Videolaryngoscopy improves intubation condition in morbidly obese patients

Résumé : Contexte clinique et objectifs: l'intubation oro-trachéale peut être plus difficile chez les patients obèses morbides (index de masse corporelle BMI > 35 kg/m2) que chez les patients non-obèses. Récemment, de nouveaux instruments permettant une intubation assistée au moyen d'une caméra ont été développés. Notre expérience pratique avec la vidéolaryngoscopie nous a conduit à l'hypothèse que celle-ci pourrait améliorer la vision laryngoscopique chez cette population spécifique et de ce fait faciliter l'intubation. Le but de cette étude était donc d'évaluer le bénéfice du vidéolaryngoscope sur le grade de laryngoscopie chez le patient obèse morbide. Résultats : le grade laryngoscopique fut abaissé de manière significative avec le vidéolaryngoscope comparé à la vision directe avec un laryngoscope standard. Lorsque le grade laryngoscopique était plus grand que 1 à la laryngoscopie directe, il fut dans la grande majorité des cas (93% des patients) abaissé avec le vidéolaryngoscope. Chez les 7 % restant, le grade laryngoscopique resta identique. Conclusions : chez le patient obèse morbide, l'utilisation du vidéolaryngoscope améliore de manière significative la visualisation du larynx et de ce fait facilite l'intubation. Une application systématique de ce procédé pourrait donc permettre de réduire l'incidence d'une intubation difficile ainsi que ses conséquences chez cette population de patients. Summary : Background and objective: Tracheal intubation may be more difficult in morbidly obese patients (body mass index >35 kgM-2) than in the non-obese. Recently, new video-assisted intubation devices have been developed. After some experience with videolaryngoscopy, we hypothesized that it could improve the laryngoscopic view in this specific population and therefore facilitate intubation. The aim of this study was to assess the benefit of a videolaryngoscope on the grade of laryngoscopy in morbid obesity. Methods: We studied 80 morbidly obese patients undergoing bariatric surgery. They were randomly assigned to one of two groups. One group was intubated with the help of the videolaryngoscope and in the control group the screen of the videolaryngoscope was hidden to the intubating anaesthesiologist. The primary end-point of the study was to assess in both groups the Cormack and Lehane direct and indirect grades of laryngoscopy. The duration of intubation, the number of attempts needed as well as the minimal SPO2 reached during the intubation process were measured. Results: Grade of laryngoscopy was significantly lower with the videolaryngoscope compared with the direct vision (P < 0.001). When the grade of laryngoscopy was higher than one with the direct laryngoscopy (n = 30), it was lower in 28 cases with the videolaryngoscope and remained the same only in two cases (P < 0.001). The minimal SPO2 reached during the intubation was higher with the videolaryngoscope but it did not reach statistical significance. Conclusions: In morbidly obese patients, the use of the videolaryngoscope significantly improves the visualization of the larynx and thereby facilitates intubation.

Fatigue et réduction de la performance motrice chez le sportif, syndrome de surentraînement [Fatigue and reduction in motor performance in sportspeople or overtraining syndrome].

The main goal of training activities is to improve motor performance. After strenuous workouts, it is physiological to experience fatigue, which relieves within two weeks, and then induce an improvement in motor capacities. An overtraining syndrome is diagnosed when fatigue is postponed beyond two weeks, and affects mainly endurance athletes. It is a condition of chronic fatigue, underperformance and an increased vulnerability to infection leading to recurrent infections. The whole observed spectrum of symptoms is physiological, psychological, endocrinogical and immunological. All play a role in the failure to recover. Monitoring of athletes activities helps to prevent the syndrome with days with no sports. Rest, patience and empathy are the only ways of treatment options.

Effectiveness of three different walking prescription durations on total physical activity in normal- and overweight women.

OBJECTIVE: While there is a dose-response relationship between physical activity (PA) and health benefit, little is known about the effectiveness of different PA prescriptions on total daily PA. AIM: To test, under real-life conditions and using an objective, non-invasive measurement technique (accelerometry), the effect of prescribing additional physical activity (walking only) of different durations (30, 60 and 90 min/day) on compliance (to the activity prescribed) and compensation (to total daily PA). Participants in each group were prescribed 5 sessions of walking per week over 4 weeks. METHODS: 55 normal-weight and overweight women (mean BMI 25 ± 5 kg/m(2), height 165 ± 1 cm, weight 68 ± 2 kg and mean age 27 ± 1 years) were randomly assigned to 3 prescription groups: 30, 60 or 90 min/day PA. RESULTS: Walking duration resulted in an almost linear increase in the number of steps per day during the prescription period from an average of about 10,000 steps per day for the 30-min prescription to about 14,000 for the 90-min prescription. Compliance was excellent for the 30-min prescription but decreased significantly with 60-min and 90-min prescriptions. In parallel, degree of compensation subsequent to exercise increased progressively as length of prescription increased. CONCLUSION: A 30-min prescription of extra walking 5 times per week was well tolerated. However, in order to increase total PA further, much more than 60 min of walking may need to be prescribed in the majority of individuals. While total exercise 'volume' increased with prescriptions longer than 30 min, compliance to the prescription decreased and greater compensation was evident. © 2014 S. Karger GmbH, Freiburg.

Embolization for multicompartmental bleeding in patients in hemodynamically unstable condition: prognostic factors and outcome.

PURPOSE: To determine prognostic factors and evaluate outcomes of transcatheter arterial embolization in severely injured patients in hemodynamically unstable condition with multicompartmental bleeding.¦MATERIALS AND METHODS: Between June 2000 and May 2008, 36 consecutive patients treated with transcatheter arterial embolization for major retroperitoneal bleeding associated with at least one additional source of bleeding were retrospectively reviewed. Mean Injury Severity Score (ISS) was 49.4 ± 15.8. Univariate and multivariate analyses were performed to identify parameters associated with failure of embolization, need for additional surgery to control bleeding, and fatal outcome at 30 d.¦RESULTS: Embolization was technically successful in 35 of 36 patients (97.2%) and resulted in immediate and sustained (> 24 h) hemodynamic improvement in 29 (80.5%). Additional hemostatic surgery was necessary after embolization in six patients (16.6%). Fifteen patients (41.6%) died within 30 d. Failure to restore hemodynamic stability was correlated with the rate of administration of packed red blood cells (P = .014), rate of administration of fresh frozen plasma (FFP; P = .031), and systolic blood pressure (SBP) immediately before embolization (P = .002). The need for additional surgery was correlated with FFP administration rate before embolization (P = .0002) and hemodynamic success (P = .003). Death was correlated with Glasgow Coma Scale score at admission (P = .001), ISS (P = .014), New Injury Severity Score (P = .016), number of injured sites (P = .012), SBP before embolization (P = .042), need for vasopressive drugs before embolization (P = .037), and hemodynamic success (P = .0004).¦CONCLUSIONS: In patients in hemodynamically unstable condition, transcatheter arterial embolization effectively controls bleeding and improves hemodynamic stability. Immediate survival is related to hemodynamic condition before embolization, and 30-d mortality is mainly related to associated brain trauma.

Sports practice among adolescents with chronic health conditions.

OBJECTIVES: To compare the level of sports practice between adolescents with chronic health conditions (CHCs) and control peers and to examine the reasons given by adolescents with CHCs for not practicing any sports in comparison with the control group. DESIGN: School survey. SETTING: Postmandatory schools. PARTICIPANTS: A total of 6790 students (3275 females) aged 16 to 20 years, grouped as adolescents with CHCs (355 females, 354 males) and control peers (2920 females, 3161 males). MAIN EXPOSURE: Chronic health condition was defined using a noncategorical approach including adolescents with a chronic disease and/or a physical handicap. MAIN OUTCOME MEASURES: Sports practice, barriers to sports practice among individuals not practicing any sports, and biological, psychological, socioeducative, and physical activity characteristics. RESULTS: Males with CHCs were less likely than control males to practice sports, whereas no significant difference was observed for females. Chronically ill youth were significantly more likely to report having a CHC as a barrier for not practicing sports. However, the most frequently reported barrier was preference for other activities for males with CHCs and lack of time for control males and for females with and without CHCs. CONCLUSIONS: Having a CHC seems to influence sports practice among males but not females. We recommend that practitioners dealing with adolescents remember to take into account sports practice as part of the care of young patients with CHCs.

Long-term effect of a school-based physical activity program (KISS) on fitness and adiposity in children: a cluster-randomized controlled trial.

