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International audience; Lung transplantation (LTx) is the last-resort treatment for end-stage respiratory insufficiency, whatever its origin, and represents a steadily expanding field of endeavor. Major developments have been impelled over the years by painstaking efforts at LTx centers to improve donor and recipient selection, and multifaceted attempts have been made to meet the challenges raised by surgical management, perioperative care, and long-term medical complications. The number of procedures has increased, leading to improved post-LTx prognosis. One consequence of these multiple developments has been a pruning away of contraindications over time, which has, in some ways, complicated the patient selection process. With these considerations in mind, the Francophone Pulmonology Society (Société de Pneumology de Langue Française [SPLF]) has set up a task force to produce up-to-date working guidelines designed to assist pulmonologists in managing end-stage respiratory insufficiency, determining which patients may be eligible for LTx, and appropriately timing LTx-center referral. The task force has examined the most recent literature and evaluated the risk factors that continue to limit patient survival after LTx. Ideally, the objectives of LTx are to prolong life while improving quality of life. The guidelines developed by the task force apply to a limited resource and are consistent with the ethical principles described below.; La transplantation pulmonaire (TxP) constitue le traitement ultime de l’insuffisance respiratoire terminale quelle qu’en soit l’origine et voit son activité en permanente expansion. Le travail minutieux des centres de TxP portant sur la sélection des donneurs et des receveurs d’un greffon pulmonaire ainsi que de l’ensemble des efforts fournis pour relever les défis de la prise en charge chirurgicale, péri-opératoire et la gestion des complications médicales de la TxP à plus long terme ont permis une augmentation du nombre de procédures et l’amélioration du pronostic post-TxP. Les membres du groupe de travail de la Société de pneumologie de langue française (SPLF) ont réalisé une mise à jour des données connues de la littérature et analysé les facteurs de risque qui limitent les chances de survie après la TxP. L’objectif de ce travail a été de guider les pneumologues dans leur prise en charge de l’insuffisance respiratoire terminale, de les aider à identifier les patients potentiellement éligibles à la TxP et de déterminer selon quels délais les adresser à centre de TxP. Les objectifs de la TxP demeurent l’allongement de la vie et l’amélioration de la qualité de vie des malades. Les propositions faites dans ce document portent sur une ressource limitée et restent guidées par des principes éthiques décrits plus loin.

Sugammadex, a specific reversal agent for steroidal neuromuscular blocking drugs, has on occasion been reported to be associated with clinical signs of awakening. We performed a study to systematically search for an increase in bispectral index values and signs of awakening in patients maintained under general anaesthesia following sugammadex administration. Patients, scheduled to receive general anaesthesia with neuromuscular blockade, were included in this double-blind randomised crossover study. After surgery was completed, and while the train-of-four ratio was zero, intravenous anaesthesia was continued with the aim of maintaining the bispectral index in the range of 40-60. Patients then received either sugammadex 4 mg.kg-1 or saline. In cases of incomplete reversal of neuromuscular blockade after 5 min, patients received the other drug. Bispectral index and train-of-four monitoring were recorded every minute and clinical signs of awakening noted. Fifty-one patients completed the study. Median (IQR [range]) bispectral index values increased after sugammadex administration from 49 (43-53 [38-64]) to 63 (53-80 [45-97]) (p < 0.01) with an increase of ≥ 20 in 22 patients; 14 (27%) patients had clinical signs of awakening. Saline had no effect on bispectral index values, clinical signs of awakening or degree of neuromuscular blockade. This study confirms that reversal of neuromuscular blockade with sugammadex may be associated with clinical signs of awakening despite maintenance of anaesthesia. Intravenous anaesthesia should be maintained until complete recovery of muscle function is achieved, especially when sugammadex is administered.

L’infusione e un atto praticato molto comunemente nel campo ospedaliero. Questo atto, spesso demandato al personale paramedico, comporta alcune specificita tanto nel posizionamento e nel controllo che nella scelta del materiale di infusione volto a rispondere alla prescrizione medica. Questa scelta e ampia, andando dalla semplice infusione con regolazione a rotella alla somministrazione di agenti farmacologici con siringa motorizzata con obiettivo di concentrazione, e richiede una buona conoscenza dei differenti sistemi esistenti. L’obiettivo di questo articolo e quello di precisare i tipi di accesso possibili per il posizionamento di un’infusione e di prendere in considerazione i vantaggi e i limiti dei sistemi disponibili.

Resume Position du probleme En decembre 2012, une controverse mediatique sur les risques sanitaires associes a l’utilisation de la contraception orale, ou « crise des pilules », eclate en France. Si plusieurs analyses ont pu mettre en evidence un changement des pratiques contraceptives des femmes suite a cette controverse mediatique, aucune analyse n’a ete conduite pour connaitre l’evolution du recours aux different·e·s prescripteurs·trices, et ses consequences sur le recours aux differentes methodes de contraception. Methodes Notre etude s’appuie sur les donnees de trois enquetes transversales conduites en population generale (Fecond 2010, Fecond 2013 et Barometre Sante 2016) ayant permis de collecter les pratiques contraceptives des femmes et la specialite de la·du professionnel·le de sante leur ayant prescrit la methode qu’elles utilisaient. Resultats Entre 2010 et 2016, les femmes se sont plus souvent rendues chez un·e gynecologue ou un·e sage-femme que chez un·e generaliste pour delivrance de leur methode de contraception principale reversible. Mais, les changements de pratiques contraceptives observes chez les femmes sur la periode ne s’expliquaient pas par l’evolution de recours aux different·e·s professionnel·le·s de sante. En 2016, le recours aux different·e·s prescripteurs·trices de sante restait largement dependant des caracteristiques sociodemographiques des femmes : celles etant plus âgees, d’une position sociale favorisee et qui residaient en zone urbaine avaient davantage recours a un·e gynecologue pour la prescription de leur methode de contraception. Le recours aux sages-femmes pour la prescription d’une methode de contraception etait plus frequent chez les femmes ayant deja eu des enfants, et beneficiant de la securite sociale mais n’ayant pas de mutuelle. Conclusion Suite a la « crise des pilules » survenue en France en 2012, le choix de certaines femmes d’utiliser le DIU au detriment de la pilule les a conduites a changer de prescripteurs·trices, d’une part, et incite ces dernier·e·s a modifier leurs pratiques prescriptives, d’autres part.

