Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results

Introduction

The extent of the French forces’ territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors.

Methods

In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities.

Results

168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39).

Conclusion

This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.

Can the number of surgery delays and postponements due to unavailable instrumentation be reduced? Evaluating the benefits of enhanced collaboration between the sterilization and orthopedic surgery units

INTRODUCTION

The development of outpatient surgery, cost-reduction pressures and instrumentation storage limitations have led to their use "just-in-time". A recent study showed that stoppage of surgical procedures immediately before the incision (No-Go) was often due to the management of supplies and implantable medical devices. To our knowledge, since the development of outpatient surgery and the shortening of hospital stays, managing the flow of instrumentation has not been optimized. At our hospital, we used a two-prong approach consisting of a tool to manage instrumentation and working group from the sterilization and orthopedic surgery units. The aims of this study were to: 1) evaluate whether this approach led to better notification of the risk of supply shortage for instrumentation and 2) determine whether it could reduce by at least half operating room disruptions such as delays or cancellation of surgical procedures.

HYPOTHESIS

This approach results in better notification of the risk of supply shortage for instrumentation and reduces by at least half operating room disruptions such as delays or cancellation of surgical procedures.

MATERIAL AND METHODS

A tool was developed to manage instrumentation flow based on a retrospective analysis of data from 2015. This tool consisted of: (1) a list of instrumentation needed for each surgical procedure from an analysis of the surgical schedule and verification of traceability labels of the instrumentation actually used, (2) a list of reasons for supply shortage identified from an analysis of non-conformities occurring in the sterilization process of instrumentation kits. These analyses resulted in the development of checklists for instrument sets for each procedure, while identifying those with a high risk of shortage. In 2017, a working group focused on instrumentation was set up with personnel from the sterilization unit and the orthopedic surgery unit. Based on the check-lists and the schedule 24hours before the surgery, the sterilization unit alerted the surgery unit by email of the risk of material shortage; the surgery ward replied with potential changes to the material or the surgery planning. This approach (instrumentation management tool and working group) was named just-in-time (JIT). The main outcome was the number of notifications of potential supply shortage with and without JIT over a 10-week period. The secondary outcomes were the number of notifications resolved in time and the occurrence of operating room disruptions (delay>30min or postponement of surgery) related to unavailable instrumentation.

RESULTS

Nine reasons for potential supply shortage were identified such as instrumentation kits used for several types of procedures, those with fast rotation and low stock, or in double pathways (on loan and on deposit). The working group reported 163 potential shortages with JIT versus 41 without (p<10^-5), of which 150 (92.5%) were resolved. Thirteen operating room disruptions occurred; only one was not detected by the JIT approach.

CONCLUSION

Our JIT approach (instrumentation management tool and working group) is effective at preventing instrumentation supply shortages.

LEVEL OF EVIDENCE

III, prospective comparative study.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P &lt; 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P &lt; 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

In situ structural analysis of calcium aluminosilicate glasses under high pressure

In situ micro-Raman spectroscopy was used to investigate the structural evolution of OH(-)-free calcium aluminosilicate glasses, under high pressure and at room temperature. Evaluation was made of the role of the SiO2 concentration in percalcic join systems, for Al/(Al  +  Si) in the approximate range from 0.9 to 0.2. Under high pressure, the intensity of the main band related to the bending mode of bridging oxygen ([Formula: see text][T-O-T], where T  =  Si or Al) decreased gradually, suggesting that the bonds were severely altered or even destroyed. In Si-rich glasses, compression induced a transformation of Q (n) species to Q (n-1). In the case of Al-rich glass, the Al in the smallest Q (n) units evolved from tetrahedral to higher-coordinated Al (([5])Al and ([6])Al). Permanent structural changes were observed in samples recovered from the highest pressure of around 15 GPa and, particularly for Si-rich samples, the recovered structure showed an increase of three-membered rings in the Si/Al tetrahedral network.

