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In March 2020, the intensive care unit of the French military teaching hospital Bégin (Saint-Mandé) had to make profound changes to deal with the first COVID-19 epidemic wave. First, the twelve beds of the intensive care unit (ICU) were allocated to COVID-19 patients, among them four beds usually dedicated to postoperative care. Then, on the model of the military medical-surgical facilities rolled out in external operations, a new transient intensive care unit was set up in Bégin within four days. This strategy of increasing capacities had to address a crucial challenge: to ensure safe and quality health care with limited resources. Based on precise specifications and an essential strengthening of staff and supplies, 20 additional ICU care rooms were fully equipped in the cardiology department of the hospital. Eventually, 32 ICU beds were available from March 20, performing a 300% increase in bed capacities. During the whole epidemic wave, 113 patients were managed. The evacuation of 16 stable patients with medicalized trains toward less impacted French regions helped to avoid saturation. The service has also been involved in various research activities, including the DisCoVeRy European clinical trial evaluating the effectiveness of several antiviral treatments. Leaving the operating room and the post-interventional surveillance room partially functional made it possible to quickly resume the elective surgical activity after the crisis, while keeping the transient ICU available in case of an epidemic rebound, as happened in the autumn of 2020, then in the spring of 2021.

Introduction La survenue de formes severes ou critiques de COVID-19, avec necessite d’une hospitalisation en reanimation, est associee a la presence d’anticorps anti-Interferon de classe I dans environ 10 % des cas [1] . Ces anticorps identifies dans le contexte de la COVID-19 bloquent les molecules d’interferon (IFN) et expliqueraient chez ces patients, la survenue d’une atteinte grave de COVID-19, avec une absence d’elimination precoce du virus SARS-CoV-2. Ainsi, il s’agirait d’une forme de deficit immunitaire, acquis, dirige contre le virus SARS-CoV-2 mais aussi potentiellement contre d’autres virus. Les caracteristiques cliniques, biologiques et morphologiques des patients presentant ces anticorps n’ont pas ete decrites precisement, l’evolution des patients n’est pas connue. Patients et methodes Une recherche d’anticorps anti-Interferon a ete realisee chez des patients ayant ete pris en charge en reanimation a l’hopital Begin, a l’hopital Avicenne et a l’hopital Foch pour une COVID-19. La presence d’anticorps anti-IFNalpha2 et anti-IFNomega etaient recherchee par test ELISA puis confirmee par un test fonctionnel d’inhibition de la phosphorylation de STAT1. Les caracteristiques cliniques des patients ont ete relevees a partir des dossiers medicaux. Un suivi medical a ete organise afin de suivre leur evolution sur le plan clinique, biologique et morphologique. Resultats Onze patients ont ete identifies. Il s’agissait de 11 hommes. L’âge median au diagnostic etait de 60 ans (min 36 - max 80). Parmi les autres facteurs de risques de COVID-19 grave classiquement identifies, on retrouvait chez eux, du diabete pour 1 patient, de l’hypertension arterielle pour 6 patients et de l’obesite (IMC > 30 kg/m2) pour 5 patients. L’IMC median etait de 29,8 kg/m2 (min 24 - max 32,8). Il n’etait pas note d’antecedent remarquable, notamment pas d’argument pour un deficit immunitaire, pas d’endocrinopathie auto-immune. On retrouvait 1 BPCO, 2 asthmes, 1 coronaropathie et 1 valve aortique mecanique. Au diagnostic de COVID-19, les signes cliniques initiaux habituels de l’infection etaient retrouves : asthenie (n = 11), fievre (n= 10), toux (n = 5). Deux patients presentaient des diarrhees et 2 de l’insuffisance renale aigue, moderee. Chez 2 patients, on notait une embolie pulmonaire sur le scanner initial. L’evolution etait marquee par une aggravation justifiant une admission en reanimation apres une mediane de 7 jours (min 3 - max 12), pour une forme severe chez 2 patients avec au maximum une oxygenotherapie au masque a haute concentration jusqu’a 15L/min pour 1 patient et 4L/min pour 1 autre. Une forme critique survenait chez 9 patients, avec recours a une intubation oro-tracheale pour ventilation mecanique pour 7 cas, une oxygenotherapie nasale a haut debit (OPTIFLOW) etait suffisante dans 2 cas. Des pneumopathies bacteriennes documentees necessitaient une antibiotherapie specifique dans 6 cas. Dans 10 cas, des traitements a visee specifique du COVID-19 etaient entrepris : corticotherapie (n = 4), hydroxychloroquine (n = 4), lopinavir/ritonavir (n = 3) et tocilizumab (n = 2). En raison du developpement d’un SDRA severe, des seances d’optimisation de l’oxygenotherapie par decubitus ventral etaient entreprises chez 5 patients, avec necessite d’un recours a une ECMO veno-veineuse pour le jeune patient de 36 ans. Afin d’eliminer les Ac antiIFN, ce dernier a egalement beneficie avec succes de 3 seances d’echanges plasmatiques. Au total, 9 patients ont survecu, la duree mediane d’hospitalisaiton en reanimation etait de 16 jours (min 2 - max 31). Les 2 deces sont intervenus apres limitation therapeutique pour SDRA refractaire. Avec un suivi median de 4,2 mois (min 1 - max 11,2), on note une bonne evolution chez l’ensemble des patients survivants, aucune reinfection n’a ete observee et une regression quasi complete des lesions pulmonaires scanographiques (n = 4/5) etait retrouvee a 3 mois. Lors du dernier bilan realise, il n’etait pas constate d’anomalie de la NFS (n = 7/8), ni syndrome inflammatoire (n = 6/7) et le taux d’immunoglobulines etait normal (4/4). Conclusion Cette serie de cas donne une premiere description des patients ayant presente une forme critique de COVID-19 avec Ac anti-IFN de classe I. En dehors de la faible prevalence de comorbidites, il ne semble pas y avoir de phenotype clinique particulier chez cette population en dehors de la predominance masculine.

