[Intervenir auprès des hommes training in the Montérégie health network. An organizational perspective]. / La formation Intervenir auprès des hommes dans le réseau de santé en Montérégie. Une perspective organisationnelle.

INTRODUCTION: The primary objective of the For'hommes project deployed since 2011 in the Montérégie region (south of Montreal in Quebec) is to increase awareness and train Health and Social Services Centers (CSSS) administrators, clinical supervisors and intervention workers in dealing with the male clientele. OBJECTIVE: An evaluation of project implementation allowed documentation of the organizational practices enabling the development of the "lntervenir auprès des hommes" training in the CSSS. METHOD: Eight interviews with administrators and supervisors from five of the seven CSSS were conducted in 2013. RESULTS: The awareness and training programmes prompted the CSSSs to assess the services offered and review certain practices (organizational or clinical) targeting male clienteles. The welcoming process, analysis of the requests and intervention with men are now more adapted to their realities and needs: more rapid intervention, phone support prior to management, helping men with referrals to community social services, a better understanding of the calls for help. To pursue the deployment of services adapted to a male clientele, administrators and supervisors emphasized the importance of continuing to offer training to CSSS intervention workers. CONCLUSION: Reflection emerging from the training of the managers and supervisors represents a promising approach, as it involves the key actors in the organization's. We can therefore consider "lntervenir auprès des hommes" training to be a key element of improvement of the services offered by CSSSs.

Anatomy of the pleura: reflection lines and recesses.

Knowledge of the anatomy of the lines of pleural reflection, triangular ligaments, and pleural recesses is important to thoracic surgeons because their anatomic areas are used daily for radiographic interpretation as well as for the performance of procedures such as chest tube insertion, thoracentesis, and pericardiocentesis. Their knowledge is also important for thoracic surgeons doing surgical procedures such as parietal pleurectomies, extrapleural mobilization and resection of the lungs, and pleuroneumonectomies for destroyed lungs or malignant pleural neoplasms.

Mediastinal divisions and compartments.

Having a clear understanding of the divisions of the mediastinum is important for the thoracic surgeon who daily has to establish a differential diagnosis of mediastinal masses based on their location, as well as to select the best surgical approach to access the mediastinum to obtain diagnostic material, to drain mediastinal spaces, or to excise mediastinal tumors. In this respect, the most useful classifications appear to be the 3-compartment model and Shields' 3-zone classification. This article describes the various classifications of the mediastinum.

Anatomy of the superior vena cava and brachiocephalic veins.

The venous side of the systemic vascular circulation returns the left ventricular cardiac output in a converging fashion to the superior and inferior vena cava and hence to the right atrium. Oxygenated blood is returned to the left atrium. The volumes of these 2 systems are in balance in a normal physiologic state.

Nerves of the mediastinum.

Knowledge of the anatomy of the mediastinal nerves is essential for the evaluation and surgical treatment of most thoracic neoplasms. Thorough knowledge of the normal anatomy of the mediastinal nerves and of their variants cannot be overestimated because nerve trauma during nerve anatomy is also important because mediastinal or lung tumors can locally infiltrate those nerves either directly or through nodal metastases, making them generally unresectable.

Correlative anatomy of the pleura and pleural spaces.

Although pleural disorders are commonly encountered in the daily practices of thoracic surgeons, their assessment can be difficult. Being able to correlate normal and abnormal anatomy with imaging characteristics provides additional information that can be useful not only to accurately locate pleuropulmonary lesions but also to characterize abnormalities, such as pleural thickening or malignant processes.

Correlative anatomy of the diaphragm.

The diaphragm acts as a partition between the thoracic and abdominal cavities. On computed tomography, it is seen as a curved soft-tissue density with fat below and aerated lung above. The direct multiplanar capability of magnetic resonance technology can improve depiction of normal or abnormal diaphragmatic anatomy. Despite the usefulness of these imaging modalities, adequate visualization of the diaphragm can be difficult. Thoracic surgeons must be familiar with the correlative anatomy of the diaphragm because this knowledge is a prerequisite to making an accurate diagnosis of diaphragmatic abnormalities.

Novel treatment for chylothorax after esophagectomy with 50% glucose pleurodesis.

Chylothorax is characterized by the presence of chyle in the pleural space and cardiothoracic surgery accounts for nearly half of all the cases. Treatment of chylothorax has traditionally been nonoperative, with alternative medical therapies involving the administration of octreotide or pleurodesis. Pleurodesis with chemical agents has previously been reported, but never with 50% glucose and 0.1% xylocaine. Herein, we report a successful method of intrapleural instillation of 50% glucose and 0.1% xylocaine to treat chylothorax. Five patients treated with this method were all recovered rapidly. This method can generate extensive adherence and prevent the effusion of the chylous fluid with minor side effects.

Birth of Airway Surgery and Evolution over the Past Fifty Years.

Significant developments in airway surgery occurred following the introduction of mechanical ventilators and intubation with cuffed endotracheal tubes during the poliomyelitis epidemic of the 1950s. The resulting plethora of postintubation injuries provided extensive experience with resection and reconstruction of stenotic tracheal lesions. In the early 1960s, it was thought that no more 2 cm of trachea could be removed. By the late 1960s, this was challenged owing to better knowledge of airway anatomy and blood supply, tension-releasing maneuvers, and improved anesthetic techniques. Currently, about half of the tracheal length can be safely removed and continuity restored by primary anastomosis.

