Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome

Recruitment maneuvers (RM) consist of a ventilatory strategy that increases the transpulmonary pressure transiently to reopen the recruitable lung units in acute respiratory distress syndrome (ARDS). The rationales to use RM in ARDS are that there is a massive loss of aerated lung and that once the end-inspiratory pressure surpasses the regional critical opening pressure of the lung units, those units are likely to reopen. There are different methods to perform RM when using the conventional ICU ventilator. The three RM methods that are mostly used and investigated are sighs, sustained inflation, and extended sigh. There is no standardization of any of the above RM. Meta-analysis recommended not to use RM in routine in stable ARDS patients but to run them in case of life-threatening hypoxemia. There are some concerns regarding the safety of RM in terms of hemodynamics preservation and lung injury as well. The rapid rising in pressure can be a factor that explains the potential harmful effects of the RM. In this review, we describe the balance between the beneficial effects and the harmful consequences of RM. Recent animal studies are discussed

Concerns on clinical application of composite tissue allotransplantation

Composite tissue allograft has become a clinical reality: hands, vascularized femoral diaphyses, abdominal walls, a larynx have all been transplanted throughout the world. Conventional immunosuppressive protocol has shown to be sufficient and effective. Rejection has been prevented in most cases and when it did occur it was successfully reversed. Skin has been confirmed as the principal target of acute and chronic rejection. There has been no mortality or early graft losses and, particularly in hand transplantation, the survival graft rate is 91% with a follow-up period ranging from 6 months to 61 months. The side effects of immunosuppression are limited and include primarily transient hyperglycemia, an increase in creatinine values and some opportunistic infections (i.e. cytomegalovirus infection). Nerve regeneration and cortical reorganization have been demonstrated in hand transplantation. Functional results have been encouraging particularly for hand and larynx transplantation. Appropriate indications and patient selection, based particularly on patient motivation and compliance, are essential requirements for composite tissue allograft success

Self-renewal capacity of human epidermal Langerhans cells: observations made on a composite tissue allograft

Epidermal Langerhans cells (LC) are dendritic, antigen-presenting cells residing within mammalian epidermis and mucosal epithelia. When massively depleted, they are replaced by cells of bone-marrow origin. However, their renewal within normal skin under steady-state conditions is not precisely known. We observed that epidermal LC within a human hand allograft remain stable in the long term (10 years) and are not replaced by cells of recipient's origin; furthermore, we observed a Langerhans cell in mitosis within the epidermis 8 years postgraft. These results show that under almost physiological conditions, human LC renew in the epidermis by local mitoses of preexisting cells

Comparaison de la chirurgie conservatrice et de la néphrectomie totale élargie dans le traitement du cancer du rein: Expérience Lyonnaise

Objectifs: Les bons résultats obtenus ces 20 dernières années dans le traitement du cancer du rein par chirurgie conservatrice pour des indications de nécessité et l'augmentation croissante du nombre de nouveaux cas de petites tumeurs du rein incitent certains auteurs à proposer un traitement conservateur du cancer du rein en tant qu'indication élective. Par opposition, d'autres avancent le risque de multifocalité et de récurrence par cette approche et préfèrent s'en tenir à la référence qui est la néphrectomie totale élargie. Nous présentons les résultats d'une étude rétrospective incluant 2 groupes de 62 patients opérés dans notre service pour cancer du rein ; le groupe 1 a eu une chirurgie conservatrice (CC) et le groupe 2 une néphrectomie totale élargie (NTE). Matériel et méthode : Entre 1988 et 1999, plus de 900 patients ont été opérés dans notre service pour cancer du rein. Nous avons comparé les résultats de la CC (néphrectomie partielle et/ou tumorectomie) à ceux de la NTE à partir de 2 groupes de même effectif (n=62), en terme de morbidité, évolution de la fonction rénale, efficacité carcinologique et survie. Les patients ont été appariés selon le sexe, la date d'intervention, le grade et le stade tumoral (classification TNM 1997). Résultats : Le recul moyen est supérieur à 5 ans pour les deux groupes. L'âge moyen est de 61 ans, le sex ratio de 1/2,2.La distribution des stades est pour les deux groupes : pT1 et pT2: 78%, pT3a: 16%, pT3b: 4%, pT3c: 2%. Celle du grade nucléaire de Fuhrman : 1 et 2: 77% ; 3 et 4: 23%. Morbidité : La durée d'hospitalisation a été de 15,5 jours pour le groupe 1 (CC) et 11 jours pour le groupe 2 (NTE) (p = 0,03) ; le taux de transfusion a été de 30% pour le groupe 1 contre 5% pour le groupe 2 (

