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Background Therapeutic failure is a frequent issue in the management of post-operative peritonitis. Objectives A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients. Patients and methods Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses. Results Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17–3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05–8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03–1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36–11.49) and diabetes (OR 6.95; 95% CI 1.34–36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13–3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02–5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21–7.01). No specific risk factors were identified for microbiological failure. Conclusions Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.

Aim In modern warfare, almost 25% of combat-related deaths are considered preventable if life-saving interventions are performed. Therefore, Tactical Combat Casualty Care (TCCC) training for soldiers is a major challenge. In 2014, the French Military Medical Service supported the development of 3D-SC1®, a serious game designed for the French TCCC program, entitled Sauvetage au Combat de niveau 1 (SC1). Our study aimed to evaluate the impact on performance of additional training with 3D-SC1®. Material and methods The study assessed the performance of soldiers randomly assigned to one of two groups, before (measure 1) and after (measure 2) receiving additional training. This training involved either 3D-SC1® (Intervention group), or a DVD (Control group). The principal measure was the individual performance (on a 16-point scale), assessed by two investigators during a hands-on simulation. First, the mean performance score was compared between the two measures for Intervention and Control groups using a two-tailed paired t-test. Second, a multivariable linear regression was used to determine the difference in the impacts of 3D-SC1® and DVD training, and the order of presentation of the two scenarios, on the mean change from baseline in performance scores. Results and discussion A total of 96 subjects were evaluated: seven could not be followed-up, while 50 were randomly allocated to the Intervention group, and 39 to the Control group. Between measure 1 and measure 2, the mean (SD) performance score increased from 9.9 (3.13) to 14.1 (1.23), and from 9.4 (2.97) to 12.5 (1.83), for the Intervention group and Control group, respectively (p

Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills.Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n =10] or after a night of rest [rested (R) group, n =10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists' non-technical skills (ANTS) assessed by two blinded evaluators.Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5-13)] compared with the R group [14.5 (14-15), P0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills.In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario.NCT02622217.

BACKGROUND Out-of-hospital cardiac arrest (OHCA) remains associated with very high mortality. Accelerating the initiation of efficient cardiopulmonary resuscitation (CPR) is widely perceived as key to improving outcomes. The main goal was to determine whether identification and activation of nearby first responders through a smartphone application named Staying Alive (SA) can improve survival following OHCA in a large urban area (Paris). METHODS We conducted a nonrandomized cohort study of all adults with OHCA managed by the Greater Paris Fire Brigade during 2018, irrespective of mobile application usage. We compared survival data in cases where SA did or did not lead to the activation of nearby first responders. During dispatch, calls for OHCA were managed with or without SA. The intervention group included all cases where nearby first responders were successfully identified by SA and actively contributed to CPR. The control group included all other cases. We compared survival at hospital discharge between the intervention and control groups. We analyzed patient data, CPR metrics, and first responders' characteristics. RESULTS Approximately 4,107 OHCA cases were recorded in 2018. Among those, 320 patients were in the control group, whereas 46 patients, in the intervention group, received first responder-initiated CPR. After adjustment for confounders, survival at hospital discharge was significantly improved for patients in the intervention group (35% vs. 16%, adjusted odds ratio = 5.9, 95% confidence interval = 2.1 to 16.5, p

Background Postpartum haemorrhage (PPH) remains the leading cause for maternal mortality worldwide. Hypofibrinogenaemia has been identified as a major risk factor for progress towards severe PPH. The efficacy of fibrinogen concentrate supplementation in PPH has been shown in various clinical settings but the level of evidence is not sufficient to prove the benefit, evaluate the risks, and determine the value, timing and dose of fibrinogen supplementation in PPH. The FIDEL trial objective is to evaluate the impact of a therapeutic strategy based on the early administration of human fibrinogen concentrate compared to the current practice based on late administration in severe PPH patients requiring second line uterotonics. Methods/design This is a prospective multicentre, randomised, double-blind, placebo-controlled trial. A total of 412 patients will be randomised if they meet the following criteria: female patients ≥ 18 years old, vaginal delivery, PPH requiring IV administration of prostaglandins (sulprostone) after 20 to 30 minutes of oxytocin failure. The participants are assigned to receive either fibrinogen 3 g or placebo infusions. The primary endpoint is a composite endpoint defined as the percentage of patients losing at least 4 g/dL of Hb, and/or requiring a transfusion of at least 2 units of packed red blood cells, within the 48 hours following fibrinogen administration. Discussion The purpose of this study is to demonstrate the efficacy and safety of an early fibrinogen concentrate infusion in uncontrolled active PPH.

