[Clinical research in general hospital centres in France, strengths and weaknesses]. / Recherche clinique au sein des centres hospitaliers généraux en France, forces et faiblesses.

Clinical research is an essential activity in cancer care. Both for patients, who can gain access to innovative therapies, and for practitioners, who can maintain their skills and stay at the forefront of new treatment approaches. First developed in university hospitals, clinical research is now established in general hospitals and private health institutions. The number of patient inclusions in clinical trials has doubled over the last ten years, thus reflecting the dynamism of it. Strengths and weaknesses, opportunities and threats concerning clinical research, and more specifically clinical research in general hospitals, are exposed in this article.

Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study.

BACKGROUND: No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. PATIENTS AND METHODS: This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). RESULTS: Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5-47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14-65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. CONCLUSION: Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

[Features distinguishing ornithosis from avian acute hypersensitivity pneumonitis - a retrospective analysis]. / Pneumopathies et exposition aux oiseaux : ornithose ou pneumopathie d'hypersensibilité aiguë aviaire ?

INTRODUCTION: The aim of our study was to compare the features at diagnosis in patients with ornithosis to patients with avian acute hypersensitivity pneumonitis (HP). Clinical, biological and radiological differences could potentially help clinicians to distinguish these diseases. METHODS: We conducted a retrospective study on patients admitted from 2000 to 2016 in three hospitals. Ornithosis was diagnosed based on a positive polymerase chain reaction for Chlamydophila psittaci on respiratory samples and/or a seroconversion while HP was diagnosed on the basis of at least one positive serum precipitin. RESULTS: Twelve patients with HP and 13 patients with ornithosis were identified. Compared to HP, ornithosis occurred more frequently in males (P=0.047), with less previous respiratory diseases (P=0.01), shorter symptom duration (P=0.03), less frequently bilateral crackles (P=0.004), more severe disease requiring more frequently intensive care admission (P=0.005), higher CRP values (P=0.005) and more profound lymphopenia (P=0.02). Ground glass shadowing on CT scan (P=0.001) or bronchiectasis (P=0.03) were more frequently noted in patients with HP. CONCLUSIONS: Our results suggest that patients with ornithosis and HP have important differences in their clinical, biological, and radiological presentation.

[Treatments of perineal neuralgia caused by involvement of the pudendal nerve]. / Traitements des névralgies périnéales par atteinte du nerf pudendal. A propos de 170 cas.

We report 170 cases of perineal neuralgia due to pudendal nerve compression within Alcock canal or by ischiatic spine. 117 women and 53 men were investigated. Mean age was 60.3 years and the follow-up one year. Infiltrations of the pudendal nerve in the ischio-rectal fossa (pudendal canal or Alcock canal) with corticoids under CT-scan guidance, were successful immediately in only 1/3 of the cases. Infiltrations of the nerve near by ischiatic spine (radioscopic guidance) were successful in 57 p. 100, but only in 15 p. 100 of the cas after one year. Surgical treatment (performed in 27 cases) was good (8 or excellent (9). For all treatments, the results are good in 65 p. 100 of the cases. Perineal neurophysiologic examinations are useful to confirm pudendal nerve lesion and propose specific medical and/or surgical treatment.

[Anaphylactoid shock due to metabisulfites during cesarean section under peridural anesthesia]. / Choc anaphylactoïde aux métabisulfites au cours d'une césarienne sous anesthésie péridurale.

Sulfiting agents are antioxidants widely used in both food and pharmaceutical industries. They have been identified as responsible for adverse severe reactions. A case is reported of anaphylactoid shock during epidural anaesthesia for caesarean section. The responsible agent was metabisulfite, additive agent of local anesthetics containing epinephrine.

[A rare and serious complication of spinal anesthesia: bacterial meningitis]. / Une complication rare et grave de la rachi-anesthésie: la méningite bactérienne.

Bacterial meningitis following spinal anaesthesia is a rare but serious complication. We describe a case in which an old woman received spinal anaesthesia for hip replacement. Diagnosing the aetiologic agent is a major medical challenge. The possible aetiological causes of this complication are discussed and the difficulty in differentiation between aseptic and bacterial meningitis noted.

[Is it possible to avoid a penal offence in carrying out ambulatory anesthesia?]. / Peut-on éviter la faute pénale en réalisant une anesthésie ambulatoire?

French jurisprudence about outpatient anaesthesia is resolutely unfavorable. It is principally based on the June 22nd 1972 decision of the cessation court, the highest court of justice in France. Preoperative non hospitalisation has been considered as a fault by negligence/carelessness of the practitioners. It resulted in their penal condemnation for involuntary injuries and compensation for the harm. This decision is linked with the evolution of the fault and the responsibility share between surgeon and anaesthetist. The post-operative phase seems to involve "theory of missing luck" (causality linkage or the detriment in itself), excluding a penal condemnation but not a partial compensation. Though some new legal considerations could be put forward, a written contract between physicians and patients is necessary in outpatient surgery, whereas the medical files and the organisation of the unit can prove the quality of medical care.

[The ambulatory anesthesia unit: a problem of organization]. / L'unité d'anesthésie ambulatoire: un problème d'organisation.

A specialized unit in outpatient anaesthesia and surgery needs an adapted planning. During the preoperative period, it is particularly important to preserve the time of the patients. Different types of structures are possible for the intraoperative period depending on their degree of independence to a hospital. The hospital based unit, with independent facilities, offers various advantages. Its size and its conception must be adapted to the constraints of ambulatory technique, and to the expected needs. During the postoperative period, a special medical organization must be planned to help the patient if necessary. The part of the secretarial work is important for the success of such a unit. Its efficiency may be improved by computerised treatment of part of the information.

[Testicular autotransplantation in children. Apropos of 2 cases]. / Auto-transplantation testiculaire chez l'enfant. A propos de 2 cas.

The authors presents 2 observations of testicular autotransplantation at 11 and 13 years age; the 2 boys had bilateral cryptorchism. Analysis of the literature allows good conclusions for the liability of this technique with less than 20% of secondary atrophies. Particularly interesting to note 2 successful operation on children 2 years old. The indications are limited, mainly discussed is bilateral abdominal cryptorchism (mostly Prune Belly Syndrome). The autotransplantation is reserved for the normal appearance testicles with good hormonal function. The operation is preferable using inguino-iliac extra-peritoneal pass; that exploration is very important and at last only in 20% of abdominal cryptorchism could autotransplantation be considered. The malignancy transformation risk is poor if break down is done before 10 years old, however a regular and very long follow-up is necessary: Clinic, vascular, biopsies sometimes at a little doubt. Preservation of hormonal function and fertility hope represent the expected advantages; spermatic analysis are still absent because the too recent autotransplantation. As for usual testicular ectopies for sure it would be preferable to do early autotransplantation, just after 2 years of age, if this is possible.

Intravenous regional anaesthesia with ketamine.

Ketamine, 40 ml 0.5% solution, was used in the technique of intravenous regional anaesthesia in 14 patients undergoing upper limb surgery. Satisfactory analgesia was obtained in 12 of the patients. The method is limited by the fact that all patients became unconscious within a few minutes of tourniquet release, and that this could not be prevented by naloxone.

[Unusual aberrant location of a left internal jugular catheter]. / Une fausse route peu courante d'un cathéter jugulaire interne gauche.

Although aberrant locations were classical complications of central venous catheterization, the left superior diaphragmatic vein was an exceptional one. A case of this particular complication occurring after left internal jugular venous catheterization is described. The venous dilatation due to portal hypertension was probably partly responsible for this.