Search

The aim of this study is to evaluate if surgical experience could influence the outcomes of retrograde intrarenal surgery (RIRS) in terms of stone clearance and complication rate. Patients from five institutions were included in this study. Patients were divided into two groups. Group 1: patients treated by three surgeons in the early phase of learning curve (surgical experience100 procedures); Group 2: cases operated by two surgeons with great endourological experience (400 procedures). Patients and stone characteristics, outcome and complications were analyzed. Multivariable regression model was used. Differences between groups were estimated using propensity scores to adjust for the bias inherent to the different characteristics. 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). Clinical data and stone parameters were comparable. The SFR was 70 % in Group 1 and 77.9 % in Group 2 (p = 0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1 min, p = 0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7, p = 0.001). At unadjusted analysis, a non-significant difference was found between centers on SFR (OR 1.51 95 % CI 0.95-2.41). Conversely, a significant difference was found on overall complications (OR 0.36 95 %CI 0.20-0.67) with lower overall complication in Group 2. This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success.

Objective Plasmodium ovale malaria occurs mainly from mild form of malaria. We present a rare case of a splenic rupture secondary to complication of Plasmodium ovale malaria. Clinical presentation A 41-year-old female from Mali admitted to intensive care unit with hemorrhagic shock secondary to splenic rupture. A laparoscopic exploration was performed and patient received a massive blood transfusion for a hemodynamic stabilization. The diagnosis of malaria was confirmed by a blood smear test indicating the presence of P. ovale. A treatment of injectable Quinine was initiated with a positive outcome. Conclusion Although usually considered as a cause of a mild form of malaria, P. ovale may be responsible for a ruptured spleen which can lead to a state of life- threatening hemorrhagic shock.

La pneumopathie est frequente chez le sujet âge. Du fait de sa semiologie souvent trompeuse avec notamment l’absence de signes specifiques, la radiographie de thorax doit etre pratiquee de facon assez large chez une personne âgee. La tachypnee doit etre recherchee systematiquement. Les scores pronostiques aident a la decision de prise en charge ambulatoire ou hospitaliere mais ne tiennent pas compte du contexte social. Le pneumocoque reste la cause la plus frequente de pneumonie du sujet âge, mais l’antibiotherapie initiale probabiliste doit aussi etre active sur les bacilles a Gram negatif et les staphylocoques.

There are no established guidelines for the treatment of disseminated strongyloidiasis in immunosuppressed patients, and many different treatment regimens have been used. Here, the case of a 48-year-old, HIV-positive, Congolese man, who was hospitalized for disseminated tuberculosis but developed life-threatening disseminated strongyloidiasis, is described. This patient died, with relapsing disseminated strongyloidiasis, 3 months after being treated with ivermectin. The reasons for this poor outcome and the various treatment options for strongyloidiasis in HIV-infected patients are discussed.

Resume Introduction Le lymphome de Hodgkin (LH) est une hemopathie lymphoide caracterisee par la presence de cellules de Reed-Sternberg ou de Hodgkin en histologie. Son evolution est marquee par une survie superieure a 80 %. Etats des connaissances L’atteinte thoracique initiale est frequente, surtout mediastinale, plus que parenchymateuse pulmonaire ou pleurale. Dans ces deux derniers cas, elle change le pronostic et un diagnostic est donc necessaire. Les complications des traitements du LH etaient representees, precocement, par les infections. Actuellement, ce sont plutot les atteintes fonctionnelles respiratoires apres radiotherapie mediastinale et chimiotherapie (incluant de la bleomycine) qui surviennent frequemment dans le suivi du LH. Par ailleurs, certaines atteintes granulomateuses precedent, accompagnent ou emaillent l’evolution du LH et le diagnostic differentiel avec des localisations specifiques est souvent difficile. Enfin, ces patients sont plus a risque de voir apparaitre des neoplasies, notamment bronchiques, a long terme. Perspectives et conclusions Les patients porteurs de LH ont maintenant une faible mortalite imputable directement a la maladie en comparaison de celle, souvent plus tardive, rapportee aux traitements. L’enjeu actuel est de developper des protocoles therapeutiques moins toxiques mais tout aussi efficaces.

