Successful rituximab therapy in a lupus patient with diffuse alveolar haemorrhage.

Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). Specific therapy is based on a heavy immunosuppressive treatment that usually associates corticosteroid and cyclophosphamide boluses and plasma exchange. Despite this treatment, an early mortality rate of 20-50% is reported in the literature. Immunosuppression-related complications are responsible for further mortality and morbidity. Rituximab, a specific anti-CD20 antigen B-cell antibody, has been used with success for the treatment of several refractory autoimmune disorders, but rarely for SLE-induced DAH. We report here the first case of SLE-induced DAH treated successfully with rituximab without cyclophosphamide administration in a patient intolerant to cyclophosphamide. We review the two other cases of SLE-induced DAH managed with rituximab as a part of the immunosuppressive regimen.

Physiological effects of adding ECCO2R to invasive mechanical ventilation for COPD exacerbations.

BACKGROUND: Extracorporeal CO2 removal (ECCO2R) could be a valuable additional modality for invasive mechanical ventilation (IMV) in COPD patients suffering from severe acute exacerbation (AE). We aimed to evaluate in such patients the effects of a low-to-middle extracorporeal blood flow device on both gas exchanges and dynamic hyperinflation, as well as on work of breathing (WOB) during the IMV weaning process. STUDY DESIGN AND METHODS: Open prospective interventional study in 12 deeply sedated IMV AE-COPD patients studied before and after ECCO2R initiation. Gas exchange and dynamic hyperinflation were compared after stabilization without and with ECCO2R (Hemolung, Alung, Pittsburgh, USA) combined with a specific adjustment algorithm of the respiratory rate (RR) designed to improve arterial pH. When possible, WOB with and without ECCO2R was measured at the end of the weaning process. Due to study size, results are expressed as median (IQR) and a non-parametric approach was adopted. RESULTS: An improvement in PaCO2, from 68 (63; 76) to 49 (46; 55) mmHg, p = 0.0005, and in pH, from 7.25 (7.23; 7.29) to 7.35 (7.32; 7.40), p = 0.0005, was observed after ECCO2R initiation and adjustment of respiratory rate, while intrinsic PEEP and Functional Residual Capacity remained unchanged, from 9.0 (7.0; 10.0) to 8.0 (5.0; 9.0) cmH2O and from 3604 (2631; 4850) to 3338 (2633; 4848) mL, p = 0.1191 and p = 0.3013, respectively. WOB measurements were possible in 5 patients, indicating near-significant higher values after stopping ECCO2R: 11.7 (7.5; 15.0) versus 22.6 (13.9; 34.7) Joules/min., p = 0.0625 and 1.1 (0.8; 1.4) versus 1.5 (0.9; 2.8) Joules/L, p = 0.0625. Three patients died in-ICU. Other patients were successfully hospital-discharged. CONCLUSIONS: Using a formalized protocol of RR adjustment, ECCO2R permitted to effectively improve pH and diminish PaCO2 at the early phase of IMV in 12 AE-COPD patients, but not to diminish dynamic hyperinflation in the whole group. A trend toward a decrease in WOB was also observed during the weaning process. Trial registration ClinicalTrials.gov: Identifier: NCT02586948.

[Invasive pulmonary aspergillosis complicating septic shock]. / Aspergillose pulmonaire invasive compliquant un choc septique.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is an opportunistic infection with a poor prognosis, occurring primarily in patients who are severely immunocompromised. CASE REPORT: We report a case of IPA that occurred in a 37-year-old woman with no history of previous immunosuppression or significant co-morbidity. She was admitted to our intensive care unit (ICU) with septic shock and multi-organ failure complicating a bacterial pneumonia. After an initial improvement, her condition deteriorated on the 10th day after admission with fever and lesions consistent with IPA seen on high-resolution computed tomography (HRCT). IPA was confirmed by isolating Aspergillus fumigatus from bronchoalveolar lavage and by a positive circulating galactomannan test (sandwich ELISA). First line therapy with voriconazole had to be stopped after 12 days due to hepatic toxicity. The patient was successfully treated with caspofungine for 2 months then itraconazole for 4 months with progressive improvement of HRCT abnormalities. Her galactomannan test became negative at 6 months. CONCLUSION: The diagnosis of IPA must be considered in critically ill patients even in the absence of underlying immunosupression where suggestive HRCT abnormalities occur in the context of septic shock and multiple organ failure.

New approaches to chromatographic purification of bovine dopamine-beta-hydroxylase.

The use of the traditional scheme for the isolation of bovine dopamine-beta-hydroxylase (bDBH) from bovine adrenal medulla resulted in active but not pure bDBH, containing about 50% of admixtures. Immobilized metal chelate affinity chromatography on agarose modified with iminodiacetic acid residues and charged with cobalt ions was applied in the final stage to obtain more than 90% pure and active bDBH. Final purification of bDBH using step elution with 0-0.5 M methyl-D-mannoside in buffer solution from concanavalin A-Sepharose was studied. The determination of bDBH in various samples was performed using size-exclusion chromatography.

