[An unusual digestive occlusion]. / Une occlusion intestinale inhabituelle.

Malignant melanoma is a rapidly metastatic disease. Metastasis in the small intestine is as such not uncommon, whereas the clinical presentation of obstruction due to intussusception is very rare. We hereafter report the case of a 58-year-old female admitted with general degradation, syndrome of intestinal occlusion and a cervical mass. Imaging studies showed signs suggesting an invagination of the small intestine. A resection of the cervical mass and segmental small intestine resection were performed. Pathological findings revealed a cervical malignant melanoma spread into the small intestine. The diagnosis of intestinal metastasis should therefore be considered in patients with intestinal occlusion and history of melanoma and presenting gastrointestinal symptoms.

Clinical and laboratory indices of severe renal lesions in children with febrile urinary tract infection.

AIM: To evaluate the predictive value of various clinical and laboratory parameters on the identification of acute extensive and/or multifocal renal involvement in children with febrile urinary tract infections (UTI). METHODS: The medical records of 148 children (median age: 2.4 months, range: 11 days-24 months), who were admitted during a 3-year period with a first episode of febrile UTI, were analysed. Acute dimercaptosuccinic acid scintigraphy (DMSA), clinical and laboratory parameters were evaluated. RESULTS: Seventy six children (51%) had abnormal findings on the acute DMSA. Of them, 20 had DMSA grade 2, while 56 had grade 3 and 4. Patients with a DMSA grade 3 and 4 were more likely to have shivering (OR 3.4), white blood count (WBC) ≥ 18 000/µL (OR 2.4), absolute neutrophil count (ANC) ≥ 9300/µL (OR 4.4), C-reactive protein (CRP) ≥ 50 mg/L (OR 2.7) and procalcitonin (PCT) ≥ 1.64 ng/mL (OR diagnostic). There was a significant difference of WBC (p = 0.004), ANC, CRP and PCT levels (p < 0.001) between children with normal and grade 2 aDMSA versus those with aDMSA grade 3 and 4. CONCLUSIONS: Shivering and elevated inflammatory markers increase the risk of acute extensive and/or multifocal kidney involvement in children with febrile UTI. Procalcitonin seems to be an excellent marker of the severity of acute parenchymal involvement.

[Acute myocardial infarction due to an acute aortic dissection]. / Infarctus myocardique aigu dû à une dissection de l'aorte ascendante.

Myocardial ischemia secondary to dissection of the ascending aorta remains a relatively rare complication. A 76-year old man with no prior history developed sudden chest pain. The electrocardiogram showed a ST-segment elevation in leads II and III suggesting an inferior wall acute myocardial infarction. Upon arrival, he received anticoagulation and antiplatelet aggregation intravenously and orally respectively. Coronary angiography showed an anomalous origin of the right coronary and extrinsic stenosis by a false lumen. Computed tomography confirmed the diagnosis of type A aortic dissection with an extension to the right coronary. Emergency ascending aorta replacement with Dacron graft and a right coronary artery graft was perfomed. This case illustrates how myocardial infarction can mask an aortic dissection. The initial treatment of a myocardial infarction with anticoagulation and/or oral antiplatelet aggregation should not be modified, even if it increases postoperative bleeding when emergent cardiac surgery is necessary.

Isolated double gastric rupture caused by blunt abdominal trauma in an eighteen months old child: a case report.

We report a case of an isolated double gastric rupture, resulted from blunt abdominal trauma, that we successfully repaired by primary closure. A 18-month-old girl injured in a motor vehicle accident was admitted to our hospital where the plain X-ray and the CT findings revealed the presence of free abdominal air. An immediate performed exploratory laparotomy disclosed two full-thickness ruptures of the stomach (on the greater curvature and the posterior wall). The ruptures were closed primarily by a two-layer closure. Twenty-four hours post-operatively the patient developed delayed shock as a result of chemical peritonitis. On the 8th postoperative day the girl developed septic shock and gastrorrhagia. She underwent a gastroscopy which revealed stress-ulcer, and was treated conservatively in the children intensive care unit of our hospital. She was discharged home on 20th postoperative day. At 3-month follow up, she was doing well with normal growth and eating a regular regimen about her age. Gastric rupture following blunt abdominal trauma is rare, with a reported incidence of 0.02-1.7%. The morbidity and mortality are directly related to the number of associated injuries, the delay in diagnosis and the development of intraabdominal sepsis. In this paper we emphasise the need for early diagnosis and the aggressive surgical treatment as a key to decreasing the mortality and morbidity from this relatively rare injury, especially in this age group of children.

