Acute interstitial pulmonary fibrosis. Comparative light and electron microscopic study of 19 cases. Pathogenic and therapeutic implications.

Comparative light and electron microscopic studies of the lung were performed in 19 cases of diffuse acute interstitial fibrosis with various etiologies. Our observations emphasize the relation between hyaline membranes (HM) and the evolution of fibrosis. HM formation is due to fibrinous exudates and epithelial necrosis. This phenomenon recurs during the evolution of the disease and appears to be responsible for new waves of fibrosis. Its pathogenesis (humoral or neurovascular ...) remains hypothetical. Modifications of the alveolar epithelium consecutive to septal fibrosis can be clearly distinguished from "fibrinoid necrosis" -type lesions, which results in HM. The formation of HM is accompanied by fibroblastic stimulation which proceeds in spite of epithelial regeneration. The exact stimulus for the proliferation and collagen hypersecretion of fibroblasts remains to be determined. The use, in association with corticosteroid treatment, of a structural analogue of L lysine, acexamic acid, to impede collagenesis reveals encouraging perspectives for improved therapy.

Pulsed field gel electrophoresis as a new epidemiological tool for monitoring methicillin-resistant Staphylococcus aureus in an intensive care unit.

Pulsed field gel electrophoresis (PFGE) of bacterial DNA was used in a 1-month epidemiological study of methicillin-resistant Staphylococcus aureus (MRSA) in a 15-bed Intensive Care Unit (ICU). Patient and hospital staff carriage as well as distribution of MRSA in the ICU environment were investigated, and a total of 3802 samples produced 175 isolates. The stability and the reproducibility of the PFGE method were satisfactory. Moreover, the plasmid content of the strains so far examined had no influence on the PFGE profiles of the MRSA strains. The polymorphic profiles observed also account for the use of this method as an epidemiological tool for investigating MRSA. Among 30 patients who stayed more than 4 days in the unit, PFGE analysis showed 11 episodes of colonization in nine patients, whereas lysotyping and plasmid DNA analysis demonstrated only eight and seven such episodes in the same patients, respectively. The combination of PFGE with lysotyping and plasmid analysis may provide a greater discriminatory capacity between MRSA isolates.

[Hyperosmolar comatose states]. / Gli stati comatosi iperosmolari

A recently determined entity, hyperosmolar coma is a good example of a clinical candition attributable to a fundamental alteration, namely extracellular hyperosmolarity. The principal stages in its history are summarised. The laws governing osmosis are recalled and the various features of the sndrome are studied. Attention is drawn to the clinical peculiarities (skin dehydration), biological features (record glycaemia value), and EEG data noted in 17 cases treated in a resuscitation centre over a period of seven years, along with the treatment employed-this being still a matter of debate. Reference is also made to 52 cases of acute drunkenness in a study of the relation between blood alcohol values and plasma hyperosmolarity.

[Post-traumatic interventricular communication. Closure under extracorporeal circulation].

Report of one case of acquired traumatic interventricular septal defect due to a stab injury of the right ventricle by a knife. The highly-placed penetrating injury involved the muscular septum and very probably resulted in a right bundle-branch block of the His system. Surgical operation performed in view of a starting clinical intolerance with moderately increased right cardiac pressures, was done under ECC with easy suture of the septal wound. The post-operative course was normal and a quick clinical cure was noted, which persisted for 8 months after surgery. The interest of this case, in addition to the very severe condition of the patient who had sustained 11 stab-knife wounds, lies in the high localization of the septal wound, which explains the involvement of the intracardiac conduction pathways.

[Hepatitis secondary to a gold salt overdose]. / Hépatite secondaire à un surdosage en un sel d'or.

The authors report the case of a 51-year-old woman who developed cholestatic and cytolytic hepatitis after an overdose of sodium aurothiopropanol sulfonate 1.1 g, namely 300 mg gold metal. Liver biopsy demonstrated cholestasis, centrolobular steatosis and portal fibrosis. Electron microscopy showed abundant lipo-pigments in the hepatic and cellular cells, as well as myelinic bodies. Gold analysis by atomic absorption spectroscopy showed a level of 22.76 micrograms per ml in the plasma and a level of 2.16 micrograms per g in the liver. Chelating agents increased the urinary gold excretion, but were without effect on the course of hepatitis. Dimercaptopropanol seemed to favor the occurrence of other gold salt side-effects and penicillamine increased the hepatic cytolysis. The patient recovered without sequelae.

[Sleep disorders and use of psychotropic drugs in 6-year-old children]. / Troubles du sommeil et consommation de médicaments psychotropes chez l'enfant de six ans.

