[Lung cancer, how to deal with critical situations?]. / Cancer bronchique, la gestion des situations critiques.

The management of a patient with cancer, including lung cancer requires the investment of many health caregivers. The development of surgical techniques as well as targeted therapies requires a specialization of each. In order to optimize the actions of each, coordination of support is required from the diagnosis of cancer. This coordination can reduce iatrogenic toxicity and improve quality of life during the disease. It may also enhance quality of accompaniment of the patient, his family and a fortiori the health care team. The development of this coordination of supportive care in oncology, as part of a department of cancerology including care of patients with lung cancer is described. This organization allows to limit the toxicities of cancer treatment, but also to improve the suffering of patients by focusing on maintaining the patient at home.

[Muromonab CD3 (Orthoclone OKT3) for the prophylaxis of heart allograft rejection. Hemodynamics and respiratory tolerance]. / Le muromonab CD3 (Orthoclone OKT3) en prophylaxie de rejet d'allogreffe cardiaque. Tolérance hémodynamique et respiratoire.

OBJECTIVE: Treatment of transplant rejection with muromonab CD3 (Orthoclone OKT3) may result in haemodynamic instability and pulmonary oedema, which would question its prophylactic use. The aim of this study was to the evaluate haemodynamic and respiratory tolerance of prophylactic treatment of cardiac rejection with OKT3. STUDY DESIGN: Prospective clinical study. PATIENTS: Twelve patients, whose pulmonary arterial resistances before transplantation were less than 400 dyn.s.cm-5, with haemodynamic and respiratory stability during the 4 hours before OKT3 administration. METHOD: Patients under preventive haemodynamic support with isoprenaline 0.05 micrograms.kg-1.min-1 and dopamine 3 micrograms.kg-1.min-1. Immunosuppressive treatment with azathioprine 5 mg.kg-1 at d0 and 3 mg.kg-1 at d1 and d2 and with methylprednisolone 720 mg at d0 and 240 mg at d1 and d2. OKT3, 5 mg administered i.v. at d0, d1, d2. Respiratory and haemodynamic variables were recorded prior to (T0), 30 min (T1) and 360 min (T2) after injection of OKT3. RESULT: Neither clinical nor radiological changes were observed after the OKT3 injections. At d0, T2, the heart rate increased and PaO2 and SaO2 decreased. At d1 and d2, T1, PaO2 decreased, and QS2QT at T1 d2 increased by nearly 3%. CONCLUSION: OKT3 does not result in major circulatory and haematosis changes, provided patients are selected, especially free of pretransplantation pulmonary hypertension. Prior to the treatment with OKT3, they should be in a satisfactory haemodynamic and respiratory status and receive high doses of corticosteroids.

Assessing human cardiac allograft rejection using MRI with Gd-DOTA.

To explore the potential role of MRI in detecting cardiac allograft rejection in transplant recipients using gadolinium tetraazacyclododecane tetraacetic acid (Gd-DOTA) for contrast enhancement, we examined 7 normal healthy volunteers and 39 patients separated into three groups according to histological findings. Quantitative myocardial enhancement (ME), expressed as the ratio of maximum signal intensity after intravenous Gd-DOTA injection to signal intensity before intravenous injection of Gd-DOTA, was significantly lower for patients without histological rejection (n = 14; regional ME = 83 +/- 41%; mean ME = 53 +/- 24%) when compared with patients with grade 1 histological rejection (n = 18; regional ME = 122 +/- 20%, p = 0.02; mean ME = 70 +/- 14%, p < 0.05) and with patients with grade 2 or 3 rejection (n = 7; regional ME = 135 +/- 44%, p = 0.02; mean ME = 81 +/- 27%, p < 0.05). Myocardial enhancement was not significantly different in patients with grade 1 histological rejection compared with patients with grade 2 or 3 rejection. Because predominant focal areas of ME were observed in all patients, regional ME seemed a better measurement than mean ME to distinguish focal histological changes when the rejection process is beginning. More sophisticated software analysis is necessary to quantify and map high ME to establish the exact relationship between the extent of edema and the severity of rejection.

Primary gastrointestinal malignant lymphomas associated with Epstein-Barr virus after heart transplantation.

