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Chronic neutrophilic leukemia (CNL) is a rare myeloproliferative syndrome characterized by a significant increase in mature neutrophils. One of the most serious complications is the occurrence of bleeding events, which may sometimes lead to death.A 75-year-old patient presented with CNL, complicated by a severe bleeding phenotype. Biological investigations revealed platelet function defect and increase in neutrophil elastase. The follow-up was marked by an intracranial hemorrhage leading to the patient's death 7 months after diagnosis.This bleeding phenotype has been reported several times in patients with CNL. However, the pathophysiological mechanisms that cause bleeding are not yet fully understood.

L’etablissement de directives de type «Choosing Wisely » est un processus dynamique: la Societe Suisse de Medecine Intensive (SSMI) souhaite faire evoluer la medecine intensive vers une approche plus intelligente et integrant le feed-back de ses membres et d’autres societes. Cette lettre est un exemple d’une telle evolution constructive et d’une collaboration entre les societes SSMI et Societe Suisse de Nutrition Clinique (SSNC). La nutrition parenterale (NP) necessite une prescription precise et une adaptation a l’etat du patient: elle peut etre requise tres tot pendant le sejour en soins intensifs. Les avantages et les limites de la NP avant le 4e jour necessitent une evaluation minutieuse.

BACKGROUND & AIMS: This position paper summarizes theoretical and practical aspects of the monitoring of artificial nutrition and metabolism in critically ill patients, thereby completing ESPEN guidelines on intensive care unit (ICU) nutrition. METHODS: Available literature and personal clinical experience on monitoring of nutrition and metabolism was systematically reviewed by the ESPEN group for ICU nutrition guidelines. RESULTS: We did not identify any studies comparing outcomes with monitoring versus not monitoring nutrition therapy. The potential for abnormal values to be associated with harm was clearly recognized. The necessity to create locally adapted standard operating procedures (SOPs) for follow up of enteral and parenteral nutrition is emphasised. Clinical observations, laboratory parameters (including blood glucose, electrolytes, triglycerides, liver tests), and monitoring of energy expenditure and body composition are addressed, focusing on prevention, and early detection of nutrition-related complications. CONCLUSION: Understanding and defining risks and developing local SOPs are critical to reduce specific risks. ispartof: CLINICAL NUTRITION vol:38 issue:2 pages:584-593 ispartof: location:England status: published

Hypnosis for burn care was introduced in 2004 in the CHUV burn center showing great benefit for burned patients. Whereas advantages of hypnosis for the patient are well established, the impact on the medical staff remains poorly assessed. This manuscrit reviews current attested benefits of hypnosis for patients, specially for burned patients. The results of a recent study assessing the impact of hypnosis on the staffs level of stress caused by burn treatment, will also be introduced.

Essential trace elements are inorganic metalloid substances: insufficient intakes cause predictable biological and clinical alterations. Numerous factors contribute to the alterations of iron, iodine, selenium, and zinc status, such as low soil content resulting in low food content, malabsorption, or biological fluid losses. Age categories at high risk of deficit in the general population include children, pregnant and lactating women, and elderly; critical illness is a specific condition. Substitution and supplementation studies that respect physiological nutritional doses result in significant clinical benefits: improved immunity and cognitive functions, better wound healing. Supplementation with supra-nutritional doses in subjects or patients with adequate status may result in deleterious cancer and cardiovascular consequences due to their potential toxicity.

Major burns are characterized by an initial capillary leak which requires fluid resuscitation for hemodynamic stabilisation. While under-resuscitation was the major cause of death until the 80ies, over-resuscitation has become an important source of complications: abdominal compartment syndrome, escharotomies, impaired gas exchange and prolonged mechanical ventilation and hospital stay. The fluid creep started in the 90ies with an increasing proportion of the first 24 hours' fluid delivery above the 4 ml/kg/% BSA Parkland prediction. The first alerts were published under the form of case reports of increased mortality due to abdominal compartment syndrome and respiratory failure. The paper analyses the causes of this fluid creep, and the ways to prevent it, which includes rationing prehospital fluid delivery, avoiding early colloids and permissive hypovolemia.

