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Introduction et but de l’etude Au CHIV, la demande institutionnelle de consultation dietetique dans les services se fait par fax, prealablement remplie par le medecin. Le Clan a realise une evaluation des pratiques professionnelles(EPP) en UGA de fevrier a mai 2018 afin de renseigner les pourcentages de prescription de regimes, de CNO ainsi que leur dispensation et consommation. Puis nous avons apporte des axes d’amelioration et nous avons fait un 2e tour d’audit. Materiel et methodes Il s’agit d’une etude prospective avant-apres moncentrique. Nous avons etudie 38 dossiers de patients en UGA sur les items precedents. Puis devant les resultats obtenus, nous avons choisi des axes d’amelioration : – arret du fax au profit d’un item informatique cree sur le logiciel Pharma. Les medecins vont renseigner les antecedents du patient et demander un regime dietetique particulier ainsi que des CNO. La dieteticienne peut visualiser la prescription de son bureau, sur son ordinateur, cibler alors le patient, venir le voir et conseiller le type de CNO, – creation pour les paramedicaux, d’items sur Pharma renseignant la date et l’heure de delivrance ainsi que la quantite consommee, – nous avons dispense un cours a tous les personnels sur les consequences de la denutrition, son interet de la depister, et avons explique l’utilisation des nouveaux outils informatiques. Nous avons refait un 2e tour d’audit 2 mois plus tard sur 20 patients denutris. Resultats et analyse statistique Nous constatons que le taux de denutrition est de 55 % en UGA. La prescription de regime par fax est de 55 % et passe a 95 % quand il y a un support informatique. La delivrance des CNO ainsi que leurs horaires et leurs consommations sont respectivement de 0 %, 0 %, 0 % ! Avec la creation d’items sur Pharma, la delivrance est notee a 60 %, les horaires a 55 % et la consommation a 15 %. 100 % des medecins prescripteurs sont satisfaits de ce mode de prescription. Conclusion Nous avons donc abandonne le fax. Le nouvel outil de prescription se deploie dans tous les services, appuyes par un cours sur les consequences de la denutrition, une intervention par la dieteticienne du service, et la demonstration informatique par la referente paramedicale du logiciel. Les equipes sont satisfaites car la tracabilite est manifeste et la surveillance plus aisee. Mais il faut etre vigilant et revenir dans les services afin de sensibiliser encore et toujours sur les mefaits de la denutrition.

Introduction Since a large proportion of patients resuscitated from out-of-hospital sudden cardiac arrest (SCA) die in the intensive care unit (ICU), early systematic investigation towards identifying etiology may be crucial to ensure appropriate future prevention among relatives, especially when the index case is young. Purpose We hypothesized that etiologic investigations were not initiated in a timely manner in a significant proportion of young SCA patients prior to death. Methods In this prospective ongoing multicenter, population-based registry (6.7 million inhabitants), data from all SCA over a 5-year period were analyzed with a specific focus on young patients ( Results Of the 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 3,028 were admitted alive to ICU. Among them, 2,190 (72.3%) died in ICU, including 367 (16.8%) young cases ( Conclusion More than half of young SCA cases who died in ICU remained unexplained. Efforts to promote early systematic investigation through better collaboration between intensivist and cardiologist may improve future targeted preventive strategies for family members.

