Is diabetes a risk factor for central venous access port-related bloodstream infection in oncological patients?

It was a dogma that patients with diabetes mellitus (DM) are at increased risk of infection or death associated with an infection. However, in cancer patients, this has not been well investigated. The aim was to investigate whether diabetic patients with cancer are at high risk of central venous access port (CVAP)-related bloodstream infection (BSI), and to analyse mortality after CVAP-BSI. A total of 17 patients with type 1 DM (T1DM), 66 with type 2 DM (T2DM) and 307 non-diabetic patients were included. Each patient was followed up until the first late CVAP-BSI or for a maximum for 1 year in the absence of a CVAP-BSI. Fifty-three CVAP-BSIs occurred in 66,528 catheter-days. The cumulative incidence of CVAP-BSI was not higher in T1DM (5.9 %; p = 0.17) and T2DM (19.7 %; p = 0.70) compared with the non-diabetic patients (12.7 %). However, in patients with CVAP-BSI, the 1-month crude mortality rate was higher in DM patients (42.9 % vs. 15.4 %; p = 0.04), whereas the mortality in patients without CVAP-BSI was similar in both groups of patients (19.8 % vs. 17.1 %; p = 0.58). Of the 12 deaths that occurred within 1 month of CVAP-BSI, 16.66 % was attributable to CVAP-BSI. The predictive factor of 1-month mortality was DM (p = 0.04). Parenteral nutrition (PN) was independently associated with CVAP-BSI in diabetic patients (p = 0.001). In this study, diabetes did not increase the risk of CVAP-BSI, but mortality was higher in diabetic patients who had a CVAP-BSI. This suggests, in addition to medical treatment, CVAP should be withdrawn after infection onset.

Contrast-enhanced harmonic endoscopic ultrasound in solid lesions of the pancreas: results of a pilot study.

BACKGROUND AND STUDY AIMS: Distinguishing pancreatic adenocarcinoma from other pancreatic masses remains challenging with current imaging techniques. This prospective study aimed to evaluate the accuracy of a new procedure, imaging the microcirculation pattern of the pancreas by contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) with a new Olympus prototype echo endoscope. PATIENTS AND METHODS: 35 patients presenting with solid pancreatic lesions were prospectively enrolled. All patients had conventional B mode and power Doppler EUS. After an intravenous bolus injection of 2.4 ml of a second-generation ultrasound contrast agent (SonoVue) CEH-EUS was then performed with a new Olympus prototype echo endoscope (xGF-UCT 180). The microvascular pattern was compared with the final diagnosis based on the pathological examination of specimens from surgery or EUS-guided fine-needle aspiration (EUS-FNA) or on follow-up for at least 12 months. RESULTS: The final diagnoses were: 18 adenocarcinomas, 9 neuroendocrine tumors, 7 chronic pancreatitis, and 1 stromal tumor. Power Doppler failed to display microcirculation, whereas harmonic imaging demonstrated it in all cases. Out of 18 lesions with a hypointense signal on CEH-EUS, 16 were adenocarcinomas. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of hypointensity for diagnosing pancreatic adenocarcinoma were 89 %, 88 %, 88 %, 89 %, and 88.5 %, compared with corresponding values of 72 %, 100 %, 77 %, 100 %, and 86 % for EUS-FNA. Of five adenocarcinomas with false-negative results at EUS-FNA, four had a hypointense echo signal at CEH-EUS. CONCLUSIONS: CEH-EUS with the new Olympus prototype device successfully visualizes the microvascular pattern in pancreatic solid lesions, and may be useful for distinguishing adenocarcinomas from other pancreatic masses.

Miniprobe EUS in the pretherapeutic assessment of early esophageal neoplasia.

