Improving the Prediction of Mortality in the High Model for End-Stage Liver Disease Score Liver Transplant Recipient: A Role for the Left Atrial Volume Index.

Left atrial volume index (LAVI) is an echocardiographic measurement used in assessing diastolic dysfunction, and is associated with mortality in many populations. In this retrospective cohort study including 254 patients, we investigated whether LAVI is an independent predictor of post-liver transplantation mortality using multivariable Cox regression. We found that elevated LAVI was associated with increased mortality among patients with high Model for End-Stage Liver Disease (MELD) scores, but not among those with lower MELD scores, indicating that recipients with high LAVI values and high MELD scores may represent patients at an increased risk of post-transplantation mortality. Specifically, there was a statistically significant interaction between LAVI and MELD score (P = .006) such that for patients with MELD scores ≥33, LAVI >27 mL/m2 was associated with increased mortality (hazard ratio = 2.3; 95% confidence interval, 1.04-5.20; P = .04.) We further show that the inclusion of LAVI in a multivariable model led to a statistically significant improvement in the ability to predict post-liver transplantation mortality, with an increase in the model's C-statistic from 0.68 to 0.71. The incorporation of LAVI in multivariable risk models may be useful in the selection of transplant recipients with high MELD scores, and may be helpful in decreasing the probability of futile transplantation.

[Acute hepatitis in the course of cyclosporine therapy of Crohn's disease]. / Hépatite aiguë au cours du traitement d'une maladie de Crohn par ciclosporine.

BACKGROUND: Cyclosporin is used for the treatment of corticosteroid-resistant inflammatory bowel disease. Secondary liver disease is a risk. CASE REPORT: Acute hepatitis with predominant major transaminase elevation occurred in a patient treated with cyclosporin for corticosteroid-resistant Crohns disease. No viral, alcoholic, autoimmune or metabolic cause could be incriminated. Complete cure was achieved after withdrawal of cyclosporin. DISCUSSION: Only one case of cholestatic hepatitis has been reported in chronic inflammatory bowel disease. Cyclosporin was the probable cause in our case as other causes of acute hepatitis were ruled out and withdrawal led to cure. Cyclosporin can induce abnormal liver tests in 25% of cases. If reducing dose does not lead to improvement, it may be necessary to discontinue cyclosporin. Regular liver tests would thus be required for patients given cyclosporin for chronic inflammatory bowel disease.

[Herpetic esophagitis in human immunodeficiency virus non infected patients]. / Oesophagite herpétique chez le sujet non infecté par le virus de l'immunodéficience humaine.

We report five cases of herpetic esophagitis in human immunodeficiency virus non-infected patients. Herpetic esophagitis is a frequent infection in immunocompromised patients. However, sixty four cases of herpetic esophagitis have been reported in immunocompetent patients. The infection presents non-specific esophageal symptoms. Diagnosis relies on esophageal histology and viral cultures. Treatment by acyclovir is recommended to prevent severe complications. This infection is probably underestimated in immunocompetent hosts but seems to be more frequent in patients with severe illness that can be responsible for transitory immunodeficiency. Biopsies of esophageal lesions should be systematically performed in these patients.

Anfotericina B. Efectos adversos de la administración intravenosa

La introducción de Anfoterecina B generó una nueva era en el tratamiento de las micosis sistémicas, entre ellas la histoplasmosis. No obstante las diferentes formas farmacéuticas utilizadas de este medicamento y las medidas de prevención, numerosos efectos adversos se observan con su uso frecuente debido fundamentalmente a las propiedades del fármaco. Se presentan dos casos clínicos con manifestaciones de reacciones adversas atribuibles a la infusión, luego de la administración intravenosa de Anfotericina B (forma convencional).Tales reacciones incluyeron escalofrío, fiebre, náuseas, vómitos, polipnea, rash cutáneo y malestar general; todas ellas presentes a pocas horas de iniciada la administración intravenosa continua.Se aplicaron medidas farmacoterapéuticas para reducir la severidad de los síntomas, específicamente la administración previa de dipirona y benadrilina, la disminución en la velocidad de infusión intravenosa y el aumento de la dilución del medicamento en dextrosa a 5 por ciento. Se realizó un seguimiento de pacientes, monitorizando la función hepatorrenal y hematológica, con vistas a prevenir posibles efectos tóxicos a este nivel, vínculados con el tiempo que duró su administración

[Gastroduodenal tolerance of methylprednisolone. Study of oral versus intravenous administration in healthy volunteers]. / Tolérance gastro-duodénale de la méthylprednisolone. Etude de la voie orale versus voie veineuse chez le volontaire sain.

