Cost of care pathways before and after appropriate and inappropriate transfers to the emergency department among nursing home residents: results from the FINE study.

BACKGROUND: Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate). METHODS: This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant. RESULTS: Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€. CONCLUSIONS: Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents. TRIAL REGISTRATION: clinicaltrials.gov, NCT02677272.

[Epidural labor analgesia and parturient with type 2B von Willebrand disease]. / Analgésie péridurale obstétricale et maladie de Willebrand de type 2B.

Type 2B von Willebrand disease (vWD) is an inherited bleeding syndrome resulting from a qualitative abnormality of von Willebrand Factor with an increased affinity for the glycoprotein Ib platelet receptor. Pregnancy increases the severity of this disease by decreasing the platelet count restricting epidural anaesthesia because of adverse risk of spinal bleeding. There is a phenotypic variability of Type 2B vWD depending of the von Willebrand Factor mutation. We report here the strategy we used to administer epidural anaesthesia for a patient with Type 2B vWD resulting from the P1337L mutation of von Willebrand Factor.

[When the pupil becomes the teacher]. / Quand l'enseigné devient enseignant.

OBJECTIVE: To evaluate the theoretical teaching provided to ophthalmology residents in Toulouse during the 2006-2007 academic year using the PowerVote(®) system. PUPILS AND METHOD: This was a prospective study concerning all ophthalmology residents in Toulouse. Classes were given by the house doctors and senior registrars as PowerPoint presentations lasting about 45 min. Just before each lecture, the house doctors took a 5 min test comprising five multiple choice questions. There were two lectures per month on average. One month after the course of lectures ended, the course as a whole was evaluated using the PowerVote(®) tool, on objectives given to the house doctors in advance. The teaching concerned the macula. RESULTS: Ten residents took part in the final evaluation in 2007. The residents who had given lectures obtained significantly better results, not only in the initial test but also in the final one. DISCUSSION: Teaching can take many forms. We evaluated teaching by the students themselves. The more involved a house doctor was in teaching, the better he remembered the lesson. CONCLUSION: Giving a theoretical lecture enables residents to reach a higher level, which is further improved if they are involved in the teaching. The use of PowerVote(®) is an interesting pedagogical tool.

[PowerVote: an evaluation tool]. / Utilisation de PowerVote pour une évaluation.

OBJECTIVE: The objective was to report the experience using PowerVote software to evaluate the teaching provided to Toulouse ophthalmology residents. SUBJECTS AND METHODS: This prospective study covers all ophthalmology residents in Toulouse during the 2006-2007 academic year. Courses were alternately given by residents and resident physicians, during a 45-minute PowerPoint presentation. At the beginning of the course, the residents answered five multiple-choice questions. A month after the end of the 12-course program, participants were tested, using PowerVote, on the content of the entire course, focusing on objectives that the residents had received at the start. RESULTS: The level of theoretical knowledge increased significantly, from 4.0/10 to 6.8/10. (P=0.0027). CONCLUSION: Tests using PowerVote allowed instantaneous correction of the answers to the test questions. Consequently, the teaching was easier to adapt to the students' knowledge. Descriptive statistics of the results obtained could be generated via the PowerVote software and displayed on an Excel spreadsheet. The use of PowerVote also allowed direct evaluation of student knowledge and adjustments in the teaching for the following courses. This interactive pedagogical tool has potential for development, particularly to evaluate practices in the context of on-going medical education.

[Ventriculus terminalis dilatation in adults: A case report and review of the literature]. / Dilatation du ventriculus terminalis chez l'adulte : à propos d'un cas et revue de la littérature.

