Post mortem scientific sampling and the search for causes of death in intensive care: what information should be given and what consent should be obtained?

PURPOSE: The search for cause of death is important to improve knowledge and provide answers for the relatives of the deceased. Medical autopsy following unexplained death in hospital is one way to identify cause of death but is difficult to carry out routinely. Post mortem sampling (PMS) of tissues via thin biopsy needle or 'mini incisions' in the skin may be a useful alternative. A study was undertaken to assess how this approach is perceived by intensive care doctors and also to evaluate how this practice is considered in ethical terms in France. METHODS: A study of PMS practices immediately after death in 10 intensive care departments was performed. The medical director of each centre was interviewed by telephone and asked to describe practices in their unit and to outline the questions raised by this practice. RESULTS: PMS is routinely performed in 70% of the units which responded, without systematically obtaining formal consent and without precise rules for communicating results. Approaches to PMS differed between centres, but all physicians felt that PMS is useful for the scientific information it gives and also for the information it provides for relatives. All physicians regret the lack of standards to structure PMS practices. CONCLUSION: Information from post mortem examinations is important for society to inform about causes of death, for doctors to improve practices and for decision-makers responsible for organising care. Debate persists regarding the balance between individual rights and community interests. It is suggested that an approach for identifying cause of death could easily be integrated into the relationship between carers and relatives, provided full transparency is maintained.

Thrombospondin-1 is downregulated by anoxia and suppresses tumorigenicity of human glioblastoma cells.

Angiogenesis, the sprouting of new capillaries from preexisting blood vessels, results from a disruption of the balance between stimulatory and inhibitory factors. Here, we show that anoxia reduces expression of thrombospondin-1 (TSP-1), a natural inhibitor of angiogenesis, in glioblastoma cells. This suggests that reduced oxygen tension can promote angiogenesis not only by stimulating the production of inducers, such as vascular endothelial growth factor, but also by reducing the production of inhibitors. This downregulation may significantly contribute to glioblastoma development, since we show that an increase in TSP-1 expression is sufficient to strongly suppress glioblastoma cell tumorigenicity in vivo.

[Tolerance and efficacy of early nicotine substitution after acute coronary syndromes]. / Tolérance et efficacité de la substitution nicotinique précoce au décours d'un syndrome coronaire aigu.

The object of this study was to assess the cardiovascular tolerance and efficacy of early nicotine substitution therapy in 100 patients admitted to the Coronary Care Unit for acute coronary syndromes (ACS). The files of the first 100 consecutive patients having received nicotine substitution therapy immediately after an ACS were consulted retrospectively and a questionnaire was sent to all patients. A reply was obtained in 90% of cases. In this series, there was a 7% rate of cardiovascular events in the days following hospital discharge, comparable to previously reported results. The smoking relapse rate at six months after the ACS was 38.9%, a percentage which was less than in previously reported series. Although consultations to help stop smoking and nicotine substitution did not seem to have significant benefits in this study, the authors recommend continuing and improving the management of coronary patients who smoke.

Organization in response to massive afflux of war victims in civilian practice - experimental feedback from the November 2015 Paris terrorist attacks.

The arrival of a large number of war-weapon casualties at a civilian trauma center requires anticipation. A plan defining the management principles and the respective roles of the involved physicians and nurses and their interaction with each other is essential. Uni-directional patient flow associated with adequate numbers of staff physicians and nurses under the leadership of a medical director is essential to prevent the overwhelming of the trauma center. Routine and regular interaction between the pre-hospital medical flow control system and the medical director, on one hand, and between surgical teams and the medical director, on the other, are necessary to know when to apply "damage control" surgical techniques. Based on the feedback of a level 1 trauma center that received 53 victims of the November 13, 2015 terrorist attack in Paris, we present the factors of success, and the stumbling blocks.

Purification and characterization of a fatty acyl-ester hydrolase from post-germinated sunflower seeds.

