[Special needs of schoolchildren with diabetes mellitus. Point of view of parents and teachers]. / Necesidades del niño escolarizado con diabetes mellitus. Visión de padres y profesores.

BACKGROUND: The daily care of a diabetic (IDDM) child is essential for the short and long term evolution of the disease, and must include the hours the child spends in school. The presence of Trained personnel are needed who will be able to intervene in time if a serious complication, such as hypoglycemia, occurs. Their presence can help to ensure correct control of the disease and avoid long term complications. OBJECTIVES: To understand of the day to day life of children with IDDM, focusing on their school hours. To understand the attitude of primary and secondary school teachers towards pupils with IDDM. PATIENTS AND METHODOLOGY: Descriptive and transversal study on IDDM patients between the ages of 3 and 18, treated within the Healthcare Area number 3 in the Madrid Region, and their teachers. Two different kinds of surveys were distributed: the 1st survey by Fundación para la Diabetes (Foundation for Diabetes) contained 80 questions aimed at patients between the ages of 3 and 18 and their parents. Questions were related to patient's daily life and school environment. The 2nd survey, which allowed free response, was aimed at primary and secondary school teachers about their own experiences working as professionals with pupils with IDDM. RESULTS: Fifty questionnaires addressed to parents and patients were valid in our remit, and we emphasize the following: the ages of major participation were 10 to 14 years; 86% of children knew how to measure blood glucose and 66% how to administer insulin; 74% had no problems with school integration, however, up to 50% of children under 6 years had suffered a problem occasionally; on the 50% of the occasions when a patient needed insulin administration during school hours, it was done by a relative; 66% of hypoglycaemias were resolved by the patient. Health personnel is present only in 8% of the schools studied; 98% of those surveyed think teachers should have written instructions on the signs and symptoms and action to be taken if a hypoglycemia occurs. Questionnaires for teachers were answered by 54% of them (76 of a total of 140), we would like to point out the following: 71% of them recognise having a diabetic pupil; the degree of teacher knowledge on diabetes, rated on a scale from 1 to 7 shows a median of 3 and a mode of 4; 47% of teachers feel insecure when having a diabetic pupil because they do not have instructions on actions to take in case a complication occurs; 97% of teachers affirm to know what a hypoglycaemia is, however only 67% and 57% of them recognise its signs and symptoms and know how to act when they occur. CONCLUSIONS: The school integration and acceptance of pupils with IDDM is good, according to both teachers and parents. Children with IDDM take responsibility for their disease at an early age and are able to develop certain skills. However they still need help, which they get from their family even during school hours. Generally, teachers are willing to learn new skills to be able to help these children, however, further training is required to improve the understanding and management of this disease.

[Adaptation of methotrexate determination in plasma with Dimension Xpand]. / Adaptation du dosage plasmatique du méthotrexate sur Dimension Xpand.

The treatment with methotrexate at high doses is responsible of many side effects. It's necessary to evaluate serum methotrexate rate to monitor the administration of the methotrexate antagonist, the folinic acid. The aim of this study is to validate the determination of methotrexate in plasma using the automate Xpand Dimension (Dade Behring). Assay results were linearly related to the concentration for the wide range which was examinated (0.15 - 1.4 micromol/L). We report the precision, accuracy, linearity, sensitivity of this assay. The CV was less than 10%. We present the results of correlations with Aca (Dade Behring) and Cobas Mira (Roche). The reagent cartridge in the instrument and the calibration are stable during 28 days.

[BNP/NT-proBNP: what is the best choice in an emergency laboratory?]. / BNP/NT-proBNP: que choisir dans un laboratoire d'urgences?

