Serial computed tomography is rarely necessary in patients with acute pancreatitis: a prospective study in 102 patients.

BACKGROUND: CT has proved to be helpful in patients with acute pancreatitis for differentiating between mild and severe forms. Followup of acute pancreatitis with CT has been advocated but rarely studied. The aim of this study was to determine if late CT performed at day 7 might be helpful in establishing the prognosis or the type of complications, and to select a subgroup of patients in whom CT could be beneficial. STUDY DESIGN: Contrast-enhanced CT was performed at the admission day and 7 days after admission in 102 patients admitted for acute pancreatitis. The extent of pancreatic inflammation was classified according to Balthazar grade, and intrapancreatic necrosis on these examinations was prospectively assessed and compared with clinical and biologic data and with patient outcomes. RESULTS: Among 102 patients, complications developed in 24 (23%). Complications developed in only 8% of patients with Ranson score <2, making routine early CT unnecessary. For the patients with Ranson score <2 and Balthazar grades A and B at day 1 CT, late CT seemed to be useless. Complication was suspected by clinical and biologic tests before day 7 in 22 of 24 complicated patients (92%), suggesting that CT could be proposed only in cases of clinical or biologic deterioration. Late CT was correlated with a complicated course in patients with Balthazar grades D and E or intrapancreatic necrosis >50%. Late CT was predictive of complications in cases of intrapancreatic necrosis enlarging since the first examination. CONCLUSIONS: Our study showed that in acute pancreatitis: 1) there is little justification for systematic early CT, especially in patients with Ranson score <2, and 2) late CT does not need to be performed routinely, but only in cases of clinical or biologic worsening.

Nitroimidazoles and hypoxia imaging: synthesis of three technetium-99m complexes bearing a nitroimidazole group: biological results.

Several Tc-99m complexes were synthesized, substituted with a nitroimidazole group, in order to visualize hypoxic tissues. The complexes were tested on rats (isolated hearts) and showed no significant uptake under hypoxic conditions.

Inflammatory cytokine response in patients with septic shock secondary to generalized peritonitis.

OBJECTIVES: The aims of this study were the following: a) to assess the proinflammatory cytokine (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1, and IL-6) response in patients with septic shock secondary to generalized peritonitis; and b) to evaluate the influence of bacteremic status, type of peritonitis (acute perforation or postoperative), and peritoneal microbial status (mono- or polymicrobial) on cytokine expression and mortality. DESIGN: Prospective study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: Fifty-two consecutive patients with septic shock caused by generalized peritonitis. INTERVENTIONS: Routine blood tests, blood cultures, and cytokine assays were performed during the first 3 days after onset of shock. MEASUREMENTS AND MAIN RESULTS: Serum TNF-alpha and IL-6 concentrations were measured by using a radioimmunoassay, and IL-1 concentrations were measured by using ELISA. Median serum concentrations on day 1 were: TNF-alpha, 90 pg/mL; IL-1, 7 pg/mL; and IL-6, 5000 pg/mL. TNF-alpha and IL-6 concentrations decreased significantly between the first and third days of septic shock (p = .0001), whereas IL-1 concentrations remained low. The decrease in IL-6 tended to be more pronounced in the survivors group (p = .057). Median TNF-alpha serum concentrations were higher in bacteremic compared with nonbacteremic patients (151 vs. 73 pg/mL, p = .003). TNF-alpha, IL-1, and IL-6 serum concentrations and mortality were not different between acute perforation vs. postoperative peritonitis and mono- versus polymicrobial peritonitis. CONCLUSIONS: The systemic release of TNF-alpha and IL-6 during septic shock caused by generalized peritonitis was maximal on day 1 and decreased rapidly during the next days. No systemic release of IL-1 was observed. IL-6 serum concentrations remained higher in patients who subsequently died. Among the different features of peritonitis studied, only bacteremia influenced the systemic cytokine response (higher TNF-alpha).