Fatty acyl-ester hydrolase was not detectable in dry sunflower seeds using various p-nitrophenyl-acyl-esters, 1,2-O-didodecyl-rac-glycero-3-glutaric acid-resorufin ester or emulsified sunflower oil as substrate. After inhibition of the seeds, acyl-ester hydrolase activity slowly developed in cotyledon extracts and was maximal after 5 days. No activity was directly measurable on oil bodies. The enzyme was purified 615-fold to apparent homogeneity, as determined by performing SDS-PAGE electrophoresis, and biochemically characterized. With p-nitrophenyl-caprylate the optimum pH was around 8.0. The purification procedure involved an acetone powder from 5-day dark-germinated seedlings, chloroform-butanol extraction and three chromatography steps. We obtained 35 micrograms of pure enzyme from 250 g of fresh cotyledons with an activity yield of around 7%. It should be possible to subsequently improve this low recovery as we gave priority here, in the first instance, to purity at the expense of the yield. The enzyme consisted of one glycosylated polypeptide chain with a molecular mass of approx. 45 kDa and, as far as we could tell, it did not seem to require metal ions to be fully active, as it was not inhibited by EDTA or o-phenanthroline and not activated by various mono or bivalent metal ions. The amino acid composition showed the presence of four cysteine and four tryptophan residues. The enzyme was partially inhibited by dithiothreitol, DTNB and PCMB. The fact that high inhibition was observed in the presence of PMSF indicates that a serine residue may possibly be involved in the catalytic mechanism. The hydrophobicity index was about 53.6% which places this enzyme in the class of the soluble proteins in good agreement with the fact that it was mainly present in the soluble part of the crude extract. Partial characterization of glycan chains, using antiglycan antibodies, showed the presence of complex Asn-linked glycans. The enzyme was active on purified sunflower glycerol derivatives. It was also able to hydrolyze monooleyl and dioleyl glycerols, as well as phosphatidylcholine, but not cholesteryl esters. Using p-nitrophenyl-acyl-esters as substrate, the highest activity was observed with middle-chain derivatives (C6 and C8). Its maximum activity was about 0.015 units mg-1 with sunflower oil. It was not activated by an organic solvent such as isooctane. This enzyme probably is involved in acyl-ester hydrolysis which follows triacylglycerol mobilization by true lipases.

[Medications in smoking cessation]. / Médicaments d'aide au sevrage tabagique.

Physicians can aid their patients' smoking cessation by providing psychological support, advice, behavioral strategies, and drugs. Success depends on appropriate management, including selection of the right moment to begin treatment and an understanding of the development of the withdrawal syndrome, smoking urges, and the possibility of failure. The standard pharmacological treatment for nicotine dependence uses different forms of nicotine substitutes and bupropion, while we await data about other drugs currently under study. The score on the "simplified" Fagerström questionnaire usually determines the initial nicotine dose. Six forms of nicotine substitutes are available. They provide either prolonged nicotine release (transcutaneous patches) that prevents withdrawal symptoms, or rapid release through the buccal and nasal mucosa (chewing gum, suckers, inhalers and nasal sprays) to anticipate the positive effects represented by cigarettes and the urges occurring during withdrawal. The efficacy of these substitutes, widely studied, is approximately twice that of placebo. Their use is no longer contraindicated in patients with heart disease, when necessary. Bupropion should be used in treating nicotine dependence either as a first-line treatment, or if nicotine substitutes (150 mg/d the first week, 300 mg/d thereafter) fail. The combination of bupropion and nicotine substitutes can be considered, either from the outset for heavy or very heavy smokers, or afterwards, if withdrawal symptoms or urges to smoke persist in subjects treated by only one of these two drug classes. One of the new drugs under evaluation is rimonabant, the first representatives of a new class of drugs, selective CB1 endocannabinoid receptor antagonists. Promising results about its use in smoking cessation were released in 2004.

[Perioperative management of asplenic patients]. / Prévention du risque infectieux postopératoire chez les patients splénectomisés.

