Search

The aim of this study was to describe the prevalence, characteristics and outcome of critically burn patients with pulmonary HSV reactivation.Retrospective, single-center cohort study in a burn critical care unit in a tertiary center, including all consecutive severely burn patients with bronchoalveolar lavage performed for pneumoniae suspicion and screened for HSV from January 2013 and April 2017. We used logistic regression to identify factors associated with HSV reactivation and outcomes.94 patients were included, mean age was 51 (39-64) years; median total body surface area burned was 36 (25-54)% and ICU mortality 38%. Fifty-five patients (59%) had pulmonary HSV reactivation and 30 (55%) were treated with acyclovir. Patients with HSV reactivation were more severely ill with higher SOFA score at admission compared to patient without HSV reactivation (6 [3-8] vs. 2 [1-4], p0.0001 respectively). In multivariate analysis, sex, SOFA score at admission and smoke inhalation were significantly associated with HSV reactivation. Only septic shock was associated with 90-day mortality when HSV reactivation was not.Pulmonary HSV reactivation is frequent among severely ill burn patients. Initial severity and smoke inhalation are risk factors. Antiviral treatment was not associated with outcome.

International audience; Rationale: The relationship between the initial treatment strategy and survival in pulmonary arterial hypertension (PAH) remains uncertain. Objectives: To evaluate the long-term survival of patients with PAH categorized according to the initial treatment strategy. Methods: A retrospective analysis of incident patients with idiopathic, heritable, or anorexigen-induced PAH enrolled in the French Pulmonary Hypertension Registry (January 2006 to December 2018) was conducted. Survival was assessed according to the initial strategy: monotherapy, dual therapy, or triple-combination therapy (two oral medications and a parenteral prostacyclin). Measurements and Main Results: Among 1,611 enrolled patients, 984 were initiated on monotherapy, 551 were initiated on dual therapy, and 76 were initiated on triple therapy. The triple-combination group was younger and had fewer comorbidities but had a higher mortality risk. The survival rate was higher with the use of triple therapy (91% at 5 yr) as compared with dual therapy or monotherapy (both 61% at 5 yr) (P < 0.001). Propensity score matching of age, sex, and pulmonary vascular resistance also showed significant differences between triple therapy and dual therapy (10-yr survival, 85% vs. 65%). In high-risk patients (n = 243), the survival rate was higher with triple therapy than with monotherapy or dual therapy, whereas there was no difference between monotherapy and double therapy. In intermediate-risk patients (n = 1,134), survival improved with an increasing number of therapies. In multivariable Cox regression, triple therapy was independently associated with a lower risk of death (hazard ratio, 0.29; 95% confidence interval, 0.11-0.80; P = 0.017). Among the 148 patients initiated on a parenteral prostacyclin, those on triple therapy had a higher survival rate than those on monotherapy or dual therapy. Conclusions: Initial triple-combination therapy that includes parenteral prostacyclin seems to be associated with a higher survival rate in PAH, particularly in the youngest high-risk patients.

Background A small proportion of patients with chronic obstructive pulmonary disease (COPD) patients present severe pulmonary hypertension (PH), defined by mean pulmonary artery pressure (mPAP) ≥35 mm Hg measured by right heart catheterization. Little is known about the characteristics of severe PH-COPD. The aim of the study based on a national registry was to describe this phenotype. Methods We prospectively included and followed patients with incident PH-COPD. Clinical, functional, hemodynamic data at inclusion and follow-up were retrieved. Survival assessed by Kaplan-Meier analysis was the primary end-point. Results From 2012 to 2016, 99 patients from 13 French centers were included in the study (82 males; median age 66.0 years [interquartile range 62.0-72.0]). At inclusion, most patients had marked dyspnea (55.6% and 22.2% New York Heart Association class III and IV, respectively). During 12 months before inclusion, 42.9% had an exacerbation requiring a hospitalization. Pulmonary function tests showed a moderate obstructive pattern with median (interquartile range) FEV1 50.0 [35.0-63.0] % predicted and low diffusing capacity for carbon monoxide, median 20.0 [16.5-30.6] % predicted. The median values for PaO2 and PaCO2 on room air were 50.0 [44.8-62.0] and 36.0 [31.1-43.0] mm Hg. Median values of mPAP, pulmonary artery occlusion pressure, cardiac index and pulmonary vascular resistance were 42.0 [37.0-48.0] mm Hg, 11.0 [9.0-14.0] mm Hg, 3.0 [2.4-3.6] L/min/m2, and 6.3 [4.2-7.9] WU, respectively. Mean restricted survival was 15.0 [13.9-16.0] months. Conclusions Severe PH-COPD is characterized by moderate airway obstruction but marked dyspnea and marked hypoxemia, low DLCO and high mPAP. This phenotype is associated with poor prognosis.

Resume Introduction L’atteinte respiratoire liee a la maladie associee aux IgG4, proteiforme et d’intensite variable, peut etre grave. Nous rapportons un cas de maladie associee aux IgG4 revelee par une pneumopathie infiltrante diffuse d’aggravation rapidement progressive. Observation Il s’agit d’un homme âge de 69 ans, ancien fumeur, hospitalise initialement pour enquete etiologique d’une pneumopathie interstitielle diffuse revelee par une toux, une dyspnee febrile et une alteration de l’etat general evoluant depuis 3 mois. L’aggravation rapide de l’hypoxemie imposait un transfert en soins intensifs respiratoires pour instauration d’une ventilation non invasive (VNI) et d’une oxygenotherapie a haut debit. Le scanner thoracique revelait des condensations lobaires inferieure droite et moyenne, des plages de verre depoli diffuses, un epaississement des septa inter-lobulaires ainsi que des adenomegalies mediastinales et une pleuresie bilaterale de faible abondance. Une maladie associee aux IgG4 etait suspectee devant une augmentation des IgG4 seriques. La confirmation diagnostique fut obtenue par une biopsie renale montrant une glomerulonephrite aigue avec une infiltration lympho-plasmocytaire, une fibrose d’aspect storiforme et plus de 60 plasmocytes IgG4+ par champ a fort grossissement. L’evolution etait rapidement favorable sous corticotherapie systemique. Conclusion Habituellement au second plan, l’atteinte respiratoire de la maladie associee aux IgG4 peut egalement se reveler par une insuffisance respiratoire severe avec ou sans atteinte extra-thoracique.

