Non accidental repeated lithium poisoning in a child: The role of hair analysis.

Non accidental intoxication due to child abuse is rare and its frequency is likely underestimated because it is difficult to diagnose. Here, we report a case of voluntary repeated exposure to lithium in an infant, for whom the clinical manifestations were convulsions. Toxicological analysis was very helpful for documenting lithium exposure during the assumed period of time. Interpreting the results of hair analysis, a simple and minimally invasive examination, is tricky at this age, but it can facilitate the differentiation of acute versus chronic exposure. Although infrequent and underestimated, lithium should be considered as a cause of intoxication in a previously healthy child with acute seizure.

[Focus on the endocannabinoid system and the reprotoxicity of marijuana in female users]. / Focus sur le système endocannabinoïde et la reprotoxicité du cannabis chez la femme à l'heure du débat sur sa dépénalisation en France.

Among recreative compounds, marijuana is the most used worldwide. Delta9THC binding on brain endocannabinoid receptors drives its psychotropic effects. The endocannabinoid system (ECS) is an endogenous neurohormonal system essential for homeostasis composed of ligands, metabolic enzymes and at least 2 receptors discovered to date. In female reproduction, the ECS regulates the hypothalamic-pituitary axis and many steps of the reproduction process, such as ovulation, tubal transportation and trophoblast implantation. Delta9THC can cross the placental barrier and bind to the fetal endocannabinoid system. In humans, fetal and obstetrical consequences of marijuana use during pregnancy are intrauterine growth restriction and preterm delivery. In the light of legalization projects currently reviewed in several western countries, further research should be conducted to improve knowledge on maternal, fetal and reprotoxic consequences of marijuana use during reproductive age and pregnancy.

Socio-economics status and metabolic syndrome: A meta-analysis.

OBJECTIVE: The metabolic syndrome (MetS) is responsible for an increased risk of type 2 diabetes, cardiovascular diseases and is associated with all-cause and cardiovascular mortality. Economic and social vulnerability is not an easy concept to grasp, but some studies investigate the association between MetS and socioeconomic and demographic factors, deprivation (more often correlations rather than causal one due to data). This work aims to assess the association between MetS and socio-economic gradient (SEG) in the literature by performing a meta-analysis. DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for systematic reviews were followed. SETTING: The raw list of studies extracted from PubMed as regard to the inclusion/exclusion criteria was imported in Word. Studies were filed with regard to our three definitions of SEG and their title. PARTICIPANTS: Subgroup analysis were performed considering several definitions of Mets: NCEP-ATPIII and IDF2006. RESULTS: The overall multivariable-adjusted OR showed that the risk of MetS was significantly increased in association with SEG The results of the subgroup analysis showed an increased risk of MetS in association with SEG when IDF definition was considered. CONCLUSIONS: Targeted interventions must be implemented in a specific way as prevention campaigns aimed at the general population are generally not adapted to this particular vulnerable population.

Secondary findings from whole-exome/genome sequencing evaluating stakeholder perspectives. A review of the literature.

With the development of next generation sequencing, beyond identifying the cause of manifestations that justified prescription of the test, other information with potential interest for patients and their families, defined as secondary findings (SF), can be provided once patients have given informed consent, in particular when therapeutic and preventive options are available. The disclosure of such findings has caused much debate. The aim of this work was to summarize all opinion-based studies focusing on SF, so as to shed light on the concerns that this question generate. A review of the literature was performed, focusing on all PubMed articles reporting qualitative, quantitative or mixed studies that interviewed healthcare providers, participants, or society regarding this subject. The methodology was carefully analysed, in particular whether or not studies made the distinction between actionable and non-actionable SF, in a clinical or research context. From 2010 to 2016, 39 articles were compiled. A total of 14,868 people were interviewed (1259 participants, 6104 healthcare providers, 7505 representatives of society). When actionable and non-actionable SF were distinguished (20 articles), 92% of respondents were keen to have results regarding actionable SF (participants: 88%, healthcare providers: 86%, society: 97%), against 70% (participants: 83%, healthcare providers: 62%, society: 73%) for non-actionable SF. These percentages were slightly lower in the specific situation of children probands. For respondents, the notion of the «patient's choice¼ is crucial. For healthcare providers, the importance of defining policies for SF among diagnostic lab, learning societies and/or countries is outlined, in particular regarding the content and extension of the list of actionable genes to propose, the modalities of information, and the access to information about adult-onset diseases in minors. However, the existing literature should be taken with caution, since most articles lack a clear definition of SF and actionability, and referred to hypothetical scenarios with limited information to respondents. Studies conducted by multidisciplinary teams involving patients with access to results are sadly lacking, in particular in the medium term after the results have been given. Such studies would feed the debate and make it possible to measure the impact of such findings and their benefit-risk ratio.

