Eyelid Chemical Burns: A Multidisciplinary And Challenging Approach.

During second- and third-degree eyelid sulfuric acid burns, many surgeons prefer to wait until primary wound separation occurs before grafting. However, this approach may miss the chance to recover the eyelids and can cause ectropion, resulting in delayed eyeball healing with exposure keratitis. We propose that early eyelid release and grafting makes a significant difference in long-term outcomes and improves eyeball healing. Here, we present the case of a woman who presented second- and third-degree burns of the eyelids secondary to physical domestic assault with acid, who had an early surgical management with a full-thickness skin graft. Ten days after surgery, we found that the graft had survived totally, and the donor site of the right arm had already healed. Eyelids were successfully grafted and the functions of both eyelids were well recovered, allowing complete cover of the eyeball. Two months after surgery, functional and cosmetic results were satisfying, with no postoperative lagophthalmos or difficulties with exposure-related problems. Case reports of eyelid chemical burns are very few. No specific and codified management of eyelid chemical burns was found in the literature search. This case report demonstrated that a multidisciplinary approach led by both ophthalmologists and plastic surgeons must be decided early (<6h) in order to achieve synergistic and coordinated management between the eye and the eyelid. There is a significant improvement in ocular healing with early excision and grafting of eyelids after sulfuric acid burn.

En cas de brûlure du 2ème ou du 3ème degré des paupières par acide sulfurique, de nombreux chirurgiens préfèrent attendre la séparation spontanée de l'escarre avant de greffer. Cette stratégie comporte le risque d'une cicatrisation défectueuse source d'ectropion, d'occlusion incomplète et de kératite. Nous conjecturons qu'une excision-greffe précoce améliore le pronostic à long terme de ce type de brûlure. Nous présentons le cas d'une femme victime d'une agression intra-familiale à l'acide sulfurique, souffrant de brûlure des 2ème et 3ème degrés des paupières traitée par excision-greffe de peau totale précoce. À J10, la greffe était totalement intégrée et le site donneur (bras droit) était cicatrisé. La fonction palpébrale était normale et l'occlusion oculaire complète. Ces bons résultats persistaient à 2 mois, sans lagophtalmie ni défaut d'occlusion, avec un aspect esthétique correct. Les rapports de brûlures chimiques des paupières sont peu fréquents et il nous n'avons pas trouvé de protocole dans la littérature. Ce cas clinique illustre la nécessité d'une analyse précoce (dans les 6h) par ophtalmologiste et plasticien afin de définir une stratégie coordonnée vis à vis du globe oculaire et de la paupière. L'excision-greffe précoce améliore la pronostic oculaire après brûlure par acide sulfurique.

Epidemiology of filamentous fungal infections in burned patients: A French retrospective study.

INTRODUCTION: Filamentous fungal infections (FFI) seem to become more frequent in burn patients, in whom they are usually accepted to cause severe. However published data regarding their incidence and consequences in that context remain scarce. The aim of this study was to evaluate the incidence of mould infections in our burn centre, and to review characteristics and outcomes of patients with such infections. METHODS: This retrospective single-centre study reviews all patients admitted in our centre with acute burns (2000-2011) and positive culture for moulds. Wound infections were defined as follows: fungal wound colonisations (FWC) for positive mycological cultures without signs of wound infection; fungal wound infections (FWI) for positive mycological cultures with local signs of wound infection; disseminated infection (DI) for FWI with a positive blood culture or a positive galactomannan (for aspergillosis) or severe sepsis or secondary organ localisation(s). RESULTS: Among 1849 patients, 31 patients presented a FFI. For 29 patients (93%), positive fungal samples were cutaneous: 20 Aspergillosis ASP (5 FWC, 8 FWI and 7 DI), 9 mucormycosis MMC (3 FWC and 6 FWI) and 3 fusariosis FUS (3 FWI). Two patients presented a catheter colonisation or a pulmonary colonisation (Aspergillus fumigatus). Incidence of FFI was 1.7%. Total body surface area burned, full-thickness burn surface area, Unit Burn Standard, Tobiasen score and SAPS2 (respectively 55% [40-73], 45% [30-63], 180 [129-259], 11 [8-12] and 50 [40-62]) were markedly higher than in burned patients without FFI hospitalised during the same time period. 30% of the patients with burn wound ASP (6/22) died. Mean length of stay was 111±67 days. CONCLUSION: FFI are essentially cutaneous, infrequent and occur in the most severe burned patients. ASP seems to be more serious than other FFI.

