Sepsis of the hip due to pressure sore in spinal cord injured patients: advocacy for a one-stage surgical procedure.

STUDY DESIGN: Retrospective study reporting characteristics and management of septic arthritis of the hip due to pressure sores in spinal cord-injured patients. OBJECTIVES: To describe clinical and biological data of septic arthritis of the hip and its treating management. SETTING: The database of the regional SCI referral center, Nantes, France. METHODS: We retrospectively collected data from 33 cases of septic arthritis of the hip in the medical files of 26 patients. RESULTS: We analyzed 33 cases of septic arthritis of the hip treated in one French referent center for spinal cord-injured patients from January 1988 to December 2009. Most patients had a thoracic complete paraplegia and nearly two-third (17 out of 26) had no systematic follow-up. In 25 out of 33 cases, the septic arthritis of the hip was due to a trochanteric pressure sore. The causal pressure sore was most frequently associated with a persistent drainage. The standard radiological examination led to the diagnosis in 30 cases and, in 7 questionable cases, magnetic resonance imaging was more contributory. Surgery always consisted of a wide carcinological-like excision and of a subtrochanteric proximal femoral resection including both greater and lesser trochanters. A musculocutaneous flap was realized for all cases and the choice of the muscle depended on the localization of the causal pressure sore but also of the remaining choices, as most of the patients had already undergone a prior surgery. An antibiotic treatment was adapted to multiple samples during surgery. CONCLUSION: We do advocate for a one-stage procedure including a subtrochanteric proximal femoral resection and a musculocutaneous flap.

[Severe skin reaction with mucous membrane inflammation during MINE chemotherapy]. / Réaction cutanée sévère avec mucite au cours d'une chimiothérapie de type MINE.

BACKGROUND: MINE chemotherapy is used to treat refractory Hodgkin's disease. Cutaneous adverse effects of MINE regimen are uncommon and chiefly consist of erythema and oedema of the extremities. More recently, a number of cases of panniculitis and subcutaneous inflammatory oedema have been described. OBSERVATION: We report the case of a 17-year-old girl developing acute and painful oedema of the limbs with panniculitis of the trunk. This incident was associated with inflammatory lesions of mucous membrane, in particularly in the genital area and on the tongue. These signs occurred 7 days after initiation of MINE chemotherapy, with no other drugs being introduced. A drug-induced reaction was suspected due to the absence of any other aetiology, particularly infectious disease. The condition gradually improved with symptomatic pain therapy. The patient's chemotherapy was subsequently modified. DISCUSSION: The chronology of the symptoms, spontaneous improvement after the end of treatment, and the absence of other potential causative factors resulted in a hypothesis of a cutaneous adverse reaction to the MINE regimen. The signs could be due to capillary leak syndrome resulting from the toxicity of vinorelbine on endothelial cells. Dermatologists should be aware of these cutaneous adverse effects and of the inflammatory lesions of mucous membrane newly described herein.

[Exercise alveolar hypoventilation in long-term survivors of bronchopulmonary dysplasia]. / Hypoventilation alvéolaire à l'exercice chez des enfants avec dysplasie bronchopulmonaire.

BACKGROUND: We aimed to confirm that children who have survived bronchopulmonary dysplasia (BPD) display lower ventilation during exercise than healthy children, and to determine whether alveolar hypoventilation associated with exercise-induced hypoxemia occurred in these children. METHODS: Twenty children with BPD (birth weight 1441+/-523 g [mean +/- SD], gestational age 31+2.3 weeks), aged 7 to 14 years, and 18 matched healthy children, born at term, performed resting pulmonary function and cardiopulmonary incremental exercise tests. Arterialized capillary blood gases were measured at rest and at maximal exercise in the BPD group. RESULTS: The BPD group showed moderate expiratory airflow limitation and hyperinflation. Maximal oxygen uptake and ventilatory threshold were similar in the two groups. The BPD group displayed ventilatory limitation on exercise, with greater use of the ventilatory reserve (p<0.01), lower maximal ventilation (p<0.01), tidal volume (p=0.01). Changes in ventilation (p<0.0001) and tidal volume (p=0.003) during exercise were significantly smaller in the BPD group than in controls, at similar submaximal workloads. At peak exercise, we observed hypoxemia in 12 BPD children (60%). In the subgroup with hypoxemia, a significant increase in PaCO2 (p=0.01) was measured at peak exercise, showing alveolar hypoventilation sustained by the lower tidal volume. CONCLUSIONS: Despite normal maximal aerobic performance, BPD children showed ventilatory limitation on exercise, frequently with hypoxemia and alveolar hypoventilation. Despite an improvement in their pulmonary condition, continued follow-up by cardiopulmonary exercise testing, is strongly recommended.

Human leukocyte elastase hydrolysis of peptides derived from human elastin exon 24.

