Réanimation Urgences最新文献

Aim: The aim of this study was to evaluate current practices for gastrointestinal bleeding prophylaxis in intensive care units (ICU) in France.

Methods: A descriptive transversal one given day survey was performed based on a national sample of adult ICUs. This survey focused on usual practices of gastrointestinal bleeding prophylaxis, and also on the type of preventive treatment in patients on prolonged mechanical ventilation (over 48 hours). A one-way analysis of variance was conducted, followed by a multivariate analysis, the results of which showed the main factors involved.

Results: One hundred and twenty-two ICUs participated in the survey, representing about 19% of the total amount of adult ICU beds. Of the 404 patients described, 268 (66.3%) received gastrointestinal bleeding prophylaxis on the day of the survey (omeprazole, 36.9%; ranitidine, 32.8%, or sucralfate, 30.2%). Preventive treatment was more common in medical or polyvalent units than in surgical ICUs (70.3% versus 55.2%; p < 0.01). The results did not show any association between the severity of the disease (estimated on an IGS II score basis) and the use of preventive treatment. Conversely, the latter was associated with the following factors: parenteral nutrition, shock, coagulopathy, history of gastrointestinal bleeding, and treatment with corticosteroids.

Conclusion: It was found that most ICUs in France use prophylactic treatment for the prevention of gastrointestinal bleeding. This probably helps to reduce the incidence of such cases.

Heatstroke is a potentially fatal disorder caused by an extreme increase in body temperature. It can result in widespread damage to the cardiovascular system, liver, kidney and blood clotting function. Classical heatstroke can occur during heat waves or as a result of intense environmental heat in persons in whom the thermoregulatory functions fail to adapt to a sudden increase in temperature, as during a heat wave, or to a high regional temperature. Exertional heatstroke can occur as a result of strenuous exercise, especially in hot, humid conditions, and may affect young, healthy individuals such as athletes during severe physical exertion and military recruits during training. A significant number of the histopathological and clinical characteristics described in persons with heatstroke indicate that these changes are a consequence of hyperthermia per se. A new hypothesis is that splanchnic vasoconstriction following heat stress leads to an increase in epithelial permeability and endotoxic translocation. The inflammatory factors involved could be similar to those observed in sepsis. Classical heatstroke is characterized by the following triad: rectal temperature 0≥40.6°C (> 105° F); neurological dysfunction with coma; and anhydrosis. Exertional heatstroke is characterized by a sudden collapse and loss of consciousness during exercise. The internal body temperature often exceeds 40.6 °C at the time of collapse, but hyperthermia is not indispensable to the diagnosis. Following heatstroke, rhabdomyolysis, renal damage, hepatic disorders and blood clotting dysfunction rapidly occur. An early diagnosis, the prompt institution of body cooling, and the rapid transportation of patients to an intensive care unit are essential for a favorable outcome. The mortality rate in these patients can be as low as 5% or less in centers where appropriate facilities for whole body cooling and emergency treatment are available.

A study on the legal liability of physicians working for the SAMU and SMUR emergency medical services was carried out based on a retrospective assessment of all the accidents involving the intervention of medical staff, recorded between 1994 and 1999 by the Sou Médical. During this period, a total of 15 claims were made concerning physicians who acted either in a transporting capacity (ten claims) or in a regulatory capacity (five claims). In the majority of cases (12 out of 15 cases), the claim followed legal proceedings. In two other cases, it was submitted after a verbal or written complaint, in one case, it was spontaneously submitted by a physician following the accidental death of a patient during transport, without any complaint being made by the victim's family. The medico-legal repercussions of the 15 accidents reported in the study were only known in 11 cases, as in the remaining cases there were ongoing legal proceedings. None of the 11 cases involved conviction for any of the doctors concerned. In particular, the criminal lawsuits brought against three regulators and three transporters led to closure of the file (two instances) or to dismissal of the case (four instances). In contrast to the high ratio of criminal lawsuits initiated by the patients, in this series of 15 accidents the fact that no doctor was sentenced by the court reflects a degree of partiality on the part of the judges towards the doctors involved in emergency medical service activity.

