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A chemo-biotechnological approach is reported for the synthesis of TMG-chitooligomycins, CO-n (NMe(3)). Their abilities to inhibit β-N-acetylhexosaminidases (HexNAcases), from Aspergillus oryzae (AoHex, fungi), Canavalia ensiformis (CeHex, plant) HexNAcases and a chitobiase from Serratia marcescens (SmCHB, bacteria) were studied and compared with their precursors CO-n (N). CO-n (NMe(3)) were revealed as potent inhibitors for AoHex and SmCHB with a proved chain length effect while CO-n (N) was a highly selective inhibitor of SmCHB. This route can be considered as the privileged way to produce easily and in large scale a wide range of size-defined chitooligosaccharide-based inhibitors to fine-tune the structure-activity relationships for inhibition of HexNAcases from various origins., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The α-Gal epitope is a carbohydrate structure, Galα-3Galβ-4GlcNAc-R, expressed on glycoconjuguates in many mammals, but not in humans. Species that do not express this epitope have present in their serum large amounts of natural anti-Gal antibodies, which contribute to organ hyperacute rejection during xenotransplantation. We first describe the efficient conversion of lactose into isoglobotriaose (Galα-3Galβ-4Glc) using high cell density cultures of a genetically engineered Escherichia coli strain expressing the bovine gene for α-1,3-galactosyltransferase. Attempts to produce the Galili pentasaccharide (Galα-3Galβ-4GlcNAcβ-3Galβ-4Glc) by additionally expressing the Neisseria meningitis lgtA gene for β-1,3-N-acetylglucosaminyltransferase and the Helicobacter pylori gene for β-1,4-galactosyltransferase were unsuccessful and led to the formation of a series of long chain oligosaccharides formed by the repeated addition of the trisaccharide motif [Galβ-4GlcNAcβ-3Galα-3] onto a lacto-N-neotetraose primer. The replacement of LgtA by a more specific β-1,3-N-acetylglucosaminyltransferase from H. pylori, which was unable to glycosylate α-galactosides, prevented the formation of these unwanted compounds and allowed the successful formation of the Galili pentasaccharide and longer α-Gal epitopes., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The cluster of genes of capsular K5 heparosan is composed of three regions, involved in the synthesis and the exportation of the polysaccharide. The region 2 possesses all the necessary genes involved in the synthesis of heparosan, namely kfiA, encoding alpha-4-N-acetylglucosaminyltransferase, kfiD, encoding β-3-glucuronyl transferase, kfiC, encoding UDP-glucose dehydrogenase (UDP-glucuronic acid synthesis), and kfiB encoding a protein of unknown function. The cloning and expression of kfiADCB into Escherichia coli K-12 were found to be sufficient for the production of heparosan, which accumulates in the cells due to a lack of the exporting system. The concentration of recombinant heparosan reached one gram per liter under fed-batch cultivation. The cytoplasmic localization of heparosan inside the bacteria allowed subsequent enzymatic modifications such as a partial degradation with K5 lyase when expressed intracellularly. Under these conditions, the production of DP 2-10 oligosaccharides occurred intracellularly, at a concentration similar to that of recombinant intracellular heparosan., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: This prospective study was designed to evaluate whether preoperative plasma brain natriuretic peptide (BNP) could identify significant preoperative cardiovascular disease in elderly hip-fractured patients., Patients and Methods: Preoperative plasma BNP measurement and rest transthoracic echocardiography (TTE) were performed within 24 h after admission in consecutive hip-fractured patients aged ≥65 years. The major echocardiographic abnormality (MEA) group included patients with at least one TTE abnormality, defined as systolic pulmonary artery pressure (PAP(s)) ≥50 mmHg, left ventricular (LV) systolic dysfunction, increased LV filling pressure (LVFP) or severe valvular disease. The control group included the remaining patients., Results: Seventy-five patients (mean±SD (range) age=85±5 (69-97) years) were included during a 6-month period. Twenty-four (32%) patients constituted the MEA group (17 elevated PAP(s), three LV systolic dysfunctions, 10 increased LVFP, one severe aortic stenosis and one severe mitral regurgitation). Median (interquartile) preoperative BNP value was significantly greater in MEA than in the control group (527 (361) vs. 119 (154) pg ml(-1); p<0.0001). A preoperative plasma BNP cut-off value at 285 pg ml(-1) predicted well MEA with an area under the receiver operating characteristic (ROC) curve equal to 0.895 (p<0.0001) and with a hazard ratio (HR) (confidence interval, CI) of 23.8 (3.7-142.9) (p=0.0008) on multivariate analysis. The presence of MEA or BNP≥285 pg ml(-1) was associated with high mortality., Discussion: The incidence of echocardiographic signs of elevated PAP(s) or elevated LVFP in elderly hip-fractured patients was high. A preoperative BNP value ≥285 pg ml(-1) can discriminate between elderly hip-fractured patients with or without MEA., (Copyright © 2011. Published by Elsevier Ltd.)

