[Cognitive and behavioral group therapy in chronic pain: expectations and satisfactions]. / Thérapie cognitivo-comportementale de groupe et douleur chronique: attentes et satisfactions.

Twenty-two patients suffering from chronic pain have participated to a behavioural and cognitive group therapy, over 8 weekly sessions, each of 90 minutes. Semi-structured interviews revealed that all of their expectations were satisfied, except for pain decrease. Although they had often negatively anticipated the group situation, all patients evaluated positively the experience: they felt less lonely; they were listen to and understood by the other participants. After 3 months, 80% of the patients had modified some of their daily behaviours. After 12 months, 55% of the patients witnessed a lasting change over the impact that pain had on their life. Even if patients expect a decrease of their pain, disappointment is not an obstacle to the process of change.

Report on initial experience with local anaesthesia for carotid artery endarterectomy.

PURPOSE OF THE STUDY: This prospective study reports our preliminary results with local anaesthesia (LA) for carotid endarterectomy (CEA). MATERIAL AND METHODS: Twenty CEA in nineteen patients were performed using a three-stage local infiltration technique. CEA were performed through a short Duplex-assisted skin incision (median length: 55 mm) using a retro-jugular approach and polyurethane patch closure (median length: 35 mm). RESULTS: There were 13 men and 6 women with a mean age of 71.2 years. The indications of CEA were asymptomatic lesions in 11 cases, stroke in 7 cases and transient ischaemic attack in 2 cases. The median degree of internal carotid artery stenosis was 90%. One patient (5%) required an intraluminal shunt. There were no peri-operative deaths, stroke or conversion to general anaesthesia (GA). The median length of stay was 3 days. CONCLUSIONS: LA is a good alternative to GA. It can be used after a feasibility study and a short teaching procedure. In our centre, it is a safe and effective procedure associated with low morbidity, high acceptance by patients and a short hospital stay.

[Preoperative assessment in visceral surgery]. / Bilan préopératoire en chirurgie viscérale.

The purpose of preoperative assessment is to evaluate the patient's health status, to address known or unidentified co-morbidities and to perform adequate complementary exams if necessary. On the other hand, it allows to prepare and protect the patient in order to reduce perioperative risk. The assessment consists of patient's history and physical examination, both focusing on cardiovascular and respiratory assessment. Complementary exams have to be chosen selectively depending on the patient's risk factors and the type of surgery. They are indicated if their result leads to a potential patient's benefit only, either by a modification in anesthetic and/or surgical management or by introduction of a pharmacological strategy, adequate and maximal if necessary, especially for cardioprotection.

Systemic and hemodynamic effects of recombinant tumor necrosis factor alpha in isolation perfusion of the limbs.

OBJECTIVE: To describe the systemic effects of high-dose recombinant tumor necrosis factor alpha (rTNF-alpha), recombinant interferon gamma (rIFN-gamma), and melphalan administered through hyperthermic isolation perfusion of the limbs (IPL) in patients with melanoma and malignant soft-tissue tumors. DESIGN: The clinical, hemodynamic, and biologic parameters were recorded after IPL during the postoperative period. SETTING: Surgical intensive care service of a 1,000-bed tertiary university medical center. PATIENTS: Nineteen patients referred to a pluridisciplinary Center for Oncology after relapse of regionally advanced melanoma or soft-tissues tumors, included in a phase 2 therapeutic study. RESULTS: Major systemic and hemodynamic changes were observed after IPL in all patients. Ninety-four percent (17/18) of the evaluable patients presented a shock unresponsive to fluid challenge, requiring the continuous perfusion of vasopressors, inotropic agents, or both. Analysis of hemodynamic data showed two distinctive patterns: a pure distributive shock in nine patients requiring norepinephrine, and a mixed distributive and cardiogenic shock in eight patients requiring vasopressor and inotropic agents. The oxygen parameters were characterized by an increase in both the delivery and the uptake of oxygen, with a prolonged reduced oxygen extraction ratio for most patients. The other observed effects were as follows: transient bilateral or mixed pulmonary infiltrates in all patients; some hematologic disturbances in 83% of patients; infection requiring a modification of the antibiotic prophylaxis in 61% of patients; and some liver toxic reactions in 50% of patients. Very high systemic TNF-alpha serum bioactivity was found in 12 patients for whom serum samples were available, indicating an early and important rTNF-alpha leakage from the IPL. No correlations could be found between the levels of TNF-alpha and the observed systemic effects. Despite the severity of the hemodynamic disturbance, no patient died. CONCLUSION: Major systemic effects, consisting mainly in cardiovascular, respiratory, and hematologic disturbances, were observed in patients after IPL with high-dose of rTNF-alpha. The likely explanation for these observations is an early rTNF-alpha leakage related to inadequate IPL technique. These data show that the iatrogenic administration of high circulating TNF levels lead to a "septic shock-like" syndrome without resulting in lethal organ dysfunction.

Limb salvage by neoadjuvant isolated perfusion with TNFalpha and melphalan for non-resectable soft tissue sarcoma of the extremities.

AIMS: Patients with non-resectable soft tissue sarcomas of the extremities do not live longer if they are treated by amputation or disarticulation. In order to avoid major amputations, we tested isolated limb perfusion (ILP) with tumour necrosis factor alpha (TNF)+melphalan+/-interferon-gamma (IFN) as a pre-operative, neoadjuvant limb salvage treatment. METHODS: Twenty-two patients were included (six men and 16 women; three upper limb and 19 lower limb tumours). The AJCC stage was IIA in four patients, III in seven and IV in 11. Thirteen cases were recurrent or progressive after previous therapy; five tumours had a diameter >/=20 cm, and four were multiple or regionally metastatic. There were six malignant fibrous histiocytomas, five liposarcomas, four malignant peripheral nerve sheath tumours, three rhabdomyosarcomas, two leiomyosarcomas, one recurrent extraskeletal osteosarcoma and one angiosarcoma. RESULTS: Twenty-four ILPs were performed in the 22 patients, and 18 (82%) experienced an objective response: this was complete in four (18%) and partial in 14 (64%). Three patients had a minimal or no response and the tumour progressed in one case. All patients had fever for 24 hours but only one developed a reversible grade 3 distributive shock syndrome with no sequelae. There was no grade 4 toxicity. Seventeen patients (77%) underwent limb-sparing resection of the tumour remnants after a median time of 3.4 months: 10 resections were intracompartmental and seven extracompartmental. Surgery included flaps or skin grafts in five patients, arterial replacement in two and knee arthrodesis in one. Adjuvant chemotherapy was given to eight patients and radiotherapy to six. In one patient amputation was necessary after a second ILP. Secondary amputations were performed for recurrence in two patients, resulting in an overall limb salvage rate of 19/22 (86%). After a median follow-up of 18.7 months, 10 recurrences were recorded: seven were both local and systemic and three were only local. The median disease free and overall survival times have been >12.5 and 18.7 months respectively: this is similar to the outcome after primary amputations for similar cases. CONCLUSION: ILP with TNF and chemotherapy is an efficient limb sparing neoadjuvant therapy for a priori non-resectable limb soft tissue sarcomas.

[Tricuspid valve insufficiency: what should be done?]. / Trikuspidalinsuffizienz: Was tun?

Tricuspid regurgitation is relatively common. Due to the progress made in echocardiography, its diagnosis is in general made readily and in reliable fashion. Basically one has to distinguish between functional tricuspid valve regurgitation due to volume and/or pressure overload of the right ventricle with intact valve structures versus tricuspid valve regurgitation due to pathologic valve structures. The clear identification of the regurgitation mechanism is of prime importance for the treatment. Functional tricuspid valve regurgitation can often be improved by medical treatment of heart failure, and eventually a tricuspid valve plasty can solve the problem. However, the presence of pathologic tricuspid valve structures makes in general more specific plastic surgical procedures and even prosthetic valve replacements necessary. A typical example for a structural tricuspid valve regurgitation is the case of a traumatic papillary muscle rupture. Due to the sudden onset, this pathology is not well tolerated and requires in general surgical reinsertion of the papillary muscle. In contrast, tricuspid valve regurgitation resulting from chronic pulmonary embolism with pulmonary artery hypertension, can be improved by pulmonary artery thrombendarteriectomy and even completely cured with an additional tricuspid annuloplasty. However, tricuspid regurgitations due to terminal heart failure are not be addressed with surgery directed to tricuspid valve repair or replacement. Heart transplantation, dynamic cardiomyoplasty or mechanical circulatory support should be evaluated instead.

