Transcaruncular anterior ethmoidal artery ligation

Recurrence of epistaxis after ligation or embolization of the sphenopalatine artery may require ligation of the ipsilateral anterior ethmoidal artery, which cannot be embolized because of the risk to the ophthalmic artery. We describe a transconjunctival transcaruncular approach that allows reliable low-risk access to the anterior ethmoidal artery. This technique offers a minimally invasive approach to the surgical site, without unsightly scar.

Description des clusters de Covid-19 nosocomiaux chez des patients, France 2020-2022

Introduction

Matériels et méthodes

Résultats

Conclusion

Bilan des signalements COVID-19 sur la plateforme e-SIN, France, 2020

Introduction

Le signalement des infections nosocomiales via l’outil e-SIN est depuis le début de l’épidémie utilisé par les équipes opérationnelles d’hygiène des établissements de santé pour signaler les cas nosocomiaux de Covid19.

Matériels et méthodes

La période d’étude est l’année 2020, du 01-01-2020 au 03-01-2021. L’analyse concerne plus précisément les cas groupés définis à partir de 3 cas survenus dans un délai entre 2 cas de 4 à 7 jours¹. Le caractère nosocomial² est caractérisé par les équipes opérationnelles d’hygiène qui signalent. Les signalements de Covid19 sont extraits de l’outil e-SIN puis analysés dans une base Microsoft® Excel (2016). ¹ Ministère des solidarités et de la santé. Gestion des cas groupés - clusters de COVID-19. (2020). ²Surveillance definitions for COVID-19. European Centre for Disease Prevention and Control.

Résultats

En 2020, 4,352 signalements (SIN) de Covid-19 nosocomiales ont été émis. Parmi ces SIN, 1845 cas groupés (CG) représentant 18 778 cas patients (60%), 12 574 cas soignants (40 %) et 10 cas visiteurs. La répartition par service des CG signalés est la suivante : 828 en médecine, 567 en SSR, 139 en chirurgie, 108 en SLD, 61 en secteur EHPAD, 42 en soins intensifs, 35 aux urgences, 13 en gynécologie-obstétrique, 3 en imagerie et 48 dans les services supports (laboratoire, cuisine, …). La part des professionnels dans les CG est variable selon les services: elle est proche de la moyenne dans les services de médecine (46 %) et de chirurgie (53 %), elle est plus faible dans les services de SSR (34 %), SLD (27 %) et secteur EHPAD (26 %) et plus élevée en Gynécologie-Obstétrique (63%), en Soins Intensifs (74 %), aux urgences (92 %) et en Imagerie (100 %). Les principales hypothèses formulées pour expliquer la transmission du virus sont: (1) la découverte fortuite d’un cas, (2) le non-respect strict des mesures barrières et (3) les pauses/transmissions entre professionnels sur leur lieu de travail. La première hypothèse est au premier plan dans les services de médecine (38 %) et de chirurgie (44 %), secteur EHPAD (46 %), SLD (41 %) et SSR (42 %). La 3^e hypothèse est au premier plan dans les services de gynécologie-obstétrique (62 %), imagerie (100 %) et urgences (43 %). En soins intensifs les 3 hypothèses sont au même niveau (environ 1/3). Le dépistage et le renforcement des mesures barrières sont de loin les 2 mesures correctives les plus décrites dans les 1,621 CG ayant renseigné des mesures correctives, tout type de service confondu.

Conclusion

La transmission nosocomiale de Covid-19 est une réalité à prendre en compte pour maîtriser la diffusion du virus. Elle prend des aspects différents selon les services. Les patients représentent la plus grande part des cas, souvent parce que le cas index n’est pas identifié à l’admission. Ce constat incite à renforcer les précautions standard, le dépistage et les mesures barrières spécifiques dès l’identification des cas. Une part importante des cas groupés implique des professionnels souvent contaminés lors des pauses ou transmission pendant lesquelles le strict respect des mesures barrières doit être maintenu.

[Headaches in a 21-year-old man with Goodpasture disease]

The case of a 21-year old man who died due to an intracranial thrombosis just after diagnosis of Goodpasture's disease, is reported. Discussion deals with the putative mechanisms, which could be responsible for the thrombosis.

[A very extensive necrotizing fasciitis]

Necrotizing fasciitis is a severe skin infection. Fluidized bed may be indicated to improve healing. We report a 36-year-old woman case, who developed an important skin emphysema on a fluidized bed that may have worsen the situation.

