Serge Motte

Risk factors for septicemia following endoscopic biliary stenting

The purpose of this study was to identify patients who were more likely to experience septicemia after endoscopic biliary drainage. In an attempt to determine the relative importance of each risk factor and their possible interdependancy to more precisely identify high-risk patients and to deduce some guidelines for prevention, a discriminant regression analysis of risk factors for septicemia was used. Clinical, biological, and radiological data of 34 consecutive patients who experienced septicemia within 3 days after endoscopic biliary stenting were reviewed retrospectively and compared with data of a group of 71 patients without any septic complication. If only data available before the procedure were used in the discriminant analysis, prior cholangitis and leucocytosis appeared as significant risk factors, but the linear combination of these data could not predict septicemia in 50% of cases. When information concerning the quality of drainage after the procedure was introduced into the analysis, 91% of the septicemic patients were identified, and other expected risk factors such as the nature of the stricture, the type of drainage, or prior cholangitis and leukocytosis had no or marginal predictive values. Patients referred from centers where duodenoscopes might have been poorly disinfected appeared to be at higher risk for Pseudomonas aeruginosa septicemia. These results emphasize the crucial role of the quality of drainage as a risk for septicemia. Regarding the prevention of infection, it is concluded from this study that (a) pure diagnostic endoscopic retrograde cholangiopancreatography should be avoided in obstructed patients if drainage cannot be performed during the same procedure; (b) drainage should be as complete as possible; (c) antibiotics should be administered before ERCP to every patient with suspected obstructive jaundice and should cover P. aeruginosa if local epidemiological data suggest that there is a problem with disinfection of the endoscopes; and (d) the quality of drainage should guide the duration of antibiotic prophylaxis.

Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism

INTRODUCTION The Wells score is widely used in the assessment of pretest probability of pulmonary embolism (PE). The revised Geneva score is a fully standardized clinical decision rule that was recently validated and further simplified. We compared the predictive accuracy of these two scores. METHODS Data from 339 patients clinically suspected of PE from two prospective management studies were used and combined. Pretest probability of PE was assessed prospectively by the Wells score. The simplified revised (SR) Geneva score was calculated retrospectively. The predictive accuracy of both scores was compared by area under the curve (AUC) of receiver operating characteristic (ROC) curves. RESULTS The overall prevalence of PE was 19%. Prevalence of PE in the low, moderate and high pretest probability groups assessed by the Wells score and by the simplified revised Geneva score was respectively 2%(95% CI (CI) 1-6) and 4% (CI 2-10), 28% (CI 22-35) and 25% (CI 20-32), 93% (CI 70-99) and 56% (CI 27-81). The Wells score performed better than the simplified revised Geneva score in patients with a high suspicion of PE (p<0.05). The AUC for the Wells score and the simplified revised Geneva score was 0.85 (CI: 0.81 to 0.89) and 0.76 (CI: 0.71 to 0.80) respectively. The difference between the AUCs was statistically significant (p=0.005). CONCLUSIONS In our population the Wells score appeared to be more accurate than the simplified revised Geneva score. The impact of this finding in terms of patient outcomes should be investigated in a prospective study.

Vascular graft infection caused by Aspergillus species: case report and review of the literature.

We report an unusual case of vascular graft infection caused by Aspergillus fumigatus that began with a false aneurysm, major arterial emboli, and septic arthritis. Successful treatment included resection of the infected graft, restoration of circulation by extraanatomic bypass, and administration of amphotericin B and itraconazole, a new antifungal agent. Graft infection in the case reported herein most likely occurred during surgery and took place during an insidious outbreak of postoperative infection.

Accuracy and safety of pretest probability assessment of deep vein thrombosis by physicians in training using the explicit Wells clinical model.

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Occluding aortic endoluminal stent graft combined with extra-anatomic axillofemoral bypass as alternative management of abdominal aortic aneurysms for patients at high risk with complex anatomic features: a preliminary report.

PURPOSE To describe an exclusion endoluminal technique for management of abdominal aortic aneurysms among high-risk patients with complex anatomic features. METHODS From January 1995 to December 1996, among 143 patients with infrarenal abdominal aortic aneurysm treated by means of endograft placement, 9 (6.3%) had complex aortic or aortoiliac morphologic features. For these patients, the endograft was delivered through a femoral cutdown in an occluding aortoiliac configuration. The contralateral iliac artery was occluded with an iliac endograft. Axillofemoral bypass grafting was performed. Computed tomographic scans were obtained regularly. RESULTS There was 1 postoperative death of severe arrhythmia. All aneurysms were found to be affected by thrombosis on immediately postoperative computed tomographic scans, except in 1 patient with a proximal leak, which was managed successfully with angiographic embolization. The mean follow-up time was 12 months. Aortic aneurysm diameter decreased from 2 mm at 6 months (2 patients) to 6 mm at 12 months (6 patients). All axillofemoral bypass grafts are patent. CONCLUSIONS Placement of an occluding endograft associated with axillofemoral bypass grafting is a good alternative for patients at high risk with complex anatomic features. Longer-term follow-up study is needed to evaluate this endoluminal technique.