The purpose of this prospective survey, conducted over a two years period, was to study the use of psychoactive drugs among six year-old children in the Bas-Rhin administrative "département", of eastern France. The factors analysed were family environment, after-school time, the child's sleep, the locality where the child lived and the drugs used. The child was examined by school doctors, in the presence of the parents, at the compulsory consultation at the start of first-year infant school. The study was exhaustive. Of the 11,274 children examined, 12.1% used a psychoactive drug, although only 1% were considered by their parents to be suffering from insomnia. Of the children using drugs, 32% had used them for more than a year, 24% for more than two years and 11% for more than three years. Consumption was also shown to vary greatly between different localities; in some areas the proportion of children using drugs was more than 50%.

[Perinatal maternal emergencies]. / Urgences maternelles périnatales.

The perinatal period (from the 28th week of pregnancy to the 28th day after delivery) is a short but special period which endangers the mother's and child's life. There has been no elective statistical assessment of this period but surveys conducted in western countries show that most of the maternal emergencies requiring admission to an intensive care unit are actually those of the perinatal period; some are specific of pregnancy: gravidic toxemia, delivery hemorrhage, acute fatty liver of pregnancy; others such as septic or embolic shock, cardiomyopathy, are found also in non-pregnant women but are favored by pregnancy. Among the numerous eventualities it was necessary to take a selection: ours results from three sorts of considerations: i) the severity of some of these perinatal emergencies: preeclampsia, eclampsia, Hellp syndrome, subcapsula hepatic rupture, septic or hemorrhagic shock are among the most serious ones; ii) the high frequency of some of them: post partum hemorrhage is, in France, the first cause of maternal mortality and the second cause of maternal morbidity whereas infection which can bring a septic shock is found to complicate one to eight per cent of the deliveries; iii) several emergency conditions raise pathophysiological problems which are still not entirely solved, for instance, gravidic toxemia, acute fatty liver of pregnancy, amniotic embolism. They will be especially studied here. Maternal perinatal emergencies remain a major public health problem. It is a necessity to realize the importance of the stakes, to encourage a team spirit, to combine the abilities of obstetricians, intensive care physicians, anaesthesists, echographists, biologists, so that this race against time can be won.

[Euthanasia, the magic of a word]. / Euthanasie, la magie d'un mot.

SOME ABUSE: The problem of euthanasia is one of the greatest subjects of ethical controversy of our time, controversy enhanced by the ambiguity of the word. Up until the Seventeenth century, the word evoked the easing of terminal suffering by a physician. At the end of the Nineteenth century the abuse is total--the word means the deliberate ending of a patient's life to spare the suffering. The various qualifications added later (active or passive euthanasia, direct or indirect, voluntary or non-voluntary, involuntary...) have certainly not helped to clarify the situation. AMBIGUITY AND PROBLEMS OF INTERPRETATION: Even worse, the word itself is not unambiguous, biased etymologically by the prefix "eu" that provides it with a positive connotation. A survey among the general public has shown that the notion of euthanasia is interpreted in different ways by the population, which would therefore discredit a public referendum preceding its legalisation, which is undesiderable because of the risks of abuses. It is unlikely that even the best efforts for clarification would ever be able to eliminate the intrinsic ambiguity that now contaminates the word. TO IMPROVE THE SITUATION: Since it appears difficult to banish the word euthanasia from the medical vocabulary, it should at least be accompanied by the objective characterisation of the behaviour corresponding to each situation. Hence in difficult situations, the place of life-saving measures, of palliative care and of analgesic sedation could be reasonably decided on by a group, made up on a case by case basis, by persons having known, cared for and accompanied the patient.

[Duodenal perforations by the hooks of a Kimray-Greenfield filter]. / Perforation duodénale par les crochets d'un filtre de Kimray-Greenfield.

A case is reported of a duodenal perforation by a Kimray-Greenfield filter hook in a 66-year-old female patient. This device had been inserted four years before, after a pulmonary embolism. The patient presented with epigastric pain, vomiting and extracellular dehydration with renal failure. A plain abdominal film showed the filter to be tilted 15 degrees to the left, with an opening 28 mm wide. Various investigations were carried out, none of which providing a satisfactory diagnosis. Steroid treatment (1 mg.kg-1 x day-1 of prednisone) was started before admission to intensive care. Only at that time gastroduodenoscopy showed on of the filter's hooks jutting through the duodenal wall. This perforation was located in the posterior wall of the third part of the duodenum, and was associated with an ulcer of the mucosa facing this hook. The diagnosis was confirmed by an abdominal CT scan. The hook was cut and the perforation sealed off during a first laparotomy. Twenty-six days later, the patient developed intestinal obstruction due to a haematoma of the jejunal wall. She later had a cerebrovascular accident, with status epilepticus and deep coma. She died four months after her admission. The late complications of vena caval filters are discussed. The position of these devices should be regularly checked by a plain abdominal film. Abdominal CT scanning is a useful investigation for the diagnosis of intra and extravascular complications.