Prevention and treatment of renal osteodystrophy in children on chronic renal failure: European guidelines.

Childhood renal osteodystrophy (ROD) is the consequence of disturbances of the calcium-regulating hormones vitamin D and parathyroid hormone (PTH) as well as of the somatotroph hormone axis associated with local modulation of bone and growth cartilage function. The resulting growth retardation and the potentially rapid onset of ROD in children are different from ROD in adults. The biochemical changes of ROD as well as its prevention and treatment affect calcium and phosphorus homeostasis and are directly associated with the development of cardiovascular disease in pediatric renal patients. The aims of the clinical and biochemical surveillance of pediatric patients with CRF or on dialysis are prevention of hyperphosphatemia, avoidance of hypercalcemia and keeping the calcium phosphorus product below 5 mmol(2)/l(2). The PTH levels should be within the normal range in chronic renal failure (CRF) and up to 2-3 times the upper limit of normal levels in dialysed children. Prevention of ROD is expected to result in improved growth and less vascular calcification.

Vulvar intraepithelial neoplasia (VIN)--diagnostic and therapeutic challenges.

PURPOSE: Vulvar intraepithelial neoplasia (VIN) represents a current diagnostic and therapeutic challenge. The present retrospective study is an institutional experience on the diagnosis and management of VIN. METHODS: One hundred and thirteen women with VIN were reviewed and analyzed. Diagnosis was established by colposcopically directed biopsies whereas treatment was performed by either a surgical or a laser CO2 approach. RESULTS: The mean age of all VIN patients was 47.4 years. The most common symptom was pruritus (60.1%). The majority of the lesions were multifocal (N = 64, 56.6%) and located in the non-hairy part of the vulva (87.6%). VIN management consisted of laser CO2 treatment in 51 patients (45.1%), surgical treatment in 37 (32.7%) whereas 25 VIN, cases were managed by conventional medical treatment. The risk of disease relapse was not associated with VIN grade (p = 0.35) nor with the treatment modality used (p = 0.42). The risk of disease relapse was significantly higher for multifocal lesions (p < 0.001). Long-term follow-up of our patients showed that four patients (3.5%) developed an invasive vulvar carcinoma. CONCLUSION: Our study confirms other reports concerning the diagnostic and treatment difficulties of the management of VIN. Although the benefits of treatment are obvious there seems to be no guarantee that invasion will not occur.

Popliteal artery pseudo-aneurysm and hereditary multiple exostoses.

We describe a rare case of a 21-year-old man presenting with hereditary multiple exostosis and a pseudoaneurysm of the popliteal artery caused by femoral osteochondroma. Principles of management and surgical technique are discussed.

Spill behaviour using REACTPOOL. Part II. Results for accidental releases of silicon tetrachloride (SiCl(4)).

Silicon tetrachloride is a toxic, corrosive water reactive substance that is used widely in the process industries. On spillage from containment it creates liquid pools that can either boil or evaporate. The main feature of the pool behaviour is the exothermic reaction with water. There are three sources of water available for reaction: free ground water, substrate water and atmospheric moisture. Hydrogen chloride gas and ortho-silicic acid solid (or silica gel) are produced by the hydrolysis reaction. The purpose of this paper is to describe the dangers involved in cases of accidental releases of silicon tetrachloride, to report its properties, referring to toxicity data, major accidents and mitigation tests. It also describes pool behaviour using REACTPOOL [1]. Model results indicate that the pool behaviour is governed mainly by the amount of water available for reaction. Surface roughness and wind speed also have a significant effect on the results. Results are compared with those for other water reactive chemicals in Part III of this series of papers [3]. The generated cloud will initially contain silicon tetrachloride and hydrogen chloride with numerous processes taking place. Although silicon tetrachloride has been involved in many major hazard incidents, there are no experimental data relevant to the modelling requirements.

