Cerebrovascular Events in Lyme Neuroborreliosis.

BACKGROUND: Cerebrovascular events in neuroborreliosis are a rare condition described only in isolated or small case series. No specific clinical or radiological features have been identified, and diagnosis is based on very different criteria. METHODS: We retrospectively describe cases diagnosed in the Stroke Unit of Nancy Hospital, located in the endemic area of the northeast of France. We also reviewed other cases found in the literature. RESULTS: We identified 5 cases in our center and 57 other reported cases. Mean age was 39 years (range 5 to 77). Possible previous contact with Borrelia burgdorferi (B burgdorferi) was found in about half of cases. Additional neurologic symptoms (headache, cognitive impairment, and/or gait disturbance) were found in 44% of cases. Cerebral imaging revealed both ischemic (87%) and hemorrhagic lesions (13%) with a multiterritorial aspect in 22% of strokes, and signs of vasculitis in 71%. Analysis of cerebrospinal fluid (CSF) revealed lymphocytic meningitis in 90% of cases and elevated protein level in 86%. CSF/serum anti-B burgdorferi antibody index (AI) was positive in 91% of cases. Outcome was favorable after appropriate antibiotic treatment. Our 5 patients presented a modified Rankin scale score 0-1, without any stroke recurrence, after a median follow-up of 2.8 years. CONCLUSIONS: The diagnosis of Lyme neuroborreliosis should be considered for patients with cerebrovascular events without obvious cause living in an endemic area, in the presence of repeat multiterritorial strokes at short intervals, other neurologic symptoms, a history of B burgdorferi infection, and radiological signs of vasculitis. Diagnosis can be confirmed by CSF analysis with AI but with an incomplete sensitivity.

Withdrawal of artificial nutrition: influence of prior experience on the perception of caregivers.

CONTEXT: In spite of the existence of clinical guidelines and a legal framework in France, the withdrawal of artificial nutrition (AN) in palliative care remains a difficult situation for caregivers who are confronted with this reality. OBJECTIVES: To describe the perception of caregivers on the withdrawal of AN and to compare this perception between caregivers who have already been confronted with this situation and those who have not. METHODS: Cross-sectional survey questionnaire of nurses and nurses' aides (n = 274) working in medicine, surgery, and palliative care departments of a regional hospital. RESULTS: Of the caregivers, 59.5% declared having been confronted with the withdrawal of AN in their professional practice. This was associated with a better perception by these caregivers even if their knowledge on the criteria to be considered in the decision was not significantly modified. CONCLUSION: The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation. The lack of information perceived by caregivers should prompt us to develop additional training on the withdrawal of AN, its objectives, and its clinical consequences.

Caregivers Confronted With the Withdrawal of Artificial Nutrition at the End of Life: Prevalence of and Reasons for Experienced Difficulties.

BACKGROUND: Withdrawing artificial nutrition in palliative care is an issue that often leads to ethical dilemmas among health care providers, despite clinical guidelines. OBJECTIVES: To describe the experience of health care providers confronted with the withdrawing of artificial nutrition at the end of life and identifying the factors related to the level of ethical dilemmas. METHODS: Cross-sectional survey questionnaire of all the nurses and nurses' aides working in medicine, surgery, and palliative care departments of a regional hospital and who have already been confronted with the withdrawal of artificial nutrition. RESULTS: Of 818 questionnaires sent, 274 were returned (response rate 33.5%); 60% (163) of the care providers who responded were involved in withdrawing artificial nutrition at the end of life. Among these, 42 (25.8%) had always or often been affected with ethical dilemmas, and 97 (60%) responded that withdrawing artificial nutrition had always or often been preceded by a multidisciplinary discussion. Items significantly associated with a high level of ethical dilemmas were (1) existence of differences in opinion within the health care team, (2) lack of information regarding the indication of the withdrawal of artificial nutrition, (3) feeling uncomfortable with the patient and his or her relatives, (4) guilt, (5) feeling of abandonment of care, and (6) uneasiness. CONCLUSION: Health care providers seem to have a lack of information and consensus regarding the withdrawal of artificial nutrition at the end of life. The ethical dimension of withdrawing artificial nutrition in palliative care has a strong impact on care providers, regardless of the circumstances of the withdrawal.

Internal carotid thrombus in patients with inflammatory bowel disease: two cases.

