Showing papers by "CHU Ambroise Paré published in 2013"

Acute cor pulmonale in ARDS

Abstract: In 1977, Zapol and colleagues [1] reported that the pulmonary circulation was injured in patients with ARDS, leading to elevated pulmonary vascular resistance and pulmonary hypertension. The investigators suggested that the pathogenesis was related to competition between alveolar distending pressure and blood flow in these patients who were ventilated with high airway pressure [2], as proposed by West et al. [3]. Pulmonary vascular remodeling also occurs with muscularization of normally non-muscularized arteries. Subsequently, using transesophageal echocardiography (TEE), 24 years later Vieillard-Baron et al. [4] reported an incidence of acute cor pulmonale (ACP) of 25 % during the first 3 days in 75 ARDS patients treated with lung protective ventilation. A few years later, the same group reported a much higher incidence of 50 % in more severe patients, all exhibiting a PaO2/FiO2 <100 mmHg [5]. The same group studied 352 patients and found that the incidence of ACP was related to elevated plateau airway pressure (Pplat) with a safe limit for the right ventricle of 27 cmH2O [6]. Since then, several questions are still unresolved, including: What is the actual incidence of ACP in a larger population? Which are the main variables associated with ACP? What is the impact of ACP on prognosis, if any? Should RV function be monitored, and, if so, how? Should clinicians adjust the ventilatory strategy to RV function? Recently published clinical studies provide answers to some of these questions. Boissier et al. [7] reported an incidence of ACP of 22 % (95 % CI 16–27 %) in a prospective single-center study of 226 patients using TEE within the first 3 days following diagnosis of ARDS. Patients met the Berlin definition criteria for moderate to severe ARDS [8]. They were ventilated in a volume control mode with a tidal volume of 6 ml/kg, a Pplat of <30 cmH2O and a PEEP of 8–9 cmH2O [7]. In a multivariate logistic regression, independent factors associated with ACP were an infection as a cause of lung injury and the driving pressure (17 cmH2O in patients with ACP versus 14 cmH2O) [7]. The driving pressure is the distending pressure related to tidal volume, and it then depends on tidal volume (i.e., the ventilatory strategy) and also on compliance of the respiratory system (i.e., the severity of injury). Infection as a factor associated with ACP is interesting. As discussed by Boissier et al. [7], circulating cytokines may contribute to myocardial dysfunction. In addition, inflammation, including infection, is an important component of vascular remodeling in chronic pulmonary hypertension. In the acute setting, vasoconstrictors may be more important, but inflammation may also enhance pulmonary vasoconstriction [9]. In the study by Boissier et al. [7], the consequences of ACP for hemodynamics included a significant increase in heart rate, a decrease in systemic blood pressure and the need for hemodynamic support. ACP was independently associated with 28-day mortality and in-hospital mortality, as well as the McCabe and Jackson class, another cause of lung injury than aspiration, driving pressure (per cmH2O) and an elevated plasma lactate (per mmol/l) [7]. In another large prospective multicenter study of 200 patients with moderate to severe ARDS, Lheritier et al. found a similar incidence of ACP (23, 95 % CI 17–29 %) [10]. The only factor independently associated with ACP was a PaCO2 ≥ 60 mmHg. Data on the driving pressure were not available [10]. This result is interesting because a few years ago Mekontso-Dessap et al. [11] suggested that increased PaCO2 had a major deleterious effect on RV function in very severe ARDS patients, also previously suggested by Vieillard-Baron et al. [4] in 2001. Hypercapnia is a vasoconstrictor of the pulmonary circulation [12]. Elevated PaCO2 can be a consequence of the ventilatory strategy and severity of lung injury, as suggested by the impact of an elevated pulmonary dead space fraction on prognosis [13]. Also, based on the results of the study by Lheriter et al. [10], monitoring RV function by transesophageal echocardiography was much more effective than transthoracic echocardiography. Finally, this study indicated that ACP was not associated with mortality [10]. Why was this result different from the result of the study by Boissier et al.? In the study by Lheritier et al. [10], almost half of the patients with ACP were ventilated in the prone position compared to only 32 % of patients without ACP. It has been clearly reported that lung protective ventilation in the prone position decreases Pplat [14]. In their cohort of 352 patients, Jardin et al. [6] suggested that the effect of ACP on prognosis depends in part on Pplat with a safe limit at 27 cmH2O. These results prompt us to recommend that clinicians consider monitoring RV function using TEE in moderate to severe ARDS patients and to adapt the therapeutic lung protective ventilation strategy according to the function of the right ventricle. This can be considered an “RV protective approach,” as illustrated in the Fig. 1. Recently, in a randomized clinical trial comparing supine to prone positioning (PROSEVA), Guerin et al. [15] reported a large beneficial effect of the prone position on reducing mortality in severe and persistent ARDS with a PaO2/FiO2 <150 mmHg. The prone positioning may have been effective in part because of the beneficial effects on the pulmonary circulation and the right ventricle. The prone position may be an ideal protective approach for improving the function of the RV because it corrects hypoxemia without increasing PEEP, and it decreases the PaCO2 and Pplat by recruiting collapsed lung zones. This result can be contrasted with the “open-lung” approach, as represented by high-frequency oscillation ventilation (HFO), which worsened mortality, with more circulatory failure and a higher vasopressor requirement [16], perhaps reflecting increased RV failure, as shown by Guervilly et al. [17]. In HFO ventilation, airway pressure remains significantly elevated during all the respiratory cycle. Fig. 1 Proposed approach to preventing acute cor pulmonale and limiting its consequences: a right ventricular protective approach. RR respiratory rate, RV right ventricular, HME heat and moisture exchanger, PP prone positioning, PEEP positive end-expiratory ... However, some issues remain unclear. Do we need to turn patients with ACP to the prone position, even though PaO2/FiO2 is still >150 mmHg? Could inflammation-driven pulmonary vasoconstriction be a therapeutic target to reduce injury to the pulmonary microcirculation, for example, with novel therapeutics such as mesenchymal stromal cells or other anti-inflammatory therapies such as statins [18]? What is the effect of isolated RV dilatation without paradoxical septal motion, and is it predictive of imminent ACP/RV failure? How should the level of PEEP be adjusted in individual ARDS patients, providing that the Pplat is maintained below 27 cmH2O? Some preliminary data suggest that the effect of PEEP on the pulmonary circulation and RV function depends on the balance between recruitment and overdistension induced by application of PEEP [11]. Finally, would the RV protective approach, as presented in the Fig. 1, have a beneficial survival effect compared to a more conventional approach? Further clinical and experimental studies will be needed to address these questions.

