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Résumé Introduction Le pronostic des infections ostéoarticulaires (IOA) s’est amélioré depuis 20 ans mais peut encore être sévère. Le traitement s’est simplifié et raccourci. En 2008, le Groupe de pathologie infectieuse pédiatrique (GPIP) a établi de nouvelles propositions pour le standardiser en France. L’objectif de cette étude était d’analyser les pratiques dans un hôpital pédiatrique et l’efficacité de ce traitement à court et moyen termes. Matériels et méthodes Il s’est agi d’une étude rétrospective sur l’année 2012 concernant les patients de plus de 3 mois sans comorbidité, hospitalisés à l’hôpital Trousseau (Paris) pour une IOA aiguë, dont le suivi avait été d’au moins 4 semaines. Résultats Soixante-quatre enfants sur 156 ont été retenus pour l’analyse. Le diagnostic d’IOA aiguë avait été confirmé bactériologiquement (29/64) ou présumé sans preuve bactériologique (35/64). L’âge médian était de 22 mois et 78 % des patients étaient fébriles. Trente-cinq (54,7 %) enfants avaient eu une arthrite, 21 (32,8 %) une ostéomyélite aiguë (OMA), 7 (10,9 %) une ostéoarthrite, 1 une spondylodiscite. Les localisations préférentielles avaient été le genou et la hanche. Soixante et un pour cent des arthrites avaient été diagnostiquées grâce à l’échographie, 54 % des ostéomyélites par la scintigraphie. Les deux germes principaux identifiés avaient été Kingella kingae (62,1 %) et Staphylococcus aureus (24,1 %). Dans 98 % des cas, les enfants avaient reçu un traitement par céfamandole associé ou non à de la gentamicine pour une durée médiane de 3 jours (1–10) par voie intraveineuse. Il y avait eu le plus souvent un relais oral par amoxicilline-acide clavulanique pendant 6 semaines, en association avec de la rifampicine sans justification dans 40 % des cas. La durée médiane du suivi avait été de 13 semaines, et le taux de succès du traitement avait été de 86 %. Conclusion L’étude de nos pratiques a montré que les propositions du GPIP n’étaient pas appliquées strictement, le traitement oral étant trop long et non conforme aux recommandations. La tendance actuelle va vers des traitements raccourcis de 10 à 20 jours, avec une phase parentérale plus courte. Summary Introduction The prognosis of osteoarticular infections has improved over the past 20 years but it still remains potentially severe. The treatment of these infections has been simplified and shortened. In 2008, the Pediatric Infectious Disease Group (GPIP) established new therapeutic guidelines in order to standardize treatment in France. The aim of this study is to analyze practices in a Parisian hospital and assess the efficacy of this treatment in short and medium terms. Materials and methods This retrospective study focused on patients older than 3 months, without comorbidities, who were hospitalized for an acute osteoarticular infection in 2012 at Trousseau Hospital (Paris), with a follow-up of at least 4 weeks. The patients were selected from the hospital register. Results The study included 64 patients of 156, who were admitted for examination with a diagnosis of acute osteoarticular infection, bacteriologically confirmed (29/64) or presumed on the basis of bacteriological evidence (35/64). The median age of the patients was 22 months. Of the patients, 78 % were febrile; 35 patients had arthritis (54.7 %), 21 osteomyelitis (32.8 %), seven osteoarthritis (10.9 %), and one spondylitis. Preferential localizations were the knees and hips; 61 % of arthritis cases were diagnosed with ultrasound, 54 % of osteomyelitis cases with scintigraphy. The two main microorganisms found were Kingella kingae (62.1 %) and Staphylococcus aureus (24.1 %). In 98 % of cases, patients were treated by cefamandole, with or without gentamicine, for a median duration of 3 days (1–10) intravenously, with oral relay by amoxicillin-clavulanic acid, for a total duration of 6 weeks, but in association with rifampicin in 40 % of cases without explanation. The median follow-up was 13 weeks, with a treatment success rate of 86 %. Conclusion The study of local practices showed us that the GPIP guidelines are not followed, with the duration of oral treatment being too long. The trend in therapy is toward short treatments of 10–20 days, with a shorter intravenous phase. [ABSTRACT FROM AUTHOR]

