Clinical validation of a prognostic tool in a population of outpatients treated for incurable cancer undergoing anticancer therapy: PRONOPALL study.

BACKGROUND: In 2008, a study of the characteristics of hospitalised patients led to the development of a prognostic tool that distinguished three populations with significantly different 2-month survival rates. The goal of our study aimed at validating prospectively this prognostic tool in outpatients treated for cancer in terminal stage, based on four factors: performance status (ECOG) (PS), number of metastatic sites, serum albumin and lactate dehydrogenase. PATIENTS AND METHODS: PRONOPALL is a multicentre study of current care. About 302 adult patients who met one or more of the following criteria: life expectancy under 6 months, performance status ≥ 2 and disease progression during the previous chemotherapy regimen were included across 16 institutions between October 2009 and October 2010. Afterwards, in order to validate the prognostic tool, the score was ciphered and correlated to patient survival. RESULTS: Totally 262 patients (87%) were evaluable (27 patients excluded and 13 unknown score). Median age was 66 years [37-88], and women accounted for 59%. ECOG PS 0-1 (46%), PS 2 (37%) and PS 3-4 (17%). The primary tumours were: breast (29%), colorectal (28%), lung (13%), pancreas (12%), ovary (11%) and other (8%). About 32% of patients presented one metastatic site, 35% had two and 31% had more than two. The median lactate dehydrogenase level was 398 IU/l [118-4314]; median serum albumin was 35 g/l [13-54]. According to the PRONOPALL prognostic tool, the 2-month survival rate was 92% and the median survival rate was 301 days [209-348] for the 130 patients in population C, 66% and 79 days [71-114] for the 111 patients in population B, and 24% and 35 days for [14-56] the 21 patients in population A. These three populations survival were statistically different (P <0.0001). CONCLUSION: PRONOPALL study confirms the three prognostic profiles defined by the combination of four factors. This PRONOPALL score is a useful decision-making tool in daily practice.

[Severe interstitial pneumopathy due to herpes virus after radiochemotherapy for esophageal carcinoma]. / Pneumopathies herpétiques sévères après radio-chimiothérapie de cancers de l'oesophage.

The authors report two cases of severe bilateral interstitial pneumopathies occurring after a medical treatment for esophageal carcinoma. In both cases a broncho-alveolar lavage revealed the presence of herpes virus and a specific treatment rapidly cured the patients.

Small-cell carcinoma of the esophagus: report of three cases and review of the literature with emphasis on therapy.

Primary small-cell carcinoma (SCC) of the esophagus is rare, with about 200 cases reported up till now in the literature. Like pulmonary SCC, it is an aggressive tumor associated with a poor prognosis. Between 1994 and 1997, three patients with SCC of the esophagus were treated at Besançon University Hospital and this represented 1.85% of all esophageal malignancies diagnosed during this period: one patient had a limited tumor and underwent initial surgical resection, then chemotherapy with cisplatine and etoposide, and radiotherapy for recurrences. The other patients had extensive disease at diagnosis and were treated by the same chemotherapy. This retrospective study reports our experience of patients with this particular tumor and outlines the management strategy based on the available literature.

[Evaluation of locoregional anesthesia in an emergency-traumatology operating room]. / Evaluation de l'anesthésie loco-régionale dans un bloc de traumatologie d'urgence.

Surgical activities concerning traumatic emergencies have been evaluated during 3.5 months. There has been 371 cases. Most of them concerned hand injuries (48%); others concerned limbs, and 5 multiple injuries, one spinal fracture and 30 various injuries. Loco-regional anesthesia has been preferred in 63% of all cases; 80% of all hand injuries, 100% of all femoral neck fractures. The success rate--no addition of morphinics--has been evaluated at 85%, with use of sedatives in 28%.

[Evaluation of ambulatory anesthesia at CHU, Brest]. / Evaluation de l'anesthésie ambulatoire au CHU de Brest.

Outpatient anaesthesia was investigated for a two-month period by means of a questionnaire filled from the preoperative anaesthesia consultation to the surgical procedure and the discharge of the patient. 868 consultations led to schedule 260 ambulatory procedures. ENT (88 patients), paediatric surgery (73 patients) and gynaecology (63 patients) were most frequently concerned. Indications of ambulatory practice could probably be enlarged provided that recovery rooms and surgical schedules were fully adapted.

[Disclosure of protein C deficiency with pulmonary embolism followed by cardiac arrest during the recovery period]. / Révélation d'un déficit en protéine C par une embolie pulmonaire suivie d'un arrêt cardiaque en phase de réveil.