The ventriculus terminalis (VT) is a virtual cavity of the conus medullaris that appears during embryonic life. The occurrence of its dilatation is very rare in adulthood. Only 27 cases have been documented so far. We present the case of a 47-year-old woman who presented with hypoesthesia and dysesthesia of the lower limb, distal paresis, and urinary dysfunction evolving for the past 5 years. Electrophysiology confirmed radiculopathy. MRI revealed a cystic dilatation of the VT. Surgery consisted in laminectomy with myelotomy and fenestration. Histology showed a simple cubic ependymal epithelium. Progression has been favorable concerning the motor deficit and sphincter dysfunction but neuropathic pain has persisted for 6 months. The data are similar to those found in the literature. The sex ratio is 6:21, the mean age is 45. Symptoms appear on average over 2 years with lower limb pain (71%), sphincter dysfunction (71%), lumbago (64%), motor deficits (57%), and sensory disorders (47%). Imaging demonstrated cystic dilatation in the conus medullaris filled with cerebrospinal fluid without contrast enhancement. The histology analysis showed a simple ependymal epithelium with no tumoral process. The fenestration of the cyst allows complete recovery of symptoms in 52% of cases and partial recovery in 43%. The VT seems to be a whole nosologic entity in itself. Myelotomy with fenestration provides good results on motor and sphincter symptoms, whereas the benefit in terms of pain is subject to discussion.

Pituitary apoplexy and idiopathic thrombocytopenic purpura: a new case and review of the literature.

Pituitary apoplexy can occur as a complication of idiopathic thrombocytopenic purpura. We report here a new case of such association. A male patient aged 59 years, complaining of decreased libido for one year, was referred to the emergency department for purpura and severe thrombocytopenia (4000 platelets/mm3). 24 hours after the cutaneous rash the patient presented with clinical symptoms of bilateral cavernous sinus compression comprising ptosis, bilateral ophtalmoplegia and right supraorbital hypoesthesia. Cranial CT scan showed an enlarged sella and a pituitary mass with signs of intrapituitary haemorrhage. Hormonal evaluation showed hyperprolactinemia (50 ng/mL) and hypopituitarism, and the patient needed substitution with hydrocortisone and levothyroxine. Immunoglobulins and corticosteroids were given to the patient to treat thrombocytopenia, then worsening of neurological and ophtalmological symptoms led to pituitary surgery. Histopathological examination found necrotical pituitary tissue. Immunostaining with an anti-prolactin antibody was positive in several groups of cells. Neurological symptoms subsided and thrombocytopenia was corrected by treatment. In conclusion, we report a case of pituitary apoplexy due to severe thrombocytopenia occurring as a complication of a preexisting macroprolactinoma.

[Direct transnasal approach. Description and feasibility in 60 patients]. / La voie transnarinaire directe. Description et faisabilité à propos de 60 cas.

BACKGROUND AND PURPOSE: The direct transnasal approach is a less invasive approach to the sella turcica and represents an alternative to the sublabial transsphenoidal approach with minor oro-nasal complications. In this study, we describe this approach with emphasis on post-operative course. METHODS: We studied retrospectively 60 patients operated on consecutively by a transnasal approach between January 1996 and December 2000. RESULTS: There were 47 macroadenomas, 9 microadenomas and 4 non-adenomatous pathologies. Despite its narrowness, the transnasal approach was possible in all cases and allowed tumor removal as satisfactory as with the sublabial approach. Eight patients had complications not directly related to the approach: 1 death (meningitis with brain stem ischemia), 3 pituitary fossa hematomas, 4 rhinorrheas and 2 meningitis. Seven patients had complications related to the approach: 2 nasal obstructions, 1 nasal dryness, 2 sinusitises and 2 hyposmias. All these local complications were transitory and disappeared within 3 months. CONCLUSIONS: In our experience, the direct transnasal approach is safe, quick and less invasive than the sublabial approach.

[Image-guided neuroendoscopy]. / Neuroendoscopie guidée par ordinateur.