OBJECTIVE: In 2003, asplenia had involved 250000 patients in France. These patients are at risk of severe infection, mostly with capsulated bacteria as pneumococci, meningococci and Haemophilus. The higher mortality and morbidity due to infection in asplenic patient led in June 2003 a French expert committee to propose preventive management based on vaccination and antibioprophylaxis. STUDY DESIGN: Update article. DATA SYNTHESIS: For vaccination, two vaccines against pneumococci are available. The first one, the antipolysaccharide (Pneumo 23) is recommended for adults. It is effective for the majority of the serotypes even if its efficacy can be variable. The second one a conjugated pneumococcal vaccine (Prenevar) is used for children under two years because it has higher activity on antibiotic resistant strains therefore increasing antibiotic prophylaxis efficiency. When splenectomy is required, vaccination against pneumococci, Haemophilus (b type) and C meningococci must be performed at least 15 days before surgery, in order to get better immune stimulation. In case of emergency, vaccines have to be administrated within 30 days after surgery. Antibioprophylaxis is based on cefazolin injection before splenectomy and by postoperative intravenous amoxicillin administration. As soon as oral intake is allowed, antibioprophylaxis is continued for at least two years in adults and five years in children. Both antibiotic and vaccination have been reported to reduce pneumococcus infections.

Changes in iron status during weight loss with very-low-energy diets.

For several decades, very-low-energy diets (VLEDs) have been used by obese individuals to achieve weight loss. During the weight loss, patients often have dramatic drops in circulating thyroid hormone concentrations and experience cold intolerance. Because poor iron status is known to alter thermogenesis, we investigated the possibility that iron intake interacts with energy intake during weight loss in obese individuals. The effects on indicators of iron and thyroid status of increasing the iron content of a VLED from 18 to 27 mg/d during 12 wk of a VLED were compared with the effects on the same indicators of increasing energy intake from 1752 kJ(420 kcal) to 3347 kJ(800 kcal)/d. Although all VLED groups initially had 30% declines in plasma transferrin saturation, increases in plasma ferritin concentrations, and decreases in plasma thyroid hormone concentrations, patients who received iron supplementation had significantly higher circulating concentrations of triiodothyronine and thyroxine at the end of the VLED than did patients who received only the recommended dietary allowance of iron. The patients who received iron supplementation also had a more rapid return of iron indicators to normal values over the course of the VLED. The transitory fall in iron delivery to bone marrow was not associated with anemia. These data suggest that higher thyroid hormone concentrations can be maintained during VLEDs that provide higher iron intakes.

Impaired thermoregulation and thyroid function in iron-deficiency anemia.

Ten women with iron-deficiency anemia, 8 with depleted iron stores (nonanemic), and 12 control women, all of similar body fatness, were exposed to a 28 degrees C water bath to test the hypothesis that iron-deficiency anemia impairs thermoregulatory performance. The anemic women had lower rectal temperatures than did control women (36.0 +/- 0.2 vs 36.2 +/- 0.1 degree C, respectively, P = 0.001) and a lower rate of oxygen consumption (5.28 +/- 0.26 vs 5.99 +/- 0.29 mL.min-1.kg body wt-1, respectively, P = 0.04) at 100 min of cold exposure. Plasma thyroxine and triiodothyronine concentrations were significantly (P less than 0.002) lower in anemic than in control women at baseline and during cold exposure. Responses of iron-depleted subjects were similar to those of control subjects. Iron supplementation corrected the anemia, significantly (P = 0.03) improved rectal temperature at 100 min, and partially normalized plasma thyroid hormone concentrations. Plasma catecholamines were unaffected by iron status. This experiment demonstrates a functional consequence of iron-deficiency anemia in the balance of heat production and loss and suggests that thyroid-hormone metabolism may be responsible.

Estimation of energy expenditure and maintenance energy requirements of college-age men and women.

Data from two nationwide dietary surveys have led to the suggestion that human energy requirements have been overestimated. A 5-wk energy balance study was conducted to estimate the energy expenditure and maintenance energy requirements of 12 college-age men and women, 20 to 29 yr of age, by the factorial method and by measurement of energy intake and changes in body energy content (intake/balance technique). Mean daily energy expenditure estimated by the intake/balance technique and the factorial method, respectively, was 3081 and 3040 kcal (r = 0.90) for the male subjects and 2183 and 2283 kcal (r = 0.53) for the female subjects. Although differences between the intake/balance and factorial estimations of energy expenditure tended to be greater for individuals than groups and for females than males, the factorial method as performed in this study provided accurate estimations of energy expenditure. In addition, the estimated energy requirements of the college-age subjects in this study provide evidence to support the Recommended Dietary Allowances for energy for this age group.