Elastic moduli of permanently densified silica glasses

Modelling the mechanical response of silica glass is still challenging, due to the lack of knowledge concerning the elastic properties of intermediate states of densification. An extensive Brillouin Light Scattering study on permanently densified silica glasses after cold compression in diamond anvil cell has been carried out, in order to deduce the elastic properties of such glasses and to provide new insights concerning the densification process. From sound velocity measurements, we derive phenomenological laws linking the elastic moduli of silica glass as a function of its densification ratio. The found elastic moduli are in excellent agreement with the sparse data extracted from literature, and we show that they do not depend on the thermodynamic path taken during densification (room temperature or heating). We also demonstrate that the longitudinal sound velocity exhibits an anomalous behavior, displaying a minimum for a densification ratio of 5%, and highlight the fact that this anomaly has to be distinguished from the compressibility anomaly of a-SiO₂ in the elastic domain.

Hysteretically reversible phase transition in a molecular glass

Pressure induced densification in a molecular arsenic sulfide glass is studied at ambient temperature using x-ray scattering, absorption and Raman spectroscopic techniques in situ in a diamond anvil cell. The relatively abrupt changes in the position of the first sharp diffraction peak, FSDP, and the pressure-volume equation of state near ∼2 GPa suggest a phase transition between low- and high-density amorphous phases characterized by different densification mechanisms and rates. Raman spectroscopic results provide clear evidence that the phase transition corresponds to a topological transformation between a low-density molecular structure and a high-density network structure via opening of the constituent As(4)S(3) cage molecules and bond switching. Pressure induced mode softening of the high density phase suggests a low dimensional nature of the network. The phase transformation is hysteretically reversible, and therefore, reminiscent of a first-order phase transition.

Progressive transformations of silica glass upon densification

The elastic and plastic behaviors of silica glasses densified at various maximum pressure reached (12 GPa, 15 GPa, 19 GPa, and 22 GPa), were analyzed using in situ Raman and Brillouin spectroscopies. The elastic anomaly was observed to progressively vanish up to a maximum pressure reached of 12 GPa, beyond which it is completely suppressed. Above the elastic anomaly the mechanical behavior of silica glass, as derived from Brillouin measurements, is interpreted in terms of pressure induced transformation of low density amorphous silica into high density amorphous silica.

Quantum cutting in CaYAlO4: Pr3+, Yb3+

The deposition of a thin layer of a quantum-cutter material on top of silicon-based solar cells seems to be a promising solution to reduce the thermalization losses. This mechanism has been reported in materials codoped with Pr3+-Yb3+, where Pr3+ can sensitize two Yb3+ ions for one absorbed blue photon. In the present Letter, we analyze precisely energy transfers between Pr3+ and Yb3+ in CaYAlO4, and we measure a quantum-cutting rate of 145%. We show that a very efficient back transfer from Yb3+ toward the (1)G4 level of Pr3+ ion leads to a strong reduction of the quantum yield.

Soda-lime silicate glass under hydrostatic pressure and indentation: a micro-Raman study

Raman micro-spectroscopy is used to analyse the plastic behaviour of window glass (a soda-lime silicate glass) under high hydrostatic pressure and Vickers indentation. We show pressure-induced irreversible structural changes, notably an increase of Q(2) species at the expense of Q(3). For the first time, a very accurate [Formula: see text] calibration curve has been established. Local density variations of a Vickers indented window glass have been characterized by micro-Raman mapping using a high spatial resolution device. The effects of glass depolymerization on indentation and hydrostatic compression are discussed. Differences between window glass and pure SiO(2) glass behaviour under high stresses are also highlighted and analysed at a local scale.

In situ Raman spectroscopy of pressure-induced changes in LaBGeO(5) glass: hysteresis and plastic deformation

In situ micro-Raman spectroscopy was performed on lanthanum borogermanate (LBG) glasses, compressed in a diamond anvil cell at ambient temperature. Up to 5.6 GPa the structural changes are reversible, whereas experiments performed at 10 GPa and higher are characterized by hysteresis loops. A noticeable change of evolution of the main Raman band at 800 cm(-1) has been evidenced around 8 GPa. Indeed, at such a pressure, this Raman band is shifted in the opposite direction while the pressure is still increasing. This change of slopes may be the sign of a pressure-induced coordination number change. Upon decompression the Raman shift of this band follows a different path from the one during compression. When the sample is returned to ambient pressure, it shows a shifted and lightly modified Raman spectrum, suggesting that a new amorphous phase for LBG glass is reached under high pressure and still exists at atmospheric pressure. However, a comparison with LaBGeO(5) crystals with the same composition shows that this material has a full elastic behaviour in the same pressure range.