Procalcitonin levels to guide antibiotic therapy in adults with non-microbiologically proven apparent severe sepsis: a randomised controlled trial

Abstract: Objective Some patients with the phenotype of severe sepsis may have no overt source of infection or identified pathogen. We investigated whether a procalcitonin-based algorithm influenced antibiotic use in patients with non-microbiologically proven apparent severe sepsis. Design This multicentre, randomised, controlled, single-blind trial was performed in two parallel groups. Setting Eight intensive care units in France. Participants Adults with the phenotype of severe sepsis and no overt source of infection, negative microbial cultures from multiple matrices and no antibiotic exposure shortly before intensive care unit admission. Intervention The initiation and duration of antibiotic therapy was based on procalcitonin levels in the experimental arm and on the intensive care unit physicians’ clinical judgement without reference to procalcitonin values in the control arm. Main outcome measure The primary outcome was the proportion of patients on antibiotics on day 5 postrandomisation. Results Over a 3-year period, 62/1250 screened patients were eligible for the study, of whom 31 were randomised to each arm; 4 later withdrew their consent. At day 5, 18/27 (67%) survivors were on antibiotics in the experimental arm, versus 21/26 (81%) controls (p=0.24; relative risk=0.83, 95% CI: 0.60 to 1.14). Only 8/58 patients (13%) had baseline procalcitonin Conclusions In intensive care unit patients with the phenotype of severe sepsis or septic shock and without an overt source of infection or a known pathogen, the current study was unable to confirm that a procalcitonin-based algorithm may influence antibiotic exposure. However, the premature termination of the trial may not allow definitive conclusions.

Echocardiography and pulmonary embolism severity index have independent prognostic roles in pulmonary embolism

Abstract: We analysed a cohort of patients with normotensive pulmonary embolism (PE) in order to assess whether combining echocardiography and biomarkers with the pulmonary embolism severity index (PESI) improves the risk stratification in comparison to the PESI alone. The PESI was calculated in normotensive patients with PE who also underwent echocardiography and assays of cardiac troponin I and brain natriuretic peptide. 30-day adverse outcome was defined as death, recurrent PE or shock. 529 patients were included, 25 (4.7%, 95% CI 3.2-6.9%) had at least one outcome event. The proportion of patients with adverse events increased from 2.1% in PESI class I-II to 8.4% in PESI class III-IV, and to 14.3% in PESI class V (p<0.001). In PESI class I-II, the rate of outcome events was significantly higher in patients with abnormal values of biomarkers or right ventricular dilatation. In multivariate analysis, the PESI (class III-IV versus I-II, OR 3.1, 95% CI 1.2-8.3; class V versus I-II, OR 5.5, 95% CI 1.5-25.5 and echocardiography (right ventricular/left ventricular ratio, OR (for an increase of 0.1) 1.3, 95% CI 1.1-1.5) were independent predictors of an adverse outcome. In patients with normotensive PE, biomarkers and echocardiography provided additional prognostic information to the PESI.

Arthroscopic management of anterior shoulder instability with glenoid bone defects

Abstract: Bony deficiency of the anterior glenoid rim may significantly contribute to recurrent shoulder instability. Today, based on clinical and biomechanical data, a bony reconstruction is recommended in patients with bone loss of greater than 20-25 % of the glenoid surface area. Recent advances in arthroscopic instruments and techniques presently allow minimally invasive and arthroscopic reconstruction of glenoid bone defects and osteosynthesis of glenoid fractures. This article underlines the role of glenoid bone deficiency in recurrent shoulder instability, provides an update on the current management regarding this pathology and highlights the modern techniques for surgical treatment. Therefore, it can help orthopaedic surgeons in the treatment and decision-making when dealing with these difficult to treat patients in daily clinical practice.

HPV genotype distribution according to severity of cervical neoplasia using the Digene HPV genotyping LQ test.

Abstract: A new genotyping-based DNA assay (Digene LQ®) was developed recently. The primary aim was to assess the distribution of HPV types using this new assay in atypical squamous cells of undeterminate significance (ASCUS). The secondary aim was to correlate the HPV types with the severity of the disease. The study population comprised 376 ASCUS women. The women were all Hybrid Capture II (HCII) positive and were admitted in three European referral gynecology clinics between 2007 and 2010. A colposcopy with histological examination was performed in all these patients. HPV 16 was typed in 40 % of patients, HPV 18 in 7 %, and HPV 31 in 17 %, and 18 % of patients had mixed genotypes. Patients aged over 30 more often had the HPV 16 genotype than patients aged under 30 (29 % vs. 11 %, chi-square test p < 0.001). The risk of cervical intra-epithelial neoplasia of grade 2 or more (CIN2 +) when HPV 18 positive is lower than the probability associated with HPV 16 or HPV 31: 28 % vs. 58 % and 52 %, respectively (chi-square test, p = 0.005 and p = 0.05, respectively). The Digene LQ®, a new sequence-specific hybrid capture sample preparation, is fast and efficient and allows high-throughput genotyping of 18 HR HPV types by PCR compared to traditional non-sequence-specific sample preparation methods.

Données épidémiologiques sur la douleur du cancer en France. Évolution sur deux décennies de la prévalence et de l’intensité de la douleur chez les malades atteints de cancer

Abstract: La douleur est frequemment rencontree en cancerologie, du fait de la maladie, du traitement de la maladie, ou d’une raison intercurrente. Ses mecanismes sont varies, elle peut etre inflammatoire, neuropathique, somatique, viscerale, aigue, chronique. Elle a un impact negatif sur la qualite de vie et potentiellement sur la survie. Son traitement fait appel a diverses approches, symptomatiques ou plus specifiques. La prise en charge est frequemment consideree comme peu satisfaisante, comme cela a ete retrouve en France. Quelques explications et propositions sont avancees.

Physiopathologie du syndrome de l’intestin irritable (SII)

Abstract: Les mecanismes physiopathologiques des symptomes du syndrome de l’intestin irritable restent encore mal compris et il est peu probable qu’une seule entite soit responsable des diverses presentations de ce trouble heterogene. On distingue des mecanismes dits peripheriques avec des troubles de la motricite intestinale, des anomalies de la paroi (micro-inflammation, permeabilite intestinale augmentee, anomalies de l’immunite muqueuse), des facteurs intraluminaux (anomalie du microbiote, role de l’alimentation, role des acides biliaires) et des mecanismes dits centraux avec le role d’une hypersensibilite viscerale, des anomalies des mecanismes de controle de la douleur, et des facteurs psychosociaux.

