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Complex regional pain syndrome (CRPS) is a potentially devastating condition that can result in severe psychological and social morbidity. It is a diagnosis of exclusion, and other pathologic entities must be ruled out first. Glomus tumors are exquisitely painful benign vascular tumors that are most common in the hand and are rarely found in the lower extremity. Here, we present a case of a patient who developed a focus of severe anterior knee pain and tenderness a few months after a car accident that had been misdiagnosed as CRPS for 15 years. She coincidentally developed a sarcoma of her ipsilateral leg distal to this site. Magnetic resonance imaging of the sarcoma included the area of knee pain where, interestingly, it identified a separate small soft-tissue mass. A glomus tumor was diagnosed histologically in a needle biopsy specimen from this mass, which was resected along with the sarcoma. For the first time in 15 years, despite the additional sarcoma surgery, she reported relief of her pain and complete resolution of her "CRPS."

Intraoperative confirmation of negative resection margins is an essential component of soft tissue sarcoma surgery. Frozen section examination of samples from the resection bed after excision of sarcomas is the gold standard for intraoperative assessment of margin status. However, it takes time to complete histologic examination of these samples, and the technique does not provide real-time diagnosis in the operating room (OR), which delays completion of the operation. This paper presents a study and development of sensing technology using Raman spectroscopy that could be used for detection and classification of the tumor after resection with negative sarcoma margins in real time. We acquired Raman spectra from samples of sarcoma and surrounding benign muscle, fat, and dermis during surgery and developed (i) a quantitative method (QM) and (ii) a machine learning method (MLM) to assess the spectral patterns and determine if they could accurately identify these tissue types when compared to findings in adjacent H&E-stained frozen sections. High classification accuracy (>85%) was achieved with both methods, indicating that these four types of tissue can be identified using the analytical methodology. A hand-held Raman probe could be employed to further develop the methodology to obtain spectra in the OR to provide real-time in vivo capability for the assessment of sarcoma resection margin status.

Solitary fibrous tumors (SFTs) of the spine are exceedingly rare tumors of mesenchymal origin. Most spinal SFTs arise from the thoracic spine, followed by cervical spine, and last lumbar spine with only 6 cases reported in literature. SFTs represent a wide range of neoplasms, ranging from benign to malignant. These tumors can develop a late recurrence, even after a decade or more of initial presentation, requiring long-term follow-up. We present a case of recurrent SFT of the lumbar spine with vertebral body involvement, presenting more than a decade after initial resection. It was initially misdiagnosed as a paraganglioma. To the best of our knowledge, there have been only 3 previous cases reporting SFT with vertebral body involvement.

B. Vallet *, Y. Blanloeil , B. Cholley , G. Orliaguet , S. Pierre , B. Tavernier a a Pole d’anesthesie reanimation, hopital Huriez, CHRU de Lille, rue Polonovski, 59037 Lille cedex, France b Service d’anesthesie-reanimation chirurgicale, hopital G.-et-R.-Laennec, CHU de Nantes, 44093 Nantes cedex 1, France c Service d’anesthesie-reanimation, hopital europeen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France d Service d’anesthesie-reanimation, hopital universitaire Necker–Enfants-Malades, universite Paris Descartes, Assistance publique–Hopitaux de Paris, 149, rue de Sevres, 75743 Paris cedex 15, France e Institut Claudius-Regaud, 20–24, rue du Pont-Saint-Pierre, 31052 Toulouse Cedex, France

Background In 2008, in France, 222 patients died because they did not receive the graft they expected. The main objective of this study was to determine the attitude of private practice physicians concerning organ donation. Methods A postal questionnaire was sent to all private practice office-based physicians in the Nord-Pas de Calais region. This questionnaire was elaborated with a panel of physicians and sociologists. It was sent with the monthly journal of the regional union of private physicians of June 2008. Results Two hundred and seventy eight questionnaires were returned. One hundred and thirty four (48.2%) respondents declared they knew what the regulations about organ donation were. The majority of respondents approved organ donation. Information to patients was provided during visits by 34.53% (96) of practitioners. For those who were knowledgeable about regulations, 50.75% of them talked about organ donation. Physicians who had already had experience with organ donation were more inclined to talk about it with other patients. The practitioners described three actions they felt could have a positive influence on family acceptance: providing information before death, talking about organ donation in an appropriate sensitive way, and relying on the confidence established by a solid patient-physician relationship. Conclusion Almost 90% of private physicians who responded to the survey were in favor of organ donation but only 34.5% delivered information and discussed the issue with their patients. The physicians coped with the topics more easily when they had experienced cases and when they were informed about existing regulations. A specific educational program on the current regulations and how to interact with patients on this subject during a visit could be a first answer to the problem and would be welcomed by practitioners.

