Non-invasive mechanical ventilation with average volume-assured pressure support. Results according to the aetiology of acute respiratory failure.

INTRODUCTION: Until now, the ventilatory strategy with BiPAP S/T plus average volume-assured pressure support (AVAPS) has not been evaluated for its use in the different types of acute respiratory failure (ARF). Consequently we report the results of the use of this ventilatory strategy in these clinical scenarios. MATERIAL AND METHODS: This is a single-centre prospective study. The subjects were categorised according to the type of ARF: (1) hypercapnic ARF: chronic obstructive pulmonary disease and bronchial asthma; and (2) hypoxaemic ARF: pneumonia, acute respiratory distress syndrome, congestive heart failure, and interstitial lung disease. Multiple logistic regression was used to determine predictors of non-invasive mechanical ventilation (NIV) failure (intubation). Further, in a subgroup of patients with de novo hypoxaemic ARF, analysis of variances with repeated measures was used to determine factors associated with NIV outcome. RESULTS: Sixty-eight subjects were included in this study. The NIV success rate was 69.1% and the mortality rate was 20.6%. A multivariate analysis showed that the number of affected lung quadrants on chest X-ray (OR: 4.23, 95% CI: 4.17-4.31; P < 0.001) and ARF precipitating disease (OR: 4.46, 95% CI: 4.43-4.51; P < 0.001) were determinants of NIV failure. In the hypoxaemic ARF subgroup (n = 58), significant differences in several parameters were found between patients with positive and negative outcomes. CONCLUSIONS: The use of BiPAP S/T - AVAPS in subjects with hypercapnic ARF is associated with a better outcome than in those with de novo hypoxaemic ARF.

Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique.

While narghile water pipe smoking has become a global phenomenon, knowledge regarding its toxicant content and delivery, addictive properties, and health consequences is sorely lagging. One challenge in measuring toxicant content of the smoke in the laboratory is the large number of simplifying assumptions that must be made to model a "typical" smoking session using a smoking machine, resulting in uncertainty over the obtained toxicant yields. In this study, we develop an alternative approach in which smoke generated by a human water pipe user is sampled directly during the smoking session. The method, dubbed real-time in situ sampling (RINS), required developing a self-powered portable instrument capable of automatically sampling a fixed fraction of the smoke generated by the user. Instrument performance was validated in the laboratory, and the instrument was deployed in a field study involving 43 ad libitum water pipe use sessions in Beirut area cafés in which we measured inhaled nicotine, carbon monoxide (CO), and water pipe ma'ssel-derived "tar." We found that users drew a mean of 119 L of smoke containing 150 mg of CO, 4 mg of nicotine, and 602 mg of ma'ssel-derived "tar" during a single use session (mean duration = 61 min). These first direct measurements of toxicant delivery demonstrate that ordinary water pipe use involves inhaling large quantities of CO, nicotine, and dry particulate matter. Results are compared with those obtained using the Beirut method smoking machine protocol.

The immediate effects of cervical spine manipulation on pain and biochemical markers in females with acute non-specific mechanical neck pain: a randomized clinical trial.

Study Design: Randomized clinical trial with pre-test, post-test control group design. Objectives: To examine the immediate effects of cervical spinal manipulation (CSM) on serum concentration of biochemical markers (oxytocin, neurotensin, orexin A, and cortisol). Background: Several studies have found an association between spinal manipulation (SM) and pain perception. However, the mechanism by which SM modulates pain remains undefined. Methods: Twenty-eight female subjects with non-specific mechanical neck pain were randomly assigned to one of two interventions (CSM versus sham CSM). Blood samples were drawn before and immediately after the respective interventions. Oxytocin, neurotensin, orexin A, and cortisol were measured from the blood and serum using the Milliplex Map Magnetic Bead Panel Immunoassay on the Luminex 200 Platform. Results: In the CSM group, there were significant increases in pre- versus post-manipulation mean oxytocin (154.5 ± 60.1 vs. 185.1 ± 75.6, p = .012); neurotensin (116.0 ± 26.5 vs.136.4 ± 34.1, p < . 001); orexin A (52.2 ± 31.1 vs. 73.8 ± 38.8, p < .01) serum concentration; but no significant differences in mean cortisol (p = .052) serum concentration. In the sham group, there were no significant differences in any of the biomarkers (p > .05). Conclusion: The results of the current study suggest that the mechanical stimuli provided through a CSM may modify neuropeptide expression by immediately increasing the serum concentration of nociception-related biomarkers (oxytocin, neurotensin, orexin A, but not cortisol) in the blood of female subjects with non-specific mechanical neck pain.

