Prothèse Roseland® : étude de qualité de vie de 68 patients avec un recul moyen de 43,8 mois

ObjectivesRoseland^® prosthesis is a ball and socket prosthesis, physiological and not anatomical. This study wants to demonstrate by a quality life questionnaire (quick DASH described by Dubert et al., 2001 [1]) that Roseland^® prosthesis gives to patients a trapeziometacarpal joint native capacities.Patients and methodsAn exterior examinator reviewed prospectively 68 patients having a mean age of 61,1 years at surgery with 11 bilateral cases that is 79 prothesis. With a mean follow-up of 43.8 months, we value by Kapandji's opposition, first comisssural openning, quality of life and patient's satisfaction.ResultsThree patients have been excuded: two of them had got post-traumatic dislocation: one trapezium fracture, one unknown reason. The third patient had got osteophytis with “came” effects. We keep 65 patients with 84,6% satisfying and very satisfaying. 75,4% of patients have a capacity of 80% and more of their joint, 40% of them had got 100%.DiscussionRoseland^® prosthesis has good results because it agrees with already known principles as on its own concept: rotula prothesis gives three axes mobility, as on its own conception: metarcarpal stem with a palmar “T” shaped against rotation and bone saving, a cup with equatorial ring to prevent burying of the spongy bone. Componenents are recovered by hydroxyapatite to favour osteo-integration with less loosening than ciment. An accurate technique avoids dislocations traps: trapezium implant centring, internal osteophytis removal. An accurate indication: trapeziometarpal joint osteoarthritis only (second degree's Dell classification).ConclusionRoseland^® prosthesis reproduces a satisfactory and functional joint for 84,6% of cases. These good results can be obtained by accurate indication (Dell II) and contra-indication (osteoarthritis around trapezium except trapeziometacarpal of course).     

Motifs de primo-consultations de néphrologie en 2014 dans le territoire de santé 5 de Bretagne

BackgroundIn France, the coordinated healthcare circuit means that patients should be referred to specialists, for example nephrologists, by another physician. However, there are no recommendations concerning the reasons justifying the referral to a nephrologist. The main purpose of our study is to describe the motif of first consultations in nephrology in the health area 5 of Brittany.MethodsWe retrospectively collected medical reports of first consultations by 17 nephrologists in the 4 centers of the study area, during the year 2014. In these letters, we noted the consultation motif, the specialty of the physician who refers the patient, and main characteristics of patients.ResultsWe included 662 first consultations. The main reason for consultations was chronic kidney disease (68.7%), including chronic renal insufficiency (56.9%), proteinuria (7.3%), microscopic hematuria (3.3%) and searching for chronic kidney disease in the presence of risk factor (1.2%). Other frequent reasons were the follow-up consultation after a pregnancy complicated by preeclampsia (9.5%), urinary lithiasis (5.7%), hypertension (3.8%) and hydroelectrolytic disorder (3.5%). Non-nephrology reasons represent 3.2% of first consultations. Almost all patients have been referred by a physician (99.7%), mainly a general practitioner (71.9%).ConclusionNephrology first consultations are realized according to the coordinated healthcare circuit since almost all are requested by another physician. The reasons are adapted to the specialty. The main reason is chronic kidney disease, often already associated with renal insufficiency chronic.     

Comparaison de sérum salé, d’air et d’un mélange oxygène–protoxyde d’azote pour le remplissage des ballonnets de sondes d’intubation chez l’enfant ? Étude prospective randomisée

Objective

The purpose of the present study was to compare how many inflate and deflate are necessary to maintain the endotracheal tube cuff pressure between 15 and 35 cm H₂O by using air, O₂–N₂O mix or saline solution.

Study design

Randomized and prospective study.

Patients and methods

Ninety children from 1 month to 15 years of age were included in the study. All patients were ventilated with O₂50%–N₂O50%. Subsequently, the patients were divided in three groups: (1) Group 1: patients with air inflated cuffs; (2) Group 2: patients with O₂–N₂O mix inflated cuffs; (3) Group 3: patients with saline solution inflated cuffs. In all groups cuffs were inflated to reach an intracuff pressure of 20 cmH₂O. The cuff pressure was then monitored every 10 minutes and adjusted to be between 15 and 35 cmH₂O. Laryngeal and tracheal symptoms were noted in the recovery room.

Results

The three groups of patients were similar for age, weight, and sex. The length of surgery was significantly longer in Group 3. The deflate rate was higher in Group 1 (60%) than in Group 2 (10%) or 3 (3.3%) (p < 0.0001). The inflate rate was higher in Group 2 (76.6%) than in Group 1 or 3 (both 3.3%) (p < 0.0001). Side effects were comparable in the three groups of patients.

Conclusion

Using air or O₂–N₂O mix to inflate cuffs is not reliable. SSI helps to maintain a more stable cuff pressure but monitoring is difficult and sometimes contraindicated by tracheal tubes producers. Inflating cuffs with air and regularly monitoring pressure is the most reliable and easiest technique.     

