Distal Balloon Angioplasty of Cerebral Vasospasm Decreases the Risk of Delayed Cerebral Infarction.

BACKGROUND AND PURPOSE: Conventional angioplasty of cerebral vasospasm combines proximal balloon angioplasty (up to the first segment of cerebral arteries) with chemical angioplasty for distal arteries. Distal balloon angioplasty (up to the second segment of cerebral arteries) has been used in our center instead of chemical angioplasty since January 2015. We aimed to assess the effect of this new approach in patients with aneurysmal SAH. MATERIALS AND METHODS: The occurrence, date, territory, and cause of any cerebral infarction were retrospectively determined and correlated to angioplasty procedures. Delayed cerebral infarction, new angioplasty in the territory of a previous angioplasty, angioplasty complications, 1-month mortality, and 6- to 12-month modified Rankin Scale ≤ 2 were compared between 2 periods (before-versus-after January 2015, from 2012 to 2017) with adjustment for age, sex, World Federation of Neurosurgical Societies score, and the modified Fisher grade. RESULTS: Three-hundred-ninety-two patients were analyzed (160 before versus 232 after January 2015). Distal balloon angioplasty was associated with the following: higher rates of angioplasty (43% versus 27%, P < .001) and intravenous milrinone (31% versus 9%, P < .001); lower rates of postangioplasty delayed cerebral infarction (2.2% versus 7.5%, P = .01) and new angioplasty (8% versus 19%, P = .003) independent of the rate of patients treated by angioplasty and milrinone; and the same rates of stroke related to angioplasty (3.6% versus 3.1%, P = .78), delayed cerebral infarction (7.7% versus 12.5%, P = .12), mortality (10% versus 11%, P = .81), and favorable outcome (79% versus 73%, P = .21). CONCLUSIONS: Our study suggests that distal balloon angioplasty is safe and decreases the risk of delayed cerebral infarction and the recurrence of vasospasm compared with conventional angioplasty. It fails to show a clinical benefit possibly because of confounding changes in adjuvant therapies of vasospasm during the study period.

[Which definition and taxonomy of incident to use for a French reporting system in primary care settings?]. / Quelle définition et taxonomie utiliser pour un recueil d'événements indésirables associés aux soins primaires en France?

BACKGROUND: There is no widely accepted definition of incident for primary care doctors in France and no taxonomic classification system for epidemiological use. In preparation for a future epidemiological study on primary care incidents in France (the ESPRIT study), this work was designed to identify the definitions and taxonomic classifications used internationally along with the usual methods and results in terms of frequency in the literature. The goal was to determine a French definition and taxonomy. DESIGN: Systematic review of the literature and consensus methods. METHOD: An exhaustive search of epidemiological surveys was performed. A structured grid was used. After having identified the definitions used in the literature, a definition was chosen using the focus groups method. Taxonomies identified in the literature were classified by relationship, architecture, code number, and number of studies published. Subsequently, a consensus among experts, who independently tested these taxonomies on six incidents, was reached for choosing the most appropriate for epidemiological data collection (little information on a large number of cases). RESULTS: Twenty-four papers reporting 17 studies were selected among 139 articles. Five definitions and eight taxonomies were found. The chosen definition of incident was based on the WHO definition "A patient safety incident is an event or circumstance that could have resulted, or did result, in harm to a patient, and whose wish it is not repeated again". The test of incidents resulted in the choice of the TAPS version of the International Taxonomy of Medical Error in Primary Care for a reproducible and internationally recognized codification and the tempos method for its current use in French general practice. DISCUSSION: The definitions, taxonomies, data collection characteristics and frequency of incidents results in the international literature on incidents in primary care are key components for the preparation of an epidemiological survey on incidents in primary care.

'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.