Postpartum haemorrhage (PPH) is defined as blood loss >= 500 mL after a delivery and severe PPH as blood loss >= 1000 mL, regardless of the a route of delivery (professional consensus). The preventive a administration of uterotonic agents just after delivery is effective in a reducing the incidence of PPH and its systematic use is recommended, a regardless of the route of delivery (Grade A). Oxytocin is the first a line prophylactic drug, regardless of the route of delivery (Grade A); a a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM a (professional consensus).After vaginal delivery, routine cord drainage a (Grade B), controlled cord traction (Grade A), uterine massage (Grade a A), and routine bladder voiding (professional consensus) are not a systematically recommended for PPH prevention. After caesarean delivery, a placental delivery by controlled cord traction is recommended (grade B). a The routine use of a collector bag to assess postpartum blood loss at a vaginal delivery is not systematically recommended (Grade B), since the a incidence of severe PPH is not affected by this intervention. In cases a of overt PPH after vaginal delivery, placement of a blood collection bag a is recommended (professional consensus). The initial treatment of PPH a consists in a manual uterine examination, together with antibiotic a prophylaxis, careful visual assessment of the lower genital tract, a a uterine massage, and the administration of 5-10 IU oxytocin injected a slowly IV or IM, followed by a maintenance infusion not to exceed a a cumulative dose of 40 IU (professional consensus). If oxytocin fails to a control the bleeding, the administration of sulprostone is recommended a within 30 minutes of the PPH diagnosis (Grade C). Intrauterine balloon a tamponade can be performed if sulprostone fails and before recourse to a either surgery or interventional radiology (professional consensus). a Fluid resuscitation is recommended for PPH persistent after first line a uterotonics, or if clinical signs of severity (Grade B). The objective a of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8 a g/dL. During active haemorrhaging, it is desirable to maintain a a fibrinogen level >= 2 g/L (professional consensus). RBC, fibrinogen and a fresh frozen plasma (FFP) may be administered without awaiting a laboratory results (professional consensus). Tranexamic acid may be used a at a dose of 1 g, renewable once if ineffective the first time in the a treatment of PPH when bleeding persists after sulprostone administration a (professional consensus), even though its clinical value has not yet a been demonstrated in obstetric settings. It is recommended to prevent a and treat hypothermia in women with PPH by warming infusion solutions a and blood products and by active skin warming (Grade C). Oxygen a administration is recommended in women with severe PPH (professional a consensus). If PPH is not controlled by pharmacological treatments and a possibly intra-uterine balloon, invasive treatments by arterial a embolization or surgery are recommended (Grade C). No technique for a conservative surgery is favoured over any other (professional a consensus). Hospital-to-hospital transfer of a woman with a PPH for a embolization is possible once hemoperitoneum is ruled out and if the a patient's hemodynamic condition so allows (professional consensus). (C) a 2015 Elsevier Ireland Ltd. All rights reserved.

Simulation in health care helps to raise health professionals' awareness of medical ethics and to understand the mechanisms involved in a difficult situation. They can thereby adopt a suitable form of behaviour and communication.

Medical education and evaluation, for both initial and continuing medical training of healthcare professionals, is experiencing profound conceptual and technical changes in the era of the digital society and economy. Using the concepts of active and blended learning, acquisition and maintenance of knowledge, skills and attitudes (KSA) now passes through upstream work before entering the Faculty of Medicine on Internet (MOOC, SPOC, OER), restitution in flipped and contextualized classrooms to solve problems and learn to learn, and ultimately on virtual platforms using mannequins (avatars) in virtual environ- ments, without risk to patients and actors. Here we provide some examples of this revolu- tion, and their development prospects.

