Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia.

BACKGROUND: Postanoxic status epilepticus (PSE) is considered a predictor of fatal outcome and therefore not intensively treated; however, some patients have had favorable outcomes. The aim of this study was to identify favorable predictors for awakening beyond vegetative state in PSE. METHODS: We studied six subjects treated with hypothermia improving beyond vegetative state after cerebral anoxia, despite PSE. They were among a cohort of patients treated for anoxic encephalopathy with therapeutic hypothermia in our institution between October 1999 and May 2006 (retrospectively, 3/107 patients) and June 2006 and May 2008 (prospectively, 3/74 patients). PSE was defined by clinical and EEG criteria. Outcome was assessed according to the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). RESULTS: All improving patients had preserved brainstem reflexes, cortical somatosensory evoked potentials, and reactive EEG background during PSE. Half of them had myoclonic PSE, while three had nonconvulsive PSE. In the prospective arm, 3/28 patients with PSE showed this clinical-electrophysiologic profile; all awoke. Treatments consisted of benzodiazepines, various antiepileptic drugs, and propofol. One subject died of pneumonia in a minimally conscious state, one patient returned to baseline (CPC1), three had moderate impairment (CPC2), and one remained dependent (CPC3). Patients with nonconvulsive PSE showed a better prognosis than subjects with myoclonic PSE (p = 0.042). CONCLUSION: Patients with postanoxic status epilepticus and preserved brainstem reactions, somatosensory evoked potentials, and EEG reactivity may have a favorable outcome if their condition is treated as status epilepticus.

Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema

BACKGROUND: The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema was assessed in a consecutive series of 328 patients between 1992 and 2002. An analysis of the predicting factors for conversion thoracotomy in presumed stage II empyema was performed. METHODS: Empyema stage III with pleural thickening and signs of restriction on computer tomography imaging was treated by open decortication, whereas a thoracoscopic debridement was attempted in presumed stage II disease. Conversion thoracotomy was liberally used during thoracoscopy if stage III disease was found at surgery. Predictive factors for conversion thoracotomy were calculated in a multivariate analysis among several variables such as age, sex, time interval between onset of symptoms and surgery, involved microorganisms, and underlying cause of empyema. RESULTS: Of the 328 patients surgically treated for stage II and III empyema, 150 underwent primary open decortication for presumed stage III disease. One hundred seventy-eight patients with presumed stage II empyema underwent a video-assisted thoracoscopic approach. Of these 178 patients, thoracoscopic debridement was successful in 99 of 178 patients (56%), and conversion thoracotomy and open decortication was judged necessary in 79 of 178 patients (44%). The conversion thoracotomy rate was higher in parapneumonic empyema (55%) as compared with posttraumatic (32%) or postoperative (29%) empyema; however, delayed referral (p < 0.0001) and gram-negative microorganisms (p < 0.01) were the only significant predictors for conversion thoracotomy in a multivariate analysis. CONCLUSIONS: Video-assisted thoracoscopic debridement offers an elegant, minimally invasive approach in a number of patients with presumed stage II empyema. However, to achieve a high success rate with the video-assisted thoracoscopic approach, early referral of the patients to surgery is required. Conversion thoracotomy should be liberally used in case of chronicity, especially after delayed referral (> 2 weeks) and in the presence of gram-negative organisms.

[Archives de la Parole]. , [Parable of the prodigal son] : récit en dravidien, telugu, Province de Madras / [Sir George Grierson], éd. ; Linguistic survey of India ; Voix parlée, homme

[Traditions. Asie. Inde. Présidence de Madras [i.e. Chennai]. Ceded Districts]

[Archives de la Parole]. , [Parable of the prodigal son] : récit en télougou / [Sir George Grierson], éd. ; Linguistic survey of India ; Voix parlée, homme

[Traditions. Asie. Inde. Province de Madras [i.e. Chennai]]

[Archives de la Parole]. , [Parable of the prodigal son] : récit en télougou [sic] / [Sir George Grierson], éd. ; Linguistic survey of India ; [Ranga], voix

[Traditions. Asie. Inde. Province de Madras [i.e. Chennai]. Etat du Tamil Nadu]

[Archives de la Parole]. , [Cowardice of the Bania class] : récit shindi [i.e. sindhi] / [Sir George Grierson], éd. ; Linguistic survey of India ; [Mulshankar Somjimal], voix

[Traditions. Asie. Inde. Présidence de Bombay. Pakistan. Province du Sind. Tharparkar]

[Archives de la Parole]. , [Parable of the prodigal son] : récit en hindoustani [mēwātī] / [Sir George Grierson], éd. ; Linguistic survey of India ; [Jainti Pershad], voix

[Traditions. Asie. Inde. Province de Delhi]

[Archives de la Parole]. , [Parable of the prodigal son] : Récit en hindoustani / [Sir George Grierson], éd. ; Linguistic survey of India ; [Jainti Pershad], voix

[Traditions. Asie. Inde. Province de Delhi]

[Archives de la Parole]. , [The story of a son-in-law] : Indo-aryen, marathi, groupe Occidental / [Sir George Grierson], éd. ; Linguistic survey of India ; [S.B. Naik], voix

[Traditions. Asie. Inde. État du Maharashtra. Dhule]

[Archives de la Parole]. , [Beauty of the beloved and the longing of the lover] : récit Hindi, Indo-aryen, g. Central / [Sir George Grierson], éd. ; Linguistic survey of India ; [Parmanand Mewaram], voix

[Traditions. Asie. Inde. Pakistan. Province du Sind. Haidarābād]

[Archives de la Parole]. , [Parable of the prodigal son] : récit en tamoul / [Sir George Grierson], éd. ; Linguistic survey of India ; Voix parlée, homme

[Traditions. Asie. Inde. Province de Madras [i.e. Chennai]]

[Archives de la Parole]. , [Parable of the prodigal son] : récit en tamoul (sic) / [Sir George Grierson], éd. ; Linguistic survey of India ; Voix parlée, homme

[Traditions. Asie. Inde. Province de Madras [i.e. Chennai]]

[Archives de la Parole]. , [The silly weaver girl] : Récit en malayālam (dravidien, province de Madras) / [Sir George Grierson], éd. ; Linguistic survey of India ; [M.G. Philips], voix

[Traditions. Asie. Inde. Province de Madras [i.e. Chennai]. État du Kerala. Etat du tamil Nadu. Travancore]

[Archives de la Parole]. , [The story of the herdsman] : shindi [i.e. sindhi], Indo-aryen, groupe occidental / [Sir George Grierson], éd. ; Linguistic survey of India ; [V.T. Shimpi], voix

[Traditions. Asie. Inde. Province de Bombay. État du Maharashtra. Dhule]

[Archives de la Parole]. , [Parable of the prodigal son] : récit en télougou / [Sir George Grierson], éd. ; Linguistic survey of India ; Voix parlée, homme

[Traditions. Asie. Inde. Province de Madras [i.e. Chennai]]