Increased ischemic stroke risk is observed in patients with inflammatory bowel disease (IBD). Causes and physiopathological aspects of cerebral infarct, in this specific population, are less often described. There is little information to provide guidelines for the best curative and preventive treatment. We report 2 cases of ischemic strokes due to internal carotid thrombus in patients during active phase of IBD. Ulceration of early atherosclerotic plaques activated by a hypercoagulation state may cause a thrombus. A combined therapy with heparin and corticosteroids was used for both our patients. Lysis of the thrombus was obtained after several days without surgical treatment and shown by ultrasonography. These cases highlight an aetiology of stroke in patients with IBD and use of a synergic treatment to respond to hypercoagulability in link with IBD. Benefits and safety of this therapy should be confirmed with clinical studies.

[Principle of double effect and sedation for intractable distress: reflexion on survival in sedated patients]. / Théorie du double effet et sédation pour détresse en phase terminale : réflexion autour de la survie des patients sédatés.

The effect of sedation for intractable distress on survival in terminally ill patients is a debated question. For certain people, this would limit the physician's intervention to the detriment of symptom alleviation for patients. The principle of double effect is traditionally used to overcome this ethical conflict. Studies conducted between 1990 and 2009 fail to show that the death of patients undergoing sedation for intractable distress is hastened. Some authors conclude that sedation does not hasten death and claim that principle of double effect is unnecessary in this debate. In our view, caution is required in the interpretation of studies results and absence of evidence of sedation effects on survival cannot be considered as an evidence of absence of sedation effects on survival. Furthermore, we consider obtaining a definitive answer as impossible in the future, as the required cannot be conducted for ethical reasons. Caution, we think, is necessary, especially as sedation is sometimes used with explicit intention of hastening the end of life. Physician's intention, key point of the principle of double effect, comes back into the foreground of ethical debate on sedation for intractable distress. Far from limiting the physician's action, the principle of double effect, which requires us to clarify our intentions, should allow us to make the distinction between sedation for intractable distress and euthanasia.

Cerebral venous thrombosis due to essential thrombocythemia and worsened by heparin-induced thrombocytopenia and thrombosis.

This case describes the medical history of a 61-year-old woman treated for cerebral venous thrombosis (CVT) leading to diagnosis of essential thrombocythemia (ET). During treatment with unfractionated heparin, after initial improvement of clinical state, signs of cerebral hypertension reappeared. Although the platelet count decreased, heparin-induced thrombocytopenia (HIT) was only suspected 2 days later when it dropped below the standard 150 × 10(9) L(-1) threshold. HIT diagnosis was confirmed by the presence of anti-PF4/heparin IgG. This late finding was the cause of the extension of CVT with worsening of cerebral hypertension necessitating decompressive craniectomy. Elevated basal platelet count due to ET can delay diagnosis and treatment of HIT. In this case, physicians should be more attentive to platelet count variations rather than thrombocytopenia threshold.

Persistent N2 disease after induction therapy does not jeopardize early and medium term outcomes of pneumonectomy.

BACKGROUND: Operative management of patients with persistent N2 disease after induction therapy is still debated. METHODS: One hundred fifty-three consecutive patients underwent pneumonectomy from January 1999 until July 2005; 28 patients (18.3%) had persistent N2 disease after induction therapy (group 1), 32 patients (20.9%) had pathologic stage N0 or N1 after induction therapy (group 2), and 93 patients (60.8%) with pathologic N2 disease underwent immediate surgery (group 3). Short-term end points were operative mortality at 30 and 90 days and major complications. Long-term end points were 5-year survival and disease-free survival rates. RESULTS: Demographics of the three groups were similar (age, sex, side of operation, type of chemotherapy, smoking status, and comorbidity such as coronary artery disease, diabetes, and chronic obstructive pulmonary disease). Thirty-day postoperative mortality was 10.7% in group 1, 3.1% in group 2 (p = 0.257), and 4.3% in group 3 (p = 0.201); 90-day postoperative mortality was 10.7% in group 1, 12.5% in group 2 (p = 0.577), and 9.7% in group 3 (p = 0.558). Incidence of major postoperative complications was similar. Five-year survival rate was 32.2% (median, 28 months; 95% confidence interval, 7 to 43) in group 1, 34.8% (median, 27 months; 95% confidence interval, 7 to 47) in group 2 (p = 0.685), and 12.4% (median, 15 months; 95% confidence interval, 11 to 19) in group 3 (p = 0.127). No statistical difference was found in terms of 5-year event-free survival, or regarding the side of pneumonectomy. CONCLUSIONS: Our results suggest that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy.

Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia.

BACKGROUND: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid. METHODS: In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day. RESULTS: Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups. CONCLUSION: After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

Induction chemotherapy does not increase the operative risk of pneumonectomy!

BACKGROUND: There is an ongoing debate whether induction therapy increases post-operative mortality and morbidity, especially when performing pneumonectomy. We therefore reviewed a consecutive series of patients having undergone pneumonectomy in a single center. METHODS: The charts of 298 patients operated on between January 1999 and July 2005 were reviewed. Patients were divided into two groups: group 1 included those who received induction chemotherapy (60 patients, 20.1%), and group 2 included those who underwent surgery alone (238 patients, 79.9%). Endpoints were operative mortality at 30 and at 90 days, and major complications such as empyema, bronchial fistula and acute respiratory distress syndrome. Statistical analyses were performed using SPSS 11.0 software. RESULTS: Demographic data were similar for both groups when considering side of operation, comorbidity and weaning from tobacco; patients were older in group 2 (61.83+/-9.58 years vs 57.75+/-8.94 years; p=0.003) and there were more female patients in group 2 (17.2% vs 5.0%; p=0.010). Post-operative mortality at 30 days was 6.7% in group 1 and 5.5% in group 2 (p=0.458), and 11.7% for group 1 and 10.9% in group 2 at 90 days (p=0.512). Incidence of empyema was 1.7% in group 1 and 2.1% in group 2 (p=0.652); incidence of bronchopleural fistulas was 1.7% in group 1 and 5.5% in group 2 (p=0.188); incidence of acute respiratory distress syndrome was 3.3% in group 1 and 3.4% in group 2 (p=0.675). CONCLUSION: In opposition to previous reports, induction chemotherapy did not significantly jeopardize post-operative outcome following pneumonectomy in our experience.

A new bioabsorbable sleeve for lung staple-line reinforcement (FOREseal): report of a three-center phase II clinical trial.

OBJECTIVE: To investigate on the feasibility, safety, and effectiveness of a new bioabsorbable material for lung staple-line reinforcement. METHODS: This prospective open trial included 66 patients (mean age of 56+/-17 years) who underwent various types of lung resection using staplers with knitted calcium alginate sleeves for buttressing (FOREseal, Laboratoires Brothier, Nanterre, France) at three academic centers: 29 lobectomies, 22 emphysema surgeries, 15 wedge resections or lung biopsies. Intraoperative air leakage was assessed at a mean respiratory peak pressure of 30 cmH2O, and rated as grade 1, 2, or 3. Persistent air leakage in the postoperative course, as well as any relevant event, was assessed daily. The follow-up period was of 6 months. RESULTS: No technical problem linked to the device occurred. Hemostasis of the cutting edges was completed in all patients. Fifty-six percent of the patients had no intraoperative air leak and 27.3% had grade 1 leaks. Mean postoperative air leaks and thoracic drainage times were 1.9+/-2.3 days and 6+/-5.3 days, respectively. In-hospital mortality was nil. There was no empyema. Mean hospital stay was 9.1+/-6.6 days. At follow-up, one patient underwent lung transplantation, and pathology of the explanted specimen showed the absence of device-related foreign-body inflammation. One patient complained from metalloptysis, and another one, with a metastatic invasive aspergillosis, developed an infectious recurrence that required reoperation. CONCLUSIONS: FOREseal is an ergonomic, safe, and promising new material instead of nonabsorbable materials and xenomaterials for staple-line reinforcement. A randomized comparative study is now in progress.

Sampling or node dissection for intraoperative staging of lung cancer: a multicentric cross-sectional study.

