Cerebral venous thrombosis in a Caribbean population.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare affliction characterized by a wide diversity in its clinical expression and etiologies. Data from black populations concerning CVT are limited. We examined the clinical, radiological, and etiological aspects as well as the outcome of CVT in Guadeloupe, a French Overseas Department in the Caribbean. METHODS: All patients hospitalized between 2000 and 2011 at the University Hospital of Pointe-à-Pitre and diagnosed with CVT were retrospectively studied. Forty-five patients, each having had a medical imaging confirming the diagnostic, were retained. RESULTS: The frequency of CVT in Guadeloupe was estimated at 15 to 20 per 100,0000 per year in our survey. Our patients were largely composed of young women (73.3%). The average patient age was 40 years (14 to 80), with an incidence peak for women in the 20 to 50 years age range. The onset was sub-acute in 69% of cases, where headaches represented 93% of initial symptoms. Thrombosis of the SLS (60%), and of the lateral sinuses (64.4%) were the most frequently encountered. We observed a majority of mild clinical forms with a good functional prognosis. The main etiological factors were oral estro-progestative contraception (40%), and a positive thrombophilia test (33.3%). The thrombophilia factors in Guadeloupe differed from those in Caucasian populations, with a higher frequency of protein S deficit. CONCLUSION: The clinical and radiological characters are similar to those described in classical studies. Our study suggests a higher incidence of CVT in Guadeloupe, compared to results from Western countries. Further investigation is necessary to better characterize the thrombo-embolic venous risk factors in the black population. Protein S deficit appears to be the most frequent cause of thrombophilia in our population.

Nitrous oxide does not produce a clinically important sparing effect during closed-loop delivered propofol-remifentanil anaesthesia guided by the bispectral index: a randomized multicentre study.

BACKGROUND: Nitrous oxide (N2O) offers both hypnotic and analgesic characteristics. We therefore tested the hypothesis that N2O administration decreases the amount of propofol and remifentanil given by a closed-loop automated controller to maintain a similar bispectral index (BIS). METHODS: In a randomized multicentre double-blind study, patients undergoing elective surgery were randomly assigned to breathe 60% inspired N2O (N2O group) or 40% oxygen (AIR group). Anaesthesia depth was evaluated by the proportion of time where BIS was within the range of 40-60 (BIS40-60). The primary outcomes were propofol and remifentanil consumption, with reductions of 20% in either being considered clinically important. RESULTS: A total of 302 patients were randomized to the N2O group and 299 to the AIR group. At similar BIS40-60 [79 (67-86)% vs 76 (65-85)%], N2O slightly decreased propofol consumption [4.5 (3.7-5.5) vs 4.8 (4.0-5.9) mg kg(-1) h(-1), P=0.032], but not remifentanil consumption [0.17 (0.12-0.23) vs 0.18 (0.14-0.24) µg kg(-1) min(-1)]. For the subgroups of men, at similar BIS40-60 [80 (72-88)% vs 80 (70-87)%], propofol [4.2 (3.4-5.3) vs 4.4 (3.6-5.4) mg kg(-1) h(-1)] and remifentanil [0.19 (0.13-0.25) vs 0.18 (0.15-0.23) µg kg(-1) min(-1)] consumptions were similar in the N2O vs AIR group, respectively. For the subgroups of women, at similar BIS40-60 [76 (64-84)% vs 72 (62-82)%], propofol [4.7 (4.0-5.8) vs 5.3 (4.5-6.6) mg kg(-1) h(-1), P=0.004] and remifentanil [0.18 (0.13-0.25) vs 0.20 (0.15-0.27) µg kg(-1) min(-1), P=0.029] consumptions decreased with the co-administration of N2O. CONCLUSIONS: With automated drug administration titrated to comparable BIS, N2O only slightly reduced propofol consumption and did not reduce remifentanil consumption. There was a minor gender dependence, but not by a clinically important amount. Clinical trial registration This study was registered at ClinicalTrials.gov, number NCT00547209.

Abrupt change of Antarctic moisture origin at the end of Termination II.

