Inflammation versus mechanical stretch biomarkers over time in acutely decompensated heart failure with reduced ejection fraction.

Heart failure can be associated with inflammation but it is unclear if inflammation is directly related to hemodynamic worsening or is an independent pathway. Our aim was to investigate inflammation and mechanical stress using serial measurements of biomarkers in acute and chronic heart failure with reduced ejection fraction (AHF and CHF). METHOD: The following biomarkers were measured on admission, at discharge and one month after discharge: B-type natriuretic peptide (BNP), high-sensitivity C-Reactive protein (hsCRP), Tumour Necrosis Factor alpha (TNFα), interleukin 6 (IL6), myeloperoxidase (MPO), suppression of tumorigenicity 2 (ST2), mid-regional pro-adrenomedullin (MR-proADM), galectin 3 (Gal3), Growth differentiating factor 15 (GDF15) and procalcitonin (PCT). RESULTS: In control CHF group (n=20, 69±11y, NYHA 1-2), most biomarker levels were low and stable over time. In AHF (n=55, 71±14y), BNP, ST2 and GDF15 levels were highly increased on admission and then decreased rapidly with clinical improvement; BNP, ST2 and GDF15 levels were statistically correlated (r=0.64, 0.46 and 0.39; p<0.001 for both). Both hsCRP, MPO, TNFα and Gal3 levels were increased in most AHF patients (70, 56, 83 and 98% respectively) with poor change over time. HsCRP, MPO and TNFα levels were correlated. IL6, MR-proADM and PCT levels were slightly increased, without change over time. Highest quartiles of BNP and ST2 were associated with death or readmission at one year (HR 2.33 [95CI 1.13-4.80] and 2.42 [1.27-4.60]). CONCLUSION: AHF is associated with systemic inflammation. This inflammatory response continued up to one month after discharge despite normalisation of mechanical stress-related markers.

[Characteristics of the population hospitalized for advanced and terminal heart failure and experiences in palliative caring in the Intensive Care Unit of cardiology]. / Caractéristiques et prise en charge des patients hospitalisés pour insuffisance cardiaque terminale ayant fait l'objet d'une limitation de soins en unité de soins intensifs cardiologiques.

PURPOSE: Advanced heart failure incidence is in progression. Palliative care access remains difficult due to its unpredictable course. The aim of this study was to describe the characteristics of patients admitted in Cardiology Intensive Care Unit for advanced heart failure who received palliative care and compare them to the whole population of acute heart failure hospitalized in the same period. PATIENTS AND METHODS: The patients hospitalized for acute heart failure were retrospectively included from 2009 to 2013. We identified among them those who received palliative care. Specific caring was decided in pluridisciplinary meeting. RESULTS: On 940 patients included, 42 patients (4.5%) receive palliative care. Ischemic heart disease was the main etiology (n=19; 45.2%). Right ventricular dysfunction (n=34; 80.9%) was associated with supra-ventricular arrhythmia (n=28; 66.7%). Twenty-eight patients (57.1%) have died in hospital, 9 (21.4%) were referred to a palliative care unit and 8 (19.1%) was discharged or referred to a rehabilitation center. Time between inclusion and death was 6 days on average. Intra-hospital mortality in control group was 6.8%. CONCLUSION: Palliative care in cardiology is uncommon and has often been too late because of its poor adaptability to advanced heart failure. It is, as consequence, necessary to identify the prognostic factors of these patients in order to propose a personalized care and to adjust the intensity of care ahead of the terminal evolution of heart failure.

[Complications of urinary incontinence surgery: 800 procedures]. / Complications des cures d'incontinence urinaire: à propos de 800 interventions.