The prion protein (PrP) resides in lipid rafts in vivo, and lipids modulate misfolding of the protein to infectious isoforms. Here we demonstrate that binding of recombinant PrP to model raft membranes requires the presence of ganglioside GM1. A combination of liquid- and solid-state NMR revealed the binding sites of PrP to the saccharide head group of GM1. The binding epitope for GM1 was mapped to the folded C-terminal domain of PrP, and docking simulations identified key residues in the C-terminal region of helix C and the loop between strand S2 and helix B. Crucially, this region of PrP is linked to prion resistance in vivo, and structural changes caused by lipid binding in this region may explain the requirement for lipids in the generation of infectious prions in vitro., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objectives: To report any item documenting the peroperative muscle relaxant effects management in anaesthesia files issued from visceral surgery processes., Type of Study: Prospective, observational and multicenter., Patients and Methods: A single operator analysed 1453 files proposed by nine anaesthetists' teams. The items selected concerned three periods: induction/tracheal intubation, paralysis maintenance, tracheal extubation. Reporting of 40 categories of items was studied., Results: Items related to laryngoscopy and intubation conditions were observed in 43% (0-95) [general average (intercentres min-max)] and in 11% (0-97) of the files, respectively. At least one level of paralysis was reported in 23% (0-96) of the files. For the paralysis maintenance, documentation of an effect appeared in 53% (4-96) of the documents. Neuromuscular assessments preceding the tracheal extubation were retrieved in 43% (12-89) of the notes. Adductor pollicis was concerned for 30% (1-89) of these observations. Detection of level of spontaneous paralysis offset, satisfying to the local standard, appeared in 14% (3-19) of the documents. Pharmacological reversal was noted for 25% (4-67) of the patients; the assessment of the effects so produced was reported in 8% (0-58)., Conclusion: In the studied collection, the traceability of the peranaesthetic curarization management appears variable on both qualitative and quantitative levels. The emergence of a dedicated guideline - defining the criteria for producing a good documentation of the muscle relaxant use - becomes necessary to secure these practices for all physicians using muscle relaxants., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Suppression ratio (SR) derived from bispectral index (BIS) monitoring is correlated to EEG burst suppression. It may occur during deep anaesthesia, but also in the case of metabolic or haemodynamic brain injury. The goal of the study was to describe the occurrence of SR and to determine factors associated with SR during propofol-remifentanil general anaesthesia maintenance., Methods: We conducted a post hoc analysis of BIS recordings in consecutive patients included in two multi-centre trials, undergoing non-cardiac surgery using a dual closed-loop BIS controller allowing automated propofol-remifentanil administration. The percentage of time spent with a BIS value between 40 and 60 (T(BIS 40-60)) was measured. Two groups of patients were defined: the SR group, including patients with at least one episode of SR value >10% lasting more than 1 min, and the control group. Factors associated with SR were analysed using a stepwise multivariate analysis., Results: A total of 1494 patients [age=57 (17) yr; T(BIS 40-60)=76 (17%)] were analysed and 131 (8.7%) patients constituted the SR group. The main independent factors associated with SR were advanced age [odds ratio (95% confidence interval)=4.80 (1.85-12.43) (P=0.027), 10.59 (3.76-29.81) (P<0.0001), for categories of age 60-80 and >80 yr, respectively], history of coronary artery disease (CAD) [2.53 (1.47-4.37) (P=0.001)] and male gender [1.57 (1.03-2.40) (P=0.03)]., Conclusions: The occurrence of SR during BIS-controlled propofol and remifentanil anaesthesia is mainly observed in elderly male patients or in patients with a history of CAD. The mechanisms underlying SR and the potential consequences for the patient's postoperative outcome remain unsolved.

