Vanessa Pauly

Long-term outcome in medical patients aged 80 or over following admission to an intensive care unit

IntroductionThe aim of this study was to evaluate factors influencing short- and long-term survival in medical patients aged 80 and over following admission to an intensive care unit.MethodsAll patients aged 80 years or over and admitted between 2001 and 2006 were included in this study. Survival was evaluated between the time of admission and June 2009; factors associated with mortality were determined. Health-related quality of life was evaluated using Short Form (SF)-36 in long-term survivors.ResultsFor the 299 patients included (mean age, 84 ± 4 y), hospital mortality was 55%. Factors independently associated with hospital mortality were a higher SAPS II score at ICU admission; the existence of a fatal disease as reflected by the McCabe score and a cardiac diagnosis at admission. In the 133 hospital survivors, median survival time was 710 days (95% CI, 499-921). Two-year mortality rates were 79% of the initial cohort and 53% of hospital survivors. The standardized ratio of mortality at 2 years after hospital discharge was 2.56 (95% CI, 2.08-3.12) when compared with age- and gender-adjusted mortality of the general population. Factors independently associated with mortality at 2 years after hospital discharge were SAPS II score at ICU admission and the McCabe score. Conversely, functional status prior to admission as assessed by Knaus or Karnofsky scores was not associated with long-term mortality. In long-term survivors, SF-36 physical function scores were poor but scores for pain, emotional well-being and social function were not much affected.ConclusionsThe severity of acute disease at admission influences mortality at the hospital and following discharge in patients aged 80 or over. Although up to 50% of patients discharged from the hospital were still alive at 2 years, mortality was increased when compared with the general population. Physical function of long-term hospital survivors was greatly altered.

Active cytomegalovirus infection is common in mechanically ventilated medical intensive care unit patients.

Objective:To assess the incidence, risk factors, and outcome of active cytomegalovirus (CMV) infection in nonimmunosuppressed intensive care unit (ICU) patients. Design:Prospective epidemiologic study. Setting:A medical ICU in a university hospital. Patients:Two hundred forty-two nonimmunosuppressed ICU patients mechanically ventilated for ≥2 days. Interventions:Routine pp65 antigenemia and serology for CMV were performed at admission, and then weekly. Bronchoalveolar lavage viral cultures were done when pneumonia was suspected. Measurements and Main Results:Thirty-nine of the 242 ICU patients (16.1%, confidence interval 11.5% to 20.7%) developed an active CMV infection, as diagnosed by positive antigenemia (85%) and/or positive rapid viral culture in bronchoalveolar lavage (26%). Antiviral treatment was initiated in 21 (54%) patients. ICU mortality (54% vs. 37%, p = 0.082) and in-hospital mortality (59% vs. 41%, p = 0.058) were increased in patients with active CMV infection, as compared with those without active CMV infection. Active CMV infection and Simplified Acute Physiology Score II at admission were associated with ICU death on multivariate analysis. The patients with active CMV infection had longer mechanical ventilation and longer ICU stay and were significantly more prone to developing bacterial nosocomial infections (p < 0.001). Logistic regression analysis showed that prior admission to other wards (p = 0.043; odds ratio [OR], 2.49), blood transfusions (p = 0.04; OR, 3.31), enteral feeding (p = 0.005; OR, 3.00), recent corticosteroid use before ICU admission (p = 0.08; OR, 2.26), and age (p = 0.07; OR, 1.026) were associated with the occurrence of active CMV infection. Conclusions:Active CMV infection is common among previously healthy patients under mechanical ventilation in a medical ICU. Further studies are needed to evaluate the role of antiviral treatments to reduce both the incidence and the outcome impact of active CMV infection.

Pelvic tilt measurement before and after total hip arthroplasty.