Day-to-day variation in iron-status indices in healthy men and women.

We evaluated the day-to-day variation of four iron-status indices: hemoglobin (Hb), hematocrit (Hct), plasma ferritin (PF), and plasma iron (PI). Finger-prick blood samples were collected for 31 consecutive days in 20 healthy men and women. Replicate (sigma 2rep) and day-to-day (sigma 2day) variance components were estimated. Day-to-day variation in the iron-status measures was similar between men and women except for PF, for which the variation was greater in women. The CVs for a single future determination for Hb, Hct, PF, and PI were 4.6%, 3.0%, 15.2%, and 26.7% for males and 4.4%, 3.2%, 26.8%, and 29.0% for females, respectively. Three to 10 independent measurements are required to accurately determine PF and PI whereas one is adequate for Hb and Hct. Thus, day-to-day biological variation is a major component of the variability in these iron-status indicators and must be considered when assessing iron status.

Protein turnover and energy expenditure increase during exogenous nutrient availability in sickle cell disease.

In the present study, energy expenditure (EE) and rates of whole-body protein, glucose, and lipid metabolism were assessed in 8 African American sickle cell disease (SCD) patients and in 6 healthy African American control subjects during the infusion of amino acids, glucose, and lipid. Whole-body protein, glucose, and lipid kinetics were estimated by using L-[1-(13)C]leucine, D-[6,6-(2)H2]glucose, and [(2)H5]glycerol, respectively. After a 2-h tracer equilibration period and a 0.5-h basal period, nutrients were administered intravenously for 3 h with 16% of the energy as protein, 52% as carbohydrate, and 32% as fat. Breath and blood were collected during the last 30 min of nutrient infusion and EE was measured by indirect calorimetry. EE was 14% greater (P < or = 0.05) in SCD patients [145.0 +/- 3.5 kJ x kg fat-free mass (FFM)(-1) x d(-1)] than in control subjects (126.8 +/- 3.8 kJ x kg FFM(-1) x d(-1)). Whole-body protein breakdown (4.4 +/- 0.4 compared with 3.1 +/- 0.1 mg x kg FFM(-1) x min(-1), P < or = 0.05) and protein synthesis (4.6 +/- 0.4 compared with 3.2 +/- 0.1 g x kg FFM(-1) x min(-1), P < or = 0.05) were 42% and 44% greater, respectively, in the SCD patients than in control subjects, but whole-body amino acid oxidation (0.90 +/- 0.05 compared with 1.03 +/- 0.09 mg x kg FFM(-1) x min(-1)) was not significantly different between the 2 groups. Whole-body glucose and lipid kinetics did not differ significantly between the groups. EE increased in SCD patients during exogenous nutrient availability, and the additional energy required for the accelerated rates of whole-body protein breakdown and synthesis made a significant contribution to the increase in EE. These metabolic aberrations may increase the dietary energy and protein requirements of SCD patients.

A potential melanoma tracer: synthesis, radiolabeling, and biodistribution in mice of a new nitridotechnetium bis(aminothiol) derivative pharmacomodulated by a N-(diethylaminoethyl)benzamide.

Radioiodobenzamides are the best-known agents under study for the diagnosis of cutaneous melanoma and its metastases. We report the synthesis of a new BAT derivative radiopharmaceutical in which radioiodine is replaced by 99m-technetium. The cyclic intermediary methyl 4-[3-(4,4,7,7-tetramethyl-5,6-dithia-2, 9-diazacyclodecyl)-2-oxapropyl]benzoate (5) occurred in two different conformations identified by spectroscopic analysis. The final BAT ligand was radiolabeled using the nitridotechnetium core by a ligand-exchange reaction. Two different complexes were purified. After macroscopic 99-technetium synthesis, syn and anti isomers were identified. The global radiochemical yield was over 80%. The biodistribution of these two complexes was evaluated in mice bearing murine B16 melanoma. Extensive liver and kidney uptake was observed, but the benzamide tropism for the tumor was partially preserved.

The role of glucagon in the control of protein and amino acid metabolism in vivo.