Baker grade III and IV breast prosthesis capsular contractures represent a major problem for patients undergoing mammoplasties. The risk factors involved in recurrence are debated, and the best surgical approach for their prevention is not established. The objective was to identify these. We carried out a retrospective study of patients operated on for capsular contracture at the Saint-Louis Hospital in Paris from 2012 to 2014. The characteristics at inclusion were compared so as to determine the risk factors of recurrence. The surgical approaches were compared between the patients with recurrence and those without at 5 years. Of the 100 patients included, 24 had a recurrence. The minimal follow-up was 5 years. No risk factors of recurrence of capsular contracture were identified. The surgical approach associated with the lowest rate of recurrence was anterior capsulectomy [OR total capsulectomy = 2.36 (0.73; 8.037) OR capsulotomy = 4.33 (1.37; 14.81)] (p

Background & Aims Long-term outcomes in portopulmonary hypertension (PoPH) are poorly studied in the current era of pulmonary hypertension management. We analysed the effect of pulmonary arterial hypertension (PAH)-targeted therapies, survival and predictors of death in a large contemporary cohort of patients with PoPH. Methods Data from patients with PoPH consecutively enrolled in the French Pulmonary Hypertension Registry between 2007 and 2017 were collected. The effect of initial treatment strategies on functional class, exercise capacity and cardiopulmonary haemodynamics were analysed. Survival and its association with PAH- and hepatic-related characteristics were also examined. Results Six hundred and thirty-seven patients (mean age 55 ± 10 years; 58% male) were included. Fifty-seven percent had mild cirrhosis, i.e. Child-Pugh stage A. The median model for end-stage liver disease (MELD) score was 11 (IQR 9–15). Most patients (n = 474; 74%) were initiated on monotherapy, either with a phosphodiesterase-5 inhibitor (n = 336) or with an endothelin-receptor antagonist (n = 128); 95 (15%) were initiated on double oral combination therapy and 5 (1%) on triple therapy. After a median treatment time of 4.5 months, there were significant improvements in functional class (p Conclusion Survival of patients with PoPH is strongly associated with the severity of liver disease. Patients who underwent liver transplantation had the best long-term outcomes. Lay summary Portopulmonary hypertension is defined by the presence of pulmonary arterial hypertension in the context of chronic liver disease and is characterized by progressive shortness of breath and exercise limitation. The presence of severe pulmonary arterial hypertension in liver transplant candidates represents a contraindication for such a surgery; however, treatments targeting pulmonary arterial hypertension are efficacious, allowing for safe transplantation and conferring good survival outcomes in those who undergo liver transplantation.

Hypoalbuminemia is a frequent condition in the first 24 h after a severe burn injury and is associated with worse outcomes.We investigated the relation between very early hypoalbuminemia (6 h after admission) and clinical outcome in a retrospective cohort admitted to our unit for severe burn injuries between 2012 and 2017.73 severely burned patients were included, with a delay of admission of 3 (2-4) h. In a context of early exogenous supply of albumin, admission and 4H Albuminemia (Alb4 h) were significantly lower in deceased patients (respectively, 34 (29-37) vs 27 (23-30) g/l; p = 0.009 and 27 (24-32) vs 21 (17-27) g/l; p = 0.022) whereas albuminemia ≥6 h were not. The best threshold value of Alb4 h to discriminate 28-day mortality was 23 g/l. Patients with an Alb4 h 23 g/l had a higher 28-day mortality than patients with an Alb4 h ≥ 23 g/l (42% vs 11%; p = 0.003); adjusted OR = 4.47 (95% CI 1.15-17.36); p = 0.03.In severely burned patients receiving early albumin supply, early hypoalbuminemia is associated with higher mortality whereas later albuminemia (≥6 h) is not. Exploration of whether early albumin infusion (8-12 h post injury) may alter clinical outcome is warranted.

Restoration of a good hand function and limitation of the sequelae are the main concerns in burns treatment. The intrinsic plus position is known as the safe position for hand splinting. This article aims at describing the technique of external fixation that have been developed in Saint Louis’ Burn Center in management of burned hands during the acute phase. Since 2013, a technique of external fixation has been developed in our burn center using Hoffmann II External Fixation System from Stryker® and pins from Medicalex®. External fixation of a deep burned hand is an efficient and safe way to immobilize the hand in a correct intrinsic plus position, to secure the skin grafts to improve graft take and to permit changes of the dressings without removing the immobilization device.

BackgroundDrugs approved for the treatment of pulmonary arterial hypertension (PAH) improve long-term outcomes. These drugs have pulmonary vasodilator properties which may potentially cause a decrease in arterial oxyhaemoglobin saturation (SaO2) in some patients. The present retrospective study of the French Pulmonary Hypertension Registry aimed to describe the clinical characteristics and outcomes of patients showing a ≥3% decrease inSaO2while treated with PAH drugs.MethodsWe reviewed 719 PAH patients. The exclusion criteria were PAH associated with congenital heart disease and PAH with overt features of venous/capillaries involvement.Results173 (24%) patients had a ≥3% decrease inSaO2. At diagnosis, they were older with a lower diffusing capacity of the lung for carbon monoxide and a shorter 6-min walk distance compared with those who did not display a ≥3% decrease inSaO2. The percentage of patients meeting the European Society of Cardiology/European Respiratory Society (ESC/ERS) low-risk criteria at re-evaluation was significantly lower in those with a ≥3% decrease inSaO2and more patients started long-term oxygen therapy in this group (16%versus5%; pSaO2was associated with a poorer survival (hazard ratio 1.81, 95% CI 1.43–2.34; pSaO2was a prognostic factor independent of age at diagnosis and ESC/ERS risk stratification at follow-up.ConclusionsWhen treated with PAH drugs, a large subset of patients experience a ≥3% decrease inSaO2, which is associated with worse long-term outcomes and reduced survival.

Study Objectives:Our objectives were to determine in an obese population (body mass index > 35 kg/m2) the number of patients, after gastric bypass (GBP), who no longer met French Ministry of Health...

