Bilateral anterior shoulder dislocation with bilateral fractures of the greater tuberosity: A case report.

Bilateral anterior dislocation of the shoulders with fractures of both greater tuberosities is very rare. A 76-year-old woman sustained a bilateral anterior dislocation of her shoulders with fractures of the greater tuberosity on both sides after a fall on stairs. Her arms were abducted and externally rotated. Radiological examination revealed the bilateral anterior dislocation and also the bilateral fractures of the greater tuberosity. Prompt closed reduction followed by a 3 weeks immobilization and subsequent rehabilitation allows a good outcome. Results at one-year follow-up were satisfactory with normal range of motion and no redislocations occurring. To our knowledge, this is the first reported case of bilateral anterior shoulder dislocation associated with fractures of both greater tuberosities in elderly woman.

[Endoscopic approaches to the orbit]. / Les abords endoscopiques de l'orbite.

During the last decade, the use of endoscopic endonasal approaches to the pituitary has increased considerably. The endoscopic endonasal and transantral approaches offer a minimally invasive alternative to the classic transcranial or transconjunctival approaches to the medial aspect of the orbit. The medial wall of the orbit, the orbital apex, and the optic canal can be exposed through a middle meatal antrostomy, an anterior and posterior ethmoidectomy, and a sphenoidotomy. The inferomedial wall of the orbit can be also perfectly visualized through a sublabial antrostomy or an inferior meatal antrostomy. Several reports have described the use of an endoscopic approach for the resection or the biopsy of lesions located on the medial extraconal aspect of the orbit and orbital apex. However, the resection of intraconal lesions is still limited by inadequate instrumentation. Other indications for the endoscopic approach to the orbit are the decompression of the orbit for Graves' ophthalmopathy and traumatic optic neuropathy. However, the optimal management of traumatic optic neuropathy remains very controversial. Endoscopic endonasal decompression of the optic nerve in case of tumor compression could be a more valid indication in combination with radiation therapy. Finally, the endoscopic transantral treatment of blowout fracture of the floor of the orbit is an interesting option that avoids the eyelid or conjunctive incision of traditional approaches. The collaboration between the neurosurgeon and the ENT surgeon is mandatory and reduces the morbidity of the approach. Progress in instrumentation and optical devices will certainly make this approach promising for intraconal tumor of the orbit.

Mechanically-induced aggregation of the monoclonal antibody cetuximab.

This study focuses on the mechanically-induced aggregation of the anticancer monoclonal antibody cetuximab and its mechanism by comparing two commercially-available formulations (old formulation [OF]: 2mg/ml in phosphate buffer; new formulation [NF]: 5mg/ml in citrate buffer with polysorbate 80 and glycine). Cetuximab aggregation under stirring was followed during a 24h period and several methods were used to describe the aggregation kinetics (turbidimetry, size-exclusion high performance liquid chromatography, cation-exchange chromatography, dynamic light scattering and peptide mapping). Depending on the formulation, the aggregation process followed different kinetics: biexponential for the OF and mono-exponential for the NF. The percentage of aggregation after 24h stirring-period was about 25% for the OF but was only 2% for the NF corresponding to a ten-fold improvement, demonstrating a strong protecting effect of polysorbate and glycine. The aggregates are mainly due to an increased exposure of antibody molecules to air/liquid interface and are formed without chemical alteration of the antibody structure. This improvement of cetuximab stability by a new formulation seems linked to the stabilisation of cetuximab under dimeric form by a higher protein concentration and the presence of stabilizing excipients.

[Evolution of functional autonomy in geriatric medium-term care units: a reliable performance indicator?]. / Evolution de l'autonomie fonctionnelle en soins de suite gériatriques: un indicateur de performance?

The objective of this study was to compare the evolution of the level of functional dependence of patients between the time of their hospital admission and release following treatment received in the geriatric medium-term care units, in order to propose this variable as a clinical performance indicator for this type of service. The differential score of physical dependence observed was determined for each hospital stay, and the adjusted significant functional improvement rate (SFI) was calculated for every unit. This adjusted SFI rate was then compared to the overall rate of all of the units combined. The overall SFI rates were 23% in 2004. Seven of the 49 units studied present an adjusted rate significantly inferior to the average rate of the total number of units combined. This study constitutes one of the first performance analyses in the medium-term sector, and the adjusted SFI rate seems to be a pertinent and reliable indicator within this framework.

