Brief International Cognitive Assessment for Multiple Sclerosis scores are associated with the cortical thickness of specific cortical areas in relapsing-remitting patients.

BACKGROUND: Cognitive impairment is frequent and disabling in multiple sclerosis (MS). The Brief International Cognitive Assessment in MS (BICAMS) is a recent short battery usable in clinical practice for cognitive evaluation of MS patients. OBJECTIVE: To find cortical areas or brain volumes on magnetic resonance imaging (MRI) structural sequences associated with BICAMS scores in MS. METHODS: In this cross-sectional single-center study (NCT03656055, September 4, 2018), 96 relapsing remitting-MS patients under natalizumab and without recent clinical or radiological inflammation were included. Patients underwent brain MRI and the three BICAMS tests, evaluating information processing speed (SDMT), visuo-spatial memory (BVMT-R), and verbal memory (FVLT). RESULTS: Cortical thickness in the left frontal superior and the right precentral gyri was associated with BVMT-R scores whereas cortical thickness in the left Broca's area and the right superior temporal gyrus was associated with FVLT scores. We observed associations between white matter inflammatory lesions connected to these cortical regions and BICAMS subscores. CONCLUSIONS: BICAMS scores are associated with specific cortical areas, the cognitive domain matching the known functions of the cortical area. Specific cognitive impairments in MS may be associated with specific cortical regions, themselves influenced by white matter inflammatory lesions and demographical parameters (age, sex, education level).

[Diagnostic pitfall: Early arising, multiple and recurrent Marjolin's ulcer. About 8 patients (16 tumors) and literature review]. / Piège diagnostique : l'ulcère de Marjolin d'apparition précoce, multiple ou récidivant. À propos d'une série de 8 patients (16 tumeurs) et revue de la littérature.

INTRODUCTION: Marjolin's ulcer (MU) is a large entity representing skin cancers resulting from the transformation of chronic wounds of a heterogeneous nature. Burn scars are the most at risk of degeneration, in particular because there are the sites of important skin tension. Atypical forms are not uncommon. The objective of this study is to present these exceptions which are underestimated. MATERIALS AND METHODS: All patients with UM in our centre between January 2011 and February 2019 have been included permitting to report the initial pathology, the location, the latency time, the histology and the management carried out. RESULTS: Eight patients were treated in our center for MU, they developed 16 skin cancers. Fourteen were squamous cell carcinomas (SCC). The shortest latency period was 2 months. The youngest patient was 22 years old when she was diagnosed with MU. Three patients had at least 2 synchronous SCC. One patient had a recurrence after a split-thickness skin grafting on artificial dermis and 2 patients had second locations. CONCLUSION: Atypic forms are not rare. MU is commonly recurrent, multiple, early arising and may appear in young people. The treatment of chronic wounds cannot be dissociated from the treatment of contractures, otherwise the wound will inevitably reappear.

[Contribution of the scrotal flap for the coverage of ischial and perineal pressure ulcers]. / Apport du lambeau scrotal pour la couverture des escarres ischiatiques et périnéales.

INTRODUCTION: The ischiatric pressure sore is a common pathology in rehabilitated spinal cord injured people, despite careful prevention. Medical treatment by discharge and directed healing is not always sufficient and surgery using local musculocutaneous flaps is often essential. Unfortunately, recidivism is frequent and the availability of local flaps is limited. The scrotal flap is an excellent complement to classic flaps, gluteal flaps or hamstrings. It can be used alone or in addition to another musculocutaneous flap, in first or second intention. MATERIAL AND METHODS: The scrotal flap is a musculocutaneous flap, using the Dartos, the platys muscle of the scrotum. It is richly vascularized, extensible and resistant. Its great plasticity makes it adaptable to any form of loss of substance, with an arc of rotation that can reach the anal margin. It can also be desepidermized and buried to fill a deep defect. Ten cases of scrotal flaps and their different indications are reviewed: some are used in first intention, others in addition to musculocutaneous flaps. RESULTS: The removal of a scrotal flap is fast and extremely easy. The simple closure of the donor site allows the sampling of half of the scrotum due to the great local laxity. The scrotal flaps achieved quickly healed, as well as the donor sites. Only one recurrence was observed after an inappropriate treatment of underlying osteitis. No complications have occurred. CONCLUSION: The scrotal musculocutaneous flap, reliable, resistant, quick and easy to remove is an excellent means of coverage of the perineal region. It can be used for the treatment of any loss of perineal substance in humans, but remains particularly useful for the treatment of ischial or perineal pressure sores.

