Médiatisation et « greffe de visage » ou « à qui appartient la greffe de visage » ?

Mediatisation of a scientific event could be neither controlled, nor verifiable. The experience which has been lived through the first worldwide allotransplantation of composite tissues of the face confirms that the actors of a surgical innovation are not the owners. Because there is neither confidentiality nor possible patent. Curiously the scientific world, providing with a sharing ethic, which rightly privileges the free spreading of knowledge in the way that most people could benefit of it. Obviously it is made without denied controversy, for truth as purpose. This scientific word that way joins the media one, with a specific ethic of the duty of information, but also interested in mercantile preoccupations quick to cultivate controversy not to enlighten this truth but to better sell pictures or papers. Than the author should only sustain this instrumentation which could certainly flatter him, and from which he could used, but in reality that paralysed him a little to go on in serenity with his shadow worker way.     

Kétamine en anesthésie pédiatrique : utile,futile ou … ?

The use of ketamine for paediatric sedation-anaesthesia-analgesia is still growing despite the availability of adequate alternatives. Based on the literature, the present work will briefly review the well-known properties underlying the widespread use of this drug in this particular clinical situation. In adult patients, the use of ketamine as a new element of the balanced anaesthesia-analgesia is also ever growing. This is based on the recently demonstrate antihyperalgesic and anti-pro-inflammatory properties of this drug. This work questions the existence of such benefits in the paediatric population. Finally, the "dark side" of ketamine will be discussed. Experimental studies on developing brain clearly demonstrate that this old anaesthetic is a potent trigger for pathologic neuronal apoptosis.     

Quand faut-il décider d'un transfert en milieu neurochirurgical spécialisé ?

The annual incidence of severe head injury lies between 9 and 25/100000 inhabitants, depending on the criteria used for its definition. In most countries, the shortage in neurosurgical ICU beds makes it impossible to take in charge all patients with a severe brain injury. But the beneficial effect of a specialized neurosurgical ICU on outcome after brain injury has been demonstrated in several retrospective studies. Ideally, the best strategy is to admit the patients with a severe head injury directly in a neurosurgical centre. When this is not possible, the appropriate decision of a secondary transfer relies on the quality of the relationships between physicians in the community and the neurosurgical hospitals. Teleradiology is the best method to avoid unnecessary transportation or deleterious delays before transfer. In an era of decreasing medical budgets, technical improvements to enhance medical cooperation should be encouraged.     

Le Flag A2 : un drapeau rouge dans le sepsis ? Rappel technique et intérêt comme marqueur du sepsis

The biphasic waveform (BPW) is an abnormality of the optical transmission waveform obtained during measurement of the activated partial thromboplastin time on a specific photometric haemostasis autoanalyzer. This abnormality is related to calcium-dependent formation of complexes between C reactive protein and very low density lipoprotein. Biphasic waveform had a high sensitivity and negative predictive value for the identification of patients with severe sepsis and septic shock. On day 3, the time course of the biphasic waveform is a marker for the prognosis of sepsis-related mortality. The BPW is not a surrogate marker for C-reactive protein or procalcitonin and provides additional information. Further trials should be necessary using BPW for diagnostic and management procedures. Compared with other laboratory markers such as C reactive protein or procalcitonin, activated partial thromboplastin time waveform analysis is a tool that is rapid, inexpensive, effective and available 24 hours a day. When the analyzer is locally available, waveform analysis of this routine coagulation test provides information for the diagnosis of severe sepsis and the prognosis of septic patients.     

Esophageal Atresia: Gastroesophageal functional follow-up in 5–15 year old children

Purpose

Esophageal atresia (EA) is one of the most frequent congenital alimentary tract anomalies with a considerable morbidity throughout childhood. This study evaluates the gastroesophageal problems in 5–15 year old children with EA and aims to identify factors predisposing to esophagitis in EA.

Material and methods

Fifty-nine patients primarily operated at Odense University Hospital, Denmark, during 1993–2005 were included in this follow-up study. The patients underwent the following examinations: Interview, upper endoscopy, endoscopic ultrasonography, high-resolution esophageal manometry (HREM), and pH- and multichannel intraluminal impedance (MII) measurements. Twenty-five patients with suspected gastro-esophageal reflux disease (GERD) underwent the same investigations and served as controls.

