Assessment of topographic brachial plexus nerves variations at the axilla using ultrasonography.

BACKGROUND: The aim of this study was to describe topographic variations in the arrangement of the four main brachial plexus nerves at the junction of the axilla and the upper part of the arm. METHODS: In 153 patients undergoing upper arm surgery using axillary block, we studied nerve arrangements with a three-step approach, combining: (A) cross-sectional ultrasound imaging using a 12 MHz linear ultrasound probe; (B) distal shift of the ultrasound scanhead from the axilla to the elbow joint following the paths of individual nerves; and (C) identifying the distal motor response to electrical nerve stimulation of each nerve. These results were then converted into a 12-section pie chart with the axillary artery (AA) as the axis. RESULTS: The order of the nerves around the AA was median, ulnar, radial, and musculocutaneous in all cases. The most frequent arrangement was observed in 65% of the patients. Five less frequent variations were observed in 4-20% of the patients, with four other variations seen in <2% of the patients. In 78% of the cases, the four nerves were seen separately using static ultrasound imaging. The musculocutaneous nerve was close to the artery in 18% of the patients. CONCLUSIONS: Topographic variations of the four main nerves at the axilla were found to be numerous, the most frequent arrangement being seen in less than two-thirds of the patients. Four separate nerves were seen on static ultrasound imaging at this sectional level of the axilla in only 78% of the cases.

Periodontopathogens antibodies and major adverse events following an acute myocardial infarction: results from the French Registry of Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI).

BACKGROUND: Periodontopathogens antibodies have been shown to be associated with primary myocardial events, but little is known regarding their impact on major adverse events after a prior acute myocardial infarction (AMI). The present prospective study evaluates the association between antibody levels of 4 periodontopathogens and the risk of all-cause death or non-fatal myocardial infarction (MI) at 1 year in 975 patients admitted for acute ST segment or non-ST segment elevation MI in French Registry of Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI), a nationwide French survey. METHODS: Multiserotype ELISAs were performed to assess levels of IgG and IgA against Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia and Tannerella forsythia. RESULTS: Adjusted HRs indicate the lack of association between IgG-anti-Po. gingivalis levels (0.96 (0.78 to 1.18)), IgA-anti-Po. gingivalis levels (1.13 (0.90 to 1.42)) and the risk of all-cause death or non-fatal MI at 1 year. Additionally, no significant association was found between the occurence of an event at 1 year and immunoglobulins levels against the others periodontopathogens. CONCLUSIONS: The present data indicate that circulating levels of periodontopathogens antibodies are not associated with an increased risk of major adverse events in patients with a prior AMI. Studies dealing with bacterial and clinical data are needed to assess the role of oral health in comprehensive cardiac rehabilitation programmes.

Guillain-Barré syndrome following danazol and corticosteroid therapy for hereditary angioedema.

A case of hereditary angioedema secondary to C1 esterase inhibitor deficiency associated with lupus-like nephritis is reported. The patient was initially treated with both corticosteroids and danazol and subsequently had Guillain-Barré syndrome together with appearance of circulating immune complexes and an increase in total complement and C1q, C3, C4, B, and C1 esterase inhibitor levels. Guillain-Barré syndrome might be secondary to danazol therapy since this drug could increase both circulating immune complex production and complement synthesis, thereby providing additional substrate for the underlying immune complex disease. Normalization of complement might therefore be hazardous in lupus with underlying complement deficiency states.

Use of pulsed-field gel electrophoresis as an epidemiologic tool during an outbreak of Pseudomonas aeruginosa lung infections in an intensive care unit.