In light of the concerns regarding the occurrence of anaplastic large-cell lymphoma, seromas, and scar capsules, there appears to be merit in analysis and presentation of the results of our series of inflatable smooth implants filled with saline solution, for which the follow-up was more than 10 years. We carried out a retrospective study, including all of the patients who underwent a first breast implant for cosmetic reasons, between 2003 and 2006. A total of 383 patients with 766 smooth implants filled with saline solution were included in our study. No cases of lymphoma and seroma were diagnosed. Eleven patients exhibited a postoperative hematoma, and four went on to develop a capsule. Twenty-two patients (5.7%) developed a Baker Grade III or IV capsule that required revision surgery. Two patients (0.5%) opted for a bilateral prosthesis replacement due to visual rippling. In total, there were 26 (3.4%) early deflations of prostheses. There is not a statistically significant correlation between the occurrence of hematomas and the formation of a capsule. We found a lower shell rate with smooth-walled versus textured implants. The fact of having a decline of 10 years allows to be exhaustive. As for wrinkling and ripples, their occurrence has not been increased by the use of inflatable retropectoral implants. Smooth inflatable implants filled with saline solution have numerous advantages such as the possibility of a very small approach route and perioperative adaptability of the volume. In light of the lack of indication of anaplastic large-cell lymphoma with smooth implants, they are clearly an attractive alternative to textured implants filled with silicone gel. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

International audience; Background: Multidrug-resistant (MDR) bacteria outbreaks represent a major threat in intensive care units. Patients may then be exposed to drug-related direct toxicity during such outbreaks. The objective of this study was to explore the impact of an outbreak of imipenem-resistant Acinetobacter baumannii (IR-AB) on renal outcomes.Methods: We performed a before-and-after observational study in a French burn intensive care unit during an IR-AB outbreak: a 13-month period before (period A, October 2013-October 2014) and a 13-month period after outbreak control (period B, December 2014-December 2015). A total of 409 patients were included, 195 during period A and 214 during period B. The main endpoint was major adverse kidney events at day 90 (MAKE 90). Secondary endpoints were acute kidney injury (AKI) and persistent renal dysfunction.Results: Incidence of MAKE 90 was 15.9% during period A versus 11.2% during period B (P = .166) and AKI 28.2% versus 18.7% (P = .023). The use of colistin was associated with renal outcomes in univariate analysis. After adjustment of potential confounding factors using a targeted Machine Learning Analysis (ie, IR-AB-related infection, septic shock, severity scores, other nephrotoxics, chronic kidney disease, serum creatinine at admission, Staphylococcus aureus), colistin remained associated with the risk of MAKE and AKI (relative risk = 2.909, 95% confidence interval [CI] [1.364, 6.204], P = .006 for MAKE 90, and relative risk = 2.14, 95% CI [1.52, 3.02], P

BACKGROUND Patients with extensive burns are at risk of developing candidemia. OBJECTIVES To identify potentially modifiable risk factors and outcomes of candidemia in critically ill burns patients. PATIENTS AND METHODS Retrospective matched cohort study including adult burns patients. Patients who developed candidemia were matched with burns patients with Candida spp colonisation and sepsis or septic shock without candidemia in a ratio of 1:3 (same severity scores and colonisation index). Univariate and multiple regression analyses were performed. RESULTS Of 130 severely burned patients with Candida spp colonisation and at least one episode of sepsis or septic shock, 14 were diagnosed with candidemia. In the candidemia group, patients had a median (IQR) total burns surface area (TBSA) of 57 (38-68)%, SAPSII of 43 (36-58) and ABSI of 11 (8-13). Multiple regression analysis showed that only duration of prior antibiotic therapy was independently associated with candidemia. ICU mortality was higher in the candidemia group (71% vs 35% [P = 0.02]). The log-rank test for 28-day mortality comparing patients with candidemia treated with an empirical strategy vs a curative strategy did not reach significance (P = 0.056). CONCLUSIONS Burns patients having received recent antibiotherapy have a higher risk of candidemia. Antifungal strategies did not influence outcome in this series.

To investigate in singleton multiparous pregnancies the effect of having a new father for an index pregnancy on new-borns' birthweights and intrauterine growth restriction.20 year-observational cohort study (2001-2020).Centre Hospitalier Universitaire Hospitalier Sud Reunion's maternity (French overseas department, Indian Ocean).Comparing the 811 multiparas (cases) who had a new partner with the 49,712 who did not (controls), there were no differences concerning maternal age, education, ovulation induction/IVF, previous miscarriages, exams during pregnancies, pre-pregnancy BMI, gestational diabetes, and chronic hypertension. Cases had more previous pregnancies than controls (gravidity 4.2 vs 2.8, p 0.001), volunteer abortions (OR1.93, p 0.001), in vitro fecundations (OR 4.34, p 0.001), were more likely to be unmarried (OR 2.94, p 0.001) smoker (OR 2.2, p 0.0001) and consuming alcohol during pregnancy (OR 2.35, p = 0.001). Cases had a much higher risk of preeclampsia than controls (OR 3.94, p 0.001), especially early-onset preeclampsia (34 weeks) with an OR 4.1 (p 0.001). Controlling for confounding factors (preeclampsia, smoking, alcohol use, early prematurity33 weeks, maternal ethnicity), primipaternity was an independent factor for small for gestational age newborns (OR 1.48, p 0.001).It has been known for decades that primiparas have lighter babies than multiparas. Primipaternity represents also a risk for lower birth weights. Human birthweight seems to be linked with a "couple habituation" (to paternal genes) which may be not fully established in the first pregnancy of the couple.

Objective: There are few means to treat large keloid scars, as exeresis—even if partial—impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation. Method: A retrospective study of patients treated for keloid scars by using the new therapeutic protocol. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume. Results: A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. The mean surface area was 21.6cm2. Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. Based on adherence with the corticotherapy, two patient groups could be discerned. For patients in the ‘adherent’ group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases. Conclusions: The healing rate in this study was close to that reported in the literature. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. The protocol in this study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids. It could potentially offer a treatment option in case of failure of other treatments, large keloid scars or scalp keloids.

Previous studies have suggested an association between uric acid (UA) and the severity of pulmonary arterial hypertension (PAH), but it is unknown whether UA contributes to disease pathogenesis.The aim of this study was to determine the prognostic value of circulating UA in the era of current management of PAH and to investigate the role of UA in pulmonary vascular remodelling.Serum UA levels were determined in idiopathic, heritable or anorexigen PAH at baseline and first re-evaluation in the French Pulmonary Hypertension Network. We studied protein levels of xanthine oxidase (XO) and the voltage-driven urate transporter 1 (URATv1) in lungs of control and PAH patients and of monocrotaline (MCT) and Sugen/hypoxia (SuHx) rats. Functional studies were performed using human pulmonary artery smooth muscle cells (PA-SMCs) and two animal models of pulmonary hypertension (PH).High serum UA levels at first follow-up, but not at baseline, were associated with a poor prognosis. Both the generating enzyme XO and URATv1 were upregulated in the wall of remodelled pulmonary arteries in idiopathic PAH patients and MCT and SuHx rats. High UA concentrations promoted a mild increase in cell growth in idiopathic PAH PA-SMCs, but not in control PA-SMCs. Consistent with these observations, oxonic acid-induced hyperuricaemia did not aggravate MCT-induced PH in rats. Finally, chronic treatment of MCT and SuHx rats with benzbromarone mildly attenuated pulmonary vascular remodelling.UA levels in idiopathic PAH patients were associated with an impaired clinical and haemodynamic profile and might be used as a non-invasive indicator of clinical prognosis during follow-up. Our findings also indicate that UA metabolism is disturbed in remodelled pulmonary vascular walls in both experimental and human PAH.

