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Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition of unknown etiology, with presumed autoimmune mechanisms. It is characterized by high levels of IgG4 and variable clinical manifestations. It can involve one or multiple organs. Herein, we reported the case of a 62-year-old man with three organs involvement. He initially presented with recurrent jaundice. Laboratory analysis revealed cholestasis, high gamma-globulin levels, renal failure, and proteinuria. Abdominal Magnetic Resonance Imaging (MRI) showed segmental strictures of the left intrahepatic bile ducts and the wirsung duct with an increased volume of the pancreas and diffuse bilateral enlargement of the kidneys. Laboratory tests revealed high IgG4 levels (770 mg/dL). Based on the biological and radiological findings, we have suggested the diagnosis of systemic IgG4-related disease involving bile ducts, the pancreas, and probably the kidneys. Renal biopsy revealed lymphoplasmacytic infiltrate and fibrosis, but no IgG4-positive cell. The patient received corticosteroid therapy with a complete resolution of all symptoms and a rapid normalization of all blood tests. The present case underlines the complexity of IgG4-RD because of its variable clinical presentation. The diagnosis is challenging and should be carefully assessed for possible multi-organ involvement.

International audience; In 2017, the Food and Drug Administration published a safety recommendation to limit the exposure to general anesthesia as much as possible below the age of three. Indeed, several preclinical and clinical studies have questioned the possible toxicity of general anesthesia on the developing brain. Since then, recent clinical studies tried to mitigate this alarming issue. What is true, what is false? Contrary to some perceptions, the debate is not over yet. Only stronger translational research will allow scientists to provide concrete answers to this public health issue. In this review, we will provide and discuss the more recent data in this field, including the point of view of preclinical researchers, neuropsychologists and pediatric anesthesiologists. Through translational research, preclinical researchers have more than ever a role to play to better understand and identify long-term effects of general anesthesia for pediatric surgery on brain development in order to minimize it.

Purpose [18F]-2-Fluoro-2-deoxy-D-glucose PET/CT (FDG PET/CT) is a sensitive and quantitative technic for detecting inflammatory process. Glucose uptake is correlated with an increased anaerobic glycolysis seen in activated inflammatory cells such as monocytes, lymphocytes, and granulocytes. The aim of the study was to assess the inflammatory status at the presumed peak of the inflammatory phase in non-critically ill patients requiring admission for COVID-19. Methods Patients admitted with COVID-19 were prospectively enrolled. FDG PET/CT was performed from day 6 to day 14 of the onset of symptoms. Depending on FDG PET/CT findings, patients’ profiles were classified as “inflammatory” or “low inflammatory.” FDG PET/CT data were compared with chest CT evolution and short-term clinical outcome. All inflammatory sites were reported to screen potential extra-pulmonary tropism. Results Thirteen patients were included. Maximum standardized uptake values ranged from 4.7 to 16.3 in lungs. All patients demonstrated increased mediastinal lymph nodes glucose uptake. Three patients (23%) presented mild nasopharyngeal, two patients (15%) bone marrow, and five patients (38%) splenic mild increase in glucose uptake. No patient had significant digestive focal or segmental glucose uptake. There was no significant physiological myocardial glucose uptake in all patients except one. There was no correlation between PET lung inflammatory status and chest CT evolution or short-term clinical outcome. Conclusion Inflammatory process at the presumed peak of the inflammatory phase in COVID-19 patients is obvious in FDG PET/CT scans. Glucose uptake is heterogeneous and typically focused on lungs. Trial registration NCT04441489. Registered 22 June 2020 (retrospectively registered). Electronic supplementary material The online version of this article (10.1007/s00259-020-04968-8) contains supplementary material, which is available to authorized users.

Stomach cancer is a major global health problem; it is one of the ten most common cancers with poor survival, and its incidence is characterized by wide variation. The aim of this work is to carry out a retrospective epidemiological study on gastric cancer in the wilaya of Tlemcen (West Algeria) over a period of 5 years (2011–2015). The data set was provided by the cancer registry of the Tlemcen wilaya. The statistical analysis was performed using software SPSS.21. During this period, 394 cases of gastric cancers were collected, including 199 patients with gastric adenocarcinoma (50.50%); gastric cancer was ranked in 5th rank of the ten most answered cancers in the wilaya. The average age of the patients was 60.5 ± 14.208 years (60.618 ± 13.556 men, 56.654 ± 14.8761 women) with an extremity ranging from 18 to 91 years. A predominance of men has been observed with 60.4% against 39.6% of women, with a sex ratio of 1.5 and a significant difference between the two sexes (p = 0.08). Patients over 50 years of age represented the predominant age group (73.4%). The tumor topography was antropyloric in 6.09% of the cases, and the vast majority of the diagnosed cases was in the local stage (17.01%). Stomach cancer remains one of the top ten cancers in the Tlemcen willaya, so extensive research on the risk factors for gastric cancer remains important to plan effective preventive and curative strategies to reduce this burden.

Resume Problematique L’analyse de la fonction ventriculaire droite au cours de la phase aigue de l’embolie pulmonaire (EP) a ete largement etudiee dans la litterature. Toutefois, l’etude des proprietes fonctionnelles ventriculaires droites a distance de cet episode n’a ete qu’exceptionnellement rapportee et ceci malgre l’importance de la morbi-mortalite de l’EP. But du travail Evaluer la fonction ventriculaire droite apres un premier episode d’EP. Methodes Dans notre etude, nous avons compare les parametres echocardiographiques de la fonction ventriculaire droite (VD) chez 25 patients ayant eu un premier episode d’EP non grave datant de plus de 6 mois avec ceux de 25 sujets temoins sains. Resultats Dans l’etude de la fonction VD, nous avons note que les valeurs moyennes des parametres standards etaient significativement plus basses dans le groupe EP par rapport au groupe temoin mais leurs valeurs sont restees dans les limites de la normale. La valeur moyenne du strain global VD etait significativement plus basse chez les patients par rapport aux temoins (−21 ± 4,8 vs −25 ± 2,4 % ; p Conclusion Notre etude a suggere l’existence d’une dysfonction systolique VD a distance d’un premier episode d’EP et ceci malgre l’absence de symptomes fonctionnels et d’HTAP.

