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Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals are at a higher risk of mental illness when compared to their heterosexual and cisgender counterparts. Most research emanates from Western countries, with a paucity of studies in the Arab world. We systematically reviewed studies assessing the mental health of LGBTQ individuals who live in the Arab world or are of Arab descent. Of 261 articles, seven were eligible for analysis. Depression was the most common psychiatric disorder. Suicidal ideations and attempts were frequent in trans women. Post-traumatic stress disorder was also common, with the majority of precipitating traumatic events being related to sexual orientation and/or gender identity. Societal and familial stressors in the Arab culture are major contributors to the increased vulnerability of the LGBTQ community to mental health challenges. Further research is of utmost need while taking into consideration the Arab socio-cultural context.

Background: Encouraging results in several series of patients on refractory cardiogenic shock (CS) led to the consideration of including temporary mechanical circulatory support (TMCS) in the guidelines for CS management. Benefit on survival might be improved when TMCS devices are initiated early. This study assessed early TMCS for CS in the real-world condition of a cardiac assistance regional network. Methods: We examined the clinical features and outcomes of patients treated with TMCS, using data from a prospective cohort of patients admitted for CS in a cardiac assistance regional network. Patients were eligible when CS included systolic blood pressure (SBP) 90 mmHg, signs of congestion or tissue hypo-perfusion or blood lactate >2mmol/L. TMCS indication, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or percutaneous left ventricle assistance (Impella) was based on the initial severity of CS or if shock was refractory to medical treatment. To estimate the effect of early TMCS on mortality, we emulated a target trial of TMCS implantation versus no TMCS within 24 hours of ICU admission. Patients were followed until hospital discharge, death, or 180 days. Inverse probability of treatment weighting with propensity score was used to adjust for confounders. Results: Among 372 patients, 246 were included in the study: 121 treated by early TMCS (TMCS group) and 125 not treated by early TMCS (controls). Median age was 59.5 years, 71.9% were male, and the main etiologies were acute myocardial infraction (MI) (46.8%) and decompensated heart failure (27.2%). Crude in-hospital mortality was 38% (46/121) in the TMCS group and 22.4% (28/125) in the control group. After emulation, in-hospital mortality was not different between the TMCS group and the control group (HR=0.91, 95%CI:0.65-1.26). In sub-group analyses, in-hospital mortality was not different among patients with MI (HR=0.82, 95%CI:0.52-1.32), with other etiology than MI (HR=1.19, 95%CI:0.70-2.04), and with VA-ECMO only (HR=0.87, 95%CI:0.62-1.22). TMCS patients had two-fold longer hospital stays, and a higher rate of complications than controls. Conclusion: In this emulated target trial from real-world data, patients with CS treated with early TMCS had no improvement in survival compared to controls. Trial registration number: NCT03528291, registered trials May 18, 2017

BackgroundAgitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists.MethodA pragmatic randomised open trial (September 2018–July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mgResultsPrimary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47–1.50].ConclusionsNeither intervention consistently impacted the outcome of ‘calm’, or ‘asleep’ and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. Methods: Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort. Results: Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63–0.98]; P =0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site–related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). Conclusions: In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.

International audience; Increasing operators’ experience and improvement of the technique have resulted in a drastic reduction in complications following transcatheter aortic valve replacement (TAVR) in patients with lower surgical risk. In parallel, the procedure was considerably simplified, with a routine default approach including local anesthesia in the catheterization laboratory, percutaneous femoral approach, radial artery as the secondary access, prosthesis implantation without predilatation, left ventricle wire pacing and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety. The minimalist strategy must not become dogmatic and careful pre-, per- and post-procedural evaluation of patients with well-defined protocols guarantee optimal care following TAVR. This review aims to evaluate the benefits and limits of the simplified TAVR procedure in a current and future vision.

