Assessment of barium diffusion from therapeutic mud wrapped in micro-perforated polyethylene bags towards the human organism.

Barium is present within the clay-derived therapeutic mud packs deposed on the patient's skin for treating some rheumatologic conditions. We studied in twenty-four young healthy volunteers the diffusion of Ba from mud wrapped in micro-perforated polyethylene bags and soaked in mineral water. No significant systematic increase in plasma or urine Ba levels was evidenced when comparing pre- and post-treatment samples using inductively-coupled plasma mass spectrometry. These levels were markedly inferior to the recommended thresholds in nearly all the participants. Noticeably variability in blood and especially urine Ba concentrations was large and mainly explained by environmental exposure (alimentation). Interestingly, we evidenced an intense Ba accumulation within the therapeutic mud at the end of the regimen. Because we chose a clay with one of the highest Ba content available in France for medical therapy and participants with an optimal transcutaneous diffusion capacity (young individuals with low-fat mass), we conclude unambiguously that there is no risk of Ba overexposure in patients receiving pelotherapy according to the procedure used in French medical spas.

The Characteristics of Diverticular Disease in Caribbean Population: A Control Group Study.

Background: Diverticulosis is not well characterized in the Caribbeans. Our aim was to compare the anatomical presentation of colonic diverticulosis in African Caribbeans (group AC) versus Europeans (group E) and severity. Methods: We conducted a prospective controlled study involving 274 patients admitted for lower gastrointestinal haemorrhage (LGIH) in France (center 1: Guadeloupe; center 2: La Roche-sur-Yon); 179 cases with diverticular haemorrhage, including 129 in group AC and 40 in group E. Exploration of the colon included a detailed assessment of diverticula using a dedicated endoscopic grid. Results: AC and E had similar characteristics in terms of age, gender, previous history of LGIH, body mass index, dietary habits, and medications, but AC had significantly poorer hemodynamic parameters at admission and required more blood transfusions (66.7% vs. 42.5%; p=0.01) during hospitalization. Out of the 169 patients included in the study, a complete exploration of the colon was achieved in 81% (N = 137) (AC, n = 106; E, n = 31), and revealed right-side diverticulosis in AC (in 90.6%, included into a pancolonic form in 73.6% vs. 35.5%; p=0.0002) and left-side diverticulosis in E (in 96.8%, isolated form in 58.1% vs. 9.4%, p=0.0002). These data were confirmed by a sensitivity analysis using an endoscopic grid in 92 patients, achieving a higher frequency and larger size of diverticula in AC. Conclusion: Our study has shown that diverticulosis was pancolonic in AC and more frequently associated with more severe haemorrhage than the left-sided diverticulosis of Europeans. This anatomical presentation may be driven by the genetic background more than the environment and diet.

Assessment of the pain induced by vaccination according to the injected arm (COVID-19 vaccination) / Évaluation de la douleur induite par la vaccination en fonction du bras d'injection (vaccination SARS-COV-2)

Since its discovery, the concept of vaccination has continued to improve in order to offer better efficacy and tolerance. Local or even diffuse reactions are often reported, but no study reports results on the injection side. We carried out a prospective observational study on the COVID-19 vaccination centers of the Landes regional hospital consortium (GHT) over three weeks. A questionnaire was given after the second injection, and assessed patients' feelings about the first injection. During this period, 2797 patients received their second injection and 2487 responded to the questionnaire, of which 2301 are usable. 81% of vaccinations were performed on the weak arm and 19% on the dominant arm. Local pain/discomfort was reported by 47% of patients on both arms, occurring the same day as the vaccination took place for half of the patients and the next day for the other half, with an average intensity of 3.3. Extensive pain/discomfort was present in 19% of patients, regardless of which arm was injected. The choice of the injected arm does not seem to have influence on pain.

