Hypertension and intra-operative incidents : a multicentre study of 125000 surgical procedures in Swiss hospitals

Rapport de synthèse : Bien que les complications sévères de l'anesthésie soient actuellement rares, des informations contradictoires existent à propos du rôle et de l'importance de l'hypertension artérielle chronique sur la survenue de complications en cours d'anesthésie. En raison de la prévalence élevée de l'hypertension artérielle dans la population et du grand nombre d'anesthésies effectuées, il est important de clarifier cette relation. Le but de l'étude était d'évaluer si les personnes hypertendues étaient à risque accru de présenter des complications lors d'anesthésies à partir de données collectées de routine lors d'anesthésies usuelles réalisées en Suisse. Nous avons utilisé les données figurant dans le registre ADS (Anesthésie Données Suisse) correspondant à des anesthésies, générales ou locorégionales, réalisées pour chirurgie élective chez des adultes, entre 2000 et 2004 dans 24 hôpitaux suisses. L'attention était portée principalement sur les incidents cardio-vasculaires, mais les autres incidents relevés de routine ont aussi été évalués. La présence d'une hypertension artérielle chronique était définie par la présence d'un traitement antihypertenseur ou par l'anamnèse d'une hypertension artérielle, combinée à la mesure d'une pression artérielle élevée (systolique >160 mm Hg ou diastolique >100 mm Hg) lors de l'examen préopératoire de l'anesthésiste. Les incidents relevés en cours d'anesthésie ont été définis a priori et sont enregistrés de routine sur la feuille d'anesthésie et reportés dans une base de données centralisée. En raison de la structure des données, des analyses hiérarchiques ont été effectuées incluant des variables individuelles (niveau 1), liées aux groupes d'interventions chirurgicales (niveau 2) et à l'hôpital (niveau 3). Parmi les 124 939 interventions, 27 881 (22%) concernaient des patients connus pour une hypertension artérielle chronique. Au moins un incident est survenu dans 16,8% des interventions (95% Cl 16,6 -17,0%). Chez 7 549 patients, au moins un incident cardio- vasculaire est survenu, soit dans 6% des anesthésies (95% Cl 5.9-6.2%). Le rapport des cotes (odds ratio) moyen ajusté pour les incidents cardio-vasculaires chez les patients hypertendus était de 1.38 (95% Cl 1.27-1.49), indiquant une augmentation du risque chez les patients hypertendus. Cependant, l'hypertension n'était pas liée à un risque augmenté de survenue d'un autre incident. Les rapports de cotes ajustés de la survenue d'une complication cardiovasculaire en présence d'une hypertension artérielle variaient selon les hôpitaux entre 0.41 et 2.25. Ainsi, cette étude confirme la présence d'un risque accru de survenue d'une complication cardiovasculaire chez un patient hypertendu lors d'une anesthésie pour chirurgie élective. Il s'agissait le plus souvent d'une arythmie ou d'une perturbation hémodynamique. Cette augmentation du risque proche de 40% a aussi été trouvée dans une revue systématique avec méta-analyse. L'hétérogénéité des institutions -qui persiste même en tenant compte des ajustements pour le type d'intervention chirurgicale et des variables individuelles (case-mix) - suggère des différences de pratique de l'anesthésie selon l'hôpital.

Clinical predictors for Legionella in patients presenting with community-acquired pneumonia to the emergency department.

