1) All the medical schools in France are public, and the admission is open to almost all the qualifieds tudents. However, the number of students allowed to advance to the clinical education is strictly limited.
2) Clerkship similar to the one in the USA is mandatory in the last two years of medical school. The students take care of inpatients under meticulous supervision by residents and attending staff.
3) Postgraduate training of generalists emphasizes the importance of experiencing sufficient number of outpatients under supervision, so that the residents become competent to work as independent practitioners in three years.
4) Specialty trainings are balanced with mixtures of inpatient care, outpatient care and procedures. The number of residency positions is determined to provide of enough opportunities in each aspect of the education

We encountered a case of femoro-popliteal bypass using the in situ saphenous vein bypass procedure employing a new valvulotome and technique of angioscopically assisted valvulotomy. The new combined angioscope and valvulotome system for the in situ saphenous vein bypass grafting is safe and effective for resection of valve leaflets and to avoid valvulotome-induced injury in comparison with blind retrograde valvulotomy, and allows minimal skin incision through identification of venous tributaries by angioscopic guidance. Further detailed clinical observation may be needed for the evaluation of the long-term benefits of this maneuver.

From January 1982 to August 1993, 23 cues of advanced renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) were treated surgically. In terms of clinical stage, 12 cases were in stage III and 11 cases were in stage IV. The 23 cases were divided into three groups according to the location of the tumor thrombus in the IVC. In two cases, the tumor thrombus extended to near the right atrium or the hepatic vein, and in six cases, the thrombus extended to the hepatic IVC. All these tumor thrombus with invasion to the IVC wall were removed under partial cardiopulmonary bypass. In 15 cases, tumor thrombus were limited to near the junction of the renal vein, which were removed by balloon catheter or finger after clamping of proximal and distal side of IVC and renal vein. Direct suture of the IVC wall in 12, patch repair with EPTFE in 10 and graft replacement with EPTFE graft in 1 were performed. Eight patients who had distant metastasis, regional lymph node metastasis and extracapsular invasion died within one year, but 4 patients were alive more than four years. Survival rate at three years and five years according to the Kaplan-Meier method was 37.5% and 18.8%, respectively. In conclusion 1) partial cardiopulmonary bypass was useful and could control bleeding when tumor thrombus in the IVC extended to the junction of the hepatic vein or right atrium. 2) long term survival cases were recognized in cases with no distant metastasis, no regional lymph node metastasis and no extracapsular tumor invasion. 3) nephrectomy associated with tumor thrombectomy in the IVC was valuable on the basis of long-term prognosis.

Direct observation of the intravascular atherosclerotic change provides many diagnostic information and supports successful vascular surgery. Angioscopic inspections were performed in the 23 patients who underwent laser angioplasty for the peripheral arteries and 7 patients with aorto-coronary bypass surgery in this study. Useful images could be obtained in 19 (83%) of 23 observations in the peripheral arteries, and the successful rates of angioscopic observation were influenced by the diameter and the degree of kinking of each vessel. On the other hand, intraoperative observation of coronary artery with angioscope could be performed easily in all cases. From these findings, intraoperative application of angioscopy was considered to be useful procedure for the cardiovascular surgery.

A 39-year-old woman was referred for assessment of abnormality of on a CT scan with a vascular anomaly of the aortic arch. This patient was completely asymptomatic with no concomitant pathologies and no reported prior trauma. Laboratory data for syphilitic or other microbial infections were negative. The diagnosis was confirmed by angiographic computed tomographic scan with 3-dimensional reconstruction. This technique documented the presence of the aneurysm and the left subclavian artery arising from the unique form of aneurysm. Early surgery was preferred because of the young age of the patient and the morphology and the size of the aneurysm (50 mm). Surgery was performed by a left postero-lateral thoracotomy through the forth intercostal space. Femoro-femoral partial cardiopulmonary bypass was used for distal perfusion. An aortic clamp was placed just distal to the left carotid artery, and a second clamp was placed in the descending thoracic aorta. The aortic isthmus was replaced with a 20-mm Dacron graft, and the left subclavian artery was reimplanted to the prosthesis with an 8-mm Dacron graft interposition. This aneurysm was the result of abnormal organogenesis of a primitive aortic arch and the remnant of the dorsal aorta, in other words, Kommerell's diverticulum. Microscopic examination demonstrated severe medial layer atrophy. In the light of the high risk of rupture, which was proved to be present by the very thin aneurysm wall at the time of surgery, we suggest early surgical treatment of idiopathic isthmus aneurysms in young patients regardless of aneurysm diameter.

