Reasons for transferral to emergency departments of terminally ill patients - a French descriptive and retrospective study.

BACKGROUND: Patients under palliative care and in hospital-at-home services are frequently transferred to emergency departments. We set out to identify the reasons for these presentations to determine the proportion that might be avoidable. METHODS: We conducted a retrospective study by assessment of patient files. We studied admissions to four emergency departments in an area of France (Puy-de-Dôme) between September 2011 and August 2013. Reasons for transfer and diagnostic conclusion by emergency doctors were noted. We collected date of admission, time spent, investigations and treatments performed and patients' outcomes after the medical conclusions. We also determined whether patients called the hospital-at-home service before going to the emergency department. From these data we discerned potentially avoidable and unavoidable consultations. RESULTS: We identified 52 transfers of patients from home to emergency departments. The most frequent reasons were: generalized weakness (11 cases), social isolation (8 cases) and end of life (7 cases). For 58 % of presentations, the investigations and treatments performed did not require presentation to an emergency department; 34 % of patients returned home after the visit, 41 % remained for simple observation and 20 % remained to receive special care. Two patients died in the emergency department. In 86 % of cases, presentations occurred when primary care was less readily available, and patients called home care services in only 42 % of cases before going to emergency departments. CONCLUSIONS: Half of the transfers to emergency departments were potentially avoidable for terminally ill patients in home care. To reduce this proportion we need to promote access to primary care, educate patients in hospital-at-home service and train care-givers and doctors in palliative medicine.

Does the technique of carotid endarterectomy determine postoperative hypertension?

BACKGROUND: Hypertension (HT) after carotid endarterectomy (CEA) is a risk factor for postoperative myocardial infarction, stroke, and neck hematoma. We compared the incidence of postoperative HT within the week after eversion CEA (e-CEA) and patch closure CEA (p-CEA). Postoperative HT was defined as a systolic blood pressure (sBP) ≥ 160 mm Hg and/or the need for postoperative vasodilatators. The aim of our study was to determine if the technique of CEA had an effect on postoperative HT. METHODS: Between January 2010 and June 2011, we prospectively reviewed 560 consecutive endarterectomies (340 p-CEAs and 220 e-CEAs) performed in 443 patients under general anesthesia. All had >70% stenoses, 119 were symptomatic, and 441 asymptomatic. We compared preoperative, peroperative, and postoperative sBP and diastolic blood pressure, carotid sinus nerve block, postoperative intravenous and oral antihypertensive medications, neurologic and cardiac complications, and mortality. RESULTS: The e-CEA group had a higher incidence of women (36.4% vs. 21.8%, P = 0.0002) and HT (85.0% vs. 78.2%, P = 0.04). The e-CEAs had a significantly higher incidence of carotid sinus nerve block (93.6% vs. 15.6%, P < 0.0001). The incidence of postoperative HT was not significantly different between the 2 groups (75.9% in the e-CEA group versus 68.5% in the p-CEA group, P = 0.06). The average postoperative sBP between postoperative hour (H) 2 and H12 was significantly higher in the e-CEA group but <160 mm Hg. The sBP dropped between H2 and H6, and this decrease was greater in the p-CEA group (30% vs. 15% in the e-CEA group). The need for postoperative antihypertensive medication was not different between the 2 groups. One independent risk factor of postoperative HT was identified: history of HT. The rate of postoperative complications was not significantly different between the 2 groups. CONCLUSIONS: The e-CEA technique is not a risk factor and does not have an effect on postoperative HT. The postoperative sBP was more stable in this group. Eversion carotid endarterectomy has been considered, in the literature, as a risk factor of postoperative hypertension. We conducted a large prospective and comparative study of the endarterectomy technique by eversion and with conventional patch closure. The primary end point was the blood pressure value and the administration of antihypertensive treatment. Our study shows that postoperative hypertension after carotid endarterectomy is not related to the surgical technique. Changes in blood pressure after carotid endarterectomy by eversion are lower than those observed after conventional endarterectomy with patch closure. This technique prevents the occurrence of possible hypotension occurrence, which can be the cause of perioperative complications.

