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Objective To evaluate the association between dose of skin-to-skin contact (SSC) per day and initiation time with the occurrence of deaths in newborns with weight up to 1800g. Method Multicentric cohort in five Brazilian neonatal units, including newborns with a birth weight of ≤1800g. The time of SSC was registered in individual file, by the team or family during the hospitalization. Maternal and newborn data were obtained through questionnaires applied to mothers and in medical records. Classification Tree was used for data analysis. Results The performance of the first SSC after 206h was significantly associated with death (p = 0.02). Although there was no association between SSC/day and death (p = 0.09), the number of deaths among those who performed more than 146.9 minutes/day was lower (3;1.5%) than among those who performed this practice for a shorter time (13;6.4%), a fact considered of great clinical importance. Early and late infections present statistically significant associations with the outcome. The chance of death was equal to zero when there was no early infection in the group with the longest duration of SSC. This probability was also equal to zero in the absence of late sepsis for the group with less than 146.9 minutes/day of SSC. Conclusions The first SSC before 206 hours of life is recommended in order to observe a reduction in the risk of neonatal death. Staying in SSC for more than 146.9 min/day seems to be clinically beneficial for these neonates mostly when it was associated with the absence of infection.

International audience; Background: Intensive care unit (ICU) healthcare workers (HCWs) are at the forefront of the coronavirus disease 2019 pandemic. To overcome the lack of human resources during this crisis, some ICUs had to mobilise staff from a reinforcement pool, with no or outdated ICU experience. This study aimed to investigate and to compare the psychological impact of the pandemic on regular ICU staff members and reinforcement workers.Material and methods: Self-assessment questionnaires were completed by HCWs who worked from March 1 to April 30, 2020, in our 16-bed neurological ICU at La Pitié-Salpêtrière Hospital in Paris, France, which was converted to a COVID ICU. The Hospital Anxiety and Depression Scale, the Post-traumatic Stress Disorder Checklist for DSM-5, McGill Quality of Life Questionnaire-Revised, and 10-item Connor-Davidson Resilience Scale were used to assess anxiety, depression and post-traumatic stress disorder, quality of life, and resilience, respectively.Results: Sixty-nine ICU HCWs completed the survey (37 from the team of regular staff members, i.e., from the public health service, and 32 from a reinforcement pool, either from non-ICU public health service or from private healthcare interim employment agencies). Prevalence of anxiety, depression, and post-traumatic stress disorder symptoms was high, at 19%, 9%, and 16%, respectively, with limited impairment in quality of life or resilience scores. Depression symptoms were observed more in regular staff members than in welcomed reinforcement workers, at 16% and 0%, respectively.Conclusions: These results revealed that during the pandemic, HCWs from the team of regular staff members were at greater risk of developing psychological disorder compared with reinforcement workers, with higher levels of depressive symptoms.

Introduction Today, the prevalence of overweight and obesity is, respectively, 49% and 17% among French adults. This research investigates their existence in the French Armed Forces, in terms of the impact on military operative response and military readiness. As no previous studies have evaluated the weight status of the whole French Armed Forces, this work assesses the situation for the first time in France. Material and Methods A prospective cross-sectional study was carried out between September 2016 and April 2017. A single anonymous questionnaire gathered the sociodemographic variables and usual care medical data. The source population was active duty members serving in units reporting to the South-Eastern French Regional Military Health Department. Results Among 1,589 respondents, prevalence of overweight and obesity was, respectively, 38.7% and 10%. Mean waist circumference was 78.2 ± 9.1 cm for women and 89.1 ± 10.5 cm for men. A third of female military and one-fifth of male military had a measure bigger than the standard International Diabetes Federation. Age, sex, weekly fitness activity, and rank were significant independent predictors of body weight excess. Less than 5% of the study population reported a diagnosis of comorbidity: diabetes 2%, high blood pressure 1%, and dyslipidemia 1.5%. Conclusions As all armies, the French Armed Forces are affected by obesity. Nevertheless, the prevalence of obesity seems lower than in other Western armies. In the French army, as in the general population, obesity is correlated with socioeconomic status and level of education. However, compared to the general French population, there is less obesity and overweight in the French Armed Forces. Moreover, overweight and obese military members have a lower cardiovascular risk than their civilian counterparts. Enlistment standards, military occupational activity, and a mandatory high level of physical fitness could explain these different proportions of overweight and obesity. This raises the question of the protective effect of regular physical activity. Is this a serious way to fight against the growing prevalence of overweight and obesity in Western countries? Indeed, this is a significant public health issue, which also affects the military’s quick response force capacity and strategic capabilities. Therefore, the identification of specific demographic characteristics should be considered in developing prevention programs.

Summary Introduction The management strategy for common bile duct stones (CBD) in patients over 75 years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients. Material and methods This study included eighty-two patients over 75 years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n = 40) or by sequential endoscopy and surgery (ES group, n = 42). Results Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P = 0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (> 3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively. Conclusion The “surgery alone” attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.

