Pressure ulcers prevention efficacy of an alternating pressure air mattress in elderly patients: E²MAO a randomised study.

OBJECTIVE: Our aim was to compare Axtair One, an alternating pressure air mattress (APAM), with a viscoelastic foam mattress (VFM) in elderly patients at moderate to high risk of developing pressure ulcers (PUs). METHOD: A randomised, controlled, superiority, parallel-group, open-label, multicentre study, was conducted, between February 2012 and March 2015, in nine French, medium- and long-term stay facilities. Eligible patients were aged 70 and over, had no PUs on enrolment, were bedridden for at least 15 hours per day, had reduced mobility, an absent or minimal positioning capability, a Braden score <14, a nutritional status score >12 and a Karnofsky score <40%. The primary endpoint was the appearance of PUs over a 30-day monitoring period. The primary objective was to demonstrate a 50% reduction in instantaneous risk of PUs in the APAM versus the VFM group. Secondary objectives were to determine if preventive care was less frequent in the APAM group, the instantaneous relative risk of PUs (hazard ratio) was constant over time and the comfort experienced was higher in the APAM group and to verify the uniformity of the preventive benefit of an APAM, regardless of the level of exposure to major risk factors for PUs. RESULTS: We randomised 76 patients (39 in the APAM group and 37 in the VFM group). The groups were comparable on enrolment and throughout the study. The cumulative risk of PUs was estimated at 6.46% [95% confidence interval (CI): 1.64; 23.66] in the APAM group and at 38.91% [95% CI: 24.66; 57.59] in the VFM group, p=0.001 (log-rank test). The adjusted hazard ratio according to the Cox model with four prognostic factors for the appearance of PUs was 7.57 [95% CI: 1.67; 34.38, p=0.009]. Preventive care proved to be equivalent in both groups. The only risk factor significantly associated with an increased risk of PUs was the type of mattress (VFM). The comfort and tolerance perceived by the patients were both high and similar in the two groups. The constancy over time of the preventive benefit of an APAM could not be verified because of the lack of a sufficient number of events (appearance of PUs) in the APAM group. CONCLUSION: The APAM was superior to a VFM for preventing PUs in elderly patients, bedridden for more than 15 hours per day, severely dependent, at moderate-to high-risk of PUs, with an instantaneous risk for the appearance of PUs 7.57 times greater in the VFM group than in the APAM group. This study provides descriptive information and evidence for practice.

An elasto-hydrodynamical model of friction for the locomotion of Caenorhabditis elegans.

Caenorhabditis elegans (C. elegans) is one of the most studied organisms by biologists. Composed of around one thousand cells, easy to culture and to modify genetically, it is a good model system to address fundamental physiological questions and in particular to investigate neuromuscular processes. Many C. elegans mutants can be distinguished by their locomotion phenotype and it then important to understand the biomechanics of their locomotion and in particular the mechanics of their undulating crawling motion on agar aqueous gels where they are commonly grown and observed. In this article, we present a mechanical model of the friction of the worms on their substrate where we have included capillarity (which pins the worm of the gel), the hydrodynamics of the lubrication film (between worm and gel) and the substrate/body elasticity. We determine the ratio of the transverse to longitudinal friction coefficients of the worm body on the culture gel as a function of a control parameter which describes the relative role of the deformation of the gel and the viscous dissipation in the lubrication film. Experimentally this ratio is - for soft gels - larger than the maximal value predicted by our model (this maximum is equal to 2, the value for an infinite cylinder in bulk liquid) and we propose to include the plasticity of the gel (i.e. the dissipation of the deformation of the gel) for a better description of the worm/gel interaction.

[Jejunal perforation by a fish bone diagnosed by CT-Scan: report of two cases]. / Perforation jéjunale par arête de poisson diagnostiquée par la tomodensitométrie abdominale : à propos de deux observations.

