Prise en charge du sevrage difficile et prolongé ; expérience du centre médical de Bligny : à propos de 146 cas sur une période de dix ans

In this retrospective study, the authors present their experience in caring for patients with prolonged and difficult weaning from mechanical ventilation. During a period of 10 years, 146 tracheostomised patients with a mean age of 68.2 ± 8.5 were transferred from different intensive care units (ICUs) to the Centre Médical de Bligny for difficult weaning, after a mechanical ventilation duration of 57 ± 33 days. One hundred and one patients were suffering from chronic lung disease (group 1) while 45 remaining patients were not (group 2). Group 1 patients were hospitalised for a mean duration of 25 ± 24 days in the ICU, and for 48 ± 43 days in the Pneumology department. In-hospital mortality was 27%. Complete weaning was obtained in 65% of the survivors. One-year survival was 64%. Group 2 patients were hospitalised for a mean duration of 24 ± 18 days in the ICU, and for 38 ± 31 days in the Pneumology department. In-hospital mortality was 23%. Complete weaning was obtained in 85% of survivors. One-year survival was 74%. The authors conclude on the necessity to develop weaning centers in France.     

Expérience d’un groupe de parole d’adolescents obèses avant une chirurgie bariatrique

Facing the increasing demand for bariatric surgery in obese adolescents, we developed discussion groups in order to assess the level of teenagers’ development around the surgical procedure. This article describes exchanges between several adolescents awaiting bariatric surgery and one operated teen. They discussed several topics such as confidence to provide other, pain, body image, and difficulty of waiting as well as issues about post-surgical treatments.     

Utilisation de la sophrologie et de l’hypnose à l’hôpital: expérience d’une infirmière

Hypnosis, used by a nurse for painful procedure or to help the children upset with anxiety, is often a particularly adapted and effective response. Success requires an appropriate pharmacological synergy (nitrous oxide/oxygen mixture mostly). Besides the dissociation between sensory and emotional components of pain, these methods also offer a valuable relationship with the child. These methods also have their limit, and it is necessary to know how to regularly analyze the failures within the involved hospital teams.     

Complexité de la chaîne de soutien médical opérationnel au cours d’une mission des Nations unies en Afrique subsaharienne. À propos d’un cas

Context

The United Nations (UN) Stabilization Mission in Mali is the deadliest of UN missions (116 dead and 500 seriously injured since 2013). The care for the wounded is carried out by a chain of operational medical support and its complexity will be illustrated through a case.

Clinical case

A Malian civilian along with his vehicle on a mine is the victim of an explosion. After an initial takeover by the UN military of the convoy and a contact with the medical regulation of the theater of operation, a Dutch paramedic team was sent through helicopter. Due to the severity of the lesions (especially severe craniofacial trauma and haemorrhagic shock), the regulation has decided to evacuate the patient to a Togolese military level 2 hospital (HN2-Togo) deployed at Kidal in Northern Mali. The evacuation was done at night without illumination on board the aircraft for safety reasons. Upon arrival at the hospital, the patient has been given a therapeutic treatment before being evacuated for the final treatment in Senegal.

Discussion

Within the framework of the UN missions, the goal of the medical support chain is that they should ensure that all staff receives a quality care, under the best conditions and within the deadlines. The constraints of the Malian theater (security, heat, sand, surface, multiple speakers and nationalities) make this channel complex. This clinical case, however, shows that it is possible to achieve in a degraded context a quality medical care, under the best conditions and delays.

     

Réinsertion sociale et professionnelle du blessé de guerre militaire français. Expérience de la cohorte de blessés suivie entre 2004 et 2010 dans le service de médecine physique et de réadaptation de l’hôpital d’instruction des Armées Percy

From 2004, due to battle intensification, the French army has undergone an increasing violence in external operations, then wounded people had increased. Social and professional reintegration is still badly assessed. We have studied social and professional features, and quality of life of 49 French wounded soldiers hospitalized in physical medicine and rehabilitation in the military instruction hospital Percy, from 2004 to 2010. That study permitted to objectify the difficulties and could help to develop the ways to improve the reintegration. This is an early study, it should be interesting to assess the same patients after a longer follow-up.     