In December 2012, a media controversy about negative side-effects of oral contraceptives on women's health, also called "pill scare", broke out in France. While several analyses highlighted a change in women's contraceptive practices following this media controversy, no analysis has been conducted to determine the possible changes in their choices of health professionals and its repercussions on their contraceptive use.Our study is based on data from three population-based cross-sectional surveys conducted in 2010, 2013 and 2016 (Fecond 2010, Fecond 2013 and Baromètre Santé 2016) that collected information on women's contraceptive practices and the specialties of the health professionals having prescribed the methods they were using.Between 2010 and 2016, women went to a gynecologist or a midwife more often than to a general practitioner for prescription of a reversible contraceptive method. However, their changes in visiting prescribers did not explain the changes in their contraceptive practices observed over the period. In 2016, access to health professional remained largely dependent on women's socio-demographic characteristics: older ones and those from a more privileged social background or living in urban areas were more likely to consult a gynecologist for prescription of their contraceptive method. On the other hand, consultations of midwives for contraceptive prescription were more frequent among women with children and among those who relied on public health insurance alone.Following the "pill scare" that occurred in France in December 2012, the decision by some women to use the IUD instead of the pill led them to change health professionals, and also led practitioners to change their prescribing practices.

Resume La transplantation pulmonaire (TP) est le seul traitement qui puisse etre propose pour permettre la survie des patients en insuffisance respiratoire terminale. L’objectif de notre etude est d’explorer les progres realises au cours des deux dernieres decennies pour demontrer l’efficacite et la securite de ce traitement. Methodes Analyse retrospective d’une cohorte monocentrique des 600 premiers patients ayant eu consecutivement une TP a l’hopital Foch (Suresnes, France) entre 1988 et 2014. Cette cohorte a ete divisee en 3 groupes chronologiques de 200 patients (1988–2004, 2004–2011, 2011–2014) Resultats La duree d’attente, la mortalite perioperatoire, l’incidence des rejets aigus cellulaires de la premiere annee et du rejet chronique (RC) a 5 ans ont toutes diminue. La survie actuarielle globale a 1 et 5 ans, de 78 % et 57 % pour les 600 patients, est passee a 86 % et 75 % pour les 200 derniers (> 2011). Elle est meilleure a 5 ans pour la mucoviscidose (68 %) que pour l’emphyseme (54 %) et la fibrose pulmonaire (37 %). Pour les 200 derniers patients, elle est a 5 ans de 81 % pour la mucoviscidose, de 78 % pour l’emphyseme et de 47 % pour les fibroses. Elle est de 60 % a 5 ans en cas de transplantation dite de super-urgence. Une surveillance attentive et prolongee doit detecter les complications proliferatives et gerer l’hypertension et la toxicite renale medicamenteuse. Conclusion En 25 ans, des progres considerables en TP ont hisse cette procedure au rang de therapeutique reconnue de l’insuffisance respiratoire chronique terminale.

Resume Objectif Faire la synthese des connaissances actuelles sur la couverture contraceptive en France et dans le monde, decrire l’efficacite des differents types contraceptifs, decrire les caracteristiques des femmes utilisant une contraception, les situations d’echecs contraceptifs et decrire les differents risques medicaux lies aux methodes contraceptives. Methodes Consultation de la base de donnees Medline, et des rapports nationaux ou internationaux sur la contraception en France et dans les pays du monde. Resultats La couverture contraceptive en France est elevee : 97 % des femmes en 2013 utilisant une methode contraceptive (parmi les femmes fertiles, actives sexuellement et sans desir de grossesse), avec notamment une majorite d’utilisation de methodes medicales (72 % d’utilisation de pilules et autres contraceptions hormonales, dispositifs intra-uterins et 25 % d’utilisation de methodes barrieres, naturelles et traditionnelles). La crise de la pilule de 2013 a remis en cause l’utilisation de la contraception œstro-progestative et l’information delivree par les medecins, mais la pilule reste le premier mode de contraception suivi ensuite par le dispositif intra-uterin, les preservatifs, les methodes dites traditionnelles ou naturelles. La couverture contraceptive au cours de la vie change selon une norme definie : preservatifs, pilule, dispositif intra-uterin. La contraception definitive est tres peu choisie et peu proposee. La contraception en France reste une contraception principalement feminine. Les femmes et les couples doivent etre informees sur l’ensemble des methodes contraceptives, qui leur permette de choisir la methode adaptee a leur etat de sante, leurs conditions de vie et leur sexualite.

Purpose Pre-formed donor-specific antibodies (pf-DSA) are associated with worse outcome after lung transplantation (LTx) and might limit access to LTx. A virtual crossmatch (CXM)-based strategy for perioperative desensitization protocol has been used for immunized LTx candidates since 2012 at Foch hospital. We compared the outcome of desensitized LTx candidates with high pf-DSA mean fluorescence intensity (MFI) and those with low or no pf-DSA, not desensitized. Methods For all consecutive LTx recipients (January 2012-March 2018), freedom from CLAD and graft survival were assessed by Kaplan-Meier analysis and Cox proportional-hazards multivariate analysis. Results We compared outcomes for desensitized patients with high pf-DSA (n=39) and those with no (n=216) or low pf-DSAs (n=66). The desensitization protocol decreased the level of immunodominant pf-DSA (class I/II) at 1, 3, and 6 month post-LTx (p Conclusion The desensitization protocol in LTx recipients with high pf-DSAs was associated with satisfactory outcome, with cleared high pf-DSAs after desensitization identified as an independent predictor of graft survival.

