[Sodium bicarbonate to slow the progression of chronic kidney disease]. / Bicarbonate de sodium pour ralentir la progression de la maladie rénale chronique.

Metabolic acidosis is a prevalent complication in moderate and late stages of chronic kidney disease (CKD). It is established that the correction of metabolic acidosis may improve metabolic bone disorders and protein degradation in the skeletal muscle, two characteristic complications of patients with advanced CKD. In the last 18 months, three randomized controlled trials have drawn the attention on a novel indication to correct metabolic acidosis in these patients, i.e., halting CKD progression. These data show that sodium bicarbonate, a cheap and easily manageable treatment, may delay the progression of CKD and the need of a renal replacement therapy such as dialysis or kidney transplantation.

[Highlights 2007 in hospital-based internal medicine: the point of view from the chief residents]. / Nouveautés en médecine interne hospitatière 2007: perspective des chefs de clinique.

In 2007, several international studies brought useful information for the daily work of internists in hospital settings. This summary is of course subjective but reflects the interests and questions of the chief residents of the Department of internal medicine who wrote this article like an original trip in medical literature. This trip will allow you to review some aspects of important fields such as heart failure, diabetes, endocarditis, COPD, and quality of care. Besides the growing diversity of the fields covered by internal medicine, these various topics underline also the uncertainty internists have to face in a practice directed towards evidence.

Dissemination of CTX-M-type beta-lactamases among clinical isolates of Enterobacteriaceae in Paris, France.

We analyzed 19 clinical isolates of the family Enterobacteriaceae (16 Escherichia coli isolates and 3 Klebsiella pneumoniae isolates) collected from four different hospitals in Paris, France, from 2000 to 2002. These strains had a particular extended-spectrum cephalosporin resistance profile characterized by a higher level of resistance to cefotaxime and aztreonam than to ceftazidime. The bla(CTX-M) genes encoding these beta-lactamases were involved in this resistance, with a predominance of bla(CTX-M-15). Ten of the 19 isolates produced both TEM-1- and CTX-M-type enzymes. One strain (E. coli TN13) expressed CMY-2, TEM-1, and CTX-M-14. bla(CTX-M) genes were found on large plasmids. In 15 cases the same insertion sequence, ISEcp1, was located upstream of the 5' end of the bla(CTX-M) gene. In one case we identified an insertion sequence designated IS26. Examination of the other three bla(CTX-M) genes by cloning, sequencing, and PCR analysis revealed the presence of a complex sul1-type integron that includes open reading frame ORF513, which carries the bla gene and the surrounding DNA. Five isolates had the same plasmid DNA fingerprint, suggesting clonal dissemination of CTX-M-15-producing strains in the Paris area.

Aqueous dynamic and histological findings after deep sclerectomy with collagen implant in an animal model.

AIM: The use of an animal model to study the aqueous dynamic and the histological findings after deep sclerectomy with (DSCI) and without collagen implant. METHODS: Deep sclerectomy was performed on rabbits' eyes. Eyes were randomly assigned to receive collagen implants. Measurements of intraocular pressure (IOP) and aqueous outflow facility using the constant pressure method through cannulation of the anterior chamber were performed. The system was filled with BSS and cationised ferritin. Histological assessment of the operative site was performed. Sections were stained with haematoxylin and eosin and with Prussian blue. Aqueous drainage vessels were identified by the reaction between ferritin and Prussian blue. All eyes were coded so that the investigator was blind to the type of surgery until the evaluation was completed. RESULTS: A significant decrease in IOP (p<0.05) was observed during the first 6 weeks after DSCI (mean IOP was 13.07 (2.95) mm Hg preoperatively and 9.08 (2.25) mm Hg at 6 weeks); DS without collagen implant revealed a significant decrease in IOP at weeks 4 and 8 after surgery (mean IOP 12.57 (3.52) mm Hg preoperatively, 9.45 (3.38) mm Hg at 4 weeks, and 9.22 (3.39) mm Hg at 8 weeks). Outflow facility was significantly increased throughout the 9 months of follow up in both DSCI and DS groups (p<0.05). The preoperative outflow facility (OF) was 0.15 (0.02) micro l/min/mm Hg. At 9 months, OF was 0.52 (0.28) microl/min/mm Hg and 0.46 (0.07) micro l/min/mm Hg for DSCI and DS respectively. Light microscopy studies showed the appearance of new aqueous drainage vessels in the sclera adjacent to the dissection site in DSCI and DS and the apparition of spindle cells lining the collagen implant in DSCI after 2 months. CONCLUSION: A significant IOP decrease was observed during the first weeks after DSCI and DS. DS with or without collagen implant provided a significant increase in outflow facility throughout the 9 months of follow up. This might be partly explained by new drainage vessels in the sclera surrounding the operated site. Microscopic studies revealed the appearance of spindle cells lining the collagen implant in DSCI after 2 months.