[Changes in clinical practice related to the arrival of next-generation sequencing in the genetic diagnosis of developmental diseases]. / Les modifications de pratique clinique liées à l'arrivée du séquençage haut débit dans le diagnostic génétique des maladies du développement.

INTRODUCTION: The arrival of high-throughput sequencing (HTS) has led to a sweeping change in the diagnosis of developmental abnormalities (DA) with or without intellectual deficiency (ID). With the prospect of deploying these new technologies, two questions have been raised: the representations of HTS among geneticists and the costs incurred due to these analyses. METHODS: Geneticists attending a clinical genetics seminar were invited to complete a questionnaire. The statistical analysis was essentially descriptive and an analysis of costs was undertaken. RESULTS: Of those responding to the questionnaire, 48% had already prescribed exome analysis and 25% had already had the occasion to disclose the results of such analyses. Ninety-six percent were aware that whole-exome sequencing (WES) had certain limits and 74% expressed misgivings concerning its use in medical practice. In parallel, the evaluation of costs showed that WES was less expensive than conventional procedures. DISCUSSION: The survey revealed that geneticists had already come to terms with HTS as early as 2015. Among the major concerns expressed were the complexity of interpreting these tests and the many ethical implications. Geneticists seemed to be aware of the advantages but also the limits of these new technologies. The cost analysis raises questions about the place of HTS and in particular WES in the diagnostic work-up: should it be used early to obtain an etiological diagnosis rather than as the last resort? CONCLUSION: It is essential for future generations of doctors and for the families concerned to learn about the concepts of HTS, which is set to become a major feature of new genomic medicine.

[Evaluation of enhanced recovery for elective cesarean section]. / Évaluation de la mise en place d'un protocole de réhabilitation précoce postcésarienne.

OBJECTIVE: To evaluate the implementation of a protocol of enhanced recovery for elective cesarean section in a level III maternity. METHODS: This is a prospective observational study such as "before/after" on the implementation of a protocol of enhanced recovery for elective cesarean section from January 1st to December 31st, 2015, in a level III obstetrics unit French maternity. Patients were separated in 2 groups: women who benefit from enhanced recovery protocol after the first of July compared to women who underwent the conventional protocol between January 1st and June 30th, 2015. Inclusion criteria included: performing an emergency or scheduled cesarean, in patients with medical history congruent with the possible hospital release at day three. Demographic and obstetrics data were gathered. Items of the protocol, adverse and secondary effects as well as, postoperative complications were collected. RESULTS: From January 1st to December 31st 2015, 408 patients were included in this study, 202 in the conventional arm protocol and 206 in the enhanced recovery protocol. Early rehabilitation protocol has been achieved for 25.7 % patients (n=105) with 18.1 % (n=19) before the establishment of the protocol and 81.9 % (n=86) after creation of the latter. Prevention of PONV by dexamethasone and droperidol was performed before and after creation of the protocol in 5.3 % (n=1) and 51.2 % of cases (n=44) (P<0.05), respectively. There were no significant differences between the 2 groups regarding the removal of the urinary catheter (94.7 % versus 76 %, P=0.14) or the shutter venous catheter SSPI (78.9 % vs 73 %, P=0.82). Administration of drinks H1 and H4 first meal were routinely performed after the creation of the protocol (52.6 % vs 100 %, P<0.05 and 63.1 % vs 100 %, P<0.05). An early rise in the first 12hours was usually performed after the drafting of the protocol (78.9 % versus 92 %, P<0.05). Average hospital stay was shorter after the establishment of early rehabilitation protocol (4 versus 5.5 days, P<0.05). CONCLUSION: Early rehabilitation protocol was applied safely. It resolved in good management of pain, nausea and vomiting in postoperative. It participated in reducing adverse outcomes that could slow recovery and therefore allowed earlier hospital discharge, while maintaining high level of satisfaction with their care.

Use of negative pressure wound therapy after vulvar carcinoma: case studies.

Surgery is widely used to treat vulvar cancer. However, postoperative complications after a vulvectomy can occur in 26-85 % of the cases. Here, the authors describe a complete radical vulvectomy with bilateral inguinal lymph node dissection performed in two patients. Both patients developed infection and wound breakdown postoperatively. Due to failure of local care, negative pressure wound therapy (NPWT) was started to reduce bacterial rates and tension on wound edges. Accelerated tissue healing was observed in both cases, as well as an improvement in the patients' quality of life.

[French residents' training in instrumental deliveries: A national survey]. / Évaluation nationale de la formation des internes de gynécologie-obstétrique à l'accouchement instrumental.