Introduction La maladie a nouveau coronavirus 2019 (COVID-19) a actuellement un taux de progression rapide mondial. Le nombre de cas severes rapportes chez les greffes d’organes solides reste limite, mais leur statut d’immunodeprime fait supposer un risque eleve de complications liees au SARS-Cov-2. L’insuffisance respiratoire aigue liee au syndrome de detresse respiratoire aigue (SDRA), qui se developpe chez environ 5 % des patients, reste la cause principale de deces. Il est maintenant etabli qu’un sous-groupe de patients porteurs d’infection severe COVID-19 developpe un syndrome de tempete cytokinique associe au risque de deces, chez qui des traitements immunomodulateurs pourraient etre benefiques. Les options therapeutiques, entre autres, incluent les corticoides a doses elevees, mais il etait anticipe une balance risque–benefice defavorable a leur utilisation au tout debut de l’epidemie. Une autre question dans la population des transplantes pulmonaires (TxP) est l’eventuel role prophylactique de l’azithromycine au long cours sur l’acquisition du SARS-Cov-2, frequemment administre dans cette population specifique en cas de la dysfonction chronique du greffon. Resultats Nous rapportons 2 cas severes de SDRA-COVID-19 hyper-inflammatoires ayant menace leur pronostic vital, survenus au sein de notre cohorte monocentrique de greffes pulmonaires malgre un traitement d’azithromycine faible-dose au long cours. Un traitement par methylprednisone a doses elevees (2 mg/kg/j), debute precocement apres le debut du SDRA sous ventilation mecanique, a permis une recuperation pulmonaire rapide et ad integrum chez les 2 patients. Conclusion Ces 2 cas de SDRA-COVID-19 suggerent : – que des formes graves peuvent survenir malgre un traitement au long-court d’azithromycine faible-dose apres TxP ; – le benefice de l’utilisation precoce des corticoides a dose elevee en cas de survenue de SDRA-COVID-19 hyper-inflammatoire apres TxP, comme observe recemment dans un essai therapeutique testant l’efficacite de la dexamethasone au sein d’une population generale de patients.

Purpose Fast-tracking in cardiothoracic surgery is highly challenging. Early postoperative extubation an aspect of this strategy. The objective of the present study was to report our whole experience of immediate end-surgery extubation (OR extubation) after lung transplantation. Methods This retrospective study was apporved by the Ethical Board of the French Society for Anesthesia and Intensive Care. All consecutive patients undergoing double-lung transplantation from 2012 to 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The strategy is possible due to short acting drugs and a strict cardio-respiratory weaning protocol based on inhaled nitric oxyde and ECMO removale at end-surgery when is possible (see Figure). The aims of the study were: to identify predictive factors of immediate extubation, and to compare outcome among patients. Results Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. Conclusion Immediate extubation via a fast-tracking protocol is feasible in one third of patients after lung transplantation. It requires transdisciplinary collaboration. It forecasts a positive outcome.

SOLSA is the first automated expert system for on-site cores analysis. The scope is to provide a prototype to be an innovative and necessary tool for geo-metallurgy, in order to optimize the valorization of the ore. The Expert System consists in the combination of an integrated drilling rig providing cores of high quality, an automated scanner and phase identification software, developed for nickel laterites and bauxites but usable as well in other sectors. SOLSA combines non-destructive sensors and the whole system is driven by an innovative, user-friendly and intelligent software. SOLSA provides more complete information while optimizing the exploration stage, with a significant reduction of costs and return time. Such objective involves, in the first place, to fast, cheaper and systematic acquisition of the data needed for optimizing the process. The adding value takes place first at the exploration or grade control stage, furnishing systematic characterization and regionalization of the different types of ore. Then such information can be used for improving the ore scheduling at the mining and processing stages, toward improving the recovery and efficiency of the processing

Purpose Fast-tracking in cardiac-thoracic surgery is highly challenging. It requires multimodal and transdisciplinary collaboration. Early postoperative extubation in the operating room (OR) is an aspect of this strategy1. The objective of the present study was to report our whole experience of immediate end-surgery extubation after lung transplantation. Methods The Ethical Board of the French Society for Anesthesia and Intensive Care approved this analysis of the prospectively Lung Transplant database. All consecutive patients undergoing double-lung transplantation from January 2012 to December 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The cardio-respiratory weaning protocol has been previously published2 (Figure). The aims of the study were: to identify factors predicting immediate extubation, and to compare outcome among patients. Results Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. Conclusion Immediate extubation via a fast-tracking protocol is feasible after lung transplantation. It forecasts a positive outcome. It requires transdisciplinary collaboration.

Purpose The thundering evolution of lung transplantation management during the past ten years and primary graft dysfunction (PGD) new definition have led to new predictive factors of PGD. Therefore, we retrospectively analyzed a monocenter database using a machine-learning method, to determine the predictive factors of grade 3 PGD (PGD3), defined as a PaO2/FiO2 ratio Methods We included all double lung transplantation from 2012 to 2019 and excluded multi-organ transplant, cardiopulmonary bypass, or repeated transplantation during the study period for the same patient. Recipient, donor and intraoperative data were added in a gradient boosting algorithm step-by-step according to standard transplantation stages. Dataset was split randomly as 80% training set and 20% testing set. Relationship between predictive factors and PGD3 was represented as ShHapley Additive exPlanation (SHAP) values. Results A total 478 patients were included in the analysis, 83 (17.3%) had PGD3. Highest performance analysis was achieved at the end-surgery stage (0.87, IC95 [0.867-0.873]) with 6 predictive factors: being under ECMO at some point in the intervention and whatever the reason for its implementation is a predictor; a recipient low total lung capacity is a predictor; ECMO is a predictor whatever the time of implantation; having a cystic fibrosis or a COPD/emphysema is protective while having a lung pulmonary fibrosis or another pathology is predictive. Conclusion Gradient boosting predicted PGD3 with high performance using variables available at the end of double lung transplantation. The implementation of strategies adapted to modifiable variables could make it possible to limit the occurrence of a PGD or its severity.

