François Dalmay

The Involvement of the Anterolateral Ligament in Rotational Control of the Knee

Background: Rotational control of the knee is crucial for knee stability. The anterolateral ligament (ALL) has been identified as a potentially important structure involved in rotational control of the knee. Purpose/Hypothesis: The purpose of this study was to determine, utilizing a navigation system, the involvement of the anterior cruciate ligament (ACL), the iliotibial band (ITB), and the ALL in tibial internal rotational control of the knee. The hypothesis was that the ALL would be involved in rotational control of the knee at varying degrees of knee flexion. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric knees were tested in internal rotation at 20° and 90° of flexion and then subsequently tested using a simulated pivot-shift test consisting of coupled axial rotation at 30° of flexion. Serial sectioning of the ACL, ALL, and ITB was performed. On the contralateral knee, sectioning was performed in the reverse order. Measurements were collected using a surgical navigation system before and after each sectioning. Results: After ACL sectioning, an incision of the ALL induced a significant increase in internal rotation (+19.2% [P = .0002] at 20°; +21.8% [P = .0029] at 90°) and in coupled axial rotation (+43.0%; P = .0035) compared with the intact knee as well as a significant increase in internal rotation at 90° (+13.4%; P = .009) and in coupled axial rotation (+30.8%; P = .0124) compared with the ACL-deficient knee. After ITB sectioning, an additional ALL section caused a significant increase in internal rotation (+39.0% [P = .002] at 20°; +63.0% [P = .0147] at 90°) and in coupled axial rotation (+59.7%; P = .0003) compared with the intact knee as well as a significant increase in internal rotation at 90° (+14.8%; P = .0067) in comparison to the ITB-deficient knee. Conclusion: The ALL is involved in rotational control of the knee at varying degrees of knee flexion and during a simulated pivot shift. Concomitant to an ACL or ITB transection, sectioning the ALL further increased rotational laxity. Clinical Relevance: This laboratory study demonstrated that the ALL provides rotational control of the knee in combination with the ACL and/or ITB.

Non-AT1-receptor-mediated protective effect of angiotensin against acute ischaemic stroke in the gerbil

Previous studies have shown that angiotensin II (Ang II), by mediating rapid recruitment of collateral circulation, has a protective effect in the setting of acute ischaemia. In an experimental model of acute cerebral ischaemia in the gerbil, Fernandez et al. have reported that the mechanism of the protective effect of Ang II is blood pressure (BP)-independent,1 and that the AT 1-receptor antagonist, losartan, but not the ACE inhibitor (ACE-I), enalapril, decreases mortality following unilateral carotid artery ligation. 2 The aim of this study was to examine the reproducibility of the respective effects of losartan and enalapril, and to verify that these differential effects are drug class-related. Acute cerebral ischaemia was induced in anaesthetised gerbils by unilateral carotid ligation. The effect of pretreatment with two different ACE-I (enalapril and lisinopril), and two different AT 1-receptor antagonists (losartan and candesartan), administered orally or intravenously, on mortality were compared. Kaplan-Meier survival curves at day three were analysed by a log-rank test. Pretreatment with both enalapril and lisinopril significantly decreased survival at day three compared with controls, while the AT1-receptor antagonists losartan and candesartan, despite similarly lowering BP, did not increase mortality. Coadministration of losartan and enalapril increased mortality to the same extent as enalapril alone. This study confirms that Ang II contributes to protective mechanisms against acute cerebral ischaemia through non AT1-receptor-mediated, BP-independent effects.

Isometric Characteristics of the Anterolateral Ligament of the Knee: A Cadaveric Navigation Study

PURPOSEnTo measure the variations in length during flexion and internal tibial rotation of the 3 different femoral insertions of the anterolateral ligament (ALL) while maintaining a fixed tibia insertion.nnnMETHODSnTwelve fresh-frozen cadaver knees were analyzed using a navigation system. Maximal distance variations of the 3 different anatomic femoral insertions of the ALL were measured during knee flexion and internal tibial rotation at 20° (IR20°) and 90° (IR90°). The 3 different femoral attachments were, as published, at the center of the lateral epicondyle, distal and anterior from this position, and proximal and posterior. Each of these 3 femoral insertions was coupled to the same tibial insertion at the tibial margin, halfway between the tip of the fibular head and the prominence of the Gerdy tubercle.nnnRESULTSnDuring IR20°, variation in the distance between paired points is not different between the proximal-posterior, epicondyle, and distal-anterior femoral insertions. These variations were statistically different during IR90° for the 3 different femoral locations. In increasing degrees of flexion, there was a length decrease between paired points observed with the proximal-posterior position. A length increase was observed for both the epicondyle location and the distal-anterior location.nnnCONCLUSIONSnThe ALL did not reveal an isometric behavior at any of the femoral insertion locations but had different length change patterns during knee flexion and internal tibial rotation at 90°. The proximal and posterior to epicondyle femoral position is the only position with a favorable isometry, as shown by being tight in extension and in internal rotation at 20° and then relaxed when the knee goes to flexion at 120° and during internal rotation at 90°.nnnCLINICAL RELEVANCEnClinical relevance is significant with respect to optimizing the femoral position of an ALL reconstruction.

