Assessment of treatment patterns and patient outcomes before vs after implementation of a severity-based Clostridium difficile infection treatment policy.

BACKGROUND: National guidelines recommend oral vancomycin for severe Clostridium difficile infection (CDI) based on results from recent clinical trials demonstrating improved clinical outcomes. However, real-world data to support these clinical trials are scant. AIM: To compare treatment patterns and patient outcomes of those treated for CDI before and after implementation of a severity-based CDI treatment policy at a tertiary teaching hospital. METHODS: This study evaluated adult patients with a positive C. difficile toxin before and after implementation of a policy where patients with severe CDI given metronidazole were switched to oral vancomycin unless contra-indicated. Patients were stratified according to disease severity using a modified published severity score. Treatment patterns based on CDI severity and rates of refractory CDI were assessed. FINDINGS: In total, 256 patients with CDI (mean age 66 years, standard deviation 17, 52% female) were evaluated (before implementation: N = 144; after implementation: N = 112). Use of oral vancomycin for severe CDI increased significantly from 14% (N = 8) to 91% (N = 48) following implementation of the policy (P < 0.0001). Refractory disease in patients with severe CDI decreased significantly from 37% to 15% following implementation of the policy (P = 0.035). No significant differences were noted among patients with mild to moderate CDI. CONCLUSION: A severity-based CDI treatment policy at a tertiary teaching hospital increased the use of oral vancomycin and was associated with decreased rates of refractory CDI.

[Pulmonary embolism diagnosed during an endobronchial ultrasound procedure]. / Embolie pulmonaire diagnostiquée au cours d'une échoendoscopie bronchique.

INTRODUCTION: Pulmonary embolism occurs frequently in lung cancer. The clinical features are non-specific and the diagnosis is often missed. CASE REPORT: A 60-year old man presented with a right upper lobe mass associated with right hilar adenopathy. Both had activity on positron emission tomography. As bronchoscopy was normal, an endobronchial, ultrasound guided, transbronchial needle aspiration (EBUS-TBNA) was performed to obtain a diagnosis. During the procedure, a hypoechogenic image was seen in the right pulmonary artery. A CT pulmonary angiogram confirmed the diagnosis of right pulmonary embolism. The transbronchial needle aspiration confirmed the neoplastic nature of the adenopathy. To our knowledge, this is the first description of a pulmonary embolism diagnosed by EBUS. This observation confirms the results of a recently published study showing that known pulmonary embolism can be detected by EBUS. CONCLUSION: Although EBUS is not the classic tool for the diagnosis of pulmonary embolism, it seems advisable to undertake a careful examination of the proximal pulmonary artery during an EBUS procedure.

[What is the interest of early knee mobilization after total knee arthoplasty?]. / Intérêt d'une mobilisation très précoce après la pose d'une prothèse totale de genou? Elaboration de recommandations françaises pour la pratique clinique.

AIMS: To develop clinical practice guidelines for early mobilisation after total knee replacement (TKR). METHOD: We used the French Society of Physical and Rehabilitation Medicine (SOFMER) methodology, which associates a systematic review of the literature, collection of information regarding current clinical practice and external review by a multidisciplinary expert panel. RESULTS: A review of the literature and French clinical practice allow for recommending early mobilisation, at day 0, after TKR. This practice, with continuous passive motion, does not seem to increase the frequency of complications and seems to help with rapid recovery of the joint range of motion. Trials with good methodology must be developed to define the criteria for prescribing early mobilisation after TKR. These trials should focus mainly on joint range of motion but also on economical criteria (duration of hospitalisation, rehabilitation, physiotherapy, use of painkillers) and the satisfaction of the patient.

Could preoperative rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration of French clinical practice guidelines.

OBJECTIVE: To develop clinical practice guidelines concerning preoperative rehabilitation for hip and knee total arthroplasty. METHOD: We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, to develop the guidelines. Main outcomes considered in the recommendations were impairment, disability, medico-economic implications and postoperative complications. RESULTS: A preoperative rehabilitation program, comprising at least physical therapy and education, is recommended before total hip and knee arthroplasty. Occupational therapy could be combined with patient home visits. Isolated physical therapy before total knee arthroplasty (TKA) is not recommended. Multidisciplinary rehabilitation comprising at least occupational therapy and education is desirable for the most fragile patients because of major disability, co-morbidity or social problems. Complementary studies are required to confirm the impact of pre-operative rehabilitation before total hip and knee arthroplasty, to define components of rehabilitation and the patients most likely to benefit. CONCLUSION: Rehabilitation before total hip and knee arthroplasty contributes to reduced hospital length of and modifying discharge conditions. This rehabilitation necessitates the collaboration of qualified health care professionals in the educational topic and return-home preparation. Preoperative patient assessment is important.

