[The value of allergy survey in a retrospective series of 40 patients with burning-mouth syndrome (stomatodynia)]. / Stomatodynies: intérêt de l'enquête allergologique dans une série rétrospective de 40 malades.

BACKGROUND: By definition, stomatodynia or burning-mouth syndrome involves oral pain with no causes being found on history taking or examination. An allergic origin is often suspected by doctors and patients alike. In this study, we attempted to assess the value of epicutaneous tests in demonstrating allergic causes for patients presenting stomatodynia. PATIENTS AND METHODS: This was a single-centre retrospective study of patients undergoing epicutaneous tests between 1996 and 2003 to screen for allergic causes of mouth pain not accounted for by any abnormalities seen during examination performed at consultations for mouth disease. RESULTS: Forty patients were included (11 male, 29 female; mean age: 58 years), and 39 were excluded. Sixteen patients presented at least one positive test, with a total of 35 positive tests in all. In decreasing order of frequency, the causes were metals, mercury derivatives (nickel salts: n=5; chrome salts: n=3; palladium salts: n=2; phenylmercuric acetate: n=2; thiomersal: n=2; cobalt salts: n=1; gold salts: n=1; mercury: n=1) and resins (acrylates: n=4). The relevance of these test results was considered probable in three cases and possible in five cases, associated with the existence of metals or resins in patients' mouths. The Peru balm test was positive in four cases but was not relevant. Tests for personal products were negative in all cases, with the exception of one case of resin from a prosthesis and one case of tixocortol pivalate. COMMENTS: Type I stomatodynia (daily occurrence with gradually increase in discomfort throughout the day) and type II stomatodynia (permanent) are not normally attributable to allergies. However, for type III stomatodynia (non-permanent, with acute episodes followed by remission), an allergy survey guided by questioning may be undertaken to determine the cause, primarily prostheses or diet. The relevance of positive test results must be interpreted with caution in view of the incidence of positive epicutaneous tests for metals and Peru balm among the general population studied.

Randomized study of 5 fluorouracil and cis platin as neoadjuvant therapy in head and neck cancer: a preliminary report.

A randomized prospective study of 5 fluorouracil (5-FU) and Cis platin preceding definitive local treatment for squamous cell carcinoma of the head and neck region was initiated in September 1986. Seventy-five patients were stratified by site (oral cavity-12, oropharynx-28, larynx-16, hypopharynx-19), and by Stage (Stage II-20, Stage III-43, Stage IV-12) and randomized to receive definitive local treatment (surgery and post-operative radiation or radiation alone) or chemotherapy followed by definitive local treatment. Chemotherapy consisted of three cycles of 120 hr 5-FU infusion 1 g/m2/day plus Cis platin 100 mg/m2 on day 1 on each cycle. Response to chemotherapy was complete in 17 patients (46%) for an overall response rate of 68%. All the patients have completed therapy with a median follow-up of more than 12 months. After local treatment, the complete response rate is 84% for the control group and 86% in the chemotherapy group. Actuarial disease-free survival at 1 year is 61% in the control group and 73% in the chemotherapy group (p = 0.25). These preliminary results show that in spite of initial tumor response, neoadjuvant chemotherapy does not improve long-term control and survival.

Recall response to cytomegalovirus in allograft recipients: mobilization of CD57+, CD28+ cells before expansion of CD57+, CD28- cells within the CD8+ T lymphocyte compartment.

