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increased with the number of failing organs. The terms “organ system failure” (OSF) and “multiple organ system failure” (MOSF) were then introduced to describe, not a specific disease entity, but a syndrome, characterized by organ failure or dysfunction affecting one or more organs as a complication of other critical illnesses as well as of sepsis syndrome

The epidemiology, risk factors, maternal and neonatal outcomes of nosocomial Pseudomonas aeruginosa acquisition in preterm premature rupture of membranes were analysed. Of 63 women receiving antibiotic prophylaxis with co-amoxiclav, 11 acquired P. aeruginosa vaginal carriage with a median delay of 15 days (6-42) i.e. an incidence of 8.94 per 1000 days of expectant management. Five neonates born to 11 positive mothers were colonized or infected, three of whom died of fulminant sepsis. The duration of antibiotic treatment and multiple pregnancy were identified as independent risk factors. The epidemiological investigation revealed a vertical transmission between mothers and neonates, and suggested selective pressure of antibiotic treatment.

To evaluate the prevalence and the mechanism of hyperchloremic acidosis component (HClA) during lactic acidosis secondary to grand mal seizures.Retrospective study.Medical intensive care unit in a university hospital.35 patients admitted for grand mal seizures with lactic acidosis (pH7.35, TCO220 mmol/l and PaCO28 kPa).HClA was defined by the ratio: excess anion gap/HCO3 deficit (delta AG/delta TCO2)0.8. A difference in the distribution space of protons and their accompanying anion, i.e., a displacement of chloride from cells by the entering lactate, was evaluated by the ratio natremia/chloremia (Na+/Cl-).Immediately after seizures, a profound lactic acidosis was observed (pH = 7.22 +/- 0.17 (mean +/- SD), AG: 23.8 +/- 7.1 mmol/l, TCO2 = 14.5 +/- 5.3 mmol/l, lactate: 14.6 +/- 6.9 mmol/. HClA was present on admission in 11 patients (31.5%). Its prevalence increased to 73% after recovery. delta AG/delta TCO2 ratios were unrelated to creatinine, level and PaCO2, but dependent on the ratio Na+/Cl- (r = 0.803; p0.001, delta AG/delta TCO2 = 6.4 x (Na+/Cl-)-7.9). These data demonstrate that HClA is not a respiratory or renal phenomenon and suggest differences in the distribution spaces of hydrogen ions and their accompanying anions.HClA component may be associated with lactic acidosis in grand mal seizures and appears to be secondary to a lactate antiport. This phenomenon could be an immediate physiological response to a sudden metabolic acidosis.

Toxoplasmosis is a disease caused by an obligate intracellular protozoal parasite, Toxoplasma gondii. It is the most common cause of focal brain lesions in patients with AIDS. The imaging features and endocrine disorders of CNS toxoplasmosis in patients with AIDS are reviewed.

Resume L'attente et l'angoisse des malades et/ou de leur famille peuvent retentir sur le vecu des consultations urgentes. Le degre de satisfaction de tous les consultants d'un departement d'urgences d'un hopital universitaire a ete evalue pendant une periode de sept jours, par une etude prospective a l'aide d'un questionnaire (16 items) remis au patient ou a sa famille. Le ressenti de cette consultation a ete analyse en fonction des delais et des informations medicales fournies aux consultants. Sur 547 consultants 497 ont recu un questionnaire et 351 ont repondu, dont 348 immediatement. Les consultants sont globalement satisfaits (65,6 % tres satisfaits ; 32,1 % assez satisfaits). L'accueil infirmier est mal ressenti par 2,5 % des consultants, l'attente du medecin ou de l'hospitalisation par un malade sur quatre. Le vecu de la consultation est independant de la duree de celle-ci, mais est correle au temps d'attente du medecin (r : 0,509 − p

