A novel complication of peritoneovenous shunt: cardiac tamponade

For the last two decades, peritoneovenous shunts (PVS) have commonly been used in the management of refractory ascites. However, these devices are associated with a wide variety of complications. We report a case of cardiac tamponade due to ventricular perforation by a PVS. Given the substantial morbidity associated with PVS, other therapeutic options should be considered before proceeding with PVS placement.

Prophylaxis against hepatitis B recurrence following liver transplantation using combination lamivudine and hepatitis B immune globulin

Patients undergoing liver transplantation for hepatitis B-related liver disease are prone to recurrence. The mainstay of prophylaxis has been passive immunotherapy with hepatitis B immune globulin (HBIG). Antiviral therapy with lamivudine has proven effective in lowering hepatitis B virus (HBV) DNA and improving histology in patients with hepatitis B infection; its role in prophylaxis against hepatitis B recurrence following liver transplantation is under investigation. Viral breakthrough and resistance, however, are a significant problem with monotherapy with either HBIG or lamivudine. The efficacy of combination lamivudine/HBIG prophylaxis has not been reported. Fourteen patients underwent transplantation for decompensated liver disease owing to hepatitis B. Lamivudine (150 mg p.o./d) was begun before transplantation in 10 patients, including 4 who were HBV DNA-positive. In addition, 1 patient was HBV DNA-positive when transplanted. HBIG was given perioperatively and continued thereafter; treatment with lamivudine was maintained or initiated at the time of transplantation and continued indefinitely. The median follow-up was 387 days. Actuarial 1-year patient and graft survival was 93% (1 patient died of unrelated causes). At a median interval of 28 days following lamivudine treatment, all 5 HBV DNA-positive patients cleared HBV DNA from the serum; 1 went on to clear hepatitis B surface antigen (HBsAg), before transplantation, at day 148 of lamivudine treatment. By the highly sensitive polymerase chain reaction (PCR), at a median of 346 days (range, 130-525 days) following transplantation, all 13 surviving patients had no detectable serum HBV DNA. Lamivudine suppresses HBV replication in patients awaiting liver transplantation. At a median follow-up of 1.1 years, combination prophylaxis with lamivudine and HBIG prevented hepatitis B recurrence following liver transplantation.

Correlating structure and stability of DNA duplexes with incorporated 2'-O-modified RNA analogues

Chemically modified nucleic acids are currently being evaluated as potential antisense compounds for therapeutic applications. 2'-O-Ethylene glycol substituted oligoribonucleotides are second-generation antisense inhibitors of gene expression with promising features for in vivo use. Relative to DNA, they display improved RNA affinity and higher nuclease resistance. Moreover, chimeric oligonucleotides with 2'-O-methoxyethyl ribonucleoside wings and a central DNA phosphorothioate window have been shown to effectively reduce the growth of tumors in animal models at low doses. Using X-ray crystallography, we have determined the structures of three A-form DNA duplexes containing the following 2'-O-modified ribothymidine building blocks: 2'-O-methoxyethyl ribo-T, 2'-O-methyl[tri(oxyethyl)] ribo-T, and 2'-O-ethoxymethylene ribo-T. In contrast to 2'-O-ethylene glycol substituents, the presence of a 2'-O-ethoxymethylene group leads to slightly reduced RNA affinity of the corresponding oligonucleotides. The three structures allow a qualitative rationalization of the differing stabilities of duplexes between oligonucleotides comprising these types of 2'-O-modified ribonucleotides and complementary RNAs. The stabilizing 2'-O-ethylene glycol substituents are conformationally preorganized for the duplex state. Thus, the presence of one or several ethylene glycol moieties may reduce the conformational space of the substituents in an oligonucleotide single strand. In addition, most of these preferred conformations appear to be compatible with the minor groove topology in an A-type duplex. Factors that contribute to the conformational rigidity of the 2'-O-substituents are anomeric and gauche effects, electrostatic interactions between backbone and substituent, and bound water molecules.

[Attempted suicide and alcohol dependence: results of an epidemiologic survey]

OBJECTIVES

The relationship between alcoholism and suicidal behaviour has long been recognized. The present study examined the lifetime prevalence of suicide attempts in alcoholic patients and the impact of comorbidity, namely with depressive anxiety disorders and antisocial personnalit disorder in alcoholic patients who attempted suicide.

METHODS

In a cross-sectional design including outpatients referring for alcohol dependance according to DSM III-R criteria, we used a specific standardized and structured interview allowing DSM III-R diagnoses.

