[The place of the child]. / Place de l'enfant.

A child's self-construction and access to his identity depend on the conditions of affective security in which he is raised and his genealogical references, the founders of his own place in society. The quality of the professional care at the different stages of the birth process is confirmed as a major variable in the parents' sense of security, followed by the child's. The drift toward the illusion of a right to a child is tempered by the attention that can be contributed by all healthcare providers who come into contact with couples when they request artificial procreation: recognition of their request, but also of their suffering, so as to separate the child's place from parental projections that may be poorly adjusted to the child's needs.

[Early prenatal interview: implementation of a sheet link "carried" by patient. The Aurore perinatal network experience]. / Entretien prénatal précoce : mise en place d'une fiche de liaison << portée >> par la patiente. A propos de l'expérience du réseau périnatal Aurore.

INTRODUCTION: Early prenatal interview has needed the implementation of a new communication tool between follow-up pregnancy professionals: a link sheet filled and carried by patients. OBJECTIVE: To assess the utilization of link sheet by trained professionals, the contribution of the interview and the patient acceptation of the link sheet. MATERIALS AND METHOD: Descriptive survey from the database of link sheets returned by professionals to Aurore perinatal network and semi-guided interviews with 100 randomized patients. RESULT: One thousand one hundred and nineteen link sheets were sent to Aurore perinatal network by 55 professionals out of 78 trained. For primipare, precocious prenatal interview contribution has concerned health care security (60%) and emotional security (56%). For multipare, this contribution has concerned mainly emotional security (80%). No interviewed patient has refused link sheet principle. CONCLUSION: Link sheet principle, like implemented by Aurore perinatal network, seems pertinent to professionals and patients but it constitutes only one of the elements of network elaboration of personalized care.

Gallbladder abnormalities in medical ICU patients: an ultrasonographic study.

Patients in the intensive care unit (ICU) have many risks factors for gallbladder stasis or acute acalculous cholecystitis (ACC), including fasting, total parenteral nutrition, sedation, mechanical ventilation, infection and shock. We have performed a prospective study to estimate the prevalence of ultrasonographic gallbladder abnormalities in 30 consecutive medical ICU patients during the first 2 days of their stay in the ICU. Two patients had previously undergone cholecystectomy and were excluded from the study. Seventeen (61%) of the remaining 28 patients presented with gallbladder abnormalities. Considering three major criteria of ACC, 14 patients (50%) presented with either sludge (25%), wall thickening (22%) or hydrops (11%). However, none of the patients needed a surgical procedure during the study because of gallbladder disease. We conclude that an important proportion of ICU patients presented with gallbladder abnormalities shown by ultrasonography and that this may have implications for establishing a diagnosis of ACC using ultrasonographic criteria.

A new simple method to perform pressure-volume curves obtained under quasi-static conditions during mechanical ventilation.

OBJECTIVE: To describe a fast, simple method to acquire pressure-volume curves of the respiratory system and to compare this with a classic method in terms of reliability of the data and speed. DESIGN: Acquisition of pressure-volume curves by low flow inflation technique (P-Vlf) versus the occlusion technique (P-Vst) using the standard equipment of a Cesar ventilator. SETTING: General ICU - Aix en Provence Hospital. PATIENTS: Ten sedated, curarized patients undergoing mechanical ventilation. INTERVENTIONS: P-Vlf curves were acquired by setting the ventilator parameters at f = 5 c./min, duty time Ti/Ttot = 80 %, VT = 1100 ml, pause time = 0. The pressure and volume data were collected directly on the ventilator screen. P-Vst curves were acquired using an airway occlusion technique. The pressures obtained for the same inflation volumes and times necessary for performance of the two techniques were compared. RESULTS: The time needed to acquire a P-Vlf curve was 3 min versus 38 min for P-Vst curve. Concordance analysis between the two methods showed a 95 % confidence interval of (-0.5 cm H2O, + 1.8 cm H2O) for pressure. CONCLUSIONS: P-Vlf curves are close to P-Vst curves, are much less time-consuming, easy to acquire with Cesar ventilator equipment, and may be used in clinical routine to assess the elastic properties of the respiratory system.

