Comparative Study of CO2 LASER Assisted and Electrocautery Assisted Tonsillectomy with Conventional Tonsillectomy.

Tonsillectomy is the most common surgical procedure performed since many years. Various methods of tonsillectomy (Electrocautery, LASER, Harmonic scalpel, Coblation) have been practiced over the last century aiming for reducing intra and postoperative morbidity. We carried out prospective randomized control study using retrospective data as secondary data to compare blood loss, excision and hemostasis time, pain, recovery time and complication between CO2 LASER and Electrocautery assisted with conventional method. Average time for surgery with CO2 LASER (82.17 min) was more than conventional (77.77 min) and electrocautery (21.40 min) was least. The postoperative pain and recovery time was more in CO2 LASER and Electrocautery group than conventional. The blood loss was more in conventional group compared to other two group. We concluded that CO2 LASER group has longest operative time but least blood loss. Postoperative pain was more and lasted longer in Electrocautery group. Conventional method had least recovery time, least tissue reaction and least hospital stay.

[Pulmonary and renal involvement in a TNFα antagonist drug-induced sarcoidosis]. / Sarcoïdose pneumo-rénale apparue sous anti-TNFα.

Several cases of sarcoidosis with pulmonary, neurological or ophthalmological involvement occurring during a treatment by anti-TNFα have been reported in the literature. We report a 66-year-old man who presented with renal failure and hypercalcaemia, associated with fatigue, shortness of breath and dry cough. He was receiving infliximab since 2004 for psoriatic arthritis. The diagnosis of sarcoidosis was obtained with biopsy sampling of a mediastinal lymph node, and the lung involvement was documented with lung function tests, bronchoalveolar lavage and computed tomographic scan. Laboratory tests were suggestive of interstitial sarcoid nephritis. Disease course was favourable with corticosteroids and discontinuation of infliximab.

A prospective, multicenter, randomized trial comparing steroids and pulse cyclophosphamide versus steroids and oral cyclophosphamide in the treatment of generalized Wegener's granulomatosis.

OBJECTIVE: To investigate the effectiveness and side effects of oral versus pulse cyclophosphamide (CYC) in combination with corticosteroids (CS) in the treatment of systemic Wegener's granulomatosis (WG). METHODS: Patients with newly diagnosed systemic WG were enrolled in a prospective, randomized trial. At the time of diagnosis, prior to randomization, every patient received a daily injection of methylprednisolone for 3 days, followed by daily oral prednisone (1 mg/kg/day) and a 0.7-gm/m2 pulse of CYC. Patients were then randomly assigned to receive either prednisone plus intravenous pulse CYC (group A) or prednisone plus oral CYC (group B) as first-line treatment. CYC was given for at least 1 year and was then progressively tapered and discontinued. RESULTS: Fifty patients were included in the study: 27 in group A and 23 in group B. At 6 months, 24 group A patients (88.9%) were in remission, versus 18 group B patients (78.3%). At the end of the trial, 18 group A patients (66.7%) and 13 group B patients (56.5%) were in remission. In group A, 66.7% of the patients experienced side effects, versus 69.6% in group B. Infectious side effects were significantly more frequent in group B (69.6%) than in group A (40.7%) (P < 0.05). The incidence of Pneumocystis carinii pneumonia was higher in oral CYC-treated patients (30.4%) than in pulse CYC-treated patients (11.1%). Nine group A patients (33.3%) and 10 group B patients (43.5%) died. Actuarial curves showed that relapses were significantly more frequent in group A (59.2%) than in group B (13%) (P = 0.02). CONCLUSION: Our results indicate that pulse CYC is as effective as oral CYC in achieving initial remission of WG and is associated with fewer side effects and lower mortality. However, in the long term, treatment with pulse CYC does not maintain remission or prevent relapses as well as oral CYC.

Caffeine clearance in subjects with constitutional unconjugated hyperbilirubinemia.