A 41-year-old woman suffering from a left cor triatrium, pregnant for the first time, was hospitalized for a caesarean section in the context of a pulmonary arterial hypertension with severe anaemia. The anaesthetic strategy which was decided on involved setting up a haemodynamic monitoring prior to induction of a general anaesthetia with etomidate, remifentanil and succinylcholine and maintained with propofol, sufentanil and cisatracurium. This strategy allowed the hemodynamic to be stabilized during the operation. The improvement of the arterial pulmonary hypertension immediately after coming out of the operating theatre allowed the patient to be briefly monitored in the intensive care unit and to be allowed home on the 10th day following the operation. The patient's cardiopathy was corrected in the 5th month after the birth., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Surgical drapes are a physical barrier between the surgical team's sterile working space (the operating field) and the non-sterile environment of the anaesthesia team and the nursing team within the operating theatre. Once the patient's position has been checked and the skin preparation has been done, they are put in place. They are usually opaque, leaving visible just the areas where the surgical and anaesthesia teams will be working. When the patient's position is changed perioperatively, malpositions may be unnoticed and cause complications. Using a transparent head drape allows one to check the position of the head and upper limbs at all times, thus reducing the risk of complications. It is a simple, easy, economic, non-restrictive method which will produce an improvement in the quality of patient care., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

We have previously reported the efficient conversion of lactose into 3'-sialyllactose by high cell density cultures of a genetically engineered Escherichia coli strain expressing the Neisseria meningitidis gene for alpha-(2-->3)-sialyltransferase [Fierfort, N.; Samain, E. J. Biotechnol. 2008, 134, 261-265.]. First attempts to use a similar strategy to produce 6'-sialyllactose with a strain expressing alpha-(2-->6)-sialyltransferase from the Photobacterium sp. JT-ISH-224 led to the production of a trisaccharide that was identified as KDO-lactose (2-keto-3-deoxy-manno-octonyllactose). This result showed that alpha-(2-->6)-sialyltransferase was able to use CMP-KDO as sugar donor and preferentially used CMP-KDO over CMP-Neu5Ac. By reducing the expression level of the sialyltransferase gene and increasing that of the neuABC genes, we have been able to favour the formation of 6'-sialyllactose and to prevent the formation of KDO-lactose. However, in this case, a third lactose derivative, which was identified as 6,6'-disialyllactose, was also produced. Formation of 6,6'-disialyllactose was mainly observed under conditions of lactose shortage. On the other hand, when the culture was continuously fed with an excess of lactose, 6'-sialyllactose was almost the only product detected and its final concentration was higher than 30g/L of culture medium., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to describe topographic variations in the arrangement of the four main brachial plexus nerves at the junction of the axilla and the upper part of the arm., Methods: In 153 patients undergoing upper arm surgery using axillary block, we studied nerve arrangements with a three-step approach, combining: (A) cross-sectional ultrasound imaging using a 12 MHz linear ultrasound probe; (B) distal shift of the ultrasound scanhead from the axilla to the elbow joint following the paths of individual nerves; and (C) identifying the distal motor response to electrical nerve stimulation of each nerve. These results were then converted into a 12-section pie chart with the axillary artery (AA) as the axis., Results: The order of the nerves around the AA was median, ulnar, radial, and musculocutaneous in all cases. The most frequent arrangement was observed in 65% of the patients. Five less frequent variations were observed in 4-20% of the patients, with four other variations seen in <2% of the patients. In 78% of the cases, the four nerves were seen separately using static ultrasound imaging. The musculocutaneous nerve was close to the artery in 18% of the patients., Conclusions: Topographic variations of the four main nerves at the axilla were found to be numerous, the most frequent arrangement being seen in less than two-thirds of the patients. Four separate nerves were seen on static ultrasound imaging at this sectional level of the axilla in only 78% of the cases.

Vulnerable individuals, lacking clear understanding, are difficult to inform about medical care and treatment. After a brief recall of the general principles of patient information and consent, we will discuss specific French law protection concerning patients under guardianship. The role in the global process of information and consent of either relatives or surrogate person, witnesses of the patient's views, will be described.

