[Cardiac sarcoidosis: Diagnosis, prognosis and therapeutics]. / Sarcoïdose cardiaque : stratégies diagnostiques et thérapeutiques actuelles.

Sarcoidosis is a systemic granulomatous disease characterized by pulmonary involvement in most patients and more rarely by extrapulmonary involvement such as ocular, skin, salivary, lymph nodes and joints damages. Neurological and cardiac involvements are uncommon but are associated with increased morbidity and mortality. Cardiac sarcoidosis affects 5 to 20% of patients depending on the studies and autopsy studies even report cardiac involvement in 25% of sarcoidosis patients. This review aims to summarise main data on the diagnostic value of the different imaging techniques in cardiac sarcoidosis and to also detail the management of these patients who require a multidisciplinary approach.

Are Gadolinium-Enhanced MR Sequences Needed in Simultaneous 18F-FDG-PET/MRI for Tumor Delineation in Head and Neck Cancer?

BACKGROUND AND PURPOSE: PET/MRI with 18F-FDG has demonstrated the advantages of simultaneous PET and MR imaging in head and neck cancer imaging, MRI allowing excellent soft-tissue contrast, while PET provides metabolic information. The aim of this study was to evaluate the added value of gadolinium contrast-enhanced sequences in the tumor delineation of head and neck cancers on 18F-FDG-PET/MR imaging. MATERIALS AND METHODS: Consecutive patients who underwent simultaneous head and neck 18F-FDG-PET/MR imaging staging or restaging followed by surgery were retrospectively included. Local tumor invasion and lymph node extension were assessed in 45 head and neck anatomic regions using 18F-FDG-PET/MR imaging by 2 rater groups (each one including a radiologist and a nuclear medicine physician). Two reading sessions were performed, one without contrast-enhanced sequences (using only T1WI, T2WI, and PET images) and a second with additional T1WI postcontrast sequences. The results were compared with the detailed histopathologic analysis, used as reference standard. The κ concordance coefficient between the reading sessions and sensitivity and specificity for each region were calculated. RESULTS: Thirty patients were included. There was excellent agreement between the contrast-free and postgadolinium reading sessions in delineating precise tumor extension in the 45 anatomic regions studied (Cohen κ = 0.96, 95% CI = [0.94-0.97], P < .001). The diagnostic accuracy did not differ between contrast-free and postgadolinium reading sessions, being 0.97 for both groups and both reading sessions. For the 2 rater groups, there was good sensitivity for both contrast-free (0.83 and 0.85) and postgadolinium reading sessions (0.88 and 0.90, respectively). Moreover, there was excellent specificity (0.98) for both groups and reading sessions. CONCLUSIONS: Gadolinium chelate contrast administration showed no added value for accurate characterization of head and neck primary tumor extension and could possibly be avoided in the PET/MR imaging head and neck workflow.

[Prospective national survey on alternatives to obstetrical peridural analgesia]. / Enquête nationale prospective sur les alternatives à l'analgésie péridurale obstétricale.

OBJECTIVE: To assess the type of an alternative technique for epidural analgesia for pain relief during labour, the reason of its choice and its efficiency. STUDY DESIGN: A one-year prospective survey in 34 french hospitals. MATERIAL AND METHODS: A questionnaire was filled for each request for a non-epidural technique during labour. The data recorded the reason for this non-epidural method, the technique used, the repeated visual analog scale (VAS) pain scores before (T0) and during the treatment (T30, T60 T120,...), the maternal and foetal side effects of the method, and the maternal satisfaction. RESULTS: 177 questionnaires were studied among the 270 collected. The lack of VAS measurements was the main reason for excluding questionnaires. Refusing the epidural by the obstetric patient was the most frequent reason for requesting a non-epidural method (39%). Five non-epidural methods were identified: nalbuphine (NAL, n = 75), sufentanil by patient-controlled analgesia (SUF, n = 44), nitrous oxide/oxygen inhalation (N2O, n = 22), pethidine (PET, n = 19), and spinal analgesia (SA, n = 17). The choice of the method was dependant on the prescribe (midwife or anaesthetist) and of the cervical dilation. The SA group exhibited the most pain relief compared to the other groups during the treatment. No difference in pain relief was noted between the 4 groups (SUF, NAL, PET, N2O). Only in the PET group did the VAS pain score remain unchanged at T30. There were 25 maternal side effects, with a significant maternal sedation in the NAL group, and pruritus in the SA group. There were 6 respiratory depressions in infants, unrelated with the analgesic method. Maternal satisfaction was higher in the SA, SUF and N2O groups than in the PET and NAL groups. Factors explaining lack of analgesic effect (i.e. no decrease in VAS pain score more than 10 mm during the treatment) were the use of pethidine, the VAS pain score at T0 and the induced labour. CONCLUSION: Epidural and spinal analgesia are the most efficient methods for pain relief during labour. The analgesic effect of non-regional methods during labour is minimal, associated with some maternal side effects. Due to its lack of analgesic effect, pethidine should be avoided in this indication.

Ventilatory effects of oxygen-enriched mixtures in the dog under althesin anaesthesia.

In six dogs anaesthetized with Althesin, minute ventilation, respiratory rate, tidal volume, PaO2 and PaCO2 were measured while breathing air (F/O2 = 0.21), and then after correction of hypoxaemia (F/O2 = 0.35), and again while breathing 100% oxygen (F/O2 = 1.00). The administration of 35% oxygen corrected the hypoxaemia (PaO2 = 8.98 +/- 0.76 kPa in air; PaO2 = 16.39 +/- 1.59 kPa with 35% oxygen), but produced a significant and sustained depression of ventilation. The administration of 100% oxygen induced a further significant and sustained decrease in ventilation. It is concluded that hypoxaemia is not necessary for the ventilatory depressant action of oxygen in the anaesthetized dog and that, under Althesin anaesthesia, peripheral arterial chemoreceptors are active up to high PaO2 values.