[Immunoallergic intravascular hemolysis and tubulointerstitial nephritis due to penicillin G]. / Hémolyse intravasculaire et néphrite tubulo-interstitielle immunoallergiques dues à la pénicilline G.

A 51-year old woman treated with high doses of penicillin G developed acute intravascular haemolysis and tubulointerstitial nephritis. Immunological investigations showed circulating immune complexes, decreased C3 and C4 components of complement, IgG deposits in the renal interstitium, positive direct Coombs test with anti-IgG sera and complement and circulating anti-penicillin antibodies demonstrated by indirect antiglobulin tests and IgG RAST. Plasma haemoglobin and anti-penicillin antibodies could be removed by an early exsanguino-transfusion. These findings suggest that the nephritis was due to immune complexes and the haemolysis, to a combined hapten-type and immune complex mechanism.

[Pulmonary toxicity of oxygen]. / A propos de la toxicité pulmonaire de l'oxygène.

Recent progress in artificial ventilation procedures sheds doubt on the toxicity of oxygen in the lung. Histological studies of the lung by light and electron microscopy were made in rats exposed to 100% oxygen at 1 ATA in spontaneous ventilation. The results are compared with the lesions observed in 19 human patients suffering from acute respiratory distress syndrome and with the data on retinopathy of prematurity. This study suggests to keep in mind that oxygen may, as well as infections or baro-traumatic factors, be involved in causing or aggravating lung fibrosis. The complexity of the mechanisms of this action is emphasized. The production of highly reactive free radicals is one of the essential factors of this aggression. These elements illustrate the value of further studies on ways of preventing these changes, especially using appropriate antioxidant molecules.

[Two years' experience teaching medical ethics in a hospital clinic course]. / Une expérience de deux ans d'enseignement de l'éthique médicale en stage clinique hospitalier.

Ethics problems arise from conflict of values: a physician has to take charge of his patients, but advances of sciences and technics make such conflicts more and more frequent. Their solution cannot be left to a mere improvization. Medical ethics have to be taught. In Strasbourg, we have elected to teach compulsory medical ethics in the course of compulsory hospital training, for five mornings running, to groups of ten fifth-year medical students, the place being different each day. Fifteen departments including five specialties, internal medicine, intensive care, pediatrics, gynecology-obstetrics, geriatrics, are involved in this experience. The training takes place near the patient bed in the presence of a medical teacher. Communication and multi-disciplinarity are the characteristics. The teaching is done with the purpose of bringing about reflection in the students, of proposing methods for the discovering and the approach of ethics problems, of leading the students up to the enlightenment of their own scale of evaluation. A few previous lectures about history of ethics through different philosophical systems, about social, economical and cultural implications, are given for basic formation of the students. This teaching experience interests students and teachers greatly. The first ones have the opportunity to perceive a new dimension of medical responsibility, the second ones appreciate this form of recovered fellowship.

[Acute post-operative peritonitis in gastro-enterological surgery. Opinion of the intensive care unit (author's transl)]. / Les péritonites post-opératoires après chirurgie digestive. Le point de vue du réanimateur.

Acute purulent post-operative peritonitis is highly severe and difficult to diagnose. Six symptoms have a real prognostic value: shock, acute renal insufficiency, respiratory failure, jaundice, acidosis and septicaemia. If more than three of these signs of severity coexist, the mortality rate reaches nearly 100%. A patient with evidence of acute diffuse post-operative peritonitis must be operated on after a short preoperative treatment to restore a situation altered by shock, renal failure and pulmonary edema. Antibiotic agent alone, though necessary, cannot bring recovery. The maintenance of high nutritional intake for excess caloric expenditure is essential. The effects of the early decision of a surgical reintervention are studied in 27 patients with only two recoveries.

[Joseph-Alexis Stoltz (1803-1896), dean of the two Faculties]. / Joseph-Aléxis Stoltz (1803-1896), doyen des deux Facultés.

Life and works of Joseph-Alexis Stoltz, gynecologist and obstetrician Professor at the Strasbourg Ecole de Medecine, then dean in the same town Faculte de Medecine (1867-1872) and after in Nancy (1872-1879). With Adolphe Wurtz, dean of Paris Faculte de Medecine, Edmond Simonin, director of Nancy Ecole de Medecine, and Jules Simon, Minister of the Instruction Publique he brought to a successful conclusion, in 1872, the transfer of the Faculte de Medecine from Strasbourg to Nancy