Medical and surgical triage.

In terrorist attacks and industrial catastrophes, management of a massive afflux of wounded must adhere to logistic imperatives while at the same time taking into account basic traumatology principles. This implies a firm, unequivocal, and precise doctrine for all stages of care. Medical and surgical triage allows a logical classification of victims according to severity of injury, the necessity of treatment and the degree of urgency. Triage should be early, dynamic, and lead to a categorization that optimally utilizes resources while ensuring efficient management.

Crosswalk time estimation and time perception: an experimental study among older female pedestrians.

Since the sense of time is strongly influenced by advancing age, this laboratory study aimed to find out more about older pedestrians' decisions to cross the road, focusing on their estimates of how long it would take them to cross. The walking times of older female adults with or without any walking impairment and of healthy young adults were recorded on a walkway representing a road section. Participants also performed actual and imagined crossings of this "road" as well as a duration production task. Results showed that misestimated crossing times were related to the individual time base, with stronger time distortions in some older participants. A comparison between the older participants with disabilities and their age-paired counterparts without disabilities revealed an overestimation of crossing time in the former, affording them a bigger safety margin.

Do individuals with intellectual disability select appropriate objects as landmarks when learning a new route?

BACKGROUND: The present study was aimed at investigating the selection of landmarks by individuals with intellectual disability (ID). The hypothesis was that they would be less efficient than individuals without IDs in the selection of landmarks when learning a new route. METHODS: The experiment took place in a natural setting with a group of participants with ID and a group of control participants matched by chronological age. The participants were first guided along a route situated in an unfamiliar district. Then, they had to guide the experimenter along the route while pointing to all the objects and features they found useful for wayfinding. RESULTS: The designated objects were categorised as a function of their landmarks properties. There were significant differences between the two groups for non-permanent landmarks, distant landmarks and non-unique landmarks. The two groups selected landmarks near intersections in the same proportions. However, the individuals with ID selected more non-unique landmarks and less textual signage than the control group at these decision points. CONCLUSION: Individuals with ID seem to be less efficient than individuals without disability in landmark selection. This may limit their wayfinding abilities in their day-to-day travelling. This may also account for their difficulties in obtaining the kind of spatial knowledge which relates to the configural structure of their environment.

Management of penetrating abdominal vessel injuries.

Vascular injury due to penetrating abdominal trauma is a major challenge for trauma teams. Arterial and venous injuries occur with equal frequency. Treatment depends on the hemodynamic status of the patient: under stable conditions, angiography can be envisioned, whereas instability is an indication for immediate surgery; damage control is the most frequent procedure. As persisting on complete surgical exploration may lead to fatal outcome, the surgeon must be prepared to perform perihepatic or pelvic packing and employ endovascular techniques as appropriate. However, the surgeon has to be prepared to deal with uncontrolled hemorrhage, and explore all central retroperitoneal hematomas, retroperitoneal hematoma located in the flanks except when stable in the hemodynamically unstable patient, and those in the pelvis only if the patient is stable. Since it is more critical to control hemorrhage than to avoid end-organ ischemia, vascular ligation is more commonly used than other techniques. However, survival is very low in these severely wounded patients.

[Surgeons can learn from pilots: human factors in surgery]. / Les chirurgiens peuvent apprendre des pilotes: place du facteur humain en chirurgie.

Human factors (HF) study is mandatory to get air transport pilot licences. In aviation, crew resource management (CRM) and declaration of adverse events (feedback) result in improving of air safety. Air missions and surgical procedures have similarities. Bridging the gap is tempting, despite severe warnings against simplistic adaptation. Putting HF theory into surgical practice: how to? Educational principles derived from CRM improve professional attitudes of a team. We propose to translate concepts of CRM to clinical teams. CRM training applying in surgery could allow the work environment to be restructured to reduce human error. Feedback: in aviation, the Bureau of Flight Safety deals with investigations for air events. Pilots, air traffic controllers can anonymously declare nuisance, resulting in a feedback for the whole air force. Adverse events are analysed. Usually, multilevel problems are found, rather than the only responsibility of the last operator. Understanding the mechanisms of human failure finally improves safety. In surgery, CRM and feedback would probably be helpful. Anyway, it requires time; people have to change their mind. Nevertheless people such as fighter pilots, who were very unwilling at the beginning, now consider HF as a cornerstone for security. But it is difficult to estimate the extent of HF-related morbidity and mortality. We propose as a first step to consider CRM and feedback in surgical procedure. HF deals with the mechanisms of human errors and the ways to improve safety and probably improve the surgical team's efficacy.

