Emergency physician performed ultrasound-assisted lumbar puncture in children: A randomized controlled trial.

BACKGROUND AND OBJECTIVE: Lumbar puncture (LP) is one of the most common procedures performed in pediatric emergency departments but first-attempt success rates remain low and traumatic LP remains frequent. The aim of this study was to determine if ultrasound performed by emergency physicians improves the probability of first-attempt success for lumbar puncture in children. METHODS: This was a prospective randomized controlled trial conducted in two tertiary care, pediatric, university-affiliated emergency departments in 2017-2018. Eligible participants were children younger than 19 years old requiring an LP in the emergency department. They were randomized to either the standard landmark-based LP (SLP) or ultrasound-assisted LP (UALP) groups. Our primary outcome was the first-attempt LP success rate. RESULTS: 166 patients were enrolled, with 84 in the UALP and 82 in the SLP group. A total of 23 physicians performed ultrasounds in the study. The proportion of successful first-attempt LP was higher in the ultrasound group (60/84; 68%) than for the standard procedure (52/82; 60%), but this failed to reach statistical significance (difference: 8.1%; 95% CI: -6.4 to 22.2). CONCLUSION: Our study does not support the routine use of ultrasound for performing lumbar puncture in children. Considering the minimal harm and ease of performance, ultrasound may be used as an adjunct and teaching tool in certain clinical situations.

Cervical Digital Photography: An Alternative Method to Colposcopy.

OBJECTIVE: This study sought to evaluate the performance of cervical digital photography as an alternative to colposcopy. METHODS: Colposcopy and cervical digital photography were performed on 228 women. The cervical digital photographs were evaluated through the Internet by three colposcopy experts. The agreement between methods was calculated with kappa and percentages of agreement. Next, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated for colposcopy and cervical digital photography. Histology was used as the gold standard (Canadian Task Force Classification II-2). RESULTS: Cervical digital photography and colposcopy were in agreement in 89.9% of the cases (κ = 0.588). Cervical digital photography had higher sensitivity (52.5%) and positive predictive value (60%) than colposcopy (35% and 48.28%, respectively). There were no other significant differences between cervical digital photography and colposcopy: specificity was 91.86% and 91.28%, negative predictive value was 89.3% and 85.8%, and diagnostic accuracy was 84.4% and 80.7%, respectively. CONCLUSION: Cervical digital photography is a promising alternative method to colposcopy.

Extensive adipose tissue necrosis following pfannenstiel incision for endometrial cancer.

BACKGROUND: Hematomas are potential postoperative complications that may arise from Pfannenstiel incisions. They usually either resolve spontaneously or are drained depending on their extent. Major risk factors such as obesity and diabetes may lead to superimposed complications and further worsen the outcome. CASE: A 73-year-old woman presented with a large subcutaneous hematoma 10 days after total abdominal hysterectomy done through a Pfannenstiel incision for endometrial cancer. The hematoma progressed and led to extensive subcutaneous fat necrosis. Extensive debridement was required, and negative pressure wound therapy with gauze was used to allow second intention closure. Satisfactory healing was achieved after 82 days of treatment without skin grafting. CONCLUSION: This case highlights the usefulness of gauze-based negative pressure wound therapy, as well as the need for a multidisciplinary approach in taking care of such complex wound complication.

Contexte : Les hématomes sont des complications postopératoires qui peuvent en venir à se manifester à la suite du recours à des incisions de Pfannenstiel. Habituellement, ils se résorbent de façon spontanée ou font l'objet d'un drainage (en fonction de leur ampleur). Des facteurs de risque importants (comme l'obésité et le diabète) pourraient mener à des complications surajoutées et aggraver davantage l'issue. Cas : Dix jours après avoir subi une hystérectomie abdominale totale par incision de Pfannenstiel en raison d'un cancer de l'endomètre, une femme de 73 ans a présenté un gros hématome sous-cutané. L'hématome en question a évolué et a mené à une nécrose étendue du tissu adipeux sous-cutané. La mise en œuvre d'un débridement de grande envergure s'est avérée nécessaire et la plaie a été traitée par pression négative au moyen de gaze afin de permettre une cicatrisation par deuxième intention. Une guérison satisfaisante a été constatée après 82 jours de traitement, sans greffe cutanée. Conclusion : Ce cas souligne l'utilité du traitement de plaie par pression négative au moyen de gaze, ainsi que la nécessité d'avoir recours à une approche multidisciplinaire au moment d'assurer la prise en charge de complications de plaie d'une telle complexité.