[Satisfaction with obstetrical care: development and validation of a scale on quality of care]. / Satisfaction des soins obstétricaux : élaboration et validation d'une échelle de mesure de la qualité des soins.

OBJECTIVES: To develop and validate a subjective and multidimensional scale to measure satisfaction in obstetrical care (SSO) during labour, delivery and two hours postpartum, which is relevant to the French-speaking context. PATIENTS ET METHODS: Forty partially directed patient interviews during the 48 hours after delivery and four care-giver interviews were conducted to build up the questionnaire. After a prior feasibility study on 40 patients, the psychometric validity of the questionnaire was evaluated by calculating the Cronbach coefficient of reliability for 432 patients. RESULTS: Hundred and eighty items were initially obtained after content analysis of the patient interviews. Expert meetings finally selected 49 items classified within 5 dimensions. The feasibility study showed that the questionnaire was easily accepted and understood with a mean time of 15 minutes to answer it. Cronbach coefficients were respectively at 0.941, 0.949, 0.808, 0.814 et 0.869 for the 5 dimensions. DISCUSSION AND CONCLUSION: SSO questionnaire is a reliable and relevant scale to measure immediate postpartum quality of care in French.

[Cycloplegia using a conjunctival insert - comparison to standard procedures]. / Zykloplegie per Bindehaut-Medikamenten-Insert - Vergleich zu etablierten Verfahren.

The widespread combination of tropicamide and phenylephrine eye drops for preoperative mydriasis und cycloplegia is completed by a conjunctival insert called Mydriasert (Théa Pharma GmbH, Berlin) as medicament tracer. This offers potential cycloplegia in a new application form. We tested 10 patients aged 5-41 years (medium 18) with good residual accommodation power. The study design was prospective. We compared the cycloplegic power of either eye drops or conjunctival insert given each at one eye at the same starting point. Then we measured every 15 minutes the pupil width and the accommodation by nearpoint testing. Refraction was measured at the point of smallest accommodation power. As result we found less cycloplegic power of the conjunctival insert (accommodation lag with Mydriasert 3.16 versus tropicamide/phanylephrine eye drops 2.61 D; atropine 1.5 D). The effect of maximal cycloplegia was delayed using the insert (Mydriasert 60 min vs. eye drops 45 min). The subjectively noted comfort for the patients of both application forms is the same using a short interview directly after the testing procedure. In conclusion, the conjuctival medicament insert offers a new application form to induce cycloplegia. The effect is less effective compared to the clinically used standard procedures using eye drops, but should be considered for special patients when eye drop instillation is problematic.

[Labour epidural analgesia for a parturient with a factor XI deficiency: an ill-considered challenge or a reasonable risk?]. / Analgésie péridurale obstétricale chez une parturiente atteinte d'un déficit en facteur XI : défi inconsidéré ou risque raisonné ?

The authors report the performance of a labour epidural analgesia in a 26-year-old parturient presenting a moderate factor XI (FXI) deficiency. If haemostasis disorders usually contraindicate an epidural analgesia (with a risk of epidural haematoma), a moderate FXI deficiency is not an absolute contraindication to perform such an epidural analgesia. Desmopressin, sometimes used in surgery to reduce the bleeding, was administered to withdraw the catheter in better haemostasis conditions. No neurological signs were observed.

[Parkes-Weber syndrome and pregnancy: anaesthetic implications]. / Syndrome de Parkes-Weber et grossesse : implications anesthésiques.

We report two deliveries in a patient with a Parkes-Weber syndrome. This parturient had a complex angiodysplasia including a soft tissue hypertrophy of a lower limb, a cutaneous angioma and arteriovenous malformations. The risk of perimedullar arteriovenous malformations was ruled out by angiographic magnetic resonance imaging of the spinal cord. We also describe other aspects of the management, including prepartum cardiovascular assessment, mode of delivery, the use of epidural analgesia and the prevention of haemorrhagia and thromboembolism.

[Glucose variability in intensive care unit]. / La variabilité glycémique en réanimation.

Hyperglycemia is significantly associated with increased mortality in critically ill patients and then, strict control of blood glucose (BG) concentration is important. Lowering of BG levels with intensive insulin therapy (IIT) was recommended in order to improve patient outcomes. But recently, some recent prospective trials failed to confirm the initial data, showing conflicting results (significantly increased mortality with IIT, more hypoglycemic episodes). So there is no consensus about efficiency and safety of IIT. Significant associations between glucose variability and mortality have been confirmed by several recent studies. A difference in variability of BG control could explain why the effect of IIT varied from beneficial to harmful. Managing and decreasing this BG variability could be an important goal of BG control in critically ill patients. Clinicians have to consider definitions, physiopathology and impacts of glucose variability, in order to improve patient outcomes.