[Role of orthoses in ligament injuries of the knee]. / Place des orthèses en pathologie ligamentaire du genou. Revue de la littérature.

OBJECTIVE: To review the literature for the benefits of the three different knee braces (prophylactic, rehabilitation, functional) that can be used to treat ligament injuries of the knee. What is their influence on stability? Do they have adverse effects? Is their use justified? METHODS: We searched the Medline and Embase databases with use of the keywords knee, orthoses, brace, proprioception, stability, rehabilitation, physical therapy, and anterior cruciate ligament for reports published between 1980 and 2003 and selected 93 articles, expert reports or literature reviews. RESULTS: Anterior tibial displacement can be controlled with mechanical strains (150 N), which are lower than physiological restraints? (400 N). The control of joint position is improved by increasing proprioception. Soft tissue stiffness influences the control of anterior tibial displacement. The beneficial effects observed are mainly subjective. Our analysis of the literature showed limitations and variations in study methodologies. CONCLUSION: We did not find any justification for use of either prophylactic or rehabilitation braces. Functional braces can improve stability, as reported by the patient, and may be used in some situations.

Influence of gamma-irradiation sterilization on the structural defects of sapphire single crystals (alpha-Al(2)O(3)).

The influence of sterilization by gamma rays on the structure and the electrical behaviour of sapphire single crystal (alpha-Al(2)O(3)) was studied successively by thermoluminescence, by cathodoluminescence and by observation of the scanning electron microscope mirror effect. The mirror method allowed us to measure the capacity of an insulating material to trap electrons. The structural analysis of the alpha-Al(2)O(3) showed that there were oxygen vacancies, as well as chromium and titanium impurities. It was possible to demonstrate that these defects, especially the oxygen vacancies, are in a different state after a 30 kilogray irradiation. The valency state changes of these defects and the presence of trapped charges are accompanied by a deformation of the crystalline lattice which results in a modification of its electrical properties. At room temperature, the irradiated alpha-Al(2)O(3), unlike non irradiated alpha-Al(2)O(3), is capable of trapping electrons. It can be concluded that gamma-ray sterilization modifies the cohesive energy of alpha-Al(2)O(3), which could lead to mechanical changes (surface charge, friction, wear, fracture strength, em leader) in this material.

Synthesis, characterization, and structural and theoretical analysis of Gd4B3C4: a novel rare earth metal borocarbide containing two different boron-carbon arrangements.

The synthesis by arc-melting techniques, the single-crystal X-ray structure, and the theoretical analysis of Gd4B3C4 are reported. It crystallizes in the triclinic space group P1 with a = 3.637(2) A, b = 3.674(2) A, c = 11.859(5) A, alpha = 93.34(5) degrees, beta = 96.77(5) degrees, gamma = 90.24(5) degrees, and Z = 1. In this structure, the boron and carbon atoms form two different types of nonmetal arrangements: 1-D (BC)infinity branched chains and finite (0-D) linear CBC "molecular" units. Gd4B3C4 is the first characterized member of the rare earth metal borocarbide series in which both 1-D and "molecular" 0-D nonmetal atom systems coexist. From the structural and theoretical analysis, the following formal charge distribution can be proposed within the ionic limit: (Gd3+)4(BC2(5-)(BC3-)2.e-. Tight-binding calculations suggest that the excess electron in the ionic limit is mainly localized on the Gd atoms (at the bottom of the 5d band), while LAPW calculations favor its localization on the (BC)infinity chain. The bonding within this compound is fully analyzed and compared to other members of the rare earth metal borocarbide series.

[Reliability of the KT-1000 arthrometer in measuring anterior laxity of the knee: comparative analysis with Telos of 48 reconstructions of the anterior cruciate ligament and intra- and interobserver reproducibility]. / Fiabilité de l'arthromètre KT-1000 pour la mesure de la laxité antérieure du genou: analyse comparative avec le Telos de 48 reconstructions du ligament croisé antérieur et reproductibilité intra- et interobservateurs.

