Accuracy of impedance cardiography for evaluating trends in cardiac output: a comparison with oesophageal Doppler.

BACKGROUND: Impedance cardiography (ICG) enables continuous, beat-by-beat, non-invasive, operator-independent, and inexpensive cardiac output (CO) monitoring. We compared CO values and variations obtained by ICG (Niccomo™, Medis) and oesophageal Doppler monitoring (ODM) (CardioQ™, Deltex Medical) in surgical patients. METHODS: This prospective, observational, single-centre study included 32 subjects undergoing surgery with general anaesthesia. CO was measured simultaneously with ICG and ODM before and after events likely to modify CO (vasopressor administration and volume expansion). One hundred and twenty pairs of CO measurements and 94 pairs of CO variation measurements were recorded. RESULTS: The CO variations measured by ICG correlated with those measured by ODM [r=0.88 (0.82-0.94), P<0.001]. Trending ability was good for a four-quadrant plot analysis with exclusion of the central zone (<10%) [95% confidence interval (CI) for concordance (0.86; 1.00)]. Moderate to good trending ability was observed with a polar plot analysis (angular bias: -7.2°; 95% CI -12.3°; -2.5°; with radial limits of agreement -38°; 24°). After excluding subjects with chronic obstructive pulmonary disease, a Bland-Altman plot showed a mean bias of 0.47 litre min(-1), limits of agreements between -1.24 and 2.11 litre min(-1), and a percentage error of 35%. CONCLUSION: ICG appears to be a reliable method for the non-invasive monitoring of CO in patients undergoing general surgery.

[French national survey on difficult intubation in intensive care units]. / Enquête nationale sur l'intubation difficile dans les services de réanimation français.

OBJECTIVES: Assessing the theoretical knowledge, practical experience of French intensivists, and their compliance with French Anesthesiology and Critical Care Society's difficult airway algorithms of the expert's SFAR conference of 2006. STUDY DESIGN: Prospective and descriptive national survey. MATERIAL AND METHODS: An anonymous questionnaire with 40 questions was emailed to physicians working in intensive care units in France. RESULTS: Five hundred and eight intensivists answered the survey. Ninety-seven percent of physicians reported having a portable storage unit for difficult intubation. As for practical experience, 421 physicians (83 %) have set up less than 10 laryngeal mask airway, 257 (51 %) have performed less than 10 intubations under fibroscopy and 269 (53 %) have never performed a cricothyroidotomy on mannequin, and 331 (65 %) on a patient. In case of emergency intubation, 29 % of them do not use a rapid sequence induction. Three hundred physicians (59 %) use capnography as monitoring of the endotracheal position. Two hundred and nine (42 %) consider they have not been trained to difficult intubation and 443 (87 %) would like to participate in high fidelity simulations mannequin. CONCLUSIONS: National airway management algorithm was insufficiently followed. Alternative techniques do not seem to be mastered by all physicians. French intensivists expect more training on difficult intubation, including high fidelity simulation.

[Life-saving cricothyrotomy before surgical tracheotomy: two cases]. / Cricothyroïdotomie de sauvetage avant trachéotomie chirurgicale: à propos de deux cas.

The two current cases reported present the situation of "can't intubate can't ventilate" patients with life-saving cricothyrotomy before surgical tracheotomy. These situations emphasize the necessity for clinicians to master difficult intubation and oxygenation algorithms and all available alternative techniques.

[Storage at room temperature does not change cisatracurium onset time: a prospective, randomized, double-blind controlled study]. / La température de conservation du cisatracurium ne modifie pas le délai d'action: étude randomisée, en double insu

OBJECTIVE: Storage of cisatracurium at room temperature seems to have no effect on its degradation in vitro contrary to the recommendations of storage at +4°C. The purpose of this study was to evaluate the influence of cisatracurium' s storage temperature on its onset time. STUDY DESIGN: Prospective, randomized, double-blind trial study. PATIENTS AND METHODS: Thirty patients were enrolled. The control group consisted of 15 patients receiving cisatracurium (0.15mg/kg) stored at room temperature and the intervention consisted of 15 patients receiving cisatracurium (0.15mg/kg) stored at +4°C. The primary endpoint was to compare cisatracurium onset time depending on the storage temperature. RESULTS: Cisatracurium onset time was 235 (180-292) seconds in the "room temperature" group vs. 240 (210-292) seconds in the "refrigerated" group. There was no difference between the onset of cisatracurium depending on the temperature of storage (p=0.51). Subgroups analysis in the "room temperature" group did not show any difference in cisatracurium onset depending on whether it was stored at room temperature for one, two or three weeks. Excellent intubation score was obtained for 100% of the patients. CONCLUSION: This study demonstrated that cisatracurium's storage at room temperature had no influence on its onset time. It provides an argument for the preservation of cisatracurium at room temperature for a period not exceeding 21 days. Monitoring the onset of curarization may increase the quality score of intubation.