Introduction Le Levetiracetam (LEV) est indique chez le patient epileptique dans le traitement des crises partielles avec ou sans generalisation secondaire chez l’adulte. Le LEV, comme tous les medicaments antiepileptiques (MAE), est pourvoyeur d’effets indesirables psychiatriques, si les effets secondaires principalement decrits et connus sont psycho-comportementaux : insomnie, irritabilite… ce qui autorise un ajustement ambulatoire, les manifestations psychiatrique aigues severes et bruyantes, telles que les episodes maniaques, les crises suicidaire ou les episodes psychotiques sont plus rares et entrainent hospitalisations et morbi-mortalites importantes qu’il convient de prevenir. Ces episodes ne sont pas bien decrits dans la litterature et les facteurs de risque de survenue de ces effets iatrogenes ne sont pas connus. Suite a la survenue d’un episode severe chez un patient hospitalise a l’hopital Begin, nous avons souhaite decrire les cas francais rapportes dans la base nationale de pharmacovigilance. Patients et methodes Dans cette etude retrospective, multicentrique, les cas de patients ayant presente une manifestation psychiatrique aigue et bruyante induite par le LEV etaient declares a l’un des 31 centres de pharmacovigilance de France. Les donnees ont ete recueillies apres interrogation de la base nationale de pharmacovigilance (BNPV) par le centre regional de pharmacovigilance (CRPV) de Paris-Creteil. La periode investiguee s’etalait du 1/01/2000 au 1/06/2019. Quatre operateurs ont relu en aveugle, de maniere retrospective les dossiers en verifiant les criteres d’inclusions et en appliquant les criteres d’exclusions. En cas de donnees manquantes, les CRPV etaient contactes pour completer les dossiers. Les dossiers incomplets ne permettant pas le calcul du score de Naranjo ont ete egalement exclus. Resultats L’interrogation de la BNPV a permis l’extraction initiale de 153 cas selon nos criteres d’inclusions. L’analyse selon les criteres d’exclusion par les differents operateurs a permis de ne retenir que 25 dossiers pertinents et complets pour notre serie de cas, avec un score de Naranjo median de 7 (imputabilite probable). Vingt-cinq patients d’âge median de 46 ans ont donc ete inclus, avec une majorite d’hommes (56 %). Onze patients avaient des antecedents psychiatriques (bipolarite, trouble de l’usage de l’alcool, depression, schizophrenie). L’observation detaillee de ces manifestations psychiatriques aigues et bruyantes permet de definir quatre grands tableaux psychiatriques selon DSM V : symptomes psychotiques (n = 6), symptomes maniaques (n = 1) symptomes d’agitations (n = 17) : auto-hetero, crise suicidaire (n = 10). La majorite des effets secondaires psychiatriques surviennent lors de l’introduction du LEV (67 %) a posologie mediane de 1 g/J. Le temps moyen d’apparitions des symptomes est de 14,6 jours (min 1 - max 60). La duree moyenne des symptomes est de 15,5 jours (min 1 - max 30). Dans 48 % des cas, on note un arret du traitement et un remplacement par un autre MAE est mis en place chez 44 % des patients. Seuls 8 % ont beneficie d’une diminution de dose. Conclusion Nos resultats et une revue de la litterature confirment l’histoire psychiatrique comme un des principaux facteur predictifs et permet de definir un profil a risque de developper des effets secondaires psychiatriques selon des tableaux specifiques.