ObjectiveA meta-analysis of proton magnetic resonance spectroscopy studies to investigate alterations in brain metabolites in people with HIV (PWH), the relationship between metabolite alterations and combination antiretroviral therapy (cART), and the relationship between metabolite alterations and cognitive impairment.MethodsThe PubMed database was searched for studies published from 1997 to 2020. Twenty-seven studies were identified, which included 1255 PWH and 633 controls. Four metabolites (N-acetyl aspartate [NAA], myo-inositol [mI], choline [Cho], and glutamatergic metabolites [Glx]) from 5 brain regions (basal ganglia [BG], frontal gray and white matter [FGM and FWM], and parietal gray and white matter [PGM and PWM]) were pooled separately using random-effects meta-analysis.ResultsDuring early HIV infection, metabolite alterations were largely limited to the BG, including Cho elevation, a marker of inflammation. cART led to global mI and Cho normalization (i.e., less elevations), but improvement in NAA was negligible. In chronic PWH on cART, there were consistent NAA reductions across brain regions, along with Cho and mI elevations in the FWM and BG, and Glx elevations in the FWM. Cognitive impairment was associated with NAA reduction and to a lesser degree mI elevation.ConclusionsThe BG are the primary region affected during early infection. cART is successful in partially controlling neuroinflammation (global mI and Cho normalization). However, neuronal dysfunction (NAA reductions) and neuroinflammation (mI and Cho elevations) persist and contribute to cognitive impairment in chronic PWH. Novel compounds targeting NAA signal pathways, along with better neuroinflammation control, may help to reduce cognitive impairment in PWH.

Malignant adenomyoepithelioma (AME) of the breast is an exceptionally rare form of breast cancer, with a significant metastatic potential. Chemotherapy has been used in the management of advanced AME patients, however the majority of treatments are not effective. Recent studies report recurrent mutations in the HRAS Q61 hotspot in small series of AMEs, but there are no preclinical or clinical data showing H-Ras protein as a potential therapeutic target in malignant AMEs. We performed targeted sequencing of tumours’ samples from new series of 13 AMEs, including 9 benign and 4 malignant forms. Samples from the breast tumour and the matched axillary metastasis of one malignant HRAS mutated AME were engrafted and two patient-derived xenografts (PDX) were established that reproduced the typical AME morphology. The metastasis-derived PDX was treated in vivo by different chemotherapies and a combination of MEK and BRAF inhibitors (trametinib and dabrafenib). All malignant AMEs presented a recurrent mutation in the HRAS G13R or G12S hotspot. Mutation of PIK3CA were found in both benign and malignant AMEs, while AKT1 mutations were restricted to benign AMEs. Treatment of the PDX by the MEK inhibitor trametinib, resulted in a marked anti-tumor activity, in contrast to the BRAF inhibitor and the different chemotherapies that were ineffective. Overall, these findings further expand on the genetic features of AMEs and suggest that patients carrying advanced HRAS-mutated AMEs could potentially be treated with MEK inhibitors.

Background and Purpose— Therapeutic decision making for small unruptured intracranial aneurysms ( Methods— We analyzed 338 small unruptured aneurysms; 35 ruptured during the observation period, and 303 remained stable. Clinical, morphological, and hemodynamic parameters were considered. Computational fluid dynamics was used to calculate hemodynamic parameters based on computed tomography images of all aneurysms in their unruptured state. Differences between the ruptured and unruptured groups were tested by the Mann-Whitney U or Fisher exact tests. Multivariate logistic regression was applied to obtain a rupture risk model. Its predictive ability was investigated by receiver operating characteristic analysis. Results— The risk model revealed that rupture may be more likely to in younger patients (odds ratio [OR], 0.92 for each age increase of 1 year [95% CI, 0.88−0.96] P P =0.03), located at a bifurcation (OR, 5.45 [95% CI, 1.87−15.85] P =0.002), with a bleb (OR, 4.09 [95% CI, 1.42−11.79] P =0.009), larger length (OR, 1.91 for each increase of 1 mm [95% CI, 1.42−2.57] P P =0.01). The sensitivity, specificity, and area under the curve were 0.800, 0.752, and 0.826 (95% CI, 0.739−0.914) respectively. Conclusions— Younger age, presence of multiple aneurysms, location at a bifurcation, presence of a bleb, larger length, and lower pressure loss coefficient were identified as risk factors for rupture of small intracranial aneurysms. The risk model should be validated in further studies.