Depuis sa découverte, la pratique de la vaccination s'est améliorée de façon continue afin d'offrir une meilleure efficacité et tolérance. Les réactions locales voire diffuses sont souvent évoquées, mais aucune étude ne rapporte de résultats en fonction du bras choisi pour l'injection. Nous avons réalisé une étude observationnelle prospective aux centres de vaccination COVID-19 du GHT des Landes pendant trois semaines. Un questionnaire était remis après la deuxième injection et évaluait les douleurs et gênes du patient lors de la première injection. Durant cette période, 2 797 patients ont reçu leur deuxième injection, 2 487 ont répondu au questionnaire dont 2 301 sont exploitables. La vaccination a été réalisée à 81 % du côté du bras non dominant et à 19 % du côté du bras dominant. Les douleurs/gênes locales ont été rapportées par 47 % des patients sur les deux bras, leur apparition étant survenue le jour même pour la moitié des personnes et le lendemain pour l'autre moitié, avec une intensité moyenne de 3,3 sur une échelle de 10. Les douleurs/gênes diffuses étaient présentes chez 19 % des personnes, quel que soit le côté. Le choix du bras pour l'injection semble ne pas avoir d'influence sur la survenue de douleurs.

Saliva Quantification of SARS-CoV-2 in Real-Time PCR From Asymptomatic or Mild COVID-19 Adults.

The fast spread of COVID-19 is related to the highly infectious nature of SARS-CoV-2. The disease is suggested to be transmitted through saliva droplets and nasal discharge. The saliva quantification of SARS-CoV-2 in real-time PCR from asymptomatic or mild COVID-19 adults has not been fully documented. This study analyzed the relationship between salivary viral load on demographics and clinical characteristics including symptoms, co-morbidities in 160 adults diagnosed as COVID-19 positive patients recruited between September and December 2020 in four French centers. Median initial viral load was 4.12 log10 copies/mL (IQR 2.95-5.16; range 0-10.19 log10 copies/mL). 68.6% of adults had no viral load detected. A median load reduction of 23% was observed between 0-2 days and 3-5 days, and of 11% between 3-5 days and 6-9 days for the delay from onset of symptoms to saliva sampling. No significant median difference between no-symptoms vs. symptoms patients was observed. Charge was consistently similar for the majority of the clinical symptoms excepted for headache with a median load value of 3.78 log10 copies/mL [1.95-4.58] (P < 0.003). SARS-CoV-2 RNA viral load was associated with headache and gastro-intestinal symptoms. The study found no statistically significant difference in viral loads between age groups, sex, or presence de co-morbidity. Our data suggest that oral cavity is an important site for SARS-CoV-2 infection and implicate saliva as a potential route of SARS-CoV-2 transmission.

Stabilization of the distal radioulnar joint by reconstructing the interosseous membrane's distal oblique bundle: Cadaver study.

INTRODUCTION: The distal radioulnar (DRU) ligaments play a key role in stabilizing the DRU joint. Ligament reconstruction in this area is an accepted treatment. However, another structure may also be a significant DRUJ stabilizer-the distal oblique bundle (DOB) of the interosseous membrane (IOM). Recent studies have described DOB reconstruction methods, which should be compared to DRU ligament reconstruction. METHODS: Twelve upper limbs were used. First, a descriptive anatomy study was done to determine the prevalence and features of the DOB (insertions, thickness, and relationship with DRU ligaments). Second, biomechanical testing was done with the wrist in neutral position, supination, and pronation. Distal radius translation was evaluated first on an intact wrist then evaluated again after creating bidirectional instability. Lastly, the same tests were repeated after DRU reconstruction using the Adams-Berger technique and DOB reconstruction using the Riggenbach technique. RESULTS: The DOB was present in 50% of specimens and was bilateral. Reconstructing the DOB stabilized the wrist to the same degree as the Adams-Berger technique in neutral and pronation (8% residual major instability). Stability was harder to achieve in supination (25% major instability). It was better at controlling posterior radial translation than anterior translation (3% versus 14% major instability). CONCLUSION: DOB reconstruction appears to be a reliable and less invasive treatment option for DRUJ instability since it is extra-articular. However, the wrist's position and the direction of radial translation seem to alter the stabilization's effectiveness. LEVEL OF EVIDENCE: IV; Cadaver study.

