[HIV Disclosure to the Child/Adolescent in Central and West Francophone Africa]. / Annonce à l'enfant et à l'adolescent de son statut VIH en Afrique francophone centrale et de l'Ouest.

We report the attitudes and practices of health care workers involved in the disclosure process to adolescents living with HIV (ALHIV) in a network including West and Central African French-speaking countries, and the experiences of young living with HIV (YLHIV). During a three-day workshop in Abidjan, Côte d'Ivoire, caregivers (doctors, psychologists, social workers) from 19 pediatric HIV treatment sites shared their practices and difficulties, and four YPLHIV their own disclosure experience. Thirty five participants from eight West/Central African countries (Benin, Burkina Faso, Ivory Coast, Cameroon, Mali, Democratic Republic of Congo, Senegal, Togo) contributed: 14 doctors, eight psychologists, six counselors, three social workers. The experience of the centers was variable, but the age at disclosure was late: 34% of 1296 adolescents between 10 and 12 years of age knew their status. The median age at disclosure was 13 years (range: 11-15 years). The practice of the disclosure was often complex, because of multiple factors (fear of the parents of the breaking of the secrecy, lack of communication between professionals). The individual disclosure was the main practice. Four centers practiced HIV disclosure in group sessions to facilitate mirror support, and one used peer-to-peer support. YPLHIV have advocated for an earlier disclosure, from 10 years. In West and Central Africa, the process of HIV disclosure remains complex for parents and caregivers, and occurs too late. The development of a good practice guideline for HIV disclosing adapted to socio-cultural contexts should help to improve this process.

Nous rapportons les attitudes et pratiques des soignants en Afrique francophone concernant l'annonce du statut VIH aux adolescents, et les témoignages de jeunes vivant avec le VIH (jvVIH). Lors d'un atelier de trois jours à Abidjan, Côte d'Ivoire, en novembre 2016, les soignants (médecins, psychologues, travailleurs sociaux) de 19 sites de prise en charge pédiatrique du VIH ont partagé leurs pratiques et difficultés et 4 jvVIH leur vécu de l'annonce. Au total, 35 participants de 8 pays d'Afrique de l'Ouest/centrale (Bénin, Burkina Faso, Côte d'Ivoire, Cameroun, Mali, République démocratique du Congo, Sénégal, Togo) ont contribué : 14 médecins, 8 psychologues, 6 conseillers, 3 travailleurs sociaux. L'expérience des centres était variable, mais l'âge à l'annonce restait tardif : 34 % des 1 296 adolescents âgés entre 10 et 12 ans connaissaient leur statut. L'âge médian à l'annonce était de 13 ans (étendue : 11-15 ans). La pratique de l'annonce s'avérait complexe, en raison de multiples facteurs (crainte des parents de la rupture du secret, manque de communication entre professionnels). L'annonce individuelle était la pratique majoritairement adoptée. Quatre centres pratiquaient une annonce en séances de groupe pour faciliter le soutien en miroir, et un avait recours à l'appui de pairs-adolescents. Les jvVIH ont plaidé pour une annonce plus précoce, dès 10 ans. En Afrique de l'Ouest/centrale francophone, le processus de l'annonce reste complexe pour parents et soignants, et l'annonce trop tardive. L'élaboration d'un guide de bonnes pratiques de l'annonce du VIH, adapté aux contextes socio-culturels devrait permettre d'améliorer ce processus.

[Perioperative conflicts between anaesthesiologists and surgeons: ethics and professionalism]. / Conflits en période périopératoire: un enjeu collectif, éthique et professionnel.

In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. They are a source of medical errors and contribute to burn-out. Patients can become the victims of such conflicts, which deserve ethical reflection. Their resolution through analysis and shared solutions is necessary. This article seeks to analyse these conflicts, taking into account their specificities and constraints. In order to understand this context, it is important to consider the specificities of each group involved and the records of such situations. Several factors can prevent these conflicts, first and foremost the patients themselves and the quality of the care that is provided. Medical deontology aims mainly at preventing and resolving these conflicts. Generally speaking, the quality approach which is increasingly applied in health care institutions (involving declarations of adverse events, morbidity/mortality reviews, benchmarking, analysis and improvement of practices, etc.) also contributes to the prevention and resolution of disagreements. The teaching of communication techniques that begins with the initial training, the evaluation of team behaviours (through simulation training for example), the respect of others' constraints, particularly when it comes to learning, as well as transparency regarding conflicts of interests, are all additional elements of conflict prevention. Lastly, conflicts may at times be caused by deviant behaviours, which must be met with a clear and uncompromising collective and institutional approach. This article concludes by offering a standardised approach for conflict resolution.