PURPOSE OF THE STUDY: The goal of this study was to compare KT-1000 and Telos measurements after anterior cruciate ligament reconstruction (ACLR). MATERIAL AND METHOD: Forty eight patients with asymptomatic ACLR (4 failures with positive pivot shift and 12 knees with positive (+) Lachman test) were assessed (mean 2.5 years after surgery) by the same examiner by means of: 1) Lachman radiographic with Telos at 150 N, 2) MEDmetric KT-1000 at 69 N, 89 N and maxi-manuel (MM). The examiner tested more than 200 patients each year. Measurements were performed for KT-1000 according to the manufacturers' recommendations and for Telos according to Staübli. Only side to side differences in millimeters are reported. Reproducibility of KT-1000 measurements were also evaluated: interobserver reproducibility was assessed by 16 examiners on a healthy patient, and the experienced examiner tested 20 times a healthy patient. RESULTS: An Interobserver error of 4 mm range (+/- 2 mm related to 0) was observed by 12 to 44 p. 100 of the examiners, respectively at 69 N to MM. An intraobserver error of 4 mm range (+/- 2 mm related to 0) was observed in 10 p. 100 at MM and in 20 p. 100 at 89 N. Mean side to side laxity with KT-1000 was 0.93 mm +/- 1.1 [-1 to 5] at 69 N, 1.3 mm +/- 1.6 [-2 to 6] at 89 N, and 1.41 +/- 1.8 [-2 to 6] at MM. With Telos the mean side to side laxity was 3.95 mm +/- 3.84 [0 to 15]. Significant differences (p = 0.0001) were found between measurements obtained by the two methods. No statistical correlation could be detected between values observed by Telos and KT-1000 (R < 0.1). If we consider a 3 mm side to side difference 23 knees (48 p. 100) had abnormal anterior laxity with Telos and with KT-1000 only 3 (6.2 p. 100) at 89 N and 6 (12.5 p. 100) at MM (1 (2 p. 100) at 69 N). With a 5 mm side to side difference, 12 knees (25 p. 100) had abnormal anterior laxity with Telos and with KT-1000 only 1 (2 p. 100) at 89 N and 1 (2 p. 100) at MM (0 at 69 N). Only Telos measurements were correlated to positive pivot shift (p = 0.007) and positive Lachman test (p = 0.01). CONCLUSION: Interobserver reproducibility of KT-1000 measurements was low, but improved for intraobserver agreement. However, even for a unique KT-1000 experienced examiner, reliability of KT-1000 was poor when comparing Telos and KT-1000 predicitive value to diagnose ACLR failure. Telos results were much more pejorative but the only ones corelated with ACLR failures. We recommand Telos instead of KT-1000 to assess laxity after ACLR.

[Radiographic course of 39 rheumatoid wrists after synovectomy and stabilization]. / Evolution radiographique de 39 poignets rhumatoïdes après synovectomie et stabilisation.

Between 1984 and 1995, 39 patients underwent wrist synovectomy-stabilisation. Among these patients, 5 had died and 2 could not rectum for review. These 7 patients were excluded from the study. 32 patients were therefore included in the study. These patients had an average age of 50 years, with an average follow-up of 65 months. We used the Larsen classification to assess wrist osteo-articular involvement. To evaluate carpal instability, we measured: the carpal height with the Mac Murtry index, Shapiro's angle and the modified Shapiro's angle (the angle between the radial diaphysis and the second metacarpal diaphysis), the angle of finger ulnar deviation, the carpal ulnar deviation with the ulnar deviation index of the carpus, the radial deviation with the radial deviation index of the carpus, the carpal frontal dislocation. Carpitis continued to develop and Larsen's grade deteriorated in 50% wrists despite surgery. The average value of the radial sliding index of the carpus increased from 0.11 to 0.15: this showed an average ulnar sliding of 2.2 mm. The average Shapiro's angle increased from 118.2 degrees to 125 degrees. At follow-up, we observed anterior translation of the carpal bones and an increased distance between the proximal and distal carpal rows. The distance between the proximal and distal rows of the carpus appeared to be corrected by extensive synovectomy. Radio-carpal and mid-carpal synovectomy increased the carpal ulnar sliding. The modified Shapiro's angle was corrected by transfer of the extensor carpi radialis longus onto the extensor carpi radialis brevis. In contrast with other operations without stabilisation, the Sauvé-Kapandji procedure limited ulnar sliding and radial tilting of the carpus. Stabilisation of the carpus therefore participates in control of ulnar deviation of the long fingers. Transfer of the extensor carpi radialis longus onto the extensor carpi radialis brevis seems effective on wrist relaxation, by medialization of the traction force of the extensor carpi radialis longus. Our results with of Larsen stage IV were encouraging. The indication for wrist arthrodesis could be limited to stage IV with radio-carpal dislocation or stage V.