BNP and NT-proBNP are both well established as diagnostic and prognostic markers for congestive heart failure (CHF). However it remains for the biologist to choose between these two biomarkers depending on his equipment availability. The aim of this study was to compare results obtained with the Biosite Triage BNP assay and the Dade Behring NT-proBNP assay with regards to the clinical status. One hundred twelve patients (average age 76 +/- 13 years) with acute dyspnea were including and stratified by diagnosis at presentation into 3 groups: patients without acute CHF (group I, n=50), patients with non-cardiac dyspnea and CHF history (group II, n=22) and patients with acute CHF (group III, n=40). Levels of both BNP and NT-proBNP were higher among patients with cardiac dyspnea (group III) than among patients with a non-cardiac dyspnea (BNP=740 pg/mL versus 84 pg/mL; p<0.001 / NT-proBNP=7.502 pg/mL versus 499 pg/mL; p<0.001). ROC analysis for BNP or NT-proBNP were not statistically different in patients with acute CHF (group III) compared with patients with a non-cardiac dyspnea (group I + II) (AUC=0.927 versus AUC=0.930, p=0.90). Neither there was a difference between ROC analysis for BNP or NT-proBNP in patients with cardiac dyspnea (group III) compared to patients with a non cardiac dyspnea (group I) (AUC=0.981 versus AUC=0.975, p=0.76). Measurement of BNP or NT-proBNP is of identical interest for the diagnosis of acute CHF in acute dyspnea. The BNP Biosite assay was faster because analysis is performed on whole blood. With regards to analytical performance, the NT-proBNP Dade Behring assay had a higher accuracy and is highly recommended for the follow-up of CHF treatment.

[Digoxin assay: results of 10 years of intralaboratory controls]. / Dosage de la digoxine: exploitation de 10 ans de contrôles interlaboratoires.

Serum digoxin measurement is often performed in medical laboratories. A professional association specialized in quality control, based in Lyon, has been organizing punctual controls of medication measurement for the past ten years. The results are analysed in term of intra and inter-technique precision, difference between methods and specificity in regard to endogenous or exogenous interfering substances. Methods have changed with a quasi disappearance of the methods used ten years ago (FPIA, EMIT) and introduction of new technologies on recent immunoanalysis automates. The results observed with the different instruments are similar. Reproductibility has not changed over ten years. Some difficulties remain in the measurement of low concentrations of digoxin. Many substances interfere in digoxin measurement : digoxigenine (inactive metabolite), endogenous digoxin-like immunoreactive factors, spironolacton, antidigoxin antibodies used for treatment of digitalic intoxications. These interferences depend on the method which is used, but it is essential to know them in order to interpret the results correctly.

Serum and erythrocyte magnesium in critically ill patients.

OBJECTIVES: To evaluate the prevalence of serum and erythrocyte magnesium (Mg) abnormalities in patients on admission to the intensive care unit (ICU) and to test the hypothesis that low levels of Mg are associated with a higher mortality. DESIGN: Prospective study. SETTING: 14-bed ICU in a 1000-bed teaching hospital. PATIENTS: 179 consecutive patients admitted over a 4-month period. MEASUREMENTS: Total serum Mg (Mgs) and erythrocyte Mg (Mge) were determined on admission by atomic absorption spectrophotometry. Severity of illness was assessed by Acute Physiology and Chronic Health Evaluation (APACHE) II and the number of organ system failures (OSF) during the first 24 h. The patients were followed up until discharge from hospital. MAIN RESULTS: On admission, 79 patients (44%) were hypomagnesemic and 10 (6%) were hypermagnesemic. A low level of Mge was observed in 119 patients (66%). In patients with similar APACHE II scores and OSF numbers, more of those with hyperMgs died during their ICU stay. However, the Mge value on admission did not correlate with patient outcome. CONCLUSIONS: We confirm the high prevalence of Mgs abnormalities as well as Mg deficiency on admission to a medical ICU. Low levels of Mgs and Mge are not associated with higher fatality. HyperMgs was associated with patient death.

Autoradiographic and quantitative study of benzodiazepine-binding sites in human hippocampus.

Benzodiazepine-binding sites were studied on frozen sections of 5 human hippocampi, using autoradiographic and biochemical techniques. The affinity, density, distribution and heterogeneity (two types) of sites were investigated using [3H]flunitrazepam as a ligand, clonazepam or C1 218872 as displacing agents. The autoradiographic images evidence a differential distribution of the binding sites in the histologic layers of the hippocampus. Subtypes I and II coexist in the same proportion in the three layers exhibiting the highest densities of binding sites (stratum granulosum and pyramidale, deep layer of stratum radiatum). The Kd, Bmax and Ki values found here are analogous to those described in animal studies, but the anatomical distribution of the sites in human hippocampus seems to differ slightly from that previously described in that of the rat.