A new etiology of acute abdominal emergencies in cirrhotic patient: secondary pneumococcal peritonitis with jejunitis.

We report the first case of secondary pneumococcal peritonitis associated with acute jejunitis in a 52-year-old homeless Child-Pugh C cirrhotic man without ascitis. The patient was admitted with clinical signs of peritonitis, and jaundice. Morphologic examination was unremarkable. A laparotomy revealed a diffuse peritonitis, and an acute jejunitis with prenecrotic lesion. The lesion was located within the first centimeters of the jejunum, immediately after the duodeno-jejunal angle, extented on 15 cm. A resection of the first 15 cm of the jejunum was performed with duodeno-jejunal side-to-side manual anastomosis. Gram-stain and cultures of blood, peritoneal pus, and jejunal mucosa revealed a penicillin-sensitive Streptococcus pneumoniae. Appropriate parenteral antibiotic treatment was initiated (aminopenicillin). The postoperative course was marked by a transient hepatic failure associated with an ascitis controlled by diuretics. The patient was discharged on the 26th day after surgery. This case reports a new etiology of acute abdominal emergencies in cirrhotic patients.

Association of TNF2, a TNF-alpha promoter polymorphism, with septic shock susceptibility and mortality: a multicenter study.

CONTEXT: Tumor necrosis factor alpha (TNF-alpha) is believed to be a cytokine central to pathogenesis of septic shock. TNF2, a polymorphism within the TNF-alpha gene promoter, has been associated with enhanced TNF-alpha production and negative outcome in some severe infections. OBJECTIVES: To investigate the frequency of the TNF2 allele in patients with septic shock and to determine whether the allele is associated with the occurrence and outcome of septic shock. DESIGN: Multicenter case-control study conducted from March 1996 to June 1997. SETTING: Seven medical intensive care units in university hospitals. SUBJECTS: Eighty-nine patients with septic shock and 87 healthy unrelated blood donors. MAIN OUTCOME MEASURES: Frequency of the TNF2 allele among patients with septic shock and among those who died and the level of corresponding TNF-alpha concentrations. RESULTS: Mortality among patients with septic shock was 54%, consistent with the predicted mortality from the Simplified Acute Physiologic Score (SAPS II) value. The polymorphism frequencies of the controls and the patients with septic shock differed only at the TNF2 allele (39% vs 18% in the septic shock and control groups, respectively, P =.002). Among the septic shock patients, TNF2 polymorphism frequency was significantly greater among those who had died (52% vs 24% in the survival group, P =.008). Concentrations of TNF-alpha were higher in 68% and 52% with the TNF2 and TNF1 polymorphisms, respectively, but their median values (48 pg/mL vs 29 pg/mL) were not statistically different (P = .31). After controlling for age and the probability of death, derived by the SAPS II score, multiple logistic regression analysis showed that, for the same rank of SAPS II value, patients with the TNF2 allele had a 3.7-fold risk of death (95% confidence interval, 1.37-10.24). CONCLUSION: The TNF2 allele is strongly associated with susceptibility to septic shock and death due to septic shock.

High tumor necrosis factor serum level is associated with increased survival in patients with abdominal septic shock: a prospective study in 59 patients.