[Femoral reconstruction with endosteal bone allografts protected by a metallic mesh in reoperation of total hip prosthesis. 19 cases with an average follow-up of 83 months]. / Reconstruction fémorale par des allogreffes spongieuses impactées et protégées par un treillis métallique au cours des révisions de prothèses totales de hanche. 19 cas au recul moyen de 83 mois (58-111 mois).

PURPOSE OF THE STUDY: To assess after 83 months of follow-up, the results of 19 femoral revisions carried out according to an original method combining a cemented stem and bone reconstruction by means of impacted-morcelized bone allograft protected by a titanium mesh. MATERIALS: Twenty hips (18 patients mean aged 58 at surgery) were included between 1986 and 1991. Five hips had a least one previous prosthetic revision, one hip was revised because of septic loosening. No patient was lost for follow-up, but two had died during the follow-up period: one patient died one month after surgery was excluded, one other died 7 years after the index procedure and was included with his last hip rating. Loss of femoral bone stock was severe according to the SOFCOT four stage rating system: 2 femurs were grade II, 14 grade III, and 3 grade IV. Femoral stem migration was assessed with landmarks recommended by Walker. All the measurements were performed with a digitizer (OrthoGraphics). METHODS: All the procedures were carried out through a posterolateral approach, augmented by 4 trochanteric osteotomies and 5 distal femoral windows. After prosthesis and cement removal, a bone plug was placed into the medullary canal. Then, cancelous bone morcelized allografts were impacted in the femoral defects through the medullary canal. A titanium mesh cylinder was placed into the femur to separate the graft from the cement introduced later to obtain fixation of the revision stem. The stem was extended about 5 centimeters over the distal edge of the grafts in order to bridge the femoral defects. The mesh was extended only in front of the grafts and was used to protect them from excessive cement penetration. RESULTS: Functional improvement was noticeable since the Merle d'Aubigné Hip score improved from 9.8 to 16.3 at follow-up. The pain score improved from 2.1 to 5.5 and walking score from 2.3 to 5. Adverse effects occurred during the first cases and were related to cement removal: 3 greater trochanter fractures, 5 distal femoral perforations and 2 non displaced femoral shaft fractures. The septic revision had recurrence of infection associated with radiolucent lines > 2 millimeters and the only one graft resorption. One trochanteric non-union was observed but no prosthetic dislocation. Only one femoral stem migration (4.4 millimeters) was detected without any other radiographic features of loosening after 9 years of follow-up. This stem was considered as loosed, but was not revised because of few clinical symptoms. Only 2 radiolucent lines less than 2 millimeters at the bone cement interface in Gruen's zones 3 to 5. Likewise, no radiographic feature of stress-shielding was observed. On follow-up X-rays, 3 hips had corticalisation of the grafts, and 12 hips demonstrated normal cancelous trabeculations in the grafts. CONCLUSION: Satisfactory functional and radiographic results were obtained with this method after 5 to 10 years of follow-up instead of severe preoperative femoral bone stock impairement. Likewise, we observed only one recurrence of loosening diagnosed with the help of digitized X-ray examination. Only one significant (> 3.5 mm) femoral stem migration was detected. Radiographic features of femoral reconstruction were observed but without histologic proof of graft integration. This method uses a longer stem than the "Exeter", but avoids a high rate of femoral stem migration and appears compatible with femoral bone reconstruction.

Computed tomography in 75 clinical cases of syringomyelia.

Seventy-five patients with a clinical diagnosis of syringomyelia were examined by computed tomography after intrathecal injection of metrizamide. A central cavity was demonstrated in 67 patients. Tilting the patient head down did not increase the rate of cavity opacification. This evidence favors transneural migration of metrizamide into the cavity. The spinal cord was measurably enlarged in only a minority of the patients. In some, the cavity appeared to have clefts or wall defects. These results are discussed according to the etiopathogenic theories advanced by Gardner, Aboulker, and Williams.

[Scannography apport in syringomyelic study. 40 syringolyelic cases (author's transl)]. / Apport de la scannographie a l'étude des syringomyélies. 40 cas de syringomyélie de l'adulte.

Forty patients with a syringomyelic syndrome were studied by means of scannography of the cervical spine and cervico-occipital joint before and after intrathecal injection of metrizamide. metrizamide transit, and more particularly the opacification of the syringomyelic cyst by metrizamide were assessed by delayed passages. This study demonstrates the value of this technique both from the morphological and dynamic point of view.