A double-blind, randomized, comparative study of Dysport vs. Botox in primary palmar hyperhidrosis.

BACKGROUND: Intradermal injections of type A botulinum toxin have been reported to reduce excessive sweating in patients with primary palmar hyperhidrosis. Two preparations are commercially available in Europe: Botox (Allergan; 100 U per vial) and Dysport (Beaufour Ipsen Biotech; 500 U per vial), which are not bioequivalent. A few studies have tried to find an appropriate conversion factor between the two preparations in dystonic patients but results remain controversial. OBJECTIVES: To compare the efficacy of Botox and Dysport in palmar hyperhidrosis using a conversion factor of 1 : 4. METHODS: In a double-blind, randomized study, eight patients with severe primary palmar hyperhidrosis received in the same session intradermal injections of Dysport in one palm and Botox in the other, after regional median and ulnar nerve blocks. Quantification of sweat production was performed by Minor's iodine starch test at baseline, 1, 3 and 6 months after the treatment. Subjective assessment of sweat production was performed using a visual analogue scale. RESULTS: The mean +/- SD number of injection sites (28 +/- 1), mean volume of reconstituted solution injected (2.8 mL) and mean sweating area at baseline (BSA) were similar in each palm group. The mean +/- SD dose injected was 69.3 +/- 3.1 U for the Botox-treated palms and 283.7 +/- 11.3 U for the Dysport-treated palms (1 : 4). At 1 month, Minor's test revealed significant decreases in mean sweating area for each preparation (Dysport palms: -78.6% vs. BSA, P = 0.0002; Botox palms: -56.6% vs. BSA, P = 0.003). The percentage of decrease was more pronounced in Dysport palms compared with Botox palms but the difference did not reach statistical significance. At 3 months, the decrease in sweating area remained significant for Dysport palms (-69.4% vs. BSA, P = 0.008) but not for Botox palms (-48.8% vs. BSA). Self-evaluation showed a similar amount of improvement in both palm groups at 1 and 3 months (77% and 75% for Dysport; 68% and 72% for Botox). Local side-effects were more frequent in Dysport palms (weakness of thumb-index pinch in four cases, lasting 8-30 days) than in Botox palms (weakness of thumb-index pinch in two cases, lasting 15-21 days). The mean duration of positive effect was similar: 17 weeks in Dysport (range 8-32) and 18 weeks in Botox palms (range 8-32). CONCLUSIONS: Using a conversion factor of 1 : 4, the efficacy of Botox and Dysport injections was similar. However, there was a trend towards a larger improvement after Dysport treatment but with a higher incidence of adverse effects.

[Risks and results after simultaneous intramedullary nailing in bilateral femoral fractures: a retrospective study of 40 cases]. / Risques et résultats de l'enclouage simultané des fractures bifémorales.

PURPOSE OF THE STUDY: A retrospective series of 40 patients who underwent simultaneous intramedullary nailings for bilateral femoral shaft fractures was analyzed. The aim of our study was to verify that simultaneous nailing without reaming does not increased risk of fat embolism and to assess clinical and radiological outcome. MATERIAL AND METHOD: This series included 27 men and 13 women, mean age 27.8 years, who underwent first intention intramedullary nailing between 1986 and February 1999. Thirty-two patients had multiple fractures. Mean ISS was 23 (range 9 to 59). Among the 80 femoral shaft fractures, 15 were open fractures, 3 were associated with sciatic paralysis, and 4 were complicated by an interruption of the femoral vessels. The AO classification was: type A=44; type B=25; type C=11. Mean delay to simultaneous centromedullary nailing was 3. 8 days: surgery was performed on the day of arrival for 25 patients. General anesthesia was used in all cases with respiratory assistance (FIO(2) =50 to 100 p. 100). Mean nail diameter was 11.6 (range 10-14). Gurd criteria and PaO(2) were followed to assess pulmonary function. Clinical and radiological outcome was assessed using the modified Thorensen criteria. RESULTS: Preoperatively, PaO(2) was< 87 mmHg in 8 patients. Four of these patients showed a discrete drop off and three improved well above the normal level. Only one patient experienced an important decrease but did not develop respiratory distress. Among the 32 patients with a normal level preoperatively, PaO(2) remained in the normal range in 18, fell to a limit level but below 87 mmHg in 4, and showed a substantial drop off of 46 to 172 mmHg in 10. Two of these 10 patients developed respiratory distress due to fat embolism which was fatal in one case. One other patient died in the immediate postoperative period of an undetermined cause. All of the other patients recovered normal gas levels within a few hours or days. There were four cases of phlebitis, including one with pulmonary embolism, one case of respiratory distress by pulmonary superinfection, and one case of septicemia. Both femoral fracture sites became infected in one patient. Malunion occurred in two cases. Two vascular repairs of the femoropopliteal axis were unsuccessful, leading to above knee amputations. Thirty-four patients have been examined after a minimal 12 months follow-up (mean 30 months). Outcome was excellent for 48 femurs, good for 10 and fair for 10. DISCUSSION: This continuous series of simultaneous bilateral femoral shaft intramedullary nailings appears to be the only such report to date. The clinical and radiological outcomes were comparable with those achieved in one-side femoral fractures. The risk of fat embolism is inevitable after long bone fractures. Many factors favoring the risk are recognized, the most important being delay to fixation. Reaming creates excessive pressure in the medullary canal and could thus contribute to the risk. The presence of an associated chest trauma is not a formal contraindication if effective hematosis is preserved as evidenced by the blood gases. CONCLUSION: Simultaneous nailing of bilateral femoral shaft fractures can be performed if blood gases remain acceptable and minimal reaming is used.

