[Pain management in subarachnoid haemorrhage: a survey of French analgesic practices]. / Prise en charge des céphalées secondaires aux hémorragies sous-arachnoïdiennes dans les centres de neurochirurgie français.

OBJECTIVE: Pain management in patients having a subarachnoid haemorrhage was assessed in French intensive care unit of neurosurgical centres. STUDY DESIGN: Nationwide survey. METHODS: A standardized postal questionnaire was sent to senior doctor of every neurosurgical centres in France inquiring pain scores assessment, analgesics used and their routes of administration, centre's opinion about efficacy of pain management. RESULTS: Of the 34 centres, 24 returned completed questionnaires. Fifty four per cent of the centres evaluated pain intensity with a non valid pain score. In the case of patients in the comatose, pain was not evaluated in fifty four per cent of the centres. Paracetamol and morphine were the most currently used analgesics drugs. Morphine was administered subcutaneously by 75% of the centres. Six centres used also PCA. Thirty-seven percent of the centres were reluctant to use opioids and 75% to use NSAIDS. CONCLUSION: The majority of the centres considered pain management in patient suffering from subarachnoid haemorrhage (SAH) was not optimal and stressed the need to establish a well validated pain rating scale dedicated to SAH patients.

Evaluation of remifentanil in endoscopic retrograde cholangio-pancreatography.

BACKGROUND AND OBJECTIVE: Endoscopic retrogade cholangio-pancreatography (ERCP) is a painful procedure that requires transient analgesia and conscious sedation. Remifentanil an ultrashort, very potent narcotic, is eliminated by plasma esterases, and does not interfere with liver function. It does not accumulate and is free of residual depression. Our aim is to find out if remifentanil can provide safe and effective sedation in ERCP, without undue technical difficulty secondary to sphincter spasm. PATIENTS AND METHODS: Thirty five patients, ASA I-II and III, scheduled to undergo elective ERCP were divided randomly in two groups: Midazolam-remifentanil group (group I), received remifentanil a loading dose of 0.2 microg/Kg/min over 5 minutes and a maintenance dose of 0.1-0.15 microg/Kg/min to achieve an adequate level of sedation and analgesia. Midazolam-fentanyl group (group II), received intermittent doses of midazolam and fentanyl guided by level of sedation. All patients were premedicated with midazolam 0.05 mg/kg IV, in divided doses as per patient tolerance, before starting the procedure. Sedation was assessed depending on Ramsey scale of sedation. SpO2, blood pressure, heart rate, respiratory rate, dosages of the medications, peroperative amnesia and operative time were recorded. Operator and patient satisfaction were rated on a scale of 1 to 4. RESULTS: There were statistically significant differences in the level of sedation (p = 0.003), patient satisfaction (p = 0.01) and the amount of midazolam used (p < 0.01) in favor of group I. Operator satisfaction was the same in the two groups. There was no statistically significant difference between the two groups regarding the peri-operative amnesia. The technical difficulty (catheterization of ampulla, duration of procedure, need of parasympatholytics...) was comparable in the two groups, as judged by the operator. There was one case of mild desaturation in group I that responded to stimulation. No other respiratory or cardiovascular events were noted. CONCLUSION: We recommend remifentanil in ERCP. Vigilance, however, must be exercised in titration and supervision of patients.

Cytosine arabinoside for induction, salvage, and consolidation therapy of adult acute lymphoblastic leukemia.

During A-ALL induction treatment, HD-ara-C (2.5 g/m2 IV, day 1), does not produce any beneficial effect, whereas the hematologic toxicity is increased. A 3-month consolidation phase comprising intermittent MTX, ara-C and 6-TG is not significantly affecting either DFI or survival in A-ALL. The association of HD-ara-C and m-AMSA appears to be a promising salvage therapy for the 20% A-ALL refractory to first induction therapy. The quality of autologous bone marrow graft, harvested after HD-ara-C, seems to be impaired as suggested by a delayed recovery of PMN and platelets. HD-ara-C (3 g/m2 X N) given the days before cyclophosphamide and TBI as conditioning treatment for BMT does not seem to induce prohibitory additional toxicity. Whether HD-ara-C was given four to six times or eight to 12 times gave no significant difference in early toxicity.

Ductal carcinoma in situ of the breast: results of treatment by conservative surgery and definitive irradiation.

PURPOSE: To determine local control, survivorship, and cosmesis in women with ductal carcinoma in situ treated by conservative surgery and radiation therapy. METHODS AND MATERIALS: We retrospectively analyzed the results of treatment in 56 women with in situ carcinoma of the breast, treated between 1976 and 1990 by conservative surgery and irradiation. Two women had bilateral tumors, for a total of 58 breasts at risk. All patients underwent gross excision of the tumor followed by radiation to the entire breast and a sequential boost to the tumor bed. Eight of the 21 evaluable tumors (38%) had inadequate pathologic margins at the time of excision. Routine re-excision was not performed. The median dose to the whole breast and primary tumor site was 5000 cGy and 6940 cGy, respectively. Median follow-up was 61 months (range 27-191 months). RESULTS: Five patients (9%) failed in the breast for an 8-year actuarial local failure rate of 11%. Median time to failure was 34 months. All five patients with local recurrence underwent mastectomy and are alive, without evidence of disease at a mean of 40 months post mastectomy. The 8-year actuarial absolute and cause specific survivals were 89% and 100%, respectively. Cosmetic results were excellent or totally acceptable in 90% of patients. CONCLUSION: Patients with ductal carcinoma in situ treated by excision and irradiation achieved acceptable local control and excellent survival and cosmetic results. Because of the long time course associated with local failure, diligent and protracted follow-up is mandatory.

