The effect of isolated phlebectomy on reflux and diameter of the great saphenous vein: a prospective study.

OBJECTIVES: To evaluate the effect of phlebectomy on venous reflux and diameter of the great saphenous vein (GSV). DESIGN: Prospective cohort study. METHOD: Patients presenting with reflux in the GSV resulting in varicose veins were included in this series. Patients were treated by phlebectomy for dilated and incompetent tributaries of the GSV with conservation of the incompetent GSV. We measured reflux duration (RD), peak reflux velocity (PRV) and the diameter of the GSV using duplex ultrasound imaging at inclusion and 1 month after surgery. PATIENTS: We included 55 limbs in 54 patients (30 women and 24 men) aged from 37 to 83 (mean age 63) years. RESULTS: Following treatment we observed a significant reduction of the mean RD (0.81 s vs. 1.5 s p < 0.01, t-test), mean PRV (120 mm s(-1) vs. 249 mm s(-1)p < 0.01, t-test) and mean diameter of the GSV (SFJ = 5.6 mm vs. 6.7 mm, p < 0.01, sub-terminal valve 4.8 mm vs. 4.4 mm p < 0.05, mid-thigh 5.0 mm vs. 4.2 mm, p < 0.01, knee 4.0 mm vs. 5.3 mm p < 0.01, mid-calf 2.7 mm vs. 4.0 mm, p < 0.01, t-test). CONCLUSIONS: We noted reduced reflux in the GSV after phlebectomy with a significant reduction in RD and PRV. Phlebectomy also led to a significant reduction in GSV diameter. These data suggest that the haemodynamics and the diameter of the SV can be improved by using a treatment focussing on the saphenous tributaries.

A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery.

A randomised study of 414 patients undergoing coronary artery surgery with cardiopulmonary bypass was conducted to compare the effects of a volatile anaesthetic regimen with either deesflurane or sevoflurane, and a total intravenous anaesthesia (TIVA) regimen on postoperative troponin T release. The primary outcome variable was postoperative troponin T release, secondary outcome variables were hospital length of stay and 1-year mortality. Maximal postoperative troponin T values did not differ between groups (TIVA: 0.30 [0.00-4.79] ng x ml(-1) (median [range]), sevoflurane: 0.33 [0.02-3.68] ng x ml(-1), and desflurane: 0.39 [0.08-3.74] ng x ml(-1)). The independent predictors of hospital length of stay were the EuroSCORE (p < 0.001), female gender (p = 0.042) and the group assignment (p < 0.001). The one-year mortality was 12.3% in the TIVA group, 3.3% in the sevoflurane group, and 6.7% in the desflurane group. The EuroSCORE (p = 0.003) was the only significant independent predictor of 1-year mortality.

Classification of saphenous refluxes: implications for treatment.

OBJECTIVE: To determine the possible correlations of patient age, symptoms and signs with findings of Doppler duplex examination in limbs with varicose veins. METHODS: A total of 2275 ultrasound examinations were done on 2275 limbs of 1751 patients (421 men and 1330 women). Ages ranged from 21 to 94 years (mean 50). Symptoms of aching, heaviness, burning pain (venous neuropathy) were recorded, and signs of ankle hyperpigmentation, scars of healed ulcers and presence of open venous ulcers were noted. RESULTS: Presence of symptoms was associated with advancing patient age (50.7 vs. 48.8 years). Varicose veins without great saphenous reflux correlated with younger age (43 vs. 53.5 years). Presence of saphenofemoral junctional incompetence correlated with an older age (54.7 vs. 49.8 years), and reflux to the ankle (Hach stage IV) also correlated with older age (mean 63.7 years). A younger age was associated with less advanced signs (C0-C2: 49.1 vs. C4-C6: 60.1 years). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4-C6: 21.3%). CONCLUSIONS: Ageing is associated with advancing clinical symptoms, signs and increasing multifocal reflux in limbs with venous insufficiency. These facts support the concept of early treatment of venous insufficiency before predictable deterioration occurs.

