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The number of hospital admissions for a hip prosthesis increased by more than 91% between 2002 and 2019 in Belgium (1), making it one of the most common interventions in hospitals. The objective of this study is to evaluate patient-report- ed outcomes and hospital costs of hip replacement six months after surgery. Both generic (EQ-5D) and specific (HOOS) PROMs of general hospital patients undergoing hip replacement surgery in 2021 were conducted. The results of these PROMs were then combined with financial and health management data. The mean difference (SD) in QALYs between the preoperative and postoperative phases is 0.20 QALYs (0.32 QALYs). The average cost (SD) of all stays is €4,792 (€1,640). Amongst the five dimensions evaluated in the EQ-5D health questionnaire, the 'pain' dimension seems to be associated with the greatest improvement in quality of life. As regards Belgium, the 26,066 arthroplasties performed in 2020 might constitute a gain of 123,000 years of life in good health. The relationship between QALYs and costs described in this study posits a ratio of €23,960 per year of life gained in good health. Given that in Belgium more than 3% of the hospital healthcare budget is devoted to hip prostheses, it would seem relevant to us to apply PROM tools to the entire patient population to assess treatment effectiveness more broadly, identify patient needs and, also, monitor the quality of care provided.

From the outset of the Covid-19 health crisis, residential care facilities for the dependent elderly (Ehpad) were faced with health and safety challenges. Strict infection prevention measures, such as visiting restrictions and the implementation of sanitary protocols, have been essential to protect residents. While Ehpad occupancy rates were stable before the health crisis, they fell sharply in the aftermath of Covid-19., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Human relationships and bonding reconfigure and reinvent themselves over time. For several decades, it has been interesting to note that both the digital dimension and the development of artificial intelligence have played a great evolutionary role in our relational society. There is an accessibility and intensification of social exchanges between internet users (published writings, photos, conversations, conferences… ). Although we access this interplanetary sharing of connection, despite everything the distancing and physical emotional social deprivation between several individuals belonging to a different household can bring significantly high suffering. Moreover, with the Covid-19 crisis, there has also been that fragility of our own personal doubt that will settle psychically in us: the uncertainty will be more intimate, more present and more distressing. If there is exposure to a potentially threatening stimulus as is the case with COVID-19, the exploration of positive or negative resources of survival and that of creativity (psychological capital) will emerge during this first increasedmajor confinement in order to bring non-negligible and bearable psychic responses to possible traumas and episodes of acute stress. However, the goal of this article is to propose a possible understanding of a resilience, thought and mobilized from a systemic approach: The relationship between the individual and his different systems of social, relational and existential belonging., (Copyright © 2021 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

This article explores the development of the most critical soft skills in midwifery through the use of a participatory method called the World Café in the context of continuing education at the Formation and Simulation Center (FORSim) in Settat, Morocco. Non-technical skills include a set of metacognitive abilities that complement technical skills to ensure the safe execution of technical activities and the parturient's satisfaction. In order to develop these midwifery skills through the World Café method, we invited nine midwives from two maternity units in the Casablanca-Settat region, with whom we elaborated our psychological, organizational, cognitive, and interactional (POCI) model. The study took place over a full day, structured into three distinct steps: a self-assessment of the level of mastery of the eight soft skills in the POCI model, four cycles of the World Café and, finally, a discussion of and feedback about the method. The use of the World Café method allowed for a dialogue on the possibilities of managing and addressing issues related to non-technical skills among midwives from various hospital settings. Based on the results, we found that the participants enjoyed the non-stressful atmosphere of the World Café and were very productive. The assessments and feedback from the midwives participating in this study suggest that managers can adopt the World Café approach to develop non-technical skills and enhance midwives' interactions and soft skills as part of their continuing education.

