[Perception of medication risk by the public and role of the media]. / Rapport 22-09. Perception du risque médicamenteux par le public et rôle des médias.

Opinion polls regularly show that the vast majority of French people have a positive perception of the efficacy and safety of using medicines, including vaccines. Distrust or hostility towards them is only the fact of a small minority of the population, but active and noisy on social networks and overvalued by the media and public authorities. However, the pandemic due to Covid 19 (SARS-CoV-2) has confirmed to what extent the perception of drug risk by the public is unstable, sometimes irrational, how many and complex the determinants of this perception are and what role as a public resonance, fears play out in the media. We can even implicitly see the general underlying tendency of our society, which is to grant primacy to risk to the detriment of profit in the assessment of a technological innovation. The risk tree often masking the forest of efficiency. This polarization of minds on risks, associated with an overestimation of low probabilities, testifies to the impregnation of our mores by the ideology of precaution. To which are added distorting factors such as naturalistic prejudice, cultural relativism and the planetary extension of social networks which instantly spread false information that is more viral and better remembered than the true ones, hampering communication based on science data. Promoting the correct perception of drug risk requires recalling both the benefits and the risks linked to action but also those linked to inaction; to clarify institutional messages by making them as factual as possible; to limit the number of public broadcasters to achieve greater consistency in their messages; to have the frankness to sometimes say that we do not know, medicine by nature being practiced in a context of uncertainty. The Academy calls for an ambitious educational policy for young people: training in critical thinking and the acquisition of the basics of drug risk should be introduced from middle school. The Academy also believes that the public is entitled to expect quality-controlled information from the media, away from rumors, by calling on indisputable experts and by favoring objective data over subjective testimonies based on personal experiences.

Surgical treatments of atraumatic avascular necrosis of the shoulder.

Humeral head atraumatic avascular necrosis is a rare diagnosis. It concerns young patients with a high functional demand. The treatments are mostly surgical. The radiographic classification of Cruess assesses the severity of the humeral head avascular necrosis and guides surgical indications. This chapter reports a review of the literature based on meta-analyses and clinical series. Surgical treatments may be conservative or prosthetic. Conservative treatments include core decompression, bone grafting and arthroscopic debridement. Prosthetic replacements are performed by resurfacing, hemiarthroplasty or total arthroplasty. For low-grade asvascular necrosis, core decompression may be functionally effective and doesn't impair later surgical procedures. For high grades, prosthetic replacements achieve good functional outcomes. Hemiarthroplasty should be preferred if the glenoid cartilage is intact, with low rates of wear complications and better long-term outcome than shoulder arthroplasty.

[The notion of conflict of interest in the field of health and environment: philosophical and legal approaches]. / La notion de conflit d'intérêts dans les champs de la santé et de l'environnement: regards philosophique et juridique.

This paper considers the conflict of interest in philosophical and legal perspective. The philosophical approach comes from two perspectives: political philosophy focuses on the role of the link of interest in the city considered in the light of a broader reflection on the conditions of living together. Antiquity philosophers have enhanced the interest link as privileged vector of humanization and socialization of individuals. In the eighteenth century, Adam Smith considers the pursuit of individual interests a stronger social base that love of neighbor advocated by Christians. Moral philosophy focuses specifically on the passage of interest linked to the conflict of interest. It wondered if we should be impartial in all circumstances or whether it's right to give priority to our friends and loved ones. Thus, it poses the question of whether introspection is sufficient to detect conflicts of interest or if the look of an external third party is still required. The legal process differs from the philosophical approach at two levels; on the one hand, its scope is more limited: the law doesn't envisage the benefits of links of interest on social life even though it may protect some of them (in the context of the family, for example) and is intended to prevent bias that may taint the decision public. On the other hand, the lawyer doesn't enter the interiority of individuals but stands by what appears on the outside: it tracks the suspicion of bias can have serious impacts, such as health and the environment. Somehow, it is more radical. It's noteworthy that despite its many developments, the law can't to stop conflicts of interest in research. Several reasons account for this impasse: scientists receive mission to partner with industry to develop products but they must remain independent in order to assess the risks; there is a tendency to always choose the same experts; there are conflicts of interest intellectuals which are not easy to detect.

Return home at the end of life: Patients' vulnerability and risk factors.