Objective: The efficacy of botulinum toxin type A (BoNT-A) injection on spasticity has usually been measured using the range of motion (ROM) of joints and Modified Ashworth Scale (MAS); however, they only evaluate muscle tone at rest. We objectively analyzed the gait of three patients with hemiplegia using three-dimensional motion analysis and ground reaction force (GRF) systems to evaluate muscle tone during gait.Materials and Methods: We measured passive ankle dorsiflexion ROM with knee extension and the MAS score for clinical evaluation, and gait speed, stride length, single-leg support phase during the gait cycle, joint angle, joint moment, and GRFs for kinematic evaluation before and one month after BoNT-A injection.Results: All patients showed an increase in ankle dorsiflexion ROM, improvement in MAS score, and increase in stride length. Case 1 showed an increase in gait speed, prolongation of the single-leg support phase, increase in hip extension angle and moment, and improvement in the vertical and anterior-posterior components of the GRFs. Case 2 showed an increase in gait speed, improvement in double knee action, increase in ankle plantar flexion moment, and improvement in propulsion in the progressive component of the GRFs. Case 3 exhibited a laterally directed force in the GRFs.Conclusion: We evaluated the effects of BoNT-A injections in three patients with hemiplegia using three-dimensional motion analysis and GRFs. The results of the gait analysis clarified the improvements and problems in hemiplegic gait and enabled objective explanations for patients.

Objective: This study evaluated the feasibility and outcomes of pneumovaginoscopy-assisted radical hysterectomy (PVRH) for cervical cancer up to stage IIA using a bidirectional fascia-oriented and nerve-sparing surgical approach. Methods: This retrospective observational cohort study examined the operative outcomes and prognoses of patients who underwent PVRH (n=59) for up to stage IIA cervical cancer. The basic procedure was Kyoto B2 (Viper Type II nerve-sparing) radical hysterectomy and pelvic lymphadenectomy through simultaneous vaginal and abdominal (open or laparoscopic) approaches. In all cases, pneumovaginoscopy (PV) was used to create a vaginal cuff and dissect the paracolpium and paracervical endopelvic fascia to minimize nerve damage. Results: Thirty-eight (64.4%) patients had stage IB1 cancer. Seven (11.9%) had vaginal invasion (stage IIA1, n=4; IIA2, n=3). The abdominal approach was open in 38 cases and laparoscopic in 21. Adjuvant therapy was administered to 24 patients (41%); one patient received concurrent chemoradiotherapy for gastric-type adenocarcinoma. There were three (6.1%) intraoperative complications (CO2 gas embolism [n=1], sigmoid colon musculosa injury [n=1], and ureteral injury [n=1]) and 8 (14%) postoperative complications (lymphedema with cellulitis [n=4], vaginal cuff dehiscence [n=1], sub-ileus [n=1], symptomatic lymphocyst [n=l], and ureterovaginal fistula [n=1]). The median urination recovery period was 3 days. Microscopic R0 was achieved in all cases. The median follow-up was 44.5 (2–122) months, and no recurrence occurred. Conclusion PVRH is a new fascia-oriented and nerve-sparing surgery for early-stage cervical cancer. Further, it has favorable operative outcomes and good prognoses, similar to those of adjacent pelvic surgery such as trans-anal total mesorectal excision and radical prostatectomy.

The survival rates of boys and men with cancer have increased due to advances in cancer treatments; however, maintenance of quality of life, including fertility preservation, remains a major issue. Fertile male patients who receive radiation and/or chemotherapy face temporary, long-term, or permanent gonadal damage, particularly with exposure to alkylating agents and whole-body irradiation, which sometimes induce critical germ cell damage. These cytotoxic treatments have a significant impact on a patient's ability to have their own biological offspring, which is of particular concern to cancer patients of reproductive age. Therefore, various strategies are needed in order to preserve male fertility. Sperm cryopreservation is an effective method for preserving spermatozoa. Advances have also been achieved in pre-pubertal germ cell storage and research to generate differentiated male germ cells from various types of stem cells, including embryonic stem cells, induced pluripotent stem cells, and spermatogonial stem cells. These approaches offer hope to many patients in whom germ cell loss is associated with sterility, but are still experimental and preliminary. This review examines the current understanding of the effects of chemotherapy and radiation on male fertility.
Alkylating Agents ; Cryopreservation ; Drug Therapy ; Embryonic Stem Cells ; Fertility ; Fertility Preservation ; Germ Cells ; Gonads ; Hope ; Humans ; Induced Pluripotent Stem Cells ; Infertility ; Infertility, Male ; Male ; Methods ; Quality of Life ; Radiotherapy ; Spermatogenesis ; Spermatozoa ; Stem Cells ; Survival Rate ; Whole-Body Irradiation