The data concerning long-term follow-up and outcomes of penetrating trauma are poorly detailed in the literature. The main objective of our study was to analyze the hospital and extra-hospital follow-up of penetrating trauma victims and to evaluate the late complications and long-term consequences of these traumas.This work was a retrospective longitudinal monocentric observational study conducted at Laveran Military Hospital, from January 2007 to January 2017. All patients hospitalized for gunshot wound or stab wound management during this period were identified via a retrospective systematic query in the hospital information system using the ICD-10 codes. Epidemiological data, traumatism characteristics, hospital management, follow-up and traumatism consequences (i.e., persistent disability) were analyzed. To improve evaluation of traumatism long-term consequences, extra-hospital follow-up data from general physicians (GP) were collected by phone call. During this interview, 9 closed questions were asked to the GP. The survey evaluated: the date of the last consultation related to injury with the GP, the specific follow-up carried out by the GP, traumatism consequences, and recurrence of traumatism. Descriptive, univariate and multivariate with regression analysis were used for statistical analysis.A total number of 165 patients were included. Median (Q1, Q3) of hospital follow-up was 28 (4, 66) days. One hundred one patients (61.2%) went to their one-month consultation at hospital. GP follow-up was achieved for 76 patients (55.2%). Median (Q1, Q3) of GP follow-up was 47 (21, 75) months. Twenty-four patients (14.5%) have been totally lost to follow up. The overall follow-up identified 54 patients (32.7%) with long-term consequences, 20 being psychiatric disorders and 30 organic injuries. Organic consequences were mainly peripheral nerve damages (n = 20; 12.1%). Most of the psychiatric consequences were diagnosed during GP follow-up (n = 14; 70%). Seventeen cases (10.3%) of recurrence were found and late mortality occurred in 4 patients (2.4%). High injury severity score, older age and gunshot wound were significantly linked to long-term consequences. Data collection and analysis were carried out in accordance with MR004 reference methodology.This study showed a high rate of long-term consequences among patients managed for penetrating injury. If all organic lesions are diagnosed during hospital follow-up and jointly managed by hospital and extra-hospital physicians, most socio-psychiatric consequences were detected and followed by extra-hospital workers. However, for half of the patients, the extra-hospital follow-up could not be assessed. Thus, these consequences are very probably underestimated. It appears imperative to strengthen the compliance and adherence of these patients to the care network. Awareness and involvement of medical, paramedical teams and GP role seems essential to screen and manage these consequences.

OBJETIVE To understand the role of exposure to skin-to-skin contact and its minimum duration in determining exclusive breastfeeding at hospital discharge in infants weighing up to 1,800g at birth. METHODS A multicenter cohort study was carried out in five Brazilian neonatal units. Infants weighing ≤ 1,800g at birth were eligible. Skin-to-skin contact time was recorded by the health care team and parents on an individual chart. Maternal and infant data was obtained from maternal questionnaires and medical records. The Classification Tree, a machine learning method, was used for data analysis; the tree growth algorithm, using statistical tests, partitions the dataset into mutually exclusive subsets that best describe the response variable and calculates appropriate cut-off points for continuous variables, thus generating an efficient explanatory model for the outcome under study. RESULTS A total of 388 infants participated in the study, with a median of 31.6 (IQR = 29–31.8) weeks of gestation age and birth weight of 1,429g (IQR = 1,202–1,610). The exclusive breastfeeding rate at discharge was 61.6%. For infant’s weighting between 1,125g and 1,655g, exposed to skin-to-skin contact was strongly associated with exclusive breastfeeding. Moreover, infants who made an average > 149.6 min/day of skin-to-skin contact had higher chances in this outcome (74% versus 46%). In this group, those who received a severity score (SNAPPE-II) equal to zero increased their chances of breastfeeding (83% versus 63%). CONCLUSION Skin-to-skin contact proved to be of great relevance in maintaining exclusive breastfeeding at hospital discharge for preterm infants weighing 1,125g–1,655g at birth, especially in those with lower severity scores.

We report the case of a civilian 27-year-old man treated in a military hospital in France who sustained multiple stab wounds, including one in the left groin, with massive external bleeding. When first responders arrived, the patient was in hemorrhagic shock. A tourniquet and two intraosseous catheters were placed to start resuscitative care. On the patient's arrival at the hospital, bleeding was not controlled, so a junctional tourniquet was put in place and massive transfusion was started. Surgical exploration revealed a laceration of the superficial femoral artery and a disruption of the femoral vein. Vascular damage control was achieved by a general surgeon and consisted of primary repair of the superficial femoral artery injury and venous ligation. The patient was discharged from the intensive care unit after 2 days and from the hospital after 8 days. This case illustrates some of the persistent challenges shared between military and civilian trauma care. The external control of junctional hemorrhage is not easily achievable in the field, and junctional tourniquets have been therefore incorporated in the Tactical Combat Casualty Care guidelines. French lyophilized plasma was used for massive transfusion because it has been proven to be a logistically superior alternative to fresh-frozen plasma. Management of vascular wounds by nonspecialized surgeons is a complex situation that requires vascular damage-control skills; French military surgeons therefore follow a comprehensive structured surgical training course that prepares them to manage complex penetrating trauma in austere environments. Finally, in this case, lessons learned on the battlefield were applied to the benefit of the patient.

The authors present here a case of a pharmacobezoar after drug overdose, diagnosed using multiple blood samples for TDM. This grand round highlights the importance of a dialog between a clinician and a TDM consultant for the optimal care of a patient.

As an aerosol and droplets generating procedure, tracheostomy increases contamination risks for health workers in the coronavirus disease context. To preserve the health care system capacity and to limit virus cross‐transmission, protecting caregivers against coronavirus infection is of critical importance. We report the use of external fixator equipment to set up a physical interface between the patient's neck and the caregiver performing a tracheostomy in COVID‐19 patients. Once the metal frame set in place, it is wrapped with a single‐use clear and sterile cover for surgical C‐arm. This installation is simple, easy, and fast to achieve and can be carried out with inexpensive material available in every hospital. This physical interface is an additional safety measure that prevents the direct projection of secretions or droplets. It should, of course, only be considered as a complement to strict compliance with barrier precautions and personal protective equipment.

