Bariatric surgery related proximal myopathy: A partially reversible complication.

Deficiency neuropathies and rhabdomyolysis have previously been reported after bariatric surgery (BS) but never myopathies. We report cases of five patients with morbid obesity who developed within 2 to 4 months of a BS, proximal myopathy following significant and rapid weight loss worsened by postoperative gastrointestinal complications. Muscle weakness concerned lower limbs in particular in quadriceps and less frequently in upper limbs and diaphragm, sometimes mimicked a Guillain-Barré syndrome. Muscle biopsy performed in 1 patient, revealed selective atrophy of type 2 fibers. Weakness slowly decreased with refeeding with vitamins supplementation. We enlarge here the clinical pattern of post-BS complications.

Maize- or potato-derived hydroxyethyl starches: is there any thromboelastometric difference?

BACKGROUND: Hydroxyethyl starches (HES) could differ with regard to the origin, and the influence on the coagulation of the raw material is unknown. This study compared the effects of a new potato-derived HES with a maize-derived HES and two crystalloid solutions. METHODS: Whole blood from 10 healthy individuals was diluted by 20% and 40% using either non-balanced potato-derived HES 130/0.42/6:1, non-balanced maize-derived HES 130/0.4/9:1, isotonic saline or Ringer's lactate solution. Samples were analysed by thromboelastometry ROTEM(®) : Coagulation was initiated by acid ellagic [intrinsic thromboelastometry (INTEM)] or tissue factor (extrinsic thromboelastometry) with and without cytochalasin to determine the functional component of fibrinogen [cytochalasin-d-modified thromboelastometry (FIBTEM)]. Platelet count and fibrinogen activity were measured. RESULTS: No effect of raw material was found as no difference was detected among the HES solutions. Whatever the solution, progressive haemodilution impaired haemostasis in a dose-dependant manner: For INTEM, the clot formation time was increased up to 308% and the maximum clot firmness (MCF) was decreased down to 49%. As dilution increased, initiation of coagulation was also impaired. Thromboelastometric alterations were more severe with HES than with crystalloids, especially regarding fibrin polymerization explorations: MCF of FIBTEM was considerably reduced from 12[10-14] to 2[2-3] mm (P<0.05). Fibrinogen activity and platelet count were reduced by dilution in a dose-dependant manner and decreased similarly in all groups. CONCLUSION: Maize- and potato-derived HES have similar effects on coagulation. Both the starch preparations tested lead to more severe haemostatic defects than crystalloids, and impairment of fibrin polymerization appears to be a leading determinant of this coagulopathy.

Pegase 03: a prospective randomized phase III trial of FEC with or without high-dose thiotepa, cyclophosphamide and autologous stem cell transplantation in first-line treatment of metastatic breast cancer.

Pegase 03 is a multicenter prospective randomized phase III trial evaluating the impact of first-line high-dose chemotherapy (HDC) with stem cell support on overall survival (OS), disease-free survival (DFS) and response rate in 308 patients with histologically proven metastatic breast cancer responding to induction therapy. Eligible patients received four induction cycles with FEC 100 (5-fluorouracil 500 mg/m(2), epirubicin 100 mg/m(2), cyclophosphamide 500 mg/m(2)). Patients with objective response (N=179) were randomized to one cycle of HDC (cyclophosphamide 6000 mg/m(2) and thiotepa 800 mg/m(2) (CHUT)) and stem cell support (N=88), or no further treatment (N=91). All patients were observed until disease progression or death. One toxic death occurred after CHUT. Other toxicities were manageable. The response rate at 3 months was higher in the intensification arm: 82.7% (25.3% complete response (CR)) versus 59.2% (14.1% CR) (P=0.0002). Median follow-up was 48 months. Median DFS was 11 and 6.6 months in the intensification and the observation arms, respectively (P=0.0001). There was no survival difference: 33.6 versus 27.3% OS at 3 years (P=0.8) and 22.9 versus 22.3 months median time to relapse in the intensification and observation arms, respectively. In this randomized trial, HDC with CHUT improved DFS but not OS, corroborating findings from earlier trials.