To investigate the behaviour of caffeine (CAF) in patients with Gilbert's Syndrome (GS), a combined oral loading test of caffeine and chenodeoxycholic acid was performed in 14 healthy subjects and 71 patients with GS. Indocyanine green (ICG) kinetics was tested in 50 subjects with GS and in all control subjects. Fasting serum bile acids (SBA) and clearance after CDCA loading were within normal range in normal and GS subjects. No significant difference in levels either of bilirubin or of SBA was observed in GS cases with normal (52 cases, 488 +/- 63 ml/min) or impaired (19 cases, 338 +/- 30 ml/min) caffeine clearance. Eleven GS cases showed altered ICG clearance. No correlation was found between bilirubin and bile acids, CAF or ICG. Fasting SBA were normal even in cases of CAF or ICG altered kinetics, thus excluding structural damage in unconjugated hyperbilirubinemia. CAF altered kinetics in 27% of GS cases may suggest multiple deficits in the hepatocellular metabolism, thus confirming the heterogeneity of this syndrome.

Increased risk of Pneumocystis carinii pneumonia in patients with Wegener's granulomatosis.

Combining cyclophosphamide (Cy) and corticosteroids has dramatically improved the prognosis of Wegener's granulomatosis (WG). But this treatment carries the risks of severe infectious complications and drug toxicity. During a 10-month period, we observed 6 cases of Pneumocystis carinii pneumonia (PCP) in 23 patients with biopsy-proven WG and renal involvement. These 23 patients were enrolled in a multicenter controlled clinical trial designed to evaluate the efficacy and safety of either intermittent high-dose pulse Cy or daily oral low-dose Cy in combination with oral prednisone. Mean delay of onset of PCP was 2.5 months after the beginning of the immunosuppressive therapy. In all cases, the diagnosis of PCP was established by cytological examination of bronchoalveolar lavage fluid. None of the patients experienced severe leukopenia at the time of diagnosis, but the mean lymphocyte count decreased to 495/mm3 (range 100 to 830/mm3) and 2 patients had inverted CD4/CD8 T-cell ratios. Renal function was significantly impaired (creatininemia = 493.5 vs 195.4 micromol/l; p = 0.03) in the 6 patients presenting PCP vs those without. High-dose co-trimoxazole therapy was successful in 3 patients, but 3 others who required mechanical ventilation died. Treatment of WG with daily prednisone and either pulse or oral Cy may have contributed to higher rates of PCP in the past than previously thought and, therefore, patients currently receiving such a regimen may be at greater risk for PCP. For these patients, this opportunistic infection must remain highly suspect in order to reach a diagnosis earlier and rapidly initiate treatment. In addition, recommendations for prophylactic therapy are needed.

["Idiopathic" extracapillary glomerulonephritides without immune deposits are vascularitides: clinical and serologic analysis]. / Les glomérulonéphrites extracapillaires "idiopathiques" sans depôt immun sont des vascularites: analyse clinique et sérologique.

To determine the spectrum of systemic diseases potentially associated with pauci-immune rapidly progressive glomerulonephritis (GN), most of which being considered as idiopathic, we have analyzed extra-renal manifestations, occurrence of extra-glomerular vasculitis and incidence and specificity of ANCAs in 40 patients selected only on histological criteria. Extra-renal symptoms were unexpectedly observed in all patients but one, and were suggestive of vasculitis in 24 of them. Extra-glomerular vasculitis was evidenced in 18 kidney biopsies and four biopsies from other organs. Among the 33 patients with suspected or established vasculitis, 13 had presumed or biopsy-proven Wegener's granulomatosis (WG), three had a macroscopic form of polyarteritis nodosa and 17 had a clinical presentation compatible with the so-called microscopic polyarteritis previously described in the british literature. An additional patient had clinical signs of WG without clinical and histological evidence of vasculitis. ANCAs were detected in 28/33 and 25/34 sera tested by IF and ELISA, respectively: 19 contained anti-myeloperoxidase (MPO) antibodies and 6 had anti-proteinase 3 (Pr3) activity. Anti-MPO and anti-Pr3 antibodies were present in all clinical subgroups but with various incidences: anti-MPO antibodies were surprisingly more often detected (6/12) than anti-Pr3 (4/12) in patients with suspected or histologically proven WG but anti-Pr3 antibodies were nonetheless 3- to 4-fold more frequent in WG than in non-WG systemic vasculitis (1/12) and necrotizing CGN without evidence of extra-renal vasculitis (1/10). These results strongly suggest that pauci-immune necrotizing CGNs belong to the broad spectrum of necrotizing vasculitides affecting glomerular capillaries. This hypothesis is also supported by the good response of patients to immunosuppressive treatments known for their efficacy in vasculitides, whereas these treatments are usually less successful in severe forms of extra-capillary GN with immune deposits.

