Patients under palliative care and in hospital-at-home services are frequently transferred to emergency departments.

Background: Hypertension (HT) after carotid endarterectomy (CEA) is a risk factor for postoperative myocardial infarction, stroke, and neck hematoma. We compared the incidence of postoperative HT within the week after eversion CEA (e-CEA) and patch closure CEA (p-CEA). Postoperative HT was defined as a systolic blood pressure (sBP) >= 160 mm Hg and/or the need for postoperative vasodilatators. The aim of our study was to determine if the technique of CEA had an effect on postoperative HT.Methods: Between January 2010 and June 2011, we prospectively reviewed 560 consecutive endarterectomies (340 p-CEAs and 220 e-CEAs) performed in 443 patients under general anesthesia. All had >70% stenoses, 119 were symptomatic, and 441 asymptomatic. We compared preoperative, peroperative, and postoperative sBP and diastolic blood pressure, carotid sinus nerve block, postoperative intravenous and oral antihypertensive medications, neurologic and cardiac complications, and mortality.Results: The e-CEA group had a higher incidence of women (36.4% vs. 21.8%, P = 0.0002) and HT (85.0% vs. 78.2%, P = 0.04). The e-CEAs had a significantly higher incidence of carotid sinus nerve block (93.6% vs. 15.6%, P < 0.0001). The incidence of postoperative HT was not significantly different between the 2 groups (75.9% in the e-CEA group versus 68.5% in the p-CEA group, P = 0.06). The average postoperative sBP between postoperative hour (H) 2 and H12 was significantly higher in the e-CEA group but < 160 mm Hg. The sBP dropped between H2 and H6, and this decrease was greater in the p-CEA group (30% vs. 15% in the e-CEA group). The need for postoperative antihypertensive medication was not different between the 2 groups. One independent risk factor of postoperative HT was identified: history of HT. The rate of postoperative complications was not significantly different between the 2 groups.Conclusions: The e-CEA technique is not a risk factor and does not have an effect on postoperative HT. The postoperative sBP was more stable in this group. Eversion carotid endarterectomy has been considered, in the literature, as a risk factor of postoperative hypertension. We conducted a large prospective and comparative study of the endarterectomy technique by eversion and with conventional patch closure. The primary end point was the blood pressure value and the administration of antihypertensive treatment. Our study shows that postoperative hypertension after carotid endarterectomy is not related to the surgical technique. Changes in blood pressure after carotid endarterectomy by eversion are lower than those observed after conventional endarterectomy with patch closure. This technique prevents the occurrence of possible hypotension occurrence, which can be the cause of perioperative complications.

OBJECTIVE:To assess the reproductive outcome after an ectopic pregnancy (EP) based on the type of treatment used, and to identify predictive factors of spontaneous fertility.DESIGN:Observational population based-study.SETTING:Regional sistry.PATIENT(S):One thousand sixty-four women registered from 1992 to 2008.INTERVENTION(S):Laparoscopic (radical or conservative), or medical treatment.MAIN OUTCOME MEASURE(S):Epidemiologic characteristics, clinical presentation, treatments performed, reproductive outcome, recurrence.RESULT(S):The 24-month cumulative rate of intrauterine pregnancy (IUP) was 67% after salpingectomy, 76% after salpingostomy, and 76% after medical treatment. IUP rate was lower after radical treatment compared with conservative treatments in univariable analysis. In multivariate analysis, IUP rate was significantly lower for patients >35 years old or with history of infertility or tubal disease. For them, IUP rate was significantly higher after conservative treatment compared with salpingectomy. The 2-year cumulative rate of recurrences was 18.5% after salpingostomy or salpingectomy and 25.5% after medical treatment. History of infertility or of previous live birth would be protective, in contrast to history of voluntary termination of pregnancy.CONCLUSION(S):Conservative strategy seems to be preferred, whenever possible, to preserve patients' fertility without increasing the risk of recurrence. The choice between conservative treatments does not rely on subsequent fertility, but more likely on their own indications and therapeutic effectiveness. Risk factors of recurrence could be considered for secondary prevention.

