Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations.

BACKGROUND: Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known. METHODS: We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009. RESULTS: Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395-1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients' outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04-0.93; p value 0.04). CONCLUSIONS: The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

[Evaluation of a teaching tool for learning the surgical technique of inguinal orchidopexy]. / Évaluation d'un outil pédagogique pour l'apprentissage de la technique chirurgicale d'abaissement testiculaire.

INTRODUCTION: Practical training of the surgery resident is based on the companionship currently hampered in particular by the increase of the number of residents in training. We created a teaching tool to promote learning and validation of a technique of classic urologic surgery, inguinal orchidopexy. The objective is to evaluate the applicability and the relevance of this tool. MATERIAL AND METHODS: The tool is a technical evaluation sheet made from reference documentation. The trainers evaluated the residents at 3 times of the semester (hetero-evaluation at 0, 3 and 6 months). Residents evaluated themselves monthly on the same items. RESULTS: Three trainers and 6 residents in surgery participated in the study between May and November 2013. The initial evaluation confirmed that the theoretical knowledge was acquired prior to the practical learning. The level of residents was very uneven at the beginning of the study but not at the end of the semester. The monthly evaluations gave a progressive and significant increase of notes. The notes of the intermediate and final hetero-evaluations rose gradually and they were always superior to those previous self-assessments (P<0.05). The tool was considered simple and useful for the participants. CONCLUSION: This tool is applicable and relevant to the technical teaching of inguinal orchidopexy in this population. A larger study would be helpful to confirm it. This type of tool could be applied to the simple and common surgery techniques to enrich the educational tools used in the training. LEVEL OF EVIDENCE: 4.

[Congenital mesoblastic nephroma: diagnosis and treatment of one case]. / Le néphrome mésoblastique congénital : diagnostic et prise en charge à partir d'un cas.

The congenital mesoblastic nephroma (CMN) described by Bolande et al. in 1967 is a renal tumor often discovered in neonatal period and early childhood. It's usually considered as a benign tumor with good prognostic for which nephrectomy is the reference treatment. But some cases of local recidives and metastatic sites had been described in the literature. For these reasons histologic analysis and quality of follow up are very important. In this observation we describe a neonatal kind of CMN and we discuss this pathology.

Impact of colostomy on intestinal microflora and bacterial translocation in young rats fed with heat-killed Lactobacillus acidophilus strain LB.

A rat animal model of left colostomy was found to significantly impair the growth curve of rats. Assessment of the intestinal flora showed that colostomy mostly affects the cecal but not colonic microflora. Generally, the number of enterococci was increased in both ileum and cecum; cecal lactobacilli also rose, accounting for a promotion of lactic acid bacteria in colostomised rats. No significant differences between colostomised, laparotomised and control rats could be observed for the translocation of intestinal bacteria to internal organs of rats (i.e. spleen, kidneys, lungs or liver), whatever their diet. Heat-killed Lactobacillus acidophilus strain LB administration (dead probiotic bacteria) tended to exhibit a stimulatory effect on bifidobacteria, probably affecting the culture-medium fermentation substances included in the pharmaceutical product. This effect was abolished by laparotomy and colostomy. A trend towards a probiotic-like effect, not susceptible to colostomy, was also witnessed as counts of lactobacilli tended to increase in both cecum and colon of all animals fed with L. acidophilus LB.

Metformin retention independent of renal failure in intestinal occlusion.

Metformin is eliminated by the kidneys, and metformin accumulation has always been noticed in oligo-anuric patients. We have reported an exception to the rule with the case of a metformin-treated patient having metformin accumulation contrasting with a mild increase in serum creatinine in the context of a volvulus of the sigmoid colon. This case prompted us to examine the association between intestinal occlusion and plasma metformin concentrations. For this purpose, we developed an experimental animal model of mechanical obstruction of the intestine. Rats were pre-treated during 3 weeks via drinking solution at a dose of approximately 100 mg/kg/day of metformin. They underwent at day 0 either sham-operation (n=7) or operation (n=8) to place a plastic tube around the ileum near the ileocaecal valve. Metformin administration was pursued on days 1, 2, and 3 giving a single dose of 100 mg/kg by intragastric gavage. Four days after the surgery, i.e. 24 h after the last metformin administration, the surviving intestinal obstructed rats (n=8) developed overt intestinal dilation but no biochemical abnormality compared to sham-operated animals (n=7; arterial lactate concentrations respectively 4.87 +/- 0.63 mmol/l and 3.97 +/- 0.30 mmol/l, NS, and serum creatinine concentrations 69.0 +/- 1.7 micromol/l and 68.7 +/- 1.9 micromol/l, NS). By contrast, there was a striking difference with regard to metformin concentrations, decreasing from 2.95 +/- 0.94 mg/l at day 0 to 0.12 +/- 0.03 mg/l at day 4 (p<0.001) in the sham-operated group but remaining unchanged (1.65 +/- 0.76 mg/l and 1.61 +/- 0.51 mg/l) in the operation group. In conclusion, this is the first experiment showing that intestinal occlusion may be responsible for metformin retention in the absence of renal failure. Whether this observation may be relevant to other drugs remains to be established.