BACKGROUND Simulator-based teaching for coronary angiography (CA) is an attractive educational tool for medical students to improve their knowledge and skills. Its pedagogical impact has not been fully evaluated yet. OBJECTIVE The aim of this study was to compare traditional face-to-face teaching with a simulator-based teaching for the acquisition of coronary anatomy knowledge and coronary angiographies interpretation. METHODS 118 medical school students, in their 4th to 6th year, were prospectively randomized in two groups: a control teaching group (n=59, CONT group) and a simulator group (Mentice AB, Sweden) (n=59, SIM group). CONT group received a PowerPoint-based course whereas SIM group received a simulator-based course including the very same information. After the course, all students were evaluated by 40 multiple choice questions (maximum of 100 points (pts)), including questions on coronary anatomy (part1), on angiographic projections (part2) and on real coronary angiographies interpretation (part3). Satisfaction of the students was also evaluated by simple questionnaire. RESULTS Student characteristics were identical in both groups: 62/118 (52.5%) were female; age was 22.6±1.4 years. 42/118 (35.6%) were in their 4th year, 42/118 (35.6%) in 5th year and 34/118 (28.8%) in 6th year. During evaluation, SIM students had higher global scores compared to CONT students irrespective of their year of medical school (59.5±10.8pts vs. 43.7±11.3pts, P CONCLUSIONS This study suggests that simulator-based teaching could potentially improve students' knowledge in coronary anatomy, angiography projections and interpretation of real clinical cases, suggesting better clinical skills. These results should encourage further evaluation of simulator-based teaching in other medical specialties. These results should further encourage evaluations of simulator-based teaching and how they can translate into clinical practice.

Medical education and evaluation, for both initial and continuing medical training of healthcare professionals, is experiencing profound conceptual and technical changes in the era of the digital society and economy. Using the concepts of active and blended learning, acquisition and maintenance of knowledge, skills and attitudes (KSA) now passes through upstream work before entering the Faculty of Medicine on Internet (MOOC, SPOC, OER), restitution in flipped and contextualized classrooms to solve problems and learn to learn, and ultimately on virtual platforms using mannequins (avatars) in virtual environ- ments, without risk to patients and actors. Here we provide some examples of this revolu- tion, and their development prospects.

Points essentiels L’arret cardiaque chez la femme enceinte est un evenement heureusement rare, estime a 1 cas pour 20 000 grossesses par an. Il menace le pronostic vital de la mere et de son fœtus. Cet evenement expose les equipes soignantes a un stress intense auquel elles ne sont pas necessairement bien preparees. Le pronostic maternel et fœtal de l’arret cardiaque intrahospitalier survenant dans la periode du peripartum pourrait etre meilleur que celui observe en dehors de ce contexte. Quatre grandes etiologies sont impliquees : l’hemorragie, l’embolie notamment amniotique, les cardiopathies incluant les maladies de l’aorte, et le sepsis. L’etat de grossesse et les modifications physiologiques associees ont un impact sur la conduite a tenir. La reanimation cardio-pulmonaire n’a rien de specifique, hormis qu’elle doit tenter de sauver le fœtus et sa mere par la realisation d’une cesarienne dite perimortem dans les 5 premieres minutes de la survenue de l’arret circulatoire en l’absence de reprise d’une circulation spontanee. Cette intervention doit etre realisee en salle de naissance sans perdre de temps pour se rendre dans un bloc operatoire. Des techniques d’assistance circulatoire peuvent egalement etre utiles dans un second temps, ainsi qu’un management proactif du risque d’hemorragie et d’installation d’un syndrome de defaillance multiviscerale. Les equipes doivent se preparer a la survenue d’un tel accident. Des exercices de simulation, en equipe, sont utiles pour cela. La litterature obstetricale fournit des algorithmes et des checklists pour bien se preparer a la survenue de cette situation de crise.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 10 - p. 1009-1018

Simulation in health care helps to raise health professionals' awareness of medical ethics and to understand the mechanisms involved in a difficult situation. They can thereby adopt a suitable form of behaviour and communication.

Objective We report an uneventful conservative approach of an advanced abdominal pregnancy discovered at 22 weeks of gestation. Study Design This study is a case report. Results Attempting to extend gestation of an advanced abdominal pregnancy is not a common strategy and is widely questioned. According to the couple's request, the management consisted in continuous hospitalization, regular ultrasound scan, and antenatal corticosteroids. While the woman remained asymptomatic, surgery was planned at 32 weeks, leading to the birth of a preterm child without any long-term complications. Placenta was left in situ with a prophylactic embolization, and its resorption was monitored. Conclusion Depending on multidisciplinary cares and agreement of the parents, when late discovered, prolonging advanced abdominal pregnancy appears to be a reasonable option.