Purpose To compare pain symptoms and quality of life between epiphenomenon and endometriosis disease. Methods Between January 2004 and July 2008, 536 new cases of endometriosis confirmed by surgical biopsy were included in this observational cohort study (Auvergne Regional Cohort of Endometriosis). Questionnaires and visual analog scale scores for dysmenorrhoea, dyspareunia, chronic pelvic pain, premenstrual dysuria and dyschesia, quality of life instruments (SF-36), and sexual activity questionnaires were compared between group A (epiphenomenon group: 119 patients) and group B (endometriosis disease group: 318 patients with deep ovarian endometrioma and/or deep infiltrating nodules). Primary outcome was patient-reported pain rates. Secondary outcomes included quality-of-life tools. Results In cases of severe endometriosis, more pain at defecation and more dysmenorrhoea were observed than in cases of minimal endometriosis. The social repercussions and deterioration in quality of life were also affected, without any distinction between group A and B except for physical limitations. Quality of sex life was also affected in both groups. Conculsions This study confirms the ubiquitous pain symptoms of endometriosis. The lack of any correlation between functional symptomatology and anatomic severity of disease underlines how important it is not to neglect patients presenting what is called “minimal” endometriosis.

Aim. Ovarian epithelial dysplasia was initially described in material from prophylactic oophorectomies performed in patients at genetic risk of ovarian cancer. Similar histopathological abnormalities have been revealed after ovulation stimulation. Since infertility is also a risk factor for ovarian neoplasia, the aim of this study was to study the relationship between infertility and ovarian dysplasia. Methods. We blindly reviewed 127 histopathological slides of adnexectomies or ovarian cystectomies according to three groups—an exposed group to ovulation induction (n = 30), an infertile group without stimulation (n = 35), and a spontaneously fertile control group (n = 62)—in order to design an eleven histopathological criteria scoring system. Results. The ovarian dysplasia score was significantly higher in exposed group whereas dysplasia score was low in infertile and control groups (resp., 8.21 in exposed group, 3.69 for infertile patients, and 3.62 for the controls). In the subgroup with refractory infertility there was a trend towards a more severe dysplasia score (8.53 in ovulation induction group and 5.1 in infertile group). Conclusion. These results raise questions as to the responsibility of drugs used to induce ovulation and/or infertility itself in the genesis of ovarian epithelial dysplasia.

Purpose: To compare pain symptoms and quality of life between epiphenomenon and endometriosis disease.Methods: Between January 2004 and July 2008, 536 new cases of endometriosis confirmed by surgical biopsy were included in this observational cohort study (Auvergne Regional Cohort of Endometriosis). Questionnaires and visual analog scale scores for dysmenorrhoea, dyspareunia, chronic pelvic pain, premenstrual dysuria and dyschesia, quality of life instruments (SF-36), and sexual activity questionnaires were compared between group A (epiphenomenon group: 119 patients) and group B (endometriosis disease group: 318 patients with deep ovarian endometrioma and/or deep infiltrating nodules). Primary outcome was patient-reported pain rates. Secondary outcomes included quality-of-life tools.Results: In cases of severe endometriosis, more pain at defecation and more dysmenorrhoea were observed than in cases of minimal endometriosis.The social repercussions and deterioration in quality of life were also affected, without any distinction between group A and B except for physical limitations. Quality of sex life was also affected in both groups.Conclusions: This study confirms the ubiquitous pain symptoms of endometriosis. The lack of any correlation between functional symptomatology and anatomic severity of disease underlines how important it is not to neglect patients presenting what is called "minimal" endometriosis.

ObjectivesTo explore the role of neuropathy in persistent pain after thoracotomy, combining a clinical follow-up and a psychophysical examination of the operated area. MethodsSeventy-three patients were followed and examined at their discharge from hospital, 6 weeks and 4 months after pneumonectomy under thoracotomy. Spontaneous and evoked pain was assessed by clinical examination, a 7-day pain score, and the Neuropathic Pain Symptom Inventory. At the fourth month follow-up, pain and tolerance thresholds to pinprick, heat, and warm sensation threshold were measured on both sides of the thorax. ResultsThe rate of spontaneous pain was 40% at discharge and went up to 59% at the sixth week follow-up. Evoked pain was rare at discharge (11%), most cases appearing at the sixth week follow-up (47%). The evolution profiles of pain between the sixth week and the fourth month follow-up were heterogeneous with a tendency to decrease. Young age, female sex, and spontaneous pain observed at discharge from hospital were identified as early predictive factors of spontaneous pain persisting at the fourth month follow-up. On the side of operation, thresholds tended to increase for warm and hot stimuli, and to decrease for mechanical stimuli. At the fourth month follow-up, spontaneous pain and evoked pain were associated to static hyperalgesia, persisting hypoesthesia, low mechanical thresholds, altered sensation of heat, and impaired quality of life. DiscussionPeripheral neuropathy is common after thoracotomy, with variant characteristics, ranging from subclinical disturbances to severe pain. The process seems to develop between the discharge from hospital and the sixth week after thoracotomy.

