Medical Pathologies and Hut Guardians' Ability to Provide First Aid in Mountain Huts: A Prospective Observational Study.

OBJECTIVE: To describe the resources for medical condition management in mountain huts and the epidemiology of such events. METHODS: We conducted a 3-step study from April 2013 to August 2014 in French mountain huts. The first step consisted of collecting data regarding the first aid equipment available in mountain huts. The second step consisted of a qualitative evaluation of the mountain hut guardian's role in medical situations through semistructured interviews. Finally, a prospective observational study was conducted in the summer season to collect all medical events (MEs) that occurred during that period. RESULTS: Out of 164 hut guardians, 141 (86%) had a basic life support diploma. An automatic external defibrillator was available in 41 (26%) huts, and 148 huts (98%) were equipped with a first aid kit. According to semistructured interviews, hut guardians played a valuable role in first aid assistance. Regarding the observational study, 306 people requested the hut guardian's help for medical reasons in 87 of the 126 huts included. A total of 501 MEs for approximately 56,000 hikers (0.85%) were reported, with 280 MEs (56%) involving medical pathologies and 221 (44%) MEs involving trauma-related injuries. CONCLUSIONS: MEs had low prevalence, but the hut guardian played a valuable role as a first aid responder.

[Duty militaries' consumption of psychotropic drugs in 2005]. / Consommation de médicaments psychotropes chez les militaires d'active en 2005.

UNLABELLED: The knowledge of psychotropic medication consumption is a Public Health stake for the armies and their social partners. Indeed, indirectly, it permits not only assessment of the state of health or the mental state of the working militaries, but also the development of actions to increase consumers' and prescribers' awareness of the main effects of psychotropic drugs and their side effects. The evaluation of the consumption of psychotropic drugs is based on the reimbursements requested from the "Caisse nationale militaire de Sécurité sociale", a particular scheme of the health fund, to which every working military is affiliated. MATERIAL AND METHOD: A retrospective inquiry was led on elements of reimbursement for antidepressants, anxiolytics, hypnotics, neuroleptics, lithium salts and medicines used in alcoholic weaning during the year 2005. RESULTS: The study concerned 35 365 social insurance contributors, i.e. 8.6% of the working militaries' population. They were mainly men (74.8%) and the mean age was 35.7 years. The refund rate was more important for women (15.6% versus 7.43%) and when the age increased: 6.13% for the 15-24 years versus 15.3% for the 50-59 years. Only 1.4% of the consumers exhibited a long-term psychiatric disorder. A percentage of 21.8% of the consumers had at least four refunds in the year. Anxiolytics, followed by antidepressants and hypnotics, were the medication most often reimbursed. A total of 93,119 prescriptions, including at least one psychotropic medication, were reimbursed in 2005. A percentage of 54.1% of the consumers had only had one prescription in the year. The coprescription of different therapeutic classes represented 41.5% of the prescriptions, the most common being an association between an anxiolytic and an antidepressant (46.8%). The consumers had consulted 49,802 doctors, mainly general practitioners (GPs) (83.6%), and psychiatrists (7.1%). The army doctor, counted with the GPs, was very little sought after (5.3%). Most of the doctors (67.4%) prescribed only once for the same consumer. Compared with GPs, psychiatrists mainly prescribed antidepressants (47.6% versus 35.7% for GPs) and associated more often, another therapeutic class on the same prescription (53.9% versus 30.9% for GPs). CONCLUSION: Our results show that the consumer's profile in the class of the working militaries does not differ from that found in other studies conducted on professionals. The GP is the main prescriber of psychotropic drugs, but this kind of prescription is different from the psychiatrist's. The military doctor is little implicated in the prescription of psychotropics, the link between aptitude and use is obviously the main explanation. The good use of psychotropic medication has to be reinforced for both consumers and prescribers. Other alternatives than the call on medicine have to be reinforced by improving the prevention and the management of psychological disorders and psychiatric affections.

Noncardiac surgery brain injury: etiologic factors and prevention.

EXCERPT: During total joint arthroplasty, showers of bony spicules, marrow fat, and clot are carried by venous blood to the lungs, creating conditions not unlike those present in patients who have suffered traumatic long bone fractures. There is recent evidence that, like the fat embolism syndrome (FES), which often has a component of neurologic dysfunction, total joint arthroplasty and femoral nailing are associated with intraoperative brain embolization as determined by transcranial Doppler ultrasonography, and magnetic resonance brain imaging. Although there are good data demonstrating that intraoperative brain embolization occurs during total joint arthroplasties, the makeup and, even more importantly, the clinical significance of these emboli remain speculative. Brain microemboli resulting from cardiac surgery occur by the millions and may cause focal ischemia resulting in significant neurologic dysfunction. Our studies suggest that the major source of these microemboli is lipid droplets of the patient's fat that drip into the blood in the surgical field. This lipid-laden blood is aspirated and then returned to the patient via the cardiopulmonary bypass (CPB) apparatus. Our investigations have focused on the causes (microemboli), consequences (brain damage), and strategies for elimination of brain lipid microemboli resulting from salvaged blood collected during surgery.

Ischemic preconditioning reduces neurologic injury in a rat model of spinal cord ischemia.

BACKGROUND: Ischemic preconditioning (IPC) is an endogenous cellular protective mechanism whereby brief, noninjurious periods of ischemia render a tissue more resistant to a subsequent, more prolonged ischemic insult. We hypothesized that IPC of the spinal cord would reduce neurologic injury after experimental aortic occlusion in rats and that this improved neurologic benefit could be induced acutely after a short reperfusion interval separating the IPC and the ischemic insult. METHODS: Forty male Sprague-Dawley rats under general anesthesia were randomly assigned to one of two groups. The IPC group (n = 20) had 3 minutes of aortic occlusion to induce spinal cord ischemia 30 minutes of reperfusion, and 12 minutes of ischemia, whereas the controls (n = 20) had only 12 minutes of ischemia. Neurologic function was evaluated 24 and 48 hours later. Some animals from these groups were perfusion-fixed for hematoxylin and eosin staining of the spinal cord for histologic evaluation. RESULTS: Survival was significantly better at 48 hours in the IPC group. Sensory and motor neurologic function were significantly different between groups at 24 and 48 hours. Histologic evaluation at 48 hours showed severe neurologic damage in rats with poor neurologic test scores. CONCLUSIONS: Ischemic preconditioning reduces neurologic injury and improves survival in a rat model of spinal cord ischemia. The protective benefit of IPC is acutely invoked after a 30-minute reperfusion interval between the preconditioning and the ischemic event.

Plasma bupivacaine concentrations and effects of epinephrine after superficial cervical plexus blockade in patients undergoing carotid endarterectomy.

OBJECTIVE: To determine if epinephrine (EPI) added to a solution of bupivacaine (BUP) injected for use in superficial cervical plexus blockade (SCPB) lowers plasma BUP concentrations after injection and whether this addition of EPI resulted in tachycardia, cardiac arrhythmias, or both. DESIGN: Randomized, unblinded prospective clinical interventional study. PARTICIPANTS: Patients scheduled to undergo carotid endarterectomy using SCPB consenting to study. SETTING: University-affiliated tertiary care hospital operating room. INTERVENTIONS: Twenty patients were given SCPB with BUP 0.5% and were randomized to receive either no EPI or 1:300,000 EPI. This study block was followed by a second period in which 20 patients were given SCPB with BUP 0.25% randomized to receive either no EPI or 1:300,000 EPI. Continuous electrocardiogram monitoring was performed during and after the block and analyzed for heart rate and rhythm changes. MEASUREMENTS AND MAIN RESULTS: Arterial plasma BUP concentrations were measured 2.5 to 120 minutes after initiation of SCPB. Plasma BUP concentrations were highest in the 0.5% no EPI group, followed by the 0.5% EPI, 0.25% no EPI, and 0.25% EPI groups. The use of EPI did not significantly affect heart rate or change the incidence of cardiac arrhythmias. CONCLUSIONS: BUP 0.25% consistently produced the lowest plasma BUP concentrations, particularly when EPI was added to the solution. BUP 0.5% without EPI can produce plasma BUP concentrations previously reported to be associated with central nervous system effects. The use of EPI in this setting does not produce untoward cardiac side effects.