BACKGROUND AND PURPOSE: By definition, image-guided neuroendoscopy is a connection between a neuroendoscope and a neuronavigational system creating a computer-guided instrument. Our objective was to adapt our rigid endoscope with our neuronavigation system to perform computer-guided endoscopy. METHODS AND RESULTS: The rigid neuroendoscope, equipped with light emitting diodes, was connected to the work station. We report our early results with this device in 17 patients: 8 ventriculocisternostomies, 5 ventriculocisternostomies with biopsies of tumors of the posterior part of the third ventricule, 4 biopsies or tumor removal like colloid cysts. No technical complications were encountered. CONCLUSIONS: The development of image-guided neuroendoscopy has modified our approach to neuroendoscopy because the surgical procedure is facilitated. The use of fluoroscopy becomes unnecessary. The surgeon can choose, independent of the preestablish surgical technique, the entry point, the target and, of course, the optimal trajectory. The technique is adaptable to the individual anatomy of each patient, the location and the nature of the target. It is an undeniably useful teaching tool and represents a real progress in minimally invasive neurosurgery.

A relapsing remitting lymphocytic hypophysitis.

Lymphocytic Hypophysitis is a rare autoimmune disease of the pituitary presenting mainly with features of a mass lesion and loss of pituitary function. Its course is quite unpredictable and its treatment is still controversial as experience in the field remains scarce. We describe a 45 year-old woman with a history of recurrent fever and meningeal symptoms who was referred 3 years later to our department for pituitary insufficiency. Hormonal studies revealed an anterior pituitary deficiency and autoimmune thyroiditis. Pituitary hypertrophy as evidenced by magnetic resonance imaging showed complete regression upon hydrocortisone substitution therapy. Two years later, fever and meningeal symptoms recurred as well as pituitary hypertrophy. Cerebrospinal fluid analysis revealed an aseptic lymphocytic meningitis. Pituitary biopsy confirmed the diagnosis of LH. The patient was started on prednisone 70 mg per day. She improved clinically and radiologically and remained free of symptoms thereafter. At a recent follow up the MRI showed an empty sella turcica. Hereby we illustrate a yet unreported pattern of LH presenting as a recurrent aseptic meningitis. We also describe one of the long-term course of the disease which is still unpredictable.

[Paraplegia and medullary arteriovenous malformation. Role of surgery, corticosteroids and embolization]. / Paraplégie et malformation artérioveineuse médullaire. Place de la chirurgie, de la corticothérapie et de l'embolisation.

CASE REPORT: We report the case of a nine-year-old child with a cervical medullary arteriovenous malformation (AVM), revealed by total paraplegia, whose regression started during steroid therapy, before embolization. CONCLUSION: The frequency of AVM's spontaneous favorable outcome is unknown but should not be underestimated. It might be improved by steroids.

Vertebral pedicle anatomy in relation to pedicle screw fixation: a cadaver study.

New techniques to stabilize and correct the thoracic and lumbar spine have been developed in recent years. In view of the wide variety and complexity of fixation devices, the optimum configuration of spinal instrumentation systems needs to be defined. Linear and angular measurements of both vertebral pedicles were made in ten complete thoracic and lumbar cadaveric spines using callipers and a goniometer. The vertical interpedicular distance gradually increased along the spine up to L5. The transverse interpedicular distance was larger at both ends of the spine. Pedicular height gradually increased from T1 to L5, plateauing between T3 and T9, being widest at the thoracolumbar junction. Pedicular width was greatest at the three junctional regions of the spine. The sagittal pedicular angle decreased along the length of the spine to zero at L5. The transverse pedicular angle decreased from T1 to T12 and then increased to L5. Of the pedicular measurements only width limits the diameter of fixation screws. The vertical interpedicular distance determines the distance between the holes of plates, while the length of the transfixator is related to the transverse interpedicular distance. The pedicular angles enable triangulation of screws and determine the stability of the fixation.

Cavernous hemangiomas of the orbit: MR imaging.