Objectives The main objective of this meta-analysis was to assess the accuracy of the Sleep-Related Breathing Disorder (SRBD) Scale in the diagnosis of obstructive sleep apnea syndrome (OSAS) in children. Patients/methods A literature search of studies comparing SRBD to polysomnography for the diagnosis of OSAS in children was performed. Risks of biases were quantified using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Analyses determined the summary receiver operator characteristic area under the curve (SROC), the pooled sensitivity (Se), the specificity (Sp), and the positive and negative likelihood ratios (LR+ and LR–). Results were graded and are expressed as means [95% confidence interval]. Post-test probabilities were computed for various populations. Results Eleven studies were included; and two were considered to have high risk of bias. The SROC was 0.73 [CI: 0.63; 0.82]. The combined Se, Sp, LR+ and LR– were: 0.72 [CI: 0.68; 0.77], 0.59 [CI: 0.56; 0.63], 1.74 [CI: 1.32; 2.30], 0.53 [CI: 0.39; 0.71], respectively. Sub-group analyses displayed similar results in comparison to overall results. GRADE evidence for the overall analysis was low to moderate. Finally, pre-test to post-test probabilities were estimated to be: 3.5%–1%, 50%–30% and 75%–30%, for the general population, the obese patients and the patients assigned for surgical treatment of OSAS, respectively. Conclusions The current meta-analysis indicates that the SRBD scale has acceptable accuracy in detecting patients with OSAS. It may be useful when evaluating patients with suspected OSAS before surgery. Study registration PROSPERO database (CRD42018088216).

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation technique with great potential in the treatment of Parkinson's disease (PD). This study aimed to investigate the clinical efficacy of accelerated rTMS and to understand the underlying neural mechanism. In a double‐blinded way, a total of 42 patients with PD were randomized to receive real (n = 22) or sham (n = 20) continuous theta‐burst stimulation (cTBS) on the left supplementary motor area (SMA) for 14 consecutive days. Patients treated with real cTBS, but not with sham cTBS, showed a significant improvement in Part III of the Unified PD Rating Scale (p, An accelerated continuous theta‐burst stimulation protocol significantly alleviates motor symptoms in Parkinson's disease. Symptom improvement can be observed as early as 1 week after the start of treatment, and maintained 8 weeks after the end of treatment. Gray matter volume in the globus pallidus (GP) increased after treatment, and the increment was positively correlated with symptom improvement as well as baseline supplementary motor area‐GP structural connectivity.

Introduction Paediatric robotic surgery is gaining popularity across multiple disciplines and offers technical advantages in complex procedures requiring delicate dissection. To date, limited publications describe its perioperative management in children. Material & methods We retrospectively analysed the prospectively collected anaesthetic data of the first 200 robotic-assisted surgery procedures in our paediatric university hospital as part of a multidisciplinary program from October of 2016 to February of 2019. Anaesthetic technique and monitoring were based on guidelines initially derived from adult data. We examined adverse events and particular outcomes including blood loss and analgesic requirements. Results Fifty-one different surgical procedures were performed in patients aged 4 months to 18 years (weight 5–144 kg). Operative times averaged 4 h and conversion rate was 3%. Neither robotic arm nor positional injury occurred. Limited access to the patient did not lead to any complication. Hypothermia was frequent and mostly self-limiting. Negative physiological effects due to positioning, body cavity insufflation or surgery manifesting as significant respiratory and haemodynamic changes occurred in 14% and 11% of patients, respectively. Overt haemorrhage complicated one case. Eighty per cent of 170 patients did not require level 3 analgesics postoperatively, while thoracic and certain tumour cases had greater analgesic requirements. Conclusion These preliminary results show that paediatric robotic surgery is well tolerated with a low bleeding risk and that major intraoperative events are uncommon. A consistent anaesthetic approach is effective across a broad range of procedures. Analgesic requirements are low excluding thoracic and some complex abdominal cases. Future studies should focus on the rehabilitative aspects of robotic surgery technique.

We report the case of a 35-year-old female with end-stage renal disease on hemodialysis for nine years. She was diagnosed with secondary hyperparathyroidism complicated with a brown tumor in the mandible. After medical therapy failed, she underwent total parathyroidectomy (PTX), which was complicated by severe and prolonged hypocalcemia (hungry bone syndrome). Post-surgery, she required prolonged and frequent intravenous calcium and a high dose of vitamin D resulting in frequent admission with symptomatic hypocalcemia. Her serum magnesium was noted to be in the normal range. She continued to be hypocalcemic for nearly eight months post-surgery despite the intensive treatment. Recombinant human parathyroid hormone (teriparatide) 20 mg daily resulted in normalization of calcium within two weeks. The use of parathyroid hormone proved to be an effective treatment approach in this case. Proper pre-operative preparation and subtotal PTX with an adequate dose of vitamin D and calcium supplement may have been a rational option for this case.

The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).In this prospective observational study, arterial desaturation95% SaOComplete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01).Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.

International audience; Measurable residual disease (MRD) status is widely adopted in clinical trials in patients with chronic lymphocytic leukemia (CLL). Findings from FILO group trials (CLL2007FMP, CLL2007SA, CLL2010FMP) enabled investigation of the prognostic value of high-sensitivity (0.7 × 10-5) MRD assessment using flow cytometry, in blood (N = 401) and bone marrow (N = 339), after fludarabine, cyclophosphamide, and rituximab (FCR)-based chemoimmunotherapy in a homogeneous population with long follow-up (median 49.5 months). Addition of low-level positive MRD

International audience; Hereditary distal renal tubular acidosis (dRTA) is a rare disorder characterized by metabolic acidosis due to impaired renal acid excretion. To date, three genes (ATP6V1B1, ATP6V0A4 and SLC4A1) have been reported to be responsible for this genetic disorder. Notably, mutations of ATP6V1B1 gene, which encode B1-subunit of H + -ATPase pump cause distal renal tubular acidosis often, associated with sensorineural hearing loss (SNHL). Furthermore, enlarged vestibular aqueduct (EVA) was also described in some patients with ATP6V1B1 mutations. Four Algerian unrelated patients presented with dRTA and SNHL were recruited. The ATP6V1B1 gene was preferentially analyzed in all these patients by Sanger sequencing. We identified two previously reported variants in ATP6V1B1 gene: a frameshift mutation (c.1155dupC: p.(Ile386Hisfs*56) in exon 12 and a splicing mutation in intron 2 (c.175-1G > C: p?). Both mutations were homozygous in affected members. Interestingly, one patient with p.(Ile386Hisfs*56) mutation presented profound SNHL and bilateral enlarged vestibular aqueduct (EVA). Our study indicates the importance contribution of ATP6V1B1 gene mutations to the pathogenesis of the dRTA in the Algerian population and will contribute to introducing principles to predict the characteristics of the dRTA in patients. Thus, screening for this gene could allow rapid patient management and provide adequate genetic counseling.

