[Suicidal risk prevention in schizophrenia: Importance of family psychoeducation]

OBJECTIVES

Although mortality by suicide in schizophrenia seems to have decreased in some countries over the last 30 years, it remains much higher than in the general population. Studies have shown this risk to impact around 5% of patients, corresponding to a risk almost 2.5 times higher than in the general population. Family psychoeducation in schizophrenia has been demonstrated to lead to symptom reductions and to an improvement of the quality of life, two factors that should contribute to decreasing the suicidal risk. Therefore, if families attend an efficient psychoeducation program, we can expect a decrease in the patient suicidal risk. Attending a family psychoeducation program at the beginning of the disease would also be associated with a stronger preventive effect on suicidal mortality. The objective of this study is to describe the suicide attempt rate of patients who suffer from schizophrenia before and one year after one of their relatives participated to the family psychoeducation program Profamille.

METHOD

We performed a retrospective study on 1209 people who attended the Profamille (V3.2 version) Family Psychoeducation Program. This program has 2 modules: an initial training module of 14 weekly or fortnightly sessions, and a consolidation module of 4 sessions over 2 years. Sessions last 4 hours and follow a precise and structured course. Data were collected from 40 different centers in France, Belgium and Switzerland and were based on participants assessed at the beginning and one year after the first module. Self-assessment from the relatives participating in the program provided the measure of patients' suicide attempts. An assessment at T0 explored the attempts over the 12 months before the beginning of the program while the assessment at T1 analyzed those during the 12 months following the end of the Program. The Chi² test was used to compare the suicide attempt rates for each period, using a significance threshold of 0.05. Since the risk of suicide is greater in the first years of the illness, rates of attempts are also calculated according to the age of disorder. The analysis was carried out with the statistical software R.

RESULTS

The number of participants reporting that their relative had attempted suicide in the previous 12 months decreased from 41 to 21. The annual attempts rate was evaluated at 6.4 % before the Profamille program and decreased to 2.4 % a year after the end of the program (P=0.0003). The reduction of the attempt rate was observed even for patients with schizophrenia for more than 10 years.

CONCLUSION

This study shows the positive impact of Profamille on reducing the rate of suicide attempts in patients with schizophrenia. It has been shown that the risk is highest at the beginning of the disorder. Therefore, based on our results, it would seem appropriate to propose the Profamille program at an early stage.

[State of the art: interventional radiology management of renovascular hypertension]

The management of renal artery stenosis (RAS) has been the subject of numerous clinical studies and recommendations, most frequently with regards to atherosclerotic RAS. We present the current recommendations from the French Society of Cardiac and Vascular Imaging updated from a recent literature review (April 2008) with regards to medical, endovascular and surgical management of atheroscletotic and non-atherosclerotic RAS. The evidence-based recommendations are ranked by level.

[Results of the French register of renal stenting: the Esternal study]

Renal artery angioplasty using the same techniques employed for coronary arteries has developed considerably. A register was set up in France to evaluate the efficacy of this treatment for improving renal function and lowering blood pressure in cardiac patients. Between 2001 and 2005, 205 patients (234 lesions) were treated in 14 centres (mean age: 69.2 +/- 10.4 years, 59% male). All of the patients had hypertension and the majority of them (171) had renal failure (creatinine clearance<90 ml/min). Direct implantation of a stent was performed in 75.2% of the cases, successfully in 196 patients (96%) with 220 lesions (95.2%). The complications encountered were segmental renal infarction in two patients (0.9%), and four cases of minor vascular complications at the puncture site (2%). The mean value for pre-implantation creatinine clearance was 54.6 +/- 32.8 ml/min and 58.1 +/- 36.0 post- implantations. The duration of follow up was 5.9 +/- 2.7 months. Mortality was 3.5% (seven patients, of whom two died from renal causes). The mean systolic and diastolic blood pressure was 142.2 +/- 16.2 and 78.9 +/- 9.5 respectively versus 164.9 +/- 25.2 and 89.1 +/- 14.8 before treatment (p<0.0001). A non-significant improvement in creatinine clearance at six months was also observed in patients with renal failure prior to treatment: 48.7 +/- 17.1 ml/min vs. 69.2 +/- 160.3. Renal artery stenting in cardiac patients with renal artery stenosis is associated with a very high success rate, with few complications and an improvement in hypertension and renal function.

