[Intensive care at extremely low gestational age: ethical issues and treatment choices]. / Cure intensive nelle bassissime età gestazionali: riflessioni sulle basi etiche delle scelte assistenziali.

With the continuing progress of obstetrical and neonatal care, the limit of human viability has continued to shift towards younger gestational ages. The survival rate as well as the survival without disability increases with each additional week of gestation but, for infants born from 22 to 25 w GA, it is still really low, and the threshold of human viability appears to be limited to the physiological development of the lungs, which take place around the 23rd-24th w GA. At present, the care of such infants, born at the threshold of human viability, presents a variety of complex medical, social, and economical decisions assuming the characteristics of ethical decisions in that the limits between benefits and disadvantages is not so clearcut. What is the true infant's best interest is far to be understood and concern about the ethical basis of providing such intensive care is arising in the scientific community. In this paper the authors provide a review of the ethical basis of decisions related to the care of such infants: to treat, not to treat, intensive or compassionate care, withhold or withdraw treatment.

[Patent and occult intra-alveolar hemorrhage in leptospirosis]. / Hémorragies intra-alvéolaires patentes et occultes au cours des leptospiroses.

PURPOSE: Pulmonary involvement (PI) is common in leptospiral infection, usually characterized by hemoptysis and diffuse bilateral infiltrates on chest radiographs. Alveolar haemorrhage (AH) has already been proved by autopsy and some case-reports with fiberoptic bronchoscopy (FB) and bronchoalveolar lavage (BAL). The purpose of this study was 1/to evaluate the incidence of AH in leptospirosis 2/to define the impact of BAL on the early diagnosis of the infection. PATIENTS AND METHODS: FB with BAL were performed in 23 consecutive patients with leptospirosis (13 patients with patent signs of PI: group 1, 10 patients without: group 2). AH was defined by a percentage of siderophages > or = 20% and/or a Golde score > 100 and/or an haemorrhagic aspect of BAL fluid. Culture tests were performed on specific medium. RESULTS: We diagnosed AH in all patients of group 1 and in 7 patients of group 2. Filaments were seen in 6 specimens of BAL fluid, initially thought to be leptospires, but culture tests were negative. CONCLUSION: AH is identified in all cases of leptospirosis with PI. Occult AH often occurs to patients without any respiratory symptom. Physicians should consider leptospiral infection in the differential diagnosis of AH. Culture-tests for leptospirosis in BAL do no help in diagnosing leptospirosis.

[Respiratory manifestations of leptospirosis. A retrospective study of 91 cases (1978-1984)]. / Les manifestations respiratoires de la leptospirose. Etude rétrospective de 91 cas (1978-1994).

Leptospirosis, an ubiquitous zoonotic disease, is a systemic infection usually producing fever with hepatorenal involvement, meningoenephalitis, and hemorrhage. Respiratory manifestations are less well known but have been described in certain regions such as Southeast Asia or the Reunion Island. From January 1978 through December 1994, 154 cases of documented leptospirosis were admitted to the South Reunion Hospital Center. Pulmonary involvement was observed in 91 of these cases (59.1%) with hemoptysis (37.4%) and radiological evidence of bilateral reticulonodular infiltration (40%). Extra-pulmonary manifestations in most cases suggested leptospirosis at admission. Thirteen consecutive patients underwent endoscopy explorations with bronchoalveolar lavage: intra-alveolar hemorrhage was evidenced in all cases. This highly typical pattern of cytolysis would emphasize (20.8%) when the classical extra-pulmonary signs are too discrete to suggest the diagnosis. In this series, 10 patients required ventilatory assistance and 2 were given corticosteroid boluses for massive hemoptysis. Mortality due to leptospirosis is two-fold higher in cases with pulmonary involvement.

Tumor necrosis factor-alpha levels and weight loss in chronic obstructive pulmonary disease.

Unexplained weight loss is common in chronic obstructive pulmonary disease (COPD). Blood levels of tumor necrosis factor-alpha (TNF-alpha), a cytokine causing cachexia in laboratory animals, are elevated in various human diseases associated with weight loss. We therefore prospectively measured TNF-alpha serum levels (immunoradiometric assay) in patients with clinically stable COPD (n = 30; all male; mean age, 65 yr) whose weight was less (Group I; n = 16) or more (Group II; n = 14) than the lower limit of normal taken from Metropolitan Life Insurance Company tables. The patients had no cause known to elevate TNF-alpha serum levels; notably, they were not infected. Group I patients had unintentionally lost weight during the previous year, whereas the weight of Group II patients had not changed during the same period. The two groups had similar chronic airflow obstruction and arterial blood gas impairment; hyperinflation and reduction in diffusing capacity were more pronounced in Group I, but differences were not significant. TNF-alpha serum levels (pg/ml; mean [SD]) were significantly higher in Group I than in Group II (70.2 [100.0] versus 6.7 [6.4]; p < 0.001). Group II TNF-alpha serum levels did not differ significantly from those of healthy subjects (7.8 [3.9]), whereas those of Group I were significantly higher (p < 0.001). Because renal function was in the normal range, we conclude that increased TNF-alpha production--and not decreased TNF-alpha clearance--is a likely cause of weight loss in patients with COPD.

[Efficacy of octreotide acetate in the treatment of a pancreatic-pleural fistula. Apropos of a case]. / Efficacité de l'acétate d'octréotide dans le traitement d'une fistule pancréatico-pleurale. A propos d'un cas.

Diseases organs below the diaphragm should be considered in the aetiologic diagnosis of liquid effusion in the pleura. We observed a cases of pleuritis resulting from chronic pancreatitis and present here the diagnostic methods and therapeutic protocol undertake for cure. The level of amylase (including the isoforms) should be measured in the pleural effusion. The effectiveness of octreotide acetate in the treatment of pancreatico-pleural fistula was confirmed in this case.

[Diffuse alveolar hemorrhage and myositis in icterohemorrhagic leptospirosis. Rapid control by a single bolus of corticoids]. / Hémorragie alvéolaire diffuse et myosite au cours d'une leptospirose ictéro-hémorragique. Contrôle rapide par un seul bolus de corticoïdes.

Leptospirosis is one of the commonest causes of diffuse alveolar haemorrhage. Despite good sensitivity to penicillin and current techniques of ventilation, there remains a considerable mortality which is particularly linked to the initial pulmonary disease at presentation. The authors describe a new case of a gravely ill patient with leptospirosis and sever hypoxaemia. There was diffuse alveolar haemorrhage and myositis thus a bolus of corticosteroids was used over the first 24 hours complementary to the traditional treatment.