Ethical issues arising from the requirement to sign a consent form in palliative care.

International audienceFrench healthcare networks aim to help healthcare workers to take care of patients by improving cooperation, coordination and the continuity of care. When applied to palliative care in the home, they facilitate overall care including medical, social and psychological aspects. French legislation in 2002 required that an information document explaining the functioning of the network should be given to patients when they enter a healthcare network. The law requires that this document be signed. Ethical issues arise from this legislation with regard to the validity of the signature of dying patients. Signature of the consent form by a guardian or trustee, a designated person--the Person of Trust--transforms the doctor-patient relationship into a triangular doctor-patient-third-party relationship

Genetic landscape of a large cohort of Primary Ovarian Insufficiency : New genes and pathways and implications for personalized medicine

Background Primary Ovarian Insufficiency (POI), a public health problem, affects 1-3.7% of women under 40 yield-ing infertility and a shorter lifespan. Most causes are unknown. Recently, genetic causes were identified, mostly in single families. We studied an unprecedented large cohort of POI to unravel its molecular pathophysiology.Methods 375 patients with 70 families were studied using targeted (88 genes) or whole exome sequencing with pathogenic/likely-pathogenic variant selection. Mitomycin-induced chromosome breakages were studied in patients' lymphocytes if necessary. Findings A high-yield of 29.3% supports a clinical genetic diagnosis of POI. In addition, we found strong evidence of pathogenicity for nine genes not previously related to a Mendelian phenotype or POI: ELAVL2, NLRP11, CENPE, SPATA33, CCDC150, CCDC185, including DNA repair genes: C17orf53(HROB), HELQ, SWI5 yielding high chromo-somal fragility. We confirmed the causal role of BRCA2, FANCM, BNC1, ERCC6, MSH4, BMPR1A, BMPR1B, BMPR2, ESR2, CAV1, SPIDR, RCBTB1 and ATG7 previously reported in isolated patients/families. In 8.5% of cases, POI is the only symptom of a multi-organ genetic disease. New pathways were identified: NF-kB, post-translational regulation, and mitophagy (mitochondrial autophagy), providing future therapeutic targets. Three new genes have been shown to affect the age of natural menopause supporting a genetic link.Interpretation We have developed high-performance genetic diagnostic of POI, dissecting the molecular pathogene-sis of POI and enabling personalized medicine to i) prevent/cure comorbidities for tumour/cancer susceptibility genes that could affect life-expectancy (37.4% of cases), or for genetically-revealed syndromic POI (8.5% of cases), ii) predict residual ovarian reserve (60.5% of cases). Genetic diagnosis could help to identify patients who may benefit from the promising in vitro activation-IVA technique in the near future, greatly improving its success in treating infertility.Funding Universite? Paris Saclay, Agence Nationale de Biome?decine.Copyright (c) 2022 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)Peer reviewe

Les enjeux de santé publique des réseaux de santé (à partir de l'évaluation externe d'un réseau de soins palliatifs à domicile)

DIJON-BU Médecine Pharmacie (212312103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Georges Lemoine (illustrer la littérature au XXè siècle)

Depuis les années soixante-dix, le travail d'illustrateur de Georges Lemoine se singularise par la modernité de son accompagnement de " grands " textes littéraires (Le Clézio, Bosco, Tournier, Yourcenar, Roy, Wilde, Andersen, etc.). Cette recherche se donne pour objet d'étudier comment l'illustration de Georges Lemoine se construit en harmonie avec les œuvres littéraires et quelles sont les spécificités graphiques de ce travail d'élaboration d'images. Cette étude va donc successivement situer l'illustrateur dans le paysage éditorial français, analyser les spécificités du travail de création d'images destinés aux livres, cerner les étapes de la genèse d'une illustration, questionner le travail interprétatif de Georges Lemoine et repérer à quels niveaux sémantiques ses images interviennent, mettre en évidence les préférences thématiques de l'illustrateur et les spécificités de son style qui s'élabore à partir des structures symboliques et allégoriques des œuvres. Ces analyses qui s'appuient sur l'ensemble de l'œuvre illustrée de Georges Lemoine et sur de nombreuses documents inédits, permettent d'approfondir plusieurs questions : qu'est-ce qu'illustrer un texte littéraire ? En quoi cet espace particulier qu'est l'illustration peut-il relever lui-même de la littérature ? A quels niveaux s'élaborent les liens entre la séquence d'images et le texte illustré ?Since the seventies, Georges Lemoine's work has become noteworthy because of the modern way in which he illustrates great literary texts (Le Clézio, Bosco, Tournier, Yourcenar, Roy, Wilde, Andersen, etc.). The aim of this thesis is to show how these illustrations develop together with the texts and to show what graphic requirements are needed in the creation of the pictures. This thesis will therefore place the illustrator within the French publishing world, and then analyse the specific requirements for book illustration. It will also look at the various steps needed in the genesis of a picture, question Georges Lemoine's interpretation, and focus on the semantic levels on which the pictures have an influence. Finally, this thesis will point out the illustrator's thematic preferences and the peculiarities of his style, which are developed around the symbolic and allegorical levels of his chosen texts. This research is based on Georges Lemoine's whole repertoire of illustrations and on a large amount of private archives. Several questions arise: what does illustrating a literary text involve? Can the illustration become some form of literature in itself? What are the relationships between text and images?RENNES2-BU Centrale (352382101) / SudocSudocFranceF

[Palliative care in delivery room for preterm infants less than 24weeks of gestation. Analysis of two different behaviors.]