BACKGROUND: In several studies including patients with septic shock of various origins, high serum cytokine levels have been reported to correlate with poor outcome. The aim of this prospective study was to assess the prognostic value of cytokine serum levels in a group of patients with perioperative septic shock of digestive origin. METHODS: From January 1992 to December 1994, 59 patients were evaluated (mean age, 68 +/- 15 years). From the first day of septic shock to day 7, blood was drawn every day to measure the conventional biologic parameters (white blood cell count, platelet count, hematocrit, blood urea nitrogen level, serum electrolytes level, pH, blood gases, serum lactate level, coagulation parameters, liver function tests) and tumor necrosis factor (TNF), interleukin-1, and interleukin-6. RESULTS: No difference was observed between the 26 survivors and the 33 nonsurvivors with regard to age, gender, and cause of sepsis. On admission, mean platelet count was significantly higher in the survivors than in the nonsurvivors (260 +/- 142 versus 177 +/- 122 10(9)/L; p = 0.01). Mean blood urea nitrogen level was significantly lower in the survivors than in the nonsurvivors (9.6 +/- 9 versus 12 +/- 7 mmol/L; p = 0.04). No difference was observed between survivors and nonsurvivors for the other conventional biologic parameters and for serum interleukin-1 and interleukin-6 levels. Mean serum TNF level tended to be higher in survivors than in nonsurvivors (565 +/- 1325 versus 94 +/- 69 pg/ml; not significant). In the group survivor 9 (35%) of 26 patients had a serum TNF level greater than 200 pg/ml versus 2 (6%) of 33 patients in the nonsurvivor group (p < 0.02). Survival was noted in 6 (100%) of 6 patients who had both a serum TNF level greater than 200 pg/ml and a platelet count greater than 100.10(9)/L versus 1 (11%) of 9 in patients with neither of these criteria (p < 0.01). CONCLUSIONS: In our patients with abdominal septic shock, high serum TNF levels were associated with increased survival. The high serum level of TNF may reflect the efficacy of peritoneal inflammatory response against abdominal sepsis. Although this possibility must be further explored, a score combining the serum TNF level and platelet count could be helpful for the prognostic assessment of patients with abdominal septic shock.

Small bowel fistulae in Degos' disease: a case report and literature review.

Degos' disease (malignant atrophic papulosis) is a rare, progressive, small- and medium-size arterial occluding disease, leading to tissue infarction and initially involving the skin. We report a case with bowel involvement followed by enterocutaneous fistulae. Diagnostic laparoscopy with jejunal biopsy was followed by jejunal perforations, peritonitis, and fistulae leading to death after a 4-month course in the intensive care unit. The usual treatment of enterocutaneous fistula by somatostatin and parenteral nutrition was ineffective in this case. The course of the disease in our patient was not usual, as can be seen in a literature review underlining the specific features of Degos' disease. Laparoscopy and bowel biopsy should be avoided in this context. Degos' disease should be considered in the differential diagnosis of a primary ulceration of the small intestine.

Levels of portal and systemic blood cytokines after colectomy in patients with carcinoma or Crohn's disease.

BACKGROUND: Cytokine overproduction has been observed in different pathophysiologic conditions, including sepsis, carcinoma, inflammatory disease, and tissue injury induced by operation. Colectomy is a procedure that may result in excessive cytokine release through the portal vein. The respective effects of an operative procedure, perioperative septic complications, and of the disease itself on cytokine production are still not known. STUDY DESIGN: This study was done to investigate the variations in the levels of interleukin-1 beta (IL-1), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) and C-reactive protein (CRP) in portal and systemic blood during and after colectomy in patients with malignancy or with Crohn's disease. Blood samples were collected intraoperatively from portal and systemic veins of 24 patients undergoing colectomy for either Crohn's disease (n = 13) or carcinoma (n = 11), and postoperatively (from days 1 to 5) from systemic veins. The changes in blood levels of cytokines and CRP in patients with an uneventful colectomy (n = 19) were compared to changes in patients whose colectomy was complicated by sepsis (n = 5). Similar changes in cytokines and CRP levels were compared between patients with malignancy and those with Crohn's disease. RESULTS: The portal and systemic blood levels of IL-1, IL-6, TNF-alpha, and CRP were significantly correlated before and after colectomy. In portal blood, the level of IL-6 was significantly higher after colectomy than before. In systemic blood, the levels of CRP, TNF-alpha, and IL-6 before colectomy were significantly higher in patients with Crohn's disease than in patients with malignancy. After uneventful colectomy, a temporary increase in CRP, TNF-alpha, and IL-6 was noted in systemic blood, followed by a rapid decrease, although systemic blood cytokine levels remained significantly higher after colectomy complicated by sepsis. Interleukin-1 beta levels in both portal and systemic blood remained unchanged during and after colectomy, regardless of the indication for operation and its outcome. CONCLUSIONS: Colectomy causes acute release of cytokines and CRP in both the portal and systemic circulation. The increase in IL-6 observed after colectomy in portal blood and subsequently in systemic blood suggests local production from the resected specimen, or at least from the area of resection. Cytokine production, especially of IL-6, was modified not only by the underlying disease itself, as higher levels were observed in Crohn's disease before colectomy, but also by the presence of perioperative septic complications.