Objectives: Decrease acute pain after breast cancer surgery by an infiltration of ropivacaine. Analyse effect on chronic pain., Study Design: Prospective randomised double blind versus placebo study., Patients and Methods: Eighty-one patients randomised between two groups received wound infiltration with 40 ml of ropivacaine 4.75 mg/ml or placebo. Acute pain was assessed during 24h with analogical visual scale and antalgic consumption. One year later, telephonic interviews looked for chronic pain and evaluate it with McGill Pain Questionnaire., Results: Analogical visual scale pain score, antalgic consumption and chronic pain incidence were similar between groups., Conclusion: Ropivacaine scar infiltration provided no acute or chronic pain relief after breast cancer surgery.

After induction of anaesthesia for lumbar disc herniation surgery, an ASA-1, 39-year-old woman presented an acute heart failure. A persistent hypotension with tachycardia was observed after a brief hypertension peak during orotracheal intubation. After electrocardiogram, echocardiogram and biologic dosages, the diagnosis seems to be coronary ischemia. Coronarography was normal; takotsubo syndrome diagnosis was made with typical ventriculographic aspect. Evolution at two days and one month was favorable.

Four Humicola insolens Cel7B glycoside hydrolase mutants have been evaluated for the coupling of lactosyl fluoride on O-allyl N(I)-acetyl-2(II)-azido-beta-chitobioside. Double mutants Cel7B E197A H209A and Cel7B E197A H209G preferentially catalyze the formation of a beta-(1-->4) linkage between the two disaccharides, while single mutant Cel7B E197A and triple mutant Cel7B E197A H209A A211T produce predominantly the beta-(1-->3)-linked tetrasaccharide. This result constitutes the first report of the modulation of the regioselectivity through site-directed mutagenesis for an endoglycosynthase.

Postpartum haemorrhage remains a dangerous obstetrical complication, which is the main cause of maternal mortality in developing countries. The diagnosis must be immediate and its management is both medically and surgically in life-threatening haemorrhage. We present a case of a thirty-three-year-old woman who asked a pregnancy interruption for premature rupture of membranes at 21(th) gestational week for her second pregnancy; she underwent a caesarean section at term for her first pregnancy. She delivered vaginally and developed a postpartum haemorrhage with hemorrhagic shock which was resistant to medical, surgical and radiological management. We decided to use recombinant activated factor VII (rFVIIa, NovoSeven) as a final attempt to rescue the patient. During surgery, two intravenous bolus injections (60, 120 mug/kg) were successfully given with a control of bleeding and haemoglobin. The patient developed later a splenic thrombosis that can be related to either rFVIIa or to the hypovolemic shock or to the sepsis. Recombinant activated factor VII is an interesting and promising haemostatic agent in the management of life-threatening postpartum haemorrhage unresponsive to conventional treatment.

Background: Postpartum hemorrhage (PPH) is a major source of maternal morbidity., Objectives: This study's objective was to determine whether changes in hemostasis markers during the course of PPH are predictive of its severity., Patients and Methods: We enrolled 128 women with PPH requiring uterotonic prostaglandin E2 (sulprostone) infusion. Two groups were defined (severe and non-severe PPH) according to the outcome during the first 24 hours. According to our criteria, 50 of the 128 women had severe PPH. Serial coagulation tests were performed at enrollment (H0), and 1, 2, 4 and 24 hours thereafter., Results: At H0, and through H4, women with severe PPH had significantly lower fibrinogen, factor V, antithrombin activity, protein C antigen, prolonged prothrombin time, and higher D-dimer and TAT complexes than women with non-severe PPH. In multivariate analysis, from H0 to H4, fibrinogen was the only marker associated with the occurrence of severe PPH. At H0, the risk for severe PPH was 2.63-fold higher for each 1 gL(-1) decrease of fibrinogen. The negative predictive value of a fibrinogen concentration >4 gL(-1) was 79% and the positive predictive value of a concentration

