B Acad Nat Med Paris
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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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To evaluate the performance of intensive care unit (ICU) the severity scores are measured on the first day; organ system dysfunctions are measured several times during the stay. The severity scores are developed from large data bases of thousands of patients. They include the patient age, previous health status, severity and sometimes the main diagnosis. ⋯ By comparing the observed and expected mortality rates the Standard Mortality Ratio (SMR) may be measured. The data collection must be rigorous, the studied population must be similar to the population of the large data bases. Other elements of performance may be evaluated, such as the cost-efficiency or the quality of life or surviving patients.
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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.
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B Acad Nat Med Paris · Jan 2000
[Aged parents and aging handicapped persons: a new situation, an attempt to respond].
The longevity increase which characterises the society evolution at the end of the 20th century, also concerns the handicapped people. The fact is particularly outstanding for mentally handicapped people such as the Down's Syndrome population. We are nowadays discovering the first generation of the "over 40 year-old people". ⋯ Many parents of mentally handicapped people who live at home, even though they are not yet too old, seem to get more and more tired with their ageing advance, which, day after day, makes their unremitting action harder and harder towards their child who is also getting older. The makers relate the innovating and experimental initiative of a "Hameau Services", nowadays located at Sommières-du-Clain, a rural parish in the south of Vienne country, which offers to welcome still valid ageing parents and their mentally handicapped ageing child who lives in their own house. The collective services which are assured by the managing association, tend to relieve them in their daily material tasks in the aim of contributing to the prejudice of the unexpected arrival of the manifestations of the subordination through a proposition of a better life quality of the handicapped adult and his parents.
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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.