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International audience; ObjectivesThe ongoing COVID-19 pandemic has caused approximately 2,350,000 infections worldwide and killed more than 160,000 individuals. In Sainte-Anne Hospital (GHU PARIS Psychiatrie & Neuroscience, Paris, France) we have observed a lower incidence of symptomatic forms of COVID-19 among patients than among our clinical staff. This observation led us to hypothesize that psychotropic drugs could have a prophylactic action against SARS-CoV-2 and protect patients from the symptomatic and virulent forms of this infection, since several of these psychotropic drugs have documented antiviral properties. Chlorpromazine (CPZ), a phenothiazine derivative, is also known for its antiviral activity via the inhibition of clathrin-mediated endocytosis. Recentin vitro studies have reported that CPZ exhibits anti-MERS-CoV and anti-SARS-CoV-1 activity.MethodsIn this context, the ReCoVery study aims to repurpose CPZ, a molecule with an excellent tolerance profile and a very high biodistribution in the saliva, lungs and brain. We hypothesize that CPZ could reduce the unfavorable course of COVID-19 infection among patients requiring respiratory support without the need for ICU care, and that it could also reduce the contagiousness of SARS-CoV-2. For this purpose, we plan a pilot, multicenter, randomized, single blind, controlled, phase III therapeutic trial (standard treatment vs. CPZ + standard treatment).ConclusionThis repurposing of CPZ for its anti-SARS-CoV-2 activity could offer an alternative, rapid strategy to alleviate infection severity. This repurposing strategy also avoids numerous developmental and experimental steps, and could save precious time to rapidly establish an anti-COVID-19 therapy with well-known, limited and easily managed side effects.; ObjectifsLa pandémie mondiale actuelle de COVID-19 a touché environ 2 350 000 personnes et fait plus de 160 000 morts. Nous avons observé dans le GHU PARIS Psychiatrie & Neurosciences (site Sainte-Anne, Paris, France) une incidence moins importante de formes symptomatiques de COVID-19 chez les patients que dans notre personnel soignant. Notre hypothèse est que les traitements psychotropes pourraient avoir une action prophylactique sur le SARS-CoV-2. Cette hypothèse est cohérente avec les propriétés antivirales connues de plusieurs psychotropes au premier rang desquels la chlorpromazine (CPZ). En plus de ses effets antipsychotiques classiques, plusieurs études in vitro ont également démontré une activité antivirale de cette phénothiazine via l’inhibition de l’endocytose dépendante des clathrines. Récemment, des études ont révélé un effet anti-MERS-CoV et anti-SARS-CoV-1 de la CPZ.MéthodesDans ce contexte, l’étude reCoVery, basée sur le repositionnement de la CPZ – molécule avec un excellent profil de tolérance et une biodistribution très élevée dans la salive, les poumons et le cerveau – vise à tester l’hypothèse que la CPZ pourrait diminuer l’évolution défavorable de l’infection COVID-19 chez des patients oxygénorequérants sans nécessité de soins en réanimation mais aussi réduire la contagiosité du SARS-CoV-2. Nous allons réaliser pour cela un essai thérapeutique pilote de phase III multicentrique, randomisé, contrôlé (traitement standard vs CPZ + traitement standard) et en simple insu.ConclusionLe repositionnement de la CPZ comme antiviral anti-SARS-CoV-2 offre une stratégie alternative et rapide pour atténuer la propagation du virus ainsi que la gravité et la létalité du COVID-19.

