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The kinetics of IgG antibodies after coronavirus disease 2019 (COVID‐19) remain poorly understood. We investigated factors influencing severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) IgG antibody levels and time to seronegativation during the follow‐up of severe and critically ill patients. We retrospectively reviewed serological evaluations drawn during the follow‐up of severe or critical laboratory‐proven COVID‐19 patients hospitalized at a large academic hospital. Specific IgG titers were measured using a chemiluminescent assay targeting anti‐spike and anti‐nucleocapsid protein IgG. The influence of time, demographic factors, clinical and paraclinical characteristics, and COVID‐19 therapeutics on IgG levels were assessed through linear regression using a mixed‐effect model, and delay until IgG negativation through a Weibull regression model. The cohort included 116 patients with a total of 154 IgG measurements drawn at a median of 79 days after diagnosis. IgG antibodies were increased with age (p = 0.005) and decreased significantly over time (p = 0.0002). Using elapsed time and age as covariates, we demonstrated higher IgG levels in patients with a higher body mass index (BMI) (p = 0.0026) and lower IgG levels in immunocompromised patients (p = 0.032). A high BMI was further found to delay and immunodeficiency to hasten significantly seronegativation, whereas no significant effect was observed with corticosteroids. These data highlight the waning over time of IgG antibodies after severe or critical COVID‐19. Age, BMI, and immunosuppression also appear to influence the IgG kinetics, while short‐term corticotherapy does not. Those data improve the understanding of SARS‐CoV‐2 serology while further research should determine the determinants of long‐term seroprotection., Highlights Anti‐SARS‐CoV‐2 IgG antibody levels measured during follow‐up of severe and critical COVID‐19 were studied. We analyzed the influence of time, demographics, clinical and paraclinical characteristics and COVID‐19 treatments on specific IgG levels and time to seronegativation. Time and immunodepression were associated to reduced IgG levels at follow‐up, while age and BMI were associated to increased levels. Corticosteroids given as short‐term treatment for COVID‐19 did not show influence. BMI and immunodepression were respectively associated with decreased and increased rates of seronegativation.

Background: Management of bile duct injury (BDI) after cholecystectomy is challenging. The authors analyzed their center’s 49-year experience.Methods: From 1968 to 2016, 120 consecutive patients we...

Chemotherapeutic advances have enabled successful cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) expansion in treating metastatic colorectal cancer. The aims of this study were to evaluate the safety of combining liver surgery (LS) with HIPEC and CRS (which remains controversial) and its impact on overall survival (OS) rates. From 2007 to 2015, a total of 77 patients underwent CRS/HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer. Twenty-five of these patients underwent concomitant LS for suspicion of liver metastases (LM; group 2), and were compared with patients who underwent CRS/HIPEC only (group 1). Demographic and clinical data were reviewed retrospectively. Among the group 2 patients, two underwent major hepatectomies, six underwent multiple wedge resections, 16 underwent single wedge resections (one with radiofrequency ablation), and one underwent radiofrequency ablation alone. For groups 1 and 2, median peritoneal cancer index was 6 and 10 (range 0–26; p = 0.08), complication rates were 15.4 and 32.0 % (Dindo–Clavien ≥3; p = 0.15), and median follow-up was 34.2 and 25.5 months (range 0–75 and 3–97), respectively. One group 2 patient died of septic shock after 66 days. Pathology confirmed LM in 21 patients in group 2 (four with benign hepatic lesions were excluded from long-term outcome analysis). Two-year OS rates were 89.5 and 70.2 % (p = 0.04), and 2-year recurrence-free survival rates were 38.3 and 13.4 % (p = 0.01) in groups 1 and 2, respectively. Simultaneous surgery for colorectal LM and PC is both feasible and safe, with low postoperative morbidity. Further longer-term studies would help determine its impact on patient survival.