[Treatment of hydroxychloroquine poisoning with extracorporeal circulation]. / Traitement d'une intoxication à l'hydroxychloroquine par circulation extracorporelle.

We report a case of massive overdose of hydroxychloroquine treated with circulatory assistance by peripheral extracorporeal circulation (ECC). We expose the case of a 39-year-old woman who ingested 12 g of hydroxychloroquine with bromazepam, paroxetine, and zolpidem, in a suicide attempt. Patient has developed central nervous system depression, hemodynamic failure, life-threatening ventricular arrhythmias, and serious hypokalemia. Initially the patient has received conventional treatment with gastric lavage and activated charcoal for gastrointestinal decontamination, blood volume expansion and vasopressive drugs, intubation and mechanical ventilation, high dose of diazepam, and potassium replacement. A ventricular fibrillation was treated with external cardiac massage. In spite of this treatment, cardiogenic shock was uncontrolled, and imposed circulatory assistance. After extracorporeal circulation, we observed a spectacular improvement of hemodynamic parameters and electrocardiographic normalization at day one. Extracorporeal circulation could be used as a rescue treatment of cardiotrope and hydroxychloroquine overdoses.

Epidemiological support for a multifactorial aetiology of Kashin-Beck disease in Tibet.

We carried out a cross-sectional study in 12 rural villages in order to identify the risk factors for Kashin-Beck disease in Tibet. Children aged 5-15 years (n=575) were examined and their corresponding houses were visited. Samples were collected in order to study fungal contamination of stored grain and the organic matter content of drinking water. Multivariate analysis was performed using logistic regression and population attributable fractions were computed to estimate the impact of each factor. The following variables were independently associated with the disease: age, gender, low socio-economic status, indicators of a poorly diversified diet, iodine deficiency and small water container size (with higher organic matter levels in small containers). Selenium deficiency was severe in all study subjects. The degree of fungal contamination of barley grain was related to the highest percentage of cases (65%) in a sample of the study population. Higher urinary iodine levels were not associated with decreasing prevalence rates when Alternaria sp. was isolated. The data that we report supports the hypothesis that Kashin-Beck disease occurs as a consequence of oxidative damage to cartilage and bone cells when associated with decreased antioxidant defence. Another mechanism that may coexist is bone remodelling stimulated by thyroid hormones whose actions can be blocked by certain mycotoxins.

Profiles of a healthful diet and its relationship to biomarkers in a population sample from Mediterranean southern France.

OBJECTIVES: The failure of single-nutrient supplementation to prevent disease in intervention studies underlines the necessity to develop a holistic view of food intake. The objectives of this study were to devise a diet quality index (DQI) and identify biomarkers of multidimensional dietary behavior. DESIGN: A nutrition survey was conducted in Mediterranean southern France by means of a food frequency questionnaire. The DQI was based on current dietary recommendations for prevention of diet-related diseases such as cardiovascular disease and some cancers. A second DQI included tobacco use. STATISTICAL ANALYSES: performed Spearman rank correlations, cross-classifications and intraclass correlations were computed between the DQI and biomarkers. RESULTS: Of the 146 subjects, 10 had a healthful diet and 18 had a poor diet. Erythrocyte omega-3 fatty acids-eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)-beta carotene, and vitamin E concentrations were lower and cholesterol concentrations were higher in the poor diet; the difference was significant for EPA and DHA and borderline significant for vitamin E. Significant correlation was found between the DQI and vitamin E (-0.12), EPA (-0.30), and DHA (-0.28), and beta carotene (-0.17) when tobacco use was considered, but not between the DQI and cholesterol. The correlation coefficient reached 0.58 (P0.01) for a composite index based on all biomarkers except cholesterol. CONCLUSIONS: Subjects with a beta carotene levels greater thanl micromol/L, vitamin E greater than 30 micromol/L and EPA greater than 0.65% and DHA greater than 4% of fatty acids in erythrocytes were likely to have a healthful diet. Each biomarker indicated the quality of diet, but correlation was higher with a composite index.

Effect of lecithin on in vitro and in vivo survival of in vitro produced bovine blastocysts after cryopreservation.