Purpose Lactic acidosis has been recently propose as independently associated with longer intubation times and length of stay in lung transplantation(1). However, there is no data on the association between elevated blood lactate concentration (BLC) and grade 3 primary graft dysfunction at day 3 after lung transplantation (PGD3). The purpose of the study was to investigate the profile of BLC during double-lung transplantation and it association with PGD3. Methods We performed a retrospective observational study of all bilateral lung transplantations at the Foch Hospital from January 2012 to December 2019, excluding those on bridge-to-transplantation, under cardiopulmonary bypass, and multiple-organ transplantation. BLC was measured at every key time of the invention: initially, at every pulmonary artery clamping or declamping, and at end-surgery stage. The ethical committee of the French Society of Anesthesia and Critical Care (SFAR) approved the study. The evolution of intraoperative BLC was evaluated with a paired T-test with Holm correction to compare lactate. AUC was constructed to determine Sp and Se. The optimal threshold of lactates variable used for separation of PGD3 was calculated using the Youden-index. Results Over 478 patients were included, 83 (17.3%) had a PGD3. BLC evolution during surgery is illustrated in figure 1. The median of BLC at end-surgery was 2 [1.5 - 3.1] and 3.3 [2.4 - 4.9] mmol/L in no PGD3 and PGD3 groups respectively, p = 0.02. BLC kinetic illustrated by its variability was the best predictive factor of PGD3 (AUC=0.84, Se= 77.03, Sp=79.82%). Conclusion Hyperlactatemia reflects anaerobic metabolism during peroperative hemodynamic unstable conditions and poor oxygen exchange after implantation of the grafts. Blood lactate variability during surgery is associated with PGD3.1. Worrell SG, et al. Is Lactic Acidosis After Lung Transplantation Associated With Worse Outcomes The Annals of Thoracic Surgery. 2020 Aug;110(2):434-40.

Skin conductance variability to assess pain has shown varying results. Skin conductance responses per second (SCR) during a standardized painful stimulus in awake adults may give further understanding of the method's validity. The purpose of this study was to validate the SCR with the visual analogue scale (VAS) for pain (P-VAS) and anxiety (A-VAS) during chest tube removal (CTR).Ninety-five patients receiving epidural or non-epidural treatment, scheduled for CTR, were studied. Pain or anxiety was considered when VAS 30 mm; the SCR cut-off value reflecting pain was ≥0.2 SCR.SCR values could not be recorded in eight cases before CTR, six cases during CTR and seven cases after CTR. CTR induced increases in SCR, P-VAS and A-VAS (p 0.001). Seventy-seven percent of all pairs of P-VAS and SCR values were well-classified; P-VAS ≤ 30 mm and SCR 0.2 or P-VAS 30 mm and SCR ≥ 0.2. SCR obtained before CTR differentiates between patients with and without pain during CTR in all patients (p = 0.04) and in the subgroup of non-anxious patients (p = 0.02), but not in the subgroup of anxious patients. SCR obtained during CTR had similar values in patients with and without pain in all patients and in the subgroup of anxious patients, but in the subgroup of non-anxious patients SCR during CTR differentiates patients with and without pain (p = 0.009).SCR increases during painful procedures. Preprocedural SCR may help predict reported pain in patients exposed to painful procedures. SCR during CTR differentiates between patients with and without pain only in non-anxious patients.Preprocedural SCR may help predict reported pain in patients exposed to painful procedures. Procedural SCR accuracy improves in a subgroup of non-anxious patients. P-VAS is influenced by anxiety different from SCR.

Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia-reperfusion syndrome. We assessed the behaviour of this automated controller during OLT.Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval).Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg(-1) h(-1) and 4.6 [3.5-8.1] mg kg(-1) h(-1); P0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] µg kg- (1) min(-1)). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 µg ml(-1) and limits of agreement of -2.2 to +3.7 µg ml(-1)) and remifentanil (bias of 1.3 ng ml(-1) and limits of agreement -4.3 to +6.8 ng ml(-1)). No adverse events were reported during anaesthesia.This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT.

We reviewed our experience with tracheal extubation in the operating room (E-OR) among cystic fibrosis patients requiring bilateral lung transplantation to evaluate safety and determine predictive factors of E-OR.The charts of 89 recipients (from May 2007 to June 2013) were analysed. Patients were divided into E-OR and E-ICU (intensive care unit extubation) groups. Data are expressed as numbers (percentages) or medians [25th-75th percentiles].There were 41 patients in the E-OR group (46%). Donor and recipient characteristics were similar between groups. Intraoperative complications occurred less frequently in the E-OR group, and fluid and transfusion requirements were lower. Postoperative courses were different in the E-OR group, including a lower rate of grade 3 primary graft dysfunction (0 compared with 19 patients, P0.0001) and shorter ICU (5.0 [3.7-7.2] compared with 11.5 [7.0-15.5] days) and hospital stays (22.0 [18.0-25.5] compared with 33.0 [25.0-56.5] days, respectively; P0.0001 for both). The 1 yr survival rates were similar: 95% in the E-OR group and 98% in the E-ICU group. A statistical model built on a development cohort of 60 randomly selected patients predicted 95% of E-OR instances in this cohort and 82% of E-OR instances in the validation cohort (28 patients). Predictive factors were complications during single-lung ventilation (second graft implantation), complications during bipulmonary ventilation (end of surgery), and the ratio of arterial partial pressure of oxygen to fractional inspired oxygen (end of surgery).Our protocol allowed for extubation of 46% of bilateral lung transplant patients without increased postoperative risks.