Candidemia in immunocompromised patients.

This study reviews data on patients with fungemia and confirms the high prevalence (50%) of infections caused by non-albicans species of Candida. Fungemia due to C. albicans or Torulopsis glabrata occurred significantly more often in patients with a solid tumor, while fungemia due to Candida tropicalis or Candida krusei was significantly more common in patients with hematologic malignancy (P = .001). For 31% of patients, only a single blood culture was positive for yeasts, and the prognosis for these patients was not significantly different than that for patients with three or more positive blood cultures (P = 1), including those who had C. albicans fungemia. The overall mortality rate was 41.8%, which is much lower than that previously reported in studies of patients with cancer. No significant difference was observed between patients treated with amphotericin B and those treated with fluconazole in this retrospective analysis. Although no significant difference was observed in the mortality rate among patients who had fungemia with or without neutropenia, the incidence of disseminated candidiasis was significantly higher among neutropenic patients (P = .03).

Concentrations of ofloxacin in serum and cerebrospinal fluid of patients without meningitis receiving the drug intravenously and orally.

The cerebrospinal fluid (CSF) penetration of ofloxacin given orally or or intravenously was studied in cancer patients without meningitis. Each patient was assigned to a different sampling time to assess the relation between time and penetration. Ofloxacin was measured in serum and CSF by high-pressure liquid chromatography and bioassay. In addition, the bactericidal titers were measured in CSF and serum against a set of relevant bacteria. Concentrations measured by high-pressure liquid chromatography and bioassay were well correlated. Peak concentrations in CSF (0.4 to 1 microgram/ml) were observed 2 to 4 h after infusion or oral administration. Peak concentrations in serum were observed just after infusion (2 to 3.5 micrograms/ml) or 1 to 2 h after oral administration (1.7 to 4 micrograms/ml). Measured bactericidal titers were well correlated with the titers expected from the MBC and concentration. High CSF bactericidal titers were observed against Neisseria meningitidis, Haemophilus influenzae, and Escherichia coli, whereas low or no bactericidal titers were obtained against Staphylococcus aureus, Listeria monocytogenes, and Streptococcus pneumoniae.

[Comparative study of 2 common tests for lupus anticoagulant determination: critical analysis of the results observed in 21 patients]. / Etude comparative de deux tests usuels de dépistage de l'anticoagulant du lupus: analyse critique des résultats observés chez 21 malades.

The Schleider and/or the Exner test have been found positive in twenty-one patients; five of these patients suffered of systemic lupus erythematosus (SLE). The Quick time and the activated partial thromboplastin time are normal in 52% of the cases. 40% have a minor haemorrhagic diathesis, without other significant clotting defect and 30% have thrombo-embolic complications. The Schleider index is more often strongly positive (greater than 2) in these two groups. 58% have an anemia, 25% a mild thrombocytopenia not deep enough to explain an haemorrhagic tendency (from 90.000 to 140.000/mm3). Several auto-immune tests are frequently positive even without SLE. The Schleider test is positive in 86% of the cases and appears a little more useful for the diagnosis than the Exner test, which has a 71% positivity.

Tamoxifen and endometrial pathologies: a prospective study.

OBJECTIVE: The purpose of this study was to prospectively follow a group of women with breast cancer, on tamoxifen, for the development of endometrial pathologies. MATERIALS AND METHODS: Eighty women with breast cancer, on tamoxifen, were prospectively followed every 6 months with pelvic examination, Pap smear, vaginal ultrasound, and endometrial biopsy. RESULTS: Nine women were lost to follow-up prior to initiation of treatment and 4 refused biopsies, leaving 67 patients for evaluation. Fifty (74.6%) of the 67 patients were already on tamoxifen for a mean duration of 15.8 +/- 16.6 months and had a baseline benign, unremarkable endometrium at the time of entry into the study. The total duration of treatment was 32.5 +/- 19.6 months (median 30 months). The mean age of the patients was 51.7 +/- 9.9 years (median 52 years). Of the patients, 56.7% were postmenopausal. Sixty-three patients had a benign endometrium (mean age 51.8 +/- 10.1 years, mean duration 33.1 +/- 19.6 months). Two patients had simple hyperplasia (mean age 43.5 years, duration 28.5 +/- 33.2 months), 1 patient had complex hyperplasia with atypia (age 57 years, duration 13 months), and another patient developed adenocarcinoma (grade 3) after 22 months. These 4 patients had abnormal vaginal bleeding. Seven patients developed endometrial polyps (mean age 54.0 +/- 8.5 years, duration 36 +/- 24.2 months). The mean endometrial thickness for patients with histologically unremarkable and abnormal endometrium was not significantly different (7.6 +/- 3.9 vs 8.8 +/- 5.0 mm, respectively) (median 7.0 mm for both groups). No endometrial thickness cutoff point reached statistical significance. The patient who developed endometrial cancer had a thickness of only 3 mm. CONCLUSION: All patients who developed an abnormal endometrium had abnormal vaginal bleeding. There was no correlation between endometrial thickness and endometrial pathology; thus the value of routine screening remains controversial.