The authors relate two cases of peritonitis secondary to jejunal perforation by a fish bone. Clinically, the first patient presented signs and symptoms of acute diverticulitis and the second had signs of duodenal perforation. In both cases, the diagnosis was made by the CT-scan revealing a linear radio-opaque object suggestive of a fish bone perforating the jejunum. At laparotomy of the first case, we found a perforation located above several loops of small bowel densely adhered to the nonabsorbable intra-abdominal mesh. Removal of the fish bone, suture of the jejunal perforation, washing and drainage of the abdominal cavity were performed. The mesh was removed and replaced by a polyglycolic acid mesh. In the second case, jejunal perforation occurred in an unaltered small bowel loop and a short intestinal resection was performed. The postoperative course was uneventful for both patients. These clinical cases allow us to discuss the several fish bone perforation site and our patients precipitating factors.

Functional evaluation by quantitative dimercaptosuccinic Acid scintigraphy after kidney trauma in children.

PURPOSE: Most pediatric surgical teams have adopted nonoperative treatment for a traumatic kidney lesion in children. In the emergency setting and at long-term followup dimercaptosuccinic acid (DMSA) scintigraphy enables us to identify the consequences on global renal function as well as on the function of each individual kidney. MATERIALS AND METHODS: Eight boys and 12 girls between 0.6 and 15.9 years old (average age 9.7) were evaluated after including renal trauma, minor and major injury in 10 each. Scintigraphy was performed 8 days and 6 months after injury. The tracer used was 2 MBq./kg. Tc-DMSA. Semiquantitative analysis of the images consisted of determining 2 parameters, namely relative renal function, corresponding to the fraction of activity of a single kidney compared to the activity of the 2 kidneys, and the calculated renal activity fraction, corresponding to the function of each kidney compared with the activity of a theoretical kidney in a child of the same age. The posttraumatic renal scintigraphy series was paired with a series of healthy children matched by age, weight, height, sex and affected side of function as a control group. Global renal function was also measured using a formula based on ethylenediaminetetraacetic acid scintigraphy with the height, weight and increased serum creatinine in each patient. RESULTS: For minor injuries the quantitative functional evaluation revealed a significant average loss of renal function +/- SD on the side of the lesion (12.8% +/- 3.1% versus 18.3% +/- 2%, p = 0.001). For major injuries on relative renal function evaluation we noted an average 36-point difference in the damaged and contralateral kidneys 8 days after the accident. Six months after trauma we noted a definitive loss of 48% in the calculated renal activity fraction on the side of the lesion. There was no compensatory hypertrophy on the noninjured side when the calculated renal activity fraction was compared with that of a normal kidney in a control patient (mean 19.1% +/- 4.2% versus 19.5% +/- 3.7%, not significant). Creatinine clearance was normal in each patient. DISCUSSION A renal contusion always induces parenchymal loss. Major kidney trauma has significant consequences on the opposite side. At 6 months the presumably uninjured contralateral kidney may be limited in its ability to compensate through hypertrophy, which worsens the global renal functional prognosis of a traumatic but initially unilateral lesion. CONCLUSIONS: Posttraumatic functional evaluation by DMSA scintigraphy, which measures the nephron capital of each kidney and the 2 together, seems essential to inform patients about the seriousness of the lesion and lead them to an eventual long-term nephrological followup with regular blood pressure assessment.

Long-term follow-up of a girl with oro-facio-digital syndrome type I due to a mutation in the OFD 1 gene.

In 1954, Papillon-Léage and Psaume described a dominant, X-linked condition which they named oro-facio-digital (OFD). This condition was split into at least nine syndromes, the more common being OFD I. We report a girl with OFD I syndrome followed up for 23 years. Clinical examination showed cleft palate, median cleft lip, multiple oral frenulae, lobulated tongue and brachydactyly. There was no mental retardation. At 19 years of age, renal insufficiency appeared. A renal transplantation was performed. The parents were unaffected. An older brother had hydrocephaly, bilateral optic atrophy and mental retardation. A younger sister is unaffected. A mutation, an insertion of a G leading to a frameshift in the OFD 1 gene, was identified in this patient.

Thoracoscopic treatment for delayed presentation of congenital diaphragmatic hernia in the infant. A report of three cases.