La anestesia para cirugia toracica presenta diversos aspectos especificos que conviene conocer para adaptar el manejo de los pacientes durante todo el periodo perioperatorio. En primer lugar, la disminucion de la funcion respiratoria secundaria a la reduccion del parenquima requiere una evaluacion preoperatoria de calidad para determinar la operabilidad (evaluacion del riesgo cardiaco, exploraciones funcionales respiratorias, etc.) y para limitar la morbimortalidad postoperatoria. Para facilitar la intervencion quirurgica, la inmovilidad del parenquima se obtiene mediante un control de las vias aereas basado en una tecnica de exclusion pulmonar, cuyas modalidades (tubo de intubacion de doble luz, bloqueador bronquial) se adaptaran al paciente y al procedimiento previsto. En todos los casos, una exploracion fibroendoscopica permite determinar la calidad de la colocacion del dispositivo escogido. Por otra parte, uno de los objetivos principales peroperatorios es evitar la aparicion de lesiones alveolares utilizando una estrategia ventilatoria protectora tanto en ventilacion bipulmonar como en ventilacion unipulmonar durante la cirugia. Por ultimo, la fase postoperatoria debe tener como finalidad una recuperacion rapida de la anatomia del paciente, lo que requiere una estrategia de control del dolor optima, asi como la implementacion de programas de rehabilitacion postoperatoria o, mas recientemente, de preparacion multimodal preoperatoria aun denominada «prehabilitacion». En ultima instancia, el conjunto de estas tecnicas puede servir en otras intervenciones (esofagectomia, manejo de la hemoptisis), por lo que su conocimiento es util para cualquier medico.

L’anestesia per chirurgia toracica riveste un certo numero di specificita che e opportuno conoscere per adattare la gestione dei pazienti per tutto il periodo perioperatorio. In primo luogo, la riduzione della funzione polmonare conseguente a una riduzione del parenchima richiede una valutazione preoperatoria per determinare l’operabilita (valutazione del rischio cardiaco, test di funzionalita polmonare, ecc.) e per limitare la morbimortalita postoperatoria. Per facilitare la procedura chirurgica, l’immobilita del parenchima si ottiene con un controllo delle vie aeree basato su una tecnica di esclusione polmonare le cui modalita (sonda di intubazione a due vie, bloccatore bronchiale) saranno adattate al paziente e alla procedura prevista. In ogni caso, un esame mediante fibroscopia permette di qualificare la qualita del posizionamento del dispositivo scelto. Peraltro, uno dei principali obiettivi intraoperatori e di evitare la comparsa di lesioni alveolari mediante il ricorso a una strategia ventilatoria protettiva allo stesso tempo in ventilazione bipolmonare e in ventilazione monopolmonare durante l’intervento chirurgico. Infine, la fase postoperatoria deve mirare a un ritorno rapido all’autonomia del paziente, e cio richiede una strategia di controllo del dolore ottimale, nonche l’attuazione di programmi di riabilitazione postoperatoria o, piu recentemente, di una preparazione multimodale preoperatoria, chiamata anche “preabilitazione”. Da ultimo, tutte queste tecniche possono interessare altri interventi (esofagectomia, gestione dell’emottisi) e la loro conoscenza e utile per ogni medico.

In the context of lung transplant (LT), because of diagnostic difficulties, antibody-mediated rejection (AMR) remains a matter of debate. We retrospectively analyzed an LT cohort at Foch Hospital to demonstrate the impact of AMR on LT prognosis. AMR diagnosis requires association of clinical symptoms, donor-specific antibodies (DSAs), and C4d(+) staining and/or histological patterns consistent with AMR. Prospective categorization split patients into four groups: (i) DSA positive, AMR positive (DSA(pos) AMR(pos) ); (ii) DSA positive, AMR negative (DSA(pos) AMR(neg) ); (iii) DSA limited, AMR negative (DSA(Lim) ; equal to one specificity, with mean fluorescence intensity of 500-1000 once); and (iv) DSA negative, AMR negative (DSA(neg) ). AMR treatment consisted of a combination of plasmapheresis, intravenous immunoglobulin and rituximab. Among 206 transplanted patients, 10.7% were DSA(pos) AMR(pos) (n = 22), 40.3% were DSA(pos) AMR(neg) (n = 84), 6% were DSA(Lim) (n = 13) and 43% were DSA(neg) (n = 88). Analysis of acute cellular rejection at month 12 showed higher cumulative numbers (mean plus or minus standard deviation) in the DSA(pos) AMR(pos) group (2.1 ± 1.7) compared with DSA(pos) AMR(neg) (1 ± 1.2), DSA(Lim) (0.75 ± 1), and DSA(neg) (0.7 ± 1.23) groups. Multivariate analysis demonstrated AMR as a risk factor for chronic lung allograft dysfunction (hazard ratio [HR] 8.7) and graft loss (HR 7.56) for DSA(pos) AMR(pos) patients. Our results show a negative impact of AMR on LT clinical course and advocate for an early active diagnostic approach and evaluation of therapeutic strategies to improve prognosis.

The fully open character of the Raman Open Database makes this novel database freely and completely usable by anybody worldwide: academics, those working in industry and the general public., Detailed crystallographic information provided by X-ray diffraction (XRD) is complementary to molecular information provided by Raman spectroscopy. Accordingly, the combined use of these techniques allows the identification of an unknown compound without ambiguity. However, a full combination of Raman and XRD results requires an appropriate and reliable reference database with complete information. This is already available for XRD. The main objective of this paper is to introduce and describe the recently developed Raman Open Database (ROD, http://solsa.crystallography.net/rod). It comprises a collection of high-quality uncorrected Raman spectra. The novelty of this database is its interconnectedness with other open databases like the Crystallography Open Database (http://www.crystallography.net/cod and Theoretical Crystallography Open Database (http://www.crystallography.net/tcod/). The syntax adopted to format entries in the ROD is based on the worldwide recognized and used CIF format, which offers a simple way for data exchange, writing and description. ROD also uses JCAMP-DX files as an alternative format for submitted spectra. JCAMP-DX files are compatible to varying degrees with most commercial Raman software and can be read and edited using standard text editors.

