Influence d'une nuit de garde sur les performances cognitives des médecins (l'exemple des réanimateurs)

INTRODUCTION: Mission de service public, tout médecin hospitalier se doit de participer au service de gardes, source d'une fatigue inéluctable. Or, le lien entre fatigue et risques d'erreurs médicales est désormais clairement établi. Les médecins sous-estiment parfois les conséquences de la privation de sommeil sur leurs performances cognitives le lendemain d'une garde et en bénéficient pas toujours d'un repos de sécurité. OBJECTIFS: Evaluer l'effet de la privation de sommeil induite par une nuit de garde sur les performances cognitives d'un groupe de réanimateurs grâce à une batterie de tests validés et pertinents. Evaluer l'influence de l'expérience professionnelle et de la quantité de sommeil sur la perturbation des aptitudes cognitives. METHODES: 51 réanimateurs (24 seniors et 27 internes) des trois services de l'Hopital Nord de Marseille ont été inclus. Chaque médecin a été évalué dans les mêmes conditions le lendemain d'une nuit de repos et le lendemain d'une garde grâce à un questionnaire d'auto-évaluations et une batterie de tests cognitifs qui permettent de quantifier quatre aptitudes cognitives nécessaires au travail de médecin. Ces tests étaient issus de la Wechsler Adult Intelligence Scale et du Wisconsin Card Sorting Test, outils de mesure de référence des fonctions cognitives, internationalement validés. RESULTATS: Les quatre aptitudes cognitives testées sont dégradées après une nuit de garde. Il n'y a pas de différence significative entre les seniors et les internes concernant cette altération cognitive, sauf pour la capacité de raisonnement perceptif diminuée uniquement chez les internes [ ]AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocSudocFranceF

Facteurs associés à l'asthme sévère avec trouble ventilatoire abstructif fixé

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

/R/ LENITION IN QUEBEC FRENCH : EVIDENCE FROM THE DISTRIBUTION OF 9 ALLOPHONES IN LARGE CORPORA

International audienceLenition is a process whereby a segment shifts to a "weaker" variant (i.e., closer to deletion in the history of languages). Lenition is also a positional phenomenon, typically affecting intervocalic or coda consonants before post-coda or post-pausal onsets. While the lenition of stops is well studied in Romance languages, investigations about other segments are rare. We propose to fill this gap by focusing on /R/ in Québec French (QF), a variety documented to exhibit up to 9 allophones. We examine 50K+ read words from the PFC-Québec Corpus [1] that we manually annotated (for voicing, manner and place of articulation-based on perception and spectrograms). The analysis of the distribution of /R/ in different syllabic positions shows that lenited (approximantized, vocalized and non-realized) variants indeed appear in leniting positions (coda and intervocalic), thus showing that /R/ realizations in QF are not in free variation but indeed an instance of lenition

/R/ LENITION IN QUEBEC FRENCH : EVIDENCE FROM THE DISTRIBUTION OF 9 ALLOPHONES IN LARGE CORPORA

International audienceLenition is a process whereby a segment shifts to a "weaker" variant (i.e., closer to deletion in the history of languages). Lenition is also a positional phenomenon, typically affecting intervocalic or coda consonants before post-coda or post-pausal onsets. While the lenition of stops is well studied in Romance languages, investigations about other segments are rare. We propose to fill this gap by focusing on /R/ in Québec French (QF), a variety documented to exhibit up to 9 allophones. We examine 50K+ read words from the PFC-Québec Corpus [1] that we manually annotated (for voicing, manner and place of articulation-based on perception and spectrograms). The analysis of the distribution of /R/ in different syllabic positions shows that lenited (approximantized, vocalized and non-realized) variants indeed appear in leniting positions (coda and intervocalic), thus showing that /R/ realizations in QF are not in free variation but indeed an instance of lenition

Barrier-Protective Effects of Activated Protein C in Human Alveolar Epithelial Cells

<div><p>Acute lung injury (ALI) is a clinical manifestation of respiratory failure, caused by lung inflammation and the disruption of the alveolar-capillary barrier. Preservation of the physical integrity of the alveolar epithelial monolayer is of critical importance to prevent alveolar edema. Barrier integrity depends largely on the balance between physical forces on cell-cell and cell-matrix contacts, and this balance might be affected by alterations in the coagulation cascade in patients with ALI. We aimed to study the effects of activated protein C (APC) on mechanical tension and barrier integrity in human alveolar epithelial cells (A549) exposed to thrombin. Cells were pretreated for 3 h with APC (50 µg/ml) or vehicle (control). Subsequently, thrombin (50 nM) or medium was added to the cell culture. APC significantly reduced thrombin-induced cell monolayer permeability, cell stiffening, and cell contraction, measured by electrical impedance, optical magnetic twisting cytometry, and traction microscopy, respectively, suggesting a barrier-protective response. The dynamics of the barrier integrity was also assessed by western blotting and immunofluorescence analysis of the tight junction ZO-1. Thrombin resulted in more elongated ZO-1 aggregates at cell-cell interface areas and induced an increase in ZO-1 membrane protein content. APC attenuated the length of these ZO-1 aggregates and reduced the ZO-1 membrane protein levels induced by thrombin. In conclusion, pretreatment with APC reduced the disruption of barrier integrity induced by thrombin, thus contributing to alveolar epithelial barrier protection.</p> </div

Effect of APC pretreatment (50 µg/ml) on tight junction ZO-1 integrity after thrombin challenge.

<p>The location and length of the tight junction ZO-1 in alveolar epithelial cells was assessed by immunofluorescence. A549 cells were pretreated with APC at 50 µg/ml or vehicle for 3 h. Subsequently, thrombin or culture medium was added to the cell culture for 5 min. In Figure A, ZO-1 fluorescence is indicated by green and Texas-red maleimide staining, which shows cell membranes, in red. Arrows show elongated aggregates of ZO-1 at cell-cell contacts. Representative results of 3 independent experiments. Scale bar = 10 µm. Figure B shows the quantification of ZO-1 length at cell-cell contacts of A549 cells; 27 images per treatment were used to quantify the ZO-1 length between cells. Results are reported as mean ± SEM. * and # denote significant differences between the vehicle + thrombin and APC + thrombin groups and between the vehicle + thrombin and control groups, respectively (p<0.05).</p

Recruitment of the tight junction protein ZO-1 at cell membrane after APC and thrombin exposure.

<p>Levels of ZO-1 protein in the membrane/cytoskeleton and cytosolic fractions were evaluated by western blot. A549 cells were pretreated with APC at 50 µg/ml or vehicle for 3 h, followed by thrombin (50 nM) or culture medium treatment for 5 min. Tubulin was used as an invariant control. Data from seven independent experiments are reported as mean values ± SEM. The results are expressed as a percentage of control (vehicle + culture medium group). The statistical significance of the results was assessed by one-way ANOVA (p = 0.038). * and # indicate significant differences between the vehicle + thrombin and APC + thrombin groups and between the vehicle + thrombin and control groups, respectively (p<0.05).</p

Outcomes of Severe ARDS COVID-19 Patients Denied for Venovenous ECMO Support: A Prospective Observational Comparative Study

Background: Few data are available concerning the outcome of patients denied venovenous extracorporeal membrane oxygenation (VV-ECMO) relative to severe acute respiratory distress syndrome (ARDS) due to COVID-19. Methods: We compared the 90-day survival rate of consecutive adult patients for whom our center was contacted to discuss VV-ECMO indication. Three groups of patients were created: patients for whom VV-ECMO was immediately indicated (ECMO-indicated group), patients for whom VV-ECMO was not indicated at the time of the call (ECMO-not-indicated group), and patients for whom ECMO was definitely contraindicated (ECMO-contraindicated group). Results: In total, 104 patients were referred for VV-ECMO support due to severe COVID-19 ARDS. Among them, 32 patients had immediate VV-ECMO implantation, 28 patients had no VV-ECMO indication, but 1 was assisted thereafter, and 44 patients were denied VV-ECMO for contraindication. Among the 44 patients denied, 30 were denied for advanced age, 24 for excessive prior duration of mechanical ventilation, and 16 for SOFA score >8. The 90-day survival rate was similar for the ECMO-indicated group and the ECMO-not-indicated group at 62.1 and 61.9%, respectively, whereas it was significantly lower (20.5%) for the ECMO-contraindicated group. Conclusions: Despite a low survival rate, 50% of patients were at home 3 months after being denied for VV-ECMO for severe ARDS due to COVID-19

How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

Abstract Background Neuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO2/FiO2 ratio less than 120 with a PEEP ≥5 cm H2O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters. Results Thirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate (p < 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period (p < 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient–ventilator asynchronies occurred in 4 patients. Conclusion A nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block