[Psychiatry]. / Psychiatrie.

Introduced this year on the Swiss market, duloxetine (Cymbalta) is a new antidepressant which inhibits the reuptake of noradrenaline and serotonin. Clinical studies have shown its efficacy in depression as well as in neuropathic pains (60-120 mg/day) with a good tolerability. In this paper are also included short reviews about the two large American studies developed by the National Institute of Mental Health in the fields of the treatment for depression (STAR-D) and of the antipsychotic treatments for schizophrenia (CATIE study). Its also reviews two questions of present interest: the use of the second generation antipsychotics for the treatment of bipolar depression and the concept of bipolar disorders in children.

[Psychiatry]. / Psychiatrie.

During the year 2005 much of the attention was given to the debate on the risk of suicide during treatments with selective serotonin reuptake inhibitors. Our review concludes with a moderate increased risk of suicidal behaviour but not a risk of death by suicide. Caution, not panic, is indicated, particularly for children and adolescents given that, in this age group, benefits of these drugs have not been well established. We also report two synthesis concerning the latest developments in the fields of cognitive psychotherapy for depressive disorders (rather stimulating news) and of pharmacotherapy for borderline personality disorders (no breaking news).

Validation of a continuous penile blood-flow measurement by pulse-volume-plethysmography.

Today, in the assessment of cavernous artery blood-flow, the most commonly used technique is Doppler ultrasound velocimetry (continuous, pulsed, color-coded or power), which is often considered as the gold standard. Plethysmographic techniques and radioactive tracers have been widely used for the assessment of global penis flow variations but are not adequate for continuous blood-flow measurement. A new pulse-volume plethysmographic (PVP) device using a water-filled penile cuff was employed to assess continuous blood-flow measurement in the penis. Simultaneously Doppler velocity was recorded and served as a gold standard. A penile water-cuff is connected through a pressure tube to a three-way tap. The pulse-volume changes in the penile water-cuff are measured by means of a latex membrane placed over one of the three-way taps. The displacements of the latex are recorded by a photoplethysmograph. The third tap is connected to a 5 l perfusion bag placed 30 cm above the penis so as to maintain constant pressure in the whole device whatever the penis volume. Twenty-four volunteers were tested. The Doppler velocity signal and pulse volume of cavernous arteries were measured simultaneously after PGE1 intra-cavernous injection. Blood-flow variations were induced by increasing penis artery compression with a second penile water-cuff used as a tourniquet fitted onto the penis root, and the pressure of which could be modified by a water-filled syringe. The amplitude of the plethysmographic pulse-volume signal and the area under the Doppler velocity signal were correlated. The inter-patient (n=24) correlation ranged from 0.455 to 0.904, with a mean correlation of 0.704 and P<0.0001. PVP measurement by a water-filled cuff was validated by ultrasound velocimetry. This new continuous, non-invasive and easy-to-use technique enables physiological and physiopathological flow-measurement during sleep, under visual sexual stimulation (VSS), or following artificial erection. Simultaneous recording of penile blood-flow by PVP and intra-cavernous pressure (ICP) measured by a non-invasive device will provide fundamental inflow and outflow information in both physiological and pathophysiological conditions, and further enable venous leakage to be assessed by a mathematical model.

[Study of the pharmacodynamic activity of daflon 500 mg]. / Etude de l'activité pharmacodynamique de Daflon 500 mg.

Daflon 500 mg, micronized purified flavonoid fraction, composed of 90% diosmin and 10% hesperidin, possesses venotonic and vasculoprotective pharmacological properties, it reinforces venous tone by prolonging the activity of parietal norepinephrine. The pharmacodynamic properties of Daflon 500 mg were demonstrated by mercury stress gauge venous occlusion plethysmography during a double-blind placebo-controlled trial in 10 women not presenting any venous disease. Venous tone was significantly reinforced by the 1st hour after a single dose of 2 tablets of Daflon 500 mg. This effect persisted for 4 to 24 hours according to the mode of administration. The rapid action of Daflon 500 mg is due to micronization of its active ingredient into particles less than 2 microns, thereby considerably increasing its absorption.

