Meningococcal carriage during a clonal meningococcal B outbreak in France.

The aim of this study performed in Normandy, France, was to analyze the pharyngeal meningococcal carriage at the peak of a clonal meningococcal B outbreak, which was subsequently controlled using an outer membrane vesicle vaccination. This cross-sectional study included randomly selected subjects aged 1-25 years. Carriers and non carriers were compared using unconditional logistic regression. Among the 3,522 volunteers, there were 196 (standardized rate: 6.46 %) Neisseria meningitidis carriers, of which there were only five with the outbreak strain (B:14:P1.7,16/ST-32; standardized rate: 0.18 %). From the multivariate analysis, older age, smoking, higher degree of socialization, and social deprivation appear to favor the carriage of all the strains included. Prior antibiotic treatment up to 12 months before swabbing, even with ß-lactam, was protective against carriage. Our data indicate a low overall meningococcal carriage rate with a surprising protective effect of prior antibiotic exposure. The observed low carriage rate of the epidemic strain (B:14:P1.7,16/ST-32) contrasts with the high incidence of invasive meningococcal diseases (IMD) due to this strain. Hence, our data underline the high virulence of the strain and suggest a low level of natural immunity of the population against this strain. Although highly resource-consuming, carriage studies are helpful in guiding the implementation of control measures of IMD, such as mass vaccination or chemoprophylaxis.

Similar slow down in running speed progression in species under human pressure.

Running speed in animals depends on both genetic and environmental conditions. Maximal speeds were here analysed in horses, dogs and humans using data sets on the 10 best performers covering more than a century of races. This includes a variety of distances in humans (200-1500 m). Speed has been progressing fast in the three species, and this has been followed by a plateau. Based on a Gompertz model, the current best performances reach 97.4% of maximal velocity in greyhounds to 100.3 in humans. Further analysis based on a subset of individuals and using an 'animal model' shows that running speed is heritable in horses (h(2) = 0.438, P = 0.01) and almost so in dogs (h(2) = 0.183, P = 0.08), suggesting the involvement of genetic factors. Speed progression in humans is more likely due to an enlarged population of runners, associated with improved training practices. The analysis of a data subset (40 last years in 800 and 1500 m) further showed that East Africans have strikingly improved their speed, now reaching the upper part of the human distribution, whereas that of Nordic runners stagnated in the 800 m and even declined in the 1500 m. Although speed progression in dogs and horses on one side and humans on the other has not been affected by the same genetic/environmental balance of forces, it is likely that further progress will be extremely limited.

[Appendiceal mucoceles, pseudomyxoma peritonei and appendiceal mucinous neoplasms: update on the contribution of imaging to choice of surgical approach]. / Mucocèles appendiculaires, pseudomyxomes péritonéaux et tumeurs mucosécrétantes du carrefour iléocaecal: apport de l'imagerie dans la stratégie thérapeutique et le choix de la voie d'abord laparoscopique ou classique.

INTRODUCTION: The treatment of pseudomyxoma peritonei (PMPs) and appendiceal mucocele (AM) has changed radically. To assess the contribution of preoperative imaging to the treatment strategy and choice of approach, a surgeon and a radiologist different from the initial radiologist examined the files of all patients treated for PMP or AM in four facilities in one district from January 1, 1996, through December 31, 2008. PATIENTS AND METHODS: The study included 27 patients (20 men and seven women, mean age: 63+/-13 years). Eleven patients had an intact AM, seven synchronous PMP (malignant appendiceal lesion in two of seven), six metachronous PMP (five with peritoneal mucinous carcinomatosis and one with diffuse peritoneal adenomucinosis) and three a ruptured AM but not PMP. The incidence of mucin-secreting tumors observed (27 cases in 12 years in a region of 500 000 inhabitants) corresponds to a prevalence of approximately five cases per year per million inhabitants. Acute clinical pictures (7/27) were significantly more frequent for the malignant forms (5/7) (p<0,02). RESULTS AND DISCUSSION: The overall sensitivity of computed tomography (CT) for all the criteria studied was 93%. The predictive value for AM rupture of visualization of thick calcifications was 100%. On the other hand, rupture never occurred when the CT showed an AM under pressure, with thin walls and septa. The predictive value for PMP of "scalloping" was 100%. The diagnostic accuracy of the initial reading was 25/27 for the imaging overall and 25/25 for the CT. Preoperative visualization of the exact size of the intact AM or of diagnostic information about ruptured AM and PMP helped to select an appropriate approach in 25 of 27 cases.