Objectif : l’objectif était d’évaluer le taux de réadmission chirurgicale après une procédure urologique et d’identifier les facteurs de risque associés à une réadmission. Matériel et méthodes : les données de toutes les hospitalisations concernant les chirurgies urologiques planifiées entre janvier 2010 et novembre 2012 ont été extraites du Programme de Médicalisation des Systèmes d'Information. Le taux de réadmission était évalué à partir des ré-hospitalisations réalisées dans les 30 jours suivant la chirurgie urologique. Les facteurs de risque suivants ont été évalués:le sexe, l’âge, le Groupe Homogène de Malades (GHM), la durée de l'hospitalisation initiale, le type d'hospitalisation (conventionnelle ou ambulatoire), le volume d’activité de chirurgie urologique global de l’établissement ainsi que le volume d’activité spécifique de la procédure réalisée et le statut administratif de l’établissement. Une analyse multivariée par régression logistique a été utilisée pour évaluer les facteurs de risque. Résultats : au total, 419 787 patients ont été inclus, dont 77 241 patients (18,40%) ont été réadmis dans les 30 jours suivant l’intervention. Après analyses multivariées, le sexe masculin (OR = 1,84 [CI95% : 1,81-1,88]), un GHM élevé (GHM 3-4 vs. 1-2 : OR = 2,14 [CI95% : 2,10-2,21]) et la prise en charge initiale dans un établissement privé (Hôpital privé vs. Hôpital universitaire : OR = 1,13 [IC95% : 1,11-1,16], Hôpital privé vs. Hôpital public : OR = 1,21 [CI95% : 1,18-1,23]) ont été associés à un risque plus élevé de réadmission dans les 30 jours. Conclusion : le taux de réadmission dans les 30 jours suivant une procédure urologique planifiée était de 20%.

International audience; INTRODUCTION:Enhanced recovery is a concept currently recognised and adopted in a number of surgical specialties. In obstetrics however, this concept remains surprisingly underdeveloped. The purpose of this survey was to study the practice of obstetric anaesthetists in France as regards the recovery of women undergoing uncomplicated, elective caesarean section.MATERIAL AND METHOD:An online 39-point questionnaire was displayed for 2months on the Caro (Club d'anesthesie réanimation en obstétrique) website. The questionnaire related to uncomplicated, elective Caesarean sections and aimed to define the following: preoperative information given regarding the recovery period, intraoperative care - both anaesthetic and surgical, postoperative analgesia, measures taken to prevent post-partum haemorrhage, reintroduction of fluids and diet, return to mobility, local practices designed to promote bonding between mother and baby.RESULTS:The overall response rate for our survey was 45%. Forty-nine percent of practitioners report that patients are provided with specific information on the recovery period preoperatively. Sixty percent of those surveyed state the absence of any specific recovery protocol for this patient population in their hospital. Eighty-one percent of respondents state that, in the majority of cases, patients are admitted on the eve of surgery and remain hospitalised for more than 72hours (89%). Ninety-nine percent of practitioners employ a regional technique to deliver anaesthesia for elective section and 44% rely on intrathecal morphine for postoperative analgesia. The concept of 'Patient Controlled Oral Analgesia' (PCOA), although widely recognised, is used by only 17% of practitioners. Forty-one percent of practitioners report the reintroduction of fluids as soon as patients return to the ward following surgery and at the same time as the urinary catheter is removed (51%). Diet is commenced 4 to 6hours following surgery amongst 40% of those surveyed. Fifty-one percent of practitioners report removal of the intravenous catheter 24hours postoperatively. Finally, 49% of practitioners feel patients are independently functioning and mobile within 24hours of surgery.CONCLUSION:This survey of national practice shows that the concept of 'enhanced recovery' following elective caesarean section can be again developed. Standardisation of practice with the design of local protocols relating to postoperative analgesia, timing of removal of the intravenous access and urinary catheter, time to first mobilisation and to commencement of diet would appear to be warranted. Surely this surgery, more than any other, merits an expeditious and effective return to normal and independent function, allowing mother to better look after baby.; IntroductionLa réhabilitation postopératoire est un concept actuellement adopté et reconnu dans de nombreuses chirurgies. En obstétrique, ce concept reste de façon surprenante peu développé. Le but de cette enquête était de recueillir les pratiques françaises de prise en charge de la réhabilitation des césariennes programmées non compliquées auprès des médecins anesthésistes réanimateurs (MAR) ayant une activité obstétricale.Patientes et méthodeUn questionnaire de 39 items a été déposé en ligne pour une durée de deux mois sur le site du Club d’anesthésie réanimation en obstétrique (Caro). Le questionnaire visait à évaluer pour les césariennes programmées, l’information donnée en préopératoire sur la réhabilitation, la prise en charge anesthésique et chirurgicale peropératoire, l’analgésie postopératoire, la prévention de l’hémorragie du post-partum, la réalimentation et la mobilisation postopératoires, les différentes pratiques mises en place pour faciliter la création du lien mère–enfant.RésultatsLe taux global de réponse était de 45 %. Pour 49 % des praticiens, une information préopératoire spécifique sur la réhabilitation était délivrée aux patientes. Aucun protocole spécifique de réhabilitation périopératoire n’était rédigé d’après 60 % des médecins sondés. Quatre-vingt-un pour cent d’entre eux estimaient qu’une hospitalisation la veille de l’intervention était la pratique la plus courante pour une durée de plus de 72 heures (89 %). En peropératoire, 99 % des praticiens réalisaient une anesthésie locorégionale. Pour 44 % d’entre eux, l’analgésie postopératoire reposait sur l’utilisation de la morphine par voie intrathécale. Le concept d’analgésie orale contrôlée par le patient (PCOA) bien que connu n’était appliqué que par 16 % des praticiens. En postopératoire, la réintroduction des boissons avait lieu dès l’arrivée en unité d’hospitalisation pour 41 % des praticiens de même que le retrait du sondage vésical 51 %. La réalimentation se faisait quatre à six heures après l’intervention dans la majorité des cas (40 % des sondés). La voie veineuse était retirée pour 51 % des anesthésistes 24 heures après l’intervention. Les praticiens estimaient que le retour à une autonomie complète se faisait en 24 heures dans 49 % des cas.ConclusionCette enquête nationale révèle que le concept de réhabilitation périopératoire mérite d’être encore développé dans le domaine de la césarienne programmée. Une standardisation des pratiques et la rédaction de protocoles locaux concernant l’analgésie postopératoire, le délai de retrait de la perfusion et du sondage vésical, le premier lever, la réintroduction des apports oraux semble indispensable dans cette chirurgie où les patientes doivent être plus encore que dans d’autres chirurgies autonomes et dynamiques.

