[Phaeochromocytoma and paraganglioma]. / Phéochromocytome et paragangliome.

Phaeochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors that arise from the adrenal medulla or sympathetic and parasympathetic ganglia. These tumors produce most often catecholamines in excess, causing hypertension and sometimes severe acute cardiovascular complications. The diagnosis is based on plasma or urines metanephrines measurements and on conventional and nuclear medicine imaging. Catecholamines-producing PPGL is very unlikely if levels are normal. The diagnosis of PPGL cannot be made without visualization of a tumor. Therapeutic management consists mostly of surgical excision, after drug preparation, and should be done in referral centers. About 40% of pheochromocytomas and paragangliomas occur in the context of an autosomal inherited syndrome, making genetic testing essential. The follow-up must be prolonged because a metastatic evolution or a recurrence can be observed in about 15% of the cases.

[Cryopreserved amniotic membranes use in resistant vascular ulcers]. / Utilisation des membranes amniotiques cryopréservées dans la prise en charge des ulcères vasculaires rebelles.

BACKGROUND AND OBJECTIVE: Amniotic membranes are used with success in ophthalmology to treat corneal wounds and ulcers. In this pilot study, we attempt to assess the tolerance of amniotic membranes in the management of resistant venous and/or arterial vascular ulcers. MATERIAL AND METHODS: We prospectively included 8 patients, 7 males and 1 female, mean age 69.5+/- 9.6 years, with venous and/or arterial ulcers resistant after 6 months with usual medical care and/or after revascularisation failure. Amniotic membranes were applied on a weekly basis with the fetal side on the ulcer, covered by a secondary bandage. The primary end-point was evaluation of tolerance of amniotic membranes on vascular ulcers. The secondary end-points were a >50% reduction of ulcer's area, a significant (P< or =0.05) improvement of pain visual scale score and the quality of life assessed by the SF-36 questionnaire. RESULTS: Tolerance was excellent in all cases. We observed no adverse effect. We observed complete healing at weeks 19 and 26 for 2 patients and a >50% reduction of ulcer area at weeks 26, 31 and 32 for 3 patients. A sixth patient had an ulcer area reduction <50% and the 2 remaining showed no improvement. A significant improvement was noticed for visual pain scale and the health feeling dimension in the SF-36 questionnaire. No adverse effect or amputation requirement was noted. CONCLUSION: These preliminary results are encouraging and require a larger confirmatory study. Further studies are required to clarify the action mode of this therapeutic option.

Carotid intima-media thickness as predictor of secondary events after coronary angioplasty.

AIM: Subjects with symptomatic or asymptomatic peripheral arterial or cerebro-vascular disease have an increased risk of death or cardiovascular event. The aim of this study was to determine whether intima-media thickening of the common carotid artery and/or a low ankle brachial index (ABI) are related with an increased risk of cardio-vascular event after percutaneous coronary angioplasty (PTCA). METHODS: One hundred and thirteen consecutive, patients (88 males, 25 females, mean age: 62 years) undergoing PTCA were included. Intima media thickness (IMT) of the common carotid artery and ABI were measured within the 2 days following the PTCA. Subjects were followed up for 10.2 +/- 4 months. The end-point was a composite criterion associating death, non fatal acute myocardial infarction, recurrence or worsening of angina pectoris, hospitalisation for heart failure, new positive exercise stress testing. RESULTS: In the follow-up study a common carotid IMT >0.7 mm was a predictor of event (p=0.03) in the univariate analysis. The other risk factors were unstable angina (p=0.001) and PTCA on the left descending coronary artery (p<0.05). We did not find any relation between the end-point and ABI or presence of atheroma on the common femoral artery. In the logistic regression analysis unstable angina was associated with a 3.14 fold increased risk (IC 95%: 1.51-6.4, p=0.002), subjects without HMG-CoA inhibitors drugs at the inclusion had also an increased risk of 2.5 (IC 95%:1.09-5.75, p=0.02). CONCLUSION: This study suggest that CCA-IMT is associated with an increased risk of cardiac events after PTCA. The measurement of subclinical disease could be useful for identifying high-risk patients.

Blunt chest trauma: a right pulmonary vein rupture.