To assess the difficulty in both laryngoscopy and tracheal intubation related to goitre and to identify factors predictive of difficult intubation due to this condition.Prospective observational.We used the Intubation Difficulty Scale (IDS) in 80 consecutive patients with large goitre (defined by the inability to palpate the cricoid cartilage, the presence of endothoracic goitre, tracheal deviation of more than 1cm or tracheal stenosis on the chest x-ray) and 77 control patients.Cormack grades 3-4 were more frequent at initial laryngoscopy in patients with goitre (23/80 vs. 9/77; p0.05), but the difference was no longer significant after application of an external laryngeal pressure (8/80 vs. 5/77). IDS scores (median [25th-75th percentiles]) were higher in the goitre group (1 [0 - 4]) than in the control group (0 [0 - 1]; p=0.001), corresponding to an increase in slightly difficult intubation (IDS 1-5: 36/80 vs. 15/77; p0.05). However, incidence of moderate to major difficulty in intubation (IDS5: 8/80 vs. 7/77) as well as time to completion of intubation were similar in both groups. Tracheal stenosis (or =30%) and reduced mouth opening (4.4cm) were the only significant predictors of increased difficulty in intubation in patients with a goitre.Large goitres are usually associated with slight difficulty in intubation only. Increased difficulty should be expected when severe tracheal stenosis is present on chest x-ray, especially when associated with a reduced mouth opening.

Resume La noradrenaline est le medicament recommande en premiere intention dans les consensus nationaux et internationaux pour le traitement hemodynamique du choc septique, parallelement au remplissage vasculaire. Cependant, aucune recommandation n’encadre le sevrage en noradrenaline qui suit necessairement cette prise en charge hemodynamique. Or, les proprietes pharmacodynamiques justifiant l’utilisation de la noradrenaline au cours du choc septique, a savoir vasoconstriction veineuse et arterielle, permettent de « normaliser » rapidement l’hemodynamique macrocirculatoire au prix potentiel d’une malperfusion regionale et/ou microcirculatoire, d’autant plus que le remplissage n’aura pas ete optimise. Le sevrage en noradrenaline, qui « relâche » la contrainte exercee sur la circulation veineuse, constitue donc une etape pendant laquelle tout defaut de remplissage initial ou secondaire peut se reveler. Les rares etudes disponibles sur le sujet montrent que le mode de sevrage habituel en noradrenaline est arbitraire et prolonge inutilement son utilisation potentiellement deletere. Le sevrage en noradrenaline pourrait se concevoir comme une epreuve fonctionnelle hemodynamique au cours de laquelle serait evaluee la precharge-dependance, demasquant un eventuel besoin en remplissage permettant de poursuivre et accelerer le sevrage ou, au contraire, un etat de « noradrenaline dependance » a respecter mais a reevaluer regulierement. De telles epreuves de sevrage pourraient etre envisagees precocement dans la prise en charge hemodynamique du choc septique, lors de toute stabilisation hemodynamique apparente, afin de prevenir ou eviter d’aggraver des troubles de perfusion regionales et microcirculatoires. Ainsi, l’enjeu du sevrage de la noradrenaline pourrait prendre une nouvelle dimension et meriter plus d’attention.

Hospital information system manages patient's hospitalization information across different applications and databases. As statistics are performed with difficulties on these different databases, the university hospital of Lille developed an anesthesia data warehouse. This common structure stores data related to anesthesia procedures and patient hospital stay. In that way, the joint analysis on intervention's events and patient's outcome is possible. However, data quality remains one of the main issues in this kind of project. Indeed, errors in patient identifier result in difficulties to link data between the different sources. This problem will be approached in the next phase of the project.

Resume Il est important d'identifier des criteres cliniques ou biologiques predictifs de l'efficacite du remplissage volemique (RV). Le contexte clinique (trauma, hemorragie, sepsis) peut constituer un element decisionnel majeur. Parmi les signes cliniques, les manœuvres d'orthostatisme sont les signes les plus sensibles d'une reponse positive au RV. La realisation d'une epreuve de remplissage vasculaire constitue un test diagnostique qui lorsqu'il est couple a la mesure de son effet sur le volume d'ejection systolique ou le debit cardiaque, permet de distinguer les patients repondeurs des patients non repondeurs. Chez le malade de reanimation, le lever de jambe passif reproduit les effets hemodynamiques d'une expansion volemique et son effet sur les variations de pression arterielle pulsee possede une bonne valeur predictive de l'efficacite du RV. Les anomalies biologiques les plus couramment observees sont l'insuffisance renale fonctionnelle et l'hyperlactacidemie. En pratique, lorsque l'indication du remplissage vasculaire est portee sur la reunion de criteres clinicobiologiques usuels, dans un contexte d'insuffisance circulatoire aigue, le pourcentage de patients repondeurs varie entre 40 et 72 % en fonction des etudes publiees.