Human recombinant growth hormone increases small bowel lengthening after massive small bowel resection in piglets.

BACKGROUND/PURPOSE: Dramatic improvement in small bowel lengthening and in weight gain has been demonstrated in newborn rats treated with human growth hormone (GH) after massive small bowel resection. The aim of this study was to confirm these results in another animal model and to specify the part food intake plays in small bowel lengthening induced by GH. METHODS: Twenty-five piglets underwent laparotomy at day 28 of life. Intestinal length was measured under general anesthesia, and animals had an 80% resection of small bowel, leaving a similar length of jejunum and ileon. There were no perioperative deaths. One animal died 3 days after surgery. Animals were assigned to five groups: (1) S (n = 4): sham, mere laparotomy; (2) GH-S (n = 4): sham and GH treatment (0.1 IU/kg/d subcutaneously); (3) R (n = 7): intestinal resection; (4) GH-R (n = 6); and (5) GH-R AdL (n = 4): intestinal resection and GH treatment. S, GH-R, and GH-R AdL had a free diet; GH-S and GH-R were pair-fed with S and R, respectively. Animals were killed 28 days later. RESULTS: Weight gain was not different in the two nonresected groups (S, 144 +/- 6% of initial weight; GH-S, 150 +/- 3%) and was significantly higher than in the resected groups (R, 67 +/- 28%; GH-R, 74 +/- 16%; GH-R AdL, 55 +/- 16%; NS). GH did not enhance small bowel lengthening in the nonresected groups; S, 41.9 +/- 23% and GH-S, 36.9 +/- 9%, in sharp contrast with the resected groups; R, 28 +/- 9 cm versus GH-R, 96 +/- 39 cm (P = .0008) and versus GH-R AdL, 89 +/- 41 cm (P = .003). Compared with initial length, the increase was R, 16.2 +/- 5%; GH-R, 56.5 +/- 24%; GH-R AdL, 51 +/- 25%. Villus height and diameter, average number of mitosis per field, intestinal muscular layer, wall thickness, and crypt ratio were higher in resected groups than in unresected ones, with no difference observed between resected groups. CONCLUSIONS: GH improves the postoperative intestinal adaptation process after massive small bowel resection in newborn piglets in terms of small bowel lengthening. In contrast to rats, GH did not improve weight gain. In addition, no difference was observed whether animals were on a free or a controlled diet.

Effect of BN 50727 on pathological findings and tissue platelet activating factor levels during ileal ischemia in newborn piglets.

The role of platelet activating factor (PAF), a potent ulcerogen mediator in the digestive tract, is thought to be important in the genesis of necrotizing enterocolitis. The aim of this study was to evaluate the role of PAF in the perpetuation and aggravation of gastrointestinal damage resulting from limited ischemia in the 2-day-old piglet using a natural PAF antagonist (BN 50727). Animals were separated into six groups: U4, controls; S, sham operated animals undergoing laparotomy; I4 and I9, ligation of the mesenteric vessels in the last ileal loop; IT4 and IT9, same procedure together with treatment with BN 50727 (50 mg/kg) orally before and after surgery and intraperitoneally during surgery. Animals were killed at day 4 in groups U4, S, I4 and IT4 and at day 9 in groups I9 and IT9, with histological studies and mediator measurements taken. Macroscopic and histological lesions of intestinal wall in groups I4, I9, IT4 and IT9 were similar to those of human neonatal necrotizing enterocolitis and did not vary according to the absence or the presence of BN 50727 treatment (P = .7, I4 v IT4 and P = .9, I9 v IT9). Peritoneal bands were significantly reduced in treated groups IT4 and IT9 as compared with untreated ones I4 and I9 (P = .003). Mucosal PAF levels in the terminal ileum were higher in group I4 than in groups U4 or I9. In the upper loop, mucosal PAF levels were comparable in all groups. An increase in stool PAF levels was observed only in group I9 (26.4 ng/g v 4.7 ng/g, I9 v U4 + S, P < .05), whereas values comparable to those observed in controls were detected in other groups (I4, 7.2 ng/g; IT4, 4.5 ng/g; IT9, 6.8 ng/g). Tumor necrosis factor alpha (TNF alpha) measurements did not exhibit any difference between groups. Using a PAF antagonist, the role of PAF in the aggravation of intestinal damage after ischemia was not remarkable because treatment did not induce any modifications of parietal intestinal lesions. PAF antagonists appeared to reduce significantly the local peritoneal consequences of local inflammation.

Ligation of the patent ductus arteriosus in premature infants--indications and procedures.

Premature newborns with patent ductus arteriosus can be managed by prostaglandin inhibition, but this medical treatment carries a high risk of renal failure, and other complications such as necrotizing enterocolitis and hematologic disorders have been described. Echocardiography gives an early confirmation of shunt and surgical treatment may be proposed. The aortic arch anatomy in the premature infant may not be as simple to determine as the anatomy of an older child. In the premature infant the use of a clip for patent ductus arterious closure seems the best technique, avoiding circular dissection of the ductus. We report our experience of 68 cases operated upon.

Evaluation of a hydrocolloid dressing.

A hydrocolloid dressing was compared to adhesive skin tapes on children's postoperative wounds. A total of 170 children of varying ages were randomised in two parallel groups, in nine centres of plastic, thoracic, gastrointestinal, urogenital and orthopaedic surgery. Skin closure was satisfactory in both groups, with 76 (89.4%) healthy closures without dehiscence in the hydrocolloid group and 81(95.3%) in the control group; a relationship was found between partial closures/dehiscence and the type of surgical procedure. No product-related maceration, infection or adverse event was reported during the study and both groups showed very satisfactory cosmetic results.

Evaluation of a hydrocolloid dressing.

A hydrocolloid dressing was compared to adhesive skin tapes on children's postoperative wounds. A total of 170 children of varying ages were randomised in two parallel groups, in nine centres of plastic, thoracic, gastrointestinal, urogenital and orthopaedic surgery. Skin closure was satisfactory in both groups, with 76 (89.4%) healthy closures without dehiscence in the hydrocolloid group and 81 (95.3%) in the control group; a relationship was found between partial closures/dehiscence and the type of surgical procedure. No product-related maceration, infection or adverse event was reported during the study and both groups showed very satisfactory cosmetic results.

Use of fast absorption material for skin closure in young children.

In pediatric surgery, skin closure is an important problem, given the need to avoid soiling by feces and urine and to have a good cosmetic result. Furthermore, the increasing number of surgical operations on outpatients or with a short period of hospitalization significantly reduce the number of medical consultations. Personal experience with a fast absorption material for skin closure in 65 children demonstrated a perfectly watertight suture, a satisfactory cosmetic result and a low cost. This procedure has another advantage: no removal of the stitches, eliminating the need for medical or paramedical care.

Management of abdominal contusion in polytraumatized children.

Management of abdominal contusion in polytraumatized children is based on the conservative treatment of spleen and liver lesions when it is possible. Ultrasonography and CTScan can give a good evaluation of splenic, liver, pancreas or kidney lesions. In some cases, if the haemodynamic conditions are good, a non-operative treatment may be proposed. We report our experience of conservative management of intra abdominal lesions in children, about 91 cases in ten years.

[Current aspects of the complications of acute appendicitis in children]. / Aspects actuels des complications de l'appendicite aiguë de l'enfant.

One thousand four hundred and ninety-one cases of acute appendicitis during infancy and childhood are reviewed, 137 were revealed by peritonitis. Complications following appendicitis with perforation (15%) are higher than acute appendicitis (2%). Many complications are reported, but the most serious of them are the 5th day syndrome after appendectomy. Early diagnosis, often difficult in infancy, and early operation before diffusion are the only means of prevention. Ultrasonography may reveal pelvic or intraperitoneal abscess. Treatment is a large drainage with antibiotics; enteral or parenteral nutrition may be associated.

[Posterior mediastinal thymus. Apropos of a case in a child]. / Thymus en situation médiastinale postérieure. A propos d'un cas chez l'enfant.

Posterior and upper mediastinal localization of the thymus gland is uncommon in young children. Presenting symptoms and signs are very variable from incidental diagnosis to bronchopneumonial with atelectasias of the left upper Chest X-Ray and CT Scan are sufficient to make the diagnosis. Treatment of complicated forms with bronchial compression requires thoracotomy and surgical excision.

[Chest injuries in children. Apropos of 93 cases]. / Les traumatismes du thorax chez l'enfant. A propos de quatre-vingt-trieze observations.

UNLABELLED: Ninety-three cases of thoracic trauma (age ranging from 1.1/2 to 15 years) were observed over a 10 year-period (1980-1990): 86 cases of blunt trauma and 7 cases of perforating injuries. Road accidents were the most prevalent (63 cases) followed by home and sport injuries (9), falls (9), perforating trauma (9) and others. Associated lesions were frequent: skeletal (67), abdominal (19), and head injuries (5)--the latter influence the vital prognosis. Rib fractures were observed in 60% of cases of blunt trauma (86). Pulmonary lesions were as follows: pneumothorax (41), hemothorax (21), and lung contusions (29). In 48 cases, several of these pulmonary lesions were associated. Diagnosis and therapy problems were encountered in 21 cases. Results were as follows: 3 deaths, within 24 hours due to hemorrhage (1 case with aortic lesion). FOLLOW-UP: 85 good results, 5 sequelae, without any clinical consequence--either pleural (2), diaphragmatic (2), or lung (1). The treatment was as follows: none (27), pleural aspiration (2), thoraco-synthesis by drain in other cases for 2 to 9 days. Surgery was necessary in 10 cases, with 2 thoracotomies, 1 orthopedic traction, 1 embolization of iliac artery.

[Thoracic injuries in children]. / Traumatismes thoraciques de l'enfant.

Chest trauma in children is rare but shows that trauma is severe and the mortality rate is high (30%). Multidisciplinary management of children includes an initial evaluation of respiratory distress, freeing the airways, placing an intercostal tube, stabilizing the chest wall, and analgesia. When vital signs are stable, secondary evaluation includes an etiologic, radiologic and biologic check-up, ending with the therapeutic strategy. Thoracotomy is rarely required, and for most children, only monitoring will be necessary, though this is important because of the risk of secondary decompensation and late diagnosis of potentially fatal lesions.

[Change in management of ureteropelvic junction obstruction]. / Evolution de la prise en charge du syndrome de la jonction pyélo-urétérale.

PURPOSE: The aim of this study was to evaluate the change in ureteropelvic junction management, from surgical correction to observation of the hydronephrosis. We checked wether or not it was deleterious for kidney. MATERIALS AND METHODS: We retrospectively reviewed 96 charts between 1988 and 1998. Initial ultrasonography, and voiding cystourethrogram were available for all cases. Intravenous urography and diuretic renography were studied when available. Minimal follow-up of patients was one year. Patients were divided into three groups: surgery right away, surgery after observation, and observation only. RESULTS: Later was the diagnosis, more significant were the hydronephrosis and impairment of renal function (p < 0.01). In group operated on right away (69 cases), drainage improved, hydronephrosis decreased, but renal function did not improve significantly (p = 0.37). Sixteen patients were operated on after observation without deleterious effect for kidney. Eleven patients were only observed: hydronephrosis progressively decreased. Initial radiological results were not different between the last two groups (p > 0.05), and were not predictive of their course. CONCLUSION: Initial non operative management of hydronephrosis was not dangerous for renal function. It is advisable to detect at the earliest all signs of obstruction, because surgery improves renal drainage but not renal function.

[Conservative treatment of esophagus ruptures and perforations. Esophageal diversion by minimal pharyngostomy]. / Traitement conservateur des ruptures ou des perforations de l'oesophage. Diversion oesophagienne par pharyngostomie a minima.

In ruptures or perforation of the oesophagus, the difficult choice between conservative methods (suture or drainage) and total exclusion of the organ can be avoided by minimal pharyngostomy. This procedure, which supersedes lateral oesophagostomy and makes use of an aspiration silicone-lined catheter to divert the oesophageal contents, is simple, rapid, effective and reversible. It is carried out in a region devoid of dangerous anatomical variants, in the avascular space below the greater cornu of the hyoid bone (a palpable landmark), the incision being made on the convexity of a curved clamp which pushes back the pharyngeal wall at the level of the sinus pyriformis. This technique has been used in 13 patients with satisfactory results.

[Pleuro-pericardial cyst in children]. / Kyste pleuro-péricardique de l'enfant.

We report the case of 3 1/2 year old child presenting a left pleuropericarditic cyst causing febrile cough and an opacity of the left lower lobe of the lung. We underline the importance of computed tomography of the thorax allows differential diagnosis with encysted effusion. Surgical treatment rarely indicated in pleuropericarditic cysts has stopped respiratory symptoms.

[Cavernous hemangioma of the bladder in children. Apropos of a case]. / Hémangiome caverneux de la vessie chez l'enfant. A propos d'un cas.

Benign tumours of the urinary bladder are very rare in children. A new case of cavernous haemangioma of the bladder is reported in a five year old boy presenting with macroscopic haematuria. This tumour is a hamartoma which usually presents with painless haematuria. In about 30% of cases, the bladder tumour is associated with angiomatous lesions in other parts of the body. The diagnosis may be suspected on intravenous urography or ultrasound examination, but it is generally made at cystoscopy. Biopsy and transurethral resection must be avoided because of the risks of haemorrhage. Partial cystectomy appears to be the most effective method of treatment.