A82 PREVALENCE AND NON-INVASIVE SCREENING FOR CYSTIC FIBROSIS RELATED LIVER DISEASE IN A COHORT FOLLOWED AT A CYSTIC FIBROSIS REFERENCE CENTER

Background

The reported prevalence of cystic fibrosis (CF) related liver disease (CFLD) varies widely based on diagnostic criteria but reaches up to 40% in some cohorts. Furthermore, its clinical impact is significant as hepatic involvement is the 3^rd leading cause of mortality in CF patients and is associated with a lower life expectancy. Due to the heterogeneous clinical presentation of CFLD, clear diagnostic criteria and non-invasive assessment methods are lacking.

Purpose

This study aimed to measure the prevalence of CFLD in a cohort of patients followed at a tertiary CF center.

Method

The files of all patients followed at the CF clinic of the Centre hospitalier de l’Université de Montréal in 2021 were retrospectively reviewed. Imaging reports, histopathology, laboratory values and transient elastography results were assessed. The NIH criteria were used to define CFLD through either presence of one major criteria (abnormal imaging) or two minor criteria (persistently abnormal lab values, hepatosplenomegaly, or transient elastography ≥ 7 kPa).

Result(s)

358 patients were included in our study, 56% male with a median age of 36 years. While mean liver tests were within normal limits (ALT 24 U/L, AST 26 U/L, ALP 96 U/L, GGT 29 U/L), 182 patients (51%) had at least one episode of abnormal liver function tests (LFTs), and 85 patients (24%) had persistently abnormal LFTs. CFLD was present in 42 patients (12%), with 39 patients presenting major criteria and 3 patients presenting minor criteria. In addition, 67 patients (19%) had solely hepatic steatosis. Furthermore, clinically significant portal hypertension and esophageal varices were detected in 50% of patients with CFLD who underwent upper endoscopy (n=20). Median transient elastography value was 5.4 kPa (interquartile range 4.25 kPa) in the 51 patients with exam results, and 32% had values ≥ 7 kPa. Fibroscan values correlated well with the presence of major criteria, with an area under the curve (AUROC) of 0.80 (0.68-0.92, p=0.0007), while non-invasive serological markers did not perform as well (Fib4: AUROC 0.70 (0.59-0.81) and APRI: AUROC 0.69 (0.59-0.80)).

Conclusion(s)

The overall prevalence of CFLD, including hepatic steatosis, was 31% in this cohort. Prompt recognition is important in clinical care in order to prevent hepatic complications from cirrhosis and portal hypertension. The use of Fibroscan seems promising for detecting CFLD.

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A271 ETIOLOGICAL CHARACTERIZATION OF DRUG-INDUCED ACUTE PANCREATITIS

Background

Drugs are considered a relatively rare and understudied cause of acute pancreatitis (AP). The lack of convincing and conclusive data on drug-induced AP (DIAP) complicates the diagnosis as well as the identification of the causative drug.

Aims

We hypothesized that documenting the causes of DIAP in the Saguenay-Lac-Saint-Jean (SLSJ) will add new evidence to the current literature and will provide a comprehensive picture of this health condition in the region. The aim of this study is to document causes of DIAP cases that occurred in the SLSJ population.

Methods

We have conducted a retrospective and descriptive population-based study of DIAP cases that occurred between 2006 and 2014 in the six hospitals deserving the SLSJ entire population. Cases were selected from the Quebec Ministry of Health hospitalizations registry (MED-ECHO) administrative public database. Medical chart review was performed in attempt to characterize DIAP hospitalizations and to identify the imputable drugs.

Results

During the studied period, 75 cases (30.7% male, 69.3% female) were included totalling 90 hospitalizations for DIAP. Among them, 51 causative drugs were identified and were distributed in 17 different drug classes. Recurrent DIAP were documented in 13 cases and among them, 6 cases have experimented positive rechallenge. Six drugs (5-fluorouracil, atorvastatin, bortezomib, nilotinib, rosuvastatin and triamcinolone) were associated with the highest degree of evidence. The most common causative drugs of DIAP hospitalization were azathioprine (n = 7), followed by atorvastatin (n =6), hydrochlorothiazide (n = 5), rosuvastatin (n = 4) and codeine (n = 4).

