[Hypertrophy of the biceps surae after post-radiation lumbar radiculopathy]. / Hypertrophie du triceps sural gauche consécutive à une radiculopathie post-radique.

A 44 year-old man who underwent radiotherapy for Hodgkin disease in 1987 developed in 1996 pain and calf hypertrophy. Nerve conduction studies were normal and needle electromyography revealed a neurogenic pattern in the L-5 and S-1 roots, predominantly on the left side. An abdominal tomodensitometry revealed a splenic and left renal atrophy. Cerebrospinal fluid analysis showed an elevated protein level (1.35 g/l) and no malignant cell. Spinal cord magnetic resonance imaging revealed no abnormality of the roots and the cauda equina. Muscular hypertrophy, as the consequence of post-irradiation lumbar radiculopathy is rarely reported. We discuss the possible mechanism of neurogenic muscular hypertrophy.

[A case of acute psychotic episode after a single dose of ecstasy]. / Un cas d'épisode psychotique aigu après prise unique d'ecstasy.

Over the last 10 years or so in Europe, there has been a development of the "ecstasy" phenomenon, which is the symbol of "recreational" drugs in general. Users, either alone or in private parties, are on the increase. The phenomenon is most frequent in England and in the Netherlands, with an estimated incidence of 13-18% amongst the 18-25 years old, which may reach 52% in "exposed populations", such as individuals who go to "techno" night clubs. In France, the prevalence is uncertain, but estimated at least 5% of males between 18 and 23 years old. Several substance, with more or less the same effects, are grouped together by the term "ecstasy", the best-known one being 3,4-methylenedioxymethamphetamine (MDMA), but there are also an N-demethylated derivative (MDA), methylenedioxyethylamphetamine (MDEA), N-methyl-benzodioxazolylbutanamine (MBDB) and 4-bromo-2,5-dimethoxyphenylethylamine (2-CB or Nexus). The psychopathological consequences of MDMA in man are relatively poorly understood. On the basis of series of cases reported in the literature, acute psychosis, chronic psychosis similar to paranoid delusions, flash-back phenomena similar to with LSD, anxiety/panic states and depressive mood disorders may occur. The case which we report is therefore that of an acute psychotic episode, with residual symptomatology 6 months later, which occurred suddenly following absorption of toxic substances (alcohol and ecstasy), at least 12 hours after taking the ecstasy tablet without his knowing it, in an individual without any previous psychopathology, other than moderate social phobia. Twelve cases of acute psychotic episodes after ecstasy have been reported in the literature. Two of them occurred after a single dose and one after 2 doses. No author was able to examined the previous history of the individuals accurately, nor any possible psychopathological history. Our patient did not have any previous history of psychosis, using a standardized validated interview, which his peers and family confirmed. He did however fulfil the criteria of "social phobia". Retrospectively, we noted the extent of his psychomotor disinhibition with ecstasy, which seemed to be proportional to the intensity of his previous social inhibition. This point does not explain the psychotic episode. From a neurobiologic point of view, acute psychotic disorders are often related to dysfunction of the mesolimbic dopaminergic system. During the first 3 hours, the effect of absorption of MDMA is a massive release of the serotonin, dopamine and noradrenaline stocks. Later, an acute hyposerotoninergic state is present. In our observation, the psychotic disorder appeared at least 12 hours after taking ecstasy, during the reduction phase of the intoxication. Toxicological analysis of the blood was negative (this detection is only positive for 24 hours). Like other authors, our hypothesis is that serotoninergic dysregulation affects the dopaminergic system. Sudden disappearance of serotoninergic feedback on the dopaminergic pathways, may contribute to an increase in the mesolimbic hyperdopaminergic state. In animals, it has been shown that serotonin depletion induced by MDMA, unmasks the effects of a hyperdopaminergic state. In addition, although it has not been mentioned much in the literature, MDMA disturbs dopaminergic function either directly, or through the peptidergic systems (neurotensin, substance P, dynorphines). A consistent series of arguments therefore suggest that there is a sudden central hyperdopaminergic state, which may be related to the appearance, sometimes de novo, of an acute psychotic disorder. From the published cases, psychotic disorders following absorption of ecstasy, appear to become chronic. Most of the cases occurred in individuals, who either abused multiple substances or were chronic ecstasy users. In a case like the one we report, in an individual with good general health, who is not a drug user and who has an acute episode following a single dose, the prognosis should be good. Similarly, a team from Milan has described the experience of 3 friends who had a brief psychotic episode, following ingestion of substances containing ecstasy. These episodes resolved completely, after rehydration and anxiolytic treatment. However, after 6 months' follow-up, our patient still has psychotic symptoms, albeit mild, but which were not present before the intoxication. The patient and his psychiatrist do not envisage changing or stopping his antipsychotic treatment. Other authors have described a lesion in the serotoninergic neurons, by making a parallel with toxic effects described in animals, in particular in primates, with MDMA. Degradation of the serotoninergic cell bodies and nerve endings has been suggested to occur with high doses and/or repeated doses of MDMA. Other authors show the large variations in MDMA and MDA metabolism. (ABSTRACT TRUNCATED)