Efficacy of HE4, CA125, Risk of Malignancy Index and Risk of Ovarian Malignancy Index to Detect Ovarian Cancer in Women with Presumed Benign Ovarian Tumours: A Prospective, Multicentre Trial.

BACKGROUND: Presumed benign ovarian tumours (PBOT) are defined by the International Ovarian Tumour Analysis (IOTA) group, without suspected sonographic criteria of cancer, without ascites or metastasis. The aim is to evaluate the efficacy of human epididymis protein 4 (HE4), cancer antigen 125 (CA125), the risk of malignancy index (RMI) and the risk of ovarian malignancy index (ROMA) to predict ovarian cancer in women with PBOT. METHODS: It is a prospective, observational, multicentre, laboratory-based study including women with PBOT in four hospitals from 11 May 2015 through 12 May 2016. Preoperative CA125 and HE4 plasma levels were measured for all women. The primary endpoint was the specificity of CA125 and HE4 for diagnosing ovarian cancer. The main secondary endpoints were specificity and likelihood ratio of RMI, ROMA and tumours markers. RESULTS: Two hundred and fifty patients were initially enrolled and 221 patients were finally analysed, including 209 benign ovarian tumours (94.6%) and 12 malignant ovarian tumours (5.4%). The malignant group had significantly higher mean values of HE4, CA125, RMI and ROMA compared to the benign group (p < 0.001). Specificity was significantly higher using a combination of HE4 and CA125 (99.5%) compared to either HE4 or CA125 alone (90.4% and 91.4%, respectively, p < 0.001). Moreover, the positive likelihood ratio for combination HE4 and CA125 was significantly higher (104.5; 95% CI 13.6-800.0) compared to HE4 alone (5.81; 95% CI 2.83-11.90) or CA125 alone (6.97; 95% CI 3.91-12.41). CONCLUSIONS: The combination of HE4 and CA125 represents the best tool to predict the risk of ovarian cancer in patients with a PBOT.

Biomarkers and algorithms for diagnosis of ovarian cancer: CA125, HE4, RMI and ROMA, a review.

Ovarian cancer is the 5th leading cause of death for women with cancer worldwide. In more than 70% of cases, it is only diagnosed at an advanced stage. Our study aims to give an update on the biological markers for diagnosing ovarian cancer, specifically HE4, CA 125, RMI and ROMA algorithms.Serum CA125 assay has low sensitivity in the early stages and can be increased in certain conditions such as menstruation or endometriosis. The level of HE4 is overexpressed in ovarian tumors. Its specificity is 94% and its level is not affected by endometriosis cysts. The combined measures of CA125 and HE4 have proved to be highly efficient with an area under the curve (AUC) of up to 0.96. Furthermore, this combined measure of CA125 can correct the variations in HE4 which are due to smoking or contraception combining estrogen plus progestin. While the specificity of RMI sometimes reaches 92%, the rather low AUC of 0.86 does not make it the best diagnostic tool. The specificity of ROMA is lower than HE4 (84% compared to 94%).To date, the most efficient biological diagnostic tool to diagnose ovarian cancer is the combination of CA125 and HE4.