A case of unexpected cardiac arrest occurring in a 17-year-old male patient is reported. The patient had been admitted after sustaining hand trauma. A first emergency surgical procedure was carried out, followed about three weeks later by another one. No incidents occurred during or after either of these two operations. A third procedure was required about two months after the accident (free toe graft to the thumb of the left hand). The twelve-hour operation was carried out under general anaesthesia and axillary block. The patient was given intravenous heparin (800 IU.h-1) during the procedure on the arm. The patient recovered quickly, and was extubated before his transfer to the recovery room. Fifteen minutes later, the patient's heart rate decreased to 40 b.min-1, followed by a transient cardiorespiratory arrest. The suspicion of pulmonary embolism was confirmed by pulmonary scintigraphy. Thrombolysis was carried out with 2,000 IU.kg-1.h-1 of urokinase for a 72 h period, combined with continuous heparin administration (16 to 36 x 10(3) IU.day-1). The patient recovered after one week. No thrombophlebitis was found for origin of the emboli. Biological investigations carried out both before and after 10 minutes of anoxia revealed a normal fibrinolytic system, but a deficit in protein C (62% antigen, 64% activity). Two years after the episode of pulmonary embolism, the patient, still taking acenocoumarol, remained free from any sequela. Current perioperative management of patients with a known protein C deficit is discussed.

[Peridural obstetrical analgesia and the cicatricial uterus. A 4-year evaluation]. / Analgésie péridurale obstétricale et utérus cicatriciel. Bilan de quatre années.

191 women with previous cesarean section in 291 indexed between October 1985 and September 1989 underwent a trial of labor. 146 patients received epidural analgesia in the course of labor. Vaginal delivery occurred in 126 patients (86.3%). Duration for epidural analgesia in labour was 163 +/- 110 min. The intrauterine pressure for monitoring continuous was 51.00 +/- 15.40 mmHg. We report four uterine dehiscences and one rupture. In no case, epidural analgesia did not delay the diagnosis. The use of epidural analgesia for trial of labor in previous cesarean section did not increase maternal or fetal risk.

[Physical and pharmacokinetic properties of anesthetics and sedatives used in neuroanesthesia and resuscitation]. / Propriétés physiques et pharmacocinétiques des substances anesthésiques et sédatives utilisées en neuroanesthésie et réanimation.

Pharmacokinetics of anesthetic drugs are widely influenced by their physical properties. Lipo-solubility is the most important characteristic. This parameter conditions tissue diffusion and subsequently potency and duration of action drugs Distribution is unequal in the different compartments of the body. The concept of effective compartment allows a best understanding of relationship between concentration, intensity and duration of action of anesthetic drugs. Constant intravenous infusion route of anesthetic drugs administration requires to be discussed.

[Hip arthroplasty and thromboembolic complications]. / Arthroplastie de hanche et complications thrombo-emboliques.

Orthopedic départment of Centre hospitalo-universitaire de Brest use one upon another two procedures: from 1974 to 1984, for 1287 cases the prevention of thromboembolic complications is done with the help of subcutaneous heparin at standard dose during 12 days; the clinical diagnosis in confirmed by an isotopic phlebography and isotopic lung scan. In 1986 and 1987, for 391 cases this prevention is done with the help of subcutaneous heparin in adapted doses during 21 days; the clinical diagnosis is confirmed by X ray phlebography and isotopic lung scan. The frequency of thromboembolic complications has been 4.6% in the first period and 1.2% in the second period. This results confirm the role of heparin in preventing post operative thromboembolic complications after total hip replacement. The results after knee arthroplasty are not so good.

Changes in intra-ocular pressure in the elderly during anaesthesia with propofol.

Variations in intra-ocular pressure during anaesthesia were studied in two groups of 15 elderly patients selected randomly. The groups were not significantly different with regard to age, sex, weight or ASA classification. The first group received intravenous propofol as a bolus followed by a continuous infusion. The second group received a bolus of thiopentone followed by maintenance with enflurane. Intra-ocular pressure, heart rate and arterial pressure were measured before and after induction, after intubation and at the end of the operation. Overall, compared with baseline values, the results showed a decrease in intra-ocular pressure of 31% in group 1 and 17% in group 2, and a decrease in systolic arterial pressure of 14% in both groups.

[Choice in the use of local and regional anesthesia in ophthalmologic surgery]. / Progression de l'anesthésie loco-régionale en chirurgie ophtalmologique.

The choice of different types of anaesthesia in ophthalmologic surgery is reviewed in 2,150 cases. Data analysis shows a real increase of anaesthetic activity in ophthalmology and a trend towards local anaesthesia especially in cataract. (45% of all operations in ophthalmology).

[Effects of propofol on intraocular pressure during the induction of anesthesia]. / Effets du propofol sur la pression intraoculaire au cours de l'induction anesthésique.

A study of variations in intraocular pressure during anaesthetic induction with propofol was carried out in 20 patients. There were compared with the effects caused by thiopentone. The intraocular pressure fell by 50%; this was very significant. Besides, a more important fall in blood pressure was seen with propofol (congruent to 15%) than with thiopentone (less than 10%). Complete recovery was faster after an anaesthesia with propofol. This drug seemed to be particularly interesting in ophthalmologic anaesthesia in elderly people.

[Antiarrhythmic effects of intravenous magnesium sulfate in torsade de pointes. Apropos of 6 cases]. / Effets anti-arythmiques du sulfate de magnésium intraveineux dans les torsades de pointes. A propos de 6 observations.