BackgroundThe 7th Airborne Forward Surgical Team (FST) has deployed to Chad in 2015 and 2016, in support of French military forces. Humanitarian surgical care is known to represent a significant part of the surgical activity in such missions, but to date limited data have been published on the subject.MethodsAll surgical patients from a civilian host population treated by the FST during these missions have been prospectively included. Indications, operative outcomes and postoperative outcomes were evaluated.ResultsDuring this period, the FST operated on 358 patients. Humanitarian surgical care represented 95% of the activity. Most patients (92.7%) were operated for elective surgery. Emergencies and infectious diseases represented, respectively, 7.3% and 9.1% of cases. The mean length of stay (LOS) was three days (2–4), and the median follow-up was 30 days (22–34). Mortality rate was 0.6% and morbidity was 5.6%. Parietal surgery had no significant complication and had shorter LOS (pConclusionsHumanitarian surgical care can be provided without compromising the primary mission of the medical forces. Close surveillance and follow-up allowed favourable outcomes with low morbidity and mortality rates. Humanitarian care is responsible for a considerable portion of the workload in such deployed surgical teams. Accounting for humanitarian care is essential in the planning and training for such future medical operations.

In a French prison, most inmates reported not being satisfied with their sleep. Life habits between good and bad sleepers were not significantly different except for television and smoking. The most frequently reported symptom of insomnia was several awakenings at night, and the most frequently cited etiologies were rumination of thoughts and noise. Most patients reported that their sleeping problems began or worsened after incarceration. A quarter of the inmates were following a hypnotic treatment, and most of these treatments began in prison. Only 42% of patients were satisfied with its effectiveness. These observations enabled us to make recommendations for healthy sleep patterns such as respecting normal night-and-day cycles, encouraging to stop smoking, and promoting appropriate use of hypnotic treatments.

Helicobacterpylori is one of the most prevalent pathogens colonizing 50% of the world’s population and causing gastritis and gastric cancer. Even with triple and quadruple antibiotic therapies, H. pylori shows increased prevalence of resistance to conventional antibiotics and treatment failure. Due to their pore-forming activity, antimicrobial peptides (AMP) are considered as a good alternative to conventional antibiotics, particularly in the case of resistant bacteria. In this study, temporin-SHa (a frog AMP) and its analogs obtained by Gly to Ala substitutions were tested against H. pylori. Results showed differences in the antibacterial activity and toxicity of the peptides in relation to the number and position of D-Ala substitution. Temporin-SHa and its analog NST1 were identified as the best molecules, both peptides being active on clinical resistant strains, killing 90–100% of bacteria in less than 1 h and showing low to no toxicity against human gastric cells and tissue. Importantly, the presence of gastric mucins did not prevent the antibacterial effect of temporin-SHa and NST1, NST1 being in addition resistant to pepsin. Taken together, our results demonstrated that temporin-SHa and its analog NST1 could be considered as potential candidates to treat H. pylori, particularly in the case of resistant strains.

Background Intraoperative photography is used extensively for communication, research, or teaching. The objective of the present work was to define, using a standardized methodology and literature review, the best technical conditions for intraoperative photography. Materials and methods Using either a smartphone camera, a bridge camera, or a single-lens reflex (SLR) camera, photographs were taken under various standard conditions by a professional photographer. All images were independently assessed blinded to technical conditions to define the best shooting conditions and methods. Results For better photographs, an SLR camera with manual settings should be used. Photographs should be centered and taken vertically and orthogonal to the surgical field with a linear scale to avoid error in perspective. The shooting distance should be about 75 cm using an 80–100-mm focal lens. Flash should be avoided and scialytic low-powered light should be used without focus. The operative field should be clean, wet surfaces should be avoided, and metal instruments should be hidden to avoid reflections. For SLR camera, International Organization for Standardization speed should be as low as possible, autofocus area selection mode should be on single point AF, shutter speed should be above 1/100 second, and aperture should be as narrow as possible, above f/8. For smartphone, use high dynamic range setting if available, use of flash, digital filter, effect apps, and digital zoom is not recommended. Conclusions If a few basic technical rules are known and applied, high-quality photographs can be taken by amateur photographers and fit the standards accepted in clinical practice, academic communication, and publications.

Cervical cancer is among the leading causes of death in women. Chemotherapy options available for cervical cancer include highly cytotoxic drugs such as taxol, cisplatin, 5-florouracil, and doxorubicin, which are not specific. In the current study, we have identified a new peptide conjugate (Fur4-2-Nal3-Ala2-Phe1-CONH2) (conjugate 4), from screening of a small library of tripeptide-conjugates of furan, as highly potent anticancer compound against human cervical cancer cells (HeLa cells) (IC50 = 0.15 &plusmn, 0.05 &micro, g/mL or 0.28 +/&minus, 0.09 &micro, M). Peptides were constructed on Rink amide resin from C- to N-terminus followed by capping by &alpha, furoic acid moiety. The synthesized peptides were purified by recycling RP-HPLC, and structures of all the peptides were confirmed by using FABMS/ESIMS, 1H- NMR, 13C-NMR, and HR-FABMS. Conjugate 4 was furthermore found to be specifically active against human cervical cancer cells since it did not inhibit the proliferation of other human normal cells (HUVEC (human umbilical vein endothelial cells) and IMR-90 (normal human fibroblasts)), and cancer cells tested (HUVEC, MCF-7, and MDA-MB-231 cells), as well as in mice 3T3 cells (normal fibroblasts). This study revealed a good structure activity relationship of various peptide conjugates. Conjugate 4 in branched forms (4a and 4b) were also synthesized and evaluated against HeLa cells, and results revealed that both were inactive. Atomic force microscopy (AFM) studies and staining with rhodamine 123 and propidium iodide (PI) revealed that conjugate 4 possesses a membranolytic effect and causes the loss of mitochondrial membrane potential.

