Why should the anesthesiologist evaluate nutritional status?

BACKGROUND: The anesthesiologist's involvement in perioperative medicine has significantly changed. In order to identify patients at risks of perioperative complications, the anesthesiologist has to consider, amongst others, screening and management of undernutrition. For this purpose knowledge of prevalence and risk factors, along with screening tools and guidelines for an adapted nutritional management and outcomes of renutrition are mandatory. The present review intends to provide these tools to the Anesthesiologists. METHOD: We conduct a literature review in Pubmed, Direct Science and Cochrane Library without limit of time related to undernutrition in the perioperative period. RESULTS: Undernutrition is common in surgical patients. Undernutrition is associated with an increase of morbidity, mortality, length of hospital stay and costs. Undernutrition could probably be detected during the anesthetic consultation with simple and rapid tests, such as SNAQ, MST, MUST and NRS-2002. Nevertheless, further studies are needed to validate such tests in surgical patients. Waiting for these results, we prefer MUST. The implementation of nutritional support recommendations would reduce postoperative complications. CONCLUSION: The anesthesiologist could play an important role in undernutrition screening and its management in order to reduce perioperative morbidity.

In vivo optical spectroscopy monitoring in a new model of muscular compartment syndrome.

BACKGROUND: Muscular compartment syndrome (MCS) is a rare but serious postoperative complication. In vivo optical spectroscopy (INVOS) monitors continuously and non-invasively regional oxygen saturation (rSO(2)), and could predict the development of MCS. METHODS: In 10 healthy volunteers, we inflated a tourniquet to the mean arterial pressure to produce slight venous congestion and arterial hypoperfusion. Comparisons were made between the relative reduction in rSO(2) with baseline (deltaINVOS) and the time to observe motor nerve block (with non-invasive electromyography). Neurological symptoms, pain, and invasive intracompartmental pressure (ICP) were assessed. RESULTS: In the eight volunteers completing the protocol, we observed a profound motor nerve conduction block, immediately reversible. Baseline values were: [mean (sd)] INVOS: 73.3 (8.9)% and ICP: 16.9 (8.6) mm Hg. At the time of the block, values were: INVOS: 46.4 (10.9)%, deltaINVOS: 28.7 (10.6)%, and ICP: 70.0 (5.5) mm Hg. The time to reach the block was 33.0 (10.9) min, and to a deltaINVOS>10%: 27.4 (10.4) min. Receiver-operating characteristic curves demonstrated a similar accuracy of ICP and INVOS to predict the occurrence of the block. Twenty minutes with a deltaINVOS>10% or ICP>30 mm Hg were associated with a sensitivity and a specificity of 95% and 70%; or 91% and 65%, respectively. CONCLUSIONS: We have developed a model of acute immediately reversible MCS. Monitoring using the INVOS technology is as accurate as measurement of ICP, and could be a useful tool to prevent development of intraoperative MCS.

Osseous manifestations of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome.

The SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome includes a complex group of disorders characterized by peculiar bone lesions, most commonly involving the anterior chest wall, and sometimes accompanied by dermatologic manifestations. The clinical and radiographic features of this syndrome are well described, but few studies have examined the histologic features of the bone lesions. We describe the clinical, radiographic, and histologic features of the osseous lesions encountered in eight patients with a clinical diagnosis of SAPHO syndrome. The patients included five female and three male patients ranging in age from 5 to 63 years (mean, 35.3 years). The most common clinical presentation was pain related to the sites of osseous involvement. Two patients also had some form of pustular dermatosis. The radiographic features of the osseous lesions varied but often suggested the possibility of a neoplasm. Nine pathologic specimens were available for review, five from the clavicle, two from the first rib, one from the calcaneus/cuboid, and one from the tibia. The histologic features varied but seemed related to the duration of the patients' musculoskeletal symptoms. Early lesions contained acute inflammation, edema, and prominent periosteal bone formation, histologically indistinguishable from ordinary bacterial osteomyelitis, whereas late lesions demonstrated markedly sclerotic bone trabeculae with prominent marrow fibrosis and only mild chronic inflammation; one of these biopsies appeared virtually identical to Paget's disease. One biopsy was performed after an intermediate duration of symptoms and contained prominent chronic inflammation only. The histologic findings in SAPHO are variable and nonspecific and may depend on the duration of disease, but it is important to recognize the spectrum of histologic changes possible in the syndrome and to realize that clinicopathologic correlation is necessary to avoid misdiagnosis and unnecessary long-term antibiotic therapy.

Sternocostal joints. Anatomic, radiographic and pathologic features in adult cadavers.

Using radiographic-pathologic correlation, we studied the sternocostal joints derived from 27 consecutive cadavers and one additional cadaver with rheumatoid arthritis. Radiographic findings that were tabulated included joint space narrowing, sternal or costal osteophytes, articular calcification, vacuum phenomena, and the degree of ossification of the costal cartilages. The first sternocostal joint could be classified as either a synchondrosis or synostosis in every instance; however, a joint cavity lateral to the first sternocostal joint represented a normal variation and was seen radiographically in 10 specimens. The second sternocostal joint was synovial in type and intimately related to the manubriosternal joint; cavitation within this joint was present bilaterally in 36% of our specimens. Degenerative changes in the sternocostal articulations were characterized much more frequently by sternal osteophytes than by costal osteophytes or joint space narrowing. Calcification compatible with chondrocalcinosis was observed in two cadavers. Radiographic and pathologic evidence of synovial inflammation was evident in the sternocostal joints of the rheumatoid specimen.

Detection of thoracolumbar vertebral body destruction with lateral spine radiography. Part I: Investigation in cadavers.

Despite few and inconclusive studies, radiography is generally believed to be insensitive for detection of osteolytic lesions of the spine. A more detailed investigation was undertaken to study the detectability of laboratory-produced osteolytic lesions in cadaveric thoracolumbar vertebral bodies using conventional lateral radiographs. The radiographs were presented to four radiologists in two sessions over a two month period. In the first session, the films were arranged in a composite of five vertebral bodies, T11 to L3 all from the same spine, in which one contained a lesion and the other four were normal. In the second session, each vertebral body film was presented individually. Area (Az) under the receiver-operating characteristic (ROC) curve was used to measure the performances of readers. Observer detection was similar in the two formats with Az ranging from 0.67 +/- 0.05 to 0.79 +/- 0.04 for the composite film arrangement and 0.57 +/- 0.08 to 0.85 +/- 0.10 for the films of individual vertebral bodies. Lesions were grouped into three relative size categories: 18% to 25%, 26% to 40%, and 41% to 60% of transverse vertebral body diameter. The mean increase in ROC area between the small and large lesions was 0.29 (P less than 0.04) for the composite films and 0.16 (P less than 0.05) for the individual films. In the composite study, all readers showed significant (P less than 0.05) increases in lesion detection in spines reflecting large increases (P less than 0.01) in bone mineral content.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of thoracolumbar vertebral body destruction with lateral spine radiography. Part II: Clinical investigation with computed tomography.

Conventional radiography in the lateral projection was used to evaluate 25 osteolytic lesions involving vertebral bodies of the thoracolumbar spine. Destruction was calculated as percentages of the maximum transverse diameter and volume of the vertebral body as measured by computed tomography (CT) and the effect of size of lesion on detection was evaluated. Areas (Az) under the receiver-operating characteristic (ROC) curves and the significance of differences were determined from the observations of four radiologists. The mean difference between areas under the ROC curve for lesions involving 32% to 60% of the transverse diameter and for larger lesions of 61% to 93% was 0.12 and significant (P less than 0.05). The effect of the presence of localized loss of vertebral body density, sclerotic bone tissue surrounding the lesion and cortical destruction was evaluated in a second session, in films with lesions the observers scored 4 (probably abnormal) or 5 (definitely abnormal). Cortical destruction was reported to be helpful for detection in 35% of lesions, sclerotic bone surrounding the lesions was helpful in 30%, and a qualitative local decrease in bone density was noted in all lesions. In comparison with the results obtained for the same four observers with experimentally produced lesions in our previous cadaveric study, the clinical lesions of comparable size were not as readily detected. The ROC area for the largest group of clinical lesions (61% to 93%, Az = 0.83 +/- 0.07) was not significantly different from that for a group of smaller cadaveric lesions (41% to 60%, Az = 0.83 +/- 0.05). The smaller clinical lesions (32% to 60%, Az = 0.71 +/- 0.08) were similar in detectability to the experimental lesions of relative diameter 26% to 40% (Az = 0.74 +/- 0.15). Caution should be exercised in the interpretation of conventional radiographs in the lateral projection if there is suspicion of vertebral body destruction.

Arthrography of the post-traumatic knee, shoulder, and wrist. Current status and future trends.

The current status of arthrography of the wrist, knee, and shoulder has been discussed with particular emphasis given to those conditions seen in patients following acute or chronic trauma. Cross-sectional techniques that impact on the current usage of arthrography of these joints also were discussed. Wrist arthrography remains the standard procedure for the evaluation of ligamentous abnormalities about the wrist. MR imaging is unlikely to make a large impact in this area until improvements in technique and surface coil technology allow routine visualization of the very small, but important, interosseous ligaments. MR imaging of the knee will likely replace arthrography except in those cases in which cost considerations or availability prevent its implementation. MR imaging undoubtedly will continue to contribute to the evaluation of shoulder abnormalities, but whether or not it will completely replace standard arthrography and CT arthrography depends upon the results of future studies.

Prospective study of osseous, articular, and meniscal lesions in recent anterior cruciate ligament tears by magnetic resonance imaging and arthroscopy.

Fifty-four patients with anterior cruciate ligament tears that were arthroscopically reconstructed within 3 months of initial injury were prospectively evaluated. Patients with grade 3 medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament tears were excluded. Eighty percent of our patients had a bone bruise present on the magnetic resonance image, with 68% in the lateral femoral condyle. Two of the latter findings--an abnormal articular cartilage signal (P = 0.02) and a thin and impacted subchondral bone (P = 0.03)--had a significant relationship with injury to the overlying articular cartilage. Meniscal tears were found in 56% of the lateral menisci and 37% of the medial menisci. A significant association was present between bone bruising on the lateral femoral condyle and the lateral tibial plateau (P = 0.02). Results of our study support the concept that the common mechanism of injury to the anterior cruciate ligament involves severe anterior subluxation with impaction of the posterior tibia on the anterior femur. Determination of the significance of bone bruising, articular cartilage injury, or meniscal tears will require a long-term followup that includes evaluation for arthritis, stability, and function. These 54 patients represent the first cohort evaluated in this ongoing prospective clinical study.

MR imaging of spinal infections.

In the appropriate clinical situation, MR imaging is a powerful tool in the diagnosis of spinal infection. Imaging of spinal infections requires the use of a combination of T1-weighted and T2-weighted or STIR sequences. Contrast enhancement is useful and helps to define paraspinal and epidural disease. Knowledge of potential pitfalls with MR imaging and of normal marrow conversion is required. With these points in mind, MR imaging will be beneficial in the care of patients with spinal infections.

Transient osteoporosis of the hip: clinical and imaging features.

Transient osteoporosis of the hip is a form of reflex sympathetic dystrophy characterized by pain, limping, limitation of hip joint motion, and delayed radiographic patchy osteoporosis of the proximal femur. Spontaneous resolution is usually paralleled by radiographic recovery, usually within a few months. We present clinical and imaging features in seven cases of unilateral transient osteoporosis of the hip. In the appropriate clinical setting, conventional radiography will support the diagnosis. The role of more sensitive imaging techniques such as bone scintigraphy and magnetic resonance imaging in the early diagnosis of this disease has yet to be defined.

Skeletal involvement in sarcoidosis: a case report.

A patient is described in whom sarcoidosis caused a pathological fracture of the middle phalanx of the little finger. A bone scan showed increased uptake. She was treated by resection of the diseased area and bone grafting, which led to bone healing. The bony manifestations of sarcoidosis are reviewed.

Percutaneous CT guided resection of osteoid osteoma of the tibial plafond.

Osteoid osteomas of the foot and ankle are relatively rare and notoriously difficult to diagnose. Juxta-articular osteoid osteomas are more difficult to treat and often have a significant delay in diagnosis. We report a case of a juxta-articular osteoid osteoma of the tibial plafond. Once the diagnosis was made, excisional biopsy was performed percutaneously under computed tomography (CT) guidance as an outpatient in the radiology suite. The patient had complete resolution of symptoms and remains pain free at two years follow-up. CT guided resection can be a lower morbidity and more cost effective technique to treat this lesion than traditional methods.

[In loco fibrinolytic treatment of acute ischemia of the lower limbs]. / Traitement fibrinolytique in loco des ischémies aiguës des membres inférieurs.

Peripheral artery occlusion produced by thrombosis or embolus can be cured by intra-arterial low dose thrombolysis without severe hemorrhagic complications. 18 patients suffering of acute ischemia of lower limbs were treated by intra-arterial streptokinase infusion. Diagnostic angiography is performed by antegrade femoral puncture using a 5F straight catheter. The tip of the catheter is placed within the thrombus. After a bolus of 10 000 U, streptokinase is infused at the rate of 2,000 U/min. Fibrinolysis is usually achieved within 70 min with a total dose of 150,000 U. Arterial recanalization occurred in 14 patients, in 6 cases underlying stenosis was successfully treated by percutaneous transluminal angioplasty. No severe complications were encountered.

Imaging modalities for study of the distal ulnar region.

Judicious use of diagnostic imaging maximizes the diagnostic capabilities of the surgeon treating the distal radio-ulnar joint (DRUJ). A good clinical history and clinical examination are necessary to direct the selection of appropriate imaging studies. Plain radiographs are almost always the first imaging examination. More advanced imaging techniques are costly and may provide only limited information. This article discusses imaging modalities useful for assessment of the DRUJ and the area around it.

[Radiologic and hemodynamic studies of sexual impotence of vascular origin]. / Investigations radiologiques et hémodynamiques de l'impuissance sexuelle d'origine vasculaire.

Vascular pathology is responsible for about 25% of male impotence, the arterial investigation is now classical. In our experience a great number of patients showed a normal arterial condition, requiring further venous exploration. Cavernographies and pressure flow dynamics were used to evaluate 45 patients. The cavernograms allowed visualization of structural abnormalities within the cavernous tissues and their venous drainage. The heparinized and diluted contrast medium is infused at 80 to 120 ml/minute until the appearance of an erection, in normal condition the intracavernous pressure rise at greater than or equal to 80 mmHg as long as the erection last. The venous leak is characterized by the absence of erection, no increase of the intra-cavernous pressure and a rapid opacification of venous plexus under a normal perfusion flow.