Mycoplasma hominis wound infection after a vascular allograft.

Cases of Mycoplasma hominis infections after allograft are rare. We report a case of M. hominis wound infection after a vascular allograft. The allograft was positive before having any contact with the recipient, and our investigation suggests that M. hominis may have been transmitted from the donor to the recipient. It is not clear, however, whether specific diagnosis of M. hominis should be performed on tissue before grafting in order to prevent such donor-to-host transmission.

[Advantages of amniotic membrane transplantation in eye surface diseases]. / Intérêt des greffes de membranes amniotiques dans les pathologies oculaires de surface.

Amniotic membrane transplantation is now a widely adopted technique in the field of eye surface diseases. Depending on the indication, the amniotic membrane can be used as either a graft or a patch. When used as a graft, the amniotic membrane serves as a substrate for regrowth of deficient epithelium; the aim is to integrate this membrane. The basal membrane reinforces the adhesion and differentiation of the corneal epithelial cells, facilitates their migration, and prevents their apoptosis. When used as a patch, the amniotic membrane is sutured epithelium-down so as to maximize the concentration of biological factors delivered by this membrane: the membrane covers the diseased cornea and acts as a biological bandage and analgesic. The best indications for amniotic membrane grafts are acute chemical burns and trophic corneal ulcers refractory to all medical treatment. When these ulcers are perforated or in the early stages of perforation, it is best to use multiple layers of amniotic membrane, restoring the thickness of the cornea. In cases of confirmed limbal deficiency, amniotic membrane grafts may be a useful complement to the necessary limbal stem cell grafts. In the future, amniotic membranes will provide an indispensable support for the expansion of cultured stem cells. Amniotic membrane grafts may also be used to reconstruct the conjunctiva following the exeresis of symblepharons or conjunctival tumors. However, the use of this technique is currently limited to diseases with little inflammation and no extensive fibrosis.

Analysing the various obstacles to cornea postmortem procurement.

AIMS: In many countries the number of corneal donations is far too low to graft all patients on waiting lists within reasonable time. The aim of this study was to define specifically what practical changes are to be implemented to fully meet corneal graft demand. METHODS: The list of potential donors drawn by the coordination team from 1 January to 31 December 1999 was compared with that of all patients who had died during the same period. In each identified record, the parameters which permitted or precluded effective collection of cornea specimens were analysed, and the reasons why other records were not identified were investigated. RESULTS: Among the 1112 patients who died in 1999, coordinating nurses were able to identify 451 records (40.5 %) including 329 patients aged between 18 and 85 years (29.5%). After excluding 184 patients (55.9 %) who presented with medical contraindications, the coordinating nurses were able to meet the relatives of only 55 out of 145 patients (38%) and obtained their agreement in 39 cases (71% approval rate). Therefore, relatives' refusal was the cause for the absence of collection in only 5.5% of cases (16/290). The number of corneas procured amounted to 11.8% of identified records and 3.5% of all deceased patients. CONCLUSION: French law and regulations regarding tissue collection are based on consent presumption but it requires that verifications be made with the relatives to ensure that potential donors were not, before their death, opposed to such tissue procurement. That provision implies a high degree of organisation on the part of coordinating teams. It was demonstrated that donation shortage is no longer the result of relatives' refusal but rather because of logistical difficulties (potential donors not identified and problems in reaching relatives). It appears necessary therefore to strengthen coordinating teams with sufficient staff levels for wider donor identification. Those teams should also find ways to keep closer contact with relatives, so as to meet the maximum transparency targets required by public opinion and regulations and to graft all patients awaiting corneal transplantation.

[Amniotic membrane graft in ocular surface disease. Prospective study with 31 cases]. / La greffe de membrane amniotique dans les pathologies oculaires de surface. Etude prospective à partir de 31 cas.