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant. Methods: Nine MHCN were encountered in our centre for over 32 years. Patients’ clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification). Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1–132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free. Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable

Venous thromboembolism has been reported in association with cytomegalovirus (CMV) infection both in immunocompromised and immunocompetent patients. In this population, it is yet undetermined whether CMV alone provokes VTE or other predisposing conditions are involved.1007 VTE patients consecutively recruited in one academic hospital were analyzed retrospectively in order to identify acute CMV infection. Acquired and inherited risk factors were screened. Only adults and immunocompetent patients were included.Among 1007 consecutive VTE patients, we identified 10 patients with synchronous acute CMV infection. Patients with coexistent VTE and acute CMV infection were younger (37.5 years vs. 56.6 years; p = 0.0088) and exhibited a female predominance (90% vs. 56%; p = 0.026), in comparison to the whole cohort. Hereditary thrombophilia was identified in 9 out of 10 patients. Acquired risk factors for VTE like estrogens administration and pregnancy were equally prevalent in patients with and without CMV infection.Acute CMV infection is a potential contributor to VTE whenever other prothrombotic conditions are required. This should help clinicians to privilege a limited duration of anticoagulant treatment like in other provoked VTE.

Background. Hypoalbuminemia commonly observed in cirrhosis is considered to be mainly related to hepatocellular dysfunction. However, the correlation between the decrease in serum albumin and liver function is far from linear and arguments in favor of an additive role of protein-losing enteropathy have been brought by a few studies. Aim. To assess the potential role of protein-losing enteropathy in a group of patients with cirrhosis, portal hypertension, and hypoalbuminemia. Design and methods. Eleven patients with documented cirrhosis, portal hypertension, and a low serum albumin level compared to liver function underwent an (111)In-transferrin scintigraphy. Results. Using this sensitive method of investigation, nine exhibited features suggestive of exudative enteropathy. Serum albumin level and digestive protein loss were even correlated (Pearson's coefficient = -0.529, one-sided p = 0.047). Protein loss were however not correlated with the degree of portal hypertension or with the extent of liver dysfunction evaluated by the aminopyrine breath test. Conclusions. Our preliminary data obtained in a small group of selected patients with cirrhosis, portal hypertension, and hypoalbuminemia indicate that protein-losing enteropathy may represent an appreciable and underestimated cause of hypoproteinemia.

BACKGROUND: Hepatotoxicity from neoadjuvant chemotherapy before liver resection for colorectal metastases (CRLM) has been recently reported. The purpose of the present study was to evaluate the prevalence and the clinical relevance of this phenomenon. It was a retrospective study conducted at an academic secondary referral hospital. METHODS: One hundred patients suffering from CRLM and having undergone the resection of at least 1 liver segment (114 hepatectomies; 100 first, 13 second, 1 third) were enrolled. The surgical specimens were reviewed using standardized criteria for diagnosis and grading of pathological liver changes. Their impact on perioperative bleeding, transfusion, morbidity, and mortality rates after liver resection was studied. RESULTS: Sinusoidal congestion was the single hepatotoxic lesion significantly more frequently encountered in patients having received neoadjuvant chemotherapy (P = .0014), even in patients having received chemotherapy more than 6 months before liver resection, but was not related to the type of chemotherapy. Despite a significant increase in perioperative blood losses, the presence of sinusoidal lesions, even severe, had no clinically significant effect on postoperative mortality, morbidity, and transfusion rates. CONCLUSION: Neoadjuvant chemotherapy before operation for CRLM is significantly associated to sinusoidal congestion, irrespective of the type of chemotherapy but without any significant impact on postoperative clinical outcome. Sinusoidal lesions may persist more than 6 months after the end of chemotherapy.

OBJECTIVES: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality. METHODS: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality. RESULTS: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p

Volumetric capnography provides a breath-by-breath analysis of ventilation-perfusion imbalances and deadspace volumes. The technique has been best described in intubated and ventilated patients, but promising clinical applications also concern spontaneously breathing patients. The objective of the study was to verify the reliability and reproducibility of a new capnographic program in various types of clinical conditions. In a first step, 56 patients, either healthy or with acute respiratory disorders, were connected to a sidestream gas sampler and flow sensor through a mouthpiece. An acquisition software synchronized expired CO2 and flow data to create volumetric capnographic curves. Mixed expired CO2 partial pressure, corresponding to the exhaled CO2 of the effective tidal volume, was simultaneously collected in a neoprene bag for comparison. In a second step, changes in airway deadspace before and after the adjunction of known spacer volumes were compared in six healthy volunteers. The mean difference between both methods in measuring mixed expired CO2 partial pressure was -0.9 mmHg (SE 0.2 mmHg, P