Introduction Nous rapportons l’observation d’une patiente avec hyperparathyroidie primitive ancienne non traitee, admise aux urgences pour hypercalcemie majeure. Observation Une patiente de 72 ans presentant une hyperparathyroidie primitive depuis 8 ans etait admise aux urgences pour hypercalcemie majeure et asthenie au long cours. Le bilan biologique aux urgences notait : calcium serique > 7,5 mmol/L (2,2–2,5), albumine = 44,8 g/L, calcium ionise = 2,48 mmol/L (1,15–1,29), phosphates 1,01 mmol/L (0,81–1,45), PTH = 2805 ng/L (15–65), vitamine D (25OHD3) = 6 μg/L. L’echographie cervicale notait un volumineux adenome parathyroidien P3 gauche iso- et hypoechogene richement vascularise avec une portion kystique. La cytoponction montrait des atypies de signification indeterminee, voire suspectes de malignite. La PTH in situ etait significative, dosee a 2198 ng/L. Apres un traitement par hydratation et diphosphonates, la patiente etait operee, permettant de retirer un nodule parathyroidien gauche unique benin de 3 cm, restaurant rapidement une calcemie normale, sans hungry bone syndrome. Le scanner thoraco-abdomino-pelvien notait des lesions osteolytiques iliaques, dont les 2 plus notables etaient mesurees a 2,3 cm et 2,8 cm. Ces lesions correspondaient a des tumeurs brunes qui n’ont pas ete biopsiees compte tenu du contexte clinique tres evocateur. Discussion L’hyperparathyroidie primitive entraine une hypercalcemie chronique qui peut etre longtemps bien toleree, malgre un calcium tres eleve. Les tumeurs brunes sont des lesions benignes correspondant a des osteites fibro-kystiques, resultant d’une anomalie du metabolisme osseux dans le cadre d’une hyperparathyroidie primaire, secondaire ou tertiaire. Elles surviendraient dans 2 a 5 % des hyperparathyroidies primitives et 1,5 a 1,7 % des hyperparathyroidie secondaire.

International audience; An outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae (ESBL-ECL) occurred in our intensive care unit (ICU) and involved 18 patients (8 infected and 10 colonized). The mean age of patients was 69 years, and all infected patients had underlying medical conditions. Within hours' recognition of the spread of ESBL-ECL, the infection control team requested for staff education, reinforcement of infection control measures, and environmental screening. New transmissions were observed in the institution after weeks of enhanced infection control measures. Microbial swabbing revealed bacterial contamination of some mattresses and syphons with epidemiologic links between environmental, screening, and clinical isolates. This outbreak resulted in the temporary closure of the ICU for complete biocleaning.

