Treatment of intracranial dural fistulas with Onyx : a prospective cohort, systematic review, and meta-analysis

BACKGROUND Onyx is important embolic material in the endovascular treatment of intracranial dural arteriovenous fistula (DAVF). However, its impact on DAVF occlusion rates, morbidity, mortality, and complication rates is not fully examined. OBJECTIVE To improve understanding of safety and effectiveness profiles associated with transarterial endovascular treatment using Onyx for intracranial DAVF METHODS We analyzed data from our prospective clinical registry and conducted a systematic review of all previous transarterial embolization studies using Onyx published between January 2005 and December 2015 in MEDLINE and EMBASE. RESULTS In the prospective study, 41 transarterial procedures were performed in 33 consecutive patients harboring 36 DAVFs. Complete initial exclusion was obtained in 32 of 36 (88.9%) fistulas; 31 fistulas were followed up showing 4 (12.9%) recurrences. Procedure-related morbidity and mortality were 3% and 0%, respectively. The literature review identified 19 studies involving a total of 425 patients with 463 DAVFs. Meta-analysis, including our registry data, showed an initial complete occlusion rate of 82% (95% confidence interval [CI]: 74%, 88%; I2, 70.6%), and recurrence rate at midterm of 2% (95% CI: 0%, 5%; I2, 21.5%). Pooled postoperative neurological deficit, procedure-related morbidity, and mortality rates were 4% (95% CI: 2%, 6%; I2, 0%), 3% (95% CI: 1%, 5%; I2, 0%), and 0%, respectively. CONCLUSION This meta-analysis suggests that transarterial embolization with Onyx is a safe treatment modality for DAVFs. Although Onyx showed a low recurrence rate at midterm, the long-term risk is poorly addressed in our study and should warrant a longer follow-up

Contributions and Prospects of Hemoglobin Derivatives

Anoxia-reoxygenation leads to severe metabolic alterations, which result in a generalized inflammatory reaction and multiple organ dysfunction. Direct blood transfusion limits these alterations, but is accompanied by risk of transmission of infections or viral diseases. To avoid these risks, "blood substitutes" have been designed. The modified hemoglobins are not true blood substitutes because they do not possess the complex functions of erythrocytes. They are only oxygen carriers, with a short intravascular life, adapted for temporary use. They are stable, devoid of toxicity and antigenicity, and are able to carry and deliver O2 without regulation of this oxygen transport and without chemical reaction with O2. They possess rheologic properties and an oncotic pressure like those of blood. The use of natural hemoglobin solutions, obtained after lysis of erythrocytes, remains "at risk" because these solutions easily form methemoglobin, increase the oncotic pressure, present renal toxicity, and possess a too high affinity for O2. For these reasons, 5 types of modified hemoglobin solutions have been designed, prepared from human or bovine hemoglobin or by genetic engineering. These hemoglobins are highly purified to eliminate trace amounts of stroma, lipids and endotoxins, which are responsible for acute toxicity. They are modified by internal cross-linking between the monomers, or by binding to macromolecules. Afterwards, they can be polymerized or encapsulated in liposomes. The purpose of these modifications is to modulate the affinity for O2 (by decreasing the binding of O2 and increasing its delivery to tissue), to reduce the dissociation into monomers and to guard against oxidation into methemoglobin. Encapsulation in liposomes allows co-encapsulation of effector molecules and protective substances. Genetic engineering allows the production of recombinant hemoglobin with selective modifications. The modified hemoglobin solutions are essentially used in hemorrhagic shock and perioperative hemodilution. Experimental work in animals has afforded good results: restoration of normal O2 pressure and no toxicity. These assays allow frequent observation of an unexpected rapid hypertensive effect, transient, reversible, and that could be controlled by antihypertensive drugs. The mechanisms of this hypertensive effect remain controverted (stimulation of endothelin production, inhibition of nitric oxide effects, etc.). In humans, studies with healthy volunteers have been completed, while phase II clinical studies are under way in hypovolemic shock, in major abdominal, orthopedic and cardiac surgery, in stroke and in intensive care patients after surgery. The detailed results are awaited, but the modified hemoglobin solutions already appear to be without toxicity and present the same hypertensive effect as observed in animals. However, until now only low doses have been used, and the catabolism of these solutions remains largely unknown

Intérêt de l'utilisation des substituts érythrocytaires

peer reviewe

Red blood cell substitutes: fluorocarbon emulsions and haemoglobin solutions.

The problems posed by transfusion of homologous blood have led to the development of substances able to replace the gas transporting properties of blood. Perfluorocarbons (PFCs) emulsions and modified haemoglobin (Hb) solutions have been developed for this goal and are now tested in clinical assays. PFCs are synthetic fluorinated hydrocarbons, capable of dissolving large quantities of oxygen (O2; without binding) at high inspired concentrations of O2, and of delivering this O2 to the tissues. They are administered as emulsions containing particles with a diameter of approximately 0.2 micron, capable of entering the microcirculation. They are eliminated unchanged by the lungs within several days. Fluosol-DA 20% was the first PFC emulsion used in clinical practice. Currently, Oxygent, a second generation PFC emulsion, is being evaluated in clinical studies. The PFCs are not blood substitutes, but rather a means to ensure tissue oxygenation during extreme haemodilution. Solutions of free Hb do not have the antigenic characteristics of the blood groups, and do not require compatibility testing. They are fully saturated with O2 at ambient FiO2. The Hbs used are derived from either human or bovine sources, or via recombinant DNA technology. In order to maintain satisfactory intravascular half-life and O2 affinity, the Hb molecules are modified by adding internal crosslinks, by polymerization, and/or by encapsulation. After promising animal studies, several of these modified Hb solutions are now being studied in Phase III clinical trials. Among them, diaspirin cross-linked haemoglobin (DCLHb) has been used in cardiac and orthopaedic surgery, and for resuscitation of traffic accident victims. The initial results of multicentre trials are now being analysed