Conclusions

This study has added new evidences about potentially pancreatitis-associated drugs in literature. This is the first study to report definite 5-fluorouracil and triamcinolone-induced AP. An updated version of the evidence-based literature review is needed to support the clinicians in the identification of the causative drugs.

Funding Agencies

None

Myocardial Perfusion Scans and Mortality in Asymptomatic Patients Awaiting Renal Transplantation

Cardiac risk assessment for asymptomatic patients awaiting renal transplantation is controversial. Patients awaiting renal transplantation in Southern Saskatchewan from 2005 to 2015 were retrospectively reviewed. Patients underwent cardiac risk stratification with stress myocardial perfusion scan. Baseline clinical characteristics, nuclear scan results, all-cause mortality, and cardiovascular events were analyzed. Abnormal scans were defined as studies with reversible defects, wall motion abnormalities, lung uptake, or transient ischemic dilation. Descriptive statistics and survival analysis were calculated. Charts from 285 consecutive patients with 608 nuclear scans were analyzed. Mean age was 55.2 ± 11.7 years and 34.7% were female. Forty-three (15.1%) patients were transplanted and 99 (40.9%) patients died while awaiting renal transplantation. One hundred fifty-three patients (63.2%) had at least one abnormal scan. The mean follow-up period was 5.47 ± 3.11 years. An abnormal scan was not associated with decreased survival and/or coronary events (hazard ratio: 0.94, P = .77; 95% confidence intervals: 0.62 to 1.43). Patients awaiting renal transplantation in Saskatchewan with abnormal myocardial perfusion scans were not at greater risk of death or coronary events.

Ralstonia mannitolilytica in cystic fibrosis: A new predictor of worse outcomes

Background

Patients with Cystic Fibrosis are subject to repeated respiratory tract infections, with recent increasing isolation of unusual pathogens. Ralstonia species have lately been isolated at our institution, an organism historically frequently misidentified as Burkholderia or Pseudomonas. The prevalence of Ralstonia spp. in cystic fibrosis populations has yet to be determined, along with its clinical implications.

Case presentations

Seven patients out of the 301 followed at our cystic fibrosis clinic have had Ralstonia strains identified in their respiratory tract. Most strains identified were multi-drug resistant. After aquisition of Ralstonia spp., the patients' clinical course was characterized by more frequent and more severe respiratory infections along with prolonged hospitalizations, greater decline of lung function, and greater mortality. The mortality rate in this group of patients was 86%. No other factor that could explain such a dramatic evolution was identified upon review of patient data. Some of the strains involved were recognized as clones on Pulse Field Electrophoresis Gel, raising the question of person-to-person transmission.

Conclusion

New pathogens are identified with the evolution of the microbiota in cystic fibrosis respiratory tracts. In our cohort of patients, acquisition of Ralstonia spp. was associated with dramatic outcomes in terms of disease acceleration and raised mortality rates. It is of critical importance to continue to better define the prevalence and clinical impact of Ralstonia in cystic fibrosis populations.

[Monitoring of vancomycin in pediatrics]

OBJECTIVES

The authors wanted to determine if the current local practice (initial prescription and monitoring) in pediatrics allowed reaching vancomycin therapeutic concentrations.

PATIENTS AND METHODS

Thirty patients that had received vancomycin for at least five days with at least one evaluation of serum concentration, at the Sainte-Justine university hospital center, were retrospectively studied. Vancomycin trough and peak levels were analyzed.

RESULTS

The values of vancomycin serum concentration were within therapeutic ranges (local standards of 5 to 10mg/L for trough level and 20 to 40 mg/L for peak level) in 60% and 33% of cases at the fifth day of treatment for trough and peak levels, respectively.

CONCLUSION

The current practice does not allow reaching vancomycin serum concentrations in the target range. Using a wider range for the trough values could be considered.

Dichotomy between postprandial glucose and lipid profiles in adults with cystic fibrosis: a pilot study

BACKGROUND

Cystic fibrosis (CF) patients present a high incidence of glucose tolerance abnormalities. Altered insulin secretion combined with recommended high-fat intake could be associated with dysregulation of glucose and lipid metabolism. We examined postprandial glucose and lipid profiles during an oral glucose tolerance test (OGTT) and following a standardized high-fat test meal (TM).

