Emergency ultrasound: a prospective study on sufficient adequate training for military doctors.

PURPOSE: To evaluate the feasibility of "accelerated" training for military doctors in front line ultrasound. To establish the number of ultrasounds required to validate the doctor's training. To assess the average acquisition time for each ultrasound target. MATERIALS AND METHODS: Prospective study on 10 novice generalist military doctors to assess training for five urgent ultrasound targets: focused assessment with sonography in trauma (FAST), pleura, bladder, abdominal aorta and gallbladder. Each student received theoretical and practical training on "healthy" people and then performed 10 timed ultrasounds in an emergency situation, the result of which was either confirmed or rejected by a nationally qualified ultrasound expert. RESULTS: Some targets were easier to acquire (bladder, aorta and pleura) with excellent diagnostic performance after 10 ultrasounds on healthy people (sensitivity = 100%; specificity = 100%). The overall number of ultrasound errors fell over time. The median investigation time also fell significantly for all targets, reaching a plateau. Twenty ultrasounds including 10 "real life" appear to be needed for FAST. A minimum number of 30 ultrasounds is required to diagnose acute cholecystitis. CONCLUSION: "Accelerated" training for generalist military doctors in front line ultrasound is achievable. The recommended number of 25 ultrasounds per target is not appropriate for all ultrasound targets.

[A rare cause of epigastric pain: isolated spontaneous dissection of the celiac artery, a case report]. / Une cause rare de douleur épigastrique: la dissection spontanée isolée du tronc coeliaque, à propos d'un cas.

Spontaneous dissection of visceral arteries, and more particularly of the celiac artery, is a rare event. We report an exceptional case of an isolated spontaneous dissection of the celiac artery which occurred in a 53-year-old man seen in an emergency setting for suspected acute pancreatitis. Computed tomography enabled the diagnosis, revealing spontaneous isolated dissection of the celiac artery, associated with a small aneurysmal dilatation of the artery. Based on a review of the literature and this clinical experience, we recall the contribution of computed tomography and 3D reconstructions to the diagnosis, the therapeutic strategy and the follow-up of spontaneous dissection of visceral arteries.

[Treatment of cholesterol gallstones with ursodesoxycholic acid (author's transl)]. / Traitement de la lithiase biliaire cholestérolique par l'acide ursodésoxycholique. Résultats d'une étude multicentrique en double insu.

A double-blind clinical trial comparing ursodesoxycholic acid and chenodesoxycholic acid in patients with cholesterol stones in the gall-bladder showed that ursodesoxycholic acid was superior to the older drug not so much in percentage of biliary calculi dissolved but in dosage reduction (50%) and improved clinical and biological tolerance.

Calcitonin-producing pancreatic somatostatinoma.

A pancreatic somatostatinoma metastatized to the liver was detected in a 70-yr-old woman presenting with chronic diarrhea, steatorrhea, pancreatic insufficiency, diabetes mellitus, and achlorhydria. At immunocytochemistry, most tumor cells stored both somatostatin and calcitoninlike substances. Chromatography of acid extracts of the tumor on G50 Sephadex gave two distinct peaks coeluting with cyclic ovine somatostatin and human calcitonin, respectively, thus ruling out the hypothesis of a single cross-reacting molecule synthetized by the neoplastic cells. When the tumor was extracted at neutral pH, larger molecular forms of the above components were found, which accounted for less than 20% of the total immunoreactivity. Gel permeation of plasma showed that the circulating calcitonin- and somatostatinlike components consisted of three and four different forms, respectively, including components of molecular weights similar to those of the reference peptides. Inhibition curves and immunoadsorption experiments indicated that the large forms were immunologically similar, if not identical, to the corresponding standard preparations. The present case illustrates the occasional ability of neoplastic somatostatin cells of pancreas to synthetize simultaneously components immunologically related to somatostatin and calcitonin. These two inappropriate secretions could account for the symptoms displayed by this patient.

[Effect of protein and energy intake on nitrogen metabolism of undernourished patients on continuous enteral nutrition]. / Influence des apports protéiques et énergétiques sur le bilan azoté de malades dénutris alimentés par voie entérale continue.

Nitrogen balance, energy balance and respiratory quotient were measured in 18 undernourished patients fed with continuous enteral nutrition in order to assess the effects of: a) various levels of protein and energy intakes with a fixed diet composition; b) energy/nitrogen ratio; c) proportions of carbohydrates in energy intake. The results were the following: 1) With energy intakes from 4,880 to 8,360 kJ/m2/day (protein: 18 p. 100) nitrogen balance and net protein absorption were significantly correlated with nitrogen intake (respectively P less than 0.01 and P less than 0.001). 2) Nitrogen balance was not significantly different whether the patient received normo (energy/nitrogen = 476 kJ/g) or hypernutrition ( energy /nitrogen = 1,056 kJ/g). 3) Nitrogen balance was not different in 6 patients receiving the same energy and nitrogen intakes but 80 or 55 p. 100 carbohydrates; high carbohydrates diet induced lipid synthesis. These results confirm the value of continuous enteral nutrition to positive nitrogen balance in undernourished patients. Except when energy expenditure level is very high they do not support a policy of routinely use hypernutrition with high carbohydrates diet.

Elastic properties of the rectal wall in normal adults and in the patients with ulcerative colitis.

The elastic properties of the rectal wall have been studied in 16 normal adults (group I) and in 24 patients with ulcerative colitis, during a nonactive (13 cases, group II) or an active period (11 cases, group III). The rectal intraluminal pressures after accommodation to the distension were significantly higher in group III than in groups I and II. These pressures were not related to distending volumes in groups I and II but were correlated with the distending volumes in group III. The rectal elasticity coefficient was significantly greater in group III than in the other two groups. There was an inverse correlation between the rectal elasticity coefficient and the rectal area. These results suggest a loss of the rectal distensibility in active colitis.

Oral BCG vaccine in Crohn's disease.

In a randomised double-blind trial over one year oral BCG has been compared with a control preparation in the treatment of chronic Crohn's disease. Overall assessment scores deteriorated in nine of 22 patients taking BCG, and 11 of 26 in the control group (P = 0.25); this deterioration was great enough to be regarded as a clinical relapse in three patients taking BCG and in seven taking the control preparation (P greater than 0.1). No significant benefit from oral BCG treatment has been demonstrated.

[Gastrointestinal haemorrhage related to alcoholic cirrhosis. Prognostical influence of digestive lavage (author's transl)]. / Hémorragies digestives des cirrhotiques. Rôle pronostique du lavage digestif.

During gastrointestinal bleeding associated with cirrhosis, the presence of blood within the lumen of the gut may cause or favorise the onset of hepatic coma. Digestive lavage by rapid intragastric infusion of an isotonic solution based upon mannitol may reduce the mortality due to hepatic coma. The value of this method was studied retrospectively by comparison of two series of haemorrhagic complications: Group I-1971-1976: 224 haemorrhagic complications treated in the usual manner; Group II-1976-1977: 127 haemorrhagic complications treated in accordance with a protocol which included digestive lavage. The results indicate the prognostic significance of certain clinical signs (ascites, jaundice, shock), and also made it possible to determine the cause of death and to demonstrate a reduction in mortality in the group treated by digestive lavage (p < 0.02), concerning only deaths as a result of hepatic coma (p < 0.01) above all in forms with a poor initial prognosis with shock or decompensation with jaundice and ascites.