Clinical and polygraphic evolution of sleep-related breathing disorders in adolescents.

It has been suggested that sleep-related breathing disorders (SRBD) involve a continuum that develops over the course of life. If modifiable factors could be identified, the progression of SRBD could perhaps be addressed early in life. Although some studies have looked at the evolution of SRBD in pre-pubertal children, very few studies obtained data in adolescents. Anthropometric, clinical and polygraphic variables were collected during a 4-yr follow-up study among 148 normal adolescents after initial cross-sectional analysis. From a total of 267 adolescents studied at baseline (mean+/-sd age 14.3+/-2.1 yrs), 148 (55.4%) were followed up for 4 yrs. During follow-up, there were no significant changes in snoring and polygraphic parameters. However, a tendency toward weight gain with centrally distributed fat was observed. Habitual snorers had a significantly higher body mass index and more centrally distributed fat than nonsnorers. Males had a higher snoring prevalence and a higher number of respiratory events than females. Snoring at baseline, male sex and poor academic performance were significant predictors of snoring at follow-up. Snoring tends to persist during adolescence and male sex acts as a risk factor. A relationship between snoring and academic performance was observed. These findings may have implications for long-term management of sleep-related breathing disorders.

[Determination of lecithin-cholesterol acyltransferase. Studies on the precipitation of beta-lipoproteins by dextran sulphate (author's transl)]. / Dosage de la lécithine-cholestérol acyltransferase. Intérêt de la précipitation des beta-lipoprotéines par le sulfate de dextrane.

Uncertainties in assays of lecithin-cholesterol acyltransferase (LCAT) are generally related to the degree of isotopic equilibrium obtained by rapid exchange of unesterified cholesterol between the different lipoproteins. A new method is presented based on the precipitation of serum beta-lipoprotein with sulfated polysaccharides prior to the LCAT determination. In the absence of Beta-lipoproteins, more than 7 per cent of serum free cholesterol is esterified in the first hour and the reaction rate is linear for about 2 h. LCAT activities with normal serum expressed as cholesterol esterified per microliter mol/1/h are lower than the values reported by others. The reason for this discrepancy is that free cholesterol specific activity in total serum does not reflect the true specific activity of LCAT cholesterol substrate.

Surgical treatment of carcinoma of the proximal esophagus.

BACKGROUND: Proximal esophageal cancer is usually diagnosed at an advanced stage, and the treatment is often limited to palliation. Surgery offers the best relief of dysphagia but it remains controversial, because a cure is unlikely even at the price of laryngeal mutilation. PATIENTS AND METHODS: We treated 40 patients with transhiatal esophagectomy for cancer of the proximal esophagus. The esophageal substitute was a stomach tube in 37 patients and colon in 3 patients. The larynx was preserved in 27 patients whose tumors did not extend to cricopharyngeus. Adjuvant treatment consisted of postoperative radiotherapy for 22 patients, chemotherapy for 1 patient, and a multimodality regimen for 4 patients. RESULTS: The postoperative complication and hospital mortality rates with gastric tube transpositions were 22% and 8%, respectively, with a 3% fistula rate. The 1- and 3-year overall survival rate was 53% and 21%, respectively. The unfavorable prognostic factors were tumor wall penetration, lymph nodal involvement, and cricopharyngeal involvement. Local recurrence of cancer was the major cause of failure. CONCLUSIONS: These results indicate that transhiatal esophagectomy with gastric tube transposition offers good palliation of dysphagia with low morbidity and mortality for proximal esophageal cancer. The laryngeal preservation can be attempted for tumors located close to, but not involving, the cricopharyngeus in order to retain speech in patients with a limited life expectancy.

Quantitative analysis of the immune cells in the anal mucosa.

The prevalence of anoperineal diseases, i.e. sexual transmitted infections, is increasing particularly in AIDS, a fact which is likely due to the alteration of mucosal immunity. However, no data were available on normal anal status. In order to study anal immunity in man, we characterized lymphocytes subtypes and Langerhans' cells (LC) using quantitative morphometric analysis and immunohistochemistry. Anal normal mucosal samples obtained from surgical specimens of 45 patients (30 suffering from hemorrhoids and 15 from fissurations) were analyzed. Immunohistochemistry was performed on frozen sections with antibodies recognizing CD1a (LC), CD3 (T lymphocytes), CD4 (T4), CD8 (T8) and CD22 (B-lymphocytes). Immunostained cells were counted per square millimeter of mucosal epithelium. The surface of CD1a cells was measured using a computerized software program and a percentage of CD1a immunostained area was calculated in comparison to the whole mucosal surface. LC and T-Lymphocytes were found in the squamous epithelium in all analyzed samples. The mean values of LC number were 84.13 +/- 9.6 and 64.77 +/- 9.8 in hemorroid- and fissure-patients, respectively. The mean values of LC area (% of CD1a stained area over total mucosal surface) were 3.89 +/- 0.44 and 4.84 +/- 0.64, respectively. In the two groups, the number of intraepithelial CD8 lymphocytes was higher than that of CD4 lymphocytes. These data suggest for the first time that anal mucosa could be considered as a part of MALT system.