Introduction/Background The use of myoelectric prosthetics in upper limb amputees introduced compensations on the residual shoulder and trunk which could be the cause of musculoskeletal disorders. Task/work involving movements in abduction of shoulder (> 60°) more than two hours per day in cumulative have been identified to be responsible of musculoskeletal disorders. The aim of the study is to evaluate the shoulder compensations in upper limb amputees with the use of the new myoelectric multi-articulated prosthetic hands compared to tri-digital hands during different functional tasks. Material and method Five unilateral trans-radial upper limb amputees (4 male, 1 female; age 45.6 ± 13.8 years old) participated in this prospective crossover study. Evaluations were realized by each participant with their own tri-digital myoelectric prosthesis and 2 multigrip prosthesis: I Limb Ultra® (IL) without a wrist mobility and Michelangelo® (MA) with a wrist mobility, after specific rehabilitation and one month of home use. Mean of internal rotation, mean of abduction shoulder, percent time in abduction higher than 60° and its extrapolation in hours were calculated by an optoelectronic system (VICON) for the both sides (amputated - non-amputated) during the Box and Block Test (BBT) and 2 common daily life tasks (cut meat, make a knot). Results Whatever the tasks, there is any significant difference in internal rotation with the different prosthetic devices. Conclusion New types of grip of innovative prosthetic hands and wrist mobility seems to decrease shoulder abduction, considered as pathogenic compensations. However, the compensation strategy is different across patients, which involve a personalized analysis for his rehabilitation program and for the prosthetic device choice. Further studies are necessary to evaluate the impact of trunk compensations.

Patellofemoral pain is likely due to compressive force acting on the patella related in turn to knee extension moment. The latter variable was assumed to be (i) reduced during short-distance free walking in case of patellofemoral pain syndrome and (ii) increased after therapeutic pain reduction. Peak knee extension moment at beginning of stance phase was recorded by three-dimensional gait analysis in 22 controls and in 23 patients with patellofemoral pain syndrome before and after rehabilitation of knee extensors and flexors to reduce the pain. Pain would occur mainly in stressful activities such as stair negotiation or squatting and was quantified by the anterior knee pain scale. Peak knee extension moment was significantly reduced in all the patients before treatment (n = 23) compared to controls, although no one had pain during free walking. In the 17 patients who experienced significant postrehabilitation pain reduction in their stressful activities, the peak knee extension moment was significantly reduced before treatment compared to controls and significantly increased after treatment, reaching values similar to control values. The peak knee extension moment during free walking appears to be a good kinetic variable related to a compensatory mechanism limiting or avoiding anterior knee pain and may be of interest in assessing knee dynamics alteration in patients with PFPS.

The authors had for aim to make an inventory of antibiotic treatment for severe community-acquired Streptococcus pneumoniae pneumonia and compare local practices to the local and national guidelines.An audit was conducted retrospectively in the Versailles hospital ICU between January 2006 and April 2009. Forty patients were included.Ninety-three percent had major risk factors for pneumonia. Ninety-eight percent were treated, with the usual empirical treatment (69%) or treatment active against Pseudomonas aeruginosa (31%). Eighty-five percent of empirical treatment complied with the French national guidelines issued by the SPILF and 49% with the local ICU protocol, more restrictive for the choice of the agent and dose. Early de-escalation to amoxicillin was applied to 41% of patients after obtaining results for pneumococcal and Legionella antigen and results of respiratory sample direct examination. For all patients, empirical treatment was reassessed according to culture results: 81% were prescribed amoxicillin. Evaluation showed that 92% of treatment complied with SPILF guidelines and 65% with the local ICU protocol that required adaptation of amoxicillin doses according to MICs; adaptation to severity and BMI was necessary for ten patients. Mortality remained high, at 37%, despite using antibiotics still effective against S. pneumoniae.This survey revealed a satisfactory adhesion to recommendations and prompt responsiveness of the team for adjustment of antibiotic therapy. The audit allowed updating the local ICU protocol.

Introduction Invasive aspergillosis is a serious disease, the lethality of which is important among hematology patients. Early diagnosis is crucial for treatment options and the prognosis. Detection of the antigen galactomannan is the most frequently used microbiological tools. But galactomannan detection may be falsely positive, and this false positivity has been associated with piperacillin-tazobactam treatment, the main antibiotic combination used in clinical hematology. Objective The purpose of our study, carried out from January 2009 to December 2010 at the Versailles hospital on in-patients with hematological disorders, was to evaluate the association between false galactomannan positivity and administration of piperacillin-tazobactam, and to study a possible variability of products issued by three manufacturers. Patients and method We noted that 207 patients were included (n = 207), accounting for 69 false positive and 138 true negative results. The intrinsic galactomannan values in the study were sensitivity 100%, specificity 68%, positive and negative predictive values respectively 16%, 100%, and a likelihood positive and negative test at respectively 3.12, and 0. Results The statistical analysis did not determine any association between false positivity in galactomannan and piperacillin-tazobactam issued by two manufacturers (P = 0.87 and P = 0.94). But, there was a significant association between false galactomannan positivity and piperacillin-tazobactam issued by the third manufacturer (P = 0.02). Four of the 25 batches issued by this manufacturer were tested and negative “in vitro” for galactomannan. Discussion This study results suggest that the association between false galactomannan positivity and piperacillin-tazobactam is not longer systematic, but can still prevail depending on the manufacturers. It also confirmed the positive contribution of testing piperacillin-tazobactam batches “in vitro” before using the antibiotic.

