Endovenous laser ablation of the great saphenous vein using a bare fibre versus a tulip fibre: a randomised clinical trial.

OBJECTIVE: This clinical trial aimed to evaluate the clinical results of the use of a tulip fibre versus the use of a bare fibre for endovenous laser ablation. METHODS: In a multicentre prospective randomised trial 174 patients were randomised for the treatment of great saphenous vein reflux. A duplex scan was scheduled 1 month, 6 months and 1 year postoperatively. Ecchymosis was measured on the 5th postoperative day. In addition, pain, analgesics requirement, postoperative quality of life (CIVIQ 2) and patient satisfaction rate were noted. RESULTS: Patients treated with a tulip fibre had significantly less postoperative ecchymosis (0.04 vs. 0.21; p < 0.001) and pain (5th day) (1.00 vs. 2.00; p < 0.001) and had a better postoperative quality of life (27 vs. 32; p = 0.023). There was no difference in analgesic intake (p = 0.11) and patient satisfaction rate (p = 0.564). The total occlusion rate at 1 year was 97.02% and there was no significant difference between the two groups (p = 0.309). CONCLUSION: Using a tulip fibre for EVLA of the great saphenous vein results, when compared with the use of a bare fibre, in equal occlusion rates at 1 year but causes less postoperative ecchymosis and pain and in a better postoperative quality of life.

Detection of anti-glomerular basement membrane antibodies by radioimmunological technique. Clinical application in human nephropathies.

A radioimmunoassay for detection of anti-glomerular basement membrane (GBM) antibody was set up with a 70,000 mol wt GBM antigen, labeled with Iodine-(125)I and containing both types of oligosaccharidic chains present in the whole membrane. Separation of free radioactive antigens from antigens bound to immunoglobulins was obtained by precipitation with polyethylene glycol (mol wt, 6,000), at a final concentration of 20%. In the presence of normal human or rabbit sera, less than 20% of labeled antigens were precipitated. In the presence of rabbit anti-human GBM antibodies, up to 82% of GBM antigens were precipitated, while in the presence of sera or of kidney eluate from a patient with Goodpasture's syndrome, the precipitation of GBM antigens reached 43%. The avidity of rabbit anti-GBM antibodies for human GBM antigens is higher than that of human anti-GBM antibodies. In the case of Goodpasture's syndrome, the binding of anti-GBM antibodies to labeled antigens was inhibited more efficiently by the disaccharide-containing glycopeptide than by the heteropolysaccharide-containing glycopeptide purified from whole GBM.Anti-GBM antibodies were searched for in the serum of 300 normal blood donors, of 120 patients with glomerulonephritis (GN) and granular deposits, and of 14 patients with GN and linear deposits of immunoglobulins. After correction for the "nonspecific" precipitation, the average percentage (+/-1 SD) of labeled antigens precipitated in the serum of normal blood donors was 0.3+/-3.2%; 12 patients with GN and linear deposits exhibited high circulating anti-GBM antibody titers, while 8% of the patients with GN and granular deposits presented significant, albeit lower, anti-GBM activity in their sera.

Possible role of human natural anti-Gal antibodies in the natural antitumor defense system.

Expression of Gal alpha 1-3Gal cell surface residues has been correlated with the metastatic potential of murine tumor cells. We report that Gal alpha 1-3Gal residues are expressed at the cell surface of malignant human cancer cells, including four cell lines and 50% of the malignant breast specimens obtained by aspiration biopsy. In contrast, all benign breast biopsies and normal cells were Gal alpha 1-3Gal negative. Affinity-purified anti-alpha-galactosyl IgG (anti-Gal) antibody, which specifically recognizes Gal alpha 1-3Gal residues, significantly inhibited cell attachment in two in vitro assays thought to indicate tumor cell extravasation of the circulatory system during the metastatic process: attachment to perfused human umbilical vein endothelium, and attachment to isolated laminin. Since anti-Gal antibody is a natural component of all human sera, we propose that it may be part of the natural antitumor defense system in humans.

Antiglomerular basement membrane nephritis after solvent exposure.