INTRODUCTION: Amniotic membrane's unique combination of properties including the facilitation of migration of epithelial cells, the reinforcement of basal cellular adhesion and the encouragement of epithelial differentiation [6] together with its ability to modulate stromal scarring and its anti-inflammatory and anti-bacterial activity has led to its use in the treatment of ocular surface pathology as well as an adjunct to stem cell grafts of the corneal limbus [6-4]. We report a prospective study of 30 patients so treated. MATERIAL AND METHODS: We studied 31 eyes of 30 patients subjected to amniotic membrane grafts between September 1999 and May 2000. There were 25 men and 5 women with an average age of 60.1 (range 25-86) years who were followed for a mean of 7.7 (range 4-11) months. 5 groups (A to D) were observed: A: 6 eyes. Small chronic ulcers without limbal involvement. B: 4 eyes. Ulcers of at least 75% corneal area or occupying 75% of the limbus. C: 9 eyes. Corneal burns. D: 8 eyes. Painful bullous corneal dystrophies unresponsive to other treatment. E: 4 eyes. Symblepharons. Amniotic membrane was placed on the corneal lesion, epithelial surface externally [6, 15], trimmed and sutured with interrupted 10/0 nylon, removed at one month. In two patients (11, 12) inflamed conjunctiva was recessed and amnion sutured to the recessed margin. For the bullous dystrophies we removed all the corneal epithelium and either sutured the amnion to peri-limbal conjunctiva (4 eyes) or to the limbus (4 eyes). For the symblepharons the conjunctiva was dissected to reform the fornix which was lined with amniotic membrane, sutured with 8/0 vicryl. Patients were reviewed regularity. RESULTS: Group A: All healed within 15 days, in most with dissolution of the amnion over 2-3 months although some persisted, covered with corneal epithelium. An eye with a Descemetocoele and one with a microperforation both healed. Vision improved more than two lines in 4 of 6 eyes. Group B: 2 of 4 eyes healed, one despite detachment of the membrane after 15 days. One eye was salvaged by tarsorrhaphy over a fresh keratoplasty after perforation of a neuroparalytic ulcer on failure of three successive amnion grafts. The final cornea vascularised despite an amnion graft for a meta-herpetic ulcer. Group C: 2 of 9 eyes had limbal damage in one quadrant but 7 had vessels in at least three-quarters of the circumference. One (15) also had a limbal autograft. 3 of 9 eyes healed satisfactorily with more than 2/10 improvement in acuity in each case. 2 showed further neovascularisation despite surface healing. One old chemical burn healed satisfactorily but vascularisation remained 5 eyes failed to heal with lysis of the graft, the patient who had a limbal autograft developed a vascular pannus, and in 4 eyes neovascularisation progressed to cover the entire cornea. Group D: 3 eyes settled with loss of symptoms but in 5 the graft detached within 15 days. All eyes where the membrane had been sutured to the conjunctiva beyond the limbus failed whilst 3 of 4 in which it had been sutured anterior to the limbus succeeded, leaving a persistent whitish membrane under the epithelium. Group E: We were able to reconstruct the cul de sac in 3 out of 4 eyes. In one patient with recurrent pterygium good ocular movement was restored, previously limited by scarring. One with associated ocular surface damage from a thermal burn failed by scarring of the cul de sac a month after surgery. DISCUSSION: Our best results were in persistent trophic ulcers of the cornea (Groups A and B) with a success rate of 80%, comparable to those of others [49, 37, 38]. The ready availability of amniotic membrane in our facility makes amniotic membrane transplantation the main secondary treatment for such lesions, especially because of the visual improvement we obtained. Because we did not observe any improvement in corneal thickness after this treatment we advise its early use before significant stromal lysis. The technique was not sufficient to control the effect of corneal anaesthesia in two eyes [40] or in chemical burns suggesting that amniotic membrane alone is insufficient to promote corneal healing in the absence of limbal stem cells. Nevertheless, three eyes did benefit. It has been suggested [13] that the anti-apoptotic function of amnion may prevent stem cell loss in such eyes [42], thus it appears logical to offer an amniotic membrane graft first, before stem cell transplantation, which may entrain complications in the donor eye if autografted [43] or because of the rejection risk of an allograft. It may be that an amniotic membrane graft simply becomes a holding procedure allowing time to settle the eye so as to allow secondary procedures to address the underlying cause of further damage. Our treatment of bullous dystrophy only succeeded on confining the graft to within the limbus, 3 out of 4 eyes becoming comfortable. By contrast we found amniotic membrane helpful in reconstructing symblepharons in the absence of local inflammation. CONCLUSION: Amniotic membrane grafting is a simple and straightforward surgical technique which should form part of the therapeutic arsenal for the treatment of ocular surface disease. Indications for the technique need further clarification for it is evident that it cannot correct all secondary pathology associated with limbal destruction. It is certainly preferable to conjunctival advancement and has proved useful in the reconstruction of the cul-de-sac.