2-Acetyl-4H-benzothiazin-3(2H)-one.

The title compound, C(10)H(9)NO(2)S, has a boat-shaped heterocyclic six-membered ring such that the S and N atoms lie essentially in the plane of the benzene ring while the remaining two C atoms are above this plane.

A specific antihistaminic premedication anti H1 anti H2 for pediatric anesthesia.

The danger of the anaphylactoid reactions which occur during pediatric general anesthesia leads the authors to use a specific antihistaminic premedication. The association of cimetidine and hydroxizine has been proved to be adequate to avoid systemic histamine adverse effects and to diminish gastric secretion in pediatric anesthesia. The authors recommend oral administration.

[Human fibronectin in the treatment of septic states. Tolerance and course of plasma levels]. / Fibronectine humaine dans le traitement des états septiques. Tolérance et évolution des taux plasmatiques.

A purified freeze-dried fibronectin concentrate prepared by the Centre National de Transfusion Sanguine from blood donors' plasma pools was tested for safety and effects on recipients' plasma fibronectin levels. The product was administered on 17 occasions to 10 patients with severe sepsis, either as bolus intravenous injection (group B) or as bolus injection of one-half of the dose followed by continuous infusion of the remaining half-dose over a 6-hour period (group B + P). The drug was well tolerated both clinically and biochemically. Following a 1 mg/kg dose of fibronectin, the maximum increase in mean plasma fibronectin levels was 17 +/- 5 mg/l in group B patients and 20 +/- 5 mg/l in group B + P patients. Mean times to peak were 188 +/- 53 min and 282 +/- 106 min respectively in the two groups. A cooperative randomized double-blind trial is currently in progress to evaluate the clinical effectiveness of the product.

[The impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999]. / Enquête sur l'impact des recommandations pour la pratique clinique (RPC) << Prise en charge des traumatisés crâniens graves à la phase précoce >>

OBJECTIVE: To evaluate the impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999. STUDY DESIGN: Nationwide survey. METHODS: 182 medical centres answered the inquiry. RESULTS: 111 centres declared to manage such patients suffering from SHI. 68% of doctors from these clinical departments did report to have read these guidelines. Fifty percent of them found in these guidelines useful data for their clinical practice. Forty four percent of centres could not monitor ICP lacking neurosurgical facility in their hospital. Conversely, all hospitals with neurosurgery available did monitor ICP. Seventy six percent of centres reported difficulties to find a facility, which would take these patients in charge when discharged from ICU. We analysed the main items included in the guidelines and report their impact. Seventy four percent of responders found that clinical management of SHI patients had improved during the last years. CONCLUSION: The French guidelines had a significant impact and seem to have provided a useful aid to clinical management of SHI patients. ICP monitoring and the shortage in post-ICU facilities are remaining issues.

[Interactions between naltrexone, an opioid antagonist, and opioids administered during general anesthesia]. / Interférences entre la naltrexone, un antagoniste des morphiniques, et les morphiniques administrés pendant une anesthésie générale.

We report a case of a probable interaction between sufentanil and naltrexone, an oral long acting opioid antagonist, prescribed for maintenance of abstinence in alcoholics and opioid addicts. The interaction resulted in an antagonisation of the effects of sufentanil and the necessity to increase the dosage. Anaesthetists should be aware of this potential drug interaction.

[Physiology of nodal tissue and effect of products used in anesthesia]. / Physiologie du tissu nodal et effet des produits employés en anesthésie.

The three fundamental properties of the nodal tissue, i.e.: excitability, automaticity and conduction of the depolarisation wave, are directly dependent on ionic transmembrane currents. These currents, either active or passive, determine the characteristics of the membrane action potential. Passive ionic movements cross gated transmembrane channels which activation is voltage-dependent, sometimes time-dependent and, for Ca2+ channels, dependent on intra-cellular cyclic AMP content. Both intra and extra-cellular ionic concentrations (K+, Ca2+, Mg2+) alter these passive movements. Active ionic movements require ATP hydrolysis and depend only on cellular metabolism. The neurovegetative system and its transmitters modulate the nodal tissue function altering passive ionic currents. Drugs employed during anesthesia change this function either by direct action on the ionic currents or by indirect action on the neurovegetative system or on histamine liberation. Thus: local anesthetics block selectively fast sodium channels; halogenated volatile anesthetics inhibit slow calcium channels: and narcotics are quite always vagomimetics, sometimes sympathicolytics, they often release histamine. Nevertheless, mechanism of action of various drugs remain unclear.

[Anesthesia in surgery of Basedow's disease]. / Anesthésie dans la chirurgie de la maladie de Basedow.

