Investigation of the ability of the Pneumonia Severity Index to accurately predict clinically relevant outcomes: a European study

In order to confirm the validity of the Pneumonia Severity Index (PSI) for patients in Europe, data from adults with pneumonia who were enrolled in two prospective multicentre studies, conducted in France (Pneumocom-1, n = 925) and Spain (Pneumocom-2, n = 853), were compared with data from the original North American study (Pneumonia PORT, n = 2287). The primary outcome was 28-day mortality; secondary outcomes were subsequent hospitalisation for outpatients, and intensive care unit admission and length of stay for inpatients. All outcomes within individual risk classes, and mortality rates in low-risk (PSI I-III) and higher-risk patients, were compared across the three cohorts. Overall mortality rates were 4.7% in Pneumonia PORT, 6.3% in Pneumocom-2 and 10.6% in Pneumocom-1 (p <0.01), ranging from 0.4% to 1.6% (p 0.06) for low-risk patients and from 13.0% to 19.1% (p 0.24) for high-risk patients. Despite significant differences in baseline patient characteristics, none of the study outcomes differed within the low-risk classes. The sensitivity and negative predictive value of low-risk classification for mortality exceeded 93% and 98%, respectively. Thus, in two independent European cohorts, the PSI predicted patient outcomes accurately and reliably, particularly for low-risk patients. These findings confirm the validity of the PSI when applied to patients from Europe.     

Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes : long-term follow-up

Background

The vast majority of superior vena cava (SVC) syndromes are of malignant causes, but with growing use of indwelling central catheters and implanted cardiac devices, benign SVC syndromes are becoming more frequent. The main objective of this study is to evaluate long term outcome in patients treated for benign SVC syndrome by endovascular techniques.

Methods

Forty-four patients, 26 men and 18 women, mean age 56, treated for benign SVC syndrome using endovascular techniques between 2002 and 2015 were included. Type of obstruction was classified according to the site of disease and degree of occlusion. Complications and recurrence of symptoms were analyzed.

Results

Technical and clinical success were achieved in all but one patient. Four patients (9 %) were treated by angioplasty alone and 40 (91 %) required stent implantation. Mean clinical follow-up was 1275 days. Nine patients had at least one episode of recurrence after a mean of 385 days. Four minor and two major complications were reported.

Conclusion

Percutaneous endovascular techniques to treat benign SVC syndrome are safe with good long term patency. Recurrence of symptoms can easily be addressed by repeat procedure.

Key Points

? Malposition of indwelling central catheter can cause superior vena cava obstruction.? Image-guided catheter placement helps prevent superior vena cava obstruction.? Imaging and superior vena cava obstruction classification allows adequate procedure planning.? Endovascular techniques are safe and effective for superior vena cava syndrome treatment.

     

Contribution of fetal middle cerebral artery peak systolic velocity in the management of non-immune hydrops

Hydrops fetalis is associated with a wide variety of fetal and maternal disorders. Among these disorders, cases with anemia may benefit from a specific treatment. The authors report on two cases of hydrops fetalis with increased middle cerebral artery peak systolic velocity and discussed the contribution of this finding in the management of fetuses with hydrops.     

Screening and timing for the delivery of fetuses with intrauterine growth restriction of vascular origin

The prenatal management of fetuses with intrauterine growth restriction (IUGR) has been a matter of perpetual evolving in obstetrics and has been the topic of numerous studies. The management of IUGR fetuses is currently available in tertiary centres using fetal heart monitoring, short term variability, or doppler investigation of the umbilical artery, ductus venosus and middle cerebral artery. The aim of the prenatal management is to detect anomalies that may predict severe fetal hypoxemia. On the other hand, any efforts should focus on the possibility to delay the time for delivery as gestational age at delivery together with birth weight appear to be essential parameters of the postnatal outcome.     

Ultrasonographic and pathological correlation in a fetal intracranial cyst: a case of "diencephalo-synapsis"

Brain imaging now provides exquisite images of the central nervous system (CNS) enabling identification of CNS malformations early during pregnancy. However, pathogenical evaluation, necessary for genetic counselling, requires a detailed neuropathological analysis. Brain imaging of a female fetus at 27 weeks gestation disclosed a paramedial cystic formation, considered to be a porencephalic lesion. Neuropathological correlation after pregnancy termination disclosed partial atresia of the third ventricle, responsible for lateral ventricle dilatation and corpus callosum lamination. Atresia of the third ventricle, that we suggest could be called "diencephalo-synapsis", is a rare CNS malformation due to an unknown cause. Further neuropathological studies and phenotype-genotype correlations are necessary for the delineation of the entity and the comprehension of its cause and pathogenesis.     

Fetal supraventricular tachycardia: a role for amiodarone as second-line therapy?

OBJECTIVE: The aim of this study was to evaluate the role of amiodarone for the prenatal treatment of hydropic fetuses with supraventricular tachycardia. METHODS: A group of 26 hydropic fetuses with supraventricular tachycardia was studied retrospectively. RESULTS: Twenty-five fetuses received transplacental treatment. The overall prenatal conversion rate was 60%. Nine fetuses were converted to sinus rhythm using either flecainide (n = 7) or amiodarone (n = 2) as first line therapy, whilst digoxin alone or in association with sotalol failed to restore sinus rhythm in all cases. After first-line therapy, supraventricular tachycardia persisted in 10 fetuses. Nine fetuses received amiodarone alone or in association with digoxin as second-line therapy, five of whom were converted to sinus rhythm. Among the 11 live neonates treated by amiodarone in utero, 2 (17%) presented an elevated thyroid stimulating hormone at day 3-4. These two infants received thyroid hormone substitution therapy and had a normal outcome. CONCLUSION: When first-line therapy fails to restore sinus rhythm in hydropic fetuses with supraventricular tachycardia, amiodarone therapy should be considered as it allows a substantial number of fetuses to be converted prenatally.