Effectiveness of Hyalobarrier and Seprafilm to prevent polypropylene mesh shrinkage: a macroscopic and histological experimental study.

INTRODUCTION AND HYPOTHESIS: Polypropylene (PP) mesh shrinkage represents a serious complication, as a significant cause of pain and recurrence of pelvic organ prolapse or ventral hernias, frequently requiring several surgical interventions. The retraction seems to be caused by the host, in response to the implantation, through the occurrence of periprosthetic adhesions and fibrosis. We hypothesized that avoiding the postoperative adhesions can prevent PP mesh shrinkage. METHODS: Sixty rats were randomly assigned to three groups. A standardized hernia defect was induced on the abdominal wall, which was repaired using an extraperitoneal PP mesh alone (group 1), with application of a hyaluronate carboxymethylcellulose-based bioresorbable membrane (Seprafilm, group 2), or an auto-cross-linked polysaccharide hyaluronan-based solution (Hyalobarrier gel, group 3). Eight weeks after the procedure, a repeat laparotomy was performed. After scoring the adhesion and measuring the mesh surface, a microscopic study of the prosthesis-host tissue interfaces was performed. RESULTS: Group 1 displayed a median shrinkage of 29% of the mesh. The Seprafilm group (p = 0.0238) and Hyalobarrier gel group (p = 0.0072) displayed a significantly smaller reduction of 19.12 and 17 %, respectively. Control group 1 displayed a significantly greater adhesion score (30.40) than the Seprafilm (11.67, p = 0.0028) and Hyalobarrier gel groups (11.19, p = 0.0013). The fibrosis was reduced in the Hyalobarrier gel group only. CONCLUSION: This experimental study revealed that Hyalobarrier gel and Seprafilm can prevent PP mesh shrinkage and postoperative adhesions. They might be integrated in a mesh size-saving strategy, which should preserve the quality and durability of the surgical repair and limit the postoperative pain.

Results of the first randomized French study evaluating self-testing of the International Normalized Ratio.

BACKGROUND AND AIM OF THE STUDY: In this single-center French study, the conventional management of patients receiving vitamin K antagonists (VKAs) was compared with an International Normalized Ratio (INR) self-testing program. The aim was to determine the reliability of self-testing devices, and to estimate the variability of the self-measured INR within the therapeutic and target range. METHODS: A total of 206 patients who had undergone valve replacement with a mechanical prosthesis, with or without myocardial revascularization, between May 2004 and September 2007 was randomized into two groups. Group 1 patients (n = 103) underwent INR monitoring at a laboratory, while Group 2 patients (n = 103) underwent self-testing INR using either the CoaguChek (Roche) (Group 2A; n = 55) or INRatio (Hemosense) (Group 2B; n = 48) system. Patients in Group 1 underwent at least once-monthly INR measurement, while those in Group 2 carried out once-weekly self-testing, and also underwent once-monthly INR measurement at the laboratory. The large majority of patients (97.9%) were treated with fluindione. RESULTS: The mean follow up period was 49.0 +/- 10.3 weeks. Self-testing was reliable, with a correlation coefficient between device- and laboratory-measured INRs of 0.80 [CI: 0.78, 0.82] (p < 0.0001). The proportion of time spent within the INR target range was significantly higher for Group 2 (61.5 +/- 19.3% versus 55.5 +/- 19.9%; p < 0.05), while the absolute mean deviation of INR from the target range was higher in Group 1 (60.1 +/- 70.2% versus 47.4 +/- 51.5%). Adverse events were reported by seven patients in Group 1, but by no patients in Group 2 (p < 0.01). CONCLUSION: INR self-testing devices are reliable and beneficial. Moreover, INR self-monitoring allows an enhanced stability within a target range, and also helps to prevent serious postoperative complications.

[Ovarian epithelial dysplasia: Description of a dysplasia scoring scheme]. / Échelle d'évaluation de la dysplasie épithéliale de l'ovaire.