Three cases of myositis with associated acute encephalopathy that required intensive care support are described. Each diagnosis was made following histology. There was one case of dermatomyositis and two cases of polymyositis. The use of essential steroid therapy may lead to amyotrophy and infectious diseases, which delay recovery.

There is little data available in the literature on the incidence, etiology and the consequences of community-acquired severe viral pneumonia in the non-immunodeficient adult. In most studies, the viral etiology has not been investigated. The results of studies carried out over the last ten years show a frequency of between 1 and 13.6%. Diagnosis is frequently based on serological testing, but full testing is only carried out in under 50% of cases. In France, respiratory viruses are mainly influenza virus (40–50%), followed by respiratory syncytial virus (RSV: 14%), parainfluenza virus (20–30%), and adenovirus (12–14%). Viruses responsible for pulmonary infection introduced via the hematogenic pathway (varicella-zoster, Epstein-Barr, measles, enterovirus, etc.) are less common, but easier to diagnose. Epidemiological studies should include a thorough investigation of the viral etiology, with for the majority of viruses, viral antigen detection by IF or Elisa, or viral isolation and culture. Serological testing is useful for certain viruses (measles, Epstein-Barr, Hantavirus). Molecular biological techniques are in the process of being assessed. Routinely, the lack of efficient therapeutic agents to treat cases of severe viral pneumonia limits the interest of an etiological approach. RSV infection can be easily and inexpensively diagnosed by viral antigen detection, or viral isolation and culture, but the diagnosis for influenza must be made early after the onset of symptoms, otherwise serological diagnosis may be made a posterior. The aim of such research is to introduce suitable anti-influenza prophylaxis for at-risk subjects, and hygienic measures to limit RSV cross-transmission.

Aim: The aim of this article is to present an analysis of the physicians' various obligations, in particular those regarding emergency care physicians.

Introduction: Progress in medicine can be made as long as the patients consider that they should not only receive medical care, but be cured as well. Patients no longer hesitate to hold the physician responsible for any failure in treatment.

Civil liability: The physician's liability is contractual, hence his main obligation regards that of using the necessary means to treat the patient. However, in certain cases he may also have an obligation involving safety-results; there is also the important obligation of fully informing the patient, which does not apply to emergency situations.

Criminal liability: This is a personal/individual liability which involves all physicians, as well as moral persons (clinics and medical centers). Certain offences are fairly characteristic of medical practice, An emergency care physician can be held responsible for failure to help a person in danger, or for manslaughter.

Administrative liability: Administrative liability only concerns medical activity in the public sector. In the private sector, including the public hospital, legal pursuit for individual malpractice involves the administration as a whole, which has to deal in the court of law with the charges brought against the erring physician. Administrative case law is evolving towards judicial case law. In jurisprudence, there is a trend toward liability without fault, aimed at the better compensation of victims of medical malpractice.

Ordinal liability: This concerns all physicians; however, this aspect is more complicated for those in the public sector. There are no exceptions to certain ordinal statutes, even in cases of emergency.

Special cases and a few statistics: Problems raised by resident physician/interns' responsibility, salaried practice and private hospitals have been considered. A few statistics regarding medical responsibility are given.

Conclusion: Case law, it would seem, is not impartial but mainly aims at awarding damages to the patient, sometimes to the detriment of the physician.

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  - Vasculogenesis, angiongenesis and arteriogenesis

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  • Angiogenesis in embryonic development vasculogenesis

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  • Angiogenesis

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  - Vessel formation

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  - Mechanical hypothesis

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  - Biological hypothesis: role of the angiogenic growth factors FGF and VEGF

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  • Combined hypothesis: angiogenesis and vascular remodelling

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  - Therapeutic angiogenesis in cardiovascular diseases

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  • Critical limb ischemia

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  • Myocardial ischemia

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  - Gene therapy

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  - Angiogenic growth factor therapy

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  - Tumour angiogenesis

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  - Angiogenesis in healing wounds