Undernutrition is a widespread problem in the intensive care and is associated with a worse clinical outcome. Enteral nutrition is the recommended nutritional support in ICU patients. However, enteral nutrition is frequently insufficient to cover protein-energy needs. The initiation of supplemental parenteral nutrition, when enteral nutrition is insufficient, could optimize the nutritional therapy. Such a combination could allow reducing morbidity, length of stay and recovery, as well as improving quality of life and health care costs. Prospective studies are currently underway to test this hypothesis.

Gaucher disease is the most frequent lysosomal storage disease. It is a progressive chronic disease that can lead to substantial bone and joint damage and hematological cytopenias. This progressive disease severely worsens the patients' quality of life. Over the past 20 years, enzymatic treatment has considerably improved both symptoms and quality of life. Yet, bone and joint damage may be irreversible. This emphasizes the importance of rigorous follow-up so as to begin uninterrupted treatment before lesion onset. The transition from pediatric to adult care is a major concern for chronic patients. This step is often associated with follow-up problems and may lead to disease worsening. We present three cases of patients who were lost to follow-up during the transition phase. For all 3 patients, the disease notably worsened because follow-up was interrupted during this period.

Two cases of simultaneous traumatic dorsal dislocation of the interphalangeal joints of the little finger are described. In both cases the patients were managed by closed reduction and neighbour strapping followed by immediate mobilisation. At review, no complications were noted. The range of movements of all the affected joints was normal.

More and more children have extremely violent behaviour which appears about the age of 15-16 months, when walking makes their hands free. This violence is individual, can appear suddenly at anytime, and is not accompanied by guilt. It is caused by early psychological and repeated traumas, whose importance is usually underestimated: unpredictable, violent parents, exposure to the spectacle of conjugal violence, distortion of the signals emitted by the toddler. These traumas bring about specific psychological structure. The prevention of these troubles exists but is impossible to realise in France.

Aneurysmal bone cyst is a rare, benign bone tumor and its location in the carpal scaphoid has never been described in the literature. We report a clinical case illustrating this location.

Nutritional support is an essential part of ICU care. Evidence based guidelines have been developed in countries such as Canada, but their implementation is not easy. After analysing our department and observing insufficiencies in nutritional support, a multidisciplinary working group was set up. A nutrition protocol adapted to local constraints was developed, associated with intensive teaching, and further strengthened by the creation of an ICU dietician position. The evolution of indicators enables analysing impact of the protocol on clinical practice: professionals have been sensitized to feeding issues and to detection of patients at risk of underfeeding. Potential difficulties and successes are reported. In a complex setting such as the ICU, presence of a dedicated dietician is required for daily application of a feeding protocol.

The toxic epidermal necrolysis (TEN) is an immunologic reaction in the skin with apoptosis of kératinocytes: most cases are reactions against drugs. The main features of this reaction are a separation of the epidermis and erosions of the mucus membranes, associated with a reduction of the general condition with kidney and liver failure. This leads to problems similar to those observed in severely burned patients. The mortality high of patients with TEN can be reduced, if the responsible drug is immediately withdrawn and if the patient is treated in a specialized burns intensive care unit. The medical treatment to stop the chain reaction of apoptosis is still under discussion. Through a case report, this article will focus on the complexity of the treatment of patients with TEN and will point out the importance of a multidisciplinary approach.

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.

The merging of two intensive care units is a time of profound change, and constitutes a risk of mishaps. We report some aspects of such a project in our institution. The evaluation of various indicators reflecting the activity, patient's hospital pathways, mortality, as well as the use of specific techniques, has shown that no particular problem was observed during the first 9 months. Improvements in performance or productivity have not been demonstrated so far. The follow-up will permit to demonstrate long-term benefits. We believe that these observations may be of interest for other departmental or hospital reorganisations.

Underfeeding causes a significant increase of postoperative complications, particularly respiratory and infectious complications. Thoracic surgery is frequently required in patients suffering wasting diseases (cancer, COPD, cystic fibrosis), which increase the risk of malnutrition. The most important risk factors are preoperative hypoalbuminemia and BMI20. The deleterious effects of underfeeding may be corrected by a preoperative nutritional support for 7 to 15 days using oral supplements or enteral feeding: respiratory muscle strength is improved, immunity is restored, and overall complications are reduced. Therefore preoperative diagnosis of underfeeding is of utmost importance. In case of emergency surgery, the nutritional assessment on admission enables the introduction of early postoperative artificial feeding.