[Technique of harvesting and preparation of amniotic membranes]. / Technique de prélèvement et de préparation des membranes amniotiques.

Amniotic membrane transplantation is a promising surgical technique for clinical management of ocular surface diseases. According to the first published results, the ease with which this highly available tissue can be prepared and preserved makes this technique very attractive. The aim of our study is to report procurement procedures and the preparation technique for amniotic membrane in accordance with the French tissue transplantation legislation.

The interview with the donor's family before postmortem cornea procurement.

PURPOSE: Asking the family of a deceased patient to consider eye donation is one of the most difficult aspects of the donation process. The aim of this prospective study was to describe the content of interviews with the families of potential donors and to analyze their reactions to improve the process of eye donation. METHODS: We consecutively met with 151 families of suitable corneal donors at the Rouen University Hospital. All interviews with donor families were analyzed using a preestablished questionnaire. RESULTS: In only 17.9% of cases was the family aware of the potential donor's last will. In 77.7% of these cases, the patient wished to donate. Procurement rate was 71.5%. This acceptance was mostly facilitated by the awareness and motivation of the hospital staff, the experience of the physician, and the 13.3-h period of time allowed after the donor's death. The commitment on the part of the ophthalmologist to carry out optimal anatomical restoration was a very important point for 32% of families who accepted donation. Twenty-one percent of families asked for a delay for reflection. This delay helped to obtain a positive response in 72.7% of cases and even sometimes helped families to reconsider a previously negative position (14% of initial refusals). CONCLUSION: We demonstrate that a high positive response (71.5%) can be obtained from the donor's family when a trained and motivated group manages the post-mortem cornea donation request.

[Kidney procurement from a heart-arrest donor]. / Prélèvement de reins chez un donneur à coeur arrêté.

Brain death occurred in a 47-year-old head trauma patient following 5 days of intensive care. The procedure for multiple organ procurement was initiated. Irreversible cardiac arrest had occurred during the period in the surgical intensive therapy unit. External cardiac massage and mechanical ventilation were maintained until in situ cooling of the kidneys was achieved. The patient was taken to the operating room for nephrectomy. Both kidneys were transplanted with a favorable outcome. Procurement of kidneys from non-heart-beating donors could increase the number of available grafts for transplantation.

[An important step in cornea procurement: interview with the family of donors]. / Une étape importante du prélèvement de cornées: l'entretien avec la famille des donneurs.

BACKGROUND: Since bioethic laws were promulgated in France in 1994, post-mortem cornea procurement can be achieved only after donor's family consent. In order to fulfil this task, we set up a group of individuals including ophthalmologists and members of the coordination team. The aim of this study was to establish the efficiency of such a group and to evaluate the content of donor's family interview. METHODS: During this 14-month prospective study, we analyzed all the interviews we performed with donor families. To report these interviews, we used a preestablished questionnaire. RESULTS: We met 60 families during this study. Procurement rate was 80%. This acceptance was mostly facilitated by advanced mean donor's age (65 years) and by the 12-hour period of time allowed after donor's death. The other important factors were the terms of the interviews, the commitment for a perfect anatomical restoration. We noticed that usually (83%), the family was not aware of donor's last will and had unfortunately to make a choice. Accepting to wait for a final decision helped getting a positive response (86%) and even sometimes helped to reconsider a previous negative position (10%). CONCLUSION: Because of a dramatic lack of corneal grafts in France, more than 7000 patients are on a waiting list. Our results show that positive response can be obtained from the donor's family when a trained group manages the donation request. We strongly suggest that each eye bank create such a group.