Isolation-induced changes in radioligand binding to benzodiazepine binding sites.

Binding of [3H]flunitrazepam was studied in brain tissues of isolated Wistar rats and compared to group-reared animals. Modifications were observed in hippocampus and cortex (Kd increased) and in cerebellum (Bmax decreased) and when brain sections of control rats were incubated in the bath fluid that had served to incubate sections from isolated rats, a flattening of the saturation curve was observed. Results are discussed in terms of possible modulators of benzodiazepine binding sites, mainly tissue GABA concentrations.

Benzodiazepine receptor and neurotransmitter studies in the brain of suicides.

The characteristics of benzodiazepine binding sites (affinity, number heterogeneity) were studied on frozen sections of hippocampus of 7 suicides and 5 controls subjects, using biochemical and autoradiographic techniques. 3H flunitrazepam was used as ligand, clonazepam and CL 218,872 as displacing agents. Some neurotransmitters or their derivatives (GABA, catecholamines, hydroxy-indols) were evaluated quantitatively in parallel in the hippocampal tissue by liquid chromatography. We observed mainly an increase in the Ki of CL 218,872 subtype I binding sites in suicides, (7.48 +/- 1.7 to 17.24 +/- 1.7 nM, P less than 0.01), (m +/- SEM) and an increase in % of type I binding sites (30 +/- 4.2 to 42 +/- 2.5, P = 0.01). Among neurotransmitters, only norepinephrine differed significantly between controls and suicides (11.34 +/- 1.9 to 24.34 ng/g tissue, P = 0.02).

Evaluation of EMIT-TOX Enzyme Immunoassay for the analysis of benzodiazepines in serum: usefulness and limitations in an emergency laboratory.

The EMIT-TOX Enzyme Immunoassay for benzodiazepines was evaluated. Reproducibility, linearity, accuracy, sensitivity, and interferences were tested and found to be in good agreement with the manufacturer's specifications. Furthermore, the reactivity of 15 benzodiazepines were studied. According their differential reactivity, the 15 benzodiazepines can be classified into three groups: good reactivity similar to diazepam (potassium clorazepate, prazepam, estazolam, medazepam, flunitrazepam, nitrazepam); medium reactivity (clobazam, clonazepam, bromazepam, chlordiazepoxide, triazolam); and low reactivity (oxazepam, ethyl loflazepate, lorazepam). A possible structure/reactivity relationship is discussed. It is concluded that this kit is well adapted for the rapid detection of most benzodiazepines, but in no way can the EMIT technique permit quantitative results without clinical information.

Mixed venous oxygen saturation in abdominal aortic surgery: intraoperative hypothermia and vasodilator therapy implications.

This prospective study was designed to test the hypothesis that intraoperative hypothermia occurring during abdominal aortic surgery and vasodilator therapy used to avoid severe consequences of aortic clamping could both disturb the mixed venous oxygen saturation signal (SVO2). Twenty high risk surgical patients, ASA physical status II or III, were catheterized with the standard pulmonary artery catheter; SVO2 was determined by direct spectrophotometric measurements of oxygen haemoglobin concentration of serial samples. The relationships between SVO2, haemodynamic, metabolic variables and core temperature were analyzed. Haemodynamic values and oxygen transport were stable while inadequate tissue oxygenation occurred. A significant correlation was found between SVO2 and CI (r = 0.59, p less than 0.01), SVO2 and SVRI (r = -0.4, p less than 0.01), SVO2 and CT (r = -0.46, p less than 0.01), SVO2 and VO2 (r = -0.76, p less than 0.001). SVO2 and Qs/Qt (r = 0.83, p less than 0.001), SVO2 and EO2 (r = -0.75, p less than 0.001. No correlation was observed between SVO2 and lactacidemia (r = 0.04, p less than 0.05). Satisfactory haemodynamic stability and oxygen transport steady-state were the main conditions for a significant correlation between SVO2 and haemodynamic factors. However, there was no correlation between SVO2 and inadequate tissue oxygenation. SVO2 reflected only oxygen extraction. Intraoperative hypothermia provided an increased haemoglobin affinity for oxygen. Vasodilator therapy which allowed a decrease in systemic vascular resistance produced an increase in the left-right shunt and in venous oxygen admission. Thus hypothermia and vasodilator therapy could be both responsible for the elevated SVO2 occurring during infrarenal abdominal aortic surgery.