Résumé Objectifs L’objectif était, dans le cadre d’une évaluation des pratiques professionnelles, de comparer la prise en charge en salle d’accueil des urgences vitales (SAUV) d’enfants gravement traumatisés dans un centre de traumatologie pour adultes à compétence pédiatrique et un centre exclusivement pédiatrique. Type d’étude Étude rétrospective monocentrique comparative sur un modèle avant-après. Patients et méthodes Cinquante-neuf enfants âgés de 1 à 15 ans, gravement traumatisés, admis dans le centre pour adultes (2005–2007) ont été comparés à 56 enfants admis dans le centre pédiatrique (2010–2012). Les données épidémiologiques et accidentologiques, les scores de gravité, le devenir et la durée en SAUV ont été recueillis et comparés. Résultats Il n’y avait pas de différence de prise en charge des enfants entre le centre pédiatrique et le centre pour adultes ayant un haut volume d’activité et une compétence pédiatrique en termes de durée en SAUV (28 min [18–40] vs 26,5 min [21–36], p = 0,89) et de mortalité précoce (8 enfants [13,5 %] vs 10 enfants [17,8 %], p = 0,35). Conclusion Ce travail a permis de valider l’organisation de notre SAUV pédiatrique. L’efficacité de la prise en charge des enfants de 1 à 15 ans en SAUV pour adultes ayant un gros volume d’activité et en SAUV pédiatrique semble similaire. Summary Objective To compare management of injured children in an adult trauma center (TC) with competencies in pediatric trauma care (2005–2007) and in a pediatric-only trauma center (2010–2012). Study design A before-after retrospective study. Patients and methods Fifty-nine children between 1 and 15 years of age admitted to the adult TC (2005–2007) were compared to 56 children admitted to the pediatric TC (2010–2012). Epidemiological data, severity scores, early outcome, and care duration in trauma resuscitation before whole-body CT were collected and compared between the two periods. Results This study found no significant differences between the two periods in terms of care duration before the whole-body CT scan (28 min [18–40] vs 26.5 min [21–36], P = 0.89) and early mortality (eight children [13.5%] vs ten children [17.8%], P = 0.35). Conclusion With no differences in early management of injured children demonstrated, this study validates the organization within our pediatric trauma center. The effectiveness of management of children between 1 and 15 years of age with severe trauma seems to be similar in the two contexts. [ABSTRACT FROM AUTHOR]

Introduction Une patiente de 36 ans présente un rhumatisme psoriasique depuis 15 ans, assez calme puisque sensible aux anti-inflammatoires non stéroïdiens, avec peu de manifestations cutanées. Observation Les uvéites antérieures récidivantes posent problème chez cette patiente avec au moins 3 épisodes par an, avec extension au pôle postérieur et nécessité d’une corticothérapie orale à chaque poussée. Un traitement de fond par méthotrexate ne prévient pas les récidives. Un traitement par anti-TNF est tenté, tout d’abord des perfusions d’infliximab, qui se soldent dès la troisième par des éruptions cutanées prurigineuses. Un remplacement par adalimumab provoque le même effet secondaire allergique. Il est décidé de changer de classe de biothérapie, par crainte de la récidive de cet effet secondaire avec un autre anti-TNF. L’ustékinumab est introduit à la dose de 45 mg selon le schéma classique, avec une excellente tolérance. Aucune récidive d’uvéite n’est survenue au bout d’un an de traitement. Discussion L’ustékinumab est un inhibiteur des interleukines IL-12 et IL-23 agissant contre la sous-unité P40 commune à l’IL-12/23. Si la place de l’ustékinumab dans le traitement du rhumatisme psoriasique demande à être précisée, on sait que l’interleukine-23 intervient dans la pathogénie des uvéites inflammatoires [1] . Conclusion Il n’existe pour le moment pas de protocole d’essai de ce médicament pour les uvéites résistantes aux anti-TNF, ou les patients avec inflammation oculaire sévère intolérants aux anti-TNF. Une évaluation à plus grande échelle serait nécessaire. [ABSTRACT FROM AUTHOR]

Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy with neurological disorder which incidence is relatively rare. Since the discovery of the ADAMTS 13 in 1996 and the changes in the treatment (plasma exchanges and rituximab), the prognosis of the TTP has considerably improved. We report the case of a 60-year-old man with a refractory TTP. The subsequent discovery of an epiglottis neoplasia and its treatment saved the patient., (Copyright © 2012. Published by Elsevier SAS.)