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension. Heritable and sporadic forms have been distinguished. Hypoxemia, profound reduction in the diffusion of carbon monoxide and haemodynamic confirmation of pre-capillary pulmonary hypertension are the major diagnostic criteria. Thoracic CT scanning and a response to pharmaceutical therapy provide additional information to confirm the diagnosis. A 52-year-old patient, three of whose siblings had pulmonary hypertension, was admitted with dyspnoea, malaise and palpitations. Right heart catheterisation confirmed pre-capillary pulmonary hypertension. A search for an EIF2AK4 mutation was carried out, and this showed a composite biallelic heterozygous mutation compatible with the diagnosis of familial PVOD, identical to that showed in one of his brothers. Given the signs of severity of the disease and the diagnosis of PVOD, whose response to pharmaceutical therapy is often poor, the patient was placed on a waiting list for lung transplantation. Despite a similar diagnosis in 3 brothers and follow-up proposed 11 years before the diagnosis, pulmonary hypertension appeared within a few weeks and led immediately to a severe clinical situation. Annual clinical and echocardiographic monitoring had been strongly advised to the patient, but had not allowed diagnosis at a mild or moderate stage of the disease. This clinical case shows that the identification of factors predicting the development of heritable PVOD at a pre-symptomatic stage is an important issue for clinical research.

BACKGROUND More than 300,0000 breast plastic surgery procedures are performed annually worldwide, of which more than 100,000 are reduction mammoplasties carried out in the United States. Although most patients tend to be satisfied with the immediate outcomes of this procedure, there is increasing concern among surgeons as well as patients with regard to breast sensibility and the postoperative recovery.The objectives of this study were to assess the variation in the sensibility in patients undergoing hypertrophic breast surgery by quantification of the impact of various variables and to evaluate its progression from before the surgery to between 3 and 6 months and 1 year postoperatively. METHODS We carried out a nonrandomized, monocentric, prospective study. All of the patients were examined by the same evaluator using a set of 20 von Frey monofilaments on the day before the surgery and at 3 to 6 months and 1 year postoperatively. The breast skin, areola, and nipple sensibilities were tested. Age, body mass index, tobacco use, and the breast volume were recorded. RESULTS We did not find any significant effect of the body mass index, tobacco use, or age on breast sensibility. The nipple and areola complex (NAC) sensibility was inversely correlated with the degree of hypertrophy before the surgery, but this difference disappeared in the postoperative evaluations. After the surgery, the NAC sensibility decreased at the first follow-up at 4.5 months and returned to normal after 1 year. CONCLUSIONS The inverse relationship between breast volume and sensibility in the preoperative evaluation disappeared after mammaplasty reduction. In the early postoperative period, the sensibility decreased on the NAC but returned to normal after 1 year.

Resume Introduction Les pneumopathies a eosinophiles sont caracterisees par une alveolite a polynucleaires eosinophiles. Elles peuvent etre idiopathiques ou relever de differentes causes. L’origine medicamenteuse doit etre toujours evoquee. Observation Nous rapportons le cas d’une femme de 57 ans, fumeuse, atteinte d’un trouble bipolaire, traitee par divalproate de sodium depuis plus de 2 ans, qui presentait une dyspnee non febrile depuis 5 mois. Les explorations realisees montraient une hypoxemie severe, un trouble ventilatoire obstructif severe, de multiples images en verre depoli avec un aspect de crazy paving au scanner thoracique, une hypereosinophilie sanguine et une alveolite a eosinophiles au lavage broncho-alveolaire. Le diagnostic de pneumopathie a eosinophiles au divalproate de sodium etait retenu apres un bilan etiologique exhaustif, et l’amelioration radio-clinique etait rapide apres l’arret du medicament, sans recours a la corticotherapie systemique. Conclusion Le divalproate de sodium peut induire une pneumopathie a eosinophiles plusieurs annees apres son introduction. Un diagnostic rapide et un arret du traitement ont permis une guerison complete dans le cas rapporte.

Introduction Deep soft tissue defects next to the joints can rapidly lead to irreversible damages and have to be covered urgently and effectively. In severely burned patients the usual approach is to use a flap even though it has its limitations in regards to the extent of the burn and the general condition of the patient. Case report A twenty seven-year-old male was admitted at the Burn Treatment Center for a thermic burn of seventy-two percent of his body surface area. At first he has benefited from several skin grafts and later on a major open right elbow had to be treated urgently to rescue the joint. Results After the burn, a revascularization of the donor site was noticed, sufficient to use the radial forearm pedicled flap as a cover for the elbow. This case reports an innovative approach based on the use of an irrigation and drainage system placed underneath the flap. The elbow was rigidly immobilized with an external fixator in order to facilitate an optimal healing of the flap. Conclusion In this case, the choice of this flap, combined with the irrigation and drainage system and the immobilization by external fixation, provided an original and efficient treatment. Post operatively the healing of the flap and of the donor site was complete. The functional results exceeded the expectations with a complete recovery of the joint amplitude. Thus, in case of no other therapeutic options, it is probably possible to use a variety of flaps recently healed.