Gastrointestinal involvement has been reported in 12-21% of post-transplant lymphoproliferative disorders but is unusual in the setting of heart transplantation. We report four post-transplant lymphoproliferative disorders observed among the 174 heart transplant recipients of our series, all of which were primary malignant lymphomas of and confined to the digestive tract. The mean onset time from transplantation was 22 months. Small intestine lesions were present in all four patients, with gastric involvement in one. Histologically, the tumour was monomorphic of immunoblastic type in one case and polymorphic in the three other cases. Analysis of cytoplasmic immunoglobulins demonstrated the presence of a major monoclonal subset in all patients. Epstein-Barr virus genome was found in numerous tumour cells by in situ hybridization. The exclusive localization to the digestive tract and the lymphoepithelial lesions observed in two cases suggest that these lymphoproliferations might originate from mucosa-associated lymphoid tissue.

[Effect of hypertension on the renal and cardiac functions of patients with heart transplantation]. / Effet de l'hypertension artérielle sur la fonction rénale et la fonction cardiaque du transplanté cardiaque.

To evaluate the incidence, risk factors and effects of systemic hypertension on renal function and left ventricular hypertrophy after heart transplantation, 85 recipients under triple drug low low dosage immunosuppressive therapy were studied. After a mean follow-up of 12.5 +/- 8.7 months, high incidence of hypertension was observed in 67% of the patient and 71% had developed de novo hypertension. None of the pre-transplant nor post-transplant cardiovascular risk factors were significantly associated with post-transplant hypertension. Faster deterioration of renal function, as assessed by intraindividual variations of serum creatinine values, was demonstrated in hypertensive patients and appeared as an early indicator of cyclosporine nephrotoxicity in patients at risk for hypertension. [table: see text] Serial (early, intermediate, late) echocardiographic evaluations demonstrated early increase in left ventricular mass and in fractional shortening in both hypertensive and normotensive heart transplant recipients with sustained enhanced contractility in hypertensive patients. [table: see text] Further studies will help to determine the exact relationship between cyclosporine dosages and hypertension, and their respective roles in the development of renal insufficiency and left ventricular hypertrophy after heart transplantation.

Effect of systemic hypertension on renal function and left ventricular hypertrophy in heart transplant recipients.

To evaluate the incidence, risk factors and effects of systemic hypertension on renal function and left ventricular hypertrophy after cardiac transplantation, 85 transplant recipients on triple drug, low dosage, immunosuppressive therapy were studied. After a mean follow-up period of 12.5 +/- 8.7 months, a high incidence of hypertension was observed in 57 (67%) of the patients, and 42 (71%) of the 57 had developed new hypertension. None of the pretransplant and posttransplant cardiovascular risk factors were significantly associated with posttransplant hypertension. Faster deterioration of renal function, as assessed by intraindividual variations of serum creatinine values, was demonstrated in hypertensive patients and appeared as an early indicator of cyclosporine nephrotoxicity in patients at risk for hypertension. Serial echocardiographic evaluations demonstrated an early increase in left ventricular mass and fractional shortening in both hypertensive and normotensive heart transplant recipients. Fractional shortening further diminished significantly in normotensive patients but remained elevated in hypertensive patients, demonstrating sustained enhanced contractility in this group. Further studies will help to determine the exact relation between cyclosporine dosages and hypertension and their respective roles in the development of renal insufficiency and left ventricular hypertrophy after cardiac transplantation.

[Value of propofol in microsurgery of the middle ear]. / Intérêt du propofol dans la microchirurgie de l'oreille moyenne.

In 21 anaesthetics on patients ASA I-II undergoing middle ear microsurgery, the induction was done by 2 mg/kg propofol and 2 mcg/kg fentanyl. Anaesthesia was maintained by a continuous infusion of propofol 100 mcg/kg/min and bolus injections of fentanyl 1 mcg/kg every 30 min, and controlled ventilation with 60% Nitrous Oxide. The side effects during induction and recovery were minor. After a slight fall in blood pressure at induction, the haemodynamic values were steady during the whole surgery. Haemostasis was always good: the operating field was bloodless in 13 patients (62%), relatively bloody in 8 (38%), but never inconvenient for the surgeon. While recovery happened later than in other studies, the time from eyes opening to complete consciousness was always short, less than 10 minutes. The adjunction of fentanyl could be responsible for the long recovery time. No correlation is found between the infusion rate of propofol and recovery time. All patients but one are satisfied with their anaesthesia, especially with their smooth recovery.