[Short emergency hospitalization]. / L'hospitalisation de courte durée à l'urgence.

In France, the number of admissions to emergency departments increase by 5 to 10 per cent per year. Traditionally, patients who require services beyond the first hours in the emergency department have been admitted to the acute care hospital. Observation unit are becoming common in hospitals because they allow an additional option to admission or discharge. In France, 60 per cent of emergency departments have observation units. Five to ten per cent of patients seen in an emergency department are transferred to the observation unit. These observation units are staffed with emergency personnel specifically assigned to the function of the unit. The average period of observation is less than 48 h. Of the patients observed, 50 per cent are discharged after extended observation and treatment. These observation units can be a safe, effective and cost-saving way of ensuring that patients who are considered to be in an intermediate category receive appropriate care.

Prevalence and consequences of nutritional depletion in lung transplant candidates.

Nutritional status was studied in lung transplant (LT) candidates. The hypotheses were that nutritional depletion was highly prevalent and lean body mass depletion was a risk factor for a higher mortality both before and after LT. Of 78 consecutive patients listed for LT, 16 (21%) died while on the waiting list, eight (10%) were alive awaiting LT, and 54 (69%) received a graft. Mean age was 42.3+/-4.4 (mean+/-SD). Thirty-eight per cent had a diagnosis of bronchiectasis or cystic fibrosis (BRO/CF), 33% of emphysema, 20% of idiopathic pulmonary fibrosis (IPF) and 8% of primary pulmonary hypertension. Body mass index (BMI) was 20.4+/-4.3 kg.m2, weight was 87.9+/-16.6% of ideal body weight (IBW). Patients were classed into four nutritional groups according to IBW and creatinine height index (CHI): 1: weight <90% IBW and CHI <60% of predicted (28% of cases); II: weight <90% IBW and CHI > or =60% (27%); III: weight > or =90% IBW and CHI <60% (17%); IV: weight > or =90% IBW and CHI > or =60% (28%). Overall, 72% were depleted corresponding to groups 1, II and III. Lean body mass depletion occurred despite normal weight in 17% of the cases (group III). Subjects with BRO/CF were mostly in groups 1, II, III whereas IPF were concentrated in group II. Lean body mass depletion was associated with more severe hypoxaemia, reduced 6-minute walking distance and a higher mortality while awaiting. After LT, duration of mechanical ventilation, time spent in intensive care unit (ICU) was related to initial body composition. Survival after LT was lowest in group III. To conclude, nutritional depletion in lung transplant candidates is highly prevalent and should be more precisely assessed with a special reference to lean body mass since it has specific consequences both while awaiting and after lung transplant. Attempts should be made to increase lean body mass before lung transplant.

[Lung volume reduction in patients with emphysema after prolonged ventilatory assistance]. / Réduction de volume pulmonaire chez un patient avec emphysème après ventilation assistée prolongée.

A 42-year-old patient with emphysema was hospitalized in the intensive care unit for an episode of acute respiratory failure. The patient became dependent on invasive mechanical ventilation and surgical lung volume reduction was performed. The indication of lung volume reduction in this pathological situation but was followed by rapid weaning 48 hours postoperatively. The patient was discharged without ventilatory assistance and has not required further ventilatory assistance after more than 2 years follow-up.

Successful stenting of a pulmonary arterial stenosis after a single lung transplant.

A 44 year old patient with end stage idiopathic pulmonary fibrosis underwent single left lung transplantation. A perfusion lung scan performed 13 days after transplantation revealed deficient perfusion in the transplanted lung. Pulmonary angiography showed severe pulmonary artery anastomotic stenosis. Percutaneous insertion of a balloon expandable stent improved both pulmonary perfusion and respiratory function.

[Neuromeningeal listeriosis in adults. Clinical aspects and contribution of cotrimoxazole in monotherapy]. / Listériose neuroméningée de l'adulte. Aspects cliniques et apport du cotrimoxazole en monothérapie.