International audience; OBJECTIVE:The clinical characteristics and prognosis of patients treated for Candida peritonitis (CP) were compared according to the type of systemic antifungal therapy (SAT), empiric (EAF) or targeted (TAF) therapies, and the final diagnosis of infection.METHODS:Patients in intensive care units (ICU) treated for CP were selected among the AmarCAND2 cohort, to compare patients receiving EAF for unconfirmed suspicion of CP (EAF/nonCP), to those with suspected secondarily confirmed CP (EAF/CP), or with primarily proven CP receiving TAF.RESULTS:In all, 279 patients were evaluated (43.4% EAF/nonCP, 29.7% EAF/CP and 25.8% TAF patients). At SAT initiation, the severity of illness was similar among EAF/nonCP and EAF/CP patients, lower among TAF patients (median Simplified Acute Physiology Score II (SAPS II) 49 and 51 versus 35, respectively; p 0.001). Candida albicans was involved in 67%, Candida glabrata in 15.6%. All strains were susceptible to echinocandin; 84% to fluconazole. Echinocandin was administered to 51.2% EAF/nonCP, 49% EAF/CP and 40% TAF patients. At day 28, 72%, 76% and 75% of EAF/nonCP, EAF/CP and TAF patients, respectively, were alive. An increased mortality was observed in patients with a Sequential Organ Failure Assessment (SOFA) score

L’intubation trachéale est une technique de réanimation qui s’impose dans deux situations : la nécessité d’administrer de l’oxygène et de ventiler des patients souffrant d’insuffisance respiratoire et pour lesquels un mode de ventilation invasif est requis, et toutes les situations dans lesquelles la protection des voies aériennes supérieures n’est plus assurée. Depuis la préhistoire, l’homme a bien compris que l’arrêt de la respiration entraînait le décès. D’Hippocrate dans l’antiquité qui émettait les premières recommandations d’intubation, à nos sociétés savantes aujourd’hui, l’histoire de l’accès aux voies aériennes est ponctuée de nombreux rebondissements, souvent en lien avec les croyances religieuses, l’évolution de la science, et le contexte politique. Au fil des siècles, la recherche et les hommes ont permis le développement de techniques et de matériaux de plus en plus performants, afin de sécuriser ce geste salvateur qu’est l’intubation trachéale.

La utilizacion de la anestesia locorregional (ALR) se recomienda siempre que sea posible, como complemento de las tecnicas de analgesia clasica, en el contexto de un tratamiento multimodal del dolor. Desde este punto de vista, los bloqueos de la pared abdominal tienen un amplio campo de actuacion, debido a la frecuencia e intensidad del dolor postoperatorio. El plano transverso del abdomen, o TAP, esta situado entre los musculos oblicuo interno y transverso. A este nivel discurren, entre otras estructuras, los ramos de los nervios intercostales T9-T12 y de la primera raiz lumbar L1. El interes clinico del bloqueo TAP se ha demostrado en estudios aleatorizados con doble anonimato, despues de intervenciones de colectomia, histerectomia y cesarea. Otros muchos estudios y casos clinicos sugieren la utilidad de este bloqueo en toda la cirugia abdominal infraumbilical, sobre todo en la cirugia urologica y herniaria. Aparte de la herniorrafia umbilical simple, este bloqueo ofrece una analgesia excelente, pero no proporciona una anestesia quirurgica. La identificacion del TAP, mediante referencias anatomicas, en el triangulo de Petit es aleatoria y no garantiza la seguridad suficiente. El ecoguiado permite visualizar el TAP y controlar en directo la inyeccion de anestesicos locales: este bloqueo se realiza con total seguridad y con una tasa de exito muy elevada. Debido a ello, durante los ultimos anos, la aparicion de la ecografia ha motivado un gran auge del bloqueo TAP. El aprendizaje de esta tecnica ecoguiada es facil y rapido y se basa en un conocimiento simple de la inervacion de la pared abdominal y de la organizacion de los distintos planos musculares.