In surgical practice, numerous sources of stress (stressors) are unpredictable, two examples being daily workload and postoperative complications. They may help to explain surgeon burnout, of which the prevalence (34 to 53%) has been the subject of many studies. That said, even though assessments are legion, recommended solutions have been few and far between, especially insofar as by nature and training, surgeons are disinclined to interest themselves in burnout, which they are prone to consider as something experienced by "others". The objective of this attempt at clarification is to identify in the literature the strategies put forward in view of avoiding surgeon burnout, and to assess the impact of this phenomenon not only on the surgeon's professional and personal entourage, but also on patient safety. Prevention-based strategies, many of them focused on modifiable stressors, will be detailed., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

This article explores the non-technical skills critical for the practice of midwives through a comparison of two maternity services in Morocco. Soft skills, or non-technical skills, present a set of metacognitive abilities, which complement hard or technical skills, in order to guarantee the safe performance of a technical activity. This exploration is based on an original methodology that triangulates observation of caring paths, qualitative interviews, and quantitative questionnaires. We identified the main soft skills mastered, those that were missing, and those to be developed, based on an observed or expressed need. The research population included 30 midwives and 70 women. The results led us to identify the most critical non-technical skills for midwifery practice at a Local Medical Centre (LMC) and a Provincial Hospital Centre (PHC) to better understand the effects of workload on the possibilities of activating non-technical skills during caring paths. Based on these results, we elaborated a model for the development and improvement of non-technical skills in midwifery.

Purpose of the Study: To assess the stress factors affecting operating theater nurses during the perioperative period., Patients and Methods: The study was conducted as a cross-sectional survey by means of a specifically drawn-up questionnaire based on the data available in the literature. Stress was measured on a 0/100 visual analogue scale (VAS)., Results: Six hundred and twelve (612) persons responded. Stress associated with an operation amounted to 31.8; it was higher at the time of the procedure (49.6) and immediately beforehand (39.4), particularly among the least experienced nurses. The most widely represented stress factors were associated with the surgical team (perceived incompetence, lack of confidence), relational problems with regard to the surgeon, and team members' disruptive behavior. By contrast, familiarity with the team or the procedure seemed to shield the nurses from stress. Feelings of stress had a relatively frequent impact on quality of life (33%), family and personal life (26%), with chronic (recurrent or constant) stress symptoms reported among 20% of respondents., Conclusion: Among operating theater nurses, stress associated with an operation was particularly strong among the least experienced professionals, when the type of procedure or the other team members were unfamiliar, and in the event of disruptive behavior. Stress factor improvement should be a priority, the objective being to enhance professional and personal quality of life, while better ensuring patient safety., (Copyright © 2021. Published by Elsevier Masson SAS.)

More than a third of the world's population is currently living under lockdown due to the coronavirus pandemic. Lockdown measures have been in place in many countries for several weeks. The health authorities are waging war against COVID-19 and have to provide information to the public on it while facing many unknowns about the virus. What impact does this have on mental health? What impact can lockdown have upon a population? What psychological impact will this lockdown have on elderly people living in nursing and care homes in Belgium and EHPADs France? We are not aware of any French-language research which has been published on the psychological aspects of the coronavirus among the population. We will try, through this article, to approach the psychological impact upon nursing staff and residents within nursing homes.

More than a third of humanity is currently under containment due to the coronavirus pandemic. Containment has been in place in many countries for several weeks. Health authorities are on the warpath against a still mysterious virus and for which they are brought to inform the population while being confronted with many unknowns concerning the Covid-19. So what about mental health? What can generate a situation of containment with the population in quarantine? What psychological impact will this confinement have on our elderly people who are accommodated in rest and care homes in Belgium or in Ehpad in France? Currently, we are not yet aware of French-language articles already published in the medical-psychological aspects related to the coronavirus among the population. We will try, through this article, to approach the medico-psychological question of the nursing staff within the nursing homes and the psychological impact of the residents.

