Nouvelles techniques radiologiques pour les patients insuffisants rénaux [New radiological techniques to investigate patients suffering from chronic kidney disease].

Radiological investigations using gadolinium or intravenous iodinated contrast products are used cautiously in patients suffering from chronic kidney disease because of their risk of acute kidney injury and systemic nephrogenic fibrosis. In this article, we review several radiological alternatives that can be useful to obtain renal anatomical and/or functional information in this patient population. The basic principles, indications, and advantages and limitations of Doppler ultrasound with measurement of the resistance index, contrast-enhanced ultrasound, and a technique called BOLD-MRI (blood-oxygenation level dependent-MRI) are discussed.

Drogues récréatives: le plaisir des complications [Recreational drugs: the complication's pleasure?].

Steadily increasing since 1990, the use of psychoactive substances was expanded to new designer drugs (bath salts, spice) with so original still unknown pharmacological effects. At the beginning, the pleasure, first feeling, turns sometimes, in acute medical emergency and then, in some cases, in chronic diseases. Side expected or not desired effects, seen in emergency departments could be necrotizing gangrene among consumers Krokodil or dystonic reactions in consumers of Spice. Moreover, adulterants could increase the dangerosity of the substances. Searching a toxidrome helps to find the incrimining substance.

Anemia and chronic kidney disease are potential risk factors for mortality in stroke patients : a historic cohort study

Rapport de synthèseApproche et objectifL'objectif de la recherche était de préciser les relations existant entre l'insuffisance rénale chronique, l'anémie et l'accident vasculaire cérébral parmi des patients hospitalisés au Centre Hospitalier Universitaire Vaudois (CHUV) pour un accident vasculaire cérébral (AVC). Les auteurs ont déterminé la prévalence de l'anémie et de l'insuffisance rénale chronique parmi ces patients et examiné s'ils sont des facteurs de risque indépendants de la mortalité suite à un AVC.L'insuffisance rénale chronique est associée à un risque élevé de développer un AVC. L'anémie est une complication et une conséquence fréquente qui découle de l'insuffisance rénale chronique et est également un facteur de risque pour les maladies cérébro- et cardiovasculaires.MéthodeLa présente étude de cohorte rétrospective se base sur le registre des AVC du CHUV et inclut tous les patients traités suite à un premier AVC au service de neurologie du CHUV entre les années 2000 et 2003.Les variables utilisées pour l'analyse sont les caractéristiques démographiques, l'insuffisance rénale chronique, le débit de filtration glomérulaire.(GFR), l'anémie et d'autres facteurs de risque d'AVC. Ils ont été récoltés au moyen du système informatique du laboratoire du CHUV, d'entretiens téléphoniques (patients ou proches) et du registre des AVC du CHUV.L'insuffisance rénale chronique a été calculée sur base de la ,,Kidney Disease Outcomes Quality Initiative (K/DOQI)-CKD Classification", laquelle est divisée en cinq stades. L'anémie a été définie par une hémoglobine de < 120g/L pour les femmes et < 130g/L pour les hommes.Les analyses statistiques réalisées sont des tests Chi-carré, des tests de Τ ainsi que des courbes de Kaplan-Meier et le modèle de régression de Cox.RésultatsParmi 890 patients adultes avec un AVC, le GFR moyen était de 64.3 ml/min/1.73 m2, 17% souffraient d'anémie et 10% sont décédés pendant la première année après la sortie de l'hôpital, suite à l'"AVC index". Parmi ceux-ci, 61% avaient une insuffisance rénale chronique de stade 3-5 et 39% de stade 1 ou 2 selon les critères de K/DOQI.D'autre part un taux d'hémoglobine élevé a pu être associé à un risque moins élevé de mortalité un an après la sortie de l'hôpital.Conclusion et perspectiveNous avons constaté que l'anémie ainsi que l'insuffisance rénale chronique sont fréquents parmi les patients souffrant d'un AVC et qu'ils sont des facteurs de risque d'un taux de mortalité élevé après un an. En conséquence, il pourrait être utile de traiter les patients souffrant d'anémie et d'insuffisance rénale dès que possible afin de diminuer les complications et comorbidités résultants de ces maladies.La perspective est de rendre les cliniciens attentif à l'importance de l'insuffisance rénale et de l'anémie parmi les patients ayants développé un AVC, ainsi que d'initier le traitement approprié afin de diminuer les complications, les comorbidités ainsi que les récidives d'un AVC. L'efficacité et l'économicité des interventions visant à améliorer le pronostic chez les patients présentant un AVC et souffrant d'une insuffisance rénale chronique et / ou d'une anémie doivent être évaluées par des études appropriées.