A rapidly progressive glomerulonephritis with definitive anuria was observed after solvent inhalation in two young women, aged 22 and 17 years. In both cases the renal biopsy specimen showed diffuse epithelial crescents in all glomeruli, with linear deposits of IgG along the glomerular basement membrane (GBM). High circulating anti-GBM antibody levels were found in sera by indirect immunofluorescence and radioimmunoassay. No anti-alveolar basement membrane antibodies were detectable by immunofluorescent microscopy in one patient. It is suggested that the solvent inhalation resulted in a chemical alteration of the alveolar basement membrane giving rise to anti-basement membrane antibodies, some of which may have cross-reacted with the GBM and initiated the glomerulonephritis.

The ability of normal human monocytes to phagocytose IgG-coated red blood cells is related to the number of accessible galactosyl and mannosyl residues in the Fc domain of the anti-red blood cell IgG antibody molecules.

The percentage of normal human monocytes (MCs) that are able to form rosettes with, and subsequently phagocytose, IgG-coated red blood cells (RBCs) has been determined in vitro using five batches of anti-RBC IgG antibodies. These antibodies differed from each other by their capacity to bind to lectins recognizing two of the oligosaccharide structures of the Fc domain, namely, peanut agglutinin (PNA) and concanavalin A (ConA) which specifically bind to beta-galactosyl and alpha-mannosyl residues, respectively. The threshold between high (H) and low (L) binding capacities (BC) was arbitrarily fixed at 15% of mean specific binding. For each level of RBC sensitization tested (1500-6000 Ab molecules/one RBC), the percentage of MCs binding at least three IgG-RBCs was similar whatever the IgG Ab preparations used. In contrast, the percentage of MCs capable of phagocytosing at least three IgG-RBCs coated with 3000, 4500 and 6000 IgG/cell, as well as the phagocytosis index (number of IgG-RBCs ingested/100 MCs) of IgG-RBCs coated with 1500, 3000, 4500 and 6000 IgG/cell, were significantly lower (P less than 0.01 at least) using IgG Ab molecules with either [(PNA-H)(ConA-H)] BC, [(PNA-L) (ConA-H)] BC or with [(PNA-L)(ConA-L)] BC than the corresponding values measured using RBCs coated with IgG Ab molecules exhibiting [(PNA-H)(ConA-L)] BC. The binding to MCs of 125I-labelled anti-RBC IgG Ab molecules exhibiting different binding profiles to PNA and to ConA was studied by Scatchard plot analysis. A single class of binding sites was observed in each case. MCs bound a mean of 23,000 IgG molecules with a mean association constant (Ka) for IgG binding of about 1.4 X 10(8) M-1. These data indicate that terminal (and/or accessible) galactosyl and mannosyl residues of IgG Ab molecules play a role in the ingestion of IgG-RBCs by human MCs, despite the fact IgG Ab binding to IgG(Fc) receptors is not significantly affected. Thus, when studying the phagocytosis of IgG-coated RBC by human MC monolayers, the assay should be performed not only using similar RBC/MC ratios and IgG coating values, but also with IgG antibodies having comparable mean PNA and ConA binding capacities.

Magnetic solid-phase enzyme immunoassay for the detection of anti-glomerular basement membrane antibodies.

A new enzyme immunoassay has been developed for the demonstration of antiglomerular basement membrane antibodies. Magnetically responsive polyacrylamide-agarose beads (Magnogel) activated with glutaraldehyde were used to bind sonicated insoluble rat glomerular basement membranes. Both the collagenous and the non-collagenous moieties were demonstrated to be fixed on the beads. Sera from brown Norway rats with anti-glomerular basement membrane antibodies induced by HgCl2 injections were incubated with the beads. After washing, the fixed rat IgG were revealed using alkaline phosphatase labelled Fab fragments from anti-rat IgG sheep, IgGs. Comparison with a radioimmunoassay showed that results were reliable. This enzyme immunoassay has several advantages which may render this assay of considerable clinical usefulness.

An enzyme-linked immunoassay for direct measurement of the gelatin-binding capacity of human plasma fibronectin.