Purpose: In this study, we evaluated the feasibility, efficacy, and safety of radiofrequency ablation of paroxysmal atrial fibrillation (AF) with the use of an ablation catheter only (non-CMC group) by retrospectively comparing its procedural success and recurrence rates at 1 year to ablation performed with the help of a circular mapping catheter (CMC group)., Methods: We compared the success and recurrence rates between 226 patients and 251 patients who underwent index ablation with and without the use of CMC, respectively., Results: Freedom from recurrence was defined as a 1-year absence of AF/atrial tachycardia (AT) episodes > 30 s, beyond the 3-month blanking period. There was no significant difference between the number of pulmonary vein isolations, recurrence rate of AF/AT, and the use of antiarrhythmic drugs after 1 year of ablation. The procedure and fluoroscopy times were lower in the non-CMC group compared with the CMC group (106 ± 33 vs. 125 ± 32 min, p < 0.0001; 2.2 ± 1.9 vs. 2.7 ± 2.3 min, p = 0.0002, respectively)., Conclusions: Pulmonary vein isolation without the use of a CMC is feasible; moreover, the material costs, procedure time, and radiation exposure were reduced compared with the CMC group. Freedom of recurrence was similar between groups. Optimized use of 3D electro-anatomical mapping systems could reduce the radiation exposure for both the patient and physician., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In view of the expected increase in expenditure on hip replacement treatment in Belgium, the complication rate and potential waste reduction, as estimated by the Organisation for Economic Cooperation and Development, we are not yet in a position to assess the efficiency of hip replacement treatment in Belgian hospitals. This objective study uses a cost-disability-adjusted life years (DALYs) ratio to propose a comparison of hip replacement surgery among 12 Belgian hospitals., Methods: Our study seeks to innovate by proposing an interhospital comparison that simultaneously integrates the weighting of quality indicators and the costs of managing a patient. To this end, we associated a DALY impact with each patient safety indicator, readmission and mortality outcome. We then compared hospitals using both costs and DALYs adjusted to their case mix index. The adjusted values (costs and DALYs) were obtained by relating the observed value to the predicted value obtained from the linear regression model., Results: We registered a total of 246.5 DALYs for the 12 hospital institutions, the average cost (SD) of a stay being €8013 (€4304). Our model allowed us to identify hospitals with observed values higher than those predicted. Out of the 12 hospitals evaluated, 4 need to reduce costs and DALYs impacts, 6 have to improve one of the two factors and 2 appear to have good results. The costs for the worst performing hospitals can rise to over €150 000., Conclusion: Evaluating the rates of patient safety indicators, associated with cost, is a prerequisite for quality and cost improvement efforts on the part of managers and practitioners. However, it appears essential to evaluate the entire care chain using a comparable unit of measurement. The hospital's case mix index must also be considered in benchmarking to avoid drawing the wrong conclusions. In addition, other indicators, such as the patient's perception of the actual results, should be added to our study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Starting in December 2019 in Wuhan Municipal Health Commission, the coronavirus disease 2019 (COVID-19) has crossed the borders forming a pandemic in 2020. The absence of pharmacological interventions has pushed governments to apply different sets of old, non-pharmacological interventions, which are, though temporary, helpful to prevent further pandemic propagation. In the context of COVID-19, research confirms that quarantine is useful, mainly if applied early and if combined with other public health measures. However, the efficacy of quarantine and isolation is limited in many ways, ranging from legal issues and suspension of economic activities to mental health considerations. This chapter is an exploration of (i) epidemiological impact of isolation and quarantine; (ii) emotional impact of isolation and quarantine; and (iii) the possible effect of culture on quarantine experience.