METHODS

Sixteen CF patients with normal glucose tolerance (NGT) or CF-related diabetes (CFRD) and 16 controls underwent a 4 h OGTT and a TM. We then measured plasma glucose, insulin, free fatty acid (FFA) and triglyceride (TG) concentrations.

RESULTS

CF patients presented higher glucose excursion compared to controls after the OGTT and TM. However, in CF patients, this excursion was significantly reduced in both amplitude and length after the TM. The TM provoked a comparable increase in TG levels in both groups whereas they remained stable during the OGTT. FFAs were suppressed similarly in both groups after both challenges.

CONCLUSION

CF is associated with abnormal glucose excursion in the presence of relatively normal lipid excursion. The rapid normalization of glucose values after a mixed meal should be further explored and, if confirmed, might have significant implications for CFRD diagnostic.

Étude pilote sur la mise en place des soins pharmaceutiques dans le service de pédiatrie générale d'un hôpital français. Collaboration et comparaison franco-québécoise

STATE OF THE PROBLEM AND OBJECTIVES: French pharmacists are quasi absent from hospital wards. Our objective was to describe the implantation of pharmaceutical care in a patient unit of a French paediatric hospital.

MATERIAL AND METHODS

Following an internship in pharmaceutical care at the Sainte-Justine hospital (SJ) in Montreal, a French pharmacist returned to France to implement the pharmaceutical model in a paediatric unit at Robert Debré hospital (RD) in Paris. We first collected pharmaceutical interventions carried out during a 5-month period. In a second phase, we compared pharmaceutical interventions provided by the team composed of the same French pharmacist and a pharmacist from Québec in both settings during 14 days respectively.

RESULTS

In the first phase, 556 interventions were done (8.2+/-2,0 per day) with a significant increase observed during the first 2 months. In the second phase, 216 interventions were done at RD and 174 at SJ. The interventions were mainly related to drug information, modification of treatment and seamless care with the pharmacy of the hospital or a community pharmacy. The interventions targeted junior (30.5 to 55.4%), senior physicians (16.2 to 38.5%) and pharmacy (11.5 to 16.2%) in the different phases and sites. A high level of physician acceptance was observed, with respectively 86.0 and 93.1% at RD and SJ.

DISCUSSION

French pharmacists can apply the pharmaceutical care model following a specific training. Further studies are required to evaluate the feasibility and the impact of pharmaceutical care in France.

[The use of head CT scan in adult trauma victims: an algorithm]

INTRODUCTION

The purpose of this study was to identify, through recursive partitioning, clinically relevant criteria which predict the need for acute neurosurgical intervention in a group of patients with mild head injury.

MATERIALS AND METHODS

A retrospective cohort of all adult patients, from April 2000 to March 2001, who sustained a blunt trauma and underwent head CT scan, was reviewed. The following inclusion criteria for mild head injury were used: initial Glasgow Coma Scale (GCS) ranging from 13 to 15; no loss of consciousness lasting more than one hour; no obvious skull fracture; a cranial CT scan performed. We collected demographic and trauma related data, interventions and outcome. Univariate and multivariate analyses were undertaken. In parallel, recursive partitioning was carried out using all variables to elaborate a decision algorithm.

RESULTS

There were 405 patients in the sample. CT identified lesions in 12% of patients. Twelve patients (3%) required acute neurosurgical intervention. The recursive partitioning analysis identified three significant sequential nodes: deterioration of the GCS; an initial GCS of 13 vs 14 or 15; and the presence of associated injuries or comorbid conditions.

CONCLUSIONS

A simple three step rule predicts the need for acute neurosurgical intervention based on clinical findings: a deteriorating GCS; an initial GCS of 13; and the presence of associated injuries or comorbid conditions.