[Long-term strategy of the initial management of facial burns: About 3 cases]. / Stratégie de prise en charge initiale des brûlures de la face : à propos de 3 cas.

INTRODUCTION: The management of facial burns in their acute stage determines most of the sequelae aspect. An initial treatment of good quality should reduce and even prevent scar ransom and should not compromise potential future corrections. This treatment is based on the respect of facial surgery standards and on the use of some particular technical points. CASE REPORTS: We described our surgical protocol through three case reports. We are performing a surgical excision of the unhealed lesions between the 12th and 15th postburn day. This excision is followed by a dermoepidermal skin graft in the same operative time. This graft must be harvested from the scalp every time it is possible and must be manually perforated. All the aesthetic units junctions are necessarily respected. Flaps can be necessary at this stage. DISCUSSION AND CONCLUSION: The long-term functional and cosmetic results observed in patients with facial burns vary a lot depending on the initial treatment. Patients with severe burns that benefited from an appropriate initial treatment may thus present better results than patients with less severe burns who were badly treated.

Prise en charge des brûlés par télé-expertise.

At the end of 2013, we proposed the possibility of obtaining specialized burn advice 24/7 via pictures transmitted through a dedicated email address, to healthcare professionals. This simple tool is now a success, and we received one request for advice per day in 2015, resulting in an exchange of numerous emails. This simple process offers a number of benefits: it allows burn centres to regulate patient flows all year long, gives healthcare professionals access to a burn care specialist when and as quickly as they need, ensures each patient receives dedicated care, and allows national authorities to provide the best public health service and gain financial profits. However, a tool that uses email is much too simple and insufficiently secure, therefore it can only represent the first step towards a much more "professional" solution.

Épilepsie et brûlure : épidémiologie et interactions.

A retrospective study was conducted to assess the interactions between epileptic seizure and burn. The study was conducted on all patients treated at the Saint Luc Saint Joseph Hospital Burn Unit from 2000 to 2015 with a diagnosis of epilepsy. Forty-eight cases associating burns and epilepsy were reviewed. Twenty-eight patients had a burn following an epileptic seizure. The average age was 43, and the burned area was 9%. Injuries resulted from contact with hot surface (32%), scald burn (50% - 32% with cooking water and 17.8% by accidental exposure to hot tap water (shower)). Burns by flames were rare (4 cases/28: 14.3%). The burns were deep, and all required surgical treatment by excision - split thickness skin graft. All the cases of tap water burns occurred before 2010 and the changes to hot tap water temperature legislation. Three patients presented a new epileptic seizure during their hospitalization. Primary prevention of domestic accidents, particularly regulation of hot tap water temperature, appears effective. Educating epileptic patients on the importance of therapeutic compliance and the elimination of risky activities during periods of therapeutic modification should further reduce the incidence of seizure-related burns.

Gain fonctionnel, antalgique et esthétique de la lipostructure dans les séquelles de brûlures.