Simple vaginal trachelectomy in early-stage low-risk cervical cancer: a pilot study of 16 cases and review of the literature.

OBJECTIVE: This study aimed to evaluate the feasibility of simple vaginal trachelectomy and node assessment in patients with low-risk early-stage cervical cancer (<2 cm). METHODS: From May 2007 to November 2012, 16 women with low-risk small-volume cervical cancer underwent a simple vaginal trachelectomy preceded by laparoscopic sentinel node mapping plus or minus pelvic node dissection. Data were collected prospectively in a computerized database. Descriptive statistics and Kaplan-Meyer estimate were used for analysis. RESULTS: Patients' median age was 30 years and 12 (75%) were nulliparous. Six had a diagnostic cone, 6 had a loop electrocautery excision procedure, 3 had cervical biopsies, and 1 had polyp excision. All patients underwent a preoperative pelvic magnetic resonance imaging. Four patients had stage IA1 with lymph vascular space invasion (LSVI), 6 IA2, and 6 IB1. Ten (62.5%) had squamous lesions, 7 had adenocarcinoma. LVSI was present in 4 cases, suspicious in 2, and absent in 10. There were 2 surgical complications: a trocar site hematoma and a vaginal laceration. The median OR time was 150 minutes (range, 120-180 minutes) and median blood loss was 50 mL (range, 50-150 mL). On final pathology, lymph nodes were negative in all patients. Thirteen (81%) patients had either no residual disease (6) or residual dysplasia only (7) in the trachelectomy specimen. Margins were negative in all cases. With a median follow-up of 27 months (range, 1-65 months), there have been no recurrences. The recurrence-free survival at 24 months is 100%. Eight patients have conceived: 3 were term deliveries and 4 are ongoing. CONCLUSIONS: Simple trachelectomy and nodes seems to be a safe alternative in well-selected patients with early-stage low-risk cervical cancer. Our data will need to be confirmed in larger series.

Prospective study on the treatment of lower-extremity chronic venous and mixed ulcers using tissue-engineered skin substitute made by the self-assembly approach.

BACKGROUND: Despite present optimal standard treatment of lower-extremity ulceration, a high incidence of recurrence and treatment failure is observed. The objective of this project was to evaluate the effect of a self-assembled skin substitute (SASS) made by tissue engineering as a temporary cutaneous dressing in the treatment of hard-to-heal chronic ulcers. PATIENTS AND METHODS: The prospective uncontrolled case study includes patients suffering from venous or mixed ulcers lasting more than 6 months and unresponsive to compression therapy, with an Ankle Brachial Index greater than 0.5. Compression therapy was combined with the weekly application of SASS, produced from the patient's own skin cells, until healing. A weekly follow-up recorded wound size, skin aspect, pain, drainage, and percentage of wound healing. Photographs were also taken to assess ulcer evolution. RESULTS: Fourteen ulcers present on 5 patients were treated. A mean of 6.7 SASS depositions by ulcer was required for healing. Two ulcers developed a minor wound infection, which was treated with oral antibiotics; another 2 ulcers recurred, and 1 healed with a second course of treatment, whereas 1 ulcer had a small recurrence treated with local wound care. CONCLUSION: The authors' study suggests that the SASS used as a biological dressing is a promising treatment for hard-to-heal chronic venous and mixed ulcers that are unresponsive to compression therapy.

Angiogenic properties of myofibroblasts isolated from normal human skin wounds.