In the absence of thromboprophylaxis, coronary artery bypass graft surgery (CABG), intrathoracic surgery (thoracotomy or video-assisted thoracoscopy), abdominal aortic surgery and infrainguinal vascular surgery are high-risk surgeries for the development of venous thromboembolic events (VTE). The incidence of VTE following surgery of the intrathoracic aorta, carotid endarterectomy or mediastinoscopy is unknown. Data from the litterature are lacking to draw evidence-based recommandations for venous thromboprophylaxis after these three types of surgeries, and the following guidelines are but experts'opinions (Grade D recommendations). Thromboprophylaxis is recommended after CABG (Grade D), with either subcutaneous (SC) low molecular weight heparin (LMWH) or SC or intravenous (i.v.) unfractioned heparin (UH) (PTT target = 1.1-1.5 time control value) (both grade D). This may be combined with the use of intermittent pneumatic compression device (Grade B). After valve surgery. The anticoagulation recommended to prevent valve thrombosis is sufficient in order to prevent VTE. We recommend thromboprophylaxis with either LMWH or low dose UH to prevent VTE after aortic or lower limbs infrainguinal vascular surgery (both grade B and D). Vitamine K antagonists (VKA) are not recommended in this indication (Grade D). We recommend thromprophylaxis following intrathoracic surgery via thoracotomy or videoassisted thoracoscopy (grade C). Either subcutaneous LMWH or subcutaneous or i.v. low dose UH may be used (Grade C). Efficacy of intermittent pneumatic compression device has been demonstrated in a study (grade C). VKA are not recommended (grade D). No further recommendation regarding the duration of thromboprophylaxis after these three types of surgeries can be made.

Objective: To evaluate the use of mannitol in prehospital care in Paris area., Study Design: Survey using telephone interviews., Methods: Emergency physicians on duty in the 37 emergency departments in charge of prehospital care in Paris area were called by one investigator. They were asked to answer a questionnaire about their own use of mannitol in the prehospital setting., Results: Ninety-six questionnaires were recorded. Physicians were anaesthesiologists (9%) or emergency physicians (87%). In three departments, mannitol was not available in the ambulances. Thirty-five per cent (n = 34) reported no use of mannitol and 17% (n = 16) just once. Fourteen physicians (15%) did not want to use it. The reasons for not using mannitol were lack of knowledge about efficacy for five, need for previous brain imaging for seven or neurosurgeon's agreement before using mannitol for three. For those who had already used mannitol or were ready to use it, the main indication was increased intracranial pressure with clinical signs of brain herniation after severe brain injury for 92% of physicians. Thirty-one % reported not knowing the dose of mannitol, 33% having a memorandum immediately available and among those who answered the question, 63% gave a value compatible with guidelines., Conclusion: A significant percentage of physicians tacking part in the French prehospital care system, do not follow published guidelines on the use of mannitol. Actions improving implementation of those guidelines should be supported.

Objective: The purpose of this study was to compare the surgical outcomes of women undergoing vaginal hysterectomy with and without morcelation., Patients and Method: Between December 1999 and December 2000, 216 women underwent vaginal hysterectomy without laparoscopic assistance at the Department of Gynecology of Hôtel-Dieu hospital in Paris. The patients were divided into two groups: 114 of them underwent vaginal hysterectomies with morcelation whereas 102 underwent vaginal hysterectomies without morcelation. The two groups were compared as to demographic data, total complications, operative time, hospital stay length and peri-operative hemoglobin concentration change., Results: Although women undergoing morcelation were significantly younger (mean 49 versus 52, p = 0.01) and less parous (mean 1.9 versus 2.3, p = 0.03), there were no significant differences in other surgical or anesthetic risks factors, including weight, BMI, nulliparity and preexisting surgical diseases. Mean uterine weight was significantly greater in those undergoing morcelation (331 versus 110 g, p < 0.001); operative time was increased in the group which had undergone morcelation (331 versus 110 g, p < 0.001). There were no significant differences between the two groups with respect to peri-operative hemoglobin concentration change or hospital stay length. Finally, the rate of surgical complication was similar in the two groups (17.5 versus 21.5%)., Conclusion: Although vaginal hysterectomy requires an increase in operative time, morcelation at the time of vaginal hysterectomy is safe and facilitates the vaginal removal of enlarged uteri without increasing peri-operative morbidity.

Objectives: To compare the rate of preoxygenation before induction of anesthesia in patients with no lung disease and in patients with chronic obstructive pulmonary disease (COPD)., Patients and Methods: End-tidal fractional oxygen concentration (FEO2) was monitored using a paramagnetic oxygen analyzer, during a 5 minute-period of preoxygenation (tidal breathing of 100% oxygen) in 16 control patients (control group) and in 15 patients with COPD. COPD was defined and its severity was characterized by clinical criteria and by respiratory functional tests. FEO2 increase was compared between groups using Anova., Results: The increase in FEO2 was slower in the COPD group than in control group (p < 0.05). After 2 and 3 minutes of preoxygenation, FEO2 was significantly lower in COPD group as compared to control group, but was not different at 5 minutes. Mean time to reach a FEO2 equal to 0.90 was significantly longer in COPD than in control group (COPD: 261 +/- 130 s; control: 165 +/- 90 s, p < 0.05). SpO2 measured during room air breathing was moderately lower in COPD group, but this difference was no more significant after 30 s of preoxygenation (SpO2 after 30 s: control: 98.8 +/- 1.0%; COPD: 98.2 +/- 1.9%, NS)., Conclusion: These results suggest that preoxygenation monitoring may be useful in patients with COPD, to ensure adequate preoxygenation is achieved.