OBJECTIVES: To evaluate French residents in Obstetrics and Gynaecology's training in instrumental deliveries in 2015. PATIENTS AND METHODS: We conducted a national descriptive survey among 758 residents between December 2014 and January 2015. Respondents were invited by email to specify their University Hospital, their current university term, the number of instrumental deliveries performed by vacuum extractor, forceps or spatulas, and whether they made systematic ultrasound exams before performing the extraction. RESULTS: Response rate was 34.7 % (n=263). There were important differences between regions in terms of type of instruments used. Vacuum extractor was the most commonly used instrument for instrumental deliveries by French residents (56.9 %), more than forceps (25.2 %) and spatulas (17.9 %). At the end of the residency, all the residents had been trained in instrumental deliveries with at least two instruments. CONCLUSION: The training of difficult techniques as well as their perfect control is required for instrumental deliveries. Yet, we are forced to note that there are substantial differences in the French residents' training in instrumental deliveries depending on their region. So, teaching at least two techniques seems essential as well as improving the training capacities and standardizing practices. A greater systematization of the teaching of the mechanics and obstetric techniques might be a solution to be considered too.

[Training achieves an internal version and a total breech extraction at birth of second twin]. / Formation à la version par manœuvre interne et à la grande extraction lors de l'accouchement du deuxième jumeau.

OBJECTIVES: To evaluate French residents in obstetrics and gynaecology's training to internal version and breech extraction during vaginal delivery of the second twin. METHODS: A national descriptive survey conducted among 1064 residents between July and October 2014. Respondents were invited by email to specify the type of theoretical and practical training they had received, their university hospital obstetrical practices and the number of vaginal internal version and breech extraction of the second twin they had seen and performed. RESULTS: Response rate was 38.7% (n=412). Regarding the type of theoretical training, 39.8% of residents (n=164) had received the obstetrical mechanics and techniques degree; 47.6% (n=196) had got a teaching during special education classes and 29.4% (n=121) a training on mannequin. There were important differences between regions. At the end of residency, 45.6% of residents (n=36) had practiced more than five vaginal internal version and breech extraction of the second twin. CONCLUSION: Internal version and breech extraction are difficult but essential maneuvers for the management of twin delivery. The French residents in obstetrics and gynaecology's training for these maneuvers seems to be insufficient. It is necessary to improve their teaching, this teaching must also be equivalent between regions.

[Relevance of the sentinel lymph node biopsy in breast multifocal and multicentric cancer]. / Pertinence de la procédure du ganglion sentinelle dans les cancers du sein multifocaux et multicentriques.

OBJECTIVES: The sentinel lymph node biopsy is a gold standard in the management of breast cancer. Its role in multifocal or multicentric tumors is still evolving. The aim of this study is to assess the feasibility and pertinence of sentinel lymph node biopsy in multifocal and multicentric tumors based on a systematic review of literature. METHODS: A systematic review was conducted searching in the following electronic databases PubMed using "sentinel lymph node biopsy", "breast cancer", "multifocal tumor", "multicentric tumor" and "multiple tumor" as keywords. We included original articles published between 2000 and 2014, both French and English, studying feasibility of sentinel lymph node biopsy in invasive breast cancer, multicentric and/or multifocal tumors. The first end point was success rate and false negative rate. RESULTS: Twenty-six articles were included in this literature review, with 2212 cases (782 multifocal, 737 multicentric and 693 multiple tumors). Percentage of tumors whose stage was higher than stage T2 ranged from 0 to 86.3%. Success rate average was 83.1%. False negative average was 8.2%. False negative rate was less than 10% in 15 articles. Mean of sentinel lymph node biopsy was 2 (1-9). The average rate of sentinel lymph node positive was 50.6%. Axillary recurrence rate was 0.5%. CONCLUSION: Despite the methodological biases of the studies included in this review of literature, the false negative rate of sentinel node biopsy in multifocal and multicentric breast cancers are less than 10% with a low rate of axillary recurrence. Despite the lack of randomized study, this procedure can be routinely performed in accordance with rigorous technical process.

Control of paradoxical kinematics in posterior cruciate-retaining total knee arthroplasty by increasing posterior femoral offset.

PURPOSE: Balancing the posterior cruciate ligament (PCL) with posterior cruciate-retaining total knee replacement (PCR-TKR) aims to restore femoral rollback. In practice, paradoxical roll forward persists. The purpose of this study is to propose a technique for optimizing PCL tension. Because PCL function starts above 60° of flexion, we hypothesize that PCL balancing requires flexion gap tightening by oversizing the femoral component and increasing posterior condylar offset (PCO). METHODS: PCR-TKR was performed in 21 osteoarthritis patients with a gap-balancing technique. The femoral component was oversized if more than a 5-mm posterior drawer existed after tibial component implantation. Kinematics was recorded intra-operatively in two steps with dedicated navigation software (Praxim, La Tronche, Isère, France): antero-posterior (AP) displacements of condylo-tibial contact points were observed in native and implanted knees, with each knee serving as its own control. The absence of paradoxical displacements was verified once the final implants were inserted. RESULTS: Paradoxical medial condyle displacement (11 mm) persisted in a single case. On average, posterior displacement of the medial condyle decreased from 9 ± 9 to 1 ± 6 mm (p = 0.001) and that of the lateral condyle from 16 ± 14 to 6 ± 6 mm (p = 0.006). In the 0°-30° flexion interval, posterior displacement was 2 times less than before implantation for the medial condyle (p = 0.001), and 4 times less for the lateral condyle (p = 0.004). The course of the lateral condyle decreased from 2 ± 3 to 0 ± 4 mm in the 90°-120° flexion interval (p = 0.046). Six-month flexion was 124° ± 17°. CONCLUSION: Femoral component oversizing allows us to control paradoxical forward displacements in 95 % of cases. When balancing PCR prostheses, AP laxity should be taken into account. Increasing PCO appears to be a reliable technique for adjusting PCL balance. Thus, it may optimize extensor mechanism action and, subsequently, the functional results of PCR-TKR. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Does the PFNA™ nail limit impaction in unstable intertrochanteric femoral fracture? A 115 case-control series.

INTRODUCTION: Femoral neck shortening after dynamic fixation of extra-capsular fracture may impair functional results, but is rarely assessed. The present study measured impaction in stable and unstable fractures (on the Ender classification) treated by PFNA™ nail. The objectives were: 1) to validate the Ender classification to assess fracture stability; 2) to determine whether neck shortening and head purchase quality varied with stability; and 3) to determine the functional impact of femoral neck shortening. HYPOTHESIS: The study hypothesis was that the PFNA™ nail stabilizes unstable as well as stable fractures. MATERIALS AND METHODS: One hundred and fifteen consecutive patients, aged over 70 years, operated on for intertrochanteric fracture using the PFNA™ nail were followed up prospectively for 6 months. Multivariate analysis, including age, gender, assembly quality and body-mass index, was applied to assess the predictive power of the Ender classification with respect to femoral neck shortening. Secondly, patients were grouped according to stable versus unstable fracture (n=70 and 45, respectively), and impaction and femoral head purchase were assessed on a dedicated radiographic protocol. Functional results were assessed on Parker score. RESULTS: In the unstable fracture group, 3 assembly failures required revision by total hip replacement. Ender grade>2 was significantly predictive of>5mm neck shortening. Neck shortening was greater in unstable fracture: 8.1 ± 8.4mm (range, 4-32 mm), versus 2.5 ± 3.7 mm (range, 3-14 mm) (P=0.0004). Mean blade cut-through was 1.2 ± 2.9 mm (range, 1-12 mm) in unstable fracture, versus 0.3 ± 1.3 mm (range, 1-6mm) (P=0.02). Mean cut-out was 2.3 ± 6 mm (range, 2-21 mm) in unstable fracture, versus 0.5 ± 2.6 mm (range, 1-8mm) (P=0.03). Parker scores diminished comparably in the two groups, without significant difference at follow-up: 3.9 ± 2.6 (range, 0-9) in stable and 3.1 ± 1.9 (range, 0-8) in unstable fracture; reduction in Parker score showed no correlation with femoral neck shortening (r=0.013, P=0.88). DISCUSSION: The PFNA™ nail provides poorer stabilization of unstable compared to stable fracture. Femoral neck shortening should be taken into account in assessing internal fixation hardware perfomances. LEVEL OF EVIDENCE: Level III. Prospective case-control study.

Current state of anterior cruciate ligament registers.

PURPOSE: The purpose of this work was to report the main characteristics and results of all active anterior cruciate ligament (ACL) reconstruction registers along with the differences between them. METHODS: We systematically searched on Google and Medline via PubMed to identify ACL registers. National or regional registers were included if they were active and took into account ACL reconstructions. The main results and characteristics, namely the number of inclusions, exhaustivity, data collection methods and results dissemination methods were determined. The collected information was then submitted to each register for validation. RESULTS: Four registers (3 national, 1 regional) were identified that routinely included every ACL reconstruction procedure. Register data were collected either through dedicated websites or on paper forms. All the registers used the same two outcome measures, namely the revision rate and a subjective patient score (KOOS score). Register results were made available through scientific publications or annual reports. The main differences between registers were in the graft choice and presence of associated meniscus and cartilage injuries. CONCLUSIONS: Although there are only a few ACL reconstruction-specific registers, their scientific contribution is undeniable thanks to the quality of the collected data and the organization and collaboration between registers. Their impact on health care and science should grow in the future.