[Pap Smear after 65 years]. / Pratique du frottis cervicovaginal après 65 ans.

The French recommendations (in favor of stopping cervical cancer screening by cervico-uterine smear from 65 years of age) are logical in the context of organized screening; however, it is not yet generalized in France. The proportion of invasive cervical cancer in the oldest patients is high and these cancers are more evolved and have a more pejorative prognosis. The prevalent infection with high-risk HPV virus remains important in elderly patients: if the HPV infection does not appear to be more risky in the elderly, HPV-induced lesions appear to be more evolving. Unfortunately, pap smear coverage rates are low in the most advanced age groups. Patients without adequate follow-up are exposed to invasive cancer after age 65: all studies insist on the protective effect of two or more normal pap smears between 50 and 65 years that would allow to stop screening. Recent publications in Europe insist, however, on the value of continuing screening beyond the age of 65 in populations that live longer. For the clinician, in France, patients who could benefit from systematic FCU after age 65 could be those: (1) who request it, (2) who have an HPV history, (3) who have not had more than 3 consecutive normal pap smears or (4) who have an associated pathogenic condition. The place of the HPV test deserves to be considered: because of its very high negative predictive value, it could be performed as an exit test or as an alternative test to the pap smear.

Probing microtubules polarity in mitotic spindles in situ using Interferometric Second Harmonic Generation Microscopy.

The polarity of microtubules is thought to be involved in spindle assembly, cytokinesis or active molecular transport. However, its exact role remains poorly understood, mainly because of the challenge to measure microtubule polarity in intact cells. We report here the use of fast Interferometric Second Harmonic Generation microscopy to study the polarity of microtubules forming the mitotic spindles in a zebrafish embryo. This technique provides a powerful tool to study mitotic spindle formation and may be directly transferable for investigating the kinetics and function of microtubule polarity in other aspects of subcellular motility or in native tissues.

[Can new molecular profiles in epithelial ovarian cancer modify therapeutics?] / Les nouveaux profils moléculaires dans le cancer de l'ovaire peuvent-ils modifier les stratégies thérapeutiques ?

Epithelial ovarian cancer (EOC) affects 4500 women a year in France, with a survival of 30% at 5 years. Treatment is based on extensive surgery and chemotherapy. Around 15% of EOCs are due to genetic mutation predisposition essentially with mutated BRCA1 and BRCA2 genes. Four histological subtypes are described (serous, endometrioid, and mucinous cells to clear), corresponding to different carcinogenesis and distinct molecular mutations. High-grade serous EOCs have a mutation of the BRCA genes in 20-30% of cases. This mutation causes a deficit of repair by homologous recombination of DNA in case of double strand break, allowing greater sensitivity to platinum salts and the use of PARP inhibitors, a protein involved in the repair of single-strand breaks of DNA. PARP inhibitors have shown efficacy in patients mutated BRCA but this effectiveness remains to be demonstrated in patients without congenital mutation, but with acquired BRCAness profile EOC. The BRCAness profile is defined by a tumor having a defect in DNA repair counterpart (not limited to BRCA mutation). Molecular definition of BRCAness is still not consensual but is necessary for the use of PARP inhibitors. Gene expression analyses have identified four subgroups of high-grade serous CEO: mesenchymal, proliferative, differentiated and immunoreactive. These four subtypes, not mutually exclusive, although correlated with prognosis, are not yet used in clinical routine.

Does uncontrolled cardiac death for organ donation raise ethical questions? An opinion survey.

BACKGROUND: Organ donation after uncontrolled cardiac death raises complex ethical issues. We conducted a survey in a large hospital staff population, including caregivers and administrators, to determine their ethical viewpoints regarding organ donation after uncontrolled cardiac death. METHODS: Multicenter observational survey using a questionnaire, including information on the practical modalities of the procedure. Respondents were asked to answer 15 detailed ethical questions corresponding to different ethical issues raised in the literature. Ethical concerns was defined when respondents expressed ethical concerns in their answers to at least three of nine specifically selected ethical questions. RESULTS: One thousand one hundred ninety-six questionnaires were received, and 1057 could be analysed. According to our definition, 573 respondents out of 1057 (54%) had ethical concerns with regard to donation after cardiac death and 484 (46 %) had no ethical concerns. Physicians (55%) and particularly junior intensivists (65%) tended to have more ethical issues than nurses (52%) and hospital managers (37%). Junior intensivists had more ethical issues than senior intensivists (59%), emergency room physicians (46%) and transplant specialists (43%). CONCLUSION: Only 46% of hospital-based caregivers and managers appear to accept easily the legitimacy of organ donation after cardiac death. A significant number of respondents especially intensivists, expressed concerns over the dilemma between the interests of the individual and those of society. These results underline the need to better inform both healthcare professionals and the general population to help to the development of such procedure.