Les tumeurs intramedullaires sont rares. Le dernier rapport de la SNCLF remonte a 1994 sur une periode de 25 ans. Il exposait les progres de la chirurgie face a ces tumeurs. Dans le meme temps, les progres de l’imagerie etaient expose en particulier par IRM. Dans les recentes publications sur le sujet, la chirurgie reste essentielle, biopsie ou exerese. Aussi, au debut de ce siecle, peut-on eviter la chirurgie et proposer un suivi medical en l’absence de troubles neurologiques ? Patients et methode Nous rapportons notre experience sur 4 cas, suivi depuis plusieurs annees par la clinique et l’imagerie par IRM. Ces tumeurs ont ete decouvertes suite a une cervicalgie chez 3 patients et un cas de dorsalgie. L’IRM a mis en evidence des lesions tumorales non clivables intramedullaires. Le suivi medical sur 8 ans et plus montre une parfaite stabilite de l’examen clinique sans troubles neurologiques. Resultats Deux patients sont en retraite, l’un est en invalidite et le dernier travaille mais evite les efforts. Pour ce dernier patient, le diagnostic d’astrocytome de bas grade est le plus vraisemblable, pour les autres cas aucun diagnostic precis ne peut etre fourni. En l’absence d’evolution, faut-il continuer la surveillance, a quel rythme ? Dans toutes les series, les risques chirurgicaux restent importants, ce qu’il faut garder a l’esprit. Dans la litterature, aucun cas de suivi medical de tumeur intramedullaire n’est rapporte. Nous sommes interpelles par des lesions etendues intramedullaires bien tolerees. L’un des patients, pompier professionnel a continue de travailler jusqu’a sa retraite sans probleme et son imagerie est toujours stable. Conclusion En l’absence de troubles neurologiques, sachant que chez tous ces patients aucun geste d’exerese complete ne peut-etre propose, il peut etre licite de proposer un suivi rigoureux annuel clinique et par imagerie chez ces patients pendant les 6 premieres annees puis tous les 2 ans jusqu’a 10 ans. Ensuite, je leur propose un suivi medical simple.

The thermal inactivation of Salmonella enteritidis phage type 4 and Escherichia coli O157:H7 as affected by temperature (54.5-64.58C), pH (4.2-9.6 with HCl or NaOH) and NaCl concentration (0.5-8.5% w / w) was studied. Cell suspensions in modified tryptone soya broth were heated in a submerged-coil heating apparatus and survivors were enumerated on tryptone soya agar incubated aerobically. For most thermal inactivation data there was a logarithmic decrease in the viable cell concentration over the initial 4-6 log reduction and D-values were fitted. In some cases, tailing of the survivor curves was 10 observed with cells surviving longer than the D-values predicted. Models describing the effect of temperature, pH and NaCl concentration on the thermal inactivation of S. enteritidis and E. coli O157:H7 were produced. For both organisms, predicted z-values of 4.6-7.0 C8 were obtained depending on conditions, with larger z-values at higher levels of NaCl. Optimum survival occurred between pH 5 and pH 7 and increasing acidity or alkalinity caused a decrease in the predicted D-values. At equivalent pH, acetic acid and lactic acid (at 0.5, 1 and 2% w / w) generally had a similar, or increased, lethal effect compared with HCl, whereas in most cases citric acid had a less lethal effect. For E. coli O157:H7, increasing NaCl concentration had a protective effect up to the maximum tested (8.5% w / w), while for S. enteritidis optimal survival at a NaCl concentration of 5-7% w / w was predicted. The models were validated in foods by comparing predictions with published data. Most (80%) of the predicted D-values from the S. enteritidis model were within the 95% confidence interval (within 2.45-fold of the published data) for different Salmonella serotypes in whole egg, egg albumen, egg yolk, beef and milk. Most (93%) of the predicted D-values from the E. coli O157:H7 model were larger than the limited published data for this organism in meat, poultry, milk and apple juice with 42% within the 95% confidence interval (within 2.05-fold of the published data). The D-value models were incorporated into Version 1, and subsequent versions, of the predictive microbiology software program, Food MicroModel. © 1997 Elsevier Science B.V.