The deuterium excess of polar ice cores documents past changes in evaporation conditions and moisture origin. New data obtained from the European Project for Ice Coring in Antarctica Dome C East Antarctic ice core provide new insights on the sequence of events involved in Termination II, the transition between the penultimate glacial and interglacial periods. This termination is marked by a north-south seesaw behavior, with first a slow methane concentration rise associated with a strong Antarctic temperature warming and a slow deuterium excess rise. This first step is followed by an abrupt north Atlantic warming, an abrupt resumption of the East Asian summer monsoon, a sharp methane rise, and a CO(2) overshoot, which coincide within dating uncertainties with the end of Antarctic optimum. Here, we show that this second phase is marked by a very sharp Dome C centennial deuterium excess rise, revealing abrupt reorganization of atmospheric circulation in the southern Indian Ocean sector.

The anatomy of past abrupt warmings recorded in Greenland ice.

Data availability and temporal resolution make it challenging to unravel the anatomy (duration and temporal phasing) of the Last Glacial abrupt climate changes. Here, we address these limitations by investigating the anatomy of abrupt changes using sub-decadal-scale records from Greenland ice cores. We highlight the absence of a systematic pattern in the anatomy of abrupt changes as recorded in different ice parameters. This diversity in the sequence of changes seen in ice-core data is also observed in climate parameters derived from numerical simulations which exhibit self-sustained abrupt variability arising from internal atmosphere-ice-ocean interactions. Our analysis of two ice cores shows that the diversity of abrupt warming transitions represents variability inherent to the climate system and not archive-specific noise. Our results hint that during these abrupt events, it may not be possible to infer statistically-robust leads and lags between the different components of the climate system because of their tight coupling.

High-resolution record of Northern Hemisphere climate extending into the last interglacial period.

Two deep ice cores from central Greenland, drilled in the 1990s, have played a key role in climate reconstructions of the Northern Hemisphere, but the oldest sections of the cores were disturbed in chronology owing to ice folding near the bedrock. Here we present an undisturbed climate record from a North Greenland ice core, which extends back to 123,000 years before the present, within the last interglacial period. The oxygen isotopes in the ice imply that climate was stable during the last interglacial period, with temperatures 5 degrees C warmer than today. We find unexpectedly large temperature differences between our new record from northern Greenland and the undisturbed sections of the cores from central Greenland, suggesting that the extent of ice in the Northern Hemisphere modulated the latitudinal temperature gradients in Greenland. This record shows a slow decline in temperatures that marked the initiation of the last glacial period. Our record reveals a hitherto unrecognized warm period initiated by an abrupt climate warming about 115,000 years ago, before glacial conditions were fully developed. This event does not appear to have an immediate Antarctic counterpart, suggesting that the climate see-saw between the hemispheres (which dominated the last glacial period) was not operating at this time.

Acute myelitis associated with dengue infection.

OBJECTIVES: To present a rare neurological complication of dengue fever. PATIENTS AND METHODS: A 24-year-old female presented with acute myelitis seven days after dengue fever onset. RESULTS: The patient presented with intense fever. The day-7 examination revealed a paraparesis, T2 sensory level, and urinary retention. The patient complained of electric discharges in the four limbs. The sitting and standing positions were impossible. An MRI of the spinal cord performed on day 8 revealed diffuse medullar hyper intense lesions on T2-weighted sequences at the cervical and thoracic levels, with enhancement of the thoracic lesion after gadolinium injection. Laboratory tests revealed positive dengue antigen on day 5 and positive IgM/IgG on day 8. Treatment with intravenous pulse methylprednisolone was initiated. CONCLUSION: Dengue virus has not often been reported as a cause of myelitis. Physicians must be aware of this rare complication in patients living in or coming from endemic areas.

Psychiatric comorbidity in temporal DNET and improvement after surgery.