Purpose Lung transplantation (LT) is limited by the shortage of suitable donors. To overcome this problem, many programs have begun to use extended criteria donors. However, the use lung donors over 65 years old is rarely reported especially among a population of young cystic fibrosis (CF) recipient. Methods We report a single center experience of lung transplantations for CF recipients between January 2005 and september 2019. Two cohorts were built and compared according to lung donor age Results Among this period, 378 bilateral lung transplantations (BLT) for CF were performed. 344 BLT were done with donors aged Conclusion Use of donor lungs over 65 years for CF recipients allows donor pool extension without compromising early and midterm results. However, longer follow up is needed to appreciate long term results.

Purpose The extreme difficulty of carrying out randomized studies in lung transplantation leads us to consider statistical methods derived from artificial intelligence. Previous studies in kidney and liver transplantations, as well as in heart surgery, showed better predictive ability than traditional statistical analysis to predict postoperative outcomes. Methods We analyzed a prospective database of all 410 double lung transplantations performed in our center, from January 2012 to June 2018. We used a Random Forest approach over 284 variables, in order to predict one-year mortality. Performance of the predictive model is evaluated at successive temporal stages of the transplantation process. Variables are incrementally acquired during the process, starting with patient-only variables at stage 1, ending with patient, donor and surgery-related measurements at stage 12. At each stage of the process, a machine-learning model has been trained based on available variables. A 80-20-cross-validation procedure has been performed at each stage, and repeated 40 times, resulting in a set of 40 area under ROC curve scores, whose distribution has been summarized using boxplots (median, 25 and 75 percentiles). Gini score allowed to each variable its weight in the model. Results The AUROC performance starts at 0.65 for step 1 and reaches 0.75 (figure) at the final step. Gini score found Lung Allocation Score as the best predictor of one-year mortality (3.17), followed by hyperlactatemia at second lung implantation (2.62), PaO2/FiO2 ratio at end-surgery (2.46) and age (2.35). Second lung ischemic time was a the 20th position in Gini Score (1.6). Conclusion Conclusion: Machine-learning approach is feasible to predict one-year mortality after lung transplantation. This study is encouraging to go further in the analysis of our database.

To summarize current knowledge on contraceptive coverage in France and worldwide, describe the effectiveness of different types of contraceptives, describe the characteristics of women using contraception, contraceptive failure situations and describe the different medical risks associated with contraceptive methods.Consultation of the Medline database and of national or international reports on contraception.Contraceptive coverage in France is high: 97% of women in 2013 use a contraceptive method (among fertile, sexually active women without a desire for pregnancy), with a majority using medical methods (72% using pills and other hormonal contraceptives, intrauterine devices and 25% using natural and traditional barrier methods). The 2013 pill scare called into question the use of estrogen-progestogenic contraception and the information provided by doctors, but the pill remains the first contraceptive method followed by the intrauterine device, condoms and the traditional and natural methods. Lifetime contraceptive coverage changes according to a defined standard in France: condoms for the teen-agers, pills before pregnancy and then intrauterine devices after childbirth. Sterilization is very rarely chosen and offered. Contraception in France remains a predominantly female domain. Women and couples should be informed about all contraceptive methods, allowing them to choose the method that best suits their health, living conditions and sexuality.

Resume L’oxygenation extracorporelle ou extra-corporeal membrane oxygenation (ECMO) constitue une suppleance de l’echangeur respiratoire (oxygenation et decarboxylation) pour laquelle un regain d’interet survient depuis quelques annees. Cet interet a ete amplifie par la pandemie grippale H1N1 mais est egalement suscite par des ameliorations technologiques significatives qui autorisent aujourd’hui la mise en œuvre chez des patients eveilles et mobiles. Mais c’est essentiellement l’emergence d’etudes randomisees comme dans le syndrome de detresse respiratoire de l’adulte avec des resultats encourageants qui valorisent cette therapeutique. Connaitre la terminologie et les principes generaux de cette technique ainsi que les situations et perspectives futures auxquelles le pneumologue et le reanimateur peuvent etre confrontes fait l’objet de cette revue generale. Deux points seront en particulier evoques tels que les perspectives d’epuration extracorporelle du CO2 dans le cadre des decompensations respiratoires hypercapniques et les situations de suppleances au cours de la transplantation pulmonaire depuis la periode preoperatoire, jusqu’a la phase postoperatoire.

We used an automated bispectral index (BIS)-guided dual-loop controller to determine propofol and remifentanil requirements during general anaesthesia in obese and lean surgical patients.Obese patients, BMI35 kg m(-2), and lean patients (25 kg m(-2)) having laparoscopic procedures were prospectively evaluated in this multicentre single-blind study. The automated controller targeted BIS between 40 and 60 by adjusting propofol and remifentanil administration. Propofol and remifentanil consumptions were calculated using both total body weight (TBW) and ideal body weight (IBW). Results are expressed as medians (inter-quartile range).Thirty obese [BMI=43 (40-49) kg m(-2)] and 29 lean [BMI=23 (21-25) kg m(-2)] patients completed the study. BIS was between 40 and 60 during 84 (69-91)% vs 85 (78-92)% of the anaesthetic time, P=0.46. The amount of propofol given during induction [1.2 (1.1-1.6) vs 1.3 (1.0-1.7) mg kg(-1), P=0.47] and maintenance [5.2 (4.1-6) vs 5.3 (4.7-6.4) mg kg(-1) h(-1), P=0.39] calculated using TBW was similar between the two groups. The dual-loop controller delivered half as much remifentanil to the obese patients during induction [1.0 (0.8-1.6) vs 2.2 (1.5-2.7) µg kg(-1), P0.001] and maintenance [0.12 (0.07-0.16) vs 0.25 (0.17-0.29) µg kg(-1) min(-1), P0.001] calculated using TBW. But when remifentanil consumption was calculated using IBW, the amounts were similar during induction at 2.2 (1.6-3.5) vs 2.0 (1.6-3.0) µg kg(-1) IBW, P=0.48, and during maintenance at 0.26 (0.16-0.34) vs 0.27 (0.18-0.33 ) µg kg(-1) min(-1), P=0.50.The amount of propofol-remifentanil administered by the controller is consistent with current knowledge, propofol is best dosed using TBW whereas remifentanil is best dosed using IBW.NCT00779844.

