Dermohypodermites bactériennes nécrosantes et fasciites nécrosantes : chez l’enfant aussi !

Necrotizing soft tissue infection in children with or without necrotizing fasciitis is a rare bacterial infection. Varicella and trauma represent the most frequent predisposing factors. These infections must be early diagnosed, before the occurrence of any complication, including extension necrosis of soft tissue and septic shock. Magnetic resonance imaging and computed tomography-scan are helpful to delimit necrosis extent in deeper tissues. However, indications should be discussed according to infection localisation and imaging timing should not delay appropriate care. Group A β-hemolytic streptococcus is the most common microorganism associated with these infections, although incidence of Staphylococcus aureus is increasing. Death occurs in 5–20% of patients. Good prognosis is related to early diagnosis, antibiotic treatment and surgery. This emergent multidisciplinary approach is sometimes difficult to manage in paediatrics because of the rarity of these infections.     

Prise en charge multidisciplinaire des pneumopathies nécrosantes ventilées

Pneumonia may be complicated by necrosis and destruction of lung tissue due to factors related to both pathogen and host as well as to their interactions. Lung necrosis may lead to two main entities sharing common features, but also several clinical and pathological differences: lung abscesses and necrotizing pneumonia. Necrotizing pneumonia is characterized by diffuse, possibly bilateral, lung parenchyma inflammation with multiple cavitations and necrosis. Necrotizing pneumonia is usually associated with severe sepsis and acute respiratory failure. Adequate antibiotics, mechanical ventilation, pleural drainage, and prolonged supportive care are mandatory. Adult patients with necrotizing pneumonia may require surgery. In our practice, indications for surgery are: (1) uncontrolled sepsis in spite of medical therapy and chest drainage; (2) major air leaks responsible for ventilation difficulties with serious hypoxemia/hypercapnia; and (3) hemodynamic disturbances by compression of vena cava and/or right heart cavities by tumor-like forms. Surgical treatment should be adapted to each case. Despite serious morbidity, massive parenchyma damage and prolonged hospitalization, long-term outcome following necrotizing pneumonia seems good when multidisciplinary care management is used in these patients with unusual but severe respiratory infectious disease.     

Détection génotypique des résistances bactériennes : de la phénotypie à la génotypie,deux méthodes complémentaires

The problem of emerging resistance urges clinicians to prescribe narrow-spectrum antibiotic targeted to the specific causative pathogen. In hospital, a high level of antibiotic use and a propensity for genetic exchange between bacteria provide a perfect environment for multiresistant micro-organisms. Detection of antimicrobial resistance is important to optimise decisions about antimicrobial therapy. In order to prevent or to slow the spread of resistance among bacterial strains, clinicians must know as soon as possible which bacteria they are dealing with and to which antibiotic the strain is susceptible. This essential information can take several days up to weeks using traditional culture-based methods. In most cases such phenotypic susceptibility tests continue to be useful and get improve. Now automated systems are available to determine the infectious strain and its susceptibility to antibiotics within hours. In the near future, genetic methods as DNA-based solutions will be able to identify an infectious agent and its resistance pattern in less than an hour. Applied DNA technology progresses and will lead to the development and application of sophisticated new strategies for the analysis of antibiotic resistant bacterial strains. In the present knowledge, both methods for the determination of antimicrobial resistance, the phenotypic and the genotypic tests, are complementary.     

Agrumes et prévention des maladies neurodégénératives

Some data from pathophysiological and epidemiological studies are consistent with the role of nutritional factors in the occurrence of neurodegenerative diseases such as Alzheimer disease and age-related cognitive decline. Citrus fruits rich in polyphenols and some vitamins are candidates for this role of nutrition, through their antioxidant and antiinflammatory effects. Some data in animals and humans report this effect. However, there is a lack of specific studies of citrus fruits on cognitive function.     