An "accidental" acute psychosis with ecstasy use.

Over the last 10 years, Europe has witnessed the development of the ecstasy phenomenon; this term is used to describe several products sharing more or less the same effects. The most widely used and hence the most well known is 3,4 MDMA, but MDA, MDEA, MBDB and even 2CB or nexus are available. The psychopathological consequences of MDMA use in man are relatively poorly understood. The case reported here involves an acute psychotic episode with residual symptoms after six months, with a sudden onset at least 12 hours after taking alcohol and ecstasy without realising it, in an individual with no previous psychopathology other than a moderate anxiety disorder. Twelve cases of acute psychotic episodes after taking ecstasy have been reported in the literature; two after taking the drug on two occasions and one after a single use. No authors have examined the previous mental state or possible previous psychopathology with any precision. The present subject had not displayed any previous psychotic behavior when tested with a proven standardized interview technique; this was confirmed by his peers and his family. He did, however, show signs of social phobia. Although the personality of an individual is a factor in taking a drug, and probably in the quality of the psychotropic effects experienced, a host of arguments favor the appearance of psychotic symptoms de novo, which were probably related to direct toxicity by MDMA and/or its metabolites on the serotoninergic neurons.

Introduction of knowledge bases in patient's data management system: role of the user interface.

As the number of signals and data to be handled grows in intensive care unit, it is necessary to design more powerful computing systems that integrate and summarize all this information. The manual input of data as e.g. clinical signs and drug prescription and the synthetic representation of these data requires an ever more sophisticated user interface. The introduction of knowledge bases in the data management allows to conceive contextual interfaces. The objective of this paper is to show the importance of the design of the user interface, in the daily use of clinical information system. Then we describe a methodology that uses the man-machine interaction to capture the clinician knowledge during the clinical practice. The different steps are the audit of the user's actions, the elaboration of statistic models allowing the definition of new knowledge, and the validation that is performed before complete integration. A part of this knowledge can be used to improve the user interface. Finally, we describe the implementation of these concepts on a UNIX platform using OSF/MOTIF graphical interface.

[Lack of sensitivity to per-anesthetic malignant hyperthermia in 32 patients who developed neuroleptic malignant syndrome]. / Absence de sensibilité à l'hyperthermie maligne peranesthésique chez 32 patients ayant développé un syndrome malin des neuroleptiques.

The aim of this study was to verify whether a relationship exists between neuroleptic malignant syndrome (NMS) and anaesthetic-induced malignant hyperthermia (MH) or not. The in vitro halothane-caffeine tests were performed on muscle tissue obtained from 32 patients with documented NMS episodes. The diagnosis of NMS relied on Levenson's criteria. The results, expressed in accordance with the criteria of the European MH Group, defined 29 subjects as MH non-susceptible. Three patients were classified as MH equivocal. These findings demonstrate the lack of any link between NMS and MH. Therefore, patients with a history of NMS are not likely to be at risk of developing MH and special measures against MH are not required for anaesthesia in these patients.

Septic shock, multiple organ failure, and disseminated intravascular coagulation. Compared patterns of antithrombin III, protein C, and protein S deficiencies.