REACTPOOL: a code implementing a new multi-compound pool model that accounts for chemical reactions and changing composition for spills of water reactive chemicals.

All chemicals that react violently with water or in contact with water liberate toxic gas are included in the list of substances covered by the majority of the international legislation on major hazards. This category includes a large number of chemicals that are used widely in the process industries. A survey of accidents that occurred in the last 10 years in the USA shows numerous major incidents that involved spillages of these substances. Even so, there are almost no experimental data on the behaviour of these chemicals on release. Furthermore, there are very few published studies on modelling the behaviour of such spillages, except in the case of hydrogen fluoride. In previous work we reported a new theoretical model [J. Haz. Mat. 62 (1998) 101-129, J. Haz. Mat. 62 (1998) 131-142, J. Haz. Mat. A67 (1999) 9-40], that describes accidental spills of SO(3) and oleum, which are substances with very complex behaviour that belong to this category. It describes both the pool [J. Haz. Mat. 62 (1998) 101-129, J. Haz. Mat. 62 (1998) 131-142] and the cloud behaviour [J. Haz. Mat. A67 (1999) 9-40]. In the work reported here the pool model was modified in a generic form in order to include other water reactive chemicals. REACTPOOL is a new code that can be used for both instantaneous and continuous liquid releases under a wide range of input parameters (steady or varying). It can be used for all liquids irrespective of their volatility and reactivity, and it describes pools consisting of more than one liquid that can have changing composition and properties. The purpose of this paper is to present the general procedure followed in REACTPOOL and to show how the new model has been modified and implemented for substances other than SO(3) and oleum. The modelling procedure has been implemented in a computer code written in Visual Basic, and results of the model have been generated using this code. It should be noted that this model requires validation data, but that the availability of such data awaits the performance of suitable experimental investigations.

Progress of ossification and epithelialization of wounds after simple or surgical extractions of teeth in rats with chronic renal failure: an experimental study.

Our aim was to investigate the progress of wound healing after simple and surgical removal of the first two molars of the right and left maxillary segments, respectively, in Wistar rats with experimentally induced moderate chronic renal failure (CRF). Sixty Wistar rats were divided into two groups of 30 rats each: experimental and control. CRF was induced in the experimental group by an intraperitoneal injection of cisplatin, 5 mg/kg body weight (BW) initially and then with two maintenance doses of 2.5 mg/kg BW at intervals of one month. The teeth were extracted one month after the last dose of cisplatin. The sockets and the kidneys of all the rats of both groups were evaluated. The mandibles of the 15 rats in the experimental group that developed moderate CRF, together with those of two controls, were evaluated for abnormalities that suggested renal osteodystrophy. The histopathological examination showed: (a) that there were no significant differences in the pattern of wound healing no matter how the tooth was extracted; (b) there were no specific abnormalities in the mandible to indicate of secondary hyperparathyroidism or renal osteodystrophy; and (c) the kidneys of the rats of the experimental group underwent histopathological changes that were significantly different from those in the controls (P < 0.001). Our results indicate that moderate CRF does not have any appreciable or significant modifying effect on wound healing after tooth extraction in Wistar rats.

Is rhGH anabolic in patients undergoing peritoneal dialysis?

The effect of rhGH treatment on protein metabolism was studied in nine prepubertal patients on CAPD. An improvement in nitrogen balance as evidenced by a falling of blood urea nitrogen and urea nitrogen appearance with a constant protein intake was noticed. The significant increase in serum creatinine and creatinine excretion with a constant weekly creatinine clearance and the increase in mid-arm muscle circumference were all indications of an improvement in lean body mass. In addition, there was an improvement in the pattern of plasma amino acids and an increase in serum albumin, possibly as a result of the improvement of protein metabolism.