Resume La fibroscopie bronchique en reanimation ne se greve generalement pas de complications majeures, mais se heurte a des contraintes particulieres chez le patient ventile mecaniquement. Certaines precautions de reglage du ventilateur et, si possible de difference de diametre entre sonde d'intubation et fibroscope, doivent etre respectees afin de ne pas engendrer de complications propres a cette procedure, notamment chez le patient hypoxemique. La sedation est le plus souvent necessaire, voire indispensable, mais ses effets n'ont pas ete evalues. L'utilisation du fibroscope au travers d'autres interfaces (masque facial ou larynge) se developpe du fait de l'essor de la ventilation non invasive. Dans cette situation, ou la tolerance semble bonne sur les premieres etudes, les contre-indications doivent etre scrupuleusement respectees et la balance benefice/risque bien evaluee. Des etudes sont necessaires dans ces situations pour que la tolerance de la fibroscopie bronchique soit mieux connue et amelioree.

Resume La ventilation est une activite cyclique continue durant laquelle se succedent des phases inspiratoires et des phases expiratoires. Cette activite n'est pas monotone et la diversite, ou variabilite, des cycles respiratoires n'est probablement pas fortuite. Une maniere d'apprehender la complexite du controle de la ventilation pourrait etre d'etudier la variabilite dans le temps des grandeurs de sortie du « generateur ». Outre l'approche physiopathologique, un certain nombre d'etudes preliminaires montrent l'interet d'analyser la variabilite de la ventilation dans certaines conditions pathologiques. Ainsi, en reanimation la baisse de la variabilite de la ventilation pourrait etre un marqueur predictif de l'echec de l'extubation. Enfin, l'utilisation d'une assistance ventilatoire variable semble pouvoir ameliorer l'oxygenation des malades presentant une hypoxemie postoperatoire.

Resume Introduction De nombreuses inconnues demeurent quant a la place de la tracheotomie en reanimation. Les reticences a la realisation d’une tracheotomie sont nombreuses, surtout quand pre-existe une insuffisance respiratoire chronique (IRC), mais certaines donnees suggerent des benefices. Cette etude a pour objectifs d’evaluer l’impact de la tracheotomie sur la mortalite en reanimation et a l’hopital, et d’analyser et le role d’une IRC prealable. Materiel et methodes Etude retrospective cas-temoins, a partir d’une base de donnees prospective et exhaustive « MSI », sur 6 ans. Sur 2 901 malades admis pendant une periode de 5 ans, 882 patients intubes et ventiles ont ete identifies. 127 patients tracheotomises (T+) ont ete compares a 755 patients non tracheotomises (T-), et avec un sous-groupe « T-app » apparie a T+ pour la severite a l’admission (IGS2). Resultats La mortalite en reanimation et a l’hopital etait significativement moindre dans T+ que dans T- (28 vs. 52 % et 42 vs. 59 %), et les durees de sejour superieures. C’etait egalement le cas apres appariement sur la gravite a l’admission (T+ par rapport a T-app : 28 vs. 49 % et 42 vs. 53 %). Une IRC prealable n’influencait pas le devenir des patients tracheotomises, qu’il s’agisse d’une insuffisance respiratoire obstructive, restrictive « pulmonaire », ou neuromusculaire. Conclusions Une tracheotomie peut, dans certaines populations de patients ventiles artificiellement et dans certains contextes de soins, etre associee a une reduction de la mortalite hospitaliere.

Resume Introduction Une mise en route efficace et une surveillance optimale sont les elements essentiels a la reussite de la ventilation a domicile (VAD). Etat des connaissances La mise en route est preferablement realisee dans une structure hospitaliere. Le choix du materiel est d’une importance capitale mais il n’y a pas de superiorite demontree d’un type de materiel par rapport a un autre. La surveillance de la VAD sera inevitablement marquee par de multiples problemes pouvant faire interrompre la therapeutique. Tous ces problemes auront souvent des solutions simples, recensees dans cet article. Perspectives Malheureusement, il existe encore de nombreux ecueils dans la surveillance. Le principal etant l’absence de donnees precises sur le sommeil des patients ventiles ne permettant pas une surveillance nocturne optimale. Un autre ecueil important est l’absence d’adaptation des interfaces aux patients handicapes. Enfin, le transfert des responsabilites et de la charge de travail vers les intervenants a domicile, dont la famille, avec un desengagement de l’hopital est aussi un fait marquant de la VAD. Conclusions Une mise en route et une surveillance optimale sont les gages d’efficacite de la VAD. Les pieges, les erreurs, des manques de connaissances sont souvent cause d’abandon de la therapeutique. Cet article propose des outils d’amelioration de ces deux etapes essentielles.

