Cardio-pulmonary interaction in premature newborn with nasal continuous positive airways pressure (n-CPAP) respiratory assistance evaluated with echocardiography

Introduction: Nasal continuous positive airways pressure (n-CPAP) is an effective treatment in premature infants with respiratory distress. The cardio-pulmonary interactions secondary to n-CPAP are well studied in adults, but less well described in premature infants. We postulated that there could be important interactions with regard to the patent ductus arteriosus (PDA). Methods: Prospective study, approved by the local ethic committee. Premature infants less than 32 weeks gestation, _7 days-old, needing n-CPAP for respiratory distress, but without the need of additional oxygen were included in the study. Every patient had a first echocardiography with n-CPAP and then n-CPAP was retrieved. 3 hours later the echocardiography was repeated by the same investigator and then the patient replaced on n-CPAP. Results: 14 premature newborn were included, mean gestational age of 28 _ 2 weeks, mean weight 1.1 _ 0.3 Kg and height 39 _ 3 cm. Echocardiographic measurements are depicted in Table 1. Significant finding were observed between measurement on n- CPAP or without n-CPAP: on end diastolic left ventricular diameter (12.8 _ 1.6 mm vs. 13.5 _ 2 mm), on end systolic left ventricular diameter (8.4 _ 1.3 mm vs. 9.1 _ 1.5 mm), left atrium diameter (8.9 _ 2.2 mm vs. 10.4 _ 2.5 mm), maximal velocity on tricuspid valve (46 _ 10 cm/s vs. 51 _ 9 cm/s), calculated Qp (3.7 _ 0.8 L/min/m2 vs. 4.3 _ 0.8 L/min/m2). Only three patients have demonstrated a PDA during the study. Conclusion: Positive end expiratory pressure (Peep) has hemodynamic effects which are: reduction of systemic and pulmonary venous return as shown by the changes on tricuspid valve inflow,on the calculated Qp and finally on the diameter of the left atrium and left ventricle.We found in premature infants the same hemodynamic effects than those described in adults but with lower Peep values. This could be due to the particular elasticity and weakness of the thoracic wall of premature infants. Interestingly the flow through a PDA seems also to be diminished with Peep, but the number of patients is insufficient to conclude. Further investigation will be needed to better understand these interactions. Table 1. Echocardiographic measurement (mean (SD)). With n-CPAP Without n-CPAP p value RV ED diameter (mm) 6.3 (1.7) 6.04 (1.1) NS LV ED diameter (mm) 12.8 (1.6) 13.5 (2.0) _0.05 LV ES diameter (mm) 8.4 (1.3) 9.1 (1.5) _0.05 SF (%) 34 (5) 33 (6) NS Ao valve diameter (mm) 7.4 (1.3) 7.4 (1.2) NS LA diameter (mm) 8.9 (2.2) 10.4 (2.5) _0.05 Vmax Ao (cm/s) 70 (16) 71 (18) NS Vmax PV (cm/s) 69 (15) 72 (16) NS Vmax TV (cm/s) 46 (10) 51 (9) _0.05 Vmax MV (cm/s) 53 (17) 54 (18) NS Qp (L/min/m2) 3.7 (0.8) 4.3 (0.8) _0.05 Qs (L/min/m2) 4.0 (0.8) 4.0 (0.7) NS Qp/Qs 0.92 (0.14) 1.09 (0.23) _0.05 RV: right ventricle, LV: left ventricle, ED: end diastolic, ES: end systolic, SF: shortening fraction,Ao: aortic valve, LA: left atrium,Vmax: maximum Doppler Velocity, Qp: pulmonary output, Qs: systemic output, NS: non significant.

Què saben els pares dels infants de 0-3 anys, sobre l'ús del rentat nasal i els inhaladors amb cambra?

