Analgésie par la buprénorphine sublinguale dans la lithotritie extracorporelle rénale

The efficacy of sublingual buprenorphine given for premedication was assessed in 287 consecutive patients scheduled for extracorporeal shock wave lithotripsy (ESWL). The patients were randomly assigned to three groups. They were given 45 min before starting ESWL 5 mg midazolam orally in group 1 (n = 97), and 5 mg midazolam orally and 0.2 mg sublingual buprenorphine in group 2 (n = 97), and 5 mg midazolam orally and 0.4 mg sublingual buprenorphine in group 3 (n = 93). Analgesia was assessed with a simple three step verbal scale : no pain, moderate pain treated with simple analgesies (Spasfon®, Viscéralgine®), and exquisite pain requiring general anaesthesia. Sublingual buprenorphine provided good analgesia in 87 % of group 2 patients, and 88 % of group 3 patients (NS) whereas 70 % of group 1 patients experienced no pain (p < 0.05). The incidence of side-effects during the 12 h following ESWL, such as nausea, vomiting and drowsiness, was higher in group 3 (31 patients) than in group 2 (13 patients) (p > 0.01). No clinical respiratory depression occurred, although 11 patients in group 3 complained of drowsiness. It is concluded that premedication with 0.2 mg of sublingual buprenorphine provides efficient analgesia for ESWL and few side-effects.     

Complication rare de la transplantation rénale : la pyélonéphrite emphysémateuse

Emphysematous pyelonephritis is a necrotizing infection of the renal parenchyma and peri-renal tissues, characterized by the presence of air within the parenchyma of the urinary tract and peri-renal space. This is a severe complication, which involves the functional prognosis of the kidney and the patient's prognosis. The emphysematous pyelonephritis is a rare complication of renal transplantation. Its gravity is linked particularly to the fragility of immunosuppressed patients. The authors report the case of an emphysematous pyelonephritis having occurred 9 months after transplantation in a patient 58 years. The evolving risks and therapeutic modalities will be outlined and discussed.     

Prévention de la douleur postopératoire

The pre-emptive analgesia concept suggests that pre-administration of analgesics may enhance the efficacy of these drugs. This review has selected the data from the literature according to two types of methodological criteria: Sackett's criteria, and those specific of pre-emptive analgesia studies. Infiltration, spinal and peripheral nerve blocks using local anaesthetic drugs do not seem to produce pre-emptive analgesia. The few positive results have limited clinical significance. The results concerning opioids are contradictory and the clinical significance is limited. Preoperative oral administration of non steroidal anti-inflammatory drugs (NSAIDs) offers no benefit. Intravenous pre-administration has a limited advantage, but enhances perioperative bleeding. Kétamine, an NMDA receptor antagonist, may have some pre-emptive analgesic properties according to the few studies available. In conclusion, pre-administration of analgesic drugs represents the usual strategy for the anaesthesiologist (spinal or peripheral block, infiltration, opioids). In other cases (NSAIDs, kétamine), pre-administration represents a change in usual practice. This is not justified for NSAIDs; NMDA receptor antagonists may offer an interesting research area. Data concerning pre-emptive analgesia for chronic pain syndrome such as phantom limb pain are quite limited.     

Techniques de la décortication

Decortication is a surgical procedure that consists in restoring the ventilatory function of the lung by removing the constricting membrane that compresses it over the mediastinum. The constricting membrane is the last stage of loculated and complicated pleural effusions: haemothorax, empyemas, pleural tuberculosis, various other pleural diseases and sequellae of earlier collapsotherapeutic procedures. Decortication typically involves removal of the entire complicated pleural disease, freeing the visceral pleura (decortication strico sensu) and the parietal pleura (pleurectomy). After decortication the lung can expand again and improved functioning can be expected. Multiple technical procedures are available. When the pleural thickening is induced by underlying lung disease, it may be necessary to resect the underlying diseased parenchyma during the same intervention. In chronic parapneumonic empyemas, the current availability of video-assisted procedures allows to avoid thoracotomy for decortication.     

Approche paléo-épidémiologique de la maladie hyperostosique

A paleoepidemiological study of diffuse idiopathic skeletal hyperostosis. — Objective. To investigate the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in ancient populations. Materials and methods. We studied 38 women and 61 men aged at least 30 years at death, whose remains were recovered from four cemeteries of the High Middle Ages (VIth to VIIIth century) located in Lorraine (eastern France). Criteria previously developed by Crubézy and Crubézy—Ibanez for paleopathological studies were used to determine whether the skeletal remains exhibited definite, possible, probable, or no DISH. Results. Definite DISH with flowing ossification along the thoracic spine and ossification of peripheral enthesopathies was seen in 2.8 to 3.7 % of the subjects from two cemeteries and in none from the other two cemeteries. Identical figures were found for possible DISH. The prevalence and male predominanc (9 of 13 subjects in any DISH category were males) were similar to those reported in contemporary studies and in other paleopathological studies. Conclusion. In the absence of clinical data on the metabolic status of the study subjects, our results suggest that DISH in our subjects was a marker for older age at death.     

Épidémiologie de la douleur postopératoire

Postoperative pain, as all types of pain, is a complex phenomenon including sensory, emotional and behavioural factors. The incidence and severity of postoperative pain is very variable between patients and is rather unpredictable. Patients characteristics as well as the types of surgery and anaesthesia will be of importance. Health professionnals have a major role to play for improving effectiveness of pain management as well as safety.     

Validation francophone de la grille d’évaluation de la douleur-déficience intellectuelle – version postopératoire

Purpose

The aim of the study was to test the validity of a French language version of the Non-Communicating Children’s Pain Checklist - Postoperative Version (NCCPC-PV): grille d’évaluation de la douleur-déficience intellectuelle (GED-DI).

Methods

We assessed the intensity of pain in 87 intellectually disabled surgical patients recruited in four Canadian and French hospitals in the pre- and post-operative settings using the GED-DI, a 100-mm visual analogue pain scale (VAS) and the Rosen sedation scale. The validity of the GED-DI was measured by the difference in scores between pre- and postoperative conditions. The checklist was made up of 30 items divided into seven subgroups. Items were rated from 0 to 3 for a total score ranging from 0 to 90 points.

Results

The mean (standard deviation) age of the patients was 17 (11) yr and the mean mental age 24.5 (24) months. The total GED-DI score was 6.1 (4.9) pre- and 13.4 (11.2) post-surgery (P < 0.001). All subgroups had a higher score after surgery (P < 0.001). The receiver operating characteristic (ROC) curves, comparing the absence of pain to mild pain scores and moderate to severe pain scores, showed a cutoff at 6 (mild pain) and 11 (moderate to severe pain).

Conclusion

The French version of the NCCPC-PV can be used to assess pain in non-communicating patients with intellectual disabilities in a postoperative setting. It has good content validity, as the total pre-surgery score for the GED-DI was significantly lower than the postoperative score, and showed a good concurrent validity when compared to the VAS.