Cephalic pancreaticoduodenectomy with preservation of a right coronary artery bypass graft using the right gastro-epiploic artery: a case report.

INTRODUCTION: Pancreatic cancer is a rare disease with a high mortality rate, for which complete surgical resection, when possible, is the preferred therapeutic. Pancreaticoduodenectomy represents the surgical technique of choice. Abdominal surgeons can be faced with the challenge of patients with a history of coronary artery bypass graft in which the right gastro-epiploic artery is used. CASE REPORT: We report the case of a patient with an adenocarcinoma of the pancreatic head, stage IIA, having previously undergone a triple coronary artery bypass, one of which being a right gastro-epiploic graft. Our challenge was underlined by the necessity of a complete oncological resection through a cephalic pancreaticoduodenectomy while preserving the necessary cardiac perfusion via the right gastro-epiploic artery. CONCLUSION: We have been able to preserve a right gastro-epiploic artery as a coronary bypass during a cephalic pancreaticoduodenectomy for a cephalic pancreatic adenocarcinoma. We have successfully been able to preserve and re-implant the right gastro-epiploic artery to the origin of the gastroduodenal artery while insuring R0 resection of the tumor. A coronary artery bypass using the right gastro-epiploic artery should therefore not be considered as an obstacle to a Whipple's procedure if total oncological resection is obtainable.

Protection against nitric oxide toxicity by tea.

It is found that green tea and black tea are able to protect against nitric oxide (NO(*)) toxicity in several ways. Both green tea and black tea scavenge NO(*) and peroxynitrite, inhibit the excessive production of NO(*) by the inducible form of nitric oxide synthase (iNOS), and suppress the LPS-mediated induction of iNOS. The NO(*) scavenging activity of tea was less than that of red wine. The high activity found in the polyphenol fraction of black tea (BTP) could not be explained by the mixed theaflavin fraction (MTF) or catechins [epicatechin, epigallocatechin, epicatechin gallate, epigallocatechin gallate (EGCG)], which were tested separately. Synergistic effects between the compounds, or the presence of a potent, unidentified NO(*) scavenger, may explain the high activity of BTP. The peroxynitrite scavenging of tea was comparable to that of red wine. The main activity was found in the polyphenol fraction. MTF and the catechins were found to be potent peroxynitrite scavengers. Tea and tea components were effective inhibitors of iNOS. Of the tea components tested, only MTF had an activity higher than that of the tea powders. The polyphenol fractions of tea were much more active than the tea powders in suppressing the induction of iNOS. On the basis of its abundance and activity, EGCG was the most active inhibitor. The protective effect of tea on NO(*) toxicity is discussed in relation to the beneficial effect of flavonoid intake on the occurrence of cardiovascular heart disease.

Nitric oxide synthase inhibition by dimaprit and dimaprit analogues.

1. The similarity in molecular structure between the histamine H2-agonist dimaprit (3-dimethylamino-propyl-isothiourea) and the endogenous nitric oxide synthase (NOS) substrate L-arginine prompted us to study the effect of dimaprit and some dimaprit analogues on NOS activity. Dimaprit and some of its analogues were tested in an in vitro assay which measures the conversion of [3H]-L-arginine to [3H]-L-citrulline. Dimaprit inhibits rat brain NOS (nNOS) concentration dependently with an IC50 of 49+/-14 microM. 2. Removal of one or both of the methyl groups from the non-isothiourea nitrogen of dimaprit improved nNOS inhibitory properties. Aminopropylisothiourea is the most potent compound (IC50 = 4.1+/-0.9 microM) of the series followed by methylaminopropylisothiourea (IC50 = 7.6 +/- microM). 3. The observed effect of aminopropylisothiourea and methylaminopropyl-isothiourea are probably not due to the compounds themselves but to the corresponding mercaptoalkylguanidines, rearrangement products formed in aqueous solutions. This hypothesis is strengthened by the finding that aminobutylisothiourea is not active since a rearrangement to mercaptobutylguanidine does not occur. 4. Remarkably, nitrosylation of the isothiourea group of dimaprit decreases nNOS inhibitory activity, while nitrosylation of the guanidine analogue of dimaprit increases the inhibition of nNOS activity. 5. The pharmacological profile of dimaprit includes inhibition of nNOS. The nNOS inhibitory activity occurs in the same concentration range as the H2-agonist and H3-agonist activity of this compound.

Peroxynitrite scavenging by flavonoids.