Monoclonal antibodies against oncofetal mucin M1 antigens associated with precancerous colonic mucosae.

We obtained seven monoclonal antibodies (MAb) against a gastric mucin of an ALeb patient. By immunoperoxidase on normal gastric mucosae, two MAbs (3-3A and 2-25 LE) reacted exclusively with the A and Lewis-positive individuals, respectively; the five other MAbs (1-13 M1, 2-11 M1, 2-12 M1, 9-13 M1, and 58 M1) stained the mucus cells of surface gastric epithelium independently of ABO or Lewis status. They did not stain normal colonic mucosae, but did stain fetal and precancerous colonic mucosae. Using serial sections, each anti-M1 MAb stained the same goblet cells in fetal and precancerous colon. Extensive search of other normal tissues showed that M1 antigens were restricted to the epithelium embryologically derived from the foregut (gastric and bronchial epithelium) and from Müllerian ducts (mucus cells of endocervix and prostatic utriculus). Some differences in the reactivities of the various anti-M1 MAb were observed in subesophageal, subtracheal, and endocervical mucus cells, suggesting that each anti-M1 MAb characterized a different M1 epitope. A mixture of these five anti-M1 MAbs allowed the estimation of M1 mucus modification in the precancerous colonic mucosae with a sensitivity near to that obtained with polyclonal anti-M1 antibodies. Papain and mercaptoethanol treatments destroyed the M1 epitopes, at variance with the A- or Lewis-related antigens. Our results therefore suggest that the expression of M1 epitopes in precancerous colonic mucosae cannot be due exclusively to alterations in mucin glycosylation but may be related to the reexpression of antigens associated with native gastric mucin which is normally produced by the fetal colon during the sixth month of gestation.

Early oncofetal antigenic modifications during rat colonic carcinogenesis.

M1 antigens, associated with adult rat surface gastric epithelium and which are present in fetal but not adult distal colon, were investigated in this colonic mucosa during carcinogenesis. Fifty Wistar rats were given s.c. injections of 1,2-dimethylhydrazine for 28 weeks. Using an immunohistochemical method, M1 antigens associated with goblet cells were shown to be present after 2 weeks of 1,2-dimethylhydrazine treatment in histologically normal mucosa and then in 78% of mucinous hyperplasia and polypoid-like glands, in 54% of hyposecreting glands, in 58% of dysplasias, Grades 1 and 2, in two of 12 dysplasias, Grade 3, and in five of five transitional mucosas adjacent to carcinoma. The production of sialomucins associated with M1 antigens was often seen in the same histological lesion, although not always associated in the same goblet cells. The number of these histological lesions as well as the production of M1 antigens increased with the number of injections. Thus, these antigenic changes of an oncofetal nature can be regarded as early transformations of goblet cell differentiation in colonic mucosa subjected to chemical carcinogen.

A new mucin-associated oncofetal antigen, a marker of early carcinogenesis in rat colon.

We report the characterization of an IgG2a monoclonal antibody, (MAb) 660, prepared against rat gastric high molecular weight glycoproteins. By immunoperoxidase staining, MAb 660 reacted only with the mucous cells of surface gastric epithelium and with a few duodenal goblet cells close to the pylorus in normal adult rats. In fetuses, it reacted with intestinal and colonic goblet cells. The adult colon was always negative. The MAb 660 stained 100% (30 of 30) of chemically induced colonic carcinomas and 100% (7 of 7) of duodenal carcinomas. Several weeks before the appearance of tumors, histologically normal glands, then hyperplasia and dysplasia were precociously stained with MAb 660. The tissue distribution was different from that of blood group related antigens and M1 fucomucins. The recognized antigen was not sensitive to neuraminidase treatment. After electrophoresis in polyacrylamide gel, staining with periodic acid-Schiff reagent and Western blotting showed that the MAb 660 recognized an epitope associated with high molecular weight glycoproteins. This epitope was unaffected by beta-mercaptoethanol reduction-periodate treatment and neuraminidase and trypsin digestion. However, trypsin digestion performed after beta-mercaptoethanol reduction destroyed the 660 epitope. These data suggest that the antibody could recognize the peptide moiety of the mucin rather than its carbohydrate moiety. Thus, the new antigen identified by MAb 660 is a mucin-type glycoprotein with an oncofetal behavior in the rat colon and is precociously expressed by precancerous colonic mucosa.