[Giant colonic or ileo-jejunal diverticulum and infra-mesocolic abdomial pseudocysts: diagnosis, pathalogical and clinical analysis]. / Diverticules géants du grêle et du côlon et formations pseudo kystiques sous-mésocoliques.

Giant diverticula of the small intestine and colon are rare. Four cases treated at our institution in the last year are reported and compared to published cases; specific features and those which differentiate them from abdominal pseudocysts are described. They most commonly present a clinical tableau similar to commonplace diverticular disease. Awareness of this unusual condition and a good CT study are the keys to diagnosis. Giant diverticula may be acquired or congenital. The acquired type is simply a more spectacular version of commonplace diverticulosis while the congenital type, having a muscular wall and myenteric plexus, is more akin to intestinal duplications. Treatment is surgical and, in the case of sigmoid giant diverticula, usually requires a colon resection similar to that required for sigmoid diverticulitis.

Nosocomial endocarditis in the intensive care unit: an analysis of 22 cases.

OBJECTIVES: To review the intensive care unit experience of patients with admitted or acquired nosocomial endocarditis (NE) defined according to the Duke criteria. DESIGN: Prospective, cohort study. SETTING: University teaching hospital. PATIENTS: We reviewed the records of 22 patients documented with NE during a 6-yr period from 1992 to 1997. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients (9 women/13 men) aged 38-83 yrs (mean 65+/-9 yrs) had a NE (prevalence of 5 per 1,000 admissions). For six patients, NE was the reason for the admission to the intensive care unit. For 17 patients, the time elapsed between admission and diagnosis of NE was 39+/-25 days. Sixteen patients were predisposed to infection and seven had underlying heart conditions that put them at risk for acute endocarditis: three prosthetic valves, two valvular diseases, and two cardiac pacemakers. In 21 cases (one unknown portal of entry), NE was the consequence of bacteremia related to a medical or surgical procedure: 11 intravascular devices, eight surgical wounds, one tracheal procedure, and one leg ulceration. The bacteriologic agents detected in blood cultures were: staphylococci (n = 17), Streptococcus (n = 2), Pseudomonas aeruginosa (n = 2), and Candida (n = 2). Fourteen patients underwent echocardiography according to cardiac signs (cardiac failure, new cardiac murmur, or embolic event). For the eight remainders, echocardiography was performed systematically because of fever and positive blood cultures. The lesions detected by 21 transthoracic and 17 transesophageal echocardiographs were the following: vegetations (n = 19), myocardial abscesses (n = 5), and valvular perforation (n = 1). On 16 surgical indications, only five patients underwent surgery because the others were in too poor of a condition. The overall mortality was 68% (n = 15) and was directly associated with NE in 36% of cases (n = 8). Seven patients (28%) were discharged 34 days after the diagnosis of endocarditis. CONCLUSIONS: NE is a frequent nosocomial infection that occurs late during hospitalization. Persistent fever with positive blood cultures is sufficient symptomology to promptly perform an echocardiogram. The poor prognosis is related to the poor condition of those patients who cannot be referred for surgical treatment.

Molecular analysis of Mycobacterium avium isolates by using pulsed-field gel electrophoresis and PCR.

