Emphysematous pyelonephritis with favourable outcome after conservative treatment

Emphysematous pyelonephritis is a necrotizing renal infection characterized by bacterial gas production in the renal and perirenal area. It is a rare infection diagnosed in diabetic patients in most cases. Emphysematous pyelonephritis is responsible for a high mortality rate. We report the case of a woman, unknown diabetic, who presented with emphysematous pyelonephritis. Early diagnosis performed by CT-scan allowed effective and conservative surgical treatment and final positive outcome.     

Impact of the law of the 4 March 2002 relative to patients' rights on request for medical information received in a medical dispatching center and mobile intensive care unit (Samu 93)

INTRODUCTION: Law of the 4 March 2002 allowed patient's access to his medical record. This law could increase the number of requests in medical dispatching centers and prehospital intensive care units. OBJECTIVE: The aim of this study was to evaluate the impact of this law on the number of requests for medical information received in our unit. METHODS: Since the promulgation of the law, from March to December 2002, medical requests were prospectively collected and classified in categories including request for transmission of medical record. Requests received before the law, from January 2000 to February 2002 were classified according to the same items. Number of requests received during the two periods were compared according to the total number of medical record managed in our medical dispatching center and prehospital intensive care unit. RESULTS: The total number of requests for medical information significantly increased since the law of March 2002 (results are expressed as cases per month per 10 000 record: 4.8 +/- 2.5 vs. 8.0 +/- 4.5; p = 0.04). Specific request for transmissions of medical record significantly increased since the law (1.3 +/- 1.6 vs. 3.0 +/- 3.0; P = 0.046). This increase was progressive and constant since March 2002. DISCUSSION: Physicians and patients should take in consideration consequences of this law. Physician should be vigilant with the quality of their medical dossiers. Interpretation of this law and its ethics consequences will probably be discussed again as one should not exclude perverse impact of this law. In effect, insurances and mutual insurances companies could find in this law a way to obtain medical information, such as circumstances of death, previously unavailable. CONCLUSION: The law of 4 March 2002 relative to patients' rights significantly increased number of requests for medical information received in our dispatching center and prehospital intensive care unit.     

Alcoholic povidone-iodine to prevent central venous catheter colonization: A randomized unit-crossover study

OBJECTIVE: To compare effectiveness in preventing central venous catheter colonization and infection of two protocols of cutaneous antisepsis using povidone-iodine solution in combination with ethanol or water. DESIGN: Randomized trial. SETTING: Medical intensive care department in a university hospital. PATIENTS: Consecutive patients requiring central venous catheter in two similar 11-bed units from January 1, 2001, to January 1, 2002. INTERVENTIONS: Alcoholic povidone-iodine solution protocol was randomly assigned to one of two units when the study began. Every 3 months the alcoholic protocol was switched from one unit to the other. Depending on the unit and the time the patient was admitted, catheters were inserted and cared for with 10% aqueous povidone-iodine solution or 5% povidone-iodine solution 70% ethanol-based combination. MEASUREMENTS AND MAIN RESULTS: Rates of catheter colonization, catheter-related bacteremia, and catheter-related infection were compared in the two protocols; 223 catheters were included in an intent-to-treat analysis. The incidence of catheter colonization was significantly lower in the alcoholic povidone-iodine solution protocol than in the aqueous povidone-iodine solution protocol (relative risk, 0.38; 95% confidence interval, 0.22-0.65, p <.001), and so was the incidence of catheter-related infection (relative risk, 0.34; 95% confidence interval, 0.13-0.91, p <.04). Catheter-related bacteremia were similar in both protocols. After adjusting for other risk factors, time to central venous catheter colonization was significantly longer in the alcoholic solution (adjusted hazards ratio, 0.3; 95% confidence interval, 0.2-0.6, p <.001). Based on a subgroup of 114 patients (57 in each protocol), analysis of 57 pairs of central venous catheters matched for age, duration, and site of insertion found similar results regarding the superiority of alcoholic povidone-iodine solution in preventing central venous catheter colonization and infection. CONCLUSIONS: The use of alcoholic povidone-iodine for skin disinfection reduced the incidence of catheter colonization and related infection compared with aqueous 10% povidone-iodine disinfection in an adult intensive care unit.     

Antioxidant defence mechanisms: new players in the pathogenesis of non-alcoholic steatohepatitis?

This comment discusses the study by Videla and colleagues in this issue of Clinical Science in which they have analysed surgical liver biopsies from obese patients with non-alcoholic fatty liver disease and demonstrate that fatty liver is associated with a state of oxidative stress and a decreased antioxidant activity. As the disease progresses to steatohepatitis, the defect in antioxidant systems increases. Thus efficiency of antioxidant defence mechanisms, by setting the threshold at which pro-oxidants would become injurious, might represent a determining factor for disease progression from stable steatosis to steatohepatitis.     

Cerebrospinal fluid lactate and pyruvate concentrations and their ratio in children: age-related reference intervals

BACKGROUND: Lactate (L) and pyruvate (P) concentrations in cerebrospinal fluid (CSF) and the L/P ratio have diagnostic value in numerous primary and acquired disorders affecting the central nervous system, but age-related reference values are not available for children. METHODS: We analyzed CSF and blood lactate and pyruvate concentrations and their ratio in a 4-year retrospective survey of a children's hospital laboratory database. Reference intervals (10th-90th percentiles) were established from data on 197 hospitalized children. A recent regression modeling method was used to normalize and smooth values against age. The model equation of best fit was calculated for each variable. RESULTS: Slight age-related variations were shown by the model, with an increase in lactate, a decrease in pyruvate, and a resulting increase in the L/P ratio with increasing age. However, the SD did not vary with age. We defined the upper limit of the reference intervals as the 90th percentiles, which from birth to 186 months of age varied continuously from 1.78 to 1.88 mmol/L (6%), 148 to 139 micro mol/L (6%), and 16.9 to 19.2 (14%) for lactate, pyruvate, and the L/P ratio, respectively. At a threshold of 2 (in Z-score units), the sensitivity for a subgroup of inborn errors of metabolism (respiratory chain disorders) was 73%, 42%, and 31% for lactate, pyruvate, and the L/P ratio, respectively. CONCLUSIONS: In children, CSF lactate and pyruvate concentrations and their ratio appear to vary slightly with age. Average 90th percentile values of 1.8 mmol/L, 147 micro mol/L, and 17, respectively, could be used in infants up to 24 months of age. In older children, age-adjusted reference intervals should be used, especially when values are close to the 90th percentile.