Aquest estudi insisteix en la importància de l’educació sanitària dirigida als pares per tald’assegurar l’eficàcia del tractament a administrar i consolidar els coneixements i habilitats del progenitors per tal de que aquests puguin dur a terme les tècniques requerides de forma adequada.Destacar la necessitat de conscienciar a tots els professionals de la salut, sobretot els quepassen més temps amb els familiars, de la importància que té la seva competència comeducador en l’àmbit de la salut.Evidenciar la importància de fer una avaluació continuada dels coneixements i les habilitatsadquirides pels cuidadors principals, sobre com dur a terme les tècniques del rentat de nas iadministració de la medicació inhalada amb cambra i mascareta, per detectar-ne els possibleserrors i poder posar-hi mesures correctores per pal·liar-los.Constatar la utilitat de preguntar i esbrinar “in situ” què saben els progenitors sobre lestècniques a avaluar (rentat de nas i administració de la medicació inhalada amb cambra i mascareta), abans de donar qualsevol explicació o iniciar l’educació sanitària per detectar lesnecessitats específiques de cada pare o mare i poder individualitzar el procés educatiu

Comparing Bone Microarchitecture by Trabecular Bone Score (TBS) in Caucasian American Women with and Without Osteoporotic Fractures.

Several cross-sectional studies have shown the ability of the TBS to discriminate between those with and without fractures in European populations. The aim of this study was to assess the ability of TBS to discriminate between those with and without fractures in a large female Caucasian population in the USA. This was a case-control study of 2,165 Caucasian American women aged 40 and older. Patients with illness or taking medications known to affect bone metabolism were excluded. Those in the fracture group (n = 289) had at least one low-energy fracture. BMD was measured at L1-L4, TBS calculated directly from the same DXA image. Descriptive statistics and inferential tests for difference were used. Univariate and multivariate logistic regression models were created to investigate possible association between independent variables and the status of fracture. Odds ratios per standard deviation decrease (OR) and areas under the ROC curve were calculated for discriminating parameters. Weak correlations were observed between TBS and BMD and between TBS and BMI (r = 0.33 and -0.17, respectively, p < 0.01). Mean age, weight, BMD and TBS were significantly different between control and fracture groups (all p ≤ 0.05), whereas no difference was noted for BMI or height. After adjusting for age, weight, BMD, smoking, and maternal and family history of fracture, TBS (but not BMD) remained a significant predictor of fracture: OR 1.28[1.13-1.46] even after adjustment. In a US female population, TBS again was able to discriminate between those with and those without fractures, even after adjusting for other clinical risk factors.

Ostéoporose : les fractures non traumatiques de la personne âgées

La survenue d'une fracture non traumatique chez la personne âgée a un impact humain, médical et économique important. L'amélioration des connaissances et des moyens à disposition pour sa prise en charge doivent nous inciter à mettre en place une stratégie multidisciplinaire personnalisée et précoce (comprenant un médecin spécialisé dans les maladies osseuses qu'il soit rhumatologue, endocrinologue, interniste/généraliste, gériatre, et al.).

Use of trochanteric nail for proximal femoral extracapsular fractures.

Proximal femoral extracapsular fractures have shown a significantly high morbidity and mortality rate at 1 year in cases of nonoperative treatment. The standard gamma nail was originally designed to provide stable fixation and allow early mobilization and weight bearing for elderly patients. The design of the standard gamma nail, however, appears to be associated with intraoperative or postoperative femoral shaft fractures in < or = 17% of patients, compromising the outcome. The trochanteric nail was developed to overcome the problems encountered with the use of the standard gamma nail. Between July 2000 and January 2001, 88 consecutive proximal femoral extracapsular fractures were treated with a trochanteric nail, Seventy-five patients (76 fractures) were observed clinically and radiographically for 2 years.

Comparison of three bone ultrasounds for the discrimination of subjects with and without osteoporotic fractures among 7562 elderly women.