INTRODUCTION Most computer-assisted navigation systems used in total hip arthroplasty (THA) reference the anterior pelvic plane, which connects the anterior superior iliac spines and the pubic symphysis. The pelvic tilt is defined as the angle between this anterior pelvic plane (APP) and a vertical line in the standing position. Important interindividual variations of this angle have been reported and may affect final functional anteversion of the acetabular cup. The preoperative value of the pelvic tilt has been included in computer-assisted navigation systems to improve acetabular cup positioning. However, there is no data available which strongly confirms the consistency of this angle for each individual after hip prosthesis implantation. HYPOTHESIS The orientation of the APP in the standing position is not significantly modified after THA. OBJECTIVES To evaluate in a prospective manner, the reproducibility of pelvic tilt measurement and its variability between THA preoperative and 3-year postoperative measurements. MATERIALS AND METHODS A lateral teleradiograph of the pelvis and dorsolumbar spine was obtained in the standing position preoperatively and 3 years after THA. Fifty patients undergoing THA performed by a single operator via an anterolateral approach (26 males and 24 females) were included prospectively. The pelvic tilt was measured on radiographs by two independent observers. The angle was defined as positive in case of pelvis retroversion relative to the vertical plane and negative in case of anteversion. Bland-Altman analysis was used to assess levels of agreement between both operator measurements while preoperative and last follow-up measurements were compared using the Student t-test for unpaired samples. RESULTS The level of agreement between measurements of both operators was satisfactory. Mean preoperative pelvic tilt was 4.68 degrees +/-0.68 S.D. (-6 degrees to 14 degrees), and 4.78 degrees +/-0.64 S.D. (-5 degrees to 14 degrees) at last follow-up. The mean difference between preoperative and last follow-up measurements was 3 degrees +/-0.3 S.D. There was no statistically significant variation between preoperative and 3-year follow-up values (p>0.05). Ninety-five percent of the patients had less than a 5 degrees difference between both measurements while 5% had a difference ranging from 5 degrees to 10 degrees ; none of the patients reported a variation greater than 10 degrees . DISCUSSION Our findings show no significant variation in pelvic tilt between preoperative and 3-year follow-up values after THA. Therefore, the individual preoperative value of this angle should be integrated to achieve proper acetabular cup placement during THA especially when using computed assisted navigation based on the APP.

Sonography of the painful shoulder: role of the operator's experience

ObjectiveThe aim of our study was to determine the role of the operator’s experience in the sonographic evaluation of the painful shoulder and to validate assumptions about its technical performance in routine practice.Materials and methodsTwo radiologists, respectively standard and expert sonographic operators, independently and prospectively scanned 65 patients with clinical suspicion of rotator cuff lesion. Magnetic resonance arthrography was the reference standard.ResultsThe sensitivity of the expert ultrasound operator was 95.3% for full-thickness rotator cuff tears (41/43), 70.6% for partial-thickness tears (12/17), 64.3% for intratendinous tears (9/14), 100% for abnormality of the long head of biceps tendon (seven of seven), 88.9% for supraspinatus tendinosis (16/18), 96.4% for subacromial bursa abnormalities (53/55), and 91.7% for acromioclavicular joint osteoarthritis (33/36). The two sonographic operators were in very good agreement about full-thickness rotator cuff tears (κ = 0.90), supraspinatus tendinosis (κ = 0.80), abnormalities of the long head of biceps tendon (κ = 0.84), subacromial bursa abnormalities (κ = 0.89), and acromioclavicular osteoarthritis (κ = 0.81). The agreement was only moderate for partial-thickness tears (κ = 0.63) and intratendinous tears (κ = 0.57).ConclusionsOur results show that in moderately experienced hands as in experts’ hands, sonography has a low level of interobserver variability for full-thickness rotator cuff tears. Considering partial-thickness and intratendinous rotator cuff tears, our data suggest that interobserver variability is higher.

Function and quality of life following medial unicompartmental knee arthroplasty in patients 60 years of age or younger

INTRODUCTION UKA is an appropriate bone-sparing solution for focal advanced knee osteoarthritis in young patients. As the expectations of patients younger than 60 years of age are different from those in an older population, we aimed to evaluate quality of life and the quality of sports activity after UKA in this population. PATIENTS AND METHODS Sixty-five UKAs in 62 patients younger than 60 (mean age: 54.7 years; mean BMI: 28 kg/m(2)) performed between 1989 and 2006 were included. At last follow-up (minimum 2 years), before the objective evaluation, patients were asked to fill in a KOOS questionnaire and a specific sports questionnaire including the UCLA score and questions from the Mohtadi score. RESULTS With a mean follow-up of 11.2±5 years (range, 2-19 years), the KOOS score was higher than 75 points in 90% of the patients for the quality-of-life categories but also for the scores four other categories: 83.4% of the patients had resumed their sports activities and the mean UCLA score was 6.8 (range, 4-9); 90% of the patients reported no or slight limitation during sports activities. The function KSS improved from 52±4 to 95±3 points postoperatively and the Knee KSS from 50±4 to 94±4 points. With three patients undergoing revision for an isolated insert exchange, one for septic loosening and three for osteoarthritis in the external compartment, the 12-year Kaplan-Meier survivorship was 94%. DISCUSSION AND CONCLUSION These results confirmed that UKA can provide good patient-rated outcomes, which is very important in this demanding population. As for TKA, wear remains a problem in this active population. LEVEL OF EVIDENCE Therapeutic study, level IV.

Clinical significance of a positive serology for mimivirus in patients presenting a suspicion of ventilator-associated pneumonia.

