Closed-Loop Insulin Delivery May Help Prevent Metabolic Complications During Bariatric Surgery in Patients with Type 1 Diabetes: A Case Report

Introduction: Obesity in patients with type 1 diabetes (T1D) may worsen their prognosis. Bariatric surgery in these patients can be associated with complications such as diabetic ketoacidosis and severe hypoglycemic episodes. Closed-loop insulin delivery could be a solution to avoid them. Case Report: A 45-year-old woman with T1D and obesity (body mass index of 38.4 kg/m2) was included in our preoperative course of bariatric surgery. Three months before surgery, a closed-loop insulin delivery was instituted due to one prior severe hypoglycemia. Patient did not have immediate or late postoperative hypoglycemia despite consuming a weak amount of carbohydrate. Three months after surgery glycemic control was on target with 86% of time in range 70-180 mg/dL and no time below 70 mg/dL. Conclusion: This case report shows that the use of a closed-loop insulin delivery made it possible to perform bariatric surgery in complete safety for our patient.

Pneumocystis pneumonia in patients with Cushing's syndrome: A French multicenter retrospective study

OBJECTIVE

Pneumocystis pneumonia (PcP) is an opportunistic infection occurring in immunocompromised patients. Cushing's syndrome (CS) impairs the immune system, and several authors have reported PcP in patients with CS. The present study aimed to characterize PcP occurring in a CS context and its management in French tertiary centers, in order to highlight the similarities in clinical presentation and treatment according to whether prophylaxis is implemented or not.

METHODS

This was a multicenter retrospective study conducted in several French University Hospitals and Cancer Centers. Patients with PcP and confirmed CS regardless of etiology were included. We excluded patients with other known causes of acquired immunodeficiency with increased risk of PcP.

RESULTS

Twenty-five patients were included. CS etiology was neoplastic in 84.0% of cases. CS clinical presentation associated predominant catabolic signs (76.0%), hypokalemia (91.7%) and lymphopenia (89.5%). CS was intense in most patients, with mean plasma cortisol levels at diagnosis of 2.424±1.102nmol/L and urinary free cortisol>10× the upper limit of normal in 85.0%. In all patients, PcP onset followed introduction of cortisol blockers, at a median 5.5 days. Patients were treated with 1 to 3 cortisol blockers, mainly metyrapone (88%), which significatively lowered plasma cortisol levels to 667±541nmol/L at the onset of PcP (P<0.001). PcP occurred in 7 patients despite prophylaxis. Finally, 60.0% patients were admitted to intensive care, and 20.0% died of PcP.

CONCLUSION

High mortality in patients with PcP implies that clinicians should be better informed about this rare infectious complication. Prophylaxis remains controversial, requiring comparative studies.

Controversies about the systematic preoperative pharmacological treatment before pheochromocytoma or paraganglioma surgery

The question of systematic use of a pharmacological treatment before surgery in patients diagnosed with pheochromocytoma and paraganglioma (PPGL) remains highly controversial. While recent guidelines suggest that this should be used in all patients, some experienced teams consider it unnecessary in some cases, provided the surgery is performed in a dedicated center that has expert endocrinologists, cardiologists, surgeons, and anesthetists. This controversy is aimed at shedding light on the potential benefits and risks of such a treatment, focusing specifically on alpha blockers which are considered as the first-line medical treatments in patients with PPGL. After discussing the rationale for alpha blockers, hemodynamic instability, tolerance, and acute cardiac complications will then be discussed in the first part of the manuscript, defending a systematic use. The second section will focus on blood pressure control, tolerance of alpha blockers, and also the management of normotensive PPGL, examining the daily risks of PPGL and arguing against the systematic use of a preoperative pharmacological treatment before surgery. Finally, we will discuss the concept of expert centers and define the patients in whom the risk/benefit profile would favor the use of this preoperative treatment.

Acute Stress Cardiomyopathy: Heart of pheochromocytoma

Stress cardiomyopathy (SCM) is a syndrome characterized by transient regional systolic dysfunction of the left ventricle in the absence of angiographic evidence of coronaropathy. This abnormality is associated with high levels of catecholamines. Stress cardiomyopathy is also called Takotsubo (TS) cardiomyopathy. Pheochromocytoma crisis can occur spontaneously or can be precipitated by manipulation of the tumor, trauma, certain medications or stress for example during non-adrenal surgery. The main drugs leading to pheochromocytoma crisis include D2 dopamine receptor antagonists, noncardioselective β-adrenergic receptor blockers, tricyclic antidepressants and related neurotransmitter uptake blockers, sympathomimetics, certain peptide and steroid hormones and several agents used during induction of anesthesia. Patients can develop symptoms of heart failure associated with tachyarrhythmia, cardiogenic shock with hypotension and collapse, or apparent acute coronary syndromes. This review describes pathophysiology, epidemiology, diagnosis criteria and management of SCM.

Six-Month Results of Treatment-Blinded Medication Titration for Hypertension Control After Randomization to Endovascular Ultrasound Renal Denervation or a Sham Procedure in the RADIANCE-HTN SOLO Trial

BACKGROUND

The multicenter, international, randomized, blinded, sham-controlled RADIANCE-HTN SOLO trial (A Study of the ReCor Medical Paradise System in Clinical Hypertension) demonstrated a 6.3 mm Hg greater reduction in daytime ambulatory systolic blood pressure (BP) at 2 months by endovascular ultrasound renal denervation (RDN) compared with a sham procedure among patients not treated with antihypertensive medications. We report 6-month results after the addition of a recommended standardized stepped-care antihypertensive treatment to the randomized endovascular procedure under continued blinding to initial treatment.