Resume La chirurgie dentaire militaire regroupe des formes multiples, originales et habituellement meconnues d’exercice ou la culture de la polyvalence, de l’efficacite et du professionnalisme peut s’exprimer. Si l’idee de la creation d’un corps de chirurgiens-dentistes de carriere au sein des armees francaises est ancienne, sa realisation effective ne date que de l’an 2000. Permise par la professionnalisation des armees, elle est en fait le fruit d’une longue evolution qui depasse le milieu militaire et s’integre dans la reconnaissance progressive et generale de notre profession au sein du monde medical. Son organisation repose avant tout sur une sectorisation geographique s’affranchissant de l’opposition unite/hopital et permettant a tous les chirurgiens-dentistes d’exercer au plus pres des forces et a leur profit. Les synergies avec le monde civil dans les soins quotidiens, au decours des actions de formation continue ou dans les activites de recherche concourent a maintenir le lien Armee-Nation. L’integration des praticiens de reserve dans toutes les activites militaires procede de cette logique. Disposant de moyens de qualite, robustes, regulierement entretenus et aux normes de securite et d’hygiene, les praticiens peuvent se consacrer a leur raison d’etre : participer, a cote de leurs camarades medecins et en collaboration avec eux, a obtenir et a maintenir le meilleur etat de sante possible des ressortissants de la defense. Parfaitement integres, polyvalents et disponibles, les chirurgiens-dentistes militaires accompagnent nos soldats partout ou ils se trouvent. Leurs roles a l’etranger, en plus du soutien des forces armees francaises ou alliees, incluent bien souvent des missions a vocation humanitaire, illustrant les devises de nos ecoles « pro patria et humanitate » et « mari transve mare hominibus semper prodesse ».

Resumen Las particularidades de la anestesia y reanimacion en la cirugia de las glandulas suprarrenales se relacionan esencialmente con las alteraciones de la secrecion endocrina y su brusca correccion por la exeresis (tumores secretantes); en ocasiones tambien pueden estar vinculadas con la amplitud de la diseccion quirurgica (corticosuprarrenalomas). Los progresos realizados en el ambito de las estrategias diagnosticas y terapeuticas han permitido reducir la mortalidad y la morbilidad perioperatorias, asi como racionalizar y simplificar el tratamiento integral de los pacientes. La generalizacion del acceso laparoscopico en la mayoria de estos tumores es una de las modificaciones mas importantes de los ultimos diez anos. En este capitulo se describen las principales caracteristicas del tratamiento anestesico pre, intra y postoperatorio, en particular en presencia de hipercortisolismo, hiperaldosteronismo o secrecion anormal de catecolaminas.

Exact diagonalizations are used to study the structure of the many-particle wavefunction in quantum dots containing up to six electrons. We are able to provide quantitative information on the correlated electron–vortex state that forms at strong magnetic fields and find that the electron–vortex distances scale as the square of the filling factor.

The aim of this study was to verify whether a relationship exists between neuroleptic malignant syndrome (NMS) and anaesthetic-induced malignant hyperthermia (MH) or not. The in vitro halothane-caffeine tests were performed on muscle tissue obtained from 32 patients with documented NMS episodes. The diagnosis of NMS relied on Levenson's criteria. The results, expressed in accordance with the criteria of the European MH Group, defined 29 subjects as MH non-susceptible. Three patients were classified as MH equivocal. These findings demonstrate the lack of any link between NMS and MH. Therefore, patients with a history of NMS are not likely to be at risk of developing MH and special measures against MH are not required for anaesthesia in these patients.