OBJECTIVES: To endoscopically evaluate the tolerance of gastroduodenal mucosa to methylprednisolone given orally and intravenously. METHODS: Thirty two healthy volunteers (age range 18-39 years) were divided randomly into two groups of 16 each (8 males and 8 females). All were Caucasians, gave their informed consent and were considered normal after a complete clinical and laboratory work-up including gastroduodenal fibroscopy. Methylprednisolone (500 mg) was administered for three consecutive days at 9 a.m., orally in one group and intravenously in the second group. No other drugs were being taken and alcohol and smoking were prohibited from day 0 to day 11. Tolerance was evaluated on days 4 and 11 based on clinical examination, blood pressure, heart rate, oral temperature, body weight, blood and urine chemistry and by video-recorded gastroduodenal endoscopy. Two independent endoscopists, uninformed of the patient's regimen, scored lesions from 0 (normal) to 5 (more than 25 lesions including at least 2 erosions). In case of abnormal findings, follow-up was continued to normalization. RESULTS: Endoscopically detectable lesions (stage I) attributed to corticosteroid therapy were observed in 4 subjects in the oral group and in 5 in the intravenous group. All regressed spontaneously. Duodenal lesions were observed only after oral administration while lesions of gastric mucosa were mostly found after intravenous administration. Systemic effects included abdominal pain after oral intake, 1 case of insomnia and bitter taste in the mouth after intravenous administration. CONCLUSIONS: These findings suggest that the effect of corticosteroid therapy, on the gastric mucosa, is basically systemic, and on the duodenal mucosa, basically local. No severe manifestations were observed after high-dose methylprednisolone given orally or by intravenous injection.

[Percutaneous endoscopic gastrostomy. 174 cases]. / Gastrostomie percutanée endoscopique. Cent soixante quatorze observations.

Nutritional assistance was given by percutaneous endoscopic gastrostomy to 174 patients with neurological diseases (80 cases), tumours of the ear, nose and throat (ENT) region (70 cases) or malnutrition (24 elderly people). These patients had either deglutition disorders with inhalation or severe malnutrition, or could not tolerate a nasogastric tube. The endoscopic catheter (Bioser) was installed by the pull technique under general anaesthesia (26 percent), neuroleptanalgesia (16 percent), premedication (14 percent) or without sedation (44 percent). Installation was possible in 98 percent of the cases. Twenty-nine percent of the patients were treated in an outpatient clinic. The problems encountered (21 percent) were mainly due to blockade of the flange and rupture of the thread. Transoperative accidents, such as dyspnoea, bleeding or cardiac arrest, all without sequelae, were noted in 5 percent of the cases. The catheter remained in situ for a mean period of 3.9 +/- 0.3 months (range: 0.1 to 20 months). The following complications were observed: short-term (15 percent), hyperthermia (5), local infection (6), abscess of the abdominal wall (3), meteorism (9), pneumoperitoneum (1), subocclusion (2); long-term (25 percent), inflammatory reactions (13), leakage (19), catheter displacement (8) and catheter rupture (3). Local infections were more frequent in patients with ENT tumours than in the others. Percutaneous endoscopic gastrostomy is a fast and reliable technique preferable to surgical gastrostomy. Complications are frequent (46 percent) but usually minor (42 percent). Contra-indications must be respected, and the catheter must be introduced with the utmost care.

[Effect of a buzepide metiodide-haloperidol combination in treating functional intestinal disorders. Randomized double-blind controlled versus placebo study]. / Effet de l'association métiodure de buzépide-halopéridol dans le traitement des troubles fonctionnels intestinaux. Etude randomisée en double-aveugle contrôlée contre placebo.