The aim of the study was to evaluate the prevalence and the risk factors of ventilation-associated pneumonia (VAP) for out-of-hospital or in the emergency department intubated patients. This was a retrospective descriptive study. All intubated adults subsequently admitted to the ICU over 1-year period were included. Among 75 patients, 15 patients developed VAP (20%; 95% CI 12-31%). A multivariate analysis revealed three variables independently associated with VAP: cardiorespiratory arrest as the reason of intubation (P=0.001), out-of-hospital as the location of intubation (P=0.011), and clinical macroaspiration as clinical characteristic at the time of intubation (P=0.024). Death rate was 17% and was not significantly higher for patients with VAP (P=0.9; 95% CI 0.32-4.95%). Emergency care workers should be aware of the potential 20% occurrence of VAP when they intubate and ventilate a patient. Preventive strategies, which have been proven effective in ICUs, should be implemented in the emergency setting.

PURPOSE: To compare multi-detector row computed tomography (CT) and ventilation-perfusion (V-P) scintigraphy in the diagnosis of acute pulmonary embolism (PE) in outpatients who were cared for in the emergency department. MATERIALS AND METHODS: Ninety-four nonconsecutive patients, in whom acute PE was suspected, underwent thin-collimation multi-detector row CT (collimation, 4 x 1 mm; pitch, 1.25; scanning time, 0.5 second) and V-P scintigraphy. Concordance between CT and scintigraphic images was used in the diagnosis of PE. Pulmonary angiography was performed within 24 hours if interpretations of V-P and spiral CT images were inconclusive or discordant. Sensitivity and specificity values were calculated for V-P scintigrams and CT scans of the lungs. The rates of conclusive results for scintigraphy and CT were compared. RESULTS: The sensitivity of thin-collimation multi-detector row CT and V-P scintigraphy for the detection of PE was 96% (27 of 28; CI: 82%, 99%) and 98% (65 of 66; CI: 92%, 99%), respectively. The specificity of CT and V-P scintigraphy was 86% (24 of 28; CI: 67%, 96%) and 88% (58 of 66; CI: 77%, 94%), respectively. Seven V-P scintigrams were of intermediate probability, and one spiral CT study was indeterminate. Examinations with spiral CT yielded conclusive results more often than examinations with planar V-P scintigraphy (P

Bacillary angiomatosis is an infection caused by Bartonella, which has first been described in human immunodeficiency virus (HIV)-infected patients. We report an unusually located lesion, in a totally asymptomatic kidney transplant recipient. The diagnosis was strongly suggested based on the iconography and our histological analysis, but was not confirmed using polymerase chain reaction (PCR) and immunohistochemical studies. We illustrate our difficult way to the diagnosis as well as the course of the disease and our therapeutic strategy.

The presence of the 20210A allele of the prothrombin gene has recently been shown to be a risk factor of venous thromboembolism, probably mediated through increased prothrombin levels. The aim of the study was to determine the frequency of the prothrombin 20210A allele in 193 consecutive unselected patients with venous thromboembolism and 100 healthy controls and to analyze the clinical profile associated with this new inherited thrombophilic factor. In agreement with previous reports, we found a frequency of 7.3% of heterozygous carriers of the 20210A allele among patients and 1% among controls. We confirm that plasma prothrombin levels are more elevated in the individuals bearing the prothrombin 20210A allele compared with those who do not. We did not find any relationship between the presence of the prothrombin 20210A allele and either a family history of thromboembolism, the rate of recurrences or the age at disease onset. However, the co-inheritance in the same individual of both prothrombin 20210A allele and factor V Leiden was associated with a significantly lower age at disease onset suggesting a synergistic contribution of both abnormalities.