OBJECTIVE: A retrospective study was performed to evaluate the use of DNA polymorphism analysis by pulsed-field gel electrophoresis (PFGE) in assessing the rate of exogenous contamination during an outbreak of Pseudomonas aeruginosa lung infections in an intensive care unit ICU. Another goal was to determine the risk factors, involved in the outbreak. DESIGN: Rectal swabs and tracheal secretions were cultured from all patients upon admission and thereafter once a week throughout their stay in the ICU. Resistance patterns were determined in all P. aeruginosa isolates. We determined the serotypes, pyocin types, plasmid profiles and total DNA macrorestriction patterns for isolates. The restriction fragment length polymorphism (RFLP) of Dra I total DNA digest was studied by PFGE. A retrospective case-control study was performed to determine the risk factors for P. aeruginosa bronchopulmonary colonization. SETTING: The study was carried out in the medical ICU of Besancon University Hospital (France). RESULTS: The typability, stability and reproducibility of phenotypic markers were not completely satisfactory. Only the RFLP profile satisfied all the criteria for a good typing technique. In four of the 17 patients, P. aeruginosa strains with the same DNA pattern were found. Among the previously reported risk factors for hospital-acquired bronchopulmonary infections, only invasive procedures were determined by multivariate analysis to be significant in our study group. The oropharynx and the bronchial tract are the most likely endogenous sources. CONCLUSION: PFGE-RFLP is a valuable tool for the epidemiologic study of P. aeruginosa. This typing method revealed that exogenous contamination is not always the major source of P. aeruginosa lung infections in mechanically ventilated patients in ICUs.

Endemicity, molecular diversity and colonisation routes of Pseudomonas aeruginosa in intensive care units.

OBJECTIVE: We carried out a prospective study to evaluate the endemicity of Pseudomonas aeruginosa in intensive care units (ICUs). Pulsed-field gel electrophoresis (PFGE) was used to determine the genotypes of P. aeruginosa isolates. This allowed us to determine the importance of cross-colonisation and the colonisation routes of P. aeruginosa. DESIGN: We screened epidemiological specimens (rectal swab, nose swab and tracheal aspiration) and routine clinical cultures from patients admitted to ICUs during a 2-year period, from 1st January, 1998, to 31st December, 1999. SETTING: The study was carried out in four separate adult ICUs located in the Franche-Comté region of France. These four units admitted a total of 1,500 patients per year. RESULTS: A total of 1686 specimens were collected from 473 patients; 122 of these patients were positive on admission, 351 became positive during hospitalisation. The overall incidence of P. aeruginosa was 15.7 cases per 100 patients and 15.1 cases per 1000 days of hospitalisation. Of 184 patients with at least one ICU-acquired positive clinical culture, 104 had been previously identified as carriers by a similar genotype. Typing of 208 non-replicate isolates revealed 101 major DNA patterns. Approximately 50% of P. aeruginosa carriage or colonisation/infection was acquired via cross-transmission; the other cases probably originated from endogenous sources. CONCLUSION: Cross-colonisation seems to play an important role in the general spread of P. aeruginosa in ICUs.

Acute fatty liver of pregnancy: CT evaluation. Case report.

CT scans of two patients with acute fatty liver of pregnancy were reviewed in conjunction with the clinical evolution of this uncommon and potentially fatal disorder. In each of the CT scans, liver density measurements were less than those of the spleen. While the findings are non-specific, in the proper clinical context they are highly suggestive and may be the sole method of diagnosis, as these patients often have coagulation problems which rule out liver biopsy. It is an important diagnosis, as the high maternal and fetal mortality rates appear to be considerably reduced by early foetal delivery.

[Hepatotoxicity of isaxonine phosphate: 4 cases of severe subacute hepatitis]. / Hépatotoxicité du phosphate d'isaxonine: quatre observations d'hépatites subaiguës sévères.

