Le syndrome de perte de sel d'origine cérébrale existe-t-il ?

Increased natriuresis is a frequent situation after subarachnoid haemorrhage (SAH). It may be responsible for hyponatremia, which can be dangerous in case of severe hypo-osmolarity or hypovolemia. Inappropriate secretion of antidiuretic hormone or cerebral salt wasting syndrome (CSWS) have been incriminated for hyponatremia after SAH, but it remains difficult to distinguish between both syndromes. There are many explanations for increased natriuresis after SAH, depending on the level of blood pressure, the volemia, and the presence or not of natriuretic peptides. The cerebral insult and the treatments, which are done to fight against elevated intracranial pressure or vasospasm, can modify any of these parameters. So it appears that the word “cerebral” in CSWS is probably not a good term and it would be better to talk about appropriate or non-appropriate natriuretic response. Corticoïds or urea can be useful for controlling hypernatriuresis.     

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.     

Qu'apporte le modèle de Stewart à l'interprétation des troubles de l'équilibre acide–base ?

Objectives

To explain the different approaches for interpreting acid-base disorders; to develop the Stewart model which offers some advantages for the pathophysiological understanding and the clinical interpretation of acid-base imbalances.

Data source

Record of french and english references from Medline^® data base. The keywords were: acid-base balance, hyperchloremic acidosis, metabolic acidosis, strong ion difference, strong ion gap.

Data extraction

Data were selected including prospective and retrospective studies, reviews, and case reports.

Data synthesis

Acid-base disorders are commonly analysed by using the traditionnal Henderson-Hasselbalch approach which attributes the variations in plasma pH to the modifications in plasma bicarbonates or PaCO₂. However, this approach seems to be inadequate because bicarbonates and PaCO₂ are completely dependent. Moreover, it does not consider the role of weak acids such as albuminate, in the determination of plasma pH value. According to the Stewart concept, plasma pH results from the degree of plasma water dissociation which is determined by 3 independent variables: 1) strong ion difference (SID) which is the difference between all the strong plasma cations and anions; 2) quantity of plasma weak acids; 3) PaCO₂. Thus, metabolic acid-base disorders are always induced by a variation in SID (decreased in acidosis) or in weak acids (increased in acidosis), whereas respiratory disorders remains the consequence of a change in PaCO₂. These pathophysiological considerations are important to analyse complex acid-base imbalances in critically ill patients. For exemple, due to a decrease in weak acids, hypoalbuminemia increases SID which may counter-balance a decrease in pH and an elevated anion gap. Thus if using only traditionnal tools, hypoalbuminemia may mask a metabolic acidosis, because of a normal pH and a normal anion gap. In this case, the association of metabolic acidosis and alkalosis is only expressed by respectively a decreased SID and a decreased weak acids concentration. This concept allows to establish the relationship between hyperchloremic acidosis and infusion of solutes which contain large concentration of chloride such as NaCl 0.9%. Finally, the Stewart concept permits to understand that sodium bicarbonate as well as sodium lactate induces plasma alkalinization. In fact, sodium remains in plasma, whereas anion (lactate or bicarbonate) are metabolized leading to an increase in plasma SID.

Conclusion

Due to its simplicity, the traditionnal Henderson-Hasselbalch approach of acid-base disorders, remains commonly used. However, it gives an inadequate pathophysiological analysis which may conduct to a false diagnosis, especially with complex acid-base imbalances. Despite its apparent complexity, the Stewart concept permits to understand precisely the mechanisms of acid-base disorders. It has to become the most appropriate approach to analyse complex acid-base abnormalities.     

Is Pelvic Lymph Node Dissection Necessary in Patients with a Serum PSA < 10 ng/ml Undergoing Radical Prostatectomy for Prostate Cancer?

OBJECTIVE: Controversy persists concerning the role of pelvic lymph node dissection (PLND) in patients with preoperative PSA values <10ng/ml undergoing treatment for prostate cancer with a curative intent. The aim of this study was to determine the incidence of lymph node metastasis in this subgroup of patients. METHODS: Patients with clinically localized prostate cancer and a serum PSA<10ng/ml, without neoadjuvant hormonal or radiotherapy, with negative staging examinations who underwent radical retropubic prostatectomy with bilateral extended PLND and with >/=10 lymph nodes detected by the pathologist in the surgical specimen, were included in the study. RESULTS: A total of 231 patients with a median serum PSA of 6.7ng/ml (range 0.4-9.98) and a median age of 62 years (range 44-76) were evaluated. A median of 20 (range 10-72) nodes were removed per patient. Positive nodes were found in 26 of 231 patients (11%), the majority of which (81%) had a Gleason score >/=7 in the surgical specimen. Of the patients with a Gleason score >/=7 in the prostatectomy specimen 25% had positive nodes, whereas only 3% with a Gleason score /=7 in the prostatectomy specimen was 25% after extended PLND. It seems that in this patient group extended PLND, including removal of nodes along the internal iliac vessels, is warranted.     

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.     

La pratique des curages ganglionnaires est-elle harmonieuse ? Analyse rétrospective de 330 cas

Aim

The aim of our study was to make evident the huge variability in lymph node dissection practice.

Material and methods

Therefore a retrospective study was conducted on 330 patients assessed for cervical, axillary or groin dissections. In each case the authors collected the primary diagnosis and clinical stage indicating lymph node clearance, identity of the surgeon and the pathologist, surgical technique including skin incision and landmarks of tissue removal, size of the clearance, and number of lymph nodes removed. Correlations between diagnosis, surgeon's or pathologist's identity, size of the clearance and number of nodes were analyzed using non-parametric tests.

Results

Standardized procedures as axillary dissections occurred few differences between surgeons. In groin or cervical dissections statistical differences were made evident with great technical variability. There was a positive correlation between size of the piece of lymphadenectomy and number of lymph nodes removed.

Conclusion

Standardized procedures as axillary dissections provide few variations. Cervical and especially groin dissections should be harmonized, published and taught harmoniously in schools of surgery. So the expression “regional lymph node clearance” would mean.     

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.