Local anaesthetic infiltration at the end of carotid endarterectomy improves post-operative analgesia.

BACKGROUND: Wound infiltration at the end of carotid endarterectomy under general anaesthesia is a simple technique that can be delegated to the surgeon. It was hypothesised that this technique could improve early post-operative analgesia by reducing the need for post-operative opioids. METHODS: Forty patients underwent carotid endarterectomy under general anaesthesia with desflurane and remifentanil supplemented with morphine for post-operative analgesia. In a prospective double-blinded randomised study, patients were allocated pre-operatively to receive either subcutaneous infiltration of both wound edges with 20 ml of 0.75% ropivacaine or infiltration with isotonic saline. The primary outcome was morphine consumption while in the post-anaesthesia care unit (PACU). Pain scores at rest and movement, sedation, and patient satisfaction were the other main outcomes used to assess post-operative analgesia. RESULTS: The median dose of morphine administered in the PACU was 2 mg [0-3] in the ropivacaine vs. 4 mg [3-6] in the placebo group (P = 0.0004, Mann-Whitney's test). Pain at rest and at movement was lower in the ropivacaine group throughout observation in the PACU. No difference was found for both pain and opioid consumption after discharge from the PACU or for patient satisfaction. Sedative events in the early post-operative period were less frequent in the ropivacaine group. CONCLUSIONS: Local anaesthetic wound infiltration performed before closure reduces the need for additional opioids, lowers the immediate post-operative pain and improves alertness. These results argue for the use of local infiltration anaesthesia for carotid endarterectomy.

Role of DegP for two-partner secretion in Bordetella.

Sorting of proteins destined to the surface or the extracellular milieu is mediated by specific machineries, which guide the protein substrates towards the proper route of secretion and determine the compartment in which folding occurs. In gram-negative bacteria, the two-partner secretion (TPS) pathway is dedicated to the secretion of large proteins rich in beta-helical structure. The secretion of the filamentous haemagglutinin (FHA), a 230 kDa adhesin of Bordetella pertussis, represents a model TPS system. FHA is exported by the Sec machinery and transits through the periplasm in an extended conformation. From there it is translocated across the outer membrane by its dedicated transporter FhaC to finally fold into a long beta-helix at the cell surface in a progressive manner. In this work, we show that B. pertussis lacking the periplasmic chaperone/protease DegP has a strong growth defect at 37 degrees C, and the integrity of its outer membrane is compromised. While both phenotypes are significantly aggravated by the presence of FHA, the chaperone activity of DegP markedly alleviates the periplasmic stress. In vitro, DegP binds to non-native FHA with high affinity. We propose that DegP chaperones the extended FHA polypeptide in the periplasm and is thus involved in the TPS pathway.

[MRI of fetal GI tract]. / IRM du tube digestif foetal.

The fetal diagnosis of GI tract abnormalities may be improved by the use of MRI that is able to visualize the normal bowel, may characterize the nature and location of gastrointestinal abnormalities, detect severe malformations, demonstrate the bowel close to cystic or tumoral intra abdominal structures. Our personal experience and recent data of the literature are reported.

Topographical distribution of fluoride in iliac bone of a fluoride-treated osteoporotic patient.

The electron microprobe was used to display the topographical distribution pattern of fluoride (F) at the microscopical level in the iliac bone of an osteoporotic patient treated with fluoride. Composite x-ray image of F K alpha emission revealed a high concentration of fluoride in the periosteal and endosteal bone layers, in the cancellous bone, and in certain osteons, which corresponded to the bone formed during the period of fluoride treatment. Fluoride was also concentrated around the Haversian canals in the vicinity of the capillary blood vessels by a diffusion process. Morphometric analysis showed that more cancellous bone than cortical bone is formed.

Fluoride content in human iliac bone: results in controls, patients with fluorosis, and osteoporotic patients treated with fluoride.

The major part of fluoride ingested is fixed on calcified tissues, mainly in bone tissue, and then is progressively but slowly recycled during bone remodeling. Thus, the measurement of bone fluoride content allows the determination of the extent of bone fluoride retention, and this parameter constitutes a useful complement to bone histology for the diagnosis of skeletal fluorosis and could also be used for the management of fluoride treatment of osteoporosis. A simple method is described to measure the fluoride content in calcined human iliac bone samples. Bone ashes were diluted in perchloric acid, and the measurement of the bone fluoride content was performed using a specific ion electrode combined with a reference electrode. Reference values are given for bone tissue from 76 control subjects (0.08 +/- 0.05% of bone ash), from two groups of 117 and 102 untreated osteoporotic patients (0.05 +/- 0.03% and 0.08 +/- 0.05%, respectively), from 166 sodium fluoride-treated osteoporotic patients (mean bone fluoride content varying from 0.24 to 0.67%, depending on the duration of therapy), and from 96 patients showing typical skeletal fluorosis (mean bone fluoride content varying from 0.56 to 1.33%, depending on the etiology of fluorosis and the relationship with the amount of fluoride ingested as well as with the duration of fluoride exposure). During a prolonged exposure of adult bone tissue to fluoride, the early bone fluoride uptake is variable and depends on the remodeling activity; then it increases rapidly before becoming more or less stable at a maximum level.

