Biomedical subjects
Publications and source records attributed to G Karam.
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OBJECTIVE: To study the efficacy of fluconazole against chronic disseminated candidiasis (hepatosplenic candidiasis) in patients with leukemia in whom amphotericin B treatment had failed. DESIGN: Retrospective analysis of patients with chronic disseminated candidiasis treated with fluconazole on a compassionate investigational new drug protocol. SETTING: Multi-institutional. PATIENTS AND METHODS: Twenty consecutive patients received 100 to 400 mg of fluconazole per day for a median of 30 weeks. All had either failed to respond to treatment with more than 2 g of amphotericin B or had serious amphotericin B-related toxicities. RESULTS: Fourteen of 16 evaluable patients (88%) responded. Responses were observed in seven of nine patients in whom adequate doses of amphotericin B had failed and in all seven patients who had amphotericin B-related toxicities. In 12 patients, cytotoxic chemotherapy was continued without flare of the infection. Fluconazole was well tolerated with rare side effects. Aspergillus superinfection developed in three patients and contributed to the death of two of them. CONCLUSION: Fluconazole is a safe and effective agent with significant activity against chronic disseminated candidiasis.
The possibility of an immunological follow-up of the pancreas through the renal transplant after simultaneous pancreaticorenal transplantation (S.P.R.T.) is controversial. Fifty patients have received a neopren-injected extraperitoneal segmental pancreatic transplant and a contralateral renal transplant, after immunological preparation with blood transfusions, without tissue matching but with a negative anti-T lymphocyte cross-match. Immunosuppression consisted in a three- or four-drug therapy during the first 10 days, then a long-term two-drug therapy (ciclosporine and azathioprine). Sixteen rejection episodes were noted in 16 patients during the first 3 postoperative months. No concomitant alteration of the pancreatic function occurred (no pancreatic histology). No isolated pancreatic rejection has been noted so far. One patients presented with 2 episodes of simultaneous rejection 15 and 26 months after transplantation. The actuarial survival rate at 2 years of the patients, kidneys and pancreata respectively is 96%, 92% and 80%. The absence of long-term alteration of the pancreatic function probably proves the absence of undetected pancreatic rejection. In our experience, the follow-up of the renal function allows screening and treating rejection episodes before a possible functional alteration of the pancreatic transplant occurs. In our opinion, extraperitoneal segmental pancreatic transplantation, a simple procedure with satisfactory metabolic results in the long term, is a good technique for S.P.R.T.
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Between January 1, 1984 and October 1, 1988, 36 cadaveric kidney transplantations were performed in 60 to 66 years' old patients (mean: 62.4 years). Induction immunosuppression consisted of rabbit antithymocyte globulins for 10 days or 33B3.1, an anti RIL2 monoclonal antibody (n = 6), with azathioprine and corticosteroids (less than 1 mg/kg/day). Cyclosporin A (CSA) was given on day 10 in doses of 8 mg/kg/day. Steroids were withdrawn on day 45. Actuarial patient and graft survivals were 66 per cent and 80.5 per cent respectively at 1 and 2 years. Mean +/- SD serum creatinine level was 178 +/- 77 mumol/l at one year. The mean CSA dose adjusted to total blood CSA levels was 4.75 +/- 1.7 mg/kg. Five patients died in the first quarter, 2 of opportunistic infections, 2 of cardiovascular disease and 1 of gastric haemorrhage. The prevalence of rejection episodes during the first 3 months was lower than in the general population (22 per cent vs 27 per cent); all were reversible with bolus injections of corticosteroids. These results indicate that kidney transplantation can successfully be performed in elderly patients with a low rejection rate and an excellent long-term graft survival. However, the mortality was higher than in younger recipients.