INTRODUCTION: Precancerous ovarian epithelial dysplasia was first described after prophylactic oophorectomy (OP) for genetic risk (BRCA mutation) or because of a strong family history of ovarian and/or breast cancer. The objective of this study was to describe histopathological features of ovarian dysplasia and to propose a dysplasia scoring sheme with a cut-off. PATIENTS AND METHOD: One hundred and twenty-five bilateral oophorectomies (genetic predisposition: n=35 and control group: n=90) were reviewed by two pathologists blinded to clinical data. Eleven epithelial cytological and architectural features were studied and an ovarian dysplasia score was defined to compare the degree of ovarian epithelial abnormalities between the two groups. RESULTS: Mean ovarian dysplasia score was significantly higher in prophylactic oophorectomy group than in control group (9.0 versus 3.5, P<0.001). Dysplasia was more severe in OP with BRCA mutation than in OP without (11.6 in BRCA 1; 7.6 in BCRA 2; 7.1 in family history). The cut off for dysplasia was 8 with a sensitivity of 60% and a specificity of 93.3%. CONCLUSION: The increased dysplasia score in OP and the gradation in dysplastic severity in OP with proven BRCA mutations may suggest that ovarian dysplasia could be a pre-malignant non invasive histopathological lesion. The 11 cytological and architectural features in the dysplasia scoring sheme could be a useful tool to study ovarian dysplasia.

Ovarian epithelial dysplasia and prophylactic oophorectomy for genetic risk.

UNLABELLED: To make an accurate histopathological description of ovarian dysplasia in a population at genetic risk of ovarian cancer and devise an ovarian dysplasia score. MATERIALS AND METHODS: In this retrospective cohort study, 90 patients who had undergone bilateral oophorectomy or ovarian cystectomy between 1992 and 2005 and whose ovaries were reported as normal were divided into two groups: Group A comprising prophylactic oophorectomies for genetic predisposition (N = 28), and Group B or control group, fertile and non-cancerous (N = 62). Eleven epithelial cytological and architectural features were defined. Ovaries were analysed and reviewed by four pathologists blinded to clinical data. An ovarian dysplasia score was devised to quantify extent of ovarian epithelial abnormalities. The degrees of ovarian epithelial abnormalities (dysplasia scores) were compared between the two groups. RESULTS: Mean dysplasia score was significantly higher in Group A (prophylactic oophorectomies) than in Group B (control group) (9.67 vs. 4.19, P < 0.001). In Group A, we observed a gradation in the severity of the dysplastic lesions between (i) proven BRCA mutations and prophylactic oophorectomies without mutations (11.26 vs. 8.1), and (ii) according to age (10.27 after age 50 years vs. 8.6 before age 50 years, P = 0.2962). CONCLUSION: These results suggest abnormalities in ovaries from high risk women. The ovarian dysplasia may be a pre-malignant, non-invasive histological lesion that could be an important step in early neoplasia.

Validity of the CAGE questionnaire in hospital.

OBJECTIVE: The CAGE questionnaire is considered a useful screening and case-finding tool for alcohol use disorders in clinical populations. Our objectives were to validate the French version of the CAGE against DSM-IV criteria and to assess performance of each item of the scale. METHOD: Data were extracted from a hospital morbidity study conducted in central France. It concerned 5452 patients-48.5% men-in short and medium-stay units. Patients answered the CAGE questionnaire as a past-year assessment. The alcohol use disorders were diagnosed by the physicians using DSM-IV alcohol abuse or dependency criteria. RESULTS: The CAGE questionnaire for a cut-off of 2 had a sensitivity of 77% and a specificity of 94%. The CAGE test was more sensitive for patients diagnosed as alcohol-dependent than for alcohol abusers (61% vs. 84%) with the same specificity (94%). These values are close to those for the English-language CAGE. The first three items (CAG) were very similar, with sensitivity 70% and specificity 94%. The eye-opening question (E) differentiated sharply between abuse and dependency, with sensitivities of 18% and 46%, respectively. A questionnaire comprising only the CAG questions of the CAGE had properties similar to the full questionnaire. CONCLUSION: CAGE is a good screening tool for alcohol abuse or alcohol dependency. Given the frequent-and insufficiently diagnosed-alcohol problems among inpatients, CAGE is indicated as a first-line tool for screening for the most severe alcohol use disorders in hospital. It should ideally be used systematically. A positive reply to any of the first three items should alert the clinician and prompt further investigation.

