B Acad Nat Med Paris
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Pollicization is a long time honored operation but more recent introduction of microsurgical techniques allowing toe to thumb transfers has changed the indications in trauma and congenital malformations. We reviewed two series of patients to assess the long-term result in both traumatized and malformed hands. Twenty-seven pollicized mutilated fingers were reviewed with a mean follow up of 9.5 years; the longest follow up published in the literature. ⋯ In congenital malformations, hypoplasia or aplasia of the thumb in presence of long fingers remains one of the best indication of pollicization. Out of 35 operated children, 27 were reviewed with a sufficient follow up (mean 6 years) to assess the result. Sensibility and growth were excellent (3 cases need some secondary shortening) mobility was close to normal in 61% of cases but the main concern was the strength which reached only 42% of the standard.
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B Acad Nat Med Paris · Jan 2000
[Conclusions. The precautionary principle: its advantages and risks].
The proposed extension to health of the precautionary principle is the reaction to two social demands: the desire for greater health safety and for more transparency in the decision making process by associating the public. In medical care, all decisions are based on the balance between cost (dangers induced by the treatment) and benefit (the therapeutic effect). It is as dangerous to overestimate the cost, in other words the risks, as it is to underestimate them. ⋯ The precautionary principle will also impose new obligations on the State, which also must conform to the requirements of proportionality between risk and action, transparency and information in the field of care and health. The application of the precautionary principle will require good judgment because the way it is implemented will determine whether its outcome will be for the better or the worse. That is why it is indispensable that jurists, medical practitioners, and scientists work together so that the precautionary principle will be as precisely defined and codified as possible.
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Septic shock is one of the leading cause of death in modern countries. Scientists have made huge improvement in the understanding of mechanisms of inflammation, and the sequence of activation of the various pro and anti-inflammatory markers is now well known. By contrary, physicians have failed to improve survival from septic shock, in spite of the development of specific targets of the various points of the cytokine cascade sought to have a key role in host survival to sepsis. ⋯ More recent findings highlighting the role of the integrity of the hypothalamic-pituitary -adrenal axis to appropriately respond to a septic insult, have led to a reappraisal of the use of steroids in septic shock. Several high quality randomised controlled trials have evaluated the efficacy and safety of a prolonged treatment with low dose hydrocortisone in severe sepsis. These trials strongly suggested that this strategy of corticotherapy reduced the morbidity of septic shock and may favourably affect survival from septic shock.
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B Acad Nat Med Paris · Jan 2000
Review[Role of microcirculation in multiorgan failure of infectious origin].
The normal host response to infection is a complex process which serves to localize and control bacterial invasion and to initiate repair of injured tissue. This inflammatory process is accompanied by activation of circulating and fixed phagocytic cells and generation of pro-inflammatory and anti-inflammatory mediators. Sepsis results when the prerequisite inflammatory response to infection becomes generalized, and thereby extends to involve otherwise normal tissue which is remote from the initial site of injury or infection. ⋯ Also, microvascular abnormalities in the intestine were associated with evidence of endothelial and leukocyte activation leading to epithelial dysfunction. Thus, sepsis appears to be associated with early onset microvascular dysfunction. The relationship between microvascular dysfunction and endothelial and leukocyte activation leading to organ failure has been suggested by numerous studies.
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At its very early phase, septic shock is characterized by severe hypovolemia related to abundant fluid losses, increased venous compliance and maldistribution of extracellular fluid (interstitial edema, splanchnic pooling). It results in a drop in venous return and cardiac output. ⋯ Clinical examination and hemodynamic monitoring (Swan-Ganz catheter) appear to provide the most useful criteria to assess the limits of liquid administration. Better understanding in the mechanisms of circulatory dysfunction due to the inflammation cascades might soon lead to a new approach in fluid therapy.