Approche expérimentale des circonstances de toxicité pulmonaire aiguë ou chronique du Granulocyte-Colony-Stimulating-Factor (G-CSF)

INTRODUCTION : Le Granulocyte Colony Stimulating Factor (G-CSF) est largement prescrit chez les patients d'hématocancérologie pour raccourcir les durées de neutropénie après chimiothérapie. Le G-CSF est aussi évalué chez des patients non neutropéniques ayant des altérations fonctionnelles des polynucléaires neutrophiles (PN). Plusieurs observations de pneumopathies médicamenteuses au G-CSF ont été rapportées: il s'agit le plus souvent de patients âgés de plus de 65 ans, ayant reçu plus de trois cures de chimiothérapie pour lymphome non hodgkinien, présentant une pneumopathie interstitielle diffuse non infectieuse pendant ou après la sortie d'aplasie. Néanmoins, cette entité reste discutée du fait: (1) de sa rareté, (2) de l'évident bénéfice à prescrire du G-CSF contre un risque incertain de pneumopathie, (3) que les études randomisées comparant G-CSF à placebo n'ont pas démontré de surcroît de pneumopathies, (4) de l'innocuité du G-CSF chez les patients non neutropéniques. QUESTION POSEE : Quelles sont les situations à risque de toxicité pulmonaire du G-CSF? INTERVENTION: Le G-CSF (25 microg/kg/j) a été administré dans plusieurs situations d'agressions pulmonaires, à des rats non neutropéniques, neutropéniques ou en sortie d'aplasie. Les explorations ont comporté une quantification de l'oedème pulmonaire, des concentrations de protéines dans le lavage bronchoalvéolaire, du recrutement alvéolaire, de la séquestration pulmonaire en PN (myéloperoxydase), des concentrations sériques et pulmonaires en TNF-alpha et IL1-beta, de la pression artérielle pulmonaire (cathétérisme droit) de la compliance pulmonaire statique, des constatations anatomopathologiques (muscularisation, fibrose). Les rôles respectifs du PN et du macrophage ont été approchés par des expériences associant la lidocaine, les anticorps anti-TNF-alpha et te cyclophosphamide...PARIS12-CRETEIL BU Multidisc. (940282102) / SudocSudocFranceF

TEST DE PROVOCATION NASALE (INTERET D'UN COUPLAGE ENTRE L'EVALUATION CLINIQUE ET LA MESURE DE RESISTANCE POUR LE DIAGNOSTIC DES ASTHMES ET RHINITES PROFESSIONNELS (DES MEDECINE DU TRAVAIL))

PARIS6-Bibl. St Antoine CHU (751122104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

A knowledge-based system for assisted ventilation of patients in intensive care units.

International audienceThe procedure for weaning a patient with respiratory insufficiency from mechanical ventilation may be complex and requires expertise obtained by long clinical practice. We designed a knowledge-based system for the management of patients receiving respiratory support and implemented a weaning procedure. The system is intended for patients whose spontaneous respiratory activity is assisted by a Hamilton Veolar ventilator delivering a positive pressure plateau during inspiration (Pressure Support Ventilation mode). Our closed-loop real-time system running on a Personal Computer continuously adapts the assistance provided by the ventilator to the patient's evolution, and indicates when the patient can be withdrawn from the ventilator. Three parameters are used to appreciate the 'respiratory comfort' of the patient: breathing frequency, which we consider the most informative index, tidal volume and end-tidal CO2 pressure. A preliminary study of 19 patients was performed to evaluate the ability of our system to adapt the assistance to the patient's needs, with the main objective of facilitating weaning by gradually lowering the level of assistance. In 10 of these patients, considered as good candidates for weaning on the strength of objective criteria, the system maintained the breathing pattern in a zone of comfort for 95% of the period of assisted ventilation and stated that they were 'weanable'. This was consistent with the clinical evolution of all 10 patients. These results show that such a system can provide effective management for mechanically ventilated patients

Costs for Acute Myocardial Infarction in a Tertiary Care Centre and Nationwide in France

Objective: We compared the estimated costs of coronary interventions from our hospital's cost accounting system with data from the French Diagnosis Related Group (DRG) cost database, taking the perspective of our hospital. Design: Cost data on hospital resources used by patients hospitalised for acute myocardial infarction (MI), with and without complications, including deceased patients, were collected in a tertiary care university hospital located in Paris, France. The data were collected using the hospital's cost accounting system and then compared with the estimates provided by the DRG reimbursement schedule for similar conditions. Main outcome measures and results: The estimated costs were 849 euro (EUR) for coronary angiography, EUR4762 for coronary angioplasty with stenting, and EUR4978 to 8067 for MI. The DRG reimbursement schedule provided for acute MI was EUR3920 to 5709. Conclusions: Although the current cost of treating acute MI in a teaching hospital is reasonably close to that in the current reimbursement schedule, rapid technological changes regarding both drugs and devices renders necessary a close monitoring of costs associated with the management of these acute care patients.Angioplasty, Antiischaemics, Cost analysis, Myocardial infarction, Pharmacoeconomics, Thrombolytics

Clinical evaluation of a computer-controlled pressure support mode.

