Doktor Seppo Laakso 15.4.1975 Tammerfors

Kirje

Evaluation d'une anisocorie et exemples de cas cliniques

L'anisocorie est une anomalie pupillaire fréquemment rencontrée en pratique clinique. Elle peut être physiologique, s'inscrire dans le cadre d'une atteinte oculaire, d'une paralysie pharmacologique, ou encore dans le cadre d'une maladie neurologique. Le but de cet article est de fournir au lecteur une approche systématique de ce problème qui lui permettra de déterminer dans la majorité des cas le mécanisme aboutissant à cette anisocorie.

Effect of fertilizer-N application and seed coating with rhizobial inoculants on soybean yield in eastern Paraguay

Nitrogen removal in soybean grains at harvest may exceed biological N2 fixation, particularly if grain yields are as high as typically achieved on "Terra Rossa" soils of Eastern Paraguay. Applying N fertilizer or coating seeds with rhizobial inoculants that enhance nodulation may represent a way of balancing the N budget. However, the effects of such treatments appear to be highly site-specific. The objective of this study was to examine the effects of N application (N) and rhizobial inoculation (I) on nodulation, N accumulation and soybean yields in Eastern Paraguay. Field experiments were conducted in two consecutive soybean seasons. Dry conditions in the first year delayed sowing and reduced plant number m-2 and pod number plant-1. Grain yields were generally below 2 t ha-1 but the +N+I treatment increased yields by about 75%. In the second year favorable conditions resulted in yields of around 4 t ha-1 and the treatments had no effect. Nitrogen accumulation was higher in the first year and could therefore not explain the observed yield differences between years and treatment combinations. The positive effect of the +N+I treatment in year one was associated with a more rapid root growth which could have reduced susceptibility to intermittent drought stress. Nodule biomass decreased between flowering and pod setting stages in the +I treatment whereas further increases in nodule biomass in the -I treatment may have led to competition for assimilates between nodules and developing pods. Based on these preliminary results we conclude that N application and seed inoculation can offer short-term benefits in unfavorable years without negative effects on yield in favorable years.

Urinalysis and pre-renal acute kidney injury: time to move on.

Urinary indices are classically believed to allow differentiation of transient (or pre-renal) acute kidney injury (AKI) from persistent (or acute tubular necrosis) AKI. However, the data validating urinalysis in critically ill patients are weak. In the previous issue of Critical Care, Pons and colleagues demonstrate in a multicenter observational study that sodium and urea excretion fractions as well as urinary over plasma ratios performed poorly as diagnostic tests to separate such entities. This study confirms the limited diagnostic and prognostic ability of urine testing. Together with other studies, this study raises more fundamental questions about the value, meaning and pathophysiologic validity of the pre-renal AKI paradigm and suggests that AKI (like all other forms of organ injury) is a continuum of injury that cannot be neatly divided into functional (pre-renal or transient) or structural (acute tubular necrosis or persistent).

Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients.

BACKGROUND: The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU). METHODS: Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRRT survivors. We conducted sensitivity analyses based on a range of differences for daily implementation cost between CRRT and IRRT (base case: CRRT day $632 more expensive than IRRT day; range from $200 to $1000) and a range of risk ratios for dialysis dependence for CRRT as compared with IRRT (from 0.65 to 0.95; base case: 0.80). RESULTS: Continuous renal replacement therapy was associated with a marginally greater gain in QALY as compared with IRRT (1.093 versus 1.078). Despite higher upfront costs for CRRT in the ICU ($4046 for CRRT versus $1423 for IRRT in average), the 5-year total cost including the cost of dialysis dependence was lower for CRRT ($37 780 for CRRT versus $39 448 for IRRT on average). The base case incremental cost-effectiveness analysis showed that CRRT dominated IRRT. This dominance was confirmed by extensive sensitivity analysis. CONCLUSIONS: Initial CRRT is cost-effective compared with initial IRRT by reducing the rate of long-term dialysis dependence among critically ill AKI survivors.