Les Ethmoidites Aigues Exteriorisees De L\'enfant Etude De 11 Observations

Les ethmoïdites sont les sinusites les plus fréquentes chez l\'enfant de moins de 3 ans. La gravité de cette affection est liée à l\'extériorisation orbito-oculaire et endocrânienne de l\'infection. But : Analyser les caractéristiques clinico- radiologiques et thérapeutiques de cette affection. Patients et méthodes : Il s\'agit d\'une étude rétrospective portant sur 11 enfants hospitalisés pour ethmoïdite aigue, dans le service de pédiatrie du CHU Farhat Hached de Sousse, durant une période de 6 ans. Résultats : L\'âge moyen de nos patients était de 4 ans et 1/2, ils se répartissaient en 8 filles et 3 garçons. Le délai de consultation était de trois jours en moyenne. La fièvre et l\'oedème palpébral étaient deux critères constants chez tous nos patients. L\'atteinte était unilatérale dans neuf cas, et bilatérale dans deux cas. La TDM éthmoïdo-orbitaire et cérébrale, réalisée pour tous les patients, nous a permis de confirmer le diagnostic et de préciser l\'extension locorégionale. Une cellulite préseptale, une cellulite orbitaire, un abcès sous périosté étaient retrouvées, dans trois cas et une collection orbitaire dans les deux autres. Une bithérapie (céfotaxime-fosfomycine) était prescrite de première intention chez 10 patients. La metronidazole a été associée dans 3 cas Un drainage chirurgical était réalisé chez quatre patients. L\'évolution était favorable dans tous les cas. Conclusion : contenu de la gravité et les germes rencontrés dans cette affection, l\'antibiothérapie de première intention doit être large, précoce et intensive. Le recours au drainage est impératif en cas de collection orbitaire.Acute ethmoiditis are bacterial infections of ethmoid sinuses, which may spread to the orbital or the endocranial spaces.They are the most frequent among bacterial sinusitis before 3 years. Population and methods:Our study is retrospective, it included all children hospitalized in our pediatric unit from 2000 to 2006 for an acute ethmoiditis. We analyzed clinical and radiological presentations, and discussed therapeutic modalities used to treat this pathology. Results:Over this 6-years period, 11 children (mean age 4.5 years) where hospitalized for acute ethmoïdites.They were 3 boy and 8 girls. All patients presented with high fever and palpabral oedems. Etmoïditis was unilateral in 9 Children and bilateral in two. Ethmoïdio-orbital CT scan confirmed acute ethmoïdis, the cerebral one assessed intra-cranial diffusion. The acute ethmoidis was complicated with, preseptal cellulites in three cases, orbital cellulitis in three cases, subperiostal abscess in three others and orbital collection in two patients. Most children received an association of cefotaxisme and fosfomycemie for a mean duration of 13 days. Metronidazole was associated to the previous antibiotherapy in three cases. Four patients, required surgical treatment in addition to antibiotherapy.All children saw favorable out come. Conclusion:It is always difficult to found the bacteria responsible for an acute ethmoiditis. The first antibiotic therapy must be chosen to be effective in the most frequently responsible bacteria tacking in consideration the potentiel severity of this sinusitis. Journal Tunisien d\'ORL et de chirurgie cervico-faciale Vol. 16 2006: pp. 22-2