[Foreign body perforation of the thoracic esophagus]. / Perforations de l'oesophage thoracique par corps étranger.

BACKGROUND: Esophageal perforation due to foreign body (FB) ingestion is an unusual occurrence. This study aims to define diagnostic difficulties of esophageal perforation by FB. PATIENTS AND METHODS: A chart review of patients on our service with FB esophageal perforation was carried out. Diagnosis of perforation was made by CT scan and/or esophagoscopy. Surgery was indicated when a FB could not be removed endoscopically or on a case-by-case basis according to clinical/laboratory, radiologic, and/or endoscopic findings. RESULTS: Seven patients (age range: 27 to 80 years) were admitted for esophageal FB perforation. All patients presented with dysphagia. Two patients presented with signs of sepsis more than 24 hours after FB ingestion. Perforation was diagnosed at initial evaluation in five cases (three by endoscopy, two by CT) and after FB extraction in two cases. Six patients underwent surgery (suture repair: n=4; esophageal exclusion: n=1; mediastinal drainage: n=1). Five surgeries were performed at the initial diagnosis and one after failure of medical management. Mortality was zero; one patient developed esophageal fistula. CONCLUSION: Diagnosis of FB esophageal perforation is difficult and is delayed in up to a quarter of patients. The perforation can be due to the FB itself or may be incurred during endoscopic extraction. Both CT and endoscopy are necessary for diagnosis and treatment. Most patients require surgical intervention.

[Post-amoxicilline neutropenic rectitis in an immunocompetent patient: a case report]. / Rectite neutropénique post-amoxicilline chez un patient immunocompétent: à propos d'un cas.

We report a 38-year-old immunocompetent patient who presented with a neutropenic rectitis after a treatment by amoxicillin for nasopharyngitis. Neutropenic colitis is a digestive wall inflammation, preferentially localized in the ileo-caecal area and the right colon, which leads to necrosis and sepsis, and usually occurs in neutropenic patients treated by chemotherapy with an incidence of 6%. It is a serious and often lethal disease. The treatment is supportive, and surgery is limited to the occurrence of complications (perforation, bleeding). Neutropenic colitis occurring in a rectal location after antibiotic therapy in an immunocompetent patient has been rarely described.

[The Main Gate Syndrome: a new format in mass-casualty victim "surge" management?]. / Le Main Gate Syndrom ou faut-il redéfinir notre conception du triage chirurgical?

INTRODUCTION: Recent suicide bombings pose the novel problem for Trauma Centers of the massive simultaneous arrival of many gravely wounded patients. METHODS: We report the experience of the French-German Military Trauma Group, a Level 2 Trauma Center, in Afghanistan during the wave of suicide bombings in February 2007. RESULTS: Fourteen casualties were received. A first triage was carried out by the U S Army Level I group prior to evacuation. A second surgical triage was carried out with systematic ultrasound exam. Four cases (ISS>25) were re-categorized and underwent emergency surgical procedures. CONCLUSION: Suicide bombing in crowded locations near an evacuation hospital may overwhelm the medical resources of the receiving center. It has been referred to as "The Main Gate Syndrome." We introduced the novel concept of a semi-evacuation hospital or receiving center where a second surgical triage was carried out. These exceptional circumstances require open-minded flexibility, a tailored approach, and close cooperation between surgeons and anesthetists to share experience, opinions, and ideas. In the setting of mass casualties, emergency ultrasound exam was shown to be a valuable and effective tool by virtue of its mobility, reproducibility, and immediate results.

[Ruptured mesenteric aneurysm from Listeria monocytogenes]. / Rupture d'un anévrisme infectieux à Listeria monocytogenes de l'artère mésentérique inférieure.

Infections due to Listeria monocytogenes usually occur in pregnant women, in elderly or immunocompromised patients. We report the case of an immunosuppressed woman who had been hospitalized for a meningoencephalitis due to L. monocytogenes. She was operated on for an abdominal hemorrhagic shock due to a ruptured mycotic aneurysm of the inferior mesenteric artery. Arterial aneurysms due to this germ are rare and occur on large arteries. Only 17 cases have been previously described in the literature and just one concerning a mesenteric artery.

The Lille apathy rating scale (LARS), a new instrument for detecting and quantifying apathy: validation in Parkinson's disease.

