Volumes of the spinal canal and caudal space in children zero to three years of age assessed by magnetic resonance imaging: implications for volume dosage of caudal blockade.

BACKGROUND: The primary aim of this study was to objectively assess the different spinal and caudal volumes that are of interest for caudal block volume dosing. METHODS: Three directly assessed (volume of spinal canal/caudal space, volume of the dural sac and volume of spinal cord) and two derived volumes (volume of the epidural space and cerebrospinal fluid volume) were determined from magnetic resonance images (MRI) in 20 children (zero - three yr of age). The assessed volumes were correlated to age, height and weight. Furthermore, the volumes of the epidural space from caudal canal to three different clinically relevant target levels (L 1, Th 10 and Th 6) and the epidural volume of each individual spinal segment at the caudal, lumbar and thoracic levels were calculated. RESULTS: All volumes correlated in a linear manner to length and weight (R2 0.614 - 0.867) whereas a curvilinear correlation was associated with best curve fit for age (R2 0.696 - 0.883). The median volumes of the epidural space from caudal canal to L 1, Th 10 and Th 6 were 1.30 ml kg-1 (95%CI 1.08-1.51), 1.57 ml kg-1 (95%CI 1.29-1.81) and 1.78 ml kg-1 (95%CI 1.52-2.08), respectively. The median volumes of the epidural space per vertebral segment were Thoracic: 0.60 ml (95%CI 0.38-0.75); Lumbar: 1.18 ml (95%CI 0.94-1.43) and Caudal: 0.85 ml (95%CI 0.56-1.18). CONCLUSIONS: The spinal volumes of interest show a linear correlation to height and weight whereas a curvilinear correlation was found for age. The volume of the epidural space per segment was found to be significantly higher at the lumbar level compared with the caudal and thoracic levels.

O6-Methylguanine-DNA methyltransferase status in neuroendocrine tumours: prognostic relevance and association with response to alkylating agents.

BACKGROUND: O(6)-Methylguanine-DNA methyltransferase (MGMT) loss of expression has been suggested to be predictive of response to temozolomide in neuroendocrine tumours (NETs), but so far, only limited data are available. We evaluated the prognostic and predictive value of MGMT status, assessed by two molecular methods and immunohistochemistry, in a large series of NETs of different origins. METHODS: A total of 107 patients, including 53 treated by alkylants (temozolomide, dacarbazine or streptozotocin), were retrospectively studied. In each case, we used methyl-specific PCR (MS-PCR) and pyrosequencing for evaluation of promoter methylation and immunohistochemistry for evaluation of protein status. RESULTS: MGMT promoter methylation was detected in 12 out of 99 (12%) interpretable cases by MS-PCR and in 24 out of 99 (24%) by pyrosequencing. O(6)-Methylguanine-DNA methyltransferase loss of expression was observed in 29 out of 89 (33%) interpretable cases. Status of MGMT was not correlated with overall survival (OS) from diagnosis. Progression-free survival and OS from first alkylant use (temozolomide, dacarbazine and streptozotocin) were higher in patients with MGMT protein loss (respectively, 20.2 vs 7.6 months, P<0.001 and 105 vs 34 months, P=0.006) or MGMT promoter methylation assessed by pyrosequencing (respectively, 26.4 vs 10.8 months, P=0.002 and 77 vs 43 months, P=0.026). CONCLUSIONS: Our results suggest that MGMT status is associated with response to alkylant-based chemotherapy in NETs.

Reduction of cerebral mean blood flow velocity and oxygenation after high-volume (1.5 ml kg⁻¹) caudal block in infants.

BACKGROUND: We have recently described a bi-directional bulk flow of cerebrospinal fluid (CSF) (coined 'the CSF rebound mechanism') after the use of high-volume caudal block in infants, which may explain the secondary longitudinal spread of the block. If important the initial cephalad transfer of CSF should be of such a magnitude that it would cause a transient reduction in cerebral blood flow (CBF) and cerebral oxygenation. The primary aim of this observational study was to delineate the magnitude of the reduction of CBF velocity (CBFV) associated with high-volume caudal block in infants. METHODS: Ultrasound Doppler measurements of CBFV in the middle cerebral artery and also haemodynamic parameters and cerebral regional oxygenation (C(R)SO2) were followed during 5 min after the initial caudal injection (1.5 ml kg(-1), ropivacaine 0.2%) in 12 infants <3 months of age. RESULTS: The caudal injection was associated with immediate and major reductions in CBFV indicating a concomitant reduction in CBF. A significant reduction of cerebral regional oxygenation C(R)SO2 was also observed. Systemic haemodynamic parameters were unchanged during the observation period. CONCLUSION: High-volume caudal block causes a biphasic change in CBFV and was also found to affect cerebral oxygenation. Our findings lend further support to 'the CSF rebound mechanism' for secondary spread of high-volume caudal block.

