[Electroconvulsive therapy in combination with psychotropic and non-psychotropic pharmacological treatments: Review of the literature and practical recommendations]. / Électroconvulsivothérapie en association avec des traitements pharmacologiques psychotropes et non psychotropes : revue de la littérature et recommandations pratiques.

CONTEXT: Electro-convulsive therapy (ECT) is the most effective treatment for treatment resistant mood disorders and catatonia. ECT also appears to be an effective treatment in combination with clozapine in the context of treatment resistant schizophrenia spectrum disorders. Although increasingly codified (guidelines on indications, contraindications, methods of implementation), the practice of ECT still lacks consensual protocols. The concomitant use of psychotropic and/or non-psychotropic medication is a common situation when ECT treatment is considered. To our knowledge, there is to date no summary of studies or case reports in France, nor any proposal for guidelines concerning the management of medication of the patient to whom ECT sessions are offered. Indeed, several particularities must be considered. This article proposes to specify for each pharmacological class the possible interaction between ECT and medication. A first section of this article will be devoted to non-psychotropic treatments, and a second section to psychotropic treatments. A practical summary table is also provided. METHOD: A review of the literature was conducted including all articles published prior to January 2019 referenced in Pub Med database, combining research with Medical Subject Headings "Electroconvulsive Therapy" and each following pharmacological class: "Cardiovascular Agents" "Bronchodilator Agents" "Bronchoconstrictor Agents" "Theophylline" "Anticoagulants" "Hypoglycemic Agents" "Insulin" "Potassium" "Benzodiazepines" "Valproic Acid" "Carbamazepine" "Lamotrigine" "Lithium" "Antidepressive Agents" "Antipsychotic Agents". RESULTS: After reading the titles, abstracts and whole articles, then searching for additional articles in the references, 50 articles were selected. A summary table summarizing the main risks and proposing a course of action has been produced. DISCUSSION: It is essential to take into account the specificity and the different physiological mechanisms involved in the ECT treatment in order to adjust the associated pharmacological treatments. The prescription for each molecule should be reviewed when ECT treatment is initiated.

Perioperative antibiotherapy should replace prophylactic antibiotics in patients undergoing pancreaticoduodenectomy preceded by preoperative biliary drainage.

BACKGROUND AND OBJECTIVES: Pancreaticoduodenectomy (PD) remains a morbid surgery. Preoperative biliary drainage (PBD) is often necessary before surgery but is associated with biliary contamination. We compared the postoperative complications of patients undergoing PBD who received the usual prophylactic antibiotics (PAs) or systematic antibiotherapy (ABT). METHODS: All patients who underwent surgery between 2008 and 2017 were included. Systematic perioperative ABT with piperacillin + tazobactam (ABT group) was implemented in 2014 as the standard of care for PBD. Patients treated in the period before such implementation, during which standard cefazolin was given, served as the controls (PAs group). The primary outcomes were postoperative complications. RESULTS: We included 122 patients with PBD who underwent surgery. There were no demographic differences between the two groups. Perioperative ABT was associated with a reduction in deep abdominal abscesses (36% vs 10%, P = .0008), respiratory tract infections (15% vs 3%; P = .02), bacteremia (41% vs 6%; P < .0001), and a shorter length of hospital stay (17 [13-27] vs 13 [10-14] days; P < .0001). ABT was a protective factor against the development of deep abdominal abscesses (odds ratio [OR] = 0.16; P = .001) whereas smoking (OR = 3.9) and pancreatic fistula (OR = 19.1) were risk factors. CONCLUSION: Systematic perioperative ABT in patients undergoing PD preceded by PBD may reduce deep surgical infections and the length of hospital stay.

Effect of flumazenil on diaphragm electrical activation during weaning from mechanical ventilation after acute respiratory distress syndrome.