The antiarrhythmic properties of magnesium salts, known for many years, are periodically recalled but rarely used in daily clinical practice. They are usually used in digitalis-induced arrhythmias and are rarely indicated in other conditions; they are often reserved for cases in which a magnesium deficiency is suspected. In 6 cases of torsades de pointes, magnesium sulphate was administered at a dose 1 to 3 g by direct intravenous injection. Although hypokalaemia was a common finding, a low magnesium concentration was only found in one case. The ventricular arrhythmia regressed completely at the end of the injection in 4 cases (one after two injections). One positive but incomplete response was observed in the only case of magnesium deficiency, probably due in retrospect to inadequate dosage. Finally, one patient with very poor ventricular function had recurrence after a good initial response. The diversity of the clinical and biological findings in this series suggests a specific antiarrhythmic action of the magnesium ion, apparently independant of the correction of magnesium deficiency; experimental studies suggest that the mode of action is a direct antagonism of Mg++-K+ and/or Mg++-Ca++. Compared to usual means of treatment of torsades de pointes (isoprenaline infusion or pacing) the advantages of intravenous magnesium sulphate are clear-cut: innocuity, simplicity and rapidity of administration, and almost immediate efficacy.

[Effect of the parenteral feeding regimen on postoperative nitrogen sparing. Comparison of 3 regimens containing 0%, 30% and 50% lipid calories]. / Influence du régime d'alimentation parentérale sur l'épargne azotée postopératoire. Comparaison de trois régimes apportant 0%, 30% et 50% de calories lipidiques.

Forty one non emaciated patients undergoing major visceral surgery were randomly divided into three groups according to the postoperative parenteral diet (0% fat versus 30% or 50% fat). During five days daily nitrogen balance was studied. There was no evidence of any significant difference between the group 0% and the group 50%. On the other hand significant differences occurred in group 30% on the second, third and fifth postoperative days. The responsibility of inappropriate glucose intakes in envisaged.

[Severe hypophosphoremia in a patient on parenteral nutrition with phosphorus enrichment]. / Hypophosphorémie sévère chez un patient sous alimentation parentérale enrichie en phosphore.

A twenty-four year old patient showed severe hypophosphataemia after emergency surgery for colectasia. A critical study of the case isolated the factors which had favoured the development of this metabolic complication. The necessity for great care in the nutrition of emaciated patients as well as that of a phosphorus supply adapted to the metabolic status of the patient were emphasized. Frequent measurement of serum phosphate was recommended for patients undergoing intravenous hyperalimentation.

[Coronary spasm during repeated anesthesia]. / Spasme coronarien lors d'anesthésies itératives.

Coronary arterial spasm observed during the course of two repeated anaesthesias in a patient having undergone aorto-femoral bypass grafting is reported by the authors. Such complications are accompanied by serious ventricular arrhythmias, though transient and healing without sequelae. Clinical and electrocardiographic characteristics of peroperative coronary arterial spasm are underlined. In patients prone to developing such spasm, peroperative alkalosis, hypothermia and parasympathetic stimuli should be avoided. Are emphasized the efficiency of preventive treatment with calcium antagonists and that of intravenous nitroglycerin in the treatment of peroperative coronary arterial spasm when it does occur.

[Postoperative hypophosphoremia in digestive surgery. Influence of the parenteral diet]. / Hypophosphorémie postopératoire en chirurgie digestive. Influence du régime d'alimentation parentérale.

Twenty-seven non emaciated patients undergoing major visceral surgery were randomly divided into two different groups according to the postoperative parenteral diet (100% glucose versus 50% fat 50% glucose). All patients received the same anaesthetic protocol and, peroperatively, none received any glucose. In the postoperative phase, parenteral feeding was started on the day of operation (18.5-21.8 kcal X kg-1) and was continued for a minimum of four days (37-44 kcal X kg-1 X 24 h-1). All patients received intravenous insulin and phosphorus (0.15 mmol X kg-1 X 24 h-1). During five days, daily measurements of serum phosphate and glucose levels were made and nitrogen balance was studied. For all these parameters, there was no evidence of any significant difference between the two groups. A significant fall in plasma phosphate occurred in each group on the first postoperative day, was maximum on the second and lasted until the fourth. This fall was not influenced by parenteral diet. No patients in this study developed symptoms of phosphate depletion. The glucose levels increased significantly and the nitrogen sparing effect was similar in both groups. The mechanism of hypophosphataemia seemed to be an intracellular transfer under the influence of hyperglycaemia and high plasma insulin levels rather than an increase in urinary phosphate excretion. The advantage of using lipid solutions did not appear under the dietary conditions studied. Indeed a glucose supply greater than or equal to 3 mg X kg-1 X min-1 seemed to induce a maximum intracellular transfer of phosphorus. Because of this, phosphate supplementation and frequent measurement of serum phosphate are recommended for patients undergoing major visceral surgery and postoperative intravenous feeding.