BACKGROUND: The role of time management in safe and efficient medicine is important but poorly incorporated into the taxonomies of error in primary care. This paper addresses the lack of time management, presenting a framework integrating five time scales termed 'Tempos' requiring parallel processing by GPs: the disease's tempo (unexpected rapid evolutions, slow reaction to treatment); the office's tempo (day-to-day agenda and interruptions); the patient's tempo (time to express symptoms, compliance, emotion); the system's tempo (time for appointments, exams, and feedback); and the time to access to knowledge. The art of medicine is to control all of these tempos in parallel and simultaneously. METHOD: Two qualified physicians reviewed a sample of 1046 malpractice claims from one liability insurer to determine whether a medical injury had occurred and, if so, whether it was due to one or more tempo-related problems. 623 of these reports were analysed in greater detail to identify the prevalence and characteristics of claims and related time management errors. RESULTS: The percentages of contributing factors were as follows: disease tempo, 37.9%; office tempo, 13.2%; patient tempo, 13.8%; out-of-office coordination tempo, 22.6%; and GP's access to knowledge tempo, 33.2%. CONCLUSION: Although not conceptualised in most error taxonomies, the disease and patient tempos are cornerstones in risk management in primary care. Traditional taxonomies describe events from an analytical perspective of care at the system level and offer opportunities to improve organisation, process, and evidence-based medicine. The suggested classification describes events in terms of (unsafe) dynamic control of parallel constraints from the carer's perspective, namely the GP, and offers improvement on how to self manage and coordinate different contradictory tempos and day-to-day activities. Further work is needed to test the validity and usefulness of this approach.

Comparison of a B2 adrenergic agonist and an anticholinergic agent given by sequential inhalation in patients with severe chronic obstructive pulmonary disease.

We evaluated the response of 15 male patients with severe chronic obstructive pulmonary disease (COPD) to sequential inhalations of an anticholinergic agent, ipratropium bromide 0.25 mg (IB) and a B2 adrenergic agonist, terbutalin 2.5 mg (TER), in a double-blind crossover study. We found no statistically significant difference in the bronchodilatory response between the two agents when comparing the change in forced vital capacity and forced expiratory volume in 1 sec. The subsequent effect of the sequential inhalation demonstrated some additional bronchodilatory response when IB was given after TER, but not when TER was given after IB. However, the end result after the two protocols was not statistically different. The results indicate that in COPD patients the two agents are equipotent. However, in order to prescribe the best treatment schedule for each patient, it is still necessary to evaluate how each individual patient responds to each of the agents. Sequential inhalation may be beneficial in some patients.

Effect of digoxin on respiratory muscle performance in patients with COPD.

The effect of 2 weeks oral digoxin administration on respiratory muscle performance (RMP) in 14 patients with chronic obstructive lung disease (COPD) was investigated in a randomized double-blind placebo-controlled cross-over study. All patients were ambulatory with severe air flow obstruction. FEV1/FVC was 0.44 +/- (SD) 0.11, FEV1 was 0.88 +/- (SD) 0.35 liter/s RMP was assessed by measuring maximal inspiratory pressure (PImax), maximal expiratory pressure (PEmax), and maximal voluntary ventilation. Although these parameters were significantly reduced in the COPD patients, 2 weeks of digoxin administration (with serum levels in the therapeutic range) did not alter any parameter of RMP or spirometry. We conclude that digoxin has no effect on RMP or spirometry in ambulatory patients with severe COPD.

Respiratory muscle performance in patients with type 1 diabetes.

Respiratory muscle strength and endurance were examined in 31 Type 1 diabetic patients and in age, sex, and weight matched control subjects. No significant difference in respiratory muscle strength was noted between the two groups. Maximal static inspiratory pressure was 92.3 +/- 33.9 (+/- SD) and 99.5 +/- 23.0% of the predicted values in the patient and control groups, respectively. Maximal static expiratory pressures were 75.1 +/- 14.3 and 77.4 +/- 14.0% of the predicted values in the patient and control groups, respectively. Respiratory muscle endurance was significantly lower in the diabetic patients 88.9 +/- 20.7 vs 103.9 +/- 15.8% predicted in the control group (p less than 0.01). Total lung capacity, vital capacity, and maximal voluntary ventilation were also significantly lower in the diabetic group and correlated with the duration of diabetes.

Extreme hypermagnesemia due to ingestion of Dead Sea water.

We describe 3 patients who developed extreme hypermagnesemia due to ingestion of water of the Dead Sea, which would have been fatal were it not for the protective effects of the accompanying hypercalcemia. We emphasize the clinical features of this condition and the importance and effectiveness of early hemodialysis as the main modality of treatment.

Amiodarone-induced dysthyroidism.

A 54-year-old man, treated with amiodarone, developed thyrotoxicosis. When rechallenged with the same drug 6 months later, he developed hypothyroidism. The therapeutic implications of this clinical sequence are discussed.