[About two big buttocks: an erysipelas with lymphoedema after pelvis surgery]. / A propos de deux grosses fesses: un érysipèle sur lymphoedème après chirurgie du pelvis.

We report the case of a 58-year-old man with erysipelas of both buttocks secondary to lymphoedema after pelvis surgery for prostatic cancer and multiple vascular interventions for iliofemoral thrombosis. The diagnosis was based on clinical examination and lymphoscintigraphy. This location of lymphoedema, limited to the buttocks, is uncommon; lower limbs are usually affected. This location needs a specific curative and preventive treatment, including antibiotic therapy, lymphatic drainage and contention to abate the condition and prevent a relapse.

[A French questionnaire to assess quality of life of the aphasic patient: the SIP-65]. / Un outil francophone de mesure de la qualité de vie de l'aphasique: le SIP-65.

OBJECTIVES: To develop and demonstrate validity and reliability of a aphasic-adapted version of the Sickness Impact Profile (SIP-136), a generic widespread questionnaire used to measure quality of life (QoL). DESIGN: Survey, outpatient oral interviews. POPULATION: Aphasic people from 20 to 80 years old, with a time from stroke or trauma of more than 12 months, living at home for more than six months, able to understand the questions with a Z-score profile at Boston Diagnostic Aphasia Examination above average for oral comprehension. METHOD: 1. Developments of the short version of the SIP-136, from a first sample of aphasic people; 35 patients were included with a mean time from stroke or trauma of 17 months. This first step consisted in excluding the least relevant items and/or subscales, rewriting some items to make them easier to understand, studying redundancy by multiple components analysis (MCA) and deleting some redundant items. 2. Validity compared with initial SIP-136 and reliability (inter-rater and test-retest) from a second sample of 55 aphasic people (mean time from stroke or trauma = 23 months). RESULTS: - 1. The first step of development led to a short version with eight subscales and 65 items (SIP-65) exploring physical, psychological and social components of QoL; it took about 16 min to fill it, less than half of the time necessary for the SIP-136. 2. Linear correlation of the responses between SIP-65 and SIP-136 was good: r = 0.97; p < 10(-6). SIP-65 demonstrated a good test-retest (r = 0.97; p < 10(-6)) and inter-rater (r = 0.92; p < 10(-6)) reliability. DISCUSSION AND CONCLUSION: SIP-65, a short version of SIP-136, is feasible and clinically sound and must be recommended to assess health-related functional status of French aphasic people.

[Treatment of neurogenic heterotopic ossifications (NHO) in brain injured patients: review of literature]. / Prise en charge des paraostéoarthropathies neurogènes (POAN) chez le traumatisé crânio-encéphalique : étude de la littérature.

This article is a review of the literature about treatment of neurogenic heterotopic ossifications (NHO) in brain injured patients, from analysis of the main data bases (Medline, Embase, Reedoc). In spite of the hope they arouse in the seventies, biphosphonates, including etidronate, have not demonstrated their efficiency to inhibit NHO in clinical practice. In fact a very early diagnosis, with the scintigraphic overactivity of the joint area and the increase of serum alkaline phosphatases, must lead to begin passive motion and postures, and may contribute to save functional range of motion. Yet, when joint stiffness or even ankylosis have led to severe functional disorders, surgery with NHO resection is the only way; it looks more reliable to manage it when NHO is mature, after a delay of more than 12 months after the first signs, but earlier operations have been reported without an enhanced risk of recurrence; this surgery must be associated with continuous passive motion for several weeks; radiation therapy and/or non-steroid anti-inflammatory drugs have been proposed in the immediate after-surgery period, but their role is still discussed.

[Physical therapy of frozen shoulder: literature review]. / Les traitements physiques dans la rétraction capsulaire de l'épaule :revue de la littérature.