Luteinizing hormone pulsatility in patients with major ovarian hyperandrogenism

Hyperandrogenism and ovulatory dysfunction are common in women with either polycystic ovary (PCOS) or ovarian virilizing tumor. However, contrasting with the numerous studies that have extensively described gonadotropin secretory abnormalities, principally increased LH pulse amplitude and frequency, few studies have concerned gonadotropin secretion in patients with ovarian virilizing tumors; low gonadotropin levels have occasionally been reported, but never extensively studied. The goal of the present study was to further evaluate the pulsatility of LH secretion in women with ovarian virilizing tumor compared with that of PCOS patients. Eighteen women with major hyperandrogenism (plasma testosterone level >1.2 ng/ml) were studied (5 women with ovarian virilizing tumor, 13 women with PCOS, and 10 control women). Mean plasma LH level, LH pulse number and amplitude were dramatically low in patients with ovarian tumors when compared to both PCOS (p<0.001) and controls (p<0.001). In case of major hyperandrogenism, LH pulse pattern differs markedly between women with ovarian virilizing tumor or PCOS, suggesting different mechanisms of hypothalamic or pituitary feedback.

[Critical limb ischaemia: endovascular treatment in diabetic patients?]

Endovascular treatment has an increasing role in the treatment of patients with critical limb ischemia, particularly in diabetic patients with a majority of infrapopliteal lesions. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses and short occlusions that impair distal vascularization. Stents are indicated when there is a suboptimal results following balloon angioplasty (recoil or dissection). Restenosis rate after primary stenting for long lesion is high. Angioplasty is a safe and effective procedure, allowing limb salvage rate in a majority of the cases with a low mortality and morbidity rate.

The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design

BACKGROUND

Atherosclerotic renal artery stenosis (ARAS) is associated with progressive loss of renal function and is one of the most important causes of renal failure in the elderly. Current treatment includes restoration of the renal arterial lumen by endovascular stent placement. However, this treatment only affects damage caused by ARAS due to the stenosis and ensuing post-stenotic ischemia. ARAS patients have severe general vascular disease. Atherosclerosis and hypertension can also damage the kidney parenchyma causing renal failure. Medical treatment focuses on the latter. Lipid-lowering drugs (statins) could reduce renal failure progression and could reduce the overall high cardiovascular risk. The additional effect on preserving renal function of stent placement as compared to medical therapy alone is unknown. Therefore, the STAR-study aims to compare the effects of renal artery stent placement together with medication vs. medication alone on renal function in ARAS patients.

METHOD

Patients with an ARAS of > or = 50% and renal failure (creatinine (Cr) clearance < 80 mL/min/1.73 m2) are randomly assigned to stent placement with medication or to medication alone. Medication consists of statins, anti-hypertensive drugs and antiplatelet therapy. Patients are followed for 2 yrs with extended follow-up to 5 yrs. The primary outcome of this study is a reduction in Cr clearance > 20% compared to baseline. This trial will include 140 patients.

Anatomical variations in the drainage of the principal adrenal veins: the results of 88 venograms

This study of 88 adrenal venograms looked at the anatomical variations in the drainage of the principal adrenal veins. These were seen with a frequency of 5% on the right and 6% on the left. On the right, we have described ectopic anastomoses with the hepatic veins. On the left, the variations were always linked to an anomaly of the renal vein.

[The radiologist and central venous stenosis]

Occurrence of a central venous stenosis or occlusion is a frequent and major complication of indwelling central venous catheters. Two mechanisms may explain such a complication: thrombosis and fibrosis causing progressive stenosis. When these central vein lesions are symptomatic or preclude the creation of an angio-access for hemodialysis, they should be treated. Then, the first choice treatment is interventional radiology. Thromboses are treated by anticoagulation, local fibrinolysis and angioplasty of the residual lesion. Stenoses and chronic occlusions are treated by angioplasty more or less stent implantation. These percutaneous treatments are very effective and incomparably simpler than surgery, which often requires thoracotomy. However, often, such a treatment should be renewed because of the occurrence of a restenosis. Theses central venous lesions should be feared and taken into account for indication of central venous catheter placement.

Manual catheter-directed aspiration and other thrombectomy techniques for declotting native fistulas for hemodialysis

Recent articles reported excellent results in the percutaneous declotting of native fistulas for hemodialysis with use of thromboaspiration, mechanical devices, or thrombolytic drugs, with success rates ranging from 76% to 100%. These results challenge the surgical approach, the effectiveness of which is not supported by comparable publications. Although it is more difficult to declot forearm native fistulas than grafts, declotting of fistulas is more rewarding because it achieves better long-term patency (1-year primary rates as high as 50% and secondary rates of 80%). The results reported from declotting of fistulas in the upper arm are not as good. The unmasking of stenoses in close to 100% of cases warrants stenosis detection programs similar to those used for grafts.

Forearm arteries entrapment syndrome: a rare cause of recurrent angioaccess thrombosis

Entrapment syndrome below or just above the elbow is uncommon. These rare causes of neurologic or vascular entrapment are linked to anomalous anatomical structures. No case of entrapment syndrome has been reported in patients with angioaccess for hemodialysis. We report, for the first time, forearm arteries entrapment in two patients presenting with recurrent angioaccess for hemodialysis thrombosis. Anatomical, radiologic, and surgical features of these uncommon syndromes are discussed.

