Impact of the national prevention policy and scrum law changes on the incidence of rugby-related catastrophic cervical spine injuries in French Rugby Union.

BACKGROUND AND AIMS: Catastrophic cervical spine injuries are rare in rugby union but require close monitoring. The aim of this study was to analyse the incidence of severe cervical spine injuries and determine the impact of a national prevention programme and new scrum rules implemented by the French Rugby Union. METHODS: A prospective study was performed between 2006 and 2013 including all players affiliated to the French Rugby Union. All cervical spine injuries resulting in death, tetraplegia or a permanent neurological deficit were included. Prevention programmes were implemented from 2007 to 2013 and a change in scrum rules in 2010. To measure the impact of rule changes, results between 2006-2010 and 2010-2013 were compared using a Poisson regression. RESULTS: Altogether, 31 injuries were observed and the mean annual incidence was 1.6 per 100 000 players. There were significantly more injuries in senior players compared to junior players (3.5 vs 0.6 per 100 000 players; CI 95% (2.1 to 4.9) vs (0.1 to 1.0)). Incidence decreased from 1.8 in 2006 to 1.0 per 100 000 players in 2013 (p<0.0001). After 2010, there were significantly fewer injuries during scrums (p=0.02). In contrast, there were significantly more injuries in backs during 2010-2013 compared to 2006-2010 (p=0.003). CONCLUSIONS: The incidence of catastrophic cervical spine injuries has declined in French Rugby Union. The implementation of specific prevention programmes and scrum law changes has notably resulted in a decrease in scrum injuries in forwards. This prospective study should be continued to monitor the future progression of injuries and adapt prevention programmes accordingly.

Epidemiology of cervical spine abnormalities in asymptomatic adult professional rugby union players using static and dynamic MRI protocols: 2002 to 2006.

OBJECTIVE: In this study, the prevalence of abnormalities in the cervical spine of asymptomatic professional rugby players using both static and dynamic magnetic resonance imaging (MRI) in order to improve the detection of abnormalities and prevention of related injuries was investigated. DESIGN: Prospective observational study. SETTING: French professional rugby union clubs, between 2002 and 2006. PARTICIPANTS: 206 elite male adult players. INTERVENTION: Static sagittal T2 and axial T2* fast spin echo (FSE), and dynamic sagittal single-shot FSE weighted MRI scans of the C2-C7 region were examined for the presence of abnormalities. Participants' spines were in supine neutral position for the static protocol but were allowed complete flexibility in a sagittal plane for the dynamic protocol. MAIN OUTCOME MEASUREMENTS: The medulla-to-canal ratio (MCR) was measured at every vertebral disc level for both MRI methods. When observed, anatomical abnormalities were categorised. RESULTS: Anatomical abnormalities mainly consisted of degenerative discopathy and were most frequently observed in players aged>21 years, as well as in players whose MCR was abnormally high based on medical expertise. Most MCRs that were initially assessed as intermediate with static MRI were subsequently assessed as abnormal with dynamic MRI assessment. CONCLUSIONS: Since dynamic MRI is more accurate than static techniques in examining the cervical spine, it contributes substantially to identifying the risk of spinal injuries in professional rugby players, and when used in association with clinical assessment, it can assist in preventing spinal injury.

Assessment of an intervention to train teaching hospital care providers in quality management.

BACKGROUND: Successful implementation of continuous quality improvement (CQI) programs in hospitals remains rare in all countries, making it necessary to experiment with implementation methods while considering the cultural factors of resistance to change. OBJECTIVE: To assess the impact of an educational intervention on involvement of clinical department staff in the quality process. SETTING: Twelve voluntary clinical departments (six experimental and six controls) in a French 2000-bed university hospital comprising 40 clinical departments. INTERVENTION: Three day training seminar to a group of 12-20 staff members from each department. DESIGN: Quasi-experimental post-test only design study with control group conducted 12 months after the intervention with a questionnaire completed in a face-to-face interview. SUBJECTS: 98 trained staff and 100 untrained staff from the six experimental departments and 100 staff from the six control departments. PRINCIPAL MEASUREMENTS: Declared knowledge of the CQI methods and participation in quality management activities. RESULTS: 286 people (96%) were involved in the study. More of the trained staff knew the CQI methods (62.4%) than staff in the control departments (16.5%) (adjusted odds ratio (ORa) = 10.6 (95% CI 4.97 to 22.62)). More trained staff also participated in quality improvement work groups than control department staff (76.3% v 14.0%; ORa = 27.4 (95% CI 11.6 to 64.4)). In the experimental departments the untrained staff's knowledge of CQI methods and their participation in work groups did not differ from that of control department staff. CONCLUSIONS: A continuing education intervention can involve care providers in CQI. Dissemination of knowledge from trained personnel to other staff members remains limited.