Epidural morphine strongly depresses nociceptive flexion reflexes in patients with postoperative pain.

The comparative effects of low doses (0.03-0.04 mg/kg) of epidural morphine on a nociceptive flexion reflex of the lower limb and on postoperative pain in volunteer patients were studied after orthopedic surgery on one knee. According to the stimulation parameters, it was found that 40-50 min after the injection, morphine produced an increase of 87% and 83% of the reflex threshold and of the threshold of maximal reflex response, respectively, as well as a 80-90% depression of the nociceptive responses when elicited by a constant level of stimulation. Onset of pain relief occurred by the 25th min and increased to a maximum stable level 40-50 min after the injection. These data support the hypothesis that the main site of the pain-relieving effect of epidural morphine is located directly at a spinal level.

Failure of naloxone to reverse the nitrous oxide-induced depression of a brain stem reflex: an electrophysiologic and double-blind study in humans.

The effects of 33% nitrous oxide on the two components of the blink reflex were studied on seven healthy volunteers. The blink responses were elicited by a supraorbital nerve stimulation and recorded from the ipsilateral orbicularis oculi muscle. The intensity of stimulation was chosen at two to three times the reflex threshold in order to obtain stable suprathreshold reflex responses as well as a tolerable pain sensation reported by the volunteers. Nitrous oxide administration resulted in a potent depression of the two components of the blink reflex. This depressive effect was more marked upon the late (R2) nociceptive component (83%) than upon the early (R1) component (41%). Simultaneously, subjects reported either a decrease in pain sensation or an indifference toward the painful stimulus. None of these effects were reversed by a double-blind intravenous naloxone (1.4 mg) injection. The analgesic effect of nitrous oxide is a nonspecific depressant action on the transmission of the nociceptive messages in central nervous structures, independent of pain-suppressive endogenous morphine-like systems.

Recurrent high-permeability pulmonary edema associated with diabetic ketoacidosis.

Delayed-onset pulmonary edema complicating severe diabetic ketoacidosis was observed twice in one patient. Hemodynamic measurements during the second episode showed normal transmural pulmonary capillary wedge pressure, suggesting an alteration in alveolocapillary permeability. Hyperventilation and acidosis may underlie this alteration. Vigorous fluid therapy, while decreasing oncotic pressure, may also contribute to the pulmonary edema. The two episodes in one patient suggest that pulmonary microvascular diabetic angiopathy may predispose some diabetics with severe ketoacidosis to increased-permeability pulmonary edema.

Hypoxic ventilatory drive in the dog under Althesin anaesthesia.

Althesin was administered i.v. to eight dogs, using two different rates of infusion (6.55 +/- 2.13 microliter kg-1 min and 12.80 +/- 2.00 microliter kg-1 min). Ventilation (TI, TE, RR, TI/Ttot, VT, VE, VT/TI) and arterial blood-gas tensions were measured in air and during a 10-min period of 100% oxygen breathing. For both rates of Althesin infusion the ventilatory response to oxygen was identical: there was significant depression of ventilation (decrease in VE and of the ventilatory drive, VT/TI) from the 1st min of inhalation lasting up to the 10th min. This decrease in ventilation was more marked and persistent than the decrease noticed in the unanaesthetized dog. We conclude that the hypoxic ventilatory drive persists in the dog under Althesin anaesthesia.

[The role of metabolic acidosis in alphathesin-induced tachypnea in dogs]. / Rôle de l'acidose métabolique dans la tachypnée provoquée par l'alfatésine chez le chien.

In the dog anaesthetized with Althesin, tachypnea has been observed under light anaesthesia. There was also a metabolic acidosis which might be responsible for the increase of the respiratory rate. The ventilatory effects of the correction of the metabolic acidosis were studied in five dogs anaesthesized with Althesin administered at a constant rate of infusion (6.06 +/- 2.67 microliters X kg-1 X min-1). The ventilatory pattern (duration of inspiration, TI; duration of expiration, TE; duration of the respiratory cycle, Ttot; respiratory rate, f; ratio TI/Ttot, tidal volume (VT), minute ventilation (VE), mean inspiratory flow (VT/TI) and blood gases, pHa, PaCO2, PaO2, were measured before and after administration of 42 p milli sodium bicarbonate (495 mmol X l-1). Arterial pH increased from 7.27 +/- 0.10 to 7.44 +/- 0.20 (p less than 0.05). There was no statistically significant change of other values, particularly for respiratory rate which varied from 41 +/- 10.5 to 43.3 +/- 17.2 per minute. Metabolic acidosis does not explain the tachypnea. Mechanisms of tachypnea, particularly the role of histamine, are discussed.

[Value of plasma exchange in the management of acute immunoallergic thrombocytopenic purpura (author's transl)]. / Intérêt des échanges plasmatiques dans le traitement des purpuras thrombopéniques immuno-allergiques aigus.

Plasma exchanges were performed in 5 patients with acute immunoallergic thrombocytopenic purpura (ITP) because of severe haemorrhages and/or inefficient or badly tolerated corticosteroid therapy. Plasma exchanges were carried out with cell separators and were usually well tolerated. They resulted in very rapid increase in platelet levels with disappearance of auto-antibodies and dramatic reduction of haemorrhages, and they brought about, or accelerated, recovery in 3 patients. One patient was slightly improved. In the 5th patient, who had meningeal haemorrhage, plasma exchange was effective in increasing platelet levels but was unable to prevent a fatal outcome. The main indications for plasma exchange seems to be acute ITP with severe, life-threatening haemorrhages.