[Clinical case of the month. Hepatitis B reactivation in an Ag HBs negative patient]. / Le cas clinique du mois. Un cas de réactivation virale B chez un patient Ag HBs négatif.

A 66-year-old man, Ag HBs negative, suffering from glomerulonephritis was treated with prednisone. Hepatitis B reactivation was observed after increasing and regression of corticotherapy. Pathogenesis, efficient therapy and prevention of reactivation of hepatitis B will be reviewed.

[Heart transplantation: secondary prevention]. / Transplantation cardiaque: prévention secondaire.

Cardiac transplantation is the treatment of choice for refractory heart failure. An immunosuppressive therapy must be given in the perioperative course to avoid graft rejection. In this article, we review the main classes of immunosuppressive agents (calcineurin inhibitors, anti-metabolities, corticoïds) and their side effects. The general preventive measures and the different kinds of rejection (hyperacute, acute vascular, acute cellular and chronical) are discussed. The current bacterial, protozoarian, mycotic and viral infections are described. We finish with the risk of cancer, mainly skin tumours and non-Hodgkinian lymphomas.

["Take this heart away!": from fear of rejection to post-transplant delirium]. / "Arrachez-moi ce coeur!": de la crainte du rejet au délire après transplantation cardiaque.

Orthotopic heart transplantation is a major surgical intervention inducing conscious and unconscious psychological distress. Though all reports indicated global improvement of quality of life from pre- to post-transplantation, most retrospective and longitudinal studies found a high prevalence of psychopathology before and after surgery. Post-operative acute psychotic disorders are uncommon but they severely hamper the medical progress and require an immediate psychiatric assistance. The case of Pascal, a young receiver who presented a brief persecution delusional disorder after the first transplantation, showed the dramatic character of such unexpected symptoms.

[Prevalence and treatment of Helicobacter pylori in gastro-duodenal ulcers. An experience in Liege]. / Prévalence et traitement de l'Helicobacter pylori dans les ulcères gastro-duodénaux. Une expérience liégeoise.

Between April 1998 and July 1999, we prospectively investigated 152 patients with gastric or duodenal ulcer and we observed concomitant H. pylori infection in 72.8% and 78.5% respectively. We proposed to the GPs of these patients the recommended triple therapy (omeprazole 20 mg, amoxicillin 1 g and clarithromycin 500 mg (OAC) twice daily for 7 or 10 days). H. pylori eradication was tested using the C13-urea breath test. Our results showed a modest overall eradication rate of about 70%. We have to persuade the patients and the GPs of the benefit of antibiotics and of the importance of the correct dosages. We have to continue to follow the resistance against antibiotics.

Psychological distress of surgical patients after orthotopic heart transplantation.

Orthotopic heart transplantation (OHT) is a major surgical intervention inducing distress and anxiety. Psychological problems after OHT have been described in many studies. Little is known, however, about the relationship between the psychological state of the patient and time after surgery. The present study involved 41 consecutive OHT patients that underwent transplantation from January 1991 to December 1992, with a retrospective review of pretransplant psychiatric evaluations to define a Diagnostic and Statistical Manual of Mental Disorders, 3rd edn., revised (DSM III-R) Axis I diagnosis. Patients completed the Beck Depression Inventory (BDI-13), Spielberger's State Trait-Anxiety Inventory (STAI-Y), and the General Health Questionnaire (GHQ-28) between 1 and 41 months after transplantation. For comparison, 29 presumably healthy volunteers were given the same questionnaires. The study confirms the occurrence of abnormal psychological scores in the OHT group as compared to the reference population. Psychological scores, however, do not appear to be related to the time they were recorded after surgery.

[Epidemiological aspects, risk factors, and detection of pancreatic cancer]. / Epidémiologie, facteurs de risque et dépistage du cancer du pancréas.

The incidence of pancreatic cancer (PC) is increasing in developing countries. Smoking, reduced consumption of fruits and vegetables, chronic pancreatitis appear to be the best established risk factors. PC is often diagnosed at a late stage. We have to look for it when dyspepsia with weight loss, pancreatic pain or impaired glucose tolerance occurs. Tumor markers are briefly exposed and we discuss the place of endoscopic retrograde cholangiopancreatography (ERCP) after non invasive imaging techniques.

[Endoscopic ultrasonography in the diagnosis and staging of pancreatic and ampullary cancer: influence on patient management]. / Apport de l'échoendoscopie (EE) au diagnostic et à la stadification des cancers pancréatiques et ampullaires: influences sur la prise en charge du patient.

Accurate preoperative staging is now more prerequisite in the management of cancer of the pancreas and ampulla in order to orientate the patient toward the best selected treatment: either a curative or a palliative surgery associated or not with a pre- or postoperative multimodal therapy, or an endoscopic palliative technique which does not require surgery. Endoscopic ultrasonography (EUS) appears to be a highly accurate diagnostic procedure in the assessment of local resectability because it enables detailed visualization of the pancreatic gland, the depth of infiltration into the surrounding tissue and organs and visualisation of regional lymph nodes involvement. EUS-guided fine needle aspiration for cytology will provide a tissue diagnosis. The likelihood of successful resection for palliative or cure can be predicted before surgery. The following overview will point out the clinical impact of EUS on diagnosis, staging and management of these tumors.

Heart graft monitoring by the ventricular evoked response.