Bone ultrasound measures (QUSs) can assess fracture risk in the elderly. We compared three QUSs and their association with nonvertebral fracture history in 7562 Swiss women 70-80 years of age. The association between nonvertebral fracture was higher for heel than phalangeal QUS. INTRODUCTION: Because of the high morbidity and mortality associated with osteoporotic fractures, it is essential to detect subjects at risk for such fractures with screening methods. Because quantitative bone ultrasound (QUS) discriminated subjects with osteoporotic fractures from controls in several cross-sectional studies and predicted fractures in prospective studies, QUS could be more practical than DXA for screening. MATERIAL AND METHODS: This cross-sectional and retrospective multicenter (10 centers) study was performed to compare three QUSs (two heel ultrasounds: Achilles+ [GE-Lunar] and Sahara [Hologic]; the phalanges: ultrasound DBM sonic 1200 [IGEA]) for determining by logistic regression nonvertebral fracture odds ratio (OR) in a sample of 7562 Swiss women, 75.3 +/- 3.1 years of age. The two heel QUSs measured the broadband ultrasound attenuation (BUA) and the speed of sound (SOS). In addition, Achilles+ calculated the stiffness index (SI) and the Sahara calculated the quantitative ultrasound index (QUI) from BUA and SOS. The DBM sonic 1200 measured the amplitude-dependent SOS (AD-SOS). RESULTS: Eighty-six women had a history of a traumatic hip fracture after the age of 50, 1594 had a history of forearm fracture, and 2016 had other nonvertebral fractures. No fracture history was reported by 3866 women. Discrimination for hip fracture was higher than for the other nonvertebral fractures. The two heel QUSs had a significantly higher discrimination power than the QUSs of the phalanges, with standardized ORs, adjusted for age and body mass index, ranging from 2.1 to 2.7 (95% CI = 1.6, 3.5) compared with 1.4 (95% CI = 1.1, 1.7) for the AD-SOS of DBM sonic 1200. CONCLUSION: This study showed a high association between heel QUS and hip fracture history in elderly Swiss women. This could justify integration of QUS among screening strategies for identifying elderly women at risk for osteoporotic fractures.

Acute total hip arthroplasty for acetabular fractures in the elderly: 11 patients followed for 2 years.

We describe the use of cable fixation and acute total hip replacement for acetabular fracture in the elderly. 12 patients with acetabular fractures, having a mean age of 79 (65-93) years, were treated with cable fixation and acute total hip arthroplasty. 8 were T-shaped fractures and 4 associated fractures of the posterior column and posterior wall. 1 patient died 5 months after surgery and the remaining 11 were followed for 2 years. All patients had a good clinical outcome. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This surgical technique provides good primary fixation, stabilizes complex acetabular fractures in elderly patients with osteoporotic bone and permits early postoperative mobilization.

Fractures dorsales du triquetrum : avulsion ou conflit ulno-carpien? Aspects IRM 3T et lésions associées.

Objectifs: Déterminer les caractéristiques en IRM 3T et discuter l'étiologie des fractures dorsales du triquetrum. Evaluer les lésions associées, notamment des ligamentsextrinsèques dorsaux.Matériels et méthodes: Etude rétrospective (septembre 2007 - décembre 2010) incluant 18 patients avec radiographies conventionnelles et IRM du poignet à 3T présentant une fracturedorsale du triquetrum. Protocole IRM comprenant une séquence T1-VIBE coronale haute résolution (0,3mm) isotropique avec suppression de graisse et aprèsinjection intraveineuse de Gadolinium. Lecture consensuelle par 2 radiologues évaluant les caractéristiques suivantes : taille et déplacement du fragment osseux,localisation de l'oedème médullaire, lésion des ligaments extrinsèques dorsaux (radio-triquetral, scapho-triquetral et ulno-triquetral), autres lésions associées.Inclusion d'un groupe contrôle de 20 patients, afin d'évaluer localisation et visibilité des enthèses ligamentaires extrinsèques dorsales .Résultats: Identification de 14 lésions ligamentaires scapho-triquetrales, 12 ulno-triquetrales et 8 radio-triquetrales, corrélées à la localisation de l'oedème osseux. Absenced'oedème de la styloïde ulnaire évocatrice de conflit. Volume moyen des fragments de 210 mm3, avec déplacement le plus fréquemment distal. Dans le groupecontrôle, visibilité des ligaments scapho-triquetral, radio-triquetral et ulno-triquetral dans respectivement 100% (20/20), 90% (18/20) et 70% (14/20) des cas.Conclusion: L'IRM 3T permet d'évaluer précisément les fractures dorsales du triquetrum et leurs lésions associées , y compris la distribution des oedèmes osseux. Cesfractures auraient donc une étiologie mixte.