Genetic relationships among 46 isolates of Mycobacterium avium recovered from 37 patients in a 2,500-bed hospital from 1993 to 1998 were assessed by pulsed-field gel electrophoresis (PFGE) and PCR amplification of genomic sequences located between the repetitive elements IS1245 and IS1311. Each technique enabled the identification of 27 to 32 different patterns among the 46 isolates, confirming that the genetic heterogeneity of M. avium strains is high in a given community. Furthermore, this retrospective analysis of sporadic isolates allowed us (i) to suggest the existence of two remanent strains in our region, (ii) to raise the question of the possibility of nosocomial acquisition of M. avium strains, and (iii) to document laboratory contamination. The methods applied in the present study were found to be useful for the typing of M. avium isolates. In general, both methods yielded similar results for both related and unrelated isolates. However, the isolates in five of the six PCR clusters were distributed among two to three PFGE patterns, suggesting that this PCR-based method may have limitations for the analysis of strains with low insertion sequence copy numbers or for resolution of extended epidemiologic relationships.

Coelioscopic cholecystectomy: experience with 2006 cases.

2006 laparoscopic cholecystectomies (LC) were performed from April 1988 to December 1992 by three senior surgeons using the French technique and selective intraoperative cholangiography (IOC). Obesity was present in 318 patients (15.8%), respiratory insufficiency in 75 (3.7%), inflammation in 251 (12.5%), and common bile duct (CBD) stones in 83 (4.1%). The presence of these additional ailments is a good indication for LC. Conversion to laparotomy occurred in 43 cases (2.1%). The rate of complications was 2%; 25 (1.25%) were nonbiliary complications and 15 (0.7%) were biliary-related; there was one death. IOC is not effective in preventing biliary complications, as those observed in this study would not have been recognized or avoided by it. IOC is carried out only selectively to locate unsuspected stones in patients with risk factors of CBD lithiasis. Laparoscopic treatment of CBD stones is still controversial.

[Laparoscopic cholecystectomy. Technique and complications. Report of 2,665 cases]. / Cholécystectomie par coelioscopie. Technique et complications. A propos de 2,665 cas.

Retrospective study of 2,665 laparoscopic cholecystectomies (LC) performed between April 1988 and December 1994 in the French technique with selective intra operative cholangiography. Obesity was present in 13% of patients, respiratory insufficiency in 4%, inflammation in 13% and common bile duct (CBD) stones in 4%. Those cases are now good indications for L.C. A conversion to laparotomy occurred in 52 cases (2%). The rate of post operative complications was 1.6%, including 24 non biliary complications with 2 death and 17 biliary ones concerning the CBD in 6 cases. Those results compare favourably with the ones of open cholecystectomy and the cost is about the half.

Extracorporeal lithotripsy associated with laparoscopic cholecystectomy: results of 60 patients.

Gallbladder extracorporeal lithotripsy was performed on 60 patients before laparoscopic cholecystectomy. Of the 44 cases with solitary stones (range, 17-45 mm; mean +/- SEM, 26.9 +/- 0.1 mm), satisfactory fragmentation was obtained in 77.2%. Of the 16 cases with multiple stones (range, 11-25 mm; mean +/- SEM, 14.9 +/- 0.7 mm), satisfactory fragmentation was obtained in 18.75%. Minimal adverse effects were observed both clinically and macroscopically during surgery. Upon histologic investigation, only two small gallbladder lesions could be attributed to extracorporeal lithotripsy. No changes in blood chemistry tests were recorded. When carried out with high performance equipment, extracorporeal lithotripsy appears to be an interesting procedure that permits an appreciable reduction in the number of parietal wall incisions that need to be widened, therefore simplifying laparoscopic cholecystectomy when dealing with large stones.

[Complications of celioscopic cholecystectomy in 2006 patients]. / Complications de la cholécystectomie coelioscopique chez 2006 malades.

The development of laparoscopic cholecystectomy is only justified if it can ensure the good results obtained by laparotomy. The purpose of this work is to study all complications which occurred in a homogeneous group of patients. From May 1988 to January 1993, we operated on 2006 patients by laparoscopy (724 men and 1282 women) with a mean age of 50.6 years. Signs of stones in the common bile duct were noted in 4.1% and acute cholecystitis was detected in 12.5%. A conversion to normal laparotomy was necessary in 2.1% of patients. All complications were systematically investigated restrospectively in any patient hospitalised for more than five days. Residual stones in the common bile duct were not taken into consideration when they were not complications obviously related to the operation. We observed five intraoperative complications (4 hemorrhages, 1 ileum puncture) and 40 postoperative complications (25 non biliary and 15 biliary). The 25 non biliary complications consisted of: 1 death by pulmonary embolism, 9 hemorrhages, 4 cases of acute pancreatitis, 4 subphrenic abscesses, 2 colon punctures, 2 parietal complications, 1 ulcer perforation, 1 myocardial infarction and 1 phlebitis. The 15 biliary complications consisted of: 3 lateral punctures of the common bile duct, 9 fistulas of the cystic duct (4 with a residual stone in the common bile duct and 5 without), 2 punctures of an abnormal right hepatic duct, one of which was treated by "Roux en Y loop" intestinal diversion, and a late stenosis of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic appendectomy. A study of 154 consecutive cases.

The recent development of mini-invasive surgery includes appendectomy. We report our results of 4 years experience in this type of approach. We have operated on 154 patients (61 men, 93 women), mean age 26.7 years, presenting with clinical signs of appendicitis. The operation was completely carried out by laparoscopy in 144 cases, including treatment of abscess in 13 and peritonitis in 8 cases. Operation was converted into laparotomy in 10 cases, 4 of which because of some difficulty in appendix dissection. No deaths were recorded. Eight (5.2%) post-operative complications occurred: 4 infections of the trocar hole, one of which the cause of readmission; 3 cases of pain and fever (in one a re-laparoscopy was performed because of suspicion of leakage of the appendicular stump); 1 residual hematoma requiring second laparoscopy. Mean duration of hospitalisation was 4.9 days (range 2-25 days): at present, mean hospitalisation is 2 and 6 days respectively in cases with and without peritonitis. In conclusion, laparoscopic appendectomy appears to be feasible in the majority of cases, with better results when the appendix is ectopic and/or in the presence of peritoneal reaction.

[Celioscopic treatment of acute obstructions of the small intestine. Immediate results in 25 patients]. / Traitement coelioscopique des occlusions aiguës du grêle. Résultats immédiats chez vingt-cinq malades.

Laparoscopic treatment of small intestinal obstruction is associated with immediate advantages and it may be expected that the recurrence rate will be decreased because of the reduction of wound scars. Between september 1989 and september 1991, 25 patients (16 men and 9 women), mean age 53.8 years, underwent initial laparoscopy for acute small intestinal obstruction. These patients had undergone a total of 43 (1.7 per patient) laparotomies an average of 13 years previously. One patient had never been operated on, 13 had one previous laparotomy, five had two, four had three, and two had four previous laparotomies. Laparoscopic treatment of intestinal obstruction was possible in nine cases including three cases of bands and six cases of adhesions. In sixteen cases, laparoscopy had to be completed by laparotomy, 13 immediately and 3 secondarily. The cause of immediate failure was the impossibility of finding and/or treating the cause in seven instances, four cases of intestinal wounds, on case of intestinal necrosis which required resection, and one case of missed right colonic carcinoma. The cause of secondary failure were incomplete release of adhesions, volvulus, and missed left colonic carcinoma in one case each. Mean hospital stay and postoperative ileus were significantly shorter in the "laparoscopy" group than in the laparoscopy + laparotomy group (p < 0.001). Two complications, with one death, were noted in the laparoscopy + laparotomy group. In conclusion, laparoscopic treatment of intestinal obstruction seems possible but in less than half of cases. Failures are related to the difficulty with which the abdomen may be explored. Laparoscopic treatment should not be pursued in case of problems.(ABSTRACT TRUNCATED AT 250 WORDS)

[Appendectomies by celioscopy. Results in 78 patients]. / Appendicectomies par coelioscopie: Résultats chez soixante-dix-huit malades.

The recent development of laparoscopic surgery has included the treatment of acute appendicitis. We report our results after three years' experience of this type of surgery. We have operated on 78 patients (54 men, 44 women) mean age 28.9 years, suspected of varying degrees of acute appendicitis. The operation was completely carried out by laparoscopy on 71 occasions, including treatment of an abscess in 4 cases and peritonitis in 4 cases (3 of which were sub-mesocolic and one was generalised). The laparoscopy was transformed into laparotomy in 7 cases, 4 of which were due to difficulties of appendix dissection. Mortality was zero. Four complications occurred: 2 minute infections of the trocar hole, one more severe parietal infection which was a cause of readmission and antibiotic treatment, one "syndrome of the fifth day". In conclusion, laparoscopic appendicectomy appears to be quite feasible in the majority of cases, particularly when the appendix is ectopic, with marked abdominal thickening and peritoneal reaction. The postoperative course is uneventful. The laparoscopic technique is very comfortable for the patient during the postoperative period. This technique is becoming increasingly feasible with the operator's experience, and this appears to us to constitute good training for any form of laparoscopic surgery.

Laparoscopic cholecystectomy: historic perspective and personal experience.

Operative laparoscopy has been an important diagnostic and therapeutic method in gynecological surgery for more than 15 years. Laparoscopic gastrointestinal surgery has only recently become accepted among general surgeons. Laparoscopic appendectomy was the first such procedure performed, in 1983, followed by cholecystectomy in 1987. Laparoscopic biliary tract surgery has been shown to offer the patient a number of advantages in patient care, such as reducing the length of hospitalization and recovery, minimizing postoperative pain and discomfort, and nearly eliminating the disfigurement associated with a major abdominal operation. Although initially offered only to those patients with uncomplicated biliary tract disease, this procedure is now safely performed in individuals with acute cholecystitis and choledocholithiasis. We describe the development of laparoscopic gastrointestinal surgery in Europe as well as our method of performing endoscopic cholecystectomy. The current results of 690 laparoscopic cholecystectomies performed at our institution are included.

Prosthetic valve endocarditis due to Thermomyces lanuginosus Tsiklinsky--first case report.

The first case of Thermomyces lanuginosus endocarditis occurring on a porcine heterograft prosthesis, secondary to a Staphylococcus aureus infection of the aortic valve, is reported. The diagnosis was made post-mortem by direct examination of the prosthesis and culture of surgical samples on Sabouraud's agar. Identification was based on the presence of warty, dark brown aleurioconidia. The route of contamination could not be established but the most likely cause was the air of the operating room or the insertion of a contaminated graft.

[Cholecystectomy with celioscopy. 330 cases]. / Cholécystectomie sous coelioscopie. 330 cas.

Laparoscopic cholecystectomy is possible. Under general anesthesia, the optic and the instruments are introduced through 4 trocarsheaths. The cystic duct and artery are dissected and clipped. The gallbladder freed by the retrograde way is removed through the umbilicus. 330 laparoscopic cholecystectomies were done with few and only benign complications. The advantages are the simple post-operative course, the short hospital stay and the minimal parietal traumatism. Some limits remains in case of too much peritoneal adhesions.

Coelioscopic cholecystectomy. Preliminary report of 36 cases.

Intra-abdominal endoscopy, routinely used for gynecologic operations can be extended safely for cholecystectomy in uncomplicated cholelithiasis. Thirty-six patients underwent coelioscopic cholecystectomy with few and only benign complications. The main advantages are cosmetic preservation, reduction of postoperative pain, shortening of hospital stay, and early recovery of a normal activity.

[Cholecystectomy under celioscopy]. / Cholécystectomie sous coelioscopie.

Cholecystectomy which is the best treatment for gallstones can be performed via laparoscopy in cases of uncomplicated stones. Thirty patients have been operated upon by this technique. The advantages are: small scars, easy recovery and short hospital stay. Nevertheless there are some risks, particularly hemorragic and traumatic complications in the biliary tract, so that operation must be done by a surgeon trained in biliary surgery.