[The effect of changes in nutritional status induced by age on oxidative liver metabolism]. / Influencia de los cambios en el estado nutritivo inducidos por la edad sobre el metabolismo oxidativo hepático.

INTRODUCTION: The hepatic oxidative metabolism is essential for the biotransformation of a large number substances, among which are found many drugs which are commonly used in clinical practice. The nutritional status of individuals has been shown to be of influence on this function. Aging produces a deterioration of the hepatic oxidative metabolism, without the cause for this situation having been clarified. Also, aging modifies the body composition of the individuals. The objective of this study is to evaluate whether the modifications which arise in the nutritive status due to age, can alter the hepatic oxidative capacity. MATERIAL AND METHODS: 165 elderly people of both sexes were studied, with an average age of 82 years, and 24 young people, with an average age of 29 years. All participants were subjected to a clinical questionnaire, along with an evaluation of anthropometric, biochemical, and immunological nutritive parameters. The study of the oxidative metabolism was conducted by evaluating the kinetics of antipyrine. RESULTS: The elderly people showed a decrease in the antipyrine clearance rate (Ap Cl) (P < 0.001), and a lengthening of their life-span (P < 0.05) with respect to the younger people. There was a significant correlation in the elderly people, between the Ap Cl and age, weight, size, the distribution volume, and the muscular area of the arm. A multiple regression analysis showed a predictive value which was independent for age, the AST, the lymphocytes, and size. CONCLUSION: Elderly people have a marked depression of the hepatic oxidative metabolism. The factors which participate in their nutritional situation, are of influence on this function. It is necessary to keep all the above in mind when it comes to prescribing drugs which require this type of biotransformation, in order to avoid adverse effects or drug interactions.

[Local analgesic action by direct effect of pethidine on the nervous trunks]. / Action analgésique locale par effet direct sur les troncs nerveux de la péthidine.

The aim of this paper is to study the analgesic effects of meperidine (pethidine) on nervous trunks. First we compared the analgesic effect of pethidine in surgery of knee and femur. Meperidine was randomly administered either by femoral block or intravenously. The onset of analgesia was shorter with femoral block (5 minutes against 146 minutes). In the surgery of shoulder, nerve block with meperidine was performed using intersclalenic block. Plasma concentrations ar lower (maximum of 0.29 mg per liter) than intravenous therapeutic concentrations (between 0.5 and 0.7 mg per liter). So we can conclude as do other papers, there is a direct effect of meperidine on nervous trunks. This effect is probably mediated by receptors located on nervous trunks.

Development of a solid/liquid extraction method for analysis of toxic drugs in serum using an automated liquid chromatograph: the Remedi.

The aim of this work was to develop a procedure for analysis of drugs in serum using a chromatographic apparatus marketed by the Bio-Rad company. This automated apparatus, the Remedi, can identify nearly 200 substances and metabolites in biological fluids. The method for pretreatment of serum recommended by the manufacturer is inefficient. We thus decided to develop and validate an extraction method for analysis of serum. Our method extends column life and improves the sensitivity of the Remedi for the detection of drugs. For psychotropic drugs, a study was carried out that enables a semi-quantitative evaluation of blood levels to be made. In addition, the sera of patients admitted to hospital for intentional drug overdosage were studied to compare the results obtained using the Remedi and Emit techniques, and also to compare these results with toxicological data obtained by questioning the patient and his immediate circle.