BACKGROUND: Strong correlations have been described between persistently elevated proportions of CD57+ (CD28-) CD8+high T lymphocytes and cytomegalovirus (CMV) infection, in healthy individuals as well as in transplant patients. We investigated whether secondary exposure to CMV triggers recall responses within the CD8 T cell compartment. METHODS: In a longitudinal study in 123 kidney recipients, we compared 17 primary CMV infections with 27 secondary CMV infections. Subset composition of the CD8 compartment was analyzed by flow cytometry. RESULTS: CD8 lymphocytosis occurred significantly earlier (by 17 days on average) in CMV reactivations than in primary infections. Both in primary and secondary infections, CD28+ CD8+high T lymphocytes were mainly recruited at the start. In formerly CMV-seropositive patients, preexisting CD57+ CD8+high T lymphocytes switched at the start from no expression of CD28 to high expression of CD28 and, concomitantly, from CD45RA to high expression of CD45RO. These cells reverted rapidly to a CD28- and CD45RA+ phenotype. Nevertheless, the accumulation of CD57+ (CD28-) CD8+high T cells was delayed similarly in primary and secondary CMV infection, progressing over a period between 2 and 8 weeks after the onset of CD8 lymphocytosis to plateau at 366 CD57+ CD8+high cells/ mm3 on average. CONCLUSIONS: The faster kinetics of CD8 lymphocytosis in secondary CMV infection suggests that a recall response triggers cycling "memory" cells within the CD28+ CD8+high subset, while preexistent CD57+ CD8+high T cells with a long-lived cell phenotype can also be mobilized, possibly through the transient acquisition of CD28 expression. The protracted accumulation of CD57+ (and CD28-) lymphocytes might then reflect an end-stage differentiation.

Immunomodulatory effect of pentoxifylline during human allograft rejection: involvement of tumor necrosis factor-alpha and adhesion molecules.

BACKGROUND: Pentoxifylline (PTX), a methylxanthine phosphodiesterase inhibitor, is poorly active as an immunosuppressant but prevents the synthesis of proinflammatory cytokines. In a randomized double-blind study comparing PTX versus placebo in 140 patients receiving cadaveric kidney grafts under cyclosporine and prednisone, we have shown that PTX weakened the consequences of rejection on graft survival. To assess the mechanism underlying the beneficial effect recorded during this trial, we analyzed the impact of PTX on tumor necrosis factor (TNF-alpha) production and expression of cell adhesion molecules. METHODS: Plasma levels of TNF-alpha and its soluble receptors (sTNF-RI, sTNF-RII) and of soluble vascular cell adhesion molecule 1 (sVCAM-1) were monitored over the 6 months postgraft period when PTX or placebo were administered. Expression of VCAM-1 and intercellular cell adhesion molecule 1 was scored by immunohistochemical staining of biopsy specimens from patients who underwent rejection crisis. Lymphocyte subset composition was analyzed longitudinally during cytomegalovirus (CMV) infections. RESULTS: Plasma TNF-alpha levels were significantly reduced in the PTX-treated group over the 6 months of administration, and specifically during isolated rejection episodes and during CMV infections. Plasma levels of sTNFR-I, sTNFR-II, and sVCAM-1 did not differ between the two groups of patients, but a decrease in renal tubular VCAM-1 expression was observed in the PTX group. During CMV infections, CD8 lymphocytosis and expansion of CD57+ (CD28-) CD8+ T cells were similar in the two groups. CONCLUSION: The data collected during this double-blind study point to an immunomodulatory role of PTX, the beneficial effect on graft survival resulting from a restraining effect of the drug on the inflammatory conditions involved in acute graft rejection.

Improvement in the outcome of rejection with pentoxifylline in renal transplantation: a randomized controlled trial.

BACKGROUND: Pentoxifylline (PTX), a methylxantine phosphodiesterase inhibitor commonly used to treat peripheral vascular disease, has been shown to decrease the production of proinflammatory cytokines and reactive oxygen species and to reduce the toxic effects of cyclosporine. Thus, administration of PTX to transplant patients, as an adjunct to immunosuppressive therapy, could prevent numerous posttransplantation complications. METHODS: One hundred forty consecutive patients receiving cadaveric kidney grafts were registered in a randomized double-blind study comparing PTX at a dose of 800 mg/day, then 1200 mg/day, versus placebo during the first 6 months after transplantation. All patients were followed up for 1 year. RESULTS: Rejection episodes were validated as the only independent risk factor for graft loss in this study. We compared graft survival rates in each group according to the presence or absence of acute rejection. Acute rejection reduced graft survival in the control group (graft survival rate at 1 year, 59% vs. 97%, P < 0.001), but this adverse effect was blunted in the PTX group (72% vs. 89%, NS). This improvement was confirmed by multivariate analysis for risk factors, with graft survival rates being described at best as the interaction between rejection and treatment (PTX vs. placebo, P = 0.045). CONCLUSION: Although PTX does not modify the incidence of any posttransplant complications, it weakens the consequences of rejection on graft survival.