Obesity and cervical ripening failure risk

Objective.u2003To estimate the impact of obesity on cervical ripening with prostaglandin E2 (PGE2). Materials and method.u2003A retrospective study compared the cervical ripening efficiency of PGE2 on patients with BMI above 30 kg/m2 and normal weight patients with BMI between 20 kg/m2 and 25 kg/m2. In case of a Bishop score (≤3), a dinoprostone tampon was used over 12 h. In case of a Bishop score (4;6), a dinoprostone gel was used over 6 h. Failure of first cervical ripening attempt was defined, as the persistence of a Bishop score <6, 12 h after dinoprostone tampon or 6 h after dinoprostone gel. Results.u2003Ninety-five obese patients were matched according to parity to 190 non-obese patients. The failure rate of the first attempt at cervical ripening was significantly higher (Pu200a=u200a0.0016) among obese patients (53.7%) as compared to patients with a BMI in between 20 and 25 (34.2%). After multivariate analysis BMI ≥ 30 (ORu200a=u200a2.32 (1.47–4.00), Pu200a=u200a0.0019), parity ≤2 (ORu200a=u200a2.50 (1.20–5.26) Pu200a=u200a0.0137), and the Bishop score ≤3 (ORu200a=u200a2.62 (1.45–4.72), Pu200a=u200a0.0014) were significantly and independently associated to prostaglandin ripening failure. Conclusion.u2003Obesity seems to be associated to lower E2 prostaglandin sensitivity.

Ultrasonographic identification and semiquantitative assessment of unloculated pleural effusions in critically ill patients by residents after a focused training

PurposeChest ultrasonography is currently a required element to achieve competence in general critical care ultrasound (GCCUS) which should be part of the training of every intensivist. We sought to assess the ability of resident novices in ultrasonography to identify and quantify unloculated pleural effusions in ICU patients after a limited training program.MethodsA total of 147 patients (mean age, 62xa0±xa017xa0years; simplified acute physiology score II, 35xa0±xa015; 78xa0% ventilated) with a suspected pleural effusion underwent a thoracic ultrasonography performed successively by a recently trained resident novice in ultrasound and by an experienced intensivist with expertise in GCCUS, considered as reference. Ultrasonographic examinations were performed randomly and independently. In the presence of a pleural effusion, the maximal interpleural distance was measured at the thoracic base.ResultsResidents performed a mean of 15xa0±xa09 examinations. Agreement between residents and experienced intensivists for the diagnosis of left- and right-sided pleural effusions was good to excellent [kappa 0.74 (95xa0% CI 0.63–0.85) and 0.86 (95xa0% CI 0.78–0.94), respectively)]. Agreement for the measurement of left and right maximal interpleural distance was excellent (intraclass concordance coefficient, 0.86 [95xa0% CI 0.77–0.91] and 0.85 [95xa0% CI 0.75–0.90], respectively). Mean bias for left and right interpleural distance was −0.3xa0mm (95xa0% CI −2.4, 1.8xa0mm) and −1.2xa0mm (95xa0% CI −3.4, 1.1xa0mm), respectively.ConclusionsAfter a focused training program, resident novices in ultrasound identify and quantify unloculated pleural effusions in ICU patients using chest ultrasonography with a good agreement with experts.

