[Which Management of Burn Sequelae to the Limbs in a Peculiar Context?] / Quelle Prise En Charge Des SÉquelles De BrÛlures Des Membres Dans Un Contexte Particulier ?

Burns are frequent lesions, often leading to serious functional or even life-threatening sequelae. Their care poses a problem in the countries of the South due to the lack of specialized centres. Through this study, we would like to share our experience. This was a descriptive retrospective study carried out over 36 months on 24 patients treated and followed up in the department for burn sequelae involving a limb. Functional results were classified as excellent, good, fairly good, fair and poor. Aesthetically, they have been categorized into satisfactory, unsatisfactory and poor. We recorded 1480 patients who underwent surgery, 24 of whom were operated on after burns. We noted a female predominance (sex ratio of 1.6) with an average age of 24.2 years (range 16-40). Domestic accidents (n=19) were the main circumstance of occurrence and there was a preponderance of thermal burns by flame (n=21). Twenty people were treated in the first year after burn with excellent, good and fair results in 10, 9 and 4 cases respectively. Burns can cause significant functional sequelae, the management of which requires specialized nursing staff. Training of caregivers oriented towards burn care without forgetting the related means remains a key element to minimizing the occurrence of these sequelae.

Cryoablation of junctional tachycardia at high risk of atrio-ventricular block.

INTRODUCTION: Transcatheter cryoablation is an alternative option for the treatment of supraventricular tachycardia, due to its very low risk of permanent atrio-ventricular block. However, the overcost of cryocatheter and the high recurrence rate of this emerging technology braked its large use. This study reports the results of an approach using cryoablation for the treatment of junctional tachycardia (JT) in selected patients at high risk of atrio-ventricular (AV) block. PATIENTS AND METHODS: Out of a series of 199 patients with JT treated by catheter ablation, 26 benefited from cryoablation (mean age 32.8+/-15 years, 15 males). The indications were the presence of an accessory pathway with a high risk of atrio-ventricular block (n=7), a slow pathway difficult to ablate, with a risk of atrio-ventricular block (n=7), a recurrence after a RF procedure, during which a transient atrio-ventricular block has occurred (n=4), and finally patients at young age (n=8). RESULTS: The primary success rate was 92%. No permanent AV block has been reported, neither with RF nor with cryoablation. The recurrence rate at 9+/-10 months was at 29% after cryoablation and 8.6% after RF. In case of AV nodal reentrant tachycardia, the additional cost of cryotherapy catheter has been avoided in 76.85% of cases. The use of a cryotherapy catheter and RF catheter has been necessary for the remaining cases. CONCLUSION: This study demonstrates that an approach, reserving cryoablation in selected patients at high risk of AV block is an alternative strategy to "the systematic use" of cryotherapy in the ablation of JT with a high efficacy, an excellent safety and a reduced cost.

Impact of early surgery on 6-month outcome in acute infective endocarditis.

BACKGROUND: The mortality in acute infective endocarditis (IE) remains high. Data on results of early surgery are limited. The aim of our study was to determine whether early surgery is associated with reduced 6-month mortality in a large cohort of acute IE. METHODS AND RESULTS: 310 consecutive patients examined by transthoracic and transoesophageal echocardiography (229 males; mean age: 60+/-15) with definite IE according to Duke criteria were prospectively enrolled. Early surgery was performed in 106 (34%) patients (37 mechanical prosthesis, 32 biological prosthesis, 19 valve repairs, 15 pace maker line extractions, three multiple valve replacements) with an operative mortality of 5,7%. The mean time between admission and early surgery was 12+/-9 days. Early surgery was performed more frequently in patients with heart failure (48% vs 33%, p=0.009), uncontrolled infection (40% vs 23%; p=0.002), abscess (35% vs 18%; p=0.001), neurological event (34% vs 20%; p=0.005), embolic event (50% vs 34%; p=0.006), severe regurgitation (60% vs 29%; p=0.001) and large vegetation (>15 mm) (50% vs 23%; p<0.001). In unadjusted analysis, early surgery was associated with lower 6-month mortality (24% vs 37%; p=0.045). After adjustment of variables associated with mortality and comorbidity index, early surgery was identified as an independent predictor of reduced 6-month mortality (HR=0.52; IC 95%=0.2-0.9; p=0.025). CONCLUSION: Early surgery performed in 34% of patients is independently associated with reduced mortality and should be considered in selected cases to improve outcome in acute IE.

Comparison of clinical and morphological characteristics of Staphylococcus aureus endocarditis with endocarditis caused by other pathogens.

OBJECTIVES: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens. DESIGN: Cohort study. METHODS: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n = 61) was compared with the group with IE caused by other pathogens (n = 133). RESULTS: Compared with IE caused by other pathogens, S aureus IE was characterised by severe co-morbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p < 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p = 0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality. CONCLUSIONS: S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases.

OBJECTIVES: To identify the prognostic markers of a bad outcome in a large population of 104 patients with prosthetic valve endocarditis (PVE), and to study the influence of medical versus surgical strategy on outcome in PVE and thus to identify patients for whom surgery may be beneficial. DESIGN: Multicentre study. METHODS AND RESULTS: Among 104 patients, 22 (21%) died in hospital. Factors associated with in-hospital death were severe co-morbidity (6% of survivors v 41% of those who died, p = 0.05), renal failure (28% v 45%, p = 0.05), moderate to severe regurgitation (22% v 54%, p = 0.006), staphylococcal infection (16% v 54%, p = 0.001), severe heart failure (22% v 64%, p = 0.001), and occurrence of any complication (60% v 90%, p = 0.05). By multivariate analysis, severe heart failure (odds ratio 5.5) and Staphylococcus aureus infection (odds ratio 6.1) were the only independent predictors of in-hospital death. Among 82 in-hospital survivors, 21 (26%) died during a 32 month follow up. A Cox proportional hazards model identified early PVE, co-morbidity, severe heart failure, staphylococcus infection, and new prosthetic dehiscence as independent predictors of long term mortality. Mortality was not significantly different between surgical and non-surgical patients (17% v 25%, respectively, not significant). However, both in-hospital and long term mortality were reduced by a surgical approach in high risk subgroups of patients with staphylococcal PVE and complicated PVE. CONCLUSIONS: Firstly, PVE not only carries a high in-hospital mortality risk but also is associated with high long term mortality and needs close follow up after the initial episode. Secondly, congestive heart failure, early PVE, staphylococcal infection, and complicated PVE are associated with a bad outcome. Thirdly, subgroups of patients could be identified for whom surgery is associated with a better outcome: patients with staphylococcal and complicated PVE. Early surgery is strongly recommended for these patients.