Lymphomes osseux primitifs : étude prospective de 28 cas

Objective. To conduct a prospective study of primary lymphoma of bone (PLB) including comparisons to primary non-Hodgkin’s lymphoma (NHL) at other sites and to secondary lymphoma of bone (SLB). Methods. The 28 patients with PLB included in the 1987 NHL protocol developed by the GELA were studied and compared to 2932 patients with NHL at other sites and 219 patients with SLB. Results. Median age in the 28 PLB patients was 48 years (range, 18-69) ; there were 17 men and 11 women. The proportion of patients younger than 60 years was 86% in the PLB group, 59% in the other NHL group, and 55% in the SLB group. Proportions of Ann-Arbor stage patients (I-II/III-IV) were:  54%/46% in the PLB group, 50%/50% in the other NHLs group, and 20%/80% in the SLB group. Performance status was 0 or 1 in 100% of the PLB patients, 50% of the other NHLs patients, and 20% of the SLB patients. The tumor exhibited a B-cell phenotype in 89% of PLB patients and in 85% of other NHLs and SLB patients. Histological patterns were distributed as follows : PLB, 54% of diffuse large cell tumors and 11% of diffuse mixed cell tumors ; other NHLs, 39% of diffuse large cell tumors, 13% of diffuse mixed cell tumors, and 8% of diffuse immunoblastic tumors; SLB, 45% of diffuse large cell tumors, 10% of diffuse mixed cell tumors, and 12% of diffuse immunoblastic tumors. Induction therapy was followed by a complete or partial response in 86% of the PLB patients, 84% of the other NHL patients, and 78% of the SLB patients. Overall five-year survival was 65%, 50%, and 40% in these three groups, respectively. Discussion. Survival was better in the PLB group. Further work is needed to determine the impact of radiation therapy at the end of treatment and to identify prognostic factors specific to PLB.     

La démographie médicale des anesthésistes réanimateurs est-elle encore compromise en France à l’horizon 2020 ?

Objectives

The demographic decline in the Anaesthesia and Intensive Care practitioners predicted for 2020 may bring into question the speciality's vocation, and indeed peri-operative care as a whole in France. The objective of this study is to assess the French Anaesthetist and Intensive Care physicians’ demographics in 2010, and predicted numbers for 2020 taking into account recently initiated corrective measures.

Methods

Data originating from the CFAR-SFAR-INED French medical demographics survey¹, the French General Medical Council, and various studies and projections published by the INED and the DREES² were collected and analysed. Factors were then identified that were likely to affect personnel numbers, speciality training requirements and the demand for patient care.

Results

French General Medical Council data is the most reliable and reports 9692 Anaesthetists and Intensive Care physicians practising regularly in France on the 1^st of January 2009. Of those, 9,391 (96.9 %) were practising on the mainland. Personnel growth reduced due to the effect of specialist training selection procedures: the percentage of doctors entering Anaesthesia and Intensive Care training dropped from 12.7 % per year in 1960 to 1.5 % in 1990. Since 2002, personnel in regular practice dropped by 1.1 % per year. Relatively few doctors were leaving the profession, the decrease was due to the reduction in the numbers entering practice: 222 per year on average from 1988 through 2004, compared to 355 per year for the two preceding decades (1971 to 1987). Anaesthetists and Intensive Care physicians are growing older; the average age increased from 42.8 years of age in 1989 to 51 on the 1^st of January 2009. Further evidence of this trend is that the number of practitioners less than fifty years of age continues to decrease; just 47.5 % in 2005 compared with 80 % in 1989. 5,139 anaesthetists between 50 and 64 years of age will leave the profession before 2020, over half (52.3 %) of the total practising in 2005. Practitioner density increased from 13.1 Anaesthetists and Intensive Care physicians per 100,000 inhabitants in 1989 to 16.2 in January 2006. If only those in regular practice are considered, density is stable at 15.3 per 100,000 inhabitants as of 1^st January 2009. The most recent 2009 projections predict a 13 % decrease in the number of practitioners between 2006 and 2015, and a 16 to 20 % decrease by 2020. Initial projections in 1991 and further projections in 1999 predicted 50 % and 35 to 50 % decreases by 2020. Numerous factors could amplify this reduction in the absence of increased training efforts. These factors include population growth (+6 to 7 % by 2020), the increasing health care demands of an ageing population (+15 %), medical progress, the increasing feminisation of the medical workforce, projected retirements and reductions in migratory flows.

Conclusion

Despite increasing training throughput and increasing medical immigration, Anaesthetists and Intensive Care physicians in France are ageing noticeably and reducing in number. This foreshadows further personnel reductions in the future. A demographic catastrophe may well have been avoided; a more moderate reduction in personnel persists for 2020 with an ongoing risk of numerical inadequacy with respect to needs. This situation justifies a further increase in training throughput, along with adaptations in the provision of care, so as to ensure maintained care standards.     