BACKGROUND: Legionella species cause severe forms of pneumonia with high mortality and complication rates. Accurate clinical predictors to assess the likelihood of Legionella community-acquired pneumonia (CAP) in patients presenting to the emergency department are lacking. METHODS: We retrospectively compared clinical and laboratory data of 82 consecutive patients with Legionella CAP with 368 consecutive patients with non-Legionella CAP included in two studies at the same institution. RESULTS: In multivariate logistic regression analysis we identified six parameters, namely high body temperature (OR 1.67, p < 0.0001), absence of sputum production (OR 3.67, p < 0.0001), low serum sodium concentrations (OR 0.89, p = 0.011), high levels of lactate dehydrogenase (OR 1.003, p = 0.007) and C-reactive protein (OR 1.006, p < 0.0001) and low platelet counts (OR 0.991, p < 0.0001), as independent predictors of Legionella CAP. Using optimal cut off values of these six parameters, we calculated a diagnostic score for Legionella CAP. The median score was significantly higher in Legionella CAP as compared to patients without Legionella (4 (IQR 3-4) vs 2 (IQR 1-2), p < 0.0001) with a respective odds ratio of 3.34 (95%CI 2.57-4.33, p < 0.0001). Receiver operating characteristics showed a high diagnostic accuracy of this diagnostic score (AUC 0.86 (95%CI 0.81-0.90), which was better as compared to each parameter alone. Of the 191 patients (42%) with a score of 0 or 1 point, only 3% had Legionella pneumonia. Conversely, of the 73 patients (16%) with > or =4 points, 66% of patients had Legionella CAP. CONCLUSION: Six clinical and laboratory parameters embedded in a simple diagnostic score accurately identified patients with Legionella CAP. If validated in future studies, this score might aid in the management of suspected Legionella CAP.

Esophageal and pharyngeal strictures: report on 1,862 endoscopic dilatations using the Savary-Gilliard technique

Treatment of symptomatic pharyngeal and esophageal strictures requires endoscopic dilatation. The Savary-Gilliard bougienage was developed by our department and has been used since 1980 for this purpose. We report our experience using this technique. The records of patients seen from January 1, 1963 to December 31, 2005, who had pharyngeal and esophageal strictures needing dilatation, were reviewed. The prevalence of different etiologies, and the incidence of complications using the Savary-Gilliard dilators were assessed. Efficiency of dilatation was assessed over a 17-year segment of this period, using number of dilatations and time intervals between dilatations until resolution of symptoms as outcome measures. Of the 2,652 pharyngeal and esophageal strictures reviewed, 90% were of organic origin (45% benign and 55% malignant stenoses), and 10% were of functional etiology. The most common etiologies were peptic strictures before the era of proton pump inhibitors, and postoperative anastomotic strictures thereafter. A total of 1,862 dilatations using the Savary-Gilliard technique were analyzed. Complication and mortality rates were 0.18 and 0.09% for benign and 4.58 and 0.81% for malignant etiologies, respectively. The number of dilatations per stricture and the time interval between different sessions were dependent on the type of strictures, varying from 1 to 23 dilatations and 7 days to 16 years, respectively. Pharyngeal and esophageal dilatations using the Savary-Gilliard technique were safe when used together with fluoroscopy. Overall, the efficiency of the dilatation procedure was good, but some types of strictures (e.g., caustic, post-surgical and/or post radiotherapy) were refractory to treatment and required repeated dilatations.

Novel pathogenic pathways in diabetic neuropathy.

Diabetic peripheral neuropathy (DPN) is a common complication affecting more than one third of diabetes mellitus (DM) patients. Although all cellular components participating in peripheral nerve function are exposed to and affected by the metabolic consequences of DM, nodal regions, areas of intense interactions between Schwann cells and axons, may be particularly sensitive to DM-induced alterations. Nodes are enriched in insulin receptors, glucose transporters, Na(+) and K(+) channels, and mitochondria, all implicated in the development and progression of DPN. Latest results particularly reinforce the idea that changes in ion-channel function and energy metabolism, both of which depend on axon-glia crosstalk, are among the important contributors to DPN. These insights provide a basis for new therapeutic approaches aimed at delaying or reversing DPN.

Early-onset Crohn's disease is a risk factor for smaller final height

OBJECTIVES: Growth retardation is a frequent complication of paediatric inflammatory bowel disease (IBD). Only a few studies report the final height of these patients, with controversial results. We compared adult height of patients with paediatric IBD with that of patients with adult-onset disease. METHODS: Height data of 675 women 19-44 years of age and 454 men 23-44 years of age obtained at inclusion in the Swiss IBD cohort study registry were grouped according to the age at diagnosis: (a) prepubertal (men≤13, women≤11 years), (b) pubertal (men 13-22, women 11-18 years) and (c) adult (men>22, women>18 years of age), and compared with each other and with healthy controls. RESULTS: Male patients with prepubertal onset of Crohn's disease (CD) had significantly lower final height (mean 172±6 cm, range 161-182) compared with men with pubertal (179±6 cm, 161-192) or adult (178±7 cm, 162-200) age at onset and the general population (178±7 cm, 142-204). Height z-scores standardized against heights of the normal population were significantly lower in all patients with a prepubertal diagnosis of CD (-0.8±0.9) compared with the other patient groups (-0.1±0.8, P<0.001). Prepubertal onset of CD emerged as a risk factor for reduced final height in patients with prepubertal CD. No difference for final height was found between patients with ulcerative or unclassified IBD diagnosed at prepubertal, pubertal or adult age. CONCLUSION: Prepubertal onset of CD is a risk for lower final height, independent of the initial disease location and the necessity for surgical interventions.