Skeletal fluorosis: histomorphometric findings.

Histomorphometric analysis of undecalcified sections was performed in transiliac biopsy cores taken from 29 patients (16 men, 13 women, aged 51 +/- 17 years) suffering from skeletal fluorosis due to chronic exposure to fluoride. The origin of the exposure, known in 20 patients, was either by water (endemic or sporadic), or industrial, or in a few cases iatrogenic. Measured on calcified bone using a specific ion electrode, bone fluoride content was significantly high in each specimen (mean +/- SD: 0.79 +/- 0.36% of bone ash) as compared to control values (less than 0.10%). The radiologically evident osteosclerosis observed in each patient was confirmed by the significant increase of cancellous bone volume (40.1 +/- 11.2 vs. 19.0 +/- 2.8% in controls, p less than 0.0001). There were significant increases in cortical width (1292 +/- 395 vs. 934 +/- 173 microns, p less than 0.0001) and porosity (14.4 +/- 6.4 vs. 6.5 +/- 1.7%, p less than 0.002), but without reduction of cortical bone mass. Osteoid parameters were significantly increased in fluorotic patients. The increase in cancellous osteoid perimeter was almost threefold greater than that noted in cancellous eroded perimeter. The fluorotic group had a greater number of osteoblasts than controls, with a very high proportion of flat osteoblasts. In 15 patients doubly labeled with tetracycline, the mineral apposition rate was significantly decreased, while mineralization lag time significantly increased. Bone formation rate and adjusted apposition rate were significantly decreased in skeletal fluorosis. Cancellous wall width was normal in fluorosis but the formation period and active formation period were significantly increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Biophysical study of bone mineral in biopsies of osteoporotic patients before and after long-term treatment with fluoride.

Crystallographic characteristics of bone mineral were examined in a group of 60 osteoporotic patients before and after 3 to 6 years of fluoride therapy. The age of the mineral was evaluated by means of X-ray absorption, as degree of mineralization of bone tissue (MDBT). Crystallinity was evaluated by measuring both X-ray diffraction line broadening, beta (31.0) and beta (00.2), and the crystallinity index (CI) by infrared spectrometry. The a and c unit-cell parameters were determined by powder X-ray diffraction. Bone fluoride content was measured by specific electrode. Patients were divided in two groups according to MDBT before treatment: one group with MDBT values less than or equal to mean value; another group with MDBT values greater than mean value. In the first group, trabecular bone volume (TBV) did not change significantly during therapy. In the second group, an increase of TBV was observed. Osteoporoses can then be distinguished, on MDBT criterion, between osteoporosis with hypermaturated mineral and osteoporosis with hypomaturated mineral. The MDBT before treatment permits one to predict the effect of fluoride therapy on TBV. In the two groups there was a significant increase in bone fluoride content between the onset and the end of treatment. Bone fluoride content increased linearly during therapy without any plateau effect. Crystallographic modifications induced by fluoride explain the mechanical and chemical improvement of bone.

Distribution of fluoride in calcified cartilage of a fluoride-treated osteoporotic patient.

Subchondral bone and calcified cartilage from a femoral head of a 74-year-old osteoporotic woman treated for 30 months with sodium fluoride were analyzed. The fluoride content of the calcified tissues was determined by a specific ion electrode, and the topographic distribution pattern of fluoride was determined with an electron microprobe. The fluoride content in calcified cartilage (0.39% of ash) was higher than in neighboring subchondral bone (0.28% of ash). Line scan and X-ray images indicated a high concentration of fluoride in the outer layer of calcified cartilage lining the uncalcified cartilage, as well as in the inner layer of the subcortical endosteal bone. This study shows that calcified cartilage is an important site of fluoride deposition, and suggests that the accumulation of fluoride is related to the calcification process.

Skeletal fluorosis: histomorphometric analysis of bone changes and bone fluoride content in 29 patients.