Diabetes: a major co-morbidity of cystic fibrosis

Cystic fibrosis-related diabetes (CFRD) is a frequent complication of cystic fibrosis, its prevalence increases with age of patient and is close to 30% at the age of 30 years. As life expectancy greatly increases, the number of cystic fibrosis patients developing diabetes will increase too. CFRD shares some features with type 1 and type 2 diabetes, initial phase is characterised by postprandial hyperglycaemia followed by a progression toward insulin deficiency. Insulin deficiency is an essential factor in the development of diabetes with an additional contribution of insulin resistance. Systematic screening with an oral glucose tolerance test is recommended from the age of 14 years because clinical signs of CFRD are often confused with signs of pulmonary infection and CFRD occurrence is associated with weight and pulmonary function deterioration. In observational studies CFRD diagnosis is associated with a significant increase in mortality, while treatment allow correction of weight and lung deterioration suggesting that CFRD has a significant impact on CF evolution. Microvascular complications are recognised, although paucity of data does not permit a clear description of their natural history. Annual screening for microvascular complication is recommended. There is no evidence by now that CF patients develop macrovascular complications. The only recommended pharmacological treatment is insulin therapy.

Analysis of SWAP-70 as a candidate gene for non-X-linked hyper IgM syndrome and common variable immunodeficiency

SWAP-70 is a recently identified protein that functions as the only B cell-specific component of an isotype switch recombination complex called SWAP. The SWAP complex has specificity for the switch regions upstream of the constant region immunoglobulin genes and it facilitates the transfer of DNA between switch regions. These features suggested that mutations in the gene encoding SWAP-70 might result in humoral immunodeficiency. To test this hypothesis we determined the genomic structure of this gene and used single-stranded conformational polymorphism (SSCP) analysis to screen DNA from 38 patients with either non-X-linked hyper IgM syndrome or common variable immunodeficiency. The results demonstrated that SWAP-70 consists of 12 exons spread over 89 kb at chromosome 11p15.2. SSCP analysis of the patient population revealed five polymorphic variants in the gene, one of which (Q505E) is an amino acid substitution in the putative nuclear export signal of SWAP-70. However, none of the alterations appeared to be associated with disease in the patients screened.

Mutations in activation-induced cytidine deaminase in patients with hyper IgM syndrome

Recent studies have shown that mutations in a newly described RNA editing enzyme, activation-induced cytidine deaminase (AID), can cause an autosomal recessive form of hyper IgM syndrome. To determine the relative frequency of mutations in AID, we evaluated a group of 27 patients with hyper IgM syndrome who did not have defects in CD40 ligand and 23 patients with common variable immunodeficiency. Three different mutations in AID were identified in 18 patients with hyper IgM syndrome, including 14 French Canadians, 2 Lumbee Indians, and a brother and sister from Okinawa. No mutations were found in the remaining 32 patients. In the group of patients with hyper IgM syndrome, the patients with mutations in AID were older at the age of diagnosis, were more likely to have positive isohemagglutinins, and were less likely to have anemia, neutropenia, or thrombocytopenia. Lymphoid hyperplasia was seen in patients with hyper IgM syndrome and normal AID as well as the patients with hyper IgM syndrome and defects in AID.

The incidence and pathogenesis of cardiopulmonary deterioration after abrupt withdrawal of inhaled nitric oxide

We studied the effect of abrupt discontinuation of inhaled nitric oxide (iNO) in patients receiving this drug for treatment of acute hypoxemic respiratory failure (AHRF), in order to determine the need for continued therapy, the incidence and nature of adverse events, and the risk factors predicting these adverse events. Thirty-one patients who showed an initial increase in Pa(O(2)) of > 20 mm Hg in response to iNO underwent a discontinuation trial at 10 to 30 h after beginning iNO. Indwelling arterial and pulmonary artery catheters facilitated monitoring of hemodynamic and gas-exchange parameters. For the group, discontinuation of iNO caused a significant decrease in Pa(O2 ), arterial and mixed venous oxygen saturation, and ratio of Pa(O(2)) to fraction of inspired oxygen (FI(O(2))). Three patterns of response were observed. Eight of 31 (25.8%) patients had minimal changes in oxygenation or hemodynamics, suggesting no need for ongoing therapy. Fifteen of 31 (48%) patients had worsened gas exchange as a predominant response. Eight of 31 patients exhibited hemodynamic collapse, defined as > 20% fall in cardiac output and/or mean arterial blood pressure. In this last subgroup, the pattern of cardiovascular changes suggested that this response arose from an acute increase in right ventricular afterload, and was not a consequence of gas-exchange abnormalities. In all cases, reinstitution of iNO promptly reversed worsened hemodynamics and gas exchange. Independent factors associated with an increased risk of cardiovascular collapse included multisystem organ failure, older age, and initial blood pressure increase in response to iNO; a smaller change in the ratio of Pa(O(2)) to FI(O(2)) with initiation of iNO therapy also tended to correlate with this phenomenon. We conclude that careful and monitored discontinuation of iNO in patients with AHRF will identify substantial fractions of patients who are either receiving no benefit from this therapy or who require iNO to maintain an adequate circulation and are therefore at risk for adverse outcome with transport or inadvertent discontinuation of iNO. Future trials of iNO should recognize this complication of such therapy and include assessments for it.

