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Resume Le volume de la chirurgie bariatrique a nettement augmente au cours des dernieres annees et le nombre d’operes obeses en parallele. Les patients doivent faire l’objet d’une preparation a la chirurgie incluant l’arret du tabac, l’appareillage d’un syndrome d’apnee du sommeil. En raison du risque potentiel d’inhalation il faut privilegier l’anesthesie locoregionale ou effectuer une intubation a sequence rapide et utiliser en peroperatoire des agents a duree d’action courte. Il faut appliquer le principe de la ventilation protectrice peroperatoire. L’analgesie postoperatoire doit eviter le recours au opiaces ou favoriser leur epargne. La thromboprophylaxie doit etre adaptee au poids. La prise en charge ambulatoire est possible si le type d’intervention s’y prete.

International audience; The obese patient is at risk of perioperative complications including difficult airway access (intubation, difficult or impossible ventilation), and postextubation acute respiratory failure due to the formation of atelectases or to airway obstruction. The association of obstructive sleep apnoea syndrome (OSA) with obesity is very common, and induces a high risk of per and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre-, per- and postoperative pressure. For any obese patient, the implementation of difficult intubation protocols and the use of protective ventilation (low tidal volume 6–8 mL/kg of ideal body weight, moderate positive end-expiratory pressure of 10 cmH20, recruitment manoeuvres in absence of contra-indications), with morphine sparing and semi-seated positioning as much as possible are recommended, associated with a close postoperative monitoring. The dosage of anaesthetic drugs is usually based on the ideal body weight or the adjusted body weight and then titrated, except for succinylcholine that is dosed according to the total body weight. Monitoring of neuromuscular blockers should be used where appropriate, as well as monitoring of the depth of anaesthesia, especially when total intravenous anaesthesia is used in association with neuromuscular blockers. The occurrence of intraoperative awareness is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolism and early mobilisation are recommended, if possible included in an early rehabilitation protocol, to further reduce postoperative complications.

Resume Les patients obeses ont une diminution de CRF et un risque d’atelectasies et de SDRA, augmente mais le pronostic du SDRA n’est pas different chez les obeses. Leurs pressions de ventilation sont augmentees du fait d’une diminution de compliance thoracique pour l’essentiel. Pour pallier ces modifications, il est recommande de les ventiler en position de Trendelemburg inverse, de regler le volume courant sur la base du poids ideal et d’utiliser des niveaux de PEP plus eleves. Le monitorage de la pression transpulmonaire pourrait etre plus adapte pour ventiler les patients obeses en reanimation.

Aims: Giant-cell myocarditis (GCM) is a rare and often fatal form of myocarditis. Only a few reports have focused on fulminant forms. We describe the clinical characteristics, management and outcomes of GCM patients rescued by mechanical circulatory support (MCS). Methods and results: The clinical features, diagnoses, treatments and outcomes of MCS-treated patients in refractory cardiogenic shock secondary to fulminant GCM admitted to eight French intensive care units (2002-2016) were analysed. We also conducted a systematic review of this topic. Thirteen patients (median age 44 [range 21-76] years, Simplified Acute Physiology Score II55 [40-79]) in severe cardiogenic shock (median [range] left ventricular ejection fraction 15% [15-35%] and blood lactate 4 mmol/L) were placed on MCS 4 [0-28] days after hospital admission. Severe arrhythmic disturbances were frequent (77%), with six (46%) patients experiencing an electrical storm prior to MCS. Venoarterial extracorporeal membrane oxygenation was the first MCS option for 11 (85%) patients. GCM was diagnosed in five (38%) patients before transplant or death and treated with immunosuppressants; infections were the main complication (80%). Four patients died on MCS and no patient presented long-term survival free from heart transplant (nine patients, 69%). All transplanted patients were alive 1 year later and no GCM recurrence was reported after median follow-up of 42 [12-145] months. Conclusion: Outcomes of fulminant GCMs may differ from those of milder forms. In this context, heart transplant might likely be the only long-term survival option. (c) 2017 Elsevier B.V. All rights reserved.