Although most of the people in good health questioned about the subject said they would like to die at home, in the western world between 60 and 80% of deaths occur in hospital. Most authors consider that the indispensable conditions for a return home are the patient's desire and presence of the family and caregivers with the appropriate skills. The assessment of other factors predictive of a return home is inadequate. The aim of this study is to clarify how the return home is influenced by the vulnerability of the patient at the end of life, and by that of the family and caregivers. We carried out a multicentric, observational, prospective, exhaustive and longitudinal epidemiological study (three months follow-up), including 146 patients hospitalized at the end of their life and desiring to return home. For these patients the caregivers respected their freedom to choose to die at home in over half the cases (56%). Their overall vulnerability (personal, family context and caregivers) had a significant influence on the return home. This overall vulnerability was in fact identified as applying in 40% of the clinical situations, and made the possibility of a return home 50% less likely.

New ethical challenges in the management of rare pediatric diseases with innovative therapies.

INTRODUCTION: Rare diseases, despite their low individual prevalence, affect a large number of children. Their management has considerably improved recently due to new treatments, modifying the diseases evolution without being totally curative. Since this raises many ethical dilemmas, we present a study about respecting the principles of medical ethics in the management of rare diseases in pediatrics. MATERIAL AND METHODS: We carried out a qualitative study in a French pediatric neurology department. In our study, we included health caregivers and parents of children being monitored for rare diseases and benefiting from innovative therapies. We conducted semi-structured interviews and, after transcription, we performed computerized and manual analysis. RESULTS: A total of 26 participants were included. Six main themes were addressed: rare diseases, science and medical research, general disease management, specific innovative treatments, neonatal screening, and cost of these treatments. Discussions centered on the children. Particular importance was given to the notions of information and the physician/family relationship. A major place is given to the treatment objectives and the improvement of quality of life. We also noted a sense of satisfaction with the current overall management of these diseases. CONCLUSION: Our study suggests that our current practice, including the use of innovative therapies, respects the four main ethical principles, from the points of view of both caregivers and parents.

Current knowledge in moral cognition can improve medical ethics.

Physicians frequently face ethical dilemmas when caring for patients. To help them to cope with these, biomedical ethics aims to implement moral norms for particular problems and contexts. As a means of studying the cognitive and neurobiological features underlying the respect for these norms, moral cognitive neuroscience could help us to understand and improve ethical questioning. The article reviews recent developments in the field and presents neurobiological arguments to highlight why some moral rules are universally shared and why some ethical responses are very dependent on context.

[Satisfaction survey on the use of autologous oocyte vitrification in Assisted Reproductive Technologies]. / Enquête de satisfaction des couples à propos de la vitrification ovocytaire autologue en assistance médicale à la procréation.

OBJECTIVES: We organized a survey for in-vitro fertilization couples who beneficiated on self-preservation of part of the oocyte cohort. The main objective was to measure couples' satisfaction. Secondary objectives were; to identify how patients had been informed; to verify that the use of the ART technique met their expectations, and how they felt about oocyte or embryo freezing. METHODS: The data were collected by a questionnaire sent electronically to couples who had undergone partial vitrification of the oocyte cohort and at least one warming cycle. The questionnaire consisted of 2 components; one for the women and another one for their husband. RESULTS: Eighty-eight women and 62 men responded to the survey respectively, representing 50.86% and 35.84% of the targeted patients. They were satisfied with a 90% rate, men and women combined. The information we give in the center is heard by couples and is part of the trust in the medical staff. Men are more worried than women about the risks of stimulation or ovarian pick-up and are not displeased to be called upon for sperm recovery for every attempt at oocyte warming. The ambiguity of the answers on the representation of the embryo confirms what is already described, but is independent of the acceptance of freezing whether it is oocyte or embryo. CONCLUSION: In the same way as evaluating the results, the evaluation of patient satisfaction is useful for the implementation of therapeutic strategies and care pathways.

Human resources needed to perform antimicrobial stewardship teams' activities in French hospitals.