Objective: To assess the efficiency of the endometrial immune profiling as a method to design personalized care to enhance the pregnancy rate in a large heterogeneous infertile population. We hypothesized that some reproductive failures could be induced by a uterine immune dysregulation which could be identified and corrected with a targeted plan. Design: Prospective cohort study. Setting: Multicentric study. Intervention(s) and Main outcome measure(s): One thousand and seven hundred thirty-eight infertile patients had an immune profiling on a timed endometrial biopsy between 2012 and 2018. This test documented the absence or the presence of an endometrial immune dysregulation and identified its type. In case of dysregulation, a targeted personalized plan was suggested to the treating clinician aiming to supply the anomaly. One year after the test, the clinician was contacted to provide the outcome of the subsequent embryo transfer with the applied suggested plan. Result(s): After testing, 16.5% of the patients showed no endometrial immune dysregulation, 28% had a local immune under-activation, 45% had a local immune over-activation, and 10.5% had a mixed endometrial immune profile. In patients with a history of repeated implantation failures (RIF) or recurrent miscarriages (RM), the pregnancy rate was significantly higher if an endometrial dysregulation was found and the personalized plan applied, compared to the patients with an apparent balanced immune profile (respectively 37.7 and 56% vs. 26.9 and 24%, p < 0.001). In contrast, in good prognosis IVF (in vitro fertilization) subgroup and patients using donor eggs, this difference was not significant between dysregulated and balanced subgroups, but higher pregnancy rates were observed in absence of dysregulation. For patients with immune over-activation, pregnancy rates were significantly higher for patients who had a test of sensitivity, regarding the type of immunotherapy introduced, when compared to the ones who did not (51 vs. 39.9%, p = 0.012). Conclusion(s): Local endometrial immunity appears to be a new and important parameter able to influence the prognosis of pregnancy. Targeted medical care in case of local immune dysregulation resulted in significantly higher pregnancy rates in RIF and RM patients.

Rationale: Pulmonary hypertension (PH) associated with neurofibromatosis type 1 (NF1) is a rare and largely unknown complication of NF1.Objectives: To describe characteristics and outcomes of PH-NF...

IntroductionTBX4 mutation causes small patella syndrome (SPS) and/or pulmonary arterial hypertension (PAH). The characteristics and outcomes of PAH associated with TBX4 mutations are largely unknown.MethodsWe report the clinical, functional, radiologic, histologic and haemodynamic characteristics and outcomes of heritable PAH patients carrying a TBX4 mutation from the French pulmonary hypertension (PH) network.Results20 patients were identified in 17 families. They were characterised by a median age at diagnosis of 29 years (0–76 years) and a female to male ratio of three. Most of the patients (70%) were in New York Heart Association (NYHA) functional class III or IV with a severe haemodynamic impairment (median pulmonary vascular resistance (PVR) of 13.6 (6.2–41.8) Wood units). Skeletal signs of SPS were present in 80% of cases. Half of the patients had mild restrictive or obstructive limitation and diffusing capacity of the lung for carbon monoxide (DLCO) was decreased in all patients. High-resolution computed tomography (HRCT) showed bronchial abnormalities, peri-bronchial cysts, mosaic distribution and mediastinal lymphadenopathies. PAH therapy was associated with significant clinical improvement. At follow-up (median 76 months), two patients had died and two had undergone lung transplantation. One-year, three-year and five-year event-free survival rates were 100%, 94% and 83%, respectively. Histologic examination of explanted lungs revealed alveolar growth abnormalities, major pulmonary vascular remodelling similar to that observed in idiopathic pulmonary arterial hypertension (IPAH) and accumulation of cholesterol crystals within the lung parenchyma.ConclusionPAH due to TBX4 mutations may occur with or without skeletal abnormalities across a broad age range from birth to late adulthood. PAH is usually severe and associated with bronchial and parenchymal abnormalities.

Background: Assessment of prognosis is of major importance when deciding on a therapeutic strategy in patients with pulmonary arterial hypertension (PAH). Objectives: The aim of this study was to investigate the prognostic value of pulmonary hemodynamics during exercise and changes during treatment in patients with PAH. Methods: Consecutive incident patients (n = 49) with PAH undergoing right heart catheterization at rest and during a constant workload cycle exercise in supine position were included. Predictors of survival were identified at baseline using Cox proportional hazard regression models in a univariate analysis unadjusted and adjusted for age and gender. Results: During a median follow-up period of 42 months, 13 (27%) of the 49 patients studied died. Two predictors of death were found: rest-to-exercise changes in heart rate and systolic pulmonary artery pressure. Adjusted hazard ratios were 0.92 (95% CI 0.86–0.99) and 0.93 (95% CI 0.88–0.99), respectively. These 2 variables were correlated with each other (r = 0.55, p < 0.001). Conclusions: Rest-to-exercise changes in heart rate and systolic pulmonary artery pressure measured at diagnosis are predictors of survival in patients with PAH. These measurements taken from an exercise test reflect right ventricular function.

BACKGROUND: Patients with COPD who experience pulmonary hypertension (PH) have worse mortality than those with COPD alone. Predictors of poor outcomes in COPD-PH are not well-described. Diffusing capacity of the lung (Dlco) assesses the integrity of the alveolar-capillary interface and thus may be a useful prognostic tool among those with COPD-PH. RESEARCH QUESTION: Using a single center registry, we sought to evaluate Dlco as a predictor of mortality in a cohort of patients with COPD-PH. STUDY DESIGN AND METHODS: This retrospective cohort study analyzed 71 COPD-PH patients from the Johns Hopkins Pulmonary Hypertension Registry with right-sided heart catheterization (RHC)-proven PH and pulmonary function testing data within one year of diagnostic RHC. Transplant-free survival was calculated from index RHC. Adjusted transplant-free survival was modelled using Cox proportional hazard methods; age, pulmonary vascular resistance, FEV(1), oxygen use, and N-terminal pro-brain natriuretic peptide were included as covariates. RESULTS: Overall unadjusted transplant-free 1-, 3-, and 5-year survivals were 87%, 60%, and 51%, respectively. Survival was associated with reduced Dlco across the observed range of pulmonary artery pressures and pulmonary vascular resistance. Severe Dlco impairment was associated with poorer survival (log-rank χ(2) 13.07) (P < .001); adjusting for covariates, for every percent predicted decrease in Dlco, mortality rates increased by 4% (hazard ratio, 1.04; 95% CI, 1.01-1.07). INTERPRETATION: Among patients with COPD-PH, severe gas transfer impairment is associated with higher mortality, even with adjustment for airflow obstruction and hemodynamics, which suggests that Dlco may be a useful prognostic marker in this population. Future studies are needed to further investigate the association between Dlco and morbidity and to determine the utility of Dlco as a biomarker for disease risk and severity in COPD-PH.