BACKGROUND: Diaphragm electrical activation (EAdi) and the ratio of tidal volume to EAdi (VT/EAdi) may provide clinical information on neuroventilatory efficiency (NVE) in patients being weaned from mechanical ventilation. We tested the hypothesis that residual sedation could interfere with respiratory recovery, by assessing the effects of flumazenil on EAdi and VT/EAdi ratio. METHODS: This observational study included 13 patients breathing with pressure-support ventilation (PSV) after a long period of controlled mechanical ventilation (i.e. >4 days) plus midazolam-based sedation for acute respiratory distress syndrome. EAdi and respiratory patterns were compared before and after a bolus of flumazenil, which was given because neurological status needed to be evaluated. RESULTS: Flumazenil induced a significant increase in EAdi [+71 (41-123)%, P=0.0002] and VT [+17 (8-32)%, P=0.0005], resulting in significantly decreased NVE [-34 (15-43)%]. The increased VT was significantly correlated with the increased EAdi (ρ=0.70, P=0.009). CONCLUSIONS: During weaning from mechanical ventilation, the diaphragmatic contribution to the breathing process may be reduced by residual midazolam-induced ventilatory depression. The increased EAdi with reversal of residual sedation was associated with a proportional increase in VT. These findings should be considered by the attending physician when interpreting daily EAdi and VT changes during weaning from mechanical ventilation.

Neuro-ventilatory efficiency during weaning from mechanical ventilation using neurally adjusted ventilatory assist.

BACKGROUND: Neuro-ventilatory efficiency (NVE), defined as the tidal volume to electrical diaphragm-activity ratio (VT/EAdi) at the beginning and end of the weaning process after acute hypoxaemic respiratory failure, may provide valuable information about patient recovery. METHODS: This observational study included 12 patients breathing with neurally adjusted ventilatory assist (NAVA). When a spontaneous breathing trial (SBT) with pressure support of 7 cm H2O and PEEP was unsuccessful, NAVA was used and the level was adjusted to obtain an EAdi of ∼60% of maximal EAdi during SBT. VT and EAdi were recorded continuously. We compared changes in NVE between NAVA and SBT at the first failed and first successful SBT. RESULTS: When patients were switched from NAVA to SBT, NVE was significantly reduced during both unsuccessful and successful SBT (-56 and -38%, respectively); however, this reduction was significantly lower when SBT was successful (P=0.01). Between the first and last day of weaning, we observed that NVE decreased with NAVA [40.6 (27.7-89.5) vs 28.8 (18.6-46.7); P=0.002] with a significant decrease in NAVA level, whereas it remained unchanged during SBT [15.4 (10.7-39.1) vs 19.5 (11.6-29.6); P=0.50] with significant increases in both EAdi and VT and no difference in respiratory rhythm. CONCLUSIONS: These results suggest that in patients after respiratory failure and prolonged mechanical ventilation, changes in VT and NVE, between SBTs are indicative of patient recovery. Larger clinical trials are needed to clarify whether changes in NVE reliably predict weaning in patients ventilated with NAVA.

Meiotic aberrations during 2n pollen formation in Begonia.

Unreduced gametes are the driving force for the polyploidization of plants in nature, and are also an important tool for ploidy breeding. The final heterozygosity of a 2n pollen grain depends on the cytological mechanism behind 2n pollen formation. In this study, chromosome pairing and chromosome segregation during the microsporogenesis of seven Begonia genotypes were analysed using fluorescent chromosome staining on (squashed) pollen mother cells. Among the seven genotypes, five genotypes produce 2n pollen (B. 'Bubbles', B. 'Florence Rita', B. 'Orococo', B. 'Tamo' and B276) and two genotypes produce only normal n pollen (B. fischeri and B243). All 2n pollen producers showed a mechanism equivalent to first division restitution (FDR), in which chromosomes did not segregate during meiosis I but only during meiosis II. This FDR was the result of (a) an irregular chromosome pairing in B. 'Tamo', (b) stickiness of chromosomes associated with numerous chromosome bridges in B. 'Florence Rita' and B276, and (c) a combination of irregular chromosome pairing and stickiness of chromosomes in B. 'Bubbles'. The exact mechanism of the nuclear restitution in B. 'Orococo' could not be determined. Other mechanisms, such as early asymmetric cytokinesis, omission of meiosis II, parallel or tripolar spindle formation, were rather uncommon. Unpaired chromosomes (univalents) were observed in all genotypes, but they had moved to one of the poles by the end of anaphase I or II. Only B. 'Tamo' formed a high number of micronuclei. Consequently, this genotype formed a large number of malformed pollen. Obviously, chromosome behaviour during meiosis in Begonia is very dynamic, which may have important consequences for chromosome evolution and biodiversity within the genus.

