Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway.

An evaluation of a post-acute rehabilitation unit after five years of operations.

Introduction: The Hospital Organization Guidelines (HOG) recently recommended that Reference Hospitals create Post-Acute Rehabilitation Units (PARU). The authors describe the quality process of a PARU in a University Hospital (UH); this quality process had previously been used in a private rehabilitation hospital.

Goals: The authors wanted to evaluate the organization of the care provided in their PARU and compare the evaluation results with the results expected at the unit's creation five years earlier.

[Ethical and legal points concerning minimally conscious state and permanent vegetative state].

The ethical and legal problems posed by severe outcome of coma are complex and their analysis requires a multi-disciplinary approach. Three aspects have been particularly studied in this paper. The first is a reminder of the medical definitions of the concepts of vegetative state and minimally conscious state.

[Intensive care handling: specific expectations of rehabilitation].

For the severe head injured patients, the way of going from coma to arousal is considerably different from one patient to the other, and it is not always easy to determine the appropriate moment for taking them out of intensive care, into rehabilitation. This is the reason why, instead of considering these two treatments as successive phases, it is better to consider them as a collaboration process. The objective of this paper is to describe the needs of this type of patients, by using the data gathered on a weekly basis in the medical data department of the Centre Médical de l'Argentière, on patients admitted in 2002 in the rehabilitation and post-intensive care departments.

[Management of infectious risk associated with therapeutic pools].

Unlabelled: There is no specific legislation concerning pools and others medical hydrotherapy equipments relating hygiene and security rules. For this reason, the hydrotherapy pools use the public swimming pools legislation.

Method: This article is based on literature review (database Medline and Embase--manual research).

[How can we define the modalities and clinical levels of coma to wakefulness?].

Objective: The starting point of the French conference of consensus concerning arousal after coma was to answer the following question: "How can we define the ways of going from coma to arousal and their clinical levels?

Materials And Method: A team of readers have picked up in the literature one hundred and fifty papers, out of which fifty six have been analysed.

Results: From this analysis, three points emerged: The concepts of coma and arousal; The conditions of evolution from coma to arousal; Various groups of patients depending on their expressing arousal. One could not find any consensual model concerning the different ways of going from coma to arousal.

[Traumatic rupture of the bladder. Apropos of 11 cases].

Eleven cases of rupture of bladder were observed within 7 years. Four of them were due to a direct trauma on a full bladder (group I), the other seven occurred during a complex trauma, constantly with a fracture of the pelvis (group II). In group I, the rupture was situated on the apex of the bladder.

[Study of incidence and risk factors of nosocomial urinary tract infection in patients with indwelling urinary catheter in intensive care units].

A prospective study was carried out in a medical and surgical ICU to determine the incidence of nosocomial urinary tract infection (NUTI) and to identify the most important risk factors. Over a 6 month period, 180 patients were included. All had an indwelling catheter.

[Role of invasive technics in the occurrence of nosocomial infections. At an intensive care unit].

A prospective study was carried out in a polyvalent medical intensive care unit to determine the role played by diagnostic and therapeutic invasive techniques in the development of four nosocomial infections. Over a 6-month period, 206 patients admitted for more than 48 hours were studied; all had undergone one or several invasive techniques: 76 patients (37 per cent) developed a total of 117 nosocomial infections including urinary tract infection (41.8 per cent), purulent bronchitis (37.

Norepinephrine therapy has no deleterious renal effects in human septic shock.

We investigated 25 patients (aged 20 to 70 yr) in septic shock with low systemic vascular resistance in order to assess the effects on renal function of prolonged (24 to 240 h) norepinephrine (NE) infusion (range 0.5 to 1.5 micrograms/kg.

[Bacterial contamination of the inspiratory circuit of artificial ventilation apparatus: influence of the frequency of circuit renewal and the duration of ventilation].

In a study concerning contamination of artificial ventilators (Drager model UV1), the influence of 2 parameters was assessed: the frequency of changing the circuit (2 and 4 days) and the interval between admission of the patient into the intensive care unit and obtaining the sample. As a function of these variables, 4 groups of 15 patients each were constituted. The levels of contamination noted at 4 sites in the inspiratory phase tubing (cascade humidifier, condensate collector, tubing nearest to the patient and tubing nearest to the humidifier) and in the gas flow showed no significant difference between the groups, regardless of whether the circuit was changed after 2 or 4 days, or whether the patient had been recently admitted to the department or had been there for at least 6 days.

[Immunologic response in herpes encephalitis: development of the antibody serum/cerebrospinal fluid ratio in 13 cases].

Serological monitoring was performed in 13 cases of herpetic encephalitis (one infant and 12 adults). Samples taken simultaneously from blood and cerebrospinal fluid (CSF) were tested before and after initiation of antiviral treatment. Antiherpesvirus (anti-HSV) antibodies were assayed by an ELISA method.

A reappraisal of norepinephrine therapy in human septic shock.

The effectiveness and safety of iv infused norepinephrine (0.5 to 1 microgram/kg X min) were evaluated in 12 hyperdynamic vasodilated septic patients, who remained hypotensive despite iv volume expansion and antimicrobial and dopamine therapy. During norepinephrine infusion, mean arterial pressure and systemic vascular resistance index increased (p less than .

[Comparison of fosfomycin-penicillin M and penicillin M-gentamycin. Apropos of 35 severe infections caused by methicillin-sensitive Staphylococcus aureus].

Two combined antibiotic treatments were compared in 35 cases of methicillin-sensitive Staph. aureus infection. Eighteen patients (including 17 with septicaemia) received penicillin M (methicillin or oxacillin) and gentamicin daily for a mean period of 11 days.

Preoperative acute volume loading in patients with pheochromocytoma.

Ten patients with pheochromocytoma underwent preoperative acute volume loading to determine whether fluid infusion severely increased pulmonary capillary wedge pressure without improving forward flow, and to provide a guide for intraoperative volume replacement. In one patient, volume loading confirmed baseline pressure data suggesting a discrepancy between right and left ventricular filling pressures. In a second patient with normal baseline wedge pressure, volume loading revealed an unsuspected ventricular dysfunction.

[Measurement by mass spectrometry of oxygen consumption and carbon dioxide production in mechanically ventilated patients].

The authors present a technique of VO2 and VCO2 measurements by a non invasive method in mechanically ventilated patients. Inspirated and expirated gas are sampled respectively in the inspiratory limb of the patient's breathing circuit and in a mixing chamber. Gas samples are analysed by mass spectrometry in the laboratory.

[Critical study of the serological diagnosis of herpetic encephalitis. Apropos of 4 cases].

Virologic study was performed in four cases of Herpes simplex virus encephalitis. Herpes simplex virus type 1 was recovered from surgical brain biopsy specimens taken in three cases. Anti-HSV antibodies were assayed in simultaneous blood and cerebrospinal fluid samples by ELISA.

[Collective acute poisoning by nitrous gases].

A collective nitrous fumes poisoning (five cases) is reported. Two patients (case 3 and case 4) were comatose, in severe respiratory distress. Shock and slate blue cyanosis were noted.

[Acute hydrocephalus in tuberculous meningitis in adults].

The authors report a case of tuberculous meningitis in a young man who developed acute hydrocephalus as soon as the fifteenth day of the course of the disease. Attention is drawn to the importance of computerized tomography in investigating sudden deterioration in patients with tuberculous meningitis. Emphasis is put on the value of a shunt procedure which, in the case reported here, led to immediate improvement before antituberculous chemotherapy could have been effective.

[Cell-mediated immunity studied by skin tests in patients receiving intensive care. Prognostic value of repeated tests. Study of some factors predisposing towards anergy (author's transl)].

Cell-mediated immunity was assessed by three skin tests (using tuberculin, candidin, and Varidase) in one-hundred patients in a medical intensive care unit. Anergy on admission was most often found after major blood loss and massive transfusion as well as in patients over sixty. For the 49 patients who were anergic on admission the mortality rate was 32%, against 12% for the 51 reactive subjects (p less than 0.