Feed the ICU patient 'gastric' first, and go post-pyloric only in case of failure.

In a randomised trial comparing early enteral feeding by gastric and post-pyloric routes, White and colleagues have shown that gastric feeding is possible and efficient in the vast majority of critically ill patients. But the authors' conclusion that gastric is equivalent to post-pyloric is true in only the least severe patients. Given the extra workload and costs, post-pyloric is now clearly indicated in case of gastric feeding failure.

Occurrence of sectoral choroidal occlusive vasculopathy and retinal arteriolar embolization after superselective ophthalmic artery chemotherapy for advanced intraocular retinoblastoma.

BACKGROUND: : Superselective ophthalmic artery chemotherapy (SOAC) has recently been proposed as an alternative to intravenous chemoreduction for advanced intraocular retinoblastoma. Preliminary results appear promising in terms of tumor control and eye conservation, but little is known regarding ocular toxicity and visual prognosis. In this study, we report on the vascular adverse effects observed in our initial cohort of 13 patients. METHODS: : The charts of 13 consecutive patients with retinoblastoma who received a total of 30 injections (up to 3 injections of a single agent per patient at 3-week interval) of melphalan (0.35 mg/kg) in the ophthalmic artery between November 2008 and June 2010 were retrospectively reviewed. RetCam fundus photography and fluorescein angiography were performed at presentation and before each injection. Vision was assessed at the latest visit. RESULTS: : Enucleation and external beam radiotherapy could be avoided in all cases but one, with a mean follow-up of 7 months. Sectoral choroidal occlusive vasculopathy leading to chorioretinal atrophy was observed temporally in 2 eyes (15%) 3 weeks to 6 weeks after the beginning of SOAC and retinal arteriolar emboli in 1 eye 2 weeks after injection. There was no stroke or other clinically significant systemic side effects except a perioperative transient spasm of the internal carotid artery in one patient. Vision ranged between 20/1600 and 20/32 depending on the status of the macula. CONCLUSION: : Superselective ophthalmic artery chemotherapy was effective in all patients with no stroke or other systemic vascular complications. Unlike intravenous chemoreduction, SOAC is associated with potentially sight-threatening adverse effects, such as severe chorioretinal atrophy secondary to subacute choroidal occlusive vasculopathy or central retinal artery embolism, not to mention the risk of ophthalmic artery obstruction, which was not observed in this series. Further analysis of the risks and benefits of SOAC will define its role within the therapeutic arsenal. Meanwhile, we suggest that SOAC should be given in one eye only and restricted to advanced cases of retinoblastoma, as an alternative to enucleation and/or external beam radiotherapy.

Asymptomatic high flow subclavian steal in a patient with hemodialysis access.

Subclavian steal phenomenon due to proximal subclavian artery stenosis or occlusion is not un-common but often remains asymptomatic. We describe the case of a 66-year-old man with end-stage renal disease hemodialysed through a brachio-brachial loop graft of the left forearm. Echo-Doppler precerebral examination showed a high reversed flow of 570 ml/min in the ipsilateral vertebral artery. After successful endovascular recanalization of the subclavian artery, access blood flow increased and vertebral flow decreased to 30 ml/min. Complete neurological examination was normal both before and after endovascular treatment. This case demonstrates how high a subclavian steal can be without causing symptoms and how well precerbral and cerebral circulation can adapt to hemodynamic changes.

Le traitement de l'hypertension artérielle: quel médicament pour quelle malade [The treatment of arterial hypertension: which drug for which patient?]

Hypertension is a multifactorial disease. Various antihypertensive drugs can lower arterial pressure in a given patient in a more or less efficient way. The sequential testing of several drugs is most promising for lowering blood pressure by monotherapy. If necessary a drug combination is preferable to dose adjustments of a single substance because of the risk for side effects growing with the dose.

Peut-on construire une alliance thérapeutique avec un patient incarcéré ?

La prison et l'évolution actuelle de la pénalité illustrent de façon paradigmatique les multiples contraintes qui viennent de plus en plus enserrer l'acte de soin. Contrainte spatiale et sensorielle par la restriction de l'espace et des mouvements consécutive à l'incarcération, contrainte réglementaire par le régime strict et stéréotypé qu'elle impose, légale par l'implication de la décision de justice sur l'avenir du patient, contrainte au soin lui-même par les injonctions qui se développent dans un but de prévention de la récidive et de diminution de la dangerosité sociale.

Hypertension is an independent predictor of mean platelet volume in patients with acute ischaemic stroke.