A total of 40 patients with stages A2 to C prostatic cancer were treated with leuprorelin acetate depot once a month for 2 months before being treated by pelvic irradiation or radical prostatectomy. In the 32 patients who were evaluable, seven (22%) were classified as minor responders after leuprorelin treatment and 23 (72%) as major responders when assessed by rectal examination. Prostate-specific antigens also returned to normal concentrations (5 ng/ml) in 26/31 (84%) patients. Leuprorelin acetate depot suppressed plasma testosterone concentrations to castration values during treatment, but concentrations returned to normal 2 months after completion of treatment. Following radical treatment, there were three deaths--one postoperative and two due to recurrent disease--but there was no isolated local relapse. It is concluded that the protocol was locally well tolerated and was effective in the treatment of stages B2 and C prostatic cancer patients.
Inguinal lymphadenectomy, as indicated in the treatment of metastases of carcinoma of the penis and of malignant melanoma in the inguinal lymph nodes, involves considerable mortality and morbidity. From February, 1988, to January, 1990, we performed 15 inguinal lymphadenectomies in 10 patients with an average age 51.9 +/- 5.3 years. The technique used combined a transverse incision parallel to the inguinal fold, complete inguinal lymphadenectomy, transposition of the sartorius muscle and vaporization of a film of fibrin glue. The last 2 operations, besides the effectives protection of the femoral pedicle, aim at suppressing dead spaces that may produce hematomas, subcutaneous infection or lymphoceles, and at avoiding the insertion of an aspiration drain, which causes persistent lymphorrhea. Out of the 15 cases of lymphadenectomy, 5 presented with a small- (48 ml in average) or medium-volume (200 ml) lymphocele, which was treated by a simple evacuating puncture. No necrosis of the skin edges, subcutaneous infection or lymphorrhea were observed. These results are encouraging, since our patients can rapidly resume their social life and have an acceptable quality of survival.
One hundred nineteen cases of women with chronic urethrocystalgia were reviewed. The symptoms were dominated by urethral burning (83%) and pollakiuria (75%). Electrosection of the paraurethral glands according to Rieser's technique and resection of the urethral floor (100% of cases) were combined with hymeneoplasty in 9% of cases. The results concern 67 women with a mean follow-up of 6 years: cure: 36%; marked improvement: 34%; no change: 30%. The authors discuss the presence of paraurethral glands, their role in the urethrocystalgia syndrome and the place of Rieser's operation in their treatment.
Spermatogenesis and plasma hormone levels (testosterone, follicle stimulating hormone and 17 beta estradiol) were studied in patients presenting stage I or IIA testicular tumors. Patients with a previous history of cryptorchidism or varicocele, and those who had received combined chemotherapy, were excluded. In 22 patients (10 seminomas and 12 non-seminoma tumors) a spermogram was obtained at the time of orchidectomy, before the procedure in 9 cases and immediately afterwards in 13. Hormone levels, together with tumor marker assay (alpha feto protein and beta HCG) were determined preoperatively. Exocrine and endocrine function were restudied after 3 years of follow up. There was an initial restudied after 3 years of follow up. There was an initial deterioration in spermatogenesis in 17 patients (77.8%) as shown by a sperm count less than 20 million per cm3, an ejaculate volume less than 1.5 cm3 and a motility after one hour of less than 60%. In this group 11 patients had a sperm count of less than 10 million per cm3. Endocrine anomalies discovered included an increase in serum beta HCG levels (7 cases), combined with a decrease in follicle stimulating hormone and an increase in 17 beta estradiol. After 3 years, only 5 of these 17 patients demonstrated fertile sperm (29.4%). The endocrine anomalies tended to regress after orchidectomy. While these endocrine anomalies were always accompanied by hypofertility, their absence was not synonymous with a normal spermogram. Thus the reestablishment of fertile sperm remains unlikely even in early stage testicular tumors.
The authors report an eighth case of emphysematous perinephritis and a new case of emphysematous pyelonephritis. The general features of these two diseases and their similarities are described: middle aged diabetic women, clinical picture of sepsis, gas images projected over the renal area with delayed excretion on intravenous pyelography, computed tomography reveals the exact site of the emphysematous images (perinephritic and or intraparenchymal). Emphysematous perinephritis may be an early form of emphysematous pyelonephritis. Surgical drainage of the renal compartment allows conservative management at this early stage.
