Liver fibrosis in patients with chronic hepatitis C and persistently normal liver enzymes: influence of HIV infection

Summary. Liver fibrosis progress slowly in patients with chronic hepatitis C and persistently normal alanine aminotransferase (PNALT) compared to subjects with elevated aminotransferases. Differences in liver fibrosis according to human immunodeficiency virus (HIV) status in this population have not been examined. All patients with serum hepatitis C virus (HCV)‐RNA and PNALT who underwent liver fibrosis assessment using elastometry since 2004 at three different European hospitals were evaluated. Patients previously treated with interferon were excluded. PNALT was defined as ALT below the upper limit of normality in at least three consecutive determinations within the last 12 months. Fibrosis stage was defined as mild (Metavir F0–F1) if stiffness ≤7.1 kPa; moderate (F2) if 7.2–9.4 kPa; severe (F3) if 9.5–14 kPa, and cirrhosis (F4) if >14 kPa. A total of 449 HIV‐negative and 133 HIV‐positive patients were evaluated. HIV‐negative patients were older (mean age 51.8 vs 43.5 years) and more frequently females (63%vs 37%) than the HIV counterparts. Mean serum HCV‐RNA was similar in both the groups (5.9 vs 5.8 log IU/mL). Overall, 78.8% of the HIV patients were on HAART and their mean CD4 count was 525 (±278) cells/μL. In HIV‐negatives, liver fibrosis was mild in 84.6%; moderate in 8.7%, severe in 3.3% and cirrhosis was found in 3.3%. In HIV patients, these figures were 70.7%, 18.8%, 6%, and 4.5%, respectively. In the multivariate logistic regression analysis, older age (odds ratio or OR: 1.04; 95% confidence interval or CI: 1.02–1.07; P < 0.001) and being HIV+ (OR: 2.6; 95% CI: 1.21–5.85; P < 0.01) were associated with severe liver fibrosis or cirrhosis (F3–F4). Thus, severe liver fibrosis and cirrhosis are seen in 6.6% of the HCV‐monoinfected and in 10.5% of HCV‐HIV co‐infected patients with PNALT. Some degree of liver fibrosis that justifies treatment is seen in 15% of the HCV‐monoinfected but doubles to nearly 30% in HIV‐HCV co‐infected patients with PNALT.     

Plasmocytose sanguine et dengue : une anomalie biologique sous-estimée ?

Introduction

A significant peripheral blood plasmacytosis is a rare finding associated with viral infections. We reported five consecutive cases of dengue virus infection, with circulating plasma cells.

Case reports

Three women and two men, aged 26 to 75 years, had returned from French West Indies less than one week before the onset of the symptoms (mean: 2.5 days). The transient blood plasmacytosis was variable in intensity (0.1 to 0.8 G/L) with a maximal level between the fourth and the seventh day following the onset of the symptoms, and was associated in four patients, with activated lymphocytes and lympho-plasma cells.

Conclusion

Reactive plasmacytosis during dengue fever is common and probably underestimated because it is transient and only identified by careful microscopic examination of a blood smear. Plasmacytosis could be explained by the intensity of the immunological response and the production of large amount of interleukins.     

Intracoronary thrombectomy with the Export Aspiration Catheter before angioplasty in patients with ST-segment elevation myocardial infarction

OBJECTIVES: We aimed to assess the safety and feasibility of thrombectomy with the Export Aspiration Catheter (EAC) before angioplasty, and its ability to improve angiographic results in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Distal embolization of atherothrombotic material often occurs during angioplasty in STEMI, compromising optimal myocardial reperfusion. METHODS: We performed a thrombus-aspiration with EAC prior to angioplasty in 64 consecutive patients with STEMI. Successful thrombectomy was defined as an improvement of TIMI flow grade > or =1. RESULTS: Successful thrombectomy (increase of TIMI flow > or =1) was achieved in 40 patients (62.5%). Mean TIMI flow grade increased from 0.7 +/- 1 to 1.9 +/- 1.2 (P < 0.0001) after thrombectomy. TIMI flow grade 3 was observed more frequently after EAC compared with guidewire alone (51.5 vs. 9%, P = 0.0062). Direct stenting was performed in most of patients (N=41, 64%). Distal embolization and noreflow/slowflow phenomenon occurred in 8 patients (12.5%). No vessel injury after EAC thrombectomy was reported. After treatment with balloon angioplasty and/or stenting, final TIMI flow grade 3 was achieved in 54 patients (84.5%). By multivariate analysis, ischemic time <6 h was a significant independent predictor of successful thrombectomy (P = 0.0437). CONCLUSIONS: Our series suggests that EAC thrombectomy prior to angioplasty in the setting of STEMI is safe and feasible. It might reduce the culprit coronary lesion's thrombus burden, leading to improved flow restoration and myocardial reperfusion. Further large randomized studies are warranted to confirm these preliminary results and to assess the impact of thrombus-aspiration on infarct size as well as on clinical outcomes.     

Free vascularized toe-joint transfer in hand reconstruction: a series of 25 patients

Twenty-eight vascularized toe-joint transfers performed on 25 patients were reviewed. A number of different techniques were used: proximal interphalangeal joint or metacarpophalangeal joint reconstruction, one-stage double joint transfer, and interphalangeal thumb or trapezometacarpal joint replacement. Using these types of vascularized joint transfer allows one-stage composite transfer (including skin, bone, and extensor tendon) and provides rapid bone healing, potential growth in the young, good long-term cartilage preservation, normal lateral stability in pinch, and limited but useful range of motion (mainly at the proximal interphalangeal level).     