Consecutive successful pregnancies in a combined liver and kidney transplant recipient with type 1 primary hyperoxaluria.

Pregnancy is now a common, but high-risk event, in young women who have received transplants. Consequences to the fetus are known, but pregnancy may also interfere with graft function. We report the outcome of two successive and successful pregnancies in a 29-year-old woman with type 1 hyperoxaluria, who received a combined liver and kidney transplant. Two healthy children were born at 35 and 37 weeks of gestation, with low birth weight. Liver function remained normal before, during, and after pregnancies up to 52 months after transplantation. Renal function was impaired before the first conception, worsened during both pregnancies, and returned to the previous level in both immediate postpartum periods. However, renal function has declined 17 months after the last delivery. This report shows the feasibility of successive pregnancies in multiple organ transplant recipients, but raises the question of long-term maternal kidney graft survival.

Pentoxifylline prevents upregulation of monocyte tissue factor in renal transplant recipients undergoing post-graft complications.

Pentoxifylline (PTX) has been demonstrated to improve graft survival in renal transplant recipients undergoing post graft complications. As activated monocytes are possible initiators of vascular damage through tissue factor (TF) expression, we evaluated the monocyte TF expression and endothelium activation markers in 140 consecutive patients receiving cadaveric kidney grafts, randomized in a double-blind study comparing PTX versus placebo. Monocyte TF expression and plasma von Willebrand factor, tissue plasminogen activator, thrombomodulin and tumor necrosis factor-alpha (TNF-alpha) levels were determined before transplantation and each month after. Additional samplings were realized in case of acute rejection. TF and TNF-alpha expression were significantly modified after graft. In patients with complications, PTX prevented the increase of TF expression at month one, and after rejection episodes. Endothelium activation markers were significantly modified after graft and in patients with complications but PTX had no significant effect on their plasma levels. These results suggest that the protective effect of PTX on graft survival could be related to the prevention of monocyte TF upregulation associated with complications.

Diagnostic and predictive value of an immunohistochemical profile in asymptomatic acute rejection of renal allografts.

We have retrospectively studied the diagnostic and predictive value of immunohistochemical characterization of adhesion molecules (ICAM-1, CD54, VCAM-1) and HLA-DR antigen in a homogeneous clinical group of 36 patients. Between 1 January 1991 and 31 January 1993, 130 patients received a kidney transplant in our unit. Biopsies of renal allografts were only performed in asymptomatic patients who had graft dysfunction, revealed by an isolated serum creatinine increase. Available frozen samples were included in this study (n = 44). The 35 cases of acute rejection diagnosed by biopsy corresponded to mild acute rejection according to the Banff classification criteria. First, we compared the expression of HLA-DR, ICAM-1 and VCAM-1 to morphological data to determine if the immunohistochemical data improved the histopathological diagnosis when the interstitial infiltrate was mild with slight tubulitis. We also studied the phenotype of infiltrating cells with monoclonal antibodies directed against T helper cells, T cytotoxic-suppressor cells, activated T cells and macrophages. Expression on tubular epithelium and density of each type of cell was graded semiquantitatively. Expression of HLA-DR, ICAM-1 and VCAM-1 was observed on tubular epithelium and endothelium in both acute rejection and other causes of graft dysfunction, limiting its diagnostic value. Activated T cells expressing CD69-AIM (activation inducer molecule) and/or HLA-DR were frequently observed in acute rejection (24/35 (69%) and 25/35 (71%) respectively) but not in other causes of renal dysfunction. We then studied the prognostic usefulness of the immunohistochemical profile in acute rejection. Of 27 patients, 12 had a progressively decreased renal function or returned to dialysis within one year after transplantation while the other 15 had a stable graft function after at least 18 months of follow-up. In the group of bad prognosis (n = 12), corticosteroid-resistant rejection episodes were significantly more frequent (p < 0.01). In this group, nine patients had an overexpression of HLA-DR on tubular epithelium versus one patient in the group of stable graft function (chi 2c = 10.57, p < 0.002). Seven patients included in the group of bad prognosis showed tubular overexpression of both ICAM-1 and VCAM-1 versus one patient in the other group chi 2c = 6.23, p < 0.02). Moreover, patients of the first group had a significantly higher number of interstitial macrophages as compared with those who had stable graft function (chi 2c = 4.87, p < 0.01). Thus, our data show that the immunohistochemical profile studied is of little value in the diagnosis of renal allograft rejection. However, an intense tubular expression of HLA-DR and/or both ICAM-1 and VCAM-1, and a high number of interstitial macrophages are significantly related to unfavorable graft outcome.