International audience; AIMS: To assess the clinical performance of pro-B-type natriuretic peptide 1-108 (proBNP) for the prognosis of acute pulmonary embolism. METHODS: This study was ancillary to a recently published multicentre study including 570 patients with acute pulmonary embolism. ProBNP values were analysed using a new sandwich immunoassay proBNP1-108, Bioplex2200 (Bio-Rade Laboratories). Data was compared with BNP and N-terminal (NT) proBNP values. Adverse outcomes at 30 days were defined as death, secondary cardiogenic shock, or recurrent venous thromboembolism. RESULTS: ProBNP values were analysed in 549 patients, with 39 (7.1%) presenting adverse outcomes. All three natriuretic peptides were significantly elevated in these 39 patients compared with the group without adverse outcomes (BNP: p < 0.001; NT-proBNP: p < 0.001; proBNP: 0.044), with median proBNP values being 605 pg/ml (113-1437) and 109 pg/ml (30-444), respectively. Multivariate analyses revealed that proBNP significantly depended on patient age (p < 0.001) and renal failure (p=0.001), with proBNP values increasing with both factors. The areas under the receiver operating curve were 0.74 (95% CI 0.69-0.79) for BNP, 0.76 (95% CI 0.72-0.80) for NT-proBNP, and 0.70 (95% CI 0.65-0.75) for proBNP, meaning that the performance of proBNP was significantly lower than that of the two other peptides (p = 0.017). CONCLUSION: ProBNP, BNP, and NT-proBNP values were significantly increased in patients with adverse outcomes after acute pulmonary embolism. However, the prognostic performance of proBNP for predicting adverse versus favourable outcomes was lower than that of the other natriuretic peptides, thus limiting the clinical relevance of proBNP as a prognostic marker in pulmonary embolism.

International audience; Background:If the prevalence of pulmonary embolism (PE) differs significantly between the US and Europe, this observation could reduce the generalizability of diagnostic protocols for PE derived in either location.Objective:To determine possible causes and potential clinical consequences of these PE prevalence differences.Methods:Secondary analysis of three prospectively collected multicenter samples (two French and one from the US) including 3174 European and 7940 American PE-suspected patients in Emergency departments (ED) (117 for Europe and 12 for US). Comparison of clinical features, resource use and outcomes of European- and US-suspected PE populations in ED.Results:European patients evaluated for PE were significantly older and had a higher clinical pretest probability (CPP) for PE. The final PE prevalence was significantly higher in Europe, in the overall sample (26.5% vs. 7.6%) and in each level of CPP. Suspected European patients categorized as low CPP had a higher posttest probability than US low CPP patients. Suspected US patients categorized as high CPP had a much lower posttest probability of PE than in Europe. The mean number of tests performed for one PE diagnosis was lower in Europe (7.4 vs. 21.6). Among patients diagnosed with PE, European patients had a higher mean severity of illness score and a higher PE-mortality rate (3.4% vs. 0.7%).Conclusions:Among patients suspected of a PE and those ultimately diagnosed with a PE, European patients had higher acuity, a higher pretest probability and worse outcome than US patients. The present study underscores the importance of disease prevalence for pretest probability scoring approaches and for significance interpretation of imaging tests.

Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking.A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis.Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p0.001], patient age greater than 70 years (OR 2.41, p0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV].Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high.

BACKGROUND: The progress of modern imaging studies has improved the diagnostic approach of benign liver tumours, leading to a tailored approach with increased conservative management. METHODS: One hundred and thirty-two patients suffering from benign hepatic tumours were enrolled in this study, including an operative (group I, 49 patients) and a conservative (group II, 83 patients) management. Patients' tumour and treatment features were analyzed. RESULTS: The mean patients' age was 39 years. Indication for resection based on diagnosis of tumour nature (hepatic cell adenoma or uncertain diagnosis) and significant tumour-related abdominal pain was 15% out of 33 patients with hepatic haemangioma, 21.7% out of 60 patients with focal nodular hyperplasia and 78.4% out of 37 patients with hepatocellular adenoma. Mortality was nihil in group I. Complications and transfusion rates were related to the performance of major hepatectomy, when required for huge tumours. With a 95.5% of complete patients' follow-up during a mean of 92 months in group I and 87 months in group II, no misdiagnosis or evolution towards malignancy was encountered. Interestingly, 87.9% of all observed benign liver tumours remained stable, decreased in size or disappeared. None of the remaining lesions required surgery. CONCLUSION: A restrictive policy of surgical management of benign liver tumours based on clinical symptoms, tumour size and nature on imaging studies (including dubious lesions) and tumour biopsies in selected cases is safe and reliable with a low-operative mortality in resected patients and satisfactory disease-control in the vast majority of observed benign liver tumours.