BACKGROUND: School-based intervention studies promoting a healthy lifestyle have shown favorable immediate health effects. However, there is a striking paucity on long-term follow-ups. The aim of this study was therefore to assess the 3 yr-follow-up of a cluster-randomized controlled school-based physical activity program over nine month with beneficial immediate effects on body fat, aerobic fitness and physical activity. METHODS AND FINDINGS: Initially, 28 classes from 15 elementary schools in Switzerland were grouped into an intervention (16 classes from 9 schools, n = 297 children) and a control arm (12 classes from 6 schools, n = 205 children) after stratification for grade (1st and 5th graders). Three years after the end of the multi-component physical activity program of nine months including daily physical education (i.e. two additional lessons per week on top of three regular lessons), short physical activity breaks during academic lessons, and daily physical activity homework, 289 (58%) participated in the follow-up. Primary outcome measures included body fat (sum of four skinfolds), aerobic fitness (shuttle run test), physical activity (accelerometry), and quality of life (questionnaires). After adjustment for grade, gender, baseline value and clustering within classes, children in the intervention arm compared with controls had a significantly higher average level of aerobic fitness at follow-up (0.373 z-score units [95%-CI: 0.157 to 0.59, p = 0.001] corresponding to a shift from the 50th to the 65th percentile between baseline and follow-up), while the immediate beneficial effects on the other primary outcomes were not sustained. CONCLUSIONS: Apart from aerobic fitness, beneficial effects seen after one year were not maintained when the intervention was stopped. A continuous intervention seems necessary to maintain overall beneficial health effects as reached at the end of the intervention. TRIAL REGISTRATION: ControlledTrials.com ISRCTN15360785.

Introduced freshwater blenny influences the diet and body condition of the invasive dice snake in Lake Geneva

Non-indigenous species can have strong impacts on biodiversity by affecting trophic relationships in their new environments. The piscivorous dice snake (Natrix tessellata) has been introduced to Geneva Lake, western Switzerland, where the endangered viperine snake (Natrix maura) is native. Local, dramatic declines in the viperine snake population might be associated with the appearance of the dice snake through dietary overlap between these 2 species, which mainly feed on bullhead (Cottus gobio). In response to this decline, a control program for dice snake was implemented in 2007 to reduce numbers of this introduced snake. In 2010, a new species of fish, the freshwater blenny (Salaria fluviatilis), which shares the same habitat as the bullhead, was introduced into Lake Geneva and has since reached high densities. We determined the impact of freshwater blenny on diet composition and body condition of dice snakes. In addition, we tested for effects of the control program on the body condition of dice snakes and viperine snakes. We collected 294 dice snakes between 2007 and 2013. Based on morphology and a genetic marker (cytochrome b gene), we determined the ®sh species contained in these snakes' stomachs. We found a drastic switch in dice snake diet following the arrival of freshwater blenny, as consumption of bullhead declined by 68% and was replaced by the blenny. In addition, the body condition of dice snakes increased significantly after the arrival of freshwater blenny. The body condition of both snake species was positively correlated with the number of dice snakes removed from the study area. This finding has important implications concerning the conservation of the endangered viperine snake, and suggests that the control program of dice snakes should be continued.

Eumelanin-based coloration and fitness parameters in birds: a meta-analysis

Although melanin is the most common pigment in animal integuments, the adaptive function of variation in melanin-based coloration remains poorly understood. The individual fitness returns associated with melanin pigments can be variable across species as these pigments can have physical and biological protective properties and genes involved in melanogenesis may vary in the intensity of pleiotropic effects. Moreover, dark and pale coloration can also enhance camouflage in alternative habitats and melanin-based coloration can be involved in social interactions. We investigated whether darker or paler individuals achieve a higher fitness in birds, a taxon wherein associations between melanin-based coloration and fitness parameters have been studied in a large number of species. A meta-analysis showed that the degree of melanin-based coloration was not significantly associated with laying date, clutch size, brood size, and survival across 26 species. Similar results were found when restricting the analyses to non-sexually dimorphic birds, colour polymorphic and monomorphic species, in passerines and non-passerines and in species for which inter-individual variation in melanism is due to colour intensity. However, eumelanic coloration was positively associated with clutch and brood size in sexually dimorphic species and those that vary in the size of black patches, respectively. Given that greater extent of melanin-based coloration was positively associated with reproductive parameters and survival in some species but negatively in other species, we conclude that in birds the sign and magnitude of selection exerted on melanin-based coloration is species- or trait-specific.