BACKGROUND AND STUDY AIMS: The high-frequency endosonography miniprobe has been advocated prior to endoscopic treatment of superficial esophageal neoplasm. We conducted a retrospective study, which summarized our clinical experience with various miniprobe techniques in the assessment of early squamous cell carcinoma (SCC) and superficial adenocarcinoma on Barrett's mucosa (SAB). PATIENTS AND METHODS: A total of 106 superficial and naive esophageal lesions were included in this series (52 SAB, 54 SCC). The results of the miniprobe staging were compared with pathology in order to determine the accuracy of this technique in differentiating mucosal from submucosal infiltration. Secondary aims were a comparison between the frequencies (20- vs. 30-MHz) and coupling methods (water-filled lumen vs. balloon-sheathed catheter) used. RESULTS: Overall accuracy, sensitivity, and specificity to differentiate T1sm from T1 m tumors were 73.5 %, 62 %, and 76.5 %, respectively. Overdiagnosis occurred in 18.6 % of the lesions. No statistically significant difference was found in the accuracy of the miniprobe staging between the two lesion types (SCC and SAB) ( P = 0.65), and results were significantly poorer in the distal part of the esophagus ( P = 0.00039). No significant difference was found between the two frequencies ( P = 0.51). Water-filled lumen proved to be superior to the balloon-sheathed catheter ( P = 0.015). CONCLUSION: High-frequency miniprobe examination has a limited accuracy in the detection of submucosal invasion in early esophageal cancer. Further improvements in acoustic coupling and ultrasound technique are required to improve the miniprobe accuracy before its implementation into clinical routine.

Long-term results of liver transplantation for Wilson's disease.

UNLABELLED: Wilson's disease is a hereditary defect in hepatic copper metabolism, causing hepatic, neurological and/or psychiatric manifestations. For patients with severe disease, liver transplantation is the treatment of choice. The aim of this study was to report the long-term outcome of patients who underwent liver transplantation for Wilson's disease. PATIENTS AND METHODS: Thirteen patients with Wilson's disease, transplanted in Lyon France between January 1987 and May 2006, were including in this study: eight women and five men, aged eight to 53 years (median 20 years, seven children and six adults). The diagnosis of Wilson's disease was established before liver transplantation. RESULTS: The indication for liver transplantation was chronic (69%) or fulminant liver failure (31%). The median follow-up after liver transplantation was 10 years with 100% patient survival. Copper metabolism returned to normal in all patients. None of the patients with exclusive liver disease required chelation treatment after liver transplantation and none developed neurological symptoms of Wilson's disease. CONCLUSION: Liver transplantation totally reverses the abnormalities of copper metabolism and subsequent hepatic failure, but the course of neurological symptoms remains unpredictable. Long-term patient survival can be excellent without occurrence of neurological complications.

[Pseudoaneurysm of the hepatic artery: rare complication of chronic pancreatitis]. / Pseudoanevrisme de l'artere hepatique: complication rare au cours de l'histoire naturelle de la pancreatite chronique: à propos de deux cas.

Bleeding from a pseudoaneurysm is a rare complication of chronic pancreatitis. We present two cases of ruptured pseudoaneurysms of the hepatic arteries. The first case involved a pancreatic pseudocyst that ruptured in the duodenum and the second resulted in an intrahepatic hematoma that compressed the bile tract causing secondary hemobilia. Angiographic embolization was the primary treatment in both cases, with surgery for the first patient and later radiological drainage in the second. The hemorrhage was controlled in both cases despite the severe prognosis and high mortality in these cases.

Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices.

We report a case of massive pulmonary embolism during cyanoacrylate glue endoscopic injection in a patient with gastric varices from portal hypertension. A review of the literature and results in an animal model show the physiopathology and risk factors associated with this endoscopic procedure.

Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial.