A new solid-phase enzyme immunoassay measuring the gelatin-binding capacity of plasma fibronectin has been developed. This assay is based on the direct and high-affinity interaction between fibronectin and gelatin coated to polyvinyl chloride plates. The amount of fibronectin bound to gelatin is then measured by sequential incubation with a specific rabbit anti-human fibronectin antiserum, with horseradish peroxidase-conjugated goat anti-rabbit IgG antibodies and with substrate. The final degradation of the substrate is read at 492-650 nm in an ELISA processor. The assay allows the accurate detection of fibronectin concentrations ranging from 1 to 20 micrograms/ml, is inhibited by the addition of gelatin to plasma, is highly reproducible (interplate CV less than 10%), requires 100 microliter of plasma only and has been fully automated. Significant linear correlations were noted between total antigenic fibronectin (measured by laser nephelometry) and fibronectin gelatin-binding capacity in plasma from 310 blood donors. Both parameters were higher in men than in women and significantly increased according to age. Dissociation between immunoreactive fibronectin and fibronectin gelatin-binding capacity was observed in two polytraumatized patients. This enzyme immunoassay therefore provides a new method to investigate functional alterations of the gelatin-binding domain of fibronectin in various pathological conditions.

Electron dense alteration of kidney basement membranes. A renal lesion specific of a systemic disease.

Described here are the findings of a clinical, anatomic and chemical study of 40 patients having an original lesion of the basement membranes of the kidney. This lesion is characterized by an ultrastructural modification of the basement membrane substance which appears very dark (black) and homogeneous in electron micrographs. It affects the basement membranes of the glomerulus, Bowman's capsule and the renal tubules. Patients with this lesion all manifest the clinical course of a chronic enphritis and is almost invariably accompanied by proteinuria and microscopic hematuria. The disease evolves generally with intermittent episodes towards irreversible renal failure. Eight patients received kidney transplants. Study of these transplants has shown that the lesion recurs in the transplanted kidneys during the year following transplantation. Moreover, it is never found in kidneys transplanted into patients who did not have it in their own kidneys. This ultrastructural lesion can therefore be placed in the framework of a systemic disease whose etiology is not yet known. The study of these transplants also shows that the lesion can exist despite the absence of any detectable clinical or biologic signs and be well tolerated for periods which now exceed 4 years for three patients.

Galactose alpha 1-3 galactose and anti-alpha galactose antibody in normal and pathological pregnancies.

The galactose alpha 1-3 galactose (Gal alpha 1-3 Gal) residue is a carbohydrate widely distributed in many non-human mammals. Since Gal alpha 1-3 Gal residues are described on the cell surface of tumor cells, we have examined the possibility of their expression on human trophoblastic cells at different stages of placental implantation and in various pregnancy-associated conditions. Using immunohistochemical methods, Gal alpha 1-3 Gal was demonstrated on interstitial and vascular trophoblast during pregnancy. For villous trophoblast, the staining disappeared in second trimester pregnancies. The density of staining for Gal alpha 1-3 Gal was increased in highly invasive trophoblast (mole and choriocarcinoma) and decreased in poorly invasive specimens (spontaneous abortion, XO monosomia). No cells displaying Gal alpha 1-3 Gal at their surface were identified in some segments of spiral arteries from pre-eclamptic women. The anti-Gal antibody titer increased in the first trimester of pregnancy and in the sera of pre-eclamptic and eclamptic patients. These findings suggest that Gal alpha 1-3 Gal residues could be considered as markers for trophoblast invasive capacity and that the binding of maternal anti-Gal antibodies to the trophoblast could contribute to limit trophoblastic invasion and thus participate to the immunological control of implantation.

Glomerular mesangial cell contractility in vitro is controlled by an angiotensin-prostaglandin balance.

Rat renal mesangial cells possess morphological and functional features of smooth muscle cells in culture, such as intracellular myosin filaments, A II receptors and a contractile response to A II. Furthermore, they represent the main glomerular site of PGE2 synthesis. In the presence of A II (50 nM), their PGE2 production rate was significantly increased, this effect being potentiated by arachidonic acid (3 micrograms/ml). After a prior inhibition of arachidonic acid metabolism by cyclooxygenase inhibitors (indomethacin 1 microM or naproxen 0.02 microM) or by a cyclo- and lipoxygenase inhibitor (phenidone 670 microM), the percentage of cells contracting in response to various A II concentrations (10 pM to 10 nM) was significantly enhanced as compared to the basal conditions. On the contrary, the percentage of cells presenting a contractile response to A II in the presence of exogenous PGE2 (50 ng/ml) or of arachidonic acid (3 micrograms/ml) was significantly decreased. These modifications were not related to some changes in the A II receptor properties of the cells, i.e. the number of receptor sites and their affinity constant. The data demonstrate that the contractile response of glomerular mesangial cells is modulated by the PGE2 content of their incubation medium. Since their own PGE2 production rate is enhanced in the presence of A II, this cellular response may represent a local regulatory mechanism of their contractile properties.