[Initial polychemotherapy in the treatment of cancers of the head and neck. The efficacy and tolerance of 2 nonrandomized combinations in 48 patients]. / Polychimiothérapie initiale dans le traitement des cancers des voies aérodisgestives supérieures. Efficacité et tolérance de deux associations non randomisées chez 48 patients.

Before loco regional treatment for head and neck cancer forty eight patients received one or the other of the following combined chemotherapy regimens: Regimen A (28 patients): high dosage methotrexate, bleomycin, cis-platin; regimen B (20 patients): common dosage methotrexate, bleomycin, hydroxyurea, vincristin. The effectiveness of regimen A seemed better than that of regimen B (46% responses versus 20%). This assessment must be accepted with caution, since, although the organization of treatment was strictly similar in the two groups, the study was not randomized, and there were noticeable differences between the two groups. Regimen B was associated with no toxicity. Regimen A was responsible for two fatalities. These two cases were linked to high dosage methotrexate. However, a combined chemotherapy regimen of type A with the high dosage methotrexate replaced by intermediate dosage methotrexate, seems feasible to us. Loco regional treatment was not impaired by initial chemotherapy with either regimen.

[The influence of present therapeutic methods and especially of beta-blockers on fetal and maternal prognosis in hypertensive syndromes in pregnancy. 43 case records (author's transl)]. / Influence des thérapeutiques actuelles et notamment des bêta-bloquants sur le pronostic foetal et maternel des syndromes hypertensifs de la grossesse. A propos de 43 observations.

The authors studied 43 cases of arterial hypertension in pregnancy in an attempt to determine the efficiency and safety of different anti-hypertensive drugs. The patients were divided into two major groups: arterial hypertension which revealed itself during pregnancy (true toxaemias of pregnancy and relapsing toxaemias), and arterial hypertensions which were added on to a pre-existing pathology (arterial hypertension, diabetes, chronic nephritis). The cases in these different classes were then divided into two definite groups according to the need for therapy: the first group was treated by rest and hydrallazine as a single therapeutic agent. In the second group multiple agents were needed because of the arterial hypertension, and one was a beta-blocker. Complications were found particularly in the second group of true toxaemias of pregnancy where unfortunately 5 fetal deaths occurred that were attributable to the severity of the hypertension more than to the beta-blockers, which were administered for longer and in higher doses without major complications in recurrent toxaemias and pre-existing arterial hypertension cases.

[Incidence and clinical expressions of microvascular complications in patients receiving kidney graft and treated with cyclosporine]. / Incidence et expressions cliniques des complications microvasculaires chez les greffés rénaux traités par ciclosporine.

Reported cases of HUS/TTP (hemolytic uremic syndrome/thrombotic thrombopenic purpura) with cyclosporin (CsA) are more and more frequent, which led us to evaluate the incidence of microangiopathic process in kidney graft patients. In our first retrospective study we noted 9.4 percent of HUS/TTP among 117 patients. We tried to detect infraclinical hemolytic events prospectively in 40 new patients by systematic measurement of haptoglobin levels after introduction of CsA. The incidence of falls in haptoglobin levels was 25 percent. The immunological context was always noted: rejection crisis in 5 cases, cytomegalovirus infection in 3 cases, isolated markers of lymphocyte-activity in 2 cases. We never found a clinical or infraclinical form of microangiopathic process without a symptomatic or asymptomatic immunological complication. Monitoring haptoglobin levels make it possible to detect early endothelial injuries which could be linked to the future arteriolopathy described with CsA therapy.

[Transplantation for primary hyperoxaluria. Role of oxalate crystal deposits in the occurrence of kidney failure]. / Transplantation pour hyperoxalurie primaire. Rôle des dépôts cristallins d'oxalate dans la survenue de l'insuffisance rénale.