METHODS

Patients with a daytime ambulatory BP ≥135/85 mm Hg and <170/105 mm Hg after a 4-week discontinuation of up to 2 antihypertensive medications, and a suitable renal artery anatomy, were randomized to RDN (n=74) or sham (n=72). Patients were to remain off antihypertensive medications throughout the first 2 months of follow-up unless safety BP criteria were exceeded. Between 2 and 5 months, if monthly measured home BP was ≥135/85 mm Hg, a standardized stepped-care antihypertensive treatment was recommended consisting of the sequential addition of amlodipine (5 mg/d), a standard dose of an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and hydrochlorothiazide (12.5 mg/d), followed by the sequential uptitration of hydrochlorothiazide (25 mg/d) and amlodipine (10 mg/d). Outcomes included the 6-month (1) change in daytime ambulatory systolic BP adjusted for medications and baseline systolic BP, (2) medication burden, and (3) safety.

RESULTS

A total of 69/74 RDN patients and 71/72 sham patients completed the 6-month ambulatory BP measurement. At 6 months, 65.2% of patients in the RDN group were treated with the standardized stepped-care antihypertensive treatment versus 84.5% in the sham group (P=0.008), and the average number of antihypertensive medications and defined daily dose were less in the RDN group than in the sham group (0.9±0.9 versus 1.3±0.9, P=0.010 and 1.4±1.5 versus 2.0±1.8, P=0.018; respectively). Despite less intensive standardized stepped-care antihypertensive treatment, RDN reduced daytime ambulatory systolic BP to a greater extent than sham (-18.1±12.2 versus -15.6±13.2 mm Hg, respectively; difference adjusted for baseline BP and number of medications: -4.3 mm Hg, 95% confidence interval, -7.9 to -0.6, P=0.024). There were no major adverse events in either group through 6 months.

CONCLUSIONS

The BP-lowering effect of endovascular ultrasound RDN was maintained at 6 months with less prescribed antihypertensive medications compared with a sham control.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov. Unique identifier: NCT02649426.

SAT-012 Urinary Aldosterone Assay Using LC-MS/MS Could Improve Primary Aldosteronism Screening

Primary aldosteronism (PA) is the first cause of endocrine hypertension accounting for about 6% of all cases of hypertension. According to international guidelines, PA screening is based on plasma aldosterone-to-renin concentration ratio (ARR) computation. Nevertheless, measurement of urine aldosterone excretion may be of interest since it integrates aldosterone secretion over 24 hours. However, available urine aldosterone immuno-assays have poor specificity. In this context, we developed a new aldosterone assay using liquid chromatography and tandem mass spectrometry detection (LC-MS/MS) to recover specifically urine free aldosterone and glucuronide metabolites after 18-hour acid hydrolysis. Our method was validated according to FDA recommendations, and covers the expected range of aldosterone concentrations found in 24-hour urine collection (from 1.10 to 75 nM) with improved specificity. It has a within-run precision below 2% and a maximum between-run precision of 5.6%. The diagnostic performance of the assay was assessed in a cross-sectional retrospective study that included 234 subjects: 63 healthy volunteers (HV), 107 patients with essential hypertension (EH) and 64 PA patients. Final diagnosis was based on routine hormone measurements in accordance with international guidelines. Median (5^th to 95^th percentile) of 24-hour urine aldosterone excretion was 19.5 (5.2-53.4) nmol/24h in HV, 39.1 (13.3-97.4) nmol/24h in EH and 91.4 (40.6-225.3) nmol/24h in PA subjects. By ROC curve analysis (area 0.864), a cutoff value of aldosterone excretion of 65 nmol/24h yielded a 76.6% sensitivity and 78.5% specificity to discriminate PA from EH patients. 24-hour urinary aldosterone:creatinine ratio was more discriminant than 24-hour aldosterone excretion, with ratios (nmol/mmol) of 1.42 (0.5-3.9) for HV, 3.4 (1.3-7.9) for EH and 6.9 (2.5-30.0) for PA. By ROC curve analysis (area 0.867) a cutoff value of 24-hour urinary aldosterone:creatinine ratio of 5.0 nmol/mmol had 81.3% sensitivity and 81.3% specificity to discriminate PA from EH patients. Finally, 11% of our 64 PA patients showed a urinary aldosterone:creatinine ratio above this suggested cutoff value while ARR was below cut-off value. In conclusion, LC-MS/MS measurement of urinary aldosterone is a specific, sensitive and effective method for the diagnosis of PA.

Diabetes, Associated Clinical Spectrum, Long-term Prognosis, and Genotype/Phenotype Correlations in 201 Adult Patients With Hepatocyte Nuclear Factor 1B (HNF1B) Molecular Defects

OBJECTIVE

Molecular defects of hepatocyte nuclear factor 1B (HNF1B) are associated with a multiorgan disease, including diabetes (maturity-onset diabetes of the young 5) and kidney abnormalities. The HNF1B syndrome is related to HNF1B mutations or to a 17q12 deletion spanning 15 genes, including HNF1B. Here, we described HNF1B-related diabetes and associated phenotypes and assessed genotype/phenotype correlations at diagnosis and in the long-term.

RESEARCH DESIGN AND METHODS

This multicenter retrospective cohort study included 201 patients, aged 18 years or older at follow-up, with HNF1B mutations (n = 101) or deletion (n = 100).