Persistent palinopsia following ingestion of lysergic acid diethylamide (LSD).

OBJECTIVE: To identify a distinctive chronic visual complication of lysergic acid diethylamide (LSD) use. DESIGN: Description of the clinical findings in three patients with this disorder. SETTING: A neuro-ophthalmology referral center. RESULTS: All three patients experienced prolonged afterimages (palinopsia) during LSD intoxication and have continued to be symptomatic up to 3 years after they ceased to ingest the drug. Results of neuro-ophthalmologic and neurologic examinations and neuroimaging and electrophysiologic studies were normal. CONCLUSIONS: We have described three patients in whom persistent palinopsia developed following ingestion of LSD. Clinicians should inquire about past LSD use in all patients who initially have seemingly spontaneous, isolated palinopsia. Recognition of this distinctive clinical syndrome associated with LSD use might avoid unnecessary anxiety and excessive diagnostic tests for patients with this disorder.

Second primary squamous cell carcinoma arising in cutaneous flap reconstructions of two head and neck cancer patients.

Early complications of myocutaneous flap transfers following surgical eradication of head and neck tumors have been extensively described. However, knowledge concerning long-term complications of these techniques remains limited. We report the cases of two patients with a prior history of squamous cell carcinoma of the head and neck (HNSCC), who developed a second primary SCC on the cutaneous surface of their flaps, years after reconstruction. Interestingly, it seems that the well-known risk of a second primary SCC in patients with previous head and neck carcinoma also applies to foreign tissues implanted within the area at risk. Given the important expansion of these interventions, this type of complication may become more frequent in the future. Therefore, long-term follow-up of patients previously treated for HNSCC not only requires careful evaluation of the normal mucosa of the upper aero-digestive tract, but also of the cutaneous surface of the flap used for reconstruction.

Improved growth with bioabsorbable sutures in both high- and low-pressure zones.

BACKGROUND: Compromised growth after operation remains a significant problem in the cardiovascular field. Some benefit of absorbable suture materials has been demonstrated for arterial anastomoses. However, for the low-pressure zone, few data are available. METHODS: To assess growth in high- versus low-pressure zones we transected the abdominal aorta (high-pressure zone) as well as the inferior vena cava (low-pressure zone) in 10 young mongrel dogs using for reanastomosis 7-0 nonabsorbable versus absorbable running sutures in random order. RESULTS: All animals survived and were evaluated over 12 months including body weight (gain, 212% +/- 45% for nonabsorbable versus 218% +/- 8% for absorbable; not significant), angiography, and, after elective sacrifice, detailed studies of aorta and vena cava. Systematic complication of angiographic data at 12 months showed at the suture level an area of 13.8 mm2 for nonabsorbable versus 24.3 +/- 14.4 mm2 for absorbable sutures in the high-pressure zone as compared with 12.9 +/- 4.9 mm2 for nonabsorbable versus 25.3 +/- 15.4 mm2 for absorbable sutures in the low-pressure zone. Residual lumen, calculated as a function of the area above and below the suture, accounted for 35% +/- 10% for nonabsorbable versus 92% +/- 12% for absorbable sutures (p < 0.001) in the high-pressure zone as compared with 37% +/- 13% for nonabsorbable versus 75% +/- 15% for absorbable sutures (p < 0.003) in the low-pressure zone (high versus low, not significant). Poststenotic dilatation accounted for 199% +/- 22% for nonabsorbable versus 126% +/- 43% for absorbable sutures (p < 0.01) in the high-pressure zone. In the low-pressure zone, poststenotic dilatation remained below the inflow area, and the residual poststenotic lumen accounted for 52% +/- 14% for nonabsorbable versus 77% +/- 16% for absorbable sutures (p < 0.004). Macroscopic, light, and scanning electron microscopic studies confirmed different growth patterns in high- versus low-pressure zones. CONCLUSIONS: Aortic narrowing resulted in poststenotic dilatation and unrestricted outflow path (hourglass-type stenosis). Caval narrowing was followed by restriction of poststenotic outflow path (funnel-type stenosis). Absorbable suture material allows for superior growth in both high- and low-pressure zones.