Effects of ex-vivo plasma adsorption over protein A sepharose in acute leukemia.

Plasma adsorption over immobilized Staphylococcus aureus Cowan I has resulted in tumor regression in several animal and human trials. Protein A, because of its ability to bind IgGs has been considered as the effective component of Staphylococcus aureus. In 4 patients with acute leukemia, a plasma volume of 1500 cm3 was passed in an ex-vivo system over immobilized SpA-Sepharose and then reinfused. Almost all of the IgGs contained in the plasma volume could thus be removed. Toxic side-effects were mild. No significant clinical improvement could be obtained. Plasma incubation with SpA did not modify blast cell viability or leukemic progenitor cell growth. Along with others, this study shows that Protein A is probably not the mediator of the tumoricidal responses observed in studies using adsorption over Staphylococcus aureus Cowan I. The ex-vivo system prepared for this study could also be used for plasma IgG removal for the treatment of autoimmune or immune-complex related disorders.

Successful double lung transplantation with a graft obtained from a methanol-poisoned donor.

A 25-year-old woman developed "brain death" 48 h after acute methanol poisoning. After the elimination of methanol and the correction of metabolic disorders, organ donation was discussed. The lungs were transplanted into a 46-year-old woman suffering from cystic "emphysematous-like" lesions as a complication of lymphangioleiomyomatosis. The procedure was not complicated, and we have an uneventful follow-up of > 12 months. In addition to the lungs, the kidneys and the liver were also removed and transplanted with success.

Ethylene glycol poisoning treated by intravenous 4-methylpyrazole.

A 19-year-old woman was admitted 45 min after ethylene glycol (EG) ingestion. The initial serum EG concentration was 1.34 g/l (21.6 mmol/l), the anion gap 14.5, and the osmolal gap 24. Renal function was preserved (serum creatinine 75.1 micromol/l). As the patient was seen soon after poisoning, before the development of metabolic acidosis, therapy with 4-methylpyrazole (4-MP) was proposed as an antidote. 4-MP was administered via the intravenous route (7 mg/kg as loading dose, followed by 3.6, 1.2, 0.6, and 0.6 mg/kg at intervals of 12 h). 4-MP alone was effective in preventing EG biotransformation to toxic metabolites (absence of metabolic acidosis and renal injury). Ethanol therapy, hemodialysis, and sodium bicarbonate administration were not required. The half-life of EG during 4-MP therapy was 11 h, with a mean EG renal clearance of 26.9 ml/min, and a total of 65.3 g EG was eliminated unchanged in the urine. 4-MP therapy was also well tolerated.

Effect of a 2 g cimetidine infusion on twenty-four-hour intragastric pH in critically ill patients.

We evaluated the effect of a cimetidine continuous infusion (2 g in 24 h) on the intragastric pH of 16 critically ill patients (11 men, 5 women, mean age 45 years). During the 24 h pre-trial period and the subsequent 24 h cimetidine infusion, an intragastric combined electrode was placed in the fundus and the pH recorded with a portable pH module and data collection unit. In each patient, the cimetidine infusion induced a prolonged rise of intragastric pH. For all patients the mean percentage of readings above pH 4.0 was 11% pre-trial and 75% during the cimetidine 24 h infusion (p less than 0.001). The percentages of readings above 5.0, 6.0, 7.0 were also significantly higher during infusion than pre-trial in the 16 patients. After starting the cimetidine infusion, there was a concomitant rise of median plasma cimetidine and median intragastric pH in the 7 patients studied. After 6 h, median plasma cimetidine remained above 1 mcg/ml. These results and recent data from the literature suggest that in critically ill patients a continuous infusion of cimetidine might prevent stress ulcerations better than bolus injections by maintaining intragastric pH above 4.0 during longer time intervals.

Intracranial pressure changes in patients with head trauma during haemodialysis.

Intracranial hypertension and acute renal failure are frequent complications in polytraumatized patients with head trauma. This paper deals with the evolution of intracranial pressure during haemodialysis in two cases of traumatic coma. Significant changes in intracranial pressure were noted. Increase of intracranial pressure during haemodialysis was 7.6 mmHg for the first patient and 4.6 mmHg for the second patient. Prophylactic measures are discussed.

Amrinone for refractory cardiogenic shock following chloroquine poisoning.