Aim To report the results of surgery for obstructive right colon cancer (ORCC) and to identify risk factors associated with worse outcomes that may help surgeons to choose the best surgical option. Methods This is a retrospective national cohort study, including all patients operated on for ORCC from 2000 to 2015. Those treated with colonic stent or symptomatic treatment were excluded. We described outcomes after surgery for ORCC and performed multivariate analyses for mortality, morbidity and survival. Results Among 776 patients analyzed, 716 (92%) had their primary tumor removed, with primary anastomosis in 582 (82%). The remaining 194 underwent anastomosis with loop ileostomy (n = 21), resection with double-end stoma (n = 113), defunctioning stoma without resection (n = 48) and ileocolic by-pass (n = 12). Postoperative mortality, morbidity and anastomotic leak rates were 10%, 51% and 14%, respectively. In multivariate analysis, age >70, ASA score ≥3 and hemodynamic instability were predictors of postoperative mortality whereas ASA score ≥3, hemodynamic instability and intra-operative complications were predictors of severe morbidity. No factors were correlated with anastomotic leak. After a median follow-up of 26 months, 8% of patients were alive with a permanent stoma. Five-year overall, disease-free and cancer-specific survival was 42%, 42% and 62%, respectively. In multivariate analysis, peritonitis, synchronous metastases and absence of adjuvant chemotherapy were predictors of decreased overall survival. Conclusions Emergency surgery for ORCC is associated with high mortality and morbidity. Two third of patients with ORCC can be managed with resection and primary anastomosis. For high-risk patients, a staged surgical management may be discussed.

In terrorist attacks and industrial catastrophes, management of a massive afflux of wounded must adhere to logistic imperatives while at the same time taking into account basic traumatology principles. This implies a firm, unequivocal, and precise doctrine for all stages of care. Medical and surgical triage allows a logical classification of victims according to severity of injury, the necessity of treatment and the degree of urgency. Triage should be early, dynamic, and lead to a categorization that optimally utilizes resources while ensuring efficient management.

Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment. Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified. In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval

Introduction The French army has been deployed in Mali since January 2013 with the Serval Operation and since July 2014 in the Sahel-Saharan Strip (SSS) with the Barkhane Operation where the distances (up to 1100 km) can be very long. French Military Medical Service deploys an inclusive chain from the point of injury (POI) to hospital in France. A patient evacuation coordination cell (PECC) has been deployed since February 2013 to organise forward medical evacuation (MEDEVAC) in the area between the POI and three forward surgical units. The purpose of this work was to study the medical evacuation length and duration between the call for Medevac location accidents and forward surgical units (role 2) throughout the five million square kilometers French joint operation area. Materials and methods Our retrospective study concerns the French patients evacuated by MEDEVAC from February 2013 to July 2016. The PECC register was analysed for patients’ characteristics, NATO categorisation of gravity (Alpha, Bravo or Charlie who must be respectively at hospital facility within 90 min, 4 h or 24 h), medical motive for MEDEVAC and the time line of each MEDEVAC (from operational commander request to entrance in role 2). Results A total of 1273 French military were evacuated from February to 2013 to July 2016; 533 forward MEDEVAC were analysed. 12,4% were Alpha, 28,1% Bravo, 59,5% Charlie. War-related injury represented 18,2% of MEDEVAC. The median time for Alpha category MEDEVAC patients was 145 min [100–251], for Bravo category patients 205 min [125–273] and 310 min [156–669] for Charlie. The median distance from the point of injury to role 2 was 126 km [90–285] for Alpha patients, 290 km [120–455] km for Bravo and 290 km [105–455] for Charlie. Conclusions Patient evacuation in such a large area is a logistic and human challenge. Despite this, Bravo and Charlie patients were evacuated in NATO recommended time frame. However, due to distance, Alpha patients time frame was longer than this recommended by NATO organisation. That’s where French doctrine with forward medical teams embedded in the platoons is relevant to mitigate this distance and time frame challenge.

Persistent blood flow in aneurysmal sac after bypass-exclusion is well documented in the literature. Aneurysm enlargement, local compressive symptoms and even sac rupture are commonly described complications. Late secondary infection of popliteal artery aneurysm (PAA) following ligation and venous bypass is exceptional. We report the case of late PAA infection six years after bypass-exclusion in a 75 year-old man which was diagnosed by 18F-FDG PET/CT. The patient was successfully treated by aneurysm resection and antibiotics. The diagnosis of popliteal aneurysm infection is often clinical, echographic and sonographic, but computed tomography scan can be false negative in chronic low-grade infection. 18F-FDG PET/CT is able to accurately diagnose and localize infection with high sensibility and specificity.

Uterine fibromyomata in Africa, which represents the most frequent benign uterine disease, is a real public health. This pathology is frequent and most of times discovered at a late stage where the volume of the uterus is responsible for invalidating symptoms that impairs patients' quality of life. Subtotal hysterectomy, which preserves the cervix, is faster than total hysterectomy and reduces intraoperative (duration of operation, blood loss) and postoperative morbidity (urinary infection, vaginal cicatrization). Subtotal hysterectomy is adapted to countries with limited resources. Its realization requires the preoperative assessment of normal cervix and a regular post-operative follow-up of the cervix left in place.