Short term essential fatty acid deficiency in rats. Influence of dietary carbohydrates.

The effects of long term (8-14 wk) essential fatty acid (EFA)-deprived diets in rats are well documented. In the present study, we compared, in weanling rats, the effect of a short term (two wk) hydrogenated coconut oil, EFA-deprived, diet (D) with that of a corn oil, EFA-adequate, diet (A), using either sucrose (SU) or starch (ST) as carbohydrate. After two wk, rats fed the sucrose/hydrogenated coconut oil diet developed some characteristic features of EFA deprivation: slower growth rate, decreases in linoleic and arachidonic acid of plasma phospholipids and an increase in n-9 eicosatrienoic acid of plasma phospholipids. When rats ate the starch/hydrogenated coconut oil diet, there was a similar decrease in linoleic acid of plasma phospholipids, but only a small effect on growth rate and no change in the arachidonic acid content of plasma phospholipids. EFA deprivation and sucrose had opposite effects on plasma triglyceride (TG) levels: deprivation induced a decrease, whereas the sucrose induced an increase in very low density lipoprotein (VLDL) triglycerides. The observed decrease in plasma triglyceride during EFA deprivation might result from an activation of lipoprotein lipase during the early stages of deprivation.

Laparoscopy for acute small-bowel obstruction secondary to adhesions.

BACKGROUND AND PURPOSE: Postoperative adhesions are the leading cause of small-bowel obstruction in developed countries. Several arguments suggest that laparoscopy may lead to fewer adhesions than does laparotomy. We report here the short-term results of laparoscopy in patients admitted on an emergency basis for acute small-bowel obstruction secondary to adhesions. PATIENTS AND METHODS: This prospective trial included 134 consecutive patients: 39 underwent emergency surgery, and 95 had laparoscopic adhesiolysis shortly after resolution of the obstruction with nasogastric suction. Of the previous operations for which the dates were known, 16% had taken place within 1 year of the obstruction and 33.5% within 5 years. In all, 27% of the patients had open laparoscopy, and 16% had conversions: 7% after elective laparoscopy and 36% after emergency laparoscopy. RESULTS: There were no operative deaths. One patient underwent a reoperation the following day for fistula after incomplete adhesiolysis attributable to multiple adhesions found during elective laparoscopy. If laparoscopy is considered to have failed when adhesiolysis was incomplete or conversion or reoperation was necessary, our success rate was 80% after elective laparoscopy and 59% after emergency laparoscopy. CONCLUSION: Emergency situations in acute small-bowel obstruction combine several circumstances unfavorable for laparoscopy: a limited work area and a distended and fragile small bowel. Laparoscopic adhesiolysis after the crisis has passed may produce better results, but only long-term follow-up can confirm the role of elective laparoscopy for this indication.

Small intestinal obstruction by an enterolith from a Meckel's diverticulum.

A new case of an enterolith, formed within a Meckel's diverticulum and subsequently expellefferential diagnosis from a gallstone ileus is virtually impossible. This nevertheless remains a rare cause of intestinal obstruction.

Aorto-digestive fistulae.

On the basis of a case of aorto-duodenal fistula due to fissuration of a tuberculous sub-renal aneurysm, the authors review the difficult question of primary and secondary aorto-digestive fistulae. Primary fistulae are due to the rupture of an artheromatous or infectious aneurysm. The latter possibility must always be borne in mind. Aneurysms secondary to an aortic suture are more common in practice. There is also often a troublesome infectious element, requiring axillobifemoral bypass prior to treatment of the aneurism itself.

Priapism and pudendal arteriovenous fistula.

The authors report a case of recurrent priapism treated by saphenocavernous bypass and accompanied by a congenital internal pudendal arteriovenous fistula. In the light of this case and the literature, they discuss the physiopathology of priapism and the sound basis of the various therapeutic methods proposed.

[Assessment of excessive day-time sleepiness in professional drivers with suspected obstructive sleep apnea syndrome]. / Evaluación de la somnolencia diurna excesiva en conductores profesionales con sospecha de síndrome de apnea obstructiva durante el sueño.

