[Central control malfunction in Wolfram syndrome: Report of one case of difficult weaning]

INTRODUCTION

Wolfram syndrome is a rare autosomal recessive genetic disease characterized by diabetes insipidus, diabetes mellitus, optic atrophy and deafness. A neurodegenerative syndrome is usually associated, including cerebellar ataxia. A few cases of central apnea have been reported in the literature. Here, we report a case of Wolfram syndrome with respiratory symptoms that led to the discovery of central apneas as well as complicated and delayed weaning in an intensive care unit (ICU).

OBSERVATION

The patient is a 39-year-old woman diagnosed with Wolfram syndrome who was admitted to an ICU for septic shock. She experienced difficult weaning before central apneas were observed while spontaneous ventilation was being attempted. After two extubation failures, cerebral MRI was performed and revealed parenchymatous atrophy of the posterior brain fossa involving the cerebral trunk, cerebellar peduncles, as well as both cerebellum hemispheres and the cerebellar vermis. Even after the patient was tracheotomized, central apneas persisted when the patient breathed spontaneously with her tracheotomy, necessitating nocturnal ventilation.

CONCLUSION

While central apneas Wolfram syndrome remain rare, they should be systematically investigated due to their association with severe morbimortality.

Treating strangeness: Medicine and human dignity at the time of COVID-19

The concomitance of a migratory wave and the hospital crisis once again raises the question of the care that the French healthcare system is able to provide to migrants. On the occasion of SFFEM's 19th annual day, we present a synthesis of the research work that has been communicated at that time. Firstly, we will discuss how doctors have been able to overcome strangeness to revive the notion of hospitality according to Levinas; secondly, we will discuss how the hospital is departing from its mission of institutional hospitality because of administrative injunctions; thirdly, we will discuss how ethnomedicine gives us keys to open up to other cultural norms; fourthly, we will see the inadequacy that exists between rights of access to medical care and their effectiveness; finally, the conclusion of Xavier Emmanuelli, founder of the social ambulance service, will remind us how much the values of the French Republic call us to the notion of care and openness to otherness.

What Do Family Caregivers of Alzheimer’s Disease Patients Desire in Smart Home Technologies?

Objectives: The authors’ aim was to investigate the representations, wishes, and fears of family caregivers (FCs) regarding 14 innovative technologies (IT) for care aiding and burden alleviation, given the severe physical and psychological stress induced by dementia care, and the very slow uptake of these technologies in our society.

Methods: A cluster sample survey based on a selfadministered questionnaire was carried out on data collected from 270 families of patients with Alzheimer’s disease or related disorders, located in the greater Paris area. Multiple Correspondence Analysis was used in addition to usual statistical tests to identify homogenous FCs clusters concerning the appreciation or rejection of the considered technologies.

Results: Two opposite clusters were clearly defined: FCs in favor of a substantial use of technology, and those rather or totally hostile. Furthermore the distributions of almost all the answers of appreciations were U-shaped. Significant relations were demonstrated between IT appreciation and FC‘s family or gender statuses (e.g., female FCs appreciated a tracking device for quick recovering of wandering patients more than male FCs: p = 0.0025, N = 195).

Conclusions: The study provides further evidence of the contrasted perception of technology in dementia care at home, and suggests the development of public debates based on rigorous assessment of practices and a strict ethical aim to protect against misuse.

["Palimpsest scar" lesions in a context of torture (Darfur, Sudan)]

BACKGROUND

As a result of the current exponentially growing refugee population from the Middle-East and East Africa (Sudan, Darfur, Eritrea), clinicians (including forensic pathologists) are seeing atypical skin lesions, mainly of a traumatic nature, but in some cases associated with long-standing lesions related to ethnic practices.

PATIENTS AND METHODS

A case of torture sequelae is presented herein in a patient originally from Darfur (Sudan): cutaneous incisions were made on old scars several times using a knife.