[Medical practices and expectations of general practitioners in relation to hepatitis C virus infection in the Auvergne region]. / Pratiques et attentes des médecins généralistes en matière d'hépatite C dans la région Auvergne.

AIMS: To determine the medical practices and expectations of general practitioners concerning screening and management of hepatitis C in the Auvergne region. METHODS: A survey was sent by mail to 250 general practitioners. They were then contacted by telephone interviews. RESULTS: 94% of general practitioners answered the survey. Each physician diagnosed an average of 0.6 new cases of hepatitis C in 1999, and had a mean of 3.2 patients with HCV in their practice. Screening was performed by 91% of general practitioners if there was a history of blood transfusion, by 87% if there was a history of intravenous drug use, by 92% in case of increased serum amino transferase levels. Screening was less frequent in case of household contact and was only performed by 68% general practitioners or of asthenia by 52% of general practitioners. Liver biopsy seems to be the main obstacle for the management of hepatitis C patients which is due to a refusal of liver biopsy by the patient according to 55% of general practitioners, a fear of complications according to 25% of general practitioners. Sixty percent of general practitioners considered that liver biopsy was performed in less than 50% of patients with hepatitis C. Fifty three percent of general practitioner thought that hepatitis C network could be useful for increasing their knowledge. CONCLUSIONS: Liver biopsy refusal by the patient restricts the management and therapy of patients with hepatitis C infection. Increase formation still requisite by 60 percent of general practitioner.

Fertility after tubal ectopic pregnancy: results of a population-based study.

OBJECTIVE: To assess the reproductive outcome after an ectopic pregnancy (EP) based on the type of treatment used, and to identify predictive factors of spontaneous fertility. DESIGN: Observational population based-study. SETTING: Regional sistry. PATIENT(S): One thousand sixty-four women registered from 1992 to 2008. INTERVENTION(S): Laparoscopic (radical or conservative), or medical treatment. MAIN OUTCOME MEASURE(S): Epidemiologic characteristics, clinical presentation, treatments performed, reproductive outcome, recurrence. RESULT(S): The 24-month cumulative rate of intrauterine pregnancy (IUP) was 67% after salpingectomy, 76% after salpingostomy, and 76% after medical treatment. IUP rate was lower after radical treatment compared with conservative treatments in univariable analysis. In multivariate analysis, IUP rate was significantly lower for patients >35 years old or with history of infertility or tubal disease. For them, IUP rate was significantly higher after conservative treatment compared with salpingectomy. The 2-year cumulative rate of recurrences was 18.5% after salpingostomy or salpingectomy and 25.5% after medical treatment. History of infertility or of previous live birth would be protective, in contrast to history of voluntary termination of pregnancy. CONCLUSION(S): Conservative strategy seems to be preferred, whenever possible, to preserve patients' fertility without increasing the risk of recurrence. The choice between conservative treatments does not rely on subsequent fertility, but more likely on their own indications and therapeutic effectiveness. Risk factors of recurrence could be considered for secondary prevention.

Educational value of an intensive and structured interval practice laparoscopic training course for residents in obstetrics and gynecology: a four-year prospective, multi-institutional recruitment study.

OBJECTIVE: To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents. DESIGN: Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate. SETTING: International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France. PARTICIPANTS: 191 PGY2 or PGY3 residents from different institutions. RESULTS: Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p < 0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p < 0.0001). CONCLUSIONS: Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Is There a Relationship between Ovarian Epithelial Dysplasia and Infertility?