Background: Infanticide is not a new concept. It is often confused with child murder, neonaticide, filicide or even genderside. Each of these concepts has to be defined clearly in order to be understood. Through time reasons for infanticide have evolved depending on multiple factors such as culture, religion, beliefs system, or attempts to control the population. It was once seen as a moral virtue. So what has changed?, Subjects and Methods: Between January 2020 and May 2020, a literature search based on electronic bibliographic databases as well as other sources of information (grey literature) was conducted in order to investigate the most recent data on infanticide and child murder, especially the newest socio-economic and psychiatric considerations as well as the different reasons why a mother or a father ends up killing their own child and the Irish situation., Results: Recent works on the subject demonstrate how some new socio economic factors and family considerations impact on infanticide. Mental illness, especially depression and psychosis, is often part of the picture and represent a very high risk factor to commit infanticide and filicide. Fathers and mothers do not proceed the same way nor for the same reasons when they kill their offspring. Neonaticide and infanticide are almost always committed by women. A recent case in Ireland (2020) proves how filicide remains an actual problem., Conclusions: Filicide is a relatively rare event, and therefore particularly impact both the public and the press when it occurs. Infanticide does not result from a unique cause, but from multiple factors (some being well known, some remaining hypothetical). Psychopathological and socio-economical parameters associated to peculiar family grounds are currently prevalent. To help and prevent infanticide, screening for psychiatric disorders and risk factors and treating or offering assistance to parents at risk should be implemented.

Background: Elderly patients are at high risk for postoperative complications and increased mortality after hip fracture (HF) surgery due to frailty and co-morbidities. The prediction of postoperative outcome could be used for clinical decision making. A reliable score to predict postoperative mortality after HF surgery in this sub-population remains unavailable., Methods: A single-centre retrospective cohort study was performed in 782 patients who were operated on for HF. Receiver Operating Characteristic (ROC)-curves were used to analyse the performance of gender, age, neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) at admission (D 0 ) as prognostic factors, alone or combined with the PreOperative Score to predict PostOperative Mortality (POSPOM) in univariate and multivariate linear regression models., Results: No correlation between gender, age, NLR D 0 or CRP D 0 and postoperative, intra-hospital mortality was found. The Area Under the ROC-curve (AUC) for age, male gender, NLR and CRP were 0.61 [95% confidence interval (CI) = 0.45-0.61], 0.56 [95% CI = 0.42-0.56], 0.47 [95% CI = 0.29-0.47] and 0.49 [95% CI = 0.31-0.49] respectively. Combination with the POSPOM score did not increase its discriminative capacity as neither age (AUC = 0.69, 95% CI = 0.54-0.69), gender (AUC = 0.72, 95% CI = 0.58-0.72), NLR D 0 (AUC = 0.71, 95% CI = 0.56-0.71), nor the CRP D 0 (AUC = 0.71, 95% CI = 0.58-0.71) improved the POSPOM performance., Conclusions: Neither age, gender, NLR D 0 nor CRP D 0 are suitable parameters to predict postoperative, intra-hospital mortality in elderly patients undergoing surgery for HF.

The aging of the population and the increasing of the neurodegenerative pathologies encourage the current policies in health to further promote the home maintenance for dependent elderly people. Therefore, informal caregivers provide a substantial assistance to the medical team by monitoring home care. These volunteer caregivers who play an essential role in the survival of our health system however may expose to dangers of systematic assistance. In order to better understand the plural risks which caregivers are likely to face, this paper proposes a critical analysis of the consequences of caregiving on health and quality of life and summarizes factors that contribute to vulnerability - protection of caregivers. It seems caregivers will present very heterogeneous reactions in the way they are considering the care situation. Facing to many difficulties encountered, caregivers are dealing with their skills and adopt personal coping strategies. There is thus a wide range of fragility profiles and needs among caregivers. Better taking into account the multiple components of aid relationships paves the way toward possible new care perspectives by recognizing the specific needs of each caregiver with respect for its uniqueness. In this way only, we can effectively contribute to challenge one of the important and actual social issue: the prevention of global exhaustion of caregivers of people with neurodegenerative disease.

[This corrects the article DOI: 10.1155/2016/8085216.].