[Antibodies against high frequency antigen and total knee replacement]. / Anticorps antipublic et prothèse totale de genou.

We report the perioperative management of a woman expressing an antibody against high frequency red cell antigen (anti-Kel4 antibody anti-kpb) who was scheduled for a total knee replacement. A specific strategy was designed to afford this major orthopedic surgery, considering specially the occurrence of unusual bleeding higher than the average bleeding assessed in our hospital in this indication. The transfusion of incompatible red cells may be responsible for acute hemolytic reaction. An autologous transfusion program, including cryopreservation, erythropoietin and iron support, was provided. Three autologous red cells units were collected before surgery. Compatible homologous red cells units were also available at the French bank for rare blood groups. We report logistical and medical problems that have occurred during the perioperative period.

[Tetragametic chimerism: Case report]. / Chimérisme tétragamétique : à propos d'un cas.

We report the third case of spontaneous monochorionic dizygous pregnancy, discovered on foetal sex discordance. Blood group testing on the female twin revealed a hematopoietic chimera. The mechanism of monochorionic dizygous formation could be the fusion of two independent zygotes at a late morula stage. A single placental mass with vascular anastomosis then develops. Stem cells exchanged during early foetal life can thus lead to chimeras, in similar conditions to stem cell transfusion in adults. Immaturity of the foetal immune system allows cell graft in the other twin's marrow. Assisted reproductive procedures are believed to promote such pregnancies.

Brachytelephalangic chondrodysplasia punctata: prenatal diagnosis and postnatal outcome.

We report the prenatal management of a brachytelephalangic chondrodysplasia punctata (CDPX1) case and how postnatal findings confirmed the diagnosis. The mother was initially referred after ultrasound revealed an abnormal fetal mid-face and punctuation of upper femoral epiphyses. Chondrodysplasia punctata (CP) with Binder anomaly was suspected. 3D-HCT revealed brachytelephalangy suggesting CDPX1. At birth, mid-face hypoplasia was marked. Postnatal imaging and genetic analysis confirmed the initial diagnosis. Binder anomaly is probably always associated with CP. The newly revised CP classification facilitates the diagnosis. The main etiologies are metabolic and chromosomal abnormalities, and arylsulfatase E enzyme dysfunction. Thus, screening for arylsulfatase E mutation is mandatory for an accurate diagnosis and can lead to better delineation among CP etiologies associated with a Binder phenotype.

Views on personalized medicine: do the attitudes of African American and white prescription drug consumers differ?

AIMS: Although recent advances in pharmacogenomics are making possible the use of genetic testing to determine the best medication for patients, little is known about how patients view such procedures. The aims for this study that were developed collaboratively as part of a community-academic partnership are: (1) What are the attitudes and perceptions of prescription drug consumers concerning personalized medicine and genetic testing for drug compatibility and how do they differ between African American and white patients? (2) What are the attitudes and perceptions of patients concerning race-based prescribing and how do they differ between African American and white patients? METHODS: We conducted 6 focus groups, 2 with white participants and 4 with African American participants. Focus groups were audio-recorded, transcribed, and analyzed to ascertain common themes. RESULTS: Our results suggest that personalized medicine and genetic testing, though not well understood by lay persons, were considered positive advances in medicine. However, participants also voiced concerns about these advances that differed by race. CONCLUSION: This study points to the need to include perspectives of at-risk communities as we move toward wider use of this technology.

[Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy]. / Troubles périnéaux quatre ans après le premier accouchement: comparaison entre épisiotomie restrictive et systématique.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. PATIENTS AND METHODS: It is a quasi-randomised comparative study between two French university hospitals with contrasting episiotomy policies: one using it restrictively and the second routinely. Population included 774 nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. A questionnaire was mailed four years after delivery. Sample size was calculated to allow showing a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures were urinary incontinence, anal incontinence, perineal pain and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, the groups did not differ in the prevalence of urinary incontinence (26% versus 32%), perineal pain (6% versus 8%), or pain during intercourse (18% versus 21%). Anal incontinence was less prevalent in the restrictive group (11% versus 16%). The difference was significant for flatus (8% versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR=1.84, 95 % CI :1.05-3.22). DISCUSSION AND CONCLUSION: A policy of routine episiotomy does not protect against urinary or anal incontinence four years after first delivery.