Aetiology of uveitis in Sierra Leone, west Africa.

BACKGROUND: In 1992, non-onchocercal uveitis caused 9% of blindness, 8% of visual impairment, and 11% of uniocular blindness among patients visiting an eye hospital in Sierra Leone, west Africa. The aim of this study was to determine the aetiology of uveitis in this population. METHODS: General and ophthalmic examination complemented by serum and aqueous humour analyses for various infectious agents was performed for 93 uveitis patients and compared with serum (n = 100) and aqueous humour (n = 9) analysis of endemic controls. RESULTS: At the initial examination, 45 patients (48%) proved to be severely visually handicapped. After clinical and laboratory analyses, an aetiological diagnosis was established for 49 patients (52%). Toxoplasma gondii was the most important cause of uveitis (40/93; 43%). Anti-toxoplasma IgM antibodies were detected in serum samples of seven of 93 patients (8%) compared with one of 100 controls (1%, p < 0.05). At least six patients (15%) with ocular toxoplasmosis had acquired the disease postnatally. Antibodies against Treponema pallidum were detected in 18 of 92 patients (20%) and in 21 controls (21%). Other causes of uveitis were varicella zoster virus (one patient), herpes simplex virus (two patients), and HLA-B27 positive acute anterior uveitis with ankylosing spondylitis (one patient), while one patient had presumed HTLV-I uveitis. CONCLUSIONS: In a hospital population in Sierra Leone, west Africa, uveitis was associated with severe visual handicap and infectious diseases. Toxoplasmosis proved to be the most important cause of the uveitis. Although the distribution of congenital versus acquired toxoplasmosis in this population could not be determined, the results indicate an important role of postnatally acquired disease. The results further suggested minor roles for HIV, tuberculosis, toxocariasis, and sarcoidosis as causes of uveitis in this population.

Blindness from uveitis in a hospital population in Sierra Leone.

A retrospective study was conducted to assess the causes of blindness and visual impairment in patients who visited an eye hospital in Sierra Leone, West Africa, in 1989 and 1992. These data were compared with figures from 1981. Throughout the years, senile cataract was the major cause of blindness, followed by uveitis (including onchocerciasis). Uveitis remained the second most important cause of blindness in this population, despite the significant decrease in blindness from onchocerciasis (from 30% in 1981 to 15% in 1992). An increasing number of patients with uveitis from non-onchocercal origin was observed: almost 10% of the blindness found in 1992 was due to uveitis of non-onchocercal origin. A reduction in visual handicap in patients with non-onchocercal uveitis could be achieved if local hospitals could obtain more accurate diagnoses in these patients.

Onchocerca Volvulus infection in Sierra Leone: relation between prevalence, intensity of infection, and ocular problems in a 'forest' region.

A two-year longitudinal study carried out in five villages in a forest region of Gorama Chiefdom, Kono District, Sierra Leone, revealed that infection with Onchocerca volvulus was hyperendemic, the overall rate of infection being 61.6%. Prevalence rose from 28.6% in the 1-5-year age group, peaking among the 21-30-year age group (82.5%) and then levelling off. The intensity of infection though low, peaked in the 31-40-year-old males and in the 41-50-year-old female cohorts. The iliac crest was more sensitive for microfilarial (mf) recovery than the shoulder and the outer canthus. The majority of the nodules were located in the pelvic region. Microfilariae invasion of the eye was low, with low anterior chamber lesions but high posterior chamber lesions comprising mainly optic atrophy and choroidoretinitis. The rate of blindness was 1.6%, ocular onchocerciasis being the leading cause of blindness followed by cornea opacities.

Decrease in adverse reactions after repeated ivermectin treatment in onchocerciasis.

