The therapeutic group in adolescence: A process of intersubjectivation.

This article analyses group processes in adolescence through therapeutic group interventions. The authors propose to analyse the group aspect, cross-identifications and projective identifications of the adolescent subjectivation process. In which ways does the adolescent subjectivation process need to go through a process of intersubjectivation? This involves a consideration of observable intersubjectivity in a therapeutic group with troubled adolescents. After redefining the notion of subjectivation process and its various manifestations in adolescent psychopathology, the authors further analyse the complex implications of this notion, from the point of view of object cathexes and of links to others. The task is to establish a metapsychology of links to introduce therapeutic psychoanalytic groups into psychic dynamics: in particular, the authors discuss the methodology of theatre-mediated therapeutic psychoanalytic groups, from which the clinical vignette discussed is taken. A case study of a group of adolescents discovers the haphazardness of the link to the other, as a cornerstone towards reinitializing the process of subjectivation that has been hindered in members of the group, and as a way of resuming self-reflectiveness and the reimagining of the self.

Pressure-controlled ventilation improves oxygenation during laparoscopic obesity surgery compared with volume-controlled ventilation.

BACKGROUND: We compared pressure and volume-controlled ventilation (PCV and VCV) in morbidly obese patients undergoing laparoscopic gastric banding surgery. METHODS: Thirty-six patients, BMI>35 kg m(-2), no major obstructive or restrictive respiratory disorder, and Pa(CO(2))<6.0 kPa, were randomized to receive either VCV or PCV during the surgery. Ventilation settings followed two distinct algorithms aiming to maintain end-tidal CO(2) (E'(CO(2))) between 4.40 and 4.66 kPa and plateau pressure (P(plateau)) as low as possible. Primary outcome variable was peroperative P(plateau). Secondary outcomes were Pa(O(2)) (Fi(O(2)) at 0.6 in each group) and Pa(CO(2)) during surgery and 2 h after extubation. Pressure, flow, and volume time curves were recorded. RESULTS: There were no significant differences in patient characteristics and co-morbidity in the two groups. Mean pH, Pa(O(2)), Sa(O(2)), and the Pa(O(2))/Fi(O(2)) ratio were higher in the PCV group, whereas Pa(CO(2)) and the E'(CO(2))-Pa(CO(2)) gradient were lower (all P<0.05). Ventilation variables, including plateau and mean airway pressures, anaesthesia-related variables, and postoperative cardiovascular variables, blood gases, and morphine requirements after the operation were similar. CONCLUSIONS: The changes in oxygenation can only be explained by an improvement in the lungs ventilation/perfusion ratio. The decelerating inspiratory flow used in PCV generates higher instantaneous flow peaks and may allow a better alveolar recruitment. PCV improves oxygenation without any side-effects.

[European normative recommendations for medical gas pipeline systems]. / Normalisation européenne et systèmes de distribution de gaz médicaux.

Several recent decisions have been made in order to increase the security of medical gases delivery in French hospitals. These different changes affect: 1) the hospital itself with the creation of working groups in charge of both monitoring and maintenance of gases networks; 2) the pharmaceutical regulation with promotion of several gases to the status of drugs or need of CE marking for the whole gas network. European rules onset required to give up French former norms (NF) to the profit of "NF EN" rules. Nevertheless, the new norm NF EN 737-3 which concerns medical gases distribution systems does not affect principal clauses of the previous NF S 90-155. It introduces new elements allowing to deploy two types of medical gases networks: the double pressure level used in France and the single pressure level used in the rest of Europe. This new norm, which attempts to harmonize alarm control systems in both types of networks, suffers from important limitations describing the double pressure level systems. Lastly, the final checking proposed by this new norm is very different from the previous one, and is likely to be problematic for the final users within the hospital.

[Management of suspected heart injuries]. / Prise en charge des suspicions de plaie du coeur.

Penetrating cardiac injury has to be ruled out in any patients with penetrating thoracic injuries, even in those with no alterations in vital functions. Undelayed echocardiography should be performed to screen for the presence of pericardial effusion. The first case underlines the risk of cardiac tamponade if the diagnosis is missed. Echocardiography was not performed because no echocardiographist was present at the time, and a high suspicion of a neck vascular injury existed. Sudden deterioration due to the onset of acute tamponade was only reversed by an immediate pericardiocentesis followed by surgical haemostasis. The second patient, although stable, had a large echographic pericardial effusion. Emergent sternotomy revealed a large amount of blood in the pericardial space and two cardiac wounds with one on a coronary artery. Penetrating wounds in proximity to the heart, even in a stable patient, require aggressive attempts at ruling out a cardiac injury. Immediate echocardiography should be systematically performed to screen for pericardial fluid.