OBJECTIVE: To determine the efficacy of physical treatments in adhesive capsulitis of the shoulder by a systematic review of literature, attempting to perform a meta-analysis from randomised clinical trials. METHOD: A systematic literature search was conducted to retrieve all randomised controlled trials of physical therapy such as physiotherapy and manipulation, but also arthrographic distension, mobilisation under general anaesthesia or nerve block, arthroscopic distension or arthrolysis, and intra-articular corticoid injections. The main outcome for meta-analysis was the restoration of range of movement between the sixth week and the third month. RESULTS: Only 16 articles could be selected, and only three about capsular distension were included in a meta-analysis because of the heterogeneity of the criteria assessing the functional results and of the poor methodological value of most of the articles. DISCUSSION: Some open studies stressed the value of daily manipulations and physiotherapy, intra-articular corticosteroid injections, but their quality was poor or limited. Nothing was written about antalgic drugs to facilitate joint mobilisation, and the use of a thoraco-brachial abduction device between exercises was only quoted. The most refractory cases might need more aggressive interventions: arthrographic distension with local anaesthesia and steroid injection; mobilisation under general or local anaesthesia, specially interscalene brachial plexus block; arthroscopic release. But there was no randomised controlled study comparing these three techniques and it seemed impossible to come to any conclusion about the superiority of one of them. The meta-analysis showed yet that capsular distension with intra-articular corticoid injections was better than corticoid injections alone. CONCLUSION: This demonstrated the need of a consensus about the criteria of assessment, the time of evaluation, before assessing by randomised clinical trials of good quality their therapeutic value.

[Locomotor reeducation and multiple sclerosis. A critical analysis of the literature]. / Rééducation locomotrice et sclérose en plaques. Analyse critique de la littérature.

Multiple Sclerosis (MS) is a disabling chronic neurological disorder with multiple motor impairments and its progressive course leads to severe disability. The question of the value of exercises program and physiotherapy to reduce these motor disorders and their consequences was raised. This literature overview is based on data from common database: Medline, Embase, Cochrane Library. Were selected articles corresponding to open studies and especially clinical controlled randomised trials. To be analysed, each article should correspond with inclusion criteria: confirmed diagnosis according to Poser's criteria, secondary or primary progressive form of MS without relapse for the study period, randomisation according to severity assessed by the Expanded Disability Status Scale (EDSS), no change in symptomatic drugs along the study period, and a simple blind assessor. Impairment, disabilities, handicap and quality of life had to be measured. Five clinical controlled randomised trials were consistent with these criteria. They demonstrated the effectiveness of comprehensive programs on motor function in the less severe forms of MS, but also their inability to change the course of the most severely affected forms. However, the effects on disability, handicap and quality of life were significant in comparison with control patients. These trials emphasised the value of multidisciplinary programs including physiotherapy and occupational therapy, carried out daily or 3 times a week by specialised staffs. The effects lasted only few weeks or months, requiring to propose them again after this period. Other controlled randomised studies also stressed the value of specific programs: temporary alleviation of spasticity and fatigue with cooling techniques; aerobic endurance training for less severely affected patients to prevent disuse consequences and improve fitness and quality of life; expiratory training to enhance coughing capacity and prevent pulmonary infections in very disabled patients. From this overview study, it seems that multidisciplinary comprehensive programs clearly provide benefits to those patients and contribute to reduce disability and improve quality of life at each stage of MS.

[Management of multidimensional clinical scores: which solutions for items aggregation?]. / Gestion des scores cliniques multidimensionnels: quelles solutions pour l'agrégation des items?

BACKGROUND: Clinical evaluation is a multifactorial process producing as many clinical scores as there are clinical dimensions. For a medicoeconomical analysis however, a single global score would be most useful. The aim of this work was to examine methods allowing relative quantification of items on multidimensional clinical scores in order to determine an appropriate solution for weighted items aggregation. METHOD: Several techniques for item weighting, developed as part of a multi-criteria decision-making tool (AMCD Aide Multi-Critère à la Décision), were examined. Two methods were applied to multidimensional assessment of disability in order to estimate the weight that should be assigned to each of its six items before aggregation in a unique score. The AHP method was used with an interview of 20 functional rehabilitation specialists. The Diakoulaki method was based on the observation of thirty patients with chronic back pain and in thirty patients with vascular hemiplegia. RESULTS: The three weighting schemes were very different from the uniform weighting and were not correlated with each other. The items best weighted by the AHP method were "physical independence" and "mobility". For the Diakoulaki method, they were "social integration" and "economic independence" for the chronic back pain patients, and "awareness of the outside world" and "economic independence" for the vascular hemiplegia patients. Application of these three weighting schemes to theoretical patients produced very different assessments of global disability. CONCLUSIONS: Weighting schemes are useful to quantify the relative importance of individual clinical items. The choice of the weighting method is determinant and depends on the objective of the investigator. If the objective is a global score, the first step is to estimate the weight of the individual items, either when applying a validation process for a new multidimensional clinical score, or secondarily to adapt a validated score to a particular protocol.