[Evaluation of an automated liquid chromatograph permitting toxicologic screening of biological fluids]. / Evaluation d'un automate de chromatographie liquide permettant un screening toxicologique dans les liquides biologiques.

This study evaluated an automated high performance liquid chromatography algorithm that allows identification of 330 substances and metabolites in biological fluids. We assessed its ability to detect in urine and gastric lavage fluids the main psychotropic drugs ingested with suicidal intent. Antidepressants and most of the phenothiazines were recognised; identification of benzodiazepines was more uncertain. Compared to EMIT techniques, chromatography is less sensitive, but allows precise identification of the offending poison, quantifies the amount, and allows broad toxicological screening of pharmacological classes inaccessible to the EMIT technique.

[Value of the Remedi chromatography automate for the analytic diagnosis of drug poisoning]. / Intérêt de l'automate de chromatographie Remedi pour le diagnostic analytique des intoxications médicamenteuses.

The aim of this study was to evaluate the liquid chromatographic system Remedi (Biorad) in comparison with traditional immunological and colorimetric methods, for the diagnosis of acute drug overdose. 469 blood samples and 95 stomach cleaning liquid samples have been analysed during 1995. The usual toxicologic analysis was composed of the benzodiazepines, tricyclic antidepressants and barbiturates research. Ethanol, meprobamate and acetaminophen assays were performed only on physician's request. Only three pharmacological classes can be analysed both with immunological methods and Remedi: benzodiazepines, tricyclic antidepressants and barbiturates. Remedi has been found to be less sensitive than immunological method for benzodiazepines, it sometimes gave false negative results for barbiturates, but it was very efficient for antidepressants. Remedi often identified drugs other than the 3 previous classes: sedatives, antipsychotic, beta-blockers, antiarythmics. Furthermore these drugs are of clinical importance due to the fact that they are able to modify the symptomatology. In every case Remedi was able to give an estimation of the blood concentration of the toxic molecule matched. Remedi can not replace traditional methods but is a good complementary tool, available in emergency. This is particularly useful when clinical signs do not correspond to the toxics suspected by questioning the patient or relatives.

[Critical analysis of different methods used for toxicology screening in emergency laboratory]. / Analyse critique des différentes méthodes utilisées pour le dépistage toxicologique dans un laboratoire d'urgence.

Emergency analysis in toxicology is a difficult exercise. It involves in diagnosis, prognosis and the treatment of intoxication. Several methods exist in emergency screening. We have distinguished three large groups. Based on specificity: screening methods of medicament family (chemical methods and immunoassays) with benzodiazepines, tricyclic antidepressants, barbiturates and phenothiazines; complementary screening methods (thin layer chromatography and high pressure liquid chromatography) for a wider screening and finally quantitative methods (enzymatic, immunoassay, spectrometry and chromatography) specific to a molecule. The first group allows a rapid qualitative research according to medicament class but lacks specificity. The second group represented by the Remedi system, offers a larger screening of molecules but is more expensive and cannot detect classic molecules. The third group allows a precise dosage but is restricted to one molecule. We need one or the other of methods following clinical context and the type of molecule. In our laboratory, we have eliminated barbiturates and benzodiazepines research. We search only tricyclic antidepressants, salicylates and paracetamol. The Remedi system acts as a complement. It is essential to have a good knowledge of the limits and specificity of each method in order to allow the clinician to see the interpretation of the given result. The execution period and the quality of analytical result depend on dialogue between analyst and clinician before and after analysis.

[Evaluation of Emit netilmicin and amikacin assays on Dimension RXL HM (Dade Behring) open channels]. / Adaptation des trousses Emit nétilmicine et amikacine sur canaux ouverts du Dimension RXL HM (Dade Behring).

The aim of this study was to evaluate and to validate an enzyme immunoassay in homogeneous phase for netilmicin and amikacin, adapted on the Dimension RXL HM (Dade Behring) machine. The results were compared with those obtained with automated polarization of fluorescence immunoassay using TDx FLx (Abbott). The protocol of the study and the analytical criteria were inspired by the protocol Valtec version 2002 recommended by the French Society of Clinical Biology (SFBC). The validation of this technique as adapted to the Dimension RXL HM has allowed its use for routine dosage adjustment of amikacin and netilmicin. The practicability is however the weak point of the adaptation of these techniques, even limiting as for their implementation.