Monitoring of the negative slew rate of the evoked T wave has been proposed as a noninvasive diagnostic tool to follow heart transplant recipients. The clinical contribution of this measurement on telemetrically recorded, paced unipolar ventricular electrograms was evaluated in the detection of grade 3 acute allograft rejection. Thirteen patients undergoing heart transplantation received a DDD pacemaker connected to two epimyocardial leads. Electrograms were recorded and digitized after each endomyocardial biopsy (EMB). The maximum slew rate of the descending slope of the repolarization phase (RSP) was extracted and normalized. A 20% downward shift of RSP from the reference value was considered abnormal. Results of signal processing were blinded during the first 6 months. Eleven patients completed the 6 months blinded period and two patients died. A total of 101 EMB were graded according to the International Society for Heart and Lung Transplantation classification. Grade 3 was assigned to 9 EMB. A significant difference was found between RSP values measured during grade 3 rejection episodes and other RSP values (P < 0.001). A diagnostic model consisting of a single threshold test confirmed the ability of RSP to predict significant signs of rejection on EMB (P < 0.0001). The sensitivity of RSP in detecting grade 3 rejections was 100%, specificity was 81%, negative predictive value 100%, and positive predictive value 35%. The use of RSP as a noninvasive monitoring tool to pose the indication for a biopsy would avoid 73% of EMB. Monitoring of transplanted hearts based on the analysis of the ventricular evoked response is promising and may markedly reduce the number of EMB.

Successful bridge to transplantation with Pierce Donachy (Thoratec) ventricular assist device.

Biventricular assistance with the Thoratec ventricular assist device was performed in a 48-year-old man waiting heart transplantation since 6 months. Indication for circulatory support was considered because of the development of progressive irreversible right heart failure with deterioration of the hepatic and renal functions. Orthotopic heart transplantation was performed after 13 days of circulatory support. No complications occurred during the assistance and in the posttransplant period. The patient was discharged on day 21 after transplantation. Five months after transplantation he is well and alive.

Successful management of acute aortic dissection in a heart transplant recipient.

A case of type III aortic dissection which occurred fourteen months after heart transplantation is presented. Medical therapy was instituted to achieve controlled hypotension. The evolution was favorable and the patient could be discharged after one month. Hypertension and increased ejection fraction after transplantation could have been predisposing factors via an increase of the shear stress in the aorta.

Fatal mural endocarditis and cutaneous botryomycosis after heart transplantation.

Fatal mural endocarditis and botryomycosis occurred concurrently in a 62-year-old women 4 months after orthotopic heart transplantation. Subsequent to mild mitral regurgitation, infection developed on a left atrial thrombus and was complicated by cerebral embolization. Simultaneously, skin nodules manifested on both forearms. Histologic examination revealed typical aspects of early evolving botryomycosis with massive infiltration of the dermis and hypodermis by necrotic granulomas framed by grains of Gram-positive coccoid forms. Bacteria were decorated by a nonspecific polyclonal antibody to Mycobacterium bovis.

Acute diverticulitis in heart transplant recipients.

Immunosuppressed patients are susceptible to complicated diverticulitis, but reports of this complication are scarce in heart graft recipients. To estimate the prevalence of acute diverticulitis in heart graft recipients, we retrospectively reviewed the cases of diverticulitis in a series of 143 patients who underwent orthotopic heart transplantation in a period of 10 years. Six (4%) of these developed acute diverticulitis and required colectomy. All of them were male patients and were older than 50 years. Four patients underwent urgent laparotomy and colon resection with end colostomy (Hartmann procedure). The two other patients suffered from diverticulitis without generalized peritonitis and underwent laparoscopic sigmoidectomy with direct transanal end-to-end anastomosis. The postoperative outcomes of these six patients were satisfactory. As are other immunosuppressed patients, heart graft recipients are susceptible to diverticulitis. Early surgical management may be safe in well-compensated patients.

Successful abdominal aortic aneurysm resection in long-term survivors of cardiac transplantation.

With the improvement of survival rates following cardiac transplantation, the probability of recipients developing extracardiac disease is increased. Three cases are reported of abdominal aortic aneurysm successfully operated on in cardiac allograft recipients 1 to 4 years after transplantation. Indications for transplantation were valvular, idiopathic and ischaemic cardiomyopathy. Post-transplant hypertension and hyperlipidaemia may have played a role in the rapid growth of the aneurysms. Cardiac function and the incidence of graft atherosclerosis were assessed before surgery by coronary angiography. All three patients were discharged from hospital. Abdominal aortic aneurysm resection may be a safe procedure in cardiac transplant patients. In view of the rapid increase in the size of the aneurysms in transplanted patients, careful screening should be performed during follow-up.

Pacemaker implantation for early sinus node dysfunction after orthotopic heart transplantation.

Among 60 patients who received OHT at our institution between November 1986 and January 1990, 4 actually needed implantation of a permanent pacemaker. Three patients with symptomatic early sinus node dysfunction were identified and were satisfactorily paced on the VVIR mode. All three showed sinus recovery within three months following implantation and had their pacemaker switched from the VVIR mode to a simple ventricular demand pacing. Interestingly, administration of beta-blocking drugs quickly reinstituted pace dependence. The patients' outcome is excellent (18 to 48 months follow-up). No difference with the global cohort of our OHT recipients was noticed, apart from an apparent high incidence of infections (3/3) with (2/3) CMV and severe rejection (3/3) during the first month postoperatively. This data suggests that sinus dysfunction may be the result of a multifactorial (rejection, CMV, ...) injury to the conduction system, and is only clinically relevant beyond a threshold level. Denervation hypersensitivity, together with correction of these factors, may account for the restoration of a sufficient reserve of conduction system, and therefore appropriate sinus node function in basal conditions.