DWI-Based Algorithm to Predict Disability in Patients Treated with Thrombectomy for Acute Stroke.

BACKGROUND AND PURPOSE: The reasons for poor clinical outcome after thrombectomy for acute stroke, concerning around half of all patients, are misunderstood. We developed a hierarchic algorithm based on DWI to better identify patients at high risk of disability. MATERIALS AND METHODS: Our single-center, retrospective study included consecutive patients with acute ischemic stroke who underwent thrombectomy for large anterior artery occlusion and underwent pretreatment DWI. The primary outcome was the mRS at 3 months after stroke onset. Multivariable regression was used to identify independent clinical and imaging predictors of poor prognosis (mRS > 2) at 3 months, and a hierarchic algorithm predictive of disability was developed. RESULTS: A total of 149 patients were analyzed. In decreasing importance, DWI lesion volume of >80 mL, baseline NIHSS score of >14, age older than 75 years, and time from stroke onset to groin puncture of >4 hours were independent predictors of poor prognosis. The predictive hierarchic algorithm developed from the multivariate analysis predicted the risk of disability at 3 months for up to 100% of patients with a high predictive value. The area under the receiver operating characteristic curve was 0.87. CONCLUSIONS: The DWI-based hierarchic algorithm we developed is highly predictive of disability at 3 months after thrombectomy and is easy to use in routine practice.

[Targeted screening of COPD in primary care: Feasibility and effectiveness]. / Détection précoce de la BPCO en soins primaires : un essai contrôlé randomisé.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common but under-diagnosed pathology in primary care. The objective was to study the feasibility of a randomized controlled trial in general practice to detect new cases of COPD at an earlier stage. METHODS: A cluster randomized, controlled, multicenter intervention study comparing, according to a 2×2 factorial plan, two case finding strategies: a systematic GOLD-HAS hetero-questionnaire and coordination of the patient's path to facilitate access to spirometry. The PIL-DISCO pilot study took place in 2017. Patients between 40 and 80 years old, with no previous history of COPD, consulting their GP on a given day regardless of the reason, were included. RESULTS: 176 patients were included in 1.5 days. Spirometry was performed in none of the control arm, in 13 (29.5%) of the questionnaire arm, in 22 (50%) in the coordination arm and in 32 (72.7%) with the combination of the two strategies. Two cases of stage 2 COPD and thirteen other respiratory diseases were diagnosed. CONCLUSIONS: This study confirms the feasibility of the protocol in primary care in terms of speed of inclusion and acceptability. An extension phase aiming to include 3200 patients will assess the diagnostic value of the two strategies tested in general practice.

[How were used recommendations for endometrial carcinoma? Britain retrospective study]. / Application des recommandations dans la prise en charge du cancer de l'endomètre en pratique clinique. Étude rétrospective bretonne.

OBJECTIVE: To assess the use of French Cancer Institute recommendations for the diagnosis and treatment of endometrial cancer. METHODS: Retrospective observational study involving 137 patients with endometrial cancer between 2011 and 2013. RESULTS: Both MRI and pathological assessment with correct report as recommended were used for 66.4% of patients with endometrial cancer. For patients with correct preoperative assessment, 44.9% of patients were uncorrectly classified and upgraded on final pathological analysis of hysterectomy concerning lymph node involvement risk. These patients did not have confident surgical assessment, according this risk. CONCLUSION: To improve relevance of preoperative assessment in endometrial cancer, radiological and pathological expertise is required. However, even performed optimally, preoperative assessment does not allow correct risk stratification of lymph node involvement in endometrial cancer. This ineffective stratification leads to propose sentinel lymph node biopsy with hysterectomy in case of preoperative low risk endometrial cancer assessment.

The effect of optokinetic and galvanic vestibular stimulations in reducing post-stroke postural asymmetry.

