[Community-acquired Staphylococcus aureus pneumonia]. / Pneumonie communautaire à staphylocoque doré.

We report a clinical case of a patient hospitalized for community-acquired Staphylococcus aureus pneumonia. A 26-year-old patient with no medical history went to the emergency department for fever. He quickly developed acute respiratory failure and community-acquired Staphylococcus aureus pneumonia as well as bacteremia were confirmed. This pulmonary infection is rare but can affect all age groups and occur in a variety of ways. Patients with community-acquired Staphylococcus aureus pneumonia have more severe clinical outcomes than those with community-acquired pneumonia caused by other germs. The article discusses the main characteristics of community-acquired Staphylococcus aureus pneumonia and recalls the recommendations in case of bacteremia with Staphylococcus aureus.

Nous rapportons le cas clinique d'un patient de 26 ans, sans antécédents médicaux, se présentant au service des urgences pour cause de fièvre persistante depuis plusieurs jours. Dans le décours de son admission à l'hôpital, le patient développe une insuffisance respiratoire aiguë d'installation rapide. Une pneumonie communautaire associée à une bactériémie à staphylocoque doré est alors mise en évidence. Les pneumonies communautaires à staphylocoque doré sont rares, mais peuvent toucher toutes les tranches d'âge et se présenter de façon variée. Leur sévérité est plus importante que celle des pneumonies communautaires imputées à d'autres germes. Par le biais de ce cas clinique, les principales caractéristiques des pneumonies communautaires à staphylocoque doré sont discutées et les recommandations médicales associées sont abordées.

Laparoscopic supracervical hysterectomy with morcellation: should it stay or should it go?

STUDY OBJECTIVE: To establish the risk of unidentified neoplasia and subsequent adverse outcomes of laparoscopic supracervical hysterectomy (SCH) with morcellation. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University community hospital. PATIENTS: Consecutive women who had undergone SCH with morcellation between January 2002 and December 2008. MEASUREMENTS AND MAIN RESULTS: Medical records were assessed for patient characteristics and outcomes. We identified 808 women who had undergone planned laparoscopic SCH with morcellation. Their median age was 44.1 years (range, 23.4-79.8 years). The most common indications were menorrhagia in 472 patients (58.4%) and leiomyomas in 400 patients (49.5%). Of the 30 patients in whom laparoscopy was converted to an open procedure before morcellation, 1 had leiomyosarcoma at final pathologic analysis. Of the 778 patients who underwent laparoscopic SCH with morcellation, 16 (2.0%) had endometrial hyperplasia and 3 (0.4%) had cancer at final pathologic analysis. Abnormal pathologic findings were more likely in women older than age 50 years with abnormal bleeding. Of the 778 patients, 189 were younger than 40 years, and 4 of these 189 women (2.1%) had hyperplasia at final pathologic analysis; none had cancer. Of the 433 patients aged 40 to 49 years, 8 (1.8%) had hyperplasia or cancer. Of the 156 patients aged 50 years or older, 7 (4.5%) had hyperplasia (p = .18); none had cancer. No patient with hyperplasia or morcellated cancer experienced adverse sequelae after a median follow-up of 90.4 months. CONCLUSION: In this cohort of patients who underwent laparoscopic SCH, the risk of hyperplasia or malignancy was low. Laparoscopic SCH with morcellation seems to be a low-risk procedure.

Microvascular and macrovascular flow are uncoupled in early polymicrobial sepsis.

BACKGROUND: Microvascular dysfunction is considered to play an important pathophysiological role in sepsis. We addressed the hypothesis that macrovascular and microvascular flow are uncoupled in early sepsis, using a rodent model with well-characterized haemodynamic and biochemical markers of severity and subsequent mortality. METHODS: Male Wistar rats received either an intraperitoneal injection of faecal slurry (sepsis, n=14) or sterile saline (sham, n=6). Identical i.v. fluid resuscitation regimens were administered 2 h later through tethered lines while conscious. At 6 h post-sepsis and in sham-operated controls, sidestream dark-field microvascular imaging of the left vastus lateralis muscle and transthoracic echocardiography were undertaken, again under anaesthesia. Non-operated rats (naive; n=5) served as negative controls. Mild and severe sepsis were defined a priori, based on the established predictive relationship between stroke volume and mortality in this model. RESULTS: Compared with sham-operated animals, there was a 19 (12-19)% and 62 (54-66)% decline in cardiac output in mild (n=8) and severe sepsis (n=6), respectively [median (inter-quartile range), P<0.0001]. Blinded assessment of microvascular imaging revealed that the microvascular flow index (MFI) was impaired in sepsis and in sham-operated controls (P<0.01), regardless of the degree of reduction in stroke volume and cardiac output. The MFI heterogeneity index revealed that only naive rats displayed a normal microvascular flow pattern. CONCLUSIONS: Microvascular flow is impaired during early sepsis and uncoupled from macrovascular function. The severity of macrovascular/cardiovascular compromise in early sepsis is not reflected by microvascular changes. Furthermore, surgery alone causes significant microvascular derangement, highlighting the importance of appropriate control subjects when using this technique.