Detection of Toxoplasma gondii DNA in horse meat from supermarkets in France and performance evaluation of two serological tests

In France, some cases of severe toxoplasmosis have been linked to the consumption of horse meat that had been imported from the American continent where atypical strains of Toxoplasma gondii are more common than in Europe. Many seroprevalence studies are presented in the literature but risk assessment of T. gondii infection after horse meat consumption is not possible in the absence of validated serological tests and the unknown correlation between detection of antibodies against T. gondii and presence of tissue cysts. We performed magnetic-capture polymerase chain reaction (MC-PCR) to detect T. gondii DNA in 231 horse meat samples purchased in supermarkets in France and evaluated the performance and level of agreement of the modified agglutination test (MAT) and enzyme-linked immunosorbent assay (ELISA) in the meat juices. The serological tests lacked sensitivity, specificity, and agreement between them, and there was no correlation with the presence of T. gondii DNA in horse meat, raising concerns about the reliability of T. gondii seroprevalence data in horses from the literature. T. gondii DNA was detected in 43% of horse meat samples but the absence of strain isolation in mice following inoculation of more than 100 horse meat samples suggests a low distribution of cysts in skeletal muscles and a low risk of T. gondii infection associated with horse meat consumption. However, to avoid any risk of toxoplasmosis, thorough cooking of horse meat is recommended.

Estimation of Daily Sodium and Potassium Excretion Using Spot Urine and 24‐Hour Urine Samples in a Black Population (Benin)

The 24‐hour urine collection method is considered the gold standard for the estimation of ingested potassium and sodium. Because of the impracticalities of collecting all urine over a 24‐hour period, spot urine is often used for epidemiological investigations. This study aims to assess the agreement between spot urine and 24‐hour urine measurements to determine sodium and potassium intake. A total of 402 participants aged 25 to 64 years were randomly selected in South Benin. Spot urine was taken during the second urination of the day. Twenty‐four‐hour urine was also collected. Samples (2‐mL) were taken and then stored at ‐20°C. The analysis was carried out using potentiometric dosage. The agreement between spot urine and 24‐hour urine measurements was established using Bland‐Altman plots. A total of 354 results were analyzed. Daily sodium chloride and potassium chloride urinary excretion means were 10.2±4.9 g/24 h and 2.9±1.4 g/24 h, respectively. Estimated daily sodium chloride and potassium chloride means from the spot urine were 10.7±7.0 g/24 h and 3.9±2.1 g/24 h, respectively. Concordance coefficients were 0.61 at d=−0.5 g, (d±2SD=−11 g and 10.1 g) for sodium chloride and 0.61 at d=−1 g, (d±2SD=−3.8 g and 1.8 g) for potassium chloride. Spot urine method is acceptable for estimating 24‐hour urinary sodium and potassium excretion to assess sodium and potassium intake in a black population. However, the confidence interval for the mean difference, which is too large, makes the sodium chloride results inadmissible at a clinical level.

Prognostic impact of left ventricular diastolic function in patients with septic shock

BackgroundLeft ventricular (LV) diastolic dysfunction is highly prevalent in the general population and associated with a significant morbidity and mortality. Its prognostic role in patients sustaining septic shock in the intensive care unit (ICU) remains controversial. Accordingly, we investigated whether LV diastolic function was independently associated with ICU mortality in a cohort of septic shock patients assessed using critical care echocardiography.MethodsOver a 5-year period, patients hospitalized in a Medical–Surgical ICU who underwent an echocardiographic assessment with digitally stored images during the initial management of a septic shock were included in this retrospective single-center study. Off-line echocardiographic measurements were independently performed by an expert in critical care echocardiography who was unaware of patients’ outcome. LV diastolic dysfunction was defined by the presence of a lateral E′ maximal velocity <10xa0cm/s. A multivariate analysis was performed to determine independent risk factors associated with ICU mortality.ResultsAmong the 540 patients hospitalized in the ICU with septic shock during the study period, 223 were studied (140 men [63xa0%]; age 64xa0±xa013xa0years; SAPS II 55xa0±xa018; SOFA 10xa0±xa03; Charlson 3.5xa0±xa02.5) and 204 of them (91xa0%) were mechanically ventilated. ICU mortality was 35xa0%. LV diastolic dysfunction was observed in 31xa0% of patients. The proportion of LV diastolic dysfunction tended to be higher in non-survivors than in their counterparts (28/78 [36xa0%] vs. 41/145 [28xa0%]: pxa0=xa00.15). Inappropriate initial antibiotic therapy (OR 4.17 [CI 95xa0% 1.33–12.5]: pxa0=xa00.03), maximal dose of vasopressors (OR 1.38 [CI 95xa0% 1.16–1.63]: pxa0=xa00.01), SOFA score (OR 1.16 [CI 95xa0% 1.02–1.32]: pxa0=xa00.02) and lateral E′ maximal velocity (OR 1.12 [CI 95xa0% 1.01–1.24]: pxa0=xa00.02) were independently associated with ICU mortality. After adjusting for the SAPS II score, inappropriate initial antibiotic therapy and maximal dose of vasopressors remained independent factors for ICU mortality, whereas a trend was only observed for lateral E′ maximal velocity (OR 1.11 [CI 95xa0% 0.99–1.23]: pxa0=xa00.07).ConclusionThe present study suggests that LV diastolic function might be associated with ICU mortality in patients with septic shock. A multicenter prospective study assessing a large cohort of patients using serial echocardiographic examinations remains required to confirm the prognostic value of LV diastolic dysfunction in septic shock.