Objective:A seroconversion to mimivirus has been observed in patients with community-acquired or nosocomial pneumonia. The aim of this study was to determine whether a positive serology for mimivirus was associated with increased morbidity and mortality in patients with a suspicion of ventilator-associated pneumonia (VAP). Design:Prospective matched-cohort study. Setting:A 12-bed medical intensive care unit (ICU) in a teaching hospital. Patients:Patients ventilated for at least 2 days presenting with a suspicion of VAP. Patients with a positive serology for mimivirus were matched to seronegative patients. Interventions:None. Measurements and Main Results:Matching criteria were: 1) the same main diagnosis on ICU admission, 2) the same age (± 10 yrs), 3) the same Simplified Acute Physiology II score (±10 points), 4) the same McCabe and Jackson comorbidity score, 5) admission within 1 year, and 6) diagnosis of at least one bacterial VAP during the ICU stay or not. A total of 55 pairs were submitted for analysis. The effectiveness of matching was 94.8%. Patients with a positive serology for mimivirus had longer duration of mechanical ventilation and ICU stay with median excesses of 7 days and 10 days, respectively. There was no difference in ICU mortality. The duration of mechanical ventilation before bronchoalveolar lavage (adjusted odds ratios [OR]1.08, p = 0.02), viral identification other than mimivirus during ICU stay (adjusted OR 0.32, p = 0.05), and enteral nutrition (adjusted OR 0.13, p = 0.01) were associated with positive serology for mimivirus. Conclusion:A positive serology for mimivirus is associated with a poorer outcome in mechanically ventilated ICU patients.

Patterns of methylphenidate use and assessment of its abuse and diversion in two French administrative areas using a proxy of deviant behaviour determined from a reimbursement database: main trends from 2005 to 2008.

AbstractBackground: Methylphenidate is a psychostimulant drug indicated for the treatment of attention-deficit hyperactivity disorder (ADHD). Its abuse and diversion have been previously described in specific populations, such as students; however, few studies investigating abuse and diversion among the overall population are available. Objectives: The aim of this study was to describe patterns of methylphenidate use and to explore the magnitude of its abuse and diversion in two French administrative areas using data from a reimbursement database. A proxy of ‘deviant behaviour’ was used for the abuse and diversion of methylphenidate, defined using the following parameters: total number of defined daily doses (DDDs) of methylphenidate dispensed; number of different pharmacies seen for dispensing of methylphenidate; number of prescribers consulted for a prescription of methylphenidate; and number of dispensings of methylphenidate. Data from the reimbursement database were analysed by clustering methods. These data were assessed from 2005 to 2008. Method: The French General Health Insurance System (GHIS) database was used to obtain data on methylphenidate use in two French administrative areas. Individuals affiliated to the GHIS who had a prescription for methylphenidate reimbursed between 1 January and 31 March of 4 selected years (2005, 2006, 2007 and 2008) were included. After the first dispensing of methylphenidate for these individuals, all their dispensings (including methylphenidate and other psychoactive drugs) were monitored over a 9-month period. Following a descriptive analysis, a clustering method was used to identify different subgroups of subjects according to the methylphenidate consumer profile characteristics. Results: With regard to the number of patients who had a dispensing for methylphenidate during the first quarter of the year, an 84% increase was observed between 2005 (n = 640) and 2008 (n= 1175). The clustering method identified two subgroups. One of them was characterized by a higher number of dispensings, different prescribers and pharmacies and a greater total dispensed quantity, suggesting a deviant behaviour and, thus, possible abuse and diversion of methylphenidate. These subjects were older (aged 35.4 ± 11.3 years) and were more frequently patients receiving benzodiazepines, antidepressants, antipsychotics and maintenance opioid treatment. The proportion of subjects with a deviant behaviour increased from 0.5% in 2005 to 2% in 2007 and then decreased to 1.2% in 2008. Conclusion: This method was able to assess the magnitude of methylphenidate abuse liability and to follow its evolution. The decrease in methylphenidate abuse and diversion seen between 2007 and 2008 can be explained by the enactment in April 2008 of specific regulations for prescription drugs (such as methylphenidate) that are deemed by the French government to have the potential for misuse; these regulations require the establishment of a ‘contract of care’ between the GHIS, prescriber and patient.

Hypoxia inducible factor 1α gene (HIF-1α) splice variants: potential prognostic biomarkers in breast cancer