Resume Cette etude retrospective a pour but de determiner sur une periode d'un an la prevalence des consultants âges (> 65 ans) dans un service d'urgences medicales d'un CHU (23,5 %), leur pourcentage d'admissions immediates (88,4 %), et la prevalence des cas sociaux purs (7 %). L'hypothese selon laquelle la specialisation de plus en plus importante des services medicaux d'un CHU risque d'orienter preferentiellement ces patients âges vers le service Porte et d'y induire une hospitalisation prolongee, n'a pas ete confirmee. En effet, 63,2 % des patients âges ont ete admis directement dans les services de specialite, avec une bonne adequation motif — lieu d'hospitalisation (56,5 % des malades cardiologiques admis en cardiologie). En cas de diagnostic mal defini (malaise, alteration de l'etat general) ou de pathologie dependant d'une specialite non representee dans l'etablissement, l'admission se fait preferentiellement vers le service Porte ou la duree moyenne de sejour des malades de plus de 65 ans (32,8 % des hospitalises) (2,5 ± 1,7 jours) depasse d'un jour celle des sujets plus jeunes (p

A case of maternal generalized edema with hyponatremia, hypoosmolality and secondary hyperaldosteronism was associated with pseudomolar plasma human chorionic gonadotropin (hCG) concentrations in a case of fetal and placental hydrops due to parvovirus B19 infection. Digoxigenin in situ hybridization techniques were effective in demonstrating parvovirus B19 infection on fixed tissues. Hydropic changes in the placenta may have massively increased the maternal plasma hCG concentration with subsequent fluid imbalance leading to maternal hydrops mimicking molar pregnancy.

Resume Les auteurs rapportent un cas complexe associant une leucemie lymphoide chronique, un leiomyoblastome digestif et une vascularite cutanee thrombosante avec anticorps anticardiolipine serique faisant discuter un nouveau mecanisme physiopathogenique des vascularites au cours des hemopathies.

A cluster-randomized two-period cross-over study comparing routine and on-demand prescription of chest radiographs in mechanically ventilated adults. Background Current guidelines recommend routine daily chest radiographs (CXRs) for mechanically ventilated patients in intensive care units (ICUs), and more if required. However, some ICUs have shifted to an on-demand strategy, in which CXRs are only prescribed if warranted by the patient9s status. Here we compared routine and on-demand strategies in 21 French ICUs. The working hypothesis was that overall, CXR prescriptions would fall with the on-demand strategy, with no change in key outcome measures. Methods Based on a cluster-randomized two-period two-strategies cross-over design, 11 and 10 participating ICUs applied the routine and on-demand strategies, respectively, during the first period, each enrolling 20 consecutive patients requiring mechanical ventilation for at least two days. Each ICU then applied the alternative strategy during the second period, again enrolling 20 consecutive patients. Findings 424 and 425 patients had 4607 and 3148 CXRs with the routine and on-demand strategies, respectively, representing a reduction of 32% (95%CI 25% to 38%) with the on-demand strategy (p Interpretation An on-demand prescription strategy reduces CXR utilization in mechanically ventilated patients with no measurable changes in key outcome measures that would suggest a reduction in quality of care or patient safety. Funding Assistance Publique–Hopitaux de Paris (Direction Regionale de la Recherche Clinique Ile de France). Introduction Dans les services de reanimation, les radiographies de thorax (RT) sont les examens d9imagerie les plus prescrits. Toutefois, la facon dont il convient de le faire reste a determiner, notamment chez les patients sous ventilation mecanique invasive. L’etude RARE vise a comparer 2 modes de prescription des radios de thorax du matin chez les patients ventiles:systematique ou a la demande. Objectifs Premierement, determiner si une strategie de prescription a la demande versus systematique permet une diminution d9au moins 20% du nombre total de RT. Deuxiemement, comparer l9impact de cette strategie a la demande sur la qualite des soins et le pronostic des patients. Patients et methodes Etude prospective, multicentrique, en cross-over (21 centres de reanimation medicale et/ou chirurgicale d9Ile de France participant au reseau CUB-Rea). Chaque centre etait randomise quant a l9ordre d9application de la strategie de prescription des radios de thorax du matin. Les patients sous ventilation artificielle a 8h pour une duree previsible superieure a 24h etaient successivement inclus (20 patients/centre/strategie). Ont a etudie pour chaque strategie: le nombre total de RT (matin et reste du nycthemere) ainsi que l9efficacite diagnostique (nouvelles anomalies), therapeutique (actions entreprises) et pronostique (duree de ventilation mecanique, duree de sejour en reanimation, mortalite en reanimation) des RP. Analyses statistiques Mann-Whitney-Wilcoxon, Kolmogorov-Smirnov et chi2. Resultats Pendant la duree de l’etude (decembre 2006 a aout 2007), 849 patients ont ete inclus (a la demande=425, systematique=424) correspondant a un nombre total de 7 755 RP. Dans la strategie a la demande, 3148 RP (0,74/patient/jour) ont ete realisees tandis que 4607 l9ont ete dans la strategie systematique (1,10/patient/jour) (p Discussion L’etude RARE confirme les resultats d’etudes anterieures plaidant pour une strategie de prescription des RP a la demande. Elle est toutefois la premiere a posseder les qualites methodologiques indispensables pour repondre de facon rigoureuse au « comment prescrire les radios de thorax en reanimation? ». L9impact economique d9une strategie a la demande reste a etablir. Conclusions Chez les patients adultes de reanimation sous ventilation mecanique, une strategie de prescription des radios de thorax du matin a la demande en comparaison a une strategie systematique, permet de reduire significativement le nombre total de radios sans alterer la qualite des soins et le pronostic des patients. Ceci plaide pour l9abandon de la strategie de prescription systematique au profit d9une prescription a la demande. Financement Appel d9offre soins courants,AP-HP (DRRC d9Ile de France).