Aim. Ovarian epithelial dysplasia was initially described in material from prophylactic oophorectomies performed in patients at genetic risk of ovarian cancer. Similar histopathological abnormalities have been revealed after ovulation stimulation. Since infertility is also a risk factor for ovarian neoplasia, the aim of this study was to study the relationship between infertility and ovarian dysplasia. Methods. We blindly reviewed 127 histopathological slides of adnexectomies or ovarian cystectomies according to three groups-an exposed group to ovulation induction (n = 30), an infertile group without stimulation (n = 35), and a spontaneously fertile control group (n = 62)-in order to design an eleven histopathological criteria scoring system. Results. The ovarian dysplasia score was significantly higher in exposed group whereas dysplasia score was low in infertile and control groups (resp., 8.21 in exposed group, 3.69 for infertile patients, and 3.62 for the controls). In the subgroup with refractory infertility there was a trend towards a more severe dysplasia score (8.53 in ovulation induction group and 5.1 in infertile group). Conclusion. These results raise questions as to the responsibility of drugs used to induce ovulation and/or infertility itself in the genesis of ovarian epithelial dysplasia.

Predictive factors of failure in management of ectopic pregnancy with single-dose methotrexate: a general population-based analysis from the Auvergne Register, France.

In a general population setting, the existence of a learning curve for treatment of ectopic pregnancy with single-dose methotrexate has been demonstrated, because a significant decrease in failure rate can be achieved over time. Despite this finding, the risk of single-dose methotrexate failure increases significantly in patients with initial hCG levels>1,300 IU/L and/or in women who report having ever used combined oral contraception before pregnancy.

Proximal ectopic pregnancy: a descriptive general population-based study and results of different management options in 86 cases.

OBJECTIVE: To describe different approaches for diagnosis and management of proximal ectopic pregnancies (PP) in general population. DESIGN: Observational population based-study. SETTING: Regional ectopic pregnancy registry. PATIENT(S): Eighty-six PP registered from 1992 to 2008. INTERVENTION(S): Surgical (radical or conservative), medical, or combined therapies. MAIN OUTCOME MEASURE(S): Epidemiologic characteristics, clinical presentation, hCG level, treatments performed, failure rate, and recurrence. RESULT(S): Mean gestational age was 48.2 days. Estimated incidence of PP was 2.7%. Abdominal pain and vaginal bleeding were the commonest symptoms. Two patients were admitted in hypovolemic shock. Diagnostic modalities included transvaginal ultrasound, abdominal ultrasonography, and laparoscopy in 38 (44%), 7 (8%), and 39 (45%) cases, respectively. Mean hCG level was 10,759 IU/L. Thirty-four patients underwent primary cornual resection (39.5%) by laparoscopy (n = 32) or laparotomy (n = 2). Twenty-seven patients (31.4%) underwent primary conservative surgery by laparoscopy: cornuostomy (n = 18) or extended salpigostomy (n = 9). Primary medical treatment with methotrexate was attempted in 14 patients (16.3%). Expectant management was attempted in one case (1.2%). Eleven cases received combined therapies (11.6%). Failure rates for medical and surgical treatments were 35.7% and 28%, respectively. No failures were noted among patients who received combined therapies. CONCLUSION(S): Proximal ectopic pregnancy remains a life-threatening condition. Diagnosis is challenging and requires a high index of suspicion. Despite available conservative strategies, management of PP remains heterogeneous.

Characteristics of the neuropathy induced by thoracotomy: a 4-month follow-up study with psychophysical examination.