Isaxonine phosphate is known to induce acute hepatitis which in most cases is reversible after withdrawal of the drug. The authors describe 4 new cases of hepatitis which differ from those previously reported by their evolutive and pathological features. In 3 cases, the outcome was fatal within a delay of 15-40 days despite discontinuation of the drug, and was associated with hepatic encephalopathy and ascites. In the 4 cases plasma concentration of alanine- and aspartate-aminotransferases were initially increased (up to 33 X upper normal range) and decreased to normal values in 2 cases. Plasma bilirubin levels were also elevated at first and continued to increase during the first 15 days of evolution. Pathological examination of the liver showed mild necrosis, sometimes with a piecemeal or a bridging aspect, marked fibrosis infiltrated with mononuclear and neutrophil polymorphonuclear cells and a conspicuous biliary neogenesis. In these particular cases of hepatitis due to isaxonine phosphate, occurrence in women, increased serum immunoglobulin levels, presence of autoantibodies, clinical and pathological aspects resembling those observed in iproniazid hepatitis may be suggestive of an immunological, or even autoimmune, mechanism.

[Acute fatty liver of pregnancy. Apropos of 4 cases: contribution of x-ray computed tomography]. / Stéatose hépatique aiguë gravidique. A propos de 4 cas: apport de la tomodensitométrie.

Acute fatty liver of pregnancy is a disease of the third trimester, generally considered to be rare and to have a grave prognosis. Histologically the characteristic fine droplet steatosis usually produces distinct vacuolization. Successful treatment depends on accurate diagnosis and early delivery. Computed tomography is of value in the diagnosis of fatty liver through liver and spleen attenuation value measurements. We reviewed 4 cases of acute fatty liver of pregnancy. Computed tomography was performed in two cases and was very helpful in the diagnosis of this condition.

[Effects of anesthetic agents on arterial reactivity]. / Effets des agents anesthésiques sur la vasomotricité artérielle.

OBJECTIVE: To review the effects of halogenated and intravenous anaesthetics on arterial vasoreactivity. DATA SOURCE: Articles were obtained from a MEDLINE review (search terms: 'vascular smooth muscle, endothelium' used separately or associated with following anaesthetic agents: 'halothane, isoflurane, enflurane, desflurane, sevoflurane, thiopentone, propofol, ketamine, etomidate'. Other sources included review articles and textbooks. STUDY SELECTION AND DATA EXTRACTION: All experimental studies published since 1975 were analysed and pertinent data extracted. DATA SYNTHESIS: Within the vascular wall, arterial vasoreactivity involves the endothelium and the vascular smooth muscle. In vivo, arterial vasoreactivity is regulated by neuronal, hormonal, and metabolic factors. In vitro, the direct action of anaesthetic agents on the vessel can be studied in the absence of such factors. In vitro studies with arterial rings have shown that inhalational anaesthetics directly decrease endothelium-independent contraction induced by various pharmacological agents. This direct effect of anaesthetics results from a decrease in intracellular calcium, mainly caused by an inhibition of transsarcoplasmic calcium influx. Volatile anaesthetics decrease endothelium-dependent vasorelaxation at a site(s) within the nitric oxide (NO) signalling pathway, located downstream from the NO-related receptors and upstream from guanylyl cyclase. They may also decrease endothelium-independent vasorelaxation by inhibiting NO activation of guanylate cyclase. Intravenous anaesthetics, such as propofol, barbiturates, ketamine and etomidate also decrease vasoconstriction by various degrees. Propofol is the most potent inhibitor of vasoconstriction and thiopental the least one. All these IV anaesthetics have been shown to inhibit in some circumstances both endothelium-dependent and -independent vasorelaxation. Further studies are required to enable a better understanding of the mechanism and the site of action of these vascular effects of anaesthetics. For example, the investigation of the effects of anaesthetic agents on vascular reactivity in diseases associated with endothelial dysfunction may indirectly provide insight into the role of endothelium.

[Pseudomonas aeruginosa epidemiology in intensive care units: importance of cross-transmission]. / Importance de la transmission croisée dans l'épidémiologie de Pseudomonas aeruginosa en service de soins intensifs.