Detection of equine herpesviruses in aborted foetuses by consensus PCR

The major role of EHV-1 in equine abortion is widely reported in the literature but the contribution of EHV-2, EHV-3, EHV-4 or EHV-5 remains less well documented. The objective of this study is to evaluate the contribution of these five different EHVs to equine abortion in a variety of biological tissues using a consensus polymerase chain reaction (PCR). The test was validated for specificity and sensitivity in horses before screening specimens from 407 foetuses, stillbirths and premature foals collected over a 2.5-year interval. Positive results obtained with this assay were compared to other EHV type-specific PCR or by sequencing. EHV-1 was identified as the major cause of abortion in French mares (59/407 cases). However, there was evidence to suggest some variation in the potential of EHV-1 strains to induce abortion. Indeed, DNA samples from EHV-2 (in three cases) and EHV-5 (in one case) inferred a role of these viruses in abortion. The presence of viral DNA from EHV-3 or EHV-4 strains was not detected in the specimens studied. The data obtained suggest that the consensus herpesvirus PCR is an efficient screening tool. In association with a specific PCR, the test provides a rapid identification of the type of herpesvirus involved in abortion and is useful for routine diagnostic tests as it allows the identification of herpesviruses other than the EHV-1 strain.

[A case of influenza A community-acquired pneumonia in an elderly subject hospitalised in intensive care unit]

Influenza pneumonia and influenza-associated severe exacerbation of pre-existing heart and lung disease are responsible for major complications that may require intensive care unit admission. Here, we report the case of a diabetic 70 year-old man hospitalised in the intensive care unit (ICU) of the University Medical Center of Reims (France) for a severe bilateral and alveolar pneumonia requiring mechanical ventilation. This patient had received a classical antibiotic treatment by amoxycillin (3 g/24 hours per os); 48 hours later, he was admitted in ICU for a respiratory failure that evolved rapidly towards an acute respiratory distress syndrome. Because of the context of a winter influenza outbreak, a nasal swabbing sample was tested for the presence of Influenzavirus nucleocapsid-antigens (Immunochromatographic test; BinaxNow Flu A & B, Binax, Portland, USA). This rapid assay revealed the presence of an Influenzavirus A respiratory infection five days after the beginning of the respiratory syndrome. This rapid viral diagnosis will be further confirmed in post mortem by the positive Influenza strain isolation onto lung tissues by classical cell culture techniques (Influenzavirus A strain, H3N2). Influenza pneumonia is a significant cause of morbidity and mortality, especially during influenza epidemics. The use of commercially available rapid diagnostic tests for influenza associated pneumonia, allows the potential use of new specific anti-neuraminidase drugs, which can be efficient during the 30 hours after the beginning of the clinical influenza syndrome.

[A fatal case of Herpes simplex virus meningoencephalitis in an immunocompetent adult]

Management of herpes simplex virus encephalitis (HSE) has been considerably improved by the development of rapid polymerase chain reaction (PCR) assays and by the use of intravenous acyclovir. However, an absence of early antiviral treatment has been associated to a poor outcome in patients with HSE. In the present report, we described the case of a 53 years-old adult immunompetent patient who was admitted to the emergency department of university medical center of Reims (France). At the time of hospitalisation, he was suffering from a febrile encephalitis syndrome evolving for more than 24 hours. A cerebrospinal fluid (CSF) puncture was performed demonstrating the presence of a lymphocytic meningitidis (42 leukocytes/mm3 which 90% of mononuclear cells; CSF protein = 1650 mg/L) associated with high levels of interferon alpha (75 UI/mL). Specific herpesvirus PCR and hybridisation assays (Herpes Consensus Hybridowell, Argene, France) were positive for the detection of HSV-1 genome on this CSF sample. Despite the intravenous acyclovir treatment (15 mg/kg/8 hours) delivered at the time of hospitalisation, this immunocompetent adult patient will dead 15 days later by a cardiorespiratory failure that was related to extensive HSE lesions. The time delay between the beginning of the clinical syndrome and the instauration of intravenous acyclovir treatment (more than 24 hours) was the only point susceptible to explain the presence of extensive CNS lesions in this patient. Specific Herpesvirus PCR detection assays are powerful tools that are actually used to establish a rapid etiological diagnosis of viral meningo-encephalitis. However, in patients demonstrating clinical signs of encephalitis associated with an aseptic CSF, it remains essential to urgently initiate a presumptive intravenous acyclovir treatment (10-15 mg/kg/8 hours). Actually, this medical practice is the only one susceptible to reduce the morbi-mortality rates linked to HSE.