The use of lipostructure to treat burn sequelae is more and more common today. The regeneration capacities of mesenchymal stem cells appear promising on this sequelae skin, which is poorly vascularized, retractile and often painful. The aim of our study is to establish the analgesic properties, and the functional and aesthetic improvements gained by using lipostructure to treat burn sequelae. Forty-three patients who received lipostructure for burn sequelae according to the Coleman method between 2005 and 2017 were selected. Results regarding aesthetic, analgesic and mobility gain were recorded, with a minimum follow-up of one year postoperatively. Our patients consisted of 32 women and 11 men, with a mean age of 31.7 years (15 to 64 years). The mean follow-up during the study was 49.8 months (2 to 205 months). Patients received an average of 1.3 (1 to 3) sessions of lipostructure with an average of 153 cc (10 to 1040 cc) per session. Sequela sites were the face for 13 patients, the upper limb for 13 patients, the lower limb for 16 patients and the trunk for 4 patients. Twelve patients had lesions on multiple locations. Twenty patients benefited from this surgery for purely aesthetic or functional reasons, and 23 for painful sequelae. A significantly lower EVA was observed after surgery and a functional gain thanks to the restoration of no longer painful amplitudes. An aesthetic gain was also reported in more than three quarters of cases. In two cases, the analgesic effect decreased after one year and required a second lipostructure. The use of lipostructure in burn sequelae has already proved its efficiency with regard to the functional aspect, aesthetics and also analgesia. However, the evaluation of results is based on scales that are still imperfect. Lipostructure is not the only type of surgery used in burn sequelae. Local plasty or skin grafts are also used, but they are more invasive and have no direct analgesic effect. Lipostructure is only possible on mature, soft and non-adherent scars in order not to traumatize adipose cells. Post-burn skin is defined by retractions and adhesions to deep planes, requiring heavy rehabilitation work beforehand. Finally, the effect is not always sustainable and the duration of efficiency remains unknown. Lipostructure has its place in the treatment of hyperalgic and unsightly burn sequelae that are responsible for a functional and social disability in the patient.

[The advantages in using cyanoacrylate glue over skin staples as a method of skin graft fixation in the pediatric burns population]. / Fixation des greffes de peau mince dans les brûlures de l'enfant : étude des avantages de la colle de cyanoacrylate versus agrafes.

INTRODUCTION: Local postoperative care and burn wound management can present with a certain degree of difficulty in the pediatric population. While the use of skin staples as a method of skin graft fixation is a well-known, rapid and simple method, their removal can be painful and may necessitate some sedation or even general anesthesia. We studied in this article the advantages and economic value of using the cyanoacrylate glue as a fixation method for skin grafts. MATERIALS AND METHODS: A comparative study was carried out from 2012 to 2016. Hundred and eighteen infants with burns up to 5% of total body surface area were included in the study. Seventy-two infants had split thickness skin grafts fixed with skin staples. Forty-six infants had split thickness skin grafts fixed with cyanoacrylate glue. We compared the quality of graft, the sedation used during the first postoperative dressing, the length of hospital stay, the amount of glue used and the presence of complications. RESULTS: There is a difference between the two groups studied in terms of age and total burn surface area. The rate of graft take was 100% in both groups. The first postoperative dressing was carried out without the use of powerful analgesia in the cyanoacrylate group, while it was necessary to use general anesthesia in 64% of the skin staples group. The average length of stay in hospital after skin grafting was 4.9 days for the cyanoacrylate glue versus 6.5 days in the skin staples group. No complications were noted in the 2 groups. CONCLUSION: The use of cyanoacrylate glue allows rapid fixation of skin grafts and avoid general anesthesia for postoperative cares. Subsequently the length of hospital stay is reduced within 25%. The medico-economic value of glue protocol is highly significant compared to skin staples, while having similar good results and without significant problems.

Nose burns: 4-dimensional analysis.

The nose is the central organ of the face. It has two essential roles, aesthetic and breathing. It is often seriously damaged in the context of facial burns, causing grotesque facial disfigurement. As this disfigurement is visible on frontal and profile views, the patient suffers both socially and psychologically. The nose is a three-dimensional organ. Reconstruction is therefore more difficult and needs to be more precise than in other parts of the face. Maintaining symmetry, contour and function are essential for successful nasal reconstruction. Multiple factors determine the optimal method of reconstruction, including the size of the defect, its depth and its site. Satisfactory social life is recovered only after multiple surgical procedures and long-term rehabilitation and physiotherapy.

[The gluteus maximus inferior split-muscle flap for the cover of ischiatic pressure ulcers: Study of 61 cases]. / Le lambeau de faisceau inférieur de muscle gluteus maximus dans la couverture des escarres ischiatiques : étude d'une série de 61 cas.