Presentation and revascularization outcomes in patients with radiation-induced renal artery stenosis

This study analyzed the initial presentation and revascularization outcomes of patients with radiation-induced renal artery stenosis, a rare complication of therapeutic irradiation. Of 11 patients with renal artery stenosis after irradiation, 7 patients fulfilled the following criteria: normotension before irradiation, radiation dose greater than 25 grays delivered to the renal arteries, associated perirenal radiation-induced lesions, and absence of arterial disease outside the radiation field. The median age at irradiation was 30 years, and the median local irradiation dose was 40 grays. The median time from irradiation to referral was 13 years. All patients were hypertensive at referral, with a median blood pressure (BP) of 171/102 mm Hg and median treatment score of two. The median glomerular filtration rate was 67 mL/min. Two patients had bilateral stenoses and 1 patient had stenosis affecting a single kidney. Stenoses were proximal in 6 patients and truncal in 1 patient, and all had the appearance of atherosclerotic stenosis. Percutaneous transluminal renal artery angioplasty (PTRA) was successful in 5 patients, but required multiple insufflations. PTRA failed in 1 patient, who subsequently underwent an aortorenal bypass. After a median follow-up of 36 months, 2 patients had died of noncardiovascular causes and 4 patients remained hypertensive, with a median BP of 136/85 mm Hg and median treatment score of two. No restenosis occurred, but aneurysms developed at the site of angioplasty in 1 patient. If hypertension occurs even decades after irradiation, a radiation-induced renal artery stenosis should be sought in patients who have undergone abdominal irradiation.

Successful endoluminal thrombo-aspiration of renal graft venous thrombosis

Renal transplant vein thrombosis is an unusual event occurring in 0.3-3% of renal transplantations. Prognosis is uniformly poor with graft loss in nearly every case. We report here the first three cases of renal graft vein thrombosis successfully treated by percutaneous endoluminal thromboaspiration. After an initially uneventful course all recipients developed anuria and required hemodialysis. In two cases, an ultrasound examination suggested a diagnosis of venous thrombosis. Emergency arteriography and phlebography were performed, confirming the complete thrombosis of the graft veins. Thromboaspiration was carried out with full heparinization and led to renal function improvement in all cases. Grafts are still functioning 6 months after the procedure, with serum creatinine levels of 176 mumol/l, 120 mumol/l and 184 mumol/l, respectively. Thus, this procedure avoids surgical and anaesthetic risks and allows, if performed at an early stage, restoration of graft function. Great care must be taken to avoid vein wall damage, vascular suture line rupture, or pulmonary embolism.

Dehydroepiandrosterone (DHEA), DHEA sulfate, and aging: contribution of the DHEAge Study to a sociobiomedical issue

The secretion and the blood levels of the adrenal steroid dehydroepiandrosterone (DHEA) and its sulfate ester (DHEAS) decrease profoundly with age, and the question is posed whether administration of the steroid to compensate for the decline counteracts defects associated with aging. The commercial availability of DHEA outside the regular pharmaceutical-medical network in the United States creates a real public health problem that may be resolved only by appropriate long-term clinical trials in elderly men and women. Two hundred and eighty healthy individuals (women and men 60-79 years old) were given DHEA, 50 mg, or placebo, orally, daily for a year in a double-blind, placebo-controlled study. No potentially harmful accumulation of DHEAS and active steroids was recorded. Besides the reestablishment of a "young" concentration of DHEAS, a small increase of testosterone and estradiol was noted, particularly in women, and may be involved in the significantly demonstrated physiological-clinical manifestations here reported. Bone turnover improved selectively in women >70 years old, as assessed by the dual-energy x-ray absorptiometry (DEXA) technique and the decrease of osteoclastic activity. A significant increase in most libido parameters was also found in these older women. Improvement of the skin status was observed, particularly in women, in terms of hydration, epidermal thickness, sebum production, and pigmentation. A number of biological indices confirmed the lack of harmful consequences of this 50 mg/day DHEA administration over one year, also indicating that this kind of replacement therapy normalized some effects of aging, but does not create "supermen/women" (doping).

