Prenatal Detection of Coarctation of the Aorta in a Non-selected Population: A Prospective Analysis of 10 Years of Experience.

The objective of this study was to assess the ability of different parameters to identify fetuses requiring neonatal care for coarctation of the aorta (CoA). Between January 2003 and December 2012, 175 fetuses referred for great vessel disproportion were divided into two groups: group A (n = 51) with high risk of CoA and delivery planned in tertiary care referral center and group B (n = 124) with no increased risk of CoA. In group A, diagnosis of CoA was confirmed in 38/51 (74 %). In group B, 2/124 had CoA. Multiple logistic regression analysis identified the best combination as diffusely hypoplastic and/or angular aortic arches, ventricular septal defect and aortic valve diameter <5 mm at 36-week gestational age (GA). Positive predictive value was 75 % when vessel disproportion was noted before 28-week GA and 73 % in the third trimester. Postnatal diagnosis involved 38 cases of CoA which had not been referred. One case of CoA diagnosed after birth was referred prenatally for difficulty of screening without any defect. The results of our prospective study are in agreement with those of previous series, but our false positive rate was lower especially when the diagnosis of vascular disproportion was made at third trimester. The performance of fetal cardiac screening does not seem to be very good, but prenatal diagnosis is probably not always possible: Among our three false negative cases, two had isolated vascular disproportion and the third no risk factors.

[Extravasation of radiopharmaceuticals: preventive measures and management recommended by SoFRa (Société Française de Radiopharmacie)]. / Extravasation des médicaments radiopharmaceutiques : mesures préventives et prise en charge recommandées par la SoFRa (Société française de radiopharmacie).

Radiopharmaceuticals extravasation is rare but may have serious clinical issues. Because no specific recommendations are being proposed to date, the goals of our working group created within the French Society of Radiopharmacy are to determine preventive measures and to establish a pragmatic management of extravasation of these drugs. Our preventive measures are to recognize the symptoms (erythema, venous discoloration, swelling), to know the risk factors (which are related to radiopharmaceutical, patient, site of injection, injection technique) and severity (from erythema to skin necrosis, depending on the radionuclide) and how to avoid them (training and awareness of staff, choice of injection site, route of drug administration test, use of a catheter for administration of therapeutic radiopharmaceuticals). Management should be immediate. It can be facilitated by a specific emergency kit. General measures recommended are the immediate cessation of injection, aspiration of fluid extravasation, delimitation of the extravasated area with an indelible pen, informing the doctor. Specific measures taking into account the radiotoxicity of the radionuclide and the type of radiopharmaceutical were also established. The patient should be informed by the doctor about the risks and how to take care of. Traceability of the incident must be ensured. A multidisciplinary reflexion is essential to manage the extravasation as early and effectively as possible.

Ebstein's anomaly and tricuspid valve dysplasia: prognosis after diagnosis in utero.

Tricuspid valve malformation is a rare congenital heart disease. Prenatal diagnosis of Ebstein's anomaly (EA) and tricuspid valve dysplasia (TVD) is associated with high mortality. There are conflicting reports concerning accurate prognostication after diagnosis in utero. The aim of our study was to assess prognostic factors based on our experience. We reviewed 37 fetuses between 1984 and June 2010 comprising 26 cases of EA and 11 cases of TVD. There were 10 terminations, 5 intrauterine deaths, 8 neonatal deaths, and 14 survivors. We found that the major prognostic factor for outcome was the flow pattern through the pulmonary valve on the first echocardiogram. Retrograde flow was strongly correlated with fetal or neonatal death (p = 8 × 10(-5)), and anterograde flow predicted good outcome (p = 8 × 10(-5)). In contrast, cardiothoracic indexes, right to left-ventricular ratio, and Celermajer index were not useful prognostic markers. The Simpson Andrews Sharland score, which was more complex, was well correlated with our series. Flow through the pulmonary valve on the first echocardiogram is a simple and excellent prognostic factor when major tricuspid valve disease is diagnosed in utero. Fetuses should be monitored throughout pregnancy, particularly those with retrograde ductus arteriosus, because several hemodynamic factors may worsen the prognosis.

