[Heart failure and stasis ulcer: A significant association (prospective study of 100 cases)]. / Insuffisance cardiaque et ulcère de stase : une association significative (étude prospective de 100 cas).

BACKGROUND: Risk factors for stasis ulcers have been poorly studied. We conducted a three-year controlled prospective study of the usual risk factors [venous insufficiency (VI), obesity, phlebitis] and of other factors suggested by our experience, such as heart failure (HF). PATIENTS AND METHODS: Both in-patients and out-patients referred for stasis ulcers were included. The diagnosis of stasis ulcer was based on clinical criteria: venous insufficiency, cutaneous signs and/or severe leg oedema. Doppler ultrasound was performed systematically if the lesions showed no dramatic improvement within two months of treatment to eliminate arterial ulcers. VI, liver cirrhosis, heart failure, deep venous thrombosis, obesity, after-effects of leg injury, homolateral artificial hip and knee joints, and consumption of anti-leukaemia or leg-oedema-eliciting drugs were the criteria analysed by clinical examination or by consulting the information in the hospital records. Data were analyzed using SPSS/PCv12 software. Chi(2) and Fischer's exact tests were to compare cases and controls, who were identical in age, gender, and department of initial contact for reasons other than leg ulcers, stasis eczema or lipodermatosclerosis. RESULTS: We included 100 cases and 200 control subjects. Most were out-patients and only 4% were hospitalized in cardiology. Univariate analysis showed that stasis ulcer was significantly associated (p < 10(-4)) with VI (71% of cases versus 32.5% of control subjects), HF (44% versus 11%), obesity (44% versus 21.5%), after-effects of injury (17% versus 0%), and to a lesser extent, with artificial knee joints (7% versus 2.5%; p = 0.04). Multivariate analysis showed that stasis ulcer was strongly associated with VI (OR=5.5; 3-9.9) and HF (OR=4.7; 2.1-10.4). HF (right 16%, left 11%, global 57%, unspecified 16%) was also significantly associated with bilateral localization of leg ulcers (p = 10(-4)) but not with delayed healing (> 6 months). DISCUSSION: This study highlights two risk factors for stasis ulcer: artificial knee joints (in the univariate analysis only) and HF. An increase in leg oedemas is probably an important mechanism but we suggest the role of hypoxaemia in patients with isolated left HF. We advise an internist approach in the management of venous leg ulcers, which we prefer to name stasis ulcers, before having ruled out a general disease. In particular, we recommend a consultation with a cardiologist in the event of doubt.

Evaluation of histamine release following intravenous injection of ionic and nonionic contrast media.

To evaluate histamine release (HR) following injection of radiocontrast media and to test the predictive value of peak-expiratory-flow rate (PEFR) in detecting high-risk patients, the authors performed in two series 90 intravenous pyelograms (IVPs). In the first group, HR was measured by a fluorometric method after injection of Hexabrix (25 patients) and Iopamiron (25 patients). In the second group, HR measured by a radioimmunoassay, and PEFR measured by a peak flowmeter were investigated after injection of Hexabrix (10 patients), Telebrix (10 patients), Omnipaque (10 patients) and Iopamiron (10 patients). Histamine release in groups 1 and 2, and PEFR in group 2, were not significantly modified by the injection of each radiocontrast media. For the four patients (two per group) who experienced minor allergic side effects, the levels of HR and PEFR were always within the normal ranges.

Contrast agents used for excretory urography impair platelet function in human patients.

The platelet function was investigated in 65 patients submitted to diagnostic excretion urography (injection of 60 ml contrast medium). Blood sampling was performed before (T0) 90 seconds after (T1) and 30 minutes after (T2) injection of the radiocontrast molecule (RCM). Five RCM of different osmolality ionicity and nature of the lateral chain have been tested. Platelet aggregation, platelet release of ATP, osmolality, total calcemia and ionized calcium level were determined on each plasma sample as well as RCM concentration at T1 and T2. Decrease (20 - 40%) of platelet aggregation occurred at T1, whichever platelet aggregating agent (ADP, collagen, Ristocetin or thrombin) were used (significant after Iopamidol 300 and Na Meg Ioxaglate). Platelet release of ATP induced by collagen was also decreased or delayed. These changes were rapidly reversible and a tendency to improvement was observed at T2. Among the five RCM tested, one (Na Diatrizoate) might be a proaggregating agent. No changes of osmolality occurred in the plasma and no correlation could be established between RCM concentration and platelet inhibition. A pathogenic hypothesis is suggested by the significant fall of total and ionized calcium level after RCM injection.