BackgroundHypoxia-inducible factor 1 (HIF-1) is a master transcriptional regulator of genes regulating oxygen homeostasis. The HIF-1 protein is composed of two HIF-1α and HIF-1β/aryl hydrocarbon receptor nuclear translocator (ARNT) subunits. The prognostic relevance of HIF-1α protein overexpression has been shown in breast cancer. The impact of HIF-1α alternative splice variant expression on breast cancer prognosis in terms of metastasis risk is not well known.MethodsUsing real-time quantitative reverse transcription PCR assays, we measured mRNA concentrations of total HIF-1α and 4 variants in breast tissue specimens in a series of 29 normal tissues or benign lesions (normal/benign) and 53 primary carcinomas. In breast cancers HIF-1α splice variant levels were compared to clinicopathological parameters including tumour microvessel density and metastasis-free survival.ResultsHIF-1α isoforms containing a three base pairs TAG insertion between exon 1 and exon 2 (designated HIF-1αTAG) and HIF-1α736mRNAs were found expressed at higher levels in oestrogen receptor (OR)-negative carcinomas compared to normal/benign tissues (P = 0.009 and P = 0.004 respectively). In breast carcinoma specimens, lymph node status was significantly associated with HIF-1αTAGmRNA levels (P = 0.037). Significant statistical association was found between tumour grade and HIF-1αTAG(P = 0.048), and total HIF-1α (P = 0.048) mRNA levels. HIF-1αTAGmRNA levels were also inversely correlated with both oestrogen and progesterone receptor status (P = 0.005 and P = 0.033 respectively). Univariate analysis showed that high HIF-1αTAGmRNA levels correlated with shortened metastasis free survival (P = 0.01).ConclusionsOur results show for the first time that mRNA expression of a HIF-1αTAGsplice variant reflects a stage of breast cancer progression and is associated with a worse prognosis.See commentary: http://www.biomedcentral.com/1741-7015/8/45

Which psychoactive prescription drugs are illegally obtained and through which ways of acquisition? About OPPIDUM survey.

The objective of the study was to determine which psychoactive prescription drugs are illegally obtained and through which ways of acquisition. OPPIDUM is an annual national study. It is based on specialized care centers that included subjects presenting a drug dependency or under opiate maintenance treatment. All their psychoactive substances consumed are reported. This work focuses on the different ways of acquisition specially the illegal ways of acquisition (bought on the street, forged prescription, stolen, given, internet). For each medication illegally obtained, a ratio has been calculated (number of illegal acquisitions divided by the number of described acquisitions). In 2008, 5542 subjects have been included and have described the consumption of 11 027 substances including 63.8% of prescription drugs. Among them, 11% were illegally obtained. The different illegal acquisition ways were ‘street market’ (77.6%), ‘gift’ (16.6%), ‘theft’ (2.3%), ‘forged prescription’ (2.3%), and ‘internet’ (0.7%). The third first drugs illegally obtained were high dosage buprenorphine, methadone, and clonazepam. Some prescription drugs, less consumed, have an important ratio of illegal acquisition like ketamine, flunitrazepam, morphine, trihexyphenidyl, or methylphenidate. This study confirms that theft, forged prescription and internet are few used and permits to highlight diversion of prescription drugs. It is important to inform healthcare professionals on the different prescription drugs that are illegally obtained.

Preoperative Imaging of Anterior Shoulder Instability: Diagnostic Effectiveness of MDCT Arthrography and Comparison With MR Arthrography and Arthroscopy

OBJECTIVE The purpose of this article is to assess the diagnostic effectiveness of MDCT arthrography in the preoperative planning of anterior shoulder instability compared with MR arthrography and arthroscopy. SUBJECTS AND METHODS Shoulder MDCT arthrography and MR arthrography examinations prospectively performed in 40 consecutive patients (30 male and 10 female patients; mean age, 26 years) were independently evaluated by two musculoskeletal radiologists who were blinded to the arthroscopic findings, which represented the reference standard. Sensitivity, specificity, and agreement with arthroscopy were determined for osseous, cartilage, and labroligamentous injuries. RESULTS In detecting glenoid rim fractures, MDCT arthrography had a sensitivity of 100% (12/12), a specificity of 96% (27/28), and better agreement with surgery (κ = 0.94) than did MR arthrography (κ = 0.74). For the depiction of glenoid cartilage lesions, MDCT arthrography had a sensitivity of 82% (18/22), a specificity of 89% (16/18), and slightly better agreement with surgery (κ = 0.70) than did MR arthrography (κ = 0.66). In identifying anterior labral periosteal sleeve avulsion lesions, MDCT arthrography had a sensitivity of 93% (26/28), a specificity of 100% (12/12), and better agreement with surgery (κ = 0.89) than did MR arthrography (κ = 0.74). For the diagnosis of humeral avulsion of the inferior glenohumeral ligament lesions, MDCT arthrography had a sensitivity and a specificity of 100% (2/2) and better agreement with surgery (κ = 1) than did MR arthrography (κ = 0.79). CONCLUSION MDCT arthrography showed better accuracy than did MR arthrography in the detection of osseous, cartilage, and labroligamentous injuries related to anterior shoulder instability. Because MDCT arthrography was particularly reliable for the detection of glenoid rim fractures and humeral avulsion of the inferior glenohumeral ligament lesions, which represent crucial findings in the preoperative planning, this technique may beneficially affect treatment by means of selecting the proper surgical treatment.