Initiation de l'adhésion leucocytaire : rôle des fucosyltransférases et des ligands des sélectines

RESUME La dissémination extramédullaire des cellules blastiques est une complication majeure des leucémies myéloïdes (LMA) ou lymphoïdes aiguës (LLA). La migration des cellules blastiques dépend de mécanismes semblables à ceux qui régulent la migration des leucocytes dans un site d'inflammation. Parmi ceux-ci, les oligosaccharides fucosylés décorant les ligands des sélectines jouent un rôle clé en interagissant avec les sélectines. PSGL-1 (P-Selectin Glycoprotein Ligand-1) est une protéine de 240 kD, exprimée à la surface des leucocytes, permettant de soutenir le roulement leucocytaire sur les sélectines, le long de la paroi vasculaire. L'interaction de PSGL-1 avec les sélectines nécessite des modifications post-traductionnelles de type sialylation, sulfatation , N et 0-glycosylation. Parmi les enzymes impliqués, les α1,3-fucosyltransférases jouent un rôle important dans la biosynthèse d'oligosaccharides fucosylés, ligands des sélectines (sLex, Lex, VIM-2, CLA). Comme l'expression des α1,3-fucosyltransférases par les cellules blastiques leucémiques n'a pas été étudiée précédemment, nous l'avons recherchée dans 120 cas de leucémies aiguës. Les ARNm des FucT-IV et -VII ont été détectés, par RT-PCR, dans tous les cas testés. L'ARNm de la FucT-IX n'a été observé que dans 40% des leucémies aiguës (48/120). L'ARNm de la FucT-IX est détecté dans 65% des LMA (47/72) et, moins fréquemment, dans 26% des LLA (11/42). A noter que les cas de LLA exprimant la FucT-IX correspondent essentiellement à des LLA secondaires à la transformation d'une leucémie myéloïde chronique ou des LLA de la lignée B de type leucémie/lymphome de Burkitt. L'expression de PSGL-1 et des oligosaccharides fucosylés par les blastes varie significativement parmi les LMA et les LLA : Lex, VIM-2 et sLex étant exprimés plus fréquemment par les myéloblastes que par les lymphoblastes. Le rôle des FucT-IV, -VII et -IX dans la synthèse des Lex, VIM-2, CLA et sLex a été examiné en exprimant l'ADNc de chaque FucT dans des cellules CHO. L'immunophénotypisation des transfectants indique que la FucT-VII synthétise sLex et CLA, mais pas Lex et VIM-2. Lex et VIM-2 sont générés par la FucT-IV. La FucT-IX ne participe qu'à la synthèse de Lex, sa capacité de synthèse de VIM-2 dans les cellules CHO est très faible. Le rôle de la FucT-IX dans la régulation du roulement cellulaire dépendant des sélectines a été testé dans des conditions de flux. Les vitesses de roulement des cellules CHO co-exprimant la FucT-LX, la core-2 01,6-N-acetylglucosaminyltransferase et PSGL-1 sont très élevées sur la P-sélectine (médiane : 497.95 µm/s, n=96) alors qu'elles sont beaucoup plus lentes sur la E-sélectine (médiane 7 µm/s, n=64). Les recrutements sur la E-sélectine des cellules CHO-C2F9PSGL¬1 et des CHO-C2F7PSGL-1 sont similaires (moyenne ± SEM : 127.44 ± 4.38 vs. 151.16 ± 3.16 cellules/min/mm2, n=5). Celui des cellules CHO-C2F4PSGL-1 est par contre plus faible (54.20 ± 2.13 cellules/min/mm2, n=5). Ces résultats indiquent que la FucT-IX est impliquée dans la biosynthèse de Lex, VIM-2 et CLA et qu'elle régule l'interaction des cellules CHO avec la E-sélectine. Contrairement aux FucT-IV et -VII, la FucT-IX ne joue qu'un rôle mineur dans la régulation du roulement cellulaire sur la L- et la P-sélectine. L'expression fréquente de la FucT-IX par les myéloblastes suggère qu'elle pourrait participer avec les FucT-IV et -VII à la régulation de la migration cellulaire dépendant de la E-sélectine. Finalement, ce travail de thèse a été étendu à l'identification des protéines cytoplasmiques qui interagissent avec le domaine cytoplasmique de PSGL-1 et qui pourraient être impliquées dans la transmission de signaux intracellulaires. Les ligands intracellulaires de PSGL-1 seront identifiés par la technique du double hybride qui nous a déjà permis de confirmer que syk et la N-moésine se lient au domaine cytoplasmique de PSGL-1. Des ligands supplémentaires seront identifiés employant une librairie provenant des cellules souches hématopoïétiques comme proie. ABSTRACT Blast cell dissemination is a major complication of acute myeloblastic (AML) and lymphoblastic leukemia (ALL). Blast cell migration is dependent on mechanisms that are similar to those which regulate leukocyte migration into inflammatory lesions. Among them, fticosylated oligosaccharides that decorate selectin ligands play a key role by interacting with selectins. PSGL-1 (P-Selectin Glycoprotein Ligand-1) is a 240 kD glycoprotein constitutively expressed on leucocytes and which supports leukocyte rolling on selectins. PSGL-1 interaction with selectins is dependent on post-translational modifications such as sialylation, sulfation, N- and 0-glycosylation. Among the involved enzymes, the α1,3-fucosyltransferases (FucT) play a major role in generating cell surface glycoconjugates carrying fucosylated oligosaccharides which interact with selectins (sLex, Lex, VIM-2, CLA). Since no information is available on the expression of α1,3-fucosyltransferases