The Fugu rubripes tyrosinase gene promoter targets transgene expression to pigment cells in the mouse.

The regulation of the mouse tyrosinase gene expression is controlled by a highly conserved element at -100 bp, the M-box, and an enhancer at -12 kb. In most vertebrates, the length of intergenic sequences makes it difficult to analyze the whole gene and the complete regulatory region. We took advantage of the compact Fugu genome to identify regulatory regions involved in pigment cell-specific expression. We isolated the Fugu tyrosinase gene, and identified putative cis-acting regulatory elements within the promoter. We then asked whether the Fugu promoter sequence functions in mouse pigment cells. We showed that E11.5 transgenic embryos bearing 6 kb or 3 kb of Fugu tyrosinase 5' sequence fused to the reporter gene lacZ revealed melanoblast and RPE-specific expression. This is the first evidence that the tyrosinase promoter is active at midgestation in melanoblasts, long before the onset of pigmentation.

Comparison of PCR-ribotyping, arbitrarily primed PCR, and pulsed-field gel electrophoresis for typing Clostridium difficile.

Clostridium difficile is now recognized as the major agent responsible for nosocomial diarrhea in adults. Among the genotyping methods available, arbitrarily primed PCR (AP-PCR), PCR-ribotyping, and pulsed-field gel electrophoresis (PFGE) have been widely used for investigating outbreaks of C. difficile infections. However, the comparative typing ability, reproducibility, discriminatory power, and efficiency of these methods have not been fully investigated. We compared the results of three methods-AP-PCR with three different primers (AP3, AP4, and AP5), PCR-ribotyping, and PFGE (with SmaI endonuclease)-to differentiate 99 strains of C. difficile that had been previously serogrouped. Typing abilities were 100% for PCR-ribotyping and AP-PCR with AP3 and 90% for PFGE, due to early DNA degradation in strains from serogroup G. Reproducibilities were 100% for PCR-ribotyping and PFGE but only 88% for AP-PCR with AP3, 67% for AP-PCR with AP4, and 33% for AP-PCR with AP5. Discriminatory power for unrelated strains was >0.95 for all the methods but was lower for PCR-ribotyping among serogroups D and C. PCR-based methods were easier and quicker to perform, but their fingerprints were more difficult to interpret than those of PFGE. We conclude that PCR-ribotyping offers the best combination of advantages as an initial typing tool for C. difficile.

Aqueous dynamics in experimental ab externo trabeculectomy.

PURPOSE: This study assessed the decrease in intraocular pressure (IOP), the residual outflow resistance of the trabeculum and the filtration site by histology in enucleated pig and human eyes after ab externo trabeculectomy. METHOD: Measurement of the resistance to aqueous outflow was performed using the constant pressure method before and after ab externo trabeculectomy. RESULTS: The outflow facility was 0.31 +/- 0.13 microl/min/mm Hg in pig eyes and 0.24 +/- 0.08 microl/min/mm Hg in human eyes before surgery, and 79.0 +/- 47. 6 microl/min/mm Hg in pig eyes and 6.33 +/- 6.67 microl/min/mm Hg in human eyes after ab externo trabeculectomy. On histological examinations the aqueous outflow pathway was seen to be at the level of the residual trabecular meshwork. CONCLUSION: This study showed that ab externo trabeculectomy significantly lowers IOP and improves outflow facility in enucleated pig and human eyes.

Mycobacterium celatum infection in two HIV-infected patients treated prophylactically with rifabutin.

Mycobacterium celatum is a recently described slow-growing species. It was identified on the basis of genomic sequencing that differentiates three types. The present report describes two cases of Mycobacterium celatum type 1 infection in patients with AIDS. Both patients had CD4+ lymphocyte counts of < 10/mm3, were receiving rifabutin prophylaxis, and had attended the same treatment units. The minimum inhibitory concentration of rifabutin for both strains was 8 mg/l, which may account for the failure of prophylaxis. As all type 1 strains have the same pulsed-field gel electrophoresis pattern, nosocomial transmission or acquisition from a common source could not be ruled out.