A series of 28 patients suffering from neuromeningeal listeriosis is reported. This disease is consecutive to infection by Listeria monocytogenes--an ubiquitous and opportunistic Gram-positive bacillus--and has become a public health problem: its incidence is increasing and its prognosis is very severe despite the development of new bacteriological identification methods. Human beings are contaminated by food, which explains the frequent outbreaks of epidemics which are widely publicized, the infection being one of the consequences of the unprecedented development of the food industry and the cold food chain. The predominant clinical picture is one of non-specific meningoencephalitis. In about 50 percent of the cases the subjects infected are "immunodepressed" and/or more than 60 years' old. The diagnosis is difficult since the bacteriological identification is delayed (direct examination of the cerebrospinal fluid is rarely positive) and this fluid may be sterile (hence the value of blood cultures). A probability treatment therefore must be initiated before the diagnosis is confirmed if an unfavourable outcome is to be avoided. In Listeria monocytogenes infection cotrimoxazole administered alone seems to be a better antibacterial therapy than the reference ampicillin-aminoside combination.

Double lung transplantation for adult respiratory distress syndrome after recombinant interleukin 2.

Patients suffering from acute respiratory failure are considered poor candidates for lung transplantation (LT). We report a successful double lung transplantation performed in a patient with adult respiratory distress syndrome (ARDS). The 32-year-old woman received recombinant interleukin 2 (rIL-2) three months after an autologous bone marrow transplant for acute myelogenic leukemia as consolidation treatment. After four days of treatment with rIL-2, she developed ARDS which worsened over a three-week period, despite treatment. Lung transplantation was carried out as ultimate treatment. The postoperative course was uneventful. The patient is alive and in a good condition 11 months after LT. This case demonstrates the feasibility of LT in selected patients with ARDS. However, this case is exceptional since lung grafts should be utilized preferably for evaluated and accepted patients in transplant programs.

Removal of circulating tumor necrosis factor. Its role in septic shock treatment.

The tumor necrosis factor (TNF) is a polypeptide secreted by macrophages in response to endotoxins, especially from Gram-negative bacteria. Previous investigations suggest that TNF plays a prominent role in septic shock and meningococcal disease toxicity. A positive correlation was found between the initial serum TNF level and the patient's outcome. Despite the progress made in intensive care management and antibiotic therapy, the prognosis of septic shock remains very poor. Because of the implication of TNF in the pathogenesis of septic shock, we suggest that neutralization or elimination of this cytokine by plasma or blood exchanges could contribute to the treatment of severe forms of this syndrome. Five plasma exchanges and two blood exchanges were performed in 6 patients admitted for septic shock or purpura fulminans. Serum TNF levels were measured by immunoradiometric assay (Medgenix, ERIA Pasteur) before and after exchange. Serum TNF levels were found to be decreased by an average of 62% after the exchange. We conclude that exchange therapies are efficient in removing plasma TNF. Nevertheless, because of the limited number of patients treated, it is not possible to evaluate the clinical efficacy of such techniques.

[Should metabolic acidosis be alkalinized?]. / Faut-il alcaliniser les acidoses métaboliques?

At present, the administration of bicarbonate for metabolic acidosis has become controversial with regard to the indications and the modalities of treatment. Scientific evidence of the therapeutic value of bicarbonate is still lacking. In the opposite, there is a strong evidence of its adverse effects, such a paradoxical acidosis, sodium load and over all a worsening of haemodynamic status. Other therapeutic measures are limited. They include the administration of Carbicarb which does not increase the CO2 content, haemodialysis with bicarbonate and/or hyperventilation. As for every therapeutic action, the treatment must rely on an interpretation of the pathophysiological mechanism, resulting in the definition of therapeutic goals. The amendment of acidosis is not always a therapeutic priority. In ketoacidosis for instance, the depth of acidosis is mainly related to the degree of dehydration, the treatment of which results in a normalization of pH.

[Heterotopic hepatic transplantation in fulminating hepatitis]. / Transplantation hépatique hétérotopique pour hépatite fulminante.

Based on a rare case of heterotopic hepatic transplantation (HHT) carried out in a 24 year old woman for fulminant hepatitis of viral origin, the authors present the technique used and the principal post-operative events (rejection, resistant large volume ascites and the clinical course for the liver itself). They discuss the rarity of success in this type of graft, where the causes of failure in man have not been entirely elucidated: the venous pre-existing portal hypertension is probably a very unfavorable factor. The place of this particular type of HHT in cases of acute severe hepatic failure is then proposed: this may produce a smaller operative insult than orthotopic transplantation and, in this respect, deserves consideration when advanced hepatic encephalopathy is present, notably due to delay in finding a suitable graft.

[Can zinc deficiency in the mother be responsible for the occurrence of spina bifida aperta in the fetus?]. / La carence en zinc chez la mère peut-elle être responsable de l'apparition de spina bifida aperta chez le foetus?

The occurrence in the fetus of closure defects of the neural tube and especially spina bifida aperta (SBA) has been related, by some authors, to nutritional deficiencies of the mother, in addition to well-known genetic factors: a folic acid deficiency and more recently a zinc deficiency have been evoked. The retrospective study of 23 couples mother/newborn selected from the presence of a SBA in the child, and 14 reference couples, shows that the mothers of children with SBA have a zinc blood level lower than that of the reference group; this result is confirmed by the alkaline phosphatases and zinc enzymes which are markedly decreased. Measurement of the incorporation of radioactive zinc in the skin fibroblasts shows, in case of SBA, in the mother, an increased incorporation rate, and in the newborn a decrease of that rate in relation to the reference group. We believe that the results of our study which confirm those from other authors, demonstrate that the administration of zinc during pregnancy is at least as important as the administration of folic acid to prevent recurrence of neurulation abnormalities.

[Severe neurologic complications secondary to poisoning by slow-release theophylline]. / Complications neurologiques graves secondaires à une intoxication par les théophyllines-retard.

Three cases of severe slow-release theophylline toxicity (plasma theophylline levels above 30 mg/l) in patients with severe chronic pulmonary disease are reported. Seizures were noted in all patients, and one had tachyarrhythmia. Two of the patients died. Several factors were present which may have impaired theophylline clearance, leading to toxic plasma levels. The mortality rate of theophylline intoxication being high, the initial doses should be sufficiently low to minimize the risk of adverse affects, and the best way to prevent theophylline toxicity is to monitor plasma concentrations. A management of patients with theophylline overdosage is suggested: oral administration of activated charcoal is the primary therapeutic measure; haemoperfusion or haemodialysis should be considered only in patients in whom conservative measures have failed.

[Use of helium and oxygen mixtures in status asthmaticus]. / Utilisation de mélanges hélium-oxygène au cours de l'état de mal asthmatique.

Four patients in status asthmaticus and with alveolar hypoventilation were given a helium-oxygen (He-O2) mixture to breathe during 4 hours. Clinical improvement and return to normal of arterial blood gas levels were rapid and dramatic in all patients. The He-O2 mixture, which is a low density gas, causes a reduction in pulmonary resistance and an improvement in overall alveolar ventilation.

Peripheral venous complications of a hyperosmolar (960 mOsm) nutritive mixture: The effect of heparin and hydrocortisone. A multicenter double-blinded random study in 98 patients.

Peripheral intravenous nutrition with hyperosmolar solutions usually results in a high rate of venous complications. The aim of this multicenter double blind randomised study in 98 patients has been to measure: (a) tolerance by the peripheral veins being perfused with a protein-glucose-lipid nutritive mixture of 960 mOsm/l (group A, n = 33), (b) the protective effect of the additive to the nutritive mixture of either heparin: 1000 IU/1 (group B, n = 32) or heparin with hydrocortisone (5 mg/l) group C, n = 33). Tolerance by the veins was evaluated on a single vein site during a 48 h perfusion with 21 per day. The following complications: oedema, erythema, induration, thrombophlebitis led to the interruption of the perfusion. The rate of interruptions of perfusions for total venous complications and for thrombophlebitis has been respectively: at 24 h, in group A: 39 and 15%, in group B: 6 and 3%, in group C: 12 and 0%; at 48 h: in group A: 82 and 42%, in group B: 53 and 18%, in group C: 36 and 6%. Venous complication rates for 24 and 48 h were significantly lower in groups B and C (p<0.05) than in group A and there was no inter group difference between groups B and C. These results suggest that peripheral venous nutrition infusing 14.1 g of nitrogen and 8.5 MJ per day can be performed with a hyperosmolar solution of 960 mOsm/1, if that heparin be added to the nutritive mixture and the perfusion site be changed daily. Under these conditions the observed venous complications rate is equal to or less than 6% of cases.