PURPOSE: To describe the MR imaging findings in eight patients with cavernous hemangioma of the orbit. METHODS: CT, MR imaging and echographic studies of eight patients with cavernous hemangioma localized in the orbit were reviewed. All patients presented with a progressive symptomatology: in seven cases with a painless proptosis, in one case with a failing of visual acuity of the concerned eye. The patients were examined with T2- and T1-weighted spin echo sequences, before and after intravenous administration of Gadolinium*, in axial, coronal and sagittal planes. In seven patients, a fat saturation prepulse was given after the Gd-enhanced study. Two patients were also examined with CT scan, with and without intravenous contrast administration. Three patients underwent a Doppler color-coded transorbital sonography. The analyzed criteria were: location, form, margins, size, signal or density. Seven patients underwent surgery with pathologically proved cavernous hemangioma. In one patient, therapy was conservative, because of the absence of significant clinical complaints. RESULTS: In all cases, MRI showed a well-defined intraconal mass. The lesions were homogeneous, isointense to muscle on the T1-weighted sequence and hyperintense to muscle on the T2-weighted sequences. In five cases, a peripheral rim, hypointense to the mass on the T1- and T2-weighted sequences could be observed. After Gadolinium*, six lesions showed initial central patchy enhancement. On the three following T1-Gadolinium* sequences, these lesions showed total and homogeneous filling. In two patients, the lesions showed immediate homogeneous enhancement. On CT, the orbital masses were spontaneously hyperdense, with associated focus of microcalcifications. On echography, the lesions appeared hyperechogenic, heterogeneous, with individualization of small areas of very slow flow. CONCLUSION: From the analysis of the MR appearance of an intraconal, well-defined mass, associating homogeneous signal, isointense to muscle on T1-weighted sequence, hyperintense on T2-weighted sequence, and especially progressive filling on Gd-enhanced sequences, the diagnosis of cavernous hemangioma may be highly suggestive, in a patient presenting a painless progressive proptosis.

[Postero-lateral surgical approach to soft cervical herniated discs. Technical note]. / Abord postéro-latéral des hernies discales cervicales molles. Note technique.

Most ruptured cervical discs are operated on by an anterolateral approach. The posterior approach is an older procedure, nowadays underused because it was associated with a high morbidity, especially in terms of medullary complications. However, posterior approach has evolved in posterolateral route, which is not so devastating and has a very low morbidity rate. It gives excellent functional results when surgery is dedicated to monoradiculopathy from soft posterolateral cervical hernias. It seems appropriate to consider this surgical route as an alternative to anterolateral surgery in these very selected cases. The authors describe and comment the technique.

Cavernous hemangioma of the intracranial optic pathways: CT and MRI.

PURPOSE: The purpose of this work was to describe the CT and MR findings in three patients with cavernous hemangioma (CH) of the intracranial optic pathways. METHOD: CT and MR studies of three patients with CH of the optic chiasm were reviewed. All patients underwent MRI of the chiasmal area, with coronal T2- and T1-weighted studies as well as gadolinium-enhanced coronal and sagittal T1-weighted studies. RESULTS: The patients (mean age, 40 years) presented with chiasmal apoplexy (two cases) and progressive decrease of visual acuity (one case). In all cases, MRI showed regular enlargement of the optic chiasm, with extension to the optic nerve in one case and to the left optic tract in one case. The chiasmatic dimension was 2.5-3 cm in two cases and 1-1.5 cm in the other case. In all cases, MRI revealed an acute (isointense signal on T1-weighted and hypointense signal on T2-weighted sequences) or subacute (hyperintense signal on T1 - and T2-weighted sequences) hemorrhage with, adjacent to it, an area with signals of blood of different ages, highly suggestive of CH. CT showed, in chiasmatic CHs, a suprasellar mass spontaneously denser than adjacent brain parenchyma. In two cases, microcalcifications were associated. In two cases, CT and MRI revealed slight heterogeneous enhancement after contrast agent administration. In one case, no enhancement was observed. Two patients underwent surgery by frontopterional craniotomy. The optic chiasms were swollen with an intrinsic bluish mass. The cerebrospinal fluid was not xanthochromic. Microscope examination confirmed the diagnosis of CH. After 12 months, the operated patients had improved visual acuity and visual field but did not completely recover. The nonoperated patient (because of spontaneous rapid recovery of visual acuity) was followed clinically and on MRI over 18 months. CONCLUSION: CH in the optic chiasm must be suspected in the presence of an acute chiasmatic syndrome. MRI is the best imaging modality, showing either an acute or a subacute chiasmatic hemorrhage or the typical pattern of CH with heterogeneous alternation of foci of blood of different ages, with a central focus of methemoglobin, a peripheral rim of hemosiderin, adjacent foci of acute or subacute hemorrhage, and slight or no enhancement after gadolinium administration.

