Outcomes of Acute Stroke Patients Requiring Mechanical Ventilation: Study Protocol for the SPICE Multicenter Prospective Observational Study.

BACKGROUND: Care pathways and long-term outcomes of acute stroke patients requiring mechanical ventilation have not been thoroughly studied. METHODS AND RESULTS: Stroke Prognosis in Intensive Care (SPICE) is a prospective multicenter cohort study which will be conducted in 34 intensive care units (ICUs) in the Paris, France area. Patients will be eligible if they meet all of the following inclusion criteria: (1) age of 18 years or older; (2) acute stroke (i.e., ischemic stroke, intracranial hemorrhage, or subarachnoid hemorrhage) diagnosed on neuroimaging; (3) ICU admission within 7 days before or after stroke onset; and (4) need for mechanical ventilation for a duration of at least 24 h. Patients will be excluded if they meet any of the following: (1) stroke of traumatic origin; (2) refusal to participate; and (3) privation of liberty by administrative or judicial decision. The primary endpoint is poor functional outcome at 1 year, defined by a score of 4 to 6 on the modified Rankin scale (mRS), indicating severe disability or death. Main secondary endpoints will include decisions to withhold or withdraw care, mRS scores at 3 and 6 months, and health-related quality of life at 1 year. CONCLUSIONS: The SPICE multicenter study will investigate 1-year outcomes, ethical issues, as well as care pathways of acute stroke patients requiring invasive ventilation in the ICU. Gathered data will delineate human resources and facilities needs for adequate management. The identification of prognostic factors at the acute phase will help to identify patients who may benefit from prolonged intensive care and rehabilitation. TRIAL REGISTRATION: NCT03335995.

[Blood pressure control in hypertensive patients with stable coronary heart disease]. / Contrôle de la pression artérielle chez l'hypertendu coronarien stable.

OBJECTIVE: To evaluate systolic blood pressure (SBP) control in hypertensive patients with a stable coronary heart disease (CHD) in general practice in France. METHODS: A survey was conducted in a sample of 206 general practitionners (GP) representative of the French medical population, in 2003 [LHYCORNE survey]. Each GP had to include 3 hypertensive patients, >18 years old, BP > or = 140/90 mmHg and/or treated for hypertension, and with evidence of CHD documented by myocardial infarction (MI) or angina pectoris (AP) [diagnosis previously established by a cardiologist]. Three office BP measurements were performed, the last two recorded. BP levels were considered as controlled by treatement if they were < 140/90 mmHg. RESULTS: 595 patients were included, 75% men mean age 66 years, 25% women mean age 73 years. All patients had a CHD: MI 46%, AP 54%; 533 (90%) had more than 2 cardiovascular risk factors: hyperlipidemia (411; 69%), smokers (375; 63%), diabetes (158; 27%). Mean BP was 140.7 +/- 14/80.8 +/- 9.7 mmHg; 553 (93%) of these hypertensive patients were treated, and 239 (40%) were considered as having a controlled SBP at the treshold of 140 mmHg: 47% in patients with previous MI and 38% with AP (p < 0.001). Diastolic BP (DBP) was <90 mmHg in 480 (81%) and pulse pressure was >65 mmHg in 202 (34%); 313 (53%) patients received a combination of three drugs or more; 354 (60%) had a beta-blocker, 260 (44%) a calcium channel blocker, 237 (40%) an ACE inhibitor, 287 (48%) other antihypertensive drugs (246 diuretics, 41%); 502 (84%) received antiplatelet therapy, 403 (68%) statins. CONCLUSION: This survey shows that systolic BP is not at goal in 6/10 hypertensive patients with stable CHD suggesting there is a place for a more effective combination therapy according to evidence-based medicine.

Lumbar lateral interbody cage with plate augmentation: in vitro biomechanical analysis.

Many studies have concluded that stand alone cages provide limited stabilization to the spine, and this primary stabilization decreases postoperatively due to various factors. A supplemental fixation may, therefore, be needed to improve the stability. Extensive biomechanical analysis was performed in the present study to further evaluate the stabilization achieved by a laterally inserted cage and the role of an anterior lateral supplemental fixation. Eight human cadaver functional spinal units were subjected sequentially to four different test conditions: (1) intact, (2) instrumented laterally with a long cylindrical threaded cage, (3) the same cage supplemented with a lateral fixation plate, the plate being firmly connected to the cage, and (4) removal of the connection between the plate and the cage. Pure moments were applied to each specimen in a quasi static manner, ranging from -7 Nm to 7 Nm in flexion/extension, lateral bending and axial rotation. Three-dimensional segmental motions were simultaneously recorded under each loading condition. Statistical analysis was carried out on the motion parameters, including the range of motion (ROM) and the neutral zone (NZ). Inter-group comparisons were made using the Friedman test and the Wilcoxon test. The results showed that the stand alone lateral cage provided stabilization by increasing segmental stiffness above that of the intact spine. The stiffness increase ratios were: 1.6 in flexion/extension ( P=0.07), 1.3 in lateral bending ( P=0.4) and 1.0 in axial rotation ( P=0.67). A supplemental plate provided significant reinforcement of the stabilization. The stiffness increase ratios relative to the intact spine were: 3.1 in flexion/extension ( P=0.012), 5.0 in lateral bending ( P=0.012) and 2.3 in axial rotation ( P=0.012). After removal of the connection between the cage and the plate, the stiffness ratios were: 2.7 in flexion/extension ( P=0.027), 4.6 in lateral bending ( P=0.027) and 2.1 in axial rotation ( P=0.027). Globally, the cage alone increased the segmental stiffness above that of the intact spine by a factor of 1.1 ( P=0.39), with the supplemental plate, segmental stiffness increased by a factor of 3.1 ( P<0.01), and the unconnected cage/plate increased stiffness by a factor of 3.0 ( P=0.02). Supplementation of the lateral cage with an anterolateral plate was thus shown to provide significant additional stabilization in all directions, which may potentially compensate for the postoperative decrease in segmental stability.