Introduction: Mean platelet volume (MPV) was shown to be significantly increased in patients with acute ischaemic stroke, especially in non-lacunar strokes. Moreover, some studies concluded that increased MPV is related to poor functional outcome after ischaemic stroke, although this association is still controversial. However, the determinants of MPV in patients with acute ischaemic stroke have never been investigated. Subjects and methods: We recorded the main demographic, clinical and laboratory data of consecutive patients with acute (admitted within 24 h after stroke onset) ischaemic stroke admitted in our Neurology Service between January 2003 and December 2008. MPV was generated at admission by the Sysmex XE-2100 automated cell counter (Sysmex Corporation, Kobe, Japan) from ethylenediaminetetraacetic acid blood samples stored at room temperature until measurement. The association of these parameters with MPV was investigated in univariate and multivariate analysis. Results: A total of 636 patients was included in our study. The median MPV was 10.4 ± 0.82 fL. In univariate analysis, glucose (β= 0.03, P= 0.05), serum creatinine (β= 0.002, P= 0.02), haemoglobin (β= 0.009, P < 0.001), platelet count (β=-0.002, P < 0.001) and history of arterial hypertension (β= 0.21, P= 0.005) were found to be significantly associated with MPV. In multivariate robust regression analysis, only hypertension and platelet count remained as independent determinants of MPV. Conclusions: In patients with acute ischaemic stroke, platelet count and history of hypertension are the only determinants of MPV.

La fonction de Moi auxiliaire dans la prise en charge des douloureux chroniques [The role of the auxiliary ego in the care of the chronic pain patient]

La prise en charge des patients souffrant de douleurs chroniques, à l'interface entre corps et psyché, nécessite une approche globale et souvent un réseau de soins coordonnés, contenant et stable. La psychiatrie de liaison a naturellement trouvé sa place dans ce réseau de soins spécifiques auprès des différents soignants impliqués. Les réflexions issues de cette expérience ont pour objectif de mieux comprendre le rôle thérapeutique des soignants et font émerger la notion de Moi auxiliaire comme élément clé dans le traitement de ces patients. Dans cet article, nous reprendrons les fondements historiques et conceptuels de la fonction de Moi auxiliaire pour nous intéresser à ses différentes applications dans ces prises en charge : consultation médicale, psychothérapie individuelle ou de groupe, colloque interdisciplinaire. The management of the patient suffering from chronic pain, situated on the interface between body and psyche, necessitates a global approach and often a coordinated, stable and containing network of care. Liaison psychiatry has become part of this network, together with various health care professionals from somatic disciplines. Based on these experiences, this article aims to better understand the therapeutic role of those who take care of the chronic pain patient by identifying the auxiliary ego as a key element of care. The historical development and conceptual framework of the auxiliary ego are utilized to highlight its roles in the different aspects of care of these patients:in the medical consultation, individual psychotherapy, group psychotherapy and in the interdisciplinary meetings.

Miller-Fisher syndrome in a patient with rheumatoid arthritis treated with adalimumab.

Adalimumab is a frequently prescribed TNFalpha inhibitor for treatment of rheumatoid arthritis. We report on a patient who probably developed a Miller-Fisher syndrome after the second injection of adalimumab.

Analysis of patient physical restraints usage in a Swiss emergency service

Introduction: Emergency services (ES) are often faced with agitated,confused or aggressive patients. Such situations may require physicalrestraint. The prevalence of these measures is poorly documented,concerning 1 to 10% of patients admitted in the ES. The indications forrestraint, the context and the related complications are poorly studied.The emergency service and the security service of our hospital havedocumented physical restraint for several years, using specific protocolsintegrated into the medical records. The study evaluated the magnitudeof the problem, the patient characteristics, and degree of adherence tothe restraint protocol.Methods: Retrospective study of physical restraint used on adultpatients in the ES in 2009. The study included analysis of medical anddemographic characteristics, indications justifying restraint and qualityof restraint documentation. Patients were identified from computerizedES and security service records. The data were supplemented byexamination of patients' medical records.Results: In 2009, according to the security service, 390 patients (1%)were physically restrained in the ES. The ES computerized systemidentified only 196 patients. Most patients were male (62%). The medianage was 40 years (15-98 years; P90 = 80 years). 63 % of the situationsoccurred between 18h00 and 6h00, and most frequently on Saturday(19%). Substance or alcohol abuse was present in 48.7% of cases andacute psychiatric crisis was mentioned in 16.7%. In most cases,restraint was motivated by extreme agitation or auto / hetero-aggressiveviolence. Most patients (68 %) were restrained with upper limb andabdominal restraints. More than three anatomic restraints werenecessary in 52 % of the patients. Intervention of security guards wasrequired in 77% of the cases. 61 restraint protocols (31 %) were missingand 57% of the records were incomplete. In many cases, the protocolsdid not include the signature of the physician (22%) or of the nurse(43.8%). Medical records analysis did not allow reliable estimation ofthe number of restraint-induced complications.Conclusions: Physical restraint is most often motivated by majoragitation and/or secondary to substance abuse. Caregivers regularlycall security guards for help. Restraint documentation is often missing orincomplete, requiring major improvement in education and prescription.