[Compared diagnostic performances of CKMB measurements by immuno-inhibition and three immunoenzyme methods for the early diagnosis of myocardial infarction]. / Performances diagnostiques comparées des mesures de la CKMB par immuno-inhibition et par trois méthodes immunoenzymologiques pour le diagnostic précoce de l'infarctus du myocarde.

In 98 patients consecutively admitted in a medical intensive care unit, an aliquot taken from the blood sample withdrawn for the cardiac enzyme admission request has been frozen. After thawing of these 98 aliquots total CK and the creatine kinase MB isoenzyme were measured on the same day. For this last determination, four methods were used and compared: an immunoinhibition method (Merck) and three immunoenzymatic assays (Abbott on IMX; Baxter on Stratus II; Hybritech on single use Icon cylinder). In 19 out of the 98 patients studied the diagnosis of myocardial infarction was made retrospectively by a cardiologist. This diagnosis was established according to the criteria defined by the WHO. The clinical performances (sensitivity, specificity, positive predictive value, negative predictive value) have been calculated for each test according to the following criteria: on the one hand, a cut-off of 8% (reference range of our laboratory) for the immunoinhibition technique; on the other hand, a cut-off defined by the manufacturer together with a cut-off obtained from the ROC curves for the three immunoenzymatic assays. Our results clearly demonstrate that the clinical performances of the three immunoenzymatic CKMB assays are very comparable and appear to be much better than the immunoinhibition method which should be abandoned.

[Biochemical and pharmacological check-up in emergency orientation]. / Bilans biochimiques and pharmacologiques d'orientation en urgence.

Biochemical and pharmacological tests usually prescribed in casualty department were reviewed taking into account their physiological significance and predictive value : ions, total proteins, carbohydrate and nitrogenous metabolites, enzymes, tissue markers, pharmacological drugs. Few blood components were kept with the first intention, ideally with a turn around time below one hour: sodium, potassium, chloride, bicarbonate, total proteins, pCO2 and pO2, creatinine, glucose, ketone compounds, calcium, bilirubin, transaminases, lipase, C-reactive protein, myoglobin, troponin, chorionic gonadotropin hormone. Those tests do not have to be systematically performed but prescribed only after the evaluation of pre-test probabilities by the clinician.

[Creatine phosphokinases and serum and urinary myoglobin following a procedure in prolonged knee-chest position for the treatment of spondylolisthesis]. / Etude des créatine-phosphokinases et de la myoglobine sanguine et urinaire après intervention en position génu-pectorale prolongée pour cure de spondylolisthésis.

Rhabdomyolysis following the knee-chest position was studied in 15 patients scheduled for surgery for spondylolisthesis. A comparison was made between 11 patients scheduled for orthopaedic surgery: ligamentoplasty (6 patients), total hip prosthesis (5 patients) and 11 patients scheduled for long oral surgery. The measurements carried out were blood CPK before surgery, 4, 8, 12 and 24 h after the beginning of surgery, and at days 2, 3 and 4. Blood and urinary myoglobin were measured at days 1, 2, 3 and 4 after surgery. The results were tested with the Mann and Whitney test. There was no statistical change in CPK and myoglobin in the test population. Following the knee-chest position, there was a statistical increase of CPK in all patients, with great individual variations. Myoglobinaemia and myoglobinuria were observed in six patients, these not being correlated with the variations of CPK. Nevertheless, the maximal increase of CPK and myoglobin was seen in one patient, without any modification of diuresis but with an increase of creatininaemia at 220 mmol X l-1. In this series, rhabdomyolysis was real. CPK was not a good index of the release of haematic pigments, the only dangerous ones. A qualitative search for myoglobinuria is suggested, this being followed, or not, by alkalization to prevent acute renal failure.