We report an unusual electromagnetic interference induced by an argon electrocautery device during a left hepatectomy on a dual chamber pacemaker, implanted for sinus node dysfunction in 87-year-old patient. Argon electrocautery induced inhibition of atrial stimulation and occurrence of irregular ventricular triggered activity. Normal pacemaker function resumed after electrocautery interruption. This case illustrates the need to focus on cardiac rhythm when a new electrical device is used in a pacemaker patient.

Purpose: We assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) task force guidelines for perioperative cardiac evaluation could reliably stratify cardiac risk before aortic surgery., Methods: We retrospectively applied the guidelines to a closed database, set up prospectively. The setting was a referral center in an institutional practice with hospitalized patients. The closed database included 133 patients who had a routine cardiac examination, which comprised an estimation of functional capacity and noninvasive testing, before aortic surgery. This cardiac evaluation led to the proposal of coronarography in 23 patients and to treating an underlying coronary artery disease in 21 patients (including three myocardial revascularizations). One patient died after myocardial revascularization, and two patients died of cardiac causes after aortic surgery. The algorithm of the ACC/AHA guidelines was applied independently by two investigators to each patient's file that was included in the existing database. The main outcome measure was a comparison between cardiac risk stratification with the ACC/AHA guidelines and the results of the routine cardiac evaluation., Results: The ACC/AHA guidelines were successfully applied to all 133 files by the two investigators. After applying the algorithm, 73 patients were stratified as low cardiac risk, and 60 patients were stratified as high risk. The 21 patients who had undergone a preoperative coronary artery disease optimization were stratified as high risk by means of the ACC/AHA guidelines. The patients who died from cardiac causes were stratified as high risk by means of the ACC/AHA guidelines, whereas none of the patients stratified as low risk died during hospitalization., Conclusion: The ACC/AHA guidelines were effective in stratifying cardiac risk by using clinical predictors and an estimate of the physical capacity of the patient. Their use may allow a reduction in unnecessary noninvasive testing in patients stratified as being at low risk, while permitting the selection of all patients likely to benefit from preoperative coronary artery disease optimization.

The risk of interference with anaesthesia and the risk of decompensation of the disease must be considered for each drug. Beta-blockers reduce the body's capacity to react to hypovolaemia, but they are beneficial by limiting the response to nociceptive stimuli and by reducing the incidence of myocardial ischaemia. Treatment should therefore be continued. Interferences with the dihydropyridine class of calcium channel blockers on peripheral vasomotor activity are moderate and additive. These agents are well tolerated and can be continued until the operation. Verapamil and diltiazem have a chronotropic and negative inotropic effect which is additive with that of anaesthetics. Administration of these drugs before the operation does not raise any major problems, nor does their discontinuation. Angiotensin-converting enzyme (ACE) inhibitors, used in hypertension and heart failure, considerably reduce the tolerance of factors modifying the blood pressure equilibrium, especially hypovolaemia or haemorrhage. In practice, ACE inhibitors carry a risk of intraoperative hypotension, requiring the use of vasopressor amines to maintain blood pressure. Continuation of treatment has only minimal advantages, regardless of the indication and there is no risk of rebound effect after stopping treatment. The treatment washout period depends on the duration of action of the product. However, discontinuation of treatment is never imperative, regardless of the context.

The aim of this prospective, placebo-controlled study was to assess if unilaterally inhaled nitric oxide 20 ppm could treat hypoxaemia during one-lung ventilation. Sixty patients undergoing pulmonary resection using a lateral thoracotomy were allocated randomly to a control or nitric oxide group (NO group). During one-lung ventilation in the lateral decubitus position, the lungs were ventilated mechanically with 90% oxygen--10% nitrogen. After randomization, if PaO2 decreased to less than 9.3 kPa during one-lung ventilation, nitric oxide 20 ppm or nitrogen was added to the inspired gas. The criterion for treatment efficacy was an increase in PaO2 to greater than 9.3 kPa after gas administration. Eight patients in the control group and eight in group NO experienced hypoxaemia during one-lung ventilation. PaO2 was not significantly different in the two groups at the time of gas administration (control group mean 8.0 (SD 0.6) kPa; NO group 8.5 (0.5) kPa). The efficacy criterion was reached in two of eight patients in the control and NO groups. The results of this study showed that inhaled nitric oxide 20 ppm, administered in the dependent lung, was not superior to nitrogen in the treatment of hypoxaemia during one-lung ventilation. Nitric oxide should not be recommended as an alternative to conventional management of hypoxaemia in this condition.

