[Hyperhomocysteinemia and leg ulcers: A prospective study of 68 patients]. / Hyperhomocystéinémie et ulcères de jambes : étude prospective de 68 observations.

BACKGROUND: Homocysteine is a sulphur-containing amino acid derived from methionine. Hyperhomocysteinaemia is now recognised as an independent risk factor for occlusive arterial disease and thrombotic venous disease. The aim of this study was to determine the prevalence of hyperhomocysteinemia in patients with leg ulcers. PATIENTS AND METHODS: We prospectively investigated hospitalised patients for vascular leg ulcers between March 2008 and June 2009 at two dermatology centres. We collected details of cardiovascular disease and determined nutritional status by means of the MNA score. Fasting blood samples were taken and analyzed for homocysteine, albumin, prealbumin, folic acid, vitamin B12, creatinine and a complete blood count. RESULTS: Sixty-eight patients were enrolled in the study: 48 women and 20 men. Fifty-three percent of patients had venous leg ulcers, 18% had arterial leg ulcers and 20% had leg ulcers of mixed origin. The prevalence of hyperhomocysteinemia was 56%, with no differences according to ulcer type or gender. DISCUSSION: While the prevalence of hyperhomocysteinemia in our population of leg ulcer patients was high, this descriptive study does not allow us to establish any causal link between hyperhomocysteinemia and leg ulcers. Moreover, since the literature indicates that homocysteine-lowering therapy does not reduce cardiovascular and thromboembolic risk, there appears to be little call for further trials on hyperhomocysteinaemia and leg ulcers.

[Anticoagulation after renal transplantation: a multicenter survey on clinical practice]. / Quelle thromboprophylaxie après transplantation rénale ? Enquête sur la prévention des thromboses du greffon en France.

OBJECTIVES: Graft thrombosis is a major complication of transplantation. However, there are no recommendation on immediate postoperative thromboprophylaxis after kidney transplantation. We recorded clinical practices in France. MATERIAL AND METHODS: In 29 transplantation centres, four case studies were submitted to the medical kidney transplantation referent (compatible graft from cadaveric donor, without perioperative complication). N(o) 1: Man, 27-years-old, IgA glomerulonephritis, without history of hypercoagulability or cardiovascular risk factor. Hemodialysis since 12months. N(o) 2: Man, 53-years-old, with history of deep venous thrombosis after cholecystectomy 15years before. Membranous nephropathy. Hemodialysis since 10months. N(o) 3: Man, 58-years-old, with history of myocardial infarction. On aspirin therapy. Nephroangiosclerosis and diabetic nephropathy. Peritoneal dialysis since 6months. N(o) 4: Woman, 63-years-old. Atrial fibrillation on vitamin K antagonists therapy. Lupus nephritis without antiphospholipid syndrome. Hemodialysis since 12months. RESULTS: N(o) 1: No anticoagulation therapy (62%), calcium heparin at prophylactic doses (34.5%). N(o) 2: No anticoagulation therapy (38%), calcium heparin at prophylactic doses (44.8%). N(o) 3: 62% interrupted aspirin of whom 22% without any immediate anticoagulation and 55% replaced aspirin with calcium heparin at prophylactic doses. Thirty-eight percent carried on with aspirin of whom 63.6% without other prophylaxis and 27.3% in association with calcium heparin at prophylactic doses. N(o) 4: Unfractionned heparin at curative dose (62%), unfractionned heparin at prophylactic doses (17.2%), calcium heparin at prophylactic doses (13.8%). CONCLUSION: Postoperative anticoagulation after renal transplantation is established as a local dogma rather than evidence-based medicine. Guideline recommendations and standardized protocols for the use of anticoagulation after kidney transplantation should be developed.

[What kind of treatment are available in deep vein thrombosis prevention?]. / Quels sont les moyens thérapeutiques (physiques, mécaniques, médicamenteux) disponibles et leurs modalités de surveillance?

In order to propose new recommendations concerning deep vein thrombosis prevention in surgery and obstetrics, we identified all the available tools. We performed a Medline search for ten years to review all the studies published in this field. This preliminary stage is mandatory in assessing guidelines able to work out strategies considering each patient in each particular surgical situation. There are no formal guidelines and we outlined a practical approach for the prevention of deep vein thrombosis. Data concerning all available treatment were not classified in an evidence-based strategy.

The effects of capsaicin on the neurogenic hyperreflexic detrusor. A double blind placebo controlled study in patients with spinal cord disease. Preliminary results.

PURPOSE: Several recent open studies have provided encouraging results as to the efficacy of intravesical installations of capsaicin for neurogenic hyperreflectivity. The present trial was performed to verify these results under controlled conditions. Intravesical installation of capsaicin represents a new therapeutic hope for the treatment of the neurogenic hyperrelfexic bladder. METHOD: This randomized, double-blind study compared the results of the intravesical installation of 30 mg capsaicin in 100 ml of 30% alcohol (experimental group) with those of installing 100 ml 30% alcohol alone (control group). On day 0 and day 30, urodynamic and biopsic examinations were performed in all subjects of each group. PATIENTS: All the subjects included in the study had a functionally disabling form of neurogenic hyperreflexic bladder resistant to the usual therapies. Cystoscopy and retrograde cystography were performed to exclude any patient who presented with a tumor-like lesion or had vesicoureteral reflux. RESULTS: Twelve paraplegic of tetraplegic subjects, seven women and five men whose average age was 46, were included. Eight had multiple sclerosis, and four had sustained a traumatic spinal cord injury. The patients were randomly separated into two groups of six. Initially, there was no clinical or urodynamic differences in these groups. Installation immediately triggered side effects and during the first 7 days (suprapubic burning sensation, sensory urgency, hot flushes, autonomic hyperreflexia, hematuria) in five of the six subjects in both groups. Bladder biopsy revealed no significant deterioration. On day 30, there was improvement in all of the experimental-group of patients with significant regression of leakage (P = 0.002) and of sensory urgency (P = 0.01). Only one control subject had amelioration. Urodynamic examination showed a rise in bladder capacity from 172.5 to 312.3 ml in the experimental group, significantly greater (P = 0.03) than the rise from 129 to 175.3 ml observed in the control group. CONCLUSION: This trial fully confirms the efficacy of intravesical installations of capsaicin, an efficacy obtained at the cost of nonnegligible side effects. An intermediate-term follow-up of this treatment will be necessary before considering more widespread use of this agent.