[Loco-regional anesthesia and orthopedic surgery of the shoulder]. / Anesthésie loco-régionale et chirurgie orthopédique de l'épaule.

Interscalene block can induce by itself anesthesia for shoulder surgery, if the opening does not reach the delto-pectoral site nor the shoulder-blade, but medical indications must be thoroughly talked over on account of the risk of phrenic paralysis with patients suffering from breezing trouble, and the surgical position that may disturb the anesthesiologist in case he has to increase anesthesia. A superficial cervical plexus block is required in anesthesia of the upper part of the shoulder. Regional anesthesia is quite useful too as a complement to general anesthesia, for it provides excellent postsurgical analgesia. A catheter may be inserted at the end of the surgical process through a nerve stimulator, but the patient does not tolerate it long, its efficiency greatly diminishes after the first day, and paresthesias may occur as after-effects. Today we prefer set interscalene block before the patient is anaesthetized, searching for paresthesias with a thin needle: this process does not take long to install, it is relatively painless and provides excellent analgesia during the per and post-surgical period, until the next day with long acting local anesthetics. Not any complication happened in fifty patients for one year.

[Propofol in emergency anesthesia]. / Le propofol en anesthésie d'urgence.

Thirty-two patients (14 women and 18 men) whose age ranged between 15 and 76 were admitted on an emergency and anesthetized with propofol in view of various surgical interventions (9 appendectomies, 9 fractures, 5 wound healing, 6 abscess incisions, 2 corneal grafts and one complex trauma surgery) undergone 24 hours after their admission. Premedication included hydroxyzine 1.5 mg.kg-1, atropine sulfate 0.5 to 0.75 mg and pethidine 1 mg.kg-1 according to pain intensity and initial pathology. Narcosis was induced by 2.5 mg.kg-1 propofol injected intravenously. Propofol was then administered continuously at a dose of 9 mg.kg-1 in the first hour and of 4.5 mg.kg-1.h-1 in the following hours for 28 of the patients. Four patients undergoing short operations were given additional injections of one third of the initial dose. Analgesia and myorelaxation were obtained with fentanyl (0.16 +/- 0.06 mg) and vecuronium (9.3 +/- 4 mg). Narcosis proved to be very efficient. The side effects observed (13% myoclonia, 6% rash, 6% bradycardia, 0.3% pains at the time of injection) were similar to those quoted in the literature. Blood pressure stabilized after a short slight depression (13% to 18% of the standard values). Pulse remained regular. We can thus say that propofol is a good hypnotic drug for emergency anesthesia provided that its contra-indications especially shocks of cardiac or septic origin and hypovolemia, are carefully respected.(ABSTRACT TRUNCATED AT 250 WORDS)

[The "3-in-1" block: myth or reality?]. / Le bloc "trois-en-un": mythe ou réalité?

The technique described by Winnie in 1973 is supposed to provide a regional block of the femoral, femoral cutaneous, and obturator nerves by a single injection within the femoral nerve sheath. This study aimed to assess the diffusion spaces for the local anaesthetic solution used in this technique. The anatomical study included the dissection of 2 adult and 1 foetal cadavers. It was associated with a radiographic study in adult volunteers. About 20 to 60 ml of an isotonic radiographic contrast (iopamidol 150) were injected into the femoral nerve sheath located with the help of a nerve stimulator. Standard pelvic radiographs and computerised tomographic scans were carried out at the time of injection, and 30 min later. Two different unpredictable distributions were found; which were independent of the injected volume. One type consisted in an internal diffusion towards the psoas major muscle, the liquid thus reaching the three nerves. The other type was an external diffusion, in front of the iliacus muscle, the liquid never reaching the internal side of the psoas major muscle, and therefore the obturator nerve. The "3 in 1" block would therefore seem to be useful for those surgical acts requiring only a block of the femoral and femoral cutaneous nerves, i.e. those involving the anterior aspect of the thigh and knee, the femoral shaft, and the patella. On the other hand, its usefulness for surgery of the hip (dislocation, fractured neck of femur) is rather uncertain.