Prise en charge des sténoses carotidiennes [Management of the carotid artery stenosis].

In the western world, the carotid-artery stenosis is one of the major causes of ischemic stroke in elderly people. The principal therapeutic indication is a symptomatic stenosis > 50% in the first two weeks and the surgical approach has shown the best results. Despite inferior results to carotid endarterectomy in terms of post-operative rate of stroke and/or death, except for young patients, carotid stenting remains the best choice in patients at high surgical risk. The best medical treatment, consisting in correction of cardiovascular risk factors, statin therapy and anti-aggregation led to a drastic reduction in the annual rate of stroke associated to carotid stenosis and thus limited the surgical intervention in asymptomatic patient to men with a life expectancy of at least 5 years and a stenosis > 70%.

Carcinomes épidermoïdes de l'hypopharynx et du larynx : prise en charge fondée sur les preuves Squamous cell carcinoma of the hypopharynx and larynx: evidence-based care.

Les carcinomes épidermoïdes de l'hypopharynx et du larynx peuvent être traités par chirurgie et/ou radiothérapie en fonction de la taille tumorale. Pour les petites tumeurs, les résultats sont équivalents. Pour les tumeurs localement avancées, l'approche chirurgicale est mutilante et nécessite une (pharyngo)laryngectomie totale. La chimioradiothérapie exclusive a montré tout son intérêt mais au prix de séquelles tardives. Dans le but de diminuer ces séquelles et les mutilations, la chimiothérapie d'induction par cisplatine, docétaxel et 5FU à visée de préservation d'organe devient le standard de traitement mais il manque des études solides de comparaison de cette approche avec la chimioradiothérapie exclusive. Il n'est pas possible de conclure quant à la supériorité d'un schéma en survie globale. Quand la chimiothérapie d'induction est choisie, les modalités de potentialisation éventuelle de la radiothérapie ne sont pas établies. Squamous cell carcinomas of larynx and hypopharynx can be treated by surgery and/or radiotherapy according to tumor size. For small tumors, the results are similar. For locally advanced tumors, the surgical approach is mutilating and requires a total (pharyngo)laryngectomy. Exclusive chemoradiotherapy has shown its interest at the cost of late sequelae. In order to reduce these effects and mutilation, induction chemotherapy with cisplatin, docetaxel and 5FU for organ preservation becomes the standard treatment but there are no solid studies comparing this approach with the exclusive chemoradiotherapy. And it is not possible to conclude as to the superiority of a scheme in terms of overall survival. When chemotherapy is chosen, the modalities of any potentiation of radiation have not been yet established.

Réplication cérébrale du VIH malgré une thérapie antirétrovirale efficace: impact clinique et prise en charge [Intracerebral HIV replication despite an efficient antiretroviral treatment: clinical impact and management].

Various neurological and neuropsychological manifestations are still relatively frequently reported in HIV infected patients in the highly active antiretroviral therapy era. A fraction of them could be related to HIV replication in the central nervous system (CNS) despite adequate peripheral viral suppression. This hypothesis is supported by numerous reports of detectable HIV RNA in the cerebrospinal fluid in the context of a low or undetectable viremia in association with neurological or neuropsychological complaints. In addition, some antiviral molecules may not achieve adequate levels in the CNS, thus potentially favoring intracerebral HIV replication and even antiretroviral resistance. Neurologic manifestations in the presence of CNS HIV replication often decrease after antiretroviral treatment CNS penetration optimization.

Dust Control Using an Asphalt Emulsion, HR-196, 1977

In an effort to control fugitive dust on a gravel surfaced roadway in Boone County, a cationic asphalt emulsion was blended with warm water and applied with an asphalt distributor. The test included various application procedures. After visual observations, it was concluded that this procedure utilizing a dilute asphalt emulsion was not an effective method of dust control.

Development of an Economic Dust Palliative for Limestone Surfaced Secondary Roads, HR-297, 1990

This research project was directed at laboratory and field evaluation of sodium montmorillonite clay (bentonite) as a dust palliative for limestone surfaced secondary roads. It had been postulated that the electrically charged surfaces of the clay particles could interact with the charged surfaces of the limestone and act as a bonding agent to agglomerate fine (-#200) particulates and also to band the fine particulates to larger (+#200) limestone particles. Laboratory testing using soda ash dispersed bentonite treatment of limestone fines indicated significant improvement of compressive strength and slaking characteristics. It was recommended that the project proceed to field trials and test roads were constructed in Dallas and Adair counties in Iowa. Soda ash dispersed bentonite solutions can be field mixed and applied with conventional spray distribution equipment. A maximum of 1.5% bentonite(by weight of aggregate)can be applied at one time. Higher applications would have to be staged allowing the excess moisture to evaporate between applications. Construction of higher application treatments can be accomplished by adding dry bentonite to the surfacing material and then by dry road mixing. The soda ash water solution can then be spray applied and the treated surfacing material wet mixed by motor graders to a consistency of 3 to 4 inch slump concrete. Two motor graders working in tandem can provide rapid mixing for both methods of construction. Calcium and magnesium chloride treatments are 2 to 3 times more effective in dust reduction in the short term (3-4 months) but are prone to washboarding and potholing due to maintenance restrictions. Bentonite treatment at the 2-3% level is estimated to provide a 30-40% dust reduction over the long term(18-24 months). Normal maintenance blading operations can be used on bentonite treated areas. Vehicle braking characteristics are not adversely affected up to the 3.0% treatment level. The bentonite appears to be functioning as a banding agent to bind small particulates to larger particles and is acting to agglomerate fine particles of limestone. This bonding capability appears recoverable from environmental effects of winter, and from alternating wet and dry periods. The bentonite appears to be able to interact with new applications of limestone maintenance material and maintains a dust reduction capability. Soda ash dispersed bentonite treatment is approximately 10 times more cost effective per percent dust reduction than conventional chloride treatments with respect to time. However,the disadvantage is that there is not the initial dramatic reduction in dust generation as with the chloride treatment. Although dust is reduced 30-40% after treatment there is still dust being generated and the traveling public or residents may not perceive the reduction.