Objective: Pulse oximetry (SpO2) is a standard monitoring device in intensive care units (ICUs), currently used to guide therapeutic interventions. Few studies have evaluated the accuracy of SpO2 in critically ill patients. Our objective was to compare pulse oximetry with arterial oxygen saturation (SaO2) in such patients, and to examine the effect of several factors on this relationship. Design: Observational prospective study. Setting: A 26-bed medical ICU in a university hospital. Patients: One hundred two consecutive patients admitted to the ICU in whom one or serial arterial blood gas analyses (ABGs) were performed and a reliable pulse oximeter signal was present. Interventions: For each ABG, we collected SaO2, SpO2, the type of pulse oximeter, the mode of ventilation and requirement for vasoactive drugs. Measurements and results: Three hundred twenty-three data points were collected. The mean difference between SpO2 and SaO2 was –0.02% and standard deviation of the differences was 2.1%. From one sample to another, the fluctuations in SpO2 to arterial saturation difference indicated that SaO2 could not be reliably predicted from SpO2 after a single ABG. Subgroup analysis showed that the accuracy of SpO2 appeared to be influenced by the type of oximeter, the presence of hypoxemia and the requirement for vasoactive drugs. Finally, high SpO2 thresholds were necessary to detect significant hypoxemia with good sensitivity. Conclusion: Large SpO2 to SaO2 differences may occur in critically ill patients with poor reproducibility of SpO2. A SpO2 above 94% appears necessary to ensure a SaO2 of 90%.

The use of heat and moisture exchangers (HME) during noninvasive ventilation (NIV) can increase the work of breathing, decrease alveolar ventilation, and deliver less humidity in comparison with heated humidifiers (HH). We tested the hypothesis that the use of HH during NIV with ICU ventilators for patients with acute respiratory failure would decrease the rate of intubation (primary endpoint) as compared with HME.We conducted a multicenter randomized controlled study in 15 centers. After stratification by center and type of respiratory failure (hypoxemic or hypercapnic), eligible patients were randomized to receive NIV with HH or HME.Of the 247 patients included, 128 patients were allocated to the HME group and 119 to the HH group. Patients were comparable at baseline. The intubation rate was not significantly different: 29.7% in the HME group and 36.9% in the HH group (p = 0.28). PaCO2 did not significantly differ between the two arms, even in the subgroup of hypercapnic patients. No significant difference was observed for NIV duration, ICU and hospital LOS, or ICU mortality (HME 14.1 vs. HH 21.5%, p = 0.18).In this study, the short-term physiological benefits of HH in comparison with HME during NIV with ICU ventilators were not observed, and no difference in intubation rate was found. The physiologic effects may have been obscured by leaks or other important factors in the clinical settings. This study does not support the recent recommendation favoring the use of HH during NIV with ICU ventilators.

— Within the superficial layers of healthy skin and of some mucosae there is a Population of accessory cells of the immune system, able to interact with T helper lymphocytes. Such cells, called tissular dendritic cells (DCs), increase their density and display different morphological features in a variety of immunologically-mediated dermatological disorders. In the present work we investigated DCs within the various urethral segments, both in normal conditions and in urethral stenosis. The specimens, obtained from urethrectomies and urethroplasties with end-to-end anastomosis, were stained with anti-S100 protein antibody and immunofluorescence techniques. We demonstrated an increasing density of S100 protein-positive epithelial DCs from the Prostatic urethra to the glandular one, where DCs were also larger and richer in dendritic Processes. In urethral stenosis the intraepithelial infiltrate of ramified DCs was much denser than any other control. We therefore hypothesize a role for the immune system in the development and maintenance of urethral stenoses, where, as already demonstrated for other types of pathological scarring, morphological changes of DCs serve as clues to their functional activation.

