[Thrombotic thrombocytopenic purpura: do not ignore cardiac involvement]. / Purpura thrombotique thrombocytopénique: ne pas méconnaître l'atteinte cardiaque.

INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy due to ADAMTS13 deficiency (a von Willebrand factor's metalloprotease) with multiple organs' involvement, one of which may be the heart. CASE REPORT: We report a 29-year-old woman who presented a TTP during her last trimester of pregnancy, under the features of a HELLP syndrome. After caesarean section, cardiac involvement was revealed by chest pain, ECG changes, antero-septal hypokinesia and troponin rise. Cardiac MRI found no large-vessel ischemic heart disease and confirmed hypokinesia. CONCLUSION: When TTP is diagnosed, cardiac involvement must be systematically investigated by ECG and troponin assay because of the risk of a cardiac arrest.

[Admission of women to an intensive care unit during pregnancy or the postpartum period: circumstances and prognosis. A retrospective series of 96 cases]. / Admissions en réanimation des femmes en cours de grossesse ou en post-partum: circonstances et pronostic. Une série rétrospective de 96 cas.

PURPOSE: Very few studies had been published about admission of obstetric patients in French intensive care units (ICU). PATIENTS AND METHODS: Files of women who had been admitted during pregnancy or the postpartum period to ICU of an academic hospital between January 1st 1997 and 31st December 2006 were analyzed. Diagnosis at admission, severity, main treatments and outcome were studied during two successive periods of 5 years. RESULTS: There were 96 admissions (0.95% of all admissions to ICU). They included 34 complications due to arterial hypertension (35%), among them 10 cases of pre-eclampsia, eight of eclampsia, seven of Hemolysis-Liver Enzymes-Low Platelet (HELLP) syndrome and two of retroplacental hematoma ; 26 postpartum haemorrhages (27%); and 36 miscellaneous diagnosis including two sepsis, four acute pulmonary oedema, four cardiomyopathy, three pulmonary embolism, and three acute liver steatosis. Mean Simplified Acute Physiologic Score (SAPS II) was 18.5±11.2 and mean Sequential Organ Failure Assessment (SOFA) 2.1±2.3. The main treatments were mechanical ventilation (50% of all cases) and transfusion (32%). The average ICU stay was 5.7±5.4 days. Two maternal deaths were observed (aortic dissection and peripartum cardiomyopathy). The number of patients admitted for postpartum haemorrhage increased from five to 21 over the two successive periods of the study. CONCLUSION: The number of women admitted to ICU during pregnancy or the postpartum period is low. Admissions for hemorrhage have increased. Regular monitoring of maternal morbidity and mortality gives relevant clues for assessing the quality of obstetrical care.

Renal function of renal transplantation patients after hospitalization in an intensive care unit.

Kidney transplantation is the favored method to treat end-stage renal disease. Some recipients develop severe diseases requiring admission to an intensive care unit (ICU). Acute kidney injury (AKI) is a common complication among critically ill patients but few data are available among renal transplant recipients. The aim of this monocenter retrospective study was to describe renal function in kidney transplant recipients admitted to an ICU and to evaluate their renal functional recovery after this stay. We identified all renal transplant recipients admitted to our medical ICU from January 1, 2001, to December 31, 2010: namely, 79 stays by 62 patients. We used the glomerular filtration rate criteria of the RIFLE classification to evaluate AKI during the ICU stay. During the ICU stay, 56 patients (70.9%) were classified as "no AKI" according to the RIFLE classification; 11 (13.9%) belonged to class R, 10 (12.7%) to class I, and 2 (2.5%) to class F. Overall, 24% of the patients needed dialysis during the ICU stay. Mortality rate at 3 months after the ICU stay was 25.3%. Among the patients who survived, 40 (68%) recovered to their baseline renal function at 3 months, most of them being classified as no AKI during the ICU stay. We have herein reported the evolution of renal function among kidney graft recipients after an ICU stay.

[Severe acute asthma: isoflurane administration via AnaConDa™, is it safe?]. / Asthme aigu grave : l'administration d'isoflurane par l'AnaConDa™ est-elle sans risque ?

Standard treatments against severe acute asthma can be insufficient and need salvation treatments, such as isoflurane delivery. These treatments have not been much assessed and could lead to unrecognized side-effects. We report the case of a young man who suffered from intracranial hypertension associated with severe hypercapnia during the delivery of isoflurane via the system AnaConDa™ or Anaesthetic Conserving Device™ (ACD) (Sedama Medical). The rising of PaCO(2) appears to be linked to an ACD-dependent increase in the dead space.

Ultrastaging of colorectal cancer by sentinel lymph node mapping technique--a multicenter trial.

