Influence of acute renal failure on FPIA rapid serum assay of midazolam and its main metabolite.

We recently developed a simple and fast assay technique, providing the possibility of monitoring of midazolam (M) during sedation. We compared HPLC vs FPIA for the measurement of the sum M plus alpha 1-hydroxymidazolam (OM), its main and pharmacologically active metabolite, in the serum of sedated ICU patients; this activity referred to as M-like. We identified certain patients in whom M-like activity appeared abnormally high in comparison with HPLC assays. Their common denominators were: long-term sedation with M, and seriously impaired renal function. Further, the conjugates of OM (OMG) accumulated in patients with acute renal failure could contribute to the sedation. We compared the metabolic and analytic behavior of M, OM, and OMG in 2 groups of sedated patients either presenting with normal renal functions (group 1) or with a picture of acute renal failure (group 2). Blood samples were assayed by HPLC and by FPIA and analysis was performed before and after hydrolysis of OMG. Before hydrolysis there was a dramatic accumulation of OMG in the patients of group 2, HPLC vs FPIA results were not different within group 1, while in group 2 the FPIA response exceeded that of HPLC. After hydrolysis, measurement by HPLC was greatly increased in group 2, in each group (vs HPLC) and from one group to another, the FPIA signal (the M-like activity) showed a significant increase. It would be important to take OMG into account as a coprotagonist in sedation whenever circumstances predispose to its accumulation.

[Revision intranasal sphenoethmoidectomy in recurrent nasosinusal diseases especially polyposis]. / Sphénoethmoïdectomie intranasale de révision dans les affections naso-sinusiennes récidivantes notamment les polyposes.

A 16 case series of intranasal revision sphenoidecthmoidectomies is presented in this study concerning 10 patients with recurrent polyposis after 245 intranasal ethmoidectomies performed between 1986 and 1990 (6.5%). The modalities of surgical decision are precisely described, pointing out the correlation between clinic and endoscopic arguments. The CT-Scan is particularly appreciated for the details of recurrence sites and the anatomical dangers along these recurrences. Comparison is established with the most recent publications in this field and the discussion is open to express the rules of this surgery. 80% of good and excellent results are obtained in this series, justifying the procedure. The causes of bad results are evocated, especially allergy and the age of polyposis.

[Sinusitis of the middle turbinate. Descriptive study and treatment]. / Sinusites du cornet moyen. Etude descriptive et traitement.

The middle turbinate inflammatory disease is a well a clinical as a radiological reality which is often unknown because of the rich sinusal surrounding diseases. This pathology represents less than 2% of the total sinusal pathologies we meet daily, and it always occurs on a concha bullosa: the middle turbinate becomes a real sinusal cavity with its own diseases. The new methods of diagnosis, nasal endoscopy and CT scanning, let identifie this turbinal own pathology better than ever. The authors emphasize a surgical treatment.

[Giant cementifying fibroma of the maxillary sinus. Apropos of a case]. / Fibrome cémentifiant géant du sinus maxillaire. A propos d'un cas.

The case of a patient presenting with a gigantiform fibrous cementoma of the maxillary sinus is described. The diagnostic, the treatment and the histologic classification of the cementifying tumours is reviewed in light of the present literature.

[The evaluation of different techniques used in the treatment of cholesteatomas (author's transl)]. / Evaluation des différentes techniques utilisées dans le traitement des cholestéatomes.

The authors study the results of surgical treatment of cholesteatomas on the basis of 748 records of chronic otitis - active or dry. Firstly at the time of eradication of lesions with a curative intention, amongst 152 cholesteatomas discovered, they noted that the result was successful in almost all cases following complete removal, contrasting with the frequent recurrence (25 to 30%) seen after other techniques. Subsequently, following closure of the ear by tympanoplasty or homograft, there was recurrence of cholesteatoma in one case out of 3 despite severe patient selection. In conclusion, the authors feel that the greatest caution should be exercised in treatment with conservative or reconstructive aims, the indications of which must be based not only on otological factors but also personal factors in the patient.