The use of soybean lecithin in an glycerol-based solution for slow freezing of in vitro matured, fertilized and cultured (IVMFC) bovine embryos was examined. Embryos were developed in vitro in INRA Menezo's B2 medium supplemented with 10% fetal calf serum (FCS) on Vero cells monolayers. Day 7 blastocysts were frozen in a two-step protocol consisting of exposure to 5% glycerol and 9% glycerol containing 0.2 M sucrose in F1 medium + 20% FCS. Soybean lecithin was either added or not to the freezing solutions at a final concentration of 0.1% (w/v). In Experiment 1, blastocysts were equilibrated in cryoprotectant solutions without cooling. Cryoprotectant was diluted from embryos with 0.5 M and 0.2 M sucrose. The percentages of fully expanded and hatched blastocysts treated with or without lecithin after 24 and 48 h in culture were not significantly different (100 versus 100% and 93.3 versus 100%, respectively). In Experiment 2, the in vitro survival of frozen-thawed IVMFC blastocysts was compared when cryoprotectant solutions were either supplemented or not with lecithin. No significant effect of lecithin was found on the ability of frozen-thawed blastocysts to re-expand after 48 h in culture (65.6 and 54.2%, respectively). However, the post-thaw hatching rate of embryos cryopreserved in the presence of 0.1% lecithin was significantly higher after 72 h in culture (52 and 31.8%, respectively). In Experiment 3, the ability of frozen-thawed IVMFC blastocysts to establish pregnancy following single embryo transfer was determined. Transfers of 58 and 66 frozen-thawed embryos cryopreserved with or without lecithin resulted in 6 and 10 (10.3 and 15.1%, respectively) confirmed pregnancies at Day 60. Addition of lecithin to cryoprotectants did not improve the in vivo development rate of cryopreserved IVMFC bovine blastocysts.

Fermentation of green alga sea-lettuce (Ulva sp) and metabolism of its sulphate by human colonic microbiota in a semi-continuous culture system.

The green alga, sea-lettuce (Ulva sp), could be considered as a new source of dietary fibre. Ulva, however, contains high levels of sulphate, part of which is chemically bound in soluble polymers (ulvan). The purpose of this study was to assess the fermentation characteristics and sulphate metabolism of Ulva and ulvan by human faecal bacteria fermentation system using a semi-continuous fermenter. Ulva and ulvan were poorly fermented, even after adaptation of the microbiota. Only 16.6% and 8.9% of Ulva and ulvan organic matter, respectively, were recovered as short chain fatty acids. Nevertheless, 40% of the sulphate in Ulva was dissimilated to sulphide by sulphate-reducing bacteria. Supplementation of Ulva with more fermentable polysaccharides, such as algal xylan and resistant starch, though decreasing the ammonia production originating from Ulva protein degradation, did not significantly reduce the sulphide levels. It is postulated that unless crude Ulva is desulphated, its daily consumption at a level of 20 g of dry product could stimulate colonic microbial sulphate reduction, which may have detrimental effects for the host.

Effects of TENS and topical skin anesthesia on soleus H-reflex and the concomitant influence of skin/muscle temperature.

The purpose of this study was to determine, in ten healthy subjects, the extent of soleus motoneuronal excitability during conditions of increased (transcutaneous electrical nerve stimulation [TENS]), decreased (Xylocaine [lidocaine]a anaesthesia) and normal (placebo anaesthesia) cutaneous inputs. Increased cutaneous activity was evoked using a TENS unit, with the two pairs of electrodes placed respectively over the Achilles (S2 dermatome) and tibialis anterior (L5 dermatome) tendons. Experimental and placebo topical anaesthesia were obtained after rubbing Xylocaine (5%) and Vaselineb ointment, respectively, on the skin surface overlying the Achilles tendon. Sets of ten H-responses (Hmax/2) were evoked at a frequency of 1 shock/30s and averaged at regular time intervals before, during and after the testing conditions. The results showed a gradual increase (up to 40% after 20 minutes) of H-reflex amplitude during TENS regardless of whether it was applied on the L5 or S2 dermatome. Furthermore, placebo anesthesia (Vaseline) caused the same gradual facilitatory response (up to 100% after 50 minutes) as that obtained during Xylocaine anaesthesia. Power spectral analysis of the H-responses obtained over time showed that the increase in the peak-to-peak H-response value was accompanied by a shift of the spectral content toward low frequencies. This shift occurred concomitantly with a cooling of the skin overlying the soleus muscle.