To compare literature data with results obtained with organs procured from donors who died from cardiac arrest and to make proposals for this mode of organ procurement in France.Over the last 10 years, 10 organ donors (2%) among a series of 486 donors in a state of brain death, had died of cardiac arrest. The arrest were perfused with double-balloon catheters. The outcome of the subsequent kidney grafts was compared with data in the literature.Fifteen of the 18 kidneys from cardiac arrest donors were functioning 1 month after implantation compared with 17 of the 20 kidneys from braindeath donors with beating hearts. The rate of acute tubular necrosis was 55% in the cardiac arrest kidneys and 40% in the beating-heart kidneys. Serum creatinine at 1 yeart was 145 +/- 69 mumol/l 17 +/- 29 mumol/l respectively.These results and those reported in the literature demonstrate that kidney procurement from cardiac arrest donors is feasible. If intensive care and surgery units are well organized, this type of organ procurement could provide a larger number of organs for transplantation. Emergency teams must be available for preparing and transferring the organs.

ORGAN procurement network needs the implication of transplant team outside of the transplant center. A transplant surgery team seems most appropriate for organ procurement because of their training in the field of organ procurement and transplantation. The 5-year kidney graft survival rate decreases to 8% when a nontransplant-surgeon makes the organ procurement. Moreover, the rate of acute tubular necrosis increases to 54% (vs 35%). The outcome of renal transplantation depends on surgical training of the organ procurement team. The purpose of this retrospective work was to compare the results of organ procurements made by our team (inside and outside our center) to those by other organ procurement teams.