Gemcitabine/vinorelbine in metastatic breast cancer patients previously treated with anthracyclines: results of a phase II trial

This phase II study was designed to evaluate the response rate (RR) and toxicity of gemcitabine/vinorelbine in patients with metastatic breast cancer. All patients had previously received anthracyclines. Treatment consisted of gemcitabine 1200 mg/m2 and vinorelbine 30 mg/m2 on days 1 and 8, every 3 weeks. Twenty-five patients were enrolled. Median age was 59 years (range, 33-73 years). Ten patients had received only adjuvant therapy with anthracyclines. The remaining 15 patients had received chemotherapy for metastatic disease, including taxanes in 11 cases. Four patients could not be evaluated for response. By intent-to-treat analysis, the overall RR was 44% (95% CI, 24.4%-65%). Median duration of response and median time to treatment failure were 21 and 17 weeks, respectively. The main toxicity was hematologic, with grade 3/4 neutropenia occurring in 13 patients and 1 patient developing febrile neutropenia. Two deaths from pneumonia occurred. These results reveal an encouraging activity with a reasonable toxicity profile in a patient population with an unfavorable prognosis. Our group is conducting a randomized study to compare this combination with vinorelbine alone in patients with metastatic breast cancer after failure to respond to anthracyclines and taxanes

AID-dependent somatic hypermutation occurs as a DNA single-strand event in the BL2 cell line

Immunoglobulin (Ig) gene hypermutation can be induced in the BL2 Burkitt's lymphoma cell line by IgM cross-linking and coculture with normal or transformed T helper clones. We describe here a T cell#150;independent in vitro induction assay, by which hypermutation is induced in BL2 cells through simultaneous aggregation of three surface receptors: IgM, CD19 and CD21. The mutations arise as a post-transcriptional event within 90 min. They are stably introduced in the G1 phase of the cell cycle, occurring in one of the two variable gene DNA strands, and eventually become fixed by replication in one of the daughter cells. Inactivation of AID (activation-induced cytidine deaminase) by homologous recombination in BL2 cells completely inhibits the process, thus validating this induction procedure as a model for the in vivo mechanism.

IL-12 secreting dendritic cells are required for optimum activation of human secondary lymphoid tissue T cells

Successful immunization requires that mature dendritic cells (mDCs) prime T cells in secondary lymphoid tissue (LT). Previously, the authors have shown that LT T cell activation has an increased costimulatory threshold for a proliferative response as compared with peripheral blood (PB) T cells. Therefore, to optimize mDC immunogenicity, DC maturation was studied using LT T cells as responders. While mDCs obtained with soluble CD40Ligand (sCD40L) or a sCD40L/IFNgamma combination similarly expressed the CD83 and CCR7 molecules on their membrane, only the latter secreted IL-12. sCD40L/IFNgamma mDCs, as compared with sCD40L mDCs, enhanced allogeneic LT T cell proliferation, LT CD4+ cell IFNgamma production and LT CD8+ cell cytotoxicity. Enhancement could be predominantly ascribed to IL-12 secreted by sCD40L/IFNgamma mDCs and to additional costimulatory signals as shown remarkably in the IFNgamma response when IL-12 was neutralized. Therefore, in addition to their membrane phenotype, mDCs to be used in immunization protocols should be assessed for IL-12 secretion as a surrogate marker for an optimum costimulatory potential.

Allogeneic peripheral blood stem cell transplantation with reduced-intensity conditioning: results of a prospective multicentre study

Reduced-intensity conditioning (RIC) regimens for allogeneic haematopoietic stem cell transplantation (SCT) have been shown to lead to engraftment of donor stem cells without the severe extra-haematological toxicities of traditional myeloablative transplants. Between December 1998 and December 2000, 76 patients underwent a RIC peripheral blood SCT in a prospective multicentre study. The median age was 53 years, and 57 patients were beyond the early phase of their disease. The conditioning regimens consisted of fludarabine (150 mg/m2) plus melphalan (140 mg/m2) or busulphan (10 mg/kg). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A plus short-course methotrexate. The preparative regimens were well tolerated. All patients experienced severe pancytopenia, but haematological recovery was prompt in all but two cases (early deaths). The 100-d probability of developing grade II-IV acute GVHD was 32% (10% grade III-IV), and the 1-year probability of developing chronic extensive GVHD was 43%. Early complete donor chimaerism was observed in 52/68 patients, and 16 evaluable patients were in complete chimaerism 1 year post transplant. With a median follow-up of 283 d (355 in 48 survivors), the 1-year probability of transplant-related mortality was 20%, and the 1-year overall and progression-free survivals were 60% and 55% respectively. In conclusion, RIC regimens lead to low early toxicity after allografting, with stable donor haematopoietic engraftment, with an apparent low risk of acute GVHD. Chronic GVHD, however, develops in a significant proportion of patients.

