Admission to intensive care of very old patients

THE EXTENT OF THE PROBLEM: Because of the costs of intensive care, there is a possibility that access to this sector may be limited for those above a certain age. It would therefore appear necessary to develop an ethical clinical strategy in order to assess as precisely as possible and on individual level, the benefits and risks of these techniques, since age itself is simply a criterion among so many others. Among the elements that are important for the decision is the respect of the patient's wish, when it can be obtained since this is a fundamental point. In studies conducted in the United States, 50 to 90% of the elderly persons interviewed did not wish to be resuscitated in the case of cardiac arrest. CRITERIA FOR ADMISSION: The decision to admit an elderly patient in an intensive care unit must take into account the functional state of the patient, appreciated on daily activity and mobility scores and the neuro-psychological assessment, before hospitalization. In parallel, the severity of the underlying disease and the impact on visceral failures, assessed by the severity scores on admission appear to be more reliable prognostic elements than the patients' age itself. FOLLOWING RESUSCITATION: The quality of life of elderly patients within the months following resuscitation is difficult to assess, but is considered as acceptable in the majority of surviving patients. IN PRACTICE: The choice of admission in intensive care of an elderly patient requires a multidisciplinary approach that takes into account the patient's and/or family's wishes, the benefit/risk ratio of the technical act but which also, in certain cases, bears in mind the principle of end of life and the patient's dignity.     

Predictive factors of mortality due to polymicrobial peritonitis with Candida isolation in peritoneal fluid in critically ill patients

BACKGROUND: Candida peritonitis (CP) is generally considered to be a severe disease, but its impact on outcome in critically ill patients remains unknown. HYPOTHESIS: The predictive factors of mortality due to CP can be determined by study of a population of patients with CP. DESIGN: A retrospective review of a prospective surgical intensive care unit (ICU) database of patients (January 1, 1994, through December 31, 2000). SETTING: University hospital in Paris, France. PATIENTS: Eighty-three patients with generalized CP. MAIN OUTCOME MEASURES: Demographic and microbiologic data and outcome were collected, and nonsurvivors were compared with survivors. RESULTS: Overall ICU mortality due to CP was 43 (52%) of 83 patients. In a stepwise multivariate logistic regression, the following 4 variables were independently associated with mortality: APACHE II (Acute Physiology and Chronic Health Evaluation II) score on admission of at least 17 (odds ratio [OR], 28.4; 95% confidence interval [CI], 5.7-142.5; P<.001), respiratory failure on admission (OR, 10.6; 95% CI, 2.2-51.2; P =.003), upper gastrointestinal tract site of peritonitis (OR, 7.7; 95% CI, 1.7-34.7; P =.007), and results of direct examination of peritoneal fluid that were positive for Candida (OR, 4.7; 95% CI, 1.2-19.7; P =.002). CONCLUSIONS: These results confirm the severity of CP in ICU patients and emphasize the prognostic value of direct examination of peritoneal fluid for Candida in this context.     

The renal epidemiology and information network (REIN): a new registry for end-stage renal disease in France.

The French Renal Epidemiology and Information Network (REIN) registry began in 2002 to provide a tool for public health decision support, evaluation and research related to renal replacement therapies (RRT) for end-stage renal disease (ESRD). It relies on a network of nephrologists, epidemiologists, patients and public health representatives, coordinated regionally and nationally. Continuous registration covers all dialysis and transplanted patients. In 2003, 2070 patients started RRT, 7854 were on dialysis and 7294 lived with a functioning graft in seven regions (with a population of 16.5 million people). The overall crude annual incidence rate of RRT for ESRD was 123 per million population (p.m.p.) with significant differences in age-adjusted rates across regions, from 84 [95% confidence interval (CI): 74-94] to 155 [138-172] p.m.p. The principal causes of ESRD were hypertension (21%) and diabetic (20%) nephropathies. Initial treatment for ESRD was peritoneal dialysis for 15% of patients and a pre-emptive graft for 3%. The one-year survival rate was 81% [79-83] in the cohort of 2002-2003 incident patients. As of December 31, 2003, the overall crude prevalence was 898 [884-913] p.m.p, with 5% of patients receiving peritoneal dialysis, 47% on haemodialysis and 48% with a functioning graft. The experience in these seven regions over these two years clearly shows the feasibility of the REIN registry, which is progressively expanding to cover the entire country.     