RESULTS

We include 507 patients (343 males of 164 females). The mean age at the intake of the study was 43.2 (SD:9.6) years without difference between males and females. 129 patients (25.4%) had attempted suicide during their lifetime. The proportion of female was found higher than males among suicide attempters (41.9 vs 29.3%; p < or = 0.001). Age of onset of alcoholism was found younger in suicide attempters than non (p < or = 0.01), either in males and females. Moreover, we found that alcoholic suicide attempters more often reported family histories of alcoholism than did nonattempters. As regard lifetime comorbidity, major depression and drugs misuse were found more frequent in alcoholics who attempted suicide (p < or = 0.001). Moreover, we found a higher prevalence for Panic Disorder and Social Phobia in male suicide attempters.

Pneumonia associated with Mycoplasma spp in three cats

Mycoplasma spp were isolated in pure culture from bronchoalveolar lavage specimens from three cats with clinical, cytological and radiographic signs of bronchopneumonia or suppurative bronchitis. Predisposing factors were not identified in the first case, the second cat had oesophageal hypomotility, while the third cat had been exposed to cigarette smoke and had advanced periodontal disease. Respiratory signs resolved promptly and completely in all cases following antimicrobial therapy directed against mycoplasmas. Mycoplasma spp are possible causes of lower respiratory tract disease in cats and this should be considered when selecting empirical therapy for feline airway disease and pneumonia. In some situations mycoplasmas may behave as primary lower respiratory tract pathogens in cats.

Antenatal HIV prevalence in Yaounde, Cameroon

From June 1994 to July 1996, 4100 pregnant women living in Yaounde, Cameroon, were tested for human immunodeficiency virus type 1 (HIV-1) and syphilis. The HIV seroprevalence was 4.2% (95% confidence interval (CI): 3.6%-4.8%), and that of antibodies to Treponema pallidum was 17.4% (95% CI: 16.3%-18.6%) (HIV infection was twice as common in women with positive syphilis serology) (7.2% vs 3.6%). Over the study period, the antenatal seroprevalence of syphilis remained stable, while there was an increase in the HIV seroprevalence rate. There was an increase in HIV seropositivity in women uninfected with syphilis between 1994/1995 and 1995/1996 from 2.9% to 4.3%. By the end of the study, HIV infection was no commoner in women with negative compared with positive syphilis serology. It is therefore postulated that HIV infection in Yaounde has entered the general, sexually active female population. We suggest that management of pregnant women in Cameroon should include routine screening for both HIV infection and other sexually transmitted diseases (STDs).

[Endoscopic therapy of cholangiolithiasis by percutaneous approach. Percutaneous gallstone therapy]

PATIENTS AND METHODS

In a retrospective study, the results of percutaneous transhepatic therapy of bile duct stones under cholangioscopic control (PTCS) were evaluated in 32 patients in which a endoscopic retrograde stone removal was impossible or failed.

RESULTS

Previous gastric surgery was the most common reason for choosing the percutaneous route (22 cases). Five patients had biliodigestive anastomosis, two pyloric obstructions, and in three patients the retrograde stone removal failed. Complete stone removal was obtained after 3 to 11 (median 5) percutaneous procedures in all cases, in 28 patients by electrohydraulic lithotripsy, and in the remaining 5 cases by mechanical extraction alone. There was no complication due to cholangioscopy and lithotripsy themselves. Two cases had major complications which needed laparotomy (4%, one case had capsular bleeding from the liver, another one had catheter perforation of the duodenum). In addition, three cases (7%) had minor complications which required no therapy during the percutaneous fistula procedure. Two elderly multimorbid patients (4%) died during hospitalisation after successful stone removal not related to the performed procedure.

CONCLUSION

The percutaneous transhepatic cholangioscopy (PTCS) and lithotripsy are highly effective techniques for endoscopic treatment of bile duct stones. Because of an increased rate of complications during the fistula procedures, both methods should be restricted to cases with difficult anatomic situation and high risk of surgery.