by leukemic blast cells, we examined it in 120 cases of acute leukemia. FucT-IV and -VII mRNAs were detected, by RT-PCR, in all tested cases. In contrast, the presence of FucT-IX mRNA was shown in only 40% of patients with acute leukemia (48/120). FucT-IX mRNA was detected in 65% of AML (47/72) and, less frequently, in 26% of ALL (11/42). Importantly, all ALL cases expressing FucT-IX were either secondary leukemia resulting from the transformation of chronic myelocytic leukemia in acute lymphoblastic leukemia or mature B-ALL (FAB L3 subtype or Burkitt lymphoma/leukemia according to WHO classification). FucT-IX was not detected in precursor B or T-ALL. The expression of PSGL-1 and fucosylated epitopes was significantly different among AML and ALL, Lex, VIM-2 and sLex being more frequently expressed by myeloblasts than by lymphoblasts. The role of FucT-IV, -VII and -IX in the biosynthesis of Lex, VIM-2, CLA and sLex was examined by expressing the cDNA of each α1,3-FucT in CHO cells. Immunophenotypic analysis of CHO transfectants indicated that FucT-VII synthesizes sLex and CLA but not Lex or VIM-2. Lex and CLA were generated by both FucT-IV and -IX. FucT-IV and FucT-IX differed in their ability to synthesize VIM-2, FucT-IX being less efficient than FucT-IV. The role of FucT-IX in regulating selectin-dependent rolling was assessed under hydrodynamic flow conditions. P-selectin-dependent interactions were transient and occurred at high velocities (median: 497.95 1,µm/s, n=96). In contrast, much slower rolling velocities were observed on E-selectin (median: 7 µm/s, n=64). The recruitment of CHO-C2F9PSGL-1 and CHO-C2F7PSGL-1 cells was similar on E-selectin (mean ± SEM: 127.44 ± 4.38, n=5 vs 151.16 ± 3.16 cells/min/mm2, n=5). In the other hand, CHO-C2F4PSGL-1 cells were less efficiently recruited on E-selectin (54.20 ± 2.13 cells/min/mm2, n=5). This results indicate that FucT-IX is involved in the biosynthesis of Lex, VIM-2 and CLA and that it confers E-selectin binding activity to CHO cells. By contrast to FucT-IV and -VII, FucT-IX had a minor role in regulating P- and L-selectin-dependent rolling on CHO transfectants. The frequent expression of FucT-IX in myeloblasts suggests that it may participate with FucT-IV and -VII in regulating E-selectin-dependent cell migration into tissues. Finally, this thesis work was extended to the identification of the cytoplasmic proteins interacting with cytoplasmic domain of PSGL-1 that may be involved in transducing intracellular signals. We planned to identify these intracellular ligands of PSGL-1 by using the double hybrid technique and already confirmed that syk and N-moesin bind to the cytoplasmic domain of PSGL-1. Additional PSGL-1 ligands will be sought by the same technique using a CD34+ stem cell library as pray. RESUME DESTINE A UN LARGE PUBLIC : L'adhésion et la migration leucocytaire sont nécessaires à de nombreux processus cellulaires comme la régulation de l'hématopoïèse, mais aussi dans la pathogenèse de l'artériosclérose, des maladies inflammatoires et de la métastatisation des cellules cancéreuses. Les molécules impliquées constituent depuis peu des cibles pour la thérapie du cancer. La migration leucocytaire vers un site d'inflammation dépend de mécanismes complexes, se déroulant en plusieurs étapes, nécessitant l'interaction séquentielle de molécules d'adhésion leucocytaires et endothéliales. Ainsi, chronologiquement, suite à un stimulus inflammatoire, les leucocytes « roulent » sur les cellules endothéliales, sont activées, s'arrêtent et traversent la paroi endothéliale (diapédèse) pour migrer dans les tissus environnants inflammés selon un gradient chimiotactique. La première étape de roulement met en jeu deux molécules principales : PSGL-1 (P-Sélectine Glycoprotéine Ligand-1) du coté des leucocytes et les sélectines du coté de l'endothélium de la paroi vasculaire. L'interaction entre ces deux molécules nécessite des décorations de ces protéines par des sucres, des résidus sulfates et des acides sialiques. Le sucre essentiel à la liaison demeure le fucose qui est attaché aux protéines grâce à des enzymes de la famille des fucosyltransferases. Actuellement, neuf fucosyltransférases humaines ont été identifiées et désignées sous FucT-I à IX. La FucT-IX, dernière fucosyltransférase clonée, a un faible degré d'homologie avec les autres fucosyltransférases mais sa séquence est extrêmement conservée entre les espèces. Ceci traduit son importance par une forte résistance à la pression évolutive. L'examen de son expression au sein de 120 cas de leucémies aiguës a mis en évidence son comportement atypique. En effet, alors que les autres FucTs sont toujours présentes, la FucT¬IX ne s'exprime que dans un cas sur deux en moyenne avec une préférence plus importante pour les leucémies myéloïdes. Ainsi, une étude plus approfondie de cet enzyme à mis en évidence sa capacité à induire une interaction cellulaire plus spécifique de la E-sélectine. Elle décore non seulement des protéines de surface, mais aussi certainement les glycolipides constituant la membrane cellulaire.