PURPOSE: The optimal timing of surgery after preoperative radiotherapy in rectal cancer is unknown. The aim of this trial was to evaluate the role of the interval between preoperative radiotherapy and surgery. PATIENTS AND METHODS: Patients with rectal carcinoma accessible to rectal digital examination, staged T2 to T3, NX, M0, were randomized before radiotherapy (39 Gy in 13 fractions) into two groups: in the short interval (SI) group, surgery had to be performed within 2 weeks after completion of radiation therapy, compared with 6 to 8 weeks in the long interval (LI) group. Between 1991 and 1995, 201 patients were enrolled onto the study. RESULTS: A long interval between preoperative radiotherapy and surgery was associated with a significantly better clinical tumor response (53. 1% in the SI group v 71.7% in the LI group, P =.007) and pathologic downstaging (10.3% in the SI group v 26% in the LI group, P =.005). At a median follow-up of 33 months, there were no differences in morbidity, local relapse, and short-term survival between the two groups. Sphincter-preserving surgery was performed in 76% of cases in the LI group versus 68% in the SI group (P = 0.27). CONCLUSION: A long interval between preoperative irradiation and surgery provides increased tumor downstaging with no detrimental effect on toxicity and early clinical results. When sphincter preservation is questionable, a long interval may increase the chance of a successful sphincter-saving surgery.

[Gastrojejunocolic fistula, report of two recent cases with original management]. / Fistule gastrojéjunocolique: prise en charge originale de deux patients.

Gastrojejunocolic fistulae, ultimate complication of anastomotic peptic ulceration, are presently uncommon. We report two recent cases of postoperative gastrojejunocolic fistulas (after duodenal ulcer surgery and total duodenopancreatectomy), which were complicated at time of diagnosis (acute peritonitis and liver cirrhosis) and required a two-stage treatment.

Role of catecholamines in the ketonemic response to somatostatin in normal man.

In order to determine if a rise of circulating catecholamines occurs during somatostatin (SRIF) infusion in normal man, and if this increase plays a significant metabolic role, we infused four normal subjects with SRIF (500 micrograms/h) alone or associated with either alpha-(phentolamine) or beta-(propranolol) adrenergic blocking agents. During SRIF infusion, the initial small decrease in blood glucose was followed by a rise of epinephrine from 25-46 ng/liter (range) to 117-143 ng/liter (range) (P less than 0.05) at 80 min and norepinephrine from 204 +/- 16 to 418 +/- 60 ng/liter at 90 min (P less than 0.05). Thereafter, plasma nonesterified fatty acids, blood glycerol, and ketone bodies increased significantly. Phentolamine adjunction modified neither the catecholamines rise, nor the metabolic changes. Propranolol adjunction did not modify the glucose fall and the catecholamine rise, but resulted in blunted increments of fatty acids and glycerol and in an almost complete suppression of the increase of ketone bodies. These results suggest that the enhanced lipolysis and ketogenesis observed during SRIF infusion are not only due to the SRIF-induced insulin deficiency but also in part to a beta-receptor mediated effect of catecholamines.

Hormonal and metabolic effects of near physiological increase of plasma immunoreactive somatostatin 14.

The possibility that somatostatin 14 (SRIF) may exert true endocrine actions in man was tested by investigating the hormonal and metabolic effects of the peptide infused for 80 min at rates of 36.5, 73, and 146 pmol kg-1 h-1 in six healthy subjects who fasted overnight. These three doses increased the level of plasma SRIF-like immunoreactivity in the range of concentrations recorded postprandially with the same assay system. These low SRIF infusion rates decreased insulinemia and to a lesser extent glucagonemia, and increased glucosemia and ketonemia. Both the reduction of insulin and the increase of glucosemia were significantly related to the increase of plasma SRIF-like immunoreactivity. All parameters returned to control values upon discontinuing the peptide infusion. This study suggests that SRIF may have an endocrine role in man and that such low dose, short time SRIF infusions could exert metabolic effects different from those of larger, probably pharmacological, infusion rates.

Endocavitary irradiation for early rectal carcinomas T1 (T2). A series of 101 patients treated with the Papillon's technique.

