Early major worsening in ischemic stroke: predictors and outcome.

INTRODUCTION: We aimed to investigate the characteristics and outcome of patients suffering early major worsening (EMW) after acute ischemic stroke (AIS) and assess the parameters associated with it. METHODS: All consecutive patients with AIS in the ASTRAL registry until 10/2010 were included. EMW was defined as an NIHSS increase of ≥8 points within the first 24 h after admission. The Bootstrap version of the Kolmogorov-Smirnov test and the χ(2)-test were used for the comparison of continuous and categorical covariates, respectively, between patients with and without EMW. Multiple logistic regression analysis was performed to identify independent predictors of EMW. RESULTS: Among 2155 patients, 43 (2.0 %) had an EMW. EMW was independently associated with hemorrhagic transformation (OR 22.6, 95 % CI 9.4-54.2), cervical artery dissection (OR 9.5, 95 % CI 4.4-20.6), initial dysarthria (OR 3.7, 95 % CI 1.7-8.0), and intravenous thrombolysis (OR 2.1, 95 % CI 1.1-4.3), whereas a negative association was identified with initial eye deviation (OR 0.4, 95 % CI 0.2-0.9). Favorable outcome at 3 and 12 months was less frequent in patients with EMW compared to patients without (11.6 vs. 55.3 % and 16.3 vs. 50.7 %, respectively), and case fatality was higher (53.5 vs. 12.9 % and 55.8 vs. 16.8 %, respectively). Stroke recurrence within 3 months in surviving patients was similar between patients with and without EMW (9.3 vs. 9.0 %, respectively). CONCLUSIONS: Worsening of ≥8 points in the NIHSS score during the first 24 h in AIS patients is related to cervical artery dissection and hemorrhagic transformation. It justifies urgent repeat parenchymal and arterial imaging. Both conditions may be influenced by targeted interventions in the acute phase of stroke.

Is it worth treating fever in intensive care unit patients? Preliminary results from a randomized trial of the effect of external cooling.

BACKGROUND: Antipyresis is a common clinical practice in intensive care, although it is unknown if fever is harmful, beneficial, or a negligible adverse effect of infection and inflammation. METHODS: In a randomized study, rectal temperature and discomfort were assessed in 38 surgical intensive care unit patients without neurotrauma or severe hypoxemia and with fever (temperature >/=38.5 degrees C) and systemic inflammatory response syndrome. Eighteen patients received external cooling while 20 received no antipyretic treatment. RESULTS: Temperature and discomfort decreased similarly in both groups after 24 hours. No significant differences in recurrence of fever, incidence of infection, antibiotic therapy, intensive care unit and hospital length of stay, or mortality were noted between the groups. CONCLUSIONS: These results suggest that the systematic suppression of fever may not be useful in patients without severe cranial trauma or significant hypoxemia. Letting fever take its natural course does not seem to harm patients with systemic inflammatory response syndrome or influence the discomfort level and may save costs.

The results of surgery, with or without radiotherapy, for primary spinal myxopapillary ependymoma: a retrospective study from the rare cancer network.

PURPOSE: The aim of this study was to assess the outcome of patients with primary spinal myxopapillary ependymoma (MPE). MATERIALS AND METHODS: Data from a series of 85 (35 females, 50 males) patients with spinal MPE were collected in this retrospective multicenter study. Thirty-eight (45%) underwent surgery only and 47 (55%) received postoperative radiotherapy (RT). Median administered radiation dose was 50.4 Gy (range, 22.2-59.4). Median follow-up of the surviving patients was 60.0 months (range, 0.2-316.6). RESULTS: The 5-year progression-free survival (PFS) was 50.4% and 74.8% for surgery only and surgery with postoperative low- (<50.4 Gy) or high-dose (>or=50.4 Gy) RT, respectively. Treatment failure was observed in 24 (28%) patients. Fifteen patients presented treatment failure at the primary site only, whereas 2 and 1 patients presented with brain and distant spinal failure only. Three and 2 patients with local failure presented with concomitant spinal distant seeding and brain failure, respectively. One patient failed simultaneously in the brain and spine. Age greater than 36 years (p = 0.01), absence of neurologic symptoms at diagnosis (p = 0.01), tumor size >or=25 mm (p = 0.04), and postoperative high-dose RT (p = 0.05) were variables predictive of improved PFS on univariate analysis. In multivariate analysis, only postoperative high-dose RT was independent predictors of PFS (p = 0.04). CONCLUSIONS: The observed pattern of failure was mainly local, but one fifth of the patients presented with a concomitant spinal or brain component. Postoperative high-dose RT appears to significantly reduce the rate of tumor progression.