Influenza virus is a negative strand RNA virus and is one of the rare RNA viruses to replicate in the nucleus. The viral RNA is associated with 4 viral proteins to make ribonucleoprotein particles (RNPs). After cell entry the RNPs are dissociated from the viral matrix protein in the low pH of the endosome and are actively imported into the cell nucleus. After translation of viral mRNAs, the proteins necessary for the assembly of new RNPs (the nucleoprotein and the three subunits of the polymerase complex) are also imported into the nucleus. Apart from these four proteins, part of the newly made matrix protein is also imported and the NEP (nuclear export protein) enters the nucleus probably through diffusion. The nuclear localisation signals on all these viral proteins and their interaction with the cellular transport system are discussed. In the nucleus, the matrix protein binds to the newly assembled RNPs and NEP then binds to the matrix protein. NEP contains the nuclear export signal necessary for transport of the RNPs to the cytoplasm for the budding of new virus particles. There appears to be a intricate ballet in exposing and hiding nuclear transport signals which leads to a unidirectional transport of the RNPs to the nucleus at the start of the infection process and an opposite unidirectional export of RNPs at the end of the infection.

Objectives: To compare O2 uptake values measured by indirect calorimetry (VO2R) with Fick-derived values (VO2Fick) over a wide range of VO2 in experimental conditions and to analyze the influence of cardiac output (QC) on the difference between VO2R and VO2Fick., Study Design: Animal study., Material: Nineteen 2.5-month-old, 29.2 +/- 2.8-kg, Large White pigs., Methods: A step-by-step decrease in venous return was obtained either by haemorrhage or progressive inferior vena cava and portal veins clamping. Measurements, of 5 to 7 minutes duration included VO2R (Deltatrac), thermodilution QC and arterial and mixed venous blood O2-content. The VO2 values were compared using Bland and Altman's bias analysis. The relationship between QC values and relative error (ER = [VO2R - VO2Fick]/0.5x[VO2R + VO2Fick] was analyzed using a Spearman rank correlation coefficient., Results: The VO2R and VO2Fick arithmetic mean ranged from 108 to 253 mL.min-1 in 130 measurements with broad limits of agreement between both methods. On average, VO2R values were higher than VO2Fick values by +15 +/- 25 mL.min-1. ER significantly decreased with QC (rs = 0.417; P = 0.0001)., Conclusion: VO2R values exceed VO2Fick values. This bias does not occur in the low QC range, presumably owing to artifactual over estimation of thermodilution QC.

Perioperative intensive care has several objectives in the context of liver transplantation. Prior to the operation, it is essential for the management of fulminant hepatic failure in order to limit the consequences of cerebral oedema. During the operation, intensive care consists of monitoring and correction of the occasionally severe circulatory and metabolic disorders induced by vascular exclusion of the liver and revascularization of the cold, ischaemic, orthotopic transplant. The possibility of major haemorrhage requiring massive transfusion with stored blood aggravates these disorders. Complex clotting disorders also play an important role; their mechanism is imperfectly understood and they are difficult to control. The severity of the problems encountered after the operation depends on graft function.

The goal of this study was to identify high-risk groups for cytomegalovirus infection after liver transplantation. Sixty-one patients were evaluated. Twenty-five patients (41 percent) had infection. Among the 16 patients who were seronegative for the virus before transplantation, 11 received a liver graft and blood products from seronegative donors and none of them developed infection. All seronegative recipients of a liver from seropositive donors (5/5) developed primary infection. Among the 45 patients seropositive before transplantation, 20 developed a cytomegalovirus infection, whatever the donor serologic status. The incidence of symptomatic reactivation or reinfection was high (14/20), and, for 12/14 of them, associated with early acute rejection. Two high-risk groups of patients, eligible for cytomegalovirus prophylaxis, were identified: seronegative recipients of seropositive donors and seropositive recipients with early acute rejection.

In pediatric liver transplantation, hepatic artery thrombosis usually leads to graft loss, early due to hepatic necrosis when it occurs during the first week following the transplant procedure, or later due to biliary complications. Liver retransplantation is the usual attitude. However, urgent surgical hepatic arterial thrombectomy to restore the blood flow can be successful when early diagnosis is made with Doppler ultrasound examination and angiography. Four hepatic arterial thrombectomies were performed as an emergency with additional intra-hepatic arterial fibrinolytic treatment, in three children, 1.5, 3 and 5.5 years of age. Mean duration between the first signs of hepatic artery thrombosis and thrombectomy was 16 hours. None of the children had an urgent liver retransplantation. A complete success was obtained in one case, with normal liver function tests and patent hepatic artery on the Doppler ultrasound examination at the present time. In the two other cases, hepatic artery thrombosis recurred, in spite of repeated thrombectomy in one case; following this attempt complications of hepatic artery thrombosis occurred in the two patients: ischemic necrosis of the left lobe (1 case), biliary leak (1 case) and stenosis of the common bile duct (2 cases). A complete success in one case and a partial success in the two others lead us to advocate urgent thrombectomy and in situ fibrinolytic treatment when early diagnosis of hepatic artery thrombosis is made.