During the 2014-2015 mutual events season, the Institut de Mécanique Céleste et de Calcul des Éphémérides (IMCCE), Paris, France, and the Sternberg Astronomical Institute (SAI), Moscow, Russia, led an international observation campaign to record ground-based photometric observations of Galilean moon mutual occultations and eclipses.We focused on processing the complete photometric observations data base to compute new accurate astrometric positions. We used our method to derive astrometric positions from the light curves of the events. We developed an accurate photometric model of mutual occultations and eclipses, while correcting for the satellite albedos, Hapke's light scattering law, the phase effect, and the limb darkening. We processed 609 light curves, and we compared the observed positions of the satellites with the theoretical positions from IMCCE NOE-5-2010-GAL satellite ephemerides and INPOP13c planetary ephemeris. The standard deviation after fitting the light curve in equatorial positions is ±24 mas, or 75 km at Jupiter. The rms (O-C) in equatorial positions is ±50 mas, or 150 km at Jupiter. © 2017 The Author(s).

Lung transplantation is deemed to be the only effective therapy that improves survival for patients with end stage lung disease. The aim of our study was to examine the progress achieved over the last two decades and to demonstrate the effectiveness and safety of this treatment.A retrospective analysis of a cohort of 600 consecutive lung transplant patients treated at the hospital Foch (Suresnes, France) between 1988 and 2014. They were split into three groups of 200 patients each: 1988-2004, 2004-2011, 2011-2014.Time and mortality on waiting list, perioperative mortality, the incidence of acute rejection in the first year and chronic lung allograft dysfunction (CLAD) at 5 years posttransplantation, have all decreased. Global survival at 1 and 5 years for the 600 patients increased from 78% and 57% to 86% and 75% respectively for the 200 last patients. Patients with cystic fibrosis have a better 5 year survival than those with emphysema or pulmonary fibrosis (68% vs. 54 % for emphysema and 37% for fibrosis). For the last 200 patients, 5 year survival is 81% for CF patients, 78 % for emphysema and 47% for fibrosis. Emergency transplantation had a 60% 5 years survival. Proliferative complications, arterial hypertension and renal function impairment are being monitored long term.The twenty-five years experience shows a consistent improvement in the results of lung transplantation which is now accepted as the only effective curative treatment for end stage lung disease.

OBJECTIVES Only 15% of brain death donors are considered suitable for lung transplantation (LTx). The normothermic ex vivo lung perfusion technique is used to potentially increase the availability of high-risk lung donors. We report our experience of LTx with initially rejected donors after ex vivo lung reconditioning (EVLR). METHODS From April 2011 to May 2013, we performed EVLR for 32 pairs of donor lungs deemed unsuitable for transplantation and rejected by the 11 French lung transplant teams. After EVLR, lungs with acceptable function were transplanted. During the same period, 81 double-lung transplantations (DLTx) were used as controls. RESULTS During EVLR, 31 of 32 donor lungs recovered physiological function with a median PO2/FiO2 ratio increasing from 274 (range 162-404) mmHg to 511 (378-668) mmHg at the end of EVLR (P < 0.0001). Thirty-one DLTx were performed. The incidence of primary graft dysfunction 72 h after LTx was 9.5% in the EVLR group and 8.5% in the control group (P = 1). The median time of extubation, intensive care unit and hospital lengths of stay were 1, 9 and 37 days in the EVLR group and 1 (P = 0.17), 6 (P = 0.06) and 28 days (P = 0.09) in the control group, respectively. Thirty-day mortality rates were 3.3% (n = 1) in the EVLR group and 3.7% (n = 3) in the control group (P = 0.69). One-year survival rates were 93% in the EVLR group and 91% in the control group. CONCLUSIONS EVLR is a reliable and repeatable technique that offers a significant increase of available donors. The results of LTx with EVLR lungs are similar to those obtained with conventional donors.

En un paciente que se encuentra en reanimacion y presenta un cuadro de insuficiencia respiratoria aguda, el estudio por imagen se hace indispensable ante una agravacion de la hematosis y si el traslado del paciente expone a un riesgo considerable. En la actualidad, la realizacion de una ecografia pleuropulmonar es de rigor tras una valoracion semiologica simple y especifica, con la ventaja de que se trata de un metodo reproducible. Por eso, se ha convertido en una tecnica alternativa segura y fiable, de aprendizaje y realizacion simples. Esto permite que el clinico, tanto en una instancia prehospitalaria como en el hospital, pueda contar rapidamente con datos relativos al estado pulmonar de un paciente y orientarse con sensatez en el proceso diagnostico y terapeutico.