La sédation–analgésie au quotidien : enquête de pratiques auprès de 218 services de réanimation en France

Objectives

To assess the current use of sedation and analgesia in a large sample of French intensive care units (ICUs) and to define structural characteristics of the units that use a written procedure.

Study design

Self-reported survey.

Participants

Three hundred and sixty French ICUs were presented the questionnaire in September 2007.

Results

Surveys were received from 228 (60.6%) ICUs. Midazolam was used in more than 50% of the patients in 79.2% of the ICUs and propofol in 22.2% of the ICUs. Sufentanil was the most frequently used morphinic. A sedation-scale was used in 68.8% of the units (80.3% Ramsay score). Sedation was assessed at least every 4 hours in 61% of ICUs. A pain-scale was used in 88.9% of the ICUs, but only 12.5% in the non-communicant patients. A written procedure was used in 29.4% of the units only. In multivariate analysis, use in the ICU of a written procedure for the early management of patients with septic shock and/or intensive insulin therapy was the single variable significantly associated with presence of a written procedure for sedation and analgesia (respectively OR 4.37; p < 0.0001 and OR 5.64; p = 0.032).

Conclusion

Although more than two-third of the responding ICUs reported the use of sedation-and-pain-scales, frequency of assessment was low, and objective assessment of pain in the non-communicating patients was extremely uncommon. Similarly, the use of written procedure was low. The use of sedation-analgesia written procedure in an ICU seems strongly influenced by a more global involvement of the ICU in the protocolisation of complex care. These findings support the reinforcement of educational programs.     

La dénervation totale du poignet : une étude rétrospective de 27 cas au recul moyen de 77 mois

ObjectivesComplete wrist denervation is a palliative operation, which yields still controversial outcomes. The aim of our study is to assess the late outcomes of complete wrist denervation.MethodsIn a retrospective continuous review of 27 complete and isolated denervations of the wrist joint performed by the same surgeon in 27 patients (15 men for 12 women) from 1995 to 2007, the pain (VAS), the function (Dash-score), the range of motion, the strength (Jamar) and the radiological changes were assessed at a mean follow-up period of 77 months (12 to 157).ResultsAt final follow-up, 12 patients (44%) were completely free of pain and 11 (41%) had little pain, four (15%) had moderate and severe pain. The average time to achieve the complete pain relief was 3 months and 3 weeks. Pain relief was stable over time in 89% of cases. There was a significant improvement in range of motion: 11° flexion/extension; 8° pronosupination. In average, the Jamar grip strength was 85% of the healthy side. The Dash-score was in average 30.4 (22 to 60). The extension of the osteoarthritic surface was observed in 14 patients (52%). Six complications were noted: one complex regional pain syndrome, five neuromas four of which resolved spontaneously. Two patients were re-operated. Eighteen patients were very satisfied (67%), six patients were satisfied (22%) and three patients were moderately satisfied (11%).ConclusionsComplete wrist denervation is an intervention with few complications indicated in chronic wrist pain of any aetiology.     

Quoi de neuf en hyperthermie maligne en 2012 ?

Malignant hyperthermia (MH) is a pharmacogenetic disorder of anesthesia. Recent advances dealing with epidemiology of MH and the safe anesthetic course of MH susceptible patients are shortly presented here with a special insight into the preparation of modern anesthesia workstations, which they will share in operating room.     

Prise en charge de la grossesse chez des patientes atteintes de syndrome de Gitelman : série de 12 cas

IntroductionGitelman syndrome is a rare hereditary renal tubulopathy, responsable of hypokalemia and hypomagnesaemia-related ionic disorders, which management is poorly codified during pregnancy. We report 12 cases of pregnancies with Gitelman syndrome and we compare our data with those of literature.Material and methodsIt is a report of 12 pregnancies in 5 patients with Gitelman syndrome between 2002 and 2016. Follow up and outcome of pregnancy, delivery modalities and maternal-fetal prognosis have been collected.ResultsIn our serie, maximum kaliemie observed was 3.4 mmol/L, with an average potassium, over all pregnancies of 2.3 mmol/L. Oral potassium and magnesium supplementation at the end of pregnancy were 8900 mg/day and 460 mg/day, respectively. There were no serious maternal complications. Two pregnancies were complicated by intrauterine growth retardation in a context of preeclampsia. There is a large disparity in the methods of anesthetic management of these patients. Materno-fetal prognosis at 1 month post-partum is good.ConclusionGitelman syndrome is a rare pathology where there is a lack of homogeneity in management of pregnancy. Monitoring of monthly ionogram is necessary. The goal is to obtain stable, non-symptomatic kaliemias, which will never be standardized even in increasing treatment. The most important is to inform and detect situations at risk of decompensation, including vomiting or the use of certain anesthetics. In agreement with literature data, monitoring of fetal growth and the amount of amniotic fluid in the third trimester is still warranted. These pregnancies require the development of a common care in multidisciplinary consultation meeting.