Background Critically ill patients with systemic rheumatic disease (SRD) have benefited from better provision of rheumatic and critical care in recent years. Recent comprehensive data regarding in-hospital mortality rates and, most importantly, long-term outcomes are scarce. Research Question The aim of this study was to assess short and long-term outcome of patients with SRD who were admitted to the ICU. Study Design and Methods All records of patients with SRD who were admitted to ICU between 2006 and 2016 were reviewed. In-hospital and one-year mortality rates were assessed, and predictive factors of death were identified. Results A total of 525 patients with SRD were included. Causes of admission were most frequently shock (40.8%) and acute respiratory failure (31.8%). Main diagnoses were infection (39%) and SRD flare-up (35%). In-hospital and one-year mortality rates were 30.5% and 37.7%, respectively. Predictive factors that were associated with in-hospital and one-year mortalities were, respectively, age, prior corticosteroid therapy, simplified acute physiology score II ≥50, need for invasive mechanical ventilation, or need for renal replacement therapy. Knaus scale C or D and prior conventional disease modifying antirheumatic drug therapy was associated independently with death one-year after ICU admission. Interpretation Critically ill patients with SRD had a fair outcome after an ICU stay. Increased age, prior corticosteroid therapy, and severity of critical illness were associated significantly with short- and long-term mortality rates. The one-year mortality rate was also associated with prior health status and conventional disease modifying antirheumatic drug therapy.

Background The field of temporary mechanical circulatory support (TMCS) has advanced in last decade justifying that TMCS is increasingly used for treatment of refractory cardiogenic shock (CS). Nevertheless, the efficacy of TMCS (extracorporeal life support (ECLS) and Impella) in CS remains controversial due to the lack of high-quality evidence. The aim of this prospective multicenter observational study simulating a randomized trial was to assess the impact of TMCS on the hospital mortality in patients with CS. Methods This study (ClinicalTrials.gov ID: NCT03528291) was conducted at 3 TMCS centers organized in a cardiac assistance network, one as a level 1 TMCS center (expert center), and 2 as level 2 centers (hub centers). The study was designed and led by the heart team of the expert center with input from the hub centers. All patients admitted to an intensive care unit between July 2017 and May 2020 either directly at the TMCS centers or after transfer from a non-specialized hospital, were screened for TMCS indication provided they were admitted for CS. CS was defined according to the European Society of Cardiology criteria. Were excluded patients younger than 18 years, CS after cardiac surgery, or after cardiac arrest if it was refractory or with a no flow >3 min and/or out-of-hospital cardiac arrest with non-shockable rhythm, or CS in the context of myocardial infarction complications, massive pulmonary embolism, and if TMCS was contraindicated TMCS indication was decided after a multidisciplinary discussion carried out by the “heart team”. Implantation of TMCS resulted from an agreement of the heart team within the first 24 hours after admission mainly based on the initial severity of the CS, or if CS was refractory to the medical treatment. The primary outcome was in-hospital survival. A propensity score-weighted analysis was done for treatment-effect estimation. This method, which weights each patient according to their propensity score, includes all participants in the analysis. Results 246 patients with CS were included in the study: 121 in TMCS group (72% ECLS, 14% Impella, 14% both ECLS and Impella) and 125 in control group. After adjustment by a propensity score, hospital mortality was comparable in the two groups (32% TMCS group vs 27% control group; Odds ratio with TMCS, 1.28; 95% confidence interval, 0.87 to 1.88; p=0.21). Mortality at D180 was also similar in the two group (33% vs 30% respectively; p=0.51). Thromboembolic events were significantly higher in the TCMS group (14% vs 4%; p Conclusion In our study, the use of TMCS does not seem to improve hospital survival in patients with cardiogenic shock. Thus, TMCS, which are iatrogenic side effects providers, should be reserved for the most severe patient and discussed by a multidisciplinary team. Funding Acknowledgement Type of funding sources: None. Flow chart

Background: Novel oral anticoagulants are used in atrial fibrillation. Idarucizumab has been approved for reversal of dabigatran in situations of life-threatening hemorrhage or emergency surgery. Objectives: We report a single center experience of ten patients on dabigatran therapy who were given idarucizumab prior to heart transplantation. Methods & results: The mean plasma concentration of dabigatran prior to reversal was 139 ± 89 ng/ml. Hemoglobin, hematocrit and platelet levels were decreased after surgery. Surgical procedures were successfully performed with no increased risk, especially regarding bleeding complications. All patients were alive after 90 days. Conclusion: Dabigatran reversal with idarucizumab in contexts of emergency surgery/urgent procedures is an attractive and safe option to be taken into consideration for patients with end stage heart disease awaiting transplantation and indication of anticoagulant therapy., Lay abstract Novel oral anticoagulants are used in atrial fibrillation. Idarucizumab has been approved for reversal of dabigatran in situations of life-threatening hemorrhage or emergency surgery. We report here a single center experience of ten patients on dabigatran therapy who were given idarucizumab prior to heart transplantation. Surgical procedures were successfully performed with no increased risk, especially regarding bleeding complications. Dabigatran reversal with idarucizumab in contexts of emergency surgery/urgent procedures is an attractive and safe option to be taken into consideration for patients with end stage heart disease awaiting transplantation and indication of anticoagulant therapy.

Agitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists.A pragmatic randomised open trial (September 2018-July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mg.Primary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47-1.50].Neither intervention consistently impacted the outcome of 'calm', or 'asleep' and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.

Background: Novel oral anticoagulants are used in atrial fibrillation. Idarucizumab has been approved for reversal of dabigatran in situations of life-threatening hemorrhage or emergency surgery. Objectives: We report a single center experience of ten patients on dabigatran therapy who were given idarucizumab prior to heart transplantation. Methods & results: The mean plasma concentration of dabigatran prior to reversal was 139 ± 89 ng/ml. Hemoglobin, hematocrit and platelet levels were decreased after surgery. Surgical procedures were successfully performed with no increased risk, especially regarding bleeding complications. All patients were alive after 90 days. Conclusion: Dabigatran reversal with idarucizumab in contexts of emergency surgery/urgent procedures is an attractive and safe option to be taken into consideration for patients with end stage heart disease awaiting transplantation and indication of anticoagulant therapy.

Critically ill patients with systemic rheumatic diseases (SRDs) have a fair prognosis, while those with interstitial lung disease (ILD) have a poorer outcome. However, the prognosis of SRD patients with ILD admitted to the intensive care unit (ICU) remains unclear. We conducted a case–control study to investigate the outcomes of critically ill SRD-ILD patients. Consecutive SRD-ILD patients admitted to five ICUs from January 2007 to December 2017 were compared to SRD patients without ILD. Mortality rates were compared between groups, and prognostic factors were then identified. One hundred and forty critically ill SRD patients were included in the study. Among the 70 patients with SRD–ILD, the SRDs were connective tissue diseases (56%), vasculitis (29%), sarcoidosis (13%), and spondylarthritis (3%). Patients were mainly admitted for acute exacerbation of SRD-ILD (36%) or infection (34%). ICU, in-hospital, and one-year mortality rates in SRD-ILD patients were higher than in SRD patients without ILD (n = 70): 40% vs. 16% (p &lt, 0.01), 49% vs. 19% (p &lt, 0.01), and 66% vs. 40% (p &lt, 0.01), respectively. Hypoxemia, high sequential organ failure assessment (SOFA) score, and admission for ILD acute exacerbation were associated with ICU mortality. In conclusion, ILD worsened the outcomes of SRD patients admitted to the ICU. Admissions related to SRD-ILD acute exacerbation and the severity of the acute respiratory failure were associated with ICU mortality.

Background Veno-arterial extracorporeal life support (VA-ECLS) results in cardiopulmonary shunting with reduced native cardiac output (NCO). Low NCO occurrence is common and associated with risk of thromboembolic and pulmonary complications. Practical tools for monitoring NCO during VA-ECLS would therefore be valuable. Pulse pressure (PP) and end-tidal carbon dioxide (EtCO2) are known to be related to cardiac output. We have designed a study to test whether PP and EtCO2 were efficient for the monitoring of NCO during VA-ECLS. Methods In this prospective single-center observational study, patients who underwent a VA-ECLS for cardiogenic shock from January 2016 to October 2017 were included, provided low NCO was suspected by a PP 2. The ability of PP and EtCO2 to predict NCO Results Among the 106 patients treated with VA-ECLS for cardiogenic shock during the study period, 26 were studied, allowing the collection of 196 study points. PP and EtCO2 relationships with NCO were nonlinear and showed strong correlations for NCO r = 0.69 and r = 0.78 respectively). A PP 2 p = 0.058). Conclusions PP and EtCO2 may offer an accurate real-time monitoring of low NCO events during VA-ECLS support. Further studies are needed to show if their utilization may help to implement therapeutic strategies in order to prevent thromboembolic and respiratory complications associated with VA-ECLS, and to improve patients’ prognosis. Trial registration NCT03323268, July 12, 2016