Workplace bullying and psychotropic drug use: the mediating role of physical and mental health status.

OBJECTIVES: The association between workplace bullying and psychotropic drug use is not well established. This study was aimed at exploring the association between workplace bullying, and its characteristics, and psychotropic drug use and studying the mediating role of physical and mental health. METHODS: The study population consisted of a random sample of 3132 men and 4562 women of the working population in the south-east of France. Workplace bullying, evaluated using the validated instrument elaborated by Leymann, and psychotropic drug use, as well as covariates, were measured using a self-administered questionnaire. Covariates included age, marital status, presence of children, education, occupation, working hours, night work, physico-chemical exposures at work, self-reported health, and depressive symptoms. Statistical analysis was performed using logistic regression analysis and was carried out separately for men and women. RESULTS: Workplace bullying was strongly associated with psychotropic drug use. Past exposure to bullying increased the risk for this use. The more frequent and the longer the exposure to bullying, the stronger the association with psychotropic drug use. Observing bullying on someone else at the workplace was associated with psychotropic drug use. Adjustment for covariates did not modify the results. Additional adjustment for self-reported health and depressive symptoms reduced the magnitude of the associations, especially for men. CONCLUSIONS: The association between bullying and psychotropic drug use was found to be significant and strong and was partially mediated by physical and mental health.

Workplace bullying and sleep disturbances: findings from a large scale cross-sectional survey in the French working population.

STUDY OBJECTIVES: The purpose of this study was to explore the associations between workplace bullying, the characteristics of workplace bullying, and sleep disturbances in a large sample of employees of the French working population. DESIGN: Workplace bullying, evaluated using the validated instrument developed by Leymann, and sleep disturbances, as well as covariates, were measured using a self-administered questionnaire. Covariates included age, marital status, presence of children, education, occupation, working hours, night work, physical and chemical exposures at work, self-reported health, and depressive symptoms. Statistical analysis was performed using logistic regression analysis and was carried out separately for men and women. SETTING: General working population. PARTICIPANTS: The study population consisted of a random sample of 3132 men and 4562 women of the working population in the southeast of France. RESULTS: Workplace bullying was strongly associated with sleep disturbances. Past exposure to bullying also increased the risk for this outcome. The more frequent the exposure to bullying, the higher the risk of experiencing sleep disturbances. Observing someone else being bullied in the workplace was also associated with the outcome. Adjustment for covariates did not modify the results. Additional adjustment for self-reported health and depressive symptoms diminished the magnitude of the associations that remained significant. CONCLUSIONS: The prevalence of workplace bullying (around 10%) was found to be high in this study as well was the impact of this major job-related stressor on sleep disturbances. Although no conclusion about causality could be drawn from this cross-sectional study, the findings suggest that the contribution of workplace bullying to the burden of sleep disturbances may be substantial.

CT and MR imaging in congenital cardiac malformations: Where do we come from and where are we going?

The management of patients with congenital heart disease was profoundly changed firstly by the advent of pediatric and prenatal ultrasound and then more recently by cardiac magnetic resonance imaging (MRI) and computed tomography (CT) of the heart and great vessels. The improved life expectancy of these patients has brought about new medical and imaging requirements. MRI and CT are increasing second line techniques in this group of patients. This article summarizes the advantages and limitations of CT and MRI in some frequently encountered situations in children and adults followed up for congenital heart disease.

[Drug interactions in an elderly population. Prospective assessment of their frequency and seriousness among 56 patients]. / Interactions médicamenteuses dans une population âgée.