During wound healing, angiogenesis plays a crucial role in inducing adequate perfusion of the new tissue, thereby allowing its survival. This angiogenic process contributes to the formation of granulation tissue, alongside myofibroblasts. Myofibroblasts are cells specialized in wound contraction and synthesis of new extracellular matrix. Fibroblasts, considered by some to be at the origin of myofibroblasts, have already been shown to promote neovascularization. Thus, we hypothesized that myofibroblasts play a key role during angiogenic development in wound healing. We isolated myofibroblasts from normal human skin wounds and dermal microvascular endothelial cells (HDMVEC) and fibroblasts from skin. Using an in vitro fibrin-based model, we compared the proangiogenic activity of wound myofibroblasts to that of fibroblasts in the presence of HDMVEC. By immunostaining with collagen IV antibodies, we observed the formation of a capillary network significantly more developed when HDMVEC were cultured with myofibroblasts compared to the network formed in the presence of fibroblasts. The differences between these cell types did not result from a differential secretion of Vascular Endothelial Growth Factor or basic Fibroblast Growth Factor. However, in the presence of myofibroblasts, a significant decrease in matrix metalloproteinase activity was observed. This finding was correlated with a significant increase in Tissue Inhibitor of MetalloProteinase (TIMP)-1 and TIMP-3. Furthermore, inhibition of TIMP-1 secretion using shRNA significantly decreased myofibroblasts induced angiogenesis. These results led to the hypothesis that normal wound myofibroblasts contribute to the vascular network development during wound healing. Our data emphasize the critical role of wound myofibroblasts during healing.

The technicity index: a useful performance indicator for minimally invasive surgery in the management of endometrial cancer.

INTRODUCTION: Minimally invasive surgery is the surgical approach of choice for the management of numerous non-oncologic and oncologic conditions. The Technicity Index (TI) is defined in this study as the ratio of minimally invasive hysterectomies to abdominal hysterectomies performed during the studied time period. The TI indicates, in this context, the level of surgical technique and can thus be used as a health care indicator. The objective of this study was to evaluate whether the TI of the surgical management of endometrial cancer had significantly increased over three different time periods in our gynaecologic oncology division. METHODS: The TI was calculated from the data recorded in a surgical management system from July 1999 to June 2011. The study period was divided into three equal time periods (P1: July 1999 to June 2003; P2: July 2003 to June 2007; P3: July 2007 to June 2011). The z-score was used to compare the TI in each period, with P = 0.05 indicating the level of significance. RESULTS: The TIs in the first two time periods were comparable (P = 0.96); however, the difference between each of the first two time periods and the third (P1 vs. P3 and P2 vs. P3) was statistically significant (P < 0.001 for each). CONCLUSION: The TI for the surgical management of endometrial cancer increased more significantly from 2007 to 2011 than in the previous eight years. The TI could be used as a performance indicator and as an incentive to promote minimally invasive surgery in the surgical management of endometrial cancer.

The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies.

OBJECTIVE: To review our first consecutive 125 vaginal radical trachelectomies (VRT) to assess the oncologic, fertility and obstetrical outcomes. METHODS: Data from our prospective database was used to identify all VRT planned between October 1991 to March 2010 in patients with early-stage cervical cancer (stages IA, IB and IIA). Chi-square test, Fisher's exact test and Student t-test were used to compare baseline characteristics and Kaplan-Meier survival curves were constructed and compared with the use of the log-rank test. RESULTS: During the study period, 140 VRT were planned and 125 were performed. The median age of the patients was 31 and 75% were nulliparous. The majority of the lesions were stage IA2 (21%) or IB1 (69%) and 41% were grade 1. In terms of histology, 56% were squamous and 37% were adenocarcinomas. Vascular space invasion was present in 29% of cases, and 88.5% of the lesions measured ≤2cm. The mean follow-up was 93months (range: 4-225months). There were 6 recurrences (4.8%) and 2 deaths (1.6%) following VRT. The actuarial 5-year recurrence-free survival was 95.8% [95% CI: 0.90-0.98], whereas it was 79% [95% CI: 0.49-0.93] in the group where the VRT was abandoned (p=0.001). Higher tumor grade, LVSI and size >2cm appeared to be predictive of the risk of abandoning VRT (p=0.001, p=0.025 and p=0.03 respectively). Tumor size >2cm was statistically significantly associated with a higher risk of recurrence (p=0.001). In terms of obstetrical outcome, 58 women conceived a total of 106 pregnancies. The first and second trimester miscarriage rates were 20% and 3% respectively, and 77 (73%) of the pregnancies reached the third trimester, of which 58 (75%) delivered at term. Overall, 15 (13.5%) patients experienced fertility problems, 40% of which were due to cervical factor. Twelve (80%) were able to conceive, the majority with assisted reproductive technologies. CONCLUSION: VRT is an oncologically safe procedure in well-selected patients with early-stage disease. Lesion size >2cm appears to be associated with a higher risk of recurrence and a higher risk of abandoning the planned VRT. Fertility and obstetrical outcomes post VRT are excellent.