[Prognosis in iatrogenic gas embolism]. / La prognosi delle embolie gassose iatrogene.

Prognosis of iatrogenic air embolism is various according to previous studies. The purpose of this study was to determine the risks factors associated with the prognosis of iatrogenic air embolism. We conducted a retrospective analysis of 113 patients treated with HBO therapy in our hyperbaric center from 1979 to 1993. Initial symptomatology consisted in neurological disorders (71% of cases), respiratory disorders (43% of cases) and hemodynamic disorders (33% of cases). When neurological disorders were observed, HBO therapy included immediate compression to 6 atm abs for 10 to 15 mn with air followed by decompression to 2 atm abs where the patients received 100% oxygen during 1 hour. When no neurological disorders was observed, HBO therapy consisted in an oxygenation for 1 h, 2 atm abs, FiO2 = 1. Overall outcome was: recovery: 69 per cent of cases, sequelae: 26 per cent of cases, death: 5 per cent of cases. Prognosis was very different according to etiologies and existence of neurological disorders. Venous emboli had a better improvement than arterial emboli. In conclusion, patterns of air embolism can be divided clinically into two major categories, cerebral and pulmonary air embolism, which should be individualised in clinical studies. The studies must also individualised etiologies.

Rupture of the stomach complicating diving accidents.

All reported cases of rupture of the stomach after a diving accident were reviewed for this study. This is a rare event that complicates brief and deep dives. It is always the consequence of equipment failure or panic reactions which induce swallowing air while under water. During a rapid ascent, the gas expands causing rupture. Diagnosis is based on the presence of abdominal distention associated with pneumoperitoneum on the x-ray and with gastric tears seen on gastroscopy. Pneumoperitoneum from gastric rupture must be distinguished from that caused by pulmonary barotrauma. Peritoneal decompression by paracentesis may quickly improve the patient's condition. After air embolism or decompression sickness has been ruled out, a surgical operation is necessary. Exploratory laparotomy exposes, in two thirds of cases, a gastric full-thickness tear that requires closing by suture. The outcome is good because subjects are young and healthy. The rupture of a filled stomach may lead to postoperative complications (abscess or fistulas).

Neurologic decompression illness: a gravity score.

Treatment of neurologic decompression accidents consists of various hyperbaric oxygen (HBO) protocols. To facilitate such comparisons between different protocols we developed a gravity score. A group of 96 divers was used to establish the score. On admission we first identified signs and symptoms that had possible predictive value (chi 2 test). The parameters included were repetitive dive, clinical course before HBO, objective sensory disorder, motor impairment, and urinary disturbances. Each parameter was assigned a coefficient. The sum of the coefficients for each accident, based on the most severe manifestations before decompression therapy, yielded a score for each diver. A multivariate analysis was used to evaluate the overall agreement between the model prediction and clinical observations, which was 78.7%. A second group (66 divers) was used to validate the score; this group showed a significant difference in the gravity score between the divers who had sequelae and those who did not (P = 0.0001), and between the divers who had incapacitating sequelae and those who had mild sequelae (P = 0.04). Eighty-six percent of the divers with a score above 7 developed sequelae. This index remains to be validated in a prospective multicenter study. If endorsed, valid comparisons can be made between the different therapeutic protocols.

[Pregnancies occurring after a perinatal death. Preparation of a psychological risk index]. / Grossesses survenant après une mort périnatale. Elaboration d'un indice de risque psychologique.

The authors have interviewed 21 women who were attending the gynaecological and obstetrical service of the hospital for pregnancies occurring after a perinatal death. They show that anxiety is characteristic of these situations, but that the intensity of anxiety varies from woman to woman. They describe, after analysing the interviews, the different variations that can be found as these pregnancies progress according to the type of anxiety. By using a statistical analysis they can separate out the most important criteria and they can work out a method of illustrating a threshold which can easily be used by obstetricians in everyday practice. They suggest a method of handling the patients according to the level of anxiety found.