Objective: To assess the quality of life of intensive care survivors 6 months after discharge. Design: Multicenter prospective study. Setting: Medical-surgical intensive care units (ICUs) of four French university hospitals. Patients: Among the 589 patients admitted to the four ICUs between 1 January and 31 March 1989, 329 were investigated. Measurements and results: A generic scale assessing health-related quality of life, the Nottingham Health Profile (NHP), a satisfaction scale, the Perceived Quality of Life scale (PQOL) and a questionnaire on professional status were sent by mail 6 months after discharge. Data concerning age, severity of acute illness (assessed by the Simplified Acute Physiology Score) and main diagnosis were recorded. A total of 223 questionnaires (67.8 %) were analysable. The professional status remained unchanged in 79.7 % of the patients, despite a significant (p < 0.01) increase (15.3 vs 22.1 %) in sick leave. Quality of life, assessed with NHP, was fair (50th percentile = 0.73 on a 0 to 1 scale), whereas satisfaction measured by PQOL was lower (50th percentile = 0.61). Both scales correlated well (z = 9.853; p = 0.0001) but with a large dispersion. The NHP scale showed a severe reduction in energy, sleep and emotional reactions, whereas social isolation, pain and physical handicap were infrequent. Family support was rated with the PQOL score as very good, whereas dissatisfaction concerning recreational and professional activities was expressed. Subsequent sick leave was associated with a poor quality of life (p < 0.05). Quality of life was mainly a function of the diagnosis, not of age and severity of illness: patients admitted for suicide attempt or chronic obstructive pulmonary disease fared poorly. Conclusions: Quality of life measured with a health-related quality of life scale and a satisfaction scale 6 months after an ICU stay depended on the admission diagnosis. Different dimensions of quality of life were variably affected.

Mortality due to acute renal failure has remained high over the last three decades despite a better understanding of the pathophysiologic mechanics involved and advances in the management of critically ill patients. This paradoxical situation raises many questions concerning the criteria used to assess treatment and disease severity as well as the effectiveness of certain recently proned "advances". In the 1980s, much progress was made in preventing and/or limiting the extent of acute renal failure. The use of very early and vigorous fluid administration associated with alkaline diuresis prevents traumatic rhabdomyolysis; saline hydration before and after radiocontrast administration protects against the acute decrease in renal function in high-risk patients; maintenance of an adequate intravascular volume and of blood pressure helps prevent acute renal failure. After the onset of acute failure, low-dose dopamine can increase urine output, whereas dobutamine improves creatinine clearance but there is no evidence that increasing urine output lowers morbidity or mortality. New techniques have been proposed for acute renal replacement therapy, but except for use of bicarbonate dialysis and biocompatible membranes, none have been shown to be superior. It has been claimed, on the basis of uncontrolled or retrospective studies, that continuous hemofiltration or hemodiafiltration could have a beneficial effect on survival and/or the course of infectious complications. However, convincing evidence of this beneficial effect is lacking since these techniques are incompatible with clinically pertinent removal of proinflammatory cytokines. The type of renal support may have no effect on outcome. Can further progress be expected in the future? Antagonists of NO receptors and growth factors have a protective effect on renal function in animal models, results which may be of clinical relevance. Their clinical potential should be evaluated in prospective randomized trials involving patients where severity of illness is assessed at inclusion using a multiparametric model combining a severity score and relevant prognostic factors.

Assess expression and management of HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) occurring before 32 weeks gestation.Among 50 patients presenting HELLP syndrome from 1990 to 1994, 22 (44%) who developed the syndrome before 32 weeks gestation were evaluated retrospectively.Most of the patients were primiparous and HELLP syndrome recurred in 2 during a second gestation before 32 weeks gestation. Only three cases began during the post partum period. All patients had severe pre-eclampsia before discovery of the HELLP syndrome. Episodes of eclampsia also occurred in 6. The most frequent clinical manifestation was epigastric pain. Ten patients had acute severe renal failure. The 3 post partum patients had severe complications (eclampsia, renal failure, subcapsular hepatic hematoma). Obstetrical intervention was required in all cases. Cesarean section was performed within 48 hours of diagnosis. Pregnancy had to be terminated in 3 cases between 24 and 29 weeks gestation. There was one fetal death in utero and one during the neonatal period. Seventeen live infants were delivered. In the group of 11 infants born after 30 weeks gestation, only 1 had hyalin membrane disease which developed in all those born before 30 weeks, including 2 with broncho-pulmonary dysplasia.Based on the physiological mechanisms involved in HELLP syndrome, criteria for obstetrical extraction and the possibilities for conservative management in very premature pregnancies, we propose a management protocol for HELLP syndrome developing before 32 weeks gestation. Corticosteroid therapy may be given for 48 hours in cases without maternal or fetal complications in order to accelerate fetal maturation before extraction.

