Trachéotomie et traumatisme crânien grave : pour qui ? Pourquoi ? Quand ? Comment ?

The aim of this study is to determine, from the data available in the literature, the indications of tracheostomy in brain injured patients, the incidence and risk factors for complications and the follow-up required until decannulation. The incidence of tracheostomy is 10% in TBI and 50 to 70% in subpopulations with a Glasgow Coma Scale (GCS) below 9. Early complications are not specific. The most frequent late complication is laryngotracheal stenosis, which occurs in 15% and is more frequently observed in the most severe patients with major hypertonia. It is likely that tracheostomy, if needed, should be performed early and the prognosis as to whether it will be required, can be made at the end of the first week. The follow-up of these patients includes surveillance of multiresistant colonisations and systematic performance of fibroscopy before decannulation. Cuffless, small diameters, soft tracheostomy tubes, are preferred on the long-term unless the risk of aspiration remains high.     

Is crude postoperative mortality rate a relevant criterion of the efficiency of a surgical team? Prospective study of 11,756 patients' postoperative course

AIM: Evaluation of the crude postoperative mortality rate as a relevant criterion of the efficiency of a surgical team. MATERIAL [corrected] AND METHODS: We studied prospectively the postoperative course of 11,756 consecutive patients who underwent a general surgery procedure between January 1(st) 1987 and December 31 2002. RESULTS: Seventy-three of patients died (0.60 percent). The median age at the time of death was 77 years old. None of the 5046 patients under 40 years old died. The operations were emergent in 3,265 patients (28 percent). The mortality rate of the 3,952 digestive surgery patients was 1.00 percent (40/3,952 patients). Among them, the mortality rate increased to 3.56 percent (17/478 patients) in case of an emergency procedure excluding procedures for non-suppurative appendicitis. Although only 8 percent of the patients were operated for a cancer (968/11,756 patients), they accounted for 49 percent of the postoperative deaths. In this cohort, the crude mortality rate varied by twice as much as were taken in account (73 deaths) or not (34 deaths) the palliative procedures in terminal phase patients, and the last-chance procedures in patients in imminent-death condition. Six hundred and twenty patients (5.3 percent) experienced at least one postoperative complication, surgical in 166 patients, and parietal in 258 patients. CONCLUSION: This study shows that a long-term rigorous self-assessment is feasible. It confirms that the crude mortality rate is not a relevant criterion to evaluate the efficiency of a surgical team, suggests that an "avoided death" concept is more representative of medical team work and more rewarding for them and allows us to propose an index taking in account the rate of postoperative complications not followed by death.     

Geographic dissemination of methicillin-resistant Staphylococcus aureus strains: a French regional study

The aim of this study was to compare methicillin-resistant Staphylococcus aureus strains collected in eight hospitals located in the same region of France (Brittany) over a short period (January 1999-July 2000). Ninety-two isolates of methicillin-resistant S. aureus were characterised by their pulsotype and their antibiotype. Pulsotype analysis permitted the definition of three clusters. Two of them comprised 83% of the studied isolates. Phenotypic analysis showed two major antibiotypes, widespread in Brittany but with a heterogeneous geographic distribution and one antibiotype fitting the definition of glycopeptide intermediate S. aureus. These data argue for the high epidemicity of methicillin-resistant S. aureus among the same region.     

Detection of the sentinal node in squamous-cell carcinoma of the oral cavity and oropharynx. Preliminary study

INTRODUCTION: The sentinel lymph node is defined as the first relay of the lymphatic drainage of the tumor. Isotopic detection of the sentinel lymph node and absence of its metastatic invasion should theoretically be predictive of total drainage of the tumor. The goal of this study was to evaluate sentinel lymph node detectability by lymphoscintigraphy in N0 and/or N1 squamous-cell carcinoma of oral cavity and oropharynx and to determine its negative predictive value. MATERIAL AND METHOD: Lymphoscintigraphy was used for sentinel lymph node detection. The procedure required peritumoral injection of technicium-labeled colloids to enable anatomical and cutaneous location of the sentinel lymph node. A one-way Tyco-Mallinckrodt probe was used for intraoperative detection of the sentinel lymph node. This prospective study included 21 patients with N0 or N1 squamous-cell carcinoma of the oral cavity and the oropharynx. The surgical attitude based on T and N was not modified in this prospective study without direct individual benefit for the patient. Neck dissection was achieved without difficulty. RESULTS: The sentinel lymph node was identified in 20 out of 21 subjects. The sentinel lymph node was not identified in one patient with recurrence T2N0M0 squamous-cell carcinoma of the oropharynx radiated 3 years earlier. The percentage of false-negatives was 12.5% (1 false-negative out of 8 positive patients), giving a sensibility of the detection method of 87.5% (IC (95%)=[47.35-99.68]). This false-negative patient had a T3N0M0 squamous-cell carcinoma of the oropharynx with a sentinel lymph node removed in territory III. Neck dissection revealed 1 N + R- in the sub-mandibular territory associated with 27 N-R-. The probability of not finding a metastatic node at neck dissection when the sentinel lymph node is not metastatic (negative predictive value) was 92.3% (12/13) (IC (95)=[63.97-99.81]). The specificity of the method was 100%, as was the positive predictive value, because no sentinel node was diagnosed positive wrongly on frozen sections among patients without true histological node metastasis. DISCUSSION: For routine care of patients with squamous-cell carcinoma of the oral cavity and the oropharynx detection of the sentinel lymph node is proposed primarily for patients with T1T2N0 staging. Larger tumors can modify the architecture and flow within the lymphatic ducts, and consequently even the concept of a sentinel lymph node. Systematic neck dissection is required or T3T4, even when N0. Our series of T1T2N0 tumors is too small to enable statistically significant conclusions. A low level of false-negative in a larger series would be necessary to propose this technique instead of convention neck dissection for T1T2 tumors of the oral cavity and oropharynx.     