Necrotizing crescentic glomerulonephritis without significant immune deposits: a clinical and serological study.

To determine the spectrum of systemic diseases associated with pauci-immune necrotizing crescentic glomerulonephritis, we have analysed extra-renal manifestations, occurrence of extra-glomerular vasculitis and incidence and specificity of antinuclear cytoplasmic antibodies (ANCA) in 40 patients selected only on renal histological criteria. Extra-renal symptoms were unexpectedly observed in all patients but one, and were suggestive of vasculitis in 24. Extra-glomerular vasculitis was seen in 18 kidney biopsies and four biopsies from other organs. Among the 33 patients with suspected or established vasculitis, 13 had presumed or biopsy-proven Wegener's granulomatosis, three had a macroscopic form of polyarteritis nodosa and 17 could not be adequately classified. An additional patient had clinical signs of Wegener's granulomatosis without clinical and histological evidence of vasculitis. ANCAs were detected in 28 of 33 and 25 of 34 sera tested by immunofluorescence and enzyme-linked immunoassay, respectively: 19 contained anti-myeloperoxidase antibodies and six had anti-proteinase 3 activity. Anti-myeloperoxidase and anti-proteinase 3 antibodies were present in all clinical subgroups but with various frequencies: anti-myeloperoxidase antibodies were more common (six of 12) than anti-proteinase 3 (four of 12) in patients with suspected or histologically proven Wegener's granulomatosis. Anti-proteinase 3 antibodies were 3- to 4-fold more common in patients with Wegener's granulomatosis than in those with systemic vasculitis of other causes (one of 12) or necrotizing crescentic glomerulonephritis without evidence of extra-renal vasculitis (one of 10). These results strongly suggest that pauci-immune necrotizing crescentic glomerulonephritis belongs to the broad spectrum of necrotizing vasculitides affecting glomerular capillaries. This study shows substantial improvement in renal prognosis and life expectancy with aggressive immunosuppressive therapy despite the older age of the patients, dissemination of the vasculitic process and often delayed diagnosis.

[Extracapillary and necrotizing glomerulonephritis without immunoglobulin deposits: clinical presentation, prognostic factors and response to treatment. Apropos of 42 cases]. / Glomérulonéphrite extracapillaire et nécrosante sans dépôt d'immunoglobulines: présentations cliniques, facteurs pronostiques et réponse au traitement. A propos de 42 cas.

Forty-two cases of pauci-immune necrotizing glomerulonephritis were reviewed on a 10 years period. Selection was exclusively based on histological criteria, i.e. at least one elementary lesion of extracapillary proliferation and/or glomerular necrosis, without immunoglobulin deposits. Mean age was 56. Thirty per cent of patients presented with normal or non-worsening renal function. At least one extra-renal sign was present in 66% of patients. ANCA were found in 9/20 cases. Death occurred in 12 patients. Age over 60 and oligo anuria were the most predictive factors for the fatal outcome. Half of the patients were on dialysis at the end of their follow-up. The renal function at presentation was the main predictive variable for renal outcome. Severe tubular necrosis was associated with a poorer renal evolution whereas treatment with cyclophosphamide led to frequent improvement in this retrospective study.

[Necrotizing extracapillary glomerulonephritis without immunoglobulin deposits. Renal localization of systemic vasculitis with anti-cytoplasm polynuclear antibodies]. / Glomérulonéphrite extracapillaire nécrosante sans dépôts d'immunoglobuline. Localisation rénale d'une vasculite systémique avec anticorps anti-cytoplasme des polynucléaires.