Corticosteroids injections versus corticosteroids with hyaluronic acid injections in rhizarthrosis: the randomised multicentre RHIZ'ART trial study protocol.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint affects approximately 10%-25% of women, especially those who are postmenopausal. It may result in thumb dysfunction. Among the treatments, intra-articular injections of corticosteroid (CS) and hyaluronic acid (HA) are both effective and recommended. However, clinical trials have shown that HA improves functional capacity, whereas CS only produces a decrease in pain. The synergy of these two drugs has not been evaluated. The primary goal of this study was to determine whether the association between HA and CS produce an additional decrease of more pain during thumb movement at three months postinjection, compared to the level of pain relief from CS alone. METHODS AND ANALYSIS: RHIZ'ART is a prospective, multicentre, comparative, randomised, controlled, double-blind trial. Patients referred to the rheumatology department for thumb rhizarthrosis will receive an injection of betamethasone with HA or placebo (serum saline) based on central randomisation and stratification by centre. Injections will be given under ultrasound guidance. The primary outcome will compare the pain Visual Analogue Scale with motion at three months for both groups using a mixed model. The expected decrease in pain intensity in the CS group is 25% and 35% in the CS with HA group. In order to achieve a 80% power for detecting this difference with α set at 5%, 73 patients are needed in each group (146 total). The main secondary outcomes are the Cochin score (hand function) and grip strength. Follow-up visits are at 1, 3, 6 and 12 months. ETHICS AND DISSEMINATION: The study project has been approved by the appropriate ethics committee (CPP île de France III, 2017-002298-20). In agreement with current French regulations, a signed informed written consent will be obtained from each patient. Results of the main trial and of the secondary endpoints will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03431584.

Predictive factors for successful cervical ripening using a double-balloon catheter after previous cesarean delivery.

OBJECTIVE: To identify predictors of successful cervical ripening using double-balloon catheter (DBC) for labor induction among women with previous cesarean delivery (PCD) and unfavorable cervix at term. METHODS: The present prospective observational study was conducted among women who underwent cervical ripening with DBC at a French tertiary care hospital between January 1, 2014, and December 31, 2017. Inclusion criteria were PCD; singleton term fetus; cephalic presentation; and unfavorable cervix (Bishop score <6). Indications for DBC were gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, pre-eclampsia, prolonged pregnancy, fetal growth restriction, or prenatal suspicion of macrosomia. The primary outcome was Bishop score of at least six after DBC removal. RESULTS: Among the 105 patients included, the initial Bishop score was 2.5 ± 1.5; successful cervical ripening occurred among 74 (70.5%) women; and vaginal delivery occurred among 46 (43.8%). The mean time from DBC insertion to delivery was 19.3 ± 6.7 hours. No adverse events were observed. Predictors of successful cervical ripening were initial Bishop score of at least three (adjusted odds ratio [aOR] 12.74, 95% confidence interval [CI] 2.78-58.47); PCD during labor (aOR 4.38, 95% CI 1.10-17.45); and internal cervical os open (aOR 4.94, 95% CI 1.44-17.01). CONCLUSION: Several factors were found to predict successful cervical ripening using DBC.

Increasing success in outpatient laparoscopic cholecystectomy by an optimal clinical pathway.

BACKGROUND: The objective of this study was to evaluate the impact of more convincing and reassuring remarks from the surgeon in the preoperative consult associated with a dedicated outpatient facility to increase our rate of success in outpatient laparoscopic cholecystectomy. METHODS: A one-centre prospective clinical study was conducted between February 2013 and May 2015. During the first time period (February 2013-March 2014), patients were hospitalized in conventional care unit and given the possibility to choose an outpatient procedure. In the second phase (April 2014-May 2015), the patients were held in a dedicated outpatient facility. Outpatient success rate was evaluated using Chung's discharge score 6 h after surgery. RESULTS: Eighty patients were included (30 in a traditional setting, 50 in an optimal clinical pathway). Both groups were comparable for mean age, American Society of Anesthesiologists score and mean operative time (P = 0.36, P = 1 and P = 0.09, respectively). Success in outpatient surgery was significantly higher in the optimal clinical pathway group (73.3% versus 96%, P = 0.005). The only criteria which was significantly improved in Chung score was perambulation (P = 0.001). There was no significant difference between the two groups for post-operative complications (P = 0.28) or readmission (P = 1). CONCLUSION: Optimal clinical pathway (more convincing and reassuring remarks in the preoperative consult and a dedicated outpatient facility) is the key to increase success in outpatient laparoscopic cholecystectomy.

