[Intravascular lymphoma simulating relapse of breast cancer: An original clinical case]. / Lymphome intravasculaire simulant une récidive de cancer du sein : une présentation clinique originale.

BACKGROUND: Intravascular lymphoma is a rare form of non-Hodgkin's lymphoma with varied but highly evocative clinical presentations, particularly in terms of dermatology. Histological examination of the skin may be sufficient to allow diagnosis. PATIENTS AND METHODS: Herein, we report the case of a 75-year-old woman with a history of infiltrative ductal carcinoma of the left breast who was hospitalised for neurological evaluation following repeated falls. During the course of her hospital stay, the patient's neurological state deteriorated rapidly, and onset of marked laboratory-documented inflammatory syndrome was observed, together with disseminated intravascular coagulation (DIC). At the same time, she developed orange-peel type skin lesions on her left breast followed by a rapidly-spreading livedoid infiltrated plaque on her side. The skin biopsy enabled a diagnosis to be made of intravascular lymphoma based on immunohistochemical demonstration of intravascular tumoral proliferation of lymphoid cells expressing CD45 marker and B-cell marker CD20, as well as Bcl2, MUM 1 and CD5. DISCUSSION: Intravascular B-cell lymphoma is a rare subtype of diffuse large B-cell lymphoma. It carries a poor prognosis and the clinical appearance varies extremely widely. The signs are primarily neurological and dermatological. Because of the varied nature of presentations as well as the rarity of the disease, diagnosis may be delayed, with worsening of the prognosis of the disease, which nevertheless requires rapid and aggressive management. However, the appearance of infiltrated and livedoid lesions on the trunk or limbs is evocative and skin biopsy constitutes a readily accessible diagnostic tool that offers rapid confirmation.

[Temporary localized alopecia following neuroradiological procedures: 18 cases]. / Alopécie circonscrite temporaire après neuroradiologie interventionnelle : une série de 18 cas.

BACKGROUND: The treatment of cerebral lesions using endovascular radiological procedures is becoming a standard of care. Radiation-induced alopecia, a type of acute radiodermatitis, is a frequent complication. Between 2009 and 2010, a number of patients reported hair loss after embolization of a cerebral arteriovenous malformation at the Neuroradiology Department of the Strasbourg University Hospital. We therefore retrospectively investigated 18 cases to better delineate the circumstances and the risk factors associated with radiation-induced alopecia. PATIENTS AND METHODS: We reviewed the records of 35 patients reporting hair loss among the 347 patients undergoing embolization of cerebral arteriovenous malformations between January 2008 and May 2010. Only patients with photographically documented complete circumscribed alopecia were included. Patients were examined and interviewed by a dermatologist and/or a radiologist at the time of hair loss and at a later point. The cumulative dose of radiation delivered to the skin in the 3 months preceding onset of alopecia, then over the entire period 2008-2010, was calculated. These doses included the diagnostic (angiography) and therapeutic (embolization) procedures. RESULTS: Definite circumscribed alopecia was noted in 18 patients. Alopecia occurred between two and four weeks after embolization; it was complete and in no cases cicatricial. Complete recovery as attested by examination or photography was observed in 12 patients. The cumulative dose over the preceding three months was between 2.5 Gy and 12.3 Gy (mean: 5 Gy). The total cumulative dose since January 2008 was between 3.2 and 17 Gy (mean: 7 Gy). DISCUSSION: We describe a series of 18 patients with radio-induced alopecia occurring after diagnostic and therapeutic procedures for cerebral arteriovenous malformations. This series is particularly interesting because it includes the largest patient sample reported to date with an uncommon large area of alopecia, and also because we were able to calculate the cumulative dose of radiation delivered to the skin. In addition, we underline the importance of the cumulative dose in interventional radiology since radio-induced alopecia probably results from the number of interventional procedures during a given time period. Moreover, analysis of these doses provided us with a new perspective on the radiobiology of the hair growth cycle. Indeed, whereas previously reported data considered alopecia as definitive where doses higher than 7 Gy were delivered, we noticed regrowth of hair with doses of up to 12 Gy. CONCLUSION: These observations underline the specific findings of radiation-induced alopecia and underline the importance of the cumulative radiation dose delivered during the 3 months preceding alopecia.

Statement of severe trauma management in France; teachings of the FIRST study.