OBJECTIVES: To update the local epidemiological data of Pseudomonas aeruginosa in intensive care units (ICU) by assessing the colonisation incidence rate and the level of cross-transmission. METHODS: Study carried out in both adult ICUs of the university-hospital of Besançon during a 2 years period. Clinical and surveillance specimens were screened for P. aeruginosa. Pulsed-field-gel-electrophoresis was used as genotyping method to evaluate the rate of cross-transmission. RESULTS: During the study, 314 patients were positive for P. aeruginosa (incidence rate of 19.1 patients per 100 admitted patients). One hundred sixty-six of these patients were detected with a clinical specimen and 148 with a screening specimen. Seventy-seven patients were colonised upon admission in the intensive care unit and 237, negative on admission, became positive during their stay. Of the ICU-acquired cases, the mean length of stay before P. aeruginosa colonisation was acquired was 15.7 days. Genotyping revealed that 53.5% of P. aeruginosa colonisation was acquired via cross-transmission (respectively 48.1% in the medical ICU and 59.2% in the surgical ICU); the other cases probably originated from endogenous sources. CONCLUSION: The incidences of P. aeruginosa colonisation upon admission and during hospitalisation are consistent with other french and european studies. Although we probably over-estimated the rate of cross-transmission, our results demonstrate that cross-transmission may be a major cause of P. aeruginosa dissemination in ICUs.

[Pseudomonas aeruginosa septicemia. Host-related risk factors in 82 episodes]. / Septicémies à Pseudomonas aeruginosa. Facteurs de risque liés à l'hôte au cours de 82 épisodes.

OBJECTIVES: The prognosis of septicaemia due to Pseudomonas aeruginosa is severe with mortality ranging from 32 to 73%. We retrospectively studied 82 episodes in order to determine whether risk factors could be identified. METHODS: Eighty-two episodes of Pseudomonas aeruginosa septicaemia, observed between 1986 and 1991, were analyzed. Risk of death within 2 days of the first positive blood culture (mortality = 19.5%) were assessed with univariate and multivariate analyses. RESULTS: Patient age ranged from 1 to 92 years. Most had been hospitalized in medical wards (49%) or intensive care units (28%) (NS). The type of septicaemia (several bacteria in 21%), the source of the infection (nosocomial in 78%), portal, predisposing factors (cancer, haematologic disease: 54%) and MacCabe index were not significantly correlated with risk of death at two days following first positive blood culture. With univariate analysis body temperature below 38,5 degrees C was significant (p = 0.007) for death at day 2 and appropriate antibiotic treatment after diagnosis was significant (p < 0.001) for absence of death on day 2. For multivariate analysis, chemotherapy and shock syndrome were significant (p = 0.005 and 0.09 respectively) for death at day 2 and appropriate antibiotic treatment was significant (p = 0.005) for absence of death on day 2. CONCLUSION: Antibiotic prescription appears to be the most easily controlled significant factor predictive of outcome in Pseudomonas aeruginosa septicaemia.

[Severe obstetric complications nescessitating hospitalization and intensive care: a ten year retrospective study]. / Complications obstétricales graves nécessitant une hospitalisation en réanimation: étude rétrospective sur 10 ans au CHU de Besançon.

OBJECTIVES: To assess the serious maternal morbidity during pregnancy, delivery and post partum, which led to an hospitalization in a medical or surgical intensive care unit. STUDY DESIGN: A Retrospective study was carried out on a period of ten years, from July 1986 to July 1996, in the University Teaching Hospital of Besançon. PATIENTS: The criterions of inclusion come from the definition of the serious maternal morbidity decided by the Inserm: any admission of a pregnant woman in a medical or surgical intensive care unit in the 42 days of the post-partum, whatever the term of the pregnancy and the type of the post-partum, extra uterine pregnancy, spontaneous miscarriage and medical or voluntary abortion. METHODS: Forty-six patient's medical file hospitalized in a medical or surgical intensive care unit between July, 1st 1986 and July, 31st 1996, have been studied. RESULTS: The analysis of the cause underline the gravity of the pathologies handled with young patients and initially healthy, the short length of controlled ventilation and hospitalization, the avoidability of great number of transfer in an intensive care unit, and the lack of hospitalization due to anaesthesia. The frequency of hospitalisation in an intensive care unit during and after the pregnancy was estimated at 0.17% of lives births. CONCLUSION: The serious maternal morbidity could be an indicator of the quality of the obstetrics cares which would complete the study of the maternal mortality. The potential gravity of the complication of the pregnancy and the delivery require better care of this patients.