We analyzed the records of 3 patients transplanted for end-stage renal failure due to primary hyperoxaluria and evaluated on repeat biopsies the role played by oxalate deposits in the constitution of renal failure after isolated kidney graft, or combined liver and kidney transplantation. Early failure of the renal graft is frequent and often interpreted as the consequence of recurrence because of the presence of oxalate deposits on the graft biopsy. In fact, the decrease in oxalate deposits observed in our 2 cases of combined liver and kidney transplantation despite the progressive renal failure, indicates that crystal deposition is not responsible for the renal lesions. However, we cannot exclude that the oxalate molecule toxicity plays a role in the constitution of the diffuse sclerosis which occurred in these two cases after a primary renal non function, aggravating a hemodynamic process by using cyclosporin. On the other hand, as observed in our isolated kidney graft, renal crystal deposition occurring before the onset of renal failure suggests the true mechanism explaining the slow recurrence of renal oxalosis.

[Lymphoedema of penis and scrotum: two observations (author's transl)]. / Le lymphcedème péno-scrotal : 2 observations.

Two cases of lymphoedema of penis and scrotum are reported: lymphanogiography is useful to distinguish between primary or secondary lymphoedema. In the first case, this is a primary tarda lymphoedema of penis and scrotum with hypoplastic lymphatics of the right leg. In the second case the lymphoedema follows repeated infection and paraphimosis. This infection may have worsened an already compromised lymphatic circulation. These genital elephantiasis are quite different from penile venereal edema, which disappears quickly after sexual abstinence. The operative treatment of lymphoedema is lymphangiectomy.

[Functional endoscopic surgery of sinusal mucocele]. / Chirurgie fonctionnelle endoscopique des mucocèles sinusiennes.

The treatment of paranasal sinus mucoceles must assure complete removal and prevention of recurrence. In order to clarify the precise indications for endoscopic management, a retrospective study was undertaken on 16 patients with paranasal sinus mucoceles treated by this method. All of the patients underwent endoscopic exploration with or without an associated bicoronal approach. The follow-up period varied between 3 months and 46 months with a mean of 24. The results were considered satisfactory if the patient's symptoms disappeared and follow-up endoscopy revealed persistence of sinus permeability. Functional endoscopic surgery can be considered as an alternative method in treatment of sinus mucoceles. Only mucoceles confined to the lateral wall of the frontal sinus, and the extended mucoceles, seem to be an out of the way place to endoscopic sinus surgery alone. In these cases, the access has to be completed by an external approach. Concerning adequate recanalization of the nasofrontal duct, results seem encouraging, however a long-term follow-up is necessary to obtain an accurate assessment of the results.

[Results of the treatment of aspergillosis of the maxillary sinus by exclusive middle meatotomy approach]. / Résultats du traitement des aspergilloses du sinus maxillaire par voie de méatotomie moyenne exclusive.

Over a 3 year period the authors have managed 12 immune competent patients with aspergillosis of the maxillary sinus by intranasal sinus surgery using only a middle meatal approach. An enlarged middle meatal window was formed by resection of the superior surface of the inferior turbinate. especially designed curve suction tubes and forceps were used to reach all areas of the maxillary sinus in order to perform a macroscopically complete resection of all lesions. On no occasion Aspergillus was the alternative use of an inferior meatal window or a Caldwell-Luc approach necessary. The authors conclude that the use of a middle meatotomy for the surgical treatment of aspergillosis of the maxillary sinus makes it possible to assure complete resection, to adapt post-operative care and to permit prolonged aeration of the sinus.

[Use of the pectoralis major myocutaneous flap in transmaxillary buccopharyngectomy]. / Utilisation du lambeau myo-cutané du grand pectoral au cours des bucco-pharyngectomies transmaxillaires.

Pectoralis major musculocutaneous flaps were used for reconstruction after transmaxillary buccopharyngectomy to treat 22 patients with large oropharyngeal tumors. Short and medium term results are discussed. Large excisions such as these raise many functional problems, even though the use of a musculocutaneous flap for reconstruction is a valid procedure from the anatomical point of view. The cancer prognosis must still be reserved as follow up is still limited for these cases.

[Taste in healthy subjects. Influence of alcohol and tobacco consumption]. / Le Goût chez le sujet sain. Influence de la consommation d'alcool et de tabac.