This report describes the case of a 37-year-old man who fell from 6 m height and presented an isolated rupture of the right pulmonary vein. The patient had a low blood pressure without any sign of intrathoracic injury. An echocardiogram revealed a tamponade with hemodynamic intolerance. The repair was made using cardiopulmonary bypass which made the inspection and total repair of the lesions easier. This case is unusual because of the isolated lesion and the few articles about similar reports founded in an extended literature review. Mechanisms and generation of blunt chest trauma lesions are discussed.

Extrapericardial cardiac tamponade caused by traumatic retrosternal hematoma.

Cardiac tamponade is an uncommon complication of blunt chest trauma, resulting typically from hemorrhage into the pericardial space. We report a case of hemodynamic compromise secondary to an extrapericardial compression caused by the acute formation of a retrosternal hematoma associated with a sternal fracture. The patient was involved in a violent deceleration accident. Initially, he only complained of an anterior thoracic pain, but subsequently became restless, pale, and dyspneic. A severe hypotension associated with sinus bradycardia (45 bpm) rapidly occurred. Both jugular veins became markedly turgescent, but no significant pulsus paradoxus was noted. Echocardiography disclosed a large hematoma, compressing anteriorly both the right ventricular cavity and outflow tract. Surgical evacuation of the retrosternal hematoma related to a bifocal fracture of the manubrium was followed by instantaneous hemodynamic improvement. Regional extrapericardial tamponade secondary to the acute formation of compressive retrosternal hematoma is an unusual cause of circulatory failure after severe blunt chest trauma. Since conventional clinical signs associated with typical tamponade physiology may be lacking in this setting, echocardiography is ideally suited for early recognition of this unusual condition.

[Long-term survival of elderly amputated vascular patients]. / Survie à long terme des amputés vasculaires âgés.

The object of this study was to assess the 10 year outcome of patients over 70 years of age who underwent amputation for vascular diseases. The secondary objective was to determine the prognostic risk factors. One hundred and four consecutive patients having undergone a leg (16 cases) or through-thigh amputation (88 cases) were reviewed. The average age at the time of surgery was 80.7 years (+/- 6.5 years, range 70-98 years). At the time of the enquiry, there were 4 survivors (operated on average 107.7 months previously +/- 14.6 months). The survival rates at one, six, twelve months and two years were 74.1%, 48.1%, 38.5% and 27% respectively. The mean survival time was 19.2 months with a median of 6 months. Univariate analysis showed the following criteria to be statistically correlated with a poor prognosis: female gender (p = 0.008), previous psychiatric disease (p = 0.007), cachexia (p = 0.004), age of 80 or over (p = 0.025), absence of diabetes (p = 0.025). Multivariate analysis showed that men had a lower risk of death (RR: 0.591--95% CI: 0.394-0.888--p = 0.011). The comparison of subjects who died during the first year with the survivors, showed a deleterious effect of proximal amputations (p = 0.032) and absence of diabetes (p = 0.021). These results confirm the very mediocre prognosis of elderly amputated vascular patients during the first postoperative year. Thereafter, the outlook is not as bad. Female gender would seem to be a poor prognostic factor whereas the presence of diabetes could identify a subgroup with a better outlook.

[Heat therapy in chronic venous insufficiency of the legs]. / Traitement thermal de l'insuffisance veinolymphatique chronique des membres inférieurs.

Water cures have long been advocated for venous and lymphatic disorders. Spa therapy combines hydrotherapy, physical therapy and education. Immersion increases central blood volume, diuresis and natriuresis. These effects are independent of the mineral characteristics of the water. Hydrotherapy is viewed as a complementary treatment of venous and lymphatic insufficiency whatever its stage of development; but this has not been formally proved.

[Ischemic neuropathy in occlusive lower limb arterial disease at the state of ischemia on effort]. / Neuropathies ischémiques dans l'artériopthie oblitérante des membres inférieurs au stade d'ischémie d'effort.

Acute or chronic prolonged ischaemia of the limbs may cause lasting neurological damage. This has been shown in clinical, electrophysiological and anatomopathological studies. The aim of this study was to search for signs of neurological suffering during ischaemia of effort. Twenty patients with occlusive lower limb arterial disease with ischaemia of effort were studied. None of the patients had other causes of neuropathy: none of the patients had potentially neurotoxic therapy. All underwent haemodynamic assessment (Doppler ultrasonography treadmill test, transcutaneous oxygen diffusion) and electrophysiological study (nerve conduction studies and an electromyogramme). Ten patients had abnormalities during stimulation-detection and on electromyography. These abnormalities were always observed in the limbs with the poorest blood flow. The pressure index and transcutaneous oxygen diffusion in lying position were significantly lower (pressure index: 0.43 vs 0.72, p < 0.03; TcPO2: 20.3 vs 27.2, p < 0.04). The authors consider that effort ischaemia is associated with neurological damage. Repeated transient episodes of ischaemia could cause neuropathy.