OBJECTIVE: In January 2015, the French ministry of Health set up a task force on antibiotic resistance. Members of the task force's "antimicrobial stewardship" group conducted a study to evaluate the human resources needed to implement all the required activities of the multidisciplinary antimicrobial stewardship teams (AST - antibiotic/infectious disease lead supervisors, microbiologists, and pharmacists) in French healthcare facilities. METHODS: We conducted an online cross-sectional nationwide survey. The questionnaire was designed based on regulatory texts and experts' consensus. The survey took place between March and May 2015. We used the mailing list of the French Infectious Diseases Society (SPILF) to send out questionnaires. RESULTS: A total of 65 healthcare facilities completed the questionnaire. The human resources needed to implement all AST's activities were estimated at 3.6 full-time equivalent (FTE) positions/1000 acute care beds for antibiotic/infectious disease lead supervisors, at 2.5 FTE/1000 beds for pharmacists, and at 0.6 FTE/1000 beds for microbiologists. This almost amounts to a total of 2000 FTE positions for all healthcare facilities (public and private) in France and to an annual cost of 200 million euros. CONCLUSION: Dedicated and sustainable funding for AST is urgently needed to implement comprehensive and functional AST programs in all healthcare facilities.

Cord blood collection and banking from a population with highly diverse geographic origins increase HLA diversity in the registry and do not lower the proportion of validated cord blood units: experience of the Marseille Cord Blood Bank.

Several Cord Blood (CB) Bank studies suggested that ethnicity impaired CB unit (CBU) qualification. The Bone Marrow Donors Worldwide registries present an over-representation of unrelated donors (UD) from Northwestern European descent. This raises the question of equality of access to hematopoietic stem cells transplant, especially in the Mediterranean zone, which has taken in many waves of immigration. The aim of our study is to address whether, in the Marseille CB Bank, CBU qualification rate is impaired by geographic origin. The study compared biological characteristics of 106 CBU disqualified for total nucleated cell (TNC) count (dCBU) and 136 qualified CBU in relation to registry enrichment and haplotype origin. A high proportion (>80%) of both dCBU and CBU had at least one non-European haplotype and enrich CB and UD registries to a higher extent than those with two European haplotypes (P<0.001). No difference was observed between TNC count and volume according to geographic origin. Our study shows that diverse Mediterranean origins do not have an impact on the CBU qualification rate. Partnership with Mediterranean birth clinics with highly trained staff is a reasonable option to increase the HLA diversity of CB Bank inventories and to improve the representation of minorities.

Homocystinuria due to 5,10-methylenetetrahydrofolate reductase deficiency revealed by stroke in adult siblings.

Three patients from a single family of six siblings had homocystinemia and homocystinuria due to 5,10-methylenetetrahydrofolate reductase deficiency and had severe recurrent strokes in adult life. Two of the patients died 1 year after clinical onset.

Watershed cerebral infarcts: retrospective study of 24 cases.

Twenty-four patients presenting an acute stroke with watershed cerebral infarct on CT scan or MRI were included in this retrospective study. Age was 63 +/- 14 years (mean +/- SD), and sex ratio was 2 men for 1 woman. Main clinical features were: in anterior location, lower limb weakness and frontal syndrome with transcortical motor aphasia in left lesions or spatial dyscalculia in right ones; in posterior location, brachiofacial weakness with constant quadranopsia and hypoesthesia, and Gerstmann syndrome in left lesion. There was no distinctive feature for subcortical and multiple infarcts. In bilateral infarcts, there were one pseudobulbar syndrome, and 2 pseudo brainstem syndromes with neuropsychological signs. Aetiologies were severe carotid artery disease in 14 cases, severe cardiopathy in 6, isolated cerebral angiitis in 1, essential thrombocythemia in 1, protein C deficiency with sickle cell disease in 1, and cholesterol emboli in 1 anatomical case. CBF performed in carotid artery occlusions or tight stenoses showed evidence of haemodynamic changes. Microembolic process can be proposed in the case with cholesterol emboli. Preventive treatment is discussed.

[Transient neurological manifestations disclosing spontaneous acute cervical epidural hematoma]. / Manifestations neurologiques transitoires révélatrices d'hématomes épiduraux cervicaux aigus spontanés.