Objective: To describe different approaches for diagnosis and management of proximal ectopic pregnancies (PP) in general population.Design: Observational population based-study.Setting: Regional ectopic pregnancy registry.Patient(s): Eighty-six PP registered from 1992 to 2008.Intervention(s): Surgical (radical or conservative), medical, or combined therapies.Main Outcome Measure(s): Epidemiologic characteristics, clinical presentation, hCG level, treatments performed, failure rate, and recurrence.Result(s): Mean gestational age was 48.2 days. Estimated incidence of PP was 2.7%. Abdominal pain and vaginal bleeding were the commonest symptoms. Two patients were admitted in hypovolemic shock. Diagnostic modalities included transvaginal ultrasound, abdominal ultrasonography, and laparoscopy in 38 (44%), 7 (8%), and 39 (45%) cases, respectively. Mean hCG level was 10,759 IU/L. Thirty-four patients underwent primary cornual resection (39.5%) by laparoscopy (n = 32) or laparotomy (n = 2). Twenty-seven patients (31.4%) underwent primary conservative surgery by laparoscopy: cornuostomy (n = 18) or extended salpigostomy (n = 9). Primary medical treatment with methotrexate was attempted in 14 patients (16.3%). Expectant management was attempted in one case (1.2%). Eleven cases received combined therapies (11.6%). Failure rates for medical and surgical treatments were 35.7% and 28%, respectively. No failures were noted among patients who received combined therapies.Conclusion(s): Proximal ectopic pregnancy remains a life-threatening condition. Diagnosis is challenging and requires a high index of suspicion. Despite available conservative strategies, management of PP remains heterogeneous. (Fertil Steril (R) 2011; 95: 867-71. (C) 2011 by American Society for Reproductive Medicine.)

Introduction. - Precancerous ovarian epithelial dysplasia was first described after prophylactic oophorectomy (OP) for genetic risk (BRCA mutation) or because of a strong family history of ovarian and/or breast cancer. The objective of this study was to describe histopathological features of ovarian dysplasia and to propose a dysplasia scoring sheme with a cut-off.Patients and method. - One hundred and twenty-five bilateral oophorectomies (genetic predisposition: n = 35 and control group: n = 90) were reviewed by two pathologists blinded to clinical data. Eleven epithelial cytological and architectural features were studied and an ovarian dysplasia score was defined to compare the degree of ovarian epithelial abnormalities between the two groups.Results. - Mean ovarian dysplasia score was significantly higher in prophylactic oophorectomy group than in control group (9.0 versus 15, P < 0.001). Dysplasia was more severe in OP with BRCA mutation than in OP without (11.6 in BRCA 1; 7.6 in BCRA 2; 7.1 in family history). The cut off for dysplasia was 8 with a sensitivity of 60% and a specificity of 93.3%.Conclusion. - The increased dysplasia score in OP and the gradation in dysplastic severity in OP with proven BRCA mutations may suggest that ovarian dysplasia could be a pre-malignant non invasive histopathological lesion. The 11 cytological and architectural features in the dysplasia scoring sheme could be a useful tool to study ovarian dysplasia. (C) 2010 Elsevier Masson SAS. All rights reserved.

BACKGROUND AND AIM OF THE STUDY:In this single-center French study, the conventional management of patients receiving vitamin K antagonists (VKAs) was compared with an International Normalized Ratio (INR) self-testing program. The aim was to determine the reliability of self-testing devices, and to estimate the variability of the self-measured INR within the therapeutic and target range.METHODS:A total of 206 patients who had undergone valve replacement with a mechanical prosthesis, with or without myocardial revascularization, between May 2004 and September 2007 was randomized into two groups. Group 1 patients (n = 103) underwent INR monitoring at a laboratory, while Group 2 patients (n = 103) underwent self-testing INR using either the CoaguChek (Roche) (Group 2A; n = 55) or INRatio (Hemosense) (Group 2B; n = 48) system. Patients in Group 1 underwent at least once-monthly INR measurement, while those in Group 2 carried out once-weekly self-testing, and also underwent once-monthly INR measurement at the laboratory. The large majority of patients (97.9%) were treated with fluindione.RESULTS:The mean follow up period was 49.0 +/- 10.3 weeks. Self-testing was reliable, with a correlation coefficient between device- and laboratory-measured INRs of 0.80 [CI: 0.78, 0.82] (p < 0.0001). The proportion of time spent within the INR target range was significantly higher for Group 2 (61.5 +/- 19.3% versus 55.5 +/- 19.9%; p < 0.05), while the absolute mean deviation of INR from the target range was higher in Group 1 (60.1 +/- 70.2% versus 47.4 +/- 51.5%). Adverse events were reported by seven patients in Group 1, but by no patients in Group 2 (p < 0.01).CONCLUSION:INR self-testing devices are reliable and beneficial. Moreover, INR self-monitoring allows an enhanced stability within a target range, and also helps to prevent serious postoperative complications.

