RESUMEN
BACKGROUND: This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS: Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS: A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS: Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.
Asunto(s)
Farmacorresistencia Bacteriana Múltiple , Enterobacteriaceae/efectos de los fármacos , Enterobacteriaceae/aislamiento & purificación , Personal Militar , Heridas Relacionadas con la Guerra/microbiología , Adulto , Enterobacteriaceae/enzimología , Enterobacteriaceae/genética , Femenino , Francia , Genotipo , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto Joven , beta-Lactamasas/biosíntesisRESUMEN
Cerebral ischemia is a common thread of acute cerebral lesions, whether vascular or traumatic origin. Hyperbaric oxygen (HBO) improves tissue oxygenation and may prevent impairment of reversible lesions. In experimental models of cerebral ischemia or traumatic brain injury, HBO has neuroprotective effects which are related to various mechanisms such as modulation of oxidative stress, neuro-inflammation or cerebral and mitochondrial metabolism. However, results of clinical trials failed to prove any neuroprotective effects for cerebral ischemia and remained to be confirmed for traumatic brain injury despite preliminary encouraging results. The addition of inert gases to HBO sessions, especially argon or xenon which show neuroprotective experimental effects, may provide an additional improvement of cerebral lesions. Further multicentric studies with a strict methodology and a better targeted definition are required before drawing definitive conclusions about the efficiency of combined therapy with HBO and inert gases in acute cerebral lesions.
Asunto(s)
Lesiones Encefálicas/terapia , Isquemia Encefálica/terapia , Oxigenoterapia Hiperbárica , Gases Nobles/uso terapéutico , Animales , Lesiones Encefálicas/fisiopatología , Isquemia Encefálica/fisiopatología , Humanos , Estrés OxidativoRESUMEN
Tuberculosis disease, in its extra pulmonary form, remains a difficult diagnosis because of its atypical symptoms and evolution. We have observed a case of acute tuberculosis neuromeningitis, without being able to make a definite diagnosis prior to the patient's death because of the negativity of the initial bacteriological samples. We started the most probable appropriate treatment but in vain. This case allows us to challenge diagnostic methods and resulting treatments in emergency cases where tuberculosis is suspected. Moreover, it seems essential to do everything possible to find the bacterium when confronted with a patient with risk factors and clinical and radiological symptoms compatible with tubercular disease, before the disease becomes acute.
Asunto(s)
Hidrocefalia/diagnóstico , Tuberculosis Meníngea/diagnóstico , Enfermedad Aguda , Antituberculosos/uso terapéutico , Ventrículos Cerebrales/patología , Femenino , Escala de Coma de Glasgow , Humanos , Hidrocefalia/etiología , Hidrocefalia/patología , Imagen por Resonancia Magnética , Persona de Mediana Edad , Tuberculosis Meníngea/complicaciones , Tuberculosis Meníngea/microbiologíaAsunto(s)
Foramen Oval Permeable/diagnóstico por imagen , Cardiopatías/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Anciano , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Resultado Fatal , Atrios Cardíacos/diagnóstico por imagen , Humanos , Masculino , Insuficiencia Multiorgánica/etiología , Embolia Pulmonar/diagnóstico por imagen , Enfermedad Cardiopulmonar/diagnóstico por imagen , Choque Cardiogénico/etiologíaRESUMEN
Hyperglycemia is significantly associated with increased mortality in critically ill patients and then, strict control of blood glucose (BG) concentration is important. Lowering of BG levels with intensive insulin therapy (IIT) was recommended in order to improve patient outcomes. But recently, some recent prospective trials failed to confirm the initial data, showing conflicting results (significantly increased mortality with IIT, more hypoglycemic episodes). So there is no consensus about efficiency and safety of IIT. Significant associations between glucose variability and mortality have been confirmed by several recent studies. A difference in variability of BG control could explain why the effect of IIT varied from beneficial to harmful. Managing and decreasing this BG variability could be an important goal of BG control in critically ill patients. Clinicians have to consider definitions, physiopathology and impacts of glucose variability, in order to improve patient outcomes.