AIM OF THE STUDY: The coverage of ischiatic pressure ulcers is characterized by a significant recurrence rate (8-64% depending on the series). It therefore seems necessary to introduce the concept of saving in the use of muscle flaps available to avoid being in a situation of therapeutic impasse. The gluteus maximus inferior split-muscle flap allows a tailored coverage to the ischiatic pressure ulcers grade IV with skin defect less than 8cm after surgical debridement. It is associated with an advancement-rotation skin flap removed above the sub-gluteal fold. PATIENTS AND METHODS: The surgical treatment is performed in a single-stage (care+coverage), undercovered by probabilistic antibiotic per- and postoperative then secondarily adapted. After excision of the cavity, a gluteus maximus inferior split-muscle flap was realized. The inferior gluteal artery ensures the muscular flap vascularization. Afterwards, patients follow a rehabilitation program in a specialized center. RESULTS: Sixty-one flaps were performed in 55 patients between September 2000 and January 2015. Fifty-nine (97%) were conducted in first-line and 2 (3%) for covering recurrent pressure ulcers. After a mean duration of 4 years and 8 months follow-up, 13 pressure ulcers (21.3%) relapsed. If reoperation, a simple remobilization of the muscle flap was achieved in 54% of cases, a myocutaneous flap of biceps femoris in 23% and surgical abstention in a patient with non-compliant perioperative care. CONCLUSIONS: The gluteus maximus inferior split-muscle flap, simple to implement, provides coverage of ischial pressure sores while sparing muscle flaps usually used for this indication. The recurrence rate associated with the gluteus maximus inferior split-muscle flap is comparable to biceps femoris and gluteus maximus muscle flaps (totally harvested). It does not sacrifice function gluteus maximus muscle and can be performed in the valid patient. This flap keeps the Superior split-muscle, mobilized in case of sacral pressure ulcer. The gluteus maximus inferior split-muscle flap is the first intention flap indicated for the cover of cover of ischiatic pressure ulcers of less than 8cm in diameter.

[Pyoderma gangrenosum: spontaneous healing after early diagnosis. Three cases and general review]. / Pyoderma gangrenosum : cicatrisation spontanée à la suite d'un diagnostic précoce. À propos de trois cas et revue générale.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare chronic inflammatory skin disease characterized by the recurring development of necrotizing and painful ulcers and therefore, often misinterpreted. This condition can simulate fulminant infection, particularly after surgery. The presentation is often impressive in extensive ulcerations and scarring and lead to significant sequelae. A rapid initial management avoids a dramatic evolution. PATIENTS AND METHODS: We report the case of three PG for patients followed for breast reconstruction after breast cancer. DISCUSSION: PG is a neutrophilic dermatosis that can occur after injuries of varying intensity. Its shape after surgery is a rare disease whose presentation loud and fast pace "infectious" contrasts with the absence of inflammatory lymphangitis or lymphadenopathy. Be aware of prescribing high doses of corticosteroids. CONCLUSION: These three cases illustrate the importance for early diagnosis and treatment of PG, who can allow spontaneous healing without complex surgery, always feared in this context.

[Weight variation after reduction mammary surgery: retrospective study of 100 cases]. / Profil pondéral après chirurgie mammaire de réduction: étude rétrospective à propos de 100 cas.

INTRODUCTION: Patients desiring breast reduction are often in overweight, and describe interferences with their daily life and minor psychological problems. We undertook this study to establish the pre- and postoperative weight pattern by age and histological breast type. PATIENTS AND METHODS: A retrospective review was performed on 100 consecutive patients who underwent bilateral reduction mammaplasty for macromastia (>300g per breast) in 2007. The patients were categorized by age in two groups: group 1 (G1) comprising the 50 younger patients (mean age: 35.5 years) and group 2 (G2) comprising the 50 older (mean age: 47.2 years). We obtained data points including: preoperative and postoperative weight pattern according to age and histological subtypes, calculation of body mass index (BMI), data from surgery including amount of resection, postoperative course and complications. RESULTS: Patients consulting for breast reduction are moderately overweight (mean BMI: 28.22 confounded all ages). Preoperative weight loss is low despite systematic surgeon request (<0.5 % on average waiting time of 6.45 months). The postoperative weight loss is higher in young patients with glandular form of HTM (respectively -4.76 kg for glandulofibrous type and -3kg for fibrous, which corresponds to a loss of 6.5 and 4.1 % of their body weight). The impact of surgery on the patient's psychological condition is better in young patients. CONCLUSION: This study demonstrated that postoperative weight loss after breast reduction are significant only in young patients with a constitutional type of macromastia (glandular or mixed forms). We believe that in addition to the functional improvement associated with surgery, these young patients lose weight they initially take to harmonize their silhouette.

