Presse Med
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Cancers of the bile ducts or cholangiocarcinomas are a rare entity whose incidence is increasing in France. Surgical resection of cholangiocarcinoma remains the only curative therapy. ⋯ No biomarker has been identified to predict the response to chemotherapy. DNA sequencing of the tumor can identify specific tumor mutations in bile duct cancers that are the focus of targeted studies.
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Obesity is often associated with obstructive sleep apnea (OSA), which increases the risk of intraoperative and postoperative complications. The role of preoperative screening of OSA is crucial, with adequate management based on continuous positive pressure before, during and after surgery. The obese patient is at risk of postoperative complications: difficult airway management, acute respiratory failure following extubation due to atelectasis and airway obstruction, added to morphine overdosing. ⋯ Drug dosing titration is fundamental due to unknown pharmacokinetic and pharmacodynamics properties in obese patients. Neuromuscular monitoring should always be used whenever neuromuscular blocking drugs are used, as depth of anaesthesia monitoring, especially when total intravenous anaesthesia is used in conjunction with neuromuscular blocking drugs. Appropriate prophylaxis against venous thromboembolism (VTE) after assessment of risk benefit ratio and early mobilisation are recommended since the incidence of venous thromboembolism is increased in the obese.
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The brain is both the orchestrator as well as the target of the innate immune system's response to the aseptic trauma of surgery. When trauma-induced inflammation is not appropriately regulated persistent neuro-inflammation interferes with the synaptic plasticity that underlies the learning and memory aspects of cognition. The complications that ensue, include postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) at two poles of a constellation that is now termed perioperative neurocognitive disorders. ⋯ With so many "moving parts" the innate immune system is vulnerable in clinical settings that include advanced age and lifestyle-induced diseases such as "unhealthy" obesity and the inevitable insulin resistance. Under these conditions, inflammation may become exaggerated and long-lived. Consideration is provided how to identify the high-risk surgical patient and both pharmacological (including biological compounds) and non-pharmacological strategies to customize care.
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Delirium in the perioperative period is a wide-reaching problem that directly affects important clinical outcomes. It is essential that anesthesiologists understand how to define and diagnose delirium, identify patients at high risk for developing delirium, recognize precipitating factors to appropriately adjust care plans, and manage patients who develop delirium in the acute postoperative period. Importantly, delirium remains underdiagnosed in the perioperative setting, but many screening and assessment tools are readily available to aid non-psychiatric trained personnel in identifying delirium. Finally, understanding and implementing strategies to prevent patients from developing delirium is of utmost importance, as evidence-based pharmacological treatments for delirium are minimal and have significant limitations.
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Psychiatric comorbidities are overrepresented in people suffering from epilepsy in comparison to the general population. There is a two-way link between epilepsy and psychiatric disorders. ⋯ Easy to use, fast and efficient self-administered questionnaires are available to evaluate depressive (NDDI-E) and generalized anxiety disorder (GAD-7) symptoms. Selective serotonin reuptake inhibitors (SSRIs) are not proconvulsant and can be safely used to treat depressive or anxious disorders.