DISCUSSION

The clinical presentation of scarification lesions and that of atypically healed wounds (presumably an effect of inflammation induced by the introduction of irritating foreign bodies such as sand, salt, etc.) are completely different: in all cases they indicate a relative timeframe of the facts, which the clinician should not overlook in reconstructing the patient's course and the injuries to which he has been subjected (hence the proposed designation of "palimpsest scar", in the sense that a palimpsest is a manuscript on a parchment that previously contained writing but has been scratched clean to be overwritten). Thus, a "palimpsest scar" constitutes a fresh scar on top of and hiding another (ritual) scar in a context of ethnic cleansing. The diagnostic and clinical significance comes from the importance of differentiating between ethnic-type lesions and those induced by physical violence and abuse in a context of war.

[Not-for-profit: A report from the fourth annual symposium of ethics held by the National Institute for Blood Transfusion (France)]

The not-for-profit issue has been debated in November 2016 in Paris; this issue is one of the four canonical pillars of ethical blood donation. It is intimately bound to benevolence though it is distinct, as not-for-profit calls for institutions while benevolence calls for individuals. It is indeed intended that voluntary blood donors do not benefit from their donation and are thus non-remunerated. Not-for-profit is essential since it refers to the public character of blood as a putative public resource aimed at being shared as a tribute of solidarity. A central question however is linked to the capacity- or not -of public sectors to ensure that blood components are universally available, with special mention to plasma derived drugs, without the contribution of the for profit, private sector.

Oral surgery in the European Union: challenges of diversity in training and practice

INTRODUCTION

At the crossroads of medicine and dentistry, oral surgery with orthodontics are the only recognised dental specialties by the European Union. The goal of our study is to evaluate the current state of oral surgery in Europe from its teaching to its practice, the hypothesis being that a notable diversity persists despite European Union harmonisation process.

MATERIALS AND METHODS

To understand the impact of this diversity applied to European Union freedom of movement and its ethical implications for the practice of oral surgery, English and French questionnaires were sent by email to universities and organisations delivering authorisation to practise in France, Germany, Spain, Sweden and United Kingdom chosen based upon inclusion and exclusion criteria. An analysis of documents on these organisations' official websites was also conducted. Demographic information was obtained from the aforementioned organisations.

RESULTS

The profile of practising oral surgeons is different dependent on the country. The university and hospital trainings conform to European recommendations and span 3-4 years. European Board certification is not required. Continuing education is mandatory only in France, Germany and United Kingdom. As for curricula and scope of practice, no consensus can be derived.

DISCUSSION

There is potential conflict of interest between European Union principles of freedom of movement and protection of all citizens, as member countries do not uniformly apply Directives and recommendations. A new survey of all European Union oral surgery programmes as well as organisations delivering authorisation to practise is necessary to implement across the board harmonisation of training and practice to insure patient safety in light of the migration of European Union practitioners.

A new definition of health? An open letter of autochthonous peoples and medical anthropologists to the WHO

Currently, for many practitioners (hospital and liberals) and researchers (including public health), the WHO definition of health is outdated: first it seems more utopian than pragmatic; then, it proves unsuitable for a large part of the world population. There is clearly a need to refine this definition or propose additional criteria to be more relevant or discriminating. In this perspective, what can indigenous people offer in the elaboration of a new definition of health? In this article, leaders or representatives of autochthonous peoples, anthropologists and physicians from many cultural origins (Amazonia, Patagonia, Papua New-Guinea, Inuit, North-American Indian, sub-Saharan Africa, India, China, Melanesia and Polynesia) have tried to identify and explain several key concepts that WHO should reintegrate into its new definition of health: human equilibrium in nature, accepted spirituality and adaptation. On the sidelines of the application of COP21 decisions that should give back to man his place into the environment, autochthonous people leaders, anthropologists and MDs explain why these three concepts are fundamental and universal health determinants, and need to be included in a new WHO definition of health.