Carinal Pneumonectomy.

Carcinoma of the lung can involve the carina. Resection then encompasses resection of the lung with the carina. Success of this complex procedure is based on careful selection of patients, judicious use of multimodality therapies, and expert multidisciplinary care. Selection of patients is based on staging of the cancer and an evaluation of their cardiopulmonary reserve. The surgery must aim at removing all of the malignancy and nodes. The anastomosis must be tension free and buttressed with a vascularized pedicled flap. Multiple ways are available to maintain proper ventilation of patients during the reconstruction of the carina.

Tuberculosis and Other Granulomatous Diseases of the Airway.

Granulomatous diseases of the airway are challenging lesions to diagnose and effectively manage not only because they are uncommon but also because they can occur in different forms, each with unique clinical and radiological characteristics. Most such lesions can be effectively managed conservatively with repeated airway dilatation, use of intraluminal stents, and specific antimicrobial treatment. The only exception is those lesions presenting with localized airway obstruction wherein surgical resection may be indicated and beneficial.

Sharing the Airway: The Importance of Good Communication Between Anesthesiologist and Surgeon.

One of the most challenging tasks during airway surgery is ensuring adequate ventilation throughout the procedure. Because the airway is shared between surgeon and anesthesiologist, successful oxygenation and ventilation of the patient can only be accomplished through close collaboration during the various stages of the procedure. This includes periods in which surgical airway manipulation compromises adequate ventilation and periods in which ventilation interferes with the surgical environment. With continuous communication between surgeon and anesthesiologist, optimal outcomes can be achieved.

Experiences with Prosthetic Airway Replacement.

Prosthetic airway reconstruction is seldom indicated in modern airway surgery because more than one-half the trachea can now be safely resected and the trachea be primarily reconstructed. In addition, an ideal prosthesis has yet to be developed with the use of those currently available being often associated with major morbidities and poor long-term outcomes. Recent developments in tracheal transplantation or tissue engineering strategies that promote and accelerate epithelial repair by controlling cell organization remains experimental, but showing great promise.

Recognition and Management of Life-Threatening Tracheovascular Fistulae and How to Prevent Them.

Formation of a fistula between trachea and a major artery or vein in the root of the neck threatens life quickly from combination of major external bleeding and hemorrhagic shock, and asphyxiation from flooding of the proximal airways with blood. This complication can occur after cervical tracheostomy open or percutaneous, tracheal resection, cervical exentration and anterior mediastinal tracheostomy, and laryngectomy. The recognition of its occurrence is clinical based on a high index of clinical suspicion. The life-saving operation for this complication carries potential risk for ischemic stroke. Impairment of arterial perfusion to the right arm and ischemia is another potential complication.

Importance of a Team Effort in Success of Airway Surgery.

The thoracic surgeon occupies a unique position in the team of those who are involved in looking after surgical patients in need of airway operations. It may be for urgent and life-threatening situations as in tracheo-vascular fistula or critical airway obstruction. Or it may be semiurgent in the intensive care unit in patients on assisted ventilation requiring tracheostomy (open or percutaneous). It may be elective for patients with tracheal stricture (benign or malignant), cervical exenteration, anterior mediastinal tracheostomy, and tracheo-bronchomalacia.

Anatomy of the neck and cervicothoracic junction.

All thoracic surgeons must have an extensive knowledge of the anatomy of the neck, because cervical approaches are used on an almost daily basis to access the cervical trachea, upper esophagus, and superior mediastinum. In addition to basic and scholarly knowledge of anatomy, they also must understand the anatomic relationships among the neck, the mediastinum, and both pleural spaces. Indeed, such knowledge forms the basis for the diagnosis and management of many aspects of pulmonary, mediastinal, and esophageal pathologies.

Glottis and subglottis: a thoracic surgeon's perspective.

Anatomically, the larynx presents several unique features that account for the difficulties in the surgical management of pathologies, such as benign strictures located in the area. These features include its unique cartilaginous support, its short length, its intrinsic and extrinsic musculatures, and its innervation, all of which are fundamental for the function of breathing, phonation, and swallowing. It is important that the thoracic surgeon operating on the larynx understand this particular anatomy, the limits of surgery, and most importantly the steps to be taken to avoid catastrophic complications.

Correlative anatomy for the sternum and ribs, costovertebral angle, chest wall muscles and intercostal spaces, thoracic outlet.

The structures of the chest wall and thoracic outlet are complex. A working knowledge of their anatomy and of its variations is essential to any thoracic surgeon working in the area. Correlating imaging with anatomy is just as important if one wants to recognize surgical indications, and potential operating difficulties. In the past, conventional radiographic examination was the norm but interpretation was often difficult and incomplete. Currently, CT and MRI are the best available imaging tools, and most times they have complementary roles in the evaluation of chest wall anatomy.

Lobes, fissures, and bronchopulmonary segments.

The clinical practice of thoracic surgery requires the surgeon to have intimate knowledge of pulmonary anatomy and of its variations. Attempts to perform thoracic procedures without this knowledge can only result in incomplete operations or technical mishaps. Proper understanding of the anatomy of the pulmonary lobes, segments, and fissures allows the surgeon to correlate imaging, pathologic processes, and possible resectional procedures, thus insuring that each patient gets the best possible operation.