L'activité des professionnel-le-s de la santé comme objet de recherche : une exploration de l'erreur médicale et de la notion de centration sur le patient

Présentation La littérature montre que le problème de l'erreur médicale est loin d'être sous contrôle, malgré les efforts déployés pour améliorer la sécurité des soins. Le problème de l'erreur est éminemment complexe et doit être abordé sous différents angles. Une approche possible du problème est l'expérience des médecins face à l'erreur. A quoi les médecins attribuent-ils une erreur et comment font-ils face à une erreur dont ils se sentent responsables ? Quels mécanismes de coping sont mis en oeuvre ? Ces questions ne sont pas banales car certains médecins vont typiquement montrer des réactions défensives visant à minimiser leurs responsabilités et d'autres vont montrer des réactions constructives visant à amener des changements concrets dans leur pratique ou dans le système de soins. Enjeux Cette recherche vise à mieux comprendre les facteurs qui influencent l'expérience de l'erreur et les mécanismes de coping après une erreur. Plus spécifiquement, cette recheche vise à explorer l'influence du genre. Les études disponibles sont quantitatives et n'abordent pas en profondeur l'expérience individuelle de femmes médecins. C'est dans ce créneau-là qu'a voulu se positionner cette recherche, en proposant une approche qualitative par interview. Contexte de recherche Le contexte général est l'expérience de l'erreur vécue par des femmes médecins. Afin de resserrer le cadre du projet, le recrutement a été ciblé sur (1) des médecins particulièrement à risque d'erreurs, c'est-à-dire des médecins novices, en formation postgraduée, et (2) des femmes travaillant en médecine interne hospitalière, un passage obligé pour nombre de médecins en formation. L'étude a été conduite au sein du Service de médecine interne du CHUV, avec 8 médecins-assistantes. Conclusions L'étude a révélé que la culture de l'erreur et de la sécurité est encore insuffisamment développée dans notre contexte de formation postgraduée et que l'expérience de l'erreur reste très douloureuse pour les médecins-assistantes. Le soutien de ia hiérarchie varie beaucoup et certaines assistantes se sentent clairement stigmatisées en situation d'erreur. Quant aux statégies de coping, nos données semblent indiquer un effet « genre » dans le type de statégies privilégiées. Certaines stratégies sont ciblées sur l'émotion et visent à minimiser l'impact émotionnel de l'erreur sur l'individu ; d'autres ciblées sur le problème et visent à engager des changements destinés à prévenir une récidive. Perspectives La profession médicale et les milieux de formation doivent travailler à une culture plus transparente de l'erreur. Avec une meilleure culture et un meilleur soutien des médecins exposées à l'erreur, il sera plus facile de les amener à des changements constructifs après une erreur. Des conclusions plus précises sur un effet « genre » impliquent de procéder à une comparaison directe entre médecins- assistants et médecins-assistantes. Contribution du doctorant J'ai eu l'idée initiale du projet, tandis que la perspective genre a été proposée par la première auteure, Cindy Ottiger Mankaka. J'ai supervisé l'ensemble du projet et apporté une contribution susbtantielle au manuscript en assurant la totalité du processus de soumission-révisions.

Nocardiose disséminée à Nocardia brasiliensis chez un patient ambulatoire [Disseminated nocardiosis due to Nocardia brasiliensis in an ambulatory patient].

We report the case of a 76-year-old man with generalized nocardiosis. The microbiologic pattern, the different clinical manifestations and the treatment of nocardiosis are discussed in general. In the particular case of our patient the disease manifested itself primarily as a subcutaneous abscess, a metastasis secondary to pulmonary nocardiosis. The disease was caused by a Nocardia brasiliensis, which is rarely seen in Europe and which does not usually cause a generalized form of nocardiosis.

Individual patient data systematic review and meta-analysis of optic nerve sheath diameter ultrasonography for detecting raised intracranial pressure: protocol of the ONSD research group.

BACKGROUND: The purpose of the optic nerve sheath diameter (ONSD) research group project is to establish an individual patient-level database from high quality studies of ONSD ultrasonography for the detection of raised intracranial pressure (ICP), and to perform a systematic review and an individual patient data meta-analysis (IPDMA), which will provide a cutoff value to help physicians making decisions and encourage further research. Previous meta-analyses were able to assess the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP but failed to determine a precise cutoff value. Thus, the ONSD research group was founded to synthesize data from several recent studies on the subject and to provide evidence on the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP. METHODS: This IPDMA will be conducted in different phases. First, we will systematically search for eligible studies. To be eligible, studies must have compared ONSD ultrasonography to invasive intracranial devices, the current reference standard for diagnosing raised ICP. Subsequently, we will assess the quality of studies included based on the QUADAS-2 tool, and then collect and validate individual patient data. The objectives of the primary analyses will be to assess the diagnostic accuracy of ONSD ultrasonography and to determine a precise cutoff value for detecting raised ICP. Secondly, we will construct a logistic regression model to assess whether patient and study characteristics influence diagnostic accuracy. DISCUSSION: We believe that this IPD MA will provide the most reliable basis for the assessment of diagnostic accuracy of ONSD ultrasonography for detecting raised ICP and to provide a cutoff value. We also hope that the creation of the ONSD research group will encourage further study. TRIAL REGISTRATION: PROSPERO registration number: CRD42012003072.