Tween-20 activates and solubilizes the mitochondrial membrane-bound, calmodulin dependent NAD+ finase of Avena sativa L

Among different treatments assayed, a mix of a nonionic detergent (5% Tween-20) with 0.5 m NaCl was found to solubilize a large part of the calmodulin-dependent NAD+ kinase bound to the inner mitochondrial membrane. It also stimulated its activity by increasing 7 times the maximal velocity. Activity stimulation was also observed with phosphatidylcholine, phosphatidylethanolamine and with reductants (HSO3 and DTT). This solubilized NAD+ kinase and the calmodulin-dependent cytosoluble isoform displayed distinct molecular masses, as well as different kinetic parameters. We propose that solubilization of membrane-bound NAD+ kinase could occur in vivo in Avena sativa and could generate a soluble isoform.

Shear-induced first-order sponge-to-lamellar transition in a lyotropic surfactant system

We report a shear-induced sponge (L3) to lamellar (L(alpha)) transition in a surfactant system. Under a constant shear rate, after a delay time t(n) we observe random nucleation and subsequent growth of the L(alpha) phase, demonstrating that the shear-induced transition is first order. A simple argument for the energy of a two-dimensional nucleus accounts for the observed delay and its shear-rate dependence.

[Peripheral stem cell collection, search for predictive factors: a multicenter study. Working Group on Transfusion and Therapeutic Techniques of the French Blood Transfusion Society ]

AIMS

A multicentric study involving 12 centers was made to investigate the results of peripheral stem cell collection carried out between 1996 and 1997 from 655 patients with hemopathic syndromes or malignant tumors, The aim of this investigation was to determine the predictive factors for transplant quality, and to thereby optimize collection procedures.

PATIENTS AND METHODS

Information sheets were completed for 1,346 cytapheretic sessions, i.e., 655 grafts. The samples were taken after induction chemotherapy and exposure to hematopoeitic colony-stimulating growth factors (except the LMCs). Each graft was defined as being of good or bad quality depending on the number of CD34+ cells that it contained. Based on the data available in the literature, a workgroup consensus was reached that a level of CD34+ cells +/- 2.10(6)/kg recipient body weight constituted a good transplant criterion. The 2 subgroups (good graft versus lower quality graft) were compared by univariate analysis followed by discriminant multivariate analysis.

RESULTS

It was established that a number of parameters were significantly linked to the criterion of collection quality; however, 3 predictive factors emerged from the multivariate analysis--the level of circulating CD34+ cells; the number of cytaphereses; the number of blood volumes treated.

CONCLUSION

It was concluded that the level of circulating CD34+ cells seems to be an essential aspect in predicting the quality of the transplant and the number of cytaphereses required to obtain a sufficiently rich collection. Moreover, it also appears that at least 2 blood volumes should be treated to optimize the results.

Adenoviral transduction of human 'clinical grade' immature dendritic cells enhances costimulatory molecule expression and T-cell stimulatory capacity

The therapeutic use of dendritic cells (DC) in antigen-specific anti-tumor vaccines, requires sufficient numbers of functional DC, the preparation of which should comply with the code of Good Manufacturing Practice. In addition, the expression of tumor specific antigen should be possible in these DC. As a preclinical step, the method reported here was developed in healthy volunteers. Monocytes (Mo) were isolated by leukapheresis from 12 donors, purified by elutriation and then cultured for 6 days in sealed bags in AIM-V serum free medium with granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-13 (IL-13). Between 6x10(8) and 1x10(9) immature DC (iDC) could be differentiated from one leukapheresis. Cells displayed a characteristic iDC phenotype (CD1a(+), CD14(-), CD80(+), CD86(+), HLA DR(+), CD83(-)), and had potent allogeneic and antigen dependent autologous T cell-stimulatory capacity. Moreover, iDC could be further differentiated into mature DC by CD40 ligation as assessed by CD83 expression and the upregulation of HLA-DR and costimulatory molecules. After infection with a recombinant adenovirus encoding for beta-galactosidase (betaGal), 50% to 80% of iDC expressed betaGal without toxicity. Adenovirus infection increased the expression of both costimulatory molecules and CD83, and also increased allogeneic stimulatory capacity. Thus, the method developed here allows us to use large numbers of functional iDC as will be required for therapeutic uses in man. These DC can express a transgenic protein.