A cluster of cases of infections due to Aeromonas hydrophila revealed by combined RAPD and ERIC-PCR.

Two polymerase chain reaction (PCR)-based methods were used for epidemiological typing of Aeromonas hydrophila. Random amplification of polymorphic DNA (RAPD) and enterobacterial repetitive intergenic consensus-PCR (ERIC-PCR) were applied to an outbreak involving seven patients. The epidemiological situation appeared complex; with the exception of two clinical isolates, all gave unique patterns with both techniques. These methods demonstrated nosocomial transmission in one unit and permitted the study to exclude a common environmental source in the hospital. The coincidental clustering of patients infected with A. hydrophila probably resulted from an increased prevalence of aeromonads in waters during summer, although no single RAPD or ERIC-PCR pattern was found among both clinical and environmental samples. RAPD and ERIC-PCR proved to be effective for the epidemiological study of A. hydrophila strains.

Neuronal NO promotes cerebral cortical hyperemia during cortical spreading depression in rabbits.

Temporary elevations in cortical cerebral blood flow (CBF) accompany cortical spreading depression (CSD) in anesthetized animals. We tested the hypothesis that nitric oxide (NO) is an important promotor of CSD-induced cortical hyperemia in urethan-anesthetized rabbits. CBF was measured at four time points by administration of 15-microm microspheres with the reference withdrawal technique. Intravenous administration of the nonspecific NO synthase (NOS) inhibitor N(omega)-nitro-L-arginine increased mean arterial blood pressure and resting cerebrovascular resistance and attenuated CSD-induced hyperemia. Cortical CBF before intraperitoneal 7-nitroindazole (7-NI), a neuronal NOS inhibitor, was 42 +/- 8 and 124 +/- 19 ml x 100 g(-1) x min(-1) at baseline and during CSD, respectively (P < 0.05 by repeated-measures analysis of variance). After 7-NI administration, mean arterial blood pressure, CBF, and cerebrovascular resistance were unchanged from baseline values; cortical CBF was 38 +/- 4 and 90 +/- 8 ml x 100 g(-1) x min(-1) post-7-NI at rest and during a second CSD, respectively. Similar to N(omega)-nitro-L-arginine, 7-NI decreased the cortical hyperemic response during CSD (P < 0.05 by repeated-measures analysis of variance). We conclude that neuronal NOS promotes the temporary cortical hyperemia observed during CSD.

Fluoroscopy-assisted intubation of a child with an unstable subluxation of C1/C2.

Patients presenting with unstable cervical spine injuries are at risk for additional neurological injury as a consequence of airway manipulation. Techniques of awake intubation may not always be desirable or practical, particularly in the pediatric patient. We describe the use of fluoroscopy during the induction of anesthesia and intubation of a child with an unstable C1/C2 spinal subluxation. Fluoroscopy is readily available and noninvasive. This technique allows for rapid establishment and maintenance of optimal head and neck positioning during induction of general anesthesia and performance of laryngoscopy and tracheal intubation.

Nitric oxide and prostaglandins interact to mediate arteriolar dilation during cortical spreading depression.

We examined whether blockade of prostaglandin synthesis by indomethacin could attenuate the effect of nitric oxide synthase (NOS) inhibition on cerebral arteriolar dilation during cortical spreading depression (CSD). CSD was induced by microinjection of 5% (670 mM) KCl onto the cerebral cortex of anesthetized adult rabbits. A closed cranial window and intravital microscopy were used to measure pial arteriolar diameter, and NOS activity was determined by the conversion assay of [14C]arginine to [14C]citrulline. CSD dilated pial arterioles by 47 +/- 3% (baseline = 80-88 microns) (n = 21, P < 0.05), and inhibition of NOS by NG-nitro-L-arginine (L-NNA) (15 mg/kg iv) reduced dilation during CSD by over one-half (n = 8, P < 0.05) without altering the onset latency to CSD. After indomethacin administration (15 mg/kg iv), CSD dilated arterioles from 73 +/- 2 to 152 +/- 6 microns (n = 4, P < 0.05). However, after administration of both indomethacin and L-NNA (n = 5), CSD-induced arteriolar dilation was not different from the situation where indomethacin alone was given. Thus indomethacin completely abolished the inhibitory effect of L-NNA on CSD-induced dilation. Administration of L-NNA inhibited NOS activity in brain cortex almost completely (n = 8, P < 0.05), whereas indomethacin itself had no effect (n = 8). In addition, L-NNA inhibited topical acetylcholine (10(-5) M)-induced arteriolar dilation (n = 3, P < 0.05), and this effect was not altered by indomethacin (n = 4). In summary, L-NNA reduced arteriolar dilation during CSD. However, after administration of indomethacin, L-NNA does not reduce CSD-induced arteriolar dilation.

Nitric oxide promotes arteriolar dilation during cortical spreading depression in rabbits.

BACKGROUND AND PURPOSE: Pial arterioles transiently dilate during cortical spreading depression (CSD), although the mechanisms are unclear. We tested the hypothesis that increased production of nitric oxide (NO) promotes arteriolar dilation. METHODS: Urethane-anesthetized rabbits were equipped with cranial windows, and the diameter (reported in micrometers) of a pial arteriole was determined via intravital microscopy. In each rabbit, a baseline CSD was elicited by microapplication of KCl onto the cortex, and resultant pial arteriolar dilation was measured. Either 100 mumol/L N omega-nitro-L-arginine methyl ester (L-NAME) or 50 mumol/L NG-nitro-L-arginine (L-NA), both competitive NO synthase inhibitors, was then applied to the brain surface. A CSD was elicited as before. The L-NAME and L-NA were then removed by artificial cerebrospinal fluid washes. An additional CSD was induced with KCl as before. RESULTS: Control CSD in the L-NAME group dilated pial arterioles; baseline diameter, 66 +/- 7 mm, with CSD = 106 +/- 8 mm (59% increase). After topically applied L-NAME, CSD dilated pial arterioles less: baseline diameter, 61 +/- 7 mm, with CSD = 77 +/- 6 mm (26% increase), P < .05 compared with control CSD diameter. Topical L-NA had similar effects on CSD: control CSD dilated pial arterioles 51%; after topical L-NA, only 14% (P < .05). After removal of L-NAME or L-NA, CSD-induced pial arteriolar dilation was similar to original control values. CONCLUSIONS: The reversible inhibition of CSD-induced pial arteriolar dilation by either L-NAME or L-NA suggests that NO contributes to arteriolar dilation observed with CSD.

Thoracic epidural analgesia with bupivacaine and fentanyl for postoperative thoracotomy pain.

