Surgical management of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients.

BACKGROUND: Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation. Standardization of the surgical management is lacking. The aim of this study was to report our experience with surgery for RUF. METHODS: This was a retrospective study of a prospectively maintained clinical database. The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality. Outcomes measured were RUF closure and permanent fecal/urinary diversion. Impact of radiotherapy was also assessed. RESULTS: Between November 2002 and January 2019, 52 patients were identified (100% males). Median follow-up was 10.5 (0.5-16.8) years. Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively. Fistula closure together with preservation of the fecal and urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair, respectively. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%, respectively. A significantly higher rate of urinary/intestinal stomas was observed in the irradiated vs non-irradiated patients (84.2% vs 42.4%; p = 0.004). CONCLUSIONS: Surgery ensured healing in 96% of the patients. Radiotherapy led to higher rate of permanent urinary/fecal diversion. Nearly all irradiated patients who had transabdominal repair end up with a definitive stoma. When transperineal repair with gracilis flap interposition was used, the rate of fistula closure approached 90%. A treatment algorithm is proposed.

Evaluation of a real-time multiplex PCR for the simultaneous detection of Campylobacter jejuni, Salmonella spp., Shigella spp./EIEC, and Yersinia enterocolitica in fecal samples.

Conventional diagnosis of infectious diarrhea caused by bacteria is time-consuming, labor-intensive, and has a suboptimal sensitivity. We have therefore developed a multiplex real-time polymerase chain reaction (PCR) for the simultaneous detection of Campylobacter jejuni, Salmonella spp., Shigella spp./enteroinvasive Escherichia coli (EIEC), and Yersinia enterocolitica in fecal samples. No cross reactivity between the different pathogens was observed, and the multiplex setup of the assay did not have an impact on the sensitivity of the PCR. The analytical sensitivity was 87 CFU/mL for C. jejuni, 61 CFU/mL for Shigella spp./EIEC, 5,528 CFU/mL for Salmonella spp., and 1,306 CFU/mL for Y. enterocolitica. An extensive validation of the assay was performed by testing 1,687 patient samples by both PCR and with conventional techniques. The use of PCR increased the overall clinical sensitivity from 78 to 100 % (p < 0.0001), the specificity was 99.4 % for the PCR, compared with 99.9 % for conventional culture. The novel PCR assay allows for rapid, sensitive, inexpensive, and high-throughput testing of the most common bacterial causes of gastroenteritis.

Association between malnutrition and stages of sarcopenia in geriatric rehabilitation inpatients: RESORT.

BACKGROUND & AIMS: Malnutrition and sarcopenia coexist in older adults, yet they remain largely undiagnosed and untreated, despite available interventions. This study aimed to assess the prevalence, the coexistence of, and the association between malnutrition and sarcopenia in geriatric rehabilitation inpatients. METHODS: REStORing health of acutely unwell adulTs (RESORT) is an observational, longitudinal cohort of geriatric rehabilitation inpatients. The association between malnutrition, diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and sarcopenia according to the revised definition of the European Working Group on Sarcopenia in Older People (EWGSOP2) (no sarcopenia, probable sarcopenia, confirmed sarcopenia and severe sarcopenia) was determined using multinomial logistic regression analyses, adjusted for age, sex, comorbidities and cognitive impairment. RESULTS: Out of 506 geriatric rehabilitation inpatients, 51% were malnourished, 49% had probable sarcopenia, 0.4% had confirmed sarcopenia (non-severe) and 19% had severe sarcopenia. Malnutrition and probable sarcopenia and malnutrition and confirmed/severe sarcopenia coexisted in 23% and 13% of the 506 patients respectively. Malnutrition was not associated with probable sarcopenia (OR = 0.91, 95% CI = 0.58-1.42, p = 0.674) but with severe sarcopenia (OR = 2.07, 95% CI = 1.13-3.81, p = 0.019). CONCLUSION: The prevalence, coexistence of, and the association between malnutrition and severe sarcopenia in geriatric rehabilitation inpatients warrant diagnosis at admission. Further research into feasible and effective interventions to counteract both conditions to improve geriatric rehabilitation outcomes is needed.

Porphyric neuropathy and hereditary delta-aminolevulinic acid dehydratase deficiency in an adult.

A man without a history of porphyric attacks developed a subacute motor neuropathy at the age of 63. At the same time the first signs of a myeloproliferative disorder were found. He had a homozygous deficiency of erythrocyte delta-aminolevulinic acid dehydratase (ALA-D) with autosomal recessive inheritance. Treatment with parenteral glucose and with hematin had a beneficial influence on the plasma ALA levels. The finding of a motor neuropathy with increased plasma levels of ALA but not of porphobilinogen (PBG) supports the potential role of ALA in the pathogenesis of porphyric neuropathy.

Screening for total and partial eosinoperoxidase deficiency by flow cytometry: prevalence in a general population, pathology and genetic implications.

