[Encapsulating peritonitis disclosing primary melanoma of the small intestine: a case report]. / Péritonite enccapsulante révélatrice d'un mélanome primitif du grêle: à propos d'une observation.

Encapsulating peritonitis is a chronic peritonitis leading to the constitution of the thick white nacred fibrosis membrane. It is a rare affection. Its physiopathology is poorly elucidated. Diagnosis is usually at operation. We report an unpublished case of a 36-year-old patient, admitted for an abdominal mass. The different investigations demonstrated small bowel tumor with entrapped ileal and jejunal loops within a capsule. Diagnosis was made at the time of operation by discovering an encapsulating peritonitis caused by a primary malignant melanoma of the small bowel, which is an exceptional affection.

Tratamiento del dolor y espasticidad en un caso de esclerosis lateral amiotrófica / Management of pain and spasticity in a case of amyotrophic lateral sclerosis

La esclerosis lateral amiotrófica (ELA) es una forma clínica del grupo de enfermedades de la motoneurona del adulto que designa un proceso degenerativo progresivo que aparece de forma esporádica y aislada, aunque se encuentran formas familiares. En cualquier caso es una enfermedad de pronóstico ominoso que se padece durante un promedio de tres años partiendo de los primeros síntomas. Paciente, material y métodos: Paciente de 45 años que en el transcurso de tres meses cursa con sintomatología propia de esclerosis lateral amiotrófica que se confirma con el estudio electromiográfico. Tras respuesta inicial a los antiespásticos por vía oral, con posterioridad resultan insuficientes para el control del dolor y espasticidad a pesar de usar dosis máximas de baclofeno y riluzol vía oral. Por ello se realiza dosis de prueba con morfina y baclofeno intratecal y posteriormente se inicia perfusión continua a través de catéter intratecal de bupivacaína, morfina y baclofeno. Resultados: Después de modificar las pautas de dosificación de morfina, bupivacaína y baclofeno intratecal, se consigue controlar el dolor y espasticidad. Conclusiones: La vía intratecal resulta efectiva en tratamiento del dolor y espasticidad de la ELA después de resultar ineficaz el tratamiento por vía oral. (AU)

Teicoplanin in cardiac surgery: intraoperative pharmacokinetics and concentrations in cardiac and mediastinal tissues.

The concentrations of teicoplanin in the sera and mediastinal and heart tissues of 23 patients undergoing cardiac surgery were measured after two regimens of teicoplanin administration. Intraoperative pharmacokinetic parameters were also obtained. Patients were randomized into two groups. Those in group 1 were given teicoplanin at 6 mg x kg(-1) intravenously at the time of induction of anesthesia. Patients in group 2 were given teicoplanin at 12 mg x kg(-1) during the same period. The maximum concentration in serum (71 +/- 20 and 131 +/- 44 mg x l(-1)), the minimum concentration in serum (3.6 +/- 1.3 and 6.8 +/- 2.1 mg x l(-1)), the area under the concentration-time curve (AUC) from 0 to 12 h (108 +/- 20 and 217 +/- 38 microg x h x ml(-1)), and the AUC from 0 h to infinity (154 +/- 36 and 292 +/- 77 microg x h x ml(-1)) were twice as high after 12-mg x kg(-1) injections as after 6-mg x kg(-1) injections. No differences in mean residence time (9.7 +/- 4.9 and 8.4 +/- 2.7 h) or terminal half-life (8.5 +/- 3.8 and 7.5 +/- 2.3 h) were observed. Teicoplanin penetrated mediastinal and heart tissues but not sternal bone, where the antibiotic was detectable in only 1 of 13 patients in group 1 and 2 of 10 patients in group 2. In group 1, 7 of 13 patients had teicoplanin concentrations in tissue that were lower than the MIC for 90% of the strains of potential pathogens tested (MIC90) that cause infection after cardiac surgery. All of the patients in group 2 but one had teicoplanin concentrations in tissue (other than in sternal bone) far in excess of the MIC90 for the potential pathogens. In conclusion, the 12-mg x kg(-1) regimen of teicoplanin is followed by a significant increase in teicoplanin concentrations in heart and mediastinal tissues and should be preferred to the 6-mg x kg(-1) regimen if teicoplanin is selected for antimicrobial prophylaxis in open heart surgery.

Penetration of ceftriaxone (1 or 2 grams intravenously) into mediastinal and cardiac tissues in humans.