In developed countries, the rate of obstetric ICU admissions (admission during pregnancy or the postpartum period) is between 0.5 and 4 per 1000 deliveries and the overall case-fatality rate is about 2%. The most two common causes of obstetric ICU admissions concerned direct obstetric pathologies: obstetric hemorrhage and hypertensive disorders of pregnancy. This review summarized the principles of management of critically ill pregnant patient. Its imply taking care of two patients in the same time. A coordinated multidisciplinary team including intensivists, anesthesiologists, obstetricians, pediatricians and pharmacists is therefore necessary. This team must work effectively together with regular staff aiming to evaluate daily the need to maintain the patient in intensive care unit or to prompt delivery. Keeping mother and baby together and fetal well-being must be balanced with the need of specialized advanced life support for the mother. The maternal physiological changes imply various consequences on management. The uterus aorto-caval compression implies tilting left the parturient. In case of cardiac arrest, uterus displacement and urgent cesarean delivery are needed. The high risk of aspiration and difficult tracheal intubation must be anticipated. Even during acute respiratory distress syndrome, hypoxemia and permissive hypercapnia must be avoided due to their negative impact on the fetus. Careful analysis of the benefit-risk ratio is needed before all drug administration. Streptococcal toxic shock syndrome and perineal fasciitis must be feared and a high level of suspicion of sepsis must be maintained. Finally the potential benefits of an ultrasound-based management are detailed.

International audience; Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus).

Francia es una de las naciones europeas mas fecundas, con mas de 800.000 nacimientos anuales. No por ello se ve menos afectada por problemas de salud publica derivados de la edad cada vez mayor de las mujeres embarazadas: aumento del indice de cesareas (mas del 20%), un indice creciente de prematuridad (mas del 15% en 10 anos) y un indice de mortalidad materna constante (10/100.000 nacimientos), sobre todo debido a hemorragias posparto. Estos hechos han dado lugar a los planes nacionales de perinatalidad (el primero data de 1994) destinados a reorganizar la asistencia en red. Una consecuencia de estos planes sucesivos ha sido la concentracion de la actividad obstetrica en un numero reducido de maternidades en todo el pais (menos de 600). Al mismo tiempo, se ha seguido desarrollando la actividad de los anestesistas en estas maternidades, de lo cual una prueba es el indice mas elevado del mundo en terminos de aplicacion de la anestesia peridural para el trabajo de parto. Estos anestesistas dedicados a la obstetricia efectuan una consulta al final del embarazo de forma sistematica, con el fin de definir los riesgos anestesicos, asi como las ventajas y los inconvenientes de las tecnicas de anestesia y analgesia para el trabajo de parto, la cesarea o cualquier otro acto complementario, teniendo en cuenta las considerables modificaciones fisiologicas vinculadas al embarazo y al parto. Por ultimo, estos equipos tambien se ocupan de las complicaciones del periparto, en estrecha cooperacion con los obstetras y los pediatras. Estos aspectos fundamentales se estudiaran en su conjunto en este articulo.

Background Patients receiving anti-platelet agents for secondary cardiovascular prevention frequently require non-cardiac surgery. A substantial proportion of these patients have their anti-platelet drug discontinued before operation; however, there is uncertainty about the impact of this practice. The aim of this study was to compare the effect of maintenance or interruption of aspirin before surgery, in terms of major thrombotic and bleeding events. Methods Patients treated with anti-platelet agents for secondary prevention and undergoing intermediate- or high-risk non-cardiac surgery were included in this multicentre, randomized, placebo-controlled, trial. We substituted non-aspirin anti-platelets with aspirin (75 mg daily) or placebo starting 10 days before surgery. The primary outcome was a composite score evaluating both major thrombotic and bleeding adverse events occurring within the first 30 postoperative days weighted by their severity (weights were established a priori using a Delphi consensus process). Analyses followed the intention-to-treat principle. Results We randomized 291 patients (n=145, aspirin group, and n=146, placebo group). The most frequent surgical procedures were orthopaedic surgery (52.2%), abdominal surgery (20.6%), and urologic surgery (15.5%). No significant difference was observed neither in the primary outcome score [mean values (sd)=0.67 (2.05) in the aspirin group vs 0.65 (2.04) in the placebo group, P=0.94] nor at day 30 in the number of major complications between groups. Conclusions In these at-risk patients undergoing elective non-cardiac surgery, we did not find any difference in terms of occurrence of major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin. ClinicalTrials.gov identifier. NCT00190307.