Efficacy of serum procalcitonin to predict spontaneous preterm birth in women with threatened preterm labour: a prospective observational study.

BACKGROUND: A hypothesis of preterm parturition is that the pathogenesis of spontaneous preterm birth (sPTB) may be associated with an inflammatory process. Based on this theory, we have hypothesized that an inflammatory biomarker, procalcitonin (PCT), may be a good predictive marker of sPTB at the admission for threatened preterm labour (TPL). The present study was aimed to investigate the association between serum PCT and sPTB in women with TPL and to evaluate whether PCT levels may predict sPTB in women with TPL within 7 or 14 days. METHODS: In a prospective observational laboratory-based study, women with singleton pregnancies, TPL between 24 and 36 weeks and intact membranes, were enrolled between January 2014 and June 2016. Participants received routine medical management of TPL (tocolysis with atosiban, antenatal corticosteroids, and biological tests at admission (C-reactive protein, white blood cell count, and PCT measured on electrochemiluminescence immunoassay)). The primary endpoint was sPTB before 37 weeks of gestation. The value of serum PCT levels to predict sPTB within 7 or 14 days were evaluated using receiver-operating curves (ROC) analysis. RESULTS: A total of 124 women were included in our study. PCT levels did not statistically differ between women with sPTB (n = 30, 24.2%) and controls (n = 94) (median in ng/mL [interquartile range]: 0.043 [0.02-0.07] compared to 0.042 [0.02-0.13], respectively; P = 0.56). PCT levels did not also statistically differ between women with sPTB within 7 days (n = 7, 5.6%) or 14 days (n = 12, 9.7%) after testing and controls. Moreover, subgroup analysis revealed no difference among PCT levels at admission between 24 and 28 weeks, between 28 and 32 weeks and over 32 weeks, and controls. On the basis of the receiver-operating characteristic curve, the highest sensitivity and specificity corresponded to a PCT concentration of 0.038 ng/mL, with poor predictive values for sPTB within 7 or 14 days. CONCLUSION: Serum PCT was not relevant to predict sPTB within 7 or 14 days in women admitted with TPL between 24 and 36 weeks, and thus it is not a suitable biological marker to confirm the hypothesis of an inflammatory process associated with preterm parturition. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT01977079 ), Registered 24 October 2013.

Efficacy of maternal and biological parameters at the time of diagnosis of gestational diabetes mellitus in predicting neonatal morbidity.

OBJECTIVE: Gestational diabetes mellitus (GDM) is independently associated with an increased risk of maternal-fetal complications. Improved glycemic control allows reducing perinatal morbidity and mortality and, specifically, the risk of macrosomia and shoulder dystocia which are the most common complications associated with GDM. Nonetheless, a need for early antenatal predictor of neonatal morbidity in women suffering from GDM is required. The objective of the study was to evaluate the efficacy of different maternal, biological, and antenatal parameters at the time of diagnosis of GDM or perinatal variables as predictors of neonatal morbidity. STUDY DESIGN: This was a prospective observational study recruited all pregnant women with diagnosis of GDM at first- or second-trimester in a tertiary care hospital from July 2014 to October 2015. Different antenatal parameters (maternal weight, weight gain during pregnancy, history of GDM, history of macrosomia, serum fructosamine, HbA1c) were obtained at the time of diagnosis of GDM. Mode of delivery was also analyzed. Neonatal morbidity was defined by at least one of the following criteria: preterm birth <37 weeks, macrosomia, shoulder dystocia, respiratory distress syndrome, 5-min Apgar score <7, pH < 7.10 and admission to the NICU (neonatal intensive care unit) for 24 h. Univariate and logistic regression analyses were performed to determine independent antenatal predictors of neonatal morbidity. RESULTS: Two hundred pregnant women with diagnosis of GDM were included. The mean gestational age at the time of diagnosis of GDM was 22 ±â€¯6 weeks. Insulin was required in 72/200 (36%) women for glycemic control during pregnancy. Neonatal morbidity occurred in 21% (n = 42). In the univariate analysis, neonatal morbidity was associated with nulliparity (50% compared to 32%, p = 0.03), induction of labor (36% compared to 27%, p = 0.03) and cesarean section (36% compared to 12%, p < 0.01). Multivariable logistic regression analysis found a significant association between nulliparity and neonatal morbidity (adjusted odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-4.7). Cesarean delivery was also significantly associated with neonatal morbidity (aOR 7.6, 95% CI 2.9-20). CONCLUSION: This suggests that nulliparity was an efficient antenatal predictor of neonatal morbidity at the time of diagnosis of GDM. Cesarean section was also associated with neonatal morbidity in women with GDM.

Interest of Using Ropivacaine for Outpatient Laparoscopic Cholecystectomy: Prospective Randomized Trial.

BACKGROUND: The objective of this study was to evaluate the interest of using ropivacaine for outpatient laparoscopic cholecystectomy. The use of local anesthesia by instillation and infiltration could reduce pain and increase the number of outpatient cholecystectomies. METHODS: A one-center randomized prospective clinical trial compared the use of ropivacaine during outpatient laparoscopic cholecystectomy to the control group of outpatients for laparoscopic cholecystectomy between April 2014 and May 2015. One hundred twenty-four were eligible, and 100 patients were randomized. Patients with outpatient cholecystectomy were randomized into 2 groups: ropivacaine group (Rop group) and control group (control group). We performed a ropivacaine intraperitoneal instillation and wound infiltration for the ropivacaine group at the end of the procedure. The primary observation was authorization for home discharge. The patient was evaluated by the surgeon using the Chung score. Secondary observations included postoperative pain at 2 h post-surgery, at 6 h post-surgery and the day following surgery. RESULTS: Ninety-eight were able to leave on the evening of surgery. At 6 h post-surgery, the Chung score was identical for both groups (p = 0.73). At 2 and 6 h post-surgery and the day following surgery, there was no significant difference in pain levels (p = 0.63; p = 0.61; p = 0.98). Analgesic consumption was no significant difference in the groups. CONCLUSIONS: The use of ropivacaine does not increase the rate of home discharge and does not change the postoperative pain of outpatient cholecystectomy.

Decreased patient exposure to ionizing radiation during interventional rheumatology procedures after optimization of protection.

OBJECTIVES: To decrease radiation exposure of patients undergoing interventional rheumatology procedures, without adversely affecting quality of care. METHODS: The radiation dose received, assessed by the dose-area product (DAP), was measured during 283 intraarticular injections performed under fluoroscopic guidance between May and July 2013. Then, three steps were taken to decrease patients' radiation exposure: a copper filter was added, the anti-scatter grid was removed, and exposure cell sensitivity was set at the highest value. DAP was measured during 158 intraarticular injections performed in 2014 with these measures in place. RESULTS: Mean DAP before optimization was 175µGray·m2 during facet joint injections (n=4) and 43µGray·m2 during hip injections but was less than 20µGray·m2 for injections into the shoulders (15.7µGray·m2), ankles (7.7µGray·m2), wrists (3.7µGray·m2), and fingers (3.3µGray·m2). After optimization, DAP decreased markedly for all injection sites, by 52% (shoulders) to 87% (facet joints, 22.7µGray·m2). Decreases occurred at all three steps of the procedure, i.e., patient installation, injection, and last image hold. Exposure during facet joint injections varied from 84 (54.5-108.5) µGray·m2 when body mass index (BMI) was <25kg/m2 to 228.9 (161.3-340.4)µGray·m2 when BMI was>30kg/m2. CONCLUSION: Simple technical changes translate into large decreases in patient radiation exposure during fluoroscopically-guided injections, particularly at the facet joints and in obese patients.