OBJECTIVES: To explore the role of neuropathy in persistent pain after thoracotomy, combining a clinical follow-up and a psychophysical examination of the operated area. METHODS: Seventy-three patients were followed and examined at their discharge from hospital, 6 weeks and 4 months after pneumonectomy under thoracotomy. Spontaneous and evoked pain was assessed by clinical examination, a 7-day pain score, and the Neuropathic Pain Symptom Inventory. At the fourth month follow-up, pain and tolerance thresholds to pinprick, heat, and warm sensation threshold were measured on both sides of the thorax. RESULTS: The rate of spontaneous pain was 40% at discharge and went up to 59% at the sixth week follow-up. Evoked pain was rare at discharge (11%), most cases appearing at the sixth week follow-up (47%). The evolution profiles of pain between the sixth week and the fourth month follow-up were heterogeneous with a tendency to decrease. Young age, female sex, and spontaneous pain observed at discharge from hospital were identified as early predictive factors of spontaneous pain persisting at the fourth month follow-up. On the side of operation, thresholds tended to increase for warm and hot stimuli, and to decrease for mechanical stimuli. At the fourth month follow-up, spontaneous pain and evoked pain were associated to static hyperalgesia, persisting hypoesthesia, low mechanical thresholds, altered sensation of heat, and impaired quality of life. DISCUSSION: Peripheral neuropathy is common after thoracotomy, with variant characteristics, ranging from subclinical disturbances to severe pain. The process seems to develop between the discharge from hospital and the sixth week after thoracotomy.

Effect of lingual nerve block on burning mouth syndrome (stomatodynia): a randomized crossover trial.

Burning mouth syndrome (stomatodynia) is associated with changes of a neuropathic nature the main location of which, peripheral or central, remains unknown. A randomised, double-blind crossover design was used to investigate the effects of lingual nerve block on spontaneous burning pain and a possible correlation with the effects of topical clonazepam, the patient's response to a psychological questionnaire, and the taste and heat thresholds. The spontaneous burning was measured with a visual analogue scale (VAS) just before and 15 min after injection. The decreases in VAS score after lidocaine or saline injection were not significantly different (2.7+/-3.9 and 2.0+/-2.6, respectively; n=20). However, two groups of patients could be identified: in a "peripheral group" (n=10) the VAS decrease due to lingual nerve injection was 4.3+/-3.1cm after lidocaine and 0.9+/-0.3 cm after saline (p=0.02). In a "central group" (n=7), there were an increase in pain intensity score (-0.8+/-2.6 cm) after lidocaine and a decrease (1.5+/-3.0 cm) after saline (p=0.15). An increase in the hospital anxiety and depression (HAD) score and a decreased taste sensitivity and heat pain threshold of painful oral area were seen in patients compared with age-and-sex-matched controls (p<0.05). Topical clonazepam treatment tended to be more effective (p=0.07) and HAD score lower (p<0.03) in the peripheral than in the central group. These results suggest that the neuropathic disorder associated with stomatodynia may be predominantly peripheral, central or mixed depending on the individual. Topical application of clonazepam and HAD may serve as indicators of which mechanism is dominating.

Predicting success of laparoscopic salpingostomy for ectopic pregnancy.

OBJECTIVE: To estimate predictive factors for failure of laparoscopic conservative treatment of ectopic pregnancy using a standardized surgical technique. METHODS: We performed a population-based study from the Auvergne ectopic pregnancy registry. A total of 3,196 cases of ectopic pregnancy were registered between 1992 and 2008. Among conservative treatments (n=1,965), 1,306 (66.5%) patients underwent laparoscopic salpingostomy exclusively. For each case, collected data included: sociodemographic characteristics, previous surgeries, gynecologic and reproductive histories, conditions of conception, Chlamydiae trachomatis serology, human chorionic gonadotropin (hCG) levels, and ectopic pregnancy characteristics. Univariable and multivariable analyses were performed to identify risk factors for treatment. A receiver operating characteristic curve was also provided. Statistical significance was established at P<.05. RESULTS: We identified 86 treatment failures (6.6%). The failure rate remained stable through the study period. Pretherapeutic hCG level was the only factor significantly associated with treatment failure. Patients with an hCG level of at least 1,960 international units/L had a failure rate of 8.6% compared with 5.1% in patients with a lower hCG level (P=.03). Sensitivity and specificity of this cutoff limit were 47% and 67%, respectively (likelihood ratio(+)=1.4 and likelihood ratio(-)=0.8). CONCLUSION: The hCG level of at least 1,960 international units/L is the only factor related to treatment failure. However, the prognostic value of this cutoff is low and with limited clinical relevance. LEVEL OF EVIDENCE: II.