Results

Median age was 10.2 years (7.1–13.3). Thirty-three (55.9%) presented with GERD symptoms, 41 (69.5%) with dysphagia, and 33 (55.9%) with respiratory symptoms. Twenty-nine (49.2%) had endoscopic esophagitis, and 26 (44.1%) histological esophagitis. Median reflux index (RI) was 8.3 (4.8–14.9). In 32 (55.2%) RI was above 7. Ten percent had eosinophilic inflammation. HREM showed dysmotility in the esophagus in all EA patients, 83.3% had no propagating swallows. No predictive factors predisposing the development of endoscopic esophagitis were identified.

Conclusions

Gastroesophageal problems in children born with EA are common. Routine follow-up with endoscopy and pH-metry in EA patients is warranted.     

Lésions ischémiques secondaires : comment les prévenir ?

In addition to the initial lesions related to the brain injury, the final outcome depends also largely on the secondary ischaemic lesions. These lesions result from hypoperfusion whatever the mechanisms. It is then essential to detect early the conditions at risk of ischaemia, to be treated aggressively since the initial care. The multimodal monitoring is the only way to diagnose these conditions, to provide information about the mechanisms, and then to better adapt the treatment. Such an early detection helps to limit the consequences of the initial trauma, and may improve outcome.     

L'entropie : un moyen d'apprécier le défaut d'analgésie ?

Objective

Comparison between BIS (Bispectral Index) and state (SE) and response (RE) entropy during laparotomy for inflammatory bowel disease patients (IBD) and evaluation of the variations of RE and SE during nociceptive stimulation.

Study design

Prospective, observational study.

Patients and methods

Fourteen IBD's patients undergoing laparotomy were included. Anaesthesia aimed to maintain BIS between 40 and 60 by isoflurane and nitrous oxide. Analgesia was performed by sufentanil bolus administrated according to an increase of 20% of systolic blood pressure (SBP) and heart rate compared with the baseline values. BIS, RE and SE were measured at each nociceptive stimulation. A variance analysis (Anova) was used to assess BIS, RE and SE variations throughout surgery (p < 0.05 as significant). Relationship between BIS, RE and SE was assessed by Pearson correlation (p < 0.01 as significant). The ability for SE and RE to predict depth of anaesthesia and intraoperative analgesia was performed by calculating aera under the receiver operated curves (AUC).

Results

BIS and entropy parameters had strictly the same evolution during anaesthesia. SBP increased significantly during nociceptive stimulation while no variation of RE was observed. A significant correlation was shown between BIS, RE and SE. The evaluation of anaesthesia depth was good for RE (AUC: 0.932 ± 0.26) and SE (AUC: 0.926 ± 0.27). There was however no difference between RE and SE to predict analgesic requirement.

Conclusion

Because RE includes muscular frequency analysis, it does not allow analgesic requirement evaluation in paralyzed patients.     

Le certificat de décès : comment le remplir et pourquoi ?

The death certificate must be established within 24 hours following the death and handed to the mayor. The obligation to place in the coffin immediately is planned by a defined list of contagious diseases. Medicolegal obstacle must be ticked if there is a doubt on the cause of death. In order to look into the causes of the death, swabs can be asked by the physician. It is a medical or scientific autopsy to look into the causes of the death apart from a juridical procedure. The presence of a battery prosthesis (pacemaker) must be specified, so that it can be removed by a physician or a thanatopractionner before the placing in the coffin. Death certificate is passed on by the city hall to Insee, which updates the identification national register of physical people. Inserm receives anonymous data of the causes of death allowing to establish the mortality national statistics. In the absence of medicolegal obstacle or obligation to place in the coffin immediately, funeral operations can begin: preservation care, body transport, placing in the coffin and finally burial or cremation.     