Spontaneous cervical epidural hematomas are uncommon lesions that usually produce permanent neurological deficit unless there is early surgical decompression. They are now well-recognized by scan X and especially by sagittal MRI of the spine. We describe 2 patients, a 24 year-old man and a 79 year-old woman with no previous history of trauma who were admitted in emergency for a sudden weakness of limbs, respectively a tetraplegia and a right hemiplegia. Both patients complained of inaugural and acute neck pain. Motor deficit completely resolved in few hours and MRI of the spine showed on T1 a signal isointense, extending respectively from C3 to C6 and C5 to C7, consistent with an hematoma. Laboratory data and angiography were normal. Surgery was recused. Neck pain lasted about a week. Follow-up MRI, in one case, was normal two months later. Cervical epidural hematomas revealed by transient neurological findings that completely and permanently resolved are exceptional. They could mimic ischemic myelopathy and should be considered in the differential diagnosis of other painful vascular conditions like symptomatic vertebral dissection to avoid inappropriate anticoagulation. Conservative management in these cases may be proposed if spontaneous neurological resolution is confirmed by MRI.

[Benign cerebral angiopathies and phenylpropanolamine]. / Angiopathies cérébrales bénignes et phénylpropanolamine.

Heroin, cocaine, amphetamines, sympathomimetic drugs can cause cerebral angiopathy. We report 2 patients with cerebrovascular disorders after ingestion of a nasal vasoconstrictor containing phenylpropanolamine (P.P.A.). The first patient had two acute repetitive attacks of severe headache and vomiting, occurring after a daily treatment with 180 mg of P.P.A. during 6 weeks. The second patient had an intracerebral hemorrhage, occurring some hours after taking for the first time 120 mg of P.P.A. In both cases, cerebral angiography, performed in the next week, demonstrated segmental narrowing and dilatations of medium-size intracranial arteries. None of the usual causes of cerebral vasculitis were present. The outcome was favorable and follow-up angiograms showed the disappearance of the beading pattern. P.P.A. is widely used over the counter in diet pills and stimulants. Cerebral vascular complications have been rarely reported, always hemorrhagic and often associated with cerebral vasculitis. They are unrelated to duration or dosage of treatment. The mechanism is unclear but could result from several factors: chronic or paroxystic high blood pressure, immuno-allergic vasculitis, arterial spasm, direct "toxic" effect of the P.P.A. on the arterial wall may be increased by other drugs and caffeine.

[Static contrast sensitivity in idiopathic Parkinson disease]. / Sensibilité au contraste statique dans la maladie de Parkinson idiopathique.

During Parkinson's disease static contrast sensitivity (C.S.) abnormalities are linked to an impairment of the sensitive visual function. C.S. was tested in twelve parkinsonians and 12 controls without neurological and/or ophthalmological pathology, using a Colored Stripes Electronic Generator (GEPCO). Results for parkinsons showed a general deficiency over the spectrum of spatial frequencies, which was statistically significant and particularly pronounced for intermediate frequencies. This study was repeated for three patients: it showed threshold deterioration for two of them, correlated by evolution in the disease, and an improvement for the third patient after introduction of dopatherapy. C.S. is subjected to dopaminergic control. Among parkinsonians. C.S. deterioration may result in an operating failure of both the visual cortex and retina, and is improved by dopatherapy. The Static Gepco contrast sensitivity test is easy to reproduce and can be used easily to monitor the sensory visual defect in parkinsonian patients under treatment.

[Clinical and developmental aspects of small brain stem hematomas. Contribution of x-ray computed tomography]. / Aspects cliniques et évolutifs des hématomes circonscrits du tronc cérébral. Apport du scanner X.

In a review of 16 cases, the authors emphasize that small brainstem haemorrhages, diagnosed by CT-scan, can have a good outcome, most often spontaneously. Twelve hematomas were in the pons, four in the mesencephalon. Several clinical features were remarkable: consciousness was not or moderately impaired, focal symptoms and signs predominantly neuro-ophthalmologic were present. Involvement of the cranial nerves and long tracts occurred rarely in isolation. Arterial hypertension was the usual cause (50 p. cent); one normotensive patient with neurological disorders prior to the bleeding had an arteriovenous malformation, demonstrated angiographically. In two cases an obstructive hydrocephalus was surgically treated. Expected advances from CT-scan and magnetic resonance imaging (M.R.I.) are discussed.