Aesthetic improvement of the nail by the "illusion" technique in partial toe transfer for thumb reconstruction.

We describe a technique to improve the cosmetic appearance of the nail of the great toe after partial toe transfer for thumb reconstruction. By harvesting a bone fragment longitudinally from the distal phalanx, it is possible to increase the curvature of the nail and decrease its visual projection.     

Cost-effectiveness analysis in colorectal cancer using a semi-Markov model

Cost and effectiveness are usually modeled according to one studied event or one health state with parametric or non-parametric methods. In this paper, we propose an original method for assessing total costs while incorporating the dynamics of change in the health status of patients. A semi-Markov model in which the distributions of sojourn times are explicitly defined is developed. The hazard function of sojourn times is modeled by Weibull distributions specific to each transition. A vector of covariates is incorporated into the hazard function of each transition. From a regression model for costs, a cumulative cost function is derived. An estimation of the mean cost per patient in each state defined in the semi-Markov model could thus be made, and this enables us to identify the determinants of direct costs. The results of incremental net benefit (INB) are assessed using the bootstrap method. A cost-effectiveness analysis is performed in order to compare two strategies of follow-up in the colorectal cancer study. Two hundred and forty patients were enrolled in this study. Three health states are defined for patients with curative resection of colorectal cancer: alive without relapse, alive with relapse, and dead. The mean survival is 4.35 and 4.12 years, respectively, in the standard and moderate follow-up groups. We show that mean cost differs significantly by follow-up strategy and Dukes stage. Finally, the INB is assessed and this indicates that neither of the strategies compared was more cost-effective than the other.     

Effect of resection of the anterior chordae on cardiac function after surgical correction of mitral valve insufficiency]

The preservation of cardiac function in surgical correction of mitral regurgitation implies partially or totally preserving the subvalvular apparatus. However, the conservation of the whole subvalvular apparatus during mitral valve replacement is technically difficult as the anatomical conditions are not always favourable. In order to determine the consequences of isolated resection of the anterior chordae, the authors studied global and segmental cardiac function by isotopic angiocardiography after mitral valve repair (n = 23) or replacement with conservation of the posterior chordae (n = 16) in 39 patients with isolated, non-ischaemic mitral regurgitation. The left ventricular ejection fraction decreased after valve replacement (64.1 +/- 8.5% to 57.4 +/- 10%, p = 0.01) but not after mitral valve repair (65 +/- 11.3% to 62.1 +/- 12.2%, p = NS). The ejection fractions of segments 4 and 5, corresponding to the zones of insertion of the anterior papillary muscle, decreased after valve replacement compared with repair (segment 4: -9 +/- 13.7 versus +2 +/- 11.3, p = 0.01) (segment 5: -15 +/- 13.2 versus 2 +/- 11.7, p = 0.003). The right ventricular ejection fraction improved after valve repair (40.9 +/- 9.1% to 46.4 +/- 10.1%, p = 0.03), whereas it remained unchanged after valve replacement (42.9 +/- 10.3% to 42.8 +/- 8.6%, p = NS). These results indicate a deleterious effect of isolated resection of the anterior chordae on cardiac function during mitral valve replacement with localised abnormalities of left ventricular function. This study supports the rationale of mitral valve repair or conservation of the anterior and posterior chordae during valve replacement for isolated mitral regurgitation.     

A modified open palm technique for Dupuytren's disease

Summary Fifty-four patients with Dupuytren's disease were operated on using transverse and Bruner incisions, leaving the transverse palmar and digital wounds open. The mean follow up was 6.6 years (minimum 5 years). The mean percentage correction of the overall fixed flexion deformity was 71%. The incidence of recurrence and extension of the disease were similar to other series of limited aponeurectomy. However, the postoperative complications were very much lower and the method is particularly suitable for patients over 50 years of age.

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Résumé Cinquante-quatre patients, présentant 67 rayons intéressés par une maladie de Dupuytren, ont été opérés par un chirurgien utilisant les avantages de l'excellente visibilité de l'incision de Bruner combinés à ceux classiques de la paume ouverte. Avec un recul moyen de 6.6 ans (minimum 5 ans), le pourcentage moyen de correction de la flexion était de 71.3%. Le taux de récidive et d'extension a été identique à celui publié dans la littérature après aponévrectomie limitée. L'avantage principal de la méthode reste le peu de complications per- et post-opératoires.

     

Free compound transfer of the distal interphalangeal joint. A case report

The first case of free vascularized transfer of a distal interphalangeal (DIP) joint, used to replace a severely damaged proximal one, is presented. The case is interesting not only for the procedure used, but it also illustrates the principle by which useful components of nonsalvageable digits are used to reconstruct other damaged, but still salvageable, parts of the hand.     

Computerized study of the functional results of a 2nd toe transfer in finger mutilation

In a series of 157 transfer cases, 73 were carried out in 58 patients using the second toe. 55 transfer operations were performed on the long toes versus 18 on the big toe. Indications are discussed on the basis of an original classification of amputations. Among tested parameters, sensitivity and mobility statistically correlated with 17 factors. Of statistical import were age, sensitivity to cold, duration of ischemia, partial exclusion of fine pinch. Significant mobility factors were industrial accident, the surgeon's experience, the number of nutrient arteries, the reconstruction level, and the amputation score.