BACKGROUND: Delayed presentations of congenital hernia occurring outside of the neonatal period have been reported for all ages. Classically, repair of the hernia defect involves a transverse subcostal laparotomy in the pediatric age group and usually a thoracotomy in the adult. The first report describing a laparoscopic repair of a congenital diaphragmatic hernia in a 6-month-old infant was published in 1995. During the past 25 years, 17 patients with delayed presentation of congenital diaphragmatic hernias have been managed by our pediatric surgery team. The last three patients underwent surgery thoracoscopically. PATIENTS AND METHODS: This study involved two boys (ages, 8.3 and 19 months, respectively) and one girl (age, 9 months) weighing 8 to 13 kg. All three infants underwent surgery using a thoracoscopic approach with general anesthesia. A thoracic epidural catheter was placed systematically for postoperative analgesia during the first 24 hours. Reduction of the hernia contents using one optical trocar and two operating trocars was difficult in the case without any hernia sac. In the cases with a hernia sac, reduction was easily and quickly obtained with a pleural insufflation of carbon dioxide (~8 mmHg). The hernia defect was repaired using interrupted sutures of 2/0 Ethibond. For two of the three patients, this repair was reinforced with staples in the one case and a nonresorbable mesh in the other case. RESULTS: The mean operative time was 78 min. The chest tube was removed on the first or second postoperative day and the patients were discharged on the fourth or fifth postoperative day. At the 19-month follow-up assessment in one case, the chest x-ray was perfectly normal and diaphragmatic motion also was confirmed to be normal by ultrasonography. CONCLUSIONS: The thoracoscopic approach for the repair of delayed-presentation congenital diaphragmatic hernia is feasible. Our results demonstrate the safety and efficiency of this surgery, as well as a remarkable functional and cosmetic result and a very quick recovery.

[Minimally invasive surgery in the treatment of Hirschsprung disease]. / La chirurgie mini-invasive dans le traitement de la maladie de Hirschsprung.

STUDY AIM: The treatment of Hirschsprung's disease was improved by the laparoscopic approach. The study aim was to report the results of a short series. PATIENTS AND METHOD: From December 1996 to January 2000, 13 children (7 boys and 6 girls) were operated for a Hirschsprung's disease with a laparoscopic approach. The mean age at the time of surgery was 6 months. A colostomy had been performed previously in 10 of them. The colostomy was closed and the colorectal anastomosis was performed with Duhamel's technique in 10 and Swenson's in 3. Location of aganglionnic bowel was rectum and sigmoid colon (n = 9) rectum (n = 2) left colon (n = 1), left colon and right transverse colon (n = 1). RESULTS: The mean duration of the procedure was 160 minutes. One conversion to laparotomy was necessary. One postoperative leak required a temporary colostomy. One intestinal occlusion due to an incarceration of an intestinal loop behind the pulled through colon, required a reoperation. The mean 26 month-follow-up was too short to draw conclusions about functional results. CONCLUSION: Laparoscopic approach was an important progress in the treatment of the Hirschsprung's disease but, more recently, the transanal approach that we used in the last five patients, seems to be another more important innovation.

Pallister-Hall syndrome with stenosis of the cricoid cartilage and microphallus without hypopituitarism.

The Pallister-Hall syndrome is characterised by a spectrum of anomalies including congenital hypothalamic "hamartoblastoma" hypopituitarism, imperforate anus, polydactyly and various visceral anomalies. Rare familial cases with an autosomal dominant inheritance pattern with variable expressivity have been reported. Cases of more mildly affected individuals with Pallister-Hall syndrome have been described, including cases of asymptomatic individuals. We report a case of Pallister-Hall syndrome with microphallus and without growth hormone deficiency that has been followed successfully for two years. The patient presented postaxial polydactyly of hands, dysplasic nails, imperforate anus, small penis, scrotum bifidum with very thin urethra, bifid epiglottis and a bilateral simian crease. There was vesico-ureteral-reflux, insertional hexadactyly of the left hand and two Y shaped metacarpal with six fingers at the right hand. Brain MR imaging revealed a large sellar and suprasellar mass. A perineal anorectoplasty and a vesicostomy were performed. Laryngeal dyspnea appeared when he was 13 months old. Bronchoscopy revealed anterior synechia of vocal cords with cricoidian stenosis. A tracheostomy was performed. Mental development was normal. No mutation of the zinc finger transcription factor gene, GLI 3 was detected.