Long-term complete responses after 131I-tositumomab therapy for relapsed or refractory indolent non-Hodgkin's lymphoma.

We present the long-term results of 18 chemotherapy relapsed indolent (N = 12) or transformed (N = 6) NHL patients of a phase II anti-CD20 (131)I-tositumomab (Bexxar) therapy study. The biphasic therapy included two injections of 450 mg unlabelled antibody combined with (131)I-tositumomab once as dosimetric and once as therapeutic activity delivering 75 or 65 cGy whole-body radiation dose to patients with normal or reduced platelet counts, respectively. Two patients were not treated due to disease progression during dosimetry. The overall response rate was 81% in the 16 patients treated, including 50% CR/CRu and 31% PR. Median progression free survival of the 16 patients was 22.5 months. Median overall survival has not been reached after a median observation of 48 months. Median PFS of complete responders (CR/CRu) has not been reached and will be greater than 51 months. Short-term side effects were mainly haematological and transient. Among the relevant long-term side effects, one patient previously treated with CHOP chemotherapy died from secondary myelodysplasia. Four patients developed HAMA. In conclusion, (131)I-tositumomab RIT demonstrated durable responses especially in those patients who achieved a complete response. Six of eight CR/CRu are ongoing after 46-70 months.

Phase I/IIa study of cilengitide and temozolomide with concomitant radiotherapy followed by cilengitide and temozolomide maintenance therapy in patients with newly diagnosed glioblastoma.

Purpose: Invasion and migration are key processes of glioblastoma and are tightly linked to tumor recurrence. Integrin inhibition using cilengitide has shown synergy with chemotherapy and radiotherapy in vitro and promising activity in recurrent glioblastoma. This multicenter, phase I/IIa study investigated the efficacy and safety of cilengitide in combination with standard chemoradiotherapy in newly diagnosed glioblastoma. Patients and Methods: Patients (age >= 18 to >= 70 years) were treated with cilengitide (500 mg) administered twice weekly intravenously in addition to standard radiotherapy with concomitant and adjuvant temozolomide. Treatment was continued until disease progression or for up to 35 weeks. The primary end point was progression-free survival (PFS) at 6 months. Results: Fifty-two patients ( median age, 57 years; 62% male) were included. Six- and 12-month PFS rates were 69% (95% CI, 54% to 80%) and 33% ( 95% CI, 21% to 46%). Median PFS was 8 months ( 95% CI, 6.0 to 10.7 months). Twelve- and 24-month overall survival ( OS) rates were 68% ( 95% CI, 53% to 79%) and 35% ( 95% CI, 22% to 48%). Median OS was 16.1 months ( 95% CI, 13.1 to 23.2 months). PFS and OS were longer in patients with tumors with O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation (13.4 and 23.2 months) versus those without MGMT promoter methylation (3.4 and 13.1 months). The combination of cilengitide with temozolomide and radiotherapy was well tolerated, with no additional toxicity. No pharmacokinetic interactions between temozolomide and cilengitide were identified. Conclusion: Compared with historical controls, the addition of concomitant and adjuvant cilengitide to standard chemoradiotherapy demonstrated promising activity in patients with glioblastoma with MGMT promoter methylation. J Clin Oncol 28:2712-2718. (C) 2010 by American Society of Clinical Oncology

Image en fluorescence en endoscopie: contribution dans la prise en charge des tumeurs de vessie [Fluorescence guided endoscopy: improvement in the management of bladder cancer].

White-light cystoscopy and cytology are the standard tools to diagnose bladder cancer. White-light cystoscopy is excellent to detect macroscopic exophytic tumors, but its sensitivity is poor for flat tumors such as carcinoma in situ. Use of fluorescence cystoscopy during transurethral bladder resection improve tumor detection, particulary for carcinoma in situ. Fluorescence cystoscopy reduce residual tumor rate, especially for voluminous and multifocal tumors with consecutive lower recurrence. Fluorescence is now recommended to diagnose and treat bladder cancer.