International audienceWe have designed a computerized system providing closed-loop control of the level of pressure support ventilation (PSV). The system sets itself at the lowest level of PSV that maintains respiratory rate (RR), tidal volume (VT), and end-tidal CO(2) pressure (PET(CO(2))) within predetermined ranges defining acceptable ventilation (i.e., 12 300 ml [> 250 if weight < 55 kg], and PET(CO(2)) < 55 mm Hg [< 65 mm Hg if chronic CO(2) retention]). Ten patients received computer-controlled (automatic) PSV and physician-controlled (standard) PSV, in random order, during 24 h for each mode. An estimation of occlusion pressure (P(0.1)) was recorded continuously. The average time spent with acceptable ventilation as previously defined was 66 +/- 24% of the total ventilation time with standard PSV versus 93 +/- 8% with automatic PSV (p < 0.05), whereas the level of PSV was similar during the two periods (17 +/- 4 cm H(2)O versus 19 +/- 6 cm H(2)O). The time spent with an estimated P(0.1) above 4 cm H(2)O was 34 +/- 35% of the standard PSV time versus only 11 +/- 17% of the automatic PSV time (p < 0.01). Automatic PSV increased the time spent within desired ventilation parameter ranges and apparently reduced periods of excessive workload

NéoGanesh: a working system for the automated control of assisted ventilation in ICUs.

International audienceAutomating the control of therapy administered to a patient requires systems which integrate the knowledge of experienced physicians. This paper describes NéoGanesh, a knowledge-based system which controls, in closed-loop, the mechanical assistance provided to patients hospitalized in intensive care units. We report on how new advances in knowledge representation techniques have been used to model medical expertise. The clinical evaluation shows that such a system relieves the medical staff of routine tasks, improves patient care, and efficiently supports medical decisions regarding weaning. To be able to work in closed-loop and to be tested in real medical situations, NéoGanesh deals with a voluntarily limited problem. However, embedded in a powerful distributed environment, it is intended to support future extensions and refinements and to support reuse of knowledge bases

NéoGanesh: a working system for the automated control of assisted ventilation in ICUs.

International audienceAutomating the control of therapy administered to a patient requires systems which integrate the knowledge of experienced physicians. This paper describes NéoGanesh, a knowledge-based system which controls, in closed-loop, the mechanical assistance provided to patients hospitalized in intensive care units. We report on how new advances in knowledge representation techniques have been used to model medical expertise. The clinical evaluation shows that such a system relieves the medical staff of routine tasks, improves patient care, and efficiently supports medical decisions regarding weaning. To be able to work in closed-loop and to be tested in real medical situations, NéoGanesh deals with a voluntarily limited problem. However, embedded in a powerful distributed environment, it is intended to support future extensions and refinements and to support reuse of knowledge bases

Evaluation of a knowledge-based system providing ventilatory management and decision for extubation.

International audienceWe evaluated whether a knowledge-based system (KBS) connected to a ventilator in pressure support mode could correctly predict the ability of patients to tolerate total withdrawal from ventilatory support. The KBS was designed to continuously adapt ventilatory assistance to the needs of the patient, to manage a strategy of gradually decreasing ventilatory assistance, and to indicate when the patient was able to breathe without assistance. Thirty-eight patients for whom weaning was being considered were evaluated using a conventional battery of parameters, including weaning criteria, tolerance of a T-piece trial, and outcome 48h after permanent withdrawal of ventilation. The results of this evaluation were compared with the suggestions made by the KBS at the end of a period of KBS-driven mechanical ventilation inserted in the conventional weaning procedure. The positive predictive value of the KBS was 89%, versus 77% for the conventional procedure and 81% for the rapid shallow breathing index alone. The KBS correctly predicted the course of five patients who tolerated a T-piece trial but required ventilation within 48 h. We conclude that our KBS ensured appropriate patient management during the weaning period and improved our ability to predict responses to weaning