[Evaluation of inpatient satisfaction. Comparison of different survey methods]. / Evaluation de la satisfaction des patients hospitalisés. Comparaison de plusieurs méthodes d'enquête.

OBJECTIVES: To assess the impact of patient satisfaction survey method on response rate, data quality and satisfaction. PATIENTS AND METHODS: Four modes of data collection were assessed during a randomized trial that included 400 inpatients discharged from a teaching hospital. RESULTS: The response rate was 58% within the mail survey group (72% with follow-up letter) versus 73% and 81% within the home and telephone interview group (p < 0.01). 69% of the mailed questionnaires contained no missing values versus 94% and 96% for home and telephone interview modes (p < 0.01). The global satisfaction scale score was greater within the mail survey groups (8.1/10 without follow-up letter and 7.9 with follow-up letter) than within the telephone interview group (7.8) and the face to face interview group (7.3), (p < 0.05). CONCLUSION: Mail survey with follow-up letter constitutes an operational method despite lower data quality and overestimation of patients' satisfaction scores.

Outpatient satisfaction: validation of a French-language questionnaire: data quality and identification of associated factors.

OBJECTIVES: Following 1996 legislation requiring French hospitals to assess patient satisfaction, this study developed and validated a brief French-language multidimensional questionnaire designed to measure outpatient satisfaction with hospital visits and compared data quality for two patient-satisfaction survey methods. DESIGN: Authors developed a 19-item questionnaire following a strict procedure (identification of dimensions to explore, formulation, and selection of items). SETTING: Validation data were obtained from patients of six outpatient clinics in a teaching hospital. PARTICIPANTS: 586 consenting eligible patients were randomized to receive the questionnaire 2 weeks after their visit with one of two survey methods: a mailed self-administered questionnaire or a telephone interview. RESULTS: The response rate (79%) was not significantly different between the two survey methods. The risk of having one or more missing values was higher in the mail survey group (odds ratio, 1.65; 95% confidence interval, 1.03-2.63), but mail respondents were less likely to use the "extremely positive" response category. Principal component analysis identified four factors that accounted for 56% of the variance: interpersonal skills and information transfer, physical surroundings, convenience, and appointment delay. Patients' comments on open-ended questions validated the semantic content of the factorial construct. The internal consistency coefficient was greater than 0.70 for three of four subscales. Patient background characteristics accounted for less than 10% of the factorial score variance. Patient satisfaction was correlated with age, type of visit, and, to a lesser extent, gender and education level. CONCLUSION: This easily administered, multidimensional out-patient-satisfaction questionnaire provided encouraging preliminary psychometric characteristics.

Parenteral supplementation with zinc in surgical patients corrects postoperative serum-zinc drop.

Zinc has been known for a long time to facilitate wound healing. But, so far, supplementation trials in patients treated by major severity surgery gave either partial or controversial results. In a double-blind, randomized study including 30 patients, we show that zinc supplements (30 mg/d for 3 d) administered by a drip correct postoperative drop of serum zinc, that this correction concerns the available part of serum zinc (i.e., zinc that is bound to compounds other than alpha-2 macroglobulin in serum), and that this supplementation can improve clinical wound healing. Possible influence of increased urinary output after the intervention is discussed, and we found that serum cortisol remains stable when zinc/albumin ratio is stable, and increases sharply when the same ratio drops. Cortisol, therefore, seems to play a major role in zinc redistribution after surgery.

[Reexpansion pulmonary edema after pneumothorax. Apropos of a case. Review of the literature]. / L'oedème de réexpansion pulmonaire après pneumothorax. A propos d'un cas. Revue de la littérature.

Pulmonary edema after re-expansion of a pneumothorax occurs within a maximum of 3 days of the pneumothorax and manifests by intense clinical signs (cough, abundant foamy expectoration, major cyanosis), marked hypoxia and a "white lung" radiologic image. The outcome was rapidly favorable in the case reported, despite the severity of the initial symptomatology. Currently accepted physiopathologic mechanisms implicate numerous factors in the genesis of edema due to re-expansion. The lesional pulmonary edema can be explained by alteration in alveolar capillary permeability, by the atelectasis, hypoperfusion and stretching during revascularization, and possibly by the action of free radicals. A hemodynamic edema also exists as a consequence of the reduction in pulmonary interstitial pressure. Possible prophylactic measures are discussed, the most appropriate appearing to be very progressive evacuation of the pneumothorax.

[Changes in blood zinc and serum zinc distribution after surgical intervention]. / Variations de la zincémie et de la répartition du zinc dans le sérum après intervention chirurgicale.

It is well established that blood zinc concentrations fall postoperatively but documented data does not exist proving a direct relation between the fall in levels and the serious or otherwise nature of surgery performed. This relation was investigated in 25 patients, distributed into three groups as a function of severity of operation, by determining total serum zinc and also its distribution amongst vector proteins and amino acids. Findings indicated that minor procedures such as leg varicose vein stripping failed to affect blood zinc whereas major surgery (extracorporeal circulation) provoked a fall of 47% in blood zinc levels. In addition, this reduction affected only the exchangeable fraction (which is therefore the only one biologically active) of serum zinc. This suggests the need for zinc supplementation to assist healing and re-establish immunity phenomena after major surgery.