Petits polypes coliques : les retirer à la montée évite d’en laisser en place !

Abstract: En coloscopie, l’ablation des polypes est possible à la montée ou à la descente du coloscope. Jusqu’à ce travail suisse publié dans Endoscopy en novembre dernier [1], aucune étude n’avait jamais comparé ces deux attitudes. Dans cette étude, les coloscopies réalisées pour hémorragies, MICI, sténose, polypose génétique ainsi que les examens dont la préparation n’était pas satisfaisante et les malades traités par antiagrégants étaient exclus. De même, les coloscopies mettant en évidence des polypes de plus de 10 mm, qui nécessitent le recueil du polype, et donc souvent une nouvelle intubation du côlon après retrait de l’endoscope, étaient également exclues. Après la découverte du premier polype, les patients étaient randomisés en salle d’endoscopie en deux groupes, le groupe A dans lequel les polypes de moins de 10 mm étaient retirés à la montée et à la descente, et le groupe B dans lequel ils étaient retirés exclusivement au retrait de l’endoscope. L’étude était validée par un comité d’éthique et les patients, aveugle de la méthode choisie, signaient un consentement éclairé. Tous les malades recevaient le lendemain de la procédure un questionnaire visant à évaluer la tolérance de la coloscopie à rendre dans les jours suivants. Les coloscopies étaient réalisées sous propofol, après préparation par 3 l de polyéthylène-glycol par des endoscopistes ayant au moins cinq ans de pratique avec un minimum de 200 coloscopies par an. La taille des polypes était appréciée à l’aide des pinces à biopsie et les polypectomies étaient réalisées selon les techniques habituelles, avec utilisation d’une anse dès que la lésion excédait 4 mm de diamètre. Dans les deux groupes, tous les polypes vus étaient retirés. De très nombreuses données étaient collectées (caractéristiques des patients, durée des coloscopies, nombre de polypes détectés à la montée et à la descente, éventuelles difficultés techniques...). Une estimation du nombre de malades requis pour observer une différence statistique était faite avant le début de l’étude. Les tests statistiques étaient les tests habituels et une différence était considérée comme statistiquement significative si la valeur du p était inférieure à 0,05. Trois cent un malades étaient randomisés, 150 dans le groupe A (polypes retirés à la montée et à la descente) et 151 dans le groupe B (polypes exclusivement retirés à la descente). Les malades des deux groupes étaient comparables ainsi que les taux de coloscopies complètes de respectivement 97,3 % dans le groupe A et 98 % dans le groupe B. Le nombre total de polypes réséqués, leurs tailles et localisations étaient comparables dans les deux groupes. Les durées totales d’examens de 30,8 ± 15,6 minutes dans le groupe A et 28,5 ± 13,8 minutes dans le groupe B n’étaient pas différentes. De même, les temps pour atteindre le cæcum étaient non significativement différents (13,7 ± 9,3 minutes vs 15,6 ± 9,2 minutes). Le score moyen de difficulté des polypectomies de respectivement 1,6 ± 0,84 dans le groupe A vs 1,5 ± 0,78 dans le groupe B et le confort du patient de respectivement 1,43 ± 0,56 dans le groupe A vs 1,32 ± 0,49 dans le groupe B étaient comparables. Dans le groupe B (polypes exclusivement retirés à la descente), 13 polypes vus à la montée de l’endoscope n’étaient pas retrouvés à la descente, soit 13 des 389 polypes (3,3 %). La taille moyenne de ces polypes était de 3,2 ± 1,3 mm. Les polypes non retrouvés à la descente étaient situés dans le côlon ascendant (1), le côlon descendant (4), le côlon sigmoïde (7) et le rectum (1). Les auteurs concluent que 3,3 % des polypes vus lors de la montée du coloscope ne sont pas retrouvés à la descente quand les polypectomies ne sont faites qu’au retrait de l’endoscope. Il s’agit toujours de petits polypes. La stratégie de polypectomie à la montée n’allonge pas la durée de la coloscopie et n’augmente pas les difficultés des polypectomies. Une telle approche est aussi bien tolérée que la réalisation des polypectomies exclusivement lors du retrait de l’endoscope. Tous ces éléments plaident donc en faveur d’une ablation des polypes de petite taille dès leur repérage lors de la montée de l’endoscope.