The peroxynitrite scavenging activity of a series of structurally related flavonoids was tested. It was found that flavonoids are excellent scavengers of peroxynitrite. Compared to the known peroxynitrite scavenger ebselen, the most active flavonoids proved to be 10 times more effective. Indications were found that the catechol group (ring B) and the hydroxyl group at position 3 give the highest contribution to the peroxynitrite scavenging effect. The peroxynitrite scavenging is discussed in relation to the beneficial effect of flavonoid intake on the incidence of coronary heart disease.

A method for measuring nitric oxide radical scavenging activity. Scavenging properties of sulfur-containing compounds.

A new method for the quantification of the nitric oxide (.NO) scavenging activity of compounds in aqueous solutions is described using an amperometric .NO sensor. After correction for the spontaneous degradation of .NO, second-order rate kinetics of the scavenging reaction are observe. The rate constant for hemoglobin found with this method is comparable with that found with an established spectrophotometric method. To demonstrate the capability of the method, several sulfur-containing compounds were tested (GSH, GSSG, S-methyl glutathione, N-acetyl cysteine, lipoic acid and dihydrolipoic acid). Of these compounds, only those that contained a thiol group displayed a considerable .NO scavenging activity.

Difference in the inhibition of nitric oxide synthase and cytochrome P-450 by some H(2)-antagonists.

The enzyme nitric oxide synthase (NOS) is reported to have some similarities to the family of cytochrome P-450 enzymes. In this study the histamine H(2)-antagonists 2-methyl-4(4-isopropylaminomethyleneiminophenyl) imidazole (DA 5047), 2-guanidino-4(3-methylaminomethyleneiminophenyl)thiazole (DA 4643), tiotidine and cimetidine, which all display cytochrome P-450 inhibition were tested in a rat brain constitutive NOS (cNOS) assay. It was found that all four compounds inhibit rat brain cNOS in a competitive way. This was compared with the inhibition of cytochrome P-450 by these compounds reported previously by Rekka et al. (Rekka et al., 1989). The pIC(50) for cNOS inhibition correlated negatively with the pIC(50) found for P-450 inhibition. Apparently, the H(2)-antagonists interact differently to NOS compared with cytochrome P-450, indicating that there is a functional difference in the molecular mechanism of both enzymes in contrast to what has been suggested.

Immediate and day-to-day reproducibility of the signal-averaged electrocardiogram in patients with coronary artery disease.

The purpose of this study was to prospectively evaluate the immediate (5 minutes) and short-term (1 day) reproducibility of the signal-averaged electrocardiogram (SAECG) in patients with coronary artery disease. A total of 59 consecutive patients with coronary artery disease (50 male, 9 female, mean age 59 +/- 13 years) were included. Analysis was performed using a commercially available system with high-pass filters of 25, 40, and 80 Hz without any change in electrode position. The following time-domain parameters were measured: (1) total filtered QRS duration; (2) duration of high-frequency low-amplitude signals (HFLA); and (3) root-mean-square voltage of the terminal 40 ms of the QRS complex (RMS40). Correlation between pairs of measurements was excellent, ranging from 0.91-0.99 for QRS and HFLA duration, and from 0.83-0.98 for RMS40 value. However, the range of differences was wide for all parameters, especially at 25 and 80 Hz, revealing marked individual variations in selected cases. The immediate reproducibility of an initially normal SAECG was 95% at 25 Hz, 100% at 40 Hz, and 81% at 80 Hz; figures for an initially abnormal SAECG were 89%, 91%, and 93%, respectively, and the coefficient of agreement kappa was highest at 40 Hz than at 25 or 80 Hz. Discordant results were most frequently observed in patients with borderline values, or in cases with nonsimilar residual noise levels. In conclusion, the immediate and day-to-day reproducibility of the SAECG is excellent in patients with chronic stable coronary artery disease. However, individual variations are observed in selected cases, leading to modification in interpretation of the result. For this reason, individual reproducibility should be considered before evaluating the effect of any therapeutic intervention on the SAECG, especially in patients with borderline values of the quantitative parameters of the SAECG.

Coronary artery bypass grafting with the inferior epigastric artery. Midterm clinical and angiographic results.