Sentinel lymph node (SLN) mapping accurately diagnoses the status of nodal basin with >95% accuracy in melanoma and breast cancer. A multicenter trial for SLN mapping was performed on 203 patients with colorectal cancer to determine accuracy, upstaging, skip metastasis, and aberrant drainage. Lymphazurin 1% was injected subserosally around the tumor and 1-4 blue staining nodes were marked as SLNs for detailed histological analysis. SLN mapping was successful in 98% of patients with an average of 1.7 SLNs per patient. SLNs were negative in 63% of the patients and positive in 37% of the patients. Skip metastasis was seen in 8 of the patients. Occult micrometastasis was found in 14% of patients. In 5% of the patients, unusual lymphatic drainage lead to an alteration of the extent of lymphadenectomy. This multicenter trial proved that SLN mapping in patients with colorectal cancer is simple, cost effective, and upstages at least 14% of patients from AJCC stage I/II to stage III. These patients may then benefit from adjuvant chemotherapy.

Pathologic evaluation of sentinel lymph nodes in colorectal carcinoma.

BACKGROUND: The identification of lymph node metastases in colorectal resection specimens is necessary for accurate tumor staging. However, routine lymph node dissection by the pathologist yields only a subset of nodes removed surgically and may not include those nodes most directly in the path of lymphatic drainage from the tumor. Intraoperative mapping of such sentinel lymph nodes (SLNs) has been reported in cases of melanoma and breast cancer. We applied a similar method to cases of colorectal carcinoma, with emphasis on the pathology of the SLNs. METHODS: Eighty-three consecutive patients with colorectal carcinoma were evaluated after intraoperative injection of 1 to 2 mL of 1% isosulfan blue dye (Lymphazurin) into the peritumoral subserosa. Blue-stained lymph nodes were suture-tagged by the surgeon within minutes of the injection for identification by the pathologist, and a standard resection was performed. Designated SLNs were sectioned at 10 levels through the block; a cytokeratin immunostain (AE1) was also obtained. To evaluate the possibility that increased detection of metastases in the SLN might be solely due to increased histologic sampling, all initially negative non-SLNs in the first 25 cases were sectioned also at 10 levels. RESULTS: Sentinel lymph nodes were identified intraoperatively in 82 (99%) of 83 patients and accounted for 152 (11.9%) of 1275 lymph nodes recovered, with an average of 1.9 SLNs per patient. A total of 99 positive lymph nodes (38 positive SLNs and 61 positive non-SLNs) were identified in 34 node-positive patients. The SLNs were the only site of metastasis in 17 patients (50%), while 14 patients (41%) had both positive SLNs and non-SLNs. Three patients (9%) had positive non-SLNs with negative SLNs, representing skip metastases. In patients with positive SLNs, 91 (19%) of 474 total lymph nodes and 53 (12%) of 436 non-SLNs were positive for metastasis. In patients with negative SLNs, 8 (1%) of 801 total lymph nodes and 8 (1.2%) of 687 non-SLNs were positive for metastasis. Multilevel sections of 330 initially negative non-SLNs in the first 25 patients yielded only 2 additional positive nodes (0. 6%). All patients with positive SLNs were correctly staged by a combination of 4 representative levels through the SLN(s) together with a single cytokeratin immunostain. CONCLUSIONS: Intraoperative mapping of SLNs in colorectal carcinoma identifies lymph nodes likely to contain metastases. Focused pathologic evaluation of the 1 to 4 SLNs so identified can improve the accuracy of pathologic staging.

Technical details of sentinel lymph node mapping in colorectal cancer and its impact on staging.

BACKGROUND: Sentinel lymph node (SLN) mapping for melanoma and breast cancer has greatly enhanced the identification of micrometastases in many patients, thereby upstaging a subset of these patients. The purpose of this study was to see if SLN mapping technique could be used to identify SLNs in colorectal cancer and to assess its impact on pathological staging and treatment. METHODS: At the time of surgery, 1 ml of Lymphazurin 1% was injected subserosally around the tumor without injecting into the lumen. The first to fourth blue nodes identified were considered the SLNs, which have the highest probability to contain metastases. A standard oncological resection of the bowel was then performed. Multilevel microsections of the SLNs, including a detailed pathological examination of the entire specimen, was performed. RESULTS: SLN was successfully identified in 85 (98.8%) of 86 patients. In 85 patients, there were 1,367 (16 per patient) lymph nodes examined, of which 140 (1.6 per patient) were identified as SLNs. In 53 (95%) of 56, of whom the SLNs were without metastases (negative), all other non-SLNs also were negative. In 29 (34% of 85) patients, SLNs were positive for metastases; in 14 of the 29 patients, other non-SLNs also were positive in addition to the SLNs. In the other 15 of the 29 patients (18% of 85 patients), SLNs were the only site of metastases, and all other non-SLNs were negative. In 7 patients (8.2% of 85 patients), micrometastases were identified only in 1 or 2 of the 10 sections of a single SLN. In five of seven patients, such micrometastases were detected by hematoxylin and eosin staining and immunohistochemistry; in the other two patients, it was detected only by immunohistochemistry. In patients with negative SLNs, the rate of occurrence of micrometastases in non-SLNs was 5 (0.4%) of 1,184 lymph nodes. CONCLUSIONS: SLN mapping can be performed easily in colorectal cancer patients, with an accuracy of more than 95%. The identification of submicroscopic lymph node metastases by this technique may have upstaged these patients (18%) from stage I/II to stage III disease, who may then benefit from further adjuvant chemotherapy.