Common SNPs of AmelogeninX (AMELX) and dental caries susceptibility.

Genetic approaches have shown that several genes could modify caries susceptibility; AmelogeninX (AMELX) has been repeatedly designated. Here, we hypothesized that AMELX mutations resulting in discrete changes of enamel microstructure may be found in children with a severe caries phenotype. In parallel, possible AMELX mutations that could explain resistance to caries may be found in caries-free patients. In this study, coding exons of AMELX and exon-intron boundaries were sequenced in 399 individuals with extensive caries (250) or caries-free (149) individuals from nine French hospital groups. No mutation responsible for a direct change of amelogenin function was identified. Seven single-nucleotide polymorphisms (SNPs) were found, 3 presenting a high allele frequency, and 1 being detected for the first time. Three SNPs were located in coding regions, 2 of them being non-synonymous. Both evolutionary and statistical analyses showed that none of these SNPs was associated with caries susceptibility, suggesting that AMELX is not a gene candidate in our studied population.

Preoperative plasma B-type natriuretic peptide (BNP) identifies abnormal transthoracic echocardiography in elderly patients with traumatic hip fracture.

INTRODUCTION: This prospective study was designed to evaluate whether preoperative plasma brain natriuretic peptide (BNP) could identify significant preoperative cardiovascular disease in elderly hip-fractured patients. PATIENTS AND METHODS: Preoperative plasma BNP measurement and rest transthoracic echocardiography (TTE) were performed within 24 h after admission in consecutive hip-fractured patients aged ≥65 years. The major echocardiographic abnormality (MEA) group included patients with at least one TTE abnormality, defined as systolic pulmonary artery pressure (PAP(s)) ≥50 mmHg, left ventricular (LV) systolic dysfunction, increased LV filling pressure (LVFP) or severe valvular disease. The control group included the remaining patients. RESULTS: Seventy-five patients (mean±SD (range) age=85±5 (69-97) years) were included during a 6-month period. Twenty-four (32%) patients constituted the MEA group (17 elevated PAP(s), three LV systolic dysfunctions, 10 increased LVFP, one severe aortic stenosis and one severe mitral regurgitation). Median (interquartile) preoperative BNP value was significantly greater in MEA than in the control group (527 (361) vs. 119 (154) pg ml(-1); p<0.0001). A preoperative plasma BNP cut-off value at 285 pg ml(-1) predicted well MEA with an area under the receiver operating characteristic (ROC) curve equal to 0.895 (p<0.0001) and with a hazard ratio (HR) (confidence interval, CI) of 23.8 (3.7-142.9) (p=0.0008) on multivariate analysis. The presence of MEA or BNP≥285 pg ml(-1) was associated with high mortality. DISCUSSION: The incidence of echocardiographic signs of elevated PAP(s) or elevated LVFP in elderly hip-fractured patients was high. A preoperative BNP value ≥285 pg ml(-1) can discriminate between elderly hip-fractured patients with or without MEA.

[The use of intermittent mandatory ventilation in resuscitation (author's transl)]. / Utilisation de la ventilation intermittente commandée en réanimation.

The technic of intermittent mandatory ventilation assures automatically a fraction of ventilatory cycles on a patient who has a spontaneous ventilation. This mechanism used in medical and surgical resuscitation, on twenty one patients of different age-group, has allowed the objectivation of the following elements: - the clinical and the analysis of gaz results are found to be satisfactory at the end of the first hour; - one the contrary from then on, the results tend to differ on the basis of the periods of misadaptation which are more or less long and frequent. Looking after such a ventilatory devise demands as much intensing attention as that of any other artificial ventilation.