Atypical dysgeusia such as having the sensation of a sweet tooth is an uncommon clinical presentation in severe depression. First, we present the case of a 67 year-old-man admitted to the psychiatric ward for depression after a suicide attempt by drug ingestion. The patient manifested a sweet taste sensation in the upper and lower gums that increased with mood swings and notably with severe depressive symptoms. Blood tests showed an elevated serum creatinine level (115 μmol/L), a normocytic anemia (hemoglobin 6.5 mmol/L; MCV 96 fL) and a deficit in vitamin B12 (122.4 pmol/L). The patient received vitamin B12 supplementation and was treated with clomipramine, lithium, mirtazapine, modafinil, and olanzapine. He was discharged after improvement of his depressive symptoms and decrease in the sweet taste. On follow-up, the patient’s dysgeusia had subsided. Second, we hypothesize that the atypical dysgeusia may have been induced by vitamin B12 deficiency and medical comorbidities, leading to deafferentation (development of erroneous mouth mucosae sensations felt by the patient). This could have been increased by depression. Dysgeusia in elederly patients with depression should be extensively investigated in order to elucidate somatic contributing factors but it may not resolve until improvement of the depressive symptoms.

International audience; Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.

The objective of the study was to analyze the frequency and severity of vocal tract symptoms in patients on statins. A total of 73 patients were enrolled in this study, 44 patients who were taking statins and 29 controls not taking statins. The severity and frequency of vocal tract discomfort was assessed using the Vocal Tract Discomfort scale. The most frequent vocal tract symptom in patients on statins was dryness followed by tightness and lump sensation. The difference in the mean of the total score and in the mean frequency of any vocal tract symptom was not significant between patients taking statins and controls. The most severe (highest mean values) vocal tract symptom in patients taking statins also was dryness followed by tightness and lump sensation. The difference in the mean of the total score and in the mean severity of any vocal tract symptom between patients taking statins and controls was not significant. This study failed to demonstrate a higher prevalence or severity of vocal tract symptoms in patients receiving statins. Despite the lack of a significant difference in the means of vocal tract discomfort symptom frequency and severity, this study carries clinical significance when considering that a higher prevalence and severity of vocal tract discomfort symptoms should alert physicians to the possible development of statin-induced myotoxicity in the laryngopharyngeal complex.

International audience; Temporary mechanical circulatory support (TCS) is recommended for patients with profound cardiogenic shock (CS). Extracorporeal membrane oxygenation (ECMO) and Impella are possible TCS devices, but the device choice and the implantation timing are not definitely established, specifically during acute myocardial infarction. We have analyzed the respective use of ECMO or Impella (2.5, CP, or 5.0) for CS following acute myocardial infarction , from a cohort of patients who underwent TCS within 72 hours after admission for emergency percutaneous coronary intervention (PCI) from January 2009 to April 2015. Among 88 TCS-treated patients, 42 had early TCS: 23 ECMO and 19 Impella. Cardiac management, including PCI, was similar between the two groups, but ECMO patients were sicker than Impella patients (higher blood lactate level at ICU admission, higher vasoactive-inotroic and ENCOURAGE scores before TCS implantation, p ≤ 0.02). Three patients (7%) have had TCS implantation before admission, but TCS was implanted mostly in cathlab (43%, 1 during PCI, 13 just after PCI) or soon after ICU admission (50%, n = 21). Modification of the initial TCS choice was required in 10 cases (24%) for assistance upgrading in case of Impella (n = 4) or for left ventricle unloading in case of ECMO (n = 6). Extracorporeal membrane oxygenation is the technique of choice in case of profound CS, whereas Impella devices seem more appropriate for less severe hemodynamic compromise. Interestingly, the combination of both techniques may help to overcome the limits inherent to each device.