[Peroperative pneumothorax in thoracotomy: the value of pulse oximetry]. / Pneumothorax peropératoire au cours de thoracotomies: intérêt de l'oxymétrie de pouls.

Two cases of pneumothorax occurring during thoracotomy under one-lung ventilation are reported. One case occurred before pneumonectomy was carried out. The decrease in Spo2 shown by pulse oximetry, together with the increase in airway pressures, rapidly led to the diagnosis of pneumothorax. In the other case, the accident occurred after pneumonectomy, with a suddenly impossible ventilation, and a drastic decrease in Spo2 leading to hypoxic circulatory arrest. Hypoxaemia occurring during one-lung ventilation may be due to different causes. Shunting in the upper part of the lung is the main cause, but other diagnoses must be discussed, such as airway obstruction by blood or sputum, displacement of the selective endotracheal tube, bronchospasm, and pneumothorax. Monitoring of Spo2 by pulse oximetry would therefore seem to be mandatory during thoracic surgery, in order to allow an early diagnosis of hypoxaemia and speed up the treatment of its cause.

[Cachectin or TNF (tumor necrosis factor): clinical implications]. / Cachectine ou TNF (tumor necrosis factor): implications cliniques.

Septic shock remains an acute condition with a bad prognosis and a high mortality rate. This could be related to our incomplete understanding of the pathophysiological mechanisms involved, especially in the immunological field. Recently, several studies have stressed the key role of cytokines. Amongst these, the tumour necrosis factor (TNF) seems to be the most important. This peptide is a hormone secreted by monocytes and macrophages under the effect of various stimuli such as lipopolysaccharides or endotoxin. Giving TNF mimicks the clinical and biological patterns of septic shock. Moreover, high concentrations of TNF have been found in patients suffering from septic shock. Pretreatment with monoclonal antibodies against TNF prevents the occurrence of septic shock after endotoxin administration. TNF acts directly via ubiquitous specific receptors; this probably explains its diffuse activity. The therapeutic implications of these recent advances are not clear. It is not known, for the moment, whether TNF secretion is beneficial or deleterious for the patient.

Influence on the myocardial and blood activity course of the characteristics of the labelled fatty acid injected i.v. into mice.

In order to choose a labelled fatty acid (FA) for the external study of myocardial metabolism, FAs that are different in chain length, saturation, nature and position of the radioactive label, are injected i.v. into mice. Myocardial and blood activities are measured at various times p.i. It appears that hexadecanoic and hexadecenoic acids, iodine labelled in omega position, have the highest maximal myocardial activity among all the FAs studied. Furthermore, the myocardial and blood time-activity course is similar for both FAs. As unsaturated FAs have apparently a higher myocardial fixation in man than the saturated ones, 123I 16 iodo-9 hexadecenoic acid has been selected and seems well suited for the study of myocardial metabolism.

Do iodinated fatty acids undergo a nonspecific deiodination in the myocardium?