[Intensive care management of critically ill adults with congenital heart disease]. / Intensivmedizinische Behandlung von Erwachsenen mit angeborenen Herzfehlern.

Due to improvements in cardiac surgery and perioperative care the number of adults with congenital heart disease is continuously growing. The perioperative and intensive care management of these patients is a challenge due to the variety of pathologies and surgical options as well as the complex pathophysiology. Many patients develop organ dysfunction with time and many require multiple cardiac operations as well as non-cardiac interventions during adulthood. While these patients are best treated in dedicated tertiary centers that provide a multidisciplinary expertise, basic knowledge of this population is important for everyone involved in acute medical care. This review will discuss some general aspects of adults with congenital heart disease such as pulmonary hypertension, Eisenmenger syndrome, cyanosis, pregnancy and perioperative care, with a special focus on the management of critically ill patients.

Peri-operative management of antiplatelet therapy in patients with coronary artery disease: joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC).

An increasing number of patients suffering from cardiovascular disease, especially coronary artery disease (CAD), are treated with aspirin and/or clopidogrel for the prevention of major adverse events. Unfortunately, there are no specific, widely accepted recommendations for the perioperative management of patients receiving antiplatelet therapy. Therefore, members of the Perioperative Haemostasis Group of the Society on Thrombosis and Haemostasis Research (GTH), the Perioperative Coagulation Group of the Austrian Society for Anesthesiology, Reanimation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society of Cardiology (ESC) have created this consensus position paper to provide clear recommendations on the perioperative use of anti-platelet agents (specifically with semi-urgent and urgent surgery), strongly supporting a multidisciplinary approach to optimize the treatment of individual patients with coronary artery disease who need major cardiac and non-cardiac surgery. With planned surgery, drug eluting stents (DES) should not be used unless surgery can be delayed for ≥12 months after DES implantation. If surgery cannot be delayed, surgical revascularisation, bare-metal stents or pure balloon angioplasty should be considered. During ongoing antiplatelet therapy, elective surgery should be delayed for the recommended duration of treatment. In patients with semi-urgent surgery, the decision to prematurely stop one or both antiplatelet agents (at least 5 days pre-operatively) has to be taken after multidisciplinary consultation, evaluating the individual thrombotic and bleeding risk. Urgently needed surgery has to take place under full antiplatelet therapy despite the increased bleeding risk. A multidisciplinary approach for optimal antithrombotic and haemostatic patient management is thus mandatory.

Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction.

Recent clinical data show that the risk of coronary thrombosis after antiplatelet drugs withdrawal is much higher than that of surgical bleeding if they are continued. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is regarded as mandatory until the coronary stents are fully endothelialized, which takes 3 months for bare metal stents, but up to 1 yr for drug-eluting stents. Therefore, interruption of antiplatelet therapy 10 days before surgery should be revised. After reviewing the data on the use of antiplatelet drugs in cardiology and in surgery, we propose an algorithm for the management of patients, based on the risk of myocardial ischaemia and death compared with that of bleeding, for different types of surgery. Even if large prospective studies with a high degree of evidence are still lacking on different antiplatelet regimens during non-cardiac surgery, we propose that, apart from low coronary risk situations, patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space. A therapeutic bridge with shorter-acting antiplatelet drugs may be considered.

[Hemodynamic surveillance: transesophageal echocardiography or Swan-Ganz catheter?]. / Surveillance hémodynamique: échocardiographie transoesophagienne ou catheter de Swan-Ganz?

Pulmonary artery catheter (PAC) and transoesophageal echocardiography (TOE) are two different windows on haemodynamics. PAC observes mainly right heart and pulmonary circulation; it measures pressures and outputs. Its contribution is essential to the management of situations accompanied by hypervolemia, pulmonary stasis, and severe pulmonary pathology, whereas it has little impact on diagnosis of hypovolemia and ventricular function. TOE offers a dynamic vision of the four heart chambers and their valves; it measures flows, surfaces and volumes. It allows quantification of systolic and diastolic functions for each ventricle. It is particularly adapted to the evaluation of hypovolemia and to the differential diagnosis of intractable hypotension. Its applications in cardiac surgery are numerous. The cost/benefice ratio of each technique is dependent of their indications and of their impact on therapy. Both require specific knowledge and learning time in order to have an major clinical impact.