Plasma leukaemia inhibitory factor, interleukin 6 and soluble interleukin 6 receptor levels during cardiopulmonary bypass with extracorporeal circulation.

In this study the authors assessed plasma leukaemia inhibitory factor (LIF), interleukin 6 (IL-6) and soluble IL-6 receptor (sIL-6R) concentrations in 28 patients undergoing coronary artery bypass graft (CABG) with extracorporeal circulation (ECC). Plasma IL-6 levels increased during ECC, reaching a 33-fold increase 6 h after surgery as compared to pre-operative values. In contrast, plasma sIL-6R and LIF concentrations did not vary significantly during cardiac surgery. Thus, LIF is not implicated in the haematological changes and in the inflammatory syndrome observed after CABG. Despite the fact that LIF and IL-6 exhibit several common biological activities, the production of these two cytokines is differently regulated during cardiac surgery with ECC. Plasma IL-6 levels increased during cardiac surgery while sIL-6R levels did not changed. These data contrast with the decreased sIL-6R concentrations with concomitantly high IL-6 levels in patients with sepsis syndrome suggesting that inflammatory reactions in sepsis and after cardiopulmonary bypass are triggered by different mechanisms.

IL-6 and IL-8 production by human bone marrow stromal cells.

By using a specific enzyme-linked immunosorbent assay, the authors demonstrated that human bone marrow stromal cells produce IL-6 and IL-8. Their synthesis is enhanced in a dose-dependent manner after stimulation with lipopolysaccharide (LPS) and phorbol myristate acetate (PMA). Interleukin 6 (IL-6) and IL-8 production in response to PMA were markedly diminished by the PKC inhibitor staurosporine. IL-6 (10 ng/ml) stimulated IL-8 production with 0% and 10% fetal calf serum (FCS) in the culture medium. In similar conditions, IL-8 (10 ng/ml) enhanced IL-6 production. IL-1 alpha, IL-1 beta, and IL-3, tumour necrosis factor alpha (TNF-alpha), Stem cell factor (SCF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) (at 10 ng/ml) stimulated IL-6 and IL-8 production in 0% and 10% FCS. G-CSF stimulated and IL-4 inhibited IL-8 production in 10% FCS. IL-2, IL-4 and bFGF stimulated IL-6 production in 0% FCS. These results suggest that bone marrow stromal cells might represent a major source for the cytokine-regulated local production of IL-6 and IL-8 inside human bone marrow.

Traumatic pulmonary hernia: surgical versus conservative management.

The therapeutic management of lung herniation, an uncommon complication of severe blunt chest trauma, remains controversial. We report here on two cases of traumatic lung herniation with different, yet successful, methods of therapeutic management according to the particular anatomic types. Because of the threat of tension pneumothorax, incarceration, or strangulation of the lung parenchyma in mechanically ventilated patients, surgical reduction of intercostal pulmonary hernias with narrow necks is usually recommended. In contrast, supraclavicular pulmonary hernias secondary to clavicle-sternal dislocation may be treated conservatively with serial clinical and thoracic imaging follow-up including chest computed tomographic scan. In this anatomical type of lung herniation, favorable spontaneous evolution is frequently observed, presumably because of the presence of a larger thoracic wall defect together with the absence of associated perforating bone trauma. The efficacy of the therapeutic approach proposed herein remains to be confirmed by further experience.

[Transesophageal echocardiography for diagnosis of traumatic injuries to the major intrathoracic vessels in 150 patients: the effect of the learning curve]. / Echocardiographie transoesophagienne pour le diagnostic des lésions traumatiques des grands vaisseaux intrathoraciques chez 150 patients: influence de la courbe d'apprentissage.