Hepatitis E Virus seroprevalence and chronic infections in patients with HIV, Switzerland.

We screened 735 HIV-infected patients in Switzerland with unexplained alanine aminotransferase elevation for hepatitis E virus (HEV) immunoglobulin G. Although HEV seroprevalence in this population is low (2.6%), HEV RNA can persist in patients with low CD4 cell counts. Findings suggest chronic HEV infection should be considered as a cause of persistent alanine aminotransferase elevation.

Chronic rejection of allogenic dermal grafts in 73 % TBSA burn patient

Rationale: Allogenic grafts are an excellent way to temporarily cover a wound. It prevents the loss of electrolytes and water, reduces the risk of infection and diminishes pain. Another advantage of the allograft is in circumventing problems such as the morbidity of skin graft donor sites. We present here the case of a patient grafted in 1991 with cultured epidermal autografts (CEA) and allogenic skin transplants on his legs, outlining the risks and potential long-term complications. Methods: The 40-year-old male patient was treated with allogenic Split Thickness Skin Graft (STSG) transplantations, CEA and Cyclosporine-A therapy. Allogenic STSG for lower extremities were harvested from a female HIV-negative organ donor. They were transplanted, de-epithelialized and subsequently covered with CEAs. Cyclosporine-A was administered systemically from the first day following transplantation until three weeks after the last CEAs were placed on the allogenic dermis. Results: Immediate results showed a 90% successful grafting under cyclosporine therapy. However, some lesions were still present 16 months later. The skin was hard with little or no elasticity. Five years after the transplantation there were no more lesions. However, a 10-year follow-up showed new ulcers on both lower extremities. All the skin of the right leg was removed and replaced by STSG from the patient's back. Postoperative results were excellent with a 100% graft take. The anatomopathology showed dermo-hypodermic tissue with fibrosis of the dermis, vasculopathy and chronic ulcers compatible with chronic rejection. Conclusion: While early functional results of the allografts may seem encouraging, their long-term evolution remains uncertain and, in this case, presents complications. The apparent antigenic effect of the dermal tissue may be controlled with long-term immunosuppression which may cause important secondary effects. Even with such treatments, 15 years after organ transplantation, about 35% of a transplant is no longer functional. It is therefore important to take these long-term observations into consideration when treating sensitive areas such as hands or a face.

Diagnosis and management of chronic obstructive pulmonary disease: the swiss guidelines: official guidelines of the Swiss Respiratory Society.

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

Polyanalgesic Consensus Conference-2012: Recommendations to Reduce Morbidity and Mortality in Intrathecal Drug Delivery in the Treatment of Chronic Pain.

Introduction:  Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality. Methods:  The Polyanalgesic Consensus Conference is a meeting of experienced implanting physicians who strive to improve care in those receiving implantable devices. Employing data generated through an extensive literature search combined with clinical experience, this work group formulated recommendations regarding awareness, education, and mitigation of the morbidity and mortality associated with intrathecal therapy to establish best practices for targeted intrathecal drug delivery systems. Results:  Best practices for improved patient care and outcomes with targeted intrathecal infusion are recommended to minimize the risk of morbidity and mortality. Areas of focus include respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error. Specific guidance is given with each of these issues and the general use of the therapy. Conclusions:  Targeted intrathecal drug delivery systems are associated with risks for morbidity and mortality that can be devastating. The panel has given guidance to treating physicians and healthcare providers to reduce the incidence of these problems and to improve outcomes when problems occur.

Pseudomonas aeruginosa et maladie broncho-pulmonaire chronique obstructive [Pseudomonas aeruginosa in chronic obstructive pulmonary disease].

The role of Pseudomonas aeruginosa isolated in sputum cultures from adults with obstructive chronic pulmonary disease (COPD) is not well known. However, this pathogen has many factors of virulence and is responsible for several clinical manifestations in this setting. Isolation of a new strain of Pseudomonas is associated with a significant risk of exacerbation of the COPD and its prevalence depends on the severity of the COPD. The role of Pseudomonas among patients with COPD apart from exacerbations is less clear, but it could be responsible for an ignition for the airways and progression for the disease. Currently, the relevance of a prophylactic antibiotic therapy has not yet been demonstrated in COPD holders of Pseudomonas.