Effect of parenteral nutrition on muscle amino acid output and 3-methylhistidine excretion in septic patients.

The effects of adequate total parenteral nutrition (TPN) on nitrogen excretion, urea N percentage, 3-methylhistidine excretion, and leg amino acid output, were studied during the ten-day period following abdominal surgery for generalized peritonitis in nine patients. The first two postoperative days were without nutritional intake, TPN was started on the third postoperative day (57 cal/KgBW--40% as Intralipid--0.30 g of N/KgBW). Leg amino acid outputs were done before TPN (DO), then two days (D2) and eight days (D8) after TPN. Total nitrogen and urea N percentage did not significantly differ before and after TPN. Between DO and D2 there was a significant reduction of urinary 3-methylhistidine (467 +/- 37 to 280 +/- 29 mumol/24 h-P less than 0.001) and leg amino acid release (604 +/- 103 to 254 +/- 87 nmol/mn/100 g of calf muscle--P less than 0.01) reflecting reduction in muscle hypercatabolism despite the persistence of the septic state. Between D2 and D8, 3-methylhistidine remained stable while leg amino acid release continued to decrease (254 +/- 87 to 68 +/- 40 nmol/mn/100 g--P less than 0.05). This association suggests an increased muscle protein synthesis. A closer examination of the clinical evolution of these patients, especially concerning their septic evolution, shows that only improved patients with recovery from sepsis increased their muscle protein synthesis. Thus, in septic hypercatabolic patients TPN seems to be able to reduce muscle catabolism while the increase in protein synthesis is mainly the consequence of recovery from the septic state. In such patients TPN should be used as a preventive therapeutic measure.

[Digestive complications of oral contraceptives: a case of extensive digestive necrosis in a young woman]. / Les accidents digestifs des contraceptifs oraux: un cas de nécrose digestive étendue chez une femme jeune.

PIP: A case of acute intestinal vascular necrosis in a 19-year-old user of oral contraceptives (OCs) is described, and hypotheses explaining the digestive complications of synthetic estrogens are reviewed. The patient had originally presented with a violent gastric pain that subsequently spread to the entire abdomen. An abrupt worsening of her condition involved cardiovascular collapse associated with a peritoneal syndrome, vomiting and dehydration, and hyperleukocytosis. Emergency opening of the peritoneum was followed by evacuation of a large quantity of fetid gas and alimentary debris, and observation of a completely necrosed stomach. A careful lavage of the entire intestinal cavity led to temporary improvement, but it became clear during an attempt at gastrectomy that further treatment would be unavailing and the patient died shortly thereafter. Estrogens were believed to be responsible for the digestive necrosis because it occurred in a young woman who had used an estrogen-rich OC for 3 years and who smoked; a hapatic biopsy confirmed the diagnosis. No traces of other risk factors such as hypertension, hyperlipidemia, diabetes, neoplasia, or obesity were observed. Recent publications indicate that OCs are responsible for a certain number of digestive problems, which may include acceleration of intestinal transit, severe diarrhea, rectorrhagia, ischemic or ulcerative colitis, intestinal infarct which is usually localized, and hepatocellular problems ranging from moderate hepatic insufficiency to malignant tumor and Budd-Chiari syndrome. OCs do not modify hemodynamic regimes, but they may cause elevation of fibrinogen and thrombin, diminution of antithrombin III acitivty, increased platelet adhesivity, and decreased fibrinolysis leading to hypercoagulability. These modifications in hemostasis occur in all OC users and are not statistically correlated with occurence of thrombotic accidents. OCs are probably responsible for parietal vascular lesions; experimental injection of synthetic estrogens is associated with both arterial and venous lesions. The most characteristic anomaly is at the level of the intima, with proliferation of smooth muscle cells and increased conjunctive tissue fibers associated with proliferation of the media or the endothelium. The absence of lipid deposits, the simultaneous appearance of arterial and venous lesions, and other evidence argues against and atheromatous origin of parietal lesions. A significant correlation has been found between high levels of anti-synthetic ethinyl estradiol antibodies and the presence of vascular lesions. It is hypothesized that these circulating immune complexes penetrate the vascular walls of OC users and produce lesions, which may depend on factors such as smoking.^ieng