Metabolism, excretion and pharmacokinetics of a single dose of [14C]-raltitrexed in cancer patients

Raltitrexed (Tomudex) is a specific inhibitor of thymidylate synthase and has recently been licensed in Europe for use in the treatment of advanced colorectal carcinoma. This study evaluated the metabolism, excretion and pharmacokinetics after a single dose of 3.0 mg/m2 [14C]-raltitrexed in patients with advanced solid malignancies not amenable to curative therapy. From April 1994 to July 1995, nine patients (six men and three women) were recruited into the study. Pharmacokinetics analysis was performed during the first cycle of treatment in all patients and, in two patients, limited sampling was done prior to and during the second cycle of treatment. The mean observed peak plasma concentration (Cmax) was 700.6 ng/ml and the median time (tmax) to reach maximal raltitrexed concentrations was 15 min after the initiation of the infusion. After reaching Cmax the drug declined in a triexponential manner with a terminal half-life of 257 h. The AUC0-infinity as predicted by the pharmacokinetic model was 2341.7 ng h ml(-1). Clearance was 41.3 ml/min, of which renal clearance accounted for 50-60%. Urinary collection for the measurement of radiolabeled drug revealed that renal excretion extrapolated to infinity accounted for 40% of the total radioactive dose. Faecal excretion accounted for only 3% of the dose when samples were collected to day 5 in the first six patients. Collection was extended to 10 days in the last three patients and faecal elimination accounted for 14% in these patients. Raltitrexed measurements prior to subsequent doses suggest that there was no accumulation of the drug with repeated administration. Low levels of radioactivity measured in the red cell pellets on days 15, 22 and 29 are likely to represent drug retained by newly forming red cells at the time of dosing. Examination of the urine revealed that the drug was excreted unchanged. The toxicities seen were in line with those encountered in previous studies. Grade 3 and 4 thrombocytopenia occurred in three patients and grade 3 neutropenia occurred in two patients.

Mycobacterial nodular granulomas affecting the subcutis and skin of dogs (canine leproid granuloma syndrome)

OBJECTIVE

To obtain a better understanding of a disease affecting dogs in which nodular mycobacterial granulomas are present in the subcutis or skin.

DESIGN

Retrospective survey

PROCEDURE

A diagnosis of an unidentified mycobacterial infection was made in 45 dogs following detection of acid-fast bacilli surrounded by granulomatous or pyogranulomatous inflammation in tissue sections. Eight cases were identified from the records of our diagnostic laboratory. In all cases culture for mycobacteria was unsuccessful. Another 37 cases were identified by practitioners and veterinary pathologists in response to a survey mailed to veterinary clinics throughout Australia. Data from these 45 cases were entered into a data base. The data set was incomplete, as some respondents did not answer all questions.

RESULTS

Over 90% of affected dogs had short coats and about half were Boxers or Boxer-cross dogs. A weak seasonal trend for the development of primary lesions in autumn and winter was identified. Cases were recorded from New South Wales (35 dogs), Western Australia (4), Queensland (4), Tasmania (1) and New Zealand (1). The subcutis and skin of the ears and head (including the ears) were involved in 64% and 85% of cases, respectively, for which lesion site was recorded. Culture was attempted but was unsuccessful in 19 cases, including 11 cases where material was submitted to our laboratory and/or a Mycobacteria Reference Laboratory. Lymph node enlargement, internal organ involvement or constitutional signs were not a feature of the syndrome, and most lesions did not worry the dogs. Although many practitioners recorded a favourable response to therapy with doxycycline (response rate 57%) or amoxycillin-clavulanate (63%), spontaneous resolution of infection was thought to have occurred in six of seven dogs (86%) not given systemic antimicrobials, and three dogs where antimicrobials had failed previously. A minority of cases failed to respond to antimicrobial therapy and continued to have chronic lesions. There was no discernible trend for dogs of a particular age or sex to be affected.

CONCLUSION

This syndrome is caused by saprophytic mycobacteria of limited pathogenicity that give rise to lesions restricted principally but not exclusively to the subcutis and skin of body extremities. Fastidious growth requirements have prevented their isolation on synthetic media used for culture of mycobacteria. Organisms presumably enter the subcutis following a breach in integrity of the epidermal barrier and produce self-limiting disease in immunocompetent dogs. Lesions tend to resolve spontaneously. The possibility of a public health threat from affected dogs is highly unlikely.

Sutureless cartilage graft laryngotracheal reconstruction using fibrin sealant

OBJECTIVE

To determine whether fibrin sealant can replace suture as a means of holding a cartilage graft securely in the trachea.

DESIGN

Randomized blinded control study comparing the use of fibrin sealant vs sutures in laryngotracheal reconstruction in ferrets. We compared results at 7 and 30 days.

SUBJECTS

Forty ferrets randomized into 2 groups of 20: fibrin sealant and sutures. Within each group, half were studied at 7 days and the rest at 30 days. No ferrets were withdrawn from study because of adverse effects of the intervention.