Necrotizing and crescentic glomerulonephritis without immunoglobulin deposits (also called pauci-immune glomerulonephritis) is the cause of approximately 50 percent of acute renal failures of glomerular origin. Our study, based on 40 case-records selected on histological criteria, and on data from the literature, shows that in most cases, if not all, this type of glomerulonephritis is part of a wider systemic vasculitis which predominantly affects the glomerular capillaries. Anti-neutrophil cytoplasm antibodies are detected in three-quarters of the cases, with a specific distribution that varies according to the clinical features. In spite of the patients' age (mean: 62 years), the severity of glomerular lesions and the extra-renal diffusion of the disease, 60 percent of these patients can be cured and recover a normal, or at least acceptable renal function, provided the corticosteroid and sometimes immunosuppressive therapy is initiated at an early stage.

Delayed extensive arterial dissection after percutaneous transluminal angioplasty for transplant renal artery stenosis.

A 26-year-old renal transplant recipient with graft artery stenosis underwent percutaneous transluminal angioplasty (PTA), which was followed by extensive renal artery dissection leading to graft loss. This report reminds one that, although widely considered a safe procedure, PTA is not free of complications.

Modifications in the serum concentrations of prolyl hydroxylase in patients with chronic hepatitis B during and after interferon therapy.

A total of eight patients with chronic active HBsAg-positive hepatitis was treated with recombinant interferon-alpha 2b for 12 months and serum aspartate aminotransferase, alanine aminotransferase, gamma-globulin and prolyl hydroxylase concentrations were determined every 3 months. Liver biopsies after 12 months' treatment revealed a significant (P less than 0.05) reduction in the histological activity score. After 6 months, alanine aminotransferase (P less than 0.01) and aspartate aminotransferase (P less than 0.05) concentrations fell significantly compared with baseline concentrations. Serum prolyl hydroxylase concentrations declined significantly (P less than 0.05) after 15 months and remained depressed. It is concluded that interferon-alpha 2b therapy reduced fibrogenetic activity in chronic active hepatitis B.

Destructive spondyloarthropathy in dialysis patients: an overview.

Destructive spondyloarthropathy has been increasingly recognized in dialysis patients. We have reviewed 39 observations published in the literature and added 11 personal cases in order to define the clinical and radiological presentation of the disease. The many hypotheses that have been proposed for its pathogenesis are discussed, including secondary hyperparathyroidism, microcrystal deposition, beta 2-microglobulin-associated amyloidosis and aluminum intoxication.

Early and late occurrences of destructive spondyloarthropathy in haemodialysed patients.

In a series of 100 patients dialysed for 3 months to 17 years destructive spondyloarthropathy was diagnosed in 11 cases. Lower cervical spine was involved in ten and dorsal spine in one. When compared to patients without arthropathy, spinal involvement was associated with longer duration of dialysis and greater prevalence of parathyroidectomy. The patients with destructive spondyloarthropathy were divided into two groups: Group 1, four patients, in whom arthropathy occurred within the first 41 months of dialysis, and Group 2, seven patients, in whom arthropathy occurred after 106 months of dialysis. Group 1 was associated with greater age, chondrocalcinosis (2 of 4), absence of overt osteoarticular bone defects, and absence of carpal-tunnel syndrome. Parathyroidectomy (PTx) was performed in one patient. Amyloidosis was not found in one patient who came to autopsy. Group 2 was associated with presence of shoulder pain (6 of 7), juxtaarticular bone cysts (6 of 7) and CTS (6 of 7), and absence of radiological chondrocalcinosis. PTx was performed in six of seven patients and amyloidosis was found in three. In conclusion, destructive spondyloarthropathy may be seen early in the course of dialysis, apart from general amyloid involvement of accelereted hyperparathyroidism. A specific finding of this study was the discovery of radiological chondrocalcinosis in association with early arthropathy, which is a well-recognised feature in non-uraemic subjects.