L'utilisation libérale des transfusions de plaquettes dans la réanimation initiale des patients polytraumatisés

Cette revue systématique évalue l’effet d’une utilisation libérale de plaquettes (ratio élevé plaquettes:culots globulaires) en comparaison à une utilisation traditionnelle (faible ratio plaquettes:culots globulaires) dans la réanimation initiale des polytraumatisés. Parmi 6123 références identifiées, nous avons sélectionné 7 études observationnelles comparatives incluant au total 4230 patients. Quatre études ont rapporté une diminution de la mortalité avec des ratios plaquettes:culots globulaires élevés chez des patients transfusés massivement. Une étude sur des patients sans hémorragie massive et une étude sur un nouveau protocole de transfusion massive n’ont rapporté aucune différence. L’hétérogénéité clinique et les failles méthodologiques des études n’ont pas permis d’effectuer une méta-analyse. Les données probantes actuelles sont insuffisantes pour appuyer l’utilisation d’un ratio plaquettes:culots globulaires spécifique dans la réanimation des polytraumatisés, surtout en considérant le biais de survie et les hémorragies non massives. Des essais cliniques randomisés évaluant la sécurité et l’efficacité d’un ratio élevé plaquettes:culots globulaires sont nécessaires avant de recommander leur utilisation.This systematic review examines the impact of a liberal use of platelet transfusions (higher platelets:red blood cells ratio) compared to a traditional use (low platelets: red blood cells ratio) for the acute resuscitation of trauma patients. Seven observational comparative studies including 4230 patients were selected among 6123 titles identified. Four studies reported decreased mortality with higher PLT:RBC ratios among massively transfused patients. One study on non-massively transfused patients and one evaluating a new massive transfusion protocol did not report a survival benefit. Clinical heterogeneity and methodological flaws of the included studies precluded performing a meta-analysis. There is insufficient evidence to strongly support the liberal use of high PLT:RBC ratio for acute trauma resuscitation. Randomized controlled trials examining both the safety and efficacy of the liberal use of platelet transfusions with adjustment for other co-interventions are warranted before high PLT:RBC ratios can be broadly recommended

Trainees’ views of physician workforce policy in Quebec and their impact on career intentions

Background: The physician workforce in Quebec is regulated by a government-controlled plan. Many specialty trainees expressed concerns about securing a position. Our objective was to analyze physicians’ employment issues in Quebec and their impact on residents’ training in specialty programs.Methods: We distributed a web-based self-administrated survey to all Quebec residents training in specialty programs to capture data about residents’ ability to find employment, career plans and perceptions regarding the workforce policy. Three groups were considered: graduates, non-graduating senior residents, and junior residents.Results: The overall response rate was 41.5% (985/2372). 47.3% of graduates did not have a position two months before finishing their training. Among residents without a position, 27.1% of graduates intend to leave Quebec, and 19.6% to complete a fellowship to postpone their start in practice. Overall, 77.9% of respondents believed there are not enough job opportunities for the number of trainees.Conclusion: Quebec specialty residents experience significant difficulties obtaining a position in the province and perceive that there are not enough job opportunities, which impacts their career plans and could drive them to complete a fellowship or plan to practice outside the province. Trainees' experience in finding employment needs to be considered in planning the physician workforce

Social media in surgery: evolving role in research communication and beyond

Purpose To present social media (SoMe) platforms for surgeons, how these are used, with what impact, and their roles for research communication. Methods A narrative review based on a literature search regarding social media use, of studies and findings pertaining to surgical disciplines, and the authors’ own experience. Results Several social networking platforms for surgeons are presented to the reader. The more frequently used, i.e., Twitter, is presented with details of opportunities, specific fora for communication, presenting tips for effective use, and also some caveats to use. Details of how the surgical community evolved through the use of the hashtag #SoMe4Surgery are presented. The impact on gender diversity in surgery through important hashtags (from #ILookLikeASurgeon to #MedBikini) is discussed. Practical tips on generating tweets and use of visual abstracts are presented, with influence on post-production distribution of journal articles through “tweetorials” and “tweetchats.” Findings from seminal studies on SoMe and the impact on traditional metrics (regular citations) and alternative metrics (Altmetrics, including tweets, retweets, news outlet mentions) are presented. Some concerns on misuse and SoMe caveats are discussed. Conclusion Over the last two decades, social media has had a huge impact on science dissemination, journal article discussions, and presentation of conference news. Immediate and real-time presentation of studies, articles, or presentations has flattened hierarchy for participation, debate, and engagement. Surgeons should learn how to use novel communication technology to advance the field and further professional and public interaction.publishedVersio

Trainees’ views of physician workforce policy in Quebec and their impact on career intentions

Background: The physician workforce in Quebec is regulated by a government-controlled plan. Many specialty trainees expressed concerns about securing a position. Our objective was to analyze physicians’ employment issues in Quebec and their impact on residents’ training in specialty programs.Methods: We distributed a web-based self-administrated survey to all Quebec residents training in specialty programs to capture data about residents’ ability to find employment, career plans and perceptions regarding the workforce policy. Three groups were considered: graduates, non-graduating senior residents, and junior residents.Results: The overall response rate was 41.5% (985/2372). 47.3% of graduates did not have a position two months before finishing their training. Among residents without a position, 27.1% of graduates intend to leave Quebec, and 19.6% to complete a fellowship to postpone their start in practice. Overall, 77.9% of respondents believed there are not enough job opportunities for the number of trainees.Conclusion: Quebec specialty residents experience significant difficulties obtaining a position in the province and perceive that there are not enough job opportunities, which impacts their career plans and could drive them to complete a fellowship or plan to practice outside the province. Trainees' experience in finding employment needs to be considered in planning the physician workforce