Diabetes mellitus after therapy with recombinant human growth hormone (rhGH).

An eight-year-old boy developed diabetes mellitus (DM) after kidney transplantation. This boy had previously been treated with recombinant human growth hormone (rhGH) for short stature due to chronic renal failure. An impaired glucose tolerance was documented after one year of rhGH treatment. An oral glucose tolerance test returned to normal six months after the discontinuation of rhGH. The boy was treated again with rhGH for seven months until his transplantation. A high fever with an enlargement of the parotid gland was noted and signs of acute rejection appeared two weeks post-transplantation. Two months after transplantation, overt DM had developed, and he was treated with insulin. The insulin dose was progressively decreased and was discontinued eight months after transplantation.

Body composition of children on CAPD.

Our objectives were to estimate the body composition of children on continuous ambulatory peritoneal dialysis (CAPD), assess the fat-free mass (FFM) by bioelectrical impedance (BIA) and skinfold anthropometry (SF), and determine the effect of various parameters of the nutritional status and adequacy of dialysis on body composition. The design was a noninterventional retrospective clinical trial. The percent of fat ranged from 10% to 25% (15 +/- 2), when it was calculated from SF, and was from 9% to 32% (18 +/- 2) when it was calculated from BIA. There was a significant correlation between the percent of fat calculated by SF and by BIA (r = 0.94, p < 0.0001 with limits of agreement 4.16 to 1.37 and -0.40 to -3.19). The water content of FFM ranged from 70%-79%(74 +/- 1). There was a weak but significant correlation (r = 0.64, p = 0.016) between protein catabolic rate (PCR) and KT/V (V = 60% of weight). This correlation became more significant (r = 0.83, p = 0.0007) when the V of KT/V was calculated from BIA. The prediction of body composition with the use of bioelectrical impedance is a simple and reliable technique. Serial measurements of BIA might be an important tool for the assessment of the nutritional intervention.

Spontaneous rupture of a left iliac arterial aneurysm. A case report.

Isolated aneurysm of the iliac arteries is rare. It represents only 1.7% of the aneurysms of the aortic bifurcation involving the arteries (7, 13) and its rupture can be fatal. It is located deep in the pelvis and it is often difficult to detect clinically. The symptoms can mimic genitourinary, gastrointestinal or neurologic disorders. Prompt diagnosis by computerized tomography must be made in cases of emergency. Urgent aneurysmectomy is indicated in case of rupture. The average mortality rate is 50%.

Effects of a chronic aortopulmonary shunt on pulmonary hemodynamics in piglets.

Systemic-to-pulmonary shunting in growing pigs has been proposed as an experimental model of high-flow pulmonary hypertension associated with congenital heart defects. We investigated multipoint pulmonary arterial pressure (Ppa) vs. cardiac output (Q) plots and pulmonary vascular impedance spectra in 13 piglets aged approximately 4 mo and ventilated alternatively in hyperoxia (inspired O2 fraction 0.4) and in hypoxia (inspired O2 fraction 0.12). The measurements were done 8 wk after either an anastomosis between the thoracic aorta and the pulmonary trunk (n = 7 piglets) or a sham operation (n = 6). Cardiac output was altered by a manipulation of venous return. In the sham-operated piglets, hypoxia increased Ppa by an average of 12 mmHg over the entire range of Q studied, from 60 to 120 ml/kg, and increased both 0 Hz (Z0) and characteristic (Zc) pulmonary vascular impedance. In the shunted piglets compared with the sham-operated piglets in hyperoxia, Ppa was increased by an average of 5-6 mmHg at all levels of Q studied, from 60 to 120 ml/kg (P < 0.01), and Zc was also increased (P < 0.01), whereas Z0 was unchanged. In the shunted piglets, hypoxia increased Ppa at all levels of Q studied only to an average of 3 mmHg, and neither Z0 nor Zc was altered by hypoxia. We conclude that an aortopulmonary shunt of 2-mo duration in growing pigs increases both pulmonary vascular resistance and impedance and is associated with a blunting of pulmonary vascular reactivity to hypoxia.