Retrospective analysis of complications of immunosuppressive therapies (steroidsand immunosuppressive therapies) in pediatric uveitis

Purpose¦The purpose of this study is to analyze the incidence rate of side effects occurring during systemic therapy (corticosteroids, methotrexate, azathioprine, cyclosporine A or biologic agents) of auto-immune uveitis.¦Material and methods¦Retrospective study including 23 / 71 patients aged between 0-16 years old presenting with a chronic non-infectious uveitis. All children were treated in the Jules-Gonin Eye Hospital and paediatric rheumatology unit of the CHUV (Centre Hospitalier Universitaire Vaudois) between January 2000 and December 31st 2010. Side effects were reported as minor (without subsequent change in systemic medication), moderate (associated with a change in systemic dosage or class of immunosuppressive therapy or in the presence of Cushingoid face or weight gain) or severe (hospitalization or life threatening).¦Results¦52% of boys and 48% of girls are present in the cohort with a mean age at the first visit of 8.1 years (1.7-15.6). Intermediate uveitis consisted of the commonest aetiology with 8 patients (35%), juvenile idiopathic arthritis (JIA) in 7 (30%), Behçet's disease in 3 (13%) and others in 5 (22%). The overall length of therapy was longer for prednisone (26.6 ± 5.4 patient / year), but was similar between methotrexate (22.1 ± 5.4 patient / year) and azathioprine (15.2 patient / year). Moderate side effects were respectively 64% for corticosteroids therapy, 54% with methotrexate and 14% with azathioprine. One severe and one moderate side effect were observed with anti-TNFα respectively stage III anaphylactic shock and pain during injection associated with a redness of the site of injection and limping after the injection.¦Discussion¦Immunomodulating agents allow a rapid decrease in corticosteroid therapy, but one severe side effect was observed with anti-TNFa agents. These agents are considered in most countries as third line therapeutic agents.

Incontinence urinaire à la toux au cours des pneumopathies interstitielles diffuses [Urinary incontinence due to chronic cough in interstitial lung disease]

INTRODUCTION: Urinary stress incontinence affects 10% to 30% of the female population and may have a major impact on psychosocial health. In interstitial lung disease, chronic cough may lead to development of urinary incontinence, but the prevalence and impact of this symptom are unknown. OBJECTIVES: To determine the rate and impact of urinary stress incontinence among women with chronic cough due to interstitial lung disease. METHODS: 28 female patients with chronic cough secondary to interstitial lung disease and 15 controls were evaluated by questionnaires to determine the prevalence of cough-related urinary incontinence, its severity, and its impact on quality of life. RESULTS: Cough-related urinary incontinence was present in 14/28 patients with interstitial lung disease and chronic cough (50%), but in only 1/15 controls (7%, p=0.005). On a 5-points quality of life scale, the median impact of urinary incontinence was 3 (minimum=1, maximal=5), and the median impact of chronic cough was 3.5. The majority of patients (64%) believed that incontinence was a natural phenomenon due to ageing, all were ashamed by this symptom and 79% were unable to mention it to their caring physician. Only one physician had previously addressed this issue. CONCLUSION: Cough-related urinary incontinence is common in patients with interstitial lung disease and is largely overlooked. It may significantly alter quality of life. A systematic questioning by the physician would allow to promptly refer these patients for appropriate therapeutic interventions, such as perineal training.

Urological complications in renal transplantation from cadaveric donor grafts: a retrospective analysis of 20 years.

INTRODUCTION: This study is a retrospective analysis of ureteral complications and their management from a monocenter series of 277 consecutive renal transplantations. MATERIALS AND METHODS: From September 1979 to June 1999, 277 renal transplantations (cadaveric origin) were performed in 241 patients. The ureter from the kidney graft was inserted into the bladder according to the technique of extravesical implantation described by Lich-Gregoir and Campos-Freire. The study analyzed the time of occurrence and the type of complications observed. The different procedures to restore the transplanted urinary tract are presented. RESULTS: Complications occurred in 43/277 renal transplantations (15.5%). Anastomotic urine leakage or ureteral stricture were the most frequent. The time to appearance of these complications was either short (<1 month) or late (>1 month) in a similar number of cases. Most cases were managed surgically: 33/43 cases (76.7%). The most frequent surgical repair was ureterovesical reimplantation (n=13), followed by: ureteroureteral end-to-end anastomosis (native ureter-ureter transplant, n=5); pyeloureteral anastomosis (native ureter-renal pelvis transplant, n=5); simple revision of ureterovesical implantation (n=4); resection and end-to-end anastomosis of the transplant ureter (n=2); calico-vesicostomy (graft-bladder, n=1); implantation according to Boari (n=1); pyelovesicostomy with bipartition of bladder (n=1), and pyeloileocystoplasty with detubularized ileal graft (n=1). No deaths related to any of the urological complications were reported. However, 2 consecutive vesico-renal refluxes led to the loss of the kidney graft in the long-term. CONCLUSION: The rate of complications observed in this retrospective analysis is similar to the experience of other studies, ranging from 2 to 20%. If the classical extravesical ureteral bladder implantation is to remain an attractive technique due to its simplicity, the surgical team at the training center should be aware of all the means to prevent any ureteral complications, such as the choice of another implantation technique and/or insertion of a transient ureteral stent.

Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system.

OBJECTIVE: Most symptomatic chronic subdural hematomas are treated by subdural drainage. However, a subperiostal (i.e., extracranial) passive closed-drainage system in combination with double burr hole trepanation is used at our institution. Therefore, we wanted to analyze our results and compare them with the alternate treatment strategies reported in the current literature. METHODS: In a retrospective single-center study, we analyzed the data of all patients undergoing double burr hole trepanation with a subperiostal passive closed-drainage system. Data analysis included general patient data, complications, postoperative seizure rate, and outcome. RESULTS: One hundred forty-seven patients underwent surgery for 183 symptomatic chronic subdural hematomas. The perioperative mortality rate was 3.4%. Hematoma persistence or recurrence occurred in 13.1% of the cases. The postoperative seizure rate was 6.6%, and the infection rate was 1.6%, including 3 cases of superficial wound infection and 1 case with deep infection. The reintervention rate was 9.3%, including trepanation in 8.2% of the patients and craniotomy in 1.1%. The overall complication rate was 10.9%. CONCLUSION: Double burr hole trepanation combined with a subperiostal passive closed-drainage system is a technically easy, highly effective, safe, and cost-efficient treatment strategy for symptomatic chronic subdural hematomas. The absence of a drain in direct contact with the hematoma capsule may moderate the risk of postoperative seizure and limit the secondary spread of infection to intracranial compartments.

Critical single proximal left arterial descending coronary artery stenosis to mimic chronic myocardial ischemia: a new model induced by minimal invasive technology.

BACKGROUND/AIMS: The present report examines a new pig model for progressive induction of high-grade stenosis, for the study of chronic myocardial ischemia and the dynamics of collateral vessel growth. METHODS: Thirty-nine Landrace pigs were instrumented with a novel experimental stent (GVD stent) in the left anterior descending coronary artery. Eight animals underwent transthoracic echocardiography at rest and under low-dose dobutamine. Seven animals were examined by nuclear PET and SPECT analysis. Epi-, mid- and endocardial fibrosis and the numbers of arterial vessels were examined by histology. RESULTS: Functional analysis showed a significant decrease in global left ventricular ejection fraction (24.5 +/- 1.6%) 3 weeks after implantation. There was a trend to increased left ventricular ejection fraction after low-dose dobutamine stress (36.0 +/- 6.6%) and a significant improvement of the impaired regional anterior wall motion. PET and SPECT imaging documented chronic hibernation. Myocardial fibrosis increased significantly in the ischemic area with a gradient from epi- to endocardial. The number of arterial vessels in the ischemic area increased and coronary angiography showed abundant collateral vessels of Rentrop class 1. CONCLUSION: The presented experimental model mimics the clinical situation of chronic myocardial ischemia secondary to 1-vessel coronary disease.

Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.

BACKGROUND: Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR). METHODS AND RESULTS: Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%). CONCLUSIONS: The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft-induced injury at surgery or necropsy in half of the patients.

Characteristics of patients with chronic hepatitis C who develop hepatocellular carcinoma.

BACKGROUND AND AIM: Hepatocellular carcinoma (HCC) is the most frequent form of primary liver cancer and chronic infection with hepatitis C virus is one of the main risk factors for HCC. This study analyses the characteristics of the patients with chronic hepatitis C participating in the Swiss Hepatitis C Cohort Study who developed HCC. METHODS: Analysis of the database of the Swiss Hepatitis C Cohort Study, a multicentre study that is being carried out in eight major Swiss hospitals since the year 2000. Patients with chronic hepatitis C and HCC were regrouped and compared to the patients without HCC. RESULTS: Among the 3,390 patients of the cohort, 130 developed an HCC. Age was one of the determining factors. Cirrhosis and its complications ascites and porto-systemic encephalopathy were associated with HCC. Males presented a higher risk for HCC than females. Alcohol consumption was associated with HCC. Diabetes mellitus was an important risk factor, especially in patients with low fibrosis. Patients with Hepatitis C genotype 2 had significantly less HCC than patients with other genotypes. A low socioeconomic status (income, education, profession) was associated with HCC. CONCLUSIONS: Beside the expected characteristics (age, gender, cirrhosis, alcohol), these data stress the role of diabetes mellitus and reveal the importance of low socioeconomic status as a risk factor for HCC in Swiss patients infected with hepatitis C virus. This vulnerable population should be closely monitored.