OBJECTIVE: To investigate the postural effect of 2 types of sensory stimulation in patients with a left hemispheric lesion (LHL) or right hemispheric lesion (RHL) compared with controls. METHODS: 35 patients (18 LHL, 17 RHL) and 27 controls (mean age 54.1 years), with a mean delay post-stroke of 3.0 months were enrolled. Subjects stood on a force platform and were stimulated on the left and right side by optokinetic (Okn) and galvanic vestibular (Gv) stimulation. Lateral displacement following stimulation toward the right and left directions was calculated as the mean position of the centre of pressure (CP) during the stimulation period minus the mean position at rest. RESULTS: Postural asymmetry was reduced in LHL and RHL patients. CP displacement was higher in cases of left-sided stimulation in the RHL group compared with control subjects and LHL patients (respectively 2.8 and 2.4 times higher, group effect, p<0.001, group × direction of stimulation interaction, p=0.007). The magnitude of displacement under Okn significantly correlated with Gv in all cases (ρ=0.635, p<0.001). CONCLUSIONS: Both GV and Okn stimulations can modulate hemiparetic's CP and their postural effects are correlated. SIGNIFICANCE: Results support a high level cortical postural effect of sensory stimulation on supramodal spatial network.

Risk factors for persistent pain after urological surgery.

OBJECTIVE: Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to identify risk factors following urology surgery. DESIGN: Retrospective observational study. PATIENTS: Two hundred and twenty-eight patients scheduled for urology surgery. Reasons for non-inclusions: patients who underwent a procedure not defined as being associated with PPSP. METHODS: Surgical urologic procedures potentially associated with PPSP were defined. All patients who had one of these procedures during the study period received a questionnaire by mail at least 3 months after the surgery. The files of these patients were retrospectively studied. RESULTS: Eight percent of the patients had preoperative pain. PPSP, assessed approximately 6 months after the surgery, was reported by 24% of the patients. Twenty-five (36%) of them reported neuropathic pain. Patients with PPSP had significantly more preoperative pain and an increased postoperative morphine consumption. Postoperative NSAID administration led to less persistent pain. Multivariate logistic regression analysis identified two independent risk factors of developing persistent pain: preoperative pain (OR=21.6, 95% CI 6.7-69.5, P<0.0001), morphine consumption 48 hours after surgery higher than 6mg (OR=2.3, 95% CI 1.2-4.3, P=0.0118). CONCLUSION: These findings confirm the role of preoperative pain and morphine consumption in the genesis of PPSP and call for establishing clinical perioperative pathways tailored to the patient.

Surgical treatment of esophageal perforations: the importance of a primary repair.

PURPOSE: The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis. METHODS: All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients. RESULTS: The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19). CONCLUSIONS: Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.

Are enterococci playing a role in postoperative peritonitis in critically ill patients?

This prospective non-interventional study is aimed at evaluating the role of enterococci in the postoperative course of postoperative peritonitis (POP) and the predictive factors for isolating Enterococcus spp. All adult patients, hospitalized in intensive care, who had POP between September 2006 and February 2010 were analysed. The patients' baseline clinical characteristics and microbiological and surgical characteristics of the first episode of POP were recorded. The rates of surgical and non-surgical complications and mortality were studied. A total of 139 patients were analysed and Enterococcus spp. were recovered in 61 patients (43%). The presence of enterococci was associated with significantly more intra-abdominal abscesses (26% vs 12%, p=0.025), but did not affect the rate of reoperation or mortality. Antibiotic use before reoperation was the only independent predictive factor for isolating enterococci (OR=2.19, CI95%: 1.02-4.70, p<0.043). Although mortality was not affected by the presence of Enterococcus spp., a higher rate of intra-abdominal abscess was found, suggesting that enterococci play a significant role in postoperative peritonitis, but the need to treat them remains to be determined. Previous antibiotic use before reoperation was a key factor in predicting the subsequent recovery of enterococci.

[Impact of age on mortality in patients with acute traumatic spinal cord injury requiring intensive care]. / Impact de l'âge sur la mortalité des patients traumatisés médullaires hospitalisés en réanimation.