OBJECTIVE: To present the complications of urinary incontinence surgery through our experience over 13 years with 800 procedures in continuous practice. These complications were compared to those of the literature for the same type of procedure. STUDY DESIGN: From January 1988 to September 2001, 800 procedures were performed in the same hospital in the gynecology unit. The procedures were: Bologna (91 cases), laparotomic Burch (83 cases), laparoscopic Burch (62 cases), Pereyra (112 cases), Stamey (8 cases), Ingelman-Sundberg (27 cases), Mouchel (40 cases), autograft sling (22 cases), mesh sling: small size (62 cases), large size (12 cases) et TVT (tension free vaginal tape) (281 cases). These procedures were performed alone in 475 cases (125 cases with hysterectomy for other reason), and in 325 cases associated with prolapse surgery. The complications were noted during the hospitalization and at the control at 3 months and 1 year. We only noted the complications attributable to the different procedures. RESULTS: Bladder injuries are found in 3.5% (0 to 6%), hemorrhage in 1% (0 to 3.8%), urinary infection in 4.5% (0 to 11.3%), fever at 48 hours in 1.5% (0 to 9.7%), momentary urine retention in 17% (1.6 to 64.5%), de novo dysuria in 10.9% (0 to 35.5%), de novo urge in 6.9% (0 to 11%). For the other complications, which were less frequent or more procedure-specific, we noted: subcutaneous emphysema in 1.6% of the laparoscopic Burch procedures, cutting thread in 4.8% of the laparoscopic Burch procedures and 2.7% in Pereyra, rejection of prosthetic mesh in 9% of the large slings, 14% with the small sling and 28.2% with the Mouchel procedure, a wound abscess in 3.8% of the Bologna procedures, 1.2% of laparotomic Burch procedures. The percentage of women who had at least one complication was a minimum of 18% for TVT and a maximum of 62.9% for small synthetic sling. In summary, 32% of the patients presented at least one complication. Overall, we noted urinary complications in 41% of the patients, which accounted for 81% of the complications. DISCUSSION: We reviewed more than 100 references concerning complications of the procedures performed in these patients. "Blind" procedures gave more bladder injuries, slings more dysuria and urine retention and procedures using mesh gave more pool healing or rejection especially with the old materials. A particular place must be made for the TVT, recent procedure, which is widely studied. We reviewed 35 references explaining complications of TVT or proposing preventions measures. CONCLUSION: There are many complications of urinary incontinence surgery, but the majority is quickly resolved without consequence. The only after-effects are dysuria which are the most often slow micturition, and urge which are a real problem, sometimes leading to sling removal.

[Development of better tolerated prosthetic materials: applications in gynecological surgery]. / Evolution des matériaux prothétiques vers une meilleure tolérance: application en chirurgie gynécologique.

UNLABELLED: Meshes have come to be widely used for surgical repair of the dysfunctional pelvic floor. The problem to date has been mesh intolerance. History. The first meshes were made with silver filigrees or stainless steel. Non-metallic and non-absorbable synthetic prostheses include nylon, silastic, polytetrafluoroethylene as well as expansive polyester and polypropylene forms. Most of the absorbable prostheses are made of polyglycolic acid and polyglactine 910. Classification. Four groups of biomaterials can be described according to pore size. Mechanical and biological properties. The mechanical properties of meshes have been tested industrially for resistance, pliability, elasticity and ductile qualities. These properties depend on type of tissue structure (woven or knitted) and the type of fiber used (mono and multi-filaments). The goal is to obtain a "silent" material, i.e. a material which does not trigger a host tissue reaction. Introducing the foreign body induces a "scarring" response. This fibroblastic reaction replaces the inflammatory reaction, leading to progressive colonization of the prosthesis. The major risk is infection caused by a disturbance of the inflammatory phase and bacterial development. Bacteria can be trapped in fibrotic tissue, with the risk of delayed infection. Immunological reactions may have an additive effect. These problems are not encountered with absorbable meshes. An ideal implant material must: not undergo physical modification by tissue fluids, be chemically inert, not trigger inflammatory or foreign body cell response in body tissues, be noncarcinogenic and nonallergenic, be capable of resisting mechanical stress and sterilization, and be able to be manufactured in the necessary shape. Polyester, polypropylene and expansive polytetrafluoroethylene fulfill these criteria. The ideal mesh. Eleven criteria are proposed. Complications for hernia repair. Infection and seroma are the most frequent complications with micro-porous meshes. Macro-porous meshes can cause erosive phenomena and adhesions. Retraction of synthetic tissues is observed in 20 to 30% of cases. Meshes in gynecology. In gynecology surgery, meshes made their first appearance in trans-abdominal sacrocolpopexy and slings. A detailed review of complications found in 32 articles studying slings and 22 studying sacrocolpopexy with approximately 10 types of meshes shows that intolerance of slings has oscillated between 1% with Prolene and 31% with Gore-Tex; for abdominal sacrocolpopexy the rate was between 1.7% with Prolene and 20% with Teflon. Rejection phenomena appear during the first year and are proportional to the surface area of the synthetic tissue and the proximity of the vaginal scar. New materials have been proposed over the last ten years for prolapse surgery, notably for cystocele, which accounts for 70% of all repair procedures. Nearly fifteen studies have reported a level of intolerance reaching 6%, the large majority of the meshes used being Prolene meshes. Our personal experience with 87 repair procedures has led us to the conclusion that Prolene is the most adapted mesh, allowing free tension between the bladder and the anterior vaginal wall. CONCLUSION: Continuous evaluation is needed to study these replacement materials which should in theory, improve the rate of recurrence, which is at present 20% with classic procedures not using a mesh.

[Tolerance of synthetic tissues and vaginal surgery. Report of 287 cases]. / Tolérance des tissus synthétiques et chirurgie vaginale. A propos de 287 cas.