Cardiopulmonary resuscitation: errors made by pre-hospital emergency medical personnel

The purpose of the current study was to evaluate the CPR techniques of emergency healthcare professionals (emergency medical technicians, firemen, emergency first responders, CPR instructors). Skills were evaluated using a Laerdal Skillmeter Manikin, which provided a computerized printout of the quantifiable data during the CPR sequence. All of the 66 subjects in the study had completed a recertification course within the last 2 years (mean = 0.86 +/- 0.18, 95% CI). The sequence was videotaped for later viewing and for correlating the errors with the data. In addition, the participants were required to fill in a questionnaire. The most frequently occurring errors were observed in landmarking, overcompression, palpating a carotid pulse and insufficient ventilation. Although 98.5% of participants made an attempt to landmark their position for compression on the sternum, 35.9% of the total compressions performed by all subjects were incorrectly positioned on the patient's chest. Overcompression of the patient's chest accounted for 55.3% of incorrect compressions. Although 94% of participants attempted to verify a carotid pulse, only 45% were able to feel it and therefore stop performing cardiac massage. Of the total ventilations, 49% were below the American Heart Association (AHA) recommended minimum (800 ml). The results of this study showed a high rate of errors occurring in the CPR provided by emergency healthcare professionals.

Trauma care regionalization: a process-outcome evaluation

BACKGROUND

Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients.

METHODS

This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III).

RESULTS

A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers.

CONCLUSION

This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Response to inhaled nitric oxide in patients with acute right heart syndrome

Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, has been shown to decrease pulmonary artery pressures but not increase cardiac output in hemodynamically stable patients with a variety of causes of pulmonary hypertension. The response to iNO in hemodynamically unstable patients with acute right heart syndrome has not been previously described. We determined the response to iNO in 26 critically ill adult patients with acute right heart failure defined by echocardiographic criteria. Patients received iNO through the inspiratory limb of the ventilator in increments of 10 ppm with hemodynamic and gas-exchange measurements made before and after each level. When maximal effect was seen, iNO was discontinued to compare parameters with baseline. iNO significantly increased cardiac output (5.5 +/- 3 to 6.4 +/- 4 L/min), stroke volume (54 +/- 27 to 65 +/- 38 ml), and mixed-venous oxygen saturation (69 +/- 8 to 73 +/- 10%), all p < 0.01. With discontinuation of iNO, all parameters returned immediately to baseline. These parameters of improved perfusion were related to a decrease in pulmonary vascular pressures and resistance. In a subset of approximately 50% of patients, these changes were substantial (> 20%) and in approximately 25% of all patients, the improvement in hemodynamic measures permitted a decrease in other vasoactive drug administration. The mean concentration of iNO required to achieve these effects was 35 ppm, and 85% of patients exhibiting a substantial improvement in hemodynamics did so at a concentration of iNO of less than or equal to 40 ppm. Underlying causes of right heart failure and baseline hemodynamics did not predict response to iNO, but the use of alpha-agonist catecholamines did. We conclude iNO improves hemodynamics in patients with respiratory failure, shock, and right ventricular dysfunction. Although mortality was not a key end point in this pilot study, it was high for both responders and nonresponders to this therapy. Further evaluation of the role of iNO in this patient population is supported by these data.

Ineffectiveness of on-site intravenous lines: is prehospital time the culprit?

The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.