[Admission of women to an intensive care unit during pregnancy or the postpartum period: circumstances and prognosis. A retrospective series of 96 cases]. / Admissions en réanimation des femmes en cours de grossesse ou en post-partum: circonstances et pronostic. Une série rétrospective de 96 cas.

PURPOSE: Very few studies had been published about admission of obstetric patients in French intensive care units (ICU). PATIENTS AND METHODS: Files of women who had been admitted during pregnancy or the postpartum period to ICU of an academic hospital between January 1st 1997 and 31st December 2006 were analyzed. Diagnosis at admission, severity, main treatments and outcome were studied during two successive periods of 5 years. RESULTS: There were 96 admissions (0.95% of all admissions to ICU). They included 34 complications due to arterial hypertension (35%), among them 10 cases of pre-eclampsia, eight of eclampsia, seven of Hemolysis-Liver Enzymes-Low Platelet (HELLP) syndrome and two of retroplacental hematoma ; 26 postpartum haemorrhages (27%); and 36 miscellaneous diagnosis including two sepsis, four acute pulmonary oedema, four cardiomyopathy, three pulmonary embolism, and three acute liver steatosis. Mean Simplified Acute Physiologic Score (SAPS II) was 18.5±11.2 and mean Sequential Organ Failure Assessment (SOFA) 2.1±2.3. The main treatments were mechanical ventilation (50% of all cases) and transfusion (32%). The average ICU stay was 5.7±5.4 days. Two maternal deaths were observed (aortic dissection and peripartum cardiomyopathy). The number of patients admitted for postpartum haemorrhage increased from five to 21 over the two successive periods of the study. CONCLUSION: The number of women admitted to ICU during pregnancy or the postpartum period is low. Admissions for hemorrhage have increased. Regular monitoring of maternal morbidity and mortality gives relevant clues for assessing the quality of obstetrical care.

[Family satisfaction in intensive care unit: a prospective survey]. / Enquête de satisfaction de familles de patients hospitalisés en réanimation.

BACKGROUND: To assess family satisfaction in the intensive care unit (ICU) and to identify parameters for improvement. STUDY DESIGN: Prospective observational monocentric study. PATIENTS AND METHODS: One hundred and twenty families were given a questionnaire of twenty-four items covering: satisfaction with reception and waiting areas, satisfaction with care and satisfaction with information/decision-making. Each item was evaluated by families according to three levels: high, intermediate, and poor satisfaction. Opinions concerning accessibility time, information notice and visitor limitations were also gathered. RESULTS: Several factors, such as waiting time, respect of family's wishes, visiting hours, lack of social support, and examination's results communication were associated with poor level of satisfaction. Twenty-three percent of families felt restricted by visitation policy for children and 17 % by visitor's number limitation. DISCUSSION: Quality of family reception in the ICU needs to be improved concerning waiting time, visiting hours, social and emotional support.

[Severe acute asthma: isoflurane administration via AnaConDa™, is it safe?]. / Asthme aigu grave : l'administration d'isoflurane par l'AnaConDa™ est-elle sans risque ?

Standard treatments against severe acute asthma can be insufficient and need salvation treatments, such as isoflurane delivery. These treatments have not been much assessed and could lead to unrecognized side-effects. We report the case of a young man who suffered from intracranial hypertension associated with severe hypercapnia during the delivery of isoflurane via the system AnaConDa™ or Anaesthetic Conserving Device™ (ACD) (Sedama Medical). The rising of PaCO(2) appears to be linked to an ACD-dependent increase in the dead space.

[Prevalence of Acinetobacter baumannii carriage in patients of 53 French intensive care units on a given day]. / Prévalence un jour donné du portage d'Acinetobacter baumannii chez les patients de 53 réanimations françaises.

OBJECTIVE: This study was made to evaluate multiresistant Acinetobacter baumannii colonization in French intensive care units. DESIGN: We conducted a prevalence study on the carriage of A. baumannii for a one-day period in various French ICUs. On December 10, 2003, one nasal and/or rectal swab sampling was performed in 506 patients of 53 ICUs. RESULTS: Sixteen patients (3.16%) from 7 centers (13%) were colonized by A. baumannii. None of the known risk factors for colonization by multiresistant A. baumannii were identified in these patients. CONCLUSIONS: Overall, A. baumannii colonization is limited except during epidemic situations. Our study reflects the carriage of A. baumannii in ICUs on a given day. This study showed that there was no multiresistant A. baumannii epidemic clone, potentially responsible for outbreaks, present in the tested French ICUs.

Influence of the severity of illness measured by the Simplified Acute Physiology Score (SAPS) on occurrence of nosocomial infections in ICU patients.

To evaluate the ability of the Simplified Acute Physiology Score (SAPS) to predict the occurrence of hospital-acquired infections in intensive care unit (ICU) patients, we conducted a cohort study in an eight-bed combined ICU. From January 1991 to December 1992, 690 patients were admitted in the ICU and 656 stayed at least 48 h. Patients' severity of illness was estimated within the first 24 h of the ICU stay using the SAPS. Nosocomial infection rates were compared between the high SAPS group (> 10 points) and the low SAPS group (< or = 10 points), with the cut-off point chosen according to a ROC curve. One hundred (15.2%) patients developed hospital-acquired infections during their ICU stay. The mean SAPS of infected patients was significantly higher than the mean SAPS of noninfected patients (15.4 +/- 4.3 vs. 12.0 +/- 5.9 points, P < 0.0001). Significantly more infections occurred in the patients with a SAPS > 10 points (20.9% vs. 5.1%, P < 0.0001). Sensitivity, specificity, positive and negative predictive values for a SAPS > 10 points were 88, 40, 21, and 95%, respectively. Our results suggest that 95% of patients at low risk for developing hospital-acquired infections could be identified on admission with the use of severity scoring systems such as SAPS < or = 10 points.

[Paraplegia after aorto-bifemoral prosthesis: systematized dysautonomic symptoms should evoke spinal cord damage]. / Paraplégie après pontage aorto-bifémoral: des troubles neurovégétatifs systématisés doivent faire évoquer l'accident médullaire.

We report a case of paraplegia following aorto-bifemoral by-pass surgery for infrarenal aortic occlusive disease. The first symptoms of spinal cord damage were systematized dysautonomic symptoms including mottled skin and sudation. Such symptoms, occurring during recovery from anaesthesia are an indication for checking the status of the spinal cord.

[Gastric necrosis caused by acute gastric dilatation. Total gastrectomy. Recovery]. / Nécrose gastrique par dilatation gastrique aiguë. Gastrectomie totale. Guérison.

Acute gastric dilatation, a rare affection, has multiple origins. An episode of bulimia following a fast in relation to an anorexia nervosa is one of the classical causes of its onset. Diagnosis is by radiology and should be made urgently before instituting medical treatment combining aspiration and effective intensive care measures. Recovery is the general rule. The formation of an infarct and gastric perforation are complications of delayed diagnosis and are of extreme gravity, leading to a fatal outcome in more than 80% of cases. In the case reported, recovery was obtained by emergency total gastrectomy for global gastric infarction. Perioperative fibroscopy is the essential key to the choice between temporary esophageal exclusion or immediate re-establishment of digestive continuity.

[Short-term obstetrical anesthesia. Study of the tiapride-ketamine combination]. / Anesthésie de courte durée en obstétrique. Etude de l'association tiapride-kétamine.

Minor surgical procedures do not always require hospitalisation for several days. The use of short-acting anaesthetic agents should make such procedures possible on an ambulatory basis. A study was undertaken of the combination of tiapride and ketamine in 97 women seen in the department of obstetrics for therapeutic abortion or biopsy-curettage. The drug combination was satisfactory in the great majority of cases. It is sufficiently analgesic for surgery of this type. The minimal level of narcosis ensures rapid recovery without any subsequent falling asleep again. The psychomotor agitation caused by ketamine is counteracted by the doses of tiapride used. Only vomiting may be felt to be too frequent. Nevertheless, this occurred in women who were fully awake and had no major consequences.