[Necrotizing fasciitis of the thoracoabdominal wall complicating Dujarier's bandage: a case report]. / Fasciite nécrosante compliquant un bandage de Dujarier: à propos d'une observation.

The necrotizing fasciitis (NF) means a serious infection of the subcutis, the fascia and superficial dermis secondarily. We report the case of a patient with cellulitis NF of the thoracoabdominal wall complicating Dujarier's bandage. It was monobacterial NF caused by ß hemolytic streptococcus, whose development was supported through an appropriate medical and surgical care. The situation mentioned is the occurrence of secondary infection of skin necrosis occurred in the bandage too tight opposite the support zone of the elbow on the trunk. We point out, through this case, the importance of the medicosurgical and also the importance of making any thoracoabdominal bandage, which could lead, if it is tight, a pressure sore can be a door entry for any NF plus a late diagnosis.

Impact des maladies mentales préexistantes sur l'évolution et la survie chez les brûlés : étude cas-témoins.

Psychiatric disorders in burn victims are well known and studied, but few articles treat the impact of pre-existing psychiatric pathologies on the evolution of burns. The aim of our study is to compare the evolution in terms of complications, length of stay and survival between patients with and without pre-existing mental disorders. This is a bi-centric case-control study (N = 92), conducted at the Plastic Surgery Department of Rabat University Hospital, and the Plastic Surgery Department of the Tangier-Morocco Regional Hospital, between January 2012 and February 2018. Characteristics of the patients were collected and two groups of patients were identified and compared (n = 67): a preexisting mental disorder group (n = 22) and a control group (n = 45). TBSA (total body surface area) burned and 2nd and 3rd degree burned TBSA were significantly greater in the group with a history of mental disorders compared to the control group (p = 0.012, p <0.001, p = 0.014). Mean length of stay before discharge was greater (p = 0.005). Finally, mortality in the group with pre-existing mental illness was 31.8% versus 6.7% in the control group (p = 0.011). Patients with pre-existing mental disorders seem to present worse burns and need more time to recover from them, resulting in higher morbidity and mortality and a higher cost of care. The systematic screening of burned patients in search of a psychiatric diagnosis and early management of these disorders could improve the prognosis and quality of life of these patients.

La prise en charge d´un afflux massif de brûlés en provenance d´une prison pour mineurs au Maroc.

Massive influx of burns (thermal, chemical or electrical) is a potential crisis situation in the world in peacetime. In fact, burn is one of the most frequently encountered injuries following natural or human disasters. The management of a massive influx of burn victims is considered to be a real challenge, not only from a medical point of view but also from a logistical and organizational point of view. It is an exceptional event requiring exceptional organization and planning in advance, including systematically training medical and paramedical personnel, without forgetting ambulance and fire workers as they will be the first to arrive at the scene. Planning must necessarily include equipment for fast and effective support. We will present our experience in managing a massive influx of burns from a juvenile detention centre. We share it in order to help establish a better plan to deal with these rare but challenging situations.

Aspects cliniques et thérapeutiques des brûlures par brasero traditionnel.

The traditional brazier remains a means of cooking and warming for thousands of families in isolated rural areas in Morocco. From simple burns due to accidental contact to limb carbonizations, these burns are all the more serious when they are secondary to epileptic seizures or carbon monoxide poisoning. The sequelae are important in the associated forms, mainly because of delay in management and non-adherence to therapeutic protocols by patients of low socioeconomic status.

Eclipsed mitral regurgitation: an unusual cause of acute heart failure.

AIMS: So far, a total of five patients with eclipsed mitral regurgitation (MR) have been reported in the literature by three different teams. The aim of this article was to detail clinical and echocardiographic characteristics, and outcome of patients presenting eclipsed MR. METHODS AND RESULTS: We defined eclipsed MR as spontaneous appearance, at rest, from 1 min to the next of an acute restriction in the motion of mitral leaflets preventing coaptation and leading to massive MR in patients with normal left ventricular end-diastolic diameter, left ventricular ejection fraction >45%, and baseline MR ≤2. Spontaneous regression occurred within 30 min, and no obvious trigger such as acute hypertension, new-onset arrhythmia, or myocardial ischaemia is present. Clinical data, ECG, echocardiographic data, surgery report, and follow-up status of six patients with eclipsed MR are reported: all were post-menopausal women with median age of 74 [57-80] years presenting hypertension (4/6), chronic kidney disease (5/6), or chronic anaemia (4/6). Five out of six patients experienced acute pulmonary oedema requiring hospitalization and underwent mitral valve replacement because of heart failure recurrence. Two patients died in the first days after surgery while the three others are free of symptoms at, respectively, 56, 18, and 10 months follow-up. CONCLUSION: Eclipsed MR is a clinical and echocardiographic syndrome responsible for heart failure with preserved EF. It is presently underdiagnosed and should be evoked in cases of recurrent acute pulmonary oedema without obvious trigger, in particular in patients presenting discordant evaluation of MR severity over time.