Cardiac arrhythmias and circulatory collapse account for the high mortality reported after severe chloroquine poisoning. We have recently observed a 17-year-old man who ingested an 8 g chloroquine overdose. Cardiac arrest occurred within 1 h. Cardiogenic shock was refractory to epinephrine, dopamine and molar sodium lactate. Amrinone, a bipyridine analog, was then successfully used to improve haemodynamic conditions.

Acute cardiogenic pulmonary edema and pregnancy: a ten-year experience.

We reviewed the cardiac emergencies that occurred during or soon after pregnancy and required admission in an intensive care unit. The study sample consisted of 22248 pregnant women representing the whole obstetrical population collected from 3 hospitals over a ten-year period. Among the 88 patients admitted to our ICU during this decade, only 5 suffered from a specific cardiac disorder. Acute pulmonary edema was the common clinical presentation in the 4 cases reported. Despite the severity of cardiac involvement on admission none had previous evidence of heart disease that could have heralded acute left ventricular failure. From these observations it can be concluded that preexisting cardiovascular disease and circulatory changes related to pregnancy should no longer be regarded as the unique contributors to the development of severe heart failure during pregnancy.

Intensive care management of Guillain-Barré syndrome during pregnancy.

A particularly severe case of Guillain-Barré syndrome occurring during pregnancy is reported. The therapeutic approach including plasmapheresis, ventilation, analgesia, sedation, metabolic requirements and heparin therapy is discussed with the consequences on foetal development and the early days of life.

Effect of enteral versus parenteral feeding on hepatic blood flow and steady state propofol pharmacokinetics in ICU patients.

OBJECTIVE: The main objective of this study was to evaluate the effect of switching from parenteral to enteral feeding on liver blood flow and propofol steady-state blood concentrations in patients in the intensive care unit (ICU). DESIGN AND PATIENTS: Steady-state blood concentrations of propofol were measured in eight ICU patients before (on days D -3, D -2, and D -1) and after (on days D + 1, D + 2, and D + 3) switching from parenteral to enteral feeding (on day DO). All patients received a continuous intravenous infusion of propofol (4.5 mg x kg(-1) x h(-1)) from several days before the start of the study, continuing throughout the experimental period. Hepatic blood flow was estimated by measuring steady-state D-sorbitol hepatic clearance. RESULTS: Hepatic blood flow was high and was not affected by switching from parenteral to enteral feeding: 33 +/- 8 ml x min(-1) x kg(-1) (mean +/- SD) and 33 +/- 10 ml min(-1) x kg(-1) on D -3 and D -1, respectively, as compared to 37 +/- 11 ml x min(-1) kg(-1) and 34 +/- 8 ml x min(-1) x kg(-1) on days D + 1 and D + 3, respectively. Systemic clearance of propofol was much higher than liver blood flow with average values on the six observation days ranging from 74.0 to 81.2 ml x min(-1) x kg(-1) and was not affected by switching from parenteral to enteral feeding. CONCLUSIONS: Liver blood flow and systemic clearance of propofol were not affected by switching from parenteral to enteral feeding in the eight ICU patients studied. Extrahepatic clearance accounted for at least two thirds of the overall systemic clearance of propofol.

Two cases of acute methanol poisoning partially treated by oral 4-methylpyrazole.

OBJECTIVE: Since the use of 4-methylpyrazole (4-MP) in the treatment of humans with methanol poisoning is poorly documented, we report two cases of acute methanol intoxication partially treated by this potent alcohol dehydrogenase (ADH) inhibitor. SETTING: Intensive Care Unit in a university hospital. PATIENTS: A 56-year-old man and an 18-year-old woman were observed, respectively, 41 and 16 h after the voluntary ingestion of an unknown amount of methanol. INTERVENTION: In both cases, ethanol was used as the first antidote. In the first patient, hemodialysis was also performed on admission because a high methanol level (0.72 g/l) and visual impairment were noted. In the second patient, ethanol therapy was withdrawn after 12 h when clinical and biological signs of acute pancreatitis became evident. Both patients received multiple oral doses of 4-MP. No recurrence of metabolic acidosis occurred and the 4-MP therapy was well tolerated. CONCLUSION: While the use of 4-MP is better documented in cases of ethylene glycol poisoning, it could also become an accepted option for the management of methanol poisoning since 4-MP offers advantages over ethanol therapy.