In a general population setting, the existence of a learning curve for treatment of ectopic pregnancy with single-dose methotrexate has been demonstrated, because a significant decrease in failure rate can be achieved over time. Despite this finding, the risk of single-dose methotrexate failure increases significantly in patients with initial hCG levels > 1,300 IU/L and/or in women who report having ever used combined oral contraception before pregnancy. (Fertil Steril (R) 2011;95:401-4. (C) 2011 by American Society for Reproductive Medicine.)

OBJECTIVE: To estimate predictive factors for failure of laparoscopic conservative treatment of ectopic pregnancy using a standardized surgical technique.METHODS: We performed a population-based study from the Auvergne ectopic pregnancy registry. A total of 3,196 cases of ectopic pregnancy were registered between 1992 and 2008. Among conservative treatments (n=1,965), 1,306 (66.5%) patients underwent laparoscopic salpingostomy exclusively. For each case, collected data included: sociodemographic characteristics, previous surgeries, gynecologic and reproductive histories, conditions of conception, Chlamydiae trachomatis serology, human chorionic gonadotropin (hCG) levels, and ectopic pregnancy characteristics. Univariable and multivariable analyses were performed to identify risk factors for treatment. A receiver operating characteristic curve was also provided. Statistical significance was established at P<.05.RESULTS: We identified 86 treatment failures (6.6%). The failure rate remained stable through the study period. Pretherapeutic hCG level was the only factor significantly associated with treatment failure. Patients with an hCG level of at least 1,960 international units/L had a failure rate of 8.6% compared with 5.1% in patients with a lower hCG level (P=.03). Sensitivity and specificity of this cutoff limit were 47% and 67%, respectively (likelihood ratio(+) = 1.4 and likelihood ratio(-) = 0.8).CONCLUSION: The hCG level of at least 1,960 international units/L is the only factor related to treatment failure. However, the prognostic value of this cutoff is low and with limited clinical relevance. (Obstet Gynecol 2010;116:701-7)

The aim of this study was to analyze the early and late results of iterative aortic surgery after bypass of infrarenal aorta. Results from Clermont-Ferrand and Saint-Etienne hospitals have been collected. Between January 1993 and December 2001, 61 patients ( 59 men and two women, mean age 65 years) underwent a partial or complete second aortic reconstruction through a direct approach. Three different indications that required redo surgery were detected. Twenty-three patients presented with an infection (37%), 17 with an occlusive pathology (28%), and 21 with an aneurysm (34%). Medical or endoluminal treatment could no longer be considered. Mean period of time for redo surgery was 101 months ( range 1-294). Eighteen of the procedures were emergency surgeries. A polyester prosthesis was used in 45 cases, an arterial allograft in 15 cases, and autogenous venous material in one case. In 22 cases (36%) a visceral, renal, or infracrural revascularization was associated. Four patients died (6.5%): three with an infection and one with an occlusive pathology. Global morbidity rate was 64%. Twelve vascular surgical complications (19%) required redo surgery: seven limb ischemia, three hemorrhage, and two colic ischemia. The preoperative factors generating severe complications were a septic context, renal insufficiency, and American Society of Anesthesiologists grade 3 or 4. Follow-up concerned the 57 surviving patients with a 43-month mean period of time ( range 4-105). Actuarial survival rate was 80.7% at 3 years and could be compared to that observed after infrarenal aortic first surgery. Primary and secondary global patency rates were, respectively, 66.4 +/- 6.7% and 94.6 +/- 3% at 3 years with no major amputation. In our series including 37% of septic patients and nearly 30% of patients operated on in emergency, aortic iterative surgery led to mortality and morbidity rates twice and four times as important as those resulting from infrarenal aortic initial surgery, respectively. In the long term, patient survival and limb salvage rates were quite similar to those obtained with de novo surgery.