BACKGROUND: "Alien tissue" may be responsible for a higher frequency of psychiatric disorders in patients with temporal lobe epilepsy (TLE). Also, ganglioglioma and dysembryoplastic neuroepithelial tumors (DNET) could represent a risk-factor for the development of post-surgical psychoses. Classically, severe psychiatric disorders contra-indicate epilepsy surgery. OBJECTIVES: Assessment of inter-ictal psychiatric disorders in 10 consecutive patients with temporal DNET, before and after epilepsy surgery with a minimum of a 2-year follow-up evaluation. METHODS: DNETs were confirmed on histological examination. Psychiatric disorders were classified according to the DSM-IV-TR. RESULTS: Five patients presented inter-ictal psychiatric disorders with, according to the DSM-IV-TR, undifferentiated schizophrenia (one case), "borderline" personality (two cases), intermittent explosive disorder with slight mental retardation (one case), and personality disorders not otherwise specified but with some traits of dependent personality and with mythomania (one case). The condition of these five patients dramatically improved after surgery. No psychiatric behavior or "de novo" psychosis was observed after surgery in any of the patients. CONCLUSION: The prevalence of inter-ictal psychiatric disorders appears to be high in epileptic patients with a temporal lobe DNET primarily in relation to personality and behavioral problems with some degree of impulsivity and verbal aggressiveness. The improvements after surgery suggest that this therapy could be performed in these patients and severe psychiatric disorders do not contra-indicate this procedure.

Prevention of postoperative venous thrombosis: a randomized trial comparing unfractionated heparin with low molecular weight heparin in patients undergoing total hip replacement.

A double blind randomized trial comparing subcutaneous enoxaparin (40 mg once daily) with standard unfractionated calcium heparin administered at a dose of 5,000 units every 8 hours in patients undergoing elective hip replacement has been performed. Treatment regimens began 12 hours preoperatively with enoxaparin, 2 hours preoperatively with standard unfractionated calcium heparin, and were continued for 15 days or until discharge. Venography was performed in all patients. Two hundred thirty-seven patients were included in the study: 113 received unfractionated heparin and 124 received enoxaparin. The incidence of proximal deep vein thrombosis was reduced from 18.5% in the unfractionated heparin group to 7.5% in the enoxaparin group (p = 0.014), and the incidence of total deep vein thrombosis was similarly reduced from 25% to 12.5% (p = 0.03). There were two major bleeding episodes and one minor bleed in the enoxaparin group compared to two minor bleeds in the unfractionated heparin group. Patients who received enoxaparin required fewer red blood cell transfusions and had a significantly higher hemoglobin on postoperative days 3 and 4. Thus prophylaxis with enoxaparin, 40 mg once daily, is simple, safe and more effective than standard low dose unfractionated heparin in preventing deep vein thrombosis in patients undergoing elective hip replacement.

[Facial palsy and central nervous system infection with varicella virus following adult chickenpox]. / Paralysie faciale et infection du système nerveux par le virus VZV après une varicelle de l'adulte.

INTRODUCTION: VZV virus-related peripheral neuropathies usually occur after shingles in adults and more rarely after chickenpox in childhood. CASE REPORT: A 54-year-old patient presented with a right VIIth nerve palsy following a chickenpox rash and recovered after antiviral treatment. CSF analysis revealed lymphocytic meningitis and the virus was identified by PCR. CONCLUSIONS: Although previous chickenpox was not found in the patient's past history, the probability of reinfection is likely. The virus can be assumed to affect the nervous system directly; the axonal or demyelinating mechanism of the neuropathy may be discussed.

[Double-blind randomized comparative study of enoxaparin and standard heparin in the prevention of thromboembolic disease during insertion of total hip replacement]. / Etude comparative en double aveugle randomisée de l'enoxaparine et de l'héparine standard dans la prévention de la maladie thrombo-embolique lors de la mise en place d'une prothèse totale de hanche.

237 patients with a non-traumatic disease of the hip requiring total hip replacement entered a multicentre trial. Treatments were allocated at random in a double-blind manner: 113 patients received 5000 IU of standard heparin t.d.s.; 124 patients received enoxaparin 40 mg once a day. Treatment lasted from 10 to 15 days until bilateral ascending phlebography of the lower limbs (BAPLL) was performed. Its effectiveness was assessed by the results of BAPLL, by evaluation of the risk of bleeding on examination of the surgical wound, by the units of blood required for perfusion and by daily blood count and differential. BAPLL was performed in 228 patients: 15 phlebographies (12.5 p. 100) were positive in the 120 assessed patients of the enoxaparin group, while 27 (25 p. 100) were positive in the 108 assessed patients of the standard heparin group (p = 0.014). Proximal deep vein thrombosis was significantly (p = 0.03) less frequent in the enoxaparin group (7.5 p. 100) than in the standard heparin group (18.5 p. 100). Pulmonary embolism was observed in a patient on standard heparin. The units of blood required for perfusion were significantly (p = 0.03) smaller in the enoxaparin group (3.37 +/- 1.81 U) than in the standard heparin group (3.84 +/- 1.70 U). Thus, one single subcutaneous injection of enoxaparin 40 mg daily was significantly more effective and safer than standard heparin 5000 IU t.d.s. in the prevention of deep vein thrombosis after total hip replacement.