RESULTS

Diabetes was present in 159 patients. At diagnosis, clinical symptoms of diabetes were present in 67 of 144 patients and HNF1B renal disease in 64 of 102. Although responsiveness to sulfonylureas/repaglinide was observed in 29 of the 51 tested, 111 of 140 patients (79%) were treated with insulin at follow-up. Diabetic retinopathy and/or neuropathy were present in 46 of 114 patients. Renal cysts were present in 122 of 166 patients, chronic kidney disease stages 3-4 (CKD3-4) in 75 of 169 (44%), and end-stage renal disease (ESRD) in 36 of 169 (21%). Compared with the patients with mutations, those with HNF1B deletion less often had CKD3-4/ESRD at diagnosis (11 of 43 vs. 27 of 35, P < 10^-4) and in the long term (40 of 78 vs. 71 of 91, P = 0.0003). They were leaner and more frequently treated with insulin.

CONCLUSIONS

In patients with HNF1B syndrome, diabetes complications, cardiovascular risk factors, CKD3-4, and ESRD are highly prevalent. At diabetes diagnosis, the presence of morphological and/or functional kidney disease may help etiological diagnosis. Genotype/phenotype correlations may have implications for the care and the prognosis of these patients.

Suppression of Aldosterone Secretion After Recumbent Saline Infusion Does Not Exclude Lateralized Primary Aldosteronism

Guidelines recommend suppression tests such as the saline infusion test (SIT) to ascertain the diagnosis of primary aldosteronism (PA) in patients with a high aldosterone:renin ratio. However, suppression tests have only been evaluated in small retrospective series, and some experts consider that they are not helpful for the diagnosis of PA. In this study, we evaluated whether low post-SIT aldosterone concentrations do exclude lateralized PA. Between February 2009 and December 2013, 199 patients diagnosed with PA on the basis of 2 elevated aldosterone:renin ratio results and a high basal plasma or urinary aldosterone level or high post-SIT aldosterone level had a selective adrenal venous sampling. We used a selectivity index of 2 and a lateralization index of 4 to interpret the adrenal venous sampling results. Baseline characteristics of the patients were the following (percent or median): men 63%, 48 years old, office blood pressure 142/88 mm Hg, serum potassium 3.4 mmol/L, aldosterone:renin ratio 113 pmol/mU, plasma aldosterone concentration 588 pmol/L. The proportion of patients with lateralized adrenal venous sampling was 12 of 41 (29%) among those with post-SIT aldosterone <139 pmol/L (5 ng/dL) and 38 of 104 (37%) among those with post-SIT aldosterone <277 pmol/L (10 ng/dL). Post-SIT aldosterone levels were not associated with the blood pressure outcome of adrenalectomy. A low post-SIT aldosterone level cannot rule out lateralized PA, even with a low threshold (139 pmol/L). Adrenal venous sampling should be considered for patients who are eligible for surgery with elevated basal aldosterone levels even if they have low aldosterone concentrations after recumbent saline suppression testing.

Tumour necrosis factor-alpha (TNFalpha) stimulates the growth of human bone marrow stromal cells

This study reports that TNF-alpha is a potent mitogen for human bone marrow sternal cells in vitro (assessed by [(3)H]-thymidine incorporation into DNA and cell counts). In contrast, cytokines such as IL-1alpha, IL-1beta, IL-2, IL-3, IL-4, IL-6, LIF, SCF, M-CSF, G-CSF and GM-CSF had no effect. The effect of TNF-alpha on the growth of human bone marrow stromal cells could be of importance during inflammatory processes which take place in the marrow, for example marrow fibrosis.

[Cryopreserved amniotic membranes use in resistant vascular ulcers]

BACKGROUND AND OBJECTIVE

Amniotic membranes are used with success in ophthalmology to treat corneal wounds and ulcers. In this pilot study, we attempt to assess the tolerance of amniotic membranes in the management of resistant venous and/or arterial vascular ulcers.

MATERIAL AND METHODS

We prospectively included 8 patients, 7 males and 1 female, mean age 69.5+/- 9.6 years, with venous and/or arterial ulcers resistant after 6 months with usual medical care and/or after revascularisation failure. Amniotic membranes were applied on a weekly basis with the fetal side on the ulcer, covered by a secondary bandage. The primary end-point was evaluation of tolerance of amniotic membranes on vascular ulcers. The secondary end-points were a >50% reduction of ulcer's area, a significant (P< or =0.05) improvement of pain visual scale score and the quality of life assessed by the SF-36 questionnaire.

RESULTS

Tolerance was excellent in all cases. We observed no adverse effect. We observed complete healing at weeks 19 and 26 for 2 patients and a >50% reduction of ulcer area at weeks 26, 31 and 32 for 3 patients. A sixth patient had an ulcer area reduction <50% and the 2 remaining showed no improvement. A significant improvement was noticed for visual pain scale and the health feeling dimension in the SF-36 questionnaire. No adverse effect or amputation requirement was noted.

CONCLUSION

These preliminary results are encouraging and require a larger confirmatory study. Further studies are required to clarify the action mode of this therapeutic option.

Carotid intima-media thickness as predictor of secondary events after coronary angioplasty

AIM

Subjects with symptomatic or asymptomatic peripheral arterial or cerebro-vascular disease have an increased risk of death or cardiovascular event. The aim of this study was to determine whether intima-media thickening of the common carotid artery and/or a low ankle brachial index (ABI) are related with an increased risk of cardio-vascular event after percutaneous coronary angioplasty (PTCA).

METHODS

One hundred and thirteen consecutive, patients (88 males, 25 females, mean age: 62 years) undergoing PTCA were included. Intima media thickness (IMT) of the common carotid artery and ABI were measured within the 2 days following the PTCA. Subjects were followed up for 10.2 +/- 4 months. The end-point was a composite criterion associating death, non fatal acute myocardial infarction, recurrence or worsening of angina pectoris, hospitalisation for heart failure, new positive exercise stress testing.