Does sacral posterior rhizotomy suppress autonomic hyper-reflexia in patients with spinal cord injury?

OBJECTIVE: To study the occurrence of autonomic hyper-reflexia (AHR) after intradural sacral posterior rhizotomy combined with intradural sacral anterior root stimulation, performed to manage the neurogenic hyper-reflexic bladder and to determine the pathophysiological basis of the uncontrolled hypertensive crisis after sacral de-afferentation. PATIENTS AND METHODS: Ten patients with spinal cord injury operated using Brindley's method between September 1990 and February 1994 were reviewed. Systematic continuous non-invasive recordings of cardiovascular variables (using a photoplethysmograph) were made during urodynamic recordings and the pre- and post-operative vesico-urethral and cardiovascular data compared. RESULTS: Nine of the 10 patients were examined using a new prototype measurement system; one woman refused the last urodynamic assessment. Eight of the nine patients who presented with AHR before operation still had the condition afterward. There was a marked elevation in systolic and diastolic blood pressure during the urodynamic examination in all eight patients, despite complete intra-operative de-afferentation of the bladder in five. The elevation of blood pressure started during the stimulation-induced bladder contractions and increased during voiding in all cases. Five patients showed a decrease in heart rate during the increase in blood pressure. However, in three patients the heart rate did not change or even sometimes slightly increased as the arterial blood pressure exceeded 160 mmHg, when the blood pressure and heart rate then increased together. CONCLUSIONS: These results confirm that even after complete sacral de-afferentation. AHR persisted in patients with spinal cord injury and always occurred during the stimulation-induced voiding phase. In cases of incomplete de-afferentation, small uninhibited bladder contractions without voiding occurred during the filling phase. The blood pressure then increased but never reached the value recorded during stimulation-induced micturition. Stimulation of afferents that enter the spinal cord by the thoracic and lumbar roots and that are not influenced by sacral rhizotomy could explain why AHR increases during urine flow. The distinct threshold of decreased heart rate by increasing blood pressure to > 160 mmHg focuses attention on the chronotropic influences of the sympathetic nerves in the heart by an exhausted baroreceptor reflex.

Has botulinum toxin type A a place in the treatment of spasticity in spinal cord injury patients?

OBJECTIVE: To present and discuss treatment of severe spasms related to spinal cord injury with botulinum toxin type A. DESIGN: A 2-year follow-up study of an incomplete T12 paraplegic patient, who was reluctant to undergo intrathecal baclofen therapy, presenting severe painful spasms in his lower limbs treated with intramuscular injections of botulinum toxin type A. SETTING: Department of Physical Medicine and Rehabilitation, Hôpital de Gravelone, Sion, Switzerland. SUBJECT: Single patient case report. MAIN OUTCOME MEASURE: Spasticity, spasms and pain measured with the modified Ashworth scale, spasm frequency score and visual analogue scale. RESULTS: Treatment of spasticity with selective intramuscular injections of botulinum toxin type A resulted in subjective and objective improvement. CONCLUSION: Botulinum toxin type A has its place in the treatment of spasticity in spinal cord injury patients. This treatment is expensive and its effect is reversible. It can complement intrathecal baclofen in treating upper limb spasticity in tetraplegic patients. Tolerance does occur to the toxin. Although high doses of the product are well tolerated, the quantity should be tailored to the patient's need. The minimal amount necessary to reach clinical effects should be adhered to and booster doses at short period intervals should be avoided.

Prostaglandin E2 measurements: their value in the early diagnosis of heterotopic ossification in spinal cord injury patients.

OBJECTIVE: To look for a possible relation between the occurrence of heterotopic ossification (HO) and the modifications of the 24-hour prostaglandin E2 (PGE2) urinary excretion. DESIGN: A 5-year prospective study to determine the 24-hour urinary excretion of PGE2 by radioimmunoassay with specific antisera not cross-reacting with TXA2, TXB2, 15-keto-PGE2 alpha, PGI2, 6-keto-PGF1 alpha. SETTING: The laboratory of a division of endocrinology and diabetology of a university hospital. PATIENTS: Of 262 acute spinal cord injury patients screened, 44 were eligible for the study. INTERVENTIONS: Serial diagnostic quantitative bone scannings with technetium 99m Tc methylene diphosphate (99mTc-MDP) and therapeutic assessment of radiotherapy and indomethacin. MEAN OUTCOME MEASURE: Hypothetical increase of PGE2 before and during HO formation. RESULTS: Of 44 patients, 8 developed an HO (18.8%) with concomitant marked increase of the PGE2 excretion for as long as the HO had not reached maturity. The results of the radiotherapy were inconclusive. Indomethacin was shown to be efficacious in holding back or slowing down the HO evolution. CONCLUSIONS: Measurement of the 24-hour PGE2 urinary excretion appears to be a valuable indicator in the early diagnosis of HO. Indomethacin should be considered as an alternative to other existing therapies.

