Isabelle Plu

Fatal Aβ cerebral amyloid angiopathy 4 decades after a dural graft at the age of 2 years

Intracerebral injection of brain homogenates containing misfolded Aβ can seed Aβ deposition in APP transgenic mice [7]. Parenchymal and vascular amyloid deposits have been observed in iatrogenic Creutzfeldt–Jakob disease (iCJD) caused by injection of cadaver-derived growth hormone (cGH) [1, 2, 5, 10]. This observation has raised the hypothesis that hormone preparations were not only contaminated with misfolded prion protein but also with Aβ aggregates able to seed amyloid formation; Aβ aggregates were, indeed, found in cGH batches produced at the time of the contamination [2]. Dural grafts, up to now associated with iCJD, have also been suspected to seed Aβ accumulation mainly in the vessel walls [3, 4, 6, 9]. Seeded Aβ aggregation, however, has not been previously associated with clinical manifestations [1]. We report here the case of a 46-year-old woman who died of repeated intracerebral hemorrhages caused by cerebral amyloid angiopathy (CAA), presumably related to contaminated cadaveric dura, grafted 44 years before death. In 1972, the patient, aged 2, had a severe cerebral contusion due to a fall from a height of 2 m. A subdural hematoma and hemorrhagic cerebral tissue were then removed. A dural defect was filled with a graft of lyophilized human cadaveric dura mater. At the age of 46, she was hospitalized after a sudden right sensorimotor deficit. She was not cognitively impaired and there was no clinical sign of CJD. Cerebral MRI showed two medium-sized hematomas in the left thalamus and occipital lobe, multiple lobar microbleeds, white matter hyperintensities, and a cavity left by the right frontal trauma (Fig. 1a, b). Four additional lobar hematomas occurred in a period of 6 months (three of those are shown in Fig. 1c, d). The diagnosis of CAA was made on a cerebral biopsy (with the hypothesis of angiitis). She was then pregnant; therapeutic abortion was performed. The patient died after a last cerebral hemorrhage responsible for intracranial hypertension and brain herniation. She had no vascular risk factors. Genetic testing excluded known mutations and duplication involved in hereditary Aβ CAA (APP, PSEN1, PSEN2). The APOE genotype was ε2/ε3. The brain (1627 g) was examined after 10% formalin fixation. Three large and recent hematomas, located in the left and right frontal lobes, were observed. They had caused a central herniation and secondary hemorrhages of the brainstem. The post-traumatic cavity in the right frontal lobe was covered by scarred dura mater. Microscopically, a

Ethical issues arising from the requirement to provide written information in palliative care

French Healthcare Networks aim to help healthcare workers take care of patients by improving co-operation, co-ordination 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. Ethical problems arise from this legislation with regard to providing terminal patients with explicit information upon their entry into the palliative phase of the disease, and requiring them to sign the document. It highlights the limitations of this practice, and the gap between the legislation and the nature of the physician-patient relationship in palliative care.

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

Healthcare 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.

[Domestic violence: what are the difficulties for practitioners? Analysis of interviews among 19 practitioners within a town-hospital care network aimed at a global approach of patients].

Resume Objectif Le but de cette etude etait de preciser, par une approche qualitative de la pratique de medecins, quels sont les difficultes et les blocages que peuvent rencontrer les medecins en presence d’une personne subissant des violences conjugales. Methode Dix-neuf medecins ont ete sollicites pour participer a une evaluation de leurs attitudes a propos du reperage et de la prise en charge des violences conjugales. Ces medecins etaient sensibilises a la dimension medico-sociale de leur pratique. Un questionnaire leur a ete propose lors d’un entretien avec un meme investigateur pour tous. Les entretiens ont ete lus et analyses par 2 evaluateurs. En cas de discordance, une relecture etait effectuee, pour degager une analyse consensuelle. Resultats La duree moyenne des entretiens a ete de 40 minutes. Les medecins interroges (11 hommes; 8 femmes) etaient âges de 29 a 60 ans, et avaient de 6 mois a 36 ans de pratique. Les medecins connaissaient la violence surtout a travers ses traces physiques, ce qui ne permet pas le reperage de toutes les formes de violence. Les outils medico-legaux a leur disposition etaient mal connus et surtout souvent inadaptes a la demande de la femme. Conclusion La notion de prise en charge globale de la personne, indispensable face a ces situations, doit etre construite et precisee au cours de la formation des medecins, car le reperage et la prise en charge des femmes subissant des violences conjugales est une question d’atteinte a la personne.

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

French 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.

Violences conjugales, quelles difficultés pour les médecins? Analyse d'entretiens avec 19 médecins d'un réseau de soins ville-hôpital orienté vers la prise en charge globale des personnes

Resume Objectif Le but de cette etude etait de preciser, par une approche qualitative de la pratique de medecins, quels sont les difficultes et les blocages que peuvent rencontrer les medecins en presence d’une personne subissant des violences conjugales. Methode Dix-neuf medecins ont ete sollicites pour participer a une evaluation de leurs attitudes a propos du reperage et de la prise en charge des violences conjugales. Ces medecins etaient sensibilises a la dimension medico-sociale de leur pratique. Un questionnaire leur a ete propose lors d’un entretien avec un meme investigateur pour tous. Les entretiens ont ete lus et analyses par 2 evaluateurs. En cas de discordance, une relecture etait effectuee, pour degager une analyse consensuelle. Resultats La duree moyenne des entretiens a ete de 40 minutes. Les medecins interroges (11 hommes; 8 femmes) etaient âges de 29 a 60 ans, et avaient de 6 mois a 36 ans de pratique. Les medecins connaissaient la violence surtout a travers ses traces physiques, ce qui ne permet pas le reperage de toutes les formes de violence. Les outils medico-legaux a leur disposition etaient mal connus et surtout souvent inadaptes a la demande de la femme. Conclusion La notion de prise en charge globale de la personne, indispensable face a ces situations, doit etre construite et precisee au cours de la formation des medecins, car le reperage et la prise en charge des femmes subissant des violences conjugales est une question d’atteinte a la personne.