L’utilizzo dell’anestesia locoregionale (ALR) e raccomandato tutte le volte possibili, a complemento delle tecniche di analgesia classica, nell’ambito di una gestione multimodale del dolore. In quest’ottica, i blocchi della parete addominale hanno un grande campo di azione, tenuto conto della frequenza e dell’intensita dei dolori postoperatori. Il transversus abdominis plane, o TAP, corrisponde al piano situato tra i muscoli obliquo interno e trasverso. A questo livello, decorrono, tra gli altri, dei rami nervosi dei nervi intercostali T9-T12 e della prima radice lombare L1. L’interesse clinico del TAP block e stato ben validato da studi randomizzati in cieco, dopo colectomia, isterectomia e cesareo. Numerosi altri studi e casi clinici suggeriscono l’interesse di questo blocco in tutta la chirurgia addominale sottombelicale, in particolare nella chirurgia urologica ed erniaria. Al di fuori dell’erniorrafia ombelicale semplice, questo blocco permette di assicurare un’eccellente analgesia, ma non procura un’anestesia chirurgica. L’identificazione del TAP, attraverso i reperi anatomici, nel triangolo di Petit, e aleatoria e non garantisce una sicurezza adeguata. L’ecoguida permette di visualizzare il TAP e di controllare in diretta l’iniezione di anestetici locali : questo blocco e realizzato in tutta sicurezza e con un tasso di successo molto elevato. Per questo motivo, negli ultimi anni, l’avvento dell’ecografia ha generato uno sviluppo importante del TAP block. L’apprendimento di questa tecnica ecoguidata e facile e rapido e si basa su una conoscenza semplice dell’innervazione della parete addominale e dell’organizzazione dei differenti piani muscolari.

Le anestesie perimidollari sono oggi ampiamente diffuse e costituiscono la tecnica di riferimento dell’analgesia ostetrica e dell’anestesia per molte chirurgie, in particolare per le chirurgie ginecologica, urologica e digestiva. Tuttavia, la morbilita secondaria all’anestesia perimidollare non e trascurabile. L’avvento dell’ecografia ha rivoluzionato la pratica dell’anestesia locoregionale, permettendo la visualizzazione dei nervi e dei plessi nervosi. L’ecografia e, oggi, poco utilizzata per la realizzazione dei differenti gesti perimidollari, sia per l’anestesia che per la diagnosi (puntura lombare), mentre e in grado di apportare delle informazioni per il medico. Nel corso degli ultimi 10 anni, molti studi hanno precisato il suo interesse in differenti situazioni cliniche. L’ecografia perimidollare permette di individuare con precisione il livello della puntura e l’orientamento da dare all’ago e di misurare la distanza tra la cute e il legamento giallo. Tali informazioni sono incontestabilmente in grado di migliorare la realizzazione e, quindi, la sicurezza dei gesti perimidollari. Lo scopo di questo capitolo e quello di descrivere la realizzazione pratica dell’ecografia perimidollare e di esporne i principali interessi. Questa tecnica e particolarmente utile nelle due situazioni cliniche costituite dall’obesita e dalla scoliosi.

The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.

Hereditary and acquired angioedema (HAE/AAE) are the clinical translation of a qualitative or a quantitative deficit of C1 esterase inhibitor (C1 INH). The frequency and severity of clinical manifestations vary greatly, ranging from a moderate swelling of the extremities to obstruction of upper airway. Anaesthesiologists and intensivists must be prepared to manage acute manifestations of this disease in case of life-threatening laryngeal edema. Surgery, physical trauma and labour are classical triggers of the disease. The anaesthesiologists should be aware of the drugs used as prophylaxis and treatment of acute attacks when considering labour and caesarean section. Androgens are contraindicated during pregnancy. If prophylaxis is required, tranexamic acid may be used with caution. The safest obstetric approach appears to be to administer a predelivery infusion of C1 INH concentrate. It is important to avoid manipulation of the airway as much as possible by relying on regional techniques. We report the case of a patient suffering from an HAE discovered during pregnancy. The management included administration of C1 INH during labor and early epidural analgesia for pain relief. A short review of the pathophysiology and therapeutic options follows.

Background Reoperation for persistent primary hyperparathyroidism is often performed after a delay of 4–6 months. Success can be expected in over 90 per cent of cases but exploration is technically difficult and there is the possibility of creating permanent hypoparathyroidism and vocal cord paralysis. This is a study of early localization and reoperation. Methods In a consecutive series of 273 patients who had surgery for primary hyperparathyroidism, three remained hypercalcaemic and in three the abnormal parathyroid was not found at initial exploration. They underwent early (6.48 h) single-tracer 99mTc Sestamibi scintigraphy with factor analysis of dynamic structures (FADS) and single photon emission computed tomography (SPECT) followed by reoperation within 24–72 h. Results Scintigraphy with FADS and SPECT was helpful in all six patients, who were cured by reoperation with no morbidity or symptomatic hypocalcaemia. Conclusion Reoperation for persistent primary hyperparathyroidism is possible and may be easier within days of an initially unsuccessful procedure. With the intact 1–84 parathyroid hormone measurement, the diagnosis is accurate. Single-tracer 99mTc Sestamibi scintigraphy with FADS and SPECT is non-invasive, easily and rapidly performed, and was accurate in these six patients.