The authors report an aneurismal bone cyst in the second metacarpal of a 16-year-old patient. It was an aneurismal bone cyst of the agressive diffuse variety involving the proximal metaphyseal, diaphyseal and distal epiphyseal zones. Conservation of the MCP joint of the index was the priority. The authors report the technique used as well as the clinical and radiological results.

Impairment of cognitive performance is associated with an excess risk of accidents. Adaptation of driving behavior in subjects with benign cognitive disorders reduces risk of automobile accidents. Cessation of driving or at least not driving alone limits the excess accident risk for drivers with dementia. Alterations in visual field and acuity increase risk of traffic accidents. Drugs affecting vigilance and neurological, cardiovascular and osteoarticular disorders increase accident risk. Screening for these disorders in the elderly is a necessary public safety measure.

Hospital malnutrition is an insidious problem which is responsible for many complications. Critically ill patients are frequently hypermetabolic with increased nutritional requirements, and are exposed to the risk of underfeeding. The case report presents the case of a patient which stayed 22 days in the intensive care unit (ICU), and whose nutritional support failed: he ultimately died of surgical and infectious complications. An optimal support includes a early metabolic support provided as glucose-insulin-potassium infusion and antioxidant micronutrients, with an enteral nutrition initiated on days 3 or 4. It is frequently difficult to reach energy targets with exclusive enteral nutrition: if the latter is not reached after 5-6 days of enteral feeding, combination with parenteral nutrition enables worsening of the energy deficit. Transition to oral feeding is another critical event which may expose the patient to underfeeding: prescription of oral supplements and/or maintenance of overnight enteral feeding providing 50-75% of energy requirements helps overcome this period. The case illustrates the importance of monitoring daily and cumulated energy balance.

The authors report the correction of an ulnar club-hand in a 16 year-old boy who complained of recurrent wrist pain after a fracture of both bones of his left forearm treated by internal fixation at the age of nine years. Correction was achieved by progressive ulnar lengthening, using Ilizarov's method, without radius osteotomy or bone grafting. Union was achieved 2 months post-operatively. Functional outcome and cosmetic appearance were satisfying.

This study concerns 46 chronically mentally ill patients living in community support systems. Their quality of life was measured with a validated questionnaire: the "Subjective Quality of Life Questionnaire" ("SQLP"). Both patients and their care givers separately completed the same version of the questionnaire. This study first shows the feasibility of such inquiries with chronically mentally ill patients. It gives a description of the patient's feeling which is different from the usual medical point of view. The life domains the patient is very satisfied with are mostly restricted to food, material conditions, and relationship with the care-givers, but exclude the other relationships. Our data also allow to estimate the degree of agreement and disagreement between the care-givers and their patients.

The micronutriment requirements, whether trace elements (inorganic) or vitamins (organic), are tightly linked to the carbohydrate, lipid and protein metabolism, since they are involved in all metabolic pathways as cofactors. The micronutriments also have major immunological, endocrinological and antioxydant functions. Especially in the surgical patient, individual requirements may vary considerably and will be particularly increased in case of prior deficiency, anabolic states, or increased losses (burns, diarrhoea, gastric aspiration, intestinal fistulae, alcoholism, use of renal replacement techniques). In some of these settings, the micronutriment requirements will be independent from the macronutriments: this has been demonstrated for burns and intestinal fistulae. In the case of depletion prior to surgery, an isolated supplementation may be required without starting a proper nutrition. In general, micronutriment supplements will have to be started upon initiation of any artificial nutrition. After elective surgery and in absence of specific losses, the micronutriment requirements will be linked to the metabolic state of the patient and to the energy-protein intakes. This is most striking for the vitamin B group, where the requirements are indicated in mg per 1000 kcal. Vitamins A and E are also at risk in the surgical patient. Recommended micronutriment supplements have been revised in 1994. Some trace element deficiencies (Se, Cr, Mo) can initiate very serious complications and will require special caution in the perioperative period. Other deficiencies (Cu, Zn) result in more slowly evolving clinical pictures, with lesser life-threatening potential, resulting in infections and prolonged wound healing. In such cases, multi-elementary supplements are inadequate, and single element solutions supplements are required. All the micronutriments are characterized by a dose-response curve. The quantity avoiding biochemical dysfunctioning in human pathological situations has not yet been established, and it is unsatisfactory to merely compensate for the losses. This notion of biochemical dysfunctioning phase preceeding the clinical deficiency syndrome is in investigation for many nutriments, especially as the importance of some micronutriments, such as Se and vitamin E, in maintaining antioxidant defences is clearly established. The potential for preventing free radical induced overproduction of cytokines by means of nutritional strategy and enhanced antioxidant defences clearly exists, and is only at an early phase of investigation in patients. The future will be marked by the development of nutritional pharmacology based on pathology-specific micronutriment supplements.