Prevention of postoperative venous thromboembolism. Risk assessment and methods of prophylaxis.

Purpose To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.Purpose: To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety. Source: Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses. Principal findings: The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events. Conclusion: Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding. Objectif : Decrire les modeles d’evaluation du risque developpes pour classer les patients selon differents niveaux de risque de thromboembolie veineuse postoperatoire (TEV) et ensuite, revoir les methodes de prophylaxie et ebaucher la preuve de leur efficacite et de leur securite.PurposeTo describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.SourceOur review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses.Principal findingsThe risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events.ConclusionAlthough risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.ObjectifDêcrire les modèles ďêvaluation du risque dêveloppês pour classer les patients selon diffêrents niveaux de risque de thromboembolie veineuse postopêratoire (TEV) et ensuite, revoir les mêthodes de prophylaxie et êbaucher la preuve de leur efficacitê et de leur sêcuritê.SourceNotre revue de la littêrature est centrêe sur des documents de consensus, de rêcentes grandes êtudes randomisêes et mêta-analyses.Constatations principalesLe risque de TEV dêpend du type de chirurgie et de facteurs sous-jacents reliês au patient. Les modèles ďêvaluation du risque sont utiles pour classer les patients selon diffêrents niveaux de risque de TEV. Cependant, de multiples facteurs de risque sont souvent prêsents chez le même patient et, en pratique, ľêvaluation de leur contribution relative au risque global demeure difficile. Diverses stratêgies prophylactiques, dont des mêthodes physiques et pharmacologiques, se sont rêvêlêes efficaces auprès de diffêrents groupes de patients. Les patients à risque modêrê ou êlevê de TEV devraient recevoir une thêrapie prêventive avec des antithrombotiques, à moins de contre-indication, utilisês seuls ou en combinaison avec une mêthode mêcanique. Les recommandations sur le choix de la prophylaxie à utiliser et sur son importance sont fondêes principalement sur les donnêes ďessais qui utilisent des paramètres indirects et ne se traduisent pas facilement en dêcisions pratiques visant à rêduire ľincidence ďêvênements symptomatiques.ConclusionMême si les modèles ďêvaluation du risque et les recommandations fournies par les documents de consensus sont pratiques, toute dêcision concernant un patient est plus juste si on combine recommandations de la littêrature et jugement clinique, comprenant les facteurs de risque individuels de thrombose et ďhêmorragie.

Nucleotide Receptors Coupling to the Phospholipase C Signaling Pathway

The earliest papers reporting a stimulatory effect of extracellular nucleotides on inositol phosphate formation were published in 1985–1987 (Charest et al., 1985; Horstman et al., 1986; Pirotton et al., 1987; Forsberg et al., 1987). Since then the number of organs and cells in which nucleotides have been shown to produce an accumulation of inositol phosphates has been growing. A list which is not claimed to be exhaustive is provided in Table 1. These actions are mediated by at least two distinct receptors, P2Y and P2U, which have been identified according to the rank order of potency of various natural and synthetic agonists and on the basis of cross-desensitization experiments. Basically, the P2Y receptor is characterized by the high potency of 2-Methylthio ATP (2MeSATP) and related agonists (Burnstock et al., 1994), similar potencies of adenosine triphosphate (ATP) and adenosine diphosphate (ADP) (the ratio being somewhat variable from one system to the other) and the lack of activity of UTP. It became apparent in the late eighties that, in many tissues and cells, not only ATP but also UTP is able to induce inositol phosphate formation. At that time it was proposed that the action of UTP is mediated by specific pyrimidinoceptors distinct from the purinoceptors (Seifert and Schultz, 1989). The existence of nucleotide or P2U receptors common to ATP and UTP constituted an alternative possibility, in favor of which experimental evidence started to accumulate: mainly the lack of additivity and the cross-desensitization of the responses to the two nucleotides (Brown et al., 1991; O’Connor et al., 1991; O’Connor, 1992).