International audience; OBJECTIVE: to present our initial experience of laparoendoscopic single site (LESS) renal surgery. METHODS: between May 2009 and March 2010, nine nephrectomies and one cyst decortication were performed in nine patients. Eight of the procedures were done with three 5mm trocars inserted through a unique peri-umbilical incision. In two cases, a specific single-port device was used. All operations were achieved with a 5-mm 30° lens and conventional laparoscopic instruments. The specimens were entrapped in a 10mm endoscopic bag and extracted through the umbilical incision. RESULTS: mean age was 56 years old. Mean BMI was 23.5 [19-34]. Mean operative time was 149min [80-240], and estimated blood loss was 90ml [20-250]. None of the patients required blood transfusion. Mean length of stay was 4.1 days [3-5]. Only one major complication occurred (functional occlusion). One conversion to conventional laparoscopy was necessary in a case of inflammatory kidney. Histologic exam showed benign lesions (cyst and non functional kidney) in seven cases, and papillary carcinoma in three cases. CONCLUSION: LESS surgery is feasible. Its advantages over conventional laparoscopy are not clear. LESS is a new procedure that should benefit from the improvement of technical instrumentation.

International audience

International audience; Analgesia and hypnosis are two separate entities and should result in distinct assessment and management for patients admitted to an intensive care unit (ICU). Those patients are exposed to moderate-severe pain and they are likely to remember pain as one bothersome experience. Any cause of patient discomfort is sought with the priority given to pain and adequate analgesia. Assessing pain must rely upon the use of clinical scoring systems, although these instruments are still underused in ICU. Satisfactory levels of analgesia by continuous infusion of opioids during times without stimulation do not guarantee against pain reactions during procedures (endotracheal suctioning, mobilization, wound care and dressing change, removal of chest tube). The concept of multimodal analgesia should be extended to the ICU since it may reduce the opioids requirements. In order to facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it appears crucial to promote educational programs and elaboration of protocols/guidelines in ICU. Protocols/guidelines may help caregivers to rationally use sedatives and opioids and possibly reduce mechanical ventilation and ICU length of stay.

