Évaluation de la qualité de l’os dans les allogreffes de main

Five bilateral forearms allograft have been performed between January 2000 and July 2009 in Lyon (France). The first four patients (three males, one female) have been the subject of an assessment of the bone quality of those allografts. The techniques selected for this study were: radioclinical analysis, bone scintigraphy, MRI, bone densitometry and High Resolution peripheral Quantitative Computed Tomography (HR-PQCT). Histology has been performed only on the first patient unilaterally grafted in 1998 who did not take part in this clinical research protocol, after amputation of his rejected graft. On the clinical, radiological and scintigraphical aspects, donor bone integration in hands allograft are good on a macroscopic point of view considering the healing and the general reaction of the bone in situation of fractures, infection and growth. The scintigraphy does not show important variations compared to the ones we can observe on contact with osteosynthesis material or during bone autografts. MRI found neither focal nor periosteal anomaly on grafted bone. The bone densitometry did not show significant difference with secondary osteoporosis one can observe in other grafted patients under immunosuppressive treatment. The HR-PQCT showed for the three males patients, a higher loss in volumetric density, for grafted bone than in the recipient patient control skeleton. Due to the few patients of this series, and the discrepancies in follow-up duration, the presented data have to be confirmed with further studies.     

Résumé de la bourse Tonipharm

Résumé / Abstract

Résumé de la bourse Tonipharm     

Une cause de difficulté de sevrage de la ventilation artificielle: la polyneuropathie de réanimation

Three cases of Critically Illness Polyneuropathy (CIP) are reported. The difficulty of weaning the patients from the ventilator, whereas sepsis and MOF had been successefully treated, was the main feature in the three cases. The diagnosis was established by electromyogram, showing a primary axonal denervation of peripheral nerve fibres, which was confirmed by a pathological study in one patient.     

Gestion de la douleur postopératoire dans une unité de soins

In order to improve the management of postoperative pain many publications insist on progressive changes in care organization. The following list outlines steps to be taken for implementation of these changes: 1) an initial analysis of management of post-operative pain allows awareness of reforms to be proposed; 2) participation of health teams in special training in order to use evaluation tools and collect data (use of analgesics, adverse effects); 3) establishing policies and procedures: recovery room, guidelines for analgesic use and adverse effects; 4) notifying patient about the various procedures to be used in postoperative period -discussion with the patient during the preoperative interview; 5) current use of standard patient-controlled analgesia (PCA) and locoregional analgesia; 6) use of combined techniques in order to achieve a balanced analgesia; 7) implementing a quality assurance programme which should include analgesic effectiveness, patient satisfaction and prevention of complications; and 8) planning of an Acute Pain Service based on a clinical nurse co-ordinator which offers highly effective forms of postsurgical analgesia.     

Cancer et religiosité : la connaissance de la maladie affecte-elle le degré de la foi en Dieu ?

ObjectiveTo measure the influence of knowledge of one's cancer on the degree of religious faith in patients.MethodQuestioning of 117 patients with cancer who were admitted to the oncology department of the Hôtel Dieu de France Hospital during the period from 24 November 2005 to 1 December 2005, and filling out of an Arabic version of the SCSORF questionnaire: the higher the score on this questionnaire, the more it indicates a high level of religious faith.ResultsWe found a higher score in patients who knew about their disease than in those who did not (p<0.001), a higher score in women than in men (p<0.05), a higher score in Muslims than in Christians (p<0.01), but Christians had a higher score on the question concerning comfort in religious faith (p<0.001), a higher score in patients with relapse of their disease than those with no relapse (p<0.01), and a higher score in patients who were not taking benzodiazepines than in those who were taking them (p<0.05). We also found a positive correlation between education level and knowledge of the disease (p<0.05), a positive correlation between the time lapsed since diagnosis and the frequency of prayer (p<0.05), and a negative correlation between education and the preference for being in a group of people of the same faith (p<0.05).ConclusionThis study is the first to demonstrate that knowing one's cancer diagnosis is a factor that increases the degree of religious faith, independently of the everyday stress experienced by the patient. This underscores the importance of the patient's faith in better controlling the symptoms of the disease and the side effects of the treatments, with a reduction in the use of benzodiazepines.     