Value of sentinel node mapping in cancer of the cervix.

OBJECTIVES: To compare the relative value of two methods of detection for the sentinel lymphatic nodes (SLNs): colorimetric with Isosulfan blue (ISB) and radio-isotopic with Technetium-99 (Tc99), and to evaluate the concept of the SLN mapping applied to cervical cancer. METHODS: From October 2000 to December 2006, radical surgery was planned in 211 patients who presented early-stage cancer of the cervix. Both ISB and Tc99 were used to detect the SLNs. In all cases, we proceeded with laparoscopy for the identification and removal of the SLNs, followed by a complete pelvic lymphadenectomy with or without para-aortic node sampling. The SLNs were sent for frozen section (1 level) and were ultra-staged (6 levels) for final pathology. Detection rate, sensitivity and negative predictive value (NPV) were calculated. RESULTS: Among the 211 patients, ISB (n=152) identified at least 1 SLN in 92.8% of the cases. With Tc99 (n=166), the detection rate of SLN increased to 96.9%. When both techniques were used together (n=107), Tc99 was significantly better than ISB by 7.8% (p=0.0094) and at least 1 SLN (hot and/or blue) was found in 99.1% of the cases. In 16.7% of patients, a SLN was located in aberrant sites, including 3.8% in the para-aortic area. Thirty-three out of the 211 patients (15.6%) had lymph node metastases. When considering only the 181 patients with bilateral SLNs identified, the NPV of SLN is 100% after ultra staging on final pathology and 94.2% on frozen section (FS). CONCLUSION: Sentinel node mapping is feasible using laparoscopy. The radio-isotopic technique adds significantly to the rate of detection. The main benefits of SLN mapping in cervical cancer are the detection of micro-metastases on ultra staging which might be missed on routine pathological evaluation, and identification of aberrant drainage sites. However, the current frozen section techniques lack sensitivity to identify very small metastases and need refinement. SLN mapping should become the standard of care in the modern management of cervical cancer and complete pelvic lymphadenectomy could be avoided when bilateral SLNs are detected in patients with lesions less than 2 cm.

Ovarian cancer in the elderly patient: are we doing enough?

INTRODUCTION: ovarian cancer is deadly and frequently affects older patients. In the next 20 years, the number of patients over 65 will double, and cancer, including ovarian cancer, will increase in incidence. We wished to determine whether surgical morbidity, outcomes, and survival rates were worse in the older age group than in younger patients, and whether measuring serum CA 125 could be helpful in triaging patients for surgery. METHODS: we conducted a retrospective chart review of patients undergoing surgery for ovarian cancer in our institution from April 1996 to May 2006. A total of 127 patients met the inclusion criteria and were divided by age into two groups: patients aged under 70 and those aged 70 or older. We used Fisher test, two-tailed Student t test, chi-square test, and Kaplan-Meyer statistical methods to obtain survival curves and to test hypotheses and probabilities. RESULTS: patients aged 70 and over were less likely to have stage I disease and to undergo optimal surgery. They also presented with more advanced disease, but this did not translate into a difference in survival rates. Serum CA 125 levels did not enable identification of older patients who would benefit from surgery. CONCLUSION: older patients with ovarian cancer did not have reduced survival rates compared to younger patients, but they were more likely to undergo suboptimal surgery and to have more advanced disease. Preoperative serum CA 125 measurements did not identify patients in the older age group for whom surgery would be optimal.

Preoperative CA 125 tumour marker in endometrial cancer: correlation with advanced stage disease.

OBJECTIVE: To evaluate if a preoperative serum CA 125 level>or=35 kU/L in patients with endometrial cancer correlates with a surgical stage III or IV and poor histopathological prognostic factors. METHODS: We conducted a retrospective cohort study of 254 patients who underwent hysterectomy and full staging for endometrial cancer. Preoperative serum CA 125 was available for each patient as well as complete clinical and histopathological data. Chi-square, Fisher exact test, multivariate logistic regression, and receiver operating characteristic curve curves were used for statistical analysis. RESULTS: A total of 186 (73%) patients had stage I or II disease and 68 (27%) had stage III or IV disease. A statistically higher number of patients from the stage III or IV group had a serum CA 125 level>or=35 kU/L (58%) compared with the stage I or II group (16%) (OR 7.44; P<0.001). There was no correlation between serum CA 125 level and histological subtype. Patients with stage I or II disease and serum CA 125>or=35 kU/L (46%) had significantly more frequent deep myometrial invasion (>50%) than did those with serum CA 125<35 kU/L (18%) (OR 3.68; P=0.006). CONCLUSION: Assay of the preoperative serum CA 125 level is a very simple test to detect patients with more advanced stage endometrial adenocarcinoma. Its routine use could help triage high risk patients preoperatively.