INTRODUCTION: The incidence of complications after baclofen pump implantation is relatively high. Diagnosis of these complications can be difficult. A diagnostic tree would be a useful tool in cases of suspected malfunctioning of the intrathecal bacolfen infusion system and would standardise the diagnostic procedure. METHOD: From results in the literature and the experience of our department, we designed a diagnostic tree to aid in finding the cause of a recrudescence of spasticity in patients with implanted baclofen pumps. RESULTS: The potential causes of recrudescence of spasticity are described and a diagnostic pathway is proposed. DISCUSSION: The aim of a standardised hierarchical method of diagnosis of the cause of increased spasticity in patients with intrathecal baclofen pumps is to gain time in the diagnosis and treatment. Such diagnosis should improve patient care by permitting rapid restoration of an adequate level of baclofen infusion as well as decreasing the length of hospital stay and, as a consequence, the cost relating to malfunctioning pumps.

International audience; Introduction. The techniques used for axillary node dissection are constantly evolving. The advent of the grip Ligasure Precise raise the question of its cost-effectiveness compared with surgical clips. OBJECTIVE: To compare the effectiveness of Ligasure compared with surgical clips for simple axillary node dissection or Patey procedure in terms of duration of drainage, cost of hospitalization and complications. MATERIAL: and method. Retrospective study extending from January 1, 2003 to December 31, 2004, concerning 187 patients who underwent simple axillary dissection (100) or Patey procedure (87), with use of surgical clips or Ligasure followed by drainage. RESULTS: The use of Ligasure increased the operative cost because its price is higher than that of a clip grip with a refill. Ligasure significantly decreased the duration of drainage in the two groups but there was significantly more abundant fluid loss in the dissection group. The cost of hospitalization related to the choice of the technique of hemostasis (cost of the material + lasted of drainage X price of the day of hospitalization), was not significantly favor of Ligasure. Taking into account the choice of the hemostasis technique and the total duration of hospitalization (material cost + duration of hospitalization X price of the day of hospitalization), there is no significant difference between the two groups. CONCLUSION: This study compares grip Ligasure Precise with surgical clips for axillary dissection. The duration of drainage was significantly shorter with Ligasure Precise but its benefit in terms of fluid loss remains to be shown. The use of Ligasure does not significantly reduce the cost of hospitalization.