A strange foot not far from CRPS I

Introduction.- Since the work of the "International Association for the Study of Pain" (IASP), complex regional pain syndrome type 1 (CRPS I) or algodystrophy includes motor disorders (tremor, dystony, myoclony) as diagnosis criterion. This can lead to confusion with some neurologic disorders which can wrongly be considered as CRPS I. The following observation illustrates this problem.Observation.- A 31-year-old man was hospitalised in a rehabilitation clinic in April 2007 with suspected CRPS I with persistent pain in the left leg. In 2005, the patient underwent ligament reconstruction at the right ankle. In May 2006, a recurrence of his ankle sprain was treated conservatively. The course of this pathology was unfavourable with an extension of the pain areas (leg and foot) as well as an appearance of abnormal motion. Toe motion in abduction was observed (especially T5) followed by a flexion cramp; an hypoesthesia in the sural nerve area, a scar allodynia and discrete vasomotor disorders. The scintigraphy was compatible with a stage 2 algodystrophy. Lower limb electromyography was normal; measurement of pseudo periodic activity of the motor unit at the foot level (abductor of the 5th toe, 4th interosseous). A "Painful legs and moving toes syndrome" was diagnosed which was treated with gabapentin and carbamazepine with a partial improvement.Discussion.- The "Painful legs and moving toes syndrome" is a rare pathology rehabilitation specialists should recognize. The origin is often peripheral nerve damage. The medullar interneuron activation (between the dorsal and ventral horn) is considered as the source of the efferent motor nerves which are responsible for the abnormal movements. This observation illustrates the need for a demanding approach before establishing the diagnosis of CRPS I and the respect of the 4th criterion of the ASP (exclusion of this syndrome when another pathology may explain pain and dysfunction).

Pseudophakic Retinal Detachment Surgery by 23 G Vitrectomy using Slit-Lamp and Non-Contact 90 D Lens.

Background: The purpose of this study is to report the anatomic and functional results of primary 23 G vitrectomy using slit-lamp and non-contact 90 D lens for the treatment of pseudophakic rhegmatogenous retinal detachment. Patients and Methods: Pseudophakic eyes were operated by 23 G vitrectomy using slit-lamp and non-contact 90 D lens, internal subretinal fluid drainage, cryopexy and internal gas tamponade. The preoperative and postoperative characteristics were analysed. Main outcome measures were anatomic success rates after initial surgical intervention and after reoperation for primary failures, visual outcome at the last follow-up visit, and complications. Results: 46 pseudophakic eyes were included in this retrospective study (October 2013- January 2014). In 40 cases, sulfur hexafluoride 23 % gastamponade was used, silicone oil in 6 cases (13 %). The retina was reattached successfully after a single surgery in 44 eyes (96 %). Recurrence of retinal detachment occurred in 2 eyes. Final anatomic reattachment was obtained in 100 % after a second operation. Silicone oil was removed in all eyes. Visual acuity improved significantly from logMAR 0 (IQR 0 - 0.9) to logMAR 0 (IQR 0 - 0.2) (p < 0.005). Conclusions: Primary 23 G vitrectomy using slit-lamp and non contact 90 D lens for the treatment of pseudophakic rhegmatogenous retinal detachment provides a high anatomic and functional success rate and is associated with few complications.

Information provision and information needs in adult survivors of childhood cancer.

BACKGROUND: Knowledge about their past medical history is central for childhood cancer survivors to ensure informed decisions in their health management. Knowledge about information provision and information needs in this population is still scarce. We thus aimed to assess: (1) the information survivors reported to have received on disease, treatment, follow-up, and late effects; (2) their information needs in these four domains and the format in which they would like it provided; (3) the association with psychological distress and quality of life (QoL). PROCEDURE: As part of the Follow-up survey of the Swiss Childhood Cancer Survivor Study, we sent a questionnaire to all survivors (≥18 years) who previously participated to the baseline survey, were diagnosed with cancer after 1990 at an age of <16 years. RESULTS: Most survivors had received oral information only (on illness: oral: 82%, written: 38%, treatment: oral: 79%, written: 36%; follow-up: oral: 77%, written: 23%; late effects: oral: 68%, written: 14%). Most survivors who had not previously received any information rated it as important, especially information on late effects (71%). A large proportion of survivors reported current information needs and would like to receive personalized information especially on late effects (44%). Survivors with higher information needs reported higher psychological distress and lower QoL. CONCLUSIONS: Survivors want to be more informed especially on possible late effects, and want to receive personalized information. Improving information provision, both qualitatively and quantitatively, will allow survivors to have better control of their health and to become better decision makers.

