[What is the impact of specialist guidelines outside their specialty?].
Explore the source record for details and available documents.
Emergencies↗
Biomedical subjects
E L'Her
Publications and source records attributed to E L'Her.
[Indications and practical issues concerning oxygen therapy].
INTRODUCTION: The initiation of oxygen therapy for acute or chronic respiratory failure is a common medical intervention, both for hospital in-patients and in out-of-hospital emergency settings. Oxygen therapy is also frequently initiated by paramedics or nurses, without any initial medical prescription, in acutely ill patients. STATE OF THE ART/PERSPECTIVES: It is important to remember that oxygen is a pharmaceutical drug, and its prescription should therefore be considered within treatment guidelines. Two main pathological situations may be encountered: tissue hypoxia and acute/chronic hypoxemia. CONCLUSION: Physicians should be aware of the clinical signs that may indicate the presence of hypoxia and the pathological situations that may lead to hypoxemia. They must also be aware of the potential complications, in particular CO(2) retention in patients with chronic type II respiratory failure as well as the overall indications, and practical issues concerning oxygen therapy.
Equipment Design↗
[Tracheostomy in intensive care - the debate rages on].
Explore the source record for details and available documents.
Critical Care↗
Prospective evaluation and outcome of patients admitted for syncope over a 1 year period.
AIMS: Syncope is a frequent and potentially dangerous symptom. The epidemiological data are based on series mainly collected 20 years ago in the U.S.A. and do not adequately assist in the management of patients admitted now for this symptom in Europe. METHODS AND RESULTS: To evaluate prospectively the epidemiological aspects and the management of the patients admitted in the emergency department of an adult university hospital for a 'verified' syncope, charts of all the patients consecutively admitted between June 1999 and June 2000 were systematically reviewed by a member of the cardiology staff. Those with a loss of consciousness were selected and those with a definite syncope were included in the study group and followed until they were discharged from the hospital. Among the 37,475 patients who presented to the emergency department, 454 (1.21%) had a definite syncope. For 296 it was the first episode and 169 (mean age 43+/-23 years) were discharged straight away; 285 (mean age 66+/-19 years; P<0.0001) were admitted to internal medicine (n=151), cardiology (n=65), neurology (n=44), endocrinology (n=14) and surgery (n=11) services. In 75.7% of all the patients a diagnosis was reported but it was inadequate to explain a syncopal episode in 56 cases (16.3%). Management differed by department: 36% of the patients had 'neurological' investigations mainly in internal medicine and neurology. Except in cardiology very few had 'cardiological' investigations particularly tilt test and electrophysiological studies (5%). CONCLUSION: Syncope is a frequent symptom but its cause often remains unknown partly due to inadequate management. Precise and simple guidelines are urgently needed.
Adult↗
A global approach to energy metabolism in an experimental model of sepsis.
Disturbances in energy metabolism during sepsis are not clearly understood. The aim of the study was to globally assess the energy drive in septic rat myocytes, studying both glycolysis rates and mitochondrial maximal activities together, using recent in vitro techniques. Measurements were assessed before (H0) and 4 h after sepsis induction (H4). Hyperlactatemia was observed in all septic animals ([lactate] = 1.2 +/- 0.3 mmol/L at H0 versus 3.3 +/- 0.6 mmol/L at H4; p < 0.001). An enhanced glycolysis rate was observed in both aerobic ( J(A) = 7.2 +/- 0.9 at H0 versus 18.2 +/- 4.1 nmol glucose/min/g at H4; p < 0.05) and anaerobic ( J(B) = 7.5 +/- 1.2 at H0 versus 15.4 +/- 3.4 micromol glucose/min/g at H4; p < 0.05) fluxes, associated with a selective significant pyruvate-malate-dependent oxygen consumption rate decrease (V O(2)-PM = 0.144 +/- 0.008 at H0 versus 0.113 +/- 0.007 micromol O(2)/h/mg at H4; p < 0.05). This oxygen consumption decrease can be interpreted either as a complex I and/or a complex I-ubiquinone relation alteration. Our results are consistent with the hypothesis that an altered mitochondrial function during sepsis is responsible, at least in part, for hyperlactatemia, which is thus a consequence of an increased glycolysis rate.