OBJECTIVE: This study compares accuracy of sampling versus formal node dissection in patients with primary lung cancer. PATIENTS AND METHODS: During a 4-month period, 208 consecutive patients (172 men, 36 women) without bulky disease underwent resection for primary lung cancer in three centers. The surgeon first sampled the main lymph node stations, and subsequently performed a radical mediastinal dissection. Endpoints were accuracy of prediction for stage N2 and radicality of node sampling compared to dissection. RESULTS: Resection consisted of 1 segmentectomy, 142 standard lobectomies, 6 bilobectomies, 14 sleeve-lobectomies, and 45 pneumonectomies. There were 108 squamous cell carcinomas, 621 adenocarcinomas, 18 bronchoalveolar carcinomas, 8 large cell carcinomas, 4 adenosquamous carcinomas and 8 neuroendocrine carcinomas. Primary tumor was stage T1 in 49 patients, T2 in 110, T3 in 43, and T4 in 6. Lymph node status (dissection) was N0 in 113, N1 in 35, and N2 in 60 patients. N2 disease concerned a single node in 16, a single node station in 19, and multiple levels in 25. Both N1 and N2 nodes were diseased in 36 patients. Sampling adequately recognized N2 disease in 31 patients (52%). Multiple level N2 was accurately identified in 10 patients (40%). Resection based on sampling would have been incomplete in 53 patients (88%). CONCLUSION: Radical mediastinal dissection is a mandatory adjunct to resection for lung cancer with curative attempt.

Bronchoplastic lobectomy: do early results depend on the underlying pathology? A comparison between typical carcinoids and primary lung cancer.

BACKGROUND: This study evaluates the impact of the underlying disease upon the surgical outcome of bronchoplastic lobectomy, comparing typical carcinoid tumours with primary lung carcinoma. PATIENTS AND METHODS: This retrospective study includes 98 consecutive patients (78 males, 20 females). Eighteen patients had a typical carcinoid tumour (group 1), and 80 had a primary bronchial carcinoma (group2). Fifty-six patients underwent bronchoplasty with full sleeve resection (10 patients from group 1, 46 from group 2) and 42 patients had a bronchoplasty with bronchial wedge resection (8 from group 1 and 34 from group 2). Right upper lobectomy was the most common procedure. We compared demographic data, surgical indications, the type of bronchoplasty and postoperative complications. RESULTS: The average age in group 1 (38.5+/-16.3 years; range 15-77) was significantly lower than in group 2 (61.4+/-9.5 years; range 14-75) (p<0.001). There were no postoperative deaths. Procedure-specific complications (anastomotic dehiscence and atelectasis) were found in 7 patients (8.75%) in group 2 (of which, three had a combination of two of the above-mentioned complications) but none (0%) in group 1 (p=0.23). Seven patients from group 2 (8.75%) required treatment for a residual pneumothorax for none (0%) in group 1 (p=0.23). The mean duration for air leak was comparable in both groups (p=0.366). Three patients (16.67%) from group 1 had non-surgical complications compared to 17 (21.25%) in group 2 (of which, one had a combination of two non-surgical complications) (p=0.35). CONCLUSION: Bronchoplastic resection is a safe operation in patients with carcinoid tumours and should be the reference for treatment.

Blood Pressure, smoking and oral contraceptive control after cryptogenic stroke in young adults in the PFO-ASA Study.

BACKGROUND: Management of vascular risk factors is not optimal in stroke patients. We assessed the control of hypertension, smoking and stopping of oral contraceptive in 581 consecutive young cryptogenic ischemic stroke patients followed in the PFO-ASA study and we identified factors associated with inadequate management. METHODS: At each follow-up visit, blood pressure (BP), smoking and use of oral contraceptive were recorded. Data were analyzed at 6 months, 1 and 2 years. Hypertension was defined as systolic BP > or = 140 or diastolic BP > or = 90 mm Hg, recorded in at least two follow-up visits. Current smoking was defined as more than one cigarette per day reported during at least one follow-up visit. RESULTS: During follow-up, 36% of patients were hypertensive and 30% were smokers. Among the 90 hypertensive patients at baseline, 60-68% remained with high BP and among the 278 patients who were current smokers at baseline, 54-58% still smoked during follow-up. Age (OR = 1.05, 95% CI 1.02-1.08), male sex (OR = 1.42, 95% CI 0.93-2.18), body mass index > or = 27 (OR = 2, 95% CI 1.27-3.17) and known hypertension (OR = 3.08, 95% CI 1.80-5.28) were significantly associated with hypertension during follow-up. Tobacco consumption at baseline (OR = 35.2, 95% CI, 19.3-64.2), alcohol consumption at baseline (OR = 2.7, 95% CI 1.4-5.2) and Rankin < or = 2 (OR = 2.6, 95% CI 1.4-4.9) were independently associated with persistent smoking. Among the 114 women who were using combined estrogen-progesterone pills at baseline, 96.5% stopped. CONCLUSIONS: Major risk factors for stroke are poorly controlled after stroke, even in the context of a prospective clinical study in young adults.

