[Perstimulus asystole during electroconvulsive therapy: Clinical case and critical literature review]. / Asystolie perstimulus résultant d'une hypertonie parasympathique au cours des électroconvulsivothérapies : cas clinique, brève revue de la littérature et discussion.

INTRODUCTION: Electroconvulsive therapy (ECT) is most frequently indicated for episodes of melancholic depression, but is also useful in the treatment of maniac syndrome and some schizophrenia subtypes. ECT is part of the treatment of movement disorders, neuroleptic malignant syndrome and even in the treatment of severe conversions. Although the therapeutic results are excellent when used appropriately, the mortality rate is estimated between 2 and 4 for 100,000 shocks. Despite this mortality rate, the benefit-risk ratio remains very positive and serious complications are extremely rare. ECT results in a biphasic cardiological effect: firstly a perstimulus parasympathetic hypertonia contemporary to the seizure's tonic phase, then a phase of contemporary sympathetic hypertonia during the epileptic clonic movement. We will focus on the perstimulus asystole as it is by far the most frequent. Very few cases and even less studies have been referenced in the literature; here, we present a clinical case followed by a discussion. CLINICAL CASE: The patient is in his fifties and has been treated for many years for a unipolar mood disorder with recurrent melancholic depressive episodes. With each new depressive episode, the clinical evolution is rapidly positive after a few sessions of ECT. Maintenance ECT was not retained due to the supra-annual periodicity of the melancholic depressive episodes and rapid recovery after electric treatment. Then, this patient developed another depressive decline in mood comparable to the previous one, despite adapted blood lithium levels associated with a new generation antidepressant treatment. According to his history, a hospitalisation was programmed to carry out a new course of ECT. Considering the short duration of the first seizures, the intensity of the stimulus was progressively increased. At 180 joules, the patient presented an immediate per-stimulus asystole of 20seconds which ceased spontaneously. The specialized cardiologic consultation following the rhythmic episode was reassuring: the patient's cardiac condition remained stable. However, after discussion with the patient and his family, we decided to stop the ECT. Was this a reasonable decision? DISCUSSION: According to the literature, the patient's medical history, sex, psychiatric diagnosis, the shock parameters (level of energy applied, duration of the stimulus, number of shocks) and clinical results, are not predictive factors in the occurrence of an asystole. Concerning the ECT protocol, the vagus nerve seems less stimulated during bifrontal stimulations in opposition to unilateral stimulations. Perasystolic patients are younger and have less prior history of cardiovascular disease or ECG abnormalities. Although the patients receiving ECT are often taking several medications (antipsychotics, benzodiazepines, antidepressants, anticholinergic correctors, calcium channel blockers, loop diuretics, converting enzyme inhibitors), these drugs are not considered as facilitating asystoles. No increase in the frequency of asystole had been observed when taking an average dose psychotropic treatment allowing the continuation of an antidepressant treatment at the recommended dose. Differently, lithium is regularly stopped during the shock phase as it could - even a few days after being stopped - potentiate the effects of succinylcholine and increase the vagal tone. Succinylcholine seems to promote asystole, whilst caffeine, methohexital and trimethaphan do not. The hypersympathetic phase can be controlled by a betablocker (propranolol, esmolol, labetalol) that does not increase the prior risk of asystole. Anticholinergic premedication using atropine does not appear to be systematic and could even potentially induce tachy-dysarrhythmia. However, in the case of perstimulus asystole, most authors recommend continuing the shocks with doses of atropine around 0.4 to 1mg. PHYSIOPATHOLOGY: Vagal stimulation is preferentially central and directly linked to the electric excitation of the lateral dorsal motor nucleus of the vagus nerve. Younger patients with no cardiac history are more at risk. This could be explained by the fact that juvenile tissue conducts electricity more rapidly than senescent (the difference being probably due to the fibrosis and adipose tissue which reduce its conductive capacity). Finally, it is appropriate to question the direct therapeutic aspect of vagal stimulation which constitutes an experimental treatment of resistant depression. CONCLUSIONS: The occurrence of perstimulus asystole is not considered as a serious complication of ECT and therefore as a contra-indication to any future sessions. On the contrary, most authors are campaigning for the continuation of shocks with the possibility of adding prophylactic intravenous atropine. Cardiac arrest reminds us that ECT requires a special attention to its cardiovascular effect, which emphasizes the role of interdisciplinarity between anaesthesiologists and psychiatrists.

Collective aeromedical evacuations of SARS-CoV-2-related ARDS patients in a military tactical plane: a retrospective descriptive study.

After the appearance of the COVID-19 pandemic in France, MEROPE system was created to transform the military tactical ATLAS A400M aircraft into a flying intensive care unit. Collective aeromedical evacuations (aero-MEDEVAC) of patients suffering from SARS-CoV-2-related acute respiratory distress syndrome was performed from June to December 2020. A total of 22 patients were transported during seven missions. All aero-MEDEVAC was performed in safe conditions for patients and crew. No life-threatening conditions occurred during flight. Biohazard controls were applied according to French guidelines and prevented crew contamination. Thanks to rigorous selection criteria and continuous in-flight medical care, the safe transportation of these patients was possible. To the best of our knowledge, this is the first description of collective aero-MEDEVAC of these kinds of patients using a tactical military aircraft. We here describe the patient's characteristics and the flight's challenges.