Resume Le placenta praevia se definit comme une insertion basse du placenta qui constitue une menace d’hemorragie du post-partum. Le placenta peut etre insere plus ou moins profondement dans le myometre, selon qu’il est accreta, increta ou percreta. Le diagnostic peut etre fortuit ou de plus en plus souvent prevu par l’echographie et l’imagerie par resonance magnetique. La prise en charge des anomalies d’insertion du placenta necessite des equipes entrainees ayant notamment la possibilite d’effectuer une transfusion massive. L’hysterectomie cede chaque fois que possible la place a des traitements conservateurs avec eventuellement embolisation. La rachianesthesie est possible pour les cesariennes electives en cas de placenta praevia de localisation posterieure, n’ayant pas saigne au cours du troisieme trimestre, en l’absence de cicatrices uterines multiples, et d’aspects echographiques suspects de placenta accreta. L’anesthesie generale est indiquee dans les contextes hemorragiques, urgents, pour les placentas anterieurs, en cas de cicatrices uterines ou de suspicion de placenta accreta ou percreta.

Post-partum haemorrhage is the first cause of maternal death in France. In addition to the treatment of the cause, its treatment consists in the association of procoagulant drugs and blood transfusion. At risk situations requiring blood transfusion are well identified. However, they are not found in one third of the actually transfused patients. Therefore, for all deliveries, the medical team should be prepared to face a post-partum haemorrhage and to transfuse. As post-partum haemorrhage onset is most frequently acute, it is rare to be able to base the transfusion decision on biological parameters such as haemoglobin concentration and / or coagulation tests. The recently defined policy of early use of fresh frozen plasma in order to better control the coagulopathy frequently associated with a large haemorrhage has not been established in obstetrical situations. However, it is recommended to apply it in large volume post-partum haemorrhage, with a fresh frozen plasma/red blood cells concentrate ratio between 1/1 and 1/2. The post-partum haemorrhage treatment may benefit from the use of drugs, the most frequently used being antifibrinolytics, such as tranexemic acid, which help to reduce the magnitude of post-partum haemorrhage. Conversely, activated factor VII use should be restricted to situations where all other conventional treatments failed, as a last attempt to avoid hysterectomy.

Background: Simulator-based teaching for coronary angiography (CA) is an attractive educational tool for medical students to improve their knowledge and skills. Its pedagogical impact has not been fully evaluated yet. Objective: The aim of this study was to compare traditional face-to-face teaching with a simulator-based teaching for the acquisition of coronary anatomy knowledge and CAs interpretation. Methods: A total of 118 medical school students in their fourth to sixth year were prospectively randomized in 2 groups: (1) a control teaching group (n=59, CONT group) and (2) a simulator group (using the Mentice VIST-Lab CA simulator; n=59, SIM group). The CONT group received a PowerPoint-based course, whereas the SIM group received a simulator-based course including the same information. After the course, all students were evaluated by 40 multiple choice questions (maximum of 100 points), including questions on coronary anatomy (part 1), angiographic projections (part 2), and real CAs interpretation (part 3). Satisfaction of the students was also evaluated by a simple questionnaire. Results: Student characteristics were identical in both the groups: 62/118 (52.5%) were female and age was 22.6 (SD 1.4) years. Moreover, 35.6% (42/118) were in their fourth year, 35.6% (42/118) were in the fifth year, and 28.8% (34/118) in the sixth year. During the evaluation, SIM students had higher global scores compared with CONT students, irrespective of their year of medical school (59.5 [SD 10.8] points vs 43.7 [SD 11.3] points, P

Resume Les femmes enceintes sont particulierement vulnerables face a la grippe pandemique A(H1N1) 2009. Elles presentent un risque accru de developper une forme grave, voire mortelle, de la maladie par rapport a la population generale. Les modifications physiologiques et l’« immunodeviation » de l’immunite cellulaire vers l’immunite humorale observees au cours de la grossesse constituent les premieres hypotheses physiopathologiques pour expliquer cette vulnerabilite. Les formes graves, essentiellement a type de pneumonie virale parfois fulminante, necessitent la prescription rapide d’un traitement antiviral a dose efficace. Les mesures preventives, en particulier la vaccination, sont essentielles pour eviter l’apparition de ces formes graves.

