[Left ventricular assist devices in cardiogenic shock]. / Assistances circulatoires dans les chocs cardiogéniques.

Cardiogenic shock is the leading cause of in-hospital death for myocardial infarction. Despite therapeutic improvements, such as medical treatment with inotropes, myocardial revascularization, circulatory assistance can be an option. Intra-aortic balloon pumping is highly recommended in the presence of haemodynamic impairment. If the patient continues to deteriorate and cardiac function cannot maintain adequate circulation to prevent end-organ failure, several mechanical circulatory assist devices can be considered: extracorporeal membrane oxygenator (ECMO), Impella(®)… These devices should be used at tertiary centres either as bridge to recovery or as bridge to transplantation or as bridge to long-term left ventricle assist device.

Hysteresis dynamics, bursting oscillations and evolution to chaotic regimes.

This article describes new aspects of hysteresis dynamics which have been uncovered through computer experiments. There are several motivations to be interested in fast-slow dynamics. For instance, many physiological or biological systems display different time scales. The bursting oscillations which can be observed in neurons, beta-cells of the pancreas and population dynamics are essentially studied via bifurcation theory and analysis of fast-slow systems (Keener and Sneyd, 1998; Rinzel, 1987). Hysteresis is a possible mechanism to generate bursting oscillations. A first part of this article presents the computer techniques (the dotted-phase portrait, the bifurcation of the fast dynamics and the wave form) we have used to represent several patterns specific to hysteresis dynamics. This framework yields a natural generalization to the notion of bursting oscillations where, for instance, the active phase is chaotic and alternates with a quiescent phase. In a second part of the article, we emphasize the evolution to chaos which is often associated with bursting oscillations on the specific example of the Hindmarsh-Rose system. This evolution to chaos has already been studied with classical tools of dynamical systems but we give here numerical evidence on hysteresis dynamics and on some aspects of the wave form. The analytical proofs will be given elsewhere.

A French study of the Dominic Interactive.

INTRODUCTION: The Dominic Interactive was developed in North America to assess a child's perception of her/his own symptoms, which is critical to balance parents' and school professionals' perception. It is a computerized, DSM-IV-based pictorial questionnaire akin to a video game, for children aged 6-11. A strengths and competencies scale displays positive situations. Most children complete the Dominic Interactive 90 situations within 10-15 min. OBJECTIVE: Because of the cultural differences between North American and French children, a study of the appropriateness of the instrument to assess French children was required. METHODS: The CD-ROM-based Dominic Interactive was completed by 253 community children, and by 150 children from outpatient clinics in four French cities. The latter also received clinical diagnoses. Prevalence estimates yielded by the Dominic Interactive in the general population and referred children, relationships between prevalence estimates based on the Dominic Interactive and clinical judgments, and differences between Dominic Interactive scores in sub-samples of children with and without a clinical diagnosis were studied. RESULTS: Significant differences between clinically referred and non-referred children were found for every diagnosis, and between Dominic Interactive scores of referred children with and without a clinical diagnosis with the exception of oppositional disorder. Parental acceptability of the instrument was never a problem, children like it, and clinicians' comments were positive. DISCUSSION: Reference and clinical judgment both indicate that the Dominic Interactive is appropriate to assess child mental health in France. Clinical judgment discrepancies between sites and small numbers are the limitations of this study. CONCLUSION: The instrument performed well in the French context. The potential advantages of using the Dominic Interactive (children enjoy the activity, parents approve of it, it is relatively cost-effective, etc.) suggest its applicability in other settings.

Fetoplacental chromosomal discrepancy.

Chorionic villus sampling is now an acceptable alternative to second trimester amniocentesis. Several reports have raised concerns about the occurrence of discrepancies between the chorionic villi and fetal chromosomal constitution, which adds multiple diagnostic complexities to the process of prenatal genetic counselling. We report on a series of 26 cases in which fetoplacental discrepancies have occurred. The chromosomal aberration was exclusively confined to the placenta in 21 cases. Twice the identical aberration was also observed in amniotic fluid with variant range of aneuploidy. The chromosomal abnormality was found in amniotic fluid and fetal blood samples in two cases, and was absent in chorionic villi. One case had very unusual cytogenetic findings as two different non-mosaic chromosomal abnormalities were identified separately in the placenta and amniocytes. Among the 21 gestations with confined placental abnormal karyotype, three cases of intrauterine growth retardation were identified. Of six cases evaluated for uniparental disomy, four demonstrated biparental inheritance. These findings support a positive correlation between placental aneuploidy and abnormal fetal development. They also emphasize the importance of further DNA analysis whenever discrepant karyotype findings between the placenta and amniocytes are identified.