Between December 1988 and September 1993, 157 patients (141 men, 16 women, average age 60.2 years, range 37 to 78 years) underwent a complete myocardial revascularization with 157 inferior epigastric artery grafts and 285 internal mammary artery grafts (281 in situ, 4 free grafts). A total of 543 distal arterial anastomoses (average 3.4, range two to five per patient) were constructed, 376 with the internal mammary artery and 167 with the inferior epigastric artery. The inferior epigastric artery grafts were anastomosed to two left anterior descending, 5 diagonal, 34 circumflex, and 126 right coronary arteries. The indications for the use of the inferior epigastric artery were the unavailability of conventional conduits in 56 patients and a favorable anatomy or a young age in 101 selected patients. The clinical follow-up averages 31.8 months (range 6 to 62 months). Four patients died early, and there were three perioperative nonfatal myocardial infarctions. Eight patients required early reoperation for thoracic bleeding (2) or drainage of an abdominal parietal collection (6). There were four late deaths (2 sudden deaths, 2 noncardiac causes) and one nonfatal myocardial infarction. Angina recurred in nine patients, of whom one required reoperation and three underwent successful percutaneous balloon angioplasty of a native coronary artery (2) or an old saphenous vein graft (1). An early recatheterization was obtained before discharge (average 11 days) in 135 patients: 132 of 135 inferior epigastric artery grafts were patent. Seventy-seven patients underwent a second angiographic restudy 6 to 43 months after the operation. Forty-four of the 48 inferior epigastric artery grafts restudied within the first postoperative year (average 8.5 months) were patent, but eight showed a diffuse narrowing. Twenty-eight of the 29 inferior epigastric artery grafts examined angiographically between 13 and 43 months (average 25 months) were open, and among those 29, 25 were widely patent, perfectly matching the receiving coronary artery. Most of the occluded or narrowed inferior epigastric artery grafts were grafted onto coronary arteries with mild stenosis at restudy. Five patients underwent a third angiographic reexamination up to 60 months after the operation (average 39 months). All five inferior epigastric artery grafts were widely patent. The early attrition rate of the inferior epigastric artery, as for any free arterial graft, is probably the result of both the loss of a true pedicle and the need for constructing an additional proximal anastomosis. The fact that the patency rate of the inferior epigastric artery graft seems to remain stable beyond 1 year could suggest a good durability in the future.

Quantitative angiographic follow-up study of the free inferior epigastric coronary bypass graft.

BACKGROUND: Attempts to improve late results of bypass coronary surgery have focused on the use of arterial conduits because of the high attrition rate of venous grafts. METHODS AND RESULTS: In our institution, 150 patients received an inferior epigastric artery (EPIG) as a free bypass graft, anastomosed to the right coronary artery in 73% and to a marginal branch in 20% of cases. These patients were followed prospectively by qualitative and quantitative angiography. Angiographic studies were performed in 122 patients (81%) early after surgery (11 +/- 5 days), and in 72 cases, a late evaluation (11 +/- 6 months) was also obtained. Quantative angiography (basal and after isosorbide dinitrate [ISDN]) was performed on the in situ EPIG in a large subset of these patients, as well as in 59 patients before bypass surgery. The patency rate was 98% at early control and remained high (93%) at late control. However, at late control, 14 EPIGs were occluded or threadlike, but of these 14, eight were grafted on a coronary artery with a moderate stenosis (< or = 60%) and with good anterograde perfusion. Mean basal EPIG diameter increased from 2.23 +/- 0.42 mm before surgery to 2.57 +/- 0.52 mm at 11 days (P < .01) but decreased to 2.20 +/- 0.47 mm in late study (P < .01 versus 11 days and P = NS versus before surgery). Vasodilation of EPIG with ISDN was observed before surgery (+0.34 +/- 0.20 mm, P < .001) and at late control (+0.20 +/- 0.17 mm, P < .001) but not in the early postoperative period for the whole group. Early after surgery, basal diameter was not different from native EPIG dimensions after ISDN (2.57 +/- 0.52 versus 2.56 +/- 0.39 mm), suggesting maximal dilation. However, vasodilation with ISDN was observed in a subgroup of patients at this time. These responder patients (n = 51) had a smaller basal diameter (2.47 +/- 0.49 versus 2.67 +/- 0.54 mm, P < .05) and a smaller runoff (P < .001) than nonresponder patients. CONCLUSIONS: EPIG grafts have a good early patency rate. The mid-term patency rate remains high and seems to depend, at least partially, on flow through the native coronary artery. EPIGs initially increase their lumen size, probably to meet the increased blood flow due to myocardial requirements. Over time, EPIG diameters decrease mainly as a result of a higher basal vasomotor tone. Long-term angiographic follow-up (eg, 5 to 10 years) is needed to assess late patency rate and the relation with these early findings and will define the place of this new coronary bypass conduit.

[The Social Defense Institution in Paifve]. / L'Etablissement de Défense sociale à Paifve.