[Consumption coagulopathies following peritoneojugular bypass. Prevention by a heparin-antithrombin III combination]. / Les coagulopathies de consommation après dérivations péritonéo-jugulaires. Prévention par l'association héparine-antithrombine III.

Consumption coagulopathy (CIVD) is a frequent complication of peritoneojugular bypass operation. Preventive treatment applied involves low-dose heparin (1.5 mg/kg/d) to maintain an antithrombin III concentration of at least 65%. Results are evaluated in 6 patients treated by 7 bypass operations. A biologic CIVD developed in 2 cases (29%) but no clinical coagulopathy was observed. This incidence is less than that usually reported, a literature review indicating a biologic coagulopathy in 65% of cases, with clinical evidence in 12.5%. Furthermore, patients with spontaneously elevated AT III levels did not develop CIVD while, in contrast, sufficiently high concentrations of AT III could not be maintained in the 2 patients with coagulopathy. These findings suggest the interest of prevention of a CIVD by the use of this procedure.

[Secondary rupture of the spleen after external cardiac massage]. / Rupture secondaire de rate après massage cardiaque externe.

A case of delayed splenic rupture occurring 18 days after external cardiac massage is reported. A 30 year old woman underwent mitral valve replacement. Two cardiac arrests in the immediate postoperative period were successfully treated by external cardiac massage. Recovery was uneventful until the 18th day, when the patient began to suffer from dizziness. Haemodynamic and biological data suggested hypovolaemia by dehydration. The day after, her abdomen became painful and anaemia was discovered. Splenic rupture was diagnosed by abdominal ultrasonography and splenectomy was carried out; no other lesion was found. In spite of the widespread practice of external cardiac massage, splenic rupture without any other lesion is unusual. It is suggested that abdominal ultrasonography should follow all cardiac massages.

[Acute renal insufficiency following endourethral surgery with glycine irrigation]. / Insuffisance rénale aiguë au décours de la chirurgie endo-uréthrale sous irrigation de glycocolle.

The authors analyse a case of acute renal failure in an old patient after a TUR of the prostate. The involved mechanism seems to be a toxicity of the glycine solution. In case of severe "TUR syndrome" with important resorption of glycine, the glycine could be catabolysed in oxalate, creating an hyperoxalemia and hyperoxaluria. The high blood level of oxalates can be responsible of acute renal failure and anuria. The treatment is simple: hemodialysis is able to eliminate quickly (in one session) the oxalates from the renal tubules and to restore the renal function. Prospective studies will give us an idea of the propitious conditions for this pathology and for the prevention.

[Acute thrombosis of the aortic bifurcation caused by heparin allergy. Apropos of 5 cases]. / Les thromboses aiguës du carrefour aortique par allergie à l'héparine. A propos de 5 observations.

Five patients with humoral intolerance to heparin developed acute thromboses, with a fatal outcome in two cases from failure to establish the diagnosis, marked sequelae in one case, and recovery without complications in the other two. Accidents of this type may occur in 0.6 p. cent of patients on heparin therapy and are almost always fatal if administration is not discontinued. They result from a severe immunoallergic. Thrombocytopenia which may lead to the formation of arterial clots. Arterial thrombosis during heparin therapy is suggestive of the diagnosis and tests for diminished platelet counts are necessary. Apart from surgery, treatment involves the immediate cessation of heparin therapy.

[Fentanyl-oxygen-pancuronium anaesthesia in cardiac surgery (author's transl)]. / Anesthésie au fentanyl-oxygène-pancuronium en chirurgie cardiaque.

A retrospective study of the anaesthetic records in cardiac surgical patients was undertaken: massive doses of fentanyl were used according to Stanley (29). The rate of drug administration was fentanyl 150 micrograms/kg for induction and 15 to 25 micrograms/kg/hour for maintenance, pancuronium bromide 0,1 mg/kg for induction and 0,015 mg/kg/hour for maintenance. Myocardial oxygen consumption (estimated by rate-pressure-product) during induction period remains constant. The oesophago-rectal temperature gradient is smaller than with other anaesthetic techniques, showing a very good perfusion homogeneity without the need of vasodilatator drugs. The temperature after-drop in the post bypass period is also reduced (less than 1,2 degrees C). The incidence of hemodynamic and rhythmic disturbances during operations and during the first post-operative day is lowered. Delayed respiratory autonomy appears to be the major drawback of this method (group 1: 25,30 h +/- 7,30 h; 30,20 h +/- 12,25 h; group 3: 21,15 h +/- 6,25 h).