Three-flap anoplasty for imperforate anus: results for primary procedure or for redoes.

UNLABELLED: Three-flap anoplasty was first described in 1987 by Yazbeck for the treatment of rectal prolapse after pull-through operations for imperforate anus, and in 1992 in a case of anterior perineal approach. It is intended to reproduce the normal anatomy of a sensitive anal canal. The purpose of this study is to evaluate 14 children (9 boys and 5 girls) operated for imperforate anus. METHOD: Eleven children had an intermediate or high imperforate anus and 3 had a low imperforate anus. Nine were operated for the first time with a three-flap anoplasty (GrA), and 5 were reoperated with this technique because of fecal incontinence and/or rectal prolapse (GrB). Seven patients had associated malformations: one Hirschsprung's disease, one cloacal defect with renal insufficiency, three complex caudal malformations with tethered cord, one Down syndrome, and two psychological and psychomotor troubles. The patients (average age = 6 years) have been evaluated every year since 1997, with a questionnaire based on a clinical score validated with 30 healthy children, used as a control group. Ten anal manometries were carried out. RESULTS: In 1998, the GrA score was 16.1 (control = 22.5) and the GrB score was 11.5 (p = 0.25). In 1999, GrA and GrB score were approximately the same. The score of those without associated anomalies was 19.6 whereas the score of the children with other malformations or anomalies was 10 (p = 0.02). Anal manometry is almost normal in patients with low or intermediate imperforate anus (rectoanal relaxation reflex for 10 cm H2O, and basal resting pressure more than 40 cm H2O). Even though anal manometry is subnormal in patients with Down syndrome or psychomotor troubles, the clinical score remains low (score = 10). In cases of complex caudal malformations or high imperforate anus, the results of anal manometry and clinical score are bad (score 9.7). CONCLUSION: The three-flap anoplasty can be carried out in newborns without colostomy and often represents the only possible surgical approach to avoid a laparotomy. This plasty, proposed secondarily to correct a defect of continence, can be performed without colostomy, with satisfactory results.

Radiological evaluation of Duhamel's operation in Hirschsprung's disease. Attempt at radio-clinical correlation.

The aim of this study was to evaluate the results of the Duhamel cure technique in a case of Hirschsprung's disease with a barium colorectal opacification by low approach. The overall height of the rectal stump (HR), the depth of the blind part of the rectum (PR), the rectal diameter (DR), the diameter of the colorectal anastomosis (DA) were measured. The rectal volume of its blind part (VRB), the rectal volume of its functional part (VRF), the surface of the colorectal and subanal anastomosis, the VRF/VRB ratio were calculated. Two types of subgroups were analysed: -the patients in whom the rectal stump had been closed by stapling (13 cases) and those where the rectal stump was manually closed (13 cases). -the patients who had no transit trouble (20 cases) and those in whom a stercoroma or coproma had formed, including phenomena either similar to encopresia or to soiling. The manual suture of the top of the rectal stump does not show any significant difference compared to stapling. The rectal height (HR=71 mm+/-1.9), the blind rectal stump depth (PR = 36 mm+/-2.2) of the 6 patients with stercoroma are significantly higher than with the other 20 patients (HR = 51.6+/-2.6 and PR = 24.4+/-2.7, i.e. respectively p = 0.0005 and p = 0.03). VRF and VRB are equal in the group with stercoroma, and VRF is twice or more than VRB in the group without any problem. If it is impossible to obtain a sufficiently short rectal pouch, an excessive HR may be balanced by a longer colorectal anastomosis with a higher VRF/VRB ratio. This is of importance in laparoscopic procedure.

Rupture of the airways after blunt chest trauma in two children.

Rupture of the airways after blunt chest trauma is exceptional in children. Two recent cases are reported, in a 3-year-old boy and in a 12-year-old girl. Both had longitudinal tears, of the trachea for Patient 1, and of the main left bronchus for Patient 2 with many associated lesions for this patient. Diagnosis of rupture of the airways must always be referred to the mechanisms of the accident. Bronchoscopy is mandatory, in order to define the lesions, and to guide the treatment. Immediate surgery is not always necessary if the chest roentgenogram demonstrates a good reexpansion, with a well tolerated and decreasing air leakage. Even in case of a delayed surgery, it is possible to perform a local reconstruction.