Macroscopic and histologic regression of duodenal polyposis with FOLFOX4 chemotherapy for an ileal pouch adenocarcinoma in a patient with familial adenomatous polyposis.

Severe (stage IV) duodenal polyposis is difficult to manage in patients with familial adenomatous polyposis (FAP), with no effective medical treatment, complex endoscopic treatment modalities, and a high morbidity and mortality from pancreaticoduodenectomy. We present the case of a 44-year-old woman with FAP, stage IV duodenal polyposis, and with an ileal pouch adenocarcinoma that required surgery and adjuvant chemotherapy. Her duodenal polyposis regressed to stage II after four sessions of FOLFOX4 adjuvant chemotherapy, which avoided the need for aggressive endoscopic therapy or pancreatoduodenectomy in this patient.

The endothelin receptor antagonist tezosentan improves renal microcirculation in a porcine model of endotoxemic shock.

BACKGROUND: Impaired renal microcirculation has been suggested as a factor contributing to the development of renal dysfunction in sepsis. This study was conducted to elucidate the role of endothelin-1 (ET-1)in mediating reductions in renal microcirculatory blood flow during endotoxemic shock. METHODS: A prospective, randomized, and experimental study was performed with 16 anesthetized and mechanically ventilated pigs. After 2 h of lipopolysaccaride-induced endotoxemia, eight animals received a bolus dose of the dual endothelin receptor antagonist tezosentan (1 mg/kg), followed by a continuous infusion of 1 mg/kg/h throughout the experiment. Eight animals served as the control group. Renal microcirculation, total renal blood flow, plasma creatinine levels, cardiac index, and mean arterial pressure were measured. Plasma samples were collected for the measurement of tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), interleukin-10 (IL-10), ET-1, angiotensin II, and aldosterone. RESULTS: Endotoxin infusion resulted in a state of circulatory shock with impairment of renal microcirculation. An increase in the plasma levels of TNF-alpha, IL-6, IL-10, ET-1, angiotensin II, and aldosterone was also observed. Tezosentan attenuated the decrease in renal microcirculation and renal blood flow, and attenuated the increase in plasma creatinine. Treatment with tezosentan did not significantly affect the plasma cytokine, angiotensin II, or aldosterone response to endotoxemia. CONCLUSION: These results indicate that treatment with the dual endothelin receptor tezosentan in endotoxemic shock attenuates the reduction of renal microcirculation and total renal blood flow independently of plasma changes in the renin-angiotensin-aldosterone system or early plasma cytokine response.

[Anxiety in palliative care]. / Anxiété dans le cadre de soins palliatifs.

In palliative care, the intensity and duration of anxiety as well as its consequences on the patient's daily activities can significantly decrease his quality of life. Anxiety that does not incapacitate the patient to the point of his being unable to communicate or perform his usual activities does not necessarily require drug treatment. The non pharmacological treatments of anxiety are presented in some detail. Prescription of anxiolytic drugs in renal or hepatic failure, as well as when oral intake or venous access are difficult, is briefly discussed.

T-lymphocyte populations in the blood of caprine arthritis encephalitis virus-infected goats.

The effect of natural infection by Caprine Arthritis Encephalitis Virus on the phenotypic pattern of T lymphocytes in peripheral blood was studied in a herd of 127 milking goats by flow cytometry. Total leukocyte and T-lymphocyte numbers tend to decrease with age, with only small changes in the CD4/CD8 ratio. The lymphocyte phenotypes show no strong correlation with seropositivity to CAEV or the presence of clinical symptoms, suggesting that this macrophagetropic lentivirus does not greatly effect the lymphocyte population.

[Not Available]. / Peau sèche-rêche et "Hydratation". Concept de la capture de l'eau organisée comme de la glace.