RESULTS

In the follow-up study a common carotid IMT >0.7 mm was a predictor of event (p=0.03) in the univariate analysis. The other risk factors were unstable angina (p=0.001) and PTCA on the left descending coronary artery (p<0.05). We did not find any relation between the end-point and ABI or presence of atheroma on the common femoral artery. In the logistic regression analysis unstable angina was associated with a 3.14 fold increased risk (IC 95%: 1.51-6.4, p=0.002), subjects without HMG-CoA inhibitors drugs at the inclusion had also an increased risk of 2.5 (IC 95%:1.09-5.75, p=0.02).

CONCLUSION

This study suggest that CCA-IMT is associated with an increased risk of cardiac events after PTCA. The measurement of subclinical disease could be useful for identifying high-risk patients.

Blunt chest trauma: a right pulmonary vein rupture

This report describes the case of a 37-year-old man who fell from 6 m height and presented an isolated rupture of the right pulmonary vein. The patient had a low blood pressure without any sign of intrathoracic injury. An echocardiogram revealed a tamponade with hemodynamic intolerance. The repair was made using cardiopulmonary bypass which made the inspection and total repair of the lesions easier. This case is unusual because of the isolated lesion and the few articles about similar reports founded in an extended literature review. Mechanisms and generation of blunt chest trauma lesions are discussed.

Extrapericardial cardiac tamponade caused by traumatic retrosternal hematoma

Cardiac tamponade is an uncommon complication of blunt chest trauma, resulting typically from hemorrhage into the pericardial space. We report a case of hemodynamic compromise secondary to an extrapericardial compression caused by the acute formation of a retrosternal hematoma associated with a sternal fracture. The patient was involved in a violent deceleration accident. Initially, he only complained of an anterior thoracic pain, but subsequently became restless, pale, and dyspneic. A severe hypotension associated with sinus bradycardia (45 bpm) rapidly occurred. Both jugular veins became markedly turgescent, but no significant pulsus paradoxus was noted. Echocardiography disclosed a large hematoma, compressing anteriorly both the right ventricular cavity and outflow tract. Surgical evacuation of the retrosternal hematoma related to a bifocal fracture of the manubrium was followed by instantaneous hemodynamic improvement. Regional extrapericardial tamponade secondary to the acute formation of compressive retrosternal hematoma is an unusual cause of circulatory failure after severe blunt chest trauma. Since conventional clinical signs associated with typical tamponade physiology may be lacking in this setting, echocardiography is ideally suited for early recognition of this unusual condition.

[Long-term survival of elderly amputated vascular patients]

The object of this study was to assess the 10 year outcome of patients over 70 years of age who underwent amputation for vascular diseases. The secondary objective was to determine the prognostic risk factors. One hundred and four consecutive patients having undergone a leg (16 cases) or through-thigh amputation (88 cases) were reviewed. The average age at the time of surgery was 80.7 years (+/- 6.5 years, range 70-98 years). At the time of the enquiry, there were 4 survivors (operated on average 107.7 months previously +/- 14.6 months). The survival rates at one, six, twelve months and two years were 74.1%, 48.1%, 38.5% and 27% respectively. The mean survival time was 19.2 months with a median of 6 months. Univariate analysis showed the following criteria to be statistically correlated with a poor prognosis: female gender (p = 0.008), previous psychiatric disease (p = 0.007), cachexia (p = 0.004), age of 80 or over (p = 0.025), absence of diabetes (p = 0.025). Multivariate analysis showed that men had a lower risk of death (RR: 0.591--95% CI: 0.394-0.888--p = 0.011). The comparison of subjects who died during the first year with the survivors, showed a deleterious effect of proximal amputations (p = 0.032) and absence of diabetes (p = 0.021). These results confirm the very mediocre prognosis of elderly amputated vascular patients during the first postoperative year. Thereafter, the outlook is not as bad. Female gender would seem to be a poor prognostic factor whereas the presence of diabetes could identify a subgroup with a better outlook.

[Heat therapy in chronic venous insufficiency of the legs]

Water cures have long been advocated for venous and lymphatic disorders. Spa therapy combines hydrotherapy, physical therapy and education. Immersion increases central blood volume, diuresis and natriuresis. These effects are independent of the mineral characteristics of the water. Hydrotherapy is viewed as a complementary treatment of venous and lymphatic insufficiency whatever its stage of development; but this has not been formally proved.

[Ischemic neuropathy in occlusive lower limb arterial disease at the state of ischemia on effort]

Acute or chronic prolonged ischaemia of the limbs may cause lasting neurological damage. This has been shown in clinical, electrophysiological and anatomopathological studies. The aim of this study was to search for signs of neurological suffering during ischaemia of effort. Twenty patients with occlusive lower limb arterial disease with ischaemia of effort were studied. None of the patients had other causes of neuropathy: none of the patients had potentially neurotoxic therapy. All underwent haemodynamic assessment (Doppler ultrasonography treadmill test, transcutaneous oxygen diffusion) and electrophysiological study (nerve conduction studies and an electromyogramme). Ten patients had abnormalities during stimulation-detection and on electromyography. These abnormalities were always observed in the limbs with the poorest blood flow. The pressure index and transcutaneous oxygen diffusion in lying position were significantly lower (pressure index: 0.43 vs 0.72, p < 0.03; TcPO2: 20.3 vs 27.2, p < 0.04). The authors consider that effort ischaemia is associated with neurological damage. Repeated transient episodes of ischaemia could cause neuropathy.