OM-MADE:An open-source program to simulate one-dimensional solute transport in multiple exchanging conduits and storage zones

International audienceOM-MADE (One-dimensional Model for Multiple Advection, Dispersion, and storage in Exchanging zones) is an open-source python code for simulating one-dimensional solute transport in multiple exchanging conduits and storage zones in steady-state flow conditions. It aims at helping the interpretation of multi-peaked skewed breakthrough curves (BTCs) that can be observed in tracer tests conducted in karstic systems. OM-MADE is based on the resolution of classical mass conservation equations. In OM-MADE, all parallel and exchanging flow zones are divided along the direction of flow into reaches, in which all model parameters are kept constant. The total flowrate may be modified through lateral in and outflows. The solute may also be affected by decay processes either in mobile or immobile zones. Each reach is subdivided into discrete segments of equal length. The partial differential equations can be solved using two second order schemes, one based on an operator-split approach, the other on Crank-Nicholson pondered scheme. A verification is performed against analytical solutions, OTIS software [Runkel, 1998], and the dual-advection dispersion equation (DADE) proposed by Field and Leij [2012]. An application to a tracer test carried out in the karstic area of Furfooz (Belgium) is then performed to reproduce the double-peaked positively skewed BTC that has been observed. It constitutes a demonstration of the software capacities in the case of two reaches and three exchanging zones, among which two are mobile ones and one represents a storage zone. It thus permits to verify numerically the consistency of the conceptual interpretation of the observed BTC

DNA repair during nonreductional meiosis in the asexual rotifer Adineta vaga

Rotifers of the class Bdelloidea are microscopic animals notorious for their long-term persistence in the apparent absence of sexual reproduction and meiotic recombination. This evolutionary paradox is often counterbalanced by invoking their ability to repair environmentally induced genome breakage. By studying the dynamics of DNA damage response in the bdelloid species , we found that it occurs rapidly in the soma, producing a partially reassembled genome. By contrast, germline DNA repair is delayed to a specific time window of oogenesis during which homologous chromosomes adopt a meiotic-like juxtaposed configuration, resulting in accurate reconstitution of the genome in the offspring. Our finding that a noncanonical meiosis is the mechanism of germline DNA repair in bdelloid rotifers gives previously unidentified insights on their enigmatic long-term evolution

Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic

Objective: We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic. Background: Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible. Methods: An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma. Results: Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed. Conclusions: There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.publishedVersio

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

Background The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery. Methods This was a scoping review of all available literature pertaining to COVID‐19 and surgery, using electronic databases, society websites, webinars and preprint repositories. Results Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross‐cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning. Conclusion Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.publishedVersio

Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid

The final publication is available at Elsevier via http://dx.doi.org/10.1016/j.hpb.2016.09.005 © 2016. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/Background: Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection. Methods: In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration. Results: No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 mu g/L (normal 0-512 mu g/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA. Conclusions: There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action

Anesthésie et sécurité des procédures en dehors du bloc opératoire: "l'affaire de tous"

peer reviewedSuite aux progrès technologiques, l’activité anesthé- sique hors du bloc opératoire connaît un essor de plus en plus important. La majorité des procédures anesthésiques réalisées en dehors du bloc opératoire le sont pour des endoscopies diges- tives; le reste se partage entre les procédures radiologiques, les sysmothérapies ou encore les cardioversions. La pratique de l’anesthésie en dehors du bloc opératoire présente des difficul- tés essentiellement logistiques avec de nombreuses contrain- tes de temps et d’espace pour l’anesthésiste-réanimateur. Le recours à un anesthésiste-réanimateur en dehors du bloc opéra- toire est généralement motivé par un inconfort ou une douleur propre à la procédure réalisée, l’absence volontaire ou non de collaboration du patient (enfant, trouble psychiatrique comme la claustrophobie), l’existence d’une situation cliniquement ins- table ou d’un état clinique extrêmement précaire (ce sont les compétences en réanimation qui seront ici nécessaires). La mise au point pré-opératoire, le monitoring approprié et le choix de la technique ainsi que des produits adéquats permettent d’opti- miser une activité anesthésique volontiers banalisée, mais dont les risques sont superposables à ceux d’une anesthésie générale au quartier opératoire.Due to important technological improvements, anesthesiological activity outside the operating theatre is increasing. Most of these procedures are performed for gastro- enterology procedures; other procedures include medical ima- ging, electroconvulsive therapy or cardioversion. The practice of anesthesia at alternative sites is associated with logistical dif- ficulties with many constraints. Anesthesia will be requested if the procedure is likely to be unpleasant or painful, if the patient is not cooperative, or if the patient’s hemodynamic condition is unstable. The pre-anesthesia assessment, an adequate monito- ring and an appropriate choice of the anesthetic technique and drugs will be helpful in managing an anesthetic procedure too frequently neglected despite it is associated with risks similar to procedures performed in the operating theatre