Bernard Vermeulen

Serum profiles of interleukin-6, interleukin-8, and interleukin-10 in patients with severe and mild acute pancreatitis

Excessive leukocyte activation has been proposed as a key mechanism in the onset of acute pancreatitis. In this study, we assessed the systemic release of various inflammatory mediators and tried to identify differences between patients with mild and severe disease. In a prospective study, 19 patients admitted for severe acute pancreatitis were compared with 24 patients with mild pancreatitis. Serum levels of interleukin-6 (IL-6), IL-8, and IL-10 were determined at the time of admission, and on days 1, 2, and 5 after hospitalization. Severity of pancreatitis was determined according to the Atlanta criteria. IL-6 levels peaked on admission in both groups with significant differences (p < 0.05) from days 0-2. IL-8 levels increased from day 0 in severe cases, and from day 1 in mild cases, to reach a plateau between days 2 and 5; significant differences were observed on days 0 and 1. IL-10 was highest on day 0; it decreased rapidly in mild cases but stayed significantly higher from days 1 to 5 in severe cases. These findings provide new evidence on the role of mediators of the inflammatory/antiinflammatory balance in acute pancreatitis. These molecules appear to be valuable early markers of severity.

IV N-Acetylcysteine and Emergency CT: Use of Serum Creatinine and Cystatin C as Markers of Radiocontrast Nephrotoxicity

OBJECTIVE The purpose of this study was to assess the effect of i.v. administration of N-acetylcysteine (NAC) on serum levels of creatinine and cystatin C, two markers of renal function, in patients with renal insufficiency who undergo emergency contrast-enhanced CT. SUBJECTS AND METHODS Eighty-seven adult patients with renal insufficiency who underwent emergency CT were randomized to two groups. In the first group, in addition to hydration, patients received a 900-mg injection of NAC 1 hour before and another immediately after injection of iodine contrast medium. Patients in the second group received hydration only. Serum levels of creatinine and cystatin C were measured at admission and on days 2 and 4 after CT. Nephrotoxicity was defined as a 25% or greater increase in serum creatinine or cystatin C concentration from baseline value. RESULTS A 25% or greater increase in serum creatinine concentration was found in nine (21%) of 43 patients in the control group and in two (5%) of 44 patients in the NAC group (p = 0.026). A 25% or greater increase in serum cystatin C concentration was found in nine (22%) of 40 patients in the control group and in seven (17%) of 41 patients in the NAC group (p = 0.59). CONCLUSION On the basis of serum creatinine concentration only, i.v. administration of NAC appears protective against the nephrotoxicity of contrast medium. No effect is found when serum cystatin C concentration is used to assess renal function. The effect of NAC on serum creatinine level remains unclear and may not be related to a renoprotective action.

Prehospital Stabilization of Pelvic Dislocations: A New Strap Belt to Provide Temporary Hemodynamic Stabilization

High energy pelvic fractures or dislocations are associated with a high rate of early complications, due to the associated intrapelvic organs. The high rate of early mortality is mostly due to the intrapelvic, retroperitoneal bleeding caused by the laceration of vascular structures located in the presacral area. External compression of the pelvic ring, using such devices as PASG or external fixators may prevent the intrapelvic collection of large hematomas by providing indirect tamponade. Unfortunately, these devices are either unavailable on the accident site, or the complexity of their handling is discouraging for the primary care-taker. A simple system of external pelvic compression which could be applied on the scene of trauma consisting of a pelvic strap-belt was therefore developed. The application of the device is easy, quick (30 seconds) and straightforward. Its use does not induce any known complications and requires minimal training. The cost and transportability of the system are further advantages. The system has already been used in 19 patients equipped on accident scene. Our first experiences using this device are reviewed.