OBJECTIVES: To evaluate the role of transoesophageal echocardiography (TOE) in the management of patients with suspected traumatic lesions of the thoracic aorta (TLA) and its branches; to assess the influence of the learning curve on the diagnostic accuracy of TOE for the identification of TLA. STUDY DESIGN: Retrospective study. PATIENTS: The study included 150 patients (age: 41 +/- 17; Injury Severity Scale score: 31 +/- 17) who were admitted during a 4-year period for severe blunt chest trauma and who underwent a TOE study. METHODS: TOE were performed with either a monoplane (n = 54) or a multiplane probe (n = 96). In all cases, TLA were confirmed by angiography, computed tomography, surgery, or necropsy. Initially performed routinely, angiography was subsequently indicated when the TOE study was inconclusive or when a disruption of supraaortic arteries was suspected. Echocardiographic studies were reviewed by an experienced reader who was unaware of the medical history and initial conclusions. To evaluate the influence of the learning curve on the diagnostic accuracy of TOE, these conclusions were compared with the initial interpretations. RESULTS: A TLA was recognized in 25 patients out of 150 (17%), and evidenced using TOE in 22 of them. Three false negative and two false positive TOE results (needless thoracotomy) were recorded. After a learning period, the rate of inconclusive TOE studies decreased (18/150 vs 7/150: P < 0.05) and no false positive finding was recorded. The sensitivity and specificity of TOE for the diagnosis of TLA were 88 and 100%, and positive and negative predictive values were 100 and 97%, respectively. CONCLUSIONS: TOE is an accurate imaging technique for the diagnosis of TLA located at the aortic isthmus. However aortography becomes essential when injuries of the aorta branches are suspected. A learning period is required to improve the specificity of TOE for this indication.

Diagnosis and management of entrapped embolus through a patent foramen ovale.

The diagnosis of impending paradoxical embolus by echocardiography is exceptional and its management remains unclear. Through a personal case, we performed an exhaustive review of the medical literature of this rare finding. Since the first report, only 43 cases have ever been reported. The superiority of transesophageal echocardiography is underlined. The clinical features are complex. The classical simultaneous pulmonary and paradoxical embolism is often absent. Therapeutic options are cardiac surgery, thrombolysis or anticoagulation. The early mortality rate is high (21%). In addition, recurrent embolisms are reported when a medical treatment is chosen. The cumulative results of each possibility are described.

Successful surgical management of a ruptured abdominal aortic aneurysm in a renal transplant patient. A case report.

With extended indications for renal transplantation and increasing survival, it can be expected that atherosclerotic vascular disease in the post-transplant patient will become more frequent. The authors report a case of a ruptured abdominal aortic aneurysm in a renal transplant recipient. A temporary axillo-femoral shunt was used to maintain perfusion of the renal graft during aortic cross-clamping. They review the literature and discuss the available methods for preserving renal function.

Cytokine and lipid mediator blood concentrations after coronary artery surgery.

UNLABELLED: This study investigates whether increased levels of cytokines and lipid mediators may be associated with complications after coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC). Hemodynamic measurements and blood samples were obtained in 32 patients before and after the end of ECC and at the 6th and the 24th postoperative hours. Coagulation and pulmonary and cardiovascular functions were specifically assessed postoperatively at the same time. Patients with cardiovascular dysfunction had higher interleukin 8 (IL-8) levels. Higher platelet-activating factor (PAF) and decreased PAF acetylhydrolase activity (AHA, the enzyme that inactivates PAF) levels were found in patients with moderate cardiovascular dysfunction. Interleukin 6 (IL-6), IL-8, and AHA levels correlated with most hemodynamic parameters and creatine phosphokinase myocardial band levels obtained after surgery. Patients with severe lung injury had lower PAF, 6-keto prostaglandin (Pg)F1alpha, and PgE2 levels and higher thromboxane (Tx) B2 concentrations compared with patients without lung injury. Increased IL6 levels were only associated with moderate lung injury. Impaired hemostasis was associated with higher IL6 levels. AHA, IL-6, and IL-8 seem to be associated with cardiovascular dysfunction. The IL-6 blood levels and the ratio of TxB2/6 keto-PgF1alpha blood levels are increased during post-CABG lung injury. These results identify an association between specific post-CABG complications and the systemic inflammatory response. The clinical significance of this association remains to be evaluated. IMPLICATIONS: Patients with pulmonary, cardiovascular, or hemostasis dysfunction after cardiopulmonary bypass demonstrate aberrancies in a variety of cytokines and lipid mediators in arterial blood or plasma. The relationship between these findings and inflammatory response-induced complications remains to be determined.