Randomized trial of adjuvant chemotherapy for operable breast cancer comparing i.v. CMF to an epirubicin-containing regimen [see comment].

From January 1985 to December 1987, 228 women with breast cancer smaller than 3 cm were treated by surgery +/- radiotherapy. All of them had axillary node involvement (N+) and/or lacked estrogen and progesterone steroid receptors (EPR-). They were randomized in an adjuvant chemotherapy trial comparing 9 intravenous CMF courses (cyclophosphamide, methotrexate, 5FU)--113 patients--to a polychemotherapy consisting of 3 courses of MTV (mitomycin C, thiotepa, vindesine) plus 3 courses of EVM (epirubicin, vincristine, methotrexate)--115 patients. Prognostic factors were well balanced between the two treatment groups. With a 59-month median follow-up, local breast relapses are more frequent in the CMF group, but regional and metastatic recurrences are the same in the two groups. Overall survival is identical. Toxicity is different: alopecia and neurotoxicity are more frequent in the MTV+EVM group, but general and digestive toxicities are equivalent. Haematologic toxicity is greater in the CMF group, requiring more frequent dosage reductions.

[Intraoperative nitroglycerin: value of determining individual doses: (surgery of the abdominal aorta)]. / Trinitrine per opératoire: intérêt d'une posologie individuelle: (chirurgie de l'aorte abdominale).

Thirteen patients requiring infrarenal aortic clamping were studied during flunitrazepam, fentanyl, pancuronium and nitrous oxide anaesthesia. Each awake patient was submitted to a volume loading test to determine the haemodynamic status and his optimal left pre-load. Anesthetic induction was well tolerated. Nitroglycerin was administered by continuous infusion before aortic clamping and we determined the dose necessary to decrease the systemic vascular resistance by 20 per cent. This dose was very variable and needed to be increased in five of 13 patients at the time of clamping. With nitroglycerin, we noticed no significant alteration of MVO2 at clamping. Volume loading allowed good stability at declamping.

Adjuvant trial for stage II receptor-positive breast cancer: CMF vs. CMF + tamoxifen in a single centre.

The purpose of a randomized trial achieved in a single centre (Fondation Bergonié, Bordeaux, France) was to compare chemotherapy alone (intravenous CMF) versus chemotherapy and hormonotherapy (CMF plus tamoxifen-30 mg per day during 2 years), for patients with stage II breast carcinoma and positive values of estrogen and/or progesterone receptor (EPR) (greater than 10 and greater than 15 fmoles mg protein-1 respectively). Three hundred and thirty four women treated by surgery +/- radiotherapy are included in this trial from 06.01.81 to 12.31.84. No patient is lost for follow-up. Eight are excluded. Three hundred and twenty six patients are evaluable with a 38 month median follow-up. For EPR assay, the dextran charcoal micromethod was used in the same centre. The two groups are identical as far as age, hormonal status, TNM, EPR values, and histological features are concerned. Analysis of results shows a significant improvement of relapse free survival (p = 0.018) and also overall survival (p = 0.04) for the CMF+ tamoxifen group.

Effects of phosphorus deficiency on rumen microbial activity associated with the solid and liquid phases of a fermentor (Rusitec).

The rumen simulation technique (Rusitec) has been used to study the effects of phosphorus (P) deficiency on bacterial protein synthesis and chemical composition and on adenosine triphosphate (ATP) concentrations in the solid and liquid phases of fermentors. 16 g DM of a P-deficient mixed diet was put into each vessel daily and the vessels were infused with about 1 l of a P-deficient (0 mg of P) or P-supplemented (120 mg of P/l) buffer. Two vessels per treatment were used, and during a second experimental period the deficient and supplemented buffers were interchanged to determine the effects of P repletion and depletion. The proportion of bacterial N directly incorporated from dietary amino acids or peptides was greater in solid-associated bacteria (SAB) than in liquid-associated bacteria (LAB) (46 vs 19%). P deficiency increased this proportion in both bacterial populations. Protein synthesis associated with the solid phase represented about 30% of the total protein synthesis in the system. P deficiency induced a marked decrease in microbial protein synthesis in both phases. Microbial yield declined by about 5 points (g of N/kg OMF) in P-deficient conditions. ATP concentrations were greatly reduced in both phases but P deficiency had no effect on protozoal numbers. The effects of P depletion during period II were similar to those of P deficiency in period I, and P repletion showed that the effects of P deficiency were almost entirely reversible.