STUDY OBJECTIVE: Our aim was to document the following in patients with septic shock and disseminated intravascular coagulation (DIC): (1) the influence of DIC in the mortality rate and the occurrence of organ failure; (2) the comparative prognostic value of initial antithrombin III (ATIII), protein C (PC), and protein S (PS) levels; and (3) the compared pattern of sequential ATIII, PC, and PS levels according to clinical outcome. DESIGN: Demographic data, criteria of severity, mortality in ICU, frequency of organ failure, hemodynamic and oxygenation parameters, and laboratory findings were compared in patients with septic shock according to the occurrence of DIC. Initial and sequential levels of ATIII (activity), PC (antigen and activity), PS (total and free), and C4b binding protein (C4bBP) were compared according to the outcome in patients with DIC. PATIENTS: Sixty patients with septic shock were studied. Forty-four entered the group DIC+; 16 entered the group DIC-. RESULTS: Simplified acute physiologic score (SAPS), frequency of acquired organ failure, blood lactate, and transaminase values were significantly higher in the group DIC+. The mortality rate reached 77 percent in group DIC+ vs 32 percent in DIC- (p less than 0.001). In patients with DIC, a fatal outcome was associated with higher bilirubin and transaminase levels, lower PaO2/FIo2 ratio, Vo2, Do2 and O2 extraction. In the group DIC+, all patients but two had severe deficiencies in ATIII and PC levels. Significant correlations were found between initial ATIII and PC levels, PC and free PS levels, and free PS and C4bBP levels. Initial ATIII levels had the best prognostic value for prediction of subsequent death. Serial measurements were consistent with a prolonged ATIII and PC deficiency with significantly different levels between survivors and nonsurvivors. CONCLUSIONS: DIC is a strong predictor of death and multiple organ failure in patients with septic shock. Sequential ATIII, PC, and PS measurements were consistent with prolonged consumption or inhibition that might account for a sustained procoagulant state and inhibition of fibrinolysis. The initial ATIII level was the best laboratory predictor of death in these patients.

Use of capnography in diagnosis of pulmonary embolism during acute respiratory failure of chronic obstructive pulmonary disease.

In chronic obstructive pulmonary disease (COPD) patients, there is a difference between PaCO2 and end-tidal partial pressure of CO2 (PetCO2). This gradient P(a-et)CO2 is due to ventilation/perfusion mismatching and deadspace, and is usually abolished by forced and prolonged expiration. We hypothesized that this gradient might not be canceled by forced expiration in the case of acute respiratory failure (ARF) related to pulmonary embolism (PE). Forty-four adult COPD patients were prospectively entered into this study; they were suspected of having ARF related to PE on the basis of clinical and biological data on admission. Maximum expired partial pressure of CO2 (PemCO2) was measured in mechanically ventilated and sedated patients by an interrupt of mechanical support. CO2 concentration was recorded during the following prolonged and passive expiration. The test was considered valid if an expiratory plateau was obtained. PemCO2 was measured in triplicate. Simultaneously, PaCO2 was measured and the ratio, R = [( 1-PemCO2]/PaCO2) x 100, was calculated. Pulmonary angiography was performed on the same day for all patients. Results showed that 17 patients had PE (PE+) and 17 had no PE (PE-). The two groups were comparable regarding mean age, severity of underlying chronic respiratory disease, PaCO2, PaO2, and hemodynamic data on admission. P(a-em)CO2 and R were significantly different in PE+ and PE- patients at 12 +/- 6.9 torr compared to 1 +/- 2.4 torr and at 28 +/- 14.8% compared to 2 +/- 6.2% (p less than .001), respectively. The positive predictive value of the test was 74%, but the negative predictive value 100% and the specificity was 65%, but sensitivity was 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

Meningococcemia and purpura fulminans in adults: acute deficiencies of proteins C and S and early treatment with antithrombin III concentrates.

It has been recently suggested that an acquired deficiency of proteins C and S could contribute to the pathogenesis of meningococcemic purpura fulminans (PF) in children. Our study was designed to measure the levels of antithrombin III (AT III), protein C, and protein S during adult PF and to determine the effects of an early infusion of high doses of AT III concentrates on clinical and biological alterations of PF. We studied five consecutive adult patients with meningococcemia (type B) and PF. The levels of AT III, protein C (antigen and activity), and protein S (total and free) were measured at admission and 24 h and 1 month later. The treatment included in each case: amoxycillin, dobutamine and high doses of AT III concentrates. All patients survived and were discharged without any sequelae. At admission, biological data were consistent with severely depressed protein C and protein S levels and moderately decreased AT III levels, without any discrepancy between protein C antigen and activity. After 24 h, AT III and protein S levels were within normal ranges, whereas protein C levels were still depressed. These data are consistent with the theory of a particular imbalance in the anticoagulant systems during meningococcemic PF, contrasting with the usual findings observed during septic disseminated intravascular coagulation. The possibility must be considered that high doses of one anticoagulant (AT III concentrates) could compensate for the acute decrease in the other (protein C system).