Erysipelas is a non-necrotizing acute dermal hypodermatitis most often of streptococcal origin. It most often affects the lower limbs. Erysipelas on surgical scar has been rarely reported in the literature. Few cases have been published since the first descriptions of this pathological entity by Baddour et al in 1982. We report the case of a 47-year-old patient. Operated for right breast mucinous carcinoma, she had neo-adjuvant chemotherapy followed by a surgical treatment (Patey) which occured without incident. The evolution was marked by the appearance after 11 months of the intervention of an Erysipelas on Patey scar. The patient was put on cefazol for 7 days intravenously injectable. The evolution was marked by the complete disappearance of the rash and the edema.

Aim The objective of the study was to estimate the cumulative incidence (CI) of relapse, relapse-free survival (RFS) and overall survival (OS) in ALL patients after a once-a-day fractionated TBI (F-TBI) regimen with 9.9 Gy. The secondary objectives were evaluation of short and long-term toxicity and non-relapse mortality (NRM). Background Total body irradiation (TBI), as a part of the conditioning regimen before allogeneic stem cell transplantation (ASCT) for acute lymphoblastic leukemia (ALL), allows disease control by eradicating residual blast cells in the transplant recipient. Materials and methods Retrospective study conducted in patients with ALL who received between March 2003 and December 2013 a conditioning regimen with F-TBI and chemotherapy. Irradiation was delivered with 3.3 Gy once-a-day for three consecutive days. Results Eighty-seven patients were included. The median age was 19 years (range: 5–49 years). The 3-year CI of relapse was 30%. The estimated 3-year RFS and OS were 54% and 58%, respectively. Cumulative incidence of acute graft-versus-host disease (aGVHD) grade II–IV and chronic GVHD (cGVHD) was 31% and 40%, respectively. Interstitial pneumonitis was observed in 2 patients. The 3-year CI of NRM was 16%. In multivariate analysis, cGVHD was associated with a lower CI of relapse (RR = 0.26, 95% CI: 0.07–0.95, p = 0.04). High-risk cytogenetics was associated with a lower RFS (RR = 2, 95 CI: 1.04–3.84, p = 0.03). Grade II-IV aGVHD was an independent predictor of higher CI of NRM (RR = 6.7, 95% CI: 1.4–31.7, p = 0.02). Conclusions Once-a-day F-TBI regimen is effective, safe and practical in patients who underwent ASCT for ALL.

Background Metaplastic breast cancer (MBC) is a rare form of breast cancer characterized by an aggressive clinical presentation, with a poor response to standard chemotherapy. MBCs are typically triple-negative breast cancers (TNBCs), frequently with alterations to genes of the PI3K-AKT-mTOR and RTK-MAPK signaling pathways. The objective of this study was to determine the response to PI3K and MAPK pathway inhibitors in patient-derived xenografts (PDXs) of MBCs with targetable alterations. Methods We compared survival between triple-negative MBCs and other histological subtypes, in a clinical cohort of 323 TNBC patients. PDX models were established from primary breast tumors classified as MBC. PI3K-AKT-mTOR and RTK-MAPK pathway alterations were detected by targeted next-generation sequencing (NGS) and analyses of copy number alterations. Activation of the PI3K-AKT-mTOR and RTK-MAPK signaling pathways was analyzed with reverse-phase protein arrays (RPPA). PDXs carrying an activating mutation of PIK3CA and genomic changes to the RTK-MAPK signaling pathways were treated with a combination consisting of a PI3K inhibitor and a MEK inhibitor. Results In our clinical cohort, the patients with MBC had a worse prognosis than those with other histological subtypes. We established nine metaplastic TNBC PDXs. Three had a pathogenic mutation of PIK3CA and additional alterations to genes associated with RTK-MAPK signaling. The MBC PDXs expressed typical EMT and stem cell genes and were of the mesenchymal or mesenchymal stem-like TNBC subtypes. On histological analysis, MBC PDXs presented squamous or chondroid differentiation. RPPA analysis showed activation of the PI3K-AKT-mTOR and RTK-MAPK signaling pathways. In vivo, the combination of PI3K and MAPK inhibitors displayed marked antitumor activity in PDXs carrying genomic alterations of PIK3CA, AKT1, BRAF, and FGFR4. Conclusion The treatment of metaplastic breast cancer PDXs by activation of the PI3K-AKT-mTOR and RTK-MAPK pathways at the genomic and protein levels with a combination of PI3K and MEK inhibitors resulted in tumor regression in mutated models and may therefore be of interest for therapeutic purposes.