International audienceAIMS OF THE STUDY: To describe the management of extremely preterm newborns at the threshold of viability before 24weeks of gestation in the delivery room when the decision has been made not to provide intensive care; to assess the role of palliative care (PC); to report the problems encountered. METHOD: A prospective qualitative study was conducted using semi-structured interviews from November 2009 to June 2010 in two level III French maternity hospitals (A and B). In each center, four midwives, two obstetricians, two pediatricians, two anesthetists, and one chief midwife were interviewed. RESULTS: In maternity hospital A, a protocol was in place that proposed PC derived from developmental care (noise limitation, drying, warming) provided by parents or staff. The problems reported were related to former euthanasia practices rather than new procedures. In maternity hospital B, no palliative care protocol had been set up. Euthanasia was practiced and accepted fatalistically because the only currently existing alternative (letting the infant die) was considered inhumane. Few problems were reported. The reluctance to carry out PC is conceptual and organizational (the ratio of births per midwife in maternity hospital B was twice that of maternity hospital A). Lexical analysis showed preferential use of the words "fetus" and "expulsion" versus "child" and "delivery" in maternity hospital B (p<0.05) when speaking of the delivery of the extremely preterm infant. Our explanatory hypothesis is that the concept of "fetus ex utero" legitimates euthanasia by assimilating it to feticide. CONCLUSION: At the time of this study, two very different approaches to the death of extremely preterm, non-resuscitated newborns in the delivery room coexisted in France. Palliative care is obviously possible, after group reflection, if a true motivation to change, a better understanding of the law, and a clear identification of the respective status of the fetus and the newborn exist in the maternity hospital

Concerning mistreatment of older people: clinical and ethical thoughts based on a study of known cases.

International audienceFollowing a report by the Health Ministry recommending a greater implication of general practitioners (GP) in the diagnosis and care of mistreated older people, we wanted to evaluate what was actually their role in this matter. A study was made of files of mistreated older persons referred to the social services in a Parisian suburb. For each file, we noted who raised the first suspicions of mistreatment, who diagnosed it, what happened next, and what precisely the GP's role was. Out of 600 files, we found 12 cases, concerning 14 persons (two couples). Although all the patients had health problems requiring frequent consultations with their GP, none of these situations were diagnosed by the GP. In all cases, the GP played only a secondary role, if at all. The following points are discussed: The link between family problems and history cannot be ignored in the follow up of such situations. The GP's role is discussed regarding clinical knowledge of mistreatment and the legal rules they have to deal with. Our results bring to light how the balance between the person's autonomy and the necessary direct action is especially delicate in this field

Terrorist attacks: cutaneous patterns of gunshot and secondary blast injuries

Terrorist attacks have been on the rise. During the recent terrorist attacks in France, terrorists perpetrated their acts using weapons of war, as well as explosive charges. These two modes of action, when combined, can create skin lesions with similar macroscopic appearances, which can sometimes go unnoticed because of body fragmentation. A total of 68 autopsies, 83 external examinations, 140 standard radiographic examinations, and 49 computed tomography (CT) scans were performed over 7 days during the 2015 terrorist attacks in France. Bodies were injured by firearms and shrapnel-like projectiles. We analysed the clinical findings for the secondary blast cutaneous lesions from the explosive devices and compared these lesions with ballistic-related lesions to highlight that patterns can be macroscopically similar on external examination. Secondary blast injuries are characterised by penetrating trauma associated with materials added to explosive systems that are propelled by explosive air movement. These injuries are caused most often by small, shrapnel-like metallic objects, such as nails and bolts. Propulsion causes ballistic-type injuries that must be recognised and distinguished from those caused by firearm projectiles. Differentiating between these lesions is very difficult when using conventional criteria (size, shape, number and distribution on the body) with only external examination of corpses. This is why the particularities of these lesions must be further illustrated and then confirmed by complete autopsies and radiological and anatomopathological examinations.Key points When occurring simultaneously in terrorist attacks, injuries caused by secondary blasts appear as cutaneous wound patterns that can be macroscopically very similar to those caused by firearm projectiles. The criteria usually found in the literature for distinguishing these two types of projectiles may be difficult to use. It is important in these difficult situations to benefit from systematic postmortem imaging. Systematic autopsy and then anatomopathological analyses of the orifices also help determine the cause of the wounds

[Neonatal resuscitation and unreasonable obstinacy: a hospital ordered to pay damages].

International audienc

[Principles and stakes of external communication of healthcare networks: the case of heathcare networks for health services accessibility]

International audienceHealthcare networks which purpose is to manage patients through better coordination of the care, need to develop a communication strategy to be recognized by the public and by healthcare professionals and to be inserted in the healthcare landscape. We firstly will present legal requirements related to external communication of healthcare networks. Then, we will describe the different tools which can be used to communicate about healthcare networks in its area, with the example from a healthcare network for health services accessibility. In the French Public health code, the legal status and the ethical charter of the healthcare network have to be delivered to the healthcare professionals in its area and to the patients. Moreover, the example healthcare network informed collectively and individually the healthcare professionals of its area about its activities. It made it known to the public by the way of departmental prevention manifestations and health education sessions in community social associations. From these examples, we will conduct an ethical reflection on the modalities and stakes of the external communication of healthcare networks