Fas-mediated apoptosis of mouse embryo stem cells: its role during embryonic development

PROBLEM

Fas antigen (APO-1/CD95) can regulate the activity of various cells during adulthood. This study aimed at determining whether Fas may also be involved in the regulation of very early events such as the embryo preimplantation stage.

METHOD OF STUDY

We used mouse embryo stem (ES) cell line as a model for testing the effect of Fas crosslinking upon anti-Fas monoclonal antibody (MoAb) treatment. In addition, this treatment was also applied to in-vitro mouse-embryo culture.

RESULTS

Flow-cytometry analysis of cultured ES cells demonstrated an increase in Fas expression. unchanged in the presence of mouse interleukin-2, while greatly upregulated in the presence of lipopolysaccharide (LPS). As determined by various means, ES cells may undergo a Fas-mediated apoptosis, slightly but significantly intensified by the addition of LPS to cell cultures. We also report that anti-Fas MoAb directly inhibited two-cell stage mouse-embryo (preimplantation) development in in-vitro culture conditions.

CONCLUSION

These data suggest a novel mechanism controlling the regulation of physiological cell turnover as well as blastocyst implantation in early embryo development.

[Blood volume changes caused by position under general anesthesia]

The cardiovascular changes in response to general anaesthesia are related to several interacting mechanisms. In addition to the intrinsic effects of anaesthetic agents on the heart and vessels which depress the physiological mechanisms of adaptation, the additive independent effects of posture and mechanical ventilation on intravascular blood volume have to be considered. Physiopathologic studies show that the ultimate related mechanism is the decrease of venous return to the heart. The major effect of posture is the change in the distribution of the blood volume, as the posture modifies the influence of gravity in addition to direct vascular compression and stretching. The deterioration of the cardiac venous return results in dramatic or insidious clinical consequences which lead finally to a low cardiac output. As cardiac function is not a limiting factor of output, any decrease of blood pressure in a patient with a healthy heart must be considered as an hypovolaemic state due to an abnormal contents to container ratio, and must be managed as such.

[Bilateral sciatica: a predictive sign of extradural hematoma after lumbar disk herniation]

The authors analyse five cases, in order to recognize a sensitive early clinical feature of extradural haematoma following lumbar diskectomy. Neither time delay (time from surgery to the suspicion of the diagnosis) nor pain intensity (a subjective factor which might be obtunded by an analgesic drug) are valuable features. The only reliable predictive sign is bilateral sciatica, which occurred in all cases, before the diagnosis was confirmed by a sensitive and motor deficit in the lower limbs.

[Characterization of specific IgG, IgM, IgA and IgE isotypes in profound candidiasis]

Enzyme-linked immunofiltration assay technique (Elisa) has been applied to the characterization of G, M, A and E anti-Candida antibodies isotypes specific to cell wall mannans in 201 sera from 126 patients. These sera were studied at the same time using Co-immunoelectrodiffusion and indirect immunofluorescence. In 18 of 21 patients with systemic candidiasis, Elisa demonstrated the presence of antimannan IgG antibodies in sera contemporary of Candida positive blood culture. These IgG were associated with antimannan IgM, A and E in 15 patients. In 37 patients colonized with Candida, used as negative controls, antimannan IgG were detected in 3 cases, and in 2 were associated with specific IgMs. The sensitivity and specificity of Elisa IgM and IgA in the diagnosis of systemic Candidiasis were 85.7% and 81%, respectively. The kinetic study shows that the different isotypes appeared most of the time simultaneously. The evolution of the 4 isotypes beyond the acute episode was variable and without correlation with the clinical status. The decrease of IgG was slower than the one of IgM, IgA or IgE. The systematic research, in at risk patients, of antimannan antibodies using Elisa required simple technology. A simple method should allow to aim at other functional antigens which could be used in a quantitative manner to determine the efficacy of the medical treatment.