Sepsis is a major cause of acute renal failure in hospital patients, but its incidence and the associated prognostic factors have rarely been assessed prospectively by multivariate analysis.We conducted a prospective 6-month study in 20 multidisciplinary intensive care units to assess the prognosis of patients hospitalized with acute renal failure due to sepsis. Sepsis syndrome and septic shock were defined according to the criteria of the Society of Critical Care Medicine Consensus Conference. Severity scoring indexes (SAPS, APACHE II, and organ system failure (OSF)) were measured on ICU admission and on inclusion. The end-point was hospital mortality.Acute renal failure had a septic origin in 157 patients (Group 1), comprising 68 with septic shock and 89 with sepsis syndrome, and did not result from infection in 188 patients (Group 2). Patients with septic acute renal failure were older (mean age: 62.2 versus 57.9 years, P0.02) and had on inclusion a higher SAPS (19.3 versus 16.1, P0.001), APACHE II (29.6 versus 24.3, P0.001), and OSF (2.07 versus 1.52, P0.001) than patients with non-septic acute renal failure. They had a higher need for mechanical ventilation (69.1% versus 47.3%, P0.001), and acute renal failure was more often delayed during the ICU stay than was present on admission (47.7% versus 32.4% respectively, P0.005). Hospital mortality was higher in patients with septic acute renal failure (74.5%) than in those whose renal failure did not result from sepsis (45.2%, P0.001). Mortality was influenced by the presence of a septic shock (79.4%) or of a sepsis syndrome on inclusion (70.8%). Using a stepwise logistic regression model, sepsis was an independent predictor of hospital mortality (OR, 2.51; 95% CI, 1.44-4.39) as well as a delayed occurrence of acute renal failure, oliguria, an altered previous health status hospitalization prior to ICU, need for mechanical ventilation, age and severity scoring indexes on inclusion. In total patients, mortality was higher in dialyzed than in non-dialyzed patients (P0.001), and in those treated by continuous compared to intermittent techniques (P0.01). Patients dialyzed with biocompatible membranes had a lower mortality than those treated with cellulose membranes (P0.005).Patients with acute renal failure due to sepsis have a worse prognosis than those with non-septic acute renal failure. Sepsis and the above-defined predictive factors are to be considered in studies on prognosis of ARF patients. Our results suggest that the use of biocompatible membranes may reduce significantly mortality in these patients.

To determine the interest of plasmapheresis in the management of cancer-associated microangiopathic haemolytic anaemia (MHA) not due to cancer treatment.[corrected] National retrospective study using the file of the French Hemapheresis Society.We isolated 6 patients (5 men and a woman aged 32 to 69-year-old) who had prostatic (4 cases) or breast carcinomas or Hodgkin's disease. Diagnosis of cancer preceeded MHA in 3 patients (from 2 to 4 years). Bone or bone marrow metastases were demonstrated in 5 patients. The clinical presentation included anuria (4 cases), bleeding (4 cases), and laboratory findings were consistent with microangiopathic haemolysis and thrombopenia in all cases and intravascular coagulation (2 cases) and/or renal failure (4 cases). MHA symptomatic treatment included 4 to 10 courses of plasmapheresis, extra-renal epuration (4 patients), anticoagulation (4 patients) and/or antiagregant (3 cases), haemodialysis (4 cases) and vincristine (2 cases). Cancer treatment consisted of antitumoural chemotherapy (2 cases) and/or hormonotherapy (5 cases). In all cases, haemolysis, thrombopenia and intravascular coagulation were controlled within 30 days. MHA treatment was effective alone in 3 patients. No relapse were observed in 3 patients whereas the course of cancer continued in 2 patients. Two patients relapsed and died from MHA after 4 and 36 months. Two patients relapsed and died from MHA within a few months and 1 was lost to follow-up.Symptomatic treatment of cancer-associated MHA including plasmapheresis may be useful while waiting for an aetiologic management of the tumour.