[Refractory thrombocytopenia by HLA alloimmunization in a multitransfused patient]. / Thrombopénie réfractaire par immunisation anti-HLA chez une patiente polytransfusée.

A case is reported of 60-year-old woman who developed transfusion refractoriness after having been transfused several times. This patient who had been transfused with 4 standard packed red cell packs (PRC) for a surgical repair of a hiatal hernia, required three further operations within two months for postoperative complications. After the first operation, she had developed anti-JK1 and anti-CW alloantibodies. Seven phenotype compatible PRC and five fresh frozen plasma (FFP) were transfused during the surgery carried out on day 32. Massive haemorrhage occurred during the fourth operation on day 48, and the patient was transfused with 31 phenotype compatible PRC, 21 fresh frozen plasma, 36 standard platelet concentrates (SPC), fibrinogen, factor VIII and anti-thrombin III. Postoperative disseminated intravascular coagulation occurred, with thrombocytopaenia (45 G.l-1). Major thrombocytopaenia persisted for 6 days (12 G.l-1 on day 52), after the other signs of intravascular coagulation had been corrected, and despite the transfusion of 40 SPC. Platelet counts progressively returned to normal (195 G.l-1 on day 56). An HLA alloimmunization was discovered, which may have been induced by leukocytes contaminating the transfused red blood cell and platelet concentrates. A fifth operation carrying a high risk of haemorrhage was therefore prepared by harvesting autologous platelet rich plasma two days before and on the morning of the operation. These were transfused intraoperatively, together with phenotyped and leukocyte-free PCR, thus avoiding massive and expensive homologous platelet transfusions. In patients with a high risk of HLA immunization (previous pregnancies, multiple transfusions), autotransfusion or leukocyte-poor blood products should be used.

[Celiac plexus block: value of x-ray computed guidance]. / Bloc coeliaque: intérêt du guidage tomodensitométrique (TDM).

Celiac plexus block is a good alternative of pain treatment in upper abdominal pain. Neurolysis of the celiac plexus by the percutaneous posterior route used CT guidance in 8 patients. Pain relief was obtained in 5 of 7 patients (70 per cent); no complication occurred.

[Postoperative cervicofacial subcutaneous emphysema]. / Emphysème sous-cutané cervico-facial post-opératoire.

Two cases of post-operative subcutaneous emphysema are reported. After excessive airway pressure, air or anaesthetic gases may spread to the neck, mediastinum, abdomen or pleural cavity. Pathogenesis and mechanisms are discussed. Possible aetiologic factors are outlined. The consequences of this condition are limited after adequate emergency treatment.

[Sedation by constant-rate propofol in the head-injured patient. Preliminary results]. / Sédation par propofol à débit constant chez le traumatisé crânien. Résultats préliminaires.

In ten head injured patients, propofol was used as a sedative drug during 8 h (3 mg . kg-1 . h-1). Clinical sedation was good, without any incidence on the cerebral perfusion pressure. 14 min after stopping the propofol infusion, the results of clinical examination were similar to those found before sedation.

[Pneumothorax after ventriculoperitoneal shunt procedure]. / Pneumothorax après mise en place d'une dérivation ventriculo-péritonéale.

A respiratory distress syndrome is reported in a four month old girl, after placement of a ventriculo-peritoneal shunt for hydrocephalus. This complication was related to a surgical pneumothorax. It was an early and spontaneously resolving complication, which one should have in mind after shunting procedures.