Adequate preparation for surgery can be achieved in patients with Grave's disease by a combination anti-thyroid medication, Lugol's solution and beta-blockers, mainly propranolol. Only in rare cases when this treatment had failed has plasmapheresis been used. No thyroid storm occurred in the 35 cases reported. Should this complication be encountered, plasmapheresis appears to be the treatment of choice.

Regional ventricular segmental dynamics in normal conscious dogs.

Left ventricular (LV) subendocardial segmental behavior was analyzed during the whole cardiac cycle for different loading and inotropic conditions in six conscious dogs that were instrumented with ultrasonic crystals in the basal (B) and apical (A) LV regions, a LV micromanometer, and an aortic cuff occluder. There were large variations of A and B segmental behavior during isovolumic contraction and relaxation. In contrast, a linear relationship between A and B was observed during ejection but segmental shortening was larger during control in A than in B, whether it was expressed as a percentage of systolic shortening (34.6 +/- 1.1 and 25.0 +/- 1.2%, respectively; P less than 0.005), or whether segments were normalized for passive resting length. This linear relationship during ejection with a slope of 1.49 was not significantly modified by alterations of loading conditions or inotropic state. The larger A than B shortening, independent of the normalization procedure, is attributed to the regional stress distribution in the LV. The absence of regional and cycle invariance particularly during isovolumic phases prevents the inference of ventricular volume from a limited number of dimensions.

X-FINE--a refinement program for FEFF input parameters.

X-FINE is an interactive and user-friendly tool to optimize input parameters (S20, sigma2, DeltaE) of the FEFF program, a package for EXAFS analysis.

Ethyl 5-[2-(2-aminophénylimino)-2-phényléthylidène]-4-(4-chlorophényl)-4,5-dihydro-1,3,4-thiadiazole-2-carboxylate et éthyl 5-[2-[2-(méthylamino)phénylimino]-2-phényléthylidène]-4-(4-nitrophényl)-4,5-dihydro-1,3,4-thiadiazole-2-carboxylate.

Condensation of N-aryl-C-(ethoxycarbonyl)nitrilimines with 4-phenyl-1,2-dihydro-3H-1,5-benzodiazepine-2-thione lead to the title compounds, C(25)H(21)ClN(4)O(2)S, (IIIa), and C(26)H(23)N(5)O(4)S, (IIIb), respectively. Crystals of both compounds were obtained by evaporation of ethanol solutions at room temperature. In the structures of both compounds, a non-bonding interaction is observed between the S atom and the imino N atom. It is established that 1,3-dipolar cycloaddition occurs on the C=S double bond of the 1,5-benzodiazepine-2-thione.

[Assessment of left ventricular function in patients with aortic regurgitation using dynamic investigation (author's transl)]. / Détection des dysfonctions myocardiques dans l'insuffisance aortique par l'exploration dynamique du ventricule gauche.

To assess accurately left ventricular function (LVF) in patients with aortic regurgitation (AR pts), isometric exercise (IE) was used in association with postextrasystolic potentiation (PESP) during diagnostic heart catheterization including left cineventriculography in 16 pts with pure moderate or severe AR. The results were compared with those observed in 8 control pts (C pts). IE resulted in a significant increase in heart rate by 15 p. cent and in an increase in mean aortic pressure by 29 p. cent (p < 0.001). During IE, LV end diastolic pressure (EDP) remained unchanged in C pts and in 6 AR pts whereas this value was increased by 49 p. cent (p < 0.01) in 7 AR pts without a significant change in LV end diastolic volume. Ejection fraction (EF) was decreased in each AR pt (mean 14 p. cent; p < 0.001) and remained unchanged in C pts. A negative correlation was evidenced between the decrease in EF and the increase in LVEDP (r = 0.76). PESP resulted in a increase in EF in both C pts and AR pts (+ 25 and + 29 p. cent respectively; p < 0.001). PESP under IE resulted in a lower increase in EF than PESP under basal conditions (+ 19 and + 24 p. cent respectively) mainly due to the increase in after load provided by IE. Dynamic investigation of the LVF in AR pts is a physiological method of investigation easy to perform which may assess both LV contractile reserve and cardiac reserve. Such a method of investigation may help to select AR pts for surgery.

[Hemodynamic interferences between diltiazem and thiopental--experimental study in the pig]. / Interférences hémodynamiques entre le diltiazem et le thiopental--étude expérimentale chez le proc.

The clinical applications of calcium channel blockers are rapidly growing; as barbiturates interfere with intracellular calcium movements, the possibility of drug interaction at this level must be considered. We have studied the haemodynamic interaction of Thiopentone and Diltiazem in pigs. A loading dose of Diltiazem (0.15 mg X kg-1) was injected followed by a continuous administration of 0.07 mg X kg-1 X hour. From the fifth to the tenth minute, the reduced afterload was associated with a moderate depression of the contractility of the left ventricle. These values returned to the initial level within 30 minutes. Heart rate and cardiac output were not modified. The stability of these two parameters is thought to result from the complex interaction of both drugs on the sympathetic nervous system and the ventricular function.