Comparison of INR stability between self-monitoring and standard laboratory method: preliminary results of a prospective study in 67 mechanical heart valve patients.

INTRODUCTION: Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring. OBJECTIVES: We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction. PATIENTS AND METHODS: Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (+/-9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (+/-11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p=0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75. RESULTS: The time spent in the INR target range (group A: 53+/-19%, group B: 57+/--19%, p=0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86+/-14%, group B: 91+/-7%, p=0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1+/-39.3 and 11.27+/-11.2) than for the control group (62.4+/-72.6 and 39.2+/-52.8). This difference is significant (p=0.0004 and p=0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study. CONCLUSION: This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p=0.06, NS).

Rapid decrease in plasma D-lactate as an early potential predictor of diminished 28-day mortality in critically ill septic shock patients.

BACKGROUND: Splanchnic ischemia plays a major role in the development of organ failure during septic shock. Plasma D-lactate has been proposed as a better marker of splanchnic hypoperfusion than L-lactate. We studied the prognostic ability of plasma D- and L-lactate levels. METHODS: A prospective study was performed in an intensive care unit and included patients with septic shock. Two samples for plasma D- and L-lactate determination were collected: the first within 6 h after the patient met the criteria for septic shock (day 1) and the second 24 h later (day 2). RESULTS: In univariate analysis, day 1 plasma D- and L-lactate values were associated with 28-day mortality. For plasma D- and L- lactate, the area under the receiver operating characteristic curve was 0.68+/-0.09 and 0.84+/-0.07 on day 1 (p=0.09), and 0.74+/-0.10 and 0.90+/-0.07 on day 2 (p=0.06), respectively. In survivors, D-lactate levels decreased between day 1 and day 2 (p=0.03), but L-lactate did not (p=0.29). In septic shock patients, plasma D- and L-lactate levels reliably discriminate between survivors and non-survivors. The prognostic ability of plasma L-lactate was better than that of plasma D-lactate. CONCLUSION: A rapid decrease in plasma D-lactate during the course of septic shock could indicate reduced 28-day mortality.

Clinical features and outcome of chronic dialysis patients admitted to an intensive care unit.

BACKGROUND: Information about chronic dialysis (CD) patients admitted to intensive care units (ICU) is scant. This study sought to determine the epidemiology and outcome of CD patients in an ICU setting and to test the performance of the Simplified Acute Physiology Score (SAPS II) to predict hospital mortality in this population. METHODS: All consecutive CD patients admitted to an adult, 10 bed medical/surgical ICU at a university hospital between January 1996 and December 1999 were included in this prospective observational study. Demographics, characteristics of the underlying renal disease, admission diagnosis, the number of organ system failures (OSFs) excluding renal failure and SAPS II, both calculated 24 h after admission, the duration of mechanical ventilation, ICU survival and survival status at hospital discharge and 6 months after discharge were recorded. RESULTS: A total of 92 CD patients, 16 on peritoneal dialysis and 76 on haemodialysis, were included. The main reason for ICU admission was sepsis and the mean ICU length of stay 6.2+/-9.9 days. ICU mortality was 26/92 (28.3%) and was associated in multivariate analysis with SAPS II (P<0.001), duration of mechanical ventilation (P<0.01) and abnormal values of serum phosphorus (high or low; P<0.05). Hospital mortality was 35/92 (38.0%) and was accurately predicted by SAPS II [receiver operating characteristics curve: 0.86+/-0.04; goodness-of-fit test: C = 6.86, 5 degrees of freedom (df), P = 0.23 and H = 4.78, 5 df, P = 0.44]. The 6 month survival rate was 48/92 (52.2%). CONCLUSIONS: CD patients admitted to the ICU are a subgroup of patients with high mortality and SAPS II can be used to assess their probability of hospital mortality. The severity of the acute illness responsible for ICU admission and an abnormal value of serum phosphorus are determinants for ICU mortality.