Bentonite Treatment for Economical Dust Reduction on Limestone Surfaced Secondary Roads, HR-351, 1995

This research project was directed at laboratory and field evaluation of sodium montmorillonite clay (Bentonite) as a dust palliative for limestone surfaced secondary roads. It was postulated that the electrically charged surfaces (negative) of the clay particles could interact with the charged surfaces (positive) of the limestone and act as a bonding agent to agglomerate fine (-#200) particulates, and also to bond the fine particulates to larger (+#200) limestone particles. One mile test roads were constructed in Tama, Appanoose, and Hancock counties in Iowa using Bentonite treatment levels (by weight of aggregate) ranging from 3.0 to 12.0%. Construction was accomplished by adding dry Bentonite to the surfacing material and then dry road mixing. The soda ash/water solution (dispersing agent) was spray applied and the treated surfacing material wet mixed by motor graders to a consistency of 2 to 3 inch slump concrete. Two motor graders working in tandem provided rapid mixing. Following wet mixing the material was surface spread and compacted by local traffic. Quantitative and qualitative periodic evaluations and testing of the test roads was conducted with respect to dust generation, crust development, roughness, and braking characteristics. As the Bentonite treatment level increased dust generation decreased. From a cost/benefit standpoint, an optimum level of treatment is about 8% (by weight of aggregate). For roads with light traffic, one application at this treatment level resulted in a 60-70% average dust reduction in the first season, 40-50% in the second season, and 20-30% in the third season. Crust development was rated at two times better than untreated control sections. No discernible trend was evident with respect to roughness. There was no evident difference in any of the test sections with respect to braking distance and braking handling characteristics, under wet surface conditions compared to the control sections. Chloride treatments are more effective in dust reduction in the short term (3-4 months). Bentonite treatment is capable of dust reduction over the long term (2-3 seasons). Normal maintenance blading operations can be used on Bentonite treated areas. Soda ash dispersed Bentonite treatment is estimated to be more than twice as cost effective per percent dust reduction than conventional chloride treatments, with respect to time. However, the disadvantage is that there is not the initial dramatic reduction in dust generation as with the chloride treatment. Although dust is reduced significantly after treatment there is still dust being generated. Video evidence indicates that the dust cloud in the Bentonite treated sections does not rise as high, or spread as wide as the cloud in the untreated section. It also settles faster than the cloud in the untreated section. This is considered important for driving safety of following traffic, and for nuisance dust invasion of residences and residential areas. The Bentonite appears to be functioning as a bonding agent.

Infarctus myocardique aigu: importance du "networking" dans la prise en charge initiate [Acute myocardial infarction: importance of the networking in the initial management].

Early reperfusion with prompt re-establishment of coronary blood flow improves survival in patients suffering from acute ST-elevation myocardial infarction (STEMI). Leaving systemic thrombolysis for primary percutaneous coronary intervention (PCI) is justified by clinical results in favor of PCI. Nevertheless, primary PCI necessitates additional transfer time and requires an efficient territorial networking. The present article summarizes the up-to-dated management of patients with acute STEMI and/or overt cardiogenic shock.

Surface Improvement and Dust Palliation of Unpaved Secondary Roads and Streets, HR-151, 1973

As of December 31, 1970 there were 57,270 miles of Local Secondary roads and 32,958 miles of Farm to Market roads in the Iowa secondary road system. The Local Secondary system carried a traffic load of 2,714,180 daily vehicle miles, accounting for 32% of all traffic in the secondary system. For all Local Secondary roads having some form of surfacing, 98% were surfaced with gravel or crushed stone. During the 1970 construction year 335 miles of surfaced roads were constructed in the Local Secondary system with 78% being surfaced with gravel or crushed stone. The total maintenance expenditure for all secondary roads in Iowa during 1970 amounted to $40,086,091. Of this, 42%, or $17,020,332, was spent for aggregate replacement on existing gravel or crushed stone roads with an additional 31% ($12,604,456) being spent on maintenance other than resurfacing. This amounts to 73% of the total maintenance budget and are the largest two maintenance expenditure items out of a list of 10 ranging from bridges to drainage assessments. The next largest item was 7%, for maintenance of existing flexible bases. Three concurrent phases of study were included in this project: (1) laboratory screenings studies of various additives thought to have potential for long-lasting dust palliation, soil additive strength, durability, and additive retention potential; (2) test road construction using those additives that indicated promise for performance-serviceability usage; and (3) observations and tests of constructed sections for evaluation of the additive's contribution to performance and serviceability as well as the relationship to initial costs.