[How to carry out the indications of cardiac resynchronization therapy in practice?]. / Comment porter les indications de stimulation multisite en pratique?

Recent studies have demonstrated that cardiac resynchronization therapy diminish morbidity and mortality of patients with heart failure, who remain symptomatic despite an optimal medical treatment and who have a wide QRS. However, 30% of patients are non-responders. Hence, echocardiography constitutes an interesting tool for the diagnosis of asynchrony. Different echocardiographic indices predict response to cardiac resynchronization therapy. In this article, a practical approach is proposed for these patients.

[Management of eyelid carcinomas: Retrospective bicentric study of 64 cases and review of the literature]. / Prise en charge des carcinomes des paupières : étude bicentrique rétrospective sur 64 cas avec revue de littérature.

PURPOSE: To study the epidemiologic, clinical and histological aspects of eyelid carcinomas in our context, and to evaluate our surgical management on an oncological, functional and aesthetic level. PATIENTS AND METHODS: This work is a retrospective bicentric study extended over a 5-year period between January 2009 and December 2013, including 64 patients with eyelid carcinoma undergoing surgery in the Plastic and Reconstructive Surgery Department at the Avicenne University Hospital of Rabat and in the ENT/Head and Neck Surgery Department at the Hassan II University Hospital of Fez. RESULTS: The study included 25 men and 39 women with a mean age of 60.6 ± 15.33 years. Advanced age and chronic sun exposure were the most important risk factors. The most commonly involved site was the lower eyelid (53%). Histological examination emphasized the very high prevalence of basal cell carcinoma (90.62%). Surgical treatment was performed in all our patients followed by an extemporaneous and/or standard histological examination of the surgical specimen. Exenteration was performed in one patient with adjuvant radiation therapy. Reconstruction incorporated a variety of techniques, of which total skin graft and Mustardé flap were the most common in our series. Aside from a few complications, the postoperative results were satisfactory for the majority of our patients. CONCLUSION: Malignant tumors of the eyelids, of which basal cell carcinoma is the most common, pose a therapeutic problem where surgery remains the most utilized treatment option. The best treatment is prevention and diagnosis of early lesions to improve prognosis and to avoid worse outcomes.

[Free floating thrombus in right cardiac chambers and thrombolysis]. / Thrombus flottant dans les cavités droites.

Free-floating thrombi in the right heart chambers is a rare phenomenon. Nearly 99% of detected cases are associated with the presence of proven pulmonary embolism. Its presence is associated with a poor outcome with a mortality between 27 to 44% according to studies. Despite the emergency of treatment, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 84-year-old man hospitalised for acute decompensated heart failure. After an initial favourable evolution, a degradation of respiratory occurred with dyspnea and desaturation. A bedside transthoracic echocardiography showed a mobile serpiginous thrombus, 7cm size, moving to and across the tricuspid valve. A computed tomography of the chest demonstrated massive bilateral pulmonary embolism. After persistence of the thrombus and seven days of heparinotherapy, thrombolysis therapy was initiated. The thrombus disappeared 24h after thrombolysis. Without contra-indication, thrombolysis is a faster, readily available treatment for the management of floating thrombus in the right heart chambers associated with pulmonary embolism.

[Pure epicarditis after surgical repair of atrial septal defect: a rare form of constrictive pericarditis. Apropos of a case]. / Epicardite pure après correction chirurgicale d'une communication interauriculaire: une forme rare de péricardite constrictive. A propos d'un cas.

The authors report a case of constrictive pericarditis occurring two years after surgical repair of an atrial septal defect in a 37 year-old-man. The diagnosis was made by right heart catheterisation and magnetic resonance imaging. The special feature of this clinical case was the exclusive localisation of the fibrosis on the visceral pericardium or epicarditis. The outcome was favourable after resection of the visceral pericardium respecting the parietal pericardium. Magnetic resonance imaging and right heart catheterisation performed 6 months after surgery were normal. Constrictive pericarditis is a classical complication of cardiac surgery but relatively rare after repair of an atrial septal defect. Isolated involvement of the visceral pericardium is rare and allows surgical correction by exclusive epicardectomy respecting the parietal pericardium.