Animals↗
Biphasic-flow induced ventilation allows simultaneous ventilation in several animals, using a single multiple output ventilator--a preliminary report.
Biphasic-flow induced ventilation (BiFIV) is a variable time-cycled tracheal gas insufflation mode, using a specific multiluminal endotracheal tube. Some recent studies have reported efficiency of this new ventilatory mode in experimental in vitro and in vivo settings. We hypothesized that this ventilatory mode could be able to deliver simultaneous efficient ventilation for several animals, using a single ventilator prototype. The study was performed in three groups of three domestic pigs with a normal lung compliance. Each pig was initially anaesthetized, intubated with the specific endotracheal tube, and ventilated with a conventional ventilatory device. The animals were then simultaneously ventilated under BiFIV, using a single ventilator prototype, for each group of three animals. Physiological parameters and arterial blood gases were recorded at each study phase. All animals but one survived the experiment. We did not observe any significant differences in arterial gas exchange, under both ventilatory modes. Oxygenation was as efficient for each three animals ventilated under BiFIV, using a single ventilator device, as under conventional ventilation, using three separate ventilators (PaO2 = 112+/-17 mmHg under conventional ventilation versus 115+/-16 mmHg under BiFIV). In conclusion, variable time-cycled tracheal gas insufflation may allow an efficient multiple ventilation on several animals, using a single multiple output ventilatory device, in a normal lung animal model. If validated on subsequent pathological models, it could thus be interesting in laboratory and/or mass casualty situations.
Animals↗
Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial.
CONTEXT: Continuous positive airway pressure (CPAP) is widely used in the belief that it may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency. OBJECTIVE: To compare the physiologic effects and the clinical efficacy of CPAP vs standard oxygen therapy in patients with acute hypoxemic, nonhypercapnic respiratory insufficiency. DESIGN, SETTING, AND PATIENTS: Randomized, concealed, and unblinded trial of 123 consecutive adult patients who were admitted to 6 intensive care units between September 1997 and January 1999 with a PaO(2)/FIO(2) ratio of 300 mm Hg or less due to bilateral pulmonary edema (n = 102 with acute lung injury and n = 21 with cardiac disease). INTERVENTIONS: Patients were randomly assigned to receive oxygen therapy alone (n = 61) or oxygen therapy plus CPAP (n = 62). MAIN OUTCOME MEASURES: Improvement in PaO(2)/FIO(2) ratio, rate of endotracheal intubation at any time during the study, adverse events, length of hospital stay, mortality, and duration of ventilatory assistance, compared between the CPAP and standard treatment groups. RESULTS: Among the CPAP vs standard therapy groups, respectively, causes of respiratory failure (pneumonia, 54% and 55%), presence of cardiac disease (33% and 35%), severity at admission, and hypoxemia (median [5th-95th percentile] PaO(2)/FIO(2) ratio, 140 [59-288] mm Hg vs 148 [62-283] mm Hg; P =.43) were similarly distributed. After 1 hour of treatment, subjective responses to treatment (P<.001) and median (5th-95th percentile) PaO(2)/FIO(2) ratios were greater with CPAP (203 [45-431] mm Hg vs 151 [73-482] mm Hg; P =.02). No further difference in respiratory indices was observed between the groups. Treatment with CPAP failed to reduce the endotracheal intubation rate (21 [34%] vs 24 [39%] in the standard therapy group; P =.53), hospital mortality (19 [31%] vs 18 [30%]; P =.89), or median (5th-95th percentile) intensive care unit length of stay (6.5 [1-57] days vs 6.0 [1-36] days; P =.43). A higher number of adverse events occurred with CPAP treatment (18 vs 6; P =.01). CONCLUSION: In this study, despite early physiologic improvement, CPAP neither reduced the need for intubation nor improved outcomes in patients with acute hypoxemic, nonhypercapnic respiratory insufficiency primarily due to acute lung injury. JAMA. 2000;284:2352-2360.
APACHE↗
[Generalized livedo during severe chloralose poisoning].
Explore the source record for details and available documents.
Chloralose↗
Glycolysis in the human muscle: a new approach.