BACKGROUND: Apathy is usually defined as reduced interest and participation in various activities. It is a frequent consequence of neurological and psychiatric disorders. Although various scoring methods have been proposed, there is a lack of validated, standardised instruments for detecting apathy and assessing its severity. OBJECTIVE: To develop an apathy rating scale using a structured standardised interview capable of distinguishing between the condition's various features. METHODS: The Lille Apathy Rating Scale (LARS) is based on a structured interview. It includes 33 items, divided into nine domains. Responses are scored on a dichotomous scale. The participants used to validate the scale consisted of 159 patients with probable Parkinson's disease and 58 healthy control subjects. The Marin Apathy Scale, the Montgomery and Asberg Depression Rating Scale, and the Mattis Dementia Rating Scale were also administered. RESULTS: Principal component analysis showed that the LARS probed a single construct which forms the root of an oblique factor structure reflecting four dimensions: intellectual curiosity, self awareness, emotion, and action initiation. The main psychometric properties of the LARS (internal consistency, inter-rater and test-retest reliability) were satisfactory. Concurrent validity was evaluated by reference to the Marin scale and to judgements provided by expert clinicians. CONCLUSIONS: Standard validity indices showed that the LARS is sensitive and capable of distinguishing between apathy and depression. As a screening tool, the scale is able to support dichotomous judgements accurately and, when greater measurement sensitivity is required, also determine the severity of apathy within a four category classification.

[BCcogSEP: a French test battery evaluating cognitive functions in multiple sclerosis]. / La BCcogSEP: une batterie courte d'évaluation des fonctions cognitives destinées aux patients souffrant de sclérose en plaques.

In French language, there is no standardized procedure to assess cognitive function in patients with multiple sclerosis (MS). Such an assessment is however very useful to determine the consequences of the disease on cognitive function, to evaluate the disease progression and the consequences of usual treatments on cognition. This study aimed to develop and validate a French language battery based on "the Brief Repeatable Battery of Neuropsychological tests for Multiple Sclerosis" (BRB-N) often used in other countries. In an initial phase, the battery was composed of the French version of the 5 BRB-N tests to which were added 4 tests assessing immediate and working memory as well as executive function. 52 healthy control subjects (20-50 years) participated in the study. A principal component analysis (PCA) of their data examined the contribution of each test into the battery. 93 other healthy subjects participated in a second phase where analyses of variance were carried out to investigate the effect of the main demographical variables. Finally, the performance of two patient groups (20 with a EDSS score3) was compared to the healthy controls in order to investigate the ability of our battery to detect cognitive impairment in MS patients. The PCA showed that each test, except one, had a specific contribution to the battery. The final battery (BCcogSEP) was thus comprised of 8 tests. MANOVA and ANOVA showed significant effects of age, sex and educational level on performance. In consequence, a procedure allowing to take into account these factors was developed. The battery was able to detect cognitive impairment in MS patients, even when the disease is not severe. In this case, deficits were observed in tests assessing executive function, information processing speed, immediate and working memory. This short battery with reliable psychometric qualities allows the interpretation of a MS patient's performance considering his/her demographical characteristics and is able to detect cognitive abnormalities even in case of mild physical handicap.

[Inguinal hernia in Africa and laparoscopy: utopia or realism?]. / Hernie inguinale en Afrique et coelioscopie: utopie ou réalisme?

Inguinal hernia is a common indication for surgery in Africa. Most cases involve men and are treated in advanced stages often with complications. Until now the benchmark technique for surgical management has been the well-defined herniorrhaphy technique. Use of prosthetic implants has been rare because of high cost. Recently there has been a growing interest in video-assisted surgery throughout developing countries. However this enthusiasm should not obscure the fact that the technique is still in the developing stage and thus is more costly for the local economy. Indications for video-assisted surgery should be carefully selected in function of local conditions as well as problems specific to developing countries.

Activity modelling for assessing the usability of telematics applications in healthcare.

With the development of Telematics Applications in Healthcare, it becomes obvious that the success of these services is tightly linked with their usability and their acceptance by users. That is why Users Requirements Analysis appears as an essential step before implementation of new computer services. In many cases, particularly when doctors are directly involved in the management of information, there is a strong interaction between their usual activity and the new tasks implied by the computer. In those cases, Activity Modelling can be useful to describe the way people are working, the motivations that underlie this activity, the place of information management in this activity. Moreover, these models can help to forecast possible difficulties or reasons for failure of the data management when computerised. Obviously, these models are highly depending on the healthcare organisation but some basic lines can be transferable. In this paper we illustrate the Activity Modelling Methodology by examples from Telematics exchanges between GPs and Hospitals.