[Influence of dietary factors on microbial protein synthesis in the rumen]. / Influence des facteurs alimentaires sur la protéosynthèse microbienne dans le rumen.

The effect of dietary factors (usually controlled in practice) on microbial protein synthesis is reviewed using in vivo experiments. Attention is drawn on the necessity to clearly distinguish variations in microbial growth efficiency from those of intestinal flow of microbial protein and to consider simultaneously variations in feed protein degradation. In practice, the relationship between microbial protein synthesis and energy intake depends mainly on diet composition and the nature of the forage. Microbial protein flow to the intestine, relative to energy intake, is lower with high concentrate diets (when given in restricted amounts), with silages and with antibiotic supplements. This flow is increased by some forage processing (such as dehydration and alkali treatments), by natural or induced defaunation, and occasionally by increased feeding frequency (when intake is restricted) and buffer and vitamin supplements. However, with some factors such as feeding frequency and antibiotics supplementation, these variations are partly counterbalanced by reverse effects on feed protein degradation.

[Effect of diets low in phosphorus and high in dietary calcium on phosphatemia and phosphorus and calcium levels in rumen contents of sheep]. / Influence d'une subcarence en phosphore et d'un excès de calcium alimentaire sur la phosphatémie et les teneurs en phosphore et calcium des contenus de rumen du mouton.

Four semi-purified diets with different calcium (Ca) and phosphorus (P) contents were given to adult sheep at a level of 1 kg daily plus 100 g of straw. The phosphorus was supplied as dicalcium phosphate, almost insoluble in rumen fluid. In the preliminary period, all the animals (16) were fed the test diet (NCa-NP) containing 8.4 g of Ca and 3.3. g of P. In the experimental period (table 3) two trials were carried out. In trial 1, two groups of 5 sheep each were given for 5 weeks a diet low in P (1 g/kg) and either low (2 g/kg) (diet BCa-BP) or high (10 g/kg) (diet HtCa-BP) in calcium. In trial 2, which lasted for 19 weeks, the HtCa-BP diet was compared to a high Ca (10 g/kg) normal P (3.3 g/kg) diet (diet HtCa-NP); two groups of 2 sheep each were fed both these diets every 3 hours, and one group (HtCa-BP) was fed twice daily. The concentration of ultrafilterable inorganic Ca (CaiU) in the rumen contents was related to the Ca level of the diet (tables 4, 5). However, individual variations were high and CaiU concentrations were negatively correlated to rumen pH (fig. 7). When diets adequate in P were fed, ruminal concentrations of ultrafilterable P (PiU) were rather high (400-490 mg/l), showing the importance of endogenous P supply in the rumen. With an adequate P supply, a high Ca intake had no effect on either plasma or ruminal PiU. When low P diets were fed, there was a steady decrease in plasma Pi from 6 to 3.5 mg P/100 ml and in ruminal PiU from 500 mg/l to values lower than 300 mg/l up to 5-6 experimental weeks. These decreases were greatest with high Ca intake (HtCa-BP diet) (figs. 2, 3), some animals being markedly affected (ruminal PiU values lower than 20 mg/l). However, the decreases in ruminal PiU were less pronounced with frequent feeding than with feeding twice a day. Considering all the results obtained, ruminal PiU concentrations were positively correlated with plasma Pi concentrations (r = + 0.77; n = 75) (fig. 8). Therefore, high Ca intake can enhance the response to P deficiency and reduce further plasma Pi concentrations and levels of available P in the rumen. Microbial P requirements may not be satisfied in such conditions, which would reduce ruminal microbial digestion in some animals.