Computer-assisted evaluation of respiratory data in ventilated critically ill patients.

In intensive care unit, a lot of data are currently available but remain unused by nurses and residents because of complexity of analysis. We have developed a system for interpretation of respiratory data (RESPAID) in order to improve monitoring of patients under respiratory support and also to provide a high level of information. RESPAID is a real-time system which interprets quantitative and qualitative aspects of the usual respiratory data at different levels of information. Initial knowledge base was built from data given by four specialists in intensive care. Major attention was paid to different aspects of the system: monitor interface, user interface and time representation. Data are issued from standard respirators and/or monitors used in the intensive care unit. Informations provided by RESPAID are alarm identification, ventilator settings modification and proposal for physiological evolution of the patient or suspected complication. RESPAID runs on IBM PCAT3 with 1st class shell. It is currently in clinical validation procedure.

Carbon dioxide mandatory ventilation (CO2MV): a new method for weaning from mechanical ventilation. Description and comparative clinical study with I.M.V. and T. tube method in COPD patient.

We describe a new technique specially designed for weaning from mechanical ventilation: carbon dioxide mandatory ventilation (CO2MV). CO2MV is based on feedback between end tidal expired partial pressure of carbon dioxide and ventilatory mode, controlled or spontaneous. In order to evaluate its real interest we performed a randomized prospective study, CO2MV vs Intermittent Mandatory Ventilation (IMV) and T. Tube Method (TTM). Fourty-two adult patients with chronic obstructive pulmonary disease entered this study at the end of acute respiratory failure requiring mechanical ventilatory support. We observed a better stability of arterial blood gas during weaning with CO2MV and an increase in success rate (CO2MV 13/14 - IMV 5/14 - TTM 10/14). From this study CO2MV seems available for weaning of COPD patients. Nevertheless, further studies are required to appreciate its real clinical interest.

[Hyperreninemic hypoaldosteronism syndrome induced by plasma exchange]. / Syndrome d'hypoaldostéronisme hyperréninémique induit par les échanges plasmatiques.

The study was designed to measure sequential changes in plasma renin activity, aldosterone, angiotensin-converting enzyme activity and ionograms, prior to, and after therapeutic plasma exchange. Each measurement was repeated before and after stimulation of renin activity induced by furosemide. The results showed that plasma exchange induces a syndrome of hyperreninemic hypoaldosteronism associated with a depletion in angiotensin-converting enzyme activity which might account for the dissociation between plasma renin activity and aldosterone.

Decrease of angiotensin-converting enzyme activity after plasma exchange.

We measured sequential changes in serum angiotensin-converting enzyme (ACE) in 12 ICU patients undergoing plasma exchange (PE) with plasma substitutes (albumin-Polygelin). A dramatic decrease in serum ACE activity was observed after each of the 51 PE procedures. Repeated PE procedures resulted in almost a total depletion of serum ACE, which returned to normal ranges in 4 to 10 days. No ACE change was observed during hemodialysis or hemofiltration. ACE activity increased after PE with fresh frozen plasma replacement. ACE changes were compared with IgG, antithrombin III, and fibronectin changes. Extraction ratio comparisons were consistent, with a loss in removed plasma accounting for 50% to 70% of the observed ACE decrease. Plasma zinc levels were not modified after PE. Mixing experiments with increasing volumes of plasma substitutes showed ACE inhibition by Polygelin. In vivo infusion of Polygelin had the same effect. The renin-induced aldosterone response studied in six exchanged patients was consistent with a relative hyperreninemic hypoaldosteronism after repeated PE. These findings may be of clinical relevance during acute hypovolemia and dehydration after PE or Polygelin infusion and in patients with impaired lung endothelial function.

Neuroleptic malignant syndrome and malignant hyperthermia. In vitro comparison with halothane and caffeine contracture tests.

The in vitro halothane and caffeine contracture tests have been performed on muscle tissue from six survivors of the neuroleptic malignant syndrome. The results, which are expressed in accordance with the criteria of the European MH Group, defined five of the subjects as MHN and one patient as MHE. It is concluded that there is no common pathophysiological link between the neuroleptic malignant syndrome and malignant hyperthermia.