Reelin expression during embryonic brain development in lacertilian lizards

The expression of reelin mRNA and protein was studied during embryonic brain development in the lacertilian lizards L. viridis and L. galloti, by using radioactive in situ hybridization and immunohistochemistry. At all stages studied, high reelin expression was consistently found in the olfactory bulb, in the lateral cortex, and in neurons of the marginal zone and subplate of medial and dorsal cortical sectors. In the dorsal ventricular ridge (DVR), reelin expression was confined to deeply located, large cells which were more abundant in the caudal than the rostral part of the DVR. In the diencephalon, the ventral lateral geniculate complex and the perirotundal were strongly positive, whereas other nuclei were mostly negative. High reelin signal was associated with some layers in the tectum, with the torus semicircularis, cerebellar granule cell layers, and the ventral horn of the spinal cord. A more moderate signal was detected in the septal nuclei, striatum, retina, habenular nuclei, preoptic and periventricular hypothalamic components, and in reticular nuclei of the mid- and hindbrain. The medial and dorsal cortical plate and Purkinje cells were reelin-negative but expressed disabled-1 (Dab1) mRNA. When they are compared with reelin expression during mammalian brain development, our data reveal an evolutionarily conserved canvas of reelin expression, as well as significant differences, particularly in developing cortical fields. The developing lizard cortex differs from that of turtles, birds, crocodiles, and mammals in that it displays heavy reelin expression not only in neurons of the marginal zone that might be homologous to mammalian Cajal-Retzius cells, but also in subplate neurons. This difference in the pattern of reelin expression suggests that the elaborate radial organization of the lacertilian cortical plate, somewhat reminiscent of its mammalian counterpart, results from evolutionary convergence. Our data lend support to the hypothesis that the reelin signaling pathway played a significant role during cortical evolution.

Preoperative assessment of the efficacy of distal radial artery ligation in treatment of steal syndrome complicating access for hemodialysis

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. We report here a case in which we applied a new diagnostic method to assess the efficacy of distal radial ligation to treat this syndrome. A favorable comparison of distal radial artery pressure measurements before and after temporary occlusion of the artery with a balloon catheter indicated that perfusion of the hand would be dramatically improved after surgical artery ligation.

Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group

Data for the effects on blood pressure of renal artery balloon angioplasty are mostly from uncontrolled studies. The aim of this study was to document the efficacy and safety of angioplasty for lowering blood pressure in patients with atherosclerotic renal artery stenosis. Patients were randomly assigned antihypertensive drug treatment (control group, n = 26) or angioplasty (n = 23). Twenty-four-hour ambulatory blood pressure, the primary end point, was measured at baseline and at termination. Termination took place 6 months after randomization or earlier in patients who developed refractory hypertension. In those allocated angioplasty, antihypertensive treatment was discontinued after the procedure but was subsequently resumed if hypertension persisted. Secondary end points were the treatment score and the incidence of complications. Two patients in the control group and 6 in the angioplasty group suffered procedural complications (relative risk, 3.4; 95% confidence interval, 0.8 to 15.1). Early termination was required for refractory hypertension in 7 patients in the control group. Antihypertensive treatment was resumed in 17 patients in the angioplasty group. Mean ambulatory blood pressure at termination did not differ between control (141+/-15/84+/-11 mm Hg) and angioplasty (140+/-15/81+/-9 mm Hg) groups. Angioplasty reduced by 60% the probability of having a treatment score of 2 or more at termination (relative risk, 0.4; 95% confidence interval, 0.2 to 0.7). There was 1 case of dissection with segmental renal infarction and 3 of restenosis in the angioplasty group. No patient suffered renal artery thrombosis. In unilateral atherosclerotic renal artery stenosis, angioplasty is a drug-sparing procedure that involves some morbidity. Previous uncontrolled and unblinded assessments of angioplasty overestimated its potential for lowering blood pressure.

Somite number and vertebrate evolution

Variation in segment number is an important but neglected feature of vertebrate evolution. Some vertebrates have as few as six trunk vertebrae, while others have hundreds. We examine this phenomenon in relation to recent models of evolution and development. Surprisingly, differences in vertebral number are foreshadowed by different somite counts at the tailbud stage, thought to be a highly conserved (phylotypic) stage. Somite number therefore violates the ‘developmental hourglass’ model. We argue that this is because somitogenesis shows uncoupling or dissociation from the conserved positional field encoded by genes of the zootype. Several other systems show this kind of dissociation, including limbs and feathers. Bmp-7 expression patterns demonstrate dissociation in the chick pharyngeal arches. This makes it difficult to recognise a common stage of pharyngeal development or ‘pharyngula’ in all species. Rhombomere number is more stable during evolution than somite number, possibly because segmentation and positional specification in the hindbrain are relatively interdependent. Although developmental mechanisms are strongly conserved, dissociation allows at least some major evolutionary changes to be generated in phylotypic stages.

Idiopathic renal arteriovenous fistula: treatment with embolization

We report a case of idiopathic renal arteriovenous fistula revealed by microscopic hematuria in a 36-year-old man with no predisposing history. Treatment with selective embolization achieved complete resolution with no parenchymal damage.

There is no highly conserved embryonic stage in the vertebrates: implications for current theories of evolution and development

Embryos of different species of vertebrate share a common organisation and often look similar. Adult differences among species become more apparent through divergence at later stages. Some authors have suggested that members of most or all vertebrate clades pass through a virtually identical, conserved stage. This idea was promoted by Haeckel, and has recently been revived in the context of claims regarding the universality of developmental mechanisms. Thus embryonic resemblance at the tailbud stage has been linked with a conserved pattern of developmental gene expression - the zootype. Haeckel's drawings of the external morphology of various vertebrates remain the most comprehensive comparative data purporting to show a conserved stage. However, their accuracy has been questioned and only a narrow range of species was illustrated. In view of the current widespread interest in evolutionary developmental biology, and especially in the conservation of developmental mechanisms, re-examination of the extent of variation in vertebrate embryos is long overdue. We present here the first review of the external morphology of tailbud embryos, illustrated with original specimens from a wide range of vertebrate groups. We find that embryos at the tailbud stage - thought to correspond to a conserved stage - show variations in form due to allometry, heterochrony, and differences in body plan and somite number. These variations foreshadow important differences in adult body form. Contrary to recent claims that all vertebrate embryos pass through a stage when they are the same size, we find a greater than 10-fold variation in greatest length at the tailbud stage. Our survey seriously undermines the credibility of Haeckel's drawings, which depict not a conserved stage for vertebrates, but a stylised amniote embryo. In fact, the taxonomic level of greatest resemblance among vertebrate embryos is below the subphylum. The wide variation in morphology among vertebrate embryos is difficult to reconcile with the idea of a phyogenetically-conserved tailbud stage, and suggests that at least some developmental mechanisms are not highly constrained by the zootype. Our study also highlights the dangers of drawing general conclusions about vertebrate development from studies of gene expression in a small number of laboratory species.

[Renal stenosis in hypertensive children. Doppler/arteriographic correlation]

To evaluate the reliability of Doppler-ultrasonography in identifying children with renal artery stenosis among those with hypertension, we compared Doppler ultrasonography results in 29 hypertensive children (mean age: 8.3 +/- 4.7 years) with angiography. Doppler-ultrasonography and arteriography were performed within a period less than two months. First, we established normal values in 40 normotensive children (mean age: 8.4 +/- 4.5 years). The diagnosis of renal artery stenosis was settled when maximal systolic velocities where > or = to 1.70 m.s-1. Peak systolic velocities values of Doppler-ultrasonography were significantly higher in patients with proven angiographic renal artery stenosis (3.56 +/- 0.70 m.s-1) than in hypertensive patients with normal renal arteries at angiography (1.02 +/- 0.29 m.s-1, p < 0.0001), and than in normotensive healthy children (1.05 +/- 0.33 m.s-1, p < 0.0001). We observed 3 false negative and 2 false positive diagnoses with Doppler-ultrasonography. Of the 3 false negatives, one had a stenosis on a right and posterior segmental artery and the other had bilateral and multiply intra-renal artery stenosis with few hemodynamic significance. The 2 false positives were due to a sinuous main renal artery and to a technical mistake, respectively. In another patient, Doppler-ultrasonography revealed a tight main renal artery stenosis, not detected by arteriography. Renal artery stenosis was subsequently confirmed by a second arteriography. Our results showed a sensitivity of 88%, a specificity of 93%, a positive predictive value of 92% and a negative predictive value of 89%, demonstrating the reliability of Doppler-ultrasonography for the diagnosis of renal artery stenosis in hypertensive children. With the use of a rigorous methodology and the increasing experience of the operators, diagnostic errors of renal artery stenosis are currently avoidable. Nevertheless, it is not excluded that intra-renal artery stenosis with few hemodynamic significance might be missed by Doppler-ultrasonography.

Value of Doppler ultrasound for the diagnosis of renal artery stenosis in children

To evaluate the reliability of Doppler ultrasonography (US) in identifying children with renal artery stenosis (RAS) among those with hypertension, we compared Doppler US results in 22 hypertensive children (mean age 8.9 +/- 4.3 years), with (13 cases) and without RAS at angiography, and in 33 normotensive children (mean age 8.8 +/- 4.7 years). We observed 2 false-negatives and 2 false-positives with Doppler US. Of the 2 false-negative diagnoses, I had RAS on an accessory renal artery located behind a normal upper polar artery and the other was observed in a patient with bilateral multiple stenosis of the very distal segments of renal arteries. The 2 false-positive diagnoses were due to sinuous left renal artery and to technical reasons, respectively. In another patient, Doppler US showed a tight RAS, while arteriography was normal. RAS was subsequently confirmed by a second arteriography. Peak systolic velocity values of Doppler US were significantly higher in patients with proven angiographic RAS (3.44 +/- 0.66 m/s) than in hypertensive patients with normal renal arteries at angiography (0.99 +/- 0.35 m/s, P < 0.0001) and normotensive healthy children (1.04 +/- 0.23 m/s, P < 0.0001). With the use of multiple views, and the experience acquired with practice, false-negatives or false-positives due to the geometry of the renal artery can be avoided. Nevertheless, very distal stenosis can be missed by Doppler US.