Critical appraisal of organ procurement under Maastricht 3 condition.

The ethics committee of the French Society of Anesthesia and Intensive Care (Sfar) has been requested by the French Biomedical Agency to consider the issue of organ donation in patients after the decision to withdraw life-supportive therapies has been taken. This type of organ donation is performed in the USA, Canada, the United Kingdom, the Netherlands and Belgium. The three former countries have published recommendations formalizing procedures and operations. The French Society of Anesthesia and Intensive Care (Société française d'anesthésie et de reanimation [Sfar]) ethics committee has considered this issue and envisioned the different aspects of the whole process. Consequently, it sounded a note of caution regarding the applicability of this type of organ procurement in unselected patients following a decision to withdraw life-supportive therapies. According to French regulations concerning organ procurement in brain-dead patients, the committee stresses the need to restrict this specific way of procurement to severely brain-injured patients, once confirmatory investigations predicting a catastrophic prognosis have been performed. This suggests that the nature of the confirmatory investigation required should be formalized by the French Biomedical Agency on behalf of the French parliamentarians, which should help preserve population trust regarding organ procurement and provide a framework for medical decision. This text has been endorsed by the Sfar.

[Euthanasia, assisted suicide and palliative care: a review by the Ethics Committee of the French Society of Anaesthesia and Intensive Care]. / Fin de vie, euthanasie et suicide assisté : une mise au point de la Société française d'anesthésie et de réanimation (Sfar).

CONTEXT: Management of the end of life is a major social issue which was addressed in France by law, on April 22nd 2005. Nevertheless, a debate has emerged within French society about the legalization of euthanasia and/or assisted suicide (E/AS). This issue raises questions for doctors and most especially for anesthetists and intensive care physicians. OBJECTIVE: To highlight, dispassionately and without dogmatism, key points taken from the published literature and the experience of countries which have legislated for E/AS. RESULTS: The current French law addresses most of the end of life issues an intensive care physician might encounter. It is credited for imposing palliative care when therapies have become senseless and are withdrawn. However, this requirement for palliative care is generally applied too late in the course of a fatal illness. There is a great need for more education and stronger incentives for early action in this area. On the rare occasions when E/AS is requested, either by the patient or their loved-ones, it often results from a failure to consider that treatments have become senseless and conflict with patient's best interest. The implementation of E/AS cannot be reduced to a simple affirmation of the Principle of autonomy. Such procedures present genuine difficulties and the risk of drift. CONCLUSION: We deliver a message of prudence and caution. Should we address painful end of life and moral suffering issues, by suppressing the subject, i.e. ending the patient's life, when comprehensive palliative care has not first been fully granted to all patients in need of it ?

[Critical appraisal of organ procurement under Maastricht 3 condition]. / Analyse critique du prélèvement en condition M3 de Maastricht.

The ethics committee of the French Society of Anesthesia and Intensive Care (Sfar) has been requested by the French Biomedical Agency to consider the issue of organ donation in patients after a decision of withdrawing life supporting therapies has been taken. This category of organ donation is performed in the USA, Canada, United Kingdom, the Netherlands and Belgium. The three former countries have published recommendations, which formalize procedures and operations. The Sfar ethics committee has considered this issue and envisioned the different aspects of the whole process. Consequently, it sounds a note of caution regarding the applicability of this type of organ procurement in unselected patient following a decision to withdraw life supporting therapies. According to the French regulation concerning organ procurement in brain dead patients, the committee stresses the need to restrict this specific way of procurement to severely brain injured patients, once confirmatory investigations predicting a catastrophic prognosis have been performed. It suggests that the nature of the confirmatory investigation required should be formalized by the French Biomedical Agency on behalf of the French parliamentarians. This should help preserving population trust regarding organ procurement and provide a framework to medical decision. This text has been endorsed by the Sfar.

Air plethysmography: an alternative method for assessing peripheral circulatory adaptations during spaceflights.