The authors report a complex case in which chronic lymphoid leukaemia was associated with leiomyoblastoma of the digestive tract and cutaneous thrombosing vasculitis with serum anti-cardiolipin antibodies. They discuss a new physiopathogenetic mechanism of vasculitis in blood diseases.

The association between thrombocytopenic thrombotic purpura (TTP) and infectious or multisystem disease, pregnancy, transplantation, drugs and toxins is well known. The onset of TTP in the course of neoplasm is rarely described. The authors report one case of TTP associated with prostatic tumor. TTP preceded the discovery of neoplasm by 12 months. Moreover, TTP showed an original course with four recurrences despite antiplatelet and hormonal therapies; the successive regressions were obtained with less and less effort, as TTP was discovered at an early stage.

The occurrence of hyperchloremia during diabetic ketoacidosis (DKA) recovery and the lack of correlation between anion gap excess (delta AG) and bicarbonate deficit (delta TCO2) on admission suggest an hyperchloremic acidosis (HCLA) component. The hypothesis that this phenomenon is not specific of DKA and can occur in other metabolic acidoses with increased anion gap was tested. HCLA component, defined by the ratio delta AG/delta TCO2 less than or equal to 0.80, was evaluated on admission and during therapy in 31 patients with DKA and 53 patients with non diabetic metabolic acidosis (ND-MA). HCLA component prevalence was similar on admission (32 p. 100 for DKA versus 41 p. 100 for ND-MA), but it increased during therapy only in DKA patients (86 p. 100 at 9 h - P less than 0.001). In view of the significant correlation (r = 0.636; P less than 0.001) observed between delta AG/delta TCO2 and creatinine, kidney acid base defense appears clearly in DKA patients: the more severe the volume depletion, the greater the ketone retention and the less prominent the HCLA. This phenomenon seems to be secondary to a large tubular excretion of ketones. In the 53 ND-MA patients no correlation between delta AG/delta TCO2 and creatinine could be found. A transfer of chloride from cells to the extracellular space secondary to intracellular diffusion of lactate ions could explain the HCLA component.

Arterial concentration of CO2 (PaCO2) is dependent of pulmonary excretion. When this excretion is lower than cellular production respiratory acid-basis occurs: rise in PaCO2 which lowers pH and produces secondary increases in bicarbonate (HCO3-) plasma concentration. Respiratory alkalosis, generated by a CO2 pulmonary excretion greater than metabolic production is characterized by a fall in PaCO2 which raises pH and induces secondary reduction of plasmatic HCO3- concentration. Attention to the possibility of serious hypoxemia, cause or consequence, should always be regarded and treated in respiratory acid-base disorders.

An hemophagocytic syndrome occured in 3 patients with active Lupus Erythematosus. None of them exhibited any evidence of infectious pathology. Steroid therapy was effective. Relapse was observed in 2 patients and again resolved under steroid therapy. Moderate levels of TNF were observed in the 3 patients. Lupus must be considered as a possible cause of hemophagocytic syndrome in the absence of underlying infection.

Eclampsia and preeclampsia are still a frightening diagnosis for mothers and infants. We retrospectively studied the vascular and obstetrical prognosis in 55 pregnant women hospitalized for eclampsia or preeclampsia in an intensive care unit. Permanent hypertension persisted in 29% women after delivery. Gravidic hypertension reccure in 28% of subsequent pregnancies. There were no differences between the groups of eclamptic and preeclamptic women.

HELLP syndrome is a severe complication of gravidic arterial hypertension. We retrospectively studied prognostic factors of 87 eclampsia or preeclampsia with or without HELLP syndrome. The HELLP syndrome is an important factor of prognosis in gravidic hypertension.