[Serum ceruloplasmin levels and cetrimonium tests in pregnancy]. / La céruléoplasmine sérique et le test au cétrimonium au cours de la grossesse.

Serum ceruloplamin levels were measured and Badin's cetrimonium tests (selective precipitation of serum glycoproteins with cetrimonium bromide) were performed after delivery in 72 out of 350 sera previously collected during the 4th-5th months of pregnancy. Thirty-six of the 72 sera were obtained from women whose pregnancy ended with toxaemia, and 36 from women chosen at random whose pregnancy ended normally. In women who developed toxaemia at 8-9 months, ceruloplasmin levels and cetrimonium test values were often higher at 4-5 months than in correlation between assays and tests. Ceruloplasmin determinations and cetrimonium tests therefore provide different types of information on the latent pathological condition which precedes toxaemia, but their predictive values must be taken jointly.

[beta-Lipoprotein serum levels in the months preceeding pregnancy toxemia and its relationship with the Cetrimonium test (author's transl)]. / Le taux de la beta-lipoprotéine sérique dans les mois précédant la toxémie gravidique et ses relations avec le test au Cétrimonium.

beta-Lipoprotein determination and selective serum protein precipitation with Cetrimonium bromide (Badin's Cetrimonium test) were carried out retroactively (after delivery) on sera selected out of 700 sera collected from women at 4-5 months and 6-7 months of pregnancy. The selected sera were those from 36 women in the first group and 37 in the second group, who had ended pregnancy with toxemia. The sera were matched to sera collected at the same period from women whose pregnancy had been normal until the end. In both the 4-5 month and the 6-7 month groups, women with toxemia at the end of pregnancy had significantly higher levels of beta-lipoprotein and higher Cetrimonium tests but the two data were not correlated. The information they provide on the abnormal condition preceeding toxemia symptoms are different : hyperlipoproteinemia would be a predisposing factor and the Cetrimonium test an evidence of some latent inflammatory process.

Clinical and immunochemical study of the serum IgG fraction not precipitated in a zinc-sodium salicylate reagent.

A reagent made of zinc sulphate (0-08 M) in a 0-4 M sodium salicylate solution at pH 7-3 precipitated most of the IgG when a small volume of human serum was added. Sera with normal IgG levels or polyclonal hyperglobulinaemia showed a close correlation between total IgG and zinc-precipitated IgG (r = + 0-95). In clinical material, not including IgG myeloma, zinc-soluble IgG varied between 0 and 6 mg/ml and was independent of the IgG serum concentration. In 31 normal subjects the average IgG concentration, as determined by the Technicon immunonephelometric method, was 10-2 +/- 1-7 mg/ml for total IgG and 2-2 +/- 1-0 mg/ml for the soluble fraction. Among 173 sera, including 24 from cord blood, 16 from pregnant women, and 133 from patients with miscellaneous diseases, no pathological conditions except three cases of IgG myeloma were found with a zinc-soluble IgG definitely above the normal values; zinc-soluble IgG levels were often low in patients with hyperglobulinaemia, and the difference was highly significant in liver disease. kappa and gamma light chains as well as the four IgG-Hp chain subclasses were found in both zinc-soluble fractions of normal IgG. A study of myeloma monoclonal IgG showed that globulins of classes 1, 3, and 4 could be either soluble or insoluble in the zinc reagent. One, G2, was mainly insoluble. Hexose and antistreptolysin contents per milligram normal IgG were not significantly different in either fraction. It is suggested that zinc-soluble IgG consists of the recently synthesized molecules, the zinc-solubility of which has not yet been decreased by protein association, lipid interaction, antigen binding, or enzymatic denaturation. Within this hypothesis, a low level of soluble IgG would mean either an increased precatabolic protein or a decreased synthesis.

[Role of phosphorylcholine group on inhibiting capacity of lecithin-cholesterol liposomes on streptolysin O]. / Rôle du groupement phosphorylcholine sur le pouvoir inhibiteur des liposomes lécithines-cholestérol vis-à-vis de la streptolysine O

Cholesterol inhibition of the hemolytic activity of streptolysin O was used for testing the presence of cholesterol on the surface of lecithin-cholesterol liposomes. Cholesterol as a liposome component is not available for streptolysin inhibition when the molar ratio lecithin-cholesterol greater than 1,25. Incubation of such liposomes with phospholipase C, which converts the phosphadylcholine group into neutral diglycerides, restores an inhibiting activity of cholesterol parallel to the phosphatid degradation. Incubation of the liposomes with phospholipase D, which converts the phosphatidylcholine group into phosphatidic acid, also restores the inhibiting capacity of cholesterol on the hemolysin. The accessibility of liposome cholesterol to streptolysin O appears to mainly depend upon the cholin group of lecithin.