Drogues récréatives: le plaisir des complications [Recreational drugs: the complication's pleasure?].

Steadily increasing since 1990, the use of psychoactive substances was expanded to new designer drugs (bath salts, spice) with so original still unknown pharmacological effects. At the beginning, the pleasure, first feeling, turns sometimes, in acute medical emergency and then, in some cases, in chronic diseases. Side expected or not desired effects, seen in emergency departments could be necrotizing gangrene among consumers Krokodil or dystonic reactions in consumers of Spice. Moreover, adulterants could increase the dangerosity of the substances. Searching a toxidrome helps to find the incrimining substance.

Courbe d'apprentissage lors de la réalisation des DALKs (Deep Anterior Lamellar Keratoplasty) : pièges et complications lors de nos 20 premières procédures

Objectif Analyser les résultats, les complications et les pièges rencontrés lors de la période d'apprentissage de la technique de la DALK avec réalisation d'une Big Bubble . Matériels et Méthodes : Étude rétrospective de 20 DALKs réalisées entre 2006 et 2007. L'âge moyen était de 45.21 ans (18 à 76). Le groupe comprenait 7 hommes et 13 femmes. Les indications opératoires étaient : kératocône (n=15), leucome herpétique (n=3) et taie cornéenne post-abcès bactérien (n=2). Le suivi comprenait la MAVC pré et post-opératoire, la réfraction post-opératoire, la transparence de la greffe, la qualité de l'interface donneur/receveur, et l'analyse des complications per et post-opératoires. Résultats Parmi les 20 DALKs, 8 cas ont été transformés en kératoplastie perforante à cause d'une perforation per-opératoire de la membrane de Descemet (40 % des cas). Le suivi moyen était de 7.77 mois. Les meilleures acuités visuelles corrigées moyennes pré et post-opératoires étaient de 0.158 (0.02 à 0.4) et 0.4357 (0.25 à 0.6) pour les DALKs et de 0.125 (0.1 à 0.3) et 0.463 (0.02 à 0.8) pour les DALKs transformées en kératoplastie perforante. Les greffes étaient transparentes dans tous les cas. Dans 3 cas, des plis de l'interface ont constitués une gêne de la qualité visuelle (di ou triplopie). Un haze de l'interface a été observé dans 5 cas avec disparition progressive lors du suivi. Discussion La DALK est une technique efficace dans le traitement des atteintes stromales profondes de la cornée, elle permet de préserver l'endothélium du donneur qui est sain dans ce type de pathologie. Conclusion La réalisation de la Big Bubble lors de la dissection de la Descemet et la qualité de l'interface donneur/receveur demeurent les éléments clés d'une telle procédure. Cette technique opératoire est probablement une des techniques les plus difficiles qu'un chirurgien de la cornée ait à maîtriser.

Traitement de tla sclérose en plaques: nouveautés et complications [New treatment options in multiple sclerosis and their complications].

A new therapeutic era opened for multiple sclerosis (MS) with the appearance of molecules given p.o. and/or molecules with greater efficiency. Early diagnosis is critical, as the time and the choice of therapeutic intervention. The initiation of treatments must be personalized, including the risks associated with MS and those potentially related to the treatment chosen, answering the question <Who, when and how to treat?>. Monitoring tools that allow to objectively evaluate: I) MS activity and aggressiveness for each patient and 2) the safety of treatments and their risks of complications, must be further investigated.

Declining labor force attachment and downward trends in unemployment and participation

The US labor market witnessed two apparently unrelated secular movements in thelast 30 years: a decline in unemployment between the early 1980s and the early 2000s,and a decline in participation since the early 2000s. Using CPS micro data and a stock-flow accounting framework, we show that a substantial, and hitherto unnoticed, factorbehind both trends is a decline in the share of nonparticipants who are at the margin ofparticipation. A lower share of marginal nonparticipants implies a lower unemploymentrate, because marginal nonparticipants enter the labor force mostly through unemployment,while other nonparticipants enter the labor force mostly through employment.

Labor market heterogeneity and the aggregate matching function

The matching function -a key building block in models of labor market frictions- impliesthat the job finding rate depends only on labor market tightness. We estimate such amatching function and find that the relation, although remarkably stable over 1967-2007,broke down spectacularly after 2007. We argue that labor market heterogeneities are notfully captured by the standard matching function, but that a generalized matching functionthat explicitly takes into account worker heterogeneity and market segmentation is fullyconsistent with the behavior of the job finding rate. The standard matching function canbreak down when, as in the Great Recession, the average characteristics of the unemployedchange too much, or when dispersion in labor market conditions -the extent to which somelabor markets fare worse than others- increases too much.

Prenatal management of monoamniotic twin pregnancies.

OBJECTIVE: To evaluate antenatal surveillance strategies and the optimal timing of delivery for monoamniotic twin pregnancies. METHODS: Obstetric and perinatal outcomes were retrospectively retrieved for 193 monoamniotic twin pregnancies. Fetal and neonatal outcomes were compared between fetuses followed in an inpatient setting and those undergoing intensive outpatient follow-up from 26 to 28 weeks of gestation until planned cesarean delivery between 32 and 35 weeks of gestation. The risk of fetal death was compared with the risk of neonatal complications. RESULTS: Fetal deaths occurred in 18.1% of fetuses (70/386). Two hundred ninety-five neonates from 153 pregnancies were born alive after 23 weeks of gestation. There were 17 neonatal deaths (5.8%), five of whom had major congenital anomalies. The prospective risk of a nonrespiratory neonatal complication was lower than the prospective risk of fetal death after 32 4/7 weeks of gestation (95% confidence interval 32 0/7-33 4/7). The incidence of death or a nonrespiratory neonatal complication was not significantly different between fetuses managed as outpatients (14/106 [13.2%]) or inpatients (15/142 [10.5%]; P=.55). Our statistical power to detect a difference in outcomes between these groups was low. CONCLUSIONS: The in utero risk of a monoamniotic twin fetus exceeds the risk of a postnatal nonrespiratory complication at 32 4/7 weeks of gestation. If close fetal surveillance is instituted after 26-28 weeks of gestation and delivery takes place at approximately 33 weeks of gestation, the risk of fetal or neonatal death is low, no matter the surveillance setting. LEVEL OF EVIDENCE: : II.