OBJECTIVE: To evaluate the impact of age (

Biological and hemodynamic effects of low doses of fludrocortisone and hydrocortisone, alone or in combination, in healthy volunteers with hypoaldosteronism.

Low doses of hydrocortisone (HC) and fludrocortisone (FC) administered together improve the prognosis after septic shock; however, there continues to be disagreement about the utility of FC for this indication. The biological and hemodynamic effects of HC (50 mg intravenously) and FC (50 microg orally) were assessed in 12 healthy male volunteers with saline-induced hypoaldosteronism in a placebo-controlled, randomized, double-blind, crossover study performed according to a 2 x 2 factorial design. HC and FC significantly decreased urinary sodium and potassium levels (from -58% at 4 h to -28% at 10 h and from -35% at 8 h to -24% at 12 h, respectively) with additive effects. At 4 h after administration, HC significantly increased cardiac output (+14%), decreased systemic vascular resistances (-14%), and slightly increased heart rate (+4 beats/min), whereas FC had no hemodynamic effect. At doses used in septic shock, HC induced greater mineralocorticoid effect than FC did. HC also induced transient systemic hemodynamic effects, whereas FC did not. New studies are required to better define the optimal dose of FC in septic shock.

Factors associated with multidrug-resistant bacteria in secondary peritonitis: impact on antibiotic therapy.

Secondary peritonitis includes community-acquired and nosocomial peritonitis. These intra-abdominal infections have a common pathogenesis but some microbiological differences, particularly with respect to the type of bacteria recovered and the level of antimicrobial susceptibility. This report describes a prospective observational study of 93 consecutive patients with secondary peritonitis during an 11-month period. Community-acquired peritonitis accounted for 44 cases and nosocomial peritonitis for 49 cases (post-operative in 35 cases). Fifteen multidrug-resistant (MDR) bacteria were recovered from 14 patients. In univariate analysis, the presence of MDR bacteria was associated significantly with pre-operative and total hospital lengths of stay, previous use of antimicrobial therapy, and post-operative antimicrobial therapy duration and modifications. A 5-day cut-off in length of hospital stay had the best specificity (58%) and sensitivity (93%) for predicting whether MDR bacteria were present. In multivariate analysis, only a composite variable associating pre-operative hospital length of stay and previous use of antimicrobial therapy was a significant independent risk-factor for infection with MDR bacteria. In conclusion, knowledge of these two factors may provide a more rational basis for selecting initial antimicrobial therapy for patients with secondary peritonitis.

[Testing nasogastric tube placement: evaluation of three different methods in intensive care unit]. / Evaluation prospective de trois méthodes de positionnement de la sonde nasogastrique en réanimation.

OBJECTIVE: Evaluation of three methods (aspiration of gastric fluid, pH measurement of gastric fluid, and insufflation of air) in order to determine the right position of the nasogastric (NG) tube. STUDY DESIGN: Prospective, observational study in an intensive care unit. PATIENTS AND METHODS: All patients requiring a NG tube were included. Since the NG tube was inserted three tests were successively performed: aspiration of gastric fluid, pH measurement of the gastric fluid, and auscultation over the epigastrium of air injected through the NG tube. The feasibility and the results obtained for each test were noted and compared to chest X-ray, considered as the reference. Chest X-ray classified the complications as major or minor. RESULTS: A total of 419 NG tube (202 decompressive NG tube and 217 gastric feeding tube) were analysed in 280 patients. Malpositions of the NG tube were observed in 10% (majors, n=11 and minors, n=31). Aspiration of gastric fluid and pH measurement were not sensible (77% and 49%, respectively) and not specific (38% and 74%, respectively). Insufflation of air was sensible (96%) but not specific (17%). The combination of the three methods did not improve the sensibility and specificity. Two complications were only detected by chest X-ray (one insertion in the intrapleural space, and one pneumothorax). CONCLUSION: None of the test evaluated, alone or associated, was sufficient to avoid chest X-ray. Moreover the occurrence of two potential and serious complications only detected by chest X-ray increase this assertion.