To elucidate the structure of a degradation product arising from a lyophilized formulation of a cyclic heptapeptide, and to provide a mechanism to account for its formation.Preparative HPLC was used to isolate the degradate in quantities sufficient for structural studies. A structure assignment was made on the basis of the compounds spectroscopic properties (UV, MS, NMR) and the results of amino acid analysis.The degradate was identified as a benzaldehyde derivative arising from the oxidative deamination of an aminomethyl phenylalanine moiety. The extent of formation of this product is influenced by the amount of mannitol used as an excipient in the formulation. A mechanism is proposed whereby reducing sugar impurities in mannitol act as an oxidizing agent via the intermediacy of Schiff base adducts which subsequently undergo tautomerization and hydrolysis.Reducing sugar impurities in mannitol are responsible for the oxidative degradation of the peptide via a mechanism that involves Schiff base intermediates. This mechanism may be a potential route of degradation of other arylmethyl amines in mannitol-based formulations.

The authors report their experience with treatment of primary hyperparathyroidism in a series of 1496 patients (September 1991). The clinical profile of the disease has changed in the past few years, incomplete or even asymptomatic forms of the disease are now more common. The results of treatment have considerably improved (99% cure rate), progress is essentially due to two factors: surgeons have gained in experience and diagnostic errors have disappeared thanks to the reliability of laboratory tests and hormone level determination.

A retrospective study was performed in chronic hemodialysis patients comparing total parathyroidectomy (PTX) followed by immediate autografting (IA) (total PTX+IA) with subtotal parathyroidectomy (subtotal PTX). One hundred six patients with severe, uncontrolled hyperparathyroidism were referred to this center and underwent surgery during the period from 1980 to 1990. Long-term follow-up after PTX was available in 49 of them: 28 patients had total PTX+IA and 21 had subtotal PTX. The two surgical methods were evaluated with respect to preoperative severity of hyperparathyroidism, immediate postoperative results, and long-term parathyroid status, as evaluated by an RIA measuring intact immunoreactive parathyroid hormone (intact iPTH; normal values, 15 to 65 pg/mL). The initial degree of hyperparathyroidism was comparable in the two groups. An excellent short-term control of hyperparathyroidism was achieved in the great majority (95%) of patients with either surgical procedure. However, long-term normalization of parathyroid gland activity was achieved in only one third of patients whereas 33% had elevated intact iPTH levels (> 130 pg/mL; i.e., higher than twice the upper range of normal) and 32% had low intact iPTH levels (< 15 pg/mL), consistent with permanent hypoparathyroidism. No difference was found in the immediate failure rates: 0 of 28 cases after total PTX+IA compared with 2 of 21 cases after subtotal PTX. Similarly, long-term intact iPTH levels were comparable: 400 +/- 105 versus 212 +/- 82 pg/mL (mean +/- SE; P = not significant). Interestingly, long-term serum intact iPTH levels were higher in patients with nodular (N = 18) than with diffusely (N = 26) hyperplastic glands: 556 +/- 146 versus 126 +/- 52 pg/mL (P < 0.001) and recurrence of hyperparathyroidism was more frequent with nodular hyperplasia (11 of 18) than with diffuse hyperplasia (4 of 26) (P < 0.02). In conclusion, although excellent short-term results were obtained with both procedures, satisfactory long-term control of parathyroid gland function was achieved in only one third of the patients, the other two third remaining either hypoparathyroid or developing recurrent hyperparathyroidism. Last, the histological subtype of parathyroid glands was partially predictive of the recurrence of hyperparathyroidism.

From 1969 to December 1988 1200 patients were successfully operated on for primary hyperparathyroidism. In 1086 cases the parathyroid lesion was an adenoma and in 252 cases (23.2%) we considered this adenoma in an unusual location. Analysis of the patient's records enables us to describe the operative difficulties for each of those locations, and to assess the value of complementary investigations in the patients whose adenomas are difficult to find.

