Staffing needs for unscheduled activity in obstetrics and gynecology.

INTRODUCTION: To determine a minimum threshold of medical staffing needs (obstetricians-gynecologists, anesthesiologists-resuscitation specialists, nurse-anesthetists, pediatricians, and midwives) to ensure the safety and quality of care for unscheduled obstetrics-gynecology activity. MATERIALS AND METHODS: Face to face meetings of French healthcare professionals involved in perinatal care in different types of practices (academic hospital, community hospital or private practice) who belong to French perinatal societies: French National College of Gynecologists-Obstetricians (CNGOF), the French Society of Anesthesia and Resuscitation Specialists (SFAR), the French Society of Neonatology (SFN), the French Society of Perinatal Medicine (SFMP), the National College of French Midwives (CNSF), and the French Federation of Perinatal Care Networks (FFRSP). RESULTS: Different minimum thresholds for each category of care provider were proposed according to the number of births/year in the facility. These minimum thresholds can be modulated upwards as a function of the level of care (Level 1, 2 or 3 for perinatal centers), existence of an emergency department, and responsibilities as a referral center for maternal-fetal and/or surgical care. For example, an obstetrics-gynecology department handling 3000-4500 births per year without serving as a referral center must have an obstetrician-gynecologist, an anesthesiologist-resuscitation specialist, a nurse-anesthetist, and a pediatrician onsite specifically to provide care for unscheduled obstetrics-gynecology needs and a second obstetrician-gynecologist available within a time compatible with security requirements 24/7; the number of midwives always present (24/7) onsite and dedicated to unscheduled care is 5.1 for 3000 births and 7.2 for 4500 births. A maternity unit's occupancy rate must not exceed 85 %. CONCLUSION: The minimum thresholds proposed here are intended to improve the safety and quality of care of women who require unscheduled care in obstetrics-gynecology or during the perinatal period.

[Inadequate involvement of general practitioners in end-of-life's decisions in an intensive care unit]. / Implication insuffisante des médecins généralistes lors des décisions de limitation et/ou d'arrêt des traitements au sein d'un service de réanimation.

INTERESTS AND OBJECTIVES: Patients' general practitioners (GPs) could be relevant consultants for collegial decisions of withholding or withdrawing treatment (WWT) defined by the Leonetti law. We therefore studied their implication by intensivists in end-of-life decisions and collected their feelings. Their wishes for the coming law revision were also investigated. METHODS: Retrospective descriptive study conducted in the polyvalent intensive care unit (ICU) of Longjumeau's hospital (France) using a distributed questionnaire to GPs of patients who benefited from collegial decisions of WWT in 2012. RESULTS: The response rate was 60.4% (32/53) and only 18.8% of the respondents participated as a consultant in WWT's decision for their patient. Two GPs out of three reported that they never participate in such decisions for their others patients. All uninvolved GPs did not contribute because intensivists did not consult them. Only 43.7% of GPs were contacted by intensivists during the stay and 21.9% at the discharge or death of their patient. GPs took news about their patient during ICU hospitalization in 37.5% of cases. Regarding uninvolved GPs, their participation could have changed WWT's decisions made for two patients (7.7%). Most respondents felt available (78.1%) and skilled (81.2 %) to participate in this kind of decision. A third was also questioned by the patient's family about it. Only 21.7% of GPs report to be familiar with the French end-of-life legislation. In case of a next revision, two thirds considered important to make the use of GPs obligatory in such decisions. CONCLUSION: Despite an undeniable interest, GPs are rarely involved in collegial processes of WWT in ICUs, partially related to an insufficient knowledge of the law by the healthcare providers. At the dawn of end-of-life law's revision, their share could however improve our practices in this field.

[Acute pancreatitis complicated by Clostridium tertium septicaemia]. / Pancréatite aiguë compliquée d'une septicémie a Clostridium tertium.

INTRODUCTION: Clostridium tertium septicaemia, although usually described in neutropenic patients, can also occur in the absence of neutropenia, as in our case report. OBSERVATION: A 61 year-old woman presented with pain in the right hypochondrium and epigastrium, constipation and vomiting that led to the diagnosis of acute pancreatitis of biliary origin. During septic shock, analysis of the liquid of an intra-abdominal mass and the results of the blood cultures revealed a Gram positive bacillus identified as C. tertium. During laparotomy, necrotic-hemorrhagic acute pancreatitis lesions were found with subtotal colic necrosis. Analysis of the peritoneal fluid revealed C. tertium. The patient died on D 46 after several nosocomial pneumopathies without identification of C. tertium. DISCUSSION: Three factors appear related to the onset of C. tertium septicaemia: neutropenia, lesions of the intestinal mucosa and previous treatment with 3rd generation, broad spectrum, cephalosporins. Such septicaemias are rare in immunocompetent patients and do not appear to have been reported before in a context of acute pancreatitis.