Objective:To make an accurate histopathological description of ovarian dysplasia in a population at genetic risk of ovarian cancer and devise an ovarian dysplasia score.Materials and Methods:In this retrospective cohort study, 90 patients who had undergone bilateral oophorectomy or ovarian cystectomy between 1992 and 2005 and whose ovaries were reported as normal were divided into two groups: Group A comprising prophylactic oophorectomies for genetic predisposition (N = 28), and Group B or control group, fertile and non-cancerous (N = 62). Eleven epithelial cytological and architectural features were defined. Ovaries were analysed and reviewed by four pathologists blinded to clinical data. An ovarian dysplasia score was devised to quantify extent of ovarian epithelial abnormalities. The degrees of ovarian epithelial abnormalities (dysplasia scores) were compared between the two groups.Results:Mean dysplasia score was significantly higher in Group A (prophylactic oophorectomies) than in Group B (control group) (9.67 vs. 4.19, P < 0.001). In Group A, we observed a gradation in the severity of the dysplastic lesions between (i) proven BRCA mutations and prophylactic oophorectomies without mutations (11.26 vs. 8.1), and (ii) according to age (10.27 after age 50 years vs. 8.6 before age 50 years, P = 0.2962).Conclusion:These results suggest abnormalities in ovaries from high risk women. The ovarian dysplasia may be a pre-malignant, non-invasive histological lesion that could be an important step in early neoplasia.

Le but de cette étude a été d'analyser les résultats précoces et tardifs de la chirurgie aortique itérative après pontage prothétique de l'aorte sous-rénale. Les observations des CHU de Clermont-Ferrand et Saint-Etienne ont été regroupées. Entre Janvier 1993 et Décembre 2001, 61 patients (59 hommes, 2 femmes, âge moyen 65 ans) ont bénéficié, par abord direct de l'aorte, du changement complet ou partiel d'une restauration aortique précédemment réalisée. Trois indications imposant la réintervention ont été distinguées : 23 patients présentaient une infection prothétique (37%), 17 une pathologie occlusive (28%), 21 une pathologie anévrysmale (34%). Les possibilités d'un traitement médical ou d'un traitement endoluminal avaient été épuisées. Le délai moyen de réintervention a été de 101 mois (1 à 294 mois). Dix-huit interventions ont eu lieu en urgence. Une prothèse en Dacron a été utilisée 45 fois, une allogreffe artérielle 15 fois et du matériel veineux autogène une fois. Dans 22 cas (36%) une revascularisation viscérale, rénale, ou sous-crurale a été associée. Quatre décès (6,5%) post-opératoires sont survenus : trois chez des patients présentant une infection prothétique et un une pathologie occlusive. Le taux global de morbidité a été de 64%. Douze complications chirurgicales vasculaires (19%) ont nécessité une réintervention : 7 ischémies de membre, 3 hémorragies, 2 ischémies coliques. Les facteurs préopératoires favorisant la survenue d'une complication sévère ont été : le contexte septique, l'insuffisance rénale, les patients classés ASA 3 ou 4. Le suivi a concerné les 57 patients survivants et a été de 43 mois en moyenne (4 à 105). La survie actuarielle a été de 80,7% à 3 ans et était comparable à celle observée après chirurgie aortique sous-rénale de première intention. La perméabilité globale primaire et secondaire à 3 ans a été respectivement de 66,4% ± 6,7 et de 94,6 ± 3. Aucune amputation majeure n'a été observée. Dans notre série qui comporte 37% de patients septiques et près de 30% de patients opérés en urgence, la chirurgie itérative aortique a entrainé respectivement une mortalité et une morbidité 2 et 4 fois plus importante que la chirurgie aortique sous-rénale de première intention. A long terme la survie des patients et le taux de conservation de membre sont comparables à ceux de la chirurgie de première intention.

INTRODUCTION:Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring. OBJECTIVES:We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction. PATIENTS AND METHODS:Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (+/-9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (+/-11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p=0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75. RESULTS:The time spent in the INR target range (group A: 53+/-19%, group B: 57+/--19%, p=0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86+/-14%, group B: 91+/-7%, p=0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1+/-39.3 and 11.27+/-11.2) than for the control group (62.4+/-72.6 and 39.2+/-52.8). This difference is significant (p=0.0004 and p=0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study. CONCLUSION:This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p=0.06, NS).