INTRODUCTION: The blunt trauma victim management is still a matter of debate and comparing studies involving different emergency medical services and health care organization remains fictitious. Hence, the French Intensive care Recorded in Severe Trauma (FIRST) was conducted in order to describe the severe blunt trauma management in France. The present paper aimed at recalling the main results of FIRST study. METHODS: The FIRST study was based on a multicenter prospective cohort of patients aged 18 or over with severe exclusive blunt trauma requiring admission to university hospital care unit within the first 72h and/or managed by medical-Staffed Emergency Mobile Unit (SMUR). Multiple data were collected about patient characteristics, clinical initial status, typology of trauma and the main endpoints were 30-day mortality. RESULTS: Sixty-one percent of trauma patients were road traffic victims and 30% were domestic, sport or leisure trauma. Patients who benefited from medical pre-hospital management were globally more severely injured than those who received basic life support care by fire brigades. Therefore, they were delivered more aggressive treatment in the pre-hospital setting and the median time for their hospital admission was lengthened. However, their 30-day mortality was significantly reduced. The probability of death was also decreased when casualties were transported by SMUR helicopter directly to the university hospital. In the in-hospital setting, the performance of a whole-body computed tomography (CT) was associated with a significant reduction in the mortality risk compared with a selective CT. CONCLUSION: The FIRST study suggests the benefit of a medical management in the pre-hospital setting on the survival of trauma patients. The emergency physician (EP) expertise in the pre-hospital and initial hospital phases would lead to the concept of the appropriate care for the appropriate trauma patient. It also highlights the necessity to set up organized regional sectors of care and registries.

[Fegelers syndrome, acquired port-wine stain or acquired capillary malformation: three cases and a literature review]. / Syndrome de Fegeler, angiome plan acquis ou malformation capillaire acquise : trois observations et revue de la littérature.

BACKGROUND: Port-wine stains or capillary malformations are generally congenital. Very few cases of acquired port-wine stains in adults have been described, and these occur particularly after trauma. PATIENTS AND METHOD: We report three cases of acquired port-wine stains and we performed a review of the literature using the keywords "port-wine stain", "capillary malformation", "angioma" and "acquired" in the Medline database PubMed. All relevant articles were included. RESULTS: Two male patients and one female patient consulted for one or more angiomatous lesions, located respectively on the upper rear part of the right thigh (case 1), the left leg (case 2) and the right side of the face, skull and chest (case 3). Each patient's skin biopsy was consistent with port-wine stain. The three patients asserted the acquired nature of the lesions: the male patients were respectively 17 and 38 years old, and the female patient was 11 years old. No causative factors were evident preceding the lesion, and there was no family history of port-wine stain. The topography was systematic in patients 2 and 3. The lesions were light red in patient 1, dark red in patient 2 and pale pink in patient 3. The remainder of the physical examination was unremarkable, except for benign angiokeratoma of the scrotum in case 1 and pigmented leucoderma-type macules in case 3. LITERATURE RESULTS: Sixty-six cases of acquired port-wine stains were reported in the literature. The average age was 25 years (3-69) with a sex-ratio of 0.88. Generally, no causative factor was given. However, trauma (30.5%), estrogenic impregnation (16.5%), and more rarely, medication, solar damage, frostbite, cluster headache, herpes zoster and acoustic neuroma were reported as causatives factors. DISCUSSION: Acquired port-wine stain is rare. Although often idiopathic, it can result from spinal trauma, which must be explored if suggested by the history. In our series, the clinical presentation suggested a latent congenital vascular malformation of late onset, in particular in patients 2 and 3, because of the segmental distribution.

[Severe trauma patients in a mountain area: an observational study]. / Les traumatisés graves en montagne: une étude observationnelle.

OBJECTIVES: The main objective was to estimate the nature, severity and medical care of severe trauma injuries following mountain activities as compared to severe trauma following traffic accident in a mountain area. STUDY DESIGN: We conducted a prospective comparative monocentric observational study at a University Hospital located in the northern Alps area, using the First national study database (French intensive care recorded in severe trauma). PATIENTS AND METHODS: Three hundred and thirty-seven patients were included during a 2-year-period from January 2005 to December 2006. Three hundred and thirty-seven patients, including 223 traffic accidents and 114 mountain accidents were included. The survey data was achieved with a standardized method on a period of 30 days after the accident, and recorded in a computerized file for optimal completeness. RESULTS: The study did not show higher severity or mortality rates in patients with mountain accidents. In both groups, we found a peak of mortality for young adults and similar causes of death. However, spinal cord injuries were statistically more frequent in mountain accidents. CONCLUSION: So, it seems important to continuously warn population about dangers of this playground.