Rationale: Oral treprostinil improves exercise capacity in patients with pulmonary arterial hypertension (PAH), but the effect on clinical outcomes was unknown.\ud \ud Objectives: To evaluate the effect of oral treprostinil compared with placebo on time to first adjudicated clinical worsening event in participants with PAH who recently began approved oral monotherapy.\ud \ud Methods: In this event-driven, double-blind study, we randomly allocated 690 participants (1:1 ratio) with PAH to receive placebo or oral treprostinil extended-release tablets three times daily. Eligible participants were using approved oral monotherapy for over 30 days before randomization and had a 6-minute-walk distance 150 m or greater. The primary endpoint was the time to first adjudicated clinical worsening event: death; hospitalization due to worsening PAH; initiation of inhaled or parenteral prostacyclin therapy; disease progression; or unsatisfactory long-term clinical response.\ud \ud Measurements and Main Results: Clinical worsening occurred in 26% of the oral treprostinil group compared with 36% of placebo participants (hazard ratio, 0.74; 95% confidence interval, 0.56–0.97; P = 0.028). Key measures of disease status, including functional class, Borg dyspnea score, and N-terminal pro–brain natriuretic peptide, all favored oral treprostinil treatment at Week 24 and beyond. A noninvasive risk stratification analysis demonstrated that oral treprostinil–assigned participants had a substantially higher mortality risk at baseline but achieved a lower risk profile from Study Weeks 12–60. The most common adverse events in the oral treprostinil group were headache, diarrhea, flushing, nausea, and vomiting.\ud \ud Conclusions: In participants with PAH, addition of oral treprostinil to approved oral monotherapy reduced the risk of clinical worsening.\ud \ud Clinical trial registered with www.clinicaltrials.gov (NCT01560624).

Resume Introduction Les anticorps anti programmed death-1 (PD-1) et programmed death-ligand 1 (PD-L1) sont des immunotherapies utilisees dans le traitement de nombreuses tumeurs solides. Des cas de pneumopathies interstitielles induites par les anti PD-1 ont largement ete decrits, mais les donnees sont moins nombreuses avec les anti PD-L1. L’avelumab est une nouvelle immunotherapie de la classe des anti PD-L1. Observation Il s’agit d’une femme de 66 ans, tabagique sevree, traitee par avelumab et axitinib depuis le 15 novembre 2016 pour un cancer renal a cellules claires. Elle presente une pneumopathie interstitielle decouverte fortuitement 4 mois apres le debut du traitement avec des lesions scannographiques de verre depoli, des reticulations intra-lobulaires et une adenopathie de la zone 4R. Le bilan exhaustif ne met pas en evidence de retentissement fonctionnel respiratoire, ni d’etiologie infectieuse ou immunologique. Les anomalies radiologiques regressent spontanement apres l’arret du traitement, permettant de retenir le diagnostic de pneumopathie medicamenteuse. Conclusion L’avelumab peut induire une pneumopathie interstitielle. Son mecanisme incertain necessite des etudes complementaires. Une surveillance des explorations fonctionnelles respiratoire et du scanner thoracique est necessaire pour une prise en charge precoce.

The analysis of right ventriculo-arterial coupling (RVAC) from pressure-volume loops is not routinely performed. RVAC may be approached by the combination of right heart catheterization (RHC) pressure data and cardiac magnetic resonance (CMR)-derived right ventricular (RV) volumetric data. RV pressure and volume measurements by Doppler and three-dimensional echocardiography (3DE) allows another way to approach RVAC.Ninety patients suspected of having pulmonary hypertension underwent RHC, 3DE, and CMR (RHC mean pulmonary artery pressure [mPAP] 37.9 ± 11.3 mm Hg; range, 15-66 mm Hg). Three-dimensional (3D) echocardiography was performed in 30 normal patients (echocardiographic mPAP 18.4 ± 3.1 mm Hg). Pulmonary artery (PA) effective elastance (Ea), RV maximal end-systolic elastance (Emax), and RVAC (PA Ea/RV Emax) were calculated from RHC combined with CMR and from 3DE using simplified formulas including mPAP, stroke volume, and end-systolic volume.Three-dimensional echocardiographic and RHC-CMR measures for PA Ea (3DE, 1.27 ± 0.94; RHC-CMR, 0.71 ± 0.52; r = 0.806, P .001), RV Emax (3DE, 0.72 ± 0.37; RHC-CMR, 0.38 ± 0.19; r = 0.798, P .001), and RVAC (3DE, 2.01 ± 1.28; RHC-CMR, 2.32 ± 1.77; r = 0.826, P .001) were well correlated despite a systematic overestimation of 3DE elastance parameters. Among the whole population, 3D echocardiographic PA Ea and 3D echocardiographic RVAC but not 3D echocardiographic RV Emax were significantly lower in patients with mPAP25 mm Hg (n = 41) than in others (n = 79). Among the 90 patients who underwent RHC, 3D echocardiographic PA Ea and 3D echocardiographic RVAC but not 3D echocardiographic RV Emax increased significantly with increasing levels of pulmonary vascular resistance.Three-dimensional echocardiography-derived PA Ea, RV Emax, and RVAC correlated well with the reference RHC-CMR measurements. Ea and RVAC but not Emax were significantly different between patients with different levels of afterload, suggesting failure of the right ventricle to maintain coupling in severe pulmonary hypertension.

In burn patients, meshed split thickness skin grafts are commonly used on large and non-flat areas whom immobilization is difficult to achieve. The frequent mobilizations of burn patients can make the graft slip and prevent the revascularization and therefore the taking of the skin graft. In order to prevent this pitfall, we modified and adapted the tie-over dressing procedure. The giant running tie-over dressing enables large skin grafts to be applied to their wound bed and therefore helps revascularization. Some cautions are necessary in order to avoid any infection. This original and easy-to-perform procedure answers to the difficulties of large split-thickness skin grafts in burn patients.