Decrease in particle‐induced osteolysis in ovariectomized mice

Postmenopausal osteoporosis is a common disorder that results from increased osteoclastic activity caused by estrogen deficiency. Whether postmenopausal bone remodeling can alter the response to particulate debris is unknown. The purpose of this study was to evaluate the bone response to polyethylene particles in an ovariectomized murine model. Polyethylene particles were implanted onto the calvaria of seven control mice and seven ovariectomized (OVX) mice, as compared with calvaria from sham‐operated and OVX mice. Calvaria were harvested after 14 days. Skulls were analyzed with a high‐resolution micro‐CT and by histomorphometry after staining with Stevenel blue and picrofuschine, and for tartrate‐specific alkaline phosphatase. As assessed by micro‐CT, particle implantation induced a significant decrease in bone thickness in control mice, while bone thickness remained stable in OVX mice. In particle‐implanted animals, the osteoclast number was 2.84 ± 0.3 in control mice and 1.74 ± 0.22 in OVX mice. Mean bone loss was ?12% ± 1.9% in control mice and ?4.7% ± 1.7% in OVX animals. The reduction of osteolytic response suggests that ovariectomy may have a protective role against particle‐induced bone resorption. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 28:178–183, 2010     

Long-term results of a multicenter randomized study on direct versus crossover bypass for unilateral iliac artery occlusive disease

OBJECTIVE: To compare late patency after direct and crossover bypass in good-risk patients with unilateral iliac occlusive disease not amenable to angioplasty. METHODS: Between May 1986 and March 1991, 143 patients with unilateral iliac artery occlusive disease and disabling claudication were randomized into two surgical treatment groups, ie, crossover bypass (n = 74) or direct bypass (n = 69). The size of the patient population was calculated to allow detection of a possible 20% difference in patency in favor of direct bypass with a one-sided alpha risk of 0.05 and a beta risk of 0.10. Patients underwent yearly follow-up examinations using color flow duplex scanning with ankle-brachial systolic pressure index measurement. Digital angiography was performed if hemodynamic abnormalities were noted. Median follow-up was 7.4 years. Primary endpoints were primary patency and assisted primary patency estimated by the Kaplan-Meier method with 95% confidence interval. Secondary endpoints were secondary patency and postoperative mortality and morbidity. RESULTS: Cardiovascular risk factors, preoperative symptoms, iliac lesions TASC class (C in 87 [61%] patients and D in 56 [39%] patients), and superficial femoral artery (SFA) run-off were comparable in the two treatment groups. One patient in the direct bypass group died postoperatively. Primary patency at 5 years was higher in the direct bypass group than in the crossover bypass group (92.7 +/- 6.1% vs 73.2 +/- 10%, P = .001). Assisted primary patency and secondary patency at 5 years were also higher after direct bypass than crossover bypass (92.7 +/- 6.1% vs 84.3 +/- 8.5%, P = .04 and 97.0 +/- 3.0% vs 89.8 +/- 7.1%, P = .03, respectively). Patency at 5 years after crossover bypass was significantly higher in patients presenting no or low-grade SFA stenosis than in patients presenting high-grade (> or =50%) stenosis or occlusion of the SFA (74.0 +/- 12% vs 62.5 +/- 19%, P = .04). In both treatment groups, patency was comparable using polytetrafluoroethylene (PTFE) and polyester grafts. Overall survival was 59.5 +/- 12% at 10 years. CONCLUSION: This study showed that late patency was higher after direct bypass than crossover bypass in good-risk patients with unilateral iliac occlusive disease not amenable to angioplasty. Crossover bypass should be reserved for high-risk patients with unilateral iliac occlusion not amenable to percutaneous recanalization.     

The transmanubrial approach: a new operative approach to cervicothoracic neuroblastoma in children

BACKGROUND: Cervicothoracic neuroblastoma originates from the cervical sympathetic nerves and ganglia and thus presents a problem when dissecting the vascular and nervous elements of the subclavian region. The standard operation is based on thoracotomy or dual cervicotomy/thoracotomy, but these approaches do not provide optimal control of the subclavian vessels. We report our experience in children with cervicothoracic neuroblastoma by using a technique usually performed for apical lung cancer. METHODS: Four patients with localized cervicothoracic neuroblastoma with no N-myc amplification were resected after chemotherapy by this approach. The anatomic evaluation was performed preoperatively with angio-magnetic resonance imaging. This transmanubrial approach, performed through a manubrial L-shaped transection and first costal cartilage resection, affords excellent access to the subclavian region with safe control of the vessels and nerves and exposure of the first 4 thoracic intervertebral foramina. RESULTS: Removal of more than 90% of the tumor was possible in all cases. The postoperative course was uneventful in 3 cases, and the fourth patient with a left-sided tumor had a transient chylothorax. No recurrence occurred with a follow-up period of 8 to 32 months. CONCLUSIONS: The transmanubrial approach is an osteomuscular-sparing technique that seems particularly suitable for the treatment of these tumors, which require a resection that is as complete as possible to avoid postoperative chemotherapy and tumor relapse.