[Perianaesthetic concerns for the new robot-assisted transaxillary thyroid surgery: a report of seven first cases]. / Implications anesthésiques de la chirurgie thyroïdienne ou parathyroïdienne par voie axillaire sous robot-assistance : à propos de sept premiers cas.

The gasless transaxillary robot-assisted endoscopic thyroid surgery is recently proposed and developed in South Corea and USA. We reported the perianaesthestic concerns for the seven first patients scheduled to undergo this innovative surgical technique in France. The anaesthetic considerations focused on the length of surgery according to the learning curve, the risk of the arm posture and the postoperative painful evaluation and relief.

[Hemofiltration during severe sepsis or multiorgan failure syndrome]. / Hémofiltratin au cours des états septiques graves ou du syndrome de défaillance multiviscérale.

Continuous renal replacement therapy (CRRT) has been used in intensive care units particularly in patients with sepsis or multiorgan failure. In comparison to intermittent haemodialysis, hemofiltration techniques offers an improved hemodynamic tolerance, related to the absence of osmotic pressure gradient. Indeed, hemofiltration is based on the physical principle of convection to remove substances from the plasma. The removal of substances that are released during sepsis, acute respiratory distress syndrome or multiorgan failure may be of particular interest. Several human studies have demonstrated that hemofiltration removes various inflammatory mediators, but the clinical significance of this removal remains questionable. If this removal occurs predominantly by convection, interest in hemofiltration will focus on high volume hemofiltration in order to obtain maximal ultrafiltrate flows. Patients with sepsis or multiorgan failure require close monitoring of most vital functions. The use of a CRRT technique emphasizes the importance of this monitoring and adds new monitoring issues relative to fluid balance, anticoagulation, hypothermia or drug removal.

Propofol-induced modifications of cardiomyocyte calcium transient and sarcoplasmic reticulum function in rats.

BACKGROUND: Propofol is considered to be an anesthetic agent with few or no negative inotropic effects. This study evaluated a possible direct depressant effect of propofol on sarcoplasmic reticulum Ca2+ accumulation and cardiomyocytes. METHODS: The effects of propofol on intracellular Ca2+ transients were evaluated in isolated rat cardiomyocytes using a microfluorometric technique with Indo-1. Sarcoplasmic reticulum function was also assessed by measuring the oxalate-stimulated Ca2+ uptake from homogenates of rat ventricles. RESULTS: The Ca2+ uptake capacity of the sarcoplasmic reticulum was decreased by propofol (10(-4) M). Large concentrations of propofol decreased the rate of decrease of the intracellular Ca2+ transient, which resulted in an increase of diastolic Ca2+ when the diastolic interval was decreased. The increased diastolic Ca2+ also resulted in a decrease in Ca2+ transient. This effect appeared for lower doses (10(-5) M) after a short diastolic pause rather than after a long (2- to 3-min) rest (appearing at 10(-4) M). CONCLUSIONS: For doses more than 10(-5) M, propofol induces a Ca2+ uptake capacity impairment of the sarcoplasmic reticulum. This is probably responsible for a slowing of the decrease of the Ca2+ transient, which in turn increases the diastolic Ca2+ for high heart rate. These diastolic modifications may participate in the slight negative inotropic effect of the drug.

Cytosolic myocardial calcium modulation by ATP-dependent potassium channel openers and NO donors.

The goal of this study was to evaluate, in rat cardiomyocytes, the effects on cytosolic calcium of a pure K-adenosine triphosphate (ATP) channel opener, aprikalim, and those of nicorandil, a dual-acting agent that increases cyclic guanosine monophosphate (cGMP) levels and opens K-ATP channels. These effects were compared with those of a pure NO donor, 3-morpholino-sydnonimine (Sin-1). Ventricular myocytes were isolated from the hearts of adult rats. Changes in cytosolic calcium concentration ([Ca2+]i) were measured by using a Ca2+ indicator, indo-1/AM. Alterations in indo-1 fluorescence were recorded during regular electrical stimulation. After 10 min of pacing, end-diastolic [Ca2+]i was significantly increased as compared with control without significant changes in calcium transient. For doses of 10(-7) to 10(-4) M, aprikalim and nicorandil did not affect significantly the calcium transient. Sin-1 produced a significant decrease in calcium transient (by approximately 20%), which was already maximal at 10(-7) M. When given with the potassium channel antagonist glibenclamide (10(-5) M), nicorandil induced the same effects as those observed with Sin-1. We conclude that potassium channel openers aprikalim and nicorandil do not not decrease calcium transient. Thus the NO-donor properties of nicorandil are not apparent when given alone but appear when ATP-dependent potassium channels are blocked.