Introduction: Estimation of residual rivaroxaban plasma concentrations may be requested before invasive procedures and some patients at high thromboembolic risk will have a bridging therapy with heparins when rivaroxaban is interrupted., Objective: The objective of this study was to assess the performance of the STA-Liquid Anti-Xa assay (STA LAX) and the low and normal procedures of the Biophen Direct Factor Xa Inhibitors (DiXaI) assay, in patients with and without bridging with low-molecular-weight heparins (LMWHs)., Materials and Methods: Seventy-nine blood samples were collected from 77 patients on rivaroxaban at C TROUGH or before an invasive procedure. Rivaroxaban plasma concentrations were estimated using Biophen DiXaI, Biophen DiXaI LOW, and STA LAX and compared to liquid chromatography coupled with mass spectrometry (LC-MS/MS) measurements. Stratifications were performed according to heparin bridging., Results: The Biophen DiXaI LOW and STA LAX showed better correlation with LC-MS/MS measurements than Biophen DiXaI in patients not bridged with LMWH (R: 0.97, 0.96, and 0.91, respectively). However, the performance of Biophen DiXaI LOW and STA LAX decreased when residual LMWH activity was present (R: 0.18 and 0.19 respectively) demonstrating that these tests are not specific to rivaroxaban., Conclusion: In patients not bridged with LMWH, we suggest to use the Biophen DiXaI LOW and STA LAX for the estimation of rivaroxaban concentrations <50 ng/mL. These results should be confirmed on a larger cohort of patients. Patients bridged with LMWH have inaccurate estimates of low levels of rivaroxaban and the 3 assays studied should not be used to estimate if it is safe to perform a procedure.

Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.

Facing coagulation disorders after acute trauma., Problems/objectives: Trauma is the leading cause of mortality for persons between one and 44 years of age, essentially due to bleeding complications., Methodology: We screened the PubMed, Scopus and Cochrane Library databases, using specific keywords. Only publications in English were considered., Main Results: The pathophysiology of trauma-induced coagulopathy (TIC) is complex and includes the classic "lethal triad" (i.e., haemodilution, acidosis, hypothermia) but may also include activation of protein C, endothelial and platelet dysfunction, and fibrinogen depletion. The time between trauma and treatment of the resultant massive bleeding should be as short as possible using techniques for rapid control of bleeding and avoiding aggravating factors (hypothermia, metabolic acidosis and hypocalcaemia). If given within three hours of injury, tranexamic acid (TXA) reduces all causes of mortality in trauma patients and reduces transfusion requirements. In a bleeding patient, crystalloids are preferred to colloids and the ratio of fresh frozen plasma to packed red blood cells should be at least 1:2. Damage control surgery (DCS) should be considered for patients who present with, or are at risk for developing, the "lethal triad", multiple life-threatening injuries or shock, and in mass casualty situations. DCS can also aid in the evaluation of the extent of tissue injuries and the control of haemorrhage and infection. Finally, there is currently no evidence of the added value of laboratory assays in the management of TIC., Conclusions: TIC appears quickly after trauma and should be anticipated and detected as soon as possible. TXA plays a central role in the management of such patients. Each institution should establish a local algorithm for the management of bleeding patients.

Introduction. We herein report our experience with new fully covered self-expanding metallic stents in the setting of inoperable recurrent benign tracheobronchial stenosis. Methods. Between May 2010 and July 2014, 21 Micro-Tech® FC-SEMS (Nanjing Co., China). were placed in our hospital in 16 patients for inoperable, recurrent (after dilatation), and symptomatic benign airway stenosis. Their medical files were retrospectively reviewed in December 2014, with focus on stent's tolerance and durability data. Results. Twenty-one stents were inserted: 13 for posttransplant left main bronchus anastomotic stricture, seven for postintubation tracheal stenosis, and one for postlobectomy anastomotic stricture. Positioning was easy for all of them. Stents were in place for a mean duration of 282 days. The most common complications were granulation tissue development (35%), migration (30%), and sputum retention (15%). Fifty-five % of the stents (11/20) had to be removed because of various complications, without difficulty for all of them. None of the patients had life-threatening complications. Conclusion. Micro-Tech FC-SEMS were easy to position and to remove. While the rate of complications requiring stent removal was significant, no life-threatening complication occurred. Further studies are needed to better define their efficacy and safety in the treatment of benign airway disease.