[Muir-Torre syndrome and familial colorectal cancer: 2 families with molecular genetic analysis]

INTRODUCTION

The Muir-Torre Syndrome is a rare genodermatosis, defined by the occurrence of cutaneous tumors (such as sebaceous adenomas, epitheliomas, or carcinomas, and/or keratoacanthomas), and internal malignancies. Recently, molecular analysis in hereditary non polyposis colorectal cancer demonstrated a common genetic basis, linking these two disorders, with the observation of germline mutations in the hMSH2 gene (one of the DNA mismatch repair system genes) in both syndromes. Such molecular demonstration of a single nosological entity should be clinically used to improve the indications of molecular testings in oncogenetics, still restricted to highly stringent criteria for hereditary non polyposis colorectal cancer.

CLINICAL CASES

We identified three patients from two different families, who fulfilled the criteria for both Muir-Torre Syndrome and hereditary non polyposis colorectal cancer. The search of a germline mutation of the hMSH2 gene was performed on an affected member from each family, and their relatives with their informed consent. Within each family, all individuals with colorectal cancer were carriers of the same mutation. In the first family, this mutation was a pathogenic microinsertion, usable for predictive testing. In the second family, a missense mutation was identified, requesting further demonstration of its pathogenicity before its use in a predictive purpose.

CONCLUSIONS

The diagnosis of cutaneous tumors compatible with Muir-Torre syndrome should lead the dermatologist to suspect an hereditary non polyposis colorectal cancer that should bring to an oncogenetic approach: personnal and familial history of colorectal cancer, molecular analysis, recommendations for colonoscopic screening in at-risk relatives. In the case of a colorectal cancer at a young age, or in the case of familial cases, the gastroenterologist should screen for cutaneous lesions of Muir-Torre syndrome, which could add a criteria for an hereditary syndrome, and lead to molecular oncogenetic analysis.

The association carbamazepine-mianserin in opiate withdrawal: a double blind pilot study versus clonidine

Our clinic has fortuitously developed the therapeutic use of the association of mianserin (maximum daily dose 90 mg) and carbamazepine (maximum daily dose 400 mg) in opiate withdrawal management. If animal studies have suggested efficacy of mianserin in such indication, no human studies have been performed. To test the efficacy of such an association, a comparison was made to clonidine (maximum daily dose 0.600 mg) in a one week treatment period according to a double blind pilot study design. Thirty-two patients were included (16 in each treatment group). The two treatments did not differ in the intensity of the withdrawal, according to the rate of retention in treatment and symptoms, and the psychic distress which were auto-evaluated every other day with the Opiate Withdrawal Questionnaire and several Visual Analog Scales (VAS). The clonidine group, however, scored significantly higher (P < 0.05) on the VAS rating of the global feeling of satisfaction on the last day. The patients in the mianserin group fortuitously had a moderately lower number of daily heroin intakes but there was no significant correlation between this variable and the global OWQ scores on Days 1, 3, 5 and 7. Given the size of the groups, we cannot conclude that the association carbamazepine-mianserin is as effective as clonidine, but a real effectiveness is probable. A study versus placebo would be necessary to draw more definitive conclusions.

Envelope proteins and replication of vesicular stomatitis virus: in vivo effects of RNA+ temperature-sensitive mutations on viral RNA synthesis

Temperature-sensitive (ts) mutants of vesicular stomatitis virus belonging to complementation groups III and V were investigated for their in vivo RNA synthesis. The sucrose gradient patterns of the RNA species which they produced at nonpermissive temperature (39.2 degrees C) were systematically compared under different experimental conditions: variation of input multiplicity and of time of infection, superinfection with T particles, and temperature shifts. Finally, a more precise analysis of the various RNA species synthesized was carried out. It appeared that the characteristics of RNA synthesis specified at 39.2 degrees C by tsIII or tsV mutants differed from the normal RNA synthesis of vesicular stomatitis virus wild type. Their common depression at 39.2 degrees C in virion-like RNA (38S) production--i.e., so-called genome replication--was tentatively paralleled with the concomitant ts events which have been previously shown to affect the two viral envelope proteins. An overproduction of the RNA transcripts was described for mutants in group III and posed the question of a regulation process to determine the amount of RNA to be transcribed.