INTERVENTION

A carved costal cartilage graft was placed in the anterior cricoid split incision, and was secured with either fibrin sealant or sutures. All animals were extubated after recovery from anesthesia. Specimens were examined grossly and histologically.

RESULTS

All animals survived until humanely killed. The pathologist, unaware of the groupings, measured lumen expansion in millimeters, cartilage graft migration, mucosal in-growth, degree of inflammation, graft integration, and graft viability. The fibrin sealant group had statistically significant (P<.05) better results in mucosal in-growth. In no categories was the suture group better than the fibrin sealant group. In comparing 7-day with 30-day results, the 30-day group had significantly better results in inflammation and graft viability.

CONCLUSIONS

Fibrin sealant can be used in place of sutures with improvement in mucosal growth in costal cartilage laryngotracheal reconstruction in the experimental animal model. Use of fibrin sealant (instead of sutures) may result in less surgical trauma and edema, less surgical time, and faster recovery.

Basque Country autochthonous population data on 7 short tandem repeat loci

Blood samples from 202-208 unrelated Basque Country autochthonous individuals were amplified, typed and their allele frequencies were determined. Results demonstrate the assumption of independence within and between the loci analyzed. Therefore, a Basque population database can be used in identity testing to estimate the frequency of a multiple PCR-based locus DNA profile.

[Medico-socioeconomic impact of anxiety disorders]

Budgetary control policies implemented in order to cope with the increase in health costs in industrialized countries and with the desequilibrium of the national health insurance accounts, give rise to the problem of preserving the quality of care and quality of life of the patients. Only health economic studies evaluating the possible different therapeutic strategies, will enable us to reconcile the 2 terms of the equation whose contradiction might be only apparent. This is particularly true for the treatment of psychiatric diseases, and especially anxiety. Budgetary control cannot be reduced to a simple management of penury, since the cheapest treatments are not necessarily the most profitable. In this context, new strategies are proposed: it is suggested that thorough diagnosis (avoiding both the non acknowledgement of the illness and the overconsumption of anxiolytic drugs) and early optimal treatment, of adequate duration, of the anxiety disorders might be the most economic attitude in the management of this pathology. On the other hand, the impact of the treatment of anxiety on the quality of life of the patient has a direct effect on costs if one considers the supplement to medical consumption and the social deficit induced by therapeutic failure in particular anxiety disorders. It remains that the evaluation of the health economics of anxiety is difficult, because of the complexity of the parameters involved. Though rather well developed in the UK and in North America, this evaluation still has to be introduced in France.

Messenger RNAs encoding lipoprotein lipase, fatty acid synthase and hormone-sensitive lipase in the adipose tissue of underfed-refed ewes and cows

The mechanisms involved in the nutritional regulation of genes encoding lipogenic (lipoprotein lipase (LPL) and fatty acid synthase (FAS)) and lipolytic (hormone-sensitive lipase (HSL)) enzymes were investigated by comparing the levels of the corresponding mRNAs in the adipose tissue (AT) of underfed or underfed-refed ewes and cows. Refeeding sharply increased LPL and FAS activities (19-25- and 6-8-fold, respectively) and moderately increased (2-4 fold) the activities of glucose-6-phosphate dehydrogenase (G6PDH), malic enzyme (ME) and glycerol-3-phosphate dehydrogenase (G3PDH). Northern blot analysis revealed three LPL transcripts and a single FAS transcript in cow and ewe AT. A single HSL mRNA was detected in cow AT and two transcripts in ewe AT. Refeeding sharply increased LPL and FAS mRNA levels, while restriction slightly increased (cows) or had no effect (ewes) on the HSL mRNA levels. This suggests that nutritional factors regulate sharply the expression of LPL and FAS genes by pretranslational mechanisms, but less clearly that of HSL gene.

Acquisition of hepatitis C virus in hemodialysis patients: a prospective study by branched DNA signal amplification assay