Continuous Analgesia / Nociception balance evaluation during general anesthesia could be of precious help for the optimization of analgesic drugs delivery, limiting the risk of toxicity due to the use of opioid drugs, limiting the risk of post operative hyper algesia, and, probably, reducing time of recovery after surgical procedure. Heart Rate Variability analysis has been shown in several studies to measure the Autonomic Nervous System tone, which is strongly influenced by anesthetic drugs. Recording RR series during general anesthesia enabled us to observe that the Respiratory Sinus Arrhythmia pattern changed when a surgical stimulation was painful, even though the patient was not conscious. We have previously developed and evaluated a pain / analgesia measurement algorithm based on the magnitude analysis of the respiratory patterns on the RR series. In this paper, we present the development of a monitoring device (PhysioDoloris), based on the previously described technology, giving in real time an Analgesia Nociception Index (ANI) which can be used during general anesthesia in order to give to the anesthetist, a complementary tool for optimized drug delivery.

A system of $N=5$ and 6 two-dimensional Coulomb-interacting electrons, trapped in a harmonic potential and subjected to a perpendicular magnetic field, is studied using an exact-diagonalization technique. The results are summarized in a phase diagram, indicating the ground state as a function of the magnetic field and the electron-electron interaction strength. The transformation to a Wigner crystal after the breakdown of the maximum density droplet is investigated and is related to the vortex structure of the different states. The internal structure of the composite fermion is investigated as function of the magnetic field and related to several properties of the quantum dot (e.g., compressibility, liquid or crystal, stability of the ground state, and so on).

La dysfonction myocardique au cours du sepsis est une entite largement reconnue. Classiquement, elle debute dans les vingt-quatre heures ou dans les premiers jours du debut du sepsis et se caracterise par une depression de la fonction systolique (diminution de la fraction d’ejection) et une dilatation biventriculaire, surtout en cas d’apports liquidiens importants. Chez les survivants, la depression myocardique evolue vers un retour a la normale au bout de cinq a sept jours. Au cours des dix a quinze dernieres annees, la generalisation de l’echocardiographie en reanimation a permis d’observer qu’en realite, son expression clinique est tres variable d’un sujet a l’autre et d’un moment a l’autre de l’evolution du choc septique. De ce fait, il semble plus approprie de parler de dysfonction que de depression myocardique au cours du sepsis. D’un point de vue physiopathologique, il est probable que cette variabilite clinique traduise l’implication ou la predominance de mecanismes differents. De tres nombreux mecanismes potentiels ont en effet ete demontres. a l’extreme, en se fondant sur les travaux experimentaux, on peut considerer que la totalite des voies de regulation des fonctions du cardiomyocyte sont alterees au cours du choc septique. De grandes incertitudes demeurent en fait sur le role reel de chacun des mecanismes proposes dans la litterature. On peut neanmoins distinguer des mecanismes extrinseques aux myocytes cardiaques (surtout plasmatiques et/ ou endotheliaux), a effet souvent immediat, et d’autres purement intramyocytaires, a effet volontiers plus retarde.

Small numbers N

The peri-operative management of patients undergoing surgery for phaeochromocytoma or paraganglioma with calcium channel blockers (CCB) and their impact on postoperative morbidity and mortality were studied. The medical records of 105 patients undergoing surgery between 1991 and 2002 were analysed retrospectively. In all patients, the calcium channel blocker nicardipine was used for the peri-operative management of haemodynamic changes. Sixty-five patients (61.9%) showed transient intra-operative hypertension. Systolic blood pressure (SBP)220 mmHg and SBP180 mmHg for10 consecutive minutes was observed in 14 (13%) and four patients (2.8%), respectively. SBP80 mmHg for10 consecutive minutes occurred in 13 patients (12.3%). Eleven patients (10.4%) developed postoperative complications and three patients died (2.8%). The median (range) ICU and hospital length of stay were, respectively, 1 (0-7) day and 10 (2-35) days. The sole use of calcium channel blockers for the peri-operative management of phaeochromocytoma and paraganglioma resection does not prevent all haemodynamic changes; however, its use was associated with a low morbidity and mortality.

The internal structure of a composite fermion is investigated for a two dimensional parabolic quantum dot containing three electrons. A Yukawa screened Coulomb interaction is assumed, which allows us to discuss the evolution of the electron-vortex correlations from the Coulomb interaction limit to the contact potential limit. The vortex structure approaches the Laughlin limit non-monotonically through the formation of intermediate composite fermions in which a flip of the spatial orientation of the vortices with respect to the position of the electrons is observed. Only when we limit ourselves to the lowest Landau level (LLL) approximation the flip appears through the formation of an intermediate giant vortex at specific values of the screening length. Beyond the LLL approximation antivortices appear in the internal structure of the intermediate composite fermions which prevent the nucleation of giant vortices. We also studied the system of five electrons and show that the mechanism of the flip of the vortex orientation found for three-electron system is reproduced for higher number of electrons.