The Seventh Airborne Forward Surgical Team (FST) has been deployed in Gao, Mali, and in Bangui, Central African Republic (CAR), for two 3-month periods in 2014. The initial role of the FST was to provide emergent care to French and coalition soldiers but it was expanded to include humanitarian assistance. The aim of the present study was to describe and compare injuries and surgical activity of the Seventh Airborne FST during these two conflicts.All surgical patients treated by the FST between January and December 2014 have been included. Patient demographics, mechanisms of injury, surgical management including triage categories and types of surgery performed and evacuation modalities were recorded.During the 6-month deployment period in 2014, the FST performed 129 operations on 134 patients, 61 of which were trauma patients (45 battle injuries (BI)). The remaining 73 patients were treated as part of the humanitarian mission. Thirty of the BI were managed during the Malian conflict and 15 in CAR; 29 patients (64%) were military. The median Injury Severity Score (range) was 20 (10-34) in Mali and 8 (5-21) in CAR with median (range) evacuation time of 390 min (240-947) in Mali and 120 min (60-120) in CAR (p0.0001). The most frequent mechanisms of injury were gunshot wounds in Mali (15/30) and road traffic accident in CAR (7/15). Extremity injuries were most common (58%) with head, face and neck injuries and thoracic injuries in 15% of cases each and 12% had suffered abdominopelvic injuries. Ten patients were categorised as T1 and underwent urgent surgery, five had damage control surgery and four received transfusion. The average length of stay was 2 days (1-2), with most patients being transferred to another hospital.Casualties from Mali and CAR presented with a wide variety of injury patterns, and there were some instances where damage control surgery and whole blood transfusion were necessary. Surgical equipment scales must allow treatment of a large variety of injuries including all body regions and extreme emergency procedures. These two conflicts differ in terms of scope, one being an urban guerrilla and the other an open conflict in a large desertic area. Long distances in the Malian desert increase significantly the evacuation time. It has to be taken into account in the FST location when coalition forces are deployed in such places.

Pancreatic neuroendocrine tumors (PNET) locally advanced may lead to significant local symptoms especially segmental portal hypertension (SPH) with risk of bleeding. The aim of our study was to evaluate the role of SPH on the PNET management in an expert center. Forty-two patients treated for locally advanced PNET with SPH between January 1984 and December 2012 were retrospectively analyzed. The median age was 55 years (25–75). The median tumor size was 7.5 cm (3–20). Thirty four (80.9 %) patients were metastatic mainly in the liver (n = 33, 79 %) with a frequent (n = 16, 38.1 %) involvement >20 %. The surgery was impossible because of SPH in 7 (16.6 %) cases. Pancreatic resection was performed in 28 (66.7 %) cases by distal pancreatectomy. Neoadjuvant chemotherapy (n = 24, 57 %) had no impact on SPH with no modification of collateral circulation. Among operated on patients, complete macroscopic resection was obtained in 19 (67.8 %) patients. The mortality and severe morbidity rate was respectively 3.6 and 18 %. Five year overall survival (OS) was similar in operated and no operated patients. (61 %; p = 0.64). The 5-year OS was 77.9 or 55.4 % in patients who underwent a complete or incomplete macroscopic resection of primary and metastases, respectively. PNET resection associated with SPH is feasible with a low morbimortality. SPH was not improved by chemotherapy. Prolonged survival was observed after complete macroscopic resection.

The scope of this study was to analyze the content of prenatal care in São Luís, Maranhão, Brazil, and the factors associated with its inadequacy. A cross-sectional study was conducted based on data from the birth cohort of São Luís in 2010. The content of prenatal care was defined as inadequate when it did not meet the criteria of the Program for Humanization of Prenatal and Delivery Care, which establishes early initiation of prenatal care, minimum number of medical consultations, basic laboratory tests, tetanus vaccination and obstetric procedures. Poisson regression was used to observe associations of the variables with the outcome. The inadequacy rate was high (60.2%). The variables associated with inadequacy were: class C socioeconomic status (PR = 1.39; CI = 1.26-1.55); class D/E socioeconomic status (PR = 1.60; CI = 1.43-1.79); unqualified/unemployed mother (PR = 1.24; CI = 1.11-1.37); 5-8 years of schooling (PR = 1.12; CI = 1.06-1.19); 0-4 years of schooling (PR = 1.13; CI = 1.01-1.26); not being religious (PR = 1.10; CI = 1.04-1.17); alcohol use during pregnancy (PR = 1.13; CI = 1.06-1.20), and being attended by the public service (PR = 1.75; CI = 1.54-2.00). The results showed inadequacy and inequality of prenatal care, revealing that women of lower socioeconomic status received lower quality care.