[Open chest cardiopulmonary resuscitation: is there an interest in France?]. / Intérêts des manoeuvres de réanimation à thorax ouvert en France ?

OBJECTIVE: To expose and clarify indications, techniques, results, complications and cost for open chest cardiopulmonary resuscitation manoeuvres (OCCRM) in traumatic or nontraumatic cardiac arrest. DATA SOURCES: References were obtained from Pubmed data bank using the following keywords: "emergency thoracotomy", "resuscitative thoracotomy". STUDY SELECTION: We focused on publications in English language, from 2000 to 2007. DATA SYNTHESIS: OCCRM are useful especially in case of traumatic cardiac arrest, penetrating trauma, but also in blunt trauma. Time between cardiac arrest and realisation of the thoracotomy seems to be the most important factor for the prognosis. CONCLUSION: According to the French "physician in ambulance" prehospital system, OCCRM might be promising in France, because this system favours the fastness of care and therefore would minimize the time factor.

[Tracheal intubation through the intubating laryngeal mask airway training on manikin: comparison of single use and reusable devices from the same manufacturer]. / Apprentissage sur mannequin de l'intubation trachéale à l'aide d'un masque laryngé pour l'intubation : comparaison des dispositifs réutilisables et à usage unique d'un même fabricant.

INTRODUCTION: Recently, the French Society for Anaesthesia and Intensive Care (SFAR) has updated algorithms for difficult airway management, in which, the place of the intubating laryngeal mask (ILMA) is well defined. Moreover, in the guidelines, the SFAR recommended that the training for the different techniques for difficult intubation should initially be achieved on manikins. However, few data are available for disposable ILMA learning process on manikins. STUDY DESIGN: To compare, on manikin, the learning curves of the disposable and reusable ILMA. MATERIALS AND METHOD: Forty operators (anaesthesiologist, nurse, resident), experienced with conventional tracheal intubation but novice to commercially available ILMAs (Sebac, Pantin, France), underwent videotape learning and manikin training. After randomisation, each participant had to perform 10 timed consecutive tracheal intubations with either reusable or disposable ILMA. The learning curve was built according to the duration of successful procedure. Failure was considered if tracheal intubation could not be achieved or if the procedure lasted more than five minutes. RESULTS: No difference was noted between the two groups in terms of learning curves, number and repartition of the failed attempts during the learning process. CONCLUSION: This study shows that both disposable and reusable ILMA share similar learning process on manikins. Further studies are needed to evaluate the efficiency of the disposable ILMA in the clinical field of difficult intubation.

[Upper airway obstruction by retropharyngeal haematoma: a complication of central venous catheter insertion attempt]. / Hématome rétropharyngé asphyxiant après tentative de pose d'une voie veineuse jugulaire interne.

Retropharyngeal haematomas are a rare complication of central venous catheters insertion. A case of a retropharyngeal haematoma in a patient treated by acetylsalicylic acid is reported. This case emphasized the difficulty in diagnosis. Close airway surveillance must be done and can lead to surgery in case of airway obstruction.

[Interest of entropy monitoring during low-grade cerebral aneurysm embolisation]. / Intérêt du monitorage de la profondeur d'anesthésie par entropie pour l'embolisation d'anévrismes intracrâniens de bas grade.

OBJECTIVE: Evaluate the use of entropy monitoring on anaesthetic drugs consumption, haemodynamic stability, and recovery time in patients undergoing embolisation of cerebral artery aneurysm (asymptomatic or low Hunt and Hess grades). METHODS: Two groups, G1 without entropy monitoring (Datex-Ohmeda S/5), G2 with entropy monitoring (16 patients in each group). Each group had similar anaesthetic protocol (propofol target control infusion and continuous intravenous infusion remifentanil). For G2, the state entropy (SE) values were kept between 35 and 45. We studied anaesthetic drug consumption, arterial pressure parameters, extubation delay and feasibility. Statistical analysis used Mann and Whitney test, Fisher test. Significativity was p<0.05. RESULTS: No intraoperative incident. Propofol consumption was lower in G2 (7.49+/-2.28 mg/kg per hour versus 9.46+/-2.50mg/kg per hour; p<0.05). A tendency to reduction was observed for remifentanil consumption (6.65+/-2.04 microg/kg per hour versus 7.94+/-2.92 microg/kg per hour; p=0.056), and extubation delay (14.1+/-8.6 min versus 26.5+/-22.0 min; p=0.056), in G2. The entropy monitoring had no repercussion on haemodynamic stability, but the arterial pressure values were significantly higher in G2 (73.60+/-8.49 mmHg versus 67.10+/-5.58 mmHg). Entropy captor does not disrupt embolisation procedure. Coils liberation alter temporarily RE and SE values.