The exact many-body wave function for small numbers $Nl5$ of two-dimensional Coulomb-interacting electrons trapped in a parabolic potential placed in a perpendicular magnetic field are investigated. The reduced wave function of this system, which is obtained by fixing the positions of $N\ensuremath{-}1$ electrons, exhibits strong correlations between the fixed electrons and the zeros of the wave function. These zeros are often called vortices. The wave functions are obtained from an exact-diagonalization scheme and the results are compared with results obtained from the recently proposed rotating electron molecule (REM) theory. We find that the vortices cluster around the fixed electrons and repel each other, which is the case to a much lesser extent for the REM results.

We show that the critical magnetic fields at which a few-electron quantum dot undergoes transitions between successive values of its angular momentum (M), for large M values follow a very simple power-law dependence on the effective inter-electron interaction strength. We obtain this power law analytically from a quasi-classical treatment and demonstrate its nearly-universal validity by comparison with the results of exact diagonalization., Comment: Uses RevTeX4, 6 figures included in the text

Few-electron systems confined in two-dimensional parabolic quantum dots at high magnetic fields are studied by the Hartree-Fock (HF) and exact diagonalization methods. A generalized multicenter Gaussian basis is proposed in the HF method. A comparison of the HF and exact results allows us to discuss the relevance of the symmetry of the charge density distribution for the accuracy of the HF method. It is shown that the energy estimates obtained with the broken-symmetry HF wave functions become exact in the infinite magnetic-field limit. In this limit the charge density of the broken-symmetry solution can be identified with the classical charge distribution., Comment: to appear in EPJ D

Diabetes mellitus is the most common metabolic disease and its incidence is increasing. New classifications have been recently proposed based upon a better knowledge of pathogenesis, mechanisms of glucose transport and insulin resistance. The perioperative care of diabetic patients is less dependent on blood-glucose control, which needs to be exceptionally tight, and is usually easily obtained thanks to pharmacological improvements, human insulins and analogues, technical progress with blood-glucose monitoring at the bedside and infusion with constant flow rates. More important is the influence of end-organ pathology, often clinically silent, which must be carefully assessed during the preoperative evaluation. The organ impairments concern especially the heart, but also all those organs that were modified by abnormal glycosylated proteins. The pre-existing pathology has many consequences on anaesthesia management; the anaesthetic technique depends essentially on their existence. A better long-term control of diabetes both for Type 1 and Type 2 by insulins, and the new oral anti-diabetic drugs reduce the incidence of the end-organ pathology and the risk linked to organ failures in the perioperative period.

It is hypothesized that tissue dysoxia and O2 debt are major factors in the development and the propagation of multiple organ failure in critically ill patients. Dysoxia is the result of an abnormal relationship between O2 supply (DO2) and O2 demand and translates into increased anaerobic metabolism and tissue and blood lactate concentration. First-line therapeutic strategies used to avoid the development of an O2 debt involve correction of cardiac output, haemoglobin, and O2 saturation in order to increase DO2 above its critical value. They are not sufficient, however, to ensure appropriate end-organ perfusion and oxygenation. The adequacy of cardiac output towards tissue metabolic requirements may be appreciated by venous-to-arterial and gut mucosal-to-arterial PCO2 differences. This review details these strategies and discusses their usefulness in current practice.

Sepsis syndrome and the systemic inflammatory response syndrome (SIRS) are characterized by a diffuse, ineffective tissue and cellular utilization of oxygen, and hemodynamic collapse with peripheral vasodilation and myocardial depression. Although the mechanisms responsible for sepsis-induced myocardial depression remain debatable, various investigators have focused during recent years on the influence of sepsis on myocardial function. Clinical and experimental studies that have attempted to assess cardiac function indicate the presence of true, intrinsic myocardial depression, independent of changes in load or heart rate.

Diabetes mellitus (DM) is a common problem in anaesthetic practice since over two per cent of surgical patients are concerned. One fourth are insulin-dependent (IDDM) and three fourth non insulin dependent diabetes (NIDDM), according to a large French anaesthetics survey [1]. This frequency is strongly increasing [2]. During a long period, the anaesthetic management has been focused on the glycaemic control, and several regimens have been proposed to obtain a tight perioperative control of glycaemia, even if this necessity remains unproved [3]. Progress in insulins, bedside monitoring of glycaemia and constant infusion techniques have pushed into the background the risks due to glycaemic impairments during the operative period [2].