OBJECTIVE: To assess the nature and the number of potential adverse drug interactions by analysis of outpatient prescriptions for elderly patients, of medications taken during the week before hospitalization in a general surgery department. METHOD: The study of 56 patients older than 65 years was conducted from November 2002 through February 2003. The outpatient prescriptions corresponding to medications taken during the 7 days before admission were analyzed by a pharmacy resident, who used data-processing tools and databases. RESULTS: Most patients (83%) knew the reason for their prescription. Thirteen (28%) reported using over-the-counter medication. Only 89% of the patients reported complete compliance with the prescription. The average age of the patients was 72.1 +/- 6.3 years and the median was 71 years [65-91]; 43% were women and 57% men. The 257 lines of prescriptions analyzed averaged 5.7 +/- 2.6 drugs (range: 2-10) per prescription. The average number of possible interactions was 3.1 +/- 2.8 per prescription for a total of 89 listed potential interactions. The levels observed were 3 warnings (3%), 37 precautions (42%) and 49 possible adverse interactions (55%). No contraindication was noted. The drugs mentioned most often were benzodiazepines, diuretics, conversion enzyme inhibitors, angiotensin II inhibitors, and beta-blockers. The potential risks most often found were hypotension, depression of the central nervous system, hypoglycemia and acute renal failure. The drug interactions were mainly due to the accumulation of the effects of separate drug classes. Deterioration in renal function was often noted as plasma concentration of the second drug increased. DISCUSSION: This exploratory study shows the reality of the iatrogenic risk for elderly patients. This analysis of outpatient prescriptions is consistent with findings in the literature. Analysis of interactions is conducted on a pairwise basis. It is thus difficult to envisage the consequences of the association of 5 or more drugs in patients with complex illnesses and diminished physiological and metabolic capacity. Patient files kept by the pharmacist could provide information about individual combinations ofthe prescription and over-the-counter drugs.

[Early detection of COPD in occupational medicine in the Alpes-Maritimes]. / Détection précoce de la BPCO en milieu professionnel dans les Alpes-Maritimes.

INTRODUCTION: This study evaluated a standardized procedure aiming at early detection of COPD in a consecutive population of employees visiting occupational medicine. METHODS: A total of 2818 employees were included by 22 occupational physicians in 5 centers. Respiratory symptoms, smoking status, occupational exposures and socioprofessional categories were collected. Subjects with at least one symptom and/or risk factor underwent spirometry. RESULTS: In this population aged 39±12 years, 2603 patients were free of known asthma or COPD. The presence of at least one symptom was observed in 23.6 % of employees and was significantly associated with smoking status, occupational exposure to organic dust, gas fumes and vapors, and agriculture (P<0.0001). Airflow obstruction (FEV1/FVC < 0.70) was detected in 1.7 % of 1605 employees who underwent spirometry. With the inclusion of known COPD subjects (n=22), the prevalence reached 2.38 %. COPD was significantly associated with smoking intensity. Information on subsequent diagnosis was obtained in only two cases. The quality of spirometry was inadequate in 30 % of cases. Thirty-three percent of detected COPD subjects did not report any respiratory symptoms. CONCLUSION: The strategy used in this study (specific questionnaire plus spirometry) allowed detection of a few cases of previously undiagnosed COPD. Occupational physicians need specific training in spirometry and a better follow-up of care pathways is required to obtain diagnostic confirmation.

Cervical pseudarthrosis in ankylosing spondylitis. A case report.