Increased left atrial pressure inhibits hypoxic pulmonary vasoconstriction.

An increase in left atrial pressure (Pla) has been reported to either inhibit or not affect hypoxic pulmonary vasoconstriction in intact dogs. We investigated mean pulmonary arterial pressure (Ppa)-flow (Q) relationships at low and high fixed Pla and Ppa-Pla relationships at fixed Q in piglets, which are known to present with a stronger hypoxic pulmonary pressor response than dogs. Seven piglets were anesthetized; equipped with balloon catheters in inferior vena cava and left atrium to control Q and Pla, respectively; and ventilated alternatively in hyperoxia [fractional concn of O2 in inspired air (FIO2) 0.4] and hypoxia (FIO2 0.12). In all experimental conditions, Ppa-Q plots were best described by a linear approximation with extrapolated pressure intercepts (Pi) not different from Pla. Hypoxia increased slope but not Pi of Ppa-Q plots. An increase in Pla from 8 to 17 mmHg induced a parallel shift of Ppa-Q plots to higher Ppa in hyperoxia but did not affect Ppa-Q plots in hypoxia. In hyperoxia, an increase in Pla at constant Q induced an approximately equal increase in Ppa, whereas in hypoxia there was no effect. The hypoxia-induced increase in Ppa was blunted by increased Pla at all levels of Q studied. We conclude that in anesthetized piglets at fixed Pla hypoxia increases the slope of Ppa-Q plots without affecting Pi and an increase in Pla inhibits hypoxic pulmonary vasoconstriction. The results suggest that no closing pressure higher than normal Pla contributes to hyperoxic or hypoxic Ppa in the intact porcine pulmonary circulation.

Benign thoracic schwannoma and postoperative chylothorax: case report and review of the literature.

Among all the neurogenic tumours, the benign intrathoracic schwannoma is a rare tumour. Most often it is discovered by accident in the course of a routine X-ray examination of the thorax. Symptoms appear only when size becomes important. The surgical removal of an intrathoracic schwannoma may result in the development of a chylothorax. According to the literature, its treatment remains controversial. The originality of the case we report here is on the one hand the exceptional size of the tumour and the success over the long term of conservative treatment with complete parenteral alimentation, and on the other hand, the inefficacy of the subcutaneous administration of the analogue of somatostatin in reducing a chylothorax with high outflow.

Pulmonary vascular impedance vs. resistance in hypoxic and hyperoxic dogs: effects of propofol and isoflurane.

The pulmonary vascular effects of inhaled anesthetics have been reported variably. We compared the effects of intravenous anesthesia (propofol) and inhalational anesthesia (isoflurane) on multipoint mean [pulmonary arterial pressure (Ppa)-pulmonary arterial occluded pressure (PpaO)]/cardiac output (Q) plots and on pulmonary vascular impedance (PVZ) spectra in eight dogs alternatively ventilated in hyperoxia [inspired O2 fraction (FIO2) 0.4] and in hypoxia (FIO2 0.1). Q was altered by a manipulation of venous return. During propofol, hypoxia increased (Ppa-PpaO) by an average of 2-3 mmHg over the entire range of Q studied, from 1 to 2.5 l.min-1 x m-2. This hypoxic pulmonary vasoconstriction (HPV) was associated with insignificant changes in PVZ. Decreasing Q in hypoxia and hyperoxia did not affect PVZ. Compared with propofol, isoflurane decreased (Ppa-PpaO) by an average of 2-5 mmHg at all levels of Q studied in both hypoxia and hyperoxia but did not affect HPV. During isoflurane anesthesia, 0 Hz PVZ was lower (P < 0.01) in hypoxia, but otherwise the PVZ spectrum was not different from that recorded during propofol anesthesia. We conclude that, in dogs, 1 degree general anesthesia with isoflurane alone decreases pulmonary vascular tone without inhibition of HPV and that 2 degrees pressure/Q plots in the time domain are more sensitive than those in the frequency domain to subtle hemodynamic changes induced by hypoxia or isoflurane at the periphery of the pulmonary vasculature.