CT-guided cervical foraminal injection: Is a direct foraminal approach still necessary?

Purpose: Cervical foraminal injection performed with a direct foraminal approach may induce serious neurologic complications. We describe a technique of CT-guided cervical facet joint (CFJ) injection as an indirect foraminal injection, including feasibility and diffusion pathways of the contrast agent. Methods and materials: Retrospective study included 84 punctures in 65 consecutive patients presenting neck pain and/or radiculopathy related to osteoarthritis or soft disc herniation. CT images were obtained from C2 to T1 in supine position, with a metallic landmark on the skin. CFJ punctures were performed by MSK senior radiologists with a lateral approach. CT control of the CFJ opacification was performed after injections of contrast agent (1 ml), followed by slow-acting corticosteroid (25 mg). CFJ opacification was considered as successful when joint space and/or capsular recess opacification occurred. The diffusion of contrast agent in foraminal and epidural spaces was recorded. We assessed the epidural diffusion both on axial and sagittal images, with a classification in two groups (small diffusion or large diffusion). Results: CFJ opacification was successful in 82% (69/84). An epidural and/or foraminal opacification was obtained in 74% (51/69). A foraminal opacification occurred in 92% (47/51) and an epidural opacification in 63% (32/51), with small diffusion in 47% (15/32) and large diffusion in 53% (17/32). No complication occurred. Conclusion: CT- guided CFJ injection is easy to perform and safe. It is most often successful, with a frequent epidural and/or foraminal diffusion of the contrast agent. This technique could be an interesting and safe alternative to foraminal cervical injection.