Importance The immunological sequelae of tonsillectomy in children have been a source of debate among physicians and a continuous concern for parents. Contradictory pertinent results exist in the literature. Objective To understand the real effect of tonsillectomy on the immune system. Data sources MEDLINE, EMBASE and COCHRANE. Study selection Articles addressing the effect of tonsillectomy on the immune system, up to Dec 2014. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed. Data extraction We checked the tests results and the conclusion of each study to classify it as supporting or refuting the hypothesis of a negative effect of tonsillectomy on the immune system. Results We reviewed 35 articles, published between 1971 and 2014, including 1997 patients. Only Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system. We performed a separate meta-analysis on various reviewed humoral and cellular immunological parameters (e.g. total and specific serum Ig's, SecIgA, cellular immunity, and Ag specific Ig). There is more evidence to suggest that tonsillectomy has no negative clinical or immunological sequalae on the immune system. Study limitations included heterogeneity in the diagnostic tools, timing of testing, indication for tonsillectomy and patients’ age. Conclusion It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system. It will be important for future studies to uniformly use both preoperative and control laboratory tests’ levels to compare the postoperative levels with, to have short and long term follow-up levels, and to include both humoral and cellular immunity in their measurements. Relevance The results should reassure both surgeons and parents that tonsillectomy has no proven clinical sequalae. If more research is to be done in the future, it should be performed in a standardized way to avoid the heterogeneity seen in the literature.

International audience; Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) exposes the patient to a pulmonary blood flow bypass and a left ventricle afterload increase. Impella, a catheter-mounted microaxial rotary pump, has been proposed for left ventricle (LV) unloading in combination with VA ECMO. In order to assess the effect of Impella on pulmonary flow and LV preload, we checked Doppler pulmonary artery velocity-time integral (pVTI) and LV diastolic diameter (LVED) by transesophageal echocardiography and end-tidal carbon dioxide (EtCO2) during a step-by-step increase in Impella flow (Impella ramp test). From 134 patients on VA ECMO retrieved from our database, 27 (20%) have benefited secondary Impella implantation, out of which 11 patients had available EtCO2, pVTI, and LVED measurements at various levels of Impella speeds. We observed a proportional increases in pVTI and EtCO2 and decrease in LVED (p ≤ 0.001) during Impella flow increase. There was a significant correlation between EtCO2 and ITV pulm (Pearson correlation coefficient 0.64; p = 0.006). The study shows that Impella improves pulmonary flow, an effect that can be easily measured by EtCO2 monitoring, and ensures LV discharge, allowing adapting Impella flow adequately to patient's individual needs.

Anterior tibial eminence fracture is the main mode of ACL failure in patients with open physes. In young children, purely cartilaginous avulsions of the tibial ACL insertion are possible. The aim of this study was to focus on patients referred for misdiagnosed cartilaginous tibial eminence fractures. Ten young patients with cartilaginous tibial eminence fractures were identified in the hospital database. Six of them were misdiagnosed and included in this retrospective case series. Clinical data at the time of injury, radiographs and MRI were analysed in order to evaluate the causes which could have led to inappropriate management. The patients’ median age at the time of injury was 7 years (5–8.5). The main cause of injury was a low-energy domestic accident (n = 4). Radiographs at the time of injury were normal (n = 4) or showed a very thin ossification (n = 2). The traditional MRI findings of ACL injuries were all negative. On T2 sequences, an epiphyseal fluid signal allowed for a retrospective diagnosis. Cartilaginous tibial eminence fractures were regularly prolonged posteriorly giving a ‘double-PCL sign’ in 4 of the 6 patients. On a median of 6 months (2.5–48) after the injury, patients were referred for repeat giving ways (n = 5) and/or limitation of extension or hyperextension (n = 4). Symptoms were related to non-union, ossification and secondary enlargement of the avulsed fragment. Post-traumatic knee joint effusions in children aged 9 or younger, even occurring after a low energy trauma and with normal radiographs, should suggest a cartilaginous tibial eminence fracture. Systematic MRI examinations should be mandatory in these patients in whom the avulsed fragment may appear as a double-PCL sign. During follow-up, new radiographs are recommended. A better knowledge of this rare entity should allow us to avoid misdiagnosis and to perform an early refixation of the avulsed fragment. III.