Paralytic poliomyelitis associated with the Sabin 3 revertant strain of poliovirus in Bahrain.

We report a case of vaccine-associated paralytic poliomyelitis (VAPP) in Bahrain. The case occurred in an 8-week-old infant who had received a dose of oral polio vaccine (OPV) 7 days after birth. She was in contact with two vaccinees who had received OPV during the national immunisation campaign conducted 10 days before her birth. Specimens from the infant were sent to the WHO Collaborating Centre for Virus Reference and Research Laboratory for serological testing and virus detection, including genomic sequencing. Clinical and virological features are presented of a case of VAPP caused by the Sabin 3 strain of poliovirus that had reverted towards neurovirulence. The case represents one in 51,879 first doses of OPV distributed between 1995 and 1998. In order to reduce further the risk of VAPP, the dose of OPV at birth has been discontinued and a sequential schedule of inactivated polio vaccine (IPV) followed by OPV will be recommended.

Acute renal failure in patients over 80 years old: 25-years' experience.

OBJECTIVE: To determine the epidemiological trends, spectrum of etiologies, morbidity and mortality of acute renal failure (ARF) in patients over 80 years old. DESIGN: Historical cohort analysis. SETTING: Intensive care unit (ICU) of nephrology, Tenon Hospital, Paris. PATIENTS AND PARTICIPANTS: The criteria of inclusion was ARF, defined on the basis of a creatinine value over 120 mumol/l, in patients over 80 years of age admitted between October 1971 and September 1996. When moderate chronic nephropathy was pre-existing, ARF was defined by the increase of at least 50% over the basal creatininemia. MEASUREMENTS AND RESULTS: Three hundred and eighty-one patients over 80 years of age were included. The etiology and mechanism of ARF are detailed. 29% of the patients received dialysis. Global mortality at the hospital was 40%. Factors significantly associated with a poor prognosis are identified. Mean survival after hospitalization was 19 months. CONCLUSION: The frequency of admission to ICUs for ARF in patients older than 80 years seems to be on the increase. Mortality is less severe than expected. These patients could benefit from the renal replacement therapy of modern intensive care medicine.

Hemolytic uremic syndrome. Recurrence after renal transplantation. Groupe Coopératif de l'Ile-de-France (GCIF).

Hemolytic uremic syndrome (HUS) is an uncommon cause of end-stage renal failure in adults, and few data are available concerning the outcome of renal transplantation in these patients. We conducted this retrospective multicentric study to appreciate the outcome of adult renal transplant recipients whose primary disease was HUS. Sixteen patients, transplanted between 1975 and 1995, were included in the study. In each case, initial diagnosis of HUS was documented by a kidney biopsy. These 16 patients received a total of 25 allografts: 1 graft for 9 patients, 2 grafts for 5 patients, and 3 grafts for 2 patients. Nine patients (56%) developed definite clinical and pathologic evidence of recurrence on at least 1 graft. Four additional patients (25%) demonstrated only some clinical or pathologic evidence of recurrence which could not be distinguished from acute vascular rejection. Three patients had no sign of recurrence of the initial disease. The 1-year graft survival rate was 63% and the 5-year graft survival rate was 18.5%. In the group of patients with proven or possible recurrence (n = 13), the 1-year and 5-year graft survival rates were 49% and less than 10%, respectively. The recurrence was an early event, occurring before the end of the first month after transplantation in half the cases. The recurrence rate was 92% in non-nephrectomized patients and 50% in patients with bilateral nephrectomy. In the literature, 71 adult patients with primary HUS had received a total of 90 kidney grafts. Among them, 54% had a recurrence on their graft, which was diagnosed in 52% of the kidney transplants. It is note-worthy that when data from the literature are pooled with our results, the rate of recurrence appears to be significantly lower in binephrectomized patients than in patients with their native kidneys at the time of transplantation (5 of 14 versus 27 of 35 patients, respectively, p = 0.0155). By univariate analysis, no other risk factor for recurrence could be identified. Treatment with cyclosporine A did not influence the recurrence rate. We conclude that recurrence of HUS after renal transplantation is a frequent, early, and severe complication, leading rapidly to graft loss. Prospective studies are needed to confirm that bilateral nephrectomy prior to transplantation decreases the rate of recurrence.