[Transesophageal echocardiography for diagnosis of traumatic injuries to the major intrathoracic vessels in 150 patients: the effect of the learning curve]

OBJECTIVES

To evaluate the role of transoesophageal echocardiography (TOE) in the management of patients with suspected traumatic lesions of the thoracic aorta (TLA) and its branches; to assess the influence of the learning curve on the diagnostic accuracy of TOE for the identification of TLA.

STUDY DESIGN

Retrospective study.

PATIENTS

The study included 150 patients (age: 41 +/- 17; Injury Severity Scale score: 31 +/- 17) who were admitted during a 4-year period for severe blunt chest trauma and who underwent a TOE study.

METHODS

TOE were performed with either a monoplane (n = 54) or a multiplane probe (n = 96). In all cases, TLA were confirmed by angiography, computed tomography, surgery, or necropsy. Initially performed routinely, angiography was subsequently indicated when the TOE study was inconclusive or when a disruption of supraaortic arteries was suspected. Echocardiographic studies were reviewed by an experienced reader who was unaware of the medical history and initial conclusions. To evaluate the influence of the learning curve on the diagnostic accuracy of TOE, these conclusions were compared with the initial interpretations.

RESULTS

A TLA was recognized in 25 patients out of 150 (17%), and evidenced using TOE in 22 of them. Three false negative and two false positive TOE results (needless thoracotomy) were recorded. After a learning period, the rate of inconclusive TOE studies decreased (18/150 vs 7/150: P < 0.05) and no false positive finding was recorded. The sensitivity and specificity of TOE for the diagnosis of TLA were 88 and 100%, and positive and negative predictive values were 100 and 97%, respectively.

CONCLUSIONS

TOE is an accurate imaging technique for the diagnosis of TLA located at the aortic isthmus. However aortography becomes essential when injuries of the aorta branches are suspected. A learning period is required to improve the specificity of TOE for this indication.

Diagnosis and management of entrapped embolus through a patent foramen ovale

The diagnosis of impending paradoxical embolus by echocardiography is exceptional and its management remains unclear. Through a personal case, we performed an exhaustive review of the medical literature of this rare finding. Since the first report, only 43 cases have ever been reported. The superiority of transesophageal echocardiography is underlined. The clinical features are complex. The classical simultaneous pulmonary and paradoxical embolism is often absent. Therapeutic options are cardiac surgery, thrombolysis or anticoagulation. The early mortality rate is high (21%). In addition, recurrent embolisms are reported when a medical treatment is chosen. The cumulative results of each possibility are described.

Successful surgical management of a ruptured abdominal aortic aneurysm in a renal transplant patient. A case report

With extended indications for renal transplantation and increasing survival, it can be expected that atherosclerotic vascular disease in the post-transplant patient will become more frequent. The authors report a case of a ruptured abdominal aortic aneurysm in a renal transplant recipient. A temporary axillo-femoral shunt was used to maintain perfusion of the renal graft during aortic cross-clamping. They review the literature and discuss the available methods for preserving renal function.

Plasma leukaemia inhibitory factor, interleukin 6 and soluble interleukin 6 receptor levels during cardiopulmonary bypass with extracorporeal circulation

In this study the authors assessed plasma leukaemia inhibitory factor (LIF), interleukin 6 (IL-6) and soluble IL-6 receptor (sIL-6R) concentrations in 28 patients undergoing coronary artery bypass graft (CABG) with extracorporeal circulation (ECC). Plasma IL-6 levels increased during ECC, reaching a 33-fold increase 6 h after surgery as compared to pre-operative values. In contrast, plasma sIL-6R and LIF concentrations did not vary significantly during cardiac surgery. Thus, LIF is not implicated in the haematological changes and in the inflammatory syndrome observed after CABG. Despite the fact that LIF and IL-6 exhibit several common biological activities, the production of these two cytokines is differently regulated during cardiac surgery with ECC. Plasma IL-6 levels increased during cardiac surgery while sIL-6R levels did not changed. These data contrast with the decreased sIL-6R concentrations with concomitantly high IL-6 levels in patients with sepsis syndrome suggesting that inflammatory reactions in sepsis and after cardiopulmonary bypass are triggered by different mechanisms.

IL-6 and IL-8 production by human bone marrow stromal cells

By using a specific enzyme-linked immunosorbent assay, the authors demonstrated that human bone marrow stromal cells produce IL-6 and IL-8. Their synthesis is enhanced in a dose-dependent manner after stimulation with lipopolysaccharide (LPS) and phorbol myristate acetate (PMA). Interleukin 6 (IL-6) and IL-8 production in response to PMA were markedly diminished by the PKC inhibitor staurosporine. IL-6 (10 ng/ml) stimulated IL-8 production with 0% and 10% fetal calf serum (FCS) in the culture medium. In similar conditions, IL-8 (10 ng/ml) enhanced IL-6 production. IL-1 alpha, IL-1 beta, and IL-3, tumour necrosis factor alpha (TNF-alpha), Stem cell factor (SCF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) (at 10 ng/ml) stimulated IL-6 and IL-8 production in 0% and 10% FCS. G-CSF stimulated and IL-4 inhibited IL-8 production in 10% FCS. IL-2, IL-4 and bFGF stimulated IL-6 production in 0% FCS. These results suggest that bone marrow stromal cells might represent a major source for the cytokine-regulated local production of IL-6 and IL-8 inside human bone marrow.