Between 1977 and 1989, 151 patients were treated in our institution for acute sigmoid diverticulitis. Thirty-one patients were operated on for diffuse peritonitis, and were excluded from the study. One hundred twenty patients had localized disease. There were 59 men and 61 women, with a mean age of 60 years (range, 30 to 87 years). Thirteen were under 40 years of age. A "phlegmonous" diverticulitis (no pericolic abscess) was diagnosed in 78 cases (group I). A pericolic abscess was identified in 42 cases (group II). The medical treatment was successful in 97% of the patients of the group I. Only 15 patients required a delayed elective resection for recurrence or chronic complications, within the next 24 months. There were no operative deaths. All the other patients were doing well after a mean follow-up of 5 years (9-144 months), without any disease-related death. Patients presenting with a localized pericolic abscess (group II, n = 42) were initially treated either conservatively (n = 22) or by a more or less extensive drainage (n = 20). There were two deaths in the "conservative" group. Primary or delayed colonic resection was indicated in 34 cases because of uncontrolled sepsis, recurrence or secondary chronic complications. It is concluded that accurate classification of the disease is essential. If no peritonitis has developed, the presence of an abscess is the main determinant in both prognosis and treatment. Most patients who develop an acute phlegmonous diverticulitis do well with conservative treatment, and prophylactic resection is not indicated. Curative colectomy is reserved for patients developing persistent complications over the next few months.(ABSTRACT TRUNCATED AT 250 WORDS)

PURPOSE: In order to assess the relation of thyroid function tests to human immunodeficiency virus (HIV) infection, we determined the levels of serum thyroid hormones, serum binding proteins [thyroxine-binding globulin (TBG), cortisol-binding globulin (CBG), and sex hormone-binding globulin (SHBG)], and serum tumor necrosis factor (TNF) in HIV-seropositive subjects at different clinical stages. PATIENTS AND METHODS: Thirty-seven HIV-seropositive patients were studied: 7 at stage II, 13 at stage III, and 17 at stage IV (eight ambulatory and nine hospitalized) according to the Centers for Disease Control's criteria. RESULTS: As compared with stage II and stage III patients, stage IV patients had significantly higher mean TBG and total thyroxine (TT4) values, similar and normal total triiodothyronine (TT3) levels, and similar and abnormally low reverse triiodothyronine (rT3) concentrations. However, stage IV hospitalized patients had significantly lower TT3 values than stage IV ambulatory patients. In contrast to TBG, mean levels of CBG and SHBG were comparable in the three groups and within normal limits. For the whole population of HIV patients, there was a highly significant correlation between the CD4 lymphocyte count and TBG (r = -0.529, p less than 0.001) but not with CBG and SHBG levels. Finally, TNF values higher than 10 pg/mL were detected in six of the 17 stage IV patients and in only one of the 13 stage III patients (p = 0.059); elevated TNF levels correlated with a lower CD4 count (p less than 0.01) but not with serum TBG levels. CONCLUSION: The progression of HIV infection is associated with an elevation of serum TNF and TBG, but not of CBG or SHBG. HIV-infected patients have an unexpectedly normal TT3-low rT3 state.