The relative contribution of hyperglucagonemia to the mechanisms of nitrogen loss during catabolic states has not been clearly established. The present study examines the independent effect of physiologic elevations of plasma glucagon on whole-body protein kinetics, as well as on net amino acid balance across the liver and gastrointestinal tract tissues, in conscious 18-hour-fasted dogs (n = 7). Each study consisted of a 120-minute equilibration period, a 30-minute basal period, and a 150-minute experimental period. Leucine kinetics were measured using L-[1-14C]leucine. Pancreatic hormones were maintained by infusing intravenous somatostatin (0.8 micrograms/kg.min), intraportal insulin (275 microU/kg.min), and intraportal glucagon (0.65 ng/kg.min basally and 2.5 experimentally). Dextrose was infused to maintain plasma glucose constant (14.1 +/- 0.3 mumol/L), thereby providing a consistent metabolic steady state for the study of protein and amino acid metabolism. In the experimental period, plasma glucagon was fourfold basal levels (112 +/- 10 v 32 +/- 6 pg/mL), whereas plasma insulin remained stable (mean, 10 +/- 1 microU/mL). Hepatic glucose production was increased 30%, but leucine rates of appearance ([Ra] proteolysis), oxidative disappearance (Rd), and nonoxidative Rd (protein synthesis) were not altered during the experimental period. Furthermore, the net release of amino acids by the gastrointestinal tract was not increased by glucagon. However, uptake and extraction of amino acids by the liver were increased, resulting in a 17% decrease in total plasma amino acids.(ABSTRACT TRUNCATED AT 250 WORDS)

In addition to membrane injury, an affinity for melanin might be involved in the high sensitivity of human melanoma cells to hederacolchiside A1.

We previously reported that hederacolchiside A1 (Hcol A1), a new oleanene saponin isolated from Hedera colchica Koch (Araliaceae) exhibits a preferential cytotoxicity on a pigmented melanoma cell line. The present study confirms the high susceptibility of melanoma cell lines to this drug and shows concentrations producing a 50% decrease in cell content (IC50 values) inversely proportional to the melanin content of each cell line. At cytotoxic concentrations, Hcol A1 induces membrane-damaging effects within 6 h, cytoplasmic vacuolization within 24 h, and non-apoptotic cell death within 48 h. Using a new high-resolution magic-angle spinning nuclear magnetic resonance method, we have shown for the first time that this hederasaponin specifically interacts with melanin. The dissociation constant (2.7 mM) is comparable to those observed with drugs known to interact with melanin. Taking into consideration that the IC50 values were inversely proportional to the melanin in each cell line, our data suggest that, in addition to the delayed membrane injury induced by this drug, the ability of Hcol A1 to bind melanin could contribute to the higher toxicity of Hcol A1 in pigmented melanoma cells.

Parenteral glutamine infusion alters insulin-mediated glucose metabolism.

BACKGROUND: Glutamine is a conditionally essential amino acid that is critical for many basic cellular processes. Its supplementation has been found to be beneficial during several critical illnesses. This study examines the effects of increased glutamine availability on insulin-mediated glucose homeostasis in vivo in multicatheterized conscious canines (n = 5). METHODS: Two weeks before the study, catheters were placed in the femoral artery and the portal, hepatic, femoral, and renal veins for blood sampling and in the splenic vein for intraportal infusion of insulin and glucagon. Doppler probes were placed to measure blood flow. The metabolic study consisted of equilibration, basal, and experimental periods during which [3-3H]glucose was infused to measure glucose kinetics. During the 5-hour experimental period, a hyperinsulinemic-euglycemic clamp was performed by infusing somatostatin, basal glucagon, fivefold basal insulin, and glucose to maintain euglycemia. The experimental period was divided evenly into two subperiods performed in random order: (1) i.v. glutamine infusion (0.72 mmol kg(-1) h(-1)) and (2) i.v. saline infusion. RESULTS: With glutamine, the glucose required to maintain euglycemia was increased 46% over saline (6.8 +/- 1.0 to 9.9 +/- 1.7 mg kg(-1) min(-1). In addition, whole-body glucose production and utilization were increased by 1.4 and 4.6 mg kg(-1) min(-1), respectively. Finally, the increase in whole-body glucose utilization was manifested by increased hepatic and hindlimb glucose utilization. CONCLUSIONS: Increased glutamine availability blunted insulin's action on glucose production and enhanced insulin-mediated glucose utilization with the changes in utilization being threefold greater than the changes in production. Thus parenteral glutamine has potential benefit as a nutrient adjuvant during clinical situations associated with insulin resistance.