A unilateral areactive mydriasis occurred in a 49-year-old ASA I woman after a coelioscopic procedure while anaesthesia was maintained for an associated procedure. The various causes of brain stem damage were considered. The inability to perform a complete neurologic assessment resulted in the indication of a cerebral computerised tomography (CT) scan. The diagnosis of Adie's tonic pupil was made a posteriori, taking into consideration: 1) complete recovery without neurologic deficit; 2) unremarkable CT scan; 3) previous transient episodes of unilateral areactive mydriasis.

Cultivation of Escherichia coli harbouring heterologous genes of oligosaccharide synthesis is presented as a new method for preparing large quantities of high-value oligosaccharides. To test the feasibility of this method, we successfully produced in high yield (up to 2.5 g/L) penta-N-acetyl-chitopentaose (1) and its deacetylated derivative tetra-N-acetyl-chitopentaose (2) by cultivating at high density cells of E. coli expressing nodC or nodBC genes (nodC and nodB encode for chitooligosaccharide synthase and chitooligosaccharide N-deacetylase, respectively). These two products were easily purified by charcoal adsorption and ion-exchange chromatography. One important application of compound 2 could be its utilisation as a precursor for the preparation of synthetic nodulation factors by chemical acylation.

Conditions for the large-scale (molar) oxidation of sucrose by Agrobacterium tumefaciens were improved, thus leading to homogeneous solutions of 3-ketosucrose in 40% yield. Treatment of this solution with hydroxylamine or methoxylamine afforded the corresponding oximes 3a and 3b (isolated as acetates) in excellent yield. Dissolving-metal reduction of these oximes gave mixtures of amino disaccharides in which the gluco epimer (3-amino-3-deoxysucrose) was predominant. A more efficient approach to this amino sucrose was provided by the highly stereoselective hydrogenation of 3-ketosucrose peracetate (7), which gave exclusively the allo isomer 8 (2,4,6-tri-O-acetyl-alpha-D-allopyranosyl 1,3,4,6-tetra-O-acetyl-beta-D-fructofuranoside). Upon reaction with lithium azide, the triflate derived from 8, compound 9, afforded 3-azido-3-deoxysucrose peracetate (10) which was converted into 3-amino-3-deoxysucrose (12). The reaction of triflate 9 with potassium ethylxanthate led to a mixture of products (the expected 3-S-ethoxythiocarbonyl-3-thiosucrose derivative and the peracetates of 3-thiosucrose and of 3-thiosucrose disulfide), which could be all converted into 3-thiosucrose (17). Sucrose analogues 12 and 17 were not substrates of dextransucrases from various strains of L. mesenteroides, nor did they participate in glycosyl transfer reactions to an acceptor (maltose). Compounds 3a and 12 were found to be strong competitive inhibitors of the dextran synthesis process (dextransucrase from strain B-1397). These results indicate that 3a and 12 compete effectively with sucrose for the sucrose binding site but are unable to participate as glycosyl donors in the polymerization or glycosyl-transfer processes.

Propofol ensures a calm and rapid induction of anaesthesia in case of planned cardioversion for supraventricular arrhythmia. An appropriate level of anaesthesia is obtained with a dose of 1.4 to 2 mg.kg-1. Propofol does not affect the success rate of cardioversion. However, given as a bolus injection, it causes a more pronounced decrease in blood pressure than other induction agents and the rate of apnoea is higher. The incidence of these adverse effects may be reduced by slowly titrating the dose. The frequent association with cardiac disease, in particular valvular disease or coronary insufficiency, should be taken into account and may represent a contra-indication for the administration of propofol. Furthermore, administration of this agent is not indicated if the arrhythmia is poorly tolerated, because of the risk of increasing hypotension. The known advantages of propofol on recovery have no significant role in this indication.