[Dissections of the carotid and vertebrobasilar arteries]. / Dissections des artères carotides et vertébro-basilaires.

Ischaemic strokes and TIA are increasingly being found to be due to arterial cervical dissection, particularly in young adults. Physicians have better knowledge of this disease, and diagnostic neuroimagery has improved. Sometimes traumatic, arterial dissection can also be truly spontaneous or coincides with ordinary neck movement. Dissection consists in an intramural hematoma, and affects most commonly the carotid artery. In 25% of cases, two or more cervical arteries appear to be affected simultaneously, suggesting fibromuscular dysplasia. Pathophysiological considerations remain unclear and several hypotheses are considered. Clinical manifestations are evocative and cervical warning signs such as pain, headache or Horner's syndrom provide an opportunity to recognize the patients few hours or days before cerebral or ocular ischemia occurs. Conventional angiography remains the gold standard in the diagnosis of arterial dissections but ultrasonography and magnetic resonance techniques are more and more often informative. Although no therapeutical trial is available, anticoagulant therapy has been recommended, except in intracranial dissection. Recurrent dissections are very rare and long term functional prognosis seems to be favourable.

Plasma DNA microsatellite panel as sensitive and tumor-specific marker in lung cancer patients.

The majority of lung cancer patients have tumor-derived genetic alterations in circulating plasma DNA that could be exploited as a diagnostic tool. We used fluorescent microsatellite analysis to detect alterations in plasma and tumor DNA in 34 patients who underwent bronchoscopy for lung cancer, including 11 small cell lung cancer (SCLC) and 23 nonsmall cell lung cancer (NSCLC) (12 adenocarcinomas, 11 squamous cell carcinomas) and 20 controls. Allelotyping was performed with a selected panel of 12 microsatellites from 9 chromosomal regions 3p21, 3p24, 5q, 9p, 9q, 13q, 17p, 17q and 20q. Plasma DNA allelic imbalance (AI) was found in 88% (30 of 34 patients), with a similar sensitivity in SCLC and NSCLC. In the 24 paired available tumor tissues, 83% (20 of 24) presented at least 1 AI. Among these patients, 85% (17 of 20) presented also at least 1 AI in paired plasma DNA, but the location of the allelic alterations in paired plasma and tumor DNA could differ, suggesting the presence of heterogeneous tumor clones. None of the 20 controls displayed plasma or bronchial DNA alteration. A reduced panel of six markers (at 3p, 5q, 9p, 9q) showed a sensitivity of 85%. Moreover, a different panel of microsatellites at 3p and 17p13 in SCLC and at 5q, 9p, 9q and 20q in NSCLC patients could be specifically used. Analysis of plasma DNA using this targeted panel could be a valuable noninvasive test and a useful tool to monitor disease progression without assessing the tumor.

Genetic heterogeneity in lung and colorectal carcinoma as revealed by microsatellite analysis in plasma or tumor tissue DNA.

BACKGROUND: Determination of tumor clonality has implications for molecular characterization and the optimal treatment of cancer. Allelotyping allows detection of the two alleles, maternal and paternal, and provides additional information regarding clonal genetic defects. The presence of allelic imbalances (AI) in tumors is a general event, but is not necessary at the same allele (alternative AI). The authors' goal was to determine whether the presence of alternative AI (AA) was a marker of heterogeneity and prognosis. METHODS: To further analyze the heterogeneity of lung tumors, tumor DNA released in the plasma was compared with primary tumor DNA from 24 lung carcinoma patients. The comparison was performed by allelotyping using 12 microsatellites targeting 9 chromosomal regions, taking in each case leukocyte DNA as reference. To extend and confirm these observations, 26 primary colorectal carcinomas with paired synchronous liver metastasis were analyzed using an enlarged panel of 33 microsatellites. RESULTS: AA were observed in 40% (20 of 50) of all patients, in 25% (6 of 24) of lung carcinoma patients but at a higher level, and in 54% (14 of 26) of colorectal carcinoma patients. They affected different chromosome localizations and each tumor stage. In both types of cancer, patients with AA had a higher AI mean frequency in their primary tumor. CONCLUSIONS: Detection of AA is an original marker of heterogeneous tumors, demonstrating that independent events occurred on specific genetic sites required for cancer progression.