Immunohistological study of precancerous mucus modification in human distal colonic polyps.

The M1 antigens associated with gastric fucomucins, oncofetal markers of the distal colonic mucosa, were demonstrated to be more closely associated with adenomas [92 of 139 (66%)] than with invasive adenocarcinomas [27 of 218 (12%)]. They were always expressed in tumors containing the M3 antigen normally associated with the intestinal mucus. The M1 antigens, present in 100% of hyperplastic polyps (30 of 30), were not specific for a particular histological type of adenoma but were found to be more closely associated with those showing a villous differentiation [41 of 47 (87%)] than with those having a tubular pattern [51 of 92 (55%)]. The presence of these M1 antigens depended neither on the size nor on the degree of cytological atypia of the nodular adenomas. However, M1 antigens were found in 94% of the adenomas (35 of 37) concomitant with adenocarcinomas; in contrast, only 56% of adenomas (55 of 102) observed on noncancerous mucosa contained these M1 antigens. As already demonstrated during rat colonic carcinogenesis, mucus modification characterized by the presence of M1 antigens could represent early molecular changes occurring before malignant transformation related to a chemical carcinogen. These M1 antigens might be regarded as early precancerous markers of an oncofetal type, associated with human distal colonic mucosa.

[Prepubic TVT: a prospective study of 164 female patients treated for stress urinary incontinence]. / TVT prépubien. Etude prospective longitudinale dans le traitement de l'incontinence urinaire d'effort de la femme: à propos de 164 cas.

OBJECTIVE: A prospective open study was conducted to evaluate the prepubic (TPP) route of TVT. PATIENTS AND METHODS: 164 patients suffering from stress or mixed urinary incontinence were operated by prepubic route mainly under spinal anaesthesia. The incision is more proximal and para-uretral dissection directed more lateral to reach ischiopubic bone. The tape is introduced while keeping the needle tip close to bone to perforate between bone and ischiocavernous muscle. Then the needle is brought forwards to get its tip in vertical position and pushed under vulva to supra pubic area. A cough test is done with more pulling than in TVT since in TPP the pulling forces will act more frontally and laterally. Evaluation included detailed clinical examination with stress test, pads, endoscopic and urodynamic assessments and questionnaires in order to detect prognostic factors and to have a global treatment policy for associated low urinary tract symptoms and prolapse. RESULTS: Mean follow-up time was 20 months (14-30). No significant intraoperative complications occurred. All patients urinated the first day. The mean postvoid residual urine was 45 ml. Objective cure rate was achieved in 135 (82.3%) patients and 7 (4.3%) patients were improved while failure was observed in 22 (13,4%) patients. From patients'point of view success and satisfaction rates were 85.4% and 86%. No significant modification of sexual activity occurred. DISCUSSION AND CONCLUSION: TPP is a simple technique with very low risks and the preliminary results are consonant with those of other published techniques.

Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V.

Three hundred six children with probable Group A beta-hemolytic streptococcal pharyngitis were enrolled in a randomized double blind trial to compare the effects of immediate vs. delayed treatment with oral penicillin V. Among the 229 culture-positive patients, 111 were randomly assigned to receive penicillin V immediately and 118 to receive a placebo for 48 to 52 hours followed by penicillin V. Patients were evaluated clinically for 48 to 52 hours following initiation of treatment. The Streptozyme test was used to measure acute to convalescent antibody titer. Both regimens resulted in a greater than 92% cure rate. Early treatment was associated with significantly fewer and milder signs and symptoms on Day 3 and a significantly lower rise in the antibody titer. On the other hand we found 8 (7%) relapses and 18 (16%) early and 14 (13%) late recurrences in this group; all were significantly higher than the corresponding numbers of 2 (2%), 6 (5%) and 4 (3%), respectively, in the late treatment group. This study shows the beneficial effect of early treatment with penicillin V on the clinical course of Group A beta-hemolytic streptococcal pharyngitis. This study also shows that delayed penicillin treatment may be associated with a lower incidence of subsequent Group A beta-hemolytic streptococcal pharyngitis.