Long-term outcome of preterm infants treated with nasal continuous positive airway pressure

RESUME La ventilation en pression positive continue (Continuous Positive Airway Pressure, CPAP), utilisée pour la première fois chez. les prématurés en 1971, est une technique actuellement très largement utilisée dans les unités néonatales. L'utilisation de la CPAP présente de nombreux avantages à court terme: diminution de la fraction maximale inspirée d'oxygène, de la durée de l'oxygénothérapie, du taux d'intubation et donc du recours à une ventilation mécanique, réduction de l'utilisation des amines, des curares et de la morphine, possible prévention de l'apparition d'une bronchodysplasie pulmonaire, et possibles réductions du nombre d'infections postnatales et des entérocolites nécrosantes. Mais peu d'études existent concernant les effets à long terme de la CPAP sur le neurodéveloppement et la croissance, qui constituent l'objectif de la présente étude. L'utilisation systématique de la CPAP comme alternative à la ventilation mécanique a été introduite à Lausanne en 1998. La population cible de cette étude est constituée des prématurés nés à moins de 32 semaines de gestation ou pesant moins de 1500 g à la naissance; ils ont été systématiquement suivis jusqu'en âge préscolaire dans le cadre de l'étude de cohorte «Unité de Développement, CHUV». L'originalité de ce travail réside dans le fait d'évaluer le neurodéveloppement et la croissance à long terme d'enfants prématurés traités préférentiellement avec la CPAP, en comparaison avec un groupe historique contrôle traité par d'autres modes ventilatoires, en tenant compte de nombreux autres paramètres néonataux. Du point de vue du neurodéveloppement, l'usage, de la CPAP montre une tendance à diminuer l'incidence d'hémorragie intraventriculaire et le risque d'avoir un mauvais neurodéveloppement à 6 mois. Ces résultats positifs sur le neurodéveloppement s'estompent à l'âge de 18 mois, où persiste néanmoins une valeur plus élevée du quotient de développement, et disparaissent complètement en âge préscolaire. Du point de vue de la croissance, l'utilisation de la CPAP ne montre aucun effet sur le poids, mais par contre un effet positif sur la taille à 6 et 18 mois et sur le périmètre crânien à 6 mois, 18 mois et en âge préscolaire. Malgré le caractère non randomisé de cette étude, les résultats positifs obtenus ici permettent sans conteste de s'assurer d'une utilisation de la CPAP sans effet négatif sur le neurodéveloppement et la croissance, et fournissent donc un argument supplémentaire pour l'utilisation systématique de la CPAP chez les prématurés.

Use of trochanteric nail for proximal femoral extracapsular fractures

Résumé Les fractures extra capsulaires du fémur proximal sont connues pour le risque élevé de morbidité et de mortalité en cas de traitement non chirurgical. Ainsi, le clou Gamma standard a été produit pour garantir une fixation stable de ces fractures permettant par conséquent une mobilisation rapide et en charge des personnes en âge avancé et présentant ce genre de fracture. Mais il a été reproché à ce type de clou un nombre relativement élevé de fracture per ou post opératoire (environ 17%). Cette complication est liée au design de cet implant. Et, de ce fait, le clou Trochantéric a été créé pour remédier à cette complication en changeant la forme du clou et notamment sa courbure. Entre juillet 2000 et janvier 2001, 88 patients ont été traités par clou Trochantéric pour une fracture pertrochantérienne et suivis consécutivement dans notre Service. 75 patients, soit 76 fractures, ont pu être évalués cliniquement et radiologiquement durant une évolution de deux ans.