The value of sympathetic skin response recordings in the assessment of the vesicourethral autonomic nervous dysfunction in spinal cord injured patients.

PURPOSE: We assessed the degree of sparing of the descending sympathetic spinal tract and correlated these findings with bladder neck function in spinal cord injured patients. MATERIALS AND METHODS: Sympathetic skin responses of the right hand and foot were recorded and compared to the urodynamic findings in 27 spinal cord injured patients. RESULTS: All tetraplegic and paraplegic patients with a lesion above the T6 level who presented with bladder neck dyssynergia associated with autonomic hyperreflexia had abnormal sympathetic skin responses in the right hand and foot. All patients with a lesion below the T6 and above the T12 levels with an abnormal sympathetic skin response in the right foot also had bladder neck dyssynergia. CONCLUSIONS: Evidence is presented that the integrity of the descending sympathetic spinal tract is necessary for a synergic function of the vesicourethral complex and that sympathetic skin responses are of value in the diagnosis of bladder neck dyssynergia. For lesions below the T12 level other investigative methods to exclude bladder neck dyssynergia are necessary.

Clinical and bacteriologic impact of rifabutin prophylaxis for Mycobacterium avium complex infection in patients with human immunodeficiency virus infection.

We conducted a prospective observational study to determine the feasibility and impact of rifabutin prophylaxis (300 mg daily) for human immunodeficiency virus-infected patients whose CD4 cell counts were <100/mm3. Three hundred seventy-one patients (65.2% of all patients with CD4 cell counts of <100/mm3 [mean +/- SD, 30 +/- 25/mm3]) received rifabutin prophylaxis for a mean duration +/- SD of 35.5 +/- 34.2 weeks; 198 patients (mean CD4 cell count +/- SD, 51.6 +/- 32/mm3) did not receive prophylaxis. Rifabutin prophylaxis for 8.4% of patients was interrupted because of adverse events. Mycobacterium avium complex (MAC) bacteremia developed in 17 (4.6%) of 371 patients receiving rifabutin prophylaxis and in 22 (11.1%) of 198 patients not receiving rifabutin prophylaxis. The mean CD4 cell count +/- SD at the diagnosis of MAC bacteremia was lower in patients receiving prophylaxis than in those not receiving prophylaxis (11.5 +/- 6.8/mm3 vs. 34.7 +/- 36/mm3, respectively; P < .01). MICs for MAC strains isolated from patients receiving prophylaxis were less than or equal to those for strains isolated from patients not receiving prophylaxis.

Autonomic hyperreflexia revisited.

PURPOSE: To analyze autonomic hyperreflexia (AHR) associated with neurogenic bladder dysfunction in high spinal cord-injured patients. MATERIAL AND METHODS: Sixty-five patients were examined using a new recording system. Seventeen suffered from a spinal cord lesion above the T5-T6 level and presented with neurogenic voiding disorders and AHR. Mean arterial pressure (MAP) changes were analyzed during 3 different urodynamic phases: bladder filling; isometric bladder contraction, and voiding. RESULTS: Of the 17 tetraplegic and high paraplegic patients, 6 dropped out and 11 entered the study. Nine of these eleven patients displayed uninhibited bladder contractions and voiding. In these 9 cases MAP increased progressively during bladder contraction until a maximal bladder pressure was reached. An ongoing elevation of MAP was observed during voiding which returned to normal values within 5 min after micturition. In 2 patients detrusor-sphincter dyssynergia prevented voiding. As opposed to the 9 previously mentioned patients, maximal MAP occurred at or before the maximal bladder pressure in these 2 cases and decreased thereafter. CONCLUSIONS: Evidence is presented that the posterior urethral receptors and their ascending pathway played a major role in the maintenance of AHR during micturition.

[Does laparoscopy increase the bacteriological risk of appendectomy? Results of a randomized prospective study]. / La coelioscopie augmente-t-elle le risque bactériologique de l'appendicectomie? Résultats d'une étude prospective randomisée.