Red Cell Substitutes: Perfluorocarbon Emulsions and Hemoglobin Solutions

OBJECTIVE: To review the current data on perfluorocarbon (PFC) emulsions and haemoglobin (Hb) solutions. DATA SOURCES: For this paper we analysed the literature using Medline search along with major review articles. DATA SELECTION AND EXTRACTION: The collected articles were reviewed and selected according to their quality and originality. DATA SYNTHESIS: PFCs are synthetic fluorinated hydrocarbons capable of dissolving, at increased FIO2, large amounts of oxygen. They deliver oxygen at tissular level, and are administered as emulsions containing particles of around 0.1 micron, reaching the smallest vessels. They are exhaled unchanged by the lungs within 7 days. The first clinically used PFC was Fluosol-DA 20%. Currently, Oxyfluor 40% and Oxygent 60% are under evaluation. PFCs are not true blood substitutes, but rather a means to support tissue oxygenation during extreme haemodilution. Solutions of free Hb do not require compatibility testing and are fully saturated with oxygen at ambient FIO2. Hb is either human, bovine or recombinant Hb. In order to maintain adequate intravascular half-life and affinity for oxygen, the Hb molecules are modified by internal cross-linking, polymerisation and encapsulation. After promising results using animal models, some of these modified Hb solutions are now undergoing phase III clinical trials. Among these, diaspirin cross-linked haemoglobin (DCLHb) has been tested in cardiac and orthopaedic surgery, as well as in trauma patients. The initial results of these multicentre trials are currently being analysed

Analgésie après chirurgie orthopédique du membre inférieur: intérêt de l'anesthésie locorégionale périphérique

peer reviewe

Occupation diachronique d'un méandre du Doubs à Osselle : plusieurs phases de la pars rustica d'une villa et occupation protohistorique : Osselle-Routelle, Base de Loisirs (Doubs) : rapport de diagnostic

Le projet d’agrandissement de la base de loisirs sur la commune d’Osselle-Routelle a suscité une prescription archéologique portant sur une surface de 56 220 m².L’opération conduite à Osselle Base de Loisirs révèle un site rural stratifié avec une occupation allant a minima de la Protohistoire à l’époque moderne voire contemporaine.Le diagnostic apporte des données sur l’évolution hydro-sédimentaire de la plaine du Doubs au cours de l’Holocène. Quatre phases ont été enregistrées au sein des sédiments fossilisés dans la dépression présente sur notre emprise : la période du Mésolithique, l’âge du Bronze final/Hallstatt, l’âge du Fer et enfin la période gallo-romaine. L’étude géomorphologique a permis de mettre en évidence un paléochenal en activité à une période correspondant probablement au Boréal.Un niveau préhistorique est présumé par une couche, Hz 7, et par la datation d’un charbon de bois provenant de la fosse st. 47 (sd 104). Bien que cette datation soit à prendre avec précaution, car il peut provenir des alluvions, la stratigraphie nous amène à penser qu’un niveau préhistorique peut être préservé sur l’emprise du diagnostic ou dans ses environs proches.Au sein d’un paléochenal fossile, la période protohistorique (Bronze final/Hallstatt) a livré des tessons céramiques pouvant provenir de l’habitat de hauteur La Veloupe ou d’une occupation de cette période localisée dans les parcelles environnantes.La période laténienne était supposée par la présence d’un enclos quadrangulaire visible en photographie aérienne dans les parcelles voisines. Sur l’emprise du diagnostic a été détecté un fossé d’enclos (sd. 15) dont la datation radiocarbone d’un charbon de bois l’attribue à La Tène B/C1. Cet enclos fait probablement partie d’un établissement rural dont les vestiges seraient situés sous la phase antique la plus ancienne du site diagnostiqué.La période antique a livré de nombreux vestiges (maçonneries, fosses, fossés, voies, sépulture) dont nous pouvons proposer au moins trois états d’occupation associée à la villa La Bourelle : le début du Ier siècle, la seconde moitié du Ier siècle-IIe siècle et enfin le IIIe-IVe siècle. Ces phases illustreraient l’évolution d’une villa modeste (état le plus ancien) vers une villa à plan axial à partir du IIIe siècle. Ce fait a déjà été observé par de nombreux exemples en Gaule.Les périodes les plus récentes (moderne et contemporaine) sont illustrées sur le site par au moins un chemin

The Hemovigilance Commission of the University Hospital Center

peer reviewedAs suggested by the National Blood Council, a Hemovigilance Committee was set up in the University Hospital of Liege in 1995. A multidisciplinary discussion takes place on any action aiming at the improvement of transfusion safety, and the follow-up of its implementation. The first issue to be discussed was the set up of a detailed documentation of all blood transfusions. The data are now recorded on a single document allowing proper identification of people and products involved, and of the eventual incidents. This document has lead to a better transfusion safety and to an improved administrative management of blood transfusion. The Commission has been coordinating two multi-centric studies analyzing the consumption of fresh blood products and the incidence of transfusion reactions. Among blood-saving policies, autologous transfusion and volume reduction of samples drawn for laboratory purposes have been discussed. Other measures were taken to improve the labeling of samples for cross-mach and to actively follow-up transfusion reactions. By its actions and advises, the Commission aims to direct strategies towards a safe and rational use of blood products