[Non-iatrogenic injuries of the ureter]. / Les plaies non iatrogènes de l'uretère.

The increasing number of non-iatrogenic ureteric injuries can be explained by the increasing crime rate in certain large cities and by the performance of intensive car teams, both in civilian practice civil and in a context of war. The discovery of an ureteric injury during salvage laparotomy for vascular or visceral lesions is no longer exceptional. The initial diagnosis is missed in 10 to 20% of cases, due to the absence of any specific clinical signs, as radiological opacification of the urinary tract is rarely performed and the clinical situation is dominated by associated lesions. The treatment of ureteric injuries is guided by the severity and septic nature of associated lesions and the ballistic context. When the ureteric lesion is short and associated lesions are limited, urinary continuity can be restored, after debridement of the extremities, by end-to-end anastomosis for the upper 2/3 and by direct vesical reimplantation or into a psoas bladder for the lower 1/3. Drainage is ensured is by an externalised ureteric catheter or a double J stent and must be kept in place for at least 3 weeks. In the presence of a defect of the upper two-thirds of the ureter, mobilization of the kidney and the renal pedicle or transureteroureterostomy may be considered. In the case of unstable haemodynamic status, very septic associated lesions or in the presence of multiple fragments, urinary diversion by nephrostomy or in situ ureterostomy is indicated. Extensive contusion of the ureteric wall must be intubated to prevent fistula secondary to necrosis. Nephrectomy is inevitable in 10 to 20% of patients.

[Fibrinogen: a risk factor]. / Le fibrinogène: facteur de risque.

More than 10 epidemiologic studies have established that a high fibrinogen level is a thrombotic risk factor. The role of fibrinogen in arterial occlusion is multiple : the atheroma plaque involvement in formation thrombus, erythrocyte aggregation, whole blood and plasma viscosity. Fibrinogen level is high during inflammation and increases with ageing and in tobacco addicts. In coronary disease, it is an independent risk factor of prognosis value. In arterial peripheral disease, it is a risk factor of postsurgical reocclusion. After a stroke, a high level of fibrinogen is a sign of severe disease. The dosage of fibrinogen is quite easy but requires a precise calibration. The determination of genetic polymorphism associated with high fibrinogen level is promising. Many circumstances can modify fibrinogen level and are targets for prophylaxis treatments. The influence of genetic factors is still discussed.

[Massive pulmonary embolism disclosing thrombocytopenia induced by low molecular weight heparin. Therapeutic success of prostacyclin]. / Embolie pulmonaire massive révélant une thrombopénie induite par héparine de bas poids moléculaire. Succès thérapeutique d'une prostacycline.

The authors report a case of massive pulmonary embolism revealing thrombocytopenia induced by a low molecular weight heparin (LMWH) initially proposed for the treatment of superficial phlebitis. The diagnosis was confirmed by in vitro aggregation tests and a fall in the platelet count when the LMWH was reintroduced. The outcome was clinically, angiographically and hematologically satisfactory in response to in situ treatment with prostaglandin, subsequently replaced by Vitamin K antagonists.

Comparative ototoxic effects of RU 25434, amikacin and neomycin in guinea-pigs.

The ototoxic effects of RU 25434, a new semi-synthetic aminoglycoside antibiotic, were compared to those of amikacin and neomycin. Experiments were performed in adult and new-born guinea-pigs, ototoxicity being assessed by Preyer's reflex response and the measurement of the cochlear microphonic potentials at the end of treatment. The well known ototoxicity of neomycin was observed and RU 25434 appeared to be relatively less toxic than amikacin. The use of new-born guinea-pigs seem to be particularly suitable for this type of study because of their apparent sensitivity to ototoxicity.

Rapid identification of patients with essential hypertension sensitive to acebutolol (a new cardioselective beta-blocker).

Acebutolol, a new cardioselective beta-blocking agent, was administered for 48 hours to 44 patients with essential hypertension at a total dosage of 2.0 g (2,000 mg). The slowing down of their pulse rate and the decrease in blood pressure were highly significant, whereas eight subjects treated with placebos had no change in either the pulse rate or blood pressure. Plasma renin activity decreased from 2.26 +/- 2.11 ng/ml/hour to 0.87 +/- 1.04 ng/ml/hour. The decrease in blood pressure was correlated with the initial plasma renin activity and with the decrease in plasma renin activity. These results demonstrate that a rapid decrease in blood pressure can be obtained in patients with essential hypertension treated with acebutolol and that the decrease in blood pressure is related to the initial state of the renin-angiotensin system.