Évaluation de la reproductibilité et de la validité de construit d’une forme modifiée de l’indice algofonctionnel de Lequesne dans l’arthrose du genou

Objectives. – To assess the test-retest reliability and the construct validity of a modified version of the Lequesne index.Methods. – Patients with symptomatic knee osteo-arthritis fulfilling the revised criteria of the american college of rheumatology completed the Lequesne index twice at a 3 h interval. Impairment outcome measures and patients’ perceived discomfort in walking and handicap were recorded. An item by item analysis was performed. Items having insufficient psychometric properties were excluded. Test-retest reliability was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated using Spearman rank correlation coefficient and a factor analysis was performed.Results. – Eighty-eight patients were included. One question assessing pain (question IE) had a weak reliability (Kappa = 0.39) and was excluded. The test-retest reliability of the modified questionnaire was excellent (ICC = 0.95). Expected convergent and divergent correlations were achieved excepted for Vas pain and Vas handicap (0.46 and 0.40 respectively), and the “a priori” double stratification was confirmed by factor analysis, explaining 48.7% of the variance.Conclusion. – The modified form of the Lequesne index has sufficient psychometric properties to be used to assess pain and function in knee osteo-arthritis in a french population.     

Transfert libre microvascularisé de fibula dans la reconstruction de l’extrémité inférieure du radius

Free vascularized bone transfers are indicated to reconstruct large bone loss, either after traumatism or bone tumor resection. Free vascularized fibular transplant is particularly well designed for reconstruction of large defect of the distal radius. Anatomy is constant and harvesting is versatile and reliable. It may be used as bony transplant alone, osteocutaneous or osteocutaneomuscular. The length of the fibula harvested can be up to 25 cm. In children bone reconstruction, the proximal physis of the fibula can be transferred to allow secondary bone growth but there is a need for double anastomosis of the anteriotibial and the fibular bundles. Donor site sequelae are minimal.     

Vers une médicalisation de l'évaluation de l'activité en Smur

ObjectiveTo test the ability of various medical criteria for classifying the patients in a physician-staffed mobile intensive care unit (MICU) by referring to intervention times.Study designProspective, open study.Patients and methodsFor all the on-scene interventions of the MICUs over a 10-month period, the following data were prospectively collected: pre-hospital diagnosis, initial severity score, medical care score, immediate outcome and three intervention times: onscene time (OS), time spent with the patient by the MICU team (MT), total duration of intervention (TD).ResultsA total of 3,672 MICU interventions were included. Median times were 45 min (32–59) for OS, 66 min (41–91) for MT and 85 min (61–116) for TD. The amount of interventions in a city was correlated with the population (R = 0.95; P < 0.001). The medical care score was greater than one in more than half of the patients. It defined five groups of patients which were different for the three intervention times (P ≤ 0.001). A third of the patients were directly transported by the MICU to an ICU. For the median test, immediate outcome groups were different for the three intervention times (P < 0.001). After exclusion of patients with initial cardiac arrest, initial severity score defined five groups of patients which were different for the three intervention times (P < 0.002). Initial severity score and medical care score were correlated (R = 0.37; P < 0.001).ConclusionA classification of the patients based on immediate outcome would be a more accurate indicator of the variability in medical care and consumption of resources in a physician-staffed MICU. In addition, a medical intervention score should be developed to better characterise this medical activity.     

Évaluation de la reproductibilité et de la validité de construit d’une forme modifiée de l’indice Womac dans l’arthrose du genou

Objective. – To assess the test–retest reliability and the construct validity of a modified version of the French-Canadian version of the Womac index.Methods. – Open prospective study conducted in departments of rheumatology, rehabilitation and orthopedic surgery of a tertiary care teaching hospital. Eighty-eight patients with symptomatic knee osteoarthritis (O.A.) fulfilling the revised criteria of the American College of Rheumatology were included. The French-Canadian version of the Womac index was completed twice at a 3–hour interval. Impairment outcome measures, patients’ perceived discomfort in walking and handicap were recorded. An item by item analysis was performed. Test–retest reliability was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated using the Spearman rank correlation coefficient and a factor analysis was performed.Results. – Eight questions assessing function (section C) and the 2 questions assessing stiffness (section B) had insufficient psychometric properties and were excluded. Although test–retest reliability of the questionnaire was fair to good (0.82, 0.85, for the Womac section A, and modified section C respectively), construct validity could not be demonstrated. Factor analysis of the modified form of the Womac extracted 4 factors which differed from the a priori stratification. However, factor analysis of the modified section C extracted 2 factors explaining 68.4% of the variance which could be clinically characterized.Conclusion. – Despite its good test–retest reliability, the modified Womac index is not valid for assessing pain and disability induced by knee OA in a French population. Section A and modified section C could be used separately to assess respectively pain and function.