Peri-operative respiratory adverse events (PRAEs) in paediatric patients with upper respiratory tract infections (URTIs) remain inadequately explored in patients allowed to proceed to anaesthesia and surgery.To determine the incidence and risk factors of PRAE in children with URTI allowed to proceed to anaesthesia.Multicentre cohort study performed over 6 months in France.Sixteen centres with dedicated paediatric anaesthetists.Eligible patients were aged from 0 to 18 years with URTI symptoms on admission or a history of such over the preceding 4 weeks.The primary outcome of the study was to determine predictors of PRAE. Secondary outcomes were: predictors of peri-operative arterial desaturation and of the decision to proceed with anaesthesia and surgery in children with URTI.Overall, 621 children were included and 489 (78.7%) anaesthetised. Of those anaesthetised, 165 (33.5%) and 97 (19.8%) experienced PRAE and arterial desaturation, respectively. Factors predictive of PRAE included patient age, tracheal intubation and the absence of midazolam premedication. Factors predictive of peri-operative arterial desaturation included patient age, anaesthetist experience, endoscopic procedures and the presence of other PRAE. Factors predicting proceeding to anaesthesia in the context of URTI included anaesthetist experience, emergency procedures and the absence of severe URTI symptoms.The risk of PRAE in patients anaesthetised in the presence of URTI was similar to previous publications - close to 30%. In the light of our findings, first, current rescheduling indications should be questioned, and second, further medical and organisational strategies should be investigated to reduce PRAE in children with URTI.The study was registered in the European Networks of Centers for Pharmacoepidemiology and Pharmacovigilance (EUPAS16436).

Tonsillectomy is considered as a therapeutic option in obstructive sleep apnoea syndrome (OSAS). Postoperative respiratory failure is a complication that can require respiratory support. The main objective of our study is to determine risk factors of postoperative respiratory complications in children undergoing tonsillectomy.This is a retrospective single centre observational study including patients with unanticipated postoperative respiratory failure. Patients with a planned preoperative intensive care admission were excluded (age is lower than 2 years, overweight (95% percentile of BMI), moderate or severe asthma, major medical conditions). Those patients were compared with randomly selected control patients. Factors studied were: age, weight, indication of surgery, ASA status, preoperative illness conditions, durations of surgery and anaesthesia and administered medications. Statistics used a univariate analysis and a multivariate logistic regression.Eight hundred and five patients underwent adenotonsillectomy during the study period and 25 developed postoperative respiratory failure. These patients were compared to 103 non-complicated control patients. Age (4 years), weight (18kg), indication of surgery (as SOAS), laryngomalacia, stable and minor congenital cardiac malformation and duration of anaesthesia were found statistically associated. Multivariate analysis found that weight18kg is a risk factor associated with the occurrence of postoperative respiratory failure. Overall the model shows a strong accuracy with an area under the curve of ROC analysis of 0.9 [95% confidence interval: 0.85-0.95].Our study found that weight18kg is a major risk factor for predicting a postoperative respiratory complication.

Minimally invasive surgery during abdominal, thoracic and urological procedures has become the standard management of many surgical interventions in adults. Recent development of smaller devices has allowed the management of many paediatric surgeries using these minimally invasive techniques. However, the lack of knowledge of (a) adequate management of haemodynamic and respiratory alterations occurring during those procedures and (b) postoperative advantages of these techniques over open surgeries, still impairs their development. The current review aimed to clarify mechanisms of those haemodynamic and respiratory alterations, propose easy rules in order to overcome them and shed the light on potential postoperative advantages of minimally invasive surgery in paediatrics.

AimPaediatric anaesthesia is a very specialised domain lacking training during the traditional curriculum. The laryngospasm is a stressful and life-threatening event that requires immediate action. The main objective of this study was to assess the effect of knowledge of a simple algorithm on the management of laryngospasm by trainee anaesthetists and nurse anaesthetists during a high-fidelity simulation session.MethodResidents in paediatric anaesthesia and training nurse anaesthetists with similar curriculum were randomly allocated to undergo a simulation session of laryngospasm with the help of a simple algorithm administered to them 5 min before the simulation session (group A) or as taught in their curriculum (group C). The primary endpoint was the assessment score of laryngospasm management using 10 technical items (validated in experienced paediatric anaesthetists). Secondary endpoints were: the non-technical skills using the Anaesthetists' Non-Technical Skills (ANTS) score and timing of critical management steps. The correlation between the technical and non-technical scores was also studied. Data are expressed as median (range).Results72 participants (18 teams in each group) were included in this study. There was a statistically significant difference between group A and C on the primary endpoint: 8.5 (2–10) vs 5 (2–8), respectively (pConclusionA simple algorithm improved the technical and non-technical skills of students during the management of a simulated laryngospasm.

Background Preventive strategies are available to reduce preoperative anxiety in children, the ideal time for implementing such strategies remains poorly determined. Aims The aim of this study was to determine psychological factors and events involved in the development of preoperative anxiety in children. Methods This study consisted of prospective evaluations of anxiety trait and state during the preoperative period. Attendance at a preanesthetic consultation is obligatory for all patients undergoing surgery in France. Anxiety trait and state assessments were quantified in mothers and children before and after the preanesthetic consultation using visual analog and faces numerical scales. Preoperative anxiety in children was assessed immediately before induction of anesthesia using an analog scale. Other data recorded included demographic and medical data and type of hospital stay. Univariate and multivariate logistic regression analyses were used. Results Overall 111 consecutive patients were included. The following factors emerged leading to anxiety state at induction of anesthesia: maternal anxiety state before the preanesthetic consultation, a feeling of not being reassured by the anesthesiologist, maternal anxiety state after the consultation, and anxiety trait in the child. Logistic regression found this combination of factors (OR = 4 [1.4 -12]) and inpatient stay (OR = 3 [1.4-7]), predicting anxiety with an accuracy of 69%. Conclusion The present study identified a combination of psychological factors and events associated with the development of anxiety at induction of anesthesia in children. Parental anxiety impacts upon children and occurs before the preanesthetic consultation. This result may assist clinicians to prescribe personalized preventive strategies against anxiety.