[Isolated carcinoid tumor of the ovary disclosed by tricuspid insufficiency]. / Une tumeur carcinoïde isolée de l'ovaire révélée par une insuffisance tricuspide.

A 68-year old woman was hospitalised because of isolated right heart failure. Doppler echocardiography revealed severe tricuspid regurgitation with thickened, shortened, hypomobile leaflets. Pulmonary valve was thickened with mild pulmonary regurgitation. Mitral and aortic valves were normal. The patient was finally diagnosed with carcinoid heart disease from an isolated ovarian carcinoid cancer without hepatic metastases. Ovarectomy was performed and the patient was considered cured of her cancer. Because of refractory right heart failure, she underwent tricuspid valve replacement with a bioprosthesis. Such cardiovascular manifestations are rarely the presenting symptoms of carcinoid disease. Carcinoid heart disease from ovarian primary cancer is exceptional. In this circumstance, carcinoid cardiac lesions may develop in the absence of hepatic metastases because the venous blood from the ovaries drains into the inferior vena cava without hepatic first past effect. Surgical resection of primary ovarian carcinoid tumor is often curative and the prognosis depends mainly on the cardiac condition. The diagnosis of carcinoid syndrome should be discussed in patients with organic tricuspid regurgitation without left valvular disease.

[Calculation of the regurgitation fraction in mitral insufficiency by Doppler echocardiography using a study of the zone of flow convergence]. / Calcul de la fraction de régurgitation des insuffisances mitrales en échocardiographie Doppler par étude de la zone de convergence.

The aim of this study was to propose a new method for calculating the regurgitation fraction of mitral insufficiency by the proximal isovelocity surface area (PISA) method and to compare it with the value of the catheter regurgitation fraction. Thirty-five patients (21 men and 14 women) aged 59 +/- 13 years with isolated mitral insufficiency were studied. Analysis of the proximal isovelocity surface area enabled calculation of an instantaneous maximum regurgitant flow, surface of the regurgitant orifice and the regurgitant volume. The regurgitant fraction was calculated by dividing the regurgitant volume by the sum of the regurgitant volume and aortic stroke volume measured by Doppler echocardiography. These parameters were compared with the corresponding catheter data and the angiographic grade of mitral insufficiency. The echocardiographic and catheter studies were performed within 1.7 +/- 1.2 days. There was a statistically significant correlation between the instantaneous maximum regurgitant flow calculated by the PISA method and the catheter regurgitant flow (r = 0.88; p = 0.0001); between the regurgitant volume calculated by the PISA method and the catheter regurgitant volume (r = 0.85; p = 0.0001) and the regurgitation fraction calculated by the PISA method and the catheter regurgitant fraction (r = 0.82; p = 0.0001). A regurgitant fraction by the PISA method of > 45% corresponded to severe mitral regurgitation (> or = angiographic grade 3 and/or a catheter regurgitant fraction > or = 50%) with a sensitivity of 88% and a specificity of 100%. The PISA method should form part or routine quantification of mitral insufficiency.

Digoxin Toxicity : Evaluation in Clinical Practice with Pharmacokinetic Correlations.

OBJECTIVE: To evaluate digoxin pharmacokinetic parameters using Bayesian estimation in 60 patients, and to identify factors that appeared to affect the risk of digoxin toxicity. PATIENTS AND METHODS: 60 patients with serum digoxin concentrations were evaluated retrospectively. We collected demographic, clinical and laboratory data, and information on concurrent medications and clinical and electrocardiographic features of digoxin toxicity. The incidence of digoxin toxicity was evaluated in 50 patients. Serum digoxin concentrations were measured with fluorescence polarisation immunoassay Individual pharmacokinetic parameters were estimated by Bayesian method using Abbottbase Pharmacokinetic Systems. RESULTS: Signs of digoxin toxicity were present in 23 patients (46%). Patients without signs of digoxin toxicity had a significantly lower mean serum digoxin concentration than patients with signs, 1.99 ± 0.9 µg/L vs 2.7 ± 1.5 µ.g/L, respectively (p = 0.047). Patients with serum digoxin concentrations >2.2 µg/L differed significantly from those with values ≤2.2 µg/L, respectively, for the following parameters: age (82.0 ± 8.0 vs 72.0 ± 16.0 years; p = 0.005), serum creatinine levels (133.0 ± 55.0 vs 106.0 ± 26.0 µmo1/L; p = 0.012), bodyweight (57.4 ± 12.8 vs 69.2 ± 17.8kg; p = 0.01), volume of distribution (208.5 ± 89.5 vs 315.7 ± 91.2L; p = 0.0001), total clearance (1.60 ± 0.65 vs 3.4 ± 1.5 L/h; p = 0.0001), and elimination half-life (94.2 ± 28.6 vs 72.4 ± 16.7h; p = 0.001). Estimation of optimal dose showed that the doses recommended in intoxicated patients should be 3.5 times lower to reach the therapeutic range. CONCLUSION: Digoxin concentrations were higher in patients with toxicity. Older age enhanced the risk of digoxin toxicity. Monitoring digoxin concentrations may help to confirm suspected digitalis toxicity.