[Problems posed by spinal anesthesia in a patient with Gélineau disease]

A 44-year-old patient, with narcolepsy-cataplexy, underwent surgery for lumbar disk hernia under spinal anaesthesia. Our purpose was to prevent an interaction between the patient's disease and general anaesthetic agents with the risk of postoperative hypersomnia. During surgical procedure, two narcolepsy fits occurred, without clinical consequences. The postoperative course was uneventful. However, spinal anaesthesia cannot be considered as a technique of choice because of the risk of narcolepsy-cataplexy fits with loss of consciousness and atonia, during regional anaesthesia. General anaesthesia seems to be the best choice for these patients cholinergic agents and mainly the alpha1 adrenergic blocking drugs are contra-indicated as they increase the risk of narcolepsy-cataplexy fits. Anaesthetic sleep, narcolepsy, cataplexy and epilepsy are clinically rather similar. The EEG does not allow to differentiate between narcolepsy and anaesthetic-sleep, whereas cataplexy and epilepsy result in specific EEG patterns.

Corticosteroids plus pulse cyclophosphamide and plasma exchanges versus corticosteroids plus pulse cyclophosphamide alone in the treatment of polyarteritis nodosa and Churg-Strauss syndrome patients with factors predicting poor prognosis. A prospective, randomized trial in sixty-two patients

OBJECTIVE

To define the most effective treatment for severe polyarteritis nodosa (PAN) and Churg-Strauss syndrome (CSS) and to investigate the indication for plasma exchange treatment.

METHODS

We conducted a prospective, randomized, multicenter trial in which 62 patients were randomly assigned to receive either prednisone plus cyclophosphamide (intravenous bolus) (group A; n = 28) or prednisone plus cyclophosphamide (intravenous bolus) plus plasma exchanges (group B; n = 34) as first-line treatment for severe PAN or CSS. Factors predicting poor prognosis were renal symptoms, gastrointestinal tract involvement, cardiomyopathy, central nervous system involvement, weight loss > 10% of body weight, and age > 50 years old. Patients with hepatitis B virus-related PAN were not included in this study. The end point of the study was control of the disease (recovery or remission) or death.

RESULTS

Clinical symptoms and laboratory findings did not differ significantly in the 2 groups. Initial control of the disease was similar in both groups. Relapse after initial control of the disease was observed in 7 patients (4 in group A and 3 in group B). The mean +/- SD followup period was 31.1 +/- 20 months for group A and 35.9 +/- 16.8 months for group B. At 5 years of followup, 38 patients (61.3%) were cured (16 in group A and 22 in group B), and 5 (8.1%) were in remission without treatment but had not yet completed the cure-defining period of 18 months (3 in group A and 2 in group B). Eight (12.9%) (2 in group A and 2 in group B) were considered to be in clinical remission and required a maintenance regimen of low-dose corticosteroids. Eleven patients died during the study period (7 in group A [25%], 4 in group B [11.8%]). Uncontrolled vasculitis was responsible for 4 deaths (2 in each group), and treatment side effects caused the death of 1 patient in group A. There was no significant difference between the 5-year cumulative survival rates of the 2 groups (75% and 88%, respectively).

CONCLUSION

Based on our data, combined treatment with prednisone, cyclophosphamide, and plasma exchanges is not superior to treatment with prednisone and cyclophosphamide alone, and plasma exchanges should not be systematically proposed for initial treatment of severe PAN or CSS.

Pharmacokinetics of ceftriaxone during plasma exchange in polyarteritis nodosa patients

Plasma exchange (PE) is currently being used to treat a variety of disorders involving immune complexes, such as polyarteritis nodosa. This procedure removes endogenous toxic components that accumulate in patients with this disease, but it also removes drugs. Plasma-protein binding and the volume of distribution (V) are two kinetic parameters which strongly affect the efficiency of drug removal by PE. Drugs that are highly bound to plasma proteins and have a low V may show a marked decrease in plasma levels as a result of PE. Because ceftriaxone exhibits saturable plasma-protein binding, which influences its pharmacokinetic parameters, particularly its V, we evaluated its removal during PE therapy in this nonrandomized crossover study. Twelve polyarteritis nodosa patients undergoing PE were studied. Each patient was given ceftriaxone intravenously in doses of 1 and 3 g on days 4 and 11, respectively, immediately before (n = six patients; group I) and 6 h before (n = six patients; group II) PE. Plasma was assayed for ceftriaxone by high-pressure liquid chromatography. The mean amounts eliminated +/- standard deviations were 230.8 +/- 38.5 mg (1 g) and 750.0 +/- 168.5 mg (3 g) for group I and 161.0 +/- 66.0 mg (1 g) and 347.0 +/- 121.0 mg (3 g) for group II. The drug fractions eliminated by PE were 23.0% +/- 3.9% (1-g dose) and 24.9% +/- 5.6% (3-g dose) for group I (P > 0.05), and 16.6% +/- 5.9% (1-g dose) and 11.5% +/- 4.0% (3-g dose) for group II (P < 0.05). These results showed that the drug fraction eliminated decreased when V increased only when the distribution phase of ceftriaxone had been completed (group II). These findings suggest that PE may influence ceftriaxone disposition and that it would be better to administer the drug after PE to assure its therapeutic efficacy.