Anatomie et neuro-imagerie de la névralgie trigéminale

The trigeminal nerve is the largest and most complex of the 12 cranial nerves. It supplies sensations to the face, mucous membranes, and other structures of the head. It is the motor nerve for the muscles of mastication and contains proprioceptive fibers. It exits the brain by a large sensory root and a smaller motor root coming out of the pons at its junction with the middle cerebral peduncle. It passes laterally to join the Gasserian (semilunar) ganglion in the Meckel cave. Trigeminal neuralgia (TN) is a debilitating facial pain disorder, frequently caused by vascular compression of the trigeminal nerve. The most frequent cause of TN is a mechanical irritation of the nerve caused by neurovascular contact, the neurovascular compression syndrome (NVCS). It is widely believed that compression in the socalled root entry or exit zone of the nerve causes NVCS. Most investigators define the root entry or exit zone as the region extending from the nerve’s point of entry into or exit from the brainstem to the point of transition from the central myelin (oligodendroglia) to the peripheral myelin (Schwann cells). The superior cerebellar artery is responsible for most cases of NVCS. Imaging combined with clinical information is critical to correctly identify patients who are candidates for microvascular decompression. We review trigeminal nerve anatomy and propose to recognize important magnetic resonance imaging findings in patients with trigeminal neuralgia.     

Bénéfices cardiovasculaires du cacao et du chocolat

Chocolate has probably a favourable effect on cardiovascular health. First we describe the nutrients which are good candidates for this benefit; then we review the experimental, clinical, epidemiological studies and the meta-analysis allowing to support this hypothesis. We analyse the probable implied mechanisms: particularly the cocoa’s polyphenols exert effects on endothelial function and through this mechanism lower blood pressure.     

Pharmacogénétique, addiction et opioïdes

Pharmacogenetics studies the effect of genetic variations, polymorphism or mutations in relation to the drug response. Its aim is to enable treatments to be adapted based on the genetic status of the patient. This paper summarises the current knowledge regarding the various genetic factors that influence the response of patients to opiates used as analgesia and that can be correlated to the risk of developing an addiction. It also provides information on the influence of inter-individual variability of the response to substitute treatments.     

États de mal convulsifs généralisés francs et larvés de l’adulte : avancées et perspectives

Overt or subtle generalized status epilepticus is a syndrome reflecting a focal or diffuse cerebral dysfunction. Its management is urgent and difficult: the diagnosis must be firmly established, seizures and other clinical and biological factors that may worsen cerebral dysfunction controlled, aetiology identified and treated. Definition of status epilepticus varies among authors, which impedes generalization of the results of the clinical trials and their acceptation by physicians. Although the first line treatment, which must include prolonged action antiepileptics, is rather well codified, difficulties persist to apply the detailed predefined management protocols. The electroencephalogram is underused, whereas it is sometimes absolutely required for diagnosis purpose (elimination of a factitious status, hypoxic-ischaemic encephalopathy, detection of a subtle generalized status epilepticus) or therapeutic purpose (rational management of refractory convulsive status epilepticus). Hypoxic-ischaemic encephalopathy, often confused with subtle generalized status epilepticus, needs to be better characterized especially its electroencephalographic patterns. First-line treatment is not consistently successful in terminating the seizures and more effective treatments are needed, particularly for refractory convulsive status epilepticus. These treatments will require rigorous evaluation through prospective controlled trials. To gain further insight into the factors that bear on the prognosis of CSE, prospective studies using standardised treatments and patient stratification on age and aetiologies are needed. Functional outcome remains poorly assessed.     

Médecins généralistes et chirurgie bariatrique : une enquête qualitative

This qualitative study focused on the opinions of general practitioners in France regarding bariatric surgery. The physicians declared that they had insufficient knowledge about this surgery. They favored prevention and education rather than the use of bariatric surgery as a tool to treat obesity. These results are discordant with the current recommendations on bariatric surgery and provide new leads for improving the care of bariatric surgery candidates and the long-term post-operative follow-up.