Mucormycose Otocerebrale: À Propos D\'un Cas

La mucormycose est une affection mycosique rare mais souvent fatale, survenant sur des terrains débilités. Elle est due à la prolifération de champignons cosmopolites de la famille de mucorales. Elle entraîne des lésions délabrantes et extensives des parties molles avec risque de thromboses vasculaires. Observation : nous rapportons l\'observation d\'une petite fille, âgée de 3 ans , issue d\'un mariage consanguin, hypotrophe, hospitalisée pour otite externe évoluant depuis 3 semaines. La patiente a bénéficié d\'une antromastoidectomie et a été mise sous antibiotiques. Devant une aggravation de l\'état local, avec extension de la nécrose et destruction du conduit auditif externe, une infection mycosique est fortement suspectée, sur un terrain particulier de déficit immunitaire probable. L\'examen parasitologique d\'un prélèvement local a mis en évidence la présence de filaments mycéliens dont la culture a isolé un Rhizopus oryzae, confirmé aussi par l\'étude anatomopathologique. L\'exploration de l\'immunité a mis en évidence un déficit de l\'immunitaire céllulaire.Un traitement par amphotéricine B était mal toléré (choc anaphylactique), l\'évolution spontanée était rapidement défavorable avec une extension locorégionale importante et une thrombophlébite du sinus latéral homolatéral, aboutissement au décés. Conclusion : la localisation oto cérebrale de la mucormycose est exeptionnelle, on doit y penser devant une otite externe maligne sur un terrain particulier. La prise en charge doit être urgente afin d\'augmenter les chances de survie.Mucormycosis is a relatively rare, potentially life-threatening, fungal infection. It occurs predominately in immunocompromised hosts. Vascular invasion, thrombosis and rapid ischemic necrosis of infected tissue are the most characteristic features of this pathology. Early diagnosis and consequently effective treatment are needed to save life in this fatal condition. Report: We report a case of otocerebral mucormycosis occurring in an hypotrophic 3-years old girl suffering from language retardation and chronic diarrhea. Immune system\'s exploration revealed a profound cell-mediated immunity defect. The diagnosis was suspected because of the rapidly extensive necrosis of the external ear conduct, the existence of lateral sinus thrombosis and the resistance to an aggressive antibiotic therapy.The diagnosis was confirmed by identifying Rhizopus oryzae by pathological examination of the necrotic tissue. Treatment by intravenous amphotericin B was certainly lately begun and unfortunately complicated by anaphylactic shock. Because no alternative drug was possible, such as liposomal amphotericin B, the girl rapidly died. Conclusion: Otocerebral mucormycosis is extremely rare.It must be considered when ear lesions are necrotic and rapidly extensive mainly in patients with predisposing conditions. Successful treatment requires tissue excision and early injection of amphotericin B, preferably in its liposomal presentation. Journal Tunisien d\'ORL et de chirurgie cervico-faciale Vol. 16 2006: pp. 42-4

L-Plastin nanobodies perturb matrix degradation, podosome formation, stability and lifetime in THP-1 macrophages

Podosomes are cellular structures acting as degradation ‘hot-spots’ in monocytic cells. They appear as dot-like structures at the ventral cell surface, enriched in F-actin and actin regulators, including gelsolin and L-plastin. Gelsolin is an ubiquitous severing and capping protein, whereas L-plastin is a leukocyte-specific actin bundling protein. The presence of the capping protein CapG in podosomes has not yet been investigated. We used an innovative approach to investigate the role of these proteins in macrophage podosomes by means of nanobodies or Camelid single domain antibodies. Nanobodies directed against distinct domains of gelsolin, L-plastin or CapG were stably expressed in macrophage-like THP-1 cells. CapG was not enriched in podosomes. Gelsolin nanobodies had no effect on podosome formation or function but proved very effective in tracing distinct gelsolin populations. One gelsolin nanobody specifically targets actin-bound gelsolin and was effectively enriched in podosomes. A gelsolin nanobody that blocks gelsolin-G-actin interaction was not enriched in podosomes demonstrating that the calcium-activated and actin-bound conformation of gelsolin is a constituent of podosomes. THP-1 cells expressing inhibitory L-plastin nanobodies were hampered in their ability to form stable podosomes. Nanobodies did not perturb Ser5 phosphorylation of L-plastin although phosphorylated L-plastin was highly enriched in podosomes. Furthermore, nanobody-induced inhibition of L-plastin function gave rise to an irregular and unstable actin turnover of podosomes, resulting in diminished degradation of the underlying matrix. Altogether these results indicate that L-plastin is indispensable for podosome formation and function in macrophages

Single domain antibodies: promising experimental and therapeutic tools in infection and immunity

Antibodies are important tools for experimental research and medical applications. Most antibodies are composed of two heavy and two light chains. Both chains contribute to the antigen-binding site which is usually flat or concave. In addition to these conventional antibodies, llamas, other camelids, and sharks also produce antibodies composed only of heavy chains. The antigen-binding site of these unusual heavy chain antibodies (hcAbs) is formed only by a single domain, designated VHH in camelid hcAbs and VNAR in shark hcAbs. VHH and VNAR are easily produced as recombinant proteins, designated single domain antibodies (sdAbs) or nanobodies. The CDR3 region of these sdAbs possesses the extraordinary capacity to form long fingerlike extensions that can extend into cavities on antigens, e.g., the active site crevice of enzymes. Other advantageous features of nanobodies include their small size, high solubility, thermal stability, refolding capacity, and good tissue penetration in vivo. Here we review the results of several recent proof-of-principle studies that open the exciting perspective of using sdAbs for modulating immune functions and for targeting toxins and microbes

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone