Haemodynamic consequences of etomidate administration in elective cardiac surgery: a randomized double-blinded study.

BACKGROUND: The consequences of inhibition of cortisol synthesis by a single dose of etomidate on subsequent vasopressor drug usage and the duration of relative adrenal insufficiency (RAI) after cardiac surgery are not known. METHODS: This was a prospective, randomized, double-blinded controlled trial of 100 patients undergoing elective cardiac surgery and receiving either etomidate or propofol at induction of anaesthesia. A short corticotropin test was performed 12, 24, and 48 h after anaesthesia induction. RAI was defined as a response <250 nmol litre(-1). RESULTS: The mean (sd) norepinephrine infusion rate during the first 48 postoperative hours was 0.11 (0.01) and 0.11 (0.01) µg kg(-1) min(-1) in the etomidate and propofol groups, respectively (P=0.89). Time to norepinephrine withdrawal was similar between the groups. The incidence of RAI was higher in the etomidate group at 12 h (100% vs 41%, P<0.001) and 24 h (85% vs 25%, P<0.001). CONCLUSIONS: A single bolus of etomidate blunts the hypothalamic-pituitary-adrenal axis response for more than 24 h in patients undergoing elective cardiac surgery, but this was not associated with an increase in vasopressor requirements.

[Microcirculatory dysfunction after cardiac surgery: Interest of NIRS technology with two case reports]. / Dysfonction microcirculatoire lors de la chirurgie cardiaque : intérêt de la technique NIRS à propos de deux cas cliniques.

Near infrared spectroscopy (NIRS) seems to be an interesting technology to study microcirculatory dysfunction. These alterations have been described after cardiac surgery under cardiopulmonary bypass. We report two case study reports with monitoring of StO(2) and reperfusion slope after an ischemic challenge. These two parameters are early altered notably in case of cardiac dysfunction (decrease of StO(2) and reperfusion slope). We discuss the interest of microcirculatory measurement in this context.

Parental knowledge and use of epinephrine auto-injector for children with food allergy.

Epinephrine should be prescribed for patients at risk of anaphylaxis. Our purpose was to determine the use of Anapen prescribed for food-allergic children, to assess parental knowledge regarding Anapen, and to evaluate the arrangements for emergency kits and personalized care projects in everyday life. A prospective study was performed with a questionnaire sent to families with a food-allergic child previously prescribed Anapen. One hundred and fifty two families were contacted and finally 111 children included (median age 6.5 yrs). Main food allergens were peanuts (n = 89), egg (n = 39) and cow's milk (n = 10). The use of Anapen had been demonstrated to 90% of parents (by prescribing physician, 69%; pharmacist, 25%; general practitioner, 5%; nurse 1%), with a training device (76%) and/or written instructions (49%). When asked to list symptoms requiring injection, 48% of parents cited more than one response: breathing difficulties only (23%), or with angio-edema (41%), collapse or faintness (38%), anaphylactic shock (48%). Of 107 children attending school, 54% had a personalized care project, 72% an Anapen device, and 60% a complete emergency kit (epinephrine, inhaled beta-agonist, corticosteroid, anti-H1 drug). Beta-agonists were forgotten at school by 34 children (13 asthmatics). Anapen was used in one child for angio-edema and dyspnea after inadvertent ingestion of egg at home. In our population, epinephrine auto-injectors and emergency kits were insufficiently available at schools and in daily life. The use of auto-injectors was not adequately demonstrated. The prescription of epinephrine for food-allergic children at risk of anaphylaxis requires accurate diagnosis, educational programs, information, and follow up.

[Ipsilateral hip and femoral shaft fractures: components of therapeutic choice]. / Fractures homolatérales de la diaphyse et du col fémoral: éléments de choix thérapeutique.

PURPOSE OF STUDY: Ten cases of ipsilateral hip and femoral shaft fractures were reviewed. MATERIAL AND METHODS: All patients were treated operatively for both fractures between 1988 and 1997 in Pitié Hospital. Five were treated with antegrade reamed intramedullary nails and cancellous screw fixation of the femoral neck, and 5 by long Gamma nail. The shaft fractures were fixed prior to definitive neck stabilization. RESULTS: Ipsilateral hip and femoral shaft fractures accounts for 5.6 p. 100 of the whole femoral shaft fractures registered in the same period. All cases occurred in young adults and resulted from high-energy impaction injuries. There were numerous associated injuries and all patients were polytrauma. The hip fracture was initially overlooked in 1 case without subsequent nonunion or avascular necrosis. At a mean follow-up examination of 22 months, two-thirds had a good result and one-third a fair or a poor result. Nonunion of the femoral neck occurred in one patient as a result of initial displacement and subsequent malreduction, while all shaft fractures united. DISCUSSION: X-ray films of the hip should be done in all cases of femoral shaft fracture in order to decrease the high incidence of missed femoral neck fractures in ipsilateral injuries of the femur. The results indicate that patients with ipsilateral fractures of the femoral neck and shaft can obtain good results when rigid anatomic stabilization of the femoral neck is performed. The femoral shaft fracture is given first priority and is reduced and immobilized with antegrade closed intramedullary nailing. The femoral neck fracture is then treated with cancellous screw fixation or compression screw with long Gamma nail. CONCLUSION: The authors recommend the use of a long Gamma nail to fix this dual fracture whenever possible.

Emulsification and lipolysis of triacylglycerols are altered by viscous soluble dietary fibres in acidic gastric medium in vitro.

This in vitro study was designed to test the hypothesis that soluble dietary fibres can alter the process of intragastric lipid emulsification and possibly subsequent triacylglycerol lipolysis. Three guar gums, two pectins and gum arabic were dissolved in acidic gastric medium in the concentration range 0.3-2.0% (w/v). Viscosities of fibre solutions were measured and apparent viscosities varied over a wide range (0.7-77 mPa/s). Emulsification of a lipid mixture (triolein/phosphatidylcholine/cholesterol) was performed under mild conditions in the presence of increasing concentrations of soluble fibres. The amount of emulsified lipid was not affected whereas the size of the emulsified droplets was increased by raising the concentration of viscous fibres only. The droplet size (r=0.75, P=0.006) and overall droplet surface area (r=-0.69, P=0.009) were strongly correlated with the medium viscosity in the range 0-20 mPa/s. The addition of solutions of viscous fibres to a preformed standard emulsion did not change the initial velocity of human gastric lipase reaction. Conversely, when emulsions prepared in the presence of fibres (i.e. with different droplet sizes) were incubated with excess gastric enzyme for 2 h, the high-viscosity guar gum significantly reduced the extent of triacylglycerol lipolysis, as compared with control and low- or medium-viscosity fibres. In conclusion, the data obtained show that reducing emulsification of dietary lipids in the mildly acid medium found in the stomach is a mechanism by which soluble viscous fibres can alter lipid assimilation.

Conformational changes of bovine serum albumin upon its adsorption in dodecane-in-water emulsions as revealed by front-face steady-state fluorescence.

Front-face fluorescence spectroscopy was used to characterise dodecane-in-buffer (0.1 M phosphate buffer; pH = 7.6) emulsions stabilised by bovine serum albumin (BSA). A 15-nm blue-shift of the emission maximum of the adsorbed protein and a significant increase of its fluorescence quantum yield were observed. The contribution of tyrosyl residues to total fluorescence was tentatively evaluated from different spectra and an R ratio taking into account the stray-light interference; R increased upon BSA absorption but the Tyrosine contribution remained weak in all cases. Thus, conformational changes of the protein take place upon BSA adsorption onto the dodecane-water interface. They involve modifications in the environment of the protein aromatic amino acids especially of the tryptophanyl residues which are displaced to a more hydrophobic location. Moreover, the proportions of absorbed and non-adsorbed BSA in emulsions can be estimated from the position of the emission maximum.

[Metastasis to the pituitary stalk in a case of breast cancer]. / Métastase de la tige pituitaire au cours d'un cancer du sein.

A 64-year old woman with breast cancer developed diabetes insipidus. CT scan showed thickening and contrast enhancement of the pituitary stalk highly suggestive of metastasis. The patient was successfully treated with desmopressin followed by external radiation therapy.

[Severe local reactions to mosquito bites. Apropos of 20 cases]. / Les réactions locales majeures aux piqûres de moustique. A propos de 21 observations.

We relate 21 observations of children who present major local reactions, immediate and delayed after mosquito bites. An associated reagin mechanism is obvious in 8 patients: five positive cutaneous or RAST tests and three a basophil degranulation tests. They are mostly young children (14/21 an less 5 years old). After some difficult years, the evolution is finally favourable with a specific hyposensitization or under antihistaminic protection (ketotifen) during summer.

[Does mugwort pollenosis occur in children in the northern region?]. / La pollinose à l'armoise est-elle fréquente chez l'enfant dans la région nord?

Is Mugwort pollenosis frequent among children in North of France? In North of France where no ragweed grows, mugwort (artemisia) is after grasses and plantago, the third pollenosis in children. Among 184 children with summer clinical signs, positive cutaneous tests with a mugwort extract are noted in 40 patients (21%). RAST are positive only in 23 on 34 children with positive cutaneous test. Among the 40 children only two are less 5 years old and 26 are more 10 years old. Respiratory provocation tests confirm in 13/19 cases a sensitization of upper or lower respiratory tract. No food allergy exists among those children.