STUDY DESIGN: This report illustrates two different cases of cervical pseudarthrosis in ankylosing spondylitis. OBJECTIVES: To point out the extreme rarity of this condition at cervical level, to discuss the pathogenesis, and to stress the necessity of surgical management. SUMMARY AND BACKGROUND DATA: Pathogenesis of pseudarthrosis in ankylosing spondylitis is discussed. Several factors are involved: trauma, which may be major or minor and undetected; stress fracture; and inflammatory changes. Major trauma was the cause of pseudarthrosis in the first patient, whereas stress fracture and inflammatory changes were the probable causes in patient 2. In patient 1 there were signs and symptoms of cord compression. Patient 2 was referred because of functional disability resulting from kyphosis and because of potential neurologic risk. METHODS: Cervical fusion was performed in both patients. Patient 1 underwent posterior fusion; patient 2 had combined fusion. Patient 1 also underwent a lamineotomy. RESULTS: The course of the disorder after surgery was uneventful in both patients. Neurologic symptoms subsided in patient 1; kyphosis was corrected in patient 2. Both patients resumed their preoperative activities. Follow-up evaluation was done 6 years after surgery in patient 1 and 2 years after surgery in patient 2. CONCLUSIONS: Pseudarthrosis of the cervical spine in ankylosing spondylitis is extremely rare. Presentation of the two patients was different in terms of pathogenesis and signs and symptoms. Surgical treatment is advocated for this disorder.

Radiologic and computed tomography image evaluation of bone regrowth after wide surgical decompression for lumbar stenosis.

STUDY DESIGN: Retrospective study of bone regrowth after decompressive surgery for lumbar spinal stenosis. OBJECTIVES: To assess bone regrowth at the operation site, to compare the bone regrowth rate calculated from plain radiographs with computed tomographic image examinations, to determine the effects of bone regrowth on clinical outcome, and to investigate the factors promoting bone regrowth. SUMMARY OF THE BACKGROUND DATA: Moderate or marked bone regrowth in a surgical defect has been reported in most patients after decompression for lumbar spinal stenosis. Postoperative bone regrowth is related to recurrence of neurologic symptoms in the middle of and later on in follow-up periods. METHODS: Twenty-three patients who underwent decompressive surgery for lumbar spinal stenosis, with an average follow-up of 8 years, were evaluated retrospectively regarding the degree of bone regrowth at the posterior arch. Early postoperative radiographs and computed tomographic images were compared with those obtained at final follow-up. Bone regrowth at the operation sites was evaluated as a regrowth percentage of the original laminectomy site. RESULTS: Decompressive surgery caused bone regrowth to occur at the operation site in most of the patients. However, this regrowth was mild because the mean bone regrowth rate evaluated from plain radiographs averaged 11% and from computed tomographic images 7.7%. In only 20% of the patients was the bone regrowth rate more than 20%. Changes were found to be more elevated at the facet joint level than at the pedicle level. Evaluations of regrowth obtained from plain films and computed tomographic image examinations were compared. Radiographs seemed to overestimate the bone regrowth. The association of postoperative spinal instability with the development of new bone was statistically significant. No relation between bone regrowth and clinical outcome was found. CONCLUSIONS: Bone regrowth in a surgical defect occurs in most patients after posterior decompression. In this study the bone regrowth rate was mild and did not affect the clinical outcome.

[Mechanisms and prediction of hemorrhagic complications during surgery of thoraco-abdominal aortic aneurysms]. / Mécanismes et prédiction des complications hémorragiques au cours de la chirurgie des anévrysmes de l'aorte thoracoabdominale.

This study, including 33 consecutive patients was designed to assess the haemostatic alterations occurring during repair of thoracoabdominal aneurysms. The surgical procedure consisted in Dacron graft replacement of the diseased aorta, using neither cardiopulmonary bypass, nor any shunting technique, nor any heparin. Blood samples were drawn before anaesthesia, before and 30 min after unclamping, and on the first postoperative day. The measured parameters were: haematocrit, platelet count, bleeding, activated cephalin, thrombin and prothrombin times, and concentrations of fibrinogen, factors V, VII, X and II, anti-thrombin III, proteins C and S, fibrin degradation products, D-dimers, alpha 2-antiplasmin, plasminogen, tissue plasminogen activator, plasminogen activator inhibitor, and serum protein. Eight patients developed severe multiple haemorrhages; 3 of them died during the procedure because of uncontrollable bleeding. Although the measured parameters were similar in the "bleeding" and control (n = 25) groups before surgery, there was, before unclamping in the first group, an important increase in activated cephalin and thrombin times, with a fall in concentrations of factor II and V, protein C, fibrinogen, and alpha 2-antiplasmin, and in platelet numbers. After unclamping, these changes worsened further, with an increase in prothrombin time and in fibrinogen levels (0,8 g.l-1), without any increase in fibrin degradation products. Abnormal bleeding started about 30 min after this in all the patients of the "bleeding" group. These changes, involving the fibrinolytic system as well as a fall in concentration of all the coagulation factors, can probably be partly explained by the clamping and unclamping of mesenteric vessels.(ABSTRACT TRUNCATED AT 250 WORDS)

