Triple Barrel Free Fibula Flap for Sternal Stabilization: A Case Report.

Sternal non-union is a rare complication of median sternotomies following cardiac surgery. It results in sternal instability and is associated with a high rate of morbidity. Patients with sternal non-union usually complain of pain and sternal clicking with movement of the chest wall. Diagnosis is confirmed on computed tomography showing a gap between two sternal halves. Surgical correction of sternal instability is challenging. The key objective is to reconstruct a thoracic cage that allows for biomimesis and preserves normal physiologic cardiac and pulmonary functions all whilst achieving an aesthetically pleasing result. In this article, we describe a novel technique for sternal instability reconstruction using a triple-barrel vascularized free fibula flap fixed with rib titanium plates. This approach provides rigid long-lasting stability while preserving chest wall biomechanics.

La désunion sternale est une complication rare des sternotomies pour chirurgie cardiaque. Il en résulte une instabilité sternale responsable d'une morbidité élevée comme la douleur et le cliquetis lors des mouvements thoraciques. Le scanner confirme le diagnostic en montrant la solution de continuité entre les 2 moitiés du sternum. La reconstruction chirurgicale est complexe. Son but est de reconstruire une cage thoracique solide, permettant des fonctions cardiaque et respiratoire normales tout en assurant une esthétique satisfaisante. Nous décrivons ici une nouvelle technique de reconstruction sternale par lambeau libre fibulaire tripartitionné fixé par des plaques costales en titane. Elle permet une stabilisation pérenne de la cage thoracique et la restauration de sa mécanique.

Comparison of whole-cell versus acellular pertussis vaccine effectiveness in school clusters of pertussis, France, 2013.

OBJECTIVES AND METHOD: We conducted a prospective study in 2013 to compare the whole-cell versus acellular pertussis vaccines effectiveness and duration of protection, following the occurrence of pertussis clusters. RESULTS: During seven school outbreaks, we identified 102 clinical pertussis cases, including 10 cases biologically confirmed by Bordetella pertussis specific PCR, among a cohort of 305 children in 2nd to 6th grade. The risk of pertussis when vaccinated with an acellular vaccine alone was 1.6 (RR=1.6; 95% CI=1.1-2.5) times higher than when vaccinated with a whole-cell vaccine or using a combined schedule. CONCLUSIONS: The limited duration of protection conferred by the acellular vaccine reinforces the 2013 introduction of the pertussis booster at six years old.

Chikungunya outbreak in Montpellier, France, September to October 2014.

In October 2014, an outbreak of 12 autochthonous chikungunya cases, 11 confirmed and 1 probable, was detected in a district of Montpellier, a town in the south of France colonised by the vector Aedes albopictus since 2010. A case returning from Cameroon living in the affected district was identified as the primary case. The epidemiological investigations and the repeated vector control treatments performed in the area and around places frequented by cases helped to contain the outbreak. In 2014, the chikungunya and dengue surveillance system in mainland France was challenged by numerous imported cases due to the chikungunya epidemic ongoing in the Caribbean Islands. This first significant outbreak of chikungunya in Europe since the 2007 Italian epidemic, however, was due to an East Central South African (ECSA) strain, imported by a traveller returning from West Africa. Important lessons were learned from this episode, which reminds us that the threat of a chikungunya epidemic in southern Europe is real.

Community outbreak of group B meningococcal disease in southwest France--December 2008 to September 2009.

Between December 2008 and September 2009, 11 cases of invasive meningococcal disease (IMD) group B were reported in a 20 km diameter area in the Département Landes, France. Two of them presented with purpura fulminans and one of them died. The strain responsible for this community outbreak was of the clonal complex ST-269.The incidence rate for IMD group B was 3 per 100,000 inhabitants in Landes from week 40 in 2008 to week 40 in 2009; it was the highest in France during that period. The number of cases observed was significantly higher than expected, especially in young adults (standardised incidence ratio: 23.5, p<0.001). A nightclub located in the 20 km diameter area was a possible place of transmission and a prophylaxis recommended for the staff members helped in decreasing the transmission. However, several cases notified later suggested that the bacteria circulated during several months through healthy carriers in the community. This situation prompted increased surveillance of IMD in Landes and medical practitioners were asked to remain vigilant because of the possible emergence of new cases within the following months.

Antiplatelet and lipid-lowering therapies for the secondary prevention of cardiovascular disease: are we doing enough?

OBJECTIVE: To evaluate whether current recommendations with respect to the treatment of dyslipidemias and the use of antiplatelet agents are being applied in the secondary prevention of cardiovascular disease in primary care settings. DESIGN: Descriptive study based on data from the FAMUS (FAmily Medicine, Université de Sherbrooke) primary care register. SETTING AND PARTICIPANTS: Two-hundred and thirty-three physicians participating in the FAMUS project contributed information from nonpregnant patients over 20 years of age consulting for a periodic health examination between 1992 and 1996. INTERVENTIONS: Data from patients in secondary prevention (those with or having had angina, a previous myocardial infarction, bypass surgery, coronary angioplasty or peripheral vascular disease) were extracted and analyzed. MAIN RESULTS: Of the 52,505 patients in the register, 4315 (8%) were identified as being in secondary prevention. Overall, 53% were noted as receiving an antiplatelet agent while 4% were taking warfarin therapy. Only 64% (2780) had a complete lipid profile on record while 38% were being treated with a hypolipidemic agent. In the treated group, only 30% had a low density lipoprotein cholesterol level below 3.0 mmol/L compared with 22% in the untreated group. CONCLUSIONS: A large number of patients identified as being in secondary prevention were not screened for dyslipidemias, and, of those who were, the majority were undertreated according to current recommendations. Antiplatelet agents were more widely prescribed but potentially underused.