Percutaneous treatment of acute iliac artery injury after intraaortic balloon counterpulsation

We report on a novel approach to correcting iliac artery occlusions caused by aortic counterpulsation. Two patients who had leg ischemia after retrieval of an intraaortic balloon pump underwent angiograms that showed occlusion of the right external iliac artery because of dissection (one case) or thrombosis (one case). Percutaneous self-expandable stents were implanted in the occluded vessels, and they fully restored normal iliac patency with no complications and satisfactory midterm follow-up results. We conclude that iliac artery occlusion induced by aortic counterpulsation can be safely treated by implanting self-expandable stents in cases of acute iatrogenic dissection.

[Non-surgical treatments of renal artery stenoses]

Management of patients with renal artery stenoses is aimed at normalizing or reducing blood pressure and correcting or preventing reduced glomerular filtration. The results of renal revascularization have been documented mainly in retrospective, uncontrolled reports in which blood pressure improvement was overestimated due to the placebo effect and optimization of drug treatment, the latter being frequently required despite adequate revascularization. In an overview of 10 series reporting blood pressure outcome following percutaneous angioplasty, cure rates were 50% in patients with fibrodysplastic stenosis but only 19% in those with atherosclerotic stenosis. The literature on revascularization of atherosclerotic stenosis with progressive renal failure shows that 55% of patients have improved renal function following surgery and 41% following angioplasty. Mortality is 6 and 5% respectively. The first controlled trials comparing revascularization to medical treatment in renal artery stenosis have recently been published. In a prospective randomized trial, Weibull et al. compared percutaneous angioplasty and surgery in 58 patients with unilateral atherosclerotic stenosis. Although 17% of the patients initially treated with angioplasty required subsequent surgery, blood pressure, renal function and renal artery patency rate did not differ between angioplasty and surgery 24 months after treatment. A Scottish group reported a prospective randomized trial of percutaneous angioplasty vs. medical therapy in patients with bilateral or unilateral atherosclerotic stenosis. In the bilateral group (n = 28), the drop in systolic pressure was significantly larger following angioplasty than following medical therapy, but diastolic pressure and creatinine did not differ after 24 months. In the unilateral group (n = 27), there were no differences in blood pressure or creatinine levels following angioplasty or medical therapy. Several randomized trials comparing angioplasty and conservative treatment or angioplasty and stent placement in patients with renal artery stenosis and normal or reduced renal function are currently underway. They should provide additional information regarding the risk/benefit ratio of these procedures.

[Spontaneous spinal epidural hematoma: 2 cases]

The authors report on two cases of spontaneous spinal epidural hematomas with atypical subacute clinical presentation and good recovery after surgical treatment. Etiologies, physiopathology, early diagnosis and treatment are considered through a brief review of the literature.

[Fibroblast growth factors (FGF-2) and delayed involution of the posterior limbs of the slow-worm embryo (Anguis fragilis, L.)]

Administration at doses of 1,800 ng to 6,200 ng of basic fibroblast growth factor (bFGF), around the posterior limb buds of young slow-worm (Anguis fragilis, L.) embryos developing in cultured eggs has, after 4 to 6 days, in several embryos (10 among 15, treated at stage of allantoic bud, from 3 to 9 mm long), delayed the involution of these posterior limbs: their anlagen are larger than the control ones and histological examination shows an increase, between 20% and 30%, of cell density in the mesodermal component of the limb bud. These results bring into light the possibility to control, to some degree, the regressive evolution of the limbs.

[Drug thrombolysis and mechanical recanalization in recent femoro-popliteal arterial occlusions]

Acute femoro-popliteal occlusions (native arteries or bypass grafts) were treated by medical and surgical treatment. Despite improvement in surgical technique, patient mortality was high and limb loss remained frequent. Percutaneous endoluminal treatment of such lesions is feasible using in situ fibrinolysis and/or thromboaspiration singly or in association with balloon angioplasty. Those techniques are effective and are currently the first intention treatment of many of those acute femoro-popliteal occlusion. The advantages and disadvantages of those techniques are discussed, as well as their respective indications, and particularly their place compared to surgical techniques. New devices such as mechanical thrombectomy may increase effectivity and indications of endovascular treatment however such devices need to be better evaluated.

[Fibroblast growth factor (FGF-2) and delayed involution of the posterior limbs of the slow-worm embryo (Anguis fragilis, L.)]

Administration at doses of 1,800 ng to 6,200 ng of basic fibroblast growth factor (bFGF), around the posterior limb buds of young slow-worm (Anguis fragilis, L.) embryos developing in cultured eggs has, after 4 to 6 days, in several embryos (10 among 15, treated at stage of allantoic bud, from 3 to 9 mm long), delayed the involution of these posterior limbs: their anlagen are larger than the control ones and histological examination shows an increase, between 20% and 30%, of cell density in the mesodermal component of the limb bud. These results bring into light the possibility to control, to some degree, the regressive evolution of the limbs.