[Which preoperative tests in ambulatory surgery?]. / Quels examens préopératoires en chirurgie ambulatoire?

Anaesthesia for ambulatory surgery implies a strict selection of patients. Screening tests are non specific, compared to these ordered for in-patients. However, detailed preoperative evaluation is mandatory for ambulatory care to function correctly. Many studies conclude that 60% of routine screening tests are of no value: no proven benefit in either anaesthetic management or in the detection of pathologies which might interfere with anaesthesia has been shown with systematic preoperative examinations in asymptomatic subjects (adults or children). The detection of an asymptomatic anomaly by routine testing is extremely infrequent and does not lead to changes in the operating schedule or in the outcome of anaesthesia. Clinical examination and patient history are the only predictive elements, so systematic complementary tests should be abandoned and replaced by judicious selective prescription.

[Pollution of operating rooms. Measurements made during five anesthesias]. / Pollution des blocs opératoires. Measures effectuées lors de cinq anesthésies.

The purpose of this study is to measure amounts of anaesthetic vapours present in operating rooms and anaesthetic places without any gas scavenging system except air conditioning with fifteen air changes per hour. Nitrous oxide, halothane and isoflurane were measured. Halothane and isoflurane concentration is slightly higher than the French standard for anaesthetic places and lower for operating rooms. Nitrous oxide concentration is five to eight times greater than recommended standard. Although no international agreement exists concerning an acceptable pollution standard, it seems that only nitrous oxide pollution is disquieting. It would seem sensible to avoid needles contamination by use of waste gas scavenging devices.

[Prehospital thrombolysis in the acute phase of myocardial infarction. Apropos of cases handled by the mobile intensive care unit,Argenteuil (Val-d'Oise) from 1988 to 1991]. / Thrombolyse préhospitalière à la phase aiguë de l'infarctus du myocarde. A propos des cas effectués par le SMUR d'Argenteuil (Val-d'Oise) de 1988 à 1991.

We have studied prehospital thrombolytic therapy in acute myocardial infarction administered by the mobile intensive care unit of the Argenteuil hospital (Val d'Oise), between 1988 and 1991, after having detailed the protocol used. Our results confirm the effectiveness of thrombolysis, showing a rapid improvement of pain and ST segment in 50% of cases. There is a significant saving of time between pain and thrombolysis when the treatment is started during the prehospital phase. At present, in accordance with Isis 3 study results, Streptokinase is the drug of choice with rtPA being reserved for cases with contraindications for Streptokinase.

[The trans-sacral route. Can the technique be simplified?]. / La voie transsacrée. La technique peut-elle être simplifiée?

Described by P. Busoni in 1988, the trans-sacral route is now often used in paediatric anaesthesia. It seems to the authors easier to search the lost of resistance only with a spinal needle without a syringe. Authors used bupivacaine 0.20% with epinephrine. Four failures have been observed, two intrathecal entering and impossibility to perform the trans-sacral block. In recovery room, not any child needed analgesic treatment. In ward, the results of 46 children only could be analyzed.

[The computerized anesthesia record]. / La feuille d'anesthésie informatisée.

The first anaesthetic record was introduced into medical practice in 1940. Since then few changes have been made to it and it remains a rudimentary memorandum. However, since the beginning of the 1980s, interest in automatic recording of the anaesthetic file has been increasing and numerous arguments can be put forward in its favour. Apart from theoretical and experimental arguments, in practice one has to master the automatic collection of data, management of alarms and the technology of the networks involved in order to manage the flow of information by channelling it and organizing it into a hierarchy. Four other objectives can be added to the clinical recording and its medico-legal applications: anaesthetic cost evaluation, quality of care, research and clinical teaching which will provide the basis of anaesthetic epidemiological research.