The association between thrombocytopenic thrombotic purpura (TTP) and infectious or multisystem disease, pregnancy, transplantation, drugs and toxins is well known. The onset of TTP in the course of neoplasm is rarely described : only 7 cases have been reported (5 cases of gastric adenocarcinoma, 1 case of breast carcinoma and 1 case of carcinoma with unknown primary site). The authors report the first case of TTP associated with prostatic tumor.

Plasma linoleic acid levels were found to be low in the atherosclerosis patients investigated. In contrast, platelet arachidonic acid levels were decreased only when atherosclerosis was combined with diabetes or mixed hyperlipidemia. In acute vascular thrombosis, a marked decrease in platelet arachidonic levels occurrrd, irrespective of whether the patient had atherosclerosis or not.

Hereditary nephritis associated with hematologic abnormalities seems to be an exceptional occurrence. We have observed a family which nephritis was combined with May-Hegglin anomaly. A girl and her father suffered from proteinuria; a paternal uncle received kidney graft; a paternal grand aunt died on periodic hemodialysis. The girl, the father and the uncle presented macrothrombocytopenia (40-100 X 10(9)/l, size 4-8 mum) with prolonged bleeding time (which precluded renal biopsy) and cytoplasmic inclusions in neutrophils (Döhle bodies). These hematologic abnormalities characterize the May-Hegglin anomaly. This kind of association has not been reported so far.

International audience; Plasma linoleic acid levels were found to be low in the atherosclerosis patients investigated. In contrast, platelet arachidonic acid levels were decreased only when atherosclerosis was combined with diabetes or mixed hyperlipidemia. In acute vascular thrombosis, a marked decrease in platelet arachidonic levels occurrrd, irrespective of whether the patient had atherosclerosis or not.

The presence of vacuolated polymorphonuclear neutrophils in blood smears of patients suffering from infection appears to be associated with massive bacterial growth and to constitute a very early symptom of rapidly life-threatening septicaemia. When these cells persist for more than 36 hours, the disease may be considered as beyond control.

Asplenic patients are at high risk for the development of fulminant pneumococcal bacteremia. The mortality rate in those infected patients remains high. Therefore pneumococcal polysaccharide vaccine has been recommended, but despite penicillin prophylaxis pneumococcal sepsis can occur in vaccinated patients. We have observed two cases (one fatal) of overwhelming postsplenectomy pneumococcal sepsis in vaccinated patients who received long-term antibiotic prophylaxis. Both exhibited a poor antibody response to polyvalent vaccine.

Periarteritis nodosa was observed in three of 266 persistent hepatitis B antigen (HBsAg) carriers undergoing long-term hemodialysis; no cases of necrotizing vasculitis occurred among 384 other patients undergoing dialysis having either no or transient antigenemia. Circulating e antigen, but no e antibody, was found in two of these three patients. The serum level of the third component of complement (C3) was normal in two patients and low in the third. Circulating immune complexes were demonstrated in all three patients, using polyethylene-glycol (PEG) precipitation, PEG-C4, and solid phase C1q tests. HBsAg and anti-hepatitis B antibody (HBsAb) were identified in the PEG precipitates using radioimmunoassay and electron microscopy technics. Direct immunofluorescence performed on a muscle biopsy specimen from one patient was positive for HBsAg, but not for immunoglobulin G (IgG), immunoglobulin M (IgM), C3 or C1q. These data support the hypothesis that circulating immune complexes involving HBsAg may be involved in the pathogenesis of periarteritis nodosa.

A patient with the Zollinger-Ellison syndrome was found to have increased blood gastrin levels associated with the secretion of a compound which produced high blood calcium levels. This compound differed from immunoreactive parathormone, and caused the clinical picture of primary neoplastic hyperparathyroidism. This case is compared with other cases of multiple-secreting Zollinger-Ellison syndrome reported in the published literature, within the framework of the "A.P.U.D." system.