[Nutritional prophylaxis of hypovitaminosis in Mauritania. Cattle rearing and beta-carotene]. / Prophylaxie nutritionnelle de l'hypovitaminose a en Mauritanie. Elevage et bêta-carotène.

Some traditional plants known for their resistance to the desert weather, has been studied for their level in beta-carotene. They are called Spartima maritima and Panicum turgidum. We hope with these plants and others, elaborate some zootechnic project. It will be very useful for all the sahel zone from Atlantic to Pakistan.

[Campaign against hypovitaminosis in Mauritania]. / Lutte contre l'hypovitaminose a en Mauritanie.

Since 1973 and 1983's droughts, different studies have proved that xerophthalmia is a public health problem in Mauritania. With the collaboration of different N.G.O.'s, Mauritanian Health Ministry has elaborated a program against xerophthalmia. In this paper, the authors relate this fight since 1987; methods, limits and future.

[Difficult intubation: decision-making algorithms in the main operating suite of the University Hospital Center]. / Intubation difficile: algorithmes décisionnels dans le bloc opératoire principal du CHUV.

In the setting of an operative suite or in the case of cardio-pulmonary resuscitation, processing algorithms are mandatory for acute crisis situations like the difficult intubation. The following recommendations have been prescribed as applicable for a teaching hospital (CHUV, Lausanne), based on three different possibilities (expected difficult intubation in elective cases, expected difficulties in emergency cases, and unexpected difficulties): awake intubation under topical and local anesthesia, if possible by fibroscopy, for all cases where difficult intubation is expected; steps for unexpected difficult intubation: laryngoscopy with flexible stylettes and special blades, laryngeal mask, trans-tracheal jet-ventilation, rigid tracheo-bronchoscopy by ENT specialist, rescue coniotomy, tracheotomy; tracheal overpressure with transtracheal O2 ventilation in "full stomach" emergency cases; limited number and length of time for intubation trials; keep oxygen inflow during and/or between the intubation attempts; return to spontaneous ventilation as soon as possible. The three algorithms are presented and commented.

Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery.

The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. A 3-month minimum delay is therefore indicated before performing non-cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.

[Therapeutic test in trachoma: putting in place a study model and preliminary results]. / Essai thérapeutique dans le trachome: mise en place d'un modèle d'étude et résultats préliminaires.

This study, performed in Atar and Nouakchott, has tested a new proceeding for biological diagnostic of trachoma (Chlamydia trachomatis direct specimen test, SYVA Merieux microtrak), and has controlled the efficiency of different therapeutic schemes against trachoma. An experimental pattern for subsequent studies is proposed.

Epidural and intravenous fentanyl produce equivalent effects during major surgery.

BACKGROUND: The benefit of epidural versus intravenous fentanyl administration for postoperative analgesia is controversial. In the current study, the intraoperative effects of epidural versus intravenous fentanyl administration were compared during major surgery. METHODS: Twenty elective patients scheduled for thoracoabdominal esophagectomy under general anesthesia with propofol infusion were randomly allocated to receive either intravenous or epidural boluses of 50-100 micrograms fentanyl in a double-blind fashion to maintain hemodynamic stability. Plasma cortisol and fentanyl, as well as total urinary catecholamines, were obtained at the end of the operations. RESULTS: Hemodynamic variations were similar except that patients receiving epidural fentanyl had a lower incidence of heart rate reduction (> 20% reduction from baseline, P < 0.05). There were no differences in mean intraoperative fentanyl (1,115 +/- 430 and 1,010 +/- 377 micrograms, epidural and intravenous, respectively) or propofol (2,281 +/- 645 and 2,452 +/- 1,169 mg) doses, number of boluses of fentanyl (nine in both groups), plasma fentanyl concentration (1.13 +/- 0.4 and 1.02 +/- 0.46 ng/ml), or number of anesthesiologists correctly identifying the site of fentanyl administration. Similarly, there were no differences in plasma glucose (8.9 +/- 1.8 and 9.3 +/- 1.8 mM) and cortisol (696 +/- 446 and 846 +/- 257 mM), or urinary epinephrine (12 +/- 3.7 and 13.1 +/- 9.2, micrograms/sample) and norepinephrine (42.7 +/- 26.7 and 39.1 +/- 27.6, micrograms/sample). CONCLUSIONS: There appears to be no clinical advantage to epidural administration of fentanyl over intravenous administration during anesthesia for major surgery.