PURPOSE: This work is a retrospective analysis of a series of patients treated with endocavitary irradiation stressing the role of transrectal ultrasound (TRUS), which has been used routinely in the staging since 1987. METHODS AND MATERIALS: Between 1977 and 1993, 101 patients with infiltrating adenocarcinomas were treated. Clinical staging was 65 T1 N0 and 36 T2 N0. TRUS used in 36 patients showed: 22 UT1 N0, 10 UT2 N0, and 3 UT2 N1. Contact x-ray was delivered with a 50 kV radiotherapy unit. The median dose was 92 Gy (60-125) in five fractions, 55 days. In 28 patients a boost was given with 192Ir implant delivering a median dose of 25 Gy/21 h. RESULTS: Complete response was observed in all patients at the completion of treatment. Loco-regional failures were seen in 14 patients (local in 7 patients, nodal pararectal in 6 patients, and local + nodal in 1 patient). A curative salvage treatment was attempted in 13 patients and resulted in an ultimate pelvic control rate of 99 patients. Rectal preservation was possible in 92 patients. Overall and specific 5-year survival was 83.3% and 94.4%. No serious complication was observed. TRUS was more sensitive than digital rectal examination to detect involvement of pararectal metastatic nodes (N1). No loco- regional relapse was observed out of 22 UT1 N0. CONCLUSION: Endocavitary irradiation can cure early adenocarcinoma of the rectum without complication. TRUS appears as a significant improvement in the selection of patients amenable to this treatment. If restricted to UT1 N0 tumors, endocavitary irradiation should control locally more than 90% of these patients. Any UN1 is a contraindication for endocavitary irradiation alone.

Regulation of somatostatin secretion in man: study of the role of free fatty acids and ketone bodies.

We have investigated in normal subjects the possible role of plasma free fatty acids (FFA) and blood ketone bodies (KB) in the regulation of human somatostatin secretion. Heparin injected during the intravenous infusion of a fat emulsion raised FFA levels acutely from 0.4 +/- 0.1 to near 3 mmol/L. Plasma somatostatin-like immunoreactivity (SLI) rose from a mean (+/- SEM) basal value of 9.2 +/- 1.0 ng Eq S14/L to 20.0 +/- 6.0 ng Eq S14/L (P less than 0.05). Plasma immunoreactive insulin (IRI) level was unchanged and glucagon (IRG) concentration decreased from 156 +/- 20 to 107 +/- 2 ng/L (P less than 0.05). During this test, there was a rise not only in FFA but also in plasma triglycerides (TG) and in blood glycerol and KB levels. The infusion of a fat emulsion alone increased triglyceride and glycerol levels to a similar extent but induced also a mild rise of FFA (0.37 +/- 0.05 to 1.13 +/- 0.5 mmol/L, P less than 0.01), KB (78 +/- 12 to 360 +/- 45 mumol/L, P less than 0.01), and SLI (14.8 +/- 4.6 to 23.8 +/- 7.1 ng Eq S14/L, P less than 0.05). The induction by DL-Na-3-hydroxybutyrate infusion of a rise of KB was associated with a decrease of FFA (P less than 0.05) and SLI (P less than 0.05) without modification of IRI or IRG levels. Phentolamine infusion did not modify the SLI or glucagon response to acute elevations of FFA, whereas propranolol suppressed the increase of SLI without preventing the concomitant decrease of IRG.(ABSTRACT TRUNCATED AT 250 WORDS)

Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding.

BACKGROUND: The most dramatic complication of portal hypertension in cirrhotic patients is oesophageal variceal bleeding. Moreover, patients with bleeding unresponsive to medical and endoscopic treatment have a poor prognosis. OBJECTIVE: The aim of this study was to evaluate the efficacy of early transjugular intra-hepatic portosystemic shunt (TIPS) in patients with refractory variceal bleeding. PATIENTS AND METHODS: TIPS was performed for 28 patients (17 were stage Child C), successfully in 26. Variceal bleeding was controlled in all but one successfully stented patient. RESULTS: There was no mortality associated with the procedure. The two patients with a failure of TIPS insertion died of persistent bleeding in the first 48 h after failed TIPS. The 40-day mortality rate was 25%. Five patients died (one from persistent bleeding from gastric varices and four from multi-organ failure). Using multivariate analysis, the only independent factor associated with early mortality was the total bilirubin value. Fifteen surviving patients were listed for liver transplantation: four deaths occurred, eight patients were transplanted in the 6 months after TIPS and three are still waiting. Among the six patients who survived but were ineligible for transplantation, two died and four are still alive. Two episodes of early rebleeding and eight of late rebleeding occurred. Actuarial survival was 75% at one year and 52% at two years. CONCLUSIONS: Early TIPS is an effective rescue therapy for controlling refractory variceal bleeding.