The flow response time theory allows the global assessment of a metabolic pathway. This study describes the first application of this concept to explore glycolysis on human skeletal muscle extracts. The muscle extract is used to convert glucose or glucose-6-phosphate into glycerol-phosphate through the first part of glycolysis. The functioning of the experimental model is assayed by a continuous recording of the reduced nicotinamide adenine dinucleotide decay in a spectrophotometer. This measurement method was applied to normal and pathologic human skeletal muscles. The aerobic (J(A)) and anaerobic (J(B)) fluxes and the time (t99) needed for the transition from J(A) to J(B) were measured under a wide clinical temperature range (30 degrees C to 40 degrees C). The two studied muscle types (gluteus maximus and tibialis anterior) have similar glycolytic flux values, with an identical functional modality. The thermal response of glycolysis is not linear, with a high thermal sensitivity in the hypothermic range (30 degrees C to 38 degrees C) and a thermal insensitivity in the hyperthermic range (37 degrees C to 40 degrees C). On the same type of muscle (tibialis anterior), a pathologic process can induce different variations in the glycolysis patterns, but further data are needed to clear this point. The flow response time concept allows an accurate assessment of glycolysis in the human skeletal muscle, whether normal or pathologic. This approach is interesting for evaluating the global influence of different stimulations on a metabolic pathway, such as temperature variation.
Body Temperature↗
Helium-oxygen breathing in the early emergency care of acute severe asthma: a randomized pilot study.
The aim of this study was to establish whether a clinical trial, comparing helium-oxygen (HeO2) breathing to standard therapy, would be feasible during the out-of-hospital care of adult patients with severe asthma. Although the primary outcome in a definitive trial will be a decrease in morbidity, the present study primarily examined: (1) if the strategy could be successfully implemented in emergency ambulatory units; (2) if the research staff could enroll enough patients, given the resources. Nine patients were included in the conventional treatment group, and seven patients in the HeO2 group. Patients randomized to the HeO2 group breathed the mixture for a 12-hour period. Clinical and biological parameters improved for all patients. There was no trend towards a HeO2 benefit, whether during the initial out-of-hospital nor the ICU care. No patient was intubated within the study period. HeO2 breathing was considered to be simple to initiate, and no side effects were reported. In conclusion, while HeO2 breathing is easy to apply, even in the out-of-hospital setting, the few enrolled patients did not appear to benefit from this treatment. Regarding our low inclusion rate and the lack of positive effect trend, we believe that a large definitive trial will be difficult to initiate in such an emergency care setting.
Acute Disease↗
[Spontaneous positive end-expiratory pressure ventilation in elderly patients with cardiogenic pulmonary edema. Assessment in an emergency admissions unit].
OBJECTIVES: Intubation and ventilatory assistance are often required in patients presenting severe hypoxemic respiratory distress, but may be contraindicated in elderly subjects due to an underlying condition. The aim of this study was to assess the feasibility, acceptability and contribution of early assistance with spontaneous positive end-expiratory pressure ventilation for elderly subjects admitted to an emergency unit for acute respiratory distress due to cardiogenic pulmonary edema. PATIENTS AND METHODS: In our emergency admission unit, all patients with life-threatening hypoxemic respiratory distress are initially assisted with noninvasive spontaneous positive end-expiratory pressure ventilation using a standardized commercial device. We retrospectively analyzed the the files of all patients aged over 70 years who were treated with this standard protocol for cardiogenic pulmonary edema from April 1996 through September 1997. RESULTS: During the study period, 36 patients aged over 70 years required ventilatory assistance according to the standard protocol. Intubation was not reasonable in most of the patients (n = 30). After 1 hour of ventilation, none of the patients developed clinical signs of life-threatening distress. Blood gases demonstrated improved oxygenation (AEPO2 = +184.9 +/- 105.4 mmHg; p < 0.000001). Thirty-two patients were considered to be cured (88.9%) and were discharged; the cardiovascular condition was fatal in 4 patients (11.1%). CONCLUSION: The rapid improvement in clinical signs and blood gases as well as the final outcome suggests that early assistance with spontaneous positive end-expiratory pressure ventilation is warranted at admission for elderly patients with respiratory distress due to cardiogenic pulmonary edema. Compared with a control group of hospitalized patients cared for during the preceding year and who were not treated with the standard protocol, we also demonstrated a clear improvement in mortality (11% versus 20%).