The efficacy and safety of a combination of buzepide metiodide and haloperidol was assessed in a placebo-controlled double-blind trial during 2 months in 224 patients (154 women, 79 men) with the irritable bowel syndrome. The 2 groups were comparable at inclusion. The efficacy was assessed at days 15, 30 and 60. Inclusion and assessment criteria were clinical, abdominal pain being considered as the main assessment criterion. The combination proved statistically better than placebo on the frequency of symptoms at all visits and on the intensity of the most frequent symptoms (abdominal pain and distension) at the final visit. A previously defined global assessment score was found significantly better in favor of the treated group at day 15 and day 30. At the final visit, the score of a visual scale assessing the patient's global impression was also found significantly better on the combination, There was no serious side-effect. In conclusion, this study demonstrates the efficacy and safety of a combination of buzepide metiodide and haloperidol in patients with the irritable bowel syndrome.

[Percutaneous endoscopic gastrostomy. Indications and follow-up in 30 patients]. / Gastrostomie percutanée endoscopique. Indications et suivi chez 30 patients.

The indications and results of percutaneous endoscopic gastrostomy (PEG) were reviewed in 30 consecutive patients, most of whom had problems of deglutition secondary to the treatment of ENT neoplasia. The procedure was successful in all patients but some difficulty was encountered in 4 cases. There were no major complications or fatalities. The benign complications were all amenable to medical therapy and did not require ablation of the gastric tube. In general, PGE was well tolerated and an easy to use method of nutritional assistance, allowing most patients to gain weight. In the authors' experience, this technique has an important role to play in the nutritional assistance of patients with problems of deglutition due to neurological disease or ENT neoplasia. The relative innocuity of PEG gives it a great advantage over surgical gastrostomy.

[Percutaneous endoscopic gastrostomy. Indications and results in 31 patients]. / Gastrostomie percutanée endoscopique. Indications et résultats chez 31 patients.

Nutritional assistance was indicated in 31 patients with an ENT tumour at different stages of treatment and different stages of the disease. These patients presented with disorders of deglutition with false passages (68%), aspiration pneumonia (10%), dysphagia (35%) or denutrition (17%). We used an endoscopic percutaneous gastrotomy kit produced by the Bioser company (pull technique). In 29 patients, the tube was inserted under general anaesthesia in the operating theatre to prevent dyspnoea during introduction of the tube in these patients with alteration of the airway-gastrointestinal tract junction or because the tube was inserted at the beginning of anaesthesia for ENT surgery. The tube was able to be inserted in every case, with cardiac arrest in one patient who was effectively resuscitated without sequelae, two obstructions of the cuff requiring advancement of the tube with a bougie, 2 ruptures of the thread and one case of dyspnoea. Two patients subsequently developed a wound abscess which was drained and one patient required removal of the tube. Follow-up of the patients demonstrated the good tolerance of this tube which was maintained for an average of 2.9 +/- 0.5 months (0.1 to 9 months) without any major complications. 3 benign wound infections, 4 inflammatory reactions, 4 minimal leaks, 1 case of hyperthermia, 12 cases of abdominal distension and 2 cases of displacement of the tube were observed. The weight gain was equal to 4%. The authors believe that this technique of endoscopic gastrostomy should be preferred to surgical gastrostomy.

[Percutaneous endoscopic gastrostomy. Indications and follow-up in 52 patients]. / Gastrostomie percutanée endoscopique. Indications et suivi chez 52 patients.

A nutritional support was indicated in 52 patients, most of whom had deglutition problems linked with post-therapeutic after-effects of neoplasia of the ORL sphere. Assistance was possible in all the cases, with difficulty in 9 cases. There were only three major complication (two of which necessitated the removal of the tube) and no fatalities. Benign, more numerous complications were all medically curable and did not necessitate the removal of the tube. The follow-up of the patients showed remarkable tolerance to, and nonproblematic use of, the GPE tube as a nutritional aid leading, in the majority of cases, to a weight gain, even when ambulatory. Our experience suggests that this technique deserves a prime place as a nutritional aid for cases of deglutition problems, of neurological origin, and in ORL cancers. Its relative safety must undoubtedly make it preferable to the surgical technique.