[Use of activated recombinant FVII in the control of haemorrhage following trauma]. / Contrôle d'une hémorragie traumatique persistante par le facteur VII activé recombinant.

Uncontrolled haemorrhage is a major cause of death in trauma patients: sometimes inaccessible to surgery and often associated with coagulopathy. We report a case of severe blunt pelvic trauma associated with suicide. The conventional treatments were unsuccessful and embolization was impossible. The patient required massive blood product transfusion. A 100 microg/kg recombinant activated factor VII dose was infused, twice. After administration of the first dose, the blood requirement decreased dramatically. Further work and trials are required to assess the safety profile and dose regimen for this drug.

Evaluation of bioassays versus contaminant concentrations in explaining the macroinvertebrate community structure in the Rhine-Meuse delta, The Netherlands.

It is often assumed that bioassays are better descriptors of sediment toxicity than toxicant concentrations and that ecological factors are more important than toxicants in structuring macroinvertebrate communities. In the period 1992 to 1995, data were collected in the enclosed Rhine-Meuse delta, The Netherlands, on macroinvertebrates, sediment toxicity, sediment contaminant concentrations, and ecological factors. The effect of various groups of pollutants (polycyclic aromatic hydrocarbons, trace metals, oil, polychlorinated biphenyls) and of ecological variables on the structure of the macroinvertebrate community were quantified. Ecological factors explained 17.3% of the macroinvertebrate variation, while contaminants explained 13.8%. Another 14.7% was explained by the covariation between ecological variables and contaminants. Polycyclic aromatic hydrocarbons explained a larger part of the variation than trace metals. The contributions of oil and polychlorinated biphenyls were small but significant. Elevated contaminant concentrations were significantly associated with differences in the macroinvertebrate food web structure. The response in bioassays (Vibrio fischeri, Daphnia magna, Chironomus riparius) was susceptible to certain contaminants but also to certain ecological factors. There was a weak correlation between in situ species composition and bioassays; 1.9% of in situ macroinvertebrate variation was explained by the bioassay responses. This seems to contradict the validity of using bioassays for a system-oriented risk assessment. Possible reasons for this discrepancy might be the manipulations of the sediment before the test and a higher pollutant tolerance of the in situ macroinvertebrates. Thus, macroinvertebrate field surveys and laboratory bioassays yield different types of information on ecotoxicological effects, and both are recommended in sediment risk assessment procedures.

Tarsal tunnel syndrome: clinical and pathological results.

The tarsal tunnel syndrome is a complex entity. The condition results from a compression of the posterior tibial nerve, either at its terminal or collateral branches, at the tibio-astragalo-calcaneal canal of Richet. A retrospective study of 27 consecutive cases, treated by epi- or perineural neurolysis, illustrates the variability of the clinical picture but fails to confirm the complete and immediate success of the intervention, as reported by the majority of authors. However, the long-term follow-up shows a significant improvement in the terminal latencies of the posterior tibial nerve at 2 years post-surgery. A pathological study of 20 cadaveric feet discloses microscopic anomalies in 22 of the 120 nerve biopsy specimens.

Intraoperative management of heart-lung interactions: "from hypothetical prediction to improved titration".