The intracellular and subcellular distribution of 16-(123I)-iodo-9-hexadecenoic acid were studied in isolated rat hearts, perfused with or without glucose. At various time intervals after injection, cardiac lipids were extracted and the activity was determined for all fractions and all lipid classes. The total cardiac activity was maximal within 1 min postinjection and most of the activity was in the aqueous phase. The presence of glucose in the perfusion medium induced an increase of total cardiac and organic fraction activities. In the latter fraction, activity was very low for FFA, but high for triglycerides (TG), and especially polar lipids. The presence of an exogenous substrate, led to a more active esterification of fatty acids. Coronary effluent analysis showed, in the hydrophilic phase, a lower activity spike in the presence than in the absence of glucose. In the mitochondrial fraction most activity occurred in the organic phase, especially as polar lipids. In the nonmitochondrial fraction, activity was much higher in the aqueous phase. At 90 s postinjection of 1-14C-palmitic acid, over 80% of the myocardial activity was found in the hydrophilic fraction, which indicates, as for the iodo-fatty acid (IFA), an immediate and important oxidation, especially without glucose. These data seem to prove that IFA is taken up by the myocardial cell, subsequently enters the mitochondria and, without an early deiodination, is oxidized with iodide release. Changes in IFA metabolism, consecutive to modifications of glucose concentration in the perfusion medium can be observed by external detection of the myocardial activity curve. Omega-Iodinated fatty acids do not undergo a nonspecific deiodination and are therefore well suited for an external study of myocardial metabolism.

[Acute postoperative pulmonary edema in the coronary patient: effects of myocardial ischemia]. / Oedème aigu pulmonaire postopératoire chez le coronarien: incidence de l'ischémie myocardique.

In order to evaluate the incidence of myocardial ischaemia in patients who developed acute pulmonary oedema during the immediate post-operative period, continuous monitoring of the electrocardiogram by the Holter method was used in 200 consecutive patients with coronary artery disease. Fourteen of these patients exhibited ST segment depression during the post-operative period and 13 during surgery. Nine patients developed acute pulmonary oedema immediately after the operation and in 7 cases the oedema was preceded by myocardial ischaemia. A continuous nitroglycerin infusion brought about regression of the pulmonary oedema in 8 cases. One patient died despite treatment. These findings underline the part played by myocardial ischaemia in the pathogenesis of acute post-operative pulmonary oedema in patients with coronary artery disease.

[Monitoring of extra- and intra-cellular compartment through total body impedance (author's transl)]. / Monitorage des compartiments hydriques extra- et intra-cellulaires par impédance corporelle.

To evaluate the extra-cellular space, we measure the impedance (or resistance) of the extra-cellular electrolyte compartment with an alternating current at a fixed frequency of 5 kHz that can't pass through the cellular membrane. Total water is measured by the impedance to a current of 1 MHz which is conducted by extra and intra cellular hydro-electrolytic space. There is a good correlation between electrical impedance measurements and distribution of isotopic markers. The extra-cellular compartment was evaluated by diffusion of D.T.P.A. marked with 99mTc or with 111In and the total water by the diffusion of Antipyrin marked with 1,311 or 1,231. The findings indicate that there is not a significant difference between the results of the size of extra-cellular water measured by electrical impedance and D.T.P.A. diffusion (r = 0.75). Comparable results have been obtained in the determination of total water by electrical impedance measure and diffusion of Antipyrin (r = 0.90). We have also studied by method of electric impedance:--The state of hydratation in head injured patients and after pituitary surgery.--The lean body mass and hydro-electrolyte compartments in pregnancy. Electrical impedance measure seems to be a simple and reliable method to assess the hydric state of patients.

[beta2-Microglobulin determination's estimation in cerebrospinal fluid (author's transl)]. / Valeurs du dosage de la beta2-microglobuline dans le liquide céphalo-rachidien.

beta2-Microglobulin levels were determined the serum and CSF by radioimmunoassay in various patients from departments of neurology and neurosurgery. Simultaneously a study of CSF protein levels was done. In normal subjects, there is a good correlation between blood and beta2m levels. In patients with pure subarachnoid hemorrhage, the beta2m was always found elevated in the CSF. In tumors of the nervous system, the number of cases studied is yet too small to allow any conclusion.