Reduced final height and indications for insulin resistance in 20 year olds born small for gestational age: regional cohort study.

OBJECTIVE: To investigate whether the association between low birth weight and increased risk of developing impaired glucose tolerance, insulin resistance, hypertriglyceridaemia, and hypertension in middle age is apparent by the age of 20 in people born small for gestational age. DESIGN: Regional cohort study. SETTING: Maternity registry, Haguenau, France. SUBJECTS: 236 full term singleton babies born small for gestational age (birth weight or length, or both, below third centile) during 1971-8 and 281 with normal birth weight (between 25th and 75th centile). All subjects were contacted and evaluated at a mean (SD) age of 20.6 (2.1) years. MAIN OUTCOME MEASURES: Adult height; concentrations of glucose, insulin, and proinsulin during an oral glucose tolerance test; lipid and fibrinogen concentrations; and blood pressure. RESULTS: After sex and target height were adjusted for, subjects who had been born small for gestational age were significantly shorter at age 20 than those with a normal birth weight (men 4.5 cm shorter (95% confidence interval 6.0 to 3.0 cm); women 3.94 cm shorter (5.2 to 2.7 cm)). After sex and body mass index were adjusted for, mean plasma glucose concentration 30 minutes after a glucose load, fasting insulin concentration (in women), and insulin and proinsulin concentrations 30 and 120 minutes after a glucose load were significantly higher in subjects who had been born small for gestational age than in those with a normal birth weight. Mean lipid and fibrinogen concentrations and blood pressure were not different between the two groups. CONCLUSIONS: Intrauterine growth retardation has long term consequences such as reduced final height Raised insulin and proinsulin concentrations are present in young adults born small for gestational age and could be markers of early changes in insulin sensitivity.

[Nephrostomy and percutaneous internal bypass. Technic and results. Apropos of 130 cases]. / Néphrostomies et dérivations internes percutanées. Technique et résultats. A propos de 130 cas.

130 percutaneous nephrostomies have been performed on 106 patients, 6 of whom had transplanted kidneys. On 4 of these patients percutaneous drainage of a perinephric abscess was performed at the same time. Over 50% of the patients were in obstructive anuria. No failure was noted in placement of the nephrostomy tubes. Only one major complication occurred, a resolvent septic shock. Minor complications i.e. pelvocalyceal blood clotting, catheter dislodgement, retroperitoneal urine extravasation, are rare. There is no contra-indication to this procedure. 30 indwelling ureteral catheters and 10 double pigtail stent catheters were also inserted by this antegrade technic. The main indications for these procedures are 1) acute or chronic supravesical obstructions, especially infected cases. The therapeutic decision is often difficult in stenosis of neoplastic origin 2) ureteral fistulas which are always dried by a nephrostomy and which can be definitely cured by indwelling catheters, 3) certain types of calculi, which can be either treated by irrigation in situ with stone-dissolving solutions, or removed percutaneously by extraction or ultrasonic lithotripsy.

[Ultrasonic diagnosis in scrotal pathology. Apropos of 137 tests]. / Apport de l'échographie dans la pathologie des bourses. A propos de 137 examens.

Ultrasound imaging of scrotum in 137 patients detected 31 inflammatory lesions of epididymis or testis, 8 tumors, 23 cystic lesions, 21 hydroceles and 19 other affections. Medical or surgical treatment was instituted in 63% of patients, the other 37% failing to attend. Therapy was effective in 90.5% of cases (100% of fluid lesions, 80.6% of inflammatory lesions and 87.5% of tumors). Ultrasound imaging appears to be an excellent complement to clinical examination, when findings are insufficient or when examination is difficult because of severe pain, allowing identification of the fluid or solid nature of a lesion. It is also of specific value for diagnosis of subclinical tumors, surveillance of patients at risk and detailed investigation of inflammatory lesions.

[Dissolution of obstructive uric acid calculi by percutaneous nephrostomy and in situ alkalinization]. / Dissolution des calculs uriques obstructifs par néphrostomie percutanée et alcalinisation in situ.