Prevention of recurrent hip fracture.

Our objective was to describe the interventions aimed at preventing a recurrent hip fracture, and other injurious falls, which were provided during hospitalization for a first hip fracture and during the two following years. A secondary objective was to study some potential determinants of these preventive interventions. The design of the study was an observational, two-year follow-up of patients hospitalized for a first hip fracture at the University Hospital of Lausanne, Switzerland. The participants were 163 patients (median age 82 years, 83% women) hospitalized in 1991 for a first hip fracture, among 263 consecutively admitted patients (84 did not meet inclusion criteria, e.g., age>50, no cancer, no high energy trauma, and 16 refused to participate). Preventive interventions included: medical investigations performed during the first hospitalization and aimed at revealing modifiable pathologies that raise the risk of injurious falls; use of medications acting on the risk of falls and fractures; preventive recommendations given by medical staff; suppression of environmental hazards; and use of home assistance services. The information was obtained from a baseline questionnaire, the medical record filled during the index hospitalization, and an interview conducted 2 years after the fracture. Potential predictors of the use of preventive interventions were: age; gender; destination after discharge from hospital; comorbidity; cognitive functioning; and activities of daily living. Bi- and multivariate associations between the preventive interventions and the potential predictors were measured. In hospital investigations to rule out medical pathologies raising the risk of fracture were performed in only 20 patients (12%). Drugs raising the risk of falls were reduced in only 17 patients (16%). Preventive procedures not requiring active collaboration by the patient (e.g., modifications of the environment) were applied in 68 patients (42%), and home assistance was provided to 67 patients (85% of the patients living at home). Bivariate analyses indicated that prevention was less often provided to patients in poor general conditions, but no ascertainment of this association was found in multivariate analyses. In conclusion, this study indicates that, in the study setting, measures aimed at preventing recurrent falls and injuries were rarely provided to patients hospitalized for a first hip fracture at the time of the study. Tertiary prevention could be improved if a comprehensive geriatric assessment were systematically provided to the elderly patient hospitalized for a first hip fracture, and passive preventive measures implemented.

Updated survival data of the phase iii clinical trial of novottf-100a versus best standard chemotherapy for recurrent glioblastoma

NovoTTF-100A (TTF) is a portable device delivering low-intensity, intermediate-frequency, alternating electric fields using noninvasive, disposable scalp electrodes. TTF interferes with tumor cell division, and it has been approved by the US Food and Drug Administration (FDA) for the treatment of recurrent glioblastoma (rGBM) based on data from a phase III trial. This presentation describes the updated survival data 2 years after completing recruitment. Adults with rGBM (KPS ≥ 70) were randomized (stratified by surgery and center) to either continuous TTF (20-24 h/day, 7 days/week) or efficacious chemotherapy based on best physician choice (BPC). The primary endpoint was overall survival (OS), and secondary endpoints were PFS6, 1-year survival, and QOL. Patients were randomized (28 US and European centers) to either TTF alone (n ¼ 120) or BPC (n ¼ 117). Patient characteristics were balanced, median age was 54 years (range, 23-80 years), and median KPS was 80 (range, 50-100). One quarter of the patients had debulking surgery, and over half of the patients were at their second or later recurrence. OS in the intent-to-treat (ITT) population was equivalent in TTF versus BPC patients (median OS, 6.6vs. 6.0 months; n ¼ 237; p ¼ 0.26; HR ¼ 0.86). With a median follow-up of 33.6 months, long-term survival in the TTF group was higher than that in the BPC group at 2, 3, and 4 years of follow-up (9.3% vs. 6.6%; 8.4% vs. 1.4%; 8.4% vs. 0.0%, respectively). Analysis of patients who received at least one treatment course demonstrated a survival benefit for TTF patients compared to BPC patients (median OS, 7.8 vs. 6.0 months; n ¼ 93 vs. n ¼ 117; p ¼ 0.012; HR ¼ 0.69). In this group, 1-year survival was 28% vs. 20%, and PFS6 was 26.2% vs. 15.2% (p ¼ 0.034). TTF, a noninvasive, novel cancer treatment modality shows significant therapeutic efficacy with promising long-term survival results. The impact of TTF was more pronounced when comparing only patients who received the minimal treatment course. A large-scale phase III trial in newly diagnosed GBM is ongoing.

