[Blood representations associated to chronic transfused patients: Symbolic interpretations and ethical perspectives]. / Lectures des représentations du sang chez les receveurs chroniques de produits sanguins labiles : interprétations symboliques et perspectives éthiques.

Since the beginning of the 20th century, major technological developments have been made in blood transfusion. Although numerous sociological studies have been conducted on donors, few have highlighted transfused patients, and in this case, the attention has almost exclusively been focused on transfusion risks in patients. Conversely, blood representations associated with the chronically transfused patients have not really been explored in the literature. Based on interviews conducted among chronically transfused patients (patients with hemoglobinopathy, malignant hemopathy or cancer), this present study enables to understand their needs and their expectations through their symbolic representations and their interpretations of blood transfusion, raising tensions as well ethical perspectives.

[Fever and jaundice... and if it was a leptospirosis. About a case of L. interrogans icterohaemorrhagiae in Northern France]. / Ictère fébrile et si c'était une leptospirose. À propos d'un cas de L. interrogans Icterohaemorrhagiae dans le Nord de la France.

Leptospirosis is an anthropozoonose, an animal disease transmissible to humans, caused by a spirochete of the genus Leptospira that lives mainly among rodents but also in wetlands. It occurs worldwide, particularly in Asia, Latin America and Africa. In Europe, the incidence is small (except in France and Great Britain, where its frequency has increased in recent years) but the frequency may be underestimated. Some areas overseas are particularly affected. In France, the potential epidemic of leptospirosis is subject to climatic variations, justifying a constant monitoring of the disease provided by the National Reference Centre (CNR) of leptospires. Transmission to humans primarily occurs through contact with environments contaminated by the urine of infected animals. The disease can affect the liver and kidneys (hepatonephritis) as cytolysis, cholestasis and renal failure associated with fever. A coagulopathy usually accompanies the clinical table. Its diagnosis is difficult because of the clinical polymorphism. Early diagnosis of leptospirosis allows effective medical care, improving patient outcomes. This is currently based on gene amplification (PCR) or serology positive by the microscopic agglutination test (MAT), which is the reference method. Its evolution is usually favorable with appropriate antibiotic treatment (aminopenicillin). However 5-10% of symptomatic patients have a severe multisystem defaillance. Nearly a century after the discovery of the causative agent, this zoonosis remains a public health problem, zoonosis priority in terms of virulence, its reporting is mandatory in our country. We report the case of a severe form of hepatonephritis due to water contaminated with Leptospira observed in Northern France.

[Sodium dichloroisocyanurate-induced acute lung injury in a child]. / Œdème pulmonaire lésionnel par intoxication au dichloro-isocyanurate de sodium.

Intoxication, by cyanurate and its chlorated derivatives in children, is increasingly reported in the literature due to accidental ingestion compared to accidental inhalation. We report a case in a 5-year-old child who presented with acute lung injury due to accidental inhalation of gas formed after a reaction of sodium dichloroisocyanurate tablets with water. Prevention remains the best way to reduce the risk of children being intoxicated by inhalation of the gas formed after contact of tablets with water.

[Mannequin-based simulation to evaluate difficult intubation training for emergency physicians]. / Intérêt de la simulation réaliste dans l'évaluation de l'enseignement de l'intubation difficile aux médecins urgentistes.

OBJECTIVES: The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation. STUDY DESIGN: Prospective. POPULATION: Emergency physicians. METHODS: Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan simulator (Laerdal was assessed. RESULTS: Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor. CONCLUSION: We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.

[Management of acute coronary syndromes without ST elevation: the TOSCANE registry]. / Prise en charge des syndromes coronaires aigus sans sus-décalage du segment ST. Registre TOSCANE.

The problem of pre-hospital management of acute coronary syndromes without ST elevation has not been extensively studied. The practitioner is faced with three simultaneous problems: suspecting the diagnosis, how to confirm the diagnosis to introduce appropriate, rapid and effective treatment, and which prognostic criteria to use to install aggressive therapy in high risk groups (anti GP lIb/IIIa, clopidogrel, angioplasty). TOSCANE is the first multicentre French registry which analyses the impact of the emergency ambulance serve in the management of these patients. There are two objectives: to gather epidemiological data about pre-hospital and hospital management by the emergency physician and the cardiologist, and to identify at an early stage criteria of "high risk" (HR) which, according to the recommendations of the European Society of Cardiology, justify using the most aggressive therapies. From April to September 2003, 797 patients with suspected acute coronary syndromes were enrolled by 36 French centre. Of these patients, 780 were managed successfully by the emergency ambulance service and hospital cardiological department with or without a "Cath Lab", and included for analysis. The diagnosis of acute coronary syndrome without ST elevation was rarely certain in the pre-hospital period. The lack of formal paraclinical features confirming the diagnosis was often a handicap for the emergency physician. Although the European recommendations are well observed in the cardiology departments, their application and adaptability should be improved in the pre-hospital period. TOSCANE showed that all invasive strategies preceded by platelet anti-aggregant therapy in the prehospital period administered to high risk patients, significantly reduced the mortality and morbidity at one month.

[Role of the regulation in the management of patients with severe head injuries]. / Rôle de la régulation dans la prise en charge du traumatisé crânien grave.

The regulator of the emergency medical ambulance service is involved in the various steps of the initial management of severe head trauma patients: handling calls, basic life support, prehospital advance life support, transport and hospital admission. The management is rapid (helicopter transports) coherent and adapted (adherence to the guidelines for severe head injury), and considers of local difficulties (geographical, possibility of admission to trauma centres), with the aim of improving the outcome of severely head-injured patients.

Safety of the posterior approach in adrenal surgery: experience in 105 cases.

BACKGROUND: At the advent of laparoscopic adrenalectomy when it was timely to reappreciate the results of time-honored procedures, we reviewed the cases of 105 patients who underwent adrenalectomy through the posterior approach. METHODS: Between 1970 and 1992 among 331 patients, 105 underwent adrenalectomy through the posterior approach (0 of 111 pheochromocytomas, 48 of 64 Conn's disease, 37 of 57 Cushing's disease, 2 of 20 virilizing-feminizing tumors, 13 of 61 nonsecreting adrenalomas, 3 of 12 metastases, 2 of 6 cysts). Adrenalectomy was bilateral in 20 cases. Among 86 tumors, 28 (32.6%) were larger than 5 cm in diameter, none exceeding 10 cm. Posterior approach, initially performed in the prone position, was used in the lateral position for the last 40 patients with tumors. A hockey-stick incision was made on the twelfth or eleventh rib, which was resected. RESULTS: During operation no patient died; one minimal caval tear and 13 pleural tears occurred and were sutured, with two pleural drainages; six patients received blood transfusion. Average operative time was 132 minutes (range, 45 to 290 minutes). After operation one patient died of iatrogenic sepsis, average time to ambulation was 1.5 days, and average in-hospital stay was 7.6 days (range, 1 to 21), which after the fourth day was mostly justified for nonsurgical reasons. From 1990 through 1992, 37 of 38 patients were walking the day after operation and average postoperative stay dropped to 4.5 days (range, 1 to 7 days). CONCLUSIONS: Adrenalectomy through the posterior approach is safe and allows early postoperative discharge.