This review examines current research on healthcare safety in highly dynamic domains of anesthesia and surgery. It emphasizes how checklists implementation and training program based on CRM and simulation may significantly improve interprofessional teamwork in a multidisciplinary obstetrical setting.

Points essentiels La notion de risque a acquis au fil des evolutions sociales une place extremement importante dans le champ du soin medical. Cette notion intervient tant dans la relation medecin-malade, notamment par l’information dont elle est le principal substrat, que comme forme de connaissance medicale. Nous proposons un module d’enseignement medical transversal portant sur cette notion de risque, destine aux etudiants en medecine, et qui s’integre dans le module 1 du programme de l’examen national classant. Cet enseignement permet d’aborder la relation de soin sur un mode nouveau en montrant la pluralite des definitions du risque et en y integrant la perception de celui-ci. Il vise par ailleurs, par une demarche a la fois epistemologique et pratique, a etablir le lien entre les connaissances medicales que nous utilisons tous les jours et la notion de risque, et ce faisant a amener l’etudiant a une prise de recul critique face a la masse des connaissances disponibles. Cet abord de la connaissance medicale au travers de la notion de risque permet de rendre cette connaissance plus operatoire et plus pertinente dans la singularite de chaque situation clinique et optimise ainsi la pratique du soin. Les techniques pedagogiques utilisees allient des cours dont la forme est classique a des ateliers avec mises en situation des etudiants sous forme de jeux de role. Ce module d’enseignement original permet de repondre a un besoin des etudiants en medecine amenes a devenir des soignants, besoin tant au niveau de l’analyse et l’utilisation des connaissances medicales disponibles dans leur pratique clinique, qu’au niveau de certains aspects de la relation de soin.

Continuous electronic fetal heart rate (FHR) monitoring is part of routine care for laboring patients under either systemic or locoregional analgesia. Opioid systemic analgesia (mainly meperidine in early labor), yet less frequently used in our country, is associated with a decrease in FHR-variability and worse acid-base and neonatal status compared to epidural or combined spinal epidural analgesia. Although epidural analgesia may cause maternal hypotension and fever, longer second stage of labour and more instrumental vaginal deliveries, these potentially adverse factors appear to be outweighed by benefits on clinical and neonatal acid-base status when compared with maternal opioid systemic analgesia. The mechanisms by which epidural or spinal analgesia may affect fetal well-being include maternal hypotension and/or uterine hyperactivity. All these undesirable side effects which may induce severe intrapartum fetal distress must be adequately detected and treated with intrauterine resuscitation techniques, including correction of maternal hypotension and/or the use of tocolytics agents. Reinstallation of electronic fetal monitoring at arrival in the operating room before cesarean section for suspected fetal hypoxia may be helpful to choose better anesthetic technique and try to avoid general anesthesia associated with increased maternal morbidity and mortality.

Resume Objectif Comparer l'impact d'une politique de prise en charge conservatrice ou radicale du placenta accreta sur la morbidite maternelle. Methodes Il s'agit d'une revue retrospective des donnees medicales de toutes les patientes ayant accouche a la maternite Port-Royal avec un diagnostic de placenta accreta, increta ou percreta de janvier 1993 a octobre 2005. Nous avons compare deux periodes consecutives. Durant la periode A (janvier 1993 a juin 1997), le protocole de service comportait une tentative de delivrance complete du placenta pour toutes les patientes. Durant la periode B (Juillet 1997 a octobre 2005), une politique conservatrice a ete appliquee. Les criteres suivants ont ete etudies pour les deux periodes : taux d'hysterectomie et de transfusion, admission en reanimation, duree de sejour en reanimation, septicemie et coagulation intravasculaire disseminee, infection du post-partum. Resultats Cinquante et un cas de placenta accreta ont ete observes pour 40 281 accouchements (1,3/1000). L'incidence des hysterectomies (11/13 versus 10/38 ; p p p p = 0,22). Conclusion Une prise en charge conservatrice du placenta accreta pourrait permettre de reduire la morbidite maternelle et de preserver la fertilite.