[Trends in therapeutic abortion management from 1986 to 1994]. / Prise en charge des interruptions médicales de grossesse. Evolution de 1986 à 1994.

OBJECTIVE: This study was performed in order to evaluate indications, techniques and maternal risks of medical abortions, and technical difficulties encountered in these procedures. TYPE OF THE STUDY: A monocentric, descriptive and retrospective study. MATERIALS AND METHODS: Four hundred seventeen medical abortions (MA) were performed in our fetal medicine Unit between 1986 and 1994, including 117 (28%) performed for maternal reasons and 300 (72%) for fetal reasons. Each indication was discussed in a collegial system and varied protocols of labor induction were used, mainly prostaglandins, RU 486, or feticide. MAIN PARAMETERS MEASURED: They were duration of the labor, maternal accidents, number of the fetal post-mortem examinations, counselling given to the couples. We considered that a MA is correctly managed when the intervention corresponded to the following criteria: expulsion by natural route without uterine damage, an examinable fetus and examination by a foetopathologist. MAIN RESULTS: Mean rate of MA satisfying our definition was about 45% in 1988 and reached to 74% in 1994. Our results show that the procedure is rarely complicated and that vaginal expulsion can be obtained. The foetopathologist examination rate increased regularly over the period. The mean gestational age of MA due to maternal indications was 14.5 weeks vs 23.9 weeks when dealing with fetal indications. The infection rate is about 6.2%, hemorrhage rate following expulsion was about 5.9% and the rate of uterine rupture was about 0.48%. CONCLUSIONS: These data suggest that medical abortion need to be evaluated regularly.

[Techniques, results and indications of embryonic reductions in multiple pregnancies. Review of the literature]. / Techniques, résultats et indications des réductions embryonnaires au cours des grossesses multiples. Revue de la littérature.

The authors report, after a review of the literature, the evolution of ideas concerning first-trimester terminations in multiple pregnancies. Different techniques are performed including transabdominal approach or transvaginal approach at the mean gestational age of 9 or 11 weeks of amenorrhea. Analysis of obstetrical results obtained after these procedures (rates of early or late abortions, preterm labor or in utero growth retardation) shows a high rate of abortions and demonstrate also that reductions are unable to prevent premature births. Indications are discussed: concerning pregnancies of high order (four or more), most part of authors agree with the procedure and also when a triplet pregnancy occurs on a scarred or malformed uterus. Concerning triplet pregnancies, the procedure remains considered by some teams as an unethical approach of theses gestations, specially when considering the recent advances in perinatal medicine. In all cases, a clear and complete information about the risks of these procedures should be given to couples faced with multiple pregnancies.

[Developmental outcome of 5-year-old children born to opiate-dependent mothers: effects of a multidisciplinary intervention during pregnancy]. / Devenir à 5 ans des enfants de mères dépendantes aux opiacés : effets d'un suivi multidisciplinaire pendant la grossesse.

BACKGROUND: Studies on infant outcomes of opiate-dependent pregnant women find a high rate of premature mother-child separation and to a lesser extent developmental delay. The specific role of in utero heroin exposure in the determination of the developmental outcome seems to be less important than the home environment. OBJECTIVE: Describe the health and development of 5-year-old children whose drug-addict mothers allowed an early multidisciplinary intervention (medical and psychological) in the maternity hospital and neonatology. PATIENTS AND METHODS: Thirty-seven children (62% of the initial cohort) were seen in consultation with their parents. Growth and development was compared with a control group of 374 children of the same age. Comparisons were made between the children's and parents' state (social, medical, drug addiction, etc.) upon discharge from the maternity hospital and 5 years later. A study was conducted on those lost to follow-up. RESULTS: The rate of placement in 5 years was very low (13%). Seven children showed a developmental delay, 21 no disorder, and nine some problems. Anxiety (37%) and overweight (48%) were the only disorders differentiating them from the control group. Compliance with the care provided in the maternity hospital was the only item significantly related to the development of the 5-year-old children (P=0.05). DISCUSSION: The hypothesis of an attachment disorder in those with the greatest need is raised. The likely relations between the quality of the care in the maternity hospital, mother-child relations, and the attrition of the cohort are also discussed. CONCLUSION: Management of the symptoms as well as social and psychological care during pregnancy and neonatal hospitalization for opiate-dependent pregnant women facilitates a long-lasting relation with childhood professionals, avoids court-ordered placements, and reduces the appearance of developmental disorders in these children.

