as a common and benign affection. Complications can occur in 10 per cent of cases. We report here four cases of complicated SHC: vena caval obstruction, intracystic bleeding, rupture, intracystic infection. Those four patients were successfully treated by partial excision of the cyst in the first 3 cases, and by percutaneous drainage with CT scan guidance in the latter. Complications of SHC occur only in large cysts, with a diameter up to 8 cm. So, small SHC do not require any treatment, while large SHC must be treated to avoid complications. Percutaneous aspiration and direct injection of alcohol can lead to recurrence. Surgical therapy by partial excision is successful, with low rates of mortality and morbidity.

Comparative bioavailability study of cefixime administered as tablets or aqueous solution

The relative bioavailability of cefixime was studied in 24 healthy male volunteers, with each subject receiving a single 400mg dose of cefixime administered as an aqueous solution, a 400mg tablet and two 200mg tablets, in a randomised crossover sequence. Serum and urine samples were analysed using high-performance liquid chromatography. Peak cefixime levels were achieved 3 hours after administration of the solution vs 4 hours for the 2 tablet formulations; however, the extent of absorption was only slightly improved with the solution (by 14 and 7% compared with the 1 x 400 and 2 x 200mg tablets, respectively). The 400mg and 2 x 200mg tablets were found to be bioequivalent. The pharmacokinetic profile of the 400mg cefixime tablet (mean maximum plasma concentrations of 4.4 mg/L at 4 hours, area under the concentration-time curve of 34.4 mg/L.h, and apparent terminal elimination half-life of 3.7 hours) supports the clinical evaluation of a 400mg once-daily dosage regimen for cefixime.

The antithrombotic activity and pharmacokinetics of enoxaparine, a low molecular weight heparin, in humans given single subcutaneous doses of 20 to 80 mg

The pharmacokinetics of enoxaparine, a low molecular weight heparin, was randomly studied in 12 healthy male volunteers. Doses of 20, 40, 60, and 80 mg were injected subcutaneously in randomized cross-over fashion. Anti-IIa and anti-Xa activities (using amidolytic methods), and calcium thrombin time, were measured over 36 hours. The maximum Amax of the anti-IIa and anti-Xa activities appeared 3 to 4 hours after administration. The terminal half-lives of anti-IIa and anti-Xa activities were approximately 2 and 4 hours, respectively, with no significant variation between the different doses. For the anti-Xa activity, there was a highly significant positive correlation between the dose injected and individual values of Amax (r = +0.915; P less than .001) and AUC (r = +0.913; P less than .001). Enoxaparine displays a relatively small apparent volume of distribution (about 7.0 L) and its total body clearance is about 1.25 L/hr. The mean residence time ranges from 4.6 to 7.6 hours. Thus, the pharmacokinetic profile of enoxaparine is characterized by a linear relationship between dose and absorption, a relatively low clearance and long elimination half-life, and a high anti-Xa/anti-IIa ratio.