[Fat grafting in facial burns sequelae]. / La lipostructure dans les séquelles de brûlures faciales.

INTRODUCTION: Fat graft is now part of the armamentarium in face plastic surgery. It is successfully used in burn scars. The aim of our study is the discussion of the value of this technique in optimizing cosmetic result of burns face sequelae. PATIENTS AND METHOD: Fifteen adult patients (10 females and five males) with scars resulting from severe burns 2 to 9 years previously were selected. The patients were treated by injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. Two to three injections were administered at the dermohypodermal junction. Ages, sexes, aetiology of burn, facial burn sequelae, recipient sites, quantity of fat injected, aesthetic results are discussed. RESULTS: Patient age ranged from 21 to 55 years (average: 38). The mean follow-up of the study was 66 months (23-118). Patients received 7.5 (5-11) facial restorative surgeries before fat graft. Patients underwent two sessions of fat transfer, 33cc average per session. We did not report any complications. The clinical appearance, discussed by three surgeons and subjective patient feelings, after a 6-month follow-up period, suggests considerable improvement in the mimic features, skin texture, and thickness. The result is good in 86% of cases and acceptable in the other cases. DISCUSSION: Burns sequelae offer local conditions which justify special cannula can cross fibrosis and explaining the value of multiplying the sessions. Indications for lipostructure include four distinct nosological situations, sometimes combined. Lipostructure can restore a missing relief, filling a localized depression, reshape a lack of face volume or smooth a scarring skin. CONCLUSION: Fat graft seems to complete and improve the results of the standard surgical approach in burned face.

[Face rehabilitation for post-burn deformities]. / Traitement chirurgical des séquelles de brûlures de la face.

Severe post-burn sequelae of the face can result from deep initial burns or inappropriate (initial or secondary) treatment. They still remain a surgical challenge, leading to both aesthetic and functional diseases. The acute treatment is preventive, and usually consists in early split thickness skin grafts from the scalp, while full thickness skin grafts and local flaps are employed for the sequels. Our surgical treatment consists in scar replacement using expanded supraclavicular skin. Depending on the location of the scars and depending on available skin, surgical procedure can use expanded full thickness skin graft or expanded advancement flaps. Some "aesthetic" procedures like lipofilling, rhinoplasty or botulinum toxin can be performed in order to improve the final aspect. Good aesthetic and functional results are usually obtained if fundamental rules are respected: preservation of aesthetic units of the face, good management of skin availability. In any case, whatever techniques are employed, numerous surgical procedures and months of rehabilitation are necessary to achieve good cosmetic and functional results.

[Management of eyelid burns]. / Particularités de la prise en charge des paupières brûlées.

Burns are devastating injuries scarring patients, both physically and psychologically, for life. This remains particularly true for facial burns. Eyelid burns occur in about 10% of thermal injuries and is a considerable challenge for the reconstructive surgeon given the particular anatomy of the eyelids. Reconstruction of the eyelids following burn injuries has been performed by plastic surgeons since the earliest days of reconstructive surgery, yet a consensus on a treatment regime has not been reached and plastic surgeons are divided on the subject. Controversies exist regarding the excision and debridement of eschar, temporary suture and surgical tarsorrhaphy, timing of surgery for eyelid contraction, and the role of full and split-thickness skin grafts in eyelid reconstruction. This paper describes the particularities of the treatment of burned eyelids in our Burn Center.

[Breast rupture: presentation, diagnosis and treatment of two cases]. / Fracture du sein : présentation, diagnostic et prise en charge chirurgicale de deux cas.