Asunto(s)
Glucemia/metabolismo , Cuidados Críticos , Algoritmos , Glucemia/análisis , Enfermedad Crítica , Diabetes Mellitus/sangre , Diabetes Mellitus/tratamiento farmacológico , Humanos , Hiperglucemia/sangre , Hiperglucemia/terapia , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Unidades de Cuidados Intensivos , Monitoreo FisiológicoRESUMEN
Since March 2003, military operations in Iraq "Operation Iraqi Freedom" (OIF) and in Afghanistan "Operation Enduring Freedom" (OEF), have made many wounded and killed in action (KIA). This article proposes to highlight the specific epidemiology of combat casualties, met in these both non-conventional and asymmetric conflicts. Personal protective equipments, Kevlar helmet and body armor, proved their efficiency in changing features of war injuries. Health Force Services organized trauma care system in different levels, with three main objectives: immediate basic medical care in battalion aid station, forward surgery and early aeromedical evacuation. The Joint Theater Trauma Registry (JTTR), a war injury registry, provides medical data, analyzed from the combat theater to the military hospital in United States. This analysis concluded that during modern conflicts, most injuries are caused by explosive devices; injuries are more severe and interestingly more specifically the head region and extremities than the trunk. Hemorrhage is the first cause of death, leading to the concept of avoidable death. Specific databases focused on mechanisms and severity of injuries, diagnostic and treatment difficulties, outcomes can guide research programs to improve war injuries prevention and treatment.
Asunto(s)
Campaña Afgana 2001- , Guerra de Irak 2003-2011 , Guerra , Heridas y Lesiones/epidemiología , Sustancias Explosivas , Humanos , Medicina Militar , Personal Militar , Ropa de Protección , TerrorismoRESUMEN
OBJECTIVE: Damage control is a strategy of care for bleeding trauma patients, involving minimal rescue surgery associated to perioperative resuscitation. The purpose of this review is to draw up a statement on current knowledge available on damage control. DATA SOURCES: References were obtained from recent review articles, personal files, and Medline database research of English and French publications. All categories of articles on this topic have been selected. DATA SYNTHESIS: Historical damage control surgery, that consist of abbreviated laparotomy with second-look after resuscitation, is now included in a wider concept called "damage control resuscitation", addressing the lethal triad (coagulopathy, hypothermia and acidosis) at an early phase. Care is focused on coagulopathy prevention. Early resuscitation, or damage control ground zero, has been improved: aggressive management of hypothermia, bleeding control techniques, permissive hypotension concept and early use of vasopressors. Transfusion practices also have evolved: early platelets and coagulation factors administration, use of hemostatic agents like recombinant FVIIa, whole blood transfusion, denote the damage control hematology. Progress in surgical practices and development of arteriographic techniques lead to wider indications of damage control strategy.
Asunto(s)
Tratamiento de Urgencia/métodos , Resucitación/métodos , Heridas y Lesiones/terapia , Acidosis/complicaciones , Acidosis/terapia , Trastornos de la Coagulación Sanguínea/complicaciones , Trastornos de la Coagulación Sanguínea/terapia , Embolización Terapéutica , Servicios Médicos de Urgencia , Hemostasis , Hemostáticos/uso terapéutico , Humanos , Hipotermia/complicaciones , Hipotermia/terapia , Laparotomía , Atención Perioperativa , Procedimientos Quirúrgicos Operativos , Vasoconstrictores/uso terapéutico , Heridas y Lesiones/fisiopatologíaRESUMEN
Fluid loading is the first step, necessary to care for severe sepsis. Two main classes of solutions are currently available: crystalloids and colloids. The concept of small volume resuscitation with hypertonic saline has emerged these last years in the care of traumatic haemorrhagic shock. The main benefits are the restoration of intravascular volume, improvement of cardiac output and improvement of regional circulations. Many experiments highlight modulation of immune and inflammatory cascades. We report the mechanisms of action of hypertonic saline based on experimental human and animal studies, which advocate its use in septic shock.
Asunto(s)
Fluidoterapia , Sustitutos del Plasma/uso terapéutico , Soluciones para Rehidratación/uso terapéutico , Solución Salina Hipertónica/uso terapéutico , Choque Séptico/terapia , Animales , Adhesión Celular/efectos de los fármacos , Ensayos Clínicos como Asunto , Evaluación Preclínica de Medicamentos , Edema/prevención & control , Endotelio Vascular/efectos de los fármacos , Hemodinámica/efectos de los fármacos , Interacciones Huésped-Patógeno/efectos de los fármacos , Humanos , Sistema Inmunológico/efectos de los fármacos , Inflamación/tratamiento farmacológico , Inflamación/fisiopatología , Leucocitos/efectos de los fármacos , Sistema de Señalización de MAP Quinasas/efectos de los fármacos , Insuficiencia Multiorgánica/etiología , Insuficiencia Multiorgánica/prevención & control , Sustitutos del Plasma/administración & dosificación , Sustitutos del Plasma/efectos adversos , Sustitutos del Plasma/farmacología , Soluciones para Rehidratación/administración & dosificación , Soluciones para Rehidratación/efectos adversos , Soluciones para Rehidratación/farmacología , Resucitación/métodos , Solución Salina Hipertónica/administración & dosificación , Solución Salina Hipertónica/efectos adversos , Solución Salina Hipertónica/farmacología , Choque Séptico/complicaciones , Choque Séptico/fisiopatología , PorcinosRESUMEN
Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.