Informatics methodologies for evaluation research in the practice setting.

A continuing challenge in health informatics and health evaluation is to enable access to the practice of health care so that the determinants of successful care and good health outcomes can be measured, evaluated and analysed. Furthermore the results of the analysis should be available to the health care practitioner or to the patient as might be appropriate, so that he or she can use this information for continual improvement of practice and optimisation of outcomes. In this paper we review two experiences, one in primary care, the FAMUS project, and the other in hospital care, the Autocontrol project. Each project demonstrates an informatics approach for evaluation research in the clinical setting and indicates ways in which useful information can be obtained which with appropriate feed-back and education can be used towards the achievement of better health. Emphasis is given to data collection methods compatible with practice and to high quality information feedback, particularly in the team context, to enable the formulation of strategies for practice improvement.

Cardiovascular disease. Physician attitudes toward prevention and treatment.

OBJECTIVE: Survey of physician attitudes toward practising cardiovascular disease prevention. DESIGN: Questionnaire administered via telecommunication from 1992 through 1994. SETTING: The FAMUS (Family Medicine, University of Sherbrooke) project, between 1992 and 1996, used weekly telecommunication to collect data from 200 general practitioners throughout the province of Quebec on cardiovascular disease risk factors and their treatment. PARTICIPANTS: Of 200 physicians contributing to the FAMUS project, 156 completed questionnaires (response rate 78%). MAIN OUTCOME MEASURES: Variations in attitudes to prevention policy and risk factor interventions. RESULTS: Survey results revealed physicians knew important risk factors for cardiovascular disease but differed in attitudes toward efficacy of treatment. Intervention to control cholesterol was thought to be very effective by 21.2% (95% confidence interval [CI] 21.2 +/- 6.4) and without effect by 10.3% (95% CI 10.3 +/- 4.8). Intervention to improve dietary habits was considered ineffective by 48.1% (95% CI 48.1 +/- 7.8). Confidence in managing risk factors varied; most respondents described themselves as only moderately skilled. A few practitioners (30.1%; 95% CI 30.1 +/- 7.2) acknowledged practice guidelines as an important source of information on which to base preventive interventions. Only 14.7% (95% CI 14.7 +/- 5.6) of those surveyed included remuneration as contributing to their implementation of prevention activities in practice. CONCLUSIONS: Variations in physician attitudes could influence risk factor intervention. Interventions to change lifestyle are associated with uncertainty about patient compliance, efficacy of treatment, and ability to effect lifestyle changes.

[Treatment patterns of hypertension in 1996. Data from the Quebec Family Practice, University of Sherbrooke registry]. / Habitudes de traitement de l'hypertension en 1996. Données du registre québécois FAMUS.

OBJECTIVE: To describe the treatment of hypertension, alone or in combination with associated conditions, by a group of general practitioners in the FAMUS network and to compare these treatment patterns to the recommendations of the Canadian Hypertension Society Consensus. DESIGN: Descriptive study based on data collected by 233 physicians in the FAMUS provincial register on hypertensive patients treated in 1996. PARTICIPANTS: Developed between 1992 and 1996, the register contains 52,505 patients, 9,094 of whom have high blood pressure. These patients consulted their general practitioners for a complete examination. The data concern the risk factors for cardiovascular disease and include the list of medications prescribed. MAIN OUTCOME MEASURES: Evaluation of the proportions in which various classes of medications were prescribed, and the most common combinations in relation to the presence or absence of associated conditions. RESULTS: Of the 4,049 hypertensive patients seen in 1996, 50.2% were treated with one medication; 32.9% were treated with more than one medication; and 16.9% received no antihypertensive medication. The most frequently prescribed medications were calcium channel blockers (26.1%), followed by diuretics (25.3%), angiotensin-converting enzyme inhibitors (24.3%), and beta-blockers (20.0%). Other agents made up the remaining 4.3% of prescriptions. The proportions were similar for patients without complications who received one medication. CONCLUSIONS: Results of this study suggest that the new molecules are widely used and that treatment patterns differ from the recommendations of the Canadian Hypertension Society Consensus, particularly in the absence of associated conditions.

Evaluation of the Newton Pen-Pad as a tool for collecting clinical research data at the bed-side.

A protocol for the study of practice variation between Quebec Intensive Care Units in the treatment of myocardial infarction by thrombolysis was coded into the Newton Pen-Pad. This tool for the direct recording of clinical data was tested in the working environment by research nurses of 4 different teaching hospitals. Data was sent directly from the pen-pad by telecommunication to the information coordinating center. The results of this evaluation confirm the reliability and robustness of this approach which promises to be an important tool for applied clinical research.

Implementation of a province-wide computerized network in Quebec: the FAMUS Project.

General practitioners have busy schedules and are accustomed to working autonomously. But they will take an interest in research issues that could increase their efficiency or improve patient care. The use of medical informatics tools to facilitate collaborative research networks requires that participants accept the tools. This article describes the implementation of a province-wide computing network and discusses the opportunities afforded by the creation of a large central database documenting the process of care.

The TEAM evaluation approach to Project FAMUS, a pan-Canadian risk register for primary care.

The application of the TEAM--Total Evaluation and Acceptance Methodology--to the development of Project FAMUS--Family Medicine, University of Sherbrooke--is described. Project FAMUS is concerned with the establishment of a pan-Canadian risk register, the data being provided from a network of 800 family physicians distributed across Canada. Emphasis is on the first phase of the project and the overall evaluation strategy.