Presse Med
-
Review Comparative Study
[What pre-operative explorations should be performed in a cardiac patient scheduled for non cardiological surgery?].
In general, preoperative assessment of cardiac patients undergoing non-cardiac surgery relies on thorough clinical evaluation and rest EKG associated if necessary with further examination. In the case of coronary failure, coronary artery disease is the pathology most frequently encountered and is worrying because of the severe complications it provokes. Modern care of such patients requires a thorough study of clinical risk factors as well as pre-test probability of post-operative complications. ⋯ If the latter reveals severe coronary stenosis, bypass grafting or percutaneous angioplasty is required if its risk does not exceed the patient's present post-operative complication rate for the scheduled surgery. For the other cardiac pathologies, echocardiography is the leading exam to assess left ventricular failure or valvular pathologies. New York Heart Association and Duke University classifications help in the risk stratification of such patients.
-
THE CONTEXT: Type II cryoglobulinemia, composed of a monoclonal IgM rheumatoid factor directed against polyclonal IgG, is associated in most cases with chronic hepatitis C viral infection. THE CHARACTERISTICS OF RENAL DAMAGE: Frequent, the renal damage usually occurs after the onset of various systemic manifestations and is expressed by moderate renal failure, microscopic haematuria, proteinuria lower than 3 g/d and hypertension difficult to control. ⋯ A renal biopsy confirms the diagnosis by revealing a membranoproliferative glomerulonephritis, characterized by the intensity of the monocyte infiltration and glomerular deposits, often arranged in curved microtubules under electronic microscopy and often associated with vasculitis lesions. Progression towards terminal renal failure is rare.
-
FROM STEATOSIS TO CIRRHOSIS: Obesity is frequently associated with steatosis. The latter may provoke inflammatory manifestations and steatohepatitis, the clinical biological and histological characteristics of which are identical to lesions of alcoholic origin. ⋯ THERAPEUTIC ATTEMPTS: Treatment is aimed at correcting the metabolic disorders and the obesity. Other treatments are currently proposed (anti-oxidants, insulin-resistance modulators), but none of them have presently been completely validated.
-
BOTULISM AND BIOWARFARE: Botulism is a severe neuro-paralysing infection due to a toxin produced by Clostridium botulinum. The use of the botulinum toxin for terrorist aims in the form of aerosols is a perfectly credible eventuality. The botulinum toxin is the most potent toxin known; it is easy to produce and can lead to massive destruction.
-
The isolation of Candida sp in nosocomial infections is on the increase and over the past 10 years many guidelines for "good" practices and recommendations have been published on the modalities for the management of systemic candidiasis. The aim of this paper was to assess the habits in the intensive care units in this domain in France. ⋯ One hundred eighty questionnaires (surgical reanimation: 12%, medical: 18%, medico-surgical: 70%) out of 200 (92.5%) were returned. The indirect diagnostic examinations: serology, search for antigenemia and PCR (Polymerase Chain Reaction) were never used in 21, 35 and 65% of cases. The systematic search for colonisation (a mean of 4 areas sampled) was conducted in all the patients by 19% of the investigators, in some patients by 53%, and never by 28%. An antifungal treatment was prescribed: in the presence of a positive haemoculture alone, once out of twice if the sample had been taken from a central catheter and in 2 cases out of 3 when the sample was peripheral. It was prescribed 6 times out of 10 after isolation of Candida sp following surgery or on needle aspiration of an intra-abdominal abscess, varyingly in the case of cadiduria, isolation of a Candida sp in a broncho-pulmonary sample or in abdominal draining and positive culture of a catheter, depending on the intensity of the colonisation, the severity of the clinical picture and the presence of factors of risk for Candida infection. It is still prescribed empirically depending on the same elements and the absence of explanation for worsening. When faced with candidemia in a non-neutropenic patient, a central catheter is not changed in 18% of cases. Depending on the microbiology, fluconazole is prescribed in: the identification of yeast without further precision (78% of cases), Candida sp without further precision (86% of cases), Candida non albicans without further precision (57% of cases), C. albicans (93% of cases), Candida non albicans other than C. krusei and C. glabrata (62% of cases), C. glabrata (36% of cases) with an increase in dose in 1 out of 2 cases. In the presence of C. glabrata or C. krusei, amphotericin B is the choice in respectively 51 and 75% of cases. To adapt the treatment.