[Reflections of a pediatric psychiatrist on pregnancy in aged couples]. / Réflexions du pédo-psychiatre à propos des grossesses chez les couples âgés.

Pregnancies in later life and their effects on children must be assessed from several points of view, those of the child and its parents and also from the medical and social viewpoints. They do not bring into play the real needs of the child so much as the cultural images. The confrontation of parents with the end of their lives and creativity and, above all, the options of society regarding the protection of human potential are brought into question.

Venous gas embolism: detection with pulsed Doppler guided by two-dimensional echocardiography.

BACKGROUND: Venous gas embolism is a rare but severe event in critically ill patients and the diagnosis should be obtained as soon as possible. Ultrasonography is a sensitive, non-invasive, and bedside means of detection. METHOD: We prospectively estimated the performance of two-dimensional (2D) echocardiography and pulsed Doppler guided by 2D echocardiography in the detection of venous embolism. We used, as a model of venous gas embolism, the decompression following a recreational dive. This activity is responsible for circulating bubbles related to nitrogen desaturation. RESULTS: Venous gas emboli were detected following 44 of 68 dives in 20 of 24 divers. Gas emboli in 36 cases (16 divers) was shown by 2D echocardiography. Parasternal short-axis and right-cavity longitudinal views were the best views for positive detection. Pulsed Doppler confirmed the existence of venous gas emboli in all of the 36 cases with positive detection by 2D echocardiography. In 8 other cases, pulsed Doppler detected circulating bubbles, which were not observed by using 2D echocardiography. Discrepancies were observed in 4 divers with an echographic image of medium or poor quality. CONCLUSION: Combined utilization of 2D echocardiography and pulsed Doppler provides a better method for the detection of venous gas embolism than 2D echocardiography alone. This protocol could be used for critically ill patients suspected of venous air embolism.

Haemoconcentration in neurological decompression illness.

Decompression illness (DCI) is attributed to the formation of bubbles, resulting from the reduction of the ambient pressure. Circulating bubbles lead to capillary leak syndrome, extravasation of plasma and haemoconcentration. Experimental model on animals has shown that a haemoconcentration carried a poor prognosis. We measured the haematocrit level in fifty-eight consecutive sport divers, victims of neurological DCI, admitted to our hyperbaric center, and in sixteen control divers. No significant difference was found in the haematocrit values between the divers with neurological DCI (median 42.5%) and the controls (median 41.75%). The median haematocrit level was significantly higher for divers with neurological sequelae when compared with control (p = 0.01) or with divers without sequelae (p < 0.05). A haematocrit level > or = 48% was correlated with persistent neurological sequelae one month after the accident (p = 0.01). However, a haematocrit < 48% had no prognostic value.

Ascent rate and circulating venous bubbles in recreational diving.

The aim of this study was to assess the effect of the ascent rate on the production of venous circulating bubbles during the decompression following a recreational dive. Twenty-eight recreational divers performed two open water dives at 35 m during 25 minutes. Ascent rate up to the decompression stop was in one case 9 meter per minute (m/min) and in the other case 17 m/min. Circulating venous bubbles were screened using continuous wave Doppler every 10 minutes during one hour after surfacing. Bubbles Doppler signals were graded according to the Spencer scale (from 0 to IV), and the Kisman integrated severity score (KISS) was calculated. Statistical analysis demonstrated a significantly higher bubbles grade and a significantly higher KISS following the rapid decompression compared to the slow one (respectively p = 0.001 and p = 0.0001). In conclusion, these results demonstrate that a 9 m/min ascent rate is safer than a 17 m/min one.