Evidence for the effect of antibodies to TSH receptors on the thyroid ultrasonographic volume in patients with Graves' disease

OBJECTIVE

It has been demonstrated that antibodies (Ab) to thyroid-stimulating hormone receptors (R), which stimulate the thyroid gland, induce hyperthyroidism in patients with Graves' disease. Furthermore, it has been shown in thyroid cells in culture that thyroid-stimulating hormone receptor Ab acts through the adenosine 3', 5'-monophosphate pathway which stimulates both thyroid hormonogenesis and growth. We investigated the relations between thyroid autoimmunity expression and thyroid ultrasonographic parameters or thyroid hormonal status in patients with Graves' disease.

PATIENTS

A prospective study of 53 consecutive patients referred with untreated Graves' disease.

MEASUREMENTS

Measurements were made of serum TSH-R, peroxidase (TPO) and thyroglobulin (Tg) Ab and basal plasma free T4 (FT4), free T3 (FT3) and TSH. Thyroid morphological characteristics (number and total volume of nodule(s), total volume of lobes and total thyroid volume) were determined by ultrasonography.

RESULTS

There were significant correlations (P < 0.001) between TSH-RAb levels and FT4 values (r = 0.48) or FT3 levels (r = 0.46). Likewise, significant correlations were found between TSH-RAb levels and total lobe volume values (r = 0.56, P < 0.001), total nodular volume values (r = 0.59, P < 0.01) or total thyroid volume values (r = 0.63, P < 0.001). By contrast, no correlation was found between TSH-RAb levels and the number of nodules or between any of the ultrasonographic parameters and TPOAb levels or TgAB values.

CONCLUSIONS

This study demonstrates, in vivo, that TSH receptor antibodies modulate the thyroid ultrasonographic extranodular and nodular volumes in patients with Graves' disease.

Stenoses of renal branch arteries in fibromuscular dysplasia: results of percutaneous transluminal angioplasty

PURPOSE

To evaluate percutaneous transluminal renal angioplasty (PTRA) in the treatment of renal branch artery stenoses caused by fibromuscular dysplasia.

MATERIALS AND METHODS

The authors retrospectively studied the files of 20 consecutive hypertensive patients with 25 branch artery stenoses associated with 10 main renal artery lesions. Results at clinical and angiographic follow-up were assessed by means of life-table analysis.

RESULTS

PTRA was technically successful in 21 of the 25 renal branch artery stenoses (84%). One of the technical failures was treated by means of selective embolization. Nine of the 10 associated main renal artery lesions were successfully dilated, and the 10th was improved. Immediately after PTRA, at 6-month follow-up, and at long-term follow-up, 70%, 76%, and 68% of the patients, respectively, were cured and 25%, 24%, and 16% were improved. Stenosis recurred in 9% of the branch arteries and was associated with clinical relapse; these arteries were redilated, and all patients were considered cured at the second 6-month follow-up.

CONCLUSION

PTRA should be considered the first-line treatment for hypertension due to renal branch artery stenosis in fibromuscular disease.

[Calcitonin gene-related peptide (CGRP)]

Calcitonin gene-related peptide (CGRP), a 37 amino acid peptide resulting from the specific maturation processes of calcitonin gene products, was discovered in 1982. Its messenger RNA was isolated from a calcitonin cancer in rats similar to the human thyroid medullary carcinoma. CGRP is closely related to calcitonin and amylin, and to a lesser extent, to the region coding for the alpha chains of relaxins, insulin and insulin growth factors. In thyroid C cells, calcitonin itself is the major gene product, but CGRP is predominant in the central and peripheral nervous system. CGRP is found in most all tissues and is considered to be a neuromediator of particular importance in the cardiovascular system. CGRP is a powerful endogenous vasodilator in man; plasma concentrations of 56 pmol/l (slightly above physiological levels) provoke flush, hypotension and secondary catecholamine release and subsequent tachycardia. Intravenous injections lead to systemic vasodilatation and redistribution of blood flow to the skin, the brain, and probably the splanchnic territory. It has been suggested that CGRP plays a role in blood pressure modulation in certain pathological conditions. CGRP level is decreased in hypertension and increased in septic shock. In patients with terminal renal failure, CGRP is correlated with excess volaemia. It could affect blood pressure by redistributing blood flow, interacting with the renin-angiotensin system or by inhibiting aldosterone secretion. CGRP may also play a role in modulating cutaneous vascular constriction in Raynaud's syndrome and cerebral vascularization in patients with migraine or meningeal hemorrhage subsequent to rupture of cerebral aneurisms. CGRP increases arterial flow in the cavernous body. Coronarian vascular tone and cardiac performance (positive chronotrope and inotrope effects) are improved. CGRP has also been studied in connection with glucose metabolism and may have other endocrine effects. Finally, CGRP increases electrolyte and water flow in the colon and its bronchoconstrictor effect could be implicated in asthma. The clinical significance of plasma CGRP is not yet known although it may be a marker of poor prognosis in thyroid medullary cancer. Recent studies suggest that CGRP could be a useful therapeutic agent in severe Raynaud syndrome, impotency, ischaemic neurological lesions due to ruptured aneurisms and in severe heart failure.