The tube cannot pass along the marked curve of the trachea, which is displaced by a large goiter extending into the posterior mediastinum. The trachea is perforated in a low thoracic location. Tracheal suture and exeresis of the goiter are performed through sternotomia. This serious accident seems to be exceptional. Can it be predicted?

From 1971 to 1984, 32 patients with endomyocardial fibrosis (EMF) were treated by endocardial resection (decortication) and valve replacement. The population consisted in 20 men and 12 women (age ranged from 8 to 64); 19 patients were european and 13 african. All were symptomatic, 78 p. 100 in stages III or IV of the NYHA. Hypereosinophilia was detected in 21 patients and its cause was determined in 11 cases. Cardiac involvement was biventricular in 22 patients and monoventricular in 10 patients. Six patients died in the immediate postoperative period and 6 late deaths were observed, owing to extracardiac causes in 4. There were no recurrence of EMF. Despite a high mortality rate, the authors suggest that all symptomatic EMF should benefit from endocardial resection.

The incidence of beta 2-microglobulin deposits appears to increase with time on dialysis. However, the precise prevalence of the disease is not known at present because adequate, noninvasive diagnostic procedures are still lacking. We performed systematic synovial biopsies of the sternoclavicular joint during surgical parathyroidectomy in 22 chronic hemodialysis patients with severe hyperparathyroidism. Nine of the patients proved to have beta 2-microglobulin amyloid deposits as demonstrated by Congo red staining and by immunofluorescence. They had undergone dialysis for longer time periods (12.6 vs 8.5 years, p less than 0.02) and tended to be older than the 13 amyloid-negative patients. They also had a significantly higher body aluminum overload, as demonstrated by a higher increase of plasma aluminum after desferrioxamine infusion. Finally, the presence of Congo-red-positive deposits correlated well with clinical and x-ray findings suggestive of dialysis amyloidosis.

The difficult and disappointing cases encountered in patients who were operated upon for hyperparathyroidism between 1960 and 1987 have been studied. Ninety two patients underwent negative cervicotomy. Among the 12 patients who underwent a second operation, 4 were found to have cervical adenomas and in 6 others mediastinal adenomas were discovered by sternotomy. Most of the other cases were diagnostic errors. The present frequency of negative surgical operations is very low: 2 to 3 per cent of the cases; errors of diagnosis are exceptional, and the unusual sites of adenomas are better known. Seventeen patients were reoperated upon for persistent or recurrent hypercalcaemia despite excision of a 1st parathyroid lesion; 3 cancers which had been mistaken for adenomas at the 1st operation; 6 had a 2nd adenoma which had passed unnoticed during an exploration that was probably too limited and as hypercalcaemia persisted all 6 were reoperated upon with success at different intervals; finally, 8 patients had undiagnosed primary hyperplasia (as part of polyadenomatosis in 5 cases). Recurrences were observed, often after a long period, up to 3 to 5 years. Hypercalcaemia was corrected by the 2nd operation in only 5 out of 8 cases. In retrospect, it was found that the pathological examination could not always determine if the lesion was malignant or distinguish between adenoma and glandular hyperplasia.

From 1960 to 1988, we successfully treated 1,200 primary hyperparathyroid patients. The serum calcium level was higher than 3.75 mmol/l (150 mg/l) in 75 patients. Sixty-five patients had acute primary hyperparathyroidism and 10 had asymptomatic severe hypercalcemia. Before admission to our department, most of the patients were given medication to lower their serum calcium levels. Analysis of our diagnostic and therapeutic experience leads us to insist upon the importance of prompt medical treatment and rapid surgical intervention. Only surgery can adequately treat severe hyperparathyroidism.