Temperature-sensitive defect of vesicular stomatitis virus in complementation group II

The prototype member of the complementation group II temperature-sensitive (ts) mutants of vesicular stomatitis virus, ts II 052, has been investigated. In ts II 052-infected HeLa cells at the restrictive temperature (39.5 degrees C), reduced viral RNA synthesis was observed by comparison with infections conducted at the permissive temperature (30 degrees C). It was found that for an infection conducted at 39.5 degrees C, no 38S RNA or intracytoplasmic nucleocapsids were present. For nucleocapsids isolated from ts II 052 purified virions or from ts II 052-infected cells at 30 degrees C, the RNA was sensitive to pancreatic RNase after an exposure at 39.5 degrees C in contrast to the resistance observed for wild-type virus. The nucleocapsid stability of wild-type virus when heated to 63 degrees C or submitted to varying pH was not found in nucleocapsids extracted from ts II 052 purified virions. The data suggest that for ts II 052 there is an altered relationship between the viral 38S RNA and the nucleocapsid protein(s) by comparison with wild-type virus. Such results argue for the complementation group II gene product being N protein, so that the ts defect in ts II 052 represents an altered N protein.

Transcription and replication of vesicular stomatitis virus: effects of temperature-sensitive mutations in complementation group IV

Temperature-sensitive (ts) mutants of vesicular stomatitis virus belonging to the RNA(-) complementation group IV were investigated under various conditions to study both their RNA and protein syntheses. In infected cells maintained at 39.2 C, viral RNA species were recovered only in the 13 to 15S region of the gradient in an amount depending on the ts mutant used. In the presence of cycloheximide at 39.2 C, the primary transcription was deficient, especially for 28S mRNA production. When mutant-infected cells were shifted to nonpermissive temperature, a shutoff of 28S mRNA synthesis occurred as a general feature. On the contrary under this condition, the two mutants chosen, ts IV100 and ts IV111, behaved very differently in their 13 to 15S and 38S RNA production. However, treatment with cycloheximide at the time of the transfer to 39.2 C resulted in a similar recovery of 13 to 15S RNA in both mutants, whereas the 28S remained very depressed. The viral proteins synthesized by cells infected with the same two mutants also showed a distinct pattern, especially regarding the N protein; a correlation between 38S RNA and protein N syntheses was tentatively drawn. The whole set of data suggested that the lesion in group IV mutants concerned a viral structural protein required for the process of in vivo transcription and which probably intervened in the replication mechanism.

Study of the transcription and the replication of vesicular stomatitis virus by using temperature-sensitive mutants

The viral ribonucleic acids (RNA species) synthesized in HeLa cells infected with temperature-sensitive (ts) mutants and with the wild type of vesicular stomatitis virus at permissive (30 C) and nonpermissive (39.2 C) temperatures were compared by sucrose gradient centrifugation. Two ts mutants (ts 5 and ts 100) representing two separate complementation groups (respectively, groups I and IV), each concerned with viral RNA synthesis, were chosen. Mutant ts 5 failed to synthesize any RNA at 39.2 C. Under the same conditions, mutant ts 100 showed a low, but easily detectable, synthesis of RNA without characteristic peaks. The in vitro transcriptase activity was tested with mutants ts 5 and ts 100 at 39.2 C: normal activity, compared with wild-type virus, was detected with purified ts 100, but no activity was detected with purified ts 5. From all our data we conclude that mutant ts 5 is defective in transcription. The defect could be in the structural transcriptase enzyme or at the level of template for transcription. Results with mutant ts 100 were not so clear-cut. However, we suggest that this mutant is concerned with some aspect of transcription in vivo. In addition, our results lead us to postulate some linkage between transcription and replication.