Surgical resection is a standard treatment of hepatocellular carcinoma, but liver cirrhosis is known to be associated to a high tumor recurrence rate.A retrospective study of 55 consecutive patients (37 males, 18 females) suffering from hepatocellular carcinoma having undergone surgical resection. Hepatocellular carcinoma developed in 29 patients with normal liver (group A) and in 26 patients with chronic liver disease (CLD) (group B). Patients were significantly older and at high-risk in Group B.Radical liver resection was achieved in 98% (100% in group A; 96% in group B). Overall 2-month mortality was 2% (0% in group A; 4% in group B). The 5-year overall and disease-free survival was respectively 55% and 35%. However, the 5-year overall and disease-free survival was significantly better in Group A (71% and 59%) compared to Group B (37% and 6%) (p0.001), respectively. Multivariate statistical analysis demonstrated that age50 years, poor tumor differentiation and presence of satellite nodules were significant independent adverse predictive factors of overall and disease-free survival.Resection of HCC is safe and effective with satisfactory overall and disease-free survival rates, except when underlying chronic liver disease and poor tumor differentiation are present.

Scrub typhus should be considered in any febrile patient presenting with a macular rash, a polyadenopathy, an eschar, or a history of environmental exposure in endemic areas. The differential diagnosis includes malaria, typhoid fever, leptospirosis, and arboviroses. Doxycycline 100 mg twice daily for 7 days should be initiated as soon as the disease is suspected.

the purpose of this study was to report a single academic institution's experience with radiofrequency ablation (RFA) of liver malignanciesSixty-five patients underwent RFA technique through a percutaneous (Group I: 33 patients) or a surgical approach (Group II: 32 patients). The two groups were different according to type of disease selection (more hepatocellular carcinoma in Group I and liver metastases in Group II) and tumour features (smaller size but greater number of lesions in Group II). In Group II, RFA was associated to liver resection in 23 patients (72%).The 2-month postoperative mortality and complication rates were low in both groups. The postoperative hospital stay was longer in Group II. During a median follow-up of 24 months in Group I and 21 months in Group II, the local "in-situ" recurrence rate was 41.4% and 9.1%, respectively. For RFA-treated tumours30 mm in size, the local "in-situ" recurrence rate was 40.5% in Group I and 0% in Group II. Multivariate statistical analysis demonstrated that larger tumour and a percutaneous approach for RFA were independent predictive factors of local "in-situ" liver tumour recurrence.RFA appears to be a safe technique for treating liver malignancies by both approaches. Tumour size and type of RFA approach are predictive factors of in-situ liver tumour recurrence.

Hepatic hydrothorax is a rare but challenging complication of cirrhosis. The Transjugular Intrahepatic Portosystemic Shunt (TIPS) appears as one of the most successful approach of therapy.To assess long-term efficacy and safety, we reviewed 28 patients (Child B/C: 43/57%) who underwent TIPS placement for refractory hepatic hydrothorax in our institution between 1992 and 2001.The 30-days mortality was 14%, reaching 25% at 90 days. The one-year survival without liver transplantation was 41.2%. Reduction in the volume of pleural effusion and improvement in clinical symptoms was observed in 68% while a complete radiological and echographic disappearance of hydrothorax was documented in 57%. Statistical analysis showed that poor liver function was predictive of mortality and non-response. Of the different liver function parameters and in this small series, the Child-Pugh score was more discriminating than the recently described Mayo risk score.This study shows that TIPS is effective in the treatment of hepatic hydrothorax for selected patients. Poor liver function is a strong predictive of bad outcome.

OBJECTIVE: To evaluate timing for surgery and management of complex valve lesions in patients with active mitral valve (MV) endocarditis. Results are based on 13 years of experience with MV repair in active endocarditis. METHOD: Between 1993 and 2005, 81 patients were operated for active MV endocarditis, of which 63 (or 78%) had MV repair. For all patients, the median time between diagnosis and surgery was 10 days. Diverse surgical techniques were applied to restore MV competence. In 59% of the patients, pericardial patches, tricuspid autograft or partial MV homografts were used as leaflet substitutes. In addition, prosthetic rings were employed in 44% of the patients. RESULTS: The overall operative mortality was 17.5%. However, considering only patients in preoperative NYHA class I or II, the operative mortality could be reduced to 4.8%. NYHA class > or =3, elevated age (above 70 years) and history of valvular were the three independent risks factors for early mortality in our multivariate analysis. The average follow-up time was 60+/-37 months. During this period, five late deaths occurred, two of which were cardiac-related. The overall 5- and 10-year survival rate was 73+/-12% and 69+/-13%, respectively. In hospital survivors, freedom from cardiac death after 5 and 10 years was 93+/-8%. Three early and five late MV reoperations occurred in seven patients, of them four could have MV re-repair. Only one endocarditis recurrence occurred after 4 months in a chronic haeamodialysed patient. Freedom from MV reoperation was 89+/-10% and 72+/-24% at 5 and 10 years, respectively. Ten-year freedom from MV replacement and from endocarditis recurrence were 95+/-5% and 98+/-1%, respectively. Annular abscesses and calcified or rheumatic MV disease were two independent risk factors associated with reoperation in our multivariate analysis. During the follow-up period, all patients were in NYHA class I or II; 89% of patients had mitral regurgitation grade < or =I, only 11% had grade II on transthoracic echocardiography. CONCLUSION: Using diverse and advanced techniques of MV repair, a reparability rate of 80% can be reached among patients with active endocarditis. We demonstrate that a high level of safety and excellent durability of MV repair can be obtained even for complex repairs.