Closed and open grade I and II tibial shaft fractures treated by reamed intramedullary nailing

RESUME Objectif : Le but de cette étude est d'évaluer les résultats du traitement par enclouage centre-médullaire alésé des fractures diaphysaires du tibia aussi bien fermées que pour les fractures ouvertes de stade I et II selon Gustillo. Méthodes: Entre 1997 et 2000, 119 patients présentant une fracture diaphysaire du tibia ont été traités dans notre service par un enclouage centre-médullaire alésé. En postopératoire, 96 patients, soit 70 fractures fermées et 26 fractures ouvertes I et II selon Gustillo, ont été suivis cliniquement et radiologiquement pour une période de plus d'une année et demi. L'introduction du clou centro-médullaire a été faite selon la technique habituelle, soit transtendineuse ou paratendineusé rotulienne. Tous les clous ont été alésés jusqu'à 1,5 mm au-dessus du diamètre du clou. Les patients ayant une fracture isolée du tibia ont été immédiatement mobilisés en charge partielle pour une période de 6 semaines. Ceux qui avaient des lésions associées, notamment au niveau de la cheville épsilatérale, ont nécessité la mise en place d'un plâtre de Type Sarmiento. Résultats : Six patients (6,3%) ont développé un syndrome des loges après chirurgie. Quarante-huit cas (50%) ont nécessité une dynamisation du clou après une période moyenne de 12 semaines en raison d'un retard de consolidation. En général, 90,6% des fractures ont consolidé après 24 semaines postopératoires en moyenne, sans aucune différence significative entre les fractures fermées et les fractures ouvertes. Deux patients (2,1 %) présentant une fracture ouverte degré II ont développé une infection profonde ayant nécessité un traitement. Nous avons également observé 9,4% de cals vicieux minimes et sans conséquence clinique. Huit patients (8,3%) ont eu une brisure des vis de .verrouillage mais également sans conséquence clinique. Au dernier contrôle, 52% des patients, dont ('introduction du clou s'est faite en transtendineux ont des douleurs antérieures du genou contre 14% parmi ceux où l'introduction était paratendineuse. Conclusion : L'enclouage centre-médullaire reste le traitement de choix pour les fractures diaphysaires du tibia, qu'elles soient fermées ou ouvertes degré I ou II selon Gustillo.

Outcome after surgical treatment of symptomatic delayed unions and nonunions of midshaft clavicle fractures

Introduction: Nonoperative treatment of displaced midshaft clavicle fractures is associated with higher nonunion rate than previously reported. Moreover, its occurrence can compromise shoulder function. The aim of this study was to evaluate the outcome of surgical treatment of symptomatic clavicle midshaft delayed and nonunion. Methods: Between 1999 and 2008, 19 clavicle delayed unions and nonunions were treated by open reduction and reconstructive plate fixation with augmentation by autologous bone graft. Iliac bone graft was used in 15 atrophic cases, and graft from the callus was used in 4 hypertrophic nonunions. There were 14 men and 5 women, with an average age of 41 years (range, 19 to 59 years) at time of surgery. No patient had undergone a previous surgery and all complained of shoulder pain. Delayed unions and nonunions were defined as non-healing after 3 and 6 months respectively. The mean time to surgery was 8 months (range, 4 to 23 months). All patients were pre and postoperatively clinically evaluated and imaged with standard radiographs until complete healing. Results: After a mean time of 3 months (range, 2 to 7 months) all fractures were completely healed. All patients reported full range of motion at time of last follow-up. Nine patients (47%) reported slight shoulder pain but all returned to their previous professional activities after a mean time of 3 months (range, 1 to 8 months). We reported 12 (63%) minor complications. There were 6 (32%) plate-related discomforts which resolved after hardware removal, two (11%) scar numbness, two (11%) adhesive capsulitis with spontaneous complete recovery, and two (11%) AC-joint pain treated successfully with local corticosteroids injection. Conclusion: Surgical treatment of delayed unions and nonunions of midshaft clavicle fractures yields satisfactory results and a high union rate. However, 50% of the patients may still complain of slight residual shoulder pain.

Effect of Lactobacillus paracasei ST11 on a nasal provocation test with grass pollen in allergic rhinitis.