About sixty years ago Frank and Evans showed, by entropy measurements, that when a "non-polar molecule dissolves in water it modifies the water structure in the direction of greater 'cristallinity', the water builds a microscopic iceberg around it" Now, we propose the "concept of ice-like-water capture": a lowering of organized ice-like water promotes aggregation (loss of solubility) of the filaggrin/keratin1/keratin10 associations through their hydrophobic patches. The capture of ice-like water may be performed by the glucoceramides-rich bilayers in stratum granulosum. Probably, the same process aggregates the proteins of corneocytes envelope as well as corneodesmosomes proteins. According to the "concept of ice-like-water capture", to regulate the keratinization, it is not total water that must be added to the stratum corneum, but ice-like water that must be removed from stratum granulosum. Both petrolatum (lipophilic ingredient) and glycerol (hydrophilic ingredient) would capture the ice-like water, most probably after combination with the lipid bilayers of stratum corneum. Moisturizing cream, when organized in secondary droplets is likely to perform the same action. Measurements by near-infrared reflectance spectroscopy of the skin show that petrolatum; glycerol and/or moisturizing cream enhance the quantity of bulk water (1890-1897 nm band). As the ice-like water is the complement of bulk water, the enhanced bulk water let presume an ice-like water lessening. Some desynchronization (late or forward) of the keratinization/differentiation which confer the somatosensory problems associated with "dry and flaky skin" may be linked to an excess or lack of ice-like. For instance, the winter xerosis, very common by chilling weather, could be explained by an increase of ice-like water driven by the fall of the temperature.

[Is length of stay in the recovery room a risk factor for cross infections?]. / Le séjour en salle de surveillance postinterventionnelle peut-il être à l'origine de transmissions croisées?

OBJECTIVE: To assess cross contamination for patients at the time of their stay in the recovery room (RR). STUDY DESIGN: Prospective study. PATIENTS AND METHODS: A prospective survey over 3 weeks with 75 adult patients admitted to RR after thoracic or neck surgery. Samples for bacterial analysis were systematically taken from all patients before they left the operating theatre and just before discharge of RR (nose-throat and skin adjacent to the surgical wound). During this period, hand's health care workers (HCW) and environmental surfaces were sampled. RESULTS: There were 3 groups of patients: endoscopy (41%), thoracic surgery (39%). And thyroidectomy (20%), 392 samples were analysed. Potentially pathogenic floras were found on the admission for 25 patients and at discharge for 31 patients. A pathogenic flora was detected at discharge in 13 patients, whereas none was found at admission in RR. These patients were principally in the thyroidectomy group and their stay in RR was longer than 20 minutes. There is no significant difference concerning the nosocomial risk between 3 groups. Pathogenic flora was found in 19% of HCW (8 of 42). CONCLUSION: Cross contamination can exist in recovery room and educative measures are to be taken regarding handwhashing, isolation precautions and environmental cleaning.

[Cutaneous histiocytosarcoma: clinical, immunohistochemical and ultrastructural aspects; difficulties of study and problems of nosology (author's transl)]. / Histiocytosarcome cutané: aspects cliniques, immunohistochimiques et ultrastructuraux; difficultés d'étude et problèmes nosologiques.

Reporting a case of cutaneous tumor of the back of recent occurrence and rapid increase in a 79-years-old woman, according to Crosti's "reticulosis", the authors discuss the following points:--the histiocytic nature of the tumor cells particularly based on immunohistochemical studies (peroxidase activity, anti-HTLA serum) and on electron microscopy with special reference to the multivesicular bodies found in their cytoplasm;--the tests for correct identification of the histiocyte (including electron microscopy, tests for HTLA and HBLA antigens, peroxidatic reaction, acid phosphatase activity, and in vivo or in vitro phagocytosis);--the out of date character of the concept of malignant "reticulosis" in the hematologica and dermatologic classifications, the recent advances in the knowledge of the nature of the so-called "reticulum" (or "reticular") cell which seems to be a distinct entity derived from the mesenchymal cell (as the fibroblast);--the clinical and evolutive characteristics of histiocytic tumors (no hematologic involvement, slow evolution, high radiosensitivity), the difficulties in defining their malignancy and, above all, in finding comparable references in the literature with complete cellular study;--the nosologic place of this affection among the group of haematodermas and in the pathology of the mononuclear phagocyte system. The generic term of cutaneous histiocytosarcoma (stage I or II) is suggested, including the whole malignant and isolated tumoral proliferations developing from the dermic histiocyte.

