[Treatment by plasmapheresis of a thrombotic thrombocytopenic purpura associated to a Still's disease: a case report]. / Prise en charge par échanges plasmatiques d'un purpura thrombotique thrombocytopénique au cours d'une maladie de Still: à propos d'un cas.

We report the seventh published case of thrombotic thrombocytopenic purpura (TTP) associated to a Still's disease. We confirmed the secondary character of TTP using the measurement of ADAMTS 13 protease. Because of clinical and biological improvement, daily plasmapheresis was stopped after eight days of ICU treatment. Unfortunately, early (24 hours) relapse occurred resulting in daily plasmapheresis resumption for 11 more days. Main therapeutic goals and aggressive treatment duration of PTT associated with a Still's disease remain to be determined.

Comparison of two methods to obtain a desired first isepamicin peak in intensive care patients.

A randomized multicenter study in intensive care unit (ICU) patients, evaluated the capacity of a Bayesian method to obtain an optimal first isepamicin (ISP) peak of 80 mg/L in comparison to a fixed loading dose (LD). Patients (n=236) over 18 years of age were enrolled from 6 September 1997 to 17 July 1999 and randomly assigned to received ISP in a calculated dose (CD) or a loading dose (LD) of 25 mg/kg body weight. The CD was estimated using a specific population model with Bayesian methodology implemented in the PKS program (Abbott PKS, Abbott Diagnostics, Rungis, France). The data required included age, body weight, height, gender and serum creatinine. ISP disposition is described by a one-compartment model. Blood samples were drawn 1 and 24 h after the start of infusion for fluorescence polarization immunoassay measurement of serum ISP concentrations. The predictive performance was assessed by computing bias and precision. Peak concentrations were significantly higher in CD group than the LD group (84.2 +/- 28.6 vs. 74.7 +/- 24.1 mg/L, respectively; P=0.008), but trough levels were comparable. The optimal ISP peak was attained by a significantly higher percentage of CD patients (P=0.018), and by significantly more CD patients on mechanical ventilation (P=0.025), and with simplified acute physiological scores (SAPS) > 35 (P=0.002). Pharmacokinetic parameters were similar for the two groups with large interindividual variations. Mean (+/- SD) volume of distribution of ventilated patients (72%) was significantly higher than of nonventilated patients (23.31 +/- 7.35 vs. 20.60 +/- 6.30 L, respectively; P=0.001). No relationship was found between the volume of distribution and SAPS. Total clearance was significantly correlated with estimated CLCR (creatinine clearance) (P=0.0001). Precision (RMSE) is better for CD than for LD strategy, respectively 27.96 and 28.66 mg/L. The Bayesian method was significantly more accurate and performed particularly well in ventilated patients and patients with high SAPS, compare to an LD of 25 mg/kg to obtain a first ISP peak of 80 mg/L in ICU patients. Therefore, a fixed dose of 28.5 mg/kg would be also adequate to reach a peak of 80 mg/L.

[Hepatopulmonary syndrome: physiopathology of impaired gas exchange]. / Syndrome hépatopulmonaire. Physiopathologie des anomalies des échanges gazeux.

The hepatopulmonary syndrome (HPS) consists of a triad of liver dysfunction, increased alveolar-arterial oxygen gradient and intrapulmonary vascular dilations. The mechanisms of impaired arterial oxygenation are still debated but the multiple inert gases elimination technique and more recently contrast echocardiography, greatly facilitated the investigation of such mechanisms. Subsequently the cause of hypoxemia can be attributed to several mechanisms such as ventilation-perfusion mismatch, right-to-left intrapulmonary shunts and alveolar-to-capillary diffusion defect, variously implicated in the severity of the disease. SHP may result from intrapulmonary vascular dilations and angiogenesis but the pathogenesis of such abnormalities is not completely explained. The hypothesis of an imbalance in vasoactive mediators and angiogenic factors has been put forward. Increasing data support the theory that the increase in synthesis and release of nitric oxide (NO) is the key factor modulating vascular tone. If this hypothesis is true, the use of compettive inhibitors of NO synthesis should restore pulmonary vascular tone, reversing the hemodynamic changes and gas exchange impairment of HPS.

[Anesthesia using intramuscular methohexital for cerebral computed tomography in the child. Apropos of 100 cases]. / Anesthésie par méthohexital intramusculaire pour tomodensitométrie cérébrale chez l'enfant. A propos de 100 cas.

Computed Tomography scans of the head demand a perfect motionless state, requiring sedation or general anesthesia for young children. Taking into account that CT Scan is innocuous, the proposed method of sedation must be devoid of any risk. A study was made about one hundred cases of intramuscular methohexital sedation of children, ages 3 weeks to 6 years (average age 26.05 +/- 19.95 months and average weight 9.9 +/- 4.07 kilograms). Children's medical antecedents were heavy foetal suffering, artificial ventilation at birth time, anticonvulsant medication for thirty percent of children. Average duration of the Scan was 35.8 +/- 12 minutes, with injection of contrast material in 83 percent of children. Injection of iodized material brings on a glow of warmth that can induce withdrawal movements of the child. Contrast material is used at the dose of 2 milliliters per kilogram. In general, CT Scan is performed after a clinical examination of the child, without any premedication. The child receives methohexital saline 2.5 percent solution intramuscularly deep in outer upper quadrant of the buttock, 10 mg per kilogram-1. Once the sedation is obtained, an infusion of isotonic glucose is set on to compensate fasting. The child, spontaneously breathing, is clinically and under ECG monitoring watched over at a distance. At the end of the Scan, children are observed in the recovery ward for 46 +/- 18 minutes before going back to their ward or their parents. Intramuscular methohexital provided adequate sedation to 96 patients. Two cases of failure to achieve a motionless state required general anesthesia induced with halothane.(ABSTRACT TRUNCATED AT 250 WORDS)

Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. The Association of Non-University Affiliated Intensive Care Specialist Physicians of France.

Low molecular weight heparins are as effective as unfractionated heparin in deep-vein thrombosis (DVT) prophylaxis for major surgery. However, there is no evidence nor consensus for prophylaxis in medical patients. We compared the efficacy and safety of nadroparin calcium (nadroparin) with placebo in medical patients at high risk of DVT. A total of 223 patients mechanically ventilated for acute, decompensated chronic obstructive pulmonary disease, were randomized to treatment with subcutaneous nadroparin adjusted for body weight (0.4 ml, i.e., 3,800 AXa IU, or 0.6 ml, i.e., 5,700 AXa IU) or placebo. The average duration of treatment was 11 d. The incidence of DVT in patients receiving nadroparin was significantly lower than that in patients receiving placebo (15.5 versus 28.2%; p = 0.045). Although the incidence of adverse events was high in both groups, there were no significant differences between nadroparin and placebo for total adverse events (46.3 versus 39.8%; p = 0.33), serious adverse events (25.0 versus 19.5%; p = 0.32), or those resulting in early permanent discontinuation of treatment (12.0 versus 8.8%; p = 0.44). The most common adverse event was hemorrhage. There was the same number of deaths in both treatment groups. Subcutaneous nadroparin resulted in 45% decrease in incidence of DVT compared with placebo.