[Malherbe's calcifying cyst. Apropos of an unusual case in the middle ear. Histopathogenic value]. / Kyste momifié de Malherbe. A propos d'un cas exceptionnel de l'oreille moyenne. Intérêt histopathogénique.

We report the case of a 54 years old man suffering with chronic otorrhea. The surgical procedure let us be surprised at a non specific cyst located in the "additus ad antrum", close to the incus but no damaging it. The result of the histologic examination was: Malherbe's calcifying cyst. After a background study of the publications concerning this type of tumor specially located in the skin, we can affirm this localisation in the middle ear cavity as exceptional. The cutaneous origin of this tumor and its vestigial type let us think about the possible persistence of amniotic fluid cellular content (AFCC) in the middle ear and its tumoral development in adult, explaining maybe partly the chronic otorrhea syndrome of this case.

[Hazards and complications of ethmoidal surgery]. / Dangers et complications de la chirurgie éthmoïdale.

The most important publications concerning the complications following transnasal ethmoid surgery are reviewed by the authors who underline the dangers in this type of surgery: meninges, the orbit and orbital elements especially the muscles, the extra-orbital portion of the optic nerve and the internal carotid artery. A great prudence during surgical procedure is emphasized as well as the necessity of a perfect knowledge in scannographic and endoscopic anatomy of ethmoid to avoid the inflation of these complications.

[The mucociliary velocimetry test]. / Le test de vélocimétrie mucociliaire (V.M.C.).

The mucociliary velocimetry test (M.C.V.) appreciates the functional status of the maxillary sinuses chronically affected by the way of a colorimetric index with a double T prosthesis. The patient is laying in decubitus with 10 degrees of proclivity neither general or local anesthetic. A fibroscope is passed through the "Double T", three drops of blue of methylene are set down in the sinusal cavity. The time recording starts at this moment. The route of the blue is followed with the optic are far as the ostium. A first timing T1 is recorded then, the fibroscope is located in the nasal fossa facing the ostium. When the blue appears a second timing T2 is recorded. T1 give the value of the sinusal function; T1 + T2 the value of the ostio sinusal function and T2 - T1, the value of the ostial function.

[Meningeal injury during surgery of the ethmoid sinus: endoscopic treatment using surgical glue]. / Plaie méningée au cours de la chirurgie ethmoïdale: traitement endoscopique par colle chirurgicale.

A case of a meningeal injury with CSF leak due to intranasal ethmoidal surgery is reported. Fibrinogen glue was used for the endoscopic repair. The importance of the immediate follow-up is stressed. The literature is revised.

Comparison of high-performance liquid chromatography and polyclonal fluorescence polarization immunoassay for the monitoring of midazolam in the plasma of intensive care unit patients.

Midazolam (M) is used as an induction agent for anesthesia. The main metabolite is alpha-hydroxymidazolam (OM), which is pharmacologically active. Use of M for sedation is a recent application, rapidly gaining favor. Monitoring of the level of sedation is fundamental in that an excessive and prolonged effect is associated with the risk of complications. Thus, it was felt both necessary and useful to measure circulating M levels. We compared a high-performance liquid chromatography (HPLC) assay with fluorescence polarization immunoassay (FPIA) for the measurement of M in the serum of 138 sedated patients in the intensive care unit (i.e., 179 samples). Response of the OM was also assessed. The degree of crossover of the metabolite was between 76.8 and 32.7%. The equation of the regression line for sigma HPLC (i.e., the sum M + OM) versus FPIA was TDx = 1.1585 sigma HPLC + 143.42 (R = 0.966). The 95% confidence interval for the slope was 1.1551, 1.1619. The regression slope differed significantly from 1 (p < 0.001) and shows that FPIA measurements overestimated concentrations obtained by HPLC on the order of 19%. The discrepancy between the two techniques was all the more notable when concentrations were > 1,000 ng/ml. The relative selectivity of Abbott industrial reagent in terms of benzodiazepines leads to the identification of what might be called a midazolam-like (M-like) activity covering both M and OM. The development of a global FPIA method for measurement of this M-like activity in sedated patients provides a satisfactory solution to the question raised.