Introduction L’hydroxychloroquine (HCQ) associée à l’azithromycine (AZM) fut un des premiers traitements suggérés pour le COVID-19. L’objectif de notre étude est de décrire l’évolution clinique et les effets secondaires de ce traitement chez des patients atteints de pneumopathie hypoxémiante à COVID-19. Matériels et méthodes Nous avons inclus rétrospectivement tous les patients atteints de pneumonie sévère à COVID-19 (saturation en air ambiant

Developed by Spanier in 1976, the Dyadic Adjustment Scale (DAS), a 32 items self-report tool, to assess couple satisfaction and to evaluate how each partner within the couple perceives his or her relationship. The aim of the study is to evaluate the psychometric properties of the DAS in the Italian context. The total sample size was 896 participants (M = 44.54; SD = 10). Exploratory and confirmatory factor analyses were performed in order to test the dimensionality of the analysis tool and these demonstrated the reliability of the four factors. The model, representing four dimensions of dyadic adjustment, was confirmed.

This study was designed to determine the prevalence of peripheral arterial disease (PAD) in candidates for coronary artery bypass grafting (CABG) and to assess the predictive value of different types of subclinical PAD (peripheral occlusive disease and medial arterial calcification [incompressible ankle arteries]).Observational studies report poor prognosis after CABG in the presence of clinical PAD, but data on subclinical PAD are scarce.We prospectively enrolled CABG candidates and measured ankle-brachial index (ABI) preoperatively. Patients were divided into four groups: clinical PAD, subclinical PAD (ABI0.85), incompressible arteries (ABI1.5), and no PAD. The primary end point was a composite combining death, acute coronary syndrome, stroke or transient ischemic attack (TIA), and coronary or peripheral revascularization. Secondary end points were overall and cardiovascular death, acute coronary syndrome, and stroke or TIA. Statistical analyses were performed using the Cox regression model.We consecutively enrolled 1,022 patients (mean age 66.9 +/- 9.2 years). In addition to the 14% with clinical PAD, we detected subclinical PAD in 13% and medial artery calcification in 12%. During an actuarial follow-up of 4.4 years, 81.2% of patients remained event-free. Adverse factors were (p0.05) supraventricular arrhythmia (odds ratio [OR] 2.5), ejection fraction0.40 (OR 2.3), combined valvular surgery (OR 2.5), clinical PAD (OR 3.6), subclinical PAD (OR 3.3), and medial artery calcification (OR 1.9). The latter three factors were also independently predictive for overall and cardiovascular death.Beyond clinical PAD, the measurement of ABI before coronary surgery provides substantial information on long-term postoperative prognosis. To our knowledge, this is the first study highlighting the prognostic role of incompressible ankle arteries in secondary prevention.

Background Coronary artery disease (CAD) is one of the main causes of death in patients with type-2 diabetes mellitus (T2DM), but is often atypical or asymptomatic. The aim of the study was to investigate the contribution of peripheral vascular ultrasound data in the risk stratification of silent CAD. Methods From 2010 to 2012, 541 patients with T2DM without cardiovascular (CV) history attended a CV screening consultation, including clinical, ECG and carotid and peripheral Duplex ultrasonography. According to findings, they were referred to a screening test for ischemic heart disease, and, if necessary, subsequent coronary angiography. Silent CAD was defined as ≥ 2 ischemic segments on stress cardiac imaging or as abnormal coronary angiography. Results Patients without chest pain and without ischemia on ECG represented 79% of the population, with a prevalence of silent CAD of 4% in this group. Medial calcinosis (MC) of crural arteries (OR = 5.6; 95% CI: 1.96–15.9, P = 0.001) and the presence of ≥ 3 other CV risk factors (OR = 3.2; 95%CI: 1.1–9.4, P = 0.038), were significantly associated with silent CAD. By excluding patients without any of these 2 parameters (55%), the coronary screening can be focused on a subgroup of patients at high risk (7.8%) for silent CAD, with a negative predictive value of 99.5%. Conclusion Vascular Duplex ultrasound can improve the risk stratification for silent CAD in T2DM patients.