Resume L'embolie gazeuse cerebrale represente un des accidents non negligeables de la chirurgie cardiaque; 67 cas ou une embolie gazeuse a ete identifie (parmi 1600 interventions a coeurouvert) sont analyses du point de vue electroclinique, pendant les periodes per-operatoires et post-operatoires. La periode per-operatoire est uniquement electrique (67 cas). Elle est caracterisee avant tout par l'apparition brutale d'un ralentissement ou d'une depression de l'EEG localise au seul hemisphere droit, parfois egalement aux deux hemispheres mais predominant constamment a droite. Cette periode, de breve duree, est suivie tout d'abord par une phase de recuperation passagere, les traces redevenant momentanement symetriques et souvent normaux; puis par une phase d'aggravation secondaire marquee par la reapparition d'ondes lentes continues, entrecoupees parfois d'elements a type de pointes du cote de l'embolie, c'est-a-dire a droite. La periode post-operatoire (64 cas) est caracterisee par l'existence de signes EEG isoles (29 cas) ou associes a des signes cliniques (35 cas). Du point de vue EEG, on note, dans les cas severes, des signes temoignant d'une alteration cerebrale diffuse (se traduisant par une symptomatologie EEG de coma plus ou moins profond) et d'une atteinte focalisee. Les anomalies focalisees sont souvent constituees par des elements a type de pointes periodiques associees ou non a des decharges critiques. Elles occupent avant tout le territoire posterieur droit. Les signes focalises ou diffus regressent en quelques jours ou quelques semaines et le trace peut redevenir normal, mais une depression de l'activite EEG persiste souvent dans le territoire posterieur droit. Du point de vue clinique, il existe des perturbations plus ou moins graves du niveau de vigilance regressant progressivement en quelques jours. Dans 25 cas se sont associees des manifestations convulsives de type myoclonique predominant nettement sur l'hemicorps gauche. Elles apparaissent le plus souvent entre la 10e h et la 48e h, et peuvent persister plusieurs jours; elles sont un facteur aggravant de la symptomatologie clinique. Les donnees electrographiques et cliniques etant exposees, une interpretation physiopathologique des divers elements de la symptomatologie est envisagee a la lueur des acquisitions recentes de l'experimentation animale.

An exceptional case of gastropericardial fistula is reported, the lesion developing from a gastric ulcer on an antireflux valve instituted ten years previously. A literature review showed 31 similar cases: 14 gastropericardial fistulae, 16 esophagopericardial fistulae and one jejunopericardial fistula. Three features common to all these fistulae were determined: the frequency of hiatus hernia in the genesis of these lesions, either from an ulcer on esophagitis or herniated stomach or from surgical complication; the extremely high mortality of these fistulae (68% mortality); the need for aggressive treatment.

The modified Fontan procedure is being used in an increasing number of complex cyanotic cardiac lesions with pulmonary stenosis. Seven patients aged 11 to 24 years (average 17.5 years) underwent surgery by a technique derived from the Fontan procedure: direct atriopulmonary anastomosis without a tube or valve. The tricuspid valve when patent was closed with a patch. The diagnoses were: single ventricule (4 cases), Taussig-Bing anomaly (2 cases) and tricuspid atresia (1 case). All patients had associated pulmonary stenosis with low pulmonary vascular resistances. The great vessels were in L-malposition in 3 cases. The hospital mortality was nil. Transient atrial fibrillation was observed in 2 cases and was well tolerated clinically. The follow-up period ranges from 2 months to 4 years (average 2.3 years). All patients are acyanotic with no signs of right-sided failure and in sinus rhythm. Control cardiac catheterisation and angiography were performed in 6 cases and showed good function of the anastomosis and a mean atrial pressure of 14 mmHg. Direct atriopulmonary anastomosis offers a very acceptable surgical solution to certain forms of single ventricle or equivalent with low pulmonary pressures. The short and medium term results seem to be better than those of intraventricular repair.

A 32-year-old man with insulin-dependent diabetes secondary to chronic calcifying pancreatitis of alcoholic origin in whom hypocalciuria (22 to 88 mg/24 hours) was discovered by chance, renal function being normal. Plasma phosphate levels were between 25 and 35 mg/l and the level of parathyroid hormone was at the upper limit of normal. Cervicotomy led to the discovery of three parathyroid glands which were removed. Their weight was increased and their histological appearance normal. The fourth parathyroid was not seen. Hypercalcaemia and hypocalciuria were found during the operation and persis 3 years after, with none of the usual causes being found. This patient has a certain number of characteristics reminiscent of familial hypercalcaemia-hypocalciuria syndrome: high plasma calcium levels associated with low calciuria despite normal renal function and a plasma parathyroid level normal in most cases. The physiopathology of this syndrome remains unknown. Its course is benign, without renal complications. Partial parathyroidectomy is ineffective.