[Endoscopic ligation of esophageal varices: prevention of hemorrhagic recurrences caused by rupture of esophageal varices. Results in 45 patients]. / Ligature endoscopique des varices oesophagiennes: prévention des récidives hémorragiques par rupture de varices oesophagiennes. Résultats chez 45 malades.

OBJECTIVES: The aim of this study was to assess the morbidity and efficacy of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices. METHODS: Forty-five patients with cirrhosis (Child's class: A: 18, B: 16, C: 11) and recent (< 48 h) variceal bleeding were included. Eleven of the patients were included after failure of sclerotherapy. All patients were treated by endoscopic ligation until the complete eradication of oesophageal varices. The mean follow-up was 8.7 +/- 6.8 months. RESULTS: Oesophageal varices were eradicated in 40 patients (89%) after an average of 2 sessions (range: 1-5). In a subset of 11 patients treated after failure of sclerotherapy, 8 (73%) had complete eradication of oesophageal varices. Six of the 45 patients (13%) had recurrence of haemorrhage, due to post-ligation ulcerations in 5 cases and to rupture of oesophageal varices in one case. The rate of complications was 7%. Of the 40 patients whose oesophageal varices were eradicated, 7 (17%) were lost for follow up, and another treatment was performed in 4 (10%): liver transplantation in 2, and transjugular intrahepatic portosystemic shunt in 2. Recurrence of oesophageal varices after eradication was observed in 3 (10%) of the remaining 29 patients after a follow-up of 8.9 +/- 12.9 months. Of these 3 patients, only one (3%) presented with recurrence of haemorrhage due to ruptured oesophageal varices. Three patients (7%) died before eradication of oesophageal varices from causes unrelated to the technique. CONCLUSION: This study confirms that endoscopic ligation is effective for eradication of oesophageal varices, with a low morbidity. This technique appears to be a method of choice in the prophylaxis of rebleeding from oesophageal varices, especially when sclerotherapy is ineffective.

[Prospective randomized single-blind trial comparing oral sodium phosphate with polyethylene glycol for colonoscopy preparation]. / Etude prospective randomisée en simple aveugle comparant phosphate de sodium oral et polyéthylène glycol pour la préparation à la coloscopie.

AIM AND METHODS: The aim of this prospective, randomized, study performed in 60 outpatients was to compare 2 precolonoscopy bowel preparations: oral sodium phosphate (NaP) versus standard polyethylene glycol-based lavage solution (PEG). None of the patients met any of NaP exclusion criteria. All patients were prepared on the day prior to colonoscopy. A patient-questionnaire and measure of serum electrolytes (calcium, phosphate, sodium, potassium), pulse and blood pressure were used to assess tolerance and acceptability of the preparation. The quality of colon cleansing was judged by blinded endoscopists. RESULTS: Patient's tolerance to NaP was superior to PEG: NaP preparation was easier to drink and feelings of abdominal plenitude occurred in a smaller proportion of patients. A potassium decrease, a sodium increase and hyperphosphatemia were observed in the NaP group but without clinical events. PEG preparation seemed to allow a better cleansing ability compared with NaP but this difference was not statistically significant. CONCLUSIONS: NaP solution was better tolerated and accepted by patients. Colonic preparation quality compared to PEG is still to be discussed depending on the intake schedule. A biochemical data check seems necessary on account of significant serum electrolytes changes induced by NaP preparation.