Long-term follow-up after adjuvant chemotherapy in completely resected early stage ovarian carcinoma

OBJECTIVE

To evaluate the impact of standardized staging, surgery and adjuvant chemotherapy on survival of patients with completely resected early ovarian carcinoma.

STUDY DESIGN

We performed a multicentric retrospective analysis of 283 patients with early stage ovarian carcinoma consecutively treated between 1977 and 1993. Borderline tumours were excluded. A comprehensive staging was performed during initial laparotomy. Patients were treated by standardized surgical resection and all excepted stage IA received a 6-course adjuvant chemotherapy.

RESULTS

Eighty patients were excluded because of incorrect substaging, inadequate surgery and adjuvant therapy. The analysis was performed on 203 patients with completely resected early stage ovarian cancer (139, stage I; 64, stage II). Relapse-free survival and overall survival rates for stage I were 66 and 69%, respectively. Relapse-free survival and overall survival rates for stage II were 57 and 61% respectively. Median time of relapse was 18 months (range, 1-107 months). Sites of relapse were peritoneum (45%), retroperitoneal lymph nodes (37%) and distant metastases (18%). Relapses occurring within 18 months had a median survival after relapse of 9 months while later relapses had a median survival of 22 months (P = 0.005). There was no significant difference in relapse-free and overall survival according to the age, performance status and pathology. Cisplatin-based chemotherapy improved the 10-year overall survival of patients with stage IIB and IIC as compared to chemotherapy without cisplatin (oral melphalan. CMF regimen); 91 vs. 33% (P = 0.012) and 75 vs. 42% (P = 0.05), respectively. Cisplatin-based regimens did not improve survival in stage IA, IB and IIA.

CONCLUSIONS

Early ovarian cancers have a good prognosis after comprehensive staging, complete surgery and adjuvant chemotherapy. Cisplatin-based regimens compared to melphalan and CMF showed a significant increase of survival in stage IIB and IIC. Prognosis of relapse depends on the relapse-free interval duration.

Comparative degree and type of sensitization to common indoor and outdoor allergens in subjects with allergic rhinitis and/or asthma

BACKGROUND AND OBJECTIVES

The determinants of variability in the clinical expression of atopy are still to be documented. The goals of this study were to determine, in subjects with a clinical diagnosis of symptomatic asthma or rhinitis, what is the possible contribution of different types of indoor and outdoor allergens to the development of their disease, by looking at the prevalence and degree of sensitization to these allergens according to age and gender.

SUBJECTS AND METHODS

We analysed allergy skin prick tests to common airborne indoor and outdoor allergens in 3371 consecutive patients, grouped according to diagnosis of allergic asthma, rhinitis, or both. For each of these three groups, we calculated the prevalence of sensitization to indoor/outdoor allergens, the atopic index (AI), the number of positive responses to allergy skin prick test and the mean wheal diameter (MWD) of these responses.

RESULTS

The prevalence of atopy and the values of AI and MWD peaked in subjects aged 16 to 25 years, declining afterwards; in subjects > or = 18 years old, atopic indices were slightly higher in men than in women. In atopic subjects, the prevalence of sensitization was, in decreasing order, housedust (84.2%), cat hair-epithelium (76.5%), dog hair-dander (63.0%), house dust mite (54.2%), grasses (51.9%), trees (47.2%) and ragweed pollens (44.9%) and finally, moulds (25.4%). Among subjects sensitized only to outdoor allergens (n = 195). 73.8% had a rhinitis, 11.8% had asthma and 14.4% had both diagnoses; for those sensitized only to indoor allergens (n = 710), these values were respectively 48.6, 24.5 and 26.9%, and for those sensitized to both indoor and outdoor allergens (n = 1793), the comparable values were 55.5, 14.6 and 29.9%.

CONCLUSION

These data show that in our population of subjects with respiratory allergic symptoms, indoor allergen sensitization is strongly associated with asthma, while exclusive sensitization to pollens is associated primarily with rhinitis. Sensitization was more prevalent for indoor allergens than for outdoor allergens in all groups determined according to diagnosis or age. Indices of atopy were higher in men in the group > or = 18 years old. Prevalence and degree of sensitization were shown to peak in young adults, regardless of the allergen, and to diminish with age. This study stresses the role of indoor allergens in the development of asthma and shows the variability of allergic manifestations according to the type of sensitization.