[Use and management of proton pump inhibitors: An observational study]. / Utilisation et gestion des inhibiteurs de la pompe à protons : une étude observationnelle.

INTRODUCTION: Proton pump inhibitors (PPIs) have improved the management and prevention of digestive diseases, leading to a heavy prescription of this therapy. In 2015, nearly one quarter of the French population had consumed a PPI and half of them were long-term users. The main objective of this study was to analyze, in patients hospitalized in several medical departments, the adequacy of long-term PPI prescriptions to recommendations. METHOD: The Use and management of proton pump inhibitors: an observational study project (UTOPPIA) is a longitudinal observational study conducted at the University Hospital of Saint-Étienne in the departments of hepato-gastroenterology, infectious and tropical diseases, internal medicine, vascular medicine and nephrology. All patients with PPI treatment on their usual outpatient prescription were interviewed. RESULTS: Over a 3-month period, 334 of hospitalized patients (30.7%) had received a long-term PPI prescription and 181 patients (54.2%) could be included in the study for a total of 274 indications. Ninety-nine patients (54.7%) had a long-term PPI prescription in accordance with the recommendations. The most frequent indication (70 prescriptions) was the prescription of an antiplatelet drug or anticoagulant for subjects at high risk of bleeding in 70 prescriptions. Fifty-three PPI treatments were amended during the hospital stay, including 9 discontinuations. The justification for the change was documented in the patients' chart in only 17% of cases. Individual interviews of patients revealed that 75.1% of them were in favour of discontinuing their PPI treatment. CONCLUSIONS: About one-third of hospitalized patients in medical wards in France have long-term PPI treatment and half of these prescriptions do not comply with good practice recommendations. A majority of patients report being willing to try to stop PPI therapy.

[Medication errors in Auvergne-Rhône-Alpes: A prospective pilot study led in collaboration by regional vigilance and support structures]. / Erreurs médicamenteuses en Auvergne Rhône-Alpes : étude pilote descriptive collaborative entre structures régionales de vigilance et d'appui (SRVA).

Medication errors (ME) are frequently encountered and present at every step of the therapeutic process. This study's aims were to take stock of the ME reported to the region's pharmacovigilance (CRPV) and poison control centers (CAPTV) and to identify potential regional actions. A 2-months (January and February 2017) prospective gathering of the calls to the CAPTV regarding the ME and of the ME declarations to the region's CRPV (Clermont-Ferrand, Grenoble, Lyon, Saint-Etienne) has been carried out. The place of occurrence, the event's description and its consequences and data regarding the patient were collected. In addition to that, the regional drug observatory OMEDIT analysis has allowed to determine the ME's types (REMED characterization, never event?) and to look for the results of a potential thorough analysis. The study reported 580 calls for 590 ME and 583 patients. ME mostly affected the ambulatory/domicile sector (76%), the medico-social sector (14%) and the healthcare facilities sector (7%). It usually was about dose errors, medication errors and patient errors with a different profile in each sector. The majority of errors (85%) occurred at the administration step. Almost all the observed ME were confirmed errors having reached the patient (99.5%) but only a few had serious consequences. One out of 5 ME was eligible for a thorough analysis but even less were subjected to that kind of analysis. The main never event concerned the unidose in the ambulatory sector. The health products involved were mostly a single medication (75%) and then the patient's full treatment (12%). The CRPV/CAPTV/OMEDIT's skills are complementary for the gathering, the analysis and the management of the ME. Training campaigns and support are to be considered for the professionals and especially within the medico-social facilities.

Sentinel lymph node biopsy in patients with gynecologic cancers Expert panel statement from the International Sentinel Node Society Meeting, February 21, 2008.

An expert panel was formed for the 6th biennial International Sentinel Node Society to review the status of sentinel lymph node biopsy (SLNB) in gynecologic oncology. This paper presents the opinion of the experts who participated regarding indications for SLNB, technical considerations, and directions for future investigation.

Indication and method of frozen section in vaginal radical trachelectomy.

Vaginal radical trachelectomy (VRT) is a fertility-sparing surgical technique used as an alternative to radical hysterectomy in early stage cervical carcinoma. With the advent of VRT, preoperative evaluation of the surgical margin has become imperative, because if the tumor is found within 5 mm of the endocervical margin, additional surgical resection is required. In a study published earlier from our center, we came to the conclusion that a frozen section should be conducted only when a cancerous lesion is grossly visible, and that it could be omitted in normal-looking specimens or VRT with nonspecific lesions. Since then, 53 VRT have been performed in our center, and frozen sections were conducted according to these recommendations. Fifteen VRT were grossly normal, 24 had a nonspecific lesion and 14 showed a grossly visible lesion. Final margins were satisfactory on all 15 grossly normal specimens. Of the 24 VRT with nonspecific lesions, 2 cases for which no frozen section was performed had unsatisfactory final margins (<5 mm). Of the 14 VRT with grossly visible lesions, 3 cases were inadequately evaluated by frozen section due to sampling errors, which led to unsatisfactory final margin assessment. These results confirm that a frozen section can be omitted on normal looking VRT specimens, but contrary to results published earlier, we recommend that a frozen section be performed on all VRT with nonspecific lesions. As for VRT with a grossly visible lesion, frozen section evaluation is still warranted, and we recommend increasing the sampling to improve the adequacy of frozen sections.

Primitive clear cell carcinoma of the vagina treated conservatively.

BACKGROUND: Clear cell adenocarcinoma of the vagina is rare tumour that is usually treated aggressively. We report a case of clear cell adenocarcinoma in which conservative treatment using new technology was successfully completed. CASE: A 19-year-old woman with a biopsy proven clear cell adenocarcinoma of the vagina was referred to our clinic. There was no history of in utero diethylstilbestrol exposure. Colposcopic examination and pelvic MRI confirmed a superficial vaginal lesion. Fertility-sparing surgery, comprising radical local vaginal excision, laparoscopy, sentinel node mapping, pelvic node dissection, and omentectomy, was planned. A staging surgical procedure including a unilateral sentinel lymph node was negative. CONCLUSION: Conservative surgery can be offered to a young woman presenting with this rare tumour in order to preserve fertility. Sentinel node mapping is an adjunct to the conservative surgery.

Fertility-preserving options for cervical cancer.

Childbearing is one of the most important life goals for many women, and fertility preservation is a very important factor in the overall quality of life of cancer survivors. Cervical cancer frequently affects young women; because some women tend to delay childbearing, fertility preservation must be considered when treatment options are discussed. Over the past decade, the radical trachelectomy procedure has become a well established fertility-preserving option for young women with early-stage cancer; this procedure is associated with low morbidity, good oncologic outcome, and a high proportion of pregnancies that reach the third trimester and babies that are delivered at term. This article will review available literature on the vaginal radical trachelectomy procedure and data from other surgical approaches, such as the abdominal radical trachelectomy. In addition, the potential future application of neoadjuvant chemotherapy followed by fertility-preserving surgery in patients with locally advanced cervical cancer will be examined. Finally, ultraconservative surgical approaches (eg, conization alone with or without laparoscopic lymphadenectomy) in very early-stage disease will be discussed.

Structuring an inter-sector research partnership: a negotiated zone.

OBJECTIVES: To document and analyze the initial steps in building a health research partnership. To enable a greater appreciation of what these processes entail and also to provide guidance in negotiating the inevitable tensions between parties with different aims and objectives. METHODS: This case study is based on participant-observation and document analysis. It employed three general analytic strategies: developing a case description, relying on theoretical propositions and thinking about rival explanations. RESULTS: The development of a research partnership framework entails a complex negotiation process marked by tensions: one of representing the interests of the various parties; and one establishing the basis for collaboration. Some factors can facilitate these processes: acknowledging the specific interests and organizational culture of the various organizations involved; designating a mediator to develop a climate of trust; and mitigating the inequalities among partners, in a process which requires considerable efforts over a rather long period of time. CONCLUSION: The process of structuring the relations among the associated partners does not end with negotiating a partnership accord. Denying this would be tantamount to denying the political nature of a research partnership, and denying those involved any autonomy in future research projects.