[Nurses mobilised in screening for osteoporosis]. / Les infirmières mobilisées dans le dépistage de l'ostéoporose.

The consequences of an osteoporotic fracture are often harmful. The teams of La Roche-sur-Yon general hospital have created a primary and secondary screening programme led by a nurse. Hospitalised female patients between the ages of 50 and 80 are screened for osteoporosis risk factors.

Validation of specific questionnaires to assess nausea and vomiting of pregnancy in a French population.

OBJECTIVE: To validate the modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) score and the Health-Related Quality of Life for Nausea and Vomiting of Pregnancy (NVP-QOL) score in a French population. METHODS: A retrospective study was conducted of data for women who delivered at a tertiary care hospital in La Roche sur Yon, France, between November 1, 2012, and April 1, 2013. Only women who reported nausea and vomiting of pregnancy (NVP) in the first trimester were invited to respond to the two questionnaires. RESULTS: Overall, complete questionnaires were available from 399 women, 238 (59.6%) of whom reported NVP in the first trimester. The modified-PUQE score was associated with the self-reported symptom severity (P<0.001). A relationship was also noted when either the NVP-QOL score or the modified-PUQE score was compared with the symptom intensity (P<0.001 for both comparisons). Furthermore, a high NVP-QOL score was associated with a high modified-PUQE score (P<0.001). CONCLUSION: The modified-PUQE and NVP-QOL scores provided valid indices for assessing NVP severity and alterations in quality of life. Owing to its simplicity, the modified-PUQE score might be used routinely among women experiencing NVP in the first trimester of pregnancy.

Under sevoflurane anaesthesia, a reduced dose of neostigmine can antagonize a shallow neuromuscular block: A double-blind, randomised study.

BACKGROUND: It has been demonstrated that small doses of neostigmine (10-30µg.kg(-1)) effectively antagonize atracurium blocks at a train-of-four (TOF) ratio of 0.4 under propofol anaesthesia. The results might not be valid with halogenated agents, which potentiate neuromuscular blockades. The goal of this study was to determine the dose of neostigmine required to antagonize a block corresponding to a TOF ratio of 0.4, a level at which fade is not visually detected. METHODS: Sixty patients were included and anaesthesia was induced with propofol, remifentanil and cisatracurium, and maintained with sevoflurane and remifentanil. Patients were randomized to receive neostigmine at 40, 20, 10µg.kg(-1) or placebo with atropine (20, 10, 5 or 0µg.kg(-1), respectively) as soon as the TOF ratio reached 0.4. Elapsed times to 0.9 and 1.0 TOF ratios were measured. RESULTS: The median times elapsed from 0.4 to 0.9 and 1.0 TOF ratios in the placebo group were 19 (10.5-36) min and 26 (20-50) min, respectively, and significantly shorter (I=0.002) with any dose of neostigmine than without. Times for complete recovery after 40 and 20µg.kg(-1) neostigmine were similar [5.5 (4-11) min and 7.8 (3.5-11) min, respectively] but significantly shorter than after 10µg.kg(-1) neostigmine [17min (7-55); I=0.001]. CONCLUSION: Under sevoflurane anaesthesia, in absence of tactile or visual TOF fade, which corresponds to a TOF ratio≥0.4, 20µg.kg(-1) neostigmine is as effective as 40µg.kg(-1) in antagonizing shallow cisatracurium block.

Laparoscopic Gastric Banding in Obese Patients with Sleep Apnea: A 3-Year Controlled Study and Follow-up After 10 Years.