INTRODUCTION: Breast rupture is an uncommon event that has become more frequent from the 1980s, with the generalisation of the seat belt, so that we can now speak of seat belt related injuries. The trauma is often forgotten and leaves a fibrous band in the breast as only mark. In this way, the breast can be deformed by the scar as much as the retraction is important. The clinical presentation can mime that of a breast cancer, so it is really important to do an echography and a mammography of the lesion. If some dilemma remains, IRM or core biopsy can be helpful. PATIENTS AND METHODS: We report two cases of breast rupture. A breast cancer has been excluded with echography and mammography. We performed a reduction mammoplasty, with inverted T scars, conserving a posterior glandular flap. We will present the observations in the article. DISCUSSION: A breast trauma often leads to haematomas, necrosis of fat and lipid cyst formation. Typically, these lesions are located in regard to the passage of the seat belt on the thorax. The surgical treatment should correct an oblique deformation. It is important to excise all the fibrous tissue and to reharmonize the glandular content. Moreover, in the accidentally discovered forms, one should take in mind the vascular damage determined by the lesions and be able to recognise its presentation before the operation. CONCLUSIONS: Breast rupture is a rare situation that should be known. The treatment is simple and consists in excising the fibrous tissue and replacing it with a well-vascularised tissue. The posterior glandular flap is a helpful tool in these situations.

[Surgical issues and outcomes in ischial pressure sores treatment]. / Stratégie chirurgicale pour le traitement des escarres ischiatiques: quelles options? quels résultats?

INTRODUCTION: Ischiatic pressure sores are frequent in spinal cord injury patients, associated with bad prognosis and high recurrence rate. Many surgical techniques were described, including surgical debridement followed by pedicled flap coverage. We aim to propose a practical decision tree for primary or secondary ischial pressure sore treatment. PATIENTS AND METHOD: Our series of 48 operated ischial sores with an average follow up of 4 years (range 2 to 8years) is analyzed and compared to previously published reports. Surgical techniques are discussed according to their specific indications. RESULTS: The optimal recurrence rate in published reports about pressure sore treatment is 20%; a rate inferior to 19% is found in our series, showing the equal importance of flap selection and postoperative care and education. Depending on each situation, various available flaps are described and compared: gluteus maximus flap, biceps femoris flap, gracilis flap, tensor fascia lata flap, fasciocutaneous thigh flaps, rectus femoris and vastus lateralis flap, rectus abdominis flap. Specific surgical indications for more extensive wounds are studied: resection arthroplasty of the hip, hip disarticulation, fillet flaps from the leg, microsurgery. CONCLUSION: Based upon our experience, a decision tree summarizes our proposition of flap selection, depending on the wound size and the patient background.

[Interventional MR imaging: state of the art and technological advances]. / Imagerie interventionnelle par résonance magnétique: état de l'art des développements techniques.

Due to its excellent soft tissue contrast and lack of ionizing radiation, MR imaging is well suited for interventional procedures. MRI is being increasingly used for guidance during percutaneous procedures or surgery. Technical advances in interventional MR imaging are reviewed in this paper. Ergonomical factors with improved access to patients as well as advances in informatics, electronics and robotics largely explain this increasing role. Different elements are discussed from improved access to patients in the scanners to improved acquisition pulse sequences. Selected clinical applications and recent publications will be presented to illustrate the current status of this technique.

3D mutifractal analysis: a new tool for epileptic fit sources detection in SPECT images.

One of the imaging modalities used for the diagnosis of epilepsy is SPECT (Single-Photon Emission Computed Tomography). Ictal and interictal images are registered to MR images (SISCOM (Substracted Ictal Spect COregistred to MR) to delineate the sources. However, in some cases and for many reasons, the used method does not lead to precise delimitation of epileptic fit sources. In this case, works have been investigated on group's studies or in combining others modalities like EEG (Electroencephalography). This study investigates the possibility of using a mathematic model for the image texture to detect the changes on SPECT images. Beyond encouraging preliminary results concerning the multifractal analysis to distinguish volunteers and epileptic patients, our aim was to detect sources by the singularity spectrum compute. The experiment is divided into two phases. First, we developed a 3D method for the singularity spectrum compute. In the test phase, we applied this multifractal spectrum to the sources detection on SPECT images. The results obtained on a base of seven patients show that the proposed method is encouraging. Indeed, the detections of epileptic fit sources obtained were in agree with the expert diagnostic.