[Association of lupus erythematosus and vitiligo (author's transl)]. / Lupus érythémateux et vitiligo.

The authors report two cases with both true vitiligo and cutaneous lupus erythematosus (LE). The latter was found only on the vitiliginous areas on both exposed and non-exposed skin. A study of the literature shows that this association is very rare and, like the association between vitiligo and antinuclear antibodies, not statistically significant. It is therefore not possible to explain the pathogenesis of this association by a common autoimmune theory, although vitiligo is well known to coexist with other autoimmune disorders and although antimelanocyte antibodies are exceptionally found in certain cases of vitiligo. The coexistence of lupus erythematosus and vitiligo must be clearly distinguished from post lupus depigmentation which is much more common. In the latter there is clinically an irregular hypomelanosis and an atrophic epidermis and, histologically, there is a pigmentary incontinence with an increased number of melanocytes. Even if it is fortuitous, the appearance of LE lesions on light exposed vitiliginous areas may be explained by the common photosensitivity of these two disorders. However, this superimposition does not explain the common points between these two diseases nor the localization on non-light exposed skin. The localizing role of vitiligo in these exceptional cases could represent a more complex disorder of the dermo-epidermal junction. This disorder could affect more than the melanocytic system and subsequently favour the occurrence of the LE. Nevertheless, the mechanism of this coexistence still remains unknown.

[Late Becker's nevus. One hundred cases (author's transl)]. / Naevus tardif de Becker. A propos d'une série de 100 observations.

The authors make a survey of a series of a hundred Becker's nevi diagnosed in a recruiting center of the French National Service. It is a statistic study bearing on the male population, aged 17 to 26, in a French region which is supposed to be representative of the French male population of the same age. First of all the authors focus on the various clinical descriptions since this nevus was first described by Becker in 1949, then discuss the problems raised by pathogenic interpretation and the results of microscopic studies. About this lesion, usually said to be pigmentary and hairy, and generally appearing before 20 years of age, is still very little known. Then after a short explanation of their method of study the authors give original results. A hundred Becker's nevi were diagnosed among 19,302 young men, that is to say in a proportion of 0.52 p. 100. A study of the racial, genetic and pigmentary background doesn't enable to retain general causes but rather leads to think of local causes. Half of these Becker's nevi appeared before ten years of age, the other half appearing between 10 and 20. In only one quarter of the cases can the role of the sun be pointed out. The location of the nevi is variable; they are mainly situated on the trunk and only 32 p. 100 of them are located above nipples, which was believed to be the usual place of the lesion. Pigmentation in three quarter of the cases is light brown. The average surface is 125 cm2. Hairs can be seen in only a little more than half of the cases of no lesion associated to the nevus could be found. The study points out that Becker's nevi seem to be more various in their clinical expression and more pigment than could be thought through more classical description.

[Dermal mastocytes, histaminaemia, and oral photochemotherapy (author's transl)]. / Mastocytes cutanés, histaminémie et photochimiothérapie orale.

One patient with urticaria pigmentosa was treated with PUVA. This treatment resulted in generalized tanning, decrease of Darier's sign and improvement of pruritus. However, the hyperpigmented macules overlying the mast cell infiltrates showed some persistence. This patient was subjected to biopsy of lesional skin before, during and at the end of oral photochemotherapy. During and after PUVA-therapy, histological examination revealed an increased number of free granules and a progressive decrease in the number of dermal mastocytes. Ultrastructurally necrotic cellular changes in the dermal mastocytes were observed. This suggests that PUVA-therapy may exercise its beneficial effect in urticaria pigmentosa by direct destruction of these cells. In addition, PUVA stimulates mast cell degranulation. Histaminaemia was estimated in this patient, before and after several irradiations. No significant changes were observed. Furthermore, histaminaemia was assayed in 15 patients with various dermatoses undergoing PUVA-therapy. No significant changes were observed. It is concluded that histaminaemia assayed using the fluorometric method of Shore et al. remains unchanged during oral photochemotherapy.