OBJECTIVE: The authors compare the risk of bacteraemia in open and laparoscopic appendectomy in a prospective randomized study. METHODS: 35 patients with a presumptive diagnosis of acute appendicitis were randomized to have conventional open or laparoscopic surgical procedures. Before randomization, patients signed a consent form to participate in the study. Patients who were converted from laparoscopic to open appendectomy (3 cases), HIV+, allergic to Augmentin or who had contraindications to laparoscopic surgery were excluded from the study. A total of 32 patients were randomized: 17 to open (group I) and 15 to laparoscopic surgery (group II). There were no significant differences with regard to age, ASA score, symptoms or macroscopic aspect of the appendix. Two patients had a normal appendix, 12 had acute appendicitis, 14 gangrenous appendicitis and 4 ruptured or abscessed appendicitis. All patients received preoperative antibiotic prophylaxis (Augmentin) after blood cultures (H1) were drawn. Five other blood cultures were performed in standard medium and medium neutralizing Augmentin: at the time of opening the peritoneum (H2), after appendectomy (H3), after closure of the abdomen (H4), and at 6 (H5) and 12 hours (H6) after the operation. Bacterial cultures from the appendix site were performed before (P1) and after (P2) appendectomy. RESULTS: The operative mortality rate after conventional or laparoscopic appendectomy was nil. The incidence of post-operative morbidity was 4 cases in group I and 2 cases in group II. No positive bacterial culture was obtained in 17 patients. The distribution of these patients was similar in groups I and II. Samples P1 and P2 were positive in 5 cases. Nine of 27 cases with negative P1 became positive in P2 (33%). There was no significant difference between the two groups with regard to the appearance of the appendix. Only two patients had positive blood cultures at H1. One of them had blood cultures at H3, H4 positive for a second germ. CONCLUSION: A low risk of bacteraemia exists for both open and laparoscopic appendectomy. This risk did not appear to increase for laparoscopy. Conventional and laparoscopic surgical procedures led to positive peritoneal bacterial cultures after appendectomy in 33% of cases.

Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients.

PURPOSE: The paralytic effect of botulinum-A toxin injections on the external urethral sphincter was investigated prospectively in patients with neurogenic voiding disorders. MATERIALS AND METHODS: Transurethral versus transperineal botulinum-A toxin injections were performed in 24 spinal cord injury male patients with detrusor-sphincter dyssynergia and the respective efficacy was compared. RESULTS: In 21 of 24 patients detrusor-sphincter dyssynergia was significantly improved with a concomitant decrease in post-void residual volumes in most cases. Botulinum-A toxin effects lasted 3 to 9 months, making reinjections necessary. CONCLUSIONS: Although costly, botulinum-A toxin injections, which aim at suppressing detrusor-sphincter dyssynergia but not bladder neck dyssynergia, appear to be a valid alternative for patients who do not desire surgery or are unable to perform self-catheterization.

Post-traumatic syringomyelia (cystic myelopathy): a prospective study of 449 patients with spinal cord injury.

OBJECTIVES: To assess the incidence of post-traumatic syringomyelia (PTS), to correlate the presence of PTS with its most common signs and symptoms, and to compare results from the Swiss Paraplegic Centre with those reported in the medical literature. METHODS: A total of 449 recent traumatic paraplegic and tetraplegic patients admitted to the Swiss Paraplegic Centre in Zurich between 1 January 1987 and 31 December 1993 were prospectively analysed. Yearly clinical tests with conventional radiographs and additional T1 and T2 weighted images were performed as soon as PTS was diagnosed. RESULTS: Of these 449 patients 20 patients displayed symptoms of PTS (4.45%). Ten non-operated patients remained clinically stable (average time: 37 months). Ten worsened--three refused operation, seven were operated on. Mean worsening time was 97 months. Deterioration was closely related to the enlargement of the cyst whereas in operated patients neurological improvement or stabilisation correlated with collapse of the cyst. CONCLUSIONS: Delay between appearance of the first symptoms of PTS and deterioration making surgery necessary may be long (mean five years in the seven operated patients) underlining the need for regular tests. "Slosh" and "suck" mechanisms could explain cyst enlargement as surgical realignment of the spine resulted in a complete cyst collapse in two of the operated patients (normalisation of CSF flow? ). Cord compression, tense syrinx at the fracture site, and kyphosis seemed to be closely linked to the enlargement of the cyst with subsequent further neurological deterioration.