The Marsden Morbidity Index: the derivation and validation of a simple risk index scoring system using cardiopulmonary exercise testing variables to predict morbidity in high-risk patients having major cancer surgery.

BACKGROUND: Morbidity and mortality risk prediction tools are increasingly being used as part of preoperative assessment of patients presenting for major abdominal surgery. Cardiopulmonary exercise testing (CPET) can predict which patients undergoing major abdominal surgery are at risk of complications. The primary objective of this study was to identify preoperative variables including those derived from CPET, which were associated with inpatient morbidity in high-risk patients following major abdominal cancer surgery. The secondary objective was to use these variables to derive and validate a morbidity risk prediction tool. METHODS: We conducted a retrospective cohort analysis of consecutive adult patients who had CPET as part of their preoperative work-up for major abdominal cancer surgery. Morbidity was a composite outcome, defined by the Clavien-Dindo score and/or the postoperative morbidity survey (POMS) score which was assessed on postoperative day 7. A risk prediction tool was devised using variables from the first analysis which was then applied prospectively to a matched cohort of patients. RESULTS: A total of 1398 patients were included in the first phase of the analysis between June 2010 and May 2017. Of these, 540 patients (38.6%) experienced postoperative morbidity. CPET variables deemed significant (p < 0.01) were anaerobic threshold (AT), maximal oxygen consumption at maximal exercise capacity (VO2 max), and ventilatory equivalent for carbon dioxide at anaerobic threshold (AT VE/VCO2). In addition to the CPET findings and the type of surgery the patient underwent, eight preoperative variables that were associated with postoperative morbidity were identified. These include age, WHO category, body mass index (BMI), prior transient ischaemic attack (TIA) or stroke, chronic renal impairment, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cancer stage. Both sets of variables were then combined to produce a validated morbidity risk prediction scoring tool called the Marsden Morbidity Index. In the second phase of the analysis, this tool was applied prospectively to 424 patients between June 2017 and December 2018. With an area under the curve (AUC) of 0.79, this new model had a sensitivity of 74.2%, specificity of 78.1%, a positive predictive value (PPV) of 79.7%, and a negative predictive value of (NPV) of 79%. CONCLUSION: Our study showed that of the CPET variables, AT, VO2 max, and AT VE/VCO2 were shown to be associated with postoperative surgical morbidity following major abdominal oncological surgery. When combined with a number of preoperative comorbidities commonly associated with increased risk of postoperative morbidity, we created a useful institutional scoring system for predicting which patients will experience adverse events. However, this system needs further validation in other centres performing oncological surgery.

Simultaneous recording of pattern electroretinography and visual evoked potentials in multiple sclerosis. A method to separate demyelination from axonal damage to the optic nerve.

Pattern electroretinograms (P-ERGs) and visual evoked potentials (VEPs) were recorded in 35 patients with multiple sclerosis and in 35 age-matched normal subjects. Four patterns of abnormalities were noted in the group with multiple sclerosis. The most frequent abnormality consisted of the following: normal P-ERG, delayed P100, and prolonged interpeak interval between the b-wave of the P-ERG and P100 (retinocortical time). This pattern indicates demyelination of the optic nerve. A second pattern consisted of absent P-ERG and absent VEP. This pattern was associated with optic atrophy and/or central scotoma, indicating severe optic nerve axonopathy with retrograde degeneration of ganglion cells. A third pattern consisted of normal P-ERG and absent VEP, suggesting a total block of transmission at the optic nerve. A fourth pattern consisted of present but low-amplitude P-ERG, delayed VEP, and prolonged retinocortical time, indicating a demyelinating process with partial axonal involvement. The concomitant use of P-ERG and VEP results in a better classification of the type and severity of dysfunction affecting the optic nerve. The prognostic value of the four patterns for recovery of visual function is discussed.

Caffeine and tremor.