[Lumbar intraspinal synovial cysts: imaging and treatment by percutaneous injection. Report of thirteen cases]. / Kystes synoviaux intraspinaux lombaires: imagerie et traitement par infiltration.

PURPOSE: The CT and MR imaging findings in 13patients with lumbar intra spinal synovial cysts were retrospectively analysed and the results of facet corticosteroid injection were evaluated. PATIENTS AND METHODS: Over a 7 year period, 13patients with radicular pain were identified as having lumbar intra spinal synovial cysts. They ranged from 42 to 87 years of age. All patients were evaluated by CT without contrast material and underwent facet arthrography associated with corticosteroid injection and CT arthrography. MR imaging was performed in all patients either before or after percutaneous treatment. CT scans and MR images were reviewed and patient outcome was evaluated at 1and 6month followup. RESULTS: CT scan revealed a cystic structure adjacent to a degenerated facet joint in 9 patients (69% sensitivity). MRI showed more accurately the cyst on T2 weighted and/or axial images. Complete or good relief of radicular pain and functional restrictions were achieved in 9 patients (69%) at 1 month follow up, still to be found in 6patients (46%) at 6months. CONCLUSION: In patients with radiculopathy and facet degenerative changes, intra spinal synovial cysts must be looked for. Facet corticosteroid injection is a useful alternative to surgical removal.

[Should varicoceles be treated in the adolescent? How?]. / Faut-il traiter la varicocèle de l'adolescent? Comment?

Adolescents rarely consult for painful varicocele. The condition has to be confirmed by physical examination and a detailed Doppler exam. An ultrasound may be necessary to measure the size of the testis. About 15% of all adolescents have varicoceles. One out of three is graded II or III in the Dubin and Amelar classification. About 20% of varicoceles graded III occur in association with testicular hypotrophy. We do not know whether boys with a varicocele will fertility problems later on, but only 13% of adult men with varicocele are infertile. Surgery can be considered as necessary only after studying a large number of patients, comparing at random patients operated at a young age and followed for 15-20 years with patients not operated and with a group of healthy controls. The best treatment has to be selected because of the low risk of testicular atrophy and the disappearance of the varicocele in more than 90% of the cases. Inguinal root with microsurgery, and pre or intra-operative radiologic opacifications are the usual choice of most pediatric surgeons. Laparoscopy or retroperitoneoscopy have no major impact on the postoperative results. They are expensive and require great experience. Embolization and other radiological techniques induce a long period of radiation, are not always possible, expensive and demand an experienced radiologist. General anesthesia is required because of the time involved and finally the success rate is low. Microsurgical venous reanastomosis is still confidential probably because of technical difficulties. Scrotal anterograde sclerotherapy is the simplest and cheapest treatment and can be performed with a local anesthetic due to the short time required. But like other procedures, it can induce testicular ischemia.

[Prenatal and neonatal management of digestive tract duplications. Diagnostic difficulties and therapeutic implications]. / Prise en charge prénatale et néonatale des duplications digestives. Difficultés diagnostiques et implications thérapeutiques.

OBJECTIVE: To insist on the difficulty of the antenatal diagnosis of digestive duplications, to show the importance of a complete malformative screening, and the need for immediate management at birth. MATERIAL AND METHODS: A cystic duplication of the tongue, a duplication, abdomino-thoracic transdiaphragmatic, and a duplication of the small bowel are described and compared with cases previously reported in th literature. RESULTS: Antenatal evacuation puncture of a duplication of the tongue must be reserved for exceptional situations. Foregut duplications are often associated with other malformations. The duplication of the small intestine can exceptionally expose to a mechanical complication, mostly during the postnatal period, which may require emergency surgery. CONCLUSION: Duplications of the alimentary tract should be detectable on prenatal ultrasound examination. A complete antenatal malformative screening is required and in utero transfer is warranted because emergency surgery may be required.

Tracheobronchial ruptures from blunt thoracic trauma in children.

BACKGROUND/PURPOSE: Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. METHODS: Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. RESULTS: There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. CONCLUSIONS: Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.