Comparison of histamine-releasing factor recovered from skin and peripheral blood mononuclear cells of patients with chronic idiopathic urticaria

BACKGROUND

The pathogenesis of chronic idiopathic urticaria is characterized by defective histamine release. Skin mast cells show an increased release of histamine while circulating basophils are less responsive to immunologic stimulus.

OBJECTIVE

The purpose of the study was to examine and compare the production of the histamine-releasing factor in the skin and within the peripheral blood of patients with chronic idiopathic urticaria and normal control subjects, as a possible factor responsible for the difference observed in the releasability of both skin mast cells and basophils.

METHODS

Using the skin chamber technique, histamine-releasing factor production and histamine concentration were assessed in normal-appearing skin of patients with chronic idiopathic urticaria (n = 12) and normal controls (n = 5) over a 2-hour observation period. In both groups, histamine-releasing factor production by peripheral blood mononuclear cells was also measured.

RESULTS

The weighted average of histamine-releasing factor production during the 2-hour observation period was higher in the non-lesional skin of patients with chronic idiopathic urticaria as compared with normal controls (5.6 +/- 1.4% versus 0.7 +/- 0.6%, P < .01). In contrast, less histamine-releasing factor was produced by peripheral blood mononuclear cells in chronic urticaria as opposed to normal controls (17.2 +/- 2.1% versus 25.7 +/- 2.8%, P < .03). Spontaneous histamine concentration was not significantly different in patients with chronic urticaria than in normal controls.

CONCLUSION

Histamine-releasing factor production is increased in the skin, and decreased in the peripheral blood of patients with chronic idiopathic urticaria when compared with nonatopic controls. The lower production of histamine releasing factor in the blood could be explained by the migration of activated T-lymphocytes in the skin.

Predictive validity and internal consistency of the pre-hospital index measured on-site by physicians

Physiological measures of injury are used as triage tools to identify patients that require treatment in trauma centres. The Pre-Hospital Index (PHI) is based on systolic blood pressure, pulse, respiratory rate, (level of) consciousness, and presence of penetrating injury. The present study evaluated the validity and internal consistency of the PHI. The study was based on 628 patients assessed by physicians at the scene. Mean age was 38.7 years (SD = 24.8), and 65% were male. Motor vehicle collisions caused the injury for 45%. The majority had head/neck (56%) and extremity (45%) injuries. Mean PHI was 4.62 (SD = 5.77), 40% had a PHI of zero, 6% between 1 and 3, 32% between 4 and 7, and 21% greater than 7. The associations between PHI and rates of hospital admission, surgery, ICU treatment, mortality, duration of hospitalization, and length of ICU stay were significant (p < 0.001). A total of 260 (41.4%) patients had major trauma requiring treatment at a trauma centre. A PHI > 3 had 83% sensitivity and 67% specificity for identifying these patients. Internal consistency of the PHI variables was above the acceptable limits. This study has shown that the PHI is a valid and reliable physiological measure of injury severity and field triage tool.

Effects of systemic corticosteroids on cutaneous histamine secretion and histamine-releasing factor in patients with chronic idiopathic urticaria

BACKGROUND

Enhanced skin mast cell releasability of histamine, increased production of histamine releasing factor (HRF), and cutaneous inflammatory process are the hallmarks of chronic idiopathic urticaria (CU). Although H1-antihistamines are known to alleviate the symptoms effectively in most cases, systemic corticosteroids (CS) are given in more resistant patients. Their mode of action remains a matter of controversy.

OBJECTIVES

In the present study, the effects of a 7-day course of CS or placebo on histamine content and HRF production in non-lesional skin of 19 CU patients were examined.

METHODS

Using the skin chamber technique, HRF production and histamine content were assessed in normal-appearing skin of patients with CU over a 2-h observation period. Those two parameters were measured before and after treatment, in a double-blind fashion.

RESULTS

No significant changes occurred in any parameters after placebo treatment. In contrast with this, significant decrease of HRF activity was observed after 1 week of oral methylprednisolone while no change was documented for histamine secretion.

CONCLUSION

These data suggest that CS therapy improves symptoms of CU in association with a decreased production of HRF in uninvolved skin.