Objective To study if nasal endoscope can be a reliable tool in assessing patients with allergic rhinitis. Materials and Methods A prospective study. Patients who were diagnosed with allergic rhinitis underwent a nasal endoscopic examination performed by two physicians blinded to the scoring of each other. A correlation was made among symptom severity, endoscopic findings, and interrater variability. Results Ninety patients were included in the study: 34 patients had mild disease and 56 had moderate-to-severe allergic rhinitis according to the Allergic Rhinitis and its Impact on Asthma guidelines. Increases in mucosal edema and bluish discoloration were predictive of the severity of allergic rhinitis disease (p < 0.05). The presence of nasal secretions was not predictive of allergic rhinitis. Interrater reliability was fair for mucosal edema, moderate-to-almost perfect for the rest of the endoscopic findings. Conclusion Nasal endoscopy may reveal signs that are predictive of the severity of allergic rhinitis. A detailed checklist is needed for the nasal endoscopic examination to decrease interrater variability.

This chapter provides a comprehensive procedural report for fine needle aspiration of cervical lymph node procedure, with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organized and practical format.

This chapter provides a comprehensive procedural report for core biopsy of cervical lymph node procedure, with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organized and practical format.

This chapter provides a comprehensive procedural report for core biopsy of neck lesion procedure, with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organized and practical format.

This chapter provides a comprehensive procedural report for core biopsy of the parotid gland procedure, with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organized and practical format.

Early reconstruction after anterior cruciate ligament (ACL) rupture in children with open physis was found to be a better strategy compared with delayed ACL reconstruction at skeletal maturity. This article focuses on an original technique for ACL reconstruction in children and adolescents. The rationale of the procedure is based on avoiding the danger of a femoral tunnel and fixation systems that may lead to growth arrest. Part of the quadriceps tendon with a trapezoidal patella bone block was harvested after arthroscopic exploration and addressing other intra-articular injuries like meniscal tears. The bone-tendon graft was inserted through a combined intraepiphyseal femoral tunnel drilled from outside-in under fluoroscopic imaging and a long vertical arthroscopically drilled transphyseal tibial tunnel. The bone block was impacted in the femoral tunnel, allowing primary fixation without any associated material. The tibial fixation is obtained with a strictly metaphyseal screw and postfixation with a staple. The advantages of the technique are multiple: anatomic and isometric reconstruction, arthroscopically surgery, strong adaptable long graft with excellent bone to bone press-fit fixation on the femur, and preservation of the femoral physis. Indications, the step-by-step procedure, postoperative care, complications, and results are reported in this paper.

IntroductionCardiogenic shock refractory to standard therapy with inotropes and/or intra-aortic balloon pump is accompanied with an unacceptable high mortality. Percutaneous left ventricular assist devices may provide a survival benefit for these very sick patients. In this study, we describe our experience with the Impella 5.0 device used in the setting of refractory cardiogenic shock.MethodsIn this observational, retrospective, single-center study we included all the consecutive patients supported with Impella 5.0, between May 2008 and December 2013, for refractory cardiogenic shock. Patients’ baseline and procedural characteristics, hemodynamics and outcome to the first 48 h of support, to ICU discharge and day-28 visit were collected.ResultsA total of 40 patients were included in the study. Median age was 57 years and 87.5 % were male. Cardiogenic shock resulted from acute myocardial infarction in 17 patients (43 %), dilated cardiomyopathy in 12 (30 %) and postcardiotomy cardiac failure in 7 (18 %). In 15 patients Impella 5.0 was added to an ECMO to unload the left ventricle. The median SOFA score for the entire cohort prior to circulatory support was 12 [10–14] and the duration of Impella support was 7 [5–10] days. We observed a significant decrease of the inotrope score (10 [1–17] vs. 1 [0–9];p = 0.04) and the lactate values (3.8 [1.7–5.9] mmol/L vs. 2.5 [1.5–3.4] mmol/L;p = 0.01) after 6 h of support with Impella 5.0. Furthermore, at Impella removal the patients’ left ventricular ejection fraction improved significantly (p p = 0.02).ConclusionsImpella 5.0 allowed fast weaning of inotropes and might facilitate myocardial recovery. Despite high severity scores at admission, day-28 mortality rate was better than predicated.