Importance Central pancreatectomy, as an alternative to standard resection for benign and low-grade pancreatic neoplasms, has been described in mainly small retrospective series. Objective To describe a large single-center experience with central pancreatectomy. Design, Setting, and Participants A retrospective case series in a tertiary referral center included 100 consecutive patients undergoing central pancreatectomy with pancreaticogastrostomy from January 1, 2000, to March 1, 2012. Main Outcomes and Measures Surgical indications, postoperative morbidity, mortality, and long-term outcomes regarding pancreatic function and recurrence. Results Central pancreatectomies were performed mainly for neuroendocrine tumors (35%), intraductal papillary mucinous neoplasms (33%), solid pseudopapillary neoplasms (12%), and mucinous cystadenomas (6%). The postoperative mortality rate was 3% (due to pulmonary embolisms in 2 patients and hemorrhage after pancreatic fistula in 1 patient). Clavien-Dindo III or IV complications occurred in 15% of patients and were due mainly to pancreatic fistula, requiring 10 radiologic drainage procedures, 7 endoscopic procedures, and 6 reoperations overall. After a median follow-up of 36 months, the rates of new-onset exocrine and endocrine insufficiency were 6% and 2%, respectively. Overall, 7 lesions could be considered undertreated, including 3 node-negative R0 microinvasive intraductal papillary mucinous neoplasms (without recurrence at 27, 29, and 34 months) and 4 node-positive neuroendocrine tumors (with 1 hepatic recurrence at 66 months). Among the 25 patients with a doubtful preoperative diagnosis, 9 could be considered overtreated (ie, operated on for benign nonevolutive asymptomatic lesions). Conclusions and Relevance Central pancreatectomy is associated with an excellent pancreatic function at the expense of a significant morbidity and a non-nil mortality rate, underestimated by the published literature. The procedure is best indicated for benign or low-grade lesions in young and fit patients who can sustain a significant postoperative morbidity and could benefit from the excellent long-term results.

Penetrating chest trauma is common but few need surgical treatment (10-20%). The mortality of gunshot wounds of the heart is 45%, among the wounded arriving at the hospital. The suspicion of wound heart with an inlet in the heart area (limited by costal awnings down, clavicles top, and mid-clavicular line outside) and pericardial effusion remains a surgical indication. Gunshot wounds of the heart with migration of the projectile in the pulmonary artery are rare. Migration of projectile into the pulmonary artery is described most often with lesions of peripheral veins without concomitant cardiac involvement. The indication of projectile extraction is not clearly defined in the literature. Conservative management of selected cases of pulmonary artery bullet emboli may be warranted in light of the risks of extraction.

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.

International audience; Monitoring cytomegalovirus circulating viral load is an important parameter of the follow-up in immunocompromised patients. It can be measured either by DNAemia or by pp65 antigenemia. The French national reference center for cytomegaloviruses organized an investigation of practice in 37 teacher hospital virology laboratories to assess the situation in France in 2010.MethodsA questionnaire was sent to collect following information: method used in routine for monitoring of circulating viral load of CMV, assay used, sample matrix and extraction method.ResultsThirty-six over thirty-seven laboratories filled the questionnaire. Among these, 67% used the quantitative PCR in routine, 11% antigenemia and 22% antigenemia or quantitative PCR; 87% of the laboratories use whole blood for quantitative PCR, whereas 10% and 3% use plasma and leukocytes respectively. Among the laboratories using DNAemia, 100% used real-time PCR assays, 91% use an automated extraction and 9% a manual extraction.ConclusionThus in France, measurement of DNAemia by real-time PCR is a tool, which gradually replaces the antigenemia for the monitoring of cytomegalovirus infection among immunocompromised patients. The very great diversity of the methods used justifies the installation of a national quality control on total blood, matrix used by 87% of the laboratories.; La surveillance de la charge virale sanguine du cytomégalovirus est un paramètre important de la prise en charge des patients immunodéprimés. Elle est mesurée soit par l’ADNémie soit par l’antigénémie. Le Centre national de référence des cytomégalovirus a organisé une enquête de pratique auprès des laboratoires de CHU pour connaitre la situation en France en 2010.MéthodeUn questionnaire a été distribué pour recueillir les informations suivantes: la méthode utilisée pour la surveillance de la charge virale circulante et la technique utilisée, la matrice utilisée et la méthode d’extraction.RésultatsTrente-six sur trente-sept laboratoires ont répondu; 67% utilisent la PCR quantitative, 11% l’antigénémie et 22% l’antigénémie ou une PCR quantitative; 87% des laboratoires utilisent du sang total comme matrice pour la PCR quantitative, alors que 10% et 3% utilisent le plasma et les leucocytes respectivement. Parmi les laboratoires qui utilisent la PCR quantitative ou l’antigénémie: 91% utilisent une extraction automatisée et 9% une extraction manuelle.ConclusionAinsi en France, la mesure de l’ADNémie par des méthodes de PCR en temps réel est un outil qui remplace progressivement l’antigénémie pour la surveillance de l’infection à cytomégalovirus chez les patients immunodéprimés. La grande diversité des méthodes utilisées justifie la mise en place d’un contrôle de qualité national sur sang total, qui est la matrice la plus utilisée.

Monitoring cytomegalovirus circulating viral load is an important parameter of the follow-up in immunocompromised patients. It can be measured either by DNAemia or by pp65 antigenemia. The French national reference center for cytomegaloviruses organized an investigation of practice in 37 teacher hospital virology laboratories to assess the situation in France in 2010.A questionnaire was sent to collect following information: method used in routine for monitoring of circulating viral load of CMV, assay used, sample matrix and extraction method.Thirty-six over thirty-seven laboratories filled the questionnaire. Among these, 67% used the quantitative PCR in routine, 11% antigenemia and 22% antigenemia or quantitative PCR; 87% of the laboratories use whole blood for quantitative PCR, whereas 10% and 3% use plasma and leukocytes respectively. Among the laboratories using DNAemia, 100% used real-time PCR assays, 91% use an automated extraction and 9% a manual extraction.Thus in France, measurement of DNAemia by real-time PCR is a tool, which gradually replaces the antigenemia for the monitoring of cytomegalovirus infection among immunocompromised patients. The very great diversity of the methods used justifies the installation of a national quality control on total blood, matrix used by 87% of the laboratories.