Are patients at nutritional risk more prone to complications after major urological surgery?

PURPOSE: The nutritional risk score is a recommended screening tool for malnutrition. While a nutritional risk score of 3 or greater predicts adverse outcomes after digestive surgery, to our knowledge its predictive value for morbidity after urological interventions is unknown. We determined whether urological patients at nutritional risk are at higher risk for complications after major surgery than patients not at nutritional risk. MATERIALS AND METHODS: We performed a prospective observational study in consecutive patients undergoing major surgery. A priori sample calculation resulted in a study cohort of 220 patients. Interim analysis was planned after 110 patients. The nutritional risk score was assessed preoperatively by a specialized study nurse. Nutritional care was standardized in all patients. Postoperative complications were defined previously using the standardized Dindo-Clavien classification. The primary end point was 30-day morbidity. Univariate and multivariate analysis was performed to identify predictors of complications. RESULTS: The study was discontinued due to significant results after interim analysis. A total of 125 patients were included in analysis from June 2011 to June 2012 and 15 were excluded because of incomplete data. Of 51 patients at nutritional risk 38 (74%) presented with at least 1 complication compared to 28 of 59 controls (47%). Patients at nutritional risk were at threefold risk for complications on univariate and multivariate analysis (OR 3.3, 95% CI 1.3-8.0). Cystectomy was the only other predictor of morbidity (OR 10, 95% CI 2-48). CONCLUSIONS: Patients at nutritional risk are more prone to complications after major urological procedures. Whether this increased morbidity can be reversed by perioperative nutritional support should be studied.

Safety of thrombolysis in stroke mimics: results from a multicenter cohort study.

BACKGROUND AND PURPOSE: Intravenous thrombolysis for acute ischemic stroke is beneficial within 4.5 hours of symptom onset, but the effect rapidly decreases over time, necessitating quick diagnostic in-hospital work-up. Initial time strain occasionally results in treatment of patients with an alternate diagnosis (stroke mimics). We investigated whether intravenous thrombolysis is safe in these patients. METHODS: In this multicenter observational cohort study containing 5581 consecutive patients treated with intravenous thrombolysis, we determined the frequency and the clinical characteristics of stroke mimics. For safety, we compared the symptomatic intracranial hemorrhage (European Cooperative Acute Stroke Study II [ECASS-II] definition) rate of stroke mimics with ischemic strokes. RESULTS: One hundred stroke mimics were identified, resulting in a frequency of 1.8% (95% confidence interval, 1.5-2.2). Patients with a stroke mimic were younger, more often female, and had fewer risk factors except smoking and previous stroke or transient ischemic attack. The symptomatic intracranial hemorrhage rate in stroke mimics was 1.0% (95% confidence interval, 0.0-5.0) compared with 7.9% (95% confidence interval, 7.2-8.7) in ischemic strokes. CONCLUSIONS: In experienced stroke centers, among patients treated with intravenous thrombolysis, only a few had a final diagnosis other than stroke. The complication rate in these stroke mimics was low.