The application and documentation of foetal surveillance in labour that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention remains discussed. The occurrence of abnormal foetal heart rate is a frequent indication for urgent Caesarean section and subsequent associated risks. Prevention, early recognition, and prompt intervention are the keys to minimizing the risks of anaesthetic mortality and morbidity, mainly from general anaesthesia. Definitions of safe standards of equipment and practices to prevent Mendelson's syndrome and to cope with a failed intubation drill are of major importance. Comprehensive communication between well-coordinated anaesthetic and obstetrical teams is one of the most important elements in the care of a compromised foetus.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 36 - N° 4 - p. 389-392

Simulation in healthcare is directly inspired by high-risk industries such as the aeronautical industry. The recent rapid growth in its use in healthcare is explained by the need to improve the quality and safety of care. It must go hand in hand with the development of a real safety culture.

Labor results in severe pain for most women. In the absence of medical contraindication, maternal request is a sufficient indication for pain relief, which is performed in the vast majority of developed countries through neuraxial analgesia. Regional analgesia techniques (spinal, epidural, and combined spinal epidural) are the most flexible, effective, and least debilitating to the central nervous system, enabling an alert and active woman to deliver an alert neonate [1].

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 10 - p. 1170-1179

Study objective To identify the preoperative factors affecting the risk of conversion to laparotomy during total laparoscopic hysterectomy (TLH) indicated for benign conditions (surgery performed in cases of genital prolapse and/or urinary stress incontinence was excluded). Design Retrospective comparative study (Canadian Task Force classification II-2). Setting University tertiary referral center for gynecologic endoscopic surgery. Patients Four hundred sixteen consecutive patients who underwent TLH during the first 5 years of our experience performing TLH. Intervention Total laparoscopic hysterectomy. Measurements and main results The rate of conversion to laparotomy was 7% (29 patients). Factors that were found to be independently related to the risk of conversion to laparotomy are the following: body mass index (adjusted OR 1.09; 95% CI 1.01–1.18); uterine width on transvaginal ultrasonography (US) between 8 and 10 cm (adjusted OR 4.01; 95% CI 1.54–10.45); uterine width on US greater than 10 cm (adjusted OR 9.17; 95% CI 2.74–30.63); lateral myoma measuring greater than 5 cm on US (adjusted OR 3.57; 95% CI 0.97–13.17); history of adhesion-causing abdominopelvic surgery (adjusted OR 2.92; 95% CI 1.23–6.94). Conclusion Transvaginal US evaluation is essential before performing TLH. Awareness of the risk factors for conversion to laparotomy is essential for proper patient information and better selection of patients.

a Service de gynecologie–obstetrique de Port-Royal, hopital Cochin Saint-Vincent-de-Paul, universite Paris-V, 123, boulevard de Port-Royal, 75014 Paris, France ; et unite de recherche epidemiologique en sante perinatale et en sante des femmes, Inserm U149, 123, boulevard de Port-Royal, 75014 Paris, France b CNGOF : college national des gynecologues et obstetriciens francais, France c CNSF : college national des sages-femmes, France d SFAR : Societe francaise d’anesthesie–reanimation, France e SFMPN : Societe francaise de medecine perinatale, France

In the liver, the importance of apoptosis is not only evident during development and homeostasis of the biliary tree but plays also a prominent role in liver pathogenesis. Ligand binding to cell surface death receptors such as Fas activates the extrinsic pathway. This pathway predominates in autoimmune liver diseases, viral hepatitis, liver allograft rejection. Hepatocyte apoptosis is also significantly increased in patients with alcoholic hepatitis and nonalcoholic steatohepatitis and correlates with disease severity and hepatic fibrosis. We have used this specific susceptibility of the liver to apoptosis to develop two different approaches: 1) a cell therapy strategy based on a survival advantage to an apoptotic stimulus conferred to transplanted hepatocytes and 2) a new model of hepatocyte conditional ablation based on a controlled activation of the cell death program.