Use of intraperitoneal pressure, ultrafiltration and purification dwell times for individual peritoneal dialysis prescription in children.

Tolerance of peritoneal dialysis is, in a part, dependent on intraperitoneal dialysate volume. Measurement of intraperitoneal pressure (IPP) in cm of water is easy to perform especially with the twin bag Y set (Baxter). Today we use IPP for following surgical catheter implantation (delaying, starting and progressing with peritoneal dialysis) and for optimizing ultrafiltration and purification. Efficiency of peritoneal dialysis is dependent on adequate ultrafiltration (UF) and on adequate purification (solute clearances). These two goals seem apparently conflicting in terms of duration of dwells: short dwell time enhances UF capacity and conversely long dwell time enhances solute clearance. Peritoneal equilibration test (PET) allows an approach to the ultrafiltration time: the point at which the overtime dialysate urea saturation and glucose desaturation curves cross, called APEX time. PET allows also an approach of the purification time: the point at which dialysate (D) to plasma (P) concentration ratios over time are high. Because the value of phosphate as uremic factor of morbidity, we have chosen the time for D/P phosphate equal to 0.6 as a purification phosphate dwell time (PPT). A total of 17 patients were studied, over a five-year period allowing 142 determinations. APEX times (range 18 to 71 min) and PPT (range 105 to 238 min) were spread over a wide distribution. PPT and APEX times were significantly shorter in children younger than 3 years of age than in children older than 10 years of age. PPT were nearly four times longer than APEX times. The knowledge of these conflicting ultrafiltration and purification times should help, in our view, in the individual choice of the PD modality: if UF is the major goal, short dwell times should be used (automatic PD); if purification is the major goal, long dwell times should be used (CAPD); if both are the target goal, tidal PD should be discussed.

Growth hormone therapy in elderly people: an age-delaying drug?

The aims of this review are to present a brief overview of growth hormone (GH) physiology and to summarize the studies of GH treatment in adults. Special attention has been paid to randomized controlled trials. Studies have revealed a partial deficiency of GH secretion in the elderly. GH secretion on the average declines by 14% with each decade in normal adults after 20 years of age. Aging has a central effect on the GH secretion and peripheric effect on insulin-like growth factor 1 (IGF-1) through changes in the body composition. GH administration may attenuate several important decrements in body composition and in function associated with aging. GH may also have very potent anabolic effects in surgical situations. Short-term side-effects of GH therapy include edema, carpal tunnel syndrome and arthralgia. A number of agents such as oral GH-releasing peptides (GHRPs) increase GH secretion; they may be an alternative to GH treatment in the future. Further studies of GH replacement are needed, examining issues such as dosage, tolerance and efficacy before the widespread use of GH in the elderly is advocated.

Relationship between intraperitoneal hydrostatic pressure and dialysate volume in children on PD.

As a result of the theoretical risk of an excessive increase in intraperitoneal pressure (IPP) in association with peritoneal dialysis, reduction of instilled intraperitoneal dialysate volume (IPV) is often proposed in infants compared to adults; a further reduction is often noted in neonates compared to children. To better evaluate the significance of this risk, we have tested the relationship between the IPP (cm of water) and the IPV (mL/m2) in our population of children on peritoneal dialysis (n = 17) during the last three years. IPP was measured after a nocturnal dialysis session, during a morning study day, after sequential exchanges of ten minutes' dwell time each, with progressively increased instilled dialysate volumes from 600 to 1400 mL/m2. Mean IPP values were 8.2 +/- 3.8 cm for a mean IPV of 990 +/- 160 mL/m2 body surface area. These values are lower than the IPP values established for adults (13.4 +/- 3.1 cm), which were given for higher IPV values of 1585 +/- 235 mL/m2. The relationship between IPP and IPV was age-dependent. In neonates, stable IPP values (3.5 +/- 1.6 cm) were noted for IPV from 600 to 800 mL/m2; thereafter, increasing IPV led to an increase in IPP. In the range of 600 to 1200 mL/m2 IPV, no significant increment of mean IPP was noted in infants (4.8 +/- 2.6 cm) and in children (9.6 +/- 2.1 cm). However, increasing the dialysate volume over 1000 mL/m2 induced an overincrement of the individual IPP value in most cases, and the rise of IPP was substantial when IPV rose from 1200 to 1400 mL/m2.