Hunter syndrome is a lethal lysosomal storage disorder caused by the deficiency of iduronate-2-sulfatase and characterized by severe skeletal and neurological symptoms. Only symptomatic treatments are available and, although bone marrow transplantation has been suggested, no encouraging results have been obtained so far. Therefore, gene therapy might be a route to be pursued for treatment of the disease. In this respect, one major goal to achieve is the generation of an overexpressing vector able to correct, in particular, central nervous system (CNS) cells. Adenoviruses have been shown to infect CNS cells efficiently with minor or even absent immunological response. We describe the generation of a replication-defective adenoviral vector, AdRSVIDS, which is able to express in vitro high levels of iduronate-2-sulfatase. After infection, accumulation of mucopolysaccharides in treated Hunter cells was normalized. Furthermore, endocytosis of the transduced IDS did occur via the mannose-6-phosphate (M6P) receptor. Since no animal model for the disease is available, we developed a system based on the generation of derma-equivalents which enabled us to verify the expression of high levels of sulfatase up to 30 days after infection.

Metastatic renal cell carcinoma has a poor prognosis, requiring systemic therapy, in addition to radical nephrectomy. Since August 1989, 50 patients were treated with continuous, systemic, chronobiological infusion of FUDR (floxuridine) at our Institution. We reported 11.7% of objective responses, a long period of stable disease and low toxicity. We also compared our actuarial survival with the results obtained with recombinant IL-2 treatment.

The plasticity of the enteric nervous system in adulthood has always been a field of research of the greatest interest. Many experimental models have been developed, allowing to investigate the importance of the peripheral field of innervation in the control of growth and differentiation of enteric neurons during postnatal life (Filogamo, 1987; Filogamo and Cracco, 1995). Among those, we were particularly interested in the chemical ablation of the myenteric plexus by means of a cationic surfactant, benzalkonium chloride (BAC).

In the Fifties we developed an experimental model of neuronal plasticity in adulthood, involving the intestinal myenteric plexus. Causing an incomplete stenosis of the gut, the thickness of the wall and the diameter of the lumen underwent a massive increase on the oral side of the obstruction. The myenteric neurons innervating such hypertrophic and hyperplastic smooth muscle became hypertrophic and increased their number per ganglion, in absence of mitoses. Therefore we hypothesized the existence of a reserve pool of morphologically undifferentiated elements within the plexus, undergoing differentiation under conditions of functional hyperactivity. Some recent experiments suggest once again the existence in adulthood of a reserve pool of potential neurons. In fact, we put in evidence a subpopulation of NADPH-diaphorase positive myenteric neurons, very small in size orally to the stenosis and even smaller in the control gut. Following experimental ablation of the myenteric plexus in an intestinal segment and induction of hypertrophy in its smooth muscle layers, we found a two-five-fold increase in neuronal density along mesenteric nerves. This increase is probably due to the recruitment of cells, not readily identifiable as neurons, along mesenteric nerves in an attempt to reinnervate the damaged ileum. Moreover, it is demonstrated that hypertrophic smooth muscle cells may induce neuronal differentiation of transplanted PC12 cells. Finally, we explain the decreased total number of myenteric neurons in advanced age with the exhaustion of this reserve pool: in fact, NADPH-diaphorase positive small neurons in the myenteric plexus of old rats could not be found.

The subpopulation of myenteric neurons able to synthesize nitric oxide was studied quantitatively in the adult rat, using the NADPH-diaphorase histochemical method on whole-mount preparations of distended distal ileum. The spatial density of NADPH-diaphorase-positive myenteric neurons was 2388 +/- 193/cm2 (S.D.; five rats), comprising about 27% of the nerve cell bodies per ganglion. Most neurons were intensely stained and displayed predominantly a Dogiel type I morphology; about 8% of the labelled nerve cells were ovoid neurons, exhibiting a pale cytoplasmic reaction product. The mean somatic size of all NADPH-diaphorase-positive myenteric neurons was 446 +/- 40 microns2, with a mean nuclear size of 96 +/- 18 microns2 (mean values +/- S.D.; five rats). Such values fell exactly within the range of neuronal sizes of the total myenteric population, marked by means of NADH-diaphorase histochemistry. Therefore, the morphometric analysis did not identify any peculiar cell size feature, characterizing this specific nerve cell subpopulation. Thus, the present study provides quantitative data on the size, density and proportion of those myenteric neurons that may synthesize nitric oxide in the distal ileum of the rat.