Radioimmunolocalization of the monoclonal antibody J28 in early transformation stages in N-nitrosobis(2-hydroxypropyl)amine-induced pancreatic tumors in the Syrian golden hamster.

We describe the in vivo localization of radiolabeled mAb J28, a murine monoclonal antibody characterizing the oncodevelopmental human fetoacinar pancreatic (FAP) protein, at different stages of chemical induction of pancreatic tumors in the Syrian golden hamster. Before doing localization studies in this model, we looked at the cross-reactivity of mAb J28. Semiquantitative dot-blot analysis demonstrated that the antigen recognized in hamster pancreas has an oncodevelopmental expression pattern, while a molecular mass identical to that of human FAP was deduced from sodium dodecyl sulfate/polyacrylamide gel electrophoresis/nitrocellulose immunoblot. 125I-labeled mAb J28 was administered through micro-osmotic pumps to hamsters treated with N-nitrosobis(2-hydroxypropyl)amine (BHP). This was done at three intervals that roughly correspond to the latent period, pretumoral stages, and terminal cancerogenesis in two independent groups of hamsters. Both studies allowed similar results: (a) mAb J28 accumulated almost specifically in the pancreas; (b) maximal accumulation was associated with pleomorphic alterations of the acinar cell tissue at pretumoral stages; (c) no accumulation was found in the case of adenocarcinoma of the pancreas. It is concluded that FAP behaves as a marker of preneoplastic lesions, and therefore that radioimmunoimaging with mAb J28 might help with early diagnosis of pancreatic cancer.

An immunohistologic study of the feto-acinar pancreatic protein (FAP) in the normal pancreas, chronic pancreatitis, pancreatic adenocarcinoma, and intraabdominal metastases of adenocarcinomas.

The immunohistologic distribution of the feto-acinar pancreatic protein (FAP), detected by the monoclonal antibody (MoAb) J28 using an indirect immunoperoxidase technique, is described. Tests were carried out on normal adult pancreas (n = 10), chronic pancreatitis (n = 14), pancreatic adenocarcinoma (n = 17), intraabdominal metastases of pancreatic and nonpancreatic origin (n = 22), metastatic tumors invading the pancreas (n = 3), nonpancreatic fetal (n = 39) and adult (n = 65) normal organs (n = 104), and nonpancreatic malignancies (n = 145). All sections were formalin fixed and paraffin embedded. In the normal pancreas, only a few positive acinar cells were found around some islets of Langerhans. In pancreatitis there was an increased expression of FAP protein in the acinar tissue in relation to inflammatory changes. In cases of primary pancreatic adenocarcinoma and metastatic tumors in the pancreas, a strong expression of FAP protein in the peritumoral acinar area was found. The tumors themselves were FAP protein negative, as were the nonpancreatic tumors and normal organs. It can be concluded that FAP protein, detected by MoAb J28 in tissue sections, is specific for pancreatic exocrine tissue with reactive changes.

Antifungal susceptibility of Candida isolates at the American University of Beirut Medical Center.

For the first time from Lebanon, the antifungal susceptibility patterns of 70 consecutive clinical candida isolates (each from one patient) representing 48 C. albicans, 12 C. tropicalis, 6 C. parapsilosis, 2 C. kruseii, and 2 C. (Torulopsis) glabrata were studied against amphotericin B (AP), 5-fluorocytosine (FC), ketoconazole (KE), fluconazole (FL), and itraconazole (IT) using the Epsilometer test (E-test; AB Biodisk, Solna, Sweden). The MIC90 (and MIC range, mg/l) determined, at 24 h incubation, for each antifungal agent against C. albicans were: AP 0.032 (< or = 0.002-0.064), FC 0.75 (0.023-2), KE 0.064 (0.002- > 32), FL 2 (0.064- > 256), and IT 0.19 (0.012-2), against C. tropicalis were: AP 0.016 (< 0.002-0.047), FC 0.125 (0.023-0.19), KE 0.094 (0.012-0.19), FL 2 (0.5-2), and IT 0.5 (0.047-1) and against C. parapsilosis were: AP < 0.002 (< 0.002-0.002), FC 0.047 (0.003-0.5), KE 0.004 (0.002-0.004), FL 0.125 (0.032-0.19), and IT 0.004 (< 0.002-0.004). Based on the NCCLS established MICs breakpoints, resistance was found among C. albicans to FL (MIC > or = 6 mg/l) and IT (MIC > or = 1 mg/l) in 6 and 4%, respectively, and among C. tropicalis to IT in 17% of the isolates. The susceptibility dependent upon dose (S-DD) was noted only to IT (MIC 0.25-0.5 mg/l) among C. albicans (8%) and C. tropicalis (58%). MICs determination at 48 h incubation were higher, showed more resistance rates and more endpoint trailing particularly with the azoles drugs. The small numbers of C. kruseii and C. glabrata preclude providing meaningful results. Thus, this study indicates that the antifungal susceptibility by E-test can be conveniently incorporated and performed in a hospital-based clinical laboratory. Despite the uniform susceptibility to AP and FC, resistance to azoles drugs is encountered in a range of 4-17% among candida isolates in this country.

Varicella pneumonitis: clinical presentation and experience with acyclovir treatment in immunocompetent adults.

OBJECTIVE: Cases of varicella pneumonitis were reviewed to examine the effects of acyclovir therapy on outcome. METHODS: A retrospective chart review was done of all admissions of adults to two hospitals, between 1985 and 1995, because of complications of chickenpox. RESULTS: Fifteen patients were hospitalized for varicella pneumonitis during this period. No patient had a history of chickenpox as a child; all had a recent history (within 2-4 weeks prior to admission) of exposure to chickenpox in their family or neighborhood and developed respiratory symptoms 1 to 4 days after the appearance of the rash. Twelve patients (80%) had a history of cigarette smoking, and seven patients had a platelet count below the normal range. All patients were treated with intravenous acyclovir within 24 hours of admission, and all but one survived and were discharged from the hospital without comorbid conditions. The one mortality was attributed to bacterial superinfection. CONCLUSIONS: Acyclovir treatment may be of benefit for varicella pneumonitis, but no controlled trial has been performed to definitively answer this question.

Pre-pubic TVT: an alternative to classic TVT in selected patients with urinary stress incontinence.

OBJECTIVES: To evaluate in a prospective open study a pre-pubic route of TVT for surgical treatment of female stress incontinence. STUDY DESIGN: Consecutively, 74 patients were operated using a pre-pubic TVT tape application. All women were suffering subjectively and objectively from female stress urinary incontinence. The mean post-operative follow-up time was 5 months (range 2-10 months). The pre- and post-operative evaluations were performed according to a standard protocol. RESULTS: According to the protocol, 60 patients (81%) were cured of their stress incontinence symptoms. Another 10 patients (13%) were improved. Four patients (6%) were considered failures. There were no significant intra- or post-operative complications. CONCLUSION: The short-term results of pre-pubic TVT are consonant with those of classic TVT. The risks of intra-operative complications should be reduced by the pre-pubic route. If the long-term results of pre-pubic TVT are the same as those after classic TVT, then this surgical approach may be a tentative alternative in selected high-risk patients.

Monoclonal antibody against sialylated Lewis(a) antigen.

We isolated hybridoma cells, which secreted monoclonal antibody (MAb) 121 SLE, an IgM showing the following reactivities: (1) by immunodiffusion, MAb 121 SLE and MAb NS 19-9 (a monoclonal antibody directed against a sialylated Lewis(a) antigen called CA 19-9) showed an identical precipitin line with mucin preparation containing this CA 19-9; (2) by immunoradiometric assay, MAb 121 SLE totally inhibited fixation of radiolabelled MAb NS 19-9; (3) by immunoperoxidase, MAb 121 SLE stained the normal gastrointestinal mucosa of Le-positive individuals exclusively, and this staining disappeared after neuraminidase treatment, as observed using MAb NS 19-9. However, the pattern of the staining obtained with MAb 121 SLE differed slightly from that given by MAb 19-9 on the different positive areas of the gastrointestinal mucosae. These differences principally concerned the number of positive epithelial cells and the intensity of their staining; (4) moreover, antibodies against idiotype determinant of NS 19-9 antibody did not react with the antibody 121 SLE. We concluded that MAb 121 SLE is different from the MAb NS 19-9. However, both these antibodies were associated with the same molecular sialylated Lewis(a) structure.

[Intra-diverticular tumors of the bladder. Natural history and management perspectives]. / Tumeurs intra-diverticulaires de la vessie. Histoire naturelle et perspectives d'approche.

The review of the literature and our study of 15 tumors in bladder diverticula (IDT) show us that these tumors are rare and mainly observed in elderly adult males. Bleeding is the major symptom. Diagnosis is difficult and treatment is not well defined. Prognosis is good for low stage tumors and catastrophic in the short term for high stage tumors. Nearly half of IDT were primary tumors, and one third of them stay primary until death of the patients. Most of the high stage tumors contained a squamous cell differentiation and all the tumors with these features were deeply invasive. The bad prognosis is mainly related to the difficult and delayed diagnosis, with a long symptomatic period, regardless of treatment. This emphasizes the need for further investigations (biopsies, sonography, computer tomography) when the diagnosis is not evident. The treatment of these tumors depends on the general status of patients and the volume and stage of tumors. Low stage tumors (Ta) and diverticula could be treated either by transurethral resection or by open surgery with good results. In (T1) tumors, only open surgery is recommended to avoid loco-regional relapse. High stage tumors (greater than or equal to P T3) were treated by either TUR or open palliative surgery with the same bad prognosis. No radical treatment was indicated since patients have a bad performance status and most of the tumors extended beyond the diverticulum. Adjuvant treatments were not helpful. While preventive diverticulectomy is to be discussed case by case, we think that an important step in improving the prognosis of these tumors is to make the diagnosis at an earlier stage.

[Uro-colonic tumors. Etiopathogenic data and practical implications]. / Tumeurs uro-coliques. Données étiopathogéniques et implications pratiques.

The authors report a case of uro-colonic tumour developing four years after ureterosigmoidostomy in a male patient treated for invasive bladder tumour. After a current follow-up of five years for this colonic tumour, they studied their case in comparison with the data from the literature and the experimental model in order to better understand the natural history of these tumours. The following principal points are discussed: time to onset, histological nature and course of these tumours; essential elements in this type of carcinogenesis, practical clinical implications and follow-up of patients after ureterosigmoidostomy.

Recolonization of anesthetic instruments after regular treatment with potentially pathogenic organisms.

Anesthetic instruments are classified as classes B with regard to sterilization status. This means that washing with soap and water or other detergents is sufficient for reuse. A prospective study was conducted over a 6 month period in the operating (rooms) theatres at Princess Basma Teaching Hospital on anesthetic instruments including laryngoscopes, oxygen masks, airways, tracheal tubes and suction catheters. Fifteen different samples were taken randomly at different sites on these instruments after they had been prepared conventionally for use, and these samples were cultured for bacterial contamination (e.g. P. Aeruginosa). The results showed that potentially pathogenic bacteria were colonizing these instruments. It was concluded that these instruments are important vehicles for transmitting various agents of infection and play an important role in causing nosocomial infections. It is recommended that more effective methods be used for sterilizing these instruments.

[Bilateral ureteral stenosis after pancreatitis]. / Sténose urétérale bilatérale après pancréatite.

The authors report a rare case of bilateral ureteric stenosis associated with necrotic infiltration due to acute alcoholic pancreatitis. The obstruction was caused by bilateral ureteric fibrosis with calcified incrustations on the right side and massive obstructive calculi on the left side. Only one faintly similar case has been reported in the literature out of 17 cases of unilateral or bilateral ureteric stenosis complicating acute or chronic pancreatitis.