[Iterative surgery for goiter]. / Les réinterventions après thyroïdectomie pour goitre.

AIM: Identify and resolve problems related to iterative surgery for goiter. PATIENTS AND METHOD: Fifty-nine patients who underwent surgery for recurrent benign goiter between 1990 and 1999 were included in the study. RESULTS: Forty-two patients had lobectomy and isthmusectomy (71.2 and 17 patients had subtotal thyroidectomy (28.8%). The delay from initial surgery to recurrence was less than 5 years for 44% of the patients and was more than 10 years for 17.8%. There was no post-operative mortality and no recurrent laryngeal nerve injury. Early post-operative hypocalcemia occurred in 2 patients (3.3%). CONCLUSION: The goal of revision surgery for recurrent goiter is total thyroidectomy. Prevention is a rational management scheme for thyroid nodules.

[The protected tendinous graft in zone 2 or fibroblast trap]. / La greffe tendineuse protégée en zone 2 ou le piège à fibroblastes.

INTRODUCTION: We present a simple technique for preventing adhesions to tendon grafts in zone 2. A silicone tube is cut longitudinally and the third of its diameter is removed. It is then introduced under the pulley with the slot towards the skeleton. The tendon graft is introduced into this tube which will protect it from adhesions except at the slot level where fibroblasts create a new vasculature. MATERIALS AND METHODS: Between April 2002 and April 2003, we have used this technique in three patients, two in their thumbs and one in the long finger. In the Boyes classification, one thumb lesion corresponded to stage 1 and the other two cases to stage 4. The main pulleys were preserved. The tube measured 12 cm in length, and extended from the proximal juncture to the distal one (Pulvertaft technique). After 5 weeks of strict immobilization, the tube was withdrawn and the patients began active mobilization. RESULTS: After 8 weeks, comparison of the results with the opposite hand showed: Normal extension in all cases. Flexion deficit of 15 degrees in the thumb interphalangeal joints. Flexion deficit of 20 degrees in the proximal and distal interphalangeal joints of the long finger. There were no reported complications. With a mean follow-up of 1 year, these results were stable. CONCLUSION: These results support the contention that a good blood supply to the tendon and a good gliding surface have been developed with this technique. The tube seems to work as a fibroblast trap and blocks harmful adhesions.

[The "necktie lasso": a new technique for the simultaneous treatment of Wartenberg's sign and claw deformities in the hand due to ulnar nerve palsy]. / Le "lasso en cravate': une nouvelle technique pour le traitement simultané du signe de Wartenberg et des déformations en griffe des mains atteintes de paralysies cubitales.

The "necktie lasso" is a new technique that allows the simultaneous active treatment, of both Wartenberg's sign and claw deformity of the fifth and the fourth digits in the hand with ulnar nerve palsy. The flexor sublimis of the fourth digit is taken by a palmar approach. It is then divided into two strips up to the proximal part of the palm; The radial strip is used as a classical "direct lasso" to treat the claw deformity of the fourth digit; The ulnar strip is wound around the base of the fifth digit by a palmar and dorsal approaches at the level of the proximal phalanx, like a necktie, being medial to its radial pedicle, dorsal and superficial to its extensor apparatus, then lateral to its ulnar pedicle; It is then recovered in the palm and sutured to itself. From September 1998 to April 2003, this technique has been used in eight patients aged between 21 and 35 years old and suffering from post traumatic low ulnar nerve palsy. It was always very effective in dealing with Wartenberg's sign: the active adduction of the fifth digit appearing at the start of flexion. The claw deformity of the fourth and fifth digits was equally actively corrected. No complications are reported in this series. With a mean follow-up of 3 years there was no recurrence of any of the deformities.