[Adverse effects and medication errors: incidence and role of the organization of drug distribution]. / Effets indésirables et erreurs de médication: incidence et rôle de l'organisation du circuit du médicament.

The true incidence of adverse drug events is controversial and there are few data concerning the percentage of potentially preventable adverse drug events. Over 2 months, in two internal medicine units, we asked the staff to report adverse drug events. All incidents were evaluated: adverse drug events (preventable and non-preventable) and potential adverse drug events (non-intercepted potential adverse drug events and intercepted potential adverse drug events). The severity, the stage in the process at which the error occurred and the type of error were evaluated by a physician reviewer. Over the 240 admissions, the incidence of adverse drug events is 18 per 1000 patient-days. The system design caused 77 per cent of the incidents. The medication errors occurred at all stages from ordering to administration. Adverse drug events resulting in medication errors (n = 22) were more serious than non-preventable adverse drug events (n = 26) (p = 0.003). A prevention strategy by pharmacovigilance centres (Centres Régionaux de Pharmacovigilance) should target all stages of the drug delivery process.

Prenatal ultrasonographic findings in Proteus syndrome.

Proteus syndrome, a disorder which consists of skeletal, hamartomatous and other mesodermal malformations proves to be tremendously variable. Although most of the patients show deformities at birth, the diagnosis is usually made later in life as the phenotype develops over time. We report on the case of a fetus presenting in utero, with a cystic abdominal mass and malposition of the fingers, which was found to have additional features of Proteus syndrome after termination of pregnancy. This case demonstrates that severe cases of Proteus syndrome can be detected prenatally.

Respiratory depression following administration of intrathecal bupivacaine to an opioid-dependent patient.

OBJECTIVE: To document two cases of respiratory depression in patients receiving morphine once the stimulating effect of pain on respiration was removed by bupivacaine. CASE SUMMARIES: Case 1: A 72-year-old 84-kg white man with cancer of the bladder and bone metastases had intense back and leg pain that was treated with intrathecal morphine for 6 months at an increasing dosage up to 10 mg twice daily. The intrathecal route was avoided for 4 days because of a suspected local infection at the site of the intrathecal catheter. During this 4-day period the patient received extended-release morphine and subcutaneous morphine daily. When the intrathecal route was used again, he received an identical dose of morphine plus bupivacaine and epinephrine. Ten minutes after the injection, fatal respiratory distress occurred. Case 2: A 92-year-old white woman was admitted for revascularization of arteritis on her left leg. To treat a painful sacrum and heel bedsores, she received extended-release oral morphine for 8 days. Induction of the intrathecal anesthesia was performed with bupivacaine. After 10 minutes, the patient became subcomatose, with miosis and apnea. Intravenous naloxone restored spontaneous respiration and normal consciousness. CONCLUSIONS: Pain is a physiologic antagonist of the respiratory depressant effects of opioid analgesics. By reducing pain stimulation, bupivacaine may make patients more susceptible to opioid respiratory depression. Such situations require titration of bupivacaine and other analgesics as well as increased monitoring of the patient.

Prenatal diagnosis of 22q11 microdeletion.

Microdeletion of 22q11 is responsible for DiGeorge syndrome, velocardiofacial syndrome, congenital conotruncal heart defects, and related disorders. Familial transmission accounts for about 10-20 per cent of cases and most of the parents with deletions are nearly asymptomatic. This phenotypic variability makes it difficult to give appropriate genetic counselling. We report our experience on prenatal diagnosis of 22q11 deletion. We proposed prenatal detection of 22q11 microdeletion in 33 pregnancies. In two instances the parents refused prenatal diagnosis and one pregnancy ended spontaneously before the time of sampling. Fluorescent in situ hybridization (FISH) analysis on cultured amniotic cells with probes mapping in the commonly deleted region was used in the remaining 30 cases. Indications were classified into two groups. The first group included four couples with an abnormal family history of a deleted child and/or a deleted parent. No deletion was found in this group. The second one concerned pregnancies with a prenatally detected heart defect. Among these pregnancies with abnormal ultrasound findings, three deletions were found in the 26 samples tested.

i(18q) in amniotic and fetal cells with a normal karyotype in direct chorionic villus sampling: cytogenetics and pathology.

A case of false-negative discrepancy between results of chorionic villi (direct preparation) and those of fetal tissue with an isochromosome 18q [i(18q)] in amniotic cells and fetal blood is reported. Fluorescence in situ hybridization (FISH) confirmed this uncommon chromosomal rearrangement. The fetus showed cyclopia and multiple congenital anomalies which have never been reported in cases of i(18q).

[Chorionic villus needle sampling by the transabdominal route or by placental centesis. A series of 930 cases]. / Les prélèvements de villosités choriales à l'aiguille par voie transabdominale ou placentocentèses. Une série de 930 cas.