L’anatomopathologie à l’ère de la médecine personnalisée : du diagnostic à la théranostique

Abstract: Le pathologiste a pour mission d’etablir un diagnostic et si possible le pronostic a partir des prelevements cellulaires ou tissulaires qui lui sont confies. Au cours des dix dernieres annees, ses activites se sont profondement modifiees. La demarche anatomoclinique utilisee depuis la fin du xviiie siecle s’est recemment completee par une participation systematique aux reunions de concertation pluridisciplinaire (RCP). Dans ces RCP, le pathologiste est generalement l’element-cle pour l’etablissement du diagnostic et joue un role majeur dans l’integration des donnees cliniques et biologiques. Une autre evolution majeure est l’emergence, initialement progressive et actuellemenThexplosive, de la pathologie moleculaire. En raison de ces changements, le pathologiste se retrouve d’une part au centre des interactions entre plusieurs specialites, et d’autre part egalement au centre de la gestion des echantillons tumoraux. Dans ce chapitre, nous decrirons tout d’abord les points cles des nouvelles fonctions du pathologiste, puis nous illustrerons ceci avec des exemples de cancerologie digestive.

Douleur neuropathique post-chirurgicale

Abstract: Il ne fait plus de doute aujourd’hui qu’une fraction importante des douleurs chroniques post-chirurgicales (DCPC) sont de nature neuropathique, bien que toute lesion nerveuse, y compris chirurgicale, ne soit pas systematiquement suivie d’une complication douloureuse a long terme [1]. Si une lesion nerveuse est necessaire mais non suffisante au developpement d’une douleur neuropathique post-chirurgicale (DNPC), les mecanismes sous-tendant l’initiation et le maintien de la douleur apres chirurgie restent mal connus, en partie parce qu’ils ont ete peu etudies et parce que la physiopathologie n’en est pas forcement univoque. En effet, la coexistence de mecanismes inflammatoires et de facteurs psychologiques est a prendre en compte lorsqu’une lesion nerveuse provoquee par un acte chirurgical, agression par nature aigue, aboutit a une douleur neuropathique chronique sequellaire. Depuis quelques annees, divers modeles cliniques ont retenu l’attention des investigateurs, en particulier de deux equipes francaises et d’une equipe danoise discutant prevalence, mecanismes et facteurs de risque de DNPC, et fournissant des donnees cliniques precises et d’evaluation semi-quantitative de la sensibilite apres herniorraphie, thoracotomie, ou prelevement de greffon iliaque.

Est-il possible de faire un diagnostic positif du syndrome de l’intestin irritable ?

Abstract: Le diagnostic du syndrome de l’intestin irritable (SII) est clinique, base sur les criteres de Rome III. La recherche de signes cliniques d’alarme devant faire rechercher une pathologie organique est une etape essentielle dans la prise en charge initiale. L’âge superieur a 50 ans, la presence de sang dans les selles et une diarrhee semblent etre les 3 signes d’alarme les plus pertinents. Les examens complementaires, biologiques et morphologiques, doivent etre realises avec discernement, leur rentabilite diagnostique est faible chez des patients repondant aux criteres de Rome. Dans la majorite des situations rencontrees en pratique quotidienne, un diagnostic positif de SII peut etre pose sans recourir a de multiples examens complementaires.

Cross-modal integration of identity and gender information through faces and voices involves a similar cortical network

Abstract: We investigate the cerebral cross-modal interactions between human faces and voices involved during gender and identity categorization in two separate functional magnetic resonance imaging (fMRI) studies. In each of these experiments, participants were scanned in four runs that contained three conditions consisting in the presentation of faces, voices, or congruent face–voice pairs. The task consisted in categorizing each trial (visual, auditory, or associations) according to its gender or identity. The subtraction between the bimodal condition and the sum of the unimodal ones, as well as psychophysiological interaction analyses (PPI), were performed. Main results suggest that the cross-modal auditory–visual categorization of human gender and identity is sustained by a network of highly similar cerebral regions. This network included several regions such as the unimodal visual and auditory regions processing the perceived faces and voices and inter-connected via a subcortical relay located in the striatum, the left superior parietal gyrus, part of a larger parieto-motor network dispatching the attentional resources to the visual and auditory modalities, and the right inferior frontal gyrus sustaining the integration of the semantically congruent information into a coherent multimodal representation. Therefore, we suggest that cross-modal processing of human stimuli requires the activation of a network of cortical regions, including both unimodal visual and auditory regions and supramodal parietal and frontal regions involved in the integration of both faces and voices and in the cross-modal attentional processes.