Bennett Berger, Generations, Politics and Culture : The 1960s in the United States The notion of generation is not as useful in the analysis of social movements as that of generational unit. Generational units are formed out of the ranks of the elites of a particular age group ; they then compete in the formation of generational identity. The confusion between age cohorts and the effects they produce has been caused in part by neo-freudians like Erik Erikson and Kenneth Keniston who celebrated youth and stages of human development. In doing so they tended to reinforce the existing tendency to pander to an already privileged age group., Berger Bennett M., Weill Claudie. Générations, politique, culture. Les années soixante américaines . In: L'Homme et la société, N. 111-112, 1994. Générations et mémoires. pp. 35-50.

Recommended trace element doses during parenteral nutrition have been revised many times and increased, especially in surgical patients. Blood products are known to provide significant amounts of trace elements under certain circumstances. In intensive care patients crystalloids and colloids are also given in large amounts. This study aimed at determining the magnitude of the unrecognized trace element administrations after major burns and/or trauma. Fifteen patients burnt 36 +/- 11% (mean +/- SD) of body surface area, aged 34 +/- 8 years, admitted to the Burns Centre and 11 trauma patients with an Injury Severity Score of 29 +/- 6 points, aged 40 +/- 13 years, admitted to the surgical Intensive Care Unit in a Swiss University Hospital. Prospective study of intakes and urinary excretion from the first post-injury day (D1) to D7. Copper and zinc were analyzed by flame atomic absorption spectrophotometry, and selenium by fluorimetry. The actual trace element administrations were much larger than those prescribed in the 3 groups of patients, and were significantly above the most recent parenteral recommended daily allowance = RDA (2.3 times RDA for copper, 5 times for selenium and zinc in Group 2, which received the largest i.v. supplements). There greatest provision of the 3 elements was by the blood products (packed red cells and frozen plasma) and by the albumin solutions (0.5 mg.L-1 Cu, 90 micrograms.L-1 Se and 2.1 mg.L-1 Zn in the 20% solutions). During the resuscitation phase, crystalloids provided a significant amount of copper (0.14 mg.L-1 NaCl 0.9%, none in dextrose) and zinc (0.3 mg.L-1 of any crystalloid), whereas selenium was not detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Idiopathic urethroseminal reflux is exceptional in children. In both of our cases, it presented in the form of epididymitis and was confirmed by suprapubic cystography, which also eliminated an obstructive cause and any associated malformations. Long-term antiseptic treatment prevented recurrent infections.

A 34.5 kDa abundant protein named MVDP (Mouse Vas Deferens Protein) is produced and secreted by vas deferens epithelial cells from adult mice. Steady-state levels of MVDP and its 1.4 kb mRNA are markedly decreased 30 days after castration. Testosterone treatment for 2 weeks is necessary to completely reverse the effect of castration. A cDNA encoding MVDP has been cloned and entirely sequenced. A protein of 316 amino acids encoded by an open reading frame of 948 nucleotides shows 82% homology with a human placental aldose reductase. A gene corresponding to MVDP cDNA has been recently isolated ans characterized. The gene extends over approximately 11 kb and consists of 10 exons. Its structure is very similar to that of the human aldose reductase gene. The promotor region of MVDP gene contains an androgen responsive element consensus located 97 nucleotides upstream the transcription initiation site.