Traumatic pulmonary hernia: surgical versus conservative management

The therapeutic management of lung herniation, an uncommon complication of severe blunt chest trauma, remains controversial. We report here on two cases of traumatic lung herniation with different, yet successful, methods of therapeutic management according to the particular anatomic types. Because of the threat of tension pneumothorax, incarceration, or strangulation of the lung parenchyma in mechanically ventilated patients, surgical reduction of intercostal pulmonary hernias with narrow necks is usually recommended. In contrast, supraclavicular pulmonary hernias secondary to clavicle-sternal dislocation may be treated conservatively with serial clinical and thoracic imaging follow-up including chest computed tomographic scan. In this anatomical type of lung herniation, favorable spontaneous evolution is frequently observed, presumably because of the presence of a larger thoracic wall defect together with the absence of associated perforating bone trauma. The efficacy of the therapeutic approach proposed herein remains to be confirmed by further experience.

[Calcified aortic valvular disease associated with adult progeria]

Adult's progeria or Werner's syndrome is a rare condition of autosomal-recessive inheritance, characterized by an apparent acceleration of many of the processes associated with aging. We describe the cardiovascular findings in a 44 year-old man with this disorder. Slightly elevation of urinary hyaluronic acid level contributes to the diagnosis.

Cytokine and lipid mediator blood concentrations after coronary artery surgery

This study investigates whether increased levels of cytokines and lipid mediators may be associated with complications after coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC). Hemodynamic measurements and blood samples were obtained in 32 patients before and after the end of ECC and at the 6th and the 24th postoperative hours. Coagulation and pulmonary and cardiovascular functions were specifically assessed postoperatively at the same time. Patients with cardiovascular dysfunction had higher interleukin 8 (IL-8) levels. Higher platelet-activating factor (PAF) and decreased PAF acetylhydrolase activity (AHA, the enzyme that inactivates PAF) levels were found in patients with moderate cardiovascular dysfunction. Interleukin 6 (IL-6), IL-8, and AHA levels correlated with most hemodynamic parameters and creatine phosphokinase myocardial band levels obtained after surgery. Patients with severe lung injury had lower PAF, 6-keto prostaglandin (Pg)F1alpha, and PgE2 levels and higher thromboxane (Tx) B2 concentrations compared with patients without lung injury. Increased IL6 levels were only associated with moderate lung injury. Impaired hemostasis was associated with higher IL6 levels. AHA, IL-6, and IL-8 seem to be associated with cardiovascular dysfunction. The IL-6 blood levels and the ratio of TxB2/6 keto-PgF1alpha blood levels are increased during post-CABG lung injury. These results identify an association between specific post-CABG complications and the systemic inflammatory response. The clinical significance of this association remains to be evaluated.

IMPLICATIONS

Patients with pulmonary, cardiovascular, or hemostasis dysfunction after cardiopulmonary bypass demonstrate aberrancies in a variety of cytokines and lipid mediators in arterial blood or plasma. The relationship between these findings and inflammatory response-induced complications remains to be determined.

M-CSF serous rate evolution during post-transplantation days in a heterotopic heart graft model mice

BACKGROUND

On heterotopic heart graft in mice, aged 7 weeks (C3H and B57), we investigate the variations of Macrophage Colony stimulating factor serous rate. The macrophage colony stimulating factor (M-CSF) is a cytokine involved in the immune response during transplantation.

METHODS

Five groups were determined, group 1 with a heterotopic transplant without immunosuppressive treatment (N=24); group 2 with a heterotopic transplant and Corticoid treatment after the graft (N=29); group 3 with a heterotopic transplant and cyclosporine treatment after the graft (N=34); group 4 with an isogenic transplant (N=31) and group 5 undergoing a laparotomy (N=31). The mice are sacrificed at D4, D7, D10 or D14 and the M-CSF dosage are done by ELISA method.

RESULTS

The serous rate of M-CSF is stable in the group with an isogenic transplant or with only a laparotomy. But in the group with a heterotopic transplant the M-CSF values increase (x1.5). If we use an immunosuppressive treatment the raising of M-CSF is less important. When we have a rejection graft, the serous rate of M-CSF increases but not significantly (Mann-Whitney test).

CONCLUSIONS

We conclude M-CSF seems to be a reliable index of disorder during immune response, but is not a good marker of the rejection.

Spontaneous and inducible production of leukaemia inhibitory factor by human bone marrow stromal cells

Leukaemia inhibitory factor (LIF) acts on the growth and differentiation of haematopoietic cells. By using a specific enzyme-linked immunosorbent assay for human LIF, we demonstrate that human bone marrow stromal cells produce LIF. LIF synthesis is enhanced in a dose-dependent manner after stimulation with lipopolysaccharide (LPS) and phorbol 12-myristate 13-acetate (PMAS). LIF production in response to PMA is PKC-dependent since the two PKC inhibitors sphingosine and staurosporine markedly diminished it. Interleukin 1alpha (IL-1alpha), IL-1beta, IL-3, IL-6, IL-8, tumour necrosis factor (TNF-alpha) and SCF (both at 10 ng/ml) stimulate LIF production. By contrast macrophage colony-stimulating factor (M-CSF), granulocyte (G)-CSF, GM-CSF, basic fibroblast growth factor (bFGF), platelet-activating factor (PAF), protaglandin E2 (PGE2), leukotriene B4 (LTB4), and leukotriene C4 (LTC4) did not. These results suggest that bone marrow stromal cells might represent a major source for the cytokine-regulated local production of LIF inside human bone marrow.