The hemangioma of the adrenal gland is an adrenal gland lesion rare, benign and usually asymptomatic. Discovered incidentally during an abdominal imaging study, it is part of incidentalomas. Imagery is the best to characterise these silent adrenal masses (computed tomography [CT], Magnetic Resonance Imaging [MRI]± Positron Emission Tomography [PET scan] with 18F-FDG). The main risks of the hemangioma are ignorance of malignancy, bleeding and abdominal mass syndrome. The analysis of the literature shows the importance of laparoscopy. A multidisciplinary discussion on this type of lesion appears indispensable both diagnostic and therapeutic.

The objective of this study is to validate the use of test INNO-LIPA HPV Genotyping Extra (Innogenetics) on liquid cytology media EasyFix Labonord by comparing the extraction kit QIAamp DNA Blood Mini Kit (Qiagen) and an automated method, Nuclisens easyMAG (Biomérieux).Thirty-two samples were typed by the technique Hybrid Capture 2 (HC2) Digene (Qiagen). DNA was extracted through manual or automated extraction and quality controlled PCR "HLA". Typing was performed with the INNO-LIPA test. A nested PCR followed by sequencing was used to compare different results.Similar results were found for the two types of extraction, with an increase of sensitivity after automated extraction. Among the nine patients with a negative result with the HC2 test, seven had a negative result in INNO-LIPA and two a positive result (one untypable and one HPV66). On the 23 patients with a positive result with the HC2 test, 17 are consistent results. The six discordant results include one negative, one HPV54, two untypable HPV and two HPV53. The overall concordance between the HC2 and INNO-LIPA tests is 81% with a kappa test of 0.79.Coupled with an automated extraction, the test INNO-LIPA confirmed its high sensitivity for detecting and typing HPV in the EasyFix media Labonord, especially in the presence of multiple genotypes. This typing systematic approach is becoming increasingly relevant in the context of HPV vaccination.

Specific immunotherapy involves the administration of allergen extracts to achieve clinical tolerance of the allergens which cause symptoms in patients with allergic conditions. Immunotherapy has been shown to be effective in patients with mild forms of allergic diseases, specially in upper airway diseases. Recent studies suggest that specific immunotherapy may also modify the course of allergic disease, by reducing the risk of developing new allergic sensitizations, and also inhibiting the development of clinical asthma in children treated for allergic rhinitis. The traditional subcutaneous route is burdened with the risk of severe adverse events, therefore, local routes have been investigated and developed. The sublingual route is supported by numerous controlled trials showing its efficacy in rhinitis. The safety profile, assessed in clinical trials studies, is satisfactory. Several points still need to be elucidated, including mechanisms of action, optimal dosage, cost-effectiveness, and adherence. New approaches using mimic bacterial DNA vaccines alone or associated to modified allergen, which enhances immunogenicity in terms of eliciting a Th1-type response vaccines, are also undergoing serious consideration.

Lung scintigraphy provides a regional, functional test of pulmonary ventilation and perfusion. It allows an early detection of pulmonary damage or dysfonction, in particular in cystic fibrosis (CF) and other chronic obstructive pulmonary disease (COPD) in childhood.We report two cases in children suffering from CF and COPD (of undefined aetiology), who had a major localized ventilation disorder. They have been detected by lung scintigraphy before the development of clinical or radiological symptoms. An obstructive bronchial cast in the corresponding lobar bronchus was then revealed and withdrawn by bronchial fiberscopy.Lung scintigraphy allows early detection of local pulmonary abnormalities, sometimes undetectable with a chest X-ray or even with a chest tomodensitometry. It can reveal bronchial obstructive plugs, avoiding thus the development of bronchectasies thanks to a quick suitable treatment.

Active aortic endocarditis is a serious condition that carries a high mortality and morbidity. The aim of this study was to analyse results obtained from 24 patients who underwent aortic valve or root replacement with cryopreserved homograft for aortic endocarditis. Eleven patients had native valve endocarditis, and 13 had prosthetic valve endocarditis. The mean age was 47.7 years: there were seven women and 17 men. Causative organisms were staphylococci (12), streptococci (four), serratia (one), candida (one), pneumococci (one), while no organisms were isolated in the remaining five patients. Complete reconstruction of the aortic annulus with homograft conduits was necessary in 20 patients (six total root and 14 mini-root). Infracoronary homograft aortic valve replacement was performed in the remaining patients. One patient died 1 day after the operation from ventricular failure, and two others died after 4 and 6 months as a result of arrhythmia. One patient died of recurrent endocarditis 1 year after surgery. The actuarial survival rate at 3 years was 83.4%. All survivors are symptom-free, with no evidence of recurrent endocarditis. Doppler echocardiography showed minimal aortic regurgitation in four patients.

Infected aortic aneurysms represent 0.85 to 1.3% of aortic aneurysms. Most often, the implicated bacteria species are Salmonella sp., Staphylococcus sp. and Streptococcus sp. Brucella-related infected aortic aneurysms are very rare. Most often, they result from endocarditis or from a local septic focus. Combined treatment by antibiotics and surgery is the standard for infectious aneurysms. In the absence of formal factual data, the surgical treatment is still discussed in the literature, especially since endovascular treatments have been in full expansion. We are reporting the case of a female patient presenting with a Brucella-related infra-renal abdominal aortic aneurysm, without primitive infectious source (area) or identified endocarditis. Surgical treatment with in situ prosthetic replacement and omentoplasty in association with adapted antibiotics allowed a favorable outcome with an excellent result after an 8-year follow up.