Surface Improvement and Dust Palliation of Unpaved Secondary Roads and Streets, Progress Report, HR-151, 1971

A combined study of dust control and low-cost surface improvements of soil and aggregate materials for immediate (and intermediate) use as a treated surface course is being conducted in three concurrent phases: (1) laboratory screening of various additives thought to have potential for long-lasting dust palliation, soil-additive strength, durability, and additive retention potential; (2) test road construction, using those additives from the screening studies that indicate promise for performance and serviceability; and (3) observation and tests of constructed sections for evaluation of the additive's contribution to performance and serviceability as well as relationship to initial costs. A brief review is presented of the problem, some methods of measuring it, previously adopted approaches to it, project field tests and a portion of the results thus far, and portions of the laboratory work accomplished in the screening studies.

Prise en charge de la pneumonie communautaire [Management of community acquired pneumonia]

Une grande partie des patients présentant une pneumonie communautaire ont un bon pronostic et peuvent être suivis dans la pratique ambulatoire moyennant un nombre limité d'examens paracliniques. Le diagnostic repose sur une clinique suggestive en présence d'un infiltrat compatible avec une pneumonie à la radiographie de thorax. Une anamnèse de voyage et une bonne connaissance de résistances locales du pneumocoque aux antibiotiques sont déterminantes pour le choix du traitement. Pour les patients de moins de 50 ans sans comorbidités et sans signes de sévérité, il est généralement recommandé de prescrire un macrolide ou une fluoroquinolone de 3e ou de 4e génération (fluoroquinolones «respiratoires»). Pour les patients plus âgés, et pour ceux qui présentent des comorbidités ou des critères de sévérité, une évaluation à l'hôpital est indiquée. La majorité des patients hospitalisés en soins généraux peuvent être traités par l'association d'une bêta-lactame et d'un macrolide, ou par une fluoroquinolone «respiratoire» seule, après prélèvements d'expectorations et de sang pour culture.

Tumeurs de l'appareil locomoteur: de la simple "bosse" a la prise en charge multidisciplinaire [Tumors of the musculoskeletal system: from the "lumps" to multidisciplinary care].

Management of musculoskeletal tumours usually begins with the appearance of a lump or bump, or the onset of unspecific symptoms. A poor initial work-up, a faulty biopsy or an inadequate resection may have a severe impact on the prognosis, including re-interventions, amputation, local recurrence or systemic spread of the disease. The patient with a suspicious lesion should be referred to a "sarcoma centers" where a planned and well-performed diagnostic work-up will allow a precise diagnosis in terms of histology and staging. After a multidisciplinary discussion of the case, an accurate treatment plan is established. Such an approach allows an adequate patient management, often with a positive impact on the survival and functional outcome.

Nouveaux aspects de la prise en charge de l'hypertension artérielle chez le patient insuffisant rénal chronique [New aspects of hypertension management in patients with chronic kidney disease].

Hypertension is a frequent finding in patients with chronic kidney disease. Whether primary or secondary to renal disease, hypertension remains an important risk factory for the progression of chronic kidney disease and the occurrence of cardiovascular events. The objective of this paper is to review different treatment strategies in hypertensive CKD patients, with the exclusion of patients with renal replacement therapy such as dialysis or renal transplantation.

Bypass gastrique: prise en charge des complications et désagrements alimentaires [Gastric bypass: management of complications and food tolerance]

La chirurgie bariatrique est le seul traitement qui permette une perte pondérale significative sur le long terme mais le succès d'une telle intervention repose avant tout dans une sélection et une préparation attentive du patient. Une bonne connaissance des implications de l'opération permet de favoriser un changement de comportement alimentaire et par là aussi de diminuer les complications et les désagréments alimentaires. L'éducation du patient n'a de sens que si elle s'inscrit dans une prise en charge pluridisciplinaire, comprenant également un suivi diététique, planifié sur le long terme. La mastication, la vitesse d'ingestion des aliments, le fait de renoncer aux boissons gazeuses et de devoir boire régulièrement entre les repas, sont les éléments les plus difficiles à mettre en place pour le patient. Bariatric surgery is the only treatment inducing effective weight loss on the long term. The success of such an intervention is possible by carefully selecting and educating the candidates. Good understanding of the bariatric surgery implications allows the patients to modify their eating habits and thus decrease complications and food intolerance. Therefore patient education requires a multidisciplinary approach which implies the follow-up of a dietician on the long term. Mastication, speed of food ingestion, avoidance of carbonated beverages as well as the obligation to drink at frequent and regular intervals are the most difficult aspects to be taught to the patients