[Synchronization of plasma exchange and cyclophosphamide in severe systemic diseases. A consecutive study of 10 patients]

Ten patients with severe systemic diseases, including systemic lupus erythematosus (n = 2), polymyositis (n = 2), essential mixed cryoglobulinaemia (n = 2), rheumatoid arthritis vasculitis (n = 3) and Wegener's granulomatosis (n = 1), were treated with 3 consecutive plasma exchanges synchronized with pulse cyclophosphamide. This therapeutic regimen was applied every 4 weeks initially and thereafter every 6 weeks in case of positive response after the first 3 cycles; it was combined in all patients with corticosteroid therapy. The treatment was administered for severe flare-up of the disease in 7 patients and for failure of previous treatments, including corticosteroids, cyclophosphamide and plasmapheresis, in 3 patients. Three kinds of response were observed: lasting complete remission without relapse after synchronization had ceased in 4 patients, partial clinical remission with post-synchronization relapse in 5 patients, and primary failure without any clinical response to treatment in only 1 patient. These results suggest that repeated plasma exchanges synchronized with cyclophosphamide are effective against progressive autoimmune diseases and in cases where conventionally administered immunosuppressive treatments had failed. However, this type of treatment cannot prevent long-term relapses, and only a prospective study can evaluate its success in terms of survival.

Endotoxin-induced tissue factor messenger RNA in human monocytes is negatively regulated by a cyclic AMP-dependent mechanism

Tissue factor (TF) is a transmembrane receptor that serves as the major cofactor for factor VIIa-catalyzed proteolytic activation of factors IX and X. In response to bacterial lipopolysaccharide (LPS), monocytes transcribe, synthesize, and express TF on their surface, thereby conveying to activated monocytes the ability to initiate the blood coagulation protease cascades. Agents that elevate cellular cyclic AMP (cAMP) inhibit the functional expression of TF by LPS-stimulated monocytes. In this study, we investigated the mechanism of this suppression. Northern blot analysis of total RNA from LPS-stimulated monocytes showed a concentration-dependent decrease in TF messenger RNA (mRNA) levels in response to dibutyryl-cAMP (dBt-cAMP). TF mRNA and procoagulant activity were inhibited as early as 1 hour after the addition of dBt-cAMP and the inhibition persisted through 4 hours. Suppression of specific mRNA abundance was also observed with agents, including forskolin and iso-butyl-methyl-xanthine (IBMX), that increase cAMP levels by independent mechanisms. Flow immunocytometric analysis confirmed that cell-surface TF protein levels declined in parallel with TF functional activity. The rate of decay of TF mRNA after the arrest of transcription by actinomycin D was not altered by the addition of dBt-cAMP, IBMX, or forskolin, thus excluding effects on TF mRNA stability. We conclude that elevated cAMP levels suppress TF mRNA by reducing the rate of TF gene transcription.

[Intraoperative posture in the surgery of lumbar disk hernia]

For surgery of the lumbar disc, with a posterior route, the patient is placed either in a prone, or a knee-chest, or a lateral position. They aim at facilitating the surgical access in decreasing local bleeding and collapsing the dural sheath. This benefit, as a result of the maintenance of the pressure in the epidural venous system at a low level, is obtained through the absence of any abdominal compression as well as the posture. In the prone position, the abdominal compression and the increase of the physiologic lordosis impair the systemic venous return and carry the risk of cardiac arrest. In addition to these adverse effects, the conventional knee-chest position increases the haemodynamic repercussions in modifying the distribution of blood volume and increasing the potential risk of mediastinal compression and air embolism. The lateral position generates only minor haemodynamic modifications, except in the obese. However it is difficult to stabilize the patients' position and to maintain the alignment of the spine. Therefore it is used the less one. The postural risks of all three positions are numerous and include mainly the compression of nerves, vessels and skin. Finally the selection of the position depends basically on morphological criteria and the adaptative capacities of the patient. The optimal position is the one offering a low pressure level in the spinal venous system, while maintaining the venous return.