Endogenous steroid profiling in the athlete biological passport.

The Athlete Biological Passport (ABP) is an individual electronic document that collects data regarding a specific athlete that is useful in differentiating between natural physiologic variations of selected biomarkers and deviations caused by artificial manipulations. A subsidiary of the endocrine module of the ABP, that which here is called Athlete Steroidal Passport (ASP), collects data on markers of an altered metabolism of endogenous steroidal hormones measured in urine samples. The ASP aims to identify not only doping with anabolic-androgenic steroids, but also most indirect steroid doping strategies such as doping with estrogen receptor antagonists and aromatase inhibitors. Development of specific markers of steroid doping, use of the athlete's previous measurements to define individual limits, with the athlete becoming his or her own reference, the inclusion of heterogeneous factors such as the UDPglucuronosyltransferase B17 genotype of the athlete, the knowledge of potentially confounding effects such as heavy alcohol consumption, the development of an external quality control system to control analytical uncertainty, and finally the use of Bayesian inferential methods to evaluate the value of indirect evidence have made the ASP a valuable alternative to deter steroid doping in elite sports. The ASP can be used to target athletes for gas chromatography/combustion/ isotope ratio mass spectrometry (GC/C/IRMS) testing, to withdraw temporarily the athlete from competing when an abnormality has been detected, and ultimately to lead to an antidoping infraction if that abnormality cannot be explained by a medical condition. Although the ASP has been developed primarily to ensure fairness in elite sports, its application in endocrinology for clinical purposes is straightforward in an evidence-based medicine paradigm.

L'hystérie : une entité historique, un trouble psychiatrique ou une maladie neurologique? [Hysteria : an historical entity, a psychiatric condition or a neurological disease?]

Il a été suggéré que l'hystérie avait disparu et n'était qu'un concept ancien, stigmatisant et péjoratif, voire erroné, reflétant l'incapacité de la communauté médicale à établir parfois un diagnostic. Actuellement ces troubles, appelés troubles dissociatifs ou de conversion, restent pourtant une réalité clinique fréquente et invalidante pour les patients. Plusieurs études et revues ont tenté de mieux décrire la présentation clinique, mais également de mieux comprendre les mécanismes neurobiologiques impliqués dans ces troubles grâce au développement de certaines techniques d'imagerie cérébrale. Si les corrélats neurobiologiques sont mieux compris, des traitements efficaces manquent encore et seule une prise en charge multidisciplinaire (généralistes, neurologues et psychiatres) et individualisée peut apporter un bénéfice au patient. It has been suggested that hysteria had waned and was an old-fashioned, stigmatizing and false concept, reflecting the incapacity of the medical community to establish a diagnosis in certain situations. Nowadays, however, those disturbances, now referred to as conversion or dissociative disorders, still remain a frequent and incapacitating condition that every clinician faces. These past decades, several studies have tried to better describe their clinical presentation and their neurobiological mechanisms, with the help of the development of new neuroimaging techniques. If the neurobiological correlates are now better understood, efficient treatments are still lacking and only a multidisciplinary (general practitioners, neurologists and psychiatrists) and individually-tailored therapy might be beneficial to the patients.

The 'help' question doesn't help when screening for major depression : external validation of the three-question screening test for primary care patients managed for physical complaints