The application of a 2 mM solution of the cationic surfactant benzalkonium chloride (BAC) to an ileal segment produced a selective and extensive myenteric denervation. The aim of the present study was to investigate whether such a selective unbalance of the enteric nervous system in the adult rat elicited any plastic response within the mesenteric nervous structures contacting it. Acetylcholinesterase (AChE) staining, β-nicotinamide adenine dinucleotide (NADH) and β-nicotinamide adenine dinucleotidephosphate (NADPH) diaphorase histochemistry and glyoxilic acid-induced fluorescence were performed on whole-mount preparations of myenteric plexus and mesenteric nerves. In both control and BAC-treated animals nervous elements were detected along the mesenteric nerves. Although rather similar in position, shape and size, these neurons displayed striking differences with regard to their arrangement and density per nerve. In the controls, few small aggregates of neurons could be detected; more commonly, isolated nerve cell bodies were scattered along the nerve trunks. In the BAC-treated animals, numerous spherical or spindle-shaped clusters of neurons were located along the nerves; the mean neuronal density per nerve displayed a two-five-fold increase over the control values. The observed changes within the mesenteric nerves might be involved in an attempt at reinnervation of the BAC-treated intestinal segments from extraenteric sources.

Langerhans cells (LCs) seem to play a crucial role in the immune system of the skin. Changes in their density, distribution, phenotype and/or morphology have been described in a number of skin diseases, mostly immunologically mediated. For this reason, we investigated LCs in human hypertrophic scars, since these scars are presently believed to have an immunological basis. A preliminary analysis of the histological features was carried out on vertical serial sections, stained with hematoxylin and eosin. Both epidermal and dermal components of hypertrophic scar biopsies were examined. The total epidermal thickness and the thickness of the single epidermal layers were also measured; the values obtained were similar to those of control skin and normotrophic scars. Subsequently, CDla-positive LCs, revealed by indirect immunofluorescence and immunoperoxidase techniques, were studied to determine their position among the epidermal layers and within the dermis, their dimensions, their density and their morphology. According to these observations, two main types of hypertrophic scars were identified. In the first type (7 scars), LCs were widely clustered within both the whole epidermis and the dermis. Their density was increased (about 750 cells/mm2 of epidermal area), if compared to control skin and normotrophic scars (both about 400 cells/mm2 of epidermal area; p less than 0.001). The epidermal cell profiles, nearly three times larger than those of control skin, exhibited a dense network of interconnected dendrites. Further analysis for the presence of HLA-DR molecules revealed an anomalous expression of these antigens on keratinocytes. In the second type (3 scars), LCs density within the stratum Malpighii was unchanged, relative to control skin and normal scars, while CDla-positive cell bodies remained numerous in basal position and within the subpapillary corion. Epidermal LCs, only slightly larger than those evidentiated in control skin, displayed short and retracted dendritic projections. The aberrant expression of HLA-DR antigens on keratinocytes was very weak and sparse. The present results strongly suggest an immunologically activated state of the tissues examined; they provide morphological data that support the involvement of the immune system in hypertrophic scarring.

In the present study, we investigated Langerhans cells (LCs) in the epidermal component of human atrophic scars, comparing them with those in control skin and normotrophic scars. A preliminary analysis of the histological features was first carried out on vertical serial sections, stained with hematoxylin and eosin. The total epidermal thickness and the thickness of the single epidermal layers were then measured, by means of a digitizing tablet and a morphometric program run on an Apple IIe computer. These parameters were found to be significantly lower (40%) in atrophic scars, if compared to control skin and normotrophic scars (p less than 0.05). CDla-positive and HLA-DR-positive LCs were marked by indirect immunofluorescence. Their position among the epidermal layers, their dimensions, their density and their morphology were examined. In atrophic scars, LCs were densely and evenly distributed in all the epidermal layers. Their density was increased (about 1200 cells/mm2 of epidermal area), if compared to control skin and normotrophic scars (both 300-400 cells/mm2 of epidermal area; p less than 0.001). The CDla-positive definite cell bodies, exhibiting an unstained nucleus, were as large as those evidentiated in the normotrophic scars and twice as much the control skin values (p less than 0.001). The present results provide morphological data that distinguish atrophic scars from control skin and normotrophic scars, and suggest an involvement of the Langerhans cells in this particular case of pathological scarring.