Penetration of ceftriaxone into heart tissues (valves, myocardium, auricles, and pericardium) and mediastinal tissues (fat and sternal bone) was evaluated after two regimens of ceftriaxone administration. Ten patients (group 1) were given 1,000 mg of ceftriaxone intravenously 30 min before anesthesia. Ten other patients (group 2) received the same dose and then a second 1,000-mg dose at the time of initiation of cardiopulmonary bypass. Similar and very satisfactory penetrations of ceftriaxone into tissue were observed for both groups. During opening and closure of the thorax, mean ceftriaxone concentration was in excess of the MIC at which 90% of the potential pathogens were inhibited (> or = 4 micrograms/g) in the thoracic fat, the sternal bone, and the pericardium. No significant differences between the two administration regimens in penetration of ceftriaxone into tissue were observed. During cardiopulmonary bypass, the ceftriaxone concentration was > or = 4 micrograms/g in the myocardium, the endocardium, and the auricle. The regimen of ceftriaxone administration did not significantly influence penetration of the drug into heart tissues. However, for some patients in the two groups and mainly in the sternal bone at the time of thorax closure (6 patients in group 1 and 5 patients in group 2), ceftriaxone levels in tissues were less than the MICs (4 micrograms/g) for some potential pathogens (methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis). During the different steps of the surgical procedures, all (10 of 10) patients in each group had tissue ceftriaxone levels greater than the MICs for gram-negative aerobic bacilli (0.1 microgram/g), except for Pseudomonas spp.

[Penetration of ceftriaxone (1 or 2 gr intravenous) into mediastinal and cardiac tissues in man]. / Pénétration de la ceftriaxone (1 ou 2 g intraveineux) dans les tissus médiastinaux et cardiaques chez l'homme.

Ceftriaxone penetration into heart tissues (valves, myocardium, auricles and pericardium) and mediastinal tissues (fat and sternal bone) was evaluated after two regimens of ceftriaxone administration. Ten patients were given 1,000 g intravenously of ceftriaxone 30 min. before anesthesia. Ten other patients received the same dose and then a second 1,000 mg dose at the time of initiation of cardiopulmonary bypass. Similar and very satisfactory ceftriaxone tissue penetrations were observed in both groups. However, for some patients in the two groups and mainly in the sternal bone at the time of thorax closure, ceftriaxone levels in tissues were less than the MICs for some potential pathogens (Methicillin susceptible Staphylococcus aureus and Staphylococcus epidermidis). During the different steps of the surgical procedures all patients in both groups had tissue levels greater than the MICs for Gram negative aerobic bacilli, except for Pseudomonas spp.

[Comparison of extrapleural and intrapleural analgesia with bupivacaine after thoracotomy]. / Comparaison de l'analgésie extrapleurale et interpleurale par bupivacaïne après thoracotomie.

OBJECTIVE: To compare the analgesic and the ventilatory effects as well as blood concentrations of bupivacaine, administered either in the extrapleural or interpleural space after posterolateral thoracotomy. STUDY DESIGN: Randomized clinical trial. PATIENTS: Twenty ASA class I and II patients, scheduled for elective thoracic surgery were randomly allocated either in the IP group (catheter inserted into the interpleural space) or the EP group (catheter inserted in extrapleural position, paravertebrally above the posterior parietal pleura). METHODS: In the catheter, inserted at the Th4 level at the end of the surgical procedure, 20 mL of 0.5% bupivacaine were injected after full recovery from anaesthesia, with the thoracic drains clamped for 30 min. The injection was repeated every six hours. Pain was evaluated after a deep inspiration with a visual analog scale (VAS), before and 1.3 and 6 hours after the injection. Analgesia was considered as effective if the VAS score at the end of the first hour was less than 30 mm. Otherwise 0.1 mg.kg-1 of morphine was administered subcutaneously. The forced vital capacity (FVC) and the forced expiratory volume one second (FEV1) were measured preoperatively and on 1st (D1) and 2nd postoperative Day (D2). Blood samples for measurements of plasma bupivacaine concentrations were obtained at 5, 10, 20, 30, 60, 90, 120, 150, 180 and 250 min respectively after the first injection. RESULTS: Bupivacaine provided a more rapid, deep and prolonged analgesia by extrapleural than by interpleural route. Analgesia was effective in 9 patients in EP group vs 4 patients in IP group (P < 0.05). Morphine requirements were 4 +/- 8 mg in EP group vs 17 +/- 10 mg in the IP group (P < 0.05). The FVC and FEV1 values were similarly decreased on D1, but recovery was better in EP group on D2 (P < 0.05). Bupivacaine peak concentrations in plasma were lower in EP group (0.86 +/- 0.42 microgram.mL-1) than in IP group (1.63 +/- 1.44 micrograms.mL-1), however the difference was not significant. CONCLUSIONS: Extrapleural administration of bupivacaine provides better analgesia as the anaesthetic agent comes in closer contact with intercostal nerves and with lower risk of loss of agent through the pleural drainage. Therefore its use is recommended preferentially over the interpleural route for analgesia after posterolateral thoracotomy.

[Penetration of vancomycin in cardiac and mediastinal tissues in humans]. / Pénétration de la vancomycine dans les tissus cardiaque et médiastinal chez l'homme.