Predictors of costs from the hospital perspective of primary pulmonary embolism

The objective of this study was to estimate the total hospital cost per patient admitted through the emergency department with a primary diagnosis of pulmonary embolism (PE), and to identify the main components and predictors of costs. Actual costs of care of 652 consecutive patients hospitalised in 10 general hospitals in Belgium, including 31 outlier patients in terms of length of stay (4.8%), were obtained by aggregating all cost components contributing to care of each patient. In both inlier and outlier patients, the mean total cost per patient increased linearly with the degree of severity of illness classes related to the All Patient Refined Diagnosis Related Group (p<0.0001). Medical procedures, nursing activities and hospitalisation accommodation were the main cost components. We identified six independent predictors of costs in inliers: age group, chronic pulmonary heart disease, heart failure, admission to intensive care unit, initial thrombolysis treatment and type of hospital. There was a statistically significant linear trend between age groups and costs (p<0.0001). An increasing burden of comorbid illness was strongly associated with increasing actual cost for caring hospitalised patients for PE. Increasing age was associated with an increase in all main cost components. Increased burden of comorbid illness is associated with increased cost of care for pulmonary embolism patients http://ow.ly/RSTPY

Vertebral arteriovenous fistula following central venous cannulation: a case report.

The authors report a case of vertebral arteriovenous fistula that has been disclosed three years after central venous cannulation (CVC). The real inci dence of this complication is discussed and various clinical presentations are enumerated. From a review of the literature, some recommendations are made to prevent the diagnosis from being missed and chiefly to reduce the risk of arterial puncture that results in fistula formation.

Management of venous thromboembolism.

Purpose To describe the drugs used to treat venous thromboembolism (VTE) and to review particular aspects of the management (elastic stockings, thrombolysis, thrombectomy, vena cava filter).PurposeTo describe the drugs used to treat venous thromboembolism (VTE) and to review particular aspects of the management (elastic stockings, thrombolysis, thrombectomy, vena cava filter).SourceOur review of the literature is focused on consensus documents and recent large randomized trials.Principal findingsSubcutaneous low molecular weight heparins (LMWH) have been shown to be both safe and effective for the initial treatment of VTE and have largely replaced unfractionated heparin, unless there is a contraindication to LMWH such as severe renal insufficiency. Low molecular weight heparins or unfractionated heparin are usually administered for five to seven days. Treatment is gradually switched from heparin to oral vitamin K antagonists (VKA) which are usually started the same day as heparin. The duration of oral anticoagulation must be tailored to the individual patient according to the presence of reversible or continuing risk factors. In patients with active cancer, long-term treatment of VTE with LMWH has been shown to be more effective than oral anticoagulation and is recommended for the first three to six months of long-term anticoagulant therapy as an alternative approach to VKA. Elastic stockings are recommended because they have been shown to prevent postthrombotic syndrome. Thrombolysis is, usually, not justified for the treatment of deep venous thrombosis, but is used in cases of massive pulmonary embolism with arterial hypotension and/or shock. Vena cava filter placement is mainly indicated in patients with a proximal deep venous thrombosis and an absolute contraindication to anticoagulation.ConclusionsThe initial management of patients with acute VTE has largely been simplified due to the use of LMWH. Early conversion to VKA is recommended for the great majority of patients. New agents, such as anti-Xa or oral thrombin inhibitors, are promising alternatives to heparins or VKA.ObjectifPrésenter les médicaments utilisés pour traiter la maladie thromboembolique veineuse (MTEV) et revoir des aspects particuliers de la thérapie comme les bas élastiques, la thrombolyse, la thrombectomie et le filtre cave.SourceRevue de documents de consensus et de grandes études récentes.Constatations principalesLes héparines de bas poids moléculaire (HBPM) sont sûres et efficaces comme traitement initial de la MTEV et remplacent largement ľhéparine non fractionnée, à moins ďune contre-indication à ľHBPM comme ľinsuffisance rénale sévère. Les HBPM ou ľhéparine non fractionnée sont habituellement administrées pendant cinq à sept jours. Puis, on passe graduellement de ľhéparine à la prise orale ďantagonistes de la vitamine K (AVK), débutés en général le même jour que ľhéparine. La durée de ľanticoagulation orale doit être adaptée au patient en fonction de facteurs de risque réversible ou continu. Dans les cas de cancer actif, le traitement de la MTEV avec ľHBPM s’est montré plus efficace que ľanticoagulation orale et il est recommandé pour les trois à six premiers mois de traitement. Les bas élastiques sont recommandés pour prévenir le syndrome post-thrombotique. La thrombolyse n’est pas habituellement justifiée pour traiter la thrombose veineuse profonde, mais est utilisée en cas ďembolie pulmonaire massive avec hypotension et/ou choc artériels. La mise en place ďun filtre cave est principalement indiquée chez les patients souffrant de thrombose veineuse profonde proximale chez qui ľanticoagulation est une contre-indication absolue.ConclusionLe traitement initial des patients atteints de MTEV a été grandement simplifié avec ľusage de ľHBPM. Le passage précoce aux AVK est recommandé pour la grande majorité des patients. De nouveaux médicaments comme les anti-Xa ou les inhibiteurs de la thrombine oraux, sont des équivalents prometteurs des héparines ou des AVK.