Serological data indicate that hepatitis C virus (HCV) infection is very common among chronic hemodialysis (HD) patients. Circumstantial evidence suggests that hemodialysis per se is an important risk factor for this infection. We used a novel methodology, the branched DNA (bDNA) signal amplification assay, which is capable of detecting HCV RNA and of quantifying HCV viral load in serum, to prospectively determine the rate of acquisition of HCV infection in 274 anti-HCV-negative patients undergoing HD treatment in four hemodialysis units. Moreover, we used bDNA testing to analyze the dynamics of HCV acquisition among HD patients, a high-risk group for HCV infection with immune compromise conferred from uremia. Two patients were identified with de novo acquisition during 1 year of prospective bDNA testing. Thus, the HCV incidence was 0.73% per year. De novo acquisition of HCV infection was observed in the absence of identifiable parenteral risk factors. Both patients showed the same pattern of HCV acquisition: they underwent an initial viremic phase that was associated with an increase in alanine transaminase (ALT) activity and that preceded the anti-HCV seroconversion. This was followed by HCV RNA clearance and normalization of ALT activity. Anti-HCV positivity occurred 1 and 2 months after the ALT increase in the first and second patients, respectively. Although HCV incidence was low (0.73%), further research is warranted to set the optimal policy for eliminating the risk of nosocomial transmission of HCV in the HD setting. Our findings show the pattern of HCV acquisition in chronic HD patients and emphasize the need to screen the HD population for ALT measurement combined with anti-HCV testing for detecting hepatitis C. HCV RNA testing can identify HCV before seroconversion in individuals with deranged liver function tests. The acquisition of HCV in HD patients without identifiable risk is confirmed.

Interferon-alpha2b therapy is efficacious in Asian-Americans with chronic hepatitis B infection: a prospective controlled trial

Chronic hepatitis B virus infection is endemic in Asian communities in the United States. The purpose of the current study was to compare the antiviral efficacy of interferon-alpha2b in a group of adult Asian patients chronically infected with hepatitis B with active replication compared to a control group of Caucasian patients treated with the same regimen. Patients with entry aminotransferase (ALT) levels greater than three times the upper limit of normal received interferon-alpha2b, 5 million units, subcutaneously daily for 16 weeks. Patients with pretreatment ALT levels 1.5-3 times the upper limit of normal received prednisone for a total of six weeks prior to interferon starting at 60 mg daily with reduction in dosage by 20 mg every two weeks with a two-week period between finishing prednisone and starting interferon-alpha2b. Eight (62%) of the 13 Asians and six (60%) of the 10 Caucasians cleared HBeAg and HBV DNA from serum (NS). By the end of one year of follow-up after therapy, four (67%) of six Caucasian responders but none of the Asian responders had cleared hepatitis B surface antigen from serum (P < 0.05). Loss of serum markers of active replication appeared less durable in the Asian responders compared to the Caucasians with reappearance of serum HBeAg in two (25%) of eight of the former but only one (17%) of the latter group. Three other Asian patients subsequently redeveloped HBeAg in serum. It is concluded that adult Asian-Americans have an identical initial response rate to antiviral therapy with interferon-alpha2b; however, the response may be less durable and does not usually lead to loss of HBsAg.

[Stereotactic radiotherapy: nomenclature of acts]

Acts of neurosurgery, neuroradiology and radiation therapy are not always identified in the French "nomenclature générale des actes professionnels" (NGAP) (general nomenclature of professional acts). Project of a new "nomenclature commune des actes professionnels" (NCAP) (communal nomenclature of professional acts) is described and discussed.

Liver transplantation for decompensated cirrhosis after jejunoileal bypass: a strategy for management

BACKGROUND

Although jejunoileal bypass results in end-stage liver disease in up to 100% of patients, little is known about outcome after liver transplantation.

METHODS

The clinical courses of six patients who underwent liver transplantation at UCLA for decompensated cirrhosis owing to a jejunoileal bypass were reviewed. Liver function, allograft pathology, renal function, and nutritional status were assessed.

RESULTS

Of the four patients with an intact jejunoileal bypass, two of the three who were biopsied had recurrent steatotic liver disease. The two patients whose jejunoileal bypass was reversed at the time of liver transplantation had lower alkaline phosphatase, lower creatinine, higher albumin, and higher cholesterol, and were more obese than their counterparts with intact bypasses.

CONCLUSIONS

Patients undergoing liver transplantation for jejunoileal bypass-associated liver disease should, if possible, have their bypass reversed at the time of transplantation; otherwise, they must be followed closely and be biopsied routinely. Recurrent liver disease should prompt reversal of the jejunoileal bypass.

Effect of HLA matching on outcome of related and unrelated donor transplantation therapy for chronic myelogenous leukemia

This article examines the diversity and biologic role of human lymphocyte antigen (HLA) genes as related to marrow transplantation for chronic myelogenous leukemia (CML). A better understanding of the nature and function of HLA variation is necessary as unrelated marrow transplantation evolves into a safe and effective treatment for CML. HLA matching is an important aspect of donor selection criteria and has a role in engraftment as well as the development of graft-versus-host disease and tolerance after transplant.