This study was designed to evaluate the potential fentanyl-sparing effect of a dilute local anesthetic, bupivacaine, administered in fixed combinations with fentanyl for post-thoracotomy analgesia via a continuous thoracic epidural infusion. Forty adult patients scheduled for thoracotomy were randomly allocated in a double-blind fashion to receive an epidural infusion containing 0, 0.03, 0.06, or 0.125% bupivacaine in combination with fentanyl (4 micrograms/mL). The epidural infusions were initiated in the operating room at 10 mL/hr. During the first 24 hours, there were no between-group differences in pain scores. Total fentanyl use was significantly decreased 24% to 33% in all bupivacaine treatment groups. However, fentanyl plasma levels at 24 hours were not significantly different between groups. Arterial blood gas measurements performed on the morning after surgery revealed significant reductions in PaCO2 values, 38 +/- 4, 36 +/- 4, 37 +/- 4 mmHg for 0.03, 0.06, and 0.125% bupivacaine groups respectively, versus 44 +/- 6 for the plain fentanyl group. Arterial pH values were significantly higher in all bupivacaine treatment groups. These findings suggest that the combination of dilute bupivacaine with fentanyl for thoracic epidural analgesia for post-thoracotomy pain may have beneficial effects on pulmonary gas exchange.

Calcitonin gene-related peptide promotes cerebrovascular dilation during cortical spreading depression in rabbits.

We examined the role of calcitonin gene-related peptide (CGRP) in cortical spreading depression (CSD)-induced dilation of rabbit pial arterioles. In urethan-anesthetized rabbits instrumented with a closed cranial window, CSD induction with KCl dilated pial arterioles from 86 +/- 10 to 132 +/- 13 (mean +/- SE, n = 6) microns (a 54 +/- 9% increase). Topical administration of 12.8 microM CGRP-(8-37), a competitive inhibitor of the CGRP receptor, reduced CSD-induced pial dilation from 54 +/- 9% baseline to 33 +/- 9% (P < 0.05). Removal of the receptor antagonist from the brain surface restored CSD-induced dilation to 59 +/- 11% (P < 0.05, compared with the response with the antagonist present). In other animals, we showed that this dose of the CGRP antagonist attenuated arteriolar dilation to topically applied 10(-7) M CGRP (n = 5), but it did not alter arteriolar dilation to arterial hypercapnia. We also evaluated the dilator potency of substance P (SP) compared with CGRP. Dilation with 10(-7) M SP was only 22 +/- 11%, whereas arterioles dilated to 57 +/- 7% above baseline diameter with 10(-7) M CGRP. We conclude that CGRP contributes to the transient arteriolar dilation that is characteristic of CSD.

[Bipolar luxation of the 5th metacarpal bone]. / Luxation bipolaire du cinquième métacarpien.

A case of post-traumatic double dislocation of the fifth metacarpal is reported. No reference has been found in the literature. Both were dorsal dislocations, mechanism appears as an axial compression on the metacarpal distal extremity, as first phalanx is hyperextended. Only the carpo-metacarpal-joint was reduced by close technic with percutaneous fixation; the metacarpo-phalangeal dislocation required surgery using a palmar approach. Normal function of the joint was recovered three months later.

Cricoarytenoid subluxation: complication of blind intubation with a lighted stylet.

Transillumination of the cervical airway with the light wand for blind intubation is a valuable adjunct to anesthesiologists and emergency room physicians, particularly for management of the complicated airway in which direct visualization of the larynx is not possible. However, as an alternative to traditional methods, this technique should be practiced in simple cases before it is attempted in more difficult airway cases. The technique is easy to learn but requires practice to master. The incidence of complications remains low but complications may be serious when they occur. We present a case of cricoarytenoid subluxation after blind intubation with a lighted stylet.

[A clinical trial of the effectiveness and tolerance of bepridil in unstable angina pectoris]. / Etude clinique de l'efficacité et de la tolérance du bépridil dans l'angor instable.

Bepridil, a new anti-anginal drug, was given in a daily dosage of 400 to 600 mg to twenty patients with unstable angina pectoris. The trial was designed to evaluate the effectiveness of bepridil in this indication and to determine the optimal dosage. A positive response evidenced by the arrest of progression towards infarction was recorded in 17 patients. Tolerance was satisfactory in 19 cases: in one diabetic patient under insulin symptoms of hypoglycemia resolved once insulin was discontinued. With the dosages used the effectiveness of bepridil in unstable angina pectoris is similar to that recorded in effort angina with 300 mg per day.