Excessive daytime sleepiness is a common symptom of obstructive sleep apnea syndrome (OSAS) and can be a cause of traffic accidents, creating a problem of particular importance for professional drivers given the associated death, disability and professional repercussions. We assessed whether the Epworth sleepiness scale (ESS), which is a subjective measure of daytime sleepiness, correlates well with multiple sleep latency (MSL) testing, which gives an objective measure of daytime sleepiness. We also compared each method with the results of polysomnography (apnea-hypopnea index, arousal index and minimum oxygen saturation). We studied 55 professional drivers suspected of OSAS. All answered the ESS questionnaire and underwent polysomnographic and MSL testing. We found a significant, though not relevant, correlation between the degree of excessive daytime sleepiness estimated by the ESS and by MSL testing (r = -0.41; p = 0.002). A significant, though weak, correlation was found between the ESS score and the arousal index (r = 0.26; p < 0.05). Our results do not clarify which method is best for measuring excessive daytime sleepiness in professional drivers suspected of OSAS.

[Association of obstructive apnea syndrome during sleep and narcolepsy]. / Asociación del síndrome de apnea obstructiva durante el sueño y la narcolepsia.

Obstructive sleep apnea syndrome (OSAS) is highly prevalent. Daytime hypersomnolence (DHS) is among its symptoms, although other diseases, such as narcolepsy, can also give rise to DHS. We describe three men diagnosed of OSAS whose DHS persisted even after snoring disappeared following treatment with continuous positive airway pressure. We suspected associated narcolepsy, which was confirmed by multiple sleep latency testing. Narcolepsy, therefore, should be considered when DHS persists even after appropriate treatment of OSAS.

[Proctitis of diversion on an excluded rectum in patients with hemorrhagic rectocolitis]. / Proctite de diversion sur rectum exclu chez des patients atteints de rectocolite hémorragique.

OBJECTIVES: Diversion colitis is characterized by inflammatory lesions affecting colon or rectum excluded from the fecal stream for varied etiologies. These lesions may mimic both ulcerative colitis and Crohn's disease. The aim of our study was to examine the excluded rectum in patients with ulcerative colitis, and to study the evolution of the pathological lesions after ileo-rectal anastomosis. METHODS: Eighteen patients with ulcerative colitis treated by total colectomy before ileo-rectal anastomosis were studied. The pathological features i.e. glandular alteration, inflammatory infiltrate and mucosal ulceration or fissure, were studied during 3 periods: initial colectomy, excluded rectum at surgery for anastomosis and rectal biopsies after anastomosis. RESULTS: We observed on the excluded rectum a follicular lymphoid hyperplasia (18 cases), granulomas with giant cells (9 cases), mucosal fissures (9 cases). The inflammation extended to the submucosa in all cases and was occasionaly transmural. These lesions disappeared after the anastomosis and then seemed to be connected with the rectal diversion. CONCLUSIONS: The pathological changes of diversion proctitis that includes mucosal fissures, granulomas with giants cells or transmural inflammation, may lead to an erroneous diagnosis of Crohn's disease. The review of the previous colectomy is then mandatory to confirm the initial diagnosis of ulcerative colitis. These lesions disappear after anastomosis.

[Salmonella pancreatic abscess. Treatment by drainage without cholecystectomy]. / Abcès pancréatique à salmonelle. Traitement par drainage sans cholécystectomie.

We report a case of necrotic collection in the head of the pancreas infected by Salmonella typhimurium. Treatment associated necrosectomy and antibiotic therapy without cholecystectomy. The course of pancreatic disease was uneventful. Complete sterilization was obtained with quinolone antibiotic therapy.

[Effectiveness of continuous positive airway pressure in the long-term treatment of the obstructive sleep apnea syndrome]. / Eficacia de la presión positiva continua en la vía aérea en el tratamiento a largo plazo del síndrome de apnea obstructiva del sueño.

Eight patients with obstructive sleep apnea syndrome were treated with continuous positive airways pressure by nasal route. The treatment was carried out in the hospital during the initial days. If the procedure was effective and the tolerance was good, the patients were discharged to continue with treatment at home. Polygraphic sleep recordings carried out 2-4 months after the beginning of therapy showed normalization of the structure and the phases of sleep, apnea and desaturation being virtually absent. After a mean follow up of 18 months the patients are asymptomatic. The treatment has been well tolerated and significant side effects have not developed.

Magnesium deprivation or short-term essential fatty acid deficiency in rats: effects on serum lipids, platelet fatty acid composition and arachidonic acid incorporation into platelet phospholipids.

The aim of this study was to evaluate the effect of short-term magnesium or essential fatty acid (EFA) deficiencies on plasma lipids, platelet fatty acid composition and [1-14C] arachidonic acid incorporation into platelet phospholipids. Weanling rats were fed purified diets (casein 20%, sucrose 70.5%, lipid 5%) for two weeks. The control and magnesium-deficient diets included corn oil as lipid source. The EFA-deficient diet included hydrogenated coconut oil. The fatty acid composition of serum lipids confirmed the linoleic acid deprivation in the EFA-deficient group. Significant changes in platelet fatty acid composition occurred in this limited period of time and arachidonic acid incorporation into platelet lipids was markedly increased. Magnesium deficiency induced hyperlipaemia. A significant decrease in the percentage of arachidonic acid in total serum lipids was observed, but fatty acid profile appeared quite different in the two deficiencies. In magnesium-deficient rats, the alteration in fatty acid composition of serum lipids was not associated with similar changes in fatty acid composition of platelet lipids. Arachidonic acid incorporation into platelet lipids was markedly increased in magnesium deficient animals as compared to control group. Relatively more arachidonic acid was incorporated into phosphatidylcholine and phosphatidylinositol when magnesium-deficient or EFA-deficient animals were compared to the control group.