This is a case of a two-year-old boy who has been suffering from food regurgitation and frequent vomiting over the past seven months which were progressively worsening with time. He was initially diagnosed with gastroesophageal reflux disease and treated accordingly but responded only minimally. Investigations and interventional procedures including a chest X-ray showed a metallic round object in the upper esophagus consistent with a button battery which was removed via a thoracotomy after an esophagoscopy was not successful. This child would not have developed such serious complications and would not have required major surgery had the foreign body been identified and removed early on.

Objective: Parents of children undergoing tonsillectomy often ask about its effect on their child’s immunity. To answer this question, we conducted a thorough review of the literature, including an unpublished study we previously conducted.Method: A Medline search was conducted. All articles up to January 2012 addressing the effect of tonsillectomy on the immune system were included. No exclusion criteria were used. We previously studied 19 patients undergoing total or partial tonsillectomy. Preoperative and postoperative serum and saliva immunoglobulin levels were taken.Results: We reviewed 27 articles, published between 1971 and 2010, including 1665 patients (aged 1.5 to 45 years). The studies looked at different parameters, for example, serum immunoglobulins, salivary immunoglobulins, and delayed hypersensitivity test. The lack of standardization of diagnostic tools, follow-up duration, indication for tonsillectomy, and patients’ ages precluded a meta-analysis. Six studies (722 patients) found that ton...

The decision to transfuse is mainly taken according to hemoglobin level (Hb) (1,2) but venous oxygen saturation (SvO2) might be helpful to guide transfusion. We carried out a study to evaluate SvcO2 changes before and after blood transfusion after cardiovascular surgery. Methods. Patients admitted in ICU after cardiovascular surgery over 5 months (September 2014 to February 2015), who were transfused, have been included in the study. Patients with active bleeding, operated on emergency, or in critical condition were excluded. The decision to transfuse blood was made according to guidelines (1). Samples were collected through central venous catheter to measure respectively Hb and SvcO2 (co-oxymetry). Statistical analysis was performed with Mann-Whitney test. Data are expressed as median [25; 75%] and p o0.05 considered as statistically significant. Results. 100 consecutive patients have been included. Hb before transfusion was 7.3 g/dl [6.8; 7.8], SvcO2 66.9% [60; 73] without any correlation between both (Spearman r1⁄4 0.001; NS). SvcO2 was not significantly different between patients with Hb o 7 g/dL (n1⁄436) and patients with Hb Z 7g/dl (n1⁄464) (65.9% [59.3;77.7] vs. 67.7% [60.5;72.2] respectively; p1⁄40.92). SvcO2 after transfusion (RBC 2 [1;2]) increased significantly (71.9% [66.3;77.4]) as well as Hb (9.1 g/dL, [8.6;9.8]) (po0.001) but the observed change in Svc02 is related to patients with Svc02 o 65% before transfusion (po0.001), not when Svc02 Z 65%. Conclusions. According the study, 64% patients have high pretransfusion SvcO2 and experienced no SvcO2 improvement after transfusion, that questions its benefit. Whether a restrictive transfusion protocol guided by SvcO2 would be safe requires further studies.

Ventricular assist devices (VADs) are used to bridge the patient with end-stage heart failure to cardiac transplantation (BTT) or to destination therapy (DT). Since 2003 in the Montpellier’s hospital, 29 VADs have been implanted (8 to DT). In the majority of cases, the VAD was used in acute end-stage of heart failure; one-year mortality was 45%. Unlike inotropic agents, levosimendan, a new calcium senziter, enhances myocardial contractility without increasing myocardial oxygen consumption. 15 out of 29 patients were on the Intermacs classification level 1, on a scale of 1 to 7, 9 received levosimendan and 6 did not. 9 of 29 patients were undergoing to levosimendan infusion to prevent right ventricular failure; 5 were under mechanical ventilation and 5 under Extra-corporal membran oxygenation (ECMO) or trans-aortic left ventricular discharge by Impella 5.0 (Abiomed) before LVAD. 7 out of 29 patients (77.8%) were alive one year later, among who one died from cancer. 2 patients were under ECMO after LVAD. In contrast, only 6 patients out of 29 patients (20,7%) without levosimendan are alive after one year. Multivariate analysis demonstrated a significant independant effect of levosimendan infusion on one year mortality in this retrospective study.