Two percent of normal controls noted that drinking coffee made their hands shaky. Eight percent of essential tremor and 6% of Parkinson's disease patients thought that coffee worsened their tremor. In formal tests, a single oral dose of caffeine (325 mg) did not increase physiologic, essential tremor, or parkinsonian tremor at 1, 2, or 3 hours after ingestion. Caffeine only infrequently induces tremor in normal people, and it does not exacerbate pathologic tremor.

Disability in essential tremor: effect of treatment.

We studied 18 patients with essential tremor for difficulty with handwriting, drinking, eating, fine manipulations, and embarrassment. Propranolol and primidone reduced the amplitude of both postural and kinetic tremor. Handwriting, drinking, and eating were improved with therapy, but fine manipulations and motor performance on tapping and pegboard tests were unaltered. Embarrassment remained unchanged. Essential tremor is not a benign condition; disability can be only partly reversed with drug therapy.

Asymmetries in simple feature searches for color.

Observers were required to search for and find a target stimulus that differed from distractor stimuli only in chromaticity. Pairs of target and distractor colors were chosen so that in some conditions the two members of a pair differed in hue, in saturation, or in both hue and saturation. For each type of condition, a number of pairs of colors representing varying degrees of perceptual difference were chosen. Each member of each pair of colors served as both the target and distractor color while the other member of the pair served in the remaining role. The largest asymmetries in search times occurred when the target and distractors differed in saturation. Somewhat smaller asymmetries occurred with differences in both saturation and hue, and no asymmetries occurred with hue differences. Results suggest that the asymmetries are related to the time required to encode and transmit the chromatic information centrally rather than the properties of the search process itself.

Clonidine in the treatment of essential tremor.

The effect of clonidine treatment (average dose 0.4 mg/day) was investigated in 10 patients with essential tremor in a double-blind placebo-controlled design. Tremor amplitude and frequency were recorded with an accelerometer. Tremor was not significantly altered by clonidine therapy. Side effects were common. It is concluded that clonidine is not effective treatment for essential tremor.

Effects of age and sex on pattern electroretinograms and visual evoked potentials.

Pattern-electroretinograms (P-ERGs) and visual evoked potentials (VEPs) were simultaneously recorded in 112 normal individuals aged 20-75. Two-sized checks subtending 15' and 31' were used as stimuli. A weighted regression analysis was used to determine which of the variables, sex or age, was significant. The latency of the a and b wave of the P-ERGs showed a progressive increase with age but no difference between sexes. The effect was statistically significant for both 15' and 31' checks. There was no statistically significant aging effect for VEPs elicited by 31' checks. Aging, however, affected N70, P100, and the interpeak interval between b wave to N70 and b wave to P100 for responses to 15' checks. Shorter VEP latencies were noted in females for both 15' and 31' checks. The simultaneous recording of P-ERGs and VEPs has demonstrated that aging is a major variable at the retinal level. The effects on the a and b waves are mostly due to optic changes with aging and only partially to aging changes in the neuronal retinal circuitry. The effect of aging on VEPs is different for different size stimuli. The cause is a random neuronal cell loss in the visual pathways from the optic nerve to the visual cortex as the individual ages. The difference in VEP data between sexes may be related to anatomical size and hormonal influences.

Electroretinograms to checkerboard pattern reversal in cats: physiological characteristics and effect of retrograde degeneration of ganglion cells.

Pattern electroretinograms (P-ERGs) evoked by alternating checks were studied in cats. Spatial frequency functions for transient and steady-state P-ERG waves showed a bimodal distribution with a preferred frequency at 0.6-0.75 c/deg and a second amplitude increase at frequencies lower than 0.5 c/deg. Decreasing the pattern luminance by 0.5 log units produced a shift of the spatial tuning curve toward lower spatial frequencies. No temporal tuning was noted in the temporal frequency functions. The bimodal distribution suggests that at spatial frequencies higher than 0.5 c/deg, the tuning reflects a 'contrast response' originating in cells with center surround organization. At spatial frequencies below 0.5 c/deg, the 'luminance response' becomes predominant and is generated in cells sensitive to mean luminance changes. Transient and steady-state P-ERGs to medium and high spatial frequencies were abolished by section of the optic nerve, while low spatial frequency stimuli at or below 0.3 c/deg continued to evoke P-ERGs at 1, 5 and 10 months after surgery. Quantitative whole mount retina microscopic examination confirmed the retrograde degeneration of the ganglion cells. It is concluded that both transient and steady-state P-ERGs to small and medium spatial frequencies checks are predominantly related to ganglion cell activity, while P-ERGs to low spatial frequencies reflect preganglionic cell activity.