In conjunction with biopsy and Doppler studies, we analysed by high resolution proton NMR spectroscopy the blood plasma of 22 heart transplant recipients. There was a significant variation in the glycosylated residues of proteins with the development of acute cardiac rejection. A more extensive study is underway to assess the sensitivity and specificity of this approach for the early diagnosis of acute cardiac rejection.

In a previous study, the authors developed a technique for evaluating the in vitro susceptibility (or resistance) of Candida albicans to fluconazole, using casitone broth and agar. Photometric readings of growth in liquid media proved more accurate for evaluating antifungal activity and consistently agreed with clinical findings in all studied cases. This method was consequently extended from C. albicans to other yeasts recovered from high-risk patients (C. glabrata, C. famata, C. tropicalis, C. krusei, C. pseudotropicalis, C. parapsilosis, etc...). High resolution antifungal assay medium (broth and agar) and casitone medium (broth and agar) with or without agitation (Autobac System) were used to study the activity of fluconazole against approximately one hundred yeast strains. MICs above 3.12 micrograms/ml were found for several strains, particularly belonging to the C. glabrata and C. krusei species. These values are equal to or greater than serum levels achieved during treatment with fluconazole, a fact which raises practical questions concerning fluconazole therapy and may explain the failure of fluconazole to eradicate yeasts in some patients.

Between 1980 and 1989, 8 patients (5 men, 3 women; mean age 30 years) were operated upon in our department of right-sided infective endocarditis. Six patients were heroin addicts and among these 3 were HIV positive and 2 had confirmed AIDS. The most frequently encountered microorganisms (6 cases) were staphylococci. It was decided to operate because of persistent infection and haemodynamic deterioration. The infection involved the pulmonary valve in only 1 of the 8 patients. Surgery was performed during the acute phase in 5 patients and was conservative in 6 patients, consisting of excision of the vegetations or valvulectomy combined or not with valvuloplasty. A high mortality rate (3/8 cases) was observed only among patients operated upon in the acute phase. This may be due to the underlying immunodeficiency and poor haemodynamic state of these patients. Among survivors, the long-term results were excellent, with no recurrent endocarditis and no death, and with only one subsequent operation, 4 years after the first one, for residual tricuspic valve regurgitation. This study shows that patients with right-sided infective endocarditis should be operated upon outside the acute phase of the disease and as soon as complications appear, and that surgery should preferably be conservative.

It is generally recognized that dental injury during and after tracheal intubation is a significant problem. Damage may occur during oro-tracheal intubation, oral endoscopy or seismotherapy. The incidence was reported in a study conducted in the contentious department of Lyon hospitals, in France, from 1978 to 1988. Results confirm that damage is relatively common and that the majority of damaged teeth (67%) were known to have been previously restored, or weakened through periodontal disease prior to the damage occurring. Maxillary incisors were the most frequently injured teeth. Fracture of crowns and roots of natural teeth (44,8%), followed by partial luxation (20,8%) and avulsion (20,8%) were the most common injury. Several cases are presented which reveal the clinical value of dental damages that occur during orotracheal intubation, oral endoscopy or seismotherapy. Besides dental or gingival complications can appear immediately but also after a few days or weeks. Some of the most recent development in dental therapy such as the butterfly bridge, titanium implants and porcelain laminate veneers are described. Tooth protective guards must be put into widespread use. Legal implications of dental lesions occurring during oro-tracheal intubation, oral endoscopy or seismotherapy are presented.

This article describes two patients with artificial heart valves who suffered thromboembolytic complications during circulatory assistance using a Biomedicus centrifugal pump. The first case involved a 25-year-old man who presented acute blockage of a mechanical aortic valve. Emergency surgery was performed to replace this valve with a bioprosthesis. Postoperatively the patient developed severe left heart insufficiency and a Biomedicus centrifugal pump was placed between the left atrium and the ascending aorta. After 3 days of total left ventricular assistance, weaning was started and successfully completed with explanation on the 5th day. Two days later the patient died of multiple coronary embolism with thrombosis of the valve. The second case involved a 30-year-old man. Six months before, he underwent surgical procedure with placement of Bio-prosthesis for dissecting aortic aneurysm due to annuloectasia. Upon admission for terminal dilated myocardiopathy, the patient was in kidney failure almost requiring dialysis. Because of this patient's size (Marfan syndrome), no donor heart was immediately available and left circulatory assistance with a Biomedicus pump had to be initiated. The patient lived without mechanical ventilation, in good clinical condition until day 23 when he presented acute right heart failure due to extensive valvular and coronary thrombosis. From these two cases, several important comments can be made about anticoagulation therapy, partial unloading of left ventricle, or need for biventricular assistance, and efficiency of centrifugal devices in these clinical applications.

Antifungal agents associations are widely used in therapy of deep mycotic diseases, particularly amphotericin B-5-fluorocytosine association. Synergistic effect has also been described between 5-fluorocytosine and imidazole derivates. The authors have tested here eventual synergy between 5-fluorocytosine and imidazole derivatives (miconazole, ketoconazole, fluconazole, itraconazole) against 57 years isolates resistant to 5-fluorocytosine by a semi-automated methods in liquid medium (Yeast Nitrogen Base and Brain Heart Infusion). The synergistic effect between 5-fluorocytosine and antifungal imidazoles varies widely with the drug tested. It's more frequent with ketoconazole. Itraconazole and fluconazole present very little synergistic effects in vitro.