Resume Introduction Le carcinome basocellulaire (CBC) est une pathologie a evolution locale, frequente chez les sujets âges qui presentent une fragilite pouvant freiner les indications du traitement chirurgical, bien qu’il soit le traitement de reference. L’objectif de cette etude est d’analyser la morbidite et la mortalite associees au traitement chirurgical des CBC chez des patients de plus de 75 ans, afin d’isoler d’eventuels facteurs pronostics de complications postoperatoires. Materiel et methode Il s’agit d’une etude retrospective realisee chez des patients de plus de 75 ans traites chirurgicalement pour un ou plusieurs CBC entre 2010 et 2015 dans le service de chirurgie plastique reconstructrice et esthetique de l’hopital Saint-Louis a Paris. Les caracteristiques demographiques, les caracteristiques du traitement ainsi que le taux de complications majeures postoperatoires ont ete recenses. Une analyse univariee puis multivariee des differents facteurs de risque retrouves ont ete effectuees. Resultats Au total, 158 patients ont ete analyses, avec un taux de complications majeures de 12 %. Les analyses statistiques ont retrouve 5 facteurs de risque significatifs : un âge superieur a 85 ans (p = 0,006), la prise d’un traitement anticoagulant au long cours (p = 0,02), la presence d’au moins une comorbidite (p = 0,018), une hospitalisation traditionnelle (p = 0,002) et la realisation d’une anesthesie generale (p = 1,2e−10). Conclusion Il a ete identifie 5 facteurs de risque de complications majeures postoperatoires dans le traitement chirurgical des CBC chez les patients de plus de 75 ans. Ces facteurs pourraient orienter les equipes medico-chirurgicales dans la prise en charge optimale du CBC chez le patient âge.

Summary Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment – excision surgery, early rehabilitation, and antalgia – seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

Resume Introduction Les complications cicatricielles post-chirurgie abdominale ou pelvienne sont plus frequentes chez les patientes obeses. L’infection, les seromes et les retards de cicatrisation occasionnes peuvent dans ce cas etre extremement difficiles a traiter. L’objectif de cette note technique est de vous presenter un cas original d’une patiente de 48 ans obese, operee neuf ans auparavant d’une hysterectomie par laparotomie et presentant de maniere chronique une fistule chronique associee a une lymphorree septique non resolutive malgre de multiples interventions chirurgicales, dont la guerison a pu etre obtenue par un lambeau de grand epiploon. Technique chirurgicale L’ideal est de realiser cette intervention en double equipe avec un chirurgien digestif en cas de survenue de plaie viscerale ou vasculaire intra-abdominale durant la dissection. Le lambeau de grand epiploon etait leve de maniere classique sur l’artere gastro-epiploique droite. Un orifice suffisamment large doit etre laisse au niveau de l’aponevrose abdominale afin d’eviter toute compression du pedicule. Enfin, le lambeau doit etre etale sur toute la surface du decollement et fixe a l’aponevrose anterieure. Conclusion La fiabilite et la richesse a la fois vasculaire et lymphatique font du lambeau de grand epiploon une methode tres efficace dans les cas de plaies chroniques associees a une lymphorrhee majeure. La cicatrisation obtenue dans le cas clinique presente met ainsi en valeur les qualites specifiques de ce lambeau.

Introduction With more than 10 million of daily users, e-cigarettes encountered a great success. But in the past few years, the number of medical reports of injuries caused by the explosion of e-cigarettes has significantly increased. This article aims at reporting our series and reviewing the literature to propose a new classification based on the mechanisms of injuries related to e-cigarettes that can guide non-specialists and specialists in the management of these patients. Method We performed a retrospective review of our institutional burn database from June 2016 to July 2017 for injuries caused by or in the context of using an e-cigarette. The patients’ demographics (age, gender), burn injury mechanisms, depth, localization, surface and interventions were described. Results Ten patients suffered from burns related to the use of e-cigarettes. The burns were located at the thigh (80%) and the hand (50%) with a mean surface of 3% of TBSA. Four different mechanisms could be described: Type A: thermal burns with flames due to the phenomenon of “thermal runaway”, Type B: blasts lesions secondary to the explosion, Type C: chemical alkali burns caused by spreading of the electrolyte solution and Type D: thermal burns without flames due to overheating. These different mechanisms suggest specific surgical and non-surgical management. Conclusion Management of injuries sustained from e-cigarettes’ explosions should be approached from the standpoint of mechanisms. Different mechanisms could be associated and should be considered in specific management.

Resume Introduction L’hypertension arterielle pulmonaire (HTAP) est une maladie vasculaire pulmonaire dont le pronostic est sombre. Le traitement par analogues des prostacyclines i.v. continu impose la mise en place d’un catheter tunnelise. Le taux d’infection liee au catheter tunnelise dans ce contexte est peu frequent du fait du pH alcalin des solutions d’analogues des prostacyclines. Observation Une patiente de 50 ans, atteinte d’HTAP heritable traitee par bosentan, sildenafil et epoprostenol presentait une alteration de l’etat general avec un amaigrissement de 9 kg sur une periode de 12 mois, sans syndrome infectieux ou tumoral. On ne notait pas d’aggravation hemodynamique. Le diagnostic est pose a un an de suivi, la patiente presentant une febricule a 38°C et un syndrome inflammatoire biologique. Les hemocultures peripheriques repetees reviennent positives a Dietzia, un bacille coryneforme alcalophile. L’evolution est favorable sous antibiotherapie. Conclusion L’infection de catheter tunnelise doit etre evoquee en cas d’aggravation clinique ou hemodynamique chez un patient atteint d’HTAP traite par analogues des prostacyclines administres en intraveineux. Dans ce contexte, le laboratoire doit etre prevenu de la recherche de germes a croissance lente.

Rare and dreaded, necrosis of the nipple-areola complex (NAC) is one of the major complications of breast reduction surgery. Our objective was to establish a management algorithm summarizing the different possible treatments reported in the literature. The data extracted from the articles selected for this literature review covered surgical techniques, frequency of NAC necrosis, type of necrosis, and management proposed for women who have had this surgery for macromastia. In the 54 articles finally selected, the mean frequency of NAC necrosis was 5.1%. The risk factors for necrosis were the weight of the tissue resected, smoking, obesity, the surgical technique used, and stretch marks. The treatments proposed were listed according to four categories of issues: patient-specific susceptibility, type of breast, surgical technique, and its technical performance. No consensus exists about the management of NAC necrosis, which remains a complication feared by surgeons. We propose a management algorithm that simplifies the therapeutic indications. Level of Evidence: Not ratable

Summary Introduction The sub-muscular placement of cosmetic breast implants leads to substantial pain due to the muscular distention. The aim of this study was to assess the efficiency of intraoperative ropivacaine instillation to reduce postoperative pain the day after surgery. Material and methods We conducted a prospective, controlled, single-blinded study comparing the intraoperative instillation of 7.5 mg of ropivacaine through Redon drains with the standard procedure in 72 patients undergoing sub-muscular cosmetic breast augmentation for the first time. Results Pain at the awakening on postoperative day 1 was 4.8 on a simple numeric pain scale in the treatment group and 5.1 in the control group (P > 0.05). On postoperative day 3, pain at awakening was 3.7 in both groups (P > 0.05), and on postoperative day 5, pain was 2.8 in the treatment group and 2.7 in the control group (P > 0.05). Conclusion Local instillation of ropivacaine in the implant pocket during surgery did not decrease postoperative pain on day 1, day 3 and day 5. From now on, we are able to tell to patients that the postoperative pain after sub-muscular cosmetic breast implants surgery is about 5/10 on postoperative day 1, 4/10 at day 3 and 3/10 at day 5. Level of evidence Level II.