The ADVIA (Bayer) haematological system differentiates leukocytes by their volume and their peroxidase (MPO and EPO) activity. It thus allows specific counting of the eosinophils and detection of totally EPO and MPO deficient individuals. EPO activity is determined by the coordinates of the eosinophil cluster on the outprint. A reliable method of quantitation by simple angle measure is suggested. It allows recognition of partial deficiencies. Among approximately 100,000 persons, 29 cases of total EPO deficiency were detected. No typical or specific pathology of the defect was noted. Family studies showed heterozygous parents and offspring to be partially deficient. The frequency of these partial deficiencies in the general population is studied. The results exclude a simple autosomal recessive monogenic transmission of the defect. A model for bigenic transmission is suggested.

[Experimental study of a model for granulocyte storage]. / Etude expérimentale d'un modèle de conservation des polynucléaires neutrophiles.

An efficient granulocytes preservation would allow an easier study of their structure and functions, of granulocytes functional diseases (e.g. chronic granulomatous disease) and an easier use of granulocytes as a clinical tool (e.g. for localizing infections or for transfusions). Unfortunately, granulocytes are nearly impossible to preserve, even in a short-term storage (less than 24 hours). This study proposes an experimental model which could improve in vitro granulocyte functions maintenance. Bicarbonate buffer, glucose, adenosine triphosphate, vitamins C and E, nicotinamide adenine dinucleotide, nicotinamide adenine dinucleotide phosphate, amikacin, and ampicillin supplementation significantly (p 0.05) improve maintenance of one or several granulocyte functions during storage.

[Storage of granulocytes]. / Conservation des polynucléaires neutrophiles.

Granulocytes transfusions set numerous problems and are less and less used. The very short maintenance of the granulocyte functions (chemotaxis) limits their use are a clinical tool (e.g. for localizing infections and for transfusions). Neither granulocyte collection by centrifugation methods (continuous or discontinuous flow) nor glucocorticoid premedication significantly alter granulocytes functions (in particular chemotaxis). Liquid preservation methods give better results than cryogenic methods. Optimal storage parameters are a temperature of 22 degrees C and a pH level close to 7.4. Chemotaxis is the most sensitive indicator of granulocyte damages in connection with storage. Bicarbonate buffer, glucose, proteins and reducing agents supplementation significantly improve chemotaxis maintenance. Cryogenic methods are less studied and less used. They allow storage of only little amounts of granulocytes. In conclusion, efficient granulocyte storage (over several days) would allow an easier use of these cells in many fields, but unfortunately, no solution is yet available.

[Platelet antiaggregants]. / Les antiagrégants plaquettaires.

Antiplatelet agents are indicated in the prophylactic treatment of certain thromboses, and in particular those due to a complication of atherosclerosis. Acetylsalicylic acid is the best-known, the most commonly used and, probably, the currently most effective agent. The dosage remains controversial; yet, a mean dose of 300 mg daily appears to be recommended nowadays. Ticlopidine and, to a lesser extent, dipyridamole can also be used for this treatment. However numerous contra-indications, such as haemorragic diathesis, surgery and gastric ulcers tend to limit their use. As regards the combination of antiplatelet agents, clinical studies do not show superior efficacy as compared with acetylsalicyclic acid alone.

[The physiology of hemostasis: plasma and tissue factors in coagulation and fibrinolysis]. / Physiologie de l'hémostase: facteurs plasmatiques et tissulaires de la coagulation et de la fibrinolyse.

Coagulation and fibrinolysis are two antagonistic phenomena, the harmonious balance of which results form a perfect regulation of their respective activators and inhibitors. Indeed, the efficacy of the response of the organism to an aggression against the blood vessel and its plasmatic and cellular contents, depends on the capacity of maintaining this balance. The mechanisms involve plasma proteins (factors) endowed with a proteolytic activity, as well as mediators released from injured tissues (endothelium). Coagulation corresponds to the process of fibrin formation (fibrin clump), which assures the consolidation of the platelet clot which was pre-formed during the activation of the platelets. Fibrinolysis consists in the gradual dissolution of this fibrin clump, aimed at re-permeabilization of the vessel at the site of the lesion, and thus at a normalization of the blood circulation at this level. Coagulation and fibrinolysis can hardly be dissociated from primary haemostasis (platelet activation), not only because of their interactions, but also because of their chronology: all these events are, indeed, triggered almost simultaneously, even though the duration varies. The mechanisms that are implicated in thrombo-embolic phenomena are comparable to those of physiological haemostasis. However, it is the imbalance between these events which constitutes the pathological aberration and thus induces the formation of a fibrin-platelet thrombus.

[The physiology of primary hemostasis]. / Physiologie de l'hémostase primaire.

Primary haemostasis, on the same grounds as coagulation and fibrinolysis, is one of the three main stages of haemostasis. It involves mainly the vascular endothelium and the blood platelets. An endothelial lesion will uncover thrombogenic structures-mainly microfibrils and collagen-to which the platelets will adhere. The latter will then undergo a complete morphological transformation, from a discoid shape to a structure provided with pseudopods. This transformation is accompanied by a biological explosion, which affects in the first place the metabolism of prostaglandins and of cyclic AMP. There occurs also a release of the contents of the platelet granules. The final phase of platelet activation consists in their aggregation, which is reversible in a first time and irreversible afterwards. On the other hand, the activated platelets can also trigger the process of coagulation, which demonstrates the narrow relationship between the various stages of haemostasis.