A new approach to the study of peripheral vascular hemodynamics in microgravity was initiated by designing an alternative methodology: air plethysmography (AP). This is the only technique that enables the quantification of vascular hemodynamics from gross measurements performed on the limbs. This paper reports a description of the device and of the measurement protocol. A comparative study showed that AP yields results that are well correlated, although not in agreement, with those obtained by means of the reference method in the laboratory (mercury strain gauge plethysmography, MSGP; for venous capacity, correlation coefficient r = 0.8, P < 0.0001, limits of agreement--0.9 ml.100 ml-1 and 1.4 ml.100 ml-1; for arterial flow index, correlation coefficient r = 0.7, P < 0.0006, limits of agreements -20.4 ml.min-1 and 37.2 ml.min-1; for half-emptying time, correlation coefficient r = 0.9, P < 0.0001, limits of agreement -0.88 s and 0.77 s), and that are characterized by good reproducibility (coefficient of variation in general lower than 12%). Preliminary findings during spaceflight, on board the Mir Space Station, yielded data that is expected to improve our knowledge of vascular deconditioning in conditions of weightlessness.

[Vascular deconditioning (correction of deconditionring) in microgravity: results obtained in the french spationaut during the spatial mission EO 22]. / Deconditionnement vasculaire en microgravite: resultats obtenus sur la spationaute francaise au cours de la mission spatiale EO 22.

First results on changes in vascular physiology in the first french spationaut during the French-russian spatial mission CASSIOPEE are reported in this paper. The data, obtained by Air Plethysmography during flight, evidence at the level of lower limbs alterations of venous filling and emptying characteristics (the latter particularly depending on the muscular pump function of the calf) and of capillary circulation.

Treatment results, survival and prognostic factors in 109 inflammatory breast cancers: univariate and multivariate analysis.

Between 1978 and 1987, 109 patients without metastatic disease were treated by induction chemotherapy for inflammatory breast cancer (IBC) or "neglected" locally advanced breast cancer (LABC): 62 patients had a clinical history of rapidly growing tumours (doubling time < or = 4 months) and inflammatory signs; conversely, the 47 neglected patients had local inflammation with a longer history of LABC. 103 patients were fully evaluable. All patients received the same induction chemotherapy with doxorubicin, vincristine, cyclophosphamide and 5-fluorouracil. After six cycles, locoregional treatment was by radiotherapy if a complete or nearly complete response had been obtained, and total mastectomy, with pre or postoperative radiotherapy, in other cases. The chemotherapy after local treatment comprised of six cycles for LABC and 12 cycles for IBC (six without doxorubicin). With a median follow-up of 120 months, the median overall survival (OS) time was 70 months as against 45 months for disease-free survival (DFS). No difference was observed for OS and DFS between LABC and IBC. The regional recurrence rate was 24% (15% for radiotherapy alone). 20 factors of potential prognostic significance were evaluated by univariate and multivariate analysis. For DFS and OS, univariate analysis suggested a worse prognostic significance for "peau d'orange" appearance of the skin, clinical evidence of node involvement and poor response to chemotherapy after three cycles, on mammographic criteria. The cumulative dose of doxorubicin after three cycles seemed to have a significant effect on OS (P < 0.03) but was too closely correlated with age to draw definite conclusions. In the multivariate analysis, "peau d'orange", menopausal status and clinical node involvement predicted DFS. "Peau d'orange" and clinical node involvement also predicted OS. Our results indicate that IBC and LABC do not behave differently when treated with our procedure.

[Subclinical lesions of the breast. Stereotactic localization and biopsy-excision]. / Les lésions infracliniques du sein. Repérage par stéréotaxie et biopsie-exérèse.

Three hundred and eighty nine preoperative localizations were performed in the senology department of the Centre Jean Perrin in 349 patients presenting with an isolated radiological image with no associated clinical signs (discovered on routine or selective screening examinations). The most frequent anomaly detected was the presence of areas of microcalcifications, sometimes associated with a high-density lesion or more rarely an opacity. Systematic enlargements allowed refinement of the surgical indications and reduced the number of tumourectomies performed for benign lesions. The histological results consisted of 41% of neoplastic and borderline lesions with a predominance of in situ or microinvasive forms without lymph node involvement. The mean age at the time of diagnosis was 40 years, i.e. ten years younger that the mean age of cancer diagnosis. The percentage of subclinical cancers discovered in this way, increased by screening and improvement in surgical techniques, has been further increased by enlargements which have improved the precision of surgical indications. Stereotactic localization allows the surgeon and pathologist to more accurately define the lesion while preserving the appearance of the breast.

[Surgical technic for the excision of subclinical radiologic anomalies of the breast]. / Technique chirurgicale pour l'exérèse des anomalies radiologiques infracliniques du sein.