Dietary sodium and potassium intakes: Data from urban and rural areas

OBJECTIVESnHypertension is highly prevalent in West African populations, but little data is available on salt and potassium intake in these populations. We assumed in this study that sodium and potassium intake might be high and low, respectively, in the Beninese population in view of the emerging nutritional transition. The aim of this study was to estimate dietary sodium and potassium intakes based on 24-h urine collections.nnnMETHODSnWe selected 420 individuals (ages 25-64xa0y), representative of the population, from urban and rural areas in Benin. Urine was collected over 24xa0h, and sodium, potassium, and creatinine were quantified. Blood pressure was measured on the left arm using a validated electronic oscillometric monitor.nnnRESULTSnAdequate data were available for 354 participants. Mean dietary intake of sodium and potassium were 4.4xa0±xa02.1 and 1.8xa0±xa00.9xa0g/24xa0h, respectively. High intake of sodium was associated with urban area, age <44xa0y, administrative occupation, higher income, body mass index (BMI) ≥25xa0kg/m2, and a large waist circumference. High potassium intake was associated with male sex, administrative occupation, BMI ≥25xa0kg/m2, and large waist circumference. Sodium intake was associated with high systolic and diastolic blood pressures. In multivariate analysis, only age <44xa0y and, marginally, BMI ≥25xa0kg/m2 were associated with high sodium intake, whereas male sex and a BMI ≥25xa0kg/m2 were associated with high potassium intake.nnnCONCLUSIONnLarge proportions of the population had sodium intake higher, and potassium intake lower, than dietary recommendations. These results suggest that interventions to reduce salt consumption and promote potassium-rich foods, including fruits and vegetables, are needed in Benin.

Hemodynamic assessment of ventilated ICU patients with cardiorespiratory failure using a miniaturized multiplane transesophageal echocardiography probe

PurposeTo assess the feasibility, image quality, diagnostic accuracy, therapeutic impact and tolerance of diagnostic and hemodynamic assessment using a novel miniaturized multiplane transesophageal echocardiography (TEE) probe in ventilated ICU patients with cardiopulmonary compromise.Study designProspective, descriptive, single-center study.MethodsFifty-seven ventilated patients with acute circulatory or respiratory failure were assessed, using a miniaturized multiplane TEE probe and a standard TEE probe used as reference, randomly by two independent experienced operators. Measurements of hemodynamic parameters were independently performed off-line by a third expert. Diagnostic groups of acute circulatory failure (nxa0=xa05) and of acute respiratory failure (nxa0=xa03) were distinguished. Hemodynamic monitoring was performed in 9 patients using the miniaturized TEE probe. TEE tolerance and therapeutic impact were reported.ResultsThe miniaturized TEE probe was easier to insert than the standard TEE probe. Despite lower imaging quality of the miniaturized TEE probe, the two probes had excellent diagnostic agreement in patients with acute circulatory failure (Kappa: 0.95; 95xa0% CI: 0.85–1) and with acute respiratory failure (Kappa: 1; 95xa0% CI: 1.0–1.0). Accordingly, therapeutic strategies derived from both TEE examinations were concordant (Kappa: 0.82; 95xa0% CI: 0.66–0.97). The concordance between quantitative hemodynamic parameters obtained with both TEE probes was also excellent. No relevant complication secondary to TEE probes insertion occurred.ConclusionsHemodynamic assessment of ventilated ICU patients with cardiopulmonary compromise using a miniaturized multiplane TEE probe appears feasible, well-tolerated, and relevant in terms of diagnostic information and potential therapeutic impact. Further larger-scale studies are needed to confirm these preliminary results.