Effect of teaching context and tutor workshop on tutorial skills

Effective faculty development workshops are essential to develop and sustain the quality of facultys teaching. In an integrated problem-based curriculum, tutors expressed the needs to further develop their skills in facilitating students’ content learning and small-group functioning. Based on the authors’ prior observations that tutors’ performance depends on their teaching context, a workshop was designed not only tailored to the tutors’ needs but also organized within their respective teaching unit. The purposes of this study are (1) to evaluate whether this workshop is effective and improves tutors’ teaching skills, and (2) to assess whether workshop effectiveness depends on tutors’ performance before the workshop and on their teaching unit environment. Workshop effectiveness was assessed using (a) tutors’ perception of workshop usefulness and of their improvement in tutorial skills, and (b) students’ ratings of tutor performance before and after the workshop. In addition, an analysis of variance model was designed to analyse how tutors’ performance before the workshop and their teaching unit influence workshop effectiveness. Tutors judged the workshop as helpful in providing them with new teaching strategies and reported having improved their tutorial skills. Workshop attendance enhanced students’ ratings of tutors’ knowledge of problem content and ability to guide their learning. This improvement was also long-lasting. The workshop effect on tutor performance was relative: it varied across teaching units and was higher for tutors with low scores before the workshop. A workshop tailored to tutors’ needs and adapted to their teaching unit improves their tutorial skills. Its effectiveness is, however, influenced by tutors’ level of performance before the workshop and by the environment of their teaching unit. Thus, to be efficient, the design of a workshop should consider not only individual tutors’ needs, but also the background of their teaching units, with special attention to their internal organization and tutor group functioning.

Treatment of gastrointestinal hemorrhage

BackgroundWe assessed the value of selective arteriography in the diagnosis and management of acute gastrointestinal hemorrhage.MethodsWe reviewed the records of 107 consecutive patients who had gastrointestinal hemorrhage and underwent selective arteriography between January 1992 and October 2003: 10 had upper gastrointestinal bleeding, 79 had lower gastrointestinal bleeding, and 18 had varicose bleeding with portal hypertension. Selective embolization was attempted in 15 patients to obtain hemostasis. Angiographic findings were reviewed and prospective reports were compared with the final diagnosis and outcome.ResultsOf 129 angiographic studies, 36 correctly revealed the bleeding site and 93 were negative. Extravasation was seen in 24 cases at the level of stomach (n = 2), duodenum (n = 1), small bowel (n = 5), or colon (n = 16). Indirect signs of bleeding sources were identified in 12 patients (stomach in one, small bowel in four, large bowel in four, liver in three). Transcatheter embolization induced definitive hemostasis in 11 of 15 patients (73%), namely in the stomach (n = 2), small bowel (n = 3), colon (n = 7), and liver (n = 3). Three patients required surgery after embolization.ConclusionAbdominal arteriography may localize gastrointestinal bleeding sources in approximately one-third of cases. Selective embolization may provide definitive hemostasis in most instances.

A new optical method for the non-invasive detection of minimal tissue alterations

Histological analysis, which is used to detect and diagnose most tissue alterations, requires an invasive biopsy procedure and a time-consuming tissue treatment, which limit its efficiency in providing rapid, cost-effective diagnosis and hinder the longitudinal study of tissue alteration. To address these limitations, we have developed a novel procedure, using the features of elastic-scattering spectroscopy, for a real-time, non-invasive analysis of tissues. We have tested whether this approach can detect in vivo changes in mouse skin induced by a single exposure to either complete Freunds adjuvant or 12-O-tetradecanoylphorbol-13-acetate, two drugs known to induce discrete alterations of epidermis and dermis, without obvious changes on the skin surface. Here we report that the evaluation of localized absorption and reduced scattering coefficients permitted the detection of changes in skin regions that showed histological alterations, but not in regions which failed to be modified by the drugs. Results show that the optical in vivo analysis of small regions has sufficient specificity and sensitivity to detect minimal alterations of superficial tissues. In view of the prominent involvement of mucosal alterations in most human diseases, including carcinomas, the method provides a useful complement to standard biopsy, notably for the in vivo screening of early in situ epithelial alterations.

The New Preclinical Medical Curriculum at the University of Geneva: Processes of Selecting Basic Medical Concepts and Problems for the PBL Learning Units

On October 1995, the medical faculty of the University of Geneva has started a new second and third years preclinical curriculum. It consists of 16 integrated “Problem-Based Learning (PBL) Units”. The first “Introduction” Unit of 2 weeks is aimed at introducing students with the PBL technique. Eleven PBL Units each of one month duration, comprise of 7 to 8 problems with themes related to important body functions or organ. Finally 4 Synthesis Units, each of 2 weeks duration, and following 2 to 3 PBL Units, comprise 4 problems aimed at integrating concepts common to preceding Units. The elaboration of such a new PBL curriculum requires to address two main issues, namely 1) how to select the important basic medical concepts and relevant problems leading to the learning objectives of each learning Unit and 2) how to verify the quality and relevance of the designed problems. This paper is aimed mainly at describing the steps followed in Geneva to solve these issues. First, it will present the process of selecting the basic science concepts, designing the problems and establishing their sequence. Second, it will describe the process of verifying whether problems fit to the identified concepts, lead to learning objectives and reach the appropriate level of learning for the students.

Prise en charge des fractures du bassin associées a une plaie périnéale

Unstable fractures of the pelvic ring, associated to perineal lacerations are severe injuries occurring during high-energy trauma. High rates of septic complications and mortality have been reported with these injuries. Current treatment guidelines, while dealing with open pelvic fractures or dislocations are discussed, based on a current review of the literature and on our local experience. At our institution, 55 unstable type B or C fractures of the pelvic ring were treated by osteosynthesis between 1991 and 1997. Of these, 11 patients presented with an associated perineal laceration (20%). Simultaneously to the immediate pelvic ring fixation, a diversion colostomy was performed in all these patients. Repeated wound debridements and wide spectrum antibioprophylaxis were associated. Of these 11 patients presenting an open pelvic fracture, only one died of pelvic sepsis at three weeks. 10 patients survived (91%) and went on to bony union, without any local infectious complications. Aggressive multidisciplinary initial surgical management is a rule when dealing with this type of injuries, immediate colostomy and careful wound debridement must be associated to the initial osteosynthesis.Unstable fractures of the pelvic ring, associated to perineal lacerations are severe injuries occurring during high-energy trauma. High rates of septic complications and mortality have been reported with these injuries. Current treatment guidelines, while dealing with open pelvic fractures or dislocations are discussed, based on a current review of the literature and on our local experience. At our institution, 55 unstable type B or C fractures of the pelvic ring were treated by osteosynthesis between 1991 and 1997. Of these, 11 patients presented with an associated perineal laceration (20%). Simultaneously to the immediate pelvic ring fixation, a diversion colostomy was performed in all these patients. Repeated wound debridements and wide spectrum antibioprophylaxis were associated. Of these 11 patients presenting an open pelvic fracture, only one died of pelvic sepsis at three weeks. 10 patients survived (91%) and went on to bony union, without any local infectious complications. Aggressive multidisciplinary initial surgical management is a rule when dealing with this type of injuries, immediate colostomy and careful wound debridement must be associated to the initial osteosynthesis.

Diagnosis and grading of gastritis by non-invasive optical analysis

Objectives The precise identification of many diseases of the gastrointestinal tract requires the histological analysis of multiple biopsies of the lining mucosae, thus preventing an immediate diagnosis and the safe screening of the entire organ. To address these limitations, we developed a novel spectroscopic procedure for a real-time, non-invasive optical analysis of mucosae. Methods We have used a fibre-optic probe that monitors light propagation through small tissue volumes to evaluate the antral and fundic mucosa of 51 patients that underwent gastroscopy for symptoms of dyspepsia. Several optical coefficients were computed from the recorded light reflectance, and confronted to the diagnosis made by an expert gastroscopist at the time of the clinical examination. Both evaluations were then validated by comparison with the histological diagnosis of a pathologist who screened biopsies taken at the sites of the optical measurements. Results We report that the optical procedure discriminated normal and pathological gastric mucosae with a higher sensitivity and specificity than endoscopic diagnosis. We also show that the changes in light-scattering coefficient, which permitted the optical diagnosis of gastritis alterations, were indirectly correlated with the extent of inflammatory infiltration of the mucosa and detected mucosal alterations mild enough to escape endoscopic detection. Conclusions The results show that, in a normal clinical setting, the optical in vivo analysis provided by our system detects alterations typical of gastritis, and allow for their graded scoring with a specificity and sensitivity that compare well with those of standard histology, while avoiding the invasiveness of the latter procedure. The method is adaptable to the screening of other types of lesions and mucosae and, hence, should prove useful in improving available diagnostic approaches.