Routine mammography screening can detect radiologically evident but subclinical breast anomalies. Insofar as these anomalies can correspond to carcinoma, either in situ or invasive, surgeons are increasingly forced to operate on non-palpable breast lesions. A regulated and strict surgical technic is necessary to ensure exeresis of a radiologically detected focus, while avoiding sufficient adjacent healthy parenchyma and thus reducing the esthetic prejudice to a minimum. Technical artifices are described to assist compliance with these imperatives. First, the periareolar incision is chosen, as a principle, for its cosmetic qualities. Insofar as it provides an often limited approach it can be extended radially. The latter is concealed during closure without major alteration to the areola. Second, the radiating exeresis assists detection and is safer. It also provides glandular reconstruction of good esthetic quality and facilitates follow up surveillance.

[Breast hamartomas. Mammographic and histologic aspects. Apropos of 5 cases]. / Hamartomes mammaires. Aspects mammographiques et histologiques. A propos de 5 observations.

Five observations of hamartomas are reported, and compared with the data in the literature. We recall the principal radiological and histological aspects.

[Significance of preclinical radiologic abnormalities of the breast. Apropos of 87 histological verifications]. / Signification des anomalies radiologiques infra-cliniques du sein. A propos de 87 vérifications histologiques.

This retrospective study was carried out on 80 patients who had abnormalities discovered on mammography without any associated clinical signs. In some patients bilateral abnormalities were found so that 87 biopsies were carried out and this gave the result that 45 of the lesions were shown to be benign, 18 lesions were borderline and 24 lesions (27.6%) were of carcinomata. The frequency of these lesions goes up to 32% if areas of microcalcification only are considered. These tumours diagnosed in this sort of way, whether they are canal lesions or lobular lesions, usually show favourable histological features as far as invasion, size and lymphatic involvement is concerned. Borderline lesions are a histological group with as yet no fully evaluated significance but it has seemed to us interesting to describe them.

[In situ breast carcinoma developing in a fibroadenoma. Apropos of 4 case reports]. / Carcinomes mammaires in situ développés dans un fibro-adénome. A propos de 4 observations.

There were 4 cases of fibro-adenoma which, when examined histologically, showed a lobular or canalicular carcinoma in situ. These are reported. The results as compared with those in the literature suggest to the authors that fibro-adenoma should be removed.

[The diagnosis of Gougerot-Sjorgen syndrome in rheumatology. I. Evaul ation of the principal complementary examinations]. / Diagnostic du syndrome de Gougerot-Sjögren en rhumatologie. I. Evaluation des principaux examens complémentaires.

The examination of a patient with Sjögren's syndrome includes evaluation of the eye, the buccal cavity, and a search for certain factors in the blood. Schirmer's blotting-paper test is a good test but is not specific. In addition, a decreased amount of tearing is difficult to interpret after the age of 45. Slit-lamp examination (rose bengal and fluorescein) yields lesions which confirm keratoconjunctivitis due to decreased tearing. The buccal component is difficult to evaluate. A biopsy of the buccal mucosa gives the best results with minimum risk and expense. Nucleotide scanning is sensitive, but less specific. Salivary flow decreases with age. After 60 years of age this decrease can not be interpreted. The chemical composition of tears or of saliva is promising, but it is not yet a part of the usual diagnostic work-up. Of the available laboratory tests, anti-SS-A antibodies and/ or anti-SS-B antibodies are of value, but they are not found consistently.

[Unsynchronized ventilation of each lung with a selective and expiratory pressure in treatment of unilateral swallowing pneumopathy (author's transl)]. / Ventilation à poumons séparés avec pression positive résiduelle sélective. Utilisation au cours du traitement d'une pneumopathie de déglutition unilatérale.

A case of unilateral lung disease, treated by independent unsynchronized ventilation of each lung, with a selective end expiratory pressure is reported. The better effects of this method seem to be the improvement of respiratory mechanics and gas exchange and the decrease of the intrapulmonary shunt.

[Principles and techniques of physiotherapy for arterial claudication of the limbs (author's transl)]. / Principes et techniques de rééducation de la claudication artérielle des membres.

Exercise training of stage II arteriopathy is set in accordance with the localisation of the lesions the walking distance and the cardio respiratory state. It must procure an improvement of the respiratory function, a stimulation of the muscles and vessels situated downstream of the lesion and a re-training of the patient to a more economical way of walking. The passive technics use warmth, massages, postures. The active methods, when they can be applied, are more efficient and include exercise under load or no load, abdominal exercises, breathing exercises, analytical exercises against a resistance, global exercises on a cycle ergometer or walking on a path or a trad mill.