Following the introduction of one or two percutaneous nephrostomy drains, 16 obstructive uric acid calculi were treated by perfusion of excretory cavities with 14% sodium bicarbonate solution. Twelve calculi had dissolved within an average of 5 days, 1 required percutaneous lithotripsy because of incomplete dissolution and 3 were unaltered. Success of this treatment appears to be dependent on the total radiotransparency of calculi, a feature difficult to demonstrate. There were no reports of major complications. The only weakly invasive nature of alkalinization in situ makes it a method of choice to be reserved for obstructive calculi, and a therapeutic strategy is proposed.

[Diagnosis of stenoses of the renal artery graft by pulsed echo Doppler velocimetry. Application to the prospective evaluation of the incidence of stenoses of renal graft artery]. / Diagnostic des sténoses de l'artère du greffon rénal par écho Doppler pulsé. Application à l'évaluation prospective de l'incidence des sténoses de l'artère du greffon rénal.

The value of pulsed Doppler velocimetry (PDV) to detect renal graft artery stenosis was evaluated in a prospective study of 42 kidney-transplanted adult patients. The results of PDV were compared with those of arteriography which is regarded as a reference examination. With PDV the diagnostic sensitivity was 85 percent and specificity was 82 percent. The low cost and good sensitivity (provided the interpretation problems are known) of this harmless examination make it a good instrument to detect renal graft artery stenosis. In order to obtain an early diagnosis, 148 kidney-transplanted patients were systematically examined by PDV 1, 3, 6 and 12 months after transplantation. The incidence of renal graft artery stenosis was evaluated at 6.8 percent.

[Obstructive anuria with non-dilated cavities]. / Anuries obstructives à cavités non dilatées.

Four patients with no evidence of acute functional or organic renal failure suddenly developed anuria. Repeated ultrasonographic exploration failed to show any dilatation of the urinary tract. After 4, 5, 7 and 34 days of anuria respectively, an obstacle was detected, located and identified by ultrasonically guided antegrade pyelography, which led to immediate urine derivation by percutaneous nephrostomy. Three of these patients were cured by percutaneous techniques alone. These 4 cases represent a small but not negligible part of a series of 74 patients with obstructive anuria, 70 of whom had dilated renal cavities. They throw doubt not on the reliability of ultrasonography, but on the idea that all obstacles are associated with dilatation upstream. They also confirm that opacification of the urinary tract is the only way of making sure that an obstacle is present. Antegrade pyelography gives excellent contrast images and can be used as first stage of a percutaneous nephrostomy. The other diagnostic methods are fraught with a high proportion of inadequacy or failure.

[Warren's operation for portal hypertension. Evaluation of results by early angiography in 23 cases (author's transl)]. / Opération de Warren pour hypertension portale: Appréciation de la méthode par contrôle angiographique précoce de 23 cas.

After distal splenorenal anastomosis, as described by Warren, in 23 patients, early assessment of results (after 2 weeks and 2 months) by endoscopic examination and celiomesenteric angiography was used to evaluate the effectiveness of the procedure and its effects on hepatic portal perfusion. The distal splenorenal shunt remained open in almost all cases (22 out of 23), the varices diminished, and postoperative hemorrhage rarely occurred (3/23 cases). The portogastric disconnection was incomplete in 8 patients, preservation of hepatoportal flow not being constant, as 6 cases with partial and 2 cases with complete portal thrombosis were observed.

[Embolization of benign non tumoral diseases of the kidney (author's transl)]. / Embolisation des affections bénignes non tumorales du rein.