[Which diagnostic and therapeutic approach to the Zollinger-Ellison syndrome should be adopted in 1990?]. / Quelles stratégies diagnostique et thérapeutique faut-il adopter en 1990 dans le syndrome de Zollinger-Ellison (SZE)?

A diagnostic and therapeutic strategy for ZES is proposed based on the vast experience (180 cases) of this rare disease gained at hospital Bichat (Paris, France). The first step is diagnostic and relies essentially a) upon measurements of gastric acid and serum gastrin in the basal state and b) upon the results of secretin test because of the overlap between ZES and duodenal ulcer disease in a large proportion of cases. In sporadic ZES cases, after adequate control of acid overproduction and attempt to localize the tumoral process(es), surgery is indicated (at the exception of patients with advanced metastatic disease). Surgery aims essentially at eradicating gastrinoma(s) as often as possible and whenever it is feasible without endangering patient's life. An apparently definite cure is attained in 60 to 80% in extrapancreatic gastrinoma(s) and 20 to 30% when gastrinomas are located within the pancreas. Liver involvement (25% of ZES cases) remains the major concern and death cause in these patients. Although liver metastases frequently stabilize and sometimes regress upon chemotherapy and chemoembolization, liver transplantation may, in the future, represent the major chance for these patients; but in this frequently slowly evolving condition, the time for liver transplantation is exceptionally difficult to settle.

[Esophageal anomalies developed from tracheobronchial remnants. Reports of two cases with delayed diagnosis in adults]. / Anomalies oesophagiennes développées sur reliquats trachéobronchiques. A propos de deux cas de diagnostic tardif chez l'adulte.

Congenital esophageal stenosis and bronchogenic cyst are secondary to the same dysembryoplastic disorder in spite of different clinical signs. These lesions are revealed during infancy, unusually during adult age. Dysphagia is the most common symptom. Our two cases highlight these topics. Imaging methods displayed, in case 1, a distal stenosis, associated with a proximal dilatation, in case 2, a benign independent mass, without connection with the respiratory tract. A chirurgical excision was carried out in the two cases and the post operative course was uncomplicated. Histologically the two resection specimens showed a respiratory mucosa trapping cartilaginous pieces.

[A case of polypoid solitary colonic plasmocytoma]. / Un cas de plasmocytome solitaire du côlon à forme polypoïde.

One case of polypoid solitary plasmacytoma in the sigmoid colon of a 60 year-old woman is presented. Plasmacytomas are rarely observed in the gastrointestinal tract and are especially uncommon in the côlon. Eight cases were published since 1972. They show a mean age of 46.3 years, a sex-ratio of 1/1, varying revealing symptoms, and no preferential colonic location. Two differential diagnosis must be discussed: an inflammatory pseudotumor, and a multiple myeloma related tumor. Multiple myeloma must be ruled out by a complete radiographic and biological research. Surgery is the only therapy described and seems to be efficient.

[Cystic pneumatosis of the colon. Report of 3 cases and review of the literature]. / Pneumatose kystique du côlon. Rapport de trois cas et revue de la littérature.

Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas is found in cysts located in the intestinal wall. PCI is a sign, not a disease; therefore, its relevance should be interpreted within the whole clinical context. PCI has been found in several distinctive clinical settings, which the authors review in the light of their 3 new cases. Morphologic and endoscopic examinations showed "polypoid" intraluminal formations corresponding to pneumocysts which should not be misdiagnosed with a diffuse polyposis. The most important tasks of the physician include: 1) recognition of the entity of PCI so that patients are not misdiagnosed and mismanaged as having malignancy or polyposis; and 2) differentiation of the benign noncomplicated cases from life-threatening forms (bowel necrosis, perforation, and infections), in which immediate surgery is necessary, and which are associated with high mortality.

[Obstruction of the small intestine caused by adhesions after appendectomy. Argument for repeated surgery as proposed by Mac Burney]. / Occlusion du grêle sur bride après appendicectomie. Plaidoyer pour un traitement par voie itérative de Mac Burney.

After appendectomy, mechanical obstruction of the small intestine is often due to local bands. This type of obstruction is classically treated by median laparotomy. We present ten cases of such obstruction treated via the initial gridiron incision, whose advantages are discussed.