[Hepatic portal venous gas: is it always a sign of severity and surgical emergency?]. / Aéroportie: est-ce toujours un signe de gravité et une urgence chirurgicale?

Hepatic portal venous gas is a radiological finding due to the presence of gas in the portal vein. It was associated with a mortality rate ranging from 75% to 90% and with an indication for exploratory laparotomy. We report one case following an abdominal trauma. The portal vein gas was detected on CT Scan. The patient who was asymptomatic was not operated on and survived. The severity of this radiological symptom requiring a laparotomy has to be reassessed. CT Scan is the most efficient method to recognize portal vein gas and its larger use has allowed to diagnose more cases not detected by simple abdominal X-rays. In conclusion, surgical exploration should not be done systematically but has to be decided in relation with the clinical status of the patient.

[Cervical spine infection with Streptococcus anginosus. Case report]. / Infection du rachis cervical A streptococcus anginosus.

A case of cervical spine infection due to Streptococcus anginosus is reported. Streptococcus milleri is encountered in the mouth, gastro-intestinal tract, vagina and nasopharynx. It is an uncommon pathogen responsible of suppurative infections such as brain liver or spleen abscesses, intra-abdominal or soft tissue abscesses and pleural empyema. In rare cases it can cause spondylodiscitis and osteomyelitis. Based on the review of eight cases of spondylodiscitis or osteomyelitis, diagnosis and treatment are discussed.

Recurrent intracranial neurenteric cysts.

Neurenteric cysts are cystic lesions lined by a columnar epithelium of endodermal derivation. They are rarely located in the central nervous system. We describe the case history of two recurrent neurenteric cysts located within the posterior fossa: one in the 4th ventricle and the second in the cerebellopontine angle. The literature is reviewed and the follow-up and recurrence of such cysts are discussed.

A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury.

OBJECT: The authors prospectively studied the efficacy of tirilazad mesylate, a novel aminosteroid, in humans with head injuries. METHODS: A cohort of 1120 head-injured patients received at least one dose of study medication (tirilazad or placebo). Eighty-five percent (957) of the patients had suffered a severe head injury (Glasgow Coma Scale [GCS] score 4-8) and 15% (163) had sustained a moderate head injury (GCS score 9-12). Six-month outcomes for the tirilazad- and placebo-treated groups for the Glasgow Outcome Scale categories of both good recovery and death showed no significant difference (good recovery in the tirilazad-treated group was 39% compared with the placebo group in which it was 42% [p=0.461]; death in the tirilazad-treated group occurred in 26% of patients compared with the placebo group, in which it occurred in 25% [p=0.750]). Subgroup analysis suggested that tirilazad mesylate may be effective in reducing mortality rates in males suffering from severe head injury with accompanying traumatic subarachnoid hemorrhage (death in the tirilazad-treated group occurred in 34% of patients; in the placebo group it occurred in 43% [p=0.026]). No significant differences in frequency or types of serious adverse events were shown between the treatment and placebo groups. CONCLUSIONS: Striking problems with imbalance concerning basic prognostic variables were observed in spite of the large population studied. These imbalances concerned pretreatment hypotension, pretreatment hypoxia, and the incidence of epidural hematomas. In future trials of pharmacological therapy for severe head injury, serious consideration must be given to alternative randomization strategies. Given the heterogeneous nature of head injury and the identification of populations that do relatively well with standard therapy, target populations with a higher risk for mortality and morbidity may be more suitable for clinical trials of such agents.