BACKGROUND: The purpose of this study was to compare the effects of intensive nutritional care (INC) and laparoscopic adjustable gastric banding (LAGB) on nocturnal non-invasive ventilation (NIV) requirement in obese patients using short-, medium-, and long-term follow-up data. METHODS: This prospective randomized controlled trial included obese patients with obstructive sleep apnea (OSA) treated by NIV. Patients were randomized to the INC and LAGB groups. The primary endpoint was the theoretical rate of weaning from NIV at years 1 and 3. Data were also collected from patients 10 years after randomization. RESULTS: Sixty-three patients were randomized. The rate of weaning from NIV did not differ significantly between the LAGB and INC groups at year 1 (35 vs. 13%) or year 3 (14 vs. 21%). Percentages of excess weight loss were greater in the LAGB group than in the INC group at years 1 (33 vs. 15%, p = 0.002) and 3 (27 vs. 8%, p = 0.014). Decreases in the apnea-hypopnea index were observed in the LAGB group from baseline to year 1 (-44%, p = 0.001) and from baseline to year 3 (-26%, p = 0.044). After 10 years, the weaning rate was low and similar between groups. CONCLUSION: LAGB was not superior to INC for weaning from NIV at 1 and 3 years in obese patients with OSA.

Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: observational study of neurological and infectious outcomes.

INTRODUCTION: Neuromuscular blockade (NMB) is widely used during therapeutic hypothermia (TH) after cardiac arrest but its effect on patient outcomes is unclear. We compared the effects of NMB on neurological outcomes and frequency of early-onset pneumonia in cardiac-arrest survivors managed with TH. METHODS: We retrospectively studied consecutive adult cardiac-arrest survivors managed with TH in a tertiary-level intensive care unit between January 2008 and July 2013. Patients given continuous NMB for persistent shivering were compared to those managed without NMB. Cases of early-onset pneumonia and vital status at ICU discharge were recorded. To avoid bias due to between-group baseline differences, we adjusted the analysis on a propensity score. RESULTS: Of 311 cardiac-arrest survivors, 144 received TH, including 117 with continuous NMB and 27 without NMBs. ICU mortality was lower with NMB (hazard ratio [HR], 0.54 [0.32; 0.89], p=0.016) but the difference was not significant after adjustment on the propensity score (HR, 0.70 [0.39; 1.25], p=0.22). The proportion of patients with good neurological outcomes was not significantly different (36% with and 22% without NMB, p=0.16). Early-onset pneumonia was more common with NMB (HR, 2.36 [1.24; 4.50], p=0.009) but the difference was not significant after adjustment on the propensity score (HR, 1.68 [0.90; 3.16], p=0.10). CONCLUSIONS: Continuous intravenous NMB during TH after cardiac arrest has potential owns effects on ICU survival with a trend increase in the frequency of early-onset pneumonia. Randomised controlled trials are needed to define the role for NMB among treatments for TH-induced shivering.

[Impact of the use of luer access devices on the quality of chronic hemodialysis]. / Impact de l'utilisation de valves bidirectionnelles sur la qualité des séances en hémodialyse chronique.

Luer access valves are medical devices used to reduce infectious risks by securing repetitive handling in chronic hemodialysis using central catheter. Their impact on the effectiveness of a hemodialysis session still remains poorly studied. This in vivo study aims to evaluate its effectiveness. Tego(®) and Q-Syte(®) valves were used in alternation for each patient for four weeks (428 hemodialysis sessions). The two-luer access valves have led to a significant increase in the dysfunction of the hemodialysis sessions (51.8% compared to the usual care (39.3%) (P=0.012). The analysis by sub-category suggests a heterogeneous behavior of the two devices. The Q-Syte(®) valve showed significantly more dysfunction than the Tego(®) valve or the absence of valve. However, both valve systems tested can maintain the performance of the hemodialysis session as they don't change the dose of dialysis. This study highlights that an evaluation of each device must be performed prior to their use to assess the risk-benefit balance.