Platelet-activating factor and antagonists modulate DNA synthesis in human bone marrow stromal cell cultures

Platelet-activating factor (PAF) is present in the human bone marrow. We have investigated the effect of PAF and antagonists (BN 52,021 and CV 3988) on the growth of human marrow stromal cells. PAF (1 microM) stimulates and PAF antagonists (0.1-1 microM) inhibit [3H]thymidine incorporation in cells grown in 5% serum. The catabolism of PAF by stromal cells was inhibited by CV 3988 suggesting the presence of specific PAF receptor on cells. PAF and antagonists (0.1 nM-10 microM) had no effect on cells cultured in high serum concentration (20%) or in low serum concentration (1%) with 0.5 ng/ml of basic fibroblast growth factor (bFGF). This study indicates for the first time that PAF modulates the serum-induced but not the bFGF-induced growth of marrow stromal cells. The interactions between PAF and stromal cells during inflammatory marrow events such as myelofibrosis deserve to be assessed.

[Postoperative transparietal Doppler ultrasonographic study of the internal mammary artery graft flow with respect to quality of the underlying myocardium]

The authors studied flow in the internal mammary artery by Doppler ultrasonography after bypass surgery of the left anterior descending artery to determine the correlation between the flow pattern and the quality of the distal run off. A pulsed Doppler was used to record flow from the right and left internal mammary arteries in the first, second and third intercostal spaces and the supraclavicular fossa. Only the best quality recordings with the highest amplitudes were retained for analysis. Forty-nine patients (average age 61 +/- 10 years), 43 men and 6 women, were included and were examined between the 10th and 15th postoperative days. All had stenosis of the left anterior descending on coronary angiography: three subgroups were identified ad the time of evaluation: (I) revascularisation of an infarcted zone with important angiographic and echographic sequellae. (II) revascularised zones with slight wall motion abnormalities. (IIIa) revascularisation of myocardium with no abnormality (including a subgroup of 5 patients (IIIb) characterised by a postoperative low output state and echocardiographic changes not present before surgery). Significant changes were observed in the flow patterns of the different groups. (I) an exclusively systolic flow (diastolic velocity time integral = 2.85 cm), (II) systolodiastolic flow (diastolic velocity time interval = 9 cm) similar to that in group IIIb, and IIIa predominantly diastolic flow (diastolic velocity time integral = 15.2 cm). The amplitude of diastolic flow in the mammary artery graft was therefore related to previous ischaemia of the revascularised myocardium; detection of stenosis by Doppler ultrasonography should therefore take into account the previous history of the patient.

[Paraneoplastic arterial thrombosis. Apropos of 2 cases]

The search for a cancer is part of the classical investigation of unexplained venous thrombosis. Arterial thrombosis associated with neoplasia is more rare. The authors report two cases in which arterial thrombosis was the final event of their malignant disease. The first case had abacterial thrombotic endocarditis and disseminated intravascular coagulation at the origin of multiple thrombotic complications. The initially unknown cancer was a pancreatic adenocarcinoma. The second case presented with acute occlusion of the iliac artery after ablation of a malignant melanoma. Despite embolectomy with a Fogarty catheter and effective anticoagulation, the thrombosis recurred several times at the same site. The clinical features and the mechanisms of these two cases suggestive of Trousseau's syndrome are discussed.

Swan-Ganz catheter induced pulmonary artery perforation during cardiac surgery concerning two cases

Two case reports describing patients having cardiac operations under extra corporeal circulation are presented. At the completion of the operation, a massive hemoptysis occurred in both patients after a Swan-Ganz catheter had perforated the pulmonary artery. A hemostasis lobectomy was then immediately required. The immediate and long term prognosis seems satisfactory. This is an unusual but serious complication. The incidence of this complication varies between 0.06 and 0.2%. The more frequently related risk factors include people over the age of 60, pulmonary artery hypertension, anticoagulant therapy, hypothermia and manipulation of the heart by the surgeon. When this accident occurs, many authors suspect the balloon. An early diagnosis is essential in the case of a major or even a minor hemoptysis, because this complication may be a lethal one as the mortality rate may reach 50%. According to us, the appropriate therapy which would reduce this mortality is a surgical one (hemostasis lobectomy).

Platelet-activating factor and haematopoiesis. XI. Platelet-activating factor has no effect on the production of interleukin-6 and tumor necrosis factor-alpha by human bone marrow stromal cells

PAF is a phospholipid mediator of inflammation with stimulates IL-6 production by murine skin fibroblasts. Although PAF is present in human bone marrow, its role in haematopoiesis is unknown. We have assessed whether PAF stimulates IL-6 and TNF-alpha production by human bone marrow stromal cells (mostly fibroblast-like cells). We report that PAF (1 nM to 10 microM) has no effect on the synthesis of IL-6 and TNF-alpha by human bone marrow stromal cells. This difference may be due to the widely accepted concept "tissue-specific fibroblasts". The role of PAF in the regulation of human haematopoiesis remains to be elucidated.

Effects of a paf-receptor antagonist on hemodynamics during and after cardiopulmonary bypass

OBJECTIVES

To assess after cardiopulmonary bypass (CPB) the role of paf-acether (paf), a phospholipid mediator whose injection in animal mimics the hemodynamics observed after CPB.

DESIGN

Prospective double-blind randomized study.

SETTING

Single institutional university hospital.

PARTICIPANTS

18 patients scheduled to undergo coronary artery bypass graft.