[Is a dynamic or stable technique needed for metacarpophalangeal joints of the hand in ulnar nerve palsy?]. / Faut-il réanimer ou juste stabiliser les métacarpophalangiennes des doigts et du pouce des mains cubitales?

INTRODUCTION: It seems interesting to choose between the dynamic and the static techniques for the rehabilitation of the hand suffering from an ulnar nerve palsy on the basis of the grasp (F1) and pinch (F2) strengths which are important in this rehabilitation. METHODS: From june 1997 to december 2001, 30 ulnar palsies all post traumatic with non complicated claw deformities have been collected and distributed in three groups of ten patients. In the group A only the static techniques have been used on the MP joints of the fourth and fifth digits and the thumb; in the group B only the dynamic techniques have been used on the fourth and fifth digits, on the flexor pollicis brevis and on the first dorsal interosseous muscle; in the group C, the MP joint of the thumb has been stabilized and dynamic techniques have been used on these two muscles, the MP joints of the fourth and fifth digits have been only stabilized. The techniques used in this study were among the most popular. The grasp and pinch strengths were measured by a mechanical dynamometer at the preoperative period and at third and sixth postoperative month. RESULTS: At sixth month, in the group A, F1 didn't change and F2 has increased by 9%; in the group B, F1 has decreased by 24% without recovery of the preoperative value and F2 has increased by 13%; in the group C, F2 has increased by 19%. DISCUSSION: For a reconstruction of an useful hand in an ulnar nerve palsy, the best solutions seem: for the fourth and fifth digits: simple stabilization of the MP joints for the thumb: an association of this stabilization and a rehabilitation of some muscles involved in the pinch prehension.

[Severe burns of lower limb due to association of hot water and citrullus colocynthis]. / Brulure grave du membre inferieur par l'association d'eau chaude et de citrullus colocynthis.

The case is reported of a patient suffering from severe burns through having used Citrullus colocynthis as a medicinal plant together with hot water. This led to carbonization of the foot and to its amputation. A description of the plant and its toxicity is given.

[Self-closing flaps in the treatment of scalp burns due to high-voltage electricity]. / Lambeaux autofermants pour le traitement des brulures electriques du scalp par haut voltage.

Electrical burns caused by high voltage are responsible for extensive tissue damage. This damage continues in the days following the accident because of the heat deriving from the Joule effect and vascular microthrombosis. In such cases of destruction of the periostum and the calvarium we use coverage flaps. From June 1997 to June 2008, 15 patients were treated for loss of scalp substance due to high-voltage electric burns. The loss, in the tonsural region and varying in size from 9 to 11 cm, was reliably covered per primam in the first week following the accident using axial and multiple coverage flaps. We report the experience of the Division of Plastic Surgery, Ibn-Sina, Rabat, Morocco.

[Electrical burns suffered by copper thieves]. / Les brulures electriques chez les voleurs de cuivre.

Thefts of copper appear to have been on the increase for some time owing to its high resale price. This has led to an increase in the number of high-voltage electrical accidents (HVEA). Such accidents are very serious because they cause deep burns along the neurovascular axis. A report is presented describing a series of nine patients presenting HVEA admitted to the Ibn Sina Hospital Plastic Surgery and Burns Division in Rabat, Morocco, with a study of the epidemiological, clinical, and therapeutic aspects. The patients all belonged to the young and active sector of the population. The burns were secondary to contact with high-voltage cables occurring during the attempted stealing of copper by stripping electric conductors in transformers (67% of the cases) and in attempts to cut overhead lines supplying electric trains on the railway network (33%). Electrothermal treatment of the lesions required repeated surgery with amputation and disarticulation of necrotic limb segments (67% of the cases), the consequences of which were marked by disabling functional sequelae. Preventing this type of HVEA remains fundamental.

[Expanded scalp flap in cicatricial areas affected by burns sequelae - an observation]. / Lambeau Expanse du Cuir Chevelu dans la Couverture des Alopecies Cicatricielles sur Sequelles de Brulures. A Propos d'une Observation.

Les séquelles esthétiques des alopécies cicatricielles sur séquelles de brûlures sont responsables de préjudices empêchant parfois la réinsertion sociale du patient, surtout chez les sujets de sexe féminin. Le cuir chevelu permet la réalisation de lambeaux permettant de couvrir ces alopécies. Les Auteurs décrivent le cas d'une jeune patiente victime d'une alopécie cicatricielle sur séquelles de brûlures chez qui ils ont réalisé un lambeau expansé du cuir chevelu et mettent le point sur la prise en charge de ces lésions à travers ce cas clinique et une revue de littérature.