L'histoire de la ventilation mécanique : des machines et des hommes

From the mid-1500s until the early 1900s attempts to resuscitate apparently dead humans by applying artificial ventilation with a bellows trough a tracheal tube were time to time recorded. In 1876 E Woillez presented the Spirophore that was the first negative pressure tank ventilator. The Pulmotor designed in 1906 by H Dräger was the first preset pressure ventilator. The first ventilator to be used successfully for long term mechanical ventilation was the Drinker-Shaw iron lung (1928) that saved many lives during the poliomyelitis epidemics. All the senior critical care physicians keep in mind the Engtröm 150 (1954) as the first electrically powered ventilator which contributed to the development of critical care. In 1959 Frumin demonstrated that the immersion of the exhalation limb under few centimetres of water was an efficient method to improve gas exchange. This simple method to improve gas exchange was promoted by Asbaugh and Petty and termed continuous positive airway pressure then positive end expiratory pressure (PEEP). Produced by Siemens the “Servo 900 A” (1970) was the first electronically device equipped with a PEEP valve and offering the possibility to monitor gas flow and airway pressure. Since 1980 the introduction of servo controlled valves have made possible the synchronisation between the patient inspiratory effort and the delivered gas flow. Assisted Spontaneous Breathing, a mode that will be termed later Pressure Support Ventilation, was the first pressure preset mode. Recent advances mainly focused on ergonomic and undesirable secondary effects of mechanical ventilation.     

Place du traitement médicamenteux et des infiltrations dans la prise en charge médicale des lésions de la coiffe des rotateurs

One of the main objectives of medical treatment of rotator cuff lesions is to attenuate or totally relieve pain and allow the patient to access the next phase of functional rehabilitation. Relative rest is desirable. Harmful sports movement should be avoided. Strict immobilization is never indicated. The question is raised as to whether wider use of analgesics would be warranted. The inflammatory nature of rotator cuff tendiopathies remains to be clearly demonstrated and the efficacy of analgesics in this indication would be related more to their intrinsic pain killer action. Analgesics should thus be prescribed prudently and limited to a few days, particularly because of the potential adverse effects. Theoretically, steroidal anti-inflammatory drugs should not be used for tendonitis. Myorelaxing agents could be used in the event of associated muscle contracture. If the patient requires further relief, corticosteroid injections could be considered, taking care to avoid contraindications for intra-articular injections and avoiding any risk of contamination while keeping in mind the possible adverse effects.     

Pathologie des adducteurs chez le rugbyman. Démembrement et conduite thérapeutique

The pathology of the adductor tendons is dreaded by rugbymen because it is invalidating in displacements and for the drop-play. An anatomical and physiological recall makes it possible to individualize three muscular "curtains" in the internal compartment of the thigh. The lesional diagnosis is made by the clinical examination and the MRI. The local treatment allows the healing of the muscular or tendinous lesion. Then the well targeted stretching of the injured muscle guarantees a flexible cicatrization without remaining pain. With each muscular group corresponds a specific stretching.     

Prise en charge initiale des états septiques graves de l'adulte et de l'enfant

The recent availability of the « Surviving Sepsis Campaign » guidelines provided the opportunity to gather a expert panel of emergency medicine, infectious diseases and intensive care physicians representing seven professional societies to elaborate this recommendation document. The guidelines document focuses on early identification and management of both adult and pediatric patients with severe sepsis, and the organization of health care systems for initial management of these patients. The document is expected to provide a basis for elaboration of clinical practice guidelines and clinical pathways for severe sepsis and their evaluation.     

