[Management of binocular diplopia in the department of ophthalmic emergencies at the Regional University Hospital of Tours]. / Prise en charge des diplopies binoculaires aux urgences ophtalmologiques du Centre hospitalier régional universitaire de Tours.

OBJECTIVES: To describe the etiologies of binocular diplopia for patients presenting to the ophthalmologic emergency department of the Regional University Center Hospital (CHRU) of Tours. METHODS: This is a retrospective study of the medical records of patients who presented with binocular diplopia in the ophthalmic emergency department of the CHRU of Tours between January 1st and December 31st, 2019. Binocular diplopia was classified as paralytic or non-paralytic according to the ocular motility examination. RESULTS: One hundred twelve patients were included. The median age was 61 years. Internal referral from other hospital services represented 44.6% of the patients. On ophthalmological examination, 73.2% had paralytic diplopia, 13.4% non-paralytic diplopia and 13.4% normal examination. Neuroimaging was performed in 88.3% of cases, with 75.7% of patients receiving it on the same day. Oculomotor nerve palsy was the most frequent cause of diplopia in 58.9%, the majority represented by abducens nerve palsy (60.6%). The most frequent etiology of binocular diplopia was ischemic, with microvascular damage in 26.8% of cases and stroke in 10.7% of cases. CONCLUSION: Among patients assessed in an ophthalmological emergency department setting, one in ten patients had stroke. It is essential to inform patients of the urgent nature of ophthalmological evaluation in the case of acute binocular diplopia. Urgent neurovascular management is also mandatory and should be based on the clinical description provided by the ophthalmologist. Neuroimaging should be performed as soon as possible, based on the ophthalmologic and neurological findings.

Outcome of older persons admitted to intensive care unit, mortality, prognosis factors, dependency scores and ability trajectory within 1 year: a prospective cohort study.

BACKGROUND: The outcome and functional trajectory of older persons admitted to intensive care (ICU) unit remain a true question for critical care physicians and geriatricians, due to the heterogeneity of geriatric population, heterogeneity of practices and absence of guidelines. AIM: To describe the 1-year outcome, prognosis factors and functional trajectory for older people admitted to ICU. METHODS: In a prospective 1-year cohort study, all patients aged 75 years and over admitted to our ICU were included according to a global comprehensive geriatric assessment. Follow-up was conducted for 1 year survivors, in particular, ability scores and living conditions. RESULTS: Of 188 patients included [aged 82.3 ± 4.7 years, 46% of admissions, median SAPS II 53.5 (43-74), ADL of Katz's score 4.2 ± 1.6, median Barthel's index 71 (55-90), AGGIR scale 4.5 ± 1.5], the ICU, hospital and 1-year mortality were, respectively, 34, 42.5 and 65.5%. Prognosis factors were: SAPS 2, mechanical ventilation, comorbidity (Lee's and Mc Cabe's scores), disability scores (ADL of Katz's score, Barthel's index and AGGIR scale), admission creatinin, hypoalbuminemia, malignant haemopathy, cognitive impairment. One-year survivors lived in their own home for 83%, with a preserved physical ability, without significant variation of the three ability assessed scores compared to prior ICU admission. CONCLUSION: The mortality of older people admitted to ICU is high, with a significant impact of disabilty scores, and preserved 1-year survivor independency. Other studies, including a better comprehensive geriatric assessment, seem necessary to determine a predictive "phenotype" of survival with a "satisfactory" level of autonomy.

Mass transfer, clearance and plasma concentration of procalcitonin during continuous venovenous hemofiltration in patients with septic shock and acute oliguric renal failure.

OBJECTIVES: To measure the mass transfer and clearance of procalcitonin (PCT) in patients with septic shock during continuous venovenous hemofiltration (CVVH), and to assess the mechanisms of elimination of PCT. SETTING: The medical department of intensive care. DESIGN: A prospective, observational study. PATIENTS: Thirteen critically ill patients with septic shock and oliguric acute renal failure requiring continuous venovenous postdilution hemofiltration with a high-flux membrane (AN69 or polyamide) and a 'conventional' substitution volume (< 2.5 l/hour). MEASUREMENTS AND MAIN RESULTS: PCT was measured with the Lumitest PCT Brahms(R) in the prefilter and postfilter plasma, in the ultrafiltrate at the beginning of CVVH (T0) and 15 min (T15'), 60 min (T60') and 6 hours (T6h) after setup of CVVH, and in the prefilter every 24 hours during 4 days. Mass transfer was determined and the clearance and the sieving coefficient were calculated according to the mass conservation principle. Plasma and ultrafiltrate clearances, respectively, at T15', T60' and T6h were 37 +/- 8.6 ml/min (not significant) and 1.8 +/- 1.7 ml/min (P < 0.01), 34.7 +/- 4.1 ml/min (not significant) and 2.3 +/- 1.8 ml/min (P < 0.01), and 31.5 +/- 7 ml/min (not significant) and 5 +/- 2.3 ml/min (P < 0.01). The sieving coefficient significantly increased from 0.07 at T15' to 0.19 at T6h, with no difference according to the nature of the membrane. PCT plasma levels were not significantly modified during the course of CCVH. CONCLUSIONS: We conclude that PCT is removed from the plasma of patients with septic shock during CCVH. Most of the mass is eliminated by convective flow, but adsorption also contributes to elimination during the first hours of CVVH. The effect of PCT removal with a conventional CVVH substitution fluid rate (<2.5 l/hour) on PCT plasma concentration seems to be limited, and PCT remains a useful diagnostic marker in these septic patients. The impact of high-volume hemofiltration on the PCT clearance, the mass transfer and the plasma concentration should be evaluated in further studies.