[Anesthesia for video-assisted surgery of the thoracic and lumbar spine: a survey of 44 patients]. / Anesthésie pour chirurgie vidéoassistée du rachis thoracolombaire.

INTRODUCTION: The development of video-assisted surgery of the dorsolumbar spine has led to the need for adaptations for appropriate anesthetic management. Data concerning anesthesia for such surgery is very sparse in the literature. AIM OF THE STUDY: The aim of this retrospective study of 44 patients was to learn more about anesthesia practices used for patients undergoing this type of surgery. PATIENTS AND METHOD: The files of 44 patients were studied retrospectively. Epidemiologic data and the perioperative phase were analysed. RESULTS: The preoperative phase was not specific with preoperative assessment adapted to each patient. Similarly, monitoring practices during the surgical procedure were not specific. The choice of the anesthetic agents depended on the patient's clinical status. For tracheal intubation, care was taken to enable lung exclusion, even if not often used. Thoracic drainage at the end of the surgery was required in the event of imperfect hemostasis and in selected patients was replaced by pneumothorax exsufflation during closure. The postoperative period was uneventful and did not require admission to intensive care; non-specific analgesia was used. DISCUSSION: Adaptations of anesthetic practices are required each time a new surgical technique is developed. Excepting lung exclusion, anesthesia for video-assisted dorsolumbar spine surgery is not specific.

Reliability of computed tomographic angiography in the diagnosis of brain death.

OBJECTIVE: This study examined the validity of cerebral computed tomographic (CT) angiography in the diagnosis of brain death (BD) compared with conventional cerebral angiography. METHODS: This prospective, monocentric study was performed over a 24-month period and included 43 patients, at least 18 years of age, with clinical criteria of BD. All patients underwent cerebral CT angiography and then cerebral angiography. To confirm BD, the CT scan had to show the absence of perfusion of A2 anterior cerebral artery segments (A2-ACA), M4 middle cerebral artery segments (M4-MCA), P2 posterior cerebral artery segments (P2-PCA), basilar artery, internal cerebral veins, and finally the great cerebral vein. Cerebral angiography showed cerebral blood flow arrest at the level of the foramen magnum for posterior circulation and carotid siphon for anterior circulation. RESULTS: For 30 patients, BD was confirmed by both examinations. For 13 patients, cerebral angiography confirmed BD, whereas CT angiography still showed cerebral perfusion; the divergence rate was 30.2%. CONCLUSIONS: CT angiography seems to be a promising exam to confirm BD. However, the divergence with cerebral angiography is significant mainly concerning A2-ACA, which are proximal. It may be possible to only use the absence of opacification of M4-MCA, P2-PCA, basilar artery, and venous blood return to remain in conformity with the French law. In all cases, the international medical community should obtain a consensus for the interpretation of CT angiography to use it extensively as a complementary exam for BD.

[Evaluation of a training method for transtracheal punction for emergency oxygenation]. / Ponction de la membrane intercricothyroïdienne pour l'oxygénation en urgence: évaluation d'une formation.

INTRODUCTION: Transtracheal oxygenation is a lifesaving technique in a cannot-ventilate, cannot-intubate situation, in setting percutaneous transtracheal catheter. OBJECTIVE: To assess training for cricoid membrane puncture performed with a Ravussin needle. METHOD: Ten residents in anaesthesiology nearing completion of their training participated in the study. Following a didactic session and a video demonstration, participants performed percutaneous transtracheal punctures on fresh cadavers. Success rate and time to perform the puncture were measured. Results are expressed as mean+/-SD. RESULTS: By the third attempt, all procedures were successful. Mean performance time at the first attempt was 31.2+/-21.8 s, progressively decreasing with the following attempts to reach a plateau by the third attempt (20.6+/-19.3s). Performance time varies with the cadaver's morphology and the ability to recognize anatomic landmarks. However, whatever the difficulty, performance time is 40 s or less by the third attempt. CONCLUSION: Percutaneous transtracheal catheter setting is a life saving technique with which every anaesthesiologist should be familiar. Viewing a pedagogic videotape and training on cadavers provides a rapid and effective training method for cricoid membrane puncture. Four attempts seem necessary to obtain an optimal success rate.