Spontaneous and inducible production of leukaemia inhibitory factor by human bone marrow stromal cells.

Leukaemia inhibitory factor (LIF) acts on the growth and differentiation of haematopoietic cells. By using a specific enzyme-linked immunosorbent assay for human LIF, we demonstrate that human bone marrow stromal cells produce LIF. LIF synthesis is enhanced in a dose-dependent manner after stimulation with lipopolysaccharide (LPS) and phorbol 12-myristate 13-acetate (PMAS). LIF production in response to PMA is PKC-dependent since the two PKC inhibitors sphingosine and staurosporine markedly diminished it. Interleukin 1alpha (IL-1alpha), IL-1beta, IL-3, IL-6, IL-8, tumour necrosis factor (TNF-alpha) and SCF (both at 10 ng/ml) stimulate LIF production. By contrast macrophage colony-stimulating factor (M-CSF), granulocyte (G)-CSF, GM-CSF, basic fibroblast growth factor (bFGF), platelet-activating factor (PAF), protaglandin E2 (PGE2), leukotriene B4 (LTB4), and leukotriene C4 (LTC4) did not. These results suggest that bone marrow stromal cells might represent a major source for the cytokine-regulated local production of LIF inside human bone marrow.

Platelet-activating factor and antagonists modulate DNA synthesis in human bone marrow stromal cell cultures.

Platelet-activating factor (PAF) is present in the human bone marrow. We have investigated the effect of PAF and antagonists (BN 52,021 and CV 3988) on the growth of human marrow stromal cells. PAF (1 microM) stimulates and PAF antagonists (0.1-1 microM) inhibit [3H]thymidine incorporation in cells grown in 5% serum. The catabolism of PAF by stromal cells was inhibited by CV 3988 suggesting the presence of specific PAF receptor on cells. PAF and antagonists (0.1 nM-10 microM) had no effect on cells cultured in high serum concentration (20%) or in low serum concentration (1%) with 0.5 ng/ml of basic fibroblast growth factor (bFGF). This study indicates for the first time that PAF modulates the serum-induced but not the bFGF-induced growth of marrow stromal cells. The interactions between PAF and stromal cells during inflammatory marrow events such as myelofibrosis deserve to be assessed.

Tumour necrosis factor-alpha (TNFalpha) stimulates the growth of human bone marrow stromal cells.

This study reports that TNF-alpha is a potent mitogen for human bone marrow sternal cells in vitro (assessed by [(3)H]-thymidine incorporation into DNA and cell counts). In contrast, cytokines such as IL-1alpha, IL-1beta, IL-2, IL-3, IL-4, IL-6, LIF, SCF, M-CSF, G-CSF and GM-CSF had no effect. The effect of TNF-alpha on the growth of human bone marrow stromal cells could be of importance during inflammatory processes which take place in the marrow, for example marrow fibrosis.

M-CSF serous rate evolution during post-transplantation days in a heterotopic heart graft model mice.

BACKGROUND: On heterotopic heart graft in mice, aged 7 weeks (C3H and B57), we investigate the variations of Macrophage Colony stimulating factor serous rate. The macrophage colony stimulating factor (M-CSF) is a cytokine involved in the immune response during transplantation. METHODS: Five groups were determined, group 1 with a heterotopic transplant without immunosuppressive treatment (N=24); group 2 with a heterotopic transplant and Corticoid treatment after the graft (N=29); group 3 with a heterotopic transplant and cyclosporine treatment after the graft (N=34); group 4 with an isogenic transplant (N=31) and group 5 undergoing a laparotomy (N=31). The mice are sacrificed at D4, D7, D10 or D14 and the M-CSF dosage are done by ELISA method. RESULTS: The serous rate of M-CSF is stable in the group with an isogenic transplant or with only a laparotomy. But in the group with a heterotopic transplant the M-CSF values increase (x1.5). If we use an immunosuppressive treatment the raising of M-CSF is less important. When we have a rejection graft, the serous rate of M-CSF increases but not significantly (Mann-Whitney test). CONCLUSIONS: We conclude M-CSF seems to be a reliable index of disorder during immune response, but is not a good marker of the rejection.