Asunto(s)
Cuidados Críticos , Nutrición Enteral , Motilidad Gastrointestinal/efectos de los fármacos , Antagonistas de Dopamina/uso terapéutico , Eritromicina/uso terapéutico , Motilidad Gastrointestinal/fisiología , Humanos , Metoclopramida/uso terapéutico , Motilina/agonistasRESUMEN
Staphylococcus aureus is responsible for two main clinical presentations in humans: suppurative infections and toxigenic diseases. A small percentage of S. aureus strains secrete Panton-Valentine leukocidin (PVL). This toxin is implicated in skin infections, furunculosis, osteoarticular infections, and particularly, in serious pulmonary infections known as necrotizing pneumonia, which affect immunocompetent patients with no comorbidity. A clear outline of the clinical presentation was described recently. Necrotizing pneumonia caused by PVL-secreting S. aureus strains is characterized by a combination of fever, hemoptysis, multilobar alveolar infiltrations, and leukopenia. The disease usually progresses to toxic shock or refractory hypoxemia. A number of interesting therapies targeting leukocidin have been proposed over the past few years based on in vitro data. This review focuses on the physiopathological basis and on the therapeutic relevance of various drugs.
Asunto(s)
Antitoxinas/uso terapéutico , Toxinas Bacterianas/toxicidad , Exotoxinas/metabolismo , Leucocidinas/metabolismo , Neumonía Estafilocócica/tratamiento farmacológico , Staphylococcus aureus/efectos de los fármacos , Adulto , Antitoxinas/toxicidad , Niño , Humanos , Neumonía Estafilocócica/complicacionesRESUMEN
We report a 69-year-old man admitted in intensive care unit for aseptic meningoencephalitis. Initially, suspicion of an infectious etiology led to introduce an anti-infectious treatment. Behçet's disease was diagnosed during hospitalization incited to screen for noninfectious etiologies. A high dose steroid therapy was rapidly effective. The diagnosis of neuro-Behçet's disease was entertained.
Asunto(s)
Síndrome de Behçet/diagnóstico , Meningoencefalitis/tratamiento farmacológico , Corticoesteroides/uso terapéutico , Anciano , Síndrome de Behçet/tratamiento farmacológico , Síndrome de Behçet/patología , Encéfalo/patología , Humanos , Imagen por Resonancia Magnética , Masculino , Resultado del TratamientoRESUMEN
Envenomation from bite of exotic snakes is rare in France and represent a serious therapeutic problem: only an adapted antivenom is effective and obtaining such a treatment is a real difficulty. The authors report two clinical cases of envenomation with defibrination after bite by pit vipers from South America. The two patients were treated with nonspecific antivenom therapy with divergent results. The use of the paraspecific effects of antivenom can allow an effective treatment in the absence of specific antivenom, but requires to be known better.
Asunto(s)
Antivenenos/uso terapéutico , Mordeduras de Serpientes/tratamiento farmacológico , Humanos , MasculinoRESUMEN
Placenta percreta is a severe condition associated with maternal morbidity and mortality even when surgery is performed electively. Arteries ligation, embolisation, medical treatment by methotrexate can be appropriate treatment to avoid catastrophic surgery. The purpose of this report is to present a case where the placenta was left in situ to avoid cystectomy at the time of cesarean section, with subsequent failure of the conservative treatment.
Asunto(s)
Placenta Accreta/cirugía , Adulto , Cesárea , Cistectomía , Cistoscopía , Femenino , Humanos , Histerectomía , Imagen por Resonancia Magnética , Metotrexato/administración & dosificación , Placenta Accreta/diagnóstico , Placenta Accreta/patología , Embarazo , Ultrasonografía , UrografíaRESUMEN
A 22-year-old man, who maintains illegally numerous exotic snakes at home (suburbs of Paris), was bitten by one of his Bresilian rattlesnakes, the lance-headed viper Bothrops moojeni, with grade III envenomation. The fibrinogen was less than 0,5 g/L, the prothombin time was 22%, the activated partial thromboplastin time was 94 seconds. The authors discuss the biological and clinical management of this defibrination, due to defibrinogenating proteases (thrombin-like enzymes), present in Bothrops moojeni venom. The patient received 7 vials of an antivenom directed to another crotal, Bothrops lanceolatus. Despite the importance of defibrinogenation, there was only a few clinical evidence of bleeding, according to the literature. The normalization of coagulation studies occured only after day 11. This case-report outlines the danger of the increase of exotic snakes maintained as pet in France and the difficulties to obtain specific antivenoms.