Introduction De multiples causes de dysphagie peuvent etre retrouvees. Parmi celles-ci, un obstacle extrinseque, comme les osteophytes de vertebres cervicales arthrosiques, peut etre responsable d’une obstruction pharyngo-œsophagienne haute. Bien que frequemment retrouves chez les sujets âges dysphagiques, les osteophytes cervicaux ne sont que rarement responsables de dysphagie severe. Nous rapportons le cas d’une jeune patiente. Observation Une femme de 43 ans est adressee en medecine interne pour l’exploration d’une dysphagie severe aux solides et aux liquides avec fibroscopie œso-gastroduodenale normale (y compris les biopsies systematiques). Elle a pour antecedent un ulcere gastrique, des douleurs articulaires chroniques, une rosacee et une agression a l’arme blanche ancienne avec des lesions au niveau du bras droit, du diaphragme et un pneumothorax. Cliniquement, il existe une stase salivaire, des troubles de la deglutition avec douleurs et fausses routes, pas de perte d’appetit. Malgre une alimentation lente (> 1 h par repas), precautionneuse et hypercalorique, ces troubles sont responsables d’une perte de poids de plus de 10 kg en 6 mois. Le reste de l’examen est sans particularite, il n’y pas de fievre, de signe infectieux, de deficit neurologique, de trouble respiratoire. Pas de troubles du transit, ni reflux gastro-œsophagien. Le bilan biologique standard est sans particularite, il n’y a pas de syndrome inflammatoire, pas de carence nutritionnelle, le bilan thyroidien et martial sont normaux. Le bilan auto-immun est negatif (Ac anti-recepteur de l’acetylcholine, anti-MUSK, anti-ADN natif, antinucleaire a 1/80) hormis les anticorps anti-Mi2b au DOT myosite mais a titre faible. Les CPK sont normales, un electromyogramme des 4 membres et des muscles cervicaux ne montre pas d’anomalie, permettant d’exclure une pathologie neuromusculaire systemique. Une manometrie œsophagienne ne retrouve pas d’anomalie de la motricite œsophagienne ou de pathologie des sphincters superieur et inferieur de l’œsophage. Un scanner cervico-thoraco-abdomino-pelvien retrouve en premiere lecture de l’arthrose moderee entre C4 et C7. L’examen fibroscopique ORL ne visualise pas d’obstacle, ni paralysie des cordes vocales. Finalement, la realisation d’un transit œso-gastroduodenal met en evidence des becs osseux osteophytiques marginaux anterieurs en C4–C5 et C5–C6 entrainant une empreinte sur la face posterieure de l’œsophage pouvant expliquer la dysphagie. Il n’est visualise de diverticule de Zenker. En reprenant l’interrogatoire, la patiente revele avoir ete victime de multiples traumatismes dans l’enfance et l’adolescence (maltraitance) pouvant etre responsables d’arthrose precoce. Devant la severite des symptomes avec echec des mesures d’adaptation dietetiques, une solution chirurgicale est envisagee. Les reconstructions 3D au scanner precisent la compression de l’œsophage par de volumineux osteophytes anterieurs. Discussion La dysphagie liee a une osteophytose cervicale anterieure resulte d’une compression mecanique extrinseque par un ou plusieurs osteophytes volumineux (> 10 mm), principalement au niveau C3–C5 [1] mais aussi de phenomenes inflammatoires locaux lies a l’irritation des tissus. Bien que connu depuis longtemps, peu de cas ont ete rapportes dans la litterature, principalement chez les sujets âges. Chez le sujet âge, une dysphagie peut aussi etre associee a une maladie de Forestier (ou hyperostose vertebrale engainante) mais la presence d’anomalies osseuses n’est pas suffisante pour retenir leur responsabilite et un bilan etiologique exhaustif doit etre entrepris, comprenant une etude videoradiographique de la deglutition (TOGD). Un traitement conservateur (mesures dietetiques, AINS, reeducation a la deglutition) doit etre entrepris le plus tot possible. Une intervention chirurgicale, risquee, (resection des osteophytes) doit etre envisagee pour les cas refractaires ou severes, avant que les compressions n’entrainent des degâts irreversibles sur la motricite de l’œsophage. L’experience dans la litterature montre qu’elle ameliore les symptomes dans la majorite des cas [1] . Conclusion Parmi les causes de dysphagie, l’existence d’osteophyte vertebraux cervicaux est a rechercher, y compris chez le sujet jeune, par la realisation d’un transit œso-gastroduodenal. Sa presentation atypique peut parfois etre severe et necessiter un traitement chirurgical.

Resume Nous rapportons la survenue d’une hyperthermie maligne chez un jeune patient de 21 ans polytraumatise. Ce cas presente pour particularites : une survenue brutale apres 4 heures de chirurgie ; une association de multiples facteurs declenchants et un diagnostic genetique prefere aux tests habituels de declenchement sur biopsie musculaire compte tenu d’anesthesies generales iteratives programmees. Les differents points sont discutes avec proposition d’un arbre diagnostique adapte au contexte.

La perfusion es un procedimiento que se realiza con mucha frecuencia en el ambito hospitalario. Esta practica, a menudo efectuada por tecnicos sanitarios, incluye aspectos especificos en cuanto a la colocacion, el control y la eleccion del material de perfusion a efectos de cumplir con la prescripcion medica. La opcion es amplia, desde la perfusion simple con venoclisis hasta la administracion de agentes farmacologicos a traves de una jeringa autopropulsada con objetivo de concentracion. Esto exige conocer bien los diversos sistemas. El proposito de este articulo es describir las vias de acceso de una perfusion y analizar las ventajas y los limites de los sistemas disponibles.

El protoxido de nitrogeno u oxido nitroso es un agente volatil que se utiliza en el ambito medico desde hace mas de 150 anos. Sus propiedades farmacologicas constituyen su particularidad, ya que posee al mismo tiempo propiedades analgesicas, de tipo no morfinico a traves de una accion supraespinal, propiedades euforizantes que le han valido la denominacion de «gas de la risa» y propiedades ansioliticas o incluso anestesicas leves, por lo que se utiliza ampliamente como agente anestesico volatil adyuvante. Con el fin de garantizar su inocuidad y eficacia maxima, se han definido con precision sus condiciones de empleo, tales como la necesidad de informar previamente al paciente cuando se utiliza con fines analgesicos (reduccion del foco de fractura, punciones diversas), un uso exclusivamente asociado a la administracion de oxigeno, la utilizacion de dispositivos especiales para su administracion con valvulas antirretorno o sistemas de ventilacion especificos en el quirofano para limitar la contaminacion ambiental, etc. Por otra parte, este agente posee algunas contraindicaciones, como por ejemplo en pacientes que presentan deficit conocidos o probables de vitamina B12 o de folatos y las ocupaciones aereas de cavidades no extensibles. Por ultimo, se han descrito algunos efectos indeseables como nauseas, vomitos postoperatorios y efectos neurotoxicos que limitan y condicionan su uso.