Indications, management, and complications of temporary inferior vena cava filters

PURPOSE: We describe the results of a preliminary prospective study using different recently developed temporary and retrievable inferior vena cava (IVC) filters. METHODS: Fifty temporary IVC filters (Gunther, Gunther Tulip, Antheor) were inserted in 47 patients when the required period of protection against pulmonary embolism (PE) was estimated to be less than 2 weeks. The indications were documented deep vein thrombosis (DVT) and temporary contraindications for anticoagulation, a high risk for PE, and PE despite DVT prophylaxis. RESULTS: Filters were removed 1-12 days after placement and nine (18%) had captured thrombi. Complications were one PE during and after removal of a filter, two minor filter migrations, and one IVC thrombosis. CONCLUSION: Temporary filters are effective in trapping clots and protecting against PE, and the complication rate does not exceed that of permanent filters. They are an alternative when protection from PE is required temporarily, and should be considered in patients with a normal life expectancy.

Mise en place d'un cathéter veineux central chez l'adulte. 1. Indications, précautions et complications [Bases of central venous catheterization]

La pose d'un cathéter veineux central est un geste fréquent dans un service de médecine interne. En suivant la formation des médecins-assistants, nous nous sommes aperçus que certaines questions, doutes ou craintes concernant cette procédure nous sont régulièrement adressées: «Est-ce qu'un cathéter sous-clavier peut être posé avec une thrombocytopénie modérée?»; «Quel site de ponction présente le moins de risques pour le patient?»; «Après combien de jours un cathéter doit-il être changé?». Cet article se propose de répondre à ces questions et à d'autres, en partant d'une mini-revue de la littérature actuelle. Central venous catheterization is a frequently performed procedure in internal medicine units. Residents in training frequently share the same questions, doubts and fears about this procedure : "Should I perform a subclavian catheterization in a patient with mild thrombopenia?"; "Which site has the lesser complication rate?"; "After how long does a catheter need to be replaced?". This mini-review of the current literature tries to answer this and other questions

Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications.

Splenic arterial interventions are increasingly performed to treat various clinical conditions, including abdominal trauma, hypersplenism, splenic arterial aneurysm, portal hypertension, and splenic neoplasm. When clinically appropriate, these procedures may provide an alternative to open surgery. They may help to salvage splenic function in patients with posttraumatic injuries or hypersplenism and to improve hematologic parameters in those who otherwise would be unable to undergo high-dose chemotherapy or immunosuppressive therapy. Splenic arterial interventions also may be performed to exclude splenic artery aneurysms from the parent vessel lumen and prevent aneurysm rupture; to reduce portal pressure and prevent sequelae in patients with portal hypertension; to treat splenic artery steal syndrome and improve liver perfusion in liver transplant recipients; and to administer targeted treatment to areas of neoplastic disease in the splenic parenchyma. As the use of splenic arterial interventions increases in interventional radiology practice, clinicians must be familiar with the splenic vascular anatomy, the indications and contraindications for performing interventional procedures, the technical considerations involved, and the potential use of other interventional procedures, such as radiofrequency ablation, in combination with splenic arterial interventions. Familiarity with the complications that can result from these interventional procedures, including abscess formation and pancreatitis, also is important.

The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain.

INTRODUCTION: The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes. METHODS: The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks. RESULTS: The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician. CONCLUSIONS: The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.

Atypical headache following dural puncture in obstetrics.

BACKGROUND: In obstetrics, post-dural puncture headache is a well-recognised complication. Typical symptoms include fronto-temporal or occipital headache, worsening with ambulation and improving in the decubitus position. Occasionally, patients present with non-postural headache, although relatively little is known about this atypical presentation. The purpose of this study was to determine the incidence, associated signs and risk factors for this atypical manifestation of post-dural puncture headache. METHODS: We analysed a series of 27 064 parturients having a neuraxial procedure between January 2001 and December 2010. Using data from electronic anaesthesia patient records, medical charts and a postpartum quality audit, we identified all parturients with atypical post-dural puncture headache. We assessed the incidence and used uni- and multivariate analysis to identify associated risk factors. RESULTS: Amongst 142 parturients with post-dural puncture headache, eight (5.6%, 95% CI 1.7-9.4%) had atypical non-postural headache. Associated symptoms were stiffness and pain in the cervical, thoracic or lumbar vertebral area, visual disturbances and vertigo. Significant risk factors for developing atypical signs were previous migraine, odds ratio 6.1 (95% CI 1.2-28.7), a more cephalad level of needle insertion, odds ratio 17.2 (95% CI 1.4-210.1) and identification of dural puncture by aspiration of cerebrospinal fluid from the epidural catheter, odds ratio 5.5 (95% CI 1.2-24.4). Following multivariate analysis, recognition of dural puncture by aspiration of cerebrospinal fluid from the epidural catheter was the most significant predictor of non-orthostatic postdural puncture headache. CONCLUSION: Anaesthetists should be aware of this atypical clinical presentation, particularly if there is a past history of migraine, a more cephalad level of needle insertion or identification of dural puncture by aspiration of cerebrospinal fluid from the epidural catheter.