Fasting plasma homocysteine level and the related clinical findings were analysed in 240 consecutive patients with venous thromboembolism. Hyperhomocysteinemia, defined as a plasma level above 20 micromol/l (corresponding to the percentile 95th in the controls), was present in 11.2% of the patients. Plasma homocysteine level was similar in patients presenting with either deep venous thrombosis, pulmonary embolism or both conditions. It was significantly higher in patients with primary (unprovoked) VTE than in patients with secondary disease (associated with at least one risk factor): 12.3 vs. 9.55 micromol/l (p < 0.005). Mean homocysteine was higher in male than in female patients (14.51 vs. 12.9 micromol/l, p < 0.05) and increased significantly with age. Hyperhomocysteinemia was more frequent in patients with relapsing disease (14 of 76, 18.4%) than in those presenting with a single episode (13 of 164, 7.9%) (p = 0.034). Furthermore, hyperhomocysteinemia was correlated with reduced protein C level (p = 0.013). In a multivariate analysis, two factors were significantly associated with hyperhomocysteinemia: older age (p < 0.0001) and idiopathic occurrence (p < 0.02). Since the frequency of homozygous MTHFR thermolabile variant was rather similar in patients and controls, testing for C677T mutation was not helpful in screening VTE patients. However, the homozygous mutation was significantly more prevalent among hyperhomocysteinemia patients, confirming its role in the genesis of hyperhomocysteinemia. According to its prevalence, to the putative role in venous and arterial disease and the availability of an effective and low-cost corrective therapy, hyperhomocysteinemia deserves interest, especially in the elderly and in the patients with idiopathic VTE disease.

Heparin-induced thrombocytopaenia is a dreaded, although infrequent, complication of heparin therapy. We report two cases of heparin-induced thrombocytopaenia (HIT) type II occurring in a patient treated with standard (unfractionated) heparin and in another patient given a low-weight molecular heparin. The clinical course of the first patient illustrates the potentially severe thrombotic complications of HIT. Both cases were treated successfully by danaparoid sodium. Clues to the diagnosis and treatment are briefly discussed.

Antimicrobial therapy for 428 episodes of bacteremia in an 850-bed university hospital was prospectively evaluated for 1 year to measure the impact of two factors--blood culture results and the therapy chosen by infectious diseases specialists (IDSs)--on quality of treatment and outcome. Initial shock, a simplified acute physiology score of >15, and inappropriateness of the empirical treatment were independently associated with increased mortality. Empirical treatment was appropriate in 63% of the episodes. This proportion reached 78% for the episodes treated by IDSs, compared with 54% for the others (P < .001). After availability of blood culture results, the proportion of appropriate treatments increased to 94%, with 97% for IDS-treated patients and 89% for other patients (P = .008). IDSs more frequently shifted to oral antibiotics and used fewer broad-spectrum drugs. This study underlines the impact of blood culture results and of IDSs on the prescription of appropriate treatment for bacteremia and on the better use of antimicrobial drugs.