The author have first studied the outcome of 68 patients, committed on the Social Defense law, out of the institution for five years. He observes that 27 patients have been well integrated, both professionally and socially (in their family). Fifteen patients had only a passive reinsertion and ten others are failures. Eight patients deceased, one through fire immolation, an other one through medicinal overdose during a holiday at home. Eight other had to be transferred: 3 in a specialized therapeutic milieu, 3 in a more closed setting and 2 in another region for linguistic reasons. In the second half of this work, the author has shown the strong incidence of somatic, familial or psychological factors in the patients population. Severly disturbed patients constitute 52% of the population for 16% of severe mental retardation and 34% of psychotics. Regardless of the heterogeneity of the population, it was possible to create a therapeutic community by organizing the permanent education of the attendants through a system of holydays and temporary liberations. This favoured the social reinsertion in the first study or a stabilisation of the situation through the allowance of reality confrontation and progress in familial and social reinsertion in the second group. The holidays and temporaray liberations produced in general few offenses which could be reduced by accompanying personnel able to collaborate more in this procedure.

[Attitudes concerning military duty and personality structures. Clinical, psychometric and projective study of Jehovah wittnesses and conscientious objectors (author's transl)]. / Attitudes face au service militaire et structure de personnalité. Etude clinique, psychométrique et projective de Témoins de Jehovah et d'objecteurs de conscience.

Refusal of military duty appearing to be a deviant social attitude, the authors have investigated the relationship between this behaviour and personality. They hypothesize that the rigid attitude of the Jehovah Wittness, refusing military duty and civil service, would be linked to paranoïd structure, and conscientious objectors to border-line states. A triple approach (clinical, Rorschach and aggressivity inventory of Buss and Durkee) was used; representative groups of these two populations were compared to control military recruits. Rorschach protocoles did not differentiate the Jehovah and control group, both being characterized by poor items and retraction. The authors interpret there data by possible absence of motivation in controls, or a rigid psychological organisation, which could be related habits in life and spirit of our societies. For the objectors, these are richer and more open. Five out of twelve appear to have a border-line organisation.

[Present state and evolution of the law of social defence (author's transl)]. / Actualité et évolution de la loi de Défense sociale.

The law of April 9, 1930 concluded to the non responsibility of the insane. It applyed a measure of social defence and treatment of some length. The evolution of ideas, the psychological and biological discoveries had bring a change in July 1964. The measure was finalized, not for the "insanes", but demented people, severe mental disturbed patients and severe mental retarded patients. The measure became non determined in time. The role of the lawyer is important, not only for the decision, but following the decision. The role of the physician is also important and the creation of a center of guidance becomes urgent. Therapy can be extended by ambulatory care with the necessary security measures.

[The problem of the treatment of the committed in Paifve (author's transl)]. / Le problème du traitement de l'interne à Paifve.

After 2 years of functioning, the Institution of Social Defence in Paifve reports on its activities. We shall be modest in our results, but see with satisfaction the climate in this House. Starting with a non-prepared personnel, we were able to train it in the live of an homogeneous and dynamic team: lectures, seminares, discussion and psychotherapy groups, frequent dialogue between personnel and direction, between personnel and committed people. All these relationships took place in a democratic way allowing people to invest the most. We can now trust the all team who has understood the aim: the resocialisation and revalorisation of the greatest possible number of patients.

[Relations with Social Defence Commissions and utility of leave techniques (author's transl)]. / Relations avec les commissions de Défense sociale et utilité des techniques de congés.

The authors insist on the importance of relations between Social Defence Commissions and institutions. The Commission has large powers, allowing a better resocialisation of the individual. Measures such as leaves of greater length are a king of trial for the patient. These measures avoid the patient to move in an unreal situation, and even if sometimes there is failure, this failure can still be used for therapeutic purpose. These leaves are the subject of discussions within the group, so that all members of the treating team are concerned.

[Clinical study of Haldol at high doses in chronic schizophrenia]. / Etude clinique du Haldol à doses élevées chez des schizophrènes chroniques

The authors have studied the action of high doses of Haldol in chronic schizophrenics in a study lasting more than five months and compared their results to a study done at the Eastern State hospital of Williamburg in Virginia (U.S., Howard). The daily doses of 75 mg caused a remission in 4 schizophrenics, and 19 patients were improved in a sample of 38 patients. The medication was given to a group exposed to neuroleptics only, without differences between the two groups. The authors have carried out the study for more than one year without observing changes in biological tests, using a dayly dose of 60 mg. Five patients out of nine were improved and could be discharged to return to their family or society with the appropriate affective follow-up.