[Metastatic pancreatic endocrine tumor with elevation of alpha-fetoprotein]. / Tumeur endocrine pancréatique métastatique avec élévation de l'alpha-foetoprotéine.

Hepatoma was diagnosed in a 47 year old man presenting with multiple liver tumors and elevated alpha-fetoprotein concentration (460 micrograms/l). Liver biopsy showed a poorly differentiated carcinoma. The discovery of 2 hypervascular tumors in the splenic area at celiac arteriography led to challenge the diagnosis: ultrasound guided-aspiration biopsy showed endocrine cells at the level of the hepatic and pancreatic tumors. The diagnosis of pancreatic islet cell tumor with liver secondaries was confirmed by the pathology of the operative specimen. During the following months, alpha-fetoprotein concentration steadily increased. The patient died 5 months later from widespread metastases. At necropsy, no evidence of hepatoma was found. Immunocytochemical study with antibody raised against alpha-fetoprotein was negative both at the level of the tumoral cells and of the liver cells around the tumor. This case adds a new cause to abnormally high plasma alpha-fetoprotein. As hepatoma and endocrine tumor metastatic to the liver could be difficult to differentiate, this new cause could be clinically relevant.

[Portasystemic anastomosis by transjugular approach: treatment of active and refractory hemorrhage caused by rupture of esophageal varices. Results in 11 patients]. / Anastomose porto-systémique par voie transjugulaire: traitement de l'hémorragie par rupture de varices oesophagiennes active et réfractaire. Résultats chez 11 malades.

OBJECTIVE: The aim of this study was to assess the feasibility and efficacy of transjugular intrahepatic portosystemic shunts for refractory variceal bleeding, uncontrolled by sclerotherapy or endoscopic ligation. METHODS: 11 patients (mean age: 52 years) with cirrhosis admitted for refractory haemorrhage from ruptured oesophageal varices were included in this study. Eight patients were Child-Pugh class C. All patients were actively bleeding. RESULTS: All the procedures were successful. Variceal haemorrhage stopped within 24 h. There was no mortality during the procedure. Early complications such as rebleeding (18%) and thrombosis (18%) occurred. Thirty days mortality was 27%. Follow-up in the 8 surviving patients was 19.5 +/- 8 months. Three patients developed recurrent bleeding, from non-variceal sources in 2. In 4 surviving patients, occlusion of the shunt was treated with dilatation or insertion of a second stent. The incidence of hepatic encephalopathy was 25%. Five patients subsequently underwent liver transplantation. Among the 3 patients ineligible for transplantation, one died of hepatocellular carcinoma after 10 months. The 2 others were alive after 19 and 25 months, respectively. CONCLUSIONS: These results suggest that transjugular intrahepatic portosystemic shunt is a safe and effective procedure of portal decompression in patients with refractory variceal bleeding. Prospective trials comparing this percutaneous procedure and surgical treatment are required.

[Clinicobiological study of drug-induced renal diseases]. / Exploration clinico-biologique des néphropathies médicamenteuses.

The kidney is the main organ involved in drugs elimination and thereby is particularly liable to their toxic effect. The determination of renal function is thus of importance, before and during treatment with a potentially nephrotoxic drug or during trial of new drugs. In this general review, the main methods to measure renal function are briefly analysed. They consist either of simple dosages in blood and urine which allow to roughly evaluate renal functional value and its variations, or more sophisticated investigations which allow a more precise analysis of various nephron functions: glomerular filtration rate and renal plasma flow with measurement of clearances of exogenous markers, determination of basal or maximal tubular activities. The interest of these specific tests is illustrated by the results of a study performed in patients receiving streptozotocin, an antineoplastic nephrotoxic drug. In conclusion, nephrotoxicity of drugs may be in most cases prevented owing to an accurate knowledge of their pharmacokinetics and of risk factors inherent in patients, and to survey of renal function with suitable methods which may lead to modify drug dosage and/or to choose a therapy considering the own evolution of the disease and the possible occurrence of irreversible renal impairment.