INTERVENTIONS

18 patients randomly received a placebo (n = 8) or 120 mg BN52021 (n = 10), a paf-receptor antagonist injected twice just before vascular cannulation and before cross-clamp release.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic measurements were performed with a pulmonary artery and a radial artery catheter before and after the first injection of BN52021 or placebo, at the end of CPB, 1, 15, and 30 minutes after protamine infusion, then 6 hours and 24 hours postoperatively. BN52021 infusion, did not affect hemodynamic parameters. After CPB, the pulmonary artery pressures, the cardiac index, and the pulmonary artery occlusion pressures were statistically the same between groups. By contrast, the pulmonary vascular resistances (1.5 +/- 0.5 IU v 4.5 +/- 0.6 IU, p < 0.05), the right ventricular systolic work index (5.3 +/- 0.91 g m m-2 v 9.37 +/- 1.02 g m m-2, p < 0.05) and the transpulmonary gradient (4.7 +/- 1.1 mmHg v 12.0 +/- 1.2 mmHg, p < 0.05) were lower in the BN52021 group as compared with the placebo group. After protamine infusion, these differences between groups disappeared.

CONCLUSION

Because the inotropic and vasodilator therapy and the volume loading were the same between groups, this study suggests that pretreatment with a paf-receptor antagonist improves post-CPB pulmonary resistance. Nevertheless, this beneficial effect is transient without consequences on left ventricular function indices.

Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption

BACKGROUND

Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality.

METHODS AND RESULTS

Thirty-two consecutive trauma patients (mean age, 40 +/- 16 years) with suspected TDA (violent deceleration accident and mediastinum > 8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n = 10) and (2) traumatic intimal tears (n = 3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57 +/- 15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA.

CONCLUSIONS

TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.

Coronary artery damage during mitral valve replacement

An anatomic study of 15 hearts has assessed the existing correlations between the mitral annulus and coronary arteries. The circumflex artery is sometimes located very close to the mitral annulus, as close as one millimetre, hence there is a risk of injury during mitral valvular replacement. This risk is especially when coronaries have a prevailing left anatomic position or a balanced coronary system.

The gender-marking effect in spoken word recognition

In this paper we examine whether the recognition of a spoken noun is affected by the gender marking--masculine or feminine--that is carried by a preceding word. In the first of two experiments, the gating paradigm was used to study the access of French nouns that were preceded by an appropriate gender marking, carried by an article, or preceded by no gender marking. In the second experiment, subjects were asked to make a lexical decision on the same material. A very strong facilitatory effect was found in both cases. The origin of the gender-marking effect is discussed, as well as the level of processing involved--lexical or syntactic.

Effects of the platelet-activating factor receptor antagonist BN 52021 on hematologic variables and blood loss during and after cardiopulmonary bypass

Cardiopulmonary bypass (CPB)-induced thrombocytopenia and leukopenia is augmented after heparin reversal of protamine. Platelet-activating factor (PAF) might be implicated in these disorders. To evaluate the effects of PAF on the hematologic disorders and blood loss during and after CPB, patients were pretreated with BN 52021, a PAF receptor antagonist, or a placebo. BN 52021 (120 mg) (n = 13) or placebo (n = 15) were infused intravenously before vascular cannulation and before cross-clamp release. Platelet and leukocyte counts were assessed in venous blood before and after the first dose of BN 52021 or placebo, 2 min after the beginning of CPB (at the entry of the oxygenator), at the end of CPB, 1, 15, and 30 min after protamine infusion, and 6 and 24 h after CPB. The decrease in platelet and leukocyte counts were the same between groups during and after CPB and after protamine infusion. Bleeding times were not modified by the pretreatment of patients with BN 52021. During surgery, blood loss reached 1660 +/- 297 mL in the BN 52021 group and 1599 +/- 283 mL in the placebo group (P > 0.05). Forty-eight hours postoperatively, the chest tube outputs were not different between groups (1460 +/- 418 mL vs 1640 +/- 362 mL in the BN 52021 and placebo groups, respectively). This study shows that BN 52021 infusion did not change the hematologic variables studied. Moreover, a PAF antagonist pretreatment did not protect the patients against CPB- or protamine-induced hematologic changes.

[Significant stenosis of the common trunk of the left coronary artery. Retrospective study of 227 cases]

Significant left main coronary artery disease is a separate disease entity in coronary artery disease. The prognosis is classically poor and the treatment of choice is surgical. A retrospective study of patients with left main coronary disease, diagnosed and treated at the CHRU Dupuytren, Limoges, between 1/01/80 and 15/06/91 was undertaken to determine the aetiological, clinical and therapeutic factors which influence mortality related to this condition. During this period, 8198 coronary angiographies were performed in the cardiology department. The diagnosis of significant left main coronary disease (> or = 50% stenosis) was made in 250 cases (3% of all investigations). Of these 250 cases, 227 were treated medically or surgically by our group during the study period. Twenty patients were treated in another centre and 3 underwent surgery after the 15/06/91. Seven patients died in the period immediately after coronary angiography. Of the 220 survivors of coronary angiography, 185 (85%) were referred for surgery (direct or sequential venous and/or arterial bypass or coronary endarteriectomy). Four patients died within 30 days of surgery. Thirty five patients were treated medically. The therapeutic decision was based on the absence of surgical contra-indications. The retrospective, non-randomized nature of this study with allocation of patients to surgical or medical treatment without control invalidated statistical analysis. At the date of the last follow-up appointment, arbitrarily chosen as the 1/01/93, 163 operated patients (88.1%) of which 130 (79.7%) were asymptomatic and 13 medically treated patients (37%) were alive. The prognostic factors after surgery in this study were: stage IV dyspnoea at the time of diagnosis, severe abnormalities on catheter study (end diastolic pressure over 18 mmHg after angiography), left ventricular wall abnormalities (functional score > 10) and incomplete revascularization. The risk of coronary angiography in this condition were confirmed in this study.