The perioperative management of dabigatran is challenging, and recommendations based on activated partial thromboplastin time (aPTT) and thrombin time (TT) are unsatisfactory. Dedicated coagulation tests have limitations at plasma concentrations < 50 ng/ml. Therefore, a more sensitive test, which is available 24/7, is required. It was the aim of this study to investigate the performance of the Hemoclot Thrombin Inhibitors® LOW (HTI LOW) kit, a diluted thrombin time, and the STA® - ECA II(ECA-II) kit, a chromogenic variant of the ecarin clotting time, that were developed to measure low dabigatran concentrations, compared to reference dabigatran analysis by liquid chromatography tandem mass-spectrometry (LC-MS/MS). This study included 33 plasma samples from patients treated with dabigatran etexilate who had plasma concentrations < 200 ng/ml. HTI LOW and ECA-II were performed along with HTI, aPTT (STA®-C. K.Prest® and SynthasIL®) and TT (STA® - Thrombin). All procedures were performed according to recommendations by the manufacturers. Linear (or curvilinear) correlations and Bland-Altman analyses were calculated. For free dabigatran concentrations < 50 ng/ml, the R² of linear correlations were 0.69, 0.84 and 0.61, with HTI, HTI LOW and ECA-II, respectively. The R² for TT, STA®-C. K.Prest® and SynthasIL® were 0.67, 0.42 and 0.15. For HTI, HTI LOW and ECA-II, Bland-Altman analyses revealed mean differences of -6 ng/ml (95 %CI: -25-14 ng/ml), 1 ng/ml (95 %CI: -18-19 ng/ml) and -1 ng/ml (95 %CI: -25-23 ng/ml), demonstrating that tests dedicated to measuring low concentrations are more accurate than HTI. In conclusion, the use of HTI LOW or ECA-II to assess low plasma dabigatran concentrations is supported by our findings.

Background: The benefit of inducing deep neuromuscular block to improve laparoscopic surgical conditions is controversial., Objective: The goal of this study was to determine the depth of neuromuscular block needed to guarantee excellent operating conditions during laparoscopic hysterectomy., Design: A randomised controlled trial., Setting: A single-centre study performed between February 2011 and May 2012., Patients: One hundred and two women of ASA physical status 1 or 2 gave consent to participate and were allocated randomly to one of two groups., Intervention: Under desflurane general anaesthesia, patients in Group S (shallow block), neuromuscular blockade was induced by administration of rocuronium 0.45 mg  kg-1 followed by spontaneous recovery or a rescue bolus dose of 5  mg if surgical conditions were unacceptable. In Group D (deep block), neuromuscular block was induced by administration of rocuronium 0.6 mg  kg-1 and maintained by bolus doses of 5  mg if the train-of-four count exceeded two, using adductor pollicis electromyography., Main Outcome Measures: With a stable pneumoperitoneum (13 mmHg), the surgeon scored the quality of the surgical field every 10  min as excellent (1), good but not optimal (2), poor but acceptable (3) or unacceptable (4). The groups were compared using the Cochran-Armitage trend test. The level of neuromuscular blockade was recorded each time the surgical field score exceeded 1., Results: For groups S and D, respectively, the maximum surgical field scores were 1 in 21 and 34 patients, 2 in 11 and 11 patients, 3 in 4 and 5 patients and 4 in 14 and 0 patients. A trend towards higher scores was demonstrated in group S (P < 0.001). Surgical field scores of 2, 3 and 4 occurred only when the train-of-four count was at least 1, 2 and 3, respectively., Conclusion: Inducing deep neuromuscular block (train-of-four count <1) significantly improved surgical field scores and made it possible to completely prevent unacceptable surgical conditions.