Propositions du Groupe de réflexion sur l’obésité et le surpoids pour une politique de santé publique en matière d’obésité

GROS (Groupe de réflexion sur l’obésité et le surpoids — Discussion Group on Obesity and Overweight, www.gros.org") is proposing another obesity prevention policy, taking into account current information regarding weight regulation, and considering the numerous factors at play. These factors are biological, psychological, social, economic and cultural. We propose ten obesity prevention measures, focused on fighting factors related to the deregulation of body fat and the promotion of factors favouring and protecting proper weight regulation. Six public health measures would facilitate the fight against deregulation factors: 1) fighting against the discrimination and stigmatisation of the obese, which promotes the loss of dietary control and the use of iatrogenic weight loss methods; 2) fighting against the demonisation of foods, which concretely leads to the same results; 3) promoting information and reassuring nutritional education; 4) demedicalising eating; 5) fighting against the hegemony of thinness; 6) improving the ethics of medical practice and the slimming trade. Four public health measures would aim at the promotion of regulation factors: 7) promoting food service industry conditions favourable to weight regulation; 8) promoting nutritional education taking into account the cultural, gastronomic, social, religious or philosophical dimensions of the act of eating; 9) developing the diversity of eating cultures; 10) promoting reconciliation with the body. Ten measures could more specifically apply to children and adolescents: 1) implementing anti-discrimination laws; 2) fighting against the stigmatisation of infantile obesity; 3) screening out cognitive restriction in parents; 4) passing on knowledge and eating cultures; 5) promoting active lifestyles; 6) promoting the social connection; 7) teaching critical reading of the world of images; 8) informing the medical fraternity of the dangers of norms and diets in children and adolescents.     

Lésions transformées réséquées incomplètement et leur suivi. Comment les craindre macroscopiquement, quand faire le contrôle endoscopique au vu de l’histologie et que faire; seconde mucosectomie ou résection chirurgicale ? Cas de la nappe villeuse ou du polype sessile

In general, the choice of endoscopic therapy lies between mucosal resection and submucosal dissection. These forms of treatment must be restricted to neoplastic lesions not at the risk of lymph-node involvement and entail complete endoscopic resection in a single piece (monobloc) if: 1) the cancer is well or moderately well-differentiated; 2) there is no lymphatic or vascular spread; 3) there is no discontinuity of the invasive margin (“budding”); 4) the margin of healthy tissue is at least 1-mm wide; 5) there is no invasion beyond the mucosa or invasion remains confined within the superficial submucosa to a depth of less than 1 mm. The following observations or test results suggest the presence of deep invasion and, therefore, the possibility of lymph-node involvement: 1) the size and shape (surface contours) of the lesion; 2) appearance of the lesional epithelial pits; 3) endoscopic ultrasound, especially using high-frequency mini-probe; 4) separation after submucosal fluid injection. Mucosal resection is 1) indicated for sessile lesions (Is) with a base diameter greater than 10 mm, or with suspicion of submucosal carcinoma (Kudo class V); 2) indicated for class II flat lesions, which should, under no circumstances, be treated by polypectomy. If a part of the lesion is of Kudo type V, the goal of R0 (microscopically negative margins) mucosal resection is advisable only for colorectal lesions of less than 15-mm diameter; 3) contra-indicated for type III ulcerated lesions, where an alternative approach must be considered, except where there is comorbidity. Submucosal dissection or colorectal ESD is at present: 1) indicated where R0 resection is strictly necessary, i.e. when the lesions are suggestive of submucosal cancer or when the crypts have Kudo classification type V naked eye appearances (such features preclude the use of EMR); 2) contraindicated in the presence of a lesion which is not elevated after submucosal injection, for lesions with Kudo type V naked eye appearances over more than a 3 cm diameter and for ulcerated lesions. Such lesions should be managed by surgical resection, taking account of the patient’s fitness for surgery. However, the chances of relapse after EMR and, therefore, the requirement to carry out repeat endoscopy should be weighed against the risk of perforation and the technical difficulty of ESD (reflected in the time needed to perform the procedure).     

Évaluation fonctionnelle isocinétique et neuromusculaire du genou,retour au sport après reconstruction du ligament croisé antérieur. Étude prospective d’une cohorte de 234 sportifs au recul moyen de 6 mois

Background

Ten percent or less reduction in isokinetic and functional test performance in comparison with the healthy side is generally considered to be a sign of satisfactory functional recovery after reconstruction of the anterior cruciate ligament (ACL). The main objective of this work was to assess postoperative functional recovery of the knee joint in a large cohort.