Background Hydroxyethyl starch (HES) solutions have shown their efficiency for intravascular volume expansion. A safety recommendation limiting their use in adult patients has recently been made. Objective To assess the efficacy and adverse effects of HES when administered intra-operatively to paediatric patients. Design Systematic review with meta-analyses. Data were analysed using classical mean differences [and their 95% confidence intervals (CIs)] and trial sequential analysis. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification was performed for all outcomes. Reviewers extracted valid data, including perioperative total fluid intakes, mortality, renal function, coagulation tests, blood loss and length of hospital and ICU stay. Data sources Searches were performed in databases (Pubmed, Embase, Cochrane central register of controlled trials), clinical trials register, and open access journals not indexed in major databases. Eligibility criteria Randomised controlled trials (RCTs) published before December 2016 involving paediatric patients who received 6% low molecular weight HES. Results Nine RCTs involving 530 peri-operative paediatric patients were analysed. Compared with other fluids, HES did not significantly modify the amount of peri-operative fluid administered [mean difference 0.04; 95% CI (-1.76 to 1.84) ml kg], urine output [mean difference -33; 95% CI (-104 to 38) ml kg] or blood loss [mean difference -0.09; (-0.32 to 0.15) ml kg]. Trial sequential analysis determined that the outcomes for peri-operative fluid and urine output were underpowered. All results were graded as very low quality of evidence. Conclusion Intravascular volume expansion with low molecular weight 6% HES did not appear to modify renal function, blood loss or transfusion when administered to children during the peri-operative period. However, given the lack of statistical power and the very low GRADE quality of evidence, more high-quality RCTs are needed to explore these outcomes.

Introduction Blood-saving strategy during spinal surgery in children often includes recombinant erythropoietin (rEPO) and antifibrinolytic therapapy (AFT). The aim of this study was to investigate the efficacy of intraoperative blood salvage in decreasing homologous blood transfusion. Material and methods Using the prospective data from patients operated during a one year period for scoliosis correction, we calculate the predictable hematocrit at day postoperative 1 without the use of blood salvage and compare it to the target hematocrit transfusion according to patient's status. Predictors analyzed were: age, weight, surgical indication, Cobb's angle, ASA status, preoperative hemoglobin, number of level fused, sacral fusion and thoracoplasty. Statistical analyses were performed using a classification tree analysis. Results This study included 147 patients. Blood salvage was estimated avoiding homologous blood transfusion in 17 patients. Predictors of the efficacy of blood salvage were: neuromuscular indications, number of level fused and BMI. Blood salvage was found totally ineffective in: patients with no neuromuscular diseases with either: surgeries interesting 13 levels with a preoperative BMI ≥ 21. In all other cases, blood salvage can decrease homologous transfusion. The model exhibited 97% of accurate for the prediction if the inefficacy of blood salvage. The AUCROC of the model was 0.93 [95% confidence interval 0.9 to 0.99] and the overall validation was 60.1% of explained variability. Conclusion The present study indicates that blood salvage is ineffective under certain circumstances. More studies are mandatory to confirm these results.

La Presse Medicale - In Press.Proof corrected by the author Available online since mercredi 31 janvier 2018

The aim of this study was to assess the efficacy of self-hypnosis in a therapeutic education program (TEP) for the management of chronic pain in 26 children aged 7 to 17 years. Outcomes of the study were a total or a partial (at least 1) achievement of the therapeutic goals (pain, quality of sleeping, schooling, and functional activity). Sixteen patients decreased their pain intensity, 10 reached all of their therapeutic goals, and 9 reached them partially. Self-hypnosis was the only component of the TEP associated with these improvements. The current study supports the efficacy of self-hypnosis in our TEP program for chronic pain management in children.

Objectives: Diabetes is one of the most challenging health problems in the 21st century that brings a considerable economic burden on worldwide healthcare resources. Indeed, people with diabetes have a higher lifetime healthcare expenditure due to the long-term complications, which include micro and macrovascular complications. This study sought to estimate the frequency of diabetes complications, and to investigate the associated risk factors. Methodology: Data were obtained from the medical records of 2401 diabetic patients followed at the Reference Center of Diabetes and Chronic Diseases (RCD) in Oujda (Morocco) during the period 2006-2011. Results: Our sample of 2401 diabetic patients include 64.7% women. 32% of patients have one or more complications; retinopathy is the most frequent complication (16.8%), followed by nephropathy (12.4%), cardiovascular diseases (5.4%), neuropathy (3.6%) and diabetes foot (2%). Logistic regression in univariate followed by multivariate analysis has showed that age, duration of diabetes and high albuminuria are the major risk factors for the development of diabetic complications in both type 1 and type 2 diabetes. Conclusions: Nearly one third of diabetic patients were affected by at least one diabetic complication; retinopathy is the most common complication in these patients. Strengthening programs to improve diabetes management and to reduce the risk of these complications should be a high priority in order to control the cost of treatment.

Background Perianal manifestations of Crohn’s disease considerably affects the life quality of patients. This study aims to assess the quality of life of patients with perineal Crohn’s disease by using the SIBDQ (Short Inflammatory Bowel Disease Questionnaire) and to evaluate its correlation with the Perineal Disease Activity Index (PDAI). Methods We retrospectively reviewed the medical records of patients with perineal Crohn’s disease between January 2018 and December 2020. Patients with active luminal disease were not included in this study (Crohn’s Disease Activity Index (CDAI) > 150). All participants answered the SIBDQ. Active perineal disease was defined as a PDAI > 7. We studied the correlation between SIBDQ and PDAI. Patients were divided into 2 groups according to the duration of the disease greater or less than 5 years. SIBDQ and PDAI were compared between the 2 groups. Results We included 52 patients with a mean age of 37 years (range: 17–62 years). There were 34 males (65.4%) and 18 females (34.6%). Crohn’s disease has been diagnosed for 7.6 years in average (range 2–19 years). The PDAI varied from 1 to 15 (average=7) and the SIBDQ ranged from 11 to 66 (average= 41). The SIBDQ was inversely correlated to the PDAI with a Pearson’s correlation coefficient equal to -0.885 (p=0.01). Indeed, the SIBDQ score for patients with an active perineal disease was significantly lower than those with inactive one (28.3 ± 11.6 vs. 50.1 ± 7.7; p< 0.0001), which indicates a worse life quality. Comparing the 2 groups, there were no significant differences in terms of age, gender and PDAI. The SIBDQ was lower in patients who had the disease for more than 5 years compared to the other ones (38.3 ±15.6 vs.48.2 ± 7.5; p=0.003). Conclusion The quality of life for patients with perineal Crohn’s disease seems to be altered by both activeness and duration of the disease. The SIBDQ is a simple tool that helps physicians detect patients with poor life quality. Other studies are necessary to validate this questionnaire for the evaluation of the quality of life in patients with perineal Crohn’s disease.

Background: Direct (anti-IIa and anti-Xa) oral anticoagulants (DOACs) have a significant impact on various coagulation test results. As the correct interpretation of these tests is mandatory to prevent misclassification and subsequent clinical consequences, withholding treatment could be necessary, with the associated risk of thrombosis. Aims: To evaluate the performance of the activated carbon DOAC-Remove (5-Diagnostics, Basel, Switzerland) in extracting DOACs from plasma samples and its effect on various routine and esoteric coagulation test results. Patients, Materials and Methods: Left-over plasmas from patients treated or not with DOAC obtained in the routine laboratory workload were evaluated. Briefly, 0.8 mL of plasma sample was incubated with 1 tablet of the activated carbon for 10 min at room temperature using a rotating shaker. After a 2 min-centrifugation at 2000x g and room temperature, the supernatant was pipetted before being analyzed. Tests were performed before and after such incubation. DOACs were measured using either a specific direct thrombin inhibitor or an anti-Xa assay with specific calibrations. Routine coagulation tests (PT, aPTT, and factor(F)V, FVIII:C, FIX, fibrinogen, and D-dimer) were performed, as well as thrombophilia panel [antithrombin, protein C (PC, chromogenic and clotting assays), PS (free PS antigen and clotting assays)], and lupus anticoagulant (LA) panel [silica clotting time (SCT), and dilute Russell venom clotting time (dRVVT)]. All assays were performed using reagents from Werfen (Bedford, MA, USA) on the ACL TOP 700 analyzer. As the distribution of data was not normal, test results were compared using non-parametric tests. Results: We evaluated a total of 756 plasma samples, obtained from patients treated with dabigatran (n=139, median concentration 129 ng/mL [range:18-905]), rivaroxaban (n=157, median concentration 159 ng/mL [range:19-815]), or apixaban (n=155, median concentration=154 ng/mL (range:11-510), and from 305 patients with various disease states and not on DOAC including 35 patients on coumadin and 32 patients on heparin (UFH: n=18 ; LMWH: n=14). In untreated patients, the DOAC-Remove had no significant impact on test results (n>30 for each parameter), except for D-dimer, free PS and FVIII:C. However, the mean biases, evaluated according to Bland-Altman, were below the accepted limits, and changes would not have had any clinical relevance. In the plasma from patients treated on DOAC, the DOAC-Remove eliminated all the three DOACs, with levels far below the detection limit of the techniques after a 10 min-incubation, leading to a dramatic correction of the DOAC-induced prolongations of PT and APTT, as well as of their lowering effect on FV, FVIII and FIX activities. The same applied to the DOAC-induced elevation of PC and PS anticoagulant activities (clotting assays), and antithrombin activity in the plasma from patients on rivaroxaban and apixaban. DRVVT screen/confirm ratios, which were above the normal ranges in 45% of the patients on dabigatran (n=31), and 78% of the patients on rivaroxaban (n=32), were normalized in most samples after a 10 min-incubation with the carbon and remained positive in only 10% of the patients on dabigatran and 12% of the patients on rivaroxaban. The impact of the DOACs on the SCT screen/confirm ratio was less noticeable with baseline positive test results in only one of the samples from patients on dabigatran (n=31), and in 2 patients on rivaroxaban (n=32). Treatment with the carbon leaded to a correction in the positive sample from patient on dabigatran and in one of the two positive samples from patients on rivaroxaban. Both dRVVT and SCT test results were within the normal range in the plasma from 32 patients on apixaban before and after treatment with the activated carbon. As expected, fibrinogen, PC activity evaluated using a chromogenic assay, free PS antigen concentration, VWF:RCo and VWF:Ag were not affected by any of the 3 DOACs, and test results were not significantly different before and after incubation with the activated carbon. Conclusion: The DOAC-Remove had no effect on test results obtained in the plasma from untreated patients and from patients on traditional anticoagulants. It effectively removed all 3 tested DOACs from the plasma of treated patients, allowing an accurate measurement of routine and esoteric coagulation tests in DOAC treated patients without withholding the treatment. Disclosures No relevant conflicts of interest to declare.

PurposeCoil embolization is a minimally invasive method used to treat cerebral aneurysms. Although this endovascular treatment has a high success rate, aneurysmal re-treatment due to recanalization remains a major problem of this method. The purpose of this study was to determine a combined parameter that can be useful for predicting aneurysmal re-treatment due to recanalization.MethodsPatient-specific geometries were used to retrospectively analyze the blood flow for 26 re-treated and 74 non-retreated aneurysms. Post-operatively aneurysms were evaluated at 12-month follow-up. The hemodynamic differences between the re-treatment and non-retreatment aneurysms were analyzed before and after coil embolization using computation fluid dynamics. Basic fluid characteristics, rates of change, morphological factors of aneurysms and patient-specific clinical information were examined. Multivariable analysis and logistic regression analysis were performed to determine a combined parameter—re-treatment predictor (RP).ResultsAmong examined hemodynamic, morphological, and clinical parameters, slight reduction of blood flow velocity rate in the aneurysm, slight increase of pressure rate at the aneurysmal neck and neck area, and hypertension were the main factors contributing to re-treatment. Notably, hemodynamic parameters between re-treatment and non-retreatment groups before embolization were similar: however, we observed significant differences between the groups in the post-embolization average velocity and the rate of reduction in this velocity in the aneurysmal dome.ConclusionsThe combined parameter, RP, which takes into consideration hemodynamic, morphological, and clinical parameters, accurately predicts aneurysm re-treatment. Calculation of RP before embolization may be able to predict the aneurysms that will require re-treatment.

Resume La presente mise au point s’interesse aux dernieres evolutions dans le domaine de l’anesthesie de l’ex-premature pour chirurgie mineure (principalement la cure de hernie inguinale). Y sont abordes : le probleme de la neurotoxicite des agents anesthesiques mais surtout les agressions cerebrales d’autres origines et les moyens de les controler. Meme si la chirurgie est mineure, l’anesthesie reste une attention de tous les moments face a toutes ces agressions qu’elles soient intra-operatoires (hypotension, hyponatremie, hypothermie…etc) mais egalement postoperatoires (risque d’apnees postoperatoires) et ce quel que soit le mode d’anesthesie utilise.

Muscle relaxation for tracheal intubation during paediatric anaesthesia remains a subject of debate.The aim of the current meta-analysis was to investigate the effect of muscle relaxants (MR) compared with opioids on intubation conditions in children.Meta-analysis of randomised controlled studies.Exhaustive literature analysis.Clinical trials, with no high-risk bias, that examined the effect of MR in comparison with opioids on intubation conditions (excellent: primary outcome, acceptable: secondary outcome) in children were included.Excellent intubation conditions were not significantly different in their occurrence between children receiving MR or opioids, risk ratio [95% Confidence Interval] = 1.17 [0.96, 1.43], I = 36%, number of studies = 5, number of patients = 226. However, trial sequential analysis indicated the lack of power of this result and the need for more trials to provide certainty for this outcome (81 patients needed in future trials). Acceptable intubation conditions were more frequent when administering MR, risk ratio = 1.25 [1.06, 1.47], I = 70%, number of studies = 6, number of patients = 362. This effect was confirmed using the trial sequential analysis. Grading of Recommendations Assessment, Development and Evaluation analysis found a low and moderate quality of evidences for excellent and acceptable intubation conditions, respectively.The current meta-analysis shows that the use of MR during tracheal intubation might improve the quality of intubation conditions. Further studies, including at least 81 children, are required to confirm this and determine the impact of MR on complications related to intubation.

Background Screening for preoperative anxiety is an important challenge during the preoperative period. The aim of our study was to validate the faces scale used to detect anxiety trait in children. Methods Children aged 8–18 yr were asked to quantify their anxiety trait using the readily available faces scale and to respond to the trait component of the State-Trait Anxiety Inventory (STAI) for children (C) or adults (A) before the anaesthesia consultation. Using receiver operating characteristics analysis, we determined the faces scale optimal value on a construct cohort. A validation cohort was recruited to assess the accuracy of the results. Results The construction cohort comprised 207 patients and the validation cohort 91 patients. The receiver operating characteristics analysis found an area under the curve of 0.75 [95% confidence interval (CI) 0.67, 0.83]. The optimal value for faces scale score was 4, with a sensitivity of 0.61 [95% CI 0.59, 0.62] and a specificity of 0.82 [95% CI 0.81, 0.83]. When this threshold was applied to the construction and validation cohorts, 61.3 and 44.4% of positives were true positives in the construction and validation cohorts, respectively; and 82.1 and 81.3% of negatives were true negatives, respectively. Conclusions Our study determined the performance of a simple faces scale to measure the preoperative anxiety trait in children aged 8–18 yr. This tool is potentially helpful for clinicians aiming to identify patients at risk of preoperative anxiety and to assign them to targeted management.

Data on major non-surgical postoperative complications following neonatal and infant surgery is lacking. The goal of the present study was to describe common major complications and their predictive factors.The study consisted of a retrospective review of medical charts of patients less than 6months of age operated in our institution over one calendar year, excluding herniorraphy surgery. The data collected included demographics, preoperative ICU bed status, ASA status, a history of cardiac malformation, hyaline membrane disease (HMD) or necrotizing enterocolitis (NEC), preoperative haemoglobin, emergent surgery status, surgery type and duration, duration of anaesthesia and the need for intraoperative fluid boluses. Complications were analysed until the 30th postoperative day. Analyses included descriptive statistics and the determination of factors associated with non-surgical complications using univariate and multivariate statistics.The study included 168 patients. Their postnatal age was 48±48days. Overall, 37 patients experienced major postoperative non-surgical complications. The most common major complications were haemodynamic compromise (n=19, 11.3%), multiple organ dysfunction syndrome (MODS, n=8, 4.8%) and respiratory failure requiring ventilation (n=3, 1.8%). Surgical complications occurred in 8 cases (4.8%). Four factors were identified as being predictive of non-surgical complications: PCA40 weeks, a history of cardiac malformation, HMD or NEC, preoperative ICU status and intraoperative fluid bolus administration.This study describes common non-surgical postoperative complications in neonates and infants, and their risk factors. They were much more common than surgical complications. Further studies should focus on preventive strategies addressing these complications.