Background: Disturbances in the thumb's movement interfere with the functioning of acceleromyography in many clinical settings. The short and light (SL) train-of-four (TOF)-Tube is a new version of a rigid tubular device that was designed to protect the thumb from external disturbances during surgery, even when the hand is not accessible by the anaesthesiologist., Objective: To compare the precision and performance of acceleromyography performed with the aid of the SL TOF-Tube (AMGTT) with standard isometric mechanomyography (MMG)., Design: Simultaneous arm-to-arm comparison of both methods in the same anaesthetised patient., Setting: A monocentric study, performed from September 2007 to June 2008., Patients: Nineteen ASA I to II patients scheduled to undergo lower limb orthopaedic surgery under general anaesthesia., Intervention: Neuromuscular transmission monitoring during baseline, onset and spontaneous recovery of rocuronium-induced neuromuscular block., Main Outcome Measures: Initial baseline and repeatability coefficients were assessed during 10 consecutive measurements of the first twitch height (T1) and TOF T4/T1 ratio and compared using a z test. The spontaneous recoveries of defined blockade levels (onset, T1 25% of initial calibration and TOF ratio 0.9) were compared in terms of duration and intensity. Agreement between both techniques was assessed by the Bland-Altman method., Results: The mean ± SD control TOF ratios were 98 ± 1% (MMG) and 103 ± 2% (AMGTT). The repeatability coefficients were higher (P < 0.001) and the onset was longer (mean 0.44 min) (P < 0.001) when they were measured by AMGTT. The recoveries of T1 25% and TOF ratio 0.9 were not significantly different between the two methods, and the limits of agreement were in the usual range of contralateral comparisons (-19 and +24% for TOF ratio 0.9)., Conclusion: Compared with mechanomyography, acceleromyography performed with the aid of an SL TOF-Tube offered acceptable precision and equivalent performance during neuromuscular block recovery.

Background: Accurate diagnosis of heparin-induced thrombocytopenia (HIT) is essential but remains challenging. We have previously demonstrated, in a retrospective study, the usefulness of the combination of the 4Ts score, AcuStar HIT and heparin-induced multiple electrode aggregometry (HIMEA) with optimized thresholds., Objectives: We aimed at exploring prospectively the performances of our optimized diagnostic algorithm on suspected HIT patients. The secondary objective is to evaluate performances of AcuStar HIT-Ab (PF4-H) in comparison with the clinical outcome., Methods: 116 inpatients with clinically suspected immune HIT were included. Our optimized diagnostic algorithm was applied to each patient. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) of the overall diagnostic strategy as well as AcuStar HIT-Ab (at manufacturer's thresholds and at our thresholds) were calculated using clinical diagnosis as the reference., Results: Among 116 patients, 2 patients had clinically-diagnosed HIT. These 2 patients were positive on AcuStar HIT-Ab, AcuStar HIT-IgG and HIMEA. Using our optimized algorithm, all patients were correctly diagnosed. AcuStar HIT-Ab at our cut-off (>9.41 U/mL) and at manufacturer's cut-off (>1.00 U/mL) showed both a sensitivity of 100.0% and a specificity of 99.1% and 90.4%, respectively., Conclusion: The combination of the 4Ts score, the HemosIL® AcuStar HIT and HIMEA with optimized thresholds may be useful for the rapid and accurate exclusion of the diagnosis of immune HIT., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Several direct oral anticoagulants (DOACs) are now widely used in the prevention and treatment of thromboembolic events. Unlike vitamin K antagonists, DOACs exhibit predictable pharmacokinetics and pharmacodynamics. DOACs are to be administered at fixed doses without routine coagulation monitoring. However, in some patient populations or specific clinical circumstances, measurement of drug exposure may be useful, such as in suspected overdose, in patients with a haemorrhagic or thromboembolic event during treatment with an anticoagulant, in those with acute renal failure, or in patients who require urgent surgery. This article provides practical guidance on laboratory testing of DOACs in routine practice and summarizes the influence of DOACs on commonly used coagulation assays.