[Voluntariness and blood donation: Proceedings of an ethics seminar held at the National Institute for Blood Transfusion]

Voluntariness stands for one of the four pillars of ethics in blood donation; it is, however, more related to tradition than to legislation. Because it seems necessary to apply "marketing" techniques to blood collection in order to meet the needs in blood components, both in terms of quantity and quality, one wonders if this may be at the expense of this principle of voluntariness. This seminar-belonging actually to a series of seminars in Ethics in Transfusion Medicine-aimed at questioning the possible weakness of voluntariness in the field of blood donation. To achieve this goal, specialists of numerous disciplines in medical sciences, law and humanities gathered to discuss all related issues to voluntariness in blood donation.

[A difficult transition from childhood to adult healthcare: the case of epilepsy]

OBJECTIVE

The purpose of this study was to analyze modalities of the transition from pediatric to adult epilepsy care and patients' acquisition of autonomy.

METHOD

This study was conducted using semidirected interviews composed of three major parts: the patient's criteria of transition toward adult healthcare (factors taken into account, anticipation, the patient's opinion, etc.), conditions (teamwork with the neurologists, transmission of the medical record, continuity of health care, etc.), and the role played by social workers and psychologists. We interviewed 10 doctors belonging to six major Parisian hospital units involved in the monitoring of children and adolescents with epilepsy and working in Pediatric Neurology Departments of the Île-de-France region.

RESULTS

For most of the doctors, reaching 18 years of age was the major argument taken into account to consider transition to adult care. According to the doctors interviewed, parents are generally worried when their child has to find another doctor (7/10). According to eight out of 10 doctors, the neurologist is selected to take over. The doctors recognize the importance of psychologists and social workers even if they are not always included. The process by which the patient gains autonomy depends a great deal on the role played by the pediatricians and parents, although some parents are very protective. This behavior weakens the patient's capacity for autonomy and it varies according to the degree of his or her physical and/or neurological disabilities. Furthermore, developing autonomy requires interdisciplinary work that is not yet fully in place.

CONCLUSION

The lack of structures well-adapted to the uniqueness of each patient and the lack of coordination between the various institutions do not favor the acquisition of autonomy. A network that could efficiently respond to the needs of epileptic patients as well as medical care tailored to adolescents would be the answer to this dilemma.

How nonverbal communication shapes the doctor-patient relationship: from paternalism to the ethics of care in oncology

The purpose of this research, led in the wake of years of pressure to reject paternalism, was to study whether controlled practice of nonverbal communication by doctors inheres a continued risk of paternalistic attitudes in oncology clinic interviews (chosen to illustrate the doctor-patient relationship). This study involved qualitative descriptive research based on interview observations and questionnaires and mobilized recognized theory borrowed from sociology and anthropology. We found that the legislative framework governing the doctor-patient relationship has simply shifted the paternalism issue from verbal communication over to a new area that doctors have not yet mastered and patients have not yet understood, i.e., nonverbal communication. This study shows that all the laws framing the doctor-patient relationship can be circumvented, and that by controlling nonverbal communication, the doctor can fall back into paternalism. The rejection of paternalism therefore needs to lead to an appropriate reading of the patient's story, which in ethical terms can only happen if hospital structures are made non-paternalizing by design, if doctors learn to understand the patient's different chronemic timeframe, and if doctors committedly engage in the Hippocratic Oath codified through the ethics of care.

[Lung cancer, how to deal with critical situations?]

The management of a patient with cancer, including lung cancer requires the investment of many health caregivers. The development of surgical techniques as well as targeted therapies requires a specialization of each. In order to optimize the actions of each, coordination of support is required from the diagnosis of cancer. This coordination can reduce iatrogenic toxicity and improve quality of life during the disease. It may also enhance quality of accompaniment of the patient, his family and a fortiori the health care team. The development of this coordination of supportive care in oncology, as part of a department of cancerology including care of patients with lung cancer is described. This organization allows to limit the toxicities of cancer treatment, but also to improve the suffering of patients by focusing on maintaining the patient at home.