We assessed the side-effects after multiple single-dose treatment with ivermectin (150 micrograms/kg) in onchocerciasis patients form a hyperendemic area in Sierra Leone, in order to investigate whether medical surveillance was always necessary. After initial treatment 87 onchocerciasis patients were examined for adverse reactions. Fourty-four of these 87 patients (51%) received a second dose of ivermectin 5 months later and thirty-five (40%) received a third dose one year later. The side-effects after the second and third doses were significantly diminished, when compared with the initial dose of ivermectin in the treatment of onchocerciasis (chi2 test p less than 0.005, resp. p less than 0.008). Side-effects requiring therapy were observed in 32% of patients after the first dose, in 18% after the second dose and in 11% after the third dose of ivermectin. Severe side-effects (9%) were only seen after the initial ivermectin dose. All the severe adverse reactions appeared within 48 hours. In view of our findings, it seems necessary that the first treatment with ivermectin should take place under strict medical supervision during at least two days. Five months after treatment with a single dose of ivermectin 29 out of 44 patients (66%) still had a positive skin-snip test. Seven months after the second dose 15 of 35 patients (43%) had a positive skin-snip count. Since almost half of the patients had a positive skin-snip test despite two treatments with ivermectin, it could be argued that in hyperendemic areas treatment should consist of at least two doses in the first year.

Ocular involvement in patients with onchocerciasis after repeated treatment with ivermectin.

We assessed ocular changes after therapy at six and 12 months with ivermectin (150 micrograms/kg of body weight) in a 12-month prospective study of 29 patients with ocular onchocerciasis and 15 patients with onchocerciasis without ocular involvement. The patients lived in a hyperendemic area in Sierra Leone, West Africa, where no vector control was instituted. Five months after initial treatment, the microfilarial load in skin and eyes had decreased significantly (P less than .0000), but 28 of 44 (63%) patients had positive skin-snip test results and nine of 29 (31%) patients with ocular involvement had active ocular disease. Twelve months after initial treatment, 15 of 41 (37%) patients had positive skin-snip test results and eight of 26 (31%) showed active ocular involvement. All patients with persistent ocular disease after therapy showed evidence of active onchocerciasis at that time, which suggests that a dose of ivermectin at six-month intervals is not sufficient for intensely infested patients with severe ocular disease. We developed an ocular involvement score to evaluate the patient's total ocular status and observed a significant relation between the pretreatment severity of ocular involvement and the persistence of active ocular disease after treatment with ivermectin.

["Determination of venous hemodynamics". Contribution of air plethysmography]. / "Quantifier l'hemodynamique veineuse" apport de la pléthysmographie a air.

Plethysmographic techniques based on the variation of a parameter linked to venous stasis, have permitted an approach to venous hemodynamics. The use of a new technique of air-plethysmography, which cold be quantified in volume variation, and permitting to study the progression of the venous stasis from a static as well as a dynamic standpoint, enable us to better assess the overall venous function. The first results obtained in healthy patients, are presented and the advantages of this new technique are discussed.

Side-effects of ivermectin in treatment of onchocerciasis.

In a prospective study to determine the tolerance for and safety of ivermectin therapy for onchocerciasis in a hyperendemic area in Sierra Leone, 28 (32%) of 87 patients had adverse reactions that required treatment with acetylsalicylic acid and antihistamines, but none of the observed adverse reactions were considered life-threatening. A significant relation was found between the frequency and severity of side-effects and the degree of parasite infestation, as quantified by the skin-snip counts. Free administration of ivermectin to severely infected onchocerciasis patients is not recommended without some form of medical supervision.

Evaluation of the clinical pharmacological activity of a phlebotonic agent. Application to the study of Daflon 500 mg.