Oculopalatal Tremor : Variations on a theme by Guillain and Mollaret

Le trémor oculo-palatin (TOP) est une complication tardive et rare faisant suite à une lésion au niveau du tronc cérébral. Il est caractérisé par des contractions involontaires du voile du palais (pratiquement toujours asymptomatique), synchronisées avec un nystagmus pendulaire à environ 2 Hz (toujours symptomatique, se manifestant par des oscillopsies). Un hypersignal du noyau de l'olive inférieure (HNOI) est visible en IRM ; l'HNOI persiste au fil des ans. Notre objectif était de mieux définir le profil clinique des patients avec un TOP. Pour ceci nous avons effectué une étude rétrospective de 8 patients présentant un TOP et avons compilé ces résultats avec les 82 cas que nous avons retrouvé dans la littérature mondiale (revue PubMed). L'âge moyen était de 54 ans, avec une prédominance masculine. L'étiologie la plus fréquente était une lésion vasculaire du tronc cérébral (80%). Un nystagmus pendulaire principalement vertical a été retrouvé dans 90% des cas. Un nystagmus dissocié était principalement associé à une HNOI controlatérale et unilatérale sur l'IRM. Un nystagmus bilatéral et symétrique résultait d'une HNOI bilatérale dans la majorité des cas. Trois singularités ont été retrouvées parmi nos 8 patients : 1) une HNOI ipsilatérale à un nystagmus dissocié ; 2) la persistance du nystagmus en cas de disparition de l'HNOI ; 3) la découverte d'un micronystagmus asymptomatique. Le profil clinique du TOP reste assez stéréotypé, malgré quelques variations possibles (cf nos trois singularités). Les oscillopsies sont parfois handicapantes et il n'existe pas à ce jour de traitement spécifique du TOP.

Surgical outcomes of Baerveldt aqueous shunt implantation versus combined phacoemulsification and Baerveldt aqueous shunt implantation

Purpose: To examine the efficacy and safety of Baerveldt shunt (BS) implantation compared to combined phacoemulsification and Baerveldt shunt implantation (PBS). This study was designed to detect a difference in IOP reduction of 20% (~4mmHg) between groups with 90% power. Methods: Sixty patients with medically uncontrolled glaucoma, prospectively underwent either or BS implantation with phacoemulsification (Group PBS; n=30) or BS implantation alone (group BS; n=30, pseudophakic eyes only). Groups were matched for age, glaucoma subtype and length of follow-up. Pre and post-operative measures recorded included patient demographics, visual acuity, IOP, number of glaucoma medications (GMs) and all complications. Success was defined as IOP≤21mmHg and 20% reduction in IOP from baseline with or without GMs. Results: Age of PBS and BS groups was 61 vs 62 years respectively (p=0.72*). There were no significant differences in preoperative baseline characteristics: PBS vs PB, mean IOP =25.5mmHg (standard deviation (SD); ±10.3mmHg) vs 26.1mmHg (SD ±10.6mmHg), p=0.81*; mean GMs=3.0 (SD ±1.1) vs 3.1 (SD ±1.0), p=0.83*; mean VA=0.3 vs 0.3, p=0.89*. At year one there were no significant differences observed between groups in post-operative IOP, GMs or VA, mean IOP =14.1mmHg (SD ±5.4mmHg) vs 11.5 mmHg (SD ±4.2mmHg), p=0.12*; mean GMs=1.6 (SD ±1.4) vs 1.1 (SD ±1.1), p=0.23*; mean VA=0.5 vs 0.4, p=0.46*. Complication rates were similar between the two groups (7% vs 14%). Success rate was lower in eyes with PBS (71%) than with BS (88%), however this did not reach statistical significance (p=0.95, log-rank test). * two-sample t-test Conclusions: There were no significant differences at year one in success or complication rates between PBS and BS groups suggesting that simultaneous phacoemulsification does not have a marked (difference of >4mmHg) effect on tube function. IOP reduction and success were less in the PBS group, a larger sample (n=120) would be required to investigate if there is a 10% difference in IOP reduction between groups, however it is unclear if this would be a clinically significant difference to justify separate surgeries.

Scleritis after proton therapy in uveal melanoma [Skleritis nach Protonentherapie bei Aderhautmelanom]

BACKGROUND: Sclera is a very radioresistant tissue and scleritis after proton therapy has not been described so far. HISTORY AND SIGNS: Four female patients, aged between 31 and 74 years, were treated with proton therapy for uveal melanoma (height range: 2.2 - 3.5 mm), located in the macula, the superior equator and 2 in the ciliary body. All patients had a history of a previous or active inflammatory disease and developed scleritis after radiotherapy. THERAPY AND OUTCOME: Two patients had infectious scleritis and were treated with adequate antibiotic therapy. After systemic corticotherapy, 3 patients recovered completely; the remaining patient was managed with additional immunosuppressive treatment as well as a conjunctival and scleral graft, but has not become pain free yet. CONCLUSION: Scleritis is a possible complication after proton therapy, probably on an ischemic basis, where there is a predisposing factor such as inflammatory systemic disease.