The authors report 62 fractures of the head of the radius treated either by excision or silastic implant arthroplasty. Fifty-two patients were reviewed with a mean follow-up period of 5 years (range 1 to 13). Of 22 prosthetic replacements, 12 were satisfactory while of 30 excisions only 10 were rated good or excellent. Excision usually yielded valgus deformity of the elbow (range 9 to 35 degrees) and with a risk of shortening of the radius. Range of flexion-extension was identical after both procedures but pronation supination was better after prosthesis replacement (78/70) than after radial head excision (65/60) 3 fractures of the implant were found at 6, 9 and 10 years postoperatively; only one of them was associated with pain and required removal of the loose fragments.

The authors report 62 fractures of the head of the radius treated either by excision or silastic implant arthroplasty. Fifty-two patients were reviewed with a mean follow-up period of 5 years (range 1 to 13). Of 22 prosthetic replacements, 12 were satisfactory while of 30 excisions only 10 were rated good or excellent. Excision usually yielded valgus deformity of the elbow (range 9 to 35 degrees) and with a risk of shortening of the radius. Range of flexion-extension was identical after both procedures but pronation supination was better after prosthesis replacement (78/70) than after radial head excision (65/60) 3 fractures of the implant were found at 6, 9 and 10 years postoperatively; only one of them was associated with pain and required removal of the loose fragments.

Several charts elaborated for the assessment of the results of surgical treatment of cuff rotators tears were critically analysed. Twenty-one patients were reviewed and results assessed with three different charts, the Patte, Kenesi and Constant ones. The correlation of the parameters was studied and was found to be satisfactory.

Nutritional assistance was given by percutaneous endoscopic gastrostomy to 174 patients with neurological diseases (80 cases), tumours of the ear, nose and throat (ENT) region (70 cases) or malnutrition (24 elderly people). These patients had either deglutition disorders with inhalation or severe malnutrition, or could not tolerate a nasogastric tube. The endoscopic catheter (Bioser) was installed by the pull technique under general anaesthesia (26 percent), neuroleptanalgesia (16 percent), premedication (14 percent) or without sedation (44 percent). Installation was possible in 98 percent of the cases. Twenty-nine percent of the patients were treated in an outpatient clinic. The problems encountered (21 percent) were mainly due to blockade of the flange and rupture of the thread. Transoperative accidents, such as dyspnoea, bleeding or cardiac arrest, all without sequelae, were noted in 5 percent of the cases. The catheter remained in situ for a mean period of 3.9 +/- 0.3 months (range: 0.1 to 20 months). The following complications were observed: short-term (15 percent), hyperthermia (5), local infection (6), abscess of the abdominal wall (3), meteorism (9), pneumoperitoneum (1), subocclusion (2); long-term (25 percent), inflammatory reactions (13), leakage (19), catheter displacement (8) and catheter rupture (3). Local infections were more frequent in patients with ENT tumours than in the others. Percutaneous endoscopic gastrostomy is a fast and reliable technique preferable to surgical gastrostomy. Complications are frequent (46 percent) but usually minor (42 percent). Contra-indications must be respected, and the catheter must be introduced with the utmost care.

The authors reported an early case of cauda equina syndrome after hemilaminectomy and discectomy for lumbar disc herniation. CT-scan revealed the migration of the free fat graft used for preventing peridural scar formation. Removal of the graft resulted in total patient's recovery.

A dosimetry study using lithium fluoride TL dosimeters was carried out during mammography in 34 patients in order to evaluate in vivo the dose of mammography rays received by these patients. The measures are made for one breast only, using two views: cranio-caudal and medio-lateral views with compression. The results show that skin entrance doses are going from 0.20 to 1.67 cGy in cranio-caudal view and from 0.15 to 1.75 cGy in medio-lateral view. The skin exit doses are from 0.001 to 0.21 cGy in cranio-caudal view and from 0.001 to 0.13 cGy in medio-lateral view. The midplane doses estimated from the skin entrance dose and the graph of the deep yield are from 0.07 to 0.48 cGy. These doses are comparable with those founded by other authors, and though maximum, they stay very low. This is important for detect the breast cancer in order to reduce radiation risks.

The authors report the case of a nonunited supra-malleolar fracture with severe angulation in an elderly patient. Poor vascular condition and severe osteoporosis prevented the use of either a surgical approach or internal fixation. Gradual realignment and union were nevertheless achieved within 6 months post operatively using the "Sequoïa" external fixation system, while weight-bearing was continued throughout the course of treatment.