[Morbidity and mortality after intensive care management of hemorrhagic stroke in Djibouti]. / Morbi-mortalité des accidents vasculaires cérébraux hémorragiques après prise en charge en réanimation a Djibouti.

Prospective data on management and outcome of stroke in Africa is scarce. The purpose of this prospective descriptive study is to present epidemiologic, clinical and outcome data for a series of patients with hemorrhagic stroke in Djibouti. All patients admitted to the intensive care unit of the Bouffard Medical-Surgical Center in Djibouti for cerebral hemorrhage documented by CT-scan of the brain were recruited in this study. A total of 18 patients including 16 men were enrolled. The median patient age in this series was 51.5 years [range, 20-72]. The median duration of intensive care was 3 days [range, 1-38]. Mean Glasgow score at time of admission was 9 [range, 3-14]. Five patients were brought in by emergency medical airlift. The main risk factors for stroke were arterial hypertension, smoking, and regular khat use. Mechanical ventilation was performed in 10 patients with a survival rate of 40%. Six patients (33%) died in the intensive care unit. Hospital mortality within one month was 39% and mortality at 6 months was 44.4%. One-year survival for patients with a Glasgow score < or = 7 at the time of admission was 33%. Arterial hypertension, khat use, and smoking appeared to be major risk factors for male Djiboutians. Neurologic intensive care techniques provided hospital mortality rates similar to those reported in hospitals located in Western countries. Functional outcome in local survivors appeared to be good despite the absence of functional intensive care. These data argue against the passive, fatalistic approach to management of hemorrhagic stroke and for primary prevention of cardiovascular risk factors.

[Acute liver failure and severe exertional heat stroke: uneasy management in Africa]. / Coup de chaleur d'exercice grave et insuffisance hépatique aiguë: difficultés de prise en charge outre-mer.

Exertional heat stroke (EHS) is a medical emergency defined as tissue injury secondary to a prolonged period of extreme hyperthemia during strenuous physical activity. In the vast majority of cases, EHS is associated with minimal liver involvement with no clinical manifestations. However acute hepatic insufficiency has been reported including a few cases treated by liver transplantation but with poor results suggesting that conservative management is preferable. The purpose of this report is to describe a patient who developed EHS with acute liver insufficiency and multiple organ failure in Djibouti. Despite the remote location and limited medical resources available, full recovery was achieved with conservative therapy and intensive care.

[Epidural anaesthesia and lumbar tattoo: what to do?]. / Analgésie par voie péridurale et tatouage lombaire: que faire?

More and more often, the anaesthesiologist may have to perform lumbar epidural anaesthesia in a patient with a central lumbar tattoo, and this can occur in an urgent obstetric setting. Before managing two uneventful cases of epidural analgesia for labour, we have performed a literature review and noted that no serious complication has been reported. Nonetheless, a needle passed through a tattoo can entrap pigmented tissue fragments (cores) into the epidural or subarachnoid space. This could theoretically induce risk of late neurological complications, related to an inflammatory or granulomatous response to the pigmented cores introduced in these spaces. To avoid this theoretical risk, the anesthesiologist should try to avoid puncturing through the tattoo, either by selecting a different vertebral interspace, or by using a paramedian approach or by finding a pigment free skin spot within the area of the tattoo. When these options cannot be implemented, a superficial skin incision prior to needle insertion should prevent from coring tattoo pigment when entering the skin. Whatever the final choice, the technique to be implemented should be determined as early as the antenatal visit, after informed consent.

[A bulky lateral cervical mass]. / Une volumineuse tuméfaction cervicale latérale.

Branchial cysts are rare, benign cervical lesions that can mimic thyroid goiters, in particular in areas where goiters are endemic. This case describes an Ivorian patient who presented with what appeared to be a voluminous thyroid goiter. At surgery, it proved to be a cyst of the second pharyngeal arch.

Cerebral activations during number multiplication and comparison: a PET study.

Positron emission tomography was used to examine the cerebral networks underlying number comparison and multiplication in eight normal volunteers. Cerebral blood flow was measured within anatomical regions of interest defined in each subject using magnetic resonance imaging. Three conditions were used: rest with eyes closed, mental multiplication of pairs of arabic digits and larger-smaller comparison of the same pairs. Both multiplication and comparison activated the left and right lateral occipital cortices, the left precentral gyrus, and the supplementary motor area. Beyond these common activations, multiplication activated also the left and right inferior parietal gyri, the left fusiform and lingual gyri, and the right cuneus. Relative to comparison, multiplication also yielded superior activity in the left lenticular nucleus and in Brodmann's area 8, and induced a hemispheric asymmetry in the activation of the precentral and inferior frontal gyri. Conversely, relative to multiplication, comparison yielded superior activity in the right superior temporal gyrus, the left and right middle temporal gyri, the right superior frontal gyrus, and the right inferior frontal gyrus. These results underline the role of bilateral inferior parietal regions in number processing and suggest that multiplication and comparison may rest on partially distinct networks.