The authors report on a series of 930 chorion villus sampling diagnoses made with a needle by the transabdominal route, from January 1991 to October 1992 at the Prenatal Diagnosis Center in Marseille. Indications for prenatal diagnosis were: raised maternal age in 75% of cases (N:698); ultrasound findings in 11% (N:106), chromosome abnormalities in the family in 6% cases (N:53), raised human chorionic gonadotrophin in 4% cases (N:38), parental rearrangement in 2% cases (N:20), and sex linked disease in 1% (N:15). The success rate was 97% with 29 failures; the number of needle insertions was one in 97% cases and two in 3% cases. The average gestational age at sampling was related to the indications; 16 weeks of amenorrhoea for raised maternal age, and 22 weeks of amenorrhoea for ultrasound findings. Thirty one abnormalities were observed, four balanced translocations, and seven placental mosaicisms. Forty eight pregnancies terminated in abortion. The rate of fetal loss was 3.5% (7 cases) for the 200 first cases and 1% (8 cases) for the 730 following cases. Choriocentesis through the transabdominal route provides a diagnosis within a few days and the rate of fetal loss is close to that of amniocentesis. These arguments are in favour of an extension of this method of sampling.

PIP: Between January 1, 1991, and September 30, 1992, at the Prenatal Diagnostic Center in Marseille, France, physicians used a needle via the transabdominal route to take chorionic villus samples (CVS) from 930 pregnant women. The indications for CVS were advanced maternal age (75%), ultrasound findings (11%), chromosome abnormalities in the family (6%), high human chorionic gonadotropin levels (4%), chromosomal rearrangement in parent (s) (2%), and condition linked to chromosome X (1%). Only 1 needle puncture was needed in 97% of cases. CVS was successful in 97% of women. Heat denaturation did not allow a satisfactory structural analysis of chromosomes in 29 cases. The average gestational age at CVS was 16 weeks for advanced maternal age and 22 weeks for ultrasound findings. Cytogenetic tests were normal in 95.5% of cases. Chromosomal abnormalities were present in 31 cases, balanced translocations in 4 cases, and placental mosaicisms in 7 cases. 48 women chose to undergo medical abortion for chromosome abnormality in 31 cases and ultrasound-identified malformations in 17 cases. The fetal loss rate was 3.5% for the first 200 CVS cases compared to 1% for the next 730 cases. The fetal loss rate for CVS performed by trained and experienced professionals is similar to that for amniocentesis (0.4-1%). CVS via transabdominal route allowed a diagnosis within 24-28 hours for a chromosomal abnormality of numbers and several days for a structural abnormality. These findings support greater use of this method of CVS.

Fragile X syndrome in an extended family with special reference to an affected male with Klinefelter syndrome.

We report on a large family (4 generations), with 77 studied individuals, 9 mentally retarded males, and one affected female with fragile X syndrome [fra(X)]. The analysis of 6 flanking polymorphic DNA markers showed that the affection is transmitted, through the carrier daughters to the grandsons and the greatgrandsons and that the great-grandfather is a transmitting male. This observation led us to question the importance of these clinically normal males, who are nonexpressing carriers and termed transmitting males. One propositus, described as a mentally retarded young man, had inherited identical restriction polymorphisms from his mother. Chromosome analysis showed a Klinefelter syndrome, with a fragile site in 18% of the cells leading to the conclusion that the nondisjunction occurred at the first stage of the maternal meiosis.

Study of a family with a fragile site of the X chromosome at Xq27-28 without mental retardation.

The fragile site Xq27-28 was observed in several individuals of a large family. It is expressed at a high frequency among the carrier females, even as adults, and in one clinically normal male. None of the members of this family is affected with the mental retardation normally linked to this fragile site. Cytogenetic and flanking DNA marker polymorphism studies suggest a possible dissociation between the fragile site and clinical expression of the disease.

[Localization of ribosomal genes and nucleolar activity in lymphocytes of swine (Sus scrofa domestica) stimulated by phytohemagglutinins]. / Localisation des gènes ribosomiques et activité nucléolaire dans les lymphocytes du Porc (Sus scrofa domestica) stimulés par la phytohémagglutinine.

The Pig chromosomes that contain rDNA sites displayed a polymorphism in the distribution of the genes among the nucleolar organizers located on pairs Nos. 8 and 10. Two, or more often three, active sites were observed in the chromosomes of lymphocytes stimulated with phytohemagglutinin. Only 5% of the metaphases showed a 4th small active site. At the onset of stimulation most cells contained one-two nucleoli; four nucleoli were never observed. After prolonged stimulation, the number of nuclei containing three nucleoli increased. A 4th small nucleolus appeared in a few cells, presumably formed by activation of the smallest rDNA site.