[Addition of fentanyl to adrenalinized lidocaine for the brachial plexus block]. / Adjonction de fentanyl à la lidocaïne adrénalinée pour le blocage du plexus brachial.

This study was designed to investigate the effects of fentanyl associated with lidocaïne in a solution used to perform axillary brachial plexus nerve block. Adrenergic, sensory and motor nerve blocks have been studied separately and compared to a control group receiving lidocaine without fentanyl. For each type of fibre, the degree of block was measured on, 2, 3, 4, 5 and 10 minutes after injection and the result were studied by variance analysis. Axillary nerve blocks were performed in two different hospitals by two anesthesiologists. After giving informed consent, the patients were randomly allocated in two groups receiving 30 ml 1.5% lidocaine with 1/200,000 epinephrine, with or without fentanyl 100 mu. There were no statistical differences between the two groups as far as adrenergic nerve block was concerned, whereas sensory and motor nerve blocks were significantly more important as soon as five minutes after injection and lasted longer when fentanyl was added to the solution. This enhancement of intensity and duration of sensory and motor nerve blocks when fentanyl is added allows a reduction of the quantity of lidocaine required, and shortens the delay between injection and complete blockade.

[Computerized anesthesia record. How far have we gone?]. / La feuille d'anesthésie informatisée. Où en est-on?

There are more and more computerized anaesthetic records becoming available from various constructors. However, the setting up and operation of such a product depends on the development of concepts in computing. The second technological breakthrough, currently underway, is challenging principles which had seemed accepted up until now. The technical development concerns computer processing units, RAM or ROM. The development in software influences the operation of networks, multiple task and object programming. The graphic interface becomes the centre of this second revolution. All of these developments should be included in the proposed computerized anaesthetic records. Three factors determine the realisation of such a product: control of the data collecting process, the man-machine interface and the utilisation of storing data. The computerized anaesthetic record should be of open conception, allowing communication with all of the data bases and providing an interface with all the monitors and ventilators used in operating and recovery rooms. Now is the time to install the infrastructure network in operating and recovery rooms and to be thinking of acquiring the new generations of computerized anaesthetic records.

[Monitoring of multiple trauma in an emergency hospital unit]. / Le monitorage des polytraumatisés en situation d'urgence hospitalière.

In the monitoring of multiple trauma patients in the emergency hospital setting the use of monitors should be graduated. However, the use and interpretation of data from these monitors is becoming increasingly complex and can lead to errors and responses which may not be adopted. Clinical nomination and observation have their limits and the anaesthetist is faced with the added difficulties of interpretation of data from monitors and is pitfalls. The management of the patient is based on this human-machine relationship, which provides the basis for the therapeutic attitude and the treatment which ensues. Basic monitoring comprises a pulse oximeter, a capnograph, an ECG and a blood pressure monitor, 52% of incidents are detected by these instruments; 27% by SpO2, 24% by capnography. The pertinence is 82% for the oximeter when used alone and 55% for the capnography alone, although when the two are used together this increases to 88%. If the blood pressure monitor is added the pertinence increases to 93%, and to 95% if the FiO2 is monitored. The use of monitors of levels of haemoglobin or haematocrit must take into account the important variations in volaemia. The displayed values have a poor predictive value. The second level of monitoring comprises the use of a pulmonary artery catheter. The errors in measurement and interpretation are reviewed and finally, we consider the possible use of FOE transoesophageal echocardiography in the multiple trauma patient.

[Pharmacokinetics of propofol as an induction agents in adults]. / Pharmacocinétique du propofol comme agent d'induction chez l'adulte.

The disposition kinetics of Propofol have been determined in 7 patients (3 men, 4 women) receiving 2.5 mg/kg for induction of anaesthesia. Peripheral venous samples were collected up to 12 hours after injection of the drug. Data analysis indicates a 3 compartment model with a terminal half-life of 480 +/- 141 min, clearance of 0.0352 +/- 0.0014 l/min/kg and volume of distribution of 24.2 +/- 6.2 l/kg.