Provided certain methodological precautions are observed, mercury strain gauge venous occlusion plethysmography represents one of the best available function tests in phlebology to evaluate the efficacy of a phlebotonic agent. All physiological and environmental parameters liable to affect venous tone must be determined and controlled before and during the procedure, which is to be carried out in controlled and fully reproducible conditions. Intra and inter-observed reproducibility of results must be checked regularly in each laboratory. The objective character of the parameters assessed (Hmax, delta Vmax, T50, T2p...) does not spare the need for randomized, crossover or comparative, double-blind placebo-controlled trials, as plethysmographic results may show wide variations from one subject to another, and even from one moment to another, in chronic venous insufficiency, depending on the subject's environment and occupation. Furthermore, knowledge of treatment by the observer may affect the validity of the results. Taking into account all of these methodological pre-requisites, the phlebotonic activity of a single dose of Daflon 500 mg in lower limb chronic venous insufficiency was assessed in placebo-controlled clinical pharmacological studies. The following characteristics emerged: (1) significant improvement of venous capacitance, distensibility, and emptying times, as from the 2nd hour following Daflon 500 mg administration; (2) dose-response relationship, with an optimal dose of 2 tablets per day; (3) rapid onset and long duration of action; (4) significant hemodynamic effect on the venous system, whatever the type of venous insufficiency: organic, functional or gestational.

[The concept of critical arterial stenosis: value of a model of measures obtained by an angiographic method and the Doppler technic before and after transluminal angioplasty of the iliac arteries]. / Notion de sténose artérielle critique: intérêt d'une modélisation des mesures obtenues par méthode angiographique et technique Doppler, avant et après angioplastie endoluminale des artères iliaques.

INTRODUCTION: Numerous studies in the literature have proven the fact that a critical size appears during the stenosis evolution. The work presented is a non invasive approach of this value, with correlation to the invasive results. The study was realized on a homogeneous group of 23 arteriopathic patients, selected for iliac artery angioplasty procedure. MATERIAL AND METHODS: Patients selection: twenty-three patients including 24 angioplasty procedures have been selected on a 21 month time study. Invasive data: two measurements are realized during angioplasty: trans-stenotic pressure gradient before and after angioplasty. stenosis calibration: both diameter and section have been calculated on radiological films. Non invasive data: a standard Doppler test is performed on lower limbs. Two parameters are compared with the invasive data: the ascending time of velocity curve at the common femoral level. the systolic pressure index (peripheral pressure/radial pressure). RESULTS: 1) Critical stenosis--invasive techniques (fig. 1): trans-stenotic pressure gradient versus stenotic measurements shaw an hyperbolic correlation. The critical stenotic level is found to be 60% in diameter and 80% in section. 2) Critical stenosis--non invasive techniques: stenotic measurements compared to ascending time (fig. 2) as well as pressure index at rest (fig. 3) shaw the same type of curve. The critical stenotic level is found to be the same than with invasive techniques. DISCUSSION: Some discordant results open the discussion about angioplasty as a "gold standard", specially with a geometrical analysis. Bad precision in non regular stenosis. Hemodynamic consequences of turbulent stenosis are not evaluated. Clinical interest of critical stenotic notion is underlined.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative study of external methods (Doppler, rheography, flow using Xe) and arteriography of the legs, in the evaluation of stenoses. Statistical evaluation by the Kappa test]. / Etude comparative des méthodes externes (Doppler, rhéographie, débit au Xe), par rapport à l'artériographie des membres inférieurs, dans l'appréciation des sténoses. Evaluation statistique par le test Kappa.

On a thirty five homogeneous group of arteriosclerotic patients, the authors study by means of the Kappa test the validity of arteriographic and non invasive techniques data interpretation by two trained observers. Then they compared between the conclusion of these methods again with Kappa test. The viability of arteriographic and Doppler interpretation is good. The comparison between arteriographic and external techniques results needs strong reduction of the arteriographic data in large classifications. Doppler (with distal pressure) is the best of non invasive techniques, the others staying less selective. The good correlation between arteriography and doppler data observed in main arteries is maximum for femoral arteries and decreases in distal arteries mainly because of a poor filling due to proximal lesions.