A comparison of air displacement plethysmography with three other techniques to determine body fat in healthy adults.

BACKGROUND: This study compared air displacement plethysmography (ADP), which relies on measurements of body density to estimate body fat, with three other techniques that measure body composition: (1) hydrostatic weighing (HW), which also measures body density; (2) bioelectrical impedance (BIA), which determines electrical resistance and total body water to estimate fat-free mass; and (3) dual-energy x-ray absorptiometry (DXA), which measures bone, fat, and fat-free soft tissue masses. METHODS: ADP, HW, BIA, and DXA were performed on 20 healthy volunteers (10 males and 10 females). The subjects were within 20% of ideal body weight, 31.1 +/- 1.8 years of age, and 75.4 +/- 2.7 kg with body mass index values of 25.2 +/- 0.9 (kg/m2) and percent body fat by ADP ranging from 6.0% to 41.0%. RESULTS: Percent body fat measurements by the four methods were highly correlated (r > .90, p < .0001). Mean body fat as determined by ADP, HW, BIA, and DXA were 23.4% +/- 2.3%, 23.9% +/-1.8%, 23.1% +/- 1.9%, and 26.4% +/- 2.4%, respectively (* p < .05 vs ADP). There was a significantly positive slope (+0.23) for the individual differences vs the average of ADP and HW percent body fat, demonstrating a slightly negative difference at lower body fat levels and a slightly positive difference at greater body fat levels. Although the average percent body fat determined by ADP was similar to that by HW for the entire population, there was a significant gender difference with the average body fat measured by ADP being 16% less in males and 7% greater in females than that determined by HW. CONCLUSIONS: Body fat measurements using ADP were highly correlated with those using HW, BIA, and DXA across a relatively wide range of body fat levels in healthy adults. These results support the utility of ADP as a relatively new technique in the estimation of percent body fat in healthy adults. However, the error associated with gender and the level of body fat is not negligible and requires further investigation.

Intramural leiomyoma during pregnancy becoming pedunculated postpartally. A case report.

BACKGROUND: The natural history of uterine leiomyomas during pregnancy has been reported. CASE: A 39-year-old primigravida presented with vaginal spotting in the 10th week of pregnancy. Ultrasonic evaluation revealed a large intramural leiomyoma. Unsuccessful tocolysis at 25 weeks' gestation resulted in a cesarean section for breech presentation. At hysterotomy a 10-cm intramural leiomyoma was found in the right fundus and was left in situ. Six months later, at open laparotomy for myomectomy, the 10-cm leiomyoma was pedunculated, on a 4-cm stalk. CONCLUSION: Large intramural leiomyomas found at cesarean section may become pedunculated postpartally, thus making myomectomy easier and safer at a postpartum intervention than at the time of cesarean section. Also, prior knowledge of the possibility of myoma transformation from intramural to pedunculated postpartally may help in planning a later myomectomy. Myomectomy prior to pregnancy should be considered when it has caused a prior pregnancy complication.

[Evaluation of postoperative mortality and quality of life of patients over 75 years of age after valve replacement for aortic stenosis. Report of 110 cases]. / Evaluation de la mortalité et de la qualité de vie postopératoire des sujets de plus de 75 ans après remplacement valvulaire pour rétrécissement aortique. A propos de 110 cas.

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

[Conditions of decision making of admission or non-admission in surgical intensive care unit]. / Conditions de prise de décision d'admission ou de non admission en réanimation chirurgicale.

OBJECTIVES: To describe the condition of the decision-making of admission and non-admission in intensive care unit. STUDY DESIGN: Non-interventional observational cohort. PATIENTS AND METHODS: Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared. RESULTS: That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given. CONCLUSION: Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.