Tip anchor flap in decubital surgery.

Anchoring a flap remains a key procedure in decubital surgery because a flap needs to be stable against shearing forces. This allows an early mobilization and undisturbed primary wound healing. This study evaluated a uniform group of eight paraplegic patients with sacral decubital ulcers and covered the lesions using gluteal rotation flaps with a deepithelialized tip to anchor the flap subcutaneously on the contralateral ischial tuber. Initial wound healing and recurrence after one year were evaluated. All but one flap showed uneventful wound healing, and all the flaps presented without any signs of recurrence or instability. The authors suggest that sufficient anchoring using a deepithelialized part of the flap helps to integrate and stabilize sacral rotation flaps.

Réadaptation cardiovasculaire, un- bien sous-utilisé [Cardiac rehabilitation, a proven intervention underutilized in the French-speaking part of Switzerland].

Cardiac rehabilitation is associated with a reduced risk of recurrence and mortality after an acute coronary syndrome. Cardiac rehabilitation is a multidisciplinary approach which starts during the acute hospital phase, then followed by a four to six weeks home-based or stationary program, in order to maintain long-term lifestyle changes. Despite the important health benefits of cardiac rehabilitation and its cost-effectiveness, only half of the patients in Europe will achieve a cardiovascular prevention program after an acute coronary syndrome. In the French part of Switzerland, one explanation for this low adherence might be the lack of both stationary and home-based program facilities.

Chimioradiothérapie postopératoire des cancers des voies aérodigestives : vers un nouveau standard [Post-operative radiochemotherapy of the head and neck: Towards new standards?]

Head and neck squamous cell carcinomas are frequently diagnosed at an advanced stage. Their treatment remains controversial, and has to be multidisciplinary. External beam radiotherapy is a recognized treatment option after radical curative surgery in order to improve local control. Different adjuvant treatment options have been studied in order to improve the outcome of these patients. We review in this paper the different prognostic factors indicating an adjuvant treatment and the interest of treatment intensification in bad prognostic patients.

Neuroretinitis: review of the literature and new observations.

Neuroretinitis (NR) is an inflammatory disorder characterized by optic disc edema and subsequent formation of a macular star figure. The underlying pathophysiology involves increased permeability of disc vasculature, but the etiology is not fully defined. In some cases, NR is probably due to an infectious process involving the disc; in others, a postviral or autoimmune mechanism is more likely. Cases can be divided into those in which a specific infectious agent has been identified, those considered idiopathic, and those with recurrent attacks. Some reports have not distinguished among these subgroups, and it is unclear if their clinical features vary. We reviewed the literature and our own patients looking particularly at features that might better distinguish these subtypes. Features common to all 3 groups included age, absence of pain, and fundus appearance. Preceding systemic symptoms were more common in patients with cat scratch disease (CSD) and uncommon in those with recurrence. The pattern and magnitude of visual field loss differed, more commonly confined to the central field in CSD cases and more severe in recurrent cases. Recovery of visual acuity and field was less substantial in recurrent cases even after the initial episode. MRI was usually normal in all 3 groups. Enhancement confined to the optic disc was found in all 3 groups, but enhancement of the retrobulbar optic nerve was seen only in recurrent cases. Findings that are strongly suggestive of CSD include very young age, preceding systemic symptoms, and poor visual acuity but with a small or absent relative afferent pupil defect (RAPD). In contrast, the following are suggestive of idiopathic NR with a high risk of recurrence: absence of systemic symptoms, visual field defect outside the central field, preserved visual acuity with a large RAPD, and poor recovery of vision. Decisions regarding evaluation and treatment should be made with these features in mind.