La dépression majeure est fréquente chez les patients qui consultent un cabinet de médecine générale. Elle reste toutefois difficile à diagnostiquer car elle est souvent masquée par une ou plusieurs plaintes physiques qui sont l'unique motif de consultation. Pour aider le médecin généraliste à démasquer ce trouble, un test de dépistage composé de deux questions a été développé et validé. Ce test indique une probabilité accrue de dépression si le patient répond positivement à au moins une des deux questions suivantes : « Est-ce que, durant le mois qui a précédé, vous vous êtes senti(e) triste, déprimé(e), désespéré(e) ? » et « Durant le mois qui a précédé, avez-vous ressenti un manque d'intérêt et de plaisir dans la plupart des activités que d'habitude vous appréciez ? ». Une troisième question, ajoutée aux deux questions ci-dessus, a été proposée récemment afin d'améliorer les performances de ce test de dépistage. Cette troisième question rend le test négatif si le patient répond négativement à la question suivante : « Souhaitez-vous de l'aide pour cela ? ». Une étude avait indiqué que l'ajout de la question supplémentaire améliorait la spécificité du test sans réduire sa sensibilité. Objectifs Il s'agissait de décrire la performance de deux tests de dépistage de la dépression majeure, composés, respectivement, de deux et de trois questions, dans une population de patients consultant dans un cabinet de médecine générale pour une plainte physique, et de les valider. Méthode Les réponses aux questions des tests de dépistage de la dépression dans la population de la cohorte SODA (Somatisation, Depression, Anxiety) ont été utilisées. Il s'agissait de patients de plus de 18 ans, sélectionnés aléatoirement, consultant pour au moins une plainte physique auprès de 24 médecins généralistes de Suisse Romande, réexaminés une année après l'inclusion dans la cohorte. Le questionnaire validé « Full Patient Health Questionnaire » a été utilisé, le même jour, pour diagnostiquer une dépression majeure. Ce résultat a été utilisé pour évaluer les performances des deux tests de dépistage en calculant la sensibilité et la spécificité, notamment. Résultats Les données de 724 / 937 patients inclus ont pu être utilisées. Un diagnostic de dépression majeure a été posé chez 9.5% des patients (n = 69). La sensibilité et la spécificité des deux questions de dépistage étaient de 91.3% (IC95% : 81.4-96.4%) et 65.0% (IC95% : 61.2-68.6%), respectivement. En ajoutant la troisième question, la sensibilité des deux questions de dépistage a diminué à 59.4% (IC95% : 47.0-70.9%) et la spécificité a augmenté à 88.2% (IC95% : 85.4-90.5%). Conclusions L'utilisation des deux questions pour le dépistage de la dépression majeure est associée à une haute sensibilité et à une basse spécificité chez des patients se présentant en cabinet de médecine générale pour une plainte physique. En ajoutant la troisième question, la spécificité augmente, mais la sensibilité diminue. Ainsi, en ajoutant la troisième question, quatre patients dépressifs majeurs sur dix ne sont pas détectés, alors que seulement un patient sur dix n'est pas détecté avec les deux questions de dépistage. Notre étude montre que le test composé de deux questions reste une méthode de choix pour le dépistage de la dépression majeure et que l'ajout de la troisième question n'est pas recommandée. Celle-ci reste toutefois pertinente dans l'incitation au dialogue sur le sujet de la dépression entre le médecin et son patient.

Barcoding human physical activity to assess chronic pain conditions.

BACKGROUND: Modern theories define chronic pain as a multidimensional experience - the result of complex interplay between physiological and psychological factors with significant impact on patients' physical, emotional and social functioning. The development of reliable assessment tools capable of capturing the multidimensional impact of chronic pain has challenged the medical community for decades. A number of validated tools are currently used in clinical practice however they all rely on self-reporting and are therefore inherently subjective. In this study we show that a comprehensive analysis of physical activity (PA) under real life conditions may capture behavioral aspects that may reflect physical and emotional functioning.¦METHODOLOGY: PA was monitored during five consecutive days in 60 chronic pain patients and 15 pain-free healthy subjects. To analyze the various aspects of pain-related activity behaviors we defined the concept of PA 'barcoding'. The main idea was to combine different features of PA (type, intensity, duration) to define various PA states. The temporal sequence of different states was visualized as a 'barcode' which indicated that significant information about daily activity can be contained in the amount and variety of PA states, and in the temporal structure of sequence. This information was quantified using complementary measures such as structural complexity metrics (information and sample entropy, Lempel-Ziv complexity), time spent in PA states, and two composite scores, which integrate all measures. The reliability of these measures to characterize chronic pain conditions was assessed by comparing groups of subjects with clinically different pain intensity.¦CONCLUSION: The defined measures of PA showed good discriminative features. The results suggest that significant information about pain-related functional limitations is captured by the structural complexity of PA barcodes, which decreases when the intensity of pain increases. We conclude that a comprehensive analysis of daily-life PA can provide an objective appraisal of the intensity of pain.