Determination of individual ultrafiltration time (APEX) and purification phosphate time by peritoneal equilibration test: application to individual peritoneal dialysis modality prescription in children.

Efficiency of peritoneal dialysis (PD) is dependent on adequate ultrafiltration (UF) and purification (solute clearance). These two goals apparently seem to conflict in terms of duration of dwells: short dwell time enhances UF capacity and, conversely, long dwell time enhances solute clearance. Peritoneal equilibration test (PET) allows an approach to the ultrafiltration time: the point at which the over time dialysate urea saturation and glucose desaturation curves cross, call APEX time. PET also allows an approach to the purification time: the point at which dialysate-to-plasma (D/P) concentration ratios over time are high. Because of the value of phosphate as a uremic factor of morbidity, we have chosen the time at which D/P phosphate is equal to 0.6 as a purification phosphate dwell time (PPT). A total of 17 patients were studied, over a five-year period, allowing 142 determinations. APEX times (range 18-71 min) and PPT (range 105-238 min) were spread over a wide distribution. PPT and APEX times were significantly shorter in children younger than three years of age than in children older than ten years of age. PPT were nearly four times longer than APEX times. Knowledge of these conflicting ultrafiltration and purification times should help, in our view, in the individual choice of the PD modality: if UF is the major goal, short dwell times should be used (automated PD); if purification is the major goal, long dwell times should be used, as in continuous ambulatory peritoneal dialysis; if both are the target goal, tidal PD should be discussed.

Nutritional effects of KT/V in children on peritoneal dialysis: are there benefits from larger dialysis doses?

Dialysis adequacy is monitored by urea kinetic modeling (UKM), in particular by calculation of KT/V (normalized whole body urea clearance) and PCRN (normalized protein catabolic rate). All children on peritoneal dialysis from our unit (7 children; mean age 7 years, 8 months) participated in our study (dialysis research program of the French Registry of Peritoneal Dialysis). Every month analysis of dialysate and urine collections and blood samples were compared to a 3-day diet survey to analyze the relations between doses of dialysis (KT/V) and nutrition [dietary protein intake (DPI) and caloric intake]. Calculated protein intake and DPI were also compared. Spearman correlation coefficients were used to assess the association between variables. KT/V values were spread over a wide range (0.8-2.8, mean 1.9). KT/V was positively (weakly) correlated to PCRN (p = 0.07, y = 0.24x + 1.08, r = 0.2), but not to DPI. No correlation could be found between PCRN and DPI, but doses of dialysis (KT/V) were positively correlated to caloric intake (p = 0.001, y = 28.97x + 13.66, r = 0.424). We assume that the correlation between KT/V and PCRN is not necessarily the reason, but only a calculation effect. On the contrary, the positive correlation between KT/V and caloric intake allows us to speculate that more efficient dialysis enhances appetite.

Inhibition of platelet aggregation by human placenta.

Human placental cytosol inhibits platelet aggregation induced by high doses of collagen. The aim of this study was to investigate whether this anti-aggregating activity was caused only by the presence of various activities already described in the placenta (an ADP-consuming enzyme, a fatty acid cyclooxygenase inhibitor, and a thromboxane synthetase inhibitor) or whether another factor was present. Heating the cytosol at 50 degrees C for 6 min destroyed the inhibitor of collagen-induced aggregation. ADPase and the AA pathway inhibitors were not modified by this treatment. We therefore show the presence of an additional anti-aggregating factor: it is destroyed by heating at 50 degrees C. We also tested for the presence of an inhibitor of AA release in the placental cytosol using three different methods (rabbit platelets in PRP, washed rabbit platelets, and NRK fibroblasts) but no inhibition could be evidenced. We conclude that this new anti-aggregating factor, which is probably a protein, acts neither through AA release inhibition nor AA cascade inhibition.