Admitting Department, Hospital↗
[Spontaneous ventilation in positive expiratory pressure in cardiogenic pulmonary edema. Prospective study].
New equipment facilitating the use of spontaneous ventilation with positive expiratory pressure (PEP) has become available in France since January 1996. This technique was applied in 38 patients with severe cardiogenic pulmonary oedema and persistent respiratory distress despite high flow classical oxygen therapy and standard treatment. After 1 hour of ventilation with a flow of 220 l/min of 100% oxygen with an average PEP of 7.7 cm H20, a significant improvement of clinical (heart and respiratory rate) and biological parameters (arterial gases) was observed. There were no side effects. Four patients died during the hospital period and only 1 was intubated. Spontaneous ventilation with PEP is a simple technique for coronary care units and, compared with conventional oxygen therapy, it rapidly improves arterial oxygenation, reduces respiratory work and improves conditions of cardiac load. Acute severe cardiogenic pulmonary oedema seems to be an indication of choice, especially in the elderly, where it may help avoid an often controversial intubation.
Aged↗
[Use of helium-oxygen gas mixtures in acute obstructive respiratory insufficiencies].
Therapeutic use of helium has been described since 1930. Its main action is to reduce bronchial resistances and consequently overall respiratory work. Helium is substituted for nitrogen. The effects of inhaling a helium-oxygen mixture result exclusively from the physicochemical properties of helium: very low density, high kinetic viscosity. With the advent of selective bronchodilators, use of helium was rapidly abandoned until recently with new interest for the treatment of severe acute asthma. We review the literature on the physical properties of helium-oxygen mixtures and propose an analysis of their therapeutic use in severe acute asthma as well as other indications such as acute episodes of obstructive bronchopneumonia and obstruction of the upper airways. Due to the non-invasive nature of this technique, its easy use with spontaneous ventilation and the large body of theoretical data emphasizing its adaptation for therapeutic use, helium-oxygen gas mixtures offer an important therapeutic option for treating severe diseases with poor prognosis. A multicentric national study is under way to validate its use early by emergency ambulatory units for the treatment of severe acute asthma.
Acute Disease↗
Leukaemia inhibitory factor (LIF) production in pleural effusions: comparison with production of IL-4, IL-8, IL-10 and macrophage-colony stimulating factor (M-CSF).
Leukaemia inhibitory factor (LIF), a pleiotropic cytokine detected in various inflammatory body fluids, plays a poorly defined role in the pathogenesis of human disease. This study was conducted to correlate the LIF concentrations in pleural effusions with the type of pathology and to compare its levels with those of IL-4, IL-8, IL-10 and M-CSF for a given pathology. Pleural fluids from 97 patients were assayed for cytokines by specific ELISAs. The concentrations of all cytokines tested were higher in infectious pleural effusions than in other pathologies (malignant or transudative). The lowest levels were observed for transudates. Significant differences were noted between pathology groups for each cytokine. A good correlation was observed between LIF and IL-8 for malignant effusions [regression correlation coefficient (RC) = 0.480, P < 0.01], between LIF and IL-4 for infectious disorders (RC = 0.543, P < 0.05) between LIF and IL-10 for transudates (RC = 0.798, P < 0.001) and between M-CSF and IL-8 in all pathologies tested except for primitive neoplasia (P < 0.05). The LIF concentration in pleural space seems to be strongly associated with the intensity of inflammatory reaction. The LIF production appears to have different regulatory patterns between aetiologic groups.
Aged↗
[Association of sarcoidosis and autoimmune thyroiditis].
The thyroid gland involvement in sarcoidosis is rare but not exceptional. Usually there is little or no clinical expression although hyperthyroidism may be present. The granulomatous infiltration of the thyroid gland cannot be responsible for all the abnormalities observed. In certain cases, there is undoubtedly an autoimmune disease. We report a case of concomitant discovery of sarcoidosis and Hashimoto's thyroiditis. Despite their relative frequency, there could be a relationship between these two pathologies, especially in light of their similar pathophysiology.
Female↗