Extensive literature describes the suitability of dynamic parameters to predict responsiveness in fluid. However, based on heart-lung interactions, these parameters can have serious limitations, including the use of protective lung ventilation. Although the latter seems to be beneficial for healthy patients undergoing high-risk surgery, the intraoperative interpretation of dynamic parameters to predict fluid responsiveness can be hazardous. In this context, the attending physician could, alternatively, titrate the need of fluids with a small fluid challenge, which remains unaffected by low tidal volume, the presence of arrhythmia, or the presence of spontaneous ventilation. When intraoperative prediction of fluid responsiveness is required in mechanically ventilated patients, "improved" titration should be preferred to a hypothetical prediction.

[Fingerprints identification of radiotherapy patients]. / Mise en œuvre d'un dispositif d'identification biométrique en radiothérapie : l'expérience du centre Oscar-Lambret.

The identification of patient plays a key role in the quality and safety of radiotherapy. It does impact on all professional staff and on patients. After the regulatory authority approval (Cnil), a pilot study has been performed on 1901 patients. Acceptance has been very high (>93%) with a low risk of misidentification (<0.1%). The next step will be to implement and test a bimodal system in order to improve registration capacity and sensitivity.

[Changes in kaliemia following rapid sequence induction with succinylcholine in critically ill patients]. / Variation de kaliémie après une induction en séquence rapide avec la succinylcholine chez les patients de réanimation.

OBJECTIVE: Evaluate the changes in potassium following rapid sequence induction with succinylcholine in critically ill-patients and determine whether hospital length of stay could influence the succinylcholine-induced hyperkaliemia. STUDY DESIGN: Prospective and observational study. PATIENTS AND METHODS: After approval by our local ethical committee, we prospectively included 36 patients admitted from more than 24hours in ICU and who required succinylcholine for rapid tracheal intubation (1mg/kg). Serum potassium was measured before, 5 and 30min after succinylcholine. The incidence of life-threatening hyperkaliemia (≥6.5mmol/L) was noted. RESULTS: We could observe significant and transient increase in serum potassium (median increase of 0.45 [0.20-0.80] mmol/L at five minutes). A significant relationship was observed between the ICU length of stay and arterial potassium increase (r=0.37, P<0.05). From the ROC curve, a threshold of 12 days had an 86% sensitivity and 69% specificity in discriminating patients in whom the potassium increase was more than 1.5mmol/L. CONCLUSION: Induction with succinylcholine is followed by significant but transient hyperkaliema. The ICU length of stay before giving succinylcholine could influence significantly the amplitude of potassium increase.

[Diagnosis and management of acute mesenteric ischemia]. / Diagnostic et prise en charge des ischémies mésentériques aiguës.

The prevalence of significant splanchnic arterial stenoses is increasing, but remains mostly asymptomatic due to abundant collateral circulation. Acute insufficiency of mesenteric arterial blood flow accounts for 60 to 70% of cases of mesenteric ischemia and results mostly from a superior mesenteric embolus. Despite major advances have been achieved in understanding the pathogenic mechanisms of bowel ischemia, its prognosis remains dismal with mortality rates about 60%. The diagnosis of acute mesenteric ischemia depends upon a high clinical suspicion, especially in patients with known risk factors. Rapid diagnosis is essential to prevent intestinal infarction. However, early signs and symptoms of mesenteric ischemia are non specific, and definitive diagnosis often requires radiologic examinations. Early and liberal implementation of angiography has been the major advance over the past 30 years which allowed increasing diagnostic accuracy of acute mesenteric ischemia. CT and MR-based angiographic techniques have emerged as alternatives less invasive and more accurate to analyse splanchnic vessels and evaluate bowel infarction. The goal of treatment of patients with acute mesenteric ischemia is to restore intestinal oxygenation as quickly as possible after initial management that includes rapid hemodynamic monitoring and support. Surgery should not be delayed in patients suspected of having intestinal necrosis.