Resume La prise en charge adequate d’une hemorragie du post-partum (HPP) est multidisciplinaire. Elle repose sur le concours simultane de professionnels qui communiquent, reaniment, surveillent et entament les gestes diagnostiques et d’arret du saignement indispensables dans ces situations d’urgence. Un protocole de service regulierement actualise et du personnel entraine, en nombre suffisant et qui communique, sont les elements essentiels du dispositif pour garantir rapidite et efficacite indispensables au controle de cette situation a tres haut risque. L’etape initiale comporte la detection rapide de l’hemorragie (horaire precis note), par l’importance « visuelle » du saignement (quantification possible par un sac de recueil), ou par des signes cliniques et para-cliniques obtenus au lit (Hemocue™) ou au laboratoire. L’anesthesiste, une fois le diagnostic etabli, doit mettre le plus vite possible en route une reanimation adaptee [surveillance (frequence cardiaque, pression arterielle, oxymetrie de pouls), voie(s) veineuse(s), prelevements biologiques initiaux si besoin, expansion volemique, oxygenotherapie]. L’anesthesiste doit procurer en toute securite les conditions de realisation de gestes diagnostiques et/ou therapeutiques (delivrance artificielle, revision uterine, inspection sous valves) par l’obstetricien. L’anesthesiste doit surveiller la mise en route d’un traitement uterotonique (Syntocinon ® en premiere ligne), son efficacite et ses effets indesirables. Enfin, l’anesthesiste doit savoir envisager, de maniere conjointe et simultanee avec l’equipe obstetricale, une strategie pro-active anticipative dans le cas ou l’hemorragie ne serait pas controlee par ces premieres mesures (appel de renfort).

Resume La prise en charge adequate d’une hemorragie du post-partum necessite la connaissance parfaite d’un protocole regulierement reactualise et accessible a tout moment, ainsi qu’une dotation suffisante en equipement adapte et en personnel. Le temps initial comporte la detection rapide de l’hemorragie. Le diagnostic est facilite par la mise en place de sacs de recueil places apres l’expulsion fœtale. Des le diagnostic, la communication de ce dernier doit etre immediate a tous les intervenants potentiels (obstetriciens, sages-femmes, equipe d’anesthesie), la prise en charge optimale etant multidisciplinaire. La cause des saignements doit etre recherchee sans delai. La palpation abdominale detecte l’atonie uterine, cause la plus frequente d’hemorragie du post-partum. Des son diagnostic, deux attitudes sont possibles en fonction de la delivrance. Si elle n’a pas eu lieu, une delivrance artificielle est imperative permettant d’obtenir la vacuite uterine et d’exclure une rupture uterine. Si la delivrance a eu lieu, la revision uterine s’impose toujours, conduisant a la vacuite uterine, seule garante d’une retraction optimale. Le massage du fond uterin, toujours associe, ne doit pas etre arrete trop precocement. Des origines evidentes peuvent etre exclues : episiotomie ou plaies de la filiere genitale necessitant une suture, troubles de la coagulation requerant une reanimation adaptee et thrombus vulvovaginal traite par des gestes chirurgicaux adaptes. Parallelement, l’emploi d’uterotoniques est indispensable. Les ocytociques (5 a 10 UI d’ocytocine en intraveineux direct) sont les plus utilises. Les prostaglandines ont ete proposees dans le traitement immediat de l’hemorragie du post-partum mais les etudes sont encore trop parcellaires pour etre validees. En parallele a cette prise en charge obstetricale immediate, les premiers gestes de reanimation doivent etre effectues.

Resume Objectif Effectuer une revue objective des donnees disponibles concernant l’histoire, la pharmacologie, la physiologie, les effets secondaires et l’efficacite du sulfate de magnesium dans ses deux principales indications obstetricales, la tocolyse et la crise d’eclampsie. Donnees Une revue de la litterature a ete effectuee dans Medline de 1966 a avril 2003 en utilisant les mots cles suivants : magnesium sulfate , tocolytic , pre-eclampsia , eclampsia , et pregnancy . Les references bibliographiques des articles ont egalement ete analysees a la recherche de donnees additionnelles. Resultats Le sulfate de magnesium (MgSO4) est utilise en pratique obstetricale depuis des decennies pour prevenir la prematurite (effet tocolytique) et la survenue d’une crise d’eclampsie (effet neuroprotecteur). Plusieurs essais randomises et des meta-analyses ont maintenant demontre l’efficacite du sulfate de magnesium dans la prevention primaire et secondaire de la crise d’eclampsie. A l’inverse, le sulfate de magnesium n’est pas efficace comme tocolytique et son utilisation a forte posologie semble etre associee a un risque accru de mortalite perinatale. Conclusion Le sulfate de magnesium previent la survenue d’une crise d’eclampsie chez la femme pre-eclamptique. En revanche, son utilisation n’est pas recommandee a visee tocolytique.