Prognostic value of preoperative border-zone (watershed) infarcts on the early postoperative outcomes of carotid endarterectomy after acute ischemic stroke.

OBJECTIVES: To evaluate the prognostic value of cerebral border-zone infarctions (watershed infarctions) on the early postoperative outcomes of patients undergoing carotid endarterectomy (CEA) after acute ischemic stroke (AIS). METHODS: Sixty-six (66) patients with symptomatic carotid stenosis (SCS) that underwent ipsilateral CEA after AIS from January 2007 to March 2012 were included in this study. They were divided into two groups according to the topographic patterns of the stroke: group 1, Territorial Cerebral Ischemic Strokes (TCIS) caused by emboli of carotid origin; group 2, cerebral border-zone infarctions (CBZI) related to an SCS associated with hemodynamic impairment. All data was collected in a prospective database and analyzed. Outcome measures included postoperative neurological morbidity and 30-day mortality. RESULTS: Forty-three (43) patients (65.15%) experienced TCIS and were included in group 1, 23 patients (34.85%) had a CBZI and were included in group 2. There were no postoperative deaths. The postoperative neurologic morbidity rate was significantly higher in the CBZI group (22% vs. 2%, p = 0.02). Multivariate analysis demonstrates that CBZI was the only independent predictive factor of neurologic morbidity after CEA for AIS related to an SCS. Furthermore, the risk of postoperative neurologic morbidity remained significantly higher for patients with CBZI after adjustment for age, sex, initial NHISS scores, and associated contralateral carotid occlusion (HR: 0.059, 95% CI 0.004-0.85; p = 0.03). CONCLUSION: CBZIs, compared to TCIS, were associated with a higher neurological complication rate during the postoperative period after CEA for SCS in cases of AIS. Further studies are required to better define the timing and the best treatment modality for patients with CBZI related to an SCS in order to reduce associated procedural complications.

Arm composite autogenous vascular access using the great saphenous vein and the femoral vein: results from a single-centre study.

OBJECTIVES: The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery. DESIGN: Retrospective single-centre study. Prospectively collected clinical database. METHODS: Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates. RESULTS: The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access. CONCLUSION: With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

[Key drugs and doses in the hypertension's treatment in child in France]. / Posologies des principaux médicaments dans le traitement de l'hypertension artérielle de l'enfant en France.

The prescription drug for hypertension in children remains difficult because of the lack of pharmacological data validated for this age of life. The Food and Drug Administration (FDA) has recently proposed some antihypertensive regimens orally. The authors found it useful to reproduce a table by adding all the necessary data for its use in France. Here is a list of French medicines and doses applied to children. Similarly, they made a second table for injectable antihypertensive treatment based on American recommendations--but not yet validated by FDA.

Improvement of surgical antibiotic prophylaxis: a prospective evaluation of personalized antibiotic kits.

This prospective study compared personalized surgical antibiotic prophylaxis kits (SAPKs) with freely prescribed antibiotics. SAPKs use significantly enhanced national guidelines on surgical antibiotic prophylaxis application (82% vs 41%, P < 0.001), and result in limited errors in terms of antibiotic choice (3% vs 28%, P < 0.001), timing of administration (12% vs 24%, P = 0.003) and prophylaxis duration (1.5% vs 22%, P < 0.001), thereby demonstrating their effectiveness.

[Etanercept--infliximab switch in rheumatoid arthritis 14 out of 131 patients treated with anti TNFalpha]. / Switch étanercept--infliximab dans la polyarthrite rhumatoïde. 14 patients sur 132 traités par anti-TNFalpha.

OBJECTIVE: Patients with severe rheumatoid arthritis and resistant to at least three DMARDS can benefit from anti-TNFalpha (tumor necrosis factor) therapy. In some patients, because of inefficacy or adverse events, treatment with one of the two available TNFalpha drugs (etanercept and infliximab) must be stopped. In this study, we explored the results in efficacy and tolerance of switching from one anti-TNFalpha to the other. PATIENTS: Between August 1999 and January 2002, we administered one of the two anti TNFalpha drugs to 131 patients: 67 patients received infiximab and 64 etanercept. RESULTS: Among the 67 patients treated with infliximab, 17 patients had to stop treatment. In 8 of them (4 allergies, 2 infections and 2 non responders) the switch from infliximab to etanercept was beneficial for 5 patients, 2 patients did not respond and 1 patient withdrew for personal reasons. Among the 64 patients treated with etanercept, 13 had to stop treatment. In 6 of them (2 adverse events, 4 failures) the switch from etanercept to infliximab was beneficial for 3 patients, 2 did not respond and 1 withdrew because of adverse events. CONCLUSION: In all, 14 patients with severe rheumatoid arthritis and treated by one of the two TNFalpha drugs (and in whom treatment was stopped because of adverse events or inefficacy) benefited from the switch to the other anti- TNFalpha, with excellent response in 8 out of 14 patients.

How to organise antibiotic prescription.

In recent years, efforts have been made in hospitals to improve antibiotic prescription. Most universities organise courses on the subject, which lead to a local university diploma. However, possessing such a diploma does not give entitlement to prescribe. In fact, most doctors prescribe antibiotics and such courses are only of interest to volunteer physicians. While some are very careful, the majority prescribe the drugs as they are rarely toxic. Others are refractory to any information and particularly to any training. Two methods are typically proposed to reduce unjustified prescription. As a result of imposed restrictions, only trained doctors having met the training standards are allowed to prescribe and have to keep to a limited budget. The persuasive method, on the other hand, opens the way for a wide scope of training courses, which are provided by industry; some are said to be biased as they encourage prescription and the risk of selecting resistant mutant bacteria is scarcely documented. This method does not always coincide with the training curricula. The industry is torn between declared objectives such as judicious drug use and prevailing commercial aims. As a result, prescription is not restrained by any objective limit. It should be noted that prescription varies greatly from one hospital to another and within a given hospital between one department and another. Certain departments prescribe much more than others and these (emergency, medical and surgical intensive care, respiratory disease) should be targeted first.

Characterization of the nuclear import pathway for HIV-1 integrase.

The karyophilic properties of the human immunodeficiency virus, type I (HIV-1) pre-integration complex (PIC) allow the virus to infect non-dividing cells. To better understand the mechanisms responsible for nuclear translocation of the PIC, we investigated nuclear import of HIV-1 integrase (IN), a PIC-associated viral enzyme involved in the integration of the viral genome in the host cell DNA. Accumulation of HIV-1 IN into nuclei of digitonin-permeabilized cells does not result from passive diffusion but rather from an active transport that occurs through the nuclear pore complexes. HIV-1 IN is imported by a saturable mechanism, implying that a limiting cellular factor is responsible for this process. Although IN has been previously proposed to contain classical basic nuclear localization signals, we found that nuclear accumulation of IN does not involve karyopherins alpha, beta1, and beta2-mediated pathways. Neither the non-hydrolyzable GTP analog, guanosine 5'-O-(thiotriphosphate), nor the GTP hydrolysis-deficient Ran mutant, RanQ69L, significantly affects nuclear import of IN, which depends instead on ATP hydrolysis. Therefore these results support the idea that IN import is not mediated by members of the karyopherin beta family. More generally, in vitro nuclear import of IN does not require addition of cytosolic factors, suggesting that cellular factor(s) involved in this active but atypical pathway process probably remain associated with the nuclear compartment or the nuclear pore complexes from permeabilized cells.

[Systematic infection consultation in the intensive care unit. Impact of short-term antibiotic use]. / Consultation systématique d'infectiologie en réanimation médicale. Impact à court terme sur la consommation antibiotique.

OBJECTIVES: Multiresistant bacteria are regularly isolated in nosocomial infections occurring in intensive care units due to wide use of antibiotics. We evaluated the impact of systematic infectiology consultations on the quality of antibiotic prescriptions in an intensive care unit. PATIENTS AND METHODS: Infectiology consultations (3 per week) were initiated mid February 1999. The infectiologist gave oral advice to be implemented (or not) by the intensive care unit according to ongoing therapeutic options. The hospital pharmacy recorded antibiotic use for March and April 1999 for comparison with use recorded in 1998 for a similar period. We retrospectively reviewed the files of patients hospitalized during these periods and who had received antibiotics to determine the modalities of antibiotic use. The 4 antibiotics used for the longest period for each patient were recorded. RESULTS: Thirty-one patients in 1999 and 30 in 1998 were given antibiotics. The SAPS score was similar for the two groups. Mean duration of antibiotic treatment was lower during the March-April 1999 period than during the corresponding period in 1998: 13 +/- 9 days/patient versus 23 +/- 21 days/patient respectively, p = 0.037. In 1998, there were 596 antibiotic-days and in 1999 there were 455 (-24%). The cost of antibiotic therapy in 1998 was 70,342 FrF compared with 56,804 FrF in 1999 (-19%). CONCLUSION: Infectiology consultation, in association with the opinion of the intensive care physician, is a simple way to limit antibiotic use.

[Malaria attacks after returning from endemic areas. Failure or inadequate chemoprophylaxis?]. / Accès palustre au retour de zone d'endémie. Echec ou inadéquation de la chimioprophylaxie?

OBJECTIVE: Determine the causes of malaria attacks in subjects who have returned from endemic areas by assessing prescriptions for chemical prophylaxis and compliance. PATIENTS AND METHODS: All patients who developed a paroxysmal episode of malaria diagnosed at the University of Nice hospital in 1995 answered specific questions concerning their anti-malaria prophylaxis. RESULTS: Thirty-three patients were hospitalized for paroxysmal episodes of malaria in 1995. In 32 cases (97%) the attack resulted from either the lack of any prophylaxis (17 cases, 52%), inadequate prescription (11 cases, 12%) or poor compliance (4 cases, 12%). The prescribed chemical prophylaxis was not adapted to the chloroquinone-resistant area in 8 cases (24%) and medical recommendations concerning administration rules were inadequate in 3 cases (9%). Only one patient developed a paroxysmal episode despite correct compliance to a chloroquine-resistant zone-adapted well-conducted prescription. The cost of poor prophylaxis in terms of human suffering and financial cost was high for this preventable disease. Four patients had to be hospitalized in the intensive care unit and one died during hospitalization. The cumulative cost of hospitalization for these 33 cases was evaluated at 660,000 FF. CONCLUSION: Preventive measures for malaria must include better information for physicians on changing recommendations for chemical prophylaxis as well as better information for travelers provided by all those involved in organizing travel to endemic areas.