Varicocele, a disease essentially observed in adults, is under-estimated in children and adolescents, in whom, for the majority of authors, the therapeutic management is surgical although the benefits in terms of fertility are unknown. Forty-eight children and adolescents, seen between 1978 and 1983, were followed by clinical examination and subsequent sperm count with a mean follow-up of 5.20 years. The presence at the first examination of the subsequent development of testicular atrophy is a pejorative element in the disease: 12% of children managed expectantly developed left testicular atrophy at puberty associated with severe anomalies of the sperm count. Persistent testicular atrophy after surgery was synonymous with anomalies of the sperm count in all of these children. Regression of moderate atrophy was observed in three children after surgical cure, but the pre and post-treatment sperm counts were normal.
Varicocele , a disease essentially observed in adults, is underestimated der-estimated in children and adolescents, in whom, for the majority of authors, , the therapeutic management is surgical although the benefits in terms of fertility are unknown. Forty-eight children and adolescents, seen between 1978 and 1983, were followed by clinical examination and subsequent sperm count with a mean follow-up of 5.20 years. The presence at the first examination of the subsequent development of testicular atrophy is a pejorative element in the disease: 12% of children simply followed developed left testicular atrophy at puberty associated with severe anomalies of the sperm count. Persistent testicular atrophy after surgery was synonymous with anomalies of the sperm count in all of these children. Regression of moderate atrophy was observed in three children after surgical cure, but the pre- and post-treatment sperm counts were normal.
Between 1973 and 1986, 57 patients presented with a fracture of the pelvis with rupture of the posterior urethra. All of these patients were treated as an emergency and were then followed periodically with a minimal follow-up of 2 years. There were 4 cases of rupture of the prostatic urethra and 53 cases of rupture of the membranous urethra, including 32 complete ruptures and 21 partial ruptures. In the case of rupture of the membranous urethra, initial treatment, in 34 cases, was realignment by guiding catheter either immediately (25 cases) or deferred emergency (9 cases) and, in the other 19 cases, end-to-end urethrorrhaphy or urethroplasty (2 cases) as a deferred emergency (15th to 32nd day). The results were evaluated on the maximal flow/second and the flowmetry curve, intravenous pyelography with micturating and post-micturating films and the need for dilatations or reoperations. In the cases treated by realignment by guiding catheter, 28 of our 34 patients (82%) developed secondary stenosis which is difficult to treat because of the large amount of granulation tissue and fibrosis, although the best results were obtained by end-to-end urethrorrhaphy (75%). In contrast, repeated dilatations and optical urethrotomies were failures. Deferred emergency end-to-end urethorrhaphy, in 17 cases, ensured a good immediate result in 60% of our patients. Secondary stenosis (7 cases) was always short and easily accessible to optical urethrotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
In order to demonstrate that the quality of the functional result after surgery for prostatic adenoma depends on the initial urodynamic equilibrium, the authors performed preoperative cystomanometry and urethral pressure profile, in addition to the standard assessment, in 115 patients. Only vesical acontractility clearly appeared to be a factor of residual dysuria, as it multiplied the risk by a factor of 3. In contrast, the values for the urethral pressure profile did not have any predictive value on incontinence, probably because they were modified by the operation. However, and understanding of the vesico-sphincteric equilibrium can lead to a modification of the therapeutic indications in certain circumstances in which this equilibrium appears to be particularly precarious.
Nephrogenic metaplasia of the bladder is rare; less than one hundred cases have been reported. Four personal cases and 16 cases reported in the literature concerning renal transplant patients demonstrate that the frequency of this disease is much higher in this group than in the general population. The symptoms and signs, age of onset, macroscopic and microscopic appearance of the lesions correspond to the description in non-transplant patients, apart from the preferential site adjacent to the reimplanted ureter and the presence, in two cases, of cells with virus-like inclusions, one of which corresponded to CMV infection. The traumatic factor in these patients is not sufficient on its own to explain the relative frequency of this lesion in renal transplant patients. The role of immunosuppression, resulting in a reduction of "immunological surveillance", is possible; this metaplasia usually has a benign course, but this high risk population must be carefully monitored for the development of this lesion.
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