Pharmacokinetics of vidarabine in the treatment of polyarteritis nodosa

The pharmacokinetics of vidarabine were studied in 8 patients with polyarteritis nodosa related to hepatitis B virus infection. The drug was administered by continuous infusion for three weeks at doses of 15 (1 week) and 7.5 (2 weeks) mg/kg per day, during which time 15 plasma exchanges were performed. Plasma was assayed for vidarabine and its principal metabolite, hypoxanthine arabinoside by high pressure liquid chromatography. Vidarabine was not detected in the plasma of any patients. Hypoxanthine arabinoside levels were used to evaluate vidarabine kinetics. The serum levels of hypoxanthine arabinoside ranged from 3.6 to 21.5 mg/l. The mean elimination half-life (+/- SD) was 3.0 +/- 1.7 h. The plasma clearance (mean +/- SD) was 195 +/- 270 ml/min when the dose was 7.5 mg/kg per day and 66.3 +/- 47 ml/min for a 15 mg/kg per day/dose (NS). Except for the elimination half-life, these results were not fully consistent with those observed in other studies. The influence of multiple plasma exchanges on vidarabine kinetics is limited and dosage adjustment is not required based on the continuous infusion of vidarabine.

[Value and limitations of anti-mannan antibodies research by co-immunoelectrodiffusion in the diagnosis of deep candidiasis]

Several groups have evaluated detection of antibodies against Candida, with somewhat conflicting results. In this study, co-counterimmunoelectrodiffusion was used to detect antimannan antibodies specific of components of the Candida membrane. Study patients were divided into two groups according to whether their history for Candida infection was negative (population A, n = 102) or positive (population B). Different antigen levels were used in order to differentiate low and high antimannan antibody levels. Among the 102 sera in population A, 42 were positive for antimannan antibodies; the antimannan antibody titer was low in 40 cases and high in 2 cases. In population B (53 patients), antimannan antibodies were found in 97 of the 98 sera studied; titers were high in 95 cases. Use of an antigen level that detects only high titers of antimannan antibodies thus provides a sensitive and specific tool for the diagnosis of deep candidiasis. The simplicity and rapidity of this test are particularly valuable in situations where emergency treatment is needed.

[Periarteritis nodosa related to hepatitis B virus. Determination of a new therapeutic strategy: 13 cases]

The treatment and prognosis of periarteritis nodosa associated with hepatitis B virus were reconsidered from a series of 13 patients representing 32.5 per cent of the 40 patients with periarteritis nodosa admitted during the same period. HBs and HBe antigens were present in every case, and hepatitis B virus replication was demonstrated by the finding of viral DNA in serum. One patient had anti-HBc IgM's. Five patients were treated with corticosteroids, cyclophosphamide and occasional plasma exchanges. All were cured or achieved complete remission. Eight patients were treated with plasma exchanges and vidarabine, either as first-line therapy (3 cases) or after failure of corticosteroids and/or immunosuppressants (5 cases). This treatment was clinically effective in 5/8 cases, including 3 with seroconversion. The 2 patients in whom the combined treatment failed were given corticosteroids; one of them also had plasma exchanges. The 8th patient died after a few days of treatment. Eleven of the 13 patients are still alive and either cured or in complete remission. Two patients who developed severe chronic hepatitis after steroids were discontinued received vidarabine alone: arrest of viral replication was obtained in both cases, with emergence of an anti-HBe (but not anti-HBs) antibody. The overall positive virological response rate to vidarabine alone or combined with plasma exchanges was 50 per cent. When vidarabine was prescribed as treatment of acute periarteritis nodosa (the 2 cases where it was used for chronic hepatitis being excluded), this response rate was 37.5 per cent. This, in patients with periarteritis nodosa associated with hepatitis B virus immunosuppressive drugs should be withdrawn and replaced by plasma exchanges and antiviral agents. This would be the first-line treatment to be replaced by corticosteroid therapy if it fails.

[Effects of enflurane and halothane on hepatic function in biliary surgery]

The effects of two volatile anaesthetics on hepatic function are compared in 80 patients in hepato-biliary surgery. 40 patients were anaesthetized either with enflurane or halothane. This study is based on the variations of blood levels of gamma GT, bilirubin, SGOT SGPT, alkaline phosphatase, L.D.H. Samples were taken the day prior to the operation, one, two and five days afterwards. The results show an increase in the levels of BD, SGPT, LDH no 5, less important with enflurane than with halothane, and mainly in patients with preoperative hepatic abnormalities. Enflurane appears to be preferable in such cases.