C-reactive protein and procalcitonin as markers of mortality in hemodialysis patients: a 2-year prospective study.

OBJECTIVE: We have previously shown in a transversal study that PCT combined to CRP is associated to an altered nutritional status in hemodialysis patients. In a 2-year prospective study, we have assessed the relationship between markers of inflammation or nutrition and mortality. DESIGN: Two-year prospective study, in 61 patients dialyzed in our unit (29 M/32 F, age 63 +/- 15 years, on dialysis for 76 +/- 94 months, 12 hrs/wk, on high-flux (HF) membrane for 25 patients and low-flux (LF) for 36 patients, without reuse). Kt/V was 1.53 +/- 0.30. SETTING: Hospital-based dialysis unit. MAIN OUTCOME MEASURE: CRP, PCT, ferritin, albumin, and prealbumin, were measured in 04/99 (T0) and every 6 months thereafter. Interleukin-6 (IL6) and fibrinogen were measured at the start of study. The outcome and the causes of death of patients were noted in 58 patients, 3 patients were lost of follow-up. RESULTS: The mortality (24 deaths) was 42% at 2 years in this hospital based unit. The main causes of mortality were cardiovascular diseases (71%) and infection (17%). Patients were classified according to their CRP (CRP+ if CRP > or = 5 mg/L; n = 40), and PCT values (PCT + if PCT > or = 0.5 ng/mL; n = 25). IL6 level was > or = 10 pg/mL for 95% of the patients. Mortality was higher in the CRP+ group (Kaplan-Meier test P < .01) but not in the PCT or IL6 positive patients. All patients of the CRP+ group at T0 remained CRP+. Only 56% of patients of PCT+ remained positive at 6 months. When patients were grouped according to CRP quartile the difference on survival remained significant (P = .03), patients who were classified in the third and fourth quartile (upper than 9.9 mg/L), exhibited a higher rate of mortality than the lower quartile. The concomitant presence of a high level of PCT and CRP was associated with a worsened nutritional status at T0 but PCT level had no influence on 2-year mortality. CONCLUSION: In this 2-year prospective study in a hospital-based cohort of high-risk hemodialysis patients, elevated CRP, but not raised PCT, was associated with increased mortality. Inflammation remained present throughout a 2-year follow-up in patients with an initial CRP higher than 5 mg/L. An upper value of CRP above 9.9 mg/L is independly predictive of mortality, mainly from cardiovascular causes. The association of high PCT and CRP was no more predictive of mortality than high CRP.

Performance of twin central venous catheters: influence of the inversion of inlet and outlet on recirculation.

BACKGROUND: The use of a central venous catheter as a permanent vascular access is constantly growing. The recirculation rate in this type of vascular access varies depending on the site of insertion, the length of the catheter, the blood flow and the time elapsed since catheter insertion. When the in/out flow of the lumens of the catheter is reduced, it is sometimes necessary to inverse the arterial and venous lines of the catheter at the beginning or in the course of the dialysis session. The impact of such a practice on the recirculation rate has only been assessed by the low flow urea dilution method. METHODS: The blood recirculation rate was measured using the ultrasound dilution velocity method (Transonic system, Ithaca, N.Y.) in 14 patients (aged 64 +/- 15 years), with a right internal jugular (n = 9) or right subclavian (n = 5) central catheter (Twincath, Medcomp), used over a mean period of 16.3 (range 1-42) months. No clinical dysfunction of the catheter was apparently noted. The distance between the vein and the artery end of the catheter was 3.9 +/- 2.8 cm, measured on chest radiography. The recirculation rate was measured over a single dialysis session at increasing blood flows in the normal and inversed position of the catheter. RESULTS: The difference between the prescribed and effective blood flow was significant with an effective blood flow of 180 +/- 16 ml/min for 200 ml/min, 264 +/- 27 ml/min for 300 ml/min and 329 +/- 16 ml/min for 400 ml/min prescribed blood flow. There was no relationship between the recirculation rate and blood flow whatever the position of the lines on the catheter. There was also no relationship between the recirculation rate and the distance between the catheter ends. However, reversing the catheter ends significantly increased the recirculation rates from 2.9 +/- 5 to 12 +/- 9% whatever the blood flow. CONCLUSION: The use of central catheters in an inversed position can result in a higher recirculation rate. Reversing the lines of the central catheters may lead to less effective hemodialysis and it seems particularly important for the nursing staff to be aware of this phenomenon. Thus, measurement of the effective blood flow and recirculation by ultrasound velocity should be included in quality monitoring and maintenance.