[Monitoring of mixed venous oxygen saturation in aortic surgery: value and limits]. / Monitorage de la SvO2 en chirurgie aortique: intérêt et limites.

This study aimed to determine perioperative changes in mixed venous oxygen saturation (SvO2) in patients undergoing aortic surgery. Continuous SvO2 monitoring was carried out using an Oximetrix pulmonary catheter. Fourteen patients were randomly assigned to 2 groups, group I (n = 7) patients being given a thoracic epidural anaesthetic with a supplementary general anaesthetic, and group II (n = 7) a general anaesthetic as usual. In both groups, SvO2 increased at induction. In group I patients, SvO2 decreased during surgery to less than 60% (n = 2) and less than 70% (n = 4). This fall was corrected by volume loading and intravenous ephedrine. The intraoperative decrease in SvO2 occuring in 2 group II patients was due to a fall in haematocrit in one, and a propranolol infusion in the other. Although patients in group I were all extubated early after the end of surgery (85 +/- 35 min), the lowest value of SvO2 after extubation was always greater than 60%. Patients undergoing aortic surgery under thoracic epidural anaesthesia can be extubated early, without markedly depressing peripheral reserves in oxygen extraction.

[Long-term osseous changes in the posterior arch after laminectomy for lumbar stenosis]. / Les remaniements à long-terme de l'arc postérieur restant après laminectomie pour sténose lombaire.

PURPOSE OF THE STUDY: Many studies have indicated favorable results of decompressive surgery for symptomatic lumbar spinal stenosis. However, little is known about the osseous changes that occur at the operative sites. Postacchini in 1992 and Chen in 1994 have studied, only from plain radiographs, osseous changes at the operative sites, and have suggested that bone regrowth possibly affects the neurologic result. The aims of this study were: to assess bone regrowth at the operative site, to compare the bone regrowth rate calculated from plain radiographs and CT-Scan examinations, to determine the effects of bone regrowth on clinical outcome, to investigate the factors promoting the bone regrowth. MATERIAL AND METHOD: 28 patients who underwent decompressive surgery for lumbar spinal stenosis were retrospectively studied with an average follow-up of 8.4 years. In order to evaluate the degree of bone regrowth at the posterior arch, early postoperative radiographs and CT images of the operative sites were compared with those obtained at final follow-up. Bone regrowth at the sites operated upon was evaluated as a percentage of regrowth of the original laminectomy site based upon plain radiographs and CT images. RESULTS: Decompressive lumbar spinal stenosis is responsible for bone regrowth at the operative site in most patients. However, this regrowth was mild, the mean bone regrowth rate evaluated from plain radiographs was 12 per cent in average and the obtained from CT images was 8.2 per cent in average. Changes were found to be predominant at the facet joint level compared to the pedicle level. The evaluation of regrowth obtained from plain films and CT image examinations were compared. Radiographs seem to overestimate bone regrowth. Postoperative spinal instability was statistically significantly associated with new bone development. This variable was the only factor that affected the degree of bone regrowth. No relationship between bone regrowth and clinical outcome was found. DISCUSSION AND CONCLUSION: Natural course of laminectomy defect includes probably new bone formation in most patients. New bone results from gradual regrowth of the laminae and articular processes partially resected at surgery and from coalescence of islets of bone tissue within the tissue filling the laminectomy defect. In the present study bone regrowth rate was moderate but in other ones it was marked. If some factors (like postoperative destabilization) promoting bone regrowth were identified many remain unknown. Factors influencing rapidity of regrowth progression remain also unknown. Patient's intrinsic features such as spinal stenosis characteristics are probably closely related to quantitative and kinetic characteristics of regrowth. Consequences of bone regrowth are also variable: in some cases regrowth may reproduce pathological conditions identical previous ones, in other ones new bone spreads around the dura a mater without any nerves roots compression. Study of bone regrowth requires further research including prospective studies and using a more precise method for the regrowth evaluation.

