Among 258 patients operated on for secondary hyperparathyroidism (HPT II) from 1971 to 1988, a total of 33 had one or more reoperations for persistent or recurrent HPT II. These reoperations did not induce any mortality or significant morbidity. After inadequate parathyroidectomy (25 cases), 15 patients were reoperated. Twelve of these had undergone initial surgery at another institution. Three patients died of causes unrelated to their HPT II. The other 12 patients are disease-free. After successful subtotal parathyroidectomy (79 cases), 2 patients (2.5%) had a recurrence 5 and 6 years later, respectively. Currently, the 2 patients remain disease-free. After total parathyroidectomy with autotransplantation (152 cases), 16 patients (10.5%) had reoperations on the grafts. The mean time before reoperation was 2 1/2 years. Hypertrophy of grafted fragments was observed in 4 cases (2.6%), but only 2 of these 4 patients were cured by removal of the grafts. Residual parathyroid tissue or a supernumerary gland in the neck or the mediastinum was suspected in 5 patients, but this could not be confirmed because one had already been reoperated on in the neck without success, another still refuses reoperation, and 3 died. In 6 other patients, the recurrence was debatable and HPT II was not confirmed. In the last 3 patients, the diagnosis was incorrect and aluminum intoxication was proved later. Results of reoperations for persistent or recurrent HPT II depend, first, on a correct diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)
La crise sanitaire liée à la COVID-19 a mis l’ensemble de l’hôpital en tension. Les services de réanimation ont été en première ligne pour prendre en charge les cas les plus graves. Le bilan des entrées et de l’occupation des lits de réanimation a été et est toujours un élément clé de mesure de l’intensité de la crise. La réanimation est une spécialité largement méconnue du grand public alors que des questions majeures se posent : priorité à la santé ou à l’économie ; perte de chance pour les malades non COVID du fait de la déprogrammation et accès à la réanimation pour les patients COVID. L’augmentation de la demande de soins critiques a nécessité une extension des capacités d’hospitalisation par transformation de lits d’USC en réanimation, par création de néo-réanimation, voire dans certaines régions par réalisation en salle classique de soins habituellement réalisés en réanimation (DV vigile, CPAP, oxygène à haut débit humidifié). Des transferts inter-régionaux voire internationaux ont été nécessaires afin de soulager les régions en forte tension. Les facteurs limitants ont été multiples mais la principale difficulté a concerné la mobilisation de personnel formé à la réanimation et la relative pénurie de médicaments. L’inadéquation entre la demande et l’offre a conduit à édicter des règles de priorisation d’accès à la réanimation. Cette revue aborde l’ensemble de ces questions et peut contribuer à une réflexion sur l’adaptation de l’hôpital pour faire face à une deuxième période épidémique.
When a candidate drug is likely to become available to prescribers and healthcare policy makers, evaluation of therapeutic progress moves forward in two stages. First, the level of expected therapeutic progress must be established. This first stage requires the determination of therapeutic needs and the comparison of these against the results of the clinical studies that will form the basis of the marketing authorisation of the drug. This determination helps anticipate the therapeutic progress that is attributable to the approved use of the new drug. The second stage of the process, the evaluation of the actual therapeutic progress, involves therapeutic drug monitoring and bases itself on observation. Since such observational data are intended to challenge the initial hypotheses and uncertainties (in terms of benefits and risks), goals and methods must be laid out before the drug becomes available to the general public. Keywords: therapeutic progress, epidemiology, evaluation When penicillin G was introduced as a therapeutic drug for human use, the therapeutic progress was so clear that no one envisaged measuring it objectively. Moreover, this question apparently sparked no interest in either physicians or scientists at that time, because of the major innovation of the antibiotic and the tangible medical progress it represented. Clinical studies were sufficient for observing that its administration cured certain infections that, until that time, systematically killed the afflicted. Although the question of therapeutic progress went unaddressed, as important as it seemed, it was, nonetheless, important to demonstrate the efficacy of the drug. In addition, the implementation of an experimental protocol defining a random controlled study was not required for this molecule to receive marketing authorisation. PHARMACOLOGIE CLINIQUESince then, the context has changed. Today, no one would consider introducing a new therapeutic molecule onto the market without data on its efficacy, based on the results of clinical trials. In the same way, anticipating the therapeutic gain of a candidate drug and measuring real therapeutic progress, obtained through its use, have become indispensable.
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