Vancomycin penetration into heart tissues (valves, myocardium, auricles and pericardium) and mediastinal tissues (fat and sternal bone) after two regimens of administration was evaluated in a prospective, randomized study. Twenty adult patients undergoing mitral or aortic valve replacement were included in the study and divided into two groups of ten patients each: Group 1 patients were administered a 15 mg/kg intravenous dose of vancomycin over 90 min upon anesthesia. Group 2 patients received the same dose followed by a second 7.5 mg/kg intravenous dose of vancomycin over 30 min at time of initiation of the cardiopulmonary bypass. In both groups further vancomycin administrations (10 mg/kg) were performed on hour 8, 16 and 24. Plasma and tissue vancomycin concentrations were assayed by fluorescence polarization immunoassay. At different times of the surgical procedures (thorax opening and closure, period of cardiopulmonary bypass) 67 to 100% of the patients in group 1 had vancomycin concentrations in the studied tissues above the MIC 90 for Staphylococcus aureus (1 microgram/g) and Staphylococcus epidermidis (2 micrograms/g). In group 2, for the same periods and the same tissues, 72 to 100% of patients had adequate vancomycin concentrations. In group 1 patients, mean ratios of vancomycin tissue concentrations/MIC 90 were 6 +/- 2 to 20 +/- 4 for Staphylococcus aureus (MIC 90: 1 microgram/g) and 3 +/- 1 to 10 +/- 4 for Staphylococcus epidermidis (MIC 90: 2 micrograms/g). In group 2 patients, mean ratios were 8 +/- 3 to 20 +/- 4 for Staphylococcus aureus and 4 +/- 1 to 10 +/- 3 for Staphylococcus epidermidis. The use of a second dose of vancomycin in group 2 significantly increased plasma concentrations (P > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Penetration of vancomycin into mediastinal and cardiac tissues in humans.

Vancomycin penetration into heart tissues (valves, myocardium, auricles, and pericardium) and mediastinal tissues (fat and sternal bone) was evaluated after two regimens of vancomycin administration. Ten patients were given 15 mg of vancomycin per kg of body weight before anesthesia. Ten other patients received the same dose and then a second 7.5-mg/kg dose at the time of initiation of cardiopulmonary bypass. Similar and satisfactory vancomycin tissue penetrations were observed in both groups. However, for some patients in the two groups, vancomycin levels in tissue were less than the MICs for potential pathogens (Staphylococcus aureus and Staphylococcus epidermidis).

[Unusual localization of embryonal rhabdomyosarcoma of the gallbladder]. / Localisation exceptionnelle du rhabdomyosarcome embryonnaire à la vésicule biliarie.

We report a second case of gallbladder embryonal rhabdomyosarcoma diagnosed in a 54 year old female. We had previously published a first similar case in a 48 year old male. In the review of the literature 5 other cases were collected. Five of the 7 cases occurred in 4 females and one male adult mean aged 63.4 years, and 2 in young girls aged 40 months. Three cases were of botryoid type, three were of alveolar type and one was of undetermined type. Immunohistochemistry demonstrated intra-cytoplasmic positivity of tumoral cells with anti-vimentin, anti-desmin and anti-actin anti-bodies. The prognosis remains bad. Death occurred, in 5 patients, in a period going from 18 days to 8 months after clinical diagnosis with a 5 months mean survival. The shortest survival was observed in a 40 month old child with AIDS. Only one case with surgical resection followed by radiochemotherapy had a 9 month survival.

[Adrenal myelolipoma]. / Le myélolipome surrénalien.

The authors report a case of myelolipoma discovered in a 57 year-old woman by ultrasonography and computed tomography. The tumour was 10 cm in diameter and weighed 350 grams. This case is discussed in the light of a review of the literature.

[Intestinal perforation by a fish bone. Apropos of a case and review of the literature]. / Perforation intestinale par arête de poisson. A propos d'une observation avec revue de la littérature.

We report a case of transverse colon perforation by a fish bone (Grouper) in a toothless-old female. A review of the literature revealed a great variety of foreign bodies which may cause perforations at variable sites of the gastrointestinal tract. Fish bones were responsible for 46% of intestinal perforations in a review of 24 cases collected in 1984. Advanced age and poor patient dentition, as well as mental debility constitute predisposing factors for the swallowing of foreign bodies. Emergency radiology may be required. An exaggerated inflammatory reaction may give rise to a misleading pseudo tumor appearance. We agree that a well conducted and well analysed clinical history associated with a careful pathologic examination are very helpful in the diagnosis.

Assessment of creatinine clearance in intensive care patients.

Assessment of creatinine clearance (CC) in ICU patients was compared using three methods. The reference method (CC 24 h) used measurements of serum creatinine and urinary creatinine after collection of urine over a 24-h period. The other two methods were predictive methods: the Kampmann nomogram and the formula developed by Gault and Cockcroft. The two predictive methods correlated well with one another. Correlation between the predictive and the reference methods was poor or absent. A discriminant analysis revealed that measurement of urinary creatinine was a major factor in CC estimation. In conclusion, the reference method of CC assessment is preferred to obtain a reliable estimation of glomerular filtration rate in ICU patients.