Bone fluoride content (BFC) was measured and histomorphometric analysis of undecalcified sections was performed in transiliac biopsy cores from 29 patients (16 men, 13 women, aged 51 +/- 17 years) suffering from skeletal fluorosis due to chronic exposure to fluoride. The origin of the exposure, known in 20 patients, was either hydric (endemic or sporadic) or industrial, or in a few cases iatrogenic. Measured on calcined bone using a specific ion electrode, BFC was significantly high in each specimen (mean +/- SD; 0.79 +/- 0.36% on bone ash). The radiologically evident osteosclerosis observed in each patient was confirmed by a significant increase in cancellous bone volume (40.1 +/- 11.2% vs. 19.0 +/- 2.8% in controls, p less than 0.0001). There were significant increases in cortical width (1292 +/- 395 mcm vs. 934 +/- 173 mcm, p less than 0.0001) and porosity (14.4 +/- 6.4% vs. 6.5 +/- 1.7%, p less than 0.002), but without reduction of cortical bone mass. Cancellous osteoid volume and perimeter, as well as width of osteoid seams, were significantly increased in fluorotic patients. The increase in cancellous osteoid perimeter was almost three-fold greater than that noted in cancellous eroded perimeter. In 15 patients doubly labeled with tetracycline, the mineral apposition rate was significantly decreased, mineralization lag time was significantly increased. The fluorotic group had a greater number of osteoblasts than controls with a very high proportion of flat osteoblasts. The ultrastructural characteristics reflecting the activity of the bone cells were clearly visible on electron microscopy. Bone formation rate and adjusted apposition rate were significantly decreased in skeletal fluorosis. On stained sections and microradiographs, bone tissue showed typical modifications for skeletal fluorosis (linear formation defects, mottled bone). The volume of cancellous interstitial mineralization defects and the proportion of mottled periosteocytic lacunae were markedly increased in skeletal fluorosis. These two parameters were significantly correlated together but neither of these was significantly correlated with BFC. Renal function did not significantly influence the changes in BFC and histomorphometry of fluorotic patients. Skeletal fluorosis is thus characterized by an unbalanced coupling in favor of bone formation, and a great number of osteoblasts with a high proportion of flat osteoblasts.(ABSTRACT TRUNCATED AT 400 WORDS)

Rapidly progressive osteoarthrosis of ochronotic origin. A pathologic study.

A case of hip osteoarthrosis associated with ochronosis in a 65-year-old woman is reported. Characteristic features of both conditions were observed macroscopically and on light and electron microscopic examination. In the cartilage the pigment deposits were located on and between thick collagen fibrils. In the synovial membrane there were embedded packets of cartilage shards of which the collagen fibrils and pigment were phagocytosed, as well as calcified bone debris whose disaggregation might have explained the presence of some apatite deposits free of any underlying collagen structure. As also previously observed, the present case of ochronotic hip osteoarthrosis is remarkable for the minor osteophyte formation and for the inclusion of pigmented cartilage shards in the osteomedullar remodeled territory. It also demonstrates a collapse of the femoral head cortex presumably related to the rapid clinical and radiologic evolution. By the well-known origin of its chondropathy and by the pigment labeling of the cartilage, ochronotic arthropathy provides an almost experimental model for analyzing a broader problem, i.e., that of the various components of an osteoarthrotic remodeling.

Metastatic carcinoma of presumed prostatic origin in cremated bones from the first century A.D.

A cremated pelvis dating from the first century A.D. showed evidence of osteosclerotic metastasis, presumably secondary to prostate carcinoma. The case demonstrates the importance of microradiography in palaeopathology as well as some of the structural changes seen in cremated bone.

Multiple bone islands in a skeleton dating from the Neolithic period.

Multiple bone islands were observed in a skeleton dating from the Neolithic period (two in a femoral head, two in the lower epiphysis of a femur, one in a humeral head). Macroscopic and radiographical examination was complemented by microradiography in the femoral head.

Magnesium whitlockite, a calcium phosphate crystal of special interest in pathology.

Whitlockite (in fact magnesium whitlockite) is a calcium orthophosphate crystal in which, in biological conditions, magnesium is partly substituted for calcium. Identified in X-ray or electron diffraction patterns, it occurs in physiological or pathological conditions at extra or intratissular sites, mainly in tissues of non-epithelial origin. In a range of pathological calcifications investigated by X-ray diffraction, we noted that whitlockite appeared to be frequently associated with apatite, particularly in "dystrophic calcifications" of tuberculous origin. These personal observations could be correlated with documented data in oral pathology (dental calculus, salivary stones, and dental caries). Whitlockite deposits have also been reported in non-infectious conditions, such as in aortic media, cartilage, and bone tissue. Whereas the formation of both apatite and magnesium whitlockite appears to be caused by the binding of their constituting ions with proteolipids, magnesium inhibits apatite originating from amorphous calcium phosphate to the benefit of whitlockite formation. Possibly, the development of magnesium whitlockite may provide an interesting marker for magnesium metabolism. Further studies linking histology to crystallography might relate the crystal to issues, such as tuberculous calcifications or diseases of bone tissue, and might be useful for potential diagnostic orientation.