Dabigatran etexilate (DE), rivaroxaban, and apixaban are nonvitamin K antagonist oral anticoagulants (NOACs) that have been compared in clinical trials with existing anticoagulants (warfarin and enoxaparin) in several indications for the prevention and treatment of thrombotic events. All NOACs presented bleeding events despite a careful selection and control of patients. Compared with warfarin, NOACs had a decreased risk of intracranial hemorrhage, and apixaban and DE (110 mg BID) had a decreased risk of major bleeding from any site. Rivaroxaban and DE showed an increased risk of major gastrointestinal bleeding compared with warfarin. Developing strategies to minimize the risk of bleeding is essential, as major bleedings are reported in clinical practice and specific antidotes are currently not available. In this paper, the following preventive approaches are reviewed: improvement of appropriate prescription, identification of modifiable bleeding risk factors, tailoring NOAC's dose, dealing with a missed dose as well as adhesion to switching, bridging and anesthetic procedures.

Rigid bronchoscopy under general anesthesia enables performing diagnostic and/or therapeutic procedures in the tracheobronchial tree. This technique is characterized by specific technical problems, insofar as the anesthesiologist and the operators share the same space, namely the airway. Several potential complications (hemorrhage inside the airway, threat to ventilation ...) may arise. These challenges render the ability to use the variable available techniques essential, as well as knowledge of the complications they could entail, and the ability to rapidly solve them. General anesthesia is usually total intravenous anesthesia, using short acting agents. Ventilation can be spontaneous, but more often insured using high-frequency jet ventilation. The hospital infrastructure and staff must have the expertise to perform this particular procedure, in order to limit the complication rate.

The field of oral anticoagulation has evolved with the arrival of non-vitamin K antagonist oral anticoagulants (NOACs) including an anti-IIa agent (dabigatran etexilate) and anti-Xa agents (rivaroxaban and apixaban). The main specificities of these drugs are predictable pharmacokinetics and pharmacodynamics but special attention should be paid in the elderly, in case of renal dysfunction and in case of emergency. In addition, their perioperative management is challenging, especially with the absence of specific antidotes. Effectively, periods of interruption before surgery or invasive procedures depend on half-life and keeping a permanent balance between bleeding and thromboembolic risks. In addition, few data regarding the link between plasma concentrations and their effects are provided. Routine laboratory tests are altered by NOACs and quantitative measurements are not widely performed. This paper provides a review on the management of NOACs in the perioperative setting, including the estimation of the bleeding and thrombotic risk, the periods of interruption, the indication of heparin bridging, the usefulness of laboratory tests before surgery or invasive procedure, and the time of resuming. Most data are based on expert's opinions.

Background: Ultimately, the experience of pain derives from changes in brain excitability. Therefore, modulating the excitability of cortical areas involved in pain processing may become an attractive option in the context of multimodal analgesia during the postoperative period. Repetitive transcranial magnetic stimulation (rTMS) can reduce morphine consumption during the postoperative period after gastric bypass surgery. We tested the potential of another method of noninvasive brain stimulation, transcranial direct current stimulation (tDCS), to reduce morphine consumption or pain perception during the postoperative period., Methods: Fifty-nine ASA I to II patients undergoing lumbar spine surgery were randomized to receive anodal (n=20), cathodal (n=20), or sham (n=19) tDCS in the recovery room in a double-blind manner. Morphine consumption administrated through patient-controlled analgesia (PCA) was the primary outcome; pain perception as measured by visual analog scale was the secondary outcome., Results: There were no statistically significant differences between the 3 groups of patients, either for PCA morphine consumption or for pain scores., Conclusions: Several factors may explain the observed lack of impact of tDCS on PCA morphine consumption and pain perception: the method of brain stimulation (tDCS/rTMS), potential interactions with anesthetic drugs, differences in patients population (gastric bypass surgery/lumbar spine surgery), and the previous experience of pain and chronic consumption of analgesic drugs. Further studies with tDCS should be performed before concluding that tDCS is inefficient for postoperative pain control, because noninvasive brain stimulation methods, such as rTMS and tDCS, may become attractive in the setting of multimodal analgesia.