[Role of osteosynthesis in the consolidation of posterolateral arthrodesis: a comparative study in patients operated for lumbar stenosis]. / Rôle de l'ostéosynthèse dans la consolidation d'une arthrodèse postéro-latérale. Etude comparative chez des patients opérés de sténose lombaire.

PURPOSE OF THE STUDY: The main objective of this work was to determine the impact of osteosynthesis for posterolateral arthodesis on bone consolidation. We also tried to isolate factors predictive of nonunion and the effect of nonunion on the final outcome. MATERIAL AND METHODS: We recaIIed for assessment patients who had undergone surgery for stenosis of the lumbar spine and who had a posterolateral lumbar or lumbosacral arthodesis in addition to the spinal decompression. Among a total of 98 operated patients, 31 had arthrodesis without instrumentation. These 31 patients were matched for age, sex, smoking habits, and extent of the fusion with 31 other patients who had an instrumented arthrodesis. Radiological and clinical assessment obtained preoperatively and at 6, 12, and 24 months postoperatively were available for all 62 patients. RESULTS: Our two groups of patients were similar for comorbidity, number of arthodesis levels, fusion zone, extent and site of associated radicular release, lumbar lordosis, slope of the sacrum, global spinal mobility, and angular anteroposterior intersegmentary mobility of the different levels of the fusion zone, and interertebral sliding (site, degree, type, ante- or retrolisthesis). At last follow-up, rate of malunion was the same in the two groups (35 p. 100). Statistical analysis demonstrated three factors significantly associated with malunion: anteroposterior intersegmentary mobility, and especially angular mobility and disk height. Disk height was not however significant if it was associated with intersegmentary hypermobility. Other parameters studied, and notably use of ostheosynthesis material or not, preoperative comorbility, presence or not of preoperative intervertebral displacement, and level of the arthrodesis, had no effect. DISCUSSION: Considering the type of arthrodesis studied (short fusion on a globally minimally mobile spine) the series demonstrated that the use of osteosynthesis material does not significantly increase the rate of fusion of posterolateral arthrodesis and that the mobility of the spinal segment involved is probably a more important predictive factor for the quality of the fusion.

[Long term results of electric stimulation of the conus medullaris in a case of neurogenic bladder]. / Résultats éloignés de la stimulation électrique du cône médullaire, en cas de vessies neurologiques.

The authors present long term results (19 to 45 months: Average 37 months) of electrical stimulation of the conus medullaris in neurologic bladder. In 3 cases, the result remain excellent: efficient stimulation, normal micturition, absence of residual urine. In 6 cases, after a long period of normal function, the micturition is poor with residual urine, eventhough the conus medullaris stimulation always produces a satisfactory contraction of the detrusor. In four cases the relapse is due to disease of the external sphincter region, poorly or untreated. In female patients the results are better than in male patients, with positive results in 2 of the 3 women and 1 of the 6 men. The authors find that their results can be compared with those of B. NASCHOLD, originator of the method. They emphasize the necessity of a close collaboration with the urologist to maintain excellent results.