Diffuse enthesopathic hyperostosis--anatomical and radiological study on a macerated skeleton.

Anatomico-radiological study of a macerated skeleton in a 43-year-old diabetic woman. An important spondylosis with hyperostosis of the cervical, thoracic and lumbar vertebrae was seen. There were associated changes of insertional hyperostosis at various levels, particularly at the iliac crests. Paget's disease of the left iliac crest was also noted in the corresponding hyperostosis. This case presentation offers an opportunity to discuss local mechanical factors (observed at the tendinous insertions) as well as generalized considerations on the "terrain" of diabetes and perhaps malnutrition. It also demonstrates the interest that an anatomico-radiological comparison on macerated specimens can have for certain osteoarticular research, teaching and paleopathology.

Presumed calcified leiomyoma of the uterus. Morphologic and chemical studies of a calcified mass dating from the Neolithic period.

An isolated, calcified mass was found among human skeletal remains that were approximately 5,000 years old. A systematic study was undertaken that included histologic examination (stained sections, polarized light microscopy, microradiographs, and electron microscopy), x-ray diffraction, and concentrations of hydroxyproline and fluorine. The results allowed us to eliminate the diagnoses of bone tissue and intracavitary deposits such as bezoar and calculi. The mass consisted of calcified tissue, with a collagenous organic matrix and deposits of apatite, and it most probably was a calcified uterine leiomyoma.

A historic skeleton with osteomyelosclerosis.

A case of osteomyelosclerosis (ie, an advanced stage of the myeloproliferative disorder named myelofibrosis) was reported in an adult male skeleton dating from the 17th or 18th century. The diagnosis was founded on the presence of a newly formed microspongiosa and a thickening of the preexisting trabeculae. A subperiosteal thickening of the cortical bone was also noted.

[Localized hypertrophic neuropathy (LHN) of the brachial plexus: diagnosis and presurgical evaluation with MRI]. / Neuropathie hypertrophique localisée (NHL) du plexus brachial: diagnostic et bilan préoperatoire par l'IRM.

The authors report a case of localized hypertrophic neuropathy diagnosed by MRI. This 10-year-old girl presented with painless progressive deltoid atrophy. Electrodiagnostic studies demonstrated chronic denervation. An MRI performed with T1, T2, T1 with gadolinium and fat saturation sequences showed a linear 5-cm long segment of hypertrophic brachial plexus cord, with moderate high T2, intermediate T1 signal, and marked post-Gadolinium enhancement. Progressive improvement followed surgical resection with nerve graft repair. Histological study confirmed LHN (perineurial cell proliferation), a rare cause of peripheral neurological deficit. MRI findings may suggest LHN, that should be suspected as well as peripheral nerve compression or tumor; inflammatory neuritis and idiopathic lesion (with normal MRI findings) remain a diagnosis of exclusion. MR aids in the precise localization of the lesion before surgery.

[Brain sonography in 2001. Evaluation of macrocrania in the infant]. / L'échographie cérébrale en l'an 2001. Le point sur l'exploration d'une macrocrânie du nourrisson.

Transfontanelle sonography has become a routine imaging modality to assess infants with macrocrania: detection of hydrocephalus and diagnosis of its underlying etiology, detection and mapping of extra-axial collections, value of Doppler US for diagnosis of intracranial lesions, hemodynamic evaluation using pulsed Doppler imaging.

[Disorders of the peritoneum]. / Le péritoine acteur de la pathologie abdominale.

The peritoneum is an important actor in diseases of the abdomen: defects of the peritoneum or mesos may lead to internal hernias; developmental anomalies of the peritoneum may lead to volvulus and bowel obstruction; diffuse or localized primary or secondary tumors of the peritoneum may develop; infectious, inflammatory or ischemic primary diseases of the peritoneum may cause abdominal pain, sepsis or result in the formation of fluid collections. The purpose of this presentation is to illustrate the role of imaging in the diagnosis of these different diseases and to provide some guidelines allowing their detection and characterization.

[Sleep apnea syndrome with complications which were reversed following adeno-tonsillectomy]. / Syndrome d'apnées du sommeil avec complications, réversible après adénotonsillectomie.

A five-year-old boy is reported with severe upper respiratory tract obstruction and sleep apnea that was associated with reversible cardio-pulmonary complications. Adenoidectomy and tonsillectomy resulted in a spectacular improvement of the symptomatology. A polysomnographic exam confirms this evolution.