In normal and pathological tissues, polymorphonuclear leukocyte proteases (elastase, cathepsin G and proteinase 3) may generate soluble peptides through limited proteolysis of elastin, the main component of mature elastic fibres. Elastin-derived peptides display diverse biological activities including cell migration, differentiation, proliferation, chemotaxis, tumor progression and up-regulation of metalloproteinases. To be biologically active, their structures must adopt a beta-turn conformation which accommodates to the cell surface-located elastin binding protein. In this study, we established that human elastin exon 24-derived peptides are hydrolysed by leukocyte elastase, when the active site is fully occupied (from S(5) to S'(3)). As shown by mass spectrometry analyses, a major cleavage site was demonstrated at a Val-Ala bond and a minor one at Gly-Val bond. For longer peptides, the hydrolysed fragments could themselves be re-hydrolysed. If the shortest fragments do not contain the GxxPG sequence known to stimulate cellular effects, some of the intermediates together with hydrolysis fragments generated by other proteases such as proteinase 3, may possess this motif.

Elastolytic activity of Pseudomonas aeruginosa elastase.

Elastolysis of insoluble elastin by Pseudomonas aeruginosa elastase was found to be less specific (higher apparent Km value) but more active (higher activity) than with pancreatic elastase. Furthermore, pancreatic and P. aeruginosa elastases act synergistically during the initial stages of elastolysis. After extensive hydrolysis, the size distribution of digestion products was lower with P. aeruginosa than with pancreatic elastase. The higher extent of hydrolysis may be explained by the fact that, if pancreatic elastase needs at least six sub-sites for activity, P. aeruginosa elastase may hydrolyse tetrapeptides such as tetraalanine, or synthetic substrates such as furylacryloyltripeptides FA-X-Leu-Y, X and Y being Gly and/or Ala.

Recent trends in protease-catalyzed peptide synthesis.

Enzymatic peptide syntheses may be either thermodynamically- or kinetically-controlled. The former may be catalyzed by any proteases; the latter is limited to serine and cysteine proteases. This methodology is quite stereospecific and avoids side chain protection but is suffering of some drawbacks. Thus, only two industrial processes are by now developed: the production of aspartame and the conversion of porcine into human insulin. However, recent improvements have been carried out in different directions: 1-Search for proteases with high and/or new P'1 and P1 specificities. 2-Protease engineering to promote synthesis towards hydrolysis and to enlarge specificity. 3-Development of mimetic or "inverse" substrates to limit further hydrolysis of synthesized peptide. 4-Change of the physical state of reactants. Three axes have mainly be explored: solid-solid conversion, use of cross-linked enzyme crystals (CLEC) and enzyme immobilization. 5-Modification of experimental conditions. The principal and recent developments deal with: heterogeneous catalysis, synthesis in low water-containing organic solvents, in ionic liquids or at subzero temperatures. This review will illustrate these new orientations with examples described in the recent literature.

Hemodynamic and electrophysiologic effects of a new alpha 2-adrenoceptor agonist, rilmenidine, for systemic hypertension.

The hemodynamic and electrophysiologic effects of rilmenidine were examined after single oral administration to hypertensive patients. In 8 untreated hypertensive patients, cardiac output, pulmonary pressure and blood pressure were measured before and for 10 hours after the administration of 25 micrograms/kg of rilmenidine (1.3 to 2.4 mg, mean 1.88). In addition, electrophysiologic investigations were performed before and 2 hours after administration. Hemodynamics were repeated in 8 other hypertensive patients receiving 50 micrograms/kg rilmenidine (3.0 to 4.8 mg, mean 3.85 mg). The electrophysiologic study was repeated in 8 other hypertensive patients receiving 50 micrograms/kg of rilmenidine (3.2 to 4.4 mg, mean 3.90). In contrast to the results obtained at the dose of 50 micrograms/kg, there was no significant variation in pulmonary arterial pressure, cardiac index or stroke index after administration of 25 micrograms/kg. No significant variation was observed in heart rate, sinus function, conduction parameters or atrial, nodal and ventricular refractory periods after administration of 25 and 50 micrograms/kg. Rilmenidine, after single oral administration at the 25 micrograms/kg dose, led to a significant reduction in blood pressure and peripheral resistance without any significant change in cardiac output; the 25- and 50-micrograms/kg doses led to no alteration in heart rate and cardiac electrophysiology.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study).

BACKGROUND: In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database. METHODS: The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors. RESULTS: Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival. CONCLUSION: Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

Convective heat transfer around an infant head.

Knowledge of heat and mass transfer between an infant and his environment is necessary to control hospital care conditions, or understand a pathology as Sudden Infant Death Syndrome (SIDS). This paper precises the particular importance of the heat transfer over the head and quantifies the influence of various parameters on natural convection heat transfer.

Human aortic elastin from normal individuals and atherosclerotic patients: lipid and cation contents; susceptibility to elastolysis.

Aortic elastins, isolated from 30 humans of different ages, were purified by alkaline extraction, and separated into two groups depending on the presence of atherosclerotic plaques and calcification (grades 0 and 1). It was confirmed that the severity of atherosclerosis increases significantly with age (P less than 0.001) and elastin content decreases with atherosclerosis (P less than 0.001). The hydrolysis of the aortic elastins using pancreatic porcine elastase (PPE) was studied. It was observed that increased elastolytic activities are connected with severity of atherosclerosis (P less than 0.001) and both Vm and Km apparent kinetic parameters are affected (P less than 0.001). Correlation tests have shown that enzymatic hydrolysis is significantly modified by cholesterol (P less than 0.05), calcium (P less than 0.001) and magnesium concentrations (P less than 0.01) but only cholesterol changes significantly Vm and Km parameters.