The dural tail sign--beyond meningioma

There have been somewhat conflicting reports published about the significance of linear meningeal thickening and enhancement adjacent to peripherally located cranial mass lesions on contrast-enhanced magnetic resonance (MR) images. Most of the authors consider this so-called "dural tail sign" or "flare sign" almost specific for meningioma. This review illustrates the MR imaging findings of a wide spectrum of disorders that show this dural sign. Causes include other extra-axial lesions and also peripherally located intra-axial lesions such as neuromas, chloromas, metastases, lymphoma, gliomas, pituitary diseases, granulomatous disorders, and also cerebral Erdheim-Chester disease. The dural tail sign is not specific to a particular pathological process. Nevertheless, useful conclusions can be drawn from the morphology of the lesion, its enhancement pattern, and its solitary or multifocal presentation. The final diagnosis must be based on cerebrospinal fluid studies or histological studies after biopsy.     

Characteristics of adolescent street youth with a history of pregnancy

This study examines characteristics of adolescent street youth with histories of pregnancy and documents important factors that merit consideration when providing global sexual health care. STUDY OBJECTIVE: To determine social and behavioral factors associated with a history of pregnancy among adolescent street youth. DESIGN, SETTING, PARTICIPANTS: In a prospective cohort study, female adolescent street youth (14-19 years) ever pregnant (AEP) were compared with adolescents never pregnant (ANP) using data from baseline questionnaires. RESULTS: Among the 225 participants, 41.8% were ever pregnant. Both groups were similar with respect to age (mean 17.8 years) and other socio-economic characteristics. However, AEP were more likely to have been kicked out of home (62.8% vs. 47.3%, P=0.022) and to have run away (78.7% vs. 64.9%, P=0.025) and were homeless younger (mean age: 13.9 vs. 14.7 years, P=0.011) and since a longer period (mean: 4.0 vs. 3.0 years, P=0.001). Both groups had problematic alcohol and drug use: 31.3% had a CAGE score >2; 72.2% had a DAST score >6. Almost half (44.0%) had ever injected drugs and AEP were younger at initiation into drug injection (15.2 years vs. 16.0 years, P=0.049). More AEP had experienced intra-familial or extra-familial sexual abuse (71.3% vs. 56.5%, P=0.024), and had had more than one abuser (71.6% vs. 50.0%, P=0.009). Among those abused by family members, abuse occurred at an earlier age for AEP (mean age: 7.4 vs. 8.9 years, P=0.090) and more AEP reported severe abuse: vaginal penetration (62.2% vs. 26.7%, P=0.004) and anal penetration (29.7% vs. 3.3%, P=0.005). CONCLUSIONS: Histories of severe sexual abuse and early injection drug use are extremely frequent in ever pregnant street adolescents. These factors need to be addressed when planning global health care and sexual health education.     

Assays for assessment of sperm DNA integrity: relationships with fertility and conceptus quality

Several assays are available for testing nuclear quality of spermatozoa, many of them allowing to define a DNA fragmentation index (DFI). Numerous recent studies on this subject agree on several points: negative correlations are observed between DFI and sperm characteristics. Concerning the relationships between DFI and artificial reproductive technologies, there are some disagreements about correlations between DFI and fertilization rates; conversely, in case of high DFI, both blastocyst formation rate and pregnancy rate are significantly reduced. Several authors have defined a threshold value for DFI, corresponding to an absence of pregnancy, or a very low pregnancy rate, for samples above this value. Unfortunately, there are no data available concerning the relationships between sperm DNA quality and abnormalities at birth.     

Histocompatibility leukocyte antigen-D related expression is specifically altered and predicts mortality in septic shock but not in other causes of shock

Although the expression of monocyte histocompatibility leukocyte antigen (HLA)-DR has been shown to be decreased during human sepsis, its level of expression in other nonseptic critical conditions is unclear. The aim of this study was to compare the level of HLA-DR expression on circulating monocytes among patients with septic, hemorrhagic, and cardiogenic shocks and severe sepsis without shock. At admission, HLA-DR expression was exclusively decreased in patients with septic shock (n = 30; P < 0.001), whereas the expression was similar between the other studied groups: cardiogenic shock (n = 16), hemorrhagic shock (n = 11), severe sepsis without shock (n = 18), and healthy volunteers (n = 8). HLA-DR expression was not predictive for overall mortality, but at day 1, an HLA-DR expression of less than 14 of mean fluorescence intensity (that corresponds to 40% labeled monocytes) was predictive of mortality exclusively in patients with septic shock (odds ratio, 11.4 and 95% confidence interval, 1.7; 78.4; P < 0.008). Catecholamine infusion, mechanical ventilation, positive blood culture, and number of units of blood or plasma transfused did not correlate with decreased HLA-DR expression. Thus, the decrease in HLA-DR expression is specific to septic shock and is associated, in septic shock patients, with increased mortality risk.