Évaluation de la douleur postopératoire

Pain is a subjective feeling; its assessment is therefore difficult, and no “gold standard” method exists for humans. Major improvements have, however, been made in the last decade by widespread acceptation of the concept of pain evaluation and widespread use on surgical wards. Evaluation by the patient himself is the rule (unless communication is impaired), as assessment of pain by nurses or doctors systematically leads to underestimation (which also occurs with observational scales). Theoretically, pain should be evaluated in its multiple dimensions such as intensity, location, emotional consequences and sémiologic correlates. Scales which have been developed to evaluate these dimensions are, however, too complex for widespread and repetitive use in surgical patients. The Mac Gill Pain Questionnaire is therefore only used in the surgical setting for research purposes. Moreover, its scientific accuracy, although often accepted, is poor and in our opinion cannot be accepted as a reference method. Only methods assessing pain intensity can be used in the clinical setting because of their simplicity. The verbal rating scale (VRS), the numerical rating scale (NRS) and the visual analogue scale (VAS) are preferred by an increasing number of groups. Although scientific validation is difficult, VAS seems the most accurate and reproducible scale. Post-operative pain should be assessed several times a day in every patient, at rest and in dynamic conditions (cough, movement) and should focus on present pain rather than on pain in the previous hours. Assessment of pain is essential before quality-assurance programmes can be implemented.     

Évaluation et analyse de la douleur en hémodialyse chronique

AimPain is an unpleasant experience that deeply affects patients’ quality of life and emotional state. Pain's epidemiology and characteristics in chronic hemodialysis are not well known and insufficiently analysed. The aim of our study was to assess the prevalence, characteristics, impact and treatment of pain in our hemodialysis patients and determine its related associated factors.MethodsWe performed a cross-sectional study including 93 chronic hemodialysis patients. We collected demographic data as well as the aspects of the reported pain on the basis of the concise pain questionnaire, and finally inferred the risk factors related to pain occurrence. Chronic pain was defined as a pain that has existed for over three months.ResultsThe prevalence of pain was 70.9% (n = 66), mean age 55.3 ± 13.3 years, sex ratio 30 males/36 females, mean duration of hemodialysis 82.4 ± 57.29 (6–252) months. This pain was permanent, daily, intermittent and rare in respectively 9%, 28.7%, 48.4% and 13.6% of cases. It was mild, moderate, severe or unbearable in respectively 42.8%, 23.8%, 19% and 14.2% of cases. Pain was multifocal in 57.4% of cases. The most frequently reported pain sites were: shoulders (47.2%), head (41.2%), knee (34.5%) and back (20%). Thus, 53.8% of patients reported using analgesics, with a daily intake, frequent or rare in respectively 28%, 44% and 28% of cases. The comparison between the group of patients reporting pain to the one without pain complaints in univariate statistical analysis found that age, Charlson's score, interdialytic weight gain and the rate of two dialysis sessions per week were linked to pain occurrence. However, in multivariate analysis, only age remained as a pain-associated factor.ConclusionPain in chronic hemodialysis patients is a very common complaint. Therefore, it is necessary to assess it regularly, using a suitable questionnaire.     

Comparaison de l'échodoppler couleur et de l'échoendoscopie pour l'évaluation préopératoire de l'axe mésentéricoportal dans les lésions pancréatiques

Aim of the studyThis prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseasesMaterial and methodsThe study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectabilty or potential resectability (n = 34) and irresectabilty (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy.ResultsFor endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar.ConclusionsImaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.     

Évaluation du risque de transmission des agents transmissibles non conventionnels par l'albumine plasmatique humaine

Transmissible spongiform encephalopathy agents (TSA) or prions induce neurodegenerative diseases in humans and animals. Their nature is still unknown, even if the main component of infectivity is identified as an abnormal isoform of a host-encoded protein, the prion protein (PrP). Today, no diagnostic test is available routinely for the detection of infected patients. TSA are resistant to most of the physical and chemical procedures that are efficient against other micro-organisms, latrogenic transmissions of TSA have been reported in the past: they always involved either brain derivatives or instruments that have been in contact with infected central nervous system. In an infected individual, infectivity is mostly detectable in brain. However, a persistent low-level viremia can be demonstrated in association with the white blood cells; infectivity is never found in plasma, serum or in red blood cells. Epidemiological data do not evidence any relationship between spongiform encephalopathies and blood transfusion. Therefore, in 1995, TSA transmission trough albumin is only a theoretical risk.     

Évaluation de la réponse histologique dans les cancers du rectum localement avancés après traitement néoadjuvant

Locally advanced rectal cancers mainly correspond to lieberkünhian adenocarcinomas and are defined by T3–T4 lesions with or without regional metastatic lymph nodes. Such tumors benefit from neoadjuvant treatment combining chemotherapy and radiotherapy, followed by surgery with total mesorectum excision. Such a strategy can decrease the rate of local relapses and lead to an easier complementary surgery. The pathologist plays an important role in the management of locally advanced rectal cancer. Indeed, he is involved in the gross examination of the mesorectum excision quality and in the exhaustive sampling of the most informative areas. He also has to perform a precise histopathological analysis, including the determination of the circumferential margin or clairance and the evaluation of tumor regression. Indeed this parameter is a major prognostic factor which has to be included in the pathology report. Moreover, the next challenge for the pathologist will be to determine and validate new prognostic and predictive markers, notably by using pre-therapeutic biopsies. The goal of this review is to emphasize the pathologist’s role in the assessment of histologic response of locally advanced rectal cancers after neoadjuvant treatment.     

Importance de l’évaluation et du traitement des traumatismes de l’articulation de Lisfranc

There are several levels of severity with regard to tarsometatarsal joint (the Lisfranc joint complex) injuries. A careful assessment of the extent of the injury, the age of the patient and an objective examination of the damage enables the best treatment to be selected, whether it is orthopaedic or surgical, for a quick and full recovery. Our case mix means that the different therapeutic approaches for these injuries can be studied and it shows that the slow recovery can become debilitating in the long term, especially after several years of treatment. These injuries can be accompanied by damage to the forefoot (metatarsal pain, clinodactyly and metatarsal dislocation) that originates from an unidentified or inappropriately treated injury to the Lisfranc joint. Percutaneous treatment is not a definitive solution as it often leads to progression of a pain syndrome to the area over time.