[Percutaneous endoluminal angioplasty of the transplanted kidney. Long-term follow-up]

A hundred and ninety five percutaneous transluminal angioplasty (PTA) of a renal transplant artery were attempted before january 1st, 1990 in 151 patients. Analysis of the series was essentially based on follow-up after PTA. PTA was initially successful in 85% of the patients. Restenoses occurred in 30% of the patient. They were usually amenable to repeat PTA. Restenosis rate after repeat PTA was of 26%. The five year secondary patency rate of the renal artery was over 85%. After a successful PTA, the blood pressure, the number of antihypertensive drug per patient and serum creatinine returned to a level close to their basal value within few days and remained stable long. After an immediate failure of PTA, secondary patency rate of the renal transplant artery was over 80% at one year. Blood pressure returned to a level close to its basal value. But, that improvement was slower (1 to 6 months) and antihypertensive drug regimen and serum creatinine remained stable. We conclude that PTA is an effective treatment at long term of hypertension and of decline in renal function due to stenoses of renal transplant arteries. However PTA carried some risks and should be attempted only stenoses of renal transplants arteries cause, severe hypertension resisting to medical therapy or decline in renal function.

[Internal mammary arteriovenous fistula. An unusual complication of sternotomy treated by embolization]

A case of arteriovenous fistula and false aneurysm of the internal mammary artery due to sternotomy is reported. The diagnosis was suspected by echo-Doppler and confirmed by arteriography, allowing percutaneous embolization in the same session.

Restenosis after a first percutaneous transluminal renal angioplasty

The incidence of restenosis after a first successful percutaneous transluminal angioplasty of a native renal artery and the clinical and angiographic variables that may influence its occurrence were studied in 104 hypertensive patients. Angiograms obtained immediately before and after angioplasty and, in 92 patients, 8.8 +/- 6.0 months after angioplasty were interpreted separately by two observers. Stenosis severity was classified into five grades, and restenosis was defined by a stenosis one grade or more higher at follow-up than immediately after angioplasty. Interobserver concordance for etiology, stenosis grade, and other angiographic items yielded kappa coefficients in the range of 0.328-0.942. Sessions were organized to reach a consensus in each case. Ostial stenoses were more frequent in patients with atheromatous stenoses, and branch stenoses were more frequent in those with fibromuscular dysplasia. There was no significant difference between the 15 patients (16%) with restenosis and those without concerning sex distribution, mean age, mean blood pressure, plasma creatinine level, and etiology distribution. Truncal stenoses were less prone to restenosis than ostial or branch stenoses (12% versus 35%, respectively; 95% confidence interval of difference, -0.6% to 47%). In patients with atheromatous stenoses, aortitis or aortic ectasia were associated with a high restenosis incidence (35% when present versus 8% when absent; 95% confidence interval of difference, 5% to 48%). In conclusion, restenosis was observed in one sixth of patients after a first successful renal angioplasty; its incidence was low in patients with truncal stenoses and high in those with severe aortic atheroma. Automated renal artery stenosis quantification methods are needed to standardize stenosis description.

DNA synthesis decline involved in the developmental arrest of the limb buds in the embryos of the slow worm, Anguis fragilis (L.)

The present study was carried out to try and detect the biochemical mechanism involved in the developmental arrest of the limb bud in a serpentiform Reptile. Autoradiograpy, following tritiated thymidine incorporation, in embryos of the slow-worm (Anguis fragilis, L.) reveals a strong decrease in the rate of DNA synthesis in the mesodermal cells of the limb bud, after the degeneration of the apical ectodermal ridge (AER); the curve (a function of Gompertz) visualizing this decline shows that the drop in DNA synthesis becomes accentuated just after the degeneration of the AER. This decrease precedes the reduction of the mitotic index, the cell degeneration in the mesoderm and the other regressive changes occurring in the limb bud; it thus appears as the main causative factor of the developmental arrest of the limb bud. Furthermore, these results suggest that one of the functions of the AER would be to maintain a high level of DNA synthesis in the mesoderm underlying the AER in a normal limb bud.

[Renovascular arterial hypertension. Evaluation of ultrasonographic measurement of kidney length]

In order to evaluate the ultrasonographic measurement of kidney length, 32 hypertensive patients with renal arterial stenosis treated by intraluminal angioplasty were examined by several ultrasonographies performed by the same observer before and after dilatation. The lack of variation in the contralateral kidney length ascertained the intra-observer reproducibility of the method. We found that ischaemic kidneys were smaller and that this diminution in size depended on the renal arterial lesion (kidneys below atheromatous lesions were of smaller size than those below fibrodysplastic lesions). The increase in size of kidneys treated by angioplasty was most probably due to an increase in perfusion pressure and was to be compared with the results of a separate evaluation of renal function. However, this method has no individual applications in view of the important kidney length distribution at cross-checkings.