[GM2-Gangliosidosis variant B1 disclosed during adolescence by an isolated multi-systemic involvement of the central and peripheral nervous systems]. / Gangliosidose à GM2 variant B1. Révélation à l'adolescence par une atteinte isolée et plurisystématisée du système nerveux central et périphérique.

The authors report on a Portuguese family with 3 adult brothers affected with GM2-gangliosidosis (B1 variant) in a sibship of 4, and more specifically on one of these brothers with neurological onset at the age of 17. Psychosis, lower motoneuron involvement and dysarthria were predominant in two of the cases; the third had a cerebellar symptomatology. Hexosaminidase A activity, studied in leukocytes, was profoundly deficient when measured using the specific sulfated substrate, but nearly normal using a conventional assay (non-sulfated substrate). These results established the diagnosis of the unusual enzymological form of GM2-gangliosidosis known as the B1 variant, which had so far not been associated with an adult phenotype. Molecular studies are in progress to study genotype/phenotype correlations in this family in comparison with known mutations in the B1 variant and in adult GM2-gangliosidosis. This report also emphasizes that a metabolic etiology, leading to genetic counselling, should be considered in some familial degenerative neurological disorders.

Rate of intravenous thrombolysis for acute ischaemic stroke in the North-of-France region and evolution over time.

The proportion of patients with ischaemic stroke treated by intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) is an indicator of quality of stroke care. The objective of the study is to evaluate the rate of i.v. thrombolysis in the North-of-France region and its evolution over time. We determined the proportion of inhabitants treated by i.v. rt-PA in 2009-2010 (period A; 8 stroke units, no telemedicine) and 2012 (period B; population campaigns, 12 stroke units with telemedicine in 5). We used hospital registries from the 12 stroke units, and population-based data were collected in a subpopulation of 226,827 inhabitants (5.6% of the whole population). 1,563 inhabitants received i.v. rt-PA for stroke (period A: 835 in 24 months; period B: 728 in 12 months). Hospital and population data were similar. Annual rates of thrombolysis increased from 103 per million inhabitants [95% confidence interval (CI) 85-125] to 181 (95% CI 157-209; relative increase 76%, 95% CI 67-83%). This rate increased in 12 districts (significantly in 6), but the increase was greater in districts where new stroke units, telemedicine, or both were implemented. In conclusion, although the proportion of patients treated was already high in period A, there was still place for improvement. Implementation of new stroke units, extension of the telemedicine network and new population campaigns are necessary to improve the rate of thrombolysis in several areas, to ensure an equal access to treatment over the whole territory. The next step is now to determine whether this high rate of i.v. rt-PA delivery at the population level translates into clinical results.

[Palliative care birth plan: a field of perinatal medicine to build]. / Projets de naissance en soins palliatifs : un domaine de la périnatalité à construire.

Some couples may choose to continue the pregnancy unable to decide for termination of pregnancy. Such situations recently occurred in neonatology units and may lead to neonatal palliative care. Faced with all uncertainties inherent to medicine and the future of the baby, medical teams must inform parents of different possible outcome step by step. Consistency in the reflection and intentionality of the care is essential among all different stakeholders within the same health team to facilitate support of parents up to a possible fatal outcome. This issue in perinatal medicine seems to be to explore how caregivers can contribute in the construction of parenthood in a context of a palliative care birth plan.

[Ethical reflection on multidisciplinarity and confidentiality of information in medical imaging through new information and communication technologies]. / Réflexion éthique sur la pluridisciplinarité et la confidentialité de l'information en imagerie médicale via les nouvelles technologies de l'information et la communication.

Technological advances in medical imaging has resulted in the exponential increase of the number of images per examination, caused the irreversible decline of the silver film and imposed digital imaging. This digitization is a concept whose levels of development are multiple, reflecting the complexity of this process of technological change. Under these conditions, the use of medical information via new information and communication technologies is at the crossroads of several scientific approaches and several disciplines (medicine, ethics, law, economics, psychology, etc.) surrounding the information systems in health, doctor-patient relationship and concepts that are associated. Each day, these new information and communication technologies open up new horizons and the space of possibilities, spectacularly developing access to information and knowledge. In this perspective of digital technology emergence impacting the multidisciplinary use of health information systems, the ethical questions are numerous, especially on the preservation of privacy, confidentiality and security of medical data, and their accessibility and integrity.