In cases involving small burns in patients without a comorbidity or associated pathology, a referral from a surgeon is necessary and sometimes it cannot be ascertained when the patient is not brought in by a specialized team. The purpose of this retrospective study was to evaluate the quality of our method for performing telemedicine. This retrospective study included the 323 patients who were initially treated using the telemedicine system implemented between 2011 and 2016. This procedure only involved patients burned over a small portion of their body's surface area (ie, ≤15%) who were between 15 and 75 years of age and who did not have a major comorbidity. The purpose of the procedure was to evaluate the need for surgery. The initial diagnosis regarding the need for a surgical procedure was accurate in 94.4% (305/323) of the cases. Eleven patients (3.4%) were transferred unnecessarily as they ultimately did not require surgery, and seven patients (2.2%) were ultimately transferred even though the need for surgery was not initially established at the time that the pictures were viewed. No initial errors in the photographic evaluation caused a worsening in the life-threatening, functional, or aesthetic prognoses. We have recently opted to use telemedicine for initial patient management. In 94.4% of cases, the opinion that was provided was accurate. Only 3.2% of the patients for whom outpatient treatment was recommended ultimately underwent surgery without subsequently experiencing the slightest injury due to any delay in therapy. Although it will never replace clinical examination, these results have encouraged us to develop telemedicine based on digital photography.

IntroductionContemporary risk assessment tools categorise patients with pulmonary arterial hypertension (PAH) as low, intermediate or high risk. A minority of patients achieve low risk status with most remaining intermediate risk. Our aim was to validate a four-stratum risk assessment approach categorising patients as low, intermediate-low, intermediate-high or high risk, as proposed by the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) investigators.MethodsWe evaluated incident patients from the French PAH Registry and applied a four-stratum risk method at baseline and at first reassessment. We applied refined cut-points for three variables: World Health Organization functional class, 6-min walk distance and N-terminal pro-brain natriuretic peptide. We used Kaplan–Meier survival analyses and Cox proportional hazards regression to assess survival according to three-stratum and four-stratum risk approaches.ResultsAt baseline (n=2879), the four-stratum approach identified four distinct risk groups and performed slightly better than a three-stratum method for predicting mortality. Four-stratum model discrimination was significantly higher than the three-stratum method when applied during follow-up and refined risk categories among subgroups with idiopathic PAH, connective tissue disease-associated PAH, congenital heart disease and portopulmonary hypertension. Using the four-stratum approach, 53% of patients changed risk category from baseline compared to 39% of patients when applying the three-stratum approach. Those who achieved or maintained a low risk status had the best survival, whereas there were more nuanced differences in survival for patients who were intermediate-low and intermediate-high risk.ConclusionsThe four-stratum risk assessment method refined risk prediction, especially within the intermediate risk category of patients, performed better at predicting survival and was more sensitive to change than the three-stratum approach.

Objectives To evaluate the interchangeability of oxygen consumption variations measured with the Fick equation (ΔVO2Fick) and indirect calorimetry (ΔVO2Haldane) in critically ill burns patients. Methods Prospective observational single-center study conducted in a university hospital. Twenty-two consecutive burns patients with circulatory insufficiency and hyperlactatemia (>2 mmol/L) who required a fluid challenge (FC) were included. All patients had cardiac output monitoring (transpulmonary thermodilution technique) and were ventilated and sedated. Simultaneous measurements of VO2Fick and VO2Haldane were performed before and immediately after the FC, at rest, and in hemodynamic conditions stabilized for at least 1 h. VO2Fick and VO2Haldane were measured, respectively, with the standard formulae (using arterial and central venous saturation measured with a blood gas analyzer) and with a metabolic monitor. Results Forty-four paired measurements of VO2 were obtained. At each timepoint, the median (interquartile range, 25-75) VO2Haldane values were significantly higher than the median VO2Fick values (126 (103-192) vs. 90 (66-149) mL O2/min/m (P = 0.004) before FC and 129 (105-189) vs. 80 (54-119) mL O2/min/m (P = 0.001) after FC). Correlation between the ΔVO2Fick and the ΔVO2Haldane (%) measurements was poor, with an r = 0.06, (P = 0.77). The mean bias was 8.6% [limits of agreement (LOA): -75.7%, 92.9%]. Conclusions Analysis of agreement showed poor concordance for the ΔVO2Haldane and the ΔVO2Fick (%) with a low mean bias but large and clinically unacceptable LOA. ΔVO2Haldane and ΔVO2Fick (%) are not interchangeable in these conditions.

Not only has tattooing been socially performed for thousands of years, but it has also been part and parcel of medical practice since antiquity. In our day and age, plastic surgeons are ever more frequently compelled to deal with tattooing, whether in terms of its medical application or its complications. While the process itself may appear harmless, it is not without risk and necessitates use of suitable tools and management by expert hands.

The aim of this study was to evaluate the benefit of using a new slow-setting fibrin sealant compared with staples for adherence of split-thickness skin grafts on the backs of hands and fingers. Staple removal is often painful for patients. Twenty-eight patients were included for a graft total of 34 hands. The authors chose to test this sealant on zones that are often difficult to graft given their varied topographies. Its low concentration of thrombin (4 IU/ml) compared with other sealants provides it with prolonged polymerization time (60 seconds) making it easier to use in this location. All 34 grafts had taken at 5 days postoperatively and no graft required revision surgery. Six of our patients had sealant on one hand and staples on the other hand. All of the patients reported less pain on the sealant hand with a mean visual analog scale inferior to 2.6 times less (Mann-Whitney U test, P = .0035). Eighteen months after treatment, all of the patients had acceptable function and esthetic aspect of their hands with no difference noted between glued or stapled hands. The only notable drawbacks to the use of this sealant are the preparation and application time which is longer than with staples, the need to evacuate small seromas under the graft and obstruction of the drainage points by the sealant. The use of Artiss Sealant enabled us to reduce the amount of care and to decrease the pain because there was no staple removal.