Absence of c4d deposition in human composite tissue (hands and face) allograft biopsies: an immunoperoxidase study

Deposition of the C4d complement degradation product has been shown to be a marker of antibody-mediated rejection of solid organ allografts, including kidney, heart, liver, and lung. We investigated whether C4d deposition also would be useful in monitoring rejection in human composite tissue allografts. A total of 60 mucocutaneous formalin-fixed, paraffin-embedded and four frozen biopsy specimens from four patients with composite tissue allografts (three hands, one face) taken during a period of 7 days to 7 years after graft were immunostained for C4d by an immunoperoxidase and an immunofluorescence technique, respectively. C4d deposition was not found in any of the specimens studied, even though several of them showed pathological signs of rejection. No human leukocyte antigen alloantibodies were detected in any of the patients during the study period. These results suggest that humoral rejection occurs rarely, if at all, in the setting of human composite tissue allografts

Endopyelotomie pour syndrome de la jonction sur rein greffe A propos de trois observations

No Abstract

Complications urologiques de l'endometriose A propos de 4 observations

No Abstract

Bilateral hand transplantation: six years after the first case

In this study we present our experience concerning bilateral hand transplantation. Two cases were performed: the first in January 2000 and the second in April 2003. Both recipients received the same immunosuppressive treatment, which was similar to those used in solid organ transplantation, including tacrolimus, prednisone and mycophenolate mofetil while antithymocyte globulins were added for induction. Both recipients presented two episodes of acute rejection (maculopapular lesions) in the first 3 months after transplantation; however, these were easily reversed after a few days increasing oral steroid doses and using topical immunosuppressants. The first recipient presented hyperglycemia and serum sickness while the second recipient suffered a thrombosis of the right ulnar artery and an osteomyelitis of left ulna. All the complications were successfully treated. Functional Magnetic Resonance Imaging (fMRI) showed that cortical hand representation progressively shifted from the lateral to the medial region in the motor cortex. After 6 and 2 years respectively, they showed a relevant sensorimotor recovery particularly of sensibility and activity of intrinsic muscles. They were able to perform the majority of daily activities and to lead a normal social life. The first recipient has been working since 2003. They are both satisfied with their grafted hands

Outcomes After Bilateral Hand Allotransplantation: A Risk/Benefit Ratio Analysis

BACKGROUND:: The clinic era of composite tissue allotransplantation was inaugurated by hand allotransplantation in 1998, giving rise to many controversies and scepticism because of the lifelong immunosuppression, the unclear risk-benefit ratio, and the uncertain long-term functional results of the procedure. The aim of this study was to evaluate the outcomes and the risk/benefit balance in bilateral hand allotransplantation. METHODS:: The study included 5 cases of bilateral hand allotransplantation performed in a single center, with a follow-up ranging from 3 to 13 years. The recipients (4 men, 1 woman) were young. The level of amputation was distal in all cases except for 2 patients amputated at the midforearm level. All the recipients initially received the same immunosuppressive treatment that included tacrolimus, mycophenolate mofetil, prednisone, and, for induction, antithymocyte globulins. RESULTS:: Patient and graft survival was 100%. All recipients showed adequate sensorimotor recovery (protective and tactile sensitivity and partial recovery of intrinsic muscles), they were able to perform the majority of activities of daily living, and had a normal social life. Most complications occurred in the first posttransplant year and were successfully managed. All recipients experienced at least 1 episode of acute rejection, which was easily reversed by increasing oral steroid dose or by intravenous steroids, except for patient 3, who presented 6 episodes of acute rejection, the latest 2 treated with Campath-1H. CONCLUSIONS:: Although bilateral hand transplantation may be a satisfactory treatment option for amputees, a careful selection of candidates and a rigorous evaluation of recipients after transplantation are imperative