OBJECTIVES: To assess the prevalence of activated protein C resistance (APC-R) among healthy subjects and thromboembolic patients and to determine the clinical characteristics associated with APC-R. DESIGN: A prospective study. SETTING: One academic medical centre. SUBJECTS: 91 health controls and 126 thromboembolic patients. MEASUREMENTS: Patients and control were genotyped for the factor V Leiden (VaQ506) mutation. The anticoagulant response of the patient's plasma to activated protein C was also determined. RESULTS: The frequency of APC-R was 3.3% among healthy control subjects and 22% among thrombotic patients of whom 18% were heterozygous and 4% were homozygous. The mean age at the first thrombotic event and the severity of thrombotic disease including the proportion of proximal deep vein thrombosis and the frequency of lung embolism were identical among APC-R positive and negative patients. A family history of thromboembolic disease was elicited more frequently in APC-R positive than in APC-R negative patients (57% vs. 22%, P < 0.001). The recurrence rate was higher for APCR-R positive patients (57% vs. 34%, P < 0.05). The percentage of cases with a factor predisposing to thrombosis was very similar in APC-R positive (57%) and negative (68%) patients. CONCLUSIONS: A familial history of thromboembolic disease and recurrences are significantly more frequent among APC-R positive than APC-R negative patients.

The aim of this retrospective study was to define a diagnostic strategy and to evaluate the efficacy of cotrimoxazole (CTMX) for presumed cerebral toxoplasmosis in patients with AIDS. Twelve patients with toxoplasma encephalitis were reviewed. The best diagnostical signs of reactivated acute cerebral toxoplasmosis were the association of neurological symptoms indicative of focal cerebral lesions, and a radiological picture showing ring contrast enhanced hypodense mass-lesions; serology was unreliable for the diagnosis. Five patients out of twelve were treated without delay and until death with CTMX. Only these improved their clinical and radiological status obviously. Moreover, their median survival time was clearly longer (160 days, versus 9 days) and their autopsy demonstrated the absence of active necrotizing lesions of toxoplasma encephalitis. So, CTMX seems to be an efficient therapy for suspected cerebral toxoplasmosis in AIDS. Nevertheless, further prospective randomized therapeutic trials are required to confirm this impression.

Sixteen patients, with a total of 18 abscesses, were treated by aspiration and systemic antibiotic therapy, to which antiepileptic prophylaxis and corticosteroids were added. Diagnosis of the abscesses and monitoring of their evolution relied principally upon computed tomography; this technique was also used per-operatively when aspirating small abscesses. Bacteriological examinations were positive in all our cases and a polymicrobial flora was found in half of these. One or, eventually, two aspirations within the same week were sufficient, in most cases, to promote healing. Nevertheless, in three patients, the abscesses, however sterilized, did not show any volume reduction, probably because of adhesions to the dura mater, of a large part of the abscess surface area. One patient died from concomitant cardiac disease and one patient remained seriously disabled. Epilepsy was observed as a sequela, in six patients. This study emphasizes the role of neuroradiological and bacteriological examinations, whilst surgery may be restricted, in most cases, to a simple aspiration.

A report of a case of haematogenous infection of a lumbar zygapophysial joint. In spite of radiographic and bone scan findings that localised the lesion, the diagnosis was not made until an operative exploration was made, which also effected a cure. This is an unusual site for sepsis and the clinical picture can easily lead to confusion with spondylosis which is much more common.

Three retrospectively diagnosed fatal AIDS cases are reported and discussed together with 4 other HIV seropositive patients, who all apparently contracted the HIV infection prior to the beginning of the present outbreak, without any other risk factor than heterosexual exposure in Central Africa. These data and simultaneous information from other sources contribute to the assumption that AIDS is an old disease in Central Africa. AIDS, having presented itself as a sporadic and ill defined entity, remained unrecognized in Central Africa until the outset of the present outbreak.

Retrospective study of 19 cases of opportunistic infections of the chorioretina in patients with the Acquired Immunodeficiency Syndrome. We observed 14 cases of CMV retinitis, 2 cases of toxoplasmic chorioretinitis, 1 case of cryptococcal choroiditis and 2 cases of herpes zoster retinitis. Review of the clinical, angiographical and histopathological aspects of these infections. Review of the vital and visual prognosis after treatment.