To define the factors which may affect gustatory function, 42 healthy subjects, without any apparent taste disorder were randomly selected and investigated by electro-gustometry and chemical gustometry. A deterioration in taste discrimination was noted in drinkers in comparison with non-drinkers, both on electro-gustometry, mean threshold (SEM: 88.0 +/- 26.5 versus 47.4 +/- 7.3 microA; p less than 0.05), and also on chemical gustometry (15.1 +/- 2.1 versus 17.4 +/- 0.7; p = 0.05) and also in smokers compared with non smokers (mean of electrical thresholds SEM 104.2 +/- 22.8 versus 38.3 +/- 5.2 microA; p less than 0.01, mean of chemical scores SEM 14.3 +/- 1.1 versus 17.9 +/- 0.9; p less than 0.05). Multivariate analysis demonstrated the influence of the two factors alcohol and tobacco on taste, evaluated by electrogustometry (R2 = 0.36) or chemical gustometry (R2 = 0.28). These results suggest that alcohol and tobacco are liable to influence gustatory function in healthy subjects thereby suggesting that this influence should be taken into account using a corrective factor.

[Critical study and role of partial vertical reconstructive laryngectomies with epiglottoplasty by the Tucker method. Apropos of 18 cases]. / Etude critique et place des laryngectomies partielles verticales reconstructives avec épiglottoplastie selon la méthode de Tucker. A propos de 18 cas.

Two groups could be distinguished in a series of 18 patients with glottic lesions: one with pure glottic tumors (12 cases) and the other with tumors extending beyond the glottic region (6 cases). All patients but one were operated upon by first intention for epidermoid carcinoma, but also for associated pronounced dysplasia. The so-called Tucker technique was used with slight modifications (less extensive resection of thyroid cartilage, conservation of the two arytenoid cartilages). The postoperative course was satisfactory with decanulation and ablation on the 13th day, and a mean hospital stay of 22 days. Two postoperative deaths due to vascular complications occurred and one patient developed a swinging epiglottis after 2 years. The remaining 16 patients are all alive, including 8 after less than 3 years. Analogous results were noted in an analysis of a total of 93 case-reports from 5 different series of patients. This method provides an elegant and satisfactory repair of pure cordal surgery, but adds nothing from the oncologic point of view since other better adapted and currently well defined operations have to be envisaged for lesions extending beyond this region.

[Value of reaming of the piriform orifices in the functional surgery of the nasal cavities]. / Place de l'alésage des orifices piriformes dans la chirurgie fonctionnelle des fosses nasales.

Reaming of piriform orifices is a simple, short procedure easily integrated into functional surgery of nasal fossae. Results in 27 cases were rated as very good in 20 patients. Results are compared with those of three series reported in the literature, and the rare side effects noted are discussed.

[The posterior pharyngeal wall in pharyngo-laryngeal cancer. Spontaneous healing after excision]. / La paroi pharyngée postérieure dans les cancers pharyngo-laryngés. Cicatrisation spontanée après exérèse.

Malignant lesions arising from the posterior pharyngeal wall, or spreading to involve it, present a therapeutic problem in cancer surgery as witnessed by the number of techniques proposed and used. In general, they require longer operating time, sometimes need a double team of surgeons and sometimes specialised training. There is an increased risk of complications. The experience with pharyngoplasty using mucosal or musculo-mucosal flaps, which leave the donor site bare, raised the possibility of partial repair in circular pharyngo-laryngectomy. A myocutaneous flap is sutured in "gutter" fashion anteriorly opposite the posterior pharyngeal wall which in fact consists of the prevertebral aponeurosis laid bare. Repair was not performed in certain partial posterior pharyngectomies. Seven patients underwent surgery using this technique. Four circular pharyngo-laryngectomies, including 2 as second stage procedures were performed. Healing occurred in all cases. No breakdown of sutures occurred. Oral feeding was possible from D12 on average and patients were discharged on D18. Three posterior pharyngectomies, including 1 as a second stage procedure, were performed. Feeding was possible in 2 patients on D15 and discharge on D18. These encouraging results suggest that this reliable, rapid single stage procedure technique should be adopted.