Continuer,limiter ou arrêter ? Évolution des modalités de décès sur une période de 6 ans en réanimation pédiatrique

Since 2005, forgoing live-support (FLS) is allowed by the French law (known as the Leonetti law) for end-of-life patients only. This study aims at describing the variations over time in the use of the following methods to end life: FLS, brain death and cardiopulmonary resuscitation failure (CPR failure). It is a single retrospective study from 2007 to 2012. The Cochran-Armitage trend test is used in the statistical analysis. Over six years, 263 of the 5100 children who were hospitalized in our intensive care unit died, which represents a 5.2% mortality rate. FLS increased yearly from 31% of the deaths in 2007, to 71% in 2012 (P = 0.0008). The rate of CPR failure decreased over the same period (P = 0.0015). The rate of brain death remained constant. Following to the Leonetti law, FLS increase, and palliative cares develop without any increase of mortality.     

Anesthésiques généraux en pédiatrie : risque ou bénéfice ?

The practice of paediatric anaesthesia has changed during the last 25 years, with a noticeable reduction of mortality and serious morbidity. This improvement results in part from the use of new anaesthetic agents which large therapeutic interval regarding cardiovascular effects. Parallel to this advance and following experimental or clinical studies in neurosciences, some new concerns have emerged regarding short and long time consequences of anaesthesia. Indeed, postoperative hyperalgesia due to opioids, emergence agitation and postoperative maladaptive behavioural changes are widely described in children, in the same way the potential epileptogenic effect of sevoflurane is demonstrated. Thus the hypothetical cerebral toxicity leads us to reconsider our practice. Basically, monitoring of cerebral cortical effects of hypnotics is now possible from automated devices based on EEG, allowing us to control the administration of hypnotic agents. The therapeutic interval of these agents, previously determined between movement at incision and deleterious cardiovascular effect, may be revisited with a cerebral approach, with the risk of memorisation for the lower limit and the risk of cerebral over dosage for the upper limit. Lastly, further experimental and clinical studies are required to analyse the effects of the anaesthetic agents on the brain of the neonate, and the interest of the cerebral monitoring in this population.     

Patella Denervation in Primary Total Knee Arthroplasty – A Randomized Controlled Trial with 2 Years of Follow-Up

We randomized 126 consecutive patients undergoing primary total knee arthroplasty into group 1: patella denervation (n = 63) and group 2: no patella denervation (n = 63). Assessment was performed preoperatively and at 3, 12 and 24 months post-operatively. Average follow-up of patients was 26.5 months for denervation group and 26.3 months for no denervation group (P = 0.84). Pain scores for anterior knee pain were significantly better in the denervation group at 3 months but not at 12 and 24 months. Patient satisfaction was higher in the denervation group. Flexion range was higher in the denervation group at 3, 12 and 24 months review (P < 0.01). There were, however, no statistically significant differences with other validated knee scores.     

Laser Doppler Imaging prediction of burn wound outcome in children: Is it possible before 48 h?

Background

Laser Doppler Imaging (LDI) assists in prediction burn wound outcome. Previous data has validated this technique in children between 48 and 72 h after burn.

Aim

To evaluate the ability of Laser Doppler Imaging (LDI) to predict burn wound outcome in paediatric patients prior to and after 48 h from the time of injury.

Methods

A prospective evaluation was performed in 400 children over a 12-month period that presented to our burns clinic. Patients were divided into two groups: those that presented within 48 h of injury (n = 160) and those that presented after 48 h (n = 240). Patients were reviewed until healing had occurred or operative intervention was required.

Results

The median age of the patients was 2.4 years (range 0.1–15.9 years). For patients who presented within 48 h, the sensitivity and specificity of the LDI was 78% and 74% respectively compared to 75% and 85% for those scanned after 48 h. This difference was not statistically significant.

Conclusions

LDI predicted burn wound outcome in children within 48 h of the burn wound. Moderate degrees of movement, infection, whether first aid was administered and type of dressing did not impact on the accuracy of LDI.     

Reconstructions mammaires différées,quelles stratégies ?

Breast reconstruction is part of the treatment of breast cancer needing mastectomy. To deal with the numbering technics in breast reconstruction surgery and with the number of patients seeking reconstruction, the authors proposed a strategy taking care of the patients wishes, of the patients morphology and of the surgicals limits of the different technics. On this aim, the authors reviewed a 30 patients series of secondary breast reconstruction composed of 23 inferior gluteal free flaps, 4 transverse rectus abdominus myocutaneous flaps and 3 latissimus dorsi musculocutaneous flaps.