The material includes 11 traumatic lesions of the kidney after needle biopsy, one hemangioma of the kidney with arteriovenous fistula and 4 renal exclusions for malignant hypertension. In traumatic lesions of the kidney after needle biopsy, embolization was followed by 90,9 p. cent excellent, permanent results without any marked loss of renal parenchyma and with simple post-operative follow-up. A hemangioma with congenital arteriovenous fistula required complex embolization owing to multiple pedicles and caused devascularisation of part of the lower pole of the kidney. The clinical result was satisfactory, but an arteriographic control carried out as a routine 3 months later after the embolization showed the development of newly formed vessels around the renal pelvis. However, no relapse of the hematuria occurred after a follow-up of 2 years. During the same period, spontaneous disappearance of 3 hemangiomas of the kidney sent up for embolization was noted, which led us to treat only hemangiomas which bled and prefer embolization in order to keep the kidney intact. In malignant hypertension, embolization proved efficacious and lasting in one case of small unilateral kidney. Carried out in two stages in one case of chronic nephritis with small kidneys, it proved efficacious on one side, insufficient on the other and had to be followed by nephrectomy. Finally, embolization of a remaining kidney due to chronic glomerulonephritis, technically incomplete, was followed by an uncontrollable attack of hypertension with later death of the patient. The blood supply of the kidney must thus be interrupted completely and embolization should not be undertaken unless it appears technically possible. The degree of pain following embolization suggests the possibility of peridural anesthesia.

[Severe digestive hemorrhage. Place and results of arterial embolization (author's transl)]. / Hémorragies digestives graves. Place et résultats de l'embolisation artérielle.

Arterial embolization for hemostatic purposes in digestive hemorrhage was carried out in 11 cases of acute hemorrhage and in 2 cases of chronic hemorrhage. In all cases (11) in which selective embolization was possible, immediate hemostasis was obtained. The two hemorrhagic relapses observed later were due to carcinomatous lesions. There was only one serious complication in the form of ischemic stenosis after jejunal embolization. Embolization is the method of choice in all cases in which surgery is contra-indicated. Apart from this category of patients of which the prognosis remains bad in spite of hemostasis, there are other indications in which embolization may permit in spite of a reasonable risk, transformation of emergency surgery into cold surgery with lesser mortality. Finally, in a few cases hemostasis alone and medical treatment may prove to be sufficient and avoid any further surgical operation.

[Pulmonary contusions. Anatomo-radiologic aspects]. / Les contusions pulmonaires. Aspects anatomo-radiologiques.

Simultaneous use of pathologic and microangiographic methods in 47 patients with lung contusions due to a closed chest injury with no parietal lesions differentiated between: early traumatic lesions consisting in alveolocapillary ruptures and hematomas distributed at random throughout both lungs, with immediate disseminated intraalveolar hemorrhage as a result; and secondary lesions, known as "shock lung", which are mainly the result of intraalveolar hemorrhage. All these lesions explain the usual development of various forms of fibrosis, responsible clinically for refractory hypoxia.

Nondilated obstructive acute renal failure: diagnostic procedures and therapeutic management.

We examined 80 patients with acute obstructive anuria by ultrasound (US). Four of the 80 patients did not have dilatation of the urinary tract. In all four cases, antegrade pyelography guided by real-time US demonstrated urinary tract obstruction after the four patients had experienced 4, 5, 8, and 34 days of anuria, respectively. Diuresis occurred as a result of percutaneous nephrostomy in all four cases. Three of the patients were successfully treated by percutaneous techniques alone. Our findings demonstrate that even a complete and long-term obstruction of the urinary tract does not necessarily induce dilatation in the upper part of the tract. In such cases, only the direct opacification of the urinary tract can help confirm that the obstruction is present. Even in the absence of dilatation, antegrade pyelography guided by real-time US is a possible diagnostic method and can be the first step in the performance of percutaneous nephrostomy.

[Diagnosis of hyperparathyroidism: value of jugular catheterization for radioimmunologic determination of parathormone. 1st results]. / Diagnostic des hyperparathyroïdies: intérêt du cathétérisme jugulaire pour le dosage radio-immunologique de la parathormone. Premiers résultats

Value of venous blood sampling by jugular catheterisation with radioimmunological estimation of parathormone in the diagnosis of hyperparathyroidism. Initial results.

Hepatography with intravenously injected emulsified iodolipids. Preliminary results.

Hepatography by slow intravenous infusion of AG 60 99 Guerbet (iodized lipids in a stable emulsion) was performed in 31 patients, aged 17 to 77 years, to detect circumscribed hepatic lesions: metastases, cysts, and hepatic abscesses. The tolerance was good with minor side effects unrelated to the patient's age. The uptake of the medium involves the entire liver and lasts for several hours, allowing tomography to be carried out. Intrahepatic lesions with a diameter of less than one centimeter may be demonstrated. Hepatography proves to be the most accurate method available at present for exploration of the liver.