Cite this as: J. Wassenberg, S. Nutten, R. Audran, N. Barbier, V. Aubert, J. Moulin, A. Mercenier and F. Spertini, Clinical & Experimental Allergy, 2011 (41) 565-573. SUMMARY: Background Probiotics have been associated with prevention and improvement of symptoms in atopic diseases such as atopic dermatitis. However, few studies exist that document their efficacy for upper airways allergies such as allergic rhinitis. Objective To investigate the effect of short-term oral administration of Lactobacillus paracasei ST11 on a nasal provocation test (NPT) with grass pollen. Methods Thirty-one adult volunteers with allergic rhinitis were enrolled in a randomized, double-blind, placebo-controlled study, based on two 4-week cross-over periods of product consumption (ST11-fermented milk vs. placebo), separated by a wash-out period of 6-8 weeks. Objective and subjective clinical parameters of NPT as well as systemic and nasal immunological parameters were compared between the two treatment periods (registration number: NCT 011 50 253). Results Subjects that received ST11-fermented milk had lower nasal congestion than subjects under placebo (visual analogical scale; P<0.05). Nasal pruritus followed the same trend. However, no significant change in combined nasal reaction threshold was observed between the two periods. IL-5 secretion by peripheral blood mononuclear cells and serum allergen-specific IgG4 were significantly lower in ST11-fermented milk group compared to placebo group. IL-8 and IL-10 secretion followed the same trend. Conclusion and Clinical Relevance Short-term treatment with ST11-fermented milk before NPT significantly improved a clinical marker of NPT (subjective nasal congestion) and down-regulated systemic immune markers (IL-5 from peripheral blood mononuclear cells and serum IgG4). These data strongly suggest that probiotics may down modulate key parameters of allergic rhinitis and warrant future evaluation in seasonal trials.

Assessment of volumetric bone mineral density of the femoral neck in postmenopausal women with and without vertebral fractures using quantitative multi-slice CT.

OBJECTIVE: To demonstrate the validity and reliability of volumetric quantitative computed tomography (vQCT) with multi-slice computed tomography (MSCT) and dual energy X-ray absorptiometry (DXA) for hip bone mineral density (BMD) measurements, and to compare the differences between the two techniques in discriminating postmenopausal women with osteoporosis-related vertebral fractures from those without. METHODS: Ninety subjects were enrolled and divided into three groups based on the BMD values of the lumbar spine and/or the femoral neck by DXA. Groups 1 and 2 consisted of postmenopausal women with BMD changes <-2SD, with and without radiographically confirmed vertebral fracture (n=11 and 33, respectively). Group 3 comprised normal controls with BMD changes > or =-1SD (n=46). Post-MSCT (GE, LightSpeed16) scan reconstructed images of the abdominal-pelvic region, 1.25 mm thick per slice, were processed by OsteoCAD software to calculate the following parameters: volumetric BMD values of trabecular bone (TRAB), cortical bone (CORT), and integral bone (INTGL) of the left femoral neck, femoral neck axis length (NAL), and minimum cross-section area (mCSA). DXA BMD measurements of the lumbar spine (AP-SPINE) and the left femoral neck (NECK) also were performed for each subject. RESULTS: The values of all seven parameters were significantly lower in subjects of Groups 1 and 2 than in normal postmenopausal women (P<0.05, respectively). Comparing Groups 1 and 2, 3D-TRAB and 3D-INTGL were significantly lower in postmenopausal women with vertebral fracture(s) [(109.8+/-9.61) and (243.3+/-33.0) mg/cm3, respectively] than in those without [(148.9+/-7.47) and (285.4+/-17.8) mg/cm(3), respectively] (P<0.05, respectively), but no significant differences were evident in AP-SPINE or NECK BMD. CONCLUSION: the femoral neck-derived volumetric BMD parameters using vQCT appeared better than the DXA-derived ones in discriminating osteoporotic postmenopausal women with vertebral fractures from those without. vQCT might be useful to evaluate the effect of osteoporotic vertebral fracture status on changes in bone mass in the femoral neck.