Audit of protocols for treatment of paediatric burns in emergency departments in the Île de France.

INTRODUCTION: The main purpose of this study was to establish the existence and accuracy of protocols for treatment of children with burns in emergency departments (EDs) across the Île de France. In addition, we also analysed the incidence of paediatric burns. METHODS: A postal questionnaire was sent to 91 EDs in the Île de France. Data collected were: number of children with burns in 2005, the absence or presence of specific written protocols. The ED was asked to send a copy of the protocol for analysis. RESULTS: Forty-six EDs (50.5%) replied to the questionnaire. These EDs treated a total of 3258 children with burns, corresponding to 0.63% of paediatric pathologies in EDs. Amongst responding EDs, 48% had specific written protocols for the management of children with burns (but only in the larger EDs: >10000 patient visits/year). A written protocol for managing pain in children was present in 65% of cases. For analgesia, 80% used oxygen/nitrous oxide. Concerning second-step analgesics, six EDs 67% used a combination of paracetamol/codeine and only 22% used non-steroidal antiflammatory drug. Regarding third-step analgesics, 67% used nalbuphine while only 43% used morphine. CONCLUSION: 3,200 children were registered with burns in half of the region's EDs during 2005 (0.63% of paediatric consultations). The larger the ED the higher was the availability of specific written protocols. International recommendations appeared to be respected concerning dressings, management of pain being marked by an under-utilisation of morphine.

Carpipramine metabolism in the rat, rabbit and dog and in man after oral administration.

Carpipramine administered orally is excreted via the urine and faeces in rat, rabbit, dog and man. Many metabolites are formed, including several conjugates in the urine. A total of 20-25 metabolites was detected by t.l.c. and h.p.l.c., 16 of which were isolated and identified. Three metabolic pathways were observed: hydroxylation of the iminodibenzyl ring to a phenol or alcohol without modification of the side-chain, hydroxylation of the terminal piperidine of the 2-piperidinol side-chain, and cyclization and dehydrogenation of the same 2-piperidinol group.

Comparison of the metabolism of oltipraz in the mouse, rat and monkey and in man. Distribution of the metabolites in each species.

4-Methyl-5-(2-pyrazinyl)-1,2-dithiole-3-thione (35 972 R.P., oltipraz) and its metabolites were extracted from human urine and from mouse, rat and monkey urine using Amberlite XAD4 resin. The metabolites were identified by GLC, TLC and HPLC and isolated by preparative TLC or HPLC. The structures of 11 compounds were determined by spectroscopic examination (MS, IR, NMR). Six of the principal metabolites isolated in sufficient quantity from human urine were administered to the mouse, confirming the metabolic pathways of oltipraz.

Identification of Encephalitozoon intestinalis in travelers with chronic diarrhea by specific PCR amplification.

With the use of Weber's modified trichrome and Uvitex 2B techniques, spores of microsporidia were detected in the stools of four travelers presenting clinically with chronic diarrhea. The general health of these patients was not impaired, and human immunodeficiency virus screening was negative. Immune evaluation, including the study of lymphocytic subpopulations, assay of serum immunoglobulins, and an intradermal multitest, showed normal results. Molecular identification of microsporidian species was based on the PCR amplification of a small-subunit rRNA sequence followed by HinfI endonuclease restriction. Encephalitozoon intestinalis microsporidiosis was thus shown in two of the four patients examined. In two patients, therapy based on albendazole made stools devoid of microsporidian spores without influence on the intestinal disorders. The pathogenic role of E. intestinalis in immunocompetent individuals remains to be demonstrated.

Large-Scale Bundle Ordering in Sterically Stabilized Latices.

Time-resolved small-angle light scattering and linear conservative dichroism measurements are presented for concentrated, sterically stabilized, aqueous latices under simple shear flow. At low stress levels, flow causes a mild distortion of the liquid-like structure in colloidally stable dispersions, which is quite well understood. In this paper flow-induced structures are investigated in concentrated dispersions when the system is brought far from equilibrium by means of hydrodynamic forces. At high stress levels various structural changes have been predicted by numerical simulation, among others string phases oriented in the flow direction. Here, experimental results are reported on a bundle-like ordering in very dense systems, which involves a length scale much larger than that of a single string of particles. Two latices, with different particle sizes and different thicknesses of the stabilizing layer, are compared. The occurrence of the bundle-like ordering is related to the rheological behavior: it causes a significant decrease in viscosity. It is shown that the presence of this phase results in a structural hysteresis, which explains a thixotropic behavior that is encountered in some stable colloidal suspensions. Also the relaxation behavior of the bundle-like phases has been studied. Interparticle forces are found to have a very strong effect on the relaxation time scales. Copyright 1999 Academic Press.