OBJECTIVE: In this presentation, we attract attention to the disadvantage of using synthetic material in functional surgery of prolapse and urinary incontinence. PATIENTS AND METHODS: Two hundred eighty seven vaginal operations using synthetic material (Gore Tex, Dacron and Lyodura) were followed. The operations were: Mouchel procedure (127 cases), small slings (118 cases), large slings (11 cases), Stamey procedure (8 cases) and patch for paravaginal repair (23 cases). These operations were performed from 01/01/89 to 31/12/95. RESULTS: Mean follow-up at study end was 49 months. The intolerance phenomenon, leading to rejection, occurred between 1 and 72 months. The Mouchel procedure gave a rejection rate of 28.3% versus 9.3% for the slings (p < 0.001). Dacron was better tolerated (rejection rate at 19.3%) than Gore tex (rejection rate at 30.2%), p < 0.05. CONCLUSION: The substratum of the intolerance process would have two explanations (infection and foreign body reaction) for the early and late rejections. We suggest that the synthetic tissue tolerance is proportional to the exposed surface and to the distance which separates it from the vaginal scar. The ideal synthetic mesh material for pelvic surgery has yet to be developed.

[Extrauterine pregnancies in patients with intrauterine devices (apropos of 9 cases)]. / Grossesses extra-utérines sur dispositifs intra-utérins (à propos de neuf observations).

PIP: The published literature reports an increase of ectopic pregnancies in patients wearing an IUD. Over the total number of pregnancies with IUD in situ, ectopic pregnancies account for about 10-17%. The incidence is lower for the first 6 months after insertion, and higher after that. The mechanism responsible for extrauterine pregnancies can be the appearance of infectious lesions in the genital tract, or the slow and continuous secretion of prostaglandin promoted by the presence of the IUD. Diagnosis of ectopic pregnancy is not always easy, and it usually follows episodes of pelvic pain and metrorrhagia.^ieng

[Pregnancy in obese women who have had jejuno-ileal short-circuit operations (author's transl)]. / La grossesse chez les obèses ayant subi une dérivation jéjuno-iléale.

The authors report two cases of obese women who had had intestinal short-circuit operations for obesity 18 months and 24 months previously. They review the indications for this type of operations and the effects the operation has on the body. It has been possible to find 85 other cases in the literature. In general the pregnancy proceeds well but it is important to carry out very strict supervision of the electrolyte balance, of the hypoprotinaemia and of the blood count. Mechanical complications of the short-circuit operation are rare. While abortions and premature labours are not more frequent in these than in other cases the child is often moderately small-for-dates. Congenital malformations can be raised and are of the order of 7 per cent. These fetal abnormalities, as well as maternal digestive troubles, are definitely more frequent if the interval between the operation and the pregnancy is short. It is therefore preferable to wait for two years before allowing a woman who has had a short-circuit type of operation to become pregnant.

[The value of measuring blood pH in fetal monitoring during labour (author's transl)]. / Intérêt de la mesure du pH sanguin dans la surveillance foetale pendant l'accouchement.

The authors present a series of methodological studies carried out to assess the value of the place of measuring fetal blood pH in monitoring in labour. Comparisons of the measures of pH, pCO2, pO2 and lowering of the base were carried out on the scalp in the 3 minutes which preceded the birth and in the umbilical vessels at birth. Comparing the three modes of taking blood in the mother, intra-arterially and from the capillaries with and without local vasodilatation was carried out. The limits of the values were defined both for the fetus and the mother of the parameters of pH, pCO2, pO2 and base deficit in 100 normal deliveries. A study was carried out of their correlations with the Apgar score at 1 minute and with the arterial pH. A comparison of the two series of measurements was carried out on the vessels of the cord--arterial and venous. The results confirm the value of measuring pH for diagnosing the state of the infant during labour.

[Epidural anaesthesia associated with induction of labour. A clinical study. Electronic monitoring of the physical and biological parameters (author's transl)]. / L'analgésie péridurale associée au déclenchement du travail. Etude clinique. Surveillance électronique des paramètres physiques et biologiques.

73 case histories of induction of labour under epidural anaesthesia have been studied very thoroughly from the different parameters of the uterine contractions as well as the fetal heart rate and the acid base balance of the fetus. From this study it is clear that the basal tone, the intensity and the frequency of contractions and the activity of the uterus are increased in comparison with different studies of normal labour. This increase however is within physiological limits and does not change in any marked way the cardiac rhythm nor the acid base balance of the fetus. The Apgar score at birth is equal to or above 8 in 89 p. 100 of cases at 1 minute and in 100 p. 100 of cases at 5 minutes. Finally, in the last phases of the labour dilatation is quicker than in normal delivery. It follows therefore that maternal comfort has not been bought at the expense of the fetus.