Antigènes fongiques en réanimation : tests disponibles et état des lieux

Numerous serological assays try to supply the pitfalls of microbiological diagnostic methods for fungal infections. Several antigens have been assessed: the galactomannan (GM), the mannan (Mn), the β-glucan (ßG), and the capsular antigen for the diagnosis of invasive aspergillosis, yeast infections, all the fungal infections, and the Cryptococcus neoformans infection respectively. The performance characteristics of these assays are usually satisfactory when serum samples collected in well defined clinical settings are used. In contrast, the results of prospective studies are often disappointing. This underlines the difficulty in standardizing the patient populations and the definitions of fungal infections. For the GM assay, the conclusions obtained in onco-hematology can be used for immunocompromised patients hospitalized in intensive care units. For the Mn assays, the hope relies on the simultaneous detection of both antigen and antibodies. The advantage over the microbiological screening for yeasts of different anatomical sites remains to be demonstrated. For the βG assay, its best interest seems to be its negative predictive value as bacterial and fungal infections are hardly distinguished when the test is positive. Excepted for the capsular cryptococcal antigen, a single test is usually not contributive for any of the assays, which should be implemented as a screening test for patients at risk for fungal infections.     

Apport des techniques de biologie moléculaire dans le diagnostic des endocardites infectieuses

There is no doubt that molecular biological techniques have dramatically altered the diagnostic procedures for infectious diseases and in particular for blood culture-negative endocarditis (BCNE), the diagnosis of which remains difficult and is often established only with delay. These molecular techniques have been developed mainly for the detection and identification of pathogens that are difficult to culture or non cultivable under standard conditions, or non viable due to previous antibiotic treatment. With the exception of some specific tests that can be carried out with serum or blood, the molecular techniques for the diagnosis of BCNE are most often carried out using cardiac tissue samples. Because of their current limitations, the molecular techniques have to be considered as adjunct procedures and care has to be taken with respect to the interpretation of the results. Also, the more or less conventional (serological, histopathological, cell and cell-free culture-based) tests must not be neglected. Future efforts should aim at the improvement of the sensitivity of the molecular techniques and also of the early (serum-based) diagnosis of BCNE, using molecular techniques as well as antigenic microarrays.     

Imagerie des syndromes canalaires de l'épaule

Paraglénoid cysts may compress the distal branches of the suprascapular nerve or compress the axillary nerve in the quadrilateral space inferoposterior to the glenohumeral joint. This nerve compression is important to recognize before it cause shoulder weakness through denervation of external rotator muscles.     

Infiltrations articulaires et para-articulaires chez le sportif : intérêts et limites

Few studies have validated the use of corticosteroid joint injections in sports medicine, and many recent studies have questioned their usefulness. The beneficial effect is essentially short lived, enabling the athlete to complete a specific performance. Local complications have been well described but the systemic effects are underestimated, especially during the first week. Corticosteroid joint injections are not on the regulatory list of products requiring an Authorization for Use for Therapeutic Applications (AUTa) for sportive events. Several studies have demonstrated that the corticotrop axis can be inhibited after a single injection, reflected by decreased production of endogenous cortisol for as long as two weeks. This biological adrenal insufficiency can lead to acute renal insufficiency if the athlete resumes competition too early under stressful conditions. Since there is no known way to identify predisposed individuals, the risk appears to be disproportionate compared with the expected benefit. Rest from sports must therefore be prescribed for any individual given a joint injection.     

Rugby et traumatismes du coude

The elbow is requested brutally during the falls, collisions, tackles, direct impacts and especially during hand-off while pushing a tackler away. All the types of lesions can be observed, from simple torn ligaments of functional treatment to complex fractures dislocations of difficult surgical processing. The clinical diagnosis is done on the ground but it must be supplemented by a systematic radiographic assessment readily refined by 3D CT-scan.     

Ruptures traumatiques de la coiffe des rotateurs chez le rugbyman

Rotator cuff tears are one of the shoulder lesions that can occur during modern Rugby. They are present in 3–10% of the traumatic lesions of the shoulder in this population and is this figure is expected to continue increasing because of the growth in popularity of the sport and the intensity of the game. The physician should be aware of the clinical signs in order to guide the correct imagery for this type of lesion to be correctly identified. The study of 29 rotator cuff tears in professional Rugby players from the French Rugby championships from 1996 to 2006 allowed us to clarify the epidemiology of these lesions and to specify the therapeutic indications. The surgical treatment, especially arthroscopic repair, proved to be efficient for the partial and full-thickness tears. Eighty-three percent of the patients were able to play Rugby at their presymptomatic competitive level with a delay of 5.5 months with a strictly normal clinical exam in more of 75% of the cases.