Recent improvements in the results of orthotopic liver transplantation (OLT) have made this a well-accepted treatment for patients with severe hepatic failure. Current problems encountered following OLT are discussed. Immediate complications comprise surgical bleeding, primary graft non-function, and graft failure due to hepatic artery occlusion. Secondary complications are frequent. Surgical ones include biliary and vascular (hepatic artery thrombosis most often) problems, as well as intra-abdominal abscesses associated with gastrointestinal perforation, biliary leak, graft ischaemia or an infected haematoma. 40% of patients having undergone OLT will be reoperated on, 2/3 of them within 3 months. Non-surgical complications are mostly pulmonary. The risk of pneumonitis is increased by prolonged mechanical ventilation; it is always potentially disastrous in the immunosuppressed, transplanted patient. Hypertension is also often seen in the early postoperative period; it requires prompt treatment. Early renal impairment after OLT is common, and of better prognosis than late onset renal failure, which is generally associated with shock, graft failure, sepsis or use of nephrotoxic agents. Seizures, usually only one, occur in about 10% of patients; recovery is complete. Encephalopathy with intracranial oedema related to fulminant hepatitis has a worse prognosis, but survival figures are quite encouraging. Three type of rejection are described after OLT: 1) severe accelerated rejection (very rare), 2) acute rejection encountered in about 70% of patients over the first 3 months, and 3) late rejection, which can lead to the vanishing bile duct syndrome (VBDS). Diagnosis of rejection is made by liver biopsy. Prophylactic immunosuppression includes cyclosporin, methylprednisolone and azathioprine. Cyclosporin toxicity and drug interactions are reviewed. Treatment of acute rejection episodes comprises an initial bolus of high doses of corticoid drugs; if there is no response, antilymphocyte globulin or monoclonal antibodies may have to be used. Infection is the main cause of death following OLT. Early infections, mostly intra-abdominal and pulmonary, are bacterial or fungal. Vital (especially CMV) and other opportunistic infections occur generally after the second week. Retransplantation, carried out in 10 to 25% of patients, may be urgent in case of primary graft failure, or hepatic artery thrombosis associated with graft failure, or hepatic artery thrombosis associated with graft failure. Other indications are early graft rejection with severe hepatic dysfunction, chronic rejection with severe VBDS, and recurrence of the initial disease.

This report adds three cases to those previously published of paradoxical reactions to benzodiazepines. The clinical syndrome, more or less complete, is fairly stereotyped, with behavioural disorders, tendency to feelings of hostility and aggressiveness and total anterograde amnesia. Personal and environmental factors seem to play a prominent role in its development. The classical contra-indication of benzodiazepines following such reactions is discussed, and the hypothesis that mamillary-thalamic benzodiazepine receptors play a part in their genesis is envisaged.

Extracorporeal shock-wave lithotripsy (ESWL) is a new non-invasive procedure allowing disintegration of upper urinary tract calculi, usually carried out in epidural anaesthesia (EA). The patient strapped to a stretcher is immersed in a bath. At the bottom of the tube is the shock-wave generator. The release of shock waves (1,000 to 2,000 for each treatment) is triggered by the R-wave of the patient's ECG. Arrhythmias and extrasystoles (ES) may occur. In the investigational trial, the preferred anaesthesia was continuous lumbar EA with a large volume of 2% lidocaine extended to the level of T6. This study was conducted to assess continuous thoracic EA at the T12 interspace with a lesser dose (12 ml) of 2% lidocaine (XT, comparing it with single dose EA with the same volume of three other agents: bupivacaine 0.5% (Ma) and mixtures of 2% lidocaine-0.2+ tetracaine (XT), and 2% lidocaine-fentanyl 50 micrograms (XF), all with 1/200,000th adrenaline. Eighty patients (ASA class I or II) were assigned randomly to receive one of the four types of EA. All were monitored with Holter's method. The demographic distribution was similar for the four groups. Mean duration of the procedure was 32 +/- 15 min. Premedication was given only in 16 patients, very anxious. The results were excellent in 68 patients; 11 had to be supplemented with one or two doses of intravenous agents: diazepam and/or fentanyl: one failure was given an intravenous general anaesthesia. Mild hypotension occurred in four patients. 242 ES occurred in 48 patients (60%).(ABSTRACT TRUNCATED AT 250 WORDS)