Pure monoparesis: a particular stroke subgroup?

BACKGROUND: Acute stroke presenting as monoparesis is rare, with a pure motor deficit in the arm or leg extending to an isolated facial paresis. OBJECTIVE: To raise the question if acute stroke presenting as monoparesis is a different entity from stroke with a more extensive motor deficit. PATIENTS: In the Lausanne Stroke Registry (1979-2000), 195 (4.1%) of 4802 patients met the clinical criteria for pure monoparesis involving the face (22%), arm (63%), or leg (15%). RESULTS: In the vast majority of cases (> 95%), monoparesis corresponded to ischemic stroke with a favorable outcome, with initial computed tomography scans or magnetic resonance images showing no signs of hemorrhage. The lesion for a facial deficit was most frequently located subcortically (internal capsule); for an arm deficit, in the superficial middle cerebral artery; and for a leg deficit, in the anterior cerebral artery territory. In pure monoparesis, only 17% of the patients had more than 1 risk factor as compared with 26% of those with bimodal and trimodal hemiparesis and with 46% of all patients with stroke other than those with pure motor stroke. The only frequent risk factor was hypertension (53%); however, this frequency was no different from that in other patients with stroke. No major stroke etiology could be identified in any of the 3 subgroups of monoparesis. CONCLUSION: Our finding of a wide range of stroke localization and etiology in monoparesis without any particular subgroup suggests that no specific plan of investigation can be recommended for these patients.

The International LAM Registry: a component of an innovative web-based clinician, researcher, and patient-driven rare disease research platform.

BACKGROUND: A relative inability to capture a sufficiently large patient population in any one geographic location has traditionally limited research into rare diseases. METHODS AND RESULTS: Clinicians interested in the rare disease lymphangioleiomyomatosis (LAM) have worked with the LAM Treatment Alliance, the MIT Media Lab, and Clozure Associates to cooperate in the design of a state-of-the-art data coordination platform that can be used for clinical trials and other research focused on the global LAM patient population. This platform is a component of a set of web-based resources, including a patient self-report data portal, aimed at accelerating research in rare diseases in a rigorous fashion. CONCLUSIONS: Collaboration between clinicians, researchers, advocacy groups, and patients can create essential community resource infrastructure to accelerate rare disease research. The International LAM Registry is an example of such an effort. 82.

Construct validity of the French version of the PRWE (Patient Rated Wrist Evaluation) with the French version of the DASH (Disabilities Arm Shoulder and Hand) is good to very good in a population of patients with wrist injuries in an inpatient rehabilitation unit

Objective.- The Patient-Rated Wrist Evaluation is a specific questionnaire for the wrist [1]. It consists of 15 questions with a total score of 100. It was recently translated into French [2]. However, its validity has not been tested in this language. The Disabilities Arm Shoulder and Hand (DASH), with well-established psychometric properties, is considered as the reference questionnaire for the evaluation of upper extremities. The objective of this study is to measure the construct validity of the PRWE-F with the DASH-F in patients with wrist pathology.Patients and methods.- Fifty-one patients (40 m, 11 w, mean age 42 years), 25 fractures of the radius and 26 lesions of the carpus.Questionnaires PRWE-F and DASH-F at entry and at discharge (0 to 100). Calculation of the construct validity of the PRWE-F comparing with the DASH-F with Pearson correlation coefficients (r) at entry and at discharge. Level of significance (alpha) was set at 5%.Results.- Correlation DASH/PRWE at entry: r = 0.799 (95% CI 0.671 to 0.881), P < 0.0001. Correlation DASH/PRWE at discharge: r = 0.847 (95% CI: 0.745 to 0.910), P < 0.0001.Discussion.- The construct validity of the two instruments indicates that they measure the same concept. Our correlation between DASH-F and PRWE-F, going from 0.799 to 0.847, are comparable to those published in different languages (0.71 to 0.84) [3,4]. The questionnaires PRWE-F can thus be used in rehabilitation patients presenting with wrist pathologies; it is comparable to the DASH but described by MacDermid [1] to be more specific. Compared to the DASH it has the advantage of consisting of two dimensions. Its construct validity is excellent. This questionnaire should be evaluated in other populations, and it should be compared with hand questionnaires more specific than the DASH.