[Mycobacterium chelonei cutaneous infections. General review apropos of a case]. / Infections cutanées à Mycobacterium chelonei. Revue générale à propos d'un cas.

Mycobacterium chelonei is a facultative pathogen which exists as a saprophyte in the environment and rarely produces clinical manifestations in humans. We describe a 62-year-old woman, long-term treated with low-dose steroids for severe asthma, who presented sporotrichoid-like lesions on one leg. These lesions appeared two months after a cat-scratch and were present for six months. Histological examination showed acute inflammation with polymorphonuclear infiltration without tuberculoid granuloma nor caseation necrosis. Ziehl-Neelsen stains were negative. Mycobacteria were found by direct examination and Mycobacterium chelonei chelonei was identified by culture. Treatment with isoniazid, rifampicin and ethambutol was given for one month and followed by complete resolution of the lesions, though each of these antibiotics was not effective in vitro. The literature about Mycobacterium chelonei infections is reviewed and the role of the antibiotherapy in clinical recovery is discussed.

[Acquired peeling skin syndrome in an adult]. / Syndrome de desquamation continue ("peeling skin syndrome") acquis à l'âge adulte.

BACKGROUND: Peeling skin syndrome is a rare form of congenital ichthyosis. The term was coined in 1982 by Levy and Goldsmith and the syndrome is clinically characterized by generalized scaling. Histologically, there is an epidermal separation in the stratum corneum. CASE REPORT: We report the case of a 73-year-old woman who had ichthyosis without cicatricial progressive alopecia since her first pregnancy. An ultrastructural study was performed confirming the clinical diagnosis of peeling skin syndrome. DISCUSSION: The peeling skin syndrome designates several different clinical entities classed by Traupe in type A and type B. Mevorah and al. expanded this classification with a type C. This classification has remained valid after additional information provided by ultrastructural studies and may suggest different pathogenic mechanisms underlying the dermatosis. A critical review of the literature shows that the case reported here is exceptional and had a late clinical onset.

[Pyoderma gangrenosum and biclonal gammapathy probably due to multiple myeloma (author's transl)]. / Pyoderma gangrenosum et gammapathie biclonale d'origine myélomateuse probable.

The authors report the observation of pyoderma gangrenosum (P. G.) leading to the discovery of an underlying biclonal gammapathy, which despite the absence of bony lesions, almost certainly represents a malignant myeloma. The authors have reviewed the different known associations with pyoderma gangrenosum, with special reference to benign and malignant gammapathies. Rare cases of biclonal gammapathies with pyoderma gangrenosum have been published but none of a malignant nature. This therefore appears to be the first reported cases. The authors are aware of the reported tendency of pyoderma gangrenosum lesions to appear in areas of previous trauma, as may be the case in this patient. Finally systemic corticosteroid therapy produced a rapid remission of the skin lesions, but with the reactivation of known treated pulmonary tuberculosis.

[Epidermolysis bullosa acquisita and hepatitis C]. / Epidermolyse bulleuse acquise et hépatite virale C.

INTRODUCTION: Epidermolysis bullosa acquisita is a bullous dermatosis. Its etiology remains unknown and the efficacy of its treatment is low. OBSERVATION: We report the first association between epidermolysis bullosa acquisita, chronic hepatitis C and cryoglobulinemia, healing with interferon alpha and ribavirine. DISCUSSION: We suggest a role for hepatitis C virus in the pathogenesis of epidermolysis bullosa acquisita. We suppose a synthesis of autoimmune antibodies in a dysimmune environment. Interferon alpha and ribavirine might be a new therapeutic avenue but further studies are necessary to confirm it.

Acute pancreatitis after transcatheter arterial chemoembolization for liver metastases of carcinoid tumors.

Acute pancreatitis is a rare side effect of non-selective transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma with an incidence ranging from 2% (clinical pancreatitis) to 40% (biological pancreatitis). This complication, due to embolization of extrahepatic arterial collaterals, has never been reported for treatment of well-differentiated endocrine carcinoma. We report here a case of acute clinical pancreatitis developing within 24 hours after a first selective TACE into the proper hepatic artery, with two peaks of hyperlypasemia, and intend to discuss its mechanism. Since it may clinically mimic a postembolization syndrome, dosage of serum pancreatic enzymes should be performed systematically in case of abdominal pain following TACE.