Objectifs Le syndrome d’encephalopathie posterieure reversible (PRES) est une entite clinico-radiologique due a un desordre de l’auto regulation cerebrale. Les causes sont nombreuses. Notre observation rapporte un cas d’hypotension intracrânienne responsable d’un PRES syndrome. Patient et resultats Une patiente de 22 ans sans antecedents particuliers est admise initialement pour torticolis febrile. La ponction lombaire s’avere normale. Le bilan scanographique montre un phlegmon amygdalien retro-pharynge gauche qui est traite par chirurgie. Les suites immediates sont simples. A 48 h la patiente presente 2 crises comitiales tonicocloniques generalisees avec phase post-critique comateuse (Glasgow 6). La tension arterielle etait normale. Un scanner fait en urgence ne montre pas d’arguments pour une thrombose veineuse. L’IRM realisee immediatement apres, montre des lesions caracteristiques d’un PRES syndrome, associees a des ventricules de petite taille, des veines corticales tres dilatees et un elargissement du sinus coronaire inferieur, evoquant une hypotension intracrânienne associee. L’EEG etait normal. Trois tentatives de ponction lombaire apres l’IRM sans obtention de liquide cerebrospinal. L’IRM de controle a 72 h montrait une regression complete des signes de PRES. A j15 normalisation complete clinique et radiologique avec disparition des signes d’hypotension intracrânienne. Discussion Selon la litterature, deux mecanismes peuvent expliquer l’association PRES et hypotension intracrânienne : soit l’augmentation du volume sanguin cerebral par stagnation veineuse, soit l’attraction de l’ampoule de Galien et du sinus droit, entrainant un obstacle au retour veineux et, par consequence, une distension du systeme veineux, une extravasation et des lesions de PRES syndrome. Conclusion Une hypotension intracrânienne responsable d’un PRES syndrome est une observation tres rare avec peu de cas rapportes dans la litterature. Le diagnostic precoce est primordial car en traitant la cause, les lesions sont en general reversibles avec un bon pronostic.

Objectifs Evaluation prospective par sequence de diffusion en IRM 3T des ischemies cerebrales silencieuses apres catheterisme des vaisseaux a destinee cerebrale dans un but diagnostique ou therapeutique. Etudier le degre d’installation et la reversibilite de ces lesions et degager les facteurs de risques eventuels. Materiels et methodes Suivi par sequences de diffusion de 3 et 5 mm d’epaisseur en IRM 3Tesla et en sequences T2 FLAIR de 20 patients ayant beneficie d’un catheterisme cerebral a visee diagnostique ou therapeutique. Resultats Nous rapportons le nombre, la taille et la topographie des hypersignaux observes sur les sequences de diffusion 3 et 5 mm d’epaisseur en IRM 3 Tesla et nous les avons comparees avec la sequence T2 FLAIR pour juger de l’evolution a distance de ces hypersignaux. Les hypersignaux vus en sequence de diffusion ont ete confrontes aux donnees cliniques avant et apres la procedure de catheterisme. Conclusion L’etude par sequence de diffusion en IRM 3 Tesla des ischemies cerebrales silencieuses apres catheterisme cerebral semble tres utile pour determiner la frequence de ces ischemies silencieuses et envisager leur prevention.