International audience; The Psychiatry department of the University Hospital Centre of Lille has developed, over the last 10 years, a treatment network for psychiatric disorders during pregnancy or in the post-partum period. There are liaison consultations in the maternity department, screening and management of psychopathological disorders in the perinatal period, training of midwives, support of patients seeking genetic counselling, collaboration with teams providing "medically-assisted procreation", etc. For severe disorders of the post-partum period (severe depression, serious alteration of mother-child interaction, puerperal psychosis), the Psychiatry department has a specialized unit where 3 "mother-child" groups can be admitted. This unit is particularly effective if the patients and their family understand this healthcare system and stick to it to a certain extent. Even if improvements are always possible, cases in which situations occur as an emergency, are when dysfunctions are most frequently seen. On 7th December 1998, a Crisis Intervention Unit (CIU) was created with 15 short-term beds, for stays up to 72 hours. The CIU was opened in the Psychiatry department, close to the main Accident and Emergency department, with 2 aims: firstly to provide a setting and resources for a number of emergency psychiatric situations, and secondly to provide a place and time for crisis situations which we admit to the unit, with a view to facilitating interaction and to propose in certain cases a process of crisis intervention, which later continues on an outpatient basis. After being open for a year, the CIU has proved to be an improvement to all of the healthcare services which are available. It should be noted that the situations which need highly specialized resources in such a short time, are those which cause the most acute problems. This is at times when the emergency services network, with its internal logic, require another network based on a different logic, that the interface problems are at their most acute. The situations reported here, which require a fluid interface between the emergency services and the "mother-child" networks, are examples. We report 3 clinical situations, which illustrate 3 possibilities of action: the first, in which 2 successive stays in the CIU allowed an admission to the "mother-child" unit in satisfactory conditions, the second, in which overall management was based on hospitalization in the Obstetrics department and several visits to our Unit, and the last one, in which the whole medico-psycho-social approach was set up after a single stay of 3 days. Since the opening of Crisis Intervention Unit, around 1,000 patients have been treated there; 37 were women with difficulties with their pregnancy, 17 of whom required direct intervention by the "mother-child" team. The contexts were: 5 prenatal depressions, 4 post-partum depressions, 3 cases of hyperemesis gravidarum, 5 rejections of pregnancy and/or situations at risk of infanticide. The almost constant suicidal risk should be noted, or even attempted suicide, at the time of admission to the CIU. The other 20 women had psychopathological disorders linked to sterility, medically-assisted pregnancy, termination of pregnancy or pregnancy in women suffering from long-term somatic illnesses (insulin-dependent diabetes, lupus, etc.). When a psychopathological episode occurs during pregnancy, it is essential to preserve the developing relationship with the child in an intermediate place, in a healthcare perspective and to prevent any future impairment of the quality of the mother-child relationship by the psychiatric disorder. The Crisis Intervention Unit is not an emergency "mother-child" unit. Other French experiences have been reported, an example being mother-baby hospitalization in a crisis centre. The aim of our interventions is not the same, and our local context, together with the availability of a healthcare network on different floors, which is specific and close-by, allows this approach. Also, the contribution of Liaison Psychiatry in emergency situations should not be minimized. It is necessary to work in collaboration with the obstetricians. In fact, the chance to work with us was given by asking for a hospitalization in the Obstetric unit, during the prepartum period of pregnancies with a psychiatric risk. This way of proceeding allows somatic monitoring in hospital to be performed, whenever the risk run by the mother and/or the child requires it. This "analogue" procedure, however preventative it may be, does not always allow specific treatment of the psychiatric disorders to be given, despite liaison psychiatry interventions. Our interventions are not a specialized "mother-child" unit, or a substitute for Liaison Psychiatry, but they are specifically aimed at the context of the crisis. Obviously, it is precisely this dimension of the crisis which makes the other types of management temporarily unsuitable. This new working framework, with the simple possibility of admitting women and interacting with them in a crisis situation, with the aid of the competence of "mother-child" teams, most often seems to allow an alternative to hospitalization in the Psychiatry department, at the same time keeping up quality management of problems linked to the pregnancy or post-partum period. The specificity of the CIU, with its project of taking the special psychiatric vulnerability of pregnancy into account, makes sure that the psychopathological aspects of the crisis situation and the physiological aspects of adaptation reactions to the perinatal period are not neglected, but that are respected by this type of interaction/intervention.

In a context of organization of care where the budget of hospitals is a function of the number and of the severity of the in-patients and not of the duration of stay, stays of long duration (SLD) in short-stay hospitals represent a problem of both medical and administrative management. To identify the characteristics of long-duration stays.The data used in this retrospective study were drawn from the Standardized Discharge Summaries of the year 1997 of a University Hospital of the Paris area (France). A stay of long duration (SLD) was defined in an arbitrary way as a stay exceeding 30 days. The stays of long duration (30 days) were subdivided in "long stays" (from 31 to 60 days) and "very long stays" (more than 60 days).The SLDs represent 3.7% of the discharge summaries of our hospital, among them, 40% are medical DRGs and 60% surgical DRGs. The patients in SLD more often come from other structures of care than the patients having a short duration stay of (SDS) coming mainly from their residence and were also hospitalised in several different units during their stay. Patients having a long stay were more often classified in DRGs outside the